GW1-2021-04040_Well Construction - GW1_20210823

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WELL C REC For fitcmnl U le n1Y=
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Wsli ntractnt Iafirtmatio
Josh ply_ �S "' T>tRS
1Veil totttraela Name
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2.Ivell Conistr Ieft Permit ft. tn.
Ust all onlAlattrle wolf mmura071011lMM0 S(1.4 fqr-GoxiNY TMl4 Yarlanrq el�J
3.NVO111Lte(chtek well rase): P. ins n: tAi.
W/teRmopiy Well: M In,
Agricultural tmfcipalJPubiic () h• &
Gcttthcrmal(14o/ting/Gooling Supply) Reaidentlal Water Supply(Angle) D, ft. In
IndusuietlCommercial Rrsidcnfmi Water Supply(sharVA) L>L UT md� atur tt
irll ration
Nnn NVnter 4upplg Well: tt. f4
Manitttriag ©Rceovety ------
Injection Well:We n. R
Aquifer Reebatgc DCrotrndwater Rcmediatirm ! A
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Aquifer Storage mid Rccawry E3sitwity Barrier
AquifcrTcst J3SmffwN=Drainage
Experimental Teeintnlony DSubside=Conroe
11. �
Gontbennal(Ciosea Loop) TO
tietsthtxmnl Heattn 1' Rt:Wm) Gmltu' innndarH21 Rcmarlcs) tt. R "
A.Datewett(s)C:ompieted. _n�wait IDO
Sa.WellLnatdnn: 4Ur 1 -T-DJU'r-
CLI i cue., C�q �Qt - ,�; �• ��,�� . -
Factliq( rner Nam* . t pad i 09(if:giptiealdc) 2 I
t 1'f l -.s u1 iy L M Layt
crap Addrecx,City,and lip
C:mtay thtteatldamificstinnNa.(PIN) r,'3t `ice r,,� rJiy
Ifl��t ?r
Sb.lAthade oat(mmp(ltade in degrecslsalmmteslseeends or decimal drgrecs:
cif,wit Oat,cmabtMangissnfttrUamtil 1.2.Ce lion:
fi.is{gR)Me Me11(A) Perraaaent or DTemporary etc of C:pww.
riaiWdle_aMraater l�at
1, a+pMUMM dux f HembP ex"10 Owl the tM WV Mw Oarrr)CMVMdod!a"W'.. 'L
7.1,titleaccpairroa»exisNnRtvdt: �Xcs or No a•rahi5A.Q,.,j'02d:.IlfOAor15,4W;Ar02C.OMD;Vd1Caw1mrA*)tSdtdxtllrAAmul JAM Ar
Iflhtr is a rcgetr..flN our Amwn wdl lhr."alum grlk eapy afrhts r+xt ff1 hot btAAPmed/n the Welt Mier,
rdxdr lredcr t21 rntanrrls rizatam 1Ttro tin:fti-oflAt-00M• 2:L SAD dlrtgtamm or addhimal wall dOW11ht
R.For GeopmheMllvror Clttstnt-i nap Geoti ot,=l Welts having fix erne you may usa titc budk.of Otis 1m/ge'to provide add&nul wall she del sib or well
wastmation,only i GYW 1 is needed, radicuta T)TAI.NUMBER or�.rlls CtI119tTitCtilnl tltYatlS. YOu ntBY also Rlptch Rddili0rlRl p/gts if Roccesary
:l'.Votal wall deptit Inlow IRnd sitrAcol (Rol 2,14. isor___ 1�: ��his,form tivithin 30 days of t ompictitm of weU
Inrmnh/prrxrgelit+alids/Ale'fd�ernttr(eexmnM-9tiT+1I10'mrdi(tAfr70i Con9muianto the l'QIII]vills:
itl.RtRtic water 1ev41 bellow top or easing: La _- (1tJ Division of Water Rewurees,10114 nnatitnt PrOgwidg 1)1fit,
/(xnrdrll.vrtlr�tivledcm/ng ttxc " 1b17 Mal Su-*eCentcr,RNltg'X?(Cx7"?-18t9
IL Rorcholedinmeter: 24b : In am don to sanding the lbtm to Me addrM in 24n
move,also I mit one copy of this fort within 30 days of compledOR of well
12 Well mmtraetloo metho , � � ra>'ttsttnction ra the followillgr
t t e•mgic',mtnq.cable,dirtt:t ptuh,ctc.)
Division ofWatcr Rteotrrc %Undc/gmu"d itijKIIcn Control Program.
IT, WATER 8 :M V W_RLJ 4 ONLY: 1636 mail Service Cea r,Ratco.WC�96"4636
M+ethntl of lest• _ x+�For Water Caaels&iaJP"o Weil/: In melon to sending the faint to
1311.Yield lgpllt) the addrw(es) above, also submit one copy of Ibis form vANn 30 days of
rib.Olsinfection type: amount- mrapletion of.yeti consttaetion to dm e4snty howtb dttnmartrnenl of the county
Prhm'a cpngttacced.
I'mm GW-1 Northl�aollnn Dapmm�anr of retr�lrtiamenraT�mlity-AjvismttoYRraIM'12aeanrea, ReviseA2-22 301 t5