_Well Construction - GW1_20230327 (56)

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ram,',.' ails lAlleache:wawaeaaavaesestfpawattoa =plain the nemre(f,h copy nliha retard Mrhaer Pronsdedrmrhewe(leittte Cvrs/ixertarrSManrlardeemrtrhaa
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S.For Geaprobe/pP[•fn.flOmd-1 oA 23.Site diagram or additional weltdandle:
canalntctiem,aq>}r I GW!is p Geat[itynml Mlle havifig the I'ou may use the heel(all*Page to provide add3leoted wa11 alit dtWS or well
doffed*
kneaded. illditiet+o TOTAL NUMBER of elIS tor>9tntetian detnil� You may also attach addl6onat pages Mammary.
9.Feta wen depth s below land althea:
tuplrwoktiti*fldeptler ,era fe aopk-.10201,t^^n5 —(�) 24aern far nt Wens: wing::. this form wlihin 30 days oft completion of well
16.3tetic trier level�w tap of lasing: COO conatRtcdon laths fallowing:.
Iwaterforditeevinrca kg ate (tG) Divides of Water Resources,Ialarnta8on Proseasieg Unit,
` 1617 Mad Service Center,Riedel,NC Zta -1617
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• eau.For Ifiggialroafelisa In tddidon to aiming the farm to the address in Seca
1Z10i@IE asb'attlan tsNtiuds, rota above,also submit one copy of this form wilhla 30 days Al eomPhaimr of Will(IC.sage,mbarex61a.dirort path, i I cortsiturdioa to the followtng; ,
FOR WATERSt.'RA1.V WELL'S ONLY: Division ofNrater Rtamltres.Uadetgt otllid Infection ComtePsograal,
l 1iii1 / i636 MaAService Cenms141etgh,NcImp-um
IJa.Yield(t!!en) 1 V me tllaU ar tab \Of 24e.Far r Walcr_SoBoly&Kmtergan W etiNN IR addition to sanding the um in
13b.Disinfection type; dm atldrasll(as) above~also submit one copy of:hie tilmt gdthin 30 days of
Aaaouat: completion of well n to the county health dgrartraeaf ofthe annrety
where eaa►stnteied.
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