WQ0000461_Additional Information Received_20200828

Certified Mail - 7017 o66o 000i 0015 3014
Return Receipt Requested
August 28, 2020
Ms. Poonam Giri
NCDEQ - DWR
1636 Mail Service Center
Raleigh, NC 277699-1636
RECEIVEDINCDEUDWR
SEP 0 9 2020
Non -Discharge
Permitting Unit
RE: Response to information request on July 31st, 2020 in pursuant of Land Application
renewal for closer of permit WQ0000461
Dear Ms. Giri
The Louisiana Pacific facility in Roaring River, NC has discontinued the Hardboard
wet process operation effective March 27, 2020, thereby eliminating the generation
of biological solids for land application. Solid residuals generated from the current
process are disposed of at the local Wilkes County municipal landfill. In response to
your letter dated July 31, 2020, please find information regarding authorized
signatory authority, applicable site maps, Operation and Maintenance Plan, and
ground water monitoring inventory.
Please contact Chad Witherspoon should you have additional questions.
Sincerely,
c
Scott Cranston
Plant Manager
Louisiana Pacific Corp.
Roaring River Plant
cc: Allan Hambley, LP
Chad Witherspoon, LP
James Kirlin, TRC
ADDRESS 1068 ABTCQ Road
North Wilkesboro. NC 28659
�'�'.i 336-696-27a1
e.Ax 336-096-3412
WEB www.lpcorp.com

LP_
6UIL01N0 FRLDUC;S
September 04, 2012
Subject: LP ENVIRONMENTAL, SIGNATORY AUTHORITY
To whom it may concern:
As established by Louisiana-Pacific Corporation Board of Directors resolutions elated
November 6, 2004:
"RISOLVED that the Chief Executive Officer and the Executive Vice President,
Administration, and Chief Financial Officer of Louisiana-Pacific Corporation MP") are
each hereby authorized to sign, on behalf of LP and its subsidiaries, environmental peratit
applications and enviromnental reports to the extent required or permitted by applicable
federal, state and local environmental laWS, regulations and agency agreements."
"RESOLVED that the Chief Executive Officer and the Executive Vice President,
Administration, and Chief Financial Officer of LP may delegate the authority set forth
herein to other employees of LP and its subsidiaries to the extent permitted by applicable
federal, state and local environmental lazes, regulations and agency agreements, provided
that such delegations of authority are set forth in uniting and are in accordance zvith the
corporate Signatory Authority Policy, as such Policy mmi front time to time be amended."
ir► accordance with these LP Board of Director resolutions, employees occupying the following
positions are hereby authorized to sign (for facilities indicated) on behalf of L,1' and its
subsidiaries, environmental permit applications and environmental reports to they extent
required or permitted by applicable federal, state and local environmental laws,
regulations and agency agreements:
• Executive Vice -Presidents (authorization for all facilities)
• Vice -President, Procurement, Logistics, & EHS (authorization for all facilities)
414 Union Street, Ste 2000
Nashville, TN 97219
F i 615-986-5600
615-986-5606
www.lpcorp.com

Louisiana-Pacific Corporation Signatory Authority Delegation Letter
January 27. 2012
Page 2 of 2
• Environmental Director (authorization for all facilities)
• Business Vice -Presidents / General Managers (authorization for facilities they are
responsible for)
• Manufacturing Operations Directors (authorization for facilities they are
responsible for)
• Regional / Business Operations Managers (authorization for facilities they are
responsible for)
• Plant Managers (authorization for facilities they are responsible for)
Curtis M. Stevens
Chief Executive Officer
Mark A. Fuchs
Corporate Secretary

L�P
11Ull OfNG SO LUTIGNS
Land Application Program
Operation and Maintenance Plan
Permit # WQ0000461
Operational Functions
General
The Louisiana Pacific Corporation (LP) Roaring River wastewater treatment plant no longer
generates residuals for Land Application as of March 30, 202U. All residuals generated from the
WWTP are landfilled.
Personnel associated with the Land Application Program include the Environmental Manager,
the 09C, and backup ORC.
Sampling and Monitoring
Groundwater monitoring is performed one time per year as specified in permit # WQ0000461.
Samples are collected by the ORC and backup ORC. Groundwater sampling procedures are
utilized to ensure that valid samples are collected, and proper sampling protocols are followed.
Groundwater wells are monitored and sampled In September. They include DS1-MW1, 051-
MW3, DS1-MW4, DS1-MWS, DSl-MW6, and DS1-MW9. Samples are analyzed as specified in
Attachment C of Permit # WQ0000641. All monitoring results are maintained for a minimum of
five years per the permit.
Maintenance
Annual maintenance is conducted at all groundwater sampling locations by the ORC and backup
ORC to insure a clear and clean area to safely collect samples. General maintenance includes
mowing, weed eating, debris clearing, and lubrication of all lacks.

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ie i
s�
k
sn
Ow"
i
� 44
vVim TA
49NFT L y. Y f- - a a5
sue"
• fr� •Q l6 ytiwr
- e w Mgt
t
Figure 20, Concentrations and horizontal distributim of nitrate in groundwater beneath and surrounding
the study field and surface waters bortfcring the Site (the blue line with the arrow across the field indicates the general
groundwater flow direction; the thicker.bluc and lighter biuc lines on two sides of the field are the unnamed creeks, the first order
tributaries flowingiko the'Yadlon Rivcr)
N
c�one�rnk�ailon, mo+L
/ [ipek on uta aaN
OMW-31 I olds ollM Auld
}. *MW-5 f
aMw/
i I �
Figure 21. nitrate concentration variation from groundwater to surface water and
from the creek to the Yadkin River
44

North Carolina

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Land Application Groundwater Monitoring Plan
Permit # WQD000461
All Groundwater monitoring wells affected by elevated levels of Nitrate 15A NCAC 02L .0202
are located within a dedicated field. The dedicated field number is 1228-10387-25 and is
located off ABTCO Rd. North Wilkesboro, NC.
Attached is the inventory of all groundwater monitoring wells active and inactive. Please note
that well DS1-MW-2 was abandoned October 4, 2018. The well abandonment documentation is
included in the attachment. Also, on the same day CPZ-1**, CPZ-2**, and CPZ-3** were
abandoned by NCDENR James Gonsiewski.
The current permit Attachment C only requires LP to sample wells DSI-MW-3, DS1-MW-5, and
DSi-MW-6 however In 2018 LP took ownership of wells DS1-MW-1, DS1-MW-4, and DS1-MW-9
from NCDENR Hydrogeologist Shuying Wang. The ownership agreement ended the Nitrate
investigation and required LPto sample DS1-MW-1, DS1-MW-4, and DS1-MW-9. LP samples all
groundwater monitoring wells each September per Permit # WQ0000461 attachment C.
All Land Application stopped on October 19, 2008 in field 1228-10387-25 to prevent additional
nitrates from affecting groundwater. NCDENR and LP in a partnership installed new wells in
field 1228-10387-2S to track the concentration of nitrates and explore other potential outside
sources of nitrates. LP's current groundwater monitoring plan is to sample ail required
groundwater wells annually each September per the current Permit WQ0000461.

t_F�-Roarin River Monitorin Welt Cons#ruction Detaita
tt
19
15
89
g
5
60
PVC
PVC
PVC
10.54
10.5
4
Q
-�
S� r
g
5
60
2
8
MW 4 513/2011
16
6
PVC
10.5
tcAW-5 3{14{2007
17
7
PVC
4
6
1
MW-5€ 5/9{2011
30
15
PVC
10.5
4
4
7
1
3/14/2007
21
.1
PVC
15
3
MW-7S 4/26/2011
23
3
PVC
10.5
4
4
4
2
MW-71 5/9/2011
23
18
PVC
10.5
$
3
1
MW-8 4/26/2011
13
7
PVC
t0.5
18
2
MW-9 5!' /2011
16.33
6.3g
PVC
9 5/8
4
4
8
6.33
1
16.
CP2-Ia• 5/17/2011
45
PVC/Steel Steel
4 and 2
40
4
CPZ-2** 5/912011
47
Ste-e
2
CPZ-3"" 5/17/2011
59
PVC;5teel
40
4
PZ-1 212412012
10
5
PVC
23I4
1
2
45
5
5
1
I. feet below land surface
0
i
3
3
3
5
5
0
0
SYF�r
or
tlpen
MP• 'tibow
�1tl4. n
Zi. fi-
102.87
0
Screened
3.35
99.52
Active LP
5
Screened
3.58
94.1$
97.76
Abandoned
9
Screened
not 8urvied
Active LP
6
Screened
3.17
88,19
91.36
Active LP
7
Screened
2.10
85.03
87.13
Active LP
Screened
3.06
85.48
88.54
Active NCDENR
Screened
1,42
$$.18
89.60
Active LP
Screened
3.29
84.6
87.89
Active NCDENR
Screened
3.07
84.55
87.62
Fictive NCDENR
Screened
3.48
39.61
93.09
•active NCDENR
33
Screened
2.96
84.9
87.86
Active LP
Screened
2.95
83.36
86.31
Abandoned
Screened
3.75
87.83
91.58
Abandoned
Screened
4.20
89.37
93.57
Abandoned
Screened
0.20
Abandoned
LYtituda
36.20294206-81.02164655
36.20199407-81.02342722
36.20753758-81.02171427
36.20063722-81.02292158
36.20196685-81-01992544
36.20197178-81,01994295
36.20125738'-81.02138145
36.20172933-81.0220974-
36.2017381-81.02205472,
36.20234584-81-02074222
36.20194181-81.01987322;
36.20187-4 -81-01980059
36.20125343-81.02130349
36.20054322-81.02281714
: does not tie in any Uanchmarlt, (as it is not feasiUle to do so), so a reference elevation of 100.tk? ft set .5.n railroad tie, 22 R ease of the center of the intecsectioxe of the access road azid the sail road, on south side of the t:
•` Inclined channel pieaometer

s �
l.6 &E CONTRACTOk
NUNR+ ESMENTUL WELL CONSTRUCTION RECMD
North Camlim Dcpartmmt of Envk mleat and lkauuat Reaotrr v& Divrafolt of Wager QuAty
WELL CONTRAC1 R c3MTMCA nOr r 0 3014 - A
SNaei Camracatr (ST".IvtdYsii mane
NCOENR -
Wa8 Conwact w ^:Gap y N oe
Zr (Jf 258 99MM
Ii7raxdAddl"
Kinston _ _ HC 28572
UtyorTow-. Staw 4Code
r 252 -A2d -
,LMO W 40 P?lone ra der
L WELL IWORNAMM:
:VEIL CONSr,RUCl"w Mural N�
CTaiER A9W.fATW PEN!a+,I1ltf(6 sp¢am6f�}N/�
srm Yr'Ei.1 10 i(,J a?9r elrewb �ll%i- _
3. •KELL i7ts8One Boni tE +l�M�nir$pr4tput>nGQ
Y�lusUlatL C; AgdaAn.MO RWOMYQinjaGfionQ
t7trgal3orc OtherQ W uea)
SATs DtR1tit. lg i -- — --
A. WELL LOCAnOM!
;Sleet Names NWOM 00WAVURitY. OMMMOM tot Na,PIMA 7ip Cafe)
.CITY• I:UUNTYUVI�ICE3
Qsope Qvwwy dFlat t6Rmge E301tw
,.ATTUDE 3e -DMS or 36.20284206 DD
LONGITUDE at % •Dms or 8t Q2t64M M
ode scIaae: Qbps 13rapo Wft reap
Qocalton olttedr xd be &1 otimona UMSAWoWA antrabed*dt6
this loonBrtaf oa:vGM
S. FACW7Y (Name of the brnkteae t fws 81e wen k 10eat8ll.)
I ni lwap .Pp arms, P.nm-
Fadlity Name FacW4 ID# (f sX4cabter
P-n BAY GA
Street Aditn
City or Town Stirt6 Coda
Rog Hari
contact NWV
P D Anx 98
reaBng Addt u
Rnarjog Eli= NC
City at Tom Slate Zip Code
(,3M 896-Rd6
Area code PC om mar4w
e.'HELL OuAns:
a. TOTAI0EPr-- 2
*. DOES WFLL t:rP(ACE OMMG WELL? YE813 NO d
e. WATER LEVEL%IvwrTopofcaft:-1 .�f2 3--_ Fr.
,A&'f- VAbae Top of Ca$ft
rl TOP OF CAS UG IS 3 FT, Above L" SWUS•
"Top of owro wff*m Md aVa berow beat surface may lagoite
a va0w um In acwtswce vM idA NCAC 30 A118,
•. YIELD (ppm): ; NIA _ METNODCF MT_bVa_
l DISINF0CTI0N.7yps NIA Mwum, NIA
p. WATER koNES (dew
Top 9ft &rcw"_ S iL`. TopSoNom
TM? _ Bottom,, Top subm
i Tap suwm
Thikknesel
7. CASING: Depth DW MW YNalplk lut►rial
Top_ _ Sabin.__ Fti_4"_.. . 49 Pvc_
Tap BotNxn Ft.
row _,Bermm R
S. GROUT:' Doth Material Method
Tap _ BottomL_ FtjkDVDite Poured
Top-0—so tom„l _ FtCemertt' Ponied
= Top Scum .._ a
4. SCREEN, Depth Dramatw that aim MaWrMt
Top $__tidtaq. 19 FL�InJ0 In. PVC
Top Bottom FL__Jn in
Top Bottom FL hr. in.
0. BANDAIRAYBL PACK
-
Depth Sim Mate"
v6P_ 7 FL__ .sBARO
Top Ft
Top Botom Ft,
11. GRt1t.IN0 LrA
Top Bnmlm Fortttallm Deaadptbn
brown to ton day
W& Body day
white nerdy day
�J
r
It Rb7 MKS:
I V0 NEREaYCERM TNATTM wEW VM COAm7RUM INACCORDING! W TH
• taANCAC 2C, yALL C=ffRUCT= arANDARM ANO TWIT A COPY OF TNai
Rt NA9,9EB1 aaWtt76tT0 THE WEtLCNMf3!
SIGNJIM OF CERTIFIED WELLQONTRAMOR DATE
.la¢¢r� M9rtin
PrZItvTE6 NAMEOFPERSON CONSTRUCTING THE WELL
Farm GW.tb
Su6m)t the ori83nat to the Dlvk(on �t�Vatsr Qtfal�► i4lth(e 30 days. Attu Inlormatlon Mg Rev. i lm8
15tT MaII Servitav Gooier— Rsllelgh, NC 2T898-1817 PirortB Ib. {918) 807.8300

�FONRE 1 r SI.DENTItiL WELL CONSTRUMON RECORD
. North Cwor a Depmjmmt of Eavi onmed aodiNalurai RaoUtoW Mbioo of Wstor QWItY
WELLcoNTRACTORC$RTIRICAT[ONff 3014 A
1.WM.LC0N RACTOR:
Wad .laaca IIA.gfflfl
CorOmdor (Indlvidusi) Noma
N['fSFNR
wmu ConkaeW Camparry Name
1766 fiWY 25f3 Soudt
SkeetAdtkaw
Kinston NC 2&5T2.
CSy or taws Slade Dp r)ods
(Z§2 j 523-3620
AM=* f%iW aanhsr
L WELL IWORMATION;
v1F1.L coNSTRucrmm PmmTi A
OTHER ASSOCIATED PERM TW aps=W-) W
SIT! WaL ID "appa "Affimy-
3. WELL USE (Check One B00 MMftWfag li( MLMIM OP ftLl
p A71culkaal O RaWvaty O kdedOn ❑
ariga0o013Other 0 Obt use)
DATE DRnaED 513111'
a. WELLLOCATION;
CITY: COUNTY M@S
TOPOGRAFKC; SETTING: (drokq*mplrebW
pswe avew i3Fkt v6Fmga ❑00cer
LATITUDE 36 ' DMs or 38.201994OT DD
LONGITUDE 61 'DMS or S1.02342722 DD
u*xWbowasmane: on Dropograplecmw
poea0brrd �� arYaUSGSaipomapmrdekY
� FACaJTY (Name of @la where tfle W� b locaisd:)
t nr ici�n�..D�riRr (`may
Facility Name Fac00 Of sp a)
.E.() .BOX .a8—
SbVdA&Wn
Edna Rhor N 2ABFi9
CMyorTom Sbie zip code
Rny Hart _
CataCt Name
P f'1 RON QR
Mailing AddrM
R(i,R,dnn River NC 2AIM
Cky or Taws awe Zip Coda
(,336 f 15--34M
Area Code Phms manbar
6. WELL DETAILS:
I. TOTAL DBPm:.l5ft
b. DOES WELL REPLACE E)MMQ WELL? YES p NOW
e. WATER LEVEL Below Top of Caskv: -g48 Fr.
Nse +• Move Top of CaskM)
d. TOP OF CASING 18 _ 3 Fr. Above Lend Surfaab'
'rap aem-n9lerndrtated Wor batow land surkm may regcdre
a varimmi In aomfti a vAh 1 UA NCAC 2C .0118.
s. YIELD (gpm): NIA MNTNOD OF TEST N/A
f. DISINI ECi1DN Typs N/,Ej Amoum- /bLA.._
g WATER ZONES. (depth):
Topes.—BauQm,.l;z8.._.,. Top saftm-
Top BotkNn Tap Eaftom—
Sop EoOact__ Top— somm
Tldsknawl
7. CASINO: Dspth cls"Our W449 l Matsrkl
Tope. _nL.��Ft�. b0 PVC
Top Bottom Ft,,,— T,,,._
= Top SoOom Ft
8. GROUT: Deplh Matadal Mathcd
Top_ _ Bottmrc_a _—FL hXdWftMired
Top, 0 Bouom_L_ FL CMOA .-- _ „Porued —
Top eotlom Ft
i. SCREEN! Dspfb Dleinator Slatslae Matadal
ToR__ W Wm.. _ Ft In 10_ k1 i%1/(: ..
Top Bob- Ft in. h
Top aWom FL_Jrti In.
10. SANDOORAVEL PACK:
Depdh sbe Maww
7aD _Bot6om i.r FL1._ BOND
Top Bottnm Ft
Top_____Joltom FL
1 t. DRILLING LOG
Top Bottom F mad m Deaalptlon
0 . . 1. 4 ._...._.—
4
14 _/IS—� .
_J
1! REdAARltS;
1001a9DYCOtMTMAT7HISWSJ.WAYMWRLi WWACCOROMMWTM
. vsa WCAr2c. weucoMsmucnat srrMDiARoa.AMorsu+rACotwaPTWie
RECORD HAS SEEN PROVEW TOT-0YA!I. WMMt.
SIG`�FUREOF CERTIFIED WELL OONTRACTOR 1— DATE
PRINTED NAME OF FIERSON CONSTRUCTING THE WELL
Fomr GW-1b
Submit the orthtal to the DlvietotT Ot YYaiiif Qeailfty 1e/itlNn days. Atin: Iidorm don Mgt, Rev.11108
98T7 um Servke Center- Raleigh, NC VdWjS17 pfiolii Nm (918) SO74M0

WELL ABANDONMENT RECORD
For Internal Use ONLY:
1. Wait Contractor Information:
Jesse Martifl
Wetl Coatn Wama (mwell owner pasoxlly abandoning well on hiMun propmty)
NCDEQ
WELL ABANDONMENT DETAIvf�S
7s. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
well construction/depth, only 1 OW-30 is needed. Indicate TOTAL NUMBER of
wells abandotuad:
NC WellCamnaetor Comfi ation Number 7b. Approximate volume of water remaining In welf(s): (gaL)
Louisiana Pacific Corp. FOR WATER SUPPLY WELLS ONLY:
co,,npesy Name
7c. Type of dishtfectant used:
2, Well Construction Permit #: NIA
LW all appilcable,adl cowlruerian perrrrin 6,e. U/C, County, Stare Variance, arc.') ifAxown
7d. Amount of dlslnfeetani used:
3. Well age (check well use):
[]Agricultural f]Municipal/Public
001colhermal (Heating/Coolbtg Supply) 01taidential Water Supply (single)
011ndustrial/Commercial OResidential Water Supply (shared)
❑Aquifer Recharge
ElAquifer Storage and Recovery
ClAquifer "Test
❑Experim nt al Technology
00eothettual (Closed Loop)
CGenthetmal I i teadnipcootins l
OGmundwater Rcmediation
❑Salinity Barrier
O'Sturmwater Drainage
❑Subsidence Control
❑Tracer
a. Date well(:) abartdnned: 10/4/2018
5a. wee location:
Louisiana Pacific Corp,
Faciiitylor.-nrNsmt Facility W# (if applicable)
1068 ABTCO Rd. North Wilkesboro NC 28659
F6ysical Addom, City, and 7.ip
Wilkes 4809-39-3017
Counnty pawl kemirwation No. (Pus)
5b. Lx t We and iongiltude In degrees/minutes/seconds or dedmal degrees;
(ifwell uctd, ante 6bioag is mine:=)
36.201994+77 K 81 02342722
7e. Sealing materials used (check ah that apply):
in New Cement Grout
❑ Rentonim Chips or pellets
❑ Sand Cement Grout
D Dry Clay
• Concrete Grout
1=1 Drill Cuttings
Cl Specialty Grout
U Gravel
❑ Semonite Slurry
❑ Other (explain under 7g)
7L For each material selected above, provide amount of materials used:
Two 80 lbs. bags
71; K'avidt a isrict desmriphon «f the abandonment procedure:
Removed well cover, cut the pipe, placed
the grout, and covered well with cement
and soil.
s. Certification:
SleOanae ofc;ht Weli Coaoactoror Weil Owner — Dm
Hp signing this form, f hereby certffy that the wells) trws (were) abandoned In
accordance with 15A MAC 02C .0100 or 2C.0200 Well Construction Slandardr
and that a eapv gf1hls record has been provided to the well owner,
9. Site diagram or additional well details:
W You may use the back of this page to provide additional well site details or well
abandonment derails. You may also attach additional pages if necessary.
CON, UCITON DETAILS OF WELL(SI REINg ABA"ONED SURMiTTtS�j� INSTRUCTIONS
Aaach welfawrstraatron mcard0)ttrataikNe. par muliWe injection arnoo-ware nWly Hrllr
ONLY with the same conatracdoa:ahandooment, you can ,whinir oneform 10s. For All Wells: Submit this form within 30 days of completion of well
6a. WWI ID#: M W 2 abandonment to the following:
6b. "f atah we@depth: 15 I ft,)
6e. Borehole diameter: 4 (in.)
6d. Water level below ground surface: 6.5 in.)
Division of Water Resources, Information Processing Unit,
1617 Mall Service Center, Raleigh, NC 276"46I7
10b. For fuiectioa Wells: In addition to sending the form to the address in toa
above, also submit one copy of this ibrm within 30 days of completion of well
abandonment to the following:
Dtvlslo t of Water Resources, Underground Injection Control ProMm.
1636 Mail Service Center, Raleigh, NC 276"-1636
6e. Outer casing length (if known): (B,) 10c. For Water Supply & Injeotion Wells: In addition to sending the form to the
address(es) above, also submit one copy of this fbmm within 30 days ofcompletion
of well abandonment to the cowry health department of the county where
6L loner casing/tubing length (if known): Ot.) abandoned.
6g. Screen length Of known): (R,)
F—C,W-30 North Carolina Depanmem or Emi—vital Quality - Division of Water ttesourm Revised 2-22-2016

b~
1. WELL CONTRACTOR:
Jes&g Martha
Nei Co"k*br ) Name
N vDEFlB _
VleA oonlraetw ComMV Name
1766 HWY M South
slRrarA
�jpstarl NC 28572
Ctj or Tow State Bp Code
r 252 i 523-362D
Ate& Lase Ph" ra mtw
1 WEAL INFOR) 'OONI.
-Au-, w4vp.uannN PERIAtTi_NLA_,__
O WER ASSLiMM PERMMY Yap wow) n1litl
tscrE :vr8.t. toxpfwrauk`;L� �%_. - -_
3.. WILL USE (Check One Sex} Montt ft W MXW*WPublc Q
�`�arFl MMW0 ApIMfta=Gs Recovery0 kodwa
DATE t3R161iA�1 i
4. l"LL LOCA"011:
S Maa+e, 4 , S1A7N on. N6„iaMwl, Mp Code)
'--y- COUMyffj ce3
mwooRApitc SETITNG: (dar*xvnpdabtwv .
73✓ope aVi+iteY OFlat i6mdw omm
LATITUDE 36 -- - . - " ous or 36-20063M DO
LONGITUDE 81 "DNS or 81tJ=158 DID
tammalonodaemaoe: MM (3rq)a raP knw
ldaNmkrafbesftnrlmasra t►SG,4kopocarparAs�Gtadsb
Etefs sWm slnoto�G�
L FACILITY (Name of d* bua6=$ where 9x vol b located.)
�L41LAC,1$r
FrtaRy tYarRe Fadbl wp (H appkaws)
P-O- Roy QR
ShWAd*m
_ Rear(rn River N . 2RRR0
CDy or Token Slate Zip Cade
CaFtaot Name
P-O- MY PR
MOny Address ---- ----
Rrrartlre RlvAr Mn 2RRRQ
CYyorTown Stwe Zip Code
M&3464
Atea coo PJnnar waw
N.RESMENTIA1, WELL CON 9TRUMON'RECORD
Cwo[ mr Depwmam ofFmvttom wa and Natraa[ Rea mmr D7vi m of Watr Qwft
WELL COMRA1C1O31t C6RTMCATiON k 3014 -- ,A:
4 TOF Of CAB8V6 t5 $ FT. Abwa MWSacred'
'Top of caring Womted aft uakwlrw SwIlaw may MR"ewrgncehaccomlla avAh18ANCAC2C.011&
e. Yiew (Bpmk NIA KEYNCD OF TEST MIA
r, OffiMPEOMIt: Typr /WA Amoura
w YYATt;RL0HL�0 (Aeplh):
Tap a —Bottom is f Top. Batter!-_,,.._.,,,_
Tap 60twk._._ ._ Top tlWEonL. _
TOR BOaam_
Twiaawf
T. CA31MG: Depth Diameter 1W(a1@ vabrial
Tap-3—satkxRA_._ FtAL- _.. - Q..__. AC('t._._..
Tap ,TBUGQm Ft. _
r(JP...—Boft-L ..._._.FL...__
S. GROLM Depth Mahaw blew
; TOP2• BolbmA ___,,, Ft Poured
TOPS_BOt._L_FL Cement _PPoo{lpd,
top_ BOtfom_FL
9, 8CRLE:N: Depth ataaraiarMIMSIM IRnterbl
:ToP-&—Boftn-j —Ft-t_-)1 10 in. PVC
Top. Bottum FL 111, ka
' "roP BokrortL,,,,,, K---M. -- in.
16. B+R IMRAVEL PACK:
Depth BZaa matww
rop�_Bdro1h�Q Ft�, SAND
Top__ BMotq_ Ft
: Top SMm FL _
1 t. OMLLING LOG
Top Bosom Fa f"on Dewolpion
_Lfl wn tiav
_brown iD red day
„ a %,� _ _ red to black r�r
13 18blagk sandymil
;1:t. REMAM:
6, WELL DETAILS: ; I DO FatrcennFY MAr rNta WELL WAN CDNSMCM WACCgRV RCawrPl
stir NCAC 201 "9"COND" WCTPW VrAMOAR06, AM rFW A COFYOFTtO
k TOTAL ..� : RMORD HX2 IM FROVIO,aD M Yll E WN plft•
b DOGS WELL REPIJICEtDGST GWELL7 ,YEB❑ NOW stG R HaTIFIED
DATS
C. WATER LEVEL &*wTOP ofCadnp:_1B.41 Fr. -Jesse Martin(Uae "+' 1l Above Tap o(Cagrtg) : PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit111A Oftingi to" bNfldon*fVVdor1 a , FormGW-1bWthlndaM' AttrE (t
Rev.11A78
761T NHttl SeMce Cettbr- tialWgir. NC 2T6981t317 Phtirtti Ala: (919j fl67-E300 .'•

A0,Ar R.-SJDE,'VTL4L WELL CONsrRUCTION RECORD ���� r�+��W���►i
North Carolina Department of Environment and Natural Resources -Division of Waur Quality ac=s=f�y
WELL CONTRACTOR CERTMCATION N .2 4 �
Weil CoMractorConpany Name
STREETADDRE58 CP r g f r a-p,-
6"A A + , / R rim
Area cods- Phone number
2, WELL INFORMATION: �p .! �—
SITE WELLID#(ltappicablej 061 /A- i l
STATE WELL PERMn*repp;4aw),
DWO or OTHER PERMrr#(ff applicable) � ! �% MC Vj&/
WELL USE (Check Applicable Box) Monimrfng . MunicipallPublic .
IndustriallCommercial. Agricultural. Recovery. injection -
Irrglition. Other. (fa�stuse)jj7^��
DATE DRILLED Z —J 'r'
TIME COMPL'ETED_ Z,Dq AM. AM..
3. WELL LOCATION:
CRr CouNTYJ
P.2 r
(SUea1 Nacre Ju txc't, gib, SIfiM won, Lot No, Parcel. Z; cme'
TOPOGRAPHIC f LAND SETTING:
Skips .Val Flaf 'i�dga0 Other 7.
ms / -
LATITUDE -a . '.Z `y rbe in deg
alo nds o
LONGITuDEin a dwhW fames
I.atkude/loagitude source: .(}PS .Topographic map
(IDcaGon ofwe6 must be shown on a USGS topo map and
affaGsedto Iris farm Anot using GPI)
b.FACILITY.lsefiwworawousiwsaWhwo iLtosalea.
FACILITY ID i if applka )
NAME OF FACILITY
STREErAD ESS R )r C..
' g
City or own State 7p Code
DONYACTPERSO
INGADDRES r
Zan
Sfa Zip Code
ZorTa�
Area cow . Phone number
6. WELL DETAILS: �J
a. TOTAL DEPTH: s ,
tt. DOES WELL REPLACE EXISTING WELL? YES. NO
e WATER LE'lEL Be m Top of Gasirlg: FT-
rvse *+"F A.bcfe TOP of rasing)
d. TOP OF CASING IS FT Abuve Land Surface
'Tap of casing terminated War below land surface may require
a valiance In accordance with 15A NCAC 2C .C770.
a. YIELD (gpm): METHOD OF TEST
f. DISINFECTION: Type Amount
g. WATER ZONES (depth):-
From %7,gTo__a From To_,_,___,_
From To From Tc
From. .To From__."_TD
G. CASING: Thicknes§/
[e-mail] star f M
From_7 / ,:.
From ---To____
7. GROUT:- D®pth Materiald
,) Metho
From 4 To F —/
From= To 7 Ft.i
From To FL_.-.
8. SCREEN: Depth Diameter Slot Size rMyaIsrial
FromZ, To� FL�in. J16 In. f/UC
From Tc Ft • in. in.
-Frr.rA To eL In. In.
0. SANDIGRAVEL PACK'.
De Size ^Pterial
From Tc FL
Frosi To_ FL
10. DRILLING LOG
From Too' on Descaip'on
11. REMARKSi
I DO RMESY CfRTFv TiiAT TM WELL WAS CONSTRUCTED IN ACC(AWICE WNH
C 2C, WELT CONMUCTIDN aT ANDTHAT A COP( OF ri W
1S RD 14A3 BMW nerd O THIIE11�
XGc itCERTIFIED WECOCIOEs�^,(WELL
PRlr,i'ED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 3D days. Aft: information Mgt, Form GW-tb
1617 Mail Service C liter— Raleigh, NC 27899-1617 Phone No. (919) 733-7D15 ext 568. Rev. 7105

im
I 0,NRESIDENTXAL'NTLLCONSTRUCI'fONPECORD
Norm CarolinaDepartmttit o`Environment and Namrai Resources_ Division of Water Quality Mike ��N7an
WELL CONTRA( -TOR CEIxIIICATION € k5
,,A/
CRY otTown ^S[a%Zip Code
Area cede• Phone number ?"
2. WELL INFORMATION' ��
.SITE WELL 10 d`(if applieeble)D,L—_
SPATE WELL PERMIT#(if sppk3b4e) p�
DWQorOTHER PERMfr#(Ifappgcable)_Wly�� ta/
WELL USE (Check Applicable Box) MMoon_ftod_ng . Municipal/Public.
IndustrialtCompierclal. AgriaAtural. Recovery. injection.
IMgallon. Other. Qlsl use)
DATE DRILLED -` _ Q
TIME COMPLETED Zrt16 � AM. aL,
3. WELL L ATIONj t r
CITY: COUNTY
(Skeet Name, Nnmbera, Gomm Subdvlelom, tat No., Parcel. Tar Code)
TOPOGRAPHIC f LAND SETTING:
Sbpe .MWtey Flat Ridge . Omer
' �iora�:iatebnoA
LATITUDE 3 Ql G 7 - I{f Mai' be in degeey,
D / T , minutes s�ondsa
LONGn"LJDE W m a decimal fan at
LaftuWongitude source. .GPS .Topographic map
ft=ffon of xeBmustbe shown on a USGS Jopo map and
attaohad to thfsform YrW using GPS)
4.FAru7Y-ivftm vrv* ixirosevMmMo mtxaea.
FACILITY ID #W applicabia)
NAME OF FACILITY
A�RESS
C11yor"IrAwn late Zip Code
IJ CONTACTPERSON
_/ ,+4 aLz
�,r, j
o(Tom
T 61 3 7 U state gP coda
Area cede - Phone number
1 S. WELL DETAft.S.. ' (�
4 a. TOTAL DEPTH �r • 7
b. DOES WELL REPLACE EXISTING WELL? .YES NO
e, WATER LEVEL Below Top of Casing: AFT.
(Lisa '+' If Above Top of Casing) '
d. TOP OF CASING IS LId.�_ FT. Above Land Surface`
Top of Casing terminated atlor below land surface may require
a variance In accordance with 15A NCAC 2C .0118.
a. YIELD {gprn): METHOD OF TEST
f. DISINFECTION: Type Amount
g. WATERZON S (depth'
From 2 �. 7To From To
From To From To
From, Tn From . To
S. CASING: Thickness/
DTo- V FL Diameter
FroVirtu 111a at
m' S` Y /'
From To FL
_�_
From Tp I
7. GROUT- rI Depth MateriaMethod
Fro To, FL,
FroTo Ft
Fron(_­'r'a FL_
8. SCREEN.,,De�tt1 Diameter Slot Size Material
From 21, Y Tc_ 7_ Ft -/ in. �a t1l in.
P le —
From To_—_ Ft,�n, in. 4
From 'To T in,
9. SAND/GRAVEL PACK:
Sly fd a!
FL r
Frori!�
From Tc_ � _ _ FL
Frore. ToFL
10. DRILLING LOG
From To _ FopttaUon'U cription
I 'Do HEREBY CERTIFYTMAT IM WELL WAS CONBTRl1CTED W A XOMANCE Wmi
1 5/-.NCAC2C, WELLCONBTRUCTION STANDARDS, AND rMATA COPY OF 11-118
;-F RA! BEEN Ok?D 0
,04A''UREOf CE(RT IED`NELLGD.CTOR DATE
t`r'1 tU NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt.,
1617 flail Service Center- Raleigh, NC 27699-1617 Phone No, [phone] ext 56E. Form GW-lb
Rev. 7105

NONRESIDENTIAL WELL CONSTRUMON RECORD
North CoraNnaDeperGmasot of Envuosmem and Nattaal Rasw mu- Division of W3Mr Quality
'.F s WELL CONTRACTOR CERMCATION!/ 3014 — 4 --
1. WWlC.L COtiT1WACfOR:
.(8s$A fF(i�lt
Wag Convector (W rAdueo None
NCQENR
0,10 C.on"dor Carrtpery Name
1766 FtW`t',y258 South
StoatAmnw
Kinston NIC Z
My or Town Stare Z!p Cods
r 252 52a-3620 _
Area code Rona runber
L WELLMFORMAMN:
WELL wisTRUCTION PERwiiRMA_
OTHER 14ISMATE0 PERMIWeppYatnat UA —
orm vVeL. ID fiq V0.,.M�hMi Is
3. WELL USE Thllck Over Boo Mo*UhM 4( Muridp WiMic 13
;,-AsbW ,ommerele 0 A -,-RA oat © ReeovaryC I*Clan p
oFdpiwc Olhx❑ (Catuae)
DATE DfdLLED ai2$ri 1
t. WWELL LOCATION•.
Great MMA iluaterm CUM- M adtyt Sm7aMdan DUaa.1501 A, Dp OM"
CrIY: COu-m-M C@$
T�'3kfF>!ir•:' " i`$E'I"flte:,: (daadrepprope[etebeiq
[ISOM tit Mq 13FNC CIRIdp 0091er
LATITUDE 3 .IMIS or 36.MI2933 m
LONWUDE 81 "oms.or 81.022M4 DD
wwl" MftMdesM— dfopoyraphk w
lbeadave ofwaatneratbe MOM one USDst*o map armed eo-
ff* fares rant eshg GFw
6. FACILM (Name of the Wwou 4tsm the het is locmed)
LnuiQlansa�Pae tip [ nm
Faril2y Name Fad %f V*Qf sppilcaplej
P.0- BOY PA
Street Aafet m
Rnadn %JLYaca
CSy of Town sgie Zp Cods
C—orit d
Ms2g Addre,s
RMrine River NC; �Afif39
CilyarTawn Brats apCade
Area code RIofMmy'll
8. WELL IMAM
L 'OTAL DSPTN: loft
b. OMWELL REPLAN BMW WELL? YES O NOW
o. WATER LEVM Below Top of CMskV. 6.3.E Fl:
tUw— RAbova Top ntCeelttp)
d. TOP op CAsua is �3_ _ _ - FT. Above Land etaface
'Tap of ca N tendwisd atbr below land Waco may fequtre
e varlance in scmdattos wllh 1 SA NC.AC 2C .0118.
e. Ymw tgpn* N/A METHOD OF TUT N/A
f. DISINFECTION: Type NIA Amount N/A
!• WATER ZONIM (deplra:
? TaP_gft_Bob- 141tTop Bad,
Top Bottam— Top wb"L—
Top BodantTop BoBam
ThklatsHf
: 7. CA81Nt3: depth flu mm" Weight Mawrial
TOO
..3_— SQWM_6...._ FL -4_ 40 PVC
Top Barba. FL
Top Hewn...__ . � ..�.. ........._._..._
is. Mour Depot M&L.&I Meow
ToP_�_. BW6om $ Fc���Oi}e poured
Topes_ Bofam_3— Ft Cemad— Egmed —
: Top Sol w — Fc
V. $CREDO. Deem Diemeter slatotav Meterltd
TCp�, Bdtam �Ft �,_W. J9— hL PVC
Tap BoWM— F —In. in.
a Top Bohom,_ FL_ In M.
10. aMDA3RAVE.PACK:
Depth she AUbrhl
Tee E 9atcm-t4—R,.2_—
TOP�otlon� F4
Tap�odom Ft --
-I. DRII UN3 LOG
TcF Bottom
; II REMARK$:
Fotmadon Omc iplton
IDOWMWCaM FY1MArtwoVAUWA6OWNMC WWACCaRnA=VATH�
• Say N(-�CW,WMLCONarnUMMVrAMMRI MDTMATACOPYCFTtMS
IIw.M "all Ww=—r0WwVw0,wNER.
St9
iyt piC OF CERTMED WWELL CON 1 RAC r OR DATE�
? _Jesse Martin
PRit ETED NAME OF PERSON 55MUC nNG THE WELL
Submit tl!e txigMa� Jib RN Dlvlskn of Wafer Offa�ty`y lhM 30 Qfgfa. Atb hltt wtttxr Ngt, Form
Rsv. i/OB 1108
t617lmaH 8arvks Canter- Rft *i i% no 278 wisi7 'Pyle Ns: s80Q ("9) MUM

dt�e
V' k jlh Carolii. na DEpara®eat of Enviraanxau earl7lagna( Resolaas- I)ivWoa oP WaW QW *
+.ems WEiCO,'4TYtAGTOR CEATIFICA1TOlY t# 3014 '" f t
1,. WELLGONTRACTOFL'
Jesse Martin
Well Canlracbr (WNCIueq Name
NCDENR
Wall CaWacfurComperty Name
1766 HWY 258 South
SbeatAddmaa
NC 285-72
City or?owa We Zip code
2252 It 523-3620
Area coda Phone number
2 WELL INFORMATION:
WELL cowltwnoN PERurm NI
oT mF-R ASSOCIATED PERMrft(tr sppao�6le) NSA
SITE WELL iD*agnirable) �S
3. INEU USE (Check One Box) Monitoring B(MunldpsWublt (3
bt WWfiCommerdal p AWkLfQusl p Recovery❑ Ir"don t3
"atlanCt c>Starn(ratesa)
DATE DOLLED 41&1-1
4. WELL LOCATION:
sC + 7 x�► �f.-� L
.SAW~; GH Na. POW. Zip CodG3
CIrY; ` NTYW&e
ToPoe&PIiIC / ❑ SETTING: (dads sppmpdabr band
c3skm &%sty anat DRtdge E30'd r
LATITUDE 39 ' ' ' DMS or 36.2023494 DD
LONGITUDE 91 'DMS or UO2UA= DO
tsSrdaaarl rdeaasoe: WPs oropwWhictrlsp
poca&w ofe49axratbe shown arr a USGS tapan p andattedW (o
tkla ftW rT not 4*v GM
a. FACIIJTY (Name of are bushess where 81B well b boated.)
t ouisiana_paryfin C`.nm_
Fac>9grlklme FacAly IDB (Ifapplicable)
P-d_ Rely OR
Sweet Addrees "
RrlarinD Rtyar NC 9AM.0
CltyorTorm Slate Zip Code
-Ray Han
COFfta Name
P-Q saxpit
Me" Address
arinn Rnrrar N C: 28MA
ClyorToao State Zip Code
(.MA 6,
Area code PInrm prattler
la''M L CETCIUIS:
a. TOTAL DEPTH: 13ft _
b. DOE VJMLMWLACgMSTIMGWELL? YES❑ NoCe
e. WATER. LEVEL BolowTop of C= 1 n Oft FC.
(Use +" I Above sop of Ceahq)
d. TOP OF CASING IS 3 FT. Above Lad Su~
'Top of csahg teminatad allow below lard awfeae may require
ovartancehacoordw wfthisANCAC2C.Oita.
a YIELD (g", NA ._ —METHOD OFTBST NIA ___.
t DISWECTION: Type NIA Amount NIA
g. WATER ZONES (deplfi).
To .A —Bottom 13— Top Bottom
i Top Bottom Top BoaorR_ _
Top SoUW TOP Bottom
Thle&nesef
7. CASINO: Depth Dlz r4wr Weight Mstadat
Top_L _ sobm_8__.. Ft4n as RAO _
Tap Bottom Ft
Top • Bottom . Ft
a. GROUT: Depth Material Method
s Top_Q_,_ @olmrtl,,--Ft Bentnnita Pnufed
Top2__ Bmtrnq, — RQtMWL— poured
Top Bottom FL
9. SCREEN: Depth Dplm W SlotStae Material
Top_ 8_ Battorq_-tj_ FL --h. .10 In. PVC
Top Botom Ft tn. _ In.
Top Bosom Ft h. In.
10. SAND/dRAVEL PACK:
Depth Slurs Material
Top Q•—Botmm_.2_FL-2— SAND
Top Bo toM_ FL
Top Bottom FL
11. DRILLING LOG
Tap Bodoni Formation Descap9an
Q...r.J a3
3 /B
8 113
k ur. H:iMrcMel TtW Mel_ It" tX64 MUMU W A4GW"r.0 WON
rU XAC a. area O Nr&T b r:tteFr sr,em ueaa ar+o rw.r a rorrc>r :cos
Sri, OFCERTIFTED OR DATE
• •1
PRINTED NAME OF PERSON NSTRIICFINO THE WELL
Submit the offginai to th6 DIVIsioii of %tor Qualtty.tiiAdtfg'30 dep. Attn: trl0prmkdm Form 1/08OW-b
Rev.ti/0a
1647 MIN tiarvica Gnbar- i'iatefgty AlC 2f898-f61T PhtiYti`No. (919) 1074M

' NQ,,V [gLSjDENTIAL WE LT, CONST'R[iCCCONI2ECO1tD
R4 Carvt&ra Dcpwbnc tl of Eirvimntnent aid Natural Resumes- Division of Wau Quality
w'E3.L CommACTok Crin ZATTON 0 327I a#
I, WELt Y'04-1"CTOR:
,lL�acll•L
�yVitae Condrack� IPYa ryaywa? FraTit
V "es7l Cas& ei; "cz(oov'r Marne
163SILx�xl rvirR
— Steeol AcwAw
C4:jaTT?',1e1
F 3 523�6ti -
Ame coda f%knbee
z w-L. Iti0F0YY3E,r4iVN:
V*a CClti;i? uc-rloN f'oiMiftF MIA
CTHE k p a ?e'NATE rrRhflTAFNgoosaw ltiilA
srre wc,-L is a Tf aPP+;¢swA k✓# 0
2. WELL USE FChecx Oft 6o+91 0"t0rin0'.l( IhunlrLpollPUW't r1
ypr4ftbPCojrnwde1 ❑ AWigllural O PMM&y 13 lrOUOr 0
kr,g&on- Oder 7 W r.aa]
DATE DRI LIED 9I1
t VYELL LOCATION'
iVC Hwv 268 Atrt 1 Rd —
tlit..L N.m+, Nr(r1tl.n. C=nuyq, &t&wWm. Las Na. PW M. ZJP Cm*
GST r R n give COUNTY Wiikes
TOPOCFtAPF-OG 1 LAND SET`r:NG: (0mck aPPftWkbm bQ4
❑SWO dia5ei OFlst ORld9e ZIMer
LATrrj.OE • DMS or 3x.xJOIX)t1(DOt DO
LMGIT3DE 75 ' DMS or DO
Lalialde@arl L;de sourca: QGPS oropographornap
aftaclrod to
"ocaGon of lve.7 must oe .�rooVn on a lISGS topo mho
ft3 fam rrnor U09 GPS)
8. FACIUTY O"me of the bus'Inese wtiere the well K located.).
Feditly Name Facillr 10# Ftf epl+ OW111i
riRnx 9A
Street Address
R!+ tiro "♦Fsr N�
city or Town SFate Zlp Code
Ray Hart
:orttad Name
n n Rnx as
Mauling Address
Rnari2AA69
City or Tatar stow 210 code
(326f BIa6-9 M
Area ow* Phone r:amber
3 rWELL. DETAILS:
a. TOTAL DEMI
b. DOES WELL REPLACE MUSTWO WELL? YES O NO [V
c. WATER LEVEL 6elovTop of Casing: jl &Y _ FT.
Nse `+- 9Abow Tap of Ca*V
d. TOP CF "WIG IS _ FT. Above Land &rrfaoD'
"rap orcwmg b mwWwd aW rWoolard wilt- M" M01M
a vwwnce In aceordarim Wth MNCAC 2C 4119
a. YIELD (Vm): METHOD OF Tl'.ST-a IUP--
L DISIMFEC ON., Type�rA APtaLrrd NIA __
q. MUTER ZONES (deplh):
Top-fL— orl+ 1fi2 Top Bolml
Top Bottom Top Solldn
Tbp aoftw _ Tap—Bdum
Ttlfell:�lea1
r. CASINO: D*Pth of new YYY m Materlat
Topes -Bottom A, _ FL�.� �S�lta.
Top Boom Ft �--
:7op Hatlom FL
S. GROUT: DeOM WWII! Metlnd
Top 0 BNDM V FL QEAEN7 EQLEEO
Top V softm 4, _ FLJ.IIQIF7Q_110 P LIRELI
: Top gosorn. Fl-
f. SGR ": D%'Ab Dlameter SkA Stae Mdwww
Top. Bottum" 18' _ Fljj�_ln 47Ii- h PVC
Tap 9oearn ft M• in.
Top Llosarrr Ft to In.
1O.9ANO6OM FL PACK:
Depthsize material
Top_Botlom i Ft. #2 SAND
Tap eotlom Ft
Top Bottom FL
11. DRILLING LAG
Top Bottom Formation Deserlptlon
1S mrjd bm sandy
1 d hm san♦1 ! I f tYT1 wd
_S1L1 ......�/.11' 1, y ,�bm�nd 1�d�ev1
IT mad a������n
r
r
r _
i
IL REMARKS
100 HERESv CERnFY THAT THIS WELL WAS COISTRUCTE01HACC0ROANCE WITH
I&AgNC .0 2C.W Lk.00 iEITRLWW 3TANOAR06.AND THAT ACOPV OF T148
CROTlEE"MTO T£VEOWI�I
CIFlEDWELCONTAIDATE
�TWELL A
PRINTe NAME OF'PERSON erONSTRl/CTIIJG THE WELL
Form GW-1b
Submit the original to the 1XVIalon of Water Quality Within 30 days. Attn: hito-offlon Mgt, Rev. 1 11/01)
1617 M&U SeMCO Cenber— Raieigh. NC 27S9g-1S17 Phone No. [phone]