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GUII FORD 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: 4i®1} k, ,fi r �� t + 5" LATITUDE 3�
Well Permit Number: dig N LONGITUDE
Well Contractor Company: rCt �Ftl_t Ins. Completion Date:__ 9- I n�,?
Total Well Depth: ; _ft. Well Yield:_ _gpm Static Water Level:_40 ft
Outer Casing Material: _lpJC Formation Log
Casing Diameter: G.,5 in. Casing Depth: 45 ft. `Depth Description
From:__ft. To:_;%, ft. _Ckd
Inner Casing Material: From:_,?O ft.To: 140 ft. P
v
Casing Diameter: in. Casing Depth: ft. From:-Uj}_ft To:Jt�—ft. ,
From:-SLft. To:-1caLft.
Grout From: ft. To: ft.
Depth Material Method From: ft. To: ft.
From:-0_ft.To:—4 LaMi— TrucV,From: ft. To: ft.
Fron ft.To: ft. From: ft. To: ft.
From: ft.To: ft. From ft. To: ft.
Water Production Zones
Depth: ft. ft. ft. ft,
Yield: __gpm gpm gpm gpm gpm
gp m gpm
Method of Repair:
I
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: Certification# �41~t t Y-0, Date: 1
Record of Pump Installation
Pump Installation Company: _ ( z1, Completion Date:
Pump Depth: I ft. Static Water Level:
Pump Brand:('T',1Ae -S �'� i'P)l�G--{�"ump Size and Rating: I�� hp (� gpm
I hereby certify that this pump was installed and wellhead completed according to the Guilford County Well
Rules in effect on ate that a cc of this ecord has been provided to the well owner.
Well Contractor. L/ Certification#: Date: t� -
Revised:January 1,2009