GW1-2021-06869_Well Construction - GW1_20210429

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WELL DRILLER SELF-CERTIFICATION
t
Henderson County Environmental Health
1200 Spartanburg Highway# 100
Hendersonville, NC 28792
PH: 828-692-4228
FAX: [phone]
OWNER: Michael Owens Construction New Well: X
ADDRESS: 330 Burge Mtn Road, Hendersonville NC 28792 REPAIR:
1 hereby certify that the above referenced well was grouted in accordance with all Henderson
County Well Rules:
WELL DRILLER: (print): Josh Plemmoms SIGN:
Date Grouted: Y2,q I 7 LI 7
Construction Grout
Total Depth:_ 5 Type:
Casing Type: J0 V �/ Thickness:
Casing Depth: Depth:
Diameter: 25
.Weight/Thick:
Height:
Drive Shoe:
GPM Flow