GW1--04096_Well Construction - GW1_20230622

Feb 1519 05:43p Cleatwater Well Drilling 82e 6224241 P•'t
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WELL UCTIc RECORD(GW4I f nr 1n cmnl U n Cn�y;
1-Weil KW lore aiC on:
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l/ WA �TAI 1
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wen ctot Crbamc —'!R f4 .
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+1 encentmoorCatifiealiionMember W
+ {� f �j t g >TNsl4R 1" If. [.�1 �1 I�l 1 �?'t.�2�_ ram:!'_ �p\J
(� �: ski 1 ,`�. ►U
Cempors Nama /L li.!d I. .. tt 1 . r i ...:.:.," .
Lt
2.f.Yell Commotion PermH P: 2 - �., g �, tn. I
UN all P(illenAfewollrnnrin+artenpwmns(l a UlA Cow,dYatc if v,cm.
3 Well Hie(cloth well me): 1
WatcrSapis(1'R'e11: t7, his tn3AM IX Stara=i l MA'AM.
Agriatkuntl unieipa IPubllo 11 anti n- ht. I
a Geothetmal(rfeado (Copltngaunt') ,),r •ciidmnial WuorSuppiy(tangio) ^• - I', ie.
TM tadtaa hialiCotmnetora1 r •'t5itIcmtal Water Satppiy(eharai) -� • a I
vo
Diet-WOW Supplg WO .,-T:1',J r L' „^) a`70 ' tY i L J
• Monitonn ,e +� Remaly ft. h' I
ifjeCttsn IVO: . 9 Z — IL R` I
Mil
qufe Recline a vy '. �V tirn�{a water Remediation —
.1 9riA L PACts I 4
AquiferUMW u 4 R cnvee+,� asr,,, lini1Y Bonier _ Ql pl n. matt g attuon
a Aquifer Test n,-. 1c01164;r.0d " tlulitwalsrfrni r"
II iNti:crimetnal Terloology DSubatdmea Control O. P'
•
$Geothermal(Closed Loop) DireseeE �I�pflll3.p�lti IiC1MIal ' :•_ _ L
a acott fiat Heathy: -�1 ,Mum lr Oita ' ,in under41/Rcrnarite -1N[dfR '`I' � + LL' .
d.DAtoWin(is)ammo: Welt 0W •b r< ` ' 'r6 () "(LJry I
o ff. '1a (1 I
No.Weil Loeetinns-- �r a •
a-r JD rc1CLO t n' alai a 1ty
Faetlitas4} erNamo . Facility►1241RapapiIc k) d' ft. I -
LAW ad C sines Li . i nctusoj-)i, oR
Pirlau A+ldreau,ay,and zip
Cwmy , Antal tamitiicatknNa.lpRdy , -
6b.Latitutin led iomattttkindegreeclmimtterrsecondsordecimal drgrecs~
(ii welt fbctd,ono tatlloaitHaatQ+ E) .�� �2.CardR
S�l fl '�I. l 4 � 5-Z3 -ZI
6.Retort)the vrdt(s) imman �1 ent or rempnrat3l
3il{tw1 efasttlied4klica tiara ado
,�,[ ivdrimwguret r"ra,1 henonpamr fy smut pre nap(*baba gleam) +al/4 w ikr aardUwe
7.io this a repotrnt an orbiting well! Eyes or Vie welt t3,fratCt C.AlDOorISA 11C.ACO2C.W WI I Cortvmcrimeshtt trd and JA Fat if
fi".;rorr7alr.INowinwwn well eansrruerrantq>Frem:tnn�rtrf�eerth:aurene rpm, aIlliaf1hisrreordhnr7rrrh Praia lodge wtlfmater.
moir raider 1:2I remarks Avon am*Ire rkefrhrs,(8ret. 73..E diagram orel dignail well delatt0
S.fteeCaapmtreillPTof Cleisat-PAnpGealbm sl Welt.havifnthcsassc YOu 1l tl90 the bnek Otitis ptsRO to ptpYldoDtl al WI aJledtRsils or wni)
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t�atammtianennly i OW.1 is needed ilidieuta TOTAL NUMBER orweus i1Ot11R1a7R. Yon my also Machtathll(foat6t pages If nttacolery.
drilled. _,,... . . - 1���10�tTRLt
Ix 9rawt wotlaaptA Maw Lid antlhee: 4 J 114 bra gaC Io getto submit Intl than'within 30/days of completion or well
IraramitIplcwdrtli alirkyhtintrewot{exnmphr-3nNllFatulst�2taa'1 consg toutothefollo :
IC.Starts•water level Maw top of essatag: a) DMltoa at Water Resuurces,ltdbritaIlon Processing Wit,
Ijetitertirccf Ire.vecar na toe f "%i O 1617 Mu Ronk';Center,Releigll{111CA7699407
IL Bot•eltoledimettx: IU I I 0 Om) ?dll,.ititr nlee icp Wenn To edd'itrat to Pendio the Awn 10 rho address In 24a
12.Wen construction method: t U+ atom,
ovetl:sU,alsoore o h fonecop or this Enna within U days of completion of wail
ito,auger,tabar%cable,alma paikotp,1
Division afWltxr Resources,Thi ugroand Injection Contrail Program,
WATER en PpL7f swiLLS ONLY ttt361HrtRSlraIne Center,Ratr�iii pIC rd?b9)�16�tb
t3a.Yield Woo ` - Method er to n ?r7C�'wlter.b@�>:et fiats n wets to r�MaRtolt In smd6l�me Rom to
the bahibress(es)above,also submit.one copy obit!'this fbmi whliln 30 days or
13b.lkb.tnrectlrrm try 2►mnuns rampt.don of Well construction to the county bdelth depifinent of tht county
where eonntt*cmd,
Peon OW-a North Catt6mtDcaaomantat't9awrdnauataiQaellOP•DiviatanOWelts'Rwanda RavGed2-222016

Well Driller SeIf-Greet Certification
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Owner: G .ct brCC9 _ New Well:
Address: b(ci Ches�/��-i`
Permit 2// f 07/'J 1
I hereby comfy that the above referenced well was grouted in appearance in accordance with
all County Well rules.
I� n,
Walt minor;, j o s/L WNW g Sued; . �- �� _-
Cerdi �Ii31 :�.,_
Construction: Grout
To Depth; 4141C ipe: ... CO W j,
Casing hype: Tli�cNs:Casing . /)U ' b
Diameter: 0 1./
Weight/ de
Height: ,
Drive Sheet
GPM 0
i