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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: &A 2h SR77 J&.as-1%,6,gdf VeSf)al LC,_; ,�L�KnTUDE 3—s° _� �`�• 7��
Well Permit Number: -¢ L I.O'W- CIIc10 LONGITUDE (2c
Well Contractor Company: ;l Completion Date:. - (Q-
Total Well Depot: ft. Well Yield: gpm Static Water Level: tip ft.
Outer Casing Material: py(t Formation Log
Casing Diameter: 6.,95 in. Casing Depth: _ft. Depth Description
From:_C_ft. To:Oft. Clau
Inner Casing Material: From: ft.To: �0 ft.. `1�'- <3°j
Casing Diameter: in. Casing Depth: ft. From:_2D ft. To:_.Z�'2_ft.
From: ft. To:eft. 'r<<F e"xr-?n&
Grout From: ft. To: ft.
Depth Material Method From: ft. To: ft.
From: c�ft.To: ft. �Ru �_��h1'•y From: ft. To: ft.
From: ft.To: ft. From: ft. To: ft.
From: ft.To: ft. From: ft. To: ft.
Water Production Zones
Depth: tl'ft. ft. ft. ft. ft. ft. ft.
Yield: 5_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 Well
Rules in effect on-this date and that a copy of this record has been provided to the well owner.
Well Contractor: 1 Certification Date:
Record of Pump Installation
Pump Installation Company: _ P\see �� �;� �' Completion Date: S-
Pump Depth: Q1'Z ft. Static Water Level: ft.
Pump Brand: MM. a ST 1 D--'�-I uSr F'+-3 Pump Size and Rating: hp gpm
I hereby certify that this pump was installed and wellhead completed according to the Guilford County Well
Rules in effect on daLethat a cop of this record has been provided to the well owner.
Well Contractor: Certification#: Date: ;
Revised:January 1,2009
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