GW1-2021-03900_Well Construction - GW1_20210823

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R !'nr Getrprohetflfrl'or[^dosed-1,onp Geolbermal Wells httvtng she slmc lrou may use the back of thispa$e to provide addhiotni well site deae[is err wc11
xnnmrction,anl' I G%%r-1 is needed. I'nstininta TOTAL NUMBER nT+vcllt com9tfnsiiDo details. You may also,plt8oh additional pegs a if nOcemly,
rngl well date[[boi(nv[anti surtitec: T y 4 5 ,(Q i
l-nrnrrrlutrlr.,,11r1lttalle-1191rifdffieraw(r�nmp/a-3(gll?((.m�'�.titao� 2*.r4w Au wells) Sultmit this JbMJvi0tin 30 dayw of completion of%veil
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24h.Rnr l6,, c1111A JK4W To addition to°Mnding t1w f0m)10 the nddtra9 to 24n
17"1Veir c(MI' effon melhnd: f� 'dmvq seen submit ono atpp Of this frnm,wilhin 30 days of compretlen of,Weil
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WATrR tiC — Division of Wetter Bcaoitraes.Undtlrground i ettloa Control fR ram,
Pt9 4 f i.9 ONLY: 163ft MR"SM Moe Catrterr RAMP,TiC l•7ti99616'36 �
13a.Yield(i;pin) "Afto of lesh Me Par Water Vantfllr&InMetlea WNttr In addition to:attMing Iht litrtru to
r.th.nlsinfection tyfro; Ammmt: die nddress(cs) above, also submit nac copy Of[big fbrm Kdthin 30 day9 oP
completion of well lxmuactw to the curly IMBIM dt(wMcnt Of tilt tailllify
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