GW1-2021-04140_Well Construction - GW1_20210823

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Well Driller Self-Grout Certification
Owner: j J t�C$-�- \A jr,k kf<_ -- New Well:
Address: D �k pair:
Wit: a5� (�� ML
I hereby y that the above referenced well was grouted in appearance in accordance with
all County Well rules.
Well Driller:
Certificate#: �`�� Date Grouted: `I-t 4' 7
Construction: Grout:
Total Depth:
S Type:
Ong Type:�__ Thidmess:
Casing Depth:L Q Depth: Q1Q
Diameter: W �
Weight/Thick:
Height
Drive Shoe: