GW1--07630_Well Construction - GW1_20231204

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db.Lititside Mid renew&hr degreesimhuttesketands or deehna1 degrees: - - •
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0.re(ere)the•well7OPermeitent or•OTemp0 lily
By Aria thitionti.1 hirebied;tai thitha tsiliff)lam eates0e0fithtidal 6s a;sessazg!c!.
•' :' I 7.Is this I _ to an editing:Well: ::101(eS or JNo with 15A NCAC MC.0100 OF 1SA ArCAC O2CO200 yell**viten'Simikirdf and thai a
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comet*reArgdlial beenpvy k l e 4 to the wit owner.tithir Lid rep*P11 Otis kpoual 1 airittiligiori tiff * , .eiptgptillenattptiofthe
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ligiciii t a WI reeptis seetioi crap iltil b se th egthrform.• •
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IL Fror Geoprobe/IIPT or Clesed-Xamp-Geotherorcl Wdlehavinn the_Pliale You May iisethe hack of thh;pogetopsvide additional trelI Site details or well
conitruCtion details:.You MaY also aminhadditionel pageolfnecessay.
construction,'ally 1 GW-1 is needed.:Inincino TOTAL NUMBEROf*anti)i
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,v; „t9'..,Tow w.-eg depoliebk.riii... g sto-fice; - OP 24i.Fitt iltit Welke. Submit this f_onn within 30:daYs ftr completion:ftt well
.-..1 'Forravgalifewells list gill qighs mut:(*toe s.6ip c.o.cad woo). conshugion to the following:
Statle water b0 ?f cOnv -4
o . (ft.) Division of Water Resources,Information Piireesdng Unit,
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•1617 NIall Service Center,nidelgh,NC 27699-1617 ioatii& Cc eis '4.
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BorhoIe dlitonter 40 24b.porlintectiOn Wens: In addition to sending the farm in the*mai in 24a• e :. . 0.
skew also submit one copy of,this them within 30 days of completion of well
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cl fotb•rif coning:canal°tho follow*
12:Well contlredion lath:WI - _ •
ii.e.ingiiatitim cables Ofecg Psh.etF)
Division ofWater Rettottrces,UndergrotindInketionCenkol Program,
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1636 Man Service eentetiNaleigh,NC 27699-1636
fog.wATErt SUPPLY-WELLS ONLY:
ili,, keer.- . 24e.Por Water Slimily&faitLttlon Wells: In addition to sending the faint to
20.- the addloss(M):above, also submit one copy Of this than within 30 days of
,.; •On.Weld(gPno
. Method of
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Idebilection completion'even Construction tit the county health deptebnein of the(Musty
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Depadment: of Erfikonmental Quality-Division of Water Ileseures Revistd 2,224016 ""trigthCegoliaa .
Fin:111617M
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