GW1 - Columbus 2018

For Internal Use �y
WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
1. Well Contractor Information:
Justin Radford
RECEIVED/NCDENR/DWR
Well Contractor Name
3270 A
NC Well Contractor Certification Number
Geological Resources, Inc.
Company Name
2. Well Construction Permit #:
List all applicable well permits (i.e. County, State, Variance, Injection, etc.)
3. Well Use (check well use):
DEC 172018
Water Quality Regional
Operations Section
Wilmington RPgicp fficc
14. WATER ZONES
FROM
TO
ft.
ft.
ft.
ft.
DESCRIPTION
15. OUTER CASING (for multi -cased wells) OR LINER (if a
U bl )
FROM THICKNESS
TO
ft.
ft.
DIAMETER
in.
p
MATERIAL
16. INNER CASING OR TUBING (geothermal closed -loop)
FROM DIAMETER
0
ft.
ft.
TO
3
ft.
ft.
2"
in.
in.
THICKNESS
sch 40
MATERIAL
PVC
17. SCREEN
Water Supply Well:
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑ Industrial/Commercial
❑Irrigation
❑Municipal/Public
OResidential Water Supply (single)
❑Residential Water Supply (shared)
Non -Water Supply Well:
RIMonitoring ❑Recovery
Injection Well:
❑Aquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer Test
❑Experimental Technology
❑Geothermal (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: 08/06/18We11 ID# MW-1
5a. Well Location:
Long's Exxon
0-0000012918
Facility/Owner Name Facility 1D# (if applicable)
953 Green Swamp Road S, Bolton, 28423
Physical Address, City, and Zip
Columbus 1270.02-99-7112.000
County Parcel Identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one Iat/long is sufficient)
34.322965 N 78.404725
6. Is (are) the well(s): Ir7Permanent or ❑Temporary
7. Is this a repair to an existing well: ❑Yes or No
If this is a repair, fill out known well construction information and explain the nature of the
repair under #2I remarks section or on the back of this form.
8. Number of wells constructed:
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:
For multiple wells list all depths ifdferent (example- 3@200' and 2@100)
13
(ft.)
10. Static water level below top of casing: 2.47' (ft.)
If water level is above casing, use "+"
11. Borehole diameter: 6" (in.)
12. Well construction method: Hand Auger/Direct push
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
FROM
3
ft.
TO
13
ft.
DIAMETER
2
in.
SLOT SIZE
0.010
THICKNESS
sch 40
MATERIAL
PVC
ft.
ft.
in.
18. GROUT
FROM
0
ft.
TO
1
ft.
MATERIAL
Grout
EMPLACEMENT METHOD & AMOUNT
ft.
ft.
ft.
ft.
1
19. SAND/GRAVEL PACK (if applicable)
FROM
ft.
TO
2
ft.
MATERIAL
Bentonite
EMPLACEMENT METHOD
2
ft.
13
ft.
Sand
20. DRILLING LOG (attach additional sheets If necessary)
TO
FROM
0
ft.
ft.
13
ft.
ft.
DESCRIPTION (color, hardness, soil/rock type, grain size, etc.)
Direct push; no cuttings retained
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
21. REMARKS
22. Certification:
Si; e o ertified Tell Contra • .r Date
By ignrng this form, I hereby certify that the well(s) was (were) constructed in accordance
with 15A NCAC 02C .0100 or 15A NCAC 02C .0200 Well Construction Standards and that a
copy of this record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTUCTIONS
24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Information Proeescing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Infection Wells ONLY: 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 Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supply & Injection 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

WELL CONSTRUCTION RECORD (GW-1)
RECEIVED/NCDENR/DWR
1. Well Contractor Information:
John Salmon
Well Contractor Name
3497-A
APR 2 1 2018
NC Well Contractor Certification Number Water Quality Re tonal
Applied Resource MaJAVV gdnal Dice
Company Name `nr
2. Well Construction Permit #: V V C P-1 8-00707
List all applicable well construction permits (i.e. UK% County, State. Variance, etc.)
3. Well Use (check well use):
Water Supply Well:
Agricultural
Geothermal (Heating/Cooling Supply)
Industrial/Commercial
Irrigation
DMunicipal/Public
IDResidential Water Supply (single)
Residential Water Supply (shared)
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 Remediation
Salinity Barrier
DStormwater Drainage
Subsidence Control
rpTracer
Other (explain under #2I Remarks)
4. Date Well(s) Completed: 2/28/18 Well iD#NIA
5a. Well Location:
McKinley Building N/A
Facility/Owner Name Facility ID/t (if applicable)
401 Beaver Ridge Drive, Rigelwood NC 28456
Physical Address, City, and Zip
Columbus Not Available
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 55.03 N 78 15 54.86
6. ls(are) the well(s)iX Permanent or DTemporary
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 21 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: 1 80
For multiple wells list all depths if different (example- 3@200' and 2@@l00')
10, Static water level below top of casing: 18 (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.)
(ft.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) 80 Method of test: Airlift
HTH
o at 10 g
13b. Disinfection type: Amount: 3 �o
Print Form
For Internal Use Only:
14. WATER ZONES
FROM
TO
DESCRIPTION
ft.
ft.
ft.
ft.
15. OUTER CASING (for multi -cased wells) OR LINER (ifa licable)
FROM
TO
DIAMETER
TI{(CKNFSS
MATERIAL
0 ft.
160 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
SLOTSI'LE
THICKNESS
MATERIAL
fit.
fit.
in.
fit.
ft.
in.
18. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METI OD & AMOUNT
0 ft.
23 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, soil/rock type, grain size, etc.)
0 rt.
28 ft.
Sand and clayey sands
28 ft-
95 ft'
Sandy clay
95 ft-
107 ft-
Limestone clay mix
107 rt•
110 rt.
Limestone
110 It.
160 ft-
Alternating limestone/clay layers
160 ft-
180 ft.
Limestoe
`i°,.�;y1
ft.
tr.
tS,,. ! t '-
21. REMARKS
0' to 25' = 8" L\FR 1 S 201u
26' to 180' = 6"
22. Certification:
gnature of ed \ e 1 Contractor
2/28/18
Date
By signing this form, 1 hereby certify that the well(s) was (were) constructed in accordance
with i5A 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 inay use the back of this page to provide additional well site details or well
constmction 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 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 Sunnly & Infection 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 Deparunent of Environmental Quality - Division of Water Resources Revised 2-22-2016

. WELL CONSTRUCTION RECORD
this trans can he used For single or multiple ylelIs
I. We nt : ctor infer
Well C;raclor •fyHwk
(}frtitication Number
mpam imc r
2. %Yell ( Ric ion Lit
list all applicable well remits tie County, . are.
3. `%'ell Use (check well use):
Water Supply Well:
fucati%
anc . etc.)
1gr!culturial
t !Geothermal (tleatiny'Coolmg Supply)
ri ln(fust vial/Commerc tat
%ilrrigaUUn
[-Municipal/Public
..411<idential Water Supply (single)
❑Residential Water Supply (shared)
Non -Water Supply Well:
[]Monitoring
Injection Well:
r1Ac)uiter Recharge
i-iAyutter Storage and Recovery
-Atlutfor lest
i 1.xperintental 'technology
1(iot thermal (Closed loop)
rl(;cothermal (fleafing/Cooling Return
❑Recovery
FIGroundwater Remediation
:Salinity Barrier
OStormwatcr Drainage
[-Subsidence Control
i7Tracer
❑Other (explain under #21 Remarks)
4. Date N'cil(s) ['ompleted/ /71ell Ill#
5a_ lZjl1 Location:
(lpunt) — Parcel Identification No (PiN)
51t. Latitude and 1.ongitude in degrees/minutes/seconds or decimal degrees:
{if we11 tietd ime Iataong rs sufficient)
6. Is (are) the walls):
ti
Permanent or ❑Temporary
7. is this a repair to an existing well: ❑Yes or (.EA
iftins rs a reparr fill art known well construction infos niation and endow the nature of the
repair under a21 remarks section or on the hock of this form.
W
$.:Nhmlter of wells constructed:
.F,nr:ralliak injeelia n or non -wale, .supply wells ONLY with
4-Total well depth below land surfacer
hiv'rretdtiple wells list all deprks if different (example- 3 aa:.00 and 2 #Q0')
10. Static water level below top of easing:
If water level it above casing, use "'i "
11. Borehole diameter:
12. Well construction method:
e auger. nanny cable. direct push, etc }
FOR Vt ATFR St'PPi -it
t3a. @ iefd (Apo)
I3h. Disinfection ty
:LI.S ONLY:
Method of test:
Amount:
ante constructiontou can
(ft.)
(ft.)
I4. WATER ZONES
FROM TO
DF.SCRIPTIO\
ft. ft.
ft. ft.
15. OUTER CASING (for
mnitr cased wells OR LINER Of atogleabie)
FRO
TO
DIAM ER l THI('KNE
IATE.R
1Vf
16, INNER
ASING OR TUB
' thermal e
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft.
ft.
in.
ft.
ft
in,
17. SCREEN
-
FROM
TO
DiAAIETER
SLOT SIZE
THICKNESS
MATERIAL
ft.
ft_
in.
ft
ft.
in.
I& GROUP
FROaI
TO
' TERM!.
'PLACEMENT My'HOD & AMOUNT
ft
t.
,3' .�
��e�M� j e
�/'I�
ft.
ft.
19. SAND/GRAVEL PACK
(if apptieakie)
FROM
TO
MATERIAL
EMPIA('I SIF.?T METHOD
ft
ft
ft.
ft.
20. DRILLING
LOG (attach additional sheets if necessary)
FROM
TO
DESCRIPTION (color, haidriess, soiVroek type, grain sore, etc.)
ft.
ft
ft.
-re
• ...
%
C 2 g
2017 -
.:.
e.
ft.
t.
ft.
t f
ft.
(z e1
21. REMARKS
,t
1.
Sit tn9 ury' ot'Certitied Well Contractor
By .signing this form. l hereby certify thin the welts) war (were) constructed in accordance
with 15.4 ;VCAC 02( .0)00 or 15.4 \('.IC 02(000 ltelt ( onstrucitim Standards and that a
copy of this record has been provided to the tie!! owner
23. Site diagram or additional well details:
You may use the hack of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary
SUBMITTAL iNSTL'CTIONS
m
24a. For All Wells: Submit this form within 30 days utetton of well n
rri
construction to the following: 5E
oa CD
D
Division of Water Resources, Information Prod °° s1 'nit, bz
1617 Mail Service ('enter, Raleigh, N(' 27699 b
24b. for Injection Wells ONLY: In addition to sending OL
tl tainNito the tlress irg
ve, also submit a copy of this form within 30day. Q4tmplet of we
truction to the following: Q a
Division of Water Resources, l nderground Injection ontrol Program,
1636 Mail Service ('enter, Raleigh, NC 27699-1636
24e. For Water Supply & Injection Wells:
Also submit one copy of this Norm within 30 day s of completion of
well construction to the county health department of the county where
constructed.

MILL CONSTRUCTION RECORD (GW-1)
1. Well Co ',.-r for Information:
Well Contractor Name
3
NC W 11 Contractor r . - tion Number
P4' Pa Ae'-(7(0ei
Company Name
2. Well Construction Permit #:
Lies all applicable well construction permits (2e. UIC, County. State, Variance, etc)
3. Well Use (check well use):
Water Supply Well:
Agricultural DMunicipa.YPnblic
Geothermal (Heating/Cooling Supply) °Residential Water Supply (single)
Industrial/Commercial °Residential Water Supply (shared)
Irri _x tton
on ' t
Aquifer Re c.heree
Aquifer Storage and Recovery
Aquifer Test
Experimental Tech.nology
Geothermal (Closed Loop)
Geothermal ; : oolin_ R
4. Date Well(s) Completed:
QRecoveay
°Groundwater Remediatioa
°Salinity bier
DStormwaterr Drainage
Subsidence Control
°Tracer
Other explain under #21 Remarks)
/ 7 WcA lJ1#
mil ity m# (if applicable)
/ Y i � ® 404Af Ale/
F'hysica I and lie
410
Facility/Owner Nfine
County
5b. Latitude and longitude in d ` br `decimcl degrees:
gists eErees/minutes/sem' is
SEP.1 1 2017
w
(if well field, one lat/fong is sufficient)
6.Is(are) the well(s) anent or UararYttC�t
7. Is this a repair to an exlstiing wells Dyes or D
If this is a repatr, fill out loom well consttuctionWorn:edam and etplabr the nature of the
repair tmder 01 remarks Of en the back of this fora.
8. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction, only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled:
9. Total well depth below land surface: (ft.)
For midtiple wells list ail depthd f8'erent (example- 3@200' and 2 t@100')
10. Static water level below.top of using. 3 / 4* (ft.)
Ifwnter level is above casing, ttse "+ r;
11. Borehole diameter:
12. Weil construction method:
(i.e. auger, rotary, cable, direct push, etc.)
TI;)4/7
F011 WATER SUPPLY WELLS ONLY: -
13a. Yield (gpm) Method of test:
13h Disinfection ape itW) " Amount:
l
ft.
f .
ft.
ft.
-
T.0Ci R-CliSINf1`(t
a ,. n *ellix.Qlt-- . t t +! rr ... ) `ae-
FROM
20
0 ,- :•
xmCicNEss
utTEw,u,
nom
DIAMETER
ft.
ire,
itfll`a.a:E
. V.aP
4, _:1'.':?C ii4,-s:gi;1147: -SYi'
.b=-A �' x: .;:.,,--.4',.
7A. -v ..-..
FRO f
,
,.
R.
IC In..1111111
-1tvV71JY �'-..-.'-�m�': iR R{f,("r.��{..SF �L-:-�j''�'yy!Sty:rY.i/%..p7.v�5i�,p�%�4=.�"'���.h-T..-. ... :i`..1�-Y.`i:
FROM
pp�pp�.F-�.:�`Tea:.
WP1R1\l t Q[ O.
M.
/
i
ft.71mm
ft
tit
0401410
X.C,A. a� - ''- 044a1 :
M�
€1►tt�haaon
ft.
120101111.106104s.
i
FROM
DESCZ T t c hhardeea, Whoa i; eft
ft.
v.
�]�r•
Q
t,
fee
...to
$ate
do
' *IF
/in!
4 ,
ft.
22. Certili
Signature of
4.1,7
Well . ;tor
Ity signing this farm, I hereby cert(fy that the well(s) was (were) constructed in aecondance
with 1JA NCAC 02C.0100 or 15A )ICAC 02C .0200 Well Construction Standards and that a
copy ethic 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
o onsttuction details. You may also attach additional pages if necessary.
Straw 'i'rA% INSTiIUCInQNS
24a. For Ali Wells: Submit this form within 30 days of coppleti� of well
construction to the following: B. w
Division of Water Resour
ces, Information Prot�,�
1617 Mail Service Center, Raleigh, NC 27699d . o
24b. For Inleciion Wells. In addition to sending the form to ikiiissin 2P
above, also submit one copy of this form within 30 days of coTkiitgra of well.
construction to the following: E.,_ o ,70
OO 00
Division of WaterResourees, Underground Injection Conf 1. P4gram,
1636 Mall Service Center, Raleigh, NC 27699-106
24c. For Water Suelly 4 injection Weill: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
compietion of well consttuctiou to the carroty health department of the county
where constructed.
aMarN3a3N/a3A13338
Form GW-1
North Carolina Deparmiont of Environmental Quality - Division of Water Resoutces Revised 2-22-2016

WELL CONSTRUCTION RECORD (GW 1)
1. Well Contractor Infoontation:
c
Vd^lt Contractor Name
NC Well,Contractor rtifrcationNumber
GllJa✓0
Company Name
2. Well Construction Permit 6:
List all applicable well construction permits (7.e. UIC County, State, Variance, etc.)
3. Well Use (check well use):
Water Supply Well:
FROM TO DESCRIPTION
ft.
ft
ft.
15'OtITERCi1S11i104°Mx[ufa cas ifielis)'QR)1TN1 Ri P lleable):;
FROM TO DIAMETER
D.15-e.....r"
TI�ICKNESSft.A3� vL
161,4N ERsCASIN ORI{TBING{geotbsYmaiclnstid-ltNiF)
FROM THICKNESS 1 MATERIAL
ft.
TO [ DIAMETER
ft.
is
ft.
ft.
in.
Agricultural ,
Geothermal (Heating/Cooling Supply)
Industrial/Commercial
1rri:ation
Non -Water Supply Well:
Monitoring
Infection Well:
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
Experimental Technology
Geothermal (Closed Loop)
Geothermal (Heating/Cooling
4. Date Well(s) Completed:
eation:
Facility/Owner Name
6r 60r(0414/
ysical&diess,lity, and Zip
County
DMunicipal/Public
Residential Water Supply (single)
Residential Water Supply (shared)
Recovery
DGroundwater Remediation
Salinity Barrier
0Stom water Drainage
Subsidence Control
Tracer
Other (explain under #21 Remarks)
(7
Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees(minutes/s`econds;ore edmal-degreeg)
(if well field, one let/long is sufficient) y, v=J ,) 4.t #-'
N
6. Is(are) the well(s)Permanent or
7. Is this a repair to an existing well:
lfthis is a repair, fell out /mown well construct n
repair render #21 remarks section or on the back
EtTemporary Si
( Jit.. r; , 5 By signing this form, 1 hereby certify that the well(s) was (were) constructed hi accordance
Yes or QNO with1 SR NCAC 02C .01P0 or 1SA NCAC 02C .0200 Well Construction Standards and that a
• ormation and explain the nature ofthe copy of this record has been provided to the well owner.
ofthisform.
-Jm
tt ft.
=18'fiRt)UIt
ip seltl;rEN
FROM TO DIAMETER SLOT SIZE THICKNESS
4V in. ArCY°
FROM TO
MATERIAL
ev c..
In
MATERIAL EMPLA METHOD & AMOUNT
b ft. ! o ft. t,�G.viz �Gr
!O ft.
ft. ft.
FROM TO MATERIAL .
ft. ft.
i
EMPLACEMENT METHOD
FROM
ft.
Lite'
)Aft.
7 to ft.
To
,rrt.
Pft-
71ft.
G
teL
TScnreTION (aloe, hirda ;oWUrack tYF4 grain rim, « e.)
SQ t 4— cP ( y
sQ
8. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction, only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled:
9. Total well depth below land surface:
For multiple wells list all depths ifdifferent (example- 3Q200' and2Qt 100)
10. Static water level below top of casing:
lfwiter level is above casing, use "+ "t
11. Borehole diameter:
12. Well construction method:
(i.e. auger, rotary, cable, direct push, etc.)
X*'y
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) _ ethod of test: 1::**"
13h. Disinfection type: / " Amount: /�� _
(ft.)
((tt)
Da
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 cobpletii n of well
construction to the following:
Division of Water Resources, Information Process ir laid
1617 Mail Service Center, Raleigh, NC 27699-16I7g• v »
co Cn ti r
24b. For Iniection VYells: In addition to sending the form to thte. sin 24a
above, also submit one copy of this form within 30 days of col p[$ti0 of well
construction to the following: ' r
c 0 _-•
Division of Water Resources, Underground Injection Contro)Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. ,For Wate 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.
SMOMN3CON/03A1333b
Form GW-1
North Carolina Department of Environmental Quality - Division of Water Resources Revised 2-22-2016

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1. Well Contractor Informatla :
Walt Contractor Name
35-
to iMwl/41
NC Well Contractor cationNumbc�
hl c6/04_ dry &&C
Company Name
4 4
2.Well Construction Permit0:
List all applicable well anulraaiou permlls (i.e. ilIC, Corauy, State, Variance, etc,)
3. Well Use (check well use):
Water Supply Well:
Aviculture!
Geothennai (Heating/Cooling Supply)
Industrial/Commercial
bri ation
Non -Water Supply Well:
Monitoring
Injection Well:
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
Experimental Technology
Geothermal (Closed Loop)
Geothermal eating/Cr/olio : R
4. Date Wells) Completed$
C.
5a.W Lacgtipn:
Facility/Owner Name Facility (if liable) c_
iaee _Wave? �,! C.4464e t
Physical Address City, and Zip
DMmaicipal/Pubiic
rArResideatial Water Supply (single)
Residential Water Supply (shared)
__Recovery
Groundwater Remediation
DSalinity Bather
Stour water Drainage
r3Subsidence Control
Tracer
Other (ex, lain under #21 Remarks)
7 Well m#
County
Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one latilong is sutfieient)
6. Is(are) the well(s) Perananent or aTemporary S E P
7. Is tbts a repair to an existing well: Yes or I `��tl*:r"
If this is a repair, fill out known well construction infsrmatlan a exploit: Thiraft it:fitie:'
repair under #21 remarks section or on the back of this form.
S. For Ceoprobell}Pf or Closed -Loop Geothermal Wells having the same
construction, only I OW-1 is needed. Indicate TOTAL NUMBER of wells
drilled: Q'
9. Total well depth below land surface: v
For multiple wells list all depths if d fferent (example- 3@a 200' and 2@100'
10. Static water Level below lop of easing:
!twofer level is above casing, use "+"
11. Borehole diameter: t7 on.)
12. Well construction method:
(Le. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY: -
13a. Yield (gpm) 7 b ��Meethod of test:
13b. DIsinfection type:` /"'' Amount:
51)
( t.)
FROM
TO
DESCRIPTION
ft
ft.
ft
ft
_
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DIAMETER
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FROM
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DESCRIPTION (crawl hardnLis, gem*gem*t➢pe, MIN AM. et)
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,tanon:
2 U , Aignaturre of Cm fled Well Contractor
59/;)
Date
By signing this fora:, I hereby cerr that the well(s) was (were) constructed in accordance
°'. with I SA NCAC 02C.0100 or 15A NCAC 02C .0200 ii'el! 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.
A AL INSSTilCTIONS
24a. For VI Wells: Submit this form within 30 days of_ amp Lion of well
oonstauction to the following: 3 o
Division of Water Resources, Infatuation Pro�f t, D>
1617 Mali Service Center, Raleigh, NC 27690461 IN.9
24b. )=oar kilesti t We It: In addition to sending the form tlfe.kddress 1.0248
above, also subruit one copy of this foray within 30 days oitionCD
of�aecll
construction to the following: qg
c,o0 oo
Division of Water Resources, Underground Injection ControlibPrograrn,
1636 Mali Service Center, Raleigh, NC 276 636
24c. Fo}, Watee t}a&v 8s l ieetlorr tWe is: 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 depantnent of the county
where constructed.
Form GW-1
North Carolina Department of Environmental Quality - Division of Viater Resources Revised 2-22-2010

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For Internal Use Only:
NC ell Conga or Certification Number
Company Name
2. Weil Construction Permit#:
Litt all applicable well construction perndrs (Le VIC, County; Stale, Variance, eta)
3. Well Use (check well use):
Water Supply Well:
Agricultural
Geothermal (Heating/Cooling Supply)
industrial/Commercial
uric- tien
Injection `Veil:
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
Experimental Technology
Geothermal (Closed Loop)
Geothermal (Heating/Cooling R
4. Dote Well(s) Completed: f
5 . Well Location:
,atCee pia, (oOn-
Facility/OwoerName
g7S?
EiMunicipalYPubiic
Residential Water Supply (single)
Residential Water Supply (shared)
Groundwater Rei ediation
Salinity Barrier
DStormwater Drainage
Subsidence Control
JTrucer
Other (ex . lain under #2I Remarks)
7 Wets IB#
Physical AdVs, City, and Zip
o(i(i 14'7
County
1. Well Contractor Info , do . —4 7 8 5 1
Well Contractor Name
IX, 41) 7/1/1
Facility IEV (ifapp ' le) Ate"
Parcel Identification No. (PHA
-tom' - �l�'^. i-. 'A
A, •"^
1,e
Sb.l,atitudcand longitude in tiwers/ri�rutesJ�s�itf5isi�dttcc,�r degrees: `
(if well field, one Ia Jioi.g is sufficient)
S r, . 1 2 0.
6. Is(are) the wells) Permanent or !Omura*,
7. Is this a repair to an existing well: iYes or DNo'
!fats ft a repair, fill aid known well constnrciron urfarrnalion and explain the nurture ofthe
repair realer it2I remarks section or on the Lack of this form. .
S. For Geoprobe/ISPT or Closed -Loop Geothermal Wells having the same
consktrction, only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled: _
9. Total well depth below land surface:
a
For multiple wells list all depths f dferent (example- 3@200'and 2 n 100)
10. Static water level below Sop of easing: (ft.)
Ifnziterlevel is above casing, use "l
11. IlorehoIe diameter: 01/
12. Well construction method:
(i.e. auger, rotary, cable, direct push, etc.)
/2111/,?'
(ft•)
FOR WATER SUPPLY WELLS ONLY: _ _
13n. Yield (spat) Cf
0 Method of test:
I3b. Disinfection type:, iArnount
Afc•
FROM TO DESERi@TION
ft.
ff.
ft.
ft.
:45!:0IITERCASING16:AlittitkelitliiiIii)rtOKEINEE0r
FROM TO DIAMETER SS
0' ft.
FROM TO 1 DIAMETER
oy , 2 . 2-
fn.
ft. ftin.
ft.
VjgainORtirMnIgi
FROM TO
ft.
TIREDNESS MATERIAL .
le-1?) pv 6.
MA FtYAL i._ ..
MATERIAL EMPLACEMENT
EMPIAC6�NTntErBon
ft.
ft.
`2UA2ittrOi?VN7Vt6tfarii ddieiialA f'- aT z •�. ::=
tYY3iy .F �::� :a - _
FRO&TO D€S*:Rfl 1O ftelor, hardness, eon/tack type, ends site. ete3
`•31: !` =�C' r 1e_�a^:'- 'YTr Trr i.'.,,.-.^`gS4
By signing this form, I hereby certify that Me welt(s) was (were) constructed in accordance
with 1SANCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
copy efthis record has been provided to Me 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 r cessary.
•-ce CD
ate DD
24a. LWeils: Submit this form within 30 days o + tion of iel1
constriction to the following:
Division of Water Resources, Information Pro
1617 Mali Service Center, Raleigh, NC 2769gt
v r+aa
24b. Par) tiectigu Wens;: In addition to seudhrg the form toj gidress i 4a
above, also submit one copy of this form within 30 days ofAvomjRhiion of well
construction to the following:
Division of Water Resourcea, Underground Injection Control Program,
1636 Mali Service Center, Raleigh, NC 27699-1636
24c For WatRrtt$rdlig & 1(12_Minx+ Welk: 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 constmction to the county health department of the county
whew constructed.
SiJ) ME .11 A�.>EAIc R IMIS
:3 r+c
=
flit,
fV
eIMa/NN3aoN/a3A13338
Form GW-1
North Carolina D..prariurent of Environmental Quality - Division of Water Resources Revised 2-22-2016

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ON
CORD W-1
For Internal Use Only:
1. Will Contractor Intorm(ota:
Well Contractor Name
I 51
u
NC Well %ontra r Certification Number
Company ..e
vi✓ 447
�ti
2. Well Construction Permit#:
List all applicable well cnrrstrnelion permits (Le. WC, Cowry, State, Variance, etc)
3. Well Use (check well use):
Water Supply Well:
Agricultural
Geothermal (Heating/Cooling Supply)
Industiial/Commercial
Irri;, riot
Non -Water Supply Well:
Monitoring
Injection, Well:
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
Experimental Technology
Geothermal (Closed Loop)
DMuoicipal,Public
ideotial Water Supply (single)
Resideetial Water Supply (shared)
Recovery
Groundwater Remediatioo
Salinity Napier
DStoranwater Drainage
Subsidence Control
Tracer
Geothermal (He atin&/Cooiing Return) rcOther (explain tinder #21 Rentarlta)
4. Date Well(s) Completed:74! � 7 Weil ID#
ga. Well cation: /
G�/4114* 4%0 r/ ,1
FaoitityJOwnerName Facility lir (if applicable)
%'7ot o!� rk ;' m ,0%;c. `
Physical As, City, Ind Zip
er
County Pir6iIdentiftcatiofo.;
5b. Latitude and longitude in degreesleninuteg(seconds ettleelraai degce
(if well field, one 1aUtong is sufficient)
3r° el-01 1 r N lt� ° /9P
W
6. Is(are) the well(s) Permanent or 13Temporary
7. Is this a repair to an existing well: DYes or No
lfthis is a repair, fill out know well construction Affirmation co axplain the nature afthe
repair spider #21 remarhssection or an the back of this form. .
8. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction, only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled:
9. Total well depth below land surface:
Z/o
For rnultiple wells list all depths ifd(l)erent (example- 3(§200'ad 29100
10. Static water level belnw.top of casing: Se) (ft.)
lfwater level is above casing, use ^� "
11. Borehole diameter:
12. Well construction method:
(ft.)
(i.e. auger, rotary, cable, direct push, eta)
FOR WATER SUPPLY WE➢.f S ONLY: _ -
13n. Yield (gpm) d Method of test: _
13b. Disinfection type: /� � "H" Amount:
FROM
TO
DMORIPTTQN
ft.
ft.
ft.
ft_
F,46i32013t
taNGfORVBFflVl
i elattI ship:'.-~ _1J. =
FROM
TO
D1AMfiTER
TffiCKNES$
MATRIOAL
ft.
ft.
in.
_ftt,
ft.
in.
`
TO
maim=l
SLOT SIZE
T Ch.NESSM
TERIA__
/1ROM
�"7.s" z ,,a fL
L?,c in.
/0
J G jStQ
c.
ft. ft.
to
:zit)7,G tlf1 ''s; -- r
. `
- _... �..- -_y
-AMOUNT
MOM
TO
htA'll.RJAL
BhiPLA METHOD et
O ft.
ft.
0a/`
Jr f6
/ o ft
,
t e.e-
el ft.
. /4° '
r ' '�
ir
$ral
FRAM
To iEAIAX.
E11iF7,AMN '. NTMSTEOB
/ppit.4L/D
it.`�
i• eV"'
ft.
ft.
a0-S 1`R)l
GI;DO'G.`.(iefiatlld isiii 5 ecA4 _ _ _ = -
sum
t0
D>OCdt '!ON (color, hardens, soil/rodtypo grain size. etc.)
et ft.
6/�
/fa.
0 .
/ j fe
0a 1 r
/7-can:
r Z( ft.
17 ..- $ TDB
/ Z ( ft./3
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22., Certiff
Wr/7
SipLure of Certified Well Contractor Date
By signing this form, 1 hereby certify that the well(s) was ('were) constructed in accordance
with 15A NCAC 02C.0100 or 11,1 NC4C 02C.0200 Weil Construction Standards and that a
copy ofthis record has been provided to the well owner.
23. Site dlagrarll Or additional well details:
You may use the back of this page to provide additional well site details or well
constriction details. You may also attach additional pages ifneces .y.
SIMMTTTAL UkIS'IRUCIflONS g.0
24a. for All Welts: Submit this form within 30 days of co 1Rog) of wello
construction to the following: - o
Division of Water Resources, Information Proeessin
1617 Mall Service Center, Raleigh, NC 276994i
2Ab. For Inieetiott Wells: In addition to sending the fona to il
above, also submit one copy of this form within 30 days of co
construction to the following:
ro
gttlx
o 75-
adEss in 24a
tenon of well
Division of Water Resources, Underground Injeedon Control Program,
1636 Mail Service Center, Raleigh, NC 27699=1636
24c. For W:otet gltpsty & 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 corsstsustion to the county health department of the cotmty
where constructed.
HMa/aN303N/43A13338
Form GW.1
North Carolina Department of Environmental Quality - Division of Water Resources Revised 2-22-2016

WELL CONSTRUCTION RECOIL) (Gr-
For Internal Use only:
1. Well Contractor Informe z on:
Welt Contractor Name
Contractor ration Number
Company Name
2. Well Construction Permit #: 7 '" $/
List all applicable wen construction permlls (i.e. UIC, Como', State, Varlat eta)
3. Well Use (check well use):
Water Supply Well:
>lrAgricultural
Geothermal (Heating/Cooling Supply)
Industrial/Commercial
Irrigation
Nou.Water Supply Well:
Monitoring
Injection Well:
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
Experimental Tozhnology
Geothermal (Closed Loop)
Facility/OwnerN7
DMunicipaYPublic
ide ntial Water Sup -ply (single)
Residential Water Supply (shared)
Recovery
DGroundvtater Remediation
*Salinity Barrier
DStomiwater Drainage
DSubsidence Control
DTracer
Geothermal (Heating/Cooling R )pother (explain under #2I Remarks))
4. Date Well(s) Completed: 7 7 � ?Weil IDff
3a.,Well Location:
�'7grr 7aeo6J
7,5-7;' O/ ,,/
dernk Arc 7.-TV
i'aciiity if;# (if aI3
Physi 1 A5 s, City, and Zip
County
Pa4TI Ifiticiik (PIN)
Sb. Latitude and longitude In degr°eesIminutes<second t fecionacclegr
(ifweit field, one Iatilong is sufficient)
• 22, Cerafi
N
6. Is(are) the well(s)cifernument or Dtremporary
7. Is this a repair to an existing well: es or NO�
If this is a repair, fill out known well consouctio information and e. plabz the nature of she
repair wider#21 remarks section or on the back of this form. -
S. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction, only I GW-1 is needed. Indicate TOTAL NUMBER dwells
drilled: �r
9. Total well depth below land surface: Ja (ft.)
For multiple wells list all depths if'dffferent (el:antale-.1 200'and 2 a IOv)
10. Static water level below top of casing: (ft.)
'futile, level is above casing, use "+ "�
11. Borehole diameter:
12. Well construction method:
(i.e. auger, rotary, cable, direct ptsb, etc.)
FOR WATER SUPPLY WE➢.I 6 ONLY: .
13a. Yield (pal) 16' Method of test:
13b. Disinfection type: J 44Q 4t Amount:
� 4
w
AJ 0
' 4i
fONIID ;:":y _ _ _..._..,.....5..7-:1 .: a ..3.....'.. ..f... ..
FROM
TO
DESCRIPTION -
ft,
ft.
ft. ft
_
.45':-0trrElie l-Gi
ma( d?#eDiais }22TdlER igr . -te, _1-::::- : .:1.;.— -
FROM
TO
DIAMETER TDI KNESS
MATERIAL
D 11.
r
2-t-.
o
dc..
FROM
TO
DIAMETER
TSICKIVESS
MATERIAL
ft.
ft.
in.
_ft,
ft.
in.
-
FROM
TO
DIAMETER-
nor SIZE
VaaatrEs4.
irintittil.
ft. ft.
m
I
-I8IGR$UUl
=�; .c .r. :
;=: ;:ffi
FROM
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MATERIAL
FLACEMENIMETRoDaAMfOUNT
ft.
/"' ft,
A� r�
ft.
/10 ft
/J ,�
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- en, i A+
ft.
ft
n o
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ri
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FROM
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MATERIAL EMFLACESIENTMaTHOD _._ ..
eft.
3t ft.
i.4d-rt 'd . •v • fl"
ft.
ft.
.(ifterA/idd1 ��M:tx-2-tt�t�#::�"=;L'
FROM
TO _
DESCRIPTION (talar,heedags,aeWreektype. wain Ste. era)
0- ft.
-Z ?-°
0 Q f
Z, Z ft.
70 ft
540//e — iQ4?
30. ft. vi
t fa
[ s77n.c...
3,ft
,,ft
.tat-
cl4 y.
et/ fG
JP Z ft.
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.. .. ....._ tea.•`.... _.:fir .:. .- ._.. _.._ . -ee:--'-<..,.
0
Signature of Certified Well Contractor
24a. 17or MI Wells: Submit this form within 30 days
consruction to the fol owing:
Division of Water Resources, Information Pro s
1617 Mall Service Center, Raleigh, NC 2764g- a ^'
ti �;an
241t. par Juice/iota Welk: In addition to sending the formctgtigiddressii?24a
above, also submit one copy of this form within 30 days otoordliletion of well
construction to the following: n
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Soo* & Iaieetiat Wells: In addition to sending the form to
-the address(es) above, also submit one copy of this foam within 30 days of
completion of well construction to the county health department of the county
where constructed,
7df/7
Date -
By signing this farm, 1 hereby certify that the wells) was (were) constructed in accordance
with 15ANCAC 02C .0100 or 15A MAC 02C .0200 Well Construction Standards and that a
ropy ofthfs 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 iiecessaty,
Si IRVIIT '.A,L )hi S'7'i'l;21JgfONS 3 p
-0ro
E' gr letian obwell
csa
net,
HMQ/liN3o3N/a3AI3336
Form GW-1
North Carolina Department of Environmental Quality - Division of Water Resources Revised 2-22-2016

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/3b. DIsinfection type:
1. Well Contractor
Well Contractor Name
3/
NC Ven contra • +rCertificationNut:ber
V k Www D rird1'�
C�TS'A'Pi€7CT ON RECORD W 1
Ovio- 44784
Company Name
2. Wen Construction Permit #: 7 -
Ltst all applicable well construction perm!' is (i. UIC, Corauy, State, Variance, etc)
3. Well Use (check well use):
lot internal Use Only:
FROM TO DESCRIPTION
ft.
ft.
R.
ft
FROM %TO
DIAMETER TACKNl SS
io. s cgo
MATERIAL
•1d ilnigftVAR NGiOR 331RGfioiksi'maisl 4ti3i Z'';: P.. ,_::
FROM TO DIAMETER TEICI{NE$S MATERIAL
in.
ft.
ft
Water Supply Well:
Agricultural Geothermal (Heating/Cooling Supply)
Industrial/Commercial
Irrigation
Non -Water Supply Well:
Monitoring
Injection Welts
DMunicipaliPublic
Residential Water Supply (single)
Residential Water Supply (shared)
Recovery
Aquifer Recharge r3Groundwater Remediation
Aquifer Storage and Recovery DSalinity Barrier
Aquifer Test DStormwater Drainage
Experimental Technology DSubsidence Control
Geothermal (Closed Loop) Tracer
Geothermal (Heating/Cooling etum) '-'J Other (explain ander #21 Remarks)
4. Date Well(s) Completed: 7` C f
rn f
Facility/(honer sme
Physicalddrqsr City, and Zip
lga CC( fit 4Ct
County
Well m#
Fecil' IDI (ifapplisable)
&it) we ZSf1.34
Parcel Identification No. (PIN)
5b. Latitude and longitude in degreesfminutesJs it4tror riggi es:.r
(if well field, one latllong is sufficient)
N (*T.ti % I7 W
6.Is(are)the well(s)Permanent or Tetc?(►gsr:
7.1s this a repair to an existing well: DYes or No
!f this is a repair, fill out !mown r+eil consbarctbon in -Armada)] =plain the nature ofthe
repair wider #21 remarks section or on the hack of thisform. .
S.1»or Geoprobe/DPf or Closed -Loop Geothermal Wells having tho same
construction. only I GW-I is needed. Indicate TOTAL.NUMBERofwells
drilled: �{
9. Total well depth below land surface: 2 ` r (ft.)
For multiple wells list all depths rfdjfferent (example- 3@200' and 2 a l00')
10. Static water level below top or easing: 30 (ft.)
!Pettier level is above cosine, use "+ ",-.
11. Borehole diameter:
12, Weil construction method:
(l.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WEY.Y - ONLY: -
13n. Yield (gptn) ✓ ° Method of teat:
rG thr Amount:
1110111
FROM
-ft.
ft.
■ DIAMETER
183tt1U5"
ft.
ft.
TO
3
1.
ft
NIAIERTAi xMM A
for
ATr METHOD & AMOUNT
(v f o lea '71i0, rru
FROM TOv24a ' �tt'�$�NTMSfROD Oft. ft. Q1 G(/� f/w
Otel-
FROM TO DEE TION feeler. hardness,;Oreek type. missies. ere.)
C
8
ft.
ft.
/ ft.
XS'
re4 /75" i;.
zr• top-
!o r1 / o4 ft. C l� 57fiit.er
17.r-1t. /77 siL
zott d(ay
�ZO - 2LZ
2-013. Sti 0_.4.
Z2-L
22. Certification:
7// 2 /0
Date
By signing this form, I hereby cer0 that the w!(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 Me well owner.
23. Site diagram or additional well details:
You may use the back afthis page to provide additional welite details or well
construction details. You may also attach additional pages if voscessaty.
—•o°'
Q a m D
o w 0D
24a, Pr Ali Wells: Submit this fond within 30 days of ogitetion oft ll
construction to the following:
Moistener Water Resources, Information Proces jtd
1617 Mail Service Center, Raleigh, NC 276901(0g•
2fib. fro niati a We is: In addition to sending the farm t the dress in 24a
above, also submit one copy of this form within 30 days ofr@ompletion of well
construction to the following:
Division of Water Resources, Underground Injeaiion Control Prom,
1636 Mail Service Center, Raleigh, NC 27699-1636
24e. For Water Sttgpjv $s /11$ a mi Wells: In addition to sending the form to
the address(es) abov also submit one copy of this form within 30 days of
completion of wall construction to the county health department of the entity
where constmeted.
SUBMITTAL )NSTRUCI7Ot' $
SMW/11N3a N/a3A13o3i1
Form GWI
North Carolina Department of Environmental Quality - Division of Water Resources Revised 2-22-2016

WE
ON RECORD (GW 1
For Internal Use Only:
1. Well Contractor Information:
Well Contractor Name
NC Wen Contractor
Company N
r ... Alion Number
tf,. 447
2. Well Construction Permit #:
List all applicable well canslnncliot: permlts (l.e. UIC, Ca+mty, Stale, Parlance, etc.)
3. Well Use (check well use):
Water Supply Well:
Agricultural -
Geothermal (Heating/Cooling Supply)
Industrial/Com mercial
briation --
Non-Water Supply Well:
Monitoring
Injection Well:
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
Experimental Technology
Geothermal (Closed Imp)
Geotherusat eating/Coolin R
OMtmicipallPublic
idential Water Supply (single)
Residential Water Supply (shared)
Recovery
Groundwater Remediation
Salinity Barrier
DStonuwater Drainage
DSubsidence Control
DTracer
0Otiler (explain under #21 Remarks)
4. Date Well(s) Completed? Z1 1/ 7 Well III#
Well Location:
!Ch N
ter
acr it"ry veer aq
e Facility MP' (if applicable)
Orof- •�r4-fw4,'t.et,f//Yt✓24N7�
Physical AddressiCity, and Zip
County I'arFgLIdentjlia#30111r:;i I?4)"
5b. Latitude and longitude in degrees/minutes/seads or dec rdegrre§:
(if well field, one Iailong is sufficient) s
SEP.
2017
6. Is(are) the welll(s)ermanent
7. Is this a repair to an existing well: Yes or
If this is a repair, f111 out known well consturtion information an explabr the nature ofthe
repair under #21 rernarh section or an the back of this form.
or emporary,:., (
S. For GeoprobafDPT or Closed -hoop Geothermal Wells having the same
construction, only 1 GW-1 is needed. Indicate TOTAL NUMBER dwells
drilled:
Z /ro
9. Total well depth below land surface: (ft.)
For multiple wells list all depths Ifd(erenr (eaanrple- 3Q200' and 2 u 100)
10. Static water level below top of casing:
(wuter level is above casing, use
11. Borehole diameter:
12. Well construction method:
(i.e. auger, rotary, cable, direct push, etc.)
<14 o (ff.)
FOR WATER SUPPLY WELLS ONLY: -
13a. Yield (gprn) t.7e, Method of test: 41-40
13h. )lDisinfeetion type:; 4f- Amrtount:, 1. 4
FROM ,
TO
DPSCRIPTIoN
ft.
ft.
ft.
ft
tis=o
CASING (ru
a Arl i e
' . : .
FROM
TO
DIAMETER
TRIMNESS
MA
Zots t
2 In.
0
v G.
FROM
TO DIAMETER
TRICt(NESS
MATERIAL .
€t.
ft. in.
.re.
f . ie.
' - i J ~ `.
'
J.)W STER
SEZE:
xci ss
e
2.0
Zt ot.
2 tr:.
sT
0
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J
tr�
ft,
fr.
in.
,-,
elDIOREIVE
` 'bfAT1AL
PROM { to
ER
EMPI,ANs ra,:. METriOD&AF10Int
b it.
51- ft.
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r 6t,
l ft.
C.
_
r G 'M e r
"--'�
ft.
ft.r-
,
MOM
IERRBAL •
EMPLACEMENT OD
/ °ft'
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npG ekz-
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fe
ft.
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FROM .
O
DEScaJPTIg t(color,herdaexe,ioWJreektytte,P.rets€ire.etc.)
a {t'
z-
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r�
z t.
3 3"-�.
-CU. � A/1,,/
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ft'
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5-0 ft.
/.5-et.
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?eft'
9 F ft
te. 57-,-2.e...
ft.
iv.:
a l47e
yM
f.ingtokiatttmvie1G �
r i as--
04,E
/11.57- 2.1 O 544,,...(..
/19
Signature ofCe led Well Contractor
7A&I?
Date
By signing this form, 1 hereby crony that the walls) was (were) constructed in accordance
with 13.E NC4C 02C .0100 or 13A NCAC 02C .0200 Well Constntction Standards and Arai a
copy of this retard has been provided to Me well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well skdetails
eonsburdiAn details. You may also attach additional pages if nece try
3O0)
SUBMITTAL L INsrRTJCTION3 ro r�o
or well
Pri
rn
24a. For Mi I Wells: Submit :his for within 30 days of co -•:� of
construction to the following: N
Division of Water Resources, Information Processin c 1%0 r- era
1617 Mail Service Center, Raleigh, NC 27699-1(.1 afro.
oQo co
246. .niestiote WVan: In addition to sending the foul: to titraddress in 24a
above, also submit one copy of this form within 30 days of coApletion of well
construction to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Moll Service Center, ttstelgb, NC 27699-1636
24c. Nor ts/a r Sur: &v &e Ri 'o Wetis: In addition to sending the fo:ai to
-the address(es) above, also submit one copy of this fort within 30 days of
completion of well construction to the county health dap etmant of the county
where constructed.
Form GW.1
North Carolina Department of Environmental Quality - Division of water Resources Revised 2-22-2016

12. We construction method:
(i,e. auger, rotary, cable, direct push, etc.)
1. Well Contractor Informs
Well CommctorName
'ell Co or Certification Number
NC
Company Name
2. Well Construction Permit t
List all applicable well construction permits (i.e. t11C, County; State, Varian:, eta)
3. Well Use (check well Ilse):
Water Supply Well:
Agricultural
Geothermal (Heating/Cooling Supply)
IndustrialfCommerial
�(sirri; Lion
Ilion='Water Supply Well:
IVlouitoring
Infection Well:
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
Experimental Technology
. Geothermal (Closed Loop)
Geothennaigieathg/Cooling R
DMunicipal/Pctbric
!►�=Residential Water Supply (single)
Residential Water Supply (shared)
Recovery
0Gmnodwata Reme diation
MISalinity Barrier
Stormwater Drainage
Subsideiice Contra'
Tracer
Other (explain under R21 Remarry)
77
4, Date Well(s) Completed
ID#
5a, Well eat pn:
Alit O l �i c rim...)
Facility/OWEerName Facility ID# (if applicable)
r ' „per 7 �h 61,° ffolizikkL try
Physical
d Zip
f/ued oana,,
County
Parci`i idelui6sitiah'tIo (')N) =.
Sb. Latitude and longitude in alq,reestutinuteslgeeonds u iti fti rid iFgr es)1
(if well field, one lat/long is nurfn"oient) U
6. Is(are) the vvell(s) ermanent or a'Tettuporary
7. Is this a repair to an existing well: jYes oron to
;Phis v A repair, fill otit latawn we!! construction ift r'rr7ation explain the nature aftbe
repair reader t121 remarlrsectron or on the bads ofthis,form.
S. For Geoprobe/DPT or Closed -Loon Geothermal Wells having the same
construction, only 1 GW-1 is needed. Indicate TOTAL NUMBER ofwells
drilled:
9. Total well depth below land surface: (ft,)
For multiple wells list all depths ifdtiferent (example- 3Qa 200' and 2 « 100)
10. Static water level bslow.top of casing: t'i (f.)
ifnrrter(eve/isabove casing, use ":-
11. borehole diatneter: _ (in.)
z
s.OR WATER SUPPLY WELLS ONLY: ,
13a. Yield (apart) • Ye) Method of test: 4 i/'
13b. Disinfection type. LI/ OW Amou•K(Li
FROM
TO
DEScmpTioN
ft.
rt.
R.
ft.
—
gi;OUTPIR
€DrGff&
hill ita"s triidlKOZET
3; il-;_::: : -
FROM
TO
DIA1+fEaER 1 SS
MA'TERLSL •
Q it.
2/Oft
Z. ' C 6
�y L
itS:anDIN.CA
iBC_ RITSI
fa:{Viiil ittififiNaiiii) -_ -..
FROM
TO
DIAMETER
TRIMNESS iCi(NESS
::,. -...
MATERIAL .
ft.
ft.
in.
_,fie
ft.
ILA.
PROM
TO
Mitain7Ei%
stet 1 CK[VEss
iti TE aAL
tic,-
2?o
2._k•
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'I
fv�
rite ft.
in.
FROM
TO
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EMTLAtar - . P/5£TAOD&AdODUNT
ft.
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ffle
/es
—.-Ir ft
i.r ft.
34444
—.. /0-
A-44T7Di�iEC6.4!4EMLiitia11ib%_
�...=:.-.:.:";:'-..��•�y..c;�::
~���-��:_.�::rEMPLACEMENT
kROM
TO
MATEMATERIAL-
hiETROB
ft.
ft.
ft.
ft.
20aiRISEANGI=OGFs
aal4€6ffaYs'lietsif .eessaagj%'-_ ='z :
FROM
TO
DESCRIPTIOBI(color,hardnaplihnrctypa..r nsize,etc.)lT
e la
et - ft.
/_cm" it
i s-fw.tJ
e ft
She -le- saw
3 o ft,
cfit.
,,fq1 /
4t1ft.
7o ft,
di'- i
7 a ft.
I sit-
fQ he/
/ °1R
/ J 5
i -_ _ , m Kit
22. Certi i riots:
Signature ofCer: ed Wctr Contractor Date
By signing this form, I hereby terrify that the well(s) ins (were) commuted in accordance
with 15ANCAC 02C.0100 or 1SA'CAC 02C.0200Well Constrr,.tian Standards and that a
copy of this record has been provided to the wen owner.
23. Site diagram or additional well details: •
You may use the back of this page to provide additional well Oe details or
eonstauotion details. Yon may also attach additional pages if resat
34n. " r We/1st Submit this form within 30 days of
coast -action to the following: _
Di -vision of Water Resources, Information ProcessditElt,
1617142%11 Sen3ee Center, Rnleiarn,P1C 27595.+-_40:vn
SiTit1WITrALL N'S UCTioNS 5'� m
oy ro -<
c& ° l&on of
v
well
fV
0 0'
246, For 2n eaJ nut W : In addi oat to sending the formto aore s in 24a
above, also submit one copy of this form within 30 days of ermpletion of well
^onstrnction to the following:
Division of WaterRQ:oneces, Undergrotnud Injection Control Program,
1636 Mali Service Carter, Raleigh, NC 2753E-1636
24c. armpit riiee oat Weis: In addition to sending the form to
-the addresses) above, also submit one copy of this font within 30 days of
completion of wall contraction to the county health deparbnent of the county
where constructed.
NMQ/NN3OON/a3AI33311
Form GW.I
North Caroline Donal -anent of Environmental Quality - Division of Pieter Resources Revised 2-22-2015

Cad
/
Z
t _I :1-
\.
Crd
N
C)

Alr��v�:®ray:®�
1. Well Contractor Info on: •
o °.b
We1l ContactorNatne
3
NCW Contract Certification Number
Company Name
2. Well Construction Permit #:
List all applicable well construction pernrfls r.e. UIC, Corotty, State, Variance, etc.)
3. Well Use (check well use):
(.0 17 -c%bV
447
Water Supply Well:
Agricultural
Geothermal (Heating/Cooling Supply)
Industrial/Commercial
Ini •.Ova
DMtmicipalYPublic
Residential Water Supply (single)
Residential Water Supply (shared)
Non Water Supply Welt:
Monitoring
Injection. Wall:
Aquifer Recharge
Aquifer Storage and Recovery
AquiferTest
Experimental Technology
Geothermal (Closed Loop)
Geothermal . eating/CoolingR
4. Date Weli(s) Compteted:
5o. Well eo-t - S
Facility/OwnerN
0,67 Aird
Physjw0110Aadms, City, and Zip
1(4
Recovery
Groundwater Remediation
DSolinity Barrier
DStonnwater Drainage
DSubsidence Control
DTracer
Other (explain under #21 Remarks)
i9//1we11Ill
cility 1D# (if applicable)
rn Zf `era
County Pahl Identification No. (PIN)'
.e-_n
Sb. Latitude and longitude In deg reesfsninuteslseconds or decimal degrees h P
(if well field, one lat/long is sufficient) 22. Certification:
For Internal Use Only:
N
=s��s•e•.tiii
6. Is(are) the well(s) Permanent or DrTemporary
7. Is Ibis a repair to au existing well: r3Yes or No
"Phis is a repair, fill opt blown wall construction informatlon an • -. pinbt the nature of the
repair wader #21 remarks section or on the back ofthis. form.
6. For Geoprobe/DF'T or Closed -Loop Geothermal Wells having the same
construction, only 1 GW-I is needed. Indicate TOTAL NUMBER of wells
drilled:
9. Total Weil depth below land surface: #0261 7
For multiple wells list all depths if different (example- 3Q200' and 43100
100
10. Static water level below top of casing: 440 (ft.)
Ifwauer level is above casing, use "' "�
11.Borehole diameter:
12. Well construction method:
(i.e. auger, rotary, cable, direct push, etc.)
//
FOR WATER SUPPLY WELLS ONLY: _ -
13n. Yield (gpna) 80 , Method of test:
13h. Disinfection type: ti 'i 'Y Amount:
._ -
TO
iiiCIUUPT10N
ft.M
rt.
ft
ft.'
:1g O1 GASR(G-(Ear; etlQf d: ,.
A .t . : _ .::_= : ; M ..
FROM
TO
DIAMETER
O n'
�r
/ 1 /'t.
in.
%�
i%G
ukammcksiNavrensziG!
FROM
TO
DIAMETER
TRIMNESS
MATERIAL
ft.
ft.
in.
t.
ft.
tn.
FROM
TO
DIAMETER
SLOT Sit£
O NE5a
Q/�9
)1
Zf in.
/0
c4o
v�
ft.
ft
in.
FROM
TO
AMATER/AL
RMFLA OD & AMUN
ft.
S' ft.
k •
ft.
/ p ft.
SA;1
..... _
0 k r—
n•
0?2'
fats � GN t4, t.
—
FROM
TO
MATERIAL
EMPLACEMENT NTMZTBOD
ft.
ft.
ft.
ft.
" 30:111111 A.11—;G
'is.(itfaik
itidsTWA f 1 ;'4t .~_
. > Fete
FRO I
TO
DES ON (calor rate reek e.
ft.
/ d ft.
(% f
if
3S
Q -
, t'
76u
e l4
® ft.
-2 j ft.
CC, /K.Cs� i 7 J1---
rft.
JOft.
r
r6ft.
et!6
/ / ft
5 7 v
, / ft.
/
(""%lte-•-•
✓ Cl r 'C
vd
a
a ''P1,11
Signature of Certified Wcii'Eotd actor
r/vX7
Date
8y signing this form,' hereby care 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 thls 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 wi site etails or well
construction details. You may also attach additional pages i1
o
o A!J
24a. for Alt Wells: Submit this form within 30 days o letion dfsWell
coasttttotion to the following: w
cgrb
(1)
Division of Water Resources, information ProctisQuit, o
1617 Mail Service Center, Raleigh, NC 27698411' co
24b. rpsjindectiou Welirr: In addition to sending the formcoo the -Address in 24a
above, also submit one copy of this form within 30 days or completion of well
construction to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mali Service Center, Raleigh, NC 276994636
24e. Fir Water S a�oli. jy c 'orr VVelEs: io addition to sending the form to
-the address(es) above, also submit one copy of this form within 30 days of
completion of well combustion to the county health department of the cotmty
where constructed.
SUBMITF •" INSTRUCTIONS
SM©/NN3aO03AI3O3J
Form GW.1
North Carolina Department of Environmental Quality - Division of Water Resources Revised 2-22-2016

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ww,f.JNSTRUCTIONRECORD (GW-11
1. Well Contra Information: 4147843
Well Contractor Name
3/ 0
NC Well Contract Certification Number /`
6 ow
Company Name
2. Well Construction Permit #:
List all applicable well construction permits?1.e. UIC, Coemty, State. Variance, etc)
3. Well Use (check well use):
Water Supply Well:
Agricultural rjMuaicipaVPublic
1` Geothermal (Reating/Cooling Supply) apesidesuial Water Supply (single)
Industrial/Commercial DRe identiai Water Supply (shared)
Ini ton
Non -Water Supply Well:
K Monitoring
nj n ell:
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
Experimental Technology
Geotherrbal(Closed hoop)
Geothermal ' Coolie R •
4. Date Well(s) Completed:
ell Le ti r:
acility/OwnerNa a Factiity fi)# (if applicable)
731.3 g gi t del(C Zan 3o
Physical Addrcge, City, and Zip T
I4CtS
5
Recovery
DGroundwater Remediation
oSalinity Ranier
DStormwater Drainage
DSubsidence Control
D
7
Other (ex lain under #2I Renrarics)
Wen JD#
County
Parcel identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(dwell field, one latilong is sufficient)
N W
6. Is(are) the well(s)Permanent or r3Temporary
7. Is Ibis a repair to an existing well: Yes or ®No
If than is a repair, fill out known well oarutructio iteorraation and esptabt the nature ofthe
repair ender #21 remarks section or cm the back ofthisform.
8. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction, only I OW -I is needed. Indicate TOTAL NUMBER of wells
drilled:
9. Total well depth below land surface: .205 (ft.)
For multiple well: list all depths rd f Brent (example- 3Q200'and 2@l00)
10. Static water level below top of easing: TO
!flatter level is above casing, use "+-
11. Borehole diameter:
12. Well construction method:
(i.e. auger, rotary, cable, direct pull, etc.)
(ft.)
FOR WATER SUPPLY WELLS ONLY: -
13a. Yield (gpm) D Method of test: r
13b. Disinfection type: AM, Or Amount:
For Internal Use Only:
FROM TO DESCRIPTION
ft.
rt.
ft.
ft.
FROM TO bIAMl?7F:R rue�eris.
a fL %J ✓�Tt
� f
,l 8lNGr .0ltrJBING.
FROM
it.
1'O
ft.
in.
G p
DIAMETER
in.
THICKNESS MAMMAL
ft.
ft.
fl.
in.
in.
CVO
'll
DFROM . 7 k/a 8h�1 TO AC
ft. 1�1EN
/ 70. A geit
ft.
OP
AMOUNT
of
Rom TO DES a • I .t fdror, Wirele
ss, m, lo9frade type. scablike, Nei
0 ft. Q 41/,[_`
Z vltx i► ' S4'
4.o 61C�
90f. /Zm 5441
Ze /'` gtcy SEP 1 i ,p17
'(4 S .� i, ti�tSCCF? tti'1i , ..'s �r �i:sEt
C'2.L 4 .., ... "4s-.3e5': t'�.... cv�*z��)3l .• ._r'?4' � r•-. ,,, k:.`•aD �_.
22. Certification:
Signature of :tiled ' ell Contractor
r•—
7447
Date
•ly signing this form, I hereby cerrify that the well(s) wos (here) constructed hi accordance
with 134 NCAC 02C ,0100 or 154 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 we11`te d
construction details. You may also attach additional pages ifnt j
TZTAL IAti3'_fitlt 19 (1,)(1)SIIl3M
0 co to
24a. izor All Wails: Submit this form within 30 days of raphylition of W1
construction to the following: co �'Crb
o (1)Division of Water Resour
ces, Information Pratt
1617Maii Service Center, Raleigh, NC 276994g
24b. For Infection Wells: In addition to sanding the form 4e 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 Sunrnf9 &g 1njgtlop Weill: 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.
or well
c:3
00
MMQ/e1N303N/03141333
Form GW.1
North Carolina Department of Environmental Quality - Division of Water Resources Revised 2-22.2016

MIL CONSTRUCTION RECORD (GW 1)
1. Well Contractor f rmation: ,0 4478
Otis'
WellCor~•` ,Name
NC Well Contra r Certification Number
Gilt#/Jt1., wits Dllrl`/41'
Company Name
2. Well Construction Permit #:
List all applicable w8U constnection permits (te UIC, Cotes% State, Variance, ett,)
3. Well Use (check well use):
Water Supply Well:
DAgticulttuai
DGeothermal (Heating/Cooling Supply)
D Iadustdal/Contnterciai
Irrigation
Non -Water Supply Well:
Monitoring
Injection Well:
[Aquifer Recharge
Aquifer Storage and Recovery
DAquifer Test
[,jExperitnental Technology
DGeotherrnal (Closed Loop)
DQeothernlal (Iieating/Cooling Ret,n
DMimicipallPublic
id itial Water Supply (single)
Residential Water Supply (shared)
Recovery
DCiroundwater Remediation
Dsalinity Barrier
DStomlwater Drainage
DSubsidence Control
DTracer
Other ex • lain under #21 Remarks)
4. Date Well(s) Completed: 2 / 7 Well Ill#
5a. Well Location:
y!/% /'aLJ/(/ility/O c(Name
80rScI l3'� A.(
Physical As City, and Zip 1
�16a
County
ili(y ID# (if applicable)
& ei% r •. /yc 2sq3
PareeI Identification No. (PIN)
Sb. Latitude and longitude In degrees/minutes/seconds or decimal degrees:
Orwell field, one latllong is sufficient)
6. Is(are) the well(s) Permanent or DTenrporary
7. Is this a repair to an existing well: [ Yes or Jill/No
If this is a repair, fill out known well construction information explain explain the nature of the
repair tender N21 remarks:ratian or on the back ofthis form.
S. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction, only 1 OW-1 is needed. Indicate TOTAL NUMBER of wells
drilled:
9. Total well depth below land surface:
For multiple wells list al! depths (f dj f erent (example- 3(§200'annd 2Q100)
10. Static water level below top of easing: (ft.)
Ifxsrter level is above casing use "+ "
11. Borehole diameter:
12. Well construction method:
(i.e. auger, rotary, cable, direct push, etc.)
(tt•)
FOR WATER SUPPLY WELLS ONLY: ,
13a. Yleld (gpm) /10 Method of test:
13b.Dlslnfectlontype: j/iItz Vr Amount:
For Internal Use Only;
2
f
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TO
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$UBhtUTAL 1NSTRUcTIONS
ICJ
rrt
24a. j?or All Walla: Submit this form within 30 days letio1 well Z
construction to the following: cra C'S
Division of Water Resources, Information Pr of Unit, z
1617 Man Service Center, Raleigh, NC 2706 1 17 00
ct� a
24b. For Irr, jecdon Was: In additions to sag the fort to tffe address in 24a g
above, also submit one copy of this form within 30 days of completion of well
construction to the folowing:
Division of Water Resources, Underground Injection Control Program,
1636 Mai! Service Center, Raleigh, NC 27699-1636
24e. For Water_Snnpjy &Int ion }'Hells: In addition to sending the form to
the address(is) 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.
Signature of Certified Well tractor Date
By signing this form, 1 hereby certift that the welt(s) was (were) constructed in accordance
with 1SA NCAC 02C .0100 or 154 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 deli details or well rA+v
0011StriletiOn details. You inay also attach additional pagesfn wry. n
I_n
A
cp
°A. m
3 CD'� 0
Form OW-1
North Carolina Department of Environmental Quality • Division of Water Resources Revised 2-22-2016

LL QS UCTION 1RECO D (GW 1
1. Weil Contractor Info
Well Contractor5ile
fr D/l�� 447
NC Well Contract r Certification Number
Pit // ok. led
Company Name
2. Well Construction Permit#:
List a applicable well construction permits (Le, UIC, County, State, Variance, etc)
3. Well Use (check well use):
Water Supply Weil:
Agricultural
Geothermal (lieating/Cooling Supply)
Industrial/Commercial
Irrigation
Non -Water Supply Well:
Monitoring
Injection Well:
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Teat
Experimental Technology
Geothermal (Closed Loop)
Geothermal (Iieating/Coolin; R...+. )
DM►nicipal/Public
idential Water Supply (single)
Residential Water Supply (shared)
DRecovery
DGroundwater Remediation
Salinity Harrier
DStormwater Drainage
Subsidence Control
Tracer
Other (ex r lain under #21 Remarks)
4. Date Well(s) Completed: 7 !t7 / r Wed DM
Physical A•• -s,C' , and Z'
to tut
County Parcel Identification No. (PIN)
ab. Latitude and longitude in degreasfminutes/seconds or decimal degrees:
Orwell field, one laUlong is sufficient)
N
6.Is(are)theweil(s) Permanent or Temporary
7. Is Yids a repair to an existing w¢D: DYes or No
If this is a repair, fill out kriavm wall construction iafiirmatlon an expsabe the nature of:he
repair snider r#21 remarks section or on the back of thisform.
8. For GeoprobafDYF or Closed -Loop Geothermal Wells having the sane
construction, only 1 GW-I is needed. Indicate TOTAL NUMBER dwells
drilled:
4. Total well depth below land surface: r /
For multiple wells list all depths if different (example- 3@200' and 2 a 100)
10. Static water level below.top of casing: Go (ft.)
Ifiszuer level is above casing, we 1
11. Borehole diameter: (in.)
12. Well construction method:
(Le. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY: .
13a. Yield (gpm) OtO Method of test:
13b. DIsinfection type:.�,ti a 0 « Amount:
rI Y
FROM
TO
DESCRIPTION
ft.
ft.
ft. ft.
-
45:_OT9.T=VAS
FROM
TO
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DMMETER
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2./5` 5 4'' ....
22, Certification:
o _
5igna tune of Certified Well tractor
geo' 7
Date
By signing this farm, l hereby certify that the well(s) was (were) constructed in accordance
with 154NCAC 02C.0100 or 15ANCAC 02C.0200 well Construction Standards and that a
copy (Phis 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 ante details or well
construction details. Yon may also attach additional pages ��cftsaryr.
SUDMITTAL JNS RUCTII QN4 o w >zp
c
24a. car Wells: Submit this fort within 30 days jpletion well
constltction to the following: . N
O rp 0 N.)
CD CZ)
Divislonof Water Resources, Information Pr a ;,1s ' •Unit, -
1617 Mall Service Center, Raleigh, NC 271.7 7
24b. Fe/ irlJaatiott Welk: In addition to sending the farm 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
24e. For Weter S3tgplq ric 1fgc p Wells: In addition to sending the form to
-the address(es) above, also submit one copy of this form within 39 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 d t'� For Internal Use only:
1. Well Contractor Tnforma% 6 �� G'� i
V
Well Contractor Name
3 / 97
NC Well Contractor cation Number
d✓Joy
Company Name
2. Well Construction Permit #:
List all applicable well construction permits (7.e. U1C, County, State, Parlance, etc.)
3. Well Use (check well use):
Water Supply Well:
Agricultural
DGeothennal (Heating/Cooling Supply)
D Ind u stri a UComm ercial
Irrigation
Non -Water Supply Well:
DMonitoring
Injection Well:
DAquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
Experimental Technology
Ali.-/loAt
DMunicipallPublic
Residential Water Supply (single)
Residential Water Supply (shared)
Recovery
®Groundwater Remediation
Salinity Barrier
0Stormwater Drainage
DSubsidence Control
DGeothemal (Closed Loop) OTracer
Geothermal (Heating/Cooling Return) Other (explain under #21 Remarks)
4. Date Well(s) Completed: W13y
,W'e11 ID#
5 W Lo
a. ea on:
(15ff..-I1OYO4
Facn ' /OwnerName Facility ID# (if applicable)
3 3 jM AA-�/ cat i - ffc git3
Physical Address, ity, and Zi
Vv (a sot 7/�J
County
Parcel identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one tat/long is sufficient)
N _ W
6. Is(are) the well(s)01Permanent or EsTemporary
7. Is this a repair to an existing well: Ties or DNo
If this is a repair, fill out known well construction 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:
9. Total well depth below land surface: _ �/ Zip (ft.)
For multiple wells list all depths ifdtfJerent (example- 3(000' and 2 u@r 10U')
10. Static water level below top of casing:
If wafer level is above casing, rise "+ "
11. Borehole diameter:
,moo
12. Well construction method:
(i.e. auger, rotary, cable, direct push, etc.)
(f•)
FOR WATER SUPPLY WELLS ONLY: _
13a. Yield (gpm) Vf/ Method of test:_
13b. Disinfection type: auY Amount:
/54
'4e.iC1 klEItiO ES.:1- t -t f .tit_'. .... ... _i.._.....
FROM
TO
DESCRIPTION
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ft.
ft.
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j 76.
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FROM
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DIAMETER
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MATERIAL ,
/,�'
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S
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ft
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DESCRIPTIO (color, hrrdness, IoiUrock type, ent n site, etc.)
Dft
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22. Certification:
Signature of Certified Well Contractor
AY/ 7
Date
By signlrrg this form, 1 hereby cer15 chat the well(s) was (were) constructed bi accordance
with ISA 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 neossary.
SUBMITTAL INSTRUCTIONS. o v�
va ID
24a. For All Wells: Submit this form within 30 days of tfuntilption of wall
construction to the following!
Division of Water Resources, Information Proms
1617 Mail Service Center, Raleigh, NC 27699- 6r7 D o
24b. For Inlection Wells: In addition to sending the form t a&1ress in 4a
above, also submit one copy of this form within 30 days of ppmpfetion of well
construction to the following: cc
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supply & Infection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
completion of well construction to the county health department of the county
where constructed.
t,
?.M O/1IN3G3N/a3M13336
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 Informa o :
Well Contractor Name
NC
er
Company Nafi/e ifow Gi)eti di)11 li
GeJQb
2. Well Construction Permit #:
List all applicable well construction permits (i,e UDC, Colony, State, Variance, etc.)
3. Well Use (check well use):
4 4•
zoNEs
DESCRIPTION
Water Supply Well:
Agricultural
Geothermal (Heating/Cooling Supply)
Industrial/Corlmtercial
Irrigation
13Municipal/Public
laResiclential Water Supply (single)
Residential Water Supply (shared)
Non -Water Supply Well:
Monitoring 13Recovery
Injection Well:
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
Experimental Technology
�Geothermal (Closed Loop)
®Groundwater Remediation
Salinity Barrier
DStormwater Drainage
Subsidence Control
DTracer
LiGeothermal (Heating/Cooling Return) Other (explain under #21 Remarks)
4. Date Well(s) Completed: 6/"v 7 /7Wetl ID#
5a._WtllI 4tr., w
Fa(cdil�it�y(/,{Owner e / 64.4
F' ID# (if Hrable)
i, j Naf2ifi47(f11 w Faci
/ /l i �ccrj4
Physical Asjtty, and
/
FROM
ft.
ft
ft.
ft
':is _ot�r•>Alt-:cASINc-(ror,�cwea:�;�>;o -�
DIAMETER
FROM
TO
ft.
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'1i5fAN ER-itiSINMOR
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DIAMETER
FROM
ft.
TO
ft.
ft.
rt.
THICKNESS
in.
MATERIAL ,
in.
y �� .141�C111- � .Yi.� C . S.�'.•.-� � 4 - r:if (..a :tT:i�.3.: � ` - �
TO DIAMETER SLOT SIZE {*THICKNESS RIAL
2` g jS PAL
FROM
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0
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EMPLACE jMETHOD & AMOUNT
MIZSANDIMAUVROAlietiKaiblok-arriju..W4W
EMPLACEMENT METHOD
FROM �� �C rt9C4,—".
TO
/t✓ t.
0-4
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/Seconds or decimal degrees:
(if well field, one tat/long is sufficient)
W
6. Is(are) the well(s)PPermanent or Temporary
7. Is this a repair to an existing well: ®Yes or No
If this is a repair, fill out known well construction information an explain the nature of the
repair under #21 remarks section or on the back ofthis form.
8. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction, only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled:
9. Total well depth below land surface: 2./5. (ft.)
For multiple wells list all depths if different (example- 3 a@200' and 2L100)
10. Static water level belowtopof casing: ✓ ( (ft.)
Ifwater level is above casing, use "+"
11. Borehole diameter:
12. Well construction method:
(i.e. auger, rotary, cable, direct push, etc.)
(In•)
?Vt.,
FOR WATER SUPPLY WELLS ONLY: -
13a. Yield (gpm) 430
• /, '' /AMMethod of test: 1
13h. DIsinfection type: 43'4K�"' /1etAmount:
ft.
ft
H2O:sl)RIIy'G'11�Cr`,LOC?(it�ach�i'i,"ilteet_s` C �' arY� �-• •;'L;'��=..:, `�� • r4
DES n• s• r a N (color, hardness,;oil/reek type, grain size, etc)
� 7
FROM
0fL
I
ft.
TO
To
1 et
z
is
t
in.
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.caltd
tr- 5 201?
in •r o ,
ai3iE igia ;o' _,:; V
22. Certiii on:
-� efil oc-JGAv/i'
Sigoature.fCetti Well Contractor
Date
By signing this form, I hereby certh, That the well(s) was (were) constrncled in accordance
with 114 NCAC 02C .0100 or 1SA NCAC 02C .0200 Well Construction Standards and that a
copy ofthis record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMTfTALINSTRVC'TIONS
24a. For All Wells: Submit this form within 30 days of.eb etion kwe1l
construction to the following: o m -
Division of Water Resources, Information Pro EfJnit, t,.
1617 Mal Service Center, Raleigh, NC 27 w •16L7 r ,
24b. For Infection Wells: In addition to sending the forrkt¢'addres 24a
above, also submit one copy of this form within 30 days ie pletion well
construction to the following:
Ell no
—
Division of Water Resources, Underground Injection`tontrol 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 Info
Well Contractor Name
3/5-
NC We Con ctor cation Number l
�� �iz�- urd/
Company Name
2. Well Construction Permit #:
List all applicable well construction permits a.e. UIC, County, State, Variance, eta)
3. Well Use (check well use):
Water Supply Well:
DAgricultural
QGeothetmal (Heating/Cooling Supply)
DIndustrial/Commerciai
• tier
Non -Water Supply Well:
Monitoring
Injection Well:
r3Aquifer Recharge
DAquifer Storage and Recovery
Aquifer Test
DMunicipal/Public
Residential Water Supply (single)
Residential Water Supply (shared)
1$Recovely
DGroundwater Remediation
Salinity Barrier
DSton waterDrainage
Experimental Technology 0Subsidence Control
DGeothennal (Closed Loop) °Tracer
®Geothermal (Heating/Cooling R ) Other (explain under #21 Remar
4. Date Well(s) Completed r ' / 7 Well ID#
Facility/Owner Name acilityt (if applicable)
7t5?. gra n we i'eetm /ftc 0141
Phygddgt$s Ci e'lem4 4)
County
Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
W
6. Is(are) the well(s)manent or CiTemporary
7. Is this a repair to an existing well: QYes or MICrer
If this is a repair, fill out known well construction information and explain the nature of the
repair wider #21 remarks section or on the back of this form.
8. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction, only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled:
9. Total well depth below land surface: �d
Far multiple wells list all depths if different (example- 3@200' and 2 rr f 00)
10. Static water level below .top of casing:
If water level is above casing, use "+
11. Borehole diameter;
12. Well construction method;
(i.e. auger, rotary, cable, dirt push, etc.)
(R•)
FOR WATER SUPPLY WELLS ONLY: -
13a. Yield (gpm) 2-0
13b. DIsinfection type:,14Z�
Method of test: ' `
Amount: �( �
For Internal Use Only:
FROM
TO
DESCRIPTION
ft.
ft.
ft.
U.
.
` 5 "OUT•ER ASINOlfor biiiltt 8sed:s'ells) QR ZEiZ Wil
w-blej ': ' _.._.
FROM
TO
DIAMETER
TBICKNFS�
MATERIAL
0 ft.
(cam
/
2 in•
L4 /�%
e C
yMATERIAL
FROM
TO
DIAMETER
TmCKNESs
ft.
ft.
in.
-ft.
rt.
in.
L;j.:v
...:L,-.,. Z;l.i.i:.
tS>v.:Y....r. :24'3c=1_.1._r. ..
TO
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S
SIZE
CKNESS
MATF.Ri'ALL
(fMOM
4,
ft.
ft.
In..
=18'Ofiot3T:
.-
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TO
MATERIAL
MIA METHOD AMOUNT
d ft
3 ft
7 r
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FROM
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d ft.
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r k41_efeY.
l cat.
4 gift.
sj_u. r
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re, ft.
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Lp2L UAkitit,S:. rr_ i }'i x <rK ` A teXV- :Whine . •-4.c, c;
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{{--
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22. Certification:
✓tl'tti:mt;ition Jr: Zfrttvi,q:r.it
Signature of Certified Well Con or ' Date
By signing this form, I hereby certi Mal the well(s) was (were) constructed is 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 Me 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
of tell
24b. For Injectiop Wells: In addition to sending the fort to@egtaress inUa
above, also submit one copy of this form within 30 days of1on of bve11
construction to the following:
CD
Division of Water 1Resources, Underground Injection Control Program,
1636 Mall Service Center, Raleigh, NC 27699-1636
24c. For Water Sunniv & I iection 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.
3 iv
24a. For All Wells: Submit this form within 30 days of owe. I: eon
construction to the following: o v -
Division of Water Resources, Information Processing`ht,
1617 Mail Service Center, Raleigh, NC 27699ft9
oro�J
ECEfVED/NCDENR/DWR
Form GW-1
North Carolina Department of Environmental Quality - Division of Water Resources Revised 2-22-2016

For internal Use Unty:
NC II Contractor rtification Number /
G PI/Pk, �i&& d6 "
WELL CONSTRUCTION RECORD (U'W—.!
1. Well Contractor I ormation:
o 4 8
Well Contractor Name
3/
Company N e
2. Well Construction Permit #:
List all applicable well construction permits (i.e. UIC, Canary, State, Variance, eta)
3. Well Use (check well use):
Water Supply Well:
Agricultural , DMtmicipal/Public
Geothermal (Heating/Cooling Supply) DRtssidential Water Supply (single)
Industrial/Commercial Residential Water Supply (shared)
i ri : • tion
Non -Water Supply Well:
Monitoring DRecoveay
Injection Well:
Aquifer Recharge C3Groundwater Remediation
Aquifer Storage and Recovery DSalinity Ranier
Aquifer Test DStormwater Drainage
Experimental Technology Subsidence Control
Geothermal (Closed Loop) DTracer
Geothermal (Heating/Cooling Return) 7Et Other (explain under #21 Remarks)
4. Date Well(s) Completed: 4' ! ` / Well ID#
S ell Location:
dJ
.S%rwFacility ID# (if applicable)
A' G flan fe f 'tti- e Ave. k L
Physical Addres city, and Zip '5
Facility/Owner Name
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/loeg is sufficient)
1V
6. Is(are) the well(s)latierletanent or DTetnno ry {
`ry t 4
7. Is this a repair to an existing well: DYes or gait — , ,
If this is a repair, fill out ?mown well construction tioRAtipt explainthe rft,,,oft e
repair raider #21 remarks section or on the back of this forth. c.,}j >li,
8. For GeoprobelDPT or Closed -Loop Geothermal Wells having the same
construction, only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled: ��
9. Total well depth below land surface:
For multiple wells list all depths ifel ferent (example- 3@200' and 2 r©100)
10. Static water level belowtop of casing.
Ifwater level is above easing, rise "+L"
11. Borehole diameter: 7 (in.)
12. Well construction method:
(Le. auger, rotary, cable, direct push, etc.)
0
(ft.)
(ft.)
FOR WATER SUPPLY WELLS ONLY: .•
13a. Yield (gpm) ✓ /+ /GMetthod of test: A
13b. Disinfection type: 'f'UI ` reT1 Amount: ‘. _.
FROM
TO
DESCRIPTION
ft.
ft.
ft.
ft.
-
FROM - .
TO
DIAMETER
THICKNESS
TERIAL
o ft' /77 ft.
y io56C{D
VG
vY I�Il�TEi .-cAsi miat.1:U
31114 Vilfhe iail4as" liar ZI* - _1...... ..
FROM
TO
DIAMETER
THICKNESS
MATERIAL .
it.
ft
hi.
_fL
ft,
in.
^ll1l.3l:EGE4`"_= =':e.%,.'-=
' ..,..`•.�'6::;yAL_: -
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,y.itu _ - - - .. _._ ..
FROM
TO
DIAMETER
SLOT SITS
TmcKNRSS
MATERIAL
/'act
of 77
if
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(
I
Sofa
ft. ft.
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18 GROi1Ttt_g,=-_ .
- i _ i :l.
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TO
MATERIAL
EMPLA TENT METHOD & AMOUNT -
0 ft.
3
y
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FROM
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DESCRIPTION (ecTr, burdness,;ail/rock type, wain sine, ael
O . ft.
/ d ft..
S/4r .
oft.
ft.
�✓R%1.0
D f't
7.5- ft
why. , 7LL1-it.
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e j'y
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96
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a
/1-r"
e t -ex'
r�y91,
�,.$
/f - 114 4 *€ r7 —' /7LT / ! 7 J'Qti--e
lit /72. etc/
22. Certification:
rLP?
Signature of Certified Well Contractor
Date .
By sighing this form, 1 hereby certify that the well(s) was (were) constructed in accordance
with I SA NCAC 02C .0100 or 15A NCAC 02C .0200 Well Constriction 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 1NSTR1UCI'IONS
24a. For All Wells: Submit this form within 30 days of col deli o of well
constriction to the following: o tv
Sam
Division of Water Resources, Information Processi4Uii t: 4.1
1617 Mail Service Center, Raleigh, NC 27699-1 ' : fL.-
o ka7
24b. For Iniection Weir: In addition to sending the forru to IR tdddt. ss in NIP
above, also submit one copy of this form within 30 days of cdmliat� of well
construction to the following: u.vci o
00
Division of Water Resources, Underground Injection Contciongram,
1636 Mail Service Center, Raleigh, NC 27699-1¢)6
24c. For Water Supply & I,plec}ion 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 constitution to the county health department of the county
where constructed.
dMa/HN3OON/ 13Al3f38
Form GW-1
North Carolina Department of Environmental Quality - Division of Water Resources Revised 2-22-2016

WELL CONSTRUCTION RECORD (GW-1)
For Internal Use Only:
1. Well Contractor I o ation: D�
Well Contractor Name
3/
NC Well ontractor Certification Number
el OVA it
Company Name
c�d�f eee-Wriff
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:
DAgriculturai
Geothermal (Heating/Cooling Supply)
DIndu al/Commercial
`gation
Non -Water Supply Well:
Monitoring
Injection Well:
DAquifer Recharge
DAquifer Storage and Recovery
▪ Aquifer Test
Experimental Technology
Geothermal (Closed Loop)
• Geothermal (Heating/Cooling Return)
4. Date Well(s) Completed:
ciMunicipal/Public
Residential Water Supply (single)
QResidential Water Supply (shared)
Recovery
®Groundwater Remediation
Salinity Barrier
QStormwater Drainage
Subsidence Control
0Tracer
[Other (explain under #21 Remarks)
5A,. We Location:
u- 4 &o(r,MA-44
Facility/Owner Name
Well ID#
4_ S 40- v/
Facility ID# (if applicable)
Physical Ad ess,/ City, and Zip PIG /1 )
County
Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutesis`econds or decimal degrees:
(if well field, one lat/long is sufficient)
6. Is(are) the well(s)Ol nanent
repair render #21 remarks section or on the back of thus form.DVV
_
8. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction, only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled: 9. Total well depth below land surface: 37i_ (ft.)
For multiple wells list all depths if different (example- 3@200' and 2u3100')
10. Static water level below top of casing: ® (ft.)
If water level is above casing, use "+ '
11. Borehole diameter:
12. Well construction method:
(i.e. auger, rotary, cable, direct push, etc.)
1;71
:14 WATER ZONES,., .. ...
FROM
TO
DESCRIPTION
ft,
ft.
ft ft.
?15 OUTER-.CASING'(formulti-cased
wells). ORLINER,(ifap'Ifcable)
FROM
TO
DIAMETER
THICKNESS MATERIAL
0 ft.
Zeyi, ft
4/ in.
$ G L1O
4...16
.INNEREASING_ORTUBING
(eotheYmal closecGlobp)(ti
,
FROM
TO
DIAMETER
THICKNESS
MpIAL
Ire
2, g 5rC
Z in.
Sc.(o
(-
in.
17 ,SC EIiE N.,
...
TO�j
DIAMETER
SLOT SIZE
MATERIAL
((FROM
Cl -1
35Str
2_, in.
l Co
THICKNESS
ice°
pvc
ft.
ft
in.
r18 GR01JT
<r,,
...
FROM
TO
MATERIAL
EMPLA EMENT METHOD & AMOUNT
0 ft
5- ft
dilte/
eer
5—• ft
/0 ft
f k,i
04X-
0 ft.
Z 00
le Are,T
Gslrt•C74_.
19.. SAI+IDIGRAVEL.:A'
(if9ppficable).:
'.. -:.e gv, g,..r..'?.'"-K ,..:..; j MV
FROM
TO
MATERIAL
EMPLACEMENT METHOD
ft.
ft.
ft.
ft.
20:`ARIEL11VCrIOG(stfach;addttional'sheets
i[vFeefilssary) .. ; f,;/�,'
FROM
TO
DESCRIPTf (color, hardness, soil/rock type, grain size, etc.)
fft
(5-11..
✓G
Ire y
/
•
ft.
r
(,75-
t _ f -7�75
174ft.
f4--/Q�` .
! 5
1f't
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ijt14 5 -afp, Ft,
Y
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1-
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et LlQl
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.24
elli4o ro 70 N
F
`7r
Z krA. fella CD. �, I
x 7r 2- 77 e /a,y 2. 55— g33,s- 5a...P
22. Certification:
or Temporary
' rgnature of Certified Well Contractor
Date
t;RR 9 8 2017 By signing this form, 1 hereby cerYi)j, that the well(s) was (were) constructed in accordance
7. Is this a repair to an existing well: lalier or ®No with 1SA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Consuuction Standards and that a
!f this is a repair, fill out known well construction information p�td R/lttr Jlrg nptu�e of tl v `f opy of this record has been provided to the well owner.
rt?tCk, 1&Eflrt F•
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) �© Method of test:
At. r
13b. Disinfection type: () /" Amount: / 4.-1
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 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
= tins firm can be used for single or mulliple Its
I. We nt ctor )nfor
N(' Well C
(At iticauon Number
ndrtm/metWell ( c on _ (
is; all applicable a '1/ permits (i.e ('wtnn•..S4ate.
3. ♦Fell t;se (check well use):
etc.)
For Internal Use ONLY
14. WATER ZONES
FROM TO
DFSCRIPrION
IS OUTER CASINCSfor multi -eased welts) OR
TO 1 DIAM
N. INNER ASINC OR TUB
FROSI TO
ft.
17. SCREEN
ER
DIAMETER
LINER (Balmlike/Me)
TIIiCK\E
THICKNESS
ATER
MATERIAL
Water Supply Well:
f'.. gricultural
I:?Geothermal (fleating/Cooltng Supply)
fl Ind ustrial/C'ommerc to l
f ;Irrigation
fl Municipal/Public
esidential Water Supply (single)
❑Residential Water Supply (shared)
Non -Water Supply Well:
1Monitoring
❑Recovery
Injection Welt:
'Aquifer Recharge
.!Aquifer Storage and Recovery
;Aquifer Test
i I-.xperimcntal Ttt:hnology
t.l(ietxhermal (Closed loop)
11(iee)thermal (Ifeat in.. Cool in Return
•
4. Date Well(s) Completed:
5a. !• II Local' .
DGroundwater Remediation
❑Salinity Barrier
❑Stormwater Drainage
FISubsidence Control
G7Yacer
❑other ex lain under k21 Remarks)
applica I
County Parcel (dentificalion No (PIN)
5b. Latitude and I.ongitude in degrees/minutes/seconds or decimal degrees:
f 'foe!! field tine Iat%Ianp is sufficient)
ti
W
6. Is tare) the well(s): QfPermanent or ❑Temporary
7. Is this a repair to an existing well: ❑Yes or cog,
;Taus a a repair fill out known well construction information and explain the nature of the
rep ur under u 21 remarks section or on the hack of this form.
S..,NNmber of wells constructed:
for muiliplr infection or non -water supplt uelis ONLY with
submit MO form.
4. Total well depth below land surfactE
- 1 us rtmliple welts list all depths ifAfferent (example- u;:00 ands
1 h. Static water level below top of casing:
If water level is above casing. use "+
11. Borehole diameter:
12_ Well construction method:
(� a atelier rotary cable_ direct push, etc )
FOR WATER SI PPI.1
13a. Field (gpm)
131s. Disinfection ty
.1.1 S ONLY:
Method of test:
Amount:
same construction. you can
(ft-)
(ft.)
FROM
ft.
TO
ft.
DIAMETER
in.
SLOT SIZE
THICKNESS
MATERIAL
ft.
Ill. GROUT
FROM
TO
N
TERIAL. iPLACEMENT MF. HOD & AMOUNT
ft
ft.
ft
ft.
ft.
19. SAND/GRAVEL
PACK (if applkablt)
FROM
TO
MATERIAL
fL
ft.
ft.
ft.
EMPLACEMENT METHOD
2B. DRILLING LOG (attach additional shoats if necessary)
FROM TO DESCRIPTION (color, haidaess, soillrork type,grais she, etc.)
ft.
ft.
=-ft°
f(. C 2 ?®fig'
ft
21. REMARKS
I . f
Siof Certified Well Contractor ' Ct Date
By signing this form. I hereby certir that the twills) was (Isere) constructed in accordance
wtih ISA \'CAC 02(' Or' (NI or IS.a N'('A(' 02(0200 Well Construction Standards and that a
copy of this record has been provided to the cell owner
23. Site diagram or additional well details:
You may use the hack 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 Alt Wells: Suhmnikh,►iliy�.�y�iktyibtiiy�icumpletion of well
construction to the following: 4CIYL {�j(iU ICJ
Division of Water Resources, information Processing Unit,
1617 Mail Service ('e AINItaJe h2lltf„27699-1617
24p.. -or Infection Wells ONLY: In addition to sending the form to the address in
ve, also submit a copy pi, this form within 30 days of completion of well
traction to the following:water Quality Regional
Operations Section
Division of Water ResouWilillifigteitRegftilteliakIEContral Program,
1636 Mail Service ("enter; Raleigh, N(' 27699-1636
24c. For Water Supply & Injection Wells:
Also submit one copy of this limn within 30 days of completion of
well construction to the county health department of the county where
constructed.