WQ0000267_Monitoring Wells 1-9_20191008

1. Well Contractor in bnjad .
Wayne Thompson
weU ConnadorMum
NCWC-2908 A
NC Well Coausaw Catera Nmubm
Ground Water Well And Pump Co
2. Welt Constrvcam ramim
list all gwliraa&e reel aoao anPrr-s (te- il1C. Camay; �4 vMimmm etc)
3. Wen Use (ebmkwA nae):
b&
QkMn&� SM*Y) t Water Supply ( )
xmmmcw Wa6er5apfTyWm*
Nos -Water Sm* We&
Rechap
SimWamdftmm"
Test
M1 Taboology
MW (Clowd LoW)
a. nate Well(s) Com~11=019
Sa. Wen i OMWR-.
Gates County
FaoWOwaa Mm
Gatesvi!!e NC
PhYSW A044mdZip
39 VMI Ln -
C -1y
WO IDS#
INIM:ala(PM
56. Latitadeasd lbs ���
(ifwell frets. one is art�rie�s)
Z
6. b(are) the s)j�or
W
7. is this a repair to an fthft wdL- (3Yes or
Ifthuisar ; jdtoarbrafwrvWcomon doe h4brmakm mda%*&Ae ammalme
repatrmrArb2l rema?b sixamor=Mebachaf&sfmw
& For Geoprabd OPT or Clased-Low Geothermal Wells Laving the same
duction, only 1 GW -1 is needed hdicate TOTAL. NUMBER of wells
drilled: _
9. Total wen depth below toad aortae(:- _ 1 � CO -M4 OM4
For-&Ipkwoks Ifs(agdo�4Fd (r—ik--3®ZW- md2@10@)
18. Stalk watwierd below top measle „ .66
1fraterk d is abm camft ane -+"
11. Borehole diameter_ 6- (-
12.We0.*,,tj.as &,& Auger
(M VAM Mai: cable, dveetp mk eV)
FOR WATER SUPPLY WELLS ONLY-.
13a. Yield ftm)
I 13b. nlainfecem type:
Method after
22. Cesocl-
11=0019
SigadmofCaffiedWeRrAmusaw ie ---
>0' �� 1 aat�y dmr the �(s) >reas (mere) m,aar to aecardFa,ce
witkiSAhCAC01C-OlWar15AAr_ACOSC_0200Welt Skndwdrwedthea
copy efd-naaardhm bampvm"to the well owner_
23. Site diagraat or additiaod welt dela W.
You may use the back of this page to pro vide adds fond well she deta& or wen
couskaction details. You may also attach additions( pages ifnmcsswy.
StMUMITAL11ci4#R[irlMM43- e
241. Far An Wells: 5alieut this fnem within 30 days of carol tion of well
tothefonowitg
Bhu ma€WddrReasurce%harmafte prommawg1jan,
1461711 Smv,RtM91,14C2709-1617
24h- 1?r Inleedea Wee In addition to seo ft the, form to the address in 24a
above} also subs ow ew of the Am witbia 30 days of c of well
- -- - - conwactianbtbefnitawing:
DWINM of Water Reasrea, Undammiand Injeehoe Control a r%mm,
M86 Mad Service Center, R*kW NC 276944636
1
21e. For Water SaaeT7r , - hk adfioa to sending the farm to
The adzes) sbnvey aW admit one COPY of tbs form within 30 days of
comma® of tied( cOGshwfm to the county health depmtovent of the county
-- whae cow
FamOW-t
Narthtbn�lkpafF.m�+om�tQm�Y-DivisimaFWataResoaeces Rtvised2-222016
1 Z
G t SOME FIVE S�
fL
iL
&
IL
2Ls
22. Cesocl-
11=0019
SigadmofCaffiedWeRrAmusaw ie ---
>0' �� 1 aat�y dmr the �(s) >reas (mere) m,aar to aecardFa,ce
witkiSAhCAC01C-OlWar15AAr_ACOSC_0200Welt Skndwdrwedthea
copy efd-naaardhm bampvm"to the well owner_
23. Site diagraat or additiaod welt dela W.
You may use the back of this page to pro vide adds fond well she deta& or wen
couskaction details. You may also attach additions( pages ifnmcsswy.
StMUMITAL11ci4#R[irlMM43- e
241. Far An Wells: 5alieut this fnem within 30 days of carol tion of well
tothefonowitg
Bhu ma€WddrReasurce%harmafte prommawg1jan,
1461711 Smv,RtM91,14C2709-1617
24h- 1?r Inleedea Wee In addition to seo ft the, form to the address in 24a
above} also subs ow ew of the Am witbia 30 days of c of well
- -- - - conwactianbtbefnitawing:
DWINM of Water Reasrea, Undammiand Injeehoe Control a r%mm,
M86 Mad Service Center, R*kW NC 276944636
1
21e. For Water SaaeT7r , - hk adfioa to sending the farm to
The adzes) sbnvey aW admit one COPY of tbs form within 30 days of
comma® of tied( cOGshwfm to the county health depmtovent of the county
-- whae cow
FamOW-t
Narthtbn�lkpafF.m�+om�tQm�Y-DivisimaFWataResoaeces Rtvised2-222016

WELL CONSTRUCTION RECORD (GW -1
1. Well Contractor Information:
Wavne Thomason
Well Conductor Name
NCWC-2908 A
NC Well Contractor Certification Numer
b
Ground Water Well And Pump Co
Company Name
2. Well Construction Permit #.-
List
:List all applicable well constnrction permits (i. e. IIIC, Comely, State, lrariowe, etc.)
3. Well Use (check well use):
Water Supply Well:
For Internal Use Only:
14. WATER ZONES
FROM A
r'� f1
fL ,
15.OUTh:R CASING far m
FROM TO
d ft. I ( O
16. INNER CASM OR TU
FROM TO
ft fJt
ft. R
rNlunicipaUPablic 0 ft, - - ft.
(Heating/Cooling Supply) DResidential Water Supply (single) l a fiL C ft.
tialResideolial Water Supply (shared) 18. GROUT J
I nuL r vun
z I y o i QVC
IG Immthermal closed4o® I
METER TERCKNESS I MATERIAL
'n 40 PVC
in.
:TER SLOT SIZE THICKNESS MATERIAL
rn' JW PVC
Non Water Supply Well:
XDMonitoring
Injection Well:
DAquit'erRecharge
Aquifer S and Recovery
Aquifer Test
:)Experimelrtal Technology
Geothermal (Closed Loop)
]Geothermal (Heating/Coo_lmg Return)
ORecovery
13GroundwaterRemediation
�SalinRBarrier
OStormwater Drainage
OSubsidence Control
Tracer
001her (explain under #21 Remarks)
fL Hole plug PORE
ft. fL
fL ft
SANNGRK able
FROM To MATERIAL
EMPLACt�NT METHOt
ft ft• PORE
ft. &
20. DR]LUNG LOG attach additional sheefs N areonu rr
rsc►sl TO DESCRrt'rlox rm ier. Yawleh,, -aaftw < t ;,, s?se,
1 C?
f
��
4. Date Well(s) Completed: 1/2/2019 Well 11D#
Sar Well Location:
Gates County
Facility/Owner Name Facility M9 (if applicable)
Gatesville NC
10 fr /5
1A, -V
f t ft.
ft. fL
ft. ft.
ft. ft.
Physical Address, City, and Zip W
39 Will Ln
County -
Parcel Identification No. (PIN)
ft.
%
21. REMARKS
5b. Latitude and longitude in degrees/minutes/secomb or decimal degrees: l —
(if well field, one lat/tong is sufficient) 22. Certification:
N w 1/2/20019
6. Is(are) the well(s)�Permanent or Temporary Signature of Certified WeIT Coadactor Date
By signing this form, I hereby certify that the well(s) was (were) constructed in accordance
7. Is this a repair to an existing well: 13Yes or [}No with 15A NCAC 02C _0100 or 15A NCAC 02C _0200 Well Construction Standards and that a
If this is a repair, fill out known well construction information and explain the nature ofthe copy of this record has been provided to the well owner.
repair under #11 remarks section or on the back ofthisform. 23. Site diagram or additional well details:
8. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction, only 1 GW -1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: — SUBMITTAL INSTRUCTIONS
9. Total well depth below land surface- _ 00 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different (example- 3@200' and 2@1001 construction to the following
10. Static water level below top of casing: _� _ (ft.) Division of Water Resources,
ceS,Information 2769946 Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
11. Borehole diameter: 6 (in.) zab F I ' ti W II In add' ' d' th
12. Well construction method: Auger
(i.e. anger, rotary, cable, direct push, etc.) —
FOR WATER SUPPLY WELLS ONLY:
or rrlec on a s. Ikon to sen mg a form to the address to 24a
above, also submit one copy of this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
13a. Yield (gpm) Method of test: 24e. For Water Sunniv & Injection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b. Disinfection type: Amount: completion of well construction to the county health department of the county
where constructed.
Form GW -1 North Carolina Department of Environmental Quality - Division of Water Resources Revised 2-22-2016

I Ill it. l Vr l I.
WELL CONSTRUCTION RECORD GW -1 For Internal Use Ont
1. Well Contractor Information:
Wayne Thompson 14. WATER ZONES
Well Contractor Name
FROM TO
NCWC-2908-A ft ft
ft. ft.
NC Well Contractor Certification Number
Ground Water Well And Pump Co
Company Name
2. Well Construction Permit #:
List all applicable well constrrtdionperalks (I -e. UIC, Coiopy Stde, Variance, etc)
3. Well Use (check well use):
Water Supply Well:
0Municipal/Public
Weating/Cooling Supply) OResideirtial Water Supply (single)
ommeroial Residential water Supply (shored)
Non -Water Supply Well:
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
Experimental Technology
Geothermal (CIosed Loop)
Geothermal (Ileatine/Coolintr'
Groundwater Remediation
OSalinity Barrier
OStormwater Drainage
OStibsidence Control
Tracer
r IOdw (exvlain under #21 F
4. Date Well(s) Completed: 1/2/2019 wen m#
52. Well Location:
Gates County
Facility/fawner Name
Gatesville NC
Physical Address, City, and Zip
39 Will Ln
Facility WO (if applicable)
15,Of117ERCASM Jbirm> wells ORf.flclER !fa ighlr
FROM TO DIAMETER 'rH lClilY YSS MATFuiAT.
f. i ft in
16. INNERCASIlYG OR TUBIIVC [ernlhermal clasrd400nl
FROM
TO
IIESCRWI]Ox
DIAMETER I THICIMSS I MATEMUL
ft
22. Certification-
ft.
i 40 PVC
&
ft
1t
in
17. SCREEN
By suing this form, I hereby certify that the well(s) was (were) constructed in accordance
with ISA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair, fill out known well construction iirfornraian and explam the nature of the
FROM I
TO
I
DIAMETER I SLOT SIZE I THICKNESS I MATF.Riar.
0 ft.
ft.
u,
ig 10 40 PVC
i1r
ft,
ft
m
I yo
I& CROUP
ft
&
�1 y Cr '0
FROM
TO
Division of Water Resources, Information Processing Unit,
MATERIAL EWLACEN"TMETHOD&AMOUNT
Q f t-
IS
I
Hole plug PORE
ft.
Auger
ft.
12. Well constriction method:
(i.e. auger, rotary, cable, direct push, etc.) — -
%
--
&
FOR WATER SUPPLY WELLS ONLY:
TO
S ft. 2l & # PORE
ft &
28. DRILLING LOC tattm*add&.aAdmizftif.. miml
FROM TO
IIESCRWI]Ox
. Aanr.ns, AoWiwk t pt gniii; see, eta)
(if well field, one lat/long is sufficient)
22. Certification-
ft.
ft
6. Is(are) the well(s)OPermanent or Temporary
Signature of Certified )X 1 Contractor 9 Date
7. Is this a repair to an existing well: r3Yes or [3No
By suing this form, I hereby certify that the well(s) was (were) constructed in accordance
with ISA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair, fill out known well construction iirfornraian and explam the nature of the
copy ofthis record has beery provided to the well owner.
&
ft.
23. Site diagram or additional well details:
ft.
&
construction, only 1 GW -1 is needed. Indicate TOTAL NUMBER of wells
construction details. You may also attach additional pages if necessary.
ft,
&
_)_'
ft
&
�1 y Cr '0
Construction to the following:
21. REMARKS
Division of Water Resources, Information Processing Unit,
Ifwater leve[ is above casing, use "+"
1617 Mail Service Center, Raleigb, NC 27699-1617
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minates/seeonds or decimal degrees:
-
(if well field, one lat/long is sufficient)
22. Certification-
____N�p
- `'l'
C,�,�-A .A 1 -L_— 1/2/20019
6. Is(are) the well(s)OPermanent or Temporary
Signature of Certified )X 1 Contractor 9 Date
7. Is this a repair to an existing well: r3Yes or [3No
By suing this form, I hereby certify that the well(s) was (were) constructed in accordance
with ISA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair, fill out known well construction iirfornraian and explam the nature of the
copy ofthis record has beery provided to the well owner.
repair under #21 remarks section or on the back of thisform.
23. Site diagram or additional well details:
8. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
You may use the back of this page to provide additional well site details or well
construction, only 1 GW -1 is needed. Indicate TOTAL NUMBER of wells
construction details. You may also attach additional pages if necessary.
drilled: _
SUBMITTAL INSTRUCTIONS
_)_'
9. Total well depth below land surface: —(ft-)
For multiple wells list all depths ifdii ferent (example- 3@200/' and 2®100)
24a. For All Wells: Submit this form within 30 days of completion of well
�1 y Cr '0
Construction to the following:
10. Static water level below top of casing: T (ft,)
Division of Water Resources, Information Processing Unit,
Ifwater leve[ is above casing, use "+"
1617 Mail Service Center, Raleigb, NC 27699-1617
11. Borehole diameter: 6
_ (in.)
24b. For Iniection Wells: In addition to sending the form to the address in 24a
Auger
above, also submit one copy of this form within 30 days of completion of well
12. Well constriction method:
(i.e. auger, rotary, cable, direct push, etc.) — -
construction to the following:
--
Division of Water Resources, Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY:
1636 Mail Service Center, Raleigh, NC 27699-1636
13a. Yield (gpm) Method of test:
24c. For Water Snnnly & Injection Wells: In addition to sending the form to
!
! the address(es) above, also submit one copy of this form within 30 days of
13b. Disinfection type: _ Amount: _
completion of well construction to the county health department of the county
-
where constructed.
Form GW -1 North Carolina Dement of Environmental Quality - Division of Water Resources Revised 2-22-2016

WELL CONSTRUCTION RECORD (GW -1)
For Internal Use Only:
1. Well Contractor Information:
_Wayne Thompson
14,WAM ZOMS
Well Contractor Name
FROM TO DESCRIPTION
NCWC-2908-A
it.
NC Well Contractor Certification Number
Ground Water Well And Pump Co
is. CUTER CASM Jhr lei sued Fel (M LIN F R d a able)
FROM To : ik14 TffiC7dVYSS MATERIAL
Company Name
I6. INNER CASING Olt TUBING fteodiernal ciaead4W
2. Well Construction Permit #:
FROM TO MmIrFdt I
TEK%N ss I MATFnrsr
List all applicable —11 c -me -J- pereeits (Le. UC., Ca-ly, State, Yararerce, etc.)
B• R• is
40 �C
3. Well Use (ebeckwell use):
R• & in.
Water Supply Well:
I7. SCREEN
Agricultural
OM®rcipal/Public
FROM TO DIAMETER sLOT sm TincKNESs MAT
f & 1°
0 10
140 PVC
Geothermal (Heating(Cooling Supply)
Residential Water Supply (single)
S ft. Cit- �fl ur I O
t , 0
'7
Industrial/Commercial
Residential Water Supply (shared)
M GROUT
Irrigation
FROM TO MATERIAL
EMPLAC NVKNT METHOD & 1
Non -Water Supply Well:
V u. IS & Hole plug
PORE
x Monitoring
QRecovery
ft. ft.
Injection Well:
]Aquifer Recharge
[3Groun4wat TRemediadion
Aquifer Storage and Recovery
OSalinity Barrier
19, SAND/GRAVEL PACK ifs '
FROM
To MATERIAL
EMPLACEMENT METHI
'Aquifer Test
[3Stormwater Drainage
PORE
]Experimental Technology
OSubsidence Control
]Geothermal (Closed Loop)
Tracer
28. DRILLING LOG attach addifieum sheets if mceman
Geothermal (Heating(Cooling Return)
Other (explain under #21 Remarks)
FROM JO DES[ RIP7[ON eer., mahret rs a is
� %r �, ft. Gc.
t
4. Date Well(s) Completed: !/2/2019 R,� ID#
� & 20 & GL
_ Mr F e
5a. Well Location:
& %
Gates County
ft. &
Facility/Owner Name
Facility IDI# (if applicable)
K' R•
Gatesville NC
& f.
Physical Address, City, and Zip
B• H-
39 Will Ln
2LRE
Comity
Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one Ltt/long is sufficient)
N W
6. Ware) the well(s)Ox Permanent or OTemporary
7. Is this a repair to an existing well: J3Yes or E]No
If this is a repair, fill out known well eanstruction infmmadan mrd explain the nature ofthe
repair under #21 remarks section or on the back of this form.
8. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction, only 1 GW -1 is needed. Indicate TOTAL NUMBER of wells
drilled:
9. Total well depth below land surface: '—a (ft.)
For multiple wells list all depths if different (example- 3@200' and 2@100)
10. Static water level below top of casing: 3 _00
lfwater level is above casing, use
11. Borehole diameter: 6
12. Well construction method: Auger
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test.
13b. Disinfection type: Amount:
1 1111! 7 V/111
22. Certifica ' n:
97
ux� 1/2/20019
Signature of Certified Well Odutractor Date
By signing this form, I hereby certify that the well(s) was (were) constructed in accordance
with 15A NCAC 02C _0100 or 15A NCAC 02C _0200 Well Construction Standards and that a
copy ofthis record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of" page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTRUCTIONS
24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Iniection Wells: In addition to sending the form to the address in 24a
above, also submit one copy of this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 276"-1636
24c. For Water Supply & Iniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this forret within 30 days of
completion of well construction to the county health department of the county
where constructed.
Form GW -1 North Carolina Department of Environmental Quality - Division of Water Resources Revised 2-22-2016
;l

WELL CONSTRUCTION RECORD GW -1
1. Well Contractor Information:
Wayne Thompson
Well Contractor Name
NCWC-2908 A
NC Well Contractor Certification Number
Ground Water Well And Pump Co
Company Name
2. Well Construction Permit #:
List all applicable well aonsbrrcrion permits (i.e. u1C, Comity, state, variance, etc.)
3. Well Use (check well use):
Water Supply Well:
For Internal Use Only:
14. WATER ZONES
FROM TO DFSCRUIMN
ft l ft
& ft
ISL 01rfER CASING for maiie-cssrti weft
FROM To AIAMETSR
O & 8 ft. in.
16. INNER CASING OR TUBING (geether
FROM I TO I DIAMETER
ft- ft
ft flt
r3Mlnicipal/Public 0 & ft
(Heating/Cooling Supply) DResideential Water Supply (single) ft ft
Immercial []ResidenlialWater Supply (shared) in r-Rnrrr
]Irrigation
Non -Water Supply Well:
Recharge
Storage and Recovery
Test
ental Technology
nal (Closed Loop)
Groundwater Remediation
Salinity Barrier
OStormwater Drainage
Subsidence Control
Tracer
rJOther (explain under #21 R
4. Date Well(s) Completed:1 /2/2019 Well ID#
Sa Well Location:
Gates County
Facility/Owner Name
Gatesville NC
Facility M# (if Wpliable)
Physical Address, City, and Zip
39 Will Ln
county Parcel Identifiratim No. (PIN)
5b. Latitude and longitude in degreWminutWseeonds or decimal degrees:
(if well field, one lat/long is sufficient)
N _ W
6. Is(are) the well(s)EIPermaneat or OTemporary
7. Is this a repair to an existing well: [3Yes or E5—N,
If this is a repair, fill out known well construction a formmiot and explain the nature ofthe
repair under #21 remarks section or on the back ofthis fo m.
8. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction, only 1 GW -1 is needed. Indicate TOTAL NUMBER of wells
drilled:
9. Total well depth below land surface: —1_ _ 00
For multiple wells list all depths if different (example- 3@200' and 2@100D
10. Static water level below top of casing: 3 �' 00
-If water level is above casing, use "+"
11. Borehole diameter: 6
12. Well construction method: Auger
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: Amount: _
Form GW -1
1 111111 V1111
'a 40 PVC
in.
Kit SLOT SIZE I THICIINESS I MATERIAL
in- 10 140 JPVC
to I qD
FROM TO MATERIAL EMPLACENUff METHOD & AMOUNT
d f`' G -P" Hole plug PORE
% it
19. SAND/GRAVEL PACK ($aaalicabiel
ft' I / fi- 1 PORE
ft
21L DRMLMG LOG attach additional slate if necessan
MOM
TO
DE4-k-, hwdwsm, uWrocic I in sae, etch
ft
g
ft.
C Lid
ft
tf2
f-
Ce-tlF,N
&
ft
ft.
ft
ft
ft.
ft
22=:(��
1/2/20019
Signature of Certified Well Iracior Date
By signing this form, I hereby certify that the well(s) was (were) constructed in accordance
with 15A NCAC 02C,0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
copy ofthis record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTRUCTIONS
24a. Ft2x All Wells: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Infection ells: In addition to sending the form to the address in 24a
above, also submit one copy of this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supply & Iniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
completion of well construction to the county health department of the county
where constructed.
Revised 2-22-2016 4
North Carolina Department of Environmental Quality - Division of Water Resources

WELL CONSTRUCTION RECORD GW -1
1. Well Contractor Information:
Wayne Thompson _
Well Contractor Name
NCWC-2908-A
NC Well Contractor Certification Number
Ground Water Well And Pump Co
Company Name
2. Well Construction Permit #:
List all applicable well cvnstnvcam permits (ie. UIC, Coun y, Sitar Variace, etc.)
3. Well Use (check well use):
Water supply Well:
]Agricultural ElMnnieipaUPublic
]Geothermal (Heating/Cooling supply) OResideuutial Water Supply (single)
]Industrial/Commercial DResidtntiai water Supply (shared)
Non -Water Supply Well:
Recovery
Recharge
QGroundwater Remediation
Storage and Recovery
Salinity Barrier
Test
OStormwaterDrainage
zmal Technology
oSubsidence control
mal (Closed Loop)
OTracer
!nal (lieatingfCooline Return)
nOther (cxolain under 421 F
4. Date Well(s) Completed: 1/2/2019 Well ID#
5s. Well Location:
Gates County
Facility/Owner Name Facility ID# (if applicable)
Gatesville NC
Physical Address, City, and Zip
39 Wiii Ln
County
Parcel Identification No. (PIIS
5b. Latitude and longitude in degrees/minutes/seeoads or decimal degrees.
(if well field, one lat/long is sufficient)
6. Is(are) the well(s)Ox Permanent or QlTemporary
7. Is this a repair to an existing well: Oyes or QNo
If this is a repair, fill out known well construction v fon>rafiat and ezplam the nature of the
repair under 421 remarks section or on the back of this form.
8. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction, only I GW -I is needed_ Indicate TOTAL NUMBER of wells
drilled: _ ?
9. Total well depth below land surface: ' 7 (ft)
For multiple wells Cut all depths ifdierent (example- 3@200' and 22@100)
10. Static water level below top of casing: v (ft.)
If water level is above casing, use "+ "
11. Borehole diameter: 6 (in.)
12. Well construction method. Auger
(i.e. auger, rotary, cable, direct push, etc.)
I nnL I Will
14. WATER ZONES
FROM TO
DFSCRUIXION
r ft, ft,
ver ice' �c
& &
19.OUTER CASUW fir mtlfi nsea OR LZrTER if a tfle
FROM
TO
DIAMETER iHICiiN£S5
MA-17dRiAR.
ft,
ft
in.
16. INNER CASING OR TUB11% (e�tlwrmaf closed -Ins
FROM To
DIAMETER TERCK LESS MATERIAL
ft fit
11m 40 PVC
fL &
in.
17. SCREEN
FROM TO DIAMETER SLOT SIZE I TIOCKNESS J MATERIAL
0 ft. &
in 10 140 PVC
13 fi- _ in10 1 qC)
18 GROUT
FROM TO
MATERIAL EMPLACEMENT METHOD& AMOUNT
0 ft. & ft,
Hole plug PORE
fL ft.
ft. ft.
19. SAND/GRAVEL PAC IZ Na liable
FROM TO
MATERIAL EMPLACEMENT METHOD
ft. ( ft.
PORE
nr I fir.
20. MKI.ING LOG attach �6saaf slams ii
FIW%l TO
DESCV"TWN ,iwdoen, k rain like, encu
C) ft ft.
S 7 -)Fr Gc
fL 13 f
r#FCLA /NE- SILT _St
fit f}
01
fit fl.
ft. fk
ft ft.
f. ft
2L REMARKS
22, Certification:
1!2/20019
Signature of Certified Well L 6nuactor Date
By signing this form, I hereby certify that the well(s) was (were) constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
copy of this record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTRUCTIONS
24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Infection Wells: In addition to sending the form to the address in 24a
above, also submit one Copy of this form within 30 days of completion of well
construction to the following:
r�
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
13a. Yield (gpm) Method of test: 24ca For Water Supink & Injection Wells: In addition to sending the form to
{ the address(es) above, also submit one copy of this form within 30 days of
13b. Disinfection type: Amount. _ i completion of well construction to the county health department of the county
— - where constructed.
Form GW -1 North Carolina Depurhnent of Euvirionmental Quality - Division of Water Resources Revised 2-22-2416 6

WELL CONSTRUCTION RECORD (GW -1)
1. Well Contractor Information:
Wayne Thompson
Well Comr.,wtor Name
NCWC-2908-A
NC Well Contractor Certification Number
Ground Water Well And Pump Co
Company Name
2. Well Construction Permit &
List all applicable well constrrrtwn perwits r.e. UIG Coswry, gate, Yarrmce, etc)
3. Well Use (checkwell use):
Water Supply Well:
Agrlenitural oNlnnicipaUPublic
Geothermal (Heating/Cooling Supply) OResidenhal Water Supply (single)
lndustrial/Commereial DResidential Water Supply (shwa)
Irti ation
Non -Water Supply Well:
Recharge
Storage and Recovery
Test
rental Technology
mal (Closed loop)
Groundwater Remediation
Salinity Barrier
ElStormwater Drainage
MSubsidence Control
MTraeer
4. Date Well(s) Completed:1 /2/2019
5a. Well Location:
Gates County
Facility/Caviar Name
Gatesville NC
Physical Address, City, and Zip
39 Will Ln
Under #21
wen l
Facility ID# (if applicable)
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one laillong is sufficient)
— - -N - -
6. Is(are) the well(s)fflPermaneut or Temporary
1 I 191 1 W4111
14. WATER ZONES
FROM To
DESCSIPMN
d (�
ft.
1 SAS
fL
I&OUTkACASING rrrsa�rnmd rtls ORIXffX ifa kabte
FROPII TO
ntAMF-rER
THH30E53 MA'fE.R1AL
o
&
� �-
n v
16. INNER CASING OR TUBING do ed
FROM TO
DIAMETER I TH CKNESS I MATERIAL
ft.
&
i]L 1 40 PVC
&
&
is
17. SCREEN
FROM TO
DIAMETER SWT%r". THICKNESS MATERIAL
0 &
in- 10 40 PVC
ft. ft.
a 1 O q
IR GROUT
FROM TO
MATERIAL EMPLACEMENT METHOD & AMOUNT
O IL 1-3
fa
Hole plug PORE
ft.
ft
ft.
ft.
19. SA 4D/GRAVEL PACK ifa inble
FROM TO
MATERIAL EMlLACEMENT METHOD
ft.
[t.
, 2 I PORE
ft.
ft
2a DRMLING LOG fa xd&tw&4 sheets N nerens r
MOM TO
DESCRICHOIV �ior,>mr ,s0itro[Ic 1 In s¢!, Err.l
CD ft. /
rt.
CUM
I
&
G� >VVIL f)Ivy B"e
ft.
ft.
&
fL
ft.
fr.
It.
ft.
ft.
2L REMARKS
22. Certifica 'o8:
W1 /2/20019
Sigoatme of Certified WelIT ontractor r Date
7. Is this a repair to an existing well: EJYes or QNo
If this is a repair, fill out known well construction it fWnsarion and eWabr die nature ofthe
repair under #21 remati'ra section or on the back of this forts.
8. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction, only 1 GW -1 is needed. Indicate TOTAL NUMBER of wells
drilled: ) Q
9. Total well depth below land surface: ! V (ft.)
For multiple wells list all depths ifdierent (example- 3@200' and 2@100)
10. Static water level below top of casing: � � , � o (ft.)
Ifwaterlevel is above casing, use "+"
11. Borehole diameter: 6 (in.)
12. Well construction method: Auger
(i.e. auger, rotary, cable, direct push, etc.)
By signing this foray, I hereby certify that the well(s) was (were) constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
copy afthis record has been povnded to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Infection Wells: In addition to sending the form to the address in 24a
above, also submit one copy of this form within 30 days of completion of well
construction to the following:
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center Raleigh NC 27699-1636
13a. Yield (gpm)
13b. Disinfection type:
Method of test: 24c. For Water Suppty & Iniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
Amount: completion of well construction to the county health department of the county
-- where constructed.
Form GW -1 North Carolina Department ofEnvironmental Quality - Division of Water Resources Revised 2-22-2016 7

Jinn I vnu
WELL CONSTRUCTION RECORD (GW -1) I For Internal Use Only:
1. Well Contractor Information:
Wavne Thompson
Well Contractor Name
NCWC-2908-A
FROM TO
NC Well Contractor Certification Number
DFSCRUIMN
Ground Water Well And Pump Co
Company Name
2. Well Construction Permit #:
List all applicable well cwutrrct- permits #e. UIC, Coavxy, St -e, Yaramace, etc)
3. Well Use (check well use):
Water Supply Well:
15.OUTERCA.SiNG %atct�dRel4s OR LINER if
3Agricultural
r3mmicipal/Prrblic
71Geothenml (Heating/Cooling Supply)
E31tesidential Water Supply (single)
_11adushial/Commercial
OResidentiid Water Supply (shored)
7�lrri Aion
i- y D
_
Non -Water Supply Well:
16. INNER CASING OR TUBING [ dw"oal dwofd-kwipp
Monitoring
r3Rccovery
Injection Well:
DIAMETER I THICKNESS
Aquifer Recharge
E)Groundwater Remediation
Aquifer Storage and Recovery
Salinity Barrier
Aquifer Test
C)Stormwater Drainage
DExperimental Technology
OSubsidence Control
Geothermal (Closed Loop)
E3Tracer
Geothermal (Heating/Cooling Return)
Other (explain under #21 Remarks)
4. Date Well(s) Completed: 112/2019
FROM TO
DIAMETER SLOT Srl.E TIDCIOUM
wellmm
Sa. Well Location:
ft
Gates County
PVC
Facility/Owner Name
Facility W# (if applicable)
Gatesville NC
0
Physical Address, City, and Zip
39 Will Ln
County
Parcel Identification No_ (PIN)
5b. Latitude and longitude in degrees/minutWiseconds or decimal degrees:
(if well field, one lat/long is sufficient)
T N ._.
6. Is(are) the well(s)�x Permancut or Temporary
14, WATER ZONES
FROM TO
DFSCRUIMN
&
15.OUTERCA.SiNG %atct�dRel4s OR LINER if
hlr
FROM TO
DIAMETER THICirNE.SS
MATERIAL
fL
i- y D
vC
16. INNER CASING OR TUBING [ dw"oal dwofd-kwipp
TO
DIAMETER I THICKNESS
MATERIAL
ft
ft.
is 40
PVC
ft
ft.
is
17. SCREEN
FROM TO
DIAMETER SLOT Srl.E TIDCIOUM
MATERIAL
0 ft-
ft
is 10 40
PVC
I f. l
� 10
0
II GROUT
FROM TO
MATERIAL XAfPLACEMENT METHOD & AMOUW
Hole plug PORE
ft.
ft.
&
ft.
19. SANMRAVEL PACK if ble
TO
MATERIAL EM2LACEMENT METHOD
ft.
2 PORE
PDRULLUM
ft.
LOG attach adtlisaa[ stems ifnecessary1
TO
DF_SC 0MON leular, haedaes, wWrock tv in sse, eta)
fL
%
ft.
&
ft.
ft.
fL
ft
2L REMARKS
22. Certifc i
W � 112/20019
Signature of Certified Well (,ntracto- Date
7. Is this a repair to an existing well: [3Yes or ONo
If ties is a repair, fill out knowrn well construction information mid explain the nature ofdw
repair under #21 remarks section or on the back of this form.
8. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction, only 1 GW -1 is needed. Indicate TOTAL NUMBER of wells
drilled: - - -- /
9. Total well depth below land surface: '1% (ft.)
For multiple wells list all depths ifdierent (example ;@200' and 2@100')
10. Static water level below top of casing: t' 7 (ft)
Ifwater level is above casing use "+"
11. Borehole diameter., 6 (in.)
12. Well construction method: Auger
(i.e_ auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm)
13b. Disinfection type:
Form GW -1
Method of test:
Amount:
By signing this form, I hereby certify that the well(s) was (were) constructed in accordance
with 15A NCAC 02C _0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
copy gfthis record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTRUCTIONS
24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Iniectioa Wells: In addition to sending the form to the address in 24a
above, also submit one copy of this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supply & Infection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this fort within 30 days of
completion of well construction to the county health department of the county
where constructed.
Revised 222-2016
North Carolina Department of Environmental Quality - Division of Water Resources

WELL CONSTRUCTION RECORD (GW -1
1. Well Contractor Information:
Wavne Thompson
Well Contractor Name
N CWC -2908 A
NC Well Contractor Certification Number
Ground Water Well And Pump Co
Company Name
TO AFSCRIP lTO1C
2. Well Construction Permit#:
1-7 fL
List all applicable well constt ua— pewits (t e. UIC, Cowry, Stere, Vari—, etc.)
3. Well Use (check well use):
I& OUTER CASING tons neffi-cawd weftOR lidNER if
Water Supply Well:
TO DIAMETER
]Agricultural
[IMumeipaliPublie
_JGeothennal (Heating/Cooling Supply)
DResidentiai Water Supply (single)
711ndustrial/Commercial
1311esidential Water Supply (shared)
�ILCis-'3tiOn
FROM
Non -Water Supply Weil:
ft.
DMonitoring
�a 'iRecovery
-
Injection Well:
I7. SCREEN
DAquifer Recharge
QGrormdwater Remediation
DAquifer Storage and Recovery
Salinity Barrier
Aquifer Test
QStomtwater Drainage
'Experimental Technology
13Subsidence Control
Geothermal (Closed Loop)
OTracer
DGeothermal (Heating/Cooling Return)
t., L, E 1,, = (explain under #2l Remarks)
4. Date Well(s) Completed: 112/2019
WeU Iv# 9
R
—
IF
5a. Well Location:
FROM
Gates County
Z
Facility/Owner Name
Facility W# (if applicable)
Gatesville NC
28. DRIQ.LING LOG jaituh ad�tieunt if ecressr
Physical Address, City, and Zip
_ L
39 Will Ln
t. cL L0
County
Parcel Identificatian No. (PIN)
5b. Latitude and longitude in degreealmiaates/secoads or decimal degrees:
(if well field, one lat4ong is sufficient)
ft
N
W
6. hare) theweif(s)0x Permanent or Temporary
A IIIRI Valli
14. WATER ZONES
FROM
TO AFSCRIP lTO1C
Iq fL
1-7 fL
ft.
ft
I& OUTER CASING tons neffi-cawd weftOR lidNER if
FROM I
TO DIAMETER
THICKWFSS
rr
® ft 1G
fL is-
1b.INNERCASMORT[JIiINGJUsIdwrmaldvsr44w
FROM
TO DIAMETER MUCKWM MATERIAL
ft.
ft. is 40 PVC
&
ft in.
I7. SCREEN
FROM TO DIAMETER SLAT SIZE TRICKINESS MATERIAL
0
'" 10 40 PVC
1 ft in. 10 90
I& GROUT
FROM
TO MATERIAL 12APIACENUM METHOD & AMOUW
Q ft
/ Z— Hole plug PORE
ft.
ft
R
fl.
19. SANDIGRAVEL PAC $ ifa
FROM
TO MATERIAL IIYI[LACIIVIENT METHOD
Z
7 & - PORE
fit
ft
28. DRIQ.LING LOG jaituh ad�tieunt if ecressr
FROM
TO L1FSGintI1ON ate.& "'M rain size, ctr-T
t. cL L0
,2—fL
C r? SOy»� 1 x r S;+c Ssq
ft
ft
ft
ft
ft
f.
ft
ft
%
ft
2L REMAR"
21 Certifrca' n: /� /�7
1/2/20019
Sigaatme of Certified Well Contractor Date
By sluing this form, I hereby certify that the well(s) was (were) constructed in accordance
7. Is this a repair to an existing well: nYes or [3No with 15A NCAC 02C.0100 or 15A NCAC 02C _0200 Well Construction Standards and that a
If this is a repair, fill ow known well cwurirrction information and explain the nature ofthe copy of this record has been provided to the well owner.
repair under #21 remarks section or an the back of this form. 23. Site diagram or additional well details:
8. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction, only I GW -1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9. Total well depth below land surface: Z I. .(ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different (example- 3@200: and 2@100) construction to the following:
10. Static water level below top of casing:
If water level is above casing, use "+ "
11. Borehole diameter: 6 (in,)
12. Well construction method: Auger
(i.e. auger, rotary, cable, direct push, etc.)
{) Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Injytion Wells: In addition to sending the form to the address in 24a
above, also submit one copy of this form within 30 days of completion of well
construction to the following:
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
13a. Yield (gpm) _ Method of test: 24e. For Water Supply & Inieetion Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b. Disinfection type: Amount: completion of well construction to the county health department of the county
where constructed.
Form GW -1 North Camlina Department of Environmental Quality - Division of Water Resources Revised 2-22-2016