GW1-2021-03901_Well Construction - GW1_20210823

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• -•--�_-_ Revfaat2 2T-?ot6

Well Driller Self-Grout Certification
Owner: -J
Address: b1L' Repair:
Permit: W'A 'ge,�S�AX.
I hereby certify that the above referenced well was grouted in appearance in accordance with
all County Well rules.
Well Driller: Ka rk AW-O S*ned: —
Cerocate#: . 2'RQ 'A Date Grouted: Lt V 3o- Z t
Construction: Grout:
Total Depth: Type: �-
Casing Type: C Thickness: rfAV yL,Q
Casing Depth:T Depth:
Diameter: LJ• P
Weight/Thick-
Height:
Drive Shoe:
GPM: 1t�