Well Construction Records Buncombe 3 CY2000

12
North Carolina • Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section 8 6
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone] '
WELL CONSTRUCTION RECO
RD WELL CONTRACTOR: /� L
WELL CONTRACTOR CE TiFICATION 0:_l
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential [ID*' Municipal 0 Industrial ❑ Agrlcultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection 0 Other n If Other, List Use:
2. WELL LOCATION: (Show,�kt?tch of the location below) ��✓ �
Nearest Town: C,¢'" / e-1,*-::, County:
LOG DEPTH
_
(Road Name and Numb /Q,r-r,, C
3. OWNER m'/ y9{IyNor �ubivision and Lot No.) DRILLINGFormation Description
0j �i( From To
Address
totreet or ou a o,
City or Town Staten Zip Code
4. DATE DRILLED
5. TOTAL DEPTH `� c�
6. CUTTINGS COLLECTED YES[] NOD
7. DOES WELL REPLACE EXISTING WELL? YE�NO� :7
8. STATIC WATER LEVEL Below Top of Casing: FT.
(Use '+' it Above Top of Casing) t-- --—
d S L
FT. Above anurface" "D -r
9. TOP OF CASING is FT. —
'Top of casing terminated atlor below land surface requires a variance In ec or-
dance with 15A NCAC 2C .pi
10. YIELD (gpm): � METHO F TES ce
rT;
11. WATER ZONES (depth): 2G� cn —+
• o
12. CHLORINATION: Type J Amount It additional space Is needed use back of lorm
13. CASING:
Wall Thickness
Depth Diameter or WelghVFt. Material
From o To Ft.
From— To Ft.
From To Ft.
14. GROUT:
Depth ) Mat vial-(/ Method
From To Ft. �'CJ
From To_Ft.--------
15. SCREEN:
Depth Diameter Slot Slze IMaterlat
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
(Show direction and distance from at least two State
Roads, or other map reference points)
[ft
� 15 C
bc.j
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRU ANDARDS, AND THAT A COPY OF THIS RE ORD HAS BEEN PROVIDED TO THE WELL OWNER.y
OFFI ELL DATE
FOR ' ATUR OF PER CONSTRUCTING THE W
Quad No:
r1
Su Inal to Division of Wale Quality, Groundwater Section within 30 days GW 1 REV. 12199
Serial No. ( _ 12000

;:'A
North
Mali Service CenterDepartment
of igh,Envi N.C. 27699 1638--Phone (919) 733 i3221n of Water Quality •Groundwater Section _14 D12
WELL CONSTRUCTION RECORD WELLCONTRACTOR: A alachian Well-Dril I n
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential® Municipal ❑Industril List Use:
Agricultural ❑ Monitoring ❑
Recovery El Heat Pump Water Injection ❑ Other C] If Other,
2, WELL LOCATION: (Show sketch of the location below) Rtincornbe
Nearest Town: Asheyl 1 1 e - County:.
DRILLING LOG DEPTH
(Road Name and Numbers, Gommunily, or Subdivision and Lot No.) From 7o Formation Dascdplion
3. OWNER Henry Ward
Address 01 H 1t -21]_
ree or oule o,
Asheville Zip coda
City or Town Stale
4.
QATE DRII_LEO_00Ou
—
5.
6.
TOTAL DEPTH __—__----
CUTTINGS COLLECTED YES[] NO®
WELL REPLACE EXISTING WELL? YES EJ NOR]
,•y, •�
='n
7.
8.
DOES
STATIC WATER LEVEL Below Top of Casing: 60 FT.
._
(Use '+' if Above Top of Casing)
9.
1 FT. Above Land Surface-
TflP OF CASING IS --
requires a variance In accor-
l t`
*Top of casing terminated at/or below land surface
dance
with 15A NCAC 2C .0118
20 METHOD OF TEST Gal . COntainex
IV) —
10.
YIELD (gpm):
280
11.
WATER ZONES (depth):
12. CHLORINATION:
13. CASING:
Type Tablet Amount _--2----- 1 It additional space Is needed use back of form -
Depth 60 Diameter
0 To Ft.
From
From To Ft.
From —To Ft.
OUT
LOCATION SKETCH
Wall Thickness
or Welght/Ft. Material (Show direction and distance from at least Iwo State
Roads, or other map reference points)
Hwy. 63
14. GR .
Depth
Material
Method
To
Ft.
Concrete
P-Q ---- r
Frorn
From
To
Ft.
15. SCREEN:
Depth
Diameter Slot Size
Material
From
. To
F1
In.
in.
From
To
Ft.
in.
In.
From
To
Ft.
in.
In.
16. SAND/GRAVEL PACK:
Depth
Size
Material
From
Yo
Ft'
From
To
Ft.
17. REMARKS:___________
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECOI
;�
FOR OFFICE USE O(7LY _ SIG 11TURE 0
Quad No: r 1 Yd z
r� pr/ 5,,�fgdg�pal pfLtslonol
Sedal No. [ l
li F
ryry o+ f
Mt. Carmel RD.
Old 20
CCORDANCE WITH 15A NCAC 2C, WELL
6HAS BEEN DROVIDED TO THE WELL OWNER.
(X i� r'� '12-29-00
SON CONSTRUCTING THE WELL GATE
ouality, Groundwater Section within 30 days rW-1 REV. 12/99

1.
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section �� [ f 4
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELLCONTRACTOR: Appalachian Well -Drilling
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMIT#:
WELL USE (Check Applicable cox): Residential ® Municipal ❑ industrial ❑ Agricultural ❑ Monitoring ❑
1 •
Recovery ❑ Heat Pump Water Injection ❑ Other n I( Other, List Use:
2. WELL LOCATION: (Show sketch of the location below) Buncombe
Nearest Town: Enka County:
DEPTH _
(Road Name and Numbe(s. Community. or Subdivision and Lot No.) DRILLING LOG Formation Description
3. OWNER Gary Latharn From To
Address P6 Box 332 o
— •�•
reo or ou a o. .Enka NC 28728
Zip Code
City or Town State ?s
r
4• DATE DRILLED --2n—o0
5. TOTAL DEPTH
YES O NO®
C-c -
6. CUTTINGS COLLECTED
DOES WELL REPLACE EXISTING WELL? YES EJ NO©
`)1i:1
7.
8. STATIC WATER LEVEL Below Top of Casing: 60 FT.
(Use '+' If Above Top of Casing)
9. TOP OF CASING IS 1 FT. Above Land Surface'
'Top of casing terminated at/or below land surface requires a variance In accor-
dance with 15A NCAC 2C .0118
10. YIELD (gpm): 40 METHOD OF TEST Ga 1 ,on ; ner
y
11. WATER ZONES (depth): 187
12. CHLORINATION: Type Tabl e t Amount If additional space Is needed use back of form
13. CASING: LOCATION SKETCH
Wall Thickness
Depth Diameter or Weight/Ft. Material (Show direction and distance from at least two State
(� 54 Ft. Roads, or other map reference points)
From To
From To Fl.
From To Ft. 19-23
14 GROUT:
Depth
Material
Method
Enka Lake Rd.
From To
Ft. Concrete
Pour
From To
Ft.
Twin Lakes Rd.
15. SCREEN:
Depth
Diameter Slot Slze
Material
Valley Dr.
From To
Ft in.
In.
From To
Ft. in.
In. -
From To
Ft. In.
in.
16. SAND/GRAVEL PACK:
Depth
Size
Malarial
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 HA6 BEEN PROVIDED TO THE WELL OWNER.
(vL;C-(f 12-29-00
FOR OFFICE USE ONLY
Quad No:
IGNATURE
itod nal to Division
,.".SubrnSadil
No.
t
F PERSON CONSTRUCTING THE WELL
Water Quality, Groundwater Section within 30 days
DATE
GW-1 REV. 12/99

North Carolina • Deparlmont of Environment and Natural Resources • Division of Water Qgality • Groundwater Section r )
1636 Mail Service Center . Raleigh, N.C. 2709.1636-Phone [phone] t 2
WELLCONTRACTOR-Appalachian Well -Drilling
WELL CONSTRUCTION RECORD WELL CONTRACTOR CERTIFICATION 0: � ajf 1 7/����.
STATE WELL CONSTRUCTION PERMIT#: i
WELL USE (Check Applicable Box): FieSidentla) d Municipal Industrial El
Agricultural Monitoring �
i .
Recovery 0 Heat Pump Water Injection 0 Other d If Other, List Ilse:
2.
WELL LOCATION: (Show sketch of the location below)
Nearest Town:. C'3nr11 ar ._..__— County: Rrtnrnrnhe
._�
i
_
(Road Name and Numbers, Community, or Subdivision and Lot No.) DRILLt_NG LOG,_,
EPTH
�_
3.
OWNER Chris Sharpe From To
Fo4atlon0oscriptlon
Address 1...�
.`_`---
ree ar ou a o,
TT(�
City or Toowwnn �Stat— a �—--
b.
DATE DRILLED
5.
TOTAL DEPTH
6.
CUTTINGS COLLECTED YES 0 NO[�J
DOES WELL REPLACE EXISTING WELL? YES [] NO[AA r _
----—r----- nj
7.
a.
STATIC WATER LEVEL Below Top of Casing: _ 60 FT. _ _
— <
(Use '+' It Above Top of Casing)
9.
TOP OF CASING IS 1 FT. Above Land Surface -
'Top or caring terminated at/or below land surface requires a variance in occor•
dance with 15A t:CAC 2C .D11e
10. YIELD (gpm): 10 METHOD OF TEST GA1— ('nn"i ] Pr
11.
WATER ZONES (depth):—.497
� o
12. CHLORINATION: Type T,1b a) Amount
13. CASING:
wan Thickness
Depth Diarneter or Weight/Ft. Material
From — 0 --To . 2-0— Ft. _
From
To FI.----------•-------- —
from
To ---- FL --
t 4. GROUT:
Depth Material Method
From ____
To _.._____Ft. _�DS1CrPf a PrnT�
From _
w To --Ft.
15 SCREEN:
if additional apace is needed use (jack of form
_LOCATION SKE7 H
(Show direction and distance from at lgast twa Slats
Roads, or other map reference points)
19-23
151
Upper Gladyfork
Depth Diameter . Slot Slze Niaterial Audria Dr.
From _To Ft in. in.
From --To To Ft- In. In. Laurel Ridge
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, W4LL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD BEEN PROVIDED TO THE WELL OWNER.
_ 12=11-00
FOR OFFICE USE ONLY — �� DATE
r -,a No SIGN RE OF PERSON C STFUCTlN(3 THE WELL
je, [ Submit original to Dhvlsion or Water QuOlY, Qroundwalsr Section within 3D days
&9 J o'W- FIEV.12I99
'�seaar�r�:—F

hor h Ciroiina • Dapartn+nnE a! Enviraur+'M end Netuml Rojources • Division of Water 04e11fy • ff"n'dweter Section
1636 MaSI Sarvico Center • AsIoigh, N.C. 27034-1636-Pfwne [phone]
1-1282'7
WELL CONSTRUCTION RECORD WELLCONTRACTOR: Tlnald rU
WELL CONTRACTOR CERTIFICATION #:,
STATE WELL CONSTRUCTION i°RrRMIT'It
WELL USE (chock Applitsbt' 900 Residential ICJ Municipal IJ 0 if tJtheuu*;u
ReC0ver^y 0 twat Pump Waster In+evtlon [�
Agricultural
1. WELL LOCATION: (Show sketch or the location below)
i^I��`w.� r �> i l l p �. diOUrlty' .----••-.�.�{}�. ''.
Neerost Town:. ;f
�(�ioAd Na,r„ sea lvcx++bsrx, Cornrrwr+t aty Subdtvtsion and Lot No.) From TO
3 OWNER
Address -""'-
rae ar ou ---
City uo Twon State zip Coda
a. DATE DRILLED 11-31�-_00
S. TOTAL DEPTH _--_-107
6. CUTTINGS COLLECTED YES Np
7. DOES WELL RE -PLACE EXISTING YES [,� NC)�
B. STATIC WATER LEVEL Below Tap at Cae1ng: _ fi2 FT.
(Use "s' i! Abare TOP of CA*V)
9. 'TOP ()F CASING IS 1-_ , FT. Above Land Surface` _
•lop of casing lorminsled eWor balow fartd surfsrts rsqutres s verlbnc't„ steer•
dent' with 15A NCAC 2C .011e METHOD OF TEST r, ^ i - c �s°� iya4
1Q. YIELD(gpm): _..5._.
11 WATER ZONES (depth): ,_..,.._ w..
Monitoring 0
TH
Fo Bon Dostriptlon
r �
12. CHLORINATION, Typt► •-- t`- Amrsualt
h
13. CASING, LOC T19U A SLIM
Well Thitwwss
Depth Diameter of Wg1ghl"rt. f edsl
From--Q----- To . 6.Z.....- Ft.
From--.-
To..._— FI. - --
Fran --To
,...._.._. - Ft.------------
t d. GROUT:
Depth Materiel Method
Concrete Pour
From
To
From ___
To
15. SCREEN:
Depth Diameter Slot Slx6 Material
From
To _ Ft _ in. -� in.
- --
From
- To - Ft.._.. -- In. In.
From
_ To Ft. _ ___T In. In.
16. SAND/GRAVEL PACK: (+,taferfaE
Depth Size
Cl -------- - -_`"
(Shorn dit"Wil er+d ditit�t9G11 barn St Matt two $tat'
Roede, or 0119e1' rr+ep rtlatet "i> e)
19-23
Jupiter Rd.
Old Mars Hill Hwy
Locust Grove Rd.
Frorn � Co -•- . ------------'
From To. ____. Ft. --• ----------- --
17. REMARKS.----�
100 ►t[REi3Y CERTIFY THAT THISWELL WAS UCPY di? THIS RECOUr ACCORDANCE Fl;OV1DeD TO T 4 OWNER.
CpNSTf UGTtpf4 STANDARDS. AND THAT , _ _ . _ .rs4�� 1 9: 4-0-0- .--
- DATE
F0A 1�nr USE ONLY SIGN Rfl OF PCR50N C 97PItlC7IW THE WELL
Ousd No' Subrn4 oAglnst to Division of Wotr►r wSilly, Gv*U +dw&0, s'tucn within 30 do I(s 0-01.1 FtF,V i2ii9
-ern
.: FV,I

. i
North Carolina - Department of Environment and Natural Resources . Division of Water Ovallty • Groundwater Section j � 2 2 8 2 4
1636 Mali Service Center • Raleigh; N.C. 27699.1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: o i r,t,; r tT�� h n-,�.. _
WELL CONTRACTOR CERTIFICATION 0:-
STATE WELL CONSTRUCTION PERMIT#.,
WELL USE Applicable Box): Residentlal Lo Municipal ❑ Industrial p Agricultural Monitoring
❑
1. (Check
Recovery Q Heat Pump Water injection Q Other (J It Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: fit' i C P S 1- P r -- County: __CZ QMb
(Road Name and Number, Convnunity, or Subdivision and Lot No.) DRILLING_ LOG LE —PTH
3. OWNER Gar- v Gri f n From To Fortatlon Descriptlon
Address
ree O( OU 9 O
Leicester NC 2874g._
City or Town State ZIp Code
4. DATE DRILLED----44-24-00
S. TOTAL DEPTH - O
6, CUTTINGS CULLEC YES Q NOM
7. DOES WELL REPLACE EXISTING WELL? YES (� N04 -r---- � �rn
a. STATIC WATER LEVEL Below Top of Casing: �:`�•(�` FT•
Iof
(Use '+' N Above Top Casing) _
9. TOP OF CASING IS___l — t`T• Above Land Surface` CA
T
'Top of casing terminated atior below land surface requires a variance In accor•
�
dance with 15A NCAC 2C .011D =C
- -
10. YIELD (gpm): 0 METHOD OF TEST _G l LOnLai.ng - CO
�?
rn --.
11. WATER ZONES (depth): - -
•
_
c>
12. CHLORINATION: Type Ta a1 P t­ Amount 2 it additional apace is needed use hack of Iorm
o
x
13. CASING:
�LOCATION SKETCH
wea thickness
Depth Diameter or Weight/Ft. Material (Shaw direction and distance from at lust two State
From __....LL._.-- To _.�-r3— Ft. --- —-------- Roads, or other map reference pants)
From - - To Ft. —
Hwy. 63
From To —•— FI._------�--
14. GROUT:
Depth Material Method L on Sherri Dr.
From To Ft. -
-fir-From To Ft. — Corner of Miahael Dr
15, SCREEN:
Depth Diameter Slot Size Material
From To . Ft in. In. -
From To Ft. in. in. -
From -- To Fi. In. . in. _ -
16. SAND/GRAVEL PACK:
Depth Size Material
From To--. Ft.
From To—____. Ft.
17. REMARKS: — —
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C. WgLL
CONSTRUCTION STANDARDS. AND THAT A COPY OF THIS RECORD BEEN PROVIDED TO THE WELL OWNER,
FOR OFFICE USE ONLY
F
FOR No: SIGN RE OF PERSON C STRUCTINCi THE WELL DATE
OuadSulNnll ortpinaI to Division of Water Ouailty, Groundwater Section Within 30 dajlS GW t REV 12/99
LFE6
3
&'ruttttrlei:�att;r Sec�l;�,

North Carolina . Department of Environment and Natural Resources • Division of Water Oyallty - Groundwater Section 2 82 8
1636 Mali Service Center • Raleigh, N.C. 27699.1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: A pPalachian Well-Dril
WELL CONTRACTOR CERTIFICATION 0:_
STATE WELL CONSTRUCTON PERMIT#:
1. WELL USE (Check Applicable Box): Residentlal � Municipal Q
IndusPtriai ❑ Agricultural ❑ Monitodng El
Recovery ❑ Heat Pump Water Injection Q Other Q
If Other, Last Use:
2. WELL LOCATION: (Show sketch of the location below)
'he
Nearest Town: ___CB —» County:
--
DRILLING LOG EPTH
_-(Road Name and Numbers, Com-nunity, or Subd %,islon and Lot No.)
3. OWNER _
--7.1_Lll1:I =--
From To Fo ation Doscriptlon
Address
o,reo or ou a o,
Candler NC 2871_5
---
City -CIT.— State Zip Code
-
C:)
a. DATE DRILLED _1-00
-
S. TOTAL DEPTH
YES Q NO U6
c'� c;
6. CUTTINGS COLLECTED
WELL REPLACE EXISTING WELL? YES Q NO[
n
-- -- - Q
7. DOES
8. STATIC WATER LEVEL Below Top of Casing:/ FT•
-- -----------
(Use '+' if Above Top of Casing)
---- —
9. TOP OF CASING IS,FT. Above Land Surface'''
--sr�-
*Top of casing terminated attor below land surlaea requires a variance In aeeor•
.� - •. On X
dance with 15A NCAC 2C .011E C>
10, YIELD (gpm): 5 METHOD OFTESTG.al.. ; CnntanPr
11. WATER ZONES (depth):
-
12. CHLORINATION: Type --T4h1 L-- f- Amount
If additional space is needed use wack of form
13. CASING:
LOCATION 5KET H
Wail Thickness
Depth Diameter or WetghVF►. Material
(Show direction and distance from at I ast two Stale
From ___._0 --To Ft. -- --------
Roads, or other map reference panto)
From To FI.
From To Ft. - ---•--
19-23
1a. GROUT:
Depth
Material
Method
Flom _
To _
Ft. --CLQX
C -Q4
___ pQ• _ 151
From
To
Fl.
15. SCREEN:
Warrens Crk.
Depth
Diameter Slot Size
Material
From ..._..---
To _
Ft
In.
In.
From ._
— To
Ft.
In.
in.
From _To
To
Fl.
ln.
in.
16. SAND/GRAVEL PACK:
Depth
Size
Material
From
To
Fl. _
From _
To
Ft..
_
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WRLL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD BEEN PROVIDED TO THE WEL( OWNER.
FOR OFFICE U8E ONLY ------- DATE
Ouad No: SIGN ;SE OF PEfiSON C STRUCTINCT THE WELL
Submit odgInat 10 Division of Wets: ousiity. Groundwater Section within 30 da3(s t;w t REV. 12199
1, TL
f
Ca
C I�
i ..,h

North Carolina • Department of Environment and Natural Resources - Division of Water Quality -Groundwater Section � ; 24516
1636 Mail Service Center - Raleigh, N.C. 27699-1635-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: ATl2alachian Well-Dri 1 1 i ng
WELL CONTRACTOR CERTIFICATION #: 1,0
STATE WELL CONSTRUCTION PERMIT#:
WELL USE (Check Applicable Box): Residential [V Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection E] Other 0 If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: _Ca n ,11 P r County:. R, in Q nmho
(Road Name and Numbers. Community, or Subdivision and Lot No.) DRILLING LOG
3. OWNER Jerry Hammock __ From To
Address
ree 12
or ou a o.
—r and 1- - �)C zf ode
City or Town State P
4. DATE DRILLED 1 1 —20-0
5. TOTAL DEPTH 9 6 7 --
6. CUTTINGS COLLECTED YES E] NOW]
7. DOES WELL REPLACE EXISTING WELL? YES [� NO®
8. STATIC WATER LEVEL Below Top of Casing: 60 FT.
(Use •+• it Above Top of Casing)
9. TOP OF CASING IS 1 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): 1 5 METHOD OF TEST Gn 1 Container
11. WATER ZONES (depth): 107
12. CHLORINATION: Type Tahl etAmount 9
13. CASING:
14
15
Depth Diameter Slot Siz6
From To Ft in. in.
From To Ft. in. In.
From To. Fl. In. In.
16. SAND/GRAVEL PACK:
Depth Size
From To -Ft.
From To Ft.
17. REMARKS:_
Wall Thickness
Depth
Diameter or WelghUFI. Material
Fromm --To 80 Ft.
From
To
Ft.
From
To
Ft.
GROUT:
Depth
Material Method
From
To
Ft.
Concrete Pour
From
To
Ft.
SCREEN:
Material
Material
Agricultural ❑ Monitoring ❑
DEPTH
Formation Description
0
O
c
ap
M =,
�F,
M u
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)
19-23
Enka Lake -Rd.
Bennett Rd.
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF T ilS RECORDtjrIPS (BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Quad No:
siGNATZIM
_
Submlt
oripinif to Division
Serial No.
yy
;
MAR
F PERSON CONSTRUCTING THE WELL
Water Quallty, Groundwater Section within 30 days
DATE
GW•1 REV. 12'99

North Carolina - Depsriment of EnvMeto
lronmen4 and Natural Resources • Dn of Water 00111y • tkoundweter S"Ifon
1636 Mall SetvICe Center • Raleigh, N.C. 27-579.1636-Phony ,9119) 733.3221
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION III, �
STATE? WELL CONSTRUCTION PERM)TSt
1. WELL JISF (Ch"k Appikabte 6ox): Aesldontlal E3 NtunWptal ( Industrial 13
Rocovery (:1 Hest Pump Water Inle-Olon 0 Other D (f Other, List uila'
AgricuNutcl 13
2. VVELL LOCATION: (Show sketch of the location below) rnrri},A
Naarest Town: Comfy:
tAoad Nurvkq era Nwnb+�rs, Comrnex+fry, a $ubdt�isfon aro9 Lot Nn.) �...`..�•,�.i�
3. OWNER irsm To
Address Warren Ave ��--�-
#�. _ ._
- , res or ou it
_r"'_ _ _ -
A sheer_- i�P Coop
Ctrs Or 70" Sruto
a. DATE DRILLED 11-13-00
5. TOTAL DEPTH — ----
6. CUTTING SCOLLECTED YFSO NOID-
7, DOES WELL REPLACE EXISTING WELL? YES 0 NOCO�-�-
8 STATIC WATES LEVEL Below Top of Caning: 60 F'• - —. -
(llse '+' I Above Top of Gas")
g. TOP OF CASING IS,., _1 FT. Above Land Surface'
,lop pr casing tsrminawd styor holow tend surlsaa requires a varlenee in eeaar•
':?2844
Monitoring 0
donee wl1h i IIA NCAC 2C .0110
10, YIELD (9prrl): ....�.-- METHOD OF TEST
11. WATEA CONIES (depth): •.._�,.� - — - ---- -�--- ......---------------•-�--' _'.'--.._..-»-_-. --
i
1t awl aetasa naax�ud 0"acic of !vim
12, CHLORINATION: Typo ..-�L�t---- °unt _ ...� . _. .�,
13. CASING: T
Well Ttrolekmas
Depth Dfurustsr or WekthV. "*del (Shown dkacbon er><3 dietarsOts 1rWsi aIs)
t two State
ft"ds, or other map rtafW*ml*�
From ,�---To 52 FT.. - - v
From
-- 7i>._.. _--
Frain _ _._
�10
.. FL• -- _ -
14. GROUT:
Material Method
depur
Front
To
1"t. 5'nnC rPt a _
Frorn _ _--
_ To ......_..
_ Fl.-
15. SCREEN:
Depth
Diameter Sral Sl28 Maisrlal
From
To _
Fl In.
From _ _ To - -___
Ft.. - In. in. _
From
To __ FI. — In, In. -
16. SAND/GRAVEL PACK:
Depth
Size Materiel
Fl
Hwy. 25
o
rn
�
C-D
Mills Gap
n
�M
N
c !
Pinners Covern
co
v
School Rd.
90
"'�'-'
Apple Wood Est.
%0
x
Moriah Lane
From .. TG -
From Ft.
17.
t DO j1E.gESY CERTIFY THAT THIS WELL
WA COAS P'f OF TNCS IT:=+r'ECOR9, BEEN PROVR}c0 TO THE WE+�LOWN.
CON5TRUCTtON 57ANOIW05. A--1c°s Ile
t=t)- LN�"'
C1: ONLY -- DAVE
5u3N . AE OF PERSON C STM1J1C,71W 74E WELL
Oua
! Submit odgine1 to ?lvtston of W*'*c 0"411y. C3MUA +rater 5ectlon wlt�+in 30 dt►)Is C,,y'•t AEV. 12114
146{�I�`iri�Z-•-r``i-r-
f r
rs il{ Vl)lP l�t� ll i9a�ioo

North Caroline _ Npartment of EnAtom"nt end Natural Resources - DMslon of Weaat t3N601y • CkOundweter Section
1634 Mail Service renter - Raleigh, N.C. 2'i0 1t334 t'itone (9 19) 733 9221
�i
<��2845
WELL. CONSTRUCTION RECORD WELLCONTRACTOR: �
WELL CONTRACTOR CERTIFICATION
STATE WELL CONSTRUCT10H PIRAMfTN:._,..-
WELL USE (Chock Appikabls box): 11"dential t.lU Murtkdpat lj Industrial 0
Recovery 0 Neat Pump Water In(arollon (3 mer 0 If Other, Llell Use:
Agricultural a' i Monitoring t 7
!
2. WELL LOCATION: (Show sketch of the location below)
I
Nearest Town: - T } P r - County: _
y
{fioad N81W end Nun*wv, Cortmur+lty, or SubdWision and Lot fio.)
DRI LINGI ..._j�1H ---
..PtA1 , l -- -•- �.o ' n t7surlptYun
3. OWNER
From To -
w
Address Hayes Cove Est.
—
res NC
- Leicester zlpco6e
---
City or Town Sots
--
4. DA1 E DRILLED.--
5. TOTAL DEPTH
5. CUTTINGS COLLECTED YES (� NO
�
DOES WELL REPLACE EXISTING WELL? YES 0 NO
.-._..
7.
8. STATIC WATER LEVEL Below Top of C811ing: _ 40— FT
(Uw •.• w Abow Too Of Ceaino)
_ ..-
g. TOP OF CASING IS_„_ J __.._ FT, Above Land Surface'
�
_.�.-----
-Top of cooing ivrmlrnlsd otior below land ourfsee raqukss a vsrlanes in wear•.�..-
dencs with 15A NCAC 2C .011e METHOD ©F TEST
10. YIELD (gpm): —6.0 -
r
WATER ZONES (depth): 16 7 _-- --
-
--
11.
T a b 1 e t Amount _�...-
Type
it oddttlanet spars is 44
'� form
12. CHLORINATION; a----�-----
13, CASING:
LOCH
Depth
Wait Thickness
t)Ias*+etar ar Walphtlt t, pialarfal
9
53.- Ft.
From -_
--.- To .-
From
To
Ft. ---------- -
From -____—To
--
FL•-------
14. GROUT:
Depth
Material Method
From _ �..-
To _
Fl.
From ___._
To _..._.----Ft.
15. SCREEN:
Depth
17te+meter Siol Slz4 trleleriel
From
To __
FI In. .__ in. -- —.
From
To ---
Ft..-.___-_ in. In. -
From _�-
To -
Fl. Ir1. in.
18, SAND/GRAVEL PACK:
Depth
Size Material
(Show dirtetior► t>Jftd distance irk+ 4t 440 two $tata
Ronde, ar other MOP refors"oe Paula)
i
Hwy. 63
0
o
Newfound Rd.
o
o
tV
co
��
Hayes Cove Rd.
CO
cn r
M;V
W
-�-t
460
n
x
From To Ft. -
From _. -To..._..---- Ft.
17. REMARKS,
I DO HEREBY CERTIFY THAT THIS WELL WASOpY OF THIS FtEC�3t�D�ED IN pR$ BEEN �� 060 TO THE E�`OWNER•
CONSTRUCTION 8T1tiJDAFiD$, - I/;10 - A .i i. nrl_
-- DATE
E.O.d
OFFICE USir ONLY SIGN . E OF PERSON C sTmm'LINO TH11WELL
o: Subn* oriotnst to Oivis►on of Wale( ousitty, t3rw.x+dwater Socuon within 30 da�o
G:Y-t RBV. 1294
Na.
^: w ..--

North Carolina . Daparlment of EnArommnt and Natural R*$Ources • DHvtslon of W01e1 Qy*"'y • Ckoundwater SeCUon i t`
I ase Mail Service Center . Raleigh, N.C. 27E39.1we-pbono (919) 7:ri•3221 !
LL CONSTRUCTION RECORD WELL CONTRACTOR; _2? achian we 1—
WELL CON"ACTO" CEATIPICATION 0:1 Q
STATE WELL CONSTRUCTION PIERMtT#t
WELL USE (Chuk Applkeblo Sax): Residential LY( Munlolpal (J industrial 13
Recovery (J Heat Pump Water injection 0 Other Q it Other, Llrt U$0*
22842
lline
Agricultural d1) Monitoring C]
WELL LOCATION: (Show sketcl, of the location below) Buncombe
Nearest Town:County:
(Road Norm and Nwnbom COMxrn(111y t No.) From
i T Fon
3• OWNER K�yiTFakry _
Address-
_2.�.� 2 8 8 01
Ashe NC �Y ---
City or Town State Zip Code —
d. DATE GRILLED —&.G—aO J,_--
S. TOTAL t7EPTH ______......-.-- ---
6. CUTTINGS COLLECTED YES D NO I
7. DOES WELL REPLACE EXISTING WE4L7 ES C _ -
6. STATIC WATER LEVEL Bolow Top of Casing: s
tUse'+' Ir Above Top Of Casing)
g, 'TOP OF CASING IS --I— FT. Above Lend Surface'
*Top of *using t*rrtJnaled stlor below lsmd sv0see requirss a vsrlan*u I" accor•dan
10. with 1(9 M): 2C .alga METHOD OF TEST �i r Q t a i n P Y - __ -- -
f a. YtELD (gprr). .�---
11. WATER ZONES (depth):
i 2. CHLORINATION: Typo l -`°"2" �it add tinrw apace is rwadw use
13. CASING: l r�cjA,T Fes?
Wall ThkBness
Dilplh i5lametsr or WNgnt/Ft. ►aartoda! (Straw direction e+'� dkt+arx:e from it
From - 0 — To .�- W. Ft. ode, or other rasp relerarr >sr
From----•------ To --
From ---To _ Ft,..._ ._ .-, -- ---- Hwy. 74
14. GROUT:
Depth Material Method Old Fort Rd.
From
To .._— —Ft. r�Cancr�te • p--r�z
From -.. To _Ft. - -- Bear Lane
15. SCREEN:
Depth gtam®tor Slot SE2e tJtateria!
From _ To Fl _ In. _ In.
From __,to _Ft. _ In. In.
From . To -- Fl. _ In. _ in.
16. SAND/GRAVEL PACK: Material
Depth Size
i)sacrrpt:en
Of form
hVo Sent*
r?
0
o rTi
rrrI
n
c rrri
tV
oC
CC)
-ern
�a
rno
co
uD
From - - To
From ._-. 1o_---- Ft.-
17. REMAFIK& .------------ ---
ED IN
LL
t t>t5 fiEREOY CERTIFY THAT i�F1D5. ANWELLU THAT rA CpPY OfAS T HIS SEC
SEEN PRO rDEO To T E WIEIX OWNED.
C(}NSTRUGSiUN 5TAtdi7 AI�� - , A nn -
-� -=•w-- DATE
FOR t3FFICE USE ONLY SfdN ICE OF PERSON C STRUf 71W THE WELL.
Quid No:
Sutmat odglns! 10 l7tvlstgn c+l Niter Quality, pAUndwsiar SscUor, within 30 da!js OW-1 REY, I2199
Serial
td

Nunh Corotins - NP-Ofiment of EnAtonment and Natural Rti3ourcea • Utvlsion of Water t>�aStty • t3rtoundwater 81aUon <+ 2 C7
2 O
1636 Mail Servlce Center • Raleigh, N.C. 278� A636-Phones (919) 733-Mi + t
WELL CONSTRUCTION RECORD WELL CONTRACTOR: AP ' ��g--
W9LL CONTRACTOn CEPITIFICATION Il:,
STATE WELL CONSTRUCTION
1. WELL USE (Cnock Appllcet,le 900 Residentlal Ed MunFclpat C3 lndustdsi p Agricultural � i Monitoring ED
Recovery Heat Pump Water Inj"llon 0 Other 0 It Other, ull Us*. _ __- _
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town County:
1;
�'�'"'"""` ri6a111 tN a LpO
_...0 -- -
t�p"'" ;� {y�rbnd Nwnber►, Con�rtxx�tty, or Sut:dlvlason end Lot tJo.} 7n —
3. OWNER
Ftam
Address 169 Carrier St.
- l_�taie ip Code ---- o - •—.
City or Toval _.
4. DA7E 0AILLE0-11 -2=_0_0 _
S. TOTAL DEPTH . _.._34-:�� ,_ ,(
6. CUTTINGS COLLECTEDYES[ NOL„)
7. DOES WCELL REPLACE EXISTING WELL? YES 0 NO S. STATIC WATER LEVEL Below Top of Casing: � � FT.
(Liss'e' Il AW" Top 04 C&*kV)
g, TOP OF CASING IS, _L _ FT. Above Land Suriac**
'Top or oesing terMlnsted attar below Isn't sud&ee requtroa a verlence In soeor•
dents with 15A NCAC 2C .0116 Gal ._ ner
10. YIELD (9pm)' _g_ METHOD OF TEST —
11. WATER ZONES (depth): _____ 12 7 —
12. CHLORINATION:
13, CASING:
T
Fo l era+ pe�rtpr:oel
-Type _14 hl L _,,, Amount -_Z,__ a_ . 11 addidonai seem Is AtOded °raa
Depth plameter
Front, r..•.a...._. To __q_1k . Ft.
From-- To - --- Ft. ---
From ..--•---•.....To . ---- Ft....�,
I . GR+"JU7:
Deriih Maiertal Mtgtlwd
-
From
To F Concrete Pour
_.._........ ----
From. To - - - Fi.
13. SCREEN.
U®pit, G+larnetor Slot Slxe tYlsierlstl
From , To _....._..•. FI in. .._ -- In.
Front, _ To . Ft. In. _ in.
From _- "I o -- Ft. a _ ._ In. In.
1 S. SAND/GRAVEL PACK: Materlat
Depth Size
Well Ttrteweoes
or WetghVFt. "tidal
of form
(Show rf4 SfAW tend d4tance Irr m 9t 484t two Male
Roads, or other mep rateralx+a s)
Hwy 63
o
v
Q
LD
Alexander Rd. r
^
{.:7
.,�. r
is
t
Alexander Place;
c�7
�;
coo
;
2+• c�a
yy
i
a
� rT1
co
cn �t
n
w
Q
From To --- Ft..From I ---- Ft.
17. REMAnKS. _ _ _----
LL
100 ►tEAESY CERTIFY THAT
IS VVIELL
THAT A S CONSTRUCTEDOTHIS IRECADi.OP0i3EEN PriO DED TO H� Et� OWNER.
Ct7NSTrirJCTION S
FOR OFF (RE U )a:'qDONLY -- DATE
hued No: SIGN RE 0t PERSON C 3$Ftti(:7st THE with
1
SvWa crt9tnel la plvls?%n of Water auettly. afoind Teter yecuar+ within 3O dais AW • 1 REV. 12/99
FEB - �3 2ilUl

North Carolina - r,�aparlment or EnAron(mnt end Neturlll flasouress • DMaWn of Water oyality • Moundvrator SeCtfon
1036 MAII 5erYICti Center . Raleigh, N.G. IT479.1636-Phone [phone]
WELL CONSTRUCTION RECORD 'WELL CONTRACTOR: Aon ac�r�i1
WELL COWRACTOR Cft FIYIFICATIO14 2:
STATE WELL CONSTRUCTION PRAMITOt
1. WELL USE (Check Applkabto cox): Sesldentiaf Municipal tndUSIdIaI ❑ ASi
rlcuitural d � i
Recovery twat Pump Waterinj"tIon Other [] It Other, LIM Uso:
2, WELL LOCATION: (Show sketch of the location below)
rn ^ YCI C V l 1 1 P ____ C.cotmty:-----�•$•L-kl�et�--'^'�'� ` '� ;,
Nourast Town:
- 2RI LNG
(Road Name ano Nwr+bars, Cprrvnex�ity, o+ guixliNsksn s+qd let Na.) - -""From Tn
3 OWNER Pete A 11 en ��.. �---------
Addrsss 382 McKinnev Rd.__. �_ --
its ar au 9 No•) �..—
Mars A�,�.� .NC----- Z��cB-- -�-
city rx Town 318to --- _
a. DATE DRILLED 11-1-00
—_
5, TOTAL DEPTH --- -- �-� --�•
6. CUTTINGS COLLECTED YES C3
7. DOES WELL FiEpLACE EXISTING WELL? YES Nt7LLI
_
6. STATIC WATER LEVEL Below Top of Calling: - Q— Fr- �•
(ua. •+• tt Abo" TOP of C&*V)
g. Top OF CASING IS 1 FT. Above Land Surfacer-�, _
"Tap or Caalne terminated atfor below land oudses requlroa a varwnce Iry mccor• .r
dance with 1riA HCAC hC .01110
10. YISL0 (gpm)' Z_... METHOO OF TEST-
11 WATER ZONES (depth):--
422853
Monlloring 0
Fon eLion Ciaaoriptlon
tt rtai speeet ror►aedrlti airs of form
12. CHLORINATION; Type Tah1 Pf Annount.�..W..Z---�-
13. CASING: LOCATIQRLUALkL
Watt Thickness
Depth t:farr,atx ar Woigtst✓Ft. �ade�
From ..-- -Q--..._ To Wa.9.$- Ft.----•-
Frorn....._...,.— To ......M.____--
Frorrl----
14. GROUT:
Depth Material Method
From_---
15. SCA EN:
Depth Dlern®ter $101 S116 tvteierlel
From Ft .._ _ _ In. —In. _ --
From --TO _ . F" in. __In. _ From To .. _ Fl.. In. -- in.
16. SANDIGRAVEL PACK: Material
Size
(Showy dktx$�w tlsrrd dtetancs from at 14ast two t vrw
Roade, or other "WP rs(srar" f s)
19-23
Rd ran
o
Bernardsville
Dillingham Rd
CO
CO
rn�
c0
0
z
Ffa1n To _.._._ _ Ft.From __. - To - Ft.--
17. SEMARKS. _ __ __ �---
1 !3C) tiEr;El3Y Ct tTt tFY THAT THtND NATWAS A COPY OF THIS ECOAq.& SETED IN A kN AOADED To T � E%`O'r'�NEFt.
CONSTstJCTION STANOARO5, A
_
i•O O F E LfSE ONLY glaN pt: OF tsER50N C 3TPlt!CV1`B TFt6 WE! t UAi
Quad No: Subff V o4ginai to DWlston at Wslar Ctuattty, C3esurulwstsr 3srtlan within 30 days
Q`N•t REV. 12l99
1A en v

North Carolina - Dopartment of Environment and Natural Resources - Division of Wale( Qgallty • (3roundwater Section : f , 0-)Q (}
163e Mail Service Center - Raleigh, N.C. 27699.1636-Phone [phone]
Appalachian Well�Dri 1,n
WELL CONSTRUCTION RECORD WELL CONTRACTOR: P1?----�—�-g
WELL CONTRACTOR CERTIFICATION N:
STATE WELL CONSTRUCTION PERMtTM:_____
1. WELL USE (Check Applicable Sox): Residentlal d Municipal ❑ Industrial ❑
Recovery 0 Heat Pump Water Injection 0 Other [j It Other, List Use:
Agrlculturai 01 Monitoring ❑
2. WELL LOCATION: (Show sketch of the location below}
Nearest Town: .--Weaven�iI I P County: R e e m be— -
(Road Name and Nurnoem Community, or Subdivision and Lot No.) DRILLING LOG
3. OWNER Robert Hughes----_ From To
Address --
rem or Houle o. O 7 p
-
City or Town State zip Code
4. DATE DRILLED 10-31-00
5. TOTAL DEPTH -Lo-L
6.. CUTTINGS COLLECTED YES Q NO�
7, DOES WELL REPLACE EXISTING WELL? YES [1 NO[A
8. STATIC WATER LEVEL Below Top of Casing: 20 FT - -----+-
(Use '+' If Above Top of Casing)
9, TOP OF CASING IS 1 FT. Above Land Surface'
-Top of casing terminated at/or below land surface requires a variance In accor-
dance with 15A NCAC 2C .011a
1 Q. YIELD (gpm): 6 0 METHOD OF TEST (,al-- Onn t- a j n PY --
11. WATER ZONES (depth):-----
12. CHLORINATION: Type -
Sa1-Lej -- Amount—2.-._--
13. CASING:
Waft Thickness
Depth
Diameter or Weight/Ft. Matedal
From.. —To .-3b— Ft. -- -
From
To
Fl.
From
—To
FL --
14. GROUT:
Depth
Material Method
From _
- To
Ft.�t-e- P-etr
From _—To
To
Ft.
15 SCREEN:
Depth Diameter Slot Size Material
From To Ft In. in.
From To Ft. In. In.
From To Ftin, in.
16. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To Ft.
17. REMARKS:
Malerlal
It addlHonal apace is needed use Oaek of form
LOCATIONS ET H
(Show direction and distance from at I1ast two State
Roads, or other map reference points) v
o
0
cD
r• 1
rr-I
n
O
C= r~r
19-23
CO
r*1
25-70
;-
0
Monticello Rd.
U
Penny Larxe
w
4
%'D
o
x
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C. WOLL
CONSTRUCTION STANDARDS. AND THAT A COPY OF THIS RECOR� BEEN PF10VIDED TO THE WELL OWNER.
SIGN RE OF PERSON C STRUCTING THE WELL DATE
Submit original to DIVISion of Water Quailty, Groundwater Section within 30 deys t3W t REV. 12/99

i
North Carolina - Depailmont of Environment and Natural Resources - Divlslon of Water Ovelity •Groundwater Section j 22 8
1636 Mail Service Center • Raleigh, N.G. 27699.1636•Phone [phone]
WELL CONSTRUCTION RECORD WELLCONTRACTOR:
WELL CONTRACTOR CERTIFICATION0:
STATE WELL CONSTRUCTION PERMIT#:
i. WELL USE (Check Applicebte Box): HesldentlaG Municipal ❑ Industrial i3 Agricultural 0; Monitoring ❑
Recovery [] Heat Pump Water Injection ❑ Other ❑ It Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: Lei e e si-e v -- County: '
-
i
-
DRILLING LOC3 dEPI
(Road Name and Numbe(s, Community, or Subdivision and Lot No.)
3. OWNER
From To For +ation Description
.»
Address BrownTown Rd _
- Y [ a 0
------------ - -
Leicester N 997�_ M_
-----
City or Town Sla a Zip Code
a
4. DATE DRILLED-
5. TOTAL DEPTH�� -
YES[] NO[&
6. CUTTINGS COLLECTED
7. DOES WELL REPLACE EXISTING WELL? YES [-] NOd-----
6. STATIC WATER LEVEL Below Top of Casing: _2D_ FT.
-
(Use's` It Above Top of Casing)
9. TOP OF CASING IS---J _ FT. Above Land Surface'
*Tap of casing iermtnated atlor below land surface requires a variance in accor-
dance with 15A NCAC 2C .0118
10. YIELD (gpm):-S-Q_-._ METHOD OF TEST Gal---Gtftt-ainer-
11. WATER ZONES (depth): 19,
12. CHLORINATION: Type Ta4�). : Amount
It additional space is needed use Mack of Iorm
13. CASING:
LOCATION SKETCH
Wail Thickness
Depth Dlamelar or Welght/Ft. Material
(Show direction and distaltee from et Igas two Slale
Roads, or other map reference pojnls)
From _-O----To - 6-&- Ft
From To Fl._-----------
From To Ft.
14. GROUT:
Depth Material Method
From To �t '�-C711G L C 1 C L Vlr"
From --To FL
15. SCREEN:
Depth Diameter Slot Slze Material
From r____._ To Ft In. in. ---
From To Ft. _ __ _ in. in.
Frorn Tc . Ft.—__.. in. in. _
16. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To Fl.
Material
cl
r_
C
Hwy. 63
©
C-
DC
Newfound Rd
N
n c
coo
BrownTown Rd
-4--
co
rn
00
M;O
W
-�
w
o
2
17. REMARKS:, ..- -----
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C. WqLL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY DATE
wlluxdallo> -- -- SlIGN RE OF PEFISON C STHUCTING THE WELL
�j Submit original to Division of Water duality, Groundwater Section within 30 dais QW t REV 12/99
U li/" rial�ro�•
FEB - 8 %'017

North Carolina . Department of Environment and Natural Resources • Division of Water QLrallty • Groundwater Section
1636 Mail Service Center • Raleigh, N.C. 27699.1636-Phone [phone]
22849
WELL CONSTRUCTION RECORD WELL CONTRACTOR: n.. ; 1
WELL CONTRACTOR CERTIFICATION II:
S'rATE WELL CONSTRUCTION PERMtTNtt
1. WELL USE (Check Applicable Box): Residential Lia Municipal ❑ Industrial El
Recovery ❑, tieat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: T o r e s t- ,..._.. County: iTl. qee r ----
(Road Name and Numbers, CommuNlY. or Subdlvision and Lot No.) DRILLING LOG
3. OWNER Bryan Bi shop _ From To
Agricultural ❑i Monitoring ❑
___PgPTH
Foapatlon Description
,w
Address e
-
Leicester N 9A7L-0 -
City or Town Slate Zip Code
4. DATE DRILLED 10 = 6-00
S. TOTAL DEPTH
6, CUTTINGS COLLECTED YES [ --I NOM� - _ —
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NOd
8. STATIC WATER LEVEL Below Top of Casing: 10 FT. � --
(Use '+' if Above Top of Casing) _ -
9. TOP OF CASING IS 1 FT. Above Land Surface' _
`Top or casing terminated attor below land surface requires a variance In accor-
dance with 16A NCAC 2C .011a
10. YIELD (gpm): _ _ METHOD OF TEST G&I r'G4 t ^
11. WATER ZONES (depth): __Fin—
12, CHLORINATION: Type -Ta h-1 Q t Amount - 11 additional apace is needed use (jack of form
13. CASING:
Wan Thickness LO ATiO� N SKj�YH
Depth Dlameter or Weipht/F1. Material (Show direction and distance from at I fast two State
From _._II__-_ To Ft. Roads, or other map reference points)
From To --• Ft. --
From To _ Fl. - - Hwy 63 A
14. GROUT:
Depth Malorlal Method ern
Concrete Pour c-) C-rit
From --To Ft. — [V ;r
From .—_ To . Ft. C4 rr
15. SCREEN: mQ
Depth Diameter Slot Slze Material ;:o
From To Ft in. in. CO rin �;oi
From To Ft. in. In. �,� C-'
From To Fl. In. In. at3
16. SAND/GRAVEL PACK:
Depth Size Malaita(
From _ To Ft.
From To., Ft.
17. REMARKS:
t DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH iSANNCA7C 2C, WOLL
CONSTRUCTION STANDARDS. AND THAT A COPY OF THIS RECORD BEEN PROVIDED HE WELL; OWNER. -
FOR OFFICE USE ONLY - DATE
Quad 11 SIGN IRE OF PERSON C STRUGTINt3 THE WELL
r r ( Submit oriatnal to Division of Waier Ousllly, Groundwater Section Within 30 days OW•I REV. 12/99
`Sea�Nbji R
,1
i )

North Carolina • Department of Environment and Natural Resources • Division of Water 04aliry. • Groundwater Seclion
1636 Mail Service Center • Raleigh, N.C. 27690•1636-Phone [phone]
<-22848
WELL CONSTRUCTION RECORD WELL CONTRACTOR: , ADpa.Lacni+
WELL CONTRACTOR CERTIFICATION 0:
STATE WELL CONSTRUCTION PERMfT#:
1. WELL USE (Check Applicable Box): Residential ti Municipal ❑ Industrial 0
Recovery 0 Heat rump Water Injection ❑ Other ❑ If Other, List Use:
Agricultural ❑l Monitoring ❑
2. WELL LOCA I IQN: (Show Sketch of the location below)
Nearest Town:. LP_.]_r' PS t P r, County: Rianc oga;
(Road Name and Numbers, Cortvnunlly, or Subdivision and Lot No.) DRILLING„ LOG
3. OWNER From To
Address . _ :Z d
--
Swa
City or Town State p Co a —_--- -
d. DATE DRILLED 19-26-00
5. TOTAL DEPTH 14-7
6. CUTTINGS COLLECTED YES ❑ NOE
7. DOES WELL REPLACE EXISTING WELL? YES[] NOIA
8. STATIC WA T ER LEVEL Below Top of Casing: � n_ FT. -- -
(Use '+' A Above Top of Casing)
9, TOP OF CASING IS 1 FT. Above Land Surface'
*Top of toeing terminated odor below land surface requlres a vorlance In accor-
dance with ISA NCAC 20 .0118
10, YIELD (gpm): 8 -- METHOD OF TEST---
11. WATER ZONES (depth): _9nn.------r
—4EPTH
Fomjrallon Descripflon
.w
12, CHLORINA7lON: Type Ta hl a t Amount 2
it additional apace is needed use Oack of form
13. CASING:
LOCATfON METH
T-
Waft Thickness
Depth Diameter or Wetght/Fl. Material
(Show direction and distance from at lgast two Slate
To Ft. - -
Roads, or other map reference pants)
From
ca
From- - --- To Ft. --------
Q
�
From —To-- Ft.—
Hwy . 63
0
G�
14. GROUT:
rrri
C)
Depth Material Method
Newfound Rd.
C-)
C= m
From To Ft.
rV
CO
Ern
From _.-- To Ft. -----
Dix Creek #2
�C)
15. SCREEN:
=.
. �n
Depth Diameter Slot SIZe Material
00
From To Ft ». In. in.
W
C")
From To Ft. In. In.
%
o
From . To Ft. In. In. _ -
16. SAND/GRAVEL PACK:
Depth Size Material
From To rt.
From To Ft.
17. REMARKS: —
DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, W4LL
OWNER.
t
STANDARDS, AND THAT A COPY OF THIS RECORD
BEEN PROVIDED TO THE WELL
CONSTRUCTION
---��—�—��----
FOR OFFICE USE ONLY —
SIC3N�REOFRSON C STRUCTING THE WELL DATE
Quad Not
Submit orpinal is Division of Water Quaty,
11 ,:.. 7­77
Groundwater Section within 30 days
GWt REV.
12/99
Sedal No. IL�r--- ----
_
'I

9'7 Q :I
North Carolina . De?artmnnt of Environment and Natural Resources - Division of Water Qgaiity • Grourxlwater Section 1 ` ' ' n
1636 Mali Service Center • Raleigh. N.C. 27699.1636-Phone [phone] % I
WELL CONSTRUCTION RECORD WELL CONTRACTOR: i
WELL CONTRACTOR CE TIFICATION N: l
STATE WELL CONSTRUCTION PERMIT#:
WELL. USE (Check Applicable box): Residential LD Municipal [j industrial ❑ Agricultural 0 Monitoring Q
Recovery [] Heat Pump Water Injection Q Other 0 It Other, Ust Use:
f /
2. WELL LOCATIO t•ow ket o{ tjie location below)
Nearest Town: i l -- County ( --
(Road Name n N r onvnun Sy or Su flsfon_a 101 Na.)
3. OWNER
Address
Yam!or Rouls
Cit r Town / Sjw ZIP P Code T+
d. DATE DRILLED!
5. TOTAL DEPTH
6, CUTTINGS COLLECTED YES[] NO[
7. DOES WELL REPLACE EXISTING WELL? YES (^] NO[�
6. STATIC WATER LEVEL Below Top of Casing: �(�_ FT.
(Use'.' it Above Top of Casing)
g. TOP OF CASING IS__�_-_— FT. Above Land Surface'
'Top of casing ivaninated attor below land surface requires a varta '10 In occor.
dance with 15A NCAC 2C .�0 �• �8Xj
10. YIELD (gpm): MET HOA � TEST
11. WATER ZONES (depth): (/ I
12. CHLORINATION: Type Amount
13. CASING:
Wan Thickness
/;� Depth. Dlarnetar or Weight.'Fr. Material
From_LL-_- To -- Ft. _—
From_ To-----... Ft. ---
From ---To — Fl.-.-_ ------
14 GROUT'
From
Depth
To _
Ft.
M
tp 1 /,I
r LL ``bbU!/t/
From ..
To ._
Ft.
15. SCREEN:
Depth Diameter
Slot Size
Material
Frorn .....r_
To _ - Ft
in.
In.
Front .—To—.
Ft.
_ In.
In.
Frnm
To Ft.
in.
in. _ ---
16. SAND/GRAVEL PACK:
Depth
Size
Maletial
From
To
Ft.
From
To
Ft.
17. REMARKS:
—_,
-
DRILLING LOG
From To
_­QEPTH r
Forr6allon Cesccaptlon
0
It additional apace is needed use rack of lorm
LOCATION SKE—TPH
(Show direcilon and distance from at l ast two Stake
Roads, or other map reference pon(a)
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C. Wts,LL r /�
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORy BEEN PROVIDED TO THE WELL OWNER.
/) `-� 1
FOR OFFICE USE t3NLY
Quad No:
SIGN RE OjF PERSON Ct3'I STRUCTING THE WELL UATF
-� SubmN o�,Qlnat to Division of Water Quailty, Groundwater Section Within 30 d8ys GWA REV. 12199
5edal tJo.

North Carolina - Deparimont of Environment and Natural Resources Division of Water Otratlty - Groundwater Section
163e Mall Service Center - Raleigh, N.C. 27699.1636-Phone [phone]
WELL CONSTRUCTION RECORD WELLCONTRACTOR: Appalachian Weil
WELL CONTRACTOR CERTIFICATION
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicabie Box): Residenilai O Munlcipat ❑ industrial
Recovery ❑ Heat Pump Water injection 0 Other (] If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: -_S.WJIIa a » County: _ Buncombe
(Road Name and Numbers. Community, or Subd Aslon and Lot No.)
3. OWNER Scoville RoberS
Address
1 y I re or ou e
City or Town State Zip Code
A. DATE DRILLED 10-16-00
5. TOTAL DEPTH 5�
6. CUTTINGS COLLECTED YES O NOL!
7. DOES WELL Ri~PLACE EXISTING WELL? YES Y NO[ �,%�
6. STATIC WATER LEVEL Below Top of Casing: 4FT.
(Use '+' it Above Top of Casing)
9. TOP OF CASING IS_ 1 FT. Above Land Surface'
-Top of casing terminated odor below land surface requires a variance In accor-
dance with 15A NCAC 2C .01 id
10. YIELD (gpm): 4 METHOD OF TEST Gal-Ln t a
11. WATER ZONES (depth): 1 �-
12. CHLORINATION. Type
..�T b��Amount �
13. CASING:
Wan Thickness
Depth
Diameter or WeighVFt. Material
From-._Q._—To
$Q-- Ft. -----
From
To
Ft.
From ---To
_ FL------- -.
14. GROUT:
Depth
Material Method
From
_ To _
-FL CQ]os'�et a P�ttr
From
To
Ft. - ----
15. SCREEN:
Depth
Diameter Slot Slz6 Material
From
To
Ft ______ In. __ in. -
From
To
FL in. in. -
From ^__
__ To
Ft. In. In.
16. SAND/GRAVEL PACK:
Depth
Size Malarial
From ^_
I*o __
Ft. -
From
_ To
Ft.
17. REMARKS:
DRi-LLING LOG
From To
; .�783
Agricultural ❑i Monitoring d
__*EPY__, TN _ _
Fora ation Description
it additional apace Is needed use !jack of (orm
LOCATION SKET H
(Show direcllon and distance from at 1 ast two State
Roads, or other map reference points)
I-40
Hwy. 70
Martin Rd.
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 1SA NCAC 2C. WOLL
CONSTRUCTION STANDARDS. AND THAT A COPY OF THIS RECORD BEEN PROVIDED TO THE WEt OWNER.
�G 10 -23-00
FOOR OFFICE USE ONLY - DATE
Ouad No; SIGN HE OF peRSON C STAUCTING THE WELL
Submit original to Division of Water Quality, Groundwater Section within 30 dej►s GW i riFv, 12199
Serial No.

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section Q C
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone] hol
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CER IFICATION #:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (check Appilcabfe Box): Residential � Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Rocovery❑ Heat Pump Water Injection ❑ Other n If Other, List Use:
2. WELL LOCATION: ot� s�yetph f the location below)
Nearest Town:
' .CC/ (�% _county: �.0 ��l.�i
(Road Name and umb rs, Co uPily. or/,Su vision and Lot No.) DRILLING LOG DEPTH -
3. OWNER 1L JCL From To
Formation Description
Addr�
/ or ou b Z�SZ J �•-i
_ ✓ L l V
City or Town ff�� . &tie Zip Code
4. DATE DRILLED ny ,,,,.
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑ NOQ::: >,
7. DOES WELL REPLACE EXISTING WELL? YES NOF -J— tv
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 var nce in e ' r- ro I t1 G`..'`
dance with 15A NCAC 2C . 118- C Af U c.
10. YIELD (gpm): METH F TEST 1
11. WATER ZONES (depth),
ifig
12. CHLORINATION: Type
Amount
13. CASING:
Wall Thickness
O
pep(h; ,y
�� v
Diameter or WeighVFt. Material
From
To
Ft.
From
To
Ft.
From
To
Ft.
14. GROUT:
Depth
�daQ,4lal/ - ll d ,(�
From
To
Ft.
—Moles
G� IC.-j"
From
To
Ft.
I
15. SCREEN:
Depth
Diameter
Slot Slze Material
From
To Ft
In. In.
From
To Ft.
In. In.
From a
To Ft.
In. in.
16. SAND/GRAVEL PACK:
Depth
Size Material
From
To
Ft.
From
To
Ft.
17. REMARKS:
-
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 oints)
!9- ?d
thH
I I
q ((fi 611
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS R D HAS BEEN P OVIDED TO THE WELL OWNER. J a
FOR OFFICE USE ONLY
Quad No: GNATU E OF PERS CONSTRUCTING THE WELL
Submit original to Divl Ion of Wate uality. Groundwater Section within 30 days
Serial No. ---
DATE
GW1 REV. 12/99

North Carolina - Department of Environment and Natural Resources - Division of Water-Cluality Groundwater Section v U 3
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACT
WELL CONTRACTOR CER IFICATION M
STATE WELL CONSTRUCTION PERMIT#:
1, WELL USE (Check Applicable Box): Residential 0 Municipal [] Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other n If Other, List Use:
2. WELL LOCATION: ($ho slSetch of the location below)
Nearest Town: L County:
(Road Name a d m rs ommunil Subdlvislo a d Lot No.) DRILLING LOG DEPTH
3. OWNER �� From To Formation Description
Address o 5
ree or ou
E�`� u
City or Town S to Zip Code
4. DATE DRILLED z ,
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES F--j NO /c r
7. DOES WELL REPLACE EXISTING WELL? YES Q NOD �
8. STATIC WATER LEVEL Below Top of Casing: G FT.
(Use '+' if Above Top of Casing)
9. TOP OF CASING ISFT. Above Land Surface'
*Top of casing terminated atlor below land surface requires a variance Ina cor-,
dance with 15A NCAC 2C .a (87 /1 %j`
10. YIELD (gpm): ��(/ MET F TEST r Lv Cv _ —
11. WATER ZONES (depth): Z rn
12. CHLORINATION: Type Amount If additional space Is needed use back of form
13. CASING:
Wall Thickness
Depth
r Diameter or Weight/Fl. Material
1
From T
To
Ft.
From
To
Fl.
From
To
Ft.
14. GROUT:
From
Depth
To -Ft.,.-,
nj9rMoll}��tl
1 C�.
From
To
Ft.
15. SCREEN:
Depth
Diameter Slot Size Material
From
To_Ft
in. in.
From
To
FL In. in.
From
To
Ft. In. In.
16, SAND/GRAVEL PACK:
Depth
Size Material
From
To_Ft*
From
To
Ft.
17. REMARKS:
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
1 3
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTJ3JU CILON STANDARDS, AND THAT A COPY OF THIS RECOR�HAS BEEN PROVIDED TO THE WELL OW R.
I� rZ - ra ra n nn n rr
FOR O
Quad Nr
Serial
SIGNAT14R5'0F/PERS0N CsTRUCTING THE WELL
original to Division of Water Quallt , Groundwater Section within 30 days
DATE
GWA REV. 12/99

r. 8 6 14
North Carolina [)apartment of Environment and Natural Resources - Division of Water Quality - Groundwater Section ,
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR 2RTPIFICATION s
STATE WELL CONSTRUCTION PERMITtk:
1, WELL USE (Check Applicable Box): Residential❑' Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATIO ' (S vy slletgIy Ahe location below) C CG `"t—L C
Nearest Town: TJ (. / l Z County: .
(Road Name and u b r3, mm cr Subdivl n and Lot DRILLING LOG DEPTH
3. OWNER :, v From To Formation Description
Address JM U (J
Cree or ou e
City or Town Slatq , Zip Code
4, DATE DRILLED U
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑ NOE� b `;;--
7. DOES WELL REPLACE EXISTING WELL? YESaFT.
NOB. STATIC WATER LEVEL Below Top of Casing:
(Use'+' If Above Top of Casing)
9. TOP OF CASING IS / FT. Above Land Surface' v
*Top of casing terminated aVor below land surface requires a variance In accof-�
dance with 15A NCAC 2C .01 j$ _ `���.V(�}/ r„
10. YIELD (gpm): _�_ METH D,QF TES
11. WATER ZONES (depth):
12. CHLORINATION: Type a� J — Amount If additional space Is needed use back of form
13. CASING:
Wail Thickness
Depth
Diameter orWeight/Ft. Material
From—To—Ft.—
From—
To
Ft.
From
To
Ft.
14. GROUT:
Depth
From
To
Fl.IC�I
From
To
Ft.
15. SCREEN:
Depth Diameter Slot Size Ma1,erial
From To Ft In. in.
From To Ft. In. In.
From To Ft. In. In.
16. SAND/GRAVEL PACK:
Depth Size Material
From To FL
From To Ft.
17. REMARKS:
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 RE�QRD'IAS BEEN/PROVIDE TOTHE WELL 0
FOR O 6-UO n
Quad No 11 SIGNA E O PERSON NSTRUCTING THE WELL
It original to Division of Water Qu fly, Groundwater Section within 30 days
Serial No _ r.nfln I
DATE
GW-I REV. 12199
h

611
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section L "
3221 '
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone (919) 1 L
WELL CONSTRUCTION RECORD WELL CONTRACTOR: ��/ �� W/r l
WELL CONTRACTOR CE T FICATiON #: f
STATE WELL CONSTRUCTION PERMIT#:
WELL USE (Check Applicable eox): Residential ET Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water injection ❑ Other ❑ if Other, List Use:
2. WELL LOCATION ( k I of TVPcation below) -sa tw t
Nearest Town: J i County: ��
(Road Name and Nmbar j Community orr7di slon and Lot No.)
✓'
DRILLING LOG DEPTH
From To Formation Description
3. OWNER `/' ' v I�Zr
Address �(GcL
-
f-eMSrouAo..,,
City or Town la Zip Code
���
4, DATE DRILLED
Lq
5. TOTAL DEPTH A�
6. CUTTINGS COLLECTED YES 0 NO[�!]_
— —_
7. DOES WELL REPLACE EXISTING WELL? YE �; NO❑i
6. STATIC WATER LEVEL Below Top of Casing: Fr.
ram_
(Use '+' If Above Top of Casing)
TOP OF CASING ISFr. Above Land Surface"
9.
*Top of casing terminated at/or below land surface requires a variance In actor-
,`77
dance with 15A NCAC 2C .011
10. YIELD (gpm): r MET O TEST
11. WATER ZONES (depth):
12. CHLORINATION: Type , Amount �—
If additional space Is needed use back of forrr�_n -{
-�-
11 r:ASINr;
"
Wall Thickness
Dep11 /)
Diameter or Weight/Ft. Material
From
To'1(
Ft.
From
To
Ft.
From
To
Ft.
14. GROUT:
Depth
) M(a')srJ l 0111 dVA
From
To
Ft.
c(�j►
From
To
Ft.
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
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)
w _, l
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 AS BEEN PROVIDED TO THE WELL OWNER./ U
SIGNATURE 6F PERSq�CONSTRUCTING THE WELL DATE
original to Divlslon.oi Water Plualily, Groundwater Section within 30 days
GW1 REV. 12199

Q i
North Carolina • Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section A 8 6 1 �3
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR C R IFICATION #:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential El Municipai ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use: �l�J
2. WELL LOCATION, Shp Lsketct p.('tb location below) �GCCI (jyt L
I '� PP ll
Nearest Town: d�1 County:
(Road Name an Num erls,,�.C/o unity or'Subdl Iona d. of N )
DRILLING LOG DEPTH
3. OWNER '`� From To Formation Description
Address (p5jl �l( �iK. �✓1!-6�`�Y. res
ree or ou a o. Z
L `(mil ,: C'
City or Town �j — State Zip Code
4, DATE DRILLED r
5. TOTAL DEPTH 77—'
6. CUTTINGS COLLECTED YES[] NO [El
7. DOES WELL REPLACE EXISTING WELL? YES�' NOF
8. STATIC WATER LEVEL Below Top of Casing: i0U FT.
(Use '+' it Above Top of Casing)
FT. Above Land Surface*
9. TOP OF CASING IS_
'Top or casing terminated aUor below land surface requires a variance InnCa.,cpor- 1
dance with 15A NCAC 2C .011�
10. YIELD (gpm): __L _</ METHOD F TEST
11. WATER ZONES (depth):
12. CHLORINATION: Type Amount If additional space is needed use back of form c�
0
13. CASING: �=
LOCATION SKETCH
Wall Thickness
(Show
Depth Diameter or Weight/Ft. Material w direction and distance from at least two Stale
— Roads, or other map reference points)
From To Ft.
From To Ft. —
From To Ft. IY'(/
14. GROUT: g
Depth � Material L Moth � J U
From To Ft. /
From To Ft.
15. SCREEN:
Ta
Depth Diameter Slot Slz© 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 STANDARDS, AND THAT A COPY OF THVIRIERD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE DATE
Quad No: IGNATURE.OF PERS N CONSTRUCTING THE WELL
I to Division of Water uallty, Groundwater Section within 30 days GW 1 REV. 12/99
serial No.
ffD7
MOO

North Carolina • Departmont of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636=Phone [phone] / L,� (7
WELL CONSTRUCTION RECORD WELL CONTRACTOR:(
WELL CONTRACTOR CERTIFICATION #: I
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential LJ Municipal ❑ industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: ( Qw $I�ptc�I f�h e�catlon below)
Nearest Town: 3 U (% l County:
Road Name and umb rs, Co unity, o ubdivision and Lot No.) DRILLING LOG
r
3. OWNER L` From To
Address 3J �G �`/ E'��-� 11W
ree rr oWL Z
l 1 L. �+
City or Town %Stale Zip Code
4, DATEDRILLED
DEPTH
Formation Description
5. TOTAL DEPTH g
6. CUTTINGS COLLECTED YES ❑ NOED-' c 7
7. DOES WELL REPLACE EXISTING WELL? YES Q NO[,f
Cn
8. STATIC WATER LEVEL Below Top of Casing: FT.
(Use '+' If Above Top of Casing) —�
9. TOP OF CASING IS FT. Above Land Surface' I 2
'Top of casing terminated at/or below land surface requires a variance In pccor-' �j _',-�'_
dance with 15A NCAC 2C .0 18 Q r. C 6((
10. YIELD (gpm): MET)OF TEST rO_---- - r
11. WATER ZONES (depth):
n
12. CHLORINATION: Type i 0 1 CID_ Amount It additional space is needed use back of fornn4j
13. CASING:
Wall Thickness
Depth Diameter or WeighUFt. Material
From 6 To Ft.
From To Ft.
From To Fl.
14. GROUT:
Depth Ma ���� Method 6-b l/�--
Frorn To Ft.
From To Ft.
15. SCREEN:
Depth Diameter Slot Slze 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 Slate
Roads, or other map reference points)
ff
461 C�
%z��
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECOR HAS BEEN PROVIDED TO THE WELL OWNER. _v
FOR OFFICE USE ONLY 2�
Quad No:
SIGNATURE OF PERSON ONSTRUCTING THE WELL DATE
S mi ai to Dlvlslon of Water Ouallly, Groundwater Sectlon within 30 days GW I REV, 12/99
Serial No.
� ��r '� 7 2ap«

North -Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section !; 1-8 6 17 1636 Mali Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential E2 Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATIO : (S ow s etch/ o,�)he location below) d LA ��61,;,�
— -e
Nearest Town: � / �/ 6' County:
(Road Name and Numbers, o`Ily% or $ubd vision and Lot No.) DRILLING LOG
3. OWNER i ����� I ` / / t _J From To
Add ess ���,(�(1-0 t ,
���. I t ` •, Streot or ou zl
P `
City or Town cy J Stale Zip Code
4. DATE DRILLED --r - !-�U-
5. TOTAL DEPTH 3 ,
6. CUTTINGS COLLECTED YES[] NOE2/
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 v lance in °ccor-
dance with i5A NCAC 213.01119 i CUl✓(j_,f,
10. YIELD (gpm): r!J METHOD �)F TEST llh` L r
11. WATER ZONES (depth): (J
Agricultural ❑ Monitoring ❑
DEPTH
Formation Description
r
O
..
M;0
12. CHLORINATION: Types 7" Amount � if additional space Is needed use back of form
13. CASING:
Wall Thickness
Depth ,/�� Diameter or Weight/Ft. Material
From T
-To==
Ft.
From
To
Ft.
From
To
FI.
14. GROUT:
Method
From
Depth
To
lorla
Ft.
From
To
Ft.
15. SCREEN:
DeP th
Diameter Slot Slze
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
(Show direction and distance from at least two State
Roads, or other map referen a points)
l l U�C�vcl` T*d
r J l(
�J
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED iN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECOp HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE U
Quad No:
.Rknfl�
fltt��
11
�ATUFlE 01"PERSON�ONSTRUCTING THE WELL r DAlh
o t Ivision 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 : J, 8 U 1 j
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone] /
WELL CONSTRUCTION RE
CORD WELL CONTRACTOR: /,' 7 t4/V,_ i�/
WELL CONTRACTOR CE T FICATION #: I
STATE WELL CONSTRUCTION PERMITN:
1. WELL USE (Check Applicable eox): Residential D/ Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show.?s tch of eLlocytlon below)
Nearest Town: _ County: �J
(Road Name and Numbgrs 2runity, or ubdlvisI n nd Lot No.
G/�
DEPTH
DRILLING LOG Formation Description
From To
3. OWNER "`u
Address�-
GLd rgq,pr u o.
`'S
City or Town /S a)e Zip Code
;
4. DATE DRILLED
J
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES[] NOL�
YES [� NO[
CD
7. DOES WELL REPLACE EXISTING WELL?
-t
8. STATIC WATER LEVEL Below Top of Casing: FT•
��—
1
(i (Use -+' If Above Top of Casing)
TOP OF CASING ISFT. Above Land Surface'
^
9.
'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
--�
11. WATER ZONES (depth): G_
c ,
12. CHLORINATION: Type I Amount
If additional space Is needed use back of form
13. CASING:
LOCATION SKETCH
Wall Thickness
Depth Diia�metteer�— or Welg VFt. atert�l
�/
�""
(Show direction and distance from at least two State
reference po ints)
Ft• �1--`�=-
Roads, or other map
From —To
From To Ft.
From
To
Ft.
14. GROUT:
Depth a
Nitp i o�j°� V
To �_Ft.
From
From
To
Ft.
15. SCREEN:
Depth Diameter Slot Slze 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:
nerd
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS R ORD HAS BEEN
%PROVIDED TO THE WELL O
FOR OFFICE USE
Quad No: nzz"r
Serial No.
SIGNATdFI E OF PeliSON CONSTRUCTING THE WELL
at to Division of Water Quality, Groundwater Section within 30 days
•- G0
DATE
GIN-1 REV. 12/99

'451'
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: ^^^"l;;rhig' (ATP11—T)ri 1.1.1naa_
WELL CONTRACTOR CERTIFICATION #: 447-
STATE WELL CONSTRUCTION PERMITit:
1. WELL USE (Check Applicable Box): Residential ff 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: Candler County: Rrrrnr•nmhA
(Road Name and Numbers, Community, or Subdivision and Lot No.) DRILLING LOG
3. OWNER Torn Leatherwood From To
Address 11 L
Candler fea or ou NC c. 28715
City or Town Slate Zip Code
4. DATE DRILLED 8-28-00
5. TOTALDEPTH 507
6. CUTTINGS COLLECTED YES ❑ NO©
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NOd
8. STATIC WATER LEVEL Below Top of Casing: 60 FT.
(Use '+' if Above Top of Casing)
9. TOP OF CASING IS 1 Fr. 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 z METHODOFTEST GaL. Container
11. WATER ZONES (depth):
12. CHLORINATION:
13. CASING:
DEPTH
Formation Description
�, rn
rn
� cr
lD
cn
r?t
n
�,D
o
Type Tabl et Amount 2 It additional space is needed use back of form
Wall Thickness
Depth Diameter or Welght/Ft. Material
From 0 To 118 Ft.
Frorn To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From To Ft. Cr)nr,rPte Pnrrr
From To FL
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft in. - In.
From To Ft. in. in.
From To Ft. In. In.
16. SAND/GRAVEL PACK:
Depth Size
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-26
280
Ron Stradley Mtn.Md.
Coffey Cir.
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED 1N ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RE l HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Quad No:
Sutimp of
Serial No.
I'GNATURE OF PERSO
I Io,Division of Water Ou
fGs`r
i
i,
Ei
2 - 2 0 - 0 0
INSTRUCTING THE WELL
Groundwater Section within 30 days
DATE
GW•i REV. 12/99

1636 NorthMail Service partmentof Envronme
h i N.C. 2nt and Natural Resources - 7699-1636-Phone (919) 733'3221n of Water Quailty •Groundwater S%ection r l j C't
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CER 1FICATION
STATE WELL CONSTRUCTION PERMIT#:
1111
WELL USE (check Applicable Box): Residential L�J Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
1 Other 11 Other, List Use:
Recovery ❑ Heat Pump Water Injection ❑ ❑ ,
2. WELL LOCATION: how .th
Nearest Town: cof tb� location below) -�J( (J •t
,
(_ j — County:
���--
DRILLING LOG DEPTH
(Road Name and Nu b rs, CorryTpnly' or So62ii side n ollNq.} From To Formation Description
3. OWNER '­ l
Address
eo or ou f T
City or Town
Slate Zip Code
4. DATE DRILLED.
rTwn-1--�------------
5, TOTAL DEPTH `
6. CUTTINGS COLLECTED YES ❑ NO[
7. DOES WELL REPLACE EXISTING WELL? YES [] NO o
8. STATIC WATER LEVEL Below Top of Casing: FT. --t �= ;•_?
(Use '+' it Above Top of Casing) 1 --
g. TOP OF CASING Is �_ FT. Above Land Surface' _ __
*Top of casing terminated atlor below land surface requires a var ante In actor. ,
dance with 15A NCAC 2C .011 � METHOP (J Q)= TEST
10. YIELD (gpm):
11. WATER ZONES (depth):
12. CHLORINATION: Type _
Amount It additional space is needed use back of form-1 o
13. CASING: LOCATION SKETCH
Wall Thickness Show direction and distance from at least two State
Q Depth �O Diameter or Weight/Ft.FAatedal
Ft Roads, or other map reference points)
From_ To
From— To Ft. —
From To Ft.
14. GROUT: ot
Depth Ma�q�alI d
,
From To Ft. 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: Material
Depth Size
From To Ft. —
From To Ft.
17. REMARKS:
I DO HEREBYCTION STANDARDS, AND THAT A COPY OF THIS RE IN AD HAS BEEN PROVIDED TO THE WELL OWNER.
CONSTRU >rCCORDANCE , G��/��j- f CJ
FOR OFFI
Quad No:
SIGNATURE dF PERSO . ONSTRUCTING THE WELL
DATE
al 10 Division of Water Quality, Groundwater Section within 30 days GW• 1 REV. 12/99

�24507
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) 733
WELL CONSTRUCTION R 3221 R Oa ��C ��.� ATION �r+^ �/
ECORD WELL CONTRACTOR:
WELL CONTRACTOR CE FIC
�,�
#:
STATE WELL CONSTRUCTION PERMIT#:
i
1. WELL USE (check Applicable Box): Residential ❑ Municipal ❑Industrial
Agricultural ElMonitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ ❑ If Other,
WELL LOCATION,: (Show sketchJJo,f th location below) d(C
Nearest Town: )% J� a v u County:
(Road Name a I` urn ers, communit r S bdlvi 1 and Lot o.)
3. OWNER �.. �G� V } � 0
Address
ree or ou a o. cS 1. 3
�Y• IIL' /��(� ��. Zi D
City or Tovrn Slate Zip Code
4. DATE DRILLED
5. TOTAL DEPTH :t—�—Y S NO
6. CUTTINGS COLLECTED ❑ ❑
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO[�j
8. STATIC WATER LEVEL Below Top of Casing:
r (Use '+' If Above Top of casing)
9. TOP OF CASING IS____L__ _ 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
11. WATER ZONES (depth): 30
12. CHLORINATION: Type �Abl Amount ) --
13. CASING:
DRILLING LOG DEPTH
From To Formatio, -�rlption
C) T
o n i
rr
u
L.O
M:5
d
It additional space Is needed use back of form
Wall Thickness
Depth Diameter or Welght/Ft. Material
�;,2_S_ �-- ✓C�
From
To .3
Ft.
From
To
Ft.
From
To
Ft.
14. GROUT:
Material Method
Depth
D
� Ne.1-e-CC, a d
From _
To
FL
From
To
F►•
- -----
15. SCREEN:
Depth
Diameter
Slot Siz© 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
(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 RECOF}D HAS BEEN PROVIDED TO THE WELL OWNER. vb
FOR OFFICE USE ONLY
Quad No:
serial No.
CONSTRUCTING THE WELL DATE
allty, Groundwater Section within 30 days Cw i REV. 12/99

1North Carolina - 638 Mall Service Center�nRaleigh, N.C. 27699-1636--Phone (919) 733In of Water Quality - Groundwater Section
3221�}
WELL CONSTRUCTION RECORD WELL CONTRACTORLL .CERTI ATION#:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential [0/ Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other C] If Other, List Use:
2, WELL LOCATION: (Show sketch of the location below)
Nearest Town: LE t' ry'
Ja
DRILLING LOG DEPTH
(Road Name and Numbers, Cbmmunlly, or Subdivlslon and Lot No.) From To Formation Description
3. OWNER Cy 1'1�i5' (�rl �Gv1r,
Address
ree or ou e
City or Town Stale Zip Code
4. DATE DRILLED Q'
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑ NO
�i
7. DOES WELL REPLACE EXISTING WELL? YES ❑ N
8. STATIC WATER LEVEL Below Top of Casing: �UV
(Use '+' II Above Top of Casing)
9. TOP OF CASING ISFT. Above Land Surface'
*Top of casing terminated atfor below land surface requires a variance In accor-
dance with 1 (g m): 2C.0118 METHOD OF TEST
10. YIELD (gpm):
11. WATER ZONES (depth):
'T—Ah�_ Amount
12. CHLORINATION: Type --
13. CASING:
Wall Thickness
Depth Diameter or Weigh fit. Material
From _--<--To Ft. - U 'q r—
From To Fl.
From To FI•
14. GROUT:
Depth Material Method
From `Q To aQ_Ft. �nc✓Qi-Q From To Fl•
n --T—
�%
r-r
:.ems
•. D
tr
W
o
It additional space is needed use back of form
15. SCREEN:
Depth Diameter Slot Slze Material
From To Fl in. in. —
From To Ft. in. In. From To Ft. in. In. _---
16. SAND/GRAVEL PACK:
Depth Size Malarial
From To Ft.
From To Ft.
17. REMARKS:
I DO HEREBY CERTIFY THAT TV WELL WAS CONSTRUCTED iN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RE CO HAS BEEN P OVIDED TO THE WELL OWNER.
ngDr 5-I
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
Ct .
FOR OFFICE USE ONLY DATE
Quad No: SIG URE O PERSON NSTRUCTING THE WELL
Submit original to Division of Water Ous y, Groundwater Section within 30 days GYV 1 REV. 12/99
Sedal No.
r''P rufi4t a

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section �) C"
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: " -n 1
WELL CONTRACTOR CERTIFICATION #: kl�8
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) n
Nearest Town:?L4 ' "` County:
(Road Name and Numbers, community, or Subdivision and Lot No.)
DRILLING LOG DEPTH
3, OWNER Y-9L.fyFrom To Fortnatlo' Descrip on
Address i I r,J R ;r?1 O
p _ ree or ou e
City or Town Mn l h State Zip Code
4. DATE DRILLED
5. TOTAL DEPTH 325
6. CUTTINGS COLLECTED 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) Cn
9. TOP OF CASING IS FT. Above Land Surface'
*Top of casing terminated atlor below land surface requires a variance in actor- _
dance with 15A NCAC 2C .0110 =`
10. YIELD (gpm): &C" METHOD OF TEST °' r
11. WATER ZONES (depth): c.
12. CHLORINATION: Type - 4 f Amount Z If additional space Is needed use back of formGlt
13. CASING:
LOCATION SKETCH
Wall Thickness
Depth Diameter ora ei Lnt aerial (Show direction and distance from at least two State
From Q To Ft. Roads, or other map reference points)
From To Ft.
From To Ft. 2 V o
14. GROUT:
Depth Material Molhod r�'U
From t' To � b Ft.
From To Fl. -
15. SCREEN:
Depth Diameter Slot SIZE Material
From To Ft in. In.
From To Ft. In. In.
From To Ft. In. In.
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft'
From To Ft.
17. REMARKS:
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED iN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD PAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY DATE
Quad No: SIGNATURE' OF ERSON CONSTRUCTING THE WELL
Submit original to Division of Water.Quality, Groundwater Section within 30 days GW t REV. 12/99
Serial No.
i:i

North Carolina • Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section Li 5 �j n 2 4
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:��
WELL CONTRACTOR CERTIFICATION #: 1 %­ 7
STATE WELL CONSTRUCTION PERMIT#:
WELL USE (Check Applicable Box): Residential E Municipal M Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2, WELL LOCATION: (Sh w sketch of the location below) �1
Nearest Town: ri r1A County:
�
W �, S i C N , DRILLING LOG DEPTH
(Road Name n Numbers, ommunity, or Subdivision and Lot No.) Fo on Doscripllon
3. OWNER i�>'OI � nCT1(C/ �m �Ta�
Address 01I')"� C yam,—j_
ree or ou a o.
Cn rl /fil' Stale Zip Code
City or Town
4. DATE DRILLED J 2-) 'J3
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES" NO
7.
DOES WELL REPLACE EXISTING WELL? YES NO❑
8,
STATIC WATER LEVEL Below Top of Casing: (D U FT.
(Use '+' II Above Top of Casing)
C'
i
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): hQ METHOD OF TEST
11.
WATER ZONES (depth):
12. CHLORINATION: Type��� -Amount 2'
13. CASING:
Walt Thickness
Depth OL Diameter orWelght/Fl.
From Q To Ft. -�'f— (J(j
From To Ft.
—
From To Ft.
14. GROUT:
Depth Material 140thod
From To 2 Fl.�
From To_Ft.
15. SCREEN:
Depth Diameter Slot Siz© 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:
If additional space Is needed use back of form r' �'
W
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 RECOpD HAS BEEN PROVIDED TO THE WELL OWNER.s ✓1 ���)
EFOR OFFICE USE ONLY
Quad No:
Serial No. -
SI3rNATU6E OF PERSp CONSTRUCTING THE WELL
Submit original to Division of Water Quallly. Groundwater Section within 30 days
DATE
GW-1 REV. 12/99

L
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]
ei
WELL CONSTRUCTION RECORD WELL CONTRACTOR:'
WELL CONTRACTOR CERTIFICATION #: 1
STATE WELL CONSTRUCTION PERMITit:
1. WELL USE (Check Applicable Box): Residential[(J Municipal ❑ Industrial
Us❑e: Agricultural ❑ Monitoring ❑
RecoveryE] Heat Pump Water Injection ❑ O ❑ It Olher,
2. WELL LOCATION: (Show sketch of the location below)
f /�vC' �'�\ 1 IS
Nearest Town: �,�.
County:
W o � 'r7'�r-�)(' l �t om DEPTH
(Road Name and _N�uImbers, Ci°mmuplly, or Subdivision` _an'd Lot No.) DRILLING LOG Formation Descdption
3. OWNER i 1�►1 / �' t A'hT= ►y-_' From To
Address \ « C� �1
EGG 66�nJr--
ree or ou a o,
- Ir C-
City or Town Stale Zip Code C:)
4, DATE DRILLED
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES [] NO❑fV =-
7. DOES WELL REPLACE EXISTING WELL? YES [] NO� -- -
8. STATIC WATER LEVEL Below Top of Casing: _ FT.
(Use +' If Above Top of Casing) r;
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 W o
10. YIELD (gpm): J Q METHOD OF TEST a
11, WATER ZONES (depth):
12. CHLORINATION: Type I �`I p - Amount U— if additional space Is needed use back of form
13. CASING: LOCATION SKETCH
Wall Thickness
Depth�Diameter,— or Weight/Ft. Mate fat (Show direction and distance from at least two State
7�
From To =-'-- Ft. -5 7 , Roads, or other map reference points)
From To Ft. _ _ z
From To Ft.r i
14. GROUT:
Depth Material �lho�
i-� 7y1
From To Ft.
From To FL
15. SCREEN:
Depth Diameter Slot Siz© 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 STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
_ (1
FOR OFFICE USE ONLY DATE
Quad No: SIGNATURE O PERSON CONSTRUCTING THE WELL
Submit original 160vislon of Water Quality, Groundwater Section within 30 days GW 1 REV. 12/99
Serial No.
i
1

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:
WELL CONTRACTOR CERTIFICATION 11: ) R 7
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residentlai Ego'_*' 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: Cbn l_�,. County: P' 1IA r
" 111 l �� S1C �S>V�52 �` C DEPTH
(Road Name an Numbers Communit , or Subdivision and Lot No.) DRILLING LOG
3. OWNER ?/ 7 Frorn To Formation DescOil 7
Address K �� (? J`. q5_ _ �l
ree or ou oj C
City or Town State Zip Code : ' •�
4. DATE DRILLED
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES [] NOmr L
7. DOES WELL REPLACE EXISTING WELL? YES [] NO[&
B. STATIC WATER LEVEL Below Top of Casing: /o 0 FT.
(Use '+' if Above Top of Casing) c
9. TOP OF CASING ISFT. Above Land Surface- ut -"-r
'Top or casing terminated at/or below land surface requires a variance In accor-
dance with i5A NCAC 2C .0118
10, YIELD (gpm): 15 METHOD OF TEST
11. WATER ZONES (depth):
12, CHLORINATION: Type 1 / J71 Amount it additional space is needed use back of form
13. CASING:
LOCATION SKETCH
Wall Thickness
Deplli Diameter or Weight/Ft. Mated] (Show direction and distance from et least two State
From_ a --To L3 S Ft. �=�- - 0 t— ��' Roads, or other map reference points)
From To Ft.
From To Fl.
14. GROUT:
Depth Material t ` M od
From �_ To `� Ft. r) PI CZ1 Y >
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:
j 3
CA
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS fl�,F.CORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Quad No:
Serial No.
SIG ATURE OF PERSON CONSTRUCTING THE WELL
Submit original to Division of Water Quality, Groundwater Section within 30 days
5��
DATE
GW i REV. 12/99

35
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section /;. t 5 �)
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone] ;" 12.0
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential d Municipal ❑ industrial ❑ Agricultural ❑ Moniloring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other 0 If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: �"�' j �'�- J County: C
(Road Name and Numbers, Community, or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER 1 rl ,.1�_ � Cz--�'S 1 A� ( From To Formation Description
Address.
(Stree or ou e N o.
City or Town Stale Zip Code CD
4. DATE DRILLED J1�T rn
5. TOTAL DEPTH �6-r
6. CUTTINGS COLLECTED YES [] NOEY
7. DOES WELL REPLACE EXISTING WELL? YES [-1 NO[:�J'
S. STATIC WATER LEVEL Below Top of Casing: -7-t' FT. '-
-
r
(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 Ca
10. YIELD (gpm): 30 METHOD OF TEST -
11. WATER ZONES (depth):
12. CHLORINATION: Type Amount Z- If additional space is needed use back of form
13. CASING:
LOCATION SKETCH
Wall Thickness
Depth D�ia�meter� or Welght/Ft.. Material (Show direction and distance from at least two State
From Q To 0 te
Ft. y== �=� - :R-TF--1=—e` Roads, or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From — To ad Ft. 0-7-i �
From To Ft. �� C.-R_.
15. SCREEN: ` R
Depth Diameter Slot Siz© 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 STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY����
Quad No: SIGNATURE OF PERSON C NSTRUCTING THE WELL DATE
Submit original to Division of Water Qualify, Groundwater Section Within 30 days
,I ) GW i REV. 12/99
Serial No.
i
n
t
AUG 5 "(NI
�r i
i
r.

North Carolina a Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential Eff Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ I( Other, List Use:
2. WELL LOCATION: (Show sketch of the location below) ,
Nearest Town: Q S County:
(Road Nam and e4umbers. Community, or Subdivision and Lot No.) DRILLING LOG
DEPTH
3. OWNER ��� �� From To
�1rJ U 5
Fogallon Description
Address l , rn Y-j
r e or oU r� o. /
City or Town 2 f State Zip Code
n
4. DATE DRILLED.
^,
5. TOTAL DEPTH 6 0-5
r=�
6. CUTTINGS COLLECTED YES [] NO�
WELL? YES [� NO�]
N
- ,.'•
'
7. DOES WELL REPLACE EXISTING
^
8. STATIC WATER LEVEL Below Top of Casing— FT.
�-
of
(Use '+' if Above Top Casing)
TOP OF CASING ISFT. Above Land Surface -
9.
'Top of casing terminated at/or below land surface requires a variance In actor-
rn
dance with 15A NCAC 2C .0110
'- r-n
-�-+
10. YIELD (gpm): METHOD OF TEST
.ate
11. WATER ZONES (depth):
12. CHLORINATION: Type ('q �> Amount Z- If additional space Is needed use back of form
13. CASING:
LOCATION SKETCH
Wall Thickness
Depth Diameter or Weight/Ft. (Show direction and distance from at least two State
From----(-2—To Ad - Ft. b=25- 7--'—((� Roads, or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Matorial yMethod
From ® To a' Q Ft. �FP� 170 i✓"°�
From To Ft.
15. SCREEN:
Depth Diameter Slot Slze 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 Fl.
From To Ft.
17. REMARKS:
P17
.kv
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C. WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS 5CORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Quad No: Slot
Submit original to
Serial No.
OF PE ON CONSTRUCTING THE WELL
i of Water OUailty, Groundwater Section within 30 days
DATE
GWA REV. 12/99

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section ? 261 09
9
1636 Mall Service Canter - Raleigh, N.C. 27699-1636-Phone (919) 733=3221
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
/ de #w e;e sa 1.21 -
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (check Applicable sox): Residential [Ef 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 n County:
l sf, f-9- DEPTH
i
(Road Name and Numbers, Community`, or Subdivision and Lot No.) DRILLING LOG
3. OWNER l�J`0.�� S"t- L - U sl From To Formation Description
Address n 2
(Street or Route o.
City or Town State Zip Code-
4. DATE DRILLED-L --00
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑ NO
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
� � rT�
S. STATIC WATER LEVEL Below Top of Casing: Lr,O FT.v <
(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 .0113
10. YIELD (gpm):_ METHOD OF TEST. PCr�IL
11. WATER ZONES (depth): '- ca ca
12. CHLORINATION: TypePcoyAmounl __2 It additional space is needed use back of form
13. CASING:
LOCATION SKETCH
Wall Thickness
Depth Dlamet r or.�W.eeiighhU/Ft. Material (Show direction and distance from at least two State
From �� . —To Ft. — - 1- �n`►`�—fit C" Roads, or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Mateeria� Methodn
�_ To �
From FI.
From To Ft.
15. SCREEN:
Depth Diameter Slot Size 4vlateriai
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:
t DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED iN ACCORDANCE WITH 15A NCAC 2C. WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF HIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER. 7
FOR OFFICE USE ONLY—— -. --' DATE
Quad No: 9 Nk .� SIGNATURE OF PERSON CONSTRUCTING THE WELL
9 Submit original to Divtalon of Water Quality, Groundwater Section Within 30 days
i °a GW-i REV. 12/99
Serial No.
Pill H MAR 1 9 2001 f
t
p �9 �vl�l i+�CP�Y�� `�411dh11

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] 226110
WELL CONSTRUCTION RECORD WELL CONTRACTOR: de S -sad
WELL CONTRACTOR CERTIFICATION 0:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential ET --municipal ❑ industrial Q Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATIC : (Shovst etch of the location below) (7
� C Q � e
Nearest own: (-a''`�O�\L2 County:
� =
0� ��
DRILLING LOG DEPTH
(Road N e and Numbers. Community, or and Lot No.)
3. OWNER �c7� J v`1
From To Formation Description
Address
ree or ou a o.
City or Town State Zip Code
4. DATE DRILLED
r--
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES
7. DOES WELL REPLACE EXISTING WELL? YES
8. STATIC WATER LEVEL Below Top of Casing: �M_ FT.
rz,
(Use -+' 11 Above Top of Casing)
1
/
9. TOP OF CASING is Above Land Surface -
*Top or casing terminated at/or below land surface requires a variance in accor
dance with 15A NCAC 2C .0118 C�
10: YiELD (gpm): _L METHOD OF TEST _
o rn
11. WATER ZONES (depth):
•
12. CHLORINATION: Type 102L % S Amount Z
o
It additional space is needed use back of form -
13. CASING:
LOCATION SKETCH
Wall Thickness
Depth Dlamel r or Weight[Ft. Ma''ieria''lII
From To Ft. �a�rrG
(Show direction and distance from at least two State
Roads, or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From To -�7- -FL
From To Ft.
15. SCREEN:
Depth Diameter Slot Slze �riateriai
From To Ft in. In.
From To Ft. In. in.
T Ft In in. —
From o
16. SAND/GRAVEL PACK:
Depth Size .
From To Ft.
From To Ft.
17. REMARKS:
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 BEEN PROVIDED TO THE WELL OWNER.
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
original to Division of Water Quatily. Groundwater. Section within 30 days GW 1 REV. i2/99

. proundwater SectIon C:.. _
Q artrrsant of Envkonmant and. Natural Resaurass - Div[slan of Water Owtky ' .
North CeroBrte - Canter Flaielgh,
183es Met{ Service N.C. 276W1838-i'hms (9'fa) 733-=1
WELL. CONSTRUCTION RECORD SAI
WELL CONTRACTOR:
CERTIFICATION P.
STATE WELL CONSTRUCTION PERMIT#:
ok A licable SO0 Residentlal �---�Munfclpal [ ] industrial ❑ Agricultural Monitoring
Recovery
❑ Hegt Pump ❑
1. WELL (tom. PP Water InjecWn [J Other j] If Other, L.is! UsG:
2. WELL L.00ATION:(Show sketch of the location below)
Nearest Town:
'u, •.. C DRILLING LOG DEPTH
(Road Name Nwnbars, CDavnurrty, or Su Sion +rnd Lot No.) From To Fo,,ftn osscr"on
3. OWNER
Address
� ro or e
City or Town State ZtP Code
4. DATE DRILLED
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES NO[]
7. DOES WELL REPLACE EXISTIN WELL? YES ❑ rtnf
8. STATIC WATER LEVEL Below Top of Casing: —6
FT -
(UM ••►' K Above Top of Csek+g)
g. TOP OF CASING IS FT. Above Land Surface` - --
" Top of cueing lormineted etfor below land surface requires a variance kr senor . .
dance with 15ANCAC2C.01t1 MEMODOFTEST
10. YIELD (gprn): 5
i i WATER ZONES (depth):
12. CHLORINATION:
13. CASING:
Type Amount
If additional $pace is needed use back of form
�: ��.r.�-.---
Depth
Fron, Ft.
From To Ft. --
From --------To - — Ft.__------
14 GROUT:
_t OCATiON SKt='fCti
Tl+k R
or WaOJMaterial (Show diredbn and distsutce MOm at least two State
a
dE %� Roads, or other map reference points)
Depth Material 1.
From ._ � To
From — To ----- FL
15. SCREEN:
Depth Diameter Slot Slue
Method
�cc R
.. •Material
From _ To Ft in- In.From --- To . _ »- Fl. - In. In. �—
From To Fl. in- — In.
16. SAND/GRAVEL PACK: Material
Depth Size
From _ To_ Ft.
O
0
t7
rrl
Cl)
tV
co
v
rJ
M ;;0
'0rn
C)n
c
rn
a.�
r*3
m�
=o
rn
M
c->
C)
2
From — To .r Ft.._�
17, REMARKS:
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 1SA NGAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A CONY 0 THIS RECORD BEEN PROVIDED TO THE WELL OWNER.
la-/'Z-yv
/Y—c•-��-� � °--'-�z' nk vgdnaf DATE
FOR OFFICE USE ONLY SIGNATURE OF pgRSON _.__.. 3T CTiN G THE WELL
Quad elm tir$acuoa-wit 30 days
t r 1 Subrdto t]ivlston of Water Ova1Ry. f#n„ut a Gw-1 RV, t?199
{ eSacla�Nbu_i y pp
�n
i. Oolllt(14�3i�c.....,1 SSA it

North Carolina -Department of Enviry wwnt And. Natural Resources - DIvIefon of Water C wNty-.t3roundwatar Seation- �' ?. i ()
I We Map Service Center 4(oleklh, N.C. 27699 1636-F hms (Sig) 733o=1 / e
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFiCATION dl:_
STATE WELL CONSTRUCTION PERMrr#.
WELL USE (Check Apppcabia Box): Residentlai --_- Unlclpal ❑ Industrial ❑ Agdculturai d Monitoring
1 Other if other, Ust Use:
Recovery ❑ Heat Pump Water injec4tort [,� ❑ .
2, WELL LOCATION: Show sketch of the locattan below)
Nearest Town:
,�' C c ✓� DEPTH
(Road Name and umbers. Canna W, or subdwialm and Lot No.) DRILLING LOCa� Pnxrn To Formadon Oescdpdon
,r.,t. (fu�ct'vnci
3. OWNER j 6-7
Address
i re
CJIy or lawn Stats Zip Code
DATE DRILLED 1 - ALQO
57
4.
S. TOTAL DEPTH _ a`_
YES NOL]
6. CUTTINGS COLLECTED
REPLACE EXISTING WELL? YESS.
7. DOES WELL
5TATiC WATER LEVEL Below TOP
tU"'+ N Above Top of C+r&V)
Surface*
9. TOP OF CASING IS _ FT. Move Lard
•Top of cssin0 terrninsted actor below Isnd surface ►sgrdms s vatiancs in sacor-• . .
dance with 15A NCAC 2C .0118
1o. YtELD (gpm): � _--_. METHOt7 OFTEST
11. WATER ZONES (depth):
_
�; /l Amount - ----
tt additional Space is needed use back of form
12. CHLORINATION: Type - ....
13. CASING:
LOCATIpN KETCH
Woo ThIckmes
A�taata+taJ
(show direction and distance tram at least two State
Depth s er . or w.
�
Frain To Ft. - C
goads, or other nw rsfarenas palyds)
From- To Ft.
From -To Ft. - --
14. GROUT:
Depth Material Melhod
a
_
`o
• LuR
From - TO Ft.
o
From _ _ - To FG - - -
C3
rn
�.
r,
15. SCREEN:
Depth Diameter Slot Slze ` •Ivlatedai
C7
iv
mac,
m
From To Ft --- In.
CO
ern
From To Ft. In. In. -
3:10
m�� M
From _ __ To Ft. In- in. _.__ _-- --
u,
16. SAND/GRAVEL PACK:
Material
CA
Depth Size
o
From To Ft.
a
From _ To Ft. --
17. REMARKS:
i DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDA ce WITH SSA NCAC 2C, WELL
N PROVIDED TO THE WELL OWNER.
CONSTRUCTION STANDARDS, AND THAT A COPYO F THIS RECORD
HAS S -
FOR OFFICE USE ONLY OATS
Quad SIGNATURE OF PERSON CONSTRUCTI fi WEU_
,_•_: rt,::: Subag edt*Sl to DjvWon of water c3ue; Groundwater Section wr aYs
aW-i REV. IV"
SeAst —11
c r l�l
e,

e
North Carolina - Department of Environment and Natural Resources - Divfston of Water Oueelily - proundwaWr Section.
IWe M&HService Center;. Raleigh, N.C.27t399 1636-Phone(91V) 733;4=1
T10N REGARD WELL cof�rRACToa: �
WELL CONSTRUC --
WELL CONTRACTOR CERTIFICATION It.
STATE WELL. CONSTRUCTION PERMIT#:
1. WELL USE (Check Appttcsbia Box): Residential �--�unictpa(❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Irgectteon ❑ Other if other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: %� u'%/'' County: i1"C- P> be
(Road Nand and Numbers. CanMMY, at Sub&viskxf and Lot No.) DRIWNG LOG
DEP I H
Fo: 11c� From To FomuSon Oesc*lon
3. OWNER _ iir^�ird / 1�g d ,!/C�- �/a✓6Z�
Address
1-51reil or PAutao No.)_ -
My or Town ZP Code
A. DATE DRILLED slaw
S. TOTAL DEPTH-
6. CUTTINGS COLLECTED YES NO CI
7. DOES WELL REPLACE EXISTING WELL? YES---
8. STATIC WATER LEVEL- Below Top of Casing: FT.
(Use '+' V Above Top of rwkv)
9. TOP OF CASING IS L FT. Above Land Surface`
•Top of casing terminated allor below land surface nquirna a variance in accor
dance with 15A NCAC 20.0110 10. YIELD (gpm): METHOD OF TEST
2---
11. WATER ZONES (depth):
12. CHLORINATION:
13. CASING:
Type_ !: ._Amount---- If additional space Is needed use back of form
Depthr
From—:2t ...-To -� -- Ft.
From----== To Ft. -
LOCATION _$KETCH
Weli Thickness
Of We ttr-{, Mstetlat (Show direction and distance iron at least two State
,Fl , T &�G Roads, or other map reference points)
From To Ft.
14. GROUT:
C3
Depth Material L Method
LtcRt'
6
O
o
n
M=
From To FL ____l
Ci'
M
r''
From To Ft'. -
F'r i
n
o
. rr-r
15. SCREEN:
r\7
a1_
Depth Diameter Slat Size -14atedal
co
From To Ft in. _ in. _____-- —
2„
�o
From TO Ft. in. In. _ ___.---
=�
=Q
From To FL In. In. _____-----
n:ci
16. SAND/GRAVEL PACK:co
w
-r
Depth Size Material
o
From To Ft. From To Ft. - - ---
17, REMARKS:
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 1SA NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD BEEN PROVIDED TO THE WELL OWNER
FOR OFFICE USE ONLY DATE
Quad No.
SIGNATURE OF PERSON' UCTIN4 S1iE WELL
subrnN original to Dl:,f of water Qualify. a teFSact4ork within 30 days CiW-1 REV. 12/9s
Serial No.°�^ffim

�. •- ..-2856
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: WLIpc �Ib3°^
WELL CONTRACTOR CERTIFICATION24
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: S A VII i l e -County: t3nr b� bt'
(Road Name and Numbers, Community, or Subdivision and Lai No.) DRILLING LOG DEPTH_
3. OWNER OCL OCN i�Mes From To Formation Description
Address �'� IS W('Y Rt?tden
ree or Route o.
City or Town State Zip Code
4. DATE DRILLED /I--4--�'-S`
S. TOTAL DEPTH 3a-S
6. CUTTINGS COLLECTED YES Z] NO❑
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
8. STATIC WATER LEVEL Below Top of Casing: ran FT.
(Use '+' If Above Top of Casing)
9. TOP OF CASING Is __1___ FT. Above Land Surface -
'Top of casing terminated at/or below land surface requires a variance In accor-:: .
dance with 15A NCAC 2C .0118
10. YiELD (gpm):_ METHOD OF TEST Ail
11. WATER ZONES (depth):
12. CHLORINATION: Type fl%NS Amount -- b_ If additional space is needed use back of form
13. CASING:
Wall Thickness
Depth
D ameter or WelghUFl. Material
#
From�To --L� —
Ft.
2t as
From To
Ft.
From To
Ft.
14. GROUT:
Depth
Material Method
Cerhe
From To
Ft.
From To
Ft.
15. SCREEN:
Depth Diameter Slot Stze h7aieriai
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
(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 15A NCAC 2C. WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF HIS RECORD H BEEN PROVIDED TO THE WELL OWNER.
" -co
FOR OFFICE USE ONLY
Quad NQ , : � �, • ,;:� -=.�
SIGNATURE OF PERSON COAT11OCTING THE WELL DATE
C {.. I—r I SUtmit original to Division of Waler Quality, ater Section Within 30 days
Serial Np _ K i h GW-1 REV. 12199

North Carolina - Department of Environment and. Natural Resources - Division of Water Cuanty - -Groundwater Section.-.
1636 Mali Service Center Raleigh, N.C. 27691636 i'hone (9'19) 733�3221 r
WELL CONSTRUCTION RECORD wELL CONTRACTOR:
W WELL CONTRACTOR CERTIFICATION 0: �ytZS-/
STATE WELL CONSTRUCTION PERMIT#:
1. WSLL USE (check Applfcsbie Box): Residential R�---iufunicipai ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection[] Other D If Other, Usf Use:
2. WELL LOCATION: (Show sketch of the location.below)
Nearest Town: 4�rdlE�t' County:✓i�r'
(Road Name and Numbers. Corrumnity, or Subdivision and Lot No.) DRILLING LOG DEP T }i
3. OWNER S ' Ram From From To Formation Desaiptfon
Address ,�e�44
151reet or fi=91957
City or Town State Zip Code
4. DATE DRILLED
5. TOTAL DEPTH 5
6. CUTTINGS COLLECTED YES -NOD
7. DOES WELL REPLACE EXISTING WELL? YES
8. STATIC WATER LEVEL Below Top of Casing: Go _ 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 sccor- :.
dance with 15A NCAC 2C .D118
10: YIELD (gpm): _ Le_ METHOD OF TEST y
11. WATER ZONES (depth):
12. CHLORINATION:
13. CASING:
Type ILL —Amount g If additional space is needed use back of form
Wall Thickness
Depth D y r or WelghlFL Material /� C
From 70 -(00 Ft.
From To Ft.
From —To Ft.
14. GROUT:
From b
Depth
To ,_ W Ff.
Material Method
From
To
FL
15. SCREEN:
Depth
-Diameter Siot 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)
0
D
G7 r
��
c
c-)
CO CO �rn
�ro
rn
0 rrn
CD o
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH i5A NCAC 2C. WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THi ,RECORD HAS S N PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY `
Quad No: SIGNATURE OF PERSON CONSTRU6nNG THE WELL DATE
Sy}t?Irattarigfnat 19, Division of Water Quality. Groundwater Section within 30 days
Serial No. GW-1 REV. 12/99
t
0i ev-

` North Carolina Department of Envkonmerd and. Nature! Resouress - Division of Wsht QUOMY t3roundwater Section !. ) Z 8
j Wg Mall Service, Center Raleigh, N.C. 27629-1636-Phone (i11tt) 733-=1
D WELL COtiTiiACTOR:
WELL CONSTRUCTION RECUR WELL CONTRACTOR CERTIFICATION fi:_ �
STATE WELL CONSTRUCTION PERMIT#:
Industrial ❑ Agricultural ❑ Monitoring
1. WELL USE (Check Applicable Box)' Residential�--•-�Other� ❑!1 other, List Use:
Recovery ❑ Heat Pump Water Injection ❑ [] '
2, WELL LOCATION: (Show sketch of the location below) i
Nearest Town: I- P�d t,� -- ""'—countwS
(Road Nama and Numtrara, CarrvtiwNh+, or Subdivision arsd lee No.)
ORILUNG LOG DEPTH
' Frarst TO Fotmstfae Oas«tpdere
3. OWNER
Address
IQ re or e
Criy or Town Slats zip Code -- —- �----
4. DATE DRILLED l/ - d ko 2�rd v�
S. TOTAL DEPTH
6. CUTTINGS COLLECTED YES 7. DOES WELL REPLACE EXISTINk4--NOCj
WELL? YES
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 *using terminsted stlor blow land surface, r"alne a variance In sceor- . .
dance with 16A NCAC 2C.0118 METHOD OF TEST
10. YIELD (gpm):-
11. WATER ZONES (depth):
12. CHLORINATION:
13. CASING:
Type __ � s - Amount _ 41 -- if addiNoteal space Is rimed use back of tom'
Depth r
From To �D Ft.
From.....------ To Ft.
From To Ft.
14. GROUT:
From From
15. SCREEN:
LOCATIQN KE- TCH
Wati Thl&"sa
or we malarial (Show direction and distance from at least I*" State
4j bc- Roads, or other rnap reference points)
Depth Material l
To Ft.
To FL ---
Depth Diameter
From To Ft
From To Ft.
From To Ft.
16. SAND/GRAVEL PACK:
Method
• �uR
Slot Size .. -Material
In. _—In..
In.' lo...�
in. In. -, .—
O
CO
0
m
C')
tV
co
n"
00
0
:iE
0
o�
=m
c) ,[
.trn
m--
;;Oc:)
m
0
z
Depth Size matenar
From — To Ft.
From To_ Fl.
17. REMARKS:
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C. WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS 8 N PROVIDED TO THE WELL OWNER.
�OG
FOR O�El PARSON CONSTFtU Ftt's WE13 OATBOuaa No
Subrnit od&W to Division of Wa1m Ouallty. Gf er Seellon within 30 days Ow r tZ/99

North Carolina • Depart-TwIld of E"vkonrnent and. Natural Resouress - Divlalon cf Water CAMMY • ,Greuntfwatar Seaton
,We Melt Service Canter = R6iei,ih, N.C. 27899►ls3e-Phone {9Y9) 733;=1
WELL CONSTRUCTION RECORD WELL CONTRACTOR;
WELL CONTRACTOR CER'ryFICATIO14--
STATE WELL CONSTRUCTION PERMIT#:
- Unlc ai Industrial Agricultural ❑ Monitoring ❑
1. WELL USE (t�rtrek Appittab4a p W� Water
ec ttlon El Other [� It Other, List Use:
Recovery [] Heat Pump M
2. WELL LOCATION: (Shows)oetch of the location below
Nearest Town: �T > c PIS h
DRILLING LOG
(Road Name and Numbers, Comrrwni V. at SubdMston and Lot No.)
3. OWNER c r v tt u/ TO l a
Address
t ro ar a
taty or Town Stela zip Cade
4. DATE DRILLED /�-v St�i yes
6. TOTAL DEPTH G
6. CUTTINGS COLLECTED YES NOQ
7. DOES WELL. REPLACE EXIST)N WELL? YES;
8. STATIC WATER LEVEL Below Top 01 Casing: ' Gz FT•
(Use •+, S Above Top of CaskVI
9. TOP OF CASING IS FT. Above land Surface'
•'Top of aiming terminated abor below land aurfaca requires a wrfanae to aecor- .
dance with 15A NCAC zC.011s METHOD OF TEST-2—
10. YIELD (gpm):
11. WATER ZONES (depth):
12. CHLORINATION:
13. CASING:
DEPTH
Formetla+ 0611010on /
Type Amount /y - If additional space Is neaded use back of term
L, Depth r
From-L.----To S9 Ft.
From ---- To - Ft. - -
From To Ft.
14 GROUT:
t of AT10N SKETCH
Wad Thickness
W we �&We" (Show direction and distance kom at (east two State
r� "7 ,J 5 bC Roads, or other reap reforenca Points)
Depth Material
From _-_ To Ft. From —To' ._ Ft:
15. SCREEN:
Depth .Diameter Slot Size
Method
• � uX
-Material
Ft In. _ . In.
From .._...^. To . "`
From ._ ._ . To Ft. In. in.From To Ft. In. In.---------
16. SAND/GRAVEL PACK:
Depth Size Material
CD
O
t�
r'=7
lV
00
a
CO
+.J
0
{
CDM
cC=
rn
o«;
-�-s o
M
70M
rn
rn
--t
0
From - --- To —Ft.
From To— Ft.
17. REMARKS:
t DO HEREBY CERTIFY THAT THIS WELL
THAT AACOPY � UCTED IN ACCORDAMCIE WrT" THIS RECORD HAS BEEN PROVIDED To � WELL OWNER.
CONSTRUCTION STANDARDS, r — ^ v /, / -') -cd U
FOR OFFICE US1=ONLY SIGNATURE OF �RSCN E WSLL - VAT9
Quad No: Subil+ oti&at to Division of water Ouality. aroundwater Section Within 3b days
ow -I Rev. 12/99
Serial Nq41
i
{r,sUn
y
Sits VIIin tiS }T,Iriridliif{ .

tf.
Groundwater Section r' `� 2 8 /
North Caroka . D Cenert ne Raleigh, N•CN C� z%� �l Resources
- D322fn of Water (]uaitY �, ...:. _..
163tf Mail Service "ea�
WELL CONSTRUCTION RECORD WELL CONTRACTOR: CONTRACTOR CERTIFICATION #..
STATE WELL CONSTRUCTION PERMIT*:
WELL USE (Check appilesbla sex': Resldentlal �.,Iunlelpal ❑ Industrial Q Agricultural ❑ Monitoring ❑
1- W Other It Other, Us! Use:
Recovery ❑ Heat Pump Water injectionEl [� ./
2. WELL LOCATION: (Shaw sketch of the location below)
Nearest Town: s �G P f �- — County:..`.
r DRILLING LOG DEPTH
(Road Name and Nymbers, Community, ar Subdivision And m e From To Fomadon Description
3. OWNER -5c)
Address
{ re m e
CJty a Town 51a1a Xlp Code _
4. DATE DRILLED Gr'
5. TOTAL DEPTH NO
6. CUTTINGS COLLECTED YES ❑
7. DOES WELL REPLACE EXISTIN WELL? YES .
8. STATIC WATER LEVEL Below Top of Casing: �-y FT�
(Use '+, N Above Top of CaskV)
9. TOP OF CASING IS,,._ IFT. Above Land Surface'
'Top of easlny terminated stfor below land surface requires a verwuee In accor
-----------------
dance with 15A NCAC 2C .011 E METi iOD OF TEST
10: YIELD (gpm): -
11. WATER ZONES (depth):
12. CHLORINATION: ---.-=
l� f Amaunl It additional space Is needed use back of loan
Type
13. CASING: eTtnN . KETCH
Wall Thickness Maledal (Show direction and distance from at least two State
Dep
_L_._ _Tom-- �^' Ft. the
p er� We
� ' G JFL
Roads, or or map reieter+ce Points)
From '
From-------- To Ft. -
From —To . _ _ Ft. - -- Q
14. GROUT:
Depth Material , Melhod t3 o
From ! To ft. 1�s4 c. t LuR ro m
From - � To ._� Ft: - -- �
15. SCREEN:
Depth Diemeter 5tot Stz® Material
co M
From ____. _ To F4 In. In. ____ ___-- C
From — To _ _ - Ft. - In. In... _..----- M �8
From To Ft. In. in. - w -"H
16. SAND/GRAVEL PACK: C>
Depth Size Material z
From To Ft.
From -- ToFt.
17. REMARKS:
I DO }HERESY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE W" 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY t7F THIS RECO / HAS BEEN pSOVIDED TO THE WELL OWNER.
�Tw
DATE
FOR OFFICE USE ONLY SItUfaa or l RsoNNG THE WEt_Lt�usd fJo ' Su ertph�ai taon of Water ., Qen+rndv+atar Section within 30 days
l OW-1 Fiiti. t7199
Serial No. ca I1J °a s
y- a
i'
1'iJ11G»�i�� i•i ',ifinii f}i'i��\:t

nt and. Natural Resources - t�vtslon otwater t�elty • t3raundvrater Section. �� 2.2 8
North CaroMa - Department of Erwironrne y/
I We Mail Service Center-Reteigh, N.C. 2769914636-Phone (919) 733-=1 Sir V
WELL CONSTRUCTION RECORD WELL COONTRACTORCERTiFICATiON P'
STATE WELL CONS'TRUCTiON PEFIMITO:
Ok Applicable 9ox): Residential Pk -- Unfclpal rj Industrial a Agricultural � Monitoring ❑
1, WELL OrY (Che Ne t pump Water injection 0 Other [3 If Other, List Use:
Recovery [� '
2.
DRILLING LOG
(Road Name and Numbers.. COrmwnity, of Subdivistort wind Cot Na.) Flom TO
3. OWNER C(
Address
t ro or e
C1ty orTown
Scala Xlp COdO _
J r cdU
d. DATE DRILLED L.�.-...-.--------�-�--•
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES NoCJ
7. DOES WELL REPLACE EXISTIN WELL? YES ❑ NOS
8. STATiC WATER LEVEL. Below Top of Casing' '7y _ FT
(Use •+, U Above Top of Caakp?
9. TOP OF CASING IS_
S FT. Above Land Surface`
-TOP of casing terminated atlor below land surface raqulres a varlancs to scoor
dams with 15A NCAC xC .0118 MEiHOO OF TEST
1t}. YIELD (gpm): 4Q�- •
11 WATER ZONES (depth): "--"
12. CHLORINATION:
13. CASING:
WELL LOCATION: (Shpw sketch of the location below)� iJic orj� `L
Nearest Town: r ii n J
DEPTH- H -----
Fom-a ton ascription
d �/� eA-
Type �; ( Amount ed use back of form
----
If additional space is Head
/ Depth 3G r
From �L---� To -- Ll- Ft.
From- To —
From --To Ft. -
A r_ arx f7l
From
From -
15. SCREEN:
LOCA11ON JKETCH
We# Ttddmaes Sty, direction and distance
from at least two State
or WeVOL iN:lfedal
-%G toads, or other map reference points)
Depth material
To � Ft. _ /r
To — Fl.
Depth Diameter
From —TO—Ft
From TO ___._... Fl.
From _To Ft*
-----
16. SAND/GRAVEL PACK:
4 Method
�aR
Slot Size -Material
in. In.. _------
In. In. _-
in. —.in.
Depth Size Material
From — To _Ft.,
C:)
CD
r"
k-?
N
From — To FL
17. REMARKS:
IS WELL WAS CONSTRUCTED IN ACCORDANCE WiTH 18A NCAC 2C, WELL
I DO HEREBY CERTIFY THAT TTI
CONSTRUCTION STANDARDS, AND THAT A COP � F THIS RECOft , SEEN PROVIDEDTO THE WELL OWN / /V _v
FOR OFFICE USE ONLY
Quad No.
Serial No.
Slat4ATURE OF
Su rodgtnal to DFvltLon of V
T TH5 WSU PATE
sac&m within 30 days GW.i tMv. 12M

r � _ t3rourdwatar Section: �- �= � .7_ .l_
North Carolina - Department of Environment and Natural Resources - Division of Water OAMY - ._ .
1636 MeW Service Canter =• Ffalaigh, N.C. 27899 T43t)-?hone (9M 733'3221
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
CONTRACTOR CERTIFICATION 0,
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Apptiwbte Box). Residential 4---Municipal Industrial Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, Ust .
2. WELL LOCATION: (Sh w sketch of the location below) err pin r
Nearest Town: county
L.UNG LOG DEP HH
(Road Name and Numbers, C n�ty, a( Subdlvtaton and Lot No.) DRIFom Lion OascfW-
3. OWNER -, c� / �" `� '" �/ / rn T s D r1 �.t= Aen'- /a,
Address
! re or a o.
City or Town slate ZIP Code
d. DATE DRILLED �-._0 U . 6
5. TOTAL DEPTH
S. CUTTINGS COLLECTED YES NOQ
7. DOES WELL REPLACE EXISTIN WELL? YES 0 NOfF"X
8. STATIC WATER LEVEL Below Top of Casing: — Fr.
(use '•' B Above Top of C&*V)
9. TOP OF CASING IS FT. Above Land Surface'
*Top of casing tartnfnated =Nor below land surface requires a valiance In ecoor- .
dance with 15A NCAC 2C.01115
10. YIELD (gprn): S- METHOD OF TEST---
11. WATER ZONES (depth):
'12. CHLORINATION:
13. CASING:
Type Amount "� If additional space is needed use back at farm
/ Depth y r
From�L ---To —. Ft.
From-- To Ft.
From To Ft.
LOCATION sM. H
Wall Thlckneas
of W �material (Show direction and distance from at least two state
- �` """%G Roads, or other map reference points)
14. GROUT:
Depth Material „f Method
From
b To � Ft• ; bZ
From _To Ft: -- -- —
15. SCI9EEN�
Depth Diameter Slot Size Material
From To Ft In. In.
From _To Ft. In. In.
From To Ft. _.r- In. In.
IS. SAND/GRAVEL PACK:
Depth Size Material
From To Ft. From - To Ft.--
17. REMARKS:
C:)
CD
C7
rrn
C'7
N
UD
nr
ao
W
OD
59
0
OX
6 PI
C3 C
m
M
=o
m
r_nz
m �o
n
--t
0
z
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 1SA NCAC 2C. WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
i 1�'/— 1?-66
!FOR OFFICE USE ONLYs1cNATURE of
d NoSubml! orlpfiat to Division of Water
la: No,
3 THE WELL
secu+m within 30 days
DATE
caw•! REV. MM

ft�
North Caronne - Department of Environment and Natural Resources - Division of Wehr QUGIRY - Groundwater $action 1C_ 40 2 916
IWe Man Service Center=•Raleigh, N.G. 2709v1a3ti-?hone {Dt9) i3 32.tt
WELL CONSTRUCTION RECORD WELL CONTRACTOR: WELL CONTRACTOR CERTIFICATION 0:�
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Mack Apptteabie sox): Residential 4--municipal Industrial
ndu tri UO Agricultural
gd iturai ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ O Othe ❑ If •
2. WELL LOCATION: (Show stretch of.the location below)
Nearest Town: Y ; l� ` County. txCo tom^
DRILUNG LOG DEP T H
(Road Nuns and Numbers, ComrtwMY, or Subdfvisfon end Lo! No.) Formation Dascr(pd a,
3. OWNER 2, �' c�Dc) � 6'.1 - - From TO
Address : / a O lr�� rid
t re or o.
City or Town Slate 21p Cod
4. DATE DRILLED --_ / e
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES NO❑
7. DOES WELL REPLACE EXISTIN WELL? YES ❑ NOS
a. STATIC WATER LEVEL. Below Top of Casing: _2? S FT.
(Use '+* R Above Top of CaskVI
9. TOP OF CASING IS
FT. Above Land Surface'
'Top of casing tsrmtnsted armor below Land surface requires a vadsnea In "cor
dance with 1SA NCAC 2C.0118
10. YIELD (gpm): -51 METHOD OF TEST
11. WATER ZONES (depth):
12. CHLORINATION:
13. CASING:
Type LIl f Arrrount y -- If add onai space is needed use back of torn
Depth y r
From_Z.L--. TO � Ft.
From--- -- To ___--_ Ft. - —
From To Ft.
14. GROUT:
Depth Material
To 121- Ft.
To Ft:
From
From
15. SCREEN:
Depth Diameter 5wt zrze
From J To Ft In.
LOCATION SKETCH -
Wait Thickness
Wv tIR. Material (Stow direction and distance from at least two State
e� r ,.4 &C_ Roads, or other map reference points)
Method
_• LccRr
,,Material
In.
From To Ft. In. In.
From TO FL In. in. __-----
16. SANDIGRAVEL PACK:
Depth Size Material
From To Ft. -
0
CO
t�
rn
n
N
UO
Ca
CA
co
a
© r-r
M
Do
mCD
:
rnPO
c-)
--t
0
z
From —To Ft. -- -- - ---
17. REMARKS:
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH /SA NCAC 2C. WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS SEEN PROVIDED TO THE WELL OWNER. —ad
FOR OFFICE USE ONLY' oATE
Quad Nm' SIGNATURE OF PERSON N 7�1NG THE WELL
submit odfjfnat to Dtviston of water OveuaY. GfOWvJ%atU argon within 30 days ow. i REV. i 2M
Serial No.
s
i'f1 aij
i, 1!

North Carolina - Department of Environment and. Natural Resources - Division of Water Quality Groundwater Section-
222
1636 Mail Service Center - Raleigh, N.C. 27699=1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION 0:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential 4--municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location.beiow)
Nearest Town: ,� f County. Z.
(Road Name and Numbers, Community, or Subdivision and Lot No.) DRILLING LOG
DE;'iFi
3. OWNER �r vnc7 d From To Formation Description
Address � ` �
(Street or Route o.
City or Town State Z(p Cade
4. DATE DRILLED _U 4 G C, i s
5. TOTAL DEPTH a 6 S
6. CUTTINGS COLLECTED YES NOD
7. DOES WELL REPLACE EXISTIN WELL? YES ❑ NOfr7(
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.0218
10. YIELD (gpm): METHOD OF TEST y
11. WATER ZONES (depth):
12. CHLORINATION:
13. CASING:
Type C L l Amount -- If additional space is needed use back of form
Walt Thickness
L / Depth Ot for
r or � f� L Material C
From_? � .—To �� Ft. DI&
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From b To _,"Ft. �•cci2�
From To FI:
15. SCREEN:
Depth Diameter Siot Size •iviatenat
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 (east two State
Roads, or other map reference points)
0
C:)
O
C)
t� :�u iYi
C-) o r.,
!71 m
CO = rn
ACC
s10 rr
3 �CD
Co U) 7-
.. rn__Q
Ck1 0
x
100 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-USSE-r N'�Y " B9 - a E -o
Quad No!
l �J SIGNATURE CF PERSO ONSTRUCTiNG THE WELL DATE
' �J-�Suginal to Division of Water Quality. Groundwater Section within 30 days
�N 91 - GW-i REV. i2/99
Serial No.

North Caroline - Department of Environment and. Natural Resources - Division of Water Quality - Groundwater Section-
1636 Mail Service Center '-Raleigh, N.C. 27699.1636-Phone [phone] / s
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION 0:
STATE WELL CONSTRUCTION PERMIT#:
.904
y l:
1. WELL USE (Check Applicabie sox): Residential �&- iunlclpal ❑ Industrial ❑ Agricultural ❑
Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location.below)
' ntal
i e
Nearest Town: —.,��� '" � County:`�
(Road Name and Numbers, Community,%�r Subdivision and Lot No.) DRILLING LOG DEP T H
Foimatfon Description
3. OWNER - ijl e ' L o u A-1 t tt 1 /e,� From To
Address
iStmeel or Route o.
City or Town State Zip Code
DATE DRILLED _o -6 DES
�f� -
4.
5. TOTAL DEPTH 3 �S
6. CUTTINGS COLLECTED YES NO❑
7. DOES WELL REPLACE EXISTINGWELL? YES'� NO _
FT.
8. STATIC WATER LEVEL Below Top of Casing: SO
(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
OF TEST ti
10. YIELD (gpm): U METHOD
11. WATER ZONES (depth):
12. CHLORINATION: Type �jZ` f Amount If additional space Is needed use back of form
13. CASING:
LOCATION SKETCH
Walt Thickness
y / Depth ui y r or Weighl/FL Material (Show direction and distance from at least two State
From _ L�-----To Ft. Roads, or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
b � Ft. � • dLGRt°
c3
VE
From To
CD
ED
From Tv FL
0
C7
M
15. SCREEN:
C) rn
Depth Diameter Slot Size -Material
Cl>
c_rrn
From To Ft in. in.
N
DD
am
::r- r*i
From To Ft. In. in.
rnC)
From To Ft. in. In.
16. SAND/GRAVEL PACK:
oo
m
Depth Size Material
w
From To Ft.
Oa
C:)
z
From To Ft. —
17. REMARKS:
THAT THIS WELL WAS CONSTRUCTED 1N ACCORDANCE WITH 15A NCAC 2C, WELL
I DO HEREBY CERTIFY
THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
CONSTRUCTION STANDARDS, AND
FOR OFFICE USE ONLY
Quad No:
Serial No. �0 rn0 ��
s. tlls(irJ ':?F
SIGNATURE OF PERSON COST CTING THE WELL
at to Division of Water Quality, Groundwater Section within 30 days
DATE
GW-1 REV. 12199

0
I .
North Carolina • Department of Environment and. Natural Resources - Division of Water Quality -Groundwater Section. _
1636 Mail Service Center Ratelgh, N.C. 27699L-1636-Phone [phone] /�
WELL CONSTRUCTION RECORD
WELL CONTRACTOR: "/�'�
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMIT#:
1 _ WELL USE (check Apptmebie sox): Residential V�--Uniclpal ❑ Industrial ElAgricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other If Other, List Use:
2. WELL LOCATION: (Sha sketch of the location.below)
Nearest Town: i Q I J c (-( '- County:
DRILLING LOG DEP 1 H
(Road Name and Numbers. Community, or Subdiv//isicn and Lot No.) Formation Description
/ J +� U-�c� v� h _ From To I
3. OWNER r-rY a, � D !/c'�- �c'/�i67.�
Address
ISIreel or Route o.
City or Town State Zip Code
4. DATE DRILLED
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES NO❑
7. DOES WELL REPLACE EXISTIN WELL? YES ❑ NO
8. STATIC WATER LEVEL Below Top of Casing: &0 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 inaccor
dance with 1(g 2C �0 METHOD OF TEST
10: YIELD (gpm):
11. WATER ZONES (depth):
12. CHLORINATION:
13. CASING:
Type J` �l S Amount -� If additional space is needed use back of form
Walt Thickness
Depth Dt for orWeight/Fl. Liar/e�daal�
From
From_ To Ft.
From To Ft.
14. GROUT:
Depth Material Method
b
From To oz—lk/ Ft.
From To Ft:
15. SCREEN:
Depth Diameter Sioi Size •,%Iaterial
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
(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_QAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE US,t v L
Quad No:
it F Submit
Serial No.
0
G� ZE
O Q
�70
rrn 0 r'i
n �M
Iv cr �
co M
n•ca
rn
0
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w --I
c O
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'IGNATURE OF PERSON CON&KOCTING THE WELL DATE
1110 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- l2
1636 Mail Service Center Raleigh, N.C. 27699-1636=Phone (919) 733=3221
RECORD WELL CONTRACTOR:
WELL CONSTRUCTION
WELL CONTRACTOR CERTIFICATION #: _
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (check Appltcxble sox): Residential 0---Municlpai ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, Llst Use:
2. WELL LOCATION: (Sh ww sketch of the location below) /
Nearest Town: " 'r' r' - County:r� i� P Dix ✓`i'
(Road Name and Numbers, Cam/mjunity, or Subdivision and Lot No.) DRILLING LOG
DEPTH
3. OWNER IL k-1 I 1 47 , V From TO Formation Description
Address
t ree or ou a o.
City or Town State Zip Code
4, DATE DRILLED & •-_36 -OU
5. TOTAL DEPTH _-
6. CUTTINGS COLLECTED YES NO❑
7. DOES WELL REPLACE EXISTIN WELL? YES [] N0f7(
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 attor below land surface requires a variance In accor
dance with 15A NCAC 2C .0118
10: YIELD (gpm): METHOD OF TEST
11. WATER ZONES (depth):
12. CHLORINATION: Type �r- _l f Amount ^ -- it additional space is needed use back of form
13. CASING:
LOCATION —SKETCH
Walt Thickness
Depth / C of �le r or We lght/FL Material' C (Show direction and distance from at least two State
From (n Ft. —— Roads, or other map reference points)
_tZ___:To
From To Ft,
From To Ft.
14. GROUT:
CD
Depth Material Method
b • - �•tciCC
Ft.
O
o
.*
�''
From To c,�_
ra,
om
From To Fl:
r�rl
c->
15. SCREEN:
Depth Diameter Siot Size ` •blatedat
N
co
From To Ft in. In.
mo
From To Ft. In. In. _—__
70n,
From To Ft. In- In.
CO
u'-f
rn�
16. SAND/GRAVEL PACK:
j
Depth Size Material
co
o
z
From To Ft.
From To Ft. - —
17. REMARKS:
WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
100 HEREBY CERTIFY THAT THIS WELL
OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
CONSTRUCTION STANDARDS, AND THAT A COPY
GU
FOR OFFICE USE ONLY ✓�x-�'-�
_ DATE
1;" S1G ATURE OF PERSON C S UCTiNG THE WELL
Quad No: r3 � �I_ ��j
l�Su mit origin -1 to Division of Water Quality, Groundwater Section within 30 days GW-1 REV. 12/99
Serial No.
I.
t; iSl"
`! `aiSi jgifr,. t i

North Carolina - Department of Environment and. Natural Resources - Division of Water Quality - Groundwater Section- ' , V
1636 Mail Service Center Raleigh, N.C. 27699=1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTiFICATiON 0: y �
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable sox): Residential 0-- 49tuniclpal ❑ Industrial Q Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water injection ❑ Other ❑ If Other, Ust Use:
2. WELL LOCATION: Show sketch of the location.below)
Nearest Town: -/--:c 01 e County:
(Road Name and Numbers, Community, at Subdivision and Lot No.) DRILLING LOG DEP T H
3. OWNER ay o W e v S From/ To Formation Description
Address
151reei or Houle o.
City or Town State Zip Cade
4. DATE DRILLED ' 0? V���
5. TOTAL DEPTH I
6. CUTTINGS COLLECTED YES NO ❑
7. DOES WELL REPLACE EXISTIN WELL? YES [] NOf4�
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 .D118
10: YIELD (gpm): 73 -_ METHOD OF TEST
11. WATER ZONES (depth):
12. CHLORINATION:
13. CASING:
Type �� �l f Amount If additional space is needed use back of form
Wall Thickness
Depth Dt eter or Weight/Fl. Material
From�To Z Ft.—--�.
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From b To � Ft. �'f9� rc R
From To FI:
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)
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED iN ACCORDANCE WITH 15A NCAC 2C. WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD " BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Quad No:
Serial No.
SIGNATURE OF
al to Division of N
THE WELL
action within 30 days
p
1
C3
Q
ryl o
t -) c C-)
N orn
-�
03 rc m
a m�
be N�
cn:
co M ;;0
w �
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y GG
DATE
GW-i REV. 12/99
v;)t3iifiSlPC2' �€S il�ps;

r .
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) 733=3221 �-'' 6 `
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (check Applicable sox): Residential V_ i unicfpat ❑ Industrial Q Agricultural EJ Monitoring ❑
Recovery ❑ Heat Pump Water injection ❑ Other ❑ If Other, Ust Use:
2. WELL LOCATION- (Show sketch of the location.below) /
Nearest Town:' � �v. <�J�< County: n o
(Road Name and Numbers, Community, or Subdivision and Lot No.) DRILLING LOG
DEPTH
3. OWNER From To
Formation Description
Address
151reei or ou o o.
City or Town State Zip Cade
4. DATE DRILLED �_U
5. TOTAL DEPTH :S V S __
6. CUTTINGS COLLECTED YES —NOD
7. DOES WELL REPLACE EXISTIN WELL? YES
8. STATIC WATER LEVEL Below Top of Casing: FT.
(Use '+' if Above Top of Casing)
9. TOP OF CASING !S FT. Above Land Surface'
'Top of casing terminated at/or below land surface requires a variance in sccor-�:. - .. .. ...:...,r : .
dance with 15A NCAC 2C .t) 18
10: YIELD (gprp): o- METHOD OF TEST y
11. WATER ZONES (depth):
12. CHLORINATION:
13. CASING:
Type 4a_ /l f Amount -T, If additional space is needed use back of form
Wall Thickness
Depth Di 5l r or WeighVFL Material
From _±L./ —To Ft.-—
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From b To � Ft. �•u��
From To Ft:
15. SCREEN:
Depth •Diameter Siol Size `• •Material
From To Ft in. in.
From To Fl. _ 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 Stale
Roads, or other map reference points)
0
C5 p
C:)
r�
M crn
x
N � :C
ao Ao
M�
� M
�rri
00
rn �
�O o
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED iN ACCORDANCE WITH 15A NCAC 2C. WELL
CONSTRUCTION STANDARDS, AND THAT A COPY 0 THIS RECORD 14AS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLYy O L
Quad No: �1 jj�j SIGNATURE OF PIERSON C S UCTiNG THE WELL DATE
r �� u �' t!J Nsu � rigtnal to Division ai Water Duattly, Groundwater 5eciton within 30 days
Serial No. _" I V is GW-1 REV. t7199

North Carolina - Department of Environment and. Natural Resources - Otvisfonof Water Quality - txaundwater Section.
1636 Mail Service Center f Raleigh, N.C. 27699-1636•Phone [phone]Z1 -
WELL CONSTRUCTIO
N RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION
STATE WELL CONSTRUCTION PERMITo:
1. WELL USE (Caeck Applicable Box): Residential P"6nicipal ❑ Industrial ❑ Agricultural Monitoring ❑
Recovery ❑ Heat Pump Water Injection [D Other [] If Other, List Use:
2. WELL LOCATION: (Show sketch of the location.beiow)
rI /3u<�co�a, lr'
Nearest Town: --i Y °" "' l� County.
(Road Name and Numbers. Comrnunity, or Subdivision and Lai No.) DRILLING LOG- DEP-i i
3. OWNER � /"G >'�i 'LJ. +' S o n - From To Forrnatton Description
Address 6 V
tsireet or Hme o.
My or Town State Zip Code -- —
4. DATE DRILLED ' -6O (/,J 3 dS
5. TOTAL DEPTH e
6. CUTTINGS COLLECTED YES —NOD
7. DOES WELL REPLACE EXiSTIN WELL? YES
8. STATIC WATER LEVEL Below Top of Casing: _o _ FT.
/ (Use '+' tf 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
dance with 15A NCAC 2C . i a _ y
10; YIELD (gpm): _5. METHOD OF TEST
11. WATER ZONES (depth):
12. CHLORINATION: Type S -Amount. It additional space is needed use back of form
13. CASING:
LOCATiON SKETCH
Wall Thickness
y �, Depth C/ D % r or � ight/FL Material ,' (Show direction and distance from at least two State
From_L.t---To —�'-- Ft. Roads, or other map reference points)
From To Ft.
From To FI.
14. GROUT:
p �
Depth Material Method
From b To Ft. (rs94 & R e C-,
n rn
From To — <
CO rn
15. SCREEN:
Depth Diameter Sfal Size ;material Mrri
a
From To Ft in. in. =
From To Ft. In. In. r"
c-�
From To Ft. in. In. .o.^�.—
16. SAND/GRAVEL PACK: z
Depth Size Material
From To Ft.
From To Ft.
17. REMARKS:
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH i5A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THiS RECORD HAS EEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY DATE
Quad No ;` SIGNATURE OF PERSON CON
S UC71N P!E +AIL
b� ,'urt Ii 1,/Lr; bl original to Division at Water Qualify, Groundwater Seeflon within 30 days
Serial No 1 Y - i) hhh GW-1 REV. 12199
C i �" ?
plfiifl<tu's": Suction

. 22-$ 7 o
North Carolina- Department of Environment and. Naturai Resources - Divislonof Water Cuaq�,-Groundwater Sectton-
1636 Mail Service Center Raleigh, N.C. 2769%0636-Phone [phone]?Zt
WELL CONSTRUCTION A ECORD WeLL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMIT#:
1. WSLL USE (Check Applicable BOX): Residential V�-- unlclpai 0 industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection [] Other C] If Other, List Use:
2. WELL LOCATION: (Sh sketch of the facation.below)
Nearest Town: /e �l ` t �� County. u H (rl
(Road Name and Number , Cacannmity, o Subdivision and Lot No.) DRILLING LOG
3. OWNER 60C� Q�� From To
Address
-( ree or a o.
City or Town State Zip Cade
4. DATE DRILLED '76 S
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES NO❑
7. DOES WELL REPLACE EXISTINGWELL? YES NOfSi7(
a. 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 atior below land surface requires a variance in actor-:.. ..... ..,:,.,a : .
dance with 15A NCAC 2C.0118
10: YIELD (gpm): `- 0 METHOD OF TEST ti
11. WATER ZONES (depth):
12. CHLORINATION:
13. CASING:
DEPTH
Formation Description
Typer" f Amount If additional space is needed use back of form
Depth D y r
-
From—t --To Ft.
From To Ft.
From To Ft.
14. GROUT:
Walt Thickness
or WeighM Material
Depth Material Method
From b To � Ft. 2 �i
From To Ft.
15. SCREEN:
Depth Diameter Slat 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
(Show direction and distance from at least two State
Roads, or other map reference points)
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED iN ACCORDANCE WITH 1SA 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.,1
Serial No,
�.. k 9i;.1 .1
d
0
tv
co
t�D
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PERSON CONS OCTING T DATE
of Water Ouality, Groundwater Section within 30 days
GW-1 F1EV. 12l99

North Carolina •Department of Environment and. Natural Resources - Division of: Water duality - Groundwater Section1. J
1636 Mail Service Center Raleigh, N.C. 27699=1636-Phone(919) 733L=1 �.-
WELL CONSTRUCTION! RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMITS:
1- WELL USE (Check Applicab{a Box): Residential �&-- 16nlcfpai ❑ Industrial Q Agricultural Monitoring ❑
Recovery ❑ Heat Pump Water Injection 0 Other If Other, List Use:
2. WELL LOCATION: (,SsSow �ic�tch of the location.below)
Nearest Town: /i �f �i County. (�
(Road Name-un oars. Cady. or Subdivision and Lai No.) DRILUNG LOG- DEH
3. OWNER LC From To / Formation Desatpiion
Address
-tStreet or Route o.
C�C7l�U��°iL
CAy or Town Stale Zip Cade _
4. DATE DRILLED //J00 C/�/-
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES NO❑
7. DOES WELL REPLACE EXISTIN WELL? YES [� NOiit7(
8. STATIC WATER LEVEL Below Top of Casing: FT.
(Use '+' if Above Top of Casing)
9. TOP OF CASING 15 FT. Above Land Surface*
,Top of casing terminated atlor below land surface requires a variance in acear
dance with 15A NCAC 2C .011
10: YIELD (gpm): METHOD OF TEST
11. WATER ZONES (depth):
12. CHLORINATION: Type �� f i Amount It additional space is needed use basic of form
13. CASING:
LOCATION SKETCH
Wait Thickness
y / Depth D eter of Wetght/Ft. Material (Show direction and distance from at least two State
Fro.— L�----To --�- Ft. �� Roads, or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
b Depth Material Method
�Ft. dLa
From To
From To FI:
15. SCREEN:
CD
Depth Diameter Slat Size `• 4riatedal
C7
Q
From To Ft in. in•
o
iTl
Q M
From To Ft. In, in.
c—)
cL;
From_To Fl, in. ln.
o -
16. SAND/GRAVEL PACK:
Depth Size Material
rd
;
From To Ft.
�?
C/)
rn :w
From To Ft.
t.J
C-)
17. REMARKS:
z
CERTIFY THAT THIS WELL WAS CONSTRUCTED 1N ACCORDANCE WITH 15A NCAC 2C. WELL
100 HEREBY
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS EN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
DATE
Quad No:
E i
S�txnit_odgtnal
SSGN/jTURE OF'PERSON CONS THE WELL
to Diriisio(r Water Quality, Groundwater Section within 30 days
�
r
�
iqf GW-i
REV. t2l99
Seda{ Na.
i�
�ly
h°ggttii+l4t'Uae, �udtMII f

North Carolina - Department of Environment and. Natural Resources - Division. of Water Quality -Groundwater Sect Ion.
_
20-2915
16ZB Mail Service Center Raleigh, N.C. 27699�1636-Phone (919) 733;3221
WELL CONSTRUCTi
ON RECORD WELL CONTRACTOR: �����s
�yt�
WELL CONTRACTOR CERTIFICATION 0:_
STATE WELL CONSTRUCTION PERMfrJ:
1. WELL USE (check Applicable Box): Residential P"unicipat C] industrial L_.t Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water injectlon El Other [j if Other, List Use: r
2. WELL LOCATION• (Show sketch of the location.below) . /1�
/ '
Nearest Town_ �S dtJ (��%`dl Gar lcG'i County.
(Road Nae and N era, Camrtnr !O. or Su4dlvisfan and Lot No.) DRIWNG LOG-
DEP i H
m
3. OWNER ✓ ,iVL C�lz. JC �EG� From To FonnaUon Description
Address •� � _7J�0 d j/c'2- ��/���
Lem �Ei
(ree- or Flouts o.
1,4Ldl-)Uk l� --
City or Town State Zip Cade
4. DATE DRILLED �� /G' 'd•-�^
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES NO❑
7. DOES WELL REPLACE EXiSTiN WELL? YES NOE(
a. STATIC WATER LEVEL Below Top of Casing: FT.
(Use '+• it Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface*
*Tap of casing terminated at/or below land surface requires a variance in sccor
dance with 1SA NCAC 2C .D11
10. YIELD (gpm): METHOD OF TEST y
11. WATER ZONES (depth):
12. CHLORINATION:
13. CASING:
Type �k of form
� Zl f Amount if additional space is needed use bar
Wall Thickness
y / Depth L '- C eler or Weighm Material
From1.�---To FL
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From b To � Ft.
From To FL
15. SCREEN:
Depth Diameter Slot Size `• 141alerial
From To Ft in. in.
Frorn To Ft. In. in.
From To Ft. in. In.
16. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To Ft.
17. REMARKS:__
Material
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
cs
C7
O CD rn
N is c
CO y rn
rq
rry
t7b rNcy �
c')
W =-
cA o
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WCTH 15A NCAC 2C. WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD H7 BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY Dn -5
Quad No: I SMATURE OF PERSON CONSTRUCTIN THE WELL
S n 4 040fhal to Division of water Quallly, Groundwater Section within 30 days
flt ik GW-1 REV- 12/99
Serial No. y
r'�i�IYEt;:i(€'spat'

North Carolina - Department of Environment and. Natural Resources - Division of -Water auallty - Groundwater Section.
1636 Mail Service Center -Raleigh, N.C. 27699"=4636-Phcine (9'19) 733 =- l
WELL CONSTR
UCTION RECORD WELL CONTRACTOR: /�
WELL CONTRACTOR CERTIFICATION 0: _ C_
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box)' Residential 4— munic!pal ❑ industrial Q Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection 0 Other [] If Other, List Use:
2. WELL LOCATION: Shaw sketch of the loca(lon.below) /
el
Nearest Town:lc d O �' 1 ( °�_ County: i,f -�PjC kl
(Road Name and Numbers, C ty, or Subdivision and Lai No.)
DRI WNG LOG
3.
OWNERA y
From To
Address
(Sireet or RouteO.
Gay or Town ' Slate Zip Cade
4.
DATE DRILLED 0 `a '0
T
5.
6.
TOTAL DEPTH .+IV
—
CUTTINGS COLLECTED YES NOD
7.
DOES WELL REPLACE EXISTING WELL? YES
8.
STATIC WATER LEVEL Below Top of Casing: 5V _ FT.
(Use '+' tt Above Top of Casing)
9.
TOP OF CASING IS FT. Above Land Surface*
'Top of casing terminated attar below land surface requires a variance in sccor-
dance with 15A NCAC 2C .D118
10;
YIELD (gpm): 0 METHOD OF TEST
11.
WATER ZONES (depth):
12. CHLORINATION:
13. CASING:
DEPTH
Formation Description
D
Type% /` S Amount If additional space Is needed use back of form
Walt Thtelinass
Depth D eler or Weight/M Material
From_? L.— To Ft. 'G
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From b To OZ-1-1y' Ff.
From To FI:
15. SCREEN:
Depth Diameter Slat Size 4viateria)
From To Ft in. in.
Front To Ft. In, in.
From To Ft, in. In.
16. SAND/GRAVEL PACK:
Depth Size Material
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
n 70
p ;.Q
C-7 <=
N �m
c
Co '
Do
00 -'
W --t
00 o
From To Ft. x
From To Ft.
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED 1N ACCORDANCE WITH 15A NCAC 2C. WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY DATE
Quad No:4 1!1 I ( RSIGNATURE OF PERSON CO STRUCTING THE WELL
i 1j. V SU_tim_ Ito p r al. to Division of Water Quality. Groundwater Section Within 30 days
Seda{ No. GW-1 REV. IM9

` North Carolina - Department of Environment and. Natural Resources - Division of Water Quagty - Groundwater Seaton- 256 8
1636 Mail Service Center ;-R'aleigh, N.C. 27699-4636-Ptxme (9-19) 733;=1 /'
ECORD WELL CONTRACTOR: "'yl
WELL CONSTRUCTION R
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMfT#:
1. WELL USE (check Applicable Box): Residenila4 -- uniclpal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection Q] Other Q It Other, List Use:
2. WELL LOCATION: Show sketch of the location.below)
Nearest Town: A8a_41 ekv 1 de- County.
(Road Name and Numbers, Coruna fly, or Subdivision and Lai No.) DRILLING LOG
3. OWNER �I%° at u y e From To
Address�� "A a, frls �• ��•
I ree or �o
Luf e� r'�U, CCU
Clly or Town Slate Zip Code
4. DATE DRILLED
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES NOQ
7. DOES WELL REPLACE EXISTIN WELL? YES [� NOfu7(
8. STATIC WATER LEVEL Below Top of Casing: J-D FT.
(Use '+' It Above Top of Casing)
9. TOP OF CASING !S FT. Above Land Surface'
,Top of casing terminated at/or below land surface requires a variance in accor
dance with 15A NCAC 2C.911
10: YIELD (gpm): % METHOD OF TEST ti
11. WATER ZONES (depth):
12. CHLORINATION:
13. CASING:
DEPTH
Forrmilon Description
Type- LL i Amount If additional space Is needed use back of form
Wall Thickness
y / Depths Q D eter at WeighvR. Material
From_1,L __- To ---u-- Ft. 4kb
From To Ft.
From To Ft.
14. GROUP:
Depth Material Method
From b To 0Z__1y Ft. du/2
From To Fl:
15. SCREEN:
Depth Diameter Slat Size IM211erial
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)
�
r,
9
c�
o r,
c
N
o
W
0
n
y.
n
m A
co
o
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 S BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY:� aATE
Qua No: '' jj3,f ( SIGNATURE OF PE NSTRUC7ING THE WELL
f l5 J 5 U_$�ltxntt o gloat to Division of Water Quality. Groundwater on within 30 days
i i — a gg GW.1 REV. 12199
fl Serial No. ) 1 f

North Carolina - Department of Environment and. Natural Resources - Division o! Water Quapty -Groundwater Section• • •. U"f
1636 Mail Service Center Raleigh, N.C. 2709.0636-Phone [phone]
WELL CONSTRUCTION RECORD WELL. CONTRACTOR:
WELL CONTRACTOR CERTIFICATION 0:-
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (check Applicsble Box): Residential �&_ u 1ianicipai ] industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water injection El Other If Other, List Use:
2. WELL LOCATIOIN:Show s�tch of the location. below) �� t^ `'
Nearest Town: //�� �' C� s �- County. -�
( oad N a and N mbers, Conzwnit ., or Subdivision and Lot No.) DRILLING LOG D
3. OWNER Gives � ��E' V`}5 From To Formation Cescription
Address � / To D i/z'/�- je�WQ4
t5frest or Route
City or Town State Zip Cade
4. DATE DRILLED 7' _
5. TOTAL DEPTH
6. CUTTINGS COLLE` Ei7 YES —NOD --
7. DOES WELL REPLACE EXISTIN WELL? YES--
e. STATIC WATER LEVEL Below Top of Casing: 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
dance with 15A NCAC 2C M 8 "-
10: YIELD (gpm): 20 METHOD OF TEST � � —
11. WATER ZONES (depth): —
12. CHLORINATION: Type �:�ls -Amount
13. CASING:
Walt Thickness
Depth n o �r or Material�
From To ,-,��- Ft.
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From b To Ft.
From To Ft.
15. SCREEN:
Depth -Diameter Sic! 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:
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)
100 HEREBY CERTIFY THAT THIS WELL WAS CON UCTED 1N ACCORDAPCE WITH 15A NCAC 2C. WELL
CONSTRUCTION STANDARDS, AND THAT A CO. THIS RECO S B N PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY ` c
Quad No: S NATURE PERSON CONSTRUGHNG THE WELL DATE
Submit original to Division of Water Quality. Groundwater Section within 30 days
Serial No. GW-1 REV. 12J99

North Carolina • Department of Environment and. Natural Resources - Division of Water Quality Groundwater Section.
` 1636 Mail Service Center Raleigh, N.C. 276901636-Phone [phone]
WELL CONTRACTOR: "=,Y�•L ��j�r�'�J 5� ���
WELL CONSTRUCTION RECORDWELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential uniclpai ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATIO S%`�tow s of of the location.below)
Near9q Town: " ' J County: t9
file f' C I S Cy i7RILUNG_LOG DEP i H
(Road Name d Numbers, Cat� Wily, or Subdivision and Lot No.) Fops Description
3. OWNER ��—'' `(_`/ {- 1-^t�eW" From TO
Address
I ree or oute o.
City or Town n Slate Zip Cade
4. DATE DRILLED `
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES NO0
7. DOES WELL REPLACE EXISTIN WELL? YES ❑ NO(47(
8. STATIC WATER LEVEL Below Top of Casing: FT,
(Use -+' It Maim of Casing) g)
9. TOP OF CASING IS FT. Above Land Surface*
'Top or casing terminated attar below land surface requires a variance In "car -
dance with 15A NCAC 2C.0118 _ y.
10: YIELD (gpm): METHOD OF TEST
11. WATER ZONES (depth):
12. CHLORINATION: Type % �` f Amount It additional space Is needed use back of farm
13. CASING: LOCATION SKETCH
Walt Thickness
Depth L%� D for
or WeighttFL �MMatt�erriaa�l�� (Show direction and distance from at least two State
_To —�— Ft• Roads, or other map reference points)
From
From- To Ft. CD c
u
From To FI.
c
14. GROUT:
Depth Material Method
t - From b To 0_Z-Z' Ff.
From To FI:
15. SCREEN: cr.
Depth Diameter Slot Slz6 •fvtaterial ry
From To Ft In. in.
Ft. 1 ____
From To n. In. From To Ft. In. In. -- __ ...
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
17. REMARKS:
100 HEREBY CERTIFY THAT THIS WELL WAS CO TRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A C . Y ICF IS R li�S BEEN PROVIDED 70 THE WELL OWNER.`
FOR OFFICE USE ONLY l
Quad No:
�IGNATURE OF PERSON CONS C71NG THE WELL DATE
Subrrdt original to Division at Water Quality, Groundwater Section Within 30 days t3W-1 REV. t?J99
Serial No. -- --

North Carolina- Department of Environment and. Natural Resources -Division. of Water ouatity - Groundwater Section-
1636 Mail Service Center =Raleigh, N.C. 27e9g�1636•Phone (919) 733 =1
WELL CONSTRUCTION RECORD WELL CONTRACTOR: � d� sdl�jls�ac�
WELL CONTRACTOR CERTIFICATION f1: 02Zy��y
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Clieck Appitcsbie Box): Residential 4_M16nic!pal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water injection Other [] If Other, List Use:
2. WELL LOCAi gl) (Sho sketch the location.below)
Nearest Town:(_ /� County, i 7
/J° / 5,DcK Dt=;r 1 i
(Road Name and Nunroers• Ca n! y, or Subdivistan and Lo! No.) DRILLING LOG
3. OWNER S�hrJ h�P 5 From To Formation Description
Address /e2
istreet or oute o.
City or Town (/ Slate Zip Cade _
4. DATE DRILLED 9 _ �b °a .220
5, TOTAL DEPTH
6. CUTTINGS COLLECTED YES NO❑ -"
7. DOES WELL REPLACE EXISTIN WELL? YES NOS` —
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 atior below land surface requires a vartancs in accort... - ... .
dance with 15A NCAC 2C.0 18
10: YIELD (gpm): . METHOD OFTEST � — --
11. WATER ZONES (depth):
12. CHLORINATiON:
13. CASING:
Type �Amount l> If additional space is needed use back of form
Wall Thickness
,// Depth �.�� D y r or � ighl/R Material, C
From_ 1--To _ 1.� Ft. _TI/ - --�- - --
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From ToFt. 4aRe
From To Ft:
15. SCREEN:
Depth Diameter Slot Size ` •,yaterial
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)
c.�
I DO HEREBY CERTIFY. THAT THIS WELL WAS CONSTRUCTED IN ACCORD NCE WITH 15A NCAC 2C. WELL
CONSTRUCTION STANDARDS, AND THAT A COP THiS RECORQ HAS 3EEN PROVIDED TO THE WELL OWNER '1
FOR OFFICE USE ONLY r' r
Quad No: SIGNATURE OF PERSON CONSTRU NG 7HE WELL DATE
SubmIl original to Division of Water Quality. Groundwater Section within 30 days
GW-i REV. 12199
Serial No.

North Carolina - Department of Environment and. Natural Resources - Division of Vllater QualityGroundwater Section•
MI •�
1636 Matt Service Center f Raleigh, N.C. 276ggi.1636-Phone (919) 733;3221
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION 0:7 c�Y
STATE WELL CONSTRUCTION PERMITS:
1. WELL USE (Check Applicabie sox). Residenital p�—fi7tunic!pai ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery [7 Heat Pump Water Injecilon [] Other 0 If Other, Ust Use:
2. WELL LOCATIO : �S,how sleet h of the location.befow) (�
Nearest Town: /, , �' �' s e — County. C O EJ
i key - DEPTH
(Road Name j Numbers, Community, or Subdi tsian and Lot No.) DRILLING LOG
3. OWNER _ /� L' Lt I /�! � From Ta Formation Description
Address ,4- 1 '%
181reet or Houte o.
City or Town Slate Zip Cade _
4. DATE DRILLED
5. TOTAL DEPTH-
6. CUTTINGS COLLECTED YES NO❑
7. DOES WELL REPLACE EXISTIN WELL? YES [] NOaa
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 atlat below land surface requires a variance in accor
dance with 15A NCAC 2C .D11h �J _
10: YIELD (gpm.): __1.4' METHOD OF TEST_ ' ► " ti --
11. WATER ZONES (depth): —
12. CHLORINATION:
13. CASING:
Type ,21 Amount' If additional space Is needed use back of form
Wall Thickness
/ Depth p Diameter or Weight/Ft. Material
From— L---To Ft. ;�
From To Ft -
—
From To Ft.
14. GROUT:
b Depth 1,0 Material Method 4-1
From ToFt. Crt9 dccRr
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 S)CE3 C)-I
(Show direction and distance from at least two State
Roads, or other map reference points)
100 HEREBY CERTIFY THAT THIS WELL WAS CONS UCTED IN ACC0 NCE H 1SA NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COP THIS RE�S� HA5 EWITH
PROVIDED TO THE WELL OWNER
FOR OFFICE USE ONLY DATE
Quad No: GMATURE OF PERSON CONSTRUCTING THE WELL
Submit odgfnal to Division of Water Quality. Groundwater Section within 30 days
GW-t REV. 12199
Sedai No.

--
/
North Carolina - Department of Environment and. Natural Resources - Division of Water• Quality - Groundwater Section.
1636 Mail Service Center Raleigh, N.C. 27698=1636-Phone [phone] -
WELL CONSTRUCTION RECORD w LL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (check Applicable Box): Residential --Municipal Q Industrial Q Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water injectlon Q Other E] If Other, Ust Use:
2.
WELL LOCATIO (S`eow s"f h of the iocatlon.below)
r-- P
`^
C �J
Nearest Town: e r-� 1 I ` County:
k� s �j — 1_ eV
v'� r3
(Road Name Nu` 'era, cammunity, or S bdivisian and Lot No.)
rl! i
DRILLJNG LOG DEP i H
From To Fofmation Desaiption
3.
OWNER C'. \� o r t
iZ
Address
(StreettStreet orRoWe o.
City or Town Slate Zip Cade
DRILLED 2 -3 `` oo
D j'
4.
DATE •
�
5.
6.
TOTAL DEPTH � U=
CUTT)NGS COLLECTED YES NOCj
.22
7.
DOES WELL REPLACE EXISTiN WELL? YES [] NOf�7(
8.
STATIC WATER LEVEL Below Top of Casing: FT.
(use '+' li Above Top of Casing)
9.
TOP OF CASING IS FT. Above Land Surface'
*Top
of casing terminated atlor below land surface requires a varlonce In accor--:.
.. .. ...:...,+ : .
dance with 15A NCAC 2C .0118
10; YIELD (gpm): METHOD OF TEST ti
11. WATER ZONES (depth):
12. CHLORINATION:
13. CASING:
Type :4Z f Amount If additional space is needed use back of tome
Walt Thickness
Depth Dt y eter or WeighVFL Material
From_1,L_—To —L,�— Ft.
From To Ft.
From To Ft.
14. GROUT:
From b
Depth
To _ � Ft.'s
Material Method
From
To
Fl.
15. SCREEN:
Depth
Diameter Slot Size •NIWerial
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 COP THiS RECOR jHA13EsN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY ` / r Quad No: S NATURE OF PERSON CONSTRU NG THE WELL DATE
Submit original to Division of Water Quality. Groundwater Section within 30 days
GW-1 REV. 12199
Serial No.

m
North Carolina - Department of Environment and. Natural Resources - Division of Water'Quality - Groundwater Section- t�
1636 Mail Service Center �-Rateigh, N.C. 27698=1636-17hone (919) 733;3?21
RECORD WELL CONTRACTOR:� S��r�ZJ V `
WELL CONSTRUCTION
WELL CONTRACTOR CERTIFICATION #: _
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable 8ox): Residential p"'Uniclpal (] Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection[] Other(] If Other, List Use:
2. WELL LOCAT10M thovy,Sk I h of the location.beiow) y1v� 1 b
Nearest Town: C I County.
' / �' l� �� � 5 DRILLING LOG Dl=
(Road N e and Nu ers, Communit , ar Subdt I fan and Lai No.)
3. OWNER Zee �[ ) D oy h D 1'I From �° Formation Oesctipttan
Address
151reet or outs
Caly or Town State Zip Cade V _
4, DATE DRILLED 3�0 C _
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES NO❑
7. DOES WELL REPLACE EXISTIN WELL? YES 0 NOiT/1( —
8. STATIC WATER LEVEL Below Top of Casing: FT. --
(Use -+' ii Above Top of Casing) _
9. TOP OF CASING IS FT. Above Land Surface'
'Top of casing terminated atlor below land surface requires s variance in actor-...
dance with 15A NCAC 2C .011
10. YIELD (gpm): -1 5 - — METHOD OF TEST y --
11. WATER ZONES (depth): —
12. CHLORINATION:
13. CASING:
Type S Amount If additional space is needed use back of form
Wall Thickness
LL // Depth �/� D efer at WeighVR. Material
From—ltl — —To 1_L Ft. i y — —�`--�
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From b To . -Ft• d[ci?L
From To FL
15. SCREEN:
Depth Diameter Slot Size Ivtaterial
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
(Show direction and distance from at feast two State
Roads, or other map reference points)
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C. WELL
CONSTRUCTION STANDARDS, AND THAT A COPYIS RECO D AS EEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY NDATE
Mad No: Si ATURE OF PERSON CONSTFtU NG,THE WELL
Subrrdt original Io Division at Water Cuallty, Groundwater Section within 30 days
GW-1 REV. t 2199
Serial No. -

North Carolina - Department of Environment and. Natural Resources - Division of Water. Quality-!3=ndwater Sectton- V " J
1636 Mail Service Canter Raleigh, N.C. 27699=1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL. CONTRACTOR:
WELL CONTRACTOR CERTIFICATION 0:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicabie sox): Residential �&_�un(clpai ❑ industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water injection [1 Other E] If Other, List Use:
2. WELL LOCA710Np (Sh w skelSh P(Ahe locatlon.beiow)
Nearest Town: �f �j7 t f /l e County:
//tj ��L/ DEPTH
(Road Nam Nunzgers, Ca niiy, or Subdivision and Lot No.) DRILLING LOG
3. OWNER,( CA �- �� "� `�� `�� w} From To Fonnatton Description
Address
151reet or a o.
city or Town State Zip Code
4. DATE DRILLED
'C�
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES —NOD
7. DOES WELL REPLACE EXiSTIN WELL? YES M NOf.1(_ —
a. STATIC WATER LEVEL Below Top of Casing: FT. —
(Use '+' if Above Top of Casing) —
9. TOP OF CASING IS FT. Above Land Surface' —
'Top or casing terminated *flat below land surface requires a variance in accor
dance with 15A NCAC 2C .a41.a- —
10: YIELD (gpm): S • METHOD OF TEST �7 —
11. WATER ZONES (depth): —
12. CHLORINATION:
13. CASING:
Type +� /l f Amount ._�— If additional space is needed use back of form
Wall Thickness
Depth �L D i, orWetghVFL
Material
From_t/_ To Ft. 'C
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From b To �Ft. 4 1-ee
From To F1:
15. SCREEN:
Depth -Diameter Sioi Size ` -,Malarial
From To Ft in. In.
Front To Ft. - In, in.
Frorn 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)
-..D
C.)
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED iN ACCORDANCE WITH 15A NCAC 2C. WELL
CONSTRUCTION STANDARDS, AND THAT A COPW THIS RECORD IS BE N PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY � L e � _
DATE
Quad No: St ATURE OF PERSON CONSTRUCTiN THE WELL
Submit original to Division at Water Quality, Groundwater Section within 30 days
GW-i REV. 12/99
Serial No.

North Carolina • Department of Environment and. Natural Resources - Divisiort of Water Quality - Groundwater Section-
1636 Mail Service Center Raleigh, N.C. 27699-1636-Phone (919) 733-=1 -
RECORD WELL CONTRACTOR:
WELL CONSTRUCTIONrJ /
WELL CONTRACTOR CERTIFICATION #:_
STATE WELL CONSTRUCTION PERMITO:
1. WSLL USE (heck Applicable Box): Residential -- u unicipai C] industrial Q Agricultural CJ Monitoring ❑
Recovery ❑ Heat Pump Water InjectionEl Other M If Other, List Use:
2.
WELL LOCATION: (Show stretch of the location.below) R
Neallost Town- � �l r�r�l ,�J d�v�i 0.� County. i,
L��J
L'-e-Y P C, Ln
(Road Name and N mbers, Carrumrnity, ar Subdivision and Lot No.)
m
DRILLING LOG D Ep HH
3.
OWNER
From To Fonnatton Description
Address
iStmeet or Route o.
City or Town fate Zip Cade
4.
DATE DRILLED
5.
6.
TOTAL DEPTH
CUTTINGS COLLECTED YES NOF
7.
DOES WELL REPLACE EXISTIN WELL? YES
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 .D1 W
10;
YIELD (gpm.): METHOD OF TEST
11.
WATER ZONES (depth):
12. CHLORINATION:
13. CASING:
Type �� �Z f Amount If additional space Is needed use back of form
Depth- r�� 4 y r
From_T1:---To -[--- Ft. r
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From b To �_FI. /�> d1tRt!
From To FL
15. SCREEN:
LOCATION SKETCH
Wall Thlcknass
or Weight/Ft. Material (Show direction and distance from at feast two State
C Roads, or other map reference points)
Depth Diameter Siat Size ` •fvtaterial I -
w �
From To Ft In. Im
From To Ft. In, in.
From To Ft. In. In..—_____--
16. SAND/GRAVEL PACK: w `
Depth Size Material ry Z,
From To FL
From To Ft. —
17. REMARKS:
100 HEREBY CERTIFY THAT THIS WELL WAS CON UCTED IN ACCORDANCE WITH 15A NCAC 2C. WELL
CONSTRUCTION STANDARDS, AND THAT::g
CORD BEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Quad No: PERSON CONSTRUCTING E WELL DATE
Submll original to Divisron of Water Quality. Groundwater Section within 30 days
GW-1 REV. 12/99
Serial No.

,:
North Carolina - Department of Environment and. Natural Resources - Division of Water Quality Groundwater Sactlon. �� 0
1636 Mail Service Center Raleigh, N.C. 27699-1636-Phone (919) 733=3221
WELL CONSTRUCTION RECOR
D WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION #: _
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (check Appllcsble Box): Residential 0 .- uniclpal ❑ lndvust l E Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other[] If O -
2. WELL LOCATIO �(ShoW tch of the location.below) n yl
Nearest Town:
County 4
DRILLING LOG DEPTH
(Road Name 'j� umbers, Cammunity o Subdivision and Lot No.) Fomtallon Description
3. OWNER From To C
Address
t ree or a a o.
City or Town State Zip Cade - -�
4. DATE DRILLED- 016 -2 c5-
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES -NOD
7. DOES WELL REPLACE EXISTIN WELL? YES ❑ NO
a. STATIC WATER LEVEL Below Top of Casing: FT.
(Use '+' i( Above Top of Casing)
9. TOP OF CASING IS Fr. Above Land Surface'
'Top of casing terminated atlor below land surface requires a variance in actor-...
dance with 1SA NCAC 2C .0 1 a
10: YIELD (gpm): METHOD OF TEST
11. WATER ZONES (depth):
12. CHLORINATION:
13. CASING:
Type f Amount= If additional space is needed use back of loam
Wall Thickness.
Dept Di ter orWelghtffil. Ma�le`dal�'C
From-.L.-To Ft.---
From. - - TO Ft.
From To Ft.
14. GROUT:
DepthMaterial Method
From
b ToFt• dcciCC
From To Ft:
15. SCREEN:
Depth -Diameter Siol Size ylateriat
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 Stale
Roads, or other map reference points)
I DO HEREBY CERTIFY THAT THIS WELL WAS CONS . UCTED 1N ACCOR ANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COP THiS RE O HA BEEN PROVIDED 70 THE WELLOW
N� ��
FOR OFFICE USE ONLY DATE
Quad No: 1GNATURE OF PERSON CONSTRU NG THE WELL
Submit original to Division of Water Quality, Groundwater Section within 30 days GW-1 REV. 12/99
Serial No.

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] r -
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (check Applicable Box): Residenllal o"unlcipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery [] Heat Pump Water Injection ❑ Other E] If Other, Ust Use:
2. WELL LOCATION: �(S/how sketch of the location below)
Nearest Town: A,54r01lCounty: �n GO/Yi y
(Road Name and Numbers, Community, or Sub/division and Lot No.)
DRILLING LOG DEPTH
�t 3. OWNER ele,*9 r /_ C )/..S
From To Formation Descriptlan _
Address
c'/c��
{S ree or ou a o.
— - - -
City or Town State Zip Code
4. DATE DRILLED'
�Sk
a ys
5. TOTAL DEPTH .
6. CUTTINGS COLLECTED YES NOE ]
—v
7. DOES WELL REPLACE EXISTIN WELL? YES [] NOf 4
--'
8. STATIC WATER LEVEL Below Top of Casing: �,� FT.
(Use '+' It Above Top of Casing)
-" c
9. TOP OF CASING IS Fr. Above Land Surface'
c�
'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
w
,S
11. WATER ZONES (depth):
ES
12. CHLORINATION: Type%' �l f Amount
if additional space Is needed use back of form
13. CASING:
Wall Thickness
LOCATION SKETCH
G / Depth Di l r or Welght/Ft. Material
From�L_--To — Ft. —-— '�
(Show direction and distance from at least two Stale
Roads, or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Materlal Method /
From b To "" Ft. ' / e ek
From To Ft.
15. SCREEN:
Depth
From
To Ft
Frorn
To Ft
From
To Ft
16. SAND/GRAVEL PACK:
Depth
From
To
From
To
17. REMARKS:
Diameter Sio1 Size 0ateriat
In.
in.
in.
In.
In.
In.
Size
Material
Ft.
Ft.
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 1SA NCAC 2C. WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY �;44
Quad No: SIGNATURE OF PERSON C ING THE WELL DATE
Submit original to Division of Wafer quallly, groundwater Section within 30 days
Serial No. GW-1 REV. 12/99
s _
i

North Carolina . Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone] ... i rl 5
,12
WELL CONSTRUCTION RECORD WELL CONTRACTOR: 641;Ie_' S,; '',ezf v 'S �
WELL CONTRACTOR CERTIFICATION N:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential v —Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, Ust Use:
2. WELL LOCATION: (Show sk tch of the location below) /
Nearest Town: ,Q f V� �County. �ct it �Af+r h�
(Road Name and Num erss, Community, or Subdivision and Lot No.)
DRILLING LOG DEPTH
3. OWNER dir�il'�S�f l�[�7�+42C2 -e
From To Formallon Description �
Address
Sr2 ���`✓�'��ot�.
`- (Street or Houle o.
City or Town Slate Zip Code
4. DATEDRILLED.3Gv
5. TOTAL DEPTH -«
z`e`r
6. CUTTINGS COLLECTED YES NO❑
7. DOES WELL REPLACE EXISTING WELL? YES ❑ N05
8. STATIC WATER LEVEL Below Top of Casing: _7S FT.
r =
(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-
_qz
J..
dance with 15A NCAC 2C.0110
10. YIELD (gpm): METHOD OF TEST
11. WATER ZONES (depth):
w -�
12. CHLORINATION: Type Amount 6
If additional space is needed use back of form
13. CASING:
SKETCH
Wall Thickness
Depth of I r or Welghtfri. Material
L /
(Show direction and distance from at least two Stale
From _Z .L_---To- Ft.
Roads, or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Material l Method
b ' ���4'r t ECtRC
From To Ft. _
From To FI.
15. SCREEN:
Depth Diameter Slot Slze 1Aaterial
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:
100 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:
SIGNATURE OF PER
S-TRUCTING THE WELL DATE
Submit o�ijlnal to Division of Water Quality. Groundwater Section Within 30 days
Serial No.
P.
GW 1 REV. 12/99
ry, i
ii

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section H � ^
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone] � `i 9
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION 0:/��
STATE WELL CONSTRUCTION PERMITrf:
1. WELL USE (Check Applicable 9ox): Residential -.-.--Municipal ❑ Industrial ❑ Agricultural ❑ Monlloring ❑
Recovery ❑ Heat Pump Water Injectlon ❑ Other ❑ If Other, List Use:
2. WELL LOCAT'how �ke(ch of the location below)
Nearest Town: —11y r r County:
(Road Name and Numbers, Community, or Su division and Lot No.) DRILLING LOG
3. OWNER ��/J`Lhal/ le%!�/' From To
Address--
is ree or ou a o.
City or Town Stale Zip Code
4. DATE DRILLED
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES NOD
7. DOES WELL REPLACE EXISTIN WELL? YES ❑ NO[�
8, STATIC WATER LEVEL Below Top of Casing: 7_ FT.
(Use '+' It 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.0)1,0
10. YIELD (gpm): '�' METHOD OF TEST—
11. WATER ZONES (depth):
DEPTH
Formation Description
41 !/e /_ ' 41L_,
Co
w
--+
0
12. CHLORINATION: Type C at__ Amount If additional space Is needed use back of form
13. CASING:
LOCATION SKETCH
Wall Thickness
/ Depth DI eler or Weight/Ft. Material (Show direction and distance from at least two Stale
From-: ,1----To ? Ft. y N°1 ;e Roads, or other map reference points)
From To Ft.
—
From To Ft.
1 A. GROUT:
Depth ��� Material l Mel
hod
From b To _�_ FL
From To FL
15. SCREEN:
Depth Diameter Slot Siz6 • 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 Fl.
Frorn To Ft.
17. REMARKS:
100 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.
siGNATURE OF PERSON C�ONS*ReCTING THE WELL
Submlt.original to Division of Water Quality. Groundwater Section Within 30 days
_ 5-j g d { Y�A' !Ei C� F
ij
gg t _ D 3
'i
�I
DATE
GW-1 REV. 12/99

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section ( Q
1636 Mail Service Center - Raleigh, N.C. 27699-1636-phone [phone] / t� 1 7 348
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residenlial z----Municipal C] Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, Ust Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: A-s County. /J.,t N Corft
(Road Name and Numbers, Community, or Subdivision and Lot No.) DRILLING LOG
3. OWNER /i/� i /I"t .Si .� �e ___- __ From To
Address
(Street or Houle o.
!City or Town Stale Zip Code
4. DATE DRILLED C<-1 e) / ri Si LIPS
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES PI—NOC)
7. DOES WELL REPLACE EXISTIN WELL? YES ❑ N0
8. STATIC WATER LEVEL Below Top of Casing: yo - FT.
(Use '+'. It Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface'
'Top of casing terminated al/or below land surface requires a variance In accor-
dance with 15A NCAC 2CG,.0118
10. YIELD (gpm): ��� METHOD OF TEST
11. WATER ZONES (depth):
DEPTH
Formallon oescdpllon
12. CHLORINATION: Type :;EW f Amount —5_ If additional space Is needed use back of form
13. CASING: `
Wall Thickness
/
Depth
of eler or Welght/Fl. Material
From.
....-To Ft.
From
To Ft.
—
From
To Ft.
14. GROUT:
From b
Depth
To s) Ft.
Malarial l Mthd
�llco t _;Mad
From
To Fl.
15. SCREEN:
Depth Diameter
Slot Size Material
From
To Ft
in. In.
From
To Ft.
in, in.
From
To Ft.
In. In.
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
17. REMARKS:
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
100 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.
SIGNATURE OF PERS06eNSTRUCTING THE WELL
Submft.origlnal to pivision of Water Quality. Groundwater Section within 30 days
r..i
.'i i
_.y
DATE
GW-1 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-lW&Phone (919) 7W-3221 ,`� 4
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable sox): Residential Z--Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Infection ❑ Other ❑ 11 Other, Ust Use:
2. WELL LOCATION: (J$how sk tch of the location below)
Nearest Town: etc Af ur, County: —Aa 4 C 0,4ft /C.
(Road Namo and Num' ors, Community, or Subdivislon and Lot No.)
3. OWNERS
Address
(Street or Houle o.
DRILLING LOG DEPTH
From ToFormation Description
93
City or Town —6` State Zip Code
4. DATE DRILLED 9PLZ D
5. TOTAL bEPTH a o2.S
6. CUTTINGS COLLECTED YES NOD
7. DOES WELL REPLACE EXISTING WELL? YES ❑ N05
8. STATIC WATER LEVEL Below Top of Casing: Sc) 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 varlance In accor-
dance with i5A NCAC 2C.0118
10. YIELD (gpm): METHOD OF TEST-
11. WATER ZONES (depth):
C
co
r
O
o
12. CHLORINATION: Type :29% /L f Amount IV If additional space Is needed use back of form
13. CASING:
Wall Thickness LOCATION SKETCH
f_/ Depth of for or Weight/Ft. Material (Show direction and distance from at least two State
From .To 2:2S Ft. 'G Roads, or other map reference points)
From To Fl.
From To Ft.
14. GROUT:
Depth Material Method
From To �� Ft. _�IcBa �LG�C
From To Ft.
15. SCREEN:
Depth Diameter Slot Size btater)al
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
17. REMARKS:
To Ft.
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 BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY ��'`" DATE
Quad No: SIGNATURE OF PERSON C THE WELL DATE
Submit original to Division of Water Quality. Groundwater Sectlon within 30 days
Serial No, l i41d s,a
GW-1 REV. 12/99
4F

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)'733-3221 ~� 3 4 J
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION 0:
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: SShow sk tch of the location below) /
NearestTown: Q t. `{y �County: 16 w 4 l�lsG9�
(Road Namo and Number3 C�`'munity, or Subdivision and Lot No.)
OWNER _ Z Ae Ste! e 4vsn[-s
Address
j'51reet or Houle o.
DRILLING LOG DEPTH
From To Formation Description �7
City or Town Stale Zip Code
4. DATE DRILLED
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES NO(_]
7. DOES WELL REPLACE EXISTIN WELL? YES NOGa
S. STATIC WATER LEVEL Below Top g: of Casing:
FT.
_
(Use -+' It Above Top of Casing)
9. TOP OF CASING IS Fr. Above Land Surface' I c'"_�
*Top of casing terminated at/or below land surface requires a variance In accor- co *i
dance with 15A NCAC 2C. 18
10. YIELD (gpm): METHOD OF TEST
11. WATER ZONES (depth):
. LTi r:J
i
12. CHLORINATION: Type f%- ff f Amount II additional space Is needed use back of form p �
13. CASING: `
Wall Thickness LOCATION SKETCH
Depth DI l r or Weight/Ft. Material (Show direction and distance from at least two State
From_Z -To Ft. N°1� 7�-S i' Roads, or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From b ToFf.
From To Fl.
15. SCREEN:
Depth Diameter Slot Size ` Material
From To Ft In. In.
From To Fl. In. _
From To Ft. In. _
16. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To Ft.
17. REMARKS:
In.
In.
Material
100 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 G
Quad No: SIGNATURE OF PERSO TING THE WELL DATE
Submit original to Division of Water Quality, Groundwater Section Within 30 days
Serial No. , e s< GW-1 REV. 12/99
-
"�'j0f3

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] `�f `Y
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION 0:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residenlial o--Municipal ❑ Industrial ❑ Agrlcultural ❑ Moniloring ❑
Recovery ❑ Heat Pump Water Injectlon ❑ Other ❑ If Other, Ust Use:
2. WELL LOCATION: (Show sketch of the location below) /
Nearest Town: _ Git3J� �ylY� County: �� ti �d+o'
(Road Name and Numbers, Community, or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER b4z,-aek Dr✓thf From To Formation Description
Address
(Street or ou a o.
City or Town Stale Zip Code
A. DATE DRILLED Qe"10 a 9 4/ .2 f
5. TOTAL DEPTH y,2s =�
6. CUTTINGS COLLECTED YES (--NO❑ - i
7. DOES WELL REPLACE EXISTIN WELL? YES [� N0f 7( 71 ,
8. STATIC WATER LEVEL Below Top of Casing: � FT. `-' rri
(Use '+' It Above Top of Casing) I =-
9. TOP OF CASING IS FT. Above Land Surface' =r�
'Top of casing terminated at/or below land surface requires a variance in accor-
dance with 15A NCAC 2C .0I 18
10. YIELD (gpm):_ METHOD OF TEST
r'r7:a
11. WATER ZONES (depth): w 2,
12. CHLORINATION: Type Amount Z If additional space Is needed use back of form
13. CASING: c
Wall Thickness LOCATION SKETCH
y �
Depth DI l r or Welght/Ft. Material (Show direction and distance from at least two State
From-Z L---To —Q- Ft. Roads, or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method /
From b To o
f& FI.
From To Ft.
15. SCREEN:
Depth Diameter Slot Size ` 44ateriai
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 Fl. --
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 8 EN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Quad No: SIGNATURE OF PERSON CONS R HE WELL DATE
Submit original to Divlsfon oivaler Quality, Groundwater Section within 30 days
Serial No. GWIREV.12/99
YI
P.
I� ' J CJ
!i
t ray
ti

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section ;
1636 Mali Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMIT#*
1. WELL USE (Check Applicable Box): Residenlial ---Municipal El industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, Ust Use:
2. WELL LOCATION: (Show sketcy of the location below)
Nearest Town: _Al.vir2IY' Co
(Road Namo and Numbers, Community, or Subdivision and Lot No
3. OWNER Tie -hey 5 A,41
Address
i5ireet or Soule o.
City or Town Stale ZIP
4. DATE DRILLED
5. TOTAL DEPTH o7 4S
6. CUTTINGS COLLECTED YES NOD
7. DOES WELL REPLACE EXISTING WELL? YES{
8. STATIC WATER LEVEL Below Top of Casing: D
(Use '+' It Above Top of Cas
9. TOP OF CASING IS FT. Above Land Surfac
*Top or casing terminated atfor below land surface requires a vatlanc
dance with 15A NCAC 2C.0118
10. YIELD (gpm): /Q_ METHOD OF TEST
11. WATER ZONES (depth):
12. CHLORINATION: Type :%' IL Amount �—
13. CASING:
Wall Thickness
/ -F
Depth p Dl�rngler or Wehuft.
From To _.�---
Frorn To Ft.
From To Ft.
14. GROUT:
unty. 4,
hrUtiy60'
DRILLING LOG DEPTH
From To Formation Description
SIP
Code
NO
FT.
CIO
r*1
c
Ing)
I
- _
e'
rl
e In accor-
M� .3
_
�;
rn
t-.
If additional space Is needed use back of form
r--
LOCATION SKETCH
Material (Show direction and distance from at least two Stale
' G
Roads, or other map reference points)
Depth Material Method
From To A9 Ft. (lww"I
From To Ft.
15. SCREEN:
Depth Diameter Slot Size dviaterial
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:
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED iN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY O FTHIS RECORI�VAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Quad No: SIGNATURE OF PERSON ONSTRUCTING THE WELL DATE
Submit original to Division of Water Quality, Groundwater Section Within 30 days
Serial No. GW-1 REV. 12/99
iF? 1, t
1�

North Carolina - Department of Environment and Natural Resources - Division of Water Quelity - Groundwater Section ti 1 ri r� 4 O
1636 Mall Service Center - Raleigh, N.C. 27699-i636-Phone [phone] ( J
WELL CONSTRUCTION RECORD WELL CONTRACTOR: ae- v
WELL CONTRACTOR CERTIFICATION
STATE WELL CONSTRUCTION PERMIT#:
1, WELL USE (Check Applicable Box): Residential v"unlcipal 0 Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ Ii Other, Us! Use:
2. WELL LOCATION: (Show sketcl of the location below) y�
Nearest Town: ,!4TL" �'�,c County: J%2hGmrsr�i�
(Road Name and Numbers, Communi� Subdivision and Lot No.)
3. OWNER oot� e�'!f2 __5/`/'
Address
iSireet or Route o,
DRILLING LOG DEPTH
From To Formation Description
City or Town State Zip Code
4. DATE DRILLED. !Z�� 766 41 /G-•S<
5. TOTAL DEPTH 14 X — n
6. CUTTINGS COLLECTED YES NOE] r�
n.
7. DOES WELL REPLACE EXISTIN WELL? YES[] NO f7( ,r:
8. STATIC WATER LEVEL Below Top of Casing: _ y0 FT.
(use '+' If Above Top of Casing) t
9. TOP OF CASING IS FT. Above Land Surface' rA ;
*Top of casing terminated at/or below land surface requires a varlancs In accor-
dance with 15A NCAC 2C .0118 x
10. YIELD (gpm):_ METHOD OF TEST h
11. WATER ZONES (depth):
CD
12. CHLORINATION: Type �% L S Amount If additional space is needed use back of. form
13. CASING:
Wall Thickness
/
Depth
Di l r or We Ight/Ft. Material{' G
From
To
Ft.
--- -�-
From
To
Ft.
—
From
To
Ft•
14. GROUT:
Depth
Material� Method /
,`Je_CcRCJ�!
From
To
Ft.cr�r
From
To
Ft.
15. SCREEN:
Depth Diameter Slot SIZE ivialerial
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 RECOR AS 6EEN PROVIDED TO THE WELL OWNER.
G FOR OFFICE USE ONLY
Ouad No: SIGNATURE OF PERSON 166NSTRUCTING THE WELL
Submit original to division of Water Quallly, Groundwater Section within 30 days
i i ,ail
Serial No.
j,.
i
DATE
GW-1 REV, 12/99
r

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: � S/�%�J v ')
WELL CONTRACTOR CERTIFICATION 0:/��
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable sox): Residential—Ivlunlcipal ❑ Industrial ❑ Agricultural ❑ Monitoring
❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, Ust Use:
2. WELL LOCATION: (Show sketch of the Ioca(lon below) /
y�
Nearest Town: --��N County. k! C c n C a Zvi b t
(Road Name and Numbers, Co 'I or Subdlvislon and Lot No.) DRILLING LOG DEPTH
3. OWNER . 0&X_tJ0d /7'y O'1 f From To Formation Description
Address
(street or Floute o.
City or Town State Zip Code
4. DATE DRILLED Z�"60
5. TOTAL DEPTH . / & S
6. CUTTINGS COLLECTED YES NOD
7. DOES WELL REPLACE EXISTIN WELL? YES ❑ NOf£7(
p-
8. STATIC WATER LEVEL Below Top of Casing: ye) FT. ram':-)
(Use '+' If Above Top of Casing)
Cr
9. TOP OF CASING IS FT. Above Land Surface* 1
'Top of or casing terminated attar below land surface requires a varlance In accor- %TJ
n- r 1
dance with 15A NCAC 2C .011
10. YIELD (gpm): All METHOD OF TEST
`-�
11. WATER ZONES (depth):
r-,
rn =a
12. CHLORINATION: Type / V'- A Amount s If additional space Is needed use back of form p
-+
o
13. CASING: c
Wall Thickness LOCATION SKETCH
Depth DI r or Weight/Ft. Material (Show direction and distance from at least two Stale
L /
From__7o —L-? Ft. -oplks'e_ Roads, or other map reference points)
From To Fl.
From To Ft.
14. GROUT:
Depth �� Material Method /
From b To �� FI. (�e'ywJ
From To FI.
15. SCREEN:
Depth Diameter Slot Slze 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:
100 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.
01
FOR OFFICE USE ONLY
Quad No: SIGNATURE OF PERSON C 5T CTING THE WELL DATE
submit original to Dlvlslon of. Water Quality, Groundwater Section within 30 days
Serial No, �.� k I i '. GW-i REV. 12/99
_. _..

North Carolina • Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
r
1636 Mall Service Center - Raleigh, N.C. 27699-1636-Phone [phone] , `(f
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION 0:/�
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (crreck Applicable Box): Residential 0—Municipal [] Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, Ust Use:
2. WELL LOCATIO(V: (Show sk t It of the location below) /
Nearest Town: S s u / { County: i �n Co H1 he
(Road Name and Numbers, COT mu�ily, or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER 1�g,_/,y i� t.(<_t! r From To � Formation Description �
Address / >/ (1 6:1 �` ✓�'��at`,
i5treei or Routo o,
City or Town State Zip Code ---- —
4. DATE DRILLED
--L�
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES NO❑
7. DOES WELL REPLACE EXISTING WELL? YES [� NOM
8. STATIC WATER LEVEL Below Top of Casing: ^�Q_ FT. © ��
(Use '+' If Above Top of Casing) �r) C)
9. TOP OF CASING IS FT. Above Land Surface' <
'Top of casing terminated a►for below land surface requires a variance In accor- �—`
dance with 15A NCAC 2C.0118 r �'
10. YIELD 0 METHOD OF TEST -� co
11. WATER ZONES (depth): - x•
12. CHLORINATION: Type �l S Amount —— If additional space Is needed use back of form r`
13. CASING: o
LOCATION SKETCH
Wall Thickness
! Depth Diameter or Welght/Ft. Material (Show direction and distance from at least two Stale
y
From_Z-Z ---To 9'-5 Ft. Roads, or other map reference points)
From To Ft.
From To FL
14. GROUT:
Depth Material Method
From To e% FI. M ty a
From To F1.
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.
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF T IS RECORD H BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Quad No: SIGNATURE OF PERSON C UCTING THE WELL DATE
Submit original to Division of Water Quality. Groundwater Section In 30 days
Serial No. GW-i REV. 12/99
IQ f
1,T i

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section Sri .) 3 J
1636 Mall Service Center - Raleigh, N.C. 27699-1636 Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION 0:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (cr,eck Applicable Box): Residential V—__Munlcipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, Ust Use:
2. WELL LOCATION, (tow sketc i of the location below) n
Nearest Town: f iO � - F In. County- �f✓ k nr en . zt
Agricultural ❑ Monitoring ❑
(Road Name and Numbers, Community, r Subdivision and Lot No.) DRILLING LOG
3. OWNER �h Lc�YtC�►^ 1 From To
Address
iSireet or ou a o.
DEPTH
Formation Description
Cl 6fie /I— /✓c"'���0'l` ,
City or Town State Zip Code
4. DATE DRILLED 19 vc) ') (.-
5. TOTAL DEPTH ca
6. CUTTINGS COLLECTED YES NO❑ G;
7. DOES WELL REPLACE EXISTIN WELL? YES ❑ NOMT __
B. STATIC WATER LEVEL Below Top of Casing: 9 a _ FT. '
(Use '+' It Above Top of Casing) i
4 r
9. TOP OF CASING IS FT. Above Land Surface' t v;c
-Top of casing terminated at/or below land surface requires a variance In accor-
dance with 15A NCAC 2C.0118 3p rYi
10. YIELD (gpm): _g� — METHOD OFTEST
11. WATER ZONES (depth): ~
12. CHLORINATION:
13. CASING:
Type //A Amount If additional space Is needed use back of form CD n
Wall Thickness
' Depth DI far
r or Weight/Ft. Maledal
L/
From �L_--To
From To Ft,
From To Ft.
14. GROUT:
Depth Material Method
From b To � ,�q Ft.
From To Ft.
15. SCREEN:
Depth Diameter Slot Size ivtaterial
From To Ft In. In.
From To Ft. In. In.
From To FL In. In.
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
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 S BEEN PROVIDED TO THE WELL OWNER.
_ fe" 3
FOR OFFICE USE ONLY DATE
Quad No: SIGNATURE OF PERSON C S CTING THE WELL
Submit original to Division of Water Quatlty, Groundwater Section within 30 days
GW-1 REV. 12J99
Serial No.
(,

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] _ �1 �? 3 A
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION 9:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential z---Municipal C] Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, Ust Use:
2. WELL LOCATIO (Show sk ch of the location below)
Nearest Town: Se q; ��t - County 46001 D/
x
(Road Name and Numbers, Community, or Subdivl on and Lol No.)
OWNER --
Address
(Street or Roule o.
DRILLING LOG DEPTH
From To / Formation Cescriptfon
City or Town Stale Zip Code
` sJ
4. DATE DRILLED -/ D v
�-• ' � - -o
> 7
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES NO[J
e�—� �
`� r
---
t
7. DOES WELL REPLACE EXISTIN WELL? YES ❑ N054
� -ter r,
6. STATIC WATER LEVEL Below Top of Casing: O_ FT.
=
(Use '+' If Above Top of Casing)
/
= `�
9. TOP OF CASING IS Ff. Above Land Surface'
r,
'Top or casing terminated atfor below land surface requires a variance In accor-
J
dance with 15A NCAC 2C .0148
METHOD OFTEST`�--
10. YIELD (gpm): _�_
11. WATER ZONES (depth):
12. CHLORINATION: Type �l f Amount
If additional space is needed use back of form
13, CASING:
LOCATION SKETCH
Wall Thickness
Depth r / Dtlmel r or Weight/Ft. Material (Show direction and distance from at least two State
From .f/ To .] - Ft. Roads, or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
b Depth
'qq
Material Method
(r��kes �` LG�2C
From To Ft.
From To Ft.
15. SCREEN:
Depth Diameter Slot Slz6 tvtaterial
From To Ft
In. in.
From To FL
In. In.
From To Ft.
In. in.
16. SAND/GRAVEL PACK:
Depth
Size Material
From To FL
From To FL
—
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS
WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY F THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Quad No:
SIGNATURE OF PERSON NSTRUCTING THE WELL DATE
Submit original to Division of Water Quality, Groundwater Section within 30 days
GW-1 REV. 12199
Serial No.
j. .
tk ;jJ
�i
5„

North Caroline - Department of Environment and Natural Resources - Division of Water Quality- Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone] ��
• �1r330
WELL CONSTRUCTION RECORD WELL CONTRACTOR: e S" ' ezj y
WELL CONTRACTOR CERTIFICATION 0:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (check Applicable Box): Residenllal pa --Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring
❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
(//Show sk tch of the location below)
2. WELL LOCATIX-5
Nearest Town:1, 0 / ��e County: -n "Oe, 0, 0,4
(Road Name and Numbers, Community, or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER Q&Jt' L✓OD c( From To FormationOescriptlon
Address
151reet or Route o.
City or Town State Zip Code
4. DATE DRILLED -ov
5. TOTAL DEPTH 3a' s
6. CUTTINGS COLLECTED YES I�-`'NOEJ
7. DOES WELL REPLACE EXISTING WELL? YES NOMJ
8. STATIC WATER LEVEL Below Top of Casing: FT. o
Q
(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): METHOD OF TEST _
=°=ate
11. WATER ZONES (depth):
�:-
1r
e ��S Amount �_ If additional space Is needed use back of form W
12. CHLORINATION: Type
-�'
13. CASING: --
_
--
Wall Thickness LOCATION SKETCH
L Depth DI eler or WeighUFt. Material (Show direction and distance from at least two Stale
From To Ft. Roads, or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Malerlal Method
From b To _p—Z-t'_ Ft. (' $�k. r sr aRL' l
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 FL _
17. REMARKS:
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:
Submit original to Division of Water Quality. Groundwater Section within 30 days
Serial No. : a
0
o I ii 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: �-e -S' - ezj vVI
SCrktip1 if, 0 `"
WELL CONTRACTOR CERTIFICATION 0:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential f 9"unlctpal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, Ust Use:
2. WELL LOCATIO(v (Show sketch of the location below)
Nearest Town: 511 orJi llC County: - of 6Qow
(Road Namo and Numbers. Commu ity, or Sub/division and Lot No.)
DRILLING LOG DEPTH
3. OWNER 1 � ^ 4 ��WaAA d.f
Address
From To Formation Description
151reet or Route o.
City or Town Stale Zip Code
4. DATE DRILLED
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES NO❑
c
7. DOES WELL REPLACE EXISTIN WELL? YES E] NO
8. STATIC WATER LEVEL Below Top of Casing: o5e 0 FT,
_
(Use '+' If Above Top of Casing)
M r ,,
9. TOP OF CASING IS FT. Above Land Surface'
r ;
'Top of casing terminated atfor below land surface requires a variance In accor-
co
dance with 15A NCAC 2C.0118
10. YIELD m (gp ) 3Q_ METHOD OF TEST � •�
�;
�
11. WATER ZONES (depth):
C? m d
��
12. CHLORINATION: Type ��f Amount __9
If additional space Is needed use back of form
w ="
13. CASING:
O o
--
Wall Thickness
LOCATION SKETCH
Depth DI I r or WelghUFt. Maledal
s—{'
(Show direction and distance from at least two Stale
Frorn_L�/ To --�= Ft. may'/'�
Roads, or other map reference points)
From To Fl.
From To Ft.
14. GROUT:
Depth Material Method
From �% To CFI. (Iewat het l
From To Ft.
15. SCREEN:
Depth Diameter Slot Slze IMaterial
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 FL —
17. REMARKS:
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COP�ISRECORDH EEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Quad No: SIGNATURE OF PERSON CONSTA ING THE WELL DATE
Submit original to Division of Water Oualily. Groundwa e n 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] �} r
WELL CONSTRUCTION RECORD WELL CONTRACTOR: � S' 4rrJ v '_ ee
WELL CONTRACTOR CERTIFICATION 0:/��
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: .k� � jO J"ll-e County:
(Road Namo and N/u�mba(s, Canununily, orSubdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER F- r St le It Alme_s From To Formation Description
�
�VQtL
Address -� zl el
-
(feel151feel or Floute o.
City or Town State Zip Code
4. DATE DRILLED '`_�
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES NOEJ
n
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NOf4� Q
8. STATIC WATER LEVEL Below Top of Casing: gy0 _ FT.
(Use '+' If Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface*
'Top of casing terminated attar below land surface requires a variance in actor- 7
- T
dance with 1SA NCAC 2C .0118 Xv.
METHOD OF TEST
M
10. YIELD (gpm): _ _ -
"Jr,;
11. WATER ZONES (depth):
ri ='
12. CHLORINATION: Type % ff S Amount 9 If additional space is needed use back of form
--i
13. CASING:
LOCATION SKETCH
Wall Thickness
Depth DI for or Welght/Ft. Material (Show direction and distance from at least two State
From _7 L .L —To (4 Ft. - �- be Roads, or other map reference points)
From To Ft.
From To Ft.
14. GROUP:
Depth �� Material l Method /
From b To _.�, Ft. ���lc. t t ' e uRC f
From To Ft.
15. SCREEN:
Depth Diameter Slot Slze ivlateriai
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 STANDARDS, AND THAT A COPY OF THIS RECORD H BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY -3
U
Quad No:
SIGNATURE OF PERSON CO ILCTING THE WELL DATE
Subml{ original to Division of Water Quality. Groun water Section within 30 days
Serial No.
�; a i�pya �'� GW-1 REV. 12/99

r : ' 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 RECOR
D WELL CONTRACTOR:
WELL CONTRACTOR CERTIF ATiON #:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residentiall�Sl-- Municipal ❑ industrial ❑ Agricultural Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, Ust Use:
2.
WELL LOCATION: (Show sketch to location below)
�� ` 1 County: ���
Ne est Town: —R
0
DRILLING LOG DEPTH
Formation Description
(Road Name and t�ym�rs, Cammuglly�r Subalv(sfon and Lai No.)
3.
OWNER �%i c/ r/�Rj ���'
From To QQ
%� Ile U�r�6yl]
Address
¢
ree or ou e a
n D -9d, A- i j
City or Town Slate Zip Code
DATE DRILLED
4.
5.
-1-=��
TOTAL DEPTH y�? �-,y NO ---------
YES
6.
CUTTINGS COLLECTED �
DOES WELL REPLACE EXISTING WELL? YES [-J NO
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 or casing terminated atfor below land surface requires a variance In accor-;:. ...
.
dance
10:
with 15A NCAC 2C .p113 .
YiELD (gpm): , METHOD OF TEST
11.
WATER ZONES (depth):
Amounl �
If additional space is needed use back of form
12.
CHLORINATION: Type--�-�
13.
CASING:
LOCATION SKETCH
Wall Thickness
Depth Diameter or Welght/Ft. Material
�'z L
(Show direction and distance from at least two State
Roads, other map reference points)
20 Ft. -u`- -t-'
or
From -To
From —To —Ft. —
From To Ft.
14. GROUT:
Depth, Material Method
From 1� To
From To Ft. -
15. SCREEN:
Depth Diameter Slott Stze -Material
From To Ft in. In.
From To Ft. in. In.
To Ft in. In. —
From
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
17. REMARKS:
100 HEREBY CERTIFY THAT THIS WELL WAS COTRUC
CONSTRUCTION STANDARDS, AND THAT��/7
I
FOR OFFICE USE ONLY- -
Quad No: I i' (� (i� (� (1 �M .. _UA
Serial No.
JUL 13 ?_000
IN
0
CM
CD
oM
-D
ryl
m�
v
� rR
cn
..
M .0
c>
Ca
o
)ANCE WITH 1SA NCAC 2C. WELL
BEEN PROVIDED TO THE WELL OWNER.
OF PERSON CONSI%UCTING THE WELL
of Wale( Quality. Groundwater Section Within 30 days
to
DATE
GW-1 REV. 12199

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
C 27moo-1636•Phond (9191 733;3221
1636 Mail Service Center - Raleigh, N. .
WELL CONSTRUCTION RECORD WELL CONTRACTOR: 'L�
WELL CONTRACTOR CERTIFICA ON #: �
STATE WELL. CONSTRUCTION PERMIT#
1. WELL USE (check Applicable sox): Residential 69--Municipai ❑ Industrial ❑ Agricultural El Monitoring ❑
Recovery ❑ Heat Pump Water Injection [] Other ❑ If Other, List Use:
2. WELL LOCATIO(Show etch of the location below)
Nearest Town: l p f County.
DEPTH
(Road Name and Numbers, Community, or Subbdivis n and Lot No.) DRILLING LOG Formation Oescripll
3. OWNER / / TZ°r� To '� Z
Address /
ree u ou a o.
Gty or Town State Zlp Cade C�, 3� Jt— ���
4. DATE DRILLED , 41
5. TOTAL DEPTH fk.5
6. CUTTINGS COLLECTED YE! NOD —'
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
a. 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
dance with 1NCAC 2C .0118 /J
10: YiELD (g (gpm): �— METHOD OF TEST
11. WATER ZONES (depth):
It additional space is needed use back of form
12. CHLORINATION: Type Amo`unt
13. CASING: LOCATION SKETCH
Wall Thickness
Depth Di m t r or�W,e�l fhUFt. Mat rial (Show direction and distance from at least two State
From :Z To Ft. J" —' Roads, or other map reference points)
From To Ft.
From To Ft. o
14. GROUT:
�
rDepth Material L Method
From 6/ To � Ft. P I M e,f 7 C
� Q m
From To F1. :=n
N o;
15. SCREEN:
Depth Diameter Slot Size ivlaterial o ?»
m�
From To Ft in. In. �rn
From To Ft. in. in. .:
From To Ft. In. In. _ t
16. SAND/GRAVEL PACK: o
Depth Size Material
From To Ft.
From To Ft. —
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CN UCTED IN ACCO ANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT466-
THIS RE A BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY DATE
NATURE OF PERSON CONST UCTING THE WELL
Ouad No: R ;SgbDivision of Water Quality, Groundwater Section within 30 days GW-1 REV. 12J99
Serial 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 [phone]
L// tELcJ ��- ✓ � Q�
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICA ON
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (check Applicable Box): Residential ❑ Municipal ❑lf Other, Industrial E Agricultural ❑ Monitoring ❑
Recovery ❑ O
Heat Pump Water Injection ❑ ❑ -
2. WELL LOCATIC . Show s(gtch e location below) C
Nearest Town: �>� P o thI
County:
'
(Road Name and , bars Communityj%r Subdivision nd Lot No.) DRILLING LOG DEPTH
3. OWNER ( C� From To Formation Description /
Address
ree or ou a o.
City or Town State Zip Code / ` TY1 ;—i�
4. DATE DRILLED -Ctv
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES 6 - NOD
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 1SFT• Above Land Surface'
'Top of casing terminated at/or below land surface requires a variance in accor
dance with 15A NCAC 2C.0118 r r
10: YIELD (gpm): —/— METHOD OF TEST
11. WATER ZONES (depth): //
12. CHLORINATION: Type �1�--Amount If additional space is needed use back of form
13. CASING:
LOCATION SKETCH
Wall Thickness
Depth ameter a W I hVFt. M terial (Show direction and distance from at least two State
..1� ! L Roads, or other map reference points)
From To Ft. ---�-
From To Ft.
From To
Ft.
14. GROUT:
Depth
Material Method /
From To
From To
Ft. -
15. SCREEN:
o
Depth Diameter Slot Size ivlateriai
C�
:;EE
From To Ft
in. in.
From To Ft.
in. in.
C
ni
F .
From To t
In. In.
r
N
c-,
rn
16• SAND/GRAVEL PACK:
i
" E °'no
o
o�
}
Depth
Size Material
4
From To
Ft.
rri
From To
Ft. --
"'
"'
17. REMARKS:
CJ
-+
Y THAT THIS WELL WAS CC 9T-'RUCTED iN ACCCFADANCE WITH 15A NCAC 2C. WELL
100 HEREBY CERTIF
CONSTRUCTION STANDARDS, AND THAT A�,9
FOR OFFICE
Quad No:
Serial No.
JUL 1 3 ?nolj
F THIS REGO NA I BEEN PROVIDED TO THE WELL OWNER.
ATURE OF PERSON.CONSTR ING THE WELL DATE
Division of Water Quality, Groundwater Section within 30 days
GW-1 REV. 12l99

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section 1 L?
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone] / C !�
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFiC TION #:
STATE WELL CONSTRUCTION PERMIT#:
1 • WELL USE (Check Applicable Box): Residential Lr1 Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water injection ❑ Other 0 If Other, List Use:
2. WELL LOCATIO Show skfth of the location below) I��
Nearest Town: 0- � County: P
(Road Name and bers Communf or Subdlvfslo and Lot No.) DRILLING_ LOG DEPTH
OWNER - c%Cj Y1 �i"l From To Formation 0escriptlon
3.
Address
ree or ou a o.
City or Town Stale Zip Code 3 a�
-/3--6o
4. DATE DRILLED
TOTAL DEPTH _ '�
5.
6. CUTTINGS COLLECTED YES NO❑
YES NO
7. DOES WELL REPLACE EXISTINGWELL? []
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): �_ METHOD OF TEST '
11. WATER ZONES (depth):
12. CHLORINATION: Type _If ' IS Amount If additional space Is needed use back of form
13. CASING:
LOCATION SKETCH
Wall Thickness
Depth Dlfpmq�qr or Welght/Ft. Mat dal (Show direction and distance from at least two State
�f t reference points)
�/ Ft. G Roads, or other map
From —To
From To Fl.
From To Ft.
14. GROUT:
DeptMaterial f Meek
c3
& Qea/
From ToFL q
Q
From To Ft. _ c-
15. SCREEN: '' tom"
_Malarial Slot Size ��� ri s�' i`' + `�ri
Depth eterC7
c m
From To Ft in. in. o
C
o
From To Ft. in. in. i t s
�a
From To Ft. In. In.
m
N X
16. SAND/GRAVEL PACK:
if 3 i
Depth Size Material
c.o
0
From To Ft.
z
From To Ft. —
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CON".UCTED 1N ACCORDA CE WITH 15A NCAC 2C, WELL
N PROVIDED TO THE WELL OWNER.
CONSTRUCTION STANDARDS, AND THAT A :0 THIS RECO AS B
FOR OFFICE USE. ONLY DATE
1 �URE O PERSON CONSTRUCTIN E WELL
Quad No:
n n of Water Duality. Groundwater Section within 30 days
�u GW.1 REV. 12/99
Serial No. !
� �'
.AIL 13 9n0n

North Carolina - Department of Environment and Natural Resources - Division of Water Quality -Groundwater Section I�
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: l[
WELL CONTRACTOR CERTIFiCA iON #: 0�
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (check Applicable Box): Residential L Municipal ❑ Industrial ❑ Agricultural 0 Monitoring ❑
RecoveryE] Heat Pump Water Injection ❑ Other [J If Other, List Use:
2. WELL LOCATI (Show s etch of the location below)
Nearest Town: g Q-- County:y-v: C
(Road Name and umbers,//Community, Subdlvis%I n and Lot No.) DRILLING LOG DEPTH
3. OWNER _r /��k�/t �0`g'l �� From To, Formation Description Address !( S'et .016A_
(Street or Route o.
City or Town State Zip Code
4. DATE DRILLED
5. TOTAL DEPTH S^
6. CUTTINGS COLLECTED YES [�2L 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 ___ L_ 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): __�7_ METHOD OF TEST
11. WATER ZONES (depth):
12. CHLORINATION: Type Amount If additional space is needed use back of form
13. CASING:
LOCATION SKETCH
Wall Thickness
Depth Di m to or�Wei
hhVFt. Mat rlal (Show direction and distance from at least two Stale
From ,/ To Ft. �L-- G Roads, or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method a
From To ow FL 1qG'/kPiO o
From To Ft. _ � - )M
15. SCREEN: ' �{ `L ft `, N C�
Depth Diameter Slot Slze Materiai ` o ^o
From To Ft in. —In.o
From To Ft.
in. in.3t± i i �o
From To Ft. In. In. i ` cn�
16. SAND/GRAVEL PACK: r'
.ass; tti„ —t
Depth Size Material ,r+air C,J o
a
From To —Ft.
From To Ft. —
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS C -//'fRUCTED IN AC RDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THA;AC Y,,OFTHISRE AS BEEN PROVIDED TO THE WELL OWNER.
!Se:dal
OFFICE USE O 1., _No: ((� II��, Aj �JRE OF PERSON CONST TING THE WELLDATE
tW SAl to pivdIon of Water Ouallly. Groundwater Section Within 30 days
r GWt REV. 12/99
No.
JUL i 3 nl

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section C i
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
CONSTRUCTION RECORD WELL CONTRACTOR: �/ ��' �`)` >°�s
WELL CONS .
WELL CONTRACTOR CERTIFiCA ON #:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable sox): Residential M Municipal ❑ industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other M If Other, List Use:
2. WELL LOCATION:*howetch of the location below)
Nearest Town: [ a 'Z- County: ,
(Road Name gnQJJumbers, Commun f r Subdivlslo and Lot No.) DRILLING LOG
3. OWNER li,/L 'C f From To
Address
ree or ou a o.
City or Town �, State Zip Code
4. DATE DRILLED �`0 %
5. TOTAL DEPTH _ -��—
6. CUTTINGS COLLECTED YES NO❑
7. DOES WELL REPLACE EXISTI WELL? YES ❑ NO i
S. 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 1(g NCAC 2C Yepth):
10. YIELD (gpm): METHOD OF TEST
11. WATER ZONES (
DEPTH
Formation Description
Amount—
It additional space is needed use back of lorm
12. CHLORINATION: Type
13. CASING:
LOCATION SKETCH
Wall Thickness
Ma►
(Show direction and distance from at least two State
Depth
/
�
DI m ter
or Weight/Ft. rial
�� L Roads, or other map reference points)
From To
Ft. —�=�--'
From To
Ft.
—
From To
Ft.
14. GROUT:
Deptfl
To d
Ft.
Material_ l MethodZE
e
C:
rE
From c2
From To
FL
II +
C
Q rfr
15. SCREEN:
i �... I
Depth Diameter Slot Size tilaterial
ti •
ii " i
N
o
x
vM
From To Ft
In.
In.
l
From To Ft.
In.
In.
I ' ..r. rr'
ni
From —To —Ft.
—In.
in.�
{
.
N
16. SAND/GRAVEL PACK:
Depth
Size
Material
0
From To
Ft.
From To
Ft.
---
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS
CONSTRUCTION STANDARDS, AND THAT A C
FOR OFFICE USE ONLY
Quad No:s
Serial No.
0
JUL 1 3 ?000
ED iN ACCOR NCE WITH 15A NCAC 2C, WELL
RFC AS EEN PROVIDED TO THE WELL OWNER.
OF PERSON CONSTRUC G THE WELL DATE
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
213216
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: e S AEU en S A-,
WELL CONTRACTOR CERTIFICA ON 0: c. 43
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (check Applicable Box): Residential Municipal O Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection Other E] If Other, List Use:
2. WELL LOCATION: Show sketc el
the location below)
Nearest Town: _ .e ,,e, e \ r County: /Z
>'U - . -% - t A I-)C3 - l` DEPTN_
(Road Name amd�umbers, Communit or Sub 4lsion and Lot No.) DRILLING_ LOG
3. OWNER %h ��l Gi �[� ��� From To r Formation Description
Address Gs--- e- v ° 4"
ree or ou a o.
City or Town // Stale Zip Code /l i/�S
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.
(Use '+' if Above Top of Casing)
9. TOP OF CASING 1S FT. Above Land Surface'
'Top of casing terminated at/or below land surface requires a variance In accor-
dance with 15A NCAC 2C .01 IS
10. YIELD (gpm): METHOD OF TEST I
11. WATER ZONES (depth):
12. CHLORINATION: Type �:D+ LL S Amount If additional space Is needed use back of form
13. CASING:
LOCATION SKETCH
Wall Thickness
Depth �/, I/ D a eler or W^eilghtl t. Male al,/ (Show direction and distance from at least two Stale
From—. To -/- 4 Ft -�— 0 C, Roads, or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth
Material Method
�% �
Ft.
c'
From To
From To
Ft.
n
15. SCREEN:
�m
m
Depth Diameter Slot Size ` Materal
I=n
From To Ft
In. In.
M
From To Ft.
In.. in.
`v
From To Ft.
In. in.
�C
Md
16. SAND/GRAVEL PACK:
tV
rn=
Depth
Size Material
N
From To
Ft.
rV
a
From To
Ft. - ---
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED 1N ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY / IS RECO,f3 AS B9EN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY DATE
Quad No: SIGNATURE OF PE(iSON CONSTRUCTI r THE WELL
Submit bdginal o Divlsio'of ale Ou�tity, (3rou dwater Section within 30 days
+ �VV� 1'i GW-1 REV. 12/99
a rb
Serial No.
,on F

213215
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
36 M iI Service Center - Raleigh N C 27699-1636-Phone [phone]
16 a
WELL CONSTRUCTION RECORD WELL CONTRACTOR: S
WELL CONTRACTOR CERTIFICAilON #: a 113
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check applicable sox): Residential Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection( OtherEJ If Other, List Use:
2. WELL LOCATION: (Show sket h of the location below)
Nearest Town: ��P % e'f�1'! County k4 L',71L,
-1111etoy , 3
(Road Name and Nu ors, Community, or S dlvisto -and Lot No.) DRILLING,LOG _ DEPTH_
3. OWNER From TO Formation Descrl tlon 1
Address U 2Gy tl o n-
ree or ou a o.
City or Town State Zip Cade
4. DATE DRILLED X -a ,
S. TOTAL DEPTH s 0 E —
6. CUTTINGS COLLECTED YES�NO�]
7. DOES WELL REPLACE EXISTING WELL? YES [] NOT( >
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 surfacerequires a variance in accor-
dance with 15A NCAC 2C.01118
10. YIELD (gpm): „ETHOD OF TEST
11. WATER ZONES (depth):
12. CHLORINATION:
13. CASING:
Type �]D; Ll -SAmount' if additional space Is needed use back of form
..yy�� Depth Dr et
From�—To Ft.
From To Ft.
From To Ft.
14. GROUT:
/Depth�y,, Material Method i
From _G.--- To °� Ft. �lCll'f _ �1L� IL
From To Ft.
15. SCREEN:
Depth Diameter Slott 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:_
LOCATION SKETCH
Wall Thickness
or Wei hl/Ft. Mat ai (Show direction and distance from at least two State
lrS C. Roads, or other map reference points)
Material
1 DO HEREBY CERTIFY THAT THiS WELL WAS CONSTRUCTED iN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY F THIS RECORP HAS B EN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Quad No: SIGNATURE OF PERSON CONSTRUCTt G THE WELL DATE
Sufi I! arf Inal o Lfiston of Water Quality. Groundwater Section Within 30 days
�i• �d{ i GW-t REV. 12/99
Sedai No.tza
A'; i,"Uf;� "

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
213224
h N C 27699-1636-Phone [phone]
1636 Mail Service Center - Raleig .
WELL CONSTRUCTION RECORD WELL CONTRACTOR: e S e2 s h✓
WELL CONTRACTOR CERTIFICA ON #: 07 y3
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (check Applicable Box): Residential Municipal C] Industrial ❑ Agricultural El Monitoring El
Recovery ❑ Heat Pump Water Injection Other ❑ If Other, List Use:
2. WELL LOCATION, (Show sketch -of the location below) j
�jI :1 (� la County - `n tiJ
Nearest Town: '
DEPTH
(R ad Name 4nd�mbers� CoTunitx„p; ubdl�� and Lot No.) DRILLING LOG Formation Descrl Lion
3. OWNER �tt��// S llX(I�ICI From To
Address + o� U It 2 e- v � 0
ree or ou a o. L
City or Town State Zip Code
4. DATE DRILLED S. TOTAL DEPTHS S
6. CUTTINGS COLLECTED YES ® NOC]
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
8. STATIC WATER LEVEL Below Top of Casing: FT.
(Use '+' 11 Above Top of Casing)
9. TOP OF CASING IS._ 1 FT. Above Land Surface'
*Top of casing terminated atfor below land surface requires a variance In accor-
dance with 15A NCAC 2C 0 18
10. YIELD (gpm): METHOD OF TEST 1
11. WATER ZONES (depth):
12. CHLORINATION:
13. CASING:
Type 'D r LL 5 Amount ---6-- If additional space is needed use back of form
Depth � Dam ter
From To -A — Ft.
From To Ft.
From To Ft.
14 GROUT:
LOCATION SKETCH
Wall Thickness
or Welght/Ft. M teda/l (Show direction and distance from at least two State
T' G Roads, or other map reference points)
Depth Material Method
� Ca_
From 0 To ad Ft.
From To Ft.---------
15. SCREEN:
Depth Diameter Slot Size,.,,Material
From To Ft in. In. --
From To Ft. in. in.
From To Ft. In. In. _-----
16. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To Ft.
17. REMARKS:
Material
v
s7
ra r,
o .c
mC:)
AC:)
rn
rn�
0
x
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED iN ACCORDANCE WITH ISA NCAC 2C. WELL
CONSTRUCTION STANDARDS, AND THAT A F OF II R OR HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY DATE
Quad No: SIGNATURE OF PERSON CONS`T`RjING THE�WELL
Submit odginat to Division of Wafer Quality. Grau�dwater� cU r• 1 tht �3gdiay5
_IREV.REV. 12/99
Serial No. —
I�
s f� /lI n�` --

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
R i igh N C 27699-1636-Phone [phone]
N
213223
1638 Mail Service Center - a e
WELL CONSTRUCTION RECORD WELL CONTRACTOR: e S G eR S n.'
WELL CONTRACTOR CERTiFICA ON N.-
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Sox): Residential Municipal ❑ industrial El Agricultural El Monitoring ElRecovery❑ Heat Pump Water Injection Other E] If Other, List Use:
2. WELL LOCATIO y*ow sket4hlaf th ,location below)
Nearest Town: _ � 'I�—( — County: Lko-) C'-G 0-1AD C
� 6 7' i7 P e= J DEPTH
(Road Name and ers, ommunilynor Subdfvistpn and Lot No.) DRILLING LOG
3. OWNER 6 l /1 �i� From To Formation Descri tion
Address r Q U>r 2 �G
ree or ou a o.
Clly or Town Slate Zip Code 3 I
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.
(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 . 118
10. YIELD (gpm): METHOD OF TEST i
11. WATER ZONES (depth):
12. CHLORINATION:
13. CASING: .
Type ::? r LL 5 Amount It add(tione[ space is needed use back of form
Wall Thickness
Depth ampler orWe ghUR. mated /
From-- To 39 Ft. Q .. W
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method - J
From-.._�.. T•o�cl 0 Ft.
From To Fl.
15. SCREEN:
Depth Diameter Slott Size i�lateriai
From To Ft In. in.
From To Ft. in. in.
From To Ft. In. In. —
16. SAND/GRAVEL PACK:
Depth Size Material
From To FL
From To Ft. —
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED iN
CONSTRUCTION STANDARDS, AND THAT A COAT THIS�R ACC
FOR OFFICE USE ONLY ­ - 1� \
Mad No: SIGNATURE OF PER
Submit original to Division of Water
Sedal No.
LOCATION SKETCH
(Show direction and distance from at least two Slate
Roads, or other map reference points)
O
o
C:)
C
CD r'n
�
G
�rn
N
o-<
:9._o
m o
ern
fV
��
N
Z
)R ANCE WITH 15A NCAC 2C, WELL
A BEEN PROVIDED TO THE WELL OWNER.
CONSTRUCT NG THE Wq,LL i,, DATE
lty, Groundwater section vAhin 30 days
GW-t REV. 12199
t

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section 01322,7
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: S' eR S �'
WELL CONTRACTOR CERTIFiCA ON #: A U3
STATE WELL CONSTRUCTION PERMIT#:
WELL USE (check Applicable Box): Residential Municipal ❑ Industrial Agricultural ❑ Monitoring ❑
1.
Recovery ❑ Heat Pump Water Injection Other ❑ If Other, List Use:
2. WELL LOCATIONy#hgdv skeEf�t� f the location below)
/ County
Nearest Town: 5 e- ' r -- -
77-
(Road Name anA.Nymbers. Co mmu or Subdlvisi and La No.) DRILLINGLOG
Fram To
DEPTH
Formation Descri li
a
3. OWNER \)/}t2LLyC��Y-
e✓on
U e. R o
Address
ree or ou a o.
City or Town State Zip Code x
li
n
4. DATE DRILLED S-- I -Oo
S. TOTAL DEPTH
6. CUTTINGS COLLECTED YES [' NoO
DOES WELL REPLACE EXISTING WELL? YES ❑ NO
7.
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 atfor below land surface requires a variance In accor-
dance with 15A NCAC 2C . 118
10. YIELD (gpm): METHOD OF TEST i
11. WATER ZONES (depth):
12. CHLORINATION:
13. CASING:
Type L� S Amount' --
if additional space is needed use back of form
Depth DI meter
From ' .t--To s� Ft.
From To Ft.
LOCATION SKETCH
Wall Thickness
or Whet hUFt. Material f (Show direction and distance from at least two State
_ —pAL Roads, or other map reference points)
From To Ft.
14. GROUT:
Depth �J Material Method
From19 To «6) Ft. i �P +
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 1N
CONSTRUCTION STANDARDS, AND THAT A �PPTbF'I RYCC
FOR OFFICE USE ONLY
Quad No:
Serial No. --
N
N
3ORDANCE WITH 15A NCAC 2C. WELL
HAS BEEN PROVIDED TO THE WELL OWNER.
SIGNATURE OF PERSON coNJTRUCTING THE WELL DATE
Submit original to Division of Water Quality. Groundwater gectlon withint30 days
;�t GW-I REV. 11199
6 r'
lit. +11R f .:,it t

21322Is I
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: e S Awl �R
WELL CONTRACTOR CERTIFICAION
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (check Applicable Box): Residentlalt3e 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: �e i C ie S K County:
DEPTH
(Road Name and umbers, Community, or Subdivision and Lot No.) DRILLING_ lOG Formation Descrl lion
3. OWNER d- 11 S From To
Address f/ //G Q U 2G r o
ree or ou a o.
City orTown State Zip Code
4. DATE DRILLED ,�
5. TOTAL DEPTH 3 Ems
6. CUTTINGS COLLECTED YES NO
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NOW
S. 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 .D118
10. YIELD (gpm)' 5 . METHOD OF TEST
11. WATER ZONES (depth):
12. CHLORINATION: Type r lL 5 Amount S
it additional space is needed use back of form
13. CASING:
LOCATION SKETCH
Wall Thickness
� � Depth Dt�my�r or WftAh Ft. Mat
�
/4
(Show direction and distance from at least two State
Roads, or other map reference points)
From_tj--To Ft.
From To Ft.
0
:E ,
p
From To Ft.
Cn �
rn
14. GROUT:
Depth Malarial M;e�tho�d
N
GC-)
rn
r-�-
From 6 To OZ d Ft. _ f P --^�`�'
`te
a
From To Fl. -
-,d
rnC)
15. SCREEN:
3
n=
Depth •Diameter Slot Size •• MatGnal
N
ro c)�
From To Ft In. in. ,
N
!
From To Ft. in. in.
'r
z
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
BEEN PROVIDED TO THE WELL OWNER.
CONSTRUCTION STANDARDS, AND THAT AG FAY OF THISE RD
OAS
FOR OFFICE USE ONLY - '
Ouad No: SIGNATURE OF PERSON
CONS RUCTINGjT.�yE1 NfsLL'� e `ATf3
' Z r '
Submit original to Division of water Ouallty. Groundwater S 30, With t 3t)"(Jos o I
12199
— -
GW 1 R��/
Serial No.
?i?I)r

213230
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:
WELL CONTRACTOR CERTiFICA ON #:
STATE WELL CONSTRUCTION PERMIT#:
11. WELL USE (check Applicable Box): Residential Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection Other [] If Other, List Use:
2. WELL LOCATION (S ow slutq of the location below) n
Nears t Town: � ! / County: v,) C:2) I'ti-,.
DEPTH
(Road Name and mbelis. Counily, or S bdlvision and Lot No.) DRILLING LOG
e f From To Formation Description
3. OWNER l •s� Q V�2 ee-j( do
Address
ree or ou a o.
City or Town Slate Zip Code S d aus"
4. DATE DRILLED
S. TOTAL DEPTH
6. CUTTINGS COLLECTED YES JW NO❑
7. DOES WELL REPLACE EXISTING WELL? YES[] NO['0
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 atfor below land surface requires a variance In accor-
dance with 15A NCAC 2C.0918
10. YIELD (gpm): METHOD OF TEST i
11. WATER ZONES (depth):
12. CHLORINATION:
13. CASING:
-------------
Type � r
LL 5 Amount It additional space Is needed use back of form
Depth D a ter
From, Sa Ft.
From To Ft.
From To Ft.
14 GROUT:
LOCATION SKETCH
Wall Thickness
or Weight/Ft. Material (Show direction and distance from at least two Stale
_____� __ i ] i G Roads, or other map reference points)
Depth Material Method
From__,0_ To �— FL r
From —To Ft.
15. SCREEN:
Depth Diameter Slot Size ` Avialenal
From To Ft In. in.
From To Ft. In. in.
From To Ft. In. In. _ —
16. SAND/GRAVEL PACK:
Depth Size
From To FL From To Ft.
17. REMARKS:
Material
0
c)
CD m
oC
c1
rrn
c7.{
a
rn
�Q
m
to x
tTi �
--I
A
z
I DO HEREBY CERTIFY THAT THIS WELL WAS CO STRUCTED iN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A Y�OF THIS REC RD AS BEEN PROVIDED TO THE WELL OWNER. O
Cx-A-L-
FOR OFFICE USE ONLY DATE
Quad No. SIGNATURE OF PERSON CONS T UCTING THE WELL.,
Submit original to Division of Water Ouallly. Groundwairi`r S�ttlar€�Yiilln/t7 16Yat 1G1W-1 REV. i2J99
Serial No. 1
�Ip ,
i

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
R I h N C 2769g-1636-Phone [phone]
1-
DIV
1636 me,, Service Center -
WELL a etg .
CONSTRUCTION RECORD WELL CONTRACTOR: e I• S A.Lu w eR
WELL CONTRACTOR CERTIFICA .ON #: 07 y3
STATE WELL CONSTRUCTION PERMIT#:
213213
6�-50
1. WELL USE (Check Applicable sox): Residential Municipal [❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection Other[] If Other, List Use:
2, WELL LOCATM5, w sket:of the tion below) (� C �Near st Town: �C'10ca
County:�(Road Name and Numb/eers� Community DEPTH
/�,or Subdivision and Lot No.) DRILLING LOG _
3. OWNER r ✓L���1 « �K-' From To,/ Formation Description 1
Address / '7 U Bey d o
(Streit or ou a o.
City or Town _ State Zip Cade TIZ ��`
4. DATE DRILLED S -UoI-DD
5. TOTAL DEPTH 70 S
6. CUTTINGS COLLECTED YES O NO❑
7. DOES WELL REPLACE EXISTING WELL? YES [] NO[Z]
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/011_s
10. YIELD (gpm): 1� METHOD OF TEST i 4 --
11. WATER ZONES (depth):
12. CHLORINATION' Type r l.� S Amount a^
If additional space is needed use back of loan
13. CASING:
LOCATION SKETCH
Wall Thickness
Depth ,i / Oi�mgter or Weight/Ft . Ma edal
i�'G
�
(Show direction and distance from at least two State
reference points)
From To Ft. (O Js%
/
Roads, or other map
From To Ft.-_Q
From To Ft.
CD
a
14. GROUT:
Depth Method
L'
C
or
,, ,M,aterriall
D To oZ Q Ft. �Lt--
N
©=�
From
From To Ft. -
3
15. SCREEN:
Depth Diameter Slot Size -Material
3
ni
C'
rn
From To Ft In. In
►V
��
From To Ft. In. in.
C.:)
From To Ft. In. in.
x
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft. —
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CON§TAUCTED IN ACCORDANCE WITH ISA NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY Oj,/,THIS ECORD AS 8 EN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY DATE
SI NATURE OF PERSON CONSTRUC G THE WELL
Quad No:
ub mil odgiri 1pto of Water Quality, Groundwater Section within 30 days
ES Division
Serial No.
GW-t REV. 12/99
j
t�,.��

213214 i
` North Carolina . Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section C+6 I A )CQ po III
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone] s
�. e S� ea s n n✓
WELL CONSTRUCTION RECORD LL CONTRACTOR:
WELL CONTRACTOR CERTIFICA 10N
STATE WELL CONSTRUCTION PERMIT#:
1, WELL USE (Check Applicable Box): Residential Municipal O industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection Other ❑ If Other, List Use:
2. WELL LOCATION �h sk(^tt;ty�t the location below) (3 " YJ CD
'�--
Nearestt Tpwn: i C V ! // County: .
l G�1DEPTH
(Road Name and_tumbers, Community. or Subdivision and Lot No.) DRILLING LOG Formation Descrf tion ,f
3. OWNER k•R t C �Oh115 0� -- From T° Q Ut° 2 u
ev orl.
Address
ree or ou a o.
City or Town Slate Zip Code
4. DATE DRILLED
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: 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 NC): 2C Ll 18 - --
10. YIELD (gpm): / METHOD OF TEST
11. WATER ZONES (depth):
12. CHLORINATION: Type '' LL 5 Amount It additional space is needed use back of form
13, CASING: LOCATION SKETCH
Walt Thickness
Depth D�ame►-er or Weight/Ft. Material (Show direction and distance from at least two State
From � To
13 Ft. - or,- I Roads, or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method I
�
To c2-6 Ft. r PLl�—�2--Gia'r
�©
From
From To Ft.
C'-
o�
15. SCREEN:
Depth Diameter Slot Size ,Material
fV
�r_t
c7
From To Ft in. _In.—
PE rn
\
From To Ft. In. in. —
o
rn
From To Ft. In. in.
N
-Z
16. SAND/GRAVEL PACK:
N
-y
Depth Size Material
z
From To Ft. —
From To Ft. --
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED iN ACCORDANCE WITH 15A NCAC 2C, WELL
A COPY,0 THIS RECORD AS BEEN PROVIDED TO THE WELL OWNER.
CONSTRUCTION STANDARDS, AND THAT
111//
`
ICE USE ONLY 'I `
NATURE OF -PERSON CONS UCTING THE WELL
FORTo:
DATE
QuSI
Quad
S4bml� brigl�ig�I loiv°('oni Waler'Ouality, Groundwater Section within 30 days
a
Gt REV. 12/99
W
a EbD _6� �r
Serial No. G+
i r4
g.

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:E'e `S� `�`�
WELL CONTRACTOR CERTIFICATION #: "�i
STATE WELL CONSTRUCTION PERMIT#:
i
1. WELL USE (Check Applicable Box): Residential Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring
❑
Recovery ❑ Heat Pump Water Injection [] Other ] If Other, List Use:
2. WELL LOCATIO (Show skVch of the location below) a
h y County:
Nearest Town: Pr _
--� DEPTH
(Road Name andj'mbe`�, Community, or Sub iviston and Lot No.) DRILLING LOG
3. OWNER C5/& a/" / ��"7 From To Formation Description
Address eh eR e,6.
— T 4/S' D i/er e ✓� 1�
(Street ou a or o.) 7t-/
City or Town State Zip Code
4. DATE DRILLED
5. TOTAL DEPTH
'NO
6. CUTTINGS COLLECTED YES r-
DOES WELL REPLACE EXISTING WELL? YES CJ NO[y�T
7.
8: STATIC WATER LEVEL Below Top of Casing: FT.
—
(Use '+' If Above Top of Casing)
9. TOP OF CASING IS_,[_ FT. Above Land Surface* C
C,rri�
'Top of casing terminated at/or below land surface requires a variance in accor•
C"
dance with 15A NCAC 2C .0118 0
10. YIELD (gpm): METHOD OF TEST N�
11. WATER ZONES (depth): —a
12. CHLORINATION: Type _ Amount If additional space is needed use back of form ;;rn5o
C
13. CASING: tV
LOCATION SKETCH
z
Wall Thickness
Depth Dtamer or Wet ht/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 Ft.
14. GROUT:
Depthaterlal
gMe:11From �— To`
From To Ft.
15. SCREEN:
Depth Diameter Slot Size '• •tiiaterial
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 A CORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A CO /OF THIS RECOR HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Quad No: ,� n" " ' IG T' R F P fiSQN ON UCTING THE WELL DATE
u ml rfq l to ivl ton W ter(( uat l , Groundwater Section within 30 days
Serial No.
OW-1 REV. 12/99
2000
t�rUttnd� t;� 5^+;;Ian

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: .� nv
_ -Sty �
WELL CONTRACTOR CEATIF]CATiON 0:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (check Applicable sox): Residential Municlpal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water injection ❑ Other ❑ if Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)11 t�Cb �,
NearestTown: t �S�County:
F�1 _ rle- 1 ( A, DEPTH
(Road Name and Nu ers, Community, or Subdivision and Lot No.) _DRILLING LOG _
3. OWNER V_el/z° J ��uP2 From To Formation Description /
Address / �� tt"e_
ree or ou a o. .�� 1� .� O,Y
City or Town Slate Zip Code
4. DATE DRILLED
5. TOTAL DEPTH 3DS
6. CUTTINGS COLLECTED YES [R�l NOD
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 attor below land surface requires a variance in accor-
dance with 15A NCAC 2C .qj l a
10. YIELD (gpm): -J METHOD OF TEST
11. WATER ZONES (depth):
12. CHLORINATION
13. CASING:
Type Amount It additional space is needed use back of form
Wall Thickness
Depth Dim ter or WeighVFt. Material
From —To � Ft. e'-
From To FI.
From To Ft.
14. GROUT:
Depth
© ;5Cl2
alerial
thod
.'e
From
To
Ft.
From
To
FL
15. SCREEN:
Depth
Diameter Slot Size
Niateriai
From
To
Ft In.
in.
From
To
Ft. In.
in.
F m
To
Ft In.
in.
ro
16. SAND/GRAVEL PACK:
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. —
17. REMARKS:
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED iN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A CqPrF THIS REPOrp HAS BEEN PROVIDED TO THE WELL OWNER.
-2'D--0a
FOR OFFICE USE ONLYZ-494,ZDATE
SIGNAT._QE
J P�RSON NSTRUCTING THE WELL
Quad No: Sobmlt oiigl I toipwl n 1'T; Waidr'o ably, Groundwater Section within 30 days
Sedai No. -�= ✓S lJ_-T~-u~h — C' GWt REV. 12/99
JUN 2 8 2i�[�0

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: d e- Sqa
WELL CONTRACTOR CER IFiCATiON #:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential Municipal d Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION- (Show sketch he location below)
Nearest Town: � `r' V � ` e County: LAVJ C Q rn 6 P
F1,44 r
(Road Name and Nub rs. Community, or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER �J �eUP— Q.&141,e2 From To Formation Descripito
Address 7l o e2 P� v
ree or ou a o. eL e—
City or Town State Zip Code
4. DATE DRILLED 41D
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES 2k�- NO❑
7. DOES WELL REPLACE EXISTING WELL? YES [__1 NOOZ1.
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 2C 8
10. YIELD (gpm): YX METHOD OF TEST
11. WATER ZONES (depth):
12. CHLORINATION: Type A, Gas Amount —
13. CASING: l�
Walt Thickness
Depth Di�me r or Wei hVFt. Male al
From To _^� Ft. #/1�'
From To Ft.
From To Ft.
14. GROUT:
�` O` Dept�Yaterial
in�ic�
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
From To Ft.
From To Ft.
17. REMARKS:
Material
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED iN
CONSTRUCTION STANDARDS, AND THAT A C9W OF THIS,9EPC
FOR OFFICE USE ONLY
Quad No: ;_ ° °• �.-_-610NATUR
Serial No.
JUN
2 8 2000
It additional space is needed use back of form"
LOCATION SKETCH
(Show direction and distance from at least two State
C Roads, or other map reference points)
:ORDANCE WITH 15A NCAC 2C, WELL
HAS BEEN PROVIDED TO THE WELL OWNER.
4 4 AJ _,:� O - ® L�)
OBSTRUCTING THE WELL DATE
Groundwater Section within 30 days
GW t 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]
kJ
WELL CONSTRUCTION RECORD WELL CONTRACTOR: �� �� C./J/ E� Sa
WELL CONTRACTOR CERTIFICATION 0:
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 LOCATIO�.: (Show sketch 6 ht location below) �C01�
Nearest Town: W 0.1 e f � , ` � County
F` 'ram 1011 DEPTH
(Road Name and Numbers, Community, or Subdivision and Lot No.) DRILLING LOG
3. OWNER o4_1-ell e— V e/, From To �y Formation Description
Address
(Street or Floute o.
City or Town State Zip Code
4. DATE DRILLED
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ®- NO❑
7. DOES WELL REPLACE EXISTING WELL? YES
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 varlance in accor-
dance with 15A NCAC 2C .0118
10. YIELD (gpm): _/— METHOD OF TEST '
11. WATER ZONES (depth): —
cn x
It additional space is needed use back of form
v
z
LOCATION SKETCH
(Show direction and distance from at least two Slate
Roads, or other map reference points)
12. CHLORINATION: Type Amount
13. CASING:
Wall Thickness
��
Depth
DiI for or Weight/Ft. Material
e"
From
To
Ft. s�—y
From
To
Ft.
From
To
Ft.
14. GROUT:
10
Depth
JAateriai Ihod
Ft.
From
To
From
To
Ft.
15. SCREEN:
Depth
Diameter Slot Size - .,Material
From
To
Ft In. in.
From
To
Ft. In. in.
From
To
Ft. In. in.
16. SAND/GRAVEL PACK:
Depth
Size Material
From To Ft.
From To Ft. —
17. REMARKS:
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C. WELL
CONSTRUCTION STANDARDS, AND THAT A�Y OF THIS RECO HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Quad No: p ° ' �,, !r' S N �y,T� URE OF PERSON C RUCTING THE WELL GATE
(} brYtl J'a'1217 0-OlLlslon of Water Quality. Groundwater Section within 30 days
Serial No.�� GW-1 REV, 12/99
JUN 2 o 2000 ;;
0

` North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mali Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RE
CORD L
WELL CONTRACTOR: L�
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential [2� Municipal 0 Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other [] If Other, List Use:
2. WELL LOCATION: Sh w sk f the location below)
County:
n ���D
kD
Nearest Town:
v�
(Road Name anfA4umbers,
jG,JDEPTH
Comm` fly, or Subdivision and Lot No.)
DRILLING_ LOG
To
Formation Description
3. OWNER-tJ/��tGl
/� B�Ap-S
/From
Address
D �al sf
ree or ou a o.
City or Town State Zip Code
4. DATE DRILLED ��
5. TOTAL DEPTH oZ e-5
6., CUTTINGS COLLECTED YES 0�4--. NO❑
7. DOES WELL REPLACE EXISTING WELL? YES M NOFV-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*
'Top of casing terminated atfor below land surface requires a variance In accor-
dance with 15A NCAC 2c .0�1 �j
10. YIELD (gpm): p� (J METHOD OF TEST
11. WATER ZONES (depth):
12. CHLORINATION: Type Amount
13. CASING:
Wall Thickness
�/ Depth/O Ft. Dia a or�W�eigh� t. Material
From To
From To Ft.
From To Ft•
14 GROUT•
Depth
Ft.
Material ethod /I
"-A e,L� rQ eL
From
To
From
To —Ft.
--
15. SCREEN:
Depth
-Diameter Slot Slze ` Material
From
To
Ft
In. in.
From
To
Ft.
in. In.
TO
Ft
In. In.
From
16. SAND/GRAVEL PACK:
Depth Size
From To Ft. From To Ft. —
17. REMARKS:
Material
7
+ Al!'
� �rn
�m
A rn�
rn
-1
If additional space is needed use back of forte o
LOCATION SKETCH
(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 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A C'9� OF THIS REC(rD HAS BEEN PROVIDED TO THE WELL OWNER.
I 1 h -
FOR OFFIC�ONLY
Quad No:
Serial No. o
INSTRUCTING THE WELL
Groundwater Section within 30 days

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: 1' e
WELL CONTRACTOR CERTIFICATION #: le, y
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (check Applicable Box): Residential u;X Municipal ❑ Industrial ElAgricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water fnJection ❑ Other ❑ if Other, Llst Use:
2. WELL LOCATION, (Show sift It of the location below)
County: 7
Nearest Town: S2y r -
T: r 'v^ ✓ �� Tom'
Community, or Sub - (vision and Lot No.)
DRILLING LOG DEPTH
_ _
(Road Name and mbevrs,
From To Formation Descrl uon
3. OWNER
Address
ree or ou a o.
City or Town State Zip Code
4. DATE DRILLED
5. TOTAL DEPTH 5
n
6. CUTTINGS COLLECTED YES 0 NO❑
WELL REPLACE EXISTING WELL? YES [.] NOe
a p
7. DOES
8. STATIC WATER LEVEL Below Top of Casing: FT•
o�
(Use '+' if Above Top of Casing)
TOP OF CASING IS-1— FT. Above Land Surface'
_ —
o
9.
*Top of casing terminated at/or below land surface requires a voila"cs In accor-
dance with 15A NCAC 2C .a118 n
rn
10. YIELD (gpm): -30 METHOD OF TEST
11. WATER ZONES (depth):
_
12. CHLORINATION: Typer Amount
if additional space is needed use back of forej .. o
13. CASING:
LOCATION SKETCH
Wall Thickness
DepthD me�ler orWei�hV�Ft. Material
(Show direction and distance from at least two State
map reference points)
Froml--L�To 20 FL
Roads, or other
From To Fl.
From To Ft.
14. GROUT:
Depth ,,ll n MaterialL �ihod
From To o�y Ft.
From Tv Ft. -
15. SCREEN:
Depth Diameter Slot Size. -Malarial
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 STANDARDS, AND THAT A C FY OF THIS EVORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY DATE
1 c `,i$IGM' AVRE OF PERSO ONSTRUCTING THE WELL
Quad No: ((� f{ c ! 11 i;:
Su�lmlt odplh 1,4Dlvlsion o1.W �I t ; uality, Groundwater Section within 30 days GW1 REV. 12/99
Serial No.
,SUN 2 8 2000

+ 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]
S >L SO
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
LL CONTRACTOR CERTIF CATION 0:�3�--
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): ResidentlaIMunicipal
❑ Industrial
Use:
Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection� U ❑ If Other,U
2. WELL LOCATI Show k�toh the location below) i?
Nearest own: n
County: v
DRILLING LOG DEPTH
(Road Namell umber Comm ily, or Sub Ivislon and Lot No.) From To Formation Descd n
a (�` �yi{'�
3. OWNER + C IL L/ (0 /L t a Due/ end
Address
ree or ou a o.
City ar Town Stale Zip Code
4. DATE DRILLED 3-AC) -60
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES®' NOF1
7. DOES WELL REPLACE EXISTING WELL? YES [:J NO®
8. STATIC WATER LEVEL Below Top of Casing: FT•
(Use +' If Above Top of Casing)
9. TOP OF CASING IS__I_ FT. Above Land Surface'
*Top of casing terminated at/or below land surface requires a variance in accor-
dance with 15A NCAC 2C .01111 METHOD OF TEST
10. YIELD (gpm): —k---
11. WATER ZONES (depth):
5 mount. If additional space is needed use back of form
12. CHLORINATION: Type A
13. CASING: LOCATION SKETCH
Wall Thickness
' / Depth Dt, a)p�►er orealghvFt. M (Show direction and distance from at least two Stale
From
�,_L___�To �-- Ft. /f+M --- ---�-- �G Roads, or other map reference points)
From To Ft. ZE
r#
v
From To Fl. -- 0 r-1
14. GROUT: Gil
Depth Material Method C�
c)rn
From --t— To Ft. 1 0 rn
From To Ft. --- N Ern
15. SCREEN:
Depth Diameter Slot Size 1+laferial 3 �v
rn
From To Ft In. In. _ _---- rn--a
From To Ft. In. In. - r
From To Ft. in. In.
16. SAND/GRAVEL PACK: Material
Depth Size
From To Fl.
From To Ft. —
17. REMARKS:
100 HEREBY CERTIFY THAT THIS WELL WAS CONS UCTED IN ACCORD CE WITH 1SA NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COP THIS EC AS B N PROVIDED TO THE WELL OWNER. ` D
FOu
7No:
ICE USE ONLY DATE
4 S N `TUFF O�•PEF SONS CONSTRUCTIN THE WELL
i11.o g not: DVLsL4r191+plei ; u(a lty. Groundwater Sectlan within 30 days OW 1 REV. iy99
I �� JUN3 2000

North Carolina - Department of Environment and Natural Resources - Division of Water Quailty - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: ��u�P hc�c��e2s f SQti
WELL CONTRACTOR CERTIFICATION #: ay-3
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (check Applicable Box): Residential Ur Municipal[] Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION*w sketch of the location below)
Nearest To County:0oad
NamCom�%nItyj/°r Sub/division nd Lot No.)
�/
DRILLING_ LOG DEPTH
From To Formation Description /
3. OWNER �L°/V /1 '� C �l /Q� e
0l/e& YerO/!v
Address
ree or Floule o.
City or Town State Zip Code
/JS R 45L
4. DATE DRILLED 1 _ 00
.
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES M NO❑
DOES WELL REPLACE EXISTING WELL? YES ❑ NON
7.
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 2C MIS
10. YIELD (gpm): 3 METHOD OF TEST '
11. WATER ZONES (depth):
12. CHLORINATION: Type � Amount
If additional space is needed use back of form
13. CASING:
Depth lameter
— -- From _4_J To = 5 Ft- ML
From To Ft.
From To Ft.
14. GROUT:
LOCATION SKETCH
Wall Thickness
or WelghUFt. Material (Show direction and distance from at least two State
_ rr Roads, or other map reference points)
Depth^� Material Method
From To "''� Fl. �1 -
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Malerlal
From To Ft in. —in.—
From —
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
CONSTRUCTION STANDARDS, AND THAT A C
FOR OFFICE USE ONLY
Ouad No:
Serial No.
S ml�rfgl ff l if I Tbi
JOLZ
IN a� V 2000
crn
z�
to.c
30
.n \
� O
tn,Z
h �
zC
iN ACCO DA E WITH 15A NCAC 2C. WELL
CO AS BE N PROVIDED TO THE WELL OWNER.
T"
PERSON CONSTRUCTING LL DATE
i le uaI " Groundw action within 30 days
GW-i 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] / C
d Rs � J �1✓
WELL CONSTRUCTION RECORD WELL
ELL CONTRACTOR-CERTIF ATiON #: yew
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water In)ectlon ❑ Other ❑ If Other, List Use:
2. WELL "MIof the location below)
NearesAlf
a3m
County:
(Road Name and Nu
nbers, community, Subdivision and Lot No.)
DRILLING_ LOG
DEPTH
Formation Description
3. OWNER �.0
liG/Ae? JDAe S _
From To
Address
ree ar ou a o.
City or Town Slate Zip Code
4. DATE DRILLED 5 -V7- Uw
5. TOTAL DEPTH 112o s
6. CUTTINGS COLLECTED YESFA NO❑
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NOW
8. STATIC WATER LEVEL Below Top of Casing: FT.
(Use '+- if Above Top of Casing)
9. TOP OF CASING IS --I— 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): /J— METHOD OF TEST
11. WATER ZONES (depth):
12. CHLORINATION: Type ' Amount _ _,y_ If additional space is needed use back of form
C
13. CASING: LOCATION SKETCH
Wall Thickness
Depth %later or Welght/Ft. Maj�dalL (Show direction and distance from at least two Stale
From 7 � To Ft.
j�=-r-- -Way /AST�'G Roads, or other map reference points)
From To Fl•
From To
Ft.
CD
ZE
14. GROUT:
Depth
Material Method /
CD
o
�_ To 0)0
FL �e/l1 �/tf u e e
xC
c
From
From To
Ft.
N
�<
15. SCREEN:
o
Depth Diameter Slot Size tviaterial
�a
From To Ft
In. —In.—,
�
N r n
z
From To Ft.
in. In. - —
••
...
rn
n
From To Ft.
In. in.
—t
o`
16. SAND/GRAVEL PACK:
x
Depth
Size Material
From To —Ft.
From To
Ft.
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS COqg RUCTED iN ACCORD CE WITH 15A NCAC 2C. WELL
CONSTRUCTION STANDARDS, AND THAT A CO THIS RE AS EN WITH
TO THE WELL OWNER. r
FOR OFFICE USE ONLYL—lim— DATE
Quad No: NA`(U%j OF PERSON CONSTRUCTING HE WELL
lslo lol Water Quality. Groundwater Section within 30 days GW I REV. 12/99
Serial No.

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mall Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
� ,✓ s � .sue
WELL CONSTRUCTION RECORD WELL CONTRACTOR CERLL CONTRACTOR:
TIF CATION #: 07 y3�0
STATE WELL CONSTRUCTION PERMIT#:
1.
WELL USE (Check Applicable Box): Residential 96 Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water injection ❑ Other ❑ if Other, List Use:
2. WELL LOCATION: hAv skel5l) q a location below) (Z�,
Nearest Town: Il t [ County: +tJ
�-�a•s e aJ e DRILLING LOG DEPTH
(Road Name and NJymoors, CommufJly, or ubaivisi�a q �o� �'�) From To Formation Descrip/ttiion
3. OWNER 4124 C //�P2f— O`er i f,/� ��/�D (7 ell?
Address �— L�----_
roe or ou a o.
City or Town Stale Zip Code
4. DATE DRILLED _ - -Df 'W
5. TOTAL DEPTH n2- S
6. CUTTINGS COLLECTED YES ® NOD
KI
7. DOES WELL REPLACE EXISTING WELL? YES [] NO(j
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 atior.below land surface requires a variance in accor-
dance with 15A NCAC 2C .01,18 METHOD OF TEST
10. YIELD (gpm):
11. WATER ZONES (depth):
12. CHLORINATION
13. CASING:
Type ____ Amount If additional space is needed use back of form
Wall Thickness
Depth i eler or WeighUFt. Mated
�/To �_ Ft.
From i �t f
From To Ft.
From To Ft. t --
14. GROUT:
Depth Material Method
From
To 6� rl. 0112e
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.
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
CD D
C cn
z cm
t a<
fV by
�. rn
_a �D
rn
--r
o
x
17. REMARKS:
I DO HEREBYCERTIFY
ANDARDS RIND THAT A CO S WELL WAS O F THIS RE UATRUCTED IN ACC OR EEN WITH
TO THE WELL OWNER. ✓
CONSTRUCTION- � (0
FOR OFFICE USE ONLY DATE
Quad Na: NATURE OF PERSON CONSTRUC G THE WELL
. rsSus mit`�r(pl fo wl n"�TWafe["Quality, Groundwater Section within 30 days GW f REV. 12/99
Serial No.�g
8
00 '

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:
e Sic 25 S
WELL CONTRACTOR CERTIF CATION
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable sox): Residential K Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION h w ske(A location below) o
Nest Town:
S 0 1 County:
l Te Oise �D�e DRILLING LOG DEPTH
(Road Name and Ntu b�rs, CommNunity, of Subdivision and t ac rvo.i Formation Description
3. OWNER �F�IYi'e /lt°G f From To
Address
City or Town Stale Zip Code - rvw«�
4. DATE DRILLED .��D"DO
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•
(Use '+' It Above Top of Casing)
9. TOP OF CASING IS �_� FT. Above Land Surface'
*Top of easing terminated atfor below land surface requires a variance 1n accor-
dance with 15A NCAC 2C .0 10
10. YIELD (gpm): METHOD OF TEST
11. WATER ZONES (depth):
12. CHLORINATION: Type Amount If additional space Is needed use back of form
13. CASING: LOCATION SKETCH
Wall Thickness
Depth D m9ter or Weight/Ft.
•�'I��I —Ma-terial(Show direction and distance from at least two State
_ 7 G nnnrit. or other map reference points)
From _—/ ---To
--2—' Ft.
From
To Ft.
From
To Ft.
14. GROUT:
Depth Material Method�
d Dk 2
0
To 02 17-1. z'/i1BA�
From
From
To_Ft.-------
15. SCREEN:
Depth Diameter Slot Size •ivtalerial
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 CO TRUCTED IN F
CONSTRUCTION STANDARDS, AND THAT A CO 16F THIS RECO�
FOR OFFICE USE ONLY AT R� `F�,F
Quad No:
n} o gg nai°io t)�G13liSF1 ot'W 01
Serial No. 1 PI
O� A
C C°rn
Z cCI
tv ao
a rn
3 �rn
Nz
.. rnx
c-3
;ca
z
)A CE WITH 15A NCAC 2C. WELL
B N WITH
TO THE WELL OWNER.
3_d 7—d
INSTRUCTING HE WELL DATE
Groundwater Section within 30 days GW-t 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 LL CONTRACTOR:
WELL CONTRACTOR CERTIF CATION #: 3
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 LOCATIO . (Show sketch of the location below)
Near//est Town: P ' `� S 7 e/L County:..
11
--Ael o� ?s / / �� a, , , ,, , N„ 1 DRILLING LOG DEPTH
(Road Name and /Nupbers, Community, or a�uu,.,�, ,, a••� -- Formation Description
From To
3. OWNER /7 ! ✓!/s!C/ W �R s ---
Address IC 2 2 s
tatleutor ou a o. S
City or Town Stale Zip Cade
4. DATE DRILLED 'Oo2 "00
5. TOTAL DEPTH �G S
6. CUTTINGS COLLECTED YES W 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 12C t8 METHOD OF TEST
10. YIELD (g (gpm):
11. WATER ZONES (depth):
12. CHLORINATION:
13. CASING:
,' S . Amount -� If additional space is needed use back of form
Type -
Depth �-�7
Walt Thickness
Di me er or Weight/Ft. material
s r, C
From
To _L Ft.
- - -A— 12ia
From—
To Ft.
From
To Ft.
— ------
14. GROUT:
Depth,)0 Ft.
MaterialMelhod
-aR
From
To
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 CON t; t
CONSTRUCTION STANDARDS, AND THAT A COP O THI
FSerlal
R OFFICE USE ONLY,..
ad No:uivin
No.
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
IN ACCJASEN
CE WITH 15A NCAC 2C, WELL
�PROVIDED TO THE WELL OWNER.
p.. A. 914 CONSTRUCTI THE WELL DATE
/a a , ality, Groundwater Section within 30 days
R n GWl 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:
WELL CONTRACTOR CERTIFICATION #:, a Y3
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (check Applicable Box): Residentlall t Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION- (Show sketch of the location below) �(� C /�
Ne st Town: _i�e & jl oe , (C �C � County: /J
fl t/
� �.Y` �'J t i I e DEPTH
(Road Name nd Numbers, co''m//munity, or Subdivision and Lot No.) DRILLING LOG Formation Description
3. OWNEA ��12Rr'ca N6� we �° �Soase 10� From �� / J
,niiwD_ /LD'
Address
ree or ou a o.
City or Town Stale Zip Code 3 aas
4. DATE DRILLED
5. TOTAL DEPTH
—
6. CUTTINGS COLLECTED YES §�J NO[I
7. DOES WELL REPLACE EXISTING WELL? YES[] NO�
8. STATIC WATER LEVEL Below Top of Casing: FT.
(Use '+' II Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface*
*Top of casing terminated at/or below land surface require, a variance in accor-
dance with 15A NCAC 2C.0jis
10. YIELD (gpm): METHOD OF TEST
11. WATER ZONES (depth):
12. CHLORINATION:
13. CASING:
Type S Amount It additional space is needed use back of form
Wall Thickness
Depth D1amteter or WeighUFt. Malaria!
From To Ft•----�- s i
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
Frome To Ft. e t?
From To Ft. -
15_ SCREEN:
Depth Diameter Slot Size
From To Ft In.
From To Ft.
From To Ft.
16. SAND/GRAVEL PACK:
In.
Material
In.
In. —
in. In. --
Depth Size
From To F►,
From To Ft.
17. REMARKS:
Material
LOCATION SKETCH
(Show direction and distance from at least two Stale
Roads, or other map reference points)
v
v ZE
oC'3
f o Ln
=rn
cn
.. rn;;u
o'
x
I DO HEREBY CERTIFY THAT THIS WELL WAS CONS RUCTED iN ACCOR NCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COP THIS REC HAS EEN PROVIDED TO THE WELL OWNER. /
FOR OFFICE USE ONLY DATE
UCTI
tl
Quad No: 16 ATUR ON CONSTRHE WELL
bbr '�orinet 0(lylog5l r uattly, Groundwater Section within 3l) days GWt REV. 12199
Serial No. lr U
JUN ? 8 2000

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]
� ,S' �� .�2s �.Sa7✓
WELL CONSTRUCTION RECORD WELL CONTRACTORLL .CERTI CATION 0: 02/3l/
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (check Applicable Box): Residentia Municipal [� Industrial ❑ Agricultural ❑ Monitoring ❑
m Water Injection j Other If Other, List Use:
Recovery ❑ Heat Pump❑
2. WELL LOCATION: (Show ketch of the location below) /�IG�CD�u OPT
Nearest Town: S ti County:
DEPTH
(Road Name and Numbers, mmur Ity, or Subdiviton an Lot N.qq DRILLING LOG From ToFormation Description
/
3. OWNER L,G�L �k/(cSC / D!/C2 �C�'Od/tr
Address L—
ree or ou a o.
City or Town State Zip Code ^- / Q�— 9le , F
4. DATE DRILLED o2'15'62
S. TOTAL DEPTH ar
6. CUTTINGS COLLECTED YES O 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 1SA NCAC 2C.01)8
10. YIELD (gpm): METHOD OF TEST
11. WATER ZONES (depth):
12. CHLORINATION:
13. CASING:
Type 4 %�Amount If additional space Is needed use back of form
Depth / D rr}e)er
From �� —To — --�— Ft. j— --
From To Ft.
From To Ft.
14 GROUT:
LOCATION SKETCH
Wall Thickness
dr Weight/Ft. Mated I (Show direction and distance from at least two State
Roads, or other map reference points)
Depth Material Method
From _� To op Ft.�.�
From To Ft.
15. SCREEN:
Depth Diameter Slot Size AMaterial
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:
100 HEREBY CERTIFY THAT THIS WELL WAS
CONSTRUCTION STANDARDS, AND THAT A C
FOR OFFICE USE ONLY
Ouad No:
Sedal No.
Material
ON RUCTED IN nc
THI RE H
ATURE FPERSON
al CDif'toI 11lter`ir,
�rtttand�vater Secfiirn
he4nlie t*o;;fficlq,
O
C
I
N
27r
Cttl
1
om
cz
r�
orn
- r-n
y0
�n
CVi:z
h
2
WITH 15A NCAC 2C, WELL
PROVIDED TO THE WELL OWNER.
CTIN ELL DATE
Hater 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:
WELL CONTRACTOR CERTIFICATION
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (check Applicable aox): Residentiali'C Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other [] if Other, List Use:
2. WELL LOCATION w sket It of the location below) .1-1 �
Neare own: County: ((��
(Road ame and Numbers, C munil , or Subdivision�and Lot No. DRILLING LOG
DEPTH
3. OWNER b YC� rli --rA From To Formation Descri tton
Address L f/
ree or ou a o.
City or Town State Zip Code
4. DATE DRILLED-�
5. TOTAL DEPTH 6
6. CUTTINGS COLLECTED YES ® NOD
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): METHOD OF TEST
11. WATER ZONES (depth):
12. CHLORINATION: Type n O Amount If additional space is needed use back of form
13. CASING:
LOCATION SKETCH
Wall Thickness
Depth D/iiam�----
eter or�Weight/Ft. Material I � (Show direction and distance from at least two State
From j —To �-y Ft. . -Lam - Roads, or other map reference points) o
From To Ft. —
From To Ft
14. GROUT: c�
Depth Material Method r^ � o—
a <
From U To oZ Ft. el No
From To Ft. - z• rn�
15. SCREEN: �M
Depth Diameter Slot Slze ` -Material
u> z
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 b0 HEREBY CERTIFY THAT THIS WELL WAS CONS CTED IN ACC DANCE WITH 1SA NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COP HI RECgF� A BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY DATE
Ouad No: b.S ,ARE F�PERSON CONSTRUCTI E WELL
Submit o Igi 3 DIv)�,long w ter (�uatljy Groundwater Section Within 3l) days GW i REV. 12/99
Serial No. L; U
kAi 2 U:' :a()�0
Crnundd ati Se llon
cash wiile Res ic,x •
-1 . t€fry

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]
C/
WELL CONSTRUCTION RECORD ELL CONTRACTOR:
WELL CONTRACTOR CERTIFI ON #: C2 y3�
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential d— Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water injection ❑ Other 0 If Other, List Use:
2. WELL LOCATION• /S�h, o,� ketch of the location below)
��
✓, J�� C5rxi�
�tCCJJ
Nearest T wn: `-" -eZ County:
fA1 �
(Road Nam and Numbers. Community r Su division and Lot No.)
DEPTH
DRILLING_ LOG Formation Description
70 rml}(Je2eRQ�J
3. OWNER _ �° Z'✓{��/
From /
Address `
ree or ou 9 0.
City or Town Stale Zip Code
-� -Oa -0 D
O2 6,57
4. DATE DRILLED
TOTAL DEPTH
5.
6. CUTTINGS COLLECTED YES V� NOD
DOES WELL REPLACE EXISTING WELL? YES ❑ NO
7.
8. STATIC WATER LEVEL Below Top of Casing: FT.
(use -+- it Above Top of Casing)
I
9.` TOP OF CASING IS FT. Above Land Surface'
'Top of casing terminated atior below land surface requires a variance in accor-
dance with 15A NCAC 2C.0118
10. YIELD (gpm): INMETHOD OF TEST
11. WATER ZONES (depth):
12. CHLORINATION:
13. CASING:
Type 115 Amount It additional space is needed use back of form
Wall Thickness
Depth p / D m ler or Weight/Ft. M edal
From_ J_To — e4— Ft. 'a �
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From __,V_ To --sue— Ft.
From —To Ft. -----
15. SCREEN:
Depth Diameter Slot Size ` •lvlaterial
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:
I DO HEREBY CERTIFY THAT THIS WELL WAS
CONSTRUCTION STANDARDS, AND THAT A C
FOR OFFICE USE ONLY
Quad No:
Serial No.
Material
IN
LOCATION SKETCH
(Show direction and distance from at least two State
M6
Roads, or other map reference points)
a.
� h
0
�q
�
rn �
�v
r
y
Clll
4
2
OFPERSON
)ANCE WITH 15A NCAC 2C. WELL
BEEN PROVIDED TO THE WELL OWNER. ` O
—�
�CTINGTHGWELL DATE
Groundwater Section within 30 days
GW1. REV. 12/99
r 6 2000
tlltlntiwater Sec';! m
It..4,.u.;?i�� :3oiiinnui f}fffC;�

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section w 3 A
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]ACTOR
`� 1
WELL CONSTRUCTION RECORD WELL
CONTR
CONTRACTOR. CERTIFICATION #:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable sox): Residential LYJ Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other M if Other, List Use:
2. WELL LOCATInnONI: (Show sketch of the location below) Q �� e0rn�
Nearest Town: /"`S "�� r (� County:
Old s— DRILLING LOG DEPTH
(Road Name Numbers. nity, or subdivision and Lot No.) Formation Description
3. OWNER From To
Address •$
tree or u e
t�_
City or Town State Zap COS
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.
(use'+' p Above Top of Casing) CD9. TOP OF CASING IS FT. Above Land Surface*
'Top of casing terminated at/or below land surface requires •variance In accor-
dance with 15A NCAC 2C o118
10. YIELD (gpm): METHOD OF TEST L
11. WATER ZONES (depth):
12. CHLORINATION: Type Amount If additional space Is needed use back of torrri_
13: CASING: �j(,( Qul yip 6iLS� ' LOCATION SKI
J l wall Thickness
h Depth� • D�'.,�t tt{e'r or WeighVFt. terial (Show direction and distance (rtxn at least two Slate _•_
From- To �]u--- Ft•- Roads, or other map reference points) O
From-- To___._— Ft.—._._— `7`Ue- rl h;- ow �r�2)2✓Jr►° �d�
Ft. i0 m be.
From-------Tc----- 1 q ( W�tI ! YL B� ('
14. GROUT: I.OYW11 i G(-S� ktlJ��rdS o
Depth 0 rp 1 Method
G 0`Lrl V
From �— To Ft. ff 2i'jiA G�e c ri q((� 0(L
From To Ft.
15. SCREEN: 0Id I� ishop Farm '
Depth Diameter Slot Size Material r� I �° Wit
From To Ft in. in. To Ft. In. r Ir�i'L POLsS 912.
From f�,rl_ ./ f�
In. d- a- 6r©wn'Qri (:ti 1ST.
______. ����
From To Ft. in. in. �& I Up 6112-r
16. SAND/GRAVEL PACK: W�,u
Depth Size Material
Cbf'LS�Y'l.�G� On 0n
From To r'
From _.._ To_— Ft.
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS THFL WAS TH CONSTRUCTED RECORD HAS BEENEPROVIDED TO THE WELL OWNER.
CONSTRUCTION STANDARDS, AND A A COPY O
FOR OFFICE USE ONLY DATE
Quad No: SIGNATURE OF PERSON CONSTRUCTING THE WELL
Submit original to Division of Water Ouality, Groundwater Section within 30 days GW1 REV. 12199
Serial No.

NT E 1-' R P UI-9.P (Gc",<'_j . a' i', a'a/ I
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
216035.
1636 Mail Service Center . Raleigh, N.C. 27699-1636 Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR.
WELL CONTRACTOR CERTIFICATI N If:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): ResidentialR Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATIOI,4:.,(Show sl tch of the location below) -9
Nearest Town: � t 1 q Q, — County: JJJJ
Chu`► n DRILLING LOG DEPTH
(Road Name and Numbers, Community. o� Subdivision and Lot No.) Formation Description
3. OWNER . 'r5 L,M� C' �(111 f e' From To
Address K
tree or,Router u e o. �
J" to Z___------
City or Town State Zip Code
r_)
4. DATE DRILLED
5. TOTAL DEPTH 45
6. CUTTINGS COLLECTED YES ❑ NON]
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
c7) c c'
B. STATIC WATER LEVEL Below Top of Casing: FT.
Iv
(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 varlana in accor-
dance with 15A NCAC 2C .0118 T► V1 lr��
10. YIELD (gpm): �? METHOD OF TEST
11. WATER ZONES (depth):
12. CHLORINATION: Type Amount if additional space is needed use back of form
13. CASING: jn.Sl'�' LOCATION SKETCH
J Wall Thickness
Depth �D,'`aMlar or W$= to aI (Show direction and distance from at least two State
S,L To Ft.
-1,1 IN Roads, or other map reference points) (� �
From // ''rr,, r l' . 7* �{-p r�C%ILL fin
From To Ft. (0't +0 left on J''I(..0 I �j
From —To Ft. ---�-- r ( Kt �j Y i uh'
14. GROUT: �� � - Il�li�l-
Depth Material Method �nA ro 0 n� � L(y t'�0.1n) 00 ff I
aSE
From 0 To .Ft..��i� — f • OGk . �-0
From To .—.— Ft. �©� l Cl �
15. SCREEN: pit- r� t"-•t '�"' "��
Depth Diameter Slot Size Material '50— ( is
From To Ft in. in. �Ql-1 Lam'" _
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 DWTHAT ROPY OTFRUCTRDCORD HAS BEENACCORDANCE
PROVIDE O THE WELL OWNER.
CONSTRUCTION STANDARDS, PIN ,
6
FOR OFFICE USE ONLY D E
SIGNATURE OF PER N CONSTRUCTING E WELL
Quad No:
r toriginal to Division of water Quality, Groundwater Section within 30 days GW,1 REV. 12/"
Serial 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 [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: f
WELL CONTRACTOR CER (CATION #: t•
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential Q_�Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below) Q
Nearest Town: County:
(Road Name and Numbers, Community, or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER/G(►'c3Y�^' Zr� — From To Formation Description
Address
(Street or Houle o. (•/ " ('�
it v ervu.L� Ill z 2 b'75 Z
City or Town state Zip Code �UU t`o�Jr
4. DATE DRILLED Z�tx�
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑ NO[�
7. DOES WELL REPLACE EXISTING WELL? YES[_] NO[PI-
8. STATIC WATER LEVEL Below Top of Casing: 2o FT.
(Use '+' if Above Top of Casing)
9. TOP OF CASING ISFT. Above Land Surface'
*Top of casing terminated atfor below land surface requires a variance In accor-
dance with 15A NCAC 2C .01 B
10. YIELD (gpm): -5 METHOD OF TEST,5e,,-WJ
11. WATER ZONES (depth): �2 • ^ G 2CX)
� , ,i, 3G0
12. CHLORINATION: Type - Amount "�`"0 If additional space is needed use back of form
13. CASING:
Wall Thickness
Depth Diameter or Weight/Ft. �Material
p
From�j To Ft.
From—+ To �� Ft. Z --_
From To Ft.
14. GROUT:
Depth Material Method .
From To Ft. -�
From To 2 0 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.
I DO HEREBY CERTIFY THAT THIS WELL WAS
CONSTRUCTION STANDAW)2 6WTHAT A C
FOR OFFICE USE
Quad No:
Serial No.
2
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
�_/ . elv-1
RUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
THIS REC_0EtD HAS BEEN PROVIDED TO THE WELL OWNER.
OF POSON CONSTRUCTING THE WELL DATE
of Water Quality, Groundwater Section Within 30 days
GW-1 REV. 12/99

North Carolina - Department of Environment, Health, and Natural Resources
Division of Environmental Management - Groundwater Section
P.O. Box 29535 - Raleigh, N.C. 27626-0535
Phone [phone]
QUAD. NO.' SERIALNO..=ram:-��
Lat. tong:
Minor Basin
WELL CONSTRUCTION RECORD Basin Code
Header Ent
DRILLING CONTRACTOR:
p
STATE WELL CONSTRUCTION
DRILLER REGISTRATION NUMBER: 106 PERMIT NUMBER:
1. WELL LOCAT)Q, (ho sketch of the location below)
Nearest Town: County:
daz�wf :,el
(Road, Community, or Subdivi ion and Lot No.) DEPTH DRILLING LOG
2. OWNER ��, �^�-�- From To Formation Description
ADDRESS
(Street or Route No.)
A.) c ZZ / -
City or Town State Zip Code
3. DATE DRILLEDaL; -W . USE OF WELL
4. TOTAL DEPTH Z30
5. CUTTINGS COLLECTED YES ❑ NOB�r'
6. DOES WELL REPLACE EXISTING WELL? YES NOE4] --
7. STATIC WATER LEVEL Below Top of Casing: /&Y,) FT.
(Use "+" if Above Top of Casing)
S. TOP OF CASING IS FT. Above Land Surface'
• Casing Terminated atlor below land surface Is Illegal unless a variance Is Issued
In accordance with 15A NCAC 2C .0118
9. YIELD (gpm): Z METHOD OF TEST --
10: WATER ZONES (depth): P!V e4 ►
orr,
rV
��
r,
C�
cn
�.
C
0
ZC
11. CHLORINATION: Type Amount If additional space is needed use back of form
12. CASING:
Wail Thickness
Depth Diameter or Weight/Ft. Material
From To Ft.
From To Ft.- © I . -
From To Ft.
13. GROUT:
Depth Material Method
From To Ft.
From V_ To ZO— 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 Size Material
From To Ft.
From To Ft.
16. REMARKS:
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference po'nt)
THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
7ARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.

North Carolina - Department of Environment, Health, and Natural Resources
Division of Environmental Management - Groundwater Section
P.O. Box 29535 - Raleigh, N.C. 27626-0535
Phone [phone]
WELL CONSTRUCTION RECORD
DRILLING CONTRACTOR:
DRILLER REGISTRATION N MBER: % 0 C %
FOR dOFICI: USE ONLYr'� e+:' ,: r
s.�
QUAD. NO..-*
Minor Basin
Basin Code ' •"a. �.: i. .:i. .`.a.•::�y,eir'� µxu.y,
Header krit.
STATE WELL CONSTRUCTION
PERMIT NUMBER:
1. WELL LOCATION (Sh w.�ketch of the location below) A4
/J
Nearest Town: County: —
(Road, Comrrluni .:br Subdivision q9d Lo o.)
DEPTH DRILLING LOG
2. OWNER / .! ' a %t C, rC, J
From To Formation Description
A D DRfi S,S
(Street o`{ Porte No.)
All J) . G
City or Town ., State Zp' Code
7 y
3. DATE DRILLED USE OF WELL
4. TOTAL DEPTH 2
5. CUTTINGS COLLECTED YES ❑ NO]''�
6. DOES WELL REPLACE EXISTING WELL? YES NO�-
7. STATIC WATER LEVEL Below Top of Casing: FT.,,
- (Use "+" if Above Top of Casing) .y
8. TOP OF CASING IS FT. Above Land SEiHace•
• Casing Terminated at/or below land surface Is Illegal unless a variance Is Issued
In accordance with 15A`CAC 2C .0118 / r
`
9. YIELD (gpm): MET�-IOD OF TE�
D '
�rn l�
C_.-
10: WATER ZONES (depth): ti�
-a-_ �
M
11. CHLORINATION: Type ir�(��1t;'Amount !,/Gy
If additional space is needed use back q orm:�
12. CASING:
--r
_�—
LOCATION SKETCH
Wall Thickness
Depth Diameter or Weight/Ft. Material
rTr
(Show direction and distance from at leasj�&Oo Ste
From To Ft.10_),.
a =�
Roads, or other map reference points) z
From To Ft.
From
To Ft.
13. GROUT:
Depth
Material
Method
From
From
To Ft.
To � Ft.
2.
(IV /t k"
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 Size
From To Ft.
From To Ft.
16. REMARKS:
ABiAR:
CONSTRUCTION S
FEB 10 2000
Material
~' l AC(116.
T THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
7S, AND THAT A COPY OF THI��f. jRECORD HAS BEEN PROVIDED TO THE WELL OWNER.
SIGNATURE OF CONTRACT6 OR AGENT
Rnhmif nrW-1 1n M.AA— of �� n.nunlel W
PATE

North Carolina • Department of Environment, Health, and Natural Resources
Division of Environmental Management - Groundwater Section
P.O. Box 29535 - Raleigh, N.C. 27626-0535
Phone [phone]
WELL CONSTRUCTION RECORD
DRILLING CONTRACTOR:
DRILLER REGISTRATION NUN BER'_&
"
FOR &Fic> USE ONLY:: s
•'`)
QUAD. NO,
SERIAL NO.
Lat
Lonfi.' FtV +vw%.r
Minor Basin
Basin Code
Header ant
STATE WELL CONSTRUCTION
PERMIT NUMBER:
1. WELL LOCATION:: (Show,�, sketch of the location below)
Nearest Town: —�— County:
64, a
(Road, Communi r bdi • ion an obNo.) DEPTH DRILLING LOG
2. OWNER From ,To Formation Description
ADDRESS
(Street or to No.) n� t
lV
City or Town State Zip Code
y f✓
3. DATE DRILLED r� USE OF WELL
4. TOTAL DEPTH
5. CUTTINGS COLLECTED YES ❑ N01 —
6. DOES WELL REPLACE EXISTING WELL? YES NOQ/r _
7. STATIC WATER LEVEL Below Top of Casing: /,5-0 - FT.,
(Use "+' if Above Top of Casing) 3 q
B. TOP OF CASING IS�_ FT. Above Land Sufface'
• Casing Terminated at/or below land surface Is Illegal unless a variance Is Issued u7
In accordance with 15A NCAC 2C .0118 f�'D
9. YIELD (gpm):1— METHOD OF TEST 04i//<
10: WATER ZONES (depth): 12 !.�,Am 41M z
11. CHLORINATION: Type Amount If additional space is needed use back of form
12. CASING:
Wall Thickness
Depth Diameter or Weight/Ft. Material
From To Ft. - r
� From ® To Ft.
From - To Ft.
13. GROUT:
Depth Material Method
From To Ft.
From 19 To Ft.
14. SCREEN:
Depth Diameter Slot Size
From To Ft in.
From To
From To
Ft, In.
Ft. in.
.15. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To Ft.
16. REMARKS:
CONSTRUCTION ST
FEB 1 0 2000
Material
in.
in.
in.
Material
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
NA
,T THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
DS, AND, THAT A COPY OF THjq RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
V. 9/91
SIGNATURE OF CONT�AC OR AGENT PATE
Submit oricinal to Divis n of Mironmental Management and copy to well owner.

North Carolina - Department of Environment. Health, and Natural Resources FOR 8PR'd : USE ONE
Division of Environmental Management - Groundwater Section
P.O. Box 29535 Raleigh, N.C. 27626 0535 QUAD. NO.: + • • SERIAL NO.
Phone [phone] LatR�'"4"^
":.w:.;::....,.
Minor Basin
WELL CONSTRUCTION RECORD Basin Code
DRILLING CONTRACTOR: r�ylo �-1 Header Lnt
+I�.-
,..— STATE WELL CONSTRUCTION
DRILLER REGISTRATION NUMBER: PERMIT NUMBER:
1. WELL LOCATI (S/ow sketch of the location below)
Nearest Town: �� County:
(Road, Community, or Subdivisi Irp and Lot No.)
DEPTH
DRILLING LOG
2. OWNER ��-%
From To
Formation Description
ADDRESS
(Street or Route No.) fn
_ , �_
t> -it
City or Town Sta a Zip Code
3. DATE DRILLED -401 USE OF WELL 413b
4. TOTAL DEPTH 32S'
5. CUTTINGS COLLECTED YES ❑ NO[�
6. DOES WELL REPLACE EXISTING WELL? YES NO�
a
7. STATIC WATER LEVEL Below Top of Casing: 100 FT.
cam,
(Use '+' if Above Top of Casing)
'o' cm-*)
8. TOP OF CASING IS`L_ FT. Above Land Sutface'
N '
' Casing Terminated at/or below land surface Is Illegal unless a variance Is Issued
q�
In accordance with 15A NCAC 2C :01IS
9. YIELD (gpm): METHOD OF TEST lA• 1
p' M
�c
10: WATER ZONES (depth): ggpM & 2�'°
a
C..
11. CHLORINATION: Type Amount
If additional space is needed usa bac of Prm
12. CASING:
Wall Thickness
Depth Diameter or Weight/Ft. Material
From To Ft.
From To Ft. -
From To Ft.
13. GROUT:
Depth Material Method
From To Ft. f
From __6 To '20 Ft. �
14. SCREEN:
Depth Diameter Slot Size Material
From
To Ft in. _
From -
To Ft. in. _
From
To Ft. in. _
15. SAND/GRAVEL PACK:
Depth Size
From
To Ft.
From
To Ft.
16. REMARKS:
in.
in.
in.
Material
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
cpp
a / 16
t
` 150 'I"- �E .Y.,.. ;ERTIFz tTHAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STA' NDAfRDS, AND. THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FEB 10 2000 �
f:�ct�trlE�attr S�c�i�n,.
Ash
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North Carolina - Department of Environment, Health, and Natural Resources
Division of Environmental Management - Groundwater Section
P.O. Box 29535 - Raleigh, N.C. 27626-0535
Phone [phone]
FOR ditidi: USE ONL r
QUAD. NO.
Minor Basin -1:
WELL CONSTRUCTION RECORD Basin Code x...'
DRILLING CONTRACTOR: Headertnt.• '-fr'-�::'
tc STATE WELL CONSTRUCTION
DRILLER REGISTRATION ABER: 10( 7 PERMIT NUMBER:
1. WELL LOCATION: (Show sketch of the location below)
Nearest Town: County:
(Road, CommuAity, r on and Lot o.)
`
DEPTH DRILLING LOG
2. OWNER _ ; {� , ��
From To Formation Description
ADDRESS �-
(Street or Route No.)
,, 7 4-
City or Town State Zip Code
3. DATE DRILLED USE OF WELL
e
4: TOTAL DEPTH
5. CUTTINGS COLLECTED YES ❑ NO[[, .--
6. DOES WELL REPLACE EXISTING WELL? YES NOO_
7. STATIC WATER LEVEL Below Top of Casing: Zo FT.�
c3
(Use "+" if Above Top of Casing)
"'=
8. TOP OF CASING IS FT. Above Land Sdfface'
rn = -�
• Casing Terminated at/or below land surface is illegal unless a variance is Issued�
'
In accordance with 15A NCAC 2C .0118
9. YIELD (gpm):1—METHOD OF TEST
c
o
10 WATER ZONES (depth):
11. CHLORINATION: Type Amount
If additional space is needed use backof forW5
12. CASING:
r
o
Wall Thickness
LOCATION SKETCH z
Depth Diameter or Weight/Ft. Material (Show direction and distance from at least two State
From To Ft.
Roads, or other map reference points)
From To Ft. —L-(14r—
From To Ft. d� �✓
13. GROUT:
Depth Material Method
J�
From To Ft. 4
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 Size Material
From To Ft.
From To Ft.
" jLSEP
EI3YTHAT THIS WELL WAS' CONSTRUCTED IN ACCORDANCE WITH 15A NCAC2C,WELL
UCTION STANDARDS, AND THAT A COPY OF THIS R CORD HAS BEEN PROVIDED TO THE WELL OWNER.
Croundwate- Sjct,.;n
Asheville Re�!o.�al Office SIGNATURE OF CONT CTOR AGENT DATE
GW-1 REV. 9141 .. e..w...:...._.__, ._ n:... .. .� e.... , ,.. ,...., a .. .. .a ,...