GW1-2022-01221_Well Construction - GW1_20220103

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CONstumtION oa1y4QW 1 isneaded. >bdica TOTALN1A oYt tis. aomweMondewlL You mridsoembAddltioudPW!frviceMW
S Tild well"tb below bard attrllteet_ tip,) 2 ft 1:ep� Submit this Sum;wlthb►30 dt s of completion of weu
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I&Weld sotaIrmOloa mak I�n�ric� ��i, above;akin submit aae eopy of this Poim 30 days of eamplet m of well
C�.a+ .> l4able.ditwtp�,at� oflanto the M"OVAaN
DMdon of Water Dervurca%vn��d�noaand IgeWW MOW Program.
IrOR WATSRStlPPLY W�Lt3 ONLY: 1636 Man Sffwce Gmtss,RldANCa7®M4M
UL.Yidd(Um)® trod of feet: (01(M ek Pm•w=Rue to Melba Wilft In cn to s mft the form to
ULDtsiul adontype: 14T, / addrOKO)abate;aim submit anejeapy of Ibis Poem witbhr 30 days of
' °Q� Amount: lfooL completion of wall cmutaaft to the county health depadmeat of rho wvuW
whereconsnucted.
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