GW1-2021-03725_Well Construction - GW1_20210823

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R.For Genprahefllr+T or f�0iaed-t.nnp GeatbarmAl Wells having the same ti14Xt mAy ttsc tits tuick of this page to provide additional welt site detAita or well
ugnstmctian,only I G%V-i is needed. fltditmto TOTAL NUK48ER nr-clis Co natruction rtetails. You may also Roach Rddititmat pages axessary.
9-TIbl well depth below land slidace; t _(R 1 141a, I;er.lit Wells: Submit thin form 1001in 20 dR3%of rnmPiation of well
l hr n,nbiPIC tt c11.0 iAt,dl deplim tfd0drnnr(nramI*-lla�T00•and s rat 1001 Com mctian to Ilic Ibllowing:
I0.Static water tevcl bet w top or aasingr (R.} Division of V4alar Raroura&Information Processing Unit,
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i#.lk►reholedlaAt¢Mr:, [tin.) 241t,Aar uiectionWIQSt to addltion to sending the form to the Itddreea in 248
12 Welt conatrneHAR method:_ I l.J A r1 l Amy'��bmtt one copy of this form within 30 hays of eompie0on of well
(i c,mt constmetion to the foilawinr
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Division ofSt+attr Resoum%Uttdergronlid injection Control Piogmin,
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WATCR SI:PPT V WFLLs ONLY: 1636 Moil Sa vice Ceitter,RAtelp,TIC 21?tt09,•1636
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(gym) Method of test: P4Glir Vt'}(lnr c� c&io Non Welter In addition to sending the(sum to
Me Rddrecs(cs) above, also submiuone copy of this form within 30 days of
Disinfection type: .Amount-. eomptetlon of mdl OkSlIU tion ro the cAanly hsal(h AWlttrtmern Of the smog
wham constmew.
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