Well Construction Records Cherokee 2 CY2000

North Carolina - Department of Environment and Natural Resources - Division of Water Quality • Groundwater Section ►'1 L+ O
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone] ! U
WELL CONSTRUCTION RECORD WELLCONTRACTOR: rL0,06e. (,deli DR;1l105
WELL CONTRACTOR CERTIFICATION It: - - G
STATE WELL CONSTRUCTION PERMITa:
1. WELL USE (Check Applicable Box): Residentlal 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: - - /YI u12 L)k.1 County: � 412o ke�Q
Gg,"P (- Ae_e K
(noad Name and Numbers. Community, or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER _ A91-P14 FC%�k From To Formation Description
Address ;�507
o�H,44�lw(A/N
Cc (Street oRouT No7�
<4= N 9
City _-
or Town Q Slate Zip Code
4. DATE DRILLED /- V- -�O
5. TOTAL DEPTH 2- L/') '
6. CUTTINGS COLLECTED YES F] NO[3— ^,
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NOE]:"
8. STATIC WATER LEVEL Below Top of Casing: d ' FT. -'
(Use '+' II Above Top of Casing) =1 7
9. TOP OF CASING IS FT. Above Land Surface- c,
*Top of casing terminated •Vor below land surface requires a variance In accor-
dance with 15A NCAC 2C 118 n r a
10. YIELD (gpm): METHOD OF TEST ,2 C
11. WATER ZONES (depth): 2 2��
� cn
12. CHLORINATION: Type _ l7"% Amount r ^S If additional space is needed use back of It?,
13. CASING:
Wall Thickness LOCATION SKETCH
Depth / s 1 ameter or W h M, d I (Show direction and distance from at least two State
Fromy To - Ft. � �5 Roads, or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From To ZO Ft.
From To _1,1 41 FL
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft In. in.
From To Ft. In. In.
From To Ft. In. In.
16. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To Ft.
17. REMARKS:
Material
I DO HEREBY CERTIFY THAT THIS jWELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDAn!)S; AND THAT`A COPY nTHIS RECORD
HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY . a_,r. I .� '
Ouad No: a i, ;; �t._8 f 1 8 JU a
Submit original to
Serial No. _.
-or-PtRSei`I CONSTRUCTING THE WELL DATE
of Water Ouality, Groundwater Section within 30 days
OW-1 REV. 12t99

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�k�v_
WELL CONSTRUCTION RECORD WELL CONTRACTOR:I ell
WELL CONTRACTOR CERTIFICATION #:a 614
STATE WELL CONSTRUCTION PERMIT#:
"'A t„ 6 J
1. WELL USE. (Check Applicable sox): 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: 1)10A1 bA(_ t_1 County:C'-
Q-Q
u
(Road Name and Numbers, or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER /l LS �JAQSyq S/N J T/ From To Formation Description
Address jAe'lkPb 2 S C 7 �7
h i
/�,� (Street or ( o.)
1 rlf[141a% N� 9�G�
City or 7own f State Zip Code
4. DATE DRILLED % ` / O D
_
5. TOTAL DEPTH _Yo
6. CUTTINGS COLLECTED YES[] NO[]'
7. DOES WELL REPLACE EXISTING WELL? YES [� NO[D'
8. STATIC WATER LEVEL Below Top of Casing: �0 FT. p
c:
9. TOP OF CASING IS (Use •+• If Above Top of Casing)
FT. Above Land Surface -
,
'Top of casing terminated at/or below land surface requires a variance In accor-
dance with 15A NCAC 2 .011e
10. YIELD (gpm): i METHOD OF TEST
11. WATER ZONES (depth): _2L C
12. CHLORINATION: Type ' Amount If additional space Is needed use back of loco*
a
13. CASING: Q
Wail Thickness LOCATION SKETCH
DToth DI
mr ter or WelflnvFll. eriG (Show direction and distance from at least two State
From O
��
Ft. ' Roads, or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Dept
1 L7
�_
Material Method
From
To
Ft.
From
TL To
-� 7
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 AN "TF�CC TC C pY:QF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE OJN_ dtQuad No: n , SI - P S CONSTRUCTING THE WELL DATE
SEP I Rutxpt �lpinaU to bivlslo Wat ualtly, groundwater Section within 30 days
Serial No. `
OW-1 REV. 12199

North Carolina • Department of Environment and Natural Resources - Division of Water Quality •Groundwater Section 2 3 61 ) 3
1636 Mail Service Center - Raleigh, N.C. 27699.1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: :�►^t;�s; �� e�( �''��''^C'
WELL CONTRACTOR CERTIFICATION 0:
STATE WELL CONSTRUCTION PERMITH:
1. WELL USE (check Applicable dox): Residentially,"
esidential l Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Flecovery ❑ Heat Pump Water Injection ❑ Other[] If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: u f D�1� County:
al ai /: �g�sGe a�� DEPTH
(Road Name and Numbers. Community, or Subdivision and Lot No.) DRILLING LOG
3. OWNER From To Forms5en Des:APU-
Address
Streetoule �Ir % ,9�
City or o Slate Zip Code
4. DATE DRILLED
5. TOTAL DEPTH �S r
6. CUTTINGS COLLECTED YFS [] NO�
7. DOES WELL REPLACE EXISTING WELL? YES [� NOB
8. STATIC WATER LEVEL Below Top of Casing: 22 , FT.
(Use '+' If Above Top of Casing)
9. TOP OF CASING IS___J _ FT. Above Land Surface*
`Top of casing terminated at/or below land surface requlres a variance In accor-
dance with 15A NCAC 2C .0118 ,,//J�
10. YIELD (gpm): 30 _ METHOD OF TEST Aze
11. WATER ZONES (depth):
12. CHLORINATION: Type,kM f10'b1 ydX Amount S If additional space is needed lse back of fc,4m
13. CASING:
LOCATION SK=TCH
Wall Thickness
Depth Diameter or Weighl/Ft. Material (Show direction and d s�ance trcm leas iHo 5'-ale
From
_0_To -�7'- Ft•-�a,a-L - — -jP9'C-- " Roads. or other rrrGp refere:cx-v points!
From To Fl.
From To Ft.
14. GROUT:
Depth Material Method
From 0 To D a FI. ----
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material m
� o
From To Ft In. In.
From To Ft. In. In. -- Cn
From To Ft. In. in.. f
16. SAND/GRAVEL PACK:
Depth Size Material �
From To Ft. — w
� o
From To Ft. —
17. REMARKS:
I DO HEREBY CERTIFY AT:THI�S WELL WAS CONSTRUCTED IN ACCORDRICE WITH 15A DJCAC 2 r. ,trELL
CONSTRUCT
EQ TAIJD C , I�NCJi,THA`f A � COPY OF THIS RECORD HAS BEEN PROVIDED -TO Twsu a%I'FF•
FOR OFFICE 11S `dN
;��0�� SIGNATURE OF PERSON CONSTRUCTING 1rc' '/v ELL
Ouad No: a
"I Subrrl(i original to Divlston of Water. puality, GrounO.waler Srccn within :ri C�Srys
Serial No. ' - [� � tK•1 Fci;V. 1.lri

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section 2 3 `) l 14 ( 6
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone] r
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION H: o24(0 i/
STATE WELL CONSTRUCTION PERMITH:
1. WELL USE (check Applicable Box): Residential [P­�- Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other [] If Other, List Use:
Agricultural ❑ Moniloring ❑
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: h County: Ckeca e P
(Road Name and Numbers. Community. or Subf ' ision and Lot No.) DRILLING LOG DEPTH
3. OWNER L�rn �.�e dGn kae From To Forrra�cn.Descriptfo,
Address
-� TSIr e or Houle o
R►'di
City or Town State Zip Code
4. DATE DRILLED
5. TOTALDEPTH Y I L9 '
6. CUTTINGS COLLECTED YFS ❑ NO[0-
7. DOES WELL REPLACE EXISTING WELL? YES [] NOP
8. STATIC WATER LEVEL Below Top of Casing: .O r FT.
(Use '+' If Above Top of Casing)
9. TOP OF CASING IS ! FT. Above Land Surface -
'Top of casing terminated at/or below land surface requires a variance In accor-
dance with 15A NCAC 2C .0118
10. YIELD (gpm): ?_ METHOD OF TESTA'At'
11. WATER ZONES (depth):
12. CHLORINATION:
13. CASING:
Type V�__Amount If additional space is needed U-S-e back of rc
Wall Thickness
Depth
Diameter or Weight/Ft. Material
Fromt--To r 7 Ft. 4�- °z
From
To
Ft.
From
To
Ft•
14. GROUT:
Depth
Material Method
From t*;>— To ZO
Ft.
From
To
Ft.
15. SCREEN:
Depth
Diameter Slot Size Material
From
To
Ft
In. In.
From
To
Ft.
In. In.
From
To
Ft.
in. In.
16. SAND/GRAVEL PACK:.
Depth
Size Material
From
To
Ft.
From
To
Ft.
17. REMARKS:
1 DO HEREBY
CONSTRUCTI
FOR OFFICE USE ONLY
Quad No: 1
LOCATION SK= iCH
(Stow direction and dis~ance Irxn aI leasrmos:tale
Roads, or other rrrGp refererce points`
t7
i
Lamc
G�
i
rn
U�
t;A
•, ,YE� WAS CONSTRUCTED IN ACCORDMICE WITH t5A ltJCAC 2C, Y✓ELL
4�`T 1AT A COPY OF THIS RECORD HAS BEEPI PROVIDED ?O THE V/StL Ot%"EF.
SubrnI
Serial No. —
o.'
c-
�SI'ONATURE OF PERSON CON STRLI :TING IXE ov £LL
,al Io DivItIon of Water t3ualhy. Groundw4ter Sracn within V.) - ys
. tK.i pigV. 1211

North Carolina • Department of Environment and Natural Resources - Division of Water Quality • Groundwater Section J
1636 Mail Service Center • Raleigh, N.C. 27699.1636-Phone [phone]
WELL CONSTRUCTION RECORD WELLCONTRACTOR: 1�'Li .fall r;llt,�� _
WELL CONTRACTOR CERTIFICATION N: 24e
STATE WELL CONSTRUCTION PERMITN:
1. WELL USE (Check Applicable Box): Residential Ly' 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: County: Lk
Gy - t-)
(Road Name ,and Numbers, Communi%t� Subdi Ision and Lot No.)
or
3. OWNER f:�A.,��'G fl; /nc.-,`�k
Address 6a j ep 0 l.J
Creel or Route o.
City or own state Zip Code
4. DATE DRILLED 'a
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑ NORJ-
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NOQ'
B. STATIC WATER LEVEL Below Top of Casing: UO , FT.
(Use '+' it Above Top of Casino(
9. TOP OF CASING IS__it'____ 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): �_ METHOD OF TEST !���
11. WATER ZONES (depth):
DRILLING LOG
From To
DEPTH
Forrraxn Desuiptio'
12. CHLORINATION: Type b t Amount S, It additional space is needed Lse back of fcrm
13. CASING:
Wall Thickness
Depth Diameter or Welght/Ft. Ma Vidal
From --To _� Ft. 6. S— — j
From To �i(S' Ft. 4 •10 , /8:?-1-
From To Ft.
14. GROUT:
Depth ateriall Method
From �_ To ^iD r Ft. .nu
From To —Ft.
15. SCREEN:
Depth Diameter Slot Size
From To Ft In.
From To Ft. in.
From To Ft. In.
16. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To Ft. —
17. REMARKS: _
Material
In.
In, _ In.
Material
LOCATION SK=TCI;
(Show direction and drr--ance hvn 91 leas: 'r'0 -`:t le
Roads, or other n-.-�--P releterce points!
'tm
C
G')
I
to
CO
W
W
0
m
I DO HEREBY CERTIFY THAT l HIS WELL WAS, CONSTRUCTED IN ACCORDANCE WITH tSti 04CAC 2r.'t✓ELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVICED 'TO TH` «St�L 0%%"Ep-
FOR OFFICE USE ONL. os'E
Ouad No: !SIGNATURE OF PERSON CDNSTRIY:TING 1 'N ELL
gu 1 original to bivlalon of Water Ouality, Ground•�ilar Sp=n within V3 C�Ys Ca l pig V. 121"
ark;:,
Serial No.

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section 2 3 6 1. `t 4
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: M J) r (,-)e11 dr;11�,��,
WELL CONTRACTOR CERTIFICATION
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): ResidenUal E[- Municipal ❑ Industrial ❑ Agricultural 0 Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATI N: (Show sketch of the location below)
Nearest Town: La 15 County: Po .rA P P
tn1 +hck 6 t,_�r.�
Road Name and umbers, Communit , or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER c p_ i From To Forma5cn Description
Address P. O. �n — 5 ' /a
— tbireet o ou e ��
a n �e y1 h1. e
Cit or Town State Zip Code
4. DATE DRILLED ?- J c6 'O t*�
5. TOTAL DEPTH I !j� 3 '
6. CUTTINGS COLLECTED YFS ❑ NOE3--
7. DOES WELL REPLACE EXISTING WELL? YES F_J NO[D—
B. STATIC WATER LEVEL Below Top of Casing: FT.
(Use '+' it Above Top of Casing)
9. TOP OF CASING IS�_ FT. Above Land Surface-
-Top or casing terminated st/or below land surface requires a variance In accor.
dance with 15A NCAC 2C .0118
10. YIELD (gpm): 36 METHOD OF TEST 44�'/1
11. WATER ZONES (depth):
12. CHLORINATION: Type kf1i - aWehi Amount Q If additional space is needed ts-- ba& of fcrm
13. CASING:
Wall Thickness
LOCATION SK=TCH
Depth Diameter or WeighVFI. Material
(Slow direction and dunce from aI leas::rro Stele
From To 17 �ri Ft. 6­24r* SOrj ! �_
Roads, or other rr� : � p relereoint!
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From _ 0 To 20' Ft.
o
ZEE
From To Ft.
"—
t>
15. SCREEN:
L~
Depth Diameter Slot Size Material
`:_
From To Ft in. in.
f
Cn
t.
From To Ft. in. In.
"
From To Ft. In. In.
`&'r
r
16, SAND/GRAVEL PACK:
M
Depth Size Material
From To Ft.
z
From To Ft.
17. REMARKS:
I DO HEREBY CERTIFY IATaTI�(S WELI,' WAS CONSTRUCTED IN ACCORDANCE WITH 1 SA rdCAC 2r,'/✓ELL
CONSTRUCTIONiSMANDARDS, ND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED 70 THE YI=�L O►�NJE
FOR OFFICE USEiONLY ' i ( :�i1' YAozen
Quad No: i b SIGNATURE OF PERSON CONSTRUCTING IXE YYELL
Submit original to Division of Water Ovelily, Groundwater Srmcn within Yi C%�ys
Serial No. 1' >I ttt)° ° ' CK,I pis V. 12Y1

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section 0 3 61.4 31636 Mail Service Center - Raleigh, N.C. 27699.1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: _i(1'); Iles L 1I)P 11 c�r► I1: �G
WELL CONTRACTOR CERTIFICATION #: ayo y
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): ResidentialI� Municipal ❑ Industrial ❑ Agricultural ❑ Monitorirg ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below) n
Nearest Town:u r P w County:
129 o✓i 4
(Road NameNd Numbers,Cpmmunity, or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER L�y,'��C�/'(Y j�,�[ �/1 From To Forrraxn Descriptio-
Address —AZT
ireet or Floule o.
City or Town State Zip Code 1t���—��l�i—r---
4. DATE DRILLED -DD
5. TOTAL DEPTH 83
6. CUTTINGS COLLECTED YFS ❑ NO[L}-
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO[e—
B. STATIC WATER LEVEL Below Top of Casing: FT.
(Use '+' If Above Top of Casing)
9. TOP OF CASING ISM_ FT. Above Land Surface -
'Top of casing terminated aVor below land surface requires a variance In accor-
dance with 15A NCAC 2C .01 8
10. YIELD (gpm): METHOD OF TEST ,4;R
11. WATER ZONES (depth):
�O'
12. CHLORINATION: Type ht%Z64&CAE Amount 4j_ If additional space is needed ts-e back of fc-m
13. CASING:
Wall Thickness
Depth Diameter or We;ght/Ft. Material
From.To 112 ' Ft.
From To Fl.
From To Ft.
14. GROUT:
Depth M terial. Method
From _ 0 To �B t Ft. r an _Qr1:4
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:
DO HEREBY CERTIFY, THAT'
CONSTRUCTION S7AtI AF1,bE
FOR OFFICE USE ONLY
Quad No:
Serial No.
Material
LOCATION SKETCH
(Show direction and distance trcm --I leas! 'No Sale
Roads, or other rrr-,p refere:,ry points;
;WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A F4CAC 2r.1feELL
ID TNATiA/CQPY OF THIS RECORD HAS BEEN PROVIDED -TO THE: Y/c".t. OWIEF..
SIGNATURE OF PERSON CONSTFIU STING "ELL
Subrnll original to Drvltdon of Water Duality, Groundwater Sracn within N.) C%f'ys
Gaa ptE V. 1291 .

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section 23613
1636 Mail Service Center - Raleigh, N.C. 27699-1636•Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: MJ1 er' (-A_)e,11 -'r QA
WELL CONTRACTOR CERTIFICATION N: a2(10!V
STATE WELL CONSTRUCTION PERMITP:
1. WELL USE (check Applicable sox): Residential Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
1=tecovery ❑ Heat Pump Water Injection ❑ Other If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: County: c_!"D E e_
(Road Name and Numbers. Community, or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER 1/an r e �P�rr`�� From To Foma5on Description
f
Address �� �� 741 f l2 lQ
(Street or Hout C b
City or wn tale Zip Code fi r a�s
4. DATE DRILLED 1 '0-1-00
5. TOTAL DEPTH SOS r
6. CUTTINGS COLLECTED YFS [] NO D-
7. DOES WELL REPLACE EXISTING WELL? YES [] NO[J-
6. STATIC WATER LEVEL Below Top of Casing: &p FT.
(Use '+' if Above Top of Casing)
9. TOP OF CASING ISM_ FT. Above Land Surface -
'Top of casing terminated at/or below land surface requires a variance in accor-
dance with 15A NCAC 2C .0118
10. YIELD (gpm): �_ METHOD OF TEST ;l?
11. WATER ZONES (depth):
12. CHLORINATION: Type & Amount II additional space is needed ls-e baci of form
13. CASING:
Wall Thickness
Depth Diameter or�W�ei�h..t/,F,l. Ma_ lariat
From Lo To T� Ft. 6�st
From To Ft.
From To Ft.
14. GROUT:
Depth Ma vial Method
From _Q_ _ To Ft. 44
From To Ft.
15. SCREEN:
Depth
From
To
From
To
From
To
16. SAND/GRAVEL PACK:
Depth
From
To _
From
To^
17. REMARKS:
I DO HEREBY
FOR OFFICE USP`ONL'
Quad No:
Diameter Slot Size Material
Ft In. In.
Ft. in. In.
Ft. In. In.
Size
Ft.
Ft.
Material
LOCATION SK= fCH
(Show direction and d'es~ance frrm 81 leas: ;No Stele
Roads, or other rrep refermocAe point!
W
a�
G7
1
m
s
CA
w
AS CONSTRUCTED IN ACCORDANCE WITH 15A f4CAC ?'..'.'/✓'ELL
1 COPY OF THIS RECORD HAS BEEN PROVICED 'TO TH: VIS!.L 0%%,EP.
X� - I -O - -
Subn ll
Serial No, '
SIGNATURE OF PERSON CONSTRLY-TING 1IZ WELL
al to DiAslon of Water Quality. Groundwater Srun within 1.0 C%�ys
Ca.l PJ9 V. 12"

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section ej , �`• 8
1636 Mail Service Center - Raleigh, N.C. 27699.1636-Phone [phone]
WELL CONSTRUCTION RECORD WELLCONTRACTOR: r��,�. -�I 6c"I1��
WELL CONTRACTOR CERTIFICATION 0:-�25���{
STATE WELL CONSTRUCTION PERMITN:
1. WELL USE (Check Applicable Box): Residential ER"' Municipal ❑ Industrial ❑
Aecovery ❑ Heat Pump Water Injection ❑ Other [] If Other, List Use:
Agricultural ❑ Monitoring ❑
2. WELL LOCATION: (Show sketch of the location below) 1 '/
Nearest Town: M l✓ %1 �� County:
�'an_ro r P jj-r- l.:11 lac_ r tid
(Aofid Name and Numbers, Community, or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER Div,4 L,1nC.ti 4- (:RkmGS eQnA From To 77 Forrra5cnDes:riptiw
Address el_ 4� © In_t.4i'r-s
S beet or Houle No.) ` �D — 4110 � - /G
City or o 4 Stale Zip Code
4. DATE DRILLED
5. TOTAL DEPTH 426
6, CUTTINGS COLLECTED YFS ❑ N0�4�'`
7. DOES WELL REPLACE EXISTING WELL? YES F-1 NOPq
B. STATIC WATER LEVEL Below Top of Casing: al) ' FT.
(Use '+' it Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface-
-Top of casing terminated at/or below land surface requires a variance In accor-
dance with 15A NCAC 2C.0118
10. YIELD (gpm): ,249 METHOD OF TEST k;e
11. WATER ZONES (depth):
12. CHLORINATION: Type h�4:/Vr_k' Amount 4_ If additional spare is needed ts-e baci of farm
13. CASING:
Wall Thickness LOCATION SK= TCH
Depth r Diameter or Welght/Ft. Material (Stow direction and d'rswl nce trrrr -:I leas: cNo Smote
FromTo_ Ft. 6 A�e Roads, or other rr� relere:rx- point
From To Ft. .
From - To Ft.
14. GROUT:
Depth Material Method
From _fZ. To -� Ft.
From To Ft.
15. SCREEN:
Depth
Diameter
From To
Ft In.
From To
Ft. In.
From To
Ft. In.
16. SAND/GRAVEL PACK:
Depth
Size
From To Ft.
From To Ft.
17. REMARKS:
Slot Size Material
In.
In.
In.
Material
1
m
C]D
r:4
DO HEREBY CERY'1rY TH` fi �HISMELL AS�CONSTRUCTED IN ACCORMICE WITH 15A 04CAC Y:,'. Y✓ELL
CONSTRUCTION STAt�©AR S AN6 THAIA.COPY OF THIS RECORD HAS BEEN PROVICEO 70 TH5 Y!'c" L Oti%NEF.•
FOR OFFICE USE ONLY "All
Quad No:
Submit ortpli
Serial No, it
IGNATURE OF PERSON CONSTRIYrTING 1X9 'rv'ELL
to DMttlon of Water Malily, Groundwater Sr=n within n C%fYS
Do.� E
tn.1 Fsi; V. 1271

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section v 1 ,� 5
1636 Mail Service Center- Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: m; liP_r 1A_LP 11 rl�. NIA
WELL CONTRACTOR CERTIFICATION P: _2qoc r
STATE WELL CONSTRUCTION PERMITH:
1. WELL USE (check Applicable Box): Residential [Z]�- Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
f'lecovery ❑ Heal Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below) V
Nearest Town: LAC* k e County: � r 0 1� p P -
-�t1 � S � Gerdu Qct'w R.
( ad Name and Numbers, Community, or Subdivision and Lot No.) DRILLING LOG DEPTH
_
3. OWNER _ From To /F�orrrna5cn DescAp6o:
_+ �� r D - �o �
Address 2 0
Ire t or outs o. n
�6 iAD Ir_Ad6
City 0 Tow6 Slate Zip Code —
4. DATE DRILLED -1010
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YFS F_J NO[Z;�—
7. DOES WELL REPLACE EXISTING WELL? YES M NO 1��--
S. STATIC WATER LEVEL Below Top of Casing: ge) 1 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 It variance In accor-
dance with 15A NCAC 2C .0118
10. YIELD (gpm): _ METHOD OF TEST.1 t2
11. WATER ZONES (depth):
12. CHLORINATION: Type Amount _4 _ If additional space is needed L--%-- baci of fcrm
13. CASING:
Depth Diameter
From —To 410 Ft. -6,�
From To Ft.
From To Ft.
14. GROUT:
LOCATION SK=TCH
Wail Thickness
or Wetght/Ft. Material (Show direction and dunce trm al leas:'Ho Slate
a l g1(G_ Roads, or other rr-r� relert:cr-- points!
Depth M trial Method
From To Ft.
From - To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft In. in.
From To Ft. In. in.
From To Ft. In. In.
16. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To Ft.
17. REMARKS:
Material
c�
1
CJl
x�
co
to
100 HEREBY CERTIFY THAT THIS WELL. WAS CONSTRUCTED IN ACCORDANCE WITH 15A 04CAC ?C. IoWELL
CONSTRUCTION STANDARDS, AND, THAT A C PY OF THIS RECORD HAS 6EEf t PROVIDED 'TO THEWSe-t- O%% %F-P-
FOR OFFICE USE ONLY
Quad No: ��� a i,, r SIGNATURE OF PERSON CONSTRIY.TING DIE VVELL 0�''E
$ubrrilt original to Division of Water Cluaitty. Ground4rator S =within v.) Gs ys
Serial No, Gn.i GtEV, L`91
iily I! it Fpj?

���i8650
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: 0 (QxkS
WELL CONTRACTOR CERTIFICATION
STATE WELL CONSTRUCTION PERMIT#:
I. WELL USE (Check Applicable Box): Residential L.1 Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection 0 Other M If Other, List Use:
a04 .
2. WELL LOCATIO o ! of he location below)
Near@st Town: County:
• •��� ..u...� . � nvmunrs, vemmunlry, of sutw(vision and Lot No.) DRILLING LOG DEPTH
3. OWNER From To
Address �\ Fo lion Description
n ae ,
ree or u e o,
City or Town Stale Zip Code
4. DATE DRILLED 0
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES 0 NO�
7. DOES WELL REPLACE EXISTING WELL? YES (—j NOE!f
B. STATIC WATER LEVEL Below Top of Casing: �M 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 .0 18
10. YIELD (gpm): METHOD qF TEST
11. WATER ZONES (depth):
12. CHLORINATION: Type Amount If additional space Is needed use back of form
13. CASING:
Depth
d
0 nns1111
�`/`���
Wall Thickness
r Wei ht/Ft.
7
From To
Ft.
�"v�
From To
Ft.
From To
Ft.
14. GROUT:
Depth
0 �
at, d Method
Qo_i:a
From To
Ft.
Pb_r�k
From To
Ft.
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. REMARKSII"'m""" Z-:z ..Y
_
•.- w --..m
®.�
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
I DO HERE TIFY THAT THIS � ONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRU I STANDARDS,_ AND THA PY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL O
I
FOR OFFIC S ONLY
Quad No: SIGNATURE OF PERSON CONSTRUCTING THE WELL
Qm
ndrr tdt $OCfIOf�ubmll or1 nal to Division of Water Quality, Groundwater Section within 30 days
Serial No. fi OIII 1()ffI
GW-1 REV. 12/99
C:7)
U3
.o

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: C`(�-y.S Q- )a 4E ��
WELL CONTRACTOR CERTIFICATION #: o�q
STATE WELL CONSTRUCTION PERMIT#;
1. WELL USE (Check Applicable Box): Residential 1EI, Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery [] Heat Pump Water Injection [] Other (] If Other, List Use:
2. WELL LOCA I (Abowskelhof the location below)
Nearest To `:�-vv County:
(Road Name 4nd Numbers, Comm nl r S Ivlsion nd Lol No.) DRILLING LOG
3. OWNER From To
Address
Fee or o e
City or Town State 21p Code 9o, kq 2 �
4. DATE DRILLED CU
5. TOTAL DEPTH l
6. CUTTINGS COLLECTED YES [] NO[ -
7, DOES WELL REPLACE EXISTING WELL? YES (D NOrV
8. STATIC WATER LEVEL Below Top of Casing: � _ FT
(Use '+' If Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface -
*Top of casing terminated atfor below land surface requires a variance In accor-
dance with 15A NCAC 2C . is
10. YIELD (gpm): METHOD OF TEST a
11. WATER ZONES (depth):�bt
DEPTH
Form tion Description
12. CHLORINATION: Type Amount If additional space is needed use back of form
13. CASING:
Depth
Wall Thickness
LOCATION SKETCH
r�-�
FromTo —
�DI� er o Wel ht/Ft. atedal
Ft. -`
(Show direction and distance from at least two State
From To
Ft.
Roads, or other map reference polnts)
From To
Ft.
14. GROUT:
Depth
M t vial Method
From To
Ft.
CD
From To
_
Ft.
o
©
ca
15. SCREEN:
Depth Diameter Slot Size Material
I
From To Ft
in. in.
t�
From To Ft.
In. In.
From To Ft.
in. In.
r ;
16. SAND/GRAVEL PACK:
Depth
Size Material
�+
From To
Ft.
o
c�
�
From To
Ft.
17. REMARK ,.®, rn _n ra
n nn �17......l:;;;�.I
IO HER � RTANTH�T NN)
CON STAN q D N
FOR OFFICE U ONLY
Quad No:
CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
JPY OF THIS RECORD/ HAS BEEN PROVIDED TO THE WELL OWNER.
-, �C
JKiNA r UHt Ut- rtHSUN cvns r HUc nNG THE WELL - DATE
final to Division of Water Quality, Groundwater Section within 30 days
GW-1 REV. 12199
Serial No.

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section �_ (O 11 (�
Center - Raleigh, N.C.
1636 MailService
CONSTRUCTION RECORD WELL CONTRACTOR: n by�� /
WELLO �IQl�o� ��II J�Ril/1v9
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMIT#:
1, WELL USE (Check Applicable Box): Residential Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below) n/
Nearest Town: utLnl County: ` ►� ���
1 ! -7O Ale)c ,ss i N CA _ee
(Road Name and Numbers, Community, or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER 't7 . t ON From To Formation Description
Address 11-y1 )'44G PIS 0 -" 6 /
(Street or Houle 2 27 1—L�
Msse, a PI` 3-2707
City or Town State Zip Code
4. DATE DRILLED 7" 3 j -00
5. TOTAL DEPTH �12_7—
6. CUTTINGS COLLECTED YES ❑ NO[F( o
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO� ea
8. STATIC WATER LEVEL Below Top of Casing: In FT.
(Use '+' if Above Top of Casing) I ---
9. TOP OF CASING IS FT. Above Land Surface' �► =^rr;
*Top of casing terminated atfor below land surface requires a variance In accor- fir,
dance with 15A NCAC 2C .0118
10. YIELD (gpm): qfZ METHOD OF TEST
11. WATER ZONES (depth):
rn �
12. CHLORINATION: Type 1--I TH Amount C N If additional space is needed use back of form
13. CASING:
Wall Thickness LOCATION SKETCH
Depth Diameter or WeighvFt. Material (Show direction and distance from at least two State
From 0 To 3 Ft. , Q a t � Roads, or other map reference points)
From 3 — To f 7 FL " L_
From To Ft.
14. GROUT:
Depth Material Method
From © To — Ft. Sta,"&JT
From _ALL To J1 Z Ft. _!qA1WJ 7
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 TH RECORD HAS N PROVIDED TO THE WELL OWNER.
`'
FOR OFFICE {USE ONLY
Quad No f SI RE OF S ONSTRUCTING THE WELL DATE
,, i (� y Submit original to Division of Ater Ouality, Groundwater Section within 30 days
Serial No. GW-1 REV. 12/99

North Carolina - Department of Environment and Natural Resources - Division of Water Quality • Groundwater Section / 0 Q 9
1636 Mail Service Center - Ralelgh, N.C. 27699-1636-Phone' [phone]
WELL CONSTRUCTION RECORD WELLCONTRACTOR: nAea, �ee We/I
WELL CONTRACTOR CERTIFICATION #: -,),-S'G s�
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: County:
}� /%/L -!SorJ 21pG C
(Road Name And Nu ors, Co unity, or Subdivision and Lot No.)
DRILLING LOG DEPTH
3. OWNER X r !FlnkD '17114k
From To Formation Description
Address cowri e Give lib
Q / 'D 9
Cit or Town �! S(ate Zip Code
4. DATE DRILLED J J
5. TOTAL DEPTH be
6. CUTTINGS COLLECTED YES NO[3'
—�
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO1:1r
8. STATIC WATER LEVEL Below Top of Casing: FT.
m r
(Use '+' It Above Top of Casing)
ry 4 r• ;
9. TOP OF CASING IS FT. Above Land Surface-
crI
•Top of casing terminated attor below land surface requlret a variance In accor-
dance with 15A NCAC 2C .0118
10. YIELD '-Z ° METHOD OF TEST
(gpm):
11. WATER ZONES (depth): 's S i -
12. CHLORINATION: Type Amount a ��
c�
It additional space is needed use back of form
13. CASING:
Wail Thickness
LOCATION SKETCH
Depth 9�larp�eter or W I hhlffl terfal
U `
(Show direction and distance from at least two Slate
From To 3 Ft. SL—� `� 1�1 `'
Roads, or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Matqr!o Method
From To `a 0 Ft.
From _2_ To % 3' Ft. 1
15. SCREEN:
Depth Diameter Slot Slze Material
From To Fl In. in.
From To Ft. in. in.
From To Ft. In. In.
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
17. REMARKS:
IDO 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.
' is Et 1i! I' ( 1 ._ �1 ."]` �U • `7J
FOR OFFICE USE; bNLY
and No: 1
:J L� sut I odgi
Serial No.
ASTRUCTING THE WELL DATE
Groundwater Section within 30 days
GW-I REV. 12f99

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section 7 0 "
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: f~� ^'
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential ER Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other E] if Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: U ►2 Dk V — County: �� D_n
^nee. s -TD 9 R D
(Road Name and Numbers, Community, or Subdivision and
Lott No.) DRILLING LOG DEPTH
3. OWNER �P13131 E �L[212A/l)C--.L. From To('0, Formation Description
Address /0_�/ c7 .DuQ�i� P-L) 0S�
City or Town/ -State Zip Code
4. DATE DRILLED I a 1. 0 0 _
5. TOTAL DEPTH Y 2 7 ' `
6. CUTTINGS COLLECTED YES[:] NO[ — e `�
7. DOES WELL REPLACE EXISTING WELL? YES F-1 NO[n-
8. STATIC WATER LEVEL Below Top of Casing:.,y FT,
(Use '+' if Above Top of Casing) 1 ­•=,
9. TOP OF CASING ISFT. Above Land Surface -
'Top of casing terminated at/or below land surlsce requires a variance In accor-
dance with 15A NCAC 2C 011t1 __
10. YIELD (gpm): °� M HOD OF TEST �' en-'-
11. WATER ZONES (depth): R-°
12. CHLORINATION: Type Amount O If additional space is needed use back of form "-
13. CASING:
Well Thickness LOCATION SKETCH
f` Depth tampter or weight/Fl. ?Medal (Show direction and distance from at least two State
From —To
To —— Ft. �� �� Roads, or other map reference points)
From To Fl.
From To Ft.
14. GROUT:
Depth Material Method
From d To ( `� Ft.
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft In. In.
From To Ft. in. in.
From To Ft. in. In.
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
17. REMARKS:
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE -ONLY
Quad No: N RE OF E SO ONSTRUCTING THE WELL. DATE
f G' Submit original to DivisloWilrWater 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 2 1 r- -/ -6 0 -
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone' [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: ?440Kee tie%I _bQ, III�ti
WELL CONTRACTOR CERTIFICATION #:'—
STATE WELL CONSTRUCTION PERMIT#:
I. WELL USE (Check Applicable Box): Residential IT, Municlpal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ if Other, List Use:
2. WELL LOCATION: (Show sketch of the location below) �/ /
Nearest Town: _—_ L11 u121� �.�/ County: Loh P
_ wV �9�1 NeLSorJ PIP&
(Road Name d Nu ers Cc unl or Sutxlivl 1
ry, s on and w, No.)
3. OWNER ICNKIIQh 4-G1
DRILLING LOG DEPTH
Address / �y C�il2i�2 Give P—b
----,, ree or
From To . Formation Description
�� fl �C
N4,�s N 2.g O
c o� e o. 9 y _
J
Of y or Town late Zip Coda
4. DATE DRILLED
5. TOTAL DEPTH o 1
6. CUTTINGS COLLECTED YES [] NO
M
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO[D
Co
B. STATIC WATER LEVEL Below Top of Casing: 0 FT,
—
9. TOP OF CASING IS (Use •+• It Above Top of Casing)
FT. Above Land Surface•
C ;
'
*Top of casing terminated at/or below land surface requires a variance In actor-
dance with 15A NCAC 2C.01 18
c�
10. YIELD (gpm): 2 o METHOD OF TEST
11. WATER ZONES (depth): -5S
1. CHLORINATION: Type �T �� Amount a
C.17 —i
It addldonal space Is needed use back of orm
13. CASING:
Wail Thickness
Depth lameter W i or hl/Fl. tedal
From O To )-h FI.
From To Ft.
From To Ft.
14. GROUT:
Depth
From a 0
Materi Method
To
Ft.
From To %3`
Ft.
n
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:
LOCATION SKETCH
(Show direction and distance from at least two state
Roads, or other map reference points)
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY rff tn1C/�� - �} o --op
Quad No:
L rUUt SIO TUBE "SON C STRUCTING THE WELL DATE
Subm1l odill o Divl at11,
Serial NoGroundwater Section Within 30 days
. y
GW-1 REV. 12/99

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section I�" 1 ►^� 6 210
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone (919) 7M-3221
WELL CONSTRUCTION RECORD WELL CONTRACTOR: -t er //
WELL CONTRACTOR CERTIFICATION #: bJ V
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residentialff Municipal ❑ Industrial ❑ Agricultural ❑ Mon(toring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: C!>
kev-__
_,� County: —
(Lo
C.0%1� WEF-
(Road Name and Numbers, Community, or Subdivision and Lot No.)
DRILLING LOG DEPTH
3. OWNER Jc��n1 jORMC?a/
From To FormallonDescdpllon
Address /(o ��c7 S Tk � ✓t�
--j';ireetor
`�
oua o..3 I57
IS— K, D,) 4
City or Town State Zip Code
4. DATE DRILLED 9-3 0 o
5. TOTAL DEPTH 601
6. CUTTINGS COLLECTED YES [_ ] NO❑-
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO[D-"
8. STATIC WATER LEVEL Below Top of Casing: 10p - FT.
(Use '+' 11 Above Top oSurface•f Casing)
9. TOP OF CASING IS % FT. Above Land
'-'
'Top or casing terminated sVor below land surface requires a variance In accor•
dance with 15A NCAC 2C .011a
10. YIELD (gpm): /JO METHOD OF TEST d
11. WATER ZONES (depth): _� 5 G a ' si a
,_
12. CHLORINATION: Type - /!Z Amount -,) a /
U _,,,:
If additional space Is needed use back of yn
13. CASING:
Wall Thickness
LOCATION SKETCH
Depth D ameter o WeiphVFl. edai (Show direction and distance from at least two Stale
From Q l t �-� rf
To Ft.
Roads, or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From �_ �''
To Ft. c�
From ' J2 To 3 5 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 THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION $TANDgRDS, �ND THAT A,COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY / ` 0,0
Quad No: RE.Q
� `; 8 C7 S t l original to'Division of
Serial No.
$WCONSTRUCTING THE WELL DATE
Quality, Groundwater Section within 30 days
GW-t REV. 12/"

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] ti 1 ) G 0 0
WELL CONSTRUCTION RECORD WELL CONTRACTOR: -C�6. 1�� lt,'rr l DR.II1�J9
WELL CONTRACTOR CERTIFICATION #:_ �►�
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): RAsidentlal (r 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: ` yl lA a County: —0kQ f
(Road Name and tubers, Community, or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER ��A.ri g t� ,J From To
Formation DescrlptIon
Address q .Q P -- O W�R7NL,e.� GRAIVJ rE
e o� o. �� R 7 _��UE
�1 �►�f�,,/ reN
City or own r Stale zip Code - 'e 7 min
4. DATE DRILLED 46 �.3_p� - q/b 2-,2 7 5/ .4 7-t.
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES,] NOMIZ
7. DOES WELL REPLACE EXISTING WELL? YES F-I NO
8. STATIC WATER LEVEL Below Top of Casing: FT,
(Use '+' 11 Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface -
'Top of casing terminated at/or below land surface requires a variance In accor-
dance with i5A NCAC 2C .0118 ✓1
10. YIELD (gpm): A2 J- METHOD OFT ST _t* L�
11. WATER ZONES (depth): XQ -,21
12. CHLORINATION: Type Amount If additional space Is needed use back of form
13. CASING:
Wall Thickness _ LOCATION SKETCH
FromDepth 7 Dla�me�tt or Weight/Ft. 10dal (Show direction and distance from at least two State
To __. i Ft. h%� SAS �I Roads, or other map reference points)
From To Fl.
From To Ft.
14. GROUT:
CI
Depth Material Method tea
From �_ To Ft. _ ON ,PL- i L- �E A ! �y 3�
_�y T / C o r-t
From -��_ To Ft. �y S 11� -,
15. SCREEN: ✓ � ���
ci Depth .:-
Diameter Slot Size Material
From To Ft In in. -v r
From To Ft. in. in. cn
From To Ft. In. in. •� n,;�
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
CONSTRUCTNONtt STANQAMDS, AND THAT A COPY F THIS (/R/TECO /R/r/////� f�A 1E PROVIDED TO THE WELL OWNER.
FOR OFFICE US
NLY _ � A J- _ ti -�
Quad No:
Serial No.
OOF PERSON CONSTRUCTING THE WELL
Of Water Quality, Groundwater Section within 30 days
DATE
Wl
" OW-t REV. 12/89
__. r;

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section f . C.
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone] �. . ,a 61
WELL CONSTRUCTION RECORD WELL CONTRACTOR: 120 Ni
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residentlal L Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other E] If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
f'
Nearest Town: rl/L N1. County: __3tCQV
V_
(Road Name and Numbers. Community, or Subdivision and Lot No _.)
DRILLING LOG
DEPTH
3. OWNER _ - M 14 0 iL Vgo Q_,JQ_
From To
Formation Description
Address A0LF7
__�Imeel ol HouleNo.)
a
�Y
City or Town State
4. DATE DRILLED •• - � �
'Z 7
lr ra,er • Z-�g
`=
'�-
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑ NOE3"
�r
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO�
8. STATIC WATER LEVEL Below Top of Casing: ,L : , FT.
(Use '+' If Above Top of Casing)
.c>
9. TOP OF CASING IS I FT. Above Land Surface-
M'
•Top of casing terminated at/or below land surface requires a variance In accor-
_
-"
Cn
dance with 15A NCAC 2C .0118
N
r7l 70,
10. YIELD (gpm): C METHOD OF TEST L ✓�
11. WATER ZONES (depth):
N
6
12. CHLORINATION: Type !'a 7 �� Amount 5
If additional apace is needed use back of form
13. CASING:
Wall Thickness
Depth., \ Dii_a ter or I t. M I d I
From To FL (T ��
From To Ft. /
From To Ft.
14. GROUT:
Depth MatedMethod
From To D D . Ft.
From ':20_ To 2-2' Ft.
15. SCREEN:
Depth
From
To Ft
From
To Ft.
From
To Ft.
16. SAND/GRAVEL
PACK:
Depth
From
To
From
To
17. REMARKS:
Diameter Slot Size Material
In.
in.
In.
in.
In.
in.
Size
Material
I DO HEREBY CERTIFY THAT
CONSTRUCT14 'STANDARD
dj...
FOR OFFICE U NL1G�o e
Ouad No: a H1J
Serial No.
Ft.
Ft.
2 12000
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points) A/C
�• 3? GCS �I;,,. o,w
) 0 -12 %
07 1
21) 3eD n •�
)NSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
'Y OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
Submit Original;)
I ki " `i •-OD
RtfAUnNG THE WELL DATE
Groundwater Section within 30 days
GW-1 REV. 12199

''1 a6
North Carolina -Department of Environment and Natural Resources •Division of Water Quality •Groundwater Section A" �•
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: Po
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential & Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ II Other, List Use:
2. WELL LOCATION: (Show t-1
sketchof the location below)Nearest Town: �/? rh County:U)L-tLC V
(Road Name and Numbers. Community, or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER _ S I j ni FAQ i n i72�g c tjjP_ From To Formation Descrfpuon
Address
(street or Route o.
City or Town State Zip Code
4. DATE DRILLED CIG IN
5. TOTAL DEPTH _2. 12 " ,; i
6. CUTTINGS COLLECTED YES ❑ NOE3—_ r-m
7. DOES WELL REPLACE EXISTING WELL? YESEJ N0EJ—
8. STATIC WATER LEVEL Below Top of Casing: r O ' FT.
(Use •+' if Above Top of Casing) - o
9. TOP OF CASING IS FT. Above Land Surface' M
1V
*Top of casing terminated sUor below land surface requires a variance In accor-
dance with 15A NCAC 2C . 118 fu
10. YIELD (gpm): to METHOD OF TEST
11. WATER ZONES (depth):
12. CHLORINATION: Type
Amount D
If additional space Is needed use back of form
13. CASING:
Depth
DI
Wall Thickness
LOCATION SKETCH
From
\,, ,,
To
my er
D_�t
or,W � terfal
�'
(Show direction and distance from at least two Slate j1�C �
Ft.
�-
Roads, or other map reference points) �y-g
From
To
Ff.--
From
To
Ft.
J •- 2 C)
14. GROUT:
Depthr
am/
alert
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. REMARKS:
Slot Size Material
In.
In.
In.
Material
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE 1' LL m OD
6U� Quad No: a 1 $I ° ATU 61 PE N7CNiTnUCTING THE WELL DATE
Submit origirlpi Io Sion o 0uroundwater Section within 30 days
Serial No,
GW-t REV. 12199

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: Cky,2okV-V- to v -
WELL CONTRACTOR CERTIFICATION 0: a-5
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential D- Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: /1) u R Dr�� County: C •` Q Ocn kee
(Road Name and Numbels, Co unity. odS_ubdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER ci�►�► (,(� 1-MIZI)e 0— rom To Formation Description
Address %// l2� � ")0 , 5C %_ C f •'rt
(Street or Floule o.) T' I—
A)C Q'9906
ity or TowA Slate Zip Code
4. DATE DRILLED �S 6''0
5. TOTAL DEPTH V 2') '
6. CUTTINGS COLLECTED YES F] NO❑— `
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NOM Q
8. STATIC WATER LEVEL Below Top of Casing: _ S 0_ FT. L,Q T
c7
(Use '+' If Above Top 01 Casing)
9. TOP OF CASING IS / FT. Above Land Surface- tv o
•Top of casing terminated stlor below land surface require$ a varlance In actor-
dance with 15A NCAC 2C .011e
10. YIELD (gpm): METHOD OF TESTlt
11. WATER ZONES (depth): 20 2'y�� 0' in rr _::
12. CHLORINATION: Type Amount I
13. CASING:
From V
Wall Thickness
Depll? Diameter or Welghl/Ft. aerial
To ``'i Ft. _3 " '1 vC
From To
Ft.
From To Ft.
14. GROUT:
Depth ,� Materijaf Method
From To Ft. �i7 U
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
From To _
From To_
17. REMARKS:
Ft.
Ft.
Size Material
l S).
11 additional space is needed use beck of fo n
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Quad No:
Serial No,
==$181�ATURE 0 f_R$dN CONSTRUCTING THE WELL
Submit original to DTVI Water Oualliy, Groundwater Section within 30 days
5, DO
DATE
GW-1 REV. 12199

North Carolina • Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section r
$ 5 1
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: Cdle�'L� UP11 bp-;/ bAj i
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residentlal 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: -
,t1.� star .
(Road Name and NUrribers, Co unity, bfr Subdivision and Lot No.)
3. OWNER
Address—p
(Street o/� u e o. 1
City or To% State Zip Code
4. DATE DRILLED ( •- T) o
5. TOTAL DEPTH 00_)
6. CUTTINGS COLLECTED YES[] NO❑_
7. DOES WELL REPLACE EXISTING WELL? YES Q NO❑s
B. STATIC WATER LEVEL Below Top of Casing: p ' FT.
(Use '+' II Above Top of Casino)
9. TOP OF CASING IS l FT. Above Land Surface -
•Top of casing terminated sVor below land surface requires a variance In accor-
dance with 15A NCAC 2C .0118 r /J
10. YIELD (gpm): �_ METHOD OFTEST
11. WATER ZONES (depth):
12. CHLORINATION: Type Amount( 0
13. CASING:
Le A,i 14'_'(
DRILLING LOG
DEPTH
From To
Formation Description
y
G
r y :-3a7
C:)T
�Y N
rn a
If additional space Is needed
use back of IC9
c�
Wall Thickness LOCATION SKETCH
Depth D miter oDJr of VFI. mat rial (Show direction and distance from at least two Slate
From i`.� To Ft. / -� CC Roads, or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
From D
Dep,�t
To . 10 Ft.
_ atoHal Method
►+ —
From r-0
To 13 YFt.
15. SCREEN:
Depth Diameter Slot Size
Material
From
To Ft
In.
In.
From
To Ft.
In. -
In.
From
To Ft.
In.
In.
16. SAND/GRAVEL PACK:
Depth
Size
Material
From
To Ft.
From
To Ft.
17. REMARKS:
2 ,
;e
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RE RD HAS BEEN PR VIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Ouad No: SIGNATU PERSO S TING THE WELL DATE
Submit original to DlvIsl66 of water au , Groundwater Section within 30 days
Serial No. GW-I REV. 12199

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section [,
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone] n 1 1 lJ
WELL CONSTRUCTION RECORD WELLCONTRACTOR:
WELL CONTRACTOR CERTIFICATION #: 25'l0�
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential c9 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: jj -A Idl-�tbAl County:
�\)r�ILINCr Suclll7!I
(Road Name and NggWers. Cbmmunl or Su (vision and Lot No.)
3. OWNER ltati 1--r �hI- IA-)
Address G-�nr)
City odTowd Stale Zip Code
4. DATE DRILLED 60
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES F] NO❑-
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO0_
8. STATIC WATER LEVEL Below Top of Casing: FT.
(Use *+* It Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface'
'Top of casing terminated atfor below land surface requires a variance In accor-
dance with 15A NCAC 2 11B /J
10. YIELD (gpm): T�METHOD OF TEST \
11. WATER ZONES (depth):
12. CHLORINATION: Type �� Amount c7
13. CASING:
iDepth
From
To
Ft.
From
To
Ft.
From
To
Ft.
14. GROUT: j .•
eply
From
To
Ft.
From
To
FI,
15. SCREEN:
Depth
From To
From To
From To
16. SAND/GRAVEL PACK:
Depth
Wall Thickness
Diameter or Welght/Ft. Material
Material Method
Diameter Slot Size Material
Ft In, in.
Ft. in. In.
Fl. In, in.
Size Material
DRILLING LOG DEPTH
From To Formation Description
i
l
z
4 r--,
r
rri
l7
�
If additional space Is needed use back of kmn
LOCATION SKETCH
(Show direction and distance from at least two Stale
Roads, or other map reference points)
From To Ft.
From To Ft.
17. REMARKS-
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS S PROVIDED TO THE WELL OWNER./
FOR OFFICE USE ONLY V Q(
Quad No: SIGNAITURE PERSON ONST CTING THE WELL DATE
Submit original to DIvi31 0l W3ter- ity, G—r6undwater Section within 30 days
Serial No. GW-1 REV.121"

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] f
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION #: �J �o 5—
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential Ca Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show ske4ch of the location below)
Nearest Town: /776 / County:
s P,b
(Road Name and Numb(s, Community. or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER ? e �L y U bte_k From To Formation Description
Address SS ' k b J G 7
r C41
+j5 ree or Ro e No.)
!
City or Towne Stale Zip Code
4. DATE DRILLED OD
5. TOTAL DEPTH :Z 0
6. CUTTINGS COLLECTED YES ❑ NO[3—
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO0_
8. STATIC WATER LEVEL Below Top of Casing: -,5-U FT. ='
(Use '+' It Above top of Casing)
9. TOP OF CASING IS FT. Above Land Surface'
*Top of casing terminated sVor below land surface requires a variance In accor-
dance with 15A NCAC 2C .011E :
10. YIELD (gpm): ,c_iZ METHOD OF TEST r ''
11. WATER ZONES (depth): _ ZOO �� c-n
l0 0 .
;s -
12. CHLORINATION: Type � — Amount U It additional space is needed use back of form
13. CASING:
Wall Thickness LOCATION SKETCH
Depth Diameter or Weight/Fl. Material (Show direction and distance from at least two State
From To Ft. L, ti— r r� �' Roads, or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
O Depll� Mated Method
From To i Ft.
From 2— To 2% Ft. QVW
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft In. in.
From To FL in. in.
From To Ft. In, In.
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 1SA NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECOR HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY _ - r0- Oa
Quad No: IG TURE OF F1 N CONSTRUCTING THE WELL DATE
Submit original to Dto's b,.W ater Quality, (3roundwater 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 �, 15G
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
06-P-0
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
5
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential 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: k County: Ctt
Q
(Road Nanfe ind Numbers, Community, or Subdivision and Lot No.) DRILLING LOG
DEPTH
3. OWNER 6L From To
Formation Description
Address 0 , / ! —T t� L/.����
��� 7 C /75•�
y
-1
- �—' ! U Q� �V(stTee or R/v uCeJNo.)NQQ
C ty or Tjwn Stale Zip Code
4. DATE DRILLED
5. TOTAL DEPTH y z
6. CUTTINGS COLLECTED YES F ] NO❑`
CD
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NOEr
cn Cl
8. STATIC WATER LEVEL Below Top of Casing:,; FT.
`-?-:
(Use '+' If Above Top of Casing)
9. TOP OF CASING ISFT. Above Land Surface'
*Top of casing terminated at/or below land surface requires a variance In accor-
C71.__:
dance with 15A NCAC 2C 011a
10. YIELD (gpm): .�_ METHOD OF TEST
�--�-
-- �-
11. WATER ZONES (depth):
to h
12. CHLORINATION: Type _� /� r� C`
yp ,Z- Amount If additional apace is needed use back of for
13. CASING:
Wall Thickness LOCATION SKETCH
Depth' DI tpr or YVe1ghVFl. RAtedal (Show direction and distance from at least two State
From 0 To I / �J Ft. )_ l - v Roads, or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From To ;) U FI.
From 20 To VK FI.
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft In. in.
From To Ft. In. In.
From To Ft. In. In.
16. SAND/GRAVEL PACK:
Depth Size Materialr5 ,,�(Itj
From To Ft.
From To Ft.
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED 1N ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY /,/ -© t7
Ouad No: A O PERSON NSTnUCTIN13 THE WELL DATE
Submit orl i t0 Ivlston W4efC6ailly, Groundwater Section Within 30 days
Serial No. GW-1 REV. 12M

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]
"" LI)Q.L-, 1(2_k LU MG, WELL CONSTRUCTION RECORD WELL CONTRACTOR: C`E �, GE�'Q� E 1 Ift
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMIT#:
I. WELL USE (check Applicable Box): Residential n Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑ Recovery ❑ Heat Pump Water Injection M Other ❑ It Other, List Use:
2. WELL LOCATI h w sk c�ofthe location below)
Nears{ Tpwn: County:
c� h\ _ JI
(Road Name Numbers; Co u or Subdivision and Lot No.) DRILLING LOG
3, OWNER
Address ` From To
Mrsel or R o. �T---
DEPTH
Crly or T wn Stale Zip Code
4. DATE DRILLED
---01
5. TOTAL DEPTH'
6. CUTTINGS COLLECTED YES 0 NOEf
7. DOES WELL REPLACE EXISTING WELL? YES NO�
8. STATIC WATER LEVEL Below Top of Casing: F T,
(Use '+' If Above Top of Casing)
9. TOP OF CASING IS l FT. Above Land Surface*
'Top of casing terminated atlor below land surface requires a variance In accor-
dance with 15A NCAC 2C� O/t, �8
10. YIELD Q
(gpm):.MET OD OF TEST
11. WATER ZONES (depth): q�
12. CHLORINATION: Type Amount
13.'CASING:
If additional space is needed use back of form
Wall Thickness p
Depth Qi��gter W al
From Q To UIP
LOCATION SKETCH
(Show direction and distance from at least two State
Ft...,_
From To Ft.
Roads, or other map reference points)
From To Ft.
14. GROUT:
Dept M4tQdaL1N od
From b To Ft.
c ) c-3
,cam
From To Ft,
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft in. in.
From To Ft. In. in.
From To Ft. In. In.
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft. From To Ft.
17. REMARKS:
"If "a'...�.' .�� T Mil LL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
UCTION STANDARDS, AT A PY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNE�R/.
Vo: SIGNATURE OF PERSON CONSTRUCTING THE WELL ATE
un wa er t10 ubmil origlnal.to Division of Water Quality, Groundwater Section within 30 days
No.
_ _ GW-1 REV. 12/99

8649
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: c (w_s
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� r sketc of the location below)
Nearest Town: County: Q
(Road N d Nu rs. C unity, or Su ivislon a Lot No.) DRILLING LOG DEPTH
3, OWNER Form tion scrt lion
Address From ToI
re e or ou�
City or To State Zip Code
4. DATE DRILLED 1
5. TOTAL DEPTH
6. CUTTINGS -COLLECTED YES ❑ NO[D'
7. DOES WELL REPLACE EXISTING WELL? YES j-j NO[�
8. STATIC WATER LEVEL Below Top of Casing: FT,
(Use '+' it Above Top of Casing)
9. TOP OF CASING IS L FT. Above Land Surface*
*Top of casing terminated atfor below land surface requires a variance In accor-
dance with 15A NCAC 2C . a ,
10. YIELD (gpm): -M METHOD OF TEST.
11. WATER ZONES (depth):
12. CHLORINATION: Type Amount If additional space Is needed use back of form
13. CASING:
Wall Thickness LOCATION SKETCH
Depth larnetsr W I ht/Ft atej� I (Show direction and distance from at least two State
From -_SG__ To � Ft. Y1` V Roads, or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth M t rial Method
From b To °curl Ft.
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft In, In. o ��
From To Ft. in. In.
From To Ft. In. in.
16. SAND/GRAVEL PACK:
Depth Size Material' ni+`
From To Ft.
From To Ft. C-)
c-
17. REMARKS: CEIEWA��I DO HERECONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELLCONSTRURDS, AND THA PY OF THIS RECORDHA/S BEEN PROVIDED TO THE WELL OWNER.
FOR OFFIC ', %1.e2
Quad No: SIGNATUbE bF PERSON CONSTRUCTING THE WELL ATEW ter SectiO 0 tod nat to Divisionof Water Quality, Groundwater Section within 30 days
Sedat No.a ,nt.,enl rlffica GW-1 REV. 12199

r
-A.8645
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] � W aL 'u-1
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION #: 3
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (check Applicable Box): Residential [ t' Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCA= \sketch f the location below)
Nearest Tc \ r �—� County: K\\IAA
(Road Na e a N bers, C m i r division and Lot No,) DRILLING LOG
3. OWNER From To
hA
ddress p 1
tree or o
City or To state Zip Code
4. DATE DRILLED
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑ NO[ l-
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO[t ]'
8. STATIC WATER LEVEL Below Top of Casing: �0()_ FT.
(Use '+' If Above Top of Casing)
9. TOP OF CASING IS- FT. Above Land Surface*
'Top of casing terminated at/or below land surface requires a variance In accor-
dance with 15A NCAC 2C.9118
10. YIELD (gpm): MET OD10F TEST Q
11. WATER ZONES (depth):
DEPTH
Form$;ion Description
12. CHLORINATION: Type k Amount If additional space is needed use back of form
13. CASING:
Wall Thickness LOCATION SKETCH
Depth(�2 tatnetgr W I ht/Ft. c tu>aterial (Show direction and distance from at least two State
From To ` `-) Ft. �l`E - -�'V Roads, or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Dept M trial Method
From To Ft. w
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
[q c
V L.
w h
From To Ft. ko
o
From To Ft. -L
17. REMARKS:
IDO HEREBY
FOR OFFICE U
Quad No:
Serial No.
LYrn1
`J(✓
IN ACCORDANCE WITH 15A NCAC 2C, WELL
CORD HAS BEEN PROVIDED TO THE WELL OWNER.
?000 1 NAT OF PERSON CONSTRUCTING THE WELL. ATE
Submit g nal o Division of Water Quality, Groundwater Section Within 30 days
GW-1 REV. 12/99

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section 4 .a V 1.3 3
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: 1'3'l� �r U ) e11 Ad" IC4
WELL CONTRACTOR CERTIFICATION #: P'-/04
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential 19' 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 tA �N County:(f
ec
(Road Name find Numbers. Commu``ntty, or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER SGX✓1 )u<h From To Fonra�onDes:riptio-
Address D — !d '/af/
(Street or Houte o.) 76 r, 4-
City or Town State Zip Code
4. DATE DRILLED 7— 31- Cw
5. TOTAL DEPTH 04(5
6. CUTTINGS COLLECTED YFS ❑ NO[9
7. DOES WELL REPLACE EXISTING WELL? YES [] NOD
B. STATIC WATER LEVEL Below Top of Casing: Yr FT.
(Use '+' if Above Top of Casing)
9. TOP OF CASING IS f 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): _ 6 METHOD OF TEST A" f?
11. WATER ZONES (depth):
12. CHLORINATION: Type .6+11 -6101 S Amount' it additional space is needed tse_ baci of farm
13. CASING:
Wall Thickness
Depth Diameter or Weight/Ft. Material
From To Ft. ——
From To Ft.
From To Ft.
14. GROUT:
Depth
From To Ft.
From To Ft.
15. SCREEN:
Material Method
Depth Diameter Slot SIZE Material
From
To Ft
In. _
From
To Ft.
In.
From
To Ft.
in. _
16. SANDIGRAVEL PACK:
Depth
Size
From
To Ft.
From
To Ft.
17. REMARKS:
I DO HEREBY C
FOR OFFICE USE
Quad No:
In.
In.
In.
Material
LOCATION SKcTCH
(Show direction and di s~ance frrm aj leas: rom Stele
Roads, or other rr--p refererr-As points!
C-:
3-
1
C71
C.J
THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A DJCAC 2'.:, vtELL
RAROS, ;AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED -TO THE Y/SU O"NEF.
ii_ i SIGNATURE OF PERSON CONSTRIY:TING PIZ IoWELL
Subrnil original to Division of Water Guality, Groundwalsr Stccn within 7) C;-ols
D�... E
M
CD
C-) ._,_,
3 rtj
c- r',
rrI
0
Grr•1 PT5V. 1:91
rr
Serial No.

North Carolina • Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section 22 JO U 13
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: On"019S We -ill dr' 11"no'
WELL CONTRACTOR CERTIFICATION ff: �?6/2c/
STATE WELL CONSTRUCTION PERIAITN:
1. WELL USE (Check Applicable eox): Residential 19"' Municipal ❑
Industrial ❑ Agricultural ❑ Monitorir g ❑
Recovery ❑ Heat Pump Water injectlon ❑ Other ❑
If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
���
Nearest Town: rO W County:
rl� �'-
Iu
n (� H; I R A
(Road me nd Numbers, Community, or Subdivision and Lot No.)
DRILLING LOG DEPTH
3. OWNER �� �i /7 Itle Ar
From To Formaxn Descriptio'
b - a
Address j'/,%j�pQ 4s, /�, / J�-,1
lD `
(Street o oule o.
���i0�
u
City or own State Zip Code
4. DATE DRILLED :2- �2 7- 02
5. TOTAL DEPTH , SQ 5 '
6. CUTTINGS COLLECTED YFS ❑ NO[9-
7. DOES WELL REPLACE EXISTING WELL? YES [-1 NO®'
S. STATIC WATER LEVEL Below Top of Casing: 0 FT.
(Use '+' It Above Top of Casing)
9. TOP OF CASING ISM_ FT. Above Land Surface'
-Top of casing terminated at/or below land surface requires a variance In accor-
dance with 15A NCAC 2C .0118
OF TEST
10. YIELD (gpm): _2 METHOD
11. WATER ZONES (depth):
12. CHLORINATION: Type ( SAmount
If additional spare is needed ise back of fum
13. CASING:
LOCATION SK=TCH
Wail Thickness
Depth Diameter or Welght/Ft. Material
(Show direction and distcm ance trZI leas: tr.o Snate
r
FromToFt. 6­2�L- Sp'Fa l -
Roads, or other rrryo refererce pointy
From To Ft.
From To Ft.
14. GROUT:
Depth r M terial Method
From To .2- 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. _
16. SAND/GRAVEL PACK:
Depth Size
From To Ft. —
In.
Material
WE
c-
c�
I
Cn
c:o
c�
From To Ft. —
17. REMARKS:
DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A DJCAC ?r.'/FELL
CONSTRUCTION'.,STANOARpS,(PMq T��(T A C Y OF THIS RECORD HAS BEEN PROVICED 10 THE YI'c^.L OWIEP.
FOR OFFICE USE ONLY
Quad No:
SIGNATURE OF PERSON CONSTRICTING lit ov EU.
$u, l. original to Division of Water Malhy. Grourowaler Sri within N. C%1ys
DA­'E
C•rf•1 P19v. 12Y1
Serial No.

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: 02149—10,0.0 C C"U;Da
WELL CONTRACTOR CERTIFICATION
STATE WELL CONSTRUCTION PERMITP:
1. WELL USE (Check Applicable sox): Residential Ul- Municipal ❑ Industrial ❑ Agricultural ED Monitoring ❑
Necovery ❑ Heal Pump Water Injection ❑ Other [] If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below) /� P
Nearest Town: m� IS I County: ( �MK
(Road Name -amend Numbarss ComE Onmunfty, or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER i > t vtn ()_ From To Forrra5cn Descript;on
Address
(Street or Route o.
City or Town Stale Zip Code
4. DATE DRILLED
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YVS [] NO[jJ
7. DOES WELL REPLACE EXISTING WELL? YES [-J NO©
B. STATIC WATER LEVEL Below Top of Casing: lot FT.
(Use '+' it Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface*
`Top of casing terminated at/or below land surface requires a variance In accor-
dance with 15A NCAC 2C .0118
10. YIELD (gpm): 10- METHOD OF TEST ,AW
11. WATER ZONES (depth):
12. CHLORINATION: Type hkti :bbl fs Amount q
13: CASING:
If additional space is needed t--,o- back of fu7n
LOCATION SK=TCH
Depth
Wail Thickness
Diameter or Weight/Ft. Material
(Show direction and dis,.ance 6•�n leas' tyro S ate
r
Fromm —To q,2
Ft. 15 -21 —
Roads, or other rrco relert:r-e points`
From To
Fl.
From To
Ft.
c�
14. GROUT:
o
"
Depth
M I al Method
From &2 To fir_
Ft.
From To
Ft.
{^
15. SCREEN:
rn
` r`'
Depth Diameter Slot Size Material
3.!!,-
M
From To Fl
in. in.
Cn
From To Ft.
In. In.
From To Ft.
In. In.
—
o
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 04CAC 2C:. VfELL
CONSTRUCTION STANDARDS; AND THAT:A COPY OF THIS RECORD HAS BEEN PROVIDED -70 THE 'N� L Ot+'%FF-
_ 2
FOR OFFICE USE ONLY
Quad No: SIGNATURE OF PERSON CONSTnUP TING lti ,"'ELL Os'1
II SubHI original to Di &Ion of Water Ovalily, Gmnd.ratar Smcrt within Y.) C;0rys
CK•1 ftirY. L'91
Serial No.

r 92
North Carolina • Department of Environment and Natural nasoUrces • 0lvlelon of Water OUsIlly • Groundwater Secllon
1636 Mail Servo Center • Raleigh, N.C. 27699-1636•Phone [phone] //
WELL CONSTRUCTION RECORD WELL CONTRACTOR: . O1-2oKee 06/ 1 J)Q; / I
WELL CONTAACTbp CrrAtIFICATION MJ
SPATS WELL CdNStniulo 10N Pehm ro:
1. WELL USE (Check AprAlcable Box): I'lesidentlalC9 Munlcipai 0 Indobblal ❑ Agricultural Monitoring ❑
flocoveryE Ii©nl Pump Water Injection E Othtar E] 11 Otheri List Use:
2. WELL LOGA1 ION: (Show sketch of the location below) n %
Nngrnat Tovrn� _— �►T ur���.. .- - ------- County: `�/i.��f�
ltload Name and Numbais, Carunurilty, or SubdlvIrJon and Lot No.) DRILLING LOG 4EP1 H
:3. OWNER -- - ' I From To FoarAtlonDesorlpuon
Atirlrncg 1/ �d' �I �/QS l �) C C. /
..^.ilt n in �nlo Zip 90 A
4. DA'I E DRILLED / - O
5. 10TALDEPTII _ y02 '
6. cu rrINGS COLLEC I ED YES NU[—�'`
7. DOPS WEI.L RFPI.A('F EXISIING WELL? YES NO[-
8. STATIC WATER LEVEL Rclow Top of Cnqlnq: ..6- FT.
(Van'4' If Abovo top o1 ('1gsing)
o TOP OF 17WaINO IS .- I__. FT. Above 1-nnd Surface•
•Tnp of r.nilnp fnrminnt—I nl/nr holnw I+nrl ttnler.� Mryutre4 A vnrinnef In Pecor-
.hncrn with 15A Hr!AC 7C Of to n
1n YIFLh (r,�m)• ..�_ _-,. MFTh1r7b OF TF T __�• O<
11. A1 ER ?ONES (deplh): 2 o a , (Yp -, -
12. CHLtu1tNATICtN Typ- . / /,.�1 Amnunt _�%3 It addltlonal ep". is needed use back of lorm
13. CASH IG.
Firm_ �
[tQpllt _
—To
Wn1111110nrt1
btpnreter or Ip tl. octal
Ft. (`.��...�, -- `J� tJ (
I'rorn_
-- To -- _--
FI.
Front
To__,—
1 d GROUT:
r�rltlt ,
Mn I a rW Method
Flom
II''
Tu art.
n
From
In
�
15. nCfIF("rl:
U�('th (?ihrnr..lnr
Slol Size Material
Front —
-- I u .- -- -_- rl
I r'.)rn ..---
— I r• - ... _ Ft.
----- In.
Fr-rn --__-- .-_
To .._.. -._-- FI.
In.
it). SAIJU;Gf1AVE(. PACK:
Uat)Ilt
Size Material
To .. .... - .._
rt. .
Float
17 REMAFIKS:
. LOSATION SKETCH
(13how dtreotbn and distance Irom of Meet two btale
Roads, or othot map reference points)
1 on IIFncny rrF1TIF-Y TI IAT TI-II9 WELL WA3 CONSTRUCTED IN ACCO110AN0E WITH 15A NCAC 20, WELL
('r.tNC I F11 Ir; Tl(?N S I-ANOAMS, AND TIIAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OrrICF USF. ONLY ___
on., t r7n _5191 in rrrls COII5TRUCTI HE WELL DATE
Sul -nit orloinai I iyl of Wgl uglily, Groundwaler Section within 30 days
�ri�lt!o. GWI f1EV. 11l99

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): Residentlal Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heal Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
r
Nearest Town: County: --
(Road Name and Numbers, Community, or Subdivision and Lot No.)
DRILLING LOG
3. OWNER - 4(2-4)Rb
From To
Address !V �, 1� cw 50C>c&
--jStree
0_ /
rroouTOJNO.
q /
City or Town jState Zip Code
- 20 0
—
4. DATE DRILLED
—
5. TOTAL DEPTH a
6. CUTTINGS COLLECTED YES ❑ NO❑�—
1"a
7. DOES WELL REPLACE EXISTING WELL? YES NO�
0
;� ,.Y
8. STATIC WATER LEVEL Below Top of Casing: FT.
(Use '+• If Above Top of Casing):
9. TOP OF CASING IS ( FT. Above Land Surface's
*Top of casing terminated at/or below land surface requires a variance In accor-
dance with 15A NCAC 2C .0118 P� 10. YIELD (gpm): __'j__ METHOD OF TEST
�-2-0 � '
11. WATER ZONES (depth): _ Vy
DEPTH
Formation Description
12. CHLORINATION: Type _1717" Amount
If additional apace is needed use back of form
13. CASING:
Wall Thickness
LOCATION SKETCH
Depth Diameter or Wei ht/Ft. material
D /
Z
(Show direction and distance from at least two Stale
From To Ft. _ f
Roads, or other map reference points)
From To Fl.
From To Ft.
14. GROUT:
C'
Depth Material -_L Method
`�0
ED
�'
From �0-- To Ft. ^
c�/'
C
� rM,..,
.Ly To
From Ft.
►"'
-�n-t
15. SCREEN:
ma's=
M
Depth Diameter Slot Size Material71
From To Ft in. In.
=
r7
From To Ft. in. In.
m
From To Ft. In. in.
N
—`j
16. SAND/GRAVEL PACK:
04
b
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 r P)A n —So ne 5 '�_ z o vo
Quad No: SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Quality, Groundwater Section within 30 days
Serial No. OW-1 REV. 12/99

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section r: a
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone] i' `it 3 8
WELL CONSTRUCTION RECORD WELL CONTRACTOR: fYlt' I 1 Q l
WELL CONTRACTOR CERTIFICATION N: 02 vO
STATE WELL CONSTRUCTION PERMITP:
1. WELL USE (Check Applicable Box): ResidentialB__�M_unicipal ❑ Industrial ❑ Agricultural El Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: 1110 ,U 12, County: i—P T v'D L �-
s cN ek
(Flad Name and Numbers, Community, or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER aun From To Forr.axn Des: rip6w-
Address 3 d " '3c� 0'
beet or RoVla No.J / 0.7
_M fd byte - /�s '
City or Ton State Zip Code
4. DATE DRILLED"
5. TOTAL DEPTH �� S
6. CUTTINGS COLLECTED YES C] NOFE—
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NOLJ-
B. STATIC WATER LEVEL Below Top of Casing: t FT.
(Use '+' If Above Top of Casino)
9. TOP OF CASING IS i FT. Above Land Surface*
`Top of casing terminated al/or below land surface requires o variance in accor-
dance with 15A NCAC 2C .0118
10. YIELD (gpm): 6-METHOD OF TEST 04,'t
11. WATER ZONES (depth):
12. CHLORINATION: Type 41h 4r� le _S Amount _-
13. CASING:
Wall Thickness
Depth Diameter or Weight/Ft.
From To �I ` Ft. — -! b" 1
If additional space is needed tse back of krrrf 25
LOCATION SK=TCH
Material (Show direction and dis~ance Iran :I leas: tyro Slate
tELYse Roads. or other rr r-p reference points!
From To Ft.
From To Ft.
14. GROUT:
Depth MVaenal ✓ Method
From b To 20 Ft.
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft in. in.
From To Ft. In. In.
From To
16. SAND/GRAVEL PrACN
Dee
From TFrom T
17. REMARKS:
Croundwew SeCTIOtt
1 DO HEREBY CERTIFY�THAT THIS WELL VaMONSTR4TED IN ACCORDANCE WITH 15A 04CAC rr. IffELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED 10 THE 71SU OWIEF..
FOR OFFICE USE ONLY
Quad No:
Serial No, -
SIGNATURE OF PERSON CONSTRU rTING P,: V/v'ELL
Submll original to DiAtlon of Water MOIlly, GroundMrliar Sr=n within Yi C%s'ys
=j_ ` 6
DA­' E
61f.1 G19 v. 1291

North Carolina •Department of Environment and Natural Resources -Division of Water Quality -Groundwater Section
r.
i32^
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential [�K 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: ANp0_eU__) S County: - C li'0 an ke-Lo.
SurfA-1,L4S-kA Q
(Road Name and Numbers. Community, or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER /j?io4-I n "J bRV e..5 From To Formation Description
Address a'To 'AOG-tl b I)Pj ✓e o .- /.2� 7- CA S N
reet or oute o. f �Z _ J�/[� N j �=
City or Town State Zip Coda /I/ O /Q UC'
4. DATE DRILLED�V L —�- T-
5. TOTAL DEPTH x/4 . =l 7 `� y AD C
6. CUTTINGS COLLECTED YES F-] NO--'
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NOEJ' d L —ro :3ag
8. STATIC WATER LEVEL Below Top of Casing: —Q FT. ',i©n
(Use '+' if Above Top of Casing) i I
9. TOP OF CASING IS % FT. Above Land Surface'
'Top of casing terminated aVor below land surface requires a variance in accor-
dance with 15A NCAC 2C .0118
10. YIELD (gpm): 51L) METHOD OF TESTR-
11. WATER ZONES (depth): Van I
12. CHLORINATION
13. CASING:
Type d L ``{ Amount AA
Wall Thickness
Depth Di me er or Welght/Ft. Material
From —To 1.Z5 Ft. - r),/r.
From To Ft.
From To Ft.
14. GROUT:
Depth Material ethod
From To 0 Ft. c°qe_ t, ✓t
From t�>,O To 1—Ft. r
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 32-3 �/ To ! 11 % Ft. 7 9_ hp 64A V
From To Ft.
17. REMARKS:
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
0
cO zz
C7 t.3
c_ p
C rT
r—
N
c2
;
rn
fV cnzz
cO .�
O o
z
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF T RECORD HAS BEEN OVIDED TO THE WELL OWNER. G
FOR OFFICE USE ONLY 7- /7 00
Quad No: Sipr9fURE OF PV6,01 C TRUCTING THE WELL DATE
Submit odginallt6 Division of W Qualit , Groundwater Section Within 30 days
Serial No. GW1 REV. 12/99

c.143 I
Nurlh Caroline - Depnrlrnenl or Environment aril Natural Resources • Division of Water OuslIN • Groundwater Section
1636 Knit Service Center - flalelgh, N.C. 27699-1036-Phono [phone]
WELL CONSTRUCTION RECORD w1rLL CONTRACTOA.- 1
WELL CONTAACTOFI CERTIFICAVON M:
Ili —
STATE WELL CONSTRUCTION PFAMIiN:
1. WELL USE (Check AppUcable Box): rtesidonllal L'-.d Municipal ❑ Indtlslrlal ❑ Aprieultural ❑ Monitorirlq ❑
RecoveryU Heal Pump Water Injection ❑ Other [j If Other, List Use:
2. WELL LOCATIOIJ: (Show sketch of the (oca(ion below) �p �
irnnrnntTnvrl'-- NQR�t�.S-- Coun1 S �!'`[
y-112—
�C24_h�L.li=�- SLj�DIVISIO�
(Road I1ama and Numbors. Cot runuNly, or Subdivisions sold Lot o.)
DRILLING LOG QEPTH
3.
OWNER - - �TpC�ry i4ND /�If��i i� �%4V1
Arjrfrns9z2 (o
From To FoarAtlonbosodptlon
�Z—_ Zz��� C
-�
Nb.'rTioof or Flo�u^o 140.) � �,G.�ZQ-.--.L�-L— ��•7'1 .' % �
��
rit}• nr Tmmi Slnle Zip Code
a.
DATE DRILLED J� /�' Oo
5.
_
IUTALDEPTFi
\ ,
6.
CUrFIN(39 CC)I.I.FCIEI7 YES[ NO[7
0
+
7.
DOES WFt. L RFF`I ACF_ EXISTING WELL? YES ❑ NOE:
H.
STATIC WATER LE VEL Below Top of Ceginq: PT.
(I!so •a' H Abovo top of Cnsirp)
1- a* r
4
TOP nF r.AtZI NG IS FT. Above Lnnd Surfat:e'
- ----
t ze
Jar
'Tnr
Js�
nt rniIrip tnfrntnnt —In Vvr hnlnw I+nt1 tIor'ferr► ►aryn6eii a verinncr In r.rcer•
rigncn with 1FA Nr7Ar; 7C O11If
to YIFI n (nprn) �� ; Mt=TROD OF TEST_
---
I.WATEnzorir-3((jepth):�==
cn c�
12.
CNL(1.r.�lp)Al InN Tyro �% .�.._ .__ Amrntnt�Q �� 5
11 additional space Is needed use back of form
13
CAGIr)C.
WnIT 1htcMnrq!
JLOCATION SKETCH
I'nnlh b nmelor or Welghl/FI. terinl
rrom To 1 :2()^ FL . % c—
(8how dtreotlon end distance from at lout two fatale
Roads, or olhor map telerence points)
I'tortt-- - To--- Ft.
Flom 1 o _--._ FI.
1A, GROUT:
thr'�Ih 7lerial Method
Front � Tu��_rt.
1, ccncr:nl:
Dr'I'tlt hI 1tTlrttrJf
none _ -- I u .. _--• -_ rl
(•turn ..__- Io ___--•--Fl.In.
rr"tn ----• -- 'To .._... - rl. _ In.
t t;. SA( IDIGRAVLL TACK:
Us3plh Size
Slot Size Material
Material
rrnm - ._. To ..
rrultt �- To rl.
17. REMARKS:
I rrn. I IP"cF%y Cr-nTlr-Y Tl IAT THIS WELL WAS CON9TRUCtE0 IN ACCORDANCE WItH 15A NCAC 2C, WELL
(Y .)Ne I RI Ir l ION 91 ANUARDS. AND THAT A COPY OF THIS RECORD HAS BEEN PF10 tM TO THE WELL OWNEf1.
r OR Or rICF USE ONLY
Owrl ttn• 510 As P{: Smu-cf Iu THE WELL DATE
Sulm>it orluIrral to bIvIslon NMI �t y, cmundweler Section within 30 days
r Y i1111n, GW-I M. 121"

North Carolina - Department of Elivironrnent and Natural Flesouregs • Division of Wolter Cuhlity • Groundwatdr Soellon
1636 Mnil Serylce Center • nalolgh, N.C. 27699.1030•Phono [phone] II,, •���^ %� + 1
WELL CONSTRUCTION RECORD WELL CONTRACTOR: --ap-ankep
WELL CONTRACTOrt CRRTIPICATION #I (� S
STATE WELL CONSTRUCTION PEgMtTM:
1. WELL USI_ (Check Applicable Pox): nesldontlal Municipal (ndu9lrlo) LJ Agricultural Monitoring ❑
flocovery F-1 Heat Pump Waler Injeclton [] . 01tihr 0 If Other, List Use:
2. WELL LOCAI ION: (Show sketch of the location below) I
NnnrpMTown:_—� •41,.� County: -- ��t�I�KEC
(noad Nam4 and Numbors. Corrununlly, r Subdivision gild Lot No.) MILLING LOG DFsPIH
3. OWNER-.--_-s.0_ MM l�©N From To Forrnatlon besoriplion
Affr)rnsg l,/ /C 0
—cam
2ily nr TOW1 ——`glnlo Zip Code
4. DATE DRILLED
5. 10TAL DEP711 Z
6. CUTTINUSCOI.I.ECIED YES[ NOE-1-
7. DOES WFI L RFPI.ACE EXISTING WELL? YES NOL_f_
R. STATIC WATER LKVEL Below Top of Cnglno: 'q • FT,
(0in *s' H Atmo tool Cnelnp) - r
4 TOP C,F r.AstNc; IS FT Above Land Surfaces
•Tnp nl .:p4trig formirim-1 il(nr hnlnw hn+•1 virrAna rA4 nerwM a vnrlgnc# In Pecor-
cc dinwith 1FA Nr r 6 Y !L
A,2C fill
10 YIFL.r) (9prn). METHQD OF TT _
11. VIA IEnI ZOfIF..3 (.aepih): �� �' TEST
Q. CHLOMNAUON
13 C:ASRIG.
Tyr" l7//- —_ Amrnrnt it addition M eprtce Is needed
Wnn Iht0neae
Unrlieler
tz or W= edal
T
Frnm.� .._n L��Lr� Ft. ` ' �
id. GROUT:
Material Method
[loll)_ To ` C' rt. /
From .�v . 'to
15 `"CnFrrl:
U''('Ih i?i tmn.lnr Slol Size Material
Iu ..._.- -- FI --�_ In. In.
t rom •_----- Ir, .-___...F I. —___-- In. In.
To _........._ FI. _. In. In.
I! - SAI1171GrlAVEt_ f ACK:
uppill Size
Tn .. __... t"t. _..
Flan) — - - ro-- .- i"I. _
17. REIv1AFIIS'
Material
LOCATION SKETCH O
(Show dlreotbn and dlotance from at bast two etal:P
Roads, or other map reference points)
i r(,) t IFITCnY rrnTIr-Y TI1AT Tltiq N/FLL WA3 (',ON9TRUCTEb IN ACCOnt)ANCE WltH t5A NCAC 2C. WELL
(r,Ne t AI Ir, T ION S rAn!(aART)S, AND TI IAT A COPY O F11S RECORD N 3b EN PROVIDED TO THE WELL OWNER.
1"OR OFFICE 115E ONLY �.
Inr� np tor
rnsnN Cp triUCTtrni THE WELL DATE
Summit uVrial to I)i'/Iq of nler Ounlily, Croundwaler Socllon within 30 days
i ill I!o.
----___--- ..-- CW1 nP. 12/99
0

Notth Carorinn • UepArtrrnent of Environment and Natural Resources Division of Welar Quality • Groundwater Section
1636 I'Anil Service Center - Flalelah N.C. 27699.1030•Phono (9191733.3221
WELL CONSTRUCTION AMORD WELL CONTRACTOR:C_jjjLA0Le,-II I N c
WELL COMACTOM CEfITIEICATION N:
STATE WELL CONMUCTION Pt!hMrrN-
1. WELL USE (Check Appuceblo Box): fiesidonllalm Municipal L_I InduMilal Agricultural Monllorinu
nocovery Ll Beal Pump Water Injection 0 Ol o C] If Other, List Use:
2. WELL LOCH I IUIJM(Show sketch of lho location below) ^�
Monrnnt Town' — • r �y - --- County:
(Road flame and 14U»rbors, Community, or Subdfvtalon and Lot No.) DRILLING LOCI U TFi
3. R _-1IFornatonb•aorpuonQWNFSAn
Arfifrnizs
sayo
-� rnOl or 1Toulo { fTo'.)--
City or Tnwi �iStnlo Zip Code
d. DATEDMLLEU-----
5. 10 I AL DEPI11
6. CU H INUS COLLEC I ED YES [� NO[-j'
7. DnES WF1L RFPI.ACF EXIS IING WELL? YES O 1`400-
9. STATIC WATEf1 LEVEL Below Top of Cnginq: _,' ) FT. _
(U�e'+• N Above top of Cnslrp)
a TnP or RACING IS %._._._- FT Above Lnnd Surface'
'Tnv nl en0no tr.rrnl,tntnlf nuor hninw I+nil trhiraeA 1`ery11lrn4 A vnrlonev fit Pecor•
d•tncn wlth 154 NCAC 7C (I 1fl ) —
1n YIFI n (q(`m)• ---.---- MFTHQb OF 7F?ST j s-�i
......_..--
11. VJATEll 7.Orlf-3 (deplh);_.._.._._._.-
12. ('HLORINATION: Tyro J�.� ../ __ Amnunf ,� 11 edditbnfit Space Is needed use beck of form
13 CASING.
Wnn Ihfctn17s! OCATI SKETCH _
1 I:►npih Dinnteter or W�Ip,h-,l/F'l. e�tel (Show dirwlon and dIstence from at heat two Stele
F In III __ `/ __ To £' rl. � 'air L- `� Roads, or other map reference points) p
-to-- Fl.
� q o
C.., a
From l o CD
r. . m
1 A. GFlOI.IT; �.
�
rlr fr Mhterial Method �M-
� � rn c
f loin T(i 0 rt. �, —p I
From oL CD
C-)
l)r I'!It Pinrnn.lor Slot Size M91e1111 0 Zi
fl o
rl
FI —__-.— In. ___ In.
rr art, ... -• TO -- Fl. _ In. In.
1!). SAIIJ1 MAVL•l. r'ACK:
DopIli Size Material
rrnm .--.... _ To _. - __.._ rl.
I7 f1EMAn1<S�
t rn i if: r)r!fly r r FItjr v;7fl T��I9 /PLL 4VAq CON4TRUCTED IN ACCORDANCE WITH tSA NCAC 20. WELL
r'raMe i pt trTlriN � I ANOARUS, ANO TIIAT A COPY OF THIS RECORD SEEN PROVIDED TO THE WELL OWNER.
F R OrrICF USE (PILY�1 r)(1�){ _ �•^--. %'l - r7 `�_
rnr,rt ftn ?: 1 TT1nE OF :n. t1r1 N5rnUCTlrfo ME WELL DATE
_ ! _ $U!nnil oriclnal to vi-Anio ter Guafily, Groundwater Sect!nn within 30 days
GW-I f1EV. 17/99

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]
WELL CONTRACTOR: CAeaokee LI X "')
WELL CONTRACTOR CERTIFICATION #: S
STATE WELL CONSTRUCTION PERMIT#:
14058
1. WELL USE (Check Applicable Box): Residential R( 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: Xhugpkx County:
1
(Road Name and N mbers, Community, or Subdivision and Lot No.)
DRILLING LOG DEPTH
3. OWNER 14,tTH \/Q12b6L CL—L
From To Formation Description
/� /�
Address / / l AS'f Kr l� K11
© — Ski C1951-J tr
Street or Houte o.
City or lown t State Zip Code
�n% ~
4. DATEDRILLED 7-IO`Ot�
c��7
5. TOTAL DEPTH p q-/
6. CUTTINGS COLLECTED YES [:D NOE]JZ
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NOd
8. STATIC WATER LEVEL Below Top of Casing: _ J/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/ n
YIELD QQ METHOD OF TEST P�
10. (gpm):
11. WATER ZONES (depth):
12. CHLORINATION: Type' NT q Amount
if additional space is needed use back of form
13. CASING:
LOCATION SKETCH
Wall Thickness
Depth Diam ter or Weight/Ft. Material
(Show direction and distance from at least two State
From Q To 55 Ft. Y.9 5bP- al py
Roads, or other map reference points) O
�-
�
From — To Ft. . /S� -L_-
o
From To FL
C=
t--
orri
�C_')
14. GROUT:
�
Depth Material Method
G'J
rno
From d Tom Ft. CeMe-)-T" CIA —IV, i
-v
1�
m�
From -7,10 To Ko '-;; Ft. '
;6
15. SCREEN:
tV
Depth Diameter Slot Size Material
fl
o
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 T I�AROIS ,N T T p
FOR OFFICE UStjdtkY -
Quad No: is 2 `Siufbiriil
Serial No.
4 CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
..OPY, 0 jIS RECORDaHAEEN PROVIDED TO THE WELL OWNER.
ATURE QqERP6XC0NSTRUCTING THE WELL DATE
Division oWVaterVuality, Groundwater Section within 30 days
GW-I REV. 12/99

Notlh Carolina - Department of Environment and Natural Resources - Division or Wolor Quality • Groundwatat Section 14059
1636 PAnil Service Center - nalalgh, N.C.27699.1G38-Phone [phone]
WELL CONSTRUCTION RECORD WELLCONTRACTOn: _ownell-G,
WELL CONTnACTOFI CENTIPICATION 0:
STATE WELL CONstnUCTION PenMrro!
1. WELL USE (check Apptrcebla sox): nasidonllal Munleipal d Industilal d Agrioultural d Monitoring ❑
nocovery U Heal Punip Water Injection 0 Older (] It Other; LIM Lisa:
2. WELL LOCATIUIJ: (Show sketch of the location below)
Nr+nrnst Town' -- y� �l ✓�� /.. -- — County:
O•Hvr�.X A Re_. A
ptoad Name and Nun,bors. Corrununity, or Subdivision ertd Lot No.) DRILLING LOG DEPTH
3. OWNER - -- J i E� Q�7fiT l�E1-61'J G►— From Tro' Fonr400n besorlpuon
a
Arlrlrnq D Y %� G
(Sirow or rtouio r o. (p 2 n r 7"/i/j, %� /)4
^r,l, or Town SIP10 ZIP Code
4. DATE DFIILLEU
5. IOIAL DEPTI I % r
6. CIJrTIN09 CC)I.I.EC1 EU YES n NOL-
7. DOES WEI.L RF.PI.ACE EXISHNG WELL? YES l__.1 NO[ r
S. STATIC WATER! LEVEL Below Top of Crialnq: gip` PT. -
(IM I-s' N Abovo top o1 Cesing)
o TnP nE r.ActN(3 IS FT Above Lnnd Surface,
•Tnr nr cnglnp tnrrTrnnrnrr nUnr hoinw I-enri 4tmlAna terinirei a Vnrinner In Prcor•
damn with 15A NCA37C.01111
r
to Ylrl.r) (arm)' %�___-- METHOD OF TEST
11. WAIEn zorlra (deplh): a a o "-X tj a'_._...-___
12. (MLORINA 1 ION: Tyre % % f� _ Amount U - //_S It additional apace H netded use beck of form
13. GASH 1G.
wain lntc►ness LOCATI N SKETCH
I:�nplh� 0 nn�elar or we h ` I JS,Mtertnl (8how direotlon and dletence from at level two Slate
From _ _ To 1 L FI. (� �" Roads, or other reap relerenee points)
1*10ol _ To --- --- FL
From T o-_____— FI. _
14. GROUT:
Praferlal Method
rth
riot
From U 'Io
15 SCnFr:rl:
Drplh DinITIP.1or Slot Size Material
rrunr --- to ----. __. f 1 in. _ in.
"rim -__—.— 't n —__-• FI. _ _-- In. _ In.
rmrp __.._..__ re ._.._— Ft._ In. _ In.
W. SAIIUIGrIAVET. TACK:
Ual,lh Size
rrrrr-1 -----. To . —.._ rt.. _..
Flcml
17 nEMArlKS.
Material
t 1`101Irnt:nV r rr1TIrY'T1 AT THI-gVIFILL WAS:CON9TAUCTED IN ACCORDANCE WITH t3A NCAC W. WELL
rriNe i Frt ►r; t ION 9 AN17Anr)13 AND THAT A COPY OF THIS RECORD H&S BEEN PROVIDED TO THE WELL OWNER.
ron orrICE USF. fffl_� ` UG 2 12Lf( tjrvNnl�m Q
SuNNI urIgInal to Division of
C, inl f!o.
gt,�
INSMUCTiNG ME WELL
Groundwater SeeWn within 30 days
0
0
c
co
N
O
fl
GWA 1`19V. 12192

North Carolina • Department of Environment and Natural Resources . Dlvlslon of Water OualltV • GmUndwatot Sectlon
1636 Mnil Service Canter - flalsigh, N.C. 27699.1038•Phono [phone]
WELL CONSTRUCTION RECORD WFLLCONTRACTOR: -L. tojwte,
WELL CONTAACTOn CSgtIFICATION Nt
STATE WELL CONSTAUCTiON p19111MITN:
1. WELL USE (Check Applicable Box): nesfdential MUn1cIpst ❑ Indughlal d AgricuitUral d Monitoring ❑
nucovery ❑ Ileat Pump Water Injecllon ❑ Other ❑ If Othar, LIsI Use:
2. WELL LOCA11014: (Show sketch of (lid location below) of %
Nnnrw.nl Town _— County:e-
� Foae-;T
(noad Name and Nunlbois. CommuNly, or Subdivislon and Lot No.) DRILLING LOG UP11A
3. OWNER �ALT ¢ CI11�t/ �VSc'�rJ From To `` F�^"0 Nsodpllon
Aririrrnsrt r (n �/ & r I3/1� 7•�
o root or rto—UTo 140.)
.rii1•nt Tnnn $Info Zip Code
d. DATE DRILLED --�,� C41 e
5. 101ALDEP11I Y )- r y 7
6. CIJ FI INGS C(JI-I.ECT ED YES[-- No
7. DOES WFI..L RFP(.ACE EXISTING WELL? YES 0 NO[�
8. STATIC WATEFI LEVEL Below Top of Cnqlnq: PT.
(Uso'+' H Abovo top of Cesfrp) —
o TOP nF r.Aq[Nr, IS-1 —_, rT. Above I-nnd Surface'
•rnr nr engine fnrmlllnin,l ntivr holnw l+nd eurfere rlfrynlrot A Vnrinnee In nrcor•
dints with 15A NCAC?C .p11B
10 Ylr=1-n (rfrrn)• '-7]::__- MCTH+7b QF TFST
11. WAT En ZONES (depth):
12. (:HLORINA T ION: Tyra O It addltlonel apace Is needed use beck of form
13 CASIf 1G.
Pe '- �'XIS%t� Wnlr Ihicionels
j UQpth ,� 01nmeter or Welphl/Ft. Mnledel
From -----To Ft.
FI.
14. GROUT:
Pr+r(11 Material Method
r1o11► A2o' Js� rt.
From •--- to ..._.._�F1. _ _ __ r �_
15 SCnrr:rt:
UrI'lh 17iarnrfler Slot Size Meleflal
riunl __to..._rl in. In.
N. —___— In. •In.
rr'!rrl ._- Te FI. _ In. In.
I U. SAI1DlGnAVEL TACK:
uppth Size
rrr,r1 _..__ _ To.. ....._.. rt.. _..
Fiont ro_..___.._. ri.
17: RLMAFIKS:
Material
- LOCATION SKETCH
(show dlreotlon and dletanto from at least two state
Roads, or other map relerenee points)
I rn I Ir:IT5F+v rr-RTIFY THAT T1al9 WELL WA9 CONIMMTED IN ACCOt1DANCE WItH 13A NCAC 2C, WELL
rr�Net pl Ir;l Il ,91 ANVAFiDS;'AISn THAT A COPY OF THIS RECOnD HAS SEEN PROVIDED to THE WELL O
ran orricE USFOHL'
011.1111 r!o pi I � 1 d
° T tat r!o.
. 12'0011
s0wit nrtul
1
3
rM
gNAWn5,0r• P1Zl`1',901`1fW-JSTyJCTlfM THE WELL DATE
to 01-ilslon of Wale- fly, Croundweter Section within 30 days
GWI MV.12199

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section 236122
1636 Mail Service Center - Raleigh, N.C. 27699.1636-Phone [phone]
WELL CONSTRUCTION RECORD WELLCONTRACTOR: M 110-r WQel A"Iklnc►
WELL CONTRACTOR CERTIFICATION #: ?goe-(
STATE WELL CONSTRUCTION PERIAITtl:
1. WELL USE (Check Applicable Box): Residen0al [ Municipal ❑ Industrial ❑ Agricultural F Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
NearestTown: tNlUrrhCounty: —
(Road N e anA Number , Community. or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER LOOT VA-1 ( /G✓1-CC From To Fonra:5a+Descripti
Address © ._ /0 '
(Street or Route o. amcos�TDnSQ�r /l
City or Town State Zip Code
4. DATE DRILLED - D
5. TOTAL DEPTH 59,!5
6. CUTTINGS COLLECTED YFS ❑ NO l�
7. DOES WELL REPLACE EXISTING WELL? YES [] NOQ-
8. STATIC WATER LEVEL Below Top of Casing:_ 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 ISA NCAC 2C .0118 10. YIELD (gpm): / %a METHOD OF TEST ,9.0
11. WATER ZONES (depth):
12. CHLORINATION: Type h VA erb{f-Amount sK It additional space is needed tSe backof form
13. CASING:
LOCATION SK-TCH
Walt Thickness
Depth , Diameter or Weight/Ft. Material (Show direction a +d d"es~ance trm leas: LNo 5!ate
From To �' � Ft. Sp F� 1 -�1'� Roads, or other n-�? relere: point
From To Ft.
From To Ft.
14. GROUT:
Depth M t riap I Method
From To 6L Ft.
From To Ft.
CZ)
15. SCREEN: --
r
Depth Diameter Slot Size Material
C
ea
1 -,
L
From To Ft In. in.
r
Z:
rr�
From To Ft. in. In. a�
From To Ft. in. In.
16. SAND/GRAVEL PACK:
Depth Size Material
m v
From To Ft. w
f
From To Ft.
ti
17. REMARKS:
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A 04CAC 2C, VO'ELL
CONSTRUCTION STAN, _, ,'MR T AT A COPY OF THIS RECORD HAS BEEN PROVICED -70 THE VI'S" I O"NEF•
FOR OFFICE USEi ONLY - --� � 62 � b�
Quad No: SIGNATURE OF PERSON CONSTRLY:TING IXE 10 ELL
Submll oNinal to D7vltilon of Water Quality, Groundwater Sracn within .K) c,Ys
" Gn.t Ft� V, 1291
Serial No.
t. jtt.
ii i

212944
North Carolina - Department of Environment and Natural Resources - Division of Water Duality . Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone] aL
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION #: 9iA
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (check Applicable Box): Residential [r Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCAT Shows etch of the location below)
Nearest Town: } , —i County:
(Road Namumbers, o unity, or SuJivlsion a d Lot No.)
DRILLING LOG
3. OWNER ;a
From To
Address 3� t
V q t
treat or RouteAC5
t
`�D t
City or Tow Mate Zip Code
6-
4. DATE DRILLED
5. TOTAL DEPTH gqrlt
6. CUTTINGS COLLECTED YES ❑ NO[D
7. DOES WELL REPLACE EXISTING WELL? YES a NO ff
8. STATIC WATER LEVEL Below Top of Casing: FT.
_tZ
(Use '+' if Above Top of Casing)
9. TOP OF CASING ISFT. Above Land Surface*
'Top of casing terminated at/or below land surface requires a variance in accor-
dance with 15A NCAC 2C o1 8
YIELD METH TEST L-
10. (gpm): 54F
11. WATER ZONES (depth):
12. CHLORINATION: Type Amount
13. CASING:
Wall Thickness
Depth
From 0_ To 'I rl
i eter WQigvFt. ,mad Ldal
Ft.— T�
From
To
Ft.
From
To
Ft.
14. GROUT:
From
Depth-
cc�1��--II
To _1_
Materlsol Metho
Ft.
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:
DEPTH
If additional space is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
0
Q
P
�t
0 c�
rn
N
-..ern
3
�rTi
N
rNri �
C71
:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH f5A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY�F,TH� IS RD HAS E E�N`PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY �}r—
Quad No:
Serial No.
SIGNATURE OF SON CONSTRUCTING THE WELL DATA
Submit original to Division of Water Quality, Groundwater Section within 30 days
GWl REV. 12/99

North Carolina - Uevnilmont of Environment and Natural Resources - blvlalon of Waldr Quality • Groundwater Saotion
1636 Mnil Servlco Cenler - Raleigh, N.C. 27699-1638•Phono [phone]
WELL. CONSTRUCTION RECORD wFLLCONTRActoR: �'11
WELL cownAtTOtI CEfitIEICATION A: _ 9_5 G 5�
STATE WELL CONStRUCT1ON PERMITII:
I . WELL USE (Check Applicable Box): rlesidonllal Municipal C] Indottla) d Agricultural d Monitoring
Recovery EJ Heal Pump Water Injection [] Other Cj It Other, Lis) Use:
2. WELL LOCAT101� w skq(ch of thCe location below) _
Nnnrnnt Tnvrrl• -- �:k� QJ� �'iountr. %t�.r�
(Road (Jame and Numbois. Commurdly, or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER _ _ � Q/Zp i l , From To ` Fo"rAtlon pesortpuon
Ar1r1lnq!;
($1+t+n1 or 1ioVTo i o.
web A)C-
rity nr 1 wn glnlo Zip Code
d. DATE DRILLEDn ------
S. 101AL DEPTII �5 D')
6. GU r-1INUS COLLEC1 ED YES n No r—+-
7. DOES WELL RFPI.ACE EXISIING WELL? YES NOD
8. STATIC WATER LEVEL Below Top of Cnatnq: _lpe)r FT._
(UsA '+' N Ahov9 top of Cttsirp) -- ---- ----•--
n Tnh f1F CA^IN(a IS PT Above Land Surface•
•Tnh nt r"Otio tnnntrt;,rnrl nVnr halnw I+nrl %mlot, r�(I * a onrlrrnCo In Pr�cor-
d,ncr with 151k NCAC 2C . t ifl ,/ 7
in YIFI.Ih (rtrrn)• _ METHOD OF TEST
11. WA1En orIE,i (depth):
12. CHLORINAI ION: type % .%_. .__ Amount a If addlttonrl space b needed use bock of form
13. CA SIrIG.
LOCATSKETCH
W �0 "(hICMnCv! ---I �
/� Dnpth C� pi meter or W� �G- (8how dtreotlon and distance from At (seal two 81als
m _- v ._ FroTo Ft. Roads, or other map reference points)
Front l o
id. GROUT:
Aalort� Method
morn To rI. ��-
From 10__--
tF.
l)rpIIJ Dintrneler Slot 61.76 Maleflal
rl _ In. it,,
Front --- re _.. - - rl. In. In.
15. SAf ID1Gr1AVLt_ rACK:
UppIlt Size Material
rrr,r.1 _._._ _ To - .._ Ft.._—
Ftem ro _..- n.
17. REb1AFIKS:
1
r
t
0
C
Orrl
C7
CA) o
o
-o rnl-�
0
N �
x
1 rn 1IF: rlcFly Cr-RTlrY T1IAT 71419 VvELL WA9 CONSTRUCTED IN ACCORDANCE,Wq�,1115A,:N0.AC 26, WELL
CONR'I fat tr; I ION S fANUARDS, AND TI IAT A COPY OF THIS RECORD HAS BEENA' 0VIbEQ',tQ *E jWELL OWNER,
FOR OFFICE USE ONLY
Or P ISTi1UCT1N01HE WELL DATE
- • SuNv it ortgfrtal to Di'dikQoflelQuaDtKcmutidwRiat Section within 30 days
�1 i11t!n• GW) REV, 12nq

21.3015
Norlh Carolina - Department of Environment and Natural Flosources • blvislon of Water OuslitV • Groundwater Section
1636 Mnil Service Center • Raleigh, N.C. 27699.1038•Phono [phone]
WELL CONSTRUCTION RECORD WELLCONTAACTOR: CAeao�eW_ oe
WELL CONTMACTOII C111111FICATION A: 7.Vx
STATE WELL ccNStnunoN Powrirs:
WELL USE (Check Appllcable Box): nesidentlA16: Municipal 0 (ndu5trlul d Agricultural d Monllorinq
nocovery CJ Heal Pump Water Injeellon 0 Other [] If Other, LIM Use:
2. WELL LOCAI"IUIJ: (Show sketch of (he location below) II_ r
N-nrPnt Town: __ ky. - _.-•___-.- Couniy a12P t> 6.c.
(noad Name and Numbors. COMMUNly, or SubdlvIAon and Lot No.) DRILLING LOG QEPTH
3. OWNER — _ "�57ASO rJ CAQ� L.L From To Form6tlon basorlptlon
Arlrlrr-!1s 520 ,,V �0.OWp�1 )/ `��oG t�
211$' or 1n�— Stnto Zlp Code
4. DATE DRILLED ^' 22 OD
5, 10TAL DEPTFI (_L') '
6. CUT-rINCTS COL.I.EC I ED YES(--) NOC}'
7. DOES WEI L REPLACE EXISTING WELL? YES 0 NO[a
8. STATIC WATER LEVEL Below Top of Crimp: _ __ Pf ;
(I!so'+' N Ahovo Top of Cnilnp)
0 7n� nr r.AGING IS FT Above LAnd Surface'
'Tnh nr rn+trip lnrrnlnn,nel nVor hnlnw I+nd 400fora tennirM a vnrinnte In or -cot•
dance with 164 NCAC 2C .01111 1q
in YIFI.h (nrm)• ... METHOD OF TEST /Z _-•- _--••--
11. WAIEn ZOtdE3 ((iepu,):
12. CHLORINA I I0N: Type . -7_j_l�._ .__ Amount �additional apace b needed use back of form
13 CASIr1G.
W N1 'I WCFnQ9!
U C,oIt q m9let p w 1 h12 , o 1
i'10111 ro—__-.— Fl.
Front l o - — Ft. _
id. GROUT:
Matcria
F7101 �—;�- Tu b Ft.
Front �V 'In
is scnrm.
Ur-1'111 Di7nrnlor Slot SIz9
FI In. _
In. _
15. BAUD/GFIAVEL PACK:
UPL,III Size
Fiem -- - r0--..._..
17. REMAFIKS:
In.
In.
In.
LOCATION SKETCH
/Kiftledri (show direction and distarice from at Ibuat two Male
Roads, or other map telerence points)
Method
Material
Material
I rn t lrnc:nv r,r- FITIrY TIJAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONS I Fat IG I ION 91 ANOARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED tO THE WELL OWNEM.
mij OFFICE U5F. ONLY _—t 1 l 1. ,
0trid Nn• SI(iNDR1AE
— Suhn,it ortgh,ll to DIYlilon
r!'igt No.
iNSTTIUMNO THE WELL
Groundwater Socilon within 30 days
G=
O
1:_
C
s
tV
47N
sue.
O
i31
0
O
oM
on
=m
a<
O
�m
cn=
Fri
Cj
0
Z_-C7 a
DATE
GW'I IIEv, 121"

213016
North Carolina - Department of Envlronmenl arld Natural Flesource6 • DtvIdlon of Water Ouallly • Groundwater Secllon
1636 Mail Service Center • Ralolgh, N.C. 27699-1036-Phono [phone]
WELL CONSTRUCTION RECORD WELL CONTAACTOM:
.WELL CONThACTOR ClrpTiFICATION M: ':-.5
STATE WELL CONstnUCTION PtMMITN:
1. WELL USE (Check Applicable Box): nesidentlal Municipal d Indughlej d AurIcullural d Monitorinp d
Recovery [_j Ifeat Pump Water Injection [] Offibr d if Other; LIM Use:
2. WELL LOCH I IOW: (Show sketch of (lie location below) /
Nnnrrint Town' County:
_mow 29 Y & /-/ !l am
(road Nam@ and Numbors. Corrvriunily, or Subdiv of l n and Lot No.) MILLING LOG DEPTH
3. OWNER --- `- -fiei L j%OPkl� From To FarrTAPont)eaorlpllon
ArlrJrncK CqS Hot, / 0
(Sligot or Flo
J"(-`—`7If rn�1nwS1p10 Zip code
4. DATE DRILLED '
5. 10IAL DEPTH _ a-0'7 '
6. CUrrINGS COL.LECI ED YES(--] NUCJ-
7, DOES WEIL RFPI.ACE EXISTING WELL? YES NO(-
8. STATIC WATER LEVEL Below Top of Cnginq: - no. FT,
1110 •a' H Alimo Top of CN4IrUl
o TnP nF r.AglNc; IS ._ �__._• rf Above I.nnd Surface•
'Tnli of rn.ln(j tnrrninnln/f nVnr hnlnw I+nd gvidAno torl,1444 A vnrfnnco In hecor•
linen with iFA NCAC 7.0 .0110
to YIFI-C7 (�1rnt) (yMETHOD OF TFST
I I. V4`Af En zorlrs ((iehti,): I t-�o /do
12. CHLORINA11ON' TYrA %7''7.//• _ -__ Amount PQ .5 If eddilbnrl space Is nelded usA Wick of form
13 CASING:
WnP lhleMnns!
- LOCATION SKETCH
Frnm.
bQplh ,
�U
bionreler or wel Vrl. M 1e8111
! 2i `• `'
(ghow direolbn and dletance from Mt keel two
(;lets
•--_To FI.
V
noads, or other map reference pointy)
f'10m
-to Fl.
From
i o
14. GROUI:
►`cFlh
To J
'Mal-rlal Mothod
p
C_
,� r 1.
From _ tor -I.
_L.d
C
r r;r
N
nialnr.ler SIOI Size Material
Flinn
to ._rt _—_--
In.10
'
x•
I"rom _—'In
_..... _ Fl. _
In. In,
``' 4 t
E5
15. SAIID;GnAVEL
rACK:.
UPplh
Size Material
'
rtaln —..__.
.. to rl.
17. RLMAF1KS
ro IlFrlrnY Cr-nTIrY TI IA7 71419 WELL WAS CONSTRUCTED IN ACCORDANCE WItH 16A NCAC 20, WELL
IIONel nl I13,110N S 1ANUARUS, AND THAT A COPY OFF THIS RECORD
HAS BEEN PROVIDED TO THE WELL OWNER.
ron OrrICF USE. ONLY 0. '�_ , (� J (n., _
00
rl,nif r:n-
I vial t;p,
str#.Vnfn5-dF Prhsoft Cptwnuicwta THE WELL ME
Suhntft prtulnai to Divlslon of Water ouallly, Groundwaler Sect!on within 30 dayg
GW1 nGV. 12199
C7
c�
oC7)
�<
4o
M
M
to
rn
m ::7
C)
q
C)

21.301. 7
North Carolina . Depmrtn,ent of Environment a11d Natural Resources • Olvlalon of Water OualiN • Groundwater Section
1636 Mnil Service Center - Raleigh, N.C. 27699-1638•Phono [phone]
WELL CONSTRUCTION RECORD WELL CONTAACTON: "// 1Q%`IIA'1
WELL CONTRACTOFI C191T1FICA11ON A: 6�
STATE WELL coNstAUCTION 1011AMIT11:
1. WELL USE (Check Applicable Box): nesidenllal8 Municipal C] indtlblslal Agricultural d Monllorino
flocovery [J_ [leel Pump Water Injection [] Other [] If Other,1_141 UM:
2. WELL LOCA11014: (Show sketch of lho location below) ff
Nnrimst Tovrn- County: CA"o4e g-
/N/P,
(Iload Name and Numbors, Corrvnunfly, or Subdivlafon and Lot No.) DRILLING LOG QEPTH
3. OWNER Cq, e O_ )rpQ I—AlP) to -/ . From To Fom-Atlon bleaadptlon
Adrhn9s / ) h&al� _ �r0'i I Q1 . b /UO' Jr e f C
'notai�o.
.^.sty of Tr n Stnio Zip Code -.
4. DATE DRILLED • - 1' .0 D -
5. 10IALDEPTII /(Z'2'
6. GIj f-I INGS COLLEC I ED YES NOC}�
7. DOES WEI-L F1FPI.ACF EXISUN(3 WELL? YES p NO[�
S. STATIC WATER LEVEL Below Top of Cnginq: _�` FT.
(t isA V' H Ahovo Top of Cnslnp)
o TnP nF r.AGING IS _ FT. Above Land Surface'
'Tap nt cnginp tnrmlrrnln.l nllr%r hnlnw I+nd Hrrfmoo Mqu1r44 A wrinnev In rrreor.
d•tnce wllh 151% NCAC 7C .0110
1n YIr1..17 (npm) I_:2 METHOD OF TEST
11. WAl Efl .'_ONG3 ((iepIh): 1/O
12. CHL0K11NA110N: Type /..7.e1... ___ Amnunl r� r5 II additional space Is needed use back of form
13 CASH JG:
wa1111Mc►ncss LO_ CATIn SKETCH
DnNih btnme►er or W IphVFI. artet (Show direotlon and dlatenoo Irom at bast two State
FI. ( _ �' � goads, or other map telererlce points)
From 10 rt.
14. GFlOLIT:
Prvii Mart' Method
from _ Tv A 0 rt.
From - _� 'io Ja!2 ...F=1.
15. nCr1Pt'rl•
Ur-l'th hi7rnr+.lor Slot Size Material
I"r(it e _ __ l o ...---__-• rl _--- In. _ _ _ . In.
n. _ In. In. — - -
111 SAI IUIGr1AVEL rnCK:
uPplh
rrr,r-,----.-- To.. ...._.._ rl
Fletlt
Size Material
M
1a
O
1-D
L
P';p
�
cm
1`r a
M
m
3>C7
m
o
m
o
.
m�
n
Cn
3
I rn I lrricFly r rnTir-Y THAT 71419 WELL WA9 CONSTRUCTED IN ACCORDANCE WITH MA NCAC go, WELL
COMP I pl Ili; LION 9 I'ANOAROS, AND THAT A COPY OF 11118 RECORD HAS BEEN pROMED TO THE WELL OWNED.
_
rOR OrrICF 115E ONLY
rnlmt f:n• ,,r R nE v Pr. N comgmcma THE WELL DATE
—.. SuNnil orfulnat to blvhloli o Water Ottatily, CmundwAler Sectlen within 30 day9
GWI nFV. 121"

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: e
WELL CONTRACTOR CERTIFICATION N:
STATE WELL CONSTRUCTION PERMITN:
1. WELL USE (check Applicable Box): Residential B Municipal ❑ Industrial ❑ Agricultural ❑`` Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ it Other, List Use:
P
2. WELL LOCATIO��jj Sow sketch of the location below) County:
Nearest Town:
(Road Name and�umbejs, Community, or Subdivision and Lot No.) DRILLING LOG
3. OWNER C' /l / `�° s S �e /� //a I'- From To Fonrazn Description
Address
( G`
(Street or Houle o.
City or Town Slate Zip Code
4. DATE DRILLED
o
5
5. TOTAL DEPTH USJ o
eln
a
6. CUTTINGS COLLECTED YES F­] NOD—
7. DOES WELL REPLACE EXISTING WELL? YES E] NOED— r
G"
B. STATIC WATER LEVEL Below Top of Casing: FT.
(Use '+' if Above Top of Casing)
-
c' f
9. TOP OF CASING IS FT. Above Land Surface
'Top of casing terminated aVor below land surface requires a variance In accor-
rTi
dance with 15A NCAC 2C .0119
5--- METHOD OF TEST
10. YIELD (gpm):
11. WATER ZONES (depth):
o
12. CHLORINATION: Type Amount If additional space is needed tts�e baci of farm
13. CASING:
LOCATION SK= fCH
Wall Thickness
Depth Diameter or Wee!ghVFt. Material (Show direction and dance trxn ec leas: rHo F%.a1edistance
—
c S- " °� / U G Roads, or other rr-.cp relerercp- points!
From 0 To c Ft. --6—''3
From To ZZLO Ft.6 zS—
From To Ft.
14. GROUT:
Depth trial M thod
From To Ft. r`Zi?
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 w; SLe Elljt ti�! Wier M
From To.
From To
17. REMARKS:
DO HEREBY CERTIFY TPAT THJ�S:'tt�itti!ltM6 S SMUCT ED IN ACCORDANCE WITH 15A f 4CAC r,,'/v-ELL
`1± 'f!_AF IS ECORD HAS BEEN PROVICEO-10 THE YI'�r". L OI%aEP.
CONSTRUCTION STAND r-+QPlt 4
o
FOR OFFICE USE ONLY _
�11Ei Z tv ELL 0A'' E
Quad No:SIGNTRIY:TING
Submit original to Divltion of Water puaitly. Gr rowalar Sr=n within :4 C;frYs
t:K.1 127i
Serial No. —

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section 4.A f! `t 3 9 Q
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]V
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION #: AqQ
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (check Applicable Bbx): Residential � Municipal ❑ Industrial ❑ Agricultural Monitoring ❑
Piecovery❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use: I t r E
2. WELL LOCATION: (Show sketch of the location below) n
Nearest Town: County: MOO
(Road Name and Ni bets, Commu/n'ity, or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER 119» Ile, ,�lbi'I� From To Fo#a�PeS•_,npt;c s ai
Address 2„ p �,� h /�
trees orr Route o.
M C', 2?
City or o State Zip Code p
4. DATE DRILLED t 1-�
5. TOTAL DEPTH J �s
6. CUTTINGS COLLECTED YES ❑ NOED--
r
7. DOES WELL REPLACE EXISTING WELL? YES [] NO[ . Cn zz-M
S. STATIC WATER LEVEL Below Top of Casing: -5n ' FT.
(Use '+' if Above Top of Casing)Irl
9. TOP OF CASING IS__1____ FT. Above Land Surface' _
'Top of casing terminated at/or below land surface requires a variance In accor- •• C—)
c-�
dance with 15A NCAC 2C .0118 .-
10. YIELD (gpm): 60 _ METHOD OF TEST
11. WATER ZONES (depth):
12. CHLORINATION: Type 646 4o I h$ Amount If additional space is needed ts-- back of foam
13. CASING:
LOCATION SK=TCH
Wall Thickness
Depth Diameter or Weight/Ft. Material (Show direction and d'�ance from as leas::no Swe
From Ft. ' `?L �rc
— Roads, or other rtp refere:� points`
From To Ft.
From To Ft.
14. GROUT:
Depth M tenal� Method
From . 2 _ To -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:
a t
Depth ,S)z :{Ma►� ria t
From To
From To t•
17. REMARKS: Crotlnd�&,Ite Sc +t
w.
VrELL
Y CERTIFY THAT
S WELL
ED IN WITH 155A 04CAC
I DOERECSTANDARDS, AIN THAT WAS
COPYNOF THIS RECORD HAS BEENACCORDANCE
70 THE /�.—_..-L O��'�EF•
CONSTRUCTION
FOR OFFICE USE ONLY ps. E
Quad No: SIGNATURE OF PERS�JN CONSTRIY:TING T>¢ vWELL
Sub,01 original to slon of Water Quality. Grovn4•raler Strut Within Vi C%Yg CN 1 Y. 129t
Serial No. - --

North Carolina - Department of Environment and Natural Resources - Division of Water Quality • Groundwater Sac -lion 4-394
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELLCONTRACTOR: :1 APIC ")P-11
WELL CONTRACTOR CERTIFICATION
STATE WELL CONSTRUCTION PERMIT#:
WELL USE (check applicable Box): Residential 132"' Municipal ❑ Industrial ❑
Recovery ❑ Heal Pump Water Injection ❑ Other [] It Other, List Use:
2. WELL LOCATIQN:�SI�ow skI i of the location below)
Nearest Town: j n r�v�5 County:
(Road Name and Numbers, Community, or Subdivision and Lot No.)
3. OWNER �; o 14 za-, y, P r
Address
`—'—(S reo or ou a o.
City or Town Stale Zlp Code
4. DATE DRILLED
5. TOTAL DEPTH 125 '
6. CUTTINGS COLLECTED D YESL) NOE'F�f—
7. DOES WELL REPLACE EXISTING WELL? YES n NO[✓ -
8. STATIC WATER LEVEL Below Top of Casing: 91*) 1 FT.
(Use '+' II Above Top of Casing)
9. TOP OF CASING IS i FT. Above Land Surface*
'Top of casing terminated at/or below land surface requires a variance In accor-
dance with 15A NCAC 2C .0110
10. YIELD (gpm): _10 METHOD OF TEST
11. WATER ZONES (depth):
12. CHLORINATION: Type VI IN }alal0-" Amount 4-
13. CASING:
Wall Thlcknoss
Depth Diameter orweight/Ft. Material
From To Ft. -ip-125 From— To— To Ft.
Agricultural ❑ Monlloring El
x
B
DRILLING LOG
From To Fo�rk1i311di��6estcr�ton
c_a
c-�
It additional space Is needed use back of tone—
o
From To Ft.
14. GROUT:
Depth M lorlal , Method
From �_ To -9b ' Ft. -P"r—1
From To Fl.
15. SCREEN:
Depth Diameter Slot S1z6 Material
From To Ft In. In.
From To Ft.
From To Ft. 14 q in_..:_V
16. SAND/GRAVEL PACK: L 11)
Depth ze ,''h_ Material
P �
From To,,
From To
17. REMARKS:
LOCATION SKETCH
Show direction and distance from at least two State
Roads, or other map reference points)
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 20, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE :USEONLY ,
Quad No:
Serial No.
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Quality, Groundwater Section within 30 days GW 1 REV. 12/99

North Carolina - Department of Environment and Natural Resources Division of Water Quality - Groundwater Section r� ..
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone (919) 7W.3221 (,, 14 J 850
WELL CONSTRUCTION RECORD WELL CONTRACTOR: W 1' 1 ) P.-C r,'�'0 11 8 C"a
WELL CONTRACTOR CERTIFICATION N:�
STATE WELL CONSTRUCTION PERMITP:
1. WELL USE (Check Applicable eox): Residential[t-'"Municipal ❑ Industrial ❑
Aecovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below) f
Nearest Town: OqUaki Sl County:y2— 1CC) n e-C I -
(Road Name and Numbers, Community. or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER ,4nr`-j C CC, IIC From To Forrraxn DescripGo.
Address
(Street or Route o.
City or Town State Zip Code
4. DATE DRILLED
5. TOTAL DEPTH 16,6 r co
6. CUTTINGS COLLECTED YFS [] NOED— T
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO o
n
B. STATIC WATER LEVEL Below Top of Casing: —,2_a_ FT. =_
(Use '+' II Above Top of Casing)
, sa
9. TOP OF CASING ISFT. Above Land Surface• a: cn
-Top of casing terminated et/or below land surface requires a variance In accor-
dance with 15A NCAC 2C .0118
10. YIELD (gpm): & METHOD OF TEST Ar .2
11. WATER ZONES (depth): Q C-)
CO � T
Agricultural 0 Monitoring ❑
12. CHLORINATION: Type Amount 5 If additional space is needed back of Ian 2
13. CASING:
LOCATION SK= fCH
Wall Thickness
Depth,, r Diameter or Weight/Ft. Material (Show direction and dis ance lrm teas 'Ho �i�te
From e—To — Ft. .5�, Roads, or other refere:c-e point?
From To Fl.
From To Ft.
14. GROUT:
Depth Ma enal
From 1_ To Ft.
From To Ft.
15. 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 PAEK: ,.'2. r l �� -.,•., (1)7�M' �yy
From To
From To
17. REMARKS:
--
I DO HEREBY CE
CONSTRUCTION
FOR OFFICE USE ONLY
Quad No:
Serial No.
Hal
ED IN ACCORDANCE WITH lSA DJCAC Y.:,'/VELL
RECORD HAS BEEN PROVIDED 70 THE Y/Ei L O�%"EF..
SIGNATURE OF PERSON CONSTRUCTING 1)c "WELL
original to Division of Water Duallly, GroundMalor Se=n within v) t;%5rys
Crr.l pig V. I2'M

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 H:
STATE WELL CONSTRUCTION PERMITH:.
1. WELL USE (Check Applicable Box): Residential Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other [:I If Other, List Use:
2, WELL LOCATION: ( how sketch of the location below)
Nearest Town: ���' 8�`l1 County:
.T6"71o1?
(Road Name and%%�umber , Community, or Subdivision and Lot No.) DRILLING LOG
3. OWNER - �dU/<'/Ohs D/1 From To
Address —
(street or Houla o.
City or Town Slate Zip Code
4. DATE DRILLED _ -­f-00
5. TOTAL DEPTH Z6 0 -
6. CUTTINGS COLLECTED YFS ❑ NO� -
7. DOES WELL REPLACE EXISTING WELL? YES [] NOD--
B. STATIC WATER LEVEL Below Top of Casing: Z 0. FT.
(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 15A NCAC 2C .0118 -
10. YIELD (gpm): I METHOD OF TEST Z2 _
11. WATER ZONES (depth): Z!�-
12. CHLORINATION:
13. CASING:
DEPTH
Forrra5cn Description
$ d • -•
C.)
r__'
i 9
:T—
O
Type % Amount �' �`� If additional space is needed Ltse back of fcrm
Wail Thickness
D
Depth `,
Z--
etorWeight/Ft. Material
r /Sf e e/
From
To
Ft.
From
To
Ft.
From
To
Ft.
14. GROUT:
Depth
�I?n hod
From 2
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 PA �
llVal
� M
Depth
From
To
Ft.
From
To
Fl:'? +'' ,�nfl(?
17. REMARKS:
DO HEREBY CERTI JY THA
CONSTRUCTION STANftARI
FOR OFFICE USE ONLY
Quad No:
Serial No. -
LOCATION SK=TCH
(Slow direction and distance tr^rn al leas: tNo Stele
Roads, or other rrr� reference polnts!
'�' - WS' 4PNSTR ICTED IN ACCORDANCE WITH 1SA 04CAC ?'�✓ELL
na; ,$;:,
1=1AT A`COPY'OF"T RECORD HAS BEEN PROVIDED
70'fH': Yl�"...L Ot�� ,•
SIGNATURtOF PERSON CONSTRUCTING 1)c 'N ELL
Submll original to Div(tlon of Water Quality. Ground"Ier Src cn Wllhin Yi C%sYs CFf. I Fit: V. t_p1

1, 2 0
Notth Carolina • Department or Environment and Natural Resources • Division of Water Quality • Groundwater Section
1636 Mail Service Center _ Raleigh, N.C. 27699-1636-Phono [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: �"// %//fNq
WELL CONTRACTOR CERTIFICATION 0:
STATE WELL CONSTRUCTION PERMITk:
1. YELL USE (Check Applicable Box): Residential E Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Racovery❑ Heat Pump Water Injection ❑ Other ❑ if Other, List Use:
2. WELL LOCATION: (Show sketch of the location below) Nnnrnq! Town: _—._ 11d l��ln _.--•—_-__ County. 1'L�//`
��
h L12� l 1
(riond Name and Numbers, Cortun nits, or Subdivision and Lot No,) DRILLING LOG DEPTH
3. OWNER —-JWJI AD From T ForrmtIon Description
Address ,r �� lt�f� 0 T
ra, 0r ft0 iIO 10, / (j �n n i - J/ / G7
U t G v` C)trt
^ly of To ri Sinle Zip Code
m
4. DA-CE DRILLED
5. 101AL DEr1l1 lot) �' - to m
6. CUTTINGS CCILLECI EU YES n NO[y
7, I?OFS WFi_L REPLACE EXISTING WELL? YES NO[�rri
A. STATIC WATER LEVEL Below Top of Cn91nq: �__ FT.
(11,n •.• If Abov9 Top of CA"!ng) - _ fV 71 —
9 TOP OF CASING ISFT. Above Land Stirfacn, cho
x
•Trp of rneMn fnrn lnnt+ef av,r boinw Iind 4mrfnnso rMrnlrA4 A virinnee in arror• -- ---
dir,c^ with 1S1k NCAr 2!: 0119 — —
In YIrI f1 (npm)• _�. - METHOD OF TF..ST 1 —^ _
1 1. MATE( Of1ES (clel:lh): 2 `!a __.--•__--.-----_
12. CHLORINATION Typo 741 Amount 11 additional space Is needed use back of Iorm
13. GAS It JG. —
W,u •ihlckness LOCATION SKETCH
f r�plh / Dinm er Of
Wrt. l hfl eler;nl (Show direction and distance from at least two State
FI nm __.�.__.__. To _6.3�__ FI. _ L " Roads, or other map reference points)
1 rim._._. To--•• ---- FI.
From to-. --- Ft. —
14 (;ROUT: Y
Motor ia MethO10
rt
t?rt^!h C?iamrinr Slot Size Material �a�
1ofIi _ _ to Ft _ _ in. —._ In.
- _ _ — --- --
In. _ In.
From To rl. In. -- In.
15. SANWGRAVEL rACK:
Uppth Size Material
rrnrt ._...__ Tn _. __.___ rt..------
F!oru --- _ TO -- -- 171.
17. FIEMAFI1C3'
1 rq HFFTcRv r.r-p-rlFy THAT TRIG WFLL WA4 CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
("ONST W IC,TION S 1-ANPARC1S, AND TI IAT A COPY OF THIS RECORD H BEEN PROVIDED TO THE WELL OWNER.
rOR OrrICF IJSF. ON Y �..__._.�r —•- 4=�•.�— t u -- _
rTi� 1 rtn SfliTInT r r r..n C ISTFIUCT1T1f3THF. WEcl1 DATE
' ' r^it nri heal to vidnl.on of ftri-lbunmy, Groundwnter Sncl!on wllhin 30 days
G'NA REV. 12199

212953
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] \ � W J 6(Ll LU I {� (�
WELL CONSTRUCTION RECORD WELLCONTRACTOR:S-I�4t11�(`ft'45�"
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 LOCATI
Nearest Town: _
the location below)
rl, County:
(Road NameNumber, mun( or Subdivisio and Lot No.) DRILLING LOG
3. OWNER From To
Address Q S�
treat or HOUtO �
City or wn \ State
4. DATE DRILLED q UU
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑ NO[✓]�
7. DOES WELL REPLACE EXISTING WELL? YES2 NOCE[
8. STATIC WATER LEVEL Below Top of Casing: FT.
(Use '+' If Above Top of Casing)
9. TOP OF CASING ISFT. Above Land Surface'
'Top of casing terminated at/or below land surface requires a variance In accor-
dance with 15A NCAC 2C.04,18
10. YIELD (gpm): METHOD OF TEST LL
11. WATER ZONES (depth): 01 3`
DEPTH
Formqo
escription
- �
PON mot_ .. _ .
12. CHLORINATION: Type Amou If additional space is needed use back of form
13. CASING:
Wall Thickness
Depth la� Apr or a VFt. teri
From To o�>)b Ft. 1
From To Ft.
From To Ft.
14. GROUT:
Depth _ M t vial Method
From To �U 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
17. REMARKS:
To Ft.
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS REC RD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Quad No: SIGNATURE OF P CONSTRUCTING THE WELL DATE
Submit original to Division of Water Quality, Groundwater Section within 30 days
Serial No. GW-1 REV. 112199
to
Q
o
C orn
z C�
N o,�
N v'
.• M;X)
U7 C')
v o
Z

2.12950
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] UaL \b�_,`
WELL CONSTRUCTION RECORD WELL CONTRACTOR: W�'L-1 W S-T0At (TEM!S
WELL CONTRACTOR CERTIFICATION #: 3
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential ff Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATIOO�Mw sketc1h of the location below)
Nearest Tow,p: - l� County:
(Road Name and N mbe s, munity d ubdivision and Lot No.)
3. OWNER \
Address 1 f1 cam._ .
4. DATE DRILLED `a. V 1 I UU
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑ NO[D'
7. DOES WELL REPLACE EXISTING WELL? YES NOE�f
B. STATIC WATER LEVEL Below Top of Casing: FT.
9. TOP OF CASING IS (Use •+• It Above Top of Casing)
FT. Above Land Surface -
'Top of casing terminated at/or below land surface requires a variance In accor-
dance with 15A NCAC 2C .0116�
10. YIELD (gpm): I_ METHOD OF TJS
11. WATER ZONES (depth):
- a G�► Y1
12. CHLORINATION: Type �'l1� Amount._
13. CASING:
DRILLING LOG
DEPTH
Formallo Description
`1111
If additional space is needed use back of form
Wall Thickness LOCATION SKETCH
d Depths i�rn�e��r o Wei h t �Matprjal (Show direction and distance from at least two State
From To Ft. YY 4�V� • Roads, or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Ma arlaljj. ethod
From b To ou 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:
_
J
Depth
Size
Material
From To
Ft.
From To
Ft.
17. REMARKS:
h
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF -THIS FJFCORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Quad No: SIGNATURE C@ARSON CONSTRUCTING THE WELL D TE
Submit original to Division of Water Ouality. Groundwater Section within 30 days
Serial No. GW-1 REV. 12/99

212949
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]c�� Tit E a.
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION #: 3
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential19 Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other 0 If Other, List Use:
2. WELL LOCATI(Jt�k-(S o�w`s�k ch f the location below)
Nearest Town: `"� County: _4016��
(Road Name laft Numhers,IC*fly. o S division and Lot No.)
DRILLING LOG DEPTH
3. OWNER I
From To Form ion Description
Ad ress �(]
b ko
ire ou
��' rj5
�5 3b'1
City or To n State Zip Code
t
4. DATE DRILLED M��
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑ NOED'
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO[►l
8. STATIC WATER LEVEL Below Top of Casing: 1p FT.
(Use '+' if Above Top of Casing)
9. TOP OF CASING ISFT. Above Land Surface*
'Top of casing terminated at/or below land surface requires a variance In accor-
dance with 15A NCAC 2"118 '
'D14
10. YIELD (gpm): METHOD OF TEST -
11. WATER ZONES (depth): t
12. CHLORINATION: Type _ Amount
If additional space is needed use back of form
13. CASING:
Wall Thickness
LOCATION SKETCH
Depth t Di et r or W�eighttt/Ft to 41
SD or'`'
(Show direction and distance from at least two State
From To Ft.—
Roads, or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Niatprial Method
b To Ft. £ e
o
Q
From
0
p
From To Ft.
c,
7,
15. SCREEN:
=
Depth Diameter Slot Size Material
To Ft in. In.
4From tm
o
From To Ft. in. In.
M.�
From To Ft. in. In.
; ; t (
'
����
('
fy
�z
rn�
16. SAND/GRAVEL PACK:
"
Depth Size Material
r2 n
From To - Ft.
From To Ft.
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD
HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Quad No:
Serial No.
SIGNATURE OF,PHEj�& CONSTRUCTING THE WELL DATE
Submit original to Division of Water Quality, Groundwater Section Within 30 days
GW1 REV. 12/99

212946
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] W�Me5f\UE
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION #: 9SS
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (check Applicable Box): Residential t-_I Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCA ION: Shows tch of the location below)
Nearest Town: County: -
Agricultural ❑ Monitoring ❑
(Road Name u b unity, or Su 'vision and Lot No,) DRILLING LOG
3. OWNER From 70
dress 'd O 13 t
ree o u o. e 3 S 10' 4'
City or Town State Zip Code I �' °a b'
4. DATE DRILLED X� aSr
5. TOTAL DEPTH 1� 3ar
6. CUTTINGS COLLECTED YES ❑ NOE t
7. DOES WELL REPLACE EXISTING WELL? YES NO ff
8. STATIC WATER LEVEL Below Top of Casing: FT. 4O '�Sr
(Use '+' it Above Top of Casing) q 3$�
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 .q).18
10. YIELD (gpm): MET OD OF TEST
11. WATER ZONES (depth)- �bs
12. CHLORINATION: Type Amount If additional space Is needed use back of form
13. CASING:
Wall Thickness O p�e� LOCATION SKETCH Depth , i r, ta�e(elt F'V (Show direction and distance from at least two State
From To Ft. t k Roads, or other map reference points)
From To Ft.
0
From To Ft. O
14. GROUT: O Q
Dept M tgrial _ Method c o
From a To Ft. N m
From To Ft. t N v
15. SCREEN:
Depth Diameter Slot Size Material r
rn
From To Ft in. in. N ��
From To Ft. In. in. cat ::j
From To Ft. in. In. zj
'r o
16. SAND/GRAVEL PACK:.,�'�- IS
Depth Size Material m)
From To Ft.
From To Ft.
17. REMARKS:
,t 'Iii Y
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Quad No:
Serial No.
DEPTH
I6
SIGNATURE OF PEtON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Quality, Groundwater Section within 30 days
GW-1 REV. 12/99

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section 214420
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: (1� SIP l,�') If
WELL CONTRACTOR CERTIFICATION #: �242 U
STATE WELL CONSTRUCTION PERMIT#:
1, WELL USE (Check Appllcxble Box): Resldenllal Municipal ❑ Industrial ElAgricultural ElMonitoring El
Recovery ❑ Heal Pump Waler Injection ❑ Other ❑ II Other, List Use:
2. WELL LOCATION: (Show sketch of the location below) %i�r=�-�-1 .�
Nearest T wn: County:l,
1 Ro
(Rond ad NaIivision and Lot No.. DRILLING LOG DEPTH
3. OWNERy: �^� 1 ��� ��v�From To Formation Description
Address
(Street or Floule o.
City or Town Stale Zip Code
4. DATE DRILLED, ") G` aC
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑ NOL_ ;
7. DOES WELL REPLACE EXISTING WELL? YES
6. STATIC WATER LEVEL Below Top of Casing: Sc)' FT.
(Use '+' it Above Top of Casing) ' I i
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): _ /S METHOD OF TESTAIIX
11. WATER ZONES (depth):
12. CHLORINATION: Type Amount It additional space Is needed use back of form
13. CASING: '
Wail 7ldcknoss LOCATION SKETCH
Depth �Diameter or WIellgght/rt. Material (Show direction and distance from at least two Stale
From __Q_To Ft.- fir— • _ Roads, or other map reference points)
From To Fl.
From To Fl.
14. GROUT:
Depth' Mal rlal Method
From � To o�Q-- FI. CD
0
From To Ft.
15. SCREEN:
r~
Depth Diameter Slot Size Material N
From To Ft In. In.
From To FL In. In.
From :.
16. SAND/GRAVEL PACK jm ' )j 4 o
S� i
Depth
From Tol.
From To 1 kl
17. REMARKS:
Croundwater Section
i b0 HEREBY CERTIFY H/17 TIiE�tA4 6Vd?�SibSTRUrCT. DIN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STAN , AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE. USE ONLY
Quad No:
Serial No.
co
c: n
o�
rn
<
.� r.-1
CJ
M
c�
rn
cn v
rn
a
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
original to Division of Water Quality, Groundwater Section within 30 days GW 1 REV. 12/99

North Carolina Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section 4 413
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: <Z�'
WELL CONTRACTOR CERTIFICATION #: 2n U
STATE WELL CONSTRUCTION PERMIT#.*
WELL USE (Check Applicable Box): Resldenlial 0--Municlpal 0 Industrial ❑
Recovery ❑ Heal Pump Water Injection ❑ Other ❑ If Other, List Use:
Agricultural ❑ Monitoring ❑
2. WELL LOCATION: (Show sketch of the location below) /� �D J��
Nearest Town: County: h
(Road Name n u bars, Co unity, or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER Al
�C'a�ir ©i—1 From To lFom,alionbescriptlon
Address - 6 / _ c1�t
--(Street or ou a o.
City or Town Slate Zip Code
4. DATE DRILLED
5. TOTAL DEPTH --�
6. CUTTINGS COLLECTED YES ❑ NOQ/
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO (�--
8. STATIC WATER LEVEL Below Top of Casing: ,,(r) 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): METHOD OF TEST
11. WATER ZONES (depth):
mount �_
If addilionai`space Is needed use back of form
12. CHLORINATION: Type
,,.
13. CASING:
- LOCATION SKETCH
Depth r Diameter
Wall Thickness
or Welglfft. Material
(Show direction and distance from at least two State
f�
From_0—To 5ioFt•
S i .�l - (.--
/
Roads, or other map reference points)
From To FI.
From To FI.
0
14. GROUT:
Depth Mal riq ai Method
C'3
r
From To FI. �2Q1-/r.vic✓rn
From To Ft.
N
15. SCREEN:
U'1
� rn
Depth Diameter Slot Slze Material
d.
rnI-
From To Ft In.
in,
M
From To FL In.
In.
o
u' �=
M7j
From To rt. In.
In.
o
_C-),
16. SAND/GRAVEL PACK:
Depth Size
Material
From To Fl•
From To Ft.
17. REMARKS:_
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 20, WELL
CONSTRUCTION STANDARDS, AND THAT A CPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Quad No:
Serial No. —
NSTRUCTING THE WELL
Groundwater Section within 30 days
DATE
GWI REV. 12/99
lip Rleo'OM�

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section l_ .1 /I /j
1636 Mail Service Center - Raleigh N.C. 27699-1636-Phone [phone] `� 4
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION #:- a S/o�/
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential 0--Municipal 0 Industrial ❑ Agricultural ❑ Monitoring d
Recovery [J Heat Pump Water Injection ❑ Other C] If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below) �I to Co
e P
Nearest Town: 4�.P_.S ll ; to County: VV
hr%CI � DEPTH
(n Name d Nur�ibers, Comrtiunity, or $ubddlvislon and Lot No.) DRILLING LOG
La �V''1, + From To Formation Description
3. OWNERv�
Address r
ree or ou a o.
City or Town Slate Zip Code
4. DATE DRILLED '��1�7 /Q�� fro
5. TOTAL DEPTH c�ccurzr--iZ
6. CUTTINGS COLLECTED YES O NO
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NOEU-
8. STATIC WATER LEVEL Below Top of Casing: ,6 FT.
(Use '+' It Above Top of Casing)
9. TOP OF CASING IS I. FT. Above Land Surface'
"Top or casing terminated eVor below land surface requires a variance In accor-
dance with 15A NCAC 2C .0110
10. YIELD (gpm): S METHOD OF TEST .1d Z
11. WATER ZONES (depth):
12. CHLORINATION: Type hl h =; ea Amount � --
13. CASING:
Wall Thickness
Depth Diameter or weighVFI. Material
From D To 949 Ft. '�/ _
From To Ft.
From To Ft.
14. GROUT:
Depllt M lorlal Method
From � To-e�f�-Ft. �7lG✓I
From To Ft.
15. SCREEN:
Depth Diameter Slot SIZE Material
From To Ft In. In.
From To Ft. In.' In.
From To.Ft: Ir12+Ts ,;_ I�
16. SAND/GRAVEL PACK
Depth SIZe Ma I
1. 1 ,4
From To r 1 L-
From 70 1. ,
17. REMARKS:,,�,,,,,,,tQ.
IS D IN ACCORDANCE WITH 15A NCAC 2C, WELL
OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER,
I DO HEREBY CERTIFY Tf•tltT—TMIS-VVEUU v
CONSTRUCTION STANDARDS, AND THAT
FOR OFFICE :USE:O:NLY
Quad No:
Serial No.
�
Q
li
n
T-
M
.y
z
It additional space is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
SIGNATURE OF PERSON CONSTRUCTING THE WELL
Submit original to Division of Water Quality, Groundwater S` action within 30 days
r
_ —i i—
DATE
OW-1 REV. 12/99

��'
North Carolina - Department of Environment and Natural Resources - Division of Water Quality • Groundwater Section � � 4 391
1636 Mall Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: P C S L nT_
WELL CONTRACTOR CERTIFICATION 0:, o2yU
STATE WELL CONSTRUCTION PERMITff:
1. WELL USE (Check Applicable Box): Resldentlal d'--Municipal ❑ Industrial ❑ Agricultural d Monitoring ❑
Recovery ❑ Heat Pump Water injection ❑ Other ❑ II Other, List Use:
2. WELL LOCATION: (Show sketch of the location below) / �D J(�
Nearest Town: County: !'1 / 1
C,4 an
(Road Na and Numbers, Community, or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER �1) c) ��j�_I_1_�� +"� 7-i- From To Formation Description
Address 6)
—J.�'--
--lSir-eet or Route o. _� r I �_ U�
City or Town State Zip Code
4. DATE DRILLED S _ j
5. TOTAL DEPTH I EF
6. CUTTINGS COLLECTED YES ❑ NO
ED-
7. DOES WELL REPLACE EXISTING WELL? YES n NO c�—
8. STATIC WATER LEVEL Below Top of Casing: _2,,� 1 FT.
(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 .0118
10. YIELD (gpm): ."'? METHOD OF TEST r`2
11. WATER ZONES (depth):
d
12. CHLORINATION: Type s Amount— If additional space is needed use back of form
13. CASING:
Wall Thickness
Depth Diameter or WelghUFI. Material
From --To 3— Ft. -6Z-2�5 - D I 10
From To Ft.
From To Fl.
14. GROUT:
Depth Material % Method
From To FL r
From To —FI.
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft In. In.
From To Ft. In. In.
From To _-FI.._._..-__Jn­
16. SAND/GRAVEL PACK. .
Depth,
From To Ft.
From To
17. REMARKS:
I DO HEREBY CERTI
CONSTRUCTION ST
FOR OFFICE USE ONLY
Quad No:
Serial No.
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
IN ACCORDANCE WITH 15A NCAC 2C, WELL
ECORD HAS BEEN PROVIDED TO THE WELL OWNER.
SIGNATURE OF PERSON CONSTRUCTING THE WELL .
Submil original to Division of Water Quality, Groundwater Section within 30 days
DATE
GW-1 REV. 12/99

North Carolina - Department of Environment and Natural Resources - Division of Water Quality -Groundwater Section 1 ["} 3 9 0
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION #: ayo U
STATE WELL CONSTRUCTION PERMIT#:
WELL USE (Check Applicable Box): Residential 0--municipal Ll Industrial
Recovery 0 Heat Pump Water Injectlon [] Other n If Other, List Use:
Agricultural ❑ Monitoring
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: _ A�nh �� ___ County: h
4Pr,4 /- � -?9L/ DEPTH
(Road Name a Numbers, Community, or Subdivision and Lot No.) DRILLING LOG
3. OWNER 1 From To Formation Description
Address S�/U ,'q —��t2 O - 5 ' C/4
'---jS reo or ou a Ao0.) �� a6
Ss Sod
City or To State Zip Code
4. DATE DRILLED -I o - 0a
5. TOTAL DEPTH ZUS'
6. CUTTINGS COLLECTED YES [] NO
7. DOES WELL REPLACE EXISTING WELL? YES n NO[a
B. STATIC WATER LEVEL Below Top of Casing: ,:�o '_ FT.
(Use '+' it Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface'
*Top or casing terminated al/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):
12. CHLORINATION: Type b�%l �e f5_ Amount It additional space Is needed use back of form
13. CASING:
LOCATION SKETCH
Wall Thicknoss
(Show
Depth r Diameter or WeigtiVFl. Material w direction and distance from at least two Stale
From To S- - FI• - — - - �yC Roads, or other map reference points)
From To Fl.
From To Ft.
14. GROUT:
Depth Material Method
From _0 To �_Ft. f� lr�
From To Fl.
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
1In Material
From To
From To
17. REMARKS:_
Aglll VNIC tie tonal untre
100 HEREBY CERTIFY THAT L'tNA, STAUCT D HAS BEEN
WITH 1 E #CAC E WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY DATE
Quad No: SIGNATURE OF PERSON CONSTRUCTING THE WELL
Su It original I.
Division of Water Quality, Groundwater Section Wllhin 30 days GW 1 REV. 12199
Serial No.

North Carolina - Deparlrnent of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center • Raleigh, N.C. 27699-1636-Phono [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION 0: to
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residontlal LIB Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Rocovery ❑ Heal Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of lite location below) ,,,,��,, GGII
Nnri mst Town: ___Zibk k ._ _�� — County. eADLq--
(Fload Name and Nur ors, Colrunurdty, or Subdivision and Lot No.) DRILLING LOG
DEPTH
3.
OWNER _—_ A. 6", hoA • p' From To �1
FoorrrnetlonDescrriiptioon?
jGot oor flo.0 F]o j r _��y�
a.S ✓/
_
^rty of Tnvei $Iolo Zlp Code
'
CD
O
o
5.
1 OTAL DEPTH
�m
6.
_�:�,�
CUT-rwUS CULLECI EU YES(_ No
c'C-)
7.
DOES WELL REPLACE EXISTING WELL? YES [--_] NO[�:`
oc
8.
STATIC WATER LEVEL Brllew Top of Casing:FT
C:)
o.
_
(IP:n •+• lr Above Top of Cmfrg)
TOP OF OASING IS FT. Above Land Surface`
_.---_-•-•— •..43.
�m
•Tnp of raalnn fnrminntnrl ,Vnr hainw I+nef arrfane renuires a vnrinnco In nr•cor-
rfincn
In.
oath 15.4 NCAC 2 0110
YIFI.h (7Fm)' �.n_-_ 1AFTHIOD OF TEST
11.
_je.__VN
V✓ATEn ZONES (depth): / t�+ 8 `�.r ._-.-•-•--�--.
....o
x
12. CHLORINATION: Typ- ��� -�� _ Amrnint ,r�J` 11 additional space fs needed use back of form
13 CASING,
IMP jhlrknn,S9 LOCATION SKETCH
/�) Caaoth D' n ter o� W�cI��fft eriel (Show direotion and distance from at least two Slate
Frnm —v __ Tn — � - Ff.
��� Roads, or other map reference points)
I'fotn To — -_— FL
From To --- — Ft. — �-
14. GROUT.
Dr•�ihMalarial Method
frunl 0 To Ft.
J
From _-� r -I) .�,� �_ F1.
15. srRFFbI:
ovi'lh Pinrnelhr Slot Sizo Material
Fium _.__ Io Fl — in, in.
From ---- 1 n — Ft. �-- In. In.
Frnm - To - --- Ff. _ In. -- In. _
16. SAND1GRAVEL PACK:
Dnplh Size Material
Frnm ._--.__ Tn-. ._-Ft.. _
Frc;rn
17. REMARKS.
I r(') HFRcIt„ TIFY THAT THIS WELL N
r�OMMRlICJ
'1 � I'ANbff!7S#NLI��VAT
roR orricFjUSFVl`JLY
r]ll�a f�7 !?rn��nr9 raiser Cnrtinn
r?'iil No
IRTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
OF THIS AEC O HAS BEEN PROVIDED TO THE WELL OWNER.
RJAMnE ON CONSTRUCTING THE WELL DATE
irls(on Wrtler Ouality, Cmundr,nler Secflon within 30 days
GW1 RSV. 12199

North Carolina - Department of Environment and Natural Resources - Division of Water Quality • Groundwater Section
1636 (Anil Service Center - Raleigh, N.C. 27699-1636•Phone [phone]
WELL CONSTRUCTION RECORD WELLCONTRACTOR: C_klP-,_D ---
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check applicable sox): Residential Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Rocovery ❑ Heal Punip Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCA LION: (Show sketch of the location below) /� r
NPgrngt T!?Wn: --�1 County. l�-j'i,e PZ LQ
�11jj,,)JA- Ica), C.2eeK
(Road None and Numbors, Community, or Subdivision and Lot No,) DRILLING LOG DEPTH
3. OWNER ___ C% i` 7 P_p�(�j j= F From To Forrnallon Description
A.cidrps-3_
NE
pig I'm�' rooter �oFJ(�r'
Dly or Tnv.n SIBIU J 21p Code
4. DAME DRILLED �- Pa
5. 1 OTAL DEPT1-f
6. CUTTINGS COLLECTED YES(__] NOET
7. DOES WELL REPLACE EXISi'ING WELL? YES NOr o
8. STATIC WATER LEVEL Below Top of Caning: FT. - _ C3 AE
(Uso 141 If Above Top of Caslrg)
P. TOP OF f ASING IS FT. Above Land Surface'
oM
`Tnp of rnelnp inrminnr^rl gl;nr hr+hW Ianri t1lffAgq tlrrlUtrl4 a VariggCp In PCCOt• '""'• ( Z rn
dince with 15A rdCAC 2C .0110
t n YIFLh (�ipri)• _ __ METHOD OF TEST c .. Arn
11. WATEn ZofdGS (depth):
12. CHLORINATION', Typos �' Amount o fps
13 GAGING:
Will Thickness
Dapth _ Diameter ar W Ight/F( etartal
It
F'rorn — To—_.—.— Ft.
Front To----.— Fl. _-
14 GROLIT:
Q!'rlh Material Method
1,10111 To ZOr Ft.
From `� . to
Flom
Fr, m .----
I ---- _ F1. �- -- In.
Frorn ---
-• ,`, - - F1. ____ In.
19. SAND/GRAVEL
PACK:
UPpth Size
Fr�:•m--_-__-.
Tn_. ...___.Ft..
Flom
To Ft.
17. REMARKS
Slot Size Material
In.
Material
�rn
m
If rtdditional apace is needed use back of form :_0
„ LOCATION SKETCH _
(Show direction and distance from at least two Stale
Roads, or other map reference points)
I rn f 1FR511Y r:r-nTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE
r'ONR i RI IC TION 5I ANDARDS, AND THAT A COPY OF JHIS RECORD HAS BEEN
rOR OFFICE USF. ORi:
Omr1 fin'
17JUN 2 8 2000 �
rK'115A f AMd1 t6Vft0on
� k2- ZfL
SIofn71' IRE of Frfttyf1 eePKTnucTINt3 THE WELL DATE
Svhrtlit oriChiftl to Division of Water Qunlity, Groundrinter Section Within 30 days
GWI nEV. 12199

North Carolina • Department of Environment and Natural Resources - Division of Water Duality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699.1036•Phono [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: QL,_Izt k se= Oe_ DIRT
WELL CONTRACTOR CERTIFICATION 111: �
STATE WELL CONSTRUCTION PERMIT#! o
1. WELL USE (Check Applicable Box): Residential M Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heal Pump Water Injection ❑ Other ❑ if Other, LIM Use:
2. WELL LOCATION: (Show sketch of the location below)
Nnnrn41 Town _— �1 a �A.k . ___. —�._ County Q,aake e-
(nand Name and Nunlbors, Communi(y, or Subdivision slid Lot No.)
DRILLING LOG D�PTI'{
3.
OWNER ,3er)hc
-
From FortnellonOeeoriplion
Address
�u L� PpIQ
�To
rent Or R �IoFlo.j
SG,' S� � � � �t �� /�'%j:• �%e-
C.ty or Tnv.rl Slat Zlp Code
`� /� • '
4.
DATE DRILLED
n
S.
toiALDEPTI-1
7.
DOES WELL REPLACE EXIST NG WELL? YES NO
TM
S.
STATIC WATER LEVEL Below Top of Cnsing: FT.
=—cam
(Uso ',r• If Ahove Top of CrWrp)
r n Cx<
P.
TOP OF r.ASIN0 IS._—/ FT. Above Land Stirface'
Ao
'Toll of rnalno Inrminahrl Mlor hninw find gi0neto rotlrrlrAit P vridance In Prcor-
d-tnce
1 (I
with 15A fICAC 2C� "I �l
YIF.IP (grm)' M THOD OF T�ST C
rn
_l: _ _-- _
,
---• ----._ _�?_.._. �
11.
WATER ?ONES (deplil): '��
G1 Q
12.
CHLt RINAT IQN: Tyre J ��.._..__ Amount �' ��'
II additional apace Is needed use beck of form
13.
CASING.
Warr Thiclrncss LOCATIO SKETCH
(:)poll) Dinnleler or Wetght/Ft. lerinl (Show direotion and distance from at (east two State
Frnm _ ._ __ To —Y-6_ Fl..� , 1 �' Roads, or other map reference points)
Fforrl - To--..---- FI,
From _ ­To___ Ft. -_
14. GROUT:
f�r'Pill r patorl I Method
Flom v Tr) v1`) ft. '✓v
From ��_ to
15. SCREEN:
Orhth Dirmirler
Ff un l _.__ to Fl it
From r--- To --__..._. Fl. Ir
Frr?m —__-. To FL.---- Ir
Ili, SAtID,,onAVEt_ PACK:
Upplh Size
17. REMARKS'
Slot Size Material
In.
In.
In.
Material
JUN, 2 8 2000
I rrr, HFP Foy r r.nTIFY THAT THIS WELL WA9 CONSTRUCTED IN ACCORDANCE WITH 15A N AC 2C �" n�j tlffice
CONSTRI ICTION S 1 ANDARDS, AND TI fAT A COPY OF THIS RECORD HAS KEEN PROVIDED T T1IEn 9fl`�' 11fia'�fµi—
I"0R OFFICE USE. ONLY-
ound NO, r4ICMA 1nE orr F! sor Cvr UCTINo THE WELL DATE
Su!}ctit ori�ln3l fe r,ht�of Wal Ousli , mundwater Section within 30 days
GWf nF_V. 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: ke-e "% Dom,' I/ra
WELL CONTRACTOR CERTIFICATION 0: 2 6,
STATE WELL CONSTRUCTION PERMiTp: L"o
1. WELL USE (Check Appllcablo cox); Residential Municipal ❑ Industrial ❑ Agricultural Cl Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ if Other, List Use:
2. WELL LOCATION: (Show sket h of the location below) l _
Nearest Town: _--/ r P -- County:
(iload Nan,e and Numbers, CornmuNly, or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER - k'j mjjolz►ty From 7 Fo_rrnu�tionDesoription
AcMresR I �F- z t.�
re t or ou o lo. �r / ✓�/7�
City or Towi Slnl Zip Code
4. DAl' E DRILLED I
5. TOTAL DEPTH
6. CUTTINGS COLLECT ED YES n NOQ� o
7. DOES WELL REPLACE EXISTING WELL? YES] NOE�J—
8. STATIC WATER LEVEL Below Top of Cesing: 3 /,' FT.
(Use '+' If Abcwo Top of Cnsing) _ om
9 TOP OF rASiNG IS � FT. Above Lnnd Surface' _ CD
•Tnr nr t:netno Inrminnrnil Wnr hainw land l r-fmon rwgnlrn4 or Vnrlaner In recor• ""' p-(�
dance wlth IrA ?WAC 2Cpp01r19 f11 Z-:M
10 YIFLC (qpm)• L___ METHOD OF TEST �.lL j
11. WATEn �or•JEs (depth): •2� ).30 rrn
12. CHLORINATION: Type � j� ._.—_ Amount 11 additional spa," is needed use beck of form C7
Will Ihicvncss LOCATIQL SK TE CH
D Depth ` Dianr or W 1p ){Ft, eril (Show direction and distance from at least two Slate
From ---� To sL L—. Ft. i2s�c _— .51/ Roads, or other map relerence points)
From _ To --- ---- F1.
From T•o --.— Ft. J
14. GROUT:
Depth Material� Method
Front To y� - rt. �VL
Front �0 -to ._.�Ft.
15. SCREEN.
Depth Diamotor Slot Sin Material
Frunl - fo FI In. _ In.
From •_--- 'TO F1. _ _— In. , _ In.
rrom --.- -• To .-__..-.— Fl. _ In. In.
16. SAfJWGRAVEL PACK:
— attll (� t� {j �iz „'1 Material
Fromm �� Ul` t5 .. 5 — --
Froru Ft. 11111
op
1 110 HFRF y . F J9Y t3AT :rH:9WEM A9 NST
13nNS TRl1 ION S T. q�l'� P)1tr�ATACO -YOF
f"On OFFICE USE. ONLY
0111d NO* Sll3 rlT
ED IN ACCORDANCE WITH ISA NCAC 2C, WELL
RECORD HAS-BEEN PROVIDED TO THE WELL OWNER.
A muCTING THE WELL DATE
Croundwnter Section Wilhin 30 days
Gw•I f1EV. 12199
SOmtit odcinal to Division

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center- Raleigh, N.C. 27699-1636•Pltone (9111) 733.3221
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION 0: _ lv15
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential12 Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Purrtp Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
NPlrest Town: _ ?vv/._.__ _-- County: aeaDLQ-
(noad Name and NuJt �bc,rs, Community, or Subdivision and Lot No.) DRILLING LOG
DEPTH
3.
OWNER __—`--ttAA&C h0� L'Te,V From To
Formation Dexriptlan
Address l� I 1-09
U�7CcoS �(1/
4.
itq or Tov,n r State Zip Code
DATE DRILLED, f��1 - -
-•
—�
5.
TOTAL DEPTH
6.
CUTTINGS COLLECTED YES n NOD'
C
G�
7.
DOES WELL REPLACE EXISTING WELL? YES NO n-
8.
STATIC WATER LEVEL Below Top of Casing: 0^ FT.
r:17
(Use 10 If Abovo Top of Casing)
9.
TOP OF CASING IS _ FT. Above Land Surface'
ITnp
of cn etnp f n r m I n AIod afin r bolnw In nd etr rf Ana requrres a varlince in Arror-
din.ce
in.
with 15A NCAC 2 0110
YIFL.D (gpm): �/_O__ NIF_THOD OF TEST
11.
WATER 70 JES (depth):
12. CHLORINAT ION: Type f _ Amnunt J` If additional space h needed use back of form
13. CASING.
wan 7nickness LOCATI-ON SKETCH
/� Daoth Drameter o Wet Ft. edal (Show direction and distance from at least two State
From v — Tn Z20 _. Ft. �('`Y, - �� G Roads, or other map reference points)
F'ro;n To--..__.— Ft.
From To __ Ft.-- --_
14. GROUT:
Horn
^nnth
0 Tu Ft.
Material Method
From
15. SGREC"N:
J ��
�r S10 �•._. Ft.
_. _
Ocpth Piarneter
Slot Sizu Material
From
_.— f'o Ft
in. in.
From
-- To — Ft.
In. in.
Fr•^m
—_ To ------ Ft. ---
In. In.
16. SAIJDIGRAY,J-LLXAGK.r.--x-....--,—,.,.,.,........
F:cr;I _ 2l.ir
17. REMARKS: ---..... ._..._ . _
1 r'n HEREBY Cf RT Ipy �f1�Y���t�rl3(l W
C01%)9TRUCTl 1J STAJ�p�jjj[�g(ppN�l(ttAj(��
roR orriCE USE oNLY
OUld No•
NO. -
5abrnit
Material
ISTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER,
TIJRE FMWTSON CONSTRUCTING THE WELL DATE
vision `Nater Quality, Groundv;nler Sect!nn Within 30 days
GW-I REV. 12199

Nuith Carolina • Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phono [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: (26Q 6-e- U
WELL CONTRACTOR CERTIFICATION 0: a 5 G
STATE WELL CONSTRUCTION PERMIT#: 6 S_o
1. WELL USE (check Applicable Box): Residential Lid Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery Cj Heat Pump Water Injection ❑ Other E] If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
County,. �-
(Road Name and tunlbors, Co(rununity, or Subdivision dnd Lot No.) DRILLING LOCI OEP_] H
3. OWNER _ TQb)) 51C.M.ER From To FortnatlonDesoriplion
Arlrir�!?n
5T A Yf- A)
it feat or rt lo'F�
�1oRS t 9U q F L�331 /
City ar Tnwn Slnlo Zip Code
4. DATE DRILLED- ` _-? 9 CD
5. 1 OTAL DEPTH !/:)_%'
6. CUT -FINDS COLLECTED YES[ --I NO[� C
7. DOES WELL REPLACE EXISTING WELL? YES L NU
8. STATIC WATER LEVEL Below Top of Cnginq: 715FT.
pllsn *0 If Abo o top of Caslnp) G
Q. TOP OFf-ASINC IS % FT. Above Lrtnd Surface'
'Tnp of rn+Intl fnrrntnntnrf nl/nr hnlnw land anrfnne reryniroi a vnrinne..r In nncor•
dlncn with iFA NCAC 2C .&I M
ir) YIrLn (grm) t)ME
THOD OF TEST
11. VIAI ER ZONES (depth): D-9 Y92' �__ _ 0.1'e
J1) o
12. CHLORINA11ON: Type. . y�1. Amount i � ,5 It additional spare Is needed use back of lorifih4 o
13. CASING.
Will Ihtrkn099 LOCATION SKETCH _
Depth D' niter or Wet huFt. serial (Show direction and dletence from at least two State
From �— To Ft. % vG Roads, or other map relerence points)
From - To— --_- Ft.
From To _ Ft.
14. GROUT:
Df�('Ih Maleriai Method
Flout ---0— To Ft. 1
From 2Q_--
15. SCRiEN:
Dchth Diampler Slot Size Material
Flung _ ro Fl In. In.
From __To _ __., Ft. ____ In. In.
From _._._. To Ft. In. In.
10. SAi ID/GnaVEL TACK:
Material
17. RI :fd � iL�t'
wR F?y Cr-RTIFY�THAT THIs EL4 WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
r, r—
T.(i) n TH T A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR'OFFICE USE ONLY I - "
Quail No, Slit OF P A NSTRUCTIN13 THE WELL DATE
Srhmit original to Division r Otlallly, 0mundwalar Section within 30 days
r 3•i11 No _:e') J%'7 GW1 REV. 12/99

North Carolina - Deparlrnent of Environment and Natural Resources • Division of Water Ouality • Groundwater Section
1636 Mail Sorvice Center • Raleigh, N.C. 27699.1636•Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION f?:>
STATE WELL CONSTRUCTION PERMIT#: 6 -ro
1. WELL USE (Check Applicable Box): Residential bk Municipal ❑ Industrial d Agricultural ❑ Monitorinq ❑
Rocovery ❑ Heal Pump Water Injection ❑ Other If Other, List Use:
2.
WELL LOCATION: (Show sketch of the location below)
N-nrpr!Town: --- - County: �,�10QCi
Jex
- 11&R-E-19us P, D
(noad Name and Numbors. Community, or Subdivision and Lot No.)
DRILLING LOG DEPTH
3.
OWNER�(Cki ]3Q2
From, TA ForrnationDescription
ArldrQ99 -7-j(ob—linl P, P.
v G r ,
F�,.or>>o to1�439 a. 3 1Y
u2- !'�i�•
City or Tnvm Slnle Zip Code
4.
DATE DRILLED-U3
S.
10 FAL DEPTH!
6.
CUTlINUS COI_LEC1 EU YES n NO[
rn
7.
DOES WELL REPLACE EXISTING WELL? YES NO[:j
g
8.
STATIC WATER LEVEL Below Ton of Cnging: _ FT.
P.
(I 'so •{• If Ahovo Top or Cnslrg)
TOP OF r•AaING IS / FT.
Above Land Sttrface'
L'Tnr
or racln(I lnrminnl-1 ,I;nr holnw Pond trlrinr-A rwqutre4 a VRrInnCP In PCCOr• �-�•'
�`
rhncr%-Itth
In.
151k FICAC n 11n r7
YIFIP
�
(gpm)• METHOD OF TEST
11.
WATER ZONES (depth):
N 4
12.
CHLOrtINATIpN: Type Amounty
If additional space Is needed use back of form
13.
CASING.
`Neu Ihl0fnrss LOCATION SKEICiH _
Dnptl} "ter o W I Ant (Show direction and distance from at least two State
From _ U._—. Tn� 1, Fl. I —.1��- Roads, or other map reference points)
Flom - To--._._.-- Ft.
Ftont To--_— Ft.
14. GROUT:
MaterlaI Method
Fran► To L� rt. y�/�
From -1 o�._ FI.
15. rCRF.t-t•I: V w
Ucl:th 17iarnoter Slot Size Material
Fnunt — To _`—__ Ft _ III. in.
Front —.___ 7o —____ Fl. In. In.
From ..._— _ To -- — FI. _ In. --- in. _v
ntf G`j Se 'I ; Material
Frnrn
ju Front 1.
. --- _7
17. REMARKS- -'�1000
I rn ►IFR5P (IF RIIT Fuyr6h1MTyftISWr0� h� WAR C NSTROCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
COINIq I RI IC (7N S r9atilll milt , .p' fit 11'i ls1T CO Y OF THIS RECOR AS BEEN PROVIDED TO THE WELL OWNER.
FOR OFf'ICE USE. ONLY _ �� ` v U
t]u�rt r7o rL7nE OF P . . 1 C0I'ISTnUCT1r1G THE WELL DATE
r; lwi! original to 0NI,;ion nlrr Ouality, Groundwater Section Within 30 days
ill f1n. GW-I FIEV. 12199

North Carolina - Department of Environment and Natural Resources •Division of Water Quality •Groundwater Section
�_14400
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: M�L1_i..'�
WELL CONTRACTOR CERTIFICATION #: AV' q
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (check Applicable sox): Residential 0--Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Flecovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below) /'� {�
Nearest Town: rn��D h,4 Counry:t -�F''r 'o e -
(Road Name add Numbers, Comm It or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER bOCA% t'1 i CE? From To Forrab n Description
Address Ur - �� *l
(Street or Route o. - r S ✓ O_ �Gl
City or Town State Zip Code
4. DATE DRILLED - -21-00
5. TOTAL DEPTH -2 O S
6. CUTTINGS COLLECTED YES ❑ NOED-
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NOD—
B. STATIC WATER LEVEL Below Top of Casing: M_ FT.
(Use '+' It Above Top of Casino)
9. TOP OF CASING IS / FT. Above Land Surface-
-Top of casing terminated atlor below land surface requires a variance in accor-
dance with 15A NCAC 2C.0118
10. YIELD (gpm): S METHOD OF TEST ,4,'Y?
11. WATER ZONES (depth):
12. CHLORINATION: Type Alh a610-Amount y
13. CASING:
If additional space is needed tse back of fcg-m
Wall Thickness LOCATION SK= fCH
Depth r Diameter or Weight/Ft. Material (Show direction and d"rs~m ance trcad leas::ko Pale
From To Ft. r. . ;Y - - vc Roads, or other rrep referer,rf point?
From To Ft.
From To Ft.
14. GROUT:
Depth r M trial Method
From O To �_ Ft. � C
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft In. in.
From To Ft. in. In.
From To Ft. in. in.
16. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To Ft.
17. REMARKS:
Material
0
C_
r—
fU
a
CD
0
N
ca
0
CC-)
c:_
rn
M
Cn
M 77
c�
0
x
I DO HEREBY TAW I& L NSTRUCTEDIN ACCORDANCE WITH 15A f4CAC YC, v)rELL
CONSTRUCTI IYOFTHISR ECORD HAS BEEN PRO=f-D 70 THE Y/S L O""ER
Ll
FOR OFFICE M� "7 '� ' � '' _� / _ 6
Quad No: t PGNATURE OF PERSON CONSTRU :TING PIE leeELL Os T£
Submit original to Division of Water Duality. Grounowater Seven within V.) C%ys
Serial No. un wate- sscti tt
evt .e Reais„ it :'c;

Norlh Uaralina - DepaFtrtleent 61 EnviroriTenl avid Natural He sources- • Limsron o! YYarer l_uamy • wruurly rrciku! yr
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone] d O
WELL CONSTRUCTION RECORD 'WELL CONTRACTOR: Mi I l -C (A) PA l Jf-:1'Ir-
WELL CONTRACTOR CERTIFICATION #: a2-110
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): ResidentialL Municipal ❑ Industrial ❑ Agricultural MonitorirgQ
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2
3
WELL LOCATION: (Show sketch of the location below)
Nearest Town: UiQh�—County: �v1 t ;i ( ) n N r
aY1 (U GA Rc'("".n , l-)nc d,
(Road Natne and N mbers, Community, or Subdivision and Lot No.) DRILLING LOG
OWNER D P_YIYI) S sM6 P.-0 From To
Address S
(Street or Route o.
City or Town We
4. DATE DRILLED
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑ NO[]--
7. DOES WELL REPLACE EXISTING WELL? YES [_J NO[}-
8. STATIC WATER LEVEL Below Top of Casing: IQ' FT.
(Use '+' if Above Top of Casing)
9. TOP OF CASING IS 1 FT. Above Land Surface -
'Top of casing terminated aVor below land surface requires a variance In accor-
dance with 15A NCAC 2C .0118 �J
10. YIELD (gpm): __LD _ METHOD OF TEST /� � 2
11. WATER ZONES (depth):
12. CHLORINATION: Type Amount _ If additional space is needed tse back of fcrrm
13. CASING:
Wall Thickness
Depth
Diameter or Weight/Ft. Material
From C9
To
' F(.. -L -sar,� i --
From
To
Ft.
From
To
Ft.
14. GROUT:
Depth
Ma enal Method
d- d r
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:
LOCATION SKETCH
(Show direction and d-its'ance trm :i leas::•r'ro Smote
Roads, or other rrrcp relert:oc�e point!
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDMICE WITH 15A 04CAC ?r, vrELL
CONSTRUCTION STANDARDS, AND THAT AC PY OF THIS RECORD HAS BEEN PROVICED "TO TxE Y/S�LL O%%'tEF.
FOR OFFICE USE ONLY �
Quad No: j2 SI A R ERSON CONSTRIYTING Tic w'ELL Ds*.'E
ot ater Qura ality. Groundwater Scn within7.) r✓ys
Soda] No. (p t-K•I pis V.1291

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section �
4
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: MA t? r We-11 d r" : no,
WELL CONTRACTOR CERTIFICATION It: a yo v
STATE WELL CONSTRUCTION PERMITP:
1. WELL USE (Check Applicable Box): Residential Ea" -Municipal.❑ Industrial ❑ Agricultural E-1 Monitoring ❑
Aecovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: -mom h-i County:
RAI
(Road Name and Numbers, Community, or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER ��; i �� C67%r "+_ From To FormanDescription
Address l��n 3�GxOh �!� d 5 t
(Street orHoouin N0.) �� _ clm ,
/14
City or To n State C� Zip Code 410 ' - ySD
4. DATE DRILLED 'V- 'L/- OD —
5. TOTAL DEPTH 4-150 —
6. CUTTINGS COLLECTED YES [_J NO 1[
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO Q_
B. STATIC WATER LEVEL Below Top of Casing: FT.
(Use '+' If Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface -
'Top of casing terminated aVor below land surface requires a variance In accor.
dance with 15A NCAC 2C .1A18
10. YIELD (gpm): 2 METHOD OF TEST �✓1
11. WATER ZONES (depth):
12. CHLORINATION: Type r2 Amount o2
13. CASING:
Depth r Diameter
From—L�To �- Ft. f .2S
From To Ft.
From To Ft.
14. GROUT:
If,additsonal space is needed us-_ back of farm
Wall Thickness LOCATION SKETCH
or WeighVFt. Material (Show direction and cfcstance frcrn ad to='iyo State
- _
Roads, or oGtier rrrco refervfwe pointy
Depth r Ma er'al Method
From _L To 2« Ft.
From To Ft.
15. SCREEN:
Depth
From
To Ft
From
To Ft.
From
To Ft.
16. SAND/GRAVEL PACK:
Depth
From
To
From
To
17. REMARKS:
Diameter Slot Size Material
In.
in.
In.
In.
In.
In.
Size
Material
Ft.
Ft.
C)
CD
r
r--
fv
ctt
zs
0
O
N
100 HEREBY CERTIFY THAT PHIS WELL WAS CONSTRUCTED IN ACCORDMICE WITH 15A 04CAC Y:, VrELL
CONSTRUCTION STANDARDS, AND THAT AIGGf Y OF THIS RECORD HAS BEEN PROVICED TO THE'//=':
FOR OFFICE a L
Quad No: SIGNATURE OF PERSON CONSTRIY.TING t>t N ELL Os ' E
Su t tnal to pivlalon of Water puality, Grounb.ealer Srr_cn within :rJ C%yg
Serial No.
r:77
u
P .'.
CZ
fTi
cam:
r�r
m;0
0
x
GPt. I pT,-_-V. t29!

1636 Mail Servic® Center -Raleigh, N.C. 27699.1636-Ph©nO [phone] 1 4 4 2 U
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential Municipal ❑ Industrial ❑ Agricultural Monitoring ❑
Aecovery ❑ Heat Pump Water Injection ❑ Other [] If Other, List Use: I
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: �t�� County: Lk e ro
�l✓1 n r
(Road Name d Numbers, Community, or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER {�/� r. ✓l�l From To a Forrraxn Description
Address —
(Street or Route o.) r f
City or Town State Zip Code
4. DATE DRILLED I 'DO
5. TOTAL DEPTH Z 1S
6. CUTTINGS COLLECTED YES ❑ NOED-
7. DOES WELL REPLACE EXISTING WELL? YES [] NOEJ
8. STATIC WATER LEVEL Below Top of Casing: -,50 '_ FT.
(Use '+' if Above Top of Casing)
9. TOP OF CASING ISFT. Above Land Surface*
'Top of casing terminated atlor below land surface requires a variance In accor-
dance with 15A NCAC 2C .0118 r
10. YIELD (gpm): /2_ METHOD OF TEST 4r,
11. WATER ZONES (depth):
12. CHLORINATION
13. CASING:
s �;t1T
Type L-A bre/ �Amount 4 — If additjonal s; r� ss needed ism back of tam
Wall Thickness
Depth
Diameter or WeighVFt. Material
From b
To
Ft.
From
To
Ft.
From
To
Ft.
14. GROUT:
Depth
From 0 To 20
Ft.
Mat dial Method
From
To
Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From
To Ft
in. —in.-
From
To Ft.
In. in.
From
To Ft.
in. in.
16. SAND/GRAVEL PACK:
Depth
Size Material
From
To
Ft.
From
To
Ft.
17. REMARKS:
LOCATION SK=TCH
(Show direction and drs -ance tarn al leas: iHo S'.ale
Roads, or other rr,---p relere:ce- points`
M
o
o
n
L :71)
G C_.) III
r--- c rn
zM
N p .t
CJ7 rn
� � J
o �" z
rn�
C3 -�-�
N p
z
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH t;A tIJCAC 2-., v✓ELL
CONSTRUCTION STANDARDS, AND THAT ArgPY OF THIS RECORD HAS BEEN PRMICED TO THE Y!S;t-L tO,%tiEF,
FOR OFFICE USE ONLY
Ouad No:
Serial No.
SIGNATURE OF PERSON CONSTRLY.TING 1xZ yv'€LL
at to Division of Water pvality, Groundwater Srccn Within Yi C%yg
CK.I pr�_:V. 1291

1 14 �'
Northw
Carolina •Department of Environment and Natural Resources -Division of Water Quality •Groundater Section 2 �� J
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: �� �� �� ✓��
WELL CONTRACTOR CERTIFICATION H: 22 �i Lim
STATE WELL CONSTRUCTION PERMITP:
1. WELL USE (check Applicable Box): Residential ©/Municipal ❑ Industrial ❑ Agricultural 0 Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below) /
Nearest Town: urn h,1 County: rJ12 0-ca/( r 1P —
(Road Name and Numbers, Community, or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER Q0, s�lAoA From To Forma�cn De-scdptio,
Address V Ar)
(Street or Houte o.
City or Town State Zip Code
4. DATE DRILLED -
5. TOTAL DEPTH �
6. CUTTINGS COLLECTED YES ❑ NOE]-'
7. DOES WELL REPLACE EXISTING WELL? YES F-I NOgD-
8. STATIC WATER LEVEL Below Top of Casing: _ / DD FT.
(Use '+' If Above Top of Casing)
}n
9. TOP OF CASING IS FT. Above Land Surface -
'Top of casing terminated aVor below land surface requires a variance In accor-
dance with 15A NCAC 2C 0118
10. YIELD (gpm): a METHOD OF TEST A 12
11. WATER ZONES (depth):
12. CHLORINATION: Type A-rlh �i9&4kSAmount V— It additional s,ace is needed baccOf (Crm-
13. CASING:
Depth Diameter
From To '%O Ft.
From To Ft.
From To Ft.
14. GROUT:
LOCATION SKcTCH
Wall Thickness
or WeighVFt. Material (Show direction and dis--ance frrm z1 leas::rro State
�410
TLC Roads, or other rrrcp retere:rce poinl_s!
Depth Material Method
From To Ft.
From To Ft-
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft in. in.
From To Ft. in. in.
From To Ft. In. In.
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To F,l.
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A r4CAC r., v/ELL
CONSTRUCTION STANDARDS, AND THAT A CAPY OF THIS RECORD HAS BEEN PRO=ED 10 THE Yl��_L 0%%,%EP...
FOR OFFICE USE ON
Quad No:
Serial No.
OF PERSON CONSTRU :•TING 1),,— vv1ELL
of water Quality. Gmurvdwater Sec_cn Within Yi C :---yg
0
tD
c_
C
f--
(V
Ln
v
0
CD
rV
OA.�
WE
0
z
trr.l F! V. 1291

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section i.., ��JJ /'�
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone] ;2 f, `�: 4 V 8
WELL CONSTRUCTION RECORD WELL CONTRACTOR: L1
WELL CONTRACTOR CERTIFICATION N:
STATE WELL CONSTRUCTION PERMITP:
1.
WELL USE (Check Applicable Box): ResidentlalO'-'Municipal ❑
Industrial ❑ Agricultural 0 Monitorir:g ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2.
WELL LOCATION: (Show sketch of the location below)
Ch e
/
C
Nearest Town: �_ County:
r E
r� - -
n,,Pa �QLf AC'\V1 2AL
DRILLING LOG DEPTH
(Road Name and Numbers, Community, or Subdivision and Lot No.)
3.
OWNER
From To Forrraxn Descriptio:
Address
E% - /'-) L'_ /Cri
(Street or Route o.
f — 1V
City or Town Stale Zip Code
4.
DATE DRILLED LI
5.
TOTAL DEPTH
6.
CUTTINGS COLLECTED YES ❑ NO l❑�-
s
7.
DOES WELL REPLACE EXISTING WELL? YES[] NO
B.
STATIC WATER LEVEL Below Top of Casing: & FT.
(Use '+' II Above Top of Casing)
9.
TOP OF CASING IS FT. Above Land Surface -
'Top of casing terminated atfor below land surface requires a variance In accor•
dance with 15A NCAC 29.0118
10. YIELD (gpm): -.D W 1 METHOD OF TEST 4112
11. WATER ZONES( epth):
12. CHLORINATION. Type LL, 111le'Amount
13. CASING:
Wait Thickness
Depth Diameter or Weight(Ft. Material
From D To Q-/ Ft. 212S iYD GQ l =r V L
From To Ft. -
From —To— Ft.
14. GROUT:
Depth M tenal Method
From 0 To �_D ` Ft.
From To Ft.
15. SCREEN:
Depth
From To _
From To _
Diameter Slot Size
Ft in.
Ft. In.
From To Ft. In. _
16. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To Ft.
17. REMARKS:
Material
In.
In.
in.
Material
If additional spce is needed tsp back of form
LOCATION SK=TCH
(Show direction aid d-fiance fr;rn zi leas; :Ho -'.ate
Roads, or other rr� refere:re points`
G'a
0
G
r—
N
U7
x.
0
0
N
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A PJCAC r., vfELL
CONSTRUCTION STANDARDS, AND THAT fj-C,OPY OF THIS RECORD HAS BEEN PROVICED -TO THE Y/S� 1 0"'SE „
real
FOR OFFICE USE O
Quad No:
Serial No.
in
C)
c ��
m I ,NATURE OF PERSON CONSTRUCTING 1rc' wIELL
Subrrdt origin c� " Islon of Water Quality, Groundwater Sercn within V) C/ye
At j" Gn.I F{ Y. 1291
ttl �i�i^F

North Carolina •Department of Environment and Natural Resources •Division of Water Quality •Groundwater Section 214435
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: ��; �) Q-11
WELL CONTRACTOR CERTIFICATION #: �JC�
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential ❑Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
Agricultural ❑ Monitoring ❑
2. WELL LOCATION: (Show sketch of the location below) n ��
Nearest Town:`M a { �� h � I \ County:.On C E'
sal eed & Gnc\A �N ,
(Road NamMndu bers, Communi or Subdvision and Lot No.) DRILLING LOG DEPTH
3. OWNER �� �l E' ji V1Ct r From To n IForrraxn Des: riptia:
Address 14 5 — /Q (�/G'i 1
(Street or Houto o. f/ — L2Q r
City or Town Stale Zip Code `J '71 q r r �
4. DATE DRILLED
5. TOTAL DEPTH 7/di
6. CUTTINGS COLLECTED YES ❑ NO� —
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NOQ— —
B. STATIC WATER LEVEL Below Top of Casing: FT. _
(Use '+' if Above Top of Casing)
9. TOP OF CASING ISFT. Above Land Surface -
'Top of casing terminated at/or below land surface requires a variance In eccor- Fr,,. • . s
dance with 15A #CAC 2C.0118
10. YIELD (gpm): _Q METHOD OF TEST M O _
11. WATER ZONES (depth): _
12. CHLORINATION: Type
Amount a-
13. CASING:
Wall Thickness
Depth
From —To ,
Diameter or Weight/Ft. Material
From To
Ft.
From To
Ft.
14. GROUT:
Depth r
M terial Method
From __Z___ To
Ft.
From To
Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From
To Ft
In.
From
To Ft.
In.
From
To Ft.
In.
16. SAND/GRAVEL PACK:
Depth
Size
From
To Ft.
From
To Ft.
17. REMARKS:
In.
In.
In.
Material
If additional space is needed tree back of fcx-rn
LOCATION SK= TCH
(Show direction and dis'ance trvm ;Ei leas; :ko 5.�tate
Roads, or other rrrr_p refere:,ry points!
Ma
C�
CO
N
DO HEREBY Cffill Y -T S-W�a� WAS r STRUCTED IN ACCORDANCE WITH t;A 04CAC ?C, It/ELL
CONSTRUCTIO N N F SINqT*T F THIS RECORD HAS BEEN PROVIDED 'TO THE. V/'—�L Ok"ER
-- _
FOR OFFICE US Y
Quad No: 1� �� NATURE OF PERSON CONSTRIY:TING T W'ELL
Submfl Divlslon of Water Ouality. Groundwater srccn Within :r) C%1ys
Serial No. (K.I Fs'c V. 1291

North Carolina • Department of Envir
1636 Mail Service Center onment and
nter • Raleigh 1636•PhonNatural Resources) - Division of W ty - Groun
WELL e`Onisr tvC. 27699-Water Quali
RUCTION ) 733.3221 Groundwater Section
RECORD WELL CONTRACTOR: TLl/tt� `Z�C'I6�u.
WELL CONTRACTOR CERTIFICATION #, STATE WELL CONSTRUCTION PERMIT# —"�-
1, WELL USE -`.`- (Check Applicable Box Recovery ) Residential
Heat pump Water Injection Municipal rl Industrial (]
2, WELL LOCAT ❑ Other If Other Agricultural ❑ Monitoring ❑
' (Sho ketch of the location below) � 'List Use:
Ne Town:
County: '
(Road N me nd Numbers, Co
3 OWNER or b ivisi
and t.ot No.i Address DRILLING LOG
From To —D
EPTH eat or Formation Description
City or Town O b
4. DATE DRILLED O State O
Zip Code
5, TOTAL DEPTH t
6.
CUTTINGS COLLECTED YES
7, DOES WELL REPLACE EXISTINCD No 8• STATIC WATER LEVEL Below Top Y
of Casing: NO(t7� 6
9, TOP OF CASING IS (Use '+• If Above Top o' jngFT'
`Top of casing terminated st/or below tend surface re J `
%dove Land Surface-
�
dance with 1SA NCAC2C.0 1 ��-
10. YIELD ��- quires a variance in accor.
11 • WATER ZONES (d— METHOD OF TEST
12. CHLORINATION: Type
13. CASING: Amount ' r'
It additional space is needed use back of form —
From
Depth la a 4f Wall Thickness
. LOCATION SKETCH
From To Ft..' fed (Show direction and distance from at leas
From `—_ To Ft 1_ —_— -- Roads, or other map reference pointst two State
---`_To— Ft.�_
14, GROUT•
Deptth�
From TO
erial�Methtod
_
From -� Ft
_
15. SCREEN: To ----._ Ft.
Depth Diameter
From To --__ Ft
Slot Size Material
From — — in.
To — FL
in: --�
—
From 1_ To In.
Ft �- In.
16• SAND/GRAVEL
_
----._ In.
In.
PACK:
"'—'-- ---�_
Depth Size
From
---- Ft
Material
_ --------
-,_ T-._
From —o
17. REMARKS: �'-" Ft, --------^
I DO HEREBY CERTIFY THAT THIS NSTR
CONSTRUCTION STANDARDS, ANDWELL THATWAS A COCOY O
ED IN
FOR OFFICE USE ONLY S FiECC
Quad No: l
5A NCAC 2C, WELL
'ED TO THE WELL O
11 G DOW1SQN CONSTRUCTING THE WELL
Serial No. (j (� ,� D t o n f
{ MAY
r Quality, Groundwater Section Within 30 days ATE
MA 1 ( 2000 GW1 REV. 12199

North Cdrolina - 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: %lea'% a U111
WELL CONTRACTOR CERTIFICATION #: oZ 6 S
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential lrJ 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/ ' County: oilp•Q�
(Road Name and Numbers. Community, or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER rLi i 1 114M P1t%P_ /G/$ /IAA% j Z_ From To Formation Description
Address 3v-71L %D_(� ��s :2 ' ..Sc �- /ems : �r►-,
(Street or a o.
1 33 41 ilY
City or Town slatd Zap Code
4. DATE DRILLED (�' /� ' 00
5. TOTAL DEPTH V 2 2 ' c
6. CUTTINGS COLLECTED YES ❑ NO❑'
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO�
B. STATIC WATER LEVEL Below Top of Casing: -S`D ' FT. M.
(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- ` J
dance with 15A NCAC 2C .0118 C.a —
10. YIELD (gpm): METHOD, OF TEST J2, -%Z
11. WATER ZONES (depth):
12. CHLORINATION: Type Amount D ��S It additional space is needed use back of form
13. CASING:
Wall Thickness LOCATION SKETCH
Depth la eter or t hvFt. Material (Show direction and distance from at least two State
From To �' S Z Ft. ,l ` 5 fc Roads, or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From To 0 Ft. �
From Q '� To `'` 2 Ft. 1d-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:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS R CORD-HAS-BEEN.EnOVI,DEQ_TO_ THE WELL OWNER.
� �. 0 42
C �y'
FOR OFFICE USE ONLY � 1
Quad No: I AtUR ru
NCONSTRUCTING THE�1 41�DATE
­ ? Submit original to Division of all(�rTJploynd� allpo8e�clion I 30 days
Serial No. y. ) UUUUtt GW-I REV. 121"

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: C" kee O. Q,11 (, ; J 1fa q
WELL CONTRACTOR CERTIFICATION #: 0—% 5
STATE WELL CONSTRUCTION PERMIT#: _
1. WELL USE (Check Applicable Box): Residential M/ Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below) I
Nearest Town: County:
(Road Name and Numbers. Community, or Subdivision and Lot No.)
DRILLING LOG DEPTH
3. OWNER
From To Formation Description
Address
o D ' y C /,;?,:5• --�
(Street or Floute o. 2 o1v_ .fir-1` -e_
-,-zi 3 D O 6
City or Town State Zip Code 17,5
4. DATE DRILLED L
5. TOTAL DEPTH _) 12
6. CUTTINGS COLLECTED YES ❑ NO❑--
7. DOES WELL REPLACE EXISTING WELL? YES M NO❑-
6. STATIC WATER LEVEL Below Top of Casing: \ 0 , FT.
c�
(Use '+• II Above Top of Casing)
CD r ,
9. TOP OF CASING IS FT. Above Land Surface*
=0 F n
'Top of casing terminated at/or below land surface requires a variance In accor-
::: r»
dance with 15A NCAC 2C 0118 G�
10. YIELD (gpm): /UD f METHOD OF TESTr�
-
CZ)
11. WATER ZONES (depth),2JU" 12
12. CHLORINATION: Type `� Amount u ��
If additional space Is needed use back of form^ C
13. CASING:
N —1
W c:>
Wall Thickness
LOCATION SKETCH
.nn Depth Diameter o W i qwt. Material
V �O
( Show direction and distance from at least two Stale
From Tomb Ft. -2— �°
Roads, or other map reference points)
From To Ft. -
From To Fl.
14. GROUT:
Depth Mate I MethodFrom
_0 Tol Ft.
T(4
From 2 ° To ' c Ft.
15. SCREEN:
Depth Diameter Slot Size MaterialFrom
To Fl In, In.
From To From To
16. SAND/GRAVEL PACK:
Depth
From To _
From To
17. REMARKS:
Ft. in. In.
Ft. in. In.
Size
Ft.
Ft.
Material
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE
CONSTRUCTION STANDARDS, AND THAT A COPY OF T"RECORD HAS 49EN
FOR OFFICE USE ONLY
Quad No: S
It p vd Submit original
Serial No. in,
TO THE WELL OWN
MAY I
OF,f��fiSq t ONSTRUCJINO E WELL
of ater Quality, Groundw er Sec r
o
)ATE
I HE . 12/99

North Carolina - Department of Environment and Natural Resources - Division of Water Duality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: (24eelo" top -it
WELL CONTRACTOR CERTIFICATION
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (check Applicable eoz): Residentlal Municipal ❑
' Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Olher ❑
If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
/ J
Nearest Town: ��� County:
/1 t?R(� K��
A P NP- AV_AC ( TRe-C
(Road Name and Numbers. Community, or Subdivision and Lot No.)
DRILLING LOG DEPTH
3. OWNER PrAfCk l�-� Sf191 QS /95 eJ.
To Formation Description
Address
/From
v /(
(Street or Houle NojJ
') ,[g )r /7 �J • ' �' c
City or Town Slate Zip Code
4. DATE DRILLED Ll - 19-
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑ NO[:J—
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO❑--
p
-n elm
e. STATIC WATER LEVEL Below Top of Casing: N,ijFT.
::� `r_i
NJ
(Use '+' It Above Top of Casing)
-
i
9. TOP OF CASING 1S FT. Above Land Surface
'Top or casing terminated atfor below land surface requires a variance In accor-
dance with 15A NCAC 2 0118
0
10. YIELD (gpm): MET OD OF TEST
11. WATER ZONES (depth):./
12. CHLORINATION: Type �ll Amount 2
Ii additional space Is needed use back of lorm
13. CASING:
LOCATION SKETCH
Wail Thickness
Dept Di meter or Weight/Ft. 4fiaterial
fy
(Show direction and distance from at least two Stale
From T2 Ft. '�� t�
Roads, or other map reference points)
From To Fl.
From To Fl.
14. GROUT:
Depth Material Method
From To ' 0 Ft.
From'_ To Id" FI.
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft In. In.
From To Ft. in. in.
From To Ft. In. In.
16. SAND/GRAVEL PACK:
Depth Size Material
From To —Ft. -
From To Ft.
17. REMARKS:
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE Nfttlle;-'WEL•l!_��­
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS ORD HAS BEE P ED TO THE WELL OWN
MAY 17 2000 00
FOR OFFICE USE ONLY
Quad No: SIGNAT OF PEROA CWTIiUC1 NG T6 WELL ATE
Submit original to Divls on of Water Quality, omundwa r Section &1tbitiva0bl .31 gon
Serial No.
t Asht� Ile ec,jtnj, I lffi(1W Yj 12/99

North -Carolina . Department of Environment, I lealth, and Nalumf rinsourcns
Division of Environmenl rl Managnmmil _ Crounrlwaier Soclion
P.O. Box 29535 - Raleigh, N.C. 27626-0535
Phone [phone]
WELL CONSTnUCTION RECORD
DRILLING CONTRACTOR: )01'
ton orrlcr_ a F orn.•r; '�
SEnIAL 1`401 14450
Lonq. — no
Minor Basin
Basin Corte —
I leader Ent. Gw I Ent.
STATE WEI-I_ CONSTRUCTION
DRILLER REGISTRATION t•tUMBER: g 4oy
PERMIT NUMBER:
--- - - - ------ —
1. WELL LOCATION: (Show skelch of the location below)
Nearest -town: y— --. County: L (2C(Q —
(rtoad, Col„ runny, or SuNlivision and Lof No.) DEPTH MILLING LOG
2. OWNER _V_—_v�c ry�Lp�--- ------------ rrorn To rormalion Desrriplion
ADDRESS----------------_.-..-._....------------- --- — C
(Slreol or noulo No) --
City or rmwn ---- - �lalo--------_— .-- ----. 7.tp Codo----
3. DATE DMI_LED __3_-LL-L(20 USE or wELL
4. TOTAL DE r i 11
5. CUTTINGS COLLECTED YES L._.I NO[ �—
G. DOES WELL FIEPLACE EXISTING WELL? YES [_(�—
7. STATIC WATER LEVEL Below Top of Casing: 1pNO
Q NO
(Us,! "r" if Above Top of Casing)
8. TOP OF CAS114G IS _� FT. Above Land Surface'
Caslnq Termhialed aVor below hind surface Is Illegal unless a vnrinrice Is Issued
In accordance with 15A NCAC 2C .0110 In
9. YIELD (gpni):_ _ METI-IOU OF TES)- A_,1jf_
10. WATER ZONES (depth): _
11. Cf-1LORINATION: 'type AiA �a /gA5 Amount A_
12. CASING:
Depth r diameter
From.—f To 3o Ft. �5--
Front To Ft.
From-To
13. GROUT:
If additional space is nneded use back of form
Wall Iar:kness LOCA-11014 SKETCH
or weighurl. Mnlerial (Show direction and distance from at least two Stale
7'0-LG-- Roads, or other map reference points)
Depth Material
From To fir_ Ft. 6CLclL2�_
From To _ Ft. —_
14. SCREEN:
Depth
From
To —
Front
To _
From ---To
15. SAND/GRAVEL
PACI
Depth
From
To —
From
To—
m REMAMS:
Method
Diameter Slot Size Malerial
r-I
In.
In. _
R.
in. —_--
In.
FL.
In. __--
In.
Fl.
Fl1 WL _
O
L
r
N
ZZ
G
N
6roundwate:� Seclion
I DO ItEREBY CERTIr 1(_{pvqm!It3JCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCT ION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
slrNnTunr Or CONInACTOn oR AGENT DArF_

North Carolina - Department of Environment, Health, and Natural .Resources
Division of Environmental Management - Groundwater Section
P.O. Box 29535 - Raleigh, N.C. 27626-0535
Phone [phone]
WELL CONSTRUCTION RECORD
DRILLING CONTRACTOR: �, )� N•,r l,,�) E' l l
FOR OFFICE USE ONLY ( Q
QUAD. NO. SERIAL NO. 9
Lat - ,Long. RO
Minor Basin
Basin Code
Header Ent. ' GW-1 Ent.
jATATE WELL CONSTRUCTION
DRILLER REGISTRATION NUMBER: _I) qo q PERMIT NUMBER:
1. WELL LOCATION: (Show sketch of the location below) n 1/
Nearest Town: �')t.h County:l h'P-CL b C E'-
1111 tnp Qj_ N�II In 1-n
(Road, Communi or Subdivision nd Lot No.) DEPTH DRILLING LOG
2. OWNER _ _Vy Up r) dvl CC(. n From To Formation Description
ADDRESS ) o d
(Street or Route No.) I _ ) L/ , - /� f ^� : /C <S��74N
City or Town State Zip Code
3. DATE DRILLED 3.- IS �OC� USE OF WELL ' 'e e
4. TOTAL DEPTH )BLS-'
5. CUTTINGS COLLECTED YES ❑ NO©�
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NOQ
7. STATIC WATER LEVEL Below -Ton of Casing:FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS ! FT. Above Land Surface*
' Casing Terminated at/or below land surface is illegal unless a variance is issued
in accordance with 15A NCAC 2C .0118
9. YIELD (gpm): 30 METHOD OF TEST
10. WATER ZONES (depth):
11. CHLORINATION: Type fh -s Amount
12. CASING:
�-, Depth Diameter
From — 2 To -20' Ft. 612,5
From To Ft.
From To Ft.
13. GROUT:
From
From
14. SCREEN:
Wall Thickness LOCATION SKETCH
or Weight/Ft. Material (Show direction and distance from at least two State
Roads, or other map reference points)
Depth Material l
To 2 o ' Ft.
To Ft.
Depth
From
To
From
To
From
To
15. SAND/GRAVEL PACK:
Depth
From
To —
From
To_
16. REMARKS:
Method
Diameter Slot Size Material
Ft in. in.
Ft. in. in.
Ft. in. ..in.
Pyi Size Mate
0
co
L
r--
ry
cn
0
Q
N
I DO HEREBY CERTIFY THATiTHIS 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.
GW-1 REV. 9/91
SIGNATURE OF CONTRACTOR OR AGENT DATE
Submit original to Division of Environmental Management and copy to well owner.

North Carolina - Departmenl of Environment, Heallh, and Nalural Rnrourcos
Division of �nvirontnenlal Manngrmnrit - Gioundwnter Seclion
P.O. Box 29535 - Raleigh, N.C. 27626-0535
Phone [phone]
WELL CON
S
TRUCTION RECORD
DRILLING CONTRACTOR:
Fon oFr:icF usE orl� j . j ouAD. No. — SEnIAL N
Lal. 42
Long. RO
Minor Basin
Basin Corte
I leader Ertl. GVI-I EIIL
STATE WELL CONSTRUCTION
DRILLER REGISTRATION NUMBER: l-3 PERMIT NUMBER:
1. WELL LOCAI ION: (Show skelch of the location below)
Nearest Town: County:. County: �7'! C'rU�G e'
(Road. Communily, or Sutxlivision and Lol No.) DEPTI I DRILLING LOG
2. OWNER -Me SLiclle✓ - -- ---- - ----- -
Frorn To Forrna Gon Dnscrinlion
ADDRESS %f r?I<c/Ir14_///tL_--
(Slreel or nouto No.) 70 — A ,; ----
Cily or Town State /}qp Code
3. DATE DRILLED USE OF WELL-
4. TOTAL DEP-rl I -Zfo _
5. CUTTIfdGS COLLECTED YES n NOE--
6. DOES WELL REPLACE EXISTING WELL? YES [:] NOO
7. STATIC WATER LEVEL Below Top of Casing: 2_,�9 FT.
( Above
8. TOP OF CASING IS ��L _ FT. Above Surface'
Casing Terminated aUor below land surface Is Illegal unless a variance Is Issued
In accordance with i5A NCAC 2C min
9. YIELD (gpm):� METHOD OF TES"- /14// sk
10. WATER ZONES (depth):
11. CHLORINATION: Type AIrIOUnt c" If additional space is needed use back of form
12. CASING: — ---
13
14
15
16
Depth
Diarneler
Wall'lhickrtoss
or WeiglrUri. Malerial
From
To /V/
R.
G.�S_
:w z/ X"--
From /`f l
10 /6z
FI.
G. 25.,
From _
To
Ft.
—
GROUT:
Depth
� M�lerial
eihod
From
_0 AP
F1.
/0/7
/� e�lv' e-
From
To
Fl.
SCREEN:
Depth
From
To Ft
From
To Ft.
From ----To
Ft,
SAND/GRAVEL
PACK:
Depih
From
To
Front
To
REMARKS:
I DO HEREBY CERTIFY 11
CONSTRUCTION STANDA
Diameter Slot Size Material
in. In.
In. _ in.
LOCATION SKETCH_
(Show direction and distance frorn at least two Slate
Roads, or other map reference points)
Q
o
0
L
►— c c'
N zm
cn
r11
rn
E5 cn
N
0
Tills C`>;RUCTD IN ACCORDANCEWITH i5A NCAC 2C, WELL
1 AT C D Y-'6l`'THIS1ECOnD HAS BEEN PnOVIDED TO THE WELL OWNER.
SiGNATunE or C0NTnACTon on AGFNr DATE
rm. I nFV o,,qI r ,J..,JI . 1A..nl In Ili;riainn nI Ciwtrnnrnnnt-il I.Innvtrrmnni nnrl rnriv in wrill nwn-r

North Carolina - Department of Environment, Health, and Natural Resources
Division of Environmental Management - Groundwater Section
P.O. Box 29535 - Raleigh, N.C. 27626-0535
Phone [phone]
WELL CONSTRUCTION RECORD
DRILLING CONTRACTOR: d"'11".,n
FOR OFFICE USE ONLY
QUAD. NO. SERIAL NO.
Lat. Long. RO
Minor Basin ,'; ) 4
Basin Code
Header Ent. GW-1 Ent.
STATE WELL CONSTRUCTION
DRILLER REGISTRATION NUMBER: �)qoq PERMIT NUMBER:
1. WELL LOCATI N: (Show sketch of the location below)
Nearest Town:.X-QCSceo- County:
(Road, Community, or Subdivision and Lot No.)
2. OWNER )(2hionSI
ADDRESS
(Street or Route No.)
City or Town State Zip Code
3. DATE DRILLED 3- QJ- c7a USE OF WELL ;= �
4. TOTAL DEPTH 22,
5. CUTTINGS COLLECTED YES ❑ NOE:j
6. DOES WELL REPLACE EXISTING WELL? YES NOE
7. STATIC WATER LEVEL Below -Top of Casing: ,.-,o FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS / FT. Above Land Surface*
Casing Terminated at/or below land surface Is illegal unless a variance is issued
In accordance with 15A NCAC 2C .0118
9. YIELD (gpm): t S METHOD OF TEST ,04,2
10. WATER ZONES (depth):
DRILLING LOG
Formation Description
1C.l /
DEPTH
From To
cc) — i
/6 " / 70
/ 70 -- "j"2'S
11. CHLORINATION: Type Amount if additional space is needed use back of form
12. CASING:
Depth Diameter
From To Ft. (o , d S
From To Ft.
From To Ft.
13. GROUT:
From
From
14. SCREEN:
Wall Thickness LOCATION SKETCH
or Weight/Ft. Material (Show direction and distance from at least two State
_vim_ Roads, or other map reference points)
Depth Material Method
To ­-?Q '_ Ft.
To Ft.
Depth
From
To Ft
From
To Ft.
From
To Ft.
15. SAND/GRAVEL PACK:
Depth
From
To
From
To
16. REMARKS:
Diameter Slot Size Material
in. in.
in. in.
in. in.
I DO HEREBY CERTIFY THAT CONSTRUCTION STANDARDS INf3l I �k�IS.f�ERD HAS BEEN PRIOVIDED TO THE WELL OWNER.
�rl
c-,
<r_ M
c� d-
:s; n
`Y G^
r�Tt�
�rn
cn
rn __j
0
SIGNATURE OF CONTRACTOR OR AGENT DATE
GW-1 REV. 9/91 Submit original to Division of Environmental Management and copy to well owner.

North Carolina - Department of Fnvirommonl, health, and Nalutal llesourcus
Division of F_nvitonmental Manahemeni - Grounrlwaler Seclion
P.O. Box 29935 - Raleigh, N.C. 27626-0535
Phone [phone]
WELL CONSTRUCTION nECOnD
DRILLING CONTRACTOR: a,,"') I e r k,� \1 121
ron omcr_ usE oriq ,
QUAD. No. —__ SEnIAL NO �. .443
3
I_aL —_— Long. — no —
Minor•Basirt
Basin Come
I leader Ent. GVJ- I Ent
TATE WELL CONSTRUCTION
DRILLER REGISTRATION NUMBER:: yp V _— -- — PERMIT NUMBER:
1. WELL LOCATION: (Show Sketch of the location below) I<
Nearest Town: IO�L,n — _. County: C--Q l E,P
(Road. Community, or Sul.ximsion and Lot No.) DEPTI I DRILLING LOG
2. OWNER _DN�s, ---- ------ — --- _ - rrom 10 Formation Description
ADDRESS— ' _1-21,4
(Sheet or nouto No.) -- ---- ----
City or Iown Slain lip Codo — - -- ---- --- —
3. DATE DRILLED Z-=/ADD USE Ol- WELL------------
d. 1011'AL DEPTI I I �(D (----
5. CUTTINGS COLLECTED YES L ( NO[_LEA __--- —
6. DOES WELL REPLACE EXISTING WELL? YES (_� NO[� —
7. STATIC WATER LEVEL below Top of Casing: FT. —
(Use -i" it Abovo Top of Cnsiny)
8. TOP OF CASING IS _.. FT. Above Land Surface'
' Casing Terminated atlor below land surlace Is Illegal unless n vnrinrice Is Issued
In accordancp with 15A NCAC 2C .01111 /� —
9. YIELD (gpn9:_,2_0 — METI IOD OF TEST j% _—.---
10. WATER ZONES (depth):
11. CHLORINATION: 'type Amount II additional space is needed use back of form
12. CASING: -- -- ------ -- ----
Wall 1 ter knee LOCA-i ION SKETCH
Depth Dianteler or weight/Ft. Material (Show direction and distance from at least Iwo State
From To / 20 rt. 6,2_5 - 00—L VOLa_ Roads, or other map reference points)
From 10 Ft.__— -----
Fr o m— To --- F L--------------- —.---
13. GROUT:
Depth Mat rial Method
r'
From — Z Tom Fl.QG^
o
c>
From
/
To --Ft. _
c
U ;
te. SCREEN:
`—
N
Y
Depth Diameter Slot Size Material
c<
.L IT1
From
To Fl in. In.
M�
Front
To Ft. In. -- In.
o
rn
From
To --- Ft. In. —_ In.
o
15. SANDj-,j'10
CD
e
lil� u u S�e
Material
FrontTo
FL
rrom
� P16.
REMA
I DO 11ERE
,;'
Y CEf Fir I; G{AT.T{-IIS WELL W
S CONSTRUCTED IN ACCORDANCE WITH 15A NCAC
2C, WELL
CONS1 RUC°fr09 �i_A4j 1111DS, AND TI- AT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWIIER.
s1cNATunE or- coNtnACTon on AGENT
DArE

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
WELL CONSTRUCTION RECORD
% �4 CA -A 1 r 12Ftt1SFs %. b��-
WELL CONTRACTOR: _ \- 4MC 1lL.LE ,
WELL CONTRACTOR CERTIFICATION
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential ff Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOC Sho ketch of the location below)
Nearest Town 1 t County:
(Road Nam and N ers, m u ty, or Subdivision and Lot No.) DRILLING LOG
3. OWNER From To
Address \ rl n s
city or Town• \ State Zip Code
4. DATE DRILLED 00
5. TOTAL DEPTH '
6. CUTTINGS COLLECTED YES (D NO tZ
7. DOES WELL REPLACE EXISTING WELL? YES NOZ
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 2C1.Q118
10. YIELD (gpm): � METHOD OF TEST 0!�U
11. WATER ZONES (depth):
DEPTH
Formation Description
c,
O
r�
_
C-)
M
..7,
17�3
C7
CT1
12. CHLORINATION: Type Amount If additional space Is needed use back of form
13. CASING:
Wall Thlckness
Depth 1 tjQr oTWUFt, ate f
From To Ft.
From To Ft.
From To Ft.
14. GROUT:
Depth MaterlakMethod
From To \6S Ft.
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft in. in.
From To Ft. In. In.
From To Ft. in. in.
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
17. REMARKS:
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONST
CONSTRUCTION STANDARDS, AND THAT A COPY OF
FOR OFFICE USE ONLY
Quad No: GNA
Submit on al to Di
Serial No.
LOCATION SKETCH
(Show direction and distance from at least two State
Roads; or other map reference points)
Water Quality, Groundwater
WELL
F1 r
Ash MIS '

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�� oM��2.P2lSES,'sNG . `�Ibl�,
WELL CONSTRUCTION RECORD WELLCONTRACTOR: _20YC�IIL.Lr_7 W IU LU
WELL CONTRACTOR CERTIFICATION #: a1Z)9(0
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCA
Nearest Town:
(Road Na nb k4ur
3. OWNER
. Address \p a
of the location below)
", -county: , 4
or Subdivision and Lot No.) DRILLING LOG DEPTH
----5� From To Formation Description
City o TOWN State'
Zip Code
4. DATE DRILLED I M
a s)
5. TOTAL DEPTH
�• ;-
6. CUTTINGS COLLECTED YES [D NO[a'
7. DOES WELL REPLACE EXISTING WELL? YES NO[EJ
N i a r
8. STATIC WATER LEVEL Below Top of Casing: FT.
(Use '+' it Above Top of Casing)
9. TOP OF
CASING IS __ FT. Above Land Surface -
* Top of casing terminated atfor below land surface requires a variance In accor-
dance with 15A NCAC 2C .0118
10. YIELD (gpm): METHOD OF TEST 3d
c >
0
11. WATER ZONES (depth):
tl7
�-
12. CHLORINATION: Type Amount
If additional space is needed use back of form
13. CASING:
Wall Thickness
Depth,,._,,.. la
LOCATION SKETCH
et W�� at riat
(` I
(Show direction and distance from at least two Stale
From To Ft.
Roads, or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth lc-� �eri Method
From To _i % Ft.
From To Ft.
15. SCREEN:
Depth
Diameter
From To
Ft in.
From To
Ft. in.
From To
Ft. In.
16. SAND/GRAVEL PACK:
Depth
Size
From To Ft.
From To Ft.
17. REMARKS:
Slot Size Material
In.
In.
In.
Material
I DO HEREBY CERTIFY THAT THIS WELL WAS CONS 'GTE IN ACCORD WITH 1
CONSTRUCTION STANDARDS, AND THAT A COPY OF THI CORD H EE PRO
_ c
FOR OFFICE USE ONLY i
Quad No: S NATURE OF P ON CONSTR TING TI
-2 Q 9 13 Submit odgln4 to Division of Water Quality, Groundwater Se on W thin 30 days
Serial No. �� VVtptlntjtt �t8 9YI �1 i 12/99

North Carolina - Department of Environment, Health, and Natural Resources
Division of Environmental Management - Groundwater Section
P.O. Box 29535 - Raleigh, N.C. 27626.0535
Phone [phone]
QUAD. NO. FOR OFFICE USE ONL�•(1.0 7 U 5
— SERIAL NO. LL1I OO I
Lat. Lon
WELL CONSTRUCB
T g' Ro
Mi '
ION RECORD nor asm
RILLING CONTRACTOR; _�� ` Basin Code
1'e�(IL.LE 1ELL K'� ��' Header Ent.
DR�LLER REGISTRATION N STATE WELL UMBER; � o�t�q(p 'ERMITNUMBERNSTRUCTION
I. WELL LOCAT how -----
S tch of the location below)
Near w
County:
(Road, om unity or Su vision and Lot No.)
2. OWNER DEPTH
ADDRESS From To
(Street or oute NO.)
City or wn State
3. DATE DRILLED Zip Code
4. TOTAL DEPTH r USE OF WELL
CUTTINGS
6. DO SWELL REPLACE EXISTING WELL? YC
7. STATIC WATER LEVEL Below -Top of Casing: � FT
8. TOP OF CASING IS (Use "+' if Above Top of Casing)
FT. Above
Casing Terminated avor below land surface is IIlleg SurfaceI sa variance +is.lssued
In accordance with 15A NCAC 2C .ol18 un es
9. YIELD (gpm);�_ METHOD OF TEST
10. WATER ZONES (depth):
11. CHLORINATION: Type 11-�
12. CASING: --Amount
Depth Wall Thickness
From To t!p9 DMl 1'�opr or, we, hVF . at rial
From— ______ To fit. �= T ��
From �_ t.
13. GROUT:
To Ft.
Depth MANrial
(oq Method From To
Ft. r
From To Ft. `
14. SCREEN: ----
Depth Diameter Slot Size
From — To Ft _ Material
From To — — in. — in.
Ft.
From — To — Ft _ in. in.
15. SAND/GRAVEL PACK: in. in.
From
Depth Size Material
.___ To
From -- To Ft. _______--
16. REMARKS:
i I DO I R BYE` E TI r� ThIATITHIS WELL WAS CONSTRUCTED I ACCORI
1�, �VSTRUCTION STANDgfjpS"AND THAT A COPY OF THIS C RD HAS
91 Jill
GW-1 Ent
DRILLING LOG
Formation Description
ED —
c7
�o
Cj
<n -•
0
If additional space is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
WITH 15A NCAC 2C, WELL
' �PVIDED TO THE WELL OWNER.
;W t. REV 9191' , .. SIGNATURE OF CO RACTOR OR AGENT
Submit original to Division of Environmental Mananp.r —t —.r
TE
'/ i

Norlh Cnrolinn - Departmenl of Fnvltonn,pnl, 110,11111. ,arid Nalutal Ilm-otircnn
Division of Environmeninl Managpmpnt • Giounrlwnlm Snclion
P.O. Box 29535 . nnieigh, N.C. 271326-0535
Phone [phone]
WELL CONSTnUCTION nECynD
UnILLING CONMACTOn: ��6'r
ran orrtcc ure arii.v r; t 4 r�
r�LInU. Na. ---_-- �EItInL hta —_ 1
1_al. —_— Lonq, — n0
Minor Itasln
tbrin Code
I leader Enl. G%7 I Ent
STATE WELL CONSTnuCT1011
UnILLEn nEGISTnATION NUMBER: PERMIT NUMBER:
1. WELL LOCATION: (Sh w sketch of the location below)
NeareSl/Town: y�,�y County:
(amid. Community, or SuNlivision and Lot No.) — DEI T1-1 MILLING LOG _.
2. OWNER r_Ml r;r------------ rrorr. �� romration D^scripfiorr
ADDRESS ---- ---------------
(sirent or nouto No.) �j - �D ---_- _ c 7 -- _
City or Town siate------ -- z�hc��ir, —UrR�'-----------
_LU �+'d_-
3. DATE MILLE1) USE Of= WI_I_L-----
d. 10 rnl. DFPTT I --° -- _ _ ----- — --- ---
5. CUTTINGS COLLECTED YES NO�----
6. DOES WELL nEPLACE EXISTING WELL? YES J NO(
7. STATIC WATER LEVEL Below fop of Casing: ��) rr. — —
i (Uso "1.11 Ahovo. rop of casing)
8. TOP Or CASING IS.--/-- FT. Above Land Surface'
Caslnq Terminnted nl/or below hand surface Is Illegal unless n vortarice Is Issued
In nccordnncp wlth t5A 14CAC 2C .0118
g. YIELD (gpnt):_ METHOD Or T ES I-i l F
10. WATEn ZONES (deplh):
.. r 4tii�iirlll�skEr:�, �•P '. v -'rf �'
11. CI-ILOnINATION: Type -i Amount It additional spncp is npedQ°d us? 64!cW'oIJ%pt
12. CASING: — — — — ---- ----
Wall llricluress LOCA'I ION SKETCH
Depth Diameter or Wei hurt. Material (Show direction and distance front at (past two Stale
r-rom J) 'ro I I. �� � �vG -- noads, or other Limp reference points)
rrorr 1 o Ft. ---- -----
rrorn To Ft. --- ----
13. GnOUr:
DPptZD�ri N�elhod Q
Front To r I. -- ��� ——`��lsar� �o -=
rrorn To _rl.
14. SCnHN: N
Depth Diameter Slot Size Maledal
From To
rrom To r-l. Ill. fit. „
Q [n T
From -- To __-- r1. In. o
15. SAND/GnAVEL
W Male►lal
From � rl.
I Dn t IEnEB`r CEf7TIrY 11,I111: ?T! IIS;.WELL'-1nFA�-PANS"f nUCiEU IN ACCORDANCE Wlil1 15A PICAC 2C, WFLL
CONSTnUC1ION S77fN[571nDS, A D 11IAT A COPY Or THIS nECOnD HAS BEEN PROVIDED 10 THE WELL OWIIEn.
S10NA Unr or comnnc1*0I1 on AGENr DnrF

North Carolina - Department of Environnnni, Health, and Naluml nosourros
Division of Envitonnenlal Managnnnnl - Groundwnler Soclion
P.O. Box 29535 - Raleigh, N.C. 27626-0535
Phone [phone]
WELL CONSS`RUCTION RECORD
DRILLING CONTRACTOR: A(^!` V
ron omcr_ usE orif_* 1 414 4
ollnU. No. _ sEnlnl No. —
I_ Long. — no
Minor Basin
Darin Corte _
Ileader Ent. GW-I Ent.
STATE WELL CONSTRUCTION
DRILLER REGISTRATION NUMBER: PERMIT NUMBER:
1. WELL LOCATION: (Show sketch of the location below)
Nearest Town: k1_1 f/ —_---- County: L��i-Q
(nond, Community, or SulKlivision and Lot No.) DEPTI I DRILLING LOG
2. OWNER f�_- (�v,/ _—_— _----------- rrom --To Frnntation Dnscriptirnt
ADDRESS__
(Sbeel or nouto No
e — -3 Z -
City or I own 7ip Codo--------- - — -- ----- --
3. DATE DRn_LEr� �Z�-,22 0o USE OF WILL. __ i,�� ---------------
5. CUTTINGS COLLECTED YES U1 NO�—_---
6. DOES WELL REPLACE EXISTING WELL? YES NO[9_-
7. STATIC WATER LEVEL Below -Top of Casing: �p FT.
(Usn "t" it Abovn Top of Casing)
8. TOP OF CASING IS __/___ FT. Above Land Surface' r
Caslnq Term<nnled nUor below land sutlace Is Illegal unless a vorlarice Is Issued r �
In eccordnnce Willi 15A NCAC 2C .0110 tr€Da+ - I?
(`Jp ) — ( d 39t{i Lri IFS y �,6P19dF!'E rr{ ;t<.. _
9. YIELD m : © _ ME-rl-Iou or -rEs r __� ,t
10. WATER ZONES (dep(h): _ —_-
1 1. CHLORINATION: Type 1z<1-�/ ___Amount_
12. CASING:
Depth Diameter
From �—•To �
From To Ft.-- -
Fron - To
13. GROUT:
If additional space is needed use back of form
Kill llrikrrns. LOCA-1ION SKETCH
or We' hurl. Malerial (Show direction and distance Iron at least two Slate
soiFgi /all.�, - noads, or other reap reference points)
Depth mp vial Method
From '9 To 2 O FI. Qf aZ
From _ To Ft. --
14. SCREEN:
Depth Diameter Slot Size Material
From To Ft
From To FI.-- In. -- In.
From To Ft. In. — In.
15. SAND/GRAVEL PACK:
Fr D tr
16. Rrj1,,4Ni<sJUL 10 7 2000
Material
r7
:zs r:�o
c
c�
_ _,
.f � C�
m
rn�
�rn
� js-
m;:u
r>
0
.z
I1EitF�� Sir ti•, tyrl nS 1VELL WAS CONSI RUC 1Eu IN ACCORDANCE WITI 115A NCAC 2C, WELL
rr
STRUOTION STAN.DAnDS, AN THAT A COPY OF 1.1-IIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
SIONAT11 r Or COt11nACTon on AGENT DATE

North Carolinri - Deparhnnnl of Fnvlronmmil, Ileallh, and Malmal nnsourcns
Division of Fnvironmenlal Ivlananr.mmil - Groonrlvyalar Snclion
P.O. Box 29535 - naleigh, N.C. 27626.05:15
Phone [phone] .
WELL CONSTRUCTION RECORD
UnILLIIJG CONTHACTOn: jMllel_
QUAD. 1.10.
Minor Ilhsin
t3asln Corle
I leader Errl.-
roe orrlcor NIA 1 4 4 4
no
STATE WELL CONSMUCTIO11
DnILLEn FIEGISTnATIOtd NUMBEn: 4e& PEnMIT NUMBEn:
2
WELL LOCATION: (Show skelch of the location below)
f laarapsl /Town: / ��%�/�� - Counly.
— Ild/'C we 6
(nn:,rl, Comrnunily, or Sufxlivision and Lol No.) -----
OWNFn - n- l fie' e..
ADDRESS
e1e, oyes
GPd- I Ent.
DEP 11 i D.131L1_ING-LOG
n rro+To rrnnrnlion d4srriplirnr
(Sheol or noulo No.) U /L� ----
------ -- --- - - ---- -- __ • - /v ��v -
Cily or Iowa Mary if) Coda -- ---- — --- --- -- -- -- -
3. pnlE pnILLED-�'z�'d�.--- USL= OI= wl=Lt_--!�•�liC--- -- --- ----- ---
d. -TOTAL DEPTII-----.-_----
5. CUTI IHGS COLLECTED YI_S U1 NOI._-
6. DOES WELL nEPLACE EXISTlh10 WELL? YES (J NO
7. STATIC WAIEn LEVEL Below -Top of Casing: fp- r-T.
(Usn'r' it Abovrr Top nl Casing) ;
8. IOP OF CASING IS_ �FT. Above Land Surface' ,; €
Cnsing Trrnrinnlyd nUor below Imrd smlace Is Illegal unless n varin6ce Is Issued
In occordnncr, with 15A NCAC 2C .0110
9. YIELD (gpm):_ ._ METHOD OF TES 1'—'�—_—_-
10. WATEn ZONES (depth):-------------
(r�wrr, •� -�
11. CHLOnINATION: type ��T�f _ — Amount Il addilional space Is nn.ednd use brick of form
12. CASING: ----- —--------------- --- -- —
w:rlt lAi kness LOCA'I ION SKETCH
Depth Diameler or Wr.ighVrt. Manorial (Show direction and dislance from al leasl Iwo Stale
From To � 0 FI. - �'L� f�'�z �`�G noads, or olher reap relerence points)
Front 'I o rl.--------- ------
F r om To —.--_
13. GnOU T:
Depth Z1114"ll"ll
From © To 2 0 Ft. _—
From To Ft.
14. SCIIEF-14:
Fronl
Front
From
15, SANS
D
Frog
Froll UU
16. FIEA1 nK
depth Diameter Slot Size
_ To r( II1.
_ To FI. _— ill.
-To __— rt.- in. —
I d
Method
Material
In.
In.
In,
Material
I DO 1'1[-Ra-YTrliffr'Y1:1-1A-TIIIS-Wh__L WAS 00NSTnUC-IED IN ACCOnDANCE WITH 15A IICAC 2C, WELL
COIJSI nLIC I ION STANDAnDS, AND 'I HAT A COPY Or THIS nECOnD HAS BEEN PnOVIDED TO TI IE WELL OWt lEn
n
.cinIt AT
2Y6
nr- Cr1NIrIAVInn on AG6f•Ir
DArE-

rlorlh Caroling - Uepartnwnl of Envhonntmd, I Iealih. and Nnlmnl (losourrns
Llivision of Environmenlrll Manngr.ntpnl - Caound - lot Snrlion
P.O. Box 29535 - tlaleigh, N.C. 27626.0535
Phone (919) 7:33.3221
WELL CONSTRUCTION RECOnU
DRILLING CONTRACI.OR- o) ./ C�li,, //'iI
Of JAU. 1.10,
Minor flasin
fla ,in Corte
Ileader Enl.
rem orrice urir: orn;r: -{
_ Long. — fl0
STATE WrLI- CONSTRUCTicim
DnILLER nEGISTRAI'ION t%iumnER: PERMIr NUMUEn:
I. WELL LOCATION: ( how skelch of Il,e localion below) ���/
I�learesl Town: � - ---- Counly: f l_c (,12e
2.
-------------_.----------------------------------
(nn a(], COrnnllrtll ly, br Slltvllvision ail(] Lot No.)
OWNrn _.��grr l2� 1/ ✓� <_-- ----- —
DL-r lll
----.----.-
rrorrr to
DnILLIFIG LOG. .
-. ---.- ,- --.__-
ronnalion D^Sr-riplion
lP o 5
A D D n C s S - -- --� .. -- - --- -- - -- ---
_—E%_- A2 ---
---- --
(Sirens or Noule fJo.)
1/0_—�!-
�c
--L�YJ��-..------------------ ----_
----- -
o.
City or town Stale 71p Corso
uArr- Dnn.lr_u USE. or WI_1-1. �� ----
--— - ---�� -- --._.. —
--
--
n.
IOrAI. 1)rr111
5.
CUTTIHGS COLLEC-rrD Yr_s L l r,lol
---- — ----
-- — -- ----
6.
DOES Wrl_L nEt,LACE. EXISTING Wla.l-? YES LJ
7.
STATIC WAI En LEVEL below Top or cashig: P._' rr.
(US!! -C it Above Top of Cnsing)
8.
TOP OF CASING IS._jrr. Above land Surface'
' Caslnq
Terminnled nUor below Innd sullace Is Illegnl Unless n variance Is Issued
In
9.
nccordancP with ISA NCAC 2C .01111
Ylrl_D (gpm):_ METHOD OF -rES I-
—
I o.
WATER ZONES (deplh): —_ ------
- ----
11.
CNLORIfJAI IOIJ: l }'pe lnoUr,l ---
II addilional space is nnednd
use bank of torn,
12.
CASING:
Depth Diameter
From To
rrom T o rl.---
r i one-
13. GnOU r:
wan f l,ir, I nrss _LOCA-1 ION SKETCI i_
or weiglNrl. Malmial (Show direction and dislance from 31 least Iwo Slate
.S{�� /y ?PYl:— noads, or other n,ap reference points)
Depth Merial Method
From �_ T o � �2 rI.. _r 14_r?d -----
From To _ rl. _---- --
1A. scnEEN:
Depth Diameter Slot Size Malelial
From To rl
rrom To FI.--
From To __— F1.-
15,
F1on1
rrorrr
16. RE t<•1
To rt.
Ro1.7 M I.
Maleilal
C) -Z
O rD
ram- <<�
cv n'
t= o
r i
p Cn :r_
rr,
o
ca C,
X
l rvunri:�?ate' Sectlon
I Do i EnEoYAQFVITIga"' I. � �12 L WAS CONS TnUCiED IN ACCORDANCE WI111 15A MCAC 2C, WFLL
CONSTRUC I ION STANDARDS, AND 'ri-IAT A COPY OF THIS RECORD HAS SEEN PROVIDED TO THE WELL OWf TER.
nrrir.lA rr mr- nr meltrlAr..Tnn nil AC;FI•lr
UAIE

Not lb Carolina - DepatlIII" III of EnVltomiintit, I IPall II. and Nalutnl IlnsnurCC) .
Llivision of Enviionmenlal Manapmnonl • Ciounrfw-1 pr Sorlion
P.O. Uox 29535 - nateigh, N.C. 27626•0535
Phone (919) 7,13.32.21
WELL CONST13uCTim REconD
DRILLING CONTRACTOR: m; 11 '- JrAl
r)I IAD. 1•10.
1_rrl. ___
Minor F1:irhi
rlasirr code -
I leader Etit.-
roll Orrlcr- war or n.v�; .l r
-. _--_-- SEIIIAL 110 ''_ I c� 4
110 —
-- - STA-I'E wrr_i_ coNsmuc-riotl
DRILLER REGISTRATION NUMBER:^y�� - ----- - - PERMIT NUMBER:---------
1. VVELL LOCATION: (Show skelch of the localion below)
Nearest Town: ---. courtly: 01 t✓fy �� e
(rl. nrl. Convnuntty, of st)l.:rfivision anri Lot No. ---- - DEP'I 1-1 _ DRILLII IG LOG
2. OWNER _-- `--_ ,� �--------___-- rrom -- io rorrnalion D^srriniign
ADDRESS -------- -- -- ----- ((-?
City or l own sialo Zir) Codo ---70 ------
---
3. DA-1 E Linll:l_El) � 00
A. 10I'AI. DEP.1'I I -fib Z� ' ___ V - ---
5. CUTTII•IGSCOLLECT ED YE.sUl NOj.�� —
6. DOES WELL REPLACE EXISTING WELL? YES �� NO���
7. STATIC WATER LEVEL Below -Top of casing:
(Use -I" if Abovn Top of Casing) d'tf iJ ,' ? r,_
8. TOP OF CASRJG IS _� rl .Above Land Surface' #
Casing Terrnlnnled nUor below Innd surface Is Illegn) urdesn n varintice Is Issued
In nccordonce wlih 15A NCAC 2C .0110
9. YIELD (gpm):_S_ METHOD Or TEST(�—_-
10. WATER zoNEs (dep1h):
11. CHLORINATION:
12. CASING:
Type blel Amount —t J It addilional space is npeded use bank of form ,, i
Depth Diameter
From TO FI.-
Fronl To FL -
From To -- Ft.
------
13. GROU 1':
Kill Irir:Hnesa LOCA-1 ION SKETCH
or weighurt. Malmial (Show direction and distance Irom at least Iwo Slale
_ lzG Roads, or olher reap reference poinls)
Depth
Material Method
rrom
O i o �D • FI. ol--�/,
rrom-to
ri.-
14. SCREEN:
Depth
Diameter Slot Size Material
rrom
To
rl hl. In.
From
To
rl.--- in. -- hi.
From
To __,�� r-I-
_.,�,J1L —_ IIt.
15. SAND14
VEj P&CI
n \ � n
1
Material
From
From
16. REM,
o
n_
Fri
r— 51
N c_.,
Cn r')
7Tr�
rn
o
W o
LOCI I tEHr-v T-:'f ff�f'"f`fTA f "I' (Ls wr_LL WAS cONSI IIUC I ED IN Acc. onDANCr WI11115A I IcAc 2C, WELL
COPJSInLlC 11014 STANDARDS, AND'IHAT A COr, Y 01: THIS 11ECofID HAS 13EEN PROVIDED 101I IE WELL OWIIER.
slrrinrunr-- or CONInnCTOrl On AGErfr DATE

North Carolina - Departrnent of Envirommnni. Hnaldt, and Nalutal fln.^.ourcos
Division of Environmental Maringmmmnt - Groundwale.r Section
P.O. Box 29935 - Raleigh, N.C. 2.762.6.0535
Phone [phone]
WELL CONSTRUCTION RECORD
DRILLING COIJTRACTOn: �1�/�' ACV
ron OFFICE urE oriLY
otJAD. rlo. --__-- sEnIAL No. —
Lon.1. no
Minor Basin
Basin Code o,3' r
I leader Ent. --4'J- I Ent
STATE WELL CONSTRUCTION
DRILLEn REGISTRATION PJUMBER: /43 PERMIT NUMBER:
1. WELL LOCATION: (Show skelch of (lie location below) /��
Nearest Town: County: LG1ero/` e, E
(nnad, ommurnily, or Subdivision an t No.) DEPTH DTI I DRILLING LOG
2. OWNER _L r l l r�Yv�_� 1 _ _ rrom — 1.0 -Forma lion Desrripli?n
(Sheol or nouto No.)_<7—
i-�-- ---. - -- -- - ��s`
Cif � or Town Slam 7_ip C xlo —--------------- ----------------
3. DATE DRILLED USE of WILL Dr, e __ - --`--- --------------- —
4. 10 I -AL DEPTI f _Jc--- _ -- -- - — ------ --- —
5. CUTTINGS COLLECTED YF_S L...� NOF__I/ ---- _— —.
6. DOES WELL REPLACE EXISTING WELL? YES �_� NOV
7. STATIC WATE 1 LEVEL Below -Top of Casing: -�D f FT,
(Use "r" if Above Top of Casing)
S. TOP OF CASING IS---1--_ FT. Above land Surface"
'Casing Terminaled nVor below land surlace Is Illegal unless a vortarice Is Issued
In nccordnncp with 15A NCAC 2C .01113
9. YIELD (gpm): QEL-- METHOD OF TES I-
to. WATER ZONES (depth): —__ _---
11. CI-ILOnINA1lON: lype''A Ale —Amount
12. CASING:
Depth �. Diameter
From.—� -To Ft. -S -
From — -to Ft.-- From —To--- Ft.
13. GnOU r:
Depth
From _ram To o20 r Ft.
From To __Ft,
14. SCREEN:
Depth
From -- To -
From To
From To
15. SAND/GRAVEL PACK:
Floill�!I
•
16. n E M A RVAIN
I DO 14EPE13Y C
CONSTnUZ110
II additional space is needed use back of form
Wail thickness _IOCA-1ION SKETCH
or WeighUrt. Material (Show direction and distance ham at least two Stale
�n £f kl C` Roads, or other map reference paints)
Ma erial Method
Diameter Slot Size Material
Fl hJ. in.
Ft. in. In.
Material
C:3
CD
C_
C
r--
rV
Cn
co
C=)
W
CD
CD
LL PAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
JAI A COPY OF TFIIS RECORD HAS BEEN PROVIDED TO TI IV WELL OWNER.
SIGtdATUIIE OF CoNInACTon oil AGENT b/1iE

North Carolina - Department of Environment, Health, and Natural Resources
Division of Environmental Management - Groundwater Section
P.O. Box 29535 - Raleigh, N.C. 27626-0535
Phone [phone]
WELL CONSTRUCTION RECORD
RILLING CONTRACTOR: Header Ent. GW-1 Ent
�10..'A`�ltLLE V.SELL�Q_IIL I�� r� STATE WELL CONSTRUCTION
DR LLER REGISTRATION NUMBER: 'F o�O�ICo PERMIT NUMBER:
of the location below)
;—; 1 County:
3. DATE DRILLED �alI M USE OF WELL
4. TOTAL DEPTH t
5. CUTTINGS COLLECTED YES[] NO[ —
6. DOES WELL REPLACE EXISTING WELL? YES NO[�
7. STATIC WATER LEVEL Below -Top of Casing: ktp FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS FT. Above Land Surface'
' Casing Terminated at/or below land surface is Illegal unless a variance Is issued
In accordance with 15A CAC 2C .011a
9. YIELD (gpm): METHOD OF TEST �k-
10. WATER ZONES (depth):
11. CHLORINATION: Type _ *� f� Amount
12. CASING:
FOR OFFICE USE ON
QUAD. NO. SERIAL N� n R
Lat. Long. RO
Minor Basin
Basin Code
DRILLING LOG
Formation Description
o
�
—
0
If additional space is needed use back of form
Wall Thickness LOCATION SKETCH
Depth Diameter or eight/Ft. ate I (Show direction and distance from at least two State
p C� From D TO q Ft. - �R-k Roads, or other map reference points)
From To Ft.
From To Ft.
13. GROUT:
Depth terial Method
From To Ft.
From To Ft. i
14. SCREEN:
Depth Diameter Slot Size Material
From To Ft in. in.
From To Ft. in. in.
From To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
16. REMARKS:
I DO HEREBY CEhTIFY THAT THIS WELL WAS CONSTRUCTED I
.CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS EC
li
f"
G
SIGNATURE OF C
,'GW-1 REV 931` Submit original to D i;
ACCORDAjj!�CE WITH 15A NCAC 2C, WELL
RD HAS,8EaN PROVIDED TO THE WELL OWNER.
ACTOR OR AGENT
of Environmental Management and copy to well owner
Z

North Carolina - Department of Environment, Health, and Natural Resources
Division of Environmental Management - Groundwater Section
P.O. Box 29535 -Raleigh, N.C. 27626-0535 FOR OFFICE USE ONLY O Q �J (� Phone [phone] QUAD. NO. SERIAL NO, v ( J v
WELL CONSTRUCTION RECORD MinLaoor Basin Long --------' Ro
4RILLING CONTRACTORIT-P �T�.� Basin Code
0 0' Witt�. tLLE7 lam( �---- Header Ent.
DR))LLER REGISTRATION NUMBER: GW-1 Ent
STATE WELL CONSTRUCTION
DC)9(o PERMIT NUMBER:_
1 • WELL L ow T how sk tch of the location below)
Nearest Town:
County:
(Road, C m nunity, or ivis• and Lot o.)
2. OWNER \\ D_ DEPTH
ADDRESS �a From To
( et or R ute No,)
City or Town��j
State
3. DATE DRILLED o� ZIP Code
4. TOTAL DEPTH , O USE OF WELL
5. CUTTINGS COLLECTED
6. DOES WELL REPLACE EXISTING WELNO Y
ES D
7. STATIC WATER LEVEL Below -Top of Casing: NO�
8. TOP OF CASING IS(Use "+" it Above Top o g)
_�IT. Above Land Surface*
' Casing Terminated at/or below land surface is illegal
In accordance with 15A unless a variance Is issued
9• YIELD 3 AC 2C .0118
(gpm): METHOD OF TEST Q,
10. WATER ZONES (depth):. _
11. CHLORINATION: Type
12. CASING: Amount ------
Depth Wall Thickness
Q►ameter or We
From—�_ tQrial To Ft. //_ , v
From -
To
From —"-"
13. GROUT:Ft.�__
From rial M t
Depth � od
Meth
From _ To Ft. g
14. SCREEN: To Ft.
r
Depth Diameter Slot Size From — To — Material
From To _ Ft -_ in. — in.
Ft. _ in.
From ..__,_. To — in.
15. SAND/GRAVEL PACK: Ft in. ----- in. ----
Depth Size
From To Ft.Material
From TO Ft.
6. REMARKS:
nV11- Yi THA T
CTION 3TANAA— — i
t J o
'j
/•1 REV: 9/91
DRILLING LOG
Formation Description
}
If additional space is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
WAS CONSTRUC ED 1 ACCORDAME
T A COPY OF T S 7.17
ORDB7'A
I
SIGNATURE OF
TRACTOR v v
OR AGENT
Submit original to Division of
15A NCAC 2C, WELL
3ED TO THE WELL OWNER.

North Carolina - Department of Environment, Health, and Natural Resources
Division of Environmental Management - Groundwater Section
P.O. Box 29535 - Raleigh, N.C. 27626-0535 Ead
O. ::::::
Phone [phone]
WELL CONSTRUCTION RECORD in
SRILLING CONTRACTOR:—�-�-�p C.
p�,Wt-r� ft�E ��� �� �� t.
R LLER REGISTRATION N r-� STATE WELUMBER: o�t��(p PERMIT NUMBER; RUCTION
1. WELL LOCA I N: (Show ske ch of the location below)
Nearest Town:
County:
(Road, Co unity, o ubdivi on Lot N .),
2. OWNER b In DEPTH DRILLING LOG
ADDRESS From To Formation Description
(Street oute No.)
City or wn State
3. DATE DRILLED Zip Code
4. TOTAL DEPTH USE OF WELL _
5. CUTTINGS COLLECTED YES [] NO
6. DOES WELL REPLACE EXISTING WELL? YES
7. STATIC WATER LEVEL Below -Top of Casing: Ff
8. TOP OF CASING IS �_ (Use +� if Above Top of Casing)
Casing Terminated at/or below land surface s (Regal unlesbove Lans a variance is Issued
Surface 7
In accordance with 15A NCAC 2C .ol18 v
9. YIELD (gpm);�_ METHOD OF TEST a�
10. WATER ZONES (depth): ~
11. CHLORINATION: Type 1
12. CASING: Amount ___
Depth Wall Thickness
From � To �s Di�rE,� e orWeigh,�1� �Qa
Ft. --._.. o�cll {�
From—_____ To---.-- Ft.-______ _
From _.__-_._To--__ Ft.
13. GROUT:
�
Depth a eri I
From --.0_ To !2 Ft. �Method
From ` To Ft.�_-
14. SCREEN: -----------
Depth Diameter Slot Si
From To ze Material
Ft — in. in.
From To — Ft.
From — In. in.
To Ft._ in.
15. SAND/GRAVEL PACK: in.
Depth Size Material
From _—_ To _ Ft.
From To ---_ Ft.
16. REMARKS:
I DOME EBjY R ?IF I TAAT�THISlIV1/ELL WAS CONSTRUCTED
CON �UCTION'STANDARDS, A, : ti y
THAT A COPY OF THIS RE
i
N-1 REV, 9/91 �+,; s ��, r ,I� SIGNATURE OF COD
Submit original to Dive:
--------------
~_
If additional space is needed use back of f
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
ACCORDANC ITH 15A NCAC 2C, WELL
RD HAS B N RO .IDED TO THE WELL OWNER.
oG
ACTOR OR AGENT
of Environmental Management and coov in w.11 DAl
VIA

North Cnrolina . Depnrlmeni of Environrnnnl. I-leallh, and Mnlurnl Ilnsourcos
Division of �nVtrOmnCrllal Manngnmmd • Groundwnlor Sncllou
P.O. Box 29535. nateigh, N.C. 27620.0535
Phone [phone]
WELL CONSTRUCTION nKynD
tMILLING CONTRACTOR:
r-on orrice lint: or►t-Y 4 4 8 4
QUAD. 110. _— SEIVAL 140. —
I'll. _--- Long. 1,10 —
Minor Basin _
Bn sin cod" —
Ileader t_nl. GVl-I Entt,
STATE WELL CONSTRUCTION
DRILLER REGISTRATION NUMBEn: PERMIT NUMBEn:
1. WELL LOCAL 10 : (Show ketch of the localion below).
Nearest Town: L' _--- Counly:
jnond. Cody 1J_ y: or Sutxfvlslop and Loi No.) ----- - UCI' I! I _URILLII"IG�LOG
/ — _ _-. II-- -
2. OWNER .- Gil Gi/ rrorn ," r"rm rlion b",.riollan
ADDRESS ` ` 4al Ga' .7' ----- _ _ _
pivel or noulo No.) �j
— �
City or Town Slalo Zip Coda
3. DATE MILLED USE OF WL=I_L
4. 1OTAL DEP'TI I �Do _ _
5. CU MHOS COLLECTED YES 1__1 NO[--
6. DOES WELL nEPLACE EXIS-TING WELL? YES
7. STAIIC WATEn LEVEL Below -Top of Casing: _�_`� FT.
(I)se "C if Abov" Top of Casing)
8. TOP OF CAS114G IS _ -__ FT. Above Land Surface'
• Casing Terrninaled at/or below land surface Is Illegal unloss a variance Is Issued
In accordance wilh M NCAC 2C .0110
9. YIELD (gp►n):___ METHOD Or
10. WA-TEn ZONES (depth): 1122/
11. CHLORINAI ION: Type (c% Ainou►11 II addilional space Is needed usR back of form
12. CASING: --------- -------------- —
Depth Uiameler
From To r1. —f—
rronl -10-- 1-1.—
rronl To rl.----
13. GROUT:
wn11, I,icknoss _LOCA1101J_SKE 101.1-
or weigl,Url. Malerial (Show direction and distance from it least Iwo Stale
noads, or olher map reference points)
DepII1 eyial Met lod
From �� To F1. �
rronl To Fl. —
14. SCREEN:
Depth Diameter Slot Size Material
From To
rronl To
F►onl _ To ---
15. SAND/GIIAVEL PACK:
Depth)
rronl T o I
From -to
16. REMARKS:
1 DO I IEIIETTY CEn TI Y I I IA
CONSTIIUCTION ST N43AW
alellal
-t ULbrt
WIN
0
c�
L
c
r--
r\3
Ln
0
IS-T UCTED IN ACCOMANCE WITI 115A NCAC 2C, WELL
OF t-IIS nECOnD HAS BEEN PROVIDED 10 THE WELL OWI1En.
SIC,NATun : or cownACTon On AGFNr
UAtE

Notch Cmollna . bepntlman) of rnvltorininirl, 14001111, fill,) HnIm l 11nnoulcus
Utvlslon of �nvironnituil if (dlfinnhmnotil • 00"(101n1et SnCllon
P.O. box 29535 • naleigh, N.C. 27020.0535
Phone [phone]
ron orrlcr unr of lt.y r, -7 �'j/�
711AU. NU. _ SOVAL tIo.
Int. _ Lm,q. ho
Mint bnsln
WELL CONS-MUCTION 111ECOM) I Nasitt Code I
lI Ic7dcr tilt. GY!• I Ent
bIIILLiIJG COfJtpnCt(7t1: i 1%ll�✓' S-rntr WELL CONST"UCTION
bIa1LLEr1 prclstrintlolJ NitMSErt: �f� _ _____ PEnMIT NUMNril:
1. WELL LOCAL IO�yN::,(Show.slcelcl, of the locallon below)
Neatest sown/��� - Counly: G/
o? -/ ----• — Urp l I I _UI71LLIHO LOG_
(t,ond. Com munily, of SuNlivhl,rn'ind Lol No.)! _.-
cJ ("fom In ronnalirn, U� ,^rrpii�n
2. OW NE to - ��
(Slrenl or noula 140.)
City of loKn Slnln Ill
3. UAlC Uh►t.l_EU %``��-CO USr or WLI-l-
-
A, 10TAL UEpI I I -moo--- _
5. CU ITIIIrS COLLEC-tEU YrS j__ � N0[:J--_ _
6. UOI:S WELL nEpLACE EXIS"IIN(3 WrLL? YES NOu-- -
7. STATIC WATEtl LEVEL t3elow Top of CnsIng: �-._- rt.
(l)sn'r" II Allow, Top of Casing)
6. lop or CASING IS �_._-- rT• Above Land Suliace'
Caeing lennlnnled allot below InIld sutloce Is Illegal unless a vnrinnce is Issued
In accordance Will ISA NCAC 20 .01 Ill r
9. YIELD (gpin):- /,,;-I - ME fl IOIJ or -I ES I- '
I0. WAl Ett ZONES (depth): SS`�
15-3 /2-
11. CNLOIlINA1 ION: TYPO Alnoun— II riddilional space Is ngednd usq hack of loam
12. CASING:
13
Depth biamcler
rrom to rl.
rlom -to—I-1.
Front --Iv I=1.
(3tloU1:
molt, P
Front
114. SMEIJ:
LocA'IloN_SKE 1 CI_I
Wall I hir.knnss
or welglil/rl. molalal (Sliow direction and dislancq Irorn al leas) 'no Stale
,5Dw'Z hoods, or oilier mop relgrgncq points)
Uepih alellal
MP�hod
/• essur�
-to..............
Uepih Ulaineler Slot Size malerlai
r 10111 1' 0
glom
15. SANDIGHAVEL PA
��•� � ' ,let lal
r l on, t o r 1. !: ,,;,,
iron, __-- •loIVA=
16. h0vlAtlKS:
C)
CD
C-
r--
rV
0
C)
W
Ca
O
�i
o w-
C3
rn
cn
`:6
n
--I
0
Groundwater becif�n
UC►11Et1CI1Y CEIl11 Y l Sit ll °i to '>©MS# UCtEb IN ACCOIibMICC W1111 15A FICAC 2C, wr_L
CONSIIIUCIION STANUAt1l7S, ANU 11IAT A COPY Or lfllS hEcOtlb LIAS (SEEN pnOVIUEU 10111E WELL OWIIEn.
zto 3
elnirnl l r. nr: r HInACtnn fin Mrllr
UAtF-

North Carolina - Depmimenl of Environment, Heallh, and Malurai flnsourcos
Division of �_nvironmonlal Managmnnnl - (,rotln(lWaler Snclintt
P.O. Box 29535 - Raleigh, N.C. 2762.E-0535
Phone [phone]
WELL CONSTnUCTION IJEConD
h"ll 1 11,10 CONTRACTOR: v1A ' Ile, [,)�%/ , A
ron orrice Usrorlt.vr)
OUAU. No. _ ___ se.- NQ. � 1- 4 4 6 5
t al. ___ Lonq. _ no
Mlnoi Hasln _ _
flasin Code-- --- - —
Ileader Ent. GVr-I Enl
SPATE WELL CONSTRUCTION
UnILLEn nEGiSTnATiON NUMBER:_- �S PERMIT NUMBER:
1.
WELL LOCAJ ION: (Show sketch of the localion below)
Nearest Town: rU_''>>0, Counly: � �r"U "g,-_.
_
v 1 '
(noad, Community. or SutxIlvision and Lot No.) DEPTI I
_URILLII_IG, LOG_
2.
OWNEn _ l,of-(Lv- �Gr `'i�x�%L�_— ---- r,o,,,�-To
rorrngt;on nq ,4ripro„
ADDRESS
-----
(sheet or noulo No.)
� �1_�-.� -- ��'_�c�� pis-`-- r
�s r.;�►n` �.
3.
—�i�c� .S3
City or T •n Slaln Zip Codo
DATE DRILLED 1�-A("% USE Or wr-LL
4.
5.
TOTAL DEP'111 _1r1.S_' • —
CUT-TINGS COLLECTED YES F—1 NO(:1 1'
---
—
6.
DOES WELL REPLACE EXIS'1ING WELL? YES[] NOLj_ _
7.
STATIC WATEn LEVEL Below Top of Casing: _y '_ rT.
(Use "C tl Above, Tnp of Casing)
8.
TOP Or CASING IS _1 ___ r-T. Above Land Surface'
• Casing
Terrnlnsled atlor below land surlace Is Illegal unless a vnrlonce Is Issued
In
9.
accordance with 15A NCAC 2C .0110 —
YIELD (gpm):9— ME'l HOD Or- TES'1 .L
M
WATER ZONES (depth): -
11. CHLORINATION:
12. CASING:
Type 1? 74A Amount --- If additional space Is needed use hack of form
Depth Uianteler
rromrl.--
rron, To --
From _ To 1=1.-----
13. GROU1:
rrom —0
rrom
14. SCREEN:
Uepth
r
1.0 t, r i.
To rL
Depth
Front To _
From To _
rton, ----- To _
15. SAND/GRAVE
rrom It
rlonT
16. REMARKS`.
I DO IVIUJIF CF_nT
CONSMUC49444
LOCA I IOIJ SI<E 1 CF1
Mill I hickness _ _
or weigh)/rl. Malerlal (Show direction and dislanco from at least Iwo Slate
Roads, or other map reletence points)
Ml alledal Method
tl� �i ii y} I li
Dialilelor Slot Size
rt In.
rl.
-- rt.
Z� LMn
T (I , JJJ J 1
Malerlal
0
0
C_
r_
ry
CA
0
O
w
Wn CONS I'I1UC1ED IN ACConDANCE WITI-I 15A NCAC 2C, WELL
CA OT'Y Or 11-IIS nECORD HAS KEEN PnOVIDED 10 ME WELL OWI IEn.
2qo
SIGNATUnr- or CONtmton on AGCPtr
.. .. .. .- . , ,..
_-_V
UME

North Carolina . Deprirlmenl of Enviromminl, IJealih, rind Nalurril fln,ourros
Division of �nvironmenlnl Mrinagninnnl • Ctoundwaler S(lclion
P.O. Box 29535 • naleigh, N.C. 27626.0535
Phone [phone]
WELL INSTRUCTION nECOnD
DnILLIIJG COIJTRACTOn' (YI' I I r' �)= It 4-.1);rY''.
ran orricr: usE at it Y 14 i 6
QUAD. 110. SUVAL 140.
Int. __ Lonq.
Minor aa,k,
1,a,in Code
I leader Ent.
—� STATE WELL CONSTRUCTION
URILLEn REGISTRATION NUMBED:_ -- PERMIT NUMBER:
no
GVJ-1 Ent.
1. WELL LOCAL ION: (Show skelch of the localion below)
Nearesl Town: �� I_� -� I� 1 �� Counly: (J7 t' i ; /1 P-
i
Con'muniiy, or So livi,im and Lol No.) UEI rl I DRILLING LOG
2. OWNEn ...... morn To Formation De,aiption
ADDRESS __ _----- -- --- '`_ -- t� Wk -- -----
(Slreel or nouto No.) n
City or Tov<•n Slaln — Zip Coda
3. DAI E UnILLED USE or- WI_I_L , `% ; --- -----
d. TOVAI_ DEf 'l I I _ --
5. CU r ICS COLLECTED YES (� NOJ
6. DOES WELL REPLACE EXIS-ZING WELL? YES-
7. STATIC WATER LEVEL Below -Top of Casing: _ _ rr.
(U,e -C it Above Top of Casing)
8. TOP Or CASING IS __L___ rr. Above Land Sul face'
' Casinq Terminnled ntlor below Innd surface Is Illegal unlr+.ss a vorlonce Is issued
In accordance with 15A NCAC 2C .011ri ,
g. YIELD (gpm) ME-rI-IOU Or 'f ES T
I0. WATEn ZONES (depth):
I I. C1-ILO11INATION:
12. CASING:
Type 1'1 7 11 �_-% l- le/_%-Amowlt L.l If addilional space Is needed use back of (arm — --- --
Depth I Diameter
From --To V x r1.
rton, To II.----
rrom _ To Fl.-----
13. GROUT:
LOCA_rION SKE 1 cl_I
Wall *1 hicknoss
or Welght/rl. Malarial (Show direction and dislance Irom at least two Slate
.S,pr-?1 .�_L.C_ noads, or other map relerence points)
Depth Material Method
From TOfi'
groin To 171 —
f
14. SCnEEN;
Depth Diameter Slot Size Material
From, --To rt h,• __ — in.
From To Ft. In, in•
riom
rtom uo r1.
F►om _ To -1..
16. nEb1AnK .
I be 1lEnE 1Y cEr� � 1 '-,�
CONSTnU AN 1 , Qs—
Matellal
O
0
r_
c
r_
tV
0
0
w
0
=E
c�
:u
C" r'•l
C7;YS
Ac
m
�m
n-i xi
0
js CONsTnuCJ'ED IN ACConDANCE WITII I5A NCAC 2C, WELL
COPY Or THIS nECOnb HAS BEEN PnOVIDED TO THE WELL owtlEn.
L__ � - � -i?:
SIGNATUnE Or CON MACTOn On AGFNr DATE
. .. . . .. ti. . . .. . — . ......... IA 11 _.._-._... _... _...1 ___..... .....II n.. n.nr

North Carolina - Department of Environment, Health, and Natural Resources
Division of Environmental Management - Groundwater Section
P.O. Box 29535 - Raleigh, N.C. 27626-0535
Phone [phone]
WELL CONSTRUCTION RECORD
DRILLING CONTRACTOR:
FOR OFFICE USE ONLY
OUAD. NO. SERIAL NO.
Lal. __ Long. RO
Minor Basin
Basin Code '
Header Ent. GW-1 Ent.
STATE WELL CONSTRUCTION
DRILLER REGISTRATION NUMBER: PERMIT NUMBER:
1.
WELL LOCATION: (Shovy sketch of the location below). /
Nearest Town: %`%%��y C'` �d lL 1p_
County:
(Road, Co munitr#� y, or 5 bdivision and of Noy DEPTH
CS��r1� �� j�;�(
DRILLING LOG
2.
OWNER Frorn To
ADDRESs�
Formation Description
(Slreel or Routo No.)
2-
City or Town Slate Zip Code
—
3.
DATE DRILLED / �l�' ap USE OF WELL
4.
TOTAL DEPTH
5.
CUTTINGS COLLECTED YES ❑ NO[E[
6.
DOES WELL REPLACE EXISTING WELL? YES NOLg—
4
7.
STATIC WATER LEVEL Below -Top of Casing: [ _Lj_ Fr.
(Use "+" if Above Top of Casing)
TOP OF IS
8.
CASING FT. Above Land Surface'
' Casing Terminated sUor below land surface Is Illegal unless a variance is Issued
In
accordance with 15A NCAC 2C .0110
9.
YIELD (gpm):_ METHOD OF TEST
10. WATER ZONES (depth):
11. CHLORINATION: Type 1711�1 Amount If additional space is needed use back of form
12. CASING:
Wall Thickness
LOCATION SKETCH
Depth
Dta ,eter or Weight/Ft. Material
(Show direction and distance from at least two State
From
To ��
Ft.
�S '`'�'�� ��
Roads, or other map reference points)
From
To
Ft.
From
To
Ft,
13. GROUT:
Depth
nM�t�rial Me-t od
G
From
To
Ft.�
ess�% e
p
From
To
Ft.
C:)Q
�?
14. SCREEN:
tl
Depth Diameter Slot Size Material ry r-J <
cn r-1
From To Ft In. In. T C�
s
From To Ft. In. in.
From To Ft. in. in. m56
15. SAND/GRAVE ,�Gl����nf°IM'�'.`==:�1( o —,
Dto Material � z
Fr0i11 0 yw Ft.
From Top t: tt F..
. U .. ; L.,, ,-
16. REtv1ARK
I DO ItEREPY CER1'`V!'TI``
R1LL 1�I
tip 1e ,S CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUOTIO-w� tvDARDS`, fJD THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
GW-1 RF.V. W91
SIG NATWE OF CONTRACTOR OR AGENT DATE
Submit odainal to Division of Environmental Man�oernent and rony to -Nell owner

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section 4-17894.
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: -0-�eaoke,2L< l l �Q; � vo
WELL CONTRACTOR CERTIFICATION N:
STATE WELL CONSTRUCTION pERMITfiI:
1. WELL USE (Check Applicable 8ox): Residential t_:1 Municipal ❑
Recovery ❑ Heat Pump
Industrial ❑ Agricultural ❑ Monitoring ❑
Water Injection ❑ Other ❑
If Other, List Use:
2. WELL LOCATION: (Show sk tch of the location below)
Nearest Town: - /1'1_.�r R _ County:
'�
)
I
t �
s K
J
(Road Name and Numbe . Community, or Subdivision and Lot No.)
DRILLING LOG DEPTH
3. OWNER k P tT K1
_
Addressree
From To Formation Description
2
City or T c/ Slate Zip Code
4. DATE DRILLED-1
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES 0 NO❑ -
7. DOES WELL REPLACE EXISTING WELL? YES [:J NO[-3
S — 29-F Zp D3 =71
6. STATIC WATER LEVEL Below Top of Casing: ':� f ' FT,
_
(Use '+' If Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface*
o -
r SYC6
*Top of casing terminated at/or below land surface requires a vsrience In accor-
dance with ISA NCAC 29.0119 a�a3 �3
10. YIELD /
(gpm): METHOD OF TEST
,
11. WATER ZONES (depth): -125 D
- m
12. CHLORINATION: Type _ Z, %% /L` Amount Lr' '
If additional space Is needed use back of form' —�
13. CASING:
•
Depth- Wall Thickness
0 P Dlarrt�ler or Wel WFI.
From To ..3 0 Ft. �' L
From To Ft.
From To Ft.
14. GROUT:
LOCATION SKETCH
Itertal (Show direction and distance from at least two State
vC Roads, or other map reference points)
�'
Depth n -Material Method
From To Ft. rv�•
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
From To Ft.
From To Ft.
17. REMARKS:
I DO HEREB
CONSTRUC'
FOR OFFICE
Quad No: i!
Serial No.
Material
kd
Vf V
05
FIT IFY.THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
0AN&RDS iAND THAT A COPY —OFF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
ONLY �J f �`SO r1c• s ci - If- co o
OCT
SIGNATURE OF PERSON CONSTAUCTING THE WELL
al to Dlviefon of water Quality, Groundwater Sedlon within 30 days
DATE
GW4 ACV. 12(”