GW1-2021-03604_Well Construction - GW1_20210823

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8•for GeapraheMPTOr Clnemd.•iamp(,eolhemtral Welts having rhesnrtte ),an may use the tack or this page to provide addi well silo dmlh or well
exinglr"c('fln,llnh 1 C,W 1 is needed, fndiMM TOTAL NUMAER of-.•rli., CrN MWinn details. Y011 lady also Ofth additionet page&If ndCmmy.
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i'^rranhlalewrltaritrelldepllu frlj�'ereae(e:canto-3f 1 `anril�AlQP9 4h, ft All-&jib: Submit tRfs IbM lYithin 30 dia"i of cmnpltdion of well
ettngtttiction la the f�lotsiag:
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l i.lbrehotedittatetcr. (in.) 241%Far_rt�rNon W ls: In,addidm to handing the Porn to gro wldtoes in 24n
r 2 Well constrdetlon met6ttd: ro'y-aj L�,j Owe,also submh one copy of this form within 30 days of t ompletlirm of well
(i c,m%-,mmry,amble,dir"I pti6lt,tKc,l -- cmMation to the following:
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R WATER A PPt Y WFt LS 0NLV: Mvislon ofWater Rrmwf %.Underground Injection CoMMI prograto,
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YieldMethtur of test 2 0,, 1?or Water SanMy& loellon VA inuddifion in sanding flit farm to
A.1)ia'rnfcemtan typo; the addrd;ss(cs) nbovu, also submit one!copy of'this form wllidn 30 days nr
Amount. ODrapletfon of wdl Consuuexioo to the Cimnty 1WAIIh derpntttate:nt of the eormty
wfwre conAttrtxed.
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