GW1-2021-03768_Well Construction - GW1_20210823

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1--4tn10inn,Aoly I GW-1 is nerded. fgdiRata T(YrAL NUMBER of wriN sfln•9tlit iDo details. You may sign mwIh Addillonat pjM if awwary.
drilled:—___ .__, -
SANUIALINNUUMM
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l�!Nett ranatrnt Hnh I11t thtNl� t �t�t.r rtlfove,al'°sirhmif rasa copy of this farm within 30 nays of eompiatlem of well
(i o.mrgr mmn,ucHO dinlPlh rnramction to the followitiX
Dit hlon of WttW Resila h Undugmund Tiontlon Control Progmin,
i�()!t WATCR SCPi7 l V1rTt L.9 ONLY: iG316 Mall tikrNos CaPme tRAtetgiy TIC z7�iGTb
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[]to addms(cs) above, also submit rltrc copy of ibis faint gdlhpl 30 days of
t3h.ntxanfcrnoq type: Amnimt: i l Al t-ram/ completion Of well awUnction m rhz cttuniy With denattnnm of Inc amnly
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Well Driller Self-Grout Certification
Owner-p6k I ti Q 063+ SURm Well:
Address:(a1Vin Wt'' U Repair:
Pm-nit: N+C�.�'S t-h 1 l KC
I hereby certify that the above referenced well was grouted in appearance in accordance with
A County Well rules.
WeRD.riller:�P-cx Ke-aaylkaS S• ed �.
Certificate#: 2 l 13 - A Date Grouted: (V Z 3 Z l
Construction: Gmut:
Total Depth: S Type:
Casing Type:�_ Thicdmess: Yy-%L-V_t 6_
Casing Depth: Depth: Z�O
Diameter: U. '(9
Weight/Thick:
Height:
Drive Shoe:
GPM: l