Well Construction Records Buncombe 2 CY2000

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:R.CALDWELL DRILLING, INC.
WELL CONTRACTOR CERTIFICATION #.2140
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (check Applicable eox): Residential E7 Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATIONS'h�ow slfetch Fthe location below)
Nearesldown: yam;/j County:
r[:
(Woad Name a d umbers, Community, o Subdivision' and Lot No.)
3. OWNER✓/�`l�C� - >��, L�-[.��L c.
Address
�wcqui nuuw w./
City or Town State Zip Code
4. DATE DRILLED I I<'- o-o
5. TOTAL DEPTH ' :s
6. CUTTINGS COLLECTED YES ❑ NO[—]
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NOD
8. STATIC WATER LEVEL Below Top of Casing: FT.
(Use '+' If Above Top of Casing)
9. TOP OF CASING ISFT. Above Land Surface -
'Top of casing terminated attor below land surface requires a vari ce In accor-
dance with 15A NCAC 2C .0118
10. YIELD (gpm): METHOD OF TEST
11. WATER ZONES (depth): '
DRILLING LOG
From To
jr r
DEPTH
Formation Description
r.
9 L�
r 4
A
12. CHLORINATION: Type 74 Amount ( 7 If additional space Is needed use back of
13. CASING:
Wall Thickness
Depth
-� k
Di afar or WeighV(Ft• Material
2
From)4— To
Ft.
—
From To
Ft.
From To
Ft.
14. GROUT:
Depth''
``��
From 0— To LO
Ft.
'Material41hod
-
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 C
CONSTRUCTIO
FOR OFFICE US
Quad No:
Serial No.
LOCATION SKETCH _ W
(Show direction and distance from at least twofate
Roads, or other map reference points)
THAT j8IIS. WELL -WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
ARpS,[i4N TI j�T I COPY ;OF THIS RECO HAS BEEN PROVIDED TO THE WELL WNER
1ha11 ILLS -
Y
p I y ATU E OF PERSON CONSTRUCTING THE WELL ATE
.� ` ` SubmIl od f1?J Io Division of Water Quality, Groundwater Section Within 30 days
GWi REV. 12/99
1�

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section C 2
1636 Mail Service Center • Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:R.CALDWELL DRILLING, INC.
WELL CONTRACTOR CERTIFICATION #?140
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable sox): Residential [9'✓ Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show e h of the location below) 2
Nearest Town: County: �y�c� �•
(Road Name an, Numbers Community. or Subdivislo and Lot No.)
DRILLING LOG DEPTH
3. OWNER
From To Formati n De ption
Address
treat or ou a o.
JI/
City or Town State Zip Code
4. DATE DRILLED =oe)
5. TOTAL DEPTH %f_L'
6. CUTTINGS COLLECTED YES ❑ NO
C=
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NOD-"
�&
8. STATIC WATER LEVEL Below Top of Casing: FT.
-.. �..
(Use '+' II Above To of Casing)
O Ri
C)
9. TOP OF CASING IS FT. Above Land Surface-
s
'Top of casing terminated at/or below land surface requires a variance In accor-
_zm
p �rn —
dance with 15A NCAC jC.011 r
10. YIELD METHOD OF TEST
(gpm):
11. WATER ZONES (depth): leap'
12. CHLORINATION: Type Amou _ � d
back o
if additional space is needed use qrm o
13. CASING:
LOCATION SKETCH
Wall Thickness
Depth �y D�:a�eter
or Wei hVFt. M teriaI
�� y G
(Show direction and distance from at least two State
From +
To -d8! Ft. -(
V
Roads, or other map�terence points)
From
- To Ft.
From
-To Ft.
14. GROUT:
Depth Material _ ethod
From _�_ To .21 Ft. el'WI P4,17
From To Ft.
15. SCREEN:
Depth
From
To Ft
From
To Ft
From
To Ft
16. SAND/GRAVEL
PACK:
Depth
From
To
From
Ta
17. REMARKS:
Diameter Slot Size Material
in. in.
in. In.
In. in.
Size Material
Ft.
Ft.
S
DO HEREBY CE _ r�F.V RUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION D� R A , !D H A O THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE
�f t�
Quad No: c� c ATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit odg at to !vision of Water Quality, Groundwater Section Within 30 days
Serial No. GW1 REV. 12/99

North Carolina -Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section _} J(_ 1. 1 3 0
1636 Mail Service Center - Raleigh, N.C. 27699-1636•Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:R.CALDWELL DRILLING, INC.
WELL CONTRACTOR CERTIFICATION #. 140
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (check Applicable aox): Residential [}� Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
Agricultural ❑ Monitoring ❑
2. WELL LOCAT)QN: (St;1p sketch of the location below)
Barest Town: (.�tl-`LlL L—. County: --
(Road Name a7'/r
umbers, Co unity, or Subdwlsion and Lot No.) DRILLING LOG DEPTH
3. OWNER From To Forrnatio Descd ion
Address 6L _�'� dZ L'3 ()
(Straret or Houle 0.) &
r4� __/C _/ �Lj A,�-71Ll ) '_L T�
City or Town State Zip Code —t-
4. DATE DRILLED10
1r) _
5. TOTAL DEPTH -�—� 2 &1<-
6. CUTTINGS COLLECTED YES ❑ NO
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO[:]
8. STATIC WATER LEVEL Below Top of Casing: FT. o
(Use '+' II Above Top of Casing) C!
9. TOP OF CASING ISFT. Above Land Surface*
*Top of casing terminated at/or below land surface requires a variance In accor- p p5
dance with 15A NCAC 2C.0118 trr�
10. YIELD (gpm): '9 1)_ METHOD OF TEST rT,
11. WATER ZONES (depth):-4 -1 Z 1
-p r,.r ^
12. CHLORINATION: Type
rt' � i�L7Amount
13. CASING:
D
Wall Thickness
Depth
From--ToFt.
Di meter or WeiphVFt. tt�n�al
From To Ft.
From To Ft.
14. GROUT:
Depth
Yateri� al _ thod
From fG— To 2er_? Ft.
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From
To Ft
in. _
From
To Ft.
In. _
From
To Ft.
In. _
16. SAND/GRAVEL PACK:
Depth
Size
From
To Ft.
From
To Ft.
17
in.
In.
In.
Material
If additional space is needed use back
CA3 ZA
LOCATION SKETCH U1 0
(Show direction and distance from at least two Staff
Roads, or other map reference points)
I DO HEREBY QE:f1,'I�TH _" " SiWEI}� V 4\( STRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
rnnlaYat tf Tl[) S !r5 )INtj TN14 G G F�1 OF THIS RECORD HAS BEEN PROVIDED TO'THE WELL OWNER.
FOR OFFICE US Y �s ,laull
Quad No: TORE OF PERSON CONSTRUCTING THE WELL DATE
Submlt orf Inai to Division of Water Quality, Groundwater Section Within 30 days
Serial No. 10n OW-1 REV. 12199
undwattgl Sect
a..6euillo R@mOnsl (1` fVfP .,.,,,,,�

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: R. CALDWELL DRILLING, INC.
WELL CONTRACTOR CERTIFICATION #2140
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable sox): Resldentlal l__�J/ Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATIO ( how sketch of the location below)
Nearest Town: "C- — Countyr
(Road Name a Nu ers, Community or Subdivision and Lot No )
3. OWNER -
Address / /n , J,
`_ . 7-.,-... C�J^ d -5
/
City or Town State Zip Code
4. DATE DRILLED 1 "l Doc�
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑ NO❑
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO❑
8. STATIC WATER LEVEL Below Top of Casing: 377 FT.
(Use '+- If Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface -
`Top or casing terminated at/or below land surface requires a variance In accor-
dance with 15A NCAC 2C.01 111
10. YIELD (gpm): [11METHOD QF TEST ex_
11. WATER ZONES (depth):
12. CHLORINATION: Type Amount
13, CASING: CT 8 7ro
DRILLING LOG
_ From To
DEPTH
Formation Description
n
Cp a
'C — Crn-)
Cal
gp
If additional space is needed use back bLSorm
s
LOCATION SKETCH C-n o
Wall Thickness
Depth � Diameteror we, IpnuFt. tertal (Show direction and distance from at {east two State
From To Ft. -�- Roads, or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Material ethod Qv
V To �L- Ft. ��'� t:
From To Ft. �+Y
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft In. In,�
From To Ft. in. In.
From To Fl. In. In.
16. SAND/GRAVEL PACK:
Depth Size Material O,
From To Ft. At
From To Ft.`
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUC N,.STANDARDS AND THAT;A;COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WEL OWNE .
�9W : __; o
r: 1W,
'a
FOR OF�G `
Quin No: SIGNATURE OF PERSON CONSTRUCTING THE WELL . DATE
dglnei to Division of Water Ouallty, Groundwater Section within 30 days
h
Serial No. I GWi REV. 12/99

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section 2 2 8 6 6S
1636 Mail Service Center - Raiei h N C 27699-1636-Ph­ [phone]
g
WELL CONSTRUCTION RECORD WELL CONTRACTOR: % ! _TJV e.
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMIT#: n- T
1. WELL USE (Check Applicable Box): Residential 13 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: w�'� ��%�r l7o County: - U 0 e,!tzf% Z. �—
(Road Name and Numbers, Community, or ubdivlsion and Lot No.) DRILLING LOG DEPTH
3. OWNER �� 1 From To Form�De3cri�tiAn
Address
treat or RouteN
or Town State Zip Code }�
4. DATE DRILLED ���
5. TOTAL DEPTH ©- -'
6. CUTTINGS COLLECTED YES ❑ NO❑
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO[:]
8. STATIC WATER LEVEL Below Top of Casing: � FT. c r
(Use '+' It Above Top of Casing)
9. TOP OF CASING ISFT. Above Land Surface* -
*Top of casing terminated at/or below land surface requires a variance In accor-
dance with 15A NCAC 2C .0118-
10. YIELD (gpm): 6'lt__ METHOD OF TEST
11. WATER ZONES (depth):
co o
12. CHLORINATION: Type ��-� - Amount 2- 73 If additional space is needed use back of form
13. CASING:
Wall Thickness
Depth Diameter or Weight/Ft. Material
From To Ft.��
From To Ft.
From To Ft.
14. GROUT:
Depth Material ethod
From To 2 Ft. D'%'� �
From To Ft.
15. SCREEN:
Depth
From To _
From To
From To
16. SAND/GRAVEL PACK:
Depth
From To _
From
17. REMARKS:
To
Diameter Slot Size Material
Ft in. in.
Ft. In. In.
Ft. In. in.
Size
Ft.
Ft.
Material
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
s �r
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION=STAND RDS, . D,THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL O NER.
�Q � i�
FOR OFFICE USE ONLY �'�`� J r
Quad No: SIGNATURE OF P RSON CONSTRUCTING THE WELL DATE
Submit, original to Division of Water Quality, Groundwater Section within 30 days
Serial No. 1n t � l GW-1 REV. 12199
� u
i � i

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section 2
1636 Mail Service Center - Raleigh, N.C. 27699.1636-Phone [phone]
D
From T
From T
15. SCREEN:
WELL CONSTRUCTION RECORD WELL CONTRACTOR: R•CALDWELL DRILLING, INC.
WELL CONTRACTOR CERTIFICATION #? 140
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable sox): Residentiai E Municipal ❑ Industrial ❑ Agricu ural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:?'/�
2. WELL LOCATION: (Show sl etch of the location below)
1.t Co
nunit yr SubdiyT on,#hd L 1 No.)
3. OWNER
City or Town Stale Zip Code
4. DATE DRILLED ll_ *3 oCJ
5. TOTAL DEPTH 9S
6. CUTTINGS COLLECTED YES ❑ NO❑
7. DOES WELL REPLACE EXISTING WELL? YES F-1 NO❑
8. STATIC WATER LEVEL Below Top of Casing: ;� I FT.
(Use'+' If Above Top of Casing)
9. TOP OF CASING IS_1_ FT. Above Land Surface'
'Top of casing terminated attor below land surface requires a variance In accor.
dance with 15A NCAC 2C .t110
10. YIELD (gpm): 16 METHOD OF TEST
11. WATER ZONES (depth):
12. CHLORINATION: Type —
Amount
13..CASING:6<,7v
Wall Thickness
Depth Diaz`}�t_er or Waight/Ft.
From_j�To Ft..2.1
From To Ft.
From To Ft.
14. GROUT:
epth Material ethod ,
o Ft.
Depth
From
To Ft
From
To Ft.
From
To Ft.
16. SAND/GRAVEL PACK:
Depth
From
To
From
To
17. REMARKS:
Diameter Slot Size Material
In. In.
In. in.
In. In.
Ft.
Ft.
Size Materfal
I DO HEREBY ONSTRUCTIl 5TI,1N4L 6,HAfJl71T L-.T�l R'i FTHICTED IN S RECORD HAS BEEN PROVIDED ROVIDED TO THE WELL 0
FOR OFFICE USfE� Y tt�t1 _
Quad No: E �G ati Sl. RE OF PERSON CONSTRUCTiNG THE WELL
SubrNt o Inal to, vislon of Water Quality, Groundwatlr Section within 30 days
DRILLING LOG DEPTH
From To Formation Description
o.
"n
r�
!:-?C-1
■C
m
O
9m
c
If additional space is needed use back Mormm
CW
LOCATION SKETCH W
W x
-1=
(Show direction and distance from at least hWStatg
Roads, or other map reference points)
a
DATE
Serial No. I GW1 REV. 12/99

''22008
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 WELLCONTRACTOR:R.CALDWELL DRILLING, INC.
WELL CONTRACTOR CERTIFICATION p, 140
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential L� Municfpal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ if Other, List Use:
2. WELL LOCATI N:: Show etch of the location below)
Nearest Town: `� ��' �� County:
(Road Nam9 arW Numbqrs, Co nity, r Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER l r 1-1_ Br"3� From To i Formation Description
Address �. _ Q — `��Ut;✓b<-w'� �
tree or o e o. rj— 2U5 �oc.'C
J"e Al1(�
'City or Town State Zip Code
4. DATE DRILLED
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES [�NO©/
7. DOES WELL REPLACE EXISTING WELL? YES [] NO�
8. STATIC WATER LEVEL Below Top of Casing: Z,_7 FT.
(Use 't' N Above Top of Casing)
9. TOP OF CASING IS�_ FT. Above Land Surface -
'Top of casing terminated at/or below land surface requires a variance In accor-
dance with 15A NCAC 2C . 18
10. YIELD (gpm): METHOD OFT44
1T t� `A
11. WATER ZONES (depth): ►v^
12. CHLORINATION: Type W(tT Amount 1 4321 If additional space Is needed use back of form
13. CASING:
Wall Thickness LOCATION SKETCH
Depth n Diar�e er or Welghtf t. Material (Show direction and distance from at least two State
From To �— Ft. —— -0\1—L Roads, or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From © To 2 n Ft.
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft In, in.
From To Ft. In. In.
From To
16. SAND/GRAVEL P
17
From To
From To
I DO HEREBY CERTIFY THAT TH13 WELL WAS CbNSTR CT D IN
CONSTRUCTION STANDARDS, AND THAT A COPY OF TECC
1 q ptek.,U,
WITH 15A NCAC 2C, WELL
PROVIDED TO THE WELL O
FOR OFFICEUSE Q t,. LY
Quad No, Rt`O PERSON CONSTRUCTING THE WELL DATE
Submit original to Division Water Quality, Groundwater Section within 30 days
Serial No. GW-1 REV. 12199

North Carolina - Department of Environment and Natural Resources • Division of Water Quality - Groundwater Section " 2 12 3 7
1636 Mail Service Center - Raleigh, N.C. 27699-1636•Phone (919) 7W-3221
WELL CONSTRUCTION RECORD WELL CONTRACTOR- R. CALDWELL DRILLING, INC.
WELL CONTRACTOR CERTIFICATION #:2140
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential E3 / Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: Sho sket yh.7 location below)
Nearest Town; County: f—
(Road Nam Numbers, Community, of S�ubdivi ion and Lot No.) DRILLING LOG DEPTH
3. OWNER �Y2 GGt`- From To _ Formation scrigtion
Address 7 (� ,�L� r) _/ 6 Z—
y or Town State Zip Code
4. DATE DRILLED
5. TOTAL DEPTH =15-
6. CUTTINGS COLLECTED YES ❑ NOE?-'
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NOEP,--
8. STATIC WATER LEVEL Below Top of Casing: FT. ® o
(Use '+' It Above Top of Casing) CD
9. TOP OF CASING IS FT. Above Land Surface- v ®�
*Top of casing terminated attor below land surface requires a variance In actor- C'- C n
dance with 15A NCAC 2C�01�18 "y®
10. YIELD (gpm): 1A_ METHOD OF TEST
11. WATER ZONES (depth): -9---R -
a.. �a
12. CHLORINATION: Type Amount It additional space is needed use back CWrm rn;o
13. CASING: `
- Wall Thickness
LOCATION SKETCH En �
or Wei h t. seria
Depthl (Show direction and distance from at least two Slate _
From To .L—Q — Ft.Roads, or other map reference points)e ((
From To Ft.
��
From To Ft.
14. GROUT:
Depth Material shod
From _n - To 2-2 FL ��P•�� cJc�
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 f F1 BY( ESA IF ) A f'HJ4 V�' *AS CONSTRUCTED IN ACCORDANCE WITH A NCAC 2C, WELL
CON TIbN Sl°TANO�RDS ANDS A� A F TV RECORD HAS BEEN PRO ED TO THE WELL OWNER.
£ �, 0 0
FOROf� USE',QNL,Yr>� _ � -
Quad No: `" IGNATURE OF PERS ONSTRUCTING THE WELL DATE
Subl,11 original to Division of Water Quality, Groundwater Section within 30 days
.•,:ry-�--�--�-GW1 REV. 12/99
Serial Noll E`.rrannritf.at-r

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section ) ram. j 9 j 7
1636 Mail Service Cepter - Raleigh, N.C. 27699.1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:R•CALDWELL DRILLING, INC.
WELL CONTRACTOR CERTIFICATION #- 1
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE Check Applictible fox): Rosidential ❑ Municipal Industrial ❑ Aprtcultural ❑ Monitoring ElRecovery (��' Heat Pump Water injection ❑ Other RIf Other, List Use:
2. WELL LOCATI N: (Show sketch of the location below) '
Noarest Town: r, r' r-� +� n County: 1y Nclrn MhQ
(Road Name and Num5era','Community, or'SubdMsion and Lot No
DRILLING LOG DEPTH
3. OWNER -
From To Formotion Description
�O
Address �-4c' ��- t�C
Q' - I 'p V0V2Dfl
J (Streetr e
10 �n 3 � c, (� j J t"C`6
City or Town plate Zip Code
4. DATE DRILLED 00
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES 0 NO[]
7. DOES WELL REPLACE EXISTING WELL? YES NO[�/
8. STATIC WATER LEVEL Below.Top of Casing: 1 FT.
a
(use •t• 9 Above Top of casing)
9. TOP OF CASING IS FT. Above Land Surface*
'Top of casing terminated at/or below land surface requires a variants In actor-
dance with 15A NCAC 2C .011•
1
10. YIELD (gpm): _143— METHOD OF TEST
rn
_
11. WATER ZONES (depth): 12 S G P rr
-o
rn
12. CHLORINATION: Type Amount 0 Z '
Paim—
It additional apace b needed use back of for
_
13. CASING:
O
Depth wallThtiickness
�� or WS
, r o� IFt. Material
LOCATION SKETCH
(Show direction and distance from at least two State
-`
From To�_ Ft, GE t)�
Roads, or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From - n To . 2 Ft. �Q N� At 1
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 HERi*, Y CEFTIFI�711�
i 1W W_ Ag CONSTRUCTED IN CCORDANCE WITH 15A NCAC 2C, WELL
CON ERE
�ii�I IS'7A�j+1',b iGOP OF THIS RECO D HAS BEEN PROVIDED TO THE WELL OWNER.
i->. r
FOR OFF1C ,E ONLY ` (� �� d
Quak1 Na I`'ll�li s �; 4 StaNATt1RE of PERSON CONSTRUCTING THE WELL DATE
Su " I or pinal a pfvisbn or water Quality. Groundwater section within 30 days
ser1111 N0. E GW-1 REV. IV"

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section ,,n
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone] ll 3 70
WELL CONSTRUCTION RECORD WELL CONTRACTOR:R • CALDWELL DRILLING, INC.
WELL CONTRACTOR CERTIFICATION #. 140
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (check Applicable Box): Residential D Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑ .
Recovery 0 Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2, WELL LOCATI/O�N (S w sketch f the location below) /J
Nearest Town: ,[! z� ���LCounty: -ti4�tic fr—
(Road Name d Numbers, Co ity, or S bd}sion and Lot No.)
3. OWNER
Address D
rest or u e o.
City or Town State Zip Code
4. DATE DRILLED
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑ NOED----
7. DOES WELL REPLACE EXISTING WELL? YES �NO❑
8. STATIC WATER LEVEL Below Top of Casing: LSD FT.
(Use •+• if Above Top of Casing)
9. TOP OF CASING IS. 4 FT. Above Land Surface'
'Top of casing terminated at/or below land surface requires a variance in accor-
dance with 15A NCAC 2C .0118
10. YIELD (gpm): -gig METHOD OF TEST _
11. WATER ZONES (depth): _ %?0 _ 20 lLl
12. CHLORINATION: Type -� `- Amount
13. CASING:
Wall Thickness
Depth or Welght/Ft. lertal
From (9 To � Ft. 5a71�
�,;U - 2 l ril C
From To Ft.
From To Ft.
14. GROUT:
Depth Material thod
From To 2-0 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:
DRILLING LOG
From To
DEPTH
Formation 0 script]
=aa —
If additional space is needed use back of form
LOCATION SKETCH c�
tU .
(Show direction and distance from at least twocSlate
Roads, or rgt"r map reference points) /
Depth Size Material
From To Ft.
From To Ft.
17. REMARKS:
I DO HEREBY I T 1 W L A109PSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTIM OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
FOR OFFICE U Ly V`11 ' � o ` ��
i i t.l.
Quad No: f
l� «Jzn
GNATURE OF PERSON CONSTRUCTING THE WELL DATE
SutxmlI dginal to Division of Water Quality, Groundwater Section Within 30 days
Serial No. @ ' GWI REV. 12l99
NO

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section 1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone (919) 7W-3221 Li Cj p
it 3 7
WELL CONSTRUCTION RECORD WELL CONTRACTOR:R. CALDWELL DRILLING, INC.
WELL CONTRACTOR CERTIFICATION #2140
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential E Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery 0 Heat Pump Water Injection ❑ Other [] If Other, List Use:
2. WELL LOCATIOfiJr (SFtow sketch f the location below)
Nearest Town:. I14 , m 7W County: c-o"
(Road Name and Numbers, Cor moty, or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER From To Formatlo Descd lion
Address —� b — ✓��+
tree or ou a o. 7k(57 72oc �C
City or Town State Zip Code
4. DATE DRILLED O �v°
5. TOTAL DEPTH o
6. CUTTINGS COLLECTED YES ❑ NOD/ —
7. DOES WELL REPLACE EXISTING WELL? YE4ofaslng)
NO❑ -
8. STATIC WATER LEVEL Below Top of Casing:FT. r-+ >-
(Use '+' it Above T-`�
9. TOP OF CASING IS (_ FT. Above Land Surface* lv _
'Top of casing terminated atlor below land surface requires a variance In accor-
dance with 15A NCAC 2C .0118 + _ - —.
10. YIELD (gpm): _27— METHOD OF TEST'
11. WATER ZONES (depth):
12. CHLORINATION: Type Amount It additional space is needed use back of loan =�
0
13. CASING:
Wall Thickness LOCATION SKETCH
Depth Di ter or Weight/Ft. �M1a�te�rriial (Show direction and distance from at least two State
From ' J _—To _77Ft. J —� Roads, or other map reference points)
From To Ft.
From To Ft..
14. GROUT:
Depth Material Method
From 0 To -42 Ft.
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material C �uJ �c45►��'j
From To Ft in. in. JJ
From To Ft. in. In.
From To Ft. in. in.
16. SAND/GRAVEL PACK:
Depth Size Material '%
From To Ft. 4 " ��
From To Ft.
17. REMARKS:
I DO HEREBY CERTIFY 7_HAT_.THIS WE - CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C. WELL
CONST T11DSS N COPY OF THIS RECORD H EEN PROVIDED T E WELL OWN ff.
FOR OFF SE ONLY
Quad No: h n; ijl SIGNATURE OF PERSON CONSTRUCTIN DATE
��� t riginal to Division of Water Quality, Groundwater Section Within 30 days
Serial No. _ GW1 REV. 12/99

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section r- �• 9 .�
1636 Mail Service Center- Raleigh, N.C. 27699.1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: R R. CALDWELL DRILLING, INC.
WELL CONTRACTOR CERTIFICATION #?140
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential Er Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATI f (Show ske h of the location below)
Nearest Town: 61 tJ r( re
County: �I ,l. vtCP, 1— a <'
(Road Name Numbers, mlmul1n ty, or Subdivision and Lot No.)
DRILLING LOG
DEPTH
3. OWNER - v' t[! �_�
Address',
From To
C9 _ U) Jy'b
Fomw}Ion Description
tree u e o.
_
(J� .• ��
City o Town State Zip Code
4. DATE DRILLED
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
8. STATIC WATER LEVEL Below Top of Casing: r�, FT.
(Use '+' It Above Top of Casing)
9. TOP OF CASING
c�
Is FT. Above Land Surface*
e_
*Top of of casing terminated at/or below land surface requires a varlance In accor-
dance with 15A NCAC 2C .0118
_
10. YIELD (gpm): t" S_ METHOO OF TEST
11. WATER ZONES (depth): ;:1-1 15
1 7—
12. CHLORINATION: Type Amount e
CJ --i
It additional space is needed use back of form c
13. CASING:
Depth Dlametr
From f To'' Ft.
From To Ft.
From To Ft.
14. GROUT:
Depth
From �'y To Ft.
From To Ft.
15. SCREEN:
Wall Thickness LOCATION SKETCH
or WelghVFI. t al (Show direction and distance from at least two State
—-- Roads, or other map reference points)
Material Method
Depth
Diameter
From —To—Ft.
In.
From To
Ft. in.
From To
Ft. In.
16. SAND/GRAVEL PACK:
Depth
Size
Slot Size Material
In. \
In. f
In.
7 �a\
Material t
lit r1 �?'u, lCl 1 T L ell.
From To Ft. 1
From To Ft. i
17. REMARKS:
TRUCTED I HEREBY C RT FY�l H� T - T�CA F THIS RECORD H R B EN P OVIDED TO THE WELL OWNER.
CEW
CONSTRUCTIO � �
FOR OFFICE US LY ` f
��11nn
Quad No: ''�' /� �uttn ATURE OF PERSO CON RUCTING THE WELL %DATE'
Submit o Inal t Ol 1 [on of Water Quality, Gioundwater Section within 30 days
Serial No. GWl REV. 12/99

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section J C'
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone] U
WELL CONSTRUCTION RECORD WELL CONTRACTOR:R.CALDWELL DRILLING, INC.
WELL CONTRACTOR CERTIFICATION #. 140
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential D Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATIOf ' (Sjaow sk5. ,f the location below)
Nearest Tvwn:o e r1(�/ County:
(Road Name Numb rs, Co or bdiv(sion and Lol No.) DRILLING LOG DEPTH
3. OWNER - From To Formation gesc ption
Address
tree r ou e yy" .3-5� "5- r
r
City or Town State Zip Code
4. DATE DRILLED
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES O NOEJ-- CZ)
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NODS
8. STATIC WATER LEVEL Below Top of Casing: FT. _
(Use '+' If Above Top of Casing)
9. TOP OF CASING ISFT. Above Land Surface' I
'Top of casing terminated at/or below land surface requires a variance In accor-
dance with 15A NCAC 29
0118
10. YIELD (gpm): Aaff& METHOD OF TEST
11. WATER ZONES (depth): -2 6 12
0
12. CHLORINATION: Type Amount It additional space is needed use back of form
13. CASING:
Wall Thickness LOCATION SKETCH
Depth Diameter or Weight/Ft. Material (Show direction and distance from at least tto
From "L' To —— Ft.. -2 ( jell Roads, other map reference points)
From To Ft. _
From - To Ft. 14. GROUT:
Depth Material Method
From 0To 2-0 Ft. 1 4*e-,v From To Ft.j,7
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft in. in.
From To Ft. in. In.
From To _ Ft. In. in. Wy
16. SAND/GRAVEL PACK: \\
Depth Size Material
From To Ft.
From To Ft.
17. REMARKS:
I DO HEREBY CESTI(-Y-TH AT THIS.WELL,WAS�GOtISTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTI . �l,)TtDA11D!EA$D I@A?AlHIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FF01IROFFICE U LYo: ii(t GNATURE OF PERSON CONSTRUCTING THE WELL DATE
ubmit o Division of Water Quality, Groundwater Section within 30 days
GW-1 REV. IV99

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section 20571
1636 Mail Service Center - Raleigh, N.C. 27699.1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:R.CALDWELL DRILLING, INC.
WELL CONTRACTOR CERTIFICATION #? 140
STATE WELL CONSTRUCTION PERMiT#:
1. WELL USE (Check Applicable Box): Residential ❑Z Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show ske�tt P (the location below)
Nearest Town: �� 2* N �4 County:
(Road Name and qumbers, Comm fly, Subdivision and Lot No.) DRILLING LOG
3. OWNER From To
Address 6 14
(Sueet or HOU18 NO ����
�•� z���2�-7 q
City or Town State Zip Code
4. DATE DRILLED
5. TOTAL DEPTH 2 D
6. CUTTINGS COLLECTED YES [:3 NOC�' _
7. DOES WELL REPLACE EXISTING WELL? YES NO
8. STATIC WATER LEVEL Below Top of Casing: FT.
(Use'+' If Above Top of Casing)
9. TOP OF CASING IS�_ FT. Above Land Surface -
•Top of casing terminated atlor below land surface requires a variance In accor.
dance with 15A NCAC 2C .0118
10. YIELD (gpm): -42-- METHOD OF TEST
11 WATER ZONES (depth): - ! 4
12. CHLORINATION: Type Amount��
13. CASING:
Wall Thickness
Depth Diameter or Wetght/Ft. Material
From l_L_ To 9- / Ft.. L- _ - 2 i c'_ C
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From __(9 To 2- 69 Ft. C?4,1eti T -2c �Z
From To
15. SCREEN:
Depth
From To Ft
From To Ft.
Ft.
Diameter Slot Size Material
in. in.
In. In.
From To Ft. in. In.
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
DEPTH
Fonnatign Description
%c v�
c�a
If additional space Is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least two State
From To Ft. \ J
17. REMARKS:
ce points)
I DO HEREBY C -BT1W—TH4T THIS -WELL WAS CQN,- TRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTIO Nt�R�, * CC 7V7
O - HAS BEEN PROVIDED TO E WELL OWNER.
FOR OFFICE US Y
Quad No: �i� ;�. I aj ) ATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit orf NO Ivislon of Water Ouality, Groundwater Section Within 30 days
Serial No. GW-1 REV. 12199

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section , ; 9 U 3 9
1636 Mail Service Center • Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:R.CALDWELL DRILLING, INC.
WELL CONTRACTOR CERTIFICATION #2140
STATE WELL CONSTRUCTION PERMIT#:
1, WELL USE (Check applicable Box): Residential E_K Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATIO : (Sh w sketch of the location below)
N st Town: County:
�c l
(Road Name d Numbers. Community, or Su rvision ari<Lot No.)
3. OWNER7/GJ.en�ttiytM�d
Address '�, r y2.C�1 ��.a�.1 gl-F' AL4
'CitJ or T(Vwn late Zip C6de
4. DATE DRILLED tp
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑ NOr--
7. DOES WELL REPLACE EXISTING WELL? YES NO❑
8. STATIC WATER LEVEL Below Top of Casing: �Vo FT.
(Use '+' If 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 2C .0118 ' /ice r
10. YIELD (gpm): . METHOD OF TEST f'�
11. WATER ZONES (depth): 1
12. CHLORINATION: Type Cr-1 l I 1,t4jAmount
13. CASING:
Wall Thickness
Depth DI ter or WeighVFI. M rfal
From To 7 D Ft.�
From To Ft.
From To Ft.
14. GROUT:
DRILLING LOG DEPTH
From To ormationCescrfpr.
J
C :J
If additional space is needed use back�borm
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
G�c�sr.
Depth Material Method
From 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 Material
From To Ft.
From To Ft.
17. REMARKS: i
i DO ISTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTi NDARDS, AND THAT A OF THIS RECORD HAS BEEN P OVIDED TO THE WELL OWN R.
ZICO
FOR OFFICE U Ly . )
Quad No: S NATURE OF PERSON ONSTKUCTING THE WELL ATE
y�Exrd gin ai o Division of Water Quality, Groundwater Section within 30 days
Sorlal No. Grot dVM8t 011 GW-1 REV. 12/99
t,vi a water filI1fFiM

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section t/) 4 n
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone] �" •J t ' 1
WELL CONSTRUCTION RECORD WELL CONTRACTOR:R . CALDWELL DRILLING, INC.
WELL CONTRACTOR CERTIFICATION #. 140
STATE WELL CONSTRUCTION PERMIT#: -
1. WELL USE (Check Applicable Box): Residentialk'J— Municipal ❑ Industrial ❑ Agricrultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection [D Other ❑ If Other, List Use: "A,4 Lp:4,4k!- L
2. WELL LOCATIO (Sho ch of the location below)
Neare,4t Town: County:
eve
(Road Name and umb is, ComrrWnI , or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER From To Form tlon Description
Address �� a"Lr i t I- 5 4� n ��3ZIS6e,0
c tree�or ou o. �`�i+ - for i� f�'rz .� , �.•
City or Town Sta a Code 1 , r~
4. DATE DRILLED- Z�
5. TOTAL DEPTH 'X a'5 ' —° ). y ?' ,
6. CUTTINGS COLLECTED YES ❑ NO� �.r
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NOM
8. STATIC WATER LEVEL Below Top of Casing: (n o FT.
(Use '+' It Above Top of Casing)
9. TOP OF CASING IS--- FT. Above Land Surface*
*Top of casing terminated at/or below land surface requires a variance In accor-
dance with 15A NCAC 2C .0119 1
10. YIELD (gpm): .4-0 METHOD OF TEST-
11. WATER ZONES (depth): k o C F rti`1
��o o 3 G (a cyl
12. CHLORINATION: Type §zAmount h' C It additional space Is needed use back of (drtn—;
13. CASING:
Wall Thickness LOCATION SKETCH
Depth DI1neeff o elght/Ft. Material (Show direction and distance from at least two State
From To `� Ft. —-� Roads, or other map reference points)
From To Ft.
From To Ft. )
14. GROUT: o n) t;
Depth, Material fvlethod'
From To '? � Ft. rrt.t,��ro,r 6,'
o!
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft in. In. 0
c•J
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 Cl! IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTIO C0 F T RECORD HAS BEENPROVIDEDTO THE WELL OWNER.
r(s)
R OFFICEX
USE
$d No:f. 8 � (1'l lI ATURE OF PERSON CONSTRUCTING THE WELL DATE
$ubmiI orl nal Division of Water Quality, Groundwater Section Within 30 days
ial No. OW-1 REV. 12t99

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section , a 9834
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:R • CALDWELL DRILLING, INC.
WELL CONTRACTOR CERTIFICATION #? 140
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residentialz 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: A51,IEV 1 1_ L- County: &(V
(Road Name,�m Numbers, Community, orr Subdivlsion and Lot No.)
3. OWNER _s. 8 � /,q� (0/7!%/I�S
Address zzoo
�tr_ ,- tree � to 1494
e0 0
City or Town State Zip Code
4. DATE DRILLED 1 D- 5 o 0
5. TOTAL DEPTH L d 'S"
6. CUTTINGS COLLECTED YES (I NO❑
7. DOES WELL REPLACE EXISTING WELL? YES MNOF1
8. STATIC WATER LEVEL Below Top of Casing: iVa FT.
(Use '+' it Above Top of Casing)
9. TOP OF CASING IS�_ . FT. Above Land Surface'
'Top of casing terminated at/or below land surface requires a variance In accor-
dance with 15A NCAC 2C .,01r 18 K
r_
10. YIELD (gpm): � METHOD OF TEST �_
11. WATER ZONES (depth): - aV2 G Or^
12. CHLORINATION: Type - FIt.d- Amount
13. CASING:
Wall Thickness
Depth Dia t r or WgIphVFt.edal
From To 35 Ft. 6 T S 0 l r vv
From To Ft.
From To Ft.
14. GROUT:
Depth ; Material ethod
From To �% �_ Ft. L�N 1 UAC D
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From -To -Ft- in. in.
From -To -Ft.- In. in.
From To Ft. In.
16. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To Ft.
17. REMARKS:
I DO HEREBY CE
CONSTRUCTION
FOR OFFICE USE _
Quad No: �UV
Submit or
Serial No. _P __
in.
Material
DRILLING LOG
From To
2Q
'LtiY�% bs
DEPTH
Formation Description
-e-C _
7 Gen
�--I
a --
It additional space Is needed use back oMrm L4
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
n /L P w.tA
a
IN ACCORDANCE WITH 15A NCAC 2C, WELL
CORD HAS BEEN PROVIDED TO THE WELL OWNER.
o_ 6 06
OF PERSON CONSTRUCTING THTWELL DATE
of Water Quality, Groundwater Section within 30 days
GW-1 REV. 12/99

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:R.CALDWELL DRILLING, INC.
WELL CONTRACTOR CERTIFICATION #? 140 —
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATN:r,(Show., tch of the location below)
Nearest Town: 'YY "r Q County: •�j�' ^^-'
(Road Name pd Numbers, Community, c Subdivision and Lot No.) DRILLING LOG !DEPTH
3. OWNER Q? From '`l To Formation Description
Address �3 �}ZIti
�X V61reet or 9t _No.)4 $ 7 39-
City or Town State Zip Code
4. DATE DRILLED D L04-1
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES NO❑
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
8. STATIC WATER LEVEL Below Top of Casing: FT. © -
f (Use '+' if Above Top of Casing)
9. TOP OF CASING is FT. Above Land Surface•
•Top of casing terminated atlor below land surface requires a variance In accor-
dance with 15A NCAC 2C .0
10. YIELD (gpm): '� MET/HOD OF TEST _
11. WATER ZONES (depth): ! x S� ✓� . x j r -
e (:,:.
12. CHLORINATION: Type Amount 3 If additional space is needed use back ON
13. CASING: o
Wall Thickness LOCATION SKETCH
�Depth�ti Dia eter or Welght/Ft. tgat I (Show direction and distance from at least two State
From To L"-2 Ft. Yz T ( N Roads, or other map reference points)
From To Ft.
From To Ft. 1�
14. GROUT:
Depth t Mated Meth
From To Ft.y
From To e Ft. v V
15. SCREEN:
Depth
Diameter
From'
—To —Ft—
In.
From
To
Ft. in.
From
To
Ft: • in.
16. SAND/GRAVEL
PACK:
Depth
Size
From
To
Ft.
From
To
Ft.
17. REMARKS:
A�
DO HEREBY Cl,.r.rIi1}
CONSTRUCTIO
DARC
t, r
FOR OFFICE US
Y
Quad No:
n
Serial No,
he
Slot Size Material
AND THAT A
8 2000
In.
In.
In.
Material
FAATURE
TED IN ACCORDAN TH 15A NCAC 2C, WELL
RECORD H B N P OVIDED TO THE WELL OWNER.
ERSON CON CTING THE WELL o ter Ouality, Groundwater Section within 30 days
GW1 REV. 12/99

North Carolina - Department of Environment and Natural Resources - Division of Water Quality • Groundwater Section �„ �, 9 8 3 3
1636 Mail Service Center • Raleigh, N.C. 27699-1636•Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: R . CALDWELL DRILLING, INC.
WELL CONTRACTOR CERTIFICATION #2140
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (check Applicable Box): Residential Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Shy s!S$tcheolVecation below) /�Nearest Town: _ Q County: _�(��� �Ki Y
(Road Name an mbers, Community, or Subdivision and Lot No.)
DRILLING LOG DEPTH
3. OWNER o-u1
From To Formation Descri ion
Address l fe). 6 _ w
( ��
str eior Houle
� (i,, O =Z:)(d A � d
` rj'
City or Town State Zip Code
4. DATE DRILLED r--
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑ NOQ-'—
REPLACE EXISTING WELL? YES NO
7. DOES WELL ❑
8. STATIC WATER LEVEL Below Top of Casing: FT.
(Use'+' If Above Top of Casing)
9. TOP OF CASING IS�_ FT. Above Land Surface'
-_
'Top of casing terminated at/or below land surface requires a variance In accor-
dance with 15A NCAC 2C .0118
`1
10. YIELD (gpm): X 0 METHOD OF TEST _�
11. WATER ZONES (depth):
12. CHLORINATION: Type Amount
It additional space is needed use back d rm
13. CASING:
LOCATION SKETCH
Wall Thickness
Depth Dl,,meter or Welght/Ft. terial
{��
' 1
(Show direction and distance from at least two State
(�/j
From m—To _219 Ft. �' 57,0�?-21
Roads, or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Material thod
From To 2_ Ft.�8�/
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.
Material
From To Ft.I
17. REMARKS:
I DO HEREBY CERTIFY THAT THUS W GQ?tJSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTIO TAN C bF THIS R HAS BEEN PROVIDED O THE WELL OWNER.
FOR OFFICE VS Quad No: t �, ji Ii �� l 1 ATUHE OF PERSON CONSTRUCTING THE CL DATE
SubmlI od i o ivislon of Water Quality, Groundwater Section within 30 days
Serial No. GW1 REV. 12/99

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section v 3 2 6
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:R.CALDWELL DRILLING, INC.
2140
WELL CONTRACTOR CERTIFICATION #.
STATE WELL CONSTRUCTION PERMIT#;
1. WELL USE (Check Applicable Box): Residential Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATigN: ( ow sket of the location below)
Nearest Town: - 4131, County: r ✓+� ��+ '�
(Road Name a9d Nr�mbers Co unity, or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER f' '+t',t+/ From To Formation Description
Address
tree or o o.
City or Town Stale Zip Code12-1
-
4. DATE DRILLED 611
_
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑ NOED-' +_--
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 + Z FT. Above Land Surface* --1
'Top of casing terminated at/or below land surface requires a variance In accor-
dance with 15A NCAC 2C ,0118 +
10. YIELD (gpm): 140 METHOD OF EST �
11. WATER ZONES (depth): `2 54a---'1 t `
12. CHLORINATION: Type - u+��- Amount 012L—
13. CASING:
Wall Thickness
Depth Diammeter or Welght/Ft. Material
From--e, 2 To Ft.
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From _0 To Z-0 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.
Material
If additional space is needed use back of ='
(Show direction and distance f m at least two State
Roads, or other map refe Vince points)
From _ To Ft.
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUC IN
CONSTRUCTION STANDARDS, AND THAT A COPY OF ECC
FOR OFFICE USE ONLY i
Quad No: I SIATVKE C
SubmU original to Division of
Serial No.
WITH 15A NCAC 2C, WELL
PROVIDED TO THE WELL, O
SON CONSTRUCTING THE WELL I
Quality, Groundwater Section within 30 days
DATE
GW-1 REV. 12/99

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section �+ l C? C
1636 Mail Service Center - Raleigh, N.C. 27699-1636•Phone [phone] U Ct
WELL CONSTRUCTION RECORD WELLCONTRACTOR:R.CALDWELL DRILLING, INC.
WELL CONTRACTOR CERTIFICATION #? 140
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential E 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: C\ 'A' \- tF'; x'?County: v (\J� 867
(Road Name and umbers, Commune ) or Subdivision and Lot No.) DRILLING LOG
3. OWNER G- From To
�
Address
atree or ou a o. q g
°IU� -n C, d 7/S
City or Town State Zip Code a g
4. DATE DRILLED : c —
5. TOTAL DEPTH -:E�y
6. CUTTINGS COLLECTED YES ❑ NO❑
7. DOES WELL REPLACE EXISTING WELL? YES NO
8 STATIC WATER LEVEL Below To of Casin • $ FT
DEPTH
Formation Description
IDJ>4L(�) L,)"E�
G�tYe
d(- G Pr--\
GZANt i e
(Use '+' It Above Top of Casing) r—s
9. TOP OF CASING IS a FT. Above Land Surface• c a
•Top of casing terminated at/or below land surface requires a variance In actor- = r
dance with 15A NCAC 2C.018
10. YIELD (gpm): METHOT OF TEST
11. WATER ZONES (depth):
12. CHLORINATION: Type "t o Amounlc ° It additional space Is needed use back of ft r
13. CASING:
Wall Thickness
Depth Diameter or W Ig t/Ft. MMate� (Show
t From To — Ft. ff Sb�` �Y R,
From To Ft. Xy
From To Ft. 1Yt�-�F
14. GROUT:
Depth Material ethod
From -1 C C m o J �c
—Ft.
D
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: — .. _ .... _�
IDO HEREBY
DTHAT A
201A
FOR OFFICE UFE OPLY
Quad No: I A ...!
Serial No.
LOCATION SKETCH
cs1 ri
and distance from at least two State "--
ther map reference points)
STRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
OF t ECORD HAS BEEN PROVIDED TO THE WELL OWNER.
m q -)S —��
0NATURE OF PERSON CONSTRUCTING THE WELL DATE
rigin to Division of Water Quality, Groundwater Section Within 30 days
„« GW-1 REV. 12/99

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636•Phone (919) 7W-3221 ,.,, J. 7 7 2 0
WELL CONSTRUCTION RECORD WELL CONTRACTOR:R. CALDWELL DRILLING, INC .
WELL CONTRACTOR CERTIFICATION #? 140
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential ErmunicipalD Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other M If Other, List Use:
2. WELL LOCAT�ow
Nearest Town: � j talc of the location below)
County: s W &0
(Road Nam"ge Num ers, Comm uSity, Slibdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER t;�-C� f f'1 . From To I Formation Description
Address '�' t; ✓�'Gh
, `r tr et or qy a o.,,, Z� L
City or Town Stale Zip Code
4. DATE DRILLED
5. TOTAL DEPTH -
6. CUTTINGS COLLECTED YES ❑ NOQ/ o
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO �n—;;
8. STATIC WATER LEVEL Below Top of Casing: -5<'() FT.
( (Use '+' If Above Top of Casing)
9. TOP OF CASING IS 1 FT. Above Land Surface -
*Top
•Top of casing terminated at/or below land surface requires a variance In accor-
dance with 15A NCAC 2C .0116
10. YIELD (gpm): METHOD OF TEST _ a� -
11. WATER ZONES (depth):
0
12. CHLORINATION: Type 7 Amount GA - It additional space Is needed use back of form
13. CASING:
w u Th' k LOCATION SKET(�!H
Depth Diameter
From To —E—t— Ft.
From To Ft.
From To Ft.
14. GROUT:
Depth�0
From To Ft.
From To Ft,
15. SCREEN:
a cc ness
or WelghVFt. Material
Material Method
Depth
Diameter
From
To
Ft in.
From
To
Ft. in.
From
To
Ft:- in.
16. SAND/GRAVEL PACK:
Depth
Size
From
To
Ft.
From
To
Ft.
17. REMARKS:_
irection and distance fro at Ie4st two Slate
s, or other m jam+ .points)
Slot Size Material
In.
In.
In.
Material
— ltdrol'11C
1 DO HEREBY CERTIFY,,THATTHIS ,WELL WAS CONSTRUJISECOR
N A OR ANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS; AND THAT'A COPY OFT HA BEEN PROVIDED TO THE WELL O NE..,, .
"
FOR OFFICE USE ONLY 66� �fy
Quad No: ° P" S E OF ERSON CONSTRUCTING THE WELL DATE
Submit odgir& to Division of Afaler Quality, Groundwater Section within 30 days
Serial No. GW1 REV. 12/99

North Carolina - Department of Environment and Natural Resources - Division of Water Quality . Groundwater Section e . .r rJ 1 �]
1636 Mail Service Center - Raleigh, N.C. 27699.1636•Phone [phone] �— -� i 7 1 J
WELL CONSTRUCTION RECORD WELL CONTRACTOR: R•CALDWELL DRILLING, INC.
WELL CONTRACTOR CERTIFICATION M. 14 0
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): ResidentialEfmunicipalEl Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: County:
(Road Name
3. OWNER
DRILLING LOG
DEPTH
Formation Description
!.H
,a.L,ry r rr f rN-�/t. A"m7 / i v cXn r r I
City or Town Stat® Zip Code --
4. DATE DRILLED o-DO
5. TOTAL DEPTH 6. CUTTINGS COLLECTED YESF] NO[�
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NOEE
8. STATIC WATER LEVEL Below Top of Casing: FT.
,���� (use '+• M 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 2ClQita — ! =� =
(9P ) �j ��.
10. YIELD m : M HOO OF TEST + �
11. WATER ZONES (depth): _m % S3 io
12. CHLORINATION: Type Amount If additional space is needed use back of form
13. CASING:
Wall Thickness
+ Depth 5.2_ Diameter or Welght/Ft. Material
From To-Ft.-
From- To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From 0 To ZO Ft.
From To Ft.
15. SCREEN:
Depth
Diameter
From To
Ft in.
From To
Ft. in.
From To
Ft: _ In.
16. SAND/GRAVEL PACK:
Depth
Size
Slot Size Material
LOCATION SKETCH
(Show direct n and distance from at least two State
Roads, or ther map reference points)
ZJ
1�4K A�&&
From To Ft.
i ` 81ir,n
From To Ft. ,'rr
17. REMARKS:
I DO HEREBY CERTI
CONSTRUCTION ST
FOR OFFICE USE ONLY
Quad No:
Serial No.
in.
In.
In.
Material
7 THIS WELL WAS, CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
DS, AND TNAT'A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
F 2 l I SIGNATURE OF PERSON CONSTRUCTING THE WELL GATE
Subrnil original to Division of Water Quality, Groundwater Section within 30 days
GWi REV. 12/99

North Carolina • Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section I r!
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone] c_ J.�f 7 2 1
WELL CONSTRUCTION RECORD WELL CONTRACTOR:R. CALDWELL DRILLING, INC.
WELL CONTRACTOR CERTIFICATION #. 2140
STATE WELL CONSTRUCTION PERMIT#: _
1. WELL USE (Check Applicable Box): Resldential[_Z�r Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCA'
Nearest Town:
3. OWNER
Address
or
of the location below) /
County:
or Subdivision and Lot No.)
Ciffor Town State Zip Code
4. DATE DRILLED"�v
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑ NO❑i�
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NOEf If
8. STATIC WATER LEVEL Below Top of Casing: 3;� FT.
f (Use '.,' it Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface*
*Top of casing terminated atlor below land surface requires a variance In accor-
dance with 15A NCAC 20.011E
10. YIELD (gpm): 15 MEqHOD OF TE5I k e I_
11. WATER ZONES (depth):
12. CHLORINATION: Type _FA _ Amount
13. CASING: )'� e Z
Ir
Wall Thickness
Depth Diameter or W hVF .
From To �3 Ft. __Z_--
From To Ft.
From To Ft.
14. GROUT:
Depth /ateria
From To � o FL
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: - -
DRILLING LOG
From To
DEPTH
Formation Description
rri
Z7
r�;_
.,
'N ..
n
If additional space is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least two State
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION ST I �DgRDS,�MO T�IA'� A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY `3 a
Quad No: j' '7(t SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Ouallty, Groundwater Section Within 30 days
Serial No. GW1 REV. iv99

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section '� 1 '1 d
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:R • CALDWELL DRILLING, INC.
WELL CONTRACTOR CERTIFICATION N. 14 0
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential u Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: County: U A� CV M
k L� " 1 ( Ie NC,
(Road Name and Numbers, Communi r Subdivision and Lot No.) DRILLING LOG
J. OWNER TTcr el a /Z i�Ar� From To
Address Q
(blreet or Houle No. 42 C)
., �►�
City or Town State Zip Code �
4. DATE DRILLED e:— b l D .— l �
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑ NO❑ _
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO❑ _
8. STATIC WATER LEVEL Below Top of Casing: FT.
1 (Use '+' If 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 2C .011a I
Agricultural ❑ Monitoring ❑
10. YIELD (gpm): �,Q METHOD OF TEST 2K l 6s',-.
11. WATER ZONES (depth):
12. CHLORINATION: Type C-1-3
13. CASING:
Wall Thickness
Depth Ola t r or We- _ IghvFt.
FromTo _�� Ft.a.�
From To Ft.
From To Ft.
14. GROUT:
DEPTH
If additional space is needed use back of ggn cr,
r� —
o
LOCATION SKETCH C)
MAterial (Show direction and distance from at least t St�te
Tdt 1''1 wlo n r d 100
From
Depth Material
To __,Q Ft. �'P�(�1�� ►�
W��q
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 ISA NCAC 2C, WELL
CONSTRUCTION kTANDgADSt A�D �H ' COPY OF THjS RECO D HAS BEEN PROVIDED TO THE WELL OWN A.
FOR OFFICE USE'' NL'Y
Quad No: i s;' ' j SIGN, TORE OF PERSON CONSTRUCTING THE WELL DATE
Ep I QSu (�� 1 original to Divislon of Water Quality, Groundwater section within 30 days
Serial No. GW-1 REV. 12/99
,Id-vo

North Carolina •Department of Environment and Natural Resources -Division of Water Quality -Groundwater Section
i'1531
1636 Mail Service Center . Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELLCONTRACTOR:R.CALDWELL DRILLING, INC.
WELL CONTRACTOR CERTIFICATION #? 140
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch ff the location below)
NearestTown: )� u-r-��� �`"� s - - County:
(Road Name a d Numbers, Community, or Subdivision and Lot No.)
3. OWNER /u�-�
Address I (, C) -/
•., mireei or
DRILLING LOG DEPTH
From To Duration Description
­7- © 1. " "
_3 — 240-;
City or Town tale Zip Code
4. DATE DRILLED
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑ NO
-=
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
8. STATIC WATER LEVEL Below Top of Casing: FT.
_!J�G
(Use '+' It Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface-
•Top of casing terminated at/or below land surface requires a variance In accor-
dance with 15A NCAC 2C .0118 V.N
10. YIELD (gpm): _26: M HOD OF TEST
r.;
11. WATER ZONES (depth):cz
12. CHLORINATION: Type )IAmountONE If additional space is needed use back of H5t'm
13. CASING:
Wall Thickness
Depth
16
Diameter or Weight/Ft. Material
From
To
Ft.
From
To
Ft.
From
To
Ft.
14. GROUT:
Dept
Material Method
®
�`s
From
To
Ft.
From
To
Ft.
15. SCREEN:
Depth
Diameter
From
To
Ft in.
From
To
Ft. in.
From
To
Ft: In.
16. SAND/GRAVEL PACK:
Depth
Size
From
To
Ft.
From
To
Ft.
17. REMARKS:-
_-
I DO HEREBY
Slot Size Material
In.
In.
in.
Material
..WAS-,CONSTRU. TED IN p
FOR OFFICE USE ONI
Quad No: iLY SIP 1 8 2000
Submil on
Serial No.
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other mapref9rence points)
t
7 �/ Z)
15A NCAC 2C, WELL
DED TO THE WELL 0
JATURE F P ON CbNSTRUCTiNG THE WELL / DATE
Division of Way
a Quality, Groundwater Section Within 30 days
GW1 REV. 12/99

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section ' t`J r) 0)
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone] �— i 0 "1 r..
WELL CONSTRUCTION RECORD WELL CONTRACTOR:R • CALDWELL DRILLING, INC.
WELL CONTRACTOR CERTIFICATION #? 140
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check applicable sox): Residential 0 Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ It Other, List Use:
2. WELL LOCATION: (Show sketch of the location below) (�
Nearest Town: LL @ A 1) JC, A V � L. I c County: �C�V � C o rr. (2, G
(Road Name and Numbers, Community, or Subdivision and Lot No.)
DRILLING LOG DEPTH
3. OWNER N L 1_•E`(J S �A E LZ v rJ
From d To n Formation Description
Address 14 t M u k-e IA la t L 1Q 0©
.✓�L u�� � `'`
(Street or Houte o.
y jUj L
City or Town Stale Zip Code
4. DATE DRILLED
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑ NO�
r°
7. DOES WELL REPLACE EXISTING WELL? YES, NO❑
8. STATIC WATER LEVEL Below Top of Casing::
asing: �i FT.
_C/�
,�,� (Use '+' if Above Top of Casing)
9. TOP OF CASING ISM— FT. Above Land Surface'—t
r
•Top of casing terminated atfor below land surface requires a variance In accor-
dance with 15A NCAC 2C .0118
10. YIELD (gpm): METH0.4 OF TEST'
--
11. WATER ZONES (depth): 2T��+}'
12. CHLORINATION: Type f4I�
yp Amount
If additional space is needed use back of fdr'� CD
13. CASING:
Wall Thickness LOCATION SKETCH
Depth Diameter or Welght/R. Material (Show direction and distance from at least two State
From To � Ft. Roads, or other map reference points
From To Ft.
From To Ft,
14. GROUT:
Depth
From _� To 2L Ft.
From To Ft.
15. SCREEN:
Material Method
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 THA7:THIS Vy f l_L WAS CONSTRUCTED
CONSTRUCTION STANDARDS, AND THAT A C0►'Y OF THIS C
FOR OFFICE USE ONLY ; '
2�i I r� ri
Quad No: , y �p I� t �t1�� SIpNATU PER
Submit original to Division of Water
Serial No..I.
15A NCAC 2C, WELL
DED TO THE WELL OWNER.
INSTRUCTING THE WELL DATE
Groundwater Section within 30 days
GWI REV. 12199

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section 0 1 * (j K
1636 Mail Service Center - Raleigh, N.C. 27699-1636•Phone [phone]� j v 0—
WELL CONSTRUCTION RECORD WELLCONTRACTOR:R.CALDWELL DRILLING, INC.
WELL CONTRACTOR CERTIFICATION #? 140
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential ❑ Municipal ❑ Industrial ❑ A ncultural ❑ Monito ' g
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use: ee+n _
lot
�sT i e l k cte t�L
2. WELL LOCATIO (Zh w sketcfl qt the location below)
0 l I ��c.� �
N�arest Town: � � County: �.
�5 ' )IJ , A-tM O'D I R o,�
(Road Name a d Numbers, Community, or Subdivisionus and Lot No.) DRILLING LOG
3. OWNER S From To
Address �n C) ` _3 0
(Street or HOUte o. N' n � cy _ �D
City or Town State Yv lZip Code _
4. DATE DRILLED 2 L
5. TOTAL DEPTH .7 ' �;— LLD "
6. CUTTINGS COLLECTED YES ❑ NO❑ �2 It, t)
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO❑ 01 �.jV
8. STATIC WATER LEVEL Below Top of Casing: FT.
(Use'+' If Above Top of Casing)
9. TOP OF CASING ISFT. Above Land Surface -
'Top of casing terminated at/or below land surface requires a variance in accor-
DEPTH
Formation D scription
RN
dance with 15A NCAC 2C . 18
10. YIELD (gp- METH D OF TEST
11. WATER ZONES (depth): I fl L2 S
12. CHLORINATION: Type ( Amount
13. CASING:
Wall Thickness
Depth Diiame�tef or Weight/Ft. Material t
FromToFt.—+-P—//
From To Ft.
From To Ft.
14. GROUT:
Depth Material_ ethod
From To 7_0_ Ft.
From
To
15. SCREEN:
Depth
From
To _
From
To _
Ft.
Diameter Slot Size
Ft In.
Ft. in.
From To Ft: in. _
16. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To Ft.
Material
in.
In.
In.
Material
If additional space is needed use back of forrfP3
LOCATION SKETCH t!
(Show direction and distance from at least two Sty C
Roads, or other map reference points) �1 �"
C- o
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS REC RD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Quad No: SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Ouality. Groundwater Section within 30 days
Serial No. GW-1 REV. 12/99

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]z15
WELL CONSTRUCTION RECORD WELL CONTRACTOR:R.CALDWELL DRILLING, INC.
WELL CONTRACTOR CERTIFICATION #? 140
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATI0111: (Show sketch of the location below)
Nearest Town: C,��� -�A� County: Z�'r`ce'y�~�%t�
(Road Name an mbers, Community, or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER From To Formation Description
Address r / Lt -7 ,� /� _- = t ji ,ejCv,
(bueei or ou eo. �1
City or Town State Zip Code
4. DATE DRILLED © a
5. TOTAL DEPTH 20 5
6. CUTTINGS COLLECTED YES ❑ NO�
7. DOES WELL REPLACE EXISTING WELL? YESJ NOF_,9� Q ��
8. STATIC WATER LEVEL Below Top of Casing: FT.
(Use '+' If Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface* w
'Top of casing terminated stlor below land surface requires a variance In accor-
dance with 15A NCAC 2C .0118
10. YIELD (gpm): A METHOD OF TEST " -- M
11. WATER ZONES (depth): /oZq4
i
12. CHLORINATION: Type Amount L,ell' It additional space is needed use back of46hn o
13. CASING:
Wall Thickness
Depth Diameter or Weight/Ft. Material
From —To �� l Ft.
From — To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From To � U Ft.
From To Ft
15. SCREEN:
Depth Diameter Slot Size
From To Ft In,
From To - Ft. In.
From To Ft. in.
16. SAND/GRAVEL PACK:
17
Depth Size
From To Ft.
From To Ft.
Material
In.
In.
Material
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECS
FOR OFFICE USE ONLY .J
Quad No: SIGNATUR O
Submit original to Division of
Serial No.
LOCATION SKETCH
(Show direction and distance from at least two StateLA h
Roads, or other map refer ints) I
15A NCAC 2C, WELL
DED TO THE WELL OWNER.
CONSTRUCTING THE WELL
ty, Groundwater Section within 30 days
o
DATE
GW-1 REV. 12199

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]�) 6
WELL CONSTRUCTION RECORD WELL CONTRACTOR: R. CALDWELL DRILLING, INC.
WELL CONTRACTOR CERTIFICATION #..2140
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential U Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show ske h of the location below) I e�ut��e County:uYXC2
Nearest Towntjeoa 6_e
0
4.
5.
6.
7.
8.
(Road Name
u"�'es, Commuurilly�, or/Subdiv ion and Lot No.)
Cl
DRILLING LOG
DEPTH
I
OWNER
Ofoloof / r Q I
From To i
Formation Description
Address
- r"
O 4b0_&�r✓N
(street or Route o.
— 1 4 iL,!
' (L A r� 1 T E
4-(D /
\ 2
City or Town
State Zip Code
g- f4-o`�
t4-G "- (65
GQAa+-rE
DATE DRILLED
TOTAL DEPTH `J
CUTTINGS COLLECTED YES ❑ NO❑
DOES WELL REPLACE EXISTING WELL? YES 1211- NO[--]
STATIC WATER LEVEL Below Top of Casing: l 0 0 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 2C .0118
10. YIELD (gpm): lm'L,— METHOD OF TYST
11. WATER ZONES (depth): 1 f G -)1 a G C M
12. CHLORINATION: Type Amount ° L
13. CASING:
Wail Thickness
Depth Diam r or Weight/Ft.
From �- To 3 Ft. � 1/ SnQ a L
From To Ft.
From To Ft.
14. GROUT:
If additional space is needed use back of form .�
r•� =
•
C70
01
LOCATION SKETCH ` %
Material (Show direction and distance from at least two State
PSG Roads, or other map reference point
Ct�r.�1
Depth
I
Material
U
Nethod
G ��
From To OR
From To
Ft. M G
Ft.
15. SCREEN:C:
Depth
Diameter Slot Size
Material
From To Ft
in, in.
J( 3
From To Ft.
in. In.
v
From To Ft.
In. in.
16. SAND/GRAVEL PACK:
60
Depth
Size Material
From To
Ft.
From To
Ft.
E:I K M TA)
6-re-
I
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACIORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF T RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY _ k t Y �a -�L-� � (4- •- 0 o
Quad No:
Serial No.
#aqse
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Quality, Groundwater Section within 30 days
GW-1 REV. 12/99

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section r �)
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: R. CALDWELL DRILLING, INC.
WELL CONTRACTOR CERTIFICATION #? 140
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATI hovth��etch of the location below)
Nearest Town: FFFF��e County:_'B WC6')'V�
(Road Name d Numb s, Co nfty, or Subdivision and Lot No.)
3. OWNER
Ad ress
'11treet or o.
D
City or Town State Zip Code
4. DATE DRILLED >_ o D
5. TOTAL DEPTH `T 0,!L
6. CUTTINGS COLLECTED YES ❑ NO[
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO[-
8. STATIC WATER LEVEL Below Top of Casing: M,40 FT.
(Use '+' If Above Top of Casing)
9. TOP OF CASING is FT. Above Land Surface -
•Top of casing terminated attor below land surface requires a variance In accor-
dance with 15A NCAC 3C.0118
10. YIELD (gpm): f METHOD OF TEST
11. WATER ZONES (depth):
12. CHLORINATION: Type _Amount
13. CASING:
DRILLING LOG
From To
Formation
DEPTH
•
If additional space is needed use back of form
Wail Thickness
Depth Di Toter or Weight/Ft. Material (Show
L From m To Z Ft. ?" U 5�—�( _,LC R1
From To Ft.
From To Ft.
14. GROUT:
Depth Material
From __Q To '-L Ft. II
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:
LOCATION SKETCH
:tion and distance from at least two State
, or other map reference points)
a
�.a
w
c_-J
i DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC , WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF T ECO AS BEEN VIDED TO T E WELL OWNER. 7
FOR OFFICE USE ONLY
Quad No: ATUR PERSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Quality, Groundwater Section within 30 days
Serial No. GW-i REV. 12/99

North Carolina • Department of Environment and Natural Resources - Division of Water Quality • Groundwater Section r ; a
1636 Mail Service Center - Raleigh, N.C. 27699.1636-Phone [phone] � -�
WELL CONSTRICTION RECORD WELLCONTRACTOR:R.CALDWELL DRILLING, INC.
WELL CONTRACTOR CERTIFICATION #. 140
STATE WELL CONSTRUCTION PERMIT#:
WELL USE (Chrck Applicable sox): Residential tg Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION:1 ( how sketch of t Ion below)
Nearest Town: //.��tr�11 County: �� r
Agricultural ❑ Monitoring ❑
(Road Name a umb , Co ity or Su is' a LoIN o.)
DRILLING LOG
DEPTH
3. OWNER _
From To l
$ 4
Forma ton Description
0 1B C- t�� Zoe r )
Address
r1
�— cm
treat or
7(LA
2p
to G M
City or Town State Zip Code
_ )
�o
N
4. DATE DRILLED �" "
5. TOTAL DEPTH 1 S
5
6. CUTTINGS COLLECTED YES ❑ NO❑
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO[J
8. STATIC WATER LEVEL Below Top of Casing: —P- 0 FT.
(Use '+' It 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 2C .0118 Q
10. YIELD (gpm): 3 METHOD OF TEST 1
'�-
11. WATER ZONES (depth): Ck C)
1 00 z_o GPN1
... n:
12. CHLORINATION: Type n I Amount °
It additional space is needed
use back of form` r
13. CASING:
Wall Thickness
Depth Diam r/r or Wei hVFt.
From To Ft. �' I ��O I
From To Ft.
From To -- Ft.
14. GROUT:
LOCATION SKETCH N rf
Material (Show declion and distance from at least two Stale
PJC, Roe s, or other map reference points) t�o
0
Depth
Material ethod
From To 0 `
Ft.
-.bY>)6Io'r i_ c�
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 CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARQS,`PND THAT A,COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL
FOR OFFICE USb bNLY n n �--ti
Quad No: p'" y �ttttl'l 'SIGNATURE OF PERSON CONSTRUCTING THE WELL
t ? t5ribhitl oribinat;fo; Division of Water Quality, Groundwater Section within 30 days
Serial No.
DATE
GW-1 REV. 12/99

,- , (`))
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section t . l (5 2
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD. WELL CONTRACTOR: R R. CALDWELL DRILLING, INC.
WELL CONTRACTOR CERTIFICATION #? 140
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential9 Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATIO how sketc f e location below)
Nearest Town: County:
3
DRILLING LOG
From To
!7 ( t,5
4-5- �. K5-
DEPTH
Formation D scription
4. DATE DRILLED - 7— O 0
5. TOTAL DEPTH _26 9 5—
6. CUTTINGS COLLECTED YES ❑ NO[fl--
7. DOES WELL REPLACE EXISTING WELL? YES NO[D,
8. STATIC WATER LEVEL Below Top of Casing: FT.
_0
(Use '+' If Above Top of Casing)
9. TOP OF CASING ISFT. Above Land Surface•
•Top of casing terminated at/or below land surface requires a variance In accor-
o
dance with 15A NCAC 2C .0118 r
10. YIELD (gpm):_ METFjOD�OF TEST
11. WATER ZONES (depth)- 60 :16FIff
t) r
12. CHLORINATION: Type Amount ©
If additional space is needed use back
13. CASING:
-- —
Wall Thickness
LOCATION SKETCH
C:)
1 Depth Diameter or Welght/ t. MJ�teriat
From 1___C_ To r Ft. �l �t�
(Show direction and di tance from at least tV5Stai
Roads, or other ap reference points) -
From To Ft.
From To Ft.—D�
14. GROUT:
�..-� /t/'e 2
f
Depth Material th-o,d,�
From �_ To 20 Ft. d-"1M-Z
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material 0
From To Ft in.—in.k
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 CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND_ THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL O
FOR OFFICE USE ONLY' -r� ���(r �� tf 1i �c�Y�i
Quad No: ) ,i SIGNATURE OF PERSON CONSTRUCTING THE WELL
' rr=� Syybmjt o ginafto Division of Water Quality, Groundwater Section within 30 days
Serial No. l i) ' .� ea�;,� �l
�D-00 0
DATE
GW-1 REV. 12/99

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section r
1636 Mail Service Center • Raleigh, N.C. 27699.1636•Phone [phone] l' ` 7 `)
WELL CONSTRUCTION RECORD WELL CONTRACTOR:R.CALDWELL DRILLING, INC..
WELL CONTRACTOR CERTIFICATION #140
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ It Other, List Use:
2. WELL LOCATIO �owjIf h of the location below)
Nearest Town: , -e_ County:
(Road NameNuipbe7,,Po
nity, or Subdivision and Lot No.)
DRILLING LOG DEPTH
3. OWNER
From �To fj�ormation Description
Address
0 — (11 a25d `ya*✓�
_ eet or Houle o ��
47 — V41
City or Town State Zip Code
4. DATE DRILLED
5. TOTAL DEPTH ZLb
6. CUTTINGS COLLECTED YES NO�
7. DOES WELL REPLACE EXISTING WELL? YES MO
8. STATIC WATER LEVEL Below Top of Casing: FT.
(Use'+' it Above Top 6f Casing)
+�
9. TOP OF CASING IS FT. Above Land Surface'
--
•Top of casing terminated at/or below land surface requires a variance In accor•
dance with 15A NCAC 2C .011 !
10. YIELD (gpm): METHOD OF TEST
`
=
_�
11. WATER ZONES (depth): �•3 D — 1 S.t p w..
; ; c
•
� ri
12. CHLORINATION: Type Amount
It additional apace Is needed use back of tp,Ig1
13. CASING:
Ln -�
Wa11 Thickness
LOCATION SKETCH O' So
Fromt4—To
Depth���
Dianlete{,
Ft.
or
terial
From — To
Ft.
From To Ft.
14. GROUT:
Depth atonal y�Ihod
From 0To zJ 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
(Show direction and distance from at least two State
Roads, or other map reference points)
1 DO HEREBY CERTIFY THAN` THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD Ij(4S pEgN PRWDED TO THE WELL 0
FOR OFFICE USE ONLY
Quad No:
Serial No.
SIGNATURE OF PERSON C(
Submit original to Division of Water Quality,
7
3 THE WELL ' OATE
Section within 30 days
GW-1 REV. 12l99

North Carolina - Department of Environment and Natural Resources • Division of Water Quality - Groundwater Section �� O
1636 Mail Service Center - Raleigh, N.C. 27699.1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:R.CALDWELL DRILLING, INC.
WELL CONTRACTOR CERTIFICATION #? 140
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential 12' Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ It Other, List Use:
2. WELL LOCATI(Shg4sketch of the location below)
Nearest Town: avid 4v' County: �t-
i ;.
(Road Name an Nu hers, C mmuni�y, or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER W�1�t31'` From To - ,J /-Form ationDes cription
Address L'
�((street or HOWON1.) 727: __11-5- ply
vtC�' e✓ t,2 `�'7l,5
City or Town State Zip Code
�
4. DATE DRILLED � ! 2_v �
5. TOTAL DEPTH 3&4K,
6. CUTTINGS COLLECTED YES ❑ NOQ/ y
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
8. STATIC WATER LEVEL Below Top of Casing: FT. _C n ,
(Use '+' if Above Top of Casing) r rT-
9. TOP OF CASING IS— IQ_ FT. Above Land Surface•
•Top of casing terminated at/or below land surface requires a variance In accor-
dance with 15A NCAC 2C 0118 r t�
10. YIELD (gpm): METHOD OF TEST
11. WATER ZONES (depth): - a_?3 ' % r-n
12. CHLORINATION: Type' Amount If additional space Is needed use back of form
13. CASING:
Wail Thickness
Depth � Diameter or Welght/Ft. Material
From t' To f ',v Ft.
From —To —Ft. -
From To Ft.
14. GROUT:
Depth
From To 2 d Ft
Material Method
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)
i DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY 9k9-__
Quad No: SIGNATURE OF PERSON CONSTRUCT THE ELL ATE
Submit original to Division of Water Quality, Groundwa or Section Within 30 days
Serial No, GW1 REV. 12/99

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] - r) ! '
WELL CONSTRUCTION RECORD WELL CONTRACTOR: R • CALDWELL DRILLING, INC.
WELL CONTRACTOR CERTIFICATION #2140
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential Municipal ❑ Industrial ❑ Agricultural 0 , ` Monitoring E
Recovery ❑ Heat Pump Water Injection E3 Other If Other, List Use:
2. WELL LOCATION: (S w sketch of the location below)
Nearyyt Town: *— �� � — County: �� C d ►y� 6
( oad Name and Nu rs, Community, or Subdivlslon and Lot No.) DRILLING LOG DEPTH
3. OWNER © A fLC-- From To / Fo tion Description
Address
(street or Hou7o. ; aA CJ I'-r6
City or Town Slate, — Zip Code �O (� - (L tT£
4. DATE DRILLED I+ a- — Do Y7G P M
5. TOTAL DEPTH
a
6. CUTTINGS COLLECTED YES ❑ NOF__j � O 1 ya 6PM
7. DOES WELL REPLACE EXISTING WELL? YES NO -4% r f G
8. STATIC WATER LEVEL Below Top of Casing: X78 FT. 3 -7
(Use '+' if Above Top of Casing) 3 ' ,(os (`Zjt, i
9. TOP OF CASING IS 1- FT. Above Land Surface*
'Top or casing terminated atfor below land surface requires a variance In accor-
dance with 15A NCAC 2C .0118 67 Fri
10. YIELD (gpm): i_ METHOD UOF TEST
PM\ G t
11. WATER ZONES (depth): �" t `'t rl_'
Fri
12. CHLORINATION: Type Q1 4�-- Amount ° Z If additional space is needed use back o Wm v, m�-
13. CASING:
Wall Thickness
Depth l o o Dla� t r tt or WVht(Ft atpd I
From —To Ft.g' Y C:
From To Ft.
From To Ft.
14. GROUT:
From _
From _
15. SCREEN:
From
From
Depth Material Method
To A I Ft. r F i i 0
To Ft.
Depth Diameter Slot Size Material
_ To Ft in, in.
_ To Ft, in. In.
From To Ft. in. In.
16. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To Ft.
17. REMARKS:
Material
c� -a
LOCATION SKETCH oD o
(Show direction and distance from at least two State —
Roads, or other map reference points)
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 1SA NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPS( OF TH1,S RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Quad No:
Serial No.
-Z7-
StdNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Quality, Groundwater Section within 30 days
GW-1 REV. IV99

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:R.CALDWELL DRILLING,
WELL CONTRACTOR CERTIFICATION #2 14 0
STATE WELL CONSTRUCTION PERMIT#: .
�� n i
L 1.
INC.
1. WELL USE (Check Applicable Box): Residential 2*'� Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATI N: Show s etch of the location below)
Nearest Town: County: c-- --r% 6
ad Name and umbers, or Subdivision and Lot No.) DRILLING LOG DEPTH
Tunity,
3. OWNER ��-vim tt4>h►v-%jm`S From To Forrnation'Description
Address JS 444V Dy
j street o )r o 7
C 'ei' 2 e
City or Town State Zip Code
4. DATE DRILLED
5. TOTAL DEPTH 7
6. CUTTINGS COLLECTED YES ❑ NOZ----'
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
8. STATIC WATER LEVEL Befow Top of Casing: — FT.
(Use '+' It Above Top of Casing)
_
9. TOP OF CASING IS I- FT. Above Land Surface-
q
•Top of casing terminated at/or below land surface requires a variance In accor-
dance with 15A NCAC 2C 0118
r
10. YIELD (gpm): 30 METHOD OF TEST
11. WATER ZONES (depth): -Za - -'TZ-r
12. CHLORINATION: Type mount Qkile— It additional space is needed use back of forW
13. CASING:
o
Wall Thickness LOCATION SKETCH
DepthL f Diameter or Weight/Ft toterial (Show direction and distance from at least two
State
From To Ft. t 4 Roads, or other map reference points)
From To Ft. —
From To Ft.
1
14. GROUT:
t
Depth Whod
O
T
From 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 Material
From To Ft.
From _ To Ft.
%--
17. REMARKS:
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RFZ
FOR OFFICE USE ONLY
Quad No:
Serial No.
SIGNATURE OF PER
Submit original to Division of Water
)ANCE WITH 15A NCAC 2C, WELL
BEEN PROVtiSED T03HE WG1t.L O
INSTRUCTING THEW L / DA
Groundwater Section m0ithin 30 days
GW1 REV. 12/99
ej

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section / 9
1636 Mail Service Center - Raleigh, N.C. 27699.1636-Phone [phone]
WELL CONSTRUCTION RECORD WELLCONTRACTOR:R.CALDWELL DRILLING, INC.
WELL CONTRACTOR CERTIFICATION #? 140
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 LOCAT"N:how j�ttch of the location below)
Nearest Town:IF % '0 -- County` ��'�
(Road Name and Num ers, C'tty, or Subdivision and Lot No.)
DRILLING LOG
3. OWNER +�� 'ems'
From To
Address
t �'✓_
reef of Houle No,
�Pock
City or Town Slate Zip Code
—
4. DATE DRILLED �w
5. TOTAL DEPTH
!
6. CUTTINGS COLLECTED YES Q NO�/
7. DOES WELL REPLACE EXISTING WELL? YES CO/N00
8. STATIC WATER LEVEL Below Top of Casing: 2D0 FT.
(Use •+• If Above Top of Casing)
9. TOP OF CASING IS "�-I FT. Above Land Surface-
,
•Top of casing terminated at/ r below land surface requires a variance In accor•
d Ith 15A NCAC 2C
DEPTH
Formation Description
n
r7
M
E2
ance w t, j.ry--rr,ltff���c �y M1t! . _ �• /A.� ..,.
10. YIELD (gpm): METHOD OFJEST ••
11. WATER ZONES (depth): C)
�
12. CHLORINATION: Type 1J4h1P1__ Amount 9 ytL-- If additional space Is needed use back of form
13. CASING:
Wall Thickness
Depth Diameter or Welght/Fl. Material
From To 7-0 Ft.
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From _ To Z9 Ft.
From -To Ft.
15. SCREEN:
Depth
From
To Ft
From
To Ft.
From
To Ft.
16. SAND/GRAVEL PACK:
Depth
From
To
From
To
17
Diameter Slot Size Material
Ft.
Ft.
_ in.
in.
_ In.
in.
_ In.
In.
Size
Material
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
M��
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD BE ROVI D TO HE WELL OWNER.
FOR OFFICE USE ONLY
Quad No: SIGNATURE OF PERSO CONST CTIN HE WELL ATE
Submit original to Division of Water Quality, Groundwater clion within 30 days
Serial No. GW1 REV. 12199

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section r ( 91636 Mail Service Center - Raleigh, N.C. 27699.1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:R • CALDWELL DRILLING, INC.
WELL CONTRACTOR CERTIFICATION #? 140
STATE WELL CONSTRUCTION PERMIT#: O i0 ©C'7 /D
1. WELL USE (check Applicable Box): Residential ❑ Municipaild Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCAT�oyRsk h of the location below)
Nearest Town: -- , County:-c7�•-•�lJ'�
(Road Name Numbers, Com unity ubdiv ion a Lot No
DRILLING LOG
DEPTH
3. OWNER
Address %
From To /
�t
, - 1 2
For"ation Description
V os tsur~e* 03
tree or au e NO 7
t 2 t '— r s�
a ,� <
D
City or Toxm state Zip Code
DATE DRILLED 7-13 -200 �
I o
C
4.
5. TOTAL DEPTH b 0 5"
G
6. CUTTINGS COLLECTED YES ❑ NO❑
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO[1
8. STATIC WATER LEVEL Below Top of Casing: q z) FT.
(Use '+' If Above Top of Casing)
1 `!
9. TOP OF CASING IS ,-
FT. Above Land Surface'
I , c' p
o
*Top of casing terminated atlor below land surface requires a variance In accor-
dance with 15ANCAC2C.0 18
YIELD F TEST Xt
='' '
10. (gpm): METHOD
= ��
--M
11. WATER ZONES (depth):
�O ' - S C;
;,�—
12. CHLORINATION: Type
t t" L Amount ° z
If additional space is needed use back of ft to
_CD
13. CASING:
LOCATION SKETCH ^�
Wall Thickness
W
Depth
j~ 'a'
D r,/ or Weipht/Ft. Material
9 /4
(Show direction and distance from at least two State o
From To
Ft.
Roads, or other map reference points)
From To
Ft.
From To
Ft.
14. GROUT:
Depth Material Method
From I _ To l 2 ( Ft. C WWT G R-" ) r.3 in---�
From --To Ft.
15. SCREEN:
Depth
From To Ft
From To Ft.
From To Ft.
16. SAND/GRAVEL PACK:
From
From
17. REMARKS:
Depth
_ To -
To -
Diameter Slot Size Material
in. in.
In. In.
In. In.
Ft.
Ft.
Size
Material
n
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT
FOR OFFICE USE ONLY
Quad No:
Serial No.
Submit original to Division of Water Quality, Groundwater Section within 30 days
GW-1 REV. 12/99

North Carolina • Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section !� .14590
1636 Mail Service Center - Raleigh, N.C. 27699.1636•Phone [phone]
WELL CONSTRUCTION RECORD WELLCONTRACTOR:R.CALDWELL DRILLING, INC.
WELL CONTRACTOR CERTIFICATION #?140
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (check Applicable Box): Residential Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (ShAw sketch c1` the location below)
Nearest Town: 5 (-Ia q 1 . -,'6- County: �V N C--
(Road Name and N tubers, Community r Subdivision and Lot No.) DRILLING LOG
3. OWNER V Frorp, To
Address i- A—i1 c'�
treet or outs o. �(� a
3oa
City or Town r State Zip Code
4. DATE DRILLED r k4­ ° o
5. TOTAL DEPTH 21bS "
6. CUTTINGS COLLECTED YES O NO❑
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 FT. Above Land Surface -
'Top of casing terminated at/or below land surface requires a variance In accor-
dance with 15A NCAC 2 0116 G
10. YIELD (gpm):a METHOD OF TEST
11. WATER ZONES (depth): 3
12. CHLORINATION: Type Amount DZ
13. CASING:
From
Dept
- To
Wall Thickness
r
Ft. D}a e r �y4ve � t. M Aert C.
From
To
Ft. —
From
To
Ft.
14. GROUT:
From
Dept /
To � 1
Material /,Method
Ft. C,6 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. SANDIGRAVEL PACK:
Depth
Size Material
From
To
Ft.
From
To
Ft.
17. REMARKS:
DEPTH
f Form lion Description
o e_ &') re-0-i3-r-')
ao Gprn
C2 R-A Cc) %-C )z
0 0
G p
C._ cn�
o c;
N o.r
c7 0
�tP Ti
:� cn=
t'- c
GJ o
It additional space is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
i DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCT IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THI COR AS B N PR VIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Quad No: SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Quality, Groundwater Section within 30 days
Serial No. GW-1 REV. 12/99

"18
North Carolina • Department of Environment and Natural Resources - Division of Water Quality • Groundwater Section r- `' "
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:R • CALDWELL DRILLING, INC.
WELL CONTRACTOR CERTIFICATION #2140
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential12f Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketph of the location below)
Nearest Town: (,� t~A t- Y_ J \ i- ( 6 County: v ro C-a M 6.,
i✓
(Road Name and Numbers, Community, or Subdivision and Lot No.)
DRILLING LOG
DEPTH
3. OWNER � 1 C AA A (LS N A -,6-
From To r
Formation Description
J6"0 ��
Address _
51
0 p
_ reetor a o.
s
ao
City or Town State Zip ode
4. DATE DRILLED 1— - ©D��
l7E
9`7 tO M
5. TOTAL DEPTH o 5
6. CUTTINGS COLLECTED YES ❑ NO❑
3� y
sJ�TE
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NOd
8. STATIC WATER LEVEL Below Top of Casing: tc (-) FT.
(Use 't' If Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface'-�
*Top of casing terminated at/or below land surface requires a variance In accor•
_ ; 75
dance with 15A NCAC 2C .0118
10. YIELD (gpm): 3 z7 METHOD OF TEST Q-A G
C 3
—1 '
11. WATER ZONES (depth):
CI
12. CHLORINATION: Type P 1wL Amount 2!
If additional space Is needed use back of form ;
13. CASING:
LOCATION SKETCH
Wall Thickness
Depth Diani�}eter or Wei ht/Ft. Matynai
�� C
�--
C q r�
(Show direction an distance from at least two Stale
From To Ft. 6' 4 Spy V
Roads, o he map reference
points)
From To Ft.
From To Ft.
14. GROUT:
Depth Material jI Method .
From To Al Ft. C'�" nor I OO �,C2 D
��
� d�
Co >>.
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
o
From - To Ft In. in.
Y
J
From To Ft. in. In.
From To Ft. In. In.
16. SAND/GRAVEL PACK:
N
Depth Size Material
E
e'K- 7
From To Ft.
From To Ft.
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONST . '"`i , ' COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL O ER.
FOR OF SE ONLY L`� rl r l Z6D�
Quad No: SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
fit ' i1 7 ?(QUO original to Division of Water Quality, Groundwater Section within 30 days
Sedal No. GW1 REV. 12199
urot
Asbvv

North Carohna - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section rA C':
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone] tw i ") 4 9 9
WELL CONSTRUCTION RECORD WELL CONTRACTOR:R • CALDWELL DRILLING, INC.
WELL CONTRACTOR CERTIFICATION #2140
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable sox): Residential 12f Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketp h of the location below)
Nearest Town: EAd � )9 J L t County:y rJ C-o M
(Road Name and Numbers, Community, or Subdivision and Lot No.)
DRILLING LOG
DEPTH
3. OWNER •\tl 1 C TAA,,A_fL_ S N A
Frorp To r
Formation Description
J69-8 b *F- 0
Address
- 51
O 0 12-
reetor eNO.)�j
7SZ
-� o2f1C1
—2
coo C
City or Town State Zip ode
4. DATE DRILLED 1` - © C
'90ol
`3�t ��
`� P
5. TOTAL DEPTH o 5
6. CUTTINGS COLLECTED YES [] NO❑
—
06
/ 01-) le
7 l0-1 --�—
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NOd'-=
8. STATIC WATER LEVEL Below Top of Casing: c FT.
�Z'
_
(Use's' if Above Top of Casing)
"
9. TOP OF CASING IS FT. Above Land Surface'
*Top of casing terminated atlor below land surface requires a variance In accor-
dance with 15A NCAC 2C .0118
10. YIELD (gpm): 32 METHOD OF TEST ILI, G
11. WATER ZONES (depth): oo -3 G P r�-\
3�0' a--t GPI
w
12. CHLORINATION: Type p 11 -t- Amount !�
If additional space Is needed use back of form
13. CASING:
Wall Thickness
LOCATION SKETCH
Depth Dia�;►'}}e�ter or Weight/Ft. Mat Hal
�--
(Show direction an distance from
at least two Slate
From To - A Ft. 6,a sa _ PVC
Roads,Lemarence
points)
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method From To A- Ft. (Iby 61)l 0
From To Ft.
15. SCREEN:
Cn
Depth Diameter Slot Size Material
o
From To Ft Iri. in.
Y
J
�.
From To Ft. in. In.
:Z
From To Ft. In. In.
16. SAND/GRAVEL PACK:
`n
Depth Size Material
E �
�o '` o C' 7
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, /{ND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL O ER.
[,
FOR OFFICE USEQNLY - ✓ r/ ( / �d�
Quad No: tg ° 46 'SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
A � f I� It or4t&Aito Division of Water Quality, Groundwater Section Within 30 days
Serial No. GW-1 REV. 12199

North Carolina • Department of Environment and Natural Resources - Division of Water Quality • Groundwater Section C"4, r, r
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone] it •1 `, 4 41
WELL CONSTRUCTION RECORD WELLCONTRACTOR:R.CALDWELL DRILLING, INC.
WELL CONTRACTOR CERTIFICATION #2140
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sk i•tchiof tth location below) Q
Nearest Town: c A � © -r County:
(Road Name and Numbers. Communit or Subdivision and Lot No.)
DRILLING LOG DEPTH
3. OWNER I o W�� �-•
rt3/ To Fo;n%alion Description
Addr s
(Street or oute
� � � �--'� 3 �
City or Town S(ate Zip ode
4. DATE DRILLED=
�u�7,, � � PdN--)
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑ NO❑ -
_
3 � �� �2 )
t�
7. DOES WELL REPLACE EXISTING WELL? YES NO
STATIC WATER LEVEL Below Top of Casing: FT.
C=
8.
(Use '+' if Above Top of Casing)=
9. TOP OF CASING IS FT. Above Land Surface'
*Top of casing terminated at/or below land surface requires a variance In actor.
dance with 15A NCAC 2C .0118
METHOD OF TEST ��
�. `_
�'
10. YIELD m
(gp: )�-
11. WATER ZONES (depth):
.C,
12. CHLORINATION: Type 1 l^t, Amount
If additional space is needed use back of form
13. CASING:
LOCATION SKETCH
Wall Thickness
Depths Di%ter or Weight/Ft. Material
i
(Show direction and distance from at least two Slate
FromTo�1-- Ft. —5� — _5D9XC -Nc�
Roads, or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Material ethod
From To �'i Ft. U MC0 � A 61)
From
To _
15. SCREEN:
Depth
From
To
From
To
From
To
16. SAND/GRAVEL PACK:
_ Ft. _
Diameter Slot Size Material
Ft in. in.
Ft. in. in.
Ft. in, in.
Depth Size
-- From To Ft.
From To Ft.
17. REMARKS:
I DO HEREBY CERTIFY THAT THI,.W,ELL:V
CONSTRUCTION ST/�N-CZAR,QS,F/\NWH�T
FOR OFFICE USE
Quad No:
Serial No.
AUO(00 SI
3 S i o ginal
Material
'ED IN ACCORDANCE WITH 15A NCAC 2C, WELL
5'ECORD HAS BEEN PROVIDED TO THE WELL OWNER,
OF PERSON CONSTRUCTING THE WELL DATE
of Water Quality. Groundwater Section Within 30 days
GW-1 REV. 12/99

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section ;' ,,L 3 8 3 J
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:R'CALDWELL DRILLING, INC.
WELL CONTRACTOR CERTIFICATION #2140
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (check Applicable Box): Residential Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Othe'r ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: A s "V_4 4 1 r F County: � � 'v
(Road Name and Numbers, Community, r Subdivision and Lot No.)
3. OWNER _ A& �AT`V 1 w IL f rJ 5
Address A t� >r LP_ V 4 ir- t7b (�� lb
(Street or OU a 0.
Ic_a (Z NG
City or Town State Zip Code
4. DATE DRILLED b aka
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑ NO❑
7. DOES WELL REPLACE EXISTING WELL? YES NOM
8. STATIC WATER LEVEL Below Top of Casing: o FT.
(Use '+' If Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface'
'Top of casing terminated attor below land surface requires a variance In accor
dance with 15A NCAC 2C .0118
10. YIELD (gpm): 1110 METHOD OF�TEST �t
11. WATER ZONES (depth): 60
1 b � ,
12. CHLORINATION: Type 1 i- LAmount 0
13. CASING:
Wall Thickness
Depth l Diam�e or Weight/Ft. Matg al
From To S Ft. -�—
From To Ft.
From To Ft.
14. GROUT:
Depth Material ,�►ethod
From '� j To a Ft. Cc Mew"( r 0 V (LL,)
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
17. REMARKS:
To Ft.
DRILLING LOG
From To
+.1, t;o
5'D - L- DT
C, o "
6 0 1Zu
\20
DEPTH
Formation Description
V tA oo t 15-
GP
C;i A.J1`r
5 G 0 '-�-
G
If additional space Is needed use back of form
LOCATION SKETCH D 1
(Show direction and distance from at least two State (o A D
Roads, or other map reference points)
G
o
4
r
cm-,
Crn
oM
;*o
tV
C3
L� tCE�-r�
.�
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS REGORD HAS B N PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Quad No: SIGNATUR F PERSON CONSTRUCTING THE WELL
)ft Sutxriit onglnal
Serial No. to Division of Water Quality, Groundwater Section within 30 days
a()"�i.` I w
I i
DATE
— o 0
GW-1 REV. 12/99

North Carolina - Department of Environment and Natural Resources • Division of Water Quality - Groundwater Section ! 13 8 4 2
1636 Mail Service Center - Raleigh, N.C. 27699.1636•Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:R • CALDWELL DRILLING, INC.
WELL CONTRACTOR CERTIFICATION #.2140
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check applicable Box): Residential 2? Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATI Show sketch of the location below)
Nearewn. - County:
(Road Name and Numbers, Co or,Subdivisi and Lot No.) DRILLING LOG DEPTH
3. OWNER/,/ S S �L�-ri-�� From To Formation Description
Address
-Tstreet or out- o.
City or Town Slat Zip Code _
4. DATE DRILLED hz)
5. TOTAL DEPTH 10 z :2 ,�t
6. CUTTINGS COLLECTED YES ❑ NO❑
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO❑
8. STATIC WATER LEVEL Below Top of Casing: ,/-) Ff.
(Use '+' If Above Top of Casing)
9. TOP OF CASING IS �_ Ff . Above Land Surface*
*Top of casing terminated atfor below land surface requires a varAlsnce in accor-
dance with 15A NCAC 2C .0118
10. YIELD (gpm): 2_ METHOD OF TEST
11. WATER ZONES (depth):
12. CHLORINATION: Type Amount � It additional space is needed use back of form
13. CASING:
Depth
Wail Thickness
Dia ter or , i VF . rt
From To � Ft.
From To Ft.
From To Ft.
14. GROUT:
Depthaterial
From �_ To q=Ft.
From To
15. SCREEN:
Depth
From To Ft
From To Ft.
Ft.
Diameter Slot Size
In. in.
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)
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A CO F_T I E-CRRID HA BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Quad No: SIGNATURE OF PER N IbONSTRUCTING THE WELL DATE
j, 1 ,$urmi It original to Division of Water Ouallty, Groundwater Section Within 30 days
[JJt�
Serial No. I
GW-1 REV. 12/99
i
0
p
co �
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c
�rn
4 co
M
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rn
cn =
rn
0

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section 2. 13 `? J
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:R • CALDWELL DRILLING, INC.
WELL CONTRACTOR CERTIFICATION #. 140
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below) C o
Nearest Town: J )0J-Lk00hdQ^L'= Q-1— County: L"
(Road Nam d Nu_mbers, Commu or Subdivision and Lot No.)
3. OWNER
Address
VV tree o�u e � o�
� a� 0
City or Town State Zip Code
4. DATE DRILLED
5. TOTAL DEPTH
6. CUTTINGS COLLEC ED YES ❑ NO❑
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO❑
8. STATIC WATER LEVEL Below Top of Casing: FT.
(Use '+' if Above Top of Casing)
9. TOP OF CASING IS�_ FT. Above Land Surface -
*Top of casing terminated at/or below land surface requires a variance In accor-
dance with 15A NCAC 2C .0118
10. YIELD (gpm): �2 0 METHOD OF TEST
11. WATER ZONES (depth): 13
DRILLING LOG
From To
o T3
DEPTH
Formation ]pli
12. CHLORINATION: Type _ZSZ_;4__ —Amount If additional space Is needed use back of form
13. CASING:
Wait Thickness LOCATION SKETCH
Depth _ Diameter or Wei httFt. Material (Show direction and distance from at least two State
From —To Ft. _421:c RoA'I`r other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Material Me!hod
From g2_ To Ft.
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft in. in.
From To Ft. in.
From To Ft. in. _
16. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To Ft.
17. REMARKS:
In.
_ in.
jl gT yj
Material
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED:IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Quad No:
Serial No.
61r27 r-e)L-10 0
r SIGNATURE OF PERSON CONSTIIUCTING THE WELL
Submit original to Division of Water Quality, Groundwater Section Within 30 days
DATE
GW1 REV. 12/99

213843
06
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
C t R I I h Mr- 27H99-163H-Phone [phone]
163H Mall Service en er • a e g , � �� / r� WELL CONTRACTOR: � �J
WELL CONSTRUCTION RECORD - /� � _ � � �!J
r/ P� �, M T � WELL CONTRACTOR CERTIFICATION p: 0 —
_ c , © ©(0 STATE WELL CONSTRUCTION PERMITM .(5311
1. WELL USE (Check Applicable sox): Resldentiol ❑ Municipal [9 Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other E] If Other, List Use:
Agricultural ❑ Monitoring El
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: 64f et'r County: J
(Hoed Name And Numbers, Comnw ty, or Subdivision and Lot N96 DRILLING LOG DEPTH
3. OWNER From To Formation Description
Address D y O�62"
ree or ou a o. (�
y or Town late 2 Zip Coed
4. DATE DRILLED I� •� r�i,��_ �,�
5. TOTAL DEPTI 5
6. CUTTINGS COLLECTED YES n NO[:] 'mod
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 / FT. Above Land Surface'
'Top or casing terminated atlor below land surface requires a varlance in accor-
dance with 15A NCAC 2C .0118
10. YIELD (gpm): MET[IOD QF TEST A 2 . o
CM
11. WATER ZONES (depth): 1 D _ 3
12. CHLORINATION: Type f Amount It additional s e Is ne ed ba form"_
O 10 SKETCH
Wall Thickness
r qe It Diametay or w�I��V�F.h. Material (Show direction and distance from at least two Stab M o
From '1 To Ft. Roads, or other map reference points)
From To Ft. Wh(Te ma
/, Hatlise MA t21;
From —To Ft.'`� / �eZ'c✓5 ,,� "
�cJ14. GROUT: ��tr,QP .'6
Malor I Moll od
From �— Tol `AFL 4t �• . (°ar A. C wc--p, pII%-
From To Ft. - ac, r � I f /i1/ M CfAS(nlCr l�
_ �o � s s. eel"',rT. ��
15. SCREEN: � `�'
Depth Diameter SlatSlz6 Malorlal
From To Ft in. In. f I �((� `0 w
From To FL in. in. nJ��/� U J 17Q - -
From To _ Ft. In. In. LPG /` fl -
16. SAND/GRAVEL PACK:
Depth Size f�aterial
From To Fl.
From To FL p�,�I ( AP11 iC4i <),'U ,
17. REMARKS: 1AV
I DO HEREBY CERTIFY THAT Tt S WECELWAS CONSTRUCTED IN ACCORDANCE WITI 115A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF TI IIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER,
FOR OFFICE USE ONLY
Quad No:
Serial No.
J SIGNATURE OF PERSON CONSTRUCTING
Submit original to Division of Water Quality, Groundwater S

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:R.CALDWELL DRILLING, INC.
WELL CONTRACTOR CERTIFICATION #. 140
STATE WELL CONSTRUCTION PERMIT#:
2.
WELL USE (Check Applicable Box): Residential Municipal ❑ Industrial ❑ Agricultural ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
WELL LOCATION: ho9sketc i t location below) �% �" �►�v�1 e
Nearest Town: f'1� � County: ��'✓t �`-<
Road Nam � Nuers, unity, or bdivision and Lot No.) DRILLING LOG
3. OWNER ..H't/ From To
Address f , ry
---(Street or Route No. _ �9 S�
41L, cf 4
City or Town ` State Zip Code
4. DATE DRILLED
5. TOTAL DEPTH TO
6. CUTTINGS COLLECTED YES ❑ NOIFT�a---
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NOE9— -
8. STATIC WATER LEVEL Below Top of Casing:. �2_ 0_ FT.
(Use '+' If Above Top of Casing)
9. TOP OF CASING is FT. Above Land Surface'
*Top of casing terminated at/or below land surface requires a variance In accor•
dance with 15A NCAC 2C .011,5
10. YIELD (gpm): rL[/ METHOD OF TEST
-I/ Q —_VD
Monitoring ❑
DEPTH
Formati Description
11. WATER ZONES (depth):
12. CHLORINATION: Type / ' _ 2 Amount �
13. CASING:
Wall Thickness
Depth �� {r/� O'�`�]et�er or Welght/Ft. MtI dal
FromTo—C10 Ft. -�—
From To Ft.
From To Ft.
14. GROUT:
Depth �Materi I )tho
From (_ To 9 Q 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:
If additional space is needed use back of forfp
�..
LOCATION SKETCH r_'
C
pC]
(Show direction and distance from at least two SI M
M
Roads, or other map reference points) _,.
G
m -�
�M
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OFT ECORD HAS BEE�PVIDED O THE WELLOW�NER.
FOR OFFICE UtE' ONLY'
Quad No: SIGNATURE OF PERSO CONSTRUCTING THE WELL DATE
t ')0mit oriiginal to Division of Water Quality, Groundwater Section within 30 days
Serial No. GW-1 REV. 12199

North Carolina - Department of Environment end Natural Resources - Division of Water Quality - Groundwater Section 211879
1 6 Pho 919 733.3221
1636 Mail Service Center - Raleigh, N.C. 27699- 63 ne ( )
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION 0: Ji / O
STATE WELL CONSTRUCTION PERMIT#: P _3
1. WELL USE (Check applicable Box): nesidentiald Municipal ❑
Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery 0 Heat Pump Water Injection F1 Other C] If Other, List Use:
2. WELL LOCATITN: (Show sket�cl ft�e location below)
Nearest Town: aN" ' p'� �!'� County:
(Road Name and Numbers. Co y, o(_Stpcuvlslon and lot No.)
DRILLING LOG DEPTH
3. OWNER
From To ,f Formation Description
i3jzv
Address
(street or o e
—
City or Town Stale Zip Code
DATE DRILLED 4 " 67 ZO
4.
5. TOTAL DEPTFI�—
6. CUTTINGS COLLECTED YES Q NO[3-
7. DOES WELL REPLACE EXISTING WELL? YES Q NOV;i
-
.:.
8. STATIC WATER LEVEL Below Top of Casing: 13'0 FT.CD
(Use '+' if Above Top of Casing)
^M
9. TOP OF CASING IS _ Fr. Above Land Surface'
C
'rn
'Top or casing larminated atlor below land surface requires a variance in accor-
�rn
dance with 15A NCAC 2C .0118
10. YIELD (gpm): -7__ METHOD OF TEST
�o
11. WATER ZONES (depth):
�D
"'
12. CHLORINATION: Type Amount
It additional space is needed use back of form �?
13. CASING:
_
LOCATION SKETCH
=i
Wall Thickness
Depth DI for or WelghUFt.
From_L---To �— Ft. J�� S�
From To Ft.
From To Ft.
14. GROUT:
aterfal (Show direction and distance from at least two State
C Roads, or other map reference points)
Depth Maloilal othod
From �_ To 9-0 Ft. eQy/ Pti % Z'
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
x
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
�✓ Z,
FOR OFFICE USE ONLYi.
li li 1 i e7
1 I ,1{ I B i
Quad No: „ £ £ S�3JATURE OF PERSON CONST TING HE WELL DA E
Sutxnit of ginel �oiOIvision of Water Quality, Oro water Section within 30 days
l I.UQl� l3W1 REV. 1?!99
Serial No.
#,5{�t£Bit30d r�' �s?t:it�it!

. 21384
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: �\�`7� / J� �-L L�1
�Z
WELL CONTRACTOR CERTIFICATION
STATE WELL CONSTRUCTION PERMIT#: (5,3111
1. WELL USE (Check Applicable Box): Residential ❑ Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring
❑
Recovery ❑ Neat Pump Water Injection ❑ Other ❑ It Other, List Use:
2. WELL LOCATP(Show sketch%%f the location below)
Nearest Town: U-) e-�r ewy ' (`'� County:
(Road Name Numbers, Communitr, or Subdivision and Lot No.) DRILLING LOG DEPTH
Description
3. OWNER'" �tv '�—` From c To Formation
Address
�
or o•()
A-416 4 ­u
�91 ! O /
City or Town State Zip Coda
4. DATE DRILLED Z- ZA>-
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES M NO
7. DOES WELL REPLACE EXISTING WELL? YES,� NO-
8. STATIC WATER LEVEL Below Top of Casing: ��— FT.
(Use '+' If Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface*
'Top of casing terminated aVor below land surface requires a variance In accor-
dance with 15A NCAC 2C .0 18 r
10. YIELD (gpm): METHOD OF TESTl�
I`'S
p
11. WATER ZONES (depth):
_
12. CHLORINATION: Type Amount C L- If additional space is needed use back of form ram"
M
orn
13. CASING:
LOCATION SKETCHra
�
M
Wall Thickness
Depth Diameter or weighuFt. Material (Show direclion and distance from at least two Stag
t-T�o
rri
From � To OV Ft. r Roads, or other map reference points)
cccn
From- To Ft.—
C-)
.c'-�
FromfV
To Ft.
raw
14..GROUT:
Depth Material Othod
From To 20 Ft.
AOt�txC.
From. To FL
15. SCREEN:
St-41'Q
Depth Diameter Slot SiZe Material 1
i��
From To Ft In, In. Y
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
4A
kin� M
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
t1
FOR OFFICE USE ONLY AT
Ouad No: SIGNATURE OF PERSON CO TRUCTI G THE WELL
ggu,bmit original to Division of Water Quality, Groundwater Section within 30 days
GWl REV. 12/99
r
Serial No. I�.: t�, �r 61 1� �;
�, -

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mall Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:-1�W LL � 1L1-1►L9, l�C.
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other 0 If Other, List Use:
2. WELL LOCATION: Show sketch of the location below)
Nearest Town: �NY /'/ County:. f�--
(Road Na rs, community, o Ivlslo d Lot No. DRILLING LOG DEPTH
3. OWNER From To Formatlo Description
Address 1
ol °—
City or Town Stale Zip Code
4. DATE DRILLED ^ 2490 C9
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES M NOR:�--_
7. DOES WELL REPLACE EXISTING WELL? YES NO
8, STATIC WATER LEVEL Below Top of Casing: � FT.
(Use 't' II Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface" p
'Top of casing terminated atlor below land surface requires a variance in accor- (_ rn
dance with 15A NCAC 2C .0118
10. YIELD (gpm): 1 S_ METHOD OF TEST `�" Grn
11. WATER ZONES (depth): �f30 �h ° T>nn
12. CHLORINATION: Type Amount It additional space Is needed use back of forrfr =.a
13. CASING:
LOCATION SKETCH
Wall Thickness-t
Depth DII�m�eter or Weiphl/Ft. eclat (Show direction and distance from at least wo Sla{2�
From _ t - To -�- Ft. -�_T — 5�=� V C Roads, or other map reference points)
From To Ft. -
From To Fl.
14. GROUT:
Depth Materlat Niolhod
From To —49 Fl. f7Ar��'y x r
From To Ft. we
15. SCREEN:
Depth Diameter Slot Slze Material
From To Ft In. In.
From To Ft. In. In.
From To FI. in. In. Q
16. SAND/GRAVEL PACK:a
Depth Size Material p
From To Ft. \�\
From To Ft.
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS REC RD HAS BEEN PROVIDED TO HE WELL OWNER.
FOR OFFICE USE ONLY
Quad No: f I v (iE QN 9b STRUCTING 1E DATE
«- ice' ,� }I Su nit tlpl atom .vis bn o1(Nya er Q a Ir` l Groundwater Section within 30 days
Serial No. 2'- 1 - } � � �� GW1 REV. 12/99
u a 2f000
rpgpyryJj7 -;.
S: G,J . s._z..T....
tin{d �tai .r i 1 I- n

208 North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section ? 1 3
1636 Mall Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: ' 1 L.� �-)- -o ,T
WELL CONTRACTOR CERTIFICATION M
STATE WELL CONSTRUCTION PERMIT#: 1
1. WELL USE (Check Appllcsbfe eox): Residential ❑ Municipal Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ,Kifocher, List Use: c -'A o Z) �-'
2. WELL LOCATION: (Show sketch f the location below)
Nearest Town: KS a E 1 r_. I.— L County:
(Road Name and Numbers, Community, or Sub ivision and Lot No.)
u b S t [�( 'C)
DRILLING LOG DEPTH
From To Formation Description
3.
OWNER /� i-
Ad�Clltysor
1 �
r
( -_
Z
ree or ou � - � -�O �j
vl i�a
7c-�� 7o C� Cn
Town tale Zip Code
DRILLED ��
J
4.
5.
DATE
TOTAL DEPTH��
6.
CUTTINGS COLLECTED YES[] NO❑
7.
DOES WELL REPLACE EXISTING WELL? YES F-1 NO
8,
STATIC WATER LEVEL Below Top of Casing: FT.
(Use '+' II Above Top of Casing)
9.
TOP OF CASING IS Ff. Above Land Surface'
r,
'Top of casing terminated at/or below land surface requires a variance In actor-
O -::;E
dance z otlir �
� �
10.
YIELD (gpm): O METHOD OF TEST
(g �
R �:Ao
7—-
11.
WATER ZONES (depth): - ) LD
__ rn
12. CHLORINATION:
13. CASING:
Type fill— )LL-_Amount C It additional space Is needed use back of to
Wall Thickness
Depth�-� I� or or Welghl/Ft. atedal
From To '1-Ft.--� L
Frorn To Ft.
From To Ft.
14. GROUT:
From
From
15. SCREEN:
From
From
_ To Ft.
Depth Diameter Slot Slze Material
To Ft In. - In.
To Ft. In.
From To FI. In.
16. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From
17. REMARKS:
To Ft.
In.
In.
Material
r'n o
LOCATION SKETCH
(Show direction and distance from at least two Plate n
4-
Roads, or other map reference points) _
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OFfiNS RECORD HASTEN PROVIDED T THE WELL OWNER.
FOR OFFICE USE ONLY
�j�GVyJyU (/ 21�L� 2 s-
Quad No:
Serial No.
SIGNATURE OF PERSON CONSTRUCTING TtIE WELL - DATE
Submit original to Division of Water Quality. Groundwater Section within 30 days
GW-,1 REV. 12/99
�flll I•,' � !

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mall Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: e /w/ b w -�-L- ��)L�f trio
WELL CONTRACTOR CERTIFICATION #: / D
STATE WELL CONSTRUCTION PERMIT#: 1`S 3�
1. WELL USE (check Applicable Box): Residenllal Er Municipal ❑ Industrlal ❑ Agricultural ❑ Monitoring ❑
Recovery[] Heat Pump Water Injection ❑ Other ❑ It Other, List Use:
2. WELL LOCATION: (S low sketch of the location below) (j v L o M C
Nearest Town: A n1 p 1. G County:
(Road Name and Numnbers. Cot unity, or Subdlvislo and Lot No.) DRILLING LOG DEPTH
3. OWNER t' A l 7�8 ss _e ` Frorn ATo Fo tion Description
Address W ti ►-r-rz �cN�,�� 12 p 1 (a o 'R&)Rb6t'j
-USree or Route o. a (, 6 0 01
CAN0 1✓E rjG 65 ce'pVIcls o GPr+�
City or Town Stale Zip Code __T _ � a �` �) ry 1 ( E
4. DATE DRILLED 5 �a'a=�o
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑ NO[ --I
7. DOES WELL REPLACE EXISTING WELL? YES NO[�
8. STATIC WATER LEVEL Below Top of Casing: (o d FT.
(Use '+' II Above Top of Casing)
9. TOP OF CASING IS a- FT. Above Land Surface'
*Top of cosing terminated at/or below land surface requires a variance In accor-
dance with 15A NCAC 2C .0118 I
10. YIELD (gpm): A Q METHOD OF TEST
11. WATER ZONES (depth): 1 6 O R a s
12. CHLORINATION: Type P I —Amount
°�-
13. CASING:
Wall Thickness
DepU11a� D�iarne r or Welghl/Ft.PVC Material
From _ To Ft. _-� --
Frorn To Fl.
From To Fl.
14. GROUT:
�
O
_
Y7�
—t
c.m
v<
r7l
�a
mm
It additional space Is needed use back of form -
Nz
LOCATION SKETCH N
--r
x
(Show direction and distance from at least two State
Roads, or other map reference points)
Depth
Malorlal
Molhod
Frorn To
Ft.
From To
Ft.
15. SCREEN:
Depth
Diameter Slot Sizo
Material _
From To
FI In.
In. 4 • G�
FromTo
FL In.
In. S''r c
From To _
FI. In.
In.
16. SAND/GRAVEL PACK:
Depth
Size
Maleilal
From To
Ft.
From
17. REMARKS:
—
To F►.
01)
n
p
r
D
F-
n.
?f�
m" (.jl{ITIE,6
ti
NuJ�E
I DO IIEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Quad No: r,•.•-.,n..• �_� �SIr3tJA►.UREQF..GELI ON CONSTRUCTING THE WELL GATE
rt{ii�jat t DlWlo I e usilly. Groundwater Section Within 30 days
Serial No. ry U GW1 REV. 12/99
.�.
2000

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1638 Mail Service Center - Raleigh, N,C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:w.� �L IL�l IJ� Lr
WELL CONTRACTOR CERTIFICATION 0: d
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (check Applicable Box): Residential 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: LA '2 6 I_-_ 6— County: � � � C-`'
(Road Name and Numbers, Communlly, or Subdivision and Lot No.)
DRILLING LOG
3. OWNER e_UGSE� L_. 'CrJ%Vr T
From To
Address
-(Street
O (--
or Flouto o.
City or Town State Zip Code��
5 a ` - DO
J S
4. DATE DRILLED
To 5
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑ NO[—]
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NOf
8. STATIC WATER LEVEL Below Top of Casing: t„ o FT.
(Use '+' If Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface'
*Top of casing terminated at/or below land surface requires a variance In accor-
dance with 15A NCAC 2C .0118 p , r•
t—
10. YIELD (gpm): a O METHOD OF TEST l7
11. WATER ZONES (depth):
12. CHLORINATION:
13. CASING:
Type
P1 L-u- _Amount '� t
Depth . DlarrneelarY
From To 60 Ft. GA
Frorn To Ft.
From To Ft.
14. GROU r:
DEPTH
Formation Description
Zo CoPM
�A u.� l 1 1✓ _
If additional space Is needed use back of form _—
LOCATION SKETCH W
Wall Thickness
or WeighUFl. Material (Show direction and distance from at least two Slate
$bR '�I PAL Roads, or other map reference points)
Depth Material Molhod
From To Ft.
From To Ft.
15. SCREEN:
Depth Diameter
From To Ft In.
From To Ft. In.
From To Ft. In.
16. SAND/G JANELPA ��From To r-FromTo17. REMARK
I b0 HE , E, Y;_EFLTI(4ytMdM t1'
CONSTtC TIONTt�/NMIDtG);[3
FOR OFFICE USE ONLY
Quad No: 7 10 2 3 U
Serial No.
Slot SIZe Material
In.
p �� In. i
i n 11 Material
L WA CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
AT A 0 OPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Quality, Groundwater Section Within 30 days
GW1 REV. 12/99

North Carolina - Department of Environment and Natural Resources - Division of Water Quality • Groundwater Section 2 1.9 2 6.4
1636 Mail Service Center - Raleigh, N.C. 27699.1636-Phone [phone]
WELL CONSTRUCTION RECORD WELLCONTRACTOR:
WELL CONTRACTOR CERTIFICATION #: / Z O
STATE WELL CONSTRUCTION PERMIT#: _ (5311
1. WELL USE (Check Applicable Box): Residential LY Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other 0 It Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Tow gAiz__ County: —
17
(Road Name u Wecs. Community, u vlsion and Lot No.) DRILLING LOG
3. OWNER 1 From To
Address 2 `T
nee tor ouNoESQ' Ffp b
City or Town State Zip Code
4. DATE DRILLED
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑ NOE9---
7. DOES WELL REPLACE EXISTING WELL? YES [-I NOEg
8. STATIC WATER LEVEL Below Top of Casing: — FT.
(Use's' II Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface'
-Top or casing terminated at/or below land surface requires a variance In accor-
dance with 15A NCAC 2C .V8
10. YIELD (gpm): _J2 METHOD OF TEST
11. WATER ZONES (depth):
DEPTH
Fonnallo ascription
12. CHLORINATION: Type Amount if additional space Is needed use back of form
13. CASING:
Wail Thickness
Depth Dla elor or Weight/Ft. Material
From�.L—_To -.CIL Ft.Z. i L- i�C
Frorn To Ft.
—
From To Fl.
14. GROUT:
Depth Material Ihod
Frorn _49_ To �2- O Fl.
Frorn To
15. SCREEN:
Depth
From To Ft
From To Ft
Front To _ FI
16. SANDIGRAVEL PACK:
Depth
From To
From To
17. REMARKS:
LOCATION SKETCH
(Show direction and distance from at least two State
or other map reference points)
.FI.
Diameter Slot Slze Material Q�RVy
In. In. Q�
In. In. �7
In. In. �lr
Size
rt.F t.
Malodal
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITII 15A NCAC 20, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF TT RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
Ie
FOR OFFICE USE ONLY
Ouad No:
Serial No.
C
r
1
W
k,- ,-� - o
SIGNATURE OF PERSON CONSTRUCTING THE WELL- „ . DATE
Submit original to Division of Water Quality, Oroun"o� a4j Secllor nyvlll�lln 30 days
I .I __ OW .i REV. 12/99
0
z

North Carolina - Depat trnent of Environment and Natural Resources - Division of Water Quality - Groundwater Section tt cr-
1636 Mail Service Center - Raleigh, N.C. 27699.1636•Phone [phone] _l. 3 2 `.) 5
WELL CONSTRUCTION RECORD WELL CONTRACTOR:? 7-
WELL CONTRACTOR CERTIFICATION M: / O
STATE WELL CONSTRUCTION PERMITM:
1. WELL USE (Check Applicable Box): Residential Lam' Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ float Pump Water injection ❑ Other [] It Other, List Use:
2. WELL LOCATI N: (Show ske ( e location below)
Nearest Tow County:
(Road Nam* and Wumbers, Co Iy, or Sgbdlvlslon and Lot No.) DRILLING LOG DEPTH
3. OWNER From To Fonnallon Description
Address7 3
(Street grqi#ule NO.)
Clly or Town Slate Zip Code
a. DATE DRILLED
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑ NO[G�
7. DOES WELL REPLACE EXISTING WELL? YES Q_
8. STATIC WATER LEVEL Below Top of Casing: �� FT.
(Use '♦' U Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface*
*Top of casing terminated at/or below land surface requires a varlance In accor-
dance with 15A NCAC 2C .0110
10. YIELD (gpm): Z.__- METHOD OF TES ._
11. WATER ZONES (depth): /A(9 r -2
12. CHLORINATION: Type Amount If additional space Is needed use back of form
13. CASING:
LOCATION SKETCH
Wall Thickness
Depth Dlamelor or Welglit/ft. Material (Show direction and distance from at least two State
From —.To - — Fl. - e �2— �- _pvc Roads, or other map reference points)
Frorn To Ft. —
From To Ft.
14. GROU r:
o
Uoplh Maloilal Molhod o
a
Frorn To D FI. 1241A^
From To .____7-Fl.
Ch
15. SCREEN:
t a
Uopih Diameter Slot Size Malorlal y
w
From To Ft In. In.
mc
rn�
ter"
From To Ft. In. In.
vs z
From To _ Fl. In. In. S ••
r>
c->
16. SAND/GRAVEL PACK: n0 r0
avrg
~
Depth Size Maleilal
T�irs
x
From To Ft.
From To Ft.
17. REMARKS:
rive
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 20, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF TIIIS RECORD HAS BEEN PROVIDED TO THE WELL OWNE
t c S
(1 0
FOR OFFICE USE ONLY0a
Quad No: IONATunE OF PERSON CONSTRUCTING 71IF WELL DATE
Submit original to Division of Water Quality. Groundwater Section within 30 days
Serial No. a —` OW-1 REV. IV99
n },

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] �,( 0
WELL CONSTRUCTION RECORD WELL CONTRACTOR: /1����_ �—L
WELL CONTRACTOR CERTIFICATION #: A
STATE WELL CONSTRUCTION PERMIT#: _ (S .3L "I—
1. WELL USE (Check Applicable eox): Residential try Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring
❑
Recovery ❑ Heat Pump Water Injectlon ❑ Other ❑ If Other, List Use:
2. WELL LOCAT Show sk c11 J he location below
(' ��
Nearest Town: SJ�I County: (� C4:;
umbers. Co nity, or Subdivision and Lot No.) DRILLING LOG DEPTH
(Road Name a vy
3. OWNER i �-64" Fro To Formation Description
Address l
'7 % ✓� J
re or Houle o.
fir
v✓1►�WCIS le,
City or Town Stale Zip Code
�� r✓
4. DATE DRILLED
5. TOTAL DEPTH 5-y5
6. CUTTINGS COLLECTED YES ❑ NO[]�
7. DOES WELL REPLACE EXISTING WELL? YES n NO�
--�
8. STATIC WATER LEVEL Below Top of Casing: U FT. O
(Use '+' II Above Top 61 Casing)
9. TOP OF CASING IS FT. Ff . Above Land Surface' y.
=rn
'Top of casing terminated at/or below land surface requires a variance In accor- "=m
-rn
dance with 15A NCAC 2C .0118_ �
10. YIELD (gpm): . Z:5 METHOD 01= TESL
11. WATER ZONES (depth):`i _
rno
12. CHLORINATION: Type Amount __L__—_ If additional space Is needed use back of form ::
13. CASING:
o
LOCATION SKETCH
Wall Thickness
��
} - Depth Diamelor or Weight/Ft. Material (Show direction and distance from at least two Stale
From To Ft. Roads, or other map reference points)
From To Ft.
From To Fl.
14. GROUT:
Depth Material Method
From To 9-0 Fl.
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.PACKc "
From
From
17. REMARKS:
100 HEREBY
Fu
R OFFICE USE ONLY
d No:
dal No.
107
*ONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
COPY 6F THIS RECORD HAS BEEN PROVIDED TO THE WELL O
SIONAiURE OP PERSON CONSTRUCTING TIIE WELL DATE
Submit original to Division of Wntor Quality, Groundwater Section within 30 days
GW1 REV. 12/99
w _

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- ,0-41 h wf-- L-L- �lJ 1L�l (Ja ' D.
WELL CONTRACTOR CERTIFICATION #: 0
STATE WELL CONSTRUCTION PERMIT#: I S 5
1. WELL USE (Check Appllcable eox): Residential 0---municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ It Other, List Use:
2. WELL LOCH (show ske ch of, a location below)
Nearest Town' "�tR- County:.y.
(Road Name rid Numbers. Community, or ubdivlslo and Lot No.) DRILLING LOG DEPTH
3. OWNER / el r(� eil From To Formation Description
Address ��I� U s ��
.,rz5 LC_ r o or ou o,�
R T
Lt.6/Vl �4vcr S..► i (� ,�
City or Town Slate Zip Code
p
4, DATE DRILLED
5. TOTAL DEPTH jCY�
3
6. CUTTINGS COLLECTED YES[] NO�
7. DOES WELL REPLACE EXISTING WELL? YES NO
`-
8. STATIC WATER LEVEL Below Top of Casing: --'FT.
�"� oc
(Use '+' it Above Top of Casing)
DO
9. TOP OF CASING IS FT. Above Land Surface'
7+ m_Q
'Top of casing terminated at/or below land surface requires a variance in accor-
in�r''1,
dance with 15A NCAC 2C .e01tS r
�' rn;o
��
10. YIELD (gpm): METHOD OF TEST _+�
_
11. WATER ZONES (depth):
c.� �'—
z
12. CHLORINATION: Type ���' Amount It additional space Is needed use back of form
13. CASING:
Wall Thickness
Depth Diameter or Welght/FI. Material
From To Fit
Frorn To Fl.
From To Ft.
14. GROUT:
D©p11
Material
Molhod
From 16 To
Fl.
From To
Ft.
15. SCREEN:
Depth Diameter Slot Slze
Material
From To Ft
In.
In.
From To Fl.
In.
In.
From To Fl.
In.
In.
16. SAND/GRAVEL PACK:
Depth
Size
Material
From To
Ft.
From To
Ft.
W. REMARKS:
LOCATION SKETCH
(Show direction and distance from at least two Stale
Roads, or other map reference points)
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL O
FOR OFFICE USE ONLY
Quad No:��,� r
Serial No.
_0dhMirk
t5ub�i1 C
4ina��f fji Isl�o
grourldwaler Sec(iur
Nb,TRUOTING THE WELL DATE
Groundwater Section within 30 days
GWI REV. 12/99

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mall Service Center - Raleigh, N.C. 27699-1636•Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: ��n�1� wL-L 1LV-1 Uo , 1.
WELL CONTRACTOR CERTIFICATION 0: / 0
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable oox): Residenllal El Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other [] If Other, List Use:
2. WELL LOCATION: how elch of 1ocalion below)
Nearest Town: `'' County:
(Road Name and Numbe(s. Communlly, or Subdivision and Lot No.) DRILLING LOG
3. OWNER 1y A � i,-. [,7 Frorn To
Address C L/;J _1 1
. reo o�ou o. i / 5 Z �7_
vz _�_-_
City or Town Slate Zip Code
4. DATE GRILLED��Y=L''a
5. TOTAL DEPTH a cT� �
6. CUTTINGS COLLECTED YES[---] NO[ol
7. DOES WELL REPLACE EXISTING WELL? YES 0 NOQ�
B. STATIC WATER LEVEL Below Top of Casing: / , () FT.
(Use '+' If Above lop of Casing)
9. TOP OF CASING IS FT. Above Land Surface'
*Top of casing terminated at/or below land surface requires a variance in eccor-
cYIELD (gpm) c zc.ott
10.MET1IOD AF TEST
11. WATER ZONES (depth): Zgd 2 k ` 16 >
12. CHLORINATION: Type d' Amount If additional space Is needed use back of
13. CASING:
Depth r Diameter
From ' To — Ft. -i- —
Frorn To Ft.
From To _ Ft.
14. GROUP:
Wall Thickness LOCATION SKETCH to
or WelghuFl. MAtedal (Show direction and distance from at least two S aRe
�- _%y6 Roads, or other map reference points)
Uoptit
C ='-0
Malolln(vl thod r')
t'n1'l
FLdu
�_—.------
NE
From To
From To
F1.
113
15. SCREEN:
L�151rW�
Uepilr
Diameter Slot SIZe Malorial
Front To
Ft In. In.
From To
Ft. In. In.
From To _
Ft. In. In.
10. SAND/GRAVE
alerial
ii77
From _
From
Ft.
M
_
17. REMARItS:
I DO I IEREBY CERTIFY
FOR OFFICE USE ONLY
Quad No:
Serial No, 0.7 a.
Z 4-
TRUCTED IN ACCORDANCE WITH I5AJ4CAC 2C, WELL
F THIS�ORD HASS EN PROVID TO THE WELL OWNER.
DEPTH
Formal n Description
J
c
•-/ DATE
SIGNA URE OF PERSON CONSTRUCTING THE .
Submit original to Division of Water Quality, Groundwater Section within 30 days
GW1 REV. 12/99

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: _Wl_l) —t--L 1,0)Ll_j a
WELL CONTRACTOR CERTIFICATION M /
STATE WELL CONSTRUCTION PERMIT#:
1 WELL USE (Check Applicable Box): Residenllal ❑ Municipat ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ It Other, List Use:
2. WELL LOCATION: (Sho ske o he location below)
Nearest Town: rgH County: u �'i I'r �'r✓1 �} C
(Road Name Nun)b4(s, Community, or Subdivision and Lot No.) DRILLING LOG
3. OWNER Frorn To
ZAdqfesp ) Q �% / f) f1.9
City or Town Slate Zip Code
4. DATE DRILLED 2- 610
5. TOTAL DEPTH �T
6. CUTTINGS COLLECTED YES [Q NO[9-
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NOE]/
B. STATIC WATER LEVEL Below Top of Casing: [q FT.
(Use '+' it Above Top of Casing)
9. TOP OF CASING is FT. Above Land Surface'
'Top of casing terminated at/or below land surface requires a varlancer In accor-
dance with 15A NCAC 2C .0118 7
10. YIELD (gpm): XQ_ METI IOD Of TEST _ _ —
11. WATER ZONES (depth):
• n
DEPTH
Forrnatlop Des rfplion
ze
12. CHLORINATION: Type /' AmounlIt additional space is needed use back of form
13. CASING:
Wall Thickness LOCATION SKETCH
Depth DI n e�tol, or welght/Ft. Material (Show direction and distance from at least two State
From t I --To Ft. >C- �" r - it C Roads, or other map referenr
1 O
Frorn To Ft.
Frorn ToFI.14. GROUT:Uopth Malorl MolhodFrorn 0_ To _'_ Ft. _('� ASM�From To Ft.
15. SCREEN:
Dor)th Dlafneler Slot Slzo Material
Front To __ Ft In.
From To Ft. In.
From To _ Fl. In.
16. SAND/GRAVEL ICI
e �Iz ti
l's I
Front To FL
From tm T--►--0-1}�}�
17. REM/aJONUIV
( DOH f Ef�P'i bjj f TjjiUn9 WELL V
c�Ns n11 T1© @ iD5tV'RID TI IAT
FOR OFFICE USE ONLY
Quad No: �y
Seelal No.
In.
In.
In.
Material
rvt E
.S CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL C
v->
S1014ATURE OF PEnSON CONSTRUCTING T1IE WELL
Submit oilginal to Division of Weiler Quality, Groundwater Section within 30 days
DATE
GW1 REV. 12/99
-L�

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: L 1,0)Q_j-iqoLr1L .
WELL CONTRACTOR CERTIFICATION #: Q
STATE WELL CONSTRUCTION PERMIT#:
i. WELL USE (check Appl►ceble Box): Residentlaluf Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery[] Heat Pump Water Injection ❑ Other
❑ If
Other, List Use:
2. WELL LOCATION: WW s c Ctt.of the location below)
Nearest Town: _ _ County:
y�
(Road Name and tubers, C nlly, or Subdivision and Lot No.)
3. OWNER
DRILLING LOG DEPTH
Address C�
From To F`s�rmallgn De cdpllon
ree of ou a J
City or Town'��Vf
Stale Zip Code
4. DATE DRILLED -.2e - 20 a
�.'
S. TOTAL DEPTH
r
6. CUTTINGS COLLECTED YES ❑ NOffj---
7. DOES WELL REPLACE EXISTING WELL? YES 0 NO[C�'
8.
STATIC WATER LEVEL Below Top of Casing: FT.
(Use '+' It Above Top of -Casing)
9. TOP OF CASING IS. FT, Above Land Surface*
G =
'Top of casing terminated at/or below land surface requires s varla ce in accor. dance with 15A NCAC 2C ,0
-"�
10. YIELD (ypm): METHOD OF TEST:
`' ''
11. WATER ZONES (depth):
co
12. CHLORINATION: TypeAmount13. CASING: —
If additional space Is needed use back of loan
Depth Wall Thickness
p Diameter or WeIghVFI. tedal
From(Show
`�To r, Ft. S R i
LOCATION SKETCH
direction and distance from at least two State
_FV
From To Fl.
Roads, or other map reference points)
From To Ft.
14. GROUT:
Depth Material, Molhod
From _10_ To ;5 Ft.
From To Fl.
15. SCREEN:
From
From
From
16. SAND/GRP
From
From
17. REMARKS:
1 DO FIEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PRO_ VIDED TO THE WELL 0
FOR OFFICE USE ONLY Q 11
Quad No: 'v
Serial No, w
b o al I
3 ti I 1:.N
MAY I Y 2000
aGnG' 0
)NSTRUCTING THE WELL DATE
Groundwater Section Within 30 days
GW1 REV. 12/99

North Carolina - Department of Environment and Natural Resources - Division of Water quality - Groundwater Section
1636 Mall Service Center - Raleigh. N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELLCONTRACTOR:
WELL CONTRACTOR CERTIFICATION 0:_ /
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential Municipal ❑
Recovery ❑ Heat
Industrial ❑ Agricultural ❑ Monitoring ❑
Pump Water injection ❑ Other ❑ if Other, List Use:
2. WELL LOCATI N: Show skelr o e location below)
Nearest Town: C County: _4,Am��
(Road Name and Numbers, Community, or Subdivision and Lot No.)
DRILLING LOG DEPTH
3. OWNER
Address
From To Form n Descdpllo
(91(eet or Houle o.
�
City or Town Slate Zlp Code
4. DATE DRILLED �� Z fJOd)
5. TOTAL DEPTFI
6. CUTTINGS COLLECTED YES ❑ NO[!J-_"
7. DOES WELL REPLACE EXISTING WELL? YES [—J NOE�r
8. STATIC WATER LEVEL Below Top of Casing: Ate_
o D
FT,
(Use -+' if Above Top of Casing)
9. TOP OF CASING IS--* FT, Above Land Surface•
*Top of casing terminated at/or below land surface requires a variance In accor.
dance with 15A NCAC 2C .011 `
N ��
- . r
10. YIELD (gpm): ;�� METHOD OF TESj
11. WATER ZONES (depth): )
12. CHLORINATION: Type mou nt L-Q1L�,
If additional space Is needed use back of form C o
13. CASING:
Walt Thickness
/ De Ili / DI19rVeeler or WeI hVFt. aledal
From L! _ To Ll� Ft. �_ __� �__ Xk6
Frorn To Ft.
—
From To Fl.
14. GROUT:
Depill Material Molhor
From _L_ To 2_ Ft.
From To Ft. —_
15. SCREEN:
Depth
Diameter
From To
FI In.
From To
Ft. In.
From To _
Fl. In.
16. SAND/GRAVEL PACK:
Depth
Size
Front To — Ft.
From To Ft.
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND TF IAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE; WELL O
FOR OFFICE USE ONLY w ��
Quad No: 10 AT�YfiE
F
o gn o von
Serial No, s
MIRY I (2()U()
Slot Size Material
In.
In.
In.
Malodal
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
PO
RSQN CONSTRUCTING THE WELL DATE
it d JaIlty. Groundwater Secllon Within 30 days
GW1 REV. 12/99
aGO

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mall Service Center - Raleigh, N.C. 27699-1636-Phone (gig) 733-3221
WELL CONSTRUCTION RECORD WELL CONTRACTOR: —� ,C kl - L
WELL CONTRACTOR CERTIFICATIONIle)L 1 IJ , l•1�C
STATE WELL CONSTRUCTION P RMIT#: If O
I. WELL USE (Check Applicable Box): Residentlal IE Muntcl al
Recovery ElHeat Pump Water In ection p ❑ Industrial El Agricultural ❑ Monitoring ❑
1 ❑ Other ❑ If Other, List Use:
2. WELL LOCATIO : ('how"s ch of the location below)
Nearest Town:
County:
(Road Name and Nurnb1e`rs..Communtly, or Su division and Lot No.
3. OWNER DRILLING LOG DEPTH
-
Address rUAb From To Formatlon Description
ree or ou a g,
City or Town Stale'
4. DATE DRILLED Zk 8\C3ode
5. TOTAL DEPTH , �-
6. CUTTINGS COLLECTED YES ❑ NO❑
7. DOES WELL REPLACE EXISTING WELL? YES E:3 NO
8. STATIC WATER LEVEL Below Top of Casing:
9. TOP OF CASING IS (Use •+• If Above Top of Casing) `-'
FT. Above Land Surface* o
'Top or casing terminated at/or below land surface requires a variance In accor -°' =c:
dance with 15A NCAC 20.0118
10. YIELD (gpm): _/_�_ METHOD OF TEST i (�-
11. WATER ZONES (depth):
J
12. CHLORINATION: Type _� A=c- r�r=
mount If addltlonal space Is needed use back of torrrED c,.)
13. CASING:
M
Wall Thickness LOCATION SKETCH 41 =r
Depth Diameter or WeighUFt. Material
(� Q///� (Show direction and distance from at least two Stale
From TO —12L Ft
From To Ft.—�`_;ZL— Roads, or other map reference points)
From
To
Ft.
14. GROUT:
—�
Depth Material M thod
From —�_ To ..AL Ft. e,--' emV� �1Q�
From
To
Ft.—�..�..��fi�n,�
15. SCREEN:
�a
— —"�W—
From
Deplll
Diameter Slot Slze Material
To
Ft in• in.
From
To
Ft. In. in.From
To
Ft. In. In.
16. SAND/GRAVEL PACK:
From
Depth
Size Material
To —FL
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 OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Quad No:
Serial No.
PERSON CONSTRUCTING THE WELL
Paler Quailty, Groundwater Sectlon within 30 days
MAY I ( 2000 11 `J I GWi REV. 12/99

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mall Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: t✓
WELL CONTRACTOR CERTIFICATION
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check applicable Box): Resldential Municipal C] Industrial ❑ Agricultural ❑ Monitoring ❑ Recovery ❑ Heat Pump Water Injection ❑ Other
❑
If Other, List Use:
2. WELL LOCATION: (Sho kelp 1 e location below)
Nearest Town: -_nn �� County:
& I�—(�
(Road Name apqNumbers. Community, or SubdIvIsIon and Lot No.)
`T
DRILLING LOG DEPTH
3. OWNER M24 e2 A 19P
Address
From pTo Fonnallon Description
`—(st—i or Mule o.—�'�--
/14
u 5
City or Town Slate Zip Code
4. DATE DRILLED -200.0
5. TOTAL DEPTH --
�
6. CUTTINGS COLLECTED YES[] NO
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO('
8. STATIC WATER LEVEL Below Top of Casing: FT,
Gy
It Above Top of Casing)
FY, Above Land Surface*
9. TOP OF CASING 19-do.
+
land surf'Top of casing terminated at/orace requires a varlance In accor-
dance with 15A NCAC 2C.0118
10. YIELD (gpm): ./ 6- METHOD OF TEST
11. WATER ZONES (depth): ): — 2 u 5
12. CHLORINATION: Type Amount
13. CASING:
If additional space Is needed use back of form �?
Wall Thickness
��/Depth DII'rpeler or We�n2 t. M ►eclat
FromMi/ To G
LOCATION SKETCH
(Show direction and distance from at least two State
Ff.
From
Roads, or other map reference points)
To Ft.
From To Ft.
14. GROUT:
Dopllt oria Molltod
From � To 2P F.I. AA�
From To Ft.
15. SCREEN:
Doplh Diameter Slot Slzo Malorlal
From To Fl 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:
Matellal
4--e &
I DO I IEREBY CERTIFY TIIAT TI IIS WELL WAS CONSTRUCTED IN ACCORDANCE WITI 115A NCAC 2C. WELL
CONSTRUCTION STANDARDS, AND TIIAT A COPY OF This RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
OuaJ No: �IG AT E pf PE(1$dN CONS TI1E WELL
�y DATE
U nil. Inal°t( • Ivif151T 8T'll/ate.r;a� silly. Groundwater Secllon will 30 days
Serial No. , , � I
MIRY I i 2(�OO L�J Gw•! REV. 12/99
C

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mall Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD
WELL CONTRACTOR; WELL CONTRACTOR CERTIFICATION q:
STATE WELL CONSTRUCTION PERM1TIl:
I. WELL USE (Check Applicable sox):Residential 1[
Recovery Heat Pump Water In ectlMunicipal ❑ Industrial ❑
1 ❑ Other ❑ I( Other, List Use: Agricultural ❑ Monitoring El
2. WELL LOCATION: (Show sketcli of the ocation below)
Nearest Town: A t fZ V E Q
County: 0J v 1v C- o rn %S C
Ltd
(Road Name and NYPbOfs. Community, or Subdivision and Lot No.)
3. OWNER (r ��
DRILLING LOG
��
Address
I� WI�-t_ C(12ct
DEPTH
From To Formation Description
t 3�
ree or ou a o.
n>� c aQ��4-—
�. r�� �tlQ E.
Cily or Town
4. DATE DRILLED---�--A
Slate
—so, © Zip Code
t
r
5. TOTAL DEPTH ;a 0 *
(
6. CUTTINGS COLLECTED YESCI N0121/
7.
6 S c F Q p c
DOES WELL REPLACE EXISTING WELL?YES NO
8. STATIC
WATER LEVEL B9� FT
Below Top of Casing:
t /Y
.
_�of Casi
9. TOP OF CASING IS ,� (Use •+• If Above Top ng)
*Top FT. Above Land Surface*
S
of casing terminated eVor below land surface requires a variance In accor-
dance wllh 15A NCAC 2C .0118
_ t"Lo �CD
10. YIELD (gpm): __- Q___ METHOD OF EST QI G
'
c_ ..-
11. WATER ZONES (depth):
12. CHLORINATION: Type P 1 t_=
13. CASING: Amount _
-- Depth Wall Thickness s
motor orWehMFrom_/To Ft. Dla
From_To____ tA FL
Mat rial
From To Ft.-
14. GROUT:
Depth Material Mothod
From To FL
From To _ FI
15. SCREEN:
Depth I
Diameter Slot Slze Material
FromTo Ft In• In. ____----
From To Ft.
From To Ft. In. —
16. SAND/GRAVEL PACK: In.
Depth Size Material
From To n.
From To Ft.
17. REMARKS:
DO HEREBY CERTIFY THAT THIS WELL WAS CONST
CONSTRUCTION STANDARDS, AND THAT A COPY OF
FOR OFFICE -USE —ONLY
Quad No:
Serial No.
---------------
--------------
It additional space Is needed use back of tornr"a v: r_'
LOCATION SKETCH C q
(Show direction and distance frgm at least two State
Roads, or other map reference points)
w1el,-ds co% ,ems
5o��wopp I �?�ITe,S
. pal ✓E C�J6
fi 42 JqL>
I-to---
ED IN ACCO NCE WITH 15A NCAC 2C, WELL
RECORD S EN PROVIDED TO THE WELL OWNER.
�I�FPS N CONSMUCTI rG TH ler Quality, Gmundwalor Section WE hin 30 days DATE
MAY I Y 2000 11 V 11 GW 1 REV. 12/99

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: WC Lt- �, l
WELL CONTRACTOR CERTIFICATION / X O
SPTE WELL CONSTRUCTION PERMIT#: (S 311— _
1. WELL USE (check Applicable Box): Residential d Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other [] If Other, List Use:
Agricultural ❑ Monitoring ❑
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: A C LL w,3 o J e2i A 10 County: tom,y rJ C_ O
(Road Name andjumbers, Communllyvpr Subdlvlsloon and Lot No.) DRILLING LOG
3. OWNER �1 l_ Z-VO (mac il- r C�aL� `�_ From To
Address i- ' a 4
— (street or flout. o.)
ZAC, ro o 1 !A t tS rJ i I
City or Town Slate Zip Code
4. DATE DRILLED 1 "L O o
5. TOTAL DEPTH �5
6. CUTTINGS COLLECTED YES ❑ NO[J
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NOfff
8. STATIC WATER LEVEL Below Top of Casing: S o O FT.
(Use '+' If Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface'
'Top of casing terminated atlor below land surface requires a variance In accor-
dance with 15A NCAC 2C .0118
10. YIELD (gpm): C METHOD OF TEST fl(L1`L 91 C'
11. WATER ZONES (depth):
DEPTH
Formglion Description
(2•A n� l i �
• _ rr,
-� J
p cn _
0
12. CHLORINATION; Type Oi t`7 rpount 11 oZ - it additional space Is needed use back of form
13. CASING:
Wall Thickness LOCATION SKETCH
` Depth Q Dia tar or WplghvFt. Matgdal (Show direction and di e f om t east two State
Fr =rJ— Ft.�( f� Z t�/ Roads, or other a r ra'�p�ints)
From To Fl.
From To --�`— Ft.
14. GROUT: sz¢� �7
r Depth Ll (Material othod
From U To `7 4 Ft.
From To Ft.
15. SCREEN:
Depth
Diameter
From To
Ft In.
From To
Ft. In.
From To
Ft. In.
16. SAND/GRAVEL PACK:
Depth
Size
From To Ft.
From To Ft.
17. REMARKS:
Slot Size Material
In.
In.
In.
Material
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS Q UNROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Ouad No: Fr SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
b 1 v l pub It dginal to Division of Waler Ouailly, Groundwater Section within 30 days
Serial No. GWIREV. ,12/99
i to lit �Sfi
MAY I 0 ?OOr `
u

—F- d 1 It uE cnvuuIII lent, rieartn, and Natural Fie sources
Division of Environmental ManagemaKt - Groundwater Section
P.O. Box 29535 - Raleigh, N.C. 27626.0535
' I Phone [phone]
1 WELL CONSTRUCTION RECORD
DRILLING CONTRACTOR: R.STATE WELL
GALrDWEL•y DRILt,IN .
DRILLER REGISTRATION NUMBER:_1537 PERMITT NUMBERNSTRUCTION"' .; 2.13 2 0 9
1. WELL LOCATIN: (Show ketch pf the location below) ;
Nearest Town: 1 14 fit.. County: 0Y�•..� �e -
(Road, Co unity, or Subdivisio d Lot No.) DEPTH DRILLING LOG
2. OWNER
From To Formation Description
ADDRESS
tr et or Route No.)'
Cily or Town —`Stale 2
Zip Code
3. DATE DRILLED USE OF WELL
4. TOTAL DEPTH 2 �� -1- ,`?��5-
5. CUTTINGS COLLECTED YES ❑ NO❑ c,
6. DOES WELL REPLACE EXISTING WELL? YES a,
7. STATIC WATER LEVEL Below -Top of Casing: FT.
(Uso "+" if Above Top of Casing) C
8. TOP OF CASING IS, ,� FT, Above Land Surface' - M
• Casing Terminated atlor below land surface Is Illegal unless a variance Is Issued -
In accordance with 15A NCAC 2C .0118 n i}o
J
9. YIELD (gpm):�_ METHODOFTEST
10. WATER ZONES (depth):LQ
11. CHLORINATION: Type — Amount V If additional space is needed use back Morm
12. CASING:
Depth Wall Thickness
o Diamefpr or W— -
From _� L___ I 0 7-S Ft. -���
From To Ft._ ---
From - To Ft.
13. GROUT:
Depth Material
From __ To .27-2 Ft.
From _ 10 _ Ft.
14. SCREEN: _
Depth Diameter Slot Size
From To _—_ Ft in. _
From ---To ----Ft. in. _
From T o _ Ft. in. _
15. SAND/GRAVEL PACK:
Depth Size
Vrom To Ft.
From To Ft.
16. REMARKS:
GWA
Method
Material
In.
In.
in.
Material
LOCATION SKETCH
(Show direction and distance from at least two Stale
Roads, or other map reference points)
�� n�tr1 t �1r,,.l HAT.,THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 20; WELL
D 1 RC)C b EST N R ;S, LAND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
y � �,��_k
1EV. 9'!99 SIGN LIRE OF CONTRACTOR OR AGENT PATE
Submit original to Division of Environmental Management and COPY°}oWell owner.

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section ++ 49
1636 Mail Service Center - Raleigh, N.C. 27699.1636-Phone [phone]
WELL CONSTRUCTION RECORD WELLCONTRACTOR:R.CALDWELL DRILLING, INC.
WELL CONTRACTOR CERTIFICATION #2140
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Olher ❑ if Other, List Use:
2. WELL LOCATION: (Show slot of the location below)
Nearest Town: W 16 & --
. dL� County: ��
(Road Name and Numbers, Community, or Sub iviston and Lot No.)
DRILLING LOG
3. OWNER M C A AL +� N
From To
Address
9
rem'.ute o �, �7�7
City or Town State Zip Code
4. DATE DRILLED
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑ NOO
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO❑
8, STATIC WATER LEVEL Below Top of Casing: Z o O FT.
(Use '+' If Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface'
'Top of casing terminated at/or below land surface requires a variance In accor-
dance with 15A NCAC 2C .0118
10. YIELD (gpm):_ METHOD.OF TEST �z
11. WATER ZONES (depth): bo D 1_� C-1 P6--\
DEPTH
Formlion Description
v CS V-er.U2p>✓ 0)
12. CHLORINATION: Type t - Amount C If additional space is needed use back ofNRm o`
13. CASING:
A Depth ,3 5 t)iatrtje(er
From To Ft. �bj �R--
From To Ft.
From To Ft.
14. GROUT:
Wall Thickness LOCATION SKETCH
r Wei t 2at (Show direction and distance from at least two State
Roads, or other map reference points)
Depth Material
From To a� Ft.
From _ To --Ft.
15. SCREEN:
Depth Diameter
From
To __— Ft in.
From
To ---Ft. _ in.
From
To _ Ft. _ in.
16. SAND/GRAVEL PACK:
Depth Size
From
Ft.
From
To Ft.
17. REMARKS:
Slot Size Material
in.
in.
in.
Material
n
k(oi$1-
I DO HEREBY CERTIFYTHAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STAN61 hp ANDI1 HPT A COPY OFT RECORD HAS PROVIDED TO THE WELL OWNER.
Z-Oc)
o n ^ G✓�J I n
FOR OFFICE USE"ON Y
Quad No: — F At G i A)( 0
Submit odoihal to'
Serial No.
t tufra3LYt '�'t:r=talc -,.
fin ilo silr4'Pri ond
t t6i
TURE OF PERSON CONSTRUCTING THE WELL
vision of Water Quality, Groundwater Section within 30 days
DATE
GW-1 REV. 12/99

"" �•..Yuui�iu v1 L-uvuv11111b111, Malt11, and Natural Hesources
Division of Environmental Managome& - Groundwater Section
P-0. BOX 29535 - Raleigh, N.C. 27626.0535
r Phone [phone] u �
WELL CONSTRUCTION RECORD /
tLj ;I
DRILLING CONTRACTOR: H,CAL•DWBL•L DRIL•LTt3Q
DRILLER REGISTRATION NUMBER: STATE WELL'G N
_1537 PERMIT NUMl3ER:
1. WELL LOCA•
Nearest Town:
(Road, Community, or
2. OWNER
ADDRESS
g
of the location below)
n A
County:
�
or Mute No.)
r `-T 3. DATE DRILLED PUSE OF WELL
4. TOTAL DEPTH LL"DA -'
5. CUTTINGS COLLE CTED YES ❑ NO❑ .'7
6. DOES WELL REPLACE EXISTING WELL? YES M PJOM
7. STATIC WATER LEVEL Below -Top of Casing: LL�rFT,
8. TOP OF CASING IS (Use •,• if Above Top of Casing)
FT. Above Land Surface`
• Casing Terminatyd at/or below land surface is Illegal unless a variance Is Issued
In accordance with 15A NCAC 2C •,0118
9. YIELD (91343,2--L METHOD OF J EST /
10. WATER ZONES (depth): i
11. CHLORINATION: Type— ^r[1Amount 2
12. CASING:
/ Diameter Depth Wall Thickness
P r eighUFt. Material
From To 0 Ft. -
From To Ft.
From To Ft.
13. GROUT:
Depth Maleria od
From_ To -La— Ft.
.From To Ft.
14. SCREEN:
Depth Diameter Slot Size Material
From To Ft in. In,
From To Ft. In. _ In.
From To Ft. In. In,
15. SAND/GRAVEL PACK:
DEPTH
From To r
Q �.8
a. Ar
1880
DRILLING LOG
Formation Description
—4G �ZA � I E
3a G i,M
�n2AoJ ► i �
o
�=
C
p rT'1
ca
-- m
`bo
�•--
--
m
cn =
If additional space is needed usb ba
of ism
_ LOCATION SKETCH
x
(Show direction and distance from at least two State
Roads, or other map reference points)
Depth Size Material l
From To Ft.
From To Ft.
16. REMARKS:
1 DO HEREBY CERTIFY THAT THIS }WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 20; WELL
CONSTRUCTION STANPA0,bSf AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER. .
MG
SIGNATURE OF CONTRACTOR OR AGENT ; •'r.. "!e's•;•
GW 1 REV, 9/91 Ir'Is1�u;� 3a Yetxp1 ... :...�. DATE };
a �4
�I� , ; ;, Submit original to Division of Envkorm*nW Mena meni end' "�` �'� 1,•
r �' iM bopjl.o v v bwnef. • . r

-r w .. a. u.ru�un,nu�, 1 �J ►Vdiulal hasources
Division of Environmental Management - Gr ;water Section
P.O. Box 29536 - Raleigh, N.C. 27626.0635 '
r Phone [phone]) r^
WELL CONSTRUCTION RECORD
DRILLING CONTRACTOR:
STATE WELMMAO&Itok4:5.?4< _:..t
DRILLER REGISTRATION NUMBER:
__1537 PERMIT NUMaER:_'�
1. WELL LOCATION: Thow sketch of the location below)
Nearest Town: V County: Rj NC 4U^ bP g 1
(Road, Cunf SuUvii nd Lot No.) DEPTH
2. OWNER
From To
ADDRESS .P� AL.e�Q(�O .—_.,•�? L f �J r
( eet or Rou No.) p - 7 �e
: z
Ci y or Town State q - a b
• Zip Cod
3. DATE DRILLED USE OF WELL - qD
4. TOTAL DEPTH
5. CUTTINGS COLLECTED YES ❑ NO[]
6. DOES WELL REPLACE EXISTING WELL? YES E] NO�]
7. STATIC WATER LEVEL Below -Top of Casing: I d FT,
DRILLING LOG
Formation Description
A rl� 1 T
C� CZA lT C'
(Use "4" if Above Top of asing) o p
8. TOP OF CASING IS �FT. Above Land Surface*
IL �x
• Casing Terminated at/or below land surface Is Illegal unless a variance Is Issued
In accordance with 15A NCAC 2C • .0110
9. YIELD (gpm): 2 S METHOD OF
10. WATER ZONES (depth):-"' UZ A
11. CHLORINATION: Type ' 10 Amount lU
12. CASING:
Wall Thickness
Depth Diameter or Wei hhU.F,L Material
From. To lie Ft. —J�>
From To Ft.
From To Ft.
13. GROUT:
Depth Material Mejhod
From To 2-0 Ft. ____Mlelf
From To Ft.
14. SCREEN:
Depth Diameter Slot Size Material
From To Ft In. in.
From To - Ft. In. _ in.
From To Ft. in. In.
15. SAND/GRAVEi: PACK:
Depth Size Material
From To Ft.
If additional space is needed use bac9l for
cl
LOCATION SKETCH z
(Show direction and distance from at least two State
Roads, or other map reference points)
r
From To Ft.
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I $A NCAC 20; WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER. .
r
aw-1 aEv, a , SIGNATURE OF COWRACTOR OR AatW. .SY `• ,� MATf: '.
ySUbmit originet to Division Of Ertvlrot>riibnfei Whagemirtt Aria
• (irCllfprj6"lc�t� �'l;ti�tl :f�' 7. •• .. -� ��r ''^�•:: ��i�.�' . �'' .

�' �•..uv nuoln, I Icuuu, d11u vidlutal flesources
Division of Environmental Managems& - Groundwater Section >
P.O. Box 29Fi35 - Raleigh, N.C. 27626.0535'>
21 I r Phone [phone]
WELL CONSTRUCTION RECORD
DRILLING CONTRACTOR: _R.CAhDWSL•), DRILLT>ti
STATE WEL:'tl
DRILLER REGISTRATION NUMBER:_1537 PERMIT NuMl6 ilk
1. WELL LOCAT N: how�sjk�tc�h of the location below)
Nearest Town, , �`"" County:
(toad, Community, or ubdivision and Lot No,) DEPTH' DRILLING LOG
2. OWNER _�� —— From To Formation Description
ADDRESy"�_� o kk Q ti
(Street or Route No.)
lty or own Stale zip e
3. DATE DRILLED 111DD USE OF WELL J t -r
4. TOTAL DEPTH htos,
5. CUTTINGS COLLECTED YES C] NOC]2A
6. DOES WELL REPLACE EXISTING WELL? YES (-j NO( _ _ �Z 0 3 p �� �!�
7. STATIC WATER LEVEL Below -Top of Casing: �_ FT, C-1 f
(Use Y 11 Above Top of Casing)
8. TOP OF CASING IS ( FT, Above Land Surface`
• Casing Terminated allor below land surface Is Illegal unless a variance is Issued
In accordance with 15A N.gAC 2C •.0118
9. YIELD (gpm):_ METHOD OF TEST i e
10. WATER ZONES (depth):
30
11. CHLORINATION: TypeAmount 11/
If additional space is needed use back rm c
12. CASING:
_LOCATION SKETCH w �M
Wall Thickness
FromDepth Diameter or Wei r�ght/Ft, Material (Show direction and distance from at least tv6tat�o .
_ To Ft. ---�—_ _— Roads, or other map reference points) o E„ Q_
From To Ft. .. m=
From _To Ft. ca
o
13. GROUT: z
Depth Material Method. W t,
� o
From J!2____ To 2G7 Ft. z •
From To Ft. ~
Q
14. SCREEN: j
Depth Diameter Slot Size Material °
From To Ft in. In._
From To Ft. in. in.
From To Ft. In. —In.
15. SANDIGRAVEL•' PACK:
Depth Size Material
From To Ft. fyN 4e�
From To Ft.
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 20; WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
AUG
7 200� €f
GW1 RE .ON.SONATUREO CONT '01-OR0 AaF.NT RATE ,
r: , O 1 • �.
Submit orlalnd 0 DMston of EtwkorlmAntei HA1�nogerrart end•bop��o •r,<

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
P.O. Box 29578 - Raleigh, N.C. 27626-0578-Pho a [phone]
WELL CONSTRUCTION RECORD
DRILLING CONTRACTOR:
DRILLER REGISTRATION #:
STATE WELL CONSTRUCTION PERMIT
LALI-115(i (
1. WELL USE (Check Applicable Box): Residential ❑ Municipal ❑ Industrial ❑ , Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use: /il/L.1 g a)4'1rnA
2. WELL LOCATION: SShow s etch of the location below)
Nearest Town: 1�5 Y1 e U -I te- County: AL COYVL b
190 I,U,'a S tt R t Z(A a
(Road, Community, or Subdivision and Lot No.) DEPTH
3. OWNER (L—#*.cZ U C�t,th a-t- i 3 eu From To
ADDRESS
(Street or Route No.)
C�7o' %ltc_ ipCo l� LlZ
City or Town State Zip Code —
4. DATE DRILLED
5. TOTAL DEPTH ? ter°' tl l
6. CUTTINGS COLLECTED YES [-1 NO❑
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO❑ C7
8. STATIC WATER LEVEL Below Top of Casing: FT. J
(Use "+" if Above Top 3f Casing)
9. TOP OF CASING Is FT. Above Land Surface' T
Casing Terminated atfor below land surface is Illegal unless a variance Is Issued In accordance with 15A NCAC 2C .0118 _
10. YIELD (gprrt):!� METHOD OF TE /(/
11. WATER ZONES (depth):
r
12. CHLORINATION: Type Amount 1 1 If additional space is needed use back of form
13. CASING:
Wall Thickness
Depth
Dlamet�r or Weight/Ft. Material
&- f 1?91
From
To
Ft.
From
To
Ft.
From
To
Ft.
14. GROUT:
Depth
Material eth
From G
To 1
Ft.
From
To --Ft.
_
15. SCREEN:
Depth Diameter
From To Ft in.
From To Ft. In.
From To Ft. In.
16. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To Ft.
17. REMARKS:
Slot Size Material
In.
In.
In.
Material
DRILLING LOG
LOCATION SKETCH
(Show direction and distance from at least two Stated
Roads, or other map reference points) "p
p
C3
c..
M
C=
_.,. ran
---
L-3 t
co
=r m
--o
o
tV
v�
r,n:�
c-)
Ul
ca
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANyCE WITH I8A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD,HAS BEEN F F OVIDED TO ,THE WELL OW716
FOR OFFICE USEONLY �t ,` u; r f .r n ✓
Quad No: SIGNATURE OF CO"—CT&'dA AoG kT
Serial No: Submit original to Division ,'of Water Quality and copy to well owner.
GW-1 REV. 1/98
DATE

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section 232343
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: 6ta� /24,04-- l)� d
WELL CONTRACTOR CERTIFICATION #: a :� / S
STATE WELL CONSTRUCTION PERMIT#: -Y�sb-
1. WELL USE (check Applicable eoz): Residential le 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: 8Ld4-w-4,, A,) County. -- - %✓I[i �i
(Road Name an umbers. Community, or Subdivision ar Lot
3. OWNER LI-yv tQ�
Address
City or Town State Zip Code
4. DATE DRILLED
5. TOTAL DEPTH 5gs'
6. CUTTINGS COLLECTED YES ❑ NO[►�
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NOr;7(
8. STATIC WATER LEVEL Below Top of Casing:_ FT.
(Use '+' it Above Top of Casing)
9. TOP OF CASING ISFT. Above Land Surface*
'Top of casing terminated atlor below land surface requires a variance in accor'
dance with 15A NCAC 2C .01 d ^
10. YIELD (gpm): im METHOD OF TEST - o[ h r5
11. WATER ZONES (depth): 3 DD r ' l 4 0 --
12. CHLORINATION: Type 4% 7 Amount / ?
13. CASING:
Wall sickness
Depth Diameaer cv WeightIFL mgedal
FromTo AQ Ft. 41 " 1/6
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From .go_ To e2b Ft.
From To Ft.
15. SCREEN:
Depth 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
DRILLING LOG DEPTH
From To Formation Des=ipUon
If additional space is needed use back d form
LOCATION SKETCH
(Stow drectton and distatnce ftcrn at least two State
Roads, or other map referaxe points)
0
C� o
C a
CZr,
a�
co
%o
m -r
rn�
From To Ft. " --q
0o 0
From To Ft. z
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CGNSTRUCTE D IN ACCORDANCE W!rTH 150. NCAC 2r, WELL
CONSTRUCTION STANDAR. 0 YP:FHIS=F4ECORD HAS BEEN PROVIDED riEL:l OM%ER.
FOR OFFICE USE ONLY O /
Quad PIo: gaGNA EIMN CONSTRUCTItNG Tt E WE1 DATZE
� jf to t@0 vs ajar Quaitmy, Grojo atmr learn wMhin rii day,$
GK•1 ReV. 12,"
Sedw No.
rd:rater St

North Carolina - Department of Environment and Natural Resources - Division of Water Quality • Groundwater Section I J
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone] �'` 8207
WELL CONSTRUCTION RECORD WELL CONTRACTOR: a 1C�0 e lk
WELL CONTRACTOR CERTIFICATION N: 2 -2
STATE WELL CONSTRUCTION PERMIT#: _qo'L
1. WELL USE (Check Applicable Box): Residential � Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
flecovery ❑ Heat Pump Water Injection ❑ Other ❑ if Other, List Use:
2. WELL LOCAT19V: (Show sketch of the location below) p
Nearest Town: - In l Y-I, l0 4 , County: h r Clr v hn
(Road Name and Numbers, Community, or Sub ' Ision and Lot No.) DRILLING LOG DEPTH
3. OWNER s`SP( F tr4l^� From To FonnaSonDescription
Address �r^r py-�V �c 1 �Cf-�Li! Lo
(Street or Houle o.)r' t
City or Town State Zip Code
4. DATE DRILLED _ - I_
5. TOTAL DEPTH 11 n
6. CUTTINGS COLLECTED YES ❑ NOO�
7. DOES WELL REPLACE EXISTING WELL? YES 0 NO�
8. STATIC WATER LEVEL Below Top of Casing: ) FT.
(Use's' If Above Top of Casing)
9. TOP OF CASING IS-_ FT. Above Land Surface*
'Top of casing terminated at/or below land surface requires a variance in accor-
dance with 15A NCAC 2C .011e
10. YIELD (gpm): METHOD OF TEST _IVA a i1
11. WATER ZONES (depth): t Lti - (• ` Cia'��ti1
12. CHLORINATION: Type � X'nr"H
YP Amount � �It addrdonal space is needed use back of focm
13. CASING:
Walt Thickness LOCATION SKETCH
Depth Diameter or Weight/Ft. IAatedal (Show direction and disaance from as least two dilate
From- To P V Ft. 1 ,
Roads, or other map reference points)
From To Ft..
From To Ft.
14. GROUT:
Depth
Material
Method
From _ l._. To 0_ Ft. Q 1-\-� o c� A-
From To
Ft.
15. SCREEN:
c�5
Depth
Diameter Slot Size
Material
ry
From To
Ft In.
in. OCT 1 0 200
From To
Ft. In.
In.
ZZ
From To
Ft. In.
in. Oroundvrater Section
"
16. SAND/GRAVEL PACK:
Asheville Re 'ovalCA)c0ffice
i
,'
Depth
Size
Material
-�
CD
From To
Ft.
From To
Ft.
17.. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A 04CAC 2C, Ve'ELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED ITO THE WEi1 OIAIKER,
FOR OFFICE USE ONLY
Quad No:
Serial No.
V
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Div(slon of Water Quality, Groundwater secticn within 30 days
Grr.t Rev. 12"

P.O. BOX 270e7 - iiALEKiH,N.C. 21011, M11ONE (e 19033-3221 Quad. No. $
Lat. Lora. Po,
WELL CONSTRUCTION RECORD Minor Basin
Basin Cods
Header Ent. GW-1 Ent..__
DRILLING CONTRACTOR' 2f
DRILLER REGISTRATION NUMBER ��� STATE WELL CONSTRUCTION
PERMIT NUMBER:
1. WELL LOCATION; how sketch of'the location below)
Nearest To Q4County:.�-
L
(Road, Co // ty, or S bdlvlelon and Lot NoJ Depth DRILLING LOG
2. OWNER !`l U _iuQ
, LO :g�_-L _ From o Formation Description
ADDRESS
treet or outs o. /
. —e�
Clty or Town State Zip Code
3. DATE DRILLED--fLC... USE OF WELL
4. TOTAL DEPTH _ CUTTINGS COLLECTED ❑Yes -GNo
5. DOES WELL REPLACE EXISTING WELL? ❑ Yes GNo
t). STATIC WATER LEVEL: �6 FT, 0 above TOP OF CASING,
TOP OF CASING IS! O below
FT. ABOVE LAND SURFACE.
7. YIELD (opm} METHOD OF TEST
8. WATER ZONES (depth):
8. CHLORINATION:4 Type 'Amount ,
10. CASING:
Depth Diameter Wall Thickness
s Material
From _.�„_ To -.L v FL'
From _ To __Ft.__,
From To—_Fl..—._
11. GROUT:
Depth Material Method
From %.=._ To ?
From To_,__, Ft.
12. SCREEN:
Depth Diameter Slot Size Material
From __ .__
Tom_ Ft.__
In,
In.
From_,..__
T_.__._ Ft.
in.
in.
From„_-___
To— FL __
kr.
h
13. GRAVEL PACK:
Depth Size Material
From, To Ft.
From_, To-._._.,,,- Fl.
14. REMARKS:
If additional space Is needed use back of form.
LOCATION SKETCH
(Show direction and distance from at least two State Roads.
or other map reference points)
r7
1 DO HEREBY CERTIFY: THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE -WITH 15 NCAC 2C, WELL CONSTRUCTION
STANDARDS, AND ;THAT A' COPY OF THIS RECORD HAS BEEN. PROVIDED TO WELL WNER.
�tr 1 SIGNATURE OF CONTRACTOR OR AGENT DATE
GW-1 Revised 6/86 Submit original to Division of Environmental Management and copy to well owner.

P.O. BOX 270a7-AALBKKKC.27e1L.PHONEW1e)733-3221
WELL CONSTRUCTION RECORD
DRILLING CONTRACTOR f
DRILLER REGISTRATION NUMBER ����
Quad No. �• Serial Ntl.2 v `r
LaL Long. Po -�
Ban
eBa� n Cods
Header Ent. GW-1 Ent. —
VSTATE WELL CONSTRUCTION
PERMIT NUMBER:
t. WELL LOCATION: how skelch of'the location below)
Nearest T . v�fy,
County:.
(Road. Co Ity, or Subdi talon and Lot NoJ
Depth DRILLING LOG
2. OWNER
From To Formation Description
d QC(
ADDRESS -
u
treet or Route o,
— ---
City or Town `,, State Zip Code
3. DATE DRILLED- USE OF WELL
4. TOTAL DEPTH' CUTTINGS COLLECTED ❑ Yes '®-No
5. DOES WELL REPLACE EXISTING WELL? ❑ Yea '-lo
6. STATIC WATER LEVEL: PT. C) above TOP OF CASING,
' ow
TOP OF CASING IS,—f FT. ABOVE LAND SURFACE.
—
7. YIELD (gpm}— METHOD OF TEST _;..� �
8. WATER ZONES (depth):
9. CHLORINATION: Type Amount 2?:
10. CASINO:
,
Wall Thickness
Depth Diameter or Weight/Ft. Material
If additional space is needed use back of form.
�
From _, C To _,, FL_
LOCATION SKETCH
(Show direction and distance from at least two State Roads,
r From ---._. To __.___Ft.
or other map reference points)
From ,__. To _.__,Ft.—
11. GROUT:
Deplo Material Method
From -.. ..__ To.., �...Ft.- � ra. �.2"
From �_.. To._,_.__ Ft._-
12. SCREEN:
o ;
Depth. Diameter Slot Size Material
`)
From To__ Ft.__ w1,�_, In,
From _____-_ To. — Ft. _ in, In.
From. To.__ Fl. __. kt k1.
-=
13. GRAVEL PACK:
n
Deem Size Materiel
From ._ To. Ft.
From.__—.. To—_ Ft.
14. REMARKS:
1 DO HERESY -CERTIFY THAT THIS WELL WAS. CONSTRUCTED IN ACCORDANCE WITH
15 NCAC 2C, WELL CONSTRUCTION
STANDARDSI._AND THAT A COPY OF THIS RECORD HAS BEEN. PROVIDED TO THE WELL WNER.
SIGNATURE OF CONTRACTOR OR AGENT DATE
..___.:.__
GW-I Revised 6/88' ' Submit original to Division of Environmental Management and copy to well owner.

P.O. BOX 27687-RALEKi►i.KC, 27e1t,yHOW (e1e)733-3221 Quad. No. `• 8er121 12 9 y
Lat. Long. Po _
WELL CONSTRUCTION RECORD Bassin Cods
Header Ent. QW-1 Ent,
DRILLING CONTRACTOR U)d Ir
DRILLER _ REGISTRATION NUMBER ���� STATE WELL CONSTRUCTION
PERMIT NUMBER:
1. WELL LOCATION: ( ow sketch of'the location below) /!
Nearest Town: '� 6 County:. _
(Road, Community, or ubdivision and Lot No From
TO DRILLING LOG
2. OWNER c `� y/ Formation Description
ADDRESS
treet or outs o. t v �r
City or Town �,, State Zip Code
3. DATE DRILLED �' /- `% �^ USE OF WELL
4. TOTAL DEPTH CUTTINGS COLLECTED ❑ Yes 'E3-No
5. DOES WELL REPLACE EXISTING WELL? ❑ Yea "E3-No
8. STATIC WATER LEVEL: FT, 0 above TOP OF CASING,
TOP OF CASINO IS / O below
-� FT. ABOVE LAND SURFACE.
T. YIELD (gpmr // METHOD OF TEST
8. WATER ZONES (depth): - •/-24�
8. CHLORINATION: Type h07 Amount
10. CASING:
Wall Thickness It additional space Is needed use back of form.
Depth Diameter or Weight/Ft. Material
From To Ft. 61,
�1�/� LOCATION SKETCH
-,G==- (Show direction and distance from of least two State Roads,
From -_ To ___Ff.__ or other map reference points)
From To _..._Fl._..__ I
1 i. GROUT:
From
Depth ^material Method
_,.�„_ To..,.:�`Ft.
From To. Ft.
12. SCREEN:
Q0
Depth Diameter Slot Size Material k©
From._To...._._ Ft._,_,.. IN
From,_ To FI. n�
s k1. in.
From.. To
13. GRAVEL PACK:
Depth Size Material `vrp
From To,_„_, Ft. W
�7f . ..
From , To_.__ Ft.
14. REMARKS:
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE•WITH 15 NCAC 2C, WELL CONSTRUCTION.
STANDARDS, AND THAT A -COPY OF THIS RECORD HAS BEEN. PROVIDED TO THE WELL WNER.
1'I"`c SIGNATURE OF CONTRACTOR OR AGENT DATE /- 9
GW 1 Revised 6/88 Submit original to Divislonf E i
o nv ronmental Management and copy to well owner.

P.G. atilt 27087 - PALEX)KKC. 2701 t, MiONE (e1e)733-3221
WELL CONSTRUCTION RECORD
A
DRILLING CONTRACTOR E
• DRILLER REGISTRATION NUMBER ���
20295$
Quad. NO. esd.
Lat. Long._ Po...
Minor sawn
Basin Code
Header Ent. QW-1 Ent.._,
STATE WELL CONSTRUCTION
PERMIT NUMBER:
1. WELL LOCATION: ( ow s�, slch ol'the location below)
Nsarott Town:
County:. _ �cJtLi rive
(flood, Cc I , or Subdlvlsl n and Lot NoJ
Depth DRILLING LOG
/
2. OWNER ri c r 1
From Tod Formation Description
ADDRESS _CL 1
/ �r
treat or outs o.
City or Town �•.. State Zip Code
3. DATE DRILLED 4_ 'j�I'
USE OF WELL �
4. TOTAL DEPTH CUTTINGS COLLECTED ❑ Yes -allo
5. DOES WELL REPLACE EXISTING WELL? ❑ Yes allo
8. STATIC WATER LEVEL: . FT. O above TOP OF CASINO,
' ow
TOP OF CASING IS ! _ FT. ABOVE LAND SURFACE,
T. YIELD (gpmr METHOD OF TEST
8. WATER ZONES (depth):
'
!i. CHLORINATION: Type Amount
,
,
10. CASING:
Wall Thickness
Depth Diameter or Weight/Ft. Material
It additional space Is needed use back of form.
From 6) To _ 5- Ff. 4, OW
LOCATION SKETCH
(Show direction and distance from at least two State Roads,
r From To __Ff.
or other map reference points)
From -To _..-._Ft..-.__
11. GROUT:
Depth Material Method
From _ 6___,_ To._Ft.
From ___ Tc. Ft.
12. SCREEN:
Depth Diameter Slot Size Material
o -_
-tea _
From. Tom.._.. Ft.____,_, In. in,
n' -
Q7
From __ To- Ft. in In.
From. To._._._ Fl. .__ h h
13. GRAVEL PACK:
=i
•
Depth Size Material
C.0-
v �;
From__ To___, Ft.
`
From_.._To_,_,_-.. Ft. _
t4. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE
WITH 15 NCAC 2C, WELL CONSTRUCTION
STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN.PROVIDED TO THE.WELL WNER.
1�
�J d _
SIGNATURE OF CONTRACTOR OR AGENT DATE
GW-1 Revised 6/88 J' Submlj r'j' Inel o bbivlsion
of Environmental Management and copy to well owner.
e� t is •

P.O. BOX 276a7-RAWIGKKQ 27011,,pHONE (e/e)733-3221
WELL CONSTRUCTION RECORD
DRILLING CONTRACTOR f
DRILLER. REGISTRATION NUMBER
Quad. No. 8er1)lQ02a
Lat. Long._ PO r.
Ben
Basin Cods
Header Ent. QW-1 Ent.
STATE WELL CONSTRUCTION
PERMIT NUMBER:
1. WELL LOCATION: (Show sketch 014he location below)
Nearest Town:fir lJ /x
County:.
(Road, Communlry, o . ubdiviston and Lo NoJ
Depth DRILLING LOG
2. OWNER
From TO Formation Description
ADDRESS
—_
Op �;( f��I,L,r treat or Route o.
City or Town �,, State Zip Code
3. DATE DRILLED - 9= -' - 9 e7 USE OF WELL
4. TOTAL DEPTH /4� CUTTINGS -COLLECTED ❑ Yes i3-No
5. DOES. WELL REPLACE EXISTING WELL? ❑ Yea •-No
8. STATIC WATER LEVEL:-- ,_.. PT, O above TOP OF CASING,
ow
TOP OF CASING ISM_ FT. ABOVE LAND SURFACE,
7. YIELD (gpm} ,70 METHOD OF TEST
8. WATER ZONES (depth): -_ /4.ti'
9. CHLORINATION: Type „ 9 Z 'Amount
10. CASING:
Depth
Diameter or Weight/Ft a Material
From ._!L_ To_
Ft.
r From
To .__.FL___
From -.-_.._,
To ------Ft..
11. GROUT:
Depth
�Materlai
Method
From
G_:..,_ To._Ft._,1�d�
From ___-
To..._..,,_
Ft.
12. SCREEN:
If additional space Is needed use back of form.
LOCATION SKETCH
(Show direction and distance from at Mast two State Roads,
or other map reference points)
Depth. Diameter Slot Size Material
From —_ To..._._.,, Ft._,_.,,_ h.__ in.
From-_._._ Tc � Ft. irL __ in.
From— To. FL in. in.
13. GRAVEL PACK: 1
Depth Size
Material
From, To—. F6
From,. To__..... Ft.;
14. REMARKS:
c
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15 NCAC 20, WELL CONSTRUCTION
STANDARDS, HAT AyCOPY OF THIS RECORD HAS BEEN -PROVIDED Tt� WELL W11 9
r j Q
Gw ,
-1 Revised 6/88
.�.*- 1 /4 — /—
SIGNATURE OF CONTRACTOR OR AGENT DATE
Submit original to Divlslon of Environmental Management and copy to well owner.

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
WELL CONSTRUCTION RECORD WELL CONTRACTOR: P-lho o ks. a Mn u�� t�� P�>✓t7�n
WELL CONTRACTOR CERTIFICATION #: _ 2 �
STATE WELL CONSTRUCTION PERMIT#: _\0 t7'L
1. WELL USE (Check Applicable Box): Residential (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: J",. A 1ti r County: - l n C1_-�y he
(Road Name and Numbers, Community, or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER _ T0cy-) �(� 41 e t tr From To FormaSon Description
Address C`� �SC) A 2 C� —(�.�.
tree, or oute o. �L� ���
MC,
City or Town Stale Zip Code ,
4. DATE DRILLED - I-C�
5. TOTAL DEPTH 2oG�
6. CUTTINGS COLLECTED YES ❑ NOE'
7. DOES WELL REPLACE EXISTING WELL? YES [] NOa
8. STATIC WATER LEVEL Below Top of Casing: r • ) FT.
(Use •+• It Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface -
'Top of casing terminated at/or below land surface requires a variance In accor-
dance with 15A NCAC 2C .0118
10. YIELD (gpm): Ln METHOD OF TEST _L'131n
11. WATER ZONES (depth): - C2C -k k &cy)
12. CHLORINATION: Type Amount_ If additional space is needed use back of form
13. CASING:
Wall Thickness LOCATION SKETCH
n Depth Diameter or Weight/Ft. Material (Show direction and disftnce from at least two Stale
From- To � Ft. -X o ` k Roads, or other m;mp reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From To 0 Ft. (" 0 r)r\ o n i _
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 CONSTRUCTED IN ACCORDANCE WITH 15A 114CAC 2C, YOELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED 'TO THE WF_It.1 OWNER.
FOR OFFICE USE ONLY
Quad No:
Serial No.
- X-1-
SIGNATURE OF PERSON CONSTRUCTING THE WSLL OAT• E
Submit odgirul to Divfslon of Water Quality, Groundwater Section within V days
Gvr•1 Rt=V. 12"

� P.O. BOX 27�93�
ee7- 11ALEKiF1,N C. 41011r j'HONE (e 1e)133-3221 Quad. No. Serfel ��-
Lat. Long. Pc
MkW Basin
WELL CONSTRUCTION RECORD Basin Code
Header Ent. GW-1 Ent._
DRILLING. CONTRACTOR
DRILLER. REGISTRATION NUMBER ���� STATE WELL CONSTRUCTION
D
• PERMIT NUMBER:
1. WELL LOCATION: (Sh )v sketch o('the location below)
Nearest To / County:.
Depth DRILLING LOG
(Road, Comm Ity, or Sub dl lelon and Lot NoJ From o / Formptlon Description
2. OWNER seldxtL
ADDRESS
tress or uls o. /
City or Town �,. State Zip Code
3. DATE DRILLED 9— Q f/'f USE OF WELL
,. TOTAL DEPTH CUTTINGS COLLECTED ❑ Yes 'e ft
5. DOES WELL REPLACE EXISTING WELL? ❑ Yes 0-No
6. STATIC WATER LEVEL: . FT. O above TOP OF CASING,
O below
TOP OF CASINO IS FT. ABOVE LAND SURFACE.
7. YIELD (gpm} METHOD OF TEST
8. WATER ZONES (depth):
9. CHLORINATION:
Type Amount
10. CASING:
Wall Thickness If additional apace is needed use back of form.
Depth Diameter or Weight/Ft. Material
i� -LOCATION SKETCH
From �_ To Ft
�IOVC(Show direction and distance from at least two State Roads,
r From
To FL or other map reference points)
From
To —Ft._ .
11. GROUT:
Depth " Material Method
From _A To- �Ilej -Ft.�!
From _..
c u�
To— Ft.
C
12. SCREEN:
N --
Depth Diameter Slot Size Material
From,
To_.._ Ft.,_ h, in. �' Y
From.:__
To— Ft. h. h. ;j
From—
To._..._ FL k1. In,
13. GRAVEL PACK:
,' • rn o
Depth Size Material
From
To. Ff.
From
Jo. Ff.
14. REMARKS:
I DO HEREBY_
CERTIFY, THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE'WITH 15 NCAC 2C, WELL CONSTRUCTION
"AND
STANDARDS, THAT A`COPY OF THIS RECORD HAS BEEMPROVIDED TO THE WELL WNER.
SIGNATURE OF CONTRACTOR OR AGENT DATE
OW-1 Revised 8/88 i .'';
Submit original to Division of Environmental Management and copy to well owner.

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section UU
1636 Mail Service Center - Raleigh, N.C. 27699.1636-Phone [phone] �- i Q 2 1 1
WELL CONSTRUCTION RECORD WELL CONTRACTOR: 2aht-G aka I�hr�l t 1P l t �- t 1✓v
WELL CONTRACTOR CERTIFICATION #: Z2`�
STATE WELL CONSTRUCTION PERMIT#:
1: WELL USE (Check Applicable Box): Residential l_f 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: County:
" � L Q.4-fl"ltC1 l t
(Road Name and Numbers, Community, or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER _ S& ` 5V-CJ emu'-* 1 From To Forrna5an Description
Address
treat or out�e o. Cirt "'—"'- ---
C _ Q `7 Ij Z �l
City or Town Slate ZIP Code
4. DATE DRILLED 231-0C,
5. TOTAL DEPTH U ?
6. CUTTINGS COLLECTED YES ❑ NO[��
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NOO-
B. STATIC WATER LEVEL Below Top of Casing: S (p FT
(Use'+' it Above Top of Casing)
9. TOP OF CASING IS�_ FT. Above Land Surface*
'Top of casing terminated at/or below land surface requires a variance in accor-
dance with 15A NCAC 2C .0118
10. YIELD (gpm): t ',) METHOD OF TEST ti
11. WATER ZONES (depth): _ (ii 000 k' 1 O-'�
1 n rl - lr -1
12. CHLORINATION: Type _ �lA Amount C. I If additional space its needed use back of form
13. CASING: is
Wall Thickness LOCATION SKETCH
From —Depth Diameter or Weight/Ft. Material (Show direction and dis3ance from ad least two State
TO D Ft. - I n " 1-Roads, or other map reference points)
From To Ft.
From —To Ft.
14. GROUT:
Depth Material Method
From _ To 1 Q Ft. 0-0 Elk Lr1E OI c, c
c
From To Ft. ••....m .�
15. SCREEN: Y
f
Depth Diameter Slot Size Material ry
From To Ft In, in. OCR is %( p�l'
rn
From To Ft, in. In.
From To Ft. In, In. r , v
16. SAND/GRAVEL PACK: Croundwatec�
IL
Depth Size Material'
From To Ft. t - '
From To Ft.
17.. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A 114CAC 2C, VYPELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED 70 THE WElf 104AnER.
FOR OFFICE USE ONLY
Quad No:
Serial No.
SIGNATURE OF PERSON CONSTRUCTING THE WrELL
Submll original to Division of Water Ousifty, Groundwater SecW within V. dayS
- L I v V
OATE
Gvr.1 REV, 12'99 -

P.O. BOX 27e87 -RALEK KICC. 276I f,,MiONE (e11e)733-3221
WELL CONSTRUCTION RECORD
DRILLING CONTRACTOR id . f
DRILLER REGISTRATION NUMBER �'
Quad. No. Serial ( 7
Lat. Long. Po
or
eBas n Coadee
Header Ent. QW-1 Ent.__
STATE WELL CONSTRUCTION
PERMIT NUMBER:
1. WELL LOCATION: (Show sketch of•the location below)
Nearest Town: {
County:. grim
(Road, Corrlmur ",I. or Su III I and Lot NoJ
Depth
DRILLING LOG
2. OWNER_
Fro
Formation Description
ADORES$ / .vim
3 D //v <,y �
.
treat or Ro is o.
City or Town�q �,. State ZIP Code
3. DATE DRILLED OF WELL L�
,. TOTAL DEPTH .,LLZ),,' CUTTINGS COLLECTED [I Yes Q•No
5. DOES WELL REPLACE EXISTING WELL? ❑ Yes S No
8. STATIC WATER LEVEL: = PT, 0 above TOP OF CASING,
TOP OF CASING IS FT. ABOVE belLAND SURFACE.
7. YIELD (gpm). / METHOD OF TEST
8. WATER ZONES (depth): —
1
9. CHLORINATION: Type _ram Amount
10. CASING:
,
Wall Thickness
Depth Diameter or Weight/Ft. Materlal
If additional space Is needed use back of form.
From _,_.,,_ To �Ft
LOCATION SKETCH
(Show direction and distance from at least two State Roads,
' From To —Ff.—
or other map reference points)
From _, To -----.Ft.._-.___
11. GROUT:
Depth Material Method
From To- Ft.,_
From __. To._.__ Ft.
`
2. SCREEN:
Depth Diameter Slot Size Material
From _.___-, To_-,._,_ Ft.kL In.
rn
From __ To Ft. _._ ItL in.
From. TO— Fl. __ kL h
<!Jl
7. GRAVEL PACK:
Depth Size Material
From. To, Ft. 11
r; �.;
irk
ca -�
From._,__,_,To_._._ FL-_ ��....
!. REMARKS;
1 DO HEREBY..CER_TIRY THAT TRI.S..,WE_LL. WAS CONSTRUCTED`IN ACCORDANCE WITH 15 NCAC 2C, WELL CONSTRUCTION
STAND �11HA7 COPY OF THIS RECORD HAS BEEN. PROVIDED TO THE.WELL WNER.
_
SIGNATURE OF CONTRACTOR OR AGENT DATE
W1 Revised 8/88Y + 0 ICG'P Submit original to Division of Environmental Management and copy to well owner.

P.O. BOX 270e7-RALbKiFMC, 27e11, PttONE (p19)733-3221
WELL CONSTRUCTION RECORD
DRILLING CONTRACTOR
DRILLER REGISTRATION NUMBER
I. WELL LOCATION: (Sho/w�skelch of -the location below)
Nearest Town: Lf �G�.� 1/t a
(Road. Co and Ity, or Subdivision Lot NDj •
2. OWNER
ADDRESS ^_S9
street r uta No.
City or To
State 21p C e
3. DATE DRILLED ` 3" USE 6F WELL s-C�
4. TOTAL DEPTH � CUTTINGS COLLECTED ❑ Yes
5. DOES WELL REPLACE EXISTING WELL? ❑ Yes Flo
8. STATIC WATER LEVEL:.i.0_, FT. O above TOP OF CASING,
ow
TOP OF CASING IS�_ FT. ABOVE LAND SURF CE.
T. YIELD (gpmr a METHOD OF TEST
0. WATER ZONES (depth): ao7Q o,20 4 -%
9. CHLORINATION:
10. CASINO:
Quad. No. Se►IaI��J
Let. Po
Minor Basin
Basin Code
Header Ent. OW-1 Ent.._
STATE WELL CONSTRUCTION
PERMIT NUMBER: %y/' 7
County: _ e-G4—p
Depth DRILLING LOG
From To Formation Description
C�
•
l7
ype Amount --3 0 o
Depth %� DI meter Wall Thickness
s Ma rl►'
To eA
From ;t 7j
r From -To ---Ft.
From To—__Ff.......... __..
11. GROUT:
Depth If Material Method
From �_ To- _Ft.
From s To._. Ff. _
12. SCREEN:
Depth Diameter Slot Size Material
From To- Ft.
From To—_ Ft. ---_._. h___,_-- M.
From To----- Ft.
13. GRAVEL PACK:
If additional space Is needed use back of form.
LOCATION SKETCH
(Show direction and distance from at least two State Roads,
or other map reference points)
Depth Size Material
From To_—,- Ft
From --- To Ft._
14. REMARKS: lL�r�
100 R $Y[10E�f141.Y THAT`THIS WELL WAS CONSTRUCTED IN ACCORDANCE•WITH 15 NCAC 2C
ARDS, Al�q THAT A OPY OF THIS RECORD HAS BEEN. PROVIDED TO THE WELL OWNER. WELL CONSTRUCTION
OCT I 4 1999
SIGNATURE OF CONTRACTOR OR AGENT DATE
GW-1 evl4 g/gg _ Submit original to Division of Environmental Man
. �t'tturi(9v�f€A a aka �fem � agement and copy to well owner.
Asheviil� `s�eitel 9(

P.O. BOX 270a7-nALEK*kK. C. 27e11,,PHONE (e1e)733-3221
WELL CONSTRUCTION RECORD
DRILLING CONTRACTOR
DRILLER REGISTRATION NUMBER
Quad. No. SerQ41jZ,
Lat. Lore. -�� Po
Minor Basin
Basin Code
Header Ent. QW-1 Ent.
STATEWELL CONSTRUCTION
PERMIT NUMBER:
I. WELL LOCATION: (Show sketch of'the locatiyn below)
Nearest Town:
County:
(Road, Ccmmtx�lfy, or Subdivision and Lot No,) Depth DRILLING LOG
2. OWNER
ADDRESS
carry or Town VState ZIP Code
3. DATE DRILLED 4t2 USE OF WELL
4. TOTAL DEPTH ll,�_, CUTTINGS COLLECTED ❑ Yes
5. DOES WELL REPLACE EXISTING WELL? ❑ Yes Q-N-0
8. STATIC WATER LEVEL: PT, p above
O below TOP OF CASINO,
• TOP OF CASING IS FT. ABOVE LAND SURFACE.
7. YIELD (gpm} METji .D OF T ST
• 8. WATER ZONES (depth): M17
9. CHLORINATION: Type Amount
10. CASING:
Depth Wall Thickness
r� Diameter or Weight/Ft. Mtteerlaalll
From To Ft.
r From To -----Ft.
From
---•� To ---.Ft. _
11. GROUT:
Depth Material Method
From TO-- , Ft.
From To,_.,_,_ Ft.
12. SCREEN:
Depth Diameter Slot Size Material
From --...__._ Tom._ Ft. IM __ In.
From - Tq....__ Ft. .
From TO-- , FL . in•,_,__ in,
13. GRAVEL PACK:
From To Formation De8crip8on
c� r7
If additional space Is needed use back of form.
LOCATION SKETCH
(Show direction and distance from at least two State Roads,
or other map reference points)
GRO;JDWATER SECTION
• ASHEVILLE REGIONAL OFFII
Depth Size Material
From To,__ Ft.
From---. To- Ft._
14. REMARKS:
ST��I D EJ30YmCFRTIF.Y THAT -THIS, WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15 NCAC 2C, WELL CONSTRUCTION
r_11T C'LS ' I i�) jW RECORD HAS BEEN.PROVIDED TO THE WELL OWNER.
r i '! SIGNATURE OF CONTRACTOR OR AGENT DATE
GW-1 Revved . �1 ��9 j' j Submit original to Division of Environmental Management and copy to well owner.

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: 11 d e yNt L. Q
WELL CONTRACTOR CERTIFICATION #: 2.285
STATE WELL CONSTRUCTION PERMIT#: \ r-IoZ
1. WELL USE (Check Applicable Box): Residential [2'_ Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other 0 If Other, List Use:
2. WELL LOCATI N: (Show sketch of the location below)
Nearest Town: l 11 1 G County: 26 t n YYl k1 D�
(Road Name and Numbers, Community, or Subdivision and Lot No.)
DRILLING LOG DEPTH
3. OWNER
From To Foams cn Description
Address
O t o O
trees o ou a o.
�!�t tAOYA lt^ Z-
City or Town b State Zip Code,
4. DATE DRILLED `1-1"1.On
5. TOTAL DEPTH 0 F�
6. CUTTINGS COLLECTED YES ❑ NO[]i
© `_
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NOCE�'
8. STATIC WATER LEVEL Below Top of Casing: LkQ FT.
C-�:,';
_
(Use'+' it Above Top of Casing)=r_
9. TOP OF CASING IS FT. Above Land Surface*
'Top or casing terminated at/or below land surface requires a variance In accor-
dance with 15A NCAC 2C .0118
10. YIELD (gpm): 2 METHOD OF TEST Z hhA
ca `—
11. WATER ZONES (depth): -
m:n
12. CHLORINATION: Type UTA - Amount
If additional space is needed use back of form —
13. CASING:
Wall Thickness
LOCATION SKETCH
Depth Diameter or Weight/Ft._Material
� �
(Show direction and distance from al least two S ate
From To _.0 C) Ft.
Roads, or other map reference points)
From— To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From C) To 2 n Ft. O LM—L rs1{ _
From To Ft.
15. SCREEN:
Depth
Diameter
From To
Ft In.
From To
Ft. In.
From To
Ft. in.
16. SAND/GRAVEL PACK:
Depth
Size
From To Ft.
From To Ft.
17.. REMARKS:
Slot Size Material
in.
In.
In.
Material
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A 114CAC 2C, YtELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED 1170 THE H/E111 ON'hER.
FOR OFFICE U E'ONLY
Ouad No: SIGNATURE OF PERSON CONSTRU THE WELL DAT£
E0)1
r� '' 'Submlt original to Division of Water Ouality, Groundwater Sectcn within V dVYS
Serial No. OW-1 Rf=v. 12'94

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 WELLCONTRACTOR: Q-71V,_Ltyun ; \,.�'b t l o► irk 0
WELL CONTRACTOR CERTIFICATION #:_228!
STATE WELL CONSTRUCTION PERMIT#: AyoZ
WELL USE (Check Applicable Box): Residential 12'- Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery M Heat Pump Water Injection ❑ Other ❑ if Other, List Use:
2. WELL LOCATI N: (Show sketch of the location below)
Nearest Town: l A l D County: —hk t In tM k o
(Road Name and Numbers. Community, or Subdivision and Lot No.)
DRILLING LOG DEPTH
3. OWNER
Address
From To Fomution Description
O l
(Street o ou a No.y`
fin t`
City or Town 0 State Zip Code
4, DATE DRILLED 7 -1-A • On
5. TOTAL DEPTH 08
6. CUTTINGS COLLECTED YES NO[D­1
7. DOES WELL REPLACE EXISTING WELL? YES NO[!�'
M - —
8. STATIC WATER LEVEL Below Top of Casing: ►{ O FT,
(Use'+' If Above Top of Casing)
9. TOP OF CASING IS- FT, Above Land Surface*
'_,,..-
— ct1
'Top or casing terminated at/or below land surface requires a variance In accor.
dance with 15A NCAC 2C ,0118
10. YIELD (gpm): 2 METHOD OF TEST _ Z
11. WATER ZONES (depth):
K)
-,
12. CHLORINATION: Type ount
c->
13. CASING:
If additional space is needed use back of form
Wall Thickness
Depth Diameter
LOCATION SKETCH
or Weight/Ft. aterial
From Q To l t) t7 Ft.
(Show direction and dLszance from at least two Mate
Roads, or other matp reference points)
From To Ft. —
From ._.__To Ft.
14. GROUT:
Depth Material Method
From _Q_ To 2_ Ft. d E► 0 6 1 _
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft in. In,
From To Ft, in. in.
r
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 CONSTRUCTED IN ACCORDANCE WITH 15A 11QCAC 2C, W'ELL
CONSTRUCTION STANpARDS'ANQ THE T'A COPY OF THIS RECORD HAS BEEN PROVIDED -,TO THE WE11 I OWAER,
FOR OFFICE USE ONLY
Quad No:
Serial No.
!lil i SIGNATURE OF PERSON CONSTRU.. THE WELL Submit original to Oivlslon of Water Quality, Groundwater Secten within 30 days
OA:,'. £
GYM RIEV. 12"