GW1--04282_Well Construction - GW1_20240719

WELL CONSTRU � 7 r f 7 717:sc s ':
i.WcH Contnrtor tnrorrnation:
Robert Teague 14,WATER ZONES
Well Canuscmr Namc FROM TO _ nfrtCHIFTTCI,� --'
!t R. I Ile
2857-A
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NC wrn Cannciet ce t lotion NQmb,-r
!e.O LA9tNG Ltl'ILR
8$K Well Drilling Inc FROM To otk TFt+ THICKMMS MATERIAL
0 re I _ft. ,l 6tt3 In. avc i
Compaq)Namo M INNER CASING OR TUBI✓'ti; therml tiaad
2.Well Coffitruetion Fertnir N. FROM TO I OtAMETFR THICKNESS MATERIAL
Lai dt appfkvNe+.e,'f waetru::eaa paimie..fi e—'✓ .Cowio,Stan,Variance,ere.)
1 well UN(tbctk xEll use):
d
Water Supply well: tt,SCTtBYN ��
FROM TO n1A41ET SLOT SIEE TH tCKNE�.e �IATLRIht.
Agriculatat QMunicipabPubitc ft. in
(koE#,aamaljHeaung`CoolingSupply) OResidential Water Supplytsingle) fC ft. ! in.
indusmalCosunercial QResidential WSW Suppjy(shared) Is,GROUT
N"Irrigation FROM TO MATERIAL [MP4ACE
"on-Plater Supply Well. ft ft ME7 TifFTHOB&tMtSL�NT
Monitorq Recovery A. ft.
ejection weA:
difcr Rcch ft.
A it
q wSc QGroundwatcr Rcmediation
Aquifer Storage and Recoven Salinity Barrier 19,SAINWGRAVEL PACK
FROM TO MkrUi—AL ENPLACEMEYT METHOD
Azlurfer lest �5tormwattr Drainage ft. rt.
Expenr=W Technology Subsidence Control tL tr.
Geothermal(Closed L,04) Tracer
20.DRiLL1NG LOG Attach,dditkasl abash ifoecaury)
Gmrhmnai Hearin Cooin Reruml Other(ex lain under 921 Remarks) FROM To i ECCl"Wit) mly ors nvn�nta,trs�
a.Dale Wd](s)Competed
��� well illy L
Sa.well Loradon;
rL rt.
Facni , 4J'l 1 h 5O VNI
t}`+ihoc Nano
ft. fL
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fftt C ( •tI , 1"� t 7\SI.M/ h ft. ft.
fL ft.
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Pared tdentr:uation No.(PIN) —�------�—`
Sb.Ladtudc aad longitude in IaE degrm/¢do Of well ates seconds or decimal degrees:
6r 4 one MAA rs sutT:ctcat)
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22.Certifies" n: "----- ?--- —1
6,h(are?the wtli(s)Ope�an�t or
®Ternporan 6 c of Ccmricd 4VM!Cnn ��� („ a•—L._4.'i�i,_.
7.la tills a repair to an a xstinb irEtJt or ON. Bc.Igmhg,his fa», I hrrrbc cr,h Date
tf relit a a n^nxS,,,TtI our krwun wet!c-ell r'Y�''��±��I/y h 1h,rh,e uelllsl xnr x-, t
repro,y bps armnta,n and esplaa the nerure nfthr <ropv of hLrecorrit h¢�100 of/3A hCdC.02C.UIt)t)Well Coe e)cua.rtrverev!fa ac�wrdaaee
-'t'+,+*arb.zactaaa.an'he ka�thrsfor...; nrlruclrOq$tandc f
hear Provided to thj pelf owner_ rds aad rhet e
B.Far a. aly I DrTor Cl-4- 23.SltE diagram or additional well Ietails:
canatnstaioA anly I -t is needdo. Indicate TO TAt.-NUMBER of wells You may use the back of this Page t�)
9.ToWells construction details, You may P g provide additional
age well cIle details tails or writ
9.local well Y also at=.ach addiNonsl pages ign� ,y�,
Fo nur y ea�owlaud surface:��j S'<QMITTAL IN TRUCTItJ t
Rrtu dfd7fferrnt iecaapre i¢rBU (fL) g
Ilk Stat3e warm level bebw to of a nrlitory> 2Aa. For All 1Vells: g
40 Submit this fi)rnt within 36 days of Completion
Jwr:.-ie,e1 a at,e r p �aluQ: eonstructlon to the('oolowing: n caring,use of well
rl-l0ra 61/8 ( ) Divisionof\3 d�nseter. ater Resources,Information
edl +nerli (in,) tab.F r I 16".S'lail Service Center,Rai Processing Unit,
l2 w nsrruttioa Airh `C 2�ti9917
aoo,, abk. n ectlon 4V let: In addhion to stndin t I'
e+,z?avd�ete above,aI50
submit one copy of this g the f o tha address FOR WATER.Uppl y%, aonsuuuion to the Following: I'onn thin-g m.4a I`
ELLS ONLY: Division
oF=ompiction of meld
f�,meta Division of 4V(CPrn) star Resources.(ncer�
Method of test:Air Flow 1636 Mail San bound Injection C
l3#a.oisintetdon type; CtLlor Tabs 'ice Center,RaleF ontrol Program
_ 24c,F r WR er S h,'�C 2'769g_I{aib
---"_ — A nAunt: r t.<t the a ddress{es} aho do in addition to"r'ndmg the furrn t0
.. € va,.t _ completion of Hell e.also submit Pia
Where oa copy of this form within ip Con,CiYt,}4(ed, eCtF1StT11Cil,�t0 ya pj
tt '+G h Carszlr ,:County
rueparz'rM:nt4tkavtranrr�nta€Qaatrty.pro<a.on vt wait, health depanznent of the Caubty
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