GW1--02074_Well Construction - GW1_20240405

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WELL CONSTRUCTION REco1w( W 1) Farms Usury; -
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6.1's(am+e)the well(s)MFcrmanent oro{Temporary
sipmmtiut:•. well Date ��l
By aloft tirsfora I hereby err*that the xzp(r)1Ear(pars)constricted in accordwers
7.Is1hlsasepa rtoanexistilgwel: jYes or 121No 3ofth254NCMCif C MOO orI54 NOW D2C.02003ieICwahaerion Standard(and that a
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repairwtder0'I terraairsxtlaroratthehockeilhisforaa.
23.SW dwar senor addittaml ma&tans: :
S.1?nrGeopcobelAPl ort -Loop »i1v n.�..:�,e,r_. . Yon may um the bank a£f>vs p -__- v• _ �,:'.-• -aTr15 or tell
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Spilled: SUBMITTAL INSTRUCTIONS
9, _ .. :,..ACC:.. (R.) 248.far VI%yob: Submit this form within 30 days of completion of Imll
_' .- "-.� .s� 1" ter . y�,, coostruelian toile following
10�icextsr lent belnr toper ca V (IL) Division ofWaferResoaroes,In3wmatianProces UDit,
Ifwererteveitr bm/cods*rue*a zA 'ante scrocecenter,Raltrg4,NC27b99-tb17
«' la addition to the form to to address in 24a
11„Borr3wlEdiametea: to fen.) ��4rLnfa� � _ $
Q_/ goal above,also submit me copy alibis form�»tlria 30 days of cornpletiou of well
V,WsR amMhod: coushacli totolhefoIIa ny& I
(in.naggQ nog,cable,dGectposb,am) I
Disisioat 9f Water Resources,ifsund injection cont tot Program.
FORWATERS PI'LYW LLSOs' ,Y pp 10611 1SmiceCcotsr,Rate ta,1SC27699-it36
7 l ' L Yt'ff ?.4c w a1n .ft Mecq"Welk; la ade i ioatosending the form to
r 99 �t dal addnes;(ys)abvr+�,t�Lsn strait ma errs of tins form ttithin 30�&of
13b.Disinfo lloafype:oval 4e, Atmra V' Id� is_, P ►�of ndl aomnn+ ea to the cout►ty haslUs department of the county
orbere ambitetad.