GW1-2021-04102_Well Construction - GW1_20210823

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lrol,niey use the buck of this Pal?P to pmvide addirmal wail silo details or well
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imnsinictian.only I OW.t is needed. Wiam TWAL NUMBER or—lis
9,irotIf'woliiticpth ttelowiend SulMCC fh•1 2�, or A 119: Suftft this form within.30 days of completion or welt
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10.stone WAteriftel b&W top of easing: (fc} Division of Water
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��� `i► / above.also suMmit one ropy of this(form ti++ilDtn 30 days of wmPletlon of wilt
1Z Weltrnnstrnefltmtlntthod. r"� — cmiruction In the following:
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_ iXvision ofWater Rtd=rrts.Unilef9 aund tajlstllin Control"ram'
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The ridilmsKes) almvo, also submit Ong copy of this fonn wllhin 30 days of
Amotmt: camptetion of.veil consuu�iea to the eonnty health dehadift"t of the county
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