GW1-2023-01124_Well Construction - GW1_20230126

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Josh Plemmons
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Cleanivamr Wen arnung Inc.
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For WWA w1blta41142er e'vMW � ►'o�i �It) 24S.JNr Aa M Snbndt thin fa m within 30 clM of Completion of arc11
wnsctuaitm to the tbpo�rdtg;
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In addition to sending the foam in ibe addteea in 24a
12 WA eoaetraed" Above,Rho suitmit a can of this tbmi within 30&ya of aomplefe of well
fLa ,rotary.eahlq atn} construction lathe Avowing:
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ER t311pp1,y WMtLI:B ONLY: 1Divaden or water QN01y,Une"Wl"d injim n Comm Pt
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t 16M Matt Servtoe C%%Wa R k%%NC 2�b+"406
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Method of t ME For WMer co.tittn A 1 iodic Wa�•.;t.�igm m ttetttHag the fl,tm ro
eifo i 1�, 1� �ItddraWes)above, ttise submit one copy of tips fatm WMIR 30
dW Amon!: !p�(L�(J co Ifft of wdl cnnsmdon ro dw a'mtit of
Wtterr c�stttt4tea. tY hwtt6 fEpattttteet of dw w11lMy
FamttiWf
North Cetollna P""NrotofEeviroameotmd Netmatlteeestea,-Dtvteton of Watrtpuiity
Reviaedlan.2013

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well Driller Solt-Great CwIlflcation
0=wme r. U, ��
I hereby off fy that the above referenced well,i&w grouted in appmanae in amordainc a wit
WI County WdIMes.
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Wel.Driller_ JO—S�j Plelwy)W-5, Signed• `v im
Certificate#-, ��3� Dab,-Gro % a�
Construcdon: Grout.
ToW Depth: (OO S Type: -Q p
v�
�g TJ�; Thirlmess:
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Diameter!
We*ht/Tide: .
. kle�ght:
Drive Shoe:
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