GW1-2021-03570_Well Construction - GW1_20210823

------- ' �..1
,
waKDdNng
par Intemn,um uvsY.
kvi'll Colitnew Rome A.
7-Well C
in
rR
Dal Rentin Ina ft
VN
Ow
Ow" ar No
ewpp"phis well mnm.
VVIARV
Orjj,
- --

Well Driller Self-Grout Certification
Owner. New Well: I/
Aaaress:J.� �1�1 ��s
ftpair:
Permit:
I hereby certify that the above referenced well woos grouted in appewan►ce m acoor mce with
all County Well rules.
Well Driller+ `l P(�- l(.�OS Sigmed:
Certificate#: 'A-k.3 -- Date
Construction: Grout:
Total Depth: Type:
` Th C•�`�"l «
Casing Type: dmess:��_ �
Casing Depth: Depth: o�
Diameter: w_lq
Weight/Thi&
Height
Drive Shoe:
GPM: V