GW1--02811_Well Construction - GW1_20240506

" Hi ®ATS�'Yt� ®101 ��® �tG a� Print__
11,.E ��..� �` For Internal 37s®® lit y
3.Well Cootree arII�ormailoat
David Belcher
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• 4594-A :/; 11; 371.- a. .i��?.ail-trti.4t(tt�a
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1( ienthensal(l[eetinglCooling bpply) fr.• eetdential Water Supply(single) _ _ _- -
Iriloduetrlal/Commereial D Reafdential Water SUpplp(sparred) me, $�Gum •
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raallllyll:k(iBappitadtle) 4i, 111 r-%;—r, ,
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Comity
aredidonikadon110.(2114 Irk.: n •.•£,: ' : _:y:dr;�
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one ilde In rongitaadoEsdegreeskelnloteskuo. 0or eggE+lM rat _.._.__ll
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ReeFermanent or Illeraporary Signature bee ecildellOnntragtor 1 I Oats
9.1i®Q>tfparapatrQo enact dog wall: lilies ®P i .0p agil,g lhis form,a Hereby cagy that Hha wdt($)svzi(wepe)ea lstraeted 10 accordance
airto etas 4tttre!! Ida IS4 NM02C.0100 op 154 NOMCWC.0200 i9e11 Conovetion Stondards and dtela
(/'ah13as eoountlnnkfinvmlmta» ciplabtthaattm olho rogNaftkimrordkisbemtlrraredtotirerefine,repletozdar021ram bocollasortmtbebackgfthro pm.
a rge Cog=or a,,:r.Moog]of,!lid>:,,,las
l/Farr GooPrekiliNoor Cooselenp®eatiter r,.,=.I wellBahavingula satmu Yarn rt ►use du basis of this pogo to k®vlda ad6itfoaal well site detab or well emstotodoo,only 1GW1•issesta Indicate MIME.ATI211� eg�velis mmsastatetlonaletm9ls. Vortmaynle®attachadditfani drilled: pages Warman*
°)• well •f"[bt�lOvllfsncH6>trraeet glIIIM9H IP4t1I.AAi 1101 day
F'apind do teRlinandeplha(/'re ns(exam •semiacdmm �.-'. o° m Ees pnaat tills fbrilaawitpfn 30 days o$COm le a9?wrell
) ®�netme9l�teen� Iliovring: P A
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(Itvolerleref is erl a eatDtg:ust t op �. al BlVisiso oll�Jt Itasearsells!r t aBfen Pre 4••-'a:a @P Mg,
SS°itder,�mle � n(ai92�IDIEDrvise0etttmrol�t,IlicLaS9d9•' i<•:9
8h1.19Y�atarmaer oa arethot90 n ( ) h° >I�Be 11►e�@s In additlori t®seadiag the thytn to lbo address td 24a
(t o. `t^ above)also submit one copy of this fart within 30 days of oamplallom of well'
4r V.sable,etaep,roi,,j — eons teaaotletatothe;•;Mowing
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mEFlBfGlO 1505j :;ia ,_
,1 tit l,, Iv" Control gmNI:- ipzr �FJ$ .$l iQ/s � 1,vo�eas,,,�E®d ,,8oL9e ,R6 $ v?41sf -
1 193m $ )_21 mammal dame rh� „ um ar t o Ye additton to sending the farm to
13343211iDf¢eilete!ti:,,es 'Q22flee eddsess(as)®have; oleo SS It one'am of olds thus within'30 days of •
ANflO^•its tfaeL � mampietlon of wall constsuotinm to the:aunty health department of the county
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