WI0400580_Well Construction Record_20220411

Print Form
WELL CONSTRUCTION RECORD (GW-1)
1. Well Contractor Information:
Mike Tynan
Well Contractor Name
2725-A
NC Well Contractor Certification Number
IET
Company Name
2. Well Construction Permit #:
List all applicable well construction permits (i.e. UIC, County, State, Variance, etc.)
3. Well Use (check well use):
Water Supply Well:
Agricultural
Geothermal (Heating/Cooling Supply)
Industrial/Commercial
0Irrigation
QlMunicipal/Public
DResidential Water Supply (single)
(Residential Water Supply (shared)
Non -Water Supply Well:
�IMonitoring Recovery
Injection Well:
DAquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
Experimental Technology
Geothermal (Closed Loop)
Geothermal (Heating/Cooling Return)
DGroundwater Remediation
QI Salinity Barrier
QI Stormwater Drainage
DSubsidence Control
01 Tracer
ID Other (explain under #21 Remarks)
4. Date Well(s) Completed: 12/10/20 Well ID#AS-1
5a. Well Location:
7-Eleven #36069
Facility/Owner Name Facility ID# (if applicable)
2375 Lewisville-Clemmons Rd, Clemmons, 27012
Physical Address, City, and Zip
Forsyth
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(dwell field, one lat/long is sufficient)
36 02 14.582 N 80 23 06.481
W
6. Is(are) the well(s)OPermanent or QTemporary
7. Is this a repair to an existing well: QYes or XQNo
If this is a repair, fill out known well construction information and explain the nature of the
repair under #21 remarks section or on the back of this form.
8. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction, only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled:
9. Total well depth below land surface: 65
For multiple wells list all depths if different (example- 3@200' and 2@100)
(ft.)
10. Static water level below top of casing: ~29 (ft.)
Ifwater level is above casing, use "+"
11. Borehole diameter: 8.25 (in.)
12. Well construction method: Auger
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
For Internal Use Only:
14. WATER ZONES
FROM
TO
DESCRIPTION
63 ft.
65 ft.
saprolite
ft.
ft.
15. OUTER CASING (for multi -cased wells) OR LINER (if ap licable)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft.
ft.
in.
16. INNER CASING OR TUBING (geothermal closed -loop) 1
FROM
TO
DIAMETER
THICKNESS
MATERIAL
0 ft.
63 ft.
2 in.
Sch40
PVC
ft.
ft.
in.
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
63 ft.
65 ft.
2 in.
0.010
Sch40
PVC
ft.
ft.
in.
18. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
0 ft.
0.5 ft.
concrete
pour
0.5 ft•
30 ft.
bent/grout
pour
30 ft.
62 ft.
bentonite
pour through augers
19. SAND/GRAVEL PACK (if applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
62 ft.
65 ft.
#1 silica sand
pour through augers
ft.
ft.
20. DRILLING LOG (attach additional sheets if necessary)
FROM
TO
DESCRIPTION (color, hardness, soil/rock type, grain size, etc.)
ft.
ft.
See report
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
21. REMARKS
Completed at surface with 12" manhole and concrete
pad. *Air Sparge Well*
22. Certification:
7i
Signature of Cep ed Well Contractor
12/16/20
Date
By signing this form, I hereby certify that the well(s) was (were) constructed in accordance
with 15A NCAC 02C .0100 or 15A NCAC 02C .0200 Well Construction Standards and that a
copy of this record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTRUCTIONS
24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Injection Wells: In addition to sending the form to the address in 24a
above, also submit one copy of this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supply & Injection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
completion of well construction to the county health department of the county
where constructed.
Form GW-1
North Carolina Department of Environmental Quality - Division of Water Resources Revised 2-22-2016

Print Form
WELL CONSTRUCTION RECORD (GW-1)
1. Well Contractor Information:
Mike Tynan
Well Contractor Name
2725-A
NC Well Contractor Certification Number
I ET
Company Name
2. Well Construction Permit #:
List all applicable well construction permits (i.e. UIC, County, State, Variance, etc.)
3. Well Use (check well use):
Water Supply Well:
Agricultural
Geothermal (Heating/Cooling Supply)
Industrial/Commercial
0Irrigation
QlMunicipal/Public
DResidential Water Supply (single)
(Residential Water Supply (shared)
Non -Water Supply Well:
�IMonitoring Recovery
Injection Well:
DAquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
Experimental Technology
Geothermal (Closed Loop)
Geothermal (Heating/Cooling Return)
DGroundwater Remediation
QI Salinity Barrier
QI Stormwater Drainage
QlSubsidence Control
01 Tracer
ID Other (explain under #21 Remarks)
4. Date Well(s) Completed: 12/10/20 Well ID#AS-2
5a. Well Location:
7-Eleven #36069
Facility/Owner Name Facility ID# (if applicable)
2375 Lewisville-Clemmons Rd, Clemmons, 27012
Physical Address, City, and Zip
Forsyth
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(dwell field, one lat/long is sufficient)
36 02 14.619 N 80 23 06.217
W
6. Is(are) the well(s)OPermanent or QTemporary
7. Is this a repair to an existing well: QYes or XQNo
If this is a repair, fill out known well construction information and explain the nature of the
repair under #21 remarks section or on the back of this form.
8. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction, only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled:
9. Total well depth below land surface: 50
For multiple wells list all depths if different (example- 3@200' and 2@100)
(ft.)
10. Static water level below top of casing: ~29 (ft.)
Ifwater level is above casing, use "+"
11. Borehole diameter: 8.25 (in.)
12. Well construction method: Auger
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
For Internal Use Only:
14. WATER ZONES
FROM
TO
DESCRIPTION
48 ft.
50 ft.
silty sand
ft.
ft.
15. OUTER CASING (for multi -cased wells) OR LINER (if ap licable)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft.
ft.
in.
16. INNER CASING OR TUBING (geothermal closed -loop) 1
FROM
TO
DIAMETER
THICKNESS
MATERIAL
0 ft'
48 ft.
2 in.
Sch40
PVC
ft.
ft.
in.
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
48 ft.
50 ft.
2 in'
0.010
Sch40
PVC
ft.
ft.
in.
18. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
0 ft.
0.5 ft.
concrete
pour
0.5 ft.
45 ft.
bent/grout
pour
45 ft.
47 ft.
bentonite
pour through augers
19. SAND/GRAVEL PACK (if applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
47 ft.
50 ft.
#1 silica sand
pour through augers
ft.
ft.
20. DRILLING LOG (attach additional sheets if necessary)
FROM
TO
DESCRIPTION (color, hardness, soil/rock type, grain size, etc.)
ft.
ft.
See report
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
21. REMARKS
Completed at surface with 12" manhole and concrete
pad. *Air Sparge Well*
22. Certification:
Signature of Ceed Well Contractor
12/16/20
Date
By signing this form, I hereby certify that the well(s) was (were) constructed in accordance
with 15A NCAC 02C .0100 or 15A NCAC 02C .0200 Well Construction Standards and that a
copy of this record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTRUCTIONS
24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Injection Wells: In addition to sending the form to the address in 24a
above, also submit one copy of this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supply & Injection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
completion of well construction to the county health department of the county
where constructed.
Form GW-1
North Carolina Department of Environmental Quality - Division of Water Resources Revised 2-22-2016

WELL CONSTRUCTION RECORD
This Fume -on be usod 8i single or mull ink wells
1. Well Contractor Information:
John Eisenman
r.e]I {'OIIniclor F. iir4
4439A
NC Well Coflhlilcior Ccrl ificaLior Number
SAEDACCO Inc
{':iii fun NanLL
2. Well ConsGalction Permit �t
List lrnopp i rtIc well pfrsreits (1_ . 'r'r,1F4'..52air, Yariurtne, ffij'abU{
3. Well Use (check well owl.:
Waxer Supply Well:
I] Agricultural
DGeollleimal tHealingrtCooling Supply)
O led u s lei a l(Co nunerc i a l
ID irrigation
DMunicipaVFtrblic
0Residerdial Wailer Supply (single)
0Residential Water Supply (sham!)
Non -Water Supply Well:
❑ rdonifnrin4
iEljCclllrci Wi..LI;
CJAgirifcr Recharge
AASiIriffr Stolagc algid Recovery
❑ A{1pirer TS5t
O E:Tukwila! Technu•LQg
❑ Geodlernml (Closed Loup)
❑ GMlien sal iHearing•'C0011 OE Retuni}
❑ Rcco3
❑Grourldwatcr RCa kerlialiLn
❑ Salinif} Harrier
❑ 5forrnyvaier iltna C
❑ 5111s5lerKe CIniml
❑ Trdt;rr
1310111er iexplain under #21 Remarks]
For fnrcraal Use ONLY:
1a-WAYE]R 2ONRS
PRO51
TO
REM 'MI. 1 ION
t$.
ft,
It.
If .
MOLTER CASING Our mull! --easel acRs} OR LIFTER {if ap Nc hki
FROM
O ft.
TO
48 IL
PL# 1FTFR
2"
io-
1
a
Tnr€'rn�FSS HATF
SCH-40 PVC
RTAI•
1b. DINER LASING OR 7ll'HING {jln rural clu dauri(!
FROM TO DEiti1ETEIt THICKNESS
MATERIAL
1i.SCRTIN
FROM
Tr}
RrAMfRTFR
SLOT Si
THFCKNTISS
MATRRI At
48 R.
50 H.
2"
iu.
.010
SCH-40
PVC
R.
It.
ia.
ia. ciwrrr
FROM
TO
?4A.TER1AL
EF1r)LtCEMLti7 3IETIIoD hMOL:Nr
O fr
45 IL
Portland
Tremmie
r
ft,
Ik,
29.SANIMIL N,ELPA iC{dglpdeillll _
. VItO1I
10
51 ATPRLAL
511 T1Ir]n
47 tt.
50 ft.
SAND
#2
ft.
1111. DRILLING LOG (attach idlfiiianaI shall if neecsran)
FROM
0 It
50 ri.
RE'.ti{'REPTIE}\ 1s„hr,hMrdns'r.. r.il'nn'I. 15p[, 7rdn
SANDY CLAY
.Bate Welts) Conipleicd: 10-7-21
SA_ k}eLl Illlrathun:
7-Eleven #36069
Fycililr' (... cr NOM
2375 Lewisville Clemmons Rd.,
Forsyth
Well 1D1rAS-3
I-acilrry IDC tirapplicablet
Clemmons, NC, 27012
Physical Addicss_ Cit}.. and Zip
G/inny Fart] Idcnnrfieynitan No fFUN}
5h.1-plitudc A1u1 1-nngituile in 11C1[1•Tcsimilltites ecian11s nr decimal degrees:
{If i 11 field. Intl Lallans is zirllicknll
Tti W
6.1s bunt Ibe welUsk OPenna ent er OTemporilr}'
7. is this a repair to an existing: well. YcJi or MI Nu
f/rhfs ix rr rrl*ur, f+J'Mar trtI,ww wed cx++urnnrr,I J eirlorrarr.rmi old r.tvfarJi rflr 0r rrrre of the
repair ranger .112.1 reenrdrl'.'.reeJiarx ar on the hark of tfi sPrui.
S.Number ofwells -onsirueced: 1
For rrortrhplr'of eerlwl or rlr.I-wbrer supply wells ONLY with rhr' sadly" CortoneCJiOe. xa, coo
mitwiirirur fornr.
9. Total well depth helm; land surfut 50 (fl.)
For MOW!' wetly ttsr ruff di'luhr ifEfdrerv+lr leyaRJpte- 3@200' thud 2@ Ifrlr}
1 U. Static water Ter. el trim' top of cariup
1f wrung 11,.4 ,s Able rr.e.s1 •. uu' '•+"
I I. BOITblrlc diameter 8.25" tA)
12. Well cona?irnctiiri method: 4.25" HSA
1i.e. aiI r. radar}', cable- direct push. etc.
FOR WATER SUPPLY WELLS ONLY:
13a, 1'idd (p i)
1J11. Disinroctiun ripe:
Melded of test:
Amount:
It
ft.
IL
It
IL
fr
It,
rt.
rt,
rt.
11. REMARKS
Bentonite Seal 45 to 47ft
22, Certification:
10/13/2021
Sismlaic of , - ;. --•
' rx sir' :'-
$s signir�� hid]. fw,K �f.' h: 41h w.a' 1re.�h eoarrrre'real in axex+oramrrx'
wrhf5.4NCACO2C. - i tR�;ZC.O We CatrarracrfanSrandardaandrtuara
ropy of this record herd' dx ew Iwm'airni err Jibe Writ .puller,
23. Site diagram or additional well details:
You may lice the back of ihis page to provide additional well sire details or well
cc+nsiruL[iori details. You eels,' also attach:idditioilat pages if ioet:essar} .
SU BM ITTAL [NSTIJCTIONS
2da Ear All Wells: Suhllui Ilus form within MI dens of compleiioo of well
Contlmtttpn to die fhlLnuing-
birisiun of Wsiter Rezuurces, Information Frucessiog Unit,
1417 Mail Service Center, Raleigh, NC 17699-1617
tab. For Inicclios Welly ONLY: In a,ddiiiaii to sending the form to the address in
2-la above. also submit a op!, of this form within 30 days of completion of well
cariSh uLLiurl [o the following:
Dh'ision of Vli'ater ReftourceN.lUnderpound Injeciiou Control Program,
1636 Mail Scriiiee Cu ntur. Raleigh, NC 27699-1636
25e, fit wAtsr_syylajLi_rjEcti.ou V4' Ll�r
Also submit one copy of this ford l VI ithin 30 days of completion of
well cnoslnictinn to the el711nrY depennneart of the county where
constructed
Farin GW-L
\nnh Carol Ira L7.pernnrJIE aC Ern minimal and Narilra] Resources - Dig ss tau eI Walcr Ravin R iscd August 211J 3

WELL CONSTRUCTION RECORD
This Form can be usod 8i single or mull ink wtIls
1. Well Contractor Information:
John Eisenman
WOI ConIrdriot NMAr114
4439A
NC Well Coflhlilcior Ccrl ificaLion Number
SAEDACCO Inc
Nomc
2. WdI ConcGalctiOn Psrtait fl
Litopp i rthIc 14YiIptnreits (1_ . Cr'r,1r'. &Mr. Yariurtne. .felpErthrittrJr.+
3. Well Use {check: well 9l10:
Water Supply Well:
In Agricultural
DGeollleimal IiealingrtCooling Supply)
O led u s f ri a VCo nunerc i a l
❑ hri ition
DMiinicipaVFlrblic
OResidcnlial Wafer Supply (single)
0Residential Wafer Supply (shared)
NoM-Water Supply Well:
❑ Tylpnilnrin4
iLlircllirll Wi..LI;
0A{]114-Cr Rcchargc
AASjllifCr Storage and RMO:KT'j'
❑ A{Tpifer T
❑ Experimrnfa1 MChnLLQg
❑ Geodrernml (Closed Lour!)
❑ Gro[II�m1al iHe4lnrg''C001.1rie Retuni
❑ Rcc n
❑Grraulidwatcr RC1114[tiatian
❑ Salinifl Harrier
❑ Storrnywzncr Dinao"C
1=1511115iiCKC CIniml
❑ Trdt;rr
® Jihev (explain under #21 Remarks)
For fretaal 4rso ON I.V:
1a- ilk 'AtER 2.ONl'S
rR{j41
TO
REM 'MI. 11{}S
H.
ft.
I.
11.OUTER CASING Our omit --rased ncRs} OR L KERfiF ap Nc hki
FROM
O ft.
TO
48 IL
PL 1FTFR
2"
io-
1
a
Tnr€'fnNFSS
MATERIAL
1b. DINER LASING OR 71'HING {jlnllcraral clu dawn(!
FROM TO DEiti1E'rEIt THICKNESS
f1. ft Pik
MATERIAL
17. SCrti1N
FROM
TO
prAMIRTFR
SLOT SIiCR
THt .14.14 SS
MATRRI AI.
48 R.
50 H.
2"
iu.
.010
SCH-40
PVC
R.
It.
ia.
ia. clrarT
FROM
TO
?dhTER1AL
EFTt2.4CEMEti7 3IFn1oIJ hMOL:Nr
O fr
45 IL
Portland
Tremmie
fi*
rt
ft
Il,
29.SANIil'GR.4N..El. PACK jfglpdeillll _
. rR{}11
w r1
50 ATER1A1.
E::41Y1..5r'}'.\II: 1' Si}'Tur]n
47 ft.
50 fl.
SAND
#2
ft.
ft.
3II DRILLIC1G LOG (attach id{fiiiormI shs1/4911 if ricccssan]
FRO"I
0 IL
TO
50 fi.
RE'.ti{'REFTlip[, 7rdn'roc'.
SANDY CLAY
.Date Welts) Conipleicd: 10-7-21
S a_ k}t'LI IJ1lr11641n:
7-Eleven #36069
Fycililr' (... cr NUM
2375 Lewisville Clemmons Rd.,
Forsyth
Well 1DifAS-4
I-aoiliry IAC tirmplicaf}del
Clemmons, NC, 27012
Physical Addicss_ Cit}.. and Zip
Cowls FBr t] Idcnisfic,iiitan No 1P N:F
5h.1.ptlitudc A1u1 1-nngitprle in tIcgrecsimintitest eciantltt nr decimal degrees:
(If se 01field.I)1tl laLlimgiszidlickvnl
T1 W
6.1s bunt Ibe welUJrk OPennaneni er ❑Temporary
7.isthis arepair toanexisting well: YcJi 11r IN Nu
f/rhfs Jx rr repdit. fill Mar trtI,ww itoficOokirralricto eitfurrr„rr.r.'+l r.tvfarJi rfle 0r rl1re of the
repair rimier 02L rrenterl•.'.r..Titan or rJn the hark of tJdr jF. ruI.
Number -onsiru ced: 1
For IWa,+rtplr'of eerrwl or rrr.1-Iva er supply w'eiIa ONLY with rflr serer romener7inu. xa, coo
mity.mir mue (Drug.
9. Total well depth helm; laird surfut= 50
FormxrJt frwrtlrtrsrrrUdr.r,j* ifEl' igemu le.yaRJpte-7@200'tiii 2@fflifx'}
1 U. Static water Ies el below top of cariup
ff wrirrr Ir' rI ,s r;llul'e rnairJ:E. ou' '• 4 •'
I I. Bali diameter 8.25" OA)
12. Well tonifirnctiori method: 4.25 HSA
1i.e. a11{cr. roar}. cable- di i push.crc.I
FOR WATER SUPPLY WELLS ONLY:
134 Yidcf (p i)
1313. bisinFoctiun ripe:
Melded of test:
Amount:
ft.
8
ft.
IL
IL
IL
fr
If,
fZ,
fr.
rt,
rt,
21. keMARECS
Bentonite Seal 45 to 47ft
22, Cerfiradsin:
10/13/2021
Sisnrlalc of , ' - ;. --• — - 1 ..
$s signEhig JJ'r1T eoarrrre'real in aex+oramrrx'
malt f5.4NC4CO2C.•_ - .0200 WetfComtrnrdrurSrandardaand Ama
ropy of 041 record. had dx {w Iwm'airni err Jibe Writ .Wolter,
23. She diagram or adelliianal well details:
You may lice the back of ihis page to provide additional well sire details or well
cc+nslrIL[iori details. You maw also attach:iddifioilat pages if 1set:essar} .
SU BM [TTAL [NSTIJCTIONS
2da liar All Wells: Subinii Iles faro- within .11 dens of complelioo of well.
Contlnittipn to )lac fhlLoning-
birisiun Water Rezuurces, Infurmatiuu Processing
1617 h1aiL Smite Center, Raleigh, NC 17699-1617
tab. For Inicclios Welly ONLY: In a,ddiiiaii to sending the form to Ills address in
2-1a shove. also submit a imp, of this form within 30 days of completion of well
conSIfliLLiurl Eft the following:
Dh'ision e£Vli'ater Resat' rceN.lfridcrpound Injeciiou Control Program,
1636 M ll Strike Curlier. Raleigh, NC 27699-1636
24 . fit wAtsr_syylajLi_rjEcti.ou V4'CLI�r
A]eti submit one copy of this foie- +tiithin 30 days ofconpletionof
well cnostnictian to tt1c C0.11nr3 bC4Ith drpantmpnt of the county where
Cpr1j'jTpC14d
Farin OW-L
I\nnh Carol lea D.pannrJIE or Ern mama and Nariira] Rt sc'luccs - Di, ss row eI War Ravu o ftt, iscd August 21113

WELL CONSTRUCTION RECORD
This Form can be usod 8i single or mull ink wtIls
1. Well Contractor Information:
John Eisenman
WOI ConIrdriot NMAr114
4439A
NC Well Coflhlilcior Ccrl ificaLion Number
SAEDACCO Inc
Nomc
2. WdI ConcGalctiOn Psrtait fl
Litopp i rthIc 14YiIptnreits (1_ . Cr'r,1r'. &Mr. Yariurtne. .felpErthrittrJr.+
3. Well Use {check: well 9l10:
Water Supply Well:
In Agricultural
DGeollleimal IiealingrtCooling Supply)
O led u s f ri a VCo nunerc i a l
❑ hri ition
DMiinicipaVFlrblic
OResidcnlial Wafer Supply (single)
0Residential Wafer Supply (shared)
NoM-Water Supply Well:
❑ Tylpnilnrin4
iLlircllirll Wi..LI;
0A{]114-Cr Rcchargc
AASjllifCr Storage and RMO:KT'j'
❑ A{Tpifer T
❑ Experimrnfa1 MChnLLQg
❑ Geodrernml (Closed Lour!)
❑ Gro[II�m1al iHe4lnrg''C001.1rie Retuni
❑ Rcc n
❑Grraulidwatcr RC1114[tiatian
❑ Salinifl Harrier
❑ Storrnywzncr Dinao"C
1=1511115iiCKC CIniml
❑ Trdt;rr
® Jihev (explain under #21 Remarks)
For fretaal 4rso ON I.V:
1a- ilk 'AtER 2.ONl'S
rR{j41
TO
REM 'MI. 11{}S
H.
ft.
I.
11.OUTER CASING Our omit --rased ncRs} OR L KERfiF ap Nc hki
FROM
O ft.
TO
48 IL
PL 1FTFR
2"
io-
1
a
Tnr€'fnNFSS
MATERIAL
1b. DINER LASING OR 71'HING {jlnllcraral clu dawn(!
FROM TO DEiti1E'rEIt THICKNESS
f1. ft Pik
MATERIAL
17. SCrti1N
FROM
TO
prAMIRTFR
SLOT SIiCR
THt .14.14 SS
MATRRI AI.
48 R.
50 H.
2"
iu.
.010
SCH-40
PVC
R.
It.
ia.
ia. clrarT
FROM
TO
?dhTER1AL
EFTt2.4CEMEti7 3IFn1oIJ hMOL:Nr
O fr
45 IL
Portland
Tremmie
fi*
rt
fL+
Il,
29.SANIil'GR.4N..El. PACK jfglpdeillll _
. rR{}11
w r1
50 ATER1A1.
E::41Y1..5r'}'.\II: 1' Si}'Tur]n
47 ft.
50 fl.
SAND
#2
ft.
ft.
3II DRILLIC1G LOG (attach id{fiiiormI shs1/4911 if ricccssan]
FRO"I
0 IL
TO
50 fi.
RE'.ti{'REFTlip[, 7rdn'roc'.
SANDY CLAY
.Date Welts) Conipleicd: 10-7-21
S a_ k}t'LI IJ1lr11641n:
7-Eleven #36069
Fycililr' (... cr NUM
2375 Lewisville Clemmons Rd.,
Forsyth
Well 1DifAS-5
I-aoiliry IAC tirmplicaf}del
Clemmons, NC, 27012
Physical Addics' Cit}.. and Zip
Cowls FBr t] Idcnisfic,iiitan No 1P N:F
5h.1.ptlitudc A1u1 1-nngitprle in tIcgrecsimintitest eciantltt nr decimal degrees:
(If se 01field.I)1tl laLlimgiszidlickvnl
T1 W
6.1s bunt Ibe welUJrk OPennaneni er ❑Temporary
7.isthis arepair toanexisting well: YcJi 11r IN Nu
f/rhfs Jx rr repdit. fill Mar trtI.ww itoficOokirralricto eitfurrr„rr.r.'+l r.tvfarJi rfle 0r rl1re of the
repair rimier 02L rrenterl•.'.r..Titan or rJn the hark of tJdr jF. ruI.
Number -onsiru ced: 1
For IWa,+rtplr'of eerrwl or rrr.1-Iva er supply w'eiIa ONLY with rflr serer romener7inu. xa, coo
mity.mir mue (Drug.
9. Total well depth helm; laird surfut= 50
FormxrJt frwrtlrtrsrrrUdr.r,j* if El' igemu le.yaRJpte-7@200'anti2@fflifx'}
1 U. Static water Ies el below top of cariup
ff wrirrr Ir' rI es r;llul'e rnairJ:E. ou' '• 4 •'
I I. Bali diameter 8.25" OA)
12. Well tonifirnctiori method: 4.25 HSA
1i.e. a11{cr. roar}. cable- di i push.crc.I
FOR WATER SUPPLY WELLS ONLY:
134 Yidcf (p i)
1313. bisinFoctiun ripe:
Melded of test:
Amount:
ft.
8
ft.
IL
IL
IL
fr.
If,
fZ.
fr.
rt,
rt,
21. keMARECS
Bentonite Seal 45 to 47ft
22, Cerfiradsin:
10/13/2021
Sisnrlalc of , ' - ;. --• — - 1 ..
$s signEhig JJ'r1T eoarrrre'real in aex+oramrrx'
malt f5.4NC4CO2C.•_ - .0200 WetfComtrnrdrurSrandardaand Ama
ropy of 041 record. had dx {w Iwm'airni err Jibe Writ .Wolter,
23. She diagram or adelliianal well details:
You may lice the back of ihis page to provide additional well sire details or well
cc+nslrIL[iori details. You maw also attach:iddifioilat pages if 1set:essar} .
SU BM [TTAL [NSTIJCTIONS
2da liar All Wells: Subinii Iles faro- within .11 dens of complelioo of well.
Contlnittipn to )lac fhlLoning-
birisiun Water Rezuurces, Infurmatiuu Processing
1617 h1aiL Smite Center, Raleigh, NC 17699-1617
tab. For Inicclios Welly ONLY: In a,ddiiiaii to sending the form to Ills address in
2-1a shove. also submit a imp, of this form within 30 days of completion of well
conSIfliLLiurl Eft the following:
Dh'ision e£Vli'ater Resat' rceN.lfridcrpound Injeciiou Control Program,
1636 M ll Strike Curlier. Raleigh, NC 27699-1636
24 . fit wAtsr_syylajLi_rjEcti.ou V4'CLI�r
A]eti submit one copy of this foie- +tiithin 30 days ofconpletionof
well cnostnictian to tt1c C0.11nr3 bC4Ith drpantmpnt of the county where
Cpr1j'jTpC14d
Farin OW-L
I\nnh Carol lea D.pannrJIE or Ern mama and Nariira] Rt sc'luccs - Di, ss row eI War Ravu o ftt, iscd August 21113

WELL CONSTRUCTION RECORD
This lorncon be usod 8i single or mull jilt wells
1. Well Contractor Information:
John Eisenman
WC]i {'OIInici41 t'ianw
4439A
NC Well Coflhlilcior Cot ifenstion Number.
SAEDACCO Inc
{'cuilfirun NanLL
2. Wdi Comi#rrrctign Permit fit;
List lrnopp i rtIc w Iptnreits (1_ . CrxErney'..52air, Yariurene, ErripErelectrJr.+
3. Well Use (chat: well use):
Water Supply Well:
In Agricultural
DGeollleimal tHeatalMgrtCooIin. Supply)
❑ led u s lei a VCo nunerc i a l
ID irrigation
DMirnicipaVFtrblic
C]Residcnlial Water Supply (single)
0Resideniial Water Supply (sham!)
NoM-Water Supply Well:
❑ ldnnilnrin4
iLlirclllrrl Wi.LI;
0A,4111ifcr Recharge
DAiIIriffr Stolagc and RceolACT)'
❑ Aquifer Tc5t
❑ Experimenta1 TechFL LQg
❑ Geodlernml (Closed Loup)
❑ GMIrenuil iHeatnrg•'Cbolirng Retun1}
❑ Rccp3
❑Groundwyatcr Rcnnec iatiLn
❑ Salinif} Harrier
❑ 5forrnyvaier ilina C
❑ 5111s5iiCMC Coilml
❑ Trdt;rr
® Jihev fexplain under M21 Remarks]
FQr Fiend Use ON
1.1. WAtER 2.ONIiS
PRO51
TC)
REM 'MI. 1 ION
ft.
It ,
ft.
If .
MOLTER CASING Our mull! --easel acRs} OR LIFTER {if sir - hkh
FROM
O fL.
TO
48 IL
PL# 1FTFR
2"
io-
1
a
Tnr€'rn�FSS
SCH-40 PVC
MATT
RTAI•
1b. INNE_ R CASING OR 1ll'H INc; { jlnralclr�udari(!u
FROM TO DEiti1ETEIt THICKNESS
MATERIAL
17. SCR]1N
FROM
TO
RrAMIRTFR
SLOT Si
THIR:KNT1SS
MATRRI At
48 R.
50 H.
2"
iu.
.010
SCH-40
PVC
R.
It.
ia.
ia. GROUT
FROM
TO
?dhTER1AL
ifiSPI tCEMLNI 3IETIIoD hMOL:Nr
O ft.
45 IL
Portland
Tremmie
ri,
FIN
ft
It,
29.SANBICILA''ELPACK {dglpdetllll _
. VItO1I
wr:
51 ATPRLAL
511T1Irin
47 O.
50 8.
SAND
#2
ft.
ft.
3II, DRILLING LOG (attach idifilianHI nceul ni
FROM
0 IL
50 A.
RE'.ti{'REPTIE}\ s„hr,hMrdns'r.. r.il'nn'I, 15 pc 7rdn
SANDY CLAY
.Bate Welts) Conipleicd: 10-7-21
Sa_ VreLI Illrrathun:
7-Eleven #36069
Fycililr' (... cr NOM
2375 Lewisville Clemmons Rd.,
Forsyth
Well 1D1fAS-6
I-loilrry IDC tir3pplicnb1e1
Clemmons, NC, 27012
Physical Addiess_ Cit}.. and Zip
0>anty FBr t] IdCnn freiEliun Nn LFUN}
5h.1.prlitudc mud 1-nngitude in 11C1{1ecsimirrplcslxccnnilc nr decimal degrees:
{If i 11 held. Intl Lallans is sank ken l
Tti W
6.1s ant Ibe welUsk OPennaneni er OTemporar}'
7. is this a repair to an existing well: YcJi or MI Nu
f/rhfs ix rr rrl*ur. f+J'Mar trtI,ww I.•ri!ctiA rnnrr,I J eafurrarr.rmi rmd r.tvfarJi rflr 0r rrrre of the
repair ranger .112.1 rreneerlwseeliarx ar on the hark of Idsprwi.
S.Number ofwells -onsirueced: 1
For rrodrhplr irtfeerlwl or rlr.I-wbrer supply we* ONLY with rhr' ilTrltr" CortoneeiiOe. xa, coo
aarpwiirtrue form.
9. Total well depth helm; land surfut 50 (fl.)
ForJrtMI W!' wrtlr trsiruff di'luhr ifr t rvJu leYempte- 3@200' thud 2@U(.8)
1 U. Static n ater Ier• el below lop of cariup
1 f wrirei. Ir' .4 ,s A l o e c n a rhi:E•. eau' '•+'
I I. BOITblrlc diameter: 8.25" 1.1-)
12. wrIl consarnctiirr method: 4.25 HSA
ii.e. aiI r. repay}, cable- dilo-_i push. tic.
FOR WATER SUPPLY WELLS ONLY:
13a• Yid(' (p i)
1J11. Disinroctiun ripe:
Melded of test:
Amount:
ft.
It.
ft.
IL
IL
IL
f!,
It,
lZ,
rr.
rt,
rt,
21. REMARKS
Bentonite Seal 45 to 47ft
22, Cerfiernion:
10/13/2021
Sisnilaic of , - ;. --•
' rx sir' 1'-
LIr signir�� JJ'r1T fw,K rl� h: 41h w.a' 1rr.�i eoarrrJre'rear in exex+oramrrx'
mirk f 5.4 NCAC 02C .';r � .0200 We Cat aura nniut Sra ndarda and Away a
ropy of this Freon-, had dx ew Iwm'airni err Jibs Writ .puller,
23. She diagram or adelliianal well details:
You may :He the back of ihis page to provide additional well sire details or well
cc+nsiruL[iori details. You ells,' also attach:idditioilat pages if 1set:essar} .
SU BM LTTAL [NSTL1CTIONS
2da Inc All Wells: Suhlrui this faros within .11 days of compleiioo of wet[
Contlnittipn to the fhlLoning-
birisiun of Water Rezuurces, lnfurmatiuu Frocessiog Unit,
1617 Mail Service Center, Raleigh, NC 17699-1617
tab. For Inicclios Welly ONLY: In a,ddiiiaii to .sending the form to :he address in
2-la above. also submit a imp, of this form within 30 days of completion of well
conSIruLLiuh [o the following:
Dh'ision of Vir'ater Ream rceN.lrridcrpound Injection Control Program,
1636 T4ir;ll Serif Curlier. Raleigh, NC 27699-1636
24 . fit W4tcr$fa(rpl L cvriun WCLII:
Also submit one copy of this form ,ti ithin 30 days of completion of
well cnoslniCtiOR to tilt 0.11nrY bC4Ith depantmpnt of the County where
construclad
Farin OW-L
Krinh Carol lea D.xtrimeJIE oCErn iloiuenj and Narilral Rcsourocs - DO, ssIVY of War Ravin Rt, iscd August2u13

WELL CONSTRUCTION RECORD
This Form can be usod 8i single or mull ink wtIls
1. Well Contractor Information:
John Eisenman
WOI ConIrdriot NMAr114
4439A
NC Well Coflhlilcior Ccrl ificaLion Number
SAEDACCO Inc
Nomc
2. WdI ConcGalctiOn Psrtait fl
Litopp i rthIc 14YiIptnreits (1_ . Cr'r,1r'. &Mr. Yariurtne. .felpErthrittrJr.+
3. Well Use {check: well 9l10:
Water Supply Well:
In Agricultural
DGeollleimal IiealingrtCooling Supply)
O led u s f ri a VCo nunerc i a l
❑ hri ition
DMiinicipaVFlrblic
OResidcnlial Wafer Supply (single)
0Residential Wafer Supply (shared)
NoM-Water Supply Well:
❑ Tylpnilnrin4
iLlircllirll Wi..LI;
0A{]114-Cr Rcchargc
AASjllifCr Storage and RMO:KT'j'
❑ A{1pifer T
❑ Experimrnfa1 MChnLLQg
❑ Geodrernml (Closed Lour!)
❑ Gro[II�m1al iHe4lnrg''C001.1rie Retuni
❑ Rcc n
❑Grraulidwatcr RC1114[tiatian
❑ Salinifl Harrier
❑ Storrnywzncr Dinao"C
1=1511115iiCKC CIniml
❑ Trdt;rr
® Jihev (explain under #21 Remarks)
For fretaal 4rso ON I.V:
1a- ilk 'AtER 2.ONl'S
rR{j41
TO
REM 'MI. 11{}S
H.
ft.
I.
11.OUTER CASING Our omit --rased ncRs} OR L KERfiF ap Nc hki
FROM
O ft.
TO
48 IL
PL 1FTFR
2"
io-
1
a
Tnr€'fnNFSS
MATERIAL
1b. DINER LASING OR 71'HING {jlnllcraral clu dawn(!
FROM TO DEiti1E'rEIt THICKNESS
f1. ft Pik
MATERIAL
17. SCrti1N
FROM
TO
prAMIRTFR
SLOT SIiCR
THt .14.14 SS
MATRRI AI.
48 R.
50 H.
2"
iu.
.010
SCH-40
PVC
R.
It.
ia.
ia. clrarT
FROM
TO
?dhTER1AL
EFTt2.4CEMEti7 3IFn1oIJ hMOL:Nr
O fr
45 IL
Portland
Tremmie
fi*
rt
ft
Il,
29.SANIil'GR.4N..El. PACK jfglpdeillll _
. rR{}11
w r1
50 ATER1A1.
E::41Y1..5r'}'.\II: 1' Si}'Tur]n
47 ft.
50 fl.
SAND
#2
ft.
ft.
3II DRILLIC1G LOG (attach id{fiiiormI shs1/4911 if ricccssan]
FRO"I
0 IL
TO
50 fi.
RE'.ti{'REFTlip[, 7rdn'roc'.
SANDY CLAY
. Date Welts) Conipleicd: 10-7-21
S a_ k}t'LI IJ1lr11641n:
7-Eleven #36069
Fycililr' (... cr NUM
2375 Lewisville Clemmons Rd.,
Forsyth
Well 1D+f AS-7
I-aoiliry IDC tirmplicaf}del
Clemmons, NC, 27012
Physical Addicss_ Cit}.. and Zip
Cowls FBr t] Idcnisfic,iiitan No 1P N:F
5h.1.ptlitudc A1u1 1-nngitprle in tIcgrecsimintitest eciantltt nr decimal degrees:
(If se 01field.I)1tl laLlimgiszidlickvnl
T1 W
6.1s bunt Ibe welUJrk OPennaneni er ❑Temporary
7.isthis arepair toanexisting well: YcJi 11r IN Nu
f/rhfs Jx rr repdit. fill Mar trtI,ww itoficOokirralricto eitfurrr„rr.r.'+l r.tvfarJi rfle 0r rl1re of the
repair rimier 02L rrenterl•.'.r..Titan or rJn the hark of tJdr jF. ruI.
Number -onsiru ced: 1
For IWa,+rtplr'of eerrwl or rrr.1-Iva er supply w'eiIa ONLY with rflr serer romener7inu. xa, coo
mity.mir mue (Drug.
9. Total well depth helm; laird surfut= 50
FormxrJt frwrtlrtrsrrrUdr.r,j* ifEl' igemu le.yaRJpte-7@200'tiii 2@fflifx'}
1 U. Static water Ies el below top of cariup
ff wrirrr Ir' rI ,s r;llul'e rnairJ:E. ou' '• 4 •'
I I. Bali diameter 8.25" OA)
12. Well tonifirnctiori method: 4.25 HSA
1i.e. a11{cr. roar}. cable- di i push.crc.I
FOR WATER SUPPLY WELLS ONLY:
134 Yidcf (p i)
1313. bisinFoctiun ripe:
Melded of test:
Amount:
ft.
8
ft.
IL
IL
IL
fr
If,
fZ,
fr.
rt,
rt,
21. keMARECS
Bentonite Seal 45 to 47ft
22, Cerfiradsin:
10/13/2021
Sisnrlalc of , ' - ;. --• — - 1 ..
$s signEhig JJ'r1T eoarrrre'real in aex+oramrrx'
malt f5.4NC4CO2C.•_ - .0200 WetfComtrnrdrurSrandardaand Ama
ropy of 041 record. had dx {w Iwm'airni err Jibe Writ .Wolter,
23. She diagram or adelliianal well details:
You may lice the back of ihis page to provide additional well sire details or well
cc+nslrIL[iori details. You maw also attach:iddifioilat pages if 1set:essar} .
SU BM [TTAL [NSTIJCTIONS
2da liar All Wells: Subinii Iles faro- within .11 dens of complelioo of well.
Contlnittipn to )lac fhlLoning-
birisiun Water Rezuurces, Infurmatiuu Processing
1617 h1aiL Smite Center, Raleigh, NC 17699-1617
tab. For Inicclios Welly ONLY: In a,ddiiiaii to sending the form to Ills address in
2-1a shove. also submit a imp, of this form within 30 days of completion of well
conSIfliLLiurl Eft the following:
Dh'ision e£Vli'ater Resat' rceN.lfridcrpound Injeciiou Control Program,
1636 M ll Strike Curlier. Raleigh, NC 27699-1636
24 . fit wAtsr_syylajLi_rjEcti.ou V4'CLI�r
A]eti submit one copy of this foie- +tiithin 30 days ofconpletionof
well cnostnictian to tt1c C0.11nr3 bC4Ith drpantmpnt of the county where
Cpr1j'jTpC14d
Farin OW-L
I\nnh Carol lea D.pannrJIE or Ern mama and Nariira] Rt sc'luccs - Di, ss row eI War Ravu o ftt, iscd August 21113

WELL CONSTRUCTION RECORD
This Forme -an be usod 8i single or mill iplc wells
1. Well Contractor Information:
For hkcraal Use ONLY:
John Eisenman
We]I {onrhiGi41 Kam.;
4439A
NC t icl1 Conlrlcior Ccrl ifecsLion Ni:llha
SAEDACCO Inc
{':iii un Name
2. Well (onstralction Permit ail;
List lrnopp i itIc well pfrsreits (1_ . 'f'r,1F4'..52air, Variance, ffij'abU{
3. Well Use (cheek well use):
Wirer Supply Well:
In Agricultural
❑ Geollleimal NeatingiCooling Supply)
O lad u s tri a VCo nunerc i a l
❑ hri ition
DMunicipaVFtiblic
0Residcinial Water Supply (single)
0Residentiai Water Supply (shared)
NoM-Water Supply Well:
❑ Monitoring
iEij 9 ilirll Wi.LI;
CJAgirifcr Recharge
DAtliriffr Storage araiRceolotry
❑ Aquifer Tem
❑ Experimuntal TI:ChFL LQg
❑ GeNodiernmi (Closed Loup)
❑ C�rorliemual iHe4lnrg''C00i1 OE Return}
❑ Rcc n
❑Grourrdwatcr RC1i14'(liatian
O .Salintr Harrier
❑ 5torrnwarer Dina
1=151is5i 1CMC Corlml
❑ Trdt;rr
®Oilier texplain udder M21 Remarks)
1a-WAT R2JON.Ls
rR{j41
To
REM 'FM. 11{}S
f$.
rt ,
ft.
MOLTER CASING Mir and -tared nc19 OR L KER {if as. Nc ski
FROM
O It.
TO
48 IL
DIAMETER
2"
io-
1
a
Tnr€'rnkFSS HATE
SCH-40 PVC
RTAI•
T. INNER LASING OR 7T11ING { rolhenlral tlurtdaurl...
FROM TO DIA ETE:I[ THICKNESS
MATERIAL
2
n.
17. SCiLTIN
uL
Irk
FROM 7D
48 50
RE*trE:rt-R SLOT$1
11, 2" in. .010
ia.
R It
iCrr THre1CM11SS 1AATRR13.1.
SCH-40
PVC
lg.-GROUT
FROM
TO
?4LTER1AL
Eri4)LtCEMLti7 3IFn1oIJ a hMOL:Nr
O IL 45 FL Portland
Tremmie
ri.
rp
ft.
29.5ANIICIL VEl.PA iC{dglpdeillll _
. rR{111
r0
'MATERIAL
E:'r1Y1..{i'}'.\1i:ti1 5i}'Tur]n
47 O.
50
it,
SAND
#2
It.
ft.
311 DRILLING LOG (attach id{filianHI nccearun)
FROM
0 IL
T[1
50 N.
RE'.ti{'REPTIE}\ lS,.hr,lurdns'++,wiUnt'I. li pt, prdn
SANDY CLAY
.Bate Welts) Conipleicd: 10-7-21
S a_ 1.11. 1Jliratilin:
7-Eleven #36069
Fycililr' (... cr NOM
2375 Lewisville Clemmons Rd.,
Forsyth
Well 1DIfAS-8
I-aoilrry IDC tirapplicablei
Clemmons, NC, 27012
Physical Addiess_ Cit}.. and Zip
Oicaly FBr e1 IdenisfreiEliun No fFUN}
5b.1-PAitudc i1w1 1.nngitUnit in dcgreesimirnatitiAcconds or decimal degrees:
{If i 11 fret.. rnu LW9uitg is xlrllickvll
Tti W
6.1ai late) the welUJak OI ennaneni e r OTemporor}'
7. is this a repair tR an existing well: Yes fir El Nu
f/rhfs Jx re- rrl*Irr, f+J'Mar trtI,ww I.•r1I,:O.urnnrr,ia eirlorrarr.rmi r.tvfarJi rflr rlr rl1re of the
repair ranger 02L remarl'.y.yrr'Jiarx or on the hark of rJdr jFJrwl.
S.Number ofwells -onaitrueced: 1
For IWadrtplr'of eerrwl or rrr.1-wbrer supply wetly ONLY rod rfir' same aarrrp ee inrr. xa, coo
.t*i1iriii fora.
9. Total well depth helm laud surfut 50
ForJWilrrf.L1 t wily Hsi rrUdi'Prhr ifdigrrv+lrleyaRJpte- 3@200' thud 2@Jllfx'}
1 U. Static n ater let• el below top of cariuz
ff near'..art r.1 ,s r;lruVe inafrJg. mu' '• 4 "
I I. Bali diameter: 8.25")
12. wr'Il conatirnctiori method: 4.25" HSA
ti.e. ail r. roar}', cable- direct push. etc.
FOR WATER SUPPLY WELLS ONLY:
13a, Yid(' (p i)
131i. bisinrtwtiun ripe:
Method of test:
Amount:
It.
It.
IL
IL
fx
rt.
R.
re-.
rt.
rt.
II - REMARKS
Bentonite Seal 45 to 47ft
22. Certification:
10/13/2021
Sisnrlalc erf , ' - ;. --•
' r . si r' ' - e
LIr signir�� whir fw,K rl� h: 41r w.a' 1rr.�J axnrr'rrra'rea! in .aex+oramriti:'
xtirh f 5.4 NCAC 02C . -1 t;R�,ZC .0200 We Catratracrfan Sra ndafda and Ma; a
ropy ofshirrecord hrjsdx{wIw L'a nil rrrIOW Wei/ Minter.
23. She diagram or adt3liianal well details:
You may lice the back of this page to provide additional %%ell sire details or well
cc+n truL[ion details. You insw also attach:idditioi}at pages if iiecessart .
SU BM LTTAL LNSTL1CTIONS
21a Ear All Wells: Suhllui Ilus form within MI dens of compleiion of well
Con5lnittipn to the fhlLoning-
biribiun of WAtur Rezuurces, lnformatiuu Frocexsiog (nit,
1617 Mail Service Center, Raleigh, NC 17699-1617
tab. For Inicciios Welly ONLY: In addiiiati to sending the form to Ilic address in
2-la above. also submit a op!, of this form within :ID days of completion of well
carialfILLiurl EI} the following:
Dh'ision e£Vli'ater Resources. Injeciio1 Control Program,
1636 T4iJili Ser4 irx Curlier. Raleigh, NC 27699-1636
24 . fit wAtsr_s_lkylajLi_rjEcti.ou WCLIN.
Also submit one copy of this forth 5l ithin 30 days of completion of
well construction to the el 1mr3 health department of the county where -
constructed
Farin GW-L
Krinh Carolina D..parurn JIE or Ern Ammar and Narilra] Rewirrccs - Dig ss row of Waacr Ravin Rt, iscd August 21113

WELL CONSTRUCTION RECORD
This Form can be u90d Cm single or ipk wells
1. Well Contractor Information:
Robert Miller
Well Collrtclow 14anw
2675
NC W'c11 Co iI1iiciorCcrlNumber
SAEDACCO Inc
{'marl u15 Namur
2. Well (om tmetion Permit tr:
List all appl'iruhle wrllpt'rmirs gr_c. County. ark, Yariartne, fripErthart Nr.+
3. Weil Use (cheek well use);
Waxer Supply Well:
In Agricultural
DGeotheimal tHeaiingrtCooling Supply}
Dkichistrialitornmercial
ID irrigation
DMitnicipaVFtiblic
0Residcntial Water Supply (single)
0ResidenEial Waler SappI. (shared)
Non -Water Supply Well:
❑ ldaniinrin4
iLl�rcll1r11 Wi.LI;
CJAgrrifcr Recharge
In Aquifer Storage and Recover'
❑ A{lpifer T
❑ ExpCr i untmI TechFL LQg
❑ Geodiernml (Closed Lour')
❑ C�torliemral il{c�lmg'Cooline ReLun11
❑ Reem
❑Grrurldwatcr 11Cr11q[liali4n
❑ Salinifl Harrier
❑ SEorrnwatCr Drains
❑ .S issideeme CoiMml
❑ Trdr;rr
®OIILer ie tplain under #21 Remarks)
For Freraal 4rsc
1a_111iAtER 2JONl'S
PRO .I
To
IE:ti{'1tEF 11{}
t$.
rt,
It.
111.OUTER CASING Our mull! --rased ncRs} OR CANER fir sp.lk bk�
FROM
O It.
TO
48 IL
PLAMFTFR
2"
1
Tnr€'rnkFSS HhTF
SCH-40 PVC
RTAI•
T. DINER LASING OR 7111ING iiirui eraral..indoor.(!.
FROM TO DEiti1E'rE.H THICKNESS
R. dt, il1.
T#, It,
MATERIAL
17. SCRICICN
FROM
TO
RWA:161TF,R
SLOT SIiCR
THFCKNTISS
MATRRI AI.
48 P-
50 H,
2"
iu.
.010
SCH-40
PVC
1t.
ft.
ia.
ia. GROUT
FROM
TO
?dh'FER1hi.
EMPIACEIrILNI SIETIIOD d ASIOL:Nr
O ft.
44 iL
Portland
trimi
r
ft
rt.
29.5ANrltGRA%''ELPACK {if glpdc#lls!
. rR{}11
in
MATERIAL
E(MF3.A.[ }'.\11:NT 3{}'Tllrin
47 O.
50
Silica Sand
20/30
It.
It.
3II DRILLING LOG (attach if ICeeasarr)
FRO"I
0 It
T[5
50 IC
DE'.ti{'REP71f}\ it„hr, hMrdnt'n, wil'nn'L 15 pc, p-rdn 49E, cit.!
SANDY CLAY
. Bate Welts) Conipleicd: 9-28-2021 Well 1DieAS-9
tL1lun11641n:
7-Eleven #36069
Facllilr'=Y1',. 4 r Narwc
2375 Lewisville Clemmons Rd.,
Forsyth
Facility IDC tirapplicablel
Clemmons, NC, 27012
It
ft.
IL
IL
IL
fx
rt,
rt.
rt,
Physical Addiess_ Ciq._ and Zip 21_ kLMARGii
t:APWF Y8r t] Idesist'1Gylitan Nn rFUN}
51.1-altitude and 1.nngit ode in tlegreetimirnrIri- tecontltt nr decimal degrees:
{If i 01 held. rat LWnnus is aidlick iI
T1 W
6. Is lam) the wellis).: OI ennarient e r OTemporilr}'
7. is this a repair to an existirag: well: Ycx tit MI Nu
f/rhfs Jx rr frd*ur, fill Mar trri,nw I.•ri!{,t+urnnrrrra eirlorrarr.r.'+l old r.tvfarJi rflr rueRlre of r#t
repair ranger All re-murky.•eriturx or on the hark of r.i sPr.ui.
S. Numberof wells constructed: 1
for ma,trrple Jrtfei'Ik I or rrxl-warer supply wetly ONLY x' rh rfir same ronsenee iou. }YNI cur)
�ar i1 rmir�f'arrA.
9. Total well depth helm; land surfut 50 11-11
FormxfrW!'wetrrtisrrririhrrbrijdi r'rJu .aripte-3@200'thud 2@IP.8'}
1 U. Static hater let el below lop of cariuz
If Kerrey tat rt ,s r;lluue rnafrJg. uu' ' + •'
I I. Bali diameter: 8.25" 1.1-)
12. Well C0119Irnctiori method; 4.25" HSA
1i.e. aiI r. near}', cable_ di xi push.ctn.I
FOR WATER SUPPLY WELLS ONLY:
13a• Yid(' (gm) Method of test'
1311. bisinrtwtiun riper Amount:
iL
Three feet bentonite Seal from 44'to 47'
22, (:ertifiradsin:
Signirbin
9/28/2021
L7ak
BF Signing drip- Parr.. F herehy tYrfifL' that Au- n?!lYl haul {wereJ LYrn Thrr'ical err aveurS@Oce
with f 5.4 ArCA C 02C .01190 or t 54 NCAC t12C ,O22.00 Wetl Cams!'rr cn ari Standards and rlxu
rev' t f th f reconf hbns brew Iwm'irdrrf ra Jibe• ,1r11 awjt4'r,
23. Site diagram or Jrdellilimal well details:
You may lice the back of ihis page to provide additional %%ell sire details or well
cC+n truli[ion details. You erns,' also attach:idditioi}at pages if iset:essar} .
SU BM LTTAL LNSTL1CTIONS
2da Poi- All Wells: Suhllui Iles faros within MI dens of compleiioo of well
ton51n1LtLpn to tlac fnlLoning-
biril.iun of Wsiter Rezuurces, lnformatiuu Frocersiog (snit,
1617 h1aiL Service Center, Raleigh, NC 17699-1617
tab. For Inicctios Welly ONLY: In a,ddiiiaii to .sending the form to Ilic address in
2-la above. also submit a op!, of this form within 30 days of completion of well
cortallUL Liuh [o the following:
DE'ision e£Vli'ater Resources. Underground Injeciiou Control Program,
1636 M ll Sends Curlier. Raleigh, NC 27699-1636
25e, fit wAtsr_s_lkyRuLt_rjEcti.ou WCLlN.
Also submit one copy of this forth ,ti ithin 30 days of completion of
well coosinrctian to the C1211flry bc4Ith department of the count!: where
constructed
Farirl OW-L
Noah Carolina D.parurn JIE or Ern iloiuenj a
Id Mantra] Rcac'I.recs - DO, J5IVY taI WaICr RmatroM.
gets iscd :August 21113

WELL CONSTRUCTION RECORD
This Form can b0 u90d Cm single or mull ink wells
1. Well Contractor Information:
Robert Miller
Well Cohn T 14anw
2675
NC W'c11 Co iI1iiciorCcrlifecaLionNiullber
SAEDACCO Inc
Nanit
2. Wdn (ors suction Permit it:
List all appriruhle wrllpt weirs gr_c. County. ark, Yariartne, frepErelart Nr.+
3. Weil Use (cheek well use):
Waxer Supply Well:
In Agricultural
DGeotheimal tHeaiingrtCooling Supply}
Dkichistrialitornmercial
ID irrigation
DMunicipaVFtiblic
0Residcntial Water Supply (single)
0ResidenEial Waler Supph (shared)
Non -Water Supply Well:
❑ Monitor
iEij 9 illr'I Wi.Ll:
CJAgrrifcr Rcchargc
l7Agrriffr Storagc and Rccovcry
El Munro' T
❑ Epee) iu mI ThChFL LQg
❑ Geodrernml (CIrrsed Loup)
❑ Gtodlkmlal iHcalnrg''C0011rIE Retunl}
❑ Rec n
❑ Groituthcalcr RC" ctliatian
EiSalintt Barrio.
❑ StorrJrytaiCr ilina C
❑ 5ris5iiCKC Cnntml
❑ Trdr;rr
®OIILer iectplain Lauder #21 Remarks)
For Fr rlh1l 4rsc L N I.‘e:
1a_211'AtER 2ON.Ls
PRO .I
To
IE:ti{'REP 11{}
f$.
rt,
ft.
MI. OUTER CASING Our and -eased Wens} OR CANER {if sp. Nca bki
FROM
O It.
TO
48 IL
PLAMFTFR
2"
Tn'€'rnkFSS HhTF
SCH-40 PVC
RTAI•
Th. INNER LASING OR 1111ING izrut eraral..indoor.(!.
FROM TO DEiti1E'rE.H THICKNESS
R. f , ilk
rt, rt, Ig
MATERIAL
17. SCRICICN
FROM
TO
RWAsr1E FR
SLOT SIi.R
THiCKNTISS
MATRRI At
48 R.
50 It,
2"
its
.010
SCH-40
PVC
1t.
ft.
ia.
ia. ciwrPr
FROM
TO
?dh'FER1AL
I1 n tC IL I SIETIIOD d ASIOL:Nr
O ft
44 iL
Portland
trimi
r
fl,
rt.
29.5AN rJ RA%''EL PACK (if glpdc#1Ls!
. rR{}11
it
MATERIAL
E(MPI.A.[ }'.\11:NT 3{}'Tllrin
47 ft.
50
it,
Silica Sand
20/30
It.
It.
311, DRILLING LOG {attach iddilianel;!seta if ICeesTarr]
FRO"I
0 It
T[5
50 IC
DE'.ti{'REPTIE}\ 1s„hr.1urdnt'n, wil'nn'L 15 pc, ^fRn'de,.MC.1
SANDY CLAY
. Bate Welts) Conipleicd: 9-29-2021 Well 1DlfAS-10
❑ a_ k}eLl l.nratiun:
7-Eleven #36069
Facllilr'=Y1',. 4 r Nnrwc
2375 Lewisville Clemmons Rd.,
Forsyth
Facility IDC tirapplicnblet
Clemmons, NC, 27012
It
ft.
rL
IL
IL
fr
rt.
rt.
rt,
Physical Addiess_ Cit}._ and Zip it. kLMARGii
Oictity Y'ar t] IdclasficAliun No fFUN}
51.1-altitude Awl 1.nngitwPC in dcgrecaimirnalriAeleontltt or dccimnl degrees:
{If i 01 field. rat Laiuug is aidlicknli
Tti W
6.1s leant the wellisk OPennanent er ❑Temporar}'
7. is this a repair to an existing: well: Yes 11r MI Nu
f/rhfs rx rr frl*ur, fill Mar trtI.nw I.•ri!{,t+urranrI,:I J eirlorrarr.r.'+l rmd r.tvfabi rflr rueRlre of r#t
repair ranger All remurl•.y.seeiiarx or on the hark of r.i s jF. r.ui.
S. Number of wells constructed: 1
for ma,rrrple irFfeak I or rrxl-warer supply wetly ONLY with die' solar consenee inu. '.OM [eirr
sir*L'irir mue forni.
9. Total well depth helm; land surfut 50 11-11
FormxfrW!' wells Usrittrihrhitt ijdi r'r Ju . aripte- 3@200'thud 2@Nlfx'}
1 U. Static water let el below lop of cariuz
If Kerrey 1rt.4 rs r;lluue rnafrig. uu' ' + •'
I I. Bali diameter: 8.25" tA)
12. Well consirnctiori method; 4.25" HSA
1i.e. aiI r. reran}', cable_ di xi push.crc.L
FOR WATER SUPPLY WELLS ONLY:
13a, Yid(' (gm) Method of test:
1311. bisinrtwtiun ripe: Amount:
iL
Three feet bentonite Seal from 44'to 47'
22. (:ertificzlinn:
Signibuc
9/28/2021
Date
$F Signing drip- Parr.. I beer.}' tYrfifL' that Au- n?! lx lens {wereJ cony) aeiedr err aveurS@Oc e
xwuh f5.4 ArCAC 02C .01190 or 54 NCAC t12C ,O22.00 Wefl Ebxagrr clan Standards and rJ'ar
r•evyofth f reconf hiu drew Iwm'irdrrf ra,the,1rlf awjt4'r,
23. Site diagram or sidellilim>rl well details:
You may lice the back of ihis page to provide additional %%ell sire details or well
cc+nstruli[ion details. You eels,' also attach:idditioi}at pages if iset:essar} .
SU BM LTTAL [NSTL1CTIONS
2da Poi- All Wells: Suhwoi Iles faro' within .0 days of complelioo of well
Con5ln1Ctipn to the fnlLouing7
iFirixiun of Water Rezuurces, lnformatiuu Frocersiog (snit,
1617 Mail Service Center, Raleigh, NC 17699-1617
tab. For Inicctios Welly ONLY: In a,ddiiiaii to .sending the form to I]ic address in
2-la above. also submit a op!, of this form within 30 days of completion of well
conSIfliLLiuri [o the following:
DE'ision e£Vli'ater Resources. Underground Injeciiou Control Program,
1636 T4ir;ll Sends Curlier. Raleigh, NC 27699-1636
2Se fit W4tcir $tkypIL1 vtiun WCLlN.
Also submit one copy of this foul) ,ti i thin 30 days of completion of
well coasinrctiaa to ttic C1211flry departnrplrt of the county where
conaniCfad
Farirl OW-L
Noah Caro]nu 1-.parurn JIE OC Ern iloiuenj a
Id NariLra] Resc'I.recs - DO, J5IVY taI Wake R oiroM.
gets iscd August 21113

WELL CONSTRUCTION RECORD
This Forme -on be u90d Cm single or mull ink wells
1. Well Contractor Information:
Robert Miller
well C15ryrtcioT rianw
2675
NC Well Co iI1iiciorCcrlifecaLionNiullber
SAEDACCO Inc
Nanit
2. Wdn (onstrquetion Permit it:
List all appriruhle wrllpt'rmirs gr_c. County. ark Yariartne, felpErthart Nr.+
3. Weil Use (cheek well use):
Waxer Supply Well:
In Agricultural
DGeotheimal tHeaiingrtCooling Supply}
Dkichistrialitornmercial
ID irrigation
DMitnicipaVFtiblic
0Residcntial Water Supply (single)
0ResidenEial Waler Supph (shared)
Non -Water Supply Well:
❑ Monitoring
illjrc1I1r11 Wi.Ll:
CJAgrrifcr Rcchargc
17A iIpiffr Storagc algid Rccovcry
❑ A{ipirer T
❑ ExpC IMgrItmI ThChFL LQg
❑ Geodrernml (CIrrsed Loup)
❑ C�torliemral il{c41mg'Cuoline ReLuml
❑ Rec n
❑Grourldnratcr Rcnucttiatian
EiSalintt Barrio.
❑ Stornr3 aicr ilina C
laStils5jEICIKC Cnntml
❑ Trdr;rr
®OIILer iectplain Lauder #21 Remarks)
For Fr rlh1l 4rsc L N I.‘e:
1a_111iAYER 2ONl'S
PRO .I
To
IE:ti{'ItEF 11{}
f$.
rt,
ft.
MI. OUTER CASING Our mind --rased acne} OR L KER {if sp. kaiak/
FROM
O rt.
TO
48 IL
PL#VFTFR
2"
1
Tnr€'rnkFSS HhTF
SCH-40 PVC
RTAI•
Th. DINER LASING OR 1111ING izrut lcraral..indoor.(!.
FROM TO DEiti1E'rE.H THICKNESS
R. dt, il1.
MATERIAL
17. SCRICICN
FROM
Tr}
pWA:161TF,R
SLOT SIi.R
THiCTcrlTISS
MATRRI At
48 R.
50 It,
2"
its
.010
SCH-40
PVC
1t.
ft.
ia.
11. GROUT
FROM
TO
?dh'FER1AL
EMPIACEIrILNI SIETIIOD d ASIOL:Nr
O ft
44 iL
Portland
trimi
r
fl,
rt.
M.5AN rJiGRA%''EL PACK (if glpdc#1Ls!
. rR{}11
it
MATERIAL
E(MPI.A.[ }'.\11:NT 3{}'Tllrin
47 O.
50
it,
Silica Sand
20/30
It.
3II DRILLING LOG {attach iddilianel;!seta if nccesrarr]
FRO"I
0 IL
T[5
50 U.
DE'.ti{'REPTIE}\ 1s„hr.1urdnvni. wil'nn'IL 15 pc, 7rdn
SANDY CLAY
. Bate Welts) Conipleicd: 9-29-2021 Well 1DIfAS-11
❑ a_ k}eLl l.nratiun:
7-Eleven #36069
Facllilr'=Y1',. 4 r NOM
2375 Lewisville Clemmons Rd.,
Forsyth
Facility IDC tirapplicablel
Clemmons, NC, 27012
It
ft.
IL
IL
fr
rt,
dZ,
rt.
rt,
Physical Addiess_ Ciq._ and Zip 21_ kLMARli-s
Ceinny Y'ar t] Idenlft'1Gyliun No fFUN}
51.1-atitude Awl 1.nngitwPC in 1lc{1'ecaimirnalriAeleonds or dccimnl degrees:
{If i 01 heldrat lablims is aidlicknll
T1 W
6.Is bunt the wellisk OPennanent er ❑Temporar}'
7. is this a repair to an existing: well: Ycx 11r ®Nu
f/rhfs ix rr frd*ur, fill Mar trtI.nw I.•ri!{,t+urranrI,:I J eirlorrarr.r.'+l rmd r.tvfarll rflr rueRlre of r#t
repair ranger All rernterl•Y Yeeitan or on the hark of tale jF. rui.
S. Numberof wells constructed: 1
for ma,rrrple irFfeak I or rrxl-warer supply wet! ONLY with rill, saint consenee inu. '.OM [eirr
sir*L'irir mue forni.
9. Total well depth helm; land surfut 50 11-11
FormxfrW!' wells Usrittrihrhitt ijdi r'r Ju . aripte- 3@200'thud 2@Nlfx'}
1 U. Static hater let• el below lop of cariuz
1f mwrl,r art.4 rs r;lluue rnafrig. uu' ' + •'
I I. Bali diameter: 8.25" OA)
12. Well consirnctiiri method; 4.25" HSA
1i.e. aiI r. royal.., cable_ di xi push. etc.!.
FOR WATER SUPPLY WELLS ONLY:
13a, Yid(' (gm) Method of tot!
1311. bisinrtwtiun ripe: Amount:
iL
Three feet bentonite Seal from 44'to 47'
22. (:errifi rhea:
Signibuc
9/28/2021
L7ak
BF signing drip. Parr.. F beer.}' trelifL' that rbr n?! lx o n {werrJ curarhaeiedr iR avectrarace.
xwuh f5.4 ArCAC 02C .01190 or 54 NCAC t12C ,O22.00 Wefl Ebxagraranrr Standards arld rJ1ar
envy t f th f FreonFreonf hiu brew Iwm'irdrrf ra i be ,1rlf awjt4'r,
23. Site diagram or aldellilim>rl well details:
You may lice the back of ihis page to provide additional %%ell sire details or well
cc+n truL[ion details. You eels,' also attach:idditioi}at pages if lrecessart .
SU BM LTTAL [NSTL1CTIONS
2da Poi- All Wells: Suhalul this faros within MI dens of compleiioo of well
Con5lmLtipn to the fnlLnuin�-
iFirixiun of Water Rezuurces, Information Frocersiog (snit,
1617 h1aiL Service Center, Raleigh, NC 17699-1617
tab. For Inicctios Welly ONLY: In a,ddiiiaii to .sending the form to Ilic address in
2-la above. also submit a op!, of this form within 30 days of completion of well
cartalruLLiurl [o the following:
DE'ision e£Vli'ater Resources. Underground Injeciiou Control Program,
1636 T4ir;ll Sends Curlier. Raleigh, NC 27699-1636
2Se,. fit W4tcir SRipI t_rjEctiou WCLlN.
Also submit one copy of this forth ,ti ithin 30 days of completion of
well coasinrctian to ttic C1211flry depsrtnrplrt of the County where
Con5truCl4d
Farin GW-L
Noah Caro]nu 1-.parurn JIE OC Ern iIIEPIL ILI a
Id Narilra] Resc'I.recs - DO, J5IVY taI Wake Ravin
gets iscd August 21113

Print Form
4. Date Well(s) Completed:
WELL CONSTRUCTION RECORD (GW-1)
1. Well Contractor Information:
Mike Tynan
Well Contractor Name
2725-A
NC Well Contractor Certification Number
IET
Company Name
2. Well Construction Permit #:
W I0400580
List all applicable well construction permits (i.e. UIC, County, State, Variance, etc.)
3. Well Use (check well use):
Water Supply Well:
Agricultural EllMunicipal/Public
Geothermal (Heating/Cooling Supply) DResidential Water Supply (single)
Industrial/Commercial DResidential Water Supply (shared)
Irrigation
Non -Water Supply Well:
Monitoring
0Recovery
Injection Well:
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
Experimental Technology
Geothermal (Closed Loop)
Geothermal (Heating/Cooling Return)
11/5/21
Ell Groundwater Remediation
QI Salinity Barrier
QI Stormwater Drainage
JSubsidence Control
QlTracer
❑I Other (explain under #21 Remarks)
Well ID# AS-12
5a. Well Location:
7-Eleven #36069
Facility/Owner Name Facility ID# (if applicable)
2375 Lewisville Clemmons Rd, Clemmons 27012
Physical Address, City, and Zip
Forsyth
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 02 14.32 N 80 23 06.98
6. Is(are) the well(s)�Ix Permanent or QQTemporary
7. Is this a repair to an existing well: QYes or Cho
If this is a repair, fill out known well construction information and explain the nature of the
repair under #21 remarks section or on the back of this form.
8. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction, only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled:
9. Total well depth below land surface: 55
For multiple wells list all depths if different (example- 3@200' and 2@100)
(ft.)
10. Static water level below top of casing: ~28 (ft.)
Ifwater level is above casing, use "+"
11. Borehole diameter: 8.5 (in.)
12. Well construction method: auger (angled)
(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
28 ft.
55 ft.
silty sand
ft.
ft.
15. OUTER CASING (for multi -cased wells) OR LINER (if ap licable)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft.
ft.
in.
16. INNER CASING OR TUBING (geothermal closed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
0 ft.
53 ft.
2 in•
Sch40
PVC
ft.
ft.
in.
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
53 ft.
55 ft.
2 in.
0.010
Sch40
PVC
ft.
ft.
in.
18. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
0 ft.
3 ft'
sand
pour
3 ft.
49 ft.
neat cement
pumped through tremie pipe
49 ft.
51 ft.
bentonite
tremie pipe
19. SAND/GRAVEL PACK (if applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
51 ft.
55 ft.
#2 silica sand
tremie pipe
ft.
ft.
20. DRILLING LOG (attach additional sheets if necessary)
FROM
TO
DESCRIPTION (color, hardness, soil/rock type, grain size, etc.)
ft.
ft.
See consultant's log
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
21. REMARKS
Well drillcd 22.5 dcgrccs from
at perpcndicular
22. Certification:
Signature of Ce> ed Well Contractor
11/26/21
Date
By signing this form, I hereby certify that the well(s) was (were) constructed in accordance
with 15A NCAC 02C .0100 or 15A NCAC 02C .0200 Well Construction Standards and that a
copy of this record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTRUCTIONS
24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Injection Wells: hi addition to sending the form to the address in 24a
above, also submit one copy of this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supply & Iniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
completion of well construction to the county health department of the county
where constructed.
Form GW-1
North Carolina Department of Environmental Quality - Division of Water Resources Revised 2-22-2016

WELL CONSTRUCTION RECORD
This [mincer' be usod Lo single or mull ink wells
1. Well Contractor Information:
John Eisenman
WOI {'nuncio- NMAii14
4439A
NC Well Conlcicior Ccrl ifecaLiori Number
SAEDACCO Inc
Nomc
2. Well ConsGaiction Permit fit;
List aril opp i rtIc 14YiIptnreits (1_ . Count'. &Mr. Far/Pore. .frepErtlati
3. Well Use (check well 9l10:
Water Supply Well:
In Agricultural
DGeollleimal tHearingiCooling Supply).
❑ lad u s f ri a VCo nunerc i a l
ID irrigation
DMirnicipaVFtrblic
0Residcnlial Wafer Supply (single)
DResidentiai Wafer Supply (sham!)
NoM-Water Supply Well:
❑ rdoniinrin4
iElit.cilnei Wi.LI;
CJAgirifcr Rcchargc
DAtliriffr Storage and Recovetj'
❑ A{lirirer T
❑ Experimrnfa1 MChnLLQg
❑ Geodlernmi (Closed Loup)
❑ GMIrennii iHe4lnrg''Cb.LlrIE Retun1}
❑ Rcc n
❑Grourldwatcr RC1u tiatiLn
❑ Salinit} Barrio.
❑ Siorrnivatcr Drainao^C
❑ SitssiiCn cCnnfml
❑ Tadt;rr
®Oiler (explain under #21 Remarks)
For frk•rl1,1l 4rsc ONI.V:
1a-WAf112.ON.Ls
PROM
TO
REM ItEF 1 ION
fir
rt ,
ftr
I.
MOLTER CASING Oar mild -eased acRs} OR LIFTER {if Nc hkh
FROM
O IL.
TO
47 1L
PL#VFTFR
2" io-
1
a
Tna€'rn�FSS HATF
SCH-40 PVC
RTAI•
16. DINER CASING OR 11201% { jln rural clu dauri(!
FROM TO DEiti1ETER THICKNESS
MATERIAL
17. SCiLTIN
FROM
TO
prA3(FPTFR
SLOT SIiCR
T IFMNTISS
MATRRI At
47 R
49 ft.
2"
IR
.010
SCH-40
PVC
R.
It.
ia.
ia. GROUT
FROM
TO
?4A.TER1AL
ifiglACEPrILsii 31FnIoIJ hMOL:Nr
O ft.
44 rL
Portland
Tremmie
rt,
rp
It,
29. SAN'MILAN''EL PACK Of g1pL9et1111 _
FROM
wn
50 ATPR1AL
E:'r1Y1..5r r.\1E: 1 5I}Tunn
46 ft.
50 I.
SAND
#2
ft.
h,
3II, DRILLING LOG (attach idlfiiiormI shall it P culun]
FROM
0 ft
TO
50
RE'.ti{'REFTIL} it„hr,hMrdnt'n, wirnn'I. lip[, 7rdn'dc'.
SANDY CLAY
.Bate Welts) Conipleicd: 10-7-21
5a_ k}tLI lluratiun:
7-Eleven #36069
Fycililr' (... cr NOM
2375 Lewisville Clemmons Rd.,
Forsyth
Well 1D+f AS-13
F �cilih IDC tirapplieahlei
Clemmons, NC, 27012
It.
ry,
fr.
fir
ft.
IL
fr
If,
fZ,
Ir.
rt,
Physical Addicss_ Cit}.. and Zip it. kumARti s
t ectns Ymi;e1 Idcnirfrtylitan No fFT:i}
5h.1.ptlitudc A1u1 1-nngitprle in tIcgreCrlmintitest eciantltt nr decimal degrees:
{If i 11 I1e1d. Intl laLlimg is aidlickvll
Tti W
6. Is lam) Ibe welUJrk OI ennaeni e r OTemporor}'
7. is this a repair tR an existing well: Ycli 1rr IN Nu
f/rhfs Jx rr rrl*ur, fill Mar trtI,ww I.•ri!cii4ifFn0,:I J eitfurrr„rr.r.'+1 old r.tvfarJi rflr 0r rrrre of ale
repairwider A71 remarl'.y.•rx'Jiaa or r.41 the bark of ridsPrJli.
S.Number ofwells -onsiru ced: 1
For IWJ,tJtplr'of eeVim of rlrx1-wbrer supply w'etla ONLY mat rflr same romener7inu. xa, coo
saner JMJr form.
9. Total will depth helm; !AMA suit'se* 49 (TO
For MOW! wrtls 'Fsr rrU 017vhr if El'Of'retir le.yaRJpte- 7@200' thud 2@ JOfx'}
1 U. Static water Res el below top of cariup
if iimee.. Ir' rt ,s r;Ilo a rnafrJ:E. mu' '• 4 "
11. Baliholc diameter: 8.25" OA)
12. Well consirnctiisi method: 4.25 HSA
ti.e. a i.jer. Kral}. cable- dirai push.cEc.I
FOR WATER SUPPLY WELLS ONLY:
134 li Jt (gpai)
1311. Disinriwtiun ripe:
Method of test:
Amount:
rt
Bentonite Seal 44 to 46ft
22, Cerfiradsrn:
10/13/2021
Sisnrlarc of ' - ;. --• — - 1 ..
.Err signEhig armrFrra'feal in aeex+oramrrx'
Infra f5.4 NCAC 02C . ;ram- .0200 Wetl Catratrnrdrur Srandafda and Ma; a
ropy of 041 record ins dx ew Iwm'irlrrf err Jibe Writ .puller,
23. Site diagram or adt3liianal well details:
You may lice the back of ihis page to provide additional ol+ell sire details or well
cc+nslrIL[iori details. You maw also attach:idditioriat pages if iset:essar} .
SU BM ITTAL [NSTL1CTIONS
2da Ear All Wells: Subinii Ilus faro- within .11 dens of complelioo of well.
Contlnittipn to f1Ec fhltouing-
birisiun aFVI'ater Resources, Information Frucessiog
1617 Mail Scririre Center, Raleigh, NC 17699-1617
tab. For Inicclios Welly ONLY: In addiiian to sending the form to Ilic address in
2-1a shove. also submit a op!, of this form within 30 days of completion of well
conSlfiLLiuhl [o the following:
Dh'ision e£Vli'ater Resat' rt. .lfrldcrpound Injeciiou Control Program,
1636 T4iJili Serif Curlier. Raleigh, NC 27699-1636
25e, fit wAtsr_syylajLi_rjEcti.ou V4' Ll�r
Also submit one copy of this foam VI ithin 30 days of completion of
well cnoslnictiOR to tilt ¢rn1rIr3 hcaltb department of the county where
con5truCf4N1
Farirl GW-L
I\nnh Carolina D.paroar E oCErn iloiumiu aid Mantra] Rcsouras - DO, ssIVY of Water Ravin Rt, iscd Augurst2u13

WELL CONSTRUCTION RECORD
This form can be usod 8i single or mullip]c wells
1. Well Contractor Information:
John Eisenman
1;C]I {ordniclor IiAiir4
4439A
NC t icl1 Corileicior Ccrl ifeciLion Number
SAEDACCO Inc
{'[u1�'Ifun NanrL
2. Well Construction Permit �l
IJitlrnopp i rthIc 14YiIptnreits (1_ . Count'. &Mr. Yariurtne. .felpErthrirtrJr.+
3. Well Use (check well owl::
Water Supply Well:
In Agricultural
DGeollreimal tHeaiingrtCooling Supply)
O lad u s tri a VCo nunerc i a l
ID irrigation
DMirnicipaVFtlblic
OResidcnlial Water Supply (single)
0Residential Water Supply (sham!)
NoM-Water Supply Well:
❑ ldoni1nrin4
iEij9ciloci Wi.LI;
CJAgirifcr Recharge
DAquifer Storage algid Recovery
❑ Aquifer Tess
❑ Experimenta1 TechFL LQg
❑ G6011iernml ICIrlsed Loup)
❑ Grodlkmla11He4lnrg''Cbol1rIE Retuni}
❑ Rcco3
❑Grourrdwnatcr RClriechatian
❑ Salinit} Harrier
❑ 5torrnr Ater Drolina
1=15111s5lesKe 'oilml
❑ Trdt;rr
510i1ier [explain udder #21 Remarks)
For Forerun Use L N 12e:
1a- ilk 'AtER 2ON.Ls
rR{j41
TO
REM 'MI. 11{}S
tr.
Ir ,
ft.
I.
MOLTER CASING (for nmani--snail Wens} OR [PIER {if as. Nc hki
FROM
O rL.
TO
48 IL
PL# 1FTFR
2"
io-
1
a
Tni€'rnNFSS
MATERIAL
16. INNE R CASING OR 11'H I1% { jlnriral cludauri
FROM TO DEiti1ETER THICKNESS
f1. fR Pik
MATERIAL
17. SCiti1N
MOM
Tr}
prAMIRTFR
SLOT $lien
THIPMNT1SS
MATRRI AI.
48 R.
50 H.
2"
iu.
.010
SCH-40
PVC
R.
It.
its. GROUT
FROM
TO
?dhTER1AL
IMP1.tC1r ILM IEn1olw hMOL.Nr
O ft.
45 IL
Portland
Tremmie
ri,
r
1
ft,
19.5AN IMILA ''EL PACK {d glpNcalkl _
. rR{}11
in
'MATERIAL
47 tt.
50 fl.
SAND
#2
It.
It.
3II DRILLING LOG (Minh idifiiianaI sheep if nr.•eessory)
FROM
0 IL
T[5
50 I1.
RE'.ti{'REPTIE}\ is„hr.lurdns'n, wil'nn'I, lip[, 7rdn
SANDY CLAY
.Date Welts) Conipleicd; 10-7-21
S a_ 1.11. Illlratilin:
7-Eleven #36069
Fycililr' (... cr NOM
2375 Lewisville Clemmons Rd.,
Forsyth
Well 1DieAS-14
I-aoiliry IDC tirapplicahlei
Clemmons, NC, 27012
Physical Addicts_ Cit}.- and Zip
I.'Qplg4' FBr c] Idcoistruilitan No fFUN}
5b.1-atitude and 1.nngit atle in tlegrecrlmirrlrlcslxccnnils or decimal degrees:
{If i 11 held. DM: laLlimg is airllic kvn i
Tti W
6.Is ant Ibe welUsk OPenna eni er OTemporilr}'
7. is this a repair tR an existing well: Yes 11r MI Nu
f/rhfs ix rr rrl*ur, f+J',Ywr trtI,ww 1. ri! { n+urnn rr rr+ eirlorr art.'s+ r.tvfarJi rflr moire of the
repair rimier. 2f rernterl'.'.r..Titan or on the hark of tldr jFJru1.
S.T antlerofwells-onsirTwced: 1
For nru+rtplr'of eerlwl or rlr.1-venter supply wails ONLY with rhr' same Car enec Ina. xa, coo
.t*i1irrrur torn.
9. Total well depth beIo'i laud surfut 50
For MOW!' wrtlr Irsr ruff di'uhr ifdigrrvJu lemP Jpte- 7@200' thud 2@ Jots)
1 U. Static water Ire el 1x115' lop of cariup
ff wriref Ir' rI ,s •ij • 4e rnafrl:E. uu' '• 4 •'
I I. Bali diameter: 8.25" OA)
12. wrIl oaniiirlrctioil method; 4.25" HSA
ii.e. saijer. tarty}', cable- dirai push. etc.
FOR WATER SUPPLY WELLS ONLY:
13a, lidd (p i)
1311. Disinfect -Lon ripe:
Method of test:
Amount:
It.
ft.
ft.
IL
IL
fl
11,
rr.
rt,
R.
11. REMARKS
Bentonite Seal 45 to 47ft
22, ('er iralinn:
10/13/2021
Signrlrnc erf , ' - ;. --• — - 1 ..
$s signEhig rliriT h: 41h w.a' 1r= eoarrrJre'rear in axex+oramrrx'
w rh f 5.4 NCAC 02C . F- i t R�.Z C .0200 We Comtrnrdrur Standards and Aar a
ropy of rhir record. hived IN{w Iwm'irk rrr Jibe Writ .7ultQr,
23. She diagram or adelitio tat well details:
You may lice the back of this page to provide additional well sire details or well
cc+nstruL[iori details. You insw ales altBCh:Ldditiotiat pages if 1iet:essart .
SU BM ITTAL [NSTOCTIONS
2da Ear All Wells: Salami.' 11iis form within I dens of compleiioo of well
Contlnittipn to the fhlLoning-
birisiun of Water Resuurues, Information Processing (snit,
1617 Mail Service Center, Raleigh, NC 17699-1617
tab. For Inieetios Welly ONLY: In addition it. sending the form to Ilic address in
2-1a above. also submit a op!, of this form within :ID days of canlple[iou Of well
conSlfuLLiuri [o [he following:
Dh'ision e£Vit'ater Ruses' two .lFridcrpound Injecilo1 Control Program,
1636 M ll Struts Curlier. Raleigh, NC 27699-1636
25 , fit wAtsr_syylajLi_rjEcti.ou wetiN.
Also submit one copy of this foini +tiithin 30 days ofcompletionof
well cnoslnictiOR to tilc ¢rn1nr3 health department of the County where
constructed
Farin OW-L
\nnh Carol lea L7.. xtrus JIE or Ern iloiuenj and Narilra] Resources - Dig ss rou of War Ravin R iscd August 21113

WELL CONSTRUCTION RECORD
This form can be usod 8i single or mullip]c wells
1. Well Contractor Information:
John Eisenman
1;C]I {ordniclor IiAiir4
4439A
NC t icl1 Corileicior Ccrl ifeciLion Number
SAEDACCO Inc
{'[u1�'Ifun NanrL
2. Well Construction Permit �l
IJitlrnopp i rthIc 14YiIptnreits (1_ . Count'. &Mr. Yariurtne. .felpErthrirtrJr.+
3. Well Use (check well owl::
Water Supply Well:
In Agricultural
DGeollreimal tHeaiingrtCooling Supply)
O lad u s tri a VCo nunerc i a l
ID irrigation
DMirnicipaVFtlblic
OResidcnlial Water Supply (single)
0Residential Water Supply (sham!)
NoM-Water Supply Well:
❑ ldoni1nrin4
iEij9ciloci Wi.LI;
CJAgirifcr Recharge
DAquifer Storage algid Recovery
❑ Aquifer Tess
❑ Experimenta1 TechFL LQg
❑ G6011iernml ICIrlsed Loup)
❑ Grodlkmla11He4lnrg''Cbol1rIE Retuni}
❑ Rcco3
❑Grourrdwnatcr RClriechatian
❑ Salinit} Harrier
❑ 5torrnr Ater Drolina
1=15111s5lesKe 'oilml
❑ Trdt;rr
510i1ier [explain udder #21 Remarks)
For Forerun Use L N 12e:
1a- ilk 'AtER 2ON.Ls
rR{j41
TO
REM 'MI. 11{}S
tr.
Ir ,
ft.
I.
MOLTER CASING (for nmani--snail Wens} OR [PIER {if as. Nc hki
FROM
O rL.
TO
48 IL
PL# 1FTFR
2"
io-
1
a
Tni€'rnNFSS
MATERIAL
16. INNE R CASING OR 11'H I1% { jlnriral cludauri
FROM TO DEiti1ETER THICKNESS
f1. fR Pik
MATERIAL
17. SCiti1N
MOM
Tr}
prAMIRTFR
SLOT $lien
THIPMNT1SS
MATRRI AI.
48 R.
50 H.
2"
iu.
.010
SCH-40
PVC
R.
It.
its. GROUT
FROM
TO
?dhTER1AL
IMP1.tC1r ILM IEn1olw hMOL.Nr
O ft.
45 IL
Portland
Tremmie
ri,
r
1
ft,
19.5AN IMILA ''EL PACK {d glpNcalkl _
. rR{}11
in
'MATERIAL
47 tt.
50 fl.
SAND
#2
It.
It.
3II DRILLING LOG (Minh idifiiianaI sheep if nr.•eessory)
FROM
0 IL
T[5
50 I1.
RE'.ti{'REPTIE}\ is„hr.lurdns'n, wil'nn'I, lip[, 7rdn
SANDY CLAY
.Date Welts) Conipleicd; 10-7-21
S a_ 1.11. Illlratilin:
7-Eleven #36069
Fycililr' (... cr NOM
2375 Lewisville Clemmons Rd.,
Forsyth
Well 1DieAS-15
I-aoiliry IDC tirapplicahlei
Clemmons, NC, 27012
Physical Addicts_ Cit}.- and Zip
I.'Qplg4' FBr c] Idcoistruilitan No fFUN}
5b.1-atitude and 1.nngit atle in tlegrecrlmirrlrlcslxccnnils or decimal degrees:
{If i 11 held. DM: laLlimg is airllic kvn i
Tti W
6.Is ant Ibe welUsk OPenna eni er OTemporilr}'
7. is this a repair tR an existing well: Yes 11r MI Nu
f/rhfs ix rr rrl*ur, f+J',Ywr trtI,ww 1. ri! { n+urnn rr rr+ eirlorr art.'s+ r.tvfarJi rflr moire of the
repair rimier. 2f rernterl'.'.r..Titan or on the hark of tldr jFJru1.
S.T antlerofwells-onsirTwced: 1
For nru+rtplr'of eerlwl or rlr.1-venter supply wails ONLY with rhr' same Car enec Ina. xa, coo
.t*i1irrrur torn.
9. Total well depth beIo'i laud surfut 50
For MOW!' wrtlr Irsr ruff di'uhr ifdigrrvJu lemP Jpte- 7@200' thud 2@ Jots)
1 U. Static water Ire el 1x115' lop of cariup
ff wriref Ir' rI ,s •ij • 4e rnafrl:E. uu' '• 4 •'
I I. Bali diameter: 8.25" OA)
12. wrIl oaniiirlrctioil method; 4.25" HSA
ii.e. saijer. tarty}', cable- dirai push. etc.
FOR WATER SUPPLY WELLS ONLY:
13a, lidd (p i)
1311. Disinfect -Lon ripe:
Method of test:
Amount:
It.
ft.
ft.
IL
IL
fl
11,
rr.
rt,
R.
11. REMARKS
Bentonite Seal 45 to 47ft
22, ('er iralinn:
10/13/2021
Signrlrnc erf , ' - ;. --• — - 1 ..
$s signEhig rliriT h: 41h w.a' 1r= eoarrrJre'rear in axex+oramrrx'
w rh f 5.4 NCAC 02C . F- i t R�.Z C .0200 We Comtrnrdrur Standards and Aar a
ropy of rhir record. hived IN{w Iwm'irk rrr Jibe Writ .7ultQr,
23. She diagram or adelitio tat well details:
You may lice the back of this page to provide additional well sire details or well
cc+nstruL[iori details. You insw ales altBCh:Ldditiotiat pages if 1iet:essart .
SU BM ITTAL [NSTOCTIONS
2da Ear All Wells: Salami.' 11iis form within I dens of compleiioo of well
Contlnittipn to the fhlLoning-
birisiun of Water Resuurues, Information Processing (snit,
1617 Mail Service Center, Raleigh, NC 17699-1617
tab. For Inieetios Welly ONLY: In addition it. sending the form to Ilic address in
2-1a above. also submit a op!, of this form within :ID days of canlple[iou Of well
conSlfuLLiuri [o [he following:
Dh'ision e£Vit'ater Ruses' two .lFridcrpound Injecilo1 Control Program,
1636 M ll Struts Curlier. Raleigh, NC 27699-1636
25 , fit wAtsr_syylajLi_rjEcti.ou wetiN.
Also submit one copy of this foini +tiithin 30 days ofcompletionof
well cnoslnictiOR to tilc ¢rn1nr3 health department of the County where
constructed
Farin OW-L
\nnh Carol lea L7.. xtrus JIE or Ern iloiuenj and Narilra] Resources - Dig ss rou of War Ravin R iscd August 21113

WELL CONSTRUCTION RECORD
This Forncon be usod 8i singly or rnullink wells
1. Well Contractor Information:
John Eisenman
WC]i ConInrctor Eranw
4439A
NC Well Coflhlilcior Cot ifeestion Number.
SAEDACCO Inc
{'[uilrkun Nan1L
2. Wdi (onstrauction Permit fit;
List lrnopp i rtIc well pfrsreits (1_ . 'r'r,1F4'..52air, Yariureer, Jr/pi-den
3. Well Use (chat: well use):
Water Supply Well:
In Agricultural
1:1Geolheimal tHeatalMgrtCooIin. Supply)
t7 led u s lei a l(Co nunerc i a l
❑ hri ition
ID M i rn i c i paVFtlb t i c
C]Residcnfial Water Supply (single)
0Resideniial Water Supply (sham!)
NoM-Water Supply Well:
❑ Monitoring
iLlirclllrrl Wi.LI;
CJAgrrifcr Recharge
DAgirifcr Storage and Rceolov1)
El Aquifer Tem
❑ Experin ila! Technu•LQg
❑ GeNodiernml (Closed Loup)
❑ C�to[liemtal iHeating''Cbolirne Retun1}
❑ Reim
❑Groundwater Rcnie liatian
O .Salintr Harrier
❑ 5tornn crier ilina C
O 5111s5iiCMC Coilml
❑ Trdt;rr
®Orliel [explain udder #21 Remarks)
For foicTaal Use ON I.'e:
1a-trL'AtER 2.ON.Ls
PRO41
TO
REM 'MI. 11{}S
f$.
It ,
ft.
I.
MOLTER CASING Our mull! --easel 1ac19 OR L KERfiF ap Nc hki
FROM
O fL.
TO
48 IL
PL# 1FTFR
2"
io-
1
a
Tnt€'fn�FSS
SCH-40 PVC
MATT
RTAI•
1b. INNE R CASING OR 1ll'H INc;; { jlnnraral cludauri(!
FROM TO DEiti1ETEIt THICKNESS
MATERIAL
17. SCR]1N
FROM
TO
RrAMIRTFR
SLOT Si
THi :KNT1SS
MATRRI At
48 R.
50 H.
2"
iu.
.010
SCH-40
PVC
R.
It.
ia.
ia. CROrrr
FROM
TO
?dhTER1AL
1eh4t1.4CEMEti7 3IETHOD hMOL:Nr
O ft.
45 IL
Portland
Tremmie
ri,
FIN
ft
It,
29.SANDICIL VELPA iC{dglpdetllll _
. rR{}11
wr:
50 ATER1AL
E:'r1Y1..{i'}'.\1-:til 5i}'TUCrn
47 O.
50 It.
SAND
#2
ft.
ft.
3II DRILL1NG LOG (attach id{filianHI strc1/4911 it Door un.)
FROM
0 IL
50 A.
RE'.ti{'REFTIE}\ lS,thr,lurdns'++,'+lirnn'L 15 pc 7rdn
SANDY CLAY
. Bate Welts) Conipleicd: 10-7-21
Sa_ VreLI planation:
7-Eleven #36069
Fycililr' (... cr NOM
2375 Lewisville Clemmons Rd.,
Forsyth
Well 1Dif AS-16
I-aoilrry IDC tir3pplicnb1e1
Clemmons, NC, 27012
Physical Addicss_ Cit}.. and Zip
GIpW}' park] Idcnirfieynitan No fFUN}
5b.1.p11itudc and 1-nngh-nde in 11cgrecrlmiittitestsC1cnn11s nr decimal degrees:
(If i 11 ticld. Intl Lallans is sank nnl
Tti W
6.1s bunt Ibe welUJrk OPennaneni er ❑Temporary
7.1s this a repair to an existi.rag well: YcJi or MI Nu
f/rhfs Jx rr rrl*ur, f+J'Mar trtI,ww wed {,OJWrnnrr,I J rlrloreavr.rmi old r.tvfarJi rflr 0r rl1re of the
repair ranger. 2L rreneerlwseeJialx ar rut the hark of Udsprui.
S.Number ofwells -onsiru ced: 1
For 1rodnplr irtfecrkkJI or next-wbrer supply wt' Ia ONLY with rhr' shyer rortoneefinu. xa, coo
arrdwlirrrur gored.
9. Total well depth helm; land surfut 50 (fl.)
For MOW!' wetri Hsi rrU diYuhr if r erekhr leYaRJpte- 3@200' thud 2@ JOfx'}
1 U. Static water Ter. el below lop of cariup
if nitlrr r 1et.4 ,s r;llo a crAdel:E•. uu' '• 4 "
I I. Balehole diameter: 8.25" tA)
12. Well conbiirnctioti method: 4.25 HSA
ii.e. ail r. radar}', cable- dirai push.crc.L
FOR WATER SUPPLY WELLS ONLY:
13a•Yw('(p i)
1J11. DisinFoctiun rape:
Melded of test:
Amount:
ft.
8
ft.
IL
IL
IL
f!,
ft,
Fr.
rt,
rt,
21. REMARKS
Bentonite Seal 45 to 47ft
22, Cerfiradsrn:
10/13/2021
Sismlaic of , ' - ;. --•
' rx sir' 1'-
$s signir�� JJ'r1T fw,K ��.' h: 41l w.a' 1rr.�J eoarrrre'real in exex+oramrrx'
with f5.4NC4CO2C.•_ - .0200 WeComtraJrnarSrandardaand Awaya
ropy of this Freon-, hewn dx {w Iwm'airni err Jibe Writ .huller,
23. She diagram or adt3liianal well details:
You may :He the back of ihis page to provide additional well sire details or well
cc+nslrIL[iori details. You ells,' also attach:Ld:itiol}at pages if 1set:essar} .
SU BM LTTAL [NSTIJCTIONS
2da Ear All Wells: Suhlrui Iles form within xlI dens of compleiioo of well.
Contlnittipn to OK fhlLoning-
birisiun of Water Resources, lnformatiuu processing Unit,
1617 Mail Service Center, Raleigh, NC 17699-1617
tab. For Inicclios Welly ONLY: In a,ddiiiaii to .sending the form to rlic address in
2-la shove. also submit a imp, of this form within 30 days of completion of well
conSIYuLLiuri [o [he following:
Dh'ision e£Vit'ater Rcwourt. .lfrldcrpound Injeellou Control Froglvm,
1636 M ll Senilx Curlier. Raleigh, NC 27699-1636
25e, fit wAtsr_syylajLi_rjEcti.ou V4'CLI�r
Also submit one copy of this fotni +tiithin 30 days ofconpletionof
well cnoslnictiOR En talc Coimr; health depamneat of Elie County where
conaruCfad
Farin GW-L
Krinh Carol lea D.paronn JIE DIEM iloiuenj and Narilra] Rcaourccs - Di, ss sou eI Waacr Ravin Rt, iscd August 211J 3

Print Form
4. Date Well(s) Completed:
WELL CONSTRUCTION RECORD (GW-1)
1. Well Contractor Information:
Mike Tynan
Well Contractor Name
2725-A
NC Well Contractor Certification Number
IET
Company Name
2. Well Construction Permit #:
W I0400580
List all applicable well construction permits (i.e. UIC, County, State, Variance, etc.)
3. Well Use (check well use):
Water Supply Well:
Agricultural EllMunicipal/Public
Geothermal (Heating/Cooling Supply) DResidential Water Supply (single)
Industrial/Commercial DResidential Water Supply (shared)
Irrigation
Non -Water Supply Well:
Monitoring
0Recovery
Injection Well:
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
Experimental Technology
Geothermal (Closed Loop)
Geothermal (Heating/Cooling Return)
11/5/21
Ell Groundwater Remediation
QI Salinity Barrier
QI Stormwater Drainage
JSubsidence Control
QlTracer
❑I Other (explain under #21 Remarks)
Well ID# AS-17
5a. Well Location:
7-Eleven #36069
Facility/Owner Name Facility ID# (if applicable)
2375 Lewisville Clemmons Rd, Clemmons 27012
Physical Address, City, and Zip
Forsyth
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(dwell field, one lat/long is sufficient)
36 02 14.32 N 80 23 06.98
NNE
6. Is(are) the well(s)�Ix Permanent or QQTemporary
7. Is this a repair to an existing well: QYes or Cho
If this is a repair, fill out known well construction information and explain the nature of the
repair under #21 remarks section or on the back of this form.
8. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction, only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled:
9. Total well depth below land surface: 55
For multiple wells list all depths if different (example- 3@200' and 2@100)
(ft.)
10. Static water level below top of casing: ~28 (ft.)
Ifwater level is above casing, use "+"
11. Borehole diameter: 8.5 (in.)
12. Well construction method: auger (angled)
(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
28 ft.
55 ft.
silty sand
ft.
ft.
15. OUTER CASING (for multi -cased wells) OR LINER (if ap licable)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft.
ft.
in.
16. INNER CASING OR TUBING (geothermal closed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
0 ft.
53 ft.
2 in•
Sch40
PVC
ft.
ft.
in.
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
53 ft.
55 ft.
2 in.
0.010
Sch40
PVC
ft.
ft.
in.
18. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
0 ft.
3 ft'
sand
pour
3 ft.
49 ft.
neat cement
pumped through tremie pipe
49 ft.
51 ft.
bentonite
tremie pipe
19. SAND/GRAVEL PACK (if applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
51 ft.
55 ft.
#2 silica sand
tremie pipe
ft.
ft.
20. DRILLING LOG (attach additional sheets if necessary)
FROM
TO
DESCRIPTION (color, hardness, soil/rock type, grain size, etc.)
ft.
ft.
See consultant's log
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
21. REMARKS
Well drillcd 22.5 dcgrccs from
at perpcndicular
22. Certification:
Signature of Certijid Well Contractor
11/26/21
Date
By signing this form, I hereby certify that the well(s) was (were) constructed in accordance
with 15A NCAC 02C .0100 or 15A NCAC 02C .0200 Well Construction Standards and that a
copy of this record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTRUCTIONS
24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Injection Wells: hi addition to sending the form to the address in 24a
above, also submit one copy of this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supply & Iniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
completion of well construction to the county health department of the county
where constructed.
Form GW-1
North Carolina Department of Environmental Quality - Division of Water Resources Revised 2-22-2016

WELL CONSTRUCTION RECORD
This Form can be u90d Cm single or rnullipk wells
1. Well Contractor Information:
Robert Miller
Well Collrtctow 14anw
2675
NC W'c11 Co iI1iiciorCcrlNumber
SAEDACCO Inc
{'marl u15 Namur
2. Well (onstmetion Permit tr:
List all appliruhle wrllpt weirs gr_c. County. ark, Yariartne, frepErelart Nr.+
3. Weil Use (cheek well use);
Waxer Supply Well:
In Agricultural
DGeolheimal tHeaiingrtCooling Supply}
Dkichistrialitornmercial
ID irrigation
DMitnicipaVFliblic
0Residcntial Water Supply (single)
0ResidenEial Waler SappI . (shared)
Non -Water Supply Well:
❑ ldaniinrin4
iLl�rcll1r11 Wi.LI;
CJAgrrifcr Recharge
In Aquifer Sloragc and Recover'
❑ Acinifer Tem
❑ Experimcnta1 TechFL LQg
❑ Geodiernml (Closed Lour')
❑ C�torliemral il{c41mg'Cuoline ReLun11
❑ Reem
❑Groundwater 11Cr11q[liali4n
❑ Salinifl Harrier
❑ SEorrnwatcr Drains
❑ .S isaiderr4a CoiMml
❑ Trdr;rr
®OIILer ie tplain under #21 Remarks)
For Freraal 4rsc
1a_211'AtER 2.ONI'S
PRO .I
To
IE:ti{'1tEF 11{}
t$.
rl,
It.
111.OUTER CASING Our mull! --rased ncRs} OR CANER fir sp.lk bk�
FROM
O It.
TO
48 IL
PLAMFTFR
2"
1
Tnr€'rnkFSS HhTF
SCH-40 PVC
RTAI•
T. DINER LASING OR 7111ING iiirui eraral..indoor.(!.
FROM TO DEiti1E'rE.H THICKNESS
R. dt, il1.
T#, It,
MATERIAL
17. SCRICICN
FROM
TO
RWA:161TF,R
SLOT SIi.R
THFCKNTISS
MATRRI At
48 P-
50 H,
2"
iu.
.010
SCH-40
PVC
1t.
ft.
ia.
ia. GROUT
FROM
TO
?dh'FER1hi.
I1thnLLEHL I SIETIIOD d ASIOL:Nr
O ft.
44 iL
Portland
trimi
r
ft
rt.
29.5ANrltGRA%''ELPACK {if glpdc#lls!
. rR{}11
wr]
MATERIAL
E(MF3.A.[ }'.\11:NT 3{}'Tllrin
47 ft.
50
Silica Sand
20/30
It.
It.
3II DRILLING LOG (attach if ICeeasarr)
FRO'rl
0 Ito
T[5
50 IC
DE'.ti{'REPTIE}\ 1s„hr.1urdnvni. wil'nn'IL 15 pc, ^fRn'de,c'k.I
SANDY CLAY
.Bate Welts) Conipleicd: 9-30-2021 Well 1110AS-18
❑ a_ k}eLl lluratiun:
7-Eleven #36069
Facllilr'=Y1',. 4 r Narwc
2375 Lewisville Clemmons Rd.,
Forsyth
Facility IAa tirapplicablel
Clemmons, NC, 27012
It
ft.
IL
IL
IL
fx
rt,
rt.
rt,
Physical Addiess_ Ciq._ and Zip 21_ kLMARGii
t:APWF Y8r t] Idesist'1Gylitan Nn rFUN}
51.1-atitude and 1.nngit ode in tlegreetimirnrIri- tecontls nr decimal' degrees:
{If i 01 held. rat Laiuug is aidlickvll
T1 W
6.1s leant the wellisk OPennarient er OTemporilr}'
7. is this a repair to an existing well: Ycx 11r MI Nu
f/rhfs rx rr frd*ur, fill Mar trri,nw I.•ri!{,t+urranrI,:I J eirlormirr.r.'+l old r.tvfabi rflr rueRlre of r#t
repair ranger All re-murky.seeilarx or on the hark of r.i s jF. r.ui.
S. Number of wells constructed: 1
for mi,lrrple irFfeak I or rrxl-warer supply wetIa ONLY x' rh rfir same consenee inu. '.OM [eirr
sir*L'irir mue forni.
9. Total well depth helm; land surfut 50 11-11
For astride wedslisrrrUihrrbrijdl r'rJuleYaipte-3@200'tiii 2@Nlfx'}
1 U. Static water let el below lop of cariuz
If wrlrrr 'r' rl ,s Aluue rnafrig. uu' ' + •'
I I. Bali diameter: 8.25" 1.1-)
12. Well consirnctiori method; 4.25" HSA
1i.e. aiI r. near}', cable_ di xi push.ctn.I
FOR WATER SUPPLY WELLS ONLY:
13a, Yid(' (gm) Method of test'
1311. Disinfect -inn riper Amount:
iL
Three feet bentonite Seal from 44'to 47'
22. (:errifi rhea:
Signirbin
9/28/2021
Dak
BF Signing drip- Parr.. F beer.}' tYrfifL' that Au- ,i,L! lx haul {wereJ curayi aeiedr err aveurS@Oc e
with f5.4 ArCAC 02C .01190 or l54 NCAC t12C ,02200 Wetl Ebxatraranrr Standards and rlxu
envy t f hie reconf hiu brew pmvidralr. rhie ,1r11 awjt4'r,
23. Site diagram or sidellilimal well details:
You may 11se the back of ihis page to provide additional %%ell sire details or well
cc+n truu[ion details. You erns,' also attach:idditioi}at pages if iset:essar} .
SU BM LTTAL LNSTL1CTIONS
2da Poi- All Wells: Suhllui Iles faros within MI dens of compleiioo of well
ton51n1LtLpn to tlac fnlLoning-
biriltiun of Wsiter Rezuurces, loformatiuu Frocersiog (snit,
1617 h1aiL Service Center, Raleigh, NC 17699-1617
tab. For Inicctios Welly ONLY: In a,ddiiiaii to .sending the form to Ilic address in
2-la above. also submit a op!, of this form within 30 days of completion of well
cartallUeLiuh [o the following:
DE'ision e£Vli'ater Resources. Underground Injeciiou Control Program,
1636 T4ir;ll Sends Curlier. Raleigh, NC 27699-1636
25e, fit W4tcir $lkypIL1 vtiuo WeLlN.
Also submit one copy of this forth ,ti ithin 30 days of completion of
well coasinrctian to the ¢1211flr3 bc4Ith department of the count!: where
constructed
Farin OW-L
Noah Caro]nu 1-.parurn JIE or Ern iloiuenj a
Id Mantra] Rcac'I.recs - DO, J5IVY taI Waier Ravin
gets iscd August 21113

WELL CONSTRUCTION RECORD
This Forncon be usod 8i singly or rnullink wells
1. Well Contractor Information:
John Eisenman
WC]i ConInrctor Eranw
4439A
NC Well Coflhlilcior Cot ifeestion Number.
SAEDACCO Inc
{'[uilrkun Nan1L
2. Wdi (onstrauction Permit fit;
List lrnopp i rtIc well pfrsreits (1_ . 'r'r,1F4'..52air, Yariureer, Jr/pi-den
3. Well Use (chat: well use):
Water Supply Well:
In Agricultural
1:1Geolheimal tHeatalMgrtCooIin. Supply)
t7 led u s lei a l(Co nunerc i a l
❑ hri ition
ID M i rn i c i paVFtlb t i c
C]Residcnfial Water Supply (single)
0Resideniial Water Supply (sham!)
NoM-Water Supply Well:
❑ Monitoring
iLlirclllrrl Wi.LI;
CJAgrrifcr Recharge
DAgirifcr Storage and Rceolov1)
El Aquifer Tem
❑ Experin ila! Technu•LQg
❑ GeNodiernml (Closed Loup)
❑ C�to[liemtal iHeating''Cbolirne Retun1}
❑ Reim
❑Groundwater Rcnie liatian
O .Salintr Harrier
❑ 5tornn crier ilina C
O 5111s5iiCMC Coilml
❑ Trdt;rr
®Orliel [explain udder #21 Remarks)
For foicTaal Use ON I.'e:
1a-trL'AtER 2.ON.Ls
PRO41
TO
REM 'MI. 11{}S
f$.
It ,
ft.
I.
MOLTER CASING Our mull! --easel 1ac19 OR L KERfiF ap Nc hki
FROM
O fL.
TO
48 IL
PL# 1FTFR
2"
io-
1
a
Tnt€'fn�FSS
SCH-40 PVC
MATT
RTAI•
1b. INNE R CASING OR 1ll'H INc;; { jlnnraral cludauri(!
FROM TO DEiti1ETEIt THICKNESS
MATERIAL
17. SCR]1N
FROM
TO
RrAMIRTFR
SLOT Si
THi :KNT1SS
MATRRI At
48 R.
50 H.
2"
iu.
.010
SCH-40
PVC
R.
It.
ia.
ia. CROrrr
FROM
TO
?dhTER1AL
1eh4t1.4CEMEti7 3IETHOD hMOL:Nr
O ft.
45 IL
Portland
Tremmie
ri,
FIN
ft
It,
29.SANDICIL VELPA iC{dglpdetllll _
. rR{}11
wr:
50 ATER1AL
E:'r1Y1..{i'}'.\1-:til 5i}'TUCrn
47 O.
50 It.
SAND
#2
ft.
ft.
3II DRILL1NG LOG (attach id{filianHI strc1/4911 it Door un.)
FROM
0 IL
50 A.
RE'.ti{'REFTIE}\ lS,thr,lurdns'++,'+lirnn'L 15 pc 7rdn
SANDY CLAY
. Bate Welts) Conipleicd: 10-7-21
Sa_ VreLI planation:
7-Eleven #36069
Fycililr' (... cr NOM
2375 Lewisville Clemmons Rd.,
Forsyth
Well 1Dif AS-19
I-aoilrry IDC tir3pplicnb1e1
Clemmons, NC, 27012
Physical Addicss_ Cit}.. and Zip
GIpW}' park] Idcnirfieynitan No fFUN}
5b.1.p11itudc and 1-nngh-nde in 11cgrecrlmiittitestsC1cnn11s nr decimal degrees:
(If i 11 ticld. Intl Lallans is sank nnl
Tti W
6.1s bunt Ibe welUJrk OPennaneni er ❑Temporary
7.1s this a repair to an existi.rag well: YcJi or MI Nu
f/rhfs Jx rr rrl*ur, f+J'Mar trtI,ww wed {,OJWrnnrr,I J rlrloreavr.rmi old r.tvfarJi rflr 0r rl1re of the
repair ranger. 2L rreneerlwseeJialx ar rut the hark of Udsprui.
S.Number ofwells -onsiru ced: 1
For 1rodnplr irtfecrkkJI or next-wbrer supply wt' Ia ONLY with rhr' shyer rortoneefinu. xa, coo
arrdwlirrrur gored.
9. Total well depth helm; land surfut 50 (fl.)
For MOW!' wetri Hsi rrU diYuhr if r erekhr leYaRJpte- 3@200' thud 2@ JOfx'}
1 U. Static water Ter. el below lop of cariup
if nitlrr r 1et.4 ,s r;llo a crAdel:E•. uu' '• 4 "
I I. Balehole diameter: 8.25" tA)
12. Well conbiirnctioti method: 4.25 HSA
ii.e. ail r. radar}', cable- dirai push.crc.L
FOR WATER SUPPLY WELLS ONLY:
13a•Yw('(p i)
1J11. DisinFoctiun rape:
Melded of test:
Amount:
ft.
8
ft.
IL
IL
IL
f!,
ft,
Fr.
rt,
rt,
21. REMARKS
Bentonite Seal 45 to 47ft
22, Cerfiradsrn:
10/13/2021
Sismlaic of , ' - ;. --•
' rx sir' 1'-
$s signir�� JJ'r1T fw,K ��.' h: 41l w.a' 1rr.�J eoarrrre'real in exex+oramrrx'
with f5.4NC4CO2C.•_ - .0200 WeComtraJrnarSrandardaand Awaya
ropy of this Freon-, hewn dx {w Iwm'airni err Jibe Writ .huller,
23. She diagram or adt3liianal well details:
You may :He the back of ihis page to provide additional well sire details or well
cc+nslrIL[iori details. You ells,' also attach:Ld:itiol}at pages if 1set:essar} .
SU BM LTTAL [NSTIJCTIONS
2da Ear All Wells: Suhlrui Iles form within xlI dens of compleiioo of well.
Contlnittipn to OK fhlLoning-
birisiun of Water Resources, lnformatiuu processing Unit,
1617 Mail Service Center, Raleigh, NC 17699-1617
tab. For Inicclios Welly ONLY: In a,ddiiiaii to .sending the form to rlic address in
2-la shove. also submit a imp, of this form within 30 days of completion of well
conSIYuLLiuri [o [he following:
Dh'ision e£Vit'ater Rcwourt. .lfrldcrpound Injeellou Control Froglvm,
1636 M ll Senilx Curlier. Raleigh, NC 27699-1636
25e, fit wAtsr_syylajLi_rjEcti.ou V4'CLI�r
Also submit one copy of this fotni +tiithin 30 days ofconpletionof
well cnoslnictiOR En talc Coimr; health depamneat of Elie County where
conaruCfad
Farin GW-L
Krinh Carol lea D.paronn JIE DIEM iloiuenj and Narilra] Rcaourccs - Di, ss sou eI Waacr Ravin Rt, iscd August 211J 3

Print Form
4. Date Well(s) Completed:
WELL CONSTRUCTION RECORD (GW-1)
1. Well Contractor Information:
Mike Tynan
Well Contractor Name
2725-A
NC Well Contractor Certification Number
IET
Company Name
2. Well Construction Permit #:
W I0400580
List all applicable well construction permits (i.e. UIC, County, State, Variance, etc.)
3. Well Use (check well use):
Water Supply Well:
Agricultural EllMunicipal/Public
Geothermal (Heating/Cooling Supply) DResidential Water Supply (single)
Industrial/Commercial DResidential Water Supply (shared)
Irrigation
Non -Water Supply Well:
Monitoring
0Recovery
Injection Well:
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
Experimental Technology
Geothermal (Closed Loop)
Geothermal (Heating/Cooling Return)
11/5/21
XQIGroundwater Remediation
QI Salinity Barrier
QI Stormwater Drainage
JSubsidence Control
QlTracer
❑I Other (explain under #21 Remarks)
Well ID# AS-20
5a. Well Location:
7-Eleven #36069
Facility/Owner Name Facility ID# (if applicable)
2375 Lewisville Clemmons Rd, Clemmons 27012
Physical Address, City, and Zip
Forsyth
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(dwell field, one lat/long is sufficient)
36 02 14.32 N 80 23 06.98
NN
6. Is(are) the well(s)�Ix Permanent or QQTemporary
7. Is this a repair to an existing well: QYes or Cho
If this is a repair, fill out known well construction information and explain the nature of the
repair under #21 remarks section or on the back of this form.
8. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction, only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled:
9. Total well depth below land surface: 55
For multiple wells list all depths if different (example- 3@200' and 2@100)
(ft.)
10. Static water level below top of casing: ~28 (ft.)
Ifwater level is above casing, use "+"
11. Borehole diameter: 8.5 (in.)
12. Well construction method: auger (angled)
(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
28 ft.
55 ft.
silty sand
ft.
ft.
15. OUTER CASING (for multi -cased wells) OR LINER (if ap licable)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft.
ft.
in.
16. INNER CASING OR TUBING (geothermal closed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
0 ft.
53 ft.
2 in•
Sch40
PVC
ft.
ft.
in.
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
53 ft.
55 ft.
2 in.
0.010
Sch40
PVC
ft.
ft.
in.
18. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
0 ft.
3 ft'
sand
pour
3 ft.
49 ft.
neat cement
pumped through tremie pipe
49 ft.
51 ft.
bentonite
tremie pipe
19. SAND/GRAVEL PACK (if applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
51 ft.
55 ft.
#2 silica sand
tremie pipe
ft.
ft.
20. DRILLING LOG (attach additional sheets if necessary)
FROM
TO
DESCRIPTION (color, hardness, soil/rock type, grain size, etc.)
ft.
ft.
See consultant's log
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
21. REMARKS
Well drillcd 22.5 dcgrccs from
at perpcndicular
22. Certification:
Signature of Cert. d Well
11/26/21
Date
By signing this form, I hereby certify that the well(s) was (were) constructed in accordance
with 15A NCAC 02C .0100 or 15A NCAC 02C .0200 Well Construction Standards and that a
copy of this record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTRUCTIONS
24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Injection Wells: hi addition to sending the form to the address in 24a
above, also submit one copy of this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supply & Iniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
completion of well construction to the county health department of the county
where constructed.
Contr
actor
Form GW-1
North Carolina Department of Environmental Quality - Division of Water Resources Revised 2-22-2016

Print Form
4. Date Well(s) Completed:
WELL CONSTRUCTION RECORD (GW-1)
1. Well Contractor Information:
Mike Tynan
Well Contractor Name
2725-A
NC Well Contractor Certification Number
IET
Company Name
2. Well Construction Permit #:
W I0400580
List all applicable well construction permits (i.e. UIC, County, State, Variance, etc.)
3. Well Use (check well use):
Water Supply Well:
Agricultural EllMunicipal/Public
Geothermal (Heating/Cooling Supply) DResidential Water Supply (single)
Industrial/Commercial DResidential Water Supply (shared)
Irrigation
Non -Water Supply Well:
Monitoring
0Recovery
Injection Well:
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
Experimental Technology
Geothermal (Closed Loop)
Geothermal (Heating/Cooling Return)
11/5/21
Ell Groundwater Remediation
QI Salinity Barrier
QI Stormwater Drainage
JSubsidence Control
QlTracer
❑I Other (explain under #21 Remarks)
Well ID#AS-21
5a. Well Location:
7-Eleven #36069
Facility/Owner Name Facility ID# (if applicable)
2375 Lewisville Clemmons Rd, Clemmons 27012
Physical Address, City, and Zip
Forsyth
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 02 14.32 N 80 23 06.98
6. Is(are) the well(s)�Ix Permanent or QQTemporary
7. Is this a repair to an existing well: QYes or Cho
If this is a repair, fill out known well construction information and explain the nature of the
repair under #21 remarks section or on the back of this form.
8. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction, only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled:
9. Total well depth below land surface: 51
For multiple wells list all depths if different (example- 3@200' and 2@100)
(ft.)
10. Static water level below top of casing: ~28 (ft.)
Ifwater level is above casing, use "+"
11. Borehole diameter: 8.5 (in.)
12. Well construction method: auger (angled)
(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
28 ft.
51 ft.
silty sand
ft.
ft.
15. OUTER CASING (for multi -cased wells) OR LINER (if ap licable)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft.
ft.
in.
16. INNER CASING OR TUBING (geothermal closed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
0 ft.
49 ft.
2 in'
Sch40
PVC
ft.
ft.
in.
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
49 fL
51 ft.
2 in.
0.010
Sch40
PVC
ft.
ft.
in.
18. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
0 ft.
3 ft'
sand
pour
3 ft.
44 ft.
neat cement
pumped through tremie pipe
44 ft.
47 ft.
bentonite
tremie pipe
19. SAND/GRAVEL PACK (if applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
47 ft.
51 ft.
#2 silica sand
tremie pipe
ft.
ft.
20. DRILLING LOG (attach additional sheets if necessary)
FROM
TO
DESCRIPTION (color, hardness, soil/rock type, grain size, etc.)
ft.
ft.
See consultant's log
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
21. REMARKS
Well drillcd 11.5 dcgrccs from
at perpcndicular
22. Certification:
7
Signature of Certjlied Well Contractor
11/26/21
Date
By signing this form, I hereby certify that the well(s) was (were) constructed in accordance
with 15A NCAC 02C .0100 or 15A NCAC 02C .0200 Well Construction Standards and that a
copy of this record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTRUCTIONS
24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Injection Wells: hi addition to sending the form to the address in 24a
above, also submit one copy of this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supply & Iniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
completion of well construction to the county health department of the county
where constructed.
Form GW-1
North Carolina Department of Environmental Quality - Division of Water Resources Revised 2-22-2016

WELL CONSTRUCTION RECORD
This Form can be u90d Cm single or ipk wells
1. Well Contractor Information:
Robert Miller
Well Collrtclow 14anw
2675
NC Well Co iI1iiciorCcrlNumber
SAEDACCO Inc
{'marl u15 Namur
2. Well (onstmetion Permit tr:
List all appliruhle wrllpt'rmirs gr_c. County. ark, Yariartne, frepErelart Nr.+
3. Weil Use (cheek well use):
Waxer Supply Well:
In Agricultural
DGeotheimal tHeaiingrtCooling Supply}
Dkichistrialitornmercial
ID irrigation
DMitnicipaVFtiblic
0Residcntial Water Supply (single)
0ResidenEial Waler SappI. (shared)
Non -Water Supply Well:
❑ Monitoring
iLl�rcll1r11 Wi.LI;
CJAgrrifcr Recharge
In Aquifer Storage and Recover'
❑ A{lpifer T
❑ Epee) iu mI TechFL LQg
❑ Geodiernml (Closed Lour')
❑ GMliemril1Healnrg''Cbolirle ReLun11
❑ Reem
❑Grrurldwatcr Rclltgtliati4n
❑ Salinifl Harrier
❑ SEorrnwatcr Drains
❑ .S issideeme CoiMml
❑ Trdr;rr
®OIILer ie tplain under #21 Remarks)
For Freraal 4rsc
1a_W11'AtER 2.ONI'S
PRO .I
To
IE:ti{'1tEF 11{}
t$.
rt,
It.
Mi. OUTER CASING Our mull! --rased ncRs} OR LIFTER fir sp.lk hk�
FROM
O rt.
TO
48 IL
PLAMFTFR
2"
1
Tnr€'rnkFSS HhTF
SCH-40 PVC
RTAI•
T. DINER LASING OR 7111INGieui lcraral..indoor.(!.
FROM TO DEiti1E'rE.H THICKNESS
R. dt, il1.
T#, It,
MATERIAL
17. SCRICICN
FROM
TO
RWA:161TF,R
SLOT SIi.R
THFCKNTISS
MATRRI At
48 P-
50 H,
2"
iu.
.010
SCH-40
PVC
1t.
ft.
ia.
ia. GROUT
FROM
TO
?dh'FER1hi.
I1 n tC IL I SIETIIOD d ASIOL:Nr
O ft.
44 iL
Portland
trimi
r
ft
rt.
M.5AN DM/AV 'EL PACK {if glpdc#lls!
. rR{}11
wr]
MATERIAL
E(MF3.A.[ }'.\11:NT 3{}'Tllrin
47 O.
50
Silica Sand
20/30
It.
It.
3II DRILLING LOG (attach iddilianal l eti if ICeeHsarr)
Feu "I
0 It
T[5
50 II.
DE'.ti{'REPTIE}\ 1s„hr.1urdnt'n, wil'nn'L 15 pc, ^fRn'de,c'k.I
SANDY CLAY
.Bate Welts) Conipleicd: 9-30-2021 Well 1110AS-22
❑ a_ k}eLl l.nratiun:
7-Eleven #36069
Facllilr'=Y1',. 4 r Narwc
2375 Lewisville Clemmons Rd.,
Forsyth
Facility IAa tirapplicablel
Clemmons, NC, 27012
It
ft.
IL
IL
IL
fx
rt,
rt.
rt,
Physical Addiess_ Ciq._ and Zip 21_ kLMARGii
t:APWF fart] Idesist'1Gylitan Nn rFUN}
51.1-altitude and 1.nngit ode in tlegreetimirnrTrtlsecontltt nr decimal degrees:
{If i 01 held. rat Laiuug is aidlick iI
T1 W
6.1s leant the wellisk OPennarient er OTemporilr}'
7. is this a repair to an existing well: Ycx tit MI Nu
f/rhfs ix rr frd*ur, fill Mar trri,nw I.•ri!{,t+urnnrrrra eirlorrarr.rai old r.tvfabi rflr rueRlre of r#t
repair ranger All re-murky.seeiiarx or on the hark of r.i s jF. r.ui.
S. Number of wells constructed: 1
for ma,trrple irFfeak I or rrxl-warer supply wetIa ONLY x' rh rfir saint consenee inu. '.OM [eirr
sir*L'irir mue forni.
9. Total well depth helm; land surfut 50 11-11
ForMOW!' weds'FMrrrUihrrbrijdi r'r Julcya ipte-3@200'ti ii 2@Nlfx'}
1 U. Static water let el below lop of cariuz
If Kerrey tat rt ,s r;lluue rnafrig. uu' ' + •'
I I. Bali diameter: 8.25" 1.1-)
12. Well consirnctiori method; 4.25" HSA
1i.e. aiI r. near}', cable_ di xi push.ctn.I
FOR WATER SUPPLY WELLS ONLY:
13a, Yid(' (gm) Method of test'
1311. bisinrtwtiun riper Amount:
iL
Three feet bentonite Seal from 44'to 47'
22. (:errifi rhea:
Signirbin
9/28/2021
Dale
BF Signing drip- Parr.. F beer.}' tYrfifL' that Au- n?! l Yl haul {wereJ curayi aeiedr err aveurS@Oc e
with f5.4 ArCAC 02C .01190 or t 54 NCAC t12C ,02200 Wetl Ebxatrr clan Standards and rlxu
revy t f th r reconf hbns brew Iwm'irdrrf ra rhie ,1r11 awjt4'r,
23. Site diagram or sidellilimal well details:
You may lice the back of ihis page to provide additional %%ell sire details or well
cC+n truli[ion details. You erns,' also attach:idditioi}at pages if 1set:essar} .
SU BM LTTAL LNSTL1CTIONS
2da Poi- All Wells: Suhllui Iles faros within MI dens of compleiioo of well
ton51n1LtLpn to tlac fnlLoning-
biriltiun of Wsiter Rezuurces, loformatiuu Frocersiog (snit,
1617 h1aiL Service Center, Raleigh, NC 17699-1617
tab. For Inicctios Welly ONLY: In a,ddiiiaii to .sending the form to Ilic address in
2-la above. also submit a op!, of this form within 30 days of completion of well
cortallUL Liuh [o the following:
DE'ision e£Vli'ater Resources. Underground Injeciiou Control Program,
1636 T4ir;ll Sends Curlier. Raleigh, NC 27699-1636
25e, fit wAtsr_s_lkyRuLt_rjEcti.ou WeLlN.
Also submit one copy of this forth ,ti ithin 30 days of completion of
well coasinrctiaa to the ¢1211flr3 bc4Ith department of the count!: where
constructed
Farirl OW-L
Noah Caro]nu 1-.parurn JIE or Ern iloiuenj a
Id Mantra] Rcac'I.recs - DO, J5IVY taI Waier RmatroM.
gets iscd :August 211J 3

Print Form
4. Date Well(s) Completed:
WELL CONSTRUCTION RECORD (GW-1)
1. Well Contractor Information:
Mike Tynan
Well Contractor Name
2725-A
NC Well Contractor Certification Number
IET
Company Name
2. Well Construction Permit #:
W I0400580
List all applicable well construction permits (i.e. UIC, County, State, Variance, etc.)
3. Well Use (check well use):
Water Supply Well:
Agricultural EllMunicipal/Public
Geothermal (Heating/Cooling Supply) DResidential Water Supply (single)
Industrial/Commercial DResidential Water Supply (shared)
Irrigation
Non -Water Supply Well:
Monitoring
0Recovery
Injection Well:
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
Experimental Technology
Geothermal (Closed Loop)
Geothermal (Heating/Cooling Return)
11/5/21
Ell Groundwater Remediation
QI Salinity Barrier
QI Stormwater Drainage
JSubsidence Control
QlTracer
❑I Other (explain under #21 Remarks)
5a. Well Location:
7-Eleven #36069
Well ID#AS-23
Facility/Owner Name Facility ID# (if applicable)
2375 Lewisville Clemmons Rd, Clemmons 27012
Physical Address, City, and Zip
Forsyth
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(dwell field, one lat/long is sufficient)
36 02 14.32 N 80 23 06.98
NNE
6. Is(are) the well(s)�Ix Permanent or QQTemporary
7. Is this a repair to an existing well: QYes or Cho
If this is a repair, fill out known well construction information and explain the nature of the
repair under #21 remarks section or on the back of this form.
8. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction, only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled:
9. Total well depth below land surface: 55
For multiple wells list all depths if different (example- 3@200' and 2@100)
(ft.)
10. Static water level below top of casing: ~28 (ft.)
Ifwater level is above casing, use "+"
11. Borehole diameter: 8.5 (in.)
12. Well construction method: auger (angled)
(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
28 ft.
55 ft.
silty sand
ft.
ft.
15. OUTER CASING (for multi -cased wells) OR LINER (if ap licable)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft.
ft.
in.
16. INNER CASING OR TUBING (geothermal closed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
0 ft.
53 ft.
2 in•
Sch40
PVC
ft.
ft.
in.
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
53 ft.
55 ft.
2 in.
0.010
Sch40
PVC
ft.
ft.
in.
18. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
0 ft.
3 ft'
sand
pour
3 ft.
49 ft.
neat cement
pumped through tremie pipe
49 ft.
51 ft.
bentonite
tremie pipe
19. SAND/GRAVEL PACK (if applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
51 ft.
55 ft.
#2 silica sand
tremie pipe
ft.
ft.
20. DRILLING LOG (attach additional sheets if necessary)
FROM
TO
DESCRIPTION (color, hardness, soil/rock type, grain size, etc.)
ft.
ft.
See consultant's log
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
21. REMARKS
Well drillcd 22.5 dcgrccs from
at perpcndicular
22. Certification:
Signature of Certijid Well Contractor
11/26/21
Date
By signing this form, I hereby certify that the well(s) was (were) constructed in accordance
with 15A NCAC 02C .0100 or 15A NCAC 02C .0200 Well Construction Standards and that a
copy of this record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTRUCTIONS
24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Injection Wells: hi addition to sending the form to the address in 24a
above, also submit one copy of this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supply & Iniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
completion of well construction to the county health department of the county
where constructed.
Form GW-1
North Carolina Department of Environmental Quality - Division of Water Resources Revised 2-22-2016

Print Form
4. Date Well(s) Completed:
WELL CONSTRUCTION RECORD (GW-1)
1. Well Contractor Information:
Mike Tynan
Well Contractor Name
2725-A
NC Well Contractor Certification Number
IET
Company Name
2. Well Construction Permit #:
W I0400580
List all applicable well construction permits (i.e. UIC, County, State, Variance, etc.)
3. Well Use (check well use):
Water Supply Well:
Agricultural EllMunicipal/Public
Geothermal (Heating/Cooling Supply) DResidential Water Supply (single)
Industrial/Commercial DResidential Water Supply (shared)
Irrigation
Non -Water Supply Well:
Monitoring
0Recovery
Injection Well:
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
Experimental Technology
Geothermal (Closed Loop)
Geothermal (Heating/Cooling Return)
11/5/21
Ell Groundwater Remediation
QI Salinity Barrier
QI Stormwater Drainage
JSubsidence Control
QlTracer
❑I Other (explain under #21 Remarks)
5a. Well Location:
7-Eleven #36069
Well ID#AS-24
Facility/Owner Name Facility ID# (if applicable)
2375 Lewisville Clemmons Rd, Clemmons 27012
Physical Address, City, and Zip
Forsyth
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(dwell field, one lat/long is sufficient)
36 02 14.32 N 80 23 06.98
NN
6. Is(are) the well(s)�Ix Permanent or QQTemporary
7. Is this a repair to an existing well: QYes or Cho
If this is a repair, fill out known well construction information and explain the nature of the
repair under #21 remarks section or on the back of this form.
8. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction, only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled:
9. Total well depth below land surface: 55
For multiple wells list all depths if different (example- 3@200' and 2@100)
(ft.)
10. Static water level below top of casing: ~28 (ft.)
Ifwater level is above casing, use "+"
11. Borehole diameter: 8.5 (in.)
12. Well construction method: auger (angled)
(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
28 ft.
55 ft.
silty sand
ft.
ft.
15. OUTER CASING (for multi -cased wells) OR LINER (if ap licable)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft.
ft.
in.
16. INNER CASING OR TUBING (geothermal closed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
0 ft.
53 ft.
2 in•
Sch40
PVC
ft.
ft.
in.
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
53 ft.
55 ft.
2 in.
0.010
Sch40
PVC
ft.
ft.
in.
18. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
0 ft.
3 ft'
sand
pour
3 ft.
49 ft.
neat cement
pumped through tremie pipe
49 ft.
51 ft.
bentonite
tremie pipe
19. SAND/GRAVEL PACK (if applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
51 ft.
55 ft.
#2 silica sand
tremie pipe
ft.
ft.
20. DRILLING LOG (attach additional sheets if necessary)
FROM
TO
DESCRIPTION (color, hardness, soil/rock type, grain size, etc.)
ft.
ft.
See consultant's log
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
21. REMARKS
Well drillcd 22.5 dcgrccs from
at perpcndicular
22. Certification:
Signature of Cert,i ed Well Contractor
11/26/21
Date
By signing this form, I hereby certify that the well(s) was (were) constructed in accordance
with 15A NCAC 02C .0100 or 15A NCAC 02C .0200 Well Construction Standards and that a
copy of this record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTRUCTIONS
24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Injection Wells: hi addition to sending the form to the address in 24a
above, also submit one copy of this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supply & Iniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
completion of well construction to the county health department of the county
where constructed.
Form GW-1
North Carolina Department of Environmental Quality - Division of Water Resources Revised 2-22-2016

WELL CONSTRUCTION RECORD
This Form can be u50d Cm Sink or mill ink wells
1. Well Contractor Information:
For fnicnnll 4rsc
Robert Miller
't'11 C15 yrtt ttn tune
2675
NC Well Conlricior Cul &testion Number
SAEDACCO Inc
'maven:. Name
2. Well Construction Psrglit fit;
List 1rnopp i rtIc well pfrsreits (1_ 'r'r,1F4'.,53u7r, Variance, .frepErelart
3. Weil Usc (cheek w II u
Waxer Supply Well:
I]Agricultural
❑ Geolheimal tHealingrtCooling Supply).
O led u s lri a ((Co nunerc i a l
El Irrigation
DMilnicipaVFubiic
0Residerdial Waiter Supply (single)
0ResidenEia[ Wader Supply [shri red I
Non -Water Supply Well:
❑ Mpni1nrin4
iEipcillrrl VkeLI;
CJAgirifcr RCch rgc
l7Agiriffr Storage and Rccoviel '
❑ A{ltlirer T
DEWCTIMMIHI TechFL•LQg
❑ Geeo111ernmi (Closed Loop)
❑ GN kmlal OE Return)
❑ Rcc n
❑Grourldwalcr RCIilgdiatirjn
❑ Salinit} Harrier
❑ 5torrnwarCr ilina C
❑ .S iiiCrKe Cnniml
❑ Trdr;rr
®Odder iexplain under #21 Remarks)
14_ WA-R 2.ONI1S
PRO,I
Too
DE:,1'MP 1 I'}'
It ,
ft.
Mi. OUTER CASING Eror mini - --rased ncRs} OR LINER fir so Ncahki
TPI€KNFSS HATF RTAI•
SCH-40 Pvc
FROM
0 ft.
15 IL
4"
Th. (FINER LASING OR 1111ING iiirai eraral..indoor.(!.
FROM TO DEiti1ETE.H THICKNESS
f1. i , uL_
MATERIAL
17. SCR11N
FROM
TO
prA:MISTF,R
SLOT SI?4
THiCKNTISS
MATRRI AI.
15 R.
25 H,
4"
IR
.020
SCH-40
PVC
1t,
ft.
ia.
` la. CRO[IT
FROM TO
MATERIAL
EFITPLtCEMLNI SIETHOD AMOL:Nr
3 ' D-
11 IL
Portland
pour
r
ft,
f4
24.SANrIIGRA%''EL PACK {if glpelc#ltsj
. vIto1I
1(]
'MATERIAL
14 tt.
25
It,
Silica Sand
6/20
tt,
It.
111, DRILLICWC LOG (attach nddilianel 3hseti if nccesaur )
FROM
0 IL
T[5
25 IL
tFE'.tj{ REFTIt)' ..,Ir.hMrdns'n, r,il'nn'L 15 pc. 7Idn
Tan Silt
4. Doe Welts) Conipleicd: 9-29-2021 Well 1Dt+SVE-1R
S a_ k}cL11 lirathun:
7-Eleven #36069
Fycililr' (... cr NOM
2375 Lewisville Clemmons Rd.,
Forsyth
I-acilihy IDC tic 'pliciblei
Clemmons, NC, 27012
It.
IL
fr.
ft
IL
IL
fr
ft,
Fr.
rt,
Physical Address_ Cit}._ and Zip it. kLMARGii
0>inny Far t] Idenirfleyniun No fFPI}
5b.1-attitude Awl 1.nngitplle in 11C1[1•cesimirriati SAceon11s or decimal degrees:
OfNall held. Int I;W9ui s is aidlickvll
T1 W
6.1a bunt the welUJik OPenna ent er ❑Temporar}'
7. is this a repair to an existing well: YcJi fir ®Nu
f/rhfs Jx rr rrd*ur, rJ J 4y1r trri,nw I,L,1I.:.: .'rancour eirlolairr.r.JI cord r.tvfarJi r8t ruerl1re of Olt
rr+Lairromi rAIL rerloarl'.y.Yee'Jiarx or rJn the bark t efirs 8.rwi.
S. TTunderof wells tonerirueced: 1
for w ifiple J.Ffei'Ik I or rrr.I-warer supply wt 8a ONLY n811 rfir same aonsenu(Ioe. xa, coo
.t*iiirmir torn.
9. Total well depth helm; iasd surfam 25
For MOW!' wrtls Hsi rrU d ..p.ths if Effferv+u l!e YarrJpfe - 3@200 thud 2@ 1
1 U. Static water level below hop of cariup N/A
If wrtrrr Irt rI ,s r;JIuue rnafrJg_ um' "+ "
I I. BoiibeIe diameter: 10. 625"
12, Well conintmetion method; 6.625" HSA
1i.e. aii{cr. Flay}', cable_ dilai posh. etc.
FOR WATER SUPPLY WELLS ONLY:
13a, Yid(' (gm) Method of test:
1311. bisinrtwtiun ripe: Amount:
n.
3' foot bentonite seal from 11'to 14'
22. ('ertifirat;sin:
Signininc
9/28/2021
Date
BF Signing efru farm, F her -Eby errs fL' rbur rbr well.Y+ H.-.:es {we, J LYJRYrrhre'I_ee�l Yis aoreramrrti•
%'Jrlt f SA NCAC 02C ,OWEk7 Pr f 54 NCAC 02C .dam C. Weti C rsrnott SfARLI'af b and rkerQ
r,TJy t f th r record hLuv brew pmvirdrrf ra J ,Irlf awjt,'r,
23. Site diagram or adelliianal well details:
You may Ilse the back of ihis page to provide additional well sire details or well
cc+nstrIL[ioii details. You inav also attach:Ldditiol}at pages if 1tet:essar} .
SU BM ITTAL [NSTLCTIONS
21a Poi- All Wells: Sublliii Iles faros within MI dens of compleiioo of weli
Con5lmLtipn to the fnlLoning-
birisiun of Waiter Rezuurces, loformatiuu Frocessiog (ini1,
1617 Mail Service Center, Raleigh, NC 17699-1617
tab. For Inieerios Welly ONLY: In a,ddiiiati to sending the form to :he address in
24a above. also submit a op!, of this form within ?0 days of completion of well
coral:nu-6A al [o the following:
Dkision of Vli'mer Resat' rt. . Underground Injeciiou Control Program
1636 Mail Serif Curlier. Raleigh, NC 27699-1636
25e, fit W4t r $yypI r cttiuu V4'r`Ll5r
A]sn submit one cop' of this foam +ti ithin 30 days of completion of
well cntsstnictian to the Crnmi; health depsrtmpnt of the county where
constmcled
TO
PL# 1FTFR
Farin OW-L
Nord rdh Carol lea D..pannrJIE aC Ern mum' and Nricara] Resources - Di, ss IVY or Waicr Ra iiro Rt, iscd August 21113

Print Form
WELL CONSTRUCTION RECORD (GW-1)
1. Well Contractor Information:
Mike Tynan
Well Contractor Name
2725-A
NC Well Contractor Certification Number
IET
Company Name
2. Well Construction Permit #:
List all applicable well construction permits (i.e. UIC, County, State, Variance, etc.)
3. Well Use (check well use):
Water Supply Well:
Agricultural
Geothermal (Heating/Cooling Supply)
Industrial/Commercial
0Irrigation
QlMunicipal/Public
DResidential Water Supply (single)
(Residential Water Supply (shared)
Non -Water Supply Well:
IDMonitoring Recovery
Injection Well:
DAquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
Experimental Technology
Geothermal (Closed Loop)
Geothermal (Heating/Cooling Return)
DGroundwater Remediation
QI Salinity Barrier
QI Stormwater Drainage
DSubsidence Control
01 Tracer
❑I Other (explain under #21 Remarks)
4. Date Well(s) Completed: 12/10/20 Well ID# SVE-2
5a. Well Location:
7-Eleven #36069
Facility/Owner Name Facility ID# (if applicable)
2375 Lewisville-Clemmons Rd, Clemmons, 27012
Physical Address, City, and Zip
Forsyth
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 02 13.295 N 80 23 08.634
6. Is(are) the well(s)10Permanent or QTemporary
7. Is this a repair to an existing well: QYes or XQNo
If this is a repair, fill out known well construction information and explain the nature of the
repair under #21 remarks section or on the back of this form.
8. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction, only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled:
9. Total well depth below land surface: 25 (ft.)
For multiple wells list all depths if different (example- 3@200' and 2@100)
10. Static water level below top of casing: none (ft.)
Ifwater level is above casing, use "+"
11. Borehole diameter: 10.25 (in.)
12. Well construction method: Auger
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
For Internal Use Only:
14. WATER ZONES
FROM
TO
DESCRIPTION
ft.
ft.
ft.
ft.
15. OUTER CASING (for multi -cased wells) OR LINER (if ap licable)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft.
ft.
in.
16. INNER CASING OR TUBING (geothermal closed -loop) 1
FROM
TO
DIAMETER
THICKNESS
MATERIAL
0 ft.
5 ft.
4 in'
Sch40
PVC
ft.
ft.
in.
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
5 ft.
25 ft.
4 in'
0.020
Sch40
PVC
ft.
ft.
in.
18. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
0 ft.
0.5 ft.
concrete
pour
0.5 ft.
4 ft.
bent/grout
pour
ft.
ft.
19. SAND/GRAVEL PACK (if applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
4 ft.
5 ft.
#1 silica sand
pour through augers
5 ft.
25 ft.
#2 silica sand
pour through augers
20. DRILLING LOG (attach additional sheets if necessary)
FROM
TO
DESCRIPTION (color, hardness, soil/rock type, grain size, etc.)
ft.
ft.
See report
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
21. REMARKS
Completed at surface with 12" manhole and concrete
pad.
22. Certification:
Signature of Ceytjfied Well Contractor
12/16/20
Date
By signing this form, I hereby certify that the well(s) was (were) constructed in accordance
with 15A NCAC 02C .0100 or 15A NCAC 02C .0200 Well Construction Standards and that a
copy of this record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTRUCTIONS
24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Injection Wells: In addition to sending the form to the address in 24a
above, also submit one copy of this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supply & Injection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
completion of well construction to the county health department of the county
where constructed.
Form GW-1
North Carolina Department of Environmental Quality - Division of Water Resources Revised 2-22-2016

WELL CONSTRUCTION RECORD
This Form can be u90d Cm single or mullilrlc wells
1. Well Contractor InformalIon:
For rnicraal Use ON
Robert Miller
Well ComillI. T N 1ii
2675
NC Well Cnnlr,,IciorCcrlifecaLionNumber
SAEDACCO Inc
{'coupon Name
2. Well (onstmction Permit th
List arI2no? i ithIc well pfurei(1_ County. .52air, Variance, !,'at'
3. Well Use (cheer: well
Winer Supply Well:
I] Agricultural
❑ Geolheimal 1-learingiCooling Supply)
O lad u s lei a ((Co nunerc i a l
El Irrigation
DMirnicipaVFublic
OResidcniial WalerSupph• [siI�gle1
0ResidenEiat Waler Supply [shri red
Nort-Water Supply Well:
❑ ldnnilnrin4
iEij cl him i4'LI:
0Agi ifcr Recharge
DA ipifer Storage and Recover)
❑ Aquifer T
❑ Expurkwila! TechFL LQg
❑ C,eodlernmt (CIrrsed Loup)
❑ Grodlkmlai iHealing''CbotirOE Return)
❑ Rccen
❑Grourrdwalcr Rcnne[tiatian
EiSalintr Harrier
❑ 5torrnwarer Drains
❑ StissiiCIKC Coilml
❑ Trdl;rr
®Other ie tplain under #21 Remarks)
1a_W4fliit 2JON.Ls
PRO,1
To
DEM'MP 1 Ir}'
rt.
rt ,
ter
It.
Mi. OUTER CASING Our and -eased ncRs} OR LINER {it air Nc hki
FROM
0 rt.
TO
5 re„
PL#VFTFR
4"
1
a
Tnr€'rn�FSS SCH-40 PVC
1ihTF
RTAI•
IL INNER CASING OR cludauri(!.
PROM TO DEiti1E'rEIt THICKNESS
ft, ft, ir1.
rt. : R -
MATERIAL
17. SCILTIN
FROM
TO
IsrA1,rRTF,R
SLOT SI?4
THrCKNTISS
MATRRI AI.
5
25 It,
4"
IR
.020
SCH-40
PVC
1e,
ft.
ia.
` la. CRO(IT
FROM TO
MATERIAL
EflTPLtCEMLti7 3IFn1oIJ AMOL:Nr
2 ft,
3
Portland
pour
rir
rp
tt
r4
24.SANDCR..43''ELPACK (Frg7p11441 j
. vIto1I
1 r]
'MATERIAL
S1}'T11E1Tl
4 O.
25
rt,
Silica Sand
6/20
ft.
rt,
3II DRILLICWC LOG (allach 3hwc1i it neeesaarr]
FROM
0 It
T[5
25 IL
11.F.y{ REPTIE}\ ..,Ir.1urdnl'n,. ,il'nn'L ripe. 7Idn
Tan Silt
.114te Welts) Conipleicd: 9-27-2021 Well 1Dt+SVE-3
S a_ k}cL111irathun:
7-Eleven #36069
Fycililr' Yl',. cr NOM
2375 Lewisville Clemmons Rd.,
Forsyth
Facility IDC tir'plic.iblei
Clemmons, NC, 27012
Physical Address_ Cat}._ and Zip
nary PaReI IdenilfreiEliun No fFPI}
5b.1-altitude A1u1 1.nngitude in lIegreCsimilltrl s,fsec4nlls nr decimal degrees:
(Ilse all held. Int lablimg is aidlick iIl
Tti W
6. Is late) the welUJrk OI ennaneni e r OTempuror}'
7. is this a repair to an existing well: Yes or ®Nu
f/rhfs Jx rr fepdir, rJ J 4y1r erri,nw I, L,1I.:.: .ran racy+ eirlorr arr.t.JI and r.lvfarJi r8t rIr rl1re of Olt
rr+Lairranger . 2f remarl'.y.• Jiarx or yin the bark of r.i s 8.r.ui.
Number -ouerinteced: 1
for nuke plr JrFfei'Ik I of rrrxl-wbrer supply weth ONLY n811 rfir ilTJnf ro1rseneeJioe. xa, coo
.t*i1ir sue foray.
9. Toth wdl depth beIo'i iasd surfut 25 (TO
FormxfrW! ka.11.4 tFMijUikruhr ifEf ervnrlemPopfr- 3@200 thud 2@1
1 U. Static water level below lap of cariup N/A
If warr'fi Ir, rI ,s .i Jioue inde.1,t au' + "
I I. BorrbeIe diameter: 10. 625" }i )
12, Wc11 COIr9tr actiIst method: 6.625" HSA
ti.e. aii{cr. coral}', cable_ dilai push-m.L
FOR WATER SUPPLY WELLS ONLY:
13a, Yid(' (gm) Method of test:
1311. bisinFoctiun ripe: Amount:
It.
Ito
fr.
rt
IL
IL
rr
re.
fi.
rt.
rt,
rt.
2t. REMARKS
One foot bentonite seal from 3'to 4'
22, Cer••t iralvin:
Signione
9/28/2021
Date
$F signing rfru pair, F Irercby errirfL' rhea rk. welr,.Y+ IraaY {werrJ c,nh rrel_ed� Yis accerakrace•
wJrlr f SA FC4C 02C ,OWEk7 or f 54 NCAC 02C .0 Wvf1 Cams!'raranrt Standants and rfprr
revy t f th r rr ord hLws dx e i pmvirdrrf ra J ,Irlf -fAri er,
23. Site diagram or adeltihanal well details;
You may 11se the hack of this page to provide additional well sire details or well
cc+nsiruL[ioti details. You insw alai attach:idditioi}at pages if 1sel:essar .
SU BM [TTAL [NSTL CTIONS
2da For All Wells: Suhalul Iles faros within 1.11. days of conlpletioo of well
Con5lmLtipn to llac fRlLOuing-
birixiun of WAter Rezuurces, loformatiuu Processing (snit,
1617 Mail Service Center, Raleigh, NC 17699-1617
tab. For Inieerios Welly ONLY: In a,ddiiiaii to sending the form to :lie address in
2-1a above. also submit a imp, of this form within 30 days of completion of well
co8SlruLLiuri [o the following:
Dkision of Water Ream' rt. . lrrtdcrpvund Injeciio1 Control Program,
1636 Mail. Ser4 ilx Curlier. Raleigh, NC 27699-1636
25e, fit W4tc+' s_lkylajL r_rjEcti.ou V4'CLI�r
Also submit one cop' of this form 11 ithin 30 days of completion of
rTeII cnos:nrctian to talc Ccn.rn health departs ent of the county where
construCfad
Aral OW-L
Dinh Carol lea D..parurn JIE aC Ern iloiultrlu aid Narilrai Rewirrccs - Di, ss row eI Waicr Ravin Rt, iscd August 2013

WELL CONSTRUCTION RECORD
This Formic -on be u50d Cm single or rnullink wells
1. Wdl Contractor Infarmatlon:
For foicraal 4rsc ONI.V:
Robert Miller
well CoInnioT Nitrn4
2675
NC Well Cnnlr,IciorCcrlifecaLionNumber
SAEDACCO Inc
Nomc
2. Well (onstrqut;tion Permit fit;
List all opp i itle. w Ipt weirs (1_ 'f'r,1r'. ark , Variance, frifiElEtrrirt
Wd1 Use (chccIh, well uNO:
Winer Supply Well:
I] Agricultural
❑ Geollleimal 1-lealingiCooling Supply)
I7 lad u s lri a ((Co nunerc i a l
❑ ImPation
ID M i to i c i paVFtrb s i c
OResidcniial Wailer Supph• (single)
0ResidenEia[ Waler Supply (shared
Non -Water Supply Well:
❑ rdonilnrin4
iElieciluici VkeLI:
CJAgrrifcr Rcchargc
DAtiIriffr Staragc and RCCL3 cry
❑ Aciliirer T
❑ ExperimgralF11 Mclincrle.gy
❑ C,eodrernml LCIrrsed Loup)
❑ Gro[I1�n11a1 il{c41mg.Cuoline Retun1}
❑ Rcc il
❑GrcUlldw•atcr RC111liatian
❑ Salinit} Harrier
❑ Stormy; to Dinao"C
❑ Trdl;rr
®Oder ie iplain under #21 Remarks)
1a_trL'Afrt 2JON1tS
rRlj41
To
IES.I.MF 1 I'}'
r$.
rt ,
rt.
MI. OUTER CASING Our ouYll tonal nclis} OR L KERfir apNc hk�
FROM
0 rt.
TO
15 IL
PL#VFTFR
4"
Tnr€'fn�FSS1
SCH-40 PVC
4thTF
RTAI•
lb. INNER LASING OR 1111ING ijl ulheraq..indoor.(!.
PROM TO Dti.METEIt THICKNESS
an: :1
17. SC1ti1N
MATERIAL
FROM
TO
prA711rPTF,R
SLOT SI?4
THfCTcNASS
MATRRI At
15 R.
25 r1,
4"
iu.
.020
SCH-4
PVC
1e.
ft.
` la. GROUT
FROM TO
MATERIAL
EMPLtCEMLti7 3IFn1oIJ AMOL:Nr
3 D-
11 IL
Portland
pour
rir
r
ft
rt.
24.5AN'II'GRAN'EL PACK{ir glpelc#llj
. FRONI
1(]
47 ATPRlAL
E:'r]Y7..5{'}'.\II: tit' 41}'Tllrin
14 O.
25
Silica Sand
6/20
ft.
rt,
111, DRILLICWIG LOG (attach additional;!sera if memory)
FRO41
0 It..
T[5
25' rL
111F.y{KEPT It)' 11„ Iar.hprrdnl,n, ..,il'ntl. 15Ps. 7Idn
Tan Silt
.114te Welts) Conipleicd: 9-28-2021 Well 1Dee SVE-4
❑ a_ k}{.1L1 l.nratiun:
7-Eleven #36069
Facility Yn. cr NOM
2375 Lewisville Clemmons Rd.,
Forsyth
I-abiliry IDC tar 'plic.iblel
Clemmons, NC, 27012
It.
1L
ft.
rt.
rt.
IL
fr
rt.
lZ,
rt.
rt,
Physical Address_ Ciq._ and Zip 21_ kLMARGii
OMmlF FBr t] Idcnisfitynilan No fFM}
5b.1.a11itude and 1.ringitulle in tlegrecrlmi1 stei,fsec4ntls or decimal degrees:
Of mall held. Int LW9uitg is aidlickvll
Tti W
6.1ai taws] the wellls): OPennaneni er OTempuror}'
7. is this a repair to an existing well: 'Yoe 11r ®Nu
f/rhfs Jx rr fr1*ur, fill 4y1r trel,nw I.•ri! c04)1 rML tart+ eirlorr arr.t.JI gold r.lvfarJi r8t rIr rl1re of Olt
re+.airranger . 2f remarl•.y.• Jiaa or on the bark of tldr 8.rwl.
S.Number ofwells -onerirueced: 1
for m ilfiple J.Ffei'Ik I or r.ion-warer supply wet! ONLY with rfir' same ao1l.t04 e(Ioe. xa, coo
aadwrirmle forn1.
9. Toth wdl depth beIo'i ixs13 surfut 25 (TO
For mxfrW!'wrflstrsrrrUdi'PrbrifEffferv+uicya,Jpfr-T@200 tiii 2@18.8}
1 U. Static water level below top of c..nduz N/A
if MWrree Irt rI ,s .i Jioue inare4t au' "+ •'
I I. BoribleIe diameter: 10. 625" ii,j
12, 'ell tonglewctiIrr method: 6.625" HSA
ii.e. aii{cr. retar}', cable_ dilai push.crc.I
FOR WATER SUPPLY WELLS ONLY:
134 Yid(' (gm) Method of test:
1J11. Disinfection ripe: Amount:
n.
3' foot bentonite seal from 11'to 14'
22. ('eriifiradsin:
Signibm
9/28/2021
Date
BF Signing this. y F hems}' eerier.- rhea Au- actor+ rraaY {we, J c ante rel_ea�r Yis accerarace.
wJrlr f S.L FC4C 02C ,OWEk7 or f 54 NCAC 02C .dam Wefl Cams!'rarnnrt SfARLI'afdb and rkerQ
.N-vy of rhir record hLws brew Iwm'irdrrf ra Jam' ,Ir1� awjt,'r,
23. She dingrum or Jrdell111ma1 well details:
You may Ilse the hack of ibis page to provide additional sire details or well
cc+nsiruL[ioii LLeldils. You ensw arse attach:idditioi}at pages if 1sel:essar} .
SU BM LTTAL [NSTIJCTIONS
2da Fur All Wells: Subenii Iles faros within .11 dens of com,leiioo of well
Contlmttipn to the fnlLnuing-
birisiun of Water Resources, Informatiuu Processing (snit,
1617 Mail Service Center, Raleigh, NC 17699-1617
tab. For Inieetios Welly ONLY: In a,ddiiiaii [o sending the form to :lie address in
2-1a above. also submit a imp, of this farm within 30 days of canlple[ioir of well
carlsIfiLLiurl Et [he following:
Dkision of WAler Refeourt. .lfrldcrpound Injeciiou Control Program,
163n T4iJrlL Scrieltr Center. Raleigh, NC 27699-1636
25e, fit W4tc+' s_ekylaJL r_rjEcti.ou V4'CLI�r
Also submit one cop' of this forth ,l ithin 30 days of completion of
tiers collsinrctiaa to ttic Crnmf3 hC41tb depsrrmpnt of the county. where
con rucled
Farin GW-L
Krbruh Carol lea D..pannrJIE aC Ern swum' and Nariira] Rtisr'luccs - Di, ss sou eI War Ravin Rt, iscd August 21113

WELL CONSTRUCTION RECORD
This Form can be u90d Cm single or mullilrlc wells
1. Well Contractor InformalIon:
For rnicraal Use ON
Robert Miller
Well ComillI. T N 1ii
2675
NC Well Cnnlr,,IciorCcrlifecaLionNumber
SAEDACCO Inc
{'coupon Name
2. Well (onstmction Permit th
List arI2no? i ithIc well pfurei(1_ County. .52air, Variance, !,'at'
3. Well Use (cheer: well
Winer Supply Well:
I] Agricultural
❑ Geolheimal 1-learingiCooling Supply)
O lad u s lei a ((Co nunerc i a l
El Irrigation
DMirnicipaVFublic
OResidcniial WalerSupph• [siI�gle1
0ResidenEiat Waler Supply [shri red
Nort-Water Supply Well:
❑ ldnnilnrin4
iEij cl him i4'LI:
0Agi ifcr Recharge
DA ipifer Storage and Recover)
❑ Aquifer T
❑ Expurkwila! TechFL LQg
❑ C,eodlernmt (CIrrsed Loup)
❑ Grodlkmlai iHealing''CbotirOE Return)
❑ Rccen
❑Grourrdwalcr Rcnne[tiatian
EiSalintr Harrier
❑ 5torrnwarer Drains
❑ StissiiCIKC Coilml
❑ Trdl;rr
®Other ie tplain under #21 Remarks)
1a_W4fliit 2JON.Ls
PRO,1
To
DEM'MP 1 Ir}'
rt.
rt ,
ter
It.
Mi. OUTER CASING Our and -eased ncRs} OR LINER {it air Nc hki
FROM
0 rt.
TO
5 re„
PL#VFTFR
4"
1
a
Tnr€'rn�FSS SCH-40 PVC
1ihTF
RTAI•
IL INNER CASING OR cludauri(!.
PROM TO DEiti1E'rEIt THICKNESS
ft, ft, ir1.
rt. : R -
MATERIAL
17. SCILTIN
FROM
TO
IsrA1,rRTF,R
SLOT SI?4
THrCKNTISS
MATRRI AI.
5
25 It,
4"
IR
.020
SCH-40
PVC
1e,
ft.
ia.
` la. CRO(IT
FROM TO
MATERIAL
EflTPLtCEMLti7 3IFn1oIJ AMOL:Nr
2 ft,
3
Portland
pour
rir
rp
tt
r4
24.SANDCR..43''ELPACK (Frg7p11441 j
. vIto1I
1 r]
'MATERIAL
S1}'T11E1Tl
4 O.
25
rt,
Silica Sand
6/20
ft.
rt,
3II DRILLICWC LOG (allach 3hwc1i it neeesaarr]
FROM
0 It
T[5
25 IL
11.F.y{ REPTIE}\ ..,Ir.1urdnl'n,. ,il'nn'L ripe. 7Idn
Tan Silt
.114te Welts) Conipleicd: 9-27-2021 Well 1Dt+SVE-5
S a_ k}cL111irathun:
7-Eleven #36069
Fycililr' Yl',. cr NOM
2375 Lewisville Clemmons Rd.,
Forsyth
Facility IDC tir'plic.iblei
Clemmons, NC, 27012
Physical Address_ Cat}._ and Zip
nary PaReI IdenilfreiEliun No fFPI}
5b.1-altitude A1u1 1.nngitude in lIegreCsimilltrl s,fsec4nlls nr decimal degrees:
(Ilse all held. Int lablimg is aidlick iIl
Tti W
6. Is late) the welUJrk OI ennaneni e r OTempuror}'
7. is this a repair to an existing well: Yes or ®Nu
f/rhfs Jx rr fepdir, rJ J 4y1r erri,nw I, L,1I.:.: .ran racy+ eirlorr arr.t.JI and r.lvfarJi r8t rIr rl1re of Olt
rr+Lairranger . 2f remarl'.y.• Jiarx or yin the bark of r.i s 8.r.ui.
Number -ouerinteced: 1
for nuke plr JrFfei'Ik I of rrrxl-wbrer supply weth ONLY n811 rfir ilTJnf ro1rseneeJioe. xa, coo
.t*i1ir sue foray.
9. Toth wdl depth beIo'i iasd surfut 25 (TO
FormxfrW! ka.11.4 tFMijUikruhr ifEf ervnrlemPopfr- 3@200 thud 2@1
1 U. Static water level below lap of cariup N/A
If warr'fi Ir, rI ,s .i Jioue inde.1,t au' + "
I I. BorrbeIe diameter: 10. 625" }i )
12, Wc11 COIr9tr actiIst method: 6.625" HSA
ti.e. aii{cr. coral}', cable_ dilai push-m.L
FOR WATER SUPPLY WELLS ONLY:
13a, Yid(' (gm) Method of test:
1311. bisinFoctiun ripe: Amount:
It.
Ito
fr.
rt
IL
IL
rr
re.
fi.
rt.
rt,
rt.
2t. REMARKS
One foot bentonite seal from 3'to 4'
22, Cer••t iralvin:
Signione
9/28/2021
Date
$F signing rfru pair, F Irercby errirfL' rhea rk. welr,.Y+ IraaY {werrJ c,nh rrel_ed� Yis accerakrace•
wJrlr f SA FC4C 02C ,OWEk7 or f 54 NCAC 02C .0 Wvf1 Cams!'raranrt Standants and rfprr
revy t f th r rr ord hLws dx e i pmvirdrrf ra J ,Irlf -fAri er,
23. Site diagram or adeltihanal well details;
You may 11se the hack of this page to provide additional well sire details or well
cc+nsiruL[ioti details. You insw alai attach:idditioi}at pages if 1sel:essar .
SU BM [TTAL [NSTL CTIONS
2da For All Wells: Suhalul Iles faros within 1.11. days of conlpletioo of well
Con5lmLtipn to llac fRlLOuing-
birixiun of WAter Rezuurces, loformatiuu Processing (snit,
1617 Mail Service Center, Raleigh, NC 17699-1617
tab. For Inieerios Welly ONLY: In a,ddiiiaii to sending the form to :lie address in
2-1a above. also submit a imp, of this form within 30 days of completion of well
co8SlruLLiuri [o the following:
Dkision of Water Ream' rt. . lrrtdcrpvund Injeciio1 Control Program,
1636 Mail. Ser4 ilx Curlier. Raleigh, NC 27699-1636
25e, fit W4tc+' s_lkylajL r_rjEcti.ou V4'CLI�r
Also submit one cop' of this form 11 ithin 30 days of completion of
rTeII cnos:nrctian to talc Ccn.rn health departs ent of the county where
construCfad
Aral OW-L
Dinh Carol lea D..parurn JIE aC Ern iloiultrlu aid Narilrai Rewirrccs - Di, ss row eI Waicr Ravin Rt, iscd August 2013

WELL CONSTRUCTION RECORD
This Forncon be u50d Cm single or mulliir]c wells
1. Well Contractor InformalIon:
For Foicrard Use
Robert Miller
well CorinnioT N 1ii
2675
NC Well Cnnlr,,IciorCcrl&testionNumber
SAEDACCO Inc
{'cuinpun Name
2. Well (omitrvetion Permit fit;
Lit all oppi itle. ptTsreies(1_ County. ark Yariureer, Jr/OrdenN,'.+
3. Weil Use (check well al NO;
Water Supply Well:
I] Agricultural
❑ Geollleimal 1-learingiCooling Supply)
I7 lnd u s lri a ((Co nunerc i a l
❑ ImPation
DMitnicipaVFtrblic
OResidcntial Wailer Supph• (single)
0ResidenEial Waler Supply (shared
Nom-Water Supply' Well:
❑ Monitorii
iri cihrei i4'LI:
DAgrlifcr Recharge
DA ipifer Storage and Recover
❑ Aquifer T
❑ Expurkwila! TechFL LQg
❑ Geodrernml (Closed Loup)
❑ Grodlknual iHe4lnrg.'Cbol ne Retuni
❑ Reem
❑Grourldw'atcr Rcine[tiatian
EiSalintr Barrier
❑ SEorrn3 arer Dina
❑ StilSiiiCnCC Cnnyml
❑ Trdl;rr
®Other Eexplain under #21 Remarks)
1a_trL'Afift 2JOT41tS
PRO,1
TO
IES.I'H[P 1 I'.}'
f$.
rt,
It.
Mi. OUTER CASING Our and -eased ncRs} OR L KER {if air Nc hki
FROM
0 IL.
TO
15 IL
PL#VFTFR
4"
1
a
Tnr€'rnNFSS MATESCH-40 PVC
RTAI•
lb. INNER LASING OR TUBING {jlnnikraral..indoor.(!.
PROM TO Dtiti1ETEIt THICKNESS
an:
f ,
17. SCiti1N
MATERIAL
FROM
TO
nrAPTFR
SLOT SI?4
THrCKNASS
MATRRI AI.
15 R.
25 f1,
4"
iu.
.020
SCH-40
PVC
1e,
ft.
` 1P. CLOUT
FROM TO
MATERIAL
EhTFldCEMLti7 3IETHOD AMOL.Nr
3 k-
11 It
Portland
pour
r
ft
rt.
24.5AN rJ RAN''EL PACK {if g7pdc#1Lsj
. FR011
1 r1
'MATERIAL
E:'r1Y1..1.(}'. II:' 1' 1{}'Tllrin
14 O.
25
is,
Silica Sand
6/20
It.
fr.
3II, DRILLICWIG LOG (aresch Idditianal;!sera if ncccsrarr)
FROM
0 It..
T[1
25 rL
111F.y{REFT15p¢. 7rdn'dc',
Tan Silt
.114te Welts) Conipleicd: 9-28-2021 Well 1Dee HVE-6
❑ a_ k}cL11 lirathun:
7-Eleven #36069
Facililr'Yn.. cr NarPC
2375 Lewisville Clemmons Rd.,
Forsyth
I-acilihy IDC tic 'plic.iblei
Clemmons, NC, 27012
It.
1L
ft.
rt.
IL
IL
fr
rt.
rt.
rt,
Physical Milieu_ Cit}._ and Zip 2L_ kLMARGfL
°Many PaReI IdCvirrreynilan No fRlN)
5b.1-alitude A1u1 1.nngitutle in tlegrecrlminst i,fs cnnils nr decimal degrees:
{If i 01 Held. rnu LW9uitg is aidlickvli
Tti W
6. la ice) the wellis).: OPennaneni e r ❑Temporary
7. is thin a repair to an existing well: 'Yoe 11r ®Nu
f/rhfs Jx rr fr1*ur, fill 4y1r erri,nw caeApirelplriou eirlorrarr.t.JI r.lvfarJi rftt rlrerrrre of Olt
rr+Lairranger . 2f rrrnurl•.y.•er•Jiarx or on the bark of UdsPrwi.
S. Number wells roneliru ced: 1
for wtJ,+rrplr JrFfei'Ik I or r.ion-warer supply overly ONLY nOli rfir same aonsenu(Ioe. xa, coo
.t*iiirmir forn1.
9. Total well depth beIo'i laud sinful= 25 (fi.)
F rmxfri.Jt veils i'isrialikruhr ifdrgfrvJu i ya, Jpfr- 3@200 thud 2@I
1 U. Static water level below tap of cariup N/A
1f veiny lrt rl ,s .i Jioue inare4t mu' "+
I I. BoribleIe diameter: 10. 625"ii
12, WdltonffIrnetiore method; 6.625" HSA
ti.e. aii{cr. roar}', nibI _ dirai push.vc.L
FOR WATER SUPPLY WELLS ONLY:
13a, Yid(' ($ipol) Method of test:
1J11. bisinfoctiun ripe: Amount:
n.
3' foot bentonite seal from 11'to 14'
22. ('ertifi rrlinn:
Signirbsic
9/28/2021
Dare
$F Signing drip. F hereby tYrfifL' Ara rh. wett.y+ x ty {we, J curaririrekkr iR atTe akrace
with f SA ArCAC 02C ,0W190 or II 54 NCAC {12C ,dam Wefl EbJdrrrr[awt Standards and rkerQ
copy of ririkr reconf 0141N dxewprovided in- J ,Irlfaw'Jter,
23. She diagram or lyddlilimal well details:
You may 11se the back of ibis page to provide additional %%ell sire details or well
cranslrue[iori details. You inav arse attach:idditiotiat pages if lrecessarx .
SUBMITTAL [NSTLCTIONS
2da For All Wells: Sublliii Iles faros within XCI dens of complerioo of well
Con5lnittipa to Ow fnlLouing-
birixiun of WAter Rezuurces, loformatiuu Frocersiog (roil,
1617 Mail Scr iee Center, Raleigh, NC 17699-1617
tab. For Inieerios Welly ONLY: In addiiiaii [o sending the form to :lie address in
2-1a above. also submit a imp, of this form within zp days of canlple[iou of well
conSlruLLicni [o [he following:
Dkision of Waler Rcwiirt. .14r141crpound Injec:io1 Control Program,
1636 T4iJrll Nerdy Cuniur. Raleigh, NC 27699-1636
25e, fit W4tc+r $tairpI 1 1 vtiuu WCLI5r
Also submit one cop' of this forth 11 ithin 30 days of completion of
rTeII cnoslnrctian to tilc Ccn.rn health department of the county where
consfnicled
ATM OW-L
KrirshCaro]IaaL7..parurnJIEaCErnstoILIMIuandNarilra]Rewirccs-Di,ssroueI WaicrRavin Rt,iscdAugust 2u13

WELL CONSTRUCTION RECORD
This Form can be u90d Cm single or mullilrlc wells
1. Well Contractor InformalIon:
For rnicraal Use ON
Robert Miller
Well ComillI. T N 1ii
2675
NC Well Cnnlr,,IciorCcrlifecaLionNumber
SAEDACCO Inc
{'coupon Name
2. Well (onstmction Permit th
List arI2no? i ithIc well pfurei(1_ County. .52air, Variance, !,'at'
3. Well Use (cheer: well
Winer Supply Well:
I] Agricultural
❑ Geolheimal 1-learingiCooling Supply)
O lad u s lei a ((Co nunerc i a l
El Irrigation
DMirnicipaVFublic
OResidcniial WalerSupph• [siI�gle1
0ResidenEiat Waler Supply [shri red
Nort-Water Supply Well:
❑ ldnnilnrin4
iEij cl him i4'LI:
0Agi ifcr Recharge
DA ipifer Storage and Recover)
❑ Aquifer T
❑ Expurkwila! TechFL LQg
❑ C,eodlernmt (CIrrsed Loup)
❑ Grodlkmlai iHealing''CbotirOE Return)
❑ Rccen
❑Grourrdwalcr Rcnne[tiatian
EiSalintr Harrier
❑ 5torrnwarer Drains
❑ StissiiCIKC Coilml
❑ Trdl;rr
®Other ie tplain under #21 Remarks)
1a_W4fliit 2JON.Ls
PRO,1
To
DEM'MP 1 Ir}'
rt.
rt ,
ter
It.
Mi. OUTER CASING Mir and -eased ncRs} OR LINER {it air Nc hki
FROM
0 rt.
TO
5 re„
PL#VFTFR
4"
1
a
Tnr€'rn�FSS SCH-40 PVC
1ihTF
RTAI•
IL INNER CASING OR cludauri(!.
PROM TO DEiti1E'rEIt THICKNESS
ft, ft, ir1.
rt. : R -
MATERIAL
17. SCILTIN
FROM
TO
IsrA1,rRTF,R
SLOT SI?4
THrCKNTISS
MATRRI AI.
5
25 It,
4"
IR
.020
SCH-40
PVC
1e,
ft.
ia.
` la. CRO(IT
FROM TO
MATERIAL
EflTPLtCEMLti7 3IFn1oIJ AMOL:Nr
2 ft,
3
Portland
pour
rir
rp
tt
r4
24.SANDCR..43''ELPACK (Frg7p11441 j
. vIto1I
1 r]
'MATERIAL
S1}'T11E1Tl
4 O.
25
rt,
Silica Sand
6/20
ft.
rt,
3II DRILLICWC LOG (allach 3hwc1i it neeesaarr]
FROM
0 It
T[5
25 IL
11.F.y{ REPTIE}\ ..,Ir.1urdnl'n,. ,il'nn'L ripe. 7Idn
Tan Silt
.114te Welts) Conipleicd: 9-27-2021 Well 1Dt+SVE-7
S a_ k}cL111irathun:
7-Eleven #36069
Fycililr' Yl',. cr NOM
2375 Lewisville Clemmons Rd.,
Forsyth
Facility IDC tir'plic.iblei
Clemmons, NC, 27012
Physical Address_ Cat}._ and Zip
nary PaReI IdenilfreiEliun No fFPI}
5b.1-altitude A1u1 1.nngitude in lIegreCsimilltrl s,fsec4nlls nr decimal degrees:
(Ilse all held. Int lablimg is aidlick iIl
Tti W
6. Is late) the welUJrk OI ennaneni e r OTempuror}'
7. is this a repair to an existing well: Yes or ®Nu
f/rhfs Jx rr fepdir, rJ J 4y1r erri,nw I, L,1I.:.: .ran racy+ eirlorr arr.t.JI and r.lvfarJi r8t rIr rl1re of Olt
rr+Lairranger . 2f remarl'.y.• Jiarx or yin the bark of r.i s 8.r.ui.
Number -ouerinteced: 1
for nuke plr JrFfei'Ik I of rrrxl-wbrer supply weth ONLY n811 rfir ilTJnf ro1rseneeJioe. xa, coo
.t*i1ir sue foray.
9. Toth wdl depth beIo'i iasd surfut 25 (TO
FormxfrW! ka.11.4 tFMijUikruhr ifEf ervnrlemPopfr- 3@200 thud 2@1
1 U. Static water level below lap of cariup N/A
If wriree- Ir, rI ,s .i Jioue inde.1,t au' + "
I I. BorrbeIe diameter: 10. 625" }i )
12, Wc11 COIr9tr actiIst method: 6.625" HSA
ti.e. aii{cr. coral}', cable_ dilai push-m.L
FOR WATER SUPPLY WELLS ONLY:
13a, Yid(' (gm) Method of test:
1311. bisinFoctiun ripe: Amount:
It.
Ito
fr.
rt
IL
IL
rr
re.
fi.
rt.
rt,
rt.
2t. REMARKS
One foot bentonite seal from 3'to 4'
22, Cer••t iralvin:
Signione
9/28/2021
Date
$F signing rfru pair, F Irercby errirfL' rhea rk. welr,.Y+ IraaY {werrJ c,nh rrel_ed� Yis accerakrace•
wJrlr f SA FC4C 02C ,OWEk7 or f 54 NCAC 02C .0 Wvf1 Cams!'raranrt Standants and rfprr
revy t f th r rr ord hLws dx e i pmvirdrrf ra J ,Irlf -fAri er,
23. Site diagram or adeltihanal well details;
You may 11se the hack of this page to provide additional well sire details or well
cc+nsiruL[ioti details. You insw alai attach:idditioi}at pages if 1sel:essar .
SU BM [TTAL [NSTL CTIONS
2da For All Wells: Suhalul Iles faros within 1.11. days of conlpletioo of well
Con5lmLtipn to llac fRlLOuing-
birixiun of WAter Rezuurces, loformatiuu Processing (snit,
1617 Mail Service Center, Raleigh, NC 17699-1617
tab. For Inieerios Welly ONLY: In a,ddiiiaii to sending the form to :lie address in
2-1a above. also submit a imp, of this form within 30 days of completion of well
co8SlruLLiuri [o the following:
Dkision of Water Ream' rt. . lrrtdcrpvund Injeciio1 Control Program,
1636 Mail. Ser4 ilx Curlier. Raleigh, NC 27699-1636
25e, fit W4tc+' s_lkylajL r_rjEcti.ou V4'CLI�r
Also submit one cop' of this form 11 ithin 30 days of completion of
rTeII cnos:nrctian to talc Ccn.rn health departs ent of the county where
construCfad
Aral OW-L
Dinh Carol lea D..parurn JIE aC Ern iloiultrlu aid Narilrai Rewirrccs - Di, ss row eI Waicr Ravin Rt, iscd August 2013

WELL CONSTRUCTION RECORD
This Formic -on be u50d Cm single or rnullink wells
1. Wdt Cantrnctor Infurmatlon:
For h•icnnal 4rso
Robert Miller
well CorinnioT N 1ii
2675
NC Well Conlr,,IciorCulNumber
SAEDACCO Inc
Nomc
2. Well (omitrvetion Permit fit;
Lit all oppi itle. ptTsreies(1_ County. ark Yariureer, Jr/OrdenN,'.+
3. Weil Use (check well u NO:
Water Supply Well:
I] Agricultural
❑ Geollleimal 1-learingiCooling Supply)
I7 lnd u s lri a ((Co nunerc i a l
❑ ImPation
DMunicipaVFtrblic
OResidcntial Wailer Supph• (single)
0Resideneia[ Waler Supph (shared
Nom-Water Supply Well:
❑ Tylcnilnrin4
iLl�rclllrrl e4'LI:
CJAgirifcr Rcchargc
DAS11IifCr StOragc and RCCOloM '
❑ A{lpirer T
❑ Experimgrinll TgChFL Low'
❑ C,eodlernml I.CIrrsed Loup)
❑ GMlienual il{c4lmg.Cuoline Retuni
❑ Rcco3
❑GrOUrldwatcr RCInCCtiati0n
❑ Salinifl Barrio.
❑ SEorrn3 zncr Dina
❑ 5dl5iiiCKC CIniml
❑ Trdl;rr
®Oilier ieciplain under #21 Remarks)
1a_ VeAf]it 2JOTNIS
PRO,1
TO
IES.I'H[P 1 I'.}'
f$.
rt,
It.
MI. OUTER CASING Our ouYll rasnl nclis} OR L KER {if apNc hk�
FROM
0 rL.
TO
15 IL
PL#VFTFR
4"
Tnr€'rnNFSS1
MATESCH-40 PVC
RTAI•
lb. INNER LASING OR 1111ING ijl ulheraq..indoor.(!.
PROM TO Dtiti1ETEIt THICKNESS
an: :1
17. SCi 11N
MATERIAL
FROM
TO
IsrAIPTFR
SLOT SI?4
THICKNASS
MATRRI AI.
15 R.
25 f1,
4"
iu.
.020
SCH-40
PVC
1e,
ft.
ia.
` 1P. CLOUT
FROM TO
MATERIAL
EhTF1dCEMLti7 3IETHOD AMOL:Nr
3 D-
11 It
Portland
pour
r
ft
rt.
24.5AN rxtGRAN''EL PACK {if g7pdc#llo
. FR011
1 r1
'MATERIAL
E:'r1Y1..1.(}'. II: tit' S1}'Tl1Enl
14 O.
25
rt,
Silica Sand
6/20
ft.
fr.
3II, DRILLICWIG LOG (attach additional Ihselw if ncccaaJan)
FRO1l
0 It..
T[7
25 IL
111F.y{REFTlips. 7rdn'dc',
Tan Silt
.114te Welts) Conipleicd: 9-28-2021 Well 1Dee SVE-8
❑ a_ k}cL1 l llratilln:
7-Eleven #36069
Facililr'Yn.. cr NarPC
2375 Lewisville Clemmons Rd.,
Forsyth
I-aciliry IDC tic 'plic.iblel
Clemmons, NC, 27012
It.
1L
fr.
rt
IL
IL
fr
rt.
lZ,
rt.
rt,
Physical Address_ Cit}._ and Zip 2i_ kLMARGii
[Cams FBr t] Idcnilrltynion No fRlN)
5b.1-altitude A1u1 1.nngit ere in elegreCrlmintitet,fsecnnlls nr decimal degrees:
{Ifi0I Held. rnu LW9uitg is aidli'.kvll
Tti W
6.Is bunt the welUJrk OPennaneni er OTempuror}'
7.1s this a repairta an existi.ragwell: 'Yoe or ®Nu
f/rhfs Jx rr fr1*ur, fill 4y1r trel,nw i.oficaeApirelplriou eirlorr arr.t.JI gold r.lvfarJi rftt ruerrrre of Olt
rr+.airranger . 2f remarl•.,.reciiarx or on the bark of UdsPrwi.
S. Number wells roneriru ced: 1
for mJ,trrple JrFfei'Ik I or r.ion-warer supply overly ONLY nOli rfir same aonsenu(Ioe. xa, coo
mitwiirmir toms.
9. Toth wdl depth beIo'i iAMA sinful= 25 (fi.)
F rmxfri.Jt wrtk trsrrrUdi'Pr*s ifdrgfrv+lrleYa,Jpfr- 3@200 thud 2@I
1 U. Static water level below tap of cariup N/A
1f w41ree Irt rt ,s .i Jioue inare4t mu' "+
I I. Boii bleIC diameter: 10. 625" P.B.)
12, Wc11 tonglenction method; 6.625" HSA
li.e. ali r. rerar}', nibI _ dirai push.crc.I
FOR WATER SUPPLY WELLS ONLY:
13a, Yid(' ($ipol) Method of toot:
1JI7. bisinfoctiun ripe: Amount:
n.
3' foot bentonite seal from 11'to 14'
22. ('ertifiradsln:
Signibm
9/28/2021
Date
$F Signing drip. F Iremby tYrfifL' Ara Au. wettiro I yty {we, J c,nh rhrelea�r YiR avre okra e
wJrlr f S.L NC'4C 02C ,OWEk7 or t 54 NCAC CUC ,dam Wetl Cams!'rarn nrt Sea Whammy and rker
r+Ty of rhis rem nf has brew Iwm'irdrrf ra Jam' ,Ir1f awjt,'r,
23. She diagram or 1rdell1limal well details:
You may Ilse the back of ibis page to provide additional %%ell sire details or well
cc+nslrue[iori details. You inav arse attach:Ldditiol}at pages if lrecessarx .
SUBMITTAL [NSTOCTIONS
2da Poi- All Wells: Sublliii Iles faros within XCI days of complerioo of well
Contlmttipn to tllc fnlLnuing-
birilriun of Water Retuurces, Information Processing Gail,
1617 Mail Scr iee Center, Raleigh, NC 17699-1617
tab. For Inieerios Welly ONLY: In addiiiaii [o sending the form to :lie address in
2-1a above. also submit a imp, of this form within ?0 days of canlple[iou of well
conSIruLLiuh [o [he following:
Dkision of Water Refeou rt. . lFrldcrp ound Injection Control Program,
1636 T4iJrlL Senilx Cuniur. Raleigh, NC 27699-1636
25e, fit W4tc+r . ai, pI 1 1 vtiuu V4'CLI�r
Also submit one cop' of this form 11 ithin 30 days of completion of
well commotion to ttic C0.11ni; hcaltb depotmpnt of the county' where
COn5j1UCf9d
ATM OW-L
Krbruh Carol Ira L7.parurn JIE aC Ern mum' and Narilra] Rcsr'luccs - Di, ss sou eI Waicr Ravin Rt, iscd August 21113

WELL CONSTRUCTION RECORD
This Formic -on be u50d Cm single or rnullink wells
1. Wdt Cantrnctor Infurmatlon:
For h•icnnal 4rso
Robert Miller
well CorinnioT N 1ii
2675
NC Well Conlr,,IciorCulNumber
SAEDACCO Inc
Nomc
2. Well (omitrvetion Permit fit;
Lit all oppi itle. ptTsreies(1_ County. ark Yariureer, Jr/OrdenN,'.+
3. Weil Use (check well u NO:
Water Supply Well:
I] Agricultural
❑ Geollleimal 1-learingiCooling Supply)
I7 lnd u s lri a ((Co nunerc i a l
❑ ImPation
DMunicipaVFtrblic
OResidcntial Wailer Supph• (single)
0Resideneia[ Waler Supph (shared
Nom-Water Supply Well:
❑ Tylcnilnrin4
iLl�rclllrrl e4'LI:
CJAgirifcr Rcchargc
DAS11IifCr StOragc and RCCOloM '
❑ A{lpirer T
❑ Experimgrinll TgChFL Low'
❑ C,eodlernml I.CIrrsed Loup)
❑ GMlienual il{c4lmg.Cuoline Retuni
❑ Rcco3
❑GrOUrldwatcr RCInCCtiati0n
❑ Salinifl Barrio.
❑ SEorrn3 zncr Dina
❑ 5dl5iiiCKC CIniml
❑ Trdl;rr
®Oilier ieciplain under #21 Remarks)
1a_ VeAf]it 2JOTNIS
PRO,1
TO
IES.I'H[P 1 I'.}'
f$.
rt,
It.
MI. OUTER CASING Our ouYll rasnl nclis} OR L KER {if apNc hk�
FROM
0 rL.
TO
15 IL
PL#VFTFR
4"
Tnr€'rnNFSS1
MATESCH-40 PVC
RTAI•
lb. INNER LASING OR 1111ING ijl ulheraq..indoor.(!.
PROM TO Dtiti1ETEIt THICKNESS
an: :1
17. SCi 11N
MATERIAL
FROM
TO
RFA1,fRTF,R
SLOT SI?4
THICKNASS
MATRRI AI.
15 R.
25 f1,
4"
iu.
.020
SCH-40
PVC
1e,
ft.
ia.
` 1P. CLOUT
FROM TO
MATERIAL
EhTF1dCEMLti7 3IETHOD AMOL:Nr
3 D-
11 It
Portland
pour
r
ft
rt.
24.5AN rxtGRAN''EL PACK {if g7pdc#llo
. FR011
1 r1
'MATERIAL
E:'r1Y1..1.(}'. II: tit' S1}'Tl1Enl
14 O.
25
rt,
Silica Sand
6/20
ft.
fr.
3II, DRILLICWIG LOG (attach additional Ihselw if ncccaaJan)
FRO1l
0 It..
T[7
25 IL
111F.y{REFTlips. 7rdn'dc',
Tan Silt
.114te Welts) Conipleicd: 9-28-2021 Well 1Dee SVE-9
❑ a_ k}cL1 l llratilln:
7-Eleven #36069
Facililr'Yn.. cr NarPC
2375 Lewisville Clemmons Rd.,
Forsyth
I-aciliry IDC tic 'plic.iblel
Clemmons, NC, 27012
It.
1L
fr.
rt
IL
IL
fr
rt.
lZ,
rt.
rt,
Physical Address_ Cit}._ and Zip 2i_ kLMARGii
[Cams FBr t] Idcnilrltynion No fRlN)
5b.1-altitude A1u1 1.nngit ere in elegreCrlmintitet,fsecnnlls nr decimal degrees:
{Ifi0I Held. rnu LW9uitg is aidli'.kvll
Tti W
6.Is bunt the welUJrk OPennaneni er OTempuror}'
7.1s this a repairta an existi.ragwell: 'Yoe or ®Nu
f/rhfs Jx rr fr1*ur, fill 4y1r trel,nw i.oficaeApirelplriou eirlorr arr.t.JI gold r.lvfarJi rftt ruerrrre of Olt
rr+.airranger . 2f remarl•.,.reciiarx or on the bark of UdsPrwi.
S. Number wells roneriru ced: 1
for mJ,trrple JrFfei'Ik I or r.ion-warer supply overly ONLY nOli rfir same aonsenu(Ioe. xa, coo
mitwiirmir toms.
9. Toth wdl depth beIo'i iAMA sinful= 25 (fi.)
F rmxfri.Jt wrtk trsrrrUdi'Pr*s ifdrgfrv+lrleYa,Jpfr- 3@200 thud 2@I
1 U. Static water level below tap of cariup N/A
1f w41ree Irt rt ,s .i Jioue inare4t mu' "+
I I. Boii bleIC diameter: 10. 625" P.B.)
12, Wc11 tonglenction method; 6.625" HSA
li.e. ali r. rerar}', nibI _ dirai push.crc.I
FOR WATER SUPPLY WELLS ONLY:
13a, Yid(' ($ipol) Method of toot:
1JI7. bisinfoctiun ripe: Amount:
n.
3' foot bentonite seal from 11'to 14'
22. ('ertifiradsln:
Signibm
9/28/2021
Date
$F Signing drip. F Iremby tYrfifL' Ara Au. wettiro I yty {we, J c,nh rhrelea�r YiR avre okra e
wJrlr f S.L NC'4C 02C ,OWEk7 or t 54 NCAC CUC ,dam Wetl Cams!'rarn nrt Sea Whammy and rker
r+Ty of rhis rem nf has brew Iwm'irdrrf ra Jam' ,Ir1f awjt,'r,
23. She diagram or 1rdell1limal well details:
You may Ilse the back of ibis page to provide additional %%ell sire details or well
cc+nslrue[iori details. You inav arse attach:Ldditiol}at pages if lrecessarx .
SUBMITTAL [NSTOCTIONS
2da Poi- All Wells: Sublliii Iles faros within XCI days of complerioo of well
Contlmttipn to tllc fnlLnuing-
birilriun of Water Retuurces, Information Processing Gail,
1617 Mail Scr iee Center, Raleigh, NC 17699-1617
tab. For Inieerios Welly ONLY: In addiiiaii [o sending the form to :lie address in
2-1a above. also submit a imp, of this form within ?0 days of canlple[iou of well
conSIruLLiuh [o [he following:
Dkision of Water Refeou rt. . lFrldcrp ound Injection Control Program,
1636 T4iJrlL Senilx Cuniur. Raleigh, NC 27699-1636
25e, fit W4tc+r . ai, pI 1 1 vtiuu V4'CLI�r
Also submit one cop' of this form 11 ithin 30 days of completion of
well commotion to ttic C0.11ni; hcaltb depotmpnt of the county' where
COn5j1UCf9d
ATM OW-L
Krbruh Carol Ira L7.parurn JIE aC Ern mum' and Narilra] Rcsr'luccs - Di, ss sou eI Waicr Ravin Rt, iscd August 21113

Print Form
4. Date Well(s) Completed:
WELL CONSTRUCTION RECORD (GW-1)
1. Well Contractor Information:
Mike Tynan
Well Contractor Name
2725-A
NC Well Contractor Certification Number
IET
Company Name
2. Well Construction Permit #:
W I0400580
List all applicable well construction permits (i.e. UIC, County, State, Variance, etc.)
3. Well Use (check well use):
Water Supply Well:
Agricultural EllMunicipal/Public
Geothermal (Heating/Cooling Supply) DResidential Water Supply (single)
Industrial/Commercial DResidential Water Supply (shared)
Irrigation
Non -Water Supply Well:
Monitoring
0Recovery
Injection Well:
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
Experimental Technology
Geothermal (Closed Loop)
Geothermal (Heating/Cooling Return)
11/5/21
XQIGroundwater Remediation
QI Salinity Barrier
QI Stormwater Drainage
JSubsidence Control
QlTracer
❑I Other (explain under #21 Remarks)
Well ID# SVE-10
5a. Well Location:
7-Eleven #36069
Facility/Owner Name Facility ID# (if applicable)
2375 Lewisville Clemmons Rd, Clemmons 27012
Physical Address, City, and Zip
Forsyth
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(dwell field, one lat/long is sufficient)
36 02 14.32 N 80 23 06.98
NN
6. Is(are) the well(s)�Ix Permanent or QQTemporary
7. Is this a repair to an existing well: QYes or Cho
If this is a repair, fill out known well construction information and explain the nature of the
repair under #21 remarks section or on the back of this form.
8. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction, only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled:
9. Total well depth below land surface: 35
For multiple wells list all depths if different (example- 3@200' and 2@100)
10. Static water level below top of casing:
Ifwater level is above casing, use "+"
11. Borehole diameter: 1 0.5 (in.)
12. Well construction method: auger (angled)
(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:
For Internal Use Only:
14. WATER ZONES
FROM
TO
DESCRIPTION
ft.
ft.
ft.
ft.
15. OUTER CASING (for multi -cased wells) OR LINER (if ap licable)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft.
ft.
in.
16. INNER CASING OR TUBING (geothermal closed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
0 ft.
15 ft.
4 in'
Sch40
PVC
ft.
ft.
in.
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
15 ft.
35 ft.
4 in.
0.020
Sch40
PVC
ft.
ft.
in.
18. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
0 ft.
3 ft.
sand
pour
3 ft.
11 ft.
neat cement
pumped through tremie pipe
11 ft.
13 ft.
bentonite
tremie pipe
19. SAND/GRAVEL PACK (if applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
13 ft.
35 ft.
#2 silica sand
tremie pipe
ft.
ft.
20. DRILLING LOG (attach additional sheets if necessary)
FROM
TO
DESCRIPTION (color, hardness, soil/rock type, grain size, etc.)
ft.
ft.
See consultant's log
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
21. REMARKS
Well drillcd 45 dcgrccs from
at perpcndicular
22. Certification:
Signature of Cert,i ed Well Contractor
11/26/21
Date
By signing this form, I hereby certify that the well(s) was (were) constructed in accordance
with 15A NCAC 02C .0100 or 15A NCAC 02C .0200 Well Construction Standards and that a
copy of this record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTRUCTIONS
24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Injection Wells: hi addition to sending the form to the address in 24a
above, also submit one copy of this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supply & Iniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
completion of well construction to the county health department of the county
where constructed.
Form GW-1
North Carolina Department of Environmental Quality - Division of Water Resources Revised 2-22-2016

WELL CONSTRUCTION RECORD
This Euroean be usod 8i single or mulliir]c wells
1. Well Contractor Informallon:
For Foicraal 4rsc ONLY:
Robert Miller
well CorinnioT N 1ii
2675
NC Well Conlr,,IciorCcrl&testionNumber
SAEDACCO Inc
{':iii un Name
2. Well (onstmetion Permit tk.
List 1rnopp i ithIc w Iptnreits (1_ County. ark, Yariureer, !,'at'frciErelart
Wd1 Use (cheer: well u NO;
Waxer Supply Well:
I] Agricultural
❑ Georheimal 1-learingiCooling Supply)
I7 lad u s lri a ((Co nunerc i a l
❑ ImPation
DMimicip8VFublic
OResidcniial Wailer Supph• (single)
0ResidenEia[ Waler Supply [shri Tel
Nort-Water Sum* Well:
❑ ldnnilnrin4
iEij 9 illrll Wi..LI:
CJAgirifcr Rcchairp
pAquiffr Storage and RC erviel)'
❑ A{lpirer T
❑ Experimcnta1 TcchFL LQg
❑ Geodrernw[ (Closed Lour')
❑ C�totliemral il{c4tmg'Cuoline Retuni
❑ Rcc n
❑Grourlda'alcr Rchictiialient
❑ $alinifl Harrier
❑ 5torrnywarCr Dinao"C
❑ StilSiiiCKC Cnnlml
❑ Trdl;rr
®Other iectplain under #21 Remarks)
1a_trL'Afft 2JON1tS
rRO ,I
TO
REM 'REF' 1 I{}'
f$.
rt ,
It.
Mi. OUTER CASING Elor mini -cased ncRs} OR L KERfiF aai Nc hki
FROM
0 fL.
TO
15 IL
PL#VFTFR
4"
1
a
Tnr€'rnNFSS MATESCH-40 PVC
RTAI•
IL INNER LASING OR TUBING {jln r�ral..indoor.(!.
PROM TO DEiti1ETEIt THICKNESS
ft, ft,
rI, : g .
MATERIAL
17. SCiLTIN
FROM
15 ri-
Tr}
25 8.
prAMIRTFR
4"
iu.
SLOT SIiMR
.020
Tni[TOViS I MATRR1A 1.
SCH-40 Pvc
1e,
ft.
` 1P. GROUT
FROM TO
MATERIAL
EfETPLtCEMLti7 3IETHOD ASIOL.Nr
3 ft.
11 It
Portland
pour
r
ft
r4
24. SAN rCRA%''EL PACK or topde.4110
. vIto1I
1 (.1
17 ATPRIAb
E:'rlp7..5{'}'.\II: tit' S1}'TIIEnI
14 O.
25
Silica Sand
6/20
ft.
h,
3II DRILLICWIG LOG (attach Iddilianel 3t1se11 if memory)
FROM
0 ft
T[1
25 IL
11.Pi{ REPT ION 7rdn
Tan Silt
.114te Welts) Conipleicd: 9-28-2021 Well 1Dt+SVE-11
❑ a_ k}cLI lAlratllin:
7-Eleven #36069
Fycililr' Yl',. cr Nome
2375 Lewisville Clemmons Rd.,
Forsyth
I-acilrry IDC tic 'plicnblei
Clemmons, NC, 27012
It.
Ito
fr.
rt.
IL
IL
fr
re.
rt.
rt,
Physical Milieu_ Cio}._ and Zip 21_ kLMARGii
°Many FBr c] Idesinfltylilan No fP N:F
5b.1.a11ihudc 4ur1 1.nngitude in tlegrecrlmirltsteslxecnntls nr decimal degrees:
(If i 11 field. Int LW9uitg is milli'.
Tti W
6.la bunt) the welUJrk OPennaneni er OTempurilry
7.1s this a repairtR an existing well: 'Yoe or ®NIP
f/rhfs Jx rr frl*ur, ill MU erri,nw I. ri! { n+urran rr rr+ eirlo lairr.r.+1 and r.lvfarJi r8t rIr rllre of Olt
rr+Lair rimier A7' remark.; .51.21i.914 or on the hark of Udy 8. rwi.
Number wells ronsir cad: 1
For muikrple'of ei'Ik I or rood -wirer supply wefla ONLY n811 rfir scot ro1l.t04 e(Ioe. xa, coo
a*Lpwiirmir torn.
9. Toth wdl depth beIo'i ias13 surfut 25 (ft.)
FormxfrW!' wrfk trsrrrUdi'Prhr if Effferekhrle a,Jpfr- 3@200 thud 2@I
1 U. Static water level below top of cariup N/A
ff Kara lrt rl ,s .i Jioue cade.1g_ au' "+
I I. BoribeIe diameter: 10. 625"
12, rrlitonglewctiI:I method: 6.625" HSA
ti.e. aii{cr. rarer}', cable_ dilai push-m.1-
FOR WATER SUPPLY WELLS ONLY:
134 Yid(' (gm) Method of test:
1313. Disinroctiun ripe: Amount:
n.
3' foot bentonite seal from 11'to 14'
22. ('ertifi china:
Signirbnc
9/28/2021
Date
$T Signing this Parr, I .fremby eerfifL' Aar rhr wrlly+ x ty {were] curiae -mire! _�YiR avre arnica
wJrlr f SA ArCAC 02C .01190 or f 54 NCAC { C .dam Weti Cams!'rarnnrr Standafdb 1rr1d rkarQ
r,TJy of rhir rr ord h41s brew provided ra J ,Irlf awjt,'r,
23. Site diagram or adeliiianal well details:
You may 11se the back of ibis page to provide additional ueil sire details or well
cc+nstrue[ioii details. You ensv alai attach:Ldditiollat pages if lrecessarx .
SU BM LTTAL [NSTL CTIONS
2da Ear All Wells: Subenii Iles faros within 1.11 dens of complerioo of well
Con5lnitti0R to floc fnlLoning-
birilriun aFV4'ater Rezources, Information Frucersiog (roil,
1617 Mail Service Center, Raleigh, NC 17699-1617
tab. For Inieerios Welly ONLY: In a,ddiiiaii [o sending the form to :lie address in
2-1a above. also submit a imp, of this form within 30 days of canlple[ion of well
conSlruLLilni [o [he following:
Dkision of Waler Refeourt. . lFrldcrpvund Injection Control Program,
1636 'Mall Service CI'niur. Raleigh, NC 27699-1636
25e, fit W4tc+' SRyp r_rjEcti.ou V4'CLI�r
Also submit one cop' of this foal l 5l ithin 30 days of completion of
rTeII cnoslnrctian to the c1711nrY bC4Ith drpantnrplrt of the county. where
constnecled
FariLi Gw-L
Krinh Carolina D.parinicaE 0CErniloiu11r1u and Narilra] Rewiarccs - DO, ssroueI water Ravin Rt, iscd August2u13

WELL CONSTRUCTION RECORD
This Form can be u50d Cm single or mull ink wells
1. Wdl Contractor Informallon:
For fnicraal Use
Robert Miller
well C1,rIr,I. T N 1ii
2675
NC Well Conlr,,IciorCcrl&testionNumber
SAEDACCO Inc
{'cuillirun Name
2. Well (onstroetion Permit it:
Lit all opp i itle. ptTsreies(1_ County. ark , Variance, Jr/Bairn
Wd1 Use (check well use ;
Water Supply Well:
I] Agricultural
❑ Geoflieimal 1-learingiCooling Supply)
I7 lnd u s f ri a ((Co nunerc i a l
ID Irrigation
DMilnicipaVFtiblic
OResidcniial Wafer Supph• (si Ingle)
0Residential Wafer Supply (shared
Nom-Water Supply Well:
❑ ldeinilnrin4
iLlirclllrrl Well;
DAgrlifcr Recharge
AAquifer Sforagc and Recery 1)'
El Aquifer T
❑ Experimernia1 TechFL LQg
❑ C,eodiernml (CIrrsed Loup)
❑ C�rorluemral iHe4lnrg''Cbollne Retun1}
❑ Rcc n
❑Grourrdwatcr RC1r14'eliatigal
❑ Salintr Harrier
❑ 5forrnwarer Drains
❑ StilsiiCn c 'oilml
❑ Trdl;rr
®Oilier iectplain udder #21 Remarks)
1a_R'Af]it 2.ONIS
PRO,1
To
IES.I'H[P 1 I'.}'
f$.
rt ,
ftr
kg. OUTER CASING Our and -eased ncN l OR L KER {if air Nc hki
FROM
0 rt.
TO
5 rL
PL#VFTFR
4"
1
a
Tnr€'rnNFSS 1ihTF
SCH-40 PVC
RTAI•
lb. INNER LASING OR TUBING {jlnnikriral clu dawn(!.
FROM TO DEiti1ETE.H THICKNESS
ft, il1.
rI. : g .
MATERIAL
17. SCiti1N
FROM
TO
RFA1,fRTF,R
SLOT SI?4
THrCKNT15S
MATRRI AI.
5
25 H,
4"
IR
.020
SCH-40
PVC
1e,
ft.
ia.
` 18, CROffT
FROM TO
MATERIAL
ECi4PLtCEMLti7 3IETHOD hMOL:Nr
2 fr.
3 rL
Portland
pour
ri.
rp
ft
ff.
24. SAN rtGRL4%''EL PACK or glpelc#llj
. FR011
1 r1
'MATERIAL
E:'r1Y1..1.(}'. II:' 1' 1{}'Tllrin
4 ft.
25
is,
Silica Sand
6/20
ft.
ft,
3II DRILLING LOG (attach s e1w if ncct ur )
FROM
0 It..
T[1
25 rL
111F.y{REFTli pt. 71an'&h..c4['.I
Tan Silt
.114te Welts) Completed; 9-27-2021 Well 1Df+SVE-12
❑ a_ k}{.1L1 lluratiun:
7-Eleven #36069
Fycililr' Yl',. cr NOM
2375 Lewisville Clemmons Rd.,
Forsyth
Facility IDC tit 'plicahlei
Clemmons, NC, 27012
Physical Address_ Cit}._ and Zip
°Many PaReI IdesalfreiElilan No fFPI}
5b.1.alitude y11u1 1.nngitPlle in degrecsimirrlriestsecnntls nr decimal degrees:
{If i 11 %raid. rat LW9uitg is milli'.
Tti W
6.1s lam) the wdil : OI enna neni e r OTemporor}'
7. is this a repair to an existi.rag: well: Ycx 11r IN Nu
f/rhfs Jx rr fr1*ur, fill 4y1r trtI.nw I.'ri7 c tleA 'ran tart+ eirlorr arr.t.JI awl r.lvfarJi r8t ruereire of Olt
rr+Lairranger . 2f re arl'.y.Yee'Jiaa or on the hark of tldr 8.rwl.
S. Number wells touerirueced: 1
for wtJ,trrple JrFfei'Ik I or r.ion-wirer supply kern' ONLY with rfir same aonse ee ion. xa, coo
.t*iiirmir foray.
9. Toth wdl depth helm; laud surfam 25
ForMOW!' wrtit HsirrUdi'Prhs ifdrgfrvnrleYmtpfr- 3@200 thud 2@18ifx'}
1 U. Static water level below top of cariup N/A
If wriree Irt rt es .i Jioue inare4t au' "+ "
I I. BoribeIe diamr:tcr: 10. 625"
12, Y011 tanglr'netiorr method; 6.625" HSA
ti.e. aii{cr. roar}', cnLele_ dirai pusFirmi.
FOR WATER SUPPLY WELLS ONLY:
13a, Yid(' (gm) Method of test:
1311. Disinfect -Lim ripe: Amount:
It.
1L
ft.
rt
R.
rL
rt.
fe.
R.
rt.
rt.
rt.
it. REMARKS
One foot bentonite seal from 3'to 4'
22, Cer bash in:
Siguraiw
9/28/2021
Dare
$F Signing rtru tarn, F freprilpy rerfifL' Aar Au- n?! l Y+ I yty {we, J c m nrel-Ed iR a.ore akrac e
wJrlr f SA ArC4C 02C .01190 or t 54 NCAC 02C .0200 We•fl Cams!'rarnnrt Standards and rtxu
r,TJy of rflis reconf has brew pmvirdral r. ,the ,Ir1f awjt,'r,
23. Site diagram or additional well details:
You may 11se the back of this page to provide additional %%ell sire details or well
cc+nslrue[iori details. You inav alai attach:idditioi}at pages if liecessarx .
SU BM LTTAL [NSTL CTIONS
2da Fur All Wells: Subinii ties faros within 1.11. days of conlplelioo of well
Con5lmLtipn to flue fRlLOuing-
birixiun of WAter Rezuurcrs, Imformatiuu Frocersiog (snit,
1617 Mail Seririeo Center, Raleigh, NC 17699-1617
tab. For Inieerios Welly ONLY: In addition [o sending the form to :lie address in
2-1a above. also submit a imp, of this form within 30 days of completion of well
carialfiLLiuri [o [he following:
Dkision of Waler Resources. Urtdcrpvuod lojeciio1 Control Program,
1636 Mail Senilx Center. Raleigh, NC 27699-1636
2S fit W4tc+r s_lkylajL r_rjEcti.ou V4' Ll�r
Also submit one cop' of this form ,ti ithin 30 days of completion of
'Tell cnoslnictiaa to tllc ¢rnmr3 hc4ltb depariuic rt of the county where
conaruCfad
Farin OW-L
I\nnh Carol lea L7..parurn JIE or Ern iloiuenj and Narilral Rewire -es - Di, ss row eI Waier Ravin Rt, iscd August 21113

Print Form
4. Date Well(s) Completed:
WELL CONSTRUCTION RECORD (GW-1)
1. Well Contractor Information:
Mike Tynan
Well Contractor Name
2725-A
NC Well Contractor Certification Number
IET
Company Name
2. Well Construction Permit #:
W I0400580
List all applicable well construction permits (i.e. UIC, County, State, Variance, etc.)
3. Well Use (check well use):
Water Supply Well:
Agricultural EllMunicipal/Public
Geothermal (Heating/Cooling Supply) DResidential Water Supply (single)
Industrial/Commercial DResidential Water Supply (shared)
Irrigation
Non -Water Supply Well:
Monitoring
0Recovery
Injection Well:
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
Experimental Technology
Geothermal (Closed Loop)
Geothermal (Heating/Cooling Return)
11/5/21
XQIGroundwater Remediation
QI Salinity Barrier
QI Stormwater Drainage
JSubsidence Control
QlTracer
❑I Other (explain under #21 Remarks)
Well ID# SVE-13
5a. Well Location:
7-Eleven #36069
Facility/Owner Name Facility ID# (if applicable)
2375 Lewisville Clemmons Rd, Clemmons 27012
Physical Address, City, and Zip
Forsyth
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(dwell field, one lat/long is sufficient)
36 02 14.32 N 80 23 06.98
NNE
6. Is(are) the well(s)�Ix Permanent or QQTemporary
7. Is this a repair to an existing well: QYes or Cho
If this is a repair, fill out known well construction information and explain the nature of the
repair under #21 remarks section or on the back of this form.
8. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction, only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled:
9. Total well depth below land surface: 35
For multiple wells list all depths if different (example- 3@200' and 2@100)
10. Static water level below top of casing:
Ifwater level is above casing, use "+"
11. Borehole diameter: 1 0.5 (in.)
12. Well construction method: auger (angled)
(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:
For Internal Use Only:
14. WATER ZONES
FROM
TO
DESCRIPTION
ft.
ft.
ft.
ft.
15. OUTER CASING (for multi -cased wells) OR LINER (if ap licable)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft.
ft.
in.
16. INNER CASING OR TUBING (geothermal closed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
0 ft.
15 ft.
4 in'
Sch40
PVC
ft.
ft.
in.
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
15 ft.
35 ft.
4 in.
0.020
Sch40
PVC
ft.
ft.
in.
18. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
0 ft.
3 ft.
sand
pour
3 ft.
11 ft.
neat cement
pumped through tremie pipe
11 ft.
13 ft.
bentonite
tremie pipe
19. SAND/GRAVEL PACK (if applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
13 ft.
35 ft.
#2 silica sand
tremie pipe
ft.
ft.
20. DRILLING LOG (attach additional sheets if necessary)
FROM
TO
DESCRIPTION (color, hardness, soil/rock type, grain size, etc.)
ft.
ft.
See consultant's log
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
21. REMARKS
Well drillcd 45 dcgrccs from
at perpcndicular
22. Certification:
Signature of Cert) d Well Contractor
11/26/21
Date
By signing this form, I hereby certify that the well(s) was (were) constructed in accordance
with 15A NCAC 02C .0100 or 15A NCAC 02C .0200 Well Construction Standards and that a
copy of this record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTRUCTIONS
24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Injection Wells: In addition to sending the form to the address in 24a
above, also submit one copy of this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supply & Iniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
completion of well construction to the county health department of the county
where constructed.
Form GW-1
North Carolina Department of Environmental Quality - Division of Water Resources Revised 2-22-2016

Print Form
4. Date Well(s) Completed:
WELL CONSTRUCTION RECORD (GW-1)
1. Well Contractor Information:
Mike Tynan
Well Contractor Name
2725-A
NC Well Contractor Certification Number
IET
Company Name
2. Well Construction Permit #:
W I0400580
List all applicable well construction permits (i.e. UIC, County, State, Variance, etc.)
3. Well Use (check well use):
Water Supply Well:
Agricultural EllMunicipal/Public
Geothermal (Heating/Cooling Supply) DResidential Water Supply (single)
Industrial/Commercial DResidential Water Supply (shared)
Irrigation
Non -Water Supply Well:
Monitoring
0Recovery
Injection Well:
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
Experimental Technology
Geothermal (Closed Loop)
Geothermal (Heating/Cooling Return)
11/5/21
XQIGroundwater Remediation
QI Salinity Barrier
QI Stormwater Drainage
JSubsidence Control
QlTracer
❑I Other (explain under #21 Remarks)
Well ID# SVE-14
5a. Well Location:
7-Eleven #36069
Facility/Owner Name Facility ID# (if applicable)
2375 Lewisville Clemmons Rd, Clemmons 27012
Physical Address, City, and Zip
Forsyth
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(dwell field, one lat/long is sufficient)
36 02 14.32 N 80 23 06.98
NNE
6. Is(are) the well(s)�Ix Permanent or QQTemporary
7. Is this a repair to an existing well: QYes or Cho
If this is a repair, fill out known well construction information and explain the nature of the
repair under #21 remarks section or on the back of this form.
8. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction, only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled:
9. Total well depth below land surface: 35
For multiple wells list all depths if different (example- 3@200' and 2@100)
10. Static water level below top of casing:
Ifwater level is above casing, use "+"
11. Borehole diameter: 1 0.5 (in.)
12. Well construction method: auger (angled)
(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:
For Internal Use Only:
14. WATER ZONES
FROM
TO
DESCRIPTION
ft.
ft.
ft.
ft.
15. OUTER CASING (for multi -cased wells) OR LINER (if ap licable)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft.
ft.
in.
16. INNER CASING OR TUBING (geothermal closed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
0 ft.
15 ft.
4 in'
Sch40
PVC
ft.
ft.
in.
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
15 ft.
35 ft.
4 in.
0.020
Sch40
PVC
ft.
ft.
in.
18. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
0 ft.
3 ft.
sand
pour
3 ft.
11 ft.
neat cement
pumped through tremie pipe
11 ft.
13 ft.
bentonite
tremie pipe
19. SAND/GRAVEL PACK (if applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
13 ft.
35 ft.
#2 silica sand
tremie pipe
ft.
ft.
20. DRILLING LOG (attach additional sheets if necessary)
FROM
TO
DESCRIPTION (color, hardness, soil/rock type, grain size, etc.)
ft.
ft.
See consultant's log
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
21. REMARKS
Well drillcd 45 dcgrccs from
at perpcndicular
22. Certification:
Signature of Ce
ed Well Contractor
11/26/21
Date
By signing this form, I hereby certify that the well(s) was (were) constructed in accordance
with 15A NCAC 02C .0100 or 15A NCAC 02C .0200 Well Construction Standards and that a
copy of this record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTRUCTIONS
24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Injection Wells: In addition to sending the form to the address in 24a
above, also submit one copy of this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supply & Iniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
completion of well construction to the county health department of the county
where constructed.
Form GW-1
North Carolina Department of Environmental Quality - Division of Water Resources Revised 2-22-2016