GW1--01103_Well Construction - GW1_20240216

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S.For Gealtmbe/lllrf or Gioled-ReroP Gtothat ttwl Welts having tltcsnme loon met d the bock lit may
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P to 11 Moll fnell ary.Weill es melt
eanonitdimuontg I OW 1 is nesded, Indicate TOTAL NUMBER of�valls
construclian ddait9, Ybu ttttW also att&ch titdli( P tgttaaeety
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ry Total'NCltdentli below laud wham i 00S - QM 21IR.Eit'oO An late &lima fits Thrill within 30 days of completion of moll
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I1,floreholcdiameter: (Ql 0 (in.) Zfin.EataatABOLWAIE to addition tto the NM IP BUS attdfdes iit Ma
above,akaiubmJ$one awn?.this feint within 30 days tt1 Colopk titm of wont
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i1Q1t WAFER fiEPALY WELLS ONLY: `
7636 NUR Service Connor,IRt S .NC X/609 636
� (/ 24e,Nor unite a..»�V$c t(Rte M.Rhdta: 1 addition to siaulhig the Rom to
iJa.Yield lttpat). 95.__ Motion!of eesn —( the mhfrosc(cs)above.also submit.cote copy tbia form Wilda 30 days of
I3b.ilttsinrectteul tjope Ammo: oompistion t co�umton to the�comtty afdt depmtrnent of the county
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