GW1-2021-03806_Well Construction - GW1_20210823

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Well Driller Self-Grout Certification
spiowner. �c, ��� New Well:
Address:n off, genar-i A Lf) Repair:
Permit: �UO K3c-
I hereby certify that the above referenced well was grouted in appearance in accordance with
all County Well rules.
Well Driller:JpS�% P*rM )5 Signed:
Certificate#: 4 13 1 `°4 Date G uteri: 40 - 3a'Z. 1
Construction: Grout:
Total Depth: -3 Type: OAU
Casing Type: VG Thiclmess: 1'1'1
Casing Depth: Z Depth 2-
Diameter: LP
Weight/Thick:
Height:
Drive Shoe:
GPM: d
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