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Home My WebLink AboutWS-29656_48783_CA_WR_ 202201220WELL CONSTRUCTION RECORD Guilford County Division of Environmental Health 1. Site Name: ______________________________________________________ Well #: ___________ 2. Well Location: ___________________________________________________________________ 3. GPS Location latitude (decimal degrees):_______________ longitude (decimal degrees): ______________ 4. Type of Well: monitoring ___ air injection ___ air sparging ___ groundwater recovery ___ SVE ___ 5. Depth of Well: ____ feet 6. Diameter of Well: ___ inches 7. Depth of Water Table below Top of Casing: _____ feet 8. Well Casing: Depth Material Depth Drilling Log from ____to ____ft _________________ From To Formation Description __________ ________________ from ____to ____ft _________________ __________ ________________ 9. Screen Interval: from ____ to ____ ft __________ ________________ 10. Grout: depth material __________ ________________ from ____to ____ft _________________ __________ ________________ from ____to ____ft _________________ __________ ________________ 11. Gravel or sand pack interval: from ___ to ___ ft __________ ________________ 12. How is the well secured? ___________________________ 13. Well Construction Date: beginning: _____________ completion: ____________ 14. Remarks: ___________________________________________________________________________ I do hereby certify that this well was constructed in accordance with the Guilford County Well Rules and a copy of this record has been provided to the well owner. ______________________________________________________ Signature of Contractor or Agent Date 01.10.2023 UST Incident #: 48783 WELL CONSTRUCTION RECORD Guilford County Division of Environmental Health 1. Site Name: ______________________________________________________ Well #: ___________ 2. Well Location: ___________________________________________________________________ 3. GPS Location latitude (decimal degrees):_______________ longitude (decimal degrees): ______________ 4. Type of Well: monitoring ___ air injection ___air sparging ___ groundwater recovery ___ SVE ___ 5. Depth of Well: ____ feet 6. Diameter of Well: ___ inches 7. Depth of Water Table below Top of Casing: _____ feet 8. Well Casing:Depth Material Depth Drilling Log from ____to ____ft _________________ From To Formation Description __________ ________________ from ____to ____ft _________________ __________ ________________ 9. Screen Interval: from ____ to ____ ft __________ ________________ 10. Grout:depth material __________ ________________ from ____to ____ft _________________ __________ ________________ from ____to ____ft _________________ __________ ________________ 11. Gravel or sand pack interval: from ___ to ___ ft __________ ________________ 12. How is the well secured? ___________________________ 13. Well Construction Date: beginning: _____________ completion: ____________ 14. Remarks: ___________________________________________________________________________ I do hereby certify that this well was constructed in accordance with the Guilford County Well Rules and a copy of this record has been provided to the well owner. ______________________________________________________ Signature of Contractor or Agent Date 01.10.2023