Well Construction Records Buncombe 4 CY2000

North Cnrolina • Dapmtrnnni of Envirmunrint, Health, And Nnlurnl fle$ource9 ~1
division Environrttnnlnf Mnnagnrnnnt Groundwntar Section �On t7FFiCE USE ONLY
2
'I of •
MAD. itt).
9SnIALNO. '>
I P.O. E3ox ?.9535 • tlnlrtlglt, N.C. ?_7628.0535 ,.
1nt. Long.
r10 I
Mona [phone] __... _
Minor Pn!ih
CONS Tf1UC TION RECOr1D nanirt rnrfn
lWELL _
1 DRILLING CONE f1ACTOti. 4 ttenrtnr Fat.- -
S1A1E WELL COflSfltUC110tJ
t)W-t Ent
DRILLER RE(;ISTr1A11U11 MMA[3rR: _C5-q rEnmIT-MUMInEt3:
1. WELL LOCH i ION: (Show Sketch of ilia location below)
Nearest Town: — County: -----._....__
(nond. Cotmiu ty, or Sul divislon riin�d�Loi No.) UEi' I I I
_DRILLING LOG.
2. OWNER __ (L. / From to
Formedon Description
ADDRESS
(Stroot or noute tJo.)
City or town Slnle TTZip Code
3. DATE Driil.l_m USE OF WELL
4. TOTAL DE P T I i
5. CUTTINGS COLLECT F:D YES ❑ NO[_✓f
c
6. DOES WELL f1EI'l_ACE EXISTING WELL? YES U NOJO
7. STATIC WATEn LEVEL Below TOP of Casing: �Q FT.
--►�,: --cr''
(Use '+" it Above Top oI Cnsing)
FT. Above Land Surface"
-{�
S. TOP OF CASING IS
• Casing T*rminaled wor bolow Innd surince is Illegal unless a variance Is Issued
In accordance rrllh 15A NCAC 2r .0118
.. m
9. YIELD (g f)ln): '�f-.Q_— ME-[ t iOD OF TEST —)(2t---- - -
-,
egs
WATER ZONES (depth): -- ---
z
11. C►TLORINA-TIOPJ:
12. CASING:
Type RIM Amouttl � II nddilionnl epncn is ngndnd usn back of form
Depth Lihninter
From- 19 - To Ft.
From To
From io --- Ft.
13. GROUT:
alerlal lhod
[)Pplh
From Q -to �rl.
From _._—_ To
K SCREEN:
r)rf)ill Dlanteler Slot Size
FromFrom --'To
From _._.__ -T o __-_- .— F1. In.-----
15. SAND/GiIAVEi_ i'ACK:
Depth Size
From
From
16. REMARKS:
Materinl
Material
L _OCA ION SKETCH
Wall thickness
or Weight/Ft. Material (Show direction and distance irorn at least two State
eiv ia5 AXLS 1Z Roads, or nlltnr nrnp reference points)
DO NE Y {�arri� If �YY��, iIIAT i111r WELL WAS COiJS1nlJCiEb It nD I1A D FE1iI WI Ivt) U 10 7.11E....WEI L OWNEn.
CONST r tUPf hJt}/�fit34, )l'�10.111AT A COPY OF TI ITS nECOr1U 1IAS r)EEtI n�)a ,rtt r e s.
t -
SlrstlATUr1F or C)tltriACT onAr.Nfr DA1E
aWt nEV. 9 i rottndwater Section Submit original to Divlelon 01 Errvironrnnntal t.tari�q^m^nt and c^py to wall owner.
SchaviIto RAOinnal Office

North 13wellon. Onpnrlrnnnl of Envlronrnord, 110,11111, And NAlurnl ►lesource9 ~
ran OFFICE USE ONLY r7 ►1 7
Dlvi�r , of Environntnntil Mnnngnmant • Groundwifat Secllon � f .L .
c71lAU. f Ir ). _ 6ERIAL fJo. - �' I
P.O. Box 29535 • Ilnlnigh, N.C. 21626.0533------- —
rhone [phone] tnt _._......__�_ Lorq. no
Minor tti^in
WELL CONSTPUCrION hEcorlD Raalnrnffn._
DITILLIN` J011111ACTOill - Ilondrtr Frrt.----
STA1E WELL COt1SIHOC 110N
brut ` _n nEGISTnA110f1 NUMI1fm: L1UM11Fr1:
VVELL LOCA f ION• S low Sketch offilp location below)
Nearest Town: __ _ County: -------- - ---
(nond, Conttnuni or SuMivlsion nr Lo1 N ) —
2. OWNEfl
ADD Ess_-----.-
• (^bent or ou a rJo.)
City or 1 avert Slaln zip Carlo
3. DATE Df111_I.F.D) 346' 0 d USE orWELL
4. TOTAL DEr'1II _
5. CUTTINGS COLLFC rFD YES(_] NOL� _
6. DOES WE=I_L nEr'I_A(,E EXISIILJC; WELL? YES NO10
7. STATIC WATER LEVEL Below Top of Casing: !�_ FT.
(Use •f• It Above Top of C1019)
8. TOP OF CASING IS __-_._.�___-- Fr. Above Laid Surface"
' Casing Terrnlnnled Mint- botow Inttd sutince is Illegal unless a vnrience Is issued
M accordance wlth 15A IICAC 2C .01 IA
9. YIELD (gpm):___,i__-_ METIIOD OF TESL
V "VATEn ZONES (depth): _
11. CHLORINATION:
12. CASING:
GW-1 Ent
f)r_I�II I _�r�it.l.rr.��_lgG
From 1 n rormndon Description
— e —
o �
c>
MCI-
1 ype /T Amount I( nr►rliliowil rzpmcn is nandad u9n back of form
Will Thickness
Depth lamnler or WelghUFh alorinl
From O To �� Ft. &,9-5_
From — To-- rt.
From To
13. GROUT:
Unplll Malerlll elhod
From Q 'To A ri. From _-.—_— To _Ft.-------
14. SCriEEPJ:
[7pplh Diatneler Slot Size Malethl
From TO —_-- rl ---- In. In. _ ----
From To ----- rt. —_— fit.
Frorn To __.-• —F1. In. Irt.
15. SAND/GIIAVEI_ PACK:
Depth Size
From To __ H.
From _— To— Ft.
16. F1EMARKS:
;Do 11Enr.- r-IN IIt 1
CONSTwifirs-IMATM
Material
LOW ION SKEJ CHi
(Show clirnclinn ind distance from et least two Slate
110ad3, or olhnr ntap rnlornnce polrtls)
,w 4
t lc F..W)
.��r:�
�`,€ Ff:f f f f3€�Ptfl I S Ia
's
s COtistnuclED Ill ACConDAIMF W1111 15A IIC/AC 2C, WELL
COr,Y OF TI Its nEConD I VAS RFEr,i r w,)VIDFU TO 11 IE WELL OMER.
It
_,
aw-1 nev. 9191
AA
SIGIIIAME- OF Cr iffAClOn on ,Frtr DATE
Submit orighm, to Vivislnn of Errvtronnrontit Ltirilq^rrr�nt ir•1i c^ry to w�A ovrrrer.

North Carolion • Dnpnrtinnnt of Environmoril, hearth, And NAlurnl flA4ouic09 w^ron orrlCE Use ONLY
r� ►j rj
Divislort of EnvirOrtn,nnlnt Mmtngninnnt • Groundwatar Section r)IJAI?, Nrt. 6EtilALfJU.�` t
P.O. [lox 29535 • nnlnigh, N.C. 27626.0531 - - - `
Phone [phone].nt. _., ..., Lonq, no
Minor Pn^•in �—
_W E_LL_ cons i Ruc rlor4 nnCOM Nnln
DRILLING comnACTUlJ� ! _ ilnndnr Fnl_,__ __-- OWi Ent
�J S1ATF.. WELL C01191ftUG11101`4
unILLEn nFGISTnAfION NIIM[1111n: �'���_ __—PEf1Mlf'NUrvinEfl:
WELL LO(.,AIION: (Sit sl;,tch of Ilia lo'cntlort below)
Nearest Town:— ��� . County:
(noad, Comrnuni y,-or S r. 11011011--n;d "No.)
.
2. OWNER - C �t° 1/ ,
ADDRESS
41
(Stroal or flouts fJo.
City or 1 Own Slain Zip Code
1)1_11_1_1 1 _ 011ILLING LUG
rron, to rotmadon Description
3. UATE Dllll_i_f:U UoE OF WELL D ,
4. TOTAL Dr- PI I _
5. CUTTINGS COLLECi I_U YES L_1 NO[V -
6. DOES WELL r1EPLACE EXISTIiJG WELL? YES NOg
7. STATIC WATER LEVEL Below Top of Casing: —j.0 FT. —gym
(Use '#.' it Abovn Top of Casing) N �—
8. TOP OF CASING FT. Above Laid Surface• No m
•Casing 7srminnled eVnr below Innd eurlaca Is Illegal unions s variance Is Issued -' x.• �
in eccordnnca Milt 13A fWAC 701 .0110 M
9. YIELD (gpnl):�_ .---ME fiIOU OF TEST--
�" WATER ZONES (depot): — — —`-- o
11. CNt_ORINAT ION: Type ---.� 4 Amount 3�d�0 II nrl(iiiior,nl "i,acn Is needed OR back of iOrm
12. CASING:
- L.00A i ION _SItEi CN
Wall 1 hicknrms
Df,pth bianinlar or yi ...iq l .. alert 1 (Show dirnriinrimid distance from At least two State
From 10 — Ft. e7 ,/;1 lloads, or oihnt map reference points)
From To —_...----- Ft. -
13. GROUT:
Urpllt Materiel nl_h��r)d��// �Q/h11
From _Q -to A© rI. / �l
From _..--- TO
14. scREErJ:
Unitilt Ulameter Slot Size Material
From Ft �— In. ---In. ____----
From --.To-------r t.------ In- In.
From _ ------ TO ------ --
Ft. In-_--
15. SAND/GiAM-1 PACK: t
L5 4
Depth Size Malerlal
Frotn ---- T ° -- f t - -- ,
_ Ft. l� �t'ir;} Vim'
From —__ to -
16. REMARKS:_ _ — - - --- --
b0 11Enh� 1Cr 11' Y 1.( IA r i1IM WELL WAS CONS i rIUCiEb Irl A C011DAfIC'E Off If 1?tA^f tCAC 7.C, WELL
CONSTi11 I ' .1MAJALZD.S.-ANDTHAT A COPY 01' "f tits nECOnt) I.IA9 E3FEtt r'nC�vIUFU l0 1(1r WELL OWNER.
8lrtf rA1UnF nF Cr ifJACTOn Orl ,r tit DATE
oW1 REV. 1N91 eroundwaTe*Section Submit rnigkmnl to Oivlsion of Frrvlronrn^Aral Plan^q^m^nt and cam► y to w^A t vrr,er.
Asheville Re 'oval Office

~ _ North Carolina • Department of Environment, Health, and Natural Resources -�
Division of Environmental Mnnagnmont • Groundwater Section FOR OFFICE USE ONLY 21273el
P.O. Box 29535 . nnlrtlgh, N.C. 27626.0535 gl1AD. NU, SERIAL NO.
Phone [phone] Lnt Long.
Minor 9a".in
WELL co JsTFlUcttori REconb
Basin Cnr{n
i
DRILLING CONTRACTOR Ilnndor Ent. _ GW 1 Ent
STATE WELL COtISTfiUCTION
DRILLER REGISTRATION NUMIMim PERMIT NUMt3ER:-___
1. WELL LOCATION:** ow skkelc i I lie location below)
Neatest Town: L"rya C/� 77U• County:
(Road, CorrxnuN , or SuM1vislon and Lot No.)
2. OWNER kon/�^--�---
ADDRESS //" '' I ���•�
(Street or Ftoule No:)
City or Town e Slat/�JJZipiCode
3. DATE DRILLEDUSE OF WELL
4. TOTAL DEPTII
5. CUTTINGS COLLECTED YES ❑ NO Fp
6. DOES WELL REPLACE EXISTING WELL? YES (-] NO[2f
7. STATIC WATER LEVEL Below Top of Casing: YA FT.
(Use '+' it Above Top of Casing)
8. TOP OF CASING IS. FT .
Above Laitd Surface'
• Casing Terminnled War bolow lend surface is Illegal unless a variance Is Issued
In accordance with 18A NC C 2C .0119
9. YIELD (gpm):_.- METHOD OF TEST
'I- WATER ZONES (depth):
11. CHLORINATION
12. CASING:
DEP I I I DRILLING LOG
From to Formation Description
c�
c�
rn
N
zm
�rn
_
rn
to as
••
n+
n --
N
o
Type
_ A If acldilionnl ^pace is needed use back of form
Wall Thickness
Qept)1 Diarr
From To �-�--- Ft. /v 26-
ogiMaterial C
��c
From To Ft.
From To Ft.
13. GROUT:
Depth Material
elhod
From To 2 Ft.
From _. To —Ft.
--------=-
14. SCREEN:
Depth Diameter Slot
Size Material
From To Ft in.
In.
From To Ft. in.
In.
".. From To —_— Ft. In.
in. �_----
'` 15. SAND/GRAVEL PACK:
Depth Size
Material
From To Ft.
From To Ft.
—
16. REMARKS:
IDO
CON
GWA REV
LOGY ION SKETCH
(Show dimclion nrrd distance Irom at least two Slate
Flonds, or other map reference points)
�U
VAS CONSTRUCTED IN AdC(
A COPY OF THIS RECOFlQ H
CE WI1I 115A NCAC 2C, WELL
mz­v
vI TO THE WELL OWNER.
i
SIGNATURE OF 14bPJTrtACTOLYOn AGENT
Submh original to rvislon of Errv6onmenlat ttlanagnment nrid cni+y to well owns►•
DATE

..: 2
-
North CArolirta - Dnpnrlrnnnl of Envirommrinl, Health, and Nnlurni nesou►ces E r
Division of Envirommnnial Mmtngnrnont • Ground•Nnier Section OUAb. f Ic). SEFi FOn OFFICE U3r-- ONLY 734
P.O. Dox 29535 - IInlnlgh, N.C. 27626.0535 .-
W.
monn [phone] 1.nt. Long. no
Minor Nn^in
WELL CONSTRUCTION nECOCTD Minhrtenrin _
r
DRILLING CON 111ACTUfI: 1zo(ms, � (_ (londnr Fnl.__� C3W-1 Ent
S I'AT F. WELL CONS 1 I IUC I ION
DRILLEIT REGIsTnA11011 NUMflf_1i:PECiMIT'
1. WELL LOCATIOr. (`'how bel=locatioll below)Nearest Town:Masi — Counly:--
(nond, Corrywni y, or Sulxfivlsiort . d Lot o.) DE I' 1 I I
2. OWNER _�/4> —� From Tn
ADDRESSl t-----NC•—g —
(St(onl or noule No.) p�
City or T own Stall? Zip Coda
3. DATE Dflll_I_ -t) 3�USE OF WELL 1 6
4. TOTAL DEI I 5. CUTTINGS COLLECTED YES [_—] NOL�
6. DOES WELL REPLACE EXISTING WELL? YES F-1 NO[ i/
7. STATIC WATER LEVEL Below Top of Casing: Z to . FT.
(Use '•' If Above Top of Castr+g)
8. TOP OF CASING IS � FT. Above Land Surface"
Casing Torminnled nVor hnlaw Innd murfnce is illegal unless a variance Is Issued
In necordnnco with 1SA ICAC 2C .0110
9. YIELD (gptn):_ .0__ ME-tIIOD OF TEST
WATER ZONES (deplll):
_D111LLING_LOG
rormadon beecriptlon
O
C
� m
M
0
=c
�o
Q
m�
N
--r
z
11. CHLORINATION: Type 1Y'%19r" Amount if nrlrliliorrnl ^•pacn is nondQd u§e back of form
12. CASING:
t.oc;n t iori sl«� ct��
Wall l hlvkrtes!
,(') DP_pth O dlarTlalar or WeighUFt atorinl (Shoal direr inn and [hslnnce from at least two Shale
From To f L —Il roads, or olltar map reference polnls)
From TO — rt.—
From --To---' Ft•
13. GROUT:
Dettlh alerial tllod
From �— 'to o? O rt.
From To
14. SCREEN:
Drtt111 Dimiteter Slot Sizb Malerlrtl
From _1 o
From .__--'ToFrom T o _._._-.--• FI•
15. SAND/GIIAVEL PACK:
Depth Size Material
From To
Froin
16. REMARKS: — - -
DO FIE c} n �dr Y�il �1r:'TIIIR WELL WAS CONS InUCTED Irl ACCOnDAIIc F W1111 15A I1 , 2C, WELL
CONST t Ar.�r,'AND 11AT A COPY OF ?Ells nECOno IIAs iIFFfJ l'FTc)vipt'U;;7o`TI IE WELL OWNER.
SIr�NATunE or M ACTo n nr3Etir MATE
OW1 REV. 9 1 ' �'' Groundwate. $v°Cfin Srrhrnit orig4rnl to lvitlon of Errvirenmentnl r.len�q�m�nt and cnpY to well owner.
Asheville Ileetoral

North Carolina • Dnr, mnnl of Fnv(ronnlAnt, Neallh, ltnd NAlural rlAsoutcAs
Division of r ommnnlnl Mnnngnrnant • Ground-Nnter Section Fon orFICE UM; ONLY 21 2 � A .�
P.' f3ox 29i>.iS • llnlnigh, N.C. 27628-0539 00A0. NU. SEr11ALNO, _ __ _ `_tom I
PhonA [phone] rill _ Lorq. no
Minor rta.n.lrt
NELL COFJSrnUCriOFJ nECOnD Minhrn,rn- __-
;� DnILLING Cl i nIACTUTIl lanrinr Fill.: -______ (3W I EnL
��S,iMF. WN-L CONS inUcr ION
uniLLFt? r_"GISTi ATIOiI Nr1MI3rf1; rj �1 `_ _� pEfiM1T'FlUMf3FI1: t
V .t_L LOCH 11014: (SIN w sketch ottile location below)
,earest Town: e'gac. Courtly: f1.2'Y_T 4e-
(nand, connnunity, or SuMIVIsinn^nd Lot No.) ur_ i' 1 I I
2. OWNER _ 22 4_1 i� ���� From - In
AUDnESS-,aQ _ZaA at
(Sheet or noule No.)
City or iarm Slele Zip code ----� "— -` -
3. DATE Dnii_i_FU -60_ USE OF WELL DOM ,
4. TO1AL UEPTI I .__-___5.__ _ --- - —
5. CUTTINGS COLLECT EU YEs L_] NO[�� _ ---.
5. DOES WELL nEPI_ACE EXISTIIIG WELL? YES NOL-0
7. STATIC WATEn LEVEL Below Top of Casing: rT. _
(IJse 'a' it Above Top of c,101g)
R. TOP OF CASING IS FT. Above Laird Surface" _
' Casing Tsrminnlod suor holow Innd surloce is Illegsl unless a vnrlance Is Issued
in accordrnnco With i5A NCAC 7C .01 to -- —
9. YIELD (gpnl):__,2Q___ ME T I IOU OF TEST
I VMEnZONES((ieptiq:
DRILLING LOG
Formadon description
O
"=
a«
a •c
cj
a,.
rn�
�TTr"
N
o
x
11. CHLORINATION: Type �T Arnounl- II nrldilionnl -pncn 19 nondnd udn back of form
12. CASING:
Wall ildr:kues! LOGAI ION SKETCH
U�pth immnle► or Welght/Ft. .1tolinl^n (Show dirnrlion and di9tinrg from at IAngt two Stale
Froin �-10 35 Ft. 10,a5 1�2' 6 SA` fronds, or ollinr rnsp tolerance points)
Front To — rt.--
From —To-----' Ft.
13. GROUT:
Uepllt Malerinl nlllod `'�''��`�""'�'�' '
From �_ -T o IA-4 _ 1,1 -�MICL
From _.._
To ____
Ft.
14. SCREEN:
Urp111
Uiantelar Slot Size
Material
From —To
From
To
From _ .____
-To __-_.__.-
Ft._ In,
in.
15. SAND/GTTAVEI_ PACK:
=1
Uepth
Size
Male IIif r'
From
To
_ '1(
Froin
To
16. REMARKS:
I D0 11F, 1_M
CONSjrlj?p_j
OW nI-V.9l9I
T If(2/ TT 1AV -i RS
AUG I i. %0i1�ql s `?
4.
7 IIL WAS cot•1Sirlt.iCTED iff AC(,nnbnrl['F-- 1JV1111 15A PICAC 2c, WELL
T A Cor'Y OF liIIS nECono l lAS E)EEtJ rrtovlUED To Tl IE WEI.L owtlEn.
slrrintunF or a Tri4Tnn ,F.r"it onrE 1
1
Suhmil orlg4rn1 to [livhlon or Errvlronn,�nlnl r.1n„ ,n�m�nl '1114 a^ry to wnM owr�r. Ij
G

North Carolina- Department of Environment and Natural Resources . Division of Water Quality . Groundwater Section ►fir O
1636 Mail Servico Center - flaleigh, N.C. 27699.1636-Phone [phone]WELL CON STDUCTION RECORD WELLCONTRACTOR: _
WELL CONTRACTOR CERTIF'ICATIOf a:
STATE WELL CONSTRUCTION PERMITa:
1. WELL USE (Check Applicable cox): Residential G� Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Meat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: f beieh er County:
(Road NamejwdNunibers, Community, or Subdivision and Lot No.)
DRILLING LOG DEPTH
3. OWNER( ��-_��is
From To Formation Description
Address Aft [ y.�
jStreet oar u o�70jT�
"
City or own s State Zip Code
4. DATE DRILLED 03-W
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES C] NO[R�
EXISTING WELL? YES ❑ N04
c�
7. DOES WELL REPLACE
8. STATIC WATER LEVEL Below Top of Casing: Q_ FT.
' -T 71
(Use '+' It Above Top of Casing)
`
9. TOP OF CASING ISFT. Above Land Surface-
•Top of casing terminnind aHor below land surface requires a variance In accor-
dance with 15A iICAC 2C .0118
iJ
10. YIELD (gprn):_ METHOD OF TEST
11. WATER ZONES (depth):
r
12, CHLORINAT ION: Type Amount
If additional space Is needed use back of forte o
13. CASING:
Wall Thickness
Depth Q� fa el�r or el hVFt.
From�To _l1sL__ Ft. `�
From — To Fl.
From To Ft.
14. GROUT:
-LOCATION SKETCH
-Material (Show direction and distance from at least two State
Roads, or other map reference points)
Depth Material N401110d
From _ To 6m�0.
From -—To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
Ca-ne Cree }�
FWcher A C
From ___ To __-- Ft In. in. From l o _._— Ft. —__ _ in. In.
From ___.—To ------Ft. —____ In. In.
16. SAND/GRAVEL PACK:
Depth Size Material
From To _ Ft.
From — To Ft.
W. REMARKS:
I DO HEREBY cm IFY TI IAT TI11S WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS nEC D AS BEEN PROVIDED TO T HE WELL OWNER.
FOR OFFICE USE ONLY DA E
Quad No: S NAT E OF PERSON NSTRUCTINO TIIE WEI.I
_ Submit original to Divislon of Water Quality, Groundwater Section Within 30 days GW i REV. 12/99
Serial No. -

North Carollrta • Dnparlrnnnl or Environrnnnl, health, and Nnlurnl finsourcas S
Division or Fnvirnnnlnnlal Mnnngnrnnnt • Groundw:llnr Secllott FOR OFFICE USE ONLY 212 3 l
6ERIALNO.
P.O. t3ox 2n535 • flnlnigh, N.C. 27620.0518 c]IJAU. NU.
mane [phone] 1 nl __- .. - (_orq. no
tillnor Fla^in _
WELL. CONSTfiUCT'ION nECOrID F1nnlit Cnrin ^ _
Ilencior Frrt.- GW1 EnL
DRILLING CONTRACTOR: _
S1'ATF WELL roNsIfiUCT1ON
DRILLER RFC;ISMA11011 NUME3l_m _ PEfimir NUMt3FR: _- ---___-
WELL LOCATION: (Show sketch nI he location below)
Nearest Town: �� _County: C.rn,
(Bond, Cor rq it y, or St b(Ilvislon and Lot No.) Dr:1' 111 DRILLING LOG
2. OWNER to FormadonDescrip6on
ADDRESS—��� = V —
(Strent or n ule No.)
City or 1 own Stal0tn Zip Code / D a (�
3. DATE DRILLED 3' -UU USE OF WELL
4. TOTAL DEPTH
5. CUTTINGS COLLECTED YES L_] NO _ —
6. DOES WELL REPLACE EXIST INCH WELL? YES NO[� - z„ �`
7. STATIC WATER LEVEL Below Top of Casing: -a� FT• --
�rn
(Use'+" If Abova Top of Cnsing) v'=
6. TOP OF CASIPJG IS —�.-__ FT. Above Ladd Surface"
• Casing Tsrmhrnled sUnr below Innd surface is Illegal unless a varlanco is Issued
In eccordanca with 13A NCAC 2C .0 119
9. YIELD (gprn):----I-O—Mr'TIIOD OF TESr —
' 'NATEIi ZONES (depth):
11. CHLonlNAlIOrJ:
12. CASING:
Tyl)e % Amount S If nrldillonal :pica is nondnd use back of form
Will 1 hlckness
U�lillt Dlnmater orWel lit/Ft Menl�arinl
From10 I b j&— Ft. ?v�
Frorn Jo --
From --To -------- Ft•-
13. GROUT:
Unpllr Maletla� nthod
From -to
From TO-
14. SCREEN:
- _
LOCAI IONSIT-M-1
(Show direcllon and dislanc9 from at least two State
(loads, or miler reap refornnca points)
Aat, nwt
�jz
Ur11lh Dlaltteter slot Size rViatut it
From To
From To ---- Ft.
From----.To-----
'r 15. SAND/GRAVEL PACK:
Depth Size Material I
From to
AUG 1 if TOO
From _____
163. REMARKS:
1 DO 11Erlr E1YCE11iIf Y t)1J1T 1lIlS WFLI Wes cONS{nUCTED III ACC'
OnDAIri &,VUi,{f,l 1AM t rLnr 2C; WFLL
CONSTnU 71ry N S'1AtJDhEIU ..n1JU 11{ATA COr'YOf' THIS nECOnU:IIl1S pFGtl f f1t u1S�F�?t: 1fIF WELL OWNER.
if
-VY -
s.
• Slr?NAiUnF Corri nC non nr:Fltf DATE
3W-1 nEV. 9191 Groundwater Section Submit original Io bivhion of Frtvironrnanlal 1.11119"nnnt nod eery to waM nvrrtar.
Asheville Regional Office

Notlh Cnrollna • Dnrltlo a of Cnvlronr. `tnl, I f", Ilil, And Nnimni rinsoutcos FOn orF ICE t1sE ONLY 2 ►7 A
Dlvislort of Envity rmnntnl Mnnngn;nnnl • Groutxhv�ldr S9cllon OLMU. 1lrt. __ GERIALrI �. (-
P.O. P x 29535 • flnlnlgh, N.C. 27626.0533 1 nt -...- Long. n0
Phono [phone]
htlnnr FTi^in I,
._I_L CONS 1 t1UC 1(Of4 r1ECOr1D
---� Ilonrinr F.nt.__� GW-1 Ent
)BILLING CC' AGJ0R. ----_--.--.....__------
_ SfDSIAIF. WELL C011SIMICTIM4
)BILLER r, ISTfTAriOtl NUMTIErI: _ j _----- rERn11r rruruTn rl:-- - -- __--- �_ _ i
i, WT LO[%ArIOtJ: (SI w sl%etch of Nle locillon below)
rest Town. ----- County:
- UEI'll I DRILLING LUG
(Rood, Conran Im , or Sul,rlrvl?Ion nn Lot No.) Fron, Formedon Oeitln
scr o
• _ _ 1n
2. OWNER
ADDRESS
(ShenI or 11oule f o.) 1--- -
City or T o%*m Slate lip Codo _ N
3. DATE DRII.LF.f) �94100 USE OF WELL �u0 L•- ------!_-
y. M.
4. TOTALDEPIII .-_?CL�------ _ �(
5. CUTTINGS COLLEC 1 EU YES L_� NO(_yJ _ -
WELL? YES- NO9 1
6. DOES WELL r1Fr'L.ACF_ EXISriPI�, FT.
7. STATIC WATER LEVEL Below Top or Casing: 00 N o
(Use 'a' it Above Top of C1019)
8. TOP OF CASING IS—.�`___ FT. Above Laird Surface"
• Caming Terminalod titlor bolow Innd surface le Illegel unlee� a variance le leeued - -
In accordance with M ff AC 2C . TrIIOU OF TEST J'
9. YIELD (gpW):_�--�-
`NATER ZONES (depth):
1^t - AnloUnt II nrlrlilionol^.Irac9 is rt9ndnd uqa back of for-m -
11. CI-ILORINA-IION: Type - - --
12. CASING: LOW Ord SKEI GI-1
Will thickness alorial (Sllow (litertinn and distanc9 born at lanst two Stela
Urplh d irnolor orVJ IghUF
2 Ft C'� rloarls, or n11mr tramp rnlorenc9 points)
From. --Gam---- � O _l.it—
e0l.From
To— rt.— — --- „/
qPW
From - ---- d `�
13. GROUT: M/Ia'le-ral e�l�ho�dv 0 0
_0
From
Ur+rTllT D /�,l�— �1�-'�'�
r o r1. S.rt'� C %�
From To
14. SCREEN:
UrlTlll DlrllTletef Slot Size Malerlrtl
From
—To _f"t In. _ In._-------
- -^ In. Front --- To �.-------
-_ rl. __ ___ In. _---
r
Frorl,
-----
'` 15. SAND/GIIAVFI_ PACK: It" °
ur71I: tb
Ur')�th Size tvlalerfal r
To
rl.
From —
1 G. REMARKS:
1 c tIEn€�j. r�,'I C 1112217 I I 17' IIl`gvlii L W� CORYJOF`TI11S nMc fECO o I V1SIt I nr3EFN f'r1�OVID u 30 it IF WELL OWNER•
CONSTFtI� ) S 'A T }!�
Gw-t nev
ntl owner.
4.rcr
GATE
rliACTOnOn ,Ftir
,uhnlll orlginil to VIvlslon of Frrvlro,amrlril rat mod c^r y to w

North Carolina • Dnpmlrnnnl of Environrnonl, Health, and Nnluril nesourcos y A c�
Fon OFf'ICE USE oIILY e% �G V Division of E:nvhonnm ,,lil Mnnnpnrnnnt • Groundwater Section QUAD. MO. _ _ 6ERIALfJO. �
P.O. 13ox 29535 - Ilnlnigh, N.C. 27628.05,15 1n1. _-_.. , — l.orq. RO I
mono [phone]
Minor Minim
WELL. CONS I(mc-tiON FIECOr1D
dr11LLING CONrfiACT0 11-� tlnndnr Fnl...— aWA EnL
SIATF WELL COIISf110C11014
rmll-LEn REGIRMA11011 famr.rt: 4Z_L-.--_-_—PEfiMiT
WELL LOCAIION: =Shoskelu'llof tti�le, locatlon below)
Nearest Town:�''oA, Counly:
----.--------.--.__..-------_-_-- ----- L)EI'll l _DRILLING LOG
(nand, COITIMn ity, or SutKfivl.nlon a Lot No.)
2. OWNER _- _ — From 1� Formndon description
ADDnESS_OB002____....__..__---
( not or flau►e NO.) 9City or 1
r��
3. DATE Uf ILLE [) USE OF WELL Z2-
4. TOTAL DE f" [ i l .__�_IL__-- ----- -- — o �=
S. CUTTINGS COLLEC I ED YES
6. DOES WELL nEPLACE EXIS[11JU WELL? YESF] N09 C c>T
C o r"1
7. STATIC WATER LEVEL Below Top of Casing: D FT. 7`;
(Use'#." it Abovn Top of Cns619) N CD<
8. TOP OF CASING IS __-.—�__-__ Fr. Above Land Surface"
• Casing TermInntod el/or below Innd surince Is illegal unless a Minn" Is Issued - m
In accordnneo rvllh 15A I AC 20 .0119 Trn
fl u� z
9. YIELD (gpnt):ME it EOD OF TEST -- —
VATER ZONES (depth): - •r~ o
111. CHLORINATION: Type 77 T �T Amount ��e 11 adclilion ,l ^,nacn Is nondnd u4e back of form , - -
12. CASING:
Will Thickness
Depth glameter or V1elghM.
From T o
From -
From
13. GROUT:
L.00.A%)orJ SITICI
atonal (Show dirnclinn Ind dislincn from at loast two Stale
rloads, or oil,nr ina) rolarnnco polnts)
Deplll Malerini rTiI d From too f I.
From —.--To __ Ft.
14. SCREEN:
Urplll Diameter Slot Size Materinl
da,6� R��.
C
From To -- - 1 t ---_
In.
In.
Front ToFrom
_ _---- 10 --- - Ft.—____
° PACK:
15. SAND/GHAVEI_
'Depth
Size
t
From T o
a.
AUG � � ?OC�1
u"
From 10 Ft.
in. REMARKS:
IDOI
CONS
aW-I nEV.
WAS Coris t nUC I ED IN AC,
T A COT'Y or it -us nEconD
2C, 4VF1_L
91 E' _L OWNEM
- _ - -- o.�-__ _
slr.3rIATUn oor-ct Th -ITnon �Frrr oats
Submit original to Divitlort of Frrvlronrn^nlnl r.len,g^m^nt C^ry ar 1 M wnA nwrter.

. North Carolina • nrininnl of E(jv(ronntnnt, Ileallh, And Nniurat ne9ource9 •� �.
Division < rnimsminnlnl Mnrtnpnrrinnt • Ground-Nnlnr Section FOFI OFFICE USE CNiL. .12769
1.). Dox 29535 • nninigh, N.C. 27626.0535 gUAD. tit). sEnIALfJO.
Phone [phone] no
Minor Rmlit
WELL CO14SVIUCTION nECOf1D Minh rn(ln __y
UiiILLiNG oritnACT Caw-1 Ent
r �1 SIATE WELL CONS iiiUCTIUti
bFti(.r 'IEGISTiTATIOrt ttllMM-M! J W _ —_ F'E►1MIT tlUMi7FfT: _ _-__ _ _—_�
1 JELL LOCA T ION: (SI w ,k tch of the locatlon below)
Nearest Town: G .�. 1- 4 .. — County:
(nand, conxnu rit , or Sulwti Islon and Lol No.) UE f' i I I
2. OWNEET
ADDRESS��
(Shoal or floule No.)
_F--_.C
_—_—.[!C of 6.7,�_� S -----
City or 1 own Sinio Zip Carlo
3. DATE Dmu_r r) USE OF WELL . DOM + `♦' � � ���—'
4. TOTAL DEPTI I -__-1/0-0 _ --- —
5. CUTTINGS COLLEC 1 EU YES Uj NOL-V —
6. DOES WELL nEPLACE EXISTING WELL? YES [—1 NOV
7. STATIC WATEn LEVEL Below Top of Casing: --9-6 FT.
(use "�' Ii Above Top of Cnsirrg)
8. TOP OF CASING IS F-T. Above Lntid Surface' —
Ceeing Terrnlnnind nVor bolow Innd mmloce is illegal unless s vndence Is Issued -"
in eccordnnce rvlih 1SA NCAC 4C .0110 —
9. YIELD --- ME T I10'D OF TEST
1f' WATER ZONES (depth): ------
11. CI-ILOIIINAT ION:
12. CASING:
DRILLING LOG
Formadon Descripdon
�6 cs
N •-t
x
Type �l�l 4 Amount If ndditionnl spncn it nnndod use back of form
Froin O
Wall Thickness
Deplit ampler or Weight/Ft jAnlodnf
— T o -o 7 Ft. — - cvk2pas jr"• W
From
To---- rt.--- --
—
_--To__
From ---To---'
' Ft.-
13. GETOUT:
From
Urpllt Materinl
T o Q rI. S.r
nihod
From _...—__
To
K scnEEN:
brpill Dlameler
From —'To --_ _ Ft In.
From To --__-_ Ft.—_-- in.
From --.---'To __.__- — Ft. In.
15. SAND/GiIAVEt- PACK:
Depth Size
From _ To — Ft.
From To Ft.
16. 1`1EMAF1KS:_
1 Do I lE
CONS dM 10
Slot Size Mateilnl
In.
In.
in.
LOCAJ ON SKETCH
(Show direction and distancn from At least two Stale
rloads, or nllrnr nrnp rnlmnnce points) �r
W
Material �� fry 11r1 r
AUG 1 5 2000,
WAS cor,is i nLJC I EQJ Ill
r A Cory or- if tIS rl CC
5A 110,Ac 2C, WELL
ED idiiil= WELL owmn.
U
tl Acmnft.�_
t�i Sic;rintuneoF-cr rirrlr DATE
Qw-i nEV. 9/9 e s Suhndt otig!ttel to UNHInn of Ertvlronrnnnrnl r.ii,1•,q,,rit and c-ry to wn0 owner.
C►olrndwa'e, Section
BchPv;ile Eeeio, dl D '.Ge

0
North Carolina • Depirlmant of Environment, Health, and Natural nesources
~~ _ ^Division of Environmental Mnnagement - Ground'Nater Section
{ P.O. Box 29535 - Rrilelgh, N.C. 27626.0535
Phone [phone]
FOR OFFICE USE ONLY
QUAD. No. GERIAL No. - 212770
d
Let. ---.-... Long. - RO
Minor Eaasirl
WELL CONSTRUCTION REConD MininCndn
Vendor Ent,C3W1 Ent
DRILLING CONTnACT0n � P _
"� T STATE WELL CONSTRUCTION
DRILLER REGISTRATION NUMBEn: SY PEnMIT NUMT3ETi:
1. WELL LOCATIO : (Sllow sketch of the location below) —
Nearest Town:. S'^ -A-W--- County: - ---
(Road, Cownunity, or Subdivi n rind Lot No.) DE I' l I I_
2. OWNER --oQ� 11 From --10
ADDRESS_
(Sheol or Route No.)
/kvzzram`-Q_14/.C. — 4 & � � • - _
City or Town Slate Zip Code
3. DATE DRILL! D,, USE OF WELL �am
4. TOTAL DEPTI I ._-2.--
5. CUTTINGS COLLECTED YES[_] NOEV
6. DOES WELL REPLACE EXISTING WELL? YES n NO[o
7. STATIC WATER LEVEL Below Top of Casing: Z5- FT.
(Use '+" It Above Top of Casing)
S. TOP OF CASING IS _ FT. Above Land Surface"
• Casing TormInnled sUor below lend surfece is illegal unless a variance Is Issued
1n secordnnco with 15A NCAC 2C .0118
9. YIELD (gpm):--- METHOD OF TEST
WATER ZONES (depot):
11. CHLORINATION:
12. CASING:
DRILLING LOG
Formadon Description
ram—
Type 14 %W Amount If additional space is Wended use back of form
Will Thickness
Depth �p D arneler or Welght/Ft.
From � To _L_ L__ Ft. --11 -
From To Ft.
From To Ft. —
13 GROUT
LOCi�710N SKETCH
aterial (Show direction and distance from at least two Stale
(loads, or other map reference points)
g( 16G
Depth Material hod
From To Ft.
From To - Ft.
14. SCREEN:
Depth Diameter Slot Size Material
From To Ft In. in. _----
From To T't. it" In. _�----
r To — Ft. In. In. _ _ ----
From
15. SAND/GRAVEL PACK:
Depth Size
From-
From-
16. REMARKS: -
IDOHE&C CONST
Material
"IIW 3 CONSTRUCTED
I9/li TMr
A COPY OF THIS RE
rr d
NCAC 2C, WELL
TO 1HE WELL OWNER.
GWA REV. 919
r
DATE
SIGNATURE OIgCoNTF1ACTTT1 On AGFNT
Submit original to Division of Environmenlal f.lanagmm�.rd and eni+y to well owner•

North Carolina • Department of Environment, Health, and Nalural nosources -� �., FOR OFFICE USE ONLY9 12 7 7 3
Division of Environmental Managarnant • Groundwater Section QUAD. NO. SERIAL NO.
P.O. Box 29535 - nnhelgh, N.C. 27626.0535 K
PO
Phone [phone] Lnt _. lord.
Minor Eh.^.in
WELL CONSTTiUCTION RECOnD fanahi Corte
r Ca Monier Ent. GW-I Ent
DRILLING CONTRACTOR ----
IJ STATE WELL COtJS TTIUCTION
DRILLER REGISTRATION NUMfTI_R: �5 PEnMIT NUMf3Ef1:
1, WELL LOCATIO : ( how sketch o�12�1110
calion below)
Neatest Town: U ZI.County: t 103�GG2.
(noad, Cormn ' y, or Subdivi or and Lot No.)
2. OWNER
ADDRESS — y�
(Street or noula No.)
City or Town Stale Zip Code
3. DATE DRILLED 2 0U USE OF WELL
4. TOTAL DE P 1 l l _
5. CUTTINGS COLLECTED YES❑ NOUL�
6. DOES WELL REPLACE EXISTING WELL? YES n NO[l/
7. STATIC WATER LEVEL Below Top of Casing: FT.
(Use '+, it Above Top of Casing)
8. TOP OF CASING IS --_—_ FT. Above Laid Surface"
• Casing Tsrrnineled etior below Innd surface is Illegal unless a variance Is Issued
in accordance with 13A CAC 2C .0118
9. YIELD (gprn): METNOD OF TEST
1^ WATER ZONES (depth):
11. CHLORINATION:
12. CASING:
1)_E__t' I ! 1 _DRILLING LOG
Porn In Formation Description
$"J�wj' �'
000
r-N
c�
CD
tV
4�m
M
rn
4
-------------ram
r.►�
Type) [s Amount It addilion,l ^pacrt is needed use back of form
Will Thickness
�/�
Depth D mele or 6gh� t. starlet
From- JQ To Ft.
From To Ft.
From To Fl.
13. GROUT:
Depth alerial hod ^/
From --Q— To 2— 0 Ft• e C•�-
From _ To —Ft.
14. SCREEN:
Depth Diameter Slot Size
Material
From
To
Ft
In.
In.
From
To
Ft.
In.
It,. r.----
F m
To
Ft.
In.
In.
I
15. SAND/GRAVEL PACK
Depth Size
From To Ft.
From To Ft.
16. REMARKS:
1 DO HEn& CONSTR
_LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
�?O/.
Material'(..� [
if ,� u,
d I' " ji
ji
VAS CONSTnUCTED IN A CORI
•A COPY OF THIS RECOR , HAS
Afe-
AC 2C, WELL
THE WELL OWNER.
7$3?,- -o
DATE
SIGt1ATUn5 OF 'ITFtACTO n AGENT
t3W1 REV. 9/91rpUl1(tW3t8` SeCtiOfl Submit on inai to Divislon of Errvlronmental Man�gnmrnt and copy to we" owner.
x Asheville2onai Offrg

North Carnllna • n rirnnnf of E'nvironrnent, tTenilh, and Nnturnl nasources • -
Division of Mnnagnrnnnt • Ground�Nnler n SeclloFOn OFFICE USE ONLYvironntnnlal
.' r. t3ox 29535 • nnlnigh, N.C. 27626.0535 QIJAiI. Nr). _ _ J 6ErilAL No. 212777
i itorte [phone] tnt. Long. no I
Minor Pa^tn
WELL CONSMUCTION rIECOIRD nailnCnrt" -
DRILLING ` Jf11f1/ICTOfI' ,� �, f, ilondw r:td.. OW-1 EnL
�J SiAtE WELL CONS iiiUCIIUN
DRII.1 ' , nEGISMA11011 Nt1Mf3f_fl:_ �/ --_--_ PEriMlr tJUMnm: t
JELL LOCATION- (SI ow SkelCII of llae location below) >
Nearest Town:County: (.C.
(no -id. Conttnunity, or SulViivisinn nn 1 Lot Dln.)
2. OWNER l �JJ
ADDRESS__—
(Slron.t or [logo No.)
City or T o.•m Slot" Zip Code
3. DATE MILLET) 1P7 _Qd USE OF WILL M ,
4. TOTAL DEP I l l .-_ O _
5. CUTTINGS COLLCC11-D YES (__I N0LiK
6. DOES WELL T FPLAGCI c-mmit1G WELL? YES NOg
7. STATIC WATER LEVEL Below Top of Casing: C!5,7r FT.
Pse'r•' If Abov" Top of Casing)
8. 'TOP OF CASING IS ------ FT. Above Lnhd Surfnce"
' Cying TotmItinl"d sUnr hnlow Innd-tnlncs Is Illegal unless a variance Is Issued
in accordnnce with 15A ti AC 2C .01In
9. YIELD (gpin):_.%__._._ MF ENOU OF TESL
1 'NATEr1 zUrJE5 (de)tlil):
UE f' 1 I I DRILLING LOG_
Front In rorrnndon Description
a
3
o
�-mac
r�
lti2
q
�a
al
rn�
x
11. CHLORINAT 1014: T ype _ .—Amount II miriitiorrnl tpncn is nnndnd use back of form
12. CASING: — - -- -
Wall thickness
Uf'ptli �.mnlor o J I hUFt.-.(vlalerinl
From 1 o _ Ft. �5rS
From — T o -- rt.—
From To---* FL —
13. GROUT:
(r t oltl O Ft n MaErlll, — nlltod
From
From _...__— T o
14. SCr1EEN:
Ur,ltlh Ulameler Slot Size Materinl
From -To —__— r-1 hi. In.
From To _ .___ f t. __— fit. _ In. _
Frorn
15. SAND/GitAVEI. PACT<:
Ueplh Size Material
From __ To___ H. ---- ,f
From T o__ _ FL
16. REMARKS:
1DOitEnl?r1YCC-jjI,if-Y11lAr1111.1WELL WAS CONS IMICTE IN
CONSTnUC7.lUtl _cn,'�r'i( r1US; APJU MAT A COPY OF 1, ITS n COD
I L
lCC
nriwate*Section Slr;rIATtDATE
GW-i nev. 9N �iSItBVI..g RC IgO�Ii)ff!CE_._ Submit originni to Dlvislon of Erwhonmamal r.11-9-m-1 m,d rnpy M rv"n d Ower.
L.OGAI1011 SKETCH
(Show ditortion and dislance from at least two Stela
flonds, or olhir mnp reference points)
mac.
AUG 1 5 2000
I i SA f IQ AC 2C, WFLL
goro-ib iitl" WELL OWNEn.

North Cnrollon • Dspnrlrr,nnl of Environrnnnl, Nealih, And NAlurnl Iipsourcas—
Division of E11Vh01vnnnlnl Mm,ngnrnnnl • CTroundwnlor Section ron orncl; USE ONLY ♦ ry p t
P.O, tlox 29535 - flninigh, N.C. 2762.6.0539 01JA0. NO. arnIAL W. 1 (O.l
Phone [phone] t Fit I.onp. FIO
Minor (ia^in
WELL CONSTnuuiot4 nECOnD rin^ir, rnrrn
DRILLING COMMIACTOn, ^� iIF? nrlor Ent.:- _ GW-1 Ent
�_,�s1111E WFLI_ COiiSif1UC1ION
DnILLEn nEGIS fnATI011 HUM13iM: �Zl rmimi ' Nulvinr 1:
1. WELL LOGA-110N• (S low Sketch of/Ilia location below)
Nearest Town: 1��%(.r,�___ County:
(nond, Cortnnuni or Surxlblsirn, nnl Lpl No.) DEf' i 11
2. OWNEn __ Frorn to
ADDR S_3�1-_-_-..
( Slrnnl or F u n.)—
___ City
4--
City or Town Slain Zip Colo F 0
3. DATE Dlli(.I_Fi) .2- -,641 USE OF WELL QM .
4. TOTAL DEPI11 __94 _ --- ---- --
5. CUTTINGS COLLECTED YES ❑ NOu.K _ - -
6. DOES WELL nEPLACE EXISTING WELL? YES NOg
7. STATIC WATEn LEVEL Below Top of Casing: ,� FT.
(Use '4v' It Above Top or C,19irrg)
0. TOP OF CASINOSFr. Above L1tld Surface"
' Casing Tvminnled eUnr holow Innd surtoce Is Illegel unless s verinnce Is Issued In eccordonce wlth 15A F AC 2C .011A - —
9. YIELD (gpin):___ ME 11 iUD OF TES T — �_.
VATER ZONES (depth):
DIMLING LUG
Formadon Description
o.
tV
�
c?
Ao
rn
�
N �
NJ
0
11. CiTLOnINATION: Typo 7z _ __.Amount If nd(Iitlrnml gmcn k nondnd usg back of form
12. CASING:
WII l i,lckness
Unpth Diameter or WelghUFt. nlnrini
From /D T o
From To— rt.—
From ---To---, rt.-
13. GROUT:
Drplir %� Melerinl �nlitt�d
From -i o � rI.
From To rt.
14. SCnEEN:
Drpill Dlameter Slot Size Malerinl
From To ____ ri In. In. _
From _—_ To f t.--- It'. In. From V _...__ T o __.___ — Ft. _-- In. In. —
15. SAND/GIIAVEI_ PACK:
Ueplh Size
From
From -i o rt.
n. REMARKS:
Material
LOGA7ION SKETCH
(Show ditnriinn ind distance Frorn at lewtl two Slate
nonde, or ether tnsp rniernnce points)
AW 1
I DO F1Fnr7nY"Cr/l t'!r,Y j-nWr'11Tt� WRLLNVA$ corJS rnLJCIED ItI�ACCOfiQ/�4t 11c11 a r1CAr 2c. Wr_LL
CONSTRUCTION STANDARDS; AND T iA�,{i'COF'Y OF TIits nECOiflUriri tT t1F1r�,�1p UrTO IiIF WELL OWNER.
^Ir.1rLglunr or Cr tf�ACTOn On ,Ftlr DATE
GW-i nev, gig C-munSwim Suhndt original to Drvitlon or Frrvborrrnnnlnl and emery to wad ovvt,er.
Ash. illt:-R9j*alOffice
1

North Carolina • Dnpmlmanl of Enviinntttent, Nealth, And Nnlural flesourcas
Division of EnvironrnnnInI Mmnngnmonl • Groundwater Section ion OFFICE USE 0fNLV_ 12 7 8 2N
P.O. Dox 29535 • flnlnigh, N.C. 27626.0535 MAO. ff ). SEnIALNO.
' _. I
Phone [phone] lnt. __...._, l.orV. no
Minor Fin^in I,
WELL CONSTnUCTiON nEConD 11aninfnrin
` Ilgndor Fir.- GWA Ent
DFIILLING coNTf1ACTO11•. _.-_.._._..-.....______..
S TAT F. WELL CONS 111uC1IUN
nnILLEn nEGISMA11011 Nl1MnEr1:__ ^—_, PEr1Ml1' NUMEIEFl: t
1. .WELL LOCAT ION: ((low ketch of Ilia location below)
Nearest Town: 01 — —_ County: _.._..----•_—�---
(nond. Connnunity, or S111AIVIs Qr and Lot Nn.)
Ur I' 1 I I
_ DRILLING LOG
2.
OWNER �� 1 b�)
From in
rormadonDescription
ADDRES =�-- � ----
—
(Saeel or floule No.) (� _
3.
City or 1 own Zip Coda
DATE DRII.i_FD __Q_'q_, 0D _ USE OF WELL _L002,.%—'
!, 4.
TOTAL DFP TI I
5.
CUTTINGS COLLECT EU YES C1 NOL
6,
DOES WELL F1EF'I_ACF_ EXIST 1,10 WELL? YES (_] NOd
©
7.
STATIC WATER LEVEL Below lop of Casing: ZQ_ FT.
-�
8.
_
I (Use "+' If Above Top of Cnoing)
TOP OF CASING IS iFT. Above Lalid Surface*
• Casing Terminnled et/or boiow Innd surface is Illegal unless a variance Is Issued
N
a
In accordance will► ti1A f1CAC 2C .011e
_
yo
9.
YIELD (glltrl):__j.___ Mr_ 1I IOD of TEST _ __�.--
m �
'HATER ZONES (depth):
o
cn z
Type T Amount `-%
If ridditionni ^. tocr; is nnndad
f `
u§e back tlbrm��
o
11.
CIILonINATION: —?�
12. CASING:
Wall ThIcknoss
U�hlil Diameter or vJ� CS rial
From ---�----to g�— Ft. (Q -a's—
From To rt.
From To -- Ft• —
13. GROUT:
Malarial etho
Uppill
From -To ri.
From To
14. SCREEN:
0r111h Diameter Slot Size
Materlril
From --To Ft --- In. In.From To --- rt._— in. Irt.
From --- T o - - — Ft. In. In. —
`• 15. SAND/G1IAVEL PACK:
Uelllil Size
Frorn To — Ft.
From _ 10 FI.
16. REMARKS:
1 DO 11Enr
CONSTnu
Malerlal
S CUFJS 1 nUC1ED I
COr'Y or TIiiS nec
1.0CAT ION SItETCN
(Show dirnrlion and distance front at least two Stale
rloads, or olirer nisp reference points)
r
f 1CA0 2C. WELL
1„Q,.1j IF WELL OWNEn.
GW1 nev.9/9i
L�­�!
ICPIATUnF corm Ton on nrpr r onT1
Svbn+it original to Division o1 F..rrvironrnnntnl r.1�n.g�n+�nt m+d car y fo wnA owner.

mil'
North Carolina • Department of Environment, Health, and Natural Resources �.
Division of Environmental Management • Groundwater Section FOR OFFICE USE ONLY 2
el 2 ►7
P.O. Box 29535 • flnInIgh, N.C. 27626.0535 QUAD. Nc). BERIAL Pro. ! I
Phone [phone] Lnt _ Long. RO
Minor Minlit j
WELL COP STFIUCTION FIEConD Pnsin Cndn
r Header Ent. GW-1 Ent
DRILLING CONTRACTOR: --.—
STATE WELL CONSMUCTION
DRILLER REGISTRATION NUMBrin:_ PERMIT NU1VlE3EIT:
1. WELL LOCATION: ( to�v s el It of the location below)
Nearest Town: County:
(Road, Cornr nity, or Subdivislo rid Lot No.) D_E__P 1 I 1 DRILLING LOG
2. OWNER From to Formation Description
ADDRES 7
(Street or noute No.) UD --
sk��a �g-1��0,�_ —
City or Town State Zip Codo
3. DATE DRILLED USE OF WELL 7�L e 44
4. TOTAL DEPTII _ _
5. CUTTINGS COLLE6TED YES ❑ NO[-✓�
6. DOES WELL REPLACE EXISTING WELL? YES [ _] NO[a
7. STATIC WATER LEVEL Below Top of Casing: _Zo FT.
(Use .+" if Above Top of Casing)
8. TOP OF CASING IS FT. Above Laird Surface'
• Casing Terminnted et/or bolow Innd surface Is illegal unless a variance Is Issued
In accordance with 1SA NCAC 2C .0119
9. YIELD (gpm):le Q, METHOD OF TEST � —
1" WATER ZONES (depth):
11. CHLORINATION: Type A ..— Amount If additiorml space is needed use back
12. CASING:
Depth ameter
From 0— To L2q Ft.
From To Ft.
From To Ft.--
13. GROUT:
o
rn
r
N
_I.00ATIGN SKETCH
Wall Thickness
or Welght/Ft. aterial (Show direction and distance from at least two State
Flonds, or Ohm map reference points)
Depth Material
From 11) . ToFt.
From --To Ft.
14. SCREEN:
Depth Diameter Slot Size
From
-fo
Ft
In.
In.
From
To
Ft.
in.
In-_--
F
To
Ft
In.
in. -
rom __
15. SAND/GRAVEL PACK:
Depth Size
From To —Ft. —
From 10— Ft.
16. REMARKS:_
1 DO NERVY CE
CONSTRUC`Y20
FY, TI lAT T} IIS,'N
Material j
L WAS CONSTRUCTED
At A COPY OF THIS RE
AUG 1 5 2000
FJCA6 2C, WELL
TO TbE WELL OWNER.
GW-1 REV.
SIGNAITUne OF CONTrlcron on AG
Submit original to DivklOd of Erw1ronmrn
mgnme.nt and cnpy to wen owner.
DATE

North Carolina • Deparirnent of Environment, Health, and Nalurai hasources
Division of Envirommnnial Managemnnt • Groundwater Section
P.O. Box 29535 . nrilelgh, N.C. 27626.0533
Phone [phone]
WELL CONSTRUCTION RECOnD
DRILLING CONTnACTOR:
auna. No.
Lnt
Minor Snfiirt
Basin enrin,
Header Enr_
FOR OFFICE USE ONLY O 12 7 $ 4
SERIAL No, f
Lang. no
STATE WELL CONSTRUCTION
DRILLER REGISTnATIOPJ NUMBFIR: S PERMIT NUMBEn:`__
1. WELL LOCATION: ( 1 w ke ch of the location below)
Nearest Town: ti�8A..) County: �---
(Road, Cornmu uty, or Subdivislon an Lo1No.)
2. OWNER 40�
ADDRESS
(Street or Route No.)
City or Town State rl
ip Codo
3. DATE DI111.LED USE OF WELL
4. TOTAL Df_PTI I 5. CUTTINGS COLLEC-TED YES I-] NO[V-f —
6. DOES WELL REPLACE EXISTING WELL? YES (P NO[O
7. STATIC WATER LEVEL Below Top of Casing: �� FT.
(Use'+' it Above Top of Casing)
8. TOP OF CASING IS FT. Above Laiid Surface"
' Casing Terminnied euor bolow Innd surface is Illegal unless it variance Is Issued
In accordance with t6A NCAC 2C .0119
9. YIELD (gprrl): to D METHOD OF TEST
I" WATER ZONES (depth):
11. CHLORINATION: Type _Amount.-
12. CASING:
Depths iameter
From0-- T042 E Ft.
From To Ft.
From To Fl.
13. GROUT:
Material
thod
Depth
From 9 To0 Ft.
From To Ft.
14, SCREEN:
Will Thickness
or We(g{i Material
DPp(Ii Diameter Slot Size
From To Ft in.
From To Ft. In. _
From To _ Ft. in.
15. SAND/GRAVEL PACK:
Deptll Size
From To Ft. From To Fl.
16. REMARKS:_
;DO H ,Ft f3
CONS, �0.
dW-i REv.9 14
Material
In.
In.
In.
Material
WAS CONSTRUCT
T A COPY OF THIS
1 D_EP_ i I i DRILLING LOG
J Nam To Formation Description
CD
c'
m
ram—
�
s
cC-)
-r
N
t7<
= m
O
M;0
If acidilional space is needed use back rrh?ormo
LOCATION SKETCH
(Show direction and distance from at least two State
noads, or niher map relerence points)
1C 2C, WELL
THE WELL OWNER.
SI NATUnE OF COP ACTOR On NT DATE
Submit original to Divl n of Environmental t.lnnig—fnt And Copy to well owner.

North Caroline • Deprtrtr innt of Erwhontnant, Health, And Nnlural flesources
rOR OFFICE USE ONLY r7 ►y p C�
Division of Envirorunnnl rl Mmmgnrnant •Groundwater Section c]11A17 NU 6Er71AL No. ! O 5
P.O. Box 29535 • Jlnlnlgh, N.C. 27626.0535 — I
Phone [phone] t nt. _ _. Lonp. no
Millar 11a^111
WELL consTnuc'non nECociD nn^Irlo,,,lnV_—
MILLING CON I nACT011: ` �a llnndar Far -- _- GW-1 EnL
SIATE WELL CONS It1UCIION
UnILLEn IIEGIST11A11011 NUMDr-n:_PEnmir NUM[lEn:
WELL LOCATION: (Siiske1l of the location below)
Nenr@at Town: LCw — County: C
(noad• Corrnnunily or Sulrlivlsion nil d of No.)
2. OWNEn _
--
(Street or noute No.)
A/C- �Z Bea ele
City or town Slals Zip Codo
3. DATE Dniu_F.0 USE OF WELL .Da'r)-,
4. TOTAL DEPII
5. CUTTINGS COLLEC 1 EU YES L_1 NO(
S. DOES WELL FIE f'LAGE; _ EXIST If JG WELL? YES F-1 NOIA
7. STATIC WTEF1 LEVEL Below lop of Casing: _� FT.
(Use '1`• if Above Top of Casing)
3. TOP OF CASING IS __ FT. Above Laitd SllrfaC9"
' Cssing Torminnlod sUnr holow Innd iurloce 1s Illegal unless a verlence Is Issued
In accordance wllh 15A CAC 2C .0119
9. YIELD (g, l Nl — ME I110D OF TEST
I- "VAT ER Z41ES ( ef)ul):
11. CHLOF11NATION:
12. CASING:
DEI' 111 DRILLING LOG
From — 10 Farmedon bescrlpdon
d
cn
p
N
d�
yr
r-r,
E5
m
`
z
Type Amount II arldillol,nl cllace is neAdnd use back of form
W:111 Thickness
o
UBplh iwilater or weight/rt.
JAilorlal
From
10$—
FroITT
To —
From —To----*Ft.
13. GROUf:
Unhlit alerlal
From Prl.
hod
--w2f Ag�
From —
To _ Ft•
14. SCnEEN:
UPp111 Diameter Slot Size
Materinl
From
To `___ Ft -- in.
In.
From
To __— rt.r_— In,
In.
From
To H. In.
ht.
. L.00A7ION SKETCH
(Show direction and clislince horn Al lenst two State
Roads, or olhnr reap relerence points)
15. SAND/GI1AVEL PACK: ! �'
Ueplh Size Material
Ij i
From To Ft.
From 10____ Ft. a`i AUG
16. FIEMARKS: Y l!
1 DO {tE C t Y ii T II. -�vAS CONsInUCTEU lrii Ad' F hll far � � il' /r1 NCAC
CONSTn UNWID At�� A COPY Or- Trits nEcc nD r� e rr c ho � Jn ro TI
2C, WELL
E WELL OWNER.
raw-1 nev. 9/91 rot!ndwale.� Section
SICirlAtUns OF CorIT CTOn On A Nr OATS
Suhndl origlnnl to hivhlon of Erlvlronrnorllat and cnpY to will owner.

A.
North Cnrolinn • Dnpnrlrnnnt of Environmelnl. Ifealih, and Nnlumi flesoutce9 w�FOfl OFFICE USE ONLY 1) 12786
p i
Division of Em nviromnnial Mona mmnnt • Groundwalor Section QUAD) f tt) _ tyEiilALNO.�-
P.O. Dox 29535 • ilnlnlgh, N.C. 27626-0531 ---- I
Phone [phone] let. .. Lorq. Fi0
tilinnr Pa^hr
WELL coup-muc-rfon nECORD
Rialr; cnlh_�,_
DRILLING con nACT011: iinnrinr Fn►._ OW-1 Ent
SFA7E WELL COiISiHUCi1ON
DRILLER nEGISMA1101`1 Nt1ME1f_R: ��PEFIMIT' NUMI3Ei1: — -_ t
1. WELL LOCATION: how sketch of the location below)
Nearest Town: D2�- County: &4n� 4,0,
(nond, conan i ity, or St1Mlvlalor d Lot No.) UE1' 1 I I
2. OWNER --� Front- --- in
ADDRESS.__
(Sheet or (fouls No.)
City or lows Stale Zip Code
3 DATE Will I FD 4 U5E OF WELL .7)6 _
_DRILLING LOG
Formadon Uescriptlon
4. TOTAL DrP i I I QD __ ---�
O
5. CUTTINGS COLLEC-1 ED YES NO`L
p
6. DOES WELL FIEPI_ACE EXISlitJG WELL? YES F-1 NO[►�
--
7. STATIC WATER LEVEL Below Top of Casing: —/V _ FT.
(Use'+' If Above Top of Cnsing)
N
q<
S. TOP OF CASIh]G IS --I—__ FT. Above Lnftd Surface"
a
"Casing Torminnlnd el/or below Innd eurtocs is illegal unless a Ynrlance Is Issued
�m-,�
In accordnnea with 15 tCAC 2C .0119
O
�—
9. YIELD (gprn):P __ METi IUD OF TEST --
—
c,�
WATER ZONES (depth):
0
11. CIiLonINATION:
12. CASING:
z
Type T_� ____ Amount %pacn is nnndad usn back o1 form
Depth Uiamotor
From To ag_ Ft. � - .2 6-
From -To-- Ft.
From —.—'To-- Ft.
13. GROUT:
nMalerla� elhod
Urpih
From _�1� 'to
From To
14. SCREEN:
Mill 1 hlcknes!
or VVcIghUFt. M'ittte,dril
Dfrplh Diameter Slot Size
Malerirtl
From To rt In. Irt•
From To _ rl.�__ in. Ir►.
Froth _____ T o
15. SAND/GiIAVEt_ PACK
Depth Size Malerlal f °;
From To FL —
Frorn _ __ to Ft.
16. REMARKS :
I o0 llE i I w51�
AS cONS111UC1Et)
CONS T rd STANOMUS. AN U A COPY OF 1FiIS f1EC f
! r= ;:i (fW8t8 $CCIIOR SIONAtunc OF-
(3W-1 REV. 9/6- "''I�° "e:?Ural '
Submit orlginnl to
}h
- LUGA71014 SKETCH
(Show dirnctinn irt(j distance from et lenst two Slate
it d-3, or o►Itnr reap reference points)
AI V1 I a onn E E k tp i P
cc'oulant_1cE wl rl tt1 sn h(;Ac 2c. WELL
U I iA3`11f I `I 11 y1( y 10 111E WELL OWNER.
g i
b a�il�'j�'srly i���l �rEllfi ilE�iP�
icloll A017flr DATE
of Errvlronrnnnlnl fAal+�g�rn�nt and copy to well owner.

North Carollon • Dnpnrlrnnni of Envirommnnt, Nealllr, and Nnlurnl flesoutce9 F OFl OFFICE USE OfJLY
Division of Envirommnnlal Mnnnpamant • Groundwater Section r) 1 2
P.O. T3ox 29535 • flnlnlgh, N.C. 2.7626.0533 OUAU. NO. _ anIALNO. � _ $ 7
Mona [phone] lnt l.orq, no
Minor Po^.in
WELL CONS MUCi 11ON nEConD pnnirl rnrli
MILLING CON T TIACT Uli: l lnndw Fat _ —_ _j4_..._ OW1 EnL
SiATE WELL COtJ51f1UCTIUN
vnILLER REGISTnAIIQII TJ(1MD1_:n: PETTMIT'tJUMF3FfT:
WELL LOCATION: (dhow SEPICII of 1 tile location below)
Nearest Town: _4 , County:
(noad, Corrxnur ity, or Suhdi Is on and Lql No.) DE II I I DRILLING LOG
2. OWNER _ Frorn to Formadon Description
ADDRESS,-_ _ -
_(Slrnot or Houle No.) _
City or t own — 91n1n zip Codn
3. DATE Dn11.1_ED USE OF WELL ; --- Q �
4. TOTAL DEPIII __� -__ -- - o p
5. CUTTINGS COLLECTED YES L_l NOUI?' _ - -
6. DOES WELL nEF't_ACE EXISTIIJU WELL? YES (� NO[ - ter'-'
7. STATIC WATER LEVEL Below Top of Casing: _41 FT.
(Use '"" if Above Top of Ca91n9) tV Sri
8. TOP OF CASING IS - I FT. Above Latid Surface" _ y,. -+�.
• Cesing Tsrminnted eUor hotow Innd surince is Illegel unless a verianca Is Issued Mrn
In eccordnnce with 15A NCAC 2C .0118 m�
9. YIELD (gpm): __ ME T I tOU OF TEST - ..,
' "VATER ZONES (depth): - -
z
11. CHLORINATION: TyIIe Alttount -+ 7� Il nrlrlilio�r�i "I�ncn is nandnd u�A back of form
12. CASING:
LOC,/1_IION _SKET CH
Will thickness
uppilJ diamator o Weigilm atorini (Show dirndrin and dislancn from et IeAM two Stet@
FromIV -T0 S rl. � floads, or oilmr ntnp relorance points)
From To
13. GROUT:
Ueptii aleriai hod
40-1
From To -AO rt.
From _.. To _ Ft.
14. SCREEN:
Drplh Dlanieler Slot Size Matednl
From -To 1.1 In. In. _ From To rt. In.
From ---To --- -Fl In.
r 15. SAND/GiIAVEI- PACK:
Depth Size
From To
From _ to Ft.
16. REMARKS:
�� /J/� C,
t`
Material
1�
AUG,
➢67F dF;S? if ,i u
to n Y r- I f A it Ir: ELLWAS CONS MUCTE' Ifl AOcg{(�f�j cl(iEt�r Vr+lrl(�tIµ15A FI(a'AC 2C, WELL
CO TIiAT A COVY OF it its r1 6TTtSr`ilnS rlFf=r7 13n6VIfSEi] T` 11IE WELL OWNEFl.
S_1011A1unE or cort ACTofI Oft ,FLIT v VATS
GW-t FlE Groundwater $ I Offal Subrnft original le blvlllon of Frrvlronrnnnlnt 1.lorrrg..mmnt nr I c r+y to wall owrtAr.
Asheville ite,ional fficr

North CArolirm • I, pnrlrnnnt of Frndrrn mnnt, f leallh, And Nnlmtnt nn.ioutcos
Dlvi^.Ion f-ovirournnninl Alnongmmnot • C3tound-N:ltnr Sectlort rCn orrICE U4E amy 0 1 2 7 Os
f .O. tlox 2hS35 - f lnlnighr N.C. 2.7626.053K c711/iU. f lr 1. _ SmIAL NO. ____ v5•
rhonA [phone] I nt l.nrq. nO
Minor [in^in
WELL CONS T11UCTFOIJ nECOnD Ramscnrh ^-�_--_----
Dr" iG C0frrRAClOf1• Ilendnr Fnf.---- GWI Ent.
SIAIF WF1.1. (3,ONSInt1C11UN
tUrn IlEGISMArtr.)II NI1Mnrr1: ICUrr-rimir NuMnimn:
WELL LOCA I ION: low 51 .left of the locatlon below)
Nearest Town: —_—s_(�C01111ty:�1�
(Rol d. Community, n St l�flvi.^.1 tend Lot M34
2. OWNER _--------..-.___ rmm ►n
ADDRESS_ ��. - O�G.-
(^,bast or noule No.)
City or Iowa Slntn Zip Corte`�-_-
3. DATE D11II-I_FI) DD USE OF WELL _/�l_ ---
4. TOTAL DEP11l--'�%Q- - -- - ---- ----- --
5. CUTTINGS COLLECT ED YES L._l NO(-t� ---- -
5. DOES WELL F1E11-AGE EXISTING WEI_l-7 YES tic)
7. STATIC WATER LEVEL Below lop of Casing: __� r-T. _--_-_--
(I.Ise '*" If Abovn Top of Cnsfnq)
B. TOP OF CASING IS rr. Above Latid Surfaro"-
Casing Tetminnlyd aUnr bofow Innd nuance Is Illegal unless a vet lance Is Issued --`--�
In accordance wllh 15A NC C QC .01 to
E— - - —
9. YILD (gflln--_- ):.-.-.- Ml: F f lOD OF TES r
ir WATER ZONES (defllil):----
)fit LLING LUG
rormadon Deicrlption
C9
--
- -
- 4
Mw
11. CI ILORINAl ION: ly)le Amount ?� If nrlrlitionnl ipncn is nnndnd use flack of form
12. CASING: --------...__ .
Will il,tcknns! LOGAI10FJi
SKEICI__
Depth imunterr or Weight/Ft. ' Mltnfln•1.,,, (Show (irnclirul Irtd dkinnc9 frorn nt lenit two State
From to �� Ft. & d6- G '"-���+ /� rloads, or ollim mnp rntnrnnco points)
From -To- rI.- -
From -10-------= H.—��
13. GROUT: ewo t3
Urfllil Malerill nlhod �f��
From -f 0 At-9rt. -{w J-A�)
�' • ,
Flom_._�- To ____ -
14. SCREEFJ:
Drillll Diameter Slot Size MalerinI
From --- To ______ rt III. --- III. —
rrom -- To _ rt.-__-_ In. In. -_
From _ To
15. SAND/GHAVEL PACK:
Depth Size
From to - rt. -
From `__ _ l o rt.
16. REMARKS:
I DO I'
CONS
Gw-I nEv.
Materlal
corm t nuc T Et) IQ. Acdj onDAf_IGF:.-:W-1 t
Jr'Y Or± 11115 n cC w I
iICAr 2C, WELL
10 TI;IE WELL OWNEn.
2 6v •ye0)
intiAIUnr nr U611AACTOn on &FtI1 DATE
uhn,11 o,Iginnl to (llvkIon of Frn•6enmor,tnf 11.1,11q••nwnt r1, d campy to wmM ovmoor.

North Carollna • Dnpnilrnnnl of Fnvironrtinnl, Health, And Nnlurel nosou►ces Y,. .__Erin OFFICE USE ONLY 2'78
Division of Fnvironrnnntnl Mn(Irignrttnnl • Groundwater Secilon
P.O. Dox 29535 • nninigh, N.C. 27626.0535 oUAD, iir). ­---_-__ 8EMA0,10.__ I
Phone [phone] tnt. --_... -__ Leiv. Flo
Minor on^in
WELL COrJSTRUCT)O14 r1ECOrTD -- —
(inain
nt.-_�-- GW-i EnL
DrTILUNa CON inncTOil ilonrknr F
• __-_.--_--- ._-_-__-_
-- Q SiATE WELL C,OilsMUCrlOfJ
t)nILLr-n nEGISMAiI011 NUMMM: —� �1 _ rumor NUtiinrn.
1. WELL LOCA i ION: (Sh skelcti of II)a location below)
Nearest Town: r7c,- Lti _ Counly:
(nond. Con`Lttn/uu�ni'ly, or SijMlvlslon rind Lol NJpj —_^---
2. OWNER _._ Y /v _
ADDRESS
($Ireet or n ����e•••• No.) 0�
City or 1 own Slnln Zip Code
3. DATE Dnli.l-Fi) - •OO USE OF WELL Lb1b .
4. TOTAL DEi'f I I _--j ^fog____
5. CUTTINGS COLLECTED YES[_-] NOL-,�f 6. DOES WELL nEf'I_AGE EXISTING WELL? YES 1-1 NoLo
7. STATIC WATER LEVEL Below lop of Casing:_ FT.
(Use '+' If Above Top of Casing)
S. TOE' OF CASING IS __ .�_ FT. Above Lnrld Surface'
' Caning Tstminnled nUor bolow Innd surface Is Illegal unless it vnrinnce is Issued
In nccordnnce wllh 15A fICAC 2C .0118
9. YIELD (grim): _-,3a--_-- ME f l lOD OF TES r
NATErl ZONES (depth):
morn 10
DRILLING LOG
Formallon Description
Q
0
3
N <
�M
11. CNLOIIINAT ION: Type N � �____ Amount �� II arlriilir,n�l ^pncn Is nondad On back of form
12. CASING: _...-----.-._._.._ _. .-.._..__.__.
L.00A ION SKE7 CN
Will ihicknens —
/j Ur?i)th L� �j di (linter or WelghUFt. alerinl (Show dirnctinn rind distnncn from at lenst two Slate
From V 'io —_ Ft. tloadn, or olhnr rnnp reference points)
From To— rt.
From --To-..---* H.
13. GETOUT:
To
l�l�^r't.S.� MnlerlilAell_ C
From �/n — �-�
From To rt.
14. SCREEN:
Depth Diameter Slot Size Malerinl
From --'To rt —_ in. _ In.
From ,to _ rt.fit. In. —
From -- —To - Ft. In. In.
15. SAND/GiiAVEI_ PACK:
Depth Size
Frorn To ---- rt.
From 10 rt.
REMARKS:
IDOL
CONS
OW-1 nF-v
-- t
'I 31 L Al if-,, i t )fit if I< k
WAS cofasinuclE
T A COPY OF 71 IIS n
f ICAC 2C, WELL
1OJI IF WELL OWNEn.
-IKIA DATE
Ri
Submit origitrril to Vivislon o1 F(rvkommonlnl ring r-nry to wm" owner.

North Cnrollnn • Depnottinni of Environment, Ifenith, And Nnlurnl ►iesourco9 USE UNLY2 12
Division of Environnrnnlal Mmingamant • GioundwnEOfT OFFICE
tar Section MAI). Ilr). Ust; NO, Q
t .O. nox 29535 • flniniglr-
F'Itone [phone] 1,nt. . _ Lorq. F10
Minor Pa^in
WELL corasTnuc-um nECorTD --
_ Ra!tln Cnrin..----
Ilondar Fnt._ GW-1 Ent
uRILLINl:3 Cori rnncroil. _S-6DS
...._------ '
1A1F.. WEl_1_ CONSIFIUCIION
uFIILLr:n nEC:ISTf1AIIOIT NUMEIEn: ��-_, _- pEFiM1T' Numnr I:_.-
WELL LOG IION: (w s cetch,pf the location below)
Nearest Town: L.c%� County:
((fond, Con~ _mitt', or Sulxiivi^Ion n Lot tJo. ^ 2 1 UI_I't I I _,MILLING LUG_
2. OWNEn��A�£ /J From 10 rotmndon Description
ADDRIE S_�
--/��-- (Slrnr,For rlgcle No.) �1' • �Q� —_ —
L C .8d� Zo�20-151—
City or 1oa,m Slate Zip Code
3. DATE Dniu_F.D --00 usE OF WELL DO , u o
4. TOTAL DEr 1 I i _-_-- _
5. CUTTINGS COLLECTED YES [�� NOL� — `'rn
6. DOES WELL f1EPLACE EXISTING WELL? YES NO
J. 3 "rn
ate—'--
7. STATIC WATEn LEVEL Below Top of Casing: F. _ _ N
(Use"** if Above Top of Casing) m�
8. TOP OF CASING IS __j.___ FT. Above Land Surface" _
n-t
Casing Tor[Ttinnlnd el/or bolow Innd surince Is Illegal unless A vnrinnce Is Issued •• m__0
c�
In er cordnnce Hill 15A NCAC 7C .0110 ..
9. YIELD (gprn):-/-4eQ-.-ME-1II0U OE TEST
'VATErI ZONES (depth):---
11. CITLOnINATION:
12. CASING:
Tyl)e 74" T M AtilOUllt If nrfdilionnl^.pace is nandad u99 back of form
Wall 1111rknes!
O
Depth
bl.�''as
� alnrinl
orweigiwrt
From
To
From
TO rt.-
From --T
0 ----- — rt.
13. GROUT:
Urpllt
Material nihod
From
ToD f I.
From----
14. SCnEEN:
Urpllt Ulanleler
Slot Size Materinl
From
.(o __-_-_ f"t--
In.
In.
From ---- To ----.---- f"t. _----
In.
--_ In. —
From
T o f t. _--
In.
in. -
15. SAND/GHAVI.-L PACK:
Depth Size Tvialer
Frorn to ___ rI. - ---
From --_ ___ 10— rt.
rIEMAr11<S: - --
IDOL
CONS
ow-1 nsv.
WAS Cots 1 nl-
T A COPY OF TI
LOCAY ION SI<E1_CN
(Show dito.drin and distnnce from At lenst two State
flond3, or oilinr rnnp rnfernnce points)
y
I AUG i J %OOQ_—
i1 I
1Etl.ltJ��lfCt�-tlDAth( �WItII i5 ; tIC/1C2C.4vFt.L
nFCd�iiFGl�itFur".°"`fl��vl()E, 10 illE WELL OWNER.
81(,fIAtunr_ r)r Cr TrI; ctOn On stir GATE
SvbnJt original to [liviglon or F..rrvtronrnnnrnl cmry to wnA owrrfor.

North Carolina • Dnpirlrnnnl of Environrttnnl, Ilealih, And Nnlurnl nnsoutce9 FOn OFFICE USE CNILYZ 12 S s
Division of Envirmhnrnnlnl Mnnnpmm�nt • C3roundwrtter Section .a.
P.O. T3ox 2.9535 • llnlnigh, N.C. 27626.0533 (]IJAU. Nt), SEnrALfJO._ ___ I
Phone [phone] l nt. , . Lorq, f70
Mhrar Ian^•in
WELL CO11SHILICUON nEconD
� q
Fat._ ~—OW-11Ent
DRILLING CoNrf1ACTUf1Ilnndnr ��D
0 STATE WEl_t_ COilsMUCH014
DRILLER RFG15TnAf IUll NUME3f rT: �� 1 __ `^ PE►1MIT
WELL LOCATION: (S w Sketch of �Ilia location below)
Nearest Town: o _ r' sc(di , ---County: ._ ..... .
(nand. Corrwnrn' , or ul-4vislorr rd Lot No.) ULP I I I DRILLING LOG
-
2. OWNER From _ 1n Formadon Description
ADDnESS_*&
(Slrnet of Flo No.)
a CSC_ a. _� _—�P1.�!�G_ `
City or To,.-m Slain ^�Zip Code 4 0
3. DATE Df711•I_f D o��'Q USE Or WELL
4. TOTAL DEPI11 .-_s �11 --.---_.—_.- CZ Gr
S. CUTTINGSCULLECIED YESi_1 NOI.v-f --- — `---
6. DOES WELL f1EP1_ACE EXIST Ill(, WELL? YES [ NOg
7. STATIC WATER LEVEL Below Ton of Casing: .r7rT.
(Use'." If Above Top of Cn41rrq) r—�►r=1n✓---
8. 'Tor OF CASING IS-___j__- r r. Abov9 Lat,d StJrface'
' Casing Terminnlod ollnr bolow innd suriocn Is illegal unless a vootll'a'ne@ Is IsauQd _ — N n""
in accordance with 15A fICAC 20 .011A
9. YIELD (grtt7):-.Q-_._ ME-iliOD OF TEST = ------
VATER ZONES (depth): _ - -- - -
11. CHLORINATION:
12. CASING:
..—�_ ..�t� -- -- - - - -- - -- ---
Type _LY_ L#:___. Amount _Tq If nrlrlitionnl ^(I 1Cn i9 n9nC)od U?f9 tlnCf( of fOrrrl
YJnll 1111ckness
Depth�-? D0.iim�nleerr or vieo,purt. ,6�alorinl
From To _S3 - rt. ��-- C� .�2
From T o --- rt.—
From
13. GROUT:
Urplll /� Malerlii ntltod
From 'To A
From __ To-
14. SCREEN:
DrpIh Ulanieter Slot Size Malerini
15
1 eS
From To in. In.
From ___ To —_-- f t.--- in. In -
From __.—To __-- -- rtIn. _-- In. —_
SAND/GiIAVEI_ PACK:
Depth SIZ©
From
Flom —_-_ To _ rt.
REMARKS:
UO 11
CONS
OW1 nEv
L0GA t ION SKE i CH
(Show (lirnciinn and disianr•.n from et ton -it two State
►londo, or ollrnr nhnp rolorence polnts)
tvlateri�I � �'3 tI�
".out)
WAS CorJS t n
TACOPY OFI
iICAC 2C, tivFLL
TO 111E WELL OWNER.
simMunc or- cr trincron on .rrtr OATS
Suhrnll original to DIVIslon of Errvironrnmrrtnl f.lon,q,mmnt mad crpy to well owner.

North Carolina • Department of Environment, Health, and Natural nosources
Division of Environntnnial Mnnngernant • Groundwater Section FOR OFFICE USE ONLY2 12793
P.O. Box 29535 • nnlelgh, N.C. 27626.0539 00AD. NU. t3ERIALNO. •�
Phone [phone] Lnt Lonq. RO
Minor Eta^in
WELL CONSTnUCTION nEconD P.1.01 CnAl
�— Iloador Fnt. GW-1 Ent. DRILLING coNrRACTorT _
C� ST'ATE WELL CONS rrtUCJION
DRILLER REGISTRATION NUMDrin:_ Sy l PEriMIT NUMt3En:
WELL LOCATION: (SI w skelch of the location below)
Nearest Town:—%� Ql_��G ZA, County: —
(Road, Community or Subdivision nd Lot No�1 U_E_ P I I I DRILLING LOG
2. OWNER Q _ tom/ gi /X — From To Formation Description
ADDRESS_ 94
(Street or Route No.)
City or Town Stals Zip Codo `—�—
3. DATE DRiI_LFD USE OF WELL
4. TOTAL DEr T11 V_,�C__ _
5. CUTTINGS COLLECTED YES ❑ NO(_J
6. DOES WELL nEPLACE EXISTING WELL? YES (_] NO[t/ M
7. STATIC WATER LEVEL Below Top of Casing: /.�_ FT._9�
(Use *+' if Above Top of Casing) N rn
S. TOP OF CASING IS. FT. Above Land Surface" ry
' Casing Termfnsled st/or bolow land sur loco Is Illegal unless it variance Is Issued xa. m�
In accordance with 15A NCAC 2C .0118 —`�'
9. YIELD (gpm):�_ METHOD OF TEST o—T---
WATER ZONES (deplli): ` F
o
ll!!�� �
11. CHLORINATION: Type �xk Amount If addilionni space is needed use back of form
12. CASING: -
Will Thickness
Depth -7 5? lameler o WeiglrvFt.
From To —4 Q Ft. a
From To Ft.
From To Ft.
13. GROUT:
From
From
14. SCREEN:
Depth Material
To o� d 17L
To Ft.
DPPIII Diameter Slot Size
From To Ft —_ In.
From To Ft. It,.
From To _—.— Ft. In.
15. SAND/GRAVEL PACK:
Depth Size
From To Fl. From To Ft.
16. REMARI«•
-_LOCATION SKETCH
'Material (Show direction artd distance from at least two State
rlonds, or other map tolerance points)
Wfit, 0 8
IN
Material
In.
In.
In.
'I , r'
Aft; 15
/oc
DON i WAS CONS. TRUCTED=1N- C,CORIIANCE WI141 15A NCAC 2C, WELL
CONS ION STANDARDS, AN 1 T A COPY OF TI lIS rfE(jgq� '1 $ ' t=tJ PROvIUEU TO TIIE WELL OWNER.
i� �> I e lF� .. _
v t ''(IOi
eggy"�
Croundwaction SIG JATUnE OF C THACTOn AGUIT DATE
Asheville ne,ionzl Office
GWA REV. 9 �^ Submit original to Divislon of Errvlronmenlnl tilansgnment and copy to well 0wner.

North CArollrin • Dnpnrirnnnl of Environutnni, itenhh, And Nniumi Fiesourcas
Division of Fnvirotminninl Mnrtngninnot • Ground-Nnlnr Secflon ron orrlCE USE ONLY r� n�
P.O. Dox 29535 • flnlnigh, N.C. 27626.0535 c]1JAIJ. Nct. �—_..__,— SEnIALNQ.. (__
Phone [phone] In1. --_- 1."rq. no
Minor Minh
WELL CONSMUCTION rIECOFiD NnIfI lndl-
MILLING CON E nAlcl oil • �� KLA� !leerier i nr —=- - - -- OWt Ent
v SiATE Wr_LL coilsrriucilotl
UnILLEn nrc:iS fiTAtlOrl tiur m-m: y L - — PEf1Mlr N ilvinr T: t
1, WELL LO(A i lON Show sl�p cii of llle location below)
Nearest Towr1:rXeL�
(nond, cornrr gtity, or Su1Nf!vinin t and Lot No.)—�---- DEL' 111
DRILLING; LOG
2. OWNER - - — �� --_--- _ rrnnl in
rormndon beecrirtfon
ADDnEss_.;
(Strout or nouto No.)City
or or 1 oval Q� Stnln Zip Cod"
3. D A I E DRI1.I-F:1)1'�Z�� 0 U5E OF WELL
4. TOTAL Dr- P111 -__ 66 4_-- _ --- - --_
NO(
c—
' a
5. CU1iINGSCOLI_E(�TE1_) YES�_I
6. DOES WELL F1EF'1_ACF= EXIST ING WELL? YES _NOg-
rT.
7. STATIC WATER LEVEL_ Below Top of Casing:
ry
(1 I,e '." It Above Top of Cn91r,g)
8. TOOF CASING IS-__.__�------ F'T. Above Lnhd Surface"
+Caiing Torrnlnntr+d ttvnr Wow Innd turinco is illegal unless to variance Is Iheued
F6
.
in eccordnnce wllh i5A NCAC 2C .011n ---
9. YIELD (gpm):_____1._..-.__ Mf2 i11OD OF TEST _ - -- -
^. rn —
_
WATER ZONES (depth):
11. CI-ILonINAT 1ON
12. CASING:
Type _$ _ Amount £ o` Ii nrlrlilianni f71Cn lotnQA!fnd use back of form
Wrlll i I Ilrkn"e!
�I)lil
DiaVy
D)Jnnr"1or orVJ.I h1t/.rt.
F-L zap CA
IInrinl
�
Frorn
Frorn
--- -to—
- rt.— —
Front --,To
_____--
r-I.--
Q. GROUT:
Dr -pill
,/7 Malerl�l othod
From
Frorn
14. SCREEN:
Urpt11
Ulanleler Slot Size Malerirtl
. L OGA t 1QrJ s.K T_ct
(Show dk or;linn and dislnncn horn at laagt two Slate
Flood3, or 0111nr imsp reference polt)19)
Q
From To —____ i"1 _ _ In. In. _
From ---'To - -- - f t -- --- in. In.
From _ _ _..-_ To ___.._ -_ f t.__. __ In, In. _
+ 15. SAND/Gf IAVEE_ PACK:
la
Depth Slza
From jo
r
From
16. nEMARKS: --
_ r
1do :n�c - I_L WAS cor•t`�inr.lci r nrdrA r, ��tI IMF WltII IM iICAC 2C, WELL
CON ,ifor J STnfJUAf1US, A (iAT A Cory�F«T•1>ItI?�iS�ilF�ixll�tbFEr1 rn)vlUr_U TO if IF WELL OWNt n.
r
' i;
-,- ... -! -- ----•--- --- -- - yr=— v� � pAi6
r . Groundwater Section
~clrrrniunr_ or cc rrincton on ,rrII
ow-i nEv. /9 I _Asheville tie 'oval Office Svbndl original Io i)ivl9lon of Errv!+onrnnrrinl r.i�,,q^m�n1 nr`d c�r`y t•� will nm�M.

North Carolina • Dnpnrlrnnnt of Environrnrtnt• I feahh• A1,14 NnIuinI no- soutces ._ FOn OFFICE USE ONLY 1 27
n
Division of Envirommnntal Mnnngnrnnnt • C3roundwater Section 3
P.O. Dox 29535 • Itnlnlgh, N.C. 27626.0535 c]t1AD. 110. SEnIAl.NO. _
Phone [phone] nt __.. _ -. Lorq. no
Minor Ra^hr
WELL CONS Tf1UCTIoui RECORD nnnh r;nrin
[7RILL114a coNFnncTON•
1 Ihnrinr Fnf ___ — :- —OW-1 Ent.
SIA7E WELL_ CONSIiluc1ION
DFULLEn REI;ISTriATION flumni-m: PEriMll'tJUMF3E11:
1. WELL LOCATION: ;IIow.Slmt 'I1 of Ille locillon below)
Nearest Town: _ County:
(nond, Conran rr'ty, or SutYlivislon end lolflo.)
2. OWNER
ADDnEss
(Shoal of floute NO.)
--CVy or 1 own uSlain Zip Code
3. DATE DRII.I_Fj) 7'0lJ usE OF WELL .JQ66f)
U
DRILLING LOG
From 10 Formndon Description
4. TOTAL DEPIIi __— Q__-- -- - -
5. CUTTINGS COLLEC I CI.) YES ❑ NOF
G. DOES WELL FIEPLACE EXISTING WELL? YES [—j NO(2/ (5,
7. STATIC WATER LEVEL Below Top of Casing: �d FT.
(Use "+" if Above Top of C,1019) �m
8. TOP OF CASING IS FT. Above Laid Surface" N p�
Casing Torrninelod sUnr below Innd iodate Is Illegal unless a vnrlence Is Issued —' to
In accordance rrllh 15A HCAC 2C .0119 - pro
9. YIELD (gpin):__ ME TI IOD OF TEST o
I
WATER ZONES (der)",):
11. CHLORINATION: Type T 4 Amount If ndrlition:rl silnce 19 nendnd uAn back of forr*
12. CASING: _ - ---------- -•
---
LOC!\YIUPJ S{«TCN
Wall 1 hlr;knes9 —
Uoplil Inmate► or WeighUFt. Malerinl (Show dirrncliorl and distance from at least two Slate
From � I,
� Ft. (loads, or other rnap reference points)
From To-- Ft.
From To
I 13. GROUT:
Ur"plli alerial Mod
From •T o _ tao Ft. Lwevt,From ___ TO Ft.
14. SCREEN:
Urpih Uinnieler Slot Size Milerlril
From —'To Ft In -
From To —___ 1 t. _-- In -
From —_.-- To __.__..— Ft, in.
15. SAND/GIiAVEI_ PACK:
Ueplh Size
From To -- Ft.
From — _ To_ F1.
16. RE T4----�-- �-�. -�-
ID jCOUC T1011 S I AIJOAI'll DS
Croundwater Section
Asheville Regional Office
OW-1 n fi
In.
In.
In. -
�l.i(JI!
rEl_L WAS CbN , rr to �rT- 'q- 9 COnDAtICE WI I 1115A tICAC 2C, WELL
MAT / COr'Y,f �� tly � } Rt1 rt) IA4 DEEtJ ('rl0vll)Ei) TO TI IE WELL OWNEn.
^111llAfunl- or c riiAACTon 1 ArF.tlr DATE
Svhndt original to ivhlon of Emironrnnwil r.1n++ng�mnnr and cnpY 10 Well owns►.

North Carolina - Department of Environment, Health, and Natural nesources FOR OFFICE USE ONLY ►y (�
Division of Environmental Managnmont • Groundwater Section QUAD. NO. 6ERIALffO. 2796
P.O. Box 29535 • nninigh, N.C. 27626.0539
Phone (g19) 733.3221 Let Long.
Minor 11miln j
WELL CONSTnUCTION nECOnD nnnin Cnrtn
DRILLING CONTRACTOfl, Header EnI_ GW-1 Ent
1/ STA1E WELL CONS IFiUCHON
DRILLER REGISTRATION NUMBf�R: E7 t PERMIT FIUMF3En:
1. WELL LOCATIW: (Show_*etch vetch of tite location below)
Nearest Town:. County:
(Road, Comrn ty, or Subdi Sion and Lot No.) PEP I I I
`
DRILLING LOG
2.
OWNER A� From to
Formation Description
ADDRESS 1919 --
—
(Street or Rout o.) _�X �'
191 -v
Ally or Town State Zip Code ICY
ZE
3.
DATE DRILLED A6USE OF WELL
4.
TOTAL DEPTH . 310O —
NOE�J'
c�
om
S.
6.
CUTTINGS COLLECTED YES ❑
DOES WELL REPLACE EXISTING WELL? YES [2 NOE
N '^
7.
STATIC WATER LEVEL Below Top of Casing: ��_ FT.
N�
(Use '+" it Above Top of Casing)
�. rn
6.
TOP OF CASING IS __ FT. Above Land Surface'
vrz
• Casing Tsrminnted at/or below lend surince in Illegal unless a variance Is Issued
'•
In
accordance with 15A NCAC 2C .0118
METHOD OF TEST
CJ o
9.
YIELD (gpm):_aQ_ --
'"
WATER ZONES (depth):
11. CHLORINATION: Type 1 - Amount A,-ya2DD II additional space is needed use back of form
12. CASING:
LOCl1TION SKETCH
Wall Thickness
Depill Diameter or WeMaterial
(Show direction and distance from at least two Stele
From-- To - Ft. noads, or other map reference points)
From To Ft. —
From To
13. GROUT:
bepth Material thod
From 0 To 2 Ft. 14 a, dA
From --To Ft. -
14. SCREEN:
Depth
Diameter
From
To
Ft In.
From
To
rt. In.
From
To _
Ft. In.
15. SAND/GRAVEL
PACK:
Depth
Size
From
To
Ft.
From
— To
Ft.
16. REM
5
IDOL _ I.
CONS TION STAI'M nDS, At
Ji.t"i- s
Slot Size Material
In. �—
In.In.
WAS 4ONSTFIUC1EQ INnACCORDnNCE WITII 15A NCAC 2C, WELL
T'A COPY OE'TTtiS}11CURp HAS 9EEIJ PROVIDED TO THE WELL OWNER.
n is
h
GW-1 REV:
- DATE
:1.10MATURE OF r rTftACTOn AGENT
Submit original to Division of Ernironmontai Manngnment and COPY to WON owner.

North Carolina • Dnpnrimnnt of Envrrorminnl, f tenim, And NAlutni n ne9outca9 y ron ouicg USG Ot1LY 21279.9
Divisioof r-ovirontnrnttal Mrtnngntnnnt • Caround-Nnlet Section
P.O, nox 29575 • llnlnlgh, N.C. 27626.05J5 (�IJAn, fIt), BEn1ALiJO. N
Phone [phone] l nl _- LotV. no
Minor 9nain
WELL COBS rnUCTION nEConD _-�—�
Rnnin rnrtn _...�,
` I Inndnr rid.- - -- - OW-1 Ent
DMLLING CON F nACJ Or1• �_�llfu��uuu
siATF.. WELL COIISIIIUC1ION
DnILLEn nE(;IS fnAf (Oli filiMnr=r1: 7 1 _ - — PERMI1' tlUN113EF1:
WELL LOCH 11Oaz==
cation below)
Nearest Town: �—____....— County:
(nond. collrMulliteof .SulAivisioj 'nd Lot No.) U_I%_f_'_ i_I I _ WILLING LOG
2. OWNEn _ — _ Ftot„ in (otrnadon Description
ADDRESS—, - . - _,_� -- — --
(Strect nr nog ,o.)
City or Town Slain Zip Code ,-
O
3. DATE Drill-I.F.D USE OF WELL DOM.
4. TOTAL D1:_ P I i i -- ----- G e m
5. CUTTINGS COLLECTED YES ❑ NOLA,
6. DOES WELL FIEPLACE EXISTING WELL? YES (_] NO[�J ^'
7. STATIC WATER LEVEL Below Top of Casing: _ � FT.
(Use'+" if Above Top of Cns(ng)
8. TOP of CASING IS---�_-_ - r- r. Above Laitd Sutface" — cn�
• Casing Torminr,lnd evor bolow Innd surface is Illegal unless a vorlance Is Issued ••
In accordance milli 15A II^CAC 20 .0118 ---
9. YIELD (gpnt):__L-C-;SME'FIIOD OF TEST - W
' 'NATEn ZONES (deplli): --
11. CI-ILonINAT ION:
12. CASING:
IT T yi)e ZY T AIT)OUnt� — If nrlrlilional "•r1aCA 19 nAACInd U�f9 back of IOfm
Wall ihickness
Uel)lll 41amele oWclg� n tint
FL cap!
From
To�—
From
To Ft.
From —To---'
Ft.
13. GnoUT:
0-
Ur'plll Materiel nlhod
"1 Ae_ rt. C
From
o
From _..
To __ Ft.
14. SCREEN:
Depth Diameter Slot Size Malerinl
From
'ro ____ F-t -- Iri. _ in.
From
10 --- FL ---- In. _ h).
From
15. SAND/GiIAVEI_
PACK:
Uei)Ilt Size Mall�rf�l I;
ri,
From
M ,t
To —
From __.`
To Ft.
I , AUG j h ?000
t n. nF_MAFTKS
I DO JL 11
WAS CONS i-nUCi EU�ird ACc
CONJ Ili
TIU"_SrAfjDAr10jS;_-. at
A COP
fittf� Ire;
L.OGA T ION SKETCH
(Show dire .lion nrld dielartcA from at lengt two Slate
floadg, or olhnr map relnrnncs points)
ZA
6nDniIC, F WIIII i5A NCAC 2C, WFLL
iAS p6Fr-i r rIOVIDED TO 11IE WELL. OWNEn.
!2-9
Croundtivale7�clion SI(IrIAtunE OF Cr IHT 01 6z&F.tlf VATS
ow-t nev. Asheville Re,6onal Office Subrnit nriginnl In Ctivl9lon of Errvlrornntnlnl t.1nr„ 9-m^nt nn i c^pY In rvRll owr`nr.

North Carolina • Unrarlrnnnl of Envlronmrint, Ne tlih, And Nniurm 1lesources FOn orncFLisE ONLY 2 1 2 7 9 8
Division of Envirommnnlnl Mnnngnmont • G►oundwAter Secllon oUAU f1r) sEnIALNo
P.O. Box 29535 • flninigl,, N.C. 27626.0635
Phone [phone] nt. _... .Lorq. no
Mlnnr ftn^in
WELL CONS Tr1UCTION nEConD EtnnlnC�rrn
DRILLING COMIRACTOr~ ���� An
1lnnrinr Fnr:.. C1W1 ant
SIAllE WELL CONS If1UCIION
URILLEFI REGISIriA11ON Nl1ME3f_fi: �� PEtIMITtJUMF]Ef1:
1. WELL LOCAIION: (J,low sketch of the location below)
Nearest Town:County:
(nond, connnu or Subdivisl rid Lot No.) UEf' 11 1
_ DRILLING LUG
2. OWNER _ — From to
rormndon Description
ADDRESS�_�_._—
(Strert orY;dute No.)
__ _1YC
—"
City or 1 own S1nIn Zip Carlo —
DATE Dlll.�� d
3, _
o -
--
4. TOTAL DEPTI I _—so o ___ ---
5. CUTTINGS COLLECT FCl NO D YES Lam'
�
6. DOES WELL rIEPLACE EXISTING WELL? YES [__] NO[; J/
N -•
7. STATIC WATER LEVEL Below Top of Casing: ,Er FT.
(Use '+" if Above Top of CAsh,g)
M.
rri
6. TOP OF CASING IS _—__.— rr. Above Lattd Surface"
"Casing T*rminnled eVnr below Innd eurince is Illegal unless a varlane@ Is Isnued
�--C7
Ftil
In accordnneo wllh 15A MCAC 20 .011A
9. YIELD (9pm) :L. _ __ ME f I IOD OF TEST ��
�—
w "
' INATER ZONES (depth): —
11. C11LonI1`IA1IOIN
12. CASING:
Type— Amount II nrlrlitionnl ^pncn is neAdnd use back of form
WAIT 11dsLness
Depth oinnintor or
e�.�
Frorn IQ— Ft.
From To — rt.
From —To— Ft.-
13. GROUT:
Material thud
Uppill
From 1� - -to �U rt.
From To --rt.
14. SCREEN:
Dr,plll Diameter
From _—•Io
From
TO
From —_ _..._._
To _._._. rt. _
15. SAND/Gf IAVEI_
PACK:
Depth Slz
From
10 rt.
From --_
TO Ft"
16. RF_MARI<_cZ_'
+--. --- �-
I t IE IN
CO TnNS
ow•t nEv. oret
Malorine
Slot Sire Material
LOCH 1 ION SKETCH.-
(Show dirn.ction nr,d distnnre born At lenst two State
flonds, or oll,nr men reference points)
I
_.--
Irt. ht.
e MatgrlCAl } ` .
�(t �+
1(,F WI II 115A IICAC 2C, WFI_L
EN rriovlDr:I) TO TIIE WELL OWNEn.
rrrrinCI On MFrlr GATE
Mon of Fnvironrnanrnl and cnry to well owner.

Norlh CArollna • DrIpittinnnl of rnVlronmrint, Neallh, And Nnlumi npgoutce9 ron OFrics UsE txat v 212 `� 9
Dlvislort of Environrnnnlal MnnnpmmMnt • GIOUnd'Nnlgr SOCIlon
P.O. Dox 2.9535 • flnlnlgh, N.C. 27626.0535 gUAU. NU.
Phone [phone]. nt. __.. _ Lenq. no
Mirror E1n^6r
WELL consTnuctioti nEconD
nnain
Ihnrinr F.nt.: _ _ GWI Ent.
DRILLING COtJTFiACTUfi• _ _ __—
�-• 5FA7F.. WELT. C011S1110131ION
OnILLEn FIEGIsinA11011 N11MBI-M: J 7 1 PEfiMl1- NUMT1E1i:
WELL LOCATION: �(SI 'w sketch of the location below)
Nearest Town: #ti — County: GYn
(Florid. Coonnur--or S11MIVNI011 n l at No ---
UF:i' I I I
_ MILLING LOG
2.
OWNEn _
Froth in
Form ilon Description
(Slront or nouto No.)
City or Town Slalo Zip Carlo
DATE Di111.1_Fi) USE OF WELL m
3.
4.
TOTAL DEP 1 I I
0
5.
6.
CUTTINGS COLLECTED YES L_] No[, _
DOES WELL FIEF'LACEms-f NG WELL? YES (_] NO9
--
7.
STATIC WATER LEVEL Below Top of Casing: FT.
(Use'** It Above Top of C.101q)
tv
c<
e.
TOT' OF CASIIIG ISFT. Above Land Surface"
• Casing TormInsled eUnr bolow Inod surface Is Illegal unless a varlence Is Issued
�o
In
accordance wilh 15A 1CAC 20 .0119
O
mT'-'�—
9.
YIELD (gpiil):-_—ME'iIIOD OP TEST
N
n
—
NATEn ZONES (depth):
- —
"o
11. CHLORINAT1orJ:
12. CASING:
z
Type _ N / A1110U1I 11 nddillonnl ihacn is nandnd u9e back of form
Will l hickness
O
Dep1
0
UJ .mnl r cu, 2l211 Ft.
�rinl
From
oth�
Frorn
To---—
From--To—.----
Ft. --
--
13. GROUT:
Unplll
.i
Materlil rllhod
From
o__-
FrOrn
14. SCREEN:
Orpl)h
Dinineler Slot S17e Matedni
LOcn t ION SKETCH
(Show (junction mtd distance from 8t IeAst two Stele
fioad!3, or oIhnr mrip rshlerence polnls //
From .____-._10 —___-- 1'I _— In. --- IiI.
From --- To _.—___ i-l. __—_— in. _ In. ----
From -- - --- T ° - Ft.
15. SAND/GRAVEL PACK:
Depth Size Material
From _ To _.___ H. --
Ft o►n _ — l o
...
FIEMARI�
1ooIiFn.
CONSM f;7T�(,
)AMS, AND
9
ow-i nev. 919
1xa,.a WELL
/A: C0 uslr1LJC1 _0Ill A(-CC)DAtu;F_: Willi i5A fICAG 2
Cc.
A Or,Y,o(, rli�I� b}f OnC l l'!14 nFEN r'rlc)VlU[D To 11 IF WELL OWNEn.
"a�Irevdll ldr n ter � , +'=
—SIMIATUnF or cr Trinclon orl Fill DATE
rind t�py fo n�A ewrur.
Submit orlginni Io Divhlon or Errvirorvnmlint i.im„q^n1�rd

:a=:._
North Ctirolina • Depalfmntlf of Environrnenl. Ifeallh, wid Nafuml rle9ouices Y•� M~ _��
Division of Envirommnnlal Mnnngntnont " Groundwnler Section FOnOFFICE Ol1Al). IIU. AEnIA1AoN LN0.LY ,
P.O, t)ox 29535 • rinlnigh, N.C. 27626.0535 I
Phone [phone] l nt.
M6ror Pa^.in
WELL CONSMUCTION nECOnU tlnn►nrnrn_Y_
DniLLING com,nACTOLI: Q C ,lC1G►r, ,,Qo , �Cp llnn(lnr Errt: _— _ _ GW-i EnL
SiATF. WELL Coils iilucIION
" DnILLEn nEGISTf1ArION i UMrlf_rl: PEr1Mir' FJUMnFr1: t
1. WELL LOCAT ION: (S110,.1v( s"Icll Of Ilse location below
Nearest Town: _t/ J��J — County: — - .-----
(nond, Convnunity, or 6ul�iivislnn and Lol No.) UE1' I I I
2. OWNEfi __- Frnrn to
—_.._--
Shent
City or 1 own Stale Zip Code Cp
3. DATE DRII-I_Er) 16 USE OF WELL��a—�-_
4. TOTAL DEPTI I —
5. CUTTINGS COLI_EC i EU YES [V] NO 1 -
S. DOES WELL r1EPLACE EXISTING WELL? YES
7. STATIC WATER LEVEL Below Top or Casing: � FT.
(Use "+" It Above Top of Casklg)
Q. TOP OF CASMG IS % FT. Above Land Surface'
' Caling Torrnlnnled mUnr below Innd surince is illegel unless a variance Is Issued —
in sccordnnee wilh 15A t1CAC 2C .Olte -
9. YIELD (9pm):—Z.0__ METI IOD OF TEST
1r' WA -TER ZONES (depth):
_U_FIILLING LOG
Formndon t)escrlptlon
— r
�
`C:
C
rn
N
rn
a�
M r, -
rn
�x
,..
C-) -
r
tao
11. CHLORINATION: Type Amount II addilionnl .^.pnce is needed uAn back of form
12. CASING:
ETCH
From --Depth/- � biarneler
To Ft. �-
From To Ft.
From —To --= Ft.
13. GROUT:
alerinl M_4�_
n Depth
From -r o
From To Ft.
14. SCREEN:
Wall l ldrkrtes!
or weight/Ft. Materiel (Show dirnclion and distance from at least two Stale
_&61W, floats, or oilrnr rnnp reference points)
Depth Dinnieter Slot Size
MaletInI
From To Ft III, In.
From To —_-- rt.___ In. In. —
Front _— --10 ----- --- Ft. -
15. SAND/GRAVEL PACK:
Depth Size ivlaterlal
From
From — T o Ft.
16.
CONST I rJ S7nrJUnnUS, AND
�JUN ! 9 2000
GW-i nEV
k
V S T�rjstnyc
tEU Its nCCnTlDnttlCE WIIII 15n (ICAC 2C, W6LL
!1 COF't(OF TI IIS FIECOF]U t-lAS vE.Erd rr10Vl[)ED 10 111E WELL OWNEn.
�;'U13f1Ll�U.dt3:. dui+lcla
/2/
SlOrIATUrnnr )rrffiArTOn n Ar;r'111` BATE
Subndt original to Nvislon of EIT01011nlnn1a1 1`1rr111q^n1"nt and rnry to wmll owner.

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section , t r
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone] . l 1a 0 J
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTI ICATIO #: _ �'
STATE WELL CONSTRUCTION PERMIT#:
1.
WELL USE (Check Applicable Box): Residential G Municipal ❑
Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑
If Other, List Use:
2.
WELL LOCATION: (Show sketch of the location below)
Nearest Town: zLsbdyl i a. -- County: Ir�+ilCor„b
Q
(Road Name and um ers, Co unity, or Su division and Lot No.)
DRILLING LOG DEPTH
3.
OWNER
From To Formation Description
Address
�T
/
_ xp
•
City or Town to Zip Code
t
4.
DATE DRILLED-.�1�?�
5.
TOTAL DEPTH
6.
CUTTINGS COLLECTED YES❑ NO [�
WELL? YES [� NO(,,/
c� ':;
7.
DOES WELL REPLACE EXISTING
6.
STATIC WATER LEVEL Below Top of Casing: _ _4(.p FT.
I (Use '+' tl Above Top of Casing)
TOP OF CASING IS—! FT. Above Land Surface-
Co
9. --
•Top of casing terminated at/or below land surface requires a variance In accor-
dance with 15A NCAC 2C .0118
10.
YIELD (gpm): Q_ METHOD OF TEST
N
11.
WATER ZONES (depth):
12.
CHLORINATION: Type Amount
It additional space is needed use back of form
13. CASING:
Wall Thickness
Depth is er or ei hVFt.
From To� Ft.
From To Ft.
From To Ft.
LOCATION SKETCH
-Material (Show direction and distance from at least two State
Roads, or other map reference points)
14. GROUT:
Depth Material Method
From _ Q 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 CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RE,C9�D AS BEEN PROVIDED TO THE WELL OWNER.
1
FOR OFFICE USE ONLY DATE
Quad No: �NAT OFPERSON NSTRUCTING THE WELL
a7 S4bm(t original o Division of Water Quality, Groundwater Section within 30 days GW 1 REV. 12/99
7, 1 bi
Serial No.
i _

North Carolina • Department of Ern mfur W and Natural Resources -Division of Water (]uality
Groundwater Section 22 3 9 '71
,We Mati Service Center • Raleigh. N.C. ZMW-16WPh0ne [phone] _ Q
ORD WELL CONTRACTOR: l�H�-t...
WELL CONSTRUCTION REC WELL CONTRACTOR CERTIFICATION e: ;�---
STATE WELL CONSTRUCTION PERMIT#:
Resldentiel CK Municipal ❑ Industrial ❑ Agdcultutal ❑ dng
Recovery [3 Heat u
i . WELL USE (Cho* /►pp n Water IWWd 0 Other Q It Other, List Uas:
2. WELL
Town:
'#�! Name and
3. OWNER j
Address /n _
of the to ation below)
WA Lot
,J
4. DATE DRILLED/
5. TOTAL DEPTH
S. CUTTINGS COLLECTED YES ❑ NO®
7. DOES WELL REPLACE EXISTING WELL? YES Q Fr.AS
S. STATIC WATER LEVEL Below Top of Casing: _(.
(imVI Abme Top of glop)
9. TOP OF CASING IS— FT. Above Land Surfewe•
'Top o! cg8bg terakmftd atlor bdm land sumacs nquk" a muhm a In aeoor-
dwm wN 15A MAC 20 Alta METHOD OF TEST T/ A4 G
10. YIELD (gpm): L,
11. WATER ZONES (depft / / 2
z-
12. CHLORINATION: Type � -
R?t3 Amount
13. CASING:
DRIWNG LOG
Flom To
DEPTH
Fannetlon DesWWm
it @&Wonai Was is rrseded !r°e OM a wxm
tyhtNW (Show dkecdon and dis*wm
Depth ofFrom To ._._....._. Ft. - =ftm- Roade, or other map refr
IAI From—%-- -- To Ft. �-[.
From To FL --
14. GROUT: MawMolmd
Depth lal
From To 20 FL
From To —FL
15. SCREEN:
Depth Dfwfmter Slot Size Material
Fromo inEi��
From �;2—To Ft. �.kL
From T F in.
is. SAN
WGF?AVEL.PACic.
F ({{p ``1 Mataritd
r h To pU l
From yG E
From �, , a T
.19: �D
23
at leeet two Stae
0 pcife)
v
cyT)-EcoI/GRd --.�
17. REMAPOC15 I ' n'
T TN1S WELLWAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
i DO HEREBY ANO T WT A COPY HASJN TO THE WELL O
CONg'(Rt1CTiON S7ANDARM
FOR OFFICE USE ONLY SMARMOF l TK WELL
owd Na &*ie 0.%* b t)l "0" a Watrer owner, o vx4vmw 3ec*m within 30 days
DATE

North CaroCna . Department of Erwironroent and Natural Reaourcas - Diygion of Water Guality
Groundwater Section � 2 3 `7 / �
1636 Mah Servk:e Ceder- RaMot. N.C. 276WlMPh0ns (91u) 733-3221
RECORD WELL CONTRACTOR: R ' � A'� �,�• JD � ����
WELL CONSTRUCTIONV
WELL CONTRACTOR CERTIFICATION i:,-� 7 y.
STATE WELL CONSTRUCTION PERMITM
1. WELL USE (Crude Appt a&b eoxr- Resider W C& Munkdpal ❑ Industrial ❑ Agric WtW ❑ Monitoring
Recovery [] Neat Pump Water IrW*n ❑ Other ❑ If Other, List Use:
2. WELL LOCATION (Show
Town:
or subiti Wm and Lot
3. OWNER
Address
%Aw a .VIA. --
4. DATE DRILLED
5. TOTAL DEPTH
& CUTTINGS COLLECTED YES ❑ NO[Z NOCR
7. DOES WELL REPLACE ExisnNG WELL? YES
8. STATIC WATER LEVEL Below Top of Ce*Q: �,g .
(tW "t' 1 Above Top of Gump)
9. TOP OF CASING IS I FT• Above Lmw
-Top or wing swadrobd atror tutow land sunset r pubes s vittaeoa In seoor6
dance wo 16A NCAC ZC.Ott$
10. YIELD (W=): _ Z_ METHOD OF TEST
11. WATER ZONE$-----
12. CHLORINATION:
13. CASING:
DRIWNG LOG
F wn To
MOM
Farfimiiort 0+
Type P3 Amount tt rddlt WW ripens is MdW use back of loan %ole
Wd Ttidom
Depth orwaiptrdR MEN"
From 0 —To _! FL A `SQd? _ "I°1OL`'
From� To.r._--- Ft. —
From _------TO - FL------
14 GROUT: Depth Maw 1L�e�1"'k'--veil
From ...�— To . '2 n Ft. "�'/
1 99611AN SKEW„_ iCH
(Show direction Wd from at Iwt two State
Roads, or other msP ralerenoe per)
From To Ft.
15. SCREEN:
Depth DlamsW Slot Sizi Materisi
From .,.._._ o in. Im
From To --- Ft. in. In.
From To F U• �-
1e. SANMRA{{ VEL PACK. I
t:,{ � i� '4i 6d li �YIO1VIar � 4
Frq0 I
omt ,�-"—
From To',
17.
�• c 7I � rr• •� H
a� . a • a •
DE
FOR OFFICE USE ONLY
Owd ft
&MATMOFPWAONCONt3( itX•'T1NdTt WELL wit
&&* o+totriwl,*tll"m ar WaW Owltb. Owl SwAm **An 90 days

WELL CONSTRUCTION RECURS WELL VXM"M: r:
WELL STATE� MM� ref:
1.
2; WELL I
N"(4 f
& OWNER
�t.dc � geoovery p waw i L7
skafth of the iota► bakA A
or
m.,Ww 0 ftwmwO
Olher [3 If Otm- L lst Use:
=rorraNn
4. DAT90AILLED
& TOTAL DEPTH
s. cam$ COUJEGM Yesm N� � MOM
7. DOES WELL E B�ppT d �
S. Sl'ATIC WATER LEVEL
I .� m" %e s AbW*Topol c "W
8. TOP OF CASING IS...L: -- FT. Above Lind Stlffi*os'
a�brftirfo•rkwo-I r s itaaoar
propef combo
-c i uM M Ti .fif
10. YII b oxn)� ,AMMO of FTW
_
1 i WATER ZONM i a= -
12. CHLIA
13. CASING:
TWO
Wd
Depth
E altt
or t_
Fmn---Q�TO � F;L fr—
Fran------ To� -- `L — ..._----
From To..•— FL
U. GROUT. Deplh Ms"m
From '(. _u Fl.
From To _._____,_Ft
15. mot Shi mawlal
From o
bi
From To FL
T ift.
Fmm �'-
I& SANDAMYEL
From
Frm
"(�239'73
mm*,0(uVo
L M.AU SKQS-
srd awes kWn**HMO
flasds, or odor msQ t ��)
Q
_� vim• -•� •-
r •

North CM tW - Deperbnertt of En*wwwlt and NO" n - olrwon or WaW OL*W - RmwdwaW section 2 2 3 9 7 �
,m it,Ia s«wm Certter- Rateiptt, N.c. gmw,fie-Phone ca,sj 7om
WELL CONSTRUCTION RECORD waL. COWMACTOR:.arr
WEu. CONTRACTOR CEONVATION C. s2 781"
STATE YELL CONSTRUCTION PERM #:
1. w@LL USE BO* PAddetttw CI Mtrr�icipal [3irtdtmuw 0 A� ❑ � 17
R mmy iw pwv Water 0 other 0 If Oem, uWt uw
2. WELL. LOCAll (show 1 bn or use woa*m bdM4
Ne"d Town: J cov .. adze ' � -
c mmtrttiyr or &bd joon end trot
3. OWNER
Address
4. DATE DRILLED LV. / I / 6y
5. TOTAL DEPTH li & '
s. cuYTaas cmimw YES ❑ NO®
7. DOES WELL RMUCE Lr WTM WELL? YES NO(R
8. STATIC WATER LEVEL Below Top d Caft- dZ 6 FT.
ttM W l Abort ioR of Ca*0
S. TOP OF CASING IS- FT. PJWN Land Serape'
'Ta+ovem eai~rM' ' - *tarbdoww sreoer.'t l a Ntwnm►ln amoon
dw oewMt MANN020 0
ETWDOF
it. WATER ZONES (dapeh)N ..._.....,
12. CHWRINATOI: Type �� Amwtt. 3
t3. CASING:
�Nf ymdmn MAN"Fnxn. n .. -To �.- - Ft.
-A..f��.
Front------- To--.-••• FL----- -- -----
From To------ FL
14. GROUr
Dwdl
/� McAerw
Fran T. 20 Ft.
From _To Ft. -----
15. SCREEN:
Depth DtW mm, Stet Suit Mdww
From o
Ftorn To Ft. in.
From T h in.
Ili. SANDAMAVEL PACK:
Oepth Oka Mau"
From To
From To Ft.,,
tt adMand.pace r -0INthe beds of Iota►
M SKE1
(Show dk a m* Wad dietMlos born at but pro 8HM
P,Omft a apter rw $1410 -os p* ts)

222�"8.
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636-Phone [phone]
1636 Mail Service Center - Raleigh, N.C. 27699-
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION #:-
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other [] If Other, List Use:
2. WELL LOCATION: (SI, w sket of the location below)
Nearest Town: o County: J�
Road Name umbers. commynity, or Su sion and Lot No.) DRILLING LOG
3. OWNER From To
Address
--(Street or Route o.
City or Town St a Zip Code
4. DATE DRILLED
5. TOTAL DEPTH 3 5
6. CUTTINGS COLLECTED YES ❑ NO[EL— "-
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 atfor below land surface requires a variance in accor-
dance with 15A NCAC 2C .0118 7—
10. YIELD (gpm): METHOD OF TEST ./�=
11. WATER ZONES (depth):
12. CHLORINATION:
13. CASING:
Type 7—�1 L2 Amountadditional space is neat -- _-- -
DEPTH
Formation Description
Depth Diameter
From 0 —To Ft. —Iet-�--
From To Ft.
LOCATION SKETCH
Wall Thickness
cr weighvR. Material (Show direction and distance from at least two State
r2 z,L -v-- Roads, or other map reference points)
From To Ft.
14. GROUT:
Depth Mat 'al Method
From — To Ft.
From To Ft. _
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft in. in.
From ToEFt. in. in.
From o T Ft. _ in. in.
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To —2, Ft.
17. REMARKS:
FOR OFFICE�Jj
NLY
Quad No:
WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C, WELL
r•'e:`rinovLlF,THISl1EC0RD HAS SUN PYPVIDED TO THE WELL O
SIGNATURE PERSON CONSPI�ICTINGTHE WELL LinIG
al to Division of Water Quality, Groundwater section within 30 days GW-t REV. 12/99
Serial No.

North Carolina - DeparWord of Eatvironrr m and. Natural Resources
63- Ofv�iort of Water CluaYty - Oraundwater Sedbrt r' `>j
1, ti.. _.
1e Mail Service Center Raleigh, N.C. 27000638•?hone (919) 733;3221
WELL CONSTRUCTION RECO
RD .WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION P
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE tctmek Appltcsbie VON): Residential5----Municipal C] Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Meat Pump Water injection [] Other [] If Ohrer, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: ---� =i ` U �' County:
DEP T }•i
(Hoed Name and Numbers. Camwnlly, as $ubdiviaten and Lot No.) DRILLING LOG
Formation dseatpdan
3. OWNER ar �c? j ► From To
Address
t met ar e
Cry or Town Stale �p �OdO
I
4. DATE DRILLED
S. TOTAL Dt+PTH © 5
YES NOC�
6. CUTTINGS COLLECTED
REPLACE EXISTING WELL? YES NOS
—
7. DOES WELL
8. STATIC WATER LEVEL. Below Top of Casing: _YO _ Fr.
(Use '+' M Above Top of C 1kVI
Surface'
-
9. TOP OF CASING IS Fr. Above Land
.Top or oaatng lertninated atfor below land wrists re"Irea a variance to secor- ...:. ..
: .....: . . .
with t 2t; Qt1 a
(q m): METHOD OF TEST
1t). YIELD (gpl»);
10.
11. WATER ZONES (depth):
Type E --Amount
if additional space is needed uSe back of to=
12. CHLOF31NATION:
13. CASING:
L_OCATION�ICErCN _
r Wall
/ Depth or W � maleAal (Show direction and distance from at least two State
map rofarenae points)
�
FromS,.L-- To-�-
Roads, or other
-
From - To Ft.
From To Ft. - ------
14. GROUT:
Depth Materiall Method
a
From b To Ft."'r `uR
q
Q
From To Ft:
L'70
rn
15. SCREEN:
e
Depth Diameter Slot SizMaterial
crn'�
N
c rn
o.c
From __ To Ft In. In. _
CO
=r= rn
Front To Ft. In. In.
in.
y„
rrn
;:Oa
From To Ft. In.
16. SAND/GRAVEL PACK:
r`''
Depth Size Material
From To Ft.
From To Ft.
17. REMARKS:
I DO HERESY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C, WELL
BEEN PROVIDED TO THE WELL OWNER
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD
—La 0
FOR OFFICEUSE SE ONLY
SIGNATURE OF PERSON
THE 1MirLL DATE
Quad NW",
r Submk orlgtnai Io t�vlslon et water ovauey. Groundwater Saeiion within 3 days
OW-i REY. 12M

FROM : FAX NN. : May. W6 20a2 05:18PM P1
Nwth C=la m - Deparlmard of E3nvkon rm* wW Natural Raaourm - ti6imn of water Quv tY - Groundwatw 8hc6on
16M mat terns Comm • Rwaick Ica 276ee-15wame (019) rd"m
WELL CONSTRUCTION RECORD wELL Cm fmAcTcm
WELL CONTBACMR CERTIFICATION d: 2 V.
STATE WELL CONSTFILIMN PERIMT#'.
1. w$LL usE Appomw t� Real�dltwM l al L7 1nt Pl O /�dtxli�cel0 ww t dm
Rs omw 01 Pratte Water Widw E] 01m 0 If Odw,'* Care:
2. WILL Lei
Nm MtT
-74214
3. OWNER
AM
5. TOTE pplt#.Ei}. TOTAL DEPTH _4
Br. otnilM COLLICM vwQ 1+0ml
7. OM WELL RSPLACE MUSTM WgLL? YES 13 1403
& STATIC WATER LEVEL Bdow Tipp► d Cadrw FT.
(t wlVNAbm7tlpot*mine)
8. 'IOP OFCASING IS , Fr. AWw Lend SusllW
loworomMl2+rr mbmdolkrpeibirhitdaatirdat ultAtwawrM�1a.aoaw
daaaa 1YMM ib1111t'.aalC �iri
14 YIELD (��: � — MtOD Ol=TES!'
11. WATM ZONES (dV**:_�
12. CHI.ORIMATIOlt TRts _$-AffAw t
13. CASIN(k
VMTddmo
Fran_ � DTohMOM
P't.�� -�+•
i4. QROUr.
lion
From TO s�FL &Amu4y�
From —To FL--_.--.�..-
16. HIV: .
FM tt O in.
From Zlio Ft. [r� Finn Ir1. = IL
16. SA"RAVIL PAM
Daplh S1# MImmm
From
FMm � To f
17. ISMAFAM
d M&NO" ep otB rtaaded uM bm* ofIona
a. �►Ttenl $IfETC:Ii
($tpw dltatlfott tllttd diptprtes 6atrt at 1peptrdt bNo
ptatf a. or cll�i�e Pdt►ts)
jo
0
ti
ail
I DOHWAWCMWffyMT"VARLWASCONfff"UMMINACCCIIDNMWWRHISA p rA02G.VftL
"I1{14TA OEM PROMOr:DT0 TW YILLOW14M
FOR
CWdNK
9u+anR etrwp*ro►+�NV:Mot�w�rnr8�ehoa�Fdn9tidi►ye
MAY d 6' 2002 14
3 sw L _ 17 Z
uvvnr" of ulluN / �j �- /_(a ?
E REGION_ A_�F�CE l UN� o 6 Z 3
G3�,+ M

ia. !r sr � ti7
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
h N C 27699-1636-Phone [phone]
I coo Maul Service Center - Ralerg .
WELL CONSTRUCTION RECORD WELL CONTRACTOR: �-•>�-` -�n [-'�'-� �' �'�"��
WELL CONTRACTOR CERTIFICATION
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check applicable Box). Residential EN Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATI (Show sketch of the location below) //��
Nearest Town: 'i���_ County: (Lol —
(Road NameAW Numbers. Conrramity, or and Lot No.) DRILLING LOG
3. OWNER J From To
Address I
A/7,
City or Town st>te 23p Code
4. DATE DRILLED
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑ NO®
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NOCR
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 allot below land surface requires a varlenco In act or -
dance with 1SA NCAC 2C .011a
10. YIELD (gpm): METHOD OF TEST %-
11. WATER ZONES (depth):_1�_'_ �S r
12. CHLORINATION: Type T#� Amount ~ --
13. CASING:
WIN ThICra+ass
Depth or WeV*41 Material
From 69-- To f 0 Ft. - - -�-a�-
From To Ft. -
From To Ft
14. GROUT:
Depth Material Me
From ,.t2_ To - SIZ D Ft. P-9 - From To Ft. ---
15. SCREEN:
Depth Diameter Slot Size Material
From o t n. in.
From 7o Ft. in. In.
From To F In. in.
16. SAND/GRAVEL PACK:
Depth size
From To
From To Ft.
17. REMARKS:
1 DO HEREBY
Material
DEPTH
Fomuttlon Description
tf additional space is needed use back of form
LOCATION AKETCH
(Stow direction and distance from at {east two
Roads, or 09C.Maorefemnce points)
IN AC DANCE WITH 15A NCAC 2C, WELL
BEEN PROVIDED TO THE WELL OWNER.
atrad No HEI' L' 3 — ' '' ` P NATURE OF PERSON CTINO THE WELL UAM
Submit oiiru>(� Division of water OuaNty, t3mundwater, Seaton within 30 days ciNl-1 REV. toes

I;
1.�'4,58
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 sox). Residential M Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL I
. Nearest
(Road Nance
3. OWNER
Address s
V: (Show sketch of the location below)
W„
/ DRILUNG LOG
Frorn TO
QW or sown
4. DATE DRILLED
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑ NO®
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO®
S. STATIC WATER LEVEL Below Top of Casing: �_ FT.
1- (Use V if Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface'
-Top of easing Unnh ated surface rsquhas a vwbnm In accor-
dance with 15A NCAC 20.0113 '
10. YIELD (gpm): __La METHOD OF TEST 72 Ad
11. WATER ZONES (depth):.., D '
12. CHLORINATION:
13. CASING:
Type -221 .9 Amount n additional spare Is needed use toads of form
Agricultural ❑ Monitoring ❑
Wall7tkkness
Depth or wew/K memiaf
From(9 --To Ft. Ur 21 - L
From To Ft.
From To Ft.
14. GROUT:
Depth Materist Me -
From To .!�20_. Ft.
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From o t n. in.
From To Ft. in. In.
From To F in. in.
16. SAND/GRAVEL PACK:
Depth Size Material
From To L
From To . Ft, ��
17. REMARKS:
_LOCATION SKETCH
(Shaw direction and distance from at least two State
Roads, or other map reference points)
I DO HEREE�7 �} II�i�vLvsCaysTRt�cTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
...... .. �,iIMW 6r m °stun rFta ! 1 COPY CF'�NI�AECORD HAS SIED1f ROVIDED TO THE WELL O
FOR OFFIC 'i ' O� y ,:
Ouad Na SIGNATURE OF PERSON CONSTRU THE WELL
original to Division of Water OuaNty, Groundwater secom within 30 days
S�ii7V VII(Q �£Rl�ftdi F) i �u
DATE
OW-1 REV. 12M
Wei
O

North Carolina - Department of Environunent and Natural Resources - Division of Water Chie ty - Groundwater Section
�J2�89
1636 Marl SerAm Center - Raleigh. N.C. 2768 I636-Phone (919) 733-Ml
WELL CONSTRUCTION RECORD weLL CONTRACTOR: - - - uuav adag &4--
WELL CONTRACTOR CERTIFICATION #l: zS�
STATE WELL CONSTRUCTION PERMIT#l:
1. WELL USE fawaAppta as soxk Residential o Muniapal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCAT IOy: (Show sketch of the location below)
Nsaroet Town: � �-�-'r' �
ecD< 1'4Re-Gh" 4
(PAW Name and Numbers. C mvnx ty, or Suba4don and tot Na) DRILLING LOG
3. OWNER Dl'&Y.-Al -ir W-Z^7TVA-8 From To
Addres>z I'D�l 6 AYL,-,"a wN Rd
or
C ky alTown St"' ZIP C�
4. DATE DRILLED
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑ NOW
7. DOES WELL REPLACE EXISTING WELL? YES NO®
S. STATIC WATER LEVEL Below Top of Casing: FT.
(UM't' 1 Above TOP of C a tnp)
9. TOP OF CASING t3 FT. Above Land Surface•
Toper" ' a- - ' ' surtme foquk" s mi Amp In a060F
Barra with 16A NW 2C a
10. YIELD (gppm): METHOD OF TEST 72Al a
11. WATER ZONES (4;:
12. CHLORINATION:
13. CASING:
Fanr"M DesWOM
Type 77211,61 _ Amount ....:. Ir addlti W apaee is needed use bak of loan
Wd n,la w"
Frorn�_DTo Zn Ft. �� -
From — To FL —
From TO Ft.
14. GROUT:
LQQ0ON1W9=
III "" (Straw dtreation and disianoe from fd feast two State
Roads, or oilier wrap reweno PC*b)
Nam D�
r n%
Depth Material metbod
From To .4Q. Ft.
From To FL
16. SCREEN:
Depth Dlarneter Slot Size Material
From o .
FromZTOZ�Zin. h.
FromT in. In.
16. SANDIGRAVEL PACK:
Depth Size Materiw
From To
From To.�G� �.----------
17.
• • t a'
:a t• ]• rr• •. It
��
r.. v.ri M•.1�����. D. _�: D �l'H !. _ •:,®�:a •ire': �__,___~�.i.� ��i1_ • r t • ] � •
FOR OFFICE rgNL"-_B — . ` owdNaTiJf� t>F pEft�oN THE watt.
&jbn* o�iptrai b*DNhan a water QtAft. Grorar&SW Section within 30 days

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Pho 919) 73%_'A"j
1636 Maul Service Center - Raleigh, N.C. 27699ne
-
WELL CONSTRUCTION RECORD WELL CONTRACTOR:��-��'
WELL CONTRACTOR CERTIFICATION 1l: .� `I Bey ---
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (check Applicable aox): Residential Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water injection ❑ Other ❑ It Other, List Use:
2. WELL LOCATIOfji: (Show sketch of the location below) Q —
Nearest Town: �jr-Q�"2�i�") County:1�'''''O''
(Road Name and Numbers, Conrrxmity, or subdivision and Lot No.) DRILLING LOG
3. OWNER ,P '' '� 9/C G �r r�NZinTi�K/S From To
Address _/a !,/ Z c S 'r-6 cJ N R d
,�iR-Jlt�cJ L(/ C. �1
City or Town State zip Code
4. DATE DRILLED AAVA
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑ NO®
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO®
S. STATIC WATER LEVEL Below Top of Casing: %, Z __ FT.
� (Use •*' If Above Top of Casing)
9. TOP OF CASING ISI— FT. Above Land Surface'
`Top of caskV wmku tsd avw below lend aurlace requires a varbace in accor-
dance with 15A NCAC 20 a '
10. YIELD (9pm): METHOD OF TEST .Z" l.t.�
11. WATER ZONES (depth):
12. CHLORINATION:
13. CASING:
Type -7-2Amount if additional space is needed use back or roan
DEPTH
Formation Desr:rip W
Wall ThkW*=
Depth arneff or waighi n Materlal
From Za Ft. 6AL_sV- -ReL-
From To Ft. -----
From To Ft.
14. GROUT:
Depth Material Mettiod
From _.rL_ To .12 0_ Ft.
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From o t n. in.
From To Ft. in. in.
From To F in. in.
16. SAND/GRAVEL PACK:
Depth Size Material
From To
From To Ft.,�
17.
LOCATION SKETCH
(Show direction and distance from Pt least two State
Roads, or other map refs points)
ffil b
I DO HEREBY GERT I FY.THAT THIS: WELL.WAS:CONMUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
---...«,....•r,..ii`e.,•wi rneoner elUn TcrnT'e r•.nPV nI-WMRMMRD HAS ( PROVIDED TO THE WELL O
run VrrIVG 'rAEwELL IJAM
PZ'
REOt'PERSONCON1' olvisNATUlon of Water OuaNty, Groundwater Section within 30 days (iw-t M. 11J89

North Carolina - Department of Environment and Natural Resources - Division of Water Cluality - Groundwater Section [�
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone] '" ' ' 9 • I►y
WELL CONSTRUCTION RECORD WELL CONTRACTOR: 1Ieoxgllr ld&4 4&9 -
WELL CONTRACTOR CERTIFICATION #: &2
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential M Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection [] Other If Other, List Use:
2. WELL LOCATIOJ�(Show Bch of the location below)
NeAest, Town: - _�� �� - - _ - - , County:
(Road Name an Numbers. pity, or Subdivision and Lot No.) DRILLING LOG
3. OWNER t- ��'` 02 _ _ From To
Address 2� � K. i/ —
VIS eet or out Po.)
A./Ic. cmwy
City or Town 9tate Zip Code — —
4. DATE DRILLED, o2s --
5. TOTAL DEPTH —
6. CUTTINGS COLLECTED YESO NOE_
7. DOES WELL REPLACE EXISTING WELL? YES M NO®
S. STATIC WATER LEVEL Below Top of Casing: / l FT. —
L (Use'+' If Above Top of Casing)
9. TOP OF CASING IS / Z__ FT. Above Land Surface- --
'Top of casing terminated atlor below hand surface requires a variance in actor- '—
dance with 15A NCAC 2C . 119 _.
10. YIELD (gpm): METHOD OF TEST
11. WATER ZONES (depth): F D 1 =
12. CHLORINATION: Type �-fi Amount
13. CASING:
Wag Thickness
Depth ter cr Weight/R. Material
From To L_ Ft. , Syi? v2 / dG
From To FL
From To Ft.
14. GROUT:
Depth Material Method
From 6)_ To c2O_ Ft.
From To Ft.
15. SCREEN:
Depth Diameter Slot Slze Material
From To Ft In. In.
From -7 To 7—Ft. Ft. in. in.
From To � in. In.
16. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To Ft.
17. REMA7FRIS:
I DO HEREBY CERTIg
CONSTRUCTION STA
FOR OFFICE USE O(V
Quad No:�
Serial No.
FEB — "
Material
DEPTH
Formation Description
If additional space Is needed use back of form
(Stow direction
Roads, or (
IN ACCORDANCE
distance from at least two State
map reference points)
OF PERSON CONSTRUCTING THE t
of water Ouaitty, Groundwater Section
NCAC 20, WELL
TO THE WELL OWNER.
30 days
OW-1 REV. 12("
x

North Carolina - Department of Environment and Natural Resources - Division of Water Ouality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone (919) 733-=1
WELL CONSTRUCTION RECORD WELL CONTRACTOR: Z2�� 1d).ev-V- a;k�
WELL CONTRACTOR CERTIFICATION #l: oL % C0
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential,( Municipal ❑ Industrial n Agricultural ❑ Monitoring ❑
Recovery C] Heat Pump Water injection ❑ Other ❑ if Other, List Use:
2. WELL LOCATION : (Show ! tch of the location below)
. Nearest Town: County: --�
and
3. OWNER
Address
or Subdivision and Lot No.)
City or Town State Zip code
4. DATE DRILLED
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑ NO®
7. DOES WELL REPLACE DUSTING WELL? YES ❑ NO®
S. STATIC WATER LEVEL 9elow Top of Casing: &2 -r FT.
(Uee -+- N Abaft Top of C&ft)
9. TOP OF CASING IS_ L:L - FT. Above Land Surface'
-Top of owing terminated at/or below land surface regefrea a variance in acm-
dance with 15A NCAC 2C.OJ1ti
10. YIELD (gpm): MD OF TEST T—>
11. WATER ZONES (depth):
a'
12. CHLORINATION:
13. CASING:
DRIWNG LOG
From To
Type Amount ? _ If additional space Is need
z
Wall Thickness
Depth or WatgMIR. Litate►ial
FromTo 6,5-- Ft.
From To Ft.
From To Ft.
14. GROUT:
Depth Mat at Method
From To 212_ Ft. ( IdLr J
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft )n. in.
From To Ft. � in.;;Z In.
From To Ft. In. In.
16. SAND/GRAVEL PACK:
DEPTH
Farrnalion Description
LOCATION SKETCH
(Show direction and distance from at IOSM two State
Roads, or other map reference points)
Depth Size Material
From TO Ft.
From To Ft.
17. REMARKS:
t DO HEREBY C 1 +'STY T UCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION ' DA1D�T Ar THIS RECORD SM PROVIDED TO THE WELL OWNER.
FOR OFFlCE US If V
F _f j 1 r ; 1VRE OF CONSTRUMMIG THE WELL
pwd No: % � ' DATE
SubrNt04gow to of Water ouality. Groundwater sec*m within 30 days
t-
S.W No. liWi-1 REV. 12�99

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section ; . 1 L . � r'1
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone] CJ 47
WELL CONSTRUCTION RECORD WELL CONTRACTOR: .? ear I?, t� WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential 21 Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATIO (Show sketch of the location below)
NearestTown:L d,�A O kelg County:
�-�L d:/9y t' .I
(Road Name and Numberspommunity, or Subdivision and Lot No.) DRILLING LOG
3. OWNER From To
Address JP�9
treet or oUt NO.)
City or Town State Zip Code
4. DATE DRILLED
5. TOTAL DEPTH _.Z_IIT-
6. CUTTINGS COLLECTED YES ❑ NO®
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NOO
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.9118
10. YIELD (gpm): METHOD OF TEST T�"
11. WATER ZONES (depth):
12. CHLORINATION: Type 7�_,f _Amount
13. CASING:
Wall Thickness
Depth /�l Di L or WeighUF . �.
From To _L4 6 Ft.
From To Ft. /
From To Ft.
14. GROUT:
Depth Material Meth -
From 19 To r J Ft.
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft in. (
From To �ZFt. in. in.
From �To J= ., Iiin, in.
16. SAND/GRAVEL PACK:
Depth Size Material
From To t.
From :To �t./
17. REMARKS:
FOR OFFICE US �NLY
Quad No: I Ij' ;Ji
DEPTH
Formation Description
If additional space is needed use back of form
(Show direction and
Roads, or other
Lit
nce from at least twoStat
reference point/l' 5
ED IN ACCORDANCE WITH �ISA NCAC 2C, WELL
RECORD HA,7,5EE,N PROYMED TO THYeWELL C
SIGNATURE OF PERSON CONSTRUCTING THE WELL
Su t,Orj i al to Division of Water Ouality, Groundwater Section within 30 days
DATE
GW-1 REV. 12199
Sedal No.

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section ; n
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone] �t ' 1 ;1
WELL CONSTRUCTION RECORD WELL CONTRACTOR: � -•ham 1 )�w — '-�"�'—�e
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable sox): Residential 21 Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCA
Near" Town:
(Road Name and Numbersmmunity, or
3. OWNER
Address
the location below) /�
County: !����
Lot No.) DRILLING LOG
From To
City or Town State Zip Code
4. DATE DRILLED b
5. TOTAL DEPTH s5E02
6. CUTTINGS COLLECTED YES ❑ NO®
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NOJ]
8. STATIC WATER LEVEL Below Top of Casing: f111Z 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 .0 18
10. YIELD (gpm): METHOD OF TEST
11. WATER ZONES (depth):
12. CHLORINATION:
13. CASING:
Type ,[1T �—Amount .�.�. _ If additional space is needed use back of form
Agricultural ❑ Monitoring ❑
DEPTH
Formation Description
Wall Thickness
D Depth Di ter or Weight/Ft . Material
From To Ft. —S.L- —�
From To Ft.
From To Ft.
14. GROUT:
Depth Mated I Meth d
From _C To � Ft.
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft in. i
Fromo �ZFt. in. in.
From AFTo Ft. �in. in.
16. SAND/GRAVEL PACK:
Depth Size Material
From To
From �To Ft.
t. .
17. REMARKS:
LOCATION SKETC
(Show direction d distance from at least State
Roads, or o or map reference points) U)�
0
O
I DO HEREBY CERTIFY THAT THI TRUCTED IN ACCORDANCE WITH I SA NCAC 2C, WELL
CONSTRUCTION "RL D IH41 A(§O THIS RECORD HAS Bf ENIROVI* TO THE W�Ei.L OWNER.
Quad No: t TORE OF PERSON CONSTRUCTING THE WEL;(/ 'DATE
Submit origfnial" ivtston of Water Quality, Groundwater Section within 30 days
Serial No. GW-i REV. 12199

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section 1„ Arc-,
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone (919) 733-=1
WELL CONSTRUCTION RECORD WELL CONTRACTOR: ������ ,-.�-s [.�6&kdsole 71-r—
WELL CONTRACTOR CERTIFICATION
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Chack Appllable tdox): ResidentladEl Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection Other If Other, List Use:
2. WELL LOCATIO�� �(,Sh-ow sketch of the location below)
Nearest Town: �tl�%,.r�i�_� f�/C Cgurtty
n
�inrlY i�_ &M
3. OWNER
Address
4. DATE DRILLED " OU
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES M NOO
7. DOES WELL REPLACE EXISTING WELL? YES] NOCZ
8. STATIC WATER LEVEL Below Top of Casing: , ZIXFT.
(US@'t' N Above Top Of CLft)
9. TOP OF CASING ISLE FT. Above Land Surface'
Top of casing ternnfnatad at toetow land surface requlm a variance In aeoor-
danee with 15A NCAC 2C . 1d
10. YIELD (gpm): MET OD OF TEST
11. WATER ZONES (depth)'
th •
•
12. CHLORINATION: Type ZG —Amount
13. CASING:
DRILLING LOG
From To
DEPTH
Fomatton Description
If additional space Is heeded use back of form --
DBpth / _ Di?rrwssr or� ��. Aetertel (show direction and distance (corn at two State
From To (—�.� Ft. � ac goads, or other map reference ants)
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From To � Ft.
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft in. in.AA
y
From To Ft. in. in. `' 0
From To Ft. - in. in.
16. SAND/GRAVEL PACK:
Depth Size Material
From To ---�`— Ft.
From To._,, 5_.._ Ft.
17. REMARK: �� ��
I DO HEREBY 6af.�AA3• b11SMW UCTED IN ACCORDANCE WITH 15A NCAC 2C,1 WELL
CONSTR /FDA" A�1DA OF THIS RECORD HAS BEN PROVIDED TO THE WELL OWNER.
ousel No —�i�� Tt1RE OF PER&ON CONMUCTMTW WELL W1Ttc
Sutxrit to Division of Water owity. Groundwater Section within 30 days
Serial No. Gw.t REV. 12/99
Grrnir;rl4aat�-' ��'cti�n

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section ;.; 1 0 ('i
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: aA ,
WELL CONTRACTOR CERTIFICATION #: _t2 %9
STATE WELL CONSTRUCTION PERMIT#: '
1. WELL USE (Check Applicable Box): Residential® Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATI (Show sketch of the location below)
Nearest Town: 422_ ��� County _Jg2
(Road Name and Numbers, Community, or Subdivi ' and Lot No.) DRILLING LOG
3. OWNER n l" From To
Address
treat or Houle o.
City or Town _ Stile Zip Code
4. DATE DRILLED
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑ NO�
7. DOES WELL REPLACE EXISTING WELL? YES NO®
8. STATIC WATER LEVEL Below Top of Casing: FT.
�..GG-- (Use'+• U Move 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): — 0L METHOD OF TEST
11. WATER ZONES (depth):
12. CHLORINATION: Type Amount
13. CASING:
Wail Thickness
Depth Diameter or Welghl/Fl, Material
FromTo06) FtA44— &,Z/
From To Ft.
From To Ft.
14. GROUT:
DepthMaterial Method
p,� G
From O To � Ft. A� 1��t
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 —.,G Ft.
From To_T/_- Ft.
17. REMARK .
I DO HEREBY
Agricultural ❑ Monitoring ❑
DEPTH
Formation Description
it additional space is needed use back of form
LOCATION SKETCH
(Show direction and distance from at feast two State
Roads, or other map reference points)
u
1N ACCORDANCE WITH 15A NCAC 2C, WELL
CORD.FM JREEN,PAOADED TO THE WELL 0
rvnvrrwr=v ter;,•,•,,, „,: (I
Quad I Ul NATURE OF PERSON CONSTRUCTING THE WELL
Submit pinal Divislon of Water Quality. Groundwater Section Within 30 days
Serial No.
GW-i REV. 12f"

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section 1
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): Resldentlai [3 Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATI( � 'Show tch of the location below)
NeW;i;Town: - County:
(Road Name
3. OWNER
Address
t?
City or Town Stale Zip Code
4. DATE DRILLED
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES Q NO®
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO®
S. STATIC WATER LEVEL Below Top of _Casing:. Z S" FT.
(Use '+' U Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface'
`Top of casing terminated at/or below land surface requires a variance in accor-
dance with 15A NCAC 2C.9118
10. YIELD (gpm): .METHOD OF TESTlze-,V,�
11. WATER ZONES (depth): add t
12. CHLORINATION: Type Z ,� 23 Amount If additional space is needed use back of form
13. CASING:
Wail Thickness LOCATION SKETCH
Depth /,�-,� 0i ter or We(ght/Ft. MWeJnal (Show direction and distance from at least two State
From �To Ft.Roads, or other map reference points)
From To Ft.
From To Ft. I
14. GROUT:
Depth Material Method
From _ -To Iz,2C) Ft. way
From To Ft.
�J
DRILLING LOG DEPTH
J From To Formation Description
15. SCREEN:
Depth
Diameter
Slot Size
Material
From To Ft
From To Ft.�
in.
In.
in.
in.
From To Ft,
in.
in.
16. SAND/GRAVEL PACK:
Depth
Size
Material
From
From To Ft.
17
a
I DO HERE E I i CONSTRUCTED 1N ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRU , AND TH PY CORD HAS B P VID TO THE WELL OWNER.
FOR OFFIC Ot 'Yi
Quad No: SIGNATURE OF PERSON CONSTRUCTING THE WELL DOE
t on nal to Division of Water Ouality, Groundwater Section within 30 days
Serial No. ltqr Section _ Gw-1 REV. 12199

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section i C�
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELLCONTRACTOR:
WELL CONTRACTOR CERTIFICATION #: 7 _
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential ® Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATI :,(Show Lketch of the location below)
Nearest, n: - . County:
(Road Name and Numbers, gnanuni or Subdivision and lot No.)
3. OWNER
Address -
treet or HOUte o.
City or Town State Zip COCW
4. DATE DRILLED ►Z �1F1%D
5. TOTAL DEPTH '
6. CUTTINGS COLLECTED YES ❑ NO®
7. DOES WELL REPLACE EXISTING WELL? YES F-] NO®
8. STATIC WATER LEVEL Below Top of Casing: 3 p FT.
// T_./._ (Use •+• it Above Top of Casing)
9. TOP OF CASING IS_L _Z.� 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): - i— METH9,D, OF TEST
11. WATER ZONES (depth): __...CCL r) t Y` / 7� '
12. CHLORINATION: Type Amount _—
13. CASING:
Depth DI me�r
FromToFt.
From To Ft.
From To Ft.
14. GROUT:
DRILLING LOG
From To
DEPTH
Formation Description
If additional space is needed use back of foriri-I �_?
Wall Thickness LOCATION SKETCH
or WeiahtlFt. M419rial (Show direction and distance from at least two
Roads, or other map reference points) ,
Depth v�� Mated Me d '
From C_ To L (J Ft.
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft in. ::,,
in.
From To � Ft. in. in.
From To Ft. in. in.
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From TO 4 Ft. Iz
17. REMAR S:
4
I DO HEREBY CERT� 1 HATTHIS.WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTIQtq" ArWAi%0§;MW 1 RArA O=YllOFSTIIS RECORD HAS BEEN_P, Q4fbED TO THE WELL OWNER.
FOR OFFICE U LY
Quad No: Jp3rNATURE OF PERSON CONSTR NG THE WELL DATE
6 iSubmit Division of Water Quality. Groundwater Section Within 30 days
Serial No. GW-1 REV. 12/99

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone] r
WELL CONSTRUCTION RECORD WELL CONTRACTOR: KL•cf A' ! -�
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable eox), Residential R Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATIO�i (Show tch of the location below)
Nearest Town: Cc
(Road Name and
3. OWNER
Address
Subdivision and Lot No.)
i tsueet or ague NO.) L
City or Town State Zip Code
4. DATE DRILLED
5. TOTAL DEPTH e'Z �2 S
6. CUTTINGS COLLECTED YES ❑ NO®
7. DOES WELL REPLACE EXISTING WELL? YES [_j NO[5Q
8. STATIC WATER LEVEL Below Top of Casing: 3 42 FT.
(Use '+' 11 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 .0!28
10. YIELD (gpm): ,L-Y METHOD OF TEST 7_4!22/i
11. WATER ZONES (depth): Ro 1 195 D 1
12. CHLORINATION: Type Try/ d Amount
—
13. CASING:
DRILLING LOG
From To
Agricultural ❑ Monitoring ❑
DEPTH
Formation Description
If additional space is needed use back of forms
c 1 c�
Wall Thickness -- - -
Depth Di miter or Wei ht/Ft. �MattQrfal (Show direction and distance from at le two State rt
From�To Ft.. �-j�-k-� Roads, or other map reference poi ) C
S.
From To Ft.
From To Ft.
14. GROUT:
Depth Material Meth d
From To _�D Ft. m
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From ZoZtin. .nFromot. in. inFromot. In. In.
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
17. REMARKS:��
J
I DO HER F}+TIFr S 7MAD - A - D LLI CONSTRUCTED IN ACCORDANCE WITH 154 NCAC2C, WELL
r n11TM Lil N T O D A_ D A rA OPY OF THIS Ft HAS BEEN P O TO E W LL OWNER.
FOR OFFI ONLY '
Quad No: ������ 51GNATURE OF PERSON CONSTRUCTING THE WELL DATE
S mit o ginal to Division of Water Quality, Groundwater Section within 30 days
Serial No. _ GW1 REV. 12/99

North Carolina • Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section 216047
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: "11,11y")aW cc_) V_411�
WELL CONTRACTOR CERTIFICATION #: `7l1
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential El Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATIONJ,: (Show�h of the location below)
Nearest Town:-, / County: ti
(Road Name and Numbers. Communi , or Subdivision and Lot No.)
3. OWNER P24 �f %
Address ' ,
_Si wvvVvw, /V b j c�c n i /rr
City or Town tale Zip Code
4. DATE DRILLED 2D
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES 0 NO[2�
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 16A NCAC 2C . 118
10. YIELD (gpm): METHOD OF TEST %f M C
11. WATER ZONES (depth): -! !9�
12. CHLORINATION: Type %-2V 13 Amount
—
13. CASING:
Wall Thickness
Depth �/� Di me er or Weight/Ft. tenal
FromTo � Ft. �- �
From To Ft.
From To Ft.
14. GROUT:
Depth Material M t od
From To �t 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:
17
Depth Size Material
From
From To Ft.
REMARKS:
Agricultural ❑ Monitoring ❑
DRILLING LOG DEPTH
From To Formation Description
=
a)
rn
Z
}C,
cr
If additional space is needed use back of form
LOCATION SKETCH
,w direction and distance from at least two Stat
Roads, or other map reference points)
e
J
r�0
J
i DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COP ORD AS B P VIDEO TO THE WELL OWNER.
G� 1 /
FSead
R OFFICE USE ONLY 0�
d No: SIGNATURE OF PERSON C RUCTiNG THE WELL DATE
�I f. Submit original to Division of Water Quar , Groundwater Section within 30 days
al No. GW1 REV. 12/99

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section 16053
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: ! 2 > )6
WELL CONTRACTOR CERTIFICATION #: flS�
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check applicable eox): Residential Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water injection ❑ Other ❑ If Other, List Use:
2. WELL LOCA
Nearest Town:
(Road Name av`40ers, Community,
3. OWNER
_ city�f Town State Zip Code
4. DATE DRILLED
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑ NO[&
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO[g
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 attar below land surface requires a variance In accor-
dance with 16A NCAC2C . 18
10. YIELD (gpm): METHOD OF TEST --0d,
11. WATER ZONES (depth):
t /.l LAY//rev
DRILLING LOG
From To
Agricultural ❑ Monitoring ❑
12. CHLORINATION: Type J-a a Amount It additional space is neeuvu LA*o wow. ,�•,
13. CASING:
DEPTH
Formation Description '
Wall Thickness
Depth _ Diameter or Weight/Ft. t4feol
FromTos 5 Ft. — -L i,
From To Ft.
From To Ft.
14. GROUT:
Depth Mat I Met od
From �_ To � Ft.1 )
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From�To
o n.
From Ft. in. in.
From To Ft. in. ; in,.
16. SAND/GRAVEL PACK:
Depth Size Material
From To
From Tq Ft" �z
17. REMARKS:
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
0.
D
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY O I O%RD H N ZPVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY�
Quad No: SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Quality, Groundwater Section within 30 days
Serial No. GW-1 REV. 12/99

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section 216 V J 4
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELLCONTRACTOR: - �7/-
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): ResidentiailA Municipal ❑ Industrial ED Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATI : (Sho sketch of the location below)
Nearest Town: Z /d �� e ' Coun :
(Road Name and Wfrnber4 00MMUnity, orSt and Lot No. DRILLING LOG
3. OWNER From To
Address �(
+ (Street or out o.
4 Al r ,
City or Town state Zip Code
4. DATE DRILLED
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑ NOQ
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NOO
8. STATIC WATER LEVEL Below Top of Casing: �20_ FT.
(Use '+' if Above Top of Casing)
9. TOP OF CASING IS. Z 121_'_ FT. Above Land Surface'
'Top of casing terminated atlor below land surface requires a variance In accor-
dance with 15A NCAC 2C .0118 t
10. YIELD (gpm): -,Z.METHOQ� F TES�
l�I
11. WATER ZONES (depth): // CC
12. CHLORINATION: Type I —A A Amount _
13. CASING:
Wall Thickness
Depth/�-,,, Di ter or WeightlFt. Material
From —�TO1.sZ1L Ft. —"—"7—"——L
From To Ft.
From To Ft.
14. GROUT:
Depth Material ,,..�� Material Met od
From _Q� To � Ft. (7 --
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From t
From To Ft. in.Zin.
From To Ft. in..
16. SAND/GRAVEL PACK:
17.
Depth Size Material
From 0
From ,=�To Ft.
If additional space is needou
DEPTH
Formation Description
(Show direction and distance frat least two State
Roads, or other map refere4ce points)
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS, EENzRjROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Quad No:
Serial No.+
SIGNATURE OF PERSON CONSTRUCTING THE WELL
Submit original to Division of Water Quality, Groundwater Section within 30 days
DATE
GWA REV. 12199
5 CA
I n:1J,

2130'73
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 p:
STATE WELL CONSTRUCTION PERMITgr
1. WELL USE (Check Applicable Box): Residentialo Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATIRP: (Show sl2tch of the location below)
Nearest Town: /Vr C , County:
(Road Name an Numbers, Comragi or Svbdivislon and Lot No.) DRILLING LOG DEPTH
3. OWNER /,J From To Formation Description
Address 7yl _ . / OD
City or Town State . Zip Code
4. DATE DRILLED
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑ NOCZ
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO®
8. STATIC WATER LEVEL Below Top of Casing: /_ Fr.
(Use '+' It Above Top of Casing)
9. TOP OF CASING ISFT. Above Land Surface -
'Top of casing terminated st/or below land surface requires a variance In ■ccor-
dance with 16A NCAC 2C .0118 k
10. YIELD (gpm): ­VQ METHOD OF TEST _Ti M C
11. WATER ZONES (depth): �('L121_
12. CHLORINATION: Type 2'_,4 _ Amount =�
13. CASING:
Wail Thickness
Depth Di meter or W� eI ht/FI M tertal
From To It a Ft. ��
From To Ft.
From To Ft.
14. GROUT:
Depth Material Meth d
From To C72 Q Ft.
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft In. in.
From To Ft. in.
From To Ft. In. in.
16. SAND/GRAVEL PACK:
Depth SI Material
From To F
From To Ft.
17. REMARKS:
i
a
v
A
iE
If additional space is needed use back of iorW
LOCATION SKETCH
o
(Show direction and distance from at least two State
Roads, or othermap reference points)
�..
fir
V
Fa
sd. z a s 7 c
C
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT
FOR OFFICE USE ONLY
Quad No:
Serial No.
Submit original to Division of Water Quality, Groundwater Section within 30 days
GWA 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: "Ov
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMIT#: 0- a7
WELL USE (Check Applicable Box): Residential ® Municipal ❑ Industrial ❑ Agricultural ElMonitoring11. Recover
y ❑ Heat Pump Water Injection [] Other F] If Other, List Use:
?. WELL LOCATION: (Show sl t of the location below) n
Nearest Town: r �_ County: -6tzed
(Road NameVumpqrs, Co unity, r Subdivisipn and Lot No.) DRILLING LOG DEPTH
i. OWNER �v�4r From To Formation Description
AddressX44)e�14.f�
City or Town tale Zip Code
DATE DRILLED 4
TOTAL DEPTH t
CUTTINGS COLLECTED YES Q NOM
DOES WELL REPLACE EXISTING WELL? YES 0 NO�
1. STATIC WATER LEVEL Below Top of Casing: /,I-_ FT.
(Use '+' II Above Top of Casing)
1. TOP OF CASING IS % 2 -. FT. Above Land Surface'
Top of casing terminated atior below land surface requires a variance In accor-
;ance with 15A NCAC 2C . 118
0. YIELD (gpm): cZ 6 METHOD OF TEST
1. WATER ZONES (depth): -- 9-4-r /DD
saiG�
a.
2. CHLORINATION: Type _%¢ d Amount -3 If additional space is needed use back of form
3. CASING:
Well Thickness
Depth Di meter or Weight/Fl. Material
From _D To ZZ _ FL IT� 7
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From To s20 Ft. 644�
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft
From To Ft. in. in.
From To t. in. in,
16. SAND/G ACK:
Depth Size Material
From To Ft.
From To t.
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 CORD HAS BE P VIDE TO THE WELL OWNER.
FOR OFFICE USE ONLY
Quad No: SIGNATURE OF PERSON CON TRUCTING THE WELL DATE
Submit original to Division of Water Quality, Groundwater Section within 30 days
Serial No. GW-1 REV. 12199
6

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section ' 13 0 7 7
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: I9i 2 f .l er�� o c
WELL CONTRACTOR CERTIFICATION #:_:z
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residentlal M Municipal ❑ Industrial [:1 Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection E] Other E] If Other, List Use:
2. WELL LOCATIO ( ow sketch of tt;ocatlon below)
Nearest Town: /'it i County:
(Road Name Nrs. TCom%
mr��'
�lot
NDRILLING LOG DEPTH n
3. OWNER
From To Formation Description
Address
treet or HOUIe o.
- City or Tovm a et rLea 3
Zip Code r-+
4. DATE DRILLED--
5. TOTAL DEPTH _
6. CUTTINGS COLLECTED YES E] NO®
7. DOES WELL REPLACE. EXISTING WELL? YES EJ NO[@
8. STATIC WATER LEVEL Below Top of Casing: _ Te) Fes'. —
(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 . 118
10. YIELD (gpm): METHOD OF TEST
11. WATER ZONES (depth): cyl o
12. CHLORINATION: Type Amount,
13. CASING:
Wall Thickness
Depth Di er or welght/Fl. M#Iedal
,
From 10 To �� Ft.
From To Ft.
From To Ft.
14. GROUT:
Depth � Material Met —
From _�. To Ft. 6if�
From To Ft.
15. SCREEN:
Depth Diameter Slot Size MAWflal
From To Ft In. n.
From To Ft. In.
From To F In. In.
16. SAND/GRAVEL P
epth SI Material
From To
From To Ft.
17. REMARKS:
If additional apace is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least two
Roads, or other map reference points)
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE
CONSTRUCTION STANDARDS, AND THAT A COPY OFJHISI9FCQRD HAS BEEN,!
FOR OFFICE USE ONLY
Quad No:
Serial No.
SIGNATURE OF PERSON C(
Submit original to Division of Water Quality,
pw -'_1cP
O
ISA NCAC 2C, WELL
DED TO THE WELL OWNER.
3 THE WELL DATE
Section within 30 days
GW-i REV. 12M

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section i r
1636 Mail Service Center - Raleigh, N.C. 27699-1636•Phone [phone] F � _%. ~}
1
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION #:_
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Resldentlal ® Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATI N: (Show sl etch of the location below) �—
Nearest Town:
County:Ayd
—_:�.r�tr.�+y,
AIL
(Road NaMe and Numbers. Community, or supgIvIsion and No.
3. OWNER �r} /1 oJ,/ ) DRILLING LOG
From To
Address
ree or ou a ,,,.r
City or Town
tale 4. DATE DRILLED Zip Coda_
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES [] NO
7. DOES WELL REP LACE.EXISTING WELL? YES NOO
8. STATIC WATER LEVEL Below Top of Casing: FT.
9. TOP OF CASING IS (use '+' 0 Above Top of Casing)
FT. Above Land Surface*
'Top of casing terminated atior below land surface requires a variance In accor-
dance with 15A NCAC 2C .0 18
10. YIELD (gpm): METHOD OF TEST
11. WATER ZONES (depth):__/�/r'
12. CHLORINATION: Type _ %—stA Amount
13. CASING:
Dth Wail Thickness
e
P Dlam ter or yye�%phVFt• M� t dal
From-12---To /0 Ft.
From To Ft.
From To Ft.
14. GROUT:
Depth Materiat Met
From �_ To s�..,� Ft.
From To Ft.
15. SCREEN:
Depth Diameter Slot Size __Material
From To Ft In. in.
From To Ft. In. In.
From To In.
16. SAND/GRAVE K:
Depth Ize Material
From To Ft.
From Ft.
17. REMARK
DEPTH
Formation Description
If additional apace is needed use back of form
LOCATION SKETCH
Show direction and distance from at least two State
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH IBA NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF RE AS BEEN P VI 0 TO THE WELL OWNER.
FOR OFFICE USA ONL i.tel -VI
Quad No: i a SIONA
Serial No.
a TURF OF PERSON CONSTR TING THE WELL
Submit ohdinal, to Division of Water Quality, Groundwater Section Within 30 days
J l 1 5�(�! I ; ,
GW-1 REV. IW9
t-�

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section 213091
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: ' << it
WELL CONTRACTOR CERTIFICATION k:
STATE WELL CONSTRUCTION PERMITM:
i. WELL USE (Check Applicable Box): Residentlal� Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery El Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATIO ShoW sketab of he Iocatloh below)
Nearest Town: County:
(Road Name and Number , Commugfty, or Subdlvlslon and Lot No.) DRILLING LOG DEPTH
3. OWNER
Address From To Formation Description
%
trAA
City or Town State Zip Code
4, DATE DRILLED
5. TOTAL DEPTH /
6. CUTTINGS COLLECTED YES (1 NO
7. DOES WELL REPLACE. EXISTING WELL? YES NOM
8. STATIC WATER LEVEL Below Top of Casing: FT.
(Use'.• if Above Top of Casing)
9. TOP OF CASING IS FT. Above Land of
-Top of casing terminated st/or below land surface requires a variance In accor-
dance with ISA NCAC 20 118
10. YIELD (gpm): .METHOD OFTEST
11. WATER ZONES (depth): 99 %� '%
©
L7
e4!r'i
AO
o
12. CHLORINATION: Type �,%3 Amount_ If additional space is needed use back of form
13. CASING:
Wall Thickness
Depth Diann Tr or Wslght/Ft. Material
From �_ To � Ft. — "-'7"— .,t'.L ae-
From To --z_ Ft.-4Z nd U_ S.T
From To Ft.
14. GROUT:
Depth Material Meth d
From _2_ To . %12) Ft.
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft In.
From To �Ft.'n.In.
From Ton. in.
16. SAND/GRAVEL CK:
Depth Size Material
From To F
From Te-_' Ft.
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL
CONSTRUCTION STANDARDS: AND'THA!
FOR OFFICE USE
Quad No:
Serial No.
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other maD reference ooints)
IN ACCORDANCE WITH 15A NCAC 2C, WELL
:01aD-HAS BEEN PROYMD-TO THE WELL OWNER.
OF PERSON CONSTRUCMNG THE WELL DATE
of Water Quality, Groundwater Sectlon within 30 days
GW-1 REV. 121"