GW1-2021-03348_Well Construction - GW1_20210603

.. ..,�, 4�I (GW 1) For Internal Use only: �
I.Well Contractor la[arotttlon:
Wag C.aotridarNtune Irl6DRc TO D iF9Et?it
tL R.
NC Well C,oatnatorCat£ScatJion Numba
s�9 tt•F. � �,'1���� - tip-- Aft
OVMCAEM
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2.Won Construction Permit#: 1:. �/5 , PROM A TO DL4hKn MATERUL
List all applteable wall s+wuoustlon nwitt(l.a.UIC,Couxv State,Fartowe,dte.) ft. R. ta.
3.Walla Use(epoch wen me): R hL
F.
Walar Wen: WM ro a AMM 11 MOT SM 'wc—i erss 7TIR"I
AgricttitttmE DMvaicipallPubiic tt ft la
(Heatiatg/CooFmS Supply) Residential Water Supply(single) IL R m
ladasiria!/Commercial
ReaWantial Water Supply(shvW)
prim TO htATOUAL EJKIti.Ai:&M9w METSOD is AMOttItT
Soo-W&W Supply Wag: 1t. fL
M Recovery !L
E
arge [3Crtountivmter Remediation
ge and Recovery D, Salirtiry'Etaaier motet TO heATtMAL .ACRhiIRtV'Y i tsrmw
Test DStormwater Drainage
Technology DSubsWewe Control tt. tt.C�d Imp) Tracer` � _mtohs � Ta oox aobr .Wretc a./Coohin Ra tunt t7ther lain wider#21 Remarks
IL
4.;Daft weir:)Co : _ West mar
3a. $I
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Facitsty/Ow ietNfmp. ._ .Facility IDN(ifapplicablC) O
h'
a /
ft.
Pbyaiaal Adthaa,City Zp f t
Parcel ldaatiscatlan Tao.(PIN T).
3b.Latitude and longitude in degreWminuteslaeconds or decimal degrees:
(ifwell fall,one is IMI is auffioie:at) 22.Callficados:
6.blare) a eroasiaeoi or Dumporary -Siam aMe of Certified Well ConQsator Date
By si8+n8 Als fom I hereby cero that the wells)was(were)—ttst W Is d"vrdm w
7.b this a repsk to ate obting well: 13Yes or No wtth ISA ArCAC.01C.0100 or I SA MCA 01C.0200 Well Constrwm Standards and that a
ythis is a rsgWn fitl ma bum"well comMuction Ir faru ao awkin the nature of the cow of this record has been provl;dW tb the well owner.
rapntr rtrdiar#?/rrMaa#+sattare or out the back of this form. 23.Site diagram or additional well db"lfa:
&Far Geoprobdi}PT or Cla»ed•Lotrp Geothermal Wells having the Satre You tray use the beck of this page to provide additiatal well site details oz well
carnststtoticm,only W%l is needed. Indicate TOTAL NUMBER of wells coa~tmction details. You may also arch addido®al pages ifaaeceSsary.
drilled: /� ,,/'+ f RUNE["1NSTRUC'TIONS
4.Total well depth below hall surface: / � (�.) 24a. fff„A Wells: Submit this'form within 30 days of ootnpietion of well
For nddpk welts Nat art depths y4L*ffe t(aa mppte-s@2tW aad 2Q1 tiTP) construction to the following:
/� i61'f Mall Servtttx�4"�
10.Stade water level below top of tuft: ��
(-�' ([t.) cee,Inforartatlos-Pr"Ming Unit,
rv*►aver is above va0e,use"+" . .
11 e+aber
lI Bardloie"dltAaater: / (�) 24b. Ill aL tQh�'-lit addi$or►t4 aeading the farm to'tlia sddt ays'i;a TAa
above,atria submit one.IDPY,of thi, farm wid&3U days of convigtson.of well;
d2 Well eometraetlett taeehod construction to the following:
o.a aoaer,rotary:ctibtr direct poet oic.}' >iklvt:lOID of Water Reeot:roa,Ui
o d I 96 9 nt 6 Fropum,
163$Moil Service ICeoter;
FOR WATER SL?nY_WELLS ONLY' � SC
13:q.X (gpau)". Method of test: �'�7. _. 24r-i+or WAtcr Susnly 6t"Igo'We3Ia `1n additiiin to sending the form to;
the.a4&*sa(es)._abave; also.submit'am Copy-Of thia..form within 30 days of
Amouot:, completion of well coustrtux%on to the.county health depattneot of the county
I3b.tJidottmcttoa;type: wh=constructed.
i
Form 4W-: Nortb tasrohns Department of Envumm"Ud Quahty-Dtvu:ion of Water Rmoatoed Revved 2-22 2oi5
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