GW1-2022-09431_Well Construction - GW1_20221017

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ar qn ju�WrA)�(a)�ttltrpcted:�'a � well III
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(if well itcid,one latnon0s rptNc)am) 11.Corti don:
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is repair to an ottiottag ellt oo t►r �Ak► +th 7?M NC'fC 02C.010t9 ar tSA NCAC 02C
?. this n A200 well Cb++amattarr S�andarads and rJYar a
g //7hti Is 0 q*tr,jiff out►;,16nta nail tatstrtrNtatu hij MQJ100 and tnrpla10 the n0luro 00he COW of has r=rrl h=bear pro%1d;d ro 1P avlf oat.
roparr,srxder NS1 rawAs secrtan&on iha back ofth eml. 23.Mrq diWam or adtillional%volt details;
R.For CooprobelDPT or 60104.oep 000Ihlt'odtl Wells h"D the xama You may lass a to freak of this pstgo to pm a ddit additional ft sits do, or well
cMiNctlon,only I OW1►s nettled, ittdifelte'i'OTAL NUMBER of watts
conetntction dctatls. You atoy ciao attach additional t If necsararjt
drifted: --
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9.Total%yell�. th bdo%v bad sur1I 5 [/ ( ) e240, Submil this iform within 30 days of comptalion Of WOOher trtu8�rtd u+'11s7trt aft dry�rtar ljd{h3nerrr lex0n+�ta•J 2(d7' tOrP► couutrmtloa to ills allowing:
10,shads water iovd Halter fop of espltlst 3 Q ) ill%�ton®f'i�►our lWourom Iltll'!MM00n E'¢t �ht8 tall,
�jtmarrfe►st/a obon,P susfug.tare"+" 1617 mail t3aMOD Ceaier,tlttlt!1$hr MC Z7694.1617
M 1 t.Bttrcitole diatnutart ►► (la) 34b.'r tnt,..�a�d o_ l in amen too the form to the asldl s In AO�. abovar also submit Ono Copy of this tbrm wittiia 30 days or coniptetion or well
13.Well cunetrttcI t�i of , canstnaetlan to tti:%(httotvittg: !
(i e.auger,rotary,sobla,dttr ct push,Ma.) Dlvi>N of Water RMU Underground to tt jeetttna Cot�oi Program,
FA13 WATER f3llt'PI W trLS ONLY; Y636 Mott t3eevfse t»oater,tirtic(gA,NC 39t;4&.1636
/ //Z ads t in addition to sanding the fbmt to
1311.Vicki IM181) t! Atstttad of last: ,f j Qt ,Wlzd club"
t 'oric cdpy Of this f0m' "n 30 days or
t%tnoantt completion of watt smnalntction to ON Countyttea111s dopartrriant of the county
13b.1l1ttlnti�etlo0 type: waste 060t[604d.
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tt'amitUorolins Dapattntartt orUnylnutaratal Quality°DWiSlanot�lalar kesautasn
itartssd 242 3036
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