GW1-2021-03766_Well Construction - GW1_20210823

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R,itor Gems rohe/lll'T or Cloned-D,onp Geolbermnt Wells bxvingthc saint. You may use the truck of thin Page to Pmvido addikanl well she daWls err will
x�nstnrctinn,aolR i GV►`-1 i5 named tndicntq TOTAL NUMBER of'wells
r q i�ttMaits, you ally aim attach additional pages If ilOC64491Y,.
lfotai Well rfcptltNOW land XMINC: `� .-_(R:) 26. 1'er AQ Wellh: Submit diis fdjM within 30 dW. of ent1frWn11 of Wi11
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Division of Winer Rtai aws.Unit crgronnd Injeetlon COMM Pr MM,
>Ytdt WATERSUMV WFUA ONLY: 1634i Mail SMMC!ie1Cmari!trltatelglr,l4CX70961636
134.Y(rtd(Rptn) q4v Dledtal arfest:,Tl �dG Apr WAtrr Qntleiv&-ieiaetNn Witt: In addition to aunding At:tbnm to
ibc rtddrgcs(cs) above, also subtini odic I copy of ft fbtm adih(»30 dV of
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Well Driller Self-Grout Certification
Owner: Lea, MCU_p' �t i aM' New Well: V
Address: NC. _UA Rq)&:
Permit: o� �()n r)qs c�
I hereby certify that the above referenced well was grouted m appearance m accordance with
all County WeU rules.
WeUDrMer: �-
Certificate#: i 1 3 A Date Grouted: L4-Z g-2A
Construction: Grout:
YUX
Total Depth: ��� rN)e:
at
Casing Type: Thickness: Cf
Casing Depth: qa Depth:
Diameter: 10 ,SS,
Weighghht/Thi& _
Height:
Drive Shoe:
GPM: �o