HomeMy WebLinkAboutGW1-2022-09666_Well Construction - GW1_20221027 828.622 72+41 p.1
f=ot>16 4005;43p Cleannraier Weil Rrilling ;,;;,�,.,,,r,.,;..�--•
WL 01'd�'rRII T)G�N RECC�uIa 4GW-Il r For Internal se nly:
It C.netraetar lnformatian: -�---- —"
t ZO ES pg9Cat
T -
SVrI!C.rntoacttx Name _
---------- �ltvr, cdren. ae Its
>t�G Well C.nn�got�atificnrrnn�1+:m1:nr n I ( Q t M $R TO pry/ 7U ffi3 MAtCnrAr
t_16.INNER C iIYG Ott�'11 diprwl
(.:e;npnnyNamn 1 T� C NAtti'NAL
h 'I�iJU✓� hu
7..}Yeti Construction Permit ri: � J �----�*^ ft. it.
(dst rr(t igr/,l(rnhfa+va11 cnncntrar(nn purm!/r�La 1111~CanNy.Sa)!�YarUrnca e(r J i�
4 —
3.Wdi ifir(check well nse): _I� N o� sMMrut tits AT ur.
�Vlitcr6npp(y�Vcil: -"oTvi ra �
Agrictdttual Munielpamblic Q o- o-
Geothermal(1;eaNn(g/ConBrtg Supply) R,sidcndal}Valet Supph_•(01191) it, ti. io.
[ndastriaUCnmtnarciai Residential Water supply(shared) e>�a M lab w t)Nr
.rp MA IL
N. �tnlcrSupplyVlalt: it
A4onitariag it�oven �_
lnjcclion cil: ft. R• :,
Aguifa TU,4la%r_ O()roundwntCrltcalediltinn IA SAN VR pAC t ilei
t t, (n M atrl►tan
Aguif:•r Storage and Recovcrg OSntinity 13anier
7leluitcrTrst r]SmnnWAtcrDroinagc
Laperiarenrai�'celurningy
Subsidence Control tat. it.
C,cotbermal(Closed Loop) DTM.CT za Rrt.L 4 ■� . .K
M �
Cicolltmua►(Heatin Coa{in Rctum) Qltler ex '4S ude nr tl21 Remarks) �e ir.
4,nam.NVeM(s)Completed-.;-- —� �all
,SO WciI Umflon..
l sgiit�s+i)anar}lame Facility[no(ifMPlIcablc)
>r.
b,,.[Addr..,CIT,and Zi
uff
_ _
Car+mp k'ared Fdantilirattan Na.{Pl�tl Info an Pmcw rwj l.lrtbS
51).l.OW&and MnAIN&in deLtrmdmllu►tesfsecandt;ordecimal degrea.'
(it wet!riald.one Monginsutiicicni) a 1 i:e 4ationq
r�trr aNirY tidnnlureefC.�1(GedWeriCoud'aaror � �`
is{arc)the wails) Pcrmanerte os' �.,r��n emwnw cd m acsnMnucc
�,.er(mrnR rNt�.trn,f Bcxly rmrr[j:rhnr thedl(eJ am him
lallrisarcpairmancxwtingwen: 'es or YpaZr.dl0Dnr1SANGACO2f,.r11aDWrltCom+rnrrlm►57amiarrl'pa,(ehm.r
/ffhevfe:7rcpn(a((1/Prrt�'nalt7Jtw+fi,la,srr7WAA►llrarm 600 and rsprOtrr7hcunruregr'Jhn Cnnl+nfilrlc hM.11(+Olt7+[•C+)�)mldWin1ALlv ell nuft%
0-17111rrmder001mmarAyswimnr^nthahockoffilbjnnn. Z,y� dlpgnrporadMorwl wall didailat
R.Mir GeoprobefOPTor Owed-lamp GOOMartnal Wclh bAviag ihr.-tine 1'ou may use tltc back.of this page to provide additional weft site dletnOs or tcrtl
mminslnretion,only I GW.I is needed. MclicatuTQTAI.NUMBFR of Nvc11c cr» i°u`irraits You may alm attach additional pagac if in:cessety.
dril[nel:^.... ._.....�.-.. - �fe1���A1 lNi►TRtiC'r[t)R1S
rak21 wdI1 doptlt below land rurfmc: y (R�) 2qA. Cot a. ii WAIA: %bmh this'facet)within 20 dais of comple)ion Of%%til
ImrrNnlffplcMrDriitralidrp)i,cJifrjr¢rrnr(rsn/rrp/e-3[n�3pfl'Qndc�e}[OP1 ) cones. i ion in therallalVtng;
In.Statiie waterh:vel bclaw tole of casing: (11:} Division of Water Retiaurrees.lnformation Prrrcessig�Uidt,
Ire'nlCrrincl(srrhrMcwc/Ag.rne�"•/� / 1611TA'l4s'w4kcCcuter',ftedgh+14C276"-1617
t9.Itnrchoiedlameter. �` —(;^) yth BE Injection♦Yells: Ai addition to vending the fnap 14 rltg O"ffts in 24a
ai)9ve,also submit one cow of this form within A day.q of complatlotr of waII
Ix.Welt cnnatrrletlag method: r O elva action to the f13116VAng
0 c.Mgr•,miry.0".olrat pltsit,etc.}
Division ofWater ltreinirmi.Undergrannd tlndtxt#on Caa1ti11 Program,
tY3RWATRRIS PPLVVVE,LLSON1,Y: ifi36 Mail Sm'VICeCenter,Ratc)$M,AICM94Ql6
13R.Yield(QpGt) L � _ Meth1)d te3L•2 1,01 zw.r' r Waicr Roaolc&is man Wells: litaddition to swuling the Ferro to
the gddrrss(es) above also submit one ropy of tbls fbim WIND 30 deys of
rib.p►sinfectton Amount comptction of well constn;cdon to,the county health depariinenl of the coutrt}•
OTC - - "hole ewlMeted.
FOMI Ow.l Nonh[.meii+mDarmmaent of r?n ininmeneil Qun111y-0M.-unn of Wmet Raaumces ReuiaeA 2 22 2a1 t
Date: `30
Well Case: Well#: O C - (D()C)
Name:
Address:'F U O-� '
Lti ,
t�G
Pump has been installed, well head ready for inspection.
Sign:
I :