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3vgjeL COISTRUCTION RztORD. — 'or Wat,al Use ONLY.
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T.(a Ibis a repair Is as existing well: ("Yes' r ONo rya afro armor/us setn pow*,iv lee well 0rw1
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You nay use the book of this page st provide additional Weil site d.stails or wcu
I.Number of welb constructed: cmytnit:.on dreads You mayalso artsdt tul uly dltlestal papas If ar:e .
A.w•eaAutls*victim t,.rr ... 'sv• sorb ONLY wek tie pose tsn.rasw.)o..aan
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• Tula w f. all Mplb blow Iota surface. a d a my tat jeer All 1Yclfg: Submit that ti•ml within IC days of cvnplsti,,n nt wt..'
1'as.vlap4vrHhiyr0I. (wk.,.fr,.r.ylr;0230'en47011001 e041lt:1:1i0n lu!he following
i t.State water(avel Nitro,top of wins: O at, Da•isio■of Warr Quality.'Information Trviceratas Lau,
1/...nr k.vI it ab..sweat to.-,. 1617 Mai fferrcca Custer,AaMI=b,NC 27iff►1617
11.Dotsbala ellssnetar: . .'`_. ,:is.) -.eb.i ,jgja, j el$: In saloon to sending lig form to Ihs stkiress u.:aa
/J y 'oat ►. t Iv..t• • eta. of ..a )1.. v V Poo .• dsyt of tomphcron of well
12.W.0 tosurottio•.me.___.. ��;.•, /A- �/ 1t r•y -- c nt rc:, •r is falowln,
• (is.sow.rotary.fable.dip.t peal Y' ) /—
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I FOR WATYit vWrP1.Y WTU ONLY: / 1636 Msil,Sa 'ica Costar,Rsislplh,NC 37411-16.36
13a Yield(span) 1..:,nd s!ult.6.Z.O1-41 Jo w ' 244. •r Wit•►dung`,It Leader.Wcllut Jp Killion to smith;pipe lino to
W oftass(ot) abort, olio submit one copy of this form wultto SO day* of
13b Dislalecti.a type:C 17 L O r i/t P Amoout: �—i) D,F completion or well sonalrvotsun to the county health depainttont c f'he ccwr.
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