GW1-2022-09748_Well Construction - GW1_20221027

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EX.L c ON -R,17Clam RECORD tGVlf-11 for Intetnni use niy: 1
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Agricutturat MtrpicipalJPuhHc
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Fnjectian Well: fit. tt
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AgUif2rStgraliaMdRCCOVcry F3. 1 L tAC NBR m�ilion
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'x)terimental TerJmoingy E)SIdwidence Control �•
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;.ly fbls a repair to an exivting well YCs or lWo u•rtl,ISA Nf_,Ar,�ME''#100 or iSA.vCAC 02C.0200 Wert Canr+rnerlmr 4orrrktrds mid chat r
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R,rar GeraitraheMPTor Gavad-1 onp G+eWhermal Wells having ille stinia you may use the bnck of this page to provide addittonhi welt atlo detath or wolf
MnAntellon,only I CtW 1 isneeded. fndicKoTOTALNUMBER017-mils constrnediontletaiLs. You may altaaltachaddlfionalpagcsifflDeessary,
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l AAA well depth below land sudkee: 0—`s— If* yl,.i,yer iau_wet&.- 9abrnh dtls faun wthin 30 dn}x of eompleaoh oP umH
1%nr ntnitlpfc n e0rli.0 alidrv,flu iftfrjjcrrnr(+uorttnle•3(?1!1(I'ond i(n11t70� epnshUCtiM 10 the M10*1119:
t0,stotie water level below top of casing: —_M) Aiviaion of Water Remrces,Infbrmadon Procession Unit,
If-lerAtralIsr-ihamam.lna,the"•' C?•c MATMail$erviceCenter,�tdgh.TfC27dtJ*-ldl7
11_Porehotedlameter:,...,..LQ ._•.(ln.) 2tb.�r►r Irtlecrinn l�'d!s: Ai addition to Beading tfta farm 19 tutu address in 2qn
lZ Well construellnD method: nhova,also submit one copy of this fwm lvllbin 30 days of completion of well
ctmrstmatinn to the fallowing:
(i c,m,grr,mnq•,ratblc,41rat posh,MeJ
s�R WATr Division of Water Rtaottt'ct%Undcirgroulld Injection ContMl Program,
R R1;1'P V VVEMS ONLY: 1636 Mfill S IM Ccntrr,FRRWIgboNC 27699-1636
t3a.Yfrld(gptn) Method of teat: zic.i or Water Sunbty&1'aiecHatt Rd tx In addition in stmiling the loan in
1bc oddra.;(es) above, Also submit one copy of No form within 30 days of
Fab,Otcinfeerfort rype:� Amatrnh 1 / Jy I romptction of well construction to the coaniy hoalHt department of the count},
whara Canstrocted.
Front C,N'•t North DiviA,nnoPWater Restmraea ReuNM2 22 7.nl R
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