Well Construction Records Cherokee 1 CY2000

:22794
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] �E �uTG W aL \'-( LL I
WELL CONSTRUCTION RECORD WELL CONTRACTOR: �" 1,'�` t� �1-14
WELL CONTRACTOR CERTIFICATION li: 3
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential Municlpal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATIO h w sketch of the location below)
Neares n: County: fl
(Road Nam Numbers, fly, or Subd i n and Lot No.) DRILLING LOG DEPTH
3. OWNER From To Form
at'on Description
Address ` LK IVI
ree or ou a o, al;^b,�
City or Town Sta Zip Code �� 3
4. DATE DRILLED O o
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑ NO[D--- t--] a?_n
7. DOES WELL REPLACE EXISTING WELL? YES M NO[a �! �
8. STATIC WATER LEVEL Below Top of Casing: � FT.
9. TOP OF CASING lSJ _ (Use *+' II Above Top of Casing)
co
FT. Above Land Surface* ¢ �`
'Top of casing terminated at/or below land surface requires a variance In accor-
dance with 15A NCAC 2C� 118 rn
10. YIELD (gpm): LA METHOD OF TEST _ &N_R, rn�
11. WATER ZONES (depth):an
x
12. CHLORINATION: Type Amount If additional space is needed use back of form
13. CASING:
Wall Thickness LOCATION SKETCH
Depth C Din tlj or Welght/Ft. �at¢�al (Show direction and distance from at least two Stale
From 0 To Ft. p-a � C Roads, or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth M teilal Method
_
From _� To � Ft. _
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From -To Ft in. In.
From To Ft. In. in.
From To Ft. In. In.
1S. SAND/GRAVEL PACK:
Depth Size Material
From To Ft. ,
From To Ft.
17. REMARKS:
I DO HEREBY
CONSTRUCTI
FOR OFFICE U LY _
Quad No: FE . - 8 ?Q(11
Submit
ISTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
OF.THIS RECORD HAS BEEN PROVIDED TO THE WELL C
JATUREAF ERSON CONSTRUCTING THE WELL DA
Division of Water Quality, Groundwater Section within 30 days
am
Bartel No. Il I I I GW-1 REV. 12199

North Carolina - Department of Environment and Natural Resources - Division of Water Ouality - Groundwater Section 236184
1636 Mail Service Center - Raleigh, N.d. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION N: �yo�
STATE WELL CONSTRUCTION PERMITH:
1. WELL USE (Check Applicable Box): Residential [O"" Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
pecovery ❑ Heal Pump Water In)ecllon ❑ Other [] If Other, Llst Use:
2. WELL LOCATION: (Show sketch of the location below) n ro K P
Nearest Town: I County: S
DEPTH_
(Road Name and Numbers, Community, or Subdivision and Lot No.) DRILLING LOG Fomaxn Des..npuo-
3. OWNER Tom^ lM i S�i i v2 From To
r
Address
tree or ou o o.
City or Town Stale Zip Code
4. DATE DRILLED.
5. TOTAL DEPTH-
6. CUTTINGS COLLECTED YfS NO[
7. DOES WELL REPLACE EXISTING WELL? RESn NNO' (�—
0. STATIC WATER LEVEL Below Top of Casing: fo(
(Use '+' If Above Top of Casing)
9. TOP OF CASING IS___1__—_ Fr. Above Land Surface'
'Top of casing terminated stfor below land surface requires a variance In accor-
dance with iSA NCAC 2C .0118
10. YIELD (gpm): —1-0— METHOD OF TEST
11. WATER ZONES (depth):
12. CHLORINATION: Type 2 Amount II additional space is needed us" bac� of Ic�m
13. CASING: LOCATION SKETCH
Wall Thickness
Depth Diameter or Welght/Fl. Material (Show direction end d's=ance Imm zj l i s! "'o Ana e
From
___�_—_To I (Q, Fl. 6 as Roads, or other n —Ga relere:� Po
From To FI•
From To F1. ---
14. GROUT:
Depth Matle,Iia Method CM
From �_ To � Ft.
QGji--((---------- z,• L—'
From To Ft. ------ c= c�"'
15. SCREEN:
Depth Diameter Slot Size Material
From To Fl In, in. m
From To Ft. In. In..
�µ
From To Fl. In. In.
16. SAND/GRAVEL PACK:
Depth
Size Malarial �
From To — Fl.
From To Ft. —
17. REMARKS:
I DO HEREBY CERTIFY`TFIAT THIS WELL WAS
ACOPY OF7 THIS RECORD HAS 8 E ED IN ACCORDANCE
"JOWITH 15A ATH� !/'LL
_U Ot%�EF.
CONSTRUCTION :ST�INDARDS, AND THAT A J
1-2
FOR OFFICE US ONLY`' ` os•�E
Mad No: a YSIGNATURE OF PERSON CONSTRU :TING Ire^ 'iv ELL
y„f; i GiG ut?rt>lloriQlnal,lo Division of Water puslity, omndKaler Srccn within :7 Clo1s Ga l FsE V. 1211
Serial No. —'slimit r ­Tie

North Carolina • Department of Environment and Natural Resources • Division of Waier Ouality • Groundwater Section 2 .3 6 18
1636 Nail Service Center • Raleigh, N.C. 27699.1636•Phone [phone]
U
01
WELL CONSTRUCTION RECORD WELL CONTRACTORR:cERTIFC T l UnU`\'
WELL CONTRACT N
STATE WELL CONSTRUCTION PERf11ITH:
Box): Resldential� Municipal ❑ Agricultural ❑ Monitoring
❑
1, WELL USE (Check Applicable Use:
Olhedr, Llsta
flecovery ❑ Heal Pump Water Injection ❑ Other [] If ,
2. WELL LOCATION: (Show sketch of the location below) C` �--
Nearest Town: Y c�County:
ee DRILLING LOG DEPTH
(Road Name and Numbers, Co uni(y, or Subdivlsien and Lot No.)
To Fomr-a5cn Descripu0n.
From
3. OWNER KQSe� I t ��1� S
6-2
Address
City or Town Stale Zip Coda
4. DATE DRILLEO,ti- »� C)�
5. TOTAL DEPTH
YFS ❑ NO�
6. CUTTINGS COLLECTED
DOES WELL REPLACE EXISTING WELL? YES CJr N ❑
7.
B. STATIC WATER LEVEL Below Top of Casing: 70
fuse '+' If Above Top of Casing)
9. TOP OF CASING IS — FT. Above Land Surface*
`Top of casing terminated itior below land surface tequlres a variance In accor-
dance with 15A NCAC 2C.01111 METHOD OF TEST 13 12
10. YIELD (gpm): _J_ __
11. WATER ZONES (depth):
)1 kS Amount--�----- If additional space is needed t� back of Icrm
12. CHLORINATION: Type
13. CASING: LOCATION SKCTCH
Wall Thickness Show direction nd dis»ance frcrrt �1 leas t'NoVale
weight/Ft. Material ( a
Depth Diameter or int'
Roads, or otter rr.__p relere:ce flo
Fromm —To Ft. -�— �— '��
From To Ft. -- ----
From --To Ft.—
CD
14. GROUT: o
Depth Material Method
c
n
From To �U -Ft.
—
r ;
From To —Ft. ---------- 1
cam :
15. SCREEN: on
Depth Diameter Slot Siz6 Material
n -
From To FI _— In. in..___---- =
oo
Ft. in. __-----
From To In.
In.
M..0
�'' .—U
From To Ft. o
16. SAND/GRAVEL PACK: Material
Depth Size
From To — Ft. —
From To — Ft. —
17. REMARKS:
Li N
HAS EE 1 RO CED 10 THE 71--U a"EF'
I DO HEREBY CERTIFY TVAT THISDWELL W�
COPY OF THIS RECORD
CONSTRUCTION STANDARDS /,;2
FOR OFFICE USE ONLY
OF PERSON CONSTRl1: TilfG T>t vwELL o.0
Ouad No:
SIGNATURE
within V. C -�Ys
Submll original to Division of Wile( OusiltY, Q,pund raler Sown Gh I p� Y. i:Pi
Serial No, I

North Carolina • Department of Environment and Natural Resources • Division of Water Quality . Groundwater Section 2 3 O
1636 Mail Service Center • Raleigh, N.C. 27699-1636•Phone [phone]
'
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION
STATE WELL CONSTRUCTION PERIAITk:
WELL USE (Check Applicable Box): Resldenllal� Municipal ❑ Industrial ❑ Agricultural ❑ Monilorirg ❑
j,
flecovery❑ Heal Pump Water Injection 0 Other 0 II Other, List Use:
2. WELL LOCATION: (ShOW sketch of the location below) C_L�r� —
County:
NearestTown:
DEPTH
(Road Name and Numbers, Co nunity, or Subdivision and Lot No.) DRILLING LOG FOrrr�xn Description.
3. OWNER ©4�D�h+U('�t�l — From To C(a
IJ�
Address _
beet or ou a o.
I
City or Town Stale Zip Code
4. DATE DRILLED
5. TOTAL DEPTH —
6. CUTTINGS COLLECTED YFS ❑ NO[>�
DOES WELL REPLACE EXISTING WELL? YES �] NO[[�
7.
e. STATIC WATER LEVEL Below Top of Casing: D Fr.
(Use •+, if Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface*
'Top of casing terminated al/or below land surface requires a variance in actor•
dance with 15A NCAC2C.011E
METHOD OF TEST
10. YIELD (gpm)'
1 1. WATER ZONES (depth):
J^ Lh (o j�� Amount �---- If additional space 4s needed t-s a bac� of Ic�m
12. CHLORINATION: Type
13. CASING: LOCATION SK-TCH
Wall Thickness
Depth Diameter or WeighUFt. Material (Show direction and d's�ance hr�rn a,lia�; ko Sn.ate
© To /1 D F1. Roads, or other rr� relere: Po
From
From To FI. —
From --To Fl. --
14. GROUT:
Depth Ma erial Method
Ft. `'vr,---------
c
From 0 To
From To —FL --
15. SCREEN:
Depth Diameter Slot Slze Material
c t
From To Ft In. in. _----- Cr,
C,r
From To FI. In. In. _ ---- m
_----- - =
Ft. In. In.Co
rn
a
From To
16. SAND/GRAVEL PACK:^?
Material ca
r
Depth Size
o
From — To _ Ft.
From To Fl. —
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS,, ELL WAS UCTED IN ACCORDANCE WITH ISA 04CAC CONSTRr., V TELL
CONSTRUCTION STANDARDS, AND'-THAT'A COPY OF THIS RECORD HAS BEEN PROVIDED "jO T1i� '�1==a- O*%"EF'
FOR OFFICE USE ONLY
" §ldNATUnE OF PERSON CONSTnU TING 1rt'/ti'ELL
Quad No:
..
submit odpinai to Division of Wslar ousilty, omund�ler Sracn within :� C%�Ys fa.l Fig V.
1211
Serial No.

nn� 19
North Carolina -Department of Environment and Natural Resources - Division of Water Ouality - Groundwater Section I .} J
1636 Mail Service Center - Raleigh, N.C. 27699-1636•Phone [phone]
WELL CONSTRUCTION RECORD WELL N
WELL CONTRACTOR CERTIFICATION 0: a�l�ya
STATE WELL CONSTRUCTION PERMITO:
1. WELL USE (Check Applicable Box): Aesidential 9'- Munlclpa) ❑ Industrial ❑ Agricultural ❑ Monilorirg ❑
Recovery ❑ Heal Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)i�°/D�(p
Nearest Town: County:
DEPTH
(Road Name and Numbers, Co unity, or Subdivision and Lot No.) DRILLING LOG
(,�(� From To Foma5on Description
3. OWNER z,J(��' k
Address
uee or ou a o./h
City or Town Stale Zip Code
4. DATE DRILLED,i��-
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YFS ❑ NO[]
7. DOES WELL REPLACE EXISTING WELL? YES ❑ N0E-
B. STATIC WATER LEVEL Below Top of Casing: D FT.
(Use'+' 0 Above Top of Casing)
9. TOP OF CASING IS_i_.__ FT. Above Land Surface'
'Top of casing ferminaled at/or below land surface requires a variance In accor.
dance with 15A NCAC 213.01115
If 0. YIELD (gpm):. A✓ METHOD OF TEST . id" 2
11. WATER ZONES (depth):
12. CHLORINATION:
13, CASING:
14
15
Type Amount =- ----- It additional space is needed rse back of farm
Depth Diameter
From r0 To - Ft. —
From To Fl. —
From To Fl•
GROUT'
LOCATION SKI fCH
Wall Thickness
or Welght/Ft. Material (Show direction ad nd ance Iran al leas: - 5'a e
Roads, or other rrt�? relertrce polnts!
Depth Ma rla) Method
From _0 To -aOL Ft. --'—�
From To Ft. ----
SCREEN:
Depth Diameter Slot Size Material
From —To_Ft In. In. _•___--
From To Ft. In. In..------
From To Fl. In. In. _-----
16. SAND/GRAVEL PACK:
Depth Size
From _— To Ft.
From To_____— Ft. —
17. REMARKS:
DO HEREBY CERT
CONSTRUCTION'81
THAT `fHIS.YVELl.t W
7ARDS. AND THAT
a u:
Material
3�
t
Cn
w
3 CQNSTRUCTED IN ACCORDANCE WITH 15A F4CAC 2-�, ,tnLL
0PY':OF THIS RECORD HAS BEEN PROVICEO -70 THE 715''
FOR OFFICE USE ONLY `' t SIGNATURE OF PER SON CONSTnIY.TIt1G1tt'OELL
Ouad No:
Submit original to Division of Water Oua]Ity, Orour,d..eler S«cn within :ri C%sys
Serial No.
c::r
c-;
• c.
0
zs- rL�D�
o..�k
GM.1 Ft9 v. I'M

� kZ
0
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section � 2 3 ) 5
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: Gl t ! � �' �� l2i Ill19
WELL CONTRACTOR CERTIFICATION N: 2S� 15
STATE WELL CONSTRUCTION PERMITN:
1. WELL USE (Check Applicable Box): ResidentlaIER Municipal ❑ Industrial Ll Agricultural d Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ It Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: m, lr County: i_eao
2 � Qb
(Road Name a numbers. Community, or Subdivision and Lot No.)
DRILLING LOG DEPTH
3. OWNER L s
From To Formation Description
Address ,JU/
(� �/ "�� s� Gy G/�Sr
(Street or RoQle
City or Twkn Slate Zip Code
4. DATE DRILLED
5. TOTAL DEPTH
4
6. CUTTINGS COLLECTED YES [] NO❑—
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NOD
o v
8. STATIC WATER LEVEL Below Top of Casing: -5 D FT.cm
(Use "+' If Above Top of Casing)
%
C3 rn
9. TOP OF CASING IS FT. Above Land Surface*
*Top or casing terminated at/or below land surface requires a variance In accor-
dance with 15A NCAC 2C .0118
10. YIELD (gpm): --� METHOD OF TEST.
—�
11. WATER ZONES (depth): Z D D d ­3Y42'
t3'f
12. CHLORINATION: Type Amount I Zl-j
It additional space Is needed use back of &
13. CASING:
Wall Thickness
LOCATION SKETCH
Depth Dionpter or Welght/Fl. M at
l2-5
(Show direction and distance from at least two State
From To Ft. I2— v
Roads, or other map reference points)
From To Ft.
From To Ft.-
14. GROUT:
Depth Material Method
From To Ft.
From To / 2 5l 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 STAND(tAR rSry\��y'{kTHrT OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE(, 'O LY 1 2
Quad No: u SION"R F PE ONSTRUCTING THE WELL DATE
(`
Subm�t prig rjal to DI s on of ualily, Groundwater Section within 30 day9
Serial No.
GWI REV. 12/99.

North Carolina - Department of Environment and Natural Aesources - Division of Water Quality - Groundwater Section j .7 4.n !� f`
1636 Mail Service Censer -Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: _ r I(DP_0
WELL CONTRACTOR CERTIFICATION
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): ResidenUai Municipal d Industrial ❑ Agricultural ❑ Monitoring d
Recovery ❑ Heat Pump Water In)ectlon [j Other Cj If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below) Nearest Town: •�%11-+��ZIQ�—iY County: cjley Oo i`
(Road Name and Numb s. Community, or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER _ VA to h ( itjC- From To Fonnauon Description
Address 0 /_ � ), � �1 C 9
(Streetor ou a o. _77p L D _ , r /911' 7 r
City or Town _ State Zip Code
4. DATE DRILLED O t'
5. TOTAL DEPTH Yo
6. CUTTINGS COLLECTED YES[] NO[�-
7. DOES WELL REPLACE EXISTING WELL? YES F_j NOEa
8. STATIC WATER LEVEL Below Top of Casing: ,S FT.
(Use '+' If Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface -
*Top of casing terminated atlor below land surface requires a variance In accor-
dance with 15A NCAC 2C .0118
10. YIFLD (gpm): /0 METHOD OF TEST —'
11. WATER ZONES (depth): J 30
12. CHLORINATION: Type la7 A/ Amount �
13. CASING:
Wall Thickness
Depth
Z O'
Diameter r W" I t. M lerlaI
1 � ��
From
To
Ft.
i
From
To
Ft.
From
To
Ft.
14. GROUT:
Depth
a-D '
Material Method
From
To
Ft.
__ I0a-r1110
From SLO
To _ 1. >2'
Ft.
15. SCREEN:
C7
C� rn
t.fl
.ern
1�1a
If additional space is needed use back of form
a
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
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 �ERTIFY�LHAT�THI-SYWELL-IWAS CgNSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTr N' T , D D , INDHA� 0i �Y OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE' vNLY l j( 5~ 0 D
Quad No: i t : i �? II 61GVATokOF 01ISeN CONSTRUCTING THE WELL DATE
r Subm1l;odgina1 to Division oTWater Quality, Groundwater Section within 30 days
Serial No. GW1 REV. 12/99
' �,hcvlilr_.t^�it�tl.:l (3dkl�r, _

North Carolina . Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section ) 2 3 5 3
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: 11e��1 _ ill bal Ao"1
WELL CONTRACTOR CERTIFICATION
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable sox): Resldential L3' Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below) I'
Nearest Town: rZ — County:
plvek
(Road Name and Numbers. Community, or Su`,ivision and Lot No.) DRILLING LOG DEPTH
3. OWNER 5�,r5a•j + LK Lj-Ari Rtze ' From To Formation Description
Address V0. h y 137.E C/ J n , S � l
�5treat or = Route o. �� j
- M Ua14"/ N C� :J=% 10r3
City or T wnn Stale Zip Code
4. DATE DRILLED--��
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES[-_-] NO[] 6
7. DOES WELL REPLACE EXISTING WELL? YES [--I NOM
8. STATIC WATER LEVEL Below Top of Casing: � t % FT. c"y Z ,i
(Use '+' II Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface•
•Top of casing terminated ot/or below land surface requires a variance In actor- M
dance with 15A NCAC 2C .0118 ;:O +�
10. YIELD (gpm): METHOD OF TEST �� . j w cn
11. WATER ZONES (depth): c' c-n
757-
UD o
12. CHLORINATION: Type Amount °Z' 75 If additional space is needed use back of form
13. CASING:
Wall Thickness LOCATION SKETCH
Depth Diameter or. Weig t. talerlal (Show direction and distance from at least two State
From C� To �� (� Ft.��l �J / �� Roads, or other map reference points)
From To Fl.
From To Ft.
14. GROUT:
Depth Material Method
From r' To `' Ft. C`t A'114-.
From /2 To "0 , Ft. —t
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:
M
FOR Of
Quad No:
CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
SAND�ARS, AND THA:A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
r �
V.
Serial No I
CgN�!`U�FO(PEPSON CONSTRUCTING THE WELL DATE
to Div on of er Quality, Groundwater Section within 30 days
GW 1 REV. 12/99

Nonh Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: o- 00 ��� IIAJ9 `
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential 0a1 Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injectlon ❑ Other ❑ It Other, List Use:
2. WELL LOCATION: (Show sketch of the location below) n'
Nearest Town: �Y1t(12A �.'! _ County: l�iv°�2t71L�
H �V � 9� �`�'� J c, � i � o
(Road Name a Numbers. Community, or Subdivision and Lot No.)
DRILLING LOG DEPTH
3. OWNER _ 412ve,r STI &.
From To Formation Description
Address c q,s 'Ho 1'$
(Street or Route OU9
NCY �
Gr....r-
'I O
1
City or T wn Stale Zip Code
4. DATE DRILLED 0 '
r'
5. TOTAL DEPTH
©
6. CUTTINGS COLLECTED YES ❑ NO[]
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO❑
8. STATIC WATER LEVEL Below Top of Casing: ,'..r'' FT.
.�.?
(Use '+' If Above Top of Casing)
1-0
9. TOP OF CASING IS FT. Above Land Surface'
-�ZZ
'Top of casing terminated at/or below land surface requires a variance In eccor-
a�
�rn
dance with 15A NCAC 2C .0118
10. YIELD (gpm): METHOD OF TEST %2 I I
•• rra:a
11. WATER ZONES (depth):
—r
12. CHLORINATION: Type b Amount -J o C'���
It additional space is needed use back of form
13. CASING:
Wall Thickness
LOCATION SKETCH
Depth 01arpeter or WefghVFt. Material
J
(Show direction and distance from at least two State
—
From '� To - t — Ft. �" -��-� 1-
Roads, or other map reference points)
From To FI.
From To Fl.
14. GROUT:
Depth Material Method
From (' To •)' FI. C i'aL�':
From To �'- Ft.
15. SCREEN:
Depth
Diameter
From
To
Ft In,
From
To
Ft. in.
From
To
Ft. in.
16. SAND/GRAVEL PACK:
Depth
Size
From
To
Ft.
From
To
Ft.
17. REMARKS:
Slot Slze Material
In.
In.
In.
Material
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION TA D RDS-ANDTHA:LA Q,OPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USEh w :1 .._ �►f_ L5 1. 1 ,�
Quad No: yi TUAE OF pEr,60N CONSTRUCTING THE WELL DATE
1 t S,u 1 orig rya (vlsfdh of Water 06allly, Groundwater Section within 30 days
Ir..w1 (.:� 3 . t l �p
Serial No. GW1 REV. 12/99
ta'rUllfi(1'.•118tr""'' �ic'i;ij,,i`:::

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section 7 L+
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone] `' 3 53 V
WELL CONSTRUCTION RECORD WELL CONTRACTOR: Clue-p-, ( Wei I bal I
WELL CONTRACTOR CERTIFICATION N:
STATE WELL CONSTRUCTION PERMITN:
1. WELL USE (Check Applicable l3ox): Residentlal E Municipal[] Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below) n'
Nearest Town: A11)6Qews County: l_f►e20k'2
EA-
(Road Name and Numbers, Community, or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER Mp.4.o6 Y A-6,n-1 S From To Formation Description
Address 5 IT&- 12,h ,� � 0 ;ems 4' ,S /_ T GAS'
—isveet or Houle o.
N,(- Z`6110
City or To --� State Zip Code
4. DATE DRILLED
5. TOTAL DEPTH iob �_ o
6. CUTTINGS COLLECTED YES F� NO❑— �--o
7. DOES WELL REPLACE EXISTING WELL? YES [� NOM,
B. STATIC WATER LEVEL Below Top of Casing: 7 �i _ FT. m b�
(Use •+- If Above Top of Casing) _ 5,
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 C 10118
10. YIELD (gpm): f 'L METHOD OF TEST
11. WATER ZONES (depth):
12. CHLORINATION: Type I q � Amount ° ' ' / S It additional space is needed use back of form z
13, CASING:
Wall Thickness LOCATION SKETCH
Depth/ laT!ler or wet ht/Ft. Material (Show direction and distance from at least two Stale
From To � -" = Ft. I Roads, or other map reference points)
From To FL
From To Ft.
14. GROUT:
Depth Mateapil Method
From To ­�L 1, Ft.
From _ To 13 � 1 Ft. r
15. SCREEN:
Depth Diameter Slot Siz6 Material
From To Ft In. In.
From To Ft. In. In.
From To Ft. in. In.
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTIOfhST t�DARO , D AT A OPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE U LY (� m f'' �o n e y -2 - y >7 0
Quad No: { ` 1GNATURE OF PERSON CONSTRUCTING THE WELL DATE
Sub N11 riging to Division of Water Ouality, Groundwater Sacuon Within 30 days
Serial No. "�" GW-1 REV. 12/"
e1lE4rlC�'$�44r, ��� z' ip

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section 2-2 31 2 7
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone] %�
WELL CONSTRUCTION RECORD WELL CONTRACTOR: �r�o oe/ 2),qI f / 1,064
WELL CONTRACTOR CERTIFICATION #: El 51 6S—
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (check Applicable Box): Residential ER Municipal ❑
Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑
If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below) n I
Nearest Town: 1411 u��-� _ County:
J�t�12C7
<�-�,�
(Road Name and Numbers, Comm or Subdivision and Lot No.)
DRILLING LOG DEPTH
' l 1itty,
3. OWNER . )L94 J /At e
From To Formation Description
Address ^^
—jSTee%r Ro-uTe-No.)—
��Gt ✓ N C"_ 2>Q
-
City or wn State Zip Code
4. DATE DRILLED •� ' �._� ,1 '
5. TOTAL DEPTH
o r
_-
6. CUTTINGS COLLECTED YES 0 NO❑
o
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO❑
a ::0::'
8. STATIC WATER LEVEL Below Top of Casing: FT.
C') c
- (Use '+' II Above Top of Casing)
w
9. TOP OF CASING IS FT. Above Land Surface'
*Top of casing terminated at/or below land surface requires a variance In accor-
Vr,7
dance with 1SA NCAC 2C .0118
10. YIELD (gpm): L� METHOD OF TEST
11. WATER ZONES (depth):
i �... •.% �l �J
12. CHLORINATION: Type � �� Amount _ ' �
Ii additional space is needed use back of form
13. CASING:
Wall Thickness
LOCATION SKETCH
el Depth Diameter or WelghVFt. Material
(Show direction and distance from at least two Stale
' �� A � \.U" � .' I.I.. •
From To c' ' Ft. ✓t
Roads, or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From To Ft.
From e To _0 Ft. '
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft In. In.
From To Ft. in. in.
From To Ft. In. In.
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
17. REMARKS:
DO HEREBY C'ORTIFYIcTHgg�T T i IS IVV51 WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C, WELL
CONSTRUCTION 1 A VAR—' N. TAATjA COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE US i$ LYE-,
Quad No: �i 9 y l s,j f��IGNATURE OF PER N CONSTRUCTING THE WELL DATE
il Submit c pinallto Division of Water Quality, Groundwater Section within 30 days
g�....,y _. �..� T.. v._,_.�_ GW 1 REV. 12/99
Serial No. 1 ., ..... ..

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION fJ: :;I,T 4 .h
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below) Nearest Town: CoP-g_,A a I t-L , i County: 0,04 e_
(Road Name and Numbers, Community, or S bdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER c� 17N to. lei From To Formation Description
Address P. O, pox Y15
�S)iert or Fj2ule No. 7� c, y •� 7 ' G r�� 7G
City cN Yown y ale Zip Code
4. DATE DRILLED
5. TOTAL DEPTH t- IL)
6. CUTTINGS COLLECTED YES ❑ NO❑` p
7. DOES WELL REPLACE EXISTING WELL? YES [� NOD o
8. STATIC WATER LEVEL Below Top of Casing: t FT. CP
(Use '+' It Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface- tv u=�
*Top of casing terminated st/or below land surface requires a variance In accor-
d once with 15A NCAC 2C .0118
�O METHOD OF TEST �% ' V9 �=
10. YIELD (gprn): _
11. WATER ZONES (depth):
12. CHLORINATION: Type LIAf Amount ° If additional space Is needed use back of fo7F ri
13. CASING:
Wall Thickness LOCATION SKETCH
Depth Diameter or Weight/Ft. alertat (Show direction and distance from at least two Slate
From Tom -- Ft. Roads, or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From U To o Ft.
From �) 0— 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 ISA NCAC 2C, WELL
CONSTRUCTION:STANDARDiS,-ANj! D THAT_A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
tIt ir° LfJ IF �'� I'��' /�✓ - 4�
FQuad
FFICE !fj)j)'9NLY: i ; <SIG URE_G PFR ON CONSTRUCTING THE WELL GATE
(� i ;I > Submi� prtpI%n r �Di"vls� of Wfiter Ouailly, Groundwater Section Within 30 days
o. GW-1 REV. 12/99
,F0tiII a Vita k. S81, 11ari

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section r , is 2
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: 0_AeppAe v_ 0e_I I DRILa q___
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential 2 Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ It Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: /7 1 fXZD ky ---- County:
1,11 R. H L PRE
(Road Name and Numbers, Community, or Subdivision and Lot No.)
DRILLING LOG DEPTH
3. OWNER TeyP,,j T)QS K0
From To Formation Description
Address 19 ';AAl LO DQ-2D
n ,2S r D LS �� CA.#. y
S.-(Street or ou a o.
AA P _3 9 ��
1, s 6 S 'RROW21/ .5 5 &Mr. _
S An w��TN�R czA
—_7 �L
City or Town State Zip Code
e�-St1RFi/�1G�,1 7
4. DATE DRILLED 1,2:22Q4
80 /n y L/- RA% l T�
5. TOTAL DEPTH .3o 7
-ti
6. CUTTINGS COLLECTED YES C] NOW�o
`��7
7. DOES WELL REPLACE EXISTING WELL? NO❑
S. STATIC WATER LEVEL Below Top of Casing: FT.
(Use '+' If Above Top of Casing)
9. TOP OF CASING ISFT. Above Land Surface'
O
c,
*Top of casing terminated at/or below land surface requires a variance In eccor•
y„g rro--
dance with 15A NCAC 2C .0118 n
14—
10. YIELD (gpm): ,312 METHOD OF TEST __f!1LC_—
11. WATER ZONES (depth): 225 70
12. CHLORINATION: Type (14U A Amount e60A
If additional space Is needed use back of form�rn
13. CASING:
^
�- —mot
LOCATION SKETCH ,p- o
Wall Thickness
Depth Diameter or Weight/Ft. terlI
(Show direction and distance from at least two Stale
��, ,�/
v
From Q To 1 7 Ft. 6 '3�e s- -�L
Roads, or other map reference points)
From To Fl.
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.
From To Ft. in. In.
From To FL in. In.
16. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To Ft.
17. REMARKS:
I DO HEREBY
Material
THIS
FOR OFFICE USED p
Quad No: i r a SIGNATURE C
�" ( Submit original.to Divislon of
Serial No.
IN ACCORDANCE WITH 1SA NCAC 2C, WELL
CORD HAS BEEN PRQV)DED TO THE WELL OWNER.
/;z -Oi7
SCLVCONSTRUCTING THE WELL DATE
Quality, Groundwater Section within 30 days
GWI REV. 12t99

224.14�:
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:��` I
WELL CONTRACTOR CERTIFICATION 0: ---
STATE WELL CONSTRUCTION PERMITP:
1. WELL USE (Check Applicable Box): Residential E Munlcipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ if Other, List Use:
2. WELL LOCATION: (Show Iketch of the location below) lZeleNearest Town: t 11(4 - _ _ County: 0-6� � -
�J LS a'cT
(Road Name and Numbers, Community, or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER �DA NQ tOAN From To Formation Description
Address f? p, 130': �' O 913 LAA444 &&4P SkawN SL4r-(_-
free, or u o. 90 1!S 34Q.6 s�9?E 4J r' ac.�✓rl srR
l.wt'St;
_ _ L7 S 1 11 S 13 �_ �j>`yE 5�.�-r-�
City or Town State Zip Code 1 ]" -, e y 5L4Tf�
4. DATE DRILLED 1�-.� Oo ZZp yw SCKI S-ras-SL 4T1-�
5. TOTAL DEPTH _, Sh
6. CUTTINGS COLLECTED YES ❑ NO -567 'F�LyAISK uNiT6 �ttA�PB(.�
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
8. STATIC WATER LEVEL Below Top of Casing::3 W FT.
(Use *+* II Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface- o
*Top of casing terminated at/or below land surface requires a variance In accor-
dance with 15A NCAC 2C .0118 C_
10. YIELD (gpm): ,1-� METHOD OF TEST1 R 17
11. WATER ZONES (depth):
12. CHLORINATION: Type l aR iyll1.4 R Amount ,2 CUPS If additional space is needed use back of form
13. CASING: �m
LOCATION SKETCH fv
Wail Thickness MC_') x�
Depth Diameter or Weight/Ft. Material (Show direction and distance from at least two Sate-:!
From—Q—To Ft. 5DIZ x I -pya- Roads, or other map reference points) C)
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From To 20 Ft. S.AM,<N7
From 'Q' _ To
15. SCREEN:
Depth Diameter Slot Size Material
From To - Ft In. in.
From To Ft. In. In.
From To Ft. In. in.
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From
17. REMARKS:
To Ft.
I DO HEREBY CERTIFY; T
CONSTRUCTION STAND
FOR OFFICE USE ONLY
Quad No: i!
Serial No.
IS1NASkO,NSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
54`oF THIS RECORD HAS BEEN PBOVI,DED TO THE WELL OWNER.
1 f <.SIONATURE OraterS916
ONSTRUCTING THE WELL DATE
Sutxnit oI# ginalo Division of Qualty, Groundwater Section within 30 days
GW-1 REV. 12199

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: / 1 eac�,�ee la—w
WELL CONTRACTOR CERTIFICATION If: 2
STATE WELL CONSTRUCTION PERMIT#:
2 414 0
S
1. WELL USE (Check Applicable Box): Residential D?( 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: 121W12 J%l County: 0ego ee
✓ / T T c) r 7
(Road N me and Numbers. Community, or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER O Q "J From To Formation Description
/
Address / ,'/ o C (J `S�% , ►= 7
5
_ ree or_ Route o.
—� F1 3 Y / l
City or Town State Zip Code
DRILLED �- % 3--GAO
4. DATE
5. TOTAL DEPTH -L L
6. CUTTINGS COLLECTED YES F__] NO[]—
7. DOES WELL REPLACE EXISTING WELL? YES JD NOEn
C'
8. STATIC WATER LEVEL Below Top of Casing: _50 ' FT.
(Use '+' If Above Top of Casing)
C
9. TOP OF CASING IS / FT. Above Land Surlace•
I
C7 '
� C
'Top of casing terminated aVor below land surface requires a variance in accor-
_ Qi-
dance with 15A NCAC 2C ,0118
-) a
10. YIELD (gpm): METHOD OF TEST `
4
11. WATER ZONES (depth):
..� s. C->
12. CHLORINATION: Type % �� Amount -�� If additional space Is needed use back of form-
13. CASING:
_�
Wall Thickness LOCATION SKETCH
Depth Diameter or Weight/Ft. tedal (Show direction and distance from at least two State
Ft. From To 6 `� ``
�'T �.3+---}s�� Roads, or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From V To FL (-P�►�an`�`�
From To T�)` Ft. J% i
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 9ER4TIFpTJHAT THI fWEI( L' WAS, CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUb.TJQ� AND# 30 � AND THAT . COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
_ $$ i
��
FOR OFFIC � O
/ O
Quad NI��t r�.t K K, G TUBE O P SON CONSTRUCTING THE WELL BATE
i Su„ t olginal to Divislo ater Quality, Groundwater Section within 30 days
Serial No. i L_s.0 �L :_,r:., -:::, :,«.II 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] ( � I,)QLAa-`u—`
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 LOCATI o cetch of th ation below)
Nearest Tow .1
ounty: —
(Ro nd)umbers. Comm uN r S on a of No.) DRILLING LOG DEPTH
3. OWNER From To Format on e$c ption
dress r, as `
roe or Ro ONO.)
�
City or Town Stale Zip Codes
C
4. DATE DRILLED t 00
5. TOTAL DEPTH 120 t'
6. CUTTINGS COLLECTED YES ❑ NOED'
7. DOES WELL REPLACE EXISTING WELL? YES NOd
a
_
o
8. STATIC WATER LEVEL Below Top of Casing: FT.
r-rl
or,t
(Use'+' 11 Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface-
'Top of casing terminated atlor below land surface requires a variance In accor-
dance with 15A NCAC 2C 118
10. YIELD (gpm): METHOD OF TEST
11. WATER ZONES (depth): %2)
12. CHLORINATION: Type Amount
If additional space Is needed use back of form
o
13. CASING:
z
Wall Thickness LOCATION SKETCH
Depth Oi�r�gtor o Weight/Ft, a dal (Show direction and distance from at least two State
From To 1 Ft. 4 9 7 Roads, or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth M t vial Method
From C_ To (0 Ft.
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft in. in.
From To Ft. in. in.
From To Ft. In. in.
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
17. REMARKS:
I DO HEREBY CE K T�'' �Yt11. W LI+�LVQ „C( N§tRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTIONPI ARDS, AND THAT A CO �i t F THIS RECOR HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE e _ 8 NOS
Quad No: SIGN.TUBE OF PERSON CONSTRUCTING THE WELL ATE
$,utKttit'origl alto tvislon of Water Quality, Groundwater Section within 30 days
aundvract tCtian GW-1 REV. 121"
Serial No. Rsh n�iiln Ppoinn,41 flftirp

��787
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]
���t.Lt✓E✓ L�Q.�. ���u.t NG, WELL CONSTRUCTION RECORD WELL CONTRACTOR: ti
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 LOCAT =.w sketc of the location below)
NearesSFe+b1N ` County:
(Road Narqe an Numbers, CpunIty, ision and Lot No.) DRILLING LOG
3. OWNER From To
Address ` p1 t
ree `oCity or Town Zip Code
4. DATE DRILLED a 13
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES M NOrz:;r�
7. DOES WELL REPLACE EXISTING WELL? YES
NO[�
n-f
8. STATIC WATER LEVEL Below Top of Casing:
� FT.
or:1
(Use '+' it Above Top of Casing)
9. TOP OF CASING
ter„
IS _ FT. Above Land Surface*
'Top of casing terminated atlor below land surface requires a variance in accor-
— - "rim
— `_
dance with 15A NCAC 2C . 18
10. YIELD �-�-
o
(gpm): =4 METH D OF TEST
11. WATER ZONES (depth): — c
cn'�M�
12. CHLORINATION: Type Amount
If additional space is needed use back of loan
13. CASING:
Wall Thickness
Dept F�Dla er qr WeIQ to CI'
From � To �`�- Ft.
From To Ft.
From To Ft.
14. GROUT:
Depth Ma Method
From iD To Ft. E
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
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
From To Ft.
From To Ft.
17. REMARKS:
I DO HEREBYkCERTi lR T`fliiA�HI L� GUNSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTI N TA .DI�'RNeA�D WAS ( OF THIS RECORD S BEEN PROVIDED TO THE WELL OWNER.
�7j:=
JF a o
FOR OFFICE U7 i IOuad No:oi�'I S GNATURE OF PERSON CONSTRUCTING THE WELL DATEubmit dgina�to Division of Water Ouality, Groundwater Section Within 30 days
Serial No. a„af, Sr roan GW-1 REV. 12/99

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable sox): Residential Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCAT ow sk tch of the location below)
NearestrTor 7 �'�'_ County: Q Q
(Hoag Nv me nd Numbers, Co nl , r Subdivision and Lot No.)
DRILLING LOG DEPTH
3. OWNER
Address
From To Forma'on Gscri lion
ree or ou e o (yam
( r bq
City or Town Stale Zbjpt CodeI
b T vl
_
4, DATE DRILLED 3D bb
5. TOTAL DEPTH r
6. CUTTINGS COLLECTED YES [] NO
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO[7
o
8. STATIC WATER LEVEL Below Top of Casing: �_ FT.
en
= rnrn
(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 2 0�18
10. YIELD (gpm): METH D QF TEST
tc
� --
11. WATER ZONES (depth): — o���
m m
12. CHLORINATION: Type tt k Amount
n
-
o
_C
If additional space is needed use back of fob
13. CASING:
x
Wail Thickness
Depth D/la er orj e(yi,VFt. tort
From l b� b jY�I�O
LOCATION SKETCH
(Show direction and distance from at least two State
To Ft. _M
Roads, or other map reference points)
From To Ft,
From To Ft.
14. GROUT:
Depth Mae al Method
From �_ To V0 Ft.
From To Ft.
15. SCREEN:
Depth
Diameter
From To
Ft In.
From To
Ft. In.
From To
Ft, In.
16. SAND/GRAVEL PACK:
Depth
Size
Slot Size Material
In.
in.
In.
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
CONSTRUC'T10'N 9LS7 NC� 'RI s,146#H T A PY F THIS RECORD HA BE N PROVIDED TO THE WELL OWN
FOR OFFICE NLY t' 7'��/�� 1
Quad No: �EB 8 I iSIGNATUREOF PERSON CONSTRUCTING THE WELL
Su,britt'ori l6al to Division of Water Quality, Groundwater Section within 30 days
Serial No. 1 1 0 1 GWA REV. 12199

North Carolina • Department of Environment and Natural Resources • Division of Water Ouality • Groundwater Section 33
1636 Mail Service Center • Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: A0 K �E� ( �Q'I (1 `
WELL CONTRACTOR CERTIFICATION:_ _` :2- -7,
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residentlal L tJ' Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below) J
Nearest Town: U k County:
enIV I Zee L
(Road Name and Numbers, Community, or Subdiivision and Lot No.) DRILLING LOG DEPTH
3. OWNER Q ^
jC.H 0_b /'jche_ 2 C 0,j From To Formation Description
Address �-( $",0µ,) e— C It
MM tree or ou a o. p / �, ;"—
City or T wn State Zip Code
4. DATE DRILLED
5. TOTAL DEPTH -age ?
c�
6. CUTTINGS COLLECTED YES ❑ NO❑'-
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO❑
8. STATIC WATER LEVEL Below Top of Casing: FT.
(Use'+' 11 Above Top of Casing) Cr3
9. TOP OF CASING IS FT. Above Land Surface -
a�
'Top of casing terminated at/or below land surface requires a variance In accor•
dance with 15A NCAC 2C .0118
10. YIELD (gpm): " n. METHOD OF TEST = �'
11. WATER ZONES (depth): rim
21
+>J7
12. CHLORINATION: Type 1-/:2. Amount ' t`'' �1 If additional space Is needed use back of form
0
13. CASING: ®_
Wall Thickness LOCATION SKETCH
Depth Diameter
or Welght/Ft. Material (Show direction and distance from at least two State
From To - ° _ Ft. 'L u " k, ':�. �1' `-
. Roads, or other map reference points)
From To FI.
From To Ft.
14. GROUT:
Depth Material Method
From To 22 Ft.��
From m To (�� Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft In. In.
From To Ft. In. in.
From To Ft. In. In.
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To FL
17. REMARKS: . . .............. .
I DO HEREB!{[C)�4TiFY fHAT�<T,NiS:1'1'IELAlodal
NSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUC II ,N TANDARDS, AND THY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
6 i j
FOR OFFICE N''Y`"
Ouad No: SIGNATU9,6 F PERS�N NSTRUCTiNG THE WELL DATE
ldt i3bg $ � i'Snuat to Division or Water buality, Groundwater Section within 30 days
Serial No. i Is 0 bnal Offict; GW 1 REV. 12/99

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section �1 2 '1. 1 r•y
1636 Mail Service Center - Raleigh. N.C. 27699-1636-Phone [phone] II 1 `)
WELL CONSTRUCTION RECORD WELL CONTRACTOR: Cheap oel l �/ 211I14
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential Municipal ❑ Industrial d Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other M If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below) 4)4
Nearest Town: 1-7,jb 0-0-va t ( I / County:
(toad Name and Numbers. Corrmunit , or Subdlvision and Lot No.) DRILLING LOG DEPTH
3. OWNER /-1"= <k 1111.T < J� From To Formation Description
Address /41%
(Street or Houte o.
r0 40-v ,r 1l e S< 396861
City or Town �— Stale 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, I
C:Jr
(Use '+' If Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface* mtz 56:;o
t7 _ r n
*Top of casing terminated st/or below land eurface requires a variance In accor- j% j
dance with 15A NCAC 2C .0118 Q
10. YIELD (gpm): y METHOD OF TEST ✓ l - �--
Li: S G� o
11. WATER ZONES (depth): � � �
12. CHLORINATION: Type ' /V Amount lc";—. If additional space Is needed use back ovm rna
40 , h
13. CASING:
z
Wall Thickness LOCATION SKETCH
Depth Diameter or.Welgh 1. M_Jerlal (Show direction and distance from at least two Stale
From To Z `r Ft. L' j c �' G ` Roads, or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From To :' Ft. CIA
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft In. in.
From To Ft. in. In.
From To Ft. In. In.
16. SAND/GRAVEL PACK:
Depth Size Material
From . To Ft.
From To FL
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTIO `STAfft Ah, bs �N THAT'A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE US LY
Quad No: :4 f S NATURE f�F PER§ON CONSTRUCTING THE WELL DATE
Submit o Inal t - Divisldn of Water Ouallty, Groundwater section within 30 days
Serial No. OW-1 REV. 121"
mundwater Suction
n- .'-..al r144ir14

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: Ne o14eP i.c 2-11 bWA 1t f4"
WELL CONTRACTOR CERTIFICATION #: �5� (, 6
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential ET" 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: 4Nbpg"'u S County: ___ Z-0 to
51t't/e►'t l"f- GsAA")i 8yd-ie-S - �-F
(Road Name and Numbers, Community, or Subdivision and Lot No.) DRILLING LOG
OWNER E
DEPTH
3. t'_ From To
Formation Description
Address qL1 Pry v (�� D
�7l
(Streetor o e o. U
_c4,) i_"1z .V r a�715.
City or Town State Zip Code
4. DATE DRILLED L
5. TOTALDEPTH
6. CUTTINGS COLLECTED YES ❑ NO❑'
7. DOES WELL REPLACE EXISTING WELL? YES [] NOE3—
6. STATIC WATER LEVEL below Top of Casing: %i FT.
o
(Use '+' It Above Top of Casing)
%
v o
9. TOP OF CASING IS FT. Above Land Surface'
am
'Top of casing terminated atlor below land surface requires a variance In Accor-
c�
dance With 15A NCAC 2C.011a
�r
10. YIELD (gpm): ? _METHOD OF TES
11. WATER ZONES (depth):
12. CHLORINATION: Type _/_/ Amount
13. CASING:
Wall Thickness
Depth , bianleler or Wel h VF I Medal
r I
t' �r
From
To Ft. `—
From
To Ft.
From
To Ft.
14. GROUT:
Depth Material Method
From
.1
To �� Ft. �2�'�
,C7
From To Ft. 44Z
15. SCREEN:
I
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:
II additional space is needed use back of I"
LOCATION SKETCH o
z
(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 ISA NCAC 2C, WELL
CONSTRUCTIO ANQA6QS4ANQ.THAT1A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE U LYQuad No: No: �� '� j ` 1. NA tOFP Soh 6ONSTRUCTING THE WELL DATE
Submit o glnal o [ ivislon of Water d6ality, Groundwater Section within 30 days
Serial No. i idw 4inn GW1 REV. 12M

i j y
North Carolina • Department of Environment and Natural Resources • Division of Water Quality • Groundwater Section
1636 Mail Service Center • Raleigh, N.C. 276M 1 636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: _C '�l�Ro �e� Cc'�:I ( D�� �( A
WELL CONTRACTOR CERTIFICATION
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable box): ResidenUal ❑ Municipal [E� Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
Agricultural ❑ Monitoring ❑
2. WELL LOCATION: (Show sketch of the location below)/ -
Nearest Town: - R^ L)O-e-County: - l JL�QD K��
/h14QR Lc --
(Road Name and Numbers, Community, or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER nfQ Q L /,t 71} (2 From To Formation Description
Address TO .6 a,<- 0 7V D . S`/ .5 7 C�'i
ma, (ti ree or Route o. �f :'�'i c, r
4, lP /Uc
City or Town Stale Zip Code
4. DATE DRILLED /` 7' 0 o
5. TOTAL DEPTH S a
6. CUTTINGS COLLECTED YES[:] NO[:3—
7. DOES WELL REPLACE EXISTING WELL? YES [] NO[�]r
8. STATIC WATER LEVEL Below Top of Casing: F 1.
(Use '+• it Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface*
'Top of casing terminated at/or below land surface requires a variance In actor-
dence with 15A NCAC 2C.0118
10. YIELD (gpm): METHOD OF TEST
11. WATER ZONES (depth):
12. CHLORINATION:
13. CASING:
TypeAmount Z 0 If addltional apace is needed use UacK of iewn o
0
� a
Wall Thickness LOCATION SKETCH
DepthC� /� Diameter or,elj�ht/Ft. Material (Show direction and distance from at least two Slate
From—To''
Ft. - �� `' Roads, or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth aterial Method
From To Ft.e� jAeritE NM_
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Malarial
From To Ft In, In.
From To Ft. In. in.
From To Ft. In. In.
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
17. REMARKS:
I DO HEREBY CERTIFY THA
CONSTRUCTION' STAND'ARI
FOR OFFICE USEiiLY _
Quad No: c�� �Y� ..
Submit
Serial No.
9UCTED IN ACCORDANCE WITH ISA NCAC 2C, WELL
THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
NSTRUCTING THE WELL DATE
Groundwater Section within 30 days
OW-1 REV. 12M

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section 2 2 1 ��
1636 Mail Service Center - Fiat-[ h N C 27699-1636-Phone [phone]
to , . . \
WELL CONSTRUCTION RECORD WELLCONTRACTOR: C ite,9D
WELL CONTRACTOR CERTIFICATION M: S6,r
STATE WELL CONSTRUCTION PERMITN,
1. WELL USE (Check Applicable Box): Residential ER/ Municipal ❑ Industrial d Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below) /'1
Nearest Town: Mu r� �y County: Ro
Nw�ti r �C lJc�q J4��
(Road Name aM Nunb6rs, Communl , or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER Ti.titr+-j✓y C' 2 From To Formation Description
Address �?s �b GA+4yeS
�14,1-j5ireet or R'u a o. j l� . S
City or lownl State Zip Code
4. DATE DRILLED I - ' C `
5. TOTAL DEPTH �!t ti
6. CUTTINGS COLLECTED YES 0 NO❑' �
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO❑-
8. STATIC WATER LEVEL Below Top of Casing: -).-s FT. C-��
(Use'+ II Above Top of Casing) _
9. TOP OF CASING IS FT. Above Land Surface' © 4{
*Top of casing terminated at/or below land surface requires a variance In accor-
dance with 15A NCAC 2C .0118
10. YIELD (gpm): l•/ METHOD OF TEST
11. WATER ZONES (depth): C4 L
12. CHLORINATION: Type / Amount ?' ' j It additional space Is needed use back of lorry]z
13. CASING:
LOCATION SKETCH
Depth
Wall Thickness
Diameter or Weight/Ft. Material
(Show direction and distance from at least two Stale
From
To �� `
Ft.
6 "1 _ 'J r ' z t ``
Roads, or other map reference points)
From
To
Ft.
From
To
Fl.
14. GROUT:
Depth
Material.. Method
From
C. To
F1.
< ` J
From
'2 G To t- r
Ft.
-
15. SCREEN:
Depth
Diameter
From
To
Ft In.
From
To
Ft. In.
From
To
Ft. in.
16. SAND/GRAVEL PACK:
Depth
Size
From
To
Ft.
From
To
Ft.
17. REMARKS:
Slot SIZE Material
In.
In.
In.
Material
I DO HEREBY CERTIFY THAT. —THIS -MILL WAS CONSTRUCTED IN ACCORDANCE WITH I SA NCAC 2C, WELL
CONSTRUCTION STA D A TI' TrA P1�; l!";THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ON
Quad No: JAN —s i�� I ; s" I-OFaERSON CONSTRUCTING THE WELL DATE
u6r5 forlpi�ai to n of Watei duality, Groundwater Section within 30 days
GW-1 REV. 12/99
Serial No.

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section ? 3 6 1 9 I
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: n"`�11ec ���� c�sIl I nJ
WELL CONTRACTOR CERTIFICATION N:
STATE WELL CONSTRUCTION PERMITO:
1. WELL USE (Check Applicable Box): Resldential � Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other[ II Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: �Mu �� County: .
1�;c�u�GSSG'P Q'i�il, C C DEPTH
(Road Name nd Numbers, Community, or Subdivision and Lot No.) DRILLING LOG
3. OWNER \/ 70 ��S From To FonraSon Description.
� C1a
_ r f
beet or
City or Town State Zip Code
4. DATE DRILLED L"� Oo
5. TOTAL DEPTH
6. CUTTINGS COLLECTED Y f S o NO[E
7. DOES WELL REPLACE EXISTING WELL? YES �] NO[�-
e. STATIC WATER LEVEL Below Top of Casing: IDt)` FT.
(Use '+' it Above Top of Casino)
9. TOP OF CASING IS__.-____ FT. Above Land Surface'
~Top of casing terminated al/or below land surface requires a variance In accor-
dance with 15A NCAC 2C .0110
10. YIELD (gpm): 10b METHOD OF TEST 41"
11. WATER ZONES (depth):
12. CHLORINATION: Type Amounl --] ---- It additional space is needed t-s,-- back of fcfm
13. CASING:
Wall Thickness
Depth Diameter or We< lg�ht/Fl. Material
From—Q- To - FL `� -r)"lL—
From To Ft.
From To Fl.
14. GROUT:
Depth r M t ria� Method
From --- To Ft.
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft In. in.
From To - Ft. in. in.
From To Fl. In. in. —_---
16. SAND/GRAVEL PACK:
Depth Size
From -- To — Ft.
From To Ft.
17. REMARKS:
1 DO HEREBY CERTIFY THAT THIS WELL N
CONSTRUCTION STANDARQ NO TffT
Material
LOCATION SK-TCH
(Show direction and dunce trcfn ad leas: tr<o Snate
Roads, or other rr-ap relere:re points
S CONSTRUCTED IN ACCORDANCE WITH 15A 04CAC 2--.'/fELL
CAPY OF THIS RECORD HAS BEEN PROVICED 70 THE Yl'—"r..-L a%.'EF-
;r
FOR OFFICE USE ONLY SIGNATURE OF PERSON CONSTRUCTING DI-c yVELL
Quad No:
I i Submit original to Division of Water pualily, orwrndwala S crt M+ithin :� Ys
Serial No.
DA-T E
Cti-I ryEv. t:T1

` 236_1:��3
North Carolina - Department of Environment and Natural Resources - Division of Water Ouality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636•Phone [phone]
Yl ' � � A � (n' A l l C� r� � � rr►G
WELL CONSTRUCTION RECORD WEI.ILL. CONTRACTOR'
ONTRACTOR CERTIFICATION 0: 62�D�/
STATE WELL CONSTRUCTION PRMITH:
1. WELL USE (Check Applicable Box): Residential ❑ Munlclpal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heal Pump Water Injection ❑ Other 0 II Other, List Use:
2. WELL LOCATION: (Show sketch of the location below) n 4
Nearest Town: County:
DEPTH
(Road Name and Numbers. Commuln•ity, or Subdivision and Lot No.) DRILLING LOG Fomuxn Description.
3. OWNER I fG V�r'ea K' From To
Address to
r `
zi coda
City or Town Stale p
4. DATE DRILLED .I ` a 5' ©�
S. TOTAL DEPTH o2bS
6. CUTTINGS COLLECTED YFS ❑ NOWKID
7. DOES WELL REPLACE EXISTING WELL? NO[�'
B. STATIC WATER LEVEL Below Top of Casing: _5D FT.
(use 't- it Above Top of Casing)
9. TOP OF CASING IS I FT. Above Land Surface'
-Top of casing terminated svor below land surface requires a variance In accor-
dance with 15A NCAC 2C .011tt
10. YIELD (gpm): Z_ METHOD OF TEST--------------
1 1. WATER ZONES (depth):
12. CHLORINATION: Type �► 5 Amount S II additional space is needed rse baciof Ic-rrn
13. CASING: LOCATION SKOCH
Wall Thickness
Depth Diameter or Weight/Fl.
Material (Show direction and dance from I i,tNo S'-a e
From
To ��i FL ���- --� — .Sb�OZ 1 Roads, or other rrr reten: c>a Po
From To Ft. —
From To Ft.
14. GROUT:
Depth Material Method
o
r'
r
From To Fl. ---- -----
�? -
__L---
From To Ft. --
C=
cn
15. SCREEN:
Depth Diameter Slot Sizs Material
t
rn
�'
From To Fl In.
r� n
From To Fl. In. In. _---
CC)n,
.
a
From To Ft. In. In. _-----
w
16. SAND/GRAVEL PACK:
Depth Size Material
From To -- Fl.
From To -- Ft.
17. REMARKS:
WITH I SA ftELL
I DO HEREBY CERTIFY THAT THIS WELL WAS CON STRUCTED IN ACCOPIDMIC
OF THIS RECORD HAS BEENE RO CED-TOATHc-'IIS -1- O""EF.
A COPY
CONSTRUCTION SYANDAROS, AND THAT+
a"
O
FOR OFFICE USE 0,NLY1
SIGNATURE OF PERSON CONSTRr1 CTII10 t� vv'EU.
r:;,>:
Owd No:
.odithin N.) C%s Y6
5tibMlQinal to Division of Wolf( Dustily, oroundMsta Srccn w
CM,1 P� V.
1:11
Serial No, ,_
,

ti . 236177
North Carolina - Department of Environment and Natural Resources . Division of Water Ouali Groundwater Section
699-1636•13hone(919)733.3221
1636 Mail Service Center . paleiflh, N.C. 27
ELL CONSTRUCTION RECORD WELL CONTRACTOR:
w WELL CONTRACTOR CERTIFICATION 0:
STATE WELL CONSTRUCTION PERIAITP:
Applicable Box): Resldentlal � Munlelpal ❑ Industrial ❑ Agricultural ❑ Monilorirg ❑
j, WELL USE (Check App )i
Recovery ❑ Heal Pump Water In)ecllon ❑ Other [] If Other, List Use:
2
WELL LOCATION: (Show sketch of the location below) InP �D Y, P rJ
Nearest Town: County:
DRILLING LOG DEPTH
(Road a ao Nurr a ommunily, or Subdivision and Lot No.) From To Forrra:bn DescdPU-
3. OWNER
��.�.�� _
Address�� 4 _ co-
�.1 �1.lt
�4. / / 5 r
V Y It -
I i, Yn kl I7
City o ow
Stale "N
4. DATE DRILLED I1-10 - c725
5. TOTAL DEPTH '
6. CUTTINGS COLLECTED YfS NO[�
7. DOES WELL REPLACE EXISTING WELL? YES r FT.
8. STATIC WATER LEVEL Below Top of Casing:
(Use'+' if Above Top of Casing)
9. TOP OF CASING I9-1— FT• Above Land Surface'
'Top of casing terminated atior below land surface requires a variance In accor-
dance with 15A NCAC 2C.0118
10. YIELD (gpm). r9b— METHOD OF TEST .f r
11. WATER ZONES (depth):
12. CHLORINATION:
13. CASING:
Type Amounl -:L II additional space is needed bah of lean
Depth Diameter
Wall Thickness
orwelghUFt. Material
Ft. --
-�-
From --L
---To
From—
To Ft.
From _----To
Ft• --
14. GROUT:
Dea octal
Method
From D
_ Topth � Ft.
From
To __ _ FL
---------
15. SCREEN:
Depth Diameter Slot Size
Material
From
To FI In.
In.
From
— To Ft. in.
In.
_-----
T Fl In.
In. __----
From — o
16. SAND/GRAVEL PACK:
Depth Size
From — To — Fl.
From — To — Fl•
17. REMARKS:
DO HEREBY CERI
CONSTRUCTION $
FOR OFFICE USE
Ousd No:
Serlal No.
FY TFIAT,THI3 WELI`,Wp
4NDARDS `AND THAT A
Q6
SubnAll
Material
LOCATION SKcTCH
(Slow direction and d's ante Iran -A leas::"o S'•ale
Roads, or other rrz---p relererce points`
CONSTRUCTED IN ACCORDANCE WITH 15A 04CAC 2^, v%ELL
DPY OF THIS RECORD HAS BEEII PROVI6EO 10 THE yl: U
c�
--1
N rz�
co Cn
C-0
Da.. E
"t:L'SIONATUFiE OF PEn30N CONSTRLY:TIfiu ME'WELL
l nal Io division of Water 008111y, tlroundMstar Sracat wilttin Ys CM I pit: V. 12T1
J e

Natural Resources •Divlslon of Waier Quality •Groundwater Section 236178
"
North Carolina • Department of Environment and
1636 Mail Service Center • Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION p: •
STATE WELL CONSTRUCTION pERMITO:
USE Applicable Box): pesidential ClyMunicipal ❑ Industrial ❑ Agricultural ❑ Monilorlrg
❑
1 WELL (Check
Recovery ❑ Heal Pump Water Injection ❑ Other ❑ 11 Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
y
Nearest Town: County:
(Flo amNumbers Corrv�j��..,Su�bd�lvlslonnd Lol No.) DRILLING LOG DEPTH
ToFOnnaSM Ots�ripuo"3.
OWNER !t �; !� rG3Y�?/n,F1' From
Address
City or Town State Zip Code
DATE DRILLED -
4.
5. TOTAL DEPTH I l
YFS ❑ NOE�]r
6. CUTTINGS COLLECTED
DOES WELL REPLACE EXISTING WELL? YES n NO[0-
7,
0. STATIC WATER LEVEL Below Top of Casing: �F) (_ FT.
(Use 't' If Above Top of Casino)
TOP OF CASING IS_.L____- FT. Above Land Surface'
9.
'Top of casing terminated at/or below land surface requires a varlance In actor -
dance with 1SA NCAC2C.'t1e METHOD OF TEST
10. YIELD (gpm): _(J_
11. WATER ZONES (depth):
Amount II additional space i5 needrl rse back of larm
12. CHLORINATION: Type
13. CASING: LOCATION SKrTCH
Wall Thickness d r'o
Wei hVFt. Material (Stow direction and ance Imm ej lea,
Depth r Diameter or
ID"it-
F1 L-, - (' Roads, or other rrG7 relertrce Po
From —To 1
From To Fl.- - —
From —To — Fl.
14. GROUT: p
Depth M t fiat Method
Q
From _-- To Ft. --------- C=
c� J
z �,.
c _s
From To Ft.
`•=
15. SCREEN: rn
Depth Diameter Slot Size Material
_!
-c
m .
From To Ft In. in. _----
=,M
From To Ft. In. In. _-- ---
C„�
rn
From To ____-- Ft. In. In. -- c�
0
0
16. SAND/GRAVEL PACK:
Material
Depth Size
From — To — Ft.
From — To — Ft. —
17. REMARKS:
i
"7OAWt Y1'=-t- 0"Ep..
fNADS CPY
DO HEREBY CERTIFY;
AIN THAT A C OF.THIS RECORD HAS B E 1 PROVIC 0
STANaaD�
CONSTRUCTION @AN �.
a I tl H .i FI Hit �� O l�/ %�i.'�
.• .
FOR OFFICE USE Of L
CCS IIWW
D` E
SlGNA7UnE OF PER3QN CONSTRl1:TING 1><'/v ELL
Quad No: ?;
Si t rT!II{o pinal to Division of Water Guallly, Ground+�ale► Srcu+ willlin C%SYs
Serial No.
c3ci�oil�,

North Carolina - Department of Environment and Natural Resources - Division of Water Ouality - Groundwater Section 2 3 6 1. 7 9
1636 Mail Service Center Raleigh, N.C. 27699-1636-phone [phone]
lw7[��� Ci1-ll,v1�
WELL CONSTRUCTION RECORD WEtL.IL. coNTRACTOR�CERTIFICATION fJ:
STATE WELL CONSTRUCTION PERMITP:
1, WELL USE (Check Applicable Box): Residential Municipal ❑ industrial ElAgricultural ❑ Monilorirg El
Recovery ❑ Heat pump Water Injecllon ❑ Other [] If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below) ��ero�C ee
Nearest Town: County:
tnn �o�ers.
DEPTH
-1v t oa i.i(Road Name and Nu mmulnity, or Subdivision and Lot No.) DRILLING LO
3. OWNER 1� t l 5 From TI r^Forrra�n Description
Address
(reel or ou
`7� � — .� •7c9
City or Town Stale Zip code
4. DATE DRILLED
5. TOTAL DEPTH -37E7 --
6. CUTTINGS COLLECTED YFS ❑ NO
7. DOES WELL REPLACE EXISTING WELL? YES Q NO®-
8. STATIC WATER LEVEL Below Top of Casing: _4p! FT.
(Use '+' It Above Top of Casing)
9. TOP OF CASING IS___L-___ FT• Above Land Surface*
'Top of casing terminated stlor below land surface requires is variance In accor-
dance with 15A NCAC 2C. 118
10. YIELD (gpm): '�"7"� METHOD OF TESTr
11. WATER ZONES (depth):
12. CHLORINATION:
13. CASING:
Type d a 1eES Amount . :5--- . It additional space is needed L--sA- back of Icrm
Wall Thickness
Depth
Diameter or Weighl/Fl. Material
FI.
From
To _&_-
JL-ems--
From
To Fl
From
—To Ft
14. GROUT:
Depth r
From n To 2&c _ Ft.
Mtprlal Method
7'/
From
To —Ft.
—`----
15. SCREEN:
LOCATION SK=TCH
(Show direction and disl-ance h"vn al leas• tko Snale
Roads, or other rr- p relererr-es points'
Depth
Diameter Slot Slze
Material
CD
From To
Ft In.
In.
m
From To
Ft. In.
In.
From To
Ft. In.
In. ____,—
W
16. SAND/GRAVEL PACK:
Depth
Size
Material
From — To
— Ft.
From To
— Ft. —
—
17. REMARKS:
DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A 114CAC ?C,'t-rELL
S+A AT A COPY; OF THIS RECORD HAS BEEN PROvIt£010 THE'/lam a`�`EF
CONSTRUCTION STANDARDS, Nt) 7ti _
'.fJ
FOR OFFICE USE ONLY o's
Quad No: H j 9 � 51GNXi6AE OF PERSON CONSTRIY:TING 1>t'N'ELL
Su i rlpl !al to Drvlelon of Water t7ueltly, Groundwater Srccn !within h Ys Ce•) Fig V. 12?1
Sadal No. # „ ....

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: (2'6eA0%4ee caq ibf lltov
WELL CONTRACTOR CERTIFICATION N: "a lfl,6—
STATE WELL CONSTRUCTION PERMITN:
1. WELL USE (Check Applicable Box): Resldentlai L5 Municipal ❑ Industrial 0 Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: �✓ County:
r/�1t,1 I
Cof�'2 et, S01I6✓ �i A� G R_O ✓�
(Road Name and Numbers. C mmunity, or Subdivlslo and Lot No.)
DRILLING LOG DEPTH
3. OWNER Ant rho
From To Formation Description
Address %3
ree or oue o.
City or Town Stale Zip Code
4. DATE DRILLED ->L
5. TOTAL DEPTH Y 6 2
6. CUTTINGS COLLECTED YES ❑ NO❑---
7. DOES WELL REPLACE EXISTING WELL? YES NOE::r
o
B. STATIC WATER LEVEL Below Top of Casing: <' FT.
t=
(Usa '+' it Above Top of Casing)
t7 0
9. TOP OF CASING IS FT. Above Land Surface*
'Top of casing terminated atlor below land surface requires a variance In accor-
m
dance with 15A NCAC 2C .0118
10. YIELD (gpm): �_ METHOD OF TEST �� ✓1
11. WATER ZONES (depth):
-m
c�
12. CHLORINATION: Type ,>`�,G, _ Amount ( n �S
If additional apace is needed use back of IornfWO Z5
z--
13. CASING: '
LOCATION SKETCH
Wall Thickness
Dept Dlanr Lller or Weightf t. Maat1dall
1;)'$ b
(Show direction and distance from at least two State
From To Ft. —&�- -- - I —=
Roads, or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
0
From To Ft.
From � o 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:
100 HEREBY CERTIFY•THAT jtil�S WELL, WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTIf Td�ilD lj D " AND T�I4 A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE NLYpi1 ' v�
Quad No: a�5=t� ? I = SiG1,, Tt�leOF PER COt�ST! t nNG THE WE DATE
Submit odpinat I�Iai4fsion of er Oualily, rotmdwatsr Section within 30 day9
Serial No. _ - .,--- GW1 REV. 12/99

North Carolina - Department of Environment and Natural Resources - Division of Water Quality • Groundwater Section 134
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: _ 1,.._ l,�o-w-0�es° tjd/
WELL CONTRACTOR CERTIFICATION #: ? .S G S
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable sox): Residentlal I 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: -_ 41*1 Qb � County: ��
��
geg ,�.eai
(Road Name and Nuers, Community, or Subdivision and Lot No.)
DRILLING LOG DEPTH
3. OWNER
From To Formation Description
cC�
Address (7o6 f%_040C_% S I
D S� -7"
o.
(Street or ou-fe No.).-
SI . C,40Lf b L l %iy
U I J
y Cr ; i Cy-
City or Town State Zip Code
4. DATE DRILLED l/'
5. TOTAL DEPTH Tj V Y
6. CUTTINGS COLLECTED YES[] NO❑"
—T V e of 1,-e- i
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO❑"
6. STATIC WATER LEVEL Below Top of Casing: � � FT.
(Use '+' It Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface'
�—
*Top of casing terminated at/or below land surface requires a varlance In accor-
dance with 15A NCAC
::0
O 6T
2C .0118
10..YIELD (gpm): t' METHOD OF TEST - /—) ✓1
11. WATER ZONES (depth): _1 D o' . 2 2
12. CHLORINATION: Type - " ,7a —Amount c c
If additional space Is needed use back of form m
13.'CASING:
Watt ThicknessLOCATION
SKETCH
Depth Material hVFt. Diameter or Wel
_ g
From �/ To 9-6 Ft. 6;1 P ✓L
(Show direction and distance from at least two Slate
_
Roads, or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Malerf Method
�12
From To Ft.
From To Ft.
15. SCREEN:
Depth Diameter Slot Siz6 Material
From To Ft in. in.
From To - Ft, in. in.
From To Ft. In. In.
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND-THAT•A,COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE_ .'NL ..� � .-- l�
Quad No: jS RATU E9 PERSON CONSTRUCTING THE WELL DATE
Serial No.f + ;`SutlI' al to Div s on of Water Quality, Groundwater Section within 30 days
,. J.11
� OW-1 REV. 12/99

r:
r
North Carolina - Department of Environment and Natural Resources • Division of Water Quality - Groundwater Section 2- " �) .( �j
$
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: k ll i M �f
WELL CONTRACTOR CERTIFICATION #: —e)-.5-
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential Municipal ❑ Industrial ❑ Agricultural d Monitoring ❑
Recovery ❑ Heat Pump Water Injectlon ❑ Other C] If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below) /
Nearest Town: Lk County:
(Road Name and Numbers, Community, or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER t C 7-�, (_ 7' C- /,�, 6
l From To Formation Description
Address
Tee or HOU10 o.
City or Town State Zip Code _
4. DATE DRILLED v
5. TOTAL DEPTH V '
6. CUTTINGS COLLECTED YES [] NOE:J" _
7. DOES WELL REPLACE EXISTING WELL? YES NOD
6. STATIC WATER LEVEL Below Top of Casing: D. ,- FT.
(Use '+' If Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface•
•Top of casing terminated eVor below land surface requires a variance In accor-
dance with 15A NCAC 2C .0118
10. YIELD (gpm): _1____ METHOD OF TEST 1
11. WATER ZONES (depth): o
12. CHLORINATION: Type _ / % /% Amount a �!�� If additional apace Is needed use back of form
13. CASING:
Depths
Wall Thickness LOCATION SKETCH
G ` Diameter or WalghvFl. Material (Show direction and distance from at least two State
From To Ft. tr S -11 - Pvc Roads, or other reap reference points)
From To Fl.
From To Ft.
14. GROUT:
Depth Material Method
From t% To 2-0 Ft.
From 7 4 _ To -/-1/ 4, Ft.
15. SCREEN: L.
Depth Diameter Slot Size Material
From To Ft in. in.
From To Ft. In. In.
From To Ft. In. in.
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
17. REMARKS:
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ON M � �1 r /)e ) < %- 2 " e.� O
Quad No:
Serial No.
Sub nI1 orl Ingal
U�J1Y � ,C�
OF PERSON CONSTRUCT 71NG THE WELL
o1 Water Quallty, Groundwater Section within 30 days
DATE
GW-1 REV. 12199

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section � �- v f (� ) r�
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: aeac:k -1/1Ng
WELL CONTRACTOR CERTIFICATION
STATE WELL CONSTRUCTION PERMITN:
1. WELL USE (Check Applicable Box): Residentlal BY" 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: u p /'- County:
-.V_n _ e
/FLn1fIJ6r LI4ce
(Road Name and Numbers, Community, or Subdivision and Lot No.)
DRILLING LOG DEPTH
3. OWNER u " al LL
From To Formation DescriptionAddress
(Streel.6r
I" '
Oi�
City or Town State Zip Code
4. DATE DRILLED LY 0 6
_ t
7 zcrl2-2
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES 0 NOD
,
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NOE ]
u ;-
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 2F 0118
10. YIELD (gpm): /�_ METHOD OF TEST-
11. WATER ZONES (depth):
N -{
12. CHLORINATION: Type NTH
YP Amount,Y <T
If additional apace is needed use back of form
13. CASING:
Wall Thickness
-LOCATION SKETCH
Depth _ Diameter or Welght/Ft. Material
%fie-e''Fbs r
(Show direction and distance from at least two State
From ►•''� Ft.
Roads, or other map reference points)
From To Fl.
From To Ft.
14. GROUT:
Depth Material Method
From RA-e `�tS� tS n" ` Ft.
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From To Fill in. In.
From To Ft. In. in.
From To Ft. in. in.
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
17. REMARKS:
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C, WELL
CONSTRUCTION ST DABD.S,.�AfalDIJAALA.00, Y OF,THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE 0
Quad No:
Serial No.
� J�) �, Sgbj[i Aglnai `r lon of Water,
Section within 30 days
DATE
OW-1 REV. 12/99
�f ur,ri!:at r Sec
� J�) �, Sgbj[i Aglnai `r lon of Water,
Section within 30 days
DATE
OW-1 REV. 12/99
�f ur,ri!:at r Sec

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section ' Z 0 J ( 4
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: - CIk-e-e
WELL CONTRACTOR CERTIFICATION M:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable sox): ResidentlaI10 Municipal ❑ Industrial ❑ Agricultural d Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ It Other, List Use:
2. WELL LOCATION: (Show sketch of the location below) /
Nearest Town: t l ' County: - - Cat
_
t�f20 k
F
(Road Name and Numbers, Community, or Subdivision and Lot No.)
DRILLING LOG DEPTH
3. OWNER P%a h(X %� t�
From To Formation Description
Address S /Oic�� lr� C(i
—/--(5tr
y Y G Sfft
e or oulp NO.
Lt /l r�
City or Town State Zip Code
4. DATE DRILLED
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES E] NO❑—
C-
7. DOES WELL REPLACE EXISTING WELL? YES [] NO[�
8. STATIC WATER LEVEL Below Top of Casing: FT,
r- ....
(Use '+' It Above Top of Casing)
/
9. TOP OF CASING IS FT. Above Land Surface-77
'Top of casing terminated at/or below land lurface requires a variance In accor-
_
dance with 15A NCAC 2C .0118
10. YIELD (gpm): / dL"O �, METHOD OF TEST i 2. "Z
'-
-7-) r __
11. WATER ZONES (depth):
12. CHLORINATION: Type %�f Amount ' �����
If additional space Is needed use back of form ca c'7
13. CASING:
Wall Thickness _ LOCATION SKETCH
Depth Diame)er or welght/Ft. Material (Show direction and distance from at least two State
From To 2- J y Ft. - — RBI e Roads, or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Material, Method
From 0 To �� Ft.
From e10_ To V F1.
15. SCREEN: 77
Depth Diameter Slot Size Material
From To Ft in. In.
From To Ft. In. in.
From To Ft. in. in.
16. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To Ft.
17. REMARKS:
I DO HEREBY CE
CONSTRUCTION
FOR OFFICE
Quad No:
Sutxnit
Serial No.
Material
RUCTED IN ACCORDANCE WITH ISA NCAC 2C, WELL
THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
�OF PE N CONSTRUCTING THE WELL DATE
of Water Quality, Groundwater Section within 30 days
GWI REV. 12M

877
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]Y�``
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION #: 3
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCA
Nearest Town:
(Road N
3. OWNER
N
of the location below)
4LE— County:
and Lot No.)
cIry or To Zip Code
4. DATE DRIL � 0� 0 State
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑ NOE!r
7. DOES WELL REPLACE EXISTING WELL? YES Q NO
8. STATIC WATER LEVEL Below Top of Casing: Q FT.
(Use '+' It Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface'
'Top of casing terminated at/or below land surface requires a variance in accor-
dance with 15A NCAC 2C 0118 �� w
10. YIELD (gpm): i�ii METHOD OF TEST
11. WATER ZONES (depth): -
12. CHLORINATION: Type Amount
13. CASING:
De th I Wall Thickness
p IerW�el�ht/Fl.—Material
From 0 Ft. y'�' -�'K-
From To Ft.
From To Ft.
14. GROUT:
x Dept M t ri I Method
From To 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 Ft.
From To Ft.
17. REMARKS:
DRILLING LOG DEPTH
From To Form - tion Description
b 9
O
CJ �-
C3
O o'
40 CZ) m
c-J �' c�
q
77a rrn \
a
r x�
an �
If additional space is needed use back of form Z
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
I DO HERESY.' CON TRUC ION 9TliAt� A� S,IAN TI XI� _CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
i� CiQPY OF THIS RECORD H S BEEN PROVIDED TO THE WELL OWN
�g
FOR OFFICE, ON iY y rt
Quad No: �'AN 2 62001 SIGNATUR PERSON CONSTRUCTING THE WELL ATE
Su t orig nal to Division of Water Quality, Groundwater Section within 30 days
Serial No. 'i _, ...«: .: .� p GWA REV. 12199

s.1331
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: Ruin —
WELL CONTRACTOR CERTIFICATION #: a9
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (check Applicable Box): Residential 15 Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCA
Nearest Town:
(Road N
3. OWNER
or
of the location below)
`, _ County: J4.0 D
tlos, q ommu i , Or Subolvlsion and Lot No.) DRILLING LOG
1 From T
> _ d _ t
r e or ou
\ State Zip Code I
4. DATE DRILLEiH bo-
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES [] NO��
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO(�
8. STATIC WATER LEVEL Below Top of Casing: �( FT.
(Use'+' if Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface*
'Top of casing terminated at/or below land surface requires a variance In accor-
dance with 15A NCAC 2C.918 lJ��
10. YIELD (gpm): METHQD QF TEST
11. WATER ZONES (depth):
12. CHLORINATION: Type Amount
13. CASING:
DEPTH
Format' n Description
� C7
I a C-)
Y
If additional space is needed use back of form
From
From
Depth'�l f
To
To
Wail Thickness LOCATION SKETCH
D WeI hVFI. at al (Show direction and distance from at least two State
Ft. Roads, or other map reference points)
Ft.
From
To
Ft.
14. GROUT:
From
Dept
To
Ft.
M t rial Method
From
To
Ft.
15. SCREEN:
Depth
Diameter
From To
Ft in.
From To
Ft. in.
From To
Ft. in.
16. SAND/GRAVEL PACK:
Depth
Size
From To Ft.
From To Ft.
17. REMARKS:
1 DO HEREBY CERTIFY � "�,� l IS CONSTRUCTION S iA, 1 1
FOR OFFICE USE 0' JAN Z 6
Quad No:
Slot Size Material
In.
in.
In.
Material
)TED IN ACCORDANCE WITH ISA NCAC 2C, WELL
S RECORD H S EE PROVIDED TO THE WELL O
;.�
OFf-PERSON CONSTRUCTING THE WELL
of Water Quality, Groundwater Section within 30 days
041
Serial No. § _I.v got n(]tiV F :ectlon i GW1 REV. 12/99

n3�t1.6
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section C ..3
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION N:
STATE WELL CONSTRUCTION PERMITP:
1. WELL USE (Check Applicable Box). Residential [E] Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring El
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: /�i7,e, -r County:
3.
(Road Name and Numbers. Community. or Subdivision and Lot No.)
OWNER S�77teJ yVva9 --
DRILLING LOG DEPTH
From To Forrr.A5- Descripti-
Address
treat or outo o.
City or Town Stale Zip Code
4. DATE DRILLED /'o `92 'DD
5. TOTAL DEPTH /Bo
6. CUTTINGS COLLECTED YES ❑ NO[
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO[�'
S. STATIC WATER LEVEL Below Top of Casing: e O Fr.
(Use *+* it Above Top of Casino)
9. TOP OF CASING IS FT. Above Land Surface'
'Top of casing terminated atfor below land surface requires a variance In accor-
dance with 15A NCAC 2C .0118
10. YIELD (gpm): -J-P METHOD OF TEST 17
11. WATER ZONES (depth): 4
n
12. CHLORINATION: Type
/f Amount
7YGv� If additional space is needed tsss ba&of !corm
13. CASING:
LOCATION SK-TCH
Wail Thickness
Material
(Show direction and d fiance hvm leas `r+o Smote
�
Depth
Diameter or Wei ht/Ft
G_�,f SD�z! lfUG.
Ft. .
Roads, or other rr� refererree points
From
/,ZO
To -L---0
Tom
Fl. �- -2-'/
From
From
To
Fl.
14. GROUT:
Depth
ten I M lhod
�.
0
To o
cssuie
Ft. ----'—
From
c
From
To
Ft. -"__
o
15. SCREEN:
Depth Diameter Slot Size Material
C
c�^
From
To Ft
In. In.t
From
To Ft.
in. In. _---
Cn
G.
From
To Ft.
in. in. _----
X-
YZ
a o
16. SAND/GRAVEL PACK:
Material
rY�
Depth
Size
From
To
Ft.
t.J
From
To_
Ft. —
17. REMARKS:
( DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A DJCAC ?':, Y✓ELL
CONSTRUCTION STAND' Dj)�ANb Tj AT�A TY, OF THIS RECORD HAS BEEN PROVICED ?O fHE'N-"-t t��tiFF..
FOR OFFICE USE ONLY i ^ o� �E
➢i SIG ATURE OF PERSON CONSTRIY:TING PZ '"'ELL
Quad No: rr S
4 i. �u�rnl�b��nal to, Divlilon of Water Duallly, G,Wnb..ator Src-ut within :4 C%Y Cn t Y 1.91
- ,J f;
Serial No.. „

North Carolina - Department of Environment and Natural Resources • Division of Waier Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone] I B✓ ' Yl.
WELL CONSTRUCTION RECORD WElL.1L. CONTRACTOR CERTIFICATION
STATE WELL CONSTRUCTION PERMITN:
1, WELL USE (Check Applicable Box): ResidentiaiUZr Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water injection ❑ Other 0 11 Other, List Use:
2. WELL LOCATION: (Show sketch of the location below) �d 1� t✓
Nearest Town: � r b f P County: ( -
�d Ute DEPTH
(Road Name a Numbers,2:=
n and Lot No.) DRILLING LOG Fo axx+ Drs:+iP�o
n� niFrom To o x3. OWNERr r�ay --
Address 1r> Ci gad ,5111.14
treat or ou a o.
City or Town Stale Zip Code
4. DATE DRILLED v0
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YFS ❑ NO
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO[f
B. STATIC WATER LEVEL Below Top of Casing:FT.
(Use '+' If Above Top of Casing)
9. TOP OF CASING IS___L_ FT. Above Land Surface-
-Top of casing terminated at/or below land surface requires a variance In accor-
dance with 15A NCAC 2C A118 ik
10. YIELD (gpm): �1- METHOD OF TEST
11. WATER ZONES (depth):
Amount
If additional space is needed tse back of I01'm
12. CHLORINATION: Type
13. CASING:
LOCATION SK= fCH
Wall Thickness
ia<�
mo ale
(Show direction and des�ance (rm (i �
Depth 1s rgr
Z
lght/t• edai
/N 7 __
Roads, or other ram? relero:� Ao
From —sue—To
Fl•
From ' To
Ft.•—
--
From To
Fl.
—
14. GROUT:
Depth-�
Material Method
""
C'
From
From To —Ft.
--------=
�
�T
Gr
15. SCREEN:'r
Depth Diameter Slot Size Material
rn
o
From To Ft
in.�
From To Ft.
I
in. n.
From To Ft.
in. In.
m ti
16. SAND/GRAVEL PACK:
-'
Depth
ial
Size Material
o
r=
From To —Ft.
—
From — To
Fl.
17. REMARKS:
DO HEREBY CERTIFY THAT41-118 WELL WAS 1. CONSTRUCTED IN ACCORDANCE WITH 15A F4CAC ?^,'�fELL
CONSTRUCTION STANOAt dS, AfJ. 7HAT,A COPY OF THIS RECORD HAS BEEN PROViCED 70 THt: Y/'--''tL O%%*'EF..
FOR OFFICE USE ONLYeflul SIGNATURE OF PERSON CONSTRtY.TING lYe'/v ELL 0��
Quad No:
Submit original to pivlAon of Water Duelily, GrounbKatar Srcu+ wiihin hY3 Ca•I
Serial No. i

North Carolina , Department of Environment and Natural Resources • Division of Water Quality • Groundwater Section 4- 1 [) 469
1636 Mail Service Center • Raleigh, N.C. 27699.1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION
STATE WELL CONSTRUCTION PERMIT11:
1. WELL USE (Check Applicable Box): Residential ❑ M nicipai EII Olhe Llstal E Agricultural ❑ Monitodr:g ❑
Aecovery❑ Heat Pump Water Injecllon ❑ ❑
2. WELL LOCATION: (Show sketch of the location below) e� , e
Nearest Town: I�(A I — County:
(Road Name and Numbers, Commu Ity, or Subdivision and Lot No.) DRILLING LOG
3. OWNER J-r('a (Vie 4 �.`t^ - From To r
Address - t)
beet or ou o o. _ «i I - S �%
City or Town Stale Zip Code ,
4. DATE DRILLED 1SD - I - �� / CJ $ - �?Q S '
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YFS Q NO�
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO[r
e. STATIC WATER LEVEL Below Top of Casing: 5b ( FT.
9. TOP OF CASING IS___((Use 't' II Above Top of Casino)
______ FT, Above Land Surface*
'Top of casing terminated aVor below land surface requires a variance In accor-
dance with 1SA NCAC 2C.0118 In
10. YIELD (gpm): 300 METHOD OF TEST 1'r
LL-
11. WATER ZONES (depth):
12. CHLORINATION:
13. CASING:
DEPTH
Fortson OtsCdPU-
11
Type .Amount S It additional space is needed L ba&of (cam
Depth
Wall Thickness
� Diameter or We_ IohVFl• material
From _12—To
From ; To
Fl.
From To
FL .
14. GROUT:
Depth r Ma eflal Method
From _.1`_2 — To .Z— Ft. -
From To
Ft. ----
15. SCREEN:
Depth
Diameter Slot Siz6 Male flat
From To
FI In. In.
From To
Ft. In. In.
From To
Fl. In. In. --
16. SAND/GRAVEL PACK:
Depth
Size Material
From — To
— Ft.
From To
Ft. —
17. REMARKS:
DO HEREBY
FOR OFF
Quad No:
LOCATION SKr TCH
(Show direction and dis-ance lrrm al IOU!' wo Sale
Roads, or other rr"�p reference polnts�
W,
ss•
i
rn
co
ca
RUCTED IN ACCORDANCE WITH 15A 11JCAC?C,'tfELa`�ER
THIS RECORD HAS BEEN PROVIDED TO THE Yl�J-
1��11 =$ IGNATURE OF PERSON CONSTRU :TRIG IXE -VTLL
p 3
sutxnll;o'dolnal to Division of Wale( Duality, Groundwater Scut Mwilhin V. t'r'ly
0
Os. : E
W
t;; r�
�r a
=-r "
mcn
�rn
cn z
rn ;Z
c-i
—t
0
GM-1 PtEY, I""
Serial No.

North Carolina • Department of Environment and Natural Resources - Division of Water Quality • Groundwater Section I") v 6 1 1 O
1636 Mail Service Center • Raleigh, N.C. 27699.1636•Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION M: a�%D
STATE WELL CONSTRUCTION PERMITO:
1. WELL USE (Check Applicable Box): Residential M nicipal QIf Other, strialList . E Agricultural ❑ Monitoring ElAecovery❑ Heat Pump Water injection ❑ []
2. WELL LOCATI N: (Show sketch of the location below) n �e r Q
Nearest Town: ndr e W ,e, County: l�
(Road Nam d N n ers, Cornmunity, or Subdivision and Lot No.)
DRILLING LOG
3. OWNER
i
From To
I IDO `
Address u,C �,
r
reel or ou a o.
c
�'�6' - o
o2 J JC2 --I`� �C zl Code
City or Town Stale p
_2
4. DATE DRILLED
•leg i 7
5. TOYAL DEPTH 77,
7
6. CUTTINGS COLLECTED YES ❑ NO[j��
DOES WELL REPLACE EXISTING WELL? YES ❑ NO
7.
8. STATIC WATER LEVEL Below Top of Casing: — FT.
(Use '+' II Above Top of Casino)
9. TOP OF CASING IS FT. Above Land Surface'
'Top of casing terminated sUor below land surface requires a variance In accor-
dance with 15A NCAC 2C.0118
10. YIELD (gpm): n- METHOD OF TEST t
11. WATER ZONES (depth):
DEPTH
Forrraxn Description
Amount 11 addidonai space is needH L baeiof la m
12. CHLORINATION: Type
-----
13. CASING:
LOCATION SK=TCH
Wall Thickness
(Show direction and di�ance (rrm cs leas! � %ate
Depth r Diameter or Welght/Fl. �MatJerriia`l
�--To OLL Ft. Roads, or other rr.� relerer po
From -
From —'Fe To -21'eL
FL � � o
From To
Fl.CD
`-
14. GROUT:
Depth
M t Method
(rial
From ___-- To /Ft.
From To
Ft. ----
_;
15. SCREEN:
Depth
Diameter Slot Size Material
co
From To
F( in. in:
ca
From To
Ft. In. In. --
o
From To
Ft. In. in.
16, SAND/GRAVEL PACK:
Depth
Size Material
From To
— Ft. —
From To
Ft.
17. REMARKS:
WAS CONSTRUCTED IN ACCORDANCE WITH tSh 04CAC ?C.'/irELL
00 HEREBY CERTIFY AT 7HIS:.WELL
CONSTRUCTION AND THATaCY OF THIS REcoRD HA5 BEEtI PROVicEO '70 TI i' Yr O+�'`EF•
�STANOARIS,
-011FOR
OFFICE USE bN, Ly
OF PERSON CONSTRIY:TING T>¢ �O ELL
Ouad No:1„g
rIGNATURE
to Division of Water Ousilty, Ground�aler Srccn within Y) �Ys
Sli t or(pfnal
Serial No.

N rth Carolina • Department of Environment and Nalural Resources • Division of Water Quality • Groundwater Section
2361_71
0
1636 Mail Service Center • Raleigh, N.C. 27699.1636-Phone [phone] l l
WELL CONSTRUCTION RECORD WELL CONTRACTOR: o
WELL CONTRACTOR CERTIFICATION N: La 3
STATE WELL CONSTRUCTION PERMITN:
1. WELL USE (Check Applicable Box): Residential a Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other [] If Other, List Use:
2. WELL LOCATION: (Shoyv sketch of the location below) County: 2 C {D�� e
Nearest Town:
!y
V e4c G'r�z DEPTH
(Road Name and
/Numbers, Community, or ubdivlsion and Lot No.) DRILLING LOG
3. OWNER /T'j�/ L(%/7From To ForrraSon Des ripGc�
Address s-D G �y
treat or ou o o. ✓�`ta f �
0-�dD.
City or Town State Zip Coda
4. DATE DRILLED 16 3�' 00•
5. TOTAL DEPTH a00'
6. CUTTINGS COLLECTED YFS ❑ NO[9-
7. DOES WELL REPLACE EXISTING WELL? YES 0 NOD,
B. STATIC WATER LEVEL Below Top of Casing: 1 FT.
(Use 't if Above Top of Casing)
9. TOP OF CASING IS l FT. Above Land Surface'
'Top of casing terminated at/or below land surface requires • variance In accor-
dance with 15A NCAC 2C .0119ir
10. YIELD (gpm): �-
METHOD Of TEST .
11. WATER ZONES (depth): Z :E
12. CHLORINATION:
13. CASING:
Type s=Tl Amount 2 6a If additional space is needy! L-_-�e back of fcx-m
Walt Thickness
Dept
6--
DI or Wel hVI'l Material
5 fD�2� �yG
From
—To Ft.
—
From
' To Fl•
From
To Ft.
14. GROUT:
Depth
I MP Hal fAelhod
ad &�s1vj' e
From ..__.
To 21— Ft.
From
To Ft.
---- —
15. SCREEN:
Depth Diameter Slot Size Material
From
To Ft
In. In. �--
From
To Ft.
In. In. �---
To FI
In. In. __----
From
16. SAND/GRAVEL PACK:
Depth Size
From ._____— To Ft.
From — To-_— Ft. —
17. REMARKS: --
DO HEREBY CERTIFY T;HAr,-1I Hlt5 VVt_LL;rvr%O vc
CONSTRUCTION STD J1D'AR6S,A 13 THAT A COP
� y I
FOR OFFICE USE QNI.Y s���----
Quad No:
Submit oriolm
Serial No.
rl sJ.
Material
LOCATION SKc fCH
(Show direction and d;sance fmcn ad leas:,,No ,,ate
Roads, or other n-.--p relererrr* points!
ISTRUCTED IN ACCORDANCE WITH 1SA 04CAC r..'r'✓ELL
OF THIS RECORD HAS BEEN PROViCED '70 THE ' IE� L O»oEF..
_ A
ION TUBE OF PERSON CONSTRUCTING DIE W'1=LL
to Division of Water Quality. Gmun*"Isr Sraan within � C;5rY3 Cr+ I V. Ia1

North Carolina • Department of Environment and Natural. Resources • Division of Water Quality •Groundwater Section 3 172
1636 Mail Service Center • Raleigh, N.C. 27699-1636-Phone [phone] �,, // j , -1, t
�i/l i t l•�/� 'WSW; � � v `t 1
WELL CONSTRUCTION RECORD CONTRACTORWELL CONTRACTOR. CERTIFICATION N:
STATE WELL CONSTRUCTION PERMITH:
1, WELL USE (Check Applicable Box): Residential Municipal ❑ Industrial ❑ Agricultural ❑ Monttodr:g ❑
Flecovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: _(Sho.sketch of the location below) c/Q,r�e e
3.
Nearest Town.yr�/ y County.
(Road Name and Numbers. Community, or Subdivision and Lot No.)
OWNER
Address
treat or ou a o.
City or Town State Zip Code
4. DATE DRILLED /"/-act •
5. TOTAL DEPTH 5�0o '
6. CUTTINGS COLLECTED YFS 0 NO[
7. DOES WELL REPLACE EXISTING WELL? YES M NO❑,
B. STATIC WATER LEVEL Below Top of Casing: _�FT.
(Use'+' If Above Top of Casing)
9. TOP OF CASING IS l FT. Above Land Surface'
'Top of casing terminated sVor below land surface requires s variance In accor-
dance with 15A NCAC 2C .0118
10. YIELD (gpm): _Z.__ METHOD OF TEST
11. WATER ZONES (depth): --7*D
12. CHLORINATION:
13. CASING:
DRILLING LOG DEPTH
From To Fomaon Des riptia=
%Tlf Amount � G II additional space is needed USA -back of fccm
Type
Depth
Wall Thickness
Diameter or Welght/Ft. Material
/yC
From --To /,z0
Ft.
6_2s" .s 'e /
From
To
FL
—
From
To
Ft
14. GROUT:
Depth
AA terial/ thod
©
Ft.
From
To
From
To
Ft.
----_'
15. SCREEN:
Depth
Diameter Slot Size Material
From
To
Ft
In. —In..
From
To
Ft.
in. In. �--
To
Ft
In. In. �-----
From
16. SAND/GRAVEL PACK:
Depth Size
From To — Ft. From To Ft.
17. REMARKS:
Material
LOCATION SK=TCH
(Stow direction and dunce imm a, leas: tao Snale
Roads, or other rr-Cp relemrrP- points
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 1sa 04CAC 2r,'/✓ELL
CONSTRUCTION STANDARDS, AND THAT A COPY�OOFF THIS RECORD HAS BEET I PROVICED -TO THE VISAA-L Ot%�EF,.
FOR OFFICE USE;O• NLY
Quad No: J
orlpinallON LIFIE OF to pivitdon of Wa ePERSON
r taus IlyGround aletr s. •t within :r) C%?Y3
Di-' E
En•I F.19Y. 1a1
Serial No.

r.
236163
636 Ma;I ServiceDCenterenRaleigh. N.C. 27699-1636--Phone (919) 733'3221n of Water Quality •Groundwater Section
i. WELL CONSTRUCTION RECORD WELL CONTRACTOR: �liit�` FI//,) �n�
WELL CONTRACTOR CERTIFICATION N: uC�U
STATE WELL CONSTRUCTION PERNIITN:
WELL USE (Check Applicable sox): Residential [g� - vlunlcipal 0 Industrial ❑ Agricultural ❑ Monitoring ❑
1,
Flecovery ❑ Heal Pump Water Injecllon ❑ Other 0 it Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: t County:
d DRILLING LOG DEPTH
(Road Na e a Numbers, Commu fly, or Subdivision and Lot No.) From To Forrraxn Desr iptio'
3. OWNER ��kYb lf�S
Address
tree or ou o o.
-------------
City or Town
Slate Zip Code
4. DATE DRILLED b' S- ,
5. TOTAL DEPTH
NO
6. CUTTINGS COLLECTED YFS Q
7. DOES WELL REPLACE EXISTING WELL? YES Q Fr.
B. STATIC WATER LEVEL Below Top of Casing: h r
(Use '+' If Above Top of Casing)
9. TOP OF CASING IS___1____ FT. Above Land Surface'
'Top of casing terminated st/or below land surface requires a variance In accor-
dance with 1m)2C.'tts METHOD OF TEST
10. YIELD (g (gp ):
11. WATER ZONES (depth):
12. CHLORINATION: Type
i1) L? Amount If additional space is needH t� m
back of fcj
13. CASING: LOCATION SKETCH
Wall Thickness ghow direction and dance hart a� leas!, 5'ale
Depth r Diameler orWeight/Ft. Material ( int`
From
__-_To Ft. -'�'�-- i Roads, or other rrr� relere:.c� Do
From To -
From —To Ft. --
14. GROUT:
Depth M teriai Method © ��
From
To �--
From To —Ft. ------' C= -,
15. SCREEN: 1
Depth Diameter Slot Siz6 Material
From
To_Ft — in. In. _------ r„�'
In.------ 1 r ,
From To Ft. in.
To _ Fl. In. In. _ CO m
From ______ c„� �
16. SAND/GRAVEL PACK' o 0
Depth Size Material
From To — Ft.
From — To Ft.
17. REMARKS:
CgWITHISA
I DO HEREBY CERTII" THAT THIS WELAT A COOY OF THIS RECORD HAS BEEN PROVIDEDNSTRUCTED IN CORDAt'-70ATHE "'S' L Ot��EF'
CONSTRUCTION STANDARDS, AND THAT G�
I ,l�
FOR OFFICE USE-' LY Ds'E
"SIt3NATUFIE OF PERSON CONSTRIY:TIN(11 t'N EL>
Ovad No: ? rt. Submit od "trial to`Divltlon of Water M11111y, arourtdMrttor SrGc^ within Y.) C%lYs V, tat
111f 'YlllfEi,�
Serial No, _

6164
North Carolina - Department of Environment and Natural Resources - Division of Water Ouality - Groundwater Section L. J
1636 Mail Service Center - Ralelgh, N.C. 27699-1636•Phone [phone]
WELL CONTRACTOR:
WELL CONSTRUCTION RECORD
WELL CONTRACTOR CERTIFICATION ff: o�Z �I 9 q
STATE WELL CONSTRUCTION PERMITN:
J. WELL USE (check Applicable Box): Residential [g"'^ Municipal ❑
Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other [] If Other, List Use:
2. WELL LOCATIQN: (fShow sketch of the location below) Cis el��
Nearest Town:
1-4a; a _ County:
A FCC ✓�/ rDRILLING LOG DEPTH
(Road Name and Numbers, Comm1 nity, or Subdivision and Lot No.) To
Forma5on Des ripGo-
3. OWNER L� ryt t i From /e
Address
treat or ou o o.
City or Town State Zip Code
4. DATE DRILLED LQ ` A►2 - d0
5. TOTAL DEPTH 29 ' --
6. CUTTINGS COLLECTED YFS ❑ NO[D
7. DOES WELL REPLACE EXISTING WELL? YES NOD
S. STATIC WATER LEVEL Below Top of Casing:
(Use -+- II Above Top of Casing)
9. TOP OF CASING IS1_ ____ FT. Above Land Surface*
'Top of casing terminated at/or below land surface requires a variance In accor-
dance with 1 (g 2C.oj to METHOD OF TEST
10. YIELD (gpm): � r
11. WATER ZONES (depth).
12. CHLORINATION:
13. CASING:
Type /' }� bI e%s _ Amount _-LJ----- If addWonal s;,ace is needed tom= back of Ium
Depth
Wall Thickness
Diameter or Welght/Ft.
�Material
From--L—ToFrom--
To
Fl. —
From
—To
FI•
14. GROUT:
Depth
Mledal Method
From _iZ--_ To 12 - Ft. ��--------_'—
From
To —Ft.
----'
15. SCREEN:
Depth
Diameter Slot Size Material
From
To
FI In. in.From
To
Ft. In. In. �-----
From
To
Ft. In. in. __----
16. SAND/GRAVEL PACK:
Material
Depth
Size
From
— To_
Ft.
From
To._____._
Ft. —
17. REMARKS:
I DO HEREBY CERTIFY;THAT4THIS•W1
CONSTRUCTION STANDARDS; AND,T
1Ou
OR OFFICE USE,ON Y, 6
ad No:
r�
Serial No.
LOCATION SKg TCH
(Stow direction and dance tram -_I leas! *No Sale
Roads, or other rr --p relerc:r-es points`
r,
C .
� .
CJ1 _r rm,
;•c--)
co
cn.-
m-,70
w -i
O o
L WAS CONSTRUCTED IN ACCORDANCE WITH ISA rJCAC ?C, yrELL
AT A COPY OF THIS RECORD HAS BEEF) PROVIC£D 70 THE YIS^r.L 0"'EP.. a
✓ 01
i � iSIONATURE OF PERSON CONSTRUCTING 1� 'WELL
ibrrtli orlpinal Io Divlttion of Wsler 13uallty, GrourWw&Igr smut within v) c�Ys
Gh.l Ft9Y. QITI

0
si6.-
North Carolina • Department of Environment and Natural Resources •Division of Water OUaliry 23
•Groundwater Section `� !"'
1636 Mail Service Center • Raleigh, N.C. 27699.1636•Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
LL CONTRACTOR CERTIFICATION M: o2�JOCl
STATE WELL CONSTRUCTION pERMITP:
Industrial ❑ Agricultural ❑ Monitoring ❑
Applicable Box)! Residential[D'
Recovery ❑
1, WELL USE (Check Heat Pump Water Injection ❑ M Olhe a❑ It Other, List Use:
2.
9
WELL LOCAT!9N: (Show sketch of the location below) Chero /�e t?
County:
Nearest Town: T
DRILLING LOG DEPTH
(Road Na and N mbers. Community, or Subdivision and lot No.) From To Foma7en Descri0o"
OWNER ®- %l9 r �xo� ��'i:
Address r-In I - .96n
trees or ou o o.
City or Town
Stale Zip Code � 7 � �� �
4. DATE DRILLED �b't�'� �•�b r - 3�1s
5. TOTAL DEPTHG
6. CUTTINGS COLLECTED YFS ❑ NO[1-1-
7. DOES WELL REPLACE EXISTING WELL? YES ❑ r
B. STATIC WATER LEVEL l3elow Top of Casing. __(ao_
(Use +• it Above Top of Casing)
9, TOP OF CASING IS___%____ FT. Above Land Surface-
-Top of casing terminated atior below land surface requires a variance In actor•
dance with i5A NCAC 2C.018 METHOD OF TEST
i o. YIELD (gp ): 1
i i _ WATER ZONES (depth):
12. CHLORINATION:
13. CASING:
Type
L' Amount 11 additional space is needed L--A- back of Ic"m
Depth rDiameter
Fromm --To �FI.---
From — To — Ft•
From —To
14 GROUT•
LOCATION SK=TCH
Wail Thickness
or WelghUnd d�aFt. Ma edal (Slow direction aIe �� ✓a e
r� Roads, or other rr- p retert 2
Depth Material
From — To — Ft.
From —To —Ft.
15. SCREEN:
Depth Diameter Slot Size
Method
Material
From To Ft
— In.
in.._----
______
From To — Ft.
In.
in. _.---
From — To ____ - Ft.
— In.
In.._---
16. SANDIGRAVEL PACK:
Material
Depth
Size
From _.— To — FI.
—'
From - To----- Ft.
—
W
Mu
cC=i
f
a�
ED
r-_
ti
0
17. REMARKS:
1 DO HEREBY CEFiT�I Y TFHATJHIS ViYEIL WAS �pY F THIS RECORD HAS BEENTRUCTED IN ACCORDAI`EPRO C D "TOAD « a��'EF.
CONSTRUCTION t?�NDAR§, AN.7HAT
0I _
FOR OFFICE USE (�Y x dt
j qz �^ � C1 S1ONATUFiE OE PERSON CON51f11Y" -TING lrt'/+rw thin :r) C%sYs
Ouad No: ,`i ;, Submit oilglnal to Divhtlon of Water puattty. OroundKa ^ 6h.1 FSE V. 12T'
Serial No. - 3r)r ss!
�i�in r

North Carolina - Department of Environment and Natural Resources • Division of Water Quality - Ground•,vater Section 236166
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRA
CTOR:
WELL CONTRACTOR CERTIFICATION N:
STATE WELL CONSTRUCTION PERMITM:
J. WELL USE (check Applicable Box): Residentiald Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Flecovery ❑ Heat Pump Water injection ❑ Other [] If Other, List Use:
2. WELL LOCATION)• (Show sketch of the location below) / /� �, Ile
Nearest Town: County: i r
r 1 DEPTH
nd
(Road Name aumbers, Community, or Subdivlsio and Lot No.) DRILLING LOG
3. OWNER t ✓✓1 From To Fonrazn De-HPU-
Address 2�� jNl , SSr GN C' () - 4C7 At
trees r oute o. gtf LO d -F
City or wn Stale Zip Code
4, DATE DRILLED 10- ZO C9
5. TOTAL DEPTH n t
6. CUTTINGS COLLECTED YFS ❑ NOKO-
7. DOES WELL REPLACE EXISTING WELL? NO[--]
S. 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 et/or below land surface requires a variance in accor-
dance with 15A NCAC 2C.0118 /-
10. YIELD (gpm): A_ METHOD OF TEST go—,:)
�r
11. WATER ZONES (depth):
12. CHLORINATION: Type a P i'S Amount __ __— it additional space is needed tse back of Icern
13. CASING:
LOCATION SK=TCH
Wall Thickness
Depth Diam ter oar Weight//Fl. Material (Show direction and dance irarn ad leas: *00 S' ate
From
.iG�To � FI. ("I—i - sP-12 2 - --7�-t`!'r`,_ Roads, or other rr�--p relermrxe point!
From ' To Ft.
From To Ft.
14. GROUT:
Depth Material '�/ Method
From To 0 FL U � � cI
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft In. —in.—
From To Ft. In. In.
F r om To Ft. In. In. _—
16. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To Ft. —
17. REMARKS:
Material
low
a
Cn
xa
p
w
0
W
r-
I DO HEREBY CERfTIFY TNA7 THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH tSA rJCAC 2r,'jlELL
CONSTRUCTION STANDARDS, AND THAT A COPY F THIS RECORD+H,�EN PROVICED 10 fHE'NE "1 Ot��FF..
FOR OFFICE USFONL l HAP s'E
SIGNATURE OF PERSON CONSTRUCTING Trt vv
Quad No: ELL
pubrnit original to Divltton of Water pusltiy, Grvund•�ator Srccn within C r ys
G"•i P.19V. i"I
Serial No.

North Carolina • Department of Environment and Natural Resources • Division of Water Quality • Groundwater Section 236167
1636 Mail Service Center • Raleigh, N.C. 27699-1636-Phone [phone] r / / 1pl, i r { `
WELL CONSTRUCTION RECORD WELL CONTRACTOR: 1 �Z3/
WELL CONTRACTOR CERTIFICATION M:
STATE WELL CONSTRUCTION PERMITH:
1, WELL USE (Check Applicable Box): Residential Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injecllon ❑ Other ❑ if Other, List Use:
2, WELL LOCATION: (Show sketch of the location below)
Nearest Town: -, f County:
U Na ko -
(Road Name and Numbers. Community, or Subdivision and Lot No.)
t M 1M bV J /y
3. OWNER T
Address
treet or ou a o.
City or Town Stale Zip Code
4. DATE DRILLED
5. TOTAL DEPTH 2 U 5
6. CUTTINGS COLLECTED YVS ❑ NO[tE
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO[C
B. STATIC WATER LEVEL Below Top of Casing: S 0 FT.
(Use '+' If Above Top of Casing)
9. TOP OF CASING IS____� FT. Above Land Surface'
'Top of casing terminated st/or below land surface requires a variance In accor-
dance with 15A NCAC 2C. 119 METHOD OF TEST
10. YIELD (gpm):
11. WATER ZONES (depth):
DRILLING LOG
From To
DEPTH
Foar•.axn Dtsu l)tl-
_ C/a
- ra U P_
12. CHLORINATION: Type Ta !9 Amount ---�-- It additional space is needed Ur, --back of Icfm
13. CASING:
Wail Thickness
Depth �� Diameter or Weight/Ft. Ma
terial
From To Fl•--�`1--- -� -1�—
From ' To Ft. ---
From To Fl. -
14. GROUT:
Depth Material Method
From D To 20 Ft. 4d r N
From To —Ft.---------
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft In. In. _ From To Ft. In. In. From To Fl. In. in. _--_----
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From — To Ft. —
17. REMARKS:_
DO HEREBY CER1
CONSTRUCTION S
FOR OFFICE USE 0
Guad No:
LOCATION SKc fCH
(Stow direction and d:s-ance Irm ZJ leas:' Sale
Roads. or otter rr-cp relere:ce point!
0
o
GD r
TP a
-00
_f
rn r*ic.;
w
fl E3
AiIE`f♦ 1'S_:WfLWWAS CONSTRUCTED IN ACCORDMICE WITH 15A 0JCAC?C.'�fELI
RDS, SAND THAT A COPY:O THIS RECORD HAS EEN PROVICED "TO THE «=I-t- / F' 2
DA.� E
SIGNATURE OF PERSON CONSTRIY.%TING T>s'N ELL
Gif Sutxr>II original to Division of Water Ouellty. Ground•�aler S�cn t►+ilhin ry C%sYs C„,I Fig V. 11,11
Serial No.

- `'361..`�8
N rth Carolina • Department of Environment and Natural Resources Divis21n of Water OUality • Groundwater Section �-
1636 Mail Service Center • Raleigh, N.C. 27699 1636 Phone 191 I
WELL CONSTRUCTION RECORD WELL
L CONTRACTOR'
E.L CONTRACTOR CERTIFICATION 9: ��vy
STATE WELL CONSTRUCTION PERMITP:
Industrial ElAgricultural ❑ Monitorirg U
1. WELL USE (check Hlt Pump Water Injection ❑ M OthePa[] 11 Other, Llsl Use:
Flecovery ❑ ea
2.
3.
WELL LOCATION: (Show sketch of the location below)
ounty:
Nearest Town:
DRILLING LOG ... DEPTH
(Road Name and Numbers. Community, or Subdivision and Lot No.) From To Fonra50+ DescriPii-
OWNER
Address
treat or ou Io o. j�
City or Town State Zlp Code
DATE DRILLED ��` y" DD
4.
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑ NOD`
REPLACE EXISTING WELL? YES [] NO[D-
7. DOES WELL r
WATER LEVEL Below Top of Casing: __yDFT
B. STATIC
(Use '+' II Above Top of Casing)
TOP OF CASING IS__J_ FT. Above Land Surface'
9.
-Top of casing terminated atior below land surface requires a variance In accor-
dance with 15A NCAC QC .otte METHOD OF TEST
`•
10. YIELD (gpm): -
11. WATER ZONES (depth):
—S ,s If additional s;ace £s need L.-sebac� of lc�
Amount ----- —
.
12. CHLORINATION: Type
13. CASING: LOCATION SK= TCH
Wall Thickness
Malaria) ( Show direction and 651ance tr7n � leas:'"°
rate
Depth r Diameter or WeighUFt. rots`
Roads, or other rr
r I �ee th.�? reference >�
To
From rL -'� - Ft —
__--- See
From• L-- To 20 o FL`5 .- L —
From —To -- Ft.---- --- —"
14. GROUT: Material Method
Depth
From — To _ Ft. ---'----
o p
c,
From — To ______--Ft.
C= QT'
15. SCREEN:
Depth Diameter Slot Size Material
t �:
From _To— Ft In. in. _ _------
�•
_ m
From — To — Ft. — In. — In. ,-----
Ft.
a? r`
From — To — —
w
16. SAND/GRAVEL PACK, Material
2
=�
Depth Size
From ._— — To — Ft.
From To Fl.-------
17. REMARKS: .
5 CONSTRUCTED IN ACCORDRICE WITH I$A p4CAC 2r. rELL .1EP
CERTIFY Tfl �T THIS iNEL� W! HAS BEEN PROVIDED 70 THE Yr
100 HEREBY
NANO°THAT A CQPY OF THIS RECORD
CONSTRUCTION STANDAFIOS,
.._ ..� Ica �.
FOR OFFICE USE ONLY ! �° [ ? r SIGNATURE OF PERSON CONSTRU CTIfIG 1>� �/� ELf
Srecn writh)n Y) C;VYS
,
Ouad No: gilt Ground�'alar
Subrnll odpinat to Mislon of Water t7u >r•
Eh.l Fig V. 1.T1
Serial 4o.

North Carolina • Department of Environment and Natural Resources • Division of Waier Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
iy,ller �� l
WELL CONSTRUCTION RECORD WELL CONTRACTOR: 5�03
WELL CONTRACTOR CERTIFICATION N: --
STATE WELL CONSTRUCTION PERMITN:
J. WELL USE (Check Applicable Box): ResidentialL"J Municipal ❑
Industrial ❑ Agricultural ❑ Monitoring ❑
Flecovery ❑ Heat Pump Water Injection ❑ Other ❑ II Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: reGcl County:
". a
(Road Na Heand Numb/ers, Community, or Subdivision and Lot No.) From To ForraScn Descripliw.
3. OWNER
Address
City or Town State
Zip Code
4. DATE DRILLED �-��s U�-------------
5. TOTAL DEPTH oo '
6. CUTTINGS COLLECTED YFS ❑ NO
7. DOES WELL REPLACE EXISTING WELL? YES n NO[�
S. STATIC WATER LEVEL Below Top of Casing: 2-0 FT.
(Use -+' It Above Top of Casing)
9. TOP OF CASING IS 1 FT. Above Land Surface'
-Top of casing terminated ellor below land surface requires a variance In accor-
dance with 15A NCAC 2C .0118 ME f HOD OF TEST
10. YIELD (gpm):
11. WATER ZONES (depth):
12. CHLORINATION: Type
`7 Amount It additional space is needed � back of lum
13. CASING:
Walt Thickness
Depth Diameter or Weight/Ft. Mt flat
�G
From To —f 41 Ft.
From--Y.L._:To°S F1.j�-
From --To Fl. --
14. GROUT: t�rial ,d
Depth � p%Cf�elho�
From To Ft..
From To _Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From —To_ Ft — In. In.From To Ft. — In. In.
From To — FL In. In.----
16, SAND/GRAVEL PACK: Material
Depth Size
From ____--- To
----------
From. To_______ Fh
17. REMARKS: —
I DO HEREBY CERI
CONSTRUCTION S
FOR OFFICE USE
Quad No: Ad 1 Inat to
1 Q'F i 73 subml,> Q
F
`t
FY'THAT THIS WELL WAS C
ANCIARDS, AND THAT A CO
1 6 2001 �
LOCATION SK=TCH
(Stow direction and d',s ance ImAn 21 leas•:wo ✓'ate
Roads, or other rr�7 relerc: ce Polnts�
'RUCTEDIN ACCORDANCE WITH ISA pdCAC?C, trELL 'ER
THIS ECORD HAS BEEF! PROVICED '70 THC- �«=t-t-
'TUBE OF PERSON CONSTRUP-,11 IG T>t'N'6LL
pivldon of Water Ouellly. Groundwater Src_cn within:) C%VYS
0,4.. E
Serial No.

North Carolina - Department of Envirdnmenl and Nalural Resources - Division of Water Ouaiity • Groundwater Section 10 3 6 16 0
1636 Mail Service Center - Ralelgh, N.C. 27699-1636•Phone [phone] `//
WELL CONSTRUCTION RECORD WECONTRACTOR: —
itLL. CONTRACTOR CERTIFICATION N: Zl� CZ90:5
STATE WELL CONSTRUCTION pERNIITH:
J. WELL USE (Check Applicable Box): Residential Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Aecovsry ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2.
3.
Address
treat or ou a o.
City or Town Stale Zip Code
4. DATE DRILLED
5. TOTAL DEPTH Spa 0 --
6. CUTTINGS COLLECTED YES ❑ NOL3*"
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NOF
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 wor below land surface requires a variance in accor-
dance with 15A NCAC 2C .0118 METHOD OF TEST
10. YIELD (gpm): ;
11. WATER ZONES (depth):
WELL LOCATION; (Shr sketch of the location below) le����
Nearest Town: �'° � y County:
DRILLING LOG
(Road Name and umbers, Community, or Subdivision and Lot No.)
OWNER c41,1e s s1' le From To
7SJ c`
2? 7S' ' c�l�• flcv �.
DEPTH
Forrra5cn Des.^ri0o'
— II additional space i5 needed the back of fcrm
12. CHLORINATION: Type Amount
13. CASING:
Depth
,
Wall Thickness
Diameter or Wei htt t. Material
�o Pae
From— e5l,—To
ff
, 3
�`y
Ft.
�,.25 fc�
G.
From
To
FL
-
From
—To
Fl.
—
14. GROUT:
Depth
�B
I r I� JMeLe,od
Or ah Juo-�-
From lr%
To
Ft.
From
To ______--Ft.
--------
15. SCREEN:
Depth
Diameter Slot Size Material
From
To
Ft
in. In.
From
To
Ft.
in. In. �-----
From
To
Ft.
In. In. -- -----
16. SAND/GRAVEL PACK: Material
Depth Size
From — To_ Ft. From To. Ft. —
17. REMARKS:
DO HEREBY CERTIFYyf1 I�T T _IS YI!E, WA§ iGt
CONSTRUCTION STOARdSrAN T _ AT A COP
LOCATION SK=TCH
(Stow direction and dsance tr" ad leas: *No Slate
Roads, or other rrr-p relertrres polnts.
ED IN ACCORDANCE WITH 15A rdCAC?C.'trEll
RECORD HAS BEEN PROVICED '70 THE v1S4.-L O,%�EF..
FOR Q FACE USE 0 ,Yg i� i`0 ATURH OE PERSON CONSTRUCTING tY �/v ELL
Quad No: .i'y Su l aripin to I,~ Islon of Water Ouelity, (around-alsr Sr�cn within'Y) c%rW
Serial No. rti,9ririt a'e �tiCiiiirl
D's' • E
C.rr•1 FtEv. 1:11

/ rr ii cc
North Carolina • Department of Environment and Natural Resources • Division of Waier Quality • Groundwater Section i- v t) .1. [)
N 27699-1636•Phone [phone]
1636 Mail Service Center - Naleigh, .C.
',I,. I �� 1211
WELL CONSTRUCTION RECORD WELL
WELL CONTRACTOR CERTIFICATION a:
STATE WELL CONSTRUCTION PERIAITa:
1. WELL USE (Check Applicable Box): Residential ❑ Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other [] If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: D County:
�� DRILLING LOG DEPTH
(Road Name(.nd /Nu er�j Comnunlly, or Su division' nd Lot No.) Forrna5cn Ces: HOc'
3. OWNER if n i�C�l�7 l�l �.t liyl A [c m _ Tom° � r 11 O11 1
Address
(reel or ou a o.
City or Town Stale Zip Code
4. DATE DRILLED s-©
5. TOTAL DEPTH ;2
6. CUTTINGS COLLECTED FS ❑ NO[Di
DOES WELL REPLACE EXISTING WELL? YES (� NO�
7.
8. STATIC WATER LEVEL Selow Top of Casing: /09 1 FT •
(Use '+' If Above Top of Casing)
9. TOP OF CASING IS — FT• Above Land Surface'
'Top of casing terminated atior below land surface requires a variance In accor•
dance with 15A NCAC 2C.0118
t METHOD OF TEST
10. YIELD (gpm):
11. WATER ZONES (depth):
7 �e
`e• Amount _3--•--- It additional space is needed back
of fa re
12. CHLORINATION: Type
13. CASING: LOCATION SK=TCH
Wall Thickness
Material (Slow direction and dance It—,xm al IOW ,
ko S'-a e
Depth �� Diameter or Welght/Ft.
From _ Q —To - �"— FI•�' - Roads, or other rr�? relerc: Po
From -- To Fl. --
From ---To Ft. —
14. GROUT:
Depth alerial Method
Ft.
I .
From .�—.- To ...212--
From To —Ft. --------
ca
=
15. SCREEN:,.
Depth Diameter Slot Size Material
From To Fl In. In. _ _------
f
From To Ft. In. In.
From To Ft. In. In..
16. SAND/GRAVEL PACK:
Material
rn
U) y
•• rn--:0
Depth Size
w
From — To — Ft.
CD
From From To �l
17. REMARKS:
M� IIN EPRO CEO '70WITH i,,A ATHE y�'� t EF'
I HEREBY CER If 1 f A717HIS WELL WAS CONSTRUCTED
DO i1� THIS RECORD HAS BEE
Sa1�f AND THAT A COPY
CONSTRUCTION 0ARDS. iOF
FOR OFFICE USE 'L({ 1rt w7 L1.
''.SIoNATunE OF pt:RSON CONSTRIK
oA -E
Quad No: x :+
.Sbtxrti : ripinal to pivl61 of Water puellty, Grvurxi•�atar Scat within :r1 C%lYs
Ch•1 �� V, t21f
r i i7 h at. ill
Serial No.

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section i 1. J 9 `) 2
1636 Mail Service Center- Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: .1.,�.��-e� �'R'��'�'y
WELL CONTRACTOR CERTIFICATION 0:
STATE WELL CONSTRUCTION PERMIT#:
Z.
1. WELL USE (check Applicable Box): Residential Municipal ❑
Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑
If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: A uaj)k_,1 County:
LJL,- SPRtA-)G-5
(Road Name and Numbers, Community, or Subdivision and Lot No.)
DRILLING LOG DEPTH
3. OWNER TV h V K IA)04 I D
From To Formation Description
Address � I u— S T
0
(street or Roule
City or T wn Slate Zip Code
4. DATE DRILLED Z, " 2 V--
5. TOTAL DEPTH=7'
6. CUTTINGS COLLECTED YES M NO❑"`
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO❑�
6. STATIC WATER LEVEL Below Top of Casing: FT.
-
(Use '+' II Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface'
*Top of casing terminated atlor below land surface requires a variance In accor-
dance with 15A NCAC 2C . 118
I-
10. YIELD (gpm): METHOD OF TEST—
v':
11. WATER ZONES (depth):
© ^"
12. CHLORINATION: Type /-,/:Z /:/- —Amount —2 Z /l-4
If additional space is needed use back of form _ J!
13. CASING:
Wall Thickness
O Depth Diameter or Wel hUFI.
From To °' Ft. - f
From To Ft.
From To Ft.
14. GROUT:
LOCATION SKETCH
M" �terial (Show direction and distance from at least two Slate
/"v C Roads, or other map reference points)
Depth Material Method
From To 7 v Ft. CPA
From _)L. U To 20 ' 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 Fl.
From To Ft.
17. REMARKS:
1 DO HEREB) (ITI Y AT TH LjNSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCT�' Y OF THIS RE CO D HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE u NIL r `e7 Z y 00
Quad No:
hY(.)V f i}I� It3 TUNE 0 SON CONSTRUCTING THE WELL DATE
SubrN origin to Division o Water Quality, Oroundwatsr Section within 30 day$
Serial No. Hater Sectloll OW-1 REV. 12/99

9!931
North Carolina •Department of Environment and Natural Resources -Division of Wafer Qualify -Groundwater Section �., t J . �.
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: .'�� d�J Z >Z; Il,ti 9
WELL CONTRACTOR CERTIFICATION #: G ��—�
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): ResldentlaI E Municipal ❑ Industrial ❑ Agricultural❑ Monitoring ❑
Recovery ❑ Heal Pump Water Injection ❑ Other ❑ if Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town:- /hUt2, �_✓ County: 490tee_
(Road Name and Numbers, Commune or Subdivision and Lot No.)
DRILLING LOG DEPTH
3. OWNER _ �nE� QP_1 A �,r,�k�vnJt/ % _ps_
From To Formation Description
Address �� 1 � r
�
%n Is'reet r oule`flo.
C
City or T Stale Zip Code
4, DATE DRILLED C.
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES M NOC3-
7. DOES WELL REPLACE EXISTING WELL? YES 0 NOE]-
8. STATIC WATER LEVEL Below Top of Casing: 7--)~ FT,
u
(Use '+' If Above Top of Casing)-,
9. TOP OF CASING IS_�_ FT. Above Land Surface -
-
*Top of casing terminated sUor below land surface requires a variance In accor-
dance with 15A NCAC 2C .0118 /
10. YIELD (gpm): METHOD OF TEST ._d- �2
-
-
11. WATER ZONES (depth): D- 20' -3 6 d
12. CHLORINATION: Type /�/Z i/ Amount 2 a
It additional space Is needed use back of f - --;
13. CASING:
—
Wall Thickness
LOCATION SKETCH
O Depth, D ameter or WeighVFt. Material
(Show direction and distance from at least two State
From To'_ Ft. - b " ' 1
Roads, or other map reference points)
From To Fl.
From To Ft,
14. GROUT:
Depth Material.. Method
From To Z�. Ft.
From 3 To Ft.'
15. SCREEN:
Depth Diameter Slot Slzs 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 CE I NSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C, WELL
CONSTRUCTION A THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE US NOV/d 2 "3 c'
Quad No: Ni- g 2G1 ATU �F PW SON CONSTRUCTING THE WELL DATE
Su t o" on f ater Quality, Groundwater Section within 30 days
Serial No,
GW1 REV. 12199
ndw8terAsheville Reviin SecAiun �.

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] J J 3 V
WELL CONSTRUCTION RECORD WELL CONTRACTOR: (�.�t�R� l��' i,)ei
WELL CONTRACTOR CERTIFICATION �
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential U Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below) ���
Nearest Town: L►7 -fL� County: —
(Road Name and Numbers, Community, or Subdivision and Lot No.)
DRILLING LOG DEPTH
3. OWNER .SI rn I C� PH p RT
From To Formation Description
Address ,_
Kip 1 4`lQtd
2
(b
reel oIrrHoua o.
A)C_ aQ 1��
, ��� /'��>>.--
City or T wn -State Zip Code
S�. ��
4. DATE DRILLED ,%0' /�..
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑ NO❑—
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO[:`
/,6 S /� G�����• c_
8. STATIC WATER LEVEL Below Top of Casing: �) J ' FT.
(Use'+' 11 Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface -
'Top of casing terminated et/or below lend surface requires a variance In accor-
Cn
dance with 15A NCAC 2C .0118
10. YIELD (gpm): METHOD OF TEST--
11. WATER ZONES (depth):
ra
12. CHLORINATION: Type _ /xI: Amount t, �' ���
If additional apace is needed use back of form-
13. CASING:—
�•—�—�
Wall Thickness
LOCATION SKETCH ..-:
r
Depth Diameter or Wei ht/Ft. Material
p p
(Show direction and distance from at least two St '
From —To J Ft.
Roads, or other map reference points) C l �;
From To Ft. —
From To Fl.
14. GROUT:
Depth
0
Material Method
`L
From
To)_ Ft.
From
��
_ To J,), Ft.
�
15. SCREEN:
Depth Diameter Slot SIz6
Material
From
To Ft
In.
1n.
From
To Ft.
In.
In.
From
To Ft.
In.
in.
16. SAND/GRAVEL PACK:
Depth
Size
Material
From
To Ft.
From To Ft.
17. REMARKS:
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTIONS )A- - A Go Y..® HIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
ft:U�, n
�3 ,
FOR OFFICE USE
Ouad No: FIE OF PE CONSTRUCTING THE WELL DATE
gut ilVoin r silty, Groundwater Section within 30 days
Serial No. I GW-1 FiEv. 17199
G- N-,

I s.'y
North Carolina - Department of Environment and Natural Resources - Division of Water Ouality • Groundwater Section ° 9929
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone] �•- �-
WELL CONSTRUCTION RECORD WELLCONTRACTOR: _ [ 1ieaoke,-_ "11
WELL CONTRACTOR CERTIFICATION 0: •S 6 �~
STATE WELL CONSTRUCTION PERMITH:
1, WELL USE (Check Applicable Box): Resldentlal [ Municipai ❑ Industrial d Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ if Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: 22UR DLV County: Jv'hC90/ 8e_
(Road Name and Numbers. Community, or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER - I-b,4AVi - /<_PP/1P, f { From To // Fomtatlon Description
Address ,p^j(a-l^AC- � Pb 0 , y, J'f %
(Streetor ou o o. L
u� O
City or own Slate Zip Code
4. DATE DRILLED
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES F] NO❑`
7. DOES WELL REPLACE EXISTING WELL? YES [:] NO❑—
8. STATIC WATER LEVEL Below Top of Casing: y�0j 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 actor-
dance with 15A NCAC 2C.0118
10. YIELD (gpm): 2METHOD OF TEST -
11. WATER ZONES (depth):%'� Y So'
12. CHLORINATION: Type - / - % H Amount ` 0 - If additional apace Is needed use back of Id` rid E,
13. CASING:
Wan Thickness LOCATION SKETCH
Depth , glagvter rrweipht/Ft. terlal (Show direction and distance from at least two State
From L To y V Ft. 2':1 ��2 �'i �% -1/ Roads, or other map reference points)
From To Fl.
From To Ft.
14. GROUT:
Depth Material Method
From To m_ Ft.
From 3 To t� Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From To Fl in, in.
From To FL In. In.
From To Ft. in, in.
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
17. REMARKS:
I DO HEREBY CE
CONSTRUCTION
FOR OFFICE USE
Ouad No: 8A
Sutxnit
Serial No. F_T___
IUCIN ACCORDANCE WITH 15A NCAC 2C, WELL
THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
CONSTRUCTING THE WELL
ly, Groundwater Section within 30 days
DATE
GWA REV. 12M

North Carolina • Department of Environment and Natural Resources - Division of Water Ouatity • Groundwater Section
2361'75
1636 Mail Service Center - Raleigh, N.C. 27699-1636•Phone [phone] n I� t �1,
G
WELL CONSTRUCTION RECORD WELL. CONTRACTOR cERTIFICATIoN a:°3
STATE WELL CONSTRUCTION PERMITN:
J. WELL USE (Check Applicable Box): Resldengal [3�_ Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Flecovery❑ Heat Pump Water Injection ❑ Other 0 II Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: _ vi�r��/ County: �l
't1ottI� 45'41et— DEPTH
(Road Name and u ors. Community, or Subdivision and Lot No.) DRILLING LOG
(Rm
�� ` From To Fom•.axn Descdl)60o'
3. OWNER �i^�/i� l.��i
Address S 4 -7
(street or HOU10 o.
City or Town Stale Zip Codo
DATE DRILLED
4.
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YFS ❑ NO[3
DOES WELL REPLACE EXISTING WELL? YES[] NOD
7.
B. STATIC WATER LEVEL Below Top of Casing: IS' FT.
(Use '+' N Above Top of Casing)
9. TOP OF CASING IS__!FT. Above Land Surface'
'Top or casing terminated atlor below land surface requires a variance in accor• -
dance with 15A NCAC 2C .0116
© OF TEST'r
10. YIELD (gpm): METHOD
11. WATER ZONES (depth):
Amount l� 11 additional space is needed L back or IcFrn
12. CHLORINATION: Type
13. CASING: LOCATION SK=T'CH
Wall Thickness
Depth Diameter or Weight/Fi. Material (Show direction and dunce Iran A lea�' No Sato
Roads. or other rr'? refert:� po
From�To ' Ft. "2l V RG
From To Fl.
From To Fl•
14. GROUT:
DepMaterial M hod C,
th
�?
=2E
From 69 To F1.
From To Fl. --- c'I
r
15. SCREEN:
Depth Diameter Slot SIz6 Material
From —To—Ft In. in.._—
m
From To FL In. In. CO
From To In...-- - —
F1. In. _ w
C-)
16. SAND/GRAVEL PACK'
_�
z
Depth Size Material
From ______ To
From To --Ft. —
17. REMARKS:
I DO HEREBY CERTIFY THAT To19 E4L WAS iN ACCORDANCE WITH 15A DJCAC t^,'�rELL
W
THIS RECORD HAS BEEN PROVIC
THAT`bCQPY FIEO "JO TFt� ��/==t Ot"EF..
CONSTRUCTION STA�DARDS,tAN
FOR OFFICE USE O99 +fl N ` URE OF pERgON CONSTRtY:TING 1rE vvELL Oa'E
d I
Ouad No: 1 _,1r�
t a111 t3�oundM>tter Sracn within :� t;sYa
_ SubmIl origin to br}!Itlon of Weler C}u y. CM•i Ptg V. 1:f1
No, r''WA-
SerialP6jon E
�heville r'4 ,ifwal o ic*

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] J /'
WELL CONSTRUCTION RECORD WELL CONTRACTOh:
WELL CONTRACTOR CERTIFICATION M: S" 6• 5
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 LOCATION: (Show sketch of the location below) 3epoko-eLNearest Town: _ County:
1—� _ I X
(Road Name and Numbers, Community, or Subdi talon and Lot No.) DRILLING LOG DEPTH
3. OWNER di— b f C ,Jg-- From To Formation Descripgon
Address v 3 c 0 � c �5 CC
ree or Route o. ,� c y �'> G r
•�i L
City or Town State Zip Code
4. DATE DRILLED & -
5. TOTAL DEPTH L/ 62 '
6. CUTTINGS COLLECTED YES ❑ NO[D-
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NOQ
8. STATIC WATER LEVEL Below Top of Casing: -�-- FT.
(Use '+' 11 Above Top of Casing) i = -
9. TOP OF CASING IS / FT. Above Land Surface'
'' '"
-Top of casing terminated aVor below land lurface requires a varlence In actor- 0
dance with 15A NCAC 2C .0118
10. YIELD (gpm): METHOD OF TEST ✓�. _
11. WATER ZONES (depth): G ~ 12. CHLORINATION: Type Amount �� o 11 additional space is needed use beck of form
13. CASING: -
Wall Thickness LOCATION SKETCH
Depth Diameter or Welght/Ft. Ma erial (Show direction and distance from at least two Slate
From (' To �('c Ft. (14 / � �, r� Roads, or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From G To -Z Ft. /YY d n�
i•
From v To Ft.
15. SCREEN:
Depth Diameter Slot Siz6 Material
From To Ft in. In.
From To Ft. in. In.
From To Ft. In. In.
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD H BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY r /� ,� 6. o 0
Quad No: O!�ATURE PEfiSO CONSTRUCTING THE WELL DATE
Submit original to DIVIsl of Water Quality, Groundwater Section within 30 days Serial No. OW-1 REV. i2/99

North Carolina • Department of Environment and Natural Resources - Division of Water Quality • Groundwater Section r �� V 41
1636 Mail Service Center - Raleigh, N.C. 27699-1636-phone [phone] I j
WELL CONSTRUCTION RECORD WELL CONTRACTOR: S.ti>e�k ` k' 1I1"o
WELL CONTRACTOR CERTIFICATION
STATE WELL CONSTRUCTION PtAMITN:
1. WELL USE (Check Applicable sox): Residential -11"Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below) J-
Nearest Town: U P- " County:
ICOMA .-) c t.
(Road Name and Numbers, Community, or Subdly Ion and Lot o) DRILLING LOG DEPTH
3. OWNER Rnri J 1 E 1) , �-�lQ� From To Formation Description
Address P. O. hoN C%5-1*5
-(Street or HoUle � a� � % �5 'r 7 Cam' �' /� �� i �
u r 0 l c� 1�
City or Town Mate Zip Code
4. DATE DRILLED
5. TOTAL DEPTH -,J y
6. CUTTINGS COLLECTED YES ❑ NO❑'
7. DOES WELL REPLACE EXISTING WELL? YES F__] NOO
8. STATIC WATER LEVEL Below Top of Casing: c r FT. CD
(Use '+' It Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface' _ —
*Top of casing terminated at/or below land surface requires a variance In actor- ! - --
dance with 15A NCAC 2CO118
10. YIELD (gpm):_ METHOD OF TEST
11. WATER ZONES (depth):
12. CHLORINATION: Type A� Amount o C''�Z5 If additional apace is needed use back of IWO
rn
13. CASING: —
LOCATION SKETCH
Depth
Well Thickness
Dt meter or Weight/Ft. Material
(Show direction and distance from at least two State
From L'
To )
Ft. � ' pu <"
Roads, or other map reference points)
From
To
Fl.
From
To
Ft.
14. GROUT:
Depth
Material Method
From
To �'�
Ft.�� '
From "Z0 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 RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY ` J 3--
Quad No: SIGNATURE OF PEAkh CONSTRUCTING THE WELL DATE
Submit orlgtnal to Division of Water Ouality, Groundwater Section within 30 day9
Serial No. OW-1 REV. 12/99

f.
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section ll a
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: (� A J�)RI
WELL CONTRACTOR CERTIFICATION #:`iCflS
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential ED 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: ko County:
(Road Name and Numbers, Community, or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER SC.C)` From To Formation Description
Address /� �7.� F,q6,� ,QJ4�cN R cod ' K N j (Street r ?r/� 3 73 J 7 ` -^ �a
City or Town ale Zip Code
4. DATE DRILLED JD �7 OCR
5. TOTAL DEPTH _SO
e�
6. CUTTINGS COLLECTED YES ❑ NOa
� ra
7. DOES WELL REPLACE EXISTING WELL? � NO� -
8. STATIC WATER LEVEL Below Top of Casing: 5-0 FT. _
(Use '+' iI Above Top of Casing) ! _
9. TOP OF CASING IS FT. Above Land Surface'
*Top of casing terminated at/or below land surface requires a variance In accor- -0
dance with 15A NCAC 2C .0118
10. YIELD (gpm): METHOD OF TEST
11. WATER ZONES (depth):-
� o
12. CHLORINATION: Type JL/ ILAmount CN if additional space is needed use back of form .
13. CASING:
Wall Thickness LOCATION SKETCH
Depth Diameter or Welght/Ft. Material (Show direction and distance from at least two State
From —To (2: Ft. GA " - 1_01? Roads, or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From _ To . 20 Ft. CN�+1t7 T
From ',90 To G'5 Ft. r AJ
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 ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS E ORD HAS UBEEROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY k 4— /.D
Ouad No: SIGNAfWE OF PE plrNSTRUCTING THE WELL DATE
Submit original to ivision of Wat 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 ( 9 f1
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELLCONTRACTOR:
WELL CONTRACTOR CERTIFICATION A: :• ,'�� ✓� `/
STATE WELL CONSTRUCTION PERMITN:
1. WELL USE (Check Applicable Box): ResidentIdI13 Municipal ❑ Industrial d Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sk tch of the location below)
k/
NearestTo/wn:/►1uQAe-
�ke
- County:
t64.0&spoe
(Road Name and Numbers, Community, or Subdivision and Lot No.)
DRILLING LOG DEPTH
3. OWNER G bgyI D<O (v
From To Formation Description
Address —� W � L W,1/
LT
0 (/VJ SC �- (f
12 �, (Street or CouteTlo. /
�,� • a.�a � r� �,�. > �.
City or T wn Slate Zip Code
4. DATE DRILLED 1- _, ' O0
5. TOTAL DEPTH 2-2:) '
n
6. CUTTINGS COLLECTED YES ❑ NO❑-
7. DOES WELL REPLACE EXISTING WELL? YES ❑ N00-
-- -
B. STATIC WATER LEVEL Below Top of Casing: �z>. FT.7-1
_--
(Use '+' If Above Top of Casing)
9. TOP OF CASING IS�_ FT. Above Land Surface*
"0
'Top or casing terminated et/or below land surface requires a variance In accor-
-
dance with 15A NCAC 2C .0118-
10. YIELD m : D METHOD OF TEST •
r� -
11. WATER ZONES (depth):
12. CHLORINATION: Type l:;1�411 Amount
If additional space Is needed use back of form
13. CASING:
Wall Thickness
LOCATION SKETCH
Depth Diameter or Wei In M tedal
From �SZ 'z ✓
(Show direction and distance from at least two State
To FL& ,
Roads, or other map reference points)
From To Ft. -
From —To— Ft.
14. GROUT:
Depth Material Method
Fromy To 16 Ft.
From fl To _lam Ft. -
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft In. In.
Frortt To Ft. In. In.
From To Ft. In. In.
16. SAND/GRAVEL PACK:
Depth Size Maledal�'.Omt
From To Ft. P
From To Ft.
17. REMARKS:
I DO HEREBY CE TkI1, - ONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUC 0 S N R Y OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
LF06—FRFFICE NLY �13a
: ;()l�� ION OFP coNSTRUCTiN(;I tHt: WELLDATE
Submi origin ioomslon ate Quality, Groundwater Section within 30 days
. = OW-1 REV. 121"
;'iietii'tie£ lonai pifke «

'300 .
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: L _ao +� 001 DD.; I 1 Nq
WELL CONTRACTOR CERTIFICATION
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential[9 Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ . Other ❑ If Other, Ust Use:
2. WELL LOCATION: (Show sketch of the location below) I
NearestTown:_Z gabL,/ County:�l�e k�
/��A2 F�1r4 r4i5� l7, i� �c' KodL_
R dN
( oa ame and Numb�ers, Community, or Subdivision and Lot No.)
/
DRILLING LOG DEPTH
3. OWNER l , 1Q 1J 1
From To Formation Description
Address
yJ,,SC�±,e%
qu o. _�
�
7 O ' _ �i r
`
City or T State Zip Code
? ° o,
jr G do . a 5' • ��
4. DATE DRILLED y z '
1 ✓�� 9 04J r� & P �.
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES [D NO❑—
7. DOES WELL REPLACE EXISTING WELL? YES [] NOD
8, STATIC WATER LEVEL Below Top of Casing: G/p _ FT.
1 0
(Uee Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface*
*Top of casing terminated at/or below land surface tequlres a variance In accor-
d once with 15A NCAC 2C .011s
10. YIELD (gpm): Y!) METHOD OF TEST
'
•31
__
11. WATER ZONES (depth): _ 7,22 ' Z 2 d
12. CHLORINATION: Type Amount r ' �Li�5
If additional epic# is heeded use back of form
13. CASING:
Wall Thickness
Depth Dlamgter or Weight/Ft. / Mate al
From U To (�0 FL (1 � �2
_LOCATION SKETCH
(Show direction and distance from at least two State
.
Roads, of other map'reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Mated r Method
0
From To ° Ft. --I -
From _ '2 ,� To _'V P 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 Pt.
From To FL
17. REMARKS:
I DO HEREBY IF
RR
I+EWL 4AS STRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTIO
OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
j' �)i�t
FOR OFFICE U
LYE)(, '
Quad No:
SI NAA 0 NER
TRUCTING THE WELL DATE
Submil.o Inal 1 • Dlvislon of Water Quality, Groundwater Section Within 30 days
Serial No. �roi ridwater Sectian
„,� ,Ile,i�e ional NicB�
OW1 REV. 12/99

t0.
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section t '
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR' Clie+okQ-�e
WELL CONTRACTOR CERTIFICATION fit:
STATE WELL CONSTRUCTION PERMITM:
1. WELL USE (Check Applicable Box): Resldential 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: u el'oku County: - i _ heizo xcs_
(Road Name and Numbers. Community, or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER 'J t From To Formation Description
Address S /*1 n S rr Cl) 5` i~ C /d -i,2
/ l� (�Q�� ✓ ree or orb C o• tcSdLL J 5 (, 7 �J- f� l� h , T
City or To Slate Tip Code
4. DATE DRILLED
5. TOTAL DEPTH G') '
6. CUTTINGS COLLECTED YES[:] NOD-
7. DOES WELL REPLACE EXISTING WELL? YES NO[
8. STATIC WATER LEVEL Below Top of Casing: 5 FT. J:P
(Use '+' 0 Above Top of Casing)
9. TOP OF CASING 15 FT. Above Land Surface' r:
*Top of casing terminated at/or below land surface requires a variance In accor-
dance with 15A NCAC 2Q.0118 f
10. YIELD (gpm): a METHOD OF TEST /) - t_=rr:
11. WATER ZONES (depth): DL V b '
12. CHLORINATION: Type /-, y/V Amount 'l '� �' If additional apace Is needed use back of form
r% %
13. CASING: v
Wall Thickness LOCATION SKETCH
Depth. Diameter or Weignt/Ft. M,jtedal (Show direction and distance from at least two State
From C To '� Ft. i- L� t r V map�- Roads, or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From L To Ft.
From 0 To -J Ft.' _
15. SCREEN:
Depth Diameter Slot Slze Material
From To Ft In. In.
Frofn 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 HERE B R IlI�. YP4 TATfjj S IEIf ONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C, WELL
CONSTRUC �"A , t�l T PY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFIC OI�YI
Quad No: St!A RE OF R CONSTRU"NG THE WELL DATE
Su t od nai visl6n ale"r6anty, oroundwittir Section within 30 days
Sedal No. �..rr w ter Sectioe OW1 REV. 12t"
e lentil 1 -.

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone] n r� 1 g 5 00
WELL CONSTRUCTION RECORD WELL CONTRACTOR: (ilie�ke,-_ ► o/,�
WELL CONTRACTOR CERTIFICATION ff: 6 ~~
STATE WELL CONSTRUCTION PERM1TN:
1. WELL USE (Check Applicable Box): Resldentlal Municipal ❑ Industrial ❑ Agrlcullural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection Ej Other E] If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
D'e-q',
Nearest Town: —A t4 k-.v County:
/LQe
/174PAea•5 � P P_ b
(Road Name and N bars, Community, or Subdivision and tot No.)
DRILLING LOG DEPTH
3. OWNER �j4(2 t TcDA-) )CbW j, e- 1,
From To Formation Description
Address f ylbuee
or Houle 7o.
City or Town State Zip Code
4. DATE DRILLED d' 6' 00
5. TOTAL DEPTH 102'
6. CUTTINGS COLLECTED YES [] NOED_
7. DOES WELL REPLACE EXISTING WELL? YES [] NO[—]
8. STATIC WATER LEVEL Below Top of Casing: 5 p ' FT.
='
(Use '+' II Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface-
P',) UJ;
'Top or casing terminated st/or below land surface requires a variance In accor-
dance with 15A NCAC 2C .QQ,,11e
10. YIELD METHOD �� '
'=
(gpm): _Z— OF TEST
11. WATER ZONES (depth):
12. CHLORINATION: Type ,/>'i /% Amount a p ��'
w -
II additional space is needed use back of form
13. CASING:
Wan Thickness
LOCATION SKETCQH
Depth DI alter or Welght/Ft. atedal
�? I j
(Show direction and distance from at least two Slate
From To Ft. `/ ° /
Roads, or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth ,Material
From To Method
0-' Ft. ��?� '^
From `ate ' � TO—SM.;,--
15. SCREEN:
Depth
.From To Ft
From To Ft.
From To Fl,
16. SAND/GRAVEL PACK:
Diameter Slot Size Material
In. - In.
In.
In.
Depth Size
From To Ft.
From To Ft.
17. REMARKS:
In.
In.
Material
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY �" c,
Quad No: SIGN/CTUR OF P , SO ONSTRUCTING THE WELL DATE
Subrnit original to Divlsloff o Ie1 ualily, Groundwater Section within 30 days
Serial No. GW1 REV. 12/99

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section J 5 O 1
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone (919) 733.MI
WELL CONSTRUCTION RECORD WELL CONTRACTOR: -% - I/ LJ2; a
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION pERMITN:
1. WELL USE (Check Applicable Box): Residential Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery [] Heat Pump Water Injection ❑ Other F] If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: /�' agjZ ' A.V County:Cll PO k e `e
—
1s FS
(Road Name nd Numbers, Community, or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER _ Al I (- con From To Formation Description
Address?4
R tree or ou a o. �S,—
' Fy 6
f �.
City or Town Stale Zip Code
4. DATE DRILLED V- �' UU �fi A tZL
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES 0 NOL_
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NOD-
8. STATIC WATER LEVEL Below Top of Casing: FT. �.
(Use '+' II Above Top of Casing)
9. TOP OF CASING ISFT. Above Land Surface*
*Top of casing terminated aVor below land surface requires a variance In accor-
dance with 15A NCAC 2C .0118
10. YIELD (gpm): METHOD OF TEST
11. WATER ZONES (depth):
W =;
12. CHLORINATION: Type _
YP �• % �� Amount D ��� If additional apace is needed use back of form
13. CASING: ors
Wan Thickness _ LOCATION SKETCH
O Depth Dla ter or Ight[Ft. F erlal (Show direction and distance from at least two State
From To `�C Ft. -? /-'`1 I--
From To Ft.
Roads, or other map reference points)
From To Ft.
14. GROUT:
Depth Material Method
Method
From _�_ To 7 v. Ft. (0-lAxlr
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft In. In,
From To Ft. in. In.
From To Ft. in. In.
16. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To Ft.
17. REMARKS:
Material
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED 1N ACCORDANCE WITH I SA NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Ouad No:
Serial No.
,
SIQNAN` F P R6N tQhSTSUCTING THE WELL
Submit original to Division of Water Oua y, Groundwater Section within 30 days
DATE
GW-1 REV. 12/"

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section O
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: (-1 /z- oca
WELL CONTRACTOR CERTIFICATION ff C
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Resldenllal LR' Municipal ❑ Industrial ❑ Agrlcultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
V1t? Nearest Town: .miCounty: l �12L� K c
- �
(Road Name and Numbers. Community, or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER /iGl� �-Sfr4Nd1Sli C0 )STR14 Tj0A) From To FomiationDescription
1
Address k p, i'Y)X I/ U q �) a/ S e 7 G%� �-\
Mtreet or HOUle o. C Z / � ) G. 7/-) 7 .
;�tfK1h� NC_ 0G
City or T wn I Slate Zip Code
4. DATE DRILLED LO ` /,f' S 4
5. TOTAL DEPTH __/L-2'
6. CUTTINGS COLLECTED YES [] NOED -
7. DOES WELL REPLACE EXISTING WELL? YES (J NO❑— r�
8. STATIC WATER LEVEL Below Top of Casing: P_o , FT. _
(Use '+' It Above Top of Casing) c7
9. TOP OF CASING 15 FT. Above Land Surface' i
*Top or casing terminated atlor below land surface requires a variance in accor-
dance with 15A NCAC 2C .0118
tJ
10. YIELD (gpm): zs METHOD OF TEST 12'yq
11. WATER ZONES (depth): a
12. CHLORINATION: Type Z"' % �J� Amount v If additional apace Is needed use back of form-4;- =�
13. CASING:
c�
Wall Thickness LOCATION SKETCH
Depth Diameter or Weight/Ft. Material (Show direction and distance from at least two State
From �_ To -2- Ft. =- _ S,5 Si r'c Roads, or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From 0 To Ft.
From To Ft.
15. SCREEN:
Depth Diameter Slot Slze Material
From To Ft In. in.
From To Ft. In. In.
From To Ft. In. In.
16. SAND/GRAVEL PACK:
Depth Size . Material
From To Ft.
From To Ft.
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY Z . " -� 0 n r' '' 1. /�`'"�� � !'
Quad No: SIGNATURE OF PERSON-OONSTRUCTING THE WELL DATE
Submit original to Division of Water Quality, Groundwater Section within 30 days
Serial No.
OW-1 REV. 12/99

2
North Carolina - Department of Environment and Natural Resources • Division of Water Quality • Groundwater Section
1636 rAnil Servico Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: , �°���� [o�P-1/
WELL CONTRACTOR CERTIFICATION 0,
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (check Applicoble sox): Residential lZ Municipal ❑ Industrial ❑ Agricultural ❑ Monitorinq ❑
Rocovery ❑ Heat Pump Water Injeclion ❑ Other ❑ If Other, List Use:
2. WELL LOCA1IUN: (Show ketGh o(ttie location below) j rnr lnPs! Tnvr. t' ----�.: County: {Z K kW—
(noad game and fluntbors, CornmunIty, or Subdlvlslon and Lot No.) DRILLING LOG DEPTH
3. OWNER K�n,N�� (-g 1LLf�t,-,>AY From To FonnetlonDescription
i5otor o to7loj—A
-A(Aep ?, � 90 � N
y or T wit State ZIP Code f
4. DATE DRILLED /05--oo -------
5. 101AL DEPI1-1 aIo7 -
6. GUT -I INCIS COLLEC1 ED YES F- NOU
7• DOES WFI_L REPLACE EXISIING WELL? YES n NOLZ]'
8. STATIC WATER LEVEL 8alow Top of Cn91nq: 'P_ -_ Fr.
(Ilse •s• If Ahovr_ Ton of CmIng)
9 TOP OF r'ASING IS F r. Above Land Surface'
'Tnp nr rna!o (1 rnrrnlnaMrl nl/nr I,PIn LV I]n,'{ tllriPgP YI!r711IMS P VP/InnCP In Pr. r, nr.-"'-'---' —
rfir cp with 1FA FICAr 2C .U1 a.-
10 YIELr? (cirri)' _ FAFTHvr?D Q - TEST ----- /�
11. VIATEn zo(1Es ((lepi!,): —
12 CNIr)RINA T InnL Tyro %t TO - - ___ A.mnunt CNb It edditionaf space h needed use beck of lorrr[�
= c'
13. � . CASING.
totem+ �weeav asr�- t- �c�z�n��/�rrea.rsv.s�ae� wer
`N,11, Thlrt/nncs
/• (.,Pnth DiRnw or or W�IphVFt. Mntertnl
Finn,----_Si_.Tn -3 FI. _)Y-
Ff. ----
Ftorll 10--_._.._ I L--_._..._... ..—.__......
14 (,ROt IT:
Dc^111 Matnrlal Method
f lulu _� Tr) It1-rI. a L,fR
From ---- Io..-.-.._. _ft• _- _._ _.
1F, srrtrr,ri:
01-r!1I F!i,11TIPler Slot Si,.e Material
Front I ....__.._--• f 1-- ------- in. in.
From ..-- -.- I n . --- Ff -- •-- In. _ in.
FrrNrn In. In.
16. SAI Ici;CinAVEL TACK:
UFlnth
Frnm-_.......... Tn _. __.._ rl. .
Flom —._..- 'To---- Ft._
17 HEIv1AF11CS'.
Size Material
LOCATION SKETCH _ = {
(Show direction and dtelancA from at least two SIR%
Road.^,, or other map relerence points) -�
. cn
rvi ;
I rt, t-1FF15PY r,rnTIFY THAT THIS WELL WA3 CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
rr.)NaT F11 ICTION STANDARDS, AND THAT A COPY OF THAEVF
CORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR rr-IICE USE ODILY _ % - S'-Od--
nu:uf No, Sh7N PF.UCTING THE WELL DATE
_... _- 5!r!'nlil ridClnat to ,rdmon of Wnlcr uglily, mundwnlor SnN'on wllhln 30 days
�) ial Vr. GWI 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] �1 J
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable sox): Residential EiK Municipal ❑
industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑
If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below) n/
/
Nearest Town: County: �--/
O)ata�,
Ur -At✓ , . q
(Road Name d Numbers, Community, or Subdivision and Lot No.)
DRILLING LOG DEPTH
3. OWNER 13(-I01Q LQi L,S Qf1J
From To Formation Description
Address rJ 6O-
(street orRoulb No.)
, �� O iW e° -4' ,J U o' ,
City or Town State Zip Code
4. DATE DRILLED
_
>u
5. TOTAL DEPTH 20")
6. CUTTINGS COLLECTED YES ❑ NO
`/
7. DOES WELL REPLACE EXISTING WELL? YES O NO
J y v - A LL5` �� d ` c't_f
8. STATIC WATER LEVEL Below Top of Casing: S'D FT.
(Use'+' if Above Top of Casing)
CD r'
-'•-
9. TOP OF CASING IS FT. Above Land Surface-
c�
•Top of casing terminated at/or below land surface requires a variance In accor-
dance with 15A NCAC 2C .o11a
10. YIELD (gpm): /0 METHOD OF TEST
11. WATER ZONES (depth):
12. CHLORINATION: Type / Amount
If additional space is needed use back of lbifrn
13. CASING:
—
LOCATION SKETCH
Wall Thickness
Depl DI n)eter or Weight/Ft. atedal
?-fir
(Show direction and distance from at least two State
From To Ft. �
Roads, or other map reference points)
From To Ft.
From To Ft.
14, GROUT:
Dept aterial Method
From To �-`^ —Ft.nn
From a To 3 FL U —
15. SCREEN: ,t
Depth Diameter Slot Size Material
$
From To Ft In. in.
From To Ft. In. In.('
ry UUU
From To Ft. In. in. i9
16. SAND/GRAVEL PACK: A�roa►►dwater
Depth Size Material sheville Secuan
From To Ft. .Ro"�! Otffce -j
From To Ft.
17. REMARKS:
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Quad No:
Serial No.
TUf�1�Eg*1ON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Quality, Groundwater Section within 30 days
GW-1 REV. 12/"

i
r
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: 01ielokee 001 �R'i IAil
WELL CONTRACTOR CERTIFICATION 0:'-I3y
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residentlal[ff Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
. Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: A U County: - 1e12p k-r-e-
Pe 5ERA C
(Road Name and Numbers, Community, or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER /)1ICat14Q fi'1If) q U� From To Formation Description
Address Q ` o
(Street or ou a o. ti i� .)
City or Town Stale Zlp Code
4. DATE DRILLED /D`S+h ^.2coo
5. TOTAL DEPTH �ZZ 7
6. CUTTINGS COLLECTED YES[] NOFk-,l
7. DOES WELL REPLACE EXISTING WELL? YES NOEDX
B. STATIC WATER LEVEL Below Top of Casing:_ FT.
(Use'+' N Above Top of Casing) c'7 its
9. TOP OF CASING IS_�_ FT. Above Land Surface-
*Top of casing terminated atlor below land surface requires a variance In accor-
dance with 15A NCAC 2C .011a --'
10. YIELD (gpm): _�3c ') METHOD OF TEST �� y
11. WATER ZONES (depth): '.
12. CHLORINATION: Type Amount If additional apace is needed use back of It'
13. CASING:
Wail Thickness LOCATION SKETCH
Depth D amgler or WelghUn. fiat (Show direction and distance from at least two State
1From O To J FL_
� 1 1 �t` e— Roads, or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From 0 To .20 Ft. "PQM q&,D 6SAv172
From 2 D To / 5 8 Ft. Cu r 1/1 '
15. SCREEN:
Depth Diameter Slot Slze Material
From To Ft in. in.
Frorm To Ft. In. In.
From To Ft. In. in.
16. SAND/GRAVEL PACK:
Depth . Size
From To Ft.
From To Ft.
17. REMARKS:
Material
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS ECORD HAS 8 N PRO TO THE WELL OWNER.
FOR OFFICE USE ONLY A
Quad No: SIGNATURE OF Plik(SONf.11INSTAUCTING THE WELL DATE
Submit original to Division of Water Quallty, Groundwater Section within 30 days
Serial No. GW1 REV. 121"

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section r', .!. ) 2 ,) J
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: tout Ri IIf��
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable sox): Residential Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below) n�e�o
Nearest Town: A U R/J County: l
kiety—
(Road Name and Numbers, Community, or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER _114ADAJi L,, I14,5D/1/ From To Formation Description
Address 0 J8 :BAQ W 47L-.PTNE/tezD 6444117"�
(Street or Houle o. 7--5 I
City or Town State Zip Code — 1"7 A7 -AAO ZDA66-S
4. DATE DRILLED 0 d 7 5 .VL ' AiW17-1
5. TOTAL DEPTH (6d ) J c)(4, c) 1 U r
6. CUTTINGS COLLECTED YES ❑ NO
�
7. DOES WELL REPLACE EXISTING WELL? YES [.] NO❑
8. STATIC WATER LEVEL Below Top of Casing: Ze v ' FT.
(Use '+' it Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface* u
*Top or casing terminated atfor below land surface requires a variance In accor- O
dance with 15A NCAC 2 118 ^
10. YIELD (gpm): METHOD OF TEST "
-!
11. WATER ZONES (depth): a C
12. CHLORINATION: Type
yp "� f Amount n If additional space is needed use back of form- _�-
13. CASING:
c,
Wall Thickness LOCATION SKETCH w
Depth Diameter or WelghttFt. material (Show direction and distance from at least two state
From f—To � � Ft. _ _ r~ r` =
From To Ft. -
From To Ft.
14. GROUT:
Depth Mated Method
From To 90 Ft." �✓ _
From To .i2 3 - 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:
Roads, or other map reference points)
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY in /) '-) � ---\ I. /r A /0 - � -0 `9
Quad No:
Serial No.
SIGNATURE'biARSON CONSTRUCTING T�IIT�ELL DATE
Submit original to Division of Water Quality, Groundwater Section within 30 days
GW-i REV. 12/99

236154
North Carolina - Department tof
o a EnvIgh.iN.C.ronment
and ral
hone Resources
- Division of Water Quality - Groundwater Section
1636 Mail Service
21
WELL CONSTRUCTION RECORD WELL. CONTRACTOR CERTIFICATION N: '�z-1/6c/
STATE WELL CONSTRUCTION PERf111TN:
l ❑ Agricultural Monllorirg
1. WELL USE (Check Applicable Box): Residenllal� Municipal ❑
Industria❑ ❑
Aecovery ❑ Heal Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCAT N: (Sho sketch of the location below)
ounty:
Nearest Town: G 5 n
r, /l,� S iM x DRILLING LOG DEPTH
(Road Name and Numbers, Community. or Subdivision and Lot No From To Fomaxn OesutPuo,
3. OWNER
Address
treat or ol{ Q n ��Lj
�j«SS 0�,� Zip Code
City or Town State
4. DATE DRILLED
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YFS ❑ NO[r]
7. DOES WELL REPLACE EXISTING WELL? YES F-] NF70E]-
a. STATIC WATER LEVEL Below Top of Casing: �_
(Use '+' II Above Top of casing)
9. TOP OF CASING IS 1 — FT. Above Land Surface'
`Top of casing terminated at/or below land surface requires a variance In accor-
dance with ISA NCAC 20.0119 METHOD OF TEST 2
10. YIELD (gpm): --
11. WATER ZONES (depth):
12. CHLORINATION: Type
i 1 G�U�e S Amount------ It additional space is needed rss back of farm
13. CASING:
Wall Thickness
Depth Diameter or We Mai
,
From__-C)---To Ft•�-
From
— To — Ft. — —
From
—To — Ft.--•---
14. GROUT:
Depth Material Method
r
From Tc> C� ..._------
From
_ To —Fl. --_—___-
15. SCREEN:
Diameter Slot Size Material
Depth
From
To — Fl In. in. __----
From
_ To — Ft. — In. In.
In.._----
From _To_
Ft. — In.
16. SAND/GRAVEL PACK:
Depth Size
From .--- To — Fl. From — To__ Ft.
17. REMARKS:
DO HEREBY CERTIFY l HA i ; t rJI0 v" •l
CONSTRUCTION ST NdARDS, MU;HAT.A
FOR OFFICE USEypjN Y T 6 200
Clued No: Submit
Serial No. £9 iti3iraaaa's�' of PCs"`Si
Material
LOCATION SK= TCH
(Show direction and dunce Iran leas :ko 5.ale
Roads. or other rr-ap refererr-AS point;
w.
TUCTED IN ACCORDAPICE WITH ISA p4CAC 21-. /rELL "
THIS RECORD HAS BEEN PR OVIC£0 7Q TH Il.-1 Ot EEfF'!y
/ 1 _— n / ` o�
M;;0
c-)
0
0I'TE
TURF OF PERSON CONSTRIY: 1iNG 1>t'Nwilhin y1 t;%JY3
vision of Water puality. omnd,"'a SK'c`t CM -I Fl9v. 12"

r.
North Carolina • Department of Environment 699 11636 Natural Seso
Phone f ce - DivI 21n of Water Quality •Groundwater Section 615 5
1636 Mail Service Center - Raleigh, N.C. 2j,
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION fJ:
STATE WELL CONSTRUCTION PERMITP:
WELL USE (Check Applicable Box): ResidentialEl"" l Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
1,
Recovery ❑ Heat Pump Water Injection ❑ Other [] If Other, List Use:
2. WELL LOCATION: (Show ketch of the location below)
yey/J S/
Nearest AT�%wn: County:
// —'
e4C/t Tom` G� DRILLING LOG DEPTH
(Road Name and Numbers �mmunlly.sr Subdivision and Lot No) From To Fomaxn Descripu0n.
3. OWNER
Address
treat or ou a o.
City or Town State
Zip code ZZ/--
4. DATE DRILLED Z� 7
S. TOTAL DEPTH U
❑ NO[�—
6. CUTTINGS COLLECTED YFS
7. DOES WELL REPLACE EXISTING WELL? YES n NOEJ,
8. STATIC WATER LEVEL Below Top of Casing: 9 b --- FT•
(Use 't- it Above Top of Casing)
9. TOP OF CASING IS l — FT. Above Land Surface'
`Top of casing terminated at/or below land surface requires it variance In actor•
dance with 15A NCAC 2C01 1e METHOD OF TEST /Jr
10. YIELD (gpm): n ,
11. WATER ZONES (depth):
12. CHLORINATION: Type .4
Amount A6 , 11 additional space is needed tsjs bacA of fc/Tn
13. CASING: LOCATION SK=TCH
Wall Thickness (Show direction and dunce hart � leas::wo S ate
Depth Diameter or Wei hM. Material ( int!
S.11..2l /�yG Roads, or other rrr�? relerc: � >�
From (%—To. -- Ft.
From— To — Ft. — —
From —To -- FL —
1 d. GROUT:
Depth erial esod
From �— To �-- FI. or7%�����---
c f
From — To — Ft.
Cn
15. SCREEN:
Diameter Slot Size Material
x„
m
Depth
From To Fl in._In. ___---
co
m=
From To Ft. in. In. _----
C.0
c->
—�
From To Ft. In. In.
16. SAND/GRAVEL PACK: Material
Depth Size
From — To
From — To Ft. —
17. REMARKS:
of
EPROVIC� 70 THE !!� Ot��EF..
THIS RECORD HAS BEE RUCTED
1 DO HEREBY CERTIFY THAWS
AIN THAT A COPY OT
CONSTRUCTION STANDAI ,;
FOR OFFICE USE 0 LAY Lim OF PERSON CONSTRIY:TING TYc'
ps'E
SIGN wvith
Quad No - CT I �u�Ortpinal l0 pl,ritlon of Water Duellly. G�vund•�iler�^ trrithin Y3 C%fYs
C„ I � v. 1211
Serial No.I
'fotsiri

. WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of Water Ouality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636•Phone [phone]
WELL CONTRACTOR:��I�
WELL CONTRACTOR CERTIFICATION 0: _ 2
STATE WELL CONSTRUCTION PERMITH:
1. WELL USE (Check Applicable Box): Residential [9— Municipal ❑ Industrial ❑ Agricultural ❑ Monttorir:g ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ II Other, List Use:
2. WELL LOCATION: (Show sketch of the location below) I r�
Nearest \Town:IM. Nfn qq P County: i1
�n CA Q c> c n l%_ P� DEPTH
(Road Name and Numbers. �ommunity. or Subd, Ision and Lot No.) DRILLING LOG
3. OWNER Ovi/I , C. c� e- r vv1 e-
From To Forrraxn Oescrip6o^
Address �)eN-f0���
beet or ou
1Valar l'\�i �`\ L' C/0<o ��D r �lK - s g/ce
City or vown nn Slate Zip Code
4. DATE DRILLED
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YFS ❑ NO[D-
7. DOES WELL REPLACE EXISTING WELL? YES F-1 NORa
S. STATIC WATER LEVEL Below Top of Casing: LlL,)! FT.
(Use '+' II Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface'
'Top of casing terminated st/or below land surface requires a variance In actor•
dance with 15A NCAC MOM
10. YIELD (gpm): '76 - METHOD OF TEST �4 i
11. WATER ZONES (depth):
�36108
12. CHLORINATION: Type ��� ��� Amount s II additional &pace is needed Ls•e beck Of fc'rTn
13. CASING:
LOCATION SK- i'CN
Wall Thickness
Depth D)ameler or Welght/Ft. Material (Show direction and dis'ance from leas iHo S' ate
From © To 10 C9 � Ft. (6 ` -�( 'n-P V C Roads, or other rr,----p refere:rpe nolnt<�
From —:To Fl.
From To FI.
1 d. GROUT:
Depth Material
From D To 1Pr Ft.
From To Ft.
15. SCREEN:
Depth
From To Fl
From To Ft
Method
Diameter Slot Size Material
In. In.
In. In.
From To Ft. in. In.
16. SAND/GRAVEL PACK,
Depth Size Material
From - - To - - — FI. —
From To Fi• —
17. REMARKS:
o
r =
r"
�r
ry
�
100 HEREBY, CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A P4CAC 2C.'/fELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVICED TO THE Y/"S!!-L OI%'NEP-
FOR OFFICE USE ONLY
SIONATURE OF PERSON CONSTRLy'TING 1�,_ -"ELL
Ouad No:
jai ,iG9 (•. t.f Submil original to Divltlon of Water t7uelily, oroundwaler Srcut Within V. c;5rys V. t_>h
CK
Serial No.

North Carolina - Department of Environment and Natural Resources - Division of Waier Ouality - Groundwater Section O 3 6 10
7
1636 Mail Service Center - Raleigh, N.C. 27699.1636-Phone [phone] �) 1
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION #:2 2q
STATE WELL CONSTRUCTION PERMITN:
1. WELL USE (Check Applicable Box): Residential &� Municipal ❑ Industrial ❑ Agricultural FI Monitoring ❑
Aecovery ❑ . Heat Pump Water Injection ❑ Other n It Other, List Use:
2. WELL LOCATION: (Show sketch of the location below) �� ��01, e
Nearest Town: �/ County: h
—�n� C ec rl t.c���r e
(Road Name and Numbers,1Communlly, or ubdivlsion and Lot No.) DRILLING LOG
3. OWNER CY From To
Address oj'7A
,reef or o.
City or Town Stale Zip Code
a. DATE DRILLED
5. TOTAL DEPTH I a6 r
6. CUTTINGS COLLECTED YFS ❑ NO l�—
7. DOES WELL REPLACE EXISTING WELL? YES n NO[D—
8. STATIC WATER LEVEL Below Top of Casing:p L FT.
(Use '•r' II Above Top of Casing)
9. TOP OF CASING IS__L___— FT. Above Land Surface'
'Top of casing terminated st/or below land surface requires a variance In accor-
dance with 15A NCAC 2C.0118
10. YIELD (gpm): 5 METHOD OF TEST ✓-
11. WATER ZONES (depth):
DEPTH
Forrra�on DesCAP!Ja-
12. CHLORINATION: Type )0±V1 e Amount �-- If additional space is needed ts-e ba& of ftx-n
13. CASING:
LOCATION SK=TCH
Wall Thickness
Depth Diameter or Wetght/Ft. /�M,a�l�ertal (Show direction and d"fiance ir•.m j leas: t�a1e
v �'-
From To — Ft. �� — �- 'P 4Z — Roads, or oUxr rr� relerc:� Poln�.'
From
To
Ft. —
From —To—
Ft.
14. GROUT:
Depth
Material Method
From To 2t2- Ft. --
From
To
Ft. --
15. SCREEN:
Depth
Diameter Slot SIZe Material
From
To
Ft In. In.
From To Ft.
From To Ft.
16. SAND/GRAVEL PACK:
In. In. In, In.
Depth Size
From To — Ft.
From To Ft. —
17. REMARKS:
Material
o
r7
C T
rj
Cn
r
i�
r=,
co
;
w
C.,.
N
o
I DO HEREBY CERTIFY THAT -THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A rdCAC ?',:.'/✓ELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEII PROVICE13 TO THE Y/V—L a%"EF•
FOR OFFICE USE ONLY
SIONATUnE OF PERSON CONSTr1LY.%TINO 1t¢ 'W
Quad No: ELL
0� E
14 Sutxnil'orlpinal to Division of Water Duality. OmfOw tlor Sr"A within :�i C%sy5
Cn-1 F-19V, 12)1
Serial No. ----
€,'t�tllqtr3v�af�

North Carolina - Department of Environment and Natural Resources • Division of Water Quality • Groundwater Section 6106
1636 Mail Service Center . Raleigh, N.C. 27699.1636-Phone [phone] '' ff
WELL CONSTRUCTION RECORD WELL CONTRACTOR: . /�l�ei- WJ` r)K, IL,
WELL CONTRACTOR CERTIFICATION H: bIG�J
STATE WELL CONSTRUCTION PERMITH:
1. WELL USE (Check Applicable Box): Residential Lil Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Aecovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: ($how sketch of the location below) f
Nearest Town: 1* ,-egos County:
(Road Name and Numb rs, Communll . or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER Cof-1'- wJ�"er From To Fomaxn Description
Address
(Street or Houle o.
/`�� ` rU� /01111�6
City or Town Stale Zip Code
v0
4. DATE DRILLED
5. TOTAL DEPTH s-od
6. CUTTINGS COLLECTED YFS [] NOED-__
7. DOES WELL REPLACE EXISTING WELL? YES E] NO[3-
8. STATIC WATER LEVEL Below Top of Casing: //S' 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.01)9
10. YIELD (gpm): .2 �� METHOD OF TEST
11. WATER ZONES (depth):
12. CHLORINATION: Type /��" Amount �2If additional space is needed tsp back of fern
13. CASING:
LOCATION SK- f CH
Wall Thickness
Depth Diameter or Wei ht/Ft. Material (Show direction and dis=ance tr.,m 21 leas: t,vo S� to
SD�z/ :� poinu, ,
From70 /�a Ft. 6 -ZS Roads, or other rr� refere
..-
From / `f 0 To !G Ft. G. �r ,1��
From To Ft.
14. GROUT:
Depth �M,aJeril Method
✓�j�rrv`��
From C% To �� Ft. °��``//a2
From To Ft.
15. SCREEN: o
Depth Diameter Slot Size Material
r?
From To Ft in. In. cG-)
From To Ft. In. In. cr,
c
:ram
From To. Ft. In. In.
° rL;
r--r,,
16. SAND/GRAVEL PACK: -�
M
Depth Size Material cap
From To Ft. W
From To Ft.
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS:WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A 04CAC r' ,'/✓ELL
CONSTRUCTIORS' TANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIC£D '70 THI YI="U Ott'NEF.•
FOR OFFICE USE ONLY'�`I
Quad No: SIG TURE OF PERSON CONSTRU11,TING PEyvELL
Subr,Nl original to Divftlon of Water avalhy. Ground+ iar stc.A wvithin vA C;o
Serial No. t°Ii �tf';. f CM•I FccY.
1291 _ .

236105
North Carolina - Department of Environment and Natural Resources - Division of Water Ouality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699.1636•Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: (,
WELL CONTRACTOR CERTIFICATION 0:
STATE WELL CONSTRUCTION PERMITP:
1. WELL USE (Check Applicable Box): Residential �Municipal industrial ❑ Agricultural F-1 Monitoring ❑
Flecovery ❑ Heat Pump Water Infection ❑ Other 0 If Other, List Use:
2. WELL LOCATION, (Show,sketch of the location below) /
Nearest Town: County:
/`e/lC_/,Al e-L' -
3.
(Road Name and Numbers, Community, or Subdivision and Lot No.)
OWNER /9'/a`1 /'",Za S
Address
(Street or Houle o.
City or Town State Zip Code
4. DATE DRILLED
5. TOTAL DEPTH Zj U
6. CUTTINGS COLLECTED YFS O NOS
7. DOES WELL REPLACE EXISTING WELL? YES N0
S. STATIC WATER LEVEL Below Top of Casing: O FT.
(Use '+' If Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface -
'TOP of casing terminated at/or below land surface requires a variance In accor-
dance with 15A NCAC 2C .0118
10. YIELD (gpm): o METHOD OF TEST��
11. WATER ZONES (depth): 1-2- 7
12. CHLORINATION: Type
13. CASING:
DRILLING LOG
From To
DEPTH
Forra�on Description
�fT Amount l e II additional s;ace is needed L-:;m back of IUrn
Depth Diameter
From To � Ft. L'2S-
From To Ft.
From To Ft.
14. GROUT:
LOCATION SKETCH
Wall Thickness
or Weight/Ft. Material (Slow direction and dunce (r.,m a�l leas: ;.vo Snmle
S042 l . Roads, or oUxr rm-a relerc:res points`
Depth
Me hod
From D
To Z­O
Ft.
From
To
Ft.
15. SCREEN:
Depth
Diameter Slot Size
Material
From
To
Ft
In.
in.
From
To
FL
In.
In.
From
To
Fl.
In.
In.
16. SAND/GRAVEL PACK:
Depth
Size
Material
From
To
FI.
From
To
Ft.
—
17. REMARKS:
DO HEREBY CERTIFY THAT THIS•WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A lt4CAC r., VrELL
CONSTRUCTION STANDARDS;'AN6 THAT A COPY OF THIS RECORD HAS (SEEN PROVICED 'JO Tit- VIS-L O%%'NEF..
/i
FOR OFFICE USE ONLY
Quad No:
Sad*]No. ---
Subf JI odo
IGNA URE OF PERSON CONSTRIY.TING 1>K "'ELL
110 Divlalon of Wale( pualily, oround+ater Smut within N.) C;?YS
Cfr.l F19V, l"I

r.
n n
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section C► . L./
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: rn"ROC
WELL CONTRACTOR CERTIFICATION N: a,'1D C/
STATE WELL CONSTRUCTION PERMITP:
1. WELL USE (Check Applicable Box): Residential a Municipal ❑ Industrial ❑ Agricultural Monitorir g ❑
flecovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below) n
Nearest Town: I iv-0 S County: C 1
(Road Name and Numbers. Community, or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER f)fQCA _MQCVQ',) From To ForrraxnDescriptio-
Address i VA Q,r{ � Q_ lL arl e i
yj5treei orRoutoo No.%— f) ` � Jh
130
City or Town Slate Zip Code
4. DATE DRILLED J
5. TOTAL DEPTH ' 5
6. CUTTINGS COLLECTED YFS M NO�
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO[2
B. STATIC WATER LEVEL Below Top of Casing: _;)C) r FT.
(Use -+- If Above Top of Casing)
9. TOP OF CASING IS I __ FT. Above Land Surface -
'Top of casing terminated allor below land surface requires a variance in accor-
dance with 15A NCAC 2C.0118
10. YIELD (gpm): ;2�_ METHOD OF TEST ,
11. WATER ZONES (depth):
12. CHLORINATION: Type Amount 5 It additional s"ce 4s needed tse back of fUm
13. CASING:
LOCATION SK-TCH
Wall Thickness
Depth Diameter or Welght/Ft. Material (Show direction and dunce lr, m at leas: two Slate
From To �� r Ft.� Dom— Roads, or other rrr� relere:re, points!
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method c
o
From To 219 Fl. c, T
From To Ft. C o
15. SCREEN:
Depth Diameter Slot Size Material l
From —To—Ft In. In.
From To Ft. In. In.
a
From To Ft. in. In.
16. SANDIGRAVEL PACK: w
tV o
Depth Size MaloHal From To Ft.
From To FL
17. REMARKS:
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A I+dCAC r' , ItrELL
CONSTRUCTION STANDARDS, AND THAT,A COPY OF THIS RECORD HAS BEEN PROVIDED 70 THE 'NFU D%NEF..
s3
FOR OFFICE USE ONLY
SIGNATURE OF Pr:1130N CONSTRII CTING 1),,-_ ,ov ELL
Quad No: I� i $�bmll original to Division of Water puathy. Groundo- ter Srccn within Y.)C;*13
Ft9 V. 1
Serial No. .11
5it��Wolf

/ . 23610
North Carolina - Department of Environment and Natural Resources - Division of Water Ouality - Groundwater Section 3
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): Residenllal � Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Aecovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show ketch of the location below) j�e- c
Nearest Town: County:el
/L
(Road Name and Numbers, Cornmunity, or Subdivision and Lot No.)
3. OWNER W. /l'� ,-n fd';e' P-r
Address
treet or FROM5 o.
City or Town State Zip Code
4. DATE DRILLED y "z 6•-o0
5. TOTAL DEPTH -3 0
6. CUTTINGS COLLECTED YFS ❑ NO�
7. DOES WELL REPLACE EXISTING WELL? YES M NOD,
S. STATIC WATER LEVEL Below Top of Casing: 2—O FT.
(Use -+- If Above Top o1 Casing)
9. TOP OF CASING IS / FT. Above Land Surface'
'Top of casing terminated aVor below land surface requires a varlance In accor.
dance with 15A NCAC 2C .011 S
10. YIELD (gpm): ,P--- METHOD OF TEST
11. WATER ZONES (depth): 9 eta
12. CHLORINATION:
13. CASING:
DRILLING LOG DEPTH
From To Forrn15on Desr-dOo-
l7
Type f Amount G ✓ It adds tonal space is needed L-,o- back of fceTn
Wall Thickness
Depth C �v Diameter r or Wei hVFI.
From To
From To Fl.
From To Fl.
14_ GROUT:
15_ _
Depth Diameter Slot Size
LOCATION SK= i CH
Material (Show direction and dunce Irm c1 leas:'"O Slale
IA�G Roads, or other rr� relererr-e polnts!
Depth as a Wthod
From To .e�� - Fl. r^ ��'I� Sc,;. e—
From To Ft.
St;pEFN:
Material
From
To
Fl
In.
In.
From
To
Ft.
In.
In.
F
To
Ft
In.
In. ___----
rom
16. SAND/GRAVEL PACK:
Depth Size
From To Fl.
From To Ft. —
17. REMARKS:
1 DO HEREBY CERTI
CONSTRUCTION ST
FOR OFFICE USE ONLY'.
Ouad No:
Sedal No.
Material
1
cn
w
N
.L WAS CONSTRUCTED IN ACCORDANCE WITH 15A 04CAC Y:. lerELL
IAT.A.COP.Y..gF THIS RECORD HAS SEEN PROVICED 70 THE' /="•-L O""EP-
{
SIGN
URE OF pER3�JN CONSTRIY'TIfIG Trc^ 'N ELL
Submit original to Divltlon of Wale( Duality, omndorater Srccn within Y) C;�rys
t: )
r-
Y
cnv-
�v
0
z
Da.drE
C.rr.I P19v. 1:11

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section 236099
106 Mail Service Center - Raleigh N C 27699.1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:��`'
WELL CONTRACTOR CERTIFICATION N:
STATE WELL CONSTRUCTION PERMITP:
1. WELL USE (check Applicable Box): Residential 2"" Municipal ❑ Industrial ❑ Agricultural ❑ Monitorirg ❑
Flecovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2
3.
WELL LOCATION: (Show sketch of the location below)
Nearest Town: %'r"P—i� County:
(Road Name and yumbers, Community, or Subdivision and Lot No.)
OWNER �Od P"//
Address
DRILLING LOG
From To
treet or Route o. d l0
City or Town State Zip Code
4. DATE DRILLED
5. TOTALDEPTH
6. CUTTINGS COLLECTED YVS F—I NO['
7. DOES WELL REPLACE EXISTING WELL? YES (__j NOQ-
S. STATIC WATER LEVEL Below Top of Casing: .2 0 FT.
(Use '+' if Above Top of Casing)
9. TOP OF CASING IS 1 FT. Above Land Surface -
'Top of casing terminated at/or below land surface requires a variance In accor-
dance with 15A NCAC 2C .0118
10. YIELD (gpm): VS� METHOD OF TEST
11. WATER ZONES (depth): Z/S~ "
DEPTH
Forrra5cn Des:riptio,
12. CHLORINATION: Type Yr1_1 Amount G if additional space is needed ts-e back of foe-
13. CASING:
Wail Thickness
Depth _
From' To �- Ft.
Diameter
or Weight/Ft. Material
From
To Ft.
From
To Ft.
14. GROUT:
Depth
�a fyial Mg1hod
er cire-
From
To Fl.
oil`/`''yZ
/�
From
To Ft.
15. SCREEN:
Depth Diameter Slot
Size Material
From
To Ft
In.
in.
From
To Ft.
In.
In.
From
To Ft.
In.
in.
16. SAND/GRAVEL PACK:
Depth
Size
Material
From To Ft.
From To Ft.
17. REMARKS:
LOCATION SK=TCH
(Show direction and d�stance ir, m e�j leas: "No Snale
Roads, or other rrrC,o relemrce points`
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A DJCAC ?';., r/ELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROViCED 70 TH: Y/c".-t- 0"'SFF.
FOR OFFICE USE ONLY 61'_Quad No: i r''iiSIOF PERSON CONSTRIY:TING 1>c'WELL Oa'E
ja Submit original to Wtlon of Water Ouality, Grour4-8ter Srau+ within v7a;-, ys
Serial No.
{

North Carolina • Department of Environment and Natural Resources . Division of Water Quality • Groundwater Section 236097
1636 Mail Service Center • Raleigh, N.C. 27699.1636-Phone [phone]
WELL CONSTRUCTION RECO
RD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION N:
STATE WELL CONSTRUCTION PERMITP:
1. WELL USE (Check Applicable Box): Residential � Municipal ❑ Industrial ❑
Flecovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
Agricultural ❑ Monitoring ❑
2. WELL LOCATION: (Show sketch of the location below) /� �
NearestTown:
i1cV_4- l/ County: lG
6 d i¢kc l I __e e I
(Road Name and Numbers, /Communllyy. or/Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER /�Ccridr!1�4T0� %/91t�r From To ForrraxnDes:ripto:
Address f�vrl /.vf,./c
(Street or ou a o. C
City or Town Slate Zip Code
4. DATE DRILLED y ' 6 o O
5. TOTAL DEPTH 6 /()
6. CUTTINGS COLLECTED YFS [- NO[D-
7. DOES WELL REPLACE EXISTING WELL? YES (—I NO©
8. STATIC WATER LEVEL Below Top of Casing: 5�O _ FT.
(Use '+' If Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface -
'Top of casing terminated at/or below land surface requires s variance In actor-
dance with 15A NCAC 2C.0118
10. YIELD (gpm): 0 METHOD OF TEST
11. WATER ZONES (depth):
c//,) . S/l� t-e
12. CHLORINATION: Type Am l G" If additional space is needed Lm-- back of fc-m
13. CASING:
Wall Thickness
Depth Diameter or Weight/Ft.
From To Ft. L 25J SOt'z/
From To Ft.
From To Ft.
LOCATION SK=TCH
Material (Show direction aid d s»ance ircm ed leas:'Ho 5".ale
vL- Roads, or other rr.—ap refers:rx-- point!
14. GROUT:
Depth Material M�91hod
From . �— To Ft. l�l //� �erfr✓�
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 W,
CONSTRUCTION STANDARDS, AND THAT F
r
(
ZC
CX)
w
N
CONSTRUCTED IN ACCORDANCE WITH 155A D4CAC?',.','/,TELL
6PY OF THIS RECORD HAS BEEN PROVAC£0 '70 THr- Ylc"....L 0t%'�FF-
Quad No: SIGN RE OF PERSON CONSTRLY.TING lY 10VELL.
Submit original to Division of Water lvality. Ground.,ator Srr-ut within :q : ys
Serial No.
0,6 'tE
c�
C).
0
6n.1 ptE v. 1291

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section 2 3 F 0 9 5
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION #: 0
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential [ K Municipal ❑ Industrial.❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heal Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION',�Sh ketch of the location below) e /
Nearest Town: p County: 18/U
Cor/ywc l/ 161
(Road Name and Numbers, Community, or ubdivislon and Lot No.)
3. OWNER ZI51'e C'W11We - I
Address %D 4)U4,11R 171ddf.W%
treet or Houle No.
City or Town Stale Zip Code
4. DATE DRILLED `07`� U
5. TOTAL DEPTH 3yo
6. CUTTINGS COLLECTED YFS ❑ NO[-3--�
7. DOES WELL REPLACE EXISTING WELL? YES [ ' NOe—
S. STATIC WATER LEVEL Below Top of Casing: p FT.
(Use'+'If Above Top of
Casing)
9. TOP OF CASING IS �L FT. Above Land Surface -
'Top of casing terminated aVor below land surface requires a variance In accor-
dance with 15A NCAC 2C .0118
10. YIELD (gpm): I METHOD OF TEST
11. WATER ZONES (depth): 305-
12. CHLORINATION: Type %/r Amount A c U
13. CASING:
Wall Thickness
� Depth � Diameter oSW�pht/Ft. material
From To
From To Ft.
Fromm To Ft.
14. GROUT:
beplhat ria) N�,elhod
From 0 To 2-D Ft. ort/aid�Jfure
From To Ft.
15, SCREEN:
Depth Diameter Slot Size Material
From To Ft In. in.
From To Ft. In. In.
From To Ft. in. in.
16. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To Ft.
17. REMARKS:
Material
DRILLING LOG DEPTH
From To Forrra5 n Description
�Df— --?Vo
if additional space is needed tse back of is M
LOCATION SKETCH
(Show direction and dis~ance Imam zl leas• tyro S:-ate
Roads, or other rt-�p refetenry potntss`
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACC0RDAPICE WITH 1'.A 04CAC ? :, ItSELL
CONSTRUCTION STANDARDS, AND�THAT A COPY OF THIS RECORD HAS BEEN PROVIDED '70 THI: Y/S".--L Ot%aEF.-
FOR OFFICE USE ONLY Ds . E
Quad No:
SI�E OF PERSON CONSTRUCTING 1� 10VELL
Submit original to D+vlttlon of Water Quality, GroundKalar Seam within n c.;--,ys
. Gn.t GtEY. c211
Serial No.

236088
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636•Phone [phone]
WELL CONSTRUCTION RECORD WELLCONTRACTOR: �
r
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable sox): Residential [J-,/ Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Aecovery ❑ Heal Pump Water Injection ❑ Olher ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below) /
`Z
Nearest Town:�Z - - County: r QUO Q -Pi e
n /) /Pry "ee r(
(Road Name and Numbers, Community, or Subdivision and Lot No.) DRILLING LOG
DEPTH
3. OWNER cl, ,����d D �+/ From To
Fom-a5cn Descripua-
Address cx Lr, i -/ C f1-Z'
(street or oute o.
e Y
(/p
City or Town State Zip Code
9- 6 �' 0
4. DATE DRILLED
5. TOTAL DEPTH 9 0 0 '
6. CUTTINGS COLLECTED YFS ❑ NO[�-
7. DOES WELL REPLACE EXISTING WELL? YES � NOQ
B. STATIC WATER LEVEL Below Top of Casing: -3 FT.
(Use, '+' If Above Top of Casing)
9. TOP OF CASING IS � v FT. Above Land Surface*
'Top of casing terminated nVor below land surface requires a variance In accor-
dance with 15A NCAC 2C�D118 Tr
10. YIELD (gpm): 7 MEN O OF TEST
11. WATER ZONES (depth):
12. CHLORINATION:
13. CASING:
Type
Amount 4�G v If additional space is needed back of fc- m
Depth Dim
From To l Ft.
From To Ft.
From To Ft.
14. GROUT:
15
LOCATION SK=TCH
Wall Thickness
orS yy��t��. Ma��a(Show direction and d"s»anca from al leas: two Smote
� & Roads, or other rr.---p relere:re points`
Depth M ppnal
From 0 To 2- U Fl. 0/(�<1�
From To Ft.
SCREEN:
Method
Depth Diameter Slot Size Material
From To Ft in. In.
From To Ft. In. in.
From To Ft. in. in.
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft. —
17. REMARKS:
100 HEREBY
FOR OFFICE USE;O,NL'
Quad No:
L WAS CONSTRUCTED IN ACCORDMICE WITH 15A FJCAC ?':,'/✓'ELL
At, -'A COPY THIS RECORD HAS BEEN PROVICED 'TO THE II/V- . 0%% %EP.
r^
CD
C —
�r SIGNATURE OF PERSON CONSTRU,,TING 1>t 'N ELL 0�"T E
Submit original to DM&Ion of Wale( pualily, Grouro"Ier Srccn within %Ys Y. 12Y1
GK•1 P1
Serial No.

North Carolina - Department of Environment and Natural Resources - Division of Water Ouality - Groundwater Section
236086
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTI
ON RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION f . M6
STATE WELL CONSTRUCTION PERMITH:
1. WELL USE (check Applicable Box): Resldentiai LT Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below) (f /
Nearest Town: County: !�e-
(Road Name and Numbers. Community, or Subdivision and Lot No.) DRILLING LOG DEPTH
OWNER C ` zf fP 1^ Z 0 GU From To Forrra5on DesctiOw-
Address & � ^"4
D
� treat or HouleNo.)!�
City or Town state —P
4. DATE DRILLED
5. TOTAL DEPTH-
6. CUTTINGS COLLECTED YFS [] NO[3' —
7. DOES WELL REPLACE EXISTING WELL? YES n NOD-
8. STATIC WATER LEVEL Below Top of Casing: Z{� FT. —
(Use '+' If Above Top of Casino)
9. TOP OF CASING IS FT. Above Land Surface* —
'Top of casing terminated at/or betow land surface requires a variance In accor-
dance with 15A NCAC 2C .D118
10. YIELD (gpm): C' METHOD OF TEST —
11. WATER ZONES (depth): —
12. CHLORINATION: Type
13. CASING:
IZ'rlf Amount i,
Wall Thickness
Depth Diameter or Weight/Ft.
From To go FL G -"_L " 21
From To Ft.
From To Ft.
If additional space is needed t5e baci of fc-rm
LOCATION SKETCH
Material (Show direction and dis. ance Ircm -I leas: tr*o S:-ate
/yG Roads, or other rrrcp refererree points
14. GROUT:
Depth aterial Method
From D To �� Ft. 0� 1�J i`i e ss
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft In. in.
From To Ft. in. In.
From To Ft. - In. _
16. SAND/GRAVEL PACK:
Depth Size
From To - Ft.
From To Ft. —
17, REMARKS:
I DO HEREBY CERTIFY THATTHIS WELL W
CONSTRUCTIONSTANOAROS, ANDTHAT A
FOR OFFICE USE ONLY j� t ( ; t �-
Ouad No:
Sub mil
Serial No.
, . ,F i, z YErRa s ,,
In.
Material
W
r~
1
rn
x�•
t�
w
rV
IUCTED IN ACCORDANCE WITH.I;A DdCAC 2`.:,1ffELL
THIS RECORD HAS BEEII PROVICED "TO THE Y/=".-L a%'hEF-
n
c;
c'C
GNA URE OF PERSON CONSTRU :TING DIZ WELL Os'' E
Io'Divislon of Water pualily, GrvurtdMator seccn within :c) d*'ys I FsE V. 12Y1
Cn•

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
236085
1636 Mail Service Center - Raleigh, N.C. 27699.1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION N: �L /O
STATE WELL CONSTRUCTION PERf11ITa:
1. WELL USE (Check Applicable Box): Residential ❑'� Municipal ❑ Industrial ❑ Agricultural I❑ Monitoring ❑
Aecovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below) /I 1
Nearest Town: MA M `I County: ( n D WKlg —
(Road Name and Numbers, Community, or Subdivision and Lot No.)
OWNER 0
Address
treet or outs o.
City or Town State zip Code
4. DATE DRILLED 9 fig- 0f�
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YFS ❑ NOB'
7. DOES WELL REPLACE EXISTING WELL? YES [] , NOt--T
S. STATIC WATER LEVEL Below Top of Casing: L/19 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 . ,
10. YIELD (gpm): /_ METHOD OF TEST i4,'r2
11. WATER ZONES (depth):
DRILLING LOG
From To
0 /19'
/,0 OF1 0
2go �— a6O
DEPTH
FomaScn DescApGa,
�'/a,/
12. CHLORINATION: Type k1k -6kl PAS Amount 6 If additional space is needed L-.s-- back of Ic -m
13. CASING:
Wall Thickness
Depth Diameter or Welght/Ft. Material
w
From 0 To / Srd F►• o. ,,?_5 S--r.;i-b V,--
From--_2YP_r To —2,15— Ff. 1n -0 l
From To Ft.
14. GROUT:
Depth Material Method
From -SZ To -2-0--Ft•
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From To Fl In. in -
From To Ft. In. —
From To Ft. In, —
16, SAND/GRAVEL PACK:
Depth Size
From To Ft. —
In.
In.
Material
LOCATION SK= f CH
(Show direction and dunce from z1 leas: oo sitale
Roads, or other rrcp relere:re points`
Ca
z� fir_
V J
I ca i
rn
M
Cb G0:r_
w �
N o
From To Ft- —
17. REMARKS:
DO HEREBY CERTIFY THff THIS WELL WAS CONSTRUCTED IN ACCORDMICE WITH 15A r4CAC rr, ,trELL
AFIDS, ANb THAT A COPY OF THIS RECORD HAS BEEN
_/ PROVICED '70 TFt- W="u
�J�
CONSTRUCTION STAND
FOR OFFICE USE ONLY �l�+ r _ os �E
Quad No: OC ii !D I t.j SIGNATURE OF PERSON CONSTRIY:TING tic^ 'N ELL
Submll original to MIslon of Water Ouallly, Oround•-atar S#ccn iwithin N.) c %"ys y 12gt
Sn.1 Ft�
Serial No.
ill �lfjl'f .}.'

Nc•nh 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]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION q:.U.�U
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential C9 Municipal ❑ Industrial ❑ Agricultural ❑ MonitoriN. ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: �`r 11 `` County:
f-F./o C�QEEC1 Rd DEPTH
( ad Name and Nu tiers, Community, or Subdivlslon and Lot No.) DRILLING LOG
3. OWNER ��`�: %•'p
Cn,�(�n �� From To Forrra�cn De'scriptio,
Address �s
treat or oute o.
City or Town State Zip Code
4. DATE DRILLED g"0�-QQ
5. TOTAL DEPTH iqS
6. CUTTINGS COLLECTED YFS ❑ NO[9'
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NOEZJ-
B. STATIC WATER LEVEL Below Top of'Casing: ( p r . FT.
(Use *+* II Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface'
'Top of casing terminated st/or below land surface requires a varlance In accor-
dance with 15A NCAC 2C.0119
10. YIELD (gpm): 3 METHOD OF TEST kf
11. WATER ZONES (depth):
12. CHLORINATION
13. CASING:
14
From - -.—
From
15. SCREEN:
Typeb:ffie Amount -:5 It additional space is needed L-se ba&of fern
Depth Diameter
From To Ft.
From To Fl.
From To Ft. —
GROUT:
Depth M terial -J-�---- Method
To 20 ` Ft. ?0-r
To Ft.
LOCATION SK- t CH
Wati Thickness
or Wgigh I. Material (Slow direction and d'�rm c" 2 l
ance teas:' a to
/ y - L Roads, or other rrr-p refete:� points`
Depth Diameter Slot Size
Material
From To Ft
in.
In. ____---
From To Ft.
in.
In. ___----
From To Ft.
In.
In. __—_--
16. SAND/GRAVEL PACK:
Depth
Size
Material
From To Ft.
From To Ft.
—
17. REMARKS: _.
1 DO HEREBY CERTIFY.THAT l' WELI'V
CONSTRUCTION "STANDARDS, AND THAT
FOR OFFICE US ONO
Quad No:
SubA
Serial No.
CONSTRUCTED IN ACCORDANCE WITH 15A ftJCAC ?�.'. VrELL
)PY OF THIS RECORD HAS BEEN PROVIDED -70 THE 1l/E:"._L C""EF•
SIGNATURE OF PERSON CONSTRUCTING Ti c '/v'ELL
original to Divlt Ion of Water oualily; Grwlrwd-91er Srac(1 writhin Y) C%�ys Ce l V. 1211

WELL CONSTRUCTION RECORD
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] . II
WELL CONTRACTOR: i ^ t i� �' `�"
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMIT#:
236084
1. WELL USE (check Applicable 6ox): Residential❑— Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATIQN:,(Show sketch of the location below)
Nearest Town:
�.^�; . , County: v t r
DEPTH
(Road Name d Numbers, Community. or Subdivision and Lot No.) DRILLING LOG
3. OWNER
From To Forra:5cn Descriptio'
Address � © f�K g6L/ F0 n
I tree or `ule Io. �9D/ -
/n D /
City or Town State Zip Code 7 r , UD
4. DATE DRILLED �l-��/-30-
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YFS ❑ NOTki
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO[f 320r y�---
8. STATIC WATER LEVEL Below Top of Casing: FT. uno—,�—
(Use '+' If Above Top of Casing)
9. TOP OF CASING IS___L__— FT. Above Land Surface*
'Top of casing terminated at/or below land surface requires a variance in accor-
dance with 15A NCAC 2C .0118
10. YIELD (gpm): D METHOD OF TEST; i Q
11. WATER ZONES (depth):
12. CHLORINATION: Type Amount If additional space is needed tse back of form
-------------
13, CASING:
Wail Thickness
Depth
Diameter or Weight/Ft. ht/Ft. Material
From D
To -_
Ft. —
From To -
From
To
Ft•
14. GROUT:
Depth
Mmalt9nal Method
From 1_
To —? L
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
FL —
LOCATION SK= t CH
(Show direction and d'esiance from 22-1 Was! 'NO S.Ia1C�
Roads, or other rreferer� point` 0
r.�
1
c
Cn
r
C:3
n
ca
—,
N
o
a:
From To Ft. —
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A fiJCAC Y:, ,frELL
CONSTRUCTION STANDARDS, AND`THAT A COPY OF THIS RECORD HAS BEEN PROVICED -70 THE VISA—L 0%%NEP..
L /S-Dry
FOR OFFICE USE ONLY'SIGNATURE OF PERSON CONSTRIY:TING 1>,c N ELL Da T E
Quad No:
Submit original to Divitlon of Water pualhy, Ground+ralar Srccn within :4 %Ys CK•I � V. 1291 ,
Serial No, -----

North Carolina - Department of Environment and Natural Resources- Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699.1636-Phone [phone]
236079
WELL CONSTRUCTION RECORD WELLCONTRACTOR: V0�3I) ",
WELL CONTRACTOR CERTIFICATION N:
STATE WELL CONSTRUCTION PERMITM:
1. WELL USE (Check Applicable Box): ResidentialMunicipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below) �� E�0 1 Y
Nearest Town: County:
t 6 5 �` and N �UC�'� P c� DEPTH
(Road Name and Numbers, G'bmmunity, or Subdivision and Lot No.) DRILLING LOG
3. OWNER �� P E � � VlAri t� From To Forrraxn Des npuo'
Address ( / P 'L / G //e, /m, ,l
�A street or o to o.
�r
City or T wn state Zip Code r
4. DATE DRILLED -
5. TOTAL DEPTH 6-
6. CUTTINGS COLLECTED YFS ❑ NOB
7. DOES WELL REPLACE EXISTING WELL? YES M NO[q-
B. STATIC WATER LEVEL Below Top of Casing: _ o , FT.
(Use '+' If Above Top of Casing)
9. TOP OF CASING IS FT FT. Above Land Surface*
'Top of casing terminated aVor below land surface requires a variance In accor-
dance with 15A NCAC 2C .0118
10. YIELD (gpm): -6 METHOD OF TEST A"'a
11. WATER ZONES (depth):
12. CHLORINATION: Type }1+h 11LE±S Amount It additional space :s needed tse back of kern
13. CASING:
Wall Thickness
Depth D ameler or WeighVFt. Material
Fromm —To -7— Ft. -
From To Ft.
From To Fl•
14. GROUT:
Depth M lariat , Method
From _0 To aW Ft.
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From
To
Ft
in.
—in.—
From
To
Ft.
In.
In.
From
To
Ft.
In.
In.
16. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To Ft.
17. REMARKS:
100 HEREBY CERTIFY THAT, THIS WELL, WAS
CONSTRUCTION STANDARDS, ANIY14t A`C
FOR OFFICE USE ON,IY 01 'E ,'� ,�n`a U
Quad No:
5utxnit o�
Serial No.
_. 5ii'6. iY� rJ'I�kNcii as e .
Material
LOCATION SK=TCH
(Show direction and distance tr art art leas: t"o Vale
Roads, or other n-�7 relere:r­e points'
ISTRUCTED IN ACCORDANCE WITH 15A OJCAC ?r. lerELL
OF THIS RECORD HAS BEEN PROVICED -70 THc Y1S...L 0%%'%EF•
IGNATURE OF PERSON CONSTRUCTING 111ZovTLL
to Divhtlon of Water puailty. Gmrtd..ater Sr=n within ':0 YS
0,4'' E
Cn•i p{v. 1_1" ,

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
2207'7a
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
LL CONTRACTOR CERTIFICATION #:-j
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery �] Heat Pump Water Injection] Other M If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: C %'1.Q.XO L 40— County: -
Q ; CA-6 t_Ye-g_& DEPTH
(Road Name an umbers,�CLommunity, or Subdivision and Lot No.) DRILLING LOG
3. OWNER 71h�`ilit�h�( From To Formation Description
Address
treet or outs o.
City or Town State Zip Code
4. DATE DRILLED Jd
5. TOTAL DEPTH 1 0
6. CUTTINGS COLLECTED YES ❑ NO
(CA-1
7. DOES WELL REPLACE EXISTING WELL? YES p NOZ c�
8. STATIC WATER LEVEL Below Top of Casing: �a I>_ FT. C —
(Use '+' if Above Top of Casing)
9. TOP OF CASING IS___J�� _ 77
_ FT. Above Land Surface- 5
'Top of casing terminated at/or below land surface requires a variance In accor-
dance with 15A NCAC 2C .0118 C .
10. YIELD (gpm): 'f METHOD OF TEST
11. WATER ZONES (depth): -- _
needed use backo �`9rm
12. CHLORINATION: Type Amount If additional space is ar;
13. CASING:
LOCATION- SKETCH
Wall Thickness
Depth Diameter_ or Weig t1F . Material (Show direction and distance from at least two State
From To -- Ft. —1'to_—iY'l— ' ( Roads, or other map reference points) i
From To Ft.�%
From To Ft.
14. GROUT: `
Depth Mated I Method
From To --��— Ft.
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft in. —in.—
From -
From To Ft. in. in. -
From To Ft, in. In. - U'
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 20, WELL
CONSTRUCTE0 T N�A T *-C- `-PY�" F THIS RECOgRD HAS BEEN PROVIDED TO THE WELL OWNER.
I I
�C ATE
FOR OFFICE US Y I NATURE OF PERS N CONSTRUCTING THE WELL DQuad No:;nt{�Division of Water Quality, Groundwater Section within 30 days
t_ , C) �._ GW-i REV. 12/99
Serial No.
As

North Carolina • Department of Environment and Natural Resources - Division of Water Ouality - Groundwater Section , 8�j , cc { C
1636 Mail Service Center - Raleigh, N.C. 27SW I 636-Phone [phone] N i `# 6 V
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CER'I'IPICATION 0: 1 6
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential Er Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: ' County:
Fy -KQ r �C
S j Ra►4 CiRc+►.I� — CouJraY �NC4paTt tAJ
(Road Name and Numbers, Community, or Subdivislo6 and Lot No.)
DRILLING LOG DEPTH
3. OWNER A L- +J
From To Formation Description ,
Address . U. eOX I L{ "50,
li a.7 ' Sc •7
(St—e oue o. �oyO� `�7 70�_ �r�'���i,
A C
Rpkv
�� /
City or Tdwn / Slate Zip Code
4. DATE DRILLED 3L
5. TOTAL DEPTH G .>
6. CUTTINGS COLLECTED YES E] NOD
7. DOES WELL REPLACE EXISTING WELL? YES NOEa
-.
8. STATIC WATER LEVEL Below Top of Casing: FT.
Q —
(Use '+• It Above Top of Casing)
%
9. TOP OF CASING IS FT. Above Land Surface'
'Top of casing terminated atior below land surface requires a varlsnce In accor-
dance with 15A NCAC 2C p11a
/
, �
Y
10. YIELD (gpm): METHOD OF TEST
11. WATER ZONES (depth):
12. CHLORINATION: Type —Amount a e'
It additional space Is needed uss back of 1r�t',`
13. CASING:
Wall Thickness
LOCATION SKETCH
Depth Diameter or Weight/Ft. M lariat
(Show direction and distance from at least two State
From To Ft. _ _ r 9- `f `
Roads, or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From 0To -�2 Ft. &I1
From Zv To �7 Ft.
15. SCREEN:
Depth Diameter Slot Slzb 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 CERT LAWA UCTED IN ACCORDANCE WITH 1I5A NCAC 2C, WELL
CONSTRUCTION S INA SAW �CleY IS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE O r^'' -, 0 r) a t, 9 C
Clued No: ��I,(� Si RE OF PERSON CO 1HUCTING THE WELL DATE
OCT
�)
Abrr�if o glnal t ton of Water Ouality, Groundwatir S/ciion within 30 day$
Serial No. OW-1 REV. 121"
Gmundwaltsr Section ,

18655
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: �`{� GED2C,,>=
WELL CONTRACTOR CERTIFICATION #:_
STATE WELL CONSTRUCTION PERMIT#:
WELL USE (Check Applicable Box): Residential Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery [:1 Heat Pump Water Injection 0 Other E] If Other, List Use:
2. WELL LOCATI
3. OWNER
Address
or
o1 the location below)
County:
or Su bdl islon and Lot No.) DRILLING LOG
From To
1b Sar
�9
Zip Code ' LA 3
4. DATE DRILLED 00
5. TOTAL DEPTH I'
6. CUTTINGS COLLECTED YES Q NO[Er
7. DOES WELL REPLACE EXISTING WELL? YES (—j NO[✓f
8. STATIC WATER LEVEL Below Top of Casing: �_ FT,
(Use's' If Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface*
'Top of casing terminated atfor below land surface requires a variance In accor-
dance with 15A NCAC 118
10. YIELD (gpm): MET QD OF TEST Q�
11. WATER ZONES (depth):
DEPTH
Formation ascription.
:� 1R,
12. CHLORINATION: Type Amount If additional space Is needed use back of form
13. CASING:
Wall Thickness LOCATION SKETCH
Depth glj�r or Wei nVFt ate I (Show direction and distance from at least two State
From To Ft. `-"'r Roads, or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth a4ted I Method
From To � Ft.
From To Ft.
15. SCREEN:
Depth
Diameter
From To
Ft In,
From To
Ft. in.
From To
Ft. In,
16. SAND/GRAVEL PACK:
Depth
Size
From To Ft.
From To Ft.
17.
a10
FOR Org(df U
Quad Not I
Slot Size . Material
In.
In.
In.
Material
FJTHI WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
NDARTA COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNE
lYSIGNATURE OF PERSON CONSTRUCTING THE WELL C
.. Su t original to Division of Water Quality, Groundwater Section within 30 days
Serial Not Asheville ite i+.,n l — GW1 REV. 12/"

North Carolina • Department of Environment and Natural FiesourcAs . Division of Water Quality - Groundwater Section 17896
1636 Mail Service Center - Raleigh, N.C. 27699-1638-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: /') i �k � % i i bLII II&A
WELL CONTRACTOR C15ATIPICATION 11: _ 25 (o ff
STATE WELL CONSTRUCTION 10MMfTA:
1. WELL USE (Check Applicable Box): Residentlai N( Municipal[] Industrial ❑ Agricultural ❑ Monitoring (�
Recovery [ 1 Heat Pump Water Injection [3 Other 0 If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below) jI
Nearest Town: � �f County: fKel2n
♦Z�
(Road NarM and Numbers. Community, or Subdivision d Lot No I
3. OWNER ZLLLE_ 1�D K
DRILLINQ LOG DEPTH
Address hh
From To Formation Description
r@@ Of O @ O.
City or To State Zip Code
4. DATE DRILLED - C� 0
5. TOTAL DEPTH ,
6. CUTTINGS COLLECTED YES 0 NO[3—
`^
7. DOES WELL REPLACE EXISTING WELL? YES M NOEj--
8. STATIC
WATER LEVEL Below Top Of Casing: -, pT,
Fg f
9. TOP OF CASING IS / (Use •+' a Above Top of Casing)
FT. Above Land Surface•
'"
•Top or casing terminated etfor below land surface require* a variance In accor.
dance with 15A NCAC 2C.011e
r?
10. YIELD (gpm); _V-_-_ METHOD OF TEST
_
11. WATER ZONES (depth): 2- Yo
12. CHLORINATION: Type Amount V� �
r Zj
__ _
13. CASING:
if additional space Is needed use beck Of form -�
Depth Ws)l Thickness
P Diameter or_We_ hvFl. Material
From L' To /On , FI.
_LOCATION SKETCH
(Show direction and distance from at least two Slate
__�2
From To Ft.
Roads, of other map reference points)
From —To— Ft.
14. GROUT:
Depth Material Method
From 0 To oZ ° Ft. -wr=>G
From 2-:-" To i D,a Ft. ' ,
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft in. in.
Fror11 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 hIEREBY,CERTIFY_THATTHIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARD1 t9 S, I'�ND,ETHAT A,COPY OF iIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE US,E,ONLY / l
_
Quad No: j p t� SI
lubmil �rlglrjal to
Serial No. !! a
'/i-(D
SON-WNSTRUCTING THE WELL
Quality, Groundwater Section within 30 days
DATE
OW-1 REV. 12/"

North Carolina • Department of Environment and Natural Resources - Division of Water Quality • Groundwater Section 1 7 8 9 5
1636 Mail Service Center • Raleigh, N.C. 27699-1836-phone [phone]
WELL CONSTRUCTION RECORD wELL CONTRACTOR: __1.- ] 1, (,CAe ( I 1"r,
WELL CONTRACTOR CERTIFICATION N:
STATE WELL CONSTRUCTION OthMITill:
1. WELL USE (Check Applicable Box): Residential M Municipal ❑ Industrial ❑ Agricultural d Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, Ust Use:
2. WELL LOCATION: (Show sketch of the location below) I'
Nearest Town: ✓ County: cl� 1p P-0
Ar�►l�s�RD`
(Road Name and Numbers. Community, or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER _ _ �P Q I CK PA n1e From To Fom>ellon Description
Address 7 q N+~ 7
n N ree or Houle o. -� C / J l ��/�} i
City or Town State �`� �� I
21p Code
4. DATE DRILLED l o�
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑ NO❑--
7. DOES WELL REPLACE EXISTING WELL? YES NO❑`
8. STATIC WATER LEVEL Below Top of Casing: pp • ,
(Use '+• fl Above To of Cuing)
r rt r-
9. TOP OF CASING IS / p �) ro `
FT. Above Land Surface' _----
'Top of casing terminated atlor below land Surface requires a variance In accor- c-n
dance with 15A NCAC 2C .�11e
10. YIELD (gpm): �> METHOD OF TEST
11. WATER ZONES (depth):
12. CHLORINATION: Type /,; �� Amount 0 S It additional space Is backf form
13. CASING: s neeuse o
-
Dep th Wall Thickness LOCATION SKETCH
To Ft. D meter hVF(. Material (Show direction and distance from at least two State
From - ( Roads, or other map reference points)
From To Ft
From To pt
14. GROUT:
Depth alerfa.)/ Method
From To .� Ft.
From _ To 6j V • Ft. 6'L '
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 SSA NCAC 2C, WELL
CONSTRUCTION STANDARDS;.AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USA 1r) / S -
sa
Ouad No: G j; SIONATUFIE OF PER NSTRUCTINO THE WELL
on Inil
Serial No. "� L 0,. to Division of Water Ouallty, Groundwater Section within 30 days
r.
R A�hnri9ita sRarq(3`1:�1 4' � "t
DATE
GW1 REV. 12/99

North Carolina - Department of Environment and Natural Resources • Division of Water Quality • Groundwater Section " 178 93
1636 Mail Service Center • Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELLCONTRACTOA- L=heQb _ep_ t'L)wl
WELL CONTRACtOR CSIitIPICATiON N:
STATE WELL CONSTRUCTION PI!AMtTN:
1. WELL USE (Check Applicable Box): Residential tT Municipal ❑ Industrial d Agricultural d Monitoring d
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
WELL LOCATION: (Show sketch of the location below) �/
Nearest Town: UFZiJi� �/ County: e3e
(Road Name and
3. OWNER
Subdivision and Lot No.) DRILLING LOG
M <t N14 From To
Address 3 1 I y
(Sifeet or Houle No.y \JC y ��
City or T State Zip Code 1L`J
4. DATE DRILLED
5. TOTAL DEPTH 2Q')
6. CUTTINGS COLLECTED YES(❑ NO❑-
7 DOES WELL REPLACE EXISTING WELL? YES NO
DEPTH
Formation Description
B. STATIC WATER LEVEL Below Top of Casing:, FT.Qr
(Use'+• N Above Top of Casing)-�
9. TOP OF CASING IS FT. Above Land Surface' rn
*Top of casing terminated at/or below land surface required a varlance In accor• r-r-,;
dance with 15A NCAC 2C pile NO --
10. YIELD (gpm): MOD OF TEST c-n = r
11. WATER ZONES (depth): -J-0
12. CHLORINATION: Type _ /--7 %/­/ Amount t
13. CASING:
Wall Thickness
Depth 01 or We t/Et. lertal
FromTo.�4ZFt. J C
From To Ft.
From To Ft.
14. GROUT:
Depth aterial Method
From �1_ To Do Ft.
From To Ft.
15. SCREEN:
It additional apace Is needed use back of form " c "
--4
0
LOCATION SKETCH
(Stow direction and distance from tit least two State
Roads, or other map reference points)
Depth Diameter Slot Slze Material
From To Ft In. In.
Front To Ft. in. In.
From To Ft. In. In.
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
17. REMARKS:
I
I DO HEREBY CERTIFY'-I[HAT THIS VYELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
C0NSTRUCTI0N,PT}1NOARD AND THXT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.10
;
FOR OFFICE USEION iY
Ouad No:� i �t,O jS�C(NATU OF E N CON CTINO THE WELL DATE
.— Submit oraglpal to on ofWater Ousilty, Oroundwater Section within 30 days 1
Serial No. 5, OW-1 REV. 12/9tl t

North Carolina • Department of Environment and Natural Resources - Division of Water Quality • Groundwater Section r�
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone] r 8 902
WELL CONSTRUCTION RECORD WELL CONTRACTOR: __CAeaoIee (�_ --11 f ;Vg
WELL CONTRACTOR CERTIFICATION p:(.,�
STATE WELL CONSTRUCTION PERMITO:
1. WELL USE (Check Applicable Box): Residential E Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ if Other, List Use:
2. WELL LOCATION: (Show sketch of the location below) j
Nearest Town:County: �/tN.tQoki`.2_
~TRW N�y-,u t ��/
(Road Name and Numbs �"C
r , ornr nity, or Subdlvlst n and t-ot No.)
3. OWNER _ RO IZ.v_R —f < (`('� (� R.S
DRILLING LOG DEPTH
Address 1_L—e-. � �
�rom To Formation Descrfpuon
�j fee or ou e
. J
hip(
)�— -
;
City or To" Stale Zip Code
4. DATE DRILLED
5. TOTAL DEPTH lry o)
6. CUTTINGS COLLECTED YES 0 NO❑- -
7. DOES WELL REPLACE EXISTING WELL? YES_0 NOES
8. STATIC WATER LEVEL Below Top of Casing:
2 FT,
(Use '+' H 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 2P'.0118
10. YIELD (gpm): METHOD OF TEST _� '!�
••
11. WATER ZONES (depth): r� ��
�;
Q
12. CHLORINATION: Type —1-1/7 // Amount `' •r - It additional space Is needed use back of form
13. CASING:
Wall Thickness _ LOCATION SKETCH
Deptt p glar�ter Of
WeI hvFt, tertal (Show direction and distance from at least two State
From ' �� To Ft. ; o Roads, or other map reference points)
From To Ft.
From To Fl.
1 A. GROUT:
�-�
Depth
Material Method
From
To �-L Ft.
/2 A
From ��
To . 6 R_ Fl.
-"
15. SCREEN:
Depth Diameter Slot Size
Material
From
To Ft
In.
In.
From
To Ft.
In.
in.
From
To Ft.
in.
In.
16. SAND/GRAVEL PACK:
Depth
Size
Material
From To Ft.
From To Ft.
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH i5A NCAC 2C, WELL
C0NSTRUCT10N SJTANDAD D (FtAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE'a 'VLY _
Quad No: 6 i '( 1
= s� Submit
Serial No. _
-- � + i'" ram^ \rJ it e` "� — S � �.5✓' fl o
GNATUAE OF PEASbN CONSTRUCTING THE WELL DATE
io Division of Wetter Ouallty, Groundwater Section within 30 day9
GW-1 REV. 121"

_0A
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section 217891
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTORt Che_4oI'A'_._ LJe,(I 1>�; ►lt�
WELL CONTINAC't'ON CeATIFICAtION N: --�
STATE WELL CONSTRUCTION PERMITM:
1. WELL USE (check Applicable sox): Flesldentlal Eg Municipal M Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, Ust Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: /71 urz4ky County: -- ea>' ke`
(Road Name and Numbers. Community, or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER i. uCl i. l E'_ VI S From To Formation Description
Address SWA.j /6
City or Tow��— Slate Zip Code-�•�-=---- -�� �'f /� ��pf
4. DATE DRILLED , -/ 5 - a ,��) %7 Gi3v c_ fr
5. TOTAL DEPTH/ .a . 7- /�-/�
6. CUTTINGS COLLECTED YES 0 NO❑— L3 /� /p
7. DOES WELL REPLACE EXISTING WELL? YES M NOED-
6. 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 cuing terminated et/or below land surface mqulrea a variance In accor-
dance with 15A NCAC 2Q 0115 ,
10. YIELD (gpm): Y O MET OD OF TEST _ L2
11. WATER ZONES (depth):
12. CHLORINATION: Type _ 7�/-/ Amount 6) E Z -3 If additlonal space Is needed use back of form
13. CASING:
Wall Thickness
LOCATION SKETCH
From L'
Depth
To '
Dipn►e�ter
FL
or Welght/Ft. terfal
r `f
(Show direction and distance from at least two State
Roads,
or other reap reference points)
From
To
FI.
From
To
Ft.
o
�-
14. GROUT:
cn
..
Depth
MateriaL< Method
From (-� To
From �'
Ft. �'
/ ,
cn
15. SCREEN:
To
Ft.
-
Depth Diameter Slot
Size Material
From
To Ft
In.
in.
--+
Front
To Ft,
in.
In.
o
_
From
To Ft.
In.
in.
16, SAND/GRAVEL PACK:
Depth
Size
Material
From
To
Ft.
From
To
Ft.
17. REMARKS:
I DO HEREBY C
FOR OFFICE
Quad No:
Sena] No.
THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
QARpS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
o
Y t �- �i �► t �j Sao O
Submit original
IATURE OF PERSON CONSTRUCTING THE WELL
Division of Water Quality, Groundwater Section within 30 days
DATE
OW-1 REV. 12/"
h� '

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section 7 17890
1636 Mail Service Center- Ralelgh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: � � k%ll . A4
WELL CONTRACTOR CERTIFICATION 0:. '1-6-- 3-
STATE WELL CONSTRUCTION PERMITM:
1. WELL USE (Check Applicable Sox): Residential e] Municipal ❑ Industrial d Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ It Other, List Use:.
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: M County: — k-
1►_
1%�PA Ce—C-Le-cl-1 /
(Road Name and N ers, Community, or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER _ IFAR L LebEip21) From To Formation Description
Address 6ye v9-e "i ABC e >, k PP_
f r o
A-i�h IE Streetool7le o. 8 `f o� 0
City or Town Stale Zip Code
4. DATE DRILLED 2
5. TOTAL DEPTH 'I �
6. CUTTINGS COLLECTED YES M NOC]J -
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO—
S. STATIC WATER LEVEL Below Top of Casing: 2fl Fr.
(Use '+' N Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface'
*Top of csslnd terminated sVor below land surface rsqulres a variance In accor-
dance with iSA NCAC 2C .0118
1 o. YIELD (gpm): /0 METHOD OF TEST A.'
11. WATER ZONES (depth): o %
12. CHLORINATION: Type AZ _ /2 Amount b ZS If additional epic* Is needed use back of form
13. CASING:
Wall Thickness LOCATION SKETCH
Depth Diameter or.w igr>,vFt. MA (Show direction and distance from at Iealt two State
From To �a Ft.—� O ��. Roads, or other map reference points)
From To Ft.
From To Ft.
14, GROUT:
Depthaterial Method s
From D Tom Ft. c/)
M c
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft In. In. ..:... M
From To Ft. In. in. �o
From To Ft. 1n. In.
r,
16. SAND/GRAVEL PACK: _
Depth Size Material
From To Ft.
From To Ft.
17, REMARKS:
I DO HEREBY CERTIFY THATTHISIWELL 1M1(AS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDAbSfANO TfA1 �1 C� �Y OF THIS RECORD HAS BEEN P VIDED TO THE WELL OWNER.
FOR OFFICE USEIONLY
Quad No: i l�) iI "' t NATUf1 * EFIWN NS Nt3 THE WELL DATE
t 4 1 s� ;
c t'' Sulxnll o tglnal o Divtslori of Water Witty, 0 *ter Sod6ri within 30 day$
Serial No. t L_ t) hh ow -I AEV. 121"
�ia,hwlii;�tialonsi ��rlce, r :.�"

A
North Carolina - Department of Environment and Natural Resources - Division of Vier Quality - Groundwater Section . • �j
1636 Mail Service Center - Raleigh, N.C. 27699-1636•Phone [phone] !. O Q
WELL CONSTRUCTION RECORD WELL CONTRACTOR-
WELL CONTRACTOR CEATIFICAtION 0:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential L J' Municipal ❑ Industrial d Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water In)ectlon ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
hy-y
Nearest Town: County:
Qj�o
-,3 oI of e4
(Road Na and Nu . Community, or Subdivision and o.)
DRILLING LOG DEPTH
�Lol
/�
3. OWNER M�C)Q i/ l9-. ( Ie-P,
From To Formation Description
Address �C)Q�5 ka ��(�— LAq Z
0' /0 ") '
0 v - re Ao teNo p
City or Town State Zip Code
4. DATE DRILLED
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑ NO['-
r
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO[� _
�
8. STATIC WATER LEVEL Below Top of Casing: �, a FT.
o
-,
--
(Use '+' If Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface -
'Top of casing terminated @Vor below land surface tequlrss a variance In accor-
dance with 15A NCAC 2C .Q118
10. YIELD (gpm): METHOD OF TEST
11. WATER ZONES (depth): % (0�-
•
_r
12. CHLORINATION: Type Amount
If additional space Is needed use back of form
13. CASING:
LOCA11014 SK_ETCN
Wall Thickness
Depth Diameter cr Welght/Fl. 4atedal
(Show direction and distance from At least two State
From `� To Z(72' Ft. -�+=1— ` 2 / rJ'' L
Roads, or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From o To Ft. ,"
From %-O To Z° Ft. �
15. SCREEN: `
Depth Diameter Slot Size Material
From To Ft in. in.
From To Ft. in. in.
From - To FL in. In.
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH i SA NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL
LOWNER.
FOR OFFICE USE ONLY -
Quad No: SIGNA E
Submit original to Division
Serial No.
OF P SbN-GTONSTRUCTING THE WELL
it star Quality, Groundwater Section within 30 day,
DATE
GW4 REV. 12("

North Carolina - Department of Environment and Natural Resources - Division of Water quality - Groundwater Section �; _� 8 3 O
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: p ke-il- yQ;
WELL CONTRACTOR CERTIFICATION M: a S 6 ��
STATE WELL CONSTRUCTION PERMITN:
1. WELL USE (Check Applicable Box): Reeldential0 Municipal C] Industrial d Agricultural ❑ Moniloring El
Recovery ❑ Heat Pump Water Injection[] Other 0 It Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: A UlaD J --- County: e1Q_0
n
/N N
(Road Name and Numb, Community, or Subdivision and Lot /� DRILLING LOG DEPTH
3. OWNER F b ' hl4 eej e � tadeA_04 LU /nFrom To Formation Description
Address 31 /✓ —1 L /l 1/ %
fee or ou a o.
M , o+�
City or Town Stale Zip Code
4. DATE DRILLED 26•nU
5. TOTAL DEPTH ,O ? o
6. CUTTINGS COLLECTED YES NO�
7. DOES WELL REPLACE EXISTING WELL? YES [] NOE:r
8. STATIC WATER LEVEL Below Top of Casing: FT.
(Use '*' li Above Top of Casing) t
9. TOP OF CASING IS FT. Above Land Surface- c.a
•Top of casing terminated Wor below land surface requires a variance In accor- _73 i
dance with 15A NCAC 2C .011a a—=_�—•-
10. YIELD (gpm): _ METHOD OF TEST �.
11. WATER ZONES (depth): ND G D
12. CHLORINATION: Type i ly Amount r� 6' if additional apace is needed use back of form
13. CASING:
Wall Thickness LOCATION SKETCH
Depth Diameter or ,W�eta�ht/,R.� kXSdall (Show direction and distance from at least two State
From To 1_/ FL - \ ht � J—= Roads, or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth aterl Method
From (9 To '19_ Ft.
From D D To // V FL
15. SCREEN:
Depth Diameter Slot Siz6 Material
From To Ft In. in.
Frol'n To Ft, in. In.
From To Ft. In. in.
16. SAND/GRAVEL PACK:
Depth
From To Ft.
From To Ft.
17. REMARKS:
Size Material
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 1SA NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY _
Quad No: ::�SIONA ateRSON CONSTOU THE WELL DATE
Submit original to s r Quality, 0muriAM& Sacoon within 30 days
Serial No. OW-1 REV. 12f"

t
North Carolina - Department of Environment And Natural Resources - Division of Water QualityGroundwater Section , 0
.
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: ae4okeo ��� -- DO,; A�g
WELL CONTRACTOR CERTIFICATION N: 6 ::r
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Resldent.! Municipal 0 Industrial ❑ Agricultural ❑ Monitoring El
Recovery ❑ Heat Pump Water Injection [J Other EJ 11 Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
: / II II
Nearest Town f
(Road Name and Numbers. Community, or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER (r9e(Z4c, &. 'YT-p RM+4^) From To Formation Description
Address .��I I A Y]Icl- QR1 ✓P (�
Se forFiOU16NO.
City or Town —State Zip Code
4. DATE DRILLED
.5. TOTAL DEPTH >
6. CUTTINGS COLLECTED YES NO[D'
7. DOES WELL REPLACE EXISTING WELL? YES NO_52=11--
8. STATIC WATER LEVEL Below Top of Casing: FT. _
(Use'+' N Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface* Ga
Ga
*Top of casing terminated aVor below land aurtace tequlres a variance In accor-
dance with 15A NCAC 2C.0118
10. YIELD (gpm): /L METHOD OF TEST ��% ✓� "� -
11. WATER ZONES (depth): .Z �Sv
12. CHLORINATION: Type A/ % Amounts' If additional apace Is needed use back of form
13. CASING:
Wan Thickness LOCATION SKETCH _ --
Depth ` Diameter or Welaht/Ft. Material (Show direction and distance from at (oast two Slate
Fromy To —1— Ft. _ii�_ �I L e ) ,, C _ Roads, or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Mat I Method
From 0 To Z Ft.�
From _J_o To z-H 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
From To Ft.
From To Ft.
17. REMARKS:
Size Material
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 1 sA NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Quad No:
Serial No.
SlOhAT61JOF PECONSTRUCTING THE WELL DATE
Submit origin to Division di W& Ousliry, Groundwllsr S406n within 30 days
OW-11 REV. 12/"

J(,
WOA
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section 324
1636 Mail Service Center - Raleigh, N.C. 27699.1636-10hone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACt0h:
WELL CONT111ACTOR OFIN ICATION N: SJ( A7_
STATE WELL CONSTAUC11ON p orrlli
1. WELL USE (Check Appllcable Box)- ResldentlalC Municipal ❑ industrial d Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, Ust Use:
2. WELL LOCATION: (Show sketch of the location below) ILA
Nearest Town: _ ^� County:
1/�.NA�2►� Sure s 2D
(Road Name and mbers, Community, or Subdivi Ion and Lot No.) DRILLING LOG
3. OWNER tCl Akrl s u12 From To
Address
'
�G
�`
(Street or Houle
S
City or own State ZIP Code
4. DATE DRILLED �z- Z V C, G now
5. TOTAL DEPTH Qj
6. CUTTINGS COLLECTED YES ❑ NO[]'•' —
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO❑-
8. STATIC WATER LEVEL Below Top of Casing: FT. —Ea-W.A M
(Use '+' N Above Top of Casing) © ;=a
9. TOP OF CASING IS FT. Above Land Surface'
*Top of casing terminated Wor below land surface requires a variance In actor-
dance with 15A NCAC 2C .011a
10. YIELD (gpm): METHOD OF TEST i' ' rI1 CIO
t
11. WATER ZONES (depth):
12. CHLORINATION: Type Amount ° ' II additional apace is needed use back of form
13. CASING:
I CICATION SKEtCH o
Wall Thickness -
Depth „.. Diameter or WelghVn. tfledal (Show diredlon and distance from at least two State
From L> To ,/ ) Ft. �"� < < I Roads, or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth :Material Method
From �• :MaterialTo a Ft. 7'U
From 20 To
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft In. in.
Frorh To Ft. in. In.
From To Ft. In. in.
16. SAND/GRAVEL PACK:
From
From
Depth Size
_ To Ft.
To Ft.
17. REMARKS:
Material
DEPTH
Formatlon Description
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
0
FOR OFFICE USE ONLY
Ouad No: SIGNA
Submit original to DI
Serial No.
SbN TRCO SNSN UCTING THE WELL
Cluawy, Groundwater Section within 30 days
DATE
OW-1 REV. 12t"

..f4
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section +'/ -
1636 Mail Service Center - Raleigh, N.C. 27699.163&Phone [phone] , 21. j 61
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION N: _ 'Z G 5
STATE WELL CONSTRUCTION PERMIT#:
I. WELL USE (Check Applicable Box): ResidenllAl Municipal [� Industrial d Agricultural Monitoring
EJ
Recovery El Heat Pump Water Injection Other If Other, List Use:
2. WELL LOCATION: (Show,sketch of the location below)
Nearest Town: County:
(Road Name and N moers, Community, or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER _L ,,yy,q AAA 2 eiL
Address S r2 �� OFrom To Formation Descr—iptiionn
ree ar ou a o. _ y,
City or Town State Zip Code `J �� l Lc�' f 7 7Ve/r.
4. DATE DRILLED '00
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES 0 NO[3-7. DOES WELL REPLACE EXISTING WELL? YES [---1 NO(�
8. STATIC WATER LEVEL Below Top of Casing: Fr
(Usb "+' N Above Top of Casing) `4' 2
9. TOP OF CASING IS / FT. Above Land Surface* ,-4
'Top or casing terminated avor below land surface requires a variance in accor- "
dance with 15A NCAC 2C 01IS ���
10. YIELD (gpm): �_ METHOD OF TEST i ,y_ c
11. WATER ZONES (depth):
• r�i
12. CHLORINATION: Type Amount • J "�- %
13. CASING: If additional apace Is needed use back oftm "
De th Wall Thickness _LOCATION SKETCH -
From
P 4? 0 ter or VYolghVFt. erfal (Show direction and distance from at least two State
To Ft. Roads, or other map reference points)
From To FL
From —TO Ff.
14. GROUT:
Depth , Material Method
From �% To 5pp`' Ft.
"Z lam, c ••
From ;J To r1 7 Ft
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft in. -in._
Froth To FL in. in.
From To Ft. In. In.
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft
From To - Ft.
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS; AND THAT A COPY OF THIS RECORD HkS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY0 - /') ..0 p
Quad No: ` EP 2 .0 2000 al A RE OF N CONSTAUC11Nt3 THE WELL DATE
Submit Original to DMSeriat No. Star Quality, Gmundw tw Section within 30 days ,
GW4 ITEV. t2M

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 CheckA Applicable Residentlal[ g
( pp ) Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: Shows etch of the location below)
Nearest Town: kvCounty: rJua kn to
(Road Name and Numbers. Community, or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER e9-401ZII� Ce1'll
From To Formation Description
Address S -UNIT Z
Tee or ou a o. Q �O
/nU4&Lj At� � - ��• i"� /9 �i' % .e
City or i own State Zip Code
4. DATE DRILLED
5. TOTAL DEPTH !h v )
6. CUTTINGS COLLECTED YES 0 NOED-
7. DOES WELL REPLACE EXISTING WELL? YES NO
8. STATIC WATER LEVEL Below Top of Casing: /❑— c
o ;�� FT. CDo
(Use `+' It Above Top of Casing)
9. TOP OF CASING IS /
FT. Above Land Surface*
*Top or casing terminated atlor below land surface requires a variance In accor-
dance with 15A NCAC 2C .0118
10. YIELD (gpm): / METHOD OF TEST
11. WATER ZONES (depth): 76 -
'
12. CHLORINATION: Type Amount ---12 If additional apace Is needed use back of fo6p 0
13. CASING:
Depth Wall Thickness LOCATION SKETCH
1 P DI meter or weight/Fl, Material (Show direction and distance from at least two State
From V To � Ft..�. �i L From Roads, or other map reference points)
- To Ft.
From To Ft.
14. GROUT:
Depth ,Material Method
From To 'A 0 Ft. L'
From � v To il::: 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 IS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY,
Ouad Na �+ �� � � `. SIONA E O 4rfSo
STAUCTINft3 THE WELL DATE
a7 (�_ 1t1
Surxrrr�b'rlolrj%txvislo ( atsr Quality, Groundwater Section within 30 days
Serial No.
GW-1 HEV. 12t"