GW1-2021-03800_Well Construction - GW1_20210823

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(ii wall recld,rMIC tttgamg in atdltefent) ;:�.1Cerrifientfon:
fi.!s(arn)the wcli(B) Pcrmancm or ©fi emporttry
tdM eun of CkAtlicd d!Cesteaator Gate
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7.is this a repairtoantibliagvrdt: }Ives or ONO u•oh tS� ACo2[:.OtOAm fSA,trCAC.07C..d?dOWellCaMIMISnnSNatnlm+Gmnlrhm,r
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rc,•anlr rindcr c it mmarkr$=Nan aron f/n,hack of1hl.:.fnml. 1:l*ate dH>gma or eddtdortol well de UP.
R.FitrGetgtmhe/11PT Ar Clttaed-t nap Geothermal Wcite baying fia same you may use llte link of alit pW to i mvide adMOM1 tmM mM dMik or well
txtmmrrxitmn and I cjwr l is needed. radicasi TOTAL NUMBER Ur+r_iis a)t19Wction errtmis. Yau may also attach addititm0l pttge>;tFnotx�ary.
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11.TOW wepdepM Now land gut'lileot,-,,, (R.) 341a.t ALW O'- Stthniit this form within 30 days of completion of%veil
lnrmnG/pfexrlltliunlidslrttu,'fd errin(ewamPI)a lUlIraad�Ar lam catiMMOOni0thtICIUMM.
l0,919Ge Water level blow tap of Calling: (ft.) Division of Water Rairw'at laihtnaation Pro WifiR Unit.
{'baler level M e7l me rming,to," _ 1617 Mall Sar*e COMMA itstdgd.MC27M-1614
tl.Rotrhotediameter: ,
�^ t�In`('in-.t) fib,Rnr tlaMrrien Walls: Li adrBtitin to sending the lbtm to ft add1M in 24n
12 Well ennrtraetloQ mMtat ` VTl 1 'I�e,aiao.whine one copy of this;Tram within 30 days of eompledoot of well
nm stmction to the foirowirc
(i c.ntgtc,tinily,cnble,Oirmj push,etc.)
Division orWater RcmmrcM Uotictgteand IRJmrMn Con"s1 Program,
FOR WATER 8C' Mr_v WELLS ON1,Y: liras Mall l4erviee Center,lRatelglt.NC 27094636
13a.Yit1d 1Rnat) Neew of tell: -- 24C Isar WAkr Sun—"ly&blecogn We1R: in addition to sending illy farm to
l Poe addAass(cs) above,elsO submit one copy of Ilib formwithin 30 deye of
13A.Disinfection jM; 'AMM nh tatrtpldion of°ven comitNCdion to the comity hoahh depjunim"of the county
."hare conattueted.
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