GW1 - Pender 2018

WELL CONSTRUCTION RECORD fGW-1) _
1. Well Contractor Information: R�CI�.�Jji�tall�lli��1lYl�at;
Donald Cummings
Well Contractor Name
2412-A
DEC 10 2018
NC Well Contractor Certification Number Water Quality Regional
Applied Resource Mawarent, E rC
Company Name
2. Well Construction Permit #:
List all applicable well construction permits (i.e. U1C•, County, State, Variance, etc)
3. Well Use (check well use):
W18-23B
Water Supply Well:
Agricultural
Geothermal (Heating/Cooling Supply)
Industrial/Commercial
X Irrigation
Non -Water Supply Well:
Monitoring
Injection Well:
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
Experimental Technology
Geothermal (Closed Loop)
Geothermal (Heating/Cooling Return)
Municipal/Public
DX Residential Water Supply (single)
Residential Water Supply (shared)
Recovery
DGroundwater Remediation
Salinity Barrier
DStormwater Drainage
Subsidence Control
DTracer
Other (explain under 421 Remarks)
4. Date Well(s) Completed: 10/31 /18 Well ID# N/A
5a. Well Location:
Ash Bell
N/A
Facility/Owner Name Facility IDN (if applicable)
2636 Brinson Road, Currie, NC 28435
Physical Address, City, and Zip
Pander 2276-62-0731
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
34 28 06.42 N 78 05.01
W
6. Is(are) the well(s)1Permanent or Temporary
7. Is this a repair to an existing well: DYes or DNo
If this is a repair, fill out known well construction information and explain the nature of the
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 dwells
drilled;
9. Total well depth below land surface: 260 (ft.)
For multiple wells fist all depths f dlerenr (example- 3 ir200'and 21'0100')
10. Static water level below top of casing: 23 (ft.)
If water level is above casing, use "+"
11. Borehole diameter: 8" (in.)
12. Welt construction method: Mud Rotary
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) sa Method of test: Air lift
13b. Disinfection type: HTH Amount: 3%@10 g
Print Form
For Internal Use Only:
182
• I4. WATER ZONES /1"
FROM
TO
DESCRIPTION
ft.
ft.
ft.
ft.
15. OUTER CASING (for multi -cased wells OR LINER (if a licable)
FROM
TO
DIAMETER THICKNESS
MATERIAL
0 ft'
200 ft.
4 in' �
SCH40
PVC
16. INNER CASING OR TUBING (geothermal closed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft.
ft.
in.
ft.
ft
in.
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
200 ft.
260 ft.
4 in'
.010
SCH40
PVC
ft.
ft.
in.
18. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
0 ft.
30 ft.
Bentonite
Poured
180 ft.
190 ft.
Bentonite
Poured
ft.
ft.
19. SAND/GRAVEL PACK (if applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
190 ft.
260 ft.
Coarse
Poured
ft.
ft.
20. DRILLING
LOG (attach additional sheets if necessary)
FROM
TO
DESCRIPTION (color, hardness, soil/rock type, grain size, etc.)
0 rt•
40 ft.
Alternating sand and clays
40 ft.
200 ft.
Clay with small rock tense
200 ft•
260 ft.
Rock layers (4'-6') with clay layers
ft.
ft.
ft.
ft,
ft.
ft.
ft.
ft
- - q
,..A
21. REMARKS 4 J;'`')
: r,
10
22. Certification:
11/26/18
S ma ure of Certified Well Contractor i Date
By signing this form, 1 hereby certt& that the well(s) was (were)constructed in accordance
with /5A 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 diagsarn ot:a.dditional.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:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Sunnty & 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.
Form GW-1
North Carolina Department of Environmental Quality - Division of Water Resources Revised 2-22-2016

RECEIVED/NCDENR/DWR
1. WELL CONTRACTOR:
Sane Drilling and Pump Services LLC.
Well Contractor (Individual) Name
Michael C. Sage
Well Contractor Company Name
STREET ADDRESS 204 Tom Ave
Castle Hayne NC
City or Town State
g( 10 )_ 231-6669
Area code- Phone number
2. WELL INFORMATION:
NOV 1 3 2018
ter Quality Regional.
, S Ia1
perationpSl�ff0 ma Department of Environment and Natural Resources- Division of Water Quality
in(on Regional Office 4119-A
WELL CONTRACTOR CERTIFICATION #
f. DISINFECTION: Type
g. WATER Z9NES (de th):
From_ To - bo From To
From To From To
To From To
From
7. CASING: Thickness/
Depth i Di eter Weight Ma ria
28429 From -i-. To (/ Ft.
Zip Code From To Ft.
From To Ft.
8. GROUT: Depth atenal Method ('
From 0) To, .3 Ft. en ion ae l ( 4- i t
SITE WELL ID #(if applicable)
3. WELL USE (Check ApRlicable Box):
DATE DRILLED
TIME COMPLETED
4. WELL LOCATION:
CITY:
WELL CONSTRUCTION PERMIT# t -(-i)t (-1
OTHER ASSOCIATED PERMIT#(if applicable)
Residential Water Supply 0
AM O PM
COUNTY
Cbs
(Street Name, Numbers, ommunity, Subdivision, Lot No., Parcel, Zip Code)
5. WELL OWNER
OWNER'S NAME ..
STREET ADDRESS , 13ii Oecloy Ln>
__L43_._E--�-�
City or Town rS Zip Code
Area code - Phone number
RESIDENTIAL WELL CONSTRUCTION RECORD
TOPOGRAPHIC f LAND SETTING:
0 Slope 0 Valley 0 Flat 0 Ridge 0 Other
(check appropriate box)
LATITUDE _-
LONGITUDE— _
Latitude/longitude source: 0 GPS 0 Topographic map
(location of well must be shown on a USGS topo map and
attached to this form if not using GPS)
t Lawkf
May be in degrees,
minutes, seconds or
in a decimal format
6. WELL DETAILS:
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL?YES0,1 ' NO
c. WATER LEVEL Below Top of Casing:
(Use "+" if Above Top of Casing)
d. TOP OF CASING IS -4- -1 fla FT. Above Land Surface*
*Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118..
•
e. YIELD (gpm): J) METHOD OF TEST A I lE 1 t
FT.
Amount', t 6,
From To Ft.
From To Ft.
9. SCREEN' Depth ��/ Diam ter Slot Size ate al
From_„O� To 1 I V Ft. 4, in. 1() in. �%
From To Ft. in. in.
From To Ft. in. in.
10. SAND/GRAVEL PACK:
Depth�/ Size
1
From / () To 1 I b Ft..
3 From To Ft.
From To Ft.
11. DRILLING LOG
From To
— 10
i0 O'
a0' -- 60
601 t7s
Material
we (� (catwei
Formation D
)1NIec-)e Kok
c 1c& y 7/ /Aw% Foci<
7 S'— I l eV 411114 Katpe
12. REMARKS: ,+ ` ' 1
ac
cwcf) `
i UC
•-t- en ;< eMb
1 00 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECORD HAS SEE L PROVIDF. p TO THE WELL OWNER.
SIGIVATURE'CEFt t IF WELL CONTRACTOR DATE
Michael C. Sage
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit he original Division Water Information Mgt.,
16MalSery Center- Raalgh NC 2799-7Phne No. [phone] ext 568.
Form GW-la
Rev. 3/07

WELL CONSTRUCTION RECp jGW-I)
wiluirin
1. Well Contractor Information:
John Salmon
Well Contractor Name
3797-A
2 2 lC13
NC Well Contractor Certification Number Water Quality Regional
al
Applied Resource Managerr►en ,! r,'nfice
Company Name
2. Well Construction Permit #:
List all applicable well construction permits (i.e. UIC, County, State, Variance, etc.)
3. Well Use (check well use):
W18-032B
Water Supply Well:
Agricultural
Geothermal (Heating/Cooling Supply)
Industrial/Commercial
Irrigation
Non -Water Supply Well:
Monitoring
Injection Well:
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
Experimental Technology
Geothermal (Closed Loop)
Geothermal (Heating/Cooling Return)
4. Date Well(s) Completed: 8/31/18
5a. Well Location:
Jerry Dixon
OMunicipal/Public
XoResidential Water Supply (single)
Residential Water Supply (shared)
QRecovery
.QGroundwater Remediation
Salinity Barrier
Stonnwater Drainage
Subsidence Control
Tracer
EllOther (explain under #21 Remarks)
Well ID# N/A
N/A
Facility/Owner Name Facility ID!! (if applicable)
Lot 4 Meeks Creek Drive; Rocky Point, NC
Physical Address, City, and Zip
Pender
3258-54-3392-0000
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
34 31 32.42 N 77 49 13.69
6. Is(are) the well(s)x Permanent or DTemporary
7. Is this a repair to an existing well: QYes or ONo
if this is a repair, fill out known well construction information and explain the nature of the
repair render II21 remarks .section or on. the hack 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: 1
9. Total well depth below land surface: 175
For multiple welly fist all depths rfd(ffereae(example-3 200'and2rx100')
10. Static water level below top of casing: 12
If water level is above casing, use "+"
11. Borehole diameter: 8 (in.)
12. Well construction method: Mud Rotary
(ft.)
(ft.)
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) 60 Method of test: Airitft
0
13b. Disinfection type: HTH Amount: 3 /o @ 10g
For Internal Use Only:
45a►O0I�
Print Form
14. WATER ZONES
FROM
TO
DESCRIPTION
ft.
ft.
ft.
ft.
15, OUTER
CASING (for
multi -cased wells) OR LINER (if ap licable)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
0 ft.
155 ft.
4 in.
SCH40
PVC
16. INNER
CASING OR TUBING
(geothermal closed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft.
ft.
in.
ft.
ft.
in.
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
155 ft.
175 ft.
2 in.
.010
SCH40
PVC
ft.
ft.
in.
18. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
0 ft.
35 ft.
Bentonite
Poured
115 ft.
150 ft•
Bentonite
Poured
ft.
ft.
19. SAND/GRAVEL
PACK
(if applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
150 ft•
175 ft.
Coase
Poured
ft.
ft.
20. DRILLING LOG (attach additional sheets if necessary)
FROM
TO
DESCRIPTION (color, hardness, soiVrock type, grain size, etc.)
0 ft.
45 ft,
Fine sand
45 ft
152 ft.
Clay
152 ft.
175 ft'
Silty sand
ft,
ft.
ft.
ft.
1fd — -
ft.
ft.
, u.
q
21. REMARKS
22. Certification:
Si attire of Certified Well Contractor
8/31/18
Date
By signing this form, 1 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
constntction 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 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.
Form GW-1
North Carolina Department of Environmental Quality - Division of water Resources Revised 2-22-2016

WELL CONSTRUCTION RECORD ( Erk Eo/NrDENR/CNJRr Internal Use Only:
Print Form
1. Well Contractor Information:
Sanford Sweeting
Well Contractor Name
2082-A
Water Quality Regi
OCT 022.01
NC Well Contractor Certification Number
Operations Secti�
Applied Resource Management nEketegional
Company Name
2. Well Construction Permit #:
List all applicable well construction permits (i.e. UIC, County, Stale, Variance, etc)
3. Well Use (check well use):
N/A
Water Supply Well:
Agricultural Municipal/Public
Geothermal (Heating/Cooling Supply) DResidential Water Supply (single)
Industrial/Commercial DResidential Water Supply (shared)
X Irrigation
Non -Water Supply Well:
Monitoring DRecovery
Injection Well:
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
Experimental Technology
Geothermal (Closed Loop)
Geothermal (Heating/Cooling Return)
Groundwater Retnediation
Salinity Barrier
DStormwater Drainage
[Subsidence Control
Tracer
Other (explain under #21 Remarks)
4. Date Well(s) Completed: 8/23/18 Well ID# N/A
5a. Well Location:
Jimmy Wolfe
N/A
Facility/Owner Name Facility ID# (if applicable)
214 Hughes Road, Hampstead, NC 28443
Physical Address, City, and Zip
Pender 3282-82-3650-0000
County Parcel identification No. (PiN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
34 21 16.32 N 77 42 47.15
6. Is(are) the well(s)JPermanent or DiTemporary
7. Is this a repair to an existing well: DYes or DNo
If this is a repair, fill out known well conslluctian information and explain the nature of the
repair under 2/ 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: 1.
9. Total well depth below land surface: 92
For nndiiple wells list all depths if different' (example-3' c200' and 2,a;1011')
10. Static water level below top of casing: 1 1
If water level is above casing, use •'-"
11. Borehole diameter: See Remark (in )
12. Well construction method: Mud Rotary
(ft.)
(ft.)
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) 80 Method of test: Airlift
13b. Disinfection type:HTH
Amount: 3 0 �o @ 10g
41
'.
14. WATER ZONES
3 FROM
TO
DESCRIPTION
ft.
rt.
lal ft.
ft.
)11 15, OUTER
CASING (for
multi -cased wells) OR LINER (if ap licable)
Urvorem
TO
DIAMETER
THICKNESS
MATERIAL
0 ft•
56 ft.
4 in•
SCH40
PVC
16. INNER
CASING OR TUBING
(geothermal closed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft.
fL
in.
ft.
ft.
in.
17. SCREEN
FROM
TO
DLkMt,1tR
SLOT SIZE
THICKNESS
MATERIAL
ft.
ft.
in.
ft.
ft.
in.
18. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
0 ft•
25 ft.
Bentonite
Poured
ft.
- ft.
ft.
ft.
19. SAND/GRAVEL
PACK
(if applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
ft.
ft,
fL
ft.
20. DRILLING LOG (attach additional sheets if necessary)
FROM
TO
DESCRIPTION (color, hardness, soiVrock type, grain size, etc.)
0 ft.
5 fit.
Fine sand
5 ft.
40 ft•
Silty clay
40 ft•
92 ft•
Limestone
ft.
ft.
ft.
ft.
r k e .
8 a 1
E
fit.
ft.
-P
�h.'1s 'L„
ft.
ft.
p-
SEP ZIJ10
21. REMARKS •
�5��" ingorinatton Prof.... r,y :-4.".
6. / lb
o?�' lv 92': I-/��3 ox.t.:ilb�.�:�
22. Certif atio,
8/23/18
edified Well Contractor Date
By . igning this form, I hereby cert(, 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 fonn 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 foam to the address in 24a
above, also submit one copy of this fonn 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.
Fonn GW-1
North Carolina Department of Environmental Quality - Division of Water Resources Revised 2-22-2016

WELL CONSTRUCTION RECORD (GW-1)
RECE1VED/NCDENR/DWR
1. Well Contractor Information:
Print Form
For Internal Use Only:
Donald Cummings
Well Contractor Name
2412-A
OCT 02/018
NC Well Contractor Certification Number Water Quality Regional
Applied Resource Man4960glePrcZ iCe
Company Name
2. Well Construction Permit #:
List all applicable well construction permits (i.e. UIC, County, State, Variance. etc.)
3. Well Use (check well use):
Water Supply Well:
W1 8-023H
Agricultural
Geothermal (Heating/Cooling Supply)
Industrial./Commercial
Irri cation
QMunicipal/Public
DResidential Water Supply (single)
Residential Water Supply (shared)
Non -Water Supply Well:
Monitoring
Injection Well:
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
Experimental Technology
Geothennal (Closed Loop)
Geothermal (Heating/Cooling Retum)
Recovery
DGroundwater Remediation
Salinity Barrier
DStorrnwater Drainage
Subsidence Control
DTracer
Other (explain under #2I Remarks)
4. Date Well(s) Completed: 8/28/18 Well ID# N/A
5a. Well Location:
Kingpost Builders N/A
Facility/Owner Name Facility ID# (if applicable)
Ballast Point, Lot 8, Hampstead, NC 28443
Physical Address, City, and Zip
Pender 4224-26-5310-0000
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
34257.16 N 77 35 57.23
6. Is(are) the well(s)JPermanent or DTetnporary
7. Is this a repair to an existing well: DYes or DM)
If this is a repair, fill out known well construction information and explain the nature of the
repair under '21 remarks section or on the hack "f 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: 1
9. Total well depth below land surface: 295
For multiple wells list all depths f different (example- _ @200' and 2"Tz1100')
(ft.)
10. Static water level below top of casing: 1 1 (ft,)
1f water level is above casing, use "+"
11. Borehole diameter: 8 (in.)
12. Well construction method: Mud Rotary
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. field (gpm) 60 Method of test: Airlift
HTH
0
13b. Disinfection type: Amount: 3 /o @ 10g
14. WATER ZONES tra
tt 1 et),
FROM
TO
DESCRIPTION
ft.
ft.
ft.
ft.
15. OUTER CASING (for multi -cased wells) OR LINER (if ap licable)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
0 ft.
275 ft.
4 in.
SCH40
PVC
16. INNER CASING OR TUBING (geothermal closed -loop
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft,
ft,
in.
ft.
ft.
in.
17.SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
275 ft•
295 ft•
2 in.
.010
SCH40
PVC
ft.
ft.
to.
18. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
0 ft•
20 ft•
Bentonite
Poured
ft.
ft.
ft.
ft.
19. SAND/GRAVEL PACK (if applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
ft.
ft.
ft.
ft.
20. DRILLING LOG (attach additional sheets if necessary)
FROM
TO
DESCRIPTION (color, hardness, soiVrock type, grain size, etc.)
0 ft.
80 ft.
Sandy silt
80 ft,
120 ft
Limestone
120 ft'
275 ft'
Clay sand
275 ft•
295 ft•
Sandstone heavy sand
ft.
ft.
_
t
r- + t-- t d I. . e...'
ft.
ft.
21. REMARKS SE? 1 % 1( b
Tri packer set at 155' , jI kin''''
y R'�rtttrilh, ri;'''sr> % ,
22. Certification:
J.1.4uA 4
Signature of Certified Well Contractor
8/28/18
Date
By signing this form, 1 hereby certify that the well(s) was (were) constructed in accordance
with ISA NCAC 02C .0100 or I5A NCAC 02C .0200 Well Construction Standards and that a
copy of this record has been provided to the well owner.
23: Site diagram, or adlli.tioual.wetL_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 MI 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 fonn to the address in 24a
above, also submit one copy of this form within 30 days of completion of Nve1l
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.
Form GW-I
North Carolina Department of Environmental Quality - Division of Water Resources Revised 2-22-2016

WELL CONSTRUCTION RECORD (GW _Fos Internal Use Only:
F iCEll►ED/NCDENR%DWR
1. Well Contractor Information:
Donald Cummings
Well Contractor Name
2412-A
0-CT 02
Water Quality
NC Well Contractor Certification Number
F
Applied Resource ManagemeP . n't,ii. nktt)n Regiotions SE
Company Name
2. Well Construction Permit #:
List al! applicable well construction pennits (i. e. UIC, County, State, Variance, etc.)
W1 8-030H
3. Well Use (check well use):
Water Supply Well:
Agricultural
Geothermal (Heating/Cooling Supply)
Industrial/Commercial
Irrigation
DMunicipal/Public
XDResidential Water Supply (single)
DResidential Water Supply (shared)
Non -Water Supply Well:
Monitoring
0 Recovery
Injection Well:
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
Experimental Technology
Geothermal (Closed Loop)
Geothermal (Heating/Cooling Retum)
QGroundwater Remediation
DSalinity Barrier
Stormwater Drainage
Subsidence Control
Tracer
DOther (explain under #21 Remarks)
4. Date Well(s) Completed: 8/27/18
5a. Well Location:
Don Beckham
Well ID# N/A
N/A
Facility/Owner Name Facility IDIl (if applicable)
104 Machine Gun Road, Hampstead, NC 28443
Physical Address, City, and Zip
Pender 4215-14-8995-0000
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one latflong is sufficient)
34 26 34.9 N 77 37 59
W
6. Is(are) the well(s)1Permanent or DTemporary
7. Is this a repair to an existing well: DYes or EjNo
If this is a repair, fill our known well construction information and explain the nature of the
repair under'21 remarks section or on the hack of this form
8. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction. only I GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled: 1
9. Total well depth below land surface: 1 10
For multiple wells list all depths if different (example- _ @,200' and 20)100')
10. Static water level below top of casing: 16
If water level rs above casing, use •'+"
11. Borehole diameter: See Remal4(in )
12. Well construction method: Mud Rotary
(ft.)
(ft.)
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) $0 Method of test: Airlift
HTH 0
13b. Disinfection type: Amount: 3% @ 10g
Print Form
! WATER ZONES Oyu 1 f5
]} oM
TO
DESCRIPTION
ft.
ft.
ft.
'Eginnal
ft.
'Ct POUTER
CASING (for
multi -cased wells) OR LINER (if a licable)
na �ceft.
TO
DIAMETER
THICKNESS
MATERIAL
90 ft.
4 i"•
SCH40
PVC
16. INNER
CASING OR TUBING
(geothermal closed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft.
ft.
in.
ft.
ft.
in.
17. SCREEN
—
FROM
TO
DIAMETER
SLAT SIZE
THICKNESS
MATERIAL
90 ft•
110 ft•
4 in-
.010
SCH40
PVC
ft.
ft.
in.
18. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
0 ft.
25 ft•
Bentonite
Poured
80 ft.
85 ft.
Bentonite
Poured
ft.
ft.
19. SAND/GRAVEL PACK
(if applicablee)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
85 ft•
110 ft•
Coarse
Poured
ft.
ft.
20. DRILLING
LOG (attach additional sheets if necessary)
FROM
TO
DESCRIPTION (color, hardness, soiVrock type, grain size, etc.)
0 ft'
55 ft.
Clay/sands
55 ft.
145 ft•
Limestone
145 ft•
230 rt.
Mudrock/clays
230 ft.
305 ft.
Sandstone/Clay layers
ft.
ft.
p T.
�.�
ft.
ft.
#gam
`a f a SI?'• .)
n
21. REMARKS e
2018
0' to 25' = 8" 25' to 306' = 6" c r 1 '
1 (!Tit tioi1 Pita:'-S`.sy-+� 'JAI
22.
!cation:
8/27/18
Signature of Certified Well Contractor V Date
By signing this form, 1 hereby certify that the well(s) was (were) constructed in accordance
with 15A NCAC 02C .0100 or 1SA 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 welt 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 AN Wells: Submit this font 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 fonn 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 fonn 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.
Form GW-I
North Carolina Department of Environmental Quality - Division of Water Resources Revised 2-22-2016

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department�of Environment and Natural Resources- Division of Water Quality
WELL CONTRA tl�EMMIRO{ # 2314A
1. WELL CONTRACTOR:
DAVID L RES LSTER
Well Contractor (Individual) Name
REGISTER WELL CO., WC
Well Contractor Company Name
721 WEST CHARITY ROAD
Street Address
ROSE HILL
City or Town
( 910) 289-3175
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT# W18-096B
OCT 02 2018
Water Quality F?cgionr
Operations
eganal OffieTo
p 0CASING: Depth
Bottom 177
Top
Top
45R4e2
g. WATER ZONES (depth):
Top Bottom Top
Bottom Top
Bottom Top
OTHER ASSOCIATED PERMIT#(t applicable)
SITE WELL ID #(if applicable)
3. WELL USE (Check Applicable Box): Residential Water Supply tiff
DATE DRILLED 08-28-2018
TIME COMPLETED AM 0 PM 0
4. WELL LOCATION:
CITY: ATKINSON COUNTYPENDER
3984 BEATTYS BRIDGE ROAD
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope ❑Valley 'Flat ❑Ridge ❑Other
LATITUDE " DMS OR N34.547879 DD
LONGITUDE " DMS OR W78.220936 DD
Latitude/longitude source: I PS Oropographic map
(location of well must be shown on a USGS topo map andatfached to
this form if not using GPS)
5. WELL OWNER
ROSEMARY EHRENFELD
Owner Name
3984 BEATTYS B__RIDGE ROAD
Street Address
ATKINSON
City or Town
Area code Phone number
6. WELL DETAILS:
NC 28421
State Zip Code
Diameter
Ft. 4
Top Bottom Ft.
Top Bottom Ft.
Bottom
Bottom
Bottom
Thickness/
Weight Material
.40 PVC
8. GROUT: Depth Material
Top 0 Bottom 20 Ft. HOLE PLUG
Top Bottom Ft.
Top Bottom Ft.
Method
POURED
9. SCREEN: Depth Diameter Slot Size Material
Top 177 Bottom 192 Ft.4 in. .016 in. PVC
Top Bottom Ft. in. in.
Top Bottom Ft. in. in.
10. SAND/GRAVEL PACK:
Depth
Top 175 Bottom 210
Top Bottom
Top Bottom Ft.
11. DRILLING LOG
Top Bottom
0 /20
20 /85
85 /86
86 /103
103 /104
104 /115
115 /120
120 /150
150 /158
158 /170
170 /175
175
/192
192 /210+
SEP 12. REMARKS:
a. TOTAL DEPTH: 192 J0 208
NC 28458
State Zip Code
c. WATER LEVEL Below Top of Casing: 42
(Use "+" if Above Top of Casing)
d. TOP OF CASING IS 1.5 FT. Above Land Surface*
*Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): 35 METHOD OF TEST AIR
b. DOES WELL REPLACE EXISTING WELL? YES Wrec rg
.Inv I DO HEREBY CERT F,,Y�,I fa,Th HHI rWLC V)*S CONSTRUCTED IN
ACCORDANCE WITH'1'SA NC(iq;2O,CW L CONSTRUCTION
STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN
PRO'ED TO THE WELL OWNE
Size Material
Ft. #2 GRAVEL
Ft.
Formation Description
CLAY
SAND AND CLAY
ROCK 12"
SAND (MED)
ROCK 6"
SAND (MED)
ROCK AND SAND
SAND (MED)
SAND AND CLAY
CLAY
ROCK 5'
SAND (MED)
SAND AND CLAY
.
rr�`9 i�,D�a.c.
`v+
f. DISINFECTION: Type HTH Amount 4 OZ
SE' 0 6 2018
08-30-2018
SIGNATURE OF CERTIFIED WELL 1ONTRACTOR DATE
DAVID L REGISTER
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
CU/r/Z;C r
Submit within 30 days of completion to: Division of Water Quality - Information Processing,
1617 Mail Service Center, Raleigh, NC 27699-161, Phone : [phone]
Form GW-la
Rev. 2/09

WELL CONSTRUCTION RECORD (_GW-1)
RECEIVED/NCDENR/DWR
1. Well Contractor Information:
Sanford Sweeting
Well Contractor Name
2082-A
Company Name
SEP 1 0 2018
NC Well Contractor Certification Number Water Quality Regional
Applied Resource Manasgeretet s PCt'all
Wilmington ej ioiia Office
2. Well Construction Permit #:
List all applicable well construction permits (i.e. VIC, County, Slate, Variance, etc)
3. Well Use (check well use):
N/A
Water Supply Well:
Agricultural
Geothermal (Heating/Cooling Supply)
D Industrial/Commercial
IMIrrigation
Non -Water Supply Well:
Monitoring
Injection Well:
DAquifer Recharge
DAquifer Storage and Recovery
DAquifer Test
DExperimental Technology
Geothermal (Closed Loop)
Geothermal (Heating/Cooling Retum)
® Municipal/Public
▪ Residential Water Supply (single)
DResidential Water Supply (shared)
QRecovery
Groundwater Remediation
Salinity Barrier
JJStormwater Drainage
DSubsidence Control
13Tracer
Other (explain under #21 Remarks)
4. Date Well(s) Completed: 7/13/2018 Well ID# N/A
5a. Well Location:
Earl Goesswein
N/A
Facility/Owner Name Facility ID# (if applicable)
715 Corcus Ferry Circle Hampstead NC 28443
Physical Address, City, and Zip
Pender 3292-38-9703-0000
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
34 22 16.49 N 77 41 40.75
W
6. Is(are) the well(s){x Permanent or OTemporary
7. Is this a repair to an existing well: ®Yes or xZNo
If this is a repair, fill ow known well construction information and explain the nature of the
repair under i121 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: 1
9. Total well depth below land surface: 185
For multiple wells list all depths if different (example- 3@200'and 2@I00)
(ft.)
10. Static water level below top of casing: 17 (ft.)
If water level is above casing, use "+"
11. Borehole diameter: 5 7/8 (in.)
12. Well construction method: Mud Rotary
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) 80 Method of test: Airlift
13b. Disinfection type: HTH Amount: 3% © 10g
For Internal Use Only:
Print Forin
14. WATER ZONES
FROM
TO
DESCRIPTION
rt.
ft.
ft.
ft.
15. OUTER CASING (for multi -cased wells) OR LINER (if ap licable)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
0 ft.
170 ft.
4 in.
SCH40
PVC
16. INNER
CASING OR TUBING
(geothermal closed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft.
ft.
in.
ft.
ft.
in.
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
165 ft'
185 ft.
2 in'
.010
SCH40
PVC
ft.
ft.
in.
18. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
0 Ft
30 ft.
Bentonite
Poured
rt.
ft,
ft.
ft.
19. SAND/GRAVEL PACK (if applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
ft.
ft.
ft.
ft.
20. DRILLING LOG (attach additional sheets if necessary)
FROM
TO
DESCRIPTION (color, hardness, soiVrock q pe, grain size, etc.)
0 ft'
10 ft.
Sand
10 ft.
25 ft.
Brown clay
25 ft*
150 ft.
Limestone
150 ft.
160 ft,
Clay
160 ft-
185 ft.
Sandstone
ft.
ft.
��
RECE C
ft.
ft.
20%
21. REMARKS
rU_5 3 ,
/ M'r" .,.atn/AOC
22
cation:
7/13/2018
fie. 'ell Contractor Date
By Signing this form, I hereby cenijy that the well(s) was (were) constructed in accordance
with 1 SA 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 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 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.

Print Form
WELL CONSTRUCTION RECiimsw I trquaNR/DWR
1. Well Contractor Information:
Donald Cummings
Well Contractor Name
2412-A
A14 11 2018
Water Quality Regional
NC Well Contractor Certification Number Operations Section
Applied Resource Mantigetvflti aetfice
Company Name
2. Well Construction Permit #:
List all applicable well construction permits (i.e. UIC, Comity, State, Variance, etc.)
3. Well Use (check well use):
WP 18-054B
Water Supply Well:
Agricultural
DGeothennal (Heating/Cooling Supply)
[J Industrial/Commercial
rllnigation
Non -Water Supply Well:
Monitoring
Injection Well:
Aquifer Recharge
▪ Aquifer Storage and Recovery
Aquifer Test
Experimental Technology
Geothermal (Closed Loop)
Geothermal (Heating/Cooling Retum)
4. Date Well(s) Completed: 7/9/18
5a. Well Location:
Genesio Mimbui
DMunicipal/Public
xDResidential Water Supply (single)
DResidential Water Supply (shared)
DRecovery
Groundwater Remediation
Salinity Barrier
DStormwater Drainage
Subsidence Control
Tracer
Other (explain under #21 Remarks)
Well ID# N/A
N/A
Facility/Owner Name Facility ID# (if applicable)
5044 Horsbranch Road Rocky Point, NC 28443
Physical Address, City, and Zip
Pender 3300-48-3958
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one latllong is sufficient)
34 35 41.62 N 77 59 23.28
W
6. Is(are) the well(s)Jx Permanent or DTemporary
7. 1s this a repair to an existing well: []Yes or x}No
If this is a repair. /ill ow known well construction information and explain the nature of the
repair under 111 remarks section or on the back of this form.
8. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction, only k GW-I is needed. Indicate TOTAL NUMBER of wells
drilled:1
9. Total well depth below land surface: 275
For multiple wells list all depths if different (example- 3 00' and 2,n,100')
(ft.)
10. Static water level below top of casing: 35 (ft.)
If water level is above casing, use
11. Borehole diameter: 7 7/8 (in.)
12. Well construction method: Mud Rotary
(i.e. auger. rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) 50 Method of test: Alritft
0
13b. Disinfection type: HT Amount: 3 /o @ 10g
For Internal Use Oply:
45►3r:
14. WATER ZONES ,
FROM
TO
DESCRIPTION •
ft.
ft.
ft.
ft.
15. OUTER CASING (for multi -cased wells) OR LINER (if ap licable)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
0 ft'
235 ft.
4 in.
SCH40
PVC
16. INNER CASING OR TUBING (geothermal closed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft.
ft.
in.
ft.
ft.
in.
17. SCREEN
FROM
TO
DIAMaIF.R
SLOT SIZE
THICKNESS
MATERIAL
235 ft-
275 ft.
.010 in.
4
SCH40
PVC
ft.
ft.
in.
18. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
0 ft.
30 ft.
Bentonite
Poured
220 ft.
230 ft.
Bentonite
Poured
ft.
ft.
19. SAND/GRAVEL PACK (if applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
230 ft.
275 ft,
Coarse
Poured
ft.
ft.
20. DRILLING LOG (attach additional sheets if necessary)
FROM
TO
DESCRIPTION (color, hardness, soiVrock type, grain size, etc.)
0 ft.
5 ft.
Sand
5 ft.
35 ft.
Brown clay with sand
35 ft.
60 ft'
Grey clay with sand seams
60 ft.
70 ft,
Limestone
70 ft.
200 ft.
Grey clay with fine sand seams
200 ft.
275 ft
Limestone with sand and silt seams
ft.
ft.
21. REMARKS
22. Certification:
7/9/18
Signature oit_eRified Well Contractor v Date
13)' signing this fonn, 1 hereby ceri fy that the well(s) was (were) constructer(,_ut,accordalwe -"'-
with 15A NCAC 02C .0100 or 15A NCAC 02C .0200 Well Cot ofio i gialydords?-94, h t a
copy of this record has been provided to the well owner. t 3 G,:: t••••
qfl
21. Site diagram or additionatwelidetails: {� fit° ZO tiI
You may use the back of this page to provide additional wr.e 1 s e details or well
construction details. You may also attach additional pages if necessary.,.,..„.„-, +;
SUBMITTAL INSTRUCTIONS n C ^:;�!, •
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 fonn 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 fonn 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

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 4119-A
1. WELL CONTRACTOR:
Sage Drilling and Pump Services LLC.
Well Contractor (Individual) Name
Michael C. Sage
Well Contractor Company Name
STREETADDRESS 204 Tom AveRECEIWED/NGDENR/DWR
Castle Hayne NC 28429
City or Town State A 14 030 2018
( 910 )_ 231-6669
Area code- Phone number
Water Quality Regional
2. WELL INFORMATION: Operations Section
SITE WELL ID #(if applicable) Wilmington Regional Office
WELL CONSTRUCTION PERMIT#
OTHER ASSOCIATED PERMIT#(if applicable)
3. WELL USE (Check licabl
DATE DRILLED
ox): R 'dential Water Supply 0
TIME COMPLETED AM O PM 0
4. WELL LO TION: �(
CITY: IJ�J �� t CAUNTY
�-n l
6
1 -1`
(Street Name, Numbers, Com nit Sub ivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / D S TTING:
0 Slope 0 Valley Flat Ridge O Other
(check appropriate box)
LATITUDE _ _
May be in degrees,
minutes, seconds or
LONGITUDE
in a decimal fonnat
Latitude/longitude source: a GPS o Topographic map
(location of well must be shown on a USGS topo map and
attached to this form if not using GPS)
5. WELL OWNER �� t n �
OWNER'S NAME
STR
T ADDR SS
City or Town State Zip Code
( )-
Area code - Phone number
6. WELL DETAILS:
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YESO COD
c. WATER LEVEL Below Top of Casing: `" FT.
(Use "+" if Above Top of Casing)
d. TOP OF CASING IS FT. Above Land Surface'
*Top of casing terminated at/or below land surface may
a variance in accordance with 15A NCAC 2C .0 18.
e. YIELD (gpm):lJ METHOD OF TEST,r1\ \
require
1 I CJ�
455.' 1 71
f. DISINFECTION: Type ,—l-1iA Amount 1 I r
g. To (de th):
From To From To
From To From To
From To From To
7. CASING: Thickness/
Depth / //, Diameter Weight Material
From r To OPPLIFt.
From To Ft.
From To Ft.
8. GROUT: Depth
From C) To 3 Ft.
From __) To7W Ft.
From To Ft.
Material vC-th d
?t A+ < i� \
9. SCREEN: epth� Dia eter Slot Size
From To--`c0 Ft.rJ in. lO in. ptal
From To Ft. in. in.
From To Ft. in. in.
10. SAND/GRAVEL PACK:
Depth Size
From — rip To q0 Ft. 9
From To Ft.
From To Ft.
11. DRILLING LOG
FRmTo
— 0-S
m e(TI
cs*0.vei
Arnation Description
- (36 3 ( k fri e S.40'_
- 6ant��. t,
12. REMARKS:
AUG I 2018
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
1SA NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED 0 THE WELLNER.
SIGNATURE 0 CERtil WELL CONTRACTOR ATE �L
Michael C. Sage
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt.,
1617 Mail Service Center— Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-la
Rev. 3/07

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 4119-A
1. WELL CONTRACTOR:
Sage Drilling and Pump Services LLC.
Well Contractor (Individual) Name
Michael C. Sage
Well Contractor Company Name
STREET ADDRESS 204 Tom Ave
Castle Hayne NC
City or Town State
( 910 ).231-6669
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable) Wapr tJ lit �`
WELL CONSTRUCTION PERMIT# AO thgL t,�,b� r�%f
ie
OTHER ASSOCIATED PERMIT#(if applicable)
3. WELL USE (Check ppli B x)• Residential Water Supply 0
DATE DRILLED — l 1 `�
TIME COMPLETED . O AM 0
4. WELL LOCATION: /tp � 6
CITY: 1 ' \•COUN
V)1 -LbT-aq-8�{
(StreName, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
RECEIVERMENNER
Zip Code
AUG 06 2018
TOPOGRAPHIC / k i ETRI Ridge
u Slope 0 Valley o Flat u Ridge 0 Other
(check appr box)
LATITUDE
LONGITUDE
Maybe in degrees,
minutes. seconds or
in a decimal format
Latitude/longitude source: o GPS u Topographic map
(location of well must be shown on a USGS topo map and
attached to this form if not using GPS),
IC)5.OWNER'S NAME (i; \ e�'�L'
WELL OWNER
STREETA DR SS'o E
)-caMMS
C_1
A jty or Tow tate
C (0)- own 1 - oo�.
,Area code - Phone number
6. WELL DETAILS:
a. TOTAL DEPTH:
Zip Code
b. DOES WELL REPLACEEXISTING WELL? YES li NO u
c. WATER LEVEL Below Top of Casing: ' FT.
(Use "+" if Above Tip of Casing)
d. TOP OF CASING IS j S F.-T. Above Land Surface*
*Top of casing terminated at/or below land surface may require
a variance in actor once with 15A NCAC 2C .0118�
e. YIELD (gpm): ll(i METHOD OF TEST
4-5,3 70
t. DISINFECTION: Type
Amount�� r.
g. WATE NES (d
FromT
�C~!-- To From To
From To From To
From To From To
7. CASING: Thickness/
Depth From ��-` Tot. LI'Diryeter et tit_ M ri
m— (v_
From To Ft. !! 1
From To Ft.
8. GROUT: Depth Material Metho
From To-- . ►i Ili % i oo
From To —Ft
) Ft. NAM ILA" •
From To Ft.
9. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in. in.
From To Ft. in. in.
10. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
3 From To Ft.
From To Ft.
11. DRILLING LOG
Frw
1C) - cs�
12. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C,WELL CONSTRUC ION STANDARDS, AND THAT A COPY OF THIS
RECORD HAS BEE) PR9yIDEv0 THE WELL OWNER.
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
Michael C. Sage
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt.,
1617 Mail Service Center— Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-la
Rev. 3/07

1. WELL CONTRACTOR:
DAVID L REGISTER
Well Contractor (Individual) Name
REGISTER WELL CO— INC.
Well Contractor Company Name
721 WEST CHARITY ROAD
Street Address
ROSE HILL
City or Town
[phone]
Area code Phone number
2. WELL INFORMATION:
NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2314A
RECEIVED/NCDENR/DWR d. TOP OF CASING IS 1.5 FT. Above Land Surface*
*Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): 35 METHOD OF TEST AIR
f. DISINFECTION: Type HTH Amount 4 07
g. WATER ZONES (depth):
Top Bottom Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
Thickness/
7. CASING: Depth Diameter Weight Material
Top 0 Bottom 245 Ft. 4 .40 PVC
Top Bottom Ft.
Top Bottom Ft.
JUL 2 3 2018
Water Quality Regional
WiI in 61 �
Refl.. derce
State Ip o.e
WELL CONSTRUCTION PERMIT#
OTHER ASSOCIATED PERMIT#(ff applicable)
SITE WELL ID #(if applicable)
3. WELL USE (Check One Box) Monitoring ❑ Municipal/Public 0
Industrial/Commercial 0 Agricultural d Recovery ❑ Injection 0
Irrigation❑ Other 0 (list use)
DATE DRILLED 06-01-2018
4. WELL LOCATION:
SHILOH ROAD
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: IVANHOE COUNTY PENDER
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope ❑Valley p"Flat ❑Ridge ❑Other
LATITUDE " DMS OR N34.608251 DD
LONGITUDE " DMS OR W78.153613 DD
Latitude/longitude source: Q 3PS pTopographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
6. FACILITY (Name of the business where the well is located.)
PRFSTAGF FARMS
Facility Name
SHII OH ROAD
Street Address
IVANHOF
Facility ID# (if applicable)
NC
City or Town State Zip Code
PRFSTAGF FARMS
Contact Name
PO ROX 43R
Mailing Address
CI INTON
City or Town
( )
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 265
NC 28329
State Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO rtr
c. WATER LEVEL Below Top of Casing: 34 FT.
(Use "+" if Above Top of Casing)
452803
8. GROUT: Depth Material Method
Top 0 Bottom 20 Ft. HOLE PLUG POURED
Top Bottom Ft.
Top Bottom Ft.
9. SCREEN: Depth Diameter Slot Size Material
Top 245 Bottom 265 Ft. 4 in. .016 in. PVC
Top Bottom Ft. in. in.
Top Bottom Ft. in. in.
10. SAND/GRAVEL PACK:
Depth Size Material
Top 235 Bottom 268 Ft. #2 GRAVEL
Top Bottom Ft.
Top Bottom Ft.
11. DRILLING LOG
Top Bottom Formation Description
235 / 268 SAND (MED)
268 / ROCK
/ JUl u 9 2fl1�
ir}Ftti;,:l303 pro,-:;'W h•�Jufl._
/ O Ctt L; j 71
12. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECHAS BEEN yjROVI DE1jyTO THE yV[tlL OWNER.
6-28-18
SIGNATURE OF CERTIFIED WELL ONTRACTOR DATE
DAVID L. REGISTER
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality - Information Processing,
1617 Mail Service Center, Raleigh, NC 27699-161, Phone : [phone]
Form GW-1b
Rev. 2/09

No ANRa , WELL CONSTRUCTION RECORD
North Carolina Department o nvfrnmon an Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2314A
JUL 2 3 2018
1. WELL CONTRACTOR:
DAVID L REGISTER
Well Contractor (Individual) Name
REGISTER WELL CO„ INC.
Well Contractor Company Name
721 WEST CHARITY ROAD
452R02
d. TOP OF CASING IS 1.5 FT. Above Land Surface*
*Top of casing terminated at/or below land surface may require
Operations Section
Writer y Regional a variance in accordance with 15A NCAC 2C .0118.
Wilmington Regional Office e. YIELD (gpm): 35 METHOD OF TEST AIR
Street Address
ROSE HILL
City or Town
(910 ) 289-3175
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT#
NC 28458
State Zip Code
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable)
3. WELL USE (Check One Box) Monitoring ❑ Municipal/Public ❑
Industrial/Commercial ❑ Agricultural ( Recovery ❑ Injection ❑
Irrigation❑ Other ❑ (list use)
DATE DRILLED 06-01-2018
4. WELL LOCATION:
SHILOH ROAD
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: IVANHOE COUNTY PENDER
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope ❑Valley p'Flat ❑Ridge ❑Other
LATITUDE " DMS OR N34.608251 DD
LONGITUDE " DMS OR W78.153613 DD
Latitude/longitude source: 6eGPS QTopographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5. FACILITY (Name of the business where the wet is located.)
PRFSTAGF FARMS
Facility Name
SHII OH ROAD
Street Address
IVANHOF
Facility ID# (if applicable)
NC
City or Town
PRFSTAGF FARMS
Contact Name
PO ROX 438
Mailing Address
CI INTON
City or Town
( )
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 265
b. DOES WELL REPLACE EXISTING WELL?
c. WATER LEVEL Below Top of Casing: 34
(Use "+" if Above Top of Casing)
State Zip Code
NC 28329
State Zip Code
YES ❑ NO 5(
FT.
f. DISINFECTION: Type HTH Amount 4 O7
g. WATER ZONES (depth):
Top Bottom Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
Thickness/
7. CASING: Depth Diameter Weight Material
Top 0 Bottom 245 Ft. 4 .40 PVC
Top Bottom Ft.
Top Bottom Ft.
8. GROUT: Depth Material
Top 0 Bottom 20 Ft. HOLE PLUG
Top Bottom Ft.
Top Bottom Ft.
Method
POURED
9. SCREEN: Depth Diameter Slot Size Material
Top 245 Bottom 265 Ft. 4 in. .016 in. PVC
Top Bottom Ft. in. _ in.
Top Bottom Ft. in. in.
10. SAND/GRAVEL PACK:
Depth
Top 235 Bottom 268 Ft.
Top Bottom Ft.
Top Bottom Ft.
11. DRILLING LOG
Top Bottom
113 / 133
133 / 134
134 / 152
152 / 159
159 / 166
166 / 175
175 / 180
180 / 194
194 / 205
205 / 208
208 / 235
12. REMARKS:
Size
#2
Material
GRAVEL
Formation Description
SAND (MED)
ROCK 12"
SAND AND CLAY
SAND (MED)
ROCK AND SAND
SAND AND CLAY
ROCK AND SAND p r ` �, /
CLAY
SAND AND CLAY 'I ��8
ROCK AND SAND it 11 t� °
SAND AND CLAY
lr" r; 1O 0-.1N G
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
6-28-18
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
DAVID L. RFGISTER
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality - Information Processing,
1617 Mail Service Center, Raleigh, NC 27699-161, Phone : [phone]
Form GW-io
Rev. 2/09

NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTIRECWWWOMON # 2314A
452801
d. TOP OF CASING IS 1.5 FT. Above Land Surface*
*Top of casing terminated aUor below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
Operations Section f. DISINFECTION: Type
Water Quality Regional e. YIELD (gpm): 35
P METHOD OF TEST AIR
HTH Amount 4 07
Street Address Wilmington Regional OffiCbg. WATER ZONES (depth):
ROSE HILL NC 28458 Top Bottom Top Bottom
City or Town State Zip Code Top Bottom Top Bottom
(910 ) 289-3175 Top Bottom Top Bottom
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT#
1. WELL CONTRACTOR:
DAVID L REGISTER
Well Contractor (Individual) Name
REGISTER WELL CO„ INC.
Well Contractor Company Name
721 WEST CHARITY ROAD
JUL 2 3 2018
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(ifapplicable)
3. WELL USE (Check One Box) Monitoring ❑ Municipal/Public ❑
Industrial/Commercial D Agricultural if( Recovery ❑ Injection 0
IrrigationD Other ❑ (list use)
DATE DRILLED 06-01-2018
4. WELL LOCATION:
SHILOH ROAD
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: IVANHOE COUNTY PENDER
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope ❑Valley Q'Flat ❑Ridge DOther
LATITUDE ° " DMS OR N34.608251 DD
LONGITUDE % DMS OR W78.153613 DD
Latitude/longitude source: VGPS Qropographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5. FACILITY (Name of the business where the well is located.)
PRFSTAGF FARMS
Facility Name Facility ID# (if applicable)
SHII OH ROAD)
Street Address
IVANHOF NC
City or Town State Zip Code
PRFSTAGF FARMS
Contact Name
PO ROX 438
Mailing Address
CL INTON NC 28329
City or Town State Zip Code
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 265
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO iti
c. WATER LEVEL Below Top of Casing: 34 FT.
(Use "+" if Above Top of Casing)
Thickness/
7. CASING: Depth Diameter Weight Material
Top 0 Bottom 245 Ft. 4 .40 PVC
Top Bottom Ft.
Top Bottom Ft.
8. GROUT: Depth Material Method
Top 0 Bottom 20 Ft. HOLE PLUG POURED
Top Bottom Ft.
Top Bottom Ft.
9. SCREEN: Depth Diameter Slot Size Material
Top 245 Bottom 265 Ft. 4 in. .016 in. PVC
Top Bottom Ft. in. in.
Top Bottom Ft. in. in.
10. SAND/GRAVEL PACK:
Depth Size Material
Top 235 Bottom 268 Ft. #2 GRAVEL
Top Bottom Ft.
Top Bottom Ft.
11. DRILLING LOG
Top Bottom
Formation Description
0 / 18 CLAY
18 / 25 SAND
25 / 53 CLAY
53 / 70 SAND
70 / 76 SAND AND CLA .- -;n :i jr,.L
76 / 77 ROCK �"
77 / 85 SAND JuL 1 9 2_U18
85 / 86 ROCK 10"
86 / 99 SAND AND CL j�(..-,. ;5,::,-, F>;:):;:,S€;;, 1,,—a3
99 / 104 ROCK AND SAND C ^:r(:OC.
104 / 113 CLAY
12. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
6-28-18
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
DAVID L. REGISTER
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality - Information Processing,
1617 Mail Service Center, Raleigh, NC 27699-161, Phone : [phone]
Form GW-1
Rev. 2/09

NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTREM'kON # 2314A
1. WELL CONTRACTOR:
DAVID L REGISTER
Well Contractor (Individual) Name
REGISTER WELL CO_ INC.
Well Contractor Company Name
721 WEST CHARITY ROAD
Street Address
ROSE HILL
City or Town
J(JI. 2 3 2018
Water Quality Regional
Operations Section
m,von Regional Office g WATER ZONES (depth):
NC 28458 Top Bottom
452 .O0.
d. TOP OF CASING IS 1.5 FT. Above Land Surface*
*Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e.
f.
YIELD (gpm): 35 METHOD OF TEST AIR
DISINFECTION: Type HTH Amount 4 07
State Zip Code
(910 ) 289-3175
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT#
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable) #1
3. WELL USE (Check One Box) Monitoring 0 Municipal/Public 0
Industrial/Commercial ❑ Agricultural 5I Recovery ❑ Injection ❑
Irrigation❑ Other ❑ (list use)
DATE DRILLED 05-30-2018
4. WELL LOCATION:
SHILOH ROAD
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: IVANHOE COUNTY PENDER
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope ❑Valley itFlat ❑Ridge ❑Other
LATITUDE "DMS OR N34.608228 DD
LONGITUDE " DMS OR W78.153470 DD
Latitude/longitude source: Q 3PS Dropographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5. FACILITY (Name of the business where the well is located.)
PRFSTAGF FARMS
Facility Name
SHII OH ROAD
Street Address
IVANHOF
Facility ID# (if applicable)
NC
City or Town State Zip Code
PRFSTAGF FARMS
Contact Name
PO ROX 43R
Mailing Address
CI INTON
City or Town
( )
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 265
b. DOES WELL REPLACE EXISTING WELL?
c. WATER LEVEL Below Top of Casing: 34
(Use "+" if Above Top of Casing)
NC 28329
State Zip Code
YES Ill NOLi
FT.
Top
Top
7. CASING: Depth
Top 0
Top Bottom
Top Bottom
Top Bottom
Bottom Top Bottom
Bottom Top Bottom
Thickness/
Diameter Weight Material
Bottom 245 Ft. 4 ,40 PVC
Ft.
Ft.
8. GROUT: Depth
Top 0 Bottom 20
Top Bottom
Top Bottom
Material
Ft. HOLE PLUG
Ft.
Ft.
Method
POURED
9. SCREEN: Depth Diameter Slot Size Material
Top 245 Bottom 265 Ft. 4 in. .0016 in. PVC
Top Bottom Ft. in. in.
Top Bottom Ft. in. in.
10. SAND/GRAVEL PACK:
Depth Size Material
Top 235 Bottom 268 Ft. #2 GRAVEL
Top Bottom Ft.
Top Bottom Ft.
11. DRILLING LOG
Top Bottom Formation Description
208 / 235 SAND AND CLAY_
235 / 236 ROCK 6"
236 / 268 SAND (MED)
268 / ROCK
/
12. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
REC HAS BEEN ROVIDEE» TO THE LL OWNER.
SIGNATURE OF CERTIFIED WELL
DAVID L. REGISTER
7 6-28-18
ONTRACTOR DATE
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality - information Processing,
1617 Mail Service Center, Raleigh, NC 27699-161, Phone : [phone]
Form GW-lb
Rev. 2/09

•1527S9
NON RESIDENF,�TRUCTION RECORD
North Carolina Department of Enviror�II'' iSlatR.,e� on
q� �mis- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2314A
1. WELL CONTRACTOR:
DAVID L REGISTER
Well Contractor (Individual) Name
REGISTER WELL CO., INC.
Well Contractor Company Name
721 WEST CHARITY ROAD
Street Add ress
ROSE HILL NC 28458
City or Town State Zip Code
(910 ) 289-3175
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT#
OTHER ASSOCIATED PERMIT#Of applicable)
SITE WELL ID #(if applicable) #1
3. WELL USE (Check One Box) Monitoring ❑ Municipal/Public 0
Industrial/Commercial ❑ Agricultural d Recovery 0 Injection 0
Irrigation❑ Other ❑ (list use)
DATE DRILLED 05-30-2018
4. WELL LOCATION:
SHILOH ROAD
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: IVANHOE COUNTY PENDER
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope ❑Valley WrFlat ❑Ridge ❑Other
LATITUDE " DMS OR N34.608228 DD
LONGITUDE " DMS OR W78.153470 DD
Latitude/longitude source: 3PS propographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5. FACILITY (Name of the business where the well is located.)
PRFSTAGF FARMS
Facility Name
SHII OH ROAD
Street Address
IVANHOF
Facility ID# (if applicable)
NC
City or Town State Zip Code
PRFSTAGF FARMS
Contact Name
PO ROX 438
Mailing Address
CL INTON
City or Town
NC 2832
State Zip Code
(-J
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 265
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO L1
c. WATER LEVEL Below Top of Casing: 34 FT.
(Use "+" if Above Top of Casing)
JUL 2 3 2018
d. TOP OF CASING IS 1 .5 FT. Above Land Surface*
*Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): 35 METHOD OF TEST AIR
f. DISINFECTION: Type HTH Amount 4 07
g. WATER ZONES (depth):
Top Bottom Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
Thickness/
7. CASING: Depth Diameter Weight Material
Top 0 Bottom 245 Ft. 4 .40 PVC
Top Bottom Ft.
Top Bottom Ft.
8. GROUT: Depth Material Method
Top 0 Bottom 20 Ft. HOLE PLUG POURED
Top Bottom Ft.
Top Bottom Ft.
9. SCREEN: Depth Diameter Slot Size
Top 245 Bottom 265 Ft. 4 in. .016 in.
Top Bottom Ft. in. in.
Top Bottom Ft. in. in.
Material
PVC
10. SAND/GRAVEL PACK:
Depth
Top 235 Bottom 268 Ft.
Top Bottom Ft.
Size Material
#2 GRAVEL
Top Bottom Ft.
11. DRILLING LOG
Top Bottom
113 / 133
133 / 134
134 /152
152 / 159
159 / 166
166 / 175
175 /180
180 / 194
194 / 195
195 / 205
205 / 208
12. REMARKS:
Formation Description
SAND (MED)
ROCK 12":`: a_ v'�
SAND AND CLAW
SAND (MED) JUL ZQIB
ROCK AND SAND
SAND AND CLAY n. U- ,t
CLAY
ROCK 8"
SAND AND CLAY
ROCK AND SAND
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
6-28-18
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
DAVID L. REGISTER
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality - Information Processing,
1617 Mail Service Center, Raleigh, NC 27699-161, Phone : [phone]
Form GW-lb
Rev. 2/09

NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2314A
1. WELL CONTRACTOR:
DAVID L REGISTER
Well Contractor (Individual) Name
REGISTER WELL CO,., INC.
Well Contractor Company Name
721 WEST CHARITY ROAD
Street Address
ROSE HILL
City or Town
NC 28458
RECEIVED/NCDENR/DWR
(910 ) 289-3175
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT#
OTHER ASSOCIATED PERMIT#(if applicable) Watcr Quality Regiurldl
SITE WELL ID #(if applicable) #1 Operations Sprtion
Wilmington Regional Office
3. WELL USE (Check One Box) Monitoring ❑ Municipal/Public ❑
Industrial/Commercial ❑ Agricultural Recovery ❑ Injection ❑
JUL 23 2018
Irrigation0 Other ❑ (list use)
DATE DRILLED 05-30-2018
4. WELL LOCATION:
SHILOH ROAD
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: IVANHOE COUNTY PENDER
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope ❑Valley "Flat ❑Ridge ❑Other
LATITUDE
" DMS OR N34.608228 DD
LONGITUDE " DMS OR W78.153470 DD
Latitude/longitude source: IMPS ❑Topographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5. FACILITY (Name of the business where the well is located.)
PRFSTAGF FARMS
Facility Name
SHII OH ROAD
Street Address
IVANHOE
Facility ID# (if applicable)
NC
City or Town State Zip Code
PRFSTAGF FARMS
Contact Name
PO BOX 438
Mailing Address
CL INTON
City or Town
NC 2832Q
State Zip Code
( )
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 265
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO C
c. WATER LEVEL Below Top of Casing: 34 FT.
(Use "+" if Above Top of Casing)
d. TOP OF CASING IS 1.5 FT. Above Land Surface*
*Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): 35 METHOD OF TEST AIR
f. DISINFECTION: Type HTH Amount 4 07
g. WATER ZONES (depth):
Top Bottom Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
Thickness/
7. CASING: Depth Diameter Weight Material
Top 0 Bottom 245 Ft. 4 .40 PVC
Top Bottom Ft.
Top Bottom Ft.
8. GROUT: Depth Material Method
Top 0 Bottom 20 Ft. HOLE PLUG POURED
Top Bottom Ft.
Top Bottom Ft.
9. SCREEN: Depth
Top 245 Bottom 265
Top Bottom
Top Bottom
Diameter Slot Size Material
Ft. 4 in. .016 in. PVC
Ft. in. in.
Ft. in. in.
10. SAND/GRAVEL PACK:
Depth Size Material
Top 235 Bottom 268 Ft. #2 GRAVEL
Top Bottom Ft.
Top Bottom Ft.
11. DRILLING LOG
Top Bottom
Formation Description
0 / 18 CLAY �' ° ., . , "`b,°
25 / 53 CLAY JUL 1 9 2.018
53 / 70 SAND
70 / 76 SAND AND Qifratw
76 / 77 ROCK 3" Lpi4CVDCY3
77 / 85 SAND
85 / 86 ROCK 10"
86 / 99 SAND AND CLAY
99 / 103 ROCK AND SAND
103 / 113 CLAY
12. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
6-28-18
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
DAVID L. REGISTER
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality - Information Processing,
1617 Mail Service Center, Raleigh, NC 27699-161, Phone : [phone]
Form GW-lb
Rev. 2/09

WELL CONSTRUCTION RECORD1(.G3V bENR/OWR
1. Well Contractor Information:
For Internal Use Only:
45231G,
1
Print Form
John Salmon
Well Contractor Name
3497-A
Water Quality Regional
Applied Resource Manageratiirierfw oice
JUL 0 9 2018 •
NC Well Contractor Certification Number
Company Name
2. Well Construction Permit #:
list all applicable well construction permits (i.e. UIC, County, State, Variance, etc.)
3. Well Use (check well use):
W18-031H
Water Supply Well:
Agricultural
Geothermal (Heating/Cooling Supply)
Industrial/Commercial
Irrigation
DMunicipal/Public
Dx Residential Water Supply (single)
Residential Water Supply (shared)
Non -Water Supply Well:
Monitoring QRecovery
Injection Well:
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
Experimental Technology
Geothermal (Closed Loop)
Geothermal (Heating/Cooling Retum)
Groundwater Remediation
Salinity Barrier
fStormwater Drainage
}Subsidence Control
Tracer
Other (explain under #2l Remarks)
4. Date Well(s) Completed: 6/20/18 well um N/A
5a. Well Location:
Mike Caveness
N/A
Facility/Owner Name Facility IDtI (if applicable)
408 East Creekview Dr, Hampstead, NC 28443
Physical Address, City, and Zip
Pender 3292-12-5554
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minntes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
34 21 16.5 77 42 10.34
6. Is(are) the well(s)I Permanent or DTemporary
7. Is this a repair to an existing well: QYes or xJNo
If this is a repair, fill out known well construction information and explain the nature of the
repair under t121 remarks section or on the hack of this form.
8. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction, nuly 1 GW-1.is.needed. Indicate TOTAL NUMBER of wells
chilled:1
9. Total well depth below land surface:
For multiple wells list all depths ttf d ferent (example- MI.200' and' 2 100')
185
10. Static water level below top of casing:
If water level is above casing, use
3
11. Borehole diameter: See Remark(in.)
12. Well construction method: Mud Rotary
(ft.)
(ft.)
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test: Airlift
13b. Disinfection type: HTH Amount: 3% U@ 10g
14. WATER ZONES -- _._,.,..-..
FROM
TO
DESCRIPTION
ft.
ft
fe.
rt.
1S. OUTER CASING (for multi -cased wells) OR LINER (f a linable)
FROM
TO
'HAMELLit -
TRIC 'ESS MATERIAL
0 ft-
162 ft•
4 in.
SCH40 PVC
16. INNER
CASING OR TUBING
(geothermal dosed -loop)
FROM -..TO
-. --- - ..-.
DIAMETER -
THICKNESS
MATERIAL
rt.
.ft. .
._.. .. in.
ft.
ft.
in.
17.SCREEN
FROM
TO .
DIAMETER...
SLOT SIZE
THICKNESS
MATERIAL
R.
ft
in.
It.
ft
. in.
15. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
0 it.
26 ft.
Bentonite
Poured
f.
ft
ft
ft.
19. SAND/GRAVEL
PACKffapplicable)
FROM
- TO
. MATERIAL-
EMPLACEMENT METHOD
ft
ft
ft
ft.
,
20. DRILLING
LOG (attach additional sheets ifnecessary)
FROM
TO
DESCRIPTION (color, hardness. soll/rock type. grain size, eta)
0 - ft
10 f'
-Sand:,:::.-
10 ft.
70 ft
Sandy clay
70 R•
145 ft
Limestone
145 ft
155 fit
Clay
155 ft.
185 ft•
Sandstone :,.,, -' = • "; 1
21. REMARKS 4'
0' to 25' = 7 7/8 L;ttit:n 2t Y.,-:v r,,, -
._.sii.tf"
25' to 185' = 5 7/8 "�'`�'' 'sY'"`
22. Certification:
/1.% 4161-'
Certifie Well Contractor Date
y signing this form, 1 hereby cerl fy That the well(s) was (were) constructed in accordance
with 154 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.
23u Site diagramroe addilioas6well_.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
6/26/18
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
constructionto the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Simply & Injection 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 welt 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

'
RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 4119-A
1. WELL CONTRACTOR: RECEIVED/NCDE i I
Sage Drilling and Pump Services LLC.
rf '
Well Contractor (Individual) Name JUN 25 2018
Michael C. Sage
Well Contractor Company Name
204 Tom Ave Water Quality Regional
STREET ADDRESS Operations Section
Castle Hayne NC Wilm%I 19Regional Office
City or Town State
( 910 )-231-6669
Zip Code
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable)
WELL CONSTRUCTION PERMIT#
OTHER ASSOCIATED PERMIT#(if applicable)
3. WELL USE (Check yplicable Box): Residential
DATE DRILLED [v `
Water Supply 0
O PM O
`'ter
TIME COMPLETED % 6t✓ AM
4. WELL LOCA ION:
CITY: COUNTY
'
r „
(Street Name, Num ers, Community, S bdivision. Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
i Slope 0 Valley at Ridge 0 Other
(check app x) .
LATITUDE
May be in degrees.
minutes, seconds or
in a decimal format
_ _
LONGITUDE
Latitudellongitude sours.: -+ OPS 0 Topographic map .
(location of well must be shownon a USGS topo map and
attached to this form if no:Fu GPS)
5. WELL OWNER `` f2
OWNER'S NAME { k.ii er-
STR ET ADDRESS 1 \a,
((11 7k -c C Cs�oc1
City or I'owtrr. St to
(�ld )- C-ofti
Zip Code i
YES!)
FT.
Area code - Phone number
6. WELL DETAILS: ` O
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL??
c. WATER LEVEL Be16w Top of Casing:
(Use "+' if Abo Top of Casing)
d. TOP OF CASING IS FT. Above
Land Surface*
surface may require
2C .0 ;8 t
*Top of casing terminated at/or below land
a variance in a cordance with 15A NCAC
e. YIELD (gpm): METHOD OF
TEST 11
_ _
451187
f. DISINFECTION: Type 1 Amount 1 ,.
g. WAT - ZONES (dep ):
From ♦ To From To
From f� To © From To
From To From To
7. CASING: Thickness/
11"��/Depth Dieter ei ht Mote?
From-r Tom C
From To Ft.
From To Ft.
8. GROUT: Depth . Material !! Method
From To- Ft. « d Jrf
Frorfl To= Ft.
From
9. SCREEN: m epth [} Diaer Slot Size at lal
From To 11%() Ft. in. in. _
From To Ft. in. in.
From To Ft. in. in.
10. SAND/GRAVEL PACK:
Dep I erial
From To Ig6 Ft. (3,t
From
From
To Ft.
To Ft.
11. DRILLING LOG
From To
DSO
a'
-1Lin -Ito
12. REMARKS:
s11p
Fprmation Description
i
Ct7- sac4 e
2-O�B
•
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C. WELL CONSTRUCTION STANDARDS. AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDE .TO THE WELL OWNER.
SIGNATi1RE OF'CE`R11F((=D WELL CONTRAGTOR DATE
Michael C. Sage
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt.,
1617 Mail Service Center — Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-1 a
Rev. 3/07

CI
RESIDENTIAL WELL CONSTRUCTION RECORI450(`'
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 4119-A
1. WELL CONTRACTOR:
Sage Drilling and Pump Service D/NC9ENR/QWR
Well Contractor (Individual) Name
Michael C. Sage
Well Contractor Company Name 018
STREET ADDRESS 204 Tom Ave
JUN 11 2
Castle Hayne NC
City or Town State
( 910 )- 231-6669
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable)
WELL CONSTRUCTION PERMIT#
Water Q Ij Regional
Oper ectinn
Wilminnt iw tonal Office
OTHER ASSOCIATED PERMIT#(if applicable)
3. WELL USE (Check Applicable Box): Ref§yential Water Su
DATE DRILLED Jle, p
TIME COMPLETED I U ; j
4. WELL LOCATION: j
I : `A x01 0 COUNTYP
n) Q._.y Coe -t, agjq
(los
t Name, Numbers, uommuni y, Subdivision, Lot No., Parcel, Zip Code)
pply 0
TOPOGRAPHIC / LANVt TTING:
0 Slope 0 Valley Flat 0 Ridge 0 Other
(check ap to box)
LATITUDE
LONGITUDE
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: u GPS 0 Topographic I
(location of well must be shown on a USGS topo map a
attached to this form if not using GPS)
5. WELL OWNER
OWNER'S NAME
STREETRE
01
City or Town
Area code - Phone number
6. WELL DETAILS: �Q
a. TOTAL DEPTH:
nap
nd
Zip
b. DOES WELL REPLACE EXISTING WELL? YES 0 .0
c. WATER LEVEL Below Top of Casing: - D FT.
(Use "+" if Above Top of Casing)
d. TOP OF CASING IS 4- 1 FT. Above Land Surface*
'Top of casing terminated at/or below land surface may require
a variance in accordance�with 15A NCAC 2C .0118.
e. YIELD (gpm): V METHOD OF TEST Ai II `r 1
I. DISINFECTION: Type
g. WA ER ES (depth)/:�
From To
I-- T I- Amount ♦ I f)
,
I 1 L) From " To
From To From To
From To From To
7. CASING: Thickness/
rDth}o/Dlr Ihhq I
��From-J-..TotFt. �
From To Ft.
From To Ft.
8. GROUT: Depth Material Met d
From 1 To Ft.� It`'LS aCrr
From 6-3 To ' Ft.
From To Ft.
9. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in. in.
From To Ft. in. in.
10. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
From To Ft.
11. DRILLING LOG
From a To C Fdrmation Description
.o- v n -for ('-1i-1'
SO' r Fla
6() - 75 ((c1 y- SE,eit MI:Y
r7S'110 ,/viPSfo()CJ
r
--- ia�+P r-
? o\ii
12. REMARKS: , "VI- ` ^'
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECORD HAS B N P I THE WELL OWNER.
SIGNATURE OF CERTIFI WELL CONTRACTOR DATE
Michael C. Sage
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt.,
1617 Mail Service Center— Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-la
Rev. 3/07

For Internal Use Only:
WELT. CONSTRUCTION RECORD RECEIVEDINCDENR/DVi�R
1. Well Contractor Information:
Donald Cummin s
Well Contractor Name
2412-A
NC Well Contractor Certification Number
Applied Resource Manage
Company Name
t ti Permit #•
None
MAY 2 8 2018
Water Quality Regiona
Section
ft
2.'Well Cons rocoo ,
Lis( all applicable well construction permits (i.c. IIIC, County, State. Variance, etc.)
3. Well Use (check well use):
Water Supply Well:
Agricultural
Geothermal (Heating/Cooling Supply)
Industrial/Commercial
ation
Non -Water Supply Well:
Monitoring
injection Well:
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
Experimental Technology
Geothermal (Closed Loop)
Geothermal (Heating/Cooling Return)
4. Date Well(s) Completed: 5/1/18
5a. Well Location:
Tommy Newber
Facility ID# (if applicable)
Facility/Owner Name
341 Dogwood Lane, Hampstead, NC 28443
EJMunicipal/Public
Residential Water Supply (single)
Residential Water Supply (shared)
DRecovery
QGroundwater Remediation
°Salinity Barrier
DStorrnwater Drainage
Subsidence Control
°Tracer
Other (explain under #21 Remarks)
14. WATER ZONES
FROM
ft.
ft.
TO
15. OUTER CASING
TO
DESCRIPTION
ft.
ft.
450188--
for multi -cased wells_) OR LINER (if a livable)
DIAMETER THICKNESS. MATERIAL
FROM
Cd ft. 160 ft- 4 in. SCH40 PVC
R TUBING (geothermal closed -loop)
16. INNER
CASING O
TO
DIAMETER
THICKNESS
MATERIAL
FROM
ft.
ft.
in.
ft.
ft.
in.
17. SCREEN
FROM
ft.
ft.
l8. GROUT
FROM
0
Well ID# NIA
Physical Address, City, and Zip
Pender
N/A
3281-83-9783-0000
Parcel Identification No. (PIN)
County
.5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, onelat./long is sufficient) �� 42 43.3
34 19 50.7 N
6. is(are) thewell(s)JPermanent or DTemporary
7. Is this a repair to an existing well: Yes or E No
Ir tpiis is rep irr jellout
known well on
st u ction i foi marmn and explain the nature of the
er
21
n or
ack
8. For Ceopribe/DPT or Closed -Loop Geothermal Wells having the same
constriction, only 1 GW-1 i$ needed. Indicate TOTAL NUMBER of wells
drilled. 1
9. Total wellalepth below land surface: 180
Fornrultiple walls list all depths if different (example-3@200'and 2@100')
10. Static wafer level below top of casing: II
If water level i`rabove casing, use "'
11. Boreholediameter: see remark (in.)
12. Well contruction method: Mud Rotary
(i.e. auger, roily, cable, direct push, etc.)
FOR WATIR SUPPLY WELLS ONLY:
Airlift
Method of test:
13a. Yield (Wm) 80
Amount: 3 �o @ log
13b. Disinti'etion type: HTH
W
(ft.)
(ft.)
TO
ft.
ft.
TO
DIAMETER
in.
in.
SLOT SIZE
THICKNESS
MATERIAL
MATERIAL EMPLACEMENT METHOD & AMOUNT
ft. 24 it Bentonite Poured
ft.
ft.
ft.
ft.
19. SAND/GRAVEL PACK (if applicable)
FROM TO
ft.
ft.
ft. ft.
MATERIAL EMPLACEMENT METHOD
20. DRILLING LOG (attach additional sheets if necessary
DESCRIPTION (color, hardness, soil/rock type, pain size, etc.)
FROM
0
ft.
20 ft.
40 ft.
122 ft.
132 ft.
140 ft.
TO
20
40 rt.
122 ft.
132 ft.
140 ft.
165 ft.
Sandy clay
Clay
Limestone
Limestone clay mix
Clay
Hard sandstone
165 ft. 180 ft. Sandstone
21. REMARKS
22. Certification:
Peptaid Cant . Date
of Certified Well Contractor
By signing this form. I hereby certify that the well(s) was hrereI constructed in accordance
with 15A NCAC 02C .0100 or 15A NCAC 02C .0200 Well Constnrction 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 Iniection Wells: In addition to sending the form to the address in ''
above, also submit one copy of this form within 30 days of completion of
construction to the following:
Division of Water Resources, Underground Injection Control Pr,
1636 Mali Service Center, Raleigh, NC 27699-1636
24c. For Water SunDly & Iniection Wells: In addition to sent
the address(es) above, also submit one copy of this form Iv
completion of well construction to the county health depart,
where constructed.
mAy 2 1 7018
44011Svikion
P
5/2/18
Form GW-1
North Carolina Department of Environmental Quality - Division of Water Resources

WELL CONSTRUCTION RECORD (GW-1)
RECEIVED
1. Well Contractor Information:
1 I l l r l 1 V I M
For Internal Use Only:
Donald Cummings
Well Contractor Name
2412-A
MAY 1 2 ZU1ti
NCDEQ
NC Well Contractor Certification Number WILMINGTON RO
Applied Resource Management, P.C.
Company Name
2. Well Construction Permit #:
W18-006H
List all applicable well construction permits (i.e. UIC, County, State, Variance, etc)
3. Well Use (check well use):
Water Supply Well:
jAgricuitural
QGeothernlal (Heating/Cooling Supply)
DIndustrial/Commercial
'Irrigation
Non -Water Supply Well:
0 Monitoring
DMunicipal/Public
xDResidential Water Supply (single)
DResidential Water Supply (shared)
Recovery
Injection Well:
Aquifer Recharge
EllAquifer Storage and Recovery
Aquifer Test
NExperimental Technology
Geothermal (Closed Loop)
Geothermal (Heating/Cooling Return)
Groundwater Remediation
QSalinity Barrier
FJStormwater Drainage
Subsidence Control
Tracer
Other (explain under #21 Remarks)
4. Date Well(s) Completed: 4/24/18 Well 1D# N/A
5a. Well Location:
Lauren Mingus
N/A
Facility/Owner Name Facility IDiI (if applicable)
103 Sundance Circle, Hampstead, NC 28443
Physical Address, City, and Zip
Pender 4214-62-1810-0000
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
34 24 33.5 N 77 37 13.0
W
6. Is(are) the well(s) Permanent or DTemporary
7. Is this a repair to an existing well: EYes or DNo
If this is a repair, fill out known well construction information and explain the nature of the
repair under till 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: 1
9. Total well depth below land surface: 1 OO
For multiple wells list all depths if different (example- 3@200' and 2@100)
(ft.)
10. Static water level below top of casing: 17 (ft.)
1f water level is above casing, use "= "
11. Borehole diameter: See Remark(in.)
12. Well construction method: Mud Rotary
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) 50 Method of test: Airlift
HTH 0
13b. Disinfection type: Amount: 3 /o @ 1 0 g
449FR'7
14. WATER ZONES
FROM
TO
DESCRIPTION
ft.
ft.
ft.
ft.
15. OUTER CASING (for multi -cased wells) OR LINER (if a licable)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
0 ft.
80 rt•
4 in.
SCH40
PVC
16. INNER CASING OR TUBING (geothermal closed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft.
ft.
in.
ft.
ft.
in.
-
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
ft.
ft.
in.
fL
ft.
in.
18. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
0 f1•
25 ft-
Bentonite
Poured
ft.
ft.
ft.
ft.
19. SAND/GRAVEL PACK (if applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
ft.
rt.
ft.
ft.
20. DRILLING LOG (attach additional sheets if necessary)
FROM
TO
DESCRIPTION (color, hardness, soillrock type, grain size, etc.)
0 ft'
45 rt.
Sand clay to clay
45 ft.
48 rt.
Limestone
as ft.
70 rt'
Clay
70 ft.
100 ft.
Limestone
ft.
ft.
ft.
ft.
_ _ �
rt.
ft.
C = °. L:..
21. REMARKS '
MAC C92013
ir%in tion Pf(:r; ss :i"+4)kirr;,
22. Certification:
( Oi
4/24/18
Signature of Certified Well Contractor \ Date
By signing this form, 1 hereby certify that the well(s) wass`(ytjire) constructed in accordance
with 15A NCAC 02C .0100 or 15A NCAC 02C .0200 Well Construction Standards and that a
copy of this record hos 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 Welts: 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 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.
Form GW-1
North Carolina Department of Environmental Quality - Division of Water Resources Revised 2-22-2016

1 ,,,,11
WELL CONSTRUCTION RECORD (GW-1)
1. Well Contractor Information:
Donald Cummings
Well Contractor Name
2412-A
RECEIVED
MAY 122018
Applied Resource Managg'� N�0C.
Company Name
2. Well Construction Permit #:
NC Well Contractor Certification Number
W174-063H
List all applicable well construction permits (i.e. UiC, County, State, Variance, nce, etc.)
3. Well Use (check well use):
Water Supply Well:
Agricultural
Geothermal (Heating/Cooling Supply)
Industrial/Commercial
Irrigation
Non -Water Supply Well:
Monitoring
lMunicipal/Public
xtResidential Water Supply (single)
Residential Water Supply (shared)
Recovery
Injection Well:
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
Experimental Technology
Geothermal (Closed Loop)
Geothermal (Heating/Cooling Retum)
4. Date Well(s) Completed: 5/2/18
5a. Well Location:
Richard Wasietewski
Facility/Owner Name
DGroundwater Remediation
['Salinity Barrier
EJStormwater Drainage
Subsidence Control
Tracer
Other (explain under #21 Remarks)
Well ID#N/A
N/A
Facility ID# (if applicable)
582 Howards Landing Road, Hampstead, NC 28443
Physical Address, City, and Zip
Pender
County
3292-67-9199-0000
Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
34 22 2.00574 N 77 41 3.897
6. is(are) the well(s)lPermanent or DTemporary
7. Is this a repair to an existing well: EJYes or INo
If this is a repair, fill ma known well construction information and explain the nature of the
repair under ii21 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: 1
9. Total well depth below land surface: 70
For multiple wells list all depths if different (example- 3@200' and 2@100')
10. Static water level below top of casing:
If water level is above casing. use "-
11. Borehole diameter: 0-70/8"
12
(in.)
12. Well construction method: Mud Rotary
W
(ft.)
(ft.)
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) 22 Method of test: Airlift
0
13b. Disinfection type: T Amount: 3 /o @ lOg
For Internal Use Only:
449Fi;t5
14. WATER ZONES
FROM
TO
DESCRIPTION
ft.
ft.
ft.
ft.
IS. OUTER CASING (for multi -cased wells) OR LINER (if a Iicable)
FROM
TO
DL4METER
THICKNESS
MATERIAL
0 ft.
55 ft.
4 in.
SCH40
PVC
16. INNER CASING OR TUBING (geothermal dosed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft.
ft.
in.
ft.
ft.
in.
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
55 ft-
70 rt.
4 in'
.010
SCH40
PVC
ft.
R.
in.
18. GROUT -,
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
0 ft•
25 ft.
Grout
Poured
50 ft•
55 ft,
Bentonite
Poured
rt.
ft.
19. SAND/GRAVEL PACK (if applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
55 ft-
70 ft•
Coarse
Poured
ft.
ft.
20. DRILLING LOG (attach additional sheets if necessary)
FROM
TO
DESCRIPTION (color, hardness, soiUrock type, grain size, etc.)
0 ft'
50 ft•
Fine sands and clay layers
50 rt.
70 rt.
Soft limestone
ft.
ft.
ft.
(t.
ft.
ft.
i
ft.
ft.
n, - Ye cn , f , 9,
s VRq 9
ft.
ft.
• o
201.4d
21. REMARKS MAX ry
'`•ll.'l
pt0Cii,s903
t rl,la*lCA1
NICI )OG
22.rtification:
114111
Sig `e of Certified Well Contractor \.\ Date
5/2/18
By signing this form, I hereby certify that the well(s) was (were) constructed in accordance
with I5A 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 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 27699-1636
24c. For Water Supply & Iniection Wells: In addition to sending the fonn 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.
Form GW-1
North Carolina Department of Environmental Quality - Division of Water Resources Revised 2-22-2016

WELL CONSTRUCTION RECORD (GW-1)
1. Well Contractor Information:
RECEIVED
11111.1 VIIYI
For Internal Use Only:
Sanford Sweeting
Well Contractor Name
2082-A
MAY 122018
NC Well Contractor Certification Number NCDEQ
Applied Resource Manage Tt1 fP. C.
Company Name 2. Well Construction Permit #: y p /
I 7-034H
List all applicable well construction permits (i.e. U1C, County, State, Variance, etc.)
3. Well Use (check well use):
Water Supply Well:
Agricultural QMunicipal/Pubiic
3Geothermal (1-(eating/Cooling Supply) DResidential Water Supply (single)
Industrial/Commercial DResidential Water Supply (shared)
- Irrigation
Non -Water Supply Well:
Monitoring DRecovery
Injection Well:
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
Experimental Technology
Groundwater Remediation
Salinity Barrier
0Stormwater Drainage
Subsidence Control
Geothermal (Closed Loop) DTracer
Geothermal (Heating/Cooling Return) DOther (explain under #21 Remarks)
4. Date Well(s) Completed:4/16/18 Well int/N/A
5a. Well Location:
Hampstead Marine
N/A
Facility/Owner Name Facility ID# (if applicable)
20840 Hwy 17 N, Hampstead, NC 28443
Physical Address, City, and Zip
Pender
4214-29-2426-0000
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one latllong is sufficient)
34 25 40.52 N 77 38 3.26
6. Is(are) the well(s)IPermanent or DTemporary
7. Is this a repair to an existing well: QYes or EDNo
If this is a repair, fill out known well construction information and explain the nature of the
repair under 121 remarks section or on the back of this fonn.
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: 1
9. Total well depth below land surface: 245 (ft.)
For multiple wells list all depths if different (example- 3@200' and 2 tr.100)
10. Static water level below top of casing: 13 (ft.)
If water level is above casing, use "- "
11. Borehole diameter: 5 7/8
(in.)
12. Well construction method: Mud Rotary
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) 50 Method of test: Airlift
HTH 0
13b. Disinfection type: Amount: 3 /o @ 10g
14. WATER ZONES
PROM
TO
DESCRIPTION
ft.
ft.
ft.
ft.
15. OUTER CASING (for multi -cased wells) OR LINER (if a • hie)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
+1.5 ft.
225 ft.
4 in.
SCH40
PVC
16. INNER CASING OR TUBING (geothermal closed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft.
ft.
in.
rt.
ft.
in.
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
_ THICKNESS
MATERIAL
225 ft
245 ft.
2 in.
.020
SCH40
_
PVC
ft.
ft.
in.
18. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
0 ft.
25 fL
Bentonite
Poured
ft.
ft.
ft.
rt.
19. SAND/GRAVEL PACK (if applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
rt.
ft.
ft.
rt.
20. DRILLING LOG (attach additional sheets if necessary)
FROM
TO
DESCRIPTION (color, hardness, soiltrock type, grain sae, etc.)
0 ft.
15 ft.
Sandy silt
15 ft.
60 ft'
Grey clay
6o ft-
180 fl'
Limestone
180 ft.
215 ft.
Sandstone with clay layer's
215 ft.
245 ft.
Sandstone
rt.
It.
ft.
ft.
; " -
7
II
21. REMARKS '1y '
.)
Knit 6 9 2.O1r�
22. Certiti tiorr
ed Well Contractor
-lniertr�3e:O. )''
°4/ 6/18
Date
By signing this form, 1 hereby certify that the well(s) was (were) constructed in accordance
with I iA 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 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 27699-1636
24c. For Water Sumnly & 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 departinent of the county
where constructed.
Form GW-1
North Carolina Department of Environmental Quality - Division of Water Resources Revised 2-22-2016

448390
RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water ua y
WELL CONTRACTOR CERTIFICATION # 2314A
1. WELL CONTRACTOR: RECEIVED/NCDENR/DWR
DAVID L REGISTER
Well Contractor (Individual) Name
REGISTER WELL CO.. INC. APR 14 2018
Well Contractor Company Name
721 WEST CHARITY RQAQ/ater (lofty Regional
Street Address Operations Section
ROSE HILL Wilmingtot egiona glii
City or Town State Zip Code
( 910) 289-3175
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT#
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable)
3. WELL USE (Check Applicable Box): Residential Water Supply i(
DATE DRILLED 11-02-2017
TIME COMPLETED AM 0 PM 0
4. WELL LOCATION:
CITY: WILLARD
25230 US 421
COUNTY PENDER
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope ❑Valley giFlat ❑Ridge ❑Other
LATITUDE 34 "DMS OR 34.665869 DD
LONGITUDE 77 ° 46 , " DMS OR 78.143521 DD
Latitude/longitude source: WhPS Ofopographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5. WELL OWNER
LUCILLE HERRING
Owner Name
25230 US 421
Street Address
WILLARD NC 28478
City or Town State Zip Code
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 177
b. DOES WELL REPLACE EXISTING WELL? YES far NO ❑
c. WATER LEVEL Below Top of Casing: 28 FT.
(Use "+" if Above Top of Casing)
d. TOP OF CASING IS 1.5 FT. Above Land Surface*
*Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): 20 METHOD OF TEST AI R
f. DISINFECTION: Type HTH Amount 3 OZ
g. WATER ZONES (depth):
Top Bottom Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
Thickness/
7. CASING: Depth Diameter Weight Material
Top 0 Bottom 157 Ft. 2 .40 PVC
Top Bottom Ft.
Top Bottom Ft.
8. GROUT: Depth Material Method
Top 0 Bottom 20 Ft. HOLE PLUG POURED
Top Bottom Ft.
Top Bottom Ft.
9. SCREEN: Depth Diameter
Top 157
Top
Top
Bottom 177 Ft.2
Bottom Ft.
Bottom Ft.
10. SAND/GRAVEL PACK:
Depth
Top 150 Bottom
Top
Top
Bottom
Bottom
11. DRILLING LOG
Top Bottom
0 /10
in.
in.
in.
Slot Size Material
.016 in. PVC
in.
in.
Size Material
177 Ft. #2 GRAVEL
10 /25
25 /26
26 /42
42 /77
77 /89
89 /96
96 /97
97 /100
100 /115
115 /123
123 /126
126 /136
136 /140
12. REMARKS:
Ft.
Ft.
Formation Description
SAND AND CLAY
CLAY
ROCK 12"
CLAY
SAND AND CLAY
ROCK, SAND AND CLAY
SAND (MED)
ROCK 12"
SAND
CLAY f L
SAND
CLAY
SAND
SAND AND CLAY
MAR 2 6 2018
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
ACCORDANCE WITH 15A NCAC 2C, WELL CONSTRUCTION
STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN
PROWDED TO THE WELL OWNER.
6./CCUCX /Ct�L 11-14-17
SIGNATURE OF CERTIFIED WEL CONTRACTOR DATE
DAVID L REGISTER
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality - Information Processing,
1617 Mail Service Center, Raleigh, NC 27699-161, Phone : [phone]
Form GW-la
Rev. 2/09

Print Form
Company Name
2. Well Construction Permit 1t:
WELL CONSTRUCTION RECORD (GW-1)
1. Well Contractor Information:
Donald Cummings
RECEWVED/NCDENR/DWR
Well Contractor Name
2412-A
NC Well Contractor Certification Number
APR 14 Z018
Applied Resource Mantii ► e D1i�;
erattnns . i?C 1011 '
W16 W,iliffin Regional Office
List all applicable well construction penults (i.e. UIC. County, Stale, Variance, etc.)
3. Well Use (check well use):
Water Supply Well:
Agricultural DMunicipal/Public
Geothermal (Heating/Cooling Supply) DResidential Water Supply (single)
'I Industrial/Commercial DResidential Water Supply (shared)
'Irrigation
Non -Water Supply Well:
Monitoring
Injection Well:
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
Experimental Technology
Geothermal (Closed Loop)
Geothermal (Heating/Cooling Return)
4. Date Well(s) Completed: 1 /23/18
5a. Well Location:
Eastern NC Home Builders
Recovery
Groundwater Remediation
Salinity Barrier
DStormwater Drainage
Subsidence Control
DTracer
(Other (explain under #21 Remarks)
Well 1D# N/A
N/A
Facility/Owner Name Facility ID# (if applicable)
Lot 11 Dan Owen Drive, Hampstead, NC 28443
Physical Address, City, and Zip
Pender 3292-15-6328-0000
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
34 21 39.13 N
77 42 04.25
W
6. Is(are) the well(s)IPermanent or OTemporary
7. Is this a repair to an existing well: DYes or x No
If this is a repair, fill out known well construction information and explain the nature of the
repair under P21 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- is needed. Indicate TOTAL NUMBER of wells
drilled. 1
9. Total well depth below land surface: 85
For multiple wells list all depths if different (example- 3@200' and 20100')
10. Static water level below top of casing:
limner level is abore casing, use "-"
11. Borehole diameter: See Remait(in )
12. Well construction method: Mud Rotary
14
(ft.)
(ft.)
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) 80 Method of test: Airlift
HTH
0
13b. Disinfection type: Amount: 3 /o@10g
For Internal 83X:
14. WATER ZONES
FROM
TO
DESCRIPTION
ft.
ft.
ft-
ft,
15. OUTER CASING (for multi -cased wells) OR LINER f f a limbic"
FROM
TO
DIAMETER
THICKNESS
MATERIAL
0 ft•
60 ft.
4 in'
SCH40
PVC
16. INNER CASING OR TUBING (geothermal closed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft.
ft.
in.
ft.
ft.
in.
17.SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
ft.
ft.
in.
ft.
ft.
in.
I8. GROUT
FROM
TO
MATERIAL
_ EMPLACEMENT METHOD & AMOUNT
0 ft•
25 ft•
Bentonite
Poured
ft,
ft.
ft.
ft.
19. SAND/GRAVEL PACK
(if applicable)
FROM
TO
MATERIAL
EMPLACEMENT MgFHOD
ft.
ft.
ft.
ft.
20. DRILLING
LOG (attach additional sheets if necessary)
FROM
TO
DESCRIPTION (color, hardness, soll/roek type, grain sae, etc.)
0 ft•
45 ft•
Sandy clay to clayey sands
45 ft•
62 ft'
Clay
62 ft•
85 fr.
Limestone (void at 83')
ft.
ft.
ft.
ft.
ft.
ft.
;- _. COVED
21. REMARKS
0- 25' = 8" FEB �,��
25' - 85' = 6" ,,Is
+, �� rr 'lily PrCCk36� g
22. Ce
Lion:
DWOMOG
2/16/18
Signature of Certified Well Contractor Date
By signing this form, 1 hereby cerify that the well(s) was (were) constructed in accordance
with ISA NCAC 02C .0100 or ISA 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 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 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.
Fonn GW-1
North Carolina Department of Environmental Quality - Division of Water Resources Revised 2-22-2016

WELL CONSTRUCTION RECORD (GW-1)
RECEIVED/NCDENR/DWR
1. Well Contractor Information:
For Internal Use Only: + 8
388
Ill 111 Vrlll
Donald Cummings
Well Contractor Name
2412-A
AI'K 14 2018
NC Well Contractor Certification Number Water Quality Regional
Applied Resource Mangd=: ; Qle,,•6#fice
Company Name
2. Well Construction Permit #:
W14-064H
List all applicable well construction permits (i.e. U1C, County, State, Variance, etc.)
3. Well Use (check well use):
Water Supply Well:
Agricultural jMunicipal/Public
Geothermal (Heating/Cooling Supply) xDResidential Water Supply (single)
Industrial/Commercial DResidential Water Supply (shared)
"Irrigation
Non -Water Supply Well:
Monitoring
D Recovery
Injection Well:
Aquifer Recharge
�IAquifer Storage and Recovery
Aquifer Test
Experimental Technology
Geothermal (Closed Loop)
Geothermal (Heating/Cooling Return)
4. Date Well(s) Completed: 02/08/1
5a. Well Location:
Grant Curry
Groundwater Remediation
fSalinity Barrier
JStormwater Drainage
Subsidence Control
Tracer
Other (explain under 421 Remarks)
8 Well ID# N/A
N/A
Facility/Owner Name Facility ID# (if applicable)
Lot 6 Ballast Point Drive, Hampstead, NC 28443
Physical Address, City, and Zip
Pender 4224-24-2949-0000
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
34 24 54.9 N 77 36 01.2
W
6. Is(are) the well(s)f% Permanent or DTemporary
7. Is this a repair to an existing well: JYes or jNo
If this is a repair, fill out known well construction information and explain the nature of the
repair under S21 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: 1
9. Total well depth below land surface: 105
For multiple wells list all depths if different (example- 3@200 • and 2@100)
(ft.)
10. Static water level below top of casing: 18 (ft.)
If water level is above casing, use "+"
11. Borehole diameter: See Remark (in.)
12. Well construction method: Mud Rotary
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) 80 Method of test: Airlift
13b. Disinfection type: HTH Amount: 3%@10g
14. WATER ZONES
FROM
TO
DESCRIPTION
ft.
ft.
ft.
ft.
15. OUTER CASING (for multi -cased wells) OR LINER (if a licable)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
0 ft'
90 ft,
4 in'
SCH40
PVC
16. INNER CASING OR TUBING (geothermal closed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft.
ft.
in.
ft.
ft.
in.
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
ft.
ft.
in.
ft.
ft.
in.
18. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METE OD & AMOUNT
0 ft-
24 ft-
Bentonite
Poured
ft.
ft.
ft.
ft.
19. SAND/GRAVEL PACK(irapplicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
ft.
ft.
ft.
ft.
20. DRILLING LOG (attach additional sheets if necessary)
FROM
TO
DESCRIPTION (color, hardness, soil/rock type, grain size, etc.)
0 ft'
80 ft-
Clayey sands to sandy clay
80 ft,
85 ft.
Weathered limestone
85 ft•
105 ft.
Limestone
ft.
ft.
ft.
ft.
ft.
ft.
RF C E \ I E- r
ft.
ft.
21. REMARKS FEB [a 2 2018
0-25'=8" .,
25' - 105' = 6" }okormstron Pt A.,. y.-r ,z) u
rw Q/bOC
22. C ai Ication:
02/15/18
Si nature of Certified Well Contractor Yl Date
By signing this fonn, 1 hereby certi that the well(s) was (were) constructed in accordance
with 1 5A NCAC 02C .0100 or I SA 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 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 27699-1636
24c. For Water Supply & Iniection Wells: In addition to sending the fonn 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.
Form GW-1
North Carolina Department of Environmental Quality - Division of Water Resources Revised 2-22-2016

1 IIIIl1 VIM
WELL CONSTRUCTION RECORD (GW-1)
1. Well Contractor information:
Donald Cummings
RECEIVED/NCDENR/DWR
Well Contractor Name
2412-A APR 14 2018
NC Well ConlractorCertification Number
Applied Resource ManagementgiRaC.
Company Name � Operations Section
Wl 7135181.4
� Regional Office
2. Well Construction Permit th vi J f�
List all applicable well construction permits (i.e. I/1C, County, State, Variance, etc.)
3. Well Use (check well use):
Water Supply Well:
Agricultural
Geothermal (Heating/Cooling Supply)
Industrial/Commercial
Irrigation
Non -Water Supply Well:
Monitoring
lMunicipal/Public
xDResidential Water Supply (single)
Residential Water Supply (shared)
Recovery
Injection Well:
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
Experimental Technology
Geothermal (Closed Loop)
Geothermal (Heating/Cooling Return)
4. Date Well(s) Completed: 1/19/18
5a. Well Location:
Thornton Builders, LLC
Facility/Owner Name
Groundwater Remediation
DSalinity Barrier
DStonnwater Drainage
Subsidence Control
Tracer
Other (explain under #21 Remarks)
Well ID# N /A
N/A
Facility ID# (if applicable)
Lot 10 Pecan Grove, N. Sea Lilly Ct, Hampstead, NC 28443
Physical Address, City, and Zip
Pender
County
4214-72-3421-0000
Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
34 24 29.0 N 077 36 59.6
6. Is(are) the well(s)IJPermanent or DTemporary
7. Is this a repair to an existing well: EYes orNo
If this is a repair, fill out known well construction information and explain the nature oldie
repair under #21 remarks section or on the back of this form.
8. For Geoprobe/DPT or Closed -Loop Geothermal' yells having the same
construction, only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled: 1
9. Total well depth below land surface: 100
For nn ltiple wells list all depths if different (example- 3 a.200' and 2@100')
10. Static water level below top of casing: 15
If water level is above casing, use ", "
11. Borehole diameter: See Remark (in.)
12. Well construction method: Mud Rotary
For Internal Use On '4
8387
14. WATER ZONES
FROM
TO
DESCRIPTION
ft.
ft.
ft.
ft.
15. OUTER CASING (for multi -cased wellslOR LINER (if a licable)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
0 ft-
80 ft.
4 in'
SCH40
PVC
16. INNER CASING OR TUBING (geothermal closed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft.
ft.
in.
ft.
ft.
in.
--
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
ft.
ft.
in.
ft.
fL
in.
18. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
0 ft.
25 ft.
Bentonite
Poured
ft.
ft.
ft.
ft.
19. SAND/GRAVEL PACK (if applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
ft.
ft.
ft.
ft.
20. DRILLING LOG (attach additional sheets if necessary)
FROM
TO
DESCRIPTION (color, hardness, soalrock type, grain size, etc.)
0 ft.
65 ft,
Sandy clay to clay
65 ft.
100 ft.
Limestone - Hard at 75'-853
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
21. REMARKS
O'to25'=8"
25' to 100' = 6"
22. Cer 'fication:
Signature of Certified Well Contractor
1/19/18
Date
By .signing this form, 1 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
t raj-Rink/pp Submit this form within 30 days of completion of well
HS olytotket'lowing:
(f E® ®6 IziiU@i n of Water Resources, Information Processing Unit,
17 Mail Service Center, Raleigh, NC 27699-1617
yfyb$l11AW43o5i ells: In addition to sending the form to the address in 24a
CslW0j1103submit 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.
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) 80 Method of test: Airlift
HTH
0
13b. Disinfection type: Amount: 3 /o@10g
Fonn GW-1
North Carolina Department of Environmental Quality - Division of Water Resources Revised 2-22-2016

WELL CONSTRUCTION RECORD (GW-1)
1. Well Contractor Information:
1483RG
For internal Use Only:
Donald Cummings
RECEIVED/NCDENR/DWR
Well Contractor Name
2412-A
NC Well Contractor Certification Number
APR 14 2018
Applied Resource Management P.0
Alter Quality tZaton2l'
Company Name - ^QQr tions Section
2. Well Construction Permit II: l n Regional Office
List all applicable well construction permits (i.e. UiC, County, State, Variance, etc.)
3. Well Use (check well use):
Water Supply Well:
Agricultural
jGeothennal (Heating/Cooling Supply)
Industrial/Commercial
Irrigation
Non -Water Supply Well:
Monitoring
tMunicipal/Public
Residential Water Supply (single)
DResidential Water Supply (shared)
Recovery
Injection Well:
['Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
['Experimental Technology
fGeothertnal (Closed Loop)
Geothermal (Heating/Cooling Retum)
4. Date Well(s) Completed: 1 /12/18
5a. Well Location:
Ralph Bigelow
DGroundwater Remediation
DSalinity Barrier
JStormwater Drainage
Subsidence Control
Tracer
Other (explain under tl21 Remarks)
Well ID/I N/A
N/A
Facility/Owner Name Facility iDti (if applicable)
117 Center Drive Hampstead, NC 28443
Physical Address, City, and Zip
Pender 3282-73-2146-0000
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
34 21 21.5 N 77 43 03.5 W
6. Is(are) the well(s) .Jx Permanent or DITemporary
7. Is this a repair to an existing well: EYes or EjNo
If this is a repair, fill out known well construction information and explain the nature of the
repair under k21 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: 1
9. Total well depth below land surface: 120
For multiple wells list all depths ,f different (example- 3@200' and 2@100')
10. Static water level below top of casing: 1 1
(ft.)
(ft.)
If water level is above casing, use "+"
11. Borehole diameter: See Remark ono
12. Well construction method: Mud Rotary
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) 80 Method of test: Airlift
HTH 0
13b. Disinfection type: Amount: 3 /o@10g
14. WATER ZONES
FROM
TO
DESCRIPTION
ft.
ft.
ft.
rt.
15. OUTER CASING (for multi -cased wells) OR LINER (if a linable)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
0 ft.
90 ft.
4 in.
SCH40
PVC
16. INNER CASING OR TUBING (geothermal closed -loop)
FROM
TO
DIAMETER
THICKNESS
_ MATERIAL
ft.
ft.
in.
ft.
ft.
in.
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
ft.
ft
in.
ft.
ft.
in.
18. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT_
0 rt•
24 rt
Bentonite
Poured
ft.
ft.
ft
ft.
19. SAND/GRAVEL PACK (if applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
ft.
ft.
ft.
ft.
20. DRILLING LOG (attach additional sheets if necessary
FROM
TO
DFSCRIPTION (color, hardness, soil/rock type, grain size, etc.)
0 f'
55 ft.
Sandy clay to clay
55 rt.
120 rt•
Limestone (void at 120')
ft.
ft.
ft.
ft.
ft,
ft,
ft.
ft.
i.... li ;� 0.-T
ft.
ft.
'''' ,.My «• k. y o. It.)
21.RE\!ARKS JAN 9) 4
0-25'=8" 2018
25' - 120' = 6" 'nrormsslirtt frees,,,,,, -y. Uf'4
22. Certification:
1/12/18
Si: atrue of Certified Well Contractor `'t - Date
By signing this form, I hereby certify that the wells) was (were) constructed in accordance
with 15A NCAC 02C .0100 or 1 5A 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 injection 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 & Injection 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.
Form GW-1
North Carolina Department of Environmental Quality - Division of Water Resources Revised 2-22.2016

WELL CONSTRUCTION RECORD (GW-1)
1. Well Contractor Information:
Donald Cummings
Well Contractor Name
2412-A
NC Well Contractor Certification Number
RtECEIVED/N.CDEN D/DWR
APR 14 2018
Applied Resource Management, P.C.
Company Name vvater aU�lily Regional
W � 7lnipR tions Section
2. Well Construction Permit #: Vd tl-fiMt n Regional Office
List all applicable well consbruction permits (i.e. UIC, County, State, Variance, etc.)
3. Well Use (check well use):
Water Supply Well:
Agricultural
Geothermal (Heating/Cooling Supply)
Industrial/Commercial
"Irrigation
Non -Water Supply Well:
Monitoring
QMunicipal/Public
QResidential Water Supply (single)
Residential Water Supply (shared)
DRecovery
Injection Well:
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
Experimental Technology
Geothermal (Closed Loop)
Geothennal (Heating/Cooling Return)
DGroundwater Remediation
DSalinity Barrier
EJStormwater Drainage
Subsidence Control
Tracer
Other (explain under #21 Remarks)
4. Date Well(s) Completed: 1 2/28/17
5a. Well Location:
Thornton Builders
Well ID# NIA
N/A
Facility/Owner Name Facility ID# (if applicable)
204 E. Colonnade Dr, Hampstead, NC 28443
Physical Address, City, and Zip
Pender 4214-71-4358-0000
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
34 24 19.08 N 77 36 57.11
6. Is(are) the well(s)fPermanent or DTemporary
7. Is this a repair to an existing well: jYes or xJNo
If this is a repair, fill out known well construction information and explain the nature oldie
repair under i21 remark' 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: 1
9. Total well depth below land surface: 100
For multiple wells list all depths if different (example- 3 a 200' and 2 c@t 100')
10. Static water level below top of casing: 16
If water level is above casing, use " - "
11. Borehole diameter: See Remail(in.)
12. Well construction method: Mud Rotary
(ft.)
(ft.)
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) 80 Method of test: Airlift
13b. Disinfection type: HTH Amount: 3%@10g
For Internal Use Only'
14. WATER ZONES
FROM
TO
DESCRIPTION
ft.
ft.
-
ft.
ft.
15. OUTER
CASING (for
multi -cased wells OR LINER (if a licable)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
0 ft*
80 ft.
4 in.
SCH40
PVC
16. INNER
CASING OR TUBING
(geothermal closed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft.
ft.
in.
ft.
ft.
in.
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
ft.
ft.
in.
ft.
ft.
in.
18. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
0 ft-
25 ft-
Bentonite
Poured - 550#
ft.
ft.
rt.
ft.
19. SAND/GRAVEL
PACK
(if applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
ft.
ft.
ft.
ft.
20. DRILLING LOG (attach additional sheets if necessary
FROM
TO
DESCRIPTION (color, hardness, soil/rock type, grain size, eta)
0 ft.
65 ft.
Sandy clay to clay
65 ft.
75 ft.
Weathered limestone
75 ft.
100 ft.
Limestone
ft.
ft.
ft.
ft.
ft.
ft.
2 p' , ;, .,
c.
ft.
ft.
21. REMARKS J 4 2018
0-25'=8"
25'-100'=6" tsc;;:.I_::-: ; . ._.:_..
22.
'cation:
Signature of Certi r.. Well Contractor
1/17/18
Date
Ry .signing this form, I hereby certify that the well(s) was (were) constructed in accordance
with 1SA R (: AC 02C .0100 or ISA 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:
Division of Water Resources, Underground Injection Control Program,
1636 N4ail 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.
Form GW-1
North Carolina Department of Environmental Quality - Division of Water Resources Revised 2-22-2016

WELL CONSTRUCTION RECORD (GW-1)
Print Form
For Internal Use Only:
2. Well Construction Permit #:
List all applicable well construction permits (i.e. WC, Cotmry, State, Variance, ete.)
1. Well Contractor Information:
Sanford Sweeting
RECEIVED/NCDENR/DWI
Well Contractor Name
2082-A
NC Well Contractor Certification Number
APR 14 2018
Applied Resource Mana foil c@ aI
Company Name Wilmin on Regional Office
W18-012-B
3. Well Use (check well use):
Water Supply Well:
Agricultural DMunicipal/Public
Geothermal (Heating/Cooling Supply) Residential Water Supply (single)
�IndustriaUCommercial Residential Water Supply (shared)
'Irrigation
Non -Water Supply Well:
Monitoring
QRecovery
Injection Weil:
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
Experimental Technology
Geothermal (Closed Loop)
Geothermal (Heating/Cool ing Return)
DGroundwater Remediation
Salinity Barrier
EDStormwater Drainage
DSubsidence Control
DTracer
Other (explain under #21 Remarks)
4. Date Welt(s) Completed: 3/27/18
5a. Well Location:
Myra McDuffie
Well ID# N/A
N/A
Facility/Owner Name Facility IDii (if applicable)
Piney Woods Road, Burgaw, NC
Physical Address, City, and Zip
Pender 2299-55-8046-000
County Parcel Identification No. (PiN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
448565
14. WATER ZONES
FROM
TO
DESCRIPTION
ft.
ff.
ft.
ft.
15. OUTER CASING (for multi -cased wells) OR LiNER (if a licable)
FROM
TO
DIAMETER `
THItKNESS
MATERIAL
+1.5 ft.
215 ft-
4 "n•
SCH40
PVC
16. INNER CASING OR TUBING (geothermal closed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft.
ff.
in.
ft.
ft.
ia.
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
215 It
240 ft.
4 in-
.020
SCH40
PVC
ft.
ft.
in.
18. GROUT
FROM
TO
MATERIAL
_ EMPLACEMENT METHOD & AMOUNT
0 ft.
30 ft.
Bentonite
Poured
ft.
ft.
ft.
ft.
19. SAND/GRAVEL PACK (if applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
210 ft
240 ft
Coarse
Poured
ft.
ft.
20. DRILLING LOG (attach additional sheets if necessary)
FROM
TO
DESCRIPTION (color, hardness, soil/rock type, grain size, etc.)
0 ff.
20 ft
Clay
20 ft.
50 ft'
Sand some silt
50 ft•
140 ft
Sandy soil some shells
140 rt.
210 ft
Clayey silt fine sand
210 ft.
240 ft
Coarse sand some shells
ft.
ft.
ft.
ft.
21. REMARKS -
.PD kh LK9nirk
(if well field, one lat/long is sufficient) 22. Ce
34.557874 N 78.016920 W
6. Is(are) the well(s)JPermaneiit or DTemporary
7. Is this a repair to an existing well: QYes or ®X No
If this is a repair, fill out known well construction information and explain the nature of the
repair under t121 remarks section or on the back of this fonn.
8. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction, only 1 GW-I is needed, Indicate TOTAL NUMBER of wells
drilled: 1
9. Total well depth below land surface: 240
For multiple wells list all depths if different (example- 3@200' and 2 rt 100')
10. Static water level below top of casing:
If water level is above casing, use "+"
27
11. Borehole diameter: 8 (in.)
12. Well construction method: Mud Rotary
(ft.)
(ft.)
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) 50 Method of test: Airlift
HTH
0
13b. Disinfection type: Amount: 3 /o @ 10g
gnat
on:
Well Contractor
intoif
as as rtr �a:r�
3tti)1
DWOi13C
Date
By signing this form 1 hereby cert fy that the well(was (were) constructed m accordance
with ISA NCAC 02C .0100 or ISA NCAC 0?C .0200 Well Cautntction 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
constniction 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:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Sunnily & Injection Wells: in addition to sending the fonn to
the address(es) above, also submit one copy of this fonn within 30 days of
completion of well construction to the county health department of the county
where constructed.
Fonn GW-I
North Carolina Department of Environmental Quality - Division of Water Resources Revised 2.22-2016

Print Form.
WELL CONSTRUCTION RECORD (GW-1)
1. Well Contractor Information:
Sanford Sweeting
Well Contractor Name
2082-A
NC Well Contractor Certification Number
Applied Resource Management, P.C.
Company Name WS0801021
2. Well Construction Permit #:
Uri all applicable well construction permits (Le. 1/IC, County, Stale, Variance, etc.)
3. Well Use (check well use):
Water Supply Well:
Agricultural
Geothermal (Heating/Cooling Supply)
Industrial/Commercial
Irrigation
Non -Water Supply Well:
Monitoring
[3 Municipal/Public
DResidential Water Supply (single)
DResidential Water Supply (shared)
0 Recovery
Injection Well:
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
Experimental Technology
Geothermal (Closed Loop)
Geothermal (Heating/Cooling Return)
DGroundwater Remediation
Salinity Barrier
DStormwater Drainage
Subsidence Control
DTracer
Other (explain under #21 Remarks)
4. Date Well(s) Completed: 3/22/18 well ID# N/A
5a. Well Location:
Signature of Topsail NC N/A
Facility/Owner Name Facility ID# (if applicable)
Former Golf Course, Wyndwater PB 60-134 - Hampstead, NC 28443
Physical Address, City, and Zip
Pender
4204-84-9114-0000
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field. one lat/long is sufficient)
34.441505 N 77.640997
6. Is(are) the well(s)0Permanent or jTemporary
7. Is this a repair to an existing well: Dyes or XI jNo
If this is a repair, fill out known well construction information and explain the nature of the
repair under a21 remarks section or on the back of this form.
W
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: 1
9. Total well depth below land surface: 270
For mtdliple wells list all depths if different (example- 3@200' and 2@100')
10. Static water level below top of casing: 17
If water level is above casing, use "*"
11. Borehole diameter: 12" (in .)
12. Well construction method: Mud Rotary
(i.e. auger, rotary, cable, direct push, etc.)
(ft.)
(ft.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) 250 Method of test: Airlift
HTH
0
13b. Disinfection type: Amount: 3 /o © 10g
For Internal Use Only:
448564
14. WATER ZONES
FROM
TO
DESCRIPTION
40 ft
120 ft.
Castle Hayne "
220 ft.
270 ft•
Pee Dee
15. OUTER CASING (for multi -cased wells) OR LINER (if a licable)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
0 ft•
75 ft•
14 in.
SCH40
PVC
16. INNER CASING OR TUBING (geothermal closed -loop)
FROa1
TO
DIAMETER
THICKNESS
MATERIAL
+2 ft.
230 ft
8 t"•
SDR-17
PVC
ft.
ft.
in.
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
230 ft.
270 ft.
8 i"•
.020
Stainless
ft
ft.
in.
18. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
0 ft.
218 ft.
Neat cement
Tremmie
218 ft•
225 ft
Bentonite
Poured
ft.
ft.
19. SAND/GRAVEL PACK (if applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
225 ft
270 ft
Coarse
Poured
ft.
ft.
20. DRILLING
LOG (attach additional sheets if necessary)
FROM
TO
DESCRIPTION (color, hardness, soiVrock type, grain sire, etc.)
ft.
ft.
SEE ATTACHED
ft.
ft.
ft.
fL�1�.I�r
(�e 1pr
I�/1�1��p
JECEIVEF(NCDENR/DWR
^�•^ r.,,
ft-
APR ftt.
4 2018 APR 0 k 2018
21. REMARKS
Water Quality Regional *MOFM Mri PR:... ``'.-,,
Operations Section "�`'`t�`t "`
22.CerTic +tio :
3/22/18
Ignatu ofCe ed Well •ontractor Date
By signing this form, I hereby cert fy that the well(s) was (were) constructed in accordance
with 15A NCAC 02C .0100 or 15A NCAC 02C .0200 Well Conslrriction 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
constniction 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:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c, For Water Sunoly & Infection 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.
Fonn GW-1
North Carolina Department of Environmental Quality - Division of Water Resources Revised 2-22-2016

PUBLIC SUPPY WELL
BORING LOG
SIGNATURE OF TOP SAIL, NC LTD.
TOPSAIL GREENS
HAMPSTEAD, NC
DRILLED BY: S. SWEETING
LOGGED BY: S. SWEETING
DATE: 3/22/18
Sample
Depth
Description
0' - 20'
Light brown to medium brown, silty to very fine sand with organic
matter. Low clay content.
20' - 40'
Medium gray, silty to fine grained sand with wood fragments. Changing
to a dark gray, silty clay from 35' - 37'. Grading to a limestone cap rock
with shell hash mixture.
40' - 60'
Soft limestone rock with consolidated rock material at 55'.
60' - 80'
Limestone rock with shells, fossils, and phosphatic nodules with minor
inter -bedded fine sand.
RECEIVED/NCDENR/DWR
80' - 100'
Soft limestone rock. APR 1 4.2018
100' - 120'
Water Quality Regional
Alternating soft limestone rock and consolidate1 imngton iligtnRegional Oft3mk ficB la ers.
120' - 140'
Extremely soft limestone rock with some inter -bedded sands.
140' - 180'
Alternating limestone rock and dark gray, silty clay layers.
180' - 220'
Pee Dee clay with mud rock mixture.
220' - 260'
Gray sandstone, clean with little fines.
260' - 270'
Poorly indurated sandstone to 265'.

Print Form
WELL CONSTRUCTION RECORD (GW-1)
1. Well Contractor Information:
Donald Cummings
Well Contractor Name
2412-A
NC Well Contractor Certification Number
Applied Resource Management, P.C.
Company Name
2. Well Construction Permit #:
W16-049H
List all applicable well construction permits (Le. UIC, County, State. Variance, etc.)
3. Well Use (check well use):
Water Supply Well:
Agricultural DMunicipal/Public
Geothermal (Heating/Cooling Supply) DResidential Water Supply (single)
IndustriaUCommercial DResidential Water Supply (shared)
'Irrigation
Non -Water Supply Well:
Monitoring
Injection Well:
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
Experimental Technology
Geothermal (Closed Loop)
Geothermal (Heating/Cooling Retum)
4. Date Well(s) Completed: 3/1 /18
DRecovery
DGroundwater Remediation
DSalinity Barrier
DStormwater Drainage
DSubsidence Control
DTracer
DOther (explain under #21 Remarks)
Wen ID# N/A
5a. Well Location:
Coastal Home Company N/A
Facility/Owner Name Facility ID# (if applicable)
Lot 5 Dan Owen Drive, Hampstead, NC 28443
Physical Address, City, and Zip
Pender
3292-24-1485-0000
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
34 21 22.68 N
77 41 59.39
For Internal Use Only:
RECEIUEC/NCDENR/DWR
14. WATER ZONES
FROM
TO
DESCRIPTION
`t'
ft.MAR
-
ft.
ft.
15. OUTER CASING (for multi -cased wells) OR LINER (if ap livable)
FROM
TO
DIAMETER
THICKNESS MATERIALWater (1
0 ft.
190 ft-
4 in-
SCH40 PVC Operas
16. INNER
CASING OR TUBING
(geothermal closed -loop) WiItiiingto
FROM
TO
DIAMETER
THICKNESS
MATERIAL
170 ft-
190 ft-
2 in'
SCH40
PVC J
ft.
ft.
in.
-
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
190 ft-
210 ft-
2 in-
.010
SCH40
PVC
ft.
ft.
in.
IS. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
0 ft.
25 ft.
Grout
Poured
185 ft-
190 ft-
Bentonite
Poured
ft
ft.
-
19. SAND/GRAVEL PACK
(if applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
ft
fL
ft.
ft.
20. DRILLING
LOG (attach additional sheets if necessary)
FROM
TO
DESCRIPTION (color, hardness, sotVrock type, grain size, etc.)
0 It
5 ft-
Topsoil
5 ft-
65 ft.
Sandy clay/clay
65 ft.
145 ft.
Limestone
145 ft-
185 it.
Clay mud rock limestone layers
185 ft-
210 ft.
Sandstone
ft
ft
ft
ft
\
�my � r'''.t,!
21. REMARKS "tyC 'O.i 5- ;!.-
0 to25'=8"
tt$
25'-210'=6". ►BAR 2018
22. Certification:
W
6. Is(are) the well(s)JPermanent or DTemporary
7. Is this a repair to an existing well: DYes or xDNo
If this is a repair, fill out known well construction information and explain the nature of the
repair wider 112/ 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: I
9. Total well depth below land surface: 210
For multiple wells list all depths ifdii different (example- 3@200' and 2@100')
(ft.)
10. Static water level below top of casing: 14 (ft.)
If water level is above casing, use "+"
11. Borehole diameter: See Remar(in )
12. Well construction method: Mud Rotary
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a, Yield (gpm) 80 Method of test: Airlift
13b. Disinfection type: HTH Amount: 3% 10g
Signature of Certified Well Contractor
P.it
Date
By signing this fonn, 1 hereby ter* that the well(s) was (were) constructed in accordance
with 1SA 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:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Sunnis, & 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.
Form OW-1 North Carolina Department of Environmental Quality - Division of Water Resources
Revised 2-22-2016
3 0 2018
ality Regional
ons Section
Regional Office

RECEIVED/NCDENR/DWR
RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
A 7 er/r»atiolity Regional
WELL CONTRACTOR CERTIFICATION # 2314A `$ (J �'iifetations Section
Wilmington Regional Office
1. WELL CONTRACTOR:
DAVID L REGISTER
Well Contractor (Individual) Name
REGISTER WELL CO.. INC.
Well Contractor Company Name
721 WEST CHARITY ROAD
Street Address
ROSE HILL NC 28458
City or Town State Zip Code
( 910 ) 289-3175
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT#
OTHER ASSOCIATED PERMIT#('rf applicable)
SITE WELL ID #(if applicable)
3. WELL USE (Check Applicable Box): Residential Water Supply
DATE DRILLED 11-02-2017
TIME COMPLETED AM ❑ PM ❑
4. WELL LOCATION:
CITY: WILLARD
25230 US 421
COUNTY PENDER
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope EValley ❑Ridge ❑Other
LATITUDE 34 " DMS OR 34.665869 DD
LONGITUDE 77
°46 ' "DMS OR78.143521
DD
Latitude/longitude source: RtPS ❑Topographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5. WELL OWNER
LUCILLE HERRING
Owner Name
25230 US 421
Street Address
WILLARD NC 28478
City or Town State Zip Code
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 177
b. DOES WELL REPLACE EXISTING WELL? YES (or NO ❑
c. WATER LEVEL Below Top of Casing: 28 FT.
(Use "+" if Above Top of Casing)
d. TOP OF CASING IS 1 .5 FT. Above Land Surface*
*Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): 20 METHOD OF TEST AIR
f. DISINFECTION: Type HTH Amount 3 OZ
Top 150
g. WATER ZONES (depth):
Top Bottom Top
Top Bottom Top
Top Bottom Top
7. CASING: Depth
Top 0 Bottom 157
Top Bottom
Top Bottom
MAR 302018
Bottom
Bottom
Bottom
Thickness!
Diameter Weight Material
Ft. 2 .40 PVC
Ft.
Ft.
8. GROUT: Depth Material
Top 0 Bottom 20 Ft. HOLE PLUG
Top Bottom Ft.
Top Bottom Ft.
9. SCREEN: Depth
Method
POURED
Diameter Slot Size Material
Top 157 Bottom 177 Ft.2 in. .016 in. PVC
Top Bottom Ft. in. in.
Top Bottom Ft. in. in.
10. SAND/GRAVEL PACK:
Depth Size
Bottom 177 Ft. #2
Top Bottom Ft.
Top Bottom Ft.
11. DRILLING LOG
Top Bottom
140 /145
145 /153
153 /157
157 /168
168 /177+
/
/
12. REMARKS:
Material
GRAVEL
Formation Description
SAND
SAND AND CLAY
ROCK AND SAND
SAND (MED)
SAND AND ROCK
MAR (.3 2018
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
ACCORDANCE WITH 15A NCAC 2C, WELL CONSTRUCTION
STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN
PROVIU D TO THE WELL.OWNE
� lvi.'e h" % 11-14-17
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
DAVID L REGISTER
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality - Information Processing,
1617 Mail Service Center, Raleigh, NC 27699-161, Phone : [phone]
Form GW-la
Rev. 2/09

RESIDENTIAL WELL CONSTRUCTION RECORD
47025
North Carolina Department of Environment and Natural Resources- Division of Water Qua y
WELL CONTRACTOR CERTIFICATION # 2314A
1. WELL CONTRACTOR:
DAVID L REGISTER
Well Contractor (Individual) Name
REGISTER WELL CO,. INC,
Well Contractor Company Name
721 WEST CHARITY ROAD
Street Address
ROSE HILL NC 28458
City or Town State Zip Code
( 910) 289-3175
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT#
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable)
3. WELL USE (Check Applicable Box): Residential Water Supply VI
DATE DRILLED 1 1-02-201 7
TIME COMPLETED AM ❑ PM ❑
4. WELL LOCATION:
CITY: WILLARD
25230 US 421
COUNTY PENDER
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope ❑Valley VFlat ❑Ridge ❑Other
LATITUDE 34 " DMS OR 34.665869 DD
LONGITUDE 77 ° 46 " DMS OR 78.143521 DD
Latitude/longitude source: IMPS Qfopographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5. WELL OWNER
LUCILLE HERRING
Owner Name
25230 US 4 1
Street Address
WILLARD NC 28478
City or Town State Zip Code
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 177
b. DOES WELL REPLACE EXISTING WELL? YES lit NO ❑
c. WATER LEVEL Below Top of Casing: 28 FT.
(Use "+" if Above Top of Casing)
d. TOP OF CASING IS 1 .5 FT. Above Land Surface*
*Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): 20 METHOD OF TEST Al R
f. DISINFECTION: Type HTH Amount 3 OZ
g. WATER ZONES (depth):
Top Bottom Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
Thickness/
7. CASING: Depth Diameter Weight Material
Top 0 Bottom 157 Ft. 2 .40 PVC
r-'
o m O
O w
trot N
cra
dh
O� o.
CD
CD
Top Bottom Ft.
Top Bottom Ft.
8. GROUT: Depth Material Method
Top 0 Bottom 20 Ft. HOLE PLUG POURED
Top Bottom Ft.
Top Bottom Ft.
9. SCREEN: Depth Diameter Slot Size Material
Top 157 Bottom 177 Ft.2 in. .016 in. PVC
Top Bottom Ft. in. in.
Top Bottom Ft. in. in.
Size Material
Top 150 Ft.#2 GRAVEL
10. SAND/GRAVEL PACK:
Depth
Bottom 177
Top Bottom Ft.
Top Bottom Ft.
11. DRILLING LOG
Top Bottom
0 /10
Formation Description
SAND AND CLAY
10 /25 CLAY
25 /26 ROCK 12" •
26 /42 CLAY
42 /77
77 /89
SAND AND CLAY
ROCK, SAND AND CLAY
89 /96 SAND (MED)
96 / 97 ROCK 12"
97 /100
100 /115
115 /123
123 /126
SAND
CLAY
SAND
CLAY
MAR 2 ci 2018
126 / 136 SAND
136 / 140 SAND AND CLAY
12. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
ACCORDANCE WITH 15A NCAC 2C, WELL CONSTRUCTION
STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN
PROWDED TO THE WELL OWN R.
11-14-17
SIGNATURE OF CERTIFIED WELeCONTRACTOR DATE
DAVID L REGISTER
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality -
Information Processing,
Form GW-1a
1617 Mail Service Center, Raleigh, NC 27699-161, Phone : [phone] Rev.2/09
IIMON303NABA1303S

WELL CONSTRUCTION RECORD (GW-1)
Print Form
For internal Use Only:
1. Well Contractor Information:
Donald Cummings
Well Contractor Name
2412-A
NC Well Contractor Certification Number
2. Well Construction Permit #:
List all applicable well construction penniis (i.e. UWC, County, State, Variance, etc.)
3. Well Use (check well use):
RECEIVED/NCDENR/DWR
MAR 0 5 2018
Applied Resource Managaltgii
iirional
Se ibn
Company Name dt/Iltnjnt?ton Regional Office
W16-055H
Water Supply Well:
Agricultural DMunicipal/Public
Geothermal (Heating/Cool ing Supply) XDResidential Water Supply (single)
j Industrial/Commercial DResidential Water Supply (shared)
Irrigation
Non -Water Supply Well:
Monitoring
Injection Well:
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
Experimental Technology
Geothermal (Closed Loop)
Geothermal (Heating/Cooling Return)
Recovery
Groundwater Remediation
DSalinity Barrier
DStormwater Drainage
Subsidence Control
DTracer
Other (explain under #21 Remarks)
4. Date Well(s) Completed:) /23/18 wen 1D# N/A
5a. Well Location:
Eastern NC Home Builders
N/A
Facility/Owner Name Facility ID!! (if applicable)
Lot 11 Dan Owen Drive, Hampstead, NC 28443
Physical Address, City, and Zip
Pender
3292-15-6328-0000
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field one lat/long is sufficient)
34 21 39.13 N 77 42 04.25
6. Is(are) the well(s)0Permanent or DTemporary
7. Is this a repair to an existing well: DYes or Cho
If this is a repair, fill out known well construction information and explain the nature of the
repair under n21 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: 1
9. Total well depth below land surface: 85
For multiple wells list all depths if different (example- 3@200' and 20100')
10. Static water level below top of casing: 14
If water level is above casing, use "-"
11. Borehole diameter: See Remab(in )
12. Well construction method: Mud Rotary
W
(ft.)
(ft.)
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) 80 Method of test: Airlift
13b. Disinfection type: HTH Amount: 3% U@ 10g
447.118
14. WATER ZONES
FROM
TO
DESCRIPTION
ft.
ft.
ft.
ft
15.OUTER
CASINO (for
multi -cased wells) OR LINER (if ap licable)
FRO8I
TO
DIAMETER
THICKNESS
MATERIAL
0 ll•
60 ft.
4 in
SCH40
PVC
16. INNER
CASING OR TUBING
(geothermal closed -loop
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft.
ft.
in.
ft.
ft
in.
17. SCREEN
-
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
ft
ft.
in.
ft.
ft.
in.
18. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
0 ft'
25 ft•
Bentonite
Poured
ft.
ft
ft.
ft.
19. SAND/GRAVEL
PACK
(if applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD ,
ft.
ft.
ft
ft.
20. DRILLING LOG (attach additional sheets if necessary)
FROM
TO
DESCRIPTION (color, hardness, soWrock type, grain size, etc.)
0 ft•
45 ft
Sandy clay to clayey sands
45 ft.
B2 ft.
Clay
62 ft
85 ft.
Limestone (void at 83')
ft
ft
ft.
ft
ft
ft.
ft.
ft.
REcovED
21. REMARKS
0-25'=8"
FEB s �Q��
25'-85'=6" Li:01
4nfr• tat 1'rG•Ge
22. Cegtion:
-` (i 4w;
MVO/EsOG
2/16/18
Signature of Certified Well Contractor Date
By signing this forth, 1 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 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 27699-1636
24c. For Water Sunnly & 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.
Fong G W -1
North Carolina Department of Environmental Quality • Division of Water Resources Revised 2-22-2016

WELL CONSTRUCTION RECORD (GW-1)
RECEIVED/NCDENR/DWR
1. Well Contractor Information:
1 11111 1 V1111
For Internal Use Only:
44 103
Donald Cummings
Well Contractor Name
2412-A
NC Well Contractor Certification Number
Applied Resource Mana
FEB 2 6 2U18
Water Quality Regionalgi
0„ioe'rst Off ce
Company Name
2. Well Construction Permit #:
List all applicable well construction permits (i.e. UIC, County, State, Variance, etc)
W 14-064 H
3. Well Use (check well use):
Water Supply Well:
Agricultural
Geothermal (Heating/Cooling Supply)
Ind ustrial/Commercial
Irrigation
Non -Water Supply Well:
Monitoring
DMunicipal/Public
EiResidential Water Supply (single)
DResidential Water Supply (shared)
Recovery
Injection Well:
Aquifer Recharge
3Aquifer Storage and Recovery
Aquifer Test
Experimental Technology
Geothermal (Closed Loop)
Geothermal (Heating/Cooling Retum)
Groundwater Remediation
Salinity Barrier
FJStormwater Drainage
Subsidence Control
DTracer
Other (explain under #21 Remarks)
4. Date Well(s) Completed: 02/08/18 Well ID#NIA
5a. Well Location:
Grant Curry
N/A
Facility/Owner Name Facility ID# (if applicable)
Lot 6 Ballast Point Drive, Hampstead, NC 28443
Physical Address, City, and Zip
Pender
County
4224-24-2949-0000
Parcel Identification No. (PiN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/iong is sufficient)
34 24 54.9 N 77 36 01.2
6. Is(are) the well(s)fx Permanent or Temporary
7. Is this a repair to an existing well: EJYes or xjNo
If this is a repair, fill out known well construction information and explain the nature of the
repair under i:21 remarks section or on the back of this form.
S. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction, only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled: 1
9. Total well depth below land surface: 105
For multiple wells list all depths if different (example- 3@200' and 2@100')
W
(ft.)
10. Static water level below top of casing: 18 (ft.)
If water level is above casing, use "+"
11. Borehole diameter: See Remark(!n.)
12. Well construction method: Mud Rotary
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) 80 Method of test: Airlift
13b. Disinfection type: HTH Amount: 3%@10g
14. WATER ZONES
FROM
TO
DESCRIPTION
ft.
ft.
ft.
ft.
15. OUTER CASING (for multi -cased wells) OR LINER (if a llcable)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
0 ft.
90 ff.
4 in'
SCH40
_
PVC
16. INNER CASING OR TURING (geothermal closed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft.
ft.
in.
ft.
ft.
in.
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
ft.
ft.
in.
ft.
ft.
in.
18. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
0 ft.
24 ft.
Bentonite
Poured
ft.
ft.
ft.
ft.
19. SAND/GRAVEL PACK(ifapplicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
ft.
ft.
ft.
ft.
20. DRILLING LOG (attach additional sheets if necessary)
FROM
TO
DESCRIPTION (color, hardness, soil/rock type,_grain size, etc.)
0 ft.
80 ft
Clayey sands to sandy clay
80 ft.
85 ft'
Weathered limestone
85 ft.
105 ft.
Limestone
ft.
ft.
ft.
ft.
RFcF4\/Er
(�
rt.
ft.
ft.
ft.
21. REMARKS E 2 2018
FEB2
0-25'=8"
25' - 105' = 6" Iil('Ormatiton i iou :r •i'.l,) u"'c
22. C [cation:
i, 1ted
Si nature of Certified Well Contractor
02/15/18
Date
By signing this form, 1 hereby certify that the well(s) was (were) constructed in accordance
with I SA NCAC 02C .0100 or ISA 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 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 27699-1636
24c. For Water Supply & Iniection Wells: In addition to sending the form to
the address(es) above, also subunit one copy of this form 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

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2314A
RECEIVED/NCDENR/DWR
1. WELL CONTRACTOR:
DAVID L REGISTER
Well Contractor (Individual) Name
REGISTER WELL CO.. INC.
FEB 262018
Well Contractor Company Name Water Quality Regional
721 WEST CHARITY ROAD Operations Section
Street Address wilmington Regional Office
ROSE HILL NC 28458
City or Town State Zip Code
( 910) 289-3175
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT#
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable)
3. WELL USE (Check Applicable Box): Residential Water Supply lit
DATE DRILLED 01-25-2018
TIME COMPLETED AM ❑ PM 0
4. WELL LOCATION:
CITY: WILLARD COUNTY PENDER
985 JOHNSON NURSERY ROAD
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope ❑Valley I'Flat ❑Ridge ❑Other
LATITUDE " DMS OR 34.683513 DD
LONGITUDE " DMS OR 77.962383 DD
Latitude/longitude source: VGPS []Topographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5. WELL OWNER
JOHNSON NURSERY
Owner Name
985 JOHNSON NURSERY ROAD
Street Address
WILLARD NC 28478
City or Town State Zip Code
( )
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 230
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
c. WATER LEVEL Below Top of Casing: 39 FT.
(Use "+" if Above Top of Casing)
d. TOP OF CASING IS 1 .5 FT. Above Land Surface*
*Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): 30 METHOD OF TEST AIR
f. DISINFECTION: Type HTH Amount 4 OZ
446115'
g. WATER ZONES (depth):
Top Bottom Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
Thickness/
7. CASING: Depth Diameter Weight Material
Top 0 Bottom 210 Ft. 4 .40 PVC
Top Bottom Ft.
Top Bottom Ft.
8. GROUT: Depth Material Method
Top 0 Bottom 20 Ft. HOLE PLUG POURED
Top Bottom Ft.
Top Bottom Ft.
9. SCREEN: Depth
Top 210
Top Bottom
Top Bottom
Bottom 230
Diameter Slot Size Material
Ft.4 in. .016
in. PVC
Ft. in. in.
Ft. in. in.
10. SAND/GRAVEL PACK:
Depth Size Material
Top 200 Bottom 236 Ft. #2 GRAVEL
Top Bottom Ft.
Top Bottom Ft.
11. DRILLING LOG
Top Bottom
180 /185
185 /202
202 /208
Formation Description
SAND AND CLAY
SAND (MED)
SAND AND CLAY
208 /214 ROCK AND SAND (MED)
214 /230 SAND (MED)
230 /236+ CLAY
12. REMARKS:
R`_.0 E ? .r
rEB ` ao%
KtgOwf;te,ti.ffl
CAmZeW;cti. i
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
ACCORDANCE WITH 15A NCAC 2C, WELL CONSTRUCTION
STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN
PRODEO TO THE WELL OWNER.
CLLt
SIGNATURE OF CERTIFIED WELL C
DAVID L REGISTER
,Z/L#�J 2-13-18
TRACTOR DATE
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality -
1617 Mail Service Center, Raleigh, NC 27699-161, Phone : [phone]
Information Processing,
Form GW-la
Rev. 2/09

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells RECEIVED/NCDENRf DWR
1. Well Contractor Information:
PAUL MCVEY
Well Contractor Name
A - 4305
FEB 2 6 2018
Water Quality Regional
NC Well Contractor Certification Number Operations Section
GEOLOGIC EXPLORATION, Vi ington Regional Office
Company Name
2. Well Construction Permit #:
List all applicable well construction permits (i.e. County, State, Variance. etc)
3. Well Use (check well use):
Water Supply Well:
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑Industrial/Commercial
❑Irrigation
❑Municipal/Public
❑Residential Water Supply (single)
°Residential Water Supply (shared)
Non -Water Supply Well:
mMonitoring ORecovery
Injection Well:
°Aquifer Recharge
°Aquifer Storage and Recovery
°Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling Return)
4. Date Well(s) Completed: 01 /29/18 Well ID#
5a. Well Location:
PHOENIX - 308
❑Groundwater Remediation
❑Salinity Barrier
OStormwater Drainage
°Subsidence Control
❑Tracer
°Other (explain under #21 Remarks)
MW-34
Facility/Owner Name Facility ID# (if applicable)
13493 NC - 210 ROCKY POINT 28457
Physical Address, City, and Zip
PENDER
County Parcel Identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
34° 26' 24.46" N 77° 52' 37.56"
w
6. is (are) the well(s): J1Permanent or °Temporary
7. Is this a repair to an existing well: ❑Yes or IZJNo
!f this is a repair. fill out known well construction information and explain the nature al the
repair under 1121 remarks section or on the back of this form.
8. Number of wells constructed: 1
For multiple injection or non -water supply wells ONLY with the same construction, you can
submit one form.
15.0
9. Total well depth below land surface: (ft.)
For multiple wells list all depths if different (example- 3 a@,200' and 2 rci 100)
10. Static water level below top of casing: 8'0 (ft.)
lfwaterlevel is above casing, use "+"
I1. Borehole diameter: 7'0 (in.)
12. Well construction method: AUGER
(i.e. auger, rotary, cable, direct push, etc.)
For internal Use ONLY:
14611_4
14. WATER ZONES
FROM
TO
DESCRIPTION
ft.
ft.
ft.
ft.
15. OUTER CASING (for multi -cased wells) OR LINER (if a licae bl )
FROM
fly
TO
ft.
DIAMETER
in.
THICKNESS MATERIAL
16. INNER CASING OR TUBING (geothermal closed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
0.0 rt.
5.0 ft.
2.0
in.
SCH 40
PVC
ft.
ft.
in.
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
5.0 It
15.0 ft.
2.0 in.
.010
SCH 40
PVC
ft.
ft.
in.
18. GROUT
FROM
TO
MATERIAL
0.0 n.
3.0 ft'
PORTLAND BENTONITE
EMPLACEMENT METIIOD & AMOUNT
SLURRY
ft.
ft.
ft.
ft.
19. SAND/GRAVEL PACK (if applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
4.0 ft.
ft.
15.0 It.
ft.
20-40
FINE SILICA SAND
20. DRILLING LOG (attach additional sheets if necessary)
FROM
0.0 ft
fry
ft.
ft.
TO
15.0 ft
ft.
ft,
ft.
DESCRIPTION (color, hardness, soil/rock type, grain size, etc.)
RED/TAN SILTY SANDY CLAY
ft.
ft.
FEB 1 9 201;
ft.
ft.
ft.
21. REMARKS
ft.
knfofWUdttt➢f1 Precoctgif.)
DWO/QOG'
BENTONITE SEAL FROM 3.0 TO 4.0 FEET
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
22. Certification:
02/02/18
Signature ofCeContractor a Date
By signing this form, 1 hereby certify that the well(s) was (were) constructed in accordance
with 1SA NCAC 02C .0100 or 1SA 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 INSTUCTIONS
24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Quality, 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 a copy of this form within 30 days of completion of well
construction to the following:
Division of Water Quality, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Stupoly & 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.
r ,111
Form GW-1
North Carolina Department of Environment and Natural Resources - Division of Water Quality Revised Jan. 2013

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2314A
RECEIVED/NCDENR/DWR
1. WELL CONTRACTOR:
DAVID L REGISTER
Well Contractor (Individual) Name
REGISTER WELL CO.. INC.
Well Contractor Company Name
721 WEST CHARITY ROAD
Street Address
ROSE HILL
City or Town
( 910) 289-3175
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT#
FEB 262018
Water Quality Regional
Operations Section
Wilmington Regional Office
NC 28458
State Zip Code
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable) �!
3. WELL USE (Check Applicable Box): Residential Water Supply Ft
DATE DRILLED 01-25-2018
TIME COMPLETED AMC] PM ❑
4. WELL LOCATION:
CITY: WILLARD COUNTY PENDER
985 JOHNSON NURSERY ROAD
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope DValley G'Flat ❑Ridge ❑Other
LATITUDE " DMS OR 34.683513 DD
LONGITUDE " DMS OR 77.962383 DD
Latitude/longitude source: [3PS ['Topographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5. WELL OWNER
JOHNSON NURSERY
Owner Name
985 JOHNSON NURSERY ROAD
Street Address
WILLARD NC 28478
City or Town State Zip Code
( )
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 230
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
c. WATER LEVEL Below Top of Casing: 39 FT.
(Use "+" if Above Top of Casing)
d. TOP OF CASING IS 1 .5 FT. Above Land Surface*
*Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): 30 METHOD OF TEST AIR
f. DISINFECTION: Type HTH Amount 4 OZ
Top Bottom
Top Bottom
g. WATER ZONES (depth):
Top Bottom Top
Top Bottom Top
Top Bottom Top
7. CASING: Depth Diameter
Top 0 Bottom 210 Ft. 4
Ft.
Ft.
8. GROUT: Depth
Top 0 Bottom 20
Top Bottom
Top Bottom
446113
Bottom
Bottom
Bottom
Thickness/
Weight Material
.40 PVC
Material
Ft. HOLE PLUG
Ft.
Ft.
Method
POURED
9. SCREEN: Depth Diameter Slot Size Material
Top 210 Bottom 230 Ft.4 in. .016 in. PVC
Top Bottom Ft.
Top Bottom Ft.
in. in.
in. in.
10. SAND/GRAVEL PACK:
Depth Size
Top 200 Bottom 236 Ft. #2
Top Bottom Ft.
Material
GRAVEL
Top Bottom Ft.
11. DRILLING LOG
Top Bottom
0 /10
Formation Description
CLAY
10 /37 SAND
37 /61 CLAY
61 /92
SAND AND CLAY
92 / 108 CLAY
108 /115
115 /119
119 /142
142 /143
143 /152
152 /155
155 /170
170 /171
171 /180
12. REMARKS:
SAND AND CLAY
ROCK AND SAND
SAND AND SHELLS
ROCK 4"
SAND AND CLAY
ROCK AND SAND
SAND (MED)
ROCK 14"
SAND (MED)
FEB q 9 2013
DVVQ!i O
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
ACCORDANCE WITH 15A NCAC 2C, WELL CONSTRUCTION
STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN
PRO \ IDED TO THE WELL OWNE
cwt.) f
SIGNATURE OF CERTIFIED WELL
DAVID L REGISTER
2-13-18
NTRACTOR DATE
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality - Information Processing,
1617 Mail Service Center, Raleigh, NC 27699-161, Phone : [phone]
Form GW-la
Rev. 2/09

WELL CONSTRUCTION RECORD (GW-1
HECEIVLD/N(VNR/DWR
1. Well Contractor Information:
�ni� r vrrn
For Internal Use Only:
1146649
Donald Cummings
Well Contractor Name
2412-A
FEB 13 2018
Water Quality Regional
NC Well Contractor Certification Number 0 erations Se� 10p,�
Applied Resource Mana meRl ,iolritQStice
Company Name
2. Well Construction Permit #:
List all applicable well construction permits (i.e. V1C, County, Slate, Variance, etc.)
W17-058H
3. Well Use (check well use):
Water Supply WcII:
Agricultural
Geothermal (Heating/Cooling Supply)
Industrial/Commercial
Irrigation
Non -Water Supply Well:
Monitoring
Injection Well:
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
Experimental Technology
Geothermal (Closed Loop)
Geothermal (Heating/Cooling Return)
jMunicipal/Public
Residential Water Supply (single)
DResidential Water Supply (shared)
e__I Recovery
DGroundwater Remediation
Salinity Barrier
DStonnwater Drainage
Subsidence Control
Tracer
Other (explain under 421 Remarks)
4. Date Well(s) Completed: 1/19/18
5a. Well Location:
Thornton Builders, LLC
Well 1D# N/A
N/A
Facility/Owner Name Facility UN (if applicable)
Lot 10 Pecan Grove, N. Sea Lilly Ct, Hampstead, NC 28443
Physical Address, City, and Zip
Pender
4214-72-3421-0000
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
34 24 29.0 N 077 36 59.6
W
6. Is(are) the well(s)x Permanent or DTemporary
7. Is this a repair to an existing well: JYes or xONo
If this is a repair, fill out known well construction information and explain the nature of the
repair under i21 remarks section or on the back of this fornt.
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: 1
9. Total well depth below land surface: 1 00
For multiple wells list all depths if different (example- 3 a.200' and 2@I00)
10. Static water level below top of casing:
If water level is above casing, use "+"
15
14. WATER ZONES
FROM
TO
DESCRIPTION
ft.
ft.
ft.
ft.
-
15.OUTER CASING (for multi -cased wells) OR LINER (if a licable)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
0 ft.
80 ft.
4 in.
SCH40
PVC _
16. INNER CASING OR TUBING (geothermal closed -loop) --
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft.
ft.
in.
-
ft.
ft.
in.
17. SCREEN -
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
ft.
ft.
in.
ft.
ft.
in.
,
18. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
0 ft'
25 ft•
Bentonite
Poured
ft.
ft.
ft.
ft.
19. SAND/GRAVEL PACK (if applicable.)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
ft.
ft.
ft.
ft.
20. DRILLING LOG (attach additional sheets if necessary)
FROM
TO
DESCRIPTION (color, hardness, soiVrock type, grain size, etc.) -
0 ft'
65 ft,
Sandy clay to clay
65 IL
100 ft.
Limestone - Hard at 75'-853
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
21. REMARKS
O'to25'=8"
25' to 100' = 6"
22. Cer
ification:
r 1
1/19/18
Signature of Certified Well Contractor Date
By signing this form, 1 hereby certify that the well(s) was (were) constructed in accordance
with I5A NCAC 02C .0/00 or 15A MAC 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 ifnecessary.
SUBMITTAL INSTRUCTIONS
AtE Fee s: r Submit this form within 30 days of completion of well
11. Borehole diameter: See Rema. rk(in )
12. Well construction method: Mud Rotary
(rue o to,the owing:
(fHr� A\ 6 izRn of Water Resources, Information Processing Unit,
r� �' 1617 Mail Service Center, Raleigh, NC 27699-1617
retatiNIP. Rtfi° f¢eNo5l ells: In addition to sending the form to the address in 24a
Cabi(1i%=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.
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) 80 Method of test: Airlift
13b. Disinfection type: HTH
Amount: 3%@10g
Fonn GW-1
North Carolina Department of Environmental Quality - Division of Water Resources Revised 2-22-2016

WELL CONSTRUCTION RECORD (GW-1)
1. Well Contractor information:
Donald Cummings
Well Contractor Name
2412-A
NC Well Contractor Certification Number
Applied Resource Management, P.C.
Company Name
2. Well Construction Permit #:
List all applicable well consuvtction permits (i.e. UJC, County, Slate, Variance, etc.)
3. Well Use (check well use):
Water Supply Well:
W17-043H
Agricultural
Geothermal (Heating/Cooling Supply)
Industrial/Commercial
Irrigation
Non -Water Supply Well:
Monitoring
QMunicipal/Public
Residential Water Supply (single)
Residential Water Supply (shared)
Recovery
Injection Well:
Aquifer Recharge
�IAquifer Storage and Recovery
Aquifer Test
Experimental Technology
Geothermal (Closed Loop)
Geothermal (Heating/Cooling Return)
4. Date Well(s) Completed: 1 2/28/1
5a. Well Location:
Thornton Builders
DGroundwater Remediation
Salinity Barrier
JStormwater Drainage
DSubsidence Control
Tracer
Other (explain under #21 Remarks)
7 Well ID#N/A
N/A
Facility/Owner Name Facility ID14 (if applicable)
204 E. Colonnade Dr, Hampstead, NC 28443
Physical Address, City, and Zip
Pender 4214-71-4358-0000
County Parcel identification No. (PiN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one Iat/long is sufficient)
34 24 19.08 N 77 36 57.11
6. Is(are) the well(s) xjPermanent or DTemporary
7. Is this a repair to an existing well: ®Yes or JNo
If this is a repair, fill out known well construction information and explain the moire of the
repair under .. i21 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:1
9. Total well depth below land surface: 100
For multiple wells list all depths if different (example- 3@200' and 2@l00')
10. Static water level below top of casing:
If water level is above casing, use "+ "
11. Borehole diameter: See Remotion.)
12. Well construction method: Mud Rotary
16
W
(ft.)
(ft.)
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) 80 Method of test: Airlift
13b. Disinfection type: HTH Amount: 3%@109
For Internal Use Only:
446336
L_
,nU, .,1111
14. WATER ZONES
FROM
TO
DESCRIPTION
ft.
ft.
ft.
ft.
15.OUTER
CASING (for multi -cased wells) OR LINER Lf a livable)
FROM
TO
DIAMETER
THICKNESS
MATERIAL -
0 ft'
80 ft.
4 in-
SCH40
PVC
16. INNER CASING OR TUBING
(geothermal closed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL -
ft.
ft.
in.
ft.
ft.
in.
17.SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
ft.
ft.
in.
ft.
ft.
in.
18. GROUT
FROM
To
MATERIAL
EMPLACEMENT METHOD & AMOUNT
0 ft.
25 ft.
Bentonite
Poured - 550#
ft.
ft.
ft.
ft.
19. SAND/GRAVEL
PACK
(if applicable) -,
FROM
TO
MATERIAL
EMPLACEMENT METHOD
ft.
ft.
ft.
ft.
20. DRILLING LOG (attach additional sheets if necessary) -
FROM
TO
DESCRIPTION (color, hardness, soil/rock type, grain size, etc.)
0 ft'
65 ft.
Sandy clay to clay
65 ft.
75 Et.
Weathered limestone
75 ft•
100 ft.
Limestone
ft.
ft.
ft.
ft.
ft.
ft.
t ' ..4::::J l; 4,
ft.
ft.
}..'
21. REMARKS BAN d 4 2018
0-25'=8"
25' - 100' = 6„ .rlic:>;.,....,.. - _... .
22.
'cation:
1/17/18
Signature ofCent Well Contractor Date
By .signing this form, I hereby certify that the well(s) was (were) constructed in accordance
with 15A NC:AC 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 additionalarnwell details:
You may use the back of if�.VUJ El WRvell site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTRUCTION$AN 2 9 2018
24a. For All Wells: Submit thishform within 30 days of completion of well
construction to the following:
Division of Water Water Q • i
1617Mail S ��f
�}Clilffif kik5ff
Re• lon�l
rocessing Unit,
099-1617
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 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.
Form GW-1
North Carolina Department of Environmental Quality - Division of Water Resources Revised 2-22-2016

WELL CONSTRUCTION RECORD (GW-1)
1. Well Contractor Information:
Donald Cummings
Well Contractor Name
2412-A
NC Well Contractor Certification Number
Applied Resource Management, P.C.
Company Name
2. Well Construction Permit #:
List all applicable well construction permits (Le. WC, County, State, Variance, etc.)
3. Well Use (check well use):
W 18-001 H
Water Supply Well:
Agricultural
Geothermal (Heating/Cooling Supply)
Industrial/Commercial
jIrrigation
Non -Water Supply Well:
Monitoring
Injection Weil:
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
Experimental Technology
Geothermal (Closed Loop)
Geothermal (Heating/Cooling Return)
fMunicipal/Public
Residential Water Supply (single)
Residential Water Supply (shared)
DRecovery
Groundwater Remediation
Salinity Barrier
DStormwater Drainage
Subsidence Control
Tracer
Other (explain under #21 Remarks)
4. Date Well(s) Completed: 1/12/18
5a. Well Location:
Ralph Bigelow
Well ID# N/A
N/A
Facility/Owner Name Facility iD# (if applicable)
117 Center Drive Hampstead, NC 28443
Physical Address, City, and Zip
Pender 3282-73-2146-0000
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
34 21 21.5 N 77 43 03.5 W
6. Is(are) the well(s)IjPcrmanent or DTemporary
7. Is this a repair to an existing well: JYes or XONo
If this is a repair, fill out known well construction information and explain the nature of the
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 I GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled: 1
9. Total well depth below land surface: 120
For multiple wells list all depths if different (example- 3@200' and 2@l00')
(ft.)
10. Static water level below top of casing: 1 1 (ft.)
If water level is above casing, use "+
11. Borehole diameter: See Remark (in.)
12. Well construction method: Mud Rotary
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) 80 Method of test: Airlift
13b. Disinfection type: HTH Amount: 3%@10g
For internal Use Only:
- _ L
111111.1 l/rtrr
14. WATER ZONES
FROM
TO
DESCRIPTION
ft.
ft.
ft.
ft.
15. OUTER CASING (for
multi -cased wells) OR LINER (ifap licable)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
0 ft.
90 ft.
4 in.
SCH40
PVC
16. INNER
CASING OR TUBING
(geothermal closed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft.
ft.
in.
ft.
rt.
in.
17. SCREEN -
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
ft.
ft.
in.
ft.
ft.
in.
18. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
0 ft.
24 ft.
Bentonite
Poured
ft.
ft.
ft.
ft.
19. SAND/GRAVEL
PACK
(if applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
ft.
ft.
ft.
ft.
20. DRILLING LOG (attach additional sheets if necessary)
FROM
TO
DESCRIPTION (color, hardness,soil/rock type, grain size, etc.)
0 ft.
55 ft•
Sandy clay to clay
55 ft
120 ft.
Limestone (void at 120')
ft.
ft.
fr.
ft.
ft.
ft.
ft.
rt.
-f-A £ . .: „ s,:.
ft.
ft.
•_ ..-.' , s" ro,, .,.- k
21. RE1IARKS JAN 2 4
0-25'=8" 2018
25' - 120' = 6" ,rreori ii*nn Pr`-;-filfj U.N.
22. Certification:
1/12/18
Signature ofCertified Well Contractor Date
By .signing this form, I hereby certt& that the well(s) was (were) constructed in accordance
with 15A NCAC 02C .0100 or I,A NCAC 02C .0200 11'ell 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 tntRalaotivirebv fill rgnecessary.
SUBMITTAL INSTRUCTIONS
24a. For All Wells: Submit thiil fgrpr ty,•i#in,3,�,flays of completion of well
construction to the following: f11V Gu 7 L11 jj
Division of Water Resources, information Processing Unit,
1617 Mail ServiW itf Qt�7PlA i�P,�flffl�p699-1617
Operations Section
24b. For Iniection Wells: Wikti(q pit iyodrioffitrg to the address in 24a
above, also submit one copy of this form wit in 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 font 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

+ ,I/It1 Vl ltl
WELL CONSTRUCTION RECORD (GW-1)
1. Well Contractor Information:
Donald Cummings
Well Contractor Name
2412-A
NC Well Contractor Certification Number
Applied Resource Management, P.C.
Company Name
2. Well Construction Permit #: W 16-0 52 H
List all applicable well construction permits (i.e. 111C. County, State, Variance, etc)
3. Well Use (check well use):
Water Supply Welk
Agricultural
Geothermal (Heating/Cooling Supply)
Industrial/Commercial
x Irrigation
Non -Water Supply Well:
Monitoring
EJMunicipal/Public
DResidential Water Supply (single)
Residential Water Supply (shared)
Recovery
Injection Well:
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
Experimental Technology
Geothermal (Closed Loop)
Geothermal (Heating/Cooling Return)
Groundwater Remediation
DSalinity Barrier
fStormwater Drainage
Subsidence Control
Tracer
Other (explain under #21 Remarks)
4. Date Well(s) Completed: 12/14/17 Well ID#N/A
5a. Well Location:
Coastal Home Company N/A
Facility/Owner Name Facility ID# (if applicable)
Lot 8 Majestic Oaks, Hampstead, NC 28443
Physical Address, City, and Zip
Pender 3292-14-8984-0000
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
34 21 36.46 N 77 42 01.93
6. Is(are) the well(s)ix Permanent or (Temporary
7. Is this a repair to an existing well: ®Yes or IDNo
If this is a repair, fill out known well construction information and explain the nature of the
repair under r21 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: 1
9. Total well depth below land surface: 205
For multiple wells list all depths if different (example- 3@200' and 2@100')
W
(ft.)
10. Static water level below top of casing: 17 (ft.)
If water level is above casing, use "+ "
11. Borehole diameter: See remark (in.)
12. Well construction method: Mud Rotary
(i.e. auger, rotary, cable, direct push, etc.)
For Internal Use Only:
viven-
14. WATER ZONES
FROM
TO
DESCRIPTION
ft.
ft.
ft.
fi.
15. OUTER CASING (for multi -cased wells) OR LINER (if a licable)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
0 ft.
185 ft.
4 in.
SCH40
PVC
16. INNER CASING OR TUBING (geothermal closed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft.
ff.
in.
ft.
ft.
in.
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
185 ft-
205 ft-
4 in.
.020
SCH40
PVC
ft.
ft.
in.
18. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
0 ft.
25 It.
Bentonite
Poured
ft.
ft.
ft.
ft.
19. SAND/GRAVEL PACK (if applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
ft.
ft.
ft.
ft.
20. DRILLING LOG (attach additional sheets if necessary)
FROM
TO
DESCRIPTION (color, hardness, soi7/rocktype, grain size, etc.)
0 ft.
65 ft.
Sandy clay to clay
65 ft.
125 ft.
Limestone
125 ft.
180 ft•
Clay/rock mix
180 ft.
190 ft
Cfay/sandstone mix
190 ft.
205 ft.
Sandstone
ft.
ft.
ft.
ft.
_
21. REMARKS'' � F•
1 lkj
L'•
.`
JAN 0 6. 2016
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) 80 Method of test: Airlift
13b. Disinfection type: HTH Amount: 3%410g
22. Cer u fication:
m4ation Proc.:*6srcg ljN
ow ` RCr3 12/18/17
Signature of Certified Well Contractor (1 Date
By signing this form. 1 hereby certify that the well(s) was (were) constructed in accordance
with 1 SA NCAC 02C .0100 or I SA 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 SeiR iVED MO-1617
24b. For Iniection Wells: In addition to sending the forum to the address in 24a
above, also submit one copy of this form within 30 days of completion of well
construction to the following: JAN 0 8 2018
Division of Water Resources, Underground Injection Control Program,
1636 Mail Serviw t ffh 0 '�699-1636
24c. For Water Simply & Midi i3g. t• S §gc.tl;',t to sending the form to
innthe address(es) above, also M S-OT 0 n 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

1111 I, l V1111
WELL CONSTRUCTION RECORD (GW-1)
1. Well Contractor Information:
Donald Cummings
Well Contractor Name
2412-A
NC Well Contractor Certification Number
Applied Resource Management, P.0
Company Name
2. Well Construction Permit #: v 1 I- 1 0 1 B
List all applicable well construction permits (i.e. UIC. County, State. Variance, etc.)
3. Well Use (check well use):
Water Supply Well:
Agricultural
Geothermal (Heating/Cooling Supply)
Industrial/Commercial
Irrigation
DMunicipal/Public
Residential Water Supply (single)
Residential Water Supply (shared)
Non -Water Supply Well:
Monitoring
°Recovery
Injection Well:
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
Experimental Technology
Geothermal (Closed Loop)
Geothermal (Heating/Cooling Return)
4. Date Well(s) Completed: 12/17/1
5a. Well Location:
Jack Van Wyck
°Groundwater Remediation
DSalinity Barrier
EStormwater Drainage
°Subsidence Control
ITraccr
°Other (explain under #21 Remarks)
7 Well ID#N/A
N/A
Facility/Owner Name Facility ID# (if applicable)
16726 Hwy 421, Burgaw, NC 28425
Physical Address, City, and Zip
Pender
3207-07-4520
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
54 30 28.9 N 78 00 09.3
W
6. Is(are) the well(s)1Permanent or °Temporary
7. Is this a repair to an existing well: °Yes or XINo
1f this is a repair, fill our known well construction information and explain the nature of the
repair under ;i21 remarks section or on the back of thisfornm.
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: 1
9. Total well depth below land surface: 30
For multiple wells list all depths if different (example- 3@.200' and 2@100)
10. Static water level below top of casing:
If water level is above casing, use "-
11. Borehole diameter: See Remark(in.)
12. Well construction method: Mud Rotary
(Le. auger, rotary, cable, direct push, etc.)
9
(ft.)
(ft.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm)- 12 Method of test: Airlift
HTH
0
13b. Disinfection type: Amount: 3 /o@10g
For Internal Use Only:
440596
14. WATER ZONES
FROM
TO
DESCRIPTION
ft.
ft.
ft.
ft.
15. OUTER CASING (for multi -cased wells) OR LINER (if a licable)
FROM
TO
DL4METER
THICKNESS
!MATERIAL
0 ft'
110 ft'
4 in.
SCH40
PVC
16. INNER CASING OR TUBING (geothermal closed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft.
ft.
in.
ft.
ft.
in.
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
110 ft'
130 ft
4 in.
.010
SCH40
_
PVC
ft.
ft-
in.
18. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
0 It•
30 It.
Bentonite
Poured
100 ft.
105 ft-
'
Grout
Poured
ft
ft.
19. SAND/GRAVEL
PACK
(if applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
105 ft-
130 ft.
Coarse
Poured
ft,
ft.
20. DRILLING LOG (attach additional sheets if necessary)
FROM
TO
DESCRIPTION (cotor, hardness, soil/rock type, grain size, etc.)
0 ft.
25 ft.
Clays to sandy clay to sand
25 ft.
105 ft.
Clay
105 ft.
132 ft.
Silty sands
182 ft.
ft.
Sticky clay
ft.
ft.
ft.
ft.
C
ft.
ft.
E
21. REMARKS pt 0 9, " ri
II �! 16
0 - 25/8"25-85/6 S1'1 1�
•rrao smatiofl p'ror:,;cs:nlg Ur>lt
22. Cer ' cation:
(1,
Signa ive of Certified ell Contractor
t)W 1%5 =
12/20/17
Date
By signing this form, 1 hereby cert& 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 ifnecessary.
SUBMITTAL INSTRUCTIONS
24a. For All Wells: Submit this_form within 30 days of completion of well
construction to the following: RECEIVED/NCDENR/DWR
Division of Water Resources, Information Processing Unit,
1617 Mail Service Centgrralalg{g§, r 699-1617
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: Water Quality Regional
`aeratit69C
Division of Water Resource rot Program,
1636 Mail Service Center, a etg , 7 636
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.
Form GW-I
North Carolina Department of Environmental Quality - Division of Water Resources Revised 2-22-2016

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
1. Well Contractor Information:
Joshua Lemere
Well Contractor Name
4310-A
NC Well Contractor Certification Number
Coastal Geothermal
Company Name
2. Well Construction Permit #: W10800493
List all applicable well permits (i.e. County, State, Variance, Injection, etc.)
3. Well Use (check well use):
Water Supply Well:
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑industrial/Commercial
❑Irrigation
❑Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
Non -Water Supply Well:
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer Test
❑Experimental Technology
PJGeothermal (Closed Loop)
❑Geothermal (Heating/Cooling Retum)
❑Groundwater Remediation
❑Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑Tracer
❑Other (explain under #21 Remarks)
4. Date Well(s) Completed: 12-18 -17 Well DM
5a. Well Location:
Moores Creek National Park
Patriots Hall
Facility/Owner Name Facility ID# (if applicable)
40 Patriots Hall Dr., Currie, NC 28547
Physical Address, City, and Zip
Pender
N/A
County Parcel Identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
N W
6. Is (are) the well(s): ©Permanent or ❑Temporary
8. Number of wells constructed: 10 1141..Irsttt ll Proctction details. You may also attach additional pages if necessary.
For multiple injection or non -water supply wells ONLY with the same construalblp'aettlic_`,
submit one form.
For Internal Use ONLY:
14. WATER ZONES
440"-"
FROM
TO
DESCRIPTION
ft.
ft.
surface water
ft.
ft.
15. OUTER CASING (for multi -cased wells) OR LINER (if applicable)
FROM TO DIAMETER THICKNESS MATERIAL
n/a ft.
ft.
in.
16. INNER CASING OR TUBING (geothermal closed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
00o ft•
250 ft.
1
in.
SDR 11
HDPE
ft.
ft.
tn,
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
n/a rr.
ft.
in.
ft.
ft.
in.
18. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
000 ft.
255 ft.
Bentonite
Pump/Tremmie
ft,
ft.
ft.
ft.
19. SAND/GRAVEL PACK (if applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
n/a rt.
ft.
ft.
ft.
20. DRILLING LOG (attach additional sheets if necessary)
FROM
TO
DESCRIPTION (color, hardness, soil/rock type, grain size, etc.)
000 ft.
020 ft,
020 rt.
120 rt.
Sand/Some Clay
Clay/Silty Sand
120 rt.
220 rt.
Limestone/Clay/Silt
220 ft.
255 rt•
Silty Sand/Clay/ Limestone
ft.
ft.
ft.
ft.
ft.
ft.
21. REMARKS
Drilled 10-250' boreholes and set 1"
Geothermal Loop @ 245' in each
22. Certification:
Sign of Certified Well Contractor
12-18-2017
Date
0 _ g this form, I hereby certify that the well(s) was (were) constructed in accordance
e• A CAC 02C .0100 or I5A NCAC 02C .0200 Well Construction Standards and that a
7. Is this a repair to an existing well: ❑Yes or E1Na .u. s record has been provided to the well owner.
If this is a repair, fill out known well construction information and explain t/telit4threfibe 4
repair under #21 remarks section or on the back of this form. �dr t' ` s L 0 Pi. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
9. Total well depth below land surface: 255 (ft.)
For multiple wells list all depths if different (example- 3@,200' and 2(§100')
10. Static water level below top of casing: (ft.)
1f water level is above casing, use ••+"
11. Borehole diameter: 4.75 (in.)
12. Well construction method: Mud Rotary
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
SUBMITTAL INSTUCTIONS
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 CII ,UVED DIR/ lute form to the address in
24a above, also submit a copy of this fonn within 30 days of completion of well
construction to the following: AA'' QQ nn
Division of Water Resources' kale�t�ul4dil ection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For water supply & inie greEttImlity Regional
Also submit one copy of this ffpenfitiQil"rigfta 98f ompletionof
well construction to the cotitj'( ildriiiij tOft 101i0b gPeounty where
constructed.
Form GW-I
North Carolina Department of Environment and
Natural Resources - Division of Water Resources Revised August 2013

l iIIfl I ...Hill
WELL CONSTRUCTION RECORD (GW-1)
1. Well Contractor Information:
Donald Cummings
Well Contractor Name
2412-A
NC Well Contractor Certification Number
Applied Resource Management, P.C.
Company Name
2. Well Construction Permit #:
List all applicable well cautrxclion permits (i.e. 111C, Count. Stale, Variance. etc)
3. Well Use (check well use):
W17-047H
Water Supply Well:
Agricultural
Geothermal (Heating/Cooling Supply)
Industrial/Commercial
' Irrigation
Non -Water Supply Well:
Monitoring
OMunicipal/Public
Residential Water Supply (single)
Residential Water Supply (shared)
Recovery
Injection Well:
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
Experimental Technology
Geothermal (Closed Loop)
'{Geothermal (Heating/Cooling Retum)
4. Date Well(s) Completed: 12/19/1
5a. Well Location:
Future Homes
DGroundwater Remediation
Salinity Barrier
DStormwater Drainage
Subsidence Control
Tracer
Other (explain under #21 Remarks)
7 Well ID# NIA
N/A
Facility/Owner Name Facility ID# (if applicable)
Howards Landing Road, Hampstead, NC 28443
Physical Address, City, and Zip
Pender 3292-77-7194-0000
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
34 21 54.7 N 77 40 56.1
W
6. Is(are) the well(s)JPermanent or DTemporary
7. Is this a repair to an existing well: EjYes or ONo
If this is a repair, fill out known well construction infornlolion and explain 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-1 is needed. Indicate TOTAL NUMBER of wells
drilled: 1
9. Total well depth below land surface: 205
For multiple wells list all depths if different (example- 3@200' and 2@100')
(ft.)
10. Static water level below top of casing: 15 (ft.)
If water level is above casing, use "= "
11. Borehole diameter: See Remark(in•)
Mud Rotary
12. Well construction method:
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) 80 Method of test: Airlift
13b. Disinfection type: HTH Amount: 3%@10g
14. WATER ZONES ri irts
i FROM
TO
DESCRIPTION
ft.
ft.
ft.
ft.
15.OUTER CASING (for multi -cased wells) OR LINER (if a licable)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
0 ft.
180 ft.
4 in-
SCH40
PVC
16. INNER CASING OR TUBING (geothermal dosed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL,
165 ft•
185 ft.
2 in.
SCH40
PVC
ft.
ft.
in.
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
185 ft•
205 ft-
.020 '"•
2"
SCH40
PVC
ft.
ft.
in.
18. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
0 ft'
24 ft.
Bentonite
Poured
ft.
ft.
ft.
ft.
19. SAND/GRAVEL PACK (if applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
ft.
ft.
ft.
ft.
20. DRILLING LOG (attach additional sheets if necessary)
FROM
TO
DESCRIPTION (color, hardness, soillrock hype, grain size, etc.)
0 ft.
55 ft.
Clay
55 ft.
120 f►.
Limestone
120 ft.
175 ft.
Clay/mud rock
175 ft,
205 ft.
Sandstone
ft.
ft.
ft.
ft.
R 6 F
\fi
ft.
ft.
`k•••J e6 &,r
21.REMARKS J N tilt 9 20%
0-25/8" 25-205/6"
°t"t1tit'ik1a1iDn Prccoe. ng Urii1
*„fig/Oh.,..
22. Certification:
C.Zaa-a6
Signature of Certified Well Contractor
12/20/17
Date
By signing this form, 1 hereby certify that the well(s) was (were) constructed in accordance
with 1SA NCAC 02C .0100 or 15.4 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 INSTRUCTIONRECEIVED/NCDENR/DWR
24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Resource), Infot'filftioZ`P1'dcessing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Iniection Wells: In add �t6�:708Reagif6"1
theaddress in 24a
above, also submit one copy ofWlisl,It1On KIlof completion of well
construction to the following: Office
Division of Water Resources, Underground Injection Control Program,
1636 i'4ail Service Center, Raleigh, NC 27699-1636
24c. For Water SupD1v & 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.
Font GW-1
North Carolina Department of Environmental Quality - Division of Water Resources Revised 2-22-2016

WELL CONSTRUCTION RECORD (GW-1)
1. Well Contractor Information:
Donald Cummings
Well Contractor Name
2412-A
NC Well Contractor Certification Number
Applied Resource Management, P.C.
Company Name
2. Well Construction Permit#:
List all applicable well construction permits (i.e. [AC, County, State. 1'ariance. etc)
3. Well Use (check well use):
W16-053H
For Internal Use Only:
O
14. WATER ZONES
I..__.(
FROM
TO
DESCRIPTION
ft.
ft.
ft.
ft.
15.OUTER CASING (for multi -cased well
FROM TO
0
ft.
65 ft.
1-1
s)OR LINER (if a Iicable)
DIAMETER THICKNESS MATERIAL
4 '"- SCH40
PVC
16. INNER CASING OR TUBING (geothermal closed -loop)
FROM TO
DIAMETER
THICKNESS
SLkTERIAL
ft.
ft.
in.
ft.
ft.
in.
Water Supply Well:
Agricultural
Geothermal (Heating/Cooling Supply)
Industrial/Commercial
Irrigation
Non -Water Supply Well:
Monitoring
DMunicipaVPublic
Residential Water Supply (single)
JResidential Water Supply (shared)
DRecovery
Injection Well:
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
Experimental Technology
Geothermal (Closed Loop)
Groundwater Remediation
Salinity Barrier
DStomnvater Drainage
Subsidence Control
DTracer
Geothermal (Heating/Cooling Retum) DOtber (explain under #21 Remarks)
4. Date Well(s) Completed: 12/19/17 Well ID# N/A
5a. Well Location:
Eastern NC Home Builders N/A
Facility/Owner Name Facility ID# (if applicable)
Dan Owen Dr, Lot 9, Hampstead, NC 28443
Physical Address, City, and Zip
Pender 3292-15-7088-0000
County Parcel identification No. (PiN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
34 21 41.2 N 77 42 6.7
6. Is(are) the well(s)fPermanent or DTemporary
7. Is this a repair to an existing well: jYes or xENo
If this is a repair, fill out known well construction information and explain the nature ofthe
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 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled: 1
9. Total well depth below land surface: 85
For multiple wells list all depths if different (example- 3@200' and 2@I00')
(ft.)
10. Static water level below top of casing: 17 (ft.)
If water level is above casing, use "- "
11. Borehole diameter: See Remark (in.)
12. Well construction method: Mud Rotary
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) 80 illethod of test: Airlift
13b. Disinfection type: HTH Amount: 3%@10g
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
ft.
ff.
in.
it.
ft.
in.
I8. GROUT
FROM
0
ft.
TO
25 ft-
MATERIAL
Bentonite
EMPLACEMENT METHOD & AMOUNT
Poured
ft.
rt.
ft.
ft.
19. SAND/GRAVEL PACK (if applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
ft.
ft.
ft.
ft.
20. DRILLING LOG (attach additional sheets if necessary)
FROM
0
ft.
TO
60 ft.
DESCRIPTION (color, hardness, soil/rock hype, grain sae, etc)
Sandy clay to clay
60 ft.
85 ft.
Limestone
ft,
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
21. REMARKS
0 - 25/8" 25-85/6"
ifitomiation rrcr v
ft1 C3J Cf .
22. Cer ' rcation:
�(c
Sign ure of Certified Well Contractor
12/20/17
Date
By signing this form, 1 hereby cerrlfy that the well(s) was (were) constructed in accordance
with I SA NC:AC 02C .0100 or l SA 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 l�
24a. For All Wells: Submit this IR ' 1V I NR tion of well
construction to the following:
Division of Water Resources, inf es
rat'o rocsing Unit,
1617 Mail Service Center,1404hUO 2M1617
24b. For Iniection Wells: In addition to sending the form to the address in 24a
above, also submit one copy of this fd1V�teitl ey 46firpletion of well
construction to the following: Operations Section
INII gro'Und1 Ins]Rtrd1al flff;�o Program,
Division of Water Resources, Under rolatnd In t otf'C gigot
1636 Mail Service Center, Raleigh, NC 27699-1636
24e. 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.
Forin GW-1
North Carolina Department of Environmental Quality • Division of Water Resources Revised 2-22-2016

WELL CONSTRUCTION RECORD (GW-1)
1. Well Contractor Information:
Donald Cummings
Well Contractor Name
2412-A
NC Well Contractor Certification Number
Applied Resource Management, P.C.
Company Name
2. Well Construction Permit #:
List all applicable well construction permits (i.e. tJIC. County, State, 1 arionce, etc.)
3. Well Use (cheek well use):
W16-054H
Water Supply Well:
[Agricultural
Geothermal (Heating/Cooling Supply)
D Industrial/Commercial
FlIrrigation
Non -Water Supply Well:
Monitoring
DMunicipal/Public
Residential Water Supply (single)
Residential Water Supply (shared)
QRecovery
Injection Well:
BAquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
Experimental Technology
Geothermal (Closed Loop)
[Geothermal (Heating/Cooling Return)
DGroundwater Remediation
[Salinity Barrier
DStomiwater Drainage
DSubsidence Control
Tracer
[Other (explain under #21 Remarks)
4. Date Well(s) Completed:12/19/17 Well ID# N/A
5a. Well Location:
Eastern NC Home Builders N/A
Facility/Owner Name Facility ID# (if applicable)
Dan Owen Dr, Lot 10, Hampstead, NC 28443
Physical Address, City, and Zip
Pender 3292-15-6294-0000
County Parcel identification No. (PiN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
34 21 42.5 N 77 42 6.9
6. Is(are) the well(s){x Permanent or DTemporary
7. Is this a repair to an existing well: EJYes or ONo
If this is a repair, fill out known well construction information and explain the nature of the
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: 1
9. Total well depth below land surface: 85
For multiple wells list all depths ifdifferent (example- 3@200' and 2 a 100)
W
(ft.)
10. Static water level below top of casing: 17 (ft.)
If water level is above casing, use ",- "
1I. Borehole diameter: See Remark(ln )
12. Well construction method: Mud Rotary
(Le. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) 80 Method of test: Airlift
13b. Disinfection type: HTH Amount: 3%@10g
For Internal Use Only:
14. WATER ZONES
FROM
ft.
TO
ft.
140*
DESCRIPTION •
ft.
ft.
15. OUTER CASING (for mniti-cased wells) OR LINER (if applicable)_
FROM DIAMETER 11
0
ft.
TO
65 ft.
4
in.
THICKNESS
MATERIAL
SCH40 I PVC
16. INNER CASING OR TUBING (geothermal closed -loop)
FROTO
ft.
ft.
DIAMETER
in.
THICKNESS
MIATERiAL
ft.
17. SCREEN
ft.
in.
FROM
TO
DIAn1ETER
SLOT SiZE
THICKNESS
ft.
ft.
ft.
in.
MATERIAL
ft.
in.
18. GROUT
FROM
0
ft.
TO
23 ft.
MATERIAL
Bentonite
EMPLACEMENT METHOD & AMOUNT
Poured
ft.
ft.
ft.
ft.
19. SAND/GRAVEL PACK (if applicable)
FROM
TO
ft.
ft.
MATERIAL
ft.
ft.
EMPLACEMENT METHOD
20. DRILLING LOG (attach additional sheets if necessary)
TO
FROM
0
R.
60 ft.
DESCRIPTION (color, hardness, soil/rock type, grain size, etc.)
Sandy clay to clay
60 ft.
85 rt.
Limestone
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
R a F:-jVlD
ft.
ft.
JAN 1 201;
21. REMARKS
0 - 25/8" 25-85/6"
22. Cer
"irc strostion Prcesai g Unii
OW C11 Gv
12/20/17
ture of Certified Well Contractor - Date
By signing this form, I hereby cent& that the well(s) wa. (were) constructed in accordance
with 15A NCAC 02C .0100 or I5A 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
1617 Mail Service
formation Processing Unit,
tt l �' 1617
24b. For Iniection Wells: in addition to sending the fonn to the address in 24a
above, also submit one copy of th4' v to 30 days of completion of well
construction to the following: U 6 2018
Division of Water Resours Underground Injection Control Program,
1636 Mail Service eCiia ;l (jer lg S�, 699-1636
✓ eratrons S
24c. For Water Supply &Y!I tlif[al�t @ lion to sendingthe form to
the address(es) above, also submit one�cd f ' fl filar m within 30 days of
completion of well construction to the county health department of the county
where constructed.
Fonn GW-1
North Carolina Department of Environmental Quality - Division of Water Resources Revised 2-22.2016

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
For Internal Use ONLY:
1. Well Contractor Information:
Joshua Lemere
RECEIVEDINCDEQIDWR
Well Contractor Name
4310-A
NC Well Contractor Certification Number
Coastal Geothermal
DEC 22 ?017
Water Quality Regional
Operations Section
Company Name
2. Well Construction Permit #: W10800493
List all applicable well permits (i.e. County, State, Variance, Injection, etc)
3. Well Use (check well use):
Water Supply Well:
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
Olndustrial/Commercial
❑ Irrigation
❑Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
Non -Water Supply Well:
❑Monitoring DRecovery
Injection Well:
❑Aquifer Recharge
❑ Aquifer Storage and Recovery
❑Aquifer Test
DExperimental Technology
ElGeothermal (Closed Loop)
❑ Geothermal (Heating/Cooling Return)
❑Groundwater Remediation
❑Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑Tracer
❑Other (explain under #21 Remarks)
4. Date Well(s) Completed: 12-18 -17 Well MN
5a. Well Location:
Moores Creek National Park
Patriots Hall
Facility/Owner Name Facility ID# (if applicable)
40 Patriots Hall Dr., Currie, NC 28547
Physical Address, City, and Zip
Pender
N/A
County Parcel Identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one Iadlong is sufficient)
N W
6. is (are) the well(s): ©Permanent or ❑Temporary
7. Is this a repair to an existing well: ❑Yes or ENo
If this is a repair, fill out known well construction information and explain the nature of the
repair under 12! remarks section or on the back of this form.
8. Number of wells constructed: 10
For multiple injection or non -water supply wells ONLY with the same construction, you can
submit one form.
9. Total well depth below land surface: 255
For multiple wells list all depths tfd erent (example- 3@200' and 2 tt 100')
(ft.)
10. Static water level below top of casing: (ft.)
!f water level is above casing, use "+ "
11. Borehole diameter: 4.75 (in.)
12. Well construction method: Mud Rotary
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
14. WATER ZONES
FROM
TO
DESCRIPTION
ft.
ft.
surface water
ft.
ft.
15. OUTER CASING (for multi -cased wells) OR LINER (if app icable)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
n/a ft*
ft.
in.
16. INNER CASING OR TUBING (geothermal closed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
000 ft.
250 ft•
1 1'
SDR 11
HDPE
ft.
ft.
in.
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
n/a ft.
ft.
in.
ft.
ft.
in.
18. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
000 ft.
255 ft•
Bentonite
Pump/Tremmie
ft.
ft.
ft.
ft.
19. SAND/GRAVEL PACK (if applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
n/a ft•
ft.
ft.
ft.
20. DRILLING LOG (attach additional sheets if necessary)
FROM
TO
DESCRIPTION (color, hardness, soil/rock type, grain size, etc.)
000 ft*
020 ft•
Sand/Some Clay
020 ft.
120 ft.
Clay/Silty Sand
120 ft-
220 ft.
Limestone/Clay/Silt
220 ft•
255 ft•
Silty Sand/Clay/ Limestone
ft.
ft.
ft.
ft.
ft.
ft.
21. REMARKS
Drilled 10-250' boreholes and set 1"
Geothermal Loop @ 245' in each
22. Certification:
12-18-2017
Signafure of Certified Well Contractor` Date
By signing this form, 1 hereby terrify that the well(s) was (were) constructed in accordance
with 15A NCAC 02C .0100 or 1 SA 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.
RECEIVED/NCDENR/DWR
SUBMITTAL INSTUCTIONS
24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
JAN 08 2018
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
waterQuality Regional
24b. For Injection Wells ONLY: InQItppgssiie form to the address in
24a above, also submit a copy oltlff1II4tonej06,4 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:
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.
Form GW-1 North Carolina Department of Environment and Natural Resources - Division of Water Resources Revised August 2013

DIVISION OF WATER RESOURCES
Water Quality Regional Operations Section - Central Office
Regional Office Interoffice Mail Routing Cover Sheet
Date: /1)-
/ 8
To: ❑ ARO- WQROS
❑ Landon Davidson ❑ Other
RECEIVED/NCDENR/DWR
JAN 0 8 2018
❑ FRO- WQROS Water Quality Regional
Operations Section
n Belinda Henson ❑ Other Wilmington Regional Office .
❑ MRO- -WQROS
❑ Cory Basinger n Andrew Pitner El Other
❑ RRO- WQROS
n Danny Smith ❑ Rick Bolich ❑ Other
❑ WaRO- WQROS
❑ David May ❑ Robert Tankard ❑ Other
WiRO- WQROS
i
❑ Jim Gregson Q Morella Sanchez -King ❑ Other
❑ WSRO- WQROS
n Sherri Knight n Other
From: /'4. / ,b) C-c-i21
, WQROS — Central Office.
For your [j Review/Information File
Please Respond with Comments:
after receipt
Comments:
P
At your convenience; n Within business days
l•
WQR.OS Regional Office interoffice Mail Routing Cover Ver. 12/16!I5