GW1-2022-03183_Well Construction - GW1_20220307

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e coast w don details. You ma W provide addi pgg well site des. a well
oo®slrttction,attly 1 W- is headed. bdicate TOTAL NC'?ttBER of�.yc3,a ' y aLw attach additiatal gapes if anceaary.
Bridled:
f.TOW well 6*6 bdew had sarfae.: 3 (R-1 For24a. Far AH weB.: Subtnit dais tnfrr► within 30 days arJayle wwk Aw ad/s�I(dtjMrrwr(orate-9 2gl r001 Ya of oompktion of well
�.� iAaa3i'slCtiop to the f0119tYinp:
�WSW i *to a4mw ld bslrw oft -�-_— — {�) f3tv9t M of Water LRmereab lesmawks haea®tm Uatlt,
fit'rw U`l 1617 M48a^riea Cwgro fit,NC 276WI617
11.11asaltala 24b.Fmre JBkymL WA&' In*MpWft MWadingthe fam to the WkkM in Uo
12.W49 same nediedt above, also subrait one copy of this form aitbm 30 days of completion of well
ria.NNW.Mary.441s.disaat pa0.atc.) - — cuttmuctioo to the following:
F04t WAIM SUPPLY VACIMS ONLY: Dtivlaloe of Water Rwsoarce%Undergrocad h4ecdon Coatrol Prograimt,
16M Melt Sersiae Castor,Itaitl4gh,AC 2700-1636
134.Y1ald(sat) Mon"of feet: Yak.191 Ur IMRh A WOMM&M. In addition t4 sending the forth to
the addrea(er) above,, also tatbtait oas copy of this form within 30 days of
13b.D610ftwes IM Aaoa rt: cerMMhoo of Won caaybuction to t6 county health department of the cuuoty
where cocutnvadd.
PWM GW-1 teatb Carohm nap s of snvirca .rant Qwbry•Drrlr;on or Watw ttewaaa F.evraod 2-22.2016
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