GW1-2021-03608_Well Construction - GW1_20210823

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2:L Site tHattrttm or atiditiotm+l aMil dtlhnlis:
&.For CeoprohrAllri or Ciex+¢tblrmp Geothermal Wci1s having the same ),Ou may use the back of this page to provide adddiomll well Silo dOW113 or well
tx""ntt:tion,only I CW.j is needed, indimta TOTAL NUMBER of urlls cnnvtnwAion details. You ally also attach volitional pages If nnt;ea3ary
'"W'Otat VMS depm Now land Sul' eg; � (R•) 2-11ry he• r AAl_W__ells: Submitthis form vitfin 30 days of cumpMon of well
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3A.Static wntoriavo below top of easing: ^(ft.) Divklon ofWator Rewurces,taibMatloul Pt-wmiM Ualt,
If nh+ae coung.we �( 1617 Msfi 3ttrvicc Cnjor,Reldgb.NiC2709-1617
11.RoreltoledianteNtr. U (11.) yth,For Intletign Wadde: TO addition to San&jnR the lbnn 10 tha AdArm in 240
t2 W di conetrnctiom method: almove,also wilm!one ropy of this form within 30 days of compledtm of well
t i�.Bade s•,ae i fl n morva had: T outstrnedon in the fallowing:
Dlvle4on of-Water � nd igjCton Co Pam,
r'M WATER ACM V WFIL.S ONLY! 3Mi � Cemrr Rat .VC 27094636
13a.Yield(gem)^� Metheu!of 1es1: Y�`' -- 2+Ir.. (fir Water 810-dt:&rokatlon,WefOr in additlmi to slalding the Mm to
t the oli t m(cs) above, also submit one copy of INS form wtOtin 30 days of
13b.Disiafeetion Amarme uDmphxion of%veil e m me don to the coamy'bealth depar nwrit of the county
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