GW1-2021-03805_Well Construction - GW1_20210823

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rr roN ender G11 ramankcsrzt/an nt rm t/n:hnrlrnfJhfxramr. 2X Site diagram or additional trail dLMW-
S.For CeoproheA PT or Closed-1,nnp Geoitierma!Welin having d,e scone Vou may use the back of UAis pe8e to proovide adddiMl wEI1911b(letAils em well
txmglnictlakonis 1 OW-1 is needed. Fridicmca TOTAL NUMBER c,r-wrlls caiwMiNion tbrtailS. YeU IrrBy a1Bo>rtluch addiGonai pages if naxa9ary
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9•Jretal wclldcPQ below land suracct„- � (R•} 24;1.EQr, q }}rills. Submit this lb m within 30 days of completion of well
rnrnaOlUprewrllclitealSdryrllae:JAyjerimrkz++Vk A70dj li lwl ennstntctinrrto the fdiolr>btg:
10.statue WAt"level b&V top of caalaw (ft.) Division of Water Rammlurece,Information Processing Mill.
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t i•$orchwedianleter: 9 , (in,) zah.AW Idectlon Wdis: To addition to sending the form to gtet addrom in 24n
y &ave,also submit one copy of this loan wlibin 30 dltys of compl alem of well
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�WATER RCPPLV't>dE S ONLY. — Division o 1W3tM 8 Sergi�nndion R to d ltgjistlon Control Program,
iglt.TIC 29044636
LJa.Yield(LtDot) M~of lesh 2.tc ttor Water iioorslt &roiaatlao!we11e to addition to minding the ltxm to
the address(cs) above, a150 Submit otic copy of th14 form wilhin 30 days of
I3h.1115infeetfan type: .Amount: w>mptation of well consumdon t:o die cotoliy hcahh devurin"t of the county
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