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Well Driller Self-Grout Certification
Owner: 7l CO t-PC---q New Well: tl
Addm%:,i: q LIC-Mg2et Vd Repair:
Permit: Mai-Is k- t l K)(-
I hereby certify that the above referenced well was grouted in appearance in accordance with
all County Well rules.
Well Driller� KNe.G �S
7l� Signed.
Certificate#: Z 1 k 3 -A Date Grouted: (Q —Zs 2.._t
Construction: Grout:
Total Depth: (P DSO;
Casing Type: Pv a Thickness: c ec t Cb
Casing Depth: 100 Depth: 60
Diameter: (0
Weight/Thick-
Height:
Drive Shoe:
GPM: