WI0400569_Permit (Issuance)_20210423

NC Department of Environmental Quality — Division of Water Resources (DWR)
NOTIFICATION OF INTENT (NOI) TO CONSTRUCT OR OPERATE INJECTION WELLS
The following. are `permitted by rule" and do not require an individual permit when constructed in accordance
with the rules of 15A NCAC 02C.0200 (NOTE: This form must be received at least 14 DAYS prior to injection)
AQUIFER TEST WELLS (15A NCAC 02C .0220)
These wells are used to inject uncontaminated fluid into an aquifer, to determine aquifer hydraulic characteristics.
INSITUREMEDIATION (15A NCAC 02C .0225) or TRACER WELLS (15A NCAC 02C .0229):
1) Passive Injection Systems - In -well delivery systems to diffuse injectants into the subsurface. Examples include
ORC socks, iSOC systems, and other gas infusion methods (Note: Injection Event Records (IER) do not need to be
submitted for replacement of each sock used in ORC systems).
2) Small -Scale Injection Operations — Injection wells located within a land surface area not to exceed 10,000
square feet for the purpose of soil or groundwater remediation or tracer tests. An individual permit shall be required
for test or treatment areas exceeding 10,000 square feet.
3) Pilot Tests - Preliminary studies conducted for the purpose of evaluating the technical feasibility of a
remediation strategy in order to develop a full scale remediation plan for future implementation, and where the
surface area of the injection zone wells is located within an area that does not exceed five percent of the land surface
above the known extent of groundwater contamination. An individual permit shall be required to conduct more
than one pilot test on any separate groundwater contaminant plume.
4) Air Injection Wells - Used to inject ambient air to enhance in -situ treatment of soil or groundwater.
5) In -Situ Thermal Wells (IST) — Used to `heat' contaminated groundwater to enhance remediation.
Print Clearly or Type Information. Illegible Submittals Will Be Returned as Incomplete.
DATE: April 9, 2021
PERMIT NO. (to be filled in by DWR)
NOTE- If this NOI is being submitted as notification of a modification of a previously issued NOI for this site (e.g.,
different injection wells, plume, additives, etc.) and still meets the deemed permitted by rule criteria, provide the
previously assigned permit tracking number and any needed relevant information to assess and approve injection:
Permit No. WI Issued Date:
A. WELL TYPE TO BE CONSTRUCTED OR OPERATED
(1) x Air Injection Well Complete sections B through F, J, M
(2) Aquifer Test Well . Complete sections B through F, J, M
(3) Passive Injection System .. Complete sections B through F, H-M
(4) Small -Scale Injection Operation Complete sections B through M
(5) Pilot Test Complete sections B through M
(6) Tracer Injection Well Complete sections B through M
(7) In -Situ Thermal (IST) Well Complete ise through M
B. STATUS OF WELL OWNER: Business/Organization
Deemed Permitted GW Remediation NOI Rev. 2-17-2020
APR 12 2021
NC DECilDVVR
Central Office
Page 1

NC Department of Environmental Quality — Division of Water Resources (DWR)
NOTIFICATION OF INTENT (NOI) TO CONSTRUCT OR OPERATE INJECTION WELLS
The following are `permitted by rule" and do not require an individual permit when constructed in accordance
with the rules of 1SA NCAC 02C.0200 (NOTE: This form must be received at least 14 DAYS prior to injection)
AQUIFER TEST WELLS (15A NCAC 02C .0220)
These wells are used to inject uncontaminated fluid into an aquifer to determine aquifer hydraulic characteristics.
IN SITU REMEDIATION (15A NCAC 02C .0225) or TRACER WELLS (15A NCAC 02C .0229):
1) Passive Injection Systems - In -well delivery systems to diffuse injectants into the subsurface. Examples include
ORC socks, iSOC systems, and other gas infusion methods (Note: Injection Event Records (IER) do not need to be
submitted for replacement of each sock used in ORC systems).
2) Small -Scale Injection Operations — Injection wells located within a land surface area not to exceed 10,000
square feet for the purpose of soil or groundwater remediation or tracer tests. An individual permit shall be required
for test or treatment areas exceeding 10,000 square feet.
3) Pilot Tests - Preliminary studies conducted for the purpose of evaluating the technical feasibility of a
remediation strategy in order to develop a full scale remediation plan for future implementation, and where the
surface area of the injection zone wells is located within an area that does not exceed five percent of the land surface
above the known extent of groundwater contamination. An individual permit shall be required to conduct more
than one pilot test on any separate groundwater contaminant plume.
4) Air Injection Wells - Used to inject ambient air to enhance in -situ treatment of soil or groundwater.
5) In -Situ Thermal Wells (IST) — Used to `heat' contaminated groundwater to enhance remediation.
Print Clearly or Type Information. Illegible Submittals Will Be Returned as Incomplete.
DATE: April 9, 2021
PERMIT NO. WI0400569 (to be filled in by DWR)
NOTE- If this NOI is being submitted as notification of a modification of a previously issued NOI for this site (e.g.,
different injection wells, plume, additives, etc.) and still meets the deemed permitted by rule criteria, provide the
previously assigned permit tracking number and any needed relevant information to assess and approve injection:
A.
B.
Permit No. WI Issued Date:
WELL TYPE TO BE CONSTRUCTED OR OPERATED
(1) x Air Injection Well Complete sections B through F, J, M
(2) Aquifer Test Well . Complete sections B through F, J, M
(3) Passive Injection System .. Complete sections B through F, H-M
(4) Small -Scale Injection Operation Complete sections B through M
(5) Pilot Test Complete sections B through M
(6) Tracer Injection Well Complete sections B through M
(7) In -Situ Thermal (IST) Well Complete sections B through M
STATUS OF WELL OWNER: Business/Organization
Deemed Permitted GW Remediation NOI Rev. 2-17-2020
Page 1

C. WELL OWNER(S) — State name of Business/Agency, and Name and Title of person delegated authority to
sign on behalf of the business or agency:
Name(s): Kinder Morgan (RJ Sherman)
Mailing Address: 78 Lafayette Street
City: Carteret State: NJ Zip Code: 07008 County:
Day Tele No.: 732-541-5161 ext. 75224 Cell No.:
EMAIL Address: [e-mail] Fax No.:
D. PROPERTY OWNER(S) (if different than well owner/applicant)
Name and Title:
Company Name
Mailing Address:
City: State: Zip Code: County:
Day Tele No.: Cell No.:
EMAIL Address: Fax No.:
E. PROJECT CONTACT (Typically Environmental Consulting/Engineering Finn)
Name and Title: Jasen Zinna, PE
Company Name: AECOM Technical Services
Mailing Address: 1600 Perimeter Park Dr. Suite 400
City: Morrisville State: NC Zip Code: 27560 County: Wake
Day Tele No.: Cell No.: 561-271-9662
EMAIL Address: [e-mail] Fax No.:
F. PHYSICAL LOCATION OF WELL SITE
(1) Facility Name & Address: Guilford Greene, 2617 Quaker Landing Rd
City: Greensboro County: Guilford Zip Code: 27455
(2) Geographic Coordinates: Latitude**: or °
Longitude**: or °
Reference Datum: Accuracy:
Method of Collection:
**FOR AIR INJECTION AND AQUIFER TEST WELLS ONLY: A FACILITY SITE MAP WITH PROPERTY
BOUNDARIES MAY BE SUBMITTED IN LIEU OF GEOGRAPHIC COORDINATES.
G. TREATMENT AREA
Land surface area of contaminant plume: square feet
Land surface area of inj. well network: square feet (< 10,000 ft2 for small-scale injections)
Percent of contaminant plume area to be treated: (must be < 5% of plume for pilot test injections)
Deemed Permitted GW Remediation NOI Rev. 2-17-2020 Page 2

H. INJECTION ZONE MAPS — Attach the following to the notification.
(1) Contaminant plume map(s) with isoconcentration lines that show the horizontal extent of the
contaminant plume in soil and groundwater, existing and proposed monitoring wells, and existing and
proposed injection wells; and
(2) Cross-section(s) to the known or projected depth of contamination that show the horizontal and vertical
extent of the contaminant plume in soil and groundwater, changes in lithology, existing and proposed
monitoring wells, and existing and proposed injection wells.
(3) Potentiometric surface map(s) indicating the rate and direction of groundwater movement, plus existing
and proposed wells.
I. DESCRIPTION OF PROPOSED INJECTION ACTIVITIES AT THE SITE — Provide a brief narrative
regarding the cause of the contamination, and purpose, scope, goals of the proposed injection activity:
J. WELL CONSTRUCTION DATA
(1) No. of injection wells: Proposed 23 Existing (provide NC Well
Construction Record (GW-1) for each well)
Appx. injection depths (BLS): 70
For Proposed wells or Existing wells not having GW-1 s, provide well construction details for each
injection well in a diagram or table format. A single diagram or line in a table can be used for
multiple wells with the same construction details. Well construction details shall include the
following (indicate if construction is proposed or as -built):
(a) Well type as permanent, Geoprobe/DPT, or subsurface distribution infiltration gallery
(b) Depth below land surface of casing, each grout type and depth, screen, and sand pack
(c) Well contractor name and certification number
(2)
(3)
K. INJECTION SUMMARY
NOTE: Only injectants approved by the epidemiology section of the NC Division of Public Health, Department
of Health and Human Services can be injected. Approved injectants can be found online at
http://deq.nc. gov/about/divisions/water-resources/water-resources-permits/wastewater-branch/ground-water-
protection/ground-water-approved-injectants. All other substances must be reviewed by the DHHS prior to use.
Contact the UIC Program for more info if you wish to get approval for a different additive. However, please
note it may take 3 months or longer. If no injectants are to be used use N/A.
Injectant: Total Amt. to be injected (gal)/event:
Injectant: Total Amt. to be injected (gal)/event:
Injectant: Total Amt. to be injected (gal)/event:
Injectant: Total Amt. to be injected (gal)/event:
Injectant: Total Amt. to be injected (gal)/event:
Total Amt. to be injected (gal/event):
Deemed Permitted GW Remediation NOI Rev. 2-17-2020 Page 3

No. of separate injection events: Total Amt. to be injected (gal):
Source of Water (if applicable):
L. MONITORING PLAN — Describe below or in separate attachment a monitoring plan to be used to determine
if violations of groundwater quality standards specified in Subchapter 02L result from the injection activity.
M. SIGNATURE OF APPLICANT AND PROPERTY OWNER
Well Owner/Applicant: "I hereby certify, under penalty of law, that I am familiar with the information
submitted in this document and all attachments thereto and that, based on my inquiry of those individuals
immediately responsible for obtaining said information, I believe that the information is true, accurate and
complete. I am aware that there are significant penalties, including the possibility of fines and imprisonment,
for submitting false information. I agree to construct, operate, maintain, repair, and if applicable, abandon the
injection well and all related appurtenances in accordance with the 15A NCAC 02C 0200 Rules."
Jasen Zinna, PE (Senior Engineer)
Signature of Applicant Print or Type Full Name and Title
Property Owner (if the property is not owned by the Well Owner/Applicant):
"As owner of the property on which the injection well(s) are to be constructed and operated, I hereby consent to
allow the applicant to construct each injection well as outlined in this application and agree that it shall be the
responsibility of the applicant to ensure that the injection well(s) conform to the Well Construction Standards
(15A NCAC 02C .0200)."
"Owner" means any person who holds the fee or other property rights in the well being constructed. A well
is real property and its construction on land shall be deemed to vest ownership in the land owner, in the
absence of contrary agreement in writing.
Signature* of Property Owner (if different from applicant)
RJ Sherman
Print or Type Full Name and Title
*An access agreement between the applicant and property owner may be submitted in lieu of a signature on this form.
Please send 1 (one) hard color copy of this NOI along with a copy on an attached CD or Flash Drive at least
two (2) weeks prior to injection to:
DWR — UIC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone: [phone]
Deemed Permitted GW Remediation NOI Rev. 2-17-2020 Page 4

AECOM
N
U
Project Management Initials: Designer.TSH
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LEGEND
▪ GROUNDWATER MONITORING WELL
▪ GROUNDWATER RECOVERY WELL
▪ VAPOR RECOVERY WELL
frE DUAL GROUNDWATER/VAPOR
RECOVERY WELL
AIR SPARGE WELL
SVE#- SVE WELL
AS# • AS WELL
—x—x— EXISTING 8' WOOD FENCE
UE- U/G ELECTRIC LINE
U/G TELEPHONE
U/G FIBER OPTIC
U/G GAS
w U/G WATER LINE
0 60
APPROX. SCALE, ft.
PROJECT
AS/SVE SYSTEM
PLANTATION PIPELINE COMPANY
1000 WINDWARD CONCOURSE
SUITE 450
ALPHARETTA, GEORGIA
PREPARED BY
AECOM
1600 Perimeter Park Dr., Suite 400
Morrisville, North Carolina 27560
919.461.100 tel [phone] fax
www.aecom.com
REGISTRATION
JASEN P. ZINNA, P.E.
LICENSE: 040228
DATE
7.23.2020
PROJECT NUMBER
60625719
SHEET TITLE
EXISTING SITE LAYOUT
SHEET NUMBER
2 of 6

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
1. Well Contractor Information:
Virgil Wilson
Well Contractor Name
4473
NC Well Contractor Certification Number
Parratt-Wolff, Inc.
Company Name
2. Well Construction Permit#:
List all applicable well permits (i,e, County, State, Variance, Infection, etc.)
3. Well Use (check well use):
Water Supply Well:
❑ Agricultural
❑Geothermal (Heating/Cooling Supply)
❑industrial/Commercial
❑irrigation
❑Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
Non -Water Supply Well:
IZMonitoring
❑ Recovery
Injection Well:
❑ Aquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer Test
❑ Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling Return)
4. Date Well(s) Completed: 6-19-20
Groundwater Remediation
❑Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑ Tracer
❑Other (explain under #21 Remarks)
5a. Well Location:
Plantation Pipe Line Co
Well ID# SVE-101
Facility/Owner Name Facility ID# (if applicable)
2617 Quaker Landing Road, Greensboro, NC
Physical Address, City, and Zip
Guilford
7847837248
County Parcel Identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field. one lat/long is sufficient)
36.146882 N-79.850500
6. Is (are) the well(s): OPermanent or ❑Temporary
w
7. Is this a repair to an existing well: ❑Yes or ENo
If this is a repair,.lil/ out known well construction it formation and explain the nature of the
repair under ,21 remarks .section or on the back of this forum.
8. Number of wells constructed: 1
For multiple injection or non -water .supply wells ONLY with the same construction, you can
.submit one /orm.
9. Total well depth below land surface: 30 (it.)
For multiple wells list all depths i/ (Wren/ (example- 3 tt 200' and 2 « 100')
10. Static water level below top of casing: 0 (ft.)
If water level is above casing, use " "
11. Borehole diameter: 4
(in.)
12. Well construction method: 8 1/4" HSA
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
For Internal Use ONLY;
14. WATER ZONES
FROM
TO
DESCRIPTION
ft.
ft.
ft.
ft.
15. OUTER CASING (for multi -cued wells) OR LINER (if Jig ie.ble)
FROM
TO
DIAMETER
TIIICTCNFSS
MATERIAL
ft.
ft.
in.
16, INNER CASING OR TUBING (geothermal closed-Iaap)
FROM
TO
DIAMETER
THIcI NE:sS
MATERIAL
0 ft.
15 ft•
1 'n•
sch40
pvc
ft.
ft.
in.
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THIC1iNE.SS
ri LITER IA I.
15 ft.
30 ft
2 in.
.010
sch40
pvc
ft.
ft.
in.
18. GROAT
FROM
TO
MATERIAL
EMPLACEM ENT METHOD & AMOUNT
1 rt.
11 ft.
Portland Cem
Pour
10 ft.
12 ft.
Bentonite Chi'
Pour
ft.
ft.
19. SAND/GRAVELPACK
(if applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
12 ft
30 ft.
#1 Sand
Pour
ft.
ft.
Ili. DRILLING
LOG (rttaeh
additional sheets ifaeressrry)
FROM
TO
DESCRIPTION I slor. hardness. avillrock type. grain she. etc)
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
2l. REMARKS
22. Ce1'tificatiud:
Signal
1
a
1. Sc'N__
uFCertilied Well Contractor
7 12Die.1c)
Hr signing this farm, 1 hereby certify that the well(s) was (were) constructed in accordance
with 15A N('AC 02(' .0100 or 15A N(A(' 02(',0200 Well Construction Standards and that a
copy q/7his 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 Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Iniection We 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 tollowing:
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
Fo, nt GW- I North Carolina Department of Environment and Natural Resources - Division of Water Resources
Revised August 2013

WELL CONSTRUCTION RECORD
This form can be used foh single or multiple wells
1. Well Contractor Information:
Virgil Wilson
Well Contractor Name
4473
NC Well Contractor Certification Number
Parratt-Wolff, 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):
Water Supply Well:
0 Agricultural
❑Geothermal (Heating/Cooling Supply)
❑lndustrial/Commercial
0-Irrigation
❑Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
Non -Water Supply Well:
Monitoring
❑Recovery
Injectiun ►Ydl:
❑Aquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling Return)
4. Date Well(s) Completed: 6-18-20
❑Groundwater Remediation
❑Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑Tracer
❑Other (tplain under #21 Rcmarks)
5a. Well Location:
Plantation Pipe Line Co
Well ID# SVE-102
Facility/Owner Name Facility ID# (if applicable)
2617 Quaker Landing Road, Greensboro, NC
Physical Address, City, and Zip
Guilford
7847837248
County Parcel identification No (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field one Iat/long is sufficient)
36.146900 N-79.850413 W.
6. Is (are) the well(s): OPermanent or ❑Temporary
7. Is this a repair to an existing well: ❑Yes or ENo
1/ this is a repair, Jill out known well construction inlbrmalian and explain the nature of the
repair under 21 remarks .section or on the back aJ this firm.
8. Number of wells constructed: 1
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: 30
(R•)
For multiple wells list all depths if different (example- 3 n 200' and 2 a IO0')
10. Static water level below top of casing: 0 (ft.)
water level is above casing, use " - "
11. Borehole diameter: 4 (in.)
12. Well construction method: 8 1 /4hh HSA
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
For Internal Use ONLY_.
14. WATER ZONES
FROM
TO
DESCRIPTION
ft.
ft.
ft.
ft.
15. OUTER CASING (for multi -cased wean) OR LINER (if applicable)
FROM
TO
ODA IFTF.R
TRICI NE5S
MATiMI II,
ft.
ft.
in.
16, INNER CASING OR TUBING (geothermal dosed -loopy
FROM
TO
DIAMETER
THICKNESS
M.'TFRI.L
0 ft'
15 ft.
1 in.
sch40
pvc
ft.
ft.
in.
17, SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
15 ft.
30 rt.
2 in.
.010
sch40
pvc
ft.
ft.
in.
18. GROUT
FROM
TO
MATERIAI.
EMPLACEMENT METHOD Ei AMOUNT
3 ft'
11 ft.
Portland Cem
Pour
11 ft.
13 ft•
Bentonite Chi
Pour
ft.
ft.
19. SAND/GRAVEL PACK (if applicable)
FROM
TO
'1L TERI AL
EMPEACEMENT METHOD
13 ft•
30 ft.
#1 Sand
Pour
ft.
ft.
20. DRILLING
LOG (attach
additional sheets if necessary)
FROM
TO
DESCRIPTION (color. hardness, soiVrock type. grain .size. etr.)
ft.
f1.
ft.
ft.
ft.
ft.
H.
ft.
ft.
ft.
ft.
ft.
ft.
H.
21. REMARKS
22. eel- tifieathin:
Sirnall ut'Crrlilird Well Contractor
Date
By signing this fOrm, I hereby certify that the uve/l(s) was (here) constructed in accordance
with 15A NCAC 02('_0100 or 15A NCAC 02(',0200 Well Construction Standards and that a
copy oPhis 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 Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For IRiecfion WelIs 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
This form can be used for single or multiple wells
1. Well Contractor Information:
Virgil Wilson
Well Contractor Name
4473
NC Well Contractor Certification Number
Parratt-Wolff, Inc.
Company Name
2. Well Construction Permit#:
List all applicable well permits (i.e, County, State, Variance, btlection, elc )
3. Well Use (check well use):
For internal Use ONLY
14. WATER ZONES
FR OM
TO
DESCRIPTION
ft.
ft.
ft.
ft.
15, OUTER CASING (for multi -rased wells) OR LINER (if ap Ruthle)
FROM THICKNESS 1 MATERIAL
TO
ft.
ft.
DIAMETER
in.
16. INNER CASING OR TUBING (geothermal dotted -Loop)
FROM
TO
DIAMETER
TI HCk-NE.SS
MATERIAL
0
ft.
15
ft.
in.
sch40
pvc
ft.
ft.
in.
17. SCREEN
Water Supply Well:
❑ Agricultural
❑Geothermal (Heating/Cooling Supply)
❑ industrial/Commercial
❑irrigation
❑Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
Non -Water Supply Well:
E Monitoring
❑ Recovery
Injection Well:
❑Aquifer Recharge
❑ Aquifer Storage and Recovery
❑Aquifer Test
❑Experimental Technology
❑ Geothermal (Closed Loop)
❑ Geothcrmal (Heating/Cooling Return)
4. Date Well(s) Completed: 6-17-20
5a. Well Location:
Plantation Pipe Line Co
❑Groundwater Remediation
❑Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑Tracer
❑Other (explain under 1121 Remarks)
Well rD# SVE-103
Facility/Owner Name Facility ID# (if applicable)
2617 Quaker Landing Road, Greensboro, NC
Physical Address, City, and Zip
Guilford
County
7847837248
Parcel Identification No. (PIN)
Sb. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(dwell field, one lat/long is sufficient)
36.146879 N,-79.850373 W.
6. is (are) the well(s): lPermanent or ❑Temporary
7. Is this a repair to an existing well: ❑Yes or 1No
1/ dtis is a repair,/ill out known well construction in/orntation and explain the nature of the
repair under =21 remarks section or on the back o/Misfit-In
8. Number of wells constructed: 1
For multiple injection or non-water.supply wells ONLY with the same construction, you can
submit one. Jorm.
9. Total well depth below land surface: 30
(ft.)
/ ssr mtdnplc well... lost all depths ,l drllerent te'rampfe- 3 a ?00' and 2 a, l00')
10. Static water level below top of casing: 0 (ft.)
/f water level is above casing, use " -
11. Borehole diameter: 4 (in.)
12. Well construction method: 8 1/4" HSA
(i.e. auger, rotary, cable, direct push, etc-)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type:
Amount:
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
15 it
30 Fr.
2
in.
.010
sch40
pvc
ft.
R.
in.
1& GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
ft.
11
ft.
Portland Cem
Pour
11
ft.
13
ft.
Bentonite Chi
Pour
ft.
ft.
19, SANI1/GR.%YEL PACK (if applicable)
FROM
TO
HATERLAL
EMPLACEMENT HETIIOD
13
ft.
30
ft.
#1 Sand
Pour
ft.
ft.
20. DRILLING LOG (attach additional sheen if tttceasat�)
FROM
ft.
TO
ft.
DESCRIPTION rcolnr_ hanlnecs. eai I/rnck lype. grain size, etr.l
Some PWR material at 28 ft
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
21_ REMARKS
22. 4r1i icalivtt:
Jo I u
SignalurdofCcriilied 1 ell Contraclur
7/&/e,‘)
11illC
By signing this firm, I hereby certify that the we//(s) was (were) constructed in accordance
with 15A N('A(' 02('-0/00 or I5A NCAC 02('.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 Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For In(ection Writs 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 et Environment and Natural Resources —Division of Water Resources Revised August 2013

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
1. Well Contractor Information:
Virgil Wilson
Well Contractor Name
4473
NC Well Contractor Certification Number
Parratt-Wolff, Inc.
Compam Name
2. Well Construction Permit #:.
List all applicable well permits (Le, County, Slate, Variance, Injection, etc.)
3. Well Use (check well use):
For Internal Use ONLY:
14. WATER ZONES
FROM
TO
DESCRIPTION
ft.
ft.
ft.
ft.
15. OUTER CASING (for multi -rased wells) OR LINER Of op limbic)
TH ICKNTSS M-aTF.k1Al.
FROM
ft.
TO
ft.
DIAMETER
m,
In. INNER CASING OR TUBING (geothernul closed -loop)
FROM
TO
DIAMETER
TitICICCFSS
MATERIAL
0
ft.
15
ft.
in.
sch40
pvc
ft.
ft.
In.
17. SCREEN
Water Supply Well:
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑ industrial/Commercial
❑irrigation
❑Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
Non -Water Supply Well:
Z Monitoring
❑ Recovery
Injection Well:
❑Aquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑ Geothermal (Heating/Cool i rig Return 1
4. Date Well(s) Completed: 6-25-20
❑Groundwater Remediation
Salinity Barrier
❑ Stormwater Drainage
❑Subsidence Control
❑Tracer
❑Other(expllain under#21 Remarks)
5a. Well Location:
Plantation Pipe Line Co
Well ID# SVE-104
Facility/Owner Name Facility ID# (if applicable)
2617 Quaker Landing Road, Greensboro, NC
Physical Address, City, and Zip
Guilford
7847837248
County Parcel Identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
36.146786 N-79.850576
6. Is (are) the well(s): EPermanent or
❑Temporary
W
7. Is this a repair to an existing well: ❑Yes or PNo
1/ this is a repair,Jil/ all known well construction information and explain the nature of the
repair under =21 remarks .section or on the back of this firm.
8. Number of wells constructed: 1
For multiple injection or non -water supply wells ONLY with the same construction, you can
submit one (Orin
9. Total well depth below land surface: 30
For multiple wells lint all depths if inherent (example- 3@200' 200' and 2 a l00')
10. Static water level below top of casing: 0 (ft.)
If water level is above casing, use "-
11. Borehole diameter: 4
12. Well construction method: HSA
(ft)
(i.e, auger, rotary. cable, direct push, etc,)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type:
Amount:
FROM
TO
DIAMETER
SLOT SUE
THICKNESS
MATERIAL
15 ft.
30 ft
2
.010
sch40
pvc
ft.
ft.
in.
18. GROUT
FROM
TO
MATERIAL
EMPLACEMENT.HETHOD & AMQI•tiT
0
ft.
11
ft.
Portland Cem
Pour
11
ft.
13
ft.
Bentonite Chi
Pour
ft.
ft.
19. SAND/GRAVEL PICK [if applicable)
FROM
TO
MATERIAL
EMPLACEMENT MFTIIOD
13
ft.
30
ft.
#1 Sand
Pour
ft.
ft.
20. DRILLING LOG (attach additiwar sheets If necessary)
FROM
ft.
TO
ft.
DESCRIPTION Icntor, rdores, snil/rock type. �rarin ziar, 11ej-
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft-
21. REMARKS
22. Cernf orlon:
Sigma
C'crritied Well Contractor
7k/w
Date
Hv s n}' this /ortn, I hereby ceri/j& that the well(s) was (were) constructed in accordance
with iSA NC.4(' 02('_WOO or /5,4 N('A(' 02C.0200 Well Construction Standards and that a
cops' 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. Fur All Welk: 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 Wefj ONLY: In addition to sending the form to the address in
24aabove, 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-I
North Carolina Department of Environment and Natural Resources - Division or Water Resources Revised August 2013

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
1. Well Contractor Information:
Virgil Wilson
Well Contractor Name
4473
NC Well Contractor Certification Number
Parratt-Wolff, Inc,
Compam Name
2. Well Construction Permit#:
List all applicable well permits (i.e. County, Stale, r ariance, Injection, ele.)
3. Well Use (check well use):
Water Supply Well:
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑industrial/Commercial
. ❑Irrigation
❑Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
Non -Water Supply Well:
O Mon itori ng
❑Recovery
Injection 11'ell:
❑Aquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
Geothermal (I-IeatingJCooiin Return)
❑Groundwater Remediation
❑Salinity Barrier
❑ S tormwater Drainage
❑Subsidence Control
Tracer
❑Other (explain under #21 Remarks)
4. Date Well(s) Completed: 6-29-20
5a. Well Location:
Plantation Pipe Line Co
Well ID# SVE-105
Facility/Owner Name Facility IDif (if applicable)
2617 Quaker Landing Road, Greensboro, NC
Physical Address, City, and Zip
Guilford
County
7847837248
Paicel Identification No (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
36.146791 -79.850476
6. Is (are) the well(s): 1Permanent or ❑Temporary
W
7. Is this a repair to an existing well: ❑Yes or 1No
1/ this is a repair, fill out known well construction it(lormalion and explain the nature of the
repair under =21 remarks section or on the back of this•lien.
8. Number of wells constructed: 1
For multiple injection or non -water supply wells ONLY with the same construction, you can
submit one litrin
9. Total well depth below land surface: 30 (ft.)
For multiple hells list all depths if different (example- 3 a 200' and 2 a /00')
10. Static water level below top of casing: 0 (ft.)
'limner level is above casing, use "- "
11. Borehole diameter: 2 (in.)
12. Well construction method: 8 1/4" HSA
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type:
Amount:
For Internal Use ONLY:
I4. WATER ZONES
FROM
TO
DESCRIPTION
ft.
ft.
ft.
ft.
15. OUTER CASING (tor tnniti-cared writs) OR LINER (if applicable)
FROM
TO
DIAMETER
THICKNESS MATERIAL
ft.
ft.
in.
J
16. INNER
CASING OR TUBING
{geothermal dosed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
0 ft.
15 ft*
1 in.
sch40
pvc
ft.
ft.
in.
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
SATERIAL
15 tt.
30 tt•
2 in.
.010
sch40
pvc
ft.
ft.
in.
19. GROUT
FROSI
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
3 ft
11 IL
Portland Cem
Pour
11 ft.
13 ft.
Bentonite Chi
Pour
ft.
ft.
19. SAND/GRAYEL PACK Of applie tblE)
FROM
TO
r.1:LTERI.AL
EMPLACEMENT METHOD
13 ft.
30 ft.
#1 Sand
Pour
ft.
ft.
20. DRILLING
LOG fatine
b addidimai thesis 1fneeetsttry)
FROM
TO
DESCRIPTION I color. hardness, soil/rack type.Lratn sit, etc)
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
21. REMARKS
22. Certification:
Sig
• of Certified WullCanTm4
_7145-/z-z)
Dale
By signing this /orm, / hereby certify that the we/l(s) was (were) constructed in accordance
with 15A N('AC 02('MOO or 15A N('A(' 02(', 0200 Well Construction Standards and that a
cow of this record hos been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTUCTIONS
24a. Far 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. Far Inieetion Wells ONLY: In addition to sending the form to the address in
24aabove, also submit a copy of this form within 30 days of completion of well
construction to the tollowing:
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-I
North Carolina Department of Environment and Natural Resources — Division of Water Resources Revised August 2013

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
1. Well Contractor Information:
Lewis Lefever
Well Contractor Name
2480
NC Well Contractor Certification Number
Parratt-Wolff, Inc.
Compam Name
2. Well Construction Permit #:
List all applicable well permits (i,e, County, State, 1'ariance, Injection, etc.)
3. Well Use (check well use):
Water Supply Well:
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑Industrial/Commercial
❑ lrri gati on
❑ Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
Non -Water Supply Well:
O Monitoring
❑ Recovery
171jttt►ont
❑ Aquifer Recharge
❑ Aquifer Storage and Recovery
❑Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling Retum)
4. Date Well(s) Completed: 6-10-20
❑Groundwater Remediation
❑Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑Tracer
❑Other (explain under #21 Remarks)
5a. Well Location:
Plantation Pipe Line Co
Well ID# `SVE-106
Facility/Owner Name Facility 113# (if applicable)
2617 Quaker Landing Road, Greensboro, NC
Physical Address, City, and Zip
Guilford
County
7847837248
Parcel Identification No (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field one lat/long is sufficient)
36.146814 N,-79.850713
6. Is (are) the well(s): 1?lPermanent or ❑Temporary
7. Is this a repair to an existing well: ❑Yes or ONu
1/ this is a repair, Jill out known well construction information and explain the nalare of the
repair under -2/ remarks section or on the hack of this Jbrm.
8. Number of wells constructed: 1
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: 35 (ft.)
For multiple wells list all depths tl different (example- 3@200' and 2 rt l00')
10. Static water level below top of casing: 0 (ft.)
If water level is above casing, use " "
11. Borehole diameter: 4
12. Well construction method: HSA
(i e. auger, rotary, cable, direct push, etc )
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:.
For Internal Use ONLY
14. WATER ZONES
FROM
TO
DESCRIPTION
ft.
ft.
ft.
ft.
15. OUTER CASING (for multi -cased wells( OR LINER (if a licablr)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft.
ft.
in.
16, INNER
CASING OR TUBING (geothermal
dosed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
0 ft.
15 ft.
1 in.
sch40
pvc
ft.
ft.
in.
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
15 ft.
35 it.
2 in.
.010
sch40
pvc
ft.
ft.
in.
18. GROUT
FRDM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
0 ft.
11 ft.
Portland Cem
Pour
11 ft.
13 It
Bentonite Chi
Pour
ft.
ft.
19. SANII/GRAVEI. PACKJif applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
13 ft.
35 ft.
#1 Sand
Pour
ft.
ft.
20. DRILLING
LOG (attach
addldonal 'ham If neeeaattry)
FROM
TO
0ESCR1PTI ON [ealon hardness, solltraek type. aralu six., etc.(
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
21. REMARKS
1 Bottom Cap
1 Slip Cap
Signature at ern lled Well Contractor
7/5/0
Date
Hy signing this firm, I hereby certify that the well(s) was (were) constructed in accordance
with /5A N('AC 02C ,0100 or 15,4 NCAC 02(' .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. Fur 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 ONLY: In addition to sending the form to the address in
24aabove, 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.
Forst GW- I North Carolina Department of Environment and Natural Resources — Division of Water Resources
Revised August 2013

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
1. Well Contractor Information:
Lewis Lefever
Well Contractor Name
2480
NC Well Contractor Certification Number
Parratt-Wolff, Inc.
Company Name
2. Well Construction Permit #:
L,sl all applicable well permits (i.e. County, State, Variance, Injection, etc.)
3. Well Use (check well use):
Water Supply Well:
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑Industrial/Commercial
❑irrigation
❑Municipal/Public
❑Residential Water Supply (single)
❑ Residential Water Supply (shared)
Non -Water Supply Well;
2 Mon itori n g
❑ Recovery
IajeelOn VWeH:
❑Aquifer Recharge
CI Aquifer Storage and Recovery
❑Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling Return)
4. Date Well(s) Completed: 6-4-20
5a. Well Location:
Plantation Pipe Line Co
❑Groundwater Remediation
❑Salinity Barrier
❑Stormwater Drainage
❑ Subsidence Control
❑Tracer
❑ Other (explain under#21 Remarks)
Well ID# `SVE-107
Facility/Owner Name Facility ID# (if applicable)
2617 Quaker Landing Road, Greensboro, NC
Physical Address, City, and Zip
Guilford
7847837248
County Parcel identification No (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field. one lat/long is sufficient)
36.146756 N-79.850510
6. Is (are) the well(s): EZPermanent or ❑Temporary
w
7. Is this a repair to an existing well: ❑Yes or lNo
1/ this is a repair, fill out known well construction in/orntation and explain the nature of the
repair under 21 remarks section or on the back of this
8. Number of wells constructed: 1
For multiple injection or non -water supply wells ONLY with the same construction, you can
submit one farm.
9. Total well depth below land surface: 30 (ft.j
For multiple wells list all depths if different (example- 3 a 200' and 2 a100')
10. Static water level below top of casing: 0
If water level is above casing, use "- "
1l. Borehole diameter: 4 (in.)
12. Well construction method: HSA
(ft.)
(i e auger, rotary. cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
For Internal Use ONLY:
14. WATER ZONES
FROM
TO
DESCRIPTION
ft.
ft.
ft.
ft.
15. OUTER CASING (for multi -cued *trill) OR LINER (ifap ticdile)
FROM
TO
DIAMETER
Tr1ICKNESS MATERIAL
ft.
ft.
in.
16.1NNER CASING OR TUBING Igeothe rmal clased-lnupl
FROM
TO
DIAMETER
THICKNESS
MATERIAL
0 ft.
15 fL
1 in.
sch40
pvc
ft.
ft.
in.
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
15 ft.
30 ft
2 in.
.010
sch40
pvc
ft.
ft.
in.
18. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
0 ft.
11 ft'
Portland Cem
Pour
11 ft.
13 ft.
Bentonite Chii
Pour
ft.
ft.
19. SAND/GRAVEI. PACK
(if applicable)
FROM
TO
MATERIAL
EMPLI..CEM ENT M ETHOD
13 ft
30 ft.
#1 Sand
Pour
ft.
ft.
20. DRILLING
LOG (attach additional sheet' if neeeasary)
FROM
TO
DESCRIPTION Irulor, hardne,r. sail/rurk Ivpc. grain sin. rtr.l
ft.
ft.
ft.
ft
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
21. REMARKS
22. Cer 's�stlion:
.Ignalure ul cnific Wall Contractor
7'212�
Dale
By signing this farm, / hereby certify that the wel(s) was (were) constructed in accordance
with 15A N('AC 02C .0100 or 15A N('A(' 02C .0200 Well Construction Standards and dun 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 Well: 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 Weill 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 tollowing:
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
This form can be used for single or multiple wells
1. Well Contractor Information:
Virgil Wilson
Well Contractor Name
4473
NC Well Contractor Certification Number
Parratt-Wolff, Inc.
Company Name
2. Well Construction Permit#:
List all applicable well permits (i.e. County, State, Variance, Injection, elc•.)
3. Well Use (check well use):
Water Supply Well:
[Agricultural
❑Geothermal (Heating/Cooling Supply)
❑ industrial/Commercial
❑Irrigation
▪ Municipal/Public
❑Residential Water Supply (single)
❑ Residential Water Supply (shared)
Non -Water Supply Well:
O Monitoring
❑ Recovery
Injection Well:
❑Aquifer Recharge
❑ Aquifer Storage and Recovery
❑Aquifer Test
❑Experimental Technology
❑ Geothermal (Closed Loop)
❑Geothermal I Heatl ng/C oo I ing Retum)
4. Date Well(s) Completed: 7-17-20
5a. Well Location:
Plantation Pipe Line Co
❑Groundwater Remediation
❑Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑ Tracer
❑Other (explain under #21 Remarks)
Well ID# SVE-108
Facility/Owner Name Facility ID# (if applicable)
2617 Quaker Landing Road, Greensboro, NC
Physical Address, City, and Zip
Guilford
7847837248
County Parcel Identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field. one lat/long is sufficient)
36.146754 Nr-79.850702
6. Is (are) the well(s): LZPermanent or ETemporary
W
7. Is this a repair to an existing well: ❑Yes or lNo
1/ this is a repair,./ill am known well construction in/on-motion and explain the nature of the
repair under -21 remarks section or on the hack q/ this form.
8. Number of wells constructed: 1
For multiple injection or non -water supply wells ONLY with the same construction, you can
submit one farm.
9. Total well depth below land surface: 30
t or multiple wells list all depths if different (example- 3 r1200' and 2@100')
10. Static water level below top of casing: 0
/f water level is above casing, use "-
11. Borehole diameter: 2 (in.)
12. Well construction method: 8 1/4" HSA
(ft.)
(ft.)
(i.e. auger, rotary, cable, direct push, etc-)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
I3b. Disinfection type:
Amount:
For internal Use ONLY!
14, WATER ZONES
FROM
TO
DESCRIPTION
ft.
ft.
ft.
ft.
l5. OUTER CASING (fur multi -cased wells) OR LINER (if ap
Feeble)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft.
ft.
in.
I. INNER
CASING OR TUBING (geothermal closed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
0 ft.
15 ft.
1 in_
sch40
pvc
ft.
ft.
in.
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
15 ft.
30 ft.
2 in.
.010
sch40
pvc
ft.
ft.
in.
18. GROUT
FROM
TO
MATERLAL
EMPLACEMENT METHOD & AMOUNT
3 ft
11 EL
Portland Cem
Pour
11 ft.
13 1t,
Bentonite Chi
Pour
ft.
ft.
19. SAND/GRAVEE.
PACK (if applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
13 ft-
30 ft.
#1 Sand
Pour
ft.
ft.
20. DRILLING
LOG (attach
additional shaelt If I:WM. r )
FROM
TO
DESCRIPTION haler, hardness, suilfnelr lype. groin ua, etc,)
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
21. REMARKS
22. Certiti+l'ation:
1
Sigmit'Certified Will Contractor
Date
By i gntFg dlis•form, / hereby c•erlili' that the well(s) was (were) constructed in accordance
with 15A NCA(' 02C .0100 or 15A NCAC 02('.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 We1LS: 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. Far 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 tollowing:
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.
Foi GW- I North Carolina Department of Environment and Natural Resources — Division of Water Resources
Revised August 2013

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
1. Well Contractor Information:
Lewis Lefever
Well Contractor Name
2480
NC' Well Contractor Certification Number
Parratt-Wolff, Inc.
Company Name
2. Well Construction Permit#:
List all applicable well permits (i.e. County, Stale, Variance, Injection, etc:)
3. Well Use (check well use):
Water Supply Well:
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑industrial/Commercial
❑ Trrigati on
❑Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
Non -Water Supply Well:
O Monitoring
❑ Recovery
Injection Well:
❑Aquifer Recharge
❑ Aquifer Storage and Recovery
❑Aquifer Test
❑ Experimental Technology
❑Geothermal (Closed Loop)
Geothermal (Heating/Cooling Retum)
❑Groundwater Remediation
❑Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑Tracer
❑Other (explain under #21 Remarks)
4. Date Well(s) Completed: 6-3-20
5a. Well Location:
Plantation Pipe Line Co
Well ID# SVE-109
Facility/Owner Name Facility ID* (if applicable)
2617 Quaker Landing Road, Greensboro, NC
Physical Address, City, and Zip
Guilford
County
7847837248
Parcel Identification No (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field. one lat/long is sufficient)
36.146658 Nr-79.850736
6. Is (are) the well(s): I[�Permanent or ❑Temporary
7. Is this a repair to an existing well: ❑Yes or ONo
If this is a repair,/ill out known well construction in/ormalion and explain the nature of the
repair under =2/ remarks section or on the hack of Ihis firm,
8. Number of wells constructed: 1
For multiple injection or non -water supply wells ONLY with the same construction, you can
submit one /Drat.
9. Total well depth below land surface: 30
For multiple wells list al/ depths tl dilferent (example- 3 ce 200' and 2 a 100')
10. Static water level below top of casing: 0
If water level is above casing, use "• "
11. Borehole diameter: 4 (in.)
12. Well construction method: 8 1/4" HSA
(ft)
(ft.)
(i,e, auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
I3b. Disinfection type: - Amount:
For Internal Use ONLY:
14. WATER ZONES
FROM
TO
DESCRIPTION
ft.
ft.
ft.
ft.
15. OUTER CASING (for multi -eased wdls) OR LINER (if op !foible)
FROM
TO
DIIMF.TRK
THICKNESS
MATFRIAI.
ft.
ft.
in.
I6. INNER
CASING OR TUBING (geothermal dosed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIA t.
0 ft.
15 ft.
1 in.
sch40
pvc
ft.
ft.
in.
17. SCREEN
FIIDM
To
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
15 ft
30 ft.
2 in.
.010
sch40
pvc
ft.
ft.
in.
1A. GROUT
FROM
TO
MATERIAL
. EMPLACEMENT METHOD & AMOUNT
0 ft'
111 ft'
Portland Cem
Pour
11 ft.
13 ft•
Bentonite Chi
Pour
ft.
ft.
19. SAND/GRAVEL PACK of applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
13 ft•
31 ft.
#1 Sand
Pour
ft.
ft.
20. DRILLING
LOG (attach
addttlosut sheer} if necessary)
FROM
TO
DESCRIPTION Icalor. hardness, saiilmck type. grain size. erc.l
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
21. REMARKS
1 Bottom
R 1 J Plug
Signature of Certified Well Contractor
607zellz
❑8[C
By signing this form, l hereby cerli(v that the well(s) was (were) constructed in accordance
with 15A NCA(' 02('.0/00 or 1.5A NCAC 02('.0200 Well Construction Standards and that a
cow 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 Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For inieelliou Was ONLY: In addition to sending the form to the address in
24aabove, 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- I
North Carolina Department of Environment and Natural Resources - Division of Water Resources Revised August 2013

WELL CONSTRUCTION RECORD
For internal Use ONLY:
This form can be used for single or multiple wells
1. Well Contractor Information:
Virgil Wilson
Well Contractor Name
4473
NC Well Contractor Certification Number
Parratt-Wolff, Inc.
Company Name
2. Well Construction Permit#:
List all applicable well permits (Le. County, Stale, Variance, Injection, etc.)
3. Well Use (check well use):
Water Supply Well:
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑industrial/Commercial
❑irrigation
❑ Municipal/Public
❑Residential Water Supply (single)
❑ Residential Water Supply (shared)
Non -Water Supply Well:
O Monitoring
❑Recovery
Injection Well:
❑Aquifer Recharge
❑Aquifer Storage and Recovery
Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling Return)
4. Date Well(s) Completed: 6-11-20
5a. Well Location:
Plantation Pipe Line Co
❑Groundwater Remediation
❑ Salinity Barrier
❑ Stormwater Drainage
❑Subsidence Control
❑Tracer
❑Other (explain under #21 Remarks)
Well ID# SVE-1 10
Facility/Owner Name Facility ID# (if applicable)
2617 Quaker Landing Road, Greensboro, NC
Physical Address, City, and Zip
Guilford
County
7847837248
Parcel identification No (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field one lat/long is sufficient)
36.146677 N-79.850850
6. is (are) the well(s): t1Permanent or ❑Temporary
w
7. Is this a repair to an existing well: Yes or No
I/this is a repair, fill out known well construction information and explain the nature of the
repair under =21 remarks section or on the back o/'this form.
8. Number of wells constructed: 1
for multiple injection or non -water .supply wells ONLY with the same construction, you can
submit one form.
9. Total well depth below land surface: 30
For multiple wells list all depths if different (example- 3 2 200' and 2 tt. /00')
10. Static water level below top of casing: 0
If wafer level is above casing, use "- '
11. Borehole diameter: 4 (in.)
12. Well construction method: 8 1/4" HSA
(ft.)
(ft.)
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type:
Amount:
14. WATER ZONES
_ FROM
TO
DESCRIPTION
ft.
ft.
ft.
ft.
I5.Ofl1JT'ER CASING ifbr multi -eased wells) OR LINER(if!p. icahle)
__FROM
TO
DIAMETER
THICKNESS
MATER EA
ft.
ft.
in.
16, INNER CASING OR TI.r6ING )yeathermal closed -loop)
FROM
TO
D1.AMETER
1111CKNESS
M:ATER IA I.
0 ft.
15 ft.
1 in.
sch40
pvc
ft.
ft.
in.
1T. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
15 ft.
30 ft-
2 in.
.010
sch40
pvc
ft.
L . ..
ft.
in.
18. GROUT
FROM
TO
MATE$1AL
EMPLACEMENT METHOD & AMQI INT
0 ft.
10 ft.
Portland Cem
Pour
10 ft.
13 ft
Bentonite Chi
Pour
ft.
ft.
I. SAND/GRA 'EI. PACK (if applicahle]
FROM
TOP
MATERIAL
EMPLACEMENTMETH OD
13 ft-
30 ft.
#1 Sand
Pour
ft.
ft.
Zit. DRILLING
LOG (attach additianai sheets if necessary)
FROM
TO
DESCRIPTION Ica nr, hardness, snairock type, grain due. etc./
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft
ft.
ft.
ft.
ft.
ft.
ft.
I1. REMARKS
22. Certification:
Slgmt1L ofCertified Well Contractor
By signing this farm, / hereby cerli& that the well(.) was (were) constructed in accordance
with 15A N('AC 02('.0100 or 15A N('A(' 02C-0200 Well Construction Standards and that a
copy q/ 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 Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Injection 1Vells 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. Far 1Vater Supply & injection W'clls:
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.
Foim GW-I
North Carolina Department of Environment and Natural Resources — Division of Water Resources
Revised August 2013

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
1. Well Contractor Information:
Virgil Wilson
Well Contractor Name
4473
NC Well Contractor Certification Number
Parratt-Wolff, Inc.
Company Name
2. Well Construction Permit #:
List all applicable we// permits (i.e. County, Slate, 1 ariance, It /ection, etc.)
3. Well Use (check well use):
Water Supply Well:
❑ Agricultural
❑Geothermal (Heating/Cooling Supply)
❑ )n d ustrial/C om m erc i a l
❑Irrigation
❑Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
Non -Water Supply Well:
E Monitoring
❑Recover'
Injection Well:
❑Aquifer Recharge
❑ Aquifer Storage and Recovery
❑ Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling Return)
4. Date Well(s) Completed: 6-22-20
5a. Well Location:
Plantation Pipe Line Co
❑Groundwater Remediation
❑ Sal inity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑ Tracer
❑Other (explain under #21 Remarks)
Well ID# SVE-111
Facility/Owner Name Facility ID# (if applicable)
2617 Quaker Landing Road, Greensboro, NC
Physical Address, City, and Zip
Guilford
7847837248
County Parcel Identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
36.146623 N-79.850889
6. Is (are) the well(s): 121Permanent or ❑Temporary
7. Is this a repair to an existing well: ❑Yes or ONo
/%this is a repair,,/ill our known well construction information and explain the nature of the
repair under 21 rentarks .section or on the back o/'this /ornt.
8. Number of wells constructed: 1
For multiple infection or non -water supply wells ONLY with the same construction, you can
submit one torn.
9. Total well depth below land surface: 30
Hitt multiple wells list all depths i/ different (example- 3 n 200' and 2 a l00')
10. Static water level below top of casing: 0
If water level is above casing, use " "
11. Borehole diameter: 4
12. Well construction method: 8 1/4n HSA
(ft.)
(ft.)
(i.e. auger, rotary, cable, direct push, etc )
FOR WATER SUPPLY WELLS ONLY:
I3a. Yield (gpm) Method of test:
13b. Disinfection type:
Amount:
For Internal Use ONLY
la. WATER ZONES
FROM
TO
DESCRIPTION
ft.
ft.
ft.
ft.
15.OUTER CASING (for multi -wed weds) OR LINER (if applicable)
FROM
TO
DIAMETER
THICKNESS j MATERIAL
ft.
ft.
in.
}I
to. INNER
CASING OR TUBING
(geothermal closed -loop)
FROM
TO
DIAMETER
THICKNESS
M.4TER►AL
0 ft'
15 ft.
1 in.
sch40
pvc
ft.
ft.
in.
17. SCREEN
FROM
TO
DIAMETER
SLOTSrLE
THICKNESS
MATERIAL
15 ft.
30 ft.
2 in.
,010
sch40
pvc
ft.
ft.
in.
IS, GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
0 ft.
11 rt•
Portland Cem
Pour
11 ft.
13 ft•
Bentonite Chi
Pour
rt.
ft.
19. SAND/GRAVEL PACK
Of applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
13 ft•
31 ft.
#1 Sand
Pour
ft.
ft.
20. DRILLING
LOG Wroth
additions& ehrett If necetsuy)
FROM
TO
DESCRIPTION I calnr, hnrdnen, sniVrnek type, grain Oar, elc.J
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
21. REMARKS
1 Bottom Cap
1 J Plug
22. Certi ration:
/•
signet of
[erlilied Well Contractor
Date
By signing this farm, / hereby certify that the well(s) was (here) constructed in accordance
with 15A NC'A(' 02('.0100 or I5A N('AC 02C.0200 Well Construction Standards and that a
copy gl'Ihis 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 Processing 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- I
North Carolina Department of Environment and Natural Resources — Division of Water Resources Revised August 20 I 3

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
I. Well Contractor Information:
Virgil Wilson
Well Contractor Name
4473
NC Well Contractor Certification Number
Parratt-Wolff, Inc.
Compam Name
2. Well Construction Permit #:
List all applicable well permiiv (Le, County, State, Variance, Injection, etc.)
3. Well Use (check well use):
Water Supply Well:
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑Industrial/Commercial
❑irrigation
Non -Water Supply Well:
Monitoring
❑Municipal/Public
❑ Residential Water Supply (single)
❑Residential Water Supply (shared)
❑ Recovery
Injection Well:
❑ Aquifer Recharge
❑Aquifer Storage and Recovery
❑ Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑ Cseothermal (Heating/Cooling Return)
4. Date Well(s) Completed: 6-8-20
5a. Well Location:
Plantation Pipe Line Co
Groundwater Remediation
❑ Sal inity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑Tracer
❑Other (explain under #21 Remarks)
Well ID# SVE-112
Facility/Owner Nance Facility ID# (if applicable)
2617 Quaker Landing Road, Greensboro, NC
Physical Address, City, and Zip
Guilford
7847837248
County Parcel Identification Na (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
36.146764 N-79.850888
w
6. Is (are) the well(s): ©Permanent or ❑Temporary
7. Is this a repair to an existing well: ❑Yes or ENo
If this is a repair,,fill our known well construction inJiormation and explain the nature (Ow
repair under 21 remarks. section or on the hack of this form
8. Number of wells constructed: 1
For multiple infection or non -water supply wells ONLY with the same construction, you can
submit one firm
9. Total well depth below land surface: 35 (ft)
I•irr nr+d/tple ux•I/s ?Li; all depths rf rlillerent (rrrmrple- 3 rt 200' and 2@100')
10. Static water level below top of casing: 0 (ft.)
/f water level is above casing, use "
11. Borehole diameter: 4 (in.)
12. Well construction method: HSA
(i.e. auger, rotary, cable, direct push, etc )
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
For Internal Use ONLY:
14. WATER ZONES
FROM
TO
DESCRIPTION
ft.
ft.
ft.
ft.
15. OUTER CASING (for multi -eased weds) OR LINER (ff ap Hcabfe)
FROM
TO
DIAMETER
THICKNESS MATERIAL
ft.
ft.
in.
16. INNER CASING OR TUBING (geothermal ducted -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
0 ft.
20 ft.
1 in.
sch40
pvc
ft.
ft.
in.
17.SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
20 ft•
35 ft.
2 in.
.010
sch40
pvc
ft.
ft.
in.
118. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD&AMOUNT
0 ft.
15 ft•
Portland Cem
Pour
15 ft.
18 ft-
Bentonite Chi
Pour
ft.
ft.
19. SAND/GRAVEL PACK
(if applleablel
FROM
TO
MATERIAL
EN, PLACEM EY!' mrrHDD
18 ft.
35 ft.
#1 Sand
Pour
ft.
ft.
20. DRILLING
LAG lrttaeh additional aheeh If necessary)
FROM
TO
DESCRIPTION I co Inv, hardness, soil/rvric r.pc. grrdn rim etc.l
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
21. REMARKS
22. Cerification:
>r
Signarur/ofCertified Well Contractor
7(g7
Date
Ht si arng this firm, / hereby certify that the well(t) was (were) constructed in accordance
with 15A N('AC 02(' .0100 or l5A N('AC 02('.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 Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Injection 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- I
North Carolina Department of Environment and Natural Resources - Division of Water Resources
Revised August 2013

WELL CONSTRUCTION RECORD
For Internal Use ONLY:
This form can be used for single or multiple wells
I. Well Contractor Information:
Lewis Lefever
Well Contractor Name
2480
NC Well Contractor Certification Number
Parratt-Wolff, Inc.
Compam Name
2. Well Construction Permit#:
List all applicable wet/ permits (i.e. (busty, Stale, I ariance, Injection, etc.)
3. Well Use (check well use):
Water Supply Well:
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑industrial/Commercial
❑ lrri gati on
❑Municipal/Public
❑ Residential Water Supply (single)
❑Residential Water Supply (shared)
-Non-Water Supply Well:
O Monitoring
❑Recovery
injection Well:
❑Aquifer Recharge
El Aquifer Storage and Recovery
❑Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling Return)
❑ Groundwater Remediation
❑Salinity Barrier
❑ Stormwater Drai nage
❑Subsidence Control
Tracer
❑Other (explain under #21 Remarks)
4. Date Well(s) Completed: 6-24-20
5a. Well Location:
Plantation Pipe Line Co
Well ID# SVE-113
Facility/Owner Name Facility ID/! (if applicable)
2617 Quaker Landing Road, Greensboro, NC
Physical Address, City, and Zip
Guilford
7847837248
County Parcel Identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
Orwell field one lat/long is sufficient)
36.146598 Nr-79.851008
6. Is (are) the well(s): OPermanent or ❑Temporary
w
7. Is this a repair to an existing well: ❑Yes or ENo
If this is a repair, fill out known well construction information and explain the nature of the
repair under ,21 remarks section or on the back of this /ornc
8. Number of wells constructed: 1
For multiple injection or non -water supply wells ONLY with the same construction, you can
.submit one,fornl.
9. Total well depth below land surface: 30
For multiple wells list all depths if different (example- 3 rt 200' and 2@l00')
10. Static water level below top of casing: 0
IJ ialer lerel is above casing, use "-
11. Borehole diameter: 4 (in.)
12. Well construction method: 8 1/4" HSA
(ft.)
(ft.)
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
14. WATER ZONES
FROM
TO
DESCRIPTION
ft.
ft.
ft.
ft.
15- OUTER CASING Srar multi -cased wefts) OR LINER (lfapptlfable)
FROM
TO
DIAMETER
THICKNESS 1 MATERIAL
ft.
ft.
in.
16. INNER
CASING OR TtrI1RtiG
(geothermal dosed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
0 ft.
15 ft.
1 in.
sch40
pvc
ft.
ft.
in.
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL,
15 it
30 ft.
2 in.
.010
sch40
pvc
ft.
ft.
in.
19. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
3 ft.
11 It
Portland Cem
Pour
11 ft.
13 ft
Bentonite Chi
Pour
ft.
ft.
19. SAND/GRAVEL
PACK
of applirihk),
FROM
TO
MATERIAL
EMPL'.CEM ENT METHOD
13 ft.
30 ft.
#1 Sand
Pour
ft.
ft.
10. DRILLING LOG (Wadi addipanal sheets it neeeaaltrg)
FROM
TO
DESCRIPTION (ruler- hat Inrss, soilfrock type, gran sire, ete.l
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
21. REMARKS
1 Bottom Cap
1 Slip Cap
22. ('ertitj
Si siaipre ot'Cerll led Well Contractor
7/s/2‹)
Date
By .signing this Arm, l hereby certify Iha1 the wells) was (were) constructed in accordance
with I5A NCAC 02('.0100 or /5A NCAC 02C.0200 Well Construction Standards and that a
copy of this record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details You may also attach additional pages if necessary.
SUBMITTAL INSTUCTIONS
24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Resources, information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For. Irliection 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.
Foi m GW-1 North Carolina Department of Environment and Natural Resources — Division of Water Resources
Revised August 2013

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
1. Well Contractor information:
Lewis Lefever
Well Contractor Name
2480
NC Well Contractor Certification Number
Parratt-Wolff, Inc.
Company Name
2. Well Construction Permit#:
List all applicable well permits (i.e. County, Stale, Variance, Injection, etc.)
3. Well Use (check well use):
Water Supply Well:
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑industrial/Commercial
❑irrigation
❑Municipal/Public
❑ Residential Water Supply (single)
❑Residential Water Supply (shared)
Non -Water Supply Well:
@Monitoring
❑ Recovery
Injection Well:
❑ Aquifer Recharge
❑ Aquifer Storage and Recovery
❑Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Coolina Retum)
4. Date Well(s) Completed: 6-26-20
5a. Well Location:
Plantation Pipe Line Co
❑Groundwater Remediation
❑Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑Tracer
❑ Other (explain under #21 Remarks)
Well ID# SVE-114
Facility/Owner Name Facility ID# (if applicable)
2617 Quaker Landing Road, Greensboro, NC
Physical Address, City, and Zip
Guilford
7847837248
County Parcel Identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one tat/long is sufficient)
36.146690 N-79.851013
6. Is (are) the well(s): @Permanent or ❑Temporary
w
7. Is this a repair to an existing well: ❑Yes or ENo
I/ this is a repair, fill out known well construction information and explain the nature o/ the
repair under r2I remarks .section or on the back of this prim
8. Number of wells constructed: 1
For multiple injection or non -crater supply wells ONLY with the same construction, you can
.submit one form,
9. Total well depth below land surface: 30 (ft,)
For multiple wells list all depths i/ different (example- 3@200' and 2@/00')
10. Static water level below top of casing: 0 (ft.)
If water level is above casing, use "-
11. Borehole diameter: 4 (in.)
12. Well construction method: 8 1/4" HSA
(i.e, auger, rotary, cable, direct push, etc,)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type:
Amount:
For Internal Use ONLY:
141. WATER ZONES
FROM
TO
DESCRIPTION
ft.
ft.
ft.
ft.
19. OUTER CASING (far multi -eased wall OR LINER (If op p
km We)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft.
ft.
in.
Ill
t6. INNER CASING OR TUBING (geothermal eIoeed-1 oop)
FROM
TO
DIAMETER
THICKNESS
MATERIAI.
0 ft.
15 ft.
1 in.
sch40
pvc
ft.
ft.
in.
17. SCREEN
FROM
TO
DIAMETER
S1.OTSIZE
THICKNESS
MATERIAL
15 ft
30 ft.
2 in.
.010
sch40
pvc
ft.
ft.
in.
-.111~GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
3 ft.
11 ft•
Portland Cem
Pour
11 ft.
13 ft•
Bentonite Chi
Pour
ft.
ft.
19. SAND/GRAVEL PACK
(il applicahk)
FROM
TO
MATERIAL
EMPLAC EIIEVE METHOT)
13 ft.
30 ft.
#1 Sand
Pour
ft.
ft.
29. DR1LLl'G
LOG (attach
additional sheers ifneeessary)
FROM
TO
IIF.SCR IPTION [color. hardnnr, soil/rock rope. grain sire. etc.(
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft
ft.
ft.
ft.
ft.
21. RE!11.►RKS
1 Bottom Cap
1 Slip Cap
22. C crtif-
Signature of C ed Well Contractor
Date
/sizr--'
Hy signing this firm, I hereby cerliJy that the we//(s) was (were) constructed in accordance
with hA NCA(' 02C.0I00 or ISA NCA(' 02C.0200 Well Construction Standards and that a
copy (Otis record has been provided to the we// 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 Welk: 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 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-I North Carolina Department of Environment and Natural Resources - Division of Water Resources
Revised August 2013

WELL CONSTRUCTION RECORD
This rin'm can b•_ used fur si i k ur multiple wells
1. Well Contractor Information:
Virgil Wilson
Well Contractor Name
4473
NC Well Contractor Certification Number
Parratt-Wolff, Inc.
Company Name
2. Well Construction Permit#:
List all applicable well permits (Le, County, State, I irrianc•e, Injection, eic)
3. Well Use (check well use):
Water Supply Well:
❑Agricultural
❑ Geothermal (Heating/Cooling Supply)
❑industrial/Commercial
❑Irrl atlnn
Non -Water Supply Well:
❑ Monitoring
Injection Well:
❑Aquifer Recharge
❑Aquifer Storage and Recovery
❑ Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑ Geothermal (Heating/Cooling Returnl
4. Date Well(s) Completed: 6-19-20
❑Municipal/Public
❑ Residential Water Supply (single)
❑Residential Water Supply (shared)
❑Recovery
❑Groundwater Remediation
❑Salinity Barrier
❑ Stormwater Drainage
❑Subsidence Control
❑ Tracer
❑ Other(explain under #2l Remarks)
5a. Well Location:
Plantation Pipe Line Co
Well ID# AS-101 SAD
Facility/Owner Name Facility ID# (if applicable)
2617 Quaker Landing Road, Greensboro, NC
Physical Address, City, and Zip
Guilford
7847837248
County Paicel Identification No (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field one lat/long is sufficient)
36.146890 N-79.850538 W
6. Is (are) the well(s): OPermanent or Temporary
7. Is this a repair to an existing well: ❑Yes or ONo
Obis is a repair, fill out known well construction information and explain the nature of the
repair under =2/ remarks section or on the back of ibis farm,
8. Number of wells constructed: 1
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: 96 (fl )
For multiple wells list all depths i/ different (example- 3i200' and 2a 100')
10. Static water level below top of casing: 52 (ft.)
If tuner level is above casing, use "-
11. Borehole diameter: 1
(in.)
12. Well construction method: 8 1/4" HSA
(Le. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
I3a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
For Internal Use ONLY:
Id. WATER ZONES
FROM
TO
DESCRIPTION
52 rt.
96 ft.
wet
ft.
ft.
15. OUTER CASING (far mufti -cased wale) OR LINER Or apPStehle)
FR DM
TO
DIAMETER
THICKNESS I MATERIAL
ft.
ft.
in.
!Ij
16. INNER
CASING OR TUBING
tgeathermel dosed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERRIAI.
0 ft.
72 ft.
1 in.
sch40
pvc
0 ft.
94 ft.
in.
17. SCREEN
FROM
TO
DIAMETER
SI.OT SIZE
THICKNESS
MATERIAL
72 ft.
74 ft.
1 in.
.010
sch40
pvc
94 ft.
96 R.
1 I"'
.010
sch40
pvc
IS. GROUT
FROM
TO
MATERLAL
KMPL►C EMENT METHOD & AMOUNT
4 ft.
68 ft.
Portland Cem
Pour
70 ft'
78 ft,
Bentonite Chi
Pour
92 ft.
96.5 ft•
Bentonite Chit
Pour
19. SANDPGRAVEL
PACK.Airapplicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
70 ft.
78 ft.
#1 Sand
Pour
92 ft,
96.5 ft•
#1 Sand
Pour
20. DRILLING LOG (attach
additional sheets If neerssery)
FROM
TO
DESCRIPTION Icolor. ha•dnns. .of/frock hype, Tin size. ele)
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
21. REMARKS
Nested Wells
1 Shallow, 1 Deep
22. f/Cer$ificatiun:
Sign n: ot•C'ertilied WeII.Contructur
Date
By signing this firm, I hereby certify that the Ire/l(s) u•as (trere) constructed in accordance
with /5A N('A(' 02('.0100 or /5.4 N('A(' 02(',0200 Well Construction Standards and that a
cope 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. Fur 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. Fur Injection 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- I
North Carolina Department of Environment and Natural Resources - Division of Water Resources Revised August 2013

WELL CONSTRUCTION RECORD
This form can be used foi single or multiple welIs
1. Well Contractor Information:
Virgil Wilson
Well Contractor Name
4473
NC Well Contractor Certification Number
Parratt-Wolff, Inc..
Company Name
2. Well Construction Permit #:
List all applicable well permits (i.e. County, Slate, Variance, Injection, etc.)
3. Well Use (check well use):
For Internal Use ONLY:
14. WATER ZONES
FROM
TO
DESCRIPTION
52
ft.
93
ft.
wet
ft.
ft.
IS. OUTER CASING !fur multi -cased wells) OR LINER (if ap lleable)
FROM THICKNESS PI MATERIAL
in
TO
ft.
ft.
DLO/ETER
16. 1NNER CASING OR TUBING teeothermal closed-lmttt)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
0
ft.
72
ft.
1
in.
sch40
pvc
0
ft.
91
ft.
1
In.
sch40
pvc
17. SCREEN
Water Supply Well:
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑industrial/Commercial
©Irritation
Non -Water Supply Well:
OMonitoring
❑Municipal/Public
❑Residential Water Supply (single)
OResidential Water Supply (shared)
❑ Recovery
Injection %Veil:
❑ Aquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer Test
❑ Experimental Technology
❑Geothermal (Closed Loop)
❑ Geothermal (I-ieatimJCoolinu Return)
4. Date Well(s) Completed: 6-19-20
5a. Well Location:
Plantation Pipe Line Co
❑Groundwater Remediation
❑Salinity Barrier
❑ Stormwater Drainage
❑Subsidence Control
❑Tracer
❑ Other (explain under #21 Remarks)
Well ID# AS-1 02 SAD
Facility/Owner Name Facility JD# (if applicable)
2617 Quaker Landing Road, Greensboro, NC
Physical Address, City, and Zip
Guilford
7847837248
County Patcel identification No (PiN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field one lat/long is sufficient)
36.146896 -79.850372
w
6. is (are) the well(s): OPermanent or ❑Temporary
7. Is this a repair to an existing well: ❑Yes or ENo
// ihis is a repair,Jill out known well construction inlhrmalion and explain the nature of the
repair under =2/ remarks section or on the hack oft/tis form
8. Number of wells constructed: 1
For multiple injection or non -water supply hells ONLY with the same construction, you can
submit one form.
9. Total well depth below land surface: 74 / 93
For multiple Ire/Ls list all depths if di/jere t (example- 3 rt.200' and 2 a 100')
(ft.)
10. Static water level below top of casing: 50 (ft.)
iJ water level is above casing, axe '
11. Borehole diameter: 1 (in.)
12. Well construction method: 8 1/4" HSA
(Le. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAI.
72 ft.
74 ft.
1
in.
.010
sch40
pvc
91 ft.
93 ft.
1
in.
.010
sch40
pvc
18. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
6
ft.
68
ft.
Portland Cern
Pour
68
ft.
70
ft.
Bentonite Chi.
Pour
79.5 ft.
89
ft.
Bentonite Chf
Pour
19. SAND/GRAVEL PACK (if appHcahle)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
70
ft.
79.5 ft.
#1 Sand
Pour
89
ft.
93
ft.
#1 Sand
Pour
20. DRILLING LOG (attach additional sheets ifneeeasary)
FROM
ft.
TO
ft.
DESCRIPTION [color. hardness. sail/rock type. yrsin .due, tic-1
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
21. REMARKS
Nested Wells
1 Shallow, 1 Deep
22. Certification:
Signa(J f Certified Well Contractor
Date
By signing this 'Orin, / hereby certify that the well(s) tilts (here) constructed in accordance
with l5A N('A(' 02('.0100 or /5A N('A(' 02(' .0200 Well Construction Standards and that a
copy oldies 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. Fur 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. Fur Injection 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-I
North Carolina Department of Environment and Natural Resources - Division of Water Resources Revised August 2013

WELL CONSTRUCTION' RECORD
This form can be used foi single or multiple wells
1. Well Contractor Information:
Virgil Wilson
Well Contractor Name
4473
NC Well Contractor Certification Number
Parratt-Wolff, Inc.
Compam Namc
2. Well Construction Permit#:
List all applicable well permits (i,e, County, Slate, Variance, Injection, etc.)
3. Well Use (check well use):
Water Supply Well:
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑industrial/Commercial
❑ lrrigati on
❑Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
Non -Water Supply Well:
O Monitoring
❑ Recovery
Injection Well:
❑ Aquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑ Geothermal (Heating/Cooling Return)
4. Date Well(s) Completed: 6-19-20
5a. Well Location:
Plantation Pipe Line Co
❑Groundwater Remediation
❑ Salinity Barrier
❑ Stormwater Drainage
❑Subsidence Control
0 Tracer
❑Other (explain under #21 Remarks)
well ID# AS-103 S/D
Facility/Owner Name Facility ID# (if applicable)
2617 Quaker Landing Road, Greensboro, NC
Physical Address, City, and Zip
Guilford
7847837248
County Parcel Identification No (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field one lat/long is sufficient)
36.146935 N-79.850549
6. Is (are) the well(s): )Permanent or ❑Temporary
w
7. Is this a repair to an existing well: ❑Yes or ONo
Il this is a repair, Jill out known well construction itllormal,on and explain the nature of the
repair under - 21 remarks section or on the hack cJ lhis_fornt.
8. Number of wells constructed: 1
For andtiple injection or non -water supply wells ONLY with the same construction, you can
submit one, form.
9. Total well depth below land surface: 74 / 93
For nadtiple wells list all depths il'dillerent (example- 3@200' and 2@ 100')
(ft.)
10. Static water level below top of casing: 50 (ft.)
if water level is above casing, use " - "
11. Borehole diameter: 1 (in.)
12. Well construction method: 8 1/4" HSA
(i,e, auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
For Internal Use ONLY;
14. WATER ZONES
FRO,H
TO
DESCRIPTION
52 ft.
93 ft.
wet
ft.
ft.
15. OUTER CASING {fur multi -cased wells) OR LINER (ifap llcaMe)
FROM
TO
DIAMETER
THICKNESS MATERIAL
ft.
ft.
in.
16. INNER CASING OR TUBING (geothermal dined -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
0 ft.
72 ft.
1 1n.
sch40
pvc
0 ft.
91 ft.
1 in.
sch40
pvc
1/. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
NL►TERIAL
72 ft.
74 ft.
1 in.
.010
sch40
pvc
90 ft.
92 it
in.
.010
sch40
pvc
18. GROUT
FROM
TO
MATERIAL
EMPL►CEM ENT METHOD & AMOUNT
5 ft.
68 ft.
Portland Cem
Pour
68 ft.
70 ft•
Bentonite Chii
Pour
78 ft.
88 ft.
Bentonite Chii
Pour
19. SANDIGRAVEI. PACK
{if applicable)
FROM
TO
►1:►TER1AL
EMPLACEMENT METHOD
70 ft.
78 ft.
#1 Sand
Pour
88 ft-
92 ft.
#1 Sand
Pour
20. DRILLING
LOG tanaeh additlnawl shuts. if nereasxry)
FROM
TO
DESCRIPTION (minr. hardness., enll& nk iypr. gran six, etc_)
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
21. REMARKS
Nested Wells
1 Shallow, 1 Deep
22. Certification:
Signe of Certified Well eontrucior
Z/ei
Date
By .signing thisJOrin, 1 hereby cerlifi- that the well(s) was (were) constructed in accordance
with 15A N('AC 02('.0100 or 15,4 N('A(' 02C,0200 Well Construction Standards and Thal 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 INSTUCT!ONS
24a. Fur 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. Fur Infection Wells ONLY: In addition to sending the form to the address in
24aabove, 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.
Foi GW-I North Carolina Department of Environment and Natural Resources - Division of Water Resources
Revised August 2013

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
1. Well Contractor Information:
Virgil Wilson
Well Contractor Name
4473
NC Well Contractor Certification Number
Parratt-Wolff, Inc.
Company Name
2. Well Construction Permit#:
List all applicable well permits (i.e. County, Stale, I uriance, Injection, etc.)
3. Well Use (check well use):
Water Supply Well:
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑ industrial/Commercial
❑irrigation
❑Municipal/Public
❑ Residential Water Supply (single)
❑Residential Water Supply (shared)
Non -Water Supply Well:
O Monitoring
❑Recovery
Injection 11'ell:
❑ Aquifer Recharge
❑Aquifer Storage and Recovery
Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling Return)
4. Date Well(s) Completed: 6-26-20
5a. Well Location:
Plantation Pipe Line Co
❑ Groundwater Remediation
❑ Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑ Tracer
❑Other (explain under #21 Remarks)
Well ID# AS-104 S/D
Facility/Owner Name Facility ID# (if applicable)
2617 Quaker Landing Road, Greensboro, NC
Physical Address, City, and Zip
Guilford
County
7847837248
Parcel Identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
36.146815
N-79'850543
6. Is (are) the well(s): EJPermanent or ❑Temporary
w
7. Is this a repair to an existing well: ❑Yes or 1No
1/ this is a repair,, fill out known well construction information and e.rplain the nature of the
repair under -2/ remarks .section or on the back of. his Jima
8. Number of wells constructed: 1
For multiple injection or non -water .supply wells ONLY with the same construction, you can
submit one, fihrin.
9. Total well depth below land surface: 74/90 (ft.)
For multiple wells list all depths if -different (example- 3 200' and 2(iD/00')
10. Static water level below top of.casing: 49 (ft.)
If [rater level is above casing, use " "
11. Borehole diameter: 1 (in.)
12. Well construction method: 8 1/4" HSA
(Le. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
I3a. Yield (gpm) Method of test:
13b. Disinfection type:
Amount:
For Internal Use ONLY
14. WATER ZONES
FROM _.
TO
DESCRIPTION
49 ft.
90 ft.
wet
ft.
ft.
IS. OUTER CASING (for multi -cased wills) OR LINER (if ap (cable)
FROM
TO
DIAMETER
THICKNESS
M.ATER IA
ft.
ft.
in.
16. INFER
CASING OR TUBING (geothermal closed -loop(
FROM
TO
—DIAMETER
THICKNESS
MATERIAL
0 ft.
72 ft.
1 in.
sch40
pvc
0 ft•
88 ft.
1 in.
sch40
pvc
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
72 ft'
74 ft•
1 in.
.010
sch40
pvc
88 ft.
90 ft.
1 in.
.010
sch40
pvc
1R GROUT
FROM
TO
MATERIAL
EMPLACEM ENT M ETH OD & AMOUNT
3 ft.
68 ft•
Portland Cem
Pour
68 ft.
70 ft*
Bentonite Chi
Pour
78.2 ft.
86 it
Bentonite Chi
Pour
19. SAND/GRAVEL PACK (if applicable)
FROM
TO
\LATER! ■L
£MPLACTMENT METHOD
70 ft'
78.2 ft•
#1 Sand
Pour
86 ft.
90 ft.
#1 Sand
Pour
20. DRILLING
LOG (ouch
additional ahem if nrceasaryl
FROM.
TO
DESCRIPf ION (color. luridness, suiFrock ripe. grin sru.etc,)
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
Ft.
21. REMARKS
Nested Wells
1 Shallow, 1 Deep
22. Certiticanon:
Si oarure
/f.(+%V•{ Slr.
eitifled Well Contractor
By Algot ttg Ihii,Jiirm, l hereby certify that the tie//(s) was (were) constructed in accordance
with 1.5.4 N('AC 02(' ,0100 or 15A NCAC 02('.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 Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Injection 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-I North Carolina Department of Environment and Natural Resources — Division of Water Resources
Revised August 2_013

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
I. Well Contractor Information:
Virgil Wilson
Well Contractor Name
4473
NC Well Contractor Certification Number
Parratt-Wolff, Inc.
Compam Name
2. Well Construction Permit#:
List all applicable well permits (i.a County, Stale, I ariance, hyaena?, ?, etc.)
3. Well Use (check well use):
Water Supply Well:
❑ Agricultural
❑Geothermal (Heating/Cooling Supply)
❑industrial/Commercial
❑ Irrigation
Non -Water Supply Well:
0 Mon itori ng
❑Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
❑Recover'
Injection Welk
❑Aquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cool ing Return 1
4. Date Well(s) Completed: 6-30-20
❑Groundwater Remediation
❑Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑Tracer
❑Other (e tpiain under #21 Remarks!
5a. Well Location:
Plantation Pipe Line Co
Well IDto AS-105
Facility/Owner Name Facility ID# (if applicable)
2617 Quaker Landing Road, Greensboro, NC
Physical Address, City, and Zip
Guilford
7847837248
County Parcel identification No (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
36.146718 N-79.850509
6. Is (are) the well(s): 11Permanent or ❑Temporary
w
7. Is this a repair to an existing well: ❑Yes or ENo
1/ this is a repair, fill aul known well construction information and explain the nature ophe
repair under =21 remarks section or an the hack of his fond.
8. Number of wells constructed: 1
For multiple injection or non -water supply wells ONLY with the same construction, you can
submit one_/orm.
9. Total well depth below land surface: 71.5
For multiple wells list all depths it dilferent (example- 3@200' and 2@ l00')
(ft.)
10. Static water level below top of casing: 52 (ft.)
If water level is above casing, use "- "
11. Borehole diameter: 1 (in.)
12. Well construction method: 8 1/4" HSA
(La auger, rotary, cable, direct push, etc)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type:
Amount:
For Internal Use ONLY:
14. WATER ZONES
FROM
TO
DESCRIPTION
52 ft.
71.5 Ft
wet
ft.
ft.
15.OUTER CASING (fur multi-cnxedweIs) OR LINER (if sip P!cable)
FROM
TO
DIAMETER
THICKNESS I MATERIAL
ft.
ft.
in.
16. INNER CASING OR TUBING (geothermal rimed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
0 ft.
69.5 ft.
1 in.
sch40
pvc
ft.
ft.
in.
17. SCREEN
FROM
TO
DIAMETER
SLAT SIZE
THICKNESS
MATERIAL
69.5 ft
71.5 ft.
1 in.
.010
sch40
pvc
ft.
ft.
in.
18. GROUT
FROM
TO
MATERIAL
EMPLACEM ENT M ETH OD & AMOUNT
4 ft.
65.5 ft
Portland Cem
Pour
65.5 ft
67.5 ft•
Bentonite Chi
Pour
ft.
ft.
19. SAND/GRAVEL PACK (if applicable)
FROM
TO
MATERIAL
EMPLACEMENT Mrill ❑D
67.5 ft
71.5 ft.
#1 Sand
Pour
ft.
ft.
20. DRILLING
LOG (attach additional sheets if necessary)
FROM
TO
DESCRIPTION I color•. hardness. sot Prot.k trim. ),rain sire, ere.I
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
21. REMARKS
Nested Wells
1 Shallow, 1 Deep
22. Certification:
Y_i
Sigiur of Certified Well Contractor
Date
l3v .slpnog this farm, 1 hereby certifk that the we//(s) was (were) constructed in accordance
with 15A NcAC 02C .0100 or 15,-) N('AC 02( .02011 Well Construction Standards and that a
copy oflhis 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 Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Injection 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-I
North Carolina Department of Environment and Natural Resources - Division of Water Resources Revised August 2013

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
1. Well Contractor Information:
Lewis Lefever
Well Contractor Name
2480
NC Well Contractor Certification Number
Parratt-Wolff, Inc.
Company Name
2. Well Construction Permit #:
List all applicable well permits (i.e. County, Slate, Variance, Injection, etc.)
3. Well Use (check well use):
Water Supply Well:
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑ Industrial/Commercial
❑ Irrigation
❑ Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
Non -Water Supply Well:
OMonitoring
❑ Recovery
Injection Well:
Aquifer Recharge
❑Aquifer Storage and Recovery
▪ Aquifer Test
❑Experimental Technology
❑ Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling Retum)
4. Date Well(s) Completed: 6-16-20
❑Groundwater Remediation
❑ Salinity Barrier
❑Stonnwater Drainage
❑Subsidence Control
❑Tracer
❑Other (explain under #21 Remarks)
5a. Well Location:
Plantation Pipe Line Co
Well ID# AS-1 06 S/D
Facility/Owner Name Facility ID# (if applicable)
2617 Quaker Landing Road, Greensboro, NC
Physical Address. City, and Zip
Guilford
County
7847837248
Parcel Identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(dwell field, one lat/long is sufficient)
36.146874 N-79.850664
w
6. Is (are) the well(s): Permanent or
❑Temporary
7. Is this a repair to an existing well: ❑Yes or lNo
If this is a repair, ill out known well construction information and explain the nature of the
repair under =2/ remarks section or on the hack ofthis form.
8. Number of wells constructed: 1
For multiple injection or non -water supply wells ONLY with the same construction, you can
submit one for .
9. Total well depth below land surface: 74.5 / 97 (ft.)
For multiple wells list all depths if different (example- 3@200' and 2 a 100')
10. Static water level below top of casing: 49 (ft.)
/f water level is above casing, use "
11. Borehole diameter: 1
(in.)
12. Well construction method: 8 1/4" HSA
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type:
Amount:
For Internal Use ONLY:
I -I. WATER ZONES
FROM
TO
DESCRIPTION
49 ft.
97 ft.
wet
ft.
ft.
IS. OUTER CASING (far ntutti-cased wells} OR LiNER (if app
ieabk}
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft.
ft.
in.
16. INNI R CASING OR TUBING ( rnthermal closed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL.
0 ft.
72.5 ft.
1 in.
sch40
pvc
0 ft.
95 ft
1 in.
sch40
pvc
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
72.5 ft-
74.5 it
in.
.010
sch40
pvc
95 ft.
97 ft.
1 in.
.010
sch40
pvc
18. GROUT
FROM
TO
MATERIAL
F.s1PLACEMENT METHOD & AMOIINT
3 ft-
67.5 ft.
Portland Cem
Pour
67.5 ft.
70 ft.
Bentonite Chi
Pour
91 ft.
93 ft.
Bentonite Chi
Pour
19. SAND/GRAVEL
PACK (if applicable)
FROM
TO
MATERAAI.
EMPLACEMENT METHOD
70 ft.
80 ft.
#1 Sand
Pour
93 ft.
97 ft.
#1 Sand
Pour
2o. DRILLING
LoG (atmchaldditi"aal sheets if necessary) _.
FROM
TO
DESCRIPTION (color, hardness, sotlhwek type. grain sire. eic.l
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
21. REMARKS
Nested Wells, 1 Shallow, 1 Deep
1 Bottom Cap; 1 Slip Cap
Signature of Certified Well Contractor
Date
By .signing lhisform, 1 hereby certify that the well(s) was (were) constructed ,n accordance
with I5A N('A(' 02C .0/00 or I5A N('AC 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 Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Injection 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-I
North Carolina Department of Environment and Natural Resources - Division of Water Resources Revised August 2013

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
1. Well Contractor Information:
Lewis Lefever
Well Contractor Name
2480
NC Well Contractor Certification Number
Parratt-Wolff, 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):
For Internal Use ONLY:
14. WATER ZONES
FROM
TO
DESCRIPTION
49
ft.
97
ft.
wet
ft.
ft.
IS. OUTER CA51NC (far multi -cased welts) q
FROM
ft.
'ro
ft.
DIAMETER
in.
R LINER Of •pplieab1r)
THICKNESS MATERIAi.
16. INNER CASING OR'r(ttuNG (geothermal etased-loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
0
ft.
71
ft.
1
in.
sch40
pvc
ft.
fL
in.
17. SCREEN
Water Supply Well:
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑ Industrial/Commercial
❑Irrigation
❑Municipal/Public
❑ Residential Water Supply (single)
❑Residential Water Supply (shared)
Non -Water Supply Well:
21Monitoring
❑ Recovery
Injection Well:
❑Aquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer Test
0 Experimental Technology
OGeothermal (Closed Loop)
0Geothermal (Heating/Cooling Return]
4. Date Well(s) Completed: 6-9-20
5a. Well Location:
Plantation Pipe Line Co
0 Groundwater Remediation
❑Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑Tracer
❑ Other (explain under #2l Remarks)
Well ID# AS-107
Facility/Owner Name Facility IDA (if applicable)
2617 Quaker Landing Road, Greensboro, NC
Physical Address, City, and Zip
Guilford
7847837248
Comity Parcel Identification No (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
36.146812 N -79 850551
6. Is (are) the well(s): E?lPermanent or ❑Temporary
7. Is this a repair to an existing well: ❑Yes or E lNo
If this is a repair, fill out known well construction information and explain the nature oldie
repair under =2/ remarks .section or on the hack of this form.
8. Number of wells constructed: 1
For multiple injection or non -water supply wells ONLY with the same construction, you can
submit one form.
9. Total well depth below land surface: 74
For multiple wells list all depths if -different (example- 3@200' and 2 rt I00')
(ft.)
10. Static water level below top of casing: 49 (ft.)
If water level is above casing, use " -
11. Borehole diameter: 1 (in.)
12. Well construction method: 8 1/4" HSA
(i.e auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
FROM
-CO
DIA NLETER
SLOT SIZE
THICKNESS
}IATERIAL
71 it
74 ft.
1
in.
.010
sch40
pvc
ft.
ft.
in.
IS, GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
2 ft.
68
ft.
Portland Cem
Pour
68
ft.
70 ft.
Bentonite Chi
Pour
ft.
ft.
19. SAND/GRAVEL PACK. (if applicable}
FROM
TO
MATERIAL
EMPLACEMENT si rnioD
72
ft.
74
ft.
#1 Sand
Pour
ft.
ft.
20. DRILLING LOG (attach additional sheets Er oeceesary)
FROM
ft.
TO
ft.
DESCRIPTION (color, hardness- moll/rock type, grain si e. the.)
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
21. REMARKS
1 Bottom Cap; 1 Slip Cap
22. CertiGtatien:
Win of Certified Well Contractor
(o129/e...4)
Date
By signing this firma, 1 hereby certfv that the well(s) was (were) constnncted in accordance
with 15A NC'AC 02('.0100 or 15A N('AC 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 Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For lniection 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
This form can be used for single or multiple wells
1. Well Contractor Information:
Lewis Lefever
Well Contractor Name
2480
NC Well Contractor Certification Number
Parratt-Wolff, Inc.
Company Name
2. Well Construction Permit #:
Liri all applicable well permits (i.e. County, Stale, Variance, Injection, etc.)
3. Well Use (check well use):
Water Supply Well:
❑Agricultural ❑Municipal/Public
❑Geothermal (Heating/Cooling Supply) ❑Residential Water Supply (single)
❑Industrial/Commercial ❑Residential Water Supply (shared)
❑Irrigation
Non -Water Supply Well:
0 Monitoring ❑ Recovery
Injection Welt:
❑Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stonnwater Drainage
❑Experimental Technology ❑Subsidence Control
❑Geothermal (Closed Loop) ❑Tracer
❑Geothermal (Heating/Cooling Return) ❑Other (explain under #2 1 Remarks)
4. Date Well(s) Completed: 6-9-20
5a. Well Location:
Plantation Pipe Line Co
Facility/Owner Name
Well ID# AS-1 08
Facility ID# (if applicable)
2617 Quaker Landing Road, Greensboro, NC
Physical Address, City, and Zip
Guilford
7847837248
County Parcel Identification No (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
36.146812 N-79.850468
6. Is (are) the well(s): EPermanent or ❑Temporary
W
7. Is this a repair to an existing well: ❑Yes or ONo
If this is a repair fill out known well construction in[,rntation and explain the nature of the
repair raider .. 21 remarks .section or on the hack of this• form,
8. Number of wells constructed: 1
For multiple injection or non -water supply wells DAILY will; the same construction, you can
submit one firm.
9. Total well depth below land surface: 68
Par multiple wells list all depths ifdifferent (example- 3@200' and?(1-J100')
10. Static water level below top of casing: 50 (ft.)
/f water level is above casing, use " "
11. Borehole diameter: 1 (in.)
12. Well construction method: 8 1/4" HSA
(re auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
For Internal Use ONLY.
14. WATER ZONES
FROM
TO
DESCRIPTION
50 ft.
68 ft.
wet
ft.
ft.
15..OUTER CASING (for multi-crsed.wenn) OR LINER (if app
ieahle)
FROM
TO
DIAMETER
THICKNESS 1
MATERIAL
ft.
ft.
in.
11
16. INNER
CASING OR TUBING
(geothermal
cloud -Imp) .
FROM
TO
DIAMETER
THICKNESS
MATERIAL
0 ft.
68 ft.
1 in.
sch40
pvc
ft.
ft.
in.
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
66 ft.
68 ft
1 in.
.010
sch40
pvc
ft.
ft.
in.
I9. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
3 ft.
62 ft
Portland Cem
Pour
62 ft
64 ft
Bentonite Chii
Pour
ft.
ft.
I9. SAND/GRAVEL PACK (if applicable)
FROM
To
MATERIAL
EMPLACEMENT' METHOD
64 ft
68 ft.
#1 Sand
Pour
ft.
ft.
20. AR1LI.1NG
LOG (mulch
additional cheer. if eeeessary)
FROM
TO
DESCRIPTION lenler, hardness, son/rack type. grain siati am -I
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
21. REMARKS
22. Certifuiition:
Tgnaiure of Certified Well Contractor
Date
By signing this farm l hereby c•ertifr that the }eel/(s) was (were) constructed in accordance
with 15A N('A(• 02(' .0100 or 15,4 N('A(' 02(' .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
(ft) 24a. For MI Wells: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Resources, information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Injection 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-I North Carolina Department of Environment and Natural Resources - Division of Water Resources
Revised August 2013

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
1. Well Contractor Information:
Lewis Lefever
Well Contractor Name
2480
NC Well Contractor Certification Number
Parratt-Wolff, Inc.
Company Name
2. Well Construction Permit #:
List all applicable well permits (i.e. County, S)ate, I'triauce, Injection, etc.)
3. Well Use (check well use):
For Internal Use ONLY:
14. WATER ZONES
FROM
TO
DESE-RIFT-ION
50
ft.
68
ft.
wet
ft.
ft.
I5. OUTER CASING (tormult1tased wells) OR LINER (ifap Limbic)
THICKNESS 1 MATERIAL
FROM
ft.
ft.
DIAMETER
in.
16. INNER CASING OR TUURING fere thermal dosed-Ipop)
FROM
TO
DIAMETER
THICKNESS
MATERIA L
0
ft.
79
ft.
in.
sch40
pvc
ft.
ft.
in.
17. SCREEN
Water Supply Well:
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑ Industrial/Commercial
❑Irrigation
❑Municipal/Public
❑Residential Water Supply (single)
❑ Residential Water Supply (shared)
Non -Water Supply Well:
❑O Monitoring
❑ Recovery
Injection Well:
❑Aquifer Recharge
❑Aquifer Storage and Recovery
DAquifer Test
Experimental Technology
❑Geothermal (Closed Loop)
❑ Geothermal (Heating/Cooling Return)
4. Date Well(s) Completed: 6-10-20
5a. Well Location:
Plantation Pipe Line Co
❑ Groundwater Remediation
❑Salinity Barrier
❑ Stonnwater Drai nage
❑ Subsidence Control
Tracer
❑Other (explain under #21 Remarks)
Well ID# AS-109
Facility/Owner Name Facility ID# (if applicable)
2617 Quaker Landing Road, Greensboro, NC
Physical Address. City, and Zip
Guilford
County
7847837248
Parcel Identification No (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(dwell field, one lat/long is sufficient)
36.146799 N-79.850720
6. Is (are) the well(s): l 1Permanent or ❑Temporary
W
7. Is this a repair to an existing well: ❑Yes or ONo
If this is a repair,. fill ma known well construction information and explain the nature of the
repair under .2/ remarks .section or on the hack of thisfionn.
S. Number of wells constructed:.1
For multiple injection or non-waler.supplr wells ONLY with the same construction, you can
submit one form.
9. Total well depth below land surface: 81
For multiple wells list all depths if different (example- 367)200' mud 20h100')
(ft.)
10. Static water level below top of casing: 50 (ft.)
If water level isabove casing, use "-
11. Borehole diameter: 1 (in.)
12. Well construction method: 8 1/4" HSA
(i e. auger. rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type:
Amount:
FROM
TO
DI AM ET£R
SLOT SIZE
THICKNESS
MATERIAL
79 ft'
81
ft.
in.
.010
sch40
pvc
ft.
ft.
in.
18, GROUT
FROM
TO
MATERIAL
EIiIPLACEM ENT 41 ETH OD & AMOUNT
5.5 ft.
73
ft.
Portland Cem
Pour
73.5 ft.
ft.
76
ft.
ft.
Bentonite Chi',
Pour
19. SAND/GRAVEL PACK. (if applice blel
FROM
TO
MATERIAL
EMPLACEMENT METHOD
76
ft.
81
ft.
#1 Sand
Pour
ft.
ft.
20, DRILLING LOG (Minh ridentivaai sheet if necessary)
FROM
ft.
TO
ft.
DESCRIPTION (color, harderss, soilfroek type, train sire, ete)
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
21. REMARKS
22. Certi
Signature of Certified Well Contractor
co/2ce /Z-0
Date
//y signing this ,form, 1 hereby cern& that the well(s) was (were) constructed in accordance
with 15,4 NC.-1 ' 02('.0100 or 15A N('AC 02('.0200 Well Construction Standards and that a
copy oj'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 Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For IHiectiot) 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.
TO
FormGW-1
North Carolina Department of Enviromnent and Natural Resources - Division of Water Resources Revised August 2013

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
1. Well Contractor Information:
Lewis Lefever
Well Contractor Name
2480
NC Well Contractor Certification Number
Parratt-Wolff, Inc.
Company Name
2. Well Construction Permit #:
List all applicable ,cell permits (i.e, ('aunty, Stare, r oriarce, injection, etc-)
3. Well Use (check well use):
Water Supply Well:
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑ Industrial/Commercial
❑Irrigation
❑Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
Non -Water Supply Well:
21Monitoring
❑ Recovery
Injection Well:
❑Aquifer Recharge
❑Aquifer Storage and Recovery
❑ Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling Return)
4. Date Well(s) Completed: 6-8-20
5a. Well Location:
Plantation Pipe Line Co
❑Groundwater Remediation
❑Salinity Barrier
❑Storrs ater Drainage
❑Subsidence Control
❑Tracer
❑Other (explain under #21 Remarks)
Well ID# AS-1 10
Facility/Owner Name Facility ID# (if applicable)
2617 Quaker Landing Road, Greensboro, NC
Physical Address. City, and Zip
Guilford
7847837248
Comity Parcel Identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
36.146683 N-79.850556 w.
6. Is (are) the well(s): (Permanent or ❑Temporary
7. Is this a repair to an existing well: ❑Yes or ENo
this is a repair., fill out known well construction information and explain the nature of the
repair tinder -? l renarkv .section or on the hack of this firm.
8. Number of wells constructed: 1
For multiple injection or non -water „y'l •l, wells ONLY with the same construction, you can
submit one firm,
9. Total well depth below land surface: 71
For multiple wells list all depth., ifdifferent (example- 3 a200' and 2 (iD/00')
(IL)
10. Static water level below top of casing: 50 (ft.)
/f wales level is above casing, lose ' -
11. Borehole diameter: 1 (in.)
12. Well construction method: 8 1/4" HSA
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
For Internal Use ONLY:
14. WATER ZONES
FROM
TO
DESCRIPTION
50 ft.
71 ft.
wet
ft.
ft.
15. OUTER CASING (for
multi -eased wells) OR LINER Of app icahle)
FROM
TO
DIAMETER
, THICKNESS
MATERIAL
ft.
ft.
in.
16. INNER CASING OR T11BING ( gent herma1 ciostd-loopy
FROM
TO
DIAMETER
THICKNESS
MATERIAL
0 ft.
69 ft.
1 in.
sch40
pvc
ft.
ft.
in.
17. SCREEN
FROM
TO
DIA',IETER
SLAT SIZE
THICKNESS
MATERIAL
69 ft•
71 ft.
1 i"•
.010
sch40
pvc
ft.
ft.
in.
18. GROLFI
FROM
TO
MATERIAL
EM PLACEMENT :41ETHOD a, AMOIiNT
2 ft.
65 ft,
Portland Cern
Pour
65 ft.
67 ft.
Bentonite Chii
Pour
ft.
ft.
19. SAND/GRAVEL
PACK
(if applicable)
FROM
TO
MATERIAL
EMPLACEMENT riIETHOD
67 ft•
71 ft.
#1 Sand
Pour
ft.
ft.
20. DRILLING
LOG (attach additional sheets if necessary)
FROM
TO
DESCRIPTION tcalm hardness. soil/rack type, grain sine, cit.)
ft.
ft.
ft.
ft. 1
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
21. REMARKS
Signature of Certified Well Contractor
ea 2 9 /zo
Date
By signing this form, l hereby certify that the well(s) Was (were) constructed in accordance
with 15A N('A(' 02(' .0100 or I5A WA( 02(' ,0200 Well Construction Standards and that a
copy of this record has been provided to the we// 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 Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Infection Wells ONLY: In addition to sending the form to the address in
24aabove, 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.
Fomi GW- I
North Carolina Department of Environment and Natural Resources — Division of Water Resources Revised August 2013

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
1. Well Contractor Information:
Lewis Lefever
Well Contractor Name
2480
NC Well Contractor Certification Number
Parratt-Wolff, Inc.
Company Name
2. Well Construction Permit #:
List all applicable well pennies (i.e. County, Seale, I uriance, Injection, etc.)
3. Well Use (check well use):
For Internal Use ONLY:
14. WATER ZONES
FROM
TO
DESCRIPTION
50
ft.
66
ft.
wet
ft.
ft.
15- OUTER CASING (for multi -mad !Mk.) LINER (if app.,irahle) easTHICKNESS MATERIAL
FROM
ft.
TO
ft.
DIAMETER
in.
16.INNER CASING ORTUIiIINf; (geothermal dosed-Iaup)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
0
ft.
64
ft.
in.
sch40
pvc
ft.
ft.
in.
11. SCREEN
Water Supply Well:
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑ Industrial/Commercial
❑ Irrigation
❑Municipal/Public
['Residential Water Supply (single)
❑Residential Water Supply (shared)
Non -Water Supply Well:
2Monitoring
❑ Recovery
Injection Well:
['Aquifer Recharge
❑Aquifer Storage and Recovery
❑ Aquifer Test
❑Experimental Technology
['Geothermal (Closed Loop)
❑ Geothermal (Heating/Ceding Return)
4. Date Well(s) Completed: 6-2-20
5a. Well Location:
Plantation Pipe Line Co
❑Groundwater Remediation
❑Salinity Barrier
❑Stonnwater Drainage
['Subsidence Control
['Tracer
❑ Other {explain under#21 Remarks)
Well ID# AS-111
Facility/Owner Name Facility WO (if applicable)
2617 Quaker Landing Road, Greensboro, NC
Physical Address, City, and Zip
Guilford
7847837248
County Parcel Identification No (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
36.146675 N-79.850702 W.
6. Is (are) the well(s): 2Permanent or ❑Temporary
7. Is this a repair to an existing well: ❑Yes or ONo
If this is a repair, fill out known well constriction information and explain the nature oldie
repair under 21 remarks section or on the hack of this./rurtn.
8. Number of wells constructed:
!'or multiple Injection or non -water supply wells ONLY with the same construction, you can
submit one. jrrm.
9. Total well depth below land surface: 66 (ft.)
For multiple wells list all depths if di/ferent (Trample- 3(200' and 2, t l00')
10. Static water level below top of casing: 52 (ft.)
If water level is above casing, use " "
11. Borehole diameter: 4 (in.)
12. Well construction method: HSA
(i.e. auger. rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
FROM
To
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
64 ft'
66 ft.
in.
.010
sch40
pvc
ft.
ft.
in.
IS. GROUT
FROM
To
.MArE RI
EMPLACEMENT METHOD & AMOUNT
1.5 ft.
59.5 ft'
Portland Cem
Pour
59.5 fL
62 ft.
Bentonite Chii
Pour
ft.
ft.
19. SAND/GRAVEL PACK (if a pal ieailc
FROM
TO
MATERIAL
EMPLACEMENT METHOD
62
ft.
66
ft.
#1 Sand
Pour
ft.
ft.
20..DRILLING LOGJa Ruch additional sheets if ReaeasaryI
FROM
ft.
TO
ft.
DESCRIPTION (color, harulness. sollhvrk type. grain sira. cur.i
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft. •
ft.
ft.
ft.
21.. REMARKS
22. CertiF tion:
gnature of Certified Well Contractor
Date
By signing this form, I hereby certify that the ire//(s) was (were) constructed in accordance
with I5A N('A(' 02(' , 0/0(1 or I5A N('A(• 02(' .0200 Well ('onsu ua•liou Standards. mul that a
copy of this record has been prorided 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 Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Iniection 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 Sr 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.
Fomi GW-1
North Carolina Department of Environment and Natural Resources - Division of Water Resources Revised August 2013

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
1. Well Contractor Information:
Lewis Lefever
Well Contractor Name
2480
NC Well Contractor Certification Number
Parratt-Wolff, Inc.
Company Name
2. Well Construction Permit #:
List all applicable well pennies (i-L County, State, Variance, Injection, etc )
3. Well Use (check well use):
Water Supply Well:
❑Agricultural
❑ Geothermal (Heating/Cooling Supply)
❑ industrial/Commerc ial
❑Irrigation
❑ Municipal/Publ is
❑ Residential Water Supply (single)
❑ Residential Water Supply (shared)
Non -Water Supply Well:
Monitoring
❑ Recovery
Injection Well:
Aquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑ Geothermal (Heating/Cooling Return)
4. Date Well(s) Completed: 6-11-20
5a. Well Location:
Plantation Pipe Line Co
Facility/Owner Name
❑Groundwater Remediation
❑Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑Tracer
❑Other (explain under #2 l Remarks)
Well ID# AS-112
Facility ID# (if applicable)
2617 Quaker Landing Road, Greensboro, NC
Physical Address. City, and Zip
Guilford
7847837248
County Parcel identification No (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field. one Iat/long is sufficient)
36.146479 N-79.850812
6. Is (are) the well(s): (Permanent or Temporary
W
7. is this a repair to an existing well: DYes or ONo
If this is a repair, fill out known well construction in/<irnmliou and explain the nature (4-the
repair under ,_ . l remarks sector or on the hack of (Instal-tn.
8. Number of wells constructed: 1
For multiple injection or non -water. supply wells ONLY with the same construction, you can
submit one firm,
9. Total well depth below land surface: 65
/•or multiple wells list all depths ifdiffere,u (example- 3C200' and 2(t1.100')
(ft.)
10. Static water level below top of casing: 53 (ft.)
/f crater leer/ r, above casing, use "
11. Borehole diameter: 4 (in.)
12. Well construction method: 8 1/4" HSA; Air Hammer
(i a auger. rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type:
Amount:
For Internal Use ONLY.
14. WATER ZONES
FROM
TO
DESCRIPTION
53 ft.
65 ft.
wet
ft.
ft.
I5.OUTER CASING (far multi -cased welts) OR LINER (if sip p
its' hit)
FROM
TO
DIAMETER
THICKNESS
MAT LIMA
ft.
ft.
in.
16. INNER CASING OR TUBING (geothermal cllned Joop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
0 ft
63 ft.
1 in.
sch40
pvc
ft.
ft.
in.
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
63 ft
65 ft.
1 in.
.010
sch40
pvc
ft.
ft.
in.
-18. GRO1fT
FROM
TO
MATERLkL
EMPLACEMENT METHOD & AMOUNT
3 ft.
59 ft•
Portland Cem
Pour
59 ft
61 ft•
Bentonite Chi1
Pour
ft.
ft.
I9. SANA/GRAVEL PACT{
(if applicable)
FROM
TO
MATERIAL
EMPLACEMENT MEPHOD
61 ft.
65 ft.
#1 Sand
Pour
ft.
ft.
20. URfLLING
LOG (aetieh
additional sheen if necessary)
FROM
'TO ,
DESCRIPTION lenlar, hanlne t, soil/reek type, grain lire, el c.l
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
21. REMARKS
22. C'ertifi Lion:
Signature of CeiFied Well Contractor
(,./2 4 /za
Date
Br signing this Arm, / hereby certify that the we//(s) was (were) constructed in accordance
with 15A N( AC 02(' .0/00 or 15A NC'A(' 02(' ,0200 Well ('anstruction Standards and that a
copy of this record has been provided to the wet/ 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 Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Injection 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- I North Carolina Department of Environment and Natural Resources - Division of Water Resources
Revised August 2013

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
1. Well Contractor Information:
Lewis Lefever
Well Contractor Name
2480
NC Well Contractor Certification Number
Parratt-Wolff, Inc.
Company Name
2. Well Construction Permit #:
List all applicable well permits (i.e. County, State, I i•imme, Injection, etc.)
3. Well Use (check well use):
Water Supply Well:
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑ Ind ustrial/Commercial
0 Irrigation
Non -Water Supply Well:
@Monitoring
❑Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
❑Recovery
Injection Well:
❑Aquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling Return)
4. Date Well(s) Completed: 6-9-20
5a. Well Location:
Plantation Pipe Line Co
❑Groundwater Remediation
❑Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑Tracer
❑Other.(.expinin under #21 Remarks)
Well ID# AS-113
Facility/Owner Name Facility ID# (if applicable)
2617 Quaker Landing Road, Greensboro, NC
Physical Address, City, and Zip
Guilford
County
7847837248
Parcel Identification No (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(dwell field. one lat/long is sufficient)
36.146773 N-79.850885
6. Is (are) the well(s): @Permanent or ❑Temporary
w
7. Is this a repair to an existing well: ❑Yes or ENo
If this is a repair, fill out known well construction information and explain the nature of the
repair under =?! remarks .section or on the hack of this
8. Number of wells constructed: 1
For multiple injection or nor -water supply wells ONLY with the same eonsrrnclion, you can
submit one firm.
9. Total well depth below land surface: 79 (ft.)
For multiple wells list all depths ifdi ffereni (example- 3 200' and 20100')
10. Static water level below top of casing: 49 (ft.)
If water level is above casing, use " "
11. Borehole diameter: 4 (in.)
12. Well construction method: 8 1/4" HSA
(i e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm)
Method of test:
13b. Disinfection type:
Amount:
For Internal Use ONLY:
14. WATER ZONES
FROM
TO
DESCRIPTION
49 ft.
79 ft.
wet
ft.
ft.
IS. OUTER CASING (far
mid -cased wells) OR LINER tlf np
icable}
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft.
ft.
in.
16, INNER CASING OR TUBING
(geothermal
Board -loop)
FROM
TO
DIAHETER
THICKNESS
MATERIAL
0 ft.
77 rt.
1 in.
sch40
pvc
ft.
ft.
in.
17. SCREEN
FROM
TO
DIAMETER
SLOTSI:ZE
THICKNESS
MATERIAL
77 ft.
79 ft.
1 in.
.010
sch40
pvc
ft.
ft.
in.
18. GROUT
FROM
TO
MATERIAL
EsIPLACEMENT NEiHOD & AMOUNT
3 ft.
73 ft•
Portland Cem
Pour
73 ft.
75 ft.
Bentonite Chi!
Pour
ft.
ft.
19. SAND/GRAVEL PACK(irapplic,Wel
FROM
TO
MATERIAL
EMPLACEMENT METHOD
75 ft.
79 ft.
#1 Sand
Pour
ft.
ft.
21L DRILLING
LOG (attach
additional aheeta if necessary)
FROM
TO
DESCRIPTION {color. hnrdne..s, soil/rock type. Brain sire, elc.I
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
21. REMARKS MI
(./2 q o
Signature of Certified Well Contractor Date
By signing this farm, ! hereby cent, that the ire//(s) was (were) constructed in accordance
with 15A N(:d(' 0 C ,0100 or I5A NC'A(' 02(' .0200 Well Construction Standards and that a
copy o/ 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 Weill: 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 [Meehan Weds 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-I
North Carolina Department of Environment and Natural Resources — Division of Water Resources Revised August 2013

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
1. Well Contractor Information:
Lewis Lefever
Well Contractor Name
2480
NC Well Contractor Certification Number
Parratt-Wolff, 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):
Water Supply Well:
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑ Industrial/Commercial
❑Irrigation
❑Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
Non -Water Supply Well:
ElMonitoring
❑Recovery
lajettion Well:
❑Aquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer Test
Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling Retum)
4. Date Well(s) Completed: 6-3-20
5a. Well Location:
Plantation Pipe Line Co
❑Groundwater Remediation
❑Salinity Barrier
Stormwater Drainage
❑Subsidence Control
❑ Tracer
❑Other (explain under #2 Remarks)
Well ID# AS-114
Facility/Owner Name Facility ID# (if applicable)
2617 Quaker Landing Road, Greensboro, NC
Physical Address, City. and Zip
Guilford
7847837248
Comity Parcel Identification No (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one latllong is sufficient)
36.146627 N-79.850740 W.
6. Is (are) the well(s): 12IPermanent or ❑Temporary
7. Is this a repair to an existing well: ❑Yes or ENo
If this is a repair,./ill out known well construction inhumation u•mation and explain the nature oldie
repair under 21 remarks- .section or on the hack of this form.
8. Number of wells constructed: 1
For multiple injection or non -water supply wells ONLY with the some construction, you can
submit one.forth
9. Total well depth below land surface: 65
For multiple wells list all depths if different (example- 3a200' and 211100')
(ft.)
10. Static water level below top of casing: 53 (ft.)
Or water level is above casing, use "-
11. Borehole diameter: 4
(in.)
12. Well construction method: 8 1/4" HSA; Air Hammer
(i e auger. rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
For Internal Use ONLY:
14. WATER ZONES
FROM
TO
DESCRIPTION
53 ft.
65 fL
wet
ft.
ft.
15. OUTER CASING (for ntulft-cooed wells) OR LINER Of <p Ilcrhle)
FROM
TO
DIAMETER
THICKNESS MATERIAL
ft.
ft.
in.
16.INNER CASING ORTUURING (geothermal closed-10npl
FROM
TO
DIAMETER
THICKNESS
MATERIAL
0 ft.
63 ft.
1 in.
sch40
pvc
ft.
ft.
in.
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
63 ft
65 ft•
1 in.
.010
sch40
pvc
ft.
ft.
in.
Ill. GROUT
FROM
TO
MATERIAL
EN IPL►CEMENT METHOD & AMOUNT
2 It.
58.5 ft•
Portland Cem
Pour
58.5 ft•
61 ft•
Bentonite Chi
Pour
ft.
it.
19. SAND/GRA VEI. PACK
of applicable)
PROM
TO
MATERIAL
EMPLACEMENT METHOD
61 ft.
65 ft.
#1 Sand
Pour
ft.
ft.
30. DRILLING
LOG (mulch
addittonol ahem If memory)
FROM
TO
DESCRIPTION (color. hardness. soil/rock type. grain size. etc.)
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
11. REMARKS
22. Certifilr$Iinn:
Signature of Certified Well Contractor
Date
By .signing this form, I hereby certify that the well(s) was (were) consintcted in accordance
with 15A N(;-1(' 02('.0100 or 15A N('A(' 02('.0200 Well ('onstn,cln,n S'Iandards and that a
c'opv 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 Atl 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 Welk ONLY: In addition to sending the form to the address in
24aabove, 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-I
North Carolina Department of Environment and Natural Resources - Division of Water Resources Revised August 2013

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
1. Well Contractor Information:
Lewis Lefever
Well Contractor Name
2480
NC Well Contractor Certification Number
Parratt-Wolff, Inc.
Company Name
2. Well Construction Permit #:
List all applicable well permits (i. e. ('ounty, State, Variance, Injection, etc.)
3. Well Use (check well use):
Water Supply Well:
❑Agricultural ❑Municipal/Public
❑Geothermal (Heating/Cooling Supply) ❑Residential Water Supply (single)
❑Industrial/Commercial ❑Residential Water Supply (shared)
❑Irrigation
Non -Water Supply Well:
OMonitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier
Aquifer Test ❑Stormwater Drainage
❑Experimental Technology 0 Subsidence Control
❑Geothermal (Closed Loop) ❑Tracer
❑Geothermal (Heating/Cooling Return) ❑Other (explain under #2I Remarks)
4. Date Well(s) Completed:-1-20
5a. Well Location:
Plantation Pipe Line Co
Facility/Owner Name
Well ID# AS-115
Facility ID# (if applicable)
2617 Quaker Landing Road, Greensboro, NC
Physical Address, City, and Zip
Guilford
7847837248
County Parcel Identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one ladlong is sufficient)
36.146645 N-79.850857
w
6. Is (are) the well(s): ElPermanent or ❑Temporary
7. Is this a repair to an existing well: ❑Yes or ENo
If this is a repair,, fill oni known well construction inf ormalian and explain the nature of the
repair under ,2/ remarks section or on the hack of this form.
8. Number of wells constructed: 1
For multiple injection or non -water supply wells ONLY with the same construction, you can
submit one form.
For Internal Use ONLY:
IC. WATER ZONES
FROM
TO
DESCRIPTION
52 ft
68.5 ft
wet
ft.
ft.
IS. OUTER CASING (for multi -cued wells) OR LINER flap
icahle)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft.
ft.
in.
16. 1 NNER CASING OR TUBING (geothermal dosed-WM
FROST
10
DIAMETER
THICKNESS
MATERIAL
0 FL
66.5 ft.
1 in.
sch40
pvc
ft.
ft.
in.
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
66.5 ft
68.5 ft
1 In.
.010
sch40
pvc
ft.
ft.
in.
18. GROUT
FROM
TO
MATERIAL
EMPLACEMENT .MF.THOD&AMOUNT
3 ft.
62.5 fa
Portland Cem
Pour
62.5 ff.
64.5 ft.
Bentonite Chi
Pour
ft.
ft.
19. SAND/GRAVEL
PACK llf applinable)
FROM
TO
MATERIAL
Ertl .PI ACEM ENT M1IET HDD
64.5 fc
68.5 ft
#1 Sand
Pour
ft.
ft.
20. DRILLING
LOG (attach additional sheets if neeeasnry)
FROM
TO
DESCRIPTION (color, hurrLrns,. soilhack t.pc, grain .ire, ctc.)
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
2i. REMARKS
ignature of Certified Well Contractor
_IsI
Date
By signing this form, I thereby cernfv that the well(s) was (were) constructed in accordance
with 15A NC'A(' 02C .0I00 or 15A NCAC 02(' .0200 Well Construction Standar& and Thai a
copy (Otis 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
9. Total well depth below land surface: 68.5 (ft.) 24a. For Ali Wells: Submit this form within 30 days of completion of well
For multiple wells list a// depths if different (example- 3(iD200' and 2@I00') construction to the following:
10. Static water level below top of casing: 52 (ft.)
If water level is above casing, use "
11. Borehole diameter: 4 (in.)
12. Well construction method: 8 1/4" HSA
(i.e auger. rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For !election 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.
Fors GW-I
North Carolina Department of Environment and Natural Resources - Division of Water Resources Revised August 2013

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
1. Well Contractor Information:
Lewis Lefever
Well Contractor Name
2480
NC Well Contractor Certification Number
Parratt-Wolff, Inc.
Company Name
2. Well Construction Permit #:
List all applicable well permits (i.e. County, Stale. Variance, Injection, etc.)
3. Well Use (check well use):
Water Supply Well:
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑ Industrial/Commercial
❑Irrigation
❑Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
Non -Water Supply Well:
Monitoring
❑ Recovery
lnjeclion Well:
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling Return)
4. Date Well(s) Completed: 6-5-20
5a. Well Location:
Plantation Pipe Line Co
❑Groundwater Remediation
❑Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑Tracer
❑Other (explain under #21 Reinarks)
Well ID# AS-1 16
Facility/Owner Name Facility ID# (if applicable)
2617 Quaker Landing Road, Greensboro, NC
Physical Address. City. and Zip
Guilford
County
7847837248
Parcel Identification No (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one latllong is sufficient)
36.146718 -79.850931 N;
6. Is (are) the well(s): 1 1Permanent or ❑Temporary
7. Is this a repair to an existing well: ❑Yes or ONo
If this is a repair.,fl1 oat known well construction in/ornuition and explain the nature of the
repair under 21 remarks .section or on the back adtisprin.
8. Number of wells constructed: 1
For multiple injection or non-water,snppls wells ONLY with the same construction, you can
submit one form,
9. Total well depth below land surface: 61 (ft.)
For multiple wells list all depths if different (example- 3(a200' and 201001
10. Static water level below top of casing:. 50 (ft.)
II -water level is above casing use "-
11. Borehole diameter: 4 (in.)
12. Well construction method: 8 1/4" HSA
(i.e. auger. rotary, cable, direct push, etc)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type:
Amount:
For Internal Use ONLY:
14. WATER ZONES
FROM
To
DESCRIPTION
50 ft•
61 ft.
wet
ft.
ft.
15. OUTER CASING (for
multi -used wells) OR LINER [if ap licahle)
FROM
TO
DIAMETER
THICKNESS MATERIAL
ft.
ft.
in.
16. INNER CASING OR TUBING (geothermal
clased:ioop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
0 ft.
59 ft.
1 in.
sch40
pvc
ft.
ft.
in.
17- SCREEN
FROM
"1"0
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
59 ft'
61 ft
1 in.
.010
sch40
pvc
ft.
ft.
in.
1& GROUT
FROM
TO
.MATERIAL
EMPLACEMENT METH OD & AMOUNT
4 ft.
54 ft•
Portland Cem
Pour
54 ft•
56 ft•
Bentonite Chi
Pour
ft.
ft.
19. SAND/GRAVEL PACK
inapplicable)
FROM
TO
MATERIAL
EMIPL►CEM ENT METHOD
56 tt•
61 ft.
#1 Sand
Pour
ft.
ft.
2& DRILLING
LOG (attach additilsnalaheets if neonsary)
FROM
TO
DESCRIPTION I color, hardness, soillruc k type, train sire, etc.}
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
21. REMARKS
22. C'ertifiotifion:
Si iaturr of Certified Well Contractor
Date
By signing ihis,farm, I hereby certify that the well(s) was (were) constructed in accordance
with I5A N('A(' 02('.010(I or 15A N('AC 02('.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 Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Iniection Wells ONLY: In addition to sending the form to the address in
24aabove, 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. Fur 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-I
North Carolina Department of Environment and Natural Resources - Division of Water Resources Revised August 2013

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
I. Well Contractor Information:
Lewis Lefever
Well Contractor Name
2480
NC Well Contractor Certification Number
Parratt-Wolff, Inc.
Company Name
2. Well Construction Permit #:
List all applicable well permits (i.e. County„late, I'ariance, Injection, ek.)
3. Well Use (check well use):
Water Supply Well:
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
ID-Industrial/Commercial
❑irrigation
❑Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
Non -Water Supply Well:
2 Monitoring
❑ Recovery
Injection %Veil:
❑Aquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (liealili_ICoolina Return
❑Groundwater Remediation
❑Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑Tracer
❑Other (explain under #21 Remarks)
4. Date Well(s) Completed: 6-22-20
5a. Well Location:
Plantation Pipe Line Co
Well ID# AS-117
Facility/Owner Name Facility ID# (if applicable)
2617 Quaker Landing Road, Greensboro, NC
Physical Address, City, and Zip
Guilford
County
7847837248
Parcel Identification No. (PTN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field. one lat/lone is sufficient)
36.146601 N-79.850886
6. Is (are) the well(s): OPermanent or ❑Temporary
w
7. Is this a repair to an existing well: ❑Yes or ENo
If this is a repair, fill out known well cmu9raclio17 inlormalion and explain the nature of the
repair under -21 remarks section or on the back of. his farm.
8. Number of wells constructed: 1
For multiple injection or non -water .supply ire/ls ONLY with the same construction, you can
.submit one form
9. Total well depth below land surface: 67
For multiple wells list all depths if different (example- 3 rt 200' and 2 a I00')
(ft.)
10. Static water level below top of casing: 49 (ft.)
Ifwater level is above casing, use "- "
11. Borehole diameter: 4 (in.)
12. Well construction method: 8 1/4" HSA
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
I3a. Yield (gpm) Method of test:
13b. Disinfection type:
Amount:
For Internal Use ONLY:
14. WATER ZONES
FROM
TO
DESCRIPTION
49 ft.
67 ft.
wet
ft.
ft.
15. OUTER CASING (for multi-casedwella) OR LINER (If appUsable)
FR DM
TO
DIAMETER
THICKNESS I MATERIAL
ft.
ft.
in.
I. INNER CASING OR TUBING (geothermal eloeed•loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
0 ft.
65 ft•
1 in.
sch40
pvc
ft.
ft.
in.
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
65 ft-
67 ft,
1 in,
.010
sch40
pvc
ft.
ft.
in.
18. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
3 ft.
61 e.
Portland Cem
Pour
61 ft.
63 ft•
Bentonite Chi
Pour
ft.
ft.
19. SAND/GRAVEL PACK (If applicable)
FROM
TO
►IATERIAL
EMPLACEMENT METHOD
63 ft.
67 ft.
#1 Sand
Pour
ft.
ft.
20. DRILLING LOG (attach
additional sheets If nreeusary)
FROM
TO
DESCRIPTION (color. hardnex,, soil/ruck type, grain sae. etc)
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
21. REMARKS
22. ('cr :il•cation:
auk ace I0ed. Well Contractor
7`i1`?
Date
13v signing This fin -in I hereby certify that the wetl(i) was (were) constructed in accnrdmtce
with 15A NCA(' 02('.Ol00 or /5A N('AC 02('.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 Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For injection 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 forth within 30 days of completion of
well construction to the county health department of the county where
constructed.
Form GW-I North Carolina Department of Environment and Natural Resources - Division of Water Resources Revised August 2013

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
I. Well Contractor Information:
Lewis Lefever
Well Contractor Name
2480
NC Well Contractor Certification Number
Parratt-Wolff, Inc.
Compam Name
2. Well Construction Permit#:
List all applicable well permits (i.e_ Counts, Stale, Variance, Injection, etc)
3. Well Use (check well use):
Water Supply Well:
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑industrial/Commercial
❑irrigation
❑Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
Non -Water Supply Well:
ElMon itori ng
❑Recover'
Injection Well:
❑ Aquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling Return)
4. Date Well(s) Completed- 6-30-20
5a. Well Location:
Plantation Pipe Line Co
❑Groundwater Remediation
❑Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑Tracer
❑Other (explain under #21 Remarks)
Well ID# AS-118
Facility/Owner Name Facility iD4 (if applicable)
2617 Quaker Landing Road, Greensboro, NC
Physical Address, City, and Zip
Guilford
County
7847837248
Parcel Identification No. (PiN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field_ one lar/Iong is sufficient)
36.146644 N-79.850969 W
6. Is (are) the well(s): EIPermanent or ❑Temporary
7. Is this a repair to an existing well: ❑Yes or 1No
4 this is a repair, Jill out known well construction it formation and explain the nature ql the
repair under r:2/ remarks section or on the hack of this /o,in.
S. Number of wells constructed: 1
For multiple injection or non -water supply wells ONLY with the same construction, you can
submit one,/orm.
9. Total well depth below land surface: 67
Inc•multiple wells list all depths 1/ different (example- 3@200' and 2 tt 100')
(ft.)
10. Static water level below top of casing: 50 (ft.)
1/water level is above casing, use " '
11. Borehole diameter: 4 (in.)
12. Well construction method: 8 1/4" HSA
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type:
Amount:
For Internal Use ONLY:
14. WATER ZONES
FROM
TO
DESCRIPTION
50 ft.
67 ft.
wet
ft.
ft.
15.OI/TF.R cum G (for multi -cased wells) OR LINER (if alp licehle)
FROM
TO
DIAr1rTF..R
THICKNESS MAT FR FA!.
ft.
ft.
in.
1
I6.INNER CASING OR TUBING (geothermal dosed -loop)
FROM
TO
DIAAMETER
Tit WEN ESS
MATERIAL
0 ft.
65 ft•
1 in.
sch40
pvc
ft.
ft.
in.
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
65 ft.
67 ft•
1 In.
.010
sch40
pvc
ft.
ft.
in.
1 L GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
3 ft'
61 ft,
Portland Cem
Pour
61 ft,
63 ft,
Bentonite Chi
Pour
ft.
ft.
19. SAND/GRAVEL. PACK if ap1licahie)
FROM
TO
NIATERIAI.
FMPLACEAIENT MF_THOD
63 ft•
67 ft.
#1 Sand
Pour
ft.
ft.
20. DRILLING
LOG (attach
additional sheet. if necessary)
FROM
TO
DESCRIPTION Icahn, hardness, soil/, ork type, grain sine, etc)
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
21. REMARKS
22. Certilikation:
zatuu nfCertilmd Well Contractor
7/«/zo
Date
By signing This Arm, / hereby certify that the wells) was (here) constructed in accordance
with 15A N('A(' 02C.0100 or l5A NGA(' 02('.0200 Well Construction Standards and that a
copy glans 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 Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Iniection 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. Fur 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- I
North Carolina Department of Environment and Natural Resources — Division of Water Resources Revised August 2013

WELL CONSTRUCTION RECORD
For Internal Use ONLY:
This form can be used foi single or multiple wells
1. Well Contractor Information:
Lewis Lefever
Well Contractor Name
2480
NC Well Contractor Certification Number
Parratt-Wolff, Inc.
Compam Name
2. Well Construction Permit#:
List all applicable well permits (i.e. County, Stale, Variance, Injection, etc.)
3. Well Use (check well use):
Water Supply Well:
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑industrial/Comm ercial
❑irrigation
❑Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
Non -Water Supply Well:
t Mon itori ng
❑Recovery
Injection Well:
❑Aquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
Geothermal (Heating/Cooling Return)
4. Date Well(s) Completed: 6-26-20
5a. Well Location:
Plantation Pipe Line Co
❑ Groundwater Remediation
❑ Sal inity Barrier
❑ Stormwater Drainage
❑Subsidence Control
❑Tracer
❑Other (explain under #2I Remarks)
Well lD# AS-119
Facility/Owner Name Facility iD# (if applicable)
2617 Quaker Landing Road, Greensboro, NC
Physical Address, City, and Zip
Guilford
County
7847837248
Parcel identification No. (PiN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well fell one lat/long is sufficient)
36.146689 N-79.851013
6. is (are) the well(s): L1Permanent or ❑Temporary
w
7. Is this a repair to an existing well: ❑Yes or ONo
if /his is a repair, Jill out known well construction inlornsation and explain the nature o%the
repair under ..21 remarks section or on the back (Jf this limn.
8. Number of wells constructed: 1
For multiple injection or non -water. supply wells ONLY with the same construction, you can
submit one /ornt,
9. Total well depth below land surface: 63
For multiple ire/Is list all depths if di(/ rem (example- 3@200' and 2 (t 100')
(ft.)
10. Static water level below top of casing: 48 (ft.)
//•water level is above casing, use " -
1l. Borehole diameter: 4 (in.)
12. Well construction method: 8 1/4" HSA
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type:
Amount:
14. WATER ZONES
FROM
TO
DESCRIPTION
48 ft.
63 ft.
wet
ft.
ft.
15. OUTER CASING (for multi -used welts) OR LINER (if se licablE)
FROM
TO
Di4.METER
THICKNESS
MATERIAL
ft.
ft.
in.
16. INNER CASING OR TURiNG (geothermal dosed -loop}
FROM
TO
DIAMETER
T111C'KNFSS
MATERIAL
0 ft'
61 ft.
1 in.
sch40
pvc
ft.
ft.
In.
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
61 rt•
63 ft.
1 in.
.010
sch40
pvc
ft.
ft.
in.
18. GROUT
FROM
TO
MATERIAL.
EMPLACEMENT METHOD & AMOENT
3 ft•
56.5 ft•
Portland Cem
Pour
56.5 ft.
58 ft•
Bentonite Chit Pour
ft.
ft.
19. SAND/GRAVEL PACK (if applieihrel
FROM
TO
MATFJtI:1L
EMPLACEMENT METHOD
58 rt.
63 ft.
#1 Sand
Pour
ft.
ft.
29. DRILLING
LOG (attach additionai ahem if necessary)
FROM
TO
DESCRIPTION (color. hardness. soil/rock type, grain size. etc.)
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
21. REM.(R IS
22. Certif
lion:
fir,
5 ature of Celli tell Well Contractor
Date
By signing Ibis,/i:rnt, / hereby certify that the Ire/l(t) was (were) constructed in accordance
with 15A NCAC 02C.0100 or 15A NCA(' 02C.0200 Well ('onslrnclion Standards and that a
copy o/ 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 Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For 1nIeetion 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 & InjectionWells:
Also submit one copy of this form within 30 days of completion of
well construction to the county health department of the county where
constructed.
Form GW- I
North Carolina Department of Environment and Natural Resources- Division of Water Resources Revised August 2013

WELL CONSTRUCTION RECORD
For internal Use ONLY:
This form can be used for single or multiple wells
I. Well Contractor Information:
Lewis Lefever
Well Contractor Name
2480
NC Well Contractor Certification Number
Parratt-Wolff, Inc.
Company Name
2. Well Construction Permit#:
List all applicable hell permits (i.e. County, Stale, 1'ariance, Injection, etc.)
3. Well Use (check well use):
Water Supply Well:
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑industrial/Commercial
❑ Trrigati on
❑Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
Non -Water Supply Well:
ICJ Monitoring
❑ Recovery
Injection Well:
El Aquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling Return)
4. Date Well(s) Completed: 6-25-20
❑ Groundwater Remediation
❑Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑Tracer
❑ Other (explain under #21 Remarks)
5a. Well Location:
Plantation Pipe Line Co
Well ID# AS-120
Facility/Owner Name Facility ID# (if applicable)
2617 Quaker Landing Road, Greensboro, NC
Physical Address, City, and Zip
Guilford
7847837248
County Parcel Identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
36.146604 N-79.851067
6. Is (are) the well(s): 17Permanent or ❑Temporary
w
7. Is this a repair to an existing well: ❑Yes or ENo
If this is a repair, fill out known well construction inlhrnlalion and explain the nature of the
repair under =21 remarks section or on the back n/ this_ form.
8. Number of wells constructed: 1
For ntuhiple injection or non -water supply wells ONLY with the same construction, you can
submit one jam
9. Total well depth below land surface: 62
For multiple wells list all depths if different (example- 3@200' and 2@ 100')
(ft.)
10. Static water level below top of casing: 48 (ft.)
!plater level is above casing, use " "
11. Borehole diameter: 4 (in.)
12. Well construction method: 8 1/4" HSA
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
14. WATER ZONES
FROM
TO
DESCRIPTION
48 et.
62 ft.
wet
ft.
ft.
15. OUTER CASING (far multi -mind wells) OR LINER (If ap
usable)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft.
R.
in.
16. INNER CASING OR TUBING (geatherm.l defied -loop)
FROM
TO
DIAMETER
TFIWKNESS
MATERIAL
0 ft.
60 ft•
1 in.
sch40
pvc
ft.
ft.
in.
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
60 ft
62 ft•
1 In.
.010
sch40
pvc
ft.
ft.
in.
18. GROUT
FROM
TO
MATERIAL
En PLACEMENT METHOD & AMOUNT
3 ft.
56 ft'
Portland Cem
Pour
56 ft.
58 ft•
Bentonite Chi
Pour
ft.
ft.
19. SAND/GRAVEL PACK I If applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
58 ft•
62 ft.
#1 Sand
Pour
ft.
ft.
20. DRILLING LOG (att■ch additional sheet If necessary)
FROM
TO
➢FSCRIPTION Irotur, hardness, soil/rock Ivpe, grain size. etc.)
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
! 21. REMAURKS
22. Cer jTaliun:
gnpture of -Certified Well Contractor
Date
By signing this.form, ! hereby cer///V that the ire//(s) was (were) constructed in accordance
with I5A NCA(' 02C .0100 or I5A NCAC 02('.0200 Well Construction Standards and that a
copy of this record has been prorided 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 INSTUCTIIONS
24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Iniection Wells 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 ofEnvironment and Natural Resources - Division of Water Resources Revised August 2013

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
1. Well Contractor Information:
Lewis Lefever
Well Contractor Name
2480
NC Well Contractor Certification Number
Parratt-Wolff, Inc.
Company Name
2. Well Construction Permit#:
List all applicable ;ref/permits (i.e. (bung', State, I'oriance, Injection, etc )
3. Well Use (check well use):
Water Supply Well:
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑industrial/Commercial
❑ irrigation
❑ Municipal/Public
['Residential Water Supply (single)
['Residential Water Supply (shared)
Non -Water Supply Welk
EIMonitoring
❑Recovery
Injection Well:
❑ Aquifer Recharge
❑ Aquifer Storage and Recovery
❑ Aquifer Test
['Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling Return)
4. Date Well(s) Completed: 6-24-20
5a. Well Location:
Plantation Pipe Line Co
❑Groundwater Remediation
❑Salinity Barrier
❑ Stormwater Drainage
❑ Subsidence Control
Tracer
❑Other (explain under #21 Remarks)
Well ID# AS-121
Facility/Owner Name Facility ID# (if applicable)
2617 Quaker Landing Road, Greensboro, NC
Physical Address. City, and Zip
Guilford
County
7847837248
Parcel Identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(dwell field. one lat/long is sufficient)
36.146604 N-79.851067
w
6. Is (are) the well(s): 1ZZPermanent or ❑Temporary
7. Is this a repair to an existing well: ❑Yes or ONo
/J this is a repair,, fill out known well construction i,Jhrmalion and explain the nature of the
repair corder =21 remarks .section or on the hack o/'this firm.
8. Number of wells constructed: 1
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: 73
1•or multiple wells list a// depths iI) different (example- 3 «200' and 2/l0(1)
10. Static water level below top of casing: 48
//'water level is above casing, use " "
11. Borehole diameter: 4 (in.)
12. Well construction method: 8 1/4" HSA
(ft.)
(ft.)
(i.e. auger, rotary, cable, direct push, etc,)
FOR WATER SUPPLY WELLS ONLY:
I3a. Yield (gpm) Method of test:
I3b. Disinfection type:
Amount:
For Internal Use ONLY:
14. WATER ZONES
FROM
TO
DESCRIPTION
48 ft.
73 ft.
wet
ft.
ft.
15. OUTER CASING (for multi -cased wens) OR LINER (if applicable)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft.
ft.
in.
16. INNER CASING OR TIJIRING
(geothermal dosed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
0 ft.
71 It.
1 in.
sch40
pvc
ft.
ft.
in.
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
71 ft.
73 ft.
1 in.
.010
sch40
pvc
ft.
ft.
in.
1S. GROUT
FROM
TO
MATERIAL
EMPLWKMENT METHOD & AMOUNT
3 ft.
67 ft-
Portland Cem
Pour
67 ft.
69 ft.
Bentonite Chi
Pour
ft.
ft.
19, SANDIGRAVEL PACK (if applicable)
FROM
TD
MATERIAI.
EMPLA CEMENT M£THOD
69 ft.
73 ft.
#1 Sand
Pour
ft.
ft.
30. DRILLING
LOG (attach
addidonal sheets if necessary)
FROM
TO
DESCRIPTION {calm Iiui ab:eSR, loll/rock tupe..ei- in .uxr, etr. I
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
11. REMARKS
Signature of Ce:li Led Well Contractor
7/q IGU
Date
By .signing this form, I hereby cent& that the trell(s) was (were) constructed in accordance
with /SA NCA(' 02(' _0100 or 15.4 N('.4C 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 Processing 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-I North Carolina Department ofEnvironment and Natural Resources — Division of Water Resources Revised August 2013

WELL CONSTRUCTION RECORD
For Internal Use ONLY:
This Form can be used for single or multiple wells
1. Well Contractor Information:
Lewis Lefever
Well Contractor Name
2480
NC Well Contractor Certification Number
Parratt-Wolff, Inc.
Company Name
2. Well Construction Permit #:
List all applicable well permits (i.e. C'owNv, Slate, Variance, /njection, etc.)
3. Well Use (check well use):
Water Supply Well:
17 Agricultural
❑Geothermal (Heating/Cooling Supply)
❑industrial/Commercial
❑irrigation
❑Municipal/Public
Residential Water Supply (single)
❑Residential Water Supply (shared)
Non -Water Supply Well:
2 Monitoring
❑Recovery
Injection Well:
❑Aquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling Retum)
4. Date Well(s) Completed: 6-25-20
❑Groundwater Remediation
❑Salinity Barrier
❑ Stormwater Drainage
❑Subsidence Control
❑ Tracer
❑Other (explain under #2I Remarks)
5a. Well Location:
Plantation Pipe Line Co
Well ID# AS-122
Facility/Owner Name Facility ID# (if applicable)
2617 Quaker Landing Road, Greensboro, NC
Physical Address, City, and Zip
Guilford
7847837248
County Parcel Identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(dwell field. one lat/long is sufficient)
36.146604 -79.851072
6. Is (are) the well(s): ©Permanent or ❑Temporary
w
7. Is this a repair to an existing well: ❑Yes or ENo
If this is a repair, fill out known well construction infiunratian and explain the nature ojthe
repair under ,=21 remarks section or on the back of this farm.
8. Number of wells constructed: 1
I -or multiple injection or non -,rater supply wells ONLY with the same construction, you can
submit one fbrin
9. Total well depth below land surface: 63 (ft.)
For multiple wells list all depths if different (example- 3@200' and 2@l00')
10. Static water level below top of casing: 51 (ft.)
If hater level is above casing, use ", "
1 I. Borehole diameter: 4
(in.)
12. Well construction method: 8 1/4" HSA
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
I3a. Yield (gpm) Method of test:
I3b. Disinfection type: _ Amount:
14. WATER ZONES
FROM
TO
DESCRIPTION
51 ft.
63 ft.
wet
ft.
ft.
15. OUTER CASING (fur multi -cased wens) OR LINER. (if a Ileahle)
FROM
TO
DIAMETER
TIICKNESS
MATERIAL
ft
ft.
in.
16. INNER CASING OR TUBING (geothermal closed -long)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
0 ft.
61 ft.
1 in.
sch40
pvc
ft.
ft.
in.
17. SCREEN
FROM
TO
1)1AMETER
SLOT SIZE
THICKNESS
JVL4TFR IA
61 ft.
63 ft
1 in.
.010
sch40
pvc
ft.
ft.
in.
18. GRO[1T
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
3 ft.
57 ft
Portland Cem
Pour _ _
57 ft.
59 ft.
Bentonite Chil
Pour
ft.
ft.
19. SANDIGRAV£L PACK
IU applieableL
FROM
TO
MATERIAL
EMPLACEMENT METHOD
59 ft,
65 ft.
#1 Sand
Pour
ft.
ft.
20. DRILLING
LOG lanach additional abeam if necessary)
FROM
TO
DFSCRIPTION fculm•, he, tines%suiVruck Iype. grain sea, !!! 1
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
21. REMARKS
22. Certifi
Signature of Certified Well Contractor
Date
By signing dris form, I hereby certify that the rue//(s) was (were) constructed in accordance
with 15A N('A(' 02('.0100 or I5A N('AC 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 Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Injection 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
For internal Use ONLY.
This form can be used for single or multiple wells
1. Well Contractor Information:
Gary Ellingworth
Well Contractor Name
3367
NC Well Contractor Certification Number
Parratt-Wolff, Inc.
Company Name
2. Well Construction Permit #:
List all applicable melt permits (i.e. County, State, f ariance, Injection, etc.)
3. Well Use (check well use):
Water Supply Well:
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑industrial/Commercial
❑irrigation
❑Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
Non -Water Supply Well:
0 Monitoring
❑Recovery
Injection Well:
❑Aquifer Recharge
❑Aquifer Storage and Recovery
❑ Aquifer Test
❑ Experimental Technology
❑ Geothermal (Closed Loop)
❑ Geothermal (Heating/Cooling Return)
Groundwater Remediation
❑Salinity Barrier
❑ Storm water Drainage
❑Subsidence Control
❑Tracer
❑Other (explain under #21 Remarks)
4. Date Well(s) Completed: 6-29-20
5a. Well Location:
Plantation Pipe Line Co
Facility/Owner Name
2617 Quaker Landing Road
Well hits AS-123
Facility iD# (if applicable)
, Greensboro, NC
Physical Address, City, and Zip
Guilford
County
7847837248
Parcel Identification No (PiN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field one tat/long is sufficient)
36.146572 N-79.851211 W
6. Is (are) the well(s): OPermanent or ❑Temporary
7. Is this a repair to an existing well: ❑Yes or ONo
i/ this is a repair, Jill out known well construction inJormatian and explain the nature o/ the
repair under 21 remarks .section or on the back n/'this form.
8. Number of wells constructed: 1
For multiple inleclion or non -water supply wells ONLY 1011, the same construction, you can
.submit one /orm.
9. Total well depth below land surface: 66 (ft.)
For multiple wells list all depths ifdiJJerent (example- 3 200' and 2 rt lOO')
10. Static water level below top of casing: 49 (ft.)
/l hater level is above casing, use ",
11. Borehole diameter: 4
(in.)
12. Well construction method: 8 1/4" HSA
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm)
Method of test:
13b. Disinfection type:
Amount:
14. WATER ZONES
FROM
TO
DESCRIPTION
49 ft.
66 ft•
wet
ft.
ft.
IS. OUTER CASING Ifor multi -cued wells) OR LINER (Rap
icablel
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft.
ft.
in.
In. INNER CASING OR TUBING (geothermal closed•lpop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
0 ft.
64 ft.
1 in.
sch40
pvc
ft.
ft.
in.
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
64 ft'
66 ft•
1 in.
.010
sch40
pvc
ft.
ft.
in.
IS. GROUT
FROM
TO
MATERIAL
EMPLACEMENT ME1IIOD.1. AMO1 Nr
4 rt.
59.5 ft.
Portland Cem
Pour
59.5 ft•
61.5 ft•
Bentonite Chi
Pour
ft.
ft.
19. SANDiGRAVEL
PACK lif applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
61.5 ft•
66 ft.
#1 Sand
Pour
ft.
ft.
ZO. DRILLING
LOG (.ttaeh
additional sheers if necessary)
FROM
TO
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ft.
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I. REMARKS
/1
22. Certi call a:
Signatuerlined WeII C n actor
Date
By .signing Ilris,/orm, / Inrc r rrrflfi' that the ire//(s) was (here) constricted in accordance
n'iih l5A NCA(' 02C MOO or i5A NCAC 02('.0200 Well Construction Standards and that a
copy o/ this record has been prorided 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 Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. for Injection Welk 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-I North Carolina Department el' Environment and Natural Resources — Division of Water Resources
Revised August 2013