Well Construction Records Buncombe 1 CY2000

..�.... ..� ..... tl: .�, Ir r t 1•r q 1".
..'�rrngwR��M1jr;".r "�►'
229391
'orth Cnroiinm - trqurrtm.?w of rnvirommn,nt and Nnlurnl Ttesources • Dlvl!-,Ion of Water Ouellly • Oroundwntr.r Section
636 Mail Smvicp Cnnirr - I thlr,iph, N.C. 27699.1636•i'hone [phone]
WELL CONSTRUC-1 ION FIECOM wELL CONTrTncIOtl: wk� p-.. ��(c�,4�0L�p
WELL CONT"ACTOFI CEnu (CATION 0___;`�,r__
STAT E= WELL COt-ISTFIUCTION PNIM110: _
1. WELL I-MV (check of I•nc,lrh noxy nesidenthilMunicipal El Industrial Agricultural Monitoring El
FRocovrry [_,] 11• .1t i'unrp Water Injection Other [_ ] It Other, List Use:
2. WELL LOCA I IOf 1: row sketch or I to location below)
Nearest 1 own:.^— County
DRILLINGL�OG _ �EF'TH
(need nmmnanCorn pity, or ubdivislon and Lot fJo.) Formation Description
3. OWNER From To
Address 53� -
--�-� l4 a _ ram!X1�4jM
or Aei+ v`Q i
City or tmvn l .. Slate
Zip Code
4. DATE Of_10'.7'oa S. TOTAL DF_r I I I )j0
6. CUTTIi I(;S COLLFC 1 EI) YES L� NOL
7. DOES mi.6- i1Fr'L.AGE EXIS I1i4G WELL? YES Q NO0 -
8. STATIC WATER LEVEL 13PIOW top of Cnsing:
(Use'+' 9 Above Top of Cnsinp)
9. TOP Or CAS11`1131 IS_--.._.__� __ FT. Above Land Surface'
'Top of cesinn in ndnnind ni'r•r below land suture• require• a variance In eeeor• `
3ance with iSA f (CAC 2C .n i III
10. YIELD MET HOD OF TEST
11. WATER ZOPJES (dri'lh): i;�- ��
12 CHLOf111JA110FJ• type
I_] _1J�---- ArTlounl 3fi
13. CASING:
l)rlilll ninnieler
From.—Q---��
Flom-
14. GROU1:
Material
Molllod
il�lrlll
1? f�,LEci
Ftom __ .._.___
T . __---- r"1.
m SCREr.1:
Orlrlil Dirnnralor Slot Size
Mn of
Front - - i n In. ill._---
• In.
Fmrn __ _ I o _ ..- ..._-- rl. __
in. in.
16. SAND/Gf1AVFi_ F ACK: Malarial
UrI11t Size
From_ ----
From Ft.
lo_ ._._-
17. pEivlAf 11CS
1 DO 11!-111 ! i r CON�Tnt1O _C)Ir
� �! n�lr r=-'iilnT l"YUR W[ll� `�,;
CONS r ni i� y ' )t � ! nhlr)nnT)ri, MIDI I1n �,QNQhY Or T nE U
F011 OFf ICE`tly, Utl�"Y of TUIIEo t'
ound ito: l u�imll orlp *1 to Ulvhlon or Witte
31 ii�Tt '
Sedal No
It addillonsl PlInce is nendnd une back of fn=
_LOCATION SKFiC}I
Wall Tirlekness
or Wel hlrTt, MalPrinl (Show direction and distnnrn trot" at least tv+o Slate
:� '►,4tlR Roads, or other reap relerence points)
S (pa-1
nC
ncCOnr)ANCF Wit II ISA tlCAC 2C, vVpi_l.
nD Iln o EN pftyyillOEU Tp 111E writ. UWr1En.
�'
ontF
nsorr Cotlsmuctm . TIIF vV17LL
er,ouellly. Ctroundwaler Seellon wilhin 30 day9 UW 1 nFv. 12/99

229392
North Carefinn - Ctr•h.irlmmtnt of F"nvlr mmenl rind Naluml Fleaources . Division of Water Quality • Croundwnter Socti•:n
1636 Mail Snivico Contpr • FMir?lgh, II.C. 27699-1636-rhone [phone]
WELL CONSTRUCTION RECORD WELLCONTFACT011: _ (dam---• —
WELL CONTfiACTOFI CEFll'irmATI I N: ✓t��-- -
STATE WELL CONSTFIUCTION F'EFIMIT'N:
1.
WELL. IISI: (Check nno,r): nesidentlif[ Municipal [] (ndusirial0 Agricultural U Monitoring ❑
Fiecovrry j:_j I Inat f timp Water Injection ❑ Other
If Other, List Use:
2.
WELL LOCAI10Hec luny skrtch of ilia location below)
Got nly: -••
NenreslTo,;n:--_JhL"�
— -- -
(now i rinmo r,,, nrn!,ms. Cummnli . or Subdivision and Lot No.)
MILLING LOG DEP T1__._---_-_
rorTnattonOrccrlption
3.
p?i'�Q�>Q' __
OWNFF{mem
From To
Addre^ �7---- -
- �J� ---- ....... -....... __-__ --- ---
City or 1 Own Stile Zip Code
—
- ---- o
4.
5.
OATS Ur{II_LFU _/40'6-,0d_
TOTAt. UEF' 111 _.._ _
NOLe
—'-- -_--
6.
7.
CUTT It 1C1S C01.1.f:C 1 Er.) YES Q
DOES V'EI_l_ F1EF'I nCF 1 XIS11Nr; WELL? YES NO[t/
FT.
- — ---- Q
B.
STATIC: WATEFI LI:VEL Below Top of Casing: _---
_ -___-
(use '+' If Above Top of Casing)
IS FT. Above Land Surface'
_ b
9.
TOT' OF- CASING;
'Top of cash,n ter n,tnnind nt,c r hnlow Innd turtace requires a va rice In accor-
.— —��—� aTt
rn
dance with 15A NCAC 2C . 118
10. YIELD (gpnl): ..1� t%_ MEI I IUD OF TEST
''"— - V
11.
WATER ZONES (depth): _
12.
I d T I N: Type — Antounl
CtiU-)n t n O y!
s IF eddltlonnl space Is need?d usr� bark of lour
— -
13. CASING:
_ LOG'nl TUN SKETCH
W all l hickne ss
O UehtlL ,� 9a_ et or weI t Vr-t. leda m
(Show dirpctlon and di^,Inncn from at mast two Slate
From Io -/--- FI• (p „ •/8i Floods, or other 2p reference polnls)
From-------- •1 °------- FI•
From
14. GROU1:
Uel�tlt Material
�j / Method
From li% _ -10 M -- F1.
Frorn ......__ _ to
15. SCFIF:EIl:
Urpih Diimeler Slot Siz© Material
Frorn `- -- 10 ----- Ft - In. In. From ----- 10 ----- F1.- in. In. __--
From _ _.-__---_. l o _F1. _ In. In. _
16. SAND/GRAVEL PACK:
Depth Size Material
From
From _-_.__.._- 1 o 77t--------
17. nEMAIlKS; -
p tr)) 2C, WELL
OO 11MIT EY�AC$rJ1i19F Vii iAl 7.111 iWff�•l WAS COIiSTITUCTED IN ACCOnDANCE WITIl ISA 1JCAC
CONS1 f1lITI�N1 ^ inrar.inFiD3, nND T1f �O Y OF THIS FIECOfTD NAS BEE F' IOEO TO I IE V/ELT. OWHEO�
-
____
f,,md
11 (.►ff ILf� (►II Y� �(�(�I ig i DATE
No: I SIC)NATt� lE QF F EFISON CON, Tf1UCrR1ri TI IF Wf:LL
_ SO mit orfoinat to Division of Waler Quatlly, Groundwater Section wilhln 30 days OW-1 /tEV. 12/99
r�
dat No.--
C tit r

.._ �' r�1'• �,t ylr.•!M Ta+TRrA`rMWW7klt'i""r ',
I
2-9395-
North Carolina • Department of Environment end Natural Resources - Division of Water Quality • Groundwater Section
1636 Mail Service Center . Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELLCONTRACTOR: Bobby W- Potts
WELL CONTRACTOR CERTIFICATION Jf: 2028
STATE WELL CONSTRUCTION PERMITN:
1. WELL USE (check Applicable nox): Residential © Municipal ❑ Industrial ❑
Recovery f_1 I seat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: Fairview County: Rttnrc)mhp
(Road flarno and Nurnhers, Community, or Subdivision and Lot No.)
3. OWNER Christian Youth SeryiceR
Address P.Q�� (-9rQ$o TiouTo o.
Hollywood, _ FL _ 33084
City or town State Zip Code
4. DATED nlLLr-D
5. TOTAL DFPTH
6. CUTTINGS COLLECTED YES ❑ NO❑X
7. DOES WELL REPLACE EXISTING WELL? YES NO®
8, STATIC WATER LEVEL Below Top of Casing: 0 FT.
(Use '+' It Above Top of Casing)
9, TOP OF CASING IS 1 FT. Above Land Surface'
'Top of casing terminatnd atlor below land surface requires a variance In accor-
dance with 15A flCAC 2C.01 10
10. YIELD (gpm): 4 _. METHOD OF TEST Rig
11. WATER ZONES (depth): _
DRILLING LOG
From To
0-74
74=805
Agricultural ❑ Monitoring ❑
_ DEPTH
Formation Description
_ Dirt'
_Bedrock _
12. CHLORINATION: Type HTH Amounl 1 6 If additional space is needed use bacK or form
13. CASING:
Depth Diameter
From 0 To —74-- Ft. ti 2 5--
From To-- Ft.
From .— To _ Ft.
14. GROUT:
LOCAL ION SKETCH
Wall Thickness
or WelghVFt. Material (Show direction and distance from at least two State
1 ti 1 2 5��DR Roads, or other map reference points)
Depth
Material
Method
From 0
To 20 Ft.
cement—
,�„�_
From ___—
To Ft.
15. SCREEN:
Depth Diameter
Slot Size
Material
From
To Ft
It,,
In.
From
To Ft.
In.
In.
From --To
_ Ft.
in.
In.
16. SAND/GRAVEL PACK:
Depth
Size
Material
From
To Ft.
From
To Ft.
17. REMARKS:
I001IERE8 PERT FY 1: tAf rtir� C 4v�.
4 JE 19 V 000NSTRUC OJ�S �NI�R15yN[THT
FOR OFFICE. NLY !�II
Quad No: t
Submit'!
Serial No. A
s�i�h�yllle leslr<<r„ ' ...
Echo Lake
off Old Fort Road
Fairview, NC
ONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
3Y OF THIS RECORD HAS B EN PROVIDED TO THE WELL OWNER.
SIGNAT E OF PERSON CONSTRUCTING THE WELL DATE
ial to Division of Water Quality, Groundwater Section within 30 days OW-1 REV. 12/99

.. � .. .. y,.•..p .I ., I. ,7..*.e,f.f., s�w,MtreWiirNir.,^•1 ...Y •7�1 n �/ L.. V'V V
i
North Cnfolir,9 -I •I,1 of fnvlr-mment rind Nnturni Cie :ourcw • Uivininn of Water Quality • Groundwrrtrr Secti,yn (�
1636 R1ni1 fil••virn (;r.,,Irr II:,Inlpl,, I I.C. 27699.1638•F'hono [phone]
WELL ji(It;, j im RECUriD Wr:LL CON1nncTOnc [,�-�-•- L
WELL CONMACron cEnT[rICA11c [-
S1AiF WELL corislnucTlotd 1,Enmllo:
1, VIr t l! 1: i rr�r H r I•r•m �nln noK): rlesi<Iontlal l Muttirirnl o Induslrial �� Agricullurnl ( _� Monitnring [:-1
flecovnry ( ) i 1,+7t r,timp Water Injection [_J Other U II Other, List Use:
2. WELI. 1-9i"A110li• ("Iho ,v skylch of the location below)
Neare l f r+l. n _ County;
InOr lrl�in� nn;I Lr ,,al. Co nnno lluily, ubdivlslon and I_ol No UFiILLIiJ(3_.0 y
3. OWN( rl From to
Addre�s _97 _�Ip
,ily or l n Vila 9 Zip Code
d, DA1E U11I1-1 111-
5. TOTAI.UFr'lll _....� Q -_.__ _
6. CUT11r1rScc)t.T_rc;iF.n 1"FS[�� NO
7. DOES w1-11 IitTl AOF: FXVI TING WELL? YES N0LA -
B. SiAT1C, WAl Eil Lt VEL. nalow Top of Cflsing: M
(Use'+• 0 Above lop of Casing)
9, TOP 01- CAMI-Ki I`�____�_�_ FT. Above Land Surface'
'Top of case ,rr lot ml,,ntnd nver bntow IYrnd surface require, a variance In accor-
donee with 1r,,NtICAC 2C .n118
10. YIELD (oprn)- g . D-_ ME"11100 OF TEST
11. WATE11701JES (cl^plh): _._---
_..._.L1ET'fli - --
rormalron UBscrlption
-
00
12. CHU:)f1ItJA1IOtJ: iylle _,�---Atnounl additional spnco Is needed use bark of ffltnl -
13. CASIi1G: LOCATION SI<E1CH
Wall TI11cHnnss
Llr 111�/ me or or WelphVf 1, atedat
PYCAQ
rrorn-----....___ 'lo....----_— rt. '.___._.._•'_
rrorn ..............._.__.1 r, _.._�.., rt, _ --
14, GnOUI:
i,,•I,tl1 � Matorial Moll
r1on1 1 n //....1l�.
rrorn . .____.._. 1( ----
�,. Scril:17r 1:
[Annieler Slot Slz© Mnlorlal riom IA. _.. I►1. In.
16. SANU/CMAVE1. VAUK:
U�I,uI Slze
rrom _ _I q-
17. F{Eh1Ar11CS
w I Irrlrpy
COt1SIrllicli
on (.)I vicir. l
Ouad ito•
WDAnI)% AND ItIAT
IL'Y 12 '21"11
Malerial
(Show direction rind dhinnre from rit Innst two Stnte
noads, or other inap referonce points)
fi�w/` T&144-d-
,�cc�o iu
�,
7� C.
ISMUCTED IiI ACC0n1)AP4CE Will' 15A 1I(,,'I2 V`!E r-11 -
or lids nECOno HAS eEEN PnoVIbF
DAiE
VIA111 _ Qr f r_n! N CONS nUCtit '(1 11 t[ Vlr.r 1_
to bivlslon of Water Quality, aroundwaler Section Wlthtll 30 days CW 1 nEV. 17191
V:

i.' .. v rlr •, � ,�.. •^"ti *.�rnT+vW'�'�Mr`,�- :1t,,1.. „ � , ,
229399
1lorlh Camlm, . I1n1.�rnr+ rrt nl (-nvlr nnt4nl and rlalural 1le^ourcr9 • Divirlarl of Water Quality • Gioundvrnler SrclPm
1836 Mail fir r.ir� C'rntrr Il lrlgh, I LC. 7.7699 1638•F'I,ono [phone]
0
WELL CUIJS-I iiuci ioti nECORD wr-LL CONTRACTOR: —��-- ,,,�� pp
W WELL CONTnACTOR CE TiriCA1I( 1 0:, _ 42
SPATE WELL CONSMUCTI01,11 1'E111MITM:
CJ
1."DELI I l�r tcl,ccr, nt l,nr ,I+Ir nox): riesldenllel� Munlclpfll ❑ Induslrinl Agrlculhiral LMnnhoring —
llecomrry ( I Ir nt rural, Water Injection j_ ] Other F1 if Other, List Use:
2. WELL, 1.O('A110N: (`;how sk Ich of the location below)
(��r, County.
- - DFIII.LiNt3 LUG UErIi _-•—
^jn0n 1 mil— nr+d rl nn'+ers, Comnwn y or SubdivlSlon and Cot No.) rOrmaUon Ur.Srrlpt(on
1 From To
3. OWNt:(1
Address •� 45—�---- T-�-�
-' - jSliFr Ef i+u1"o10.
�111e Zip Code ----d
�Cily (If Inv. n A
4. DATE UIM-1.1'.f)__� "�� ----
5. TOTALUGrfll C-m
6. CUT] ING,^.. c;(�Lt-r(:1 Et) ��r_S [� NO � 1J0[v�
7. DUES Wt=1.t_ Ilr:rl n(;F EXIr TINC; WELL? YES rr
8. STA11G WA11-1j LEVEL. Mow Top 01 Cllsing: _ 3�0
(Use'+' 11 Above 1opal CASinp) ma
L, �•�__ --T. Above Land Surf ' nce
*Top of ce+4+g r�r minrino r!ror bnlow Imnd surface tequlres a variance In accor•
rn
dance with 15A 11CAC 2C.01 ill O
10. YIELU (uhnt): J 0_ ME-11 IOU OF TEST
11.WATEll ZONES (r:frpth):__. ______ ----- -----�---
Arnount 3�-�s It addillonal Space 19 needed use bark of loan
12, C{1L( MIATION: IY O �. _ ....... ...... .._... -
13. CASING: LOCAIIUN SKETCH_
WAIT ihlcl,nrss Show direction and dialnnr.-i from al IMaSI two Slnle
IAmeler or WAIphVI'1. Mntednl nn11�,
� - . J "�. rl• � •a� �'�� �,Y� � Roads, or other map (e(crence Points)
Flom _-....
From---
rron
. .............__.
14. GfiOU I : Mat°rlal Mold _ � � � ��' `-••�
t�� I+1It � _�LkIG�CS..�T-�.. -•f� L�'CZ ��rl�,�,(��.A
1rr 1.
15. SCTII (t t: Slot Slzo MnlarinI
I,,.l,lt, f IimnE+ler
In._ --
iron, I r, • ----
' F I of n .. _ I r• ... h l...._-._-_-------
front .
16. SANU16flnVrl. rnGl:: Maier{al
Ur1rn, Size
Front.-.....__.-�-- t"-----_.-_ (1....__----•--•---=-----'—'�----�
riot,, - -- 1 ° -- - -i.. T 1.----
17. nEhtn(11cS:__-_ _
9 [� �C1f15Tr1UCIE0 it ACConOANCE wlIII 1SA tl(;AC ?.C, wELI
i n�tn rtr nr r..rhtni�1lnl �Tlittl �w,s
Cptl!' I nt.rr.1 lctt I}I� j/1.1r1/�tl�r %1N0.I111111 A49_G F'Y Ur 11 ft3 nECO(i011A5 BEEN f'FtOVIOFU iCt 1(fE W( Ll UWfIFn.
_ _---- IT-6
_ _ DATE
ro11 l)F f IC:r ifS-1-1 l ['.Y t S!(3tJAl1 E Of f F fiSOtl COf .+1nUC11Nri llir. wr?I1.
Ouad I 1 Irtir•1le ptvlsl0n or Water Ounllty, Clrounttwaler SAclton Wltltitt 30 <la oW I nEv. 17119
Subrrtll o p ,

.. .... .: � •,•tt �♦ h:,., I. �...�.1„*.L. .t rwrH�N�'MMM'r ��1'1ir n � i _ ,.
209,400
North Csmrl,1 • I1,pn,tnr•„t of FnvIt-mmeni and Nslurat nenourcrs - t)ivision of Water Quality • Oroundwnter Sncti•m
1636 f.lnil Srrvirn Crntrr rlodnlph, 0.0. 27699.163641honn (919) 733.32210
WELL CO JS"I f RK. 11014 RECORD WELL CONT"ACTon: !LPL _ _ -i
WELL CONMACTon CmirT ICAlIt I N:_ �_ D43LAO—
SPATE WELL CONSTFIUCTIOFJ F'EnMITN:
1. "JELL IIrr: (chrcl rI,iir•:,hlm nnq nesldentialLYJ Municipal Industrial Agrlcultural L] Monitnring U
Flecovrry j ; I ionl rump Water Injecllon L] Other L] If Other, List Use:----
2. WELL 1.0CA1101I (` ,o�,w/yy skrrtch of the location below)
��reSl Inr•n:.. _.._.�/\.eSeS•RM+ 1 � l j � �L . .�. COUnty:
N.
Cnnnnunll d Lot N
, or Subdivision and DFIILL1140 LOG _.._ OEP TI I
_..
3. OWNI'rt I'` _ From To r'otmallonUcScrrplion
AddrF^s
' 1Surrl orPoV o o.
CRY It" t-nv;,, fir,le Zip Code
.30,pa
4. a.nlE t�lul.l r-r) _..
6. CUT 111RIV`;C01.Lrcm) )fSCI NOg --- -- A
7. DOES w[ 1.L nrrl �t;f- rxlrtlrt(I WELL? YES
6. STAII(; VJAI1.11 LI:VEL.1)elbVr Top of Casing, (1t b rT. _—__ -•-- ------ — -
(Use'•►' B Above lop of Caslnq)-
9, TOFF t_rl' (:n"RI(; I`,. _.. 1---•. __ F1.
holow lv,d surface re ulres tw Votiance in eccor• - Av
Top ofce,h,tlJ�,n,l�,nt�t r' h _ .------ "`
dance wlth lr-n 11CnC 9C.n110
10. YIELD (rt(,rn): _. ,,-_ ME•1I IOUor- 'TEST t1 - -- "�__ �.. cn=
.JJ
11. WAIF-MZ.OIJE`+(cl
12. (,t-IL0rMJAI10H
13. CASH IU:
_._..._ o
I YI'0 - 1 _—Amount -to -��s' II additional sparn la needr+d u.A bark of Inrrn z
Wall 1106 ,os3
�r
olgr,'l. Mmednl
eler or WUl
l,rlrtit 1I:Fm��1
From-•.—
From
Ft.-r. —
14. GIIOU1:
rrll
(,rl,lit � material Molho
q
"to
wort, _._._.._
In ._.----�;-F1.---------'
15. SCFII=r.r l:
I)rr,ih J)imneler Slot Sizo Material
F'ron,
to F 1.__. __ In. in—�_------
16. SAtJU/GfIAVF_IYACK:
Url tl, Size
rrom ri.
From
17. nEMAI1KS:
f r� �i�,; , ILL
Ib0111 lIF j1Y(tjtr'f�ilg9lls�l'IIIW W�
COt1.......RI ,r it "t NCIAnoi,'AP D I'-InT�Aii
Luad
('tJQ 2o•to L
Malerirtl
_ LOGA1 ION-_SKE 1.CF_1_
(Show direction and dhiitire from nt Innsl Iwo Slnle
noads, or other reap reference pnint!F)
cot•ISMUCTED Ill ACC0110ANCE Will ISA tJCAr,, 2c, WELL
OPY OF it IIS nECOnD NAS BEEN PnOVIDED TO I IE V`/r.LL owur.n.
SlorIATt1 DATE
E Of f Ei150N CONS r1UCTI1Fr1 11If: V�f:F t_
Ipinal to Division of Water Quallty, Groundwater Section Wlil►In 30 days GW t nCV. I2/99

......»....«..«......._ .t if .. �. .�.,.. _..: ., 4I��.�.
•'; .+ I•Vr]Il: '�. +... •..I.n .11 r: .I�H .ry.r.. 1 N1••'•. r'+• '. .,••r �..� 0 1 .. ' .. ,�;. .. .. ,...:` :•;,.� n • � ry''f. � ,11r.f •+'►'1 r 1. • rl'�r�' li�N.f ..�'. �.p� t. • .I r: .. 1
229406
orlh Crom1k,:, - I+,,I :,rtlru+nt vI Viw1f'+nnt-nt and IJntulnl 11r9moil rnq • blvl^Inn of WAlot (juetlly islot nflwtlif? r Sncli'xt
1636 Mnil S'+1vicr, (:rr,lrr Milf l(llt, I1.1:, 2I699.1638-Phalle [phone]
WELL C 01-IS )111.1C i I014 11ECOrID wELL CON 111nctOil:
WELL CUFJ11111C10t1 centirICATIM) R._
SIA11: WELL 11301'ISMUC1f(7N ('E11f,11"'
1. %VI'LL t 11:1: (clit, !•I r•Ilcmhl^ Ill, Y): 11naldeltlinlMuniclpnl (j (nduslrinl AgricuIII)MI �.__� FAonlloring ��
Flocovrrq [ j I i-,ni rump Wnlnr Injecllon [] Utlior [J II Olher, List Use:
2. WELL 1 O(:A I IOt I: ,I�tot%� ^�k�el�r+lt of the Iocnllort below)
Nentesl lr„:n:•-
(fl0ncl I I�n•n nn'1 I1tun''^rs. Con,r nudiyror bdivisron end Lol Ito.) UFiILLIfJ(1 UU--.-----
3. OWNEtI .� — From To rorrnAllonUcscrippon
Addres ,
CI11'rr lnv:r -- —`0— Zip Code
4. DATE rttul.l.r:r.) _9 •c . � D �_--
"a. TOTAL t?r:1,11I---
6. ICU
7. UUES %AJ( 1.1. 11[711.Acf: rxIS11140 WELL? YES NO
8. S11111(; WAT[:I1 [_rVEL Ctelo+v 1op of Cnslrtg: (1�,^ ---—
(Use'*' M Above top nt CAe1119) —
9. TOP Ur ['nrlr 1t; i" �___._ rr. Abovo Lend Sullnce'-rn -
`Tai+ OI crt�lntt 1t`rmh+nl'+r1 rtt''•r hrla,Y Initd tUtltCe NgUltet � VMIatICt In Ai)i)Ot• �-^— ____��,�----- .
dancewith tsAIMAC9.C.nIIt' _ — A'
10. YI :LU (alt�tt): 4:;L .. ME_II IOU OF TEST —" M _- _. ern
11. VVATE11 Z(A]ES, 01111): —.._ �_ •• �
(� i If eddlllonnt r•pnre is tip '(Ind v n hnct(o[ {(riot .
12. CIILOtIIiJnilOhl; type — .1L----Anloun�p
Q. CASI11(3:
Iir,l,llt tt IrNnrnnlm
14. Gf10U1: M It nd
l tr I,IIt Mniviltil a 1.
rront .
rn)til
15. SCr1E:1:11
1 lr I,1I, I 11rometer
iron/
rionl
rrorn t n rt. __._ — In.
tE3, SAND1C�IlAVFl.1'nta::
Ur) nl Size
rrorn
rrorn
1 UC111('I'y11 ( Y� I,r-�r'Iti�ii,��I�(j t�i'11�1�Ift
Corlsi�f;!���r�Ort i�l .tlr-�nnt �.nllolt€1
I
FU11 1)I I I(r U 0 11 IY , a
OuA4 tta: t
1
L-11111 Ito
Slot Sizo MnImIal
Mnlmlril
LUCA;I IOfJ,-SKf:1
WAIT 1111cNies9
or Wel hGfh tdnlnrinl (Show directlon 111 dlslnnr.n Irorn nl Inn^.1 tvfn Stnh
floods, or other rnnp relerence p�ln►9)
l
a&�Wka-' k(
9 Col
in J l�CCono/VICF will 15 t 111E VII-1.1- Fn.
Cor'UnU�11A8 8HN i'
W11F. r rnSnN COt131nUC11t) i1 fan Y,Iihln 30 clnY!
original to I)WIslan or WAler QuAllty, tlround""t Secl t3W.1 IIFV. 12191

229407
North Carolina • Ur?linfimorit of F"nvir-)nment rind Natural rlesourcns . Division of Water Quality • Groundwiter Sncti,m
1636 Mail Snrvic:n Cnnlnr . flainigh, II.C. 27699-163641Irone [phone]
WELL CONSTRUCTION RECORD WELLCONTRACTOR:
WELL CONTRACTOR CERTIrICAM 1 9:�-
STATE WELL CONSTRUCTION r EnMITH:
1. WELL USF (Check Appnra)tn nox): nesldentialu?( Municipal ❑ Industrial Agricultural ❑ Monitoring ❑
Recovery I' I I lent Pump Water Injection ❑ Other I j If Other, List Use:
2. WELL LOGAT 10 : Show skntc 1 of tile location below) konco2�-
Neatest Trn�n:. et/wv County:
- LOG_ _ rmpEPTF� —
(no,,,1 r)anrn nr d tl L '` Conununity, or Subdivision a
rind Lot No.) -DRILLING, — roation oescriplion
3. OWNFr1 -. From To
Address 01 D Te
(Strict or o �^ r7 t7 � O a — �„ J ,.•��
--r—Slate Zip Code —_ ill Lit
City or 1 own (�
4, DATE UftlLl_FU=l``--'��.Dzp_ ' V
5, TOTAL DEP f l l __' t1
6. CUT11I MS COLLEC T ED YES ❑ N09
7. DOES WELL mr-ri.ACF EXISTING WELL? YES 0 FT.
8. STATIC; WAl ER LEVEL BeloW Top of Casing: � o
(Use'+' It Above Top of Casing)
Surface' -0
9. TOP Or CASING IS-__�--
FT. Above Land
'Top of cashrn t^rmirrntnd ntlor below land surface requires a variance In accor•
dance with 15.A It
2 118 _—�---
tU. YIELD (a ItMETHOD OF TEST - l"
z c'
11. WATER ZONES (deplll):
--TS It eddlFlanal spare Is nreded use bark of Fe► n cr't�M
12. CFILORINA11ON: Type _Amount / _ .._.__..._. __ - --
13. CASING: _LOCAIIQN SKETCH
Well Ttiickness
Urptil Iameter or WalghtIrt. Mat(Show direction and distance from at mast two State
•nj t� F 5 Roads, or other map reference points)
F
From__S/�1 l o �--
From-_—_ To -- — F1. --------- —
From • — 1'? Fl.------ ------ - /(
1A. GT10UT: ff ^
/� Uepth Material Moll Y04 �.r � .
From - �! _- To AV F1.
Fiore lo--
15. SCREEti:
!)r'plh Slot Slz© Malarial
Fromir1. In.
From To f"t. _-- in.
In.
From -- to _...---_F1._
16. SAND/GRAVEL TACK: Material
Depth Size
From ____- o _ rt.. _--
From _. _ 10----'rl.
17. REMAfII<S 1 r .
OtISTfiUCTED IN ACC0r1DANCF WITI I M NCAC 2C, WE.LL
PY OF it its FTECQFib HAS BEEN PFIOVIDED TCr 111E V'1ELL���—�—
WIGUTUr f Ef1SOit CONSI UCTIf1D IiIF VJ[I.l_
DATE
nal to Division of Water Quality, Groundwater Section Wllhln 30 days oW 1 MV. 12199
r
DOIIFr1170Y Cf�.l1itrr r rani rr,., •••
CONSffll)r ilk tI,r'iANDAr1D% AND It
FUf\UTTIGE,I 1UtJLY
Ouad No:
r
serial NO.

..1.'.:.';.i7�i,�
:1:.�; ..... . ,�..:!:N:�:�.N .I !*•.9FIi.'"'�'r..,1vh��ll� ,..��M �,' r4.,.,i. r,�.: �:.t:�r '� t •.
229409
North Cnrl,bnn . rtoynrltnrnl nl rnvlrrrunAnt and Noturni rieaouroas • blvl:don of Walfr Ousilly • droundwaler Section
$36 Mail Scrvirn Cwtter • Ilnlelgh, N.C. 21699-1636-Phone [phone]
WELL CONSIFIUCI ION I- ECOFID WFLLCONtnAC70", ��rEZ�1 44
WELL CONTt1ACTOFI centiF'ICATIOII
SF"ATE WELL CONSTFIUCTIOf11'Etimilp:
1. WELL USE (Check AF-pllrrhle nr•x): flesldontialu Murilclpal Industrial AgrlculturAl Monitoring C�
Flecovrriy I Iont f'uny Water Injection [] Other [j If Other, List Use:
2. WELL I.OGAI : ��((S��hm��v �s��ketic�(h��of the location below)/-
Nentest town: �(A/lLh�n�a:.3.t1 x • -----County:
IF10"tI i1irt,nfind NumhorS. Cornnuml y, or Subdlvislon end Lol No.) Uf11LLINO LU(3
s. OWNEfI _h �n� From To fomteltonDescriplton
Add ess
City nr 1 rvm _—� M-Ile Zip Code
4. VATE
5. TOTAI.Ilr:I'1II _
G. CUTTIIJI SG(A.I.P.1ED Y1=S�_) NOL%d _
7. UOES WFLI_ f U=f'I1�CE C)(15 f IfJC3 WELL7 YES I -I NO[ V
8. STATIC WA'I Erl LEVEL Uelol•r lop of Casing: t o
(Use's' n Above Top of Ceslrrg)
( FT. Above Land Sutl)nce'
9. Top Cif" CArINC S _�-- ._.__.. -' '-`- y,... ��
*Top o1 eoslnn irnnhtnhrt rlh•r below Wit! ttutleca taqulraa A verianee In accor•
once wllh ISA IMAC 2C 01 to •
tU. YIELD (ovill): Zl%0. ME1) IOU OF TEST
r++
11. WATEn 7-oNES (dri,lh):
12. CI IL01111JA1 IUIJ: 1 ypo _. �AmoUnl �' 11 eiddltlonal Space is nrerled unn bnrk of form ZX QC
• .
13. CASING: _ LQCAI ION SItE 1 CFI N c
Well 11dcNnes!'
Urirlh Inrn�ter or Welgt,Vrl. Matertrl (Show direction and dlntmlce born nt Ioasl Iwo Stt119 x
From aR Floads, or olh©r map reference points)
14. 0110111:
11r)�Ih
From ......
Fiorn ..._._-...... la
Mn1erlAl olhod
AA &
15. SCr1E1'll:
1.)r.l,lll Uianlotor Slot Slze MAIorIAI
Flom _ 10- -- rt - 111.-
Front ___. _ '10 .--_....— I'L _-. in. In. -
From ............. To. in. ht. -
16. SANU/G11AVIA. f ACIC: Material
Depth Size
From 10 __
From T o
4kay�- 4�. rc-w.
49AIA,Sruj-&I n.c
17. FIEMAII c. ..� . _,.
j:l .
1 DO 11171 - t. n t it v 11 InYr?I ItsO F rt COPY,OFNII 9 nECOftD A9 BEEN P IOVIDF_v Yo MIDANcr 1116 WELL IOWNEf1.
CONS 1 tl. r fi r N .• 1 AI•JU�11D., AN i �P � (�
— DATE
Fon erne r-- �� r_ OtILY SI , unEorrcAP
n_ t
NS1nVCTIFIO TIIF-VVF.II
I puod Nn. ; n n
Sutxrril Orlpind to Ivhlon of Water OU1114, Oroundwtler Section Willdrt 30 days OW 1 nEY. 12199
Ser1Tl f to

... ..._ ,,. •.�,.,.. h...,r,.,.r,,r. .,,. ,ayrvaargrjw*.,.-, •r•7.• ,�
229412
North Carolina • U^Ilrnhrntnt of Fnvlr,mmoml and Nattnal r1esnurcr1 - DivIsIon of Water Quality • Grotmdwnler Snclkm
1636 Mail Service Cnnlrr - rinleigh, II.C. 27699-1636•Phone [phone]
WELL CONSTHUCTION RECORD WELLCONTFIACTOn: z --
WE WELL CONTFIACTOn CEn11FICAIR f 0:
STATE WELL CONSTnUCTION PETTMITH:
1. WELL USf Icneck nlylnc�bin no><): flesidentiniR Municipal 0 Industrial ❑ Agricullurel U Monitoring U
necovely [_) I Icnl Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL. I.CICAT 101f :'('Show sketch of the location below) ]
Nearest lov:n: ,a,U�"- ��,iQ�T� County:
�Inon-i Ilhnlr nnl� f lump ars, Cooinumlty, Subdivlsion and Lot No.)
DRILLING LOG _._._.
To r'orrnallon Descr+plion
3.
OWNFfl �1
`L„ _�3
From
C
Address
ed
�O
Clly of 1 OV-01 A StileO� Zlp Code
,
•�
a.
[-
DATE I1ruLLFD --- -
_____ ___ .--�-�—ate--.
� Grn-
5.
6.
TOTAI.UrPTII _.._���--
CUTT II IG S (301 ..FC: i Et) YES [_-] NO[g
- _____
7.
DOES WFI..I_ rlr=P1 ACF. EXISTING WELL? YES [11 NO[�
----- ---_�
S.
STATIC WATER Lt=VEI. 13e10vl Top of Casing: __yp
— -- --
If Above Top of Casing)
_Fn
_ _ __ _.•-. N-
9.
TUf CtF CASING I ; _.__-_�_---- FT. Above Land Surface'
ternllnatnd nvor hnfow Innd surface requires a variance in sccor•
_
--
'Top of ces1119
dance with 15A NCAC 2C .v 1 Q
TEST--
10.
YIELD (apnl): v .. MET 1 IUD OF
11
WATEf17C1NES (d'1)IIr):---
-
har---
12. CIILOl11IJAT ION: Type - _ � s---ArTtounl � it addillornl spar.Q Is needAd use k - form
13. CASING: LOGAI ION SK_FICH_
Wall 11110ness
al (Show
Licillir, lameler or Wei9htlf 1. Materiw diroctinrt and dl,lance (rein at In"" two Stale
_. _ _ � F1.
li Roads, or oilier map relerencp points)
FIom10 _
F rorTI----....--- 'Io------- Ft. -% - `aED ,r (Id�
From _.- - - T r' — Ft a �/��
114. GROU I `i
Dr�pllt Material Moth
From -_ _-- 10 Ft.
Frorn ...__.__ l o--
15. sCriEFf I:
U�I,Iit Diameter Slot Size Mpterlal
From Ft_----
Frorn -.._-_ l0 ___-.- Ft,_ ----
From .---_-__-- To _ ••_.__ Ft. in. In.. -----
16. SAND/GRAVEL PACK:
Depth Size
From _ TO - Ft.--
Frorn To FI.
17. nEMARKS:
DO ! IFIIFE• T Il>t[f YCI 11' TIJISWI E
r
CONS Ir1l1Cl f t Tn Jf)AnD Iamb 14 AT A
FUR UFfI(,EtU$Ii!Utffy��
Quad No: �� Sub,nit
Sadal No. ryli itYtr r
Maleri +l
)NsmUCTED IN AcconDANcE WITH 15A NGAC 2C, WELL
of TF Is mcortD HAS BVtOVIDEO TCt THE WEII. OWNER
� DATE --
SICTtJATU OFF .11 ON COrIflr3 TIIE Wft.L
al to Dlvis on of Water GUMMY. Groundwaterundwater Suction W1111111 30 days r3W t nFv. 12/99

.� -�.
vy';Nfr'�-l-\r^I -!. f- eyynr.:Ya'A/.ri �.-.la 1ti+1 i - -1•.
a. ...a , ... ._ -
�! : ... ,. ..jr �, +.. ... � .r"w .�w;C, rY..-f •••-!�:�i!f ;hir:4 r., i' �.:. a n.r.. ,. .... ?� � �� ..
229411
North Carplion - Uepnrlrnnnt of Environment and Natural Resources • Division of Water Quality • Groundwater Section
1636 Mail Servico Cenler • llnleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:-�11�.5��N
WELL CONTRACTOR CERTIFICATION q:
STATE WELL CONSTRUCTION PERMITN:
1. WELL USE (Check Ar•plicable Sox): Residential Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery (_] I ►eat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Sf v�sketch tie location below)
Nearest Town: --��- ' — County::
(noacl f lnn,o an urnt _ s, Comnw Y,0fSybdJVlslonandLol No.)
3. OWNFR
Address
WE ci or o'
City or Town State Zip Codey�.
4. DATE DRILLED
5. TOTAI. pEP I I--
6. CUTTINGS COLLECT T ED YES O NO[V9
7. DOES WELL fiFrL.ACE EXISTING WELL? YES NO[ 1d
8. STATIC WATER LEVEL Below Top of Casing: FT.
(Use's' It Above Top of Casing)
9. TOP or CASING IS___� _.. FT. Above Land Suriace`
*Top of caslnn If-m:fnnlnd nilor below land surface requires a variance In accor-
dance wilh 15A NCAC 2C .011
iO. YIELD (gpril): -AV- METHOD OF TEST
11. WATER ZOtJES
12. CHLoniNA1ION: Type _/M7,._Amouli—_ ---
13. CASING:
DRILLING LOG ___DEPTH —
From To Formation Description
"AD
----`ram--
m-
E
Tom. o
p�
ryl t;J
C13
o
If additional apace Is nredad use back of form
J
Wall Thickness
Depth
Q Ft.
lamet�er or�We Igh�VF�r. Ma,,, - ler♦a� D
1t-- ��u•'vc s�M1
From _To __
From -.-- To---
Ft-
-Flom _...- _To ---
Ft.
14. GROUT:
t)cpifl
Material . kAethod
Fiom ---k- - To
Fiorn _ ...------ -- To-
15. SCREEiJ:
Orri,th
Diairteter
Slot Slzo Material
Flom To
i't _.
in. ___ in.___
From
Ft. _.
in, .--- In.
From __.-___ To ..__.,
Ft.__
In. In. --
16. SANU/GRAVFt_ PACK:
Depth
Size Material
From __.__ To _______
ft.
-
From _--- To—rt..
.--
17. FIEMAi1KS:
LOCATION SKETCH
(Show direction and distance from at least two Stale
Roads, or other map reference points)
,� r' r a WELL
100 I IEn r `�1 a 1711 �Y) q-�OA - i7l.Sf W L-C,'WA9 CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,
CONS7RU 7tIrLSTANOARDS, AND TH/.IIOPY F THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNE
d ��>'�!1 t {{1 y
FOR OFf IC 1 Uly` l f GATE
Quad No: GNATunE Or PERSON CON nUCTiNG PIE WELL
9ubmll odFl at to Division of Water Quality, Groundwater Section within 30 days OW-1 nEV. 12l99
1 I Y
Sedai No. "CDlllttitili L �i L1111,� SS

.... .� ., ,...r .r ., ��. Y,.ayr,._ .y rw.ry•rfrM�i'MY�r P., ., ..�r•yn i � i .... .,,
22941
North Carolinm • of [nvir,yunent and Natural t1es0urce9 • Divirion of Water Quality • Groundwater Section
1636 Mail Srrvirn Crntrr - llnlrflgh, N.C. 27699-1636•Phone [phone]
WELL CONSTHUCT 1014 RECORD WELLCONMACTOR: L
WELL CONMACTon CEn'tirICATI I H:
STATE WELL CONSTr1UCTION prnMITH:
j, WELL USE. (Check Ar,llr.abtr, tiny): neSldentiallp Municipal D Industrial ❑ Agilculturel �_� Monitoring U
Recovrry ):) I irnl Pump Water Injection [_] Other U If Other, List Use:
2, WELL LOCATION: (Shop sknich of lh location below)
Nearest lowli:_.._____
County:---
(noP l tlnrn and iumhets, Community, Or S
3. OWNFR _
Addrer•s
end Lot NO
tau Zlp Code
city or 1 own Stale
4. DA1EDIII11ED-�9•do
5. TOTAL DF1' I I I
6. CUTT H MS COLI_FC I ED YES ❑ NOg
7. DUES WEI-1- nFF'I.ACP FXIS TING WELL? YES[ I NO[�
8. STATIC WAT En LEVEL Below Top of Casing: -14 FT.
(Use '+• It Above Top of Casing)
9, TOP OF CASING I .-__-� _ rr. Above Land Surface'
'Top of eosin.1lerrnlnntnd nUor helow land surface requires a variance In accor•
dance with 15A f iCAC 2C`011
10, YIELD (arm): ,,1 METHOD OF TEST
11. WATER ZONES (dcpth):__—�
DRILLING LUG
From To
--- DEPT11___�
rbmralion Description
----z, —
c
�rn
CO
12. CHLORINATaON: Type: Anloun4� �M� I1 eddillonel space Is needed use hack of I o--
13. CASING:
_LOCAIIUN SI<ETCH
Wall "Thickness
Depot iameter or Welpht/i'L Maledal (Show direction and distance born at least two Stale
From To ZZ/
Fi• 'J �� �` Roads, or other reap reference points)
From--.--. To Fl.
From ----
14. GROUT: (%
Depth Material Method
d
From ___Q T o 4.4Q— Ft.
Frorn ......__— T o _ rt.
15. SCTiEEtJ:
Drl,(II Dirnneler Slot Size Material
From _---- TO------ Ft - In. It" --
From _ —: 'T o ___—.� Ft. — In. In._ ---
Front --- To ... -- FT. In. In..�----
16. SAND/GnAVEI- PACT:
Depth Size Material
From To — Fl. ___----
From _ _ --- To
17. REMARKS:
1 DO I IF.FIi"[TYIFprV tl F(�l�l`FII' W. �LLV
CONSTnIl,rr��G)f�, 1 tjnl�flD ,ANUiT11/1iT';
1� l
6
Fo—h orr IC` 1 ,E
Guad rho: °-
Sariat Ito.
F t ahR4r
.�. ==-fit:.
CONSTt1UCTED IN ACCOMANCE WITH 15A NCAC 2C, WELL
3PY OF THIS nECOnD HAS SEE [10VIDED TC►1HE WELL OWIIE��/��
PATE
k1014ATUt or rEr1SON coNSrinUCTltrr"T 111E WELL
pinal to Division or Witter ouatlty, Groundwater Section WI1111n 30 d-1Y9 13W 1 nEV. 12199

y. t .. . i J• I.�'�..Y u a� � ,. 'i ff'm A.
.!!.: ....... Div-:..". .�'.`! ,. .to':,��f"!'^..;,r .w•�� 1;.. •r•.,_ ri'aY�^t�4� .. .. ��'"' ' .. '.
229414
North Carplion - Dtpirtment of Environment and Natural Resources - Division of Water Quality • Groundwater Section
1636 Mail Service Center - flateigh, N,C. 27699.1636-Phone [phone]
WELL CONSI,RUC1•(ON RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION
STATE WELL CONSTRUCTION PERMITa: _
1. WELL USI: (Check Appflr:able nox): nesidentialu Municipal [_-1 Industrial ❑ Agricultural U Monitoring ❑
Recovery [j I lent Purnp Water Injection n Other n If Other, List Use:
2.
WELL LOCATION:: (SIt %vv sketch of Te location below)
Nearest Town: —+� J — County:
...�.
(noa 1 rlan,n and Nvr rs, Comrtumlty, or bdlNston and Lot No.)
DRILLING LOG_-
3.
OWNFn
From To rormalion Description
Ad rasa
� ou o,
!Code
Cily or Town $late Zip
4.
DATE 011111171) —9 . g• Q
�_ r� '� -
5.
6.
TOTAL 1)r--r T 11
CUTTIM35 COLI.FC T ED YES [—� NO 1[
N04
—
----"""�~���
7.
DOES WELL IIEf LADE FXISI-ING WELL? YES 1-1
- — —
S.
STATIC WATER Lr-VEL Elelow Top of Casing: FT.
(Uso'+• it Above Top of Casing)
9.
TOP or CASING I^ ______� _. FT. Above Land Surface'
3 �
'Top of cesin.1 lernllnnlnd et/or below land surface requires a variants In actor•
dance vrinr l5A rICAC 2C .0119 Q •
�
�'
0.
YIELD (gent):-
11.
WATE117_C1NES (dr f+lh):
&J©______Amounl �A
If additional space Is needed use bark of form
12.
CHLOMNAT ION: Type _
13. CASING:
Wall Thickness
Depth
- ledal
plam�et�er or WeIghUFh FAa
!�—
From
To
From ------
To---- F t.
------- —
From
Ft.
--
14. GROUT:
Depth
Material elhod
To
Ftom
From _._.___
To __ F►•
--
15. SCREEN:
Ucpih Diameter
Slot Slze Malerlal
From ____—To
_--- FI —
In. In.
From --
1'0 FI.
In. In.
From _--To
_..___ Ft.
In. In.
16. SAND/GRAVEL.
PACK:
Depth
Size Material
From
To - I'•t•
From _—__ To Ft.
17. REMARKS:.... _
1 00IIEnr9Y CFnlir'Y T
i.
CONSTRUCTION STANDA
FOR OFFICE- LIST ONLY'$
Quad No: !
it
JI
lftz �
TI ES WELL,,WA8
>, AND THAT d . c
tool
LOCATION SKFILCN
(Show direction and distance from At least two Stale
Roads, or other map reference points)
SMUCTED IN ACC011DANCE WITH 15A NCAC 2C, WELL
VATunE
RECORD HAS BEEN PROVIDED TOT L!Lq:��e
I IIE WELL OWN R.
OF PERSON CON f1UCTINO TILE WELL GATE
o Division of Water Ouallty, Groundwater Section within 30 days t3W 1 REV. 12199
1

>• m,- S i fi„.'!� SLIM
..
229415
North Carohnn - Department of Environment and Natural Resources • Division of Water Quality • Groundwater Section
1636 Mail Servico Cantor - naleigit, N.C. 27699.1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: _ 4:jtA.*a L-
WELL CONTRACTOR CERTIFICATION R: r Q
STATE WELL CONSTRUCTION PERMIT0.
1. WELL USE (check Applicable nax): Residential Municipal [J Industrial ❑ Agricultural ❑ Monitoring EJ
Recovery U I ►eat Pump Water Injection [] Other n If Other, List Use:
2. WELL LOCATION: (SI w sketc�h f the location below)
Nearest Town: 1[do County: &4Lup...r-------
(noftd f larna am rind f n! rrrs. Gomunl Sub v Ion nd Lot No.) DRILLING LUG
3. OWNER�1 From To
Address y _
- j5lrec. or ou a � � p��j��
Ciry or ovm Eitrlle Zlp Code
4. DATE DIIII.LED 6
5. TOTAL DEf' I I I
6. CUTTINGS C()LLEC T ED YES Ll NOM
7. DUES WELL REPLACE EXISTING WELL? YES [_] N T. .
8. STATIC WATER LEVEL ©elow Top of Casing: F
(Use'+' If Above Top of Cashrg)
9. TOp or CASING 15 _—J .-. FT. Above Land Surface'
,top of casing terminnted eilor below land surf see rsryulres a variance In accor-
------------
dance with 15A IICAC 2C .lyl
MEIN 100 OF TEST -
DEPTH
Formation Description
10. YIELD (dpnr). _ ---- - n
11. WATER ZONES (depth):
12. CHLORINATION:
13. CASING:
Typo �A�l_!_1►�----Amount ILs 11 additional space Is needed use beck of form y�
Depth �lam�et�or
From — _ To _40 Ft. �t �a--
From--__._ FI.
From
14 GROU1 •
LOCATION SKE70
Wall 71110.ness
or WelghVFI. P �'pC
Material (Show direction and distnnce frorn at loast two Slate
1103, AR Roads, or other map reference points)
Depth
Material �,.
-Method
From _..__--
To --
Ft.
15. SCREEN:
Depth
Diameter
Slot Size
IMaterial
From
To
In.
in.
From
To
Ft.
in.
In.
From _—To
- --
Ft.
In.
In. _
16. SAND/GRAVEL PACK:
Depth
Size
Material
From
To
FI•
From _.-_-_-- To
Ft.
17. REMARKS:
CONSTr1UCTIpN ST'ANOAr�DS IANrD THA ryAdCtpPY OF R iIS RECORD HAS BEENLICTEDIN
DATETo THE WELLLOWNER.
R OFFICEI�ISEION Xi ) ' GATE
FO
Quad No: i i ' Y tt J L Sl(1 Une OF PERSON CONSTRU INO TIIE WELL
Subfr>fl on lnal to Division of Water Ouatily, Groundwater Sectlon Within 30 days OW.1 REV. 12199
Serial No. is1r at

.. ....... _.. .,r.�py .,. m.. y..,.�. �t rsrry�y�.�y..Mr �., .. •,y.yn „ ..,
229416
North Carnlrrn . r_lgrwItfrnlnI of Cnvir-mment and Natural ilesourcrs • Divirion of Water Qualily • Gfnunriwaler Sncli,m
1636 Mail S-rvicn Crnlrr - 11n1etgh, N.C. 27699-1636-Phono [phone] —_ r
WELL CUtJS•rnuc., on RECORD WELL CONTRACTOR:—
WELLCONTnACTonCEFITIFICAil( I P:_
STATE WELL CONSTRUCTION PERMIT
J. WELL USE (chock Al,prir:obir noz): nesIdenllaiR Municipal ❑ Industrial ❑ Agricullurel �� Monitoring ❑
Recovery [_j I ient F unip Water Injection ❑ Other ❑ If Other, List Use:
2, WELL LOCATION: (gpow sk('JC11 pF the location below)
Nearest Town: __ _�7���g � County: — —
UW
rs, Conv ru ily, or Subdivision and Lot No.)
3.
J�Jlrrel Of F1�U� O. ��COde//��State P
4. DATE DF11t_I.ED 0 Ob
5. TOTAL DEPI t I
6. CUTiiNGS COLLF-C i ED YES ❑ N09 _
7. DOES WELL REPLACE EXISTING WELL? YES NO[�
B. STAT IC: WAi EF1 LEVEL Below Top of Casing: FT.
(Use'+' If Above Top of easing)
9: TOE' OF CASING IS �_�—__ FT. Above Land Surface'
'Top of casinq lnnnlnntf d nvor below Innd surface requires a variance In accor-
dance with 15A i1CAC 2C .0118
10. YIELD (qpm): MEii IOD OF TEST
11. WATER TONES (depot): _.—_-
12. CHLORINATION:
13. CASING:
Type __��Amoun1.Z�11S If additional spnce is needed use bark of form
----
DRILLING LOGFrom To r ormatlon Description
ID t
From)—t;/—
Doi lit lamer
T o / F 1. 10 50? J
Wall thickness
orr�W/eelghVFt. Material
42
� �
7 Ft.=—--
- /-ff—
Fro
To
Fronl-
14. GROLI1:
tlr,),Ilr material
Method
O
�
'10�— Ft. L&�-���
From _
_
From ......
To------
15. SCREFiJ:
O�F,Ih Diameter Slot
SI2e Material
From —
To _ .__.___. Ft -. In,
in. �---
From _ —_
i o ._._----- f t.
In.
From _ ___.____
10 ...._.__._ Ft. _
--
16. SANDIGRAVEL PACK:
Depth Size
Material
From _ __--
i o --_ 1 -
From __ __-.--
10 -- Ft. ^__ _---
17. REMARKS:
1 Do 1+r.nr nv cr:rllir v iir
CONS T f1UrT iOt,l � l Af lr),AFI
FOn orric.E-9 UOf1LY
�.
Quad No
Soria) fio.
I
LOCAiION SKETCH
(Show direction and distrinre from at In"ll two Stale
Roads, or other reap reference points)
.ISTiIUCTED III ACCOr1DAf10E WITII 15A NCAC 2C, WELL
,or. 1109 nECOn �1AS BEE PfiOVIDED TO Ill[: WELL OWNEn. ,
` DATE
ICTrIA riE OF r Ff1SON CON. TnUCTINO TI IE N1fI.L U do
to Division or Water Quality, Gmundwaler Soction within 3 y �W 1 flEV 12r99

•r,..y„ry ». �r,nlr►rrm-, •••r••t�� ,� ,
229421
North Carotins . [ 2pnrhnvinl of Fnvir•xirtient and Natural Flesourcrs - Divl,^.fort of Water Quality • Groundwater Section
1636 Mail Srrvicn Crnirr _ Flnie(gli, N.C. 27699-1636-111hone [phone]
WELL CONSTRUCT ION RECORD WELL CONTRACTOR: --L�-�
WELL CONTRACTOR CERTIfICAii(t k:___ , a
STATE WELL CONSTRUCTION PEnMITfl:
1, WELL USF; (Check ni,rtt­ablr 1100: FlesidenUal5? Municipal Industrial ❑ Agricultural Monitoring ❑
rtecovrry [J I loaf Pump Water Injection U Other L-I If Other, List Use:
2. WELL I.(lr;1�110Fd: 1(.�I��w sketch of the location below)
Neared roitin: ___----tNg ���/1� �`�- County: �---
(noa-i ttamo and�jmid{�ems. Conun injiv, or Subdivision and Lot No.) DRILLING LUG
3. OWNr rl I�_l4? •_dbr From To
Addre.^.s �V 7 7 �� -
7
1511rC1 Or (�U�10 O �•�
Co�Le--
Ciry or 1 own State p
4, DATE UItILLFO
5. TOTAL DPP I I I —
6. CUT1ItKiS COLLFCIED 1'FS0 NOLE
7. DOES WFI_l_ Fir-PIACF EXISTING WELL? YES U NO[>� - -
8. STAT IC: WA1 EF1 LEVEL Below Top of Cnsing: 27 FT.
(Use '+' II Above Top of Casing)
9. TOP OfCASING IR --- _ - FT. Above Land Surface'
'Top of easing W11111 and stror below lend furltce requires • variance In accor-
dance with ISA IICAC 2C.0I IS
1O. YIELD (gpnl): __(,f- METHOD OF TEST
i t _ WATER ZONES (deplll): _
12. CNLOFIINAIION:
13. CASING:
- - UEPTIi—__--
r"orrnation Descrtpllon
Type _� Amount . IV If additional Space Is needed use back of form
Diameter
Urlilh e
From 10 �-
From To -- Ft. —
From Ft.
I . GFi0U1:
Material Meth
Deplil
From O 1 o Ajo_ Ft.
Float 10
15. SCREEN:
()('pill Dinmeter blot Size
Material
From ___-- To -__—• Fl - In, in.---
Frortl __.—. T o ___._ - Fl• ill• In.
From _ ____.. 10 _-•_-_-- FL In.---
16. SAND/GRAVEL PACK: Material
Depth Size
From - To Ft.
From 10 'Ft.
-LOC(1TION SKETCH
Wall thickness
or WelghVI'l. �Mvatte�riaall �1] (Show direction rind dNInnce from at IFlasl two Stale
j6,42 Lls.-'>�G Roads, or other map reference points)
l�,CQ,J.lrkll'dLC' 7-("
17. REMAFIKS _.. I
• a p,
I b0 1 If r UCl IC t r�r'�1 `1Jf)MDS, nN�D T'1�1ATWA OE#YJOF Tilts RECOf1D HAS BEEN f'F1nDANCE lOVI0ED TTH i5A iC► l IlE WELL OWNEFI.
CONSin ?! j��
FOR —OF fiC.0 U�OtJLY s �, 'iATE
I, SI(lNATun OF r'EnSON COCOrISTr1UCTitIr3 ME WFI.t.
Ouad No: Submit oripinal;lo Division or Water Oualily, Groundwater Section within 30 d lyg
Ow-1 f1EV. 12J99
Serlat Na.

229425
North Careiin❑ - t)r?rirtrtm••nt of r nvir•xunenl and Natural rlesourcr9 - Division of Water Duality • C+rnundw°ter Sncti,,n
1636 tolaif.Srrvic:n Crnirr - rtniMilh, N.C. 27699-163641hono [phone]
WELL CONSTiiUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIPICATI( 9:•
STATE WELL CONSTRUCTION PEFlMITR:
1. WELL USP (Chick Ar•pncabin nnx): nesidentialu? Municipal ❑ Industrial ❑ Agricullurel ❑ Monitoring ❑
necovmy [' I i lent F unip water Injection ❑ Other 0 I[ Other, List Use:
2. WELL 1_UCATION; (��j1 o�kr.tch cf t�heelocation below)
Neare^•t Town:— __ �-l�G �e.e County:
— DRILLING LUG` _ UEPTII _
(Flea I tlantr nnc lumt+res. Comm n ty, or Subdivi. a� And Lot No.) From TO r'omatton Description _ 3. OWNFFl
Address • `7f—,•�O
L/�`y►�'LG�Ircl of Ttc u�g, Or (�D /
City or 1 own qq State Zip Coda �-
4. DATE 01111_LF0_--
5. TOTAL_ OF [ I I--
6. CUTiINGSCOLLF-CIED li'ES❑ NOg _ s�
7. DOES WFI_L F1E=PI.ACF EXISTING WELL7 YES [_ ] NO[� _ CZze
8. STATIC: WAi ER LI VEL Se(ow Top of Casing: _ r r
(Use'+• if Above Top of Casing)
9, TOP or CASING IS•___L__-_ FT. Above Land SurfaceE�rn
'Top of cesRcp lerminalnd ntlor hclow fond surface requires a variance In actor•m
dance with 15A 11CAC 2C .0118
10. YIELD (qpm): 30-- METHOD OF TEST
11. WATER ZONES (deplh): 'M
12. CHL0111NA1I0N
13. CASING:
. 0. M:;o
'Type -- EJ r-Antount �S If additional space is needed use bark of Inr t�, n
Well ilrickness
Uehllt , _ �
lamelor or We1011Ur'1. Mal erial
�
9__10
rton, -�/—���F'I.
From------ •10 --._
f"t.-- ---- —
From .-----Tn--
14. GROU1:
Material Method
[)r,ftllt
O l A4
F 1• — `T
From __ __ o
Front .. _..__— 10-------FL
-- --+
15. SGRE=
Url,th
Dinmeler Slot SIZE Material
_—
• Frorn---..._ __.. 'l o ..-_..__._ f't.
______. in.
From ..--_--_.-- To - ..__.__ Fl.
-- In. In. _----
16. SAND/cnAVEL PACK:
Uei,tit
Size Material
Fran, _ _ — T o —_
Fl. _____-------
Front — To
'Ft. _______---
LOGAi ION SI<E7CN
(Show direcllon and distance from at Inast two State
Floods, or other inap reference points)
d
17. REMARKS:_
W ELL
1 DO t imr..nY Cr fll Ir Y -(i Ini9TII1S W.EL�!WAS COI.1STnUCTED I1! ACCOf1D/WCE WITH 15A NCAC 2
CONS lfit.IC1101! �1'nr•1,r)nnDS, ArJU Tt1AT A CO", OF irrlS nECOnD HAS BE P OVIDFD TCr 11iE WELL OWNER
1 DATE
Fon car ri�1_ usP�ti�rJhY C sio(1nTur pF r 0soN MIST Irrr.) THE WEI.L
Quad No: 1 Submit orllnal 1o;01vls on of Water t]ualily, Oroundwaler Snclion Within 30 days OW 1 rtEV 12l99
Secial Ho.

.i:::::.t�.:::::.:i:;: • .; ;• .. .;:7 r,.., : �I!«C.:tral.EGr ll! �`•" t`.�::�t�ir "�"»i:;i"'^'.u::"...! �:�: t::.'L.iir'L'` ' �t, "sw.' ;1 ..,;� :: ... .. _
r`;
229424
North Carolina - Depnriment of Environment and Natural Resources • Division of Water Quality • Groundwater Section
1636 Mail Service Center - flalelgh, N.C. 27699-1636•Phons [phone]
WELL CONST RUCTION RECORD WELL CONTRACTOR:_ �U-SipN
WELL CONTRACTOR CERTIFICATION ff:
STATE WELL CONSTRUCTION PERMITO:
1. WELL LISE (Check Applicable 13ox): Resldentialu Municipal E Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery [_) I Ir,,rrt Punip Water Injection 0 Other [J If Other, List Use:
2. WELL LOCATIO (Show sketch of the location below) �C�n
Nearest Town: �� ,QJ% �_County:
(nowt il1lo a and Nurntler , ComnurnIty, or Su Islon a d Lot No.)
DRILLING LUG _ bEPT'H —
rormallon Description
3.
OWNER
From To
Address a q 9
Q
i i('ee or ou o o
Ciiy or Town SITIe Zip Code
DATE 0I1ILLED 1_171_a•o o
4.
S.
TOTAL DEr- 11 I
Y1=SO NO[f
C.,)ME —
6.
7.
CUTTINCISCOI_LUCTED
DOES WELL IlErLACE EXISTING WELL? YES [—] NO[ d
—p d.-,�
8.
STATIC WA1 Eft LEVEL E3elovi Top of Casing: __Y&_ Fr.
rr7
(Use's' It Above Top of Casing)"-
CID 'Tr
9.
TOP Cif' CASING IS ___I FT. Above Land Suffice'
'Top or casing rrrminnind M/or below land surface requital a variance In accor-
dance with 15A NCAC 2r,. 11e •
�M
r�
10.
YIELD (gpnt): _ _Q . METI IOD OF TEST
-- — .. M;
11.
___.
WATER ZONES(d(Ipth):------------
—+
-
�'�" �5
I( additional space Is needed use back of form " x
12.
C1lLOrliIJAT ION: Type _._.!_i__l._CL.------Amounl
13. CASING:
Depth plamelor
From_ Q
From --_---
From -.-- l o - Ft --
I A GROUT:
LOCATION SKETCH
Wail Thickness
or Welghvirt, Material (Show
p (Show direction and distance from at toast two State
�iie.l� hRoads, or other map reference points)
Depth Material ethod
From To _A0_ Ft.
From _.... To _ Ft. —
15. SCREEN:
Ueplh Diameter Slot Size Material
From TO --- Ft _ In. In.
From To Ft. in. In. From To _ -- F1.r.-_—.. In. In. -
16. SAND/GRAVEL PACK:
Depth Size Material
From To _ Ft.
From — To Ft.
17, REMARKS:
jA
WELL
iIN
100 1IERF13Y CFln l 10( 71IXTiT1 NDlTHAT A C Y OF THCT RECORD HAS BEEN PROVIO D TO THE WELL OWNER.
CONSTRUCTIOIJ�TNC1/�f10S,_: ti 1'
FOR OFFICE USE" + 14Y t TR OAIE!
�; � y � 1 Sf(3t�A E OF PERSON CONSCTINO TIIE WELL
Quad No: ,
4 ` . Submit orlgtd to pi slon of Water Quality, Groundwater Section within 30 days t3W.1 hEV t 2/99
Serial No. ,...
t tbY:ft�a
ij
„t i yq1._

'IT.
,....w....r......•....w.....— y 1 T.f �.fil, y�My�ir� i :,' I• ''M'r:'': ��
a'n X r' 1 :tRt► IL J_L::.E I'.�Y: _.. w .I'11.1:
•�: '1 „• '�'�'4.,'.M'�� A 1W.10—r •M�Int,ihlMfl��i �����
:: .....;�... ! 1
942s
ollh cnroli"., (+' 1 +rtnn 11 r'l I min>nm^nl wid tJalurnl tlrn"t"" • 1)Ivl^Inrl of Mier Ouellty - C3m11nrlwnlrr Recli• n
163(1 Wit5.•rvicn C�nlrr Ilnlrlgh, ILi:. 27699 103© f'Itoite [phone]
YELL C01)�, I I11.1t:1 IUiJ RE-CUCIU wri-L cUiJTfInCTon cEnllnrnTl(�11 V.
w
[ i fvlunlci nl Ll Industrial CJ Agricuhurnl J__J bJlonitoring J. wrLL I I"a_ (t'I,nr.k !.I 1-IN-111. r"K): E1Ag1linnilril P _-
Flocovoly J .. J I I ;It I'uni)> avatar Inlecllon M Other L1 It Other, List Use:
?• WELL I ( i I; -I I of the locntiort below) � - `_--
_ County:
Nenrest ^�'�r+:
_-
---(—n00t1 -I 'I:,n•n nl s'•^r C, Cnnofl,lnll, on rSubdivised l.oi o.
n..iny
�St'.rlpiipn
From to
Zip Code __-----=- -
Cil}•or 1n :n' r^lplxxe —
4. DAT E 111111.1 f t) Q :. .
5, T11TAL1)r?rill
G. CUT7i1' V-19 t;(,I.I E t' I E.I)1. t ' "0 d --- -- _-
7. DUES VJt.I l.. I 'l. �tCE E?X1511NU WELL? 9E rTi
8. Si ATIG W A t E;EI l_1=VEL Below (Use'+ M Above lop of Cstelr+C)
T. /lbovo LAnd Surtaco' �_ co
uite$ a vnrlerlce in rlccor• o �
'Tof, of c1,tLftt tet n,lnnl�rl n!'t r below bind sulfate rery
kfe1jeel%'Ilh115AIW.nc2c.ntln t�1E1F1000FTEST
10. YIELD ((1{it11Y 0
11. WATE117_(.)111-S (drl,lh
�-�-� i' �� fi 1f eddltlonnl ef,nc(t b ncndnd u^n back of
12. C) (LO11 IM11011: 'l y)to -- 11
13. CASltdt-:
Ilrl,tll rilnmelnr
From---t�------1(,..-.�-•� 1'I.l���-•
rt..—
rieni ...._ ._..._. __.
_ LQCni"IUtJ_SKF 1_(. __
W r11w hicltne �!
or 1Ne1 hlrFl, M �tellnl (show dirIor other n inprrelerence pItolt, fit !,tintsj '0 5lrttP
i. . I floods.
14. G110111 1: Mnlvlinl Malllod
11r1,11' Q.�.Ed.
From
15, SC11r:t t t' 5101 Size Mnlolinl
1 tr•I,tll (11�itinlef
In. In. _--------
In. __--- In. _ ------
rronl ..._ _..... 1 r, .. ....._._ 1l. Ill. ------~-
1-1 (n.
From .. - -I (I ....- -- . __-__-_•-
18. SAi 0101IAVE'I.I'n(-1C Size
Url�lll
Rain r
rr nr n 1 o. -- r t ----- ----
--
1 UO 11('I,r t, r' ct'l
CotlS r ni IC'. 11(.it t
WEii �
OUe4 flp'
I IAA '111r9W(-LL Wn9
MIMI! nt(u 11In.t /t C
)lNl to dtvt�l
'-nJ'V) 7�4
dU l nCCCtf1DnF1Ct? WI111 15n f tCM 27,
1'I On) Nn aipm rin I[tr?p 1v 11IF Wr?Ll. UWNrn.
l_�s� _
_ �---' ---- UniE
pf rrnso►l cotrsrnucrlr t►+F welt 3O r1ny9
of Weler Ouellly. Clroundweter Seclinn W11hin law-1 LIFT I2
197

. ... �, � r'P 1 •,.hT •. „'a'Fr.i. wf �w,m7'r1w.r.�w.Mr F^
229429
North Cnreijnn • t.��T+nrhnnnl of Envir•)rtrnenl rind Naturril tlesourcrs • Divi.^.ion of Water Quality • Gmurowmer Section
1636 hiriil Fprvirn Crnrrr • ftnteigh, N.C. 27699.1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTFTACTOn' --- p
WELL CONTnACTOn CERTIFICAII( 1 H:__:;
STATE WELL CONSTRUCTION PEtTMITH:
1• WELL USE (Check Appnr:nble nox): Residential[d Municipal ❑ Industrial ❑ Agricultural Monitoring
❑
Recovmy [_I I Icat r untp Water Injection [] Other [_] If Other, Lisl Use:
2. WELL LOCATION: (ShnYknicb of the locatlon below) f1v
•DT I /� t� C unty: --'.
Nearest "Town:
DRILLING LUG _ t)EP1Fj_—__
^Inep l tign,P and tlu d,grs, Comn,unI , or SubdivNon end Lot No.) Formation 17escriplion
%� From To
AddresO.0 C 201
Stale Zip Code__—.
City or 1 own _ME
4. DATE Unll-1-1_1) _-..7...."
5. TOTAL DFf' i l l --_�_ -- --- — ----- -- :�`'—'a`_
6. CUT11tI(;S COLT-.FCTEi) YES[ NO _ ------
NO �En
7. DUES WEI_l_ Flta'I ACE EXISTINC WELL? YES [ ._
FT. Ot?
B. STA11C WAl E R LEVEL [ielorl Top of Casiny: Z) --�
(Use'+' it Above 1op or Caslnp) ---- a—
__ rr. Above Land Snrfnce' ---m
s. Tot' or ,As Is __ _ ---- _
'Top of ces4,.1lerminntnd nVer below Innd •urlece reryulrera ra�erlence In •ccor• — —N -- � --
dance with 15A IICAC 2C .0118 �- _r'
10. YIELD (°prtt): 4 __ MET IOD OF TEST � ---
11. WATER ZO!JES
S II additional
space eeded use bar
of 10MI
Is n
12. CHLOf1INA11ON: •Type �� --Amount
13. CASING: -1-0 ('A11UN SKI51Q
Wall 1hici,ness
n Dr rlh Diameter or WAIQh�V�FtC, Ma�l�edcal� (Show olds Ior otheror m1pWelf"ice points) cc) from at Imilt WO $lal9
From-(�_..._._10.:_.1_L-.F•I. �
From---_.-_- To ---.— Ft. ------ f i
From . _----_._-_.l n _---- F L
14. GROU 1: Depth Material Method`.. ,t'/,tom✓ l
ivy" f
From �Q-- -To 14 0— F1. _
Frorn 10 - ... -.___- -
15. SCREEtJ:
Url>th Diameter Slot Size Material
Frorn
T°--- Ft _-- In. In- _
In. In. ____-----
Frorn __. _ To Ft. _ In,
__- ----
From ______.-- 10 _ F1. _ _ — In.
16. SAND/GRAVEL t'ACK:
Depth Size
From __ _-- I o - ----- Ft. �_-------From
-
17. REMARKS:
1 DO IiCrtFE1Y Cf 11TIFY THAT THIS WELL
C0NSTf1UC1I6N''4',AIJDAnDS AND It TATI�j
Eaus
FFICE URF UtILY
S bmif"a�unt 4V,A r,. 4o.
Material
ISTnUCTED IN ACCOIIDANCE WITH 15A NCAC 2C, WELL
OF TIits t1ECOt1D HAS BEEN rnOVIDED TO l 11E WELL OWi E-n- Q
3tJAT r1E OF PETTSON C tiSTnUCTINZE WELL
DATE
to Division of W>iler Ouetlty, Groundwater Section Whhln 30 d"Ys ow-1 f1EV. ty99

North Carolina . (?r!pnrhrntnl of Fnvlrr,nmenl and Nalurat Flesources • Division of Water Quality • Groundwater Section
1636 Mail Srrvire Crater • f laieigh, II.C. 27699-1636-Pltone [phone]
WELL CONSTRUCTION RECORD WELL CONTEIACTOR:
WELL CONTRACTOR CEFiTIFICAM 9
STATE WELL CONSTRUCTION I EnMITN:
1, WELL USE (check Arpnr:,bin nox): nesidentialu? Municipal 0 Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery [Tj I lent Punli, Water Injectlon 0 Other C] II Other, List Use:
2. WELL LCIGAT IOFJ=."a"
t�h of the location below)
Nearest town: _.--
County: LGQ
DRILLING LOG
(no,•I Name slid rYtrers, Community, or ubdivlslon and Lot No.)
From To-
3. OWNF RAddress
(Strati or'TTnulo
City or 1 own Sale Zip Code
4. DATE DRIt_LE'U.-
5. TOTAL DFF' i I I
6. CUTTINGS COLLF-CI ED YES ❑ NO(+
7. DOES WELL REI'I.ACF EXISTING WELL? NO
8. STATIC, WAT ER LEVEL Balow Top of Casing: FT.
(Use '+' II Above Top of Casing)
9. TOP OF CASING IS�._f� _ FT• Above Land SIITIaCe'
•Top of casing tennin,ted ntror below Irnd surface requires s variance in accor-
dance with J';A MAC 2C.0118 f
10. YIELD (gprn): METHOD OF TEST
11. WATER ZONES (depth):-
12. CHLOIIINATION
13. CASING:
~~ Amount �S It additional space Is needed use oaracUl
.. -- _ -
Type _ _
— [)Euy A-
--Formation Description
wall 11ticHness Mal
erial
U�i!lh Iam�elC or WelghUfl.
From To i� FI. sr•�
From----- TO FI. —
From -- -- T ^ F t. _-- ------
14. GROU I : Material Method
(trplh
Front
From io �
-
15. SCREFiI:
DnfY((t Diameter Slot SIz6 Material
Front _— __ io _- _----- Fl _
In. In. �-----
From -_ T o .__.__-- Ft. _ in. _ ___-----
From10 - - FI. _ In.
16. SANDIGFIAVEI �ell AGK' 1 (a Material
MIZ t r
1Ir \il ,'.
From MD . � tr
From J3 g{ To
17. REMAi)<,:,�I
oOliF.grrnY&'1Atrn>v rrrnri
CONS TUUl
a�h�vl'9c 4 ,
��,.� •:dui-c. �'.= _ "_
FOR UFTIC E USE WILY
Ouad No:
Serial
LOCl11 ION SKETCH
(Show direction and distance from at least two Slate
Roads, or other map reference points)
LL
v
WELL O."AS CONSMUCTEo If! ACC0TIDANCE Willi )E T 2C, r-LWELL
D,TtIAT " Cop OF 1H1 nECOno HAS BEEN OVIUEU T t 111E VlELL OWNEFl. M � �—
__— DATE
SIGNATUrl F r FfiSON CofJ51nUCTIt1rl 111F: W17-t.L
Submit original to Division of Water ouallly, Groundwater Section Wilttln 30 dnYs GW 1 nEv. 12/99

:... ::.:
2211'9355
North Crimlinn • I1r,ImrIITi-II of Fnvir•)nment rind Natural Flesourcrs • Divintort of Water Quality • Groundwater Snclion
1636 fvlriil `;rrvir-o Gr Ifrr . flafeigh, II.C. 27699-1636•Plione [phone]
WELL CONSTRUCTION RECORD WELLCONTRACTOFT: - �
WELL CONMACTOFI CERTIFICATI(I P:
STATE WELL C0NSTRUC1-IOf4 PEnrAiTn: -
1, WELL USr (Check nI•hnr;mnir no><); nesldentialu? Municipal Industrial ElAgricullim-il L Monitoring ❑
Recovery I j I tont Punlp Water Injection [_] Other 1-1 11 Other, List Use:
2, WELL 1.0CA1101A: (Show sN ..tr ► the►locallon below)
Neared County:
-" DRILLING LUG
(noA lithnrr nn Nurrd,ars, ommimtty, or Subdivision And Lot rJoJ
From To
3. OWNE"�FT _. — —'
Address Q )
y Zip Code
Cily or 1 own
4, DATE U[lil_LE[)
5. TOTAL DEF' 1 I I
6. CUTTIHC�SCOLLF=CTED YE S❑ NO[�
NO
7. DUES WELL nEPI ACF EXISTING WELL? YES 0[
S. STATIC, WATER LEVEL Below Top of Casing: _____
(Use'+' If Above TOP of Casing)
9. TOP OF CASING IF, FT, Above Land Surface'
'Top or ceshr0 terminnlyd rVor below land surface requires s variance In actor-
E159 MAC 2C .0110
10. . _
10YIELU (gprrt): _-_— METI-10D OF TEST IS, J+f.—.—_----
--DEPTH _---
formation unscrihlion
11. WATER ZONES (depth): -
12. CHLOMNATION
13. CASING:
_ a
Type r~ _ _ Amour, pa dditlonrii spare is needed use bark of m. _
Wall jhl6ne ss
UchUt lamer o��`
elgl . Matelot
Flom-0— To Ft.,�
From .10 --_ _, FI. -- —
From _— Tr,._ Ft.------- —
14. GF10UT: M it od
nrlrlh
From — Q T u�— F 1.
Flom :....__-- To
15. SCREEIJ:
Material o,� _ , _
J6��� �-!
Drplh Diameter
From ----- T 0 -- -- Ft In.
From _._ _ _ To .-____ FI• in.
From .---- TO -
16. SAND/GRAVEL
Frog,- --- To
17. R1<S:_2_ �—
IT',T111S V
b�31, AND
FOR (i f ICE USE ONLY
avad No:
Sedalllo.
Slot SIZE Material
Material
LOCAIIUN SKETCH_
(Show direction rind distnnre from at least two State
Roads, or other reap reference points)
LL WAS CONSTFTUCTED Ill ACCOnDANCE WITH 15A NCAC 2C, WELL
FIAT A COP OF TH S nECOFTD HAS E PFTOVIDEO 7Ct THE WELL— WfIED�
DATE
.--- --
SIGNATU a or m--rism otISTnUCTINr3 TIIF Wf..t.
Submit Original ►o Division or Waler ouality, Groundwater Section Witllin 3C1 days OW 1 r1EV. 12r99

.��{Y�l«fl: L. ... ...7.' i r ... ..... .. +. .. v .. . .
«�. �. ...- :... -• .µr..4. , ....� .. '�'. ....,r,� .Y,....._ 'i�w..
229357
North Carplirrn • Dopnrtrnn.nt of Environment and Natural Resources • Divlslon of Water Quality • Groundwater Section
1636 Mail Servico Cnntnr - flaleigh, N.C. 27699.1638-Phone [phone]
WELL CONSITIUCTION RECORD WELL CONTRACTOR: - w�,,-����
WELL CONTRACTOR CEntIFICATION a:. y> •-
STATE WELL CONSTRUCTION PERMIT#:
El
J. WELL USE (Check Ai•pnrable nnx): nesidentlaluf Municipal El Industrial � Agriculturai L� Monitoring
Recovery [,] 1 left Pump Water Injection ❑ Other 0 If Other, List Use:
2. WELL LOCATION: (SlIw sketch of Ilia location below)
Nearest Town: County:
DRI_ LLIN(? LOG
(noad tramp and Jurnhets. Comr runny, or Su�divislon end Lot No.)
From To
3. OWNERtld-------
Address
51Fi—
L�..LYL
City or T Orin stale Zip Code
4. DATE 0i111-1_170
5. TOTAL 1)Er'II1----
6. CUTTIIJGS COLLECT FD YIcS [_ ] NOL_0
7. DOES WELL 11EPLAGE EXISTING WELL? YES L NOL Y� -
a. STATIC WA1 ER LEVEL ©elr)i•J Top of Casing: FT.
(Use'+' It Above Top of Casing)
FT, Above Land Surface"
9. TOP orCA611Jc Ili_____-�._.. _ -
'Top of eesinn iernihinind nVor below lend surface requires a variance in actor-
dance villh irA NCAO 2C ,nl in _
o. YIELD (n1)111): _.5-.U_- METi IOU OF TEST S ---- ---
ri WATFn 70NES (drl?Ih):-_—.--
12. CHLORINA110N
13. CASING:
rormallon Description
i Yho _ Amount �,,��J►� It additional spnce Is needed use beck of loan
Uehlh Inmelor
From Q --lo - Ft. -a-s-
Fiom----- to----- FL —
F►om--
14 GriOU I'•
_LOCATION SKE;ICH
Willi ThlcH.nces
r W1gt,V�t. Maledal pp (Show direction and distance front At lust two Stale
oS. � bM1 noads, or other map reference points)
JW
Delrlll Material
Flom To _.��_F'1• -�
Frorn ....- ---- to _..__.- _ r1.
15. SCREEN:
UrfrUt Ui:inteler Slol Slze
From -----. f'I _..__...
In.
In. __.--------
_�_--.'To
From To ___-- F L _
In.
In. _----
From .. _._ To _.._.-.-- Ft._._ ___
In.
16, SAND/Gr1AVEL PACK:
Malerinl
Uehlh
Size
From _ To--ft.__---
From
17. RF_MAn1E'1SrE.
A
� r
CONSTr1,"J
IF on OFf
Mad No:
Sedal No.
fit Ir-Y -11 JAT TI iIS WE
STni)D/�riDS,}?�)NP T
1- OrILY w: --
S. x- Submit
Q&�
COtJSTnt)CTED IN ACCOtIDANCE WITH 15A i ll 20, WELL
OPY OF 11S RECOrID HAS BEEN PROVIDED To,1iE WELL OWNS `
�--- DATE
Siot TUME:- OF F EnSON CONS�UcTma TtiE VVEtI.
glnsl 10 Division of Witter Ouallty, Groundwater Section Within 30 days OW 1 nEV. 12199

R. ..-. .......... I, ..
..- ...._.. �,r••.py .,. �.,,,.,-*. p. ..•rwn��nnM'Y'Y+M rn^r "•r'�•+ n . ... �
.2293,98
North Carelilm • F7(?pnrtm,?ni of Environment and Natural flesources - Division of Water Quality - Groundwater Suction
1636 Mail Snrvicr+ Crnlrr . flairigh, N.C. 27699-1636•Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTnACTOTI: p
WELL CONTRACTOFl CERTIFICATI N: �l� -
STATE WELL CONSTFIUCTION PEf1MITH:
1. WELL USE (Check A1•pilr:abin flex): nesldential lid Munlclpal O Industrial ❑ Agricultural ❑ Monitoring
FJ
Flecovery [_] 11e.11 rump Water Injectlon ❑ Other [] II Other, List Use:
2. WELL LO(.-All0tJ: (,;I10 sknlcl loc Ilon below) !�
Nearest 1 own: County:
(non,111inrn And Nund+ars, Commun ly, Qr Su di Islon and Lot No.)
3. OWNF-n
Address
Cily or 1 own �Stale 21p Code
4. DATE Dflil_t.FD _�__.-7'�d
5. TOTAL DFrII I -_�?�
6. CUTI U MS COLLF C TED YES ❑ NO
7. DUES WELL nul ACF FXIS TING WELL? YES NO[j?j
8, STATIC: WATER LEVEL Below Top of Casing: _ _FT.
(Use'+• if Above Top of Casing)
9. TOP Or C'ASRJG IS—__� _ FT. Above Land Surface'
'Top of casing terminstnd nuor below Innd surface requires a variance In accor-
dance with IS.A IICAC 2C . 0
10. YIELD (gpni): _6 — MET I-IOD OF TEST
DRILLING LUG
From To Formation Description
11. WATER ZONES (&P111):— --r
_ .Amount .Di'/�S It addilionai space Is needed use bark of Form z
12. CHLORINATION: Type —� - — _•___ _ _ _ .._._.___._ - ---
13. CASING:-LOCATIUNSKEICN_
Ue(1Ih Diameter Wall or WeIphUFh 1111cNie93 Mal `Show direction and dislanre from at mast two Stale
�J � Roads, or other map reference points)
From___ __To
From— To -- -- rl. -- /`// �L�2" ��•
From •--- Tn _^ rl. /'
14. GROUI:
I)rPtl1 Material Molhod e
From
From ...--- TU-----ft. -----_ _'
15. SCF1EEtJ:
t)rlrth Cli�meler Slot Size MAlerlal
Frorn---____-- 10 __..._.__. F 1 In In. __ _----
From —_ _ _ To _-•__-- rt. _
In. In.
In. in.
From ___.-._.__ To __._.__.__F1._
_—
16. SANDIGFIAVEI_ PACK: Material
Depth Size
From 10 --- Ft. .
From --- ---- — To Ft.______--
17. REtr1A(IICS:
1 DO I IFF1i"F1Y CM11IF•Y lI IAT T1114 WELL WAS CONSTf-1IJIS IN AC HAS B fJCE WITH 1 E NCAr, 2C,
WELL
CONSyt:f11.1C'T IC)tJ r' i ANF)AnD , AND 1_FiAT`A COPY U TNIS F1ECOnD N/1S BEEN PFIOVIDED TO T NE WELL OWNE
++ r+ �l� 2
kk DATE
Lua
gYar TUnEOFPEn5NCONSTnUCTlfIG TI1EW[.IL
i! I y Oroundwaler Section wilhin 30 days
o:l V 1-1 r !11 f ubmll original to btvlslon of Water Quallly.S1) t3W1 nEV. 12199
lo

.tr•r•h1 •,.tT..�"af.1..1... .i.
2 0.r)
North CnroGna • of Fnvlr,nrnenl and Natural Flesourcas - Divi^ion of Water Quality • Groundwater Section
1636 Mail Sorvir.? Crnirr - flnl(lgh, N.C. 27699-1636•Phone [phone]
WELL CONSTRUCTM4 RECORD WELL CONTRACTOR:
WELL CONTRACTOR CEnTIFICATI( f1:
STATE WELL CONSTRUCTION PEFIMITN:
1. WELL USF; (cheek nh�tit:ahla noz): f1eslden1IiI5?( Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring —
Flecovrty (_) I Ient pump Water Injection [] Other [_ ] It Other, List Use:
2. WELL LUCAT ION: skV.. ch of the ation below) � —
Nnaresl 1 Oval: _.__---ff County: —Ake22�
DRILLING LUG _ DEPTH____
(noa r ttune encf f! nh4r5. Community Subd'vI I n end Lof Na) ----- From To rorn,arlon Description
-
3. OWNFFI
Address
----
grate Zip Code
City or Town ^
/} 1 —�—
4. DATE DIIILLE1) __:Z.'p� ' Od
S. TOTALDEplll
6. CUTlIllGS COLLFCTEU YESO N09 � -.XTINWS _� NO[�
7. DUES WFI_t- IIE 1.ACF tS"-
62
8. ST'ATIC WAT En t.I:VEL Elelo'.v T op of Cnsing: _ FT. ----------•- -� z �_
(Use'+' If Above Top of Caslnp) --
ING; 18__.__� _ _.,_ FT. Above Land SllrfnCe•
9. TOP OF CAS
'Top of casing tern,lnat�cf ntlor below Iend surf Re* rsqutre� variance In �ccor-
]ar.
dance with t5A NCAC 2C .0110 _
10. YIELD (ap►n): — ___ ME IOD OF TEST — �= rn�
r —.I
11. WATEf17_CINESOti---C7--
12. CHLOWNATION:
13. CASING:
S Ii additional space Is nr±eded u;a bnck of form z
Amount - ---
TYpe —
Wall ThicHness
Dri,th Iameg or Weighl/rI. Maleda`l n�
F►om T o F1. _------
Ft.From
. ----I^ — Ft.--
1 A. GROU I : Material
Depth
Method
Q To �-0 FL
From __ _
Frorn ...... -- T o ---Ft.
—___---
15. SCREEN:
Diameter slot Size
Material
Ucpt{t
From Ft _ In.
in.
From - To ---- Ft.
in.
From _-.__-- To - -•-.__ Fl.
------
16. SAND/GRAVEI. PACK:
Material
Depth Size
From_ ___-- I'(' ------ Ft.. -------
From To 'Ft.
17. REMARKS:777
1 Do F li nFFSY
CONS i nm. I
FOn CTFFIC a
puad No:
Serial flo.
1ICY TIIA7;:T)ilS WEI
T-ANDAFIDS, AND TH
—0-t IV" 1(1
LOCf111UN SICETC;N_
(Show direction and dislnnce from at Isill two Stale
Roads, or other map reference points,)
014SrnUCTED IN ACCOFIDANCE WITII 15A NCAC 2C, WELL
aY OF THIS RECORD HAS 13EEN PnOVIDED TC► T FIE WELL OWNEn.
[)ATE
SI(TtIATL E OF F`EFISON Y aroundwaller Sect 1WWilhlrt 30 days
nal to Division of Water Duetll , pW.1 rIEV. 12l99

.. - ....... : i�..�p r •�. . •„�•. �-1Nrr•;- �...•.gTrro�•t+�Pr�,.. .r�•,n �. � ... ,229360
North Carolilin •UPI nrinntnl of f"nvir,rnnlenf and Natural Fresourcrs - division of Water Quality • Groundwater Snclk)"
1636 Mail Srrvi('n Crnlrr • rtrlleigh, I'I.C. 27699-1636•1'hone [phone]
WELL CONSTRUCTION IUIJ RECORD WE, L CO NTFlACTOFl CErnMrICATI( 1 0:` li�?ll
STATE WELL coNSTRUCT101`1 PEnMITH:
_—�• IIIndustrial � Agricullurnl ❑ Monitoring ❑
J. WELL. SF_ (clip PI•r,llr:abin rinx): Reslden1tal� Municipal [�
Recovrry [) 1 lea► f'un111 Water Injecllon 0 Other U If Other, Llsl Use: ------
2, WELL 11,9CATION: `' low skrlch of U ocallon below)
Nearest 1 rn%,l: _._--_- _
County:
DRILLING LOG UEPTII___
rinoa.l tlim rind I -i hr! s• Community, or Subdivlslon and Lot Na) ._ ---- --- -- rorrnation t)escription
From To -
3. OWNFrl
T
Address -_--$ — —
G_."- �..—Slate Zip Code �_
City or 1 own --�^
4. DATE DIUI-L-FD-
5. TOTAL_ DFI' I I _-_��
6. CUTTINGS COLLECTED YES[] NO[� �
7. DOES WELL TTFF'LACF EXISTING WELL? YES U NO[�
B. STATIC: WATER LEVEL Below Top of Casing: D FT• p
(Use'+' it Above Top of Casing) �y .. �=
9. TOP OF CASING IS FT. Above Lend Surface' = C")
'Top of ceshnl lernllnnlyd ntror below tend surface requires a variance In actor• ... ��
dance with 1 g Nml1C 2C .0118
(j� •� �,o
10. YIELD gprrt) -- METHOD OF TEST A� M
11. WATER ZONES (depth):__- 3 xra
tY7 =
S If additional Spare Is needed use back or Wm
. Amount lei - �- ---
12. CHLOMNATION: Type _..._.- .. -
13. CASING: LOCAL IUN SKETCH ,.x
Walt llilcknoss Material (Show direction and dislnnce from at host two Stale
U�hlh lame or WeIghVF'6 Floods, or other map reference points)
From To -�= Ft. sM'r�— `�A_5
From--- T o---- Ft. —' �!
From • — j n -- rt.— — / `'
14. GROUP: a(,t ( 7 �+�• /�, C .
Mterial Method
Dr�ptl•t)
From o �}Z Ft.
From 1 o Ft' —
15. SCREF: N:
Uoplil Uiarneler Slot Size Material
T o - --- A— In.
From In.----
- In.
From __ T o _____ FL — In. -----
From .. _ T ° - - Ft. in'
16. SAND1GIIAVEI-TACK: Malerlal
Depth Size
From -- T o Ft.._ _----
From 1 o _---- M.
17, REMAnKS:
^ AS
LUW O
COt
I OO t iFfrf E1Y ' �i tlal if �l' rrlh�l Ttiil r W
CONS1nUrT101 '1/�J1)AFIC�.i,°ANDT}IATA�RY
Eau
R CtF f ICEtALY
d No: 11 s Submit, Q11131l
s t- - �.a
rial tlo. t- vi
TnUCTED III ACCOMANCE WITH 15A NGAC 2C, WE.LL
F T111S nECOno HAS BEEN nOVIDFO TCI 11IE WELL. OWflEn. `'
_ -- — pnrE (/
lnrunF_ r rEnsofl CONSrnucnnra rl+r vrr.:t.L
rlin 30 daY
division of Water Ouelily, Oroundwaler Soction Wit g 4W 1 nFv. 12199

! �4.:• 'M «M. ,.. a..�l �.. ��.«.. «.1yvHi��N r ill+'!, .. :... t: � %` ..
229361
florth Cnroli„n . I)ef+nrirnent of Environrnent and Natural Resources • Division of Water Quality • Groundwater Section
1636 Mail Servico Center - flnleigh, N.C. 27699.1638•Phone [phone]
WELL CONSTRUCTION RECORD WFLLCONTrIACTOR: ��F-&5LxsPg-.�-/-
WELL CONTRACTOR CERTIFICATION
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Appl1rabla tloxy nesldentlalu Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery [_j I [(?,It Pump Water Injection ❑ Other ❑ it Other, List Use:
2. WELL LOCATION: (ShOP sketch of th.9 location below) -
Nearest Town: �� /�//L,� County:
(no,%d Ilmmn and I tr ts. co"Immilb or Subdivision end Lot IJo.) DRILLING LOG
3. OWI` n ..t•�_ From To
Address �t-
�ou
._ Zip Cod d
City or T mvn St le p
4. DATE UI11LL1=U
5. TOTAL UEl- F I I _. _
6. CUTTIHOS COLLECTED YIDS ❑ NO[1� r;�
7. DOES WFI_L- F1Ef'L.ACE EXISI ING WELL? YES [�D NFTOLJ
'
8. STATIC WAf En LEVEL Belo%., Top of Casing: -
(Uso'+" It Above Top' of Casing)
9. TOP C)r CASHIG I __..._._�.___.... FT. Above Land SuriaCe'
•Top or eashln terntinntnd rir(,r below Iend surface requlres a varlance In actor -
dance wllll 15A NCAC 2C (1
0. YIELD Of1f11): -.--D ..--- METHOD OF TEST I14_a
11 WATPn 7.OPJES (dull): —
12. C111-017lif,IM ION
13. CASING:
DEPTH _R_—
r'ormallon Desrdption
T yT,o _ Alttounl-��'� If additional spare Is needed nse back of town
Km
Dr'I, 11 %
-1 o� �11nletef
From _.__.__ __._ Ft.
FL -
From
14 GROU I :
LOCAT1c7N SKEICH
Wall 11110-nest
or WelgnUFt. �PA-alydnl (Show direction find dt ;tarlCe F(orit al I9 1SI two 51310
.11L.115 T MC: SQLP Roads, or other map reference points)
T telith Material
Ftor11 ___ U _ To
Frorn 10
15. SCREEN:
Urplh Diameter Slot Slze
eW,
.VolI d
_hA&MCL
Material
From _______T0 __— r" - In. In. _------
From To _ Ft. in. 111-7---------
From To Ft. — In. In..._.---
16. SANUJGnAVEI. PACK:
Ueplll Size
From --- ToFrom
-
[-
17. REMAnKSi*,r" �- `
1 DO t tEr1EE}N CIF t I IFY TI IAT TI IIS WELL
CONSTr1UC' `Qd 'iBTnitlpAnp jtAp,,13,, j
FOR OFFICE USE NLY
Ouad No: Ql3tid4 a� r
Serial No.
Material
)NSTnUCTED IN ACCOrIDANCE WITH ISA NCAC 2C, WELL
Y Or THIS RECORD HAS BEEN PROVI ED TO TI IE WELL OWNER. 0
DATE
S ATUnE OF rmsot CON nUCTING TIIE WEIt.
el to Divlston of Water Ouslity, Groundwater Section willtln 30 days oW I REV 12199

_.—.._.�..��.�_.,,�.- �,y. rr �t..e..,.i—... _.rx rMrlYr1•!yi}Y7KMr �s .,y..�c. i. .... ...
... is .. .. .. ... ... � y�
�1'7 375
North Carolina • Dehartrnnnt of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Cenler - Raleigh, N.C. 27699.1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION N: '
STATE WELL CONSTRUCTION PERMITf1:
1. WELL USE (Check Appllc,bta Flax): Ftesidentlal❑ Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery Cl I leat Pump Water Injection ❑ Other ❑ If Other, LIst Use:
2. WELL LOCATION: (SIt sketch of the location below) �'`-��/_
Nearest Town: —_
i q d��L County: d`S
(n0ad Narno and Numbers, q7aluly or Subdivloop and Lot No.) DRILLING LOG
3. OWNER From To
Address
NO.1
i istato
ffl,Ro, Zipp Codeeiry 0"r l ov+�
4. DATE DIIILLED� ���
5. TOTAL DEPI I I __3
6 CUTTlt4GS COLLECTED YES [] NO[ 1 r
— DEPTH _
Formation Description
7. DOES WELL REPi_ACE EXIS TING WELL? YES
8. STATIC WATER LEVEL Below Top of Casing: jAp FT• p a
(Use '+' If Above Top of Casing)
9. TOP OF CASING IS __f FT. Above Land Surface"
'Top of casing terntinatod stuor below land surface requires is variance in accor-
dance with ISA NCAC 2C .0118 r _ _
10. YIELD (gpm): _LO-0 METHOD OF TEST
11. WATER ZONES (depth):
If additional space Is needed use back o orm
12. CHLOpiiNATION: Type _ Amount .s _ —
13. CASING:
-_LOCATION SKETCH
Wall Thickness
Dehlh /D),a�m�elo�r el UFt. serial (Show direction and distance from at IFlast two Slate
From 6�-'�- Ft.
-"-�—_-- �� �� Roads, or other map reference points)
From— TO -- Ft
From - I o - Ft. '
14. GROUT: 1
Del'
Material elhod /J From _S� To � Ft. _ %%A/1J&tlf
From .-...____ To —Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From __ To Ft _ In. In. From ---- To --- Ft. In. in.
From __-- T o Ft. In. in.-
16. SAND/GRAVEL PACK:
Depth Size Malarial
From _ _ _— To Ft. �-----------
From To Ft.
17. REMARKS:
DO t iEREDY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS 8 EN PROVIDED TO THE WELL OWNER. 4'a
FOR OFFICE USE ONLY DATE
Quad No: SIGMA nE OF PERSON CONSTRUCTING THE WELL
Submit original to Division of Water Quality, Groundwater Section Within 30 days GW 1 nEV 12199
Serial No.

North Carolina - nepnrtinent of Environment and Natural Resources • Division of Water Quality • Groundwater Section 2"
1636 Mail Service Center • mileigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICA ON #:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (check Applir lA nox): Residential ❑ Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery [_I I Teat Pump Water Injection ❑ other ❑ If Other, List Use:
2. WELL LOCATION: w sketc t f the location below) ��,� l�ti�-
Nearest Town: —� County:
-- DRILLING LOG __ UEPTH
(Road ftnmu And 11 it) , Com ,ily�or Subdivision and Lot No.) To Formation Description
From
3. OWNER _
Address _/ C �ll1� 5,� /�.• /��_
Ir
�Slrcet or iTo—u a� % �
State
Zip Code
city or 1 own —
4. DATE DRILLED-
5. TOTAL mmI I
6. CUTTINGS COLLECTED YES ❑ N05
7. DOES WELL nE:PLACE EXISTING WELL? YES ❑ NOIW(
8. STATIC WATER LEVEL Below Top of Casing: FT.
(Use +' if Above Top of Casing) C/)
9. TOP OF CASING IS__( __ __ FF• Above Land Surface'
'Top of casing IerminAlnd Atlor below land surface requires a variance in accor-
dance with 15A IICAC 2C.0118 = ,�
10. YIELD (gpnt): 11_0 METHOD OF TEST _
11. WATER ZONES (depth):
Amount If additional space Is needed use back of I tf
12. CHLoniNATION: Type _ r
13. CASING: LOCATION SKETCH— `� o
Wail Thickness alerial (Show direction and distance from at least two State `
Depth �� %�lam�ete� or Wei hVF
From
�_To -Lam= Ft-111 Roads, or other map reference points)
From l o -- Ft. — ---
From - To Ft. ------ - —
14. GROUT: Method
Uep^lit� Materia
From D To aD--- Ft.
From .___—To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From -._ To
Ft _ In. In. ___----
Ft. in. In.
From - TO In. _------
Front To _____-___ FI. In.
16. SAND/GRAVEL PACK: Material
Depth Size
From To Ft. _-----
From __ To Ft.
17. REMARKS:
i DO i 1EREEIY CFRi IFY TA ADS'IAND TkiA7 A COPY OF THI CONSTRUCTEDLL.WAS RECORD HAS B E EPRIOVIDED TO TF-1E WEB LOWNER.
CONSTRUCTION ,STAND . f? t —/� y� •
1
—TDATE
Eouad
FICE USE UNLY SIGNATUr} OF PERSON CONSTRUCTING; TIIF. WELL
!i ��j
Submitoripinal to Division of Water Quality, t3roundwater Suction Withlrt 30 ays t3W 1 REV. 12/99

North Carolina • Deparin,ant of Environment and Natural Resources - Division of Water Quality - Groundwater Section
7 3 7 l
1636 Mail Service Center • naleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATIOD�g
STATE WELL CONSTRUCTION PERMITH:
1, WELL USE (Check A`pficabin nox): Residential❑ Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery 0 f teat Pump Water Infection ❑ Other ❑ If Other, List Use:
2. WELL LOCATIO • Show sk Itch of the location below)
Nearest Town: .0 County:
DRILLING LOG
(Woad Narno and umt rs, Cornrr city, or Subdivision and Lot No.) Formation Description
,, ,„',� - From To
3. OWNER
Address C
_ice
!reel or Tiou o No.�+
coy�orlownSlal�Zip Code r/
4. DATE DRILLED _ SC'�d•-��►a►--a __
5. TOTAL UEP'l H _J� •-
6. CUTTIi.IGS COLLECTED YES ❑ NO[
7. DOES WELL REPLACE EXISTING WELL? YES 0 [>�
S. STATIC WATER LEVEL Below Top of Casing: _W
(Use '+' If Above Top of Casing) r:�
9. TOP OF CASING IS ___- FT. Above Land Surface"
'Top of casing torminstnd atlor below land surface requires a v r.ance In actor- i 7-
dance with 15A NCAC 2C.01 18
10. YIELD (gprn): METHOD OF TEST
-�
11. WATER ZONES (depth): -== r�
_Amount " !s if additional space Is needed use back of fd►At r-
12. CHLORINATION: Type - --- -- ---+
13. CASING:
LOCATION SKETCH �-
Wall Thickness
Depth qlametq, or W I9hUFt. aterial (Show direction and distance from at IRast Iwo Slate
Roads, or other map reference points)
From —AD —To Ft.
From 1 o F1,
From To - Ft.-----
14. GROUi: elI d
Dept�hMaterial ) A /
From ____a l o �l — Ft. i�
From _..__ __ To Ft-
15. SCREEN:
Uop1h Diameter Slot Size Material
From To Fl In, in.-------
- From To
Ft. in. In. --
From _. _ To FI• In.
16. SAND/GRAVEL PACK: Material
Depth Size
From __ __ - To Ft.
Front ___ _ To Ft.
17. REMARKS:
2C, WELL
CFR1 IFY Tt IAl -THINT IA WAS
COPY OF TI4IS RECORD HAS EEN PRIOVIDED TO T HE WELL OWNER.
LON STnNDAnt?:S, V' i /
�d on1E
USF ONLY SIGNA UnE OF PERSON CONSTRUCTINC III 1E WF..LL
S + o cc
I .' `Submit original to Division of Water Quality, Groundwater Section Wilfllrt 30 days GW 1 REV. 12/99
DO tiERELI
CONSTRUC
FOR OFFICE
Quad No:
Serial No.

�n u T\. •• eW1t ,yt.., ..�. �, .p ��. i
Iorlh CnroNna • f ^I'mlrnrnl r.\I Fm'tr irunrtril nrtd 6Jnlurnl ilcarnrrr rs • Divl.^.Ion of Water Ouality a Ornundwnter Section
630 Mail Srrvirr Cnnirr • ilnirnigh, N.C. 27699.1636-none [phone]
WELL cui4s,rmjc,mtA nECOnD WELLCONVIACtOFI:
WELL CONTFIACT011 CEntir-ICATION A. ---
STATE WELL CONSTFIUCTION PFFIM110' —
Ej2( MUnlclpnl [J- Industrinl EJ AgricullUrsl Monitoring ❑
1. WELL UHF (Check AI I•ncahh nox): neSidentlnl
Faecovnly [_ ) I Irrtl 1'ulnp Wnter Injection 0 Other [j if Other, List Use:
2. WELL LOGAIION: toW sketch i the location below)
Nearest l own: -
County:
(�oad nan,n and N, ,hnrs, Communil r Subdivisl n and Lol No.)
MILLING. LOG--_—
To formation Vescdption
3. OWNER
Address
From
--
ity or l nwn Stale Zip Code
4. DATE Urill.I.E:O
TOTAL i)r-r T I 1�-
5.
6. CUTTINGS COLLFC 1 ED YES E] NO[1/
L/\cE EXISTING WELL? l�l
7. DOES WELL FiE: gE5 �F0
LEVEL 13e10W Top of Caslit-----------
6. STATIC WATER
(use•-.
'+• 9 Above Top of Casing)
9. TOP Or' CASING IS _..___�— __ FT. Above Land Sutlnce•
�-
c
'Top of ceslnrl ier nClnnlnd ei'm below bind surfeoe requires a Verlenee In Actor -
fence with 15A iICAC 2C .011 `
MEII-IOD OF TEST
3>c�
10, YIELD -
3:
Vic?
11. WATEFI 7.ONES (depot):
Is needed une brick o1 Ion'
rrnm
Ari1,�
f► Ii eddillon21 gimce
-
12. CNLO►UNATIUN: 'Type _
-- -
13. CASING:
__1OC/1TIUN SKFtCH
x
Wall Tillckness
D�illlt ninmelnr crdV1 IQI url. Malrrtnl
r� Ft. L-- a�a1rJ P-
-
From.-----_--- l o _--.-- FL_ / --• ------'_• --
From
14. GF10U i ; Mntefl�Cl E� Motltod
Itr+lrlh ����
Fier" n-
From _ .._..___ T o ..._-----F't. —
15. SCF1EFf I:
l.trl,lh I)Innlnlor Slol Size Mnimi�l
From ----------
In. In.
F( In, Ill.
From -.. - _ - i o _ ..._.._
16, SAND/GiIAVFi. rnCK: c
Ur1�lh alZe
From ---- - 1 n -_. F1.
F r nm t o ---- F l. ____-----
17. FTEMAIIICS
I UO►rr1U'nY"
CONS 1 n1 K' 1
Ouar7 No:
Serial No _ ��..----
n.rJDA110 3, AND TI IAT
Mntorial
(Show direction and disinncn born fit Dell two State
Floods, or other reap reference points)
J^. ICT1° IN ACCUr1DAtJCF WITIi 1SA iICAr T►IE YI2C, Y✓EI_I.
tits Ero m OEEN En vmro TU F.LI. U�!ir
r
GIIATtl or rrnSOtl C0f „r section whhln 30 drays
to DIVIslon o1 Willa( Cuellly t3W•1 pFV. 12/99
r4i

t � . w. �. ...,. •M cw..ar•..ry,l.a�.. .s. ..+.a� �•MM`: a• r 1� 1+W.. e;a. ., .:. � ..
North Carplion - Drpnrlrrwrit of Environment and Natural nesources • DivirIon of Water Quality • Groundwater Section 4w 8 0
1636 Mail Servico Contnr - Flnleigh, N.C. 27699.1636-Phonoo [phone]
WELL CONSTRUCTION RECORD WELL CONTFIACTOR: �u �7pl�
WELL CONTRACTOR CERTIFICATION q:-
STATE WELL CONSTRUCTION PEnMIT#:
1. WELL USE (Check nprlic,tilo r3ax): Resldentlal51 Munlctpal [l Industrial EJ Agricultural U Monitoring ❑
Recovery 0 1 teat Pump Water Injection 0 Other n If Other, List Use:
2. WELL LOCATION: (S'w s tch o! the location below)
Nearest Town: �_ �s� '!� --- County:
(noarl Nano and` nbr, s, Corn wnity, or Su vision and Lot No.)
3. OWNER
Addr/essAt y 1
It ri or o p�
City or Tovin Stale OZip Code
4. DATE MILLED 4-_'a6 'D6
5. TOTAL DEP F I I
6. CUTTINGSCOLLFCTEU YirS[_] NO[1�
7. DOES WELL REPLACE FXISTING WELL? YES [,J NOEO
8. STATIC WATER LEVEL Below Top of Casing: _/� FT.
(Use's' if Above Top of Caslrrp)
9. TOP or CASING IS __ I _.-. FT. Above Land Surface'
*Top of esshrn tenninntnd eiror below land surfrce reryulres a variance In accor-
dance with 15A 11CAC 2C 118
10. YIELD (gent): L.-� MEl l IOD OF TEST
it. WATER 7-ONES (depth): --
DRILLING LOG
From To
X
_DEPTH
Fomratlon Description
12. CHLORINA, ION: type — _ Amount If additional space Is needed use beck of fnrrn —
13. CASING:
Wall Thickness
Depth plam�el,o.r orRW� Iq; fit
Fro m.--
From----._-__.
To _-- - FI.
From -
_10 -- H.
14. GROU F:
Depth ethod
�Material
Ft.
From _ _
ToD_
Flom _... --
10--------
15. SCREEN:
Uopth Diameter Slot Size Malerinl
From
To __— FI - In. In. _______---
From
To _ Ft. In. In.From
_To_-_-.—FI•._
In. In.
16. SAND/GRAVEL.
PACK:
Depth Size Material
From
To _ Ft -
From --.--- _
to Ft.
17. REMARKS:
LOCATION SI<EiCH
(Show direction and distance from at least IWQ State
Road , or other map reference points)
1 DO 1tEnCf1Y CIF niii 'TIIAT T(-tIS W6lL WAS CON SMLICTED IN ACCOnDANCE WITH 15A NCAC 2C, WELL COPY
CONS inUCTIOP) STANO'MDS;'AND TIfAT A C,OF'Y OF TH FtECORO HA3 BEEN PR VIDED 70 711E WE4lL OWNER�
E&d
F-ICE USF Ol`ILY DATE
i 1 1 SiClr nE OF PERSON ONSMUCTING THE WELL
i �� (! t
Subm11 original to ivlslon of Water Duallly, Groundwater Section Willtlrt 30 days GW i REV 12J99

2f.133f)! i
North CarOlina - Department of Environment and Natural Resources . Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:o�aQlII.So�I!
WELL CONTRACTOR CERTIFICATION p: 69,26.
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (check Applicable rlox): Residential LYJ Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery 0 Beat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: how sketch of the location below)
Nearest Town: _���ll— County:
(noarl rlamo and t rnbers. Communily, or Sub ivision and L t No.)
3. OWNER
Ad ress
1 tree or u�i o. �-
City or Town Slal ZipCode
4. DATE DRILLED ���0�
5. TOTAL DEPTli
6. CUTTINGS COLLECTED YES ❑ NO[�
7. DOES WELL f1EPVACE EXISTING WELL? YES ❑ NOEV
8. STATIC WATER LEVEL Below Top of Casing: .70 FT.
(Use '+' It Above Top of Casing)
9. TOP OF CAS114G Is__FT. Above Land Surface'
'Top of casing ternnfnnted vl/or below land surface requires a variance In accor-
dance with 15A fICAC 2C .01 9 -
10. YIELD (Weil): METHOD OF TEST
11. WATER ZONES (depth):
12. CHLORINATION: Type _ Amount
13. CASING:
Wall Thickness
Depth Diameter or We�1�91�5 Material
lR
Q
To Ft. ltaL
.
From
-mod —
From—
To Fl.
From
To Ft.
--
14. GROUT:
Depth
����Material
ethod
From
To � Fl.
sue.
From
To Ft.
---------
15. SCREEN:
Depth Diameter
Slot Size
Material
From
To _ Ft
in.
in. _-------
From
To Ft.
In.
In.
From
To _. Ft.
In.
in. -
16. SAND/GRAVEL
PACK:
Depth
Size
Material
From
To Ft.
—
DRILLING LOG _ DEPTH _
From To Formation Description
r
0 �
cm
co <
�n
--t
Ii additional space Is needed use back of fold _
_LOCATION SKETCH
(Show direction and distance from at least two Stale
Roads, or other map reference points)
liWiL�uxa.Ho�--
From _— To Ft,
V. REMARKS:
I DO HERE©'ONR TI�tJDAROS;`AND THAT A COpY ST THIS RECORD HAS BEEN PROVIDE
TO THE WELL OWNER.
CONSTRUCT ; $,;
���`� DATE
FOR OFFICE U E ONL�(,�f� /1 .r-n;
Ouad No: {Lw(�..,.' $I ATURE OF PERSON CON RUCTIN(3 THE WELL
!; Submll oripin8l to Division of Water Clusllty, Oroundwaler Section Within 30 days OW i REV 12/99
Serfat No.

... ��, _. .. T, •, n, �.. •.. ,.r �.....y..rr•.l.. .w rs..Tr.•M►'�.I'rrr r• � t �. � �. .. .
North Cnrrfnn . (rnpnrlivionl of I-nvirnnms?nt find 1lnlufal r1f nnurcn'1 - VIvI.^.loft of Water Quality • (lrnundwntor Sn(.11-n 'L 17 3 8 4
1636 Mail Snrvir-n Cnnlnr • flatniph, 11 C. 27699-1636-Phorin [phone]
U WEL1. CONTnAC1011:
WELL CUtJS i iiU(rl IONFiECOFi
WELL CONT11ACTOf1 CEf1TIrICn
.31ATE WELL CONSTf1UCTIoll i rIM1116:
Monllnrirtg
1. WELL U�r (crier k nf,hnrnlnlr now): flesldenll,l� 1vlunlr,(pa( L� Industrial I_J Anrlcullur:,l I__� —
flvco mry ( f Innt f v1111, Wilvr Injecllon (_]
2. WELL 1.O(:AI ION: n1micll,Of Ili© locallon below)
__-
Nenrenl 1 r,cn: -_---
_ unILLIN(3LUU
Lvn� N,(l Ilan, ��r5 �C,-)mnnlnity o slon Prtd lol 140.) — r0nr,nllOn Qe"cripvon
� Front to
3• OW N r r 1-------
-- (-
•tin4,
.-
_ — gale Zip Code
:i,q ni lm•.,,
4. VAlE (,r111.1 t:lt -_gam �7'.�.
5. 10TAI. 11iT I I _ ... 3&-5_.
s. CurlIr11;r; (;l)1.I rr 1r.li YFS(_ 1 NO(j7� �.� ><L� - - — ----- a-- --
7, bUT1 b'1i ,, Ilrl'I �(;f" rxlSlltd(1 WELL? YES NO -
©. SIATIU �V/�lF:rl LiiVl"L f)r_low Top o1 Cnsln
II Move Top of C114,rJ) _-- _ -- ---- -
rT. Abovn Lnrld Siirincv' _...._.. _---- -.
9. TOP Or' (:A`�11d(; 1�; __ _____----------
•Tot, of ca,in(l i.rn,h,ni^.I r•trr•r hrlow Innd eurlece loqulres • veriance In •ecor•
danceYrllhir,/\IIrAC9C.niIR
10. YIEL11 (q(`rr1) _% '. h1Eli lUU OF ZEST
11. WATEiI 71MUS .......
_- -- ---
12. CIiLOI11NAiIUr1;
�.�, �AnrolUtl SdI�H�S Ii nddltlonnl �(,nr:n Iq nnnclnrl r)rn hark o o.....
13. CASH I(' --- 1_0CA110.1J.SKE1-C!1
Wnillld H.noss
Ulnmrl r or WAIphUr1, rAalcrinl (Show diret;llon rind dill-Irprn at Innol two S1a19 lloads, Or 011,t!r ri,np relr!rPr,cv polnls)
v I.J _ /
From . l o - — --- 1 1 — — yj '
14. G110U 1: Matvll 11 wlollrod �•/�
non, . _- lr, ...:.. _..._r"1. _-
15. SCf1C r" (1: MnlvrlfTl
11ri,llt 1iis,tnnlvr Slot Sltti
In• _ In. -----
-__------
I rom
From
- ....... l o .. ... _..__ Ft._----
16. SANDIGflAVUL PACK: Nlalerlal
i)r(�It, 51ze
From-----•—...-------
rrOrTi ._ -- 1 °
17. FIEtu1Al11:S— _�
F 11119 Mono HAS 13EEN 1'F10VIDF.D TO 111E WELL OWNER
1 DO IIt tlr f,Y ('r iltlr-Y 111n1,TIh9 WELL WAS COY isMILIC1CD IN nCCOf1DMICF Wlrll 15A N(:AC 7.C. WELL
CONSTfIi,lcII ,t1 �Tnr)t�/111nS 1�1J0,111ATAC0
' UATF
FC)ICE IS - SO
1f COtISTUCTllir3 1
►11(liAT 1if: Wrl.l.
0uad flo: Submit orlpina110 blvlsl0n of WAIef Ouelily, l3roundwAler Snclion Wlll,lri 30 CI7ys 13W 1 nEV 12r91

229369
North Carolina - I)nhartinr+rrt of E'nvirorimenl and Natural flesources - Division of Water Ouality • Gioundwnter Section
1636 Mail Service Center - flaieigh. IJ.C. 27699.1636•rhone [phone]
WELL CONS"[ RUM'1014 RECORD WELL CONMACTOn:
WELL CONTRACTOR CERTIrICA1l( N:
STATE WELL CONSTRUCTION PEnMITfl:
El
1, WELL list: (check n.l I ncnbin nox): FlesldentialLYJ Municipal [3 Industrial ❑ Agricultural ❑ Monitoring
rlecovery [T[ I lent Pump Water Injection ❑ Other 0 If Other, List Use:
2, WELL I.00ATIOh County:
S-h�o-w kn,tch of the location below)
1 1 c' D_ U
Nearest Totsn: —_—.o-...�----
DRILLING LOG UEpTI�
(norvf rtnnfo y—tJunthcrs, Cbnvnunit , or S bdi Mon qPALot 1`40 ._______ _-----•-- `
From To F'ofmalion pescrlplion
3. OWNFF1 _
Address $
li". it rf`l Of OU-10 0.
City or 1 own
Stale Zip Code
4. DATE DRILLED-�--
f
S. TOTAL DF 1' l l l _--- __� O —
OIIF('- EED YES[I Nor
6. CUT1111(�S C ..
YES
DOES WELL IIE PI ACF EXISTING WELL? [_ ]
7. FT.
6. S1'ATIC; WAl ErI LI:VEL r3elow Top of Casing:..�
.
A
If Above lop of Ct+slnp)
2s
��
9, TOP OF CASING FT. Above Land Surface'
allot below (nnd surface requires a� variance In accor•
. __--
C-n
d lenilnd
'Top of ceslnnnn
dancewilh 19.41JC11C2C.a1i0
v�
10. YIELD (gprlt): A"_ _ METI IUD OF TEST L,f,J{�--
--
11. WAT Ell ZONES (drplh):—
_ _
—S
If additional space Is needed use back of 1t�m
12. CHLORINA11ON: Type — Amount ' " T'
_- - _...- -
_.... 00
25
13. CASING:
L0.CA110N 5_1 EF! H
Wail
Mal
(Shodirection rtwo Stale
�erll,cknoss
Drl)llt Diameter or WeighUfL
olnls)ds,or olicrtaprelerence p
�
From _.------
From
14. GROU l : Material Mothod
Orpllt
Q l 0� Ft•
Q/hlt_
From _
Front ......_._— to
15. SCpEEN:
I DIaIrlP.ter SIDE $IZA MRterial
I)nitl 1
Frain
From 10 __-- rt. — in.
From __.- --- To _.._-- Ft. In.
16. SANDlGr1AVEI_ PACK: Material
Depth Size
From _ _- T o — Ft. _.
From 0-----'Ft'
17• REMAnKS WELL
1 Op F IF f1F nY�� 'I 1IF Y 1}IIAI(�(11L4r`W�.s GQNSTFIUCTED IN ACCOf1DMICE WITH 15A TO II 2C,
I Do I it 1l1CT l�AIJDAFIDS; AND'T'FIAT AiCOf'Y OF HIS RECOm HAS BE N PF10ViDED TO 111E WELL OWNEFI. ,
C ---__ _—
Ze Aw—
t'ii'R 2 r'i?'ll DATE
Eauadrrlt,E ! ��� t4 a ,' '41(tNAT E OF r EF1SOtJ C tJSTnUCTltrr3 TrIF WEI.I
o: `Submit orlplrial to b(vlslon of Water Ouellly, Groundwater SectionWilhln 30 daysaW 1 nEV. 12r99
o. iitr .
k

1or1h CnroNnn • ir` l`�rhrn7nt nl i"rtvirnnm^nl rind Natural Fleznurr 't • Uivl^Inn of Water Quality • Oroundwnlr.r Secti< n
,636 Mail Snrvir-n Cantor Ilalclgh, 11.0. 27699-1636•F (tone (91B) 733.3?.21
ECOFlU WELL CONTFTACt0111:
YELL CUtJS (filJ(,1 IOt F�c2.c7
WELL C01J111AC1On CEnTIrICAT1011 R.
STA1 r' WELL CONSTnUCTION t'FnMll f): _._
l� tvlunicl nl Uj Industrial 17 Agricultural (� F,Aonlloring
1• WELL I.111: (Chick r,l t•n�,hl�Tlnsldn itlnl other It other, List Use:
n llon O
.Covery [_l I Ir`nt (wall) Water Injec[]
2. WELL I.O(-Ai1O Chitty sketch of ilia location below)
Nenrr±sl tov:n:
0,!County: ---�-
DRILLING
(rloed rl�n,n rd thin`!`^ C:amnnudty or bdiv n end Lot No.) From o rorrnAtton Descdption
3. OWN _ I
Address J ---
- to`r rrila�ZIP Cade
No`.
City nr "In%•+n �r
-•�-&In►e
4. DATE r-
[?iIILLE U_ 0 •. a. d o o
5• TOTAL DrIII I i _.
6. CUTTRIGSCOLLECIED YES [� NOL _
7, DOES WELL TIET'V10E E XISTING WELD YES F . o
of Casing:
�
S. S'TATIC WATEFI LEVEL Below N e'+C (shove lop of Casing) --
FT. Above Land Surince'y.v'
g Tpp or r•ASIt IG I.,r -_-.-_- - 1e9
•Top or ceshra vtoonce In actor• a• ma
n ►rr nthtnlnd n'I,(,( below land surtaee 141u,
lance wllh l6A tirAC 2C .0I18 �•" cn
A_ MEIHUD OF TEST
to. YIELD (Qltt�+): --
WATEII ZONES ( c-'
do tlh -------"�_.._----►----
11. I ): oz-
Amount
S II eddltlonal teltrice is needa d u ,3 bn,k of tl i t' _- ^-
V. Cl-IL0111NA-TION: lype
'-7
13. CASING: _._LOCA11tJN SK�1CI_I
IPf8111111cp'1le, !
Dlnrneler or Wet id%t'1. MateAnl (Show direction And dislt+ncn Irom fit mast two State
UPIt1h � Roads, or other mnp reference points)
Fromo-a=
Flom
14. GT10U1: Malarial � ^ Mntlwd
Front ___.0_
From _. .._.._.__ to --rt•
t5 scnEr.11: SIOI Slze Mnletial
l)rltllt UhmClor
From - - t n _._..._..._ F't -- --- in.
- in.
• From 1 rt 1"t. _--
_ ..._ - - In. — In. --
From rt•---
16. SANDIGHAVn. rAGK: size Matellnl
Dr1`Ilt
Frornrt.___-------
F i oat lo..F t . _-------•~
---
I[)r D 10111E Wrl.t. UwrrEn.
AT -A COPY C)F 1 Fi UIiC) Fits OEEN P . Q
UO lu'ttt't�Y c r rid) it l�tl/�1lri}tltort W:14 WAS GONntttllG cU I 1 ACC0n00131 1NITH i5A 1lGAC 2c,
I �.CONSinUC:tt(ttl'��'�i�rglf7ntl[)3, AtJU_TFi
j `-,,
F011 Clf fICE U ,f �( tll( j I r 1' I ! SI(31JATUnE F rrnsotl Cor,stnucTl n TtiF WF.tI 12199
OurdNo: � .)�2 r_ ,� , 1 GINA npV.
t,t ;{ Suhn>I1 odpinil to plvlslnn of Weler Quetlly, drourtdweler Secllon Y+11111n 30 t y9
Serial110

North Cnrolinn • Dal1mirnent of rnvirgnm8nt and Nalurnl Flesrnures - Divlsinn of Water Quality • 13roundwnter Section 9 2�
1636 Mail Service Cnt)lnr • Ilnlelgh, N.C. 27699-1636-Phone [phone]
VVELL CONSTRUCTION RECORD WELL CONTnACTOn: "Al—Lk-� &-QL--
WELL coNTnnCTon CEnTlricnTI0I4 a. , �Qr �—
STATE WELL CONSTnUCTION t'F..n itf: —_ —
WELL USE (Check my llcnhlo ilex): Residential tvlunicipol ❑ Industrial d Agricultural U Monitoring El
Recovery [_) I Ir.at ['ump Water Injection [] Other ❑ If Other, List Use:
2. WELL LTown: TJ:,(SI!p�v t `[ I cat�ow)
Nearest Town;.--�� County:
(noad damn ar Nur b rs, Cornmunily, or divisl and Lot No.) DRILLING LOG
DEPTH
! From To rormatlon Description
3. OWNEfT
Address
(Sir Clot otloTlo�^
City or Town Stale C Zip Code
A. DATE Uf 111.LF1) _ d
5. TOTAL_ DF_f iII _ �� r
6. CUTTIf IGS COLLEC I ED YES 0 NO[� to
7. DOES VVELL RErLACE EXISTING WELL? YES [4- NO[kr
6. STATIC WATER LEVEL Below Top of Cnsing: FT,
(Use '+' If Above Top of Casing) ..
9. TOP Or CAS111C, IS_.___-�—_-- FT. Above Land Surfnce'
'Top of csebrrl lerminnlod nt'or below land surface requires s verlance In accor-
dance with 15A HCAC 2C .D118 .
'0. YIELD (grill): _._ METHOD OF TEST
11. WATER 7-ONES (depth): w ��
12. ChI_Amount 0 Is It additional space is needsd use back of form -_ -
LOT1IIJAT ION: Type
13. CASING: . LOCATION S_KFTCH
Wall Thickness
r� Df,hlll Dlarnetor or Wet hUFt, tilalerial (Show direction and distance born of least two Stale
C/ rt L •aS� Floods, or other map reference points)
From--_ To -
Fror1T----- T o --.._ rt. --
From --To _— Ft.
14. GROU I :
Derlll Material Method ' �f ee ►/(/
From 'To
From _--- To
15. SCREEN:
Dr,11I11 01,1111eter Slot SIZE Material
From — I o — -- rt In. In. -
From — -- T c1- -- 1 t. —_ in. In. From --- -- In. In..�-----
16. SAND/V[lAVEt rAC,IC
Size Material
Dnhlh r�tl
I,
From ?_g
Frorn _ T o Ft.
17. REMA[tltS
1 UO l t( I Ir f� Y t'r n 1 rl r T I IAT T LA JU ELL WAS 1AT A COPY C)FN. tT TIS iT C�fTD liAn� SEE
N P I VIDEO TO T I IE WELL I OWNER /�j
CONST,nr!C11<�t1-S1AfJny�r�t],} t / - - J
tl 9tJ SI➢t�3f���r�„. � gg �, 1
r01T UrrIC� USE``( ILY" DATE
SIOIJATII or r : Soti collSTnu ING TI IF WELL
oued No: al to o!vislon of Water ouellty, oroundwater Secllon within 30 days
12/99
--- — --- Subm I o p n (3W.
Serial No. --

.. - .�. _: .. ti , roe' rt �. ;.-*•�ir••I• +rw.gYr�►p•'•tr•Mrt ,r �. „ � ... � .
North Cnroiinn • Itrl rtrh n rrl rl rnviromn2nt rind thIMnI IIV, ^rwrrnI I. Ltivl.^.Ion of WAI@r Ounlity • (Itnundwnlnr Sor•li,�n 1 ►'� (i J
1636 NIM Snrvicn Cnntnr • flnlcit)h, N C. 27699AG36•F'Itone [phone]
OCib WELLCONTFIACTOFI: ._i.�• /�-�� -
WELL. CONS 1 ICU (` ..1 ION REC
WELL CUNTHACIOFI CEFIFII"ICA1 of) H:- ,!L_C
S1AIE WEI_l. CONSIFIUCIIoII t'rFlfm'TN:
Muniriftnt U indu.^.hlal � _� Agric,llturni � _[ Monlinring I_�
1. WELL Imr: (check AI il,nhin nnx): rlf rld.,n nI Bal
Flf,covrry [_ [ I I-nl F'unip Wnlor Injeclloll [_J Ulster If Uthor, Llst Usv: _- ___---_-`----- -
2. WELL I ()r'AI I(_M: �,Iinw rkrtrc7k, off lhn locnllon below)
��,Q�Q4%G.c� �_ Counly: _ �--lcc�r4•-^�---..-....__---_._.._
rJ�nleSl 1 nr, n:.-....-
-- - --- -" - UFIILLIIJ(3 l_UC� UFF' I I I
(ring I rl nn rtnr Innr' ` s, Gnnununlly, o Subdivision and Lot Ito) -- -• ConnAllon OeSr.rllrliat
rrOITt l o
Addre-
.Irrr Of FtrV O.
`irt. rr j mt,r p �ralp Zip Code
_8-
4. DATEI,IIII.Lr:fl,0. 7'Qd T-------------..
5. 10TAI. PI -I'll I _ _-�y - - --._-------- _.—.__---
G. CUT III I(;� t'tal.l r r: I F.1,f_ 1 t.j6 �.) l� - -- ----- -- _ _—
7. DUES wrl.l_ Ilrl't A(a" rXISI 111(a WEl_I.7 YES NU ------ -
r T. _----- --
EJ. STA11G, WAIErI L1-VEL.13e10W 1Op Of CnsDlg; _1f�
(Use'+' If Above Top of Cnshrg)
FT, Abovn Lnnd Sininco'
'Top of caetnp I,nninnt-1 clrrr hnlow Intl eurlace requires a variance In actor• _ _ CD -
dance with 17A IIrAC 2C .0I I
10, YIELD (al'tI Q-. ME F I IUD OF TEST-
11. WA1Er17.QIIES(rinrtllt):------ _........ .._----E3-
_._.___.
Etddlllonnl Rpnc9 Is nnIYIndncf u.;n brick of �n c�
_ __ Amount _. _ _..._.. .
12. C111_01III 1A 11011: 1 Y110 ____ - o
13. CASit I(;: -- - i-.QC:nI-I�)lJ_SI:F1 C11_
WnI1lhlcknCss
Ltrl,ll, Oln el r o WelphVf•1. Malr.rinl/y� (Show direction rind dislnnrn from nt Inagl two Slete
F►om_--- -10 --7� rt.
Jl..t2� e' nosds, or oilier mnp relerence ftolnts)
rrorTt-.__ I o •-- rl.--------- //C
F10m ---_.I ---- F1._ - --- /?/1
J",A�r
14. GF1OII1:
Front
F l o m 1 o
15. SCFIL"f?11: Mnlerinl
Url�lh Ltinn,elor Slot Site
From _.. 10 _........... f 1
I rom - - ---- 1 O - - - - rl• In•
rrom _.-._ _---- - I O -... _ ...._ Ft.
16. SAND/GFIAVEI_ F'ACK' M2lerinl
Uel,llt Size
rrom _ 1 n
rrom
17. FlEN1AI1Ks i
WELL
100 1 ICI1r:Ipy C' IRitry I I I l TI jig WELL Wn COPYS COI,UF Tt1 s nEconu, HAS BEEN MOVIOED 70111E WELL OMER
COtJST uci
_ -- -`DATE
roil OfrICE USF (JNLY SI(TNATt)f1E rrr-nlONCofiSTf4UCTltlr1711G WFIL
Ouad
No Submit original to Division of Witter Duality, Groundwater Section Wllitirt 30 days GW 1 My. 1?J99
Srtrlai tto

North Carolina • r1�i+nrlrnrnt of Cnvironntertt and Natural Tlosources • Divi^hn of Water Ounlity • C',rounrJwater $rrtion 1 ty
1636 Mail Srrvicr Crnipr • rlaleigh, N.C. 27699-1636•Phone [phone] `j
HELL CUNS'T f3UC'1 ION REC(?RU WELL CON Ti1nCT011:b____g�—''"--
WELL CONTIiACT011 CEFITIFICAIIUN ff:Q
SLATE WELL CONSTRUCTION PE11tv111ff:
—� � __,( tv1unicipal [j Industrial E_1 Ac)ricvllural �� Monitoring U
1. WELL USf (Check nl.l,11r:,l,tn Pox): n r Inje tral Cl(J
necovery L] I lent Pulnit Wator InJecllon [] Other L] 11 Other, List Use:
2. WELL L()CAT 1014 show skr.1-1 of th© location belovi)
y: -
Nearest Town:.___b'�'s�� Count
- --- _ DRILLING LOG
(nea l r lane tlurnhytrs, c;or Mani , or Subdivision and Lol No.) - From To r-ommilon Desr-riplion
3. OwN F n-
AddressAci
State Zip Code
4. DATE [tftILLEC)--._.-
5. TOTAL i)FIII I I--`------
6. CUTTIiI(;`:COLLf(;IF,r.) Yi_S[] NUL�j _ — _ — :•.
7. DOES NJFI.1.. itFPt_ACE FXIS TING WELL? YES [_ � NO[�Y —------- --�� =�
B. STATIC WA'Mn LE Etelow To of casing:
(Use'+' It Above Top of Cashrp) ---- ;'
FT. Abovr3 Lnnd Sulfaco•—._....___
9. TOP or CA`�ING IS_..._.....___--
'Top of caahrd Irrminntnd rt'nr below lend surface requires s variance In arcor•—
dence vrllh 1�� rICl1C 2C .0 10 �
j ME1 I IOD OF 1 EST
10. YIFLU (gpnt): _---tom.._
11. WATE117.ONE:S (cl('P"'):_�__ _ ___ _._-• s;:>---�
,
_ Amount If ttdditlonal spare 13 nr r±rind a^.r+ back of r n c�^�
12. C11LOr1114A1ION: iyfte — _--- __
13. CASING: LOCATIONS)<E1
Wall
lh10,11C_ss
Del,llt jtinmeter or Welght/1"I fAaieriel (Showo Ids for other nnvnprreference poln ts)two Stab
Frorn __�-----�10 n ,
From-------- __.._ 10
tA. GfIOl1I: Material ��inihod � %'
Flora
Float-----
15. S G I`11 1: f I :
I)r(�Ih hinmeter Slot Slz© Mnlntinl
f
In.
Flora
From__.._.._-- 10 _.... _._.__. f t._._—
Frorn __._._...._.
T o _ - F t. _- --- in. In.
16. AV
SANDiORVf l "(;lS N►alerlat,� i1)�I�►I'�9,� .
From --- h =.— (_►:—
F rorn _ .. ' 10`__--
17. REMn1ucS , ._ _--
Y OF IS RECOnO AS BEEN mOVIDED TO 111E WELL OWNEn.
1 b0lIEnFElYCPntlr Y'111A1rTi11S WELLWAS 7ACOP NGTf1l1C1E0IN ACCOr1DANCE WIiII 15A NC;AC 2C, WELL
nND THAT ---
CONSTnUCTiON-TAp1hAF1Da, -- y _
_ _ ontE
FOn Ol'fICE LIST O1fl.Y� "" qiC AttlnEOt-rrigot,�otnUCTirI(alrtEwF.tI.
Ouad No: Submit original o Division of Water Ouellty, Groundwater Section wilhht 30 days GW 1 REV 17199
Serial No. _------_

...-.......'r '.. _,n'I _, pr,v+,�i,r Y.-t•-..^r rw.gw.�tWM-Tr;r—: •..r.•,tt. it � .. .., � ...
North Carolirin - Depnrimnnl of Envirrrimeol rind Natural Ile.nourcas • Divi-^,Ion of Water Quality • Groundwater Snctirm 17 3 J
1636 Mail Service Cnnlnr - rinli lgh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WEI-L ONTnACTOn CEnTIFICA ON 9:
STATE WELL CONSTRUCTION PEnfAITH:
�,/ Industrial El Agricultural ❑ Monitoring ❑
1, WELL USE (Check nl�pnr:,)lA nox): FTesidentialLvJ Municipal El
Recovery [_j i teat Pump Water Injection 0 Other [—] If Other, List Use:
2. WELL LOCATION: 3hoYv sk(ltc�l;of the localion below)
Nearest lows: Qdr r�rJdJ County:
iiy
r Nnrno and 1 urphers, Cornmunl y or Subdivision And Lot No.)
3. R
s
OU O O.
or 1 own StaleZip Code
dd ov
4. DATE Urlll_LF0
5. TOTAL DEP 111
6. CUTTINGS COLI..FCiEU YES❑ NOLYJ [�/
7. DOES WELL RE- LACE EXISTING WELL7 YES n NO
8. STATIC: WAT EFT LEVEL Below Top o1 Casing: _ 45__
(Use '+• If Above Top or Casing)
9. TOP OF CASING I1171___._1 -.-- F7• Above Land Surface'
•Top of cesin(l tf-rn,lnntnd eUor below lard surface requires • variance In mccor•
dance with 1rA 110AC 2C,.Qlie
10. YIELD (grill): EyC ,6) ME1 EiOD OF TEST
11 WATER ZONES
DRI_ ,LUNG LUG
From To
rormallon Description
CD
1=;
__,
_ ---I
C7�
-
0
Amount S If additional spare Is needed use bark of form
12. CHLOFUNMION: 'iype _...__..._._._._ __
13. CASING:
Wall 1hicHnr-es
L)clrllt Ula-mei r or Weigwrt Material
From--
10 - - -- F 1.-------- -- -" From ...----- - i o-
14. GnOU I: /�M.atterriaalp �. eethod— I
Front
Front - F 1.
LOCATION SKETCH
(Show direclion and distance from at mast two State
Roads, or other map reference points)
15. SCFTEr:N: t Mnlerial
i)�{rllt r iartteler Slot Size
Front
-- - T o .- .._.-._._—
Frorn - -- T o . - Ft.
Front
T o _
16. SANWGiTAVEI_ F'ACK: Material
-017I"th, Size
17. REMCE
(1F1i<S i
DO I IC'f tF EtY GFrl l if Y l l inT Tills WELL WACOpy OF THIS RECORD HAS BEEN P IOVIDED TO TF1E WE LLOWNEfi.
CONSTn0CTipfl SrntJDAnDS, AND lflAT A Q
_ DATE
EQuad
ri(.E USE ONLY SIONAT nEOrPEnSONCONSTnUCTINCl TIIF WELL
Submit original to Division of Water Ouallty, Groundwater Section Wilitlrt 30 days Gw JnEV1y99
—

r . .• F"1 (�
North Carolina • Derartrnrni of Environment and Natural Resources - Division of Water Quality • Groundwater Section 2 (3 9 9
1636 Mail Service Center - naleigh, N.C. 27699-1636-Phone [phone]
YVELL CONSTRUCTION RECORD WELL CONTRACTOR: li A0�
WELL CONTRACTOR CERTIFICATION .(�
STATE WELL CONSTRUCTION PERMITN:
1. WELL USE (Check Aprilcable Box): Residential Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ I lent Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: Phow sktalch 9fthe location below)
�_
Nearest Town:-� `i1�142 County: —
(Road Name and f rnbers, Commu r Subdivision and Lot No.)
3. OWNER p
Address p
�heel o ou o ,
Townstate Zip Code
4. DATE DRII-LED V
5. TOTAL DEPTH _
6, CUTTINGS COLLECTED YES [] NO[►T
7. DOES WELL REPLACE EXISTING WELL? YES NO�
8. STATIC WATER LEVEL Below Top of Casing: FT.
(Use '+' It Above Top of Casing)
9. TOP OF CASING IS iL- FT. Above Land Surface*
'Top of casing terminnlod odor below land surface requires ra variance In accor-
dance with 15A NCAC 210 e ,
10. YIELD (gpm): METHOD OF TEST
!1. WATER ZONE (depth):
DRILLING LOG
From To
_DEPTH
Formation Description
WIN
12. CHLORINATION: 'Type _. Amount-?� II additional space is needed use back of form
13. CASING:
Wall Thickness
Depth Diameter or Wel hUFI. Material
✓✓11 �/(��/�
C/ 920 Ft. Lit—' 2--P Q
From
To —
From
To Fl•
From
To Ft.
14. GROUT:
Depth Material Method
From _Q`
To Ft.
From _
To _ Fl.
15. SCREEN:
Depth Diameter Slot Size Material
From
._'I'o _._ Ft in. In.
From _____
T'o __-- Ft. In. in.
From
___'To Ft. _ In. in.
_LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
16. SANDIGRAVEI_ PACK:
Depth Size Material
From — To Ft
From
17. REMARK'S
DO NFI1�•E�Y cr"riT IrY TI IAT THIS WELL WAS CONS=OEnsotJ
ANCE WITH 15A NCAC 2C, WELL
CONSTFIUCTION S1 ANDARDs, AND THAT A COPY OTVOEE PROVID TOT HE WELL OWNER. ✓O
F011 OFFICE USE.UftLY DATE
Quad No: SlotNSTRUCTING HE WELL
Submit original to Division of Water Cluallty, Groundwater Section within 30 days DW 1 REV 12/99
Serial No.

IorUt CnroRn t • (r�harinrnnl r.l rnvGnnrtt�nt rind Flnlurnl r109otrrrnq • Olvl.^.Inrr of WAter ouAllly • Orrnmdwnlr!r SCrlinrt 21740
.636 Mai) Srrvir.r Conlnr • I1r11r,19h, tJ (.:. 2.7699.16364111one [phone]
�U WELL coNrrinclon:
WELL CU�JS I RUC,I IUN RECUR
WELL CONT11AC1Or1 CEnTIrTcnT
ST'AIE WELL COITS1111-1010N Cr'rlMlrtt:
1, WELL t ffai (Chnr.k Al1 !Ir,!•I(. nr,r): rlesldontl i[ Munlcipnl
Fj Induslrinl �� ngriculturni L Monitoring
riecovrry (.__] I I•'nl [wrap Wnlor In)ecllotl [] Other 0 If Other, List Use: ___ _---•--
2, WELL 10(.,\1101'1- `1!ow s(rich of lire locallon below) _-
Courtly: -
;j
Nenrest t own:
Ur11LLl-NG LUG----_UEPTII ------
(noad I lama And m,hors, Community - Subdivision a td Lol No.) From to rormA!Ion Description
3. OWNER - --- —- --�
Addr ss --
lice or °u o 70
�� ~Sinle Zip�Codue
City r r 1 nwn Q
4. DATE f)ftil.I.Ef) _ _A7-4 _
5. TOTAL 1)ra' T l l
6. CUTTIf I(�S CCtLLFC 1 ED Yf:S �] NO _ t
7. DOES W[=1-I_ 110'LA(:E EXISTING WELL? YES [_J F . -
6. STATIC: WATER LEVEL 1301OW Top of Casing: �S -
QQ (Use'+' it Above Top of C"1119)
9. TOP Or CASRIG FT. Above Land SkIdnce' .
trr ndnnlnrt nl'<•r below I tad suriscS riryulres A trerlanee In Accor•
•Top of ceshrp
dance with 15A IlrAC 2C •11 10 MET HOD OF TEST
10. YIELD (gilt"): --
11. WATE11 ZONES WC11111): ,
12• CNL01111INT ION: 'typo
13. CASING:
Thlcl<nesf MalnriAl
r� I)Vplh Olanteler ofWot hl/I'l.
Flom
o-_---
14. G11OU 1: �llnletinl Mr.,thod
Frem _ ._. --
15. SCF1EFtl: MntntInI
UrpIll UI ,Inlet Slot S176
n _....._..._ VI Irt.
From ..._.. - - —In. -_---
From
Frorn I o _ ......__ FI' _-.--
In.
16. SAND/Gf1AVEl_ rACI(: Size Maletlnl
l)ppIll
Frorn Ltr- ---
rinrn
17. AEMMI(, l i
r r VJr l_I.
'LL WA
COPY orT1119 F1ECUno tIAS SEENYMOVIL)HU TO1tIF. VVr Lt. UWr1Fn
1 Uo t!f!ar. t,v 1r.r ill II Y l l In1 t 1Ill W IIA7 A 9 CON9T11U0tr- IN /\CCOr1DMJOE WITII 15A NCA 2
CONS I rlt .-1 lCttl r t n�!rinrlf)!3, AFJU T _- —Q�
vAl
r {L_ CnS N Co tIS UCTINc� 111E WELL 9
f O11 (rrIS
icF. U-,C alit=Y Sicln ant orr
Ove4 No: Submit oripinal Io t)Ivlston of Weter OURIIly, t3mundNater Secll°n within 30 day CW.I t1EV. 1V99
C)
-`
Fri
M,
J ri
f\ if additlonal t;prlco is needrld a^.a beck of lorrn -
LOCA110N_SKF1_CTi_
(Show direction rind dislrinrrn train nl lend two Stale
roads, or other neap reference poinit)
11 40,C ed�-

1-7404
►Iorlh Cnroll„n • (�^J+min,m,l nl (nvirnrnn�n(arid idnlufnl Fleanurcea • Ulvlsinrt of Water Ounllty • (3roundwlttn.r Section
�
636 Mail Snivicn Cenler • ilnlnlgh, N.C. 27699.1636-nions [phone]
Q�[) WELL CollIflACIOtl: 6K
b
-
WELL CONS1IMC1ION nEC TInIt: ,,__ _.�s2 -�-
WF.I,1_ CONIF1ACTOFI CEn
STALE WELL CONSTFIUCTION
EJ
1 �'VELL I ME (Check 1\1 rllciwe mix):tlesldc±tttlnl lJU Municipal [, Induslrlal �� Agricultural �� Monitoring
Flecovmy L.l 11,,nt rump Water In)ecllon [] Other [_] If Other, Llst Use: _____ ----
2, WELL LOGATIOH: Pow stkelrl f the locnllon beloCounty:
Nearest 1 own: —
Uf11LL NG LOG __-_ DEPIL___--
(nonddamn mu rna+ors, Communlly or ubdlvislon And Lol No.) From o r"orrr,illion Description
3. OWNErl —�
AddAss
i
ily or lnvn +le
Zip Code Q
�7a s-� _
4. DATE U1111.1_EU rn
S. TOTAL- Ur_r F I I
6. CUTT11 IGS COLI.FC; i EU YF:S NO&T
7, DOES W( I_I_ f1ErLACE EXiSIIiJG WELL? YES —y� NOL-0
S. STATIC WATER LEVEL Below Top of Cnsin9: y
(Use'** P Above Top of Clrslnp)
FT. Above Lend Surince'CAS
Top Or IG I
•Top of ceslnct trr n-vr below Innd aurlac• requires vilriutc• In �ccor•
dance with 1FA 11CAC 2C ,01 to m+
10. YIELD MEIFIUD OF TEST
11. WATER 7.ONES (d('hih): _-- _ ----- —
I_j M ouftl / � II eddltlonal r.pnce Is nnn(ind a^e b,)ck of (orm -
12. CHLp111tJA110P.1; type ._.._--1J� " I _ _.._.-
13. CASING: _.LOCATION SICETCFI_
Wall lhlc{cnee!Istlinre fro"' at
[)r llh t)immolnr o,r��,W,--ntQhl/rl, tAalFY .rinl (Show diIor outer map reference polnll)lv+o Slr�le
�L.4�` floods,
From_._._..-._---
From---- _., l o •---___ F t..------ fi�nn,, �/j
riom
14. Gr10U 1: Matelinl Mrthod C
) trl,ll•t� n ^ �A._f�B.ilFci
From _....0---- .i"-,alU.._rl.
From
15. SCRErtl: MnloliM
UPI+th Ufantnler Slot Slz©
-
From
rn •._ .-....._ -i n
Frorn ...._ _.._.._ 1 r, _........__ I t. __- -- in.
In.
F
Front10
16. SAND1G11AV171- rACK: Size Mntellnl
UrI+Ih
From
From
17. REMARKS:.ii—:---
_----
r r VJF I_:
T A COPY tit 1 HI9 f1ECUnD HA3 BEEN pFtOViDF 0 1 O 11 iF WF.1_l. UWNEn.
1 Uoilr•Ilr [�� <'r•tilllr Y lIIA7 I'll' D f linWn9CON.^r ,Is
rlr=c ADHAS PJCI WIT11 t5A tICA.2.,
CONS i nl ic: 1 I( t 1 nit /`.tJi,)nfih9,
_ ttE Or (rnSO I COt13MUCTINr3 itlin WF.LI
F011 or i I(F U;`-,C Otll_Y nW.i f1EV. 12/99
Oved No: Subn,ll ortptnal to Division of Willer Ouellly, amundwaler Secllon whltln 30 cinys
Serial tlo_— — — -- ---

North Cnrplinn - ftrf+artrnrnl of Fnviro inil?nl and llahrfnl Tiesaurces - Liivisiort of Witter Quality - oioundwnter Section �j ►J O
1636 Mail Snrvicn Cnntnr - Ilaieigh, N.C. 27699.1636•f (tone [phone] L 74
WELL CONS] R(.1C1ION RECORD WELLCONT[TACTOn:
WEI.L CONTTIACIOn CEntirICAIIOII H: r_
STATE WELL CONSTRUCTI011 ['Enfv111N:
1, �VELI. [ISC: (Check /+l fllr.nble nnx): neSldential Municipal L_J Indusltill E- Agricullural L.] Monitoring ❑
necovery {. ] I Tent Punip Water Injection Other E] II Other, List Use:
2. WELL L.00'ATIOPJ: rnv sketch gf tie location below)
Nearest Town:.---V....�G-� County: — ------
_ UEP_l.11...._ ..._
jno, l tlnmo and I! nn`rers, C;onunrrr y, or Subdivision and Lot No.) UFIILLING L.OU __.. _.
d626 from To rbnnatlon Oesulplian
Virloi/. o
_G-- - tci-Cq�----_ _
ily nr l n,•;n J .... -- Sinle zip Code -- —.1 -----
5. TOTAL PFf'111 _ ,-- - —._—_ _ ---•
6. CU i T It K1; 3 GULLFL; I P.l) YIiS L NUL1%
7. DOFS VJFI_L- IIFr'i..A(:F. FXir I ING WFLL7 YES �� NO[=v� ___._._---------
8. S'1 ATIC WA"rErl LEVEL FIVIOIv "T op of Casing: FT. -.-_- ----- ----- -- �. ,
(use '+' II Above Top of Casing) __.----------- ice-- �_-7
9. TOT' Or('ASIIIG Ir _...._._._..__._ FT. Above Lend SUrfnCO'_---
'Top of ce.1lnn trinonnind rVer below trend surlace requlrea a variance in Accor-
dance with 15A ll(AC 2C .01 in _ ___•—. _ —
10. YIELD METI IOD OF TEST _ l._! •- - ^^ -^
12. CTI1-0111 L^T ION
13. CASING:
14
1 }'Itra -- Amount ii�S 11 additional Sparg Is needed n^e hnck of IcllZ3 -4
Drl111 tinmetor
Frorn -- �- - - T ^ F1. l�--A�
From ......_.._..- l o--
Gf10U I
LOCAT ION SKF T GI I _
Wall Ildobnens
or WelghUf-1. IIllerinl p (show direction mid dislnnce Im n III Innsl two slate
#JV"-
RFloads, or other mop reference points)
hod
itri,lit Mnlorinl „Nlnl
Flora ....__.U._ 1n .�4Q.._rI. —lo'tALck
Front 1 n .. ...._._ r I.--
15. ,Cner-rl:
jlrltilt Di-imeter Slot Slz© Mnintinl
Front _ "T o ..... _........ _ FI __._.. In. in.
From - --- ....- 10 _..- ---- r 1.
In.
FromT oIn. In.---
16. SAND/GRAVEL. TACK: Materlrtl
Size
From - _ 16 f `(• ---_
Frorn _ l o - Ft. --------
REMAIII( CZ:
1I)o1irnrnYCrnilr'y'TIIATI111SWELLWASCONSInUCTEDINACCOTI Ano,
3EENANCE ITII ISA N -TIJEVAC WELL , 'rJ�
CONS Tnt)GTION S T Al'IDAnDs, AND TriAT A COPY OF ITS nECOEEN Pn ED TO TI IE WELL OWNE f4
DATE
ATl1nE Of (T ISTTIUCTING Ttir WELL.
Quad No: - — Submit original to Division of Water Quality, Groundwater Section Within 30 days
OW•1 fiEV. 1?J99
Serial No.

North Carolinn - f ^.t vtnrnnl r,i Fnvir,: nrnt ml and Natural tlesourcns - Division of Water Ouslity • Groundwater Seclkm
1636 r1 a 191 733-3221
40�
1636 Marl Service Comtnr - Ilnln.iph, N.C. 27699 lone (
ff
WELL CONSTRUCI"IOri nECOFlD WELL CONTRACTOR: �'v
WFI_L CONTTlACTOri CEnTirICATIOIJ e
Sl'ATF WELL CONSTRUCTION pr-mmim
1. WELL UqE (Check At�pucst+to nox): Ttesidentlnl B�' Municipal E l Industrial J Agricuilural Monitoring E)
Recovery [_.j I io nt rump Water Injection ❑ Other C] If Other, List Use: `
2. WELL I..U(.,AMlOr (Show sketch of the location below)Nearesl Town:� a-�� County:
DRI� LL1i4G LOG
(noad Nainn Pnd umh�rs. COmnlunl or Subdivislo and Lot No.) ('ormatlon Description
3, OWNER From To
Address
r
or Olio O.
&ww
Stile
l/J Zip Code
Cit � _
4. DATEOfIII_I..EU__L'�
5. TOTAL_ D F r T 1 I
6. CUTTINGS COLLECTED YES[] NO[kf
7. DOES WELL FIErL10E EXISTING WELL? YES NOLO — -o _ r-•.
B. STATIC WATER LEVEL Below Top of Casing: _-t %.1 F-T.
(Use •+' It Above Top of Ca31119) c
9. TOP OF" CASING IS---.___L - FT. Above Land Sulface'
'Top of caslnn Iennlnr,tod aVor below Irrnd aurimes requires s variance In accor• -;
dance with 15A rlCAC 2C .011a �___ ram'^
'0. YIELD (nrttt) — _ METHOD OF TEST + ^ � � ,
r 1. WATER ZONES (deplll):
T ' If additlonat sprtce Is neednd usn back of Corm—
12. CNLOr111JAT IUN: 'Type � Amount-
13. CASING: _LOCA:TFUN SKETCH
Wall Thickness
Depth Diarneter ar IN I t Ifrl, hlalerinl (Show direction and disianco from at Ieo,t two State
From_--.. _To
�d2 F► t�._a 5 ,�2.5_ p ��� Roads, or other Wrap reference points)
From
14. GROU I:
Uclrllt Malarial Metho• d_
From-_.-0-_
Frorn --- --- 10 ..---- Ft.
15. SCREF.11:
(-)nhih Diqnieter Slot Slze Mnlerial
In, in.
From __. _._ T o ----- -- _. f'l. _____ In. In.
From ---- - 10 - — 171.__ In. In.
16. SAND/GRAVCI rA(,IC c Material
DOt11
4 f`-
From =To „ .
FroF t
m _ o — �._.._-.—•
17. REMAI'll'
UO 1IFItFVy r'`rrll11-Y 11IAT-11119 WELL. WAS CONSVILICTE N AC OnDANCE WILH 15n NCnr 7.C, VJ17-1-1.
COn IlAr,BEE F'nOVIC 7oT11EWECI•U/vrlEn•
CONS1nrIGTIr!1Jg1nIJi)AnD`3,/�NDTIIATACOPY(.)FTi Ll/ _�y,�.,tr. 2
--i f'ICE USE UFILY -- . .ngr.)N CON5Tnl1CTINC1111E WELL
DAT
F011 O SIOrlATUf1E. Oi
Ouad No: -- — - —_— Submit original to Division of Water Cuallty, Oroundwaler Section wlihin 30 days
BW•1 1NIEV. 12/99

North Carolina - f?et)arinvtnl of Environment and NMUMI ttesourceq . Divislon of Water Quality • C3roundwnler Section 17409
/636 Mail Service Cantor • fi,lrigh, t'J.C, 27699 1838 Phono [phone]
WELL CONSTRUCTION IOIJ RECORD WETFIACTOM
L COLL NTRACTOFI CEnTIFICA ON 9:
STATE WELL CONSTF{UCTION VEMAIT11:
— ,�,/ Industrial ❑ Agricultural ❑ Monitoring ❑
1, WELL USF (Check �r p!1e,hte noxy Residentlal I� Municipal [�
F{ecovery [ _] I feat F up n,Water Injectlon ❑ Other [J II Other, List Use:
2, WELL LOCATION ketch of the location below)
Nearest'lown: �A� County:
_ ___ _ DRILLING LOG UEPTH_
(noacl Mime and thn ,boars, omn,u„II , r Subdivisio end Lot No.) Fra---- To �ormaalliioon�Descrlption
3. O W N F R
Address —
-----_
/1 -. _.�L1
- - State (- ZIp Coda 5�--
City or 1 own l D a"r —
4. DATE DIIII.LFD(_'�
5. TOTAL uE TI I
6. CUT,IIICTS COLLFCIED YES❑ LYJ r� rn
WELL? YES —] N U — -
7. DOES WELL FIEF LnGE EXISTING -,_�.:
Casing: _ i -i
8. STATIC WAT ER LEVEL Below (Us o+ bove Top of Caslnq) c� car i
FT. Above Land Silrl— _ ace*
9. TOP CF CASING
terminnt�d etler below land surlsce requires a variance In accor•
•Top of casing —
dance with 1SA NCAC 2C O1 8 m'
10. YIELD (gl nl): _
MEl MOD of TEST
11. WATER ZONES (deptll):_ - —__---
d d use bnrk of form
12. CHLORMATiON:
13. CASING:
Amount ay—fS II additional spare Is note a -_-- -
,Type .. - -
WRII Thlrkness Ma� d I
Depll, Dt rtameo�v;etgtr^
From_.-----
From------—
From -- ---- I o ..._-----
14. GROUi: Nlalerlal�kielhod t
From .- -D _ ,,, _aQ F1.
Front _ In -_-- ---
15. SCREFII: Slot Size Mnlerlal
I )�I�lll I:,inrrleler
From .--__-_-- 10 --- -_.-._..
In. In. ----
Fron, _..-._-- 1 o In. _ _------ -
Front ___._..._
10 _
16. SANC)/QTIAVEt_ PACKSlze
From
From T o __--- Ft. --
Material
LOCAlION SKETCH
(Show direction and distance from at lo'nst two state
Roads, or other map reference p )
17. REMARKS +_I,'_I—= -
PY OP T111S F{ECOITD HAS BEEN PROVIDED 70 THE WELL OWtJFFi.
Ill rlF(tY;CEII(IEY 'illAl 7111$ WELL WASOONST(TUCTEO IN ACCO(TDAIdCE WITH 15A NC%Ar E WEL ✓ rO�
IDO //
COPJSirIUCT IOIJ RTAIJf7Aftf!S. AND TI TAT �U ( — DATE
rouad
f{ (1FF{CE USE ONLY SICttJA )r1E O f Er1SON CONSTr1UCTltlr; iIIF. WE!.l
r3W1 nEV. 12J33
No: Submit odglnal to Division of Water Quality. Groundwater Section witllirt 3CJ days
rial11o.
--

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1l41
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR CERTIFICATIO
STATE WELL CONSTRUCTION PERMITP:
1. WELL USE (Check Applicable Box): Residential lr Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other [] If Other, List Use:
2. WELL LOCATION: f�gj�owMsknet�rtiPt the location below) (01 2L�s
Nearest Town: —�/� County: _—o---
(Road Name an Numbe Communi , Subdiv si�nd Lo No.)
3. OWNER
Address
treet or ou o o. Q
ity �®rTown�.�— Slate Zip Code
4. DATE DRILLED
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑ NO[j
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NFTOFf
8. STATIC WATER LEVEL Below Top of Casing:
/ (Use'+' it Above Top of Casing)
9. TOP OF CASING IS _l—_ FT. Above Land Surface'
*Top of casing terminated atlor below land surface requires a v ante in accor-
dance with 15A NCAC 2C .0
10. YIELD (9pr71): METHOD OF TEST
11. WATER ZONES (depth):
12, CHLORINATION: Type —0Amount--
13. CASING:
Wall Thickness
Depth Qlameler or Weight/Ft— Ma erial
From To — Ft. --
From To Fl.-------
14. GROUT: thod
n Depth Material
From _�C_— To A&Ft.
From _--To To Ft. -- —'
15. SCREEN:
De )th Diameter Slot Size Material
I
From To —_Ft
in.
In. _------
From __ To —
Ft.
in.
in. --
From _—To ___--
Ft. _..-
In.
In.
16, SAND/GRAVEL PACK:
Lo Material
From __— --', Tg
....___—�
F
,
From _ To
_ Ft
�_---
'
17 REMARKS:
DRILLING LOG
From To
DEPTH
H _
Formation Description
r
r+i
C
It additional space Is neededuseback o
d --+
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
1 DO HEREAYICERTIFY THAT ON STANDARDS I31S WELLAND,TFiATWAS
A COPY OF IRE ORD HAS BEEN PROVID D TO ED THE WELL LOWNER.
CONSTRUCT
__
ENO:
USE ONLYDATE
SIGNAT�-RPERSON CON 7RUCTING �THEELL
Submit original to Division of Water Quality, Groundwater Section Within 30 daysGW 1 REV. 12f99

f Joilh Cnrohim • (Inpirirnnrtl of f nvirnnnient and N1lural fle.rourreq - L)ivl^Inn 01 Water Quality • (+roundwnter Section `-
1636 Mail r4VICn C rr1 PT • finleighI f1.C. 27699.1638•T'hon0 [phone]
WELL coN` ] HUG-1IONRECORD WELL CONTnACTOn: �a�, -- _r - -__ e),1'�01}
WELL. CONT11ACTOn CEFITirICA11011 M:
SMIE WELL CONSTF1UCTI011 F'Fnh111N: __•_•______ —__
fvlunicipal ❑ Industrial El Agricultural IJ Monitoring
1. WELL UHF. (Check �1 r`Ilr.able nnx): flesld�ntlal�lCl
necovrry LJ I leal T'untp Wiler Injecllon ❑ Other (=] It Other, List Use:
2. WELL I_C)CATIC)fJ: (E' my s(cn,tclt of the location below)
�
Nearest iovm:.__ eC_E • ., County: - -- ---
- ---� DFTI_
(nowt damn nn--lun,h4r5, Community, or division and Lot No) From To rormallon Description
3. OWNFf1
Address -�
Q ' "j r1iCr or Tlou[o A,97YT1 J
ity or 1 oval
�J slat;f�-- Zip Code
4. DATE MILLED-
5. TOT -AI_ DF[IT I I _
6. CUTT I►1C,S CU[_L.Fc;1 EL) YES Cl NO[ %
7. DOES WE=1.1_ III -PLACE FXISHNG WELL? YES [ _� tr1 [ N
8. STATIC WA*Fran [_I:VEL Below Top of Casing: --__
(Use '+' II Above Top of Casing)
9. TOP Or C'Ar,111C1 IS_..._._.L___._ FT. Above Land SutfaCcl'
'Top of cash,n irnninntnd rthu below Iand eurrsce rerlulres s variance In accor-
dance with 15A IWAC 2C .011n 10. YIELD (merit): _,��_.- MET[IOD OF 1 EST *
il. VVATET17_C)tIES (f.icc[lIh):- -.
12. Cl-[LO[11NA110H
13. CASING:
14
Tyfle _ --Amount
Drrtli QQ jj)iarnelor
-1n __Z_0
Froln - 10...---- F1._-----
I
--05
5
,
�---- .-
It addilioml space Is
Weill Thi ncndnd a^e back of lot r� m�
L0CAT I014.S)CE I C►1 _
hl/rl-
or We1phV�t, hlaleri"l (Show direction and dirlanca (foul nl I,�-lSI two Slate
;kWa5 ?j [LL R nonds, or other map relerencn points)
GfAOL [ . Material nthod
I?rl�ih
Flom
Frnrn _ ..
15. SCFTC.I t l: Sint Size Mnloria)
[)rf,lli I)ianteler
From
From In. In.
Froth o _ -._- F1. ----- In.
16. SAND/(:3FtAVEL F'ACIC:
,
From _-- I n
From
=)
17. REMA[ll<r _ , f-, f tom- `•''`I�'! --- --
COPY U 1111S TTEC0 D 11AS BEEN T'TTOVIoED 10111E VVELt_ OVJh1Hf1.
1 r�011t nr nY C r r111r Y'[111�i itlt5 WELL WAS CONSTnLICTED IfJ ACCOr10ANCE WIfH 15/1 NCAC 2C, WELL n !1
CONSTnI)CTIOtl ^TAr((?ARO^.,ANDiHATA
DATE
FOn Uff'ICE USF (It1l_Y t.IATIIFIEor'rr.f1S IICotISTnl1CTItICT 1t1E WF:U.
Quad No: —' - Submit original to Division of Water GUMMY. Groundwater Section Wilhht 30 day9 GW•i r1EV. IV99
Malori'll
Serial No. __ _

1636 h1a'1 Sorvice Cn.r,tr r rfint,i Fnvironr
PJrC,27699.1and f 636-Phone (919) 733-t3221n of Water Quality •Groundwater Snrtir�n l 7 ^ 1 _
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICA1 ON N:
STATE WELL CONSTRUCTION PERMITN: -
,ncablr nox rlesidential Lh Municipal ❑ Industrial ❑ Agric•ullurill ❑ Monitoring
J. WELL USf• (check �r'I )'
Recovmy [] I I�at runi(, Water Injecllon [] Other [� If Oilier, List Use:
2• WELL LOCATION: r OW . etch of th location below)
Nearest -1 pwn: _—_
County: ux�
-"- DRILLING LOG
(non•1 rinntn e ul Nundrn onununi y, or Subdtvislon end Lot No.) From To formation Description
3. OWNZn�
Addre" �� L
AT K
E—State Zip Code
City of i own -
5. TOTAL 1)EI" i I I _.-.- NO[j�
6. CUT-litl IS COLL CiED YES[] - NOLV--' Fq -----"
7. DOES WELL iiE rI.ACF FINC WELL? YES FT• ,.._;
8. STATIC, WAJ Erl LEVEL Lielow Top of Casing: _
(Use '+' II Above Top of Casing)
9. TOP OF CASING IS _---�---
FT. Above Land Surface'Uj
�4
'Top or ceernp terntlnrtnrr ntr(•r below lend surlace requires a variance In actor, _•A,Y.,
Once with 1SA iICAC 2C I1 2 W rU',_t
10. YIELD(q{,rri): _- ME1 HOD OF TEST J�
11. WATER ZONES (de)th):-_--- ---- o
S Ii eddillonTl space is needed use bark of form 12. CHLO11INA11ON: -
Amounl
Type �-
13. CASING: LOCATION SKETCH
Wall T hicl(ne as
Dr,l,llr Q Dlamel r or,Weighl/Ft. Mat SI - (Sho�vdtds!vr other matwo Stale
p reference points)
�_ �.
_ l o _ F1.--goFrom--—
—_-""
From --.— l o -- Fl.------
14. GnOU T : Material(+ ettiod
Ueplh "'
-lo�FL�
From __.__._
From . ....-- 10-------17-1.
15. SCr1EE111: Material
lJr{alit Diameter Slot Size
From ----- l o _..-.__._.. F I --
__._.----
From __-_ 10-..__---1-1. _
—_---
From _-__..--_ to - Ft._
16. SAND/GTIAVF=t. PACK: Size
Material
Deplli
From - - o _ Ft. -- - --
Front _ ---• -- o - Ft. -
17. REMARKS: _
COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER•
100 I IFf1EE�Y CEfi(IFY TI InT THIS 1NELL WA S CONSTRUCTED IN ACCORDArICE WIT11 15n NCAC 2C, WELL
CONSinUCTIOfJ STnrJDMDS; ANniliAT
-- — DATE
F
ORFFICE USE C)tILYr j` o� (I StONATU OF f Er1SON CONSTnUCTIND 1HF. WFI-L ty99
�,} oW.t nEV.
Submit original to Division or Water Quality, Groundwater Section Willilrt 30 �y9
o.

North Cnrolirl t . Uct,mtrrlenl of 1"nviroornent and hiatural tie.^.ource.q - Division of Water Quality • C3roundwrrtr. r Bottle n 1,_ 4
17
1636 Mail Sorvicr+ Collor - flnlpigh, N.C. 27699-1636-Phone [phone]
ELL CONSTRUCTION RECORD WELL CONTfaACTon: �Rk-A&kg��'�
w WELL CONTnACTOn CEnTirICATIOIJ e , ,I
STA1E WELL CONSTRUCTION F'EnMITH:
�� Munlcl al Industrial ❑ Agricultural ❑ Monitoring ❑
1• WELL II.,F (check Afy llcahte nox). nesldAnll�l P ❑
necovnry [_] I IlInt ('ump Water Injectlon ❑ Other [] if Other, List Use:
2• WELL LOCATIf)keI I I it a location below)
�� ✓✓ C ��w /. ii .[f% County:
Nearest 1 own: __�C/�..711r-'�
--- --" URI^ LING LUG _ UEPTH ----
(noad tl0rnn And tun,h2rs, Commr it , or S bdivls(on and Lot No.) From To Formrtllon Descrlpiion
3. OWNER
Address D __ 1
Ilree or cu�%('
w '� ZIP Code �---y`�-..•-'— r�
City or lawn ��►► SIAIe
4, DATE Uf11LLED _L`A vx
5. TOTAL DEPTtI _
6. CUTTINGS COLLECT ED YES
❑ NOI�
t --
7. DUES WELL TIEf tJ�CE EXISTING WELL? YES NOO
FT -
LACE
8. STATIC WATER LEVEL Below Top of Casing: - --'
(Use '+' It Above Top of Caslnp)
9. TOP OF CASItlG IS
FT. Above Land Surince'
__..._-�-
-Top of casing tenninnind tOrm below land surface requires a variance In aceor• r�
dance with 15A tlCAC 2C . 18 t ._ ---------`
0. YIELD (gpnt):,,-- METHOD OF TEST - rD
11. WATER ZONES (depth): _ _— ----------" ""
11—� Amoun✓.�---1 �' it additional t p rce Is needed use back of loom
12. CHLOf11TJA"T ION: Type ._.. .._..- -
13, CASING: _IOCATIUN SKETCH
1Wall Thickness (Show
(Show direction and distnncO from at Ia_ asl two State
D0iil �Dia�metW
�er or et ht/ M+° v
From � --0 Ft. J Roads, or other map reference points)
From—Fl.— — ---`--
_._ To --------
_ TO - Ft._ -- - ---
From _--- --�"
14. GROU 1: Material Mptho�d�
From
From _...._-- 10
15. SCREF--ti: Mniorial
Urllih Ulnitlel©r Slot Slzo
0 - - r� i _ -- in. In.
From Irt.-_.------
- From _._-.._ 10 -..._ __-- r-t. In. - In. ___-- -----
Frorn _-_--- -- 10 --_....__ F.1. __-- - In. -
16. SAND/GfiAVFt_ PACK: Malorhl
Dr,plll Size
From __------ 10 __—_— Ft.
From ... _.._.__.._ 10._—
r
17. AEMARKS
r• , Jf nn03 '/\Nk� Tr;fA7`sA COr)Y OF T F1E onD HAS BEEN r'n VIDFp TO T t jr-ELI. UWNEn.
1 UO 1IFnf t�Y c.t rii Ir ;lI tnT 71E11� WEIsL WnJ CQNSTnUC' D J ACCOrtDANCE WITH 15n NCAr1jr- WFI_ . n. ��
CONSint)CTlcttl tot /�LSl—�—
.- —�--
.----- — 'mac - GATE
F011 UFf ICF. USE Otll_Y+ I ,� Cp� g1C3NATl1ftE r'[ nSON COfJSTr1UCiINCT TIt
L
d No: ( Submil drlpinal to Division of Water ouality, Oroundwaler Snctton wIl►tin 30 d Ysr3W 1 r1EV. IV99
al No. `--

North Carplinn - hn_rartmnni of Environment and NaturalTlesources - Division of Water Quality • Groundwater Section -f r i
1636 Mail Service Cenler - Raleigh, N.C. 27699-1636•Phone [phone] A- l 7418
Q Ca
WELL CONSTRUCTION RECORD WELL CONTRACTOR: v�--'r'^V
WELL CONTRACTOR CERTIFICATION N:`-RvaVay.
STATE WELL CONSTRUCTION PERMITH:
J. WELL (LSE (cherk Appflcable nox): Residential LYJ Municipal ❑ Industrial ❑ Agricultural L] Monitoring ❑
Recovery Lj I leaf Pump Water Injection [] Other L] If Other, List Use:
2. WELL LOCATION: ( how sketch of the location below)
Nearest Town:----E,++-'"`--"-"-&f&-¢ County:
(noa 1 tinn,o Nunrh^rs, Cornmur or Subdivision and Lot No.) DRILLING LOG
From To
f omrnllon On
3.
OWNFR,�/���3-1-=1�C� 1'OWI4
Address %
_ �T. J�F;H-vcl or "ul -No.
A-
_ _
-EA-cfod<
----RI,� Cod' e
Ciry or ovm ate Zip
��yy
UPILLED
4.
DATE _..C..'-
5.
6.
TOTAL DEPi I I•--
CUTTIHO S COLL.f:Ci ED YES [---i NO 0
N04
7.
DOES WELL f1E F L.AC:E EXIfi f IPJG WELL? YES 0
B.
STATIC WATE=R LEVEL Below Top of Casing: ___DS FT,
-
�;
(Use'+' it Above Top of Caslnp)
, ci r:,
9.
TOP OF CASING FT. Above Land Surface'
- ---- I -
'Top of casing Inrmhrnind nVor below land surface requires a variance in actor-
dance
10.
with 15A iICAC 2C .0116
YIELD (gpt11): o1Lz--- MEI-110D OF TESTrh
i 1.
WATER 7.ONES (depth):
r-r -
12. CHLoniNATION
13. CASING:
���L ____ Amount '� it additional space is need©d use bark of fi c "�
Type .—. �------�-�
Depth
Wall Thickness
piam�et�er
oalrWelL°z '"erial
From Q
--To �
Ft.
From---
To
Ft, —
From -.._
To
— F t.------- —--------
14. GROUT:
material ett►od
Q
Depth. 1
To �Q FI.
From
--ev.-�%�-
From _. -
_- To _
Ft. ---_'—'
15. SCREEN:
Dnplh
Diameter Slot Size Material
From
_ To -
Ft In. _In------
_
_� To
Ft. in.
From ______
To _ .-_—
Fl. In. In. �----
16. SAND/GRAVEL PACK:
Depth
Size Material
From ---
To -
FI. _-_
From __----
/ �
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
i9'�lJc�/? .
j7 2
I—El?e /V�(
17.
1 DO HERFEIY,CEFITIFY II IAT THIS WELL" WAS CONSTRUCTED IN ACCOnDANCE WITH 15A NCAC 2C,
WELL
CONSTRUCTION STAI IQAROS; AND THAT A DOPY O THIS RECORD AS BEEN PROVIDED TO THE WELL OWNER.
____ { �1- — DATE
FOR OFFICE USE UNLY. J (� NATURE Or PERSON C NSTnUCTING THE WELL
Quad No: Submit oript al to Divlslon or Water Ounlily, Groundwater Section Within 30 days oW t nEV 12/99
Serial No.

North Carolilm • Urn
cparlrr,ni of Enviroment and Natural ne^OUrce9 . Divislon of Water Quality •Groundwater Scrlion if 41
1636 Mail Service Center • f inleigh, N.C. 27699.1636•Phone [phone]b �S LL CONMACTO�
WELL CONSTRUCTION RECORD WELL CONTRACTOR CEn FICATION 9: +
STATE WELL CONSTRUCTION t'FRMITH:
1, esldential Municipal 0Industrial 0 Agricultural ❑ Monitoring
WELL USE (Check Appflc:+hte nox): ►1❑
necovery [_] I leaf Pump Water injection [] Other 0 if Other, List Use:
2, WELL LOCATION: (Show sketch of the location below)
Nearest To,vn:.---
County:
_ _— --'------ DRILLING LUG _ UEPTI�__ _
(nopri riamo and Iturntrers, Comnwnity, or Sub ivislon and Lol fJa) From To Foemailon Description
3. OWNF=n _
r
Address -EI--
Cily or T oven
Stale Zip Code
4. DATE I -MILLED 7_1-- ;
5. TOTALDE T11---
6. CUTTINGS COLt_f:C 1 ED YES NO[
7. DOES WELL nErt.ACE EXISTING WELL? ES NO o
B. STATIC WATEn LEVEL Below Top of Casing:_ -
(Use'+• it Above Top of casing) rTj f
_ FT. Above Land Suriaco'
9. TOP Or -CASING
IS__ ,�
'Top of cesh,n ter minnind ^Ucr below land surface requlree a verle�ce n actor•
dance with i5A 11CAC 2C .0118 MEPHOD OF TEST
10. YIELD WPM): -�Q--
�;.
11. WATEn 7.ONES (00h): -- _ ---- - cna-
_ rn
.S it addition-M spare Is needed use bark of for
Amount ___� - ----- - --- -- -- - --_ _
12. CHLOniNATION; Type - w o
ETCH
13. CASING:
horn at mast two Stale
Wall Thickness
Material
(Show direction and dislflnce
UppIll lametur
or WeIghUFt.
Roads, or other map reference points)
I
From---_
l o ------r
_____-----
� L✓2 /�' ((( (( J
From .- __-----10
14. GROU 1:
---------
l 1 Method
j
• J/
Dnplh Mater a
Frorn
From-
15. SCnfCdJ: Material
Or'hth [lirnneler Slot Size
From
From
__-----
From ---.---- to _..----_F1._
16. SAND/Gr1AVEL PACK' Size Matellal
Depth
From --- .I n I
From -- To
(/l%QfydGi'U� �ic�
NC,
17. REMAnKS:
r WELL
f1LiS AN[) 7{ 1AT A COPY F THIS 1iECOnD HAS BEEN f Fl VI ED TO THE WELL OWrJE✓
DO 1 tEfIEETY Gr ►1TIFY T11A) TIll4<<}NE(.L WAS CONS7f1UCTE0IN ACCOf1DANCE WITH 15A NCAf. 2
COtisTnLlCT0f4,STANDA
�? DATE
FUn UFT I(,E 115E UtJLY ;; 1. J r k �hj� i ginrt ME of �F . oft Cotrsrnucnruz THE wFl-L
rSkId3l
tad No: - dW•1 REV. 1?J99
' gutimlt original to Division of Water Queltly, Groundwater Suction within 30 days
Ito. _ -----

i/ 4 Y)
North Carofna • Orpmhn,n,t of Fnvir �nmenl and Nnlurnl Re^ourcrs • DivinIon of Water Quality • Croundwntrr Snclloll N .�. i i 2
1636 Mail S�tvfcc+ Crntrr - tlnleiult, N.C. 27699-MG-Phone [phone]
- � (`,Q(�(� WELL CONTFIACTOFI:
WELL CONSTRUCTION ICE
WELL CONTnACTOn CEnTirICA ON P!
STATE WELL CONSTRUCTION PERMITH:
ncablr n°X flesldential LvJ Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
WELL II,; (check Epp )
Flecovery [_] 1 lest Pump Water Injection �] Other �] If Other, List Use:
2. WELL LOCATION (SI v sketch of Ile location below)
Nearest Town: -
_ County: vvv���cccr��
`"- DRILLING LOG
Ino, l rlamo aul Jun,t,ers, C ur,unpy ubdivlslon and Lol No.) From--T° rbrmation oescrlption
Address �j ^
1; [ (-r F I All
XSIa1e Zip Code
lily or l oval -
4. DATE D1111.1-t:0 - . a CS
5. TOTAL D E r i l I _ .�— n
6. CUTTINGNO[Y
SCOLI-EGGED YES❑ LE 1-1 NOBV?( rn T-fir?,
7. DOES WELL rlErI.ACE EXISTING WELL? YES
B. STATIC WAT Eft LEVEL Below Top of Casing: ` I _
(Use'+' if Above Top of Caslnp)
_ f`T. Above Land Surlace'
9. TOp Or CASING IS _ r --
'Top of cesinct I,,nnlnntnd ntlor below land surface requires a variance In sccor• ^r-,
dance wlth 15A ilCAC 2C .0118
10. YIELD (g11111): /,PQ- MEi MOD OF TEST {
11. WATER ZONES (deplll): --
It additional space is needed use bark of form
�S ---------- ---------
1Amount2. CHLonINATION: 'TYPO
13. CASING: LOC/1%IUN SKETCH
Wall I hickne s!
(S slid
pr111h Ulamel r orweighVFl. Male at ho odirectiondoother maprce) frorn tit IMISI two Stale
reference points)
From _--
1
From "- ---
1 A. GROU I : Material Method I
tl,.l,tlt e .�L.� `� `�•
Frorn _ __ .1 - ---..__rl. — _ -----
15. SCREt 11:
()(`I,lll t11aITlelBf Slot Sile Material
Frorn
Frorn __._.___-- 1 r. _.._.__._._
Fron1 ___-...._ to- __.__.._ Ft._�_-_ in.
In.
16. SAND/GfIAVEI_ i'ACK: Size Material
Depth
Front ------ � r1--__._-_-- rt...__--•---- -----'-,-------
From _. _ _..._-- °--
17. RENIAilKS:, - - _ _ -- CAC 2C, WELL
llAllfli, A�JD`lfl IAT A COPY OF TITIS RECORD HAS EE PROVIDED TO THE WELL OWMER. ✓
1 DO I1E 11FE<Y',(r 11TIfY TIIAI(E?li fi WPLL,WAS COtJSTRUCTED IN ACCOrTDAtJCE WITH 15A
CpplSlnlICT1(�tl ST')\fJ.
- DATE
Latiad
TFFICE USE ONLY (! C� ;'(II i gi(1 TlJf1EOF PF_r1SOtJ CONSTnUCTINCI TIiF: WELL
f, ;S
a Subrnll odpinal to Division of Water Ouslity, Groundwater Section within 30 nYgQW1 t1EV. t2199
—

North Carplina • r)epartrnent of Environment and Natural Re sources . Division of Water Quality • Groundwater Section r r d
1636 Mail Service Cn.nler - Raleigh, N.C. 27699-1636-Phone [phone] �" S
WELL CONSTRUCTION RECORD WELL CONTRACTOR: �0 — ows—ow
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check nr•pllcable Flax): Residential Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery [_] I leaf Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: ('Show sketch of the location below)
Nearest Town: _.5-1L"�'� .NAL✓d R' County:g 4d_Q � � `�
(Road rlarno a Numbers, Cornet or Sub vision and Lot No.) DRILLING LOG
3. OWNER From To
Address - d NOW!reel or ou o o.
zt cod
&1yorsown A &tale P
4. DATE DiTII._LED
5 TOTAL DEP) I i
Formation Description
6. CUTTItK S COLLECTED YES[] NO[1%�
7. DOES WELL REPLACE EXIS rING WELL? YES [u] NOR( v
8. STATIC WATER LEVEL Below Top of Casing: 3b FT• ---- :.
iT1
I (Use '+' II Above Top of Casing) _ —
9. TOP OF CASING IS___J__.__ FT. Above Land Surface'
'Top of ceshrg rerminnind rvor below hind surf see requires a variance In eccor- CO ?
dance with 15A NCAC 2C .011a • —n m''
10. YIELD (gent): - .-._ MET1 IOD OF TEST I -
11. WATER 7.ONES (depth):
12. CHLORINATION: Type Amount —�-
13. CASING:
Wall Thicr:ness
Depth pametor orwelphUFt. ,iklarterdal
From
---To Ft.—
From
_— To - - Ft. -
From - ----10
-- FI.
14. GROU r:
Drpllt
Material elhod
From .
U _ To _a0_ F1.�—
Flom _----
To ---Ft.
--------
15. SCREEN:
pnplh Diameter Slot Size Material
From .--
T o ---- 1.1 ---
Ir1. In.From
__
To __ Ft.
in. In. --
Ft
in in. —
-+
If additional spare is neednd use bark of for o
_LOCATION SKETCH •
(Show direction and distance from at less) two Slate
Roads, or other map reference points .
U
From -- — To - —
16. SAND/GRAVEL PACK:
Depth Size Material
From
From To Ft. V. REMARKS:
WELL
DO i iERE©Y CFRT &cY j`1 lAY THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NC
2C,
CONSTnuCTIOi' STANDARDS; AND THAT A COPY OF THIS RECORD HAS BEEN VIDED TO THE WELL OWNER.
FOR OFFICE U 9raLY ; (cj /.', '' -r-- GATE
Ouad No: ! I SI TUn OF PERSON C NSTRUCTING THE WELL
Submit oripinaP Division of Water Ouality, Groundwater Section within 30 days GW 1 REV 12l99
Serial No.

North Carplinn • Dgiiriment of Environment and N8lufai rlesources - Division of Water Quality - Groundwater Section EJ 1 7 4 ? 4
1636 Mail Service Cenler • rinleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: ""--6--k �N
WELL CONTRACTOR CERTIFICATIO
STATE WELL CONSTRUCTION PERMIT#:
w �( ❑ Agricultural ❑ Monitoring ❑
1 • WELL USE (Check Appficnble nox): Residential b Municipal ❑ industrial
Recovery [_] I font Pumi, Water Injection ❑ Other ❑ If Other, List Use:
2• WELL LOCATION: ( liaw sketch of the location below) —`
Nearest Town: 'C je �t County:
-- ----- —.--- DRI_ LING LOG_
(noarf Hanna and tkuntmers, Cornmunity, or Subdivision and Lol IJo.)
--- DEPTH _
Formation Description
From To
3. OWNER _
Address
'�IrCel or o f2 I to —
(
`�--•-� �---
slate ZIP Co
City or T ovm a
d
—
4. DATE DFTIL.t-FO —7`_�
I
5. TOTAL_ DFPTI __--►1•-- r-�f
6. CUTTItJGS COLL_FGTED YES O NOLJ — N04
[�
7. DOES WEI-L nt-PLACE FXIS rING WELL? YES
FT._
_
S. STATIC WATER LEVEL Below Top of Casing:
-+' it Above Top of Casino)
.:_. __
(Use
9. TOP OF CASING IS ____� -_- FT. Above Land Suriaco'
'Top of casing ternminniod n1lor below land surface requires s variance In accor-
dance with 15A IICAC 2C .0118
YIELD (gpnl): 3Q- METI IOD OF TEST
10.
rn :�
11. WATER ZONES (depth):
_------�--�
12. CHLOf11NATION:
13. CASING:
Type Amount If additional space Is needed use back of lord _
Wall Thickness
Depth Vrametor or Way � i l9�m^Ft. Material
.�
From From
� �
—To / d 4' Ft. fit--
�'Jll+lw.s
iJQ
From
— To Ft.
—
From --To
Ft.---
—
14. GROUT:
Depth
Material
ethod
From
To _A..Q Ft.
From ---_
- To ---Ft.___---
15. SCREEN:
Diameter
Slot Slz6
Material
Dcpth
From
To __ _ F►
in.
in.
In.
From
1.0 Ft.
In.
-------
in.
From
To _ .__— Ft. -- ____
In.
__ ----
16, SAND/GRAVEL PACK:
Material
Depth
Size
From __--
To _ 1-1•
----'—'
From
T `------- Ft.
�_____--
S'
LOCATION SKETCH
(Stiow direction and distance Irom at least two State
Roads, or other map reference points)
�/a/ a�
17. REMARK
DO I IErIEDY CFRI IFY, iNAT TIiAINO 1AT A COPYCL WAS JSTRUCTED IN ACCORDAN OF THIS RECORD HAS BEEN PROVIDED TO THE WELL LOWNER.
CONSTRUCTION S.TfANDAnDS, � � 7
rw`l — DATE
EoICE USE ONLY . tf� t?. ''', >S ATUnE OF F F1SON NSTnUCTING TIIE WELL
Submit origi to Division of Water Quality, Groundwater SeUion Within 30 daysGW•1 nEV. 12/99

North Carplirm • i1cpirtrnont of Environment and Natural Flesources - Division of Water Quality - Groundwater Section
1636 Mail Service Cenler . Raleigh, N.C. 27699-1636"Phone [phone],02 5
WELL CONSTRUCTION RECORD WFLL CONTRACTOR: -TO"gw
WELL CONTRACTOR CERTIFICAT ION N: Z,.
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable nox): Residential Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery 0 F feat Pump Water Injection ❑ Other ❑ It Other, List Use:
2. WELL LOCATION: ('tow sketch o the location below) �kC . �) �
Nearest Town: - � _County: tJ
__ DEPTH
(noa<i tlamo and f vn,bers, Cornrtry , or ub 'vision and Lol No.) DRILLING LUG _ --
From To Formation Description
3, OWNER
AddregE7p a'
Sheol ar ou o ;7-8 ZP
City or Town �51a1e zip Code
4. DATE DFIILLED--
5. TOTAL_ DEPTI I-
6. CUTTINGS COLt_ECT'ED YFS [ _] NOLZ ,.-, -'=_
7. DOES WELL nFrL.ACE EXISTING WELL? YES n NO[ 1�
S. STATIC WATER LEVEL Below Top of Casing: � FT• ,
t'Yl � • r
(use
11 Above Top of Casing)T
9. TOP OF CASING IS ____�—___ FT. Above Land Surface'
'Top of cnsin9 tlrnllnntnd PHor below land surface requires s variance In accor- CO - -
dance with 15A NCAC 2C.( 1 -n
10. YIELD (gprn): 39 METHOD OF TEST
III WATER ZONES (deplit): - r*t
�
.a
12. CHLOnINATION:
13. CASING:
Type Amount if Additional space is needed use back of lo� «_
Depth - /� prameter
From _-Q To - U 0 Ft. —
From — To--- Ft.
From Ft.
I . GROUt
Depth Material ethod
To 0,C`-
To
From _ Q -
From
15. SCREEN:
Depth
Diameter blot 517e
From
--T o ____--
F't -"___ It"
From ---
To -___--
Ft. _.__ _ In. _
From —
-- TO -
— Fl._ In.
16. SAND/GRAVEL PACK:
Depth
Size
FromFrom
— l o
Ft. '-
17. REMARKS: —
Material
Irt.
In.
In.
Material
DO lfEnEErY CFni IrY-TI IAT:THis' W,FLL WAS CONST UCT
CONSTnUGTION STA�JDnF1DS,:AsND.lHAT;A COPY O HIS
LOCATION SKETCH
Wall ThicHness
or WelghUFt. �maaterial (Show direction and distance front At least two State
�1�.195 T��,'SbLR Roads, or other map reference points)
knlujk /2d
as�w� N c.
IN ACCORDANCE WITH ISA NCAC 2C, WELL
CORD HAS BEEN PROVIDED TO THE WELL OWNER.
F
rQuad
FFICE USE ONUM
o
' DATE
I AT OF PERSOr CONSTRUCTING TIIE WEl1.
:�Submit oriptna to Division ofWater quality, Groundwa►er Section within 30 d1YsYV 1 REV 12/99
o.
CJ

North Carolina • Depart[Twril of Environment and Natural nesources - Division of Water Quality • Groundwater Section r14
26
1636 Mail Service Center - nateigh, N.C. 27699-1636-Phone [phone]
CONSTRUCTION RECORD WELL CONTRACTOi
WELL C
WELL CONTRACTOR CERTIF�AON N:
STATE WELL CONSTRUCTION PERMITf1:
1. WELL USE (Check AppflcablP Box): Residential tJ Munlcipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ 1 feat Pump Water Injection ❑ Other 0 If Other, List Use:
2. WELL LOCATION%/• (Show sketch of the location below) [� %�J►(CQ�IL'pr_-------
Nearest Town: '. •4C e.S f e r County:
— ------ DRILLING LOG
(no,vi rJarno ar Nm ihers, Community o Subdivlsi n and L I o.) From To Fonnalton Description
3. OWNER
Addresss� jl1rel or
1.
'—"�--I. ��Statf-e Zip Code
City or Town
4.
DATE DRILLED
DEP'TII---
5.
6.
TOTAL
CUT-TIPJGS COLLECTED YF_S" NO[kf
DOES WELL nEPI.ACE EXISTING WELL? YES NFTO
— o
7.
8.
STATIC WATER LEVEL Below Top of Casing:
-o r
(Use •+' it Above Top of Casing)
i �� , -:
9.
TOP OF CASING IS —_ �_ FT. Above Land Suriace'
;
-Top or cesinp terminstnd nt/or below land surface requires variance In actor•
dance
10.
with 15A FICAC 2C .0118
YIELD (gpm): �- ME1HOD OFT EST
11.
WATER ZONES (depth): —
___ �Z .'-
12. CHLOniNATION:
13. CASING:
Antourll �TJ �Ifadd&tlonnlace is needed use bark of fo
Typeff --
Depth IDlagmetpr
From O -To Ft.-�--
From TO-- Fl.---
From ­--10_--
14 GROU T:
LOCATION SKETCH
Wall Thickness
(Show
or WeighUFL Maw direction and distance from at least two State
'11s ), Roads, or oilier map reference points)
Depth �+,M�.a�terriyal� ��
From __ 0 _ 10 �Q
f t. -.Lzl1��-�-i-�
From ... - --- 10 _-----Ft.
15. SCREEN:
Donth Diameter Slot Slz©
ethod
Material
From __---To____ Ft _
III, in.
_ ---
From _ 10 - Ft• in. In.
in. ��--
From ___-- T*o Ft. In.
16. SAND/GRAVEL PACK: Material
Depth Size
From �-- 1 o - Ft.
From To Ft. --
6? u
5
e e far, /Y-. C.
17. REMARKS:
1 DO t IEITEFIY CFn11FYTANO TFIAT rA COPY OFAS R HIS RECORD D HAS BEEN PRUCTED IN ACCORDANCE OVIDED TO THE WELL LOWNER`
CONSTRUCTION STANDARDS,I f � .5-0
DATE
Ed
ICE USE ONLY .E.;1 (� iiiO�J
d U SIOiJA nE OFF SON CONSMUCTING THE WELL
Submit odginal to Division or Water Quality, Groundwater Section Within 30 dayst3W 1REv121g9
-----

( loft h Carolina . inrinrrnl nI FIIvimrtntertl and NIttit ol fIesourcns - Divinion oI WnIer Quality • Grrnrndwnter Sec Iinn r,) O r
1636 fr1,i1 Svivicn Cnntrr - Ilnleigh N C. 27699-1636•Plione [phone] {: i 4 2 7
WELL GUNSTRUGI [ON RECORD wall -CONTRACTOR:
WELL CONTFIACTOR CERTIfICA11011 H:
SPATE WELL CONSTRUCTION MIM110:
1, WELL USE (cl,rck nl•l,llr,hio nnx): nesidentiat[i Municipal Induslrial [._l Agricullural Monitoring
R(?covrtry [_) I Ira, Pump Water Injection 0 Other 0 If Other, List Use:
2. WELL LOCATION;. (�' ow sketch of the location below)
NearestTov:n:__�! .� County:----
-- DRILLING LOG
(nond riamn and i rm1wrs, Cornmunily, r Subdivision and Lot No r orrnalion pescriplion
3. OWN(-n From 1p
Address � ---- -- -
-- ;liect or Fto. a o
1 own own State Zip Code _ -- ly nr �y
4. DATE UiIILI_EU __./_'' d d ----•- --`- '-
5. TOTAL_ 1)E1' F i I _ - CD
6. CUTTIi 105 t_LF'
CO(; I EU Y1:S 0 NO[ 1� _ ---�— ram-
7. DOES WELL. i1(=f'L.A(;E FXIr PING WELL? YES [� NO - -- tT ,�..;
FT. - - -- — —
p of Casing:
B. S)-ATIC WATEn LEVEL Below lo---- t
(Use '+' It Above Top Of Cnslnp)
9. TOP Or CASING IS....__.'.—__. I-T. Above Land Sulfaco'
'Top of ca�hrn ipr rninntod rl'or below land surface reclulres a variance in actor• --- 13 �� r
dance will, 1SA iWAC 2C J) n
'0. YIELD
ern ME1 l IUD OF TEST
1 i. WATEtl 7_0NES WC11111);
12. CHLO(11NAHON
13. CASING:
F-10i11 _—O
From-----
Froin -..---
14. GROUi:
1 Y{ 1n �� A1T10Un( 3J�5 II eddilionni s11ar,© Is needed a^.e bark of loan
_ ... __._ ._. _...__...........
ilrhlhe7 9 (�iarnetor
10..._..__.— FL-
_1�Ft.-
Front
(1rl,n••,�,
Front
Finni 1n _.f1
15. SUrIEr11:
_L.UCA71c�fd SI<F:1Cli_
Wail INCi•nc19
or Wvigti 1. Mnlednl UU (Show direction and disl,ncn irorn fit least two Shle
JjUaj ?V_%SQR Roads, or other ninp reference points)
Material rithod
Uriill) l7ia,nleter blot ti176
Material
Fl oin -- - ....__ 1 rI .... _. _ - 1-1 In, --
Flail, _._. _....__ 10 _._..['t. In.
From _ _ --..— 10 _ .... _-- f t. In. _
16. SANDlGF1AVEt. f A(,K: Malotint
[)Pl,tli Size
From ---- - -- [ n---
Frorn _ ........ 10
17 FIEMAt1KS: —
no ►11 nrn r rr:n l lry 11 IA1' T i )IS WELL WAS CO Tf1UC1 E0 IN ACCOf1OANCH WITH 15/1 FICAC 2C, WELL
CONS1 f1l Ir_.TIOI;! S T nlll)nf1U`3• AND 1HAT /',COPY OF IIS RECOfio h1/1S BEEN PR VIDED TO TI IE VJCLL OWNEn.'
s on oo� F i�r use (rll�u� ����� (6 a -- PATE
i( (,;l) gl ,r ATI.111E or r r. SOtJ OiISTnUCTitIG 1IIr_ WFII.
Ouad No: e
_ Submit odpinat p blviston of Water Ouetlty, Groundwater Section Wllhitl 30 r. ayg OW i fiEV i2199
Serial No. ____------------ •;

- .. ...., i. •.; r..T. i7p.•;...,.Tr. .. a. eetn'jr+Mp`I`j'FX'`"Yw.V '+1 ►kt :. ._ �`,
North Carolina - Oepartrnr.nt of Environment and Natu7420ral Resources • Division of Water Quality •Groundwater Section ��
1636 Mail Service Center • Raieigh, N.C. 27699-1636•Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: �Da 9
WELL CONTRACTOR CERTIFICATIONI.
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential L7a Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ I ieat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: ( howskelcl of the location below)
Nearest Town:.-- County:C
(Road Namo and
3. OWNER
lot o.) DRILLING LOG DEPTH
7 From To Formation Description
Addre s P
u Cr oo.
ity or Town State Zip Code
4. DATE DRILLED
5. TOTAL DEPTH �=
6. CUTTINGS COLLECTED YES F—] NO[Pr o
7. DOES WELL REPLACE EXISTING WELL? YES [�� NO[o rn r7>
B. STATIC WATER LEVEL Below Top of Casing:, FT. ryl
(Use'+' If Above Top of Casing) _n
9. TOP OF CASING 15 L—_ FT. Above Land Surface- P, ;
•Top of casing terminntod at/or below land surisce requires s variance In secor-
dance with 1SA #CAC 2C 0 8 . �- 'V m
'0. YIELD (gprn): METHOD OF TEST
rn �'
11. WATER ZONES (depth): n, J
ri:
12. CHLORINATION: Type--�Amounl _--•-Ps If additional space Is ne9dad use backof IorMo 0
13. CASING:
Depth LL��//// Diameter
From To ALL Ft. j,.a q
From - To-- Ft. —
From To — Ft.
14 GROUT•
_LOCATION SKETCH
Wall Thickness
or Wei hUFt. UMaterial (Show direction and distance from at least two State
F Y- Roads, or other map reference points)
Depth
Material
Mot hod
From To --ADL- Ft.
From _ To _
Ft.
------
15. SCREEN:
Depth
Diameter
Slot Size
Material
From _--To To __Ft
_
in.
in. _
From To _.--
Ft. --
— in.
in.
From To -.,-__Ft.
In.
In. __------
16. SAND/GRAVEL PACK:
Depth
Size
Material
From To
Ft.
_
From To
Ft.
—
17. REMARKS:
1 DO FIEREBY CFFiTif Y THAT7NIS WELL WAS GONSTfiUCTED I ACC RDANCE WITH 15A NCAC 20, WELL
CONSTRUCTION S1'ANDAFIOS,•/1ND THAT A COPY OF THIS C AS PEEN P ViDE2DT THE WELL OWNEfl. ' Q
Cl /�
EQuad
rlcE usE o�1LY DATE
E�� SIGNATURE OF PENCONSTRUCTiNCiT►tEW L'tSubmit odginal to Division of Water Quality, Groundwater Section within 30 dayst3Wt REV. 12/99

.. .. ._ �. Y, r r-r"'1 41` :�'^WO'/-' •Y'P nt�R'•'ri 1:w., .. .i"M. v-II... 1 , Y Y - .. ,
North Carolina of Environrnent find Natural nesources • Division of Water Quality - Groundwater Snclion 7430
1636 Mail Service Center Tl ter • nleigh, N.C. 27699-1636•Phone [phone] b�
WELL CONSTRUC110N RE CORD WELL C - MACTOF �^' S
WELL CONTRACTOR CEnTIFICATI N:
STATE WELL CONSTRUCTION TIMMiTN: _--
1. WELL USE. (check Appucnbla nox)! nesldenllal [R( Municipal El Industrial ❑
Recovery U I feat Purlip Water Injection n Other 0 If Other, List Use:
2. WELL LOCATION: (!31iow sketch of the location below) �2
Nearest 'Town: ye , County: O
Agricultural ❑ Monitoring ❑
-- DRILLING LOG
(no„i Ilamo and! fibers, Comr unity, ASubdivislon and Lot No.) Formation Description
R
3. OWNFFrom To
Address
�1 S-L — Zlp Code
Cily or lows slate
4, DATELMILLFD__�7'
5. TOTAL_ DGP [ I I _-_
6. CUTT It IGS COLLECT ED YES ❑ NO&?� CD7. DOES WELL nEPI.ACE EXISTING WELL? YES [,] NO c�
8. STATIC WATER LEVEL Below Top of Cnsing: FT.
It Above lop of Casing) r-
9. TOP OF CASING IS___.__L_— ET• Above Land Surince' r _
'Top of eeshlp I^n„Inri^d ^tlor below land furtece requires w variance In accor- w_ o
dance with I IICAC 2C .011A
10. YIELD (gent): METHOD OF TEST
11. WATER 7.ONES (depth): M a
It additional spare Is naeded use bark of f%t —+
t,� Amount �2J� _ --.— -
12. CHLOfTitJAT ION; Type_..._..._. ,Y
13. CASING: LOCA1•ION_SI<ETCH�
Wall lhicknnss
plam�e�lor or Welght/Ft. Material (Show direction and disiance from at Innst two State
Roads, or outer ap reference
mpoints)
Flom10 _ _-2,
From-------
Front - — -- —..--- ��
14. GROU i : Method
[trpllt '�.Mwate�rial c
Frvm _._Q._-_ 10 _�,�_--
r1. _�.. � /'C IFS #12,
Front-
15. SCREFN:
11(,I,th Slot Slze Material
rrottt
From ____._
Front .-----10.......-- F1._
16. SAND/GnAVEi. PACK: N[alerial
Depth Size
From ---
From _......
_---
17. REMARKS:-
1 1^Np-1 T L
DOIIEt1rFY crnJA,s (AACOPY OFTEIS nECOnDHAS EN nOVIDEDTO11IE WELL OWNER
CONSrUCTIM STnJ^tnO .
0 �MANCON'qln(l
c/ DATE
rOuad
UR OFFICE USF O[JLY Y�I°I';, il� SIOtJ nE OF CTIrtG it IF WF..II
No; ( Submit original to Division of Water Quallty, Groundwater Snclion within 30 days UW I REV• 12199
nrial tto.

North Camlirm f.,epnrtn,r.nt of Unviroriment and Natumi ne.^•ources • Division of Water Quality - Groundwater Section' �� ( !�
106 Mail :service Cenier • rintelgl,, N.C. 27699-1636•Phono [phone] J
WELL CONSTRUCT ION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERT CATION N. D
STATE WELL CONSTRUCTION PFRMITff: _
1, WELL USr_ (check AFpncnl,Ie noz): Fiesldential Municipal [�
Industrial ❑ Agricultural Monitoring El
Recovery [_] I teat Pump Water Injection 0 Other 0II Other, List Use:
2. WELL l_C)CATION:'(Sh w sketch of the location below) C _ -
Nearest Imvn:Dd/irOi'7/�Irle_ County:
_ `-- DRILLING LOG
Mond rranie tlumhe s�urily, or ubdiv on and Lot o.) From To - Formation Description
3. O W N F H ��� r ��� .. _-- _ - •
vc+� �
Address f
L `c 4lion o o. y C8287--
Zip Code
CO. or loom dale
//- I S46 -7
4. DATE (MILLED �R — c
5. TOTAL UEP r I I _-_ — cn
6. CUTTItIGSCOLLr=CrED YESO NO�
NO
7. DOES WELL f1Er'I_nC:F EXISTING WELL? YES FT. --
8. STATIC WATEn LEVEL 00IOW Top of Casing: ► r=-�
// (Use'+• It Above lop of Castnq)
9. TOP OF CASING Is FT. Above Land Surface, -; ,.-;,-1
'Top of cashrg ronninntn I ever below land surface requires variance In eccor- ( L
dance with t5n flrnC 2C .o11a METHOD OF TEST
10. YIELD (gf,rn):- -
11. COWATER ZONESES
- --
_S
AnloUnl If additlonal sparse is nr!odad use bark or form
12. CriLOrlIrJATION: Type
13. CASING: LOCAl10N_SI<E1C H_
Wall Tldckness
nce rrorn at Inist two State
lameter or Welght/1-1. J�M�aleerinl �p (Show direction and dista
L)rI,llt
%i�. Roads, or other map reference points)
Flom
From------- ► o --- - -- Ft. Auks ,'v /
Fron, ._ -_10 - ---
14. GROUT: Material Method
DrPllI
From __ 0— T o -9. a Ft.
10
From .. ----- ----
15. SCREEN:
I)rhih Diameter Slot Slze Material
-'in -- FL in• In. _------
From
From _—___-- 10 .- .. _..__ Ft. _
ba.
16. SAND/GFIAVEI. PACK: Size Material
()epth
From - 10 --- Ft. �--- ---
F To - Ft- ----
�EE/Xs
j/ c- 24/;//4e j /t/. (— .
rorn
17. REMARKS:
NCAG 2C. WELL
n COPY OF HIS nECOnD HAS BEEN PnOVIDEO TO TF1E WELL OWNER + O
DO f 1Ef1EEtY CF.r1NCY T11AT THi3 WELL WAS CONS7nUC1ED IN ACCOriDMICE WITH 15A TO-TI
CONSTnUCTIONSTANDAnD.� AND,1t1ATA'/ lo�
_ _ rCC G f DATE
Eouad
FICE USE OIILY Stc�'rtnT nE or FEn fl coNslnucTtrl� li1F wr:r.L
? � ubmif rorigtnal to Divisionof Water Duality. Groundwater SeClton within UU days OW_1 nEV. 12/99

_.. �, .... 7� 1. ..�. �...'....,wFM•r - w�'�wrn"M/W'7ynrt. ;r•. ...r..M �r r 7
North Carolkrtn - DcpnrItnon I of Fnvirnnrnenl and Natural nesources • Division of Water Ouslity • Groundwater S4cti^n 0) � ~f 4 3 J
16:16 Mail S-rvice Crnlrr • rinteigh, M,C, 27699-1636-Phone [phone] l (—
WELL CONSTRUCTION RECORD WELLCONTIZU: W
���
WELL CONTHACTOR C nTIFICATION H:
STATE WELL CONSTRUCTION PFnMITN:
1. WELL USE (check Ar•hnc,bin nox): nesidentialld Municipal Industrial ❑
Recovery [-I I teat Pump Water Injection ❑ Other ❑ II Other, List Use:
2, WELL l_OCAI ION• SI ow s�kj(ItIt I it location below) C
CQ�
Nearest 1oti.rr. — H[—. r�F-�� —County: b.,
Agrlcullural ❑ Monitoring ❑
[)EPTH
(noso llama and I Ur ihers, C IlMunll , or Subd vl, on and Lot No.) DRILLING LOG ----
I'1+ From To formation pescrlpuan
3. OWNER
Address J, `
City or 1 own ) _ state Zip Code
4. DATE MULLED
5. TOTAL UFP I i I
6. CUT11t1GS COLLFCI ED YES ❑ NO [1 Q
7, DOES WELL nErl.ACE EXISTING WELL? YES NO 17,
6. STATIC WATEn LEVEL Below Top of Cnsing: FT.
(Use'+' If Above Top of Casing) r-
9. TOP OF CASINGIS_____L __ FT. Above Land Sutince`
co
'Top or ceslnP terntMrtrd ntlor helow Wid surface requires a variance In accor•
dance with 15A IICAC 2C .0118 r
10. YIELD (4prlt): _ - METHOD OF TEST _
11. WATEFT ZONES (depth); _ P-1
Anlol. S J� If additional space is needed use bark or Ior
12. ChILORItJATION: Type
13. CASING: _LOCAIION_SKETCH
Wall Thickness
Deplh lla�me�llor or Wetght/n. �Material (Show direction and distince from at Innst two Slate
Flom — --10� Ft• '��� �� Roads, or other rung reference points)
From------
rroni
14. GROU T: ✓��
Dr,pth Material Method
/��
Frorn ... ----- 10 --- ---Ft. -- —
15. SCREEf I:
Depth Dinnieler Slot Size Material
Frorn -_ __ To _ _-_-- Ft _
In. In. —
From _ -_--- T 0 ____._ Ft, ln, In.
From --.__-- 10 ....____ FL_
16. SAND/GnAVEI, PACK: Material
Depth Size
From --- -I o _ Ft..---_------
Frorn T 0 — Ft• —
17 REMARKS:
BlacE Al A /.C.
ONSMUCTED IN I DO 1 IEr UCTIONISTnt DARt?a IAM WELL WAS C
AND iMT A COPY OF Tf IS nECO D HAS OB EN PFtoVIDED Tt1 TI fE WELL LOWNER•
CONsTn
FUn C7F FICE USF UfILY f OATS
[ .i;irrr) ci(1I t1nE or r . Oft COf1ST UCT1110 711E WF.t l
Quad tio:Submit original `o Divlslon of Water Quality, Oroundwaler Section Within 30 r tYs aW 1 nEV. 12/99
Serial No.

. �, r i. ..r ,'1"':"'�'C r' w•r w,n•rr+►N'tt+'Ms.,m. ., I .n,..,,_,,..
North Carolinn • Depnrimoill of Environment and Natural Resources • Division of Water Quality • Groundwater Sp.cllon
r` -4 It A 4 0
1636 Mail Service Centrr • Rnleiph, 14.0. 27699 1838•F'Frone [phone]s , /•
L CONTA"Ab
WELL CONSTRUCTION RECORD WELL
CONTRACTOR CERT(IJFI(•CJAT )N P.
STATE WELL CONSTRUCTION rERMiTH:
[� Industrial ❑ Agricultural ❑
onitoring
M❑
1. WELL USE (check nr hncni,in nox); Residential Muntclpal
Recovery ❑ I leaf Pump Water Injection ❑ Other ❑ I( Other, List Use:
2. WELL LOCATION: (Show sketch or the location below) GO L� --
Nearest i own: ��� �n 1//,%� County: AD - �-
`- DRILLING LUG
(Flog l trarte and tlurnbCrs, C rttmunity, or Subdivision and Lot No.) �----- - --'
To Formation Oescrlplion
n r� ►/+ _ From
Addrerr
—F�►— --ICI F+o.,
Or jn�Uh3
�) �..,
—+`1a C Code
Zlp
City of lown / GIAIO _
DATE P111LL1'U b-a_a 0©
4.
S. TOTAL r)EP I it ,�( --
YES ] NOLJ
--yc °-
-,
6. CUTTINCIS COLLECTED. _,
7. DUES WELL REPI.ACF_ EXISTING WELL? YESf' NO
LEVEL ©elow Top or Casing: 1 L� FT.
r�
;
B. STAI IC WAT Fn
It Above Top of Casing)
co
F T. Above Land Surface'.
9. TOP OF GAS IF-_-- - -
rU(,r below land surface requires a variance In accor-
;
{�
-Top of cash,(> rennlnptod r
dance with 11;A IICAC 2C .01 to
MET'rIUD OF TEST
cn
10. YIELD (ol)srl):
N �-t
11. WATETI ZONES (&pll,):
cs
~
�S It additional space 19 Itredod use bark of loan --- -
Arnounl
12 CHLOr11tIA1IOW Type -- - - -
13. CASING:LOCAIION_SF«YCH
wall 1 hlctmo ss
Ljr,l,lli lamelar or WeIphVTL Maledal (Show direction find distance l(orn at Inasl two Stale
Fl. % 7 r L�� Roads, or other ms�p reference pelnts)
From _To _ f�L.e�:.>!
From---- 10 ---- — CL
,p(From -- _-1 o -- . vQJr'�/7%��!ffarPer
14. GriOU I: Material Method
L)pplh
From _Q T, -A _ Ft. �
From -----
15. SCREEN: Material
Uohtlt Dilrlleler Slot Size
To - - - FI - In,
Irl. __------
Ft. Ul.
From �_---_ T ° -
From ---- 10-
16. SAND/GnAVEI- PACK: Size Material
Depth
Front -- To --- - Ft...__------
Frorn To _ _____ - Fl. ____
17. REMARKS:
WELL
AND THAT; A COPY OF THIS REOORD HAS BEEN PROVIDED TO THE WELL OWNER. -
DO rlfrlEF y Crmir'`/ T11AT TIAS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C. WELL
CONSTRUCTION STnNDAF1DS,
DATE
FUR QFFICE U.ggt(MLY r 91C3it Unr Or r`F . ON CONS1nUCTirlo THr- WEr_L
[mo,d IIo' �'A'� � r' j (3W1 nEV. 12/99
JSubmirlorlpinar to Division or Water Ouallly, Groundwater Section wilhirl 30 r ays
eat No. __--- ---

...... ...,.. ��.-.,...._M „I,..rT '.. -K•...•r.•pt.r•• .rr...n•rr�h+.�rz„-. •r•-e+ �,. ..• �y
North Carolilm • fl4'pnrirT10nl of Environment and Natural fleaources - Divieion of Water Quality • Groundwater Snclion ii 7
1636 Mail Sorvice Crntrr • flnfelgh, N.C. 27699-1636•Phone [phone]&� / 1 ! 4 4
WELL CONS TF3UC1 ION RECOfiD WELL CONTf1ACTOFI�:L/,GS
WELL CONTRACT OR CERTIFICA�1): C�D�
STATE WELL CONSTRUCTION PEnMiT11:
1. WELL UST: (Check Applicable nox): nesidentlalld Municipal U Industrial ❑ Agricullural ❑ Monitoring ❑
necoveiy [-) I teat Pump Water Injection [] Other F] If Other, List Use:
2. WELL L-UCATION:,(SI)ow sketch of the location below) , NCOhi
Nearest T own , : ��jg-r hCounty:
DRILLING LLING LOG DEPTH _
(npPtl darn rd Nurnbnrs Comr, r I , or 5ubdl Is on and Lot No.) Formation Descrlpiion
3. OWNFn _ From To
Address
(}[r, cI or nulo�o.
Zip Code
Cily, or 1 own Slate _
4. DATE DHILLED &- 0-0.66
5. TOTAL Uf:P T I 1 —74 _
6. CUTT INGS COL_LFCTED YES ❑ N052f cz`
7. DOES WEt-L nr-rl-ACE EXISTING WELL? YES [] NO c �;
8. STATIC: WAT En L[:VEL E3elow Top of Casing: Q_ FT n
(Use'+' if Above Top of Casing)
__L_- FT. Above Land Surface'
9. TOP OF CASING IS_-
'Top or casing teiminrtnd ntfor below land surface requires a variance in actor-
dance with 15A NCAC 2C .0 18
,Itt -_ _ METIHO OF TEST
(
10. YIELD qj ):
11. WATER 7.ONES (depth):
Amount .s If additional space is needad use bark of I�ryr --r
12. CHLORINATION: Type - —_
13. CASING: LOCl1TION_SKElCH
Wall Thickness
Url�ihQ� lamelor or WeIphUF"1. AMate�daCl �p (Show direction and distance from at IFlast two Slate
._- o _ J !.L Ft ���-- Roads, or other map re[erance paints)
FI om .---�
From-----
From - - —3'� - Ft. --- 6jA !s 6
IV
1 A. Gf10U T: Drplh Melttod j% `
Material / r
From .._fa - 1 o `� a Ft.
From ---- T ° ------Ft. _ --
15. scnutJ:
L)r[,Iir Diameter Slot Size Material
From __.•_-_-: To.._.___--- Fl - In. in.
Fran, _ __ 'T o _..-�_ n. --__ In.
Frorn
16. SAND/GRAVE:l PACK'. Matellal
DF,pth Size
From --- T <r Ft.
From -...__ -- 10 rt. ____-----
17. REMATIKS:
100 1 iEnFF1Y'CCt' ST n Jn IAI' l AND T 1AT A COPY OF I IS nECOnD HAS BEEN PnIOVIDED TOT I fE WELL OWNER. ' O�
CONSTnMJ n0'3 ,r „ i �
�— OATS �—
EO-j8d
FI(E U$E ONLY LY
41(ATUrtE OFF - 1SON CO1`1, In Tltirl TIIF WEr.I
f; r`��� j Sur rit.o4tpinal o OlvisIon or Ater Quslily, GroundwaterSectionWilh30 daYgaW-1 nEV. 1?l99
---- - .77=_.

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section �) 1 ( 4
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION #:_ d g
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable sox): Residential Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: S ow ketch of the loc`)ion below) -) !'M `C
Nearest Town:
U
( D.4-//P�2i'//ea County: l�/t_��' b
(Road Name and tubers, Community, or Subdivision nd Lot No.) DRILLING LOG DEPTH
-
3. OWNER From To Formation Descdplion
Address 17
l or oul0 w --
• 71
City or Town State Zip Code
4. DATE DRILLED 17D
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑ NO2" CD
7. DOES WELL REPLACE EXISTING WELL? YES ❑ , NO[
8. STATIC WATER LEVEL Below Top of Casing: _ Y Fr.
(Use'+• if Above Top of Casing) "--=
9. TOP OF CASING IS____L_ FT. Above Land Surface- CO .=r_
'Top of casing terminated at/or below land surface requires a variance In actor-
dance with 15A NCAC 2C .0118 4
10. YIELD (gpm): Y& METHOD OF TEST _ps -4 .
11. WATER ZONES (depth):
12. CHLORINATION: Type Amount If additional space Is needed use back of form =-
13. CASING:
LOCATION SKETCH
Wall Thickness
Depth (J Diameter or eight/Ft. atenal (Show direction and distance from at least two State
From 0 To Ft• -++` S Roads, or other map reference points)
From To Ft. -
From To Ft. lL�(/ �K•'C /`• d
14. GROUT:
Depth Material Method n�. �/��j�•��1�� � •
From _ To cSCk Ft.
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft in. in.
From To Ft. in. in.
From To Ft. in. in.
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONS4NATURE
1 ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAW A COPY ORD HAS EEN PR IDED TO THE_ WELL OWNER.
FOR OFFICE USE.ONLY DATE
Quad No:_ pSIGPERSON CONSTRUCTING THE WELL
`bmi¢riginal to Division of Water Quality, Groundwater Section within 30 days GW 1 REV. 12199
Serial No. — --

North Carplina - Department of Environment and Natural Resources • Division of Water Quality • Groundwater Section
1636 Mail Sr_rvice Center - rlafeigh, N.C. 27699.1636-Phone [phone],
NELL CONsmUCTION RECORD WELL CONTRACTOR: °
WELL CONTRACTOR CERTIFICATION 0: Q _
STATE WELL CONSTRUCTION PERMITP:
1. WELL USE (Check Appilr.abfe Pox): Residential LYJ Municipal ❑ Industrial ❑ Agricultural U Monitoring ❑
Recovery [_] neat Pump Water Injection ❑ Other ❑ If Other, Lisl Use:
2. WELL LOCATION: (Show sket%h�off,the location below) BC,� t
Nearest Town: �—� County: D
From
(Rosd flama and Nunllhr5, Cornnl Illy, or Subdivision and Lot No.) FLING LOG
3. OWNFRFrom To
Address Q�/
�►�jp i�� �r Ztreel orlon
T '— Zip Code ~
Cily or Iovin tt State P
4. DATE Drill_LED P`a�
5. TOTAL DFf' I I i t---1
6. CUTTlf,lGS COLLF( TED YES 11 NO[fr�
7. DOES WEl_t_ nEr LACE EXIT rING WELL? YES ( NO[ 1�
8. STATIC WATER LEVEL Delow Top or Casing: Fr.
(Use '+' it Above Top of Casing)
9. TOP OF CASING 19,__J._._.. FT. Above Land Sutiaco' _
'Top of casing lcrnllnnind rver helow Innd surface require a variance In accor-
dance with 15A iWAC 2C .0118
10. YIELD (ghnl): J.r...7.__ METI IOD OF TEST !
,1. WATER ZONES (depth):
12. CIII-onINAT ION:
13. CASING:
Forrnalion Description
�
o
r
J
V
Type ,_Amount a� If additional space is nr.eded use back of form
n Depth iameler
From V --To '' Ft. —
From — To FI•
From _.__.. To — Ft.
14. GROU'r:
Material emod
Depth
From TO
From T'o _ Ft.
15. SCREEN:
—LOCATION SJSETCH
Wail Thloness
or WelghU1-1. Material p (Show direction and distance trom at least two State
AHt. 5 Roads, or other map reference points)
Drpill Diameter blot Size
Material
From To _ Fl It" Ir1.
From TO -- Ft. In. In. From To _ Ft. In. In. —
16, SAND/GRAVEL PACK:
Depth Size Material
From To _ Ft.
From ___— 10 Ft.,
17. REMARKS:
100 IiERE13Y CEriT if'Y T) IAT THIS WELL WAS CONSTRUCTEO IN ACCORDANCE WITII 15A NCAC 2C, WELL
CONSTRUCTION ST MTDA(1DS1=nND TFIAT A COPY OF -TS RECORD HAS BEEN PROVIDED TO THE WEU. OWNER.—
s
FOR OFFICE USE OTILY ��— DATE
T ! S, URE OF PERSON C 1STnUCTING THE WELL.
Quad No: I (i r, }(
a?1<,3) 'ISubmil original to Ivlsion of Water Quali►y, Groundwater Section Willtln 30 days QW 1 REV 12/99
Serial No. —

.~ _'•..�,."rFT..r,..._��'!+`IvM Y!.t.. +r•wnYtty}q'y7wTri«. ._. «f �.'..-n .... .,_.. _r..__ . � �.. ,
North Carolinn • Unrnilmonl of Unvironrnent rind Natural nesources - Division of Water Quality - Groundwnter Snclion
2)174r�
1636 Mail Scivice Center • rtnieigh, N.C. 27699.1636-Phone, (919) 733.322,
WELL CONSTRUCTION RECORD WELL CONTRACTOR: 'S
WELL CONTRACTOR CERTI CATION N: D
STATE WELL CONSTRUCTION PERMITN:
1. WELL USF: (Check Arpncnble Flax): Residentlal Municipal ❑ Industrial ❑ Agricullural ❑ Monitoring ❑
Recovery L] I l(,at Punip Water injection ❑ Other 0 if Other, List Use:
2.
WELL LOCATION: S w sketchthe location below)
Nearest Town:.County:
(n0� I f lama rid f U.unhrrs, Comm Wily, or Subdivl. nand Lot t o.j
DRILLING LOG
3.
OWNf".Fi
From To iormaUon Description
AddreSr
— -
-2p,7
/`�'���
4.
ity "I own Siale Zip Code
DATE Fled-1_17-1) &! l_. ,•�l�
c,
_ � C
5.
TOTAL 1)FP I I i '
YES❑ NOd
`— m ct`
6,
CUT1111CISCOI_LFCIED
WELL? YES [�] NO[1/
7.
DUES WELL FIFF'L.ACE FXISfING
8.
STATIC WATER LEVEL [Below Top of Casing: �0 FT.
CJ cr- a-1
(Use '+' if Above Top of Casing)
9,
TOP OF CASING I �__._�__ FT. Above Lund Surface'
'Top of ce,inn rermlmond Wer below land surface requires a variance in accor-
r
••�___
dancewllh
10.
15A1ICAC2C.01 ta
YIELf) (qpn,) _!J/_- METHOD OF TEST
11.
WATER 70NE9 (dopth):^
J�
If additional sparse Is ripeded use brink of Ivan
12.
CHLOf11NA-1 ION: Type --a _ . _ _Amount
^----
13. CASING:
_LULAI IUN SI<ETC}{
Wall thickness
Uepllt� rt hmelor or We� Mate (Show direction rind distance teem nt Inast two Slate
From --10 --� ,c Roads, or other map reference points)
From------
rrom---------10 — rt.
14. GROU1:
ftr•f,tl, Material Method
Frorn —Q _ 10 -S 0 F t.
4
From ....... ____ 10-_----FI. —
15. SCFIEEIJ:
UgpUt D11111eler Slot Sire Material
Frorn .- --- .1-o - ---- rt in. in.._.__ ----
From --- in ---- rt. in, In. —
Frorn _ __ _ 10 -- Ft. In. In.
16. SAND/GRAVEL PACK:
Depth Size Material
From _ - -- 10 Ft -
From _..-- To rl.
17. REMARKS:
Do HEnF-DY CFn11FY I IAt.TIill S WELL, WAS CONSTRUCTED IN ACCOFTDANCE WI11I 15A it 2C, WELL
�t,jo, III $, %1NDITHAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
CONS TFIUCTIOH';ST+D�
i v DATE
FOR OFFIC E USfF tOIJLY !;} SI(VATUnE bF FiSON COrrSTnUCTif1C1 Ti1F WF.t l
Quad No. I I (` f1f
Submit orlpinal to Division o Ater Quality, Oroundwafer Snclion Will,irt 30 days OW 1 REV. 12/99
Sarial No.

._ ,i . nT., p... ;..+-w r...•:.a .s•rn:at„'i'7or-�. ..l:.�n. .,.-�� - -. ,
J 7454
North Carolina • De artrnrtnt of Environment and Natural Resources - Division of Water QualityGroundwater Section t. .
1636 Mail Service Center • naleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFI TION H:
STATE WELL CONSTRUCTION PERMITff:
1. WELL USE (Check Applicable tlox): Residential Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery U I feat Punlp Water Injection ❑ Other ❑ if Other, List Use:
2. WELL LOCATION: tow skett h of the location below)
Nearest Town:�ily�/>- -- - County:�����l77�
(Road NarTio ar d Numbers, Comm i y, or Subdivision and Lo No.) DRILLING LOG
3. OWNER From To Formation Description
Address _ •
• `( reet or ou o o.
City O 1OYJrT / state Zip Codev C__
a. DATE DnILLEU _(p_' • d� _ r i
5. TOTAL DI:PTH C w'
6. CUTTINGS COLLECTED YES [] NOL01,
7. DOES WELL TIFPI..ACE EXISTING WELL? YES NO
NO�— 7
.l�G__. i r-
8. STATIC WATER LEVEL Below Top of Casing: FT.
(Use '+' If Above Top of Casing)
9. TOP OF CASING IS__� FT. Above Land Sutiace• ° r;
'Top of caslim lerminatnd stfor below land surface requires a variance In accor-
dance with 15A fiCAC 2C .0118 r•"�
( ) �� s C7 -
10. YIELD gprn : METHOD OF TEST y—iQJf— ~
11. WATER ZONES (depth):
12. CHLORINATION; Type —Amount S If additional spare is needed use bark of form --
13. CASING:
LOCATION SKETCH
Wall Thickness
Dehlit plammeller' or Weipht/Fl. Material p (Show direction and distance from at least two State
Flom—T o a Ft. ��"`—' ��` Roads, or other map reference points)
From— To ---- Ft --
From Ft.
1 a. G ROUT:
Uep111 Material Method � dl,From _Q_ ToFt. _� '� - �/f/
From --- To _—__Ft. _
15. SCREEN:
Depth Diameter Slot Size Materlal
From To —_ Ft _ In. in.
From --To Ft. _ fn, In. _ _ From --_ To .-_...-- FI• in, in. —
16. SAND/GRAVEL PACK:
Depth Size Material
From __— To Ft.
From To Ft.
17. REMARKS:
DO tiEnEsY CFnTIFY Tl iAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTn1 C., . t1,,, , , b/1RDS, AND,THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
_ ___ €h3 t 1t .�
FOR OFF10-E`USE ONLY DATE
Ouad No: SI ATUnE OF PE SON CONSTRUCTItJr THE WELL
", t(l� Submit original to Division of Water Quallly, Groundwater Section within 30 days GW i REV: 12/99
Serial No.

North Carolinn - Depnrlrnent of Fnvironment and Natural Resources - Division of Water Quality - Groundwater Secli•-iin �` 1 7 746
6
1636 Mail Service Cenlnr - Rnteigh, N.C. 27699-1636-Phone [phone] ! C)
NELL CONSTRUCTION RECORD WELL CONTRACTOR:WELL CONTRACTOR CERTIFICATION
STATE WELL CONSTRUCTION PERMITH:
1. WELL USE (Check Ary+ucable Box): Residential Eig' Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ I lent Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATIOt` • ('S�Io�w's/ket�chQof the location below) �
Nearest Town:-r"��-``� County:
(Road Naino id NUM crs, Cor ,n,it�y,�or SS b,divislon ar Lot No.) DRILLING LOG
3. OWNER From To
Address V1 ool-
j reel or o O.
y or loom Slate Zip Code
T-
4. DATE DFlll_l_EO 1P ` Q�
5. TOTAL DEPTH --
6. CUTTINGS COLLEC fEU YES [-] NO t(
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO[o -
8. STATIC WATER LEVEL Below Top of Casing: _4-t2 FT.
(Use '+' it Above Top of Casing)
9. TOP OF CASING 15 ____�__ FT. Above Land Surface'
'Top of casing lerminnind ntror below land surface requires a variance In accor-
dance with 15A f ICAC 2C .0118
10. YIELD (gprn): j4r ME1 HOD OF TEST
,1. WATER ZONES (deplh):
12. ChILOF11NA1l0N
13. CASING:
Formation Description
`" ,
C1�
_• ri
—
r�
rn
Type Amount41afi If additional space is needed use back of form -- `
Depth /� Diameter
FromQ—
10 �(/ Ft.I*-A6
From----- TO--- Ft.
From — 1 o Ft.
14. GROU I':
LOCATION SKFTCH
Wall Thickness
or W�eiQh�UrFt. Material (Show direction and distance from at least two State
9",1, pr('-UR Roads, or other reap reference points)
Depth Material t .,
From -_O-. 10 Ft. sPLF. From _ __ 10 -. Fl.
15. SCREEN:
Depth Diameter Slot Slze
. Melhod
Material
From - - -- I o -- — Ft - In. In. From o _ Ft. In. In.
From To _.-_-- Ft. __ In. in.
16. SAND/GRAVEL- PACK:
Depth Size
From -__— To - Ft. _
From _-.--__---- To - Ft.
17. REMARKS:
Material
r WELL
DO 1tEr1EE►Y Cr"17TIf Y T'rl/1TG 11134W �L WAACODY OF TH T CORD HAS DE CEPROV 1 E TO1IIF WELL OWNEn.
CONS rnuc. IQN"S1 Af 1[]AR9 fA 61/j
FOR OFFICE �1SEIOIJLY GC - DATE V
Quad No: 1 q
SIGNATUnE OFF SON CONSTnUCTING T IE WELL
�' ( `I r i;� !ftSubr'nfl oripinal to Division of Water Quality, Groundwater Section Within 30 ►Ys t3W 1 REV 12/99
Serial No.

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section 217 4
1636 Mail Service Center- Raleigh, N,C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR 69
WELL CONTRACTOR CERTI CATION H:
STATE WELL CONSTRUCTION PERMITff:
1. WELL USE (Check Applicable nox): Residential Ltd Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION:/Show sketch of the location below)
Je�. •�'�_f^ County: edc �--_
Nearest Town: ,�z,-
(Road Narne and 1`JUmt ers, Co muni , or Subdivision and Lot No.)
DRILLING LOG ! DEPTH
Formation Description
3. OWNER _
From To
Address
r
reel or ou a o
—
�s '' •�' G-�- ��L,R-aa�`4--
City or Town �OState Zip Code
4. DATE DRILLED _
—
5. TOTAL DEPTH
YES ❑ NO[
6. CUTTINGS COLLECTED
7. DOES WELL REPLACE EXISTING WELL? YES [� NOF
-----`
8. STATIC WATER LEVEL Below Top of Casing: '�_ FT.
c:
(Use'+' If Above Top of Casing)-
9. TOP OF CASING IS t FT. Above Land Surface"
'Top of casing terminated aUor below land surface requires a variance In actor-
t7
dance with 15A NCAC 2C .0118
10. YIELD (gpm): _5.-a- METHOD OF TEST
1
i=5 <•
11. WATER ZONES (depth):--------------
r n
Amount
It additional space Is needed use back of forPil,�
r�*10
12. CHLORINATION: Type !_
_••
13. CASING:
LOCATIO�. N SKETCH
o
Wall Thickness
Depth rameter or W ight/Ft. Material (Show (Show direction and distance from at least two State
From To _ L .— Ft. �— -f r� �i1% Roads, or other map reference points)
From To Ft. Sc,
� n � -
el/ -From
14. GROUT:
Depth 0 C�MatCe_rial Met
hod
From � To Ft. ---n--�—��
From _—To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft In. in.._. ---
From --To Ft. In. In.
From To Ft. In. in.
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
17. REMARKS:
DO HEREBY CERTIFY 7HATTHIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTIONaSTE1tNDADI, {lNDC
HAT, A, COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER. /
FOR OFFICE USE ONLY DATE
li Sl ATURE O ERSON CONSTRUCTING THE WELL
Quad No:
Submit original to Division of Water Quallty, Groundwater Section within 30 days GWA REV. 12199
Serial No.

North Carolina - Depirirnrtnt of Environment and Natural Resources - Division o1 Water Quality - Groundwater Section 2 'j ►J /) 1-9
1636 Mail Service Center • Raleigh, N.C. 27699-1636-Phone [phone] L I `t ;7
WELL CONSTRUCTION RECORD WELL CONTRACTOR: 5
WELL CONTRACTOR CERTI ICATIOtJ :
STATE WELL CONSTRUCTION PEnmim
1. WELL LI SF (Check A`pllriwe nox): nesidential Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ I lent Punip Water Injection ❑ Other n If Other, List Use: _ —
2. WELL LOCATION: (Show sketch of the location below)
Nearest Iown: .Le-1 P_s4_4-_r _ County:
(noad Namo end Numbers, Community, or Subdivision and Lot No.) DRILLING LOG
3. OWNER Ri G K OF
To
Address Cow
—o.)
r.Cl Of (iU 0 T4O.r
s et^ • h r . q 11 '2?. 8
City or 1 own State Zip Code
4. DATE DRILLED
5. TOTAL 6F-rTI I _ —
6. CUTTINGS COLLECTED YES [] NO
7, DOES WELL nErl.ACE EXISTING WELL? YES D NO
8. STATIC WATER 1_rVEL Below Top of Casing: eV FT. —
(Use'+' It Above Top of Casing)
9. TOP OF CASING IS_ FT. Above Land Surface'
'Top of castng lerminatod st/or below land surface requires a variance In accor-
dance with 15A flCAC 2C. 8 •
10. YIELD (gprn):— METHOD OF TEST
11. WATER ZONES (depth):
_ DEPTH
Formation Description
co
r+i
FrI
M a-
N
-•(
0
12. CHLOnINATION: Type Amount $ ;>D 11 additional space is needed use bark of form
13. CASING:
Wall Thickness LOCAT^ION SKETCH
De ill OJQ Diam ter or WelghUFl. Maalee+dall'� (Show direction and distance from at least two State
From To sue— FL ��� ��`-�'�� Roads, or outer map reference points)
From To -- Ft.—�/+
From __ To — Ft.
14. GROUT: &axl V-4 Cove, Rzt.
Depth Material
Melt
o
� i� `
From � To a_Ft. L�tGcS4 e f - 0-C, .
From __.___— T o Ft.
15. SCREEN:
Depth Diameter Slot Size Malerial
From To _--- Ft -- In. In.
From To Ft, In. In.
From _ To Ft. In. in.
16. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To Ft.
17. REMARKS: _
Material
100 HEnEDY CFM IFY,TLIAI',TI1IS WELL WAS CONSTRUCTED IN ACCOnDANCE WITH 15A NCAC 2C, WELL
CONS r(1S1C�TION TAt�PA Dq IiAND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL✓`
jL
FOn 0FAlbG0 E ONLY DATE
Quad No r rg SIGt. TUnE OF FE ON CONSTnUCTING THF- WELL
't (!'! �' Submit ortpinal to Division o1 Water Ouallty, Groundwater Section within 30 days
GW1 nEV. 12/99
Serial No. F

North Carolina - Depnrinrnnt of Environment and Natural Elesources - Division of Water Quality - Groundwater Section 217461
1636 Mail Service Center - naleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION #
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Rox): Residential V Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery [_] i feat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (St t sketch of the location below) �N CO m��"
Nearest Town: ' , J! r County:
(Road Namo s umbers, Communit r Subdivision pd-Lol No.)L� DRILLING LUG _DEPTH
3. OWNER To Formation Description
Address h_ y�_ q �p + '—t�—�
tree or u o N* f r`j—"—
City or Town State Zip Code
4. DATE DRit_LED 'p0 —
5. TOTAL_ DEPTH
6. CUTTINGS COLLECi'ED YES[] NO['�K
7. DOES WELL FlErLACE EXISTING WELL? YES 0 NO[j2
8. STATIC WATER LEVEL Below Top of Casing:l FT. cam_
(Use '+' It Above Top of Casing) '
9. TOP OF CASING IS_ FT. Above Land Surface'
'Top of casing terminnted nt/or below land surface requires s variance In accor-
dance with 15A #CAC 2C.01 18
nt MET HOD OF TEST
10. YIELD (qP ): —..— -
11. WATER ZONES (depth):_,/ p�
TI %.� Amount t1�/—r-1= ' IL additional space is needed use bark of fe►oi
12. CHLORINATION: Type �,__,_.,--� -
13. CASING:
_LOCATION SI<ETCH
Wall 1 hickne ss
Depil Diameter or W i9h�t atedal (Show direction and distance from at least two Stale
From O To FI• �e Roads, or outer map reference points)
From To FI,
From __To - Fl.' rylo i'e- �� r ,e5f
14. GROUT': � • "
Depth Material .L� Method 1 � /`
From © To Q. Ft, l<-z i—s-- lJ►r 1�2. � -G Ir I
Front --- To --Ft. ----
15, SCREEN:
Depilt Diameter Slot Size Material
From _--To Ft _ In. in. ___---
From To Fi. in. In. ----
From T o _._ Ft. In. In.
16. SAND/GRAVEL PACK:
Depth Size Material
From __— To Ft.
From To Ft.
17. REMARKS:
DO I IEREDY CFRiIFY 71IAl THIS WELL WAS CONSTRUCTE ACCOFIDANCE WITH ISA #CAC 2C, WELL
CONSMUCTION STAND/�n ;AND THAT A COPY OF Tull E Of1D HA$�EEN PF�pVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY DATE
Ouad No: SIGNATURE PFRSON CONSTRUCTING THE WELL
I ,` \`s Submit'oripinal to Division of Water Quality, t3roundwaler Section Within 30 days GW 1 REV. 12199
Serial No.

North Carplina - Department of Environment and Natural Resources • Division of Water Quality • Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone] q 74
162
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION ff:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential LY1 Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: ( w sjcetcflof the cation below) 2�LR+^-�i� —
Nearest Town: l County:
(Road Name and Number , Comrrwnlly, Subdiv to and of No DRILLING LOG
3. OWNER From To
Address -:1 tt�
it, t ct or ou a )
ID`
(�
City or Town � Slate Zip Code — -
4. DATE DRILLED
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑ NO[%
7. DOES WELL REPLACE EXISTING WELL? YES 0 NO[ 1� -
S. STATIC WATER LEVEL Below Top of Casing: FT.
(Use'+' If Above Top of Casing)
9. TOP OF CASING Is FT. FT. Above Land Surface'
'Top of casing terminated atlor below land surface requires a variance in accor-
dance with 15A NCAC 2C . 118 i
10. YIELD (qpm): METHOD OF TEST _
11. WATER ZONES (depth):_--�----
12. CHLORINATION
13. CASING:
DEPTH_____
Formation Description
aj. �Lc kkE—,
E
CS
C
rrI
m x-,
_ N
o
Type — Amount .-T-- T— — If additional space is needed use back of form
Depth Diameter
From To Ft. From— To To Ft.
From --To Ft.
14 GROU-r•
_LOCATION SKETCH
Wall Thickness
or Weight/Ft. Material (Show direction and distance from at least two State
or
Pic-lulk Roads, or other map reference points)
Depth Material ethod
From 0 To _AD-- Ft.
From — To_Ft.
15. SCREEN:
Depth Diameter Slot Size
Material
From To Ft in. In. _ �--
From To Ft. in. In. _-----
From To Ft. in. in.----
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
17. REMARKS:
2 mac.
1 DO HEREBY CERTIFY TI IAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A;COPY F THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USo ONLIC}{;f (, �'� 9i DATE
Quad No i ;1 r t`,> GNATURE OF PERS CONSTRUCTING THE WELL
SubmiFo nal to Division of Water Quality, Groundwater Section Within 30 days GW I REV. 12/99
Serial No.

North Carolina - Department of. Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center - Rafeicgh, N.C. 27699.1636-Phone [phone] ^ 63
tNELL CONSTRUCTION RECORD WELL CONTRACTOR-
WELL
�t#:
`#WELL CONTRACTOR CERTIFICATIOp__G
STATE WELL CONSTRUCTION PERMITP.
1. WELL USE (Check Applicable noo Residential G Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Meat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below) tt
Nearest Town: A?La ,-- rh h2trJ_ County:
(Road Name and Numberrst, Community, or Subdivision and Lot No.)
DRILLING LOG DEPTH
3.
OWNER pQi/2 L��la� ��
From To Formation Description
Address Ia a
�is
ar�et or nI I
t V� a�
� .,ou a oft _ I 1 l
`Slate
t�
City or Town Zip Code
4.
DATE DRILLED
5.
TOTAL DEPTH
6.
CUTTINGS COLLECTED YES ❑ NO[►J
EXISTING WELL? YES ❑ NOd
7.
DOES WELL REPLACE
8.
STATIC WATER LEVEL Below Top of Casing: Je7o— FT.
(Use *+* II Above Top of Casing)
TOP OF CASING IS FT. Above Land Surface'
9,
'Top or casing terminnted eVor below land surface taquires a variance In actor-
ri'
cn d
C)
dance with 15A NCAC 2C .0118
10. YIELD (gpm): --q--- METHOD OF TEST
11.
WATER ZONES (depth):''
12.
CHLOf11NA1lON: Type Amount
If additional space Is needed use back of form
13. CASING:
Wall Thickness
Depth la el�r or yolghhr//Ft.
From To 1 3 Ft. �� Z& a5
From To— Ft.
—
From To Ft.
14. GROUT':
ethod
1 Depth Material
From _ i — To -A.U__
From
15. SCREEN:
Depth Diameter Slot Size
Material
LOCATION SKETCH
atefial (Show direction and distance from at least two State
Roads, or other map reference points)
xkl",e S
&ac� Mrn.,nC.
From _To _-__-_— Ft in. in. From _ To Ft. In. In. _—
From To _.__-__._. Ft. _ In. In.
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
17. REMARKS:
DO HEREBY CFR;iIf ��TiI{-� TIiI rV1/ L'L WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 20, WELL
CONSTRUCTIbN STANDAFIDS, AND TIAT A COPY OF THIS REC D AS BEEN PROVIDED TO THE WELL OWNER.
_ �"
FOR OFFICE:! O,N�L=x t�3 1;ri DATE
n {3,� �iL,l t� +1'.tj S NAT EOFPERSON NSTRUCTINOTFIEWELL
Ouad No
Submit original to Division of Water Quality, Groundwater Section Within 30 days GW 1 REV. 12/99
p
Serial No.

North Carolinn - Depnrtmenl of Environment and Natural Flesources • Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699.1636•Phone [phone]
217464
11
f�IYJ �,—
JVELL CONSTRUCTION RECORD WELL CONTRACTOR CERTIFICAT101 1!:
STATE WELL CONSTRUCTION PERMITP:
1. WELL USE (Check Applicable Box): Residential lYJ Municipal ❑ Industrial ❑ Agricultural Monitoring ❑
Recovery ❑ Bleat Pump Water Injection ❑ Other ❑ 11 Other, List Use:
2• WELL LOCATION: (Show sketch of the location below) ,nCOm L�
Nearest Town: .9r-Q-C 11-M County: D
---
(Road Name and Numbers, Community, or Subdivislon and Lot No.)
DRILLING LOG DEPTI_�
Formation Description
3.
OWNER Lam, C490
From To
Address M
�A 01�
—E —_
t or U a
$ - uo ti
City or Town Stale Zip Code
DATE Df lLLED
- 4,
5.
TOTAL DEPTH---
p
6.
CUTTINGS COLLECTED YESEXISTING N0
DOES WELL REPLACE E S
7.
8.
STATIC WATER LEVEL Below Top of Casing: _19— FT
(Use "+* it Above Top of Casing)
-
c�
9.
FT. Above Lan
TOP OF CASING IS d Surface
'Top of casing terminated aVor below land sumacs requires variance In eccor-
dance
10.
with 15A NCAC 2C .0118
YIELD (gpm): METHOD OF TEST
?
,.
M
11.
WATER ZONES (depth):
N
Amount
if additional space is needed use back of form
12.
CHLORINATION: Type
-
13. CASING:
Depth is et�r
From � To � Ft. �-�-�/-�--
From----- To — f t-
From - To - Ft. -
LOCATION SKETCH
Wall Thickness -Material (Show direction and distance from at least two state
or ei hVFt•
Roads, or other map reference points)
14. GROUT:
Depth
elttod
material,�
Q
From _
ToP1-�—
From _-
To
Ft.
15. SCREEN:
UPPUI
Diameter Slot Size Material
From
1 o
FI in. In. _-------
From
—'TO - _
Ft. — In. In. __-----
From __.__
To
Ft. --- In. In. __-------
16. SAND/GRAVEL PACK:
Depth
Size Material
From
— To -
Ft. -----
From
To _
Ft. __----
H ►?h- R�c �1 kre s
Ka-r,hi mrp, po
17. REMARKS:
I DO FIEnEE1Y CFnTIFY TI IAT T.I IIS WELL WAS CONSTIIUCTED IN ACCORDANCE WITH DE NCAC 2C, WELL
CONSTFTUCTIUN STANDARDS; AND TEIAT A COPY OF THIS REC TD AS BEEN PROVIDED TO 1'HE WELL OWNER.
_ DATE
FOR OFFICE USE ONLY a r3 g NAT E OF PERSON NSTRUCTINO TtIF VJEI.L
Ouad No: �'t �' 1 ' rt3 Subinit original to Dlvislon of Water Quality, Groundwater Section Wlihlrt 30 days GW1 REV• 12199
Serial No.

i*' ' YI
North Carolina • Denartrnr_nt of Environment and Natural Resources • Division of Water Ouality Groundwater Section S �}
1636 Mail Service Center • Raleigh, N.C. 27699-1636•Phone [phone]
WELL
CONSTRUCTION RECORD WELL CONTRACTOR: CAN-- -
WELL CONTRACTOR CERTIFI ATION fl:
STATE WELL CONSTRUCTION PERMITN:
1, WELL USE (check Applicable Box): Residential m" Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Ifeat Pump Water Injection[] Other n If Other, List Use:
2. WELL LOCAT`I,OtN: eo
Show sket t f the location below) 'bon��
Nearest Town: P—W —'r 1 � e County:
DRILLING LOG DEPTH——
(Road rJamo and Numbers, Community, or Subdivision and Lot No.) Fomalion Description
3, OWNER)dn� From To
Address ee or `o e o.
W ecAye'iv 111�, � � oZ.1 � yo - ► ��
City or T own ' State Zip Code
4. DATE DRILLED
5. TOTAL DEP11-1
6. CUTTINGS COLLECTED YES ❑ NO
7. DOES WELL REPLACE EXISTING WELL? YES ❑ No
S. STATIC WATER LEVEL Below Top of Casing: —lQo FTc�
(Use'+' if Above Top of Casing) t,
FT. Above Land Surface*t� t
9. TOP OF CASING IS �`-
*Top of casing terminnind twor below land surface requires a variance In accor• CO
dance with 15A HCAC 2C .0118
10. YIELD (gpm): "h METHOD OF TEST
11. WATER ZONES (depth):
Amount If additional spare is needed use back of forty ��_---
12. CHLORINATION: Type --- J o
13. CASING: _LOCATION SKETCH
Wall Thickness
Depth lame r W.1,1,11'r� aerial (Show direction and distance from at least two State
From--
To _—� L�-- Ft•� " Roads, or other map reference points)
From To FI.-- -- 64-e'R�
Frorn -- To Ft. �C.
14. GROUT: Valeo-ver'V1 ` �j
Dept) Materi I elhod
From .- To AV Ft.
From _'10 Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From _—To _- Ft _ In. In,----
Frorn To __ Ft,
In. In..----
From To Ft. In. In. _-------
16. SAND/GRAVEL PACK:
Depth Size
From -- To Ft.From T° Ft. --
17. REMARKS:
DO tlEflF©Y cen 1's1ril/�� T(�(ISWELL
CONS TRI CTlO ,� rAN AR ;�' N0,70AT
FUR OFFI'd, F,'USE 0. H. L
QuadNo:
Material
WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C, WELL
A COPY OF THIS RECO D HAS BEEN PROVIDED TO THE WELL OWNER.
­1
OATS
Submit o
//
GNATUnE OF PER N CONSTRUCTING TILE WELL
to Division of Water Quality, Groundwater Section within 30 days GW 1 REV. 12/99
r
Serial No. —

North Carelinn - Dnrnit1r1ent (itEhvirnnnient and Natural rle^ources - Divinion of Water Ouaiity •Groundwater Snr iron `= 1 �f /� � 1 1
1636 Mail Sr>rvice. Cnntnr • rinleigh, N.C. 27699-1636-Phone [phone] `2
HELL EONS f'RIJCTIUPJ RECORD WELL CONTn ACTOR CEFITirICATION
S1'ATF WELL CONSTFiUCTIOtl PFFIh11Tf1:
Industrial ❑ Agricultural �� Monitoring ❑
1, WELL t1Sl: (Check Ar•pucahle nox): Flesidenlial� Municipal ❑ —
Recovery ❑ I ir'nt Pump Water Injection ❑ Other ❑ it Other, List Use:
2. WELL LOCATION: .tow sl etch t le location below)
Nearest 'Town: _ County:
(noad rlanie and N milers, Cornm illy, r Subdivision And Lot No.)
3. OWNER _
Address
�f lot
�__ Zip Code /
Ciiy or 1 own // Slate
4. DATE DfIILl_ED
5. TOTAL DEP i i I --
6. CUTTINGS COLL ECTE EXISTING ELL?O Y S n NO[o
7. DOES WELL REFT
B. STATIC WATER LEVEL Below Top of Casing:
WL(Use '+' If Above op of casing)
9. TOP OF CASING IS L__ FT. Above Land Surface'
'Top of casing lerminnted nVor below land surface requires s verience In accor-
dance with 1 (91111): 2�METFIOD OF TEST
10. YIELD (gprll): JJJ
WATER ZONES (depth):
DRI^— LUNG LUG
From To
rwlffi�wffffl.]Mal
_ UEPTH
formation Descdplion
(77, —
)
�lC
Fri
`-i
— CO
r rn
— ro
�Anlounl S It additional space Is needed use back of form
12. CHLOIIINATION: Type _-.- • _ _
13. CASING:
Wall Thickness
erial
Depill'�?? �Diammetteer or Wel ht1l t, Mal
From _--� To l�2� Ft. l�'�--
From To Ft. —
From To-
14. GROUT: Depth Material Method
4��
From _.C)- To ._XQ— Ft.
From _ -- ° Ft. — ---
15. SCREEit:
Urpih Diameter Slot Slze Material
From
in. in. --
'T o _-._-- Ft. �__ __ in. In. ------
From in. ____-------
From __.—_--'To _...___ Ft.__ In.
16. SAND/GRAVEL PACK: Material
Deptll Slze
From —_.__ . To _-- rt. -----_•
To Ft. --
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other reap reference points)
M;7 .moo ,61.
/v
From-
17. REMARKS _--
r- W E.LL
ACC r1DMN
TIi ISA NCA . 2C,
R { �IDED Lit WELL OWNFFl.
I DO IIC11FnY t r r111r Y;THnT Tt11SiWEt L WAS CONSTr1UCTEU CONSTFItICT10 C,1/1rIf�ARDS,ANd'TFtATACOPYOFThIIS DATE
FOf1 OFFICE USE O�JI,(t9 ,i Tl('� QATUF FEnSONCONG 111E V' LL
Ouad No: 4 Submit odginal to Divislon of Wrter Quality, Groundwater section within 30 d�y3 GW 1 RE`1. 12J99
Serial No.

W.
North Carolina • Urpariment of Environment and Natural Flesources - Division of Water Quality • Groundwater Section 1 (1 475
1636 Mail Service Center • Raleigh, N.C. 27699-1636-Phone [phone] (/
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
L CONTRACTOR CERTIFI ATION a:
STATE WELL CONSTRUCTION PERMITO:
�._,f Agricultural ❑ Monitoring ❑
Industrial ❑
1, WELL USE (Chock Applicable Pox): Residential lYJ Municipal ❑11 Other, List Use:
Recovery ❑ I feat Puntp Water injectlon ❑ ❑
WELL LOCAT ON: (Show sketch of the location below) Y��`l„ ` �tiP
Nearest Town:
�r�Qi r County:
DRILLINGG LO
(Road Name and Numbers. Community, or Subdivision and Lot No.) From
._-- -- To
3. OWNER
Address 5
tr e or uIf q o• ---"
Stale Zip Code
City or Town O
4. DATE DRit.l_ED
5. TOTAL DEPT H
6. CUTTINGS COLLECTED YES ❑ NO
7. DOES WELL REPLACE EXISTING WELL? YES ❑
NOW(
6. STATIC WATER LEVEL Below Top of Casing:
(Use -+- If Above Top of Casing)
TOP OF CASING IS� FT. Above Land Surface'
9.
.Top or casing terminnied ot/or below land surface requires a variance In accor-
dance with 15A NCAC 2C .0118 METHOD OF TEST
10. YIELD (gpm): --
NES (de th):
DEPTH -
Formation Description
co
y
•s'r�
N
11. WATER 1-1-1P _
If additional spare is need ad use back of form
12. CHLORIhdATION:
A tounl _�aS
Type
_
SKETCH
13. CASING:
Wall Thickness
_LOCATION
(Show direction and distance from at least two Stale
Depth lame r or W IghUF Zteriat
points)
Roads, or other Wisp reference p )
From
To F1.�
From------
FI
To --- .---
From --
10 — FL----
14. GROUT:
Malerll etltod�
To
Cto�dl.�r lVl.r.
From A
TO� Ft.
T o —Ft. Ft. �-
From -._
15. SCREEN:
E,Material
r,pgt Diameter Slot Slze
From
TO rl __-- In. _--. in. __- - ---
- in. ------
in.
From ___----
To - Ft.
in.
From --To
_.__ _ _ Ft. __----
16. SAND/GRAVEL PACK:
Material
Depth Size
-- -
TFt. --- - - ---- - ---- -- - --
From ___----
From To Ft.
17. REMARKS:
ELL
A COPY;O)r- THIS RECO D HAS BEEN PROVIDED TO THE WELL OWNER'
i DO 1iEFTFt3Y CFrltlfY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WIT1i 15A NCAC E L
CONSTRUCTION STAND�IRDS AND;THA
FOR OFFICE -;USE ONLY SIGNATUr1E OF PEn. N CONSTRUCTING THE WELL
DATE
11 GW.1 REV. 12/99
Ouad No: ti,�'^ " !..lie�JSub l,o, naI to Divlslon of Water GuaiHy, Groundwater Section within 30 days
i,
Serial No. r,

North Carolina - Department of Environment and Natural Resourres Division of Water Quality - Groundwater Section JJ I 1 4 A [)
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone],
WELL CONSTRUCTION RECORD WELLCONTRACTOR CERTIFICATI JN
WELL CONTRACTOR
STATE WELL CONSTRUCTION PEF1M1T'N:
a ❑
Industrial ❑ Agricultural El
Monitoring ❑
1.
Applicable Dox Residential Municipal
WELL USE (Check )
Recovery [] Meat PUMP Water Injection ❑ Other ❑
IF Other, List Use:
2.
WELL LOCATION: (%w1w sket jiqf the location below)
Nearest Town: /A County: _
(Road Name and tl rcr Cornr mity, or Subdivision and Lol No.)
DRILLING LOG DEPTH
---- --o Formation Description
Fror—
3.
OWNER
Address
/� heel or ou
Stale Zip Code
City or Town 6
DRILLED O -
a
-'
4.
5.
6
DATE
TOTAL DEPTH
CUTTINGS COLLECTED YESENO
r*
-
t:a
8.
STATIC WATER LEVEL Below Top of Casing: ��_
,
(Use'+' It Above Top of Casing)
9.
TOP OF CASING IS L- FT, Above Land Surface'
-Top
of casing terminated 9Vor below land euriace tequlres A variance In actor-
G� r—, .0
r--t
dance with 15A NCAC 2C .0118 MEl'IiOD OF TEST . _
tV —'
10.
YIELD (gprn):
rD
11.
WATER ZONES (depth):
--- �---
12. CHLORINATION:
13. CASING:
Amount If eddilionsl space Is needed use back of form —
Type --- —_�
Wall Thickness r alednl
//�� Depth �11ar nJBJ or of hVFI.
From! _To �� Ft. JF �"?G/ _ _ -
From---- To Ft.— —
From -- To Ft.--
14. GROUT: Method �
Depth"
Mated a__i��/__ j
From ���— To - .U__Ft. �.fZ
Frorn _......._ __ To
15. SCREEN:
Dehllt Diameter Slot Size Material
'1 a _-- — Ft _ In. In. __ -- ---
From ---- In. In. _ -----
1 �, ___ Ft. —
From _____ in.
F►ortt _: To _.----- Ft. __ --- In.
16. SAND/GRAVEL- PACK: Material
Depth Size
From — -- To Ft._—_�
From _._ To Ft. _ __---
17. REMARKS:
I DO ►IEttE©Y CEf�IIFYFTIAT `IiI'�WELL
CONSTFIUCTintJ STA�JDA DS,- A D 7 1A'
i
Eau
FIC E U � U
,--�" 1 3 itJ s
Sut
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
CONSTFIUCTED IN ACCORDANCE WITH I SA NCAC 2C, WELL
SPY 917 THIS RECORD HA EN PROVIDED TO THE WELL OWNER.
, _..- s ..9, e
DATE
SI(3NATU OF r EF1SOtJ CON nUCTINO TILE NJEI_L
original 1.0 Division of Water Ouaiily, Groundwater Section Witltln 3tJ days Gw 1 REV 12J99

North Carolina - Department of Environment and Natural Resources - Division of Water Quality Groundwater Section
1636 Mail Service Center . Raleigh, N.C. 27699.1636•Phone [phone] ! v
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATIOl4 a:3j
STATE WELL CONSTRUCTION PERMITH:
1, WELL USE (Check Applicable Box): Residential 6 . Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring [J
Recovery F] Meat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION; (Sl ow sketch o�f�thhe�rlooc�ation below)
Nearest Town: _ b/�fL''-' =="` ' County: G� --
DRILLING LOG UEPTH _
(Woad Narno an lumbers, orn unl , or 5u di Ion and Lot No.) --- — —
From To Formation Description
3. OWNER — _
Address -
q���( if t r ou o.
City or Town State Zip Code
4. DATE DRILLED' ' Q
5. TOTAL DEPTH _ 7-a 6---
6. CUTTINGS COLLECTE EXI ES L_jWE N6 NO[ �/
7. DOES WELL FIEPLACE 8. STATIC WATER LEVEL Below Top of Casing: O FT.—
I (Use '+' 11 Above Top of casing)
9. TOP OF CASING IS _ ! FT. Above Land Surface'
CD
'Top of cesrnq terminnind aVor below land surface requires s v�ance In sccor•
dance with 15A IICAC 2C .0118
10. YIELD (gpm): --1— METHOD OF TEST '
r
11. WATER ZONES (depth): - Co =' "
rnounlL�-- If additional space is needed use back of tpon rs,
12. CHA
CHLORINATION: Type _ cn:z
13. CASING:
l_OCATIUN St<ETCH �
Wall Thickness 1ateAal (Show direction and distance horn at least lvroZT to C
Depth �1iar_ el�r or el ht
From
_To 1� Ft Roads, or other map relerence points)
From -- To Fl. — k"A
From To Ft.----
14. GROU T: ethod
p rt.�
_..
po Ih Material
Frorn -
,7t.-C.
From -----To
15. SCREEN:
Depth Diameter Slot Size Material
From -_—To ---- Ft __ __ in. In.From _
TO - _-_ rt. _ _ __ in. in. -- -- ---
Frorn _.—.__ l o _....____ Ft. In.
In. �_-_----
16. SAND/GRAVEL PACK: Material
Depth Size
From To _ Ft. _— -- -----"-
From To Ft.
17. REMARKS:
NCE
11 DO HEnEDY'CE ST/JY THAT
IAND ELLWHAT A COPY OF Tlrls nE O D HASNsTnUCTED IN DAEEN PRIOVID D TO THE WELL LOWNER.
CONSTnUCT. �Qd
FOR OFFICE USE ONLY DATE
t` p , n Sit ,NATO of rEnsor CONs UCTINO Tr1E WELL
Ouad No: 1 ed ; U J rt'�� CW.i REV. 12199
;+) Submit original to Division of Water Quality, Groundwater Section Within 30 days
Serial No.

North Caroli,ta - DepnrUnent of Environment and Natural nesources • Division of Water Quality Groundwater Section F! Ire 4 4 �l
1636 Mail Service Center - nileigh, N.C. 27699.1636-Phone [phone] j
Y
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTWICATIOI H:
STATE WELL CONSTRUCTION PEi1MIT1l:
Industrial ❑ Agricultural ❑ Monitoring ❑
1. WELL USE (check Applicable °°X)•Re atersln ecttion ❑ Municipal
❑ II Other, List Use:
Recovery [_] i-lent pump W
2. WELL LOCATION: ?)ow skettf11 of the location below)
ounry:
Nearest Town:
DRILLING LOG _UEP—­A-4 Tfi___
(Road Name n N) umbers. Comr tinily, or Subdivls 0 and of No.) f ------ ^Formation Description
Cs/ From To
3. OWNER a ��
Address—
tie ol or ou o o.
City or Town State
Zip Codo
4. DATE DRILLED �
5. TOTAL DEPTI I _ NOd t
6. CUTTINGS COLLECIED YES[:]�./ c�
7. DOES WELL REPLACE EXISTING WELL? YES[--] NOL✓J 6. STATIC; WATER LEVEL Below Top of Casing: r7_6 Fr. ------------ :'
(Use '+' 11 Above Top or Casing) , V
9. TOP OF CASING IS FT, Above Land Surface' _
'Top of easing termtnated eUor below land surface requires a variance In eecor-
dance with 15A fICAC 2C .0118-----�--
10. YIELD (gprn): _&4L METHOD OF TEST r
11. WATER ZONES (depth):
II additional space is needed use back of lodly� —+
____ �-----
12. CFILOf11NATi0N: Type Amount--- - --
13. CASING:
14
Wall Thickness
Depth�Iarr�etRr or et hq UFt.
From To 7:� Ft.
From— TO —
From -- To Ft._ ------
LOCATION SKETCFI_
f�l,anterClain (Show direction and distance from at least two Slate
.[ es Iwa Roads, or other map reference points)
GROUT . thod
Depth
From To
From __ To Ft
15. SCREEN:
material
Depth Diameter blot z,rzd
Material
From
To Ft in. In. ____---.
In. _-------
From _ To Ft. -- In.
From _.__.--To _._______ Ft.
_ In. In. __ ---
16. SAND/GRAVEL PACK: Material
Depth Size
From — To _
From __— To_ Ft.
17. REMARKS:
DO HEnE©Y CEnT
CONSTnUCTI 157
FOR OFFICE
Quad No:
Serial No.
WELL
wr�r:R
TI tAT;7HiS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2
DAF1D3, AND THAT ACOPY- THIS RECORD HA BEEN PROVIDED TO THE WELL f
I jU - T-
tl Lyt,' ,SIC3NATUr F r EFlSON CON nUCTINd THE WELL
Subm(t odginal to division of Water Quality, Groundwater Section Within 30 days
{
GWA nEV. 12199

`
North Carotina - Department of Environment and Natural nesourr,es i • Division of Water Quality •Groundwater Section 0~r4$
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone] J�C,�"�'1�- —
WELL CONSTRUCTION T IOtJ RECORD WELL
CONTRACTOR CERTIt1CATIOf4f a:
STATE WELL CONSTRUCTION PEnMIT9:
1, WELL USE (Check Applicable Box): Residential Municipal ❑
Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATIO (Shows ejch of the location below) 1,7
Nearest Town: T��n - County:
— DRILLING LUG _ DEPTH
(Road IJart d Nun )r.rs, Co nity, or Su division and Lot rJo.) From To Formation Description
3. OWNER _ —
Address .• _ — �_T------
lfCOt O OU fl O.
Stale Zip Code �J
City or Town +O x <<-?
4. DATE DRILLED_
5. TOTAL DEPTtI �?
6. CUTTINGS COLLECTED�-- YES ❑ NO�
7. DOES WELL REPLACE EXISTING WELL? YES N04
8. STATIC WATER LEVEL Below Top of Casing:
FT.
/I (Use'+' 11 Above Top of Casing)
9. TOP OF CASING IS Fr. Above Land Surface'
'Top of casing terminated at%or below land surface requires a variance In accor• _ Cn
dance with 15A NCAC 2C.0118 METHOD OF TEST (V C
10. YIELD (gplrt): J
11. WATER ZONES (depth): _
12. CV1LORINATION:
13. CASING:
Amount If additional space is needed use back of form �^
Type
Wall Thickness
Depth tar elBr or et hUFL
5'
-Material
From-0
To Ft.
From-
To Ft. ——
From _I-o
Fl.----- ------'
`_- -
14. GROUT:
Depth Material Method
To Ft.
From _
_A.0
From --
To Ft. ---
—
15. SCREEN:
Depllt Diameter Slot Size
material
From —___
In. ��----
T o ---- Ft _ _ __ In. In.
From
__ To — _ _ Ft. ��-- inn.
-----
Ft In. In. __--
-- --
From - — To -----
16. SAND/GRAVEL PACK: Size
Depth
From — 'ToFrom _ To— Ft'-'__--
17. REMARKS:_ -.--__-_--
I DO tiEFTEDY CFnII Y TI,IAT J111 J WELL, ^ S C4
CONSTFUCTION ST/lNDAnD,ii
Af Dt.
FO FILE
Gluad No: ( 8 c„hml't oifair
Material
LOCATION SKETCH
(Show direction and distance from at least two state
Roads, or other m--ap reference points)
G�
TnUCTED IN ACCOFTDANCE WITH 15A NCAC 2C, WELL
F THis RECORD HAS 13EEN PROVIDED; O THE WELL OWNER. !,%Ol�
DATE
3NATUFI F PERSON CON nUCTIN�3 TI IE WEILI.
to Division of Water Qualily. Groundwater Section wilhlrt 30 days GW 1 REV 12/99
Serial No.

North Carplina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section j �1 �1 /1
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone] ! `� `f
WELL CONSTRUCTION RECORD WELL CONTRACTOR: /YJ
WELL CONTRACTOR CERTIPICATIO #:_T D _
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable eox): Residential5 Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: Show sketch of the location below)
Nearest Town: ,5Z11. .— County:
(Road Name and bers, Commun , or Subdivision and Lot No.)
DRILLING LOG DEPTH
3. OWNER
From To Formation Description
Address
tre t r ou a o. C ad �o
Al
D -
—
City or Town Stale Zip Code
4. DATE DRILLED • 166
r7
5. TOTAL DEPTH
ri
6. CUTTINGS COLLECTED YES ❑ NOF
YES NO[�
c'
cn
7. DOES WELL REPLACE EXISTING WELL?
-°
_
8. STATIC WATER LEVEL Below Top of Casing: O �•
-
(Use '+' 11 Above Top of Casing)
-
9. TOP OF CASING IS _L___ FT. Above Land Surface
*Top of casing terminated at1or below land surface requires a variance In accor-
dance with 15A NCAC 2C .01 18
10. YIELD m : METHOD OF TEST
11. WATER ZONES (depth):
o
�
12. CHLORINATION: TypeoU7NAmount:: /
If additional space is needed use back of form
13. CASING:
Wall Thickness
�
Depth
t!)
is elgr or ei ht/Fl. -material
�_
From
To -A Ft.
From
To Ft.
—
From
To- Ft•
14. GROUT:
Depth
Material Method
From Q
To Ft.
From
To Ft.
15. SCREEN:
Depth Diameter
Slot Size Material
From _To
—Ft
in. in.
From
To Ft. _—
In. In.
From
To Ft.
In. in.
16. SAND/GRAVEL PACK:
Depth Size
From To _ Ft.
From To Ft.
17. REMARKS:
Material
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
1;4;1;6
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS AND THAT A COPY F THIS RECORD HA EEN PROVIDED TO THE WELL OWNER. �.
z tf
FOR OFFICE USE','ONLY DATE
Quad No: SIGNAT OF PERSON CON RUCTING TFIE WELL
p, i; c� SUb tt orj9in51 to Division of Wale GW-1 REV. 12/99
r Quality. Groundwater Section within 30 days
A� bit
Serial No. i

r
North Carolina - Department of Environment and 1` iturai Resourres •Division of Water Quality •Groundwater Section �i 1 y `l
1636 Mail Service Center - rlafeigh, N.C. 27699.1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: _ —
J�
WELL CONTRACTOR CER 1 ICATIOf N:
STATE WELL CONSTRUCTION PERMITH:
1. WELL USE (Check Appilcable aox): Residential5 Municipal El Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery 0 !-teat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: how sketch f the location below) d &t�
Nearest Town: County:
(nond Marne and r1 iber , Cou rnu ty, or Subdivision and Lot 14o.)
3. OWNER
Ad ess .- —
r treet or ou '9 1- 9• J-T
City or Town state Zip Code
4. DATE DRILLED • Q _
5. TOTAL DEPTH _L
6. CUTTINGS COLLECTED YES[] NOd
7. DOES WELL REPLACE EXIS rING WELL? YES ❑ NO
S. STATIC WATER LEVEL Below Top of Casil T.
(Use •+• It Above Top or Casing)
9. TOP OF CASING IS __t __ FT. Above Land Surface -
'Top of casino terminntnd et%or below land surface requires a variance In accor-
dance with 15A 11CAC 2C .0118
10. YIELD (gprn): -3 METHOD OF TEST
11. WATER 7.ONES (depth):
12. CHLORINATION
13. CASING:
DRILLING LUG DEPTFI,_._
From To Formation Description
CO
r t
r
�
Type Amount If additional space Is needed use back of form
LOCATION SKETCH
atertat
(Show direction and distance from at least two State
Roads, or other map reference points)
Wall Thickness
Depth to -ter ar ei I /Ft.
From
To Ft.
Front
To Ft.
From
—To Ft.
14. GROU T:
Dc,p11t Material, e'lftod �
From --Q—
To
From _______
To _ Ft.
15. SCREEN:
Depilt Diameter Slot SIz6 Material
From
To __-- Ft -- In. In.
From
To . FL — In. In. - —
From _--To ------- Ft. __-_ In. In. __----
16. SAND/GRAVEL PACK:
Depth Size Material
From
To Fl. -- _-.____—
From
To Ft.
17. REMARKS:
le
CE WITH 15A NCAC 2 ,, WELL
DO HEREBY CERTIFY T1IADT�7�tiILS�DW FIP.�T A..COLL WAS PY SF THIS RECORD HAS TRUCTED IN FEN PROVIDED TO T HE WELL OWNER. /J
CONSTRUCTION STA[)AiT gg �j j( j{ �a Qv
FOR OFFICE USE'U�JYDATE
;3 d Ii SIGNATU F PERSON CO4tiUcTiNG THE WELL
Quad No: t i jj I' i N
09�Sbt;} orip�nat IbOtvision of Water Quality, Groundwater Section within 30 days Gw 1 nEV. 12/99
Serial No.

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section `j •j1 "1 /� Q Q
1636 Mail Service Center - naleigh, N.C. 27699.1636-Phone [phone] J v
WELL CONSTRUCTION RECORD WELL CONTRACTOR: --�
WELL CONTRACTOR CERTIFICATIOf N:
STATE WELL CONSTRUCTION PERMIT9.
Industrial ❑ Agricultural ❑ Monitoring ❑
1, WELL USE (Check Appllcable ©ox): Residencltfolr� Municipal
❑if Other, List Use:
Recovery ❑ I lent Pump Water Inje ❑ ❑ .
2. WELL L.00ATIQN: (9how sketch of tit location below)
Nearest Town:
li/1�/�A♦//0 County:
l DRILLING LOG
_ DEPTH .-
(Fload Name Numbers, omm ni y, o ubdivislon a t f�O 1 J
From To
Formation Description
3.
OWNER
Address�.�,--—
• latreo or ou 0. 8864___
City or Town State Zip Code
�
- 4.
DATE DRILLED
5.
6.
TOTAL DEPTH -- ���rs—'_' NO
CUTTINGS COLLECTED YES [] N04
YES ❑
= `ri
DOES WELL REPLACE EXISTING WELL?
7.
8,
STATIC WATER LEVEL Below Top of Casing: T.
—�- —.
(Use '+• It Above Top of Casing)
FT. Above Land Surface'
-- r Fr L
9.
TOP OF CASING IS____L__
atJor below lend surface requires a v�ance In accor•
--J o
'Top
of casing terminntnd
dance with 15A 11CAC 2C .01� METHOLOF TEST
10,
YIELD (gptlt): 0:2 --
—
co ZONES (depth):
11. WAT I ----
12, CHLonINATION:
13, CASING:
Amount It addilional space Is needed use back of torm
Type - -- --
Wall Thickness
Depth fan Zr or al h
From_4! To Ft. ,7 %
From — To . Fl. —
From To Ft. —
LOCATION SKETCH
Medal (Show direction and distance from at least two State
Roads, or other map reference points)
14. GROUT:
Depth
material Method ,
From _
To FI•
From __
15. SCREEN:
Diameter Slot Size Material
popttt
From ___I
o
Ft —_
In. in. _ _----
Frorn _—To
—.___
Ft
In. _ In.
From _--- 10 -..---- --
16. SANDIGRAVEL PACK: Size Material
Depth
From _._ -To From _._— To Ft.-
17. REMARKS:
2 WELL
I DO IIEnE.(3Y CEnIir j Ti I SAND WELL
WAS A COPY SF THIS f1ECOnD ACCORDANCE EEN P IOVIDED To HE WELL OWNER.
CONSTRUCTION STAI; D f
DATE
FOR OFFICE UE�J Ot✓ L`Y�r SIGNATU OF PERSON CON UCTING Tt1E WELL
g t1
Quad No: `; N y 'i}S�bmi1 oripirial to Division of Water Quality, Groundwater Section Within 30 ays GW 1 F1EV 12/99
Serial No.

11,
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section �! 1 rIf 491
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATIO #: p%
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential5 Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: ovsketcla QfJhe location below) —
county:
Nearest Town:.
Ll e
(Road Name and tiers Communi , r Subdivision of o.) % DRILLING LOG DEPTH
3. OWNER / From To Formation Description
Address J9�w
treet or ou a
City or Town St to Zip Code'�'L---
4. DATE DRILLED V- - d .
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES E] NOd c�
7. DOES WELL REPLACE EXISTING WELL? YES ❑ N04 --�
cn �'
6. STATIC WATER LEVEL Below Top of Casing: ro FT. -;•
/I (Use '+' if Above Top of Casing) _� r
9. TOP OF CASING IS FT. Above Land Surface- I
•Top of casing terminated at/or below land surface requires a varlence In accor-
dance with 15A NCAC 2C 0118
10. YIELD (gpm): 660 _ METHOD OF TEST
cn
11. WATER ZONES (depth):
12. CHLORINATION: Type Amount If additional space is needed use back of fora-4 0
13. CASING:
LOCATION —SKETCH
Wall Thickness
Depth,. - , is 'F or ei htlFt. aterial (Show direction and distance from at least two State
�— Ft ' Roads, or other map reference points)
From�To
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From
Q To -AD-- Ft. r
From _ To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft in. in.
From To Ft.in. in. From To Ft. In. In.
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
17. REMARKS:
DO HEREBY GERTLFY,TH Tfi)S WELL WAS CONSTRUCTED IN ACCORD CE WITH 15A NCAC 2C, WELL
CONSTRlC1TipN iyST1D PD ND ,HAT A COPY F THIS RECORD HAS EEN PROVIDED TO THE WELL OWNER,
FOR OFFICE �1S=ON�LY DATE
Quad No: ij ,i i t t' SIGNATU OF PERSON CON UCTING TrtE WELLyi) I J Subrmlt original to Division of Water Ouality, Groundwater Section within 30 days
GW-1 REV. 12/99
Serial No.1 -

17496
North Carolina - Department of Environment and Natural Resources • Division of Water Quality . Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
A
V1/ELL CONSTRUCTION RECORD WELL CONTRACTOR CERTIFICATIOLL CONTRACTOR: .A2a:
STATE WELL CONSTRUCTION PERMITH:
1.
WELL USE (Check Applicable sox): Residential Municipal ❑ Industrial ❑
Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2.
WELL LOCATIOL(��°[J� k tc he Iocation below)
�I
Nearest Town: fY County:
RName d Numbers. Co unity, or Subdivision and Lot No.) DRILLING LOG
DEPTH
Formation Description
3.
From To
t�0
iciyorToown
reat or ou o r7r �-5
oS�te Zip Code
4.
5.
6.
DATE DRILLED T,
TOTAL DEPTH
CUTTINGS COLLECTED YES ❑ NOEV� -�
NO[J
e
7.
DOES WELL REPLACE EXISTING WELL? YES []
cn
8.
STATIC WATER LEVEL Below Top of Casing:__ FT.
(Use '+' it Above Top of Casing)
FT• Above Land Surface'
9. TOP OF CASING IS
*Top of casing terminated atlor below land surface requires n variance in accor-
y
dance with 1SA NCAC 2C .011a
10. YIELD (gpm): q,Q_ METHOD OF TEST
�2
11.
WATER ZONES (depth):
12. CHLORINATION:
13. CASING:
Type L!Rcunt If additional space is needed use back of form
Wall Thickness
From
Depth is er
To �'�- Ft.
or ei hUFt. aterfal
From
To FI•
From
To Ft• —
14. GROUT:
Material
Method
Depth
- /
From Q
_ To _aO-- Ft.
7���-_
From
To Ft.
--
15. SCREEN:
Depth Diameter Slot
Size Material
From
To Ft in.
in. ____----
From
To Ft. in.
In. ___------
-r Ft in
In.
LOCATION S_ KETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
�•d
n^nA�
J �C
From
16, SAND/GRAVEL PACK: Material
Depth Size
From To Ft. —
From To Ft.
17. REMARKS:
I DO HEREBY CERTIFY THAT �THIS WELL WA SOCOY SFT HIS RE ORD HA D EEN PRCE IOVIDED TO THE WELL OWNER.
CONSTRUCTION 8T,^yNO/Ep�TfRD r A}�ry''jD T •e}j�
{�',a I
1 n' DATE
FOR OFFICE U� ONLY SIGNATU OF PERSO CON UCTING THE WELL
Quad No: 3 al ,� ' S r��mil tigrat to Division of Water Quality, Groundwater Section within 30 days
__ i i i L:_.:: I..
GW1 REV. 12199
Serial No.
3, t

North Carolina • Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section 4 rl 4 9
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATIO V
STATE WELL CONSTRUCTION PERMIT#:
1, WELL USE (check Applicable sox): Residential5 Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: ( w sketch of he loc' 'o below)
Nearest Town: County: GCti.....
(Road Name and tkyiber.s, Commu,iily, or Su ivision nd Lot No.) DRILLING LOG
3. OWNER From To
Address
treet or ova o. S q
ity or Town State Zip Code
4. DATE DRILLED 1040.
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES F-] NO Yf
7. DOES WELL REPLACE EXISTING WELL? YES ❑ N04
8, STATIC WATER LEVEL Below Top of Casing: _,74_ FT.
(Use '+' II Above Top of Casing)
9. TOP OF CASING IS _ FT. Above Land Surface'
*Top of casing terminated atfor below land surface requires a variance in accor-
dance with 15A NCAC 2Cr0116
1.0. YIELD (gpm): )�L METHOD OF TEST —
11. WATER ZONES (depth):
DEPTH
Formation Description
C31
0
12. CHLORINATION: Type
Amount � If additional space is needed use back of form
13. CASING:
Wall Thickness
Depth is ear
From To Ft. .7
or ei ht/Ft. -Material
From
To Ft.
From
To Ft.
14. GROUP:
Depth Material Method
Q
From
To-�Q—Ft.
From
To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From
To Ft in.
in. --
From
To Ft. In.
in.
F
To Ft. in.
In. -
rom
16. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To Ft. —
17. REMARKS:
Material
LOCATION SKETCH
(Show direction and distance from at least two State
Roads r other map reference points)
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,
WELL
CONSTRUCTION
N ST/, ND�(((j�,f1D8 A Dj\'HAT A)COPY F THIS RECORD H EEN PROVIDED TO THE WELL OWNER. D�
FOR OFFICE USENt.Y DATE
ii1v I SIGNAT E OF PERSON CON RUCTING THE WELL
Quad No: r a
j �bmlt bngihal to Divl on of Water Quality, Groundwater Section within 30 days GW 1 REV. 12/99
Serial No. a
!w
,P.

North Carglina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section �} 1 rl 9
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATIO #:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (check Applicable Box): Residential5 Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Fleat Pump Water Injection ❑ Other[] If Other, List Use:
2. WELL LOCATION: (S sketch of the location below)
County:
Town:
Nearest ---�►�--�
unity or ' b tuts on and Lot No.) DRILLING LOG
(Road Nameand N bars, Co D
To
DEPTH
Formation Description
3.
From.
OWNER ----"'
Address
__-_—
1e� treat or ou o.
�D
h/y•
Cit or Town Stale Zip Code
DATE DRILLED
4.
5.
TOTAL DEPTH
'
6.
CUTTINGS COLLECTED YES ❑ NOd
YES ❑ N04
7.
DOES WELL REPLACE EXISTING WELL?
WATER LEVEL Below Top of Casing: Ir_ FT.
? r�
�-
8,
STATIC _I,
(Use '+' it Above Top of Casing)
d Surface*
FT. Above Lanur
FT.
-
9. TOP OF CASING is
*Top terminnted aUor below land surface requires a variance in actor-
r t
of casing
dance with 15A NCAC 2C .0118
2 METHOD OF TEST
�, r
10.
YIELD (gpm): .2
t�t�
-9
11.
WATER ZONES (depth):
—
12. CHLORINATION
13. CASING:
14
_ If additional space is needed use back of form
Type Amount
Wail Thickness
Depth is or or ei ht/Ft.
FromTO Ft.
From To Ft, —
From To FI. ---
r�ont tr•
_ Depth Material
From Q To -W— Ft.
From To Ft,
15. SCREEN:.
Depth Diameter Slot Size
LOCATION SKETCH
aterial (Show direction and distance from at least two State
Roads, or other map reference points)
ethod
Material
From To Ft
In.
in. _-----
From To Ft.
In.
in. ____---
From To _ Ft.
In.
in._-----
16. SAND/GRAVEL PACK:
Depth
Size
Material
From To Ft.
From To Ft.__-
17. REMARKS:
WELL
p0 HEREBY CERTIFY;.THAT TfiIS IWF L VVAS CONSTRUCTED
fE, -:CORD HAS ANEN PROVIDED TO THE WELL OWNER.
CONSTRUCTION aSTANpAPDs',f:PND Y' , AlA COPY f O C
FOR OFFICE DATE
1-gg p f If1 12 SIGNATU F PERSON CONS UCTING THE WELL
Quad No: ' ? i, ?4 ,i"` 1 8 26JU0
Submit �igirlal to Division of Water Quality, Groundwater Section within 30 days GW 1 REV. 12r99
Serial No.
i ,iqY A`� 3 .9•E3 fti

North Carglina • Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATIO #:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (check Applicable sox): Residential Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (St i v sk tch of a location below)
Nearest Town: �dd� p ° -County:.
(Road Name an Numbers Com Ity, or Subdivisi n and Lot No.) DRILLING LOG DEPTH
3. OWNER From To Formation Description
Address ohis JDA
,e
XL
City or Town Stale Zip Code
- 4. DATE DRILLED
5. TOTAL DEPTH �
6. CUTTINGS COLLECTED YES ❑ NOEd
7. DOES WELL REPLACE EXISTING WELL? YE�NO[ty/
_�
6. STATIC WATER LEVEL Below Top of Casing: FT. n
4 2
(Use *+* If Above Top of Casing) I
c-
9. TOP OF CASING ISFT. Above Land Surface'
v
'Top of casing terminated aVor below land surface requires a variance In accor-
dance with 15A NCAC 2C 0116
Z�IE OF TEST
i
10. YIELD (gpm): METHOD
11. WATER ZONES (depth):
Amount If additional space is needed use back of form
12. CHLORINATION: Type
13. CASING:
LOCATION SKETCH
Wall Thickness
Depth is etgr or ei hl/Ft.-Material (Show direction and distance from at least two State
7� points)
FromTo Ft. Roads, or other map reference
From To Ft. —
From To Ft.
14. GROUT:
peplil Material fAethod /U
From Q To � D Ft.
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft in. in.
From - To FL—.____ in. In.
From To Ft. in. In.
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
17. REMARKS:
DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
EEN PROVIDED TO THE WELL OWNER.
CONSTRUCTION STANDARDS, AND THAT A COPY,9F THIS RECORD HA
FOR OFFICE USE ONLY
SIGNATU OF PERSON CON UCTING THE WELL DATE
Quad No:
t� original io DIvIsf n of Water Quality, Groundwater Section within 30 days
nU� Sib GW-1 REV. 12199
Serial No.

North Car lina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section �J a
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone] �-� �- ` 5 `( � �-
WELL CONSTRUCTION RECORD WELL CONTRACTOR: fYJ
WELL CONTRACTOR CERTIFICATIO #: D —
STATE WELL CONSTRUCTION PERMIT#
1. WELL USE (Check Applicable Box): Residential GZ Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION:jh�o- s�ketclrof the location below)
/
Nearest Town: Cam(-=1J•GO- County:
L�•L�
(Road Name an Numbe4ommunil y, or ubdivision and Lot No.)
DRILLING LOG DEPTH
Formation Description
3. OWNER —
From To
Address 8lp /
� 3�
treet or ou o p.
O
City or Town n State Zip Code`"
X�dd
`J
4. DATE DRILLED
5. TOTAL DEPTH;
6. CUTTINGS COLLECTED YES[] No
N04
7. DOES WELL REPLACE EXISTING WELL?
I
",8.
STATIC WATER LEVEL Below Top of Casing: FT.
!eW—
(Use '+' It Above Top of Casing)
IS FT. Above Land Surface*
--'
-U --.
9. TOP OF CASING
*Top of casing terminated actor below land surface requires a variance In actor-
dance with 15A NCAC 2C .0 8
10. YIELD (gpm): o" METHOD OF TEST
al
11. WATER ZONES (depth):
77"
12. CHLORINATION: Type _1_�Amount
If additional space is needed use back of form
13. CASING:
Wall Thickness
Depth is ott or Weight/Ft.
From To Ft.
From To Ft.
From To Ft. '"-
14. GROUT:
ethod
Depth Material
From Q To --L- Ft. -6Z'
From To F1-
15. SCREEN:
Depth Diameter Slot Size
_LOCATION SKETCH
aterial (Show direction and distance from at least two Slate
Roads, or other map reference points)
4&dc6'�
X
Material
From To Ft in. In. --
From To Ft. _.— in. in. -
From To Ft. in. In. -
16. SAND/GRAVEL PACK:
Depth Size
From To Ft. From To Ft.
17. REMARKS:
Material
DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION'STANDARDS `AND THAT A dPYF THIS RECORD HAS EEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USA ONLY DATE
Quad No: SIGNATU OF PERSON CONST CTING THE WELL
�( i `ISUbmI► original to Division of Water Quality, Groundwater Section Within 30 days GW 1 REV. 12199
Serial No.

North Carqlina • Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section 1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone] ►� i L l 01
NELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFI ATION #:
STATE WELL CONSTRUCTION PERMIT#:
1.
WELL USE (Check Applicable Box): Residential51 Municipal ❑
Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ I( Other, List Use:
2.
WELL LOCATION: how gket �hh of the location below)
Nearest Town: �1ei�11�, County:
�� —
(Road Name and mbers, Co nity, or Subdivision and Lot No.)
DRILLING LOG DEPTH
3.
OWNER 0 do -From
To Formation Description
Address 7
Z)
.. treat or ou +j p•
r --
City or Town Stale Zip Code
— C:) -
4.
DATE DRILLED
5.
TOTAL DEPTH''
6.
CUTTINGS COLLECTED YES ❑ NO[j<
NOd
7.
DOES WELL REPLACE EXISTING WELL? YES
8.
STATIC WATER LEVEL Below Top of Casing: FT.
_.,
(Use '+• if Above Top of Casing)
_� 3a•:
9.
TOP OF CASING ISFT. Above Land Surface'
*Top of casing terminated at/or below land surface requires a variance In actor -
'
- i
dance with 15A NCAC 2C .0 18
TEST
10.
YIELD (gpm): — METHOD OF
11.
WATER ZONES (depth):
Amount
It additional space is needed use back of form
12.
CHLORINATION: Type 474-144 --
13.
CASING:
LOCATION SKETCH
Wall Thickness
Depth lame r or W Ight/ , alerial
(Show direction and distance from at least two Slate
10
Ft
Roads, or other map reference points)
From
From To Ft.
From To Ft.
14. GROUT: / I
De ll Materiel elltod
From A ToPAO Ft.
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft in, —In.—
From To Ft. in. In. -
From To Ft. In. in.
16. SAND/GRAVEL PACK:
Depth Size
From To Ft. From To Ft. —
17. REMARKS:
Material
67 64;, /�/C'
DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS AND THAT A COPY OF THIS RECORD S BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE QNLY _ DATE
wad No: NATURE OF PERSON C S7RUCTING THE WELL
Submit original to Division of Water Quality, Groundwater Section within 30 days GW 1 REV. 12199
`0- 4) i.
Serial No.

North Carolina - Department of Environment and Natural Resources Division of Water Quality - Groundwater Section :i ��
1636 Mail Service Center • Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
CONTRACTOR CERTIFICATIOAA-t—
WELL p%
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential G Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: ow sketch of the location below) P/
Nearest Town: �.� County: � :2t-
(Road Name and Numbers, Comm , or Sub •vision and of No,.) DRILLING LOG DEPTH
3. OWNER From To Formation Description
AddressRt-1-�f
treat or Route
City or Town State Zip Code
Y"1
4. DATE DRILLED
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑ NO[+�
7. DOES WELL REPLACE EXISTING WELL? YES ❑_ N04 -,
8, STATIC WATER LEVEL Below Top of Casing: �,'� �• t
(Use'+' If Above Top of Casing)
9. TOP OF CASING IS___1___ FT. Above Land Surface'
*Top of casing terminated at/or below land surface requires a variance In accor-
dance with 15A NCAC 2C OAS M -v
10. YIELD (gpm): METHOD OF TEST -
11. WATER ZONES (depth): rn F
12. CHLORINATION: Type _Amount If additional space is needed use back of form
13. CASING:
LOCATION SKETCH
Wall Thickness
Depth//is et�r or ei ht/Ft. -Material (Show direction and distance from at least two State
FromTo -#9-- Ft. ,5 Roads, or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From Q To 2 D—Ft.
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft in. in.
From To Ft. In. In.
From To Ft. in. In.
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
17. REMARKS:
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY THIS RECORD HA EN PROVIDED TO THE WELL OWNER.
Ill
FOR OFFICE USE� ONLY t DATE
Quad No: ) + t� ! tfGNAT E OF PERSON CON UCTING THE WELL
Submit oripjrl,;lo Divislon of Water Quality, Groundwater Section Within 30 days
isa• GW-1 REV. 12199
Serial No. ;. j o c p 8 ")noo
........ , . 1, a _:..

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center . Raleigh, N.C. 27699-1636-Phone [phone] �-� { O v
NELL CONSTRUCTION RECORD WELL CONTRACTOR: ��-
WELL CONTRACTOR CERTIFI TION #:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable 1300 Residential Rr Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: ((�SP9W s��ket //h. of the location below) jam-^n����
Nearest Town: ��"`�Gt.QLt/ County: ;a F�
a umber . Commu or Sub vision and Lot No.)
DRILLING LOG DEPTH
Formation Description
AA
3. ,L
From To
iCity
r
1(ECI Or 0 O.
•
-
r'
wn S� e ip Code
4. DATE DRILLED
5. TOTAL DEPTH AA JS
6. CUTTINGS COLLECTED YES ❑ No
YES [] NOd
FT1
7. DOES WELL REPLACE EXISTING WELL?
8. STATIC WATER LEVEL Below Top of Casing: FT.
(Use '+' it Above Top of Casing)
'f
FT. Above Land Surface*
TOP OF CASING Is Fr.
'
9.
*Top of casing torminnted actor below land surface requires a variance In accor-
dance with 15A NCAC 2C .011 B
10. YIELD (gpm): � METHOD OF TEST
r T
11. WATER ZONES (depth):
-------------
Type Amount
x
If additional space is needed use back of form
12. CHLORINATION: _
13. CASING:
LOCATION SKETCH
Wall Thickness
Depot lame r or W Ight/F . alerial
(Show direction and distance from at least two State
Roads, or other map reference points)
From ..To f — Fl•�
From To F1.
'
From To Ft.
14. GROUT:
DepU Materi I ethod
From To AD— Ft.
-t'°`--
G
%
From To Fl. --
15. SCREEN:
Depth Diameter Slot Size Material
From --To Ft In. in.
From To Ft. In. in. �----
From To Ft. in. in.
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft. —
17. REMARKS:
DO HEREBY CERTIFY Ti IAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STA(J;DARD�;ANp T�tA�F'A COPY OF THIS REC D HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY DATE
t, y I ��. IGI ATURE OF PER N CONSTRUCTING THE WELL
Quad No: ai {
�rS�ibjm l�orip al to Division of Water Quality. Groundwater Suction within 30 days
GW-1 REV. 12/99
C!
Serial No.

North CArolina • Dnpnrlrnnnt of Environrnnnt, I lealth, And NAlurnl nAsourcesn ~Fos OFFICE USE OfJLY 2
Division of Ertvirorunnnlnt Mnnngnmont • Giounchminr Sectlo
P.O, t3ox 29535 • hninigh, N.C. 27626-0539 Q1)A(l. fIU. SEi11ALM0„
Phone [phone] Int.
fdlnnr Pnain - �
WELL CONS 11LICTiO14 RECORD MmIlli Cnffn
llAnrinr Ent._^_ (3W-1 Ent
DRILLINGco rr1ACTU(1� ___.._._--
SIAiE WELL CONS IIIUC11014
URILLEn nEGISTRATION I1(jMr3t-n: _ rENMir NUti1F1En: I
1. WELL LOCATION: (Show =,,4AdA5&
lte-locallon below)
Nearest Town: _ _ County: �%AA.--------
(nond. Conan city, or ButYflvl. nand Lot No.) U_f_i'_ 111 _ DRILLING LOG
2. OWNER _ Front In Formadon Descriptlon
ADDRESS_
(SI 1 or Flouts No.)
Ci or 1 vn Stan Zip Corte
3.
ty o• .
DATE Dfllt-I_FU •3 51 ` ao _ USE OF WELL Zorn
a.
4.
TOTAL Dr_P I I 1 -- ----- _-------_—
Cam'
-
�"
5.
6.
CUTTINGS COLLECTED YES UI NOL,�
DOES WELL r1EPLAGr: EXISTING WELL? YES(__] NOg
C=�
7.
STATIC WATER LEVEL Below Top or Casing: J4Q FT.
(Use's•• if Abovn Top of Cnshrg)
Da
8.
TOP OF CASING IS - ----- Fr. Above Laird Surface"
Casing Twirtinrriod el/or below Inrtd surfacer is Illegal unless a variance Is Issued
O
cnx r
In
occordnnco rrlih 15APpAC 20 .0110 - -
METIIOD OF TEST
—
fv
C"3 .
-'
9.
YIELD (gpm):_
--
0
'HATER ZONES (depth): ----
-- �
'T
11. CNLORINAT ION:
12. CASING:
Type TF T 14 AnloUlit If nrhlitlnnnl attncn k nandAd uhn back of form
Wall ihk:knPss
Uel)lllPlan'lQler
or Weight/Ft. vitmini
From
From
-- -ro -
—
From
—To -------
Fl.--- —
13. GROUT:
L)r'plh
-to
Malerlll olitod,,/
From .- .0
Gi
To--
14. SCREEN:
T)npllt
r:)inmeler Slot Sire Malerinl
From
In. In.
From _ _.--
To _--------- f"t.
,_ In. In. —
From
_ T o-_- ---- .. __ Ft.
----- in. __ Ill.
L_OCA:110t1 SKCICH
(Show diterlinn and disinnr.e hom at lenit two State
floada, or ollrnr ntnp mIntonco points)
r
15. SAND/GIIAVra_ PACK: ,i11
Depth Size Material �:..s �
From _- -- T o - ---- r t•
i
16. REMARKS:_—
I o FmEnr-n•r CFrlrlr-Y 111AT �ilils WFLL WAS CONSMUCTED IFf ACCOMAMF WII11 00 f`IC Ah•,2C, wFLL
CON _ _ _ — _ ,� IATACOrrYOF iiiiS nEConoilAS EIEEMif'F1c)v1Ut'`t3tT'O TIIF WELI OWNER.
- -
XN 19 TOO SlrZ*MunF OF Cc. 1fLACiOn Orl ,Ft IT fJATE
OW-1 nEv. 9191 Submit original Io blvhlon of Frrviroronnntnl r.Ltn�q^m^nt +�+d copy M weA owner.

North CArollna • bnpnrtrnnnl of Environntnnl. Flenllh, And Nnlurnl Flesource9 A ron OFFICE UsE MLY21
A
Dlvislorl Of Environrnm,lnl Mnnngnrnnnt • CTround-.vnter Section OIJAD. IV). __ AEFilALNO. 2 `� 5
P.O. Dox 29575 - flnfnigh, N.C. 27626.0535 �Lar 80 -
Phone [phone] l nt. ...._._ !
Minor Pa^in f.
WELL CONSMUCTION nEC_O[ID rtonlnCrnln.__�__
Ilnn(Inr linrG*I EnL
DRILLING CON InACT011' Al WELL CONS 111UCTIUN
bnILLER f1EGiSMATI011 tIummiTT:_ .��� __ PERMIT NUMTIM: - - ....
1. WELtLOCA110N: (SW)
Neatest Town: w=e j
County:4�- ___._.----.-�---
UE P I_I I
(F,oad, Conmwnity, o� SulYiivl2lon and Lot Na.)
From to
2. OWNER
-- St�ln _Zip Coda
city or I own -
_ Df11LLIiJG LUG_
Formadon Deecriptlon
i
3. DATE D1111.1_FD _ Q'�'l!� USE OF WELL _�_ LJ-t-- _- _ �
4. 1OTAL UEPI I i
5. CUT-TINGS COLLE0, 1 CU YES [__] " _
6. DOES WELL T1EPLACF_ EXIST 11101 WELL? YES (_] Nog
n 9 � _ F t. -- =r--=
7. STATIC WATEr1 LEVEL_ Below 10 of CASir1 ----
(Usa'r•" ii Above Tap of Cnehrg) �r_ __- m
FT. Above L,1hd Surfnr.rt" ��u
8. TOP OF CASING IS _,_..__i--____
• Casing Tsrrninnlod ellor holow Innd aurfncA Is i"W" unless a vnrinnee is Issued
In arcordnnco yrilh 15A NCAC 2C .0119 0 — ----
9. YIELDMr l I IUD OF TEST
NATE11 ZONES WWII):--- - _ _ a NO o
11. OfJLORINATlot J:
12. CASING:
_ ___ AI,tOUnt it nrldrllonal nimcn is no
ndnd ude back of orm
uppIll Inrnnl r
Wnll ihlcknesl
or Wflg�SD2
From t o I
f t. -- --
From- To --
Ft. -
-
-
From To --.-. __
Ft.-------
13. GROUT:
Ospilt
o
Material
g1IIod
�j��,
�_- "i o P
Ft.
From
From - To ___-Ft
-
14. SCTIEEN:
UpoIll
Ulrarllelr�r Slot S170
Malerlrti
LocAl ION_sL(E1 O
(SNOW dirr,don Innd CI1S1inCA 40"1 e1 Ieng1 two State
Flonda, or nlhnr map rntarAnce points)
r
__ 'To __ _ _ Ft
From ___. in. ---
From---- TO - Ft._
15. SAND/GRAVE(- PACK r'
Ivlalerlal 1I l • �`; t� '
Depth Size I r
From - 10 -
rL. _.---- — r.
From ______ 10--- Ft. ---
16. FIEMARKS: --- --
11MEA lFM
ELL WAS CONS T nUCTED11
111AT A COr'Y OF 7111S nEDC
AUG, i 'Id,001
15A IWAC 2C. WELL
[)ED 10.11lE WELL OWNEri.
s �.tl 5� f r..-- a`- .
{ "i_W
— -----� DATE
d gir�ttATUf1Cc Tr)A I F ry CT 0"ronFill end c^t,y to wnA ewrt++r.
r v .cam `-�..«-.•� Suhmlt prig Ivl3lon o
r,,,Z."" ,; iort � � innl fo D
OW -I r1EV.9/9t M- •t.ar.: n
S�vali)1��:Ily"1l..._,...�

North Carolina • Unpnrtrunnl of Environrnnnl, Neallh, and Nrltutal Tleaources ron orrlCE USE ONLY 2 ►� 4
Dlvislort of EnOmminntil Adnnngninnnt • Grourrcbrontor Section MAU, 110. ._--.___. at=RIALW. —•-_ I
i'.O. Dox 29535 • ►lnlnigh, N.C. 2.1626.0538 lnt. ____ - Lor+O• M
mane [phone], I•
Mirror nn^in
WELL CONSTnUC'TIotJ nEconD nn!rkrrnrrn_�_-
i (londor Fnt,_ CiW1 Ent
dnILLING CONinACTO1T• _.._
STATE, WELL CONS111UCTI0N
MILLER nEGISTRA11011 NUMMin:_ F NUMSTEN:
1. WELL LOCATION: (S�jlow Sketch 0,1 the location below)
Nearest Town: = /�1� .[�� e. County:
- Ulif' I I I _ Qnll-LING LOG
(Road, Connnunt , o SulYlivislon nod Lot N .) rormadon Description
trout In
2. OWNER _
ADDRESS_ L_� -
(Street or flouts No.)
City or T own
state zip Code
3. DATE D1111-1-r-D .:Z� d USE OF WELL —ZOLm
4. TOTAL DEFT I I f2-�-- ES _ _ f -"
5. CUTTINGS COLLECT rU YES [—] NOL7'J - ern-'
6. DOES WELL TTEPLACE EXISTING WELL? YES (a FT.
7. STATIC WATER LEVEL Below Top o1(✓asin
g: _�Q FT.
(Use '+" it Above Top of
8. TOP OF CASING IS _—.__ _ FT. Above Lrtitd Surface' `" rn
Casing Terminnlod nUnr bolow Innd surince Is 111e9e1 unless a vnrlance is Issued
in sccordnnce y+lth 13A f AC 2C .0110
_- _—
9, YIELD (gpitt):--- ME-IIIOD OF TEST N3 ,o
NATEn ZONES (depth): _—_--
AIT10Urt-t ,.Z�� 11 ncldillon1l cftncn is nendnd u:1e back of form
11. CHLORINATION: Typo -
12. CASING: - - - - LO A ION SKE_T CI 1
Wall 1ldckness
Depth tamele► or YJ .IghUFt. Malerinl (Show dirnclinn and distance from at least two Slate
�_� o�� noadg, or oilier map rnlernnco Points) '
From
From— To____-----
F r om—To — t. - ----- _---- —
13. GROUT: Mzlerinl nlhod
Urplh
FromFrom To--
14. SCREEN:
Drirllr Ulaineler Slot Size Materlttl
From
From RFrom o -__-. -• -- I: t• ---_ in.
$ 1� C3
15. SAND/GITAVEI. PACK: � r ..__
Ut'i1lh Size Mllerirt)� ;
Ur
From -- ---- — + � :
o F 1.
fi
44, nEMAn_KS: , ri ELL
1 Do f ¢tIt WELL WAS ca1JS1r1l.1CTED IIJ ACcc�t�blr {wl ll l 15A fIc Ar 2C. w
CONS CTIUIJ STAtJUAnDS, I�NT) 7;1UT A COPY OF THIS RECORo I IAS BEErI r rlovIUFD 10 T11E WELL OWNER•
r r rtr
.— DATE
Group water Section
�sirlrintunE �ra trincTrn on ,
t3W-1 REAshevitle Re Tonal Office Submit orlgh+n) to btvislon of Errvironrnenlnl rAa,r,q^rrr�nt and c�`y to w^ o"'r+^r'

North Caroilna • 11 mrlmenl of Environment, Neallh, and Nnlumi Flesou►ces ron OFFICE USE OfJLY 2 1 2 ( 4
Divi9lon of .-_nv1rnmmnn1nl Mnnnpnmont • Groundwator Section 00AU.IR). w BEnIALNO.
'.U. Dox 29535 • flntnigh, N.C. 27626.0533 ` `- `
Phone [phone] l rat
Mirror f1a^in
WELL COtis muC-TIot4 11EConD 11,101
�`�,7. (,�� Itnnclnr Fnl.t3W1 Ent
FiIL DLlIR
1" CONACTUfIc,r l.S�dL!s' J"DS1111E WELL CONstI=11014
DRl' cR t1EGIST11A11011 1iurvin gin: PERMIT tIUMF1Ef1:
WELL LOCA I IONJf1low sketch of the localion below)
Nearest Town: Cot►nly:
(nood, Conran lit , or SutAlvislnrr nrid Lot No.) -- — DEII 1 I I _ DRILLING LUG_
2. OWNE1i_._ +J,,o�`�( From to rormndonDescription
ADDRESS_ _.__/1.L/$
City or Town Slalo Zip Code
3. DATE D1111.1_F1)a uu_ USE OF WELL _ J
4. TOTAL. DE I' T 1 I ____�D_� __ - - - ca
5. CUTTINGS COl_LEC I EU YES(] NO� — - c �r�l
6. DOES WELL RE1'I_ACE EXISTING WELL? YES NO� m
7. STATIC WATER LEVEL Below Top of Casing: 4 rT. — ry �m
(Use •+' It Above Top of Casing) �-
--_
8. TOP OF CASING IS __-�.- _ rT. Above Land Surface' - m
' Casing Tsrminntod sUnr balow Innd surlacs Is Illegal unless a varlence Is Issued
In sccordnncs with 15A N AC 20 .0119 •• cm)
9. YIELD (gpm): ME"11 IUD OF TEST
1r ''VATER ZONES (dep111):._
11. CHLORINATION
12. CASING:
1 Ypo —�- F-�--- Amount -- If nrlditlowil e"pncn 19 nendnd uSe back of form -- - -
Depth b amnia
From O 10 -s-."— rt.
From TO --
From —To FL-
13. GROUT:
1.0CATION SKTTCH_
W;111 1 hickness
or W .ighVrt, atnrinl (Show direction and distance from at least two Slate
fioad9, or olllnr neap rnlerence points)
Unplll Malerl�l
From __0 -10�
From _. 10
14. SCREEN:
Urp111 Ulanteler Slot Size
From To __ rl -- 111. _ III. _-----
From --- To —___ t-1. In. In. _--.-----
Front -- -- To ----_...___ Fl. In.
15. SAND/GIIAVEL PACK'
Size Material'
Uel�lil --���
From T o ---- rI. — ------ 'I I
From ___ ___ To. rl.
16. REMARKS:
Dot
I11}nYL F"f
CONS 1 ctJ
ti'(,hlh T fIS..•.FtILWASCOtJSinUC1EUIN�ACCnn
FfiJH7FFlt l'(l D'!AT A COPY OF 1t its nEC0110 I IAA,
NI ,l l ,15A NCAC 2C, WELL
f16VIUE() 10 111r WELL OWNEn.
ow• t
-_ _ DATE
S,1011Ait-or -c iAA iOn on._ ' ,FtIt
SLIN1111 originai to bivhlon of T_rlviroronantni 1.1en�q^mint and cr•`y to wRA nwrl�r.

North Caroilna • brrnarlrnnnt Of Environntenl, Harillh, and NnImni nnsoutcas Toll ci ICE USE of ILY i 4'
Divislort Of Ennm virnm�inl M,n m,ngnent • Giound-nratrit Secllort 00M. t(T. — lSEI11ALN0. 4 - - "
P.O. tlox 29535 • llnlnigh, N.C. 2162.0.0538 1n1. _.._-. - _ Long. -
Phone [phone] —�
Mh,nr Fla^in
WELL coNSTrTUCtIOti nECOr1U Nninr7n,ln_.._—_
-__QWA EnL ;
MILLING CoNmA01011: �S1111E WELL COtJSf f1UGT1UN
DTIILLEr1 r1EGISTTIATION NUM[31_fl:VEIIMII, Ntimm1-
1. WELL LOCATION: (S 1 skr�Jch of the locallOn below)
Nearest Town:
UEI' I I I -DRILLING _LOG
(nond, Convtntnity r ,If 'JivIRIOtt rind Lnl nFrom.) — - Fortrtndon Description
l o
2. OWNE11 __--
ADDRESS___
Slate ff Zip Code
— -
r l own -
3. DATE Dflil-I-EU �• d 'd_ USE OF WELL
4. TOTAI. UEP i I I _
5. CUTTINGS COLLECT EU YES (___] NO(_� c
6. DOES WELL nEP1_ACE EXISTING WELL? YES [j NOg
7. STATIC WA1 ER LEVEL Below Top oT Casing: FT
(Use '+• it Above Top of CAsing) -
fV .fir i
8, TOP OF CASING IS -_—IF-T. Above Land Surface"
• Caning T•rrnlnnind munr bolow Inrtd „rrince le illegal uniean vnrinnce is Inauxd _ 221
rn accordance yrllh 1SA ygAC 2C .0111,; --- rn
9. YIELD (gTTln):-�Y--ME"TrIOU OF TEST ~+_-%k •• �m
-�.
+ vATER ZONES (depth):
_ ,
IT10U111 II nrhlilionnl ^ltncq is nandad udq back OI or
11. CNLORINA1 ION: Type A
-- �r -�-- - __ --- -- -----
12. CASING: LOU/ 1014_SI<1E
Wrtll thickness
Uepth Dirimeler or Welgi vFt Materiel (Show (fito lort
From 0 F t. nilt�r rnnPtrAlerirg tnr cle poiat nis)011 tWo. Stele
-
1-- -- ------ %I ��
From — To — — Ft. -- G��
From -----TO --- Fl. —
13. GnOUT: nthod �'
Urplit
From _ 10� f"t
Frorn _... To Ft. ----`
1 A. SCrIEEN:
Unplit Ulanteler Slot Size Materlrtl
To r"t _ _ __ In, --Ill. --- -
From Irt, __—.---------
From —TO
From ____
15. SAND/GIIAVCI_ PACK: Material
Depth Size
T 0 ---
From H. � �4�•,��i� +<
_ 10_- -- ���i�
From From---- -.._-
�a. t `G , WlrliEco„c� nIjE lit ltl Y�fj)s?tY,lr f"u.Ti,Arzc,wrLL
otlIFwELLowNEl.
o01IE tllst1
CONST �1
iJ1
- - - DATE
x SIr;iIAfUrlFr7r Cf Tr(ACiO►IOrI F.rir
1 f Frrv6ornna,lnl !.1.,rnq^n,nnt And crpy fo rv�A ewrtr•r.
t3W-1 t1EV. 9 1 i;roundwate' Section Suhtnll original to (livltion o
shevile R�lonai t;ffire

North Carolina • Dnpr (it inn of Env lint unnnt, health, And Nnlurnl flesources�rOn OFFICE USE CNJL 1 2 f 4
Division of Er anitrnnn nlil Mnngrimant • Gioundw�lar Section OUAU. If(). _ 6Fn1ALN0.._
P.0 . Dox 29535 • tlnlnlgh, N.C. 27628.05,15 -- "
Phone [phone] lnt. ___.. - lord. no I
Minor Mimi
HELL coNs rnucTlof4 nEconD
DRILLING C1' t nACTOII� Ilnncinr Fnr.. _ aW I Ent
SIATE WELL CONS IMC11014
DRILLEn , :cisTnAII0If fItJMDL!n:
1, !° � LOCA t ION: h w ske •h of the I ali0n below) // -- __
,treat Town:— ��Y Counly: 11'lGl� _..-----
(nond. Common" or SntAlvislor rid Lot No.) - —
�. OWNER _.
ADDnESS_—v.
P, ch 14K—(Slron. l -_ naula No.)
City or 1 own Stale Zip Code
3. DATE D►i11.1_FI)USE OF WELL 2?0—. +
1. TOTAL DE P f I I
5. CUTTINGS COLLP.31H) YES D NOL� 3. DOES WELL FlEF'LAGE EXIS-1ING WELL? YES E-1 NOL-0
7. STATIC WATER LEVEL Below Top of Casing: _IQS_ FT.
(Use •." If Nbova Top of Cn0,911
11. TOP OF CASIFIG is Fr. Above Lattd SiJrficn*
Casing Tsrrninnled el/or below Innd sutince is Illegsi unless to vnrlanca Is Issued
In sccordnnce wI11r 15A tICAC 2C .0110
.3. YIELD (gptrt): q_-__ ME
-I I IOD OF TEsr
1` '1ATER ZONES (depth):
11. CHLORINATION:
12. CASING:
Uf_r'll I _DRILLING LUG
From to rormndon Description
J
S
Typo N Amount _� II nddilionni ^•pica in nendnd usn back of form
Depth D amnter
From To - -3 Ft. 6.
From TO —
From --To----' Ft.
13. GROUT:
LOW I0f.J SI(E_TCFI
Will I Idckness
or vJnight/rt. nte+inl (Show dirnrtion and distanc9 horn at 1989t two State
A161, pleads, or olirer rnnpt refernnro points)
Ur'pill Malerinl
From ._— -to P�� rt.�--
From '10 — - Ft•
14. SCREEN:
Dal)III Diameter Slot Size
nihod
Materinl
From To _ f"t I",From To _— rt. fit.
From _._.�Jo ____._.__ FL_ Ill.
15. SAND/GiIAVEI_ PACK:
Depth Size
From
From __.__ to Ft.
16. REMARKS:
t DU1TV414-►alr� 1
JUN 1. 9 200(')
GW-1 ns-A 9/91
Materiel
I�J�kw�/le
,�(a� i✓ffN., Nc.
eta
NEI_L. WnS COIJ51T1UC1EU IIJ nc,.nti�ir?tt;'�Nif'f i'1 gin` �aenr 2c, WELL
11IAT A COPY OF 71IIS nECOnU I InS PEEtJ pnoVIOED 10 11IE WELL oWNEn.
SIr3f 1A1UnF or Cr ir1nCTOn On .F11T OATS
Submit oilgrnnl to Vivielon of Frrvironrnnnlnl rAnniq-m-rd and c ry to well owner.

North Carolina • Department of Environment, Health, and Natural Resources
Division of Environmental Menngnmant • Groundwater Section
P.O. Box 29535 • nnlelgh, N.C. 27626.0515
Phone [phone]
WELL CONSTnUCTION FIECORD
Fon OFFICE USE ONLY 21 ►y
OUAD. NO. _ SERIAL PNO. {
Lnt Long. " no
Mirror flnsin
8anin Code
TI 4 11 GINA Ertl
DRILLING CONTRACTOR: Ferguson's Well Drilling Co. I oe
STATE, WELL COfNSTRUC1I0N
DRILLER REGISTRATION NUMBER: 541 PERMIT NUME3En:
1. WELL LOCATION: (Show sketch of the location below)
Nearest Town: Montreat County:
(nond, Community, or Subdivision and Lot Na.) DE pill I I I
DRILLING LOG
2.
OWNER John Burris From To
Formationbescriptlon
ADDRESS 0-57
..—
Dirt
(Street ornouleNo.) 57-225
_Bedrock
City or Town State Zip Code
`
3.
DATE DRILLED 3-2.2= 00_ USE OF WELL Dom
4.
TOTAL DEPTH 225
a
�'
S.
CUTTINGS COLLECTED YES o NOO
:o
6.
DOES WELL REPLACE EXISTING WELL? YES 0 NOP
7.
STATIC WATER LEVEL Below Top of Casing: 30 FT.
(Use "+' II Above Top of Casing)
r N
ZEm
8.
TOP OF CASING IS 1 FT. Above LAW Surface"
�•
''�
• Casing Terminaled aVor below land surface is Illegal unless a variance Is Issued
�r*i
In accordance with 1SA NCAC 2C .0110
M:;0
9.
YIELD (gpm): 15 METHOD OF TEST Rim--
WATER ZONES (depth):
z
11. CHLORINATION: Type _.HTH Amount-38 —
12. CASING:
Will l ldckness
Depth Diametor or Welght/Ft. Material
From 0 To 57 Ft, 6.2 5 2 J 6 PAC= -SD
From To Ft.
From To Ft.
13. GROUT:
Depth Material Method
From 0 To 20 Ft cement pc)ured
From To Ft.
14. SCREEN:
Depth Diameter Slot Size Material
From
To
Ft
in.
It"
From
To
Ft.
in.
in. -
F
To
Ft.
In.
In. --
rom
SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To— Ft.
16. REMARKS:_
I DO HEnEB`( CEnTIFY;7I`1AT THIS WI
CONSTRUCTION S111N0iAF1b$'AC}t? I
Material
If nddilionil rpncn is needed use back of form
__LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or oUrer map reference points)
Graybeard Trail
Montreat, NC
as d f
t\UG 1 A. n o
L WAS CONSTRUCTED IN XcconiI WITI I tSl1NCAC 2C, WELL
AT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
oQ
GW-1 nEV. 9191 „nr1 `+ 't ` section
:?s� ., iiie.:z�;i naL OflricF�,
SI rlATunn OF CONT6ACTOn On AGENT DATE
Submit original to Division of Erntronmental Manngoment and copy to WON owner.

North Cnrollna • Dernrr it of Fnvironrnnnl, Ilenhh, Find Nnlu(nl nesoutces _• •_. �_ pn OFFICE U9E CkJLY7 r-
DIVh0on of Env;- onnnlnl Mnnngmmnril • clioundwntor Section <_ ? �,
P.O. r ox 29535 • flnlnlgh, N.C. 2762.6.0535 01MI). tit), cr-MALNO..'
Phone [phone] (nl _..__...._. l.onp. w
htlnnr ftan•ir/
JELL CONS I RUCTION FIECOFID -`—
_ lhnln r:nrrn -.--
'MILLING CO'. ,nAclorl•
_ Iiondnr Ent. GWA EnL
00 0 SIAT F Wrl-L COIISI11UCIION
MILLET? ('-_Gl,;TnA11011 tIl1ME1f_R: ��1 —_ PEriMl1' NUMFiEn:
' LL LOCATION: If sketch of the Igcatloil bolow)
,earest Town: �_-, l�P�Q.t/�F/�ct'L Counly: mar
(nond• Cornrn�un Y• or S11Ix`vlrI0
n Fin of No.) D_E 1' 1 I I
?. OWN En _-_/ u _D — �_ 7 Fran, ..-. _ 1a
ADDRESS_d�Oc2__� - -
(Shnel or rloul No D
F -
City or 1 own Slain Zip Code
3. DATE DR1I.l_FD __,2J_-10L USE OF WELL ZQtb +
1. TOTAL DEPTI i
3. CUTTINGS COL1_EC I EU YES[—] NO[.j
_ DRILLING LOG
Formndon Description
3. DOES WELL nEPI_A(,F_ EXIS I INU WELL? YES NOLJ
7• STATIC WATER LEVEL Below Top of Casing: � FT.
(Use •+" If Abovo Top of Cnslrrg) c>
3. TOP OF CASING IS F"T. Above Laiid Surfacrl" _— C o�
' Casing Terminnied et/nr helow Innd surloce Is Illegal unless rt vnrlance Is Issued
ht eccordnnce rvllh 1SA NCAC 2C .0110 - N :�:_m
3. YIELD (gpnl)%__,/_0_ _ ME rI I0D OF TEST 7z`'
lc 'HATER ZONES (deplli): -- v " __V1
m
11. CNLOnINAT ION
12. CASING:
cn a
t,
Type H %• 1T If adJilionnl gp-icn Is nendnd u9e back ofkrn -c-i - --
Wnll I hirkness
Del)lh D))aninter or WeighUFt Rimini
From-0 '10 M&_ Ft. 6016
F"rom -10— Ft.
From —To ----= Ft. —
13. GROUT:
��11
Doplli Malerlri) nlhod
From __0 -to
From To-
14. scnEEN:
Deplll Diameter Slot SI7r3 Matedrll
From To _ Ft __ — Ill. _ In.
From --To
From
15. SAND/G11AVE1_ PACK: ,i I '
n1
r11 <<
Delillt Size tvlalerial ;f; ,
10 FL I
From
From Ft. ,AUG 1 /� 2000 ;
.___.— '
16. nEMARI<S:
IDOI
CONS
Gw_I nF_V
LOCAYIOid_SKETCH
(Show dirriclinn Find distance from at 18nst twa Stele
noFiJs, or othrir nuip rnf©rence points)
1,th
WAS CordSinUCTEU IN Accorl)
T A COPY OF THIS nEcono I IAS`
IcAc Pc, WELL
O'1110- WELL OWNEn.
SIr,IIAluOFCr Tf�ACTOnOr) ,r-tlr DATE
Suhrnll rnlgtnnl to VIvhlan of Frrvlrnmvr ntit t.l:tnig lnr♦ cory ro wn1 eyvrr+rr.

North Carollo t • r' ortmanI of ErndroninAnl, Neallh, And Natural ►lesources
FOn OFFICE USE ONLY
ty
Olvisinr± rvironmmlial Mnnnpmm�nt • Grourtdwnter Secliort glJAll. f IO. _ BEnIAL N"O. `' f 56
,O. 13ox 29535 • nnlnlyll, N.C. 2.7626.0535
Phone [phone] lnl _._._.. - ._. Long, no
Mirror Pa^in __ I
WELL CONSrnUC11014 nECOr1D 11,10icnrtn
DnILLl'' f londw Flll._ GW-1 Ent.
STATE WELL CONSHILICTION
_r_R nEGISTRA11011 NUMr3ER: y % rEllmli, f4UMt3ER: I
WELL LOCATION: ( Illoyv Sketch of Ilse locallon below)
Nearest Town: County: &11�!/1-hLtr¢.,..
(Florid, Community, or Sul-livision rind L o.)
2. OWNER _- , �'
ADDRESS- _1G
' im,t Or ri0ute O.)
City or To"vn Stale Zip Code
3. DATE DRILLED -3-,24-66 USE OF WELL _ _h • _ ---
1. TOTAL DEPI l I —
5. CUTTINGS COLLEC 1 I_U YES[__] NOL� _
3. DOES WELL REPLACE EXISTING; WELL? YES [_] NOL-0
7. STATIC WATER LEVEL Below Top of Casing: _5FT.
(Use '4�' it Above Top of Crising)
9. 1'OP OF CASING IS __ '..__-._ F-r. Above 1-mid Surface"
Casing Terminnind st;nr br+low Innd surface is Inegel unless a vnrinnce le Issued
In ar_cordsneo Mill 13A N AC 20 .0110
J. YIELD (gpm):_ '___- ME i1 IVU OF TEST ----
1' 'EATER ZONES (depilt):
UE1'111
Ftorn 10
011ILL114G LUG
Farmridon Descrfpdon
o -
r- _ M
m
I -
r-,t
— --- -- ...__
11. CI-1LORINA1101d: Type � rJT AITroUnt �' _ If ndtlitiort,l nr,acri is neindQd use back orr5m MM -- -
12. CASING:
1.00A1ION SKETC1-1 � �
Will Tllicknes!
O Depth/ ffnrn�ai©rr or Y clghtlFI. aloani (Show dirriction rir±d distince from At leaet two State
From in — r t. �-- ponds, or nllrrir rnriln rriforrinco polite)
From To F1.
2From --To .1//it-Q/1
13. GROUT: l/ ,r %�'
Ueplh O M''a.le--r,in��l �rTlltod �P �(/, ,
From
—0-r o t-t.
From To —Ft. -
14. SCREEN:
Uepih Uianteher Slot SIZe Malerin]
From To
From To ---
From __..__ T o --___- _ F 1.__-
15. SANDIGHAVEL PACK:
Depth SIZE) Material
From
From ____ To_ Ft.
1n. REMA
r1o
uuCo t(WAS CONS1nl-1CTEO IfI
CONS l� f STANOnr1OS, AN T A copy of it us nECC
i
( rt
r , t
i ' 7
cconnnrlc>t wlrt%1�n:�ic,ncac,wLL
C I IAS ETE. rJ rrlovii,)FC'tilo Tl,lt ?WELL oWflEn.
` f'YQrt rt QlV )ice ,l�la.l Vlt
Ast± vine*:e,u.�i Qg1�� rintunF or C(O ifinCTOn OrT .Ffrr
ow -I nEv. 9 w.... M Suhmlt otiginnl to ptvhlon or tray to wen owner.
DATE

.. .� _ t ..
North Carollm • nnr.. rnnnt of E nvirnmmont, health, And Natural Resources Fpn OFFICE USE ONLY? 12 7 5 7
Division of F nnm-nlnl Mm, "Inrnnnt • Gloundwntar Section
R. f3ox 29535 • flntnigh, N.C. 27626.0535 OUAD. IIU. _ SEMAL NO. �+
Phone [phone] tot. . _ _ l ony. no
Minor Pa^in
WELL CONSMUCTION nECOITD
0r11LLING c,t nACTUR' IInndw Fn1__ -_ QWI Ent
111l dcaar s Zt�[�?,D �t�1 -.- --
O stnTE WELL cofJsrflUClloN
::3nILLt' nEGISTr1ATI011 r1UMElr_n:—^5q1—_—___ rEriM11- NUMf3Ef1: - — ----- —
TELL LOCA 1 ION; SI ow sketch of the locallon below)
Nearest Town: County:
(nond, Commur' y, qr Suhiivision and Lot No.)
z. OWNER __
ADDRESS_-r,�-%-- -1�-
(51rent or flout@ No.)
h re
city o 1 own ` SInIn Zip Coda
3. DATE DI111,1_ED 1--/9' USE OF WELL DIY .
1, TOTAL DEr'1I I —
5. CUTTINGS COLLEC I EU YES [Y] NO& —
_ DIIILLING LUG
From In Formedon Description
3. DOES WELL REPLACE EXISTING WELL? YES (—] NO[y �
7. STATIC WATER LEVEL Below Top of Casing: FT. __-- Cm
CD
(Use '•* if Above Top of C"@(ng) c>
3. TOP OF CASING IS ____�__, rT. Above Land Surface" — bC,
' Casing Torminnied aUor bolow Innd imface Is Illegal unless a vnrlence is Issued r-"
M accordnnco rrllh 15 1,CAC 20 ,0119 N m
9. YIELD (gpm):rQSL—_ ME F I IOU OF TEST -
V PATER ZONES (depth): M
11. CHLORINATION:
12. CASING:
Type AmountII additional n[mcn is nendad u9n back obrm 2
D,?p1h Uhninter
From— o 7 Ft.
FrolT1 -- T o — Ft.
From --T o ----- Ft.-
13. GROUT:
LOCAY ION SKETCH
Walt tldckness
o Y .IghUFt, nte+inl (Show direction and dislanc9 hom Al lenst two Stale
floads, or oihnr map refernrice points)
Uf,pIII Material
From _01 To A4 FI.
From 'To
14. scnEEN:
Urplh Utanleter Slot Slze
From 'I o —___-- r_t --.— In. _ In.
From ---To _ -- F t.----- In. In.
Frorn - T o _._..--. — Ft. Irt. Ill.
15. SAND/GIIAVEI- PACK:
Uepllt Size
From To __ FL
Frorn _ — 10 H.
In. REMARKS:
aw• I
nlhod
Maletlnl
Materlal
_I_L WAS cO1J51i UCTED
I IAT A COr'Y OF if its I1F_
{yjw,�,t�r/r✓�kP�
AUG
ACCQ11DAf 1GF WI 11I fM IIcnC.' 2C, WFLL
i1D I IA9 bEF..td movIDED to 111F WELL OWNEn.
pA1B
AnipOF ifSIACTOn On Fm
Submit origin", to iilvtslon of Frrvironrnantnl r.immg•,m�nt "n.f cnry to wall awrrer.

North Carollna • Dnpmlrnnnl of Environment, Health, And Natutal Resoutces 1'On OFFICE USE ONLY !) 2 $
Division of Environrnnnlal Mnnngnment • Giound'Nniar Sectlott t7tJA1). f 1t). acnIALNO.
P.O, r3ox 29535 • Rntnigh, N.C. 27626.0535 �
no
Phone [phone] tn1. Mf_._....._�_ l.orq,
nor flaairt
WELL CONSTRUCTION REconD rtanfornrrn __
DRILLING CONTRACT Oil r C� Header Fnr. ..... _......... t3Wi Ent
Si.AlE WELL COIISiIiUC11UN
DRILLER nE( IS7(1AIION NUM131_i1: --)� I PERMIi' NUM13EF3: - _ _—` r
WELL LOCA'iION: '311ow•skelch of the locatlon below)
Nearest Town: County:
(nond, Convnu ' , or SubriivlMon idi Lot No.)
UEf' I I I DRILLING LOG
2. OWNEn --
Front 1 o Formedon bescoption
ADDRESS_ —
- —
—�
(Sir el or rl ule f,lo.) �Q�_—__
Cityr l own Stale Zip Code
C7
3. DATE DRII.I-Ei) 3IT OD USE OF WELL
------------=.
4. TOTAL DEPI I I—
YES[] NOLj'
_ C o
-- r=
5. CUTTINGS COLLECTED
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO[,/
7. STATIC WATER LEVEL Below Top of Casing: __L,�;' FT.
—
(Use 'r•" It Above Top of CM91119)
8. TOP OF CASING IS ___ _ FT. Above L1hd Surface"
t'n�e
• Casing Tsrrnh,nlnd et/nr below Innd surioce le Illegal unless s vnrlence Is Issued
M secordnnce wllh 13A HCAC 2C .0119
N �_
T
9. YIELD (gPrrt):--L&— ME -it IOD OF TEST
{ `NATER ZONES (depth):
`-
TJ I T'Q AIiIOUflt
Type_
If arlrlillottai space 19 nnRdnd uto back of form
----
1111. cHLORINnTION:
_ - -
12. CASING:
LOCA-1 ION SKETOt 1
Will I hirkness
Depth i�m�el�er or WcIghVFt. M�lorini
� v �S
(Show dirnraion and ditlnnc9 from Al least iW0 State
n0�d4, or outer mnp relornnce polnls)
From-0 -�-, — Ft' -""�=-�'S
From To Ft.
From To - Ft. -
13. GROUT:
Malerial elhod
-�
r l C
Ueplh �
From p 10 C,�� F t. ' -6\k
From -.. 10------
14. SCREEN:
pppIll Ulanteler Slot Size Material
From 'To _ Ft __ _ In. In. ____----
From ToFrom
'' 15. SAND/GRAVEL PACK:
xv-�
`� r'
, C� L�
' Depth Size Material
T4
From 10 —
i 4 200
I E AUG 0 4
Frorn -- _ _ 10—
;
18 REMARKS'
N1 i
o01tEF1 . 1? 11� ^8 ilUs �F1 tins cotJstnuc3Ep It n ;connnr' c F wni t 15A frCAC ze, ELL O
I DO t iE . _ 1 ;A Copy OF THIS r1FCont) I inS kEN r n0 vtUr_D 10 11.1E-WEt.I OWNER.
DATE
( 10r1 Ml11 .1
;s_..._ ...-.. _ 1.11(311A tt)nF cot11 rin1
OW-t FIEV. gig Submit orlginn to VIVIllon of Frtv6onrr,0rtle„d co(y to wnfl owner.

North Carollon ttnnnrfrrtnnt of Pnvironrnent, iionitit, and Nnlumi nnsoutcas .A frpn OFFICE USE OHLI� 1 2 ►'i 2
Divislr• ()IEnvironntnnlnl Mnnngmmont • Groundwnler Sectlon , f
P.O. Dox 29535 • linlnigh, N.C. 27626.0535 01JAU. NBERIALNO
tt. ^_
Phone [phone] tot. Lony. no
Minor Pn^in
WELL cot,lsmuc'iu4 nECOriD nnnir,r;nrr� —_-
r1r_ING CON1"nACTOi% llonrror EnL_ - _ _ GW1 EnL
cJ S1A7F.. WrLI_ CONSiiiUCiION
(tILLEn nE(:ISTRATI011 NUMfIL"fi:_—_ ICZL-_------ PE1iMl1' NUMnEIi:
WELL LOCAiION: �(SIIVW sketch of thefocallon below)
Nearest Town: County: —
(nond, Connrn rty, or Sulxf(vislo _ u1 L01 0.) Ur_ 1' i I I
2. OWNER __- _ _ From 10
AUDnESs_--�
($t(OntOr nOUte llo. D � � _
City or 1 own —Stntn Zip Codn--r`--F--- -
3. DATE mil.l_F:1) 3, 000 USE OF WELL DO /Y) , -
4. TOTAL DEf 1I I _ -- -- -- -"--
5. CUiTINGS COl_LEC im) YES L ] NOL ------
6. DOES WELL REf't_ACF_ EXISritJG WELL? YES NOLA
7. STATIC WA1ER LEVEL Below Top of Casing: 4� FT.
(Use 'f' It Above Top of Cri0tq)
S. TOP OF CASING IS _.___ FT. Above Laitd Surface" —�--
• CAeing Totminetnd et/nr holow Innd sutfece is Illegel unless a vn►lence Is Issued
In eccordnnce rrlth 15Ar
14AC 20 .0110 —
9.---
_ UI11l.l,IPJG LUG
Formndon Description
Mr—le-9-7-MR51-05
1f, WATER ZONES (dep(h):
x
11. CHLORINAT ION
12. CASING:
T Y1)a N L Amount If ndrliilanat ^•(7 1C9 19 nA9dnd U!�9 back of farm
UPplh ' / U molar
From To 2y Ft.
From To — Ft. -
From —To
13. GROUT:
L.00A110N SKETCH
Vrinillhickness
gitl�[d � 11011nl (Show ditnrlinn nod distance from al lengt two Slate
ld (loads, or ollrnr mrip re1nrenc9 paints)
Upplit Maleri�i nlhod
From _A19-1 o�
From _. To
14. SCREEN:
Urplll Ulameter Slot Size Malerinl
From To —.__ 1-t
From To ____-- Ft.
From ______ To In, ln. —
15. SAND/GiIAVEI_ PACK:
Is
Depth size Material
'k
Front To _ r I.
�l 1
16. REMARKS:
IDO1
CONS
GW_I nEV
WAS CONS i nUC 1 ED Ill ACCnnDAI ICP VVI t C, VYELL
T A COr'Y OF TI IIS nFCOI1D i iAS 8FEt1 r'r•jOVII)L11J,1_fO'TI IF -,WELL OWPJEn.
UADATE
S1rrACOnon ;F.tlr
Suhrnit orrgtnnl to Division vl Frrvkonrn-ntnt t.1-i ­q^awn► morl rnry rn wnrl ewrur.