GW1-2022-10768_Well Construction - GW1_20221208

Well Con/a�xr&anu R IL
CN Well Cmunctor C,,*,o-N®bet OD G, imNd edweDs b "1 T `� r.'•
Morgan Well&Pump;Inc. FsoM TO D1
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Company Name lEYfflom C'ABIHG OR.T1 'rlo'sid.-Id'15:•,..; x;::..,
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2.Well Construction Permit#:UJ����•�xnn R R
Lie.B,piphaab/e aril rmarivedonPer-du Ae LUC Comay.Sml�mimur,e><) R m.
3.Well Use(check well ose): 17: _ :,'�`:. ;;= .�.;'-:.`w:.i;.:..:.:. ='•
517tEH+Y.: - +•�"„ •' IQUa6 MATHAiA1..,•
Water Sup ply Well: FROTS To '" ,.`~-auoT arr<s TMC
.9Sicultuml 13MuuDicipal(Pubffc - R
Geotie>mal(Heating/Cooling S Pply) 111'es de 'Water Supply(single) R R 'D-
Resid®tialWaterSupply(shamd) "'' r"'- c: .•hCZT
>"18:'Cd;OIIL:.+ .• - uavvarar. _ �^rMg1HOD&IMON7f
FROM TO
oa 0 R 20 fL b.nN 7ou
NOn-Wafer Supply Well;
Moa ionng
®Recovery R R
jectien - R R
Recharge
Grouodwatir Rem on ediati :. ^...... .... . .. ..
..39:SdND/I�AVEL'PA 'r - "yca6R
Storage and Rwd;mq 0Salm4Baer FROM TO
DStormwatrrmDratnsge R R M rxarar �LAC8MF1'11'MgfR(N
3Aquifa Test
Experimental Technology Subsidence Control R R
3
p��{tTracm :suto G
m II.T�VTAG'ktlich'iddittun'llaYivJsSt...., ':.':
Oeothermal(Closed Loop) [ 2&. TO DFSCRIP•t10N alor bardneq sot9mak'^
Geo���(g - Rebrm) Other( lain under#21 Ramada) 0.1L R a,
4.Date Well(s)Completed:„-t"-� Well EN � R O R ,Y
3O R 'SO ft '�OG
5a.wen Lo1ca ion: R 1L
Fee ity/Owner Nm ae Fem'dty IDd Clfapplicablee) R R
S q ercck o R R
Pbysx.1Address,City,and TOP �•" :' ,-n`¢M1Rrrc°: :,i,y' _ - =d"' y :;... J .d_
County Pmcelld=bfic ti allo.MN)
Cauo
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: tion:
(fwell field,one lavlong is sufficiem) }� �p 1`
35 a�O'� N " la. a `l� W Den, t
71srATCO2�-0100�15AMCACO2C,a2oDW-a
edwdlnmbaemr �`
6.Ls(are)the Well(s) Permaneat or Temporary I hereby oadSY il�m�0 wrll(r)ams(were)rymtrucrrd in occordwa
mwell: Yes or ®Ne ovdedm Ce CO1uN'uion Smndm'ds and thins
7.Is this a repairman enshag ® ropy Direr reard has bemP wn
Ifddr is a repair ffdl out loran arL aruaucdan Mformaaon aid 4P/dv the nniin"af@e
mpm andn#21 remm'krreedav or on the back ofddsform" 23.Site diagram or additional well details:
You may use the back of this page 10 provide additiona
l well site details m well
S.For GeoprobelDPT or Closed-Loop Geothermal Wells having tie same onstr cuction details. You may also attach additional Pages if necessary. .
construction,only 1 -1 is needed bud sate TOTALNUMBBR of wells
- SUBMITTAL INMUCITONS
9-Total well depth below land surface:
�� (ft) 24a.For All Wells: Submit this form vathm 30 days of completion of v H
Far nm(dple walls'& d1t depdar ijdlgerent(esample-3Q200'mid 2Q1007 eonsuuction m the follovng.
10.Static water level below top of casing: A) Division of Water Res°mcas,Information roc 1617�
$anon level is above coring�e +, 1.17 Mall Service Center,Raleigh,
- 6 in. 246.For Iniectioa Wells: In addition m sending the Hum m the address in 24a
11.Borehole diameter: �—(( ) above;also submit one copy of this form within 30 days of completion Of well
U Well construction method: f-O 1 "`r c®swOtion to the following .
(u eugm,Stacy,able,dvee pull+ era) I)fAdon of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY:
1636 Marl Service Center,Raleigh,NC 27699-1636
__ ethod of test air pressure 24c For Water Suonty s Isubmit Wells: m ed litim m sending the form m
13a.Yield(gpm) the addresses) 'above, also scti one copy of [his n to within the
days of
completion of Well conSbUe ioa m the county health department of the county
13b.Disinfection typ `�Dunti Where caostructed.
Revised 2-22-2016
Form O4J-1
North CMHUDepemocut orRavitoumeatd Qualityim-Drns of WetetRaomca