GW1-2021-02045_Well Construction - GW1_20210620

Jan. 24. 241E 10:58AM Env. H_ala O 2021 No. 6711 P. 1
V��cONnRIIc�rlax co n r�v_Z�UN
se nly:
ion�'C0 on
i.tiv Contractor inso don: -
;
dt ]twee -
^OA
�llr—:"—�3
h h
tic W CoiauetorCtaroal4oeabtr 1
FA?M I TO DLUfH t+L4 MA
n u �f S I�t`d i vl G
�.
2.wenetuairaaleapamicg: om to rep t --
L►ii�l spplimharxrAemauaeamrparttttt LUt;Cmeay. Yariaat{ex} h h.
Z- 2 1
3.We11 We(d ie&rvell use). IL
waterSuppiffelb 'MOM I To I D
AVieultnml U
C,-W-Mal(Heod4cooliag Supply) W Y(s+r ) ft 1t
_IndubriaUCommaciei OR.W dtml Wece[3upply(ItOMO)
lrriP9ttattZRM T- ��� ]tI'Ettt�d dbftTtJt�i
Noa•4YaterSuppiyWel� 0 Q ,• '1r�/y Z� f
Mrs dxe�veTy m R `f-
eedoa : —
_ AquifdtRcct�orgo [�GmundweterRemedietion _ _ _
St=pandRrsuvay mSaiwwBeakr TO U&r, - -
_AgviforTcst dStannv ater DMiaage $ I m
Fa?ximcmalTcd wnlogv Qsuh3w mcoffiot & ILC,eob w(clalaa Loop) MTrscer
ro asaczu
C,enrhrYmat(Reating/C8o! Rettafl Ofliei underftZ[Remtsda S it d G .Y
t.I1ALe WtH(s)Completcdt w - r .•lg�F .cl, �,�T^'j•�� 1
51WeDI.oeatiam S � a � G/
l &
FaaligiOwn.KNaw tL h
�.Lafitude and lnt�l Coe to de�ttxslminatulmonds or deehmal —
cirraau J
tv w
6.Wan)lhewellmerrer—eat or QT.-P-7 s Wdlcom c r nape
By LD2B tJis fa .rhre6yWO chat AS 14W for(WSO eetsaaad a oo:crdofra
7.Is ibis a repair to au eshfing well• E3Yim or o .ul,lfit aC.t'L`02C.d1AD w Il! C d2C.d7M IrT C�:sot S�+dcr��d m o
jj�hisftargai�jiUwn6a�,rctrm:trr+,rnmrlafaranrianmMetplemdelmamafJx �9Y�d¢s.�teefdLarDrtalaosid�peErbcJa�rac:
rr,�air mdet�!rewarls zeedOn ar an the bath of d>itfarm.
U Sift daWa>s or atitCWntll rref3 de3liEt
&For GeoprobelDPT or Closed-Loop Geothermal Wells having the Come You may vso ft beck af dm pegs to taavic�-- wa sr?e ddmis or well
conmetioo,only i GW I is needed.lndicsto TMAL NUMBER of uelis cammxdw detmis.YOU my alm attach rd5ti3oxi page if amenmy.
driva&.
9.Total well depth beiowhaodao Em 00 21a.For AD WtB� Unit[bag kM WWI 30 days ogeompletiat of well
Form,inykvdtrbsr aI d�yrTa yd fc s�2 Do-) cow to ffm agommam
io.Static water level bdw top oraliggc �Q tom) Dhvigaa or Wsmras art*&infermstim Froceulog Unit
6rwaw Irwt u abowcnmgCosa'+• I la-I Usk SrMee Cc 3 ,Rslekk NC276994617
(Y !
]I.SIIrel#tllL diastt:ttx: {III.) jdb,For iniecliar WW# it edditica to sendneg tbt Jixm 40 tht eddtts in 74a
1 above,wisp its Cale cow of dds:then utitl>in 30 days of camplama of wdll
it wen consirmetinh Atoiltn& Pyupyrbpo i9 tLefpiitwaog
C�m_vourY.uhte.diasipalk aa)
Dbuim ofvmw&aoaroea,Un,iagrkmd InjCeloa GOMW rragram.
eAo UFI'rgb QMUT V VMT 4 jrw V. Vat Id—a 0 ra le.T.;et,.TSf`""&.c,