GW1-2022-09731_Well Construction - GW1_20221027

828-622 72�M1 P.1
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� 91�F�EMARKS A
Caunly i+aecel identification No.(MNI
Sh.ILanlndr.nod Innlnitudeindegrmfmhnitesisecondsordccimnldegt'ces: 4••--� -- h��� ,':� ;
cl(.wn ticla,nna!!iak�9nn►a iF�5luiii�nicnli t r i t f :r�:e1 ti11 007
.Is(arc)(hc well(s} Pcrmnncnt ar OffamilmrY Signnt o 1gy I wt irrvAv tnrotar Dale
t���fff'q Itur•�+rnr,!ll y r mtlfj+IAnr rhr,It+s11(� xvtr hrrvrJ rnnam4rtivl M acinrdn!trr
.lathlkaxrpalrtnentxivtingwr]I: �tXc3 ttTIKtI na' S,t 4f.'.1r:n]C!lIDllarrSrl�YCAras'a.uanl►A'rllCnntfrtrrtl+urS7nnrhu+Ltrmilrhnr•r
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r:I xtlrnndcr t`�(rmm�rl:rocs(l4n nrmll(trhnrk nf(Llv.(nrni. a1.91tt.c tua R�or wdditlood WWI 411 MAll:
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R.For GI!oprnhNlkl►I op Closed-I.nnp GBMherntal We1H having thr mole You mny,Ise.the luick of!Ills page to ptovi0o addttionnt well sAo dethlb or well
M1191mGtian,only 1 GW-1 is needed, 1'ndicMel TR'rA)-NUMBER rif wclfa c,matnlclinn<trtnits. -Van BM also attatoh addltianal palm if pet essety,
drillcci: _ �r�-r
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9 TMal Welk depth below rand mr/Stce: v S _ (k.) In_tg sH r Suhrait Ods£osm within 3t1 days of complebon of:veil
f"nrnruhltrlr Rpeift&V 01MirPAV ifd(jlernnt(rramele•s(gilsn(nl andi�(na') t;ona(nlclinn fO tbC ibi181Slfl�:
ln.:itnfS-enter lmgl k►clow to or rash -._ ✓ (fr_) Division of Water Rcmurcrs,lofhrmatlon Prormtag Untt,
(f Mnrur(urr:1ls+rhnna CaNeg,Ilia '�" 1617n4mil Service Center,M*'e4gU,T4C274M-'till
t 1_llorahoR:diameter: w (in.) ?.49a F rnr I�kertlnn tYsli> In addition to Bonding*forge 1414 Paraw In 840
altoVe,also submit ono copy of this fall mllhin 3n days of complallDln of well
i�1Velt ronnrnellnn ma1hM1: -- -T eansmaian to the fallowing:
(i c•allu r,reTan.Mb!o,d!ravt plot),etc.)
.9IvIllon or%ter Rrsourm%Underground tl$ltllon IComrpl ftOR am,
IY3Wt�'WATIRK,Sj,Pi'LY WEL1.9ONLY, irt3614fpil144i WctCa0;Rltic18l4N%7-76?MON
I3a,Viet If(apm) Mtth o of Im:�T— ?-ic.t`or t`Jai- CanQly&rake9na Wells In addidcn in sanding Mr.11,rrrt fn
I(t0 nddrr'tc(es) nbnm, also submit one copy of this rorin Within 30 dm. nC
19h.OlOnfeetinn type: _ Amnnnr. comprct!on of well constmCOQP to Cho 4minty 1mallh department of Ilia county
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1'ern1(:14-I North C:mnliAnAcpanmcntofurt iranmCnI.4911allly-m4smnofWusrRa mncea Reviaed2.�2-ZR16