GW1-2022-09804_Well Construction - GW1_20221027

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fi•]s{arc}the well(s)�pwnfil)Mt or 13Temprpry Silin lire nfCall(irdq/dI Camraernr
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R.Fnr G. ropt/I/P zd.Site diagram or vkdM mwl well tdcagita:t"oP Tor Clraaed-l-onp GetNhermal Welis having the same Tau met'use the back or this page to provide Addilioald well silo deenil+M'n5lnrctlan,nnlr I GW-i isnwrled. titdicggT0 TAI-NUh4aEP,r,,, lc
drttiui: cnnstructintt tlrtAifs. YOU tMagako rdtaeh additionai pages if necie at or well
.7fotal woll*13111 below land surface:,,,,. r � f 1
!vMJxnlfJpfrw�iJrtirrPl:drpdar%ld �.„a raa,,pr�_3G aioa ar,+ atnP� —Il)•) �1a- fFm nFt W..na;
submit rniv form vrintin 30 diis«r of completion of tvefi
(0.Stnt(c wa Construction in the ibllotting;
(rf'levt:t hetnw tap of caSiag:
if Haug Irrreflsrrhlnxcylriny,we " «} Division of WaterRewureea.InTa" uilon l ro"yybg ilnlf,
Fi_Rorrhote diamercr. �(� 14;17 A d StImjee Ceater,Rotefgh.MC:,Vd"-1617
12 Welt cnnstntellnR method: 7A:h or t+wicrtian W¢lirr Itt g tt form 10 d14 nddrerts in 24a
addition to nondin
1 s•nn It niMve,also suhmi:one copy of this form within a()days of eoropletion of well
e• rniilty,',*a,dlrert puah,�Ye.) '""'^- ^ wirstruetien to the fo(lowing:
VO TEWA R S=vIetbal.oftest,
iAWS1on of Water Rcamirceg.Undergtnnnd igltstianCOAtroizr36 Nail ScrvlEc CCater,Raleigh.NC"09-1636 'ram,
134.y1eld(f�At1t) 2te Jtnr WArer Snap1►&ioir�Hnn 17Y.v; 1tS rttjditton itt sanding iht:form to
13h,tllsinfeellan type. fire nddtzss(cs) above also submit nnc co Arantmr. MolPtaion of%yell constaSCdOn to the count'hZ tth form within fb days of
where cowntuana, h lualth department of the county
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