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RESIDENTIAL WELL CONSTRUCTION RECORD
North Caroline Deportment of Environment and Natural Raourves. Division of Water Qualhy
WELL CONTRACTOR CERTWPTCATION N .30UZ A
f, DISINFECTION: Typo! -70 le Amount
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11, REMARKS:
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information Processing Unit •
100 ARMY CSRTtn THAT THE Will WAS CONSTRUCTED ACCCIlONI U % tW
11A NCAC 1C. WILL CON$T11U011014 STANOMOS. NOWA DOPY OF TIN
RICORC MI NIN PROVIDE) TO THE WELL OWNdL
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PRINTED NAME OF PERSON COA$TRVCT110
Submit the *right! to the DIvislon of Water quality within 30 days;, Attn: Information Mgt., 1 -I Berke - Raleigh, NC 27098.1017 Phone No. (910) 733.7015 ext 888, Fin pVy`1'a
Roy. 7106
a waL DETM.$1
a TOTAL OEpnR • 0D
a Does WILL RPMcR DOIMNO WELL? YES
a WATER LIWI L aMowTip cf Casing: 35' FT,
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0 MD Ws* .,,_/0 METHOD OR TEST AIl2