GW1-2022-09830_Well Construction - GW1_20221028

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3.WrIl Tric(check well list): 17.3CR8 N sum
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Sb.I.nlitude and longlihtde in degroulminnteslsecondsordecimal degrees:
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l.ls{xrc)thewelt(s) ivrtrnoom ar 0TetrrllnMry tu(cGeCcntrwdWr1iCantmetar Data
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i.l t this n rcpalrtn pn cxfstip Elves cs or IKJNQ a lfb 1 Lf 4f'ar.:ozr..n►orl n,lS�i,Y(AC.A?C.',n1a0 rt'erl G.turnurtntr Uandardc mr,l thnr.r
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1 vnir rotdar A 2 r mmarkca fj#m air rmilia hurl offAfxlnnn, a3,site 41108'ttm or attditlonal wall details:
$.For Gen raha/)PT or ameti-I.Anit Geoll ill Welis having the some You mny'tsa the back of this page ter provide Additional well site lit ails or tvell
nonsmtction,oniv I CTW.I is needed. litdimbt TOTAL.NLIMSFR of-c' c +.tip �intt ticrsils. You rnayafso nittach additional pages if ttocessety.
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9.Total welt dcpdt below toad smime:,,� (R} t I f.far AN Wells; Submit this form within 30 d,g's of wmplrlion of+yell
!%nrmtrlllpkwNJtGtrnl;Aeplfmjdf/fernnlfirtunpla3010R'nndi�afORI constnictionto The follo%tttg:
I n,Statre Walter level below top of caslog: (ft-) Division of Water Resourccfk Information Processing 130%
Q-Mn1arlLncllvrtblive Caving tct(c"•} 16171i'Ii+flSwyiceCem,tcr,RsteiglyMC 274"-Ibl'1
t 1.ltttrnbotedlAmetcr: lJ r v Ctn•) ?.ab.irnr Irriection W" to addition to fending the forts t4 111q.nddrM Io 240
�{ allow,sign submit one copy of this form within 30 days of compledon of well
IZ,Wel[tnngtrnctlnn method: cimsto imr to the following:
G c:,eager,rntity.cable,direct pttsh,etc.) -—
1)Ivision of Winer Rraouriz%Undeigroliud Irdirtlon Coltlrlll ProgrAM,
FOR WATER S TK Y W,LLS ONLY: Q t 1636 Mnll Smim Cotter,RAMP,TqC 7,7699.106
1.3A,yield(gpm) ilitlthbd of teak �J`�i 1:m Ifnr VYater Srtt�dr&iaicctlan Y6►eltl» In udditioo to sanding the font to
tim nddw(es) above, also submit one copy of this form within 30 dttya AF
tab.Disinfection type: _ Ammrr+h_ - completion (if well constmction to Lilo county health department of the county
-- v�here cotlstmctod.
horn)CM-1 North(',amtirtnll'?apnnmcnt of tiu.irrinmcotil quality-Aivistnn of Water Raeonrces Ravrmd2 22 IRI 6

Well Driller Sglf_em ut Cordfic Lion ,
F H ,.I 'rtu��(�Uowner.,* j(����IIL Ne�FWell: ---.---
WIN
Addrew
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uez&y cer*that the above refermced well,was grouted in appearanae M accordmce with
all County WdI MeS
Well Driller: �G, �� S SirnecL• _ _ ��---�
CNtficaM#:
Conti diow.
TbtM Depth,
Ga Type:
Wig' U
(, '�wrlmess•
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Diameter;. 4
xeig�,t:
Drive Shoe:
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