GW1-2021-07755_Well Construction - GW1_20211116

WELL CONSTRUCTION RECORD(GW 1) For Inletnal Use only:
1.Well Contractor Informadon:
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2.Wen eomaaelioi!Persil#: TO MMMAL
Lietafl applfaoble as g c xsftc mpesmfts(ciL t7/G cwoaj:sme.Vbrn c4 eW R R to
3.WeV Use(check well see): I R R td
Water Supply WdL- 17.91�5®�I
> M Tro MIAt�a Moral= TSK30erss MATMAL
0 R Rta.
Gacthr�QV Supply) Bidential Water Supply(single) a, R is
cat water supply(shared) 1s`GRM
IBM TO MAMsuAL tttMAC=rrtme =&Ateromvr
won water Sappy Wei32
R R
- M R-
Ljeetion WeM
RechaW Remediation R R
I9:SADIDJGBAVSLPAC�
Slarage and Recovery []SalmBy Barrier lam m saA�tAr. >an Iwt>s�rrlae�a®
Test DraioaBe R R
lowainnotaTwoology Cow R R
Geotliennd(Closed Loop) OTaacer 2L raeum.�IAM att:el shee>s tr
RC,eotheamal(Hea tiogf Cooling Ream) - (explain under 921 Rentaft) FEBM r0 r er.r r rtiaet ere
R ' R2d `
a Date Wdl(s)completed: 11 4S 10 WeD mp 31A1 8 1-7R 0 G`
SM.Wen Location: r` R
J�G �O`Y►15,�L��+1�')�1�`'�T1V?/1Q�.?i R R
Far gf0wnwXz a T—� F—TAyM#QfVpficable) R
p]5 i Ci:S�0 rn 3b. .16&5 nIn A(,xIs? R � NnV �r
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Ceamy ParcaMe MNo.(P9t) [;:FORMATIp
Sb.Latitude and ba gitode is degetea/mia bdseaonds or deehud degrees:
(dwelt Seta,see tarAasg u sffidan) 2L Cerfffleadon:
W 4 Luj R -4
6.Is(an)the weli(s)Wermmnent or [jumponwy ftmoaeof Wctt draw: Dare
By aWdng Ms fo,m I leoeby e-Vyl ftt Aff VWJ),wa(wro wrsxisdad fn aoaosdmee
7.is fhh a rqnfr to an well: EJYCB or, No wilt 1SAIVCAC 02C.0100 or 15AIVCAC 62C.02W W*U Cossosdian SYadmds and dint a
lfddsisarepab;ftNoafblownwaBomvnsdtonb ionandesplanOnso8aegfbW ca"ofddrsaw hasbeenpivvkbdm&rweaowrrar.
npafr sadw l2i re mob snem Oren die ba4ofdrlsfom 23.Site dbgram or additional weD detaitx
L For Geoprohe/DPT or Closed-Loop Geothersai Wells having the same You may use the back of this page to provide additional well site details or well
camstrructioo,only OW-1 is needed. Indicame TOTAL MIhMER of wells construction details You may also attach additional paps if necessary.
// SDIITFAL IIHSTRUC1TOlti;
9.Tatal well depth below land smifne: fa 0.S (fL) 24a.For AD Wdia: Submit this form within 30 days of complbion of well
Forssdajple wells lWaUdepths f40-*(ea agpfe-3®I00'ad 2@IM mop to the f dlowhw
10.Statie water lsvd below top ofeasing: .3 o (it.) Dtvtsh ad Water R i revs,hdbrmation Processing Unit,
.(fwarer kvd is above sae.+. 1617 Mail Service Center,Ralelgh,NC 270SL1617
1L Borehole diameter: (in.) ! 206 For Int*CdM Wells: In addition to sending the foam to the address in 24a
14 I Q 0 Tl�-2 1 above,also submit one copy of this form within 30 days of completion of wen
ix Wert teastr�tioa seti:od:
roe.)(Le.—M-Wy.cable.diteetpast� "1 eom6tafian lfl the foDmvmg
M,dd a of Water Resources,UndiegJroand 1*.Gm Control Program,
FOR WATER SUPPLY WENS ONLY: 1636 Mall Service'Center,Role%%NC 27699-16M
13a.Yidd(gps) rdelbod of test= L o 24e.For Water Snook elk Idecd,WA, 1,addition to seudmg the faun to
the addresses) above, also sub®$erne copy of this form within 30 days of
136►1idefKtion Amami completion of well consttodion'to the county leeahh department of the county
where constructed.
RIM GW-1 Naft 0 aIwa Depaomess afEnwow :wd Qoaldy-Dmsm of Wean Rama= Rmised 2-22 2016