GW1-2021-03594_Well Construction - GW1_20210823

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WELL CONSTRIIG"!<'ION RE—Co '
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Physirni Addrets,City,end Zia 21. ItKS + *JJ1
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i.l,rhic a ri pate to nn existing vycll: Xas ae }Nn copy nfthls raved fiarbam prilowIn the M:ll mums.
I(tblt is repair.fill rntrl'liattvl iodl emminicllon krArnatioamid exprmn ihe ann,re n(thc
,mir rmr*r,t?!remnrlr<accrlml M'anilic bark oflbtr fomt• 2;Site diyg"a or additional We11 do"ll9t
R-For Geop-heMPT or aowd-lAnp Geodbm•mni Wells having the same foul ins'Lisa file back o1'thia PW to PMvida eddkiOnal well Stro rlmils or wet]
oonstnirtion,onh i GW-t is needed. ritdicao TOTAL NUMBER of-Writs a 3u UurAion details. You may Faso attach additional pages if tl8eeSs"
drilled:_._� __ ammulAUMMUMI
1.Total well depO%below land surface _(�! 24a. BAR Weila: Submit this them within 30 days of eomplf"on of well
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ail.*Rtle water level befew top of ensiagr `a (il.) Division otvi'amr Relult irm%A Information Procanft U1111,
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li_liortehotedlametrr. �� _ _ (1n•) zstl,For tn.� In aftti n o Sending tll�low a s in24a
ldrnve,also submit one copy of this form tvltW 30 days of completion of well
I Z Well c(mstrnu tlnrt mctMld: �� rmtstmstion to the following:
0 C.tn,ge•,mmry able,direct posh,Mt.)
Division of Water Rescurt,es,Undctground injection Control aerogram,
FOR WATER Si:PPJ V WF,LLS ONLY: Matl3ervtae Comer,Itatclglt,NCx7k�^t636
13a-Yield(rpm) , Method arse":--- TACG inr WaMr Quetlty&lfa Non Wells: 1n addition to son
daig Ilu ilatrt to
file nddrt ss(es) above, also submit one copy of this fofm Niiihln 30 days of
13h.Disinfection type: _ _ Amoullf- completion of N9+d1 ansttnaion to chi county hMlth olejlarlrneat of the alum).
vihurc constracmd. I
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t'enn CiIV-1 North Qnaflty-Division of VA=Povatitem Raufm42 22-2016
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