GW1-2022-03329_Well Construction - GW1_20220314

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WELL�O�T�'RUCT�ON��
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7.Well Cormfuellon Permit St.
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3.IN[iFie(eked well 113CY. "ia.sc N [c IIaB u
Water SapptYY Well: +retoINS
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e_sideniial Watp•Supply{�ingla} ¢
t;leothct+lral(ROBI n IDOOtins Suppl l) p
lndusiddlCommemW 101ta-t& MI WOW SuPP1Y(8bitecd) L UT L � sscA
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Non-Whow Supply q'ci4 f
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in action p" R
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hsidcncc Cotttsol -
E)mcrimental Tedionlogy ypG
Geodtemial(Closed Loop) t�• x
Cientllamal Ha - ReIItlal Other Ilia ender{t21 R,ematks) � te. l �� te. .S lA•N t-�-t"
A.ilateyVdi{s}L"tNtePtetRd:�'6.�.,...�-.--•,wett><nu �- .�a S -
Sn.Well L""dari- i) n. �lTSte' yQ ANkJ c—
facaliFyfo met HMO . Fnalihr[ C �p "r;. F .+ q i7 1
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ii-5'-v'.`tly.*.yi fl. �:'1�;.•L'ti..�::.�t.:�i..
.rib.Latituda nod langltude in degree 011111 ttes/secoadsardccimni
61%vo11 ffctd,ant leMolnl in swiicicnt) Af
S1>itimnre of CAM red WdlCoaumw
pale
6.le('RM)Me wellogi'a nbu or OTeamormy mar )rnanrnfrad a,aeannle rer
Iry arRnfaJJ lisp;film.!het dev e+mrN [lint flirt.020 l n 59andardr rmel rhm.e
ndrh JSA;Y'f.'A4'aK.4100 m'TSA.VCAC 4?C..OXrDWdlCmtrrrr+�
7.t:i flits it re Pairto aneldiitlagwdl: �Yas err No r�,Ppr filrtrncmrlharbrcnl>nDutrimf tr'filewell ftww.
lr'ddr ico re{rolr.�Jl mrrAmwn mcll.+oas+raulM+�Mipnmrd F,plirh+!}ns unium�riha
+rryolr r+ndcr n 2i ralnnlPa suxtfnt ra mt tfi 1K+rk oflMs f°m'• gHenem or ad�itlo>mt well delftli9t
1'aa my us n e 111c bn&of this pv*to provida addittont►l fuel[Aim demos or well
R.For Geoprobe/11PT or(3cmdA mp Cieeryortnal Walla having tdc snore ci)RAuuciiari lirlails. You MAY alse'ttltach additionst PRW tf i=ffiary.
unnsln+ctiem,oaly 1 GWt is needed. ltrdim[o TOTAL NUMSMOf�+clls
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�. rotTt srelletcp�pe lori Jana aperlacc (fkl �bt sbrN yi!� 9trhmh thin fottn•vltlrin 30 day9 of cOmPlelion of toeli
r�Trn.urNplcw�llefis�nlidrfA4ej.ngarnnr/psampA 3tF7+.TQA�aud�110U7 Cn[{91ltIClSUReIiltIG1�1014�' -
ill.stator Naterlevel betaw tap of ealfiRg: ��� Ot.) Division orwatcr RRwturc�.11ufi►rmitNon i�GRM6�UR1t,
1liAT tiWl3etrolca CatMr,li1tllgh,IVC27M§IS17
1Punier U rul Is ahisu cWrg toe'/a
li.Revcheleedtitetatcr: t' �1{1,n.} t1 fib.Tier Isi¢Ctin11 WLW to admtinn IO I�RdiR$tilE IbRt!W dIC nQ{II>7�in 24n
above,Mm subrnh one copy oPtt is form willsi[t 30 glrys Of tmmplNloa of well
12.W0 emstrnclion methd: a misltnctinn to the foiinwiR�
(i r..+u+gc,-in.rabk,oad pub.txe.) U
DlvWion at Watef Reaouroeg.UndergM ld fq)eetloo Control Program,
Center,Ratdgfi.NC27�4. U6
FXM WATER SL7 .V WMLS ONLY.- 1G46MoR9arda
?era jtor"Jatcr ce v B�ioieetion WttL� in Addition to amdhtg the form to
13m.Yield iRirm) Memm of test: U addtcss(as) ahtw>; also ambqut Otte copy of it"tome artmin 30 days of
tamptction of Vveil ewrst<roction•Eo the county tallith elm imml of Me CetnllY
tab,t)Isiofcctitm type: Amo�mr. whore COMUROM6.
I'nnn C:W-1 Worth eam+limi Aopmonent of Qmt1ity-r)ivis+nn orwam posournaR RevlfleA2�2 1�I ff