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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: I _ l c,mtc PC4 A 1C Z935 i LATITUDE 3_&O ►W
Well Permit Number: - .� LONGITUDE 1' —e
Well Contractor Company: ��1 _� Completion Date:
Total Well Depth:—Tli—ft. Well Yield: 90 gpm Static Water Level:
Outer Casing Material: 'Flit Formation Log
Casing Diameter: <'. S in. Casing Depth:9^ft. Depth P Description
From: o ft. To: 6 ft.
Inner Casing Material: From:j6 _ft. To:�_ft.
Casing Diameter: in. Casing Depth: ft. From• 5 ft. To• ft.
Ll
From: ft. To: ft.
Grout From: ft. To: ft.
Depth Material Method From: ft. To: ft.
From: Q ft.To:,eft. LkVyFrom ft. To: ft.
From ft.To: ft. From:
From: ft.To: ft, ft. To: ft.ft
From: To: ft.
Water Production Zones
Depth: 1�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 Wei
Rules in effect on-this date and that a copy of this record has been provided to the well owner.
Well Contractor: C Certification#: L Date. 9—2A �7 ,
Record of Pump Installation
Pump Installation Company: 1{ ' Completion Date:
Pump Depth: (l ft `static Water Level: ftC4D)
Pump Brand: (Y1T___
I aPluump Size and Rating: hp 1 © gpm
I hereby certify that this pump was installed and wellhead completed according to the Gui ford County Well
Rules in effect on e an that
taa c y of is record has been provided to the well owner.
Well Contractor: Certification#: ��'�
r � Date: `2..
Revised:.lanuary 1,2009