GW1-2021-03678_Well Construction - GW1_20210823

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K.15 AM)the wdJ(A)�Pcrmantmt os �mpnrar}' 8 nnotur�of(kttifivt WellCaltraaor Doe
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I.la this a repair to an cxisdag weM Oves or t f m will,15,l:tr'lC 02C.0100 or TJA NCAC.07C.0T00 Wall Cnmlrarnvn stow4mb owllAm jr
rrld.;xorcpnlr../111makMwn Two,anatraerumirdn,melFonmulerlatninthr.x,n,rr,r1ho 6nlapafdtlsnrl/nlaaRfrtEnpnDtddhAlAlhL'NMI/nW►ter.
mvolr wader A11 rtrmnrkc s 110 WCM t(a:sad ofllltSfnrla. XL Site dA*X Am or addidotmt wall deailiv.
S.for Geoproke/APTnr dosed-1 nnp Geothm'tettl Wells having thcstnne You may us ilia tack of thi&page to pmvidn addifiml ta'ell silo dataita or well
txrnsttltetian,onh I M 1 is.rp:eded. Irldieato TOTAL MMISM orwells eoommibndetaiis. YOU Mayalt oMWh additional pBgl:s ifn=maiy,
1 7rotat well delup below land aurht z 1 2-Ba• ti'nr Ail dlie: Submit this flat»within 30 days of complMon of welt
t nr M""ore congMMitmtothe fOUMVing•
10.8MUR water Itwcl below tap of easing: ___,_-.____00 D(virdoa of Water Resommes,lu%rmation Pracenion Unh,
1/wnler Laz!lr erhrYa txrs/ng,trre 1617 Mafl Suvke Center,ROdg t.NCZ769MM7
Ilotxltoiedieeteter. (In,) 24b,F � tnI : o sending the f6m to dto amain in 240
i2 WeiF amttracfton retklld: nhove,Mw Submit are copy of this form wlpdn 30 days of comphitim of well
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WATRRIiCM V WE119 ONLY:Ja.Yiatd(13DQI) � Method Of le!". ?Ac,Apr _&krSoM9 &�imNanlVef1� Ireadditloainsondhlg(heformto
the mddxss(cs) abcwcr also mAndc arc copy o£this fort within 30 days nF
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3A.11Isinfcctku type; Amount." completion of adl consu=cvon to the Qunty health depanntsnt of the mmntp
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IoarGW-! J4nrth(pmnifrtailapnttmontoFtinv ttm,�taiQw�nty-INviermtoi'Wmcrltasatueac Rnvhted222-21116

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