GW1-2022-08190_Well Construction - GW1_20220519

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pnraaf rdeniftfaniipn No.(Piet) —
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r+:p oironder Alt ramorkt ws/fAn of ra the hPtfinf ihfv,(amr. •1;L SM r 1JSr M or additional well)du Mr.
ti.for Gennrabe/APTor Caked-Lon GeMbarnral Wtlb having the saute 1'°0 nlayvrA its
%)1 fire tmett of this also
4o i h addit addioral i0tlf11 fil a BrY. tre welt
P oan,9trurAints rtrtails. You may also t1t18,c11 additional pages if pgoessaty.
rxinsinictlan•only i GW"i it;needed. r1tdinato TOTAL NUMBER QF%vr--lls
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yUL.4tt(L}�11sf suhmit ibis fotrn within 30 days at compleAon of PC"
Rv mnlupk ra.v 1k,nl;Aip/la•trdlferornr{FP--M;1a-3trtlT/Jo`ard xhiIno7 canalrticlinn to ft follDWiR:
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!f s'ater Gntd 1s irMrrrs cm'fn1G one"�'l ` ,_+,,�,''
111.finncholedtreeenMr� ` " (la.) 24h, EQICSilQs, W Tit addition to Sending dw Am W Adlimm in 24n
" f�j] :eY Ov also submit one:copy of this form w11Ain 30 days cotilpledtltm Of Well
i2 �vcu cnntirnenolt me116od; v ,— r--r r- construction to the following:
(i 0.nvyc:',rorory.rn¢fe, Dlelslote t►i'Watei'HeaaaFrtagr lJnd pits t prteh,ttc,) egrouud Injection f:ontrol Program,
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t1(JdtW.r,'i'FF�fi1APt.V WI�i.LRS4N>~Y: — T rag M4113a d-4124ww,RRieialr NC"094157b
Method of rest: �r tea 1'nr__Wa—�u `��: In addtNon la sarrdietg the Form to
iJa,Vitt A(Rptt1l___z the oddros(rs) sons; also Submit,One copy of thist forth within 3(l days of
tab,01sinfeetian t Amotme; -��- ma elation of.vdl cor,sutuxian to the cRrmty health department of the county
ylw=.....--�-------^ — where coetArrtwated.
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