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GUILFORD COUNTY DEPARTMENT OF PUBLIC HEALTH
Division of Environmental Health,Water Quality Unit
400 W.Market St.,Suite 300, Greensboro,NC 27401
Record of Construction, Repair, or Abandonment of a Well
Address of Well: lrrl �`7) ,�r��► 1����;���, � � LC S)ZATirudE 3 6" 1 t/` 3t ,;P
Well Permit Number: , LONGITUDE
Well Contractor Company: Completion Date: - - __
Total WeII Depth: Uf-5 _ft. Well Yield: _gpm Static Water Level:
Outer Casing Material: PVC Formation Log
Casing Diameter. (a• 5 in. Casing Depth: 65 ft. Depth Description
From:_Q_ft. To: 2C ft. '
Liner Casing Material: From:_A ft.To: (go ft.. - g.�
Casing Diameter: in. Casing Depth: ft. From: rift. To: _ft. ,
From:_L ft. To: ft,
Grout From: ft. To: ft.
Depth Material Method From: ft. To: ft.
Frozn:-6—ft.To: _ft. To: ft.
From: fL To.-­ft. From: ft. To: ft.
From: ft.To; ft. From: ft. To: ft.
Water Production Zones
Depth: ft. ft. ft. ft. ft. ft. ft.
Yield: �gpm gpm
gpm gpm gpm gpm gpm
Method of Repair:
Method of Abandonment:
i hereby certify that this well was constructed,repaired,or abandoned according to the Guilford County We]I
Rules in effect on-this date and that a copy of this record has been provided to the well owner.
Well Contractor. Certification#:RLLJV-A, Date:­9-2�Z
Record of Pump installation
Pump Installation Company:_ ���=J r' , -
Completion Date: 1 O
Pump Depth: QL- ft. Static Water Level:
Pump Brand: �`-1�`S �`S i� l e--PKAs*q ump Size and Rating: ,l hp gpm
I hereby certify that this pump was installed and wellhead completed according to the Guilford County Well
Rules in effect on nidate d that a copy of this record has been provided to the well owner.
Well Contractor: e2 Certification#:%eti!!�17ate: Qt
Revised:January 1,2009