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GUI FORD COUNTY DEPARTMENT OF PUBLIC HEALTH
Division of Environmental Health,Water Quality Unit
400 W. Market St., Suite 300, Greensboro,NC 27401
eeerd of C©notructriona Repp�a56.o ©� Abandonment coif a Well
Address of Well: /i 3i Norm 1 1; VaLq 5rAn►n t ,NC. n97214 LATITUDE 3 Co 1 47 . 1
Weil Permit Number: chi..Oy.1,JUkiA-mo571
_ LONGITUDE )9 35 50 . 1
Well Contractor Company: A, ,ta .
Completion Date: 2-Q?d.ay
Total Well Depth: 165 ft. Well Yield: 30 gpm Static Water Level:
o-- �I.n__ft.
®amen Casing Material: /C
in. CasingFormationti®�Log Casing Diameter:
5_ Depth: '75 ft. Depth Description
Inner CasingFrom:,o__ft. To:.L_ft. [,tan
Material: From: a© ft. To. ft.
-. ft. From: fe0 ft. To
Casing Diameter: in. Casing Depth: :
._.._ :_lc_ft.
Grout From: 70 ft. To: 75_ft. tik,From: ',-
75 ft. To:j ft. Slut. C-treu e
Depth Material Method From: ft. To: ft.
From: cO ft. To: 3t ft. Cei' r,c;,kh fnu,K From: —.
From: ft. To: ft. ft.To: _ft.
From: ft. To: ft.
From: ft. To:
ft. From: ft. 'To• ft.
Water Production Zones
Depth: jr-) ft. ft. ft.
Yield: � gPrn gpm ft.gpm �_�._. ..._�Ft. ft. _ ft.
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:I, .
(,'�j � Certification #: S5.2L�
_. Date:
.�Y. .-.-r,^: . Ana.a.• - .'_.' �, .
Q coat of Pomp Er otaflat0®n ��—
Pump Installation Company: ! jC
---- __._ Completion Date:_a2/ ZS Z
Pump Depth: 1 sd ft. Static Water ft.
Pump Brand:
Pump Size and Rating: hp gpm
I hereby certify that this pump was installed and wellhead completed according to the Guilford Count Well
Rules in effect on this date and that a copy of this record has beer, provided to the well owner. y
Well Contractor �
�'..� ' Certification #: Z6 Date: 7 Zs Z
Revised:January 1,2009