GW1-2021-00965_Well Construction - GW1_20210404

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WELL CONSMUCITION RECORD(GW-1) use Only:
L Well contractor bdormation:
14.wATSRZOMS
wenc4nbeck0ftme YAM TD
AGO 15
3541 ft. t<
Ntc wen Caearaetoc NT®bei 1S
M�s I eu s l,�.e�l����l►►��nG, OU=C� soingl4 d was RLtl�
FSOM A3
m � hL
MATlOg(AI.
2.Wen c,wh,,ana Permit#-. 39,34N PIMM t CABIrIG I--- AM
FRO1R m DiA� aaATFnrAI.
Ltstaff afo 6cabk sw cwnMcd +pwmds(Lu EUC comb•.Skft Yevim m ear) R R hL
3.Well Use(cheek well use): d. tL in.
Water Supply Well: 17..SCRIW
FRM TO DSAsa� aLots� MAT�iAL
whacal �Mumicipa!/Public 0 tit
IL
(Hera JCooimg 3opply) �Resrdenhal Wa1ua Supply( ) 1L 8 W
water y(� M GRpU[.
F80M TO MA1EtW. FAQIACIRIEMMBEMM&AMOUM
Non-Water Supply Well: 01_____ Q R. R
Injection Well: tt. tt.
19 SATMX" ffi.PACR
Storage and Reoovay y Bam®r MMI TO 19MMUL I ENUMACEMIM 11
qest
T (� et7onhot � tt:
Geothermal(Chad Loop) 0Tiacxr 2a DRIIddNG LOG add dleds K
RG000"MalFRW TO DFSt�N elver II lee,eua
Retain (e�uunder 621 ltemado) >z bo tt. I5d�e ,50�
4.Date Well(a)Completed: 14jWAo;ti Well m# 30 ti' Sbif ✓Q L�n SWAe""4 rorj4L.
Sa.Well Location: 0 ' 0 DW Q CAA
hit. tr.
Fan7iry/OwaerNlame FanlayIDA(� ) R R
C X`75'bs � 1
Phy3icatAddmss.Cit.-d2Nn n.
G ra�y 11 e, 19 `51 coo �}e;<2h. zl.R1 A�
County Puma lacafficasmn No.(MN) r
i
5b.Ltitade and longitude in deglrea/minnteshocomb or decimal degrees: W R Section
(¢wen rya am fora8 is safes) 2L Certification:
rN N '7�S, w .
6.h(are)the wa(s)ORPermaneat or []TCMPHW y Signaaae al Wei!Cbnfimcw 0 Dam
By sung dds fwm.1 hw*by eestpyy dint f vell(S),ran(wary aansnxctea a:ae,ao d6noa
7.b this a repair to an esisdog well: OYea or RNio welt ISANCAC 02C.0100 or ISANCAC 02C.0200 Weft Censbsaam Sandatdt mid rho a
(fells tr a fill ort bows wsUoorutradlort tafasscatiat and the x ,e eJdn Capy 4fdds rem hw bum pto to die mA owner
npavtinder Bal>rmmi:mtatat oron dabartafd�4s,jaau.
23.Site diagram or additional well details:
&For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may an the bad[of this paW lto pwvWc additional well site detais or well
won,o 1 GW-1 is needed hdicale TORAL NUMBER of walls ooashnction drink You may also attach additional pages if> sary.
drilkxL-
SuRAIMAL I NSTRUMOM,
9.Total
well depft
below lead amber: ��� 04 24a.Far AN Wells: Submit this� :wm wig 30 days of completion of well
d�l (fie` �M conshnnc ionm the following
10.Statie water lewd below top of cadeg: 30 VL) Dividoa of Water Rewn.ees ohrmatio n Procesdag Unit,
I(fwnter fowl it above toe-1- 1617 Mail Service Cmtew,RaIdgb,NC 27699d617
IL Borebole diameto•: `P (in.) 24b.For Inleetlon WAs: In addition to eroding tha fo=to the address in Ua
IL Wen coesh�etim (�Q o���`� abom also submit one copy of this tome within 30 days of completion.of well
(Le.mium fOfary;cage, pn6,de.) OOnShnLhOiD t0 ti1C
i
Division of Water Resomoes,Underground to jeetion Control Program,
FOR WATER SUPPL iY WENS ONLY: 1636 Mall Service Center,Rahigh,NC 2709-16M
13a.Yield(gpm) I ® McHnod of teat: a 24e.For Water Suodv&Isdection WM. hr addition to seceding the form to
the a&kws(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Anoant: 6 0) Z completion of well conAmclion to,'the county haft dgmft nt of the county
IQ where aoushuded.
Fenn GW--1 NaeSt Caolma Depmtmmt ufErvuonmmtal Qmfitp-lbvieioa of wasaResoatoes Revi"Y22-2016