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Well Driller Self-Grout Certification
Frees
Address: �Ot S��,n a s, NC Q'�'I43 Repair:
Permit:
I hereby certify that the above referenced well was grouted in appearance in accordance with
all County Well rules.
Well Driller: Ql� VA,60(6,tz,`'�S Signed: ---
Certificate#: 9 t 13 — Date Grouted:— 3 �'
Construction: Gr ut
Total Depth: aS Type:
-
Casing Type: 5 �� Thickness:
Casing Depth: Dept,: a 0
Diameter:
Weight/Thick
Height:
Drive Shoe:
GPM: 1S
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