_Well Construction - GW1_20230327 (39)

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1 tegairto Ad1wag9re0: Mat or�NA By atk1Nag tmlk furor,I hereby owl,that thr txrll(a)law(wen)crarnrnn tlIN�eraforce
ld*icnrahv►eA11car idimwe1dea.a try.ittPuamtonaiaraprdn!beware eda iraflbtwith at e'rcardl4acQyets� lathe wet Io CanrJtr oteSYant�ndRmrdtheia
rem*miler All magma/0 am the bad ntiNxIban.
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23.Sion diagram or addidoaal[vat :
Von canalnrctipn„ I GW!is needed. GeoNtta aml WNUMBER a a Iis c ru�Way use the
b ck o this page to provide Additional dniied:_ MAY alco each addl(ional Penes if ake details or well
9.Tagt well depth helltq►innd sitfditcdw �.�(�5 1UO YZEA Emagm
eracasaws+wasM orkszprisoff cadet fassapk-3aimireudA 109) t�l 1. For cti n l am thi ceing:. this farm-within 30
construction[o the Itblo►rrag:, d or completion of well
10,stalk war level below oleast
I t Statate a war►ra tw' n 1 �—'"—i_' tilt:) Diniainn of Water Rennweea,laformadan
Procession i i.Done6ole+Naattxer; 1617 MR Service Center, Halt,
�a) Raleigh.
12,Well Zee.War lwicctiopjvetlae to adStion to sanding the 0mfl to the addtena in 24n
C(11►ab tletlaD methods �(`��-� ebony,also submit one copy of Ns form*thin 30 days of completion of welt
ac.auge•,► ry.' .direspadL,ete.) cansttatliaat to the following
FOR WATER SUM WELLS ONLY: �"` Divbion of Water Reemiroea.Uadergroan inJd tion Content
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1636Ma0 Service Center,kaleto4.NC276094636 •
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Oa.Yield(RP4), iNatlintl or des„ ill 9:1.. rtnr wilier$pansy&WNW Wank fo adddlnit fi
sanding dm 13b,btaitr(lectien typt~ Amman dbndress(es) above,also sutatit awe copy of this than within 30 tamer in
ptation of well coruu�n to the ofs
amply,health,depatmrcat of the manly
whore an+4rcted.
I Penn GIYA WAf lint ant of tinvbiSiStimtal Qtofity-Aiv�eNm oP Wmer Re9msre� Ravlsml2.22 2at0
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