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otyetr artsiee't2.1 warerb sdriia ii ar no an bosh of tit&farm.
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It".!tor GeopiraWDPI or Mona-Loop Costhereetal Weds having the cope You may tl,te the back of Nil pap to provide additions.;well site mils iv mil
coutauetitak.aril 0 i it eieeaiatd. indict-ft TOTAL NUMBER of walla c aeltritetio'a details You!oily alto mania addi iul pn;,,; s if pile r 1.
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9.Toed Weld dap*Woo toad wince: . �(k) 36a. {r Submit this form within 30 days of compIttion of well
For+a 1tbli en?*ten a Bates V feeaaeaafe-3{ti 'event 2®)we; �' senetatetian to the following:
M.&Ade maw twat his top of ens*: -_ . • ._(f1.) Weise of'Water-Reaauaraaea,Infor aandon Processing Unit,
ZrIffredir daaldia filaMW CONtSy our"4" 1617 MadO S n hies Cestur,litakiekt,NC 274194627
it 4 ,or ._(in.) 7Mb. 't ,daiggtL .fig: In addition to sag the form to the 1141thre tz m 24a
/� / �, above, hug;submit car,copy of this farce wiittin 30 days of completion of well
P.R.W s mat C t c ,17, -,—*_ aomstat tioi to the Mewing.
maw,Men.ate,area post..awl
_...__• _...__ ...�....�-_ lls9atls9un of Water li?t• raci a,ti' rottard lra*retac Cos+tra •a. rsrmtm,
ESMEWililtil. UY? Y WELLS ONLYt �)R— 1b361°JimtEi r a�ltsz C ti r Y4alea�te 1�C 2� =ice,
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ditldti )... a__-_-..K. Me hed of mat: 1t/l 1%/! 24r. W4f •So�l6�&I,tefl P ' : In additio to sending the form io
the to tteas(rxt) above, arlso aubsoit ua- y-of this form within 30 days of .
114sinfiestrion type: t 4.. Ara:etont: __/?,.. completion of avail construction to the eounty halals departmatit of the couraty
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Rua OW-1 Nostk C aroliaa Dapteaasnm t of:esevironraantel Qmityy-Diviaioa r f Wears itam3L/C86 1Yaviaet 242-2016