GW1-2023-02317_Well Construction - GW1_20230331

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Parcel identification No.914
RixWpftude and lanai&is degreeslm)mrterlseenads or deeirul degrees: IIIILIIOIIIIIIIIIIIIIIIIIIIIIIINNENDEIEI
l(knelt field,one intelligent)
d•Nate}ffie wNt(s A t I11 ( ''`_,��
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i.in this a repair In gnlYitligate
(Mr icn our �walk Yes or No a'*nnum lbor f,rm.I hereby camel gm the unity was Press)c a o to od y, er
Moir ana ►il biers:wageua r Wilt 41110 eel Alf;_Olga m L!1 XCACdladi Yell wn prCflCnn:ltxdfni►SImala>aLc r
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&For C 234.She magma or additional welldetRira:
eomo on,onlyut p ased•Lonn Geothermal Mlle having the same You may use tiro bock of this page to provide additional swill alit d�tiy re ma
ddited` deeded beano TOTAL NUMBER ofwcoos construction derails. You may also attach additional
Aagec ifnoccagaty;
TaWt'+vdl depth below land euiiaee; �� it±IriTei�h�er Xlt`rI(,lh�
Per wrUr/tq al/dcptJm if (rxa91 )
10. pk-.0100'and4)10) cam SOP A_ pie
gg Submit this form within 30 days of
3ra�te.veter revs!below tap otimstng: conwrnctinn to the fMlosttag:. completion of wall
mallrobenc we", a Ut:) DivTisio7ofWater Utdt,
rcsacpri 1.gonaltotedhunetent , Ida Sarviee Center,Raleigh,4Non Prue
An) - NC17619-i617
12.1ueli imam 24b.Ear rate w a! e merg to addition to scalding the farm to Om
addnua in
ii c.tntge, mouth
above,also sahmit one copy of this form within 30 days of mompfesvmt of well
ell
1p cable,aired mob,exci eanahnebon to the fatlowiam
(1�WATER RCp�Y 4[INLY Division of Water BRa4ttrag,Underground
134.Yield(Qpo}) 1mu Malt service Center
Rtetirod of haft i 'sett*"N�6�2'1b99�t4 gym,
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rib.draim(gpan type: 24e.l' ter cn.w.. a e..« .,
Ainomii: me addtess(rs) in addition to sanding{bt Conn to
wherecompletion of well construction tot am tlsc S Of llds loon within 30 drys of
where CAf171Rtmedhealth dNrttttraeol or the courtly
Feat Cm.I
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