GW1-2021-03609_Well Construction - GW1_20210823

82M22 7241 p.1
Feb 1519 05:43p CleetrwaterWell Drilling ••n••••-•r••
WELL COST§•ACTION I2ECORi¢(t W-1j- Fri rIntemaI Use only:
1. 11 C.ontmclor Information: 1-- -
nk (1 3L�V.� 14 w coxes
meox To n
%veilC11attnoraaorName tt; fw
Pr
VC Well CContmactce"Ifiention N11M;;' S Ol)1 BR CASING, t6rmotima[d t tNATERI�
t K 6-MY, c Yam!
Campmfy Name {{�� � _ WNBR CASING atR tltcrttutl e
aO�V TO D"MCTI�t T71 MATFd14At.
2-IYeN construction 1'etaattll: ft ft. 1n.
i lsl all applicable+veil t» imarlon parnttls R+t l/1C.CfrmNY Stair;rrarta»ce cec)
K,• ft in.
3.1vr]l file(cb&k Welt use): 17.SC N
WatcrSupplyWeq: oftOM ra• D sGOT Ttitctattas T'ShfAL
Agricultural DMunicipolMublic () R• !+- of.
Geothcrmal(lieating(Cooling Supply) tkResidentiot Water Supply(ainglc) R-
InduslriallC.otmnerciai ElResidattiat Water Supply(shamd) I&CR011T ,RM D&A
qp MA L fiM
ird lion VROM tt� D R
Non Water Supply Well: fc
h4onitoring Recovery ir.
injection Well. ft. R•
AquiferReclim;c [30roundwaterRcmcdiati+m l4.SANtI/GRAt/BLPAC No b!e
Stour a turd Itccovcty Salinity Barrier PROMAT fit-
Aquifer toltrt,nC Mn uoo
AgwtcrTc-q 11 08tttrmwatcr Drain-go n n.
a.
Experimentai Technology [ISuMidence Control n. w
Geothermal(Ciaced Loop) 13Ttacrs x0.DEiI,LiNG LOG ttlladr tebr, en
..scold To
Creothcnnal Hearin li ILeotrn) Odter( lain under 421 Rcrnfvlrs) [t. (t j
.4.DAteWetl(s)Completed. ` J = Well IDMin.Well Lacadnn:
IL
11 Itty.'(hlnetName FAality It>il(ifarfplical>fe) �,, �
�C� �o u PJ 1`n S F���t-�rvt � /}1i fl + Y V��(�go�/w[.�V'•1/���. � A. ,•.'';,
sfcrd Addresx,City,and Zip 1�1 r ZI,RP.MAR1�4
Camay — pnrml idelnification No.(PIM
51).Latitude nod lttnjAude in dLgreedminutestsecands or decimill dcgrecs:
(ii tvoR Geld,one latMMI;is stdiicicro) tiont
!'•ipnolurc of irnd WellCanumar f1AiC
6.is(arc)the well(A) PtxmaneDt or em Pora rY
\ J,,V dt}W!n!1 rins,inrnq J hrtrrhv exM/f}r that flirt nvfl(x)fret I_'Nmz:)ea+rdJraUarl!a aeanr407Cr
7-is 111ts A repair to an exisdag well: r3Yes orl fat r No 0411,lSt.tiC'AC 02C.0100 or MA JVc4c 01t:'.inoo Wdl Camlrnrxrelr 9mu4nrd<aml thm Jr
carp nfdrir rryyml horbtxn provtilet!lnthewdl amrer.
lydri.isn rtpalr.,�)!oatbrowa rwarl.oasrrnctlno i,l/ormatia mnf rsplarrr thr.nnmrc n(thc
revalr nude►t:1 retAMkr stTrlan nr un l/+c haGh of tAtxlnmt. 2;,P.Site diagram or additional well detitliS
8.For GeoprohdDPT or Clawed-1 anp Geothermal Welts having the samc )'ou tnay use rite tack of this page to piovido addlLontil avail Slid tl WIS or well
txlnalntctian,only I GW-t �needed i'ndiaato'fCYPi�L 1`ILSMBER of+.slis
ct)I"ruction drtttiis. You may also attach additional pages if ntltxasary.
drillod:,_ _r _ �nant ih,4TRLfCT1E0AiS
9.Irotal well depth below Ialld surfacct '� (R'.t yly,F9 eN__wci! Submit this fbrrn arid»n 30 days of completion of well
l�armulfiprc+rellrlistalJdrp!!u fd�a.nr(esa�ak-3fii1J00'aruis�llil0a9 constntctitmtn the ihltolft:
IA.$totie water levet below top of casing: (ft.) Division ar Water paxla'eea,lufitrmaklon Processitrg Uldt,
/(a'nhtr•h:1rllsalvlvecaving,Info " 1617 Man servicc center,Raldgb,MC274"-1617
1t.11orehotediameter: La (in.) 24b Fni1■fcSHon Wells: In addition to sanding the form to die addto r in 24n
�� �� p above,also submit one copy of this form wldiin 30 days of cmttpledM of We11
12 Welt CotutMctton 1n0thad! c,,no action to the fallowing:
0 a oM-,mtlay,cable,dtrwt gush,c1e,1
Division ofH'ster Rtaotltxxt,Underground Injection Control Program.
FAR WATER ACPP!'V WEL S ONLY: 1636 Mait Service Carter,Riltelo,iVC 274"-11636
13a.Yield(gpm) Metlaw of lest: ZtG Ilor Water SpDDiL&laiae80n WlIt4 In addition in sanding Ihr.farm to
The address(cs) above, also submit one copy of this font within 30 days of
Amotmtr rampldion of.veil consuuceon to the cOuntp health dgtarlmcnt of the courtly
13A.UlsinPecKan type: — where conatracmd,
VMM Gw-1 North(walling jDapanmont of Iim•Ininmental Quality-rAvisinn of Waver Rasanteas Revi.w t222 2a16
i
I.