GW1-2021-03762_Well Construction - GW1_20210823

828t22 7241 PJ
1 oh 1619 05:43p Clearw'aiefWell Drilling
C {V r�-.�s/Al- rFnr lntclttni U:tc nty;
�'r 16I.��VYN►7 1. l la rr�`t
1,�+V�!t ootraetnr I (brtnstton t�.W pigs
T� .
r; tt.
well'ContrActgr Name
VC well Cnanannr CeRificntion NrmttKr '( trlltltYl TO in,
CefmP+Ny Nsunn
Ir►
2.Well Contraction Permit t1: I
iJst ak anplicahld wd(1 crntstmalan ptrrgrR.s(tuCtttrtNy Sfalq YarlrmcK era) R. n
3.lVtM ilte(cheep Will 119C)- 17. TA Talc t u
Watt rSgko* cell: tR. d-
AgriculturalviunlaipaUPuhOc IT 1n.
(^reothr riltal(Licatingicooting Supply) idential WatcrStrpply(singlcj R
[ndustriallC.omtaereial Residential Water5uPply(shared) I& iTt' T r+era L
trrl gtion
Non-Water Supply wrJL^ to n-
A4onitortA Recovery ft. P'
Injection WOU tKentoo
Aquifer Itechatgc �(irorrndwatCr ttt:trrcdiatitm tnttj
Aquifer Storage and R gelinity Barrie'
t:cavcry �"
AquiferTcst 138tormwpta Drainage n.
Lixperintental TcctmMogy [3SSuitgidcncc ContrM pgILL 1 e1
Geothermal(Closed L-P) �Tcaccr pltota I�
st_
Ceothermat Raatin aoti Retuml Othor gain under ik21 Remarks) it. -
� + •� e.
I -C 1 Wcll ID11
a.ilstt Wdt(ttj C'.gmpletcd: -- !l rf_ q0 h I ti E
514.WeUl.ocadnnn n, \
Ak
1 v Faclityl51of.mrlieabte) Rt • :�
ikrl - �•�.,
MAddress,C(ty,and 7.rP gl. Alt Pntcel ydautiiicationNo.(Pns}
C aratty
5h.lAtitude gad longiitade in deltrW41miroltesrsecoads or decimnl degrees: Ire tyrdow ,�'
(if twit Gael rme tnt4nna in suRieterd} ti ' [
33'
Doc
sr nrOael{tcJwa g,acdnrAxrcr
j, / 6raly am.iorn.1 hF11-*1'esrrtlfy rhar.,die Ivey(A)xrA firarrJ ct+. ?gt ftd
A.in(acc}tht wdi(aljrerriraDCM 4r n (,V tr}Ir!(g$
\ �j �rhA 1.Lt vrA['A21:-R/aU nr 19A Nf:AC 47C..!!1[i0 It'r.N 4'mtsfrnaian SGnndmdA mnl ohm�r
7.i�tlttsarcpairtnancxuttiagwdl= �i' orZjNo rdnygfdkisirm111kwWP'MPmlq&Atntixwaf(msntrx.
ly'ril'o is a repair fill vurkwwn lved.rons�rnufnn iormatronarrrt erp(mn tln adrnn gfrFv ;L3.5W dlatta•+yn or,.ddl*wW wl•'ll 011011191
r,•narr ender g?(remarks strum"nr'ng fire batkofrrdsfan" you may use the hack of this page to'p Wdo additional VA site dtttsits or well
Welia having
R.for Geoprobeffiff or Closed-l-Anit C*othel'"I
the somt: G gtntctittn tTetaits. You lacy AtWo t'Ittaeb addititmnl pages if nttt�sery.
rx}nwnrctian,onR I C.W-t is;nit er[ tndWe TMAL it1LiMRBR arrsits „ itCii01
a of¢tpnpled of well
_�tE.1 �•!A.j��' 9tthtrrit 9tic fitrn�'titltin 30 dtq
9.7retat,welldepth WOW land swralm;
I:nrrault/pleaellditrntid�jrlhs7fdl�e►.tntfeutmFM-i�d20r1mtd�oll>�7 Cail4lilali(nt(lrhoNOW
lnibrrnatian Prcaesa
p i)f$t►
OR
(ft.) MO of Water Ptmtt 121
t0.$tali+atlt>`N1e1rR1tr tap of easing: ~'— i1 Saralee Centar,Rtttltgll.A1C�7699-61�
61
1b1?NIn
ifi wnterNw.1Is4viveC01ng 14t "l I ut addition to Paditrg the foam to"adre"In Zrin
( � (in.) Ulf �' $' of this form libin 30 days of rxmpitdlrm of well
11.herehatedilimeter:. .1�-- ` dwore,sieo iubmil ant:copy '9
�l /�� ctnattnt flan to the following
17-wet;constrat:tiam m"Itad: > Underglronnd livectton Coact'd Program.
(i..mrgc,own.P*w.diroetpulb.,.t* Dlvilion or water Be ttailtCGR.
l fi36 Mail Sarvtae Centar,Ratalgir WC
a� eale
FOR WATER fX*M V WF.t.L.S ONINt � Irnr Wo 'he Tom M
oer Cott'` p�ir.k�dtln W1111; in addigim trf--Md 83r1 days of
also Submit one copy of this fbnn `vi�iln
13a.Yield(9W) c� Mcthorl of tear — the addKrsss(es) abov4 to,the cvanty heats depalla"t of the eoumy
b✓� Aglbult- ptare con of ed. conststtction i
F ih.Utsinfectian tY1ft:: „�°°eat~rr�' �
1'nrntGtA-1 NoahcmnlfantapmmnantdrEllwlrrinvilmud ln+-r�ivis�r.noPWaterrto7aarenv
Reviaed2 22 2olts

t ..J^�Mr'~ .r.P'..d�'wlirttr^M ..ur' .�...........♦ .....nR'�� ^ •-.
molaft Q `�