GW1-2021-03808_Well Construction - GW1_20210823

828-622-7241 p•1
Feb 1519 06:43p OIearwaterWall Drilling
WELL,CONVMjJCjjON RECtDRD(GW 111 �"1?or lmtamal Use nty:
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S.For GrnpmhdilPTor(9nt>ed-Lfmp GedOerntAl We)ltt having the curate Tou finny use the back of this page to provide add(Gellnl wdi SO details or well
conanrctian•only i GW i is needed. fndianto TMAL NUMBER nf„eclls cof>9tluCtiQn drtalls. You may also ttnacfi additiot►at paces If ittieeataty,
drilled:_.
`t.71•otat•welldeptp below land Sutimca: --Jf�•) 14g• Bey gy W M: Submit this form within 3D dnys of complwitm of well
nrnitrprew fits fist pi;ddprhefdrddrnnr(erampM-3t(t17ga"aialsLnllOOry enn7littetionto the fwlm►v)ag:
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1 alcove,aLm Submit one copy of this forth wilbin 30 dip of eonnpletloa of wdl
IZ Vveli wnstrnennD method; _�`l 1 _._ <aea huction m the fullo wing;
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The address(es) above, also sulmnt one copy of this roan willfla 34 days of
13b.OkInfettkn type:, r1 rttormt: comptrxi m of+vdl conafdoction is klae erNvity litalth ftodri rot of the eaunty
vuhare amttacted.
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Well Driller Self-Grout Certification
� adDf�d PIGcCe /
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Owner: New WeU:
a S La X� TGi t'1uva Vw
Address: k1 cc. Repair:
Permit: Sw D. - 0�'Vca
I hereby certify that the above referenced well was grouted in appearance in accordance with
all County Well rules.
Well Driller: Tosh n lQxyyc1 Coil S Signed:
Certificate#: `-E k_51- PV Date G ted: 4-5-DA
Construction: Grout:
Total Depth: 3 0S- Type:
Casing Type: Thickness: ry--\ tL L
Casing Depth: "l S Depth: a
Diameter:
Weight/Thick:
Height:
Drive Shoe:
GPM: