Well Construction Records Clay CY2000

P2 1294 5
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone] L L i
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION #: S _
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (check Applicable Box): Residential U Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LO ATIO Show sketdh df the location below)
Nearest T County:
n:
(Road Na d Numbe , C nity, or Subdtvisio and Lot No.) DRI LING LOG DEPTH
3. OWNER From To Formation Description
Address 104
treet or Roule
LRL
City or Town State Zip Code
4. DATE DRILLED
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑ NO ►Q/
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO[rf
8. STATIC WATER LEVEL Below Top of Casing: (d-() FT.
(Use '+' If Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface'
'Top of casing terminated atlor below land surface requires a variance In accor-
dance with 15A NCAC 2C 118
10. YIELD (gpm): METTID�OF TEST L-
11. WATER ZONES (depth):
12. CHLORINATION: Type Amount If additional space is needed use back of form
13. CASING:
Wall Thickness
LOCATION SKETCH
Depth
�
'[�ila�,mrr �ester or Weipht/Ft. Mate al
(Show direction and distance from at least two State
From
To
Ft. 1_
Roads, or other map reference points)
From
To
Ft.
From
To
Ft.
14. GROUT:
p
o
Dept
teri Method
From U
To d
Ft.
�
cm
From
To
Ft.
or^
15. SCREEN:
Depth
Diameter Slot Size
Material
—0
From To
Ft in.
in.
rM*_1
;o�
From To
Ft. in.
in.
iV
..
rncnr=
From To
Ft. in.
In. 3
i f I'�
{ �` t° �s3 �
Cf1
—1
16. SAND/GRAVEL PACK:
. �
Depth
Size
Material
From To
Ft.
tt k
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.
MAIN,
SIGNATURE OF PE N CONSTRUCTING THE WELL DATE
Submit original to Division of Water Quality, Groundwater Section within 30 days
GW-1 REV. 12/99

1, WEELL USE:(Ch.e&A.ppl,icable Bok); Residential3 • Muriicipa.l%Public �: .,fndiisttia! ❑'. Agricultural ❑''
Monitoring. ❑ Recov'ery ❑ Heat Pump Water lrijection,' ❑ .Other
❑ If 0•ther; List Use'
.. `. Z,: bYELL•.LOCATI ; .... � 1 .:.
Near tTowrt GL(. County
... Topographic/Land setting .. , .. .
Ridge .❑.Slope :❑Yalley ❑Flat
(Street Nnine,.Numbors, nmurtity, Subdivision, Loi No., Zip Code). ..
(cheWopproprWe box) .
Latitude/longitude ibf well location*.'
3: 'OWNER;
"AddrQss .
(degrees/miniites!se<onds)
Ladwdc/lorigitude source,C3GPS13Topographic mup
(Sire or Route I .)
(check box)
-DEPTH,.' DRILLING LOG
yorT w at Zip Coda ..
(
From � 'Formation Description-
0' T
" Area code - Phone nwnber
_c1 av &
c r 'Grcill,lt@
4•. DATE DRILLED —
RE
6_ DOES WELL PLACE EXISTING tiVELL YES ❑ ' 0
7• STATIC WATER LEVEL Below Top of Casing:
• .. (IJsp "*" If Abova Top.afCa;ink)
8; .TOP OF CASING IS 2 FT, Above Land Surface*
"Top of casing.terminated at/orbtlowl2ndjurrace requires a .:.
variance In.accordancf With ISA NCAC 2C 0118,'
91YIELD (Spm)t —L2_ MET Op OFr TEST ' ' blow .. ::.
:...10. WATER ZONES (depth):
LOCATION SKETCH -
III: DISINFECTION; Type H .m H .' Amount 16oz`:;Show.dire.ctioncnd
distance in miles t'ro.tii at.leasl
.:'.12. CAS1NGt ," '.' '.. Wall Thickness . :;
:two State Roads or County:Roads. Include the road...
Depth ;''':;; Di e�fr o� WeigtiVFt. M' e�iat •...riu`ribe�s
and common road names.,,
Froni To
From ... To • Ft. "
r+-
11'GROUT;: Depth ': Material Metho{�
.
':From— 0 To 2p: Ft Lt6 &,
�.M
:From To F1;
:. ,14 SCREEN:. Depth.:.:.•': Diameter . SIot.Size.. Material
'Fro.m To
-�
:.. From To Ft,' in', iti:
S;ANDLGRAVEL P'ACK;.
Ma
Depth Size Mite. fal
�.
From T.o .. Ft,
ry
c
From ..._ __Tc> Ft.
1 DO.FiEREBYCERTIFY'[HAT.THIS WELL WAS CONSTRUCTED Iw ACCORDANCE
i
;.CONSTRUCTION STANDARDS, AND THAT A COPY.Op Twt.c mt�C C mm M, EJ A e 1 . W'lTH I3A NCAC 2C, WELL

North Carolina
- DDCentment o a nvironN.C. nt an Natural
hResources
9 19) 733 f3221n of Water Oualiy •Groundwater Section
236190
1636 Ma
CONTRACTOR:
WELL CONSTRUCTION RECORD WELL CONTRACTOR CERTIFICATION N: -2�lau
STATE WELL CONSTRUCTION PERIAITN:
esidentlaIndustrial ❑ Agricultural ❑ Monitoring ❑
WELL USE (Check Applicable
PUMP lt P
♦'recovery Water injection ❑ M OthePr E] It Other, List Use:
❑
2. WELL LOCATI N: (Show sketch of the location below) n /
Nearest Town: County: S
1 DRILLING LOG DEPTH
(Road Name and Numbers. Commu or Subdivision and Lot No.) From To Fortraxn Descripli-
�d3. OWNER � t> � r �r. � ,� — © _ . ,
Address _ �� I
uee or ou o o, n�� �G
City or Town Stale Zip Codo
4. DATE DRILLED
5. TOTAL DEPTH 15
6. CUTTINGS COLLECTED D YTS ❑ NO[ 3_
7. DOES WELL REPLACE EXISTING WELL? YES 0 NOgj
S. STATIC WATER LEVEL Below Top of Casing: _ FT•
(Use '+' II Above Top of Casing)
9. TOP OF CASING IS _- FT. Above Land Surface'
-Top of casing terminated atlor below land surface requires a variance In accor-
dance with 15A NCAC 2C .a11e METHOD OF TEST---
10. YIELD (gpm): _-.
1 1. WATER ZONES (depth):
12. CHLORINATION: Type
��QAmounl � If additional space is needed txe bac� of Ictm
13. CASING: LOCATION SK=TCH
Wall Thickness $(ww direction end dance Ir-m
Depth leas v+o FDepthr Diameter or Welghl/Ft. Material ( points!
From
__0 ___To �� Ft. ` ` d ,r Road9. or other rrr� relert:� 10
From To FI, -- ----
From —To — Ft. --
14. GROUT: _?
Depth M teriai d
Method Q g
From --in— To �. {?--,
From To __—__--Ft.
15. SCREEN:
Depth Diameter Slot Slze Material a%
mo
From To Fl In. in. -----
r*icD
From To Ft. In. in. _------- err
From To
Ft- In. in..___----- rnt�
N
16. SAND/GRAVEL PACK: �o
Depth Size Material z
From -- To — Fl.
From To. Fl.
17. REMARKS:
1 DO HEREBY CERTIFY THAT THIS`D LL_W COPY OF THIrELL
NSTRUCS RECORD HAS B ETED IN N FROVICEO -1OWITH 15A ATHG !f''"�' OWNER.
CONSTRUCTION STANDARDS, AN 7 ` /
FOROFFICE USE ONLY �� rE
SIONATUnE OF PERSON CONSTRIY.TING 1►{ ,fv ELL
Mild No: e111 Ground,sle► Srcut within Y) C�Ys
Submli original to D;vitlon of Witter t7u r• f; n,l Fs� y, 1211
Serial No.

North Carolina • Department of Environment and Natural Resources • Division of Water Ouality • Groundwater Section 2 3 11 1.
1636 Mail Service Center • Raleigh, N.C. 27699.1636•Phone [phone]
WELL CONSTRUCTION RECORD NTRACTOR: a9--
WELL
CONTRACTOR CERTIFICATION 0:_ a '�
STATE WELL CONSTRUCTION PERMITII:
WELL USE (Check Applicable Box): Residential [g�Municipal EldLlstaUs�e'. Agricultural ❑ Monitoring ❑
pecovery❑ Heal Pump Water Injection ❑ Olher ❑ If Other,
2. WELL LOCATION: (Shoyv sketch of the location below)
�
Nearest Town: cCtSS } ©L.�YZ County: C�C�
P t1 i��1 2 DRILLING LOG DEPTH
(Road Name and Numbers, Community, or Subdivision and Lot No.) Fom'a�cn Oes'�nptiO'
i ��
3. OWNER From To � j �
Address
reel or ou a o. .—
City or Town State Zip Code
4. DATE DRILLED �a _ - OO
5. TOTAL DEPTH _ 1�5w ----
6. CUTTINGS COLLECTED YES o NO[9-
7. DOES WELL REPLACE EXISTING WELL? YES[] NO[]
B. STATIC WATER LEVEL Below Top of Casing: 70 `-- FT.
(Use '+' If Above Top of Casing)
9. TOP OF CASING IS 1 FT. Above Land Surface'
'Top of casing terminated eVor below land surface requires a variance In actor-
dance with 15A NCAC 2C.011E
10. YIELD (gpm): � METHOD OF TEST
11. WATER ZONES (depth):
12. CHLORINATION: Type
y,� ,ble,�1-s Amount YJ -- II additional space 4s needed t:s-e back of icjm
13. CASING: LOCATION SKJTCH
Wall Thickness
Depth am
or Weighm. Material (Show direction and d';sVance Iran liar; ko S -a e
From ---To
(QS ' Ft L2 snr�, _ Roads, or other rr�? relere: Po
From To Ft. --
From .--To FI. --
14. GROUT:
Depth r Material Method
From O To .2`Z-- Ft. �C�� ✓tom From
To —Ft. ----
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft In. in.
From ___. To Ft. In.
y
From
To FI. In. In. _------ � C--,
16, SAND/GRAVEL PACK:
Material CA3
Depth Size
From To
F1. � x
From To FL —
17. REMARKS:
WITH 15A
1 DO HEREBY CERTIFY ARDS, AIN THAT A COPY OF7 HIS REC RD HAS BEENEPROVICED -70ATFtE Yl: rL
CONSTRUCTION STAN,• , _ 7 _
FOR OFFICE USE ONLY'.
Owd No: L�Z;SIGNATURE OF PERso CONSTfi(Y:11fiG 1>t'NfLL
Subr!?II original to Division of Wtler puallly, Qrourtd.�><Nr Smut within C%ry�
[h,l Fliev, I,?,
Serial No• e

North Carolina . Department of Environment and Natural Resources - Division of Water Quality . Groundwater Section 2361,85
1636 Mail Service Center • Raleigh, N.C. 27699.1636•Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION 0:-2Z/lS�
STATE WELL CONSTRUCTION PERMiTN:
1, WELL USE (Check Applicable Box): Residential L'j Municipal ❑ Industrial
List . UsC�l: Agricultural ❑ Monitoring El
Recovery ❑ Heat Pump Water injection ❑ Other El II Other,
2. WELL LOCATpN: (Show sketch of the location below)
Nearest Town: N) I Q— County:
S
(R ad Name and Numb s,�C`ommunity, or Subdivision and Lot No.)
3. OWNER__
Address
ueet or ou o o.
City or Town
State Zip Code
4. DATE DRILLED 1 62- On
5. TOTAL DEPTH 262- ----
6. CUTTINGS COLLECTED Y fS E] NO[9—
7. DOES WELL REPLACE EXISTING WELL? YES NNOFq-
6. STATIC WATER LEVEL Below Top of Casing: ____ __
(Use '+' N Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface'
'Top of casing lerminalad at/or below land surface requires a variance In accor-
dance with 15A NCAC 2C .o11e METHOD OF TEST 44 �
10. YIELD (gpm):-
11. WATER ZONES (depth):
DRILLING LOG
From To
-- Ito
7
DEPTH
Fom.exn Desr.r PU-
c
P-
' e
f�
12. CHLORINATION: Type . �Amount It additional space 1s needed �' back of fcrn
13, CASING:
Wall Thickness
Depth r Diameter or Weighl/ft. Material
From To LL—
From To FI. -- —
From —To Ft. -- —
14. GROUT:
Depth r Matedal Method
From _AL— To _2622-- 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, Malerlal
Depth Size
From — To -- Fl. —
LOCATION SKETCH
(Show direction and dcs~ance hrrn 21 leas: t"o -`-'•ate
Roads, or oftr n---p relere:r-A- points!
From To_ FI.
17. REMARKS:
eELL
I DO HEREBY CERTIFY, THAT THIS WELL WAS,CONSTRU RECORD HAS BEENE WITH
15 O 'TOAC 2 Yr!"1 Oa�EF..
.CONSTRUCTION STANDAR,Q,Si /�NR TF,IP�IA COPYOF THIS
FOR OFFICE USE ONLY D� ~E
SIONATME OF PERSON CONSTntY:TING 1 'N Fu
Owd No:
SubrrJl original to Divlaton of Water pusilty, Orcund•raler Seaut within :4 G;sYs CM I F19 y
Serial No. e .

''>2'788
".
North Carolina • Department of Environment and Natural Resources • Division of Water Ouality • Groundwater Section
1636 Mail Service Center . Raleigh, N.C. 27699-1636•Phone [phone]
tk"EF41kL.1.E- W0.L l21t._l.,t I.1C,, --.
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ if Other, List Use:
2. WELL LOCATIO how sketc f the location below)
Nearest Town: County:
(Road Name a Numbers, Commu or Subdivision and Lot No.) DR LING LOG DEPTH
3. OWNER From To qorTnalion D scription
Address O 1 S t
Fee or e o. s ��
City or Town Stale Zip Code �I r
4. DATE DRILLED 1a 1
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑ NO[3-' ry
7, DOES WELL REPLACE EXISTING WELL? YES [-j NOcm r;?
8. STATIC WATER LEVEL Below Top of Casing: �-= FT, S
(Use '+' It Above Top of Casing) N rTi
9. TOP OF CASING IS FT. Above Land Surface*
'Top or casing terminated at/or below land surface requires a varlance In accor-
dance with 15A NCAC 2C.0 18_�_
10. YIELD (gpm): METH F VEST zln,
11. WATER ZONES (depth): b
—I
12. CHLORINATION: Type kA3AA Amount It additional space is needed use back of form
13. CASING:
Wall Thickness LOCATION SKETCH
Depth 1 I DJjarryetq, o WeI hVFI atto al (Show direction and distance from at least two State
From b To `�� Ft. (v 4 t `FG Roads, or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Mat r al Method
From b To Ft.
From To Ft. t
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft in. In.
From To Ft. In. in.
From To Ft.
16. SAND/GRAVEL PACK:
Depth
From To
In. In.
Size Material
Ft.
From To Ft.
17. REMARKS:
I DO HEREBY TlHTEG�TCACCORDANCE
�0'DSA OAS NPROVID D TO THE WELL OWNER.CONSTRUCTI O HIS REORD� co
FOR OFFICE L NLYEB — 8
Quad No: IGNATUR OF PERSON CONSTRUCTING THE WELL D TE
_Submit rtgln to Division Of Water Quality. Groundwater Section within 30 days
Serial No. GW1 REV. 17199

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]�ESJILL�
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION #: Al
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential 13 Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery [J Heat Pump Water Injection 0 Other M If Other, List Use:
2. WELL LOCA
Nearest Town:
(Road Nr
3. OWNER
Address
location below)
County: _
ilvislon and Lot No.) DRIL ING LOG
From To
,1
city or to State Zip Cod QM
4. DATE DRIL'L60 NDO
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES Q NO[Er'
7. DOES WELL REPLACE EXISTING WELL? YES Q NO[/
8. STATIC WATER LEVEL Below Top of Casing: � FT.
(Use '+' It Above Top of Casing)
9. TOP OF CASING IS- FT. Above Land Surface'
'Top of casing terminated at/or below land surface requires a variance In accor-
dance with 15A NCAC 2C . 118 Q 10. YIELD (gpm): METHODbOF TEST
11. WATER ZONES (depth):
12. CHLORINATION: Type Amount
13. CASING:
DEPTH
GO
Dta
m 5e
C
O
- - -- ----- ----
It additional space Is needed use back of form
Wall Thickness LOCATION SKETCH
D Depth (� DJarrptert or eight/Ft. at �tl (Show direction and distance from at least two State
From To `t Ft. ((��7% �. Roads, or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth �,- M tgrial Method
From To , I Ft. L
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:
I DO HEREBY f TIFF' T t IIS� W L 1�IAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION AN -A S ANi�°r' AT A C'OP�f"O THIS RECORD
%HAS BEEN PROVIDED TO THE WELL OWNER
E 7/
FOR OFFICE U � LYFE , —
Quad No I � NATURE PERSON CONSTRUCTING THE WELL DAT
__Submit o�glnal Division of Water Quality, Groundwater Section within 30 days
Serial No. *nt. ndwate, Section GWA REV. 12/99

793
North Carolina - Department of Environment and Natural Resources - Division of Water Ouality - Groundwater Section
1636 Mail Service Center • Raleigh, N.C. 27699.1636•Phone [phone] � aL \109--t LL 1 A (
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION #: 3
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential EZ Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection M Other E] If Other, List Use:
2. WELL LOCATI
Nearest Town
Numbers,
3. OWNER
sketch
location below)
County:
division and Lot No.)
DRI
ING LOG
From
To
1 -A, k
I �k3'
DEPTH
city or TO State Zip Code
4. DATE DRI D 12\k�
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES
en
6
7. DOES WELL REPLACE EXISTING WELL? YES M NOZ(
_�
8. STATIC WATER LEVEL Below Top of Casing: I D FT.
h
�rn
(use '+' if Above Top ofCasing)
N
9. TOP OF CASING IS FT. Above Land Surface•
va
'Top of casing terminated at/or below land surface requires a variance In accor-
dance with 15A NCAC 2Q,91
� o
�18
10. YIELD (gpm): C )V METHOD OF TEST �?`�
5 I
cnIli
�
11. WATER ZONES (depth):
a
rJ
c,
12. CHLORINATION: Type Amount
If additional space is needed use back of form
x
13. CASING:
Wall Thickness LOCATION SKETCH
Depth la�j°�te, or t�t�t/Ft. alert I (Show direction and distance from at least two State
FromTo Ft. -TaIT Roads, or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Dept M t,riai Method
From To �`e Ft. le
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:
1 DO HEREBY
CONSTRUCTI
FOR OFFICE U LY )
Ouad No FE ) — 8—
Submit
Serial No.
,,::�,;�, ears •,. �,r
ED IN ACCORDANCE WITH 15A NCAC 2C, WELL
RECORD HAS BEEN PROVIDED TO THE WELL 0
JATURE 001ERSON CONSTRUCTING THE WELL
Division of Water Quality, Groundwater Section within 30 days
l
DA
OW-1 REV. 12199

"22795
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]CY�u
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION #: ?J
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential Municipal ❑
Industrial ❑
Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑
If Other, List Use:
2. WELL LOCATI : (Show sket h f the location below)
Near st To County:
_
oad Name d Numbers, om uni , or S divisio an Lot No.)
DRIL ING LOG
DEPTH
3. OWNER
From To
Fo tion Description
Address
IoOt
City or Town stile Zip Code
lb'
4. DATE DRILLED 00
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑ NO[a'
•�
7. DOES WELL REPLACE EXISTING WELL? YES NO[El'
cn
8. STATIC WATER LEVEL Below Top of Casing: FT,
o s
r,
(Use '+' If Above Top of Casing)
r q r*i
ca
9. TOP OF CASING IS FT. Above Land Surface'
� in
`Top of casing terminated at/or below land surface requires a variance In accor•
dance with 15A NCAC 2C . 118
corn
10. YIELD (gpm): METHOD OF TEST n' --X
MW
11. WATER ZONES (depth): c� �tl
= rn
m �o
12. CHLORINATION: Type Amount
It additional space is needed use back of form �
13. CASING:
fl
Wall Thickness LOCATION SKETCH
Depth q Dia ter corn Weight/Ft. aterial (Show direction and distance from at least two State
From d To 1 Ft. " �2�-� �� Roads, or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Mat flat 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:
I DO HEREBY CE
CONSTRUCTION
FOR OFFICE USE
Ouad No:
Slot Size Material
in.
In.
In.
Material
ED IN ACCORDANCE WITH 15A NCAC 2C, WELL
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
�l 00
EB Inn,QNAURE PERSON CONSTRUCTING THE WELL DA
ubmit orlglnallov61�lslon of Water Quality, Groundwater Section Within 30 days
Serial No.
Gw•1 REV. 12199

2 2'796
North Carolina • Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699.1636-Phone [phone]�``�
WELL CONSTRUCTION RECORD WELL CONTRACTOR: D
WELL CONTRACTOR CERTIFICATION #: 3
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential Q9 Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (h w sketch of
Nearest Town:
(Road N
3. OWNER
location below)
County:
livision and Lot No.) DRI ING LOG
From To
a 1nt
ctky or Town State" Zip Code
4. DATE DRILL b b b
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES 0 NO
7. DOES WELL REPLACE EXISTING WELL? YES NOe
8. STATIC WATER LEVEL Below Top of Casing: FT.
c)
(Use '+' if Above Top of Casing)
its9.
TOP OF CASING IS FT. Above Land Surface'
O
'Top of casing terminated at/or below land surface requires a variance in accor.
o
dance with 15A NCAC 2C .0118
k 7
n
10. YIELD (gpm): METHOD OF TEST
.�{Z
t
r,
11. WATER ZONES (depth): _�
12. CHLORINATION: Type Amount
If additional space is needed use back of foraio
0r27
13. CASING:
rk
Wall Thickness
_LOCATION SKETCH CD
o
Depth _ Nnmar. ,,., �.,�. , ...._ ,_�
���_ ..,:_ . _
X
•--- y..�. TZ % ow W avudn and distance tram at least two state
From To Ft..� Roads, or other map reference points)
From To Ft. -
From To Ft.
14. GROUT:
Dept M ted -Method
From d 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:
1 DO HEREBY CE
CONSTRUCTION
FOR OFFICE USq��,tY F
Ouad No:
Serial No.
Slot Size Material
In.
In.
In.
_ B ? If) '11
Submit
Material
RUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
THIS 1590
JID HAS BEEN PROVIDED TO THE WELL O
s
OF PERSON CONSTRUCTING THE WELL DATE
of Water Quality, Groundwater Section within 30 days
GW1 REV. 12/99

� 22357
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone] II
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CtATIFICATION M:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable sox): Residential ER/ Municipal ❑ Industrial d Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection [:] Olher [] II Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: '°� L `o -- County:
IA D �2 P_( 01W
(Road Name and Numbers. Community, Subdivi n and Lot No.) DRILLING LOG DEPTH
3. OWNER (,l Orr I �� From To Formation Description
Address 1 �?1(5 0 1/ l74il� ki • Apri--�
(str-ee or oue o.) Id. �2�' �t/ �/1• i r_
�)►4Qo 2
__ ____
t
City or Town Stale Zip Code
4. DATE DRILLED 1'Z' /` 0(9
y�
5. TOTAL DEPTH - -a r)'
6. CUTTINGS COLLECTED YES ❑ NOE3-
7. DOES WELL REPLACE EXISTING WELL? YES [] NOM-
8. STATIC WATER LEVEL Below Top of Casing: ,�'p - FT.
_
/ (Use '+' N Above Top of Casing) 1-0
9. TOP OF CASING IS C __ FT. Above Land Surface- :7
�
*Top of casing terminated atlor below land surface requires a variance In accor-
�m
dance with 15A NCAC 2C .0118 nn -��
1s METHOD OF TEST /� ��
10. YIELD (gpm): _
Iwo
11. WATER ZONES (depth): D 0
;
12. CHLORINATION: Type /7/ -Amount r ° i-S It additional space is needed use back of form
13. CASING:
LOCATION SKETCH
Wall Thickness
Depth ,� laneter or Weight/Fl. f (atertal (Show direction and distance from at least two State
N`
From To Q Ft. _`�— Roads, or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Materials Method
From To 2" Ft. ✓�
From `� To IJ 19. Ft.
611
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft In. In.
From To Ft.
From To Ft. _
16. SAND/GRAVEL PACK:
Depth
From To Ft
From To Ft.
17. REMARKS:
In. In.
In, In.
Size Material
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION' '� 'NCB'- " A -OPy OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
`"�"
FOR OFFICE US Y
_. ' l
Quad No: ,1 R OF N CONSTRUCTING THE WELL DATE
Su"l ort i t iDivision of Water Quality, Groundwater Section within 30 day9
Serial No. w>> ' OW-1 REV. 12/"
i

.... 26
Nonh Carolina • Department of Environment and Natural Resources • Division of Waier Ouality • Groundwater Section 3617
h N C 27699.1636-Phone[phone]
1636 Mail Service Center • Raleig , . . 1 `'„; ��
WELL CONSTRUCTION RECORD WELL CONTRACTOR: d
WELL CONTRACTOR CERTIFICATIONU©�%
STATE WELL CONSTRUCTION PERiAITf1:
Industrial ❑ Agricullural ❑ Monitorirg❑
1, WELL USE (check ApplHocable Box): Resldenflal[q�— st Pump Water Injection ❑ Municipal Olher(] if Other, List Use:
Recovery ❑ ea
2. WELL LOCATIIQN: (Show sketch of the location below)�`t
r (�
Nearest Town: �I W t County:
` DRILLING LOG DEPTH
(Road Name Numbers, C mrnunit , or Subdivision and Lol No.) From To Fo`rr-A�+ Des..npG°'
� i P i011
3. OWNER Vvi�a 2 - /0 � 1
Address 'V _ 7Q 1 '2
City or Town
Stale Zip Code
4. DATE DRILLED -
5. TOTAL DEPTH
6. CUTTINGS COLLECTED Y f S 0 NO[ (.
7. DOES WELL REPLACE EXISTING WELL? YES n NFr. [ q-
6. STATIC WATER LEVEL Below Top of Casing:_
i (Use'+' N Above Top of Casing)
9. TOP OF CASING IS t FT. Above Land Surface'
'Top of casing terminated atior below land surface requires a varlance In actor-
dance with 15A NCAC 2CAl11E METHOD OF TEST 0
10. YIELD (gpm):
11. WATER ZONES (depth):
M Amount _s��---- If additional space is needH rse bac� of Icy
12. CHLORINATION: Type
13. CASING: LOCATION SKETCH
Wall Thickness Show direction and dance ImIn � leas: rrro S:.ale
Material (
Depth Diameter or Weh �j`• lntr
r / szr.ot-�L �1'/�'-- Roads, or o►her rr"� relertrre 1�0
From_ ---To Fl.d¢j— TfA
From To FI, ---
From _-----To F1. —
o
14. GROUT: Method
Depth M lariat
Z'
CD
r
From �— To �- Fl. dr _--_---
2-
From To _ Ft. ---- rn'
15. SCREEN:
Depth Diameter Slot Size Material ,
m
M('
From To Ft In. In.._----- co
From To Ft. in. In. _---- ca
From _To — _ Ft. In. In. ___ ------ o
0
x
16. SAND/GRAVEL PACK' Material
Depth Size
From __-- To_ FI.
From — To — Fl.
17. REMARKS:
/�
qq
DO HEREBY CERTIFY 7NAAINO IT C)F THICS RECORD HAS BEEN PROVIDED -10ATllz ,r
CONSTRUCTION STANDARDS id7WA�yrCOIPY
FOR OFFICE USE ONLY' '�1 4 _~ ` a'E
r of PERSON CONSTRtnTING, V; '/v ELF
SIO'NA1UnE
Owd No: Subn-41 odolnal'lo Division of Wsler pusltly, Qround.'atsr S#r_u+ within :ri t:%sy3
r-q.1 pigv. t2t1
Serial No, •

2�1878
North Carolina - Department of Environment and Natural Resources - Division of Water Ouality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]�E1L<
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION #: A61 �1
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential EDII� Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION:
Nearest Town: f
3. OWNER
of the location below)
County:
or SubPlvlsion and Lot No.) DRIL ING LOG
From To
y - 3S'
3s1 - I L�q '
C_LCl I
any or t own Stale Zip Code 1 g 1 -.2,a
4. DATE DRILLIE ak W
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑ NO[] ,-
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NOE]
8. STATIC WATER LEVEL Below Top of Casing: -ya FT.
(Use '+' II Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface'
'Top of casing terminated atlor below land surface requires a variance In accor-
dance with 15A NCAC
10. YIELD (gpm): METHaDtOF, TEST
11. WATER ZONES (depth):
12. CHLORINATION: Type Amount
13. CASING:
It additional space is needed use back of form z
Wall Thickness LOCATION SKETCH
Depth' �C) DI r or I h t. to I (Show direction and distance from at least two State
From D TO — Ft. _ Roads, or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth M t rial Method
From To �Ft.
From To Ft. t
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft in. In.
From To Ft. In. In.
From To Ft. in. In.
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION I$?ANDARD$ °PtND [HAT A COPY F THIS RECORD H%AS BEEN PROVIDED TO THE WELL OWN R.
Lr
FOR OFFIGrz tU ONLY i �y ✓�/ I
Quad No: t0i
SIGNATURE OF PERSON CONSTRUCTING THE WELL ATE
JAKI 2001 Suglnal to Division of Water Quality, Groundwater Section within 30 days
Serial No. "�`�
GW1 REV. 12/99

2-)13'�6
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] *�ivess\u_z W al— )Z)'P__(
WELL CONSTRUCTION RECORD WELL CONTRACTOR: iAtllk``(TN45"`y
WELL CONTRACTOR CERTIFICATION tt: 3
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check applicable Box): Residential © Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATI
(Road N
3. OWNER
Address
i the location below) j
County:
or Subdivision and Lot No.) D LING LOG
From To
'c)'
t2j CO
Ulty Of Town State Zip Code
4. DATE DRILL \` o0
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑ NO[D_
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO[D
S. STATIC WATER LEVEL Below Top of Casing: FT.
(Use '+' If Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface -
'Top of casing terminated at/or below land surface requires a variance In accor-
dance with 15A NCAC 2C 118
10. YIELD (gpm): METHQ OF TEST
11. WATER ZONES (depth): 11``��
12. CHLORINATION: Type Amount
13. CASING:
ow
Agricultural ❑ Monitoring ❑
DEPTH
If additional space Is needed use back of form
Wall Thickness LOCATION SKETCH
Dept C/ DI tQXr or��Igh� t. I Show direction and distance from at least two State
From �To `1 b Ft. " J =""• ( Roads, or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Dept r� Ma6dal Method
From To Ft.
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft in. in.
From To Ft. In. In.
From To Ft. In. In.
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
17. REMARKS:
IDO
CON
FOR OFfil. US F� Q/�lLY�!1
Quad No:'a I � r J��IV ( 6 i
Bedell No
s
VAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNE
�rn
W rn�
CD -,
iIGNATUWOF PERSON CONSTRUCTING THE WELL DALE
original to Division of Water Quality, Groundwater Section within 30 days
Gw.1 REV. 12/"

North Carolina - Department of Environment and Natural Resources • Division of Water Quality . Groundwater Section 221380
1636 Mail Service Center • Raleigh, N.C. 27699-1636-Phone [phone] VM'ESJkLL.E` U)aL
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (check Applicable Box): Resldential0 Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCA
Nearest Town
(Road Name
3. OWNE
AAA­_
4. DATE DRILLED �� D
5. TOTAL DEPTH I M41 -
6. CUTTINGS COLLECTED YES ❑ NO[D'
7. DOES WELL REPLACE EXISTING WELL? YES NO[v"
8. STATIC WATER LEVEL Below Top of Casing: FT..
(Use '+' 11 Above Top of Casing) o r�
9. TOP OF CASING IS FT. Above Land Surface* c, n
'Top of casing terminated atior below land surface requires a variance In accor.
dance with 15A NCAC 2C .0118
10. YIELD (gpm): _,__L METHOD OF TEST �-�- x. mQ
11. WATER ZONES (depth): — <��0 m
rn�
12. CHLORINATION: Type Amount If additional space Is needed use back of f ►W
13. CASING:
location below)
County:
livision and Lot No.) DRI ING LOG
From To
1 L —I
csq, __
21p Code n rn , _
DEPTH
„ Wall Thickness LOCATION SKETCH
O Depth m D or W' ht/Ft. alert I (Show direction and distance from at least two State
From TO Ft. ' Roads, or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Dept �1�� M rial Method
From _SL_ To `` Ft.
From To Ft. '
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft in. in.
From To Ft. In. In.
From To Ft. In. In.
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft. ,
From To Ft.
17, REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION S7AN }RC55 "1�NN•�,T' COPY OF,THIS RE�C'ORDH� � BEEN TO THE WELL 0
FOR OFFICE Us'. ONLY
r i nnII §SIGNATURE OF PERSON CONSTRUCTING THE WELL
Quad No: 3
a JAN 6 20`'Su t o I al to Division of Water Quality, Groundwater Section within 30 days
Serial No. t'
TE
GWA REV. 12199
rt11.1ndwater Section

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]\bQ[ LL I
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION #i: 3
STATE WELL CONSTRUCTION PERMIT##:
1. WELL USE (Check Applicable Box): Residential EQ Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
Agricultural ❑ Monitoring ❑
2. WELL LOCATIO ' ( how sketch he location below) \
Nearest Town: ( Court -�
(Road Name ar�d flttmbers, Co It r u 'vision and Lot No.) DRIL ING LOG
3. OWNER `( �(
From To
1 _
"treat or g,
City or Town State vZip Code
4. DATE DRILL —
5. TOTAL DEPTH 1 _ —
6. CUTTINGS COLLECTED YES ❑ NO[Er
7. DOES WELL REPLACE EXISTING WELL? YES NO[Er a--';3R _ZD2
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 atfor below land surface requires a variance In accor-
dance with 1SA NCAC 2 0118 _
10. YIELD (gpm): !S METHOD OF TEST
11. WATER ZONES (depth): _
12. CHLORINATION: Type Amount
13. CASING:
DEPTH
Formation bescription
If additional space is needed use back of form
Wall Thickness LOCATION SKETCH
t Depth I DI rr,}tr or Wel t. tt 1 � (Show direction and distance from at least two State
From U To 1 Ft. (�� ? I -�' Roads, or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Maitgri Method
From To 2� Ft. ��_k� _
From To Ft. t
15. SCREEN:
POE
0
z
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 E TIFDTt�{!#D7]AN'O 1t1A1wA G�QPY OFTU iCS RED D HASTED IN DBEENEPROVIDED TO THE WELL OWNE
CONSTRUCTI % i� /�kEi Ste'
FOR OFFICE tinNLY ('' \1 '� 6�
Ouad No: %1.N �` �} b)GNAT OF PERSON CONSTRUCTING THE WELL DA E
Submit 0. dglnat to Division of Water Ouallty, Groundwater Section within 30 days
Serial No. ` GW-1 REV. 12/99
2 ll , }6 i7'eZ
c-,
rn

' North Carolina - Department of Environment and Natural Resources - Division of Waier Ouality - Groundwater Section 236161
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
Ilel-
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
L CONTRACTOR CERTIFICATION 0:240 37
STATE WELL CONSTRUCTION PERIAITN:
1, WELL USE (Check Applicable Box). Reslden0al ED'--- Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Flecovery ❑ Heal Pump Water Injection ❑ Other [] II Other, List Use:
2. WELL LOCATION• (Show sketch of the location below) C /k
Nearest Town: /14' �'!h County: l
5���� ��'we- �� DRILLING LOG DEPTH
(qoa� d N and Numbers, Commur�lly, or Subd(vislon and Lot No.) FomaScn Des �iptio'
3. OWNER J �1 /�odec — From To
Address D _ ys- �. 14
treat or ou o o. G/ f
City or Town Stale Zip Code
4. DATE DRILLED /0
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES [] NO[��
7. DOES WELL REPLACE EXISTING WELL? YES NOD-S. STATIC WATER LEVEL Below Top of Casing:
(Use '+' If Above Top of Casing)
9. TOP OF CASING IS — FT. Above Land Surface-
'Top of casing terminated al/or below land surface requires a variance In accor-
dance with 15A NCAC 2C.0118
10. YIELD (gpm)' METHOD OF TEST_
11. WATER ZONES (depth): /2�S
back Icon
12. CHLORINATION: Type 1� ty Amount ` If additional space is needed �
13. CASING: LOCATION SKETCH
Wail Thickness
Depth Diameter or Welght/Ft. Material (Show direction and d;s,-ance Ir.,rrt a, lea Ho -,,,a e
Roads, or other mrm7 relerence- po
From G/ To — Ft.
From To
Ft. —
From To
Fl. --
14. GROUT:
Depth
rja) �
Mpffiod
To
From
From To
— Ft.Cn
`-------'
I
15. SCREEN:
Diameter Slot Size
Material
Depth
Fl In.
In.._----
N'n
From To
Ft. In.
In. _ _----
rm;o
From To
in.
in..-----
o
0
From To
Ft.
16. SAND/GRAVEL PACK:
Material
Depth
Size
From To_
Ft.
From To.
Ft. —
17 REMARKS:
1 DO HEREBY CER1 IFV'N� Al11 4H1. f�11 FIAT A Ct)PY..OFRU IS RECORD HAS SEE 1 PROOCEO 70ATFt� � Ot�"EF,
CONSTRUCTION STNbARDSI,.A
FOR OFFICE USE ON ' o� ,E
rr�� TING 1l,'c '/WELL
Ouad No: `1 7 , , 6 ?O ;SIGNAT RE OF PEg50N CONSTRIY.
lr
i Submit original to Division of Water M8111Y, GMrWJ�ilar "�^ within V) CisYs C„ i V. 12YI
Serial No. ` r
r ;.

North Carolina • Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section 9 '7 9
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone] k-�"ESQ,
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION #: _ ALI :7q
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check applicable Box): Residential a Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection [] Other ❑ If Other, List Use:
2. WELL LOCATIO
Nearest Town:
or
3. OWNER
Address
or rown Stale
the location below)
' County: _�i_--
S vision and Lot No.) D LLING LOG
From To
b ^ s`
Zip Code �
DEPTH
4. DATE DRILL.O , t�` _CXD
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES[] NOd
o
7. DOES WELL REPLACE EXISTING WELL? YENO ✓( _
O r,
8. STATIC WATER LEVEL Below Top of Casing: ��_ FT.
(Use"II Above Top of Casing)
9. TOP OF CASING IS FT.
9?
CVTI T_ -
Above Land Surface"
z—
*Top or casing terminated aUor below land surface requires a variance In accor-
dance with 15A NCAC 2C .0118r+�
10. YIELD (gpm): 5D METH �D OF TEST
11. WATER ZONES (depth):
12. CHLORINATION: Type k Amount
It additional space Is needed use back of forte
13. CASING:
o
Wall Thickness
LOCATION SKETCH
Depth of o� e14ryt/Ft.
From C) �a
(Show direction and distance from at least two State
To - Fit
Roads, or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth(--�
M tortL. Method
From
To
Ft. E
From
To
Ft.
15. SCREEN:
Depth Diameter Slot Size
Material
From
To Ft
in.
In.
From
To Ft.
In.
in.
From
To Ft.
In.
in.
16. SAND/GRAVEL PACK:
Depth
Size
Material
From To Ft. ,
From To Ft.
17. REMARKS:
FOR OFFIG USE ONLY I3 I
Quad No: JAN
CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
OPY.OF THIS RECORD HAS BEEN PROVIDED TO THE WELL C
SIGNATURE OF PERSON CONSTRUCTING THE WELL
at to Division of Water Quality, Groundwater Section within 30 days
/00
Serial No. GW1 REV. 171"
v�$, Ctiitll

North Carolina - Department of Environment and, Natural
Phone (9rce - DivI 21n of Water Quality -Groundwater Section
23615'7
1636 Mail Service Center - Raleigh, N.C. 27699-
rn
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
LL CONTRACTOR CERTIFICATION H: ;iyOy
STATE WELL CONSTRUCTION PERMITH:
lEl Industrial ❑ Agricultural ❑
1 • WELL USE (Check Applicablrrp B°W
Ftecovery ❑ Heat Puater Injection ❑ esidential � M OihePa❑ It Other, List Use:
Monitoring ❑
2. WELL LOCATION: (Show sketch of the location below) /0 1
II n`n c,f fly County:
Nearest Town: «l
DRILLING LOG DEPTH
(Road Name and Numbers. Communlry, or Subdivision and Lot No.) Fom.axn DescriPuw-
� From To
3. OWNER
Address "--�- --
Ireet or ou o o.
City or Town
Slate Zip Code
4. DATE DRILLED
5. TOTAL DEPTH _i a 5�----=
6. CUTTINGS COLLECTED YFS ❑ NO[l�'
7. DOES WELL REPLACE EXISTING WELL? YES �]r FT [�
8. STATIC WATER LEVEL Below Top of Casing: r _
(Use'+' II 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 2Ce MET HOD OF TEST In 2
10. YIELD (gpm):
11. WATER ZONES (depth):
S Amount Lj_ If additional space es needed tse back of Ian
12. CHLORINATION: Type
13. CASING: LOCATION SK---TCH
Wail Thickness (Show direction and di�ance Irvm leas :ko `'ate
Depth —1 Diameter or WetphUFl. Material ( Roads, or other rr m7 relerc: flolnts!
From___�> To �-- FI• �5 S QL "[emu/
From — To -- Ft.-------
From ------
To — Ft.
CD c�
14. GROUT: M terial Method
Depth
�.
r'
From To .12---
.�---
From — To Ft. ---------
15. SCREEN:
Diameter Slot Siz6 Material
�'
m
;,,, ._
Depth
To Ft — In.
From —
Fl. in. In. _-------
0
From To --- _ --
In. In.
0
From _ To — F1. —
16. SANDIGRAVEL PACK:
Material
Depth Size
From ., _-- To — Fl.
From — To _-- FI•--------
17. REMARKS.
I DO HEREBY CERTIFY THAT;THIS.WEI:L WA
ACOPY OF THIS RE ORD HAS BEEN 1 PRO
S CONSTRUCTED IN AG VICED 'TO THE /, �L QN`%EF..
-
CONSTRUCTION STANDARDS, AND THAT A
7FOROFF17CEUSE ONLY staNATunEOF pEpgON CONSTnuCTiNc tr4 w ti-
0C 1 �1 �r Uf eiit Oround+�sler Src-cn M+)Ihin :�i CijYs V. 1:11
I 5utxrrf odpInal to Divl ton o► Water t7u T. 6N.1

North Carolina - Department of Environment and Natural Resources - Division of Water Quality • Groundwater Section
1636 Mail Service Center • Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONTRACTOR: k9 QJ� I�
WELL CONTRACTOR CERTIFICATION #: .2 <I
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (check Applicable Box): ResidenfiaiMunicipal ❑ Industrial ❑ Agricultural 0 Monitoring ❑
Aecovery ❑ Heat Pump Water Injection ❑ Other [] If Other, List Use:
2. WELL LOCATI[QN: (Show ketch of the location below)
Nearest Town: �I "tf S %r� County: 'l
(Flo Name and Numbers. Community. or Subdivision and Lot No.) DRILLING LOG
DEPTH
3. OWNER t �wt^,rie� From To Forma Des ripGo•
Address 2 jo, VIP_
ireet or ou o. .S
City or own Slate Zip Code
4. DATE DRILLED _40- O
5. TOTAL OEPTH I ) '
6. CUTTINGS COLLECTED YVS ❑ NO®'
7. DOES WELL REPLACE EXISTING WELL? YES F-1 NO®
S. STATIC WATER LEVEL Below Top of Casing: _ FT•
(Use '+' If Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface'
'Top of casing terminated at/or below land surface requires a variance In accor-
dance with 15A NCAC 2C .0118
10. YIELD (gpm): /$ METHOD OF TEST
11. WATER ZONES (depth):
12. CHLORINATION: Typeh+�i Amount _ 11 additional space is needed t-s- back of form
WELL CONSTRUCTION RECORD
13. CASING:
Wall Thickness
Depth Diameter or Weight/Ft. Material
From To -tS_- Ft. ,fo.25- =—
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From _0- 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
2360'7'7
LOCATION SK= TCH
(Stow direction and dislance tr n e-:l leas:'"o "'ale
Roads, or other rr.Gp refere:ce points:
I DO HEREBY CERTIFY,THA7 THIS, WELL WAS CONSTRUCTED IN ACCORDANCE WITH t SA DdCAC ?r, ,tTELL
CONSTRUCTION:$TANOARDS ; AND TI tAT A COPY OF THIS RECORD HAS BEEN PROVICED 'TO TH- V/::�,-I-
_ r
FOR OFFICE USE ONLY, 1f,�� ' .
4iti { t I $I i SIGNATURE OF PERSON CONSTRUCTING 1>t VV'EL.L 0� E
Quad No: 5utxnit'odginal to DMslon of water t3uality. Groun4»'ater Srcxn y rithin Yi t:%fys CM•i V. 1_vl
Serial No.

North Carolina - Department of Environment and Natural Resources - Division of Water Ouality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636•Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION N: A40 q
STATE WELL CONSTRUCTION PERNiITN:
2361.01
1. WELL USE (Check Applicable Box): Residential (9�- Municipal ❑ Industrial ❑ Agricultural 0
MoniloriN ❑
Recovery ❑ Heat Pump Water In)ecllon ❑ Other ❑ If Other, List Use:
2. WELL LOCATI N: (Show sketch of the location below)
Nearest Town: 0 A r� e-5 v I 1 p County:
&W, V\ P'
(Road Name and Numbers, Community, or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER Map t%er / From To Forrra5on Descriptia'
Address Q - 5 _�Crt/
r�
S 3!Z/ r
/e
(Street or ou a o. `/Cs /
`i
�SLr�i
City or Town c State Zip Code
DATE DRILLED 7 42 ` 00'
4.
5. TOTAL DEPTHS `
6. CUTTINGS COLLECTED YFS F NO�
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NOM
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 atfor below land surface requires a variance In accor-
dance with 1SA NCAC 2C.01IS
10. YIELD (gpm): L METHOD OF TEST )�
11. WATER ZONES (depth):
12. CHLORINATION:
13. CASING:
Type \Ah - \ AO-S _ AIt additional space- is needed L_—_e_ back of form
Depth Diameter
Fromm —To Ft. �` S
From To Ft.
From To Ft.
14. GROUT:
LOCATION SKETCH
Wail Thickness
or Weight/Ft. Material (Show direction and dal'ance Iran 21 leas: two Sale
r,41nPj1r - Roads. or other rrrarelere:ocepolnu`
Depth Material Method
From . 0 — To �20 Ft. . r4
From To Ft.
15. SCREEN:
Depth Diameter Slot SIz6 Material
From
To Ft
in.
From
To Ft.
in. —
From
To Fl.
In. —
16. SAND/GRAVEL PACK:
Depth
Size
From
To Ft.
From
To Ft.
—
17. REMARKS:
in.
In.
In.
Material
c
I
rT
33*
p
GJ
N
I DO HEREBY CERTIF.Y.,THAT THIS WELL WAS CONSTRUCTED IN ACCORDMNCE WITH iSA DdCAC Y.:.'/✓ELL
CONSTRUCTION $TANQARDS, AN.0 THAT A.COPY OF THIS RECORD HAS BEEN PROVIDED 'TO THE Y/5�U 0" FF-
i ` 0,
FOR OFFICE USE'O,N
Ouad No:
L, ��6�
i� ��Iyrnll
IGNATURE OF PERSON CONSTRIY:TING 1>t 'WELL
I to Divltlon of Wsler Mallly, Groundwater Srccn within 4) C;Vys
Ox'� E
`3
c
CK.I F19V. I"I
Serial No.

North Carolina - Department of Environment and Natural Resources - Division of Water Quality -GroundNater Section 2 3 `) ,y 0
1636 Mail Service Center • Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION 9: �9- I q __
STATE WELL CONSTRUCTION PERMITNt-
1. WELL USE (Check Applicable Box): Residential 0__�Munlcipal [l Industrial ❑ Agricultural ❑ Monitorir:g ❑
Flecovery ❑ Heal Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town:11' TV t' - County: e— U
DEPTH
(Road Name and Numbers, Community, or Subdivision and Lot No.) DRILLING LOG
Forrra5m 0 �'PGo'
3. OWNER �(yj_�C� (R'i �S€ 0 From To GGGG'''t'
Address
treet or ou o o.---
City or Town State Zip Code
4. DATE DRILLED
5. TOTAL DEPTH -596
6. CUTTINGS COLLECTED YFS ❑ NO[P
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO[,
B. STATIC WATER LEVEL Below Top of Casing: FT.
(Use '+' II Above Top or Casing)
9. TOP OF CASING IS ( FT. Above Land Surface -
'Top of casing terminated at/or below land surface requires a variance In actor.
dance with 15A NCAC2C.0118
10. YIELD (gpm): _ n METHOD OF TEST ti
11. WATER ZONES (depth):
12. CHLORINATION:
13. CASING:
Type ) h lab'e-Amount It additional space is needed L-s-e back of fern
Wail Thickness
Depth
Diameter
orWelghUFt.
From —To r� 2
Fl• ' S
pM�aatterial
`� t.�"_
From To
Ft.
From To
Ft•
14. GROUT:
Depth
M11terial I Method
From __C2._- To ao
`
Fl.
-
From To —Ft.
----�
15. SCREEN:
Depth
Diameter Slot Size Material
From To
Ft
In.
In... -----
From To
Ft.
in.
—In.—
From To
Ft.
In.
In. ___---
16. SAND/GRAVEL PACK:
Depth
Size
Malarial
From — To
F�• —
From To
Ft. —
17. REMARKS:
LOCATION SK=TCH
(Show direction and distance Ir'rn -:I Ions! tNo Snate
Roads, or other rr—p relererr-e polnt<`
r;
y r ;
i3
w
N
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH i5A 04CAC ?C, ,trELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORf7 HAS BEEN PROVICED '70 THc y/ V,-.L Ot%*%Ep..
FOR OFFICE USE ONLY
SIGNATURE OF PERSON CONSTptY:TRIG let ry1:LL
Submit original to Dividon of Water Quality, Ground"lar So= within I� Quad No: C;%sYs
Serial No.
—C�
Oi. ' E
C•K•I F19V- I""

r . (� (�
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section 2 3 9 0 9 8
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
RECORD WELL CONTRACTOR: �" et "
WELL CONSTRUCTION
of
WELL CONTRACTOR CERTIFICATION fl:
STATE WELL CONSTRUCTION pERMITH:
1, WELL USE (Check Applicable Box): ResidentlalET'-Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Flecovery ❑ Heal Pump Water Infection ❑ Other ❑ II Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
�L / /a /
Nearest Town: r/ n` �County:— ( /
(Road Name and Numbers, ConvnunIty. or Subdivision and Lot No.) DRILLING LOG
DEPTH
From To Forrra�on Descrip6w.
3. OWNER / Sd .Sgry
Address -6
feet or ou a o. _� 2-�?
City or Town State Zip Code
4. DATE DRILLED
5. TOTAL DEPTH
6, CUTTINGS COLLECTED YfS ❑ NO�
7. DOES WELL REPLACE EXISTING WELL? YES NO[�
B. STATIC WATER LEVEL Below Top of Casing: _a FT.
(Use '+' If 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.JU 18 METHOD OF TEST %� r
10. YIELD (gpm):
11. WATER ZONES (depth): 200 `
12. CHLORINATION: Type Amount
13. CASING:
W all Thickness
Depth I �,� Diameter or Wet hV t. Material
From 6 To-�-�•�- Ft. -�--
From ' To Ft.
From To Ft•
14. GROUT:
Depth Material Method
From Q To / 0 Ft. % % N
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
To Ft.
From --
From
17. REMARKS:_
To Ft. —
II additional space is needed Ls-- baci of fcf5
0
z
LOCATION SK;CH
C
c
(Show direction and d'eswance l rrn e-A leas: two
..dale
Roads, or other n-rGp relere:r-e Polnu�
-^;=
m r-
cn nr
r-;
ff
c)
l —
z
100 HERESY C!_RTIFY THA� Tg1S WEVt WAS CONSTRUCTED IN ACCOROMICE WITH 15A >tJCAC ?r,'/✓ELL
CONSTRUCTION STANDARDS, `AND} THAT IA COPY OF THIS R ORD HAS BEEN PROVIDEDO►� la
i v:
FOR OFFICE USE ONLYUG SIGNATURHOFpBRSONCDNSirttr'1INGlet "ELL
Quad No:
Subr►>II original to Division of Water tOusltly, Groundo-tler SK'-ut within V. C%SYs Ce.l Fig V. 12?1
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 CONTRACTOR: { ��� ` "� 't
WELL CONTRACTOR CERTIFICATION P: 2
STATE WELL CONSTRUCTION PERMITH:
1. WELL USE (Check Applicable Box): Residenllal [9' Municipal ❑ Industrial ❑ Agricultural ❑ Monitorir:g ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: ', V 11 County: --
�A%N( 1i vlP�l�i�
DEPTH
(Road Name nd Nu b rs, CommU Ily, o Subdivision and Lol No.) DRILLING LOG
3. OWNER ( �' j ! P F' Y'l From To Forrrazn Desmcfiptio.^
_ >s' C'/�
Address r
treat or ou o o. ��� '�--
City r Town State Zip Code
4. DATE DRILLED
5. TOTAL DEPTH '85 `
6. CUTTINGS COLLECTED YES ❑ NOF-3"'
7. DOES WELL REPLACE EXISTING WELL? YES 0 NOEJ--
B. STATIC WATER LEVEL Below Top of Casing: LL r FT•
(Use '+' If Above Top of Casing)
9. TOP OF CASING ISFT. Above Land Surface'
`Top of casing terminated al/or below land surface requires a variance In accor-
dance with 15A NCAC 2C .0118
10. YIELD (gpm): . 6 METHOD OF TEST r�
11. WATER ZONES (depth):
12. CHLORINATION: Type I +h AnLc6Amount
13. CASING:
WELL CONSTRUCTION RECORD
Wall Thickness
Depth Diameter or Weighl/Ft. Material
From__�Z___—To �D F1.-L,2!�- -T
From To Ft.
From To Ft
14. GROUT:
Depth M1at1erial-� Method
From ._Q_ To (�-O '— Ft.
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft In. —In.—
From To Ft.
From - To Ft.
16. SAND/GRAVEL PACK:
In. in.. In. in. _— —
Depth Size
From To Ft. From To Ft. —
17. REMARKS:
Material
236080
If additional space is needed L--"- back of form
LOCATION SK= f CH
(Show direction and dis'ance from o:I leas: tao 5;mle
Roads, or other rr---p relere:r,-e- point.'
C
I
rn
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A DJCAC 2',:,'/FELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVICED -10 THE '«::'� I 0WI P.
FOR OFFICE USE ONLY Vt-
Ouad No: SIGNATURE OF PERSON CONSTRIY:TING he 'WELL
Submit original to Division of Water pualhy, Ground-'Lter Src cn within Vi : ys
Serial No,
WWAF
Ch•1 �V. 1291

North Carolina . Department of Environment and Natural Resources - Division of Waier Quality - Groundwater Section 236102
7 3224
1636 Mail Service Center. Raleigh, N.C. 27699-1636-Phone (919) 33-
WELL CONSTRUCTION RECORD WELL CONTRACTOR: ' l� '
WELL CONTRACTOR CERTIFICATION 0: oZ ��
STATE WELL CONSTRUCTION pERMIT11:
1. WELL USE (Check Applicable Box): Residential t. l Municipal ❑ Industrial ❑ Agricultural ❑ Monitorir g ❑
Aecovery ❑ Heat Pump Water Injection ❑ Other [] If Other, List Use:
2. WELL LOCATION- (Show sketch of the location below) /
Nearest Town: 1 TR�`Uyr_`�� County:
(road Name an Numbers, Community, or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER 1-e,217Y 24y From To ForraS0+0escripuw-
Address
beet or ou e o. l� �
pia--�-
City or Town State Zip Code
4. DATE DRILLED LZZ-06 '
5. TOTAL DEPTH IA6 '
6. CUTTINGS COLLECTED YFS M NO�
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO�_
B. STATIC WATER LEVEL Below Top of Casing: / D FT.
(Use '+' If Above Top of Casing)
9. TOP OF CASING IS Fr. Above Land Surface -
'Top of casing terminated eVor below land surface requires a variance In accor-
dance with 15A NCAC 20.0118
10. YIELD (gpm): __2METHOD OF TEST
11. WATER ZONES (depth): 9w
12. CHLORINATION: Type ��r�Y Amount �`f C�' If additional s;=-e is needed tse back of Ice
13. CASING:
LOCATION SK=I CH
Wall Thickness
Depth Diameter or WeighVFt. Material (Show direction and diswance from � leas•: tko S'.ate
cfS ' ?s� SO.ezf �1116 Roads, or other rrr� referc:� flolnts`
From — To Ff•—�---
From To Ft.
—
From To Ft.
1 d. GROUT:
Depth ativial Method
�
From To ,2-9 Ft. ��l=mod ��rfa-e
From _
15. SCREEN:
To Ft.
Depth Diameter Slot Size Malarial
From —To_Ft— in. In.
From To Ft. In. in.
From To Fl. in. In. _-
16. SAND/GRAVEL PACK:
Depth Size
From To Fl•
Material
From To rt. —
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCOROANCE WITH I5A F4CAC ?^, ,t TELL
CONSTRUCTION STANDARDS, AND THAT A COPY F THIS RECORD HAS BEEN PROVICED '70 THE -L O"'NEF•
FOR OFFICE USE ONLY-tC%9 ! o..�E
Quad No: SI ATURE CF PER90N CONSTptyrTlNG 1rE 'N ELL
SubMt vaginal to MItIon of Willer puallty. rround"l$t Sr=n within . C%lYS
Serial No. .
Ilte tyatYt:iS a !

North Carolina •Department of Environment and Natural Resources •Division of Water Ouaiiry -Groundwater Section 18653
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 Municipal ❑
Industrial ❑
Agricultural ❑ Monitoring ❑
Recovery E]
Heat Pump Water Injection [] Other
If Other, List Use:
2. WELL LOCATI
(Show sketc a location below)
Neare Town:=��
County:
(Road Na e
DRILLING LOG
DEPTH
u ers, munity, or Subdivision and Lot No.)
3. OWNER
Address
k
From To
O t bt
Fo ation Description
ree =aN
1 b 1
City or T
a� 1 4
Stale Zip Code
4. DATE DRILL D Il� �b
5. TOTAL DEPTH - k4 t
6. CUTTINGS COLLECTED YES Q NO[Ef'
7. DOES WELL REPLACE EXISTING WELL? YES NO[!�
8. STATIC WATER LEVEL Below Top of Casing: b 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 2 0118
10. YIELD (gpm): bD METHOD PF TEST
11. WATER ZONES (depth): \3S
12. CHLORINATION: Type Amount
13. CASING:
Wall Thickness
From b Depth
�Ja Ft (�t�gr> r or etghj[F� / V qt
From To Ft. /�" �((��3 a V
From To Ft.
14. GROUT:
Dept ted Method
From To � Ft.
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft In. in.
From To Ft. In, in.
From To Ft. In. In.
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To . Ft.
17. REMARKS:
It additional space is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
I DO HERE �,�FM°dI4IV/L�'E CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRU r STANDARDS, AND THA PY OF THIS RECORD HAS/BEEN PROVIDED TO THE WELL OWNE
FOR OFFICI J01§4 ONLY lit' 1 62/4/� q
Quad No: SIGNATURE OF PERSON CONSTRUCTING THE WELL C
hv, tar Section ubmil orl final to Division of Water Quality, Groundwater Section within 30 days
Serial No. I r<i,.; ;11. R[gional Office _j GWA REV. 12199

8 65 4
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 #:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential IT
Recovery ❑ Heat Pump Water Injection 0
2. WELL LOCATIO =($how ketch
Nearest Town._
(Road Name
3. OWNER
Municipal ❑ Industrial E] Agricultural ❑
Other If Other, List Use:
location below)
ounty: _
Monitoring ❑
and Lot No.) DPWLING LOG DEPTH
_� From To ForrrMtion Description
City or Town Stale Q Stale Zip Code �� 1 D t
4. DATE DRILLED) ` w 00
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES M NO[a
7. DOES WELL REPLACE EXISTING WELL? YES NO[�
B. STATIC WATER LEVEL Below Top of Casing: PT,
(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,q 11,8 ,n ; A
10. YIELD (gpm): � METHOD OF TEST
11. WATER ZONES (depth):
12. CHLORINATION: Type Amount
13. CASING:
Wall Thickness
Depth I @( W I hht/Ft. a e al
From To Ft. ►¢
From To Ft.
From To Ft.
14. GROUT:
- Dept Mate 1 _ Method
From b To Ft:
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. REMARKS:
If additional space is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
QL�
n
cam,
.-
�
o
AS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
1 COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWN R.
2u S G-7, P:�'cle"•L_ q1l $ o 0
SIGNATURE OF PERSON CONSTRUCTING THE WELL BATE
original to Division of Water Quality, Groundwater Section within 30 days
GW1 REV. 12/"

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section 18642
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]C�d.(���
WELL CONSTRUCTION RECORD WELLCONTRACTOR:
WELL CONTRACTOR CERTIFICATION #: 3
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential Q Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATIOkl1(Show sf
(Road Name Cr
3. OWNER
Address qS
)f the location below)
County;
i
or Subdivision and Lot No.) DR LING LOG
Q3 From To
r
City or Town \ State Zip Code
4. DATE DRILLED
Gkl M
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES Q NO[Er
7. DOES WELL REPLACE EXISTING WELL? YES rj NOr7f
8. STATIC WATER LEVEL Below Top of Casing: p FT.
(Use '+' if Above Top of Casing)
9. TOP OF CASING IS l FT. Above Land Surface -
'Top of casing terminated atfor below land surface requires a variance In accor-
dance with 15A NCAC 2C . 118
10. YIELD (gpm): MET O,4 OF TEST
-
11. WATER ZONES (depth): 24D
or
12. CHLORINATION: Type Amount
13. CASING:
Wall Thickness
DTOth i�r]iett�er SWeighVFt. �IvlGl
From d
Ft. YY 11��
From To Ft.
From To Ft.
14. GROUT:
Depth ate ' 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:
I DO HERE
In.
In.
In.
Agricultural ❑ Monitoring ❑
DEPTH
It additional space is needed use back of for
LOCATION SKETCH
(Show direction and distance from at least two Stare
--•; ;;
Roads, or othebmap reference points)
u> -�
r,
�
L-0
I
o
ROd44*Tw*MI€,»W66WAG ONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
MID S fAAF13S.PANVT&Tn&PY OF THIS -RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFIC1�ONLY
Quad I Our
i Jil; L U SIGNATUA"F PERSON CONSTRUCTING THE WELL DA
Su V nal to Division of Water Quality, Groundwater Section within 30 days
��
Serial No. 1 1 I I I GW-1 REV. 12/99

,00
North Carolina • Department of Environment and Natural Resources - Divlsion of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N,C. 27699-1636-Phone [phone]
'I Ns
WELL CONSTRUCTION RECORD WELL CONTRACTOR:,�1°�oh,22. (� 9�
WELL CONTRACTOR CERTIFICATION N:
STATE WELL CONSTRUCTION PRAMI 'k: G''
1. WELL USE (Check Applicable Box): Residentiala]-/Municipal [] Industrial ❑ Agricultural ❑ Monitoring
Recovery ❑ Heat Pump Water Injection g ❑
1 ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: County: CL J4- v/
T77d�>IG n
(iioad Name an .+ Numbers. AYrrilnl •Utl1s. Co ty. Or Subdivision and Lot No.) DRILLING LOG
3. OWNER R DEPTH
Address I — �fom T Formation Description
r
roe
e or ou e o.
City or Town Stale Zip Code
4. DATE DRILLED C�
5. TOTAL DEPTH �'�`
6. CUTTINGS COLLECTED YES[] NO ©'
7. DOES WELL REPLACE EXISTING WELL? YES E NO�
S. STATIC WATER LEVEL Below top Of Casing: �b ' FT.
9. TOP OF CASING IS (Ut°++ Above Top of Casing) N =i
— FT. Above Land Surface* J *Top of casing terminated al/or below land surface requires a varlance In accor-
dance with 15A NCAC 290110 —71 r
0. YIELD (gpm); METHOD OF TEST __/. 't5� �' --
11. WATER ZONES (depth):
o
12. CHLORINATION: Type
13. CASING: Amount i3.4�115 If additional space is needed use back of form
Depth Wall Thickness _LOCATION KETCH
From To C, r D//la'nr°ter or WelghVFt. terfal (Show direction and distance from at leas(
Ft. cam_ ('L / ✓ c two State
From To Fl Roads, or other map reference points)
From To Ft.
14. GROUT:
Dep h -Material Method
From Tot1 Fi.
From 2 To Ft.
15. SCREEN:
Depth Diameter Slot Slze Material
From To Ft In. In.
Frop 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 STANbAFIDS -ANp THAT P COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
G i U
FOR OFFICE USE Or.'.' �G /'t1
Qusd No: ] 9 �' J Q n P 5 — a• oil
SIONAtUpE OF PEfISON ONSTRUCtINO 7HE WELL, Serial No. V 9,uf I originil to Division of Water Quality, groundwater Section within 30 days DATE
u V
OW-1 nEV. 12M

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section 1 J `) - 2
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: 11 er
WELL CONTRACTOR CERTIFICATION P: QUO
STATE WELL CONSTRUCTION PERMITH:
1. WELL USE (Check Applicable Box); Residential [1l Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Aecovery ❑ Heat Pump Water Injection ❑ Other [] If Other, List Use:
2. WELL LOCATI,C�N: (Show sketch of the location below)
Nearest Town: lQ\I as V i j j County: C )cw
DEPTH
(Road Name and Numbers. Community, or Subdivision and Lot No.) DRILLING LOG
3. OWNER DQry► U D1ro! l0 Af 11 From To Forrra5on DescripGo'
Address l� I �G/�jcq, �'�'� H.?D,S^
, C , (reel U1 HouleTdo.) � Co — <K-19 r
334/93 g5 -
City or Town State Zip Code
4. DATE DRILLED QQ
5. TOTAL DEPTH Ll If) `
6. CUTTINGS COLLECTED D YVS ❑ NOC��
7. DOES WELL REPLACE EXISTING WELL? YES [-1 NO❑L -
8. STATIC WATER LEVEL Below Top of Casing: V2 '_ FT.
(Use '+' II Above Top of Casing)
9. TOP OF CASING IS--L— FT. Above Land Surface -
'Top of casing terminated at/or below land surface requires a variance In accor-
dance with 1SA NCAC 2C.01IS
10. YIELD (gpm): . 15_ METHOD OF TEST Q
11. WATER ZONES (depth):
12. CHLORINATION:
13. CASING:
Type WHi Amount' --- II additional space Is needed tse ba& of 1cx-m
Wall Thickness
Depth Diameter or Weight/Ft. Material
From To q� Ft. 6,1 Z-�-- From— To To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From tD To _&LL— Ft. an
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:
I DO HEREBY
CONSTRUCTI
FOR OFFICE US
Quad No:
Material
LOCATION SK=TCH
(Stow direction and diszlance tr:fn ZI leas: tiro Smote
Roads, or other rrr� refervroce points`
HA�THIS t;T, WELL WAS CONSTRUCTED IN ACCORDMICE WITH t1A 0JCAC Y,:,'/fELL
4RDS,. AND THAT A COPY OF THIS RECORD HAS BEEN PROViCEO -TO TFtE YI=�" t- 01�'�EF.•
6 20Ui SIGNATURE OF PERSON CONSTRLY:TING iXE'WELL
Submit original to Division of Water Duality, Groand.rator Seam within N.)C%f'ys
Os•'t:
GK.I �V. 1291
Serial No.

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section 23 U 1..4 2
1636 Mail Service Center - Raleigh, N.C. 27699.1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: i i Ile-f 1_, '2 P 0 Ar ; ) - n Q_
WELL CONTRACTOR CERTIFICATION r<:
STATE WELL CONSTRUCTION PERMITH:
1. WELL USE (Check Applicable flox): Residential D Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATAON: (Show ketch of the location below)
Nearest Town: ffi °� I �� �- County:—
� m P
(Road Namil And Numbers, Community, or Subdivisi n and Lot No.) DRILLING LOG DEPTH
3. OWNER P_Jlfl q Yl din �From To r Forraxn Descripuoo-
Address - A
S'
beet or outs o. �� — � �j :,.rc,/��' P-
City or Town Stale Zip Code
4. DATE DRILLED ' ©D
5. TOTAL DEPTH
6. CUTTINGS COLLECTED Y€S ❑ NOM-
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO©
B. STATIC WATER LEVEL Below Top of Casing: r_)o ' FT.
(Use '+' if Above Top of Casing)
9. TOP OF CASING IS l FT. Above Land Surface -
`Top of casing terminated atlor below land surface requires a variance In accor-
dance with 15A NCAC 2C .0118
10. YIELD (gpm): -,6 METHOD OF TEST A
11. WATER ZONES (depth):
12. CHLORINATION: Type 641 lcxbi eL Amount_
13. CASING:
Wall Thickness
Depth Diameter or Weight/Ft. Material
From 10 To �� Ft. 612S _DCL I -,D V(_-.
From To Fl.
From To Ft.
14. GROUT:
Depth Material Method
From -_ To Ft. 41 -
IF
From To Ft.
15. SCREEN:
Depth
From To -
From To -
From To
16. SAND/GRAVEL PACK:
Diameter Slot Size
Ft In.
Ft. in.
Ft. In.
Material
In,
In.
In.
If additional space is needed is-e back of fcfm
LOCATION SK= fCH
(Show direction and d'es~.ance from al leas: tyro Sate
Roads, or other n-r-a relere:r-e- Points!
C
1
Cn
ao
w
c_:
o �-
Depth Size Material
From To Fl.
From To Ft.
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 155A OJCAC r' . lt✓ELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED 70 THE 1 /5"U O" P.
FOR OFFICE USE ONLY
Quad No: SIGNATURE OF PERSON CONSTRL)CTING TY vVELL
Submit original to DivltIon of Water Quality, Grouts«-ater Soc." within n. C%1ys
Serial No,

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section 2 3 U 1_ 4 1
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: JMM Ly- 44ekl Ae.11: V►o,
WELL CONTRACTOR CERTIFICATION N: .2404
STATE WELL CONSTRUCTION PERMITN:
1. WELL USE (Check Applicable Box): Residential[ Municipal ❑ Industrial ❑ Agricultural ❑ MonitoriN. ❑
Aecovery❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: County: h(Qul
1Us ui�ee
(Road Warne —and Numbers, Comm nIty, or Subdivlsion and Lot No.) DRILLING LOG DEPTH
3. OWNER c ter- j (° From To Fonra5on DescripUo-
Address
veer or Route o. l,// © 01
City or Town Stale Zip Code r 7� f `"2S ,
4. DATE DRILLED
5. TOTAL DEPTH 13 6 '
6. CUTTINGS COLLECTED YFS F--] NOEP—
7. DOES WELL REPLACE EXISTING WELL? YES[--] NOEg
S. STATIC WATER LEVEL Below Top of Casing: ;26' _ FT.
(Use '+' II 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): -20_ METHOD OF TEST ArR
11. WATER ZONES (depth):
12. CHLORINATION: Type b4) 1061e_b Amount _i _
it additional space is needed t back of form
13. CASING:
LOCATION SK=TCH
Wall Thickness
Depth or Weight/Ft. Material
(Show direction and d'cs�r.,m ance t21 leas: `rro Smote
�Diameteerr
From To _620 Ff. -t.� �- - (- VC,
Roads, or other rr-.---p refere:,cy points!
From To Ft.
From To Ft.
14. GROUT:
c:5
Depth Material Method
From _0 To 410 ' Ft. 0061pnj
C=
From To Ft.
15. SCREEN:
+T�_
Depth Diameter Slot Size Material
From To Ft In. in.
wry
From To Ft. in. In.
Cp
w
to d
�'
From To Ft, In. In.
---
E3
16. SAND/GRAVEL PACK:
Depth Size Material
From To - Ft.
From To Ft.
17. REMARKS:
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 1 SA 04CAC ?^,'r�rtLl
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED 70 THE Y/S"_LL 0%%%%EF,.
FOR OFFICE USE ONLY Lyca can
Quad No: SIGNATURE OF PERSON CONSTFIL rTING 1> c yv1ELL
Sutxnl1, original to Division of Water Quality, Gmvn6Kaler Scam within n C;%
Serial No. Sh.l PigV, 1291

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section 236140
1636 Mail Service Center - Raleigh, N.C. 27699-1636•Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: 1p.r �-L)p ll C1 r-., U :r'a
WELL CONTRACTOR CERTIFICATION P: r2U1)4
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (check Applicable Box): Residential 113'- Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Aecovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below) //+�
Nearest Town: I►4v a 5t/i j%e County:.t—)C+\/
(Road Name and Numbers. Community, or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER _ CGQla S 4/& -h From To Forrra5cn Desr_dption
Address / i-2 >�e�q ®� Gin,
,//
trees
IlAV QSU" Ise Meg
g
City or Yown Stale Zip Code
4. DATE DRILLED -00
5. TOTAL DEPTH '
6. CUTTINGS COLLECTED YFS ❑ NO[l.
7. DOES WELL REPLACE EXISTING WELL? YES [J NO[3-
8. STATIC WATER LEVEL Below Top of Casing: 3m , FT.
(Use '+' if Above Top.of Casing)
9. TOP OF CASING IS I_ 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): _ 2s METHOD OF TEST
11. WATER ZONES (depth):
12. CHLORINATION: Type �?� )41r.& Amount _ If additional space is needed rs-e back of form
13. CASING:
Depth Diameter
From To _O Fl. I-Las5
From To Ft.
From To Ft.
14. GROUT:
Wall Thickness LOCATION SK=TCH
or Weight/Ft. Material (Show direction and distance Imm aA leas: v+o S;ate
4= ( PILL' Roads. or other m---P relemrce points!
Depth Ma enal Method
From To s26 • 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
A
C=
t
Cn
z�
r.a
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDRICE WITH 1 SA DJCAC ?r, VtELL
CONSTRUCTION STANDARQS, AND THAT A C PY OF THIS RECORD HAS EEEf f PROVICED 'TO THE
FOR OFFICE USE.ONLY
Quad No: SIGNATURE OF PERSON CONSTRIY.:TING h 1c yv ELL
Subrnll original to Divltlon of Water puaihy. Groundwater se=n within :4) t:%VyS
Serial No.

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section 7 3 6 .� 7
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): ResidenUal [r Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Infection ❑ Other ❑ If Other, List Use:
Agricultural ❑ Monitoring ❑
2. WELL LOCATI1N: (Show sketch of the location below)
Nearest Town:�1�4V�S U� (l County:,( , -
(Road Name and mbers, Community, or SubdIVIsIon and Lot No.) DRILLING LOG DEPTH
3. OWNER H1�(-C'd i-?A6er From To Foma5mDescrip6w.
Address — ( ep r
(Street or Route o. J _ 115
( City or Town Slate Zip Code G
4. DATE DRILLED Si-H-00
5. TOTAL DEPTHS'
6. CUTTINGS COLLECTED YVS 0 NO©-
7. DOES WELL REPLACE EXISTING WELL? YES 0 NO[t�
B. STATIC WATER LEVEL Below Top of Casing: ,SO r FT.
(Use '+' It Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface*
'Top of casing terminated at/or below land surface requires a variance in accor-
dance with 15A NCAC 2C .0118
10. YIELD (gpm): �_ METHOD OF TEST
11. WATER ZONES (depth):
12. CHLORINATION: Type Amount It additional space is needed t back of farm
13. CASING:
Wall Thickness
Depth Diameter r Weight/Ft. Material
�/
From To __3(a Fl. -PVC--
From
To Ft.
From
To Ft.
14. GROUT:
Depth M trial Method
From _ �_ To • �D t Ft.
From
To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From
To Ft In. In.
From
To Ft. In. In.
From
To Ft. in. In.
16. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To Ft.
17. REMARKS:
Material
LOCATION SK=TCH
(Show direction and dis;4-ance tr.,m cal leas!'Ovo Stale
Roads, or other rr.---p refere:,ce pointy
CD
CD
I o ;
Cn rr+
>> r
M
GX) [n u
MM
w
-- o
z
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A rJCAC ?'.','/TELL
CONSTRUCTION STANDARDS, AND THAT A C PY OF THIS RECORD HAS BEEN PROVICEO 'TO THE YIXL O►��t:F..
FOR OFFICE USE ONLY
Quad No:
t, 'jp(iSubrr}�Ii o
Serial No.
SIGNATURE OF PERSON CONSTRIYTING T>t'/v'ELL
at to Divltlon of Water Quality, Grovrid"ler Sec" within Y) t:%1ys
DA-'r E
Cr1.1 P19v. 12?1

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION 9 a4D U
STATE WELL CONSTRUCTION PERMITN:
1. WELL USE (Check Applicable l3ox): Residential 0--municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other.[] If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below) u
Nearest Town: �� r t�rr 11 County:
A, I e DEPTH
(Road Name and Numbers, Community, or Subdivision and Lot No.) DRILLING LOG
3. OWNER �D i� �(�1�'-Q� From To t Forts cn DescriPGo-
WELL CONSTRUCTION RECORD
Address
treat or ou a o.
City or Town State Zip Code
4. DATE DRILLED �- 31'8a
5. TOTAL DEPTH 1 z5
6. CUTTINGS COLLECTED YVS ❑ NO[Gr
7. DOES WELL REPLACE EXISTING WELL? YES NOP-
B. STATIC WATER LEVEL Below Top of Casing: _5C�! FT.
(Use '+' If Above Top or Casing)
9. TOP OF CASING IS_j_-__ FT. Above Land Surface*
'Top of casing terminated at/or below land surface requires a variance In accor-
dance with 1SA NCAC 2C .O11e
10. YIELD (gpm): -L5_ METHOD OF TESTA te
11. WATER ZONES (depth):
236078
MIAW,.tom
fL i
mounl A�—
It additional space needed tse baciof (rrm
12. CHLORINATION: Type
13. CASING:
LOCATION SK=1•CH
Wall Thickness
Depth Diameter or Weight[Ft. Material
(Show direction and d'es~ance h-, n leas' *oo 1—,We
Fromm ---To - Ft. �-- �- �
Roads, or other rr,-- re(ere: point`
From To Ft.
From To Ft.
14. GROUT:
Depth M lariat Method
From --- To �- Ft. v --
p
Zlz
From To Ft.
)
15. SCREEN:
Depth Diameter Slot Size Material
1-D ?'
`: E;
From To Ft in. In.
From To Ft.
From To Ft. In. in.
e
16. SANDIGRAVEL PACK:
c�
CM2
Depth Size Material
tV
-'
`p
From To_ Ft.
From To Ft. —
17. REMARKS:
DO HEREBY CERTIFYTHAT THIS1kEL:L WAS CONSTRUCTED IN ACCORDANCE WITH 15A 114CAC n,'/fELL
CONSTRUCTION STANDARDS, AND THATiA COPY OF THIS RECORD HAS BEEN PR01nCED -TO THC "«Z�4' 0"'tiEF.•
FOR OFFICE t�SE ONL ,, SIGNATURE OF PERSON CONSTRUCTING 11,Z yv'ELL
Quad No:
- 1t.i eie t ? ubrnll original to D+iAtion of Water Duality. Groun*"ter Srcen within n C;�
Serial No, ' Mile
� ;ie,�

North Carolina • Department of Environment and Natural Resources - Division of Water Quality • Groundwater Section �.i8652
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 a Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery Cj Heat Pump Water Injection M Other If Other, List Use:
2. WELL LOCATI Show sketcF the location below)
Nearest Tow . County:
(Road Name a tubers, Community o Subd Ision and lot No.) DRIL G LOG DEPTH
3. OWNER o o �
Address From ,T�` Format!Descripti
(Streetor Route o.
City or Town Slate Zip Code
4. DATE DRILLED
5. TOTAL DEPTH I o1
6. CUTTINGS COLLECTED YES M NO[✓D'
7. DOES WELL REPLACE EXISTING WELL? YES M NO ff
8. STATIC WATER LEVEL Below Top of Casing: 2�Q Fr.
(Use 't' it Above Top of Casing)
9. TOP OF CASING ISFT. Above Land Surface*
'Top of casing terminated at/or below land surface requires a variance In accor-
dance with 15A NCAC 2C 118
10. YIELD (gpm): METHOD OF TEST
11. WATER ZONES (depth):—
12. CHLORINATION: Type Amount
13. CASING:
Wall Thickness
]� Depth er o Weight/Ft. Material
From To �3 Ft. Di r� 7• PVC,
From To Ft.
From To Ft.
14. GROUT:
Depth a eria Metho
From To (01 Ft. C�"`a'�
From To Ft.
15. SCREEN:
If additional space Is needed use back of form
�»r
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other m ference points)
a'
,9
Depth
Diameter Slot Size
Matetai
(C)q C
fJ
From To
Ft In.
In.
C-)
From To
Ft. In.
In.
t,.
From To
Ft. In.
in.
16. SAND/GRAVEL PACK:,
=i
Depth
Size
Material
-
^i-;
From To
Ft.
to }
From To
Ft.
4-
17. REMARKS:
!�-'
I DO HE CT Y IA T S CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONST I N H COPY OF THIS
/RECORD
HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFF SE NLY)
Ouad No: ��' r ?1��1f� SIGNATURE bF PERSON CONSTRUCTING THE WELL ATE
u I original to Division of Water Ouality, Groundwater Section within 30 days
Serial No. GW-1 REV. 121"
Ice

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section 217087
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD 'WELL CONTRACTOR: liGee f 1
WELL CONTRACTOR CERTIFICATION #: 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: CL4—'�
I C3 4 D fZt v It::
(Road Name and Numbers. Community, or Subdivision and Lot No.)
DRILLING LOG DEPTH
3. OWNER (,ARY b%¢ t!I ©S(9
From To Formation Description
Address ��
(Street or out e-RO.j-
i� IWO e nN C �� 90!7
City or Town State Zip Code
4. DATE DRILLED d- .1 a
5. TOTAL DEPTH -/L) "
6. CUTTINGS COLLECTED YES F ] NO[:a'
7. DOES WELL REPLACE EXISTING WELL? YES F] NOM
`='
B. STATIC WATER LEVEL Below Top of Casing: 6-0 ' FT.
CD c`
(Use '+' If Above Top of Casing)
C? _.
9. TOP OF CASING IS FT. Above Land Surface'
•Top of casing terminated stfor below land surface requires a variance In accor-
dance with 15A NCAC 2C .D118
10. YIELD (gpm): _� METHOD OF TEST
11. WATER ZONES (depth)- � �o
/
12. CHLORINATION: Type Amount 12 '
If additional apace Is needed use back of form CD
13. CASING:
Wall Thickness
LOCATION SKETCH
Depth QQ � DI ter Wat t, tedaI
From To Ste_ Ft. DI,nr U G
(Show direction and distance from at least two Slate
Roads, or other map reference points)
From To FI.
From To Ft.
14. GROUT:
Do p Materia Method
From To ll� Ft.
From O To Ft.
15. SCREEN:
Depth Diameter Slot Slze Material
From To Ft In. In.
From To Ft. In. In.
From To Ft. in. in.
16. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To Ft.
17. REMARKS:
Material
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL.
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE'ONLY. -
Quad No: SIGNATURE 01�'RSON CONSTRUCTING THE WELL DATE
Submit ortginai 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 y L+
1636 Mail Service Center - Raleigh, N.C. 27699.1636-Phone [phone] T>
WELL CONSTRUCTION RECORD WELL CONTRACTOR: ^j
WELL CONTRACTOR CERTIFICATION N:
STATE WELL CONSTRUCTION PERMITN:
1. WELL USE (Check Applicable Box): Residenllal Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injecllon ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
�)r'i ye-S J t LLB County:
Nearest Town: T
(Road Name and Numbers, Community, or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER _—s 14' Ve_ 13U 1 Le- From To Formation Description
Address SDI 8J •5G 7
(Street or Route o.)
City or Town State Zip Code
4. DATE DRILLED 3 '',/V' - 2
5. TOTAL DEPTH Y lr)
6. CUTTINGS COLLECTED YES F_j NO❑-
7. DOES WELL REPLACE EXISTING WELL? YES �j NOD
8. STATIC WATER LEVEL Below Top of Casing: �.� FT. c �.
(Use '+• it Above Top of Casing) C r
9. TOP OF CASING IS FT. Above Land Surface*
*Top of casing terminated attor below land surface requires a variance In actor- _ - -
dance with 15A NCAC 2C 011E cc� �1 M y� _=
10. YIELD (gpm): 6 METHOD OF TEST'�`��' //� / / l 72' r
11. WATER ZONES (depth): 2 2°
. F,
12. CHLORINATION: Type 172_l/ Amount '��s If additional space is needed use back of I(
13. CASING:
Wall Thickness LOCATION SKETCH
Depth ^ DI meter or W I t./ ratte`al (Show direction and distance from at least two State
From D To Ft. Z Roads, or other map reference points)
From To Ft
From To Ft.
14. GROUT:
Dept hMaterial Method
From D To a O Ft.
From i7 To i� :9 Ft.
15. SCREEN:
Depth Diameter Slot Slze Material
From To Ft in. in.
From To Ft. In. In.
From To Ft. In. In.
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Quad No: .15 A E Cy PqRiA CONSTRUCTING THE WELL DATE
Submit original to Division o Wat Quality, Groundwater Section within 30 days
Serial No. GW-1 REV. 12/99

North Carolina - Department of Environment and Natural Resources - Division of Water Quality • Groundwater Section O 3 61 2
1636 Mail Service Center • Raleigh, N.C. 27699-1636•Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: M J 1 Af (A) @.I I L" NnG
WELL CONTRACTOR CERTIFICATION 0: 290 C(
STATE WELL CONSTRUCTION PERMITP:
WELL USE (Check Applicable Box): Residential[ --Municipal ❑ Industrial ❑
Aecovery ❑ Heat Pump Water injection ❑ Other ❑ It Other, List Use:
Agricultural ❑ Monitoring ❑
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town:-",, es V County: C �cw
1
LCCAr PC C—QVc
(Road Name and Numbers, Communlly, or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER �YIbYVIGS LGTI G✓\ From To Forrra:�on Descrip6w.
Address
(Street or Route o.)
City or Town State Zip Code
4. DATE DRILLED �� - 26 -00
5. TOTAL DEPTH 30S
6. CUTTINGS COLLECTED YVS [J NOED--
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NOQ-
8. STATIC WATER LEVEL Below Top of Casing: O ' FT.
(Use '+' If Above Top of Casing)
9. TOP OF CASING IS (_ FT. Above Land Surface -
`Top of casing terminated el/or below land surface requires a variance In accor-
dance with 15A NCAC 2C .0118
10. YIELD (gpm): .�_ METHOD OF TEST 14%j?
11. WATER ZONES (depth):
12. CHLORINATION: Type \xIA"b IA142- sAmount Ll If additional space is needed is a back of fcrm
13. CASING:
Wail Thickness
Depth Diameter or Weight/Ft. Material
From To J , Ft. 1­2-5'-- - P vc--
From To Fl.
From To Ft.
14. GROUT:
Depth Material Method
From To -0 '-Ft. 'D�
From To Ft.
15. SCREEN:
LOCATION SK=TCH
(Show direction and dis:.ance lrcm all leas: tyro Stele
Roads, or other rrr�a refererce point'
c�
Q
r�
G')
c
c r.n
p
cn
Depth Diameter Slot Size Material CaES
-,
From To Ft In. In.
z
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 p4CAC 2-.. ,tTELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVICEO 'TO THE 715".l. C"EF..
FOR OFFICE USE :ONL]Y'( `i0ll
Quad No:
Sutx
Serial No.
SIGNATURE OF PERSON CONSTRLnTING IxE yv ELL
original to Divitlon of Willer avalily, Grgundw+alor Seam within N.) C%rys
t: K. i P9 V. I!'"

0363 North Carolina • Department of Environment and Natural Resources • Division of Water Quality • Groundwater Section J ,) 1..)
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: M31er �, yell clr;l),'t�a
WELL CONTRACTOR CERTIFICATION a: 2 2 y
STATE WELL CONSTRUCTION PERMITP:
1, WELL USE (check Applicable Box): Residential[Q-�' Municipal ❑ Industrial ❑
Aecovery ❑ Heat Pump Water Injection ❑ Other [] If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: d ' �'y i I County: C�'
Agricultural ❑ Monitoring ❑
(Road Name and Numbers, Community, or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER Aa h ro✓t / � ru a nor "f' From To Forrra5cn Des:riptio-
Address
(Street or Hout No.)
City or Town Stale Zip Code
9DD ` — 1125 r rrmNi �P
4. DATE DRILLED
5. TOTAL DEPTH 3.25� -
6. CUTTINGS COLLECTED YFS ❑ NOE9'
7. DOES WELL REPLACE EXISTING WELL? YES [] NO a
8. STATIC WATER LEVEL Below Top of Casing: 50r 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): o1 METHOD OF TEST �i 2
11. WATER ZONES (depth):
12. CHLORINATION: Type h Lh �a%tehs Amount !-
13. CASING:
Wall Thickness
Depth Diameter or Weight/Ft. Material
From
r
To Ft. ns.z
f - C
From
To Ft.
From
To Ft.
14. GROUT:
Depth Material
Method
From Q
To .2 69� Fl..T
From
To Ft.
15. SCREEN:
Depth Diameter Slot Size
Material
From
To Ft in.
in.
From
To Ft. In.
In.
From
To Fl. in.
In.
16. SAND/GRAVEL PACK:
Depth Size
Material
From To Ft.
From To Ft.
17. REMARKS:
II additional space is needed t-a back of fcrm
LOCATION SK=TCH
(Stow direction end disl-ance tnm 2=11 leas: rko State
Roads, or other n--zap retere:r-,e points`
ca
� ,mac-•
Cl -
C G
co cn
m a
W --A
^� o
z
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 1 SA pJCAC ?',.',' ✓ELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROViCED '70 THt: 7L'S". .L• 0t% ,EF.
�l-
FOR OFFICE USE ONLY
Ouad No: tSubrr
Serial No. - -
IONATURE OF PERSON CONSTRLJ rTING 11c '"'ELL
1Q I}ivlalon of Water puality, G�nd.rator Sratn within Y3 C�ys
6M•t F115v, 1111

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section 0 0 O J
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION N: aUf�U
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential � Municipal ❑ Industrial ❑ Agricultural ❑ MoniloriN ❑
Aecovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCAT N: (Show lch of the location below) ' ^
Nearest Town: „rQ55"t�wV1 County: lie
YIY S t .z
(R ad Name and Num-�ers, Comm
�unity. or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER aj�� tM�, de �r From To Forra5cn DescripGc'
Address C• el �' 1�� �j�'
treat or ou a o. :?
City or Town State Zip Code 3 , , ,
4. DATE DRILLED �„�
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YVS ❑ NO[e-
7. DOES WELL REPLACE EXISTING WELL? YES n NOED
B. STATIC WATER LEVEL Below Top of Casing: _2QQL FT.
(Use '+' If Above Top of Casing)
9. TOP OF CASING IS, - FT. Above Land Surface*
'Top of casing terminated atlor below land surface requires a variance In accor-
dance with 15A NCAC 2C .0118
10. YIELD (gpm): METHOD OF TEST A +�
11. WATER ZONES (depth):
12. CHLORINATION:
13. CASING:
Type Amount -C3 It additional space is needed tsa baci of fcx-m
Depth r Diameter
From To 3ti Ft. —
From To Ft.
From To Ft.
14. GROUT:
LOCATION SK=TCH
Wall Thickness
or Weight/Ft. Material (Show direction and dis ance from ZI leas: tyro Sale
V:.( A/C� Roads, or other n-�p refere:cx- points`
Depth M teral 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 Fl•
From To Ft. —
17. REMARKS:
Material
c
I
an
r
co
w
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A 04CAC ?C:. Y✓ELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED -TO THE'Ns:-L D%NEF•
FOR OFFICE USE ONLY,.:,; f
Quad No:
Sulxn(
Serial No. -
SIGNATURE OF PERSON CONSTRInTING ixe tv ELL
original to Divit ion of Water OUalhy, Gmndw&tor Sfc�" within 30 C;-o�ys
c
71.
0
6K•I PTSV, 12"

/Uo5v
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section 236124
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: Mll r- 0 /,:n
WELL CONTRACTOR CERTIFICATION P: a?U 24/
STATE WELL CONSTRUCTION PERfAITH:
1. WELL USE (check Applicable Box): ResldenUal ❑ Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Aecovery ❑ Heal Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATI N: (Show sketch of the location below)
Nearest Town: le County: �t
ir P1'
(Road Name an um ers, Community, or Subdivision and Lot No.) DRILLING LOG . DEPTH
3. OWNER t�q ?It 0# From To Formaxn Descrip6w.
h
Address I �ifif-tex l r m e lZd d, `S 1, �
treet�Ror�Cu a o. � �/} � fly i o.0 lie l.� /, '
City or Town State Zip Code �`S 2
4. DATE DRILLED
5. TOTAL DEPTH `
6. CUTTINGS COLLECTED YVS ❑ NOC�
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
8. STATIC WATER LEVEL Below Top of Casing: _.�-01 FT.
(Use '+' If Above Top of Casing)
9. TOP OF CASING IS_I FT. Above Land Surface*
'Top of casing terminated at/or below land surface requires a variance In accor.
dance with 15A NCAC 2C .0118
10. YIELD (gpm): . < METHOD OF TEST P1,12
11. WATER ZONES (depth):
12. CHLORINATION: Type kill IaA kis Amount It additional space is needed t,-s* baci of Icrr n
13. CASING:
Wall Thickness LOCATION SK= f CH
Depth Diameter or Weight/Ft. Material (Show direction and d"dance lr" aI leas: 'No Stele
From ID -To Ft. "", 2,5 pice— Roads, or other n-.---p relerer-r-es point!
From To Ft.
From To Ft.
14. GROUT:
o
='
Depth
M terial
Method
""
"
From 0_ To r 0' Ft.
From To Ft.
--=
15. SCREEN:
Cn
r^
Depth Diameter Slot Size
Material
M
From To Ft
In.
In.
t—
From To Ft.
In.
In.
From To Ft.
In.
In.
0
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 DJCAC ?-, ,/FELL
CONSTRUCTION STANDARDS,. AND THAT A COPY OF THIS RECORD HAS BEEU PROVIDED 'TO THE V/mil 0►%NEF..
—
FOR OFFICE USE ONLY nrtc T>t wELL o�'E
Quad No: SIGNATURE OF PERSON CONSTRl1:
Submit original to Division of Water Ovelily. Grwndwatar Sr=n within ':r) C%Sys
Sn.i �V. 1_91
Serial No. „ t

North Carolina - Department of Environment and Natural Resources • Division of Water Quality - Groundwater Section 2 3 1`3 j 0 1.
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone] t 1
WELL CONSTRUCTION RECORD WELLCONTRACTOR: ffli 1I r DC-11 CJr,11; nG
WELL CONTRACTOR CERTIFICATION
STATE WELL CONSTRUCTION PERMITP:
1. WELL USE (Check Applicable Box): Residential ❑--Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring, ❑
Aecovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: County:
(Road Name ind Numbers. Community, or Su division and Lot No.) DRILLING LOG DEPTH
3. OWNER From To Forrra:en Desciptio:
Address © — S C )G V
(street or Houte o. _,:� - -r"n rS
City or Town State Zip Code ( r' 3 u
4. DATE DRILLED - 5 -
5. TOTAL DEPTH t
6. CUTTINGS COLLECTED YES ❑ NO[D`
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NOE
B. 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 atlor below land surface requires it variance in accor-
dance with 15A NCAC 2C .0118 n
10. YIELD (gpm): 30 METHOD OF TEST
11. WATER ZONES (depth):
12. CHLORINATION: Type l S Amount 40 If additional space its needed tse back of krm
13. CASING:
Walt Thickness
Depth Diameter or Weight/Ft. Material
FromTo61D - Ft. 1 T_
From To Ft.
From To Ft.
14. GROUT:
Depth M anal Method
From 'U 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 Ft. in. in.
16. SAND/GRAVEL PACK: ,
Depth Size Material
From To Ft.
From To Ft.
17. REMARKS:
I DO HEREBY
FOR OFFICE USE ONLY
Quad No: CT t'
LOCATION SK=TCH
(Show direction and dunce from ad leas: v+o Smote
Roads, or other rr~.� refererce points!
c
C
t
m
c:o
CJ3
A
CONSTRUCTED IN ACCORDANCE WITH i5A DJCAC 2S,'/SELL
7PY OF THIS RECORD HAS BEEN PROVIDED 10 THE VIS t. Ots'AEF.-
SIGNATURE OF PERSON CONSTRUK:TING 1>t vv'ELL
inal to Divlslon of Water Quality, Gmunb.rater Srccn within n C%xys
Os E
6K.1 pie v. i291
Serial No.

i.8644
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELLCONTRACTOR:
WELL CONTRACTOR CERTIFICATION #: 3
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential 10 Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other M If Other, List Use:
2. WELL
(Road Name
3. OWNER
location below)
County:
ivision an of o.) DRI LING LOG
J From To
b 1 �'
City -or To State Zip Code
4. DATE DRILL a t b ✓o
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑ NO[D'-
7. DOES WELL REPLACE EXISTING WELL? YES Q NO�
8. STATIC WATER LEVEL Below Top of Casing: EL FT.
(Use '+' If Above Top of Casing)
9. TOP OF CASING IS ' FT. Above Land Surface'
'Top of casing terminated at/or below land surface requires a variance In accor-
dance with 15A NCAC 2C 011
10. YIELD (gpm): . T METHOD 9F TEST 2-
11. WATER ZONES (depth):
12. CHLORINATION: Type Amount
13. CASING:
DEPTH
If additional space is needed use back of form
Wall Thickness
LOCATION SKETCH
Depth
�S
DI r Wet ht/Ft
_M
( Show direction and distance from at least two State
From
To
Ft. �L�
Roads, or other map reference points)
From
To
Ft.
From
To
Ft.
r�
14. GROUT:
C D
c>
Depth
aterial Method
_
From
_
b To ��
Ft.
1
r_
From
To
Ft.
J
15. SCREEN:
Depth
Diameter Slot Size Material
_
may_'
From
To Ft
in. In.
~
�D
From To Ft. in. in.
From To Ft. In. In.
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft. l
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTIONQ1,6RJ1l F THIS RE CORD HAS BEEN PROVIDED TO THE WELL OWNER,
FOR OFFICE US Y l! `�00
Quad No: .. , ,_ I ATURE F RSON CONSTRUCTING THE WELL ATE
f )� Submit on i al Division o Water Quality, Groundwater Section within 30 days
Serial I GW-1 REV. 12/99

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Ground -Hater Section 2 14 3 v 7
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:WELL CONTRACTOR CERTIFICATION #: O
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): ResidentialQ- Municipal ❑ Industrial ❑ Agricultural F-1 Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below) /'
Nearest Town: H �1kl P."V i j) E County: C114V -
�� seS rce-e K
(Road Name and Numbers, Community, or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER From To ForraScn Descriptio--
Address 0 - 4D
(Street or Houle 0. Z©.%%i City or or Town Slate Zip Code
4. DATE DRILLED '7'- In -00
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YVS ❑ NOED--
7. DOES WELL REPLACE EXISTING WELL? YES [] NOD-
B. STATIC WATER LEVEL Below Top of Casing:^ FT.
(Use '+' if Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface- 1;
'Top of casing terminated eVor below land surface requires a variance In accor-
dance with 15A NCAC 2C .0118
10 YIELD ( pm): _lag_ METHOD OF TEST d%2
CD
s re"-'
— o
g% I�'iiE 6�.:4�6� Y4 rake_,-�.:' ` ,..:�....:•D =: � o
11. WATER ZONES (depth): '-
0 r.r,
12. CHLORINATION: Type k Amount If additional space is needed L_­s-_ back of
13. CASING: z
LOCATION SK= TCH
Wall Thickne ss
Depth Diameter or Welght/Ft. Material (Show direction aid dunce term leas :No Smote
FromTo— Ft. (C ­:2-5- _ - P-ye- Roads, or other m p refere:r-re point'
From To Ft.
From To Ft.
14. GROUT:
Depth M tenal Method
From n_ To .-'�O Fl.
From To Ft.
15. SCREEN:
Depth Diameter
From To Ft In.
From To Ft. In.
From To Ft. In.
16. SAND/GRAVEL PACK:
F _
From T -- ---LS
From o Ft.
17. REMARKS: ; Il , , 'Y ?n%fl
I DO HEREEIT CEgTIIFY THA, 7.Im
CONSTRUC ION STAfy6AR'09,W
FOR OFFICE USE ONLY
Quad No:
Slot Size Material
In.
In.
In.
Material
, VAS ONSTRUCTED IN ACCORDANCE WITH 15A 04CAC ?^, vfELL
T A C PY OF THIS RECORD HAS BEEN PROVIC£D TO THE lm:�L OWNED
SIGNATURE OF PERSON CONSTRIY.:TING 11c IrVELL 0�'E
wT41 original to Divltfon of Water Quality, Gmr4,-&t4r Seam ►within V) c-�ys
CM.I pig V. 12Y1
Serial No.

North Carolina • Department of Environment and Natural Resources • Division of Water Quality • Groundwater Section 43
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELLCONTRACTOR: rn't1"r- �A U.II nit ; WNna
WELL CONTRACTOR CERTIFICATION N: 2410el
STATE WELL CONSTRUCTION PERMITN:
WELL USE (Check Applicable Box): Residential[ Municipal ❑ Industrial ❑
1lecovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show s�etch of the location below)
Agricultural ❑ Monitoring ❑
County:
NLL//Ie11a",rest Town: e,�/�
i+
')
fiC , �1,00 l /r
DRILLING LOG DEPTH
(Road Name and Numbers, Community ortubdivision a Lot No.)
3. OWNER 1QV) Yl 68C if eV
From To Forrraxn DescAption
Address
beet or Routo o.
n
City or Town State Zip Code
_
4. DATE DRILLED %-) I - OD
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YFS ❑ NO[
7. DOES WELL REPLACE EXISTING WELL? YES [] NOE�J—
c�
o1Q
8. STATIC WATER LEVEL Below Top of Casing: r FT.
�o—
(Use '+' II Above Top of Casing)
9. TOP OF CASING ISFT. Above Land Surface'
w
�o
-Top of casing terminated at/or below land surface requires a variance in actor-
dance with 15A NCAC 2C .0118
_3n
-- O
10. YIELD (gpm): METHOD OF TEST &A?
11. WATER ZONES (depth):
_
12. CHLORINATION: Type Acil�l 41e Amount L
if additional space is needed L-s-e back of fum
13. CASING:
LOCATION SK-TCH
Wall Thickness
Diam�ete`r or Weighl/Fl. Material
Depth Diameter
(Show direction and dis=ante Mm leas ?rro Smote
�
From To ��— FL ��+—%t- I/,--
Roads, or other r,.Ga relere:Acx- point`
From To Ft.
From To Ft.
14. GROUT:
Depth Ma eriat Method
From __ To as 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:
or,tr, rn 2 11 �iz19 M Material
From -
From o El. --
17. REMARKS
I DO HERE CE 4 AS ONSTRUCTED IN ACCORDANCE WITH 15A fJCAC ?C, ,trELL
CONSTRUC ION 5T •�t j S,.AI g C1fAT A PY OF THIS RECORD HAS BEEN PROVIDED 'TO THE YI'—"�L Ot�`1=F•
a�!.�
FOR OFFICE USE ONLY D,•-E
Quad No: SIGNATURE OF PERSON CONSTRLY:TING Tic 'WELL
Su I original to Dividon of Water Quality, GMnd.raler Srocn wlthin Y) c sys
Crr.i pr::Y. 1Z91
Serial No.

/S
North Caroiina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section i w43-8
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 sox): Residential Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Pecovery ❑ Heat Pump Water Injection ❑ Other [] If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: i ��A�I j County: C Ict/
DEPTH
(Road Name an umbers Community, or Subdivision and Lot No.) DRILLING LOG
3. OWNER ` ' From To Formaxn Description.
Address [ Ll
_eS (' 4 f-ry I/, I t'e d r
(Street or Flouter o.
City or Town Stale Zip Code r
4. DATE DRILLED 2- t b '- Oa O _TJrn
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YVS ❑ NO
7. DOES WELL REPLACE EXISTING WELL? YES
8. STATIC WATER LEVEL Below Top of Casing: =�— FT. _ _------ ram
(Use '+' if Above Top of Casing) r,
9. TOP OF CASING IS 1 FT. Above Land Surface-
-Top of casing terminated at/or below land surface requires a variance In accor.
dance with 15A NCAC 2C .0118 8
10. YIELD (gpm): _ i o METHOD OF TEST A'2 `-
11. WATER ZONES (depth): !_1
12. CHLORINATION: Type l� j'+ '+t leAmount LI If addhiona► space is needed back of roan
13, CASING:
LOCATION SKc fCH
Wall Thickness
Depth r �Diameeteer or Weight/Ft. /M�atteerial (Show direction a-d d-es'ance k= ai leas: rHo Smote
From --To --6` - Ft. /:. -.25 - -��- —f "' Roads, or other rrcp relere:cre points`
From To Ft.
From To Ft.
14. GROUT:
Depth M to Method
From �_ To Ft. F
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft in. in.
From To Ft. in. In.
From To Fi
16. SAND/GRAVEL PA ( (a 1 �
From To
C L.
From To F • —
17. REMARKS:
DO HEREBY CERTIF t�rONSTR CTED IN ACCORDANCE WITH 15A DJCAC 2^,'/✓EL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVICED ?O THE v/'_—U D� IEP.
FOR OFFICE USE ONLY
Quad No:
Serial No.
SIGNATURE OF PERSON CONSTRIY.:TING DIZ WELL Da T E
SubmU original to Division of Water Ouatity. Grwr4,water Srccn within Vi C;5rys Ce,1 t%tt: V. 1211

421-874
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]�E�u�
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION #: 3
oo
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.
(Road Narr
3. OWNER, —
Address c\
or
the location below)
County:
— _
1LI.NG LOG
Subdivision and Lot No.)
From To,
r
kb
City or Town State ] Zip Code r 1-
4. DATE DRILLED,(o a 00
5. TOTAL DEPTH I Y �U r
6. CUTTINGS COLLECTED YES ❑ NO FP
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO"t'
8. STATIC WATER LEVEL Below Top of Casing: 25 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): .'MET OD OF TEST (W -
11. WATER ZONES (depth): U i
12. CHLORINATION: Type Wm Amount
13. CASING:
Wall Thickness
Depth i Dlaetq( o Weight/Ft. -Material
From To Ft. �C
From To Ft.
From To Ft.
14. GROUT:
Depth M tSri Method
From 0 To 3(- Ft.WU
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
C7
rn
J a�
0
--tom
'5o
CO —4
If additional space is needed use back of form CD
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
I DO HEREBY1-11
CF`. T4FY Aj`THI,S WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUC "EN S77113N AR �S AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE NLY
iVo
/� (
Quad No t,'; i `'' SIGNATURE ERSON CONSTRUCTING THE WELL DATE
Submli oripinal to Division of Water Quality, Groundwater Section within 30 days
Serial No. GW1 REV. 12/99

4ti.2 ..873
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] AYE;'aL
WELL CONSTRUCTION RECORD WELL CONTRACTOR: w�u-� St1lk�(`ft�4S�y
WELL CONTRACTOR CERTIFICATION #: �J
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential Municipal ❑
Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ OtherEJ
If Other, List Use:
2. WELL L CAT (Show sk of the location below)
Neares TQw County:
-
(Road Name Nu bers, o u iry, or Subdivision and Lot No.)
D ING LOG DEPTH
3. OWNER;
From To Form lion Description
A dress
(�
(Strefat or Ro t N,
rJr
City or Tow State Zip Cod
Li g 1�' C J--
4. DATE DRILL
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑ NOF
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NOF71
C3
8. STATIC WATER LEVEL Below Top of Casing: �(_ FT.
n ��
(Use '+' if Above Top of Casing)
9. TOP OF CASING ISFT. Above Land Surface'
(-7 r�
1 0�
'Top of casing terminated atlor below land surface requires a variance in accor-
T-tJ
dance with 15A NCAC 2C . 11s
l
rn
10. YIELD (gpm): METHOD OF TEST it
11. WATER ZONES (depth): ; QLL
12. CHLORINATION: Type W-MAmount
If additional space is needed use back of form 00 o
13. CASING:
z
Wall Thickness
LOCATION SKETCH
Depth 9faeter o weiynt/Ft at rial
(Show direction and distance from at least two State
FromTo Ft. `� ��� ��
Roads, or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth M4 na Method
From U To � Ft.
From To Ft. t
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft In, in.
From To Ft. In. in.
From To Ft. in. in.
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
17. REMARKS:
I DO HEREBY CfE }�T�kAtS WEL6,WAS,CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTIOJAtj� gOPY OF THI RECORD H S BEEN PROVIDED TO THE WELL OWNEFOR OFFICE US
n� `� " " SIGNATU ftRSON CONSTRUCTING THE WELL ATE
Quad No: IV /..
Submit original to Division df Water Quality, Groundwater Section within 30 days
Serial No. GW1 REV. 12/99

'?1 72
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] wvess\`E
WELL CONSTRUCTION RECORD WELLCONTRACTOR:
WELL CONTRACTOR CERTIFICATION #: �J
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 LOCATId . (Show ske of the location below)
Nearest To County:
-
- r
(Road-N an ers uni , or Su d4l 'o n ,L t No:)
DR LING LOG DEPTH
3. OWNER
From To Formation Des ripti
&,
Address \
h 1 b�
4�'' 14?S, `
City or Town State Zip Code
�----
4. DATE DRILLE
5. TOTAL DEPTH t
6. CUTTINGS COLLECTED YES ❑ NO❑,
tg
7. DOES WELL REPLACE EXISTING WELL? YES (-j NO ff
8. STATIC WATER LEVEL Below Top of Casing: FT.
rn o
_J�
(Use '+' If Above Top of Casing)
z rn
9. TOP OF CASING IS FT. Above Land Surface*
v—
'Top of casing terminated atlor below land surface requires a variance in accor-
dance with 15A NCAC 2Cd 0118
10. YIELD (gpli 010 METH O1TTD OF TEST
11. WATER ZONES (depth): �"S�>I
'• ��
C5 —+
12. CHLORINATION: Type Amount
If additional space is needed use back of form z
13. CASING:
LOCATION SKETCH
Wail Thickness
Depth Di1 eter r Wei9ht/Ft. at vial
� / " ��
(Show direction and distance from at least two State
FromTo Ft.
Roads, or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth a riai Method
From _b To � Ft. _
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft in. in.
From To Ft. in. in.
From To Ft. in. In.
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
17. REMARKS:
I DO HEREBY PRTI TH' TT.HI WFLL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTI I$ At pA�4" T�JATi A COPX OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
J 1 •� � ��
FOR OFFICE U 4�'
LY r , ' i G
Quad No: I1A 12 p:; ! SIONATU E" F PERSON CONSTRUCTING THE WELL DATE
Submit oiripinal to Division of Water Quality, Groundwater Section within 30 days
Serial No. GW-1 REV. 12199

r�213'�i
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]Q ��� UL
WELL CONSTRUCTION RECORD WELLCONTRACTOR:
WELL CONTRACTOR CERTIFICATION #: �J
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 LOB� TIO% how sketch t e location below) \
Nearest Tow?>ti - County: _
(Road Name an umbers, Unity, o Subdivision and of No.) DRIL ING LOG DEPTH
3. OWNER `' From To Fo ation De;c ' tion
Address � r
(StreetL�
or Route o. ';W eta,
City or Town State Zip Code
4. DATE DRILLED `� 00
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑ NO[:$,Y-
7. DOES WELL REPLACE EXISTING WELL? YES. NO
8. STATIC WATER LEVEL Below Top of Casing: 1--� FT.
(Use '+' it Above Top of Casing)
9. TOP OF CASING ISFT. Above Land Surface'
'Top of casing terminated at/or below land surface requires a vprlance In accor-
dance with 15A NCAC 2C . 116
10. YIELD (gpm): METHOD 9F TEST
11. WATER ZONES (depth): 4A
12. CHLORINATION: Type Amount
13. CASING:
Wail Thickness
Depth - , T' � Ln ' or; `i hUFt. ate al
From To Ft. (�
From To Ft.
From To Ft.
14. GROUT:
Depth4' teri Method
From _Q_ To �� Ft. A
I j
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft in. in.
From To Ft. in. In.
From To Ft. in. in.
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
17. REMARKS:
If additional space Is needed use back of iormu+ o
Y
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
M
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USEON L - lini h U l'1
�a_ x
Quad No: � �SSSI6NATURE ERSON CONSTRUCTING THE WELL DA E
C 2SS,U rnit o,,Inlalito Division of Water Quality, Groundwater Section within 30 days
Serial No. A 2 6 L (JI 1-,��.yJ GW1 REV. 12199

221870
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: w�u-� S-1Lk-`iTS
WELL CONTRACTOR CERTIFICATION #: 29SS
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential L �l ' Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATI N. (Show, sketc of the location below) (`\
Nearest T wn County:
(Roa a d Nu bers ommunity, r Subdivision and Lot No.) DRIL ING LOG DEPTH
3. OWNER From To Formation es ription
A res or o leMLa' 9Z
City or Town State zip Cod— e—f-
4. DATE DRILLS UO
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑ NO[ ► '
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NOG o
8. STATIC WATER LEVEL Below Top of Casing: - 'c e,
(Use '+' If Above Top of Casing) t rl o rn
9. TOP OF CASING ISFT. Above Land Surface'
`Top of casing terminated at/or below land surface requires a variance In actor -
dance with 15A NCAC 2C .t11" rn
10, YIELD (gpm): �`-2 METHOD OF TEST L n �'
11. WATER ZONES (depth):U �n
C.J rn :4
12. CHLORINATION: Type tl�Amount If additional space is needed use back of form _4
13. CASING:
Wall Thickness LOCATION SKETCH
Depth U Di rprtgr o ei VFt./I Material (Show direction and distance from at least two State
From G 7o Ft. W Roads, or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Teri Method
From To (rly Ft.
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft in. in.
From To Ft. In. In.
From To Ft. in. in.
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
17. REMARKS:
I DO HEREBY :CERTIFY ,THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRU TON AN�DAR S 'DS+;AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
iI 1)J r.
F
R OFFICE U ONL d No: JI�� ! SIGNATUA F PERSON CONSTRUCTING THE WELL DA E
6 fSubmit<drtylnal to Division of Water Quality, Groundwater Section within 30 days
al No. — ,� ,, 4 GW1 REV. 12199

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section <'21863
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]YE`U�
WELL CONSTRUCTION RECORD WELL CONTRACTOR: W kL1 W SS nW `( FSMS
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 LOCATIO Show sketch helocationbelow)
Nearest To Uu County:
(Ro a umbers, Co or ub ivision and Lot No.) DRIL�%G LOG DEPTH
3. OWNER From To F ration Descript'on
Addless b Apr 1-
tree or u(e o. 1-1l]
`City`or Town State Zip Code
4. DATE DRILLED vU
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑ NO lQ-'
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO tt
8. STATIC WATER LEVEL Below Top of Casing: �Lj 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 .0118
10. YIELD (gpm): METHF TEST
-
11. WATER ZONES (depth):
12. CHLORINATION: Type Amount
13. CASING:
0
O
p
r.�
C7_C
m
�
o<
�o
3
Mn
rA
qD
o
If additional space is needed use back of form
Wall Thickness LOCATION SKETCH
Depth G i e ei F , �A�tqq I Show direction and distance from at least two State
From To 1� Ft. ��T4�4r 5�.� F'y (Roads, or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
From
Dept�-2_
To
Ft.
�d
� A
Method
From
To
Ft.
t
15. SCREEN:
Depth
Diameter Slot Size
Material
From
To Ft
in. in.
From
To Ft.
in. in.
From
To Ft.
in. in.
16. SAND/GRAVEL PACK:
Depth
Size Material
From
To
Ft.
From
To
Ft.
17. REMARKS:
I DO HEREBY QERT FY� A �T` S �j �,t I WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTIOyy ctS1NQARu - NDHk1�T�PY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE U, NL
Ouad No: I TAN ! 6 ( N ! SIGNATUR O PERSON CONSTRUCTING THE WELL DA E
Submli original to Division df Water Oualtty, Groundwater Section within 30 days
Serial No. GW-1 REV. 12/99
'iiai

121868
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] Av��`uE Qal., .Dp--L L -
WELL CONSTRUCTION RECORD WELLCONTRACTOR: V�1k�- AM S�
WELL CONTRACTOR CERTIFICATION #: 29 SS
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other M If Other, List Use:
2. WELL LOCATIU Show sketc the location below)
Barest _ - County: -�
(Road Name u bers,•Co un , or ubd ision a d Lot No.) D LING LOG
3. OWNER From To
Address
A—'x ree . 0 0.
City or Town State Zip Code
4, DATE DRILLED V
5. TOTAL DEPTH <<�`� 3 �bq .
6. CUTTINGS COLLECTED YES [❑ NO= brlr I bl
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO M ll (V L i S'
8. STATIC WATER LEVEL Below Top of Casing: It) FT.
(Use '+' It Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface- ya
'Top of casing terminated attor below land surface requires a variance In accor-
dance with 15A NCAC 2C 118 3 22 o
10. YIELD (gpm): METH D OF TEST �U4- _ W
11. WATER ZONES (depth): _ 1 � d ��
Co 0
12. CHLORINATION: Type ILM Amount If additional space is needed use back of form
13. CASING:
DEPTH
Wall Thickness LOCATION SKETCH
Depth ,te I (Show direction and distance from at least two State
From �% TO Ft. ' �i " LM Roads, or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth to ' Method
From To Do Ft. ,
t
From To Ft.
15. SCREEN:
Depth
From
To
From
To
From
To
16. SAND/GRAVEL PACK:
Depth
From
To
From
To-
17. REMARKS:
Diameter Slot Size Material
Ft in. in.
Ft. In. in.
Ft. in. in.
Ft.
Ft.
Size Material
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STA AR S Ar' IT AT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFIC ,l�NL'Y�"
Quad No: C' SIGNATUR , F PERSON CONSTRUCTING THE WELL D E
l / 6 1, Su !1 or(pinal to Divlsi of Water Quality, Groundwater Section within 30 days
Serial No. GWA REV. 12/99

jt - 8I 6
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 #: 3
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable sox): Residential ff Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery[] Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATIOO how sketc the location below) —
Nearest Town: County:
(Road Name n Numbers, C muni , Su ion and Lot No.) DRIL ING LOG DEPTH
3. OWNER From To Form tion Description
dress h bt
tree, or
City or To State Zip Code �� t
4. DATE DRIL Jw�bb
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑ N027C
7. DOES WELL REPLACE EXISTING WELL? YES NOd
8. STATIC WATER LEVEL Below Top of Casing: — FT,
(Use -.' if Above Top of Casing)
9. TOP OF CASING ISFT. Above Land Surface -
'Top of casing terminated at/or below land surface requires a variance In accor-
dance with 15A NCAC 2C . 18
10. YIELD (gpm): -M METHOD_OFTEST
11. WATER ZONES (depth):
12. CHLORINATION: Type Amount
13. CASING:
Wall Thickness
Q Depth QlametQr Wgight/Ft. '-t;4aty�al
From To �l — Ft. ((mod— /—iy�7-{'VC_.
From To Ft.
From To Ft.
14. GROUT:
If additional space is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
Depth teri Method
From C) To L-51 Ft.
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft in. in. _
From To Ft. In. in. o
C'] c.
From To Ft. In. In. p r ,
16. SAND/GRAVEL PACK: r c-,
Depth Size Material
cr) c�
From To Ft.
From To Ft. y=
17. REMARKS: %=
I DO HEREB THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL CA
CONSTRUC P%STRNPRIM, ,gN0)j(j"Hff ArCQPY OF THIS RE90RD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE NLY
Quad No: , I � jf)) SIGNATURE f RSON CONSTRUCTING THE WELL ATE
' )Ill 'Sudtmi at to Division of Water Quality, Groundwater Section within 30 days
Serial No. GW-1 REV. 12/99
Groundwater Section
_,,..�Rshe��iife Rye ionxl Office

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section r } //�� (� M
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone] `t 3 9 1
WELL CONSTRUCTION RECORD WELL CONTRACTOR: L�; �lzr )ell Ar. II:vigr
WELL CONTRACTOR CERTIFICATION p:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (check Appllceble eox): Resldenliai ❑Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring
Recovery ❑ Heat Pump Water Injection ❑ Other C] It Other, List Use:
2. WELL LOCATI N: (Show sketch of the location below) C!
Nearest Town: �25 V r I1 County:
DE�'TF�ja
,.'tNta f
Q UCA+J
(Road Nang and Numbers, Community, or Subdivision and Lot No.) DRILLING LOG
3. OWNER IJ i 4 Q2(/L[�, i 3 �c �P From _ To Formation Description
Address l [0
ree or oy e o.
-iT 'Pe1, low a.20
City or Town Stale It Code
. DATE DRILLED
53
. TOTAL DEPTH
6. CUTTINGS COLLECTED YES O NO[D-'
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO©
6. STATIC WATER LEVEL Below Top of Casing: 1,0 ' FT.
(Use '+' it Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface'
'Top of casing terminated eUor below land surface requires a variance In accor-
dance with 15A NCAC 2C .0118
10. YIELD (gpm): 10 METHOD OF TEST
11. WATER ZONES (depth):
12. CHLORINATION: Type I? b C SAmounl4_
13. CASING:
Wail Thickness
Depth Diameter or Weight/Ft. Material
From 0 To --L±L'Ft. .25 b 17.21
From--O To �� Ft.4 P--
From To Ft•
14. GROUT:
Depth Material Method
From To Ft.
From To Ft.
15. SCREEN: '
Depth Diameter Slot SIZE Material
From To Ft In. In.
From To FL In. In.
From To
16. SAND/GRAVEL PACK:
Depth �+� 51ze an3rr r
From TOr
From
i
17. REMARKS: € H
DO HEREBY CERTIFY THA_ THIS WELL WAS CONSTRUCI
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
rya
n
C1 K,
�C3
o
cn=
If additional space Is needed use back of lorry.
nt
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
N ACCORDANCE WITH 15A NCAC 2C, WELL
:ORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY DATE
Quad No: SIGNATURE OF PERSON CONSTRUCTING THE WELL
Su It original to Division of Water Quality, Groundwater Section within 30 days GW 1 REV 12/99
Serial No.

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mall Service Center - Raleigh, N.C. 27699-1636•Phone (9t9) 733-3221 L. 14 J 9 V
WELL CONSTRUCTION RECORD WELL CONTRACTOR: M • U� P c ; ; na
WELL CONTRACTOR CERTIFICATION #: `o24404
STATE WELL CONSTRUCTION PERMITP:
1, WELL USE (check Appilceble Box): Residential[ Municipal U Industrial ❑ Agricultural El Monitoring ❑I ,
Recovery ❑ Heal Pump Water Injection C] Other ❑ If Other, List Use:
2. WELL LOCATI N: (Show sketch of the location below)
Nearest Town: �— County:E;
/
ar e-01 OyE �cy'ci toy 5 ¢ r t��Joiv jas�{Ott
(Road Name and Numbers, Community, or Subdivision and Lot No.) DRILLING LOG D��i 1 ¢ 'r "nbl.xr
3. OWNER 1-iarl ilaccYl From To '­rorrridt6hbes6ription
Address a 3 Ci�t
ree or ou o o. 3 D r f(
City or Town Stale Zip Code
4. DATE DRILLED ' & ' 00
5. TOTAL DEPTH 25
6. CUTTINGS COLLECTED YES ❑ NO[� C=)
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO[E-
8. STATIC WATER LEVEL Below Top of Casing: 5 o ` FT.
(Use '+' If Above Top of Casing) �- �� r
9. TOP OF CASING IS FT. Above Land Surface'
'Top of casing terminated atlor below land surface requires a variance In accor- U1T r7
dance with 15A NCAC 2C .0118 '
10. YIELD (gpm): 60 METHOD OF TEST r ►2 Tom,o
11. WATER ZONES (depth): M 50
�%� -i ab� e]-SAmount It additional space Is needed use back of forrt� "+
12. CHLORINATION: Type .�1 — ^
e �
13. CASING:.
LOCATION SKETCH
Wall Thickness
Depth Diameter or Weight/Ft. Material (Show direction and distance from at least two State
From To ACR'— FL----- 4 `)Qk_C_ Roads, or other map reference points)
From To Ft.
From To Ft
14. GROUT:
Depth M lerlal Method
From _ 0 To -�— FI
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From —To—Ft In. —in.
—
From To Ft. In. In.
From To FIin
16. SAND/GRAVEL PACK:
Depth I Size MaterialMm it
.y
From To Wt
FromTo PI
17. REMARKS: �-,.._.�.
slit sy�,._ :.u+ i
I DO HEREBY CERTIFY THA iitS�Ef:-WASRei
-6
STR�CTEU t ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A CfOPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Quad No:
Serial No.
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Division at Water Qusilly. Groundwater Section within 30 days GW-1 REV. 12/99

North Carolina - Department of Environment and Natural Flesources - Division of Water Quality - Groundwater Section r ; t �•
1636 Mall Service Center - Flalelgh, N.C. 27699-1636-Phone [phone] " L 4 J
WELL CONSTRUCTION RECORD WELL CONTRACTOR: ,(rig ll �r L .`�e) I C1
WELL CONTRACTOR CERTIFICATION 0: _ a2gQ 4!
STATE WELL CONSTRUCTION PERMIT#:
WELL USE Applicable Box): Residential I❑ ---Municipal ❑ Industrial ❑ Agricultural ❑
Monitoring ❑
1.
(Check
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ II Other, List Use:
2.
WELL LOCATION: (Show sketch of the location below)
County:
Nearest Town:" .
' i 1► Ue,1) e�!� -f�EPTH
(Road Name and Numbers, C ynllty, or Subdivision and Lot No.) DRILLING LOG
3.
OWNER From To Format)
r:Desg,(1p�lvri't��
//
Address C, ���d�C v�er/ iec�
-—js eo or ou a o.
/-�adeSv, /� P — 7D' — 1,25'
City dr Town Stale Zip Code
4.
DATE DRILLED le - 62 - d 6
5.
TOTAL DEPTH 12 S'
o
6.
CUTTINGS COLLECTED YES ❑ NO[ —
DOES WELL REPLACE EXISTING WELL? YES n NO
Q
7.
8.
STATIC WATER LEVEL Below Top of Casing: � FT.
` �'
N
Qm
(Use '+' If Above Top of Casing)
ram— e.--n-
9.
TOP OF CASING IS FT. Above Land Surface'
a
'Top of casing terminated at/or below land surface requires a variance in accor-
c-n ni
dance with i5A NCAC 2C .0118 /%
IQ METHOD OF TEST 412
Xim_ M
10.
YIELD (gpm):
_,. M
11.
WATER ZONES (depth):
r n
If additional space Is needed use back of for fiP
12.
CHLORINATION: Type Arnounl
13. CASING:
LOCATION SKETCH
Wall Thickness
Material (Show
Depth
Diameter or WelghVFl. w direction and distance from at least two Stale
From—To—ro Ft. 4- 25 bra/ Roads, or other map reference points)
From To Fl.
From To �Ft.
14. GROUT:
beplh r Mal ria/ I � Method
From Q To FI.! .
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From —To—Ft In. In.
From
From To —Ft.
In �L,' 15 1 in
th L ..��
i I , .. n,_.,...... -1
16. SAND/GRAVEL PACK: ; -•,/
H
Depth Ize„ , Material
From To
From To Ft.
17. REMARKS: !•'r
fisheville Regional Office ]]�
I DO HEREBY CERTIFY THAT THIS WELL WAS CON fFICJdTM°ACCORDANCE WITH ISA NCAC 20, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY r DATE
Guad No: SIGNATUnE OF PERSON CONSTRUCTING THE WELL
Submit odginal to Div
lslon of Water Cl
Groundwater Section Within 30 days GW t REV. 12199
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]
384
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION N:
STATE WELL CONSTRUCTION PERMITP:
1. WELL USE (Check Applicable Box): Residential D---Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Plecovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATI N: (Show sketch of the location below) n'
Nearest Town: HA I S V,' to _ County:
(Road Name and (Numbers, Community, or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER �0.t •n hot x-23 e? n From To p Foorrnaxcn/Descriptio'
Address ��
cc/
tbireet or HouleNo.1
tmtg
o
ily or 'own L State Zip Code /P
4. DATE DRILLED 6>0
-
5. TOTAL DEPTH 30 S
6. CUTTINGS COLLECTED YfS ❑ NO[�
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO L[ F
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 al/or below land surface requires a variance In accor-
dance with 15A NCAC 2C .0118
10. YIELD (gpm): '_ METHOD OF TEST A"a
11. WATER ZONES (depth):
12. CHLORINATION: Type VJ Li If additional space is needed L---- back of fc-m
13. CASING:
LOCATION SK=i'CH
Wall Thickness
Depth Diameter or Weight/Ft. Material (Slow direction and d'rs::ance trxn aEI leas'tno 5�'Mle
From en To Ft. -Zo� -6�­7/— �y-r—�-- Roads, or other rr�7 referr:c-e- polnt!
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From V To •.20 , Ft.
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft In. in.
From To
From To F Ir1�
16. SAND/GRAVEL PA
Depth Sizes
From To F`,
From
17. REMARKS:
To
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH ISA PxAC ?r. vrELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS SEEPt PROVIDED 'TO THE Y/ L Q%%NEP-
FOR OFFICE USE ONLY
Quad No:
Serial No. ,
SIGNATURE OP PERSON CONSTRLI:TING DZ '/v'ELL
Submit original to Divltlon of Water Quality, Ground"19f Srrcrl lwithin n C%s'ys
o19
C.K.1 Fat: V, till

North Carolina - Department of Environment and Natural Resources • Division of Water Quality - Groundwater Section r, •1
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELLCONTRACTOR:� 2 IA�P11 �'t1''� J I'c��
WELL CONTRACTOR CERTIFICATION
STATE WELL CONSTRUCTION PERfAIT#:
1. WELL USE (Check Applicable eox): Residential [Municipal ❑ Industrial ❑
Aecovery ❑ Heat Pump Water injection ❑ Other ❑ If Other, List Use:
Agricultural ❑ Monitoring ❑
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: A6,115 V County: —
(Road Name and Numbers, Community, or Subdivision and Lot No.) DRILLING LOG DEPTH
3.. OWNER .1.L10 ' (,r ff °/7 From To Forrraxn DescfipGo^
Address y ` t
rreet or NOUIC No.) 10 — .. t
,00r,0 t All LA, 62 r
City or Town State Zip Code
4. DATE DRILLED o2Lo - 00_
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YFS ❑ NOZ�— —'
7. DOES WELL REPLACE EXISTING WELL? YES F-1 NOU B. STATIC WATER LEVEL Below Top of Casing: &,C) FT. ._
(Use '+' II Above Top of Casing) _
9. TOP OF CASING IS FT. Above Land Suriace' —
'Top of casing terminated atlor below land surlace requires s variance In scoot.
dance with 15A NCAC 2C .0118
10. YIELD (gpm): _, 2- METHOD OF TEST
11. WATER ZONES (depth):
0
"" o
12. CHLORINATION: Type ? Amount If additional space is needed ts-e back of farm
13. CASING:
LOCATION SK=T'CH
Wall Thickness
Depth Diameter or Weight/Ft. Material (Show direction and distance front a? leas: *mo Smote
From __4.':2—To 1190 Ft. 6' 12-5 '�I -'DVn— Roads, or other rr�p relem r,.e. point`
From To Fl.
From To Ft•
14. GROUT:
Depth Material Method
From rt� To a/9 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
Lie t
Slot Size Material
From Tol — -
From To
17. REMARKS:
I DO HEREBY CERTIFY THAT
CONSTRUCTION STANDARD
FOR OFFICE USE ONLY
Quad No:
Serial No.
In.
In.
In.
:'tL W. ASC0ONSTRUC�ED IN ACCOROMICE WITH 15A DJCAC Y.;,'/fELL
HAyin'OPYbE T.N�S RECORD HAS BEEN PRO\nCED 'TO THE y/E <t a%NFF•
SIGNATURE OF PERSON CONSTRIY:TIflG 1> c 'WELL 0�'T E
Submit original to Divirtfon of Water Duality, Gmur4,.ra1er Sr=n within `4 : ys
plsV. 12T1

North Carolina - Department of Environment and Natural Resources • Division of Water Quality • Groundwater Section
1636 IAAit Service Center • Raleigh, N.C. 27699-1036•Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: ^A°��e� �6// /��'
WELL CONTRACTOR CERTIFICATION I!:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential LJ Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heal Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of 010 location below) /
NPnrna! Town' County. ry
_ AA /ZD
(road Name and N nlbors, Community, or Subdivision end Lot No.) DRILLING LOG DEPTH
3. OWNER _ heapke-- From To FonnatlonDesoription
Arirlrnca d C/ C- /
r9o1 or J'lrioio 1`o. / �/ -- 6 r
Ci'yorTowi Stele ZIP Code
4. DATE DRILLED c 0 -
5. 101-AL DEPTH 10 e Y -
6. CUifINGS COLI_EC1 ED YES[_] NUF T­ -
7, DOES WELL REPLACE EXISTING WELL? YES ❑ NO[�J'_
@. STATIC WATER LEVEL Below Top of Crlginci: j(�0__ Ff.
(Uso'r' If Abovo Top or Castro)
o TOP OF r'A4ING IS FT. Above Land Surface*
•Tnr nt cn.lno rnrrnlnnt^rl nUr+r hnlnw lanrt eurrarre rorlydro4 o vnrlance In aocor• `
.hnc^ with 1Fn flIrAr, 2P,.0110
10 YIFI.D (nrm)'�, k4FT-H
D OF TEST- _
11 WATEn ZONES (dell1h)• D -- -_--
1�
-
CA o
12. CHLORINATION..
Tvr'°
/ /
.,_Amount
• y
II additional space t4 needed use back of form
13. CAGING.
I OCATIO_ETCH
Fin _____T
DAnth
To �l _
Dinryleter
r1.
W 11' lhlr.kn^44
Of yacel�, t.
�. • f
lerlllll
(Show direction and distance from at lead two State
Roads, or other map reference points)
I•lo!n_
_ To —.. ---- Fl.
From
1 a --- --
Ft.
--
14. GROUT:
M11r_ri ll Method
Flom O DPIToROr Fl.
Flonl q to , `'l..-
Dr-I'th Piameler Slot Si: r3 Material
Floill _. 1 U __..__ Ft ill.
r-r.,r., In.
From To FI. _—_ In.
15. SAND;GRAVL--L PACK:
Donth Size
Flcin -- __ To _ - - Ft.
17. REMARKS.
_- In.
--- - In. — —
Material
.;
Mffi
1 ft.
�S
(1 n�Cy.
i r n HFRFPY rFFITiFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
(',0!,IgTAI 1r11r?N S fANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
roR or-r-lce usF oriLY
011ar11 No, gIC;rJnTtlnE or. Prim N CONSTRUCTING THE WELL DATE
5uhvdt oripinrll to (?iiision of welar ounlily, Groundvrnler Snd!on within 30 days
GW1 fiEV. 12/99

212955
North Carolina - Department of Environment and Natural Resources - Division of Water Ouality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]Y"_L
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION #: 1 19 SS
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
(Road N
3. OWNER
Address
ow skefc f the location below)
Q --- County:
and Lot No.) DRIL'tING LOG
From To
City or Town ` \ State Zip Cod
4. DATE DRILLE&T_
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑ NOED'
7. DOES WELL REPLACE EXISTING WELL? YES NO[Jf
8. STATIC WATER LEVEL Below Top of Casing: FT.
(Use '+' if Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface -
'Top of casing terminated at/or below land surface requires a variance In accor-
dance with 15A NCAC 2C 0118
10. YIELD (gpm): M METHOD OF TEST
11. WATER ZONES (depth): a��
or
12. CHLORINATION: Type Amount
13. CASING:
Wall Thickness
D Depth O D at �r or ei ht/Ft. atgnal
From To � Ft. Y V
From To Ft.
From To Ft.
14. GROUT:
Depth M trial Method
From To (oO Ft.
t
From To Ft.
15. SCREEN:
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)
Depth
Diameter Slot Size
Material
From To
Ft in.
in.
From To
Ft. In,
In.
From To
Ft. In.
In.
s
16. SAND/GRAVEL PACK:
x6
Depth
Size
Material
From To
Ft.
From To Ft.
17. REMARKS: —
0
G
O o
C �m
= Crn
N CJ.<
N �rri
tV ��
rn�
cn C-)
v o
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS REC D HAS BE N PROVIDED TO THE WELL OW ER
FOR OFFICE USE ONLY
Quad No: SIGNATURE OF ON CONSTRUCTING THE WELL bATIE
Submit original to Division of Water Quality, Groundwater Section wlthin 30 days
Serial No. GW1 REV. 12/99

21295.4
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 \u� 'm
WELL CONSTRUCTION RECORD WELL CONTRACTOR: W�LLI� S'MIL�Tr4S
WELL CONTRACTOR CERTIFICATION #: 9SIZ
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable sox): Residential Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (S+yow sketch of the location below)
Nearest Tow County:
(Road N d bers, Comm Ubdivision and Lot No.) DR ING LOG DEPTH
3. OWNER From To Formation es iption
Q
Address 1 b ts� 1, t
_
l `� (Street o u e o. d k�q nQ ,D'
A
City or Town State Zip Code
4. DATE DRILLED 00
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑ NO[E'
7. DOES WELL REPLACE EXISTING WELL? YES NO IIf
S. 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 actor below land surface requires a variance In accor-
dance with 15A NCAC 2C .118
10. YIELD (gpm): METHOD OF TEST
11. WATER ZONES (depth): _ " 2b
12. CHLORINATION: Type \-k-RA Aount
13. CASING:
Wall Thickness
J� Depth i miter or Wei h Ft. ate ' I
FromTo � Ft. ��
From To Ft.
From To Ft.
14. GROUT:
Depth td Method
From 0 To � Ft.
From To Ft. t
15. SCREEN:
If additional space Is needed use back of form
OCATION SKETCH
(Show directi Fdistance from at least two State
Roads, erence points)
Depth
Diameter Slot Size Material
v
From To
Ft in. in.
's
p
From To
Ft. in. in
i
r
c'
From To
Ft. in. In
cM
16. SAND/GRAVEL PACK:
tV
Depth
Size Matbti,i'
R`'
i
Do
From To
Ft.U'
-a
rn
Mm
From To
Ft.
N
�"
M�
17. REMARKS:
-
p"
o
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
Z
CONSTRUCTION STANDARDS, AND THAT A COPY OFF IS RECORD HAS�N
PROVIDED TO THE WELL OWNER.'
FOR OFFICE USE ONLY a o0
Quad No: SIGNATURE OF E ON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Quality, Groundwater Section Within 30 days
Serial No. GW1 REV. 12/99

212952
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��Ess`uz U aL L(. l
WELL CONSTRUCTION RECORD WELL CONTRACTOR: WkL-UW S - eTE�
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 LOC : (Sho ket h of the location below)
Nearest Town: County:
(Road Name Numbers,
3. OWNER rA �)11t .
or Town i I State
Subdivision and Lot No.) DRIL ING LOG DEPTH
4. DATE DRILLED LkD
5. TOTAL DEPTH '
6. CUTTINGS COLLECTED YES ❑ NO�
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
�
8. STATIC WATER LEVEL Below Top of Casing: (oD 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 2Cc�1 )8
10. YIELD (gpm): M METHOD OFTEST_ O k
11. WATER ZONES (depth):.
12. CHLORINATION: Type Amount_ If additional space is needed use back of form
13. CASING:
Wall Thickness LOCATION SKETCH
Depth�� i�met�er oW iiy�ht-/F,l. a`tq I (Show direction and distance from at least two State
From To --�`— Ft. 4�`� Roads, or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth �jeri Method
From d To `(�� Ft. F
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
O
Go
C
N
N
From
To Ft
In,
in.
From
To Ft.
in.
In.t,
From
To Ft.
in,
in.CJn
h;
_.(!
tit a+
16. SAND/GRAVEL PACK:
Auur
Depth
Size
Material
,.
From
To Ft.
j
From
To Ft.
a ri) {r •�..•
f'x 1
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 PIER
ON CONSTRUCTING THE WELL dATEf
Submit original to Division of Wr Quality, Groundwater Section within 30 days
GW-1 REV. 12/99

212951
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELLCONTRACTOR:
WELL CONTRACTOR CERTIFICATION #: �J _
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 LOCA
(Road N
3. OWNER
Address
the location below)
County: _\
Subdivisi and Vo 00� I DRILLING LOG
=_Ys? From To t
b S
S is�
.� `s1
City or Town State Zip Code
4. DATE DRILL S
5. TOTAL DEPTH '
6. CUTTINGS COLLECTED YES ❑ NO ✓�
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO(tD
8. STATIC WATER LEVEL Below Top of Casing: t� FT.
(Use '+' if Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface -
*Top of casing terminated at/or below land surface requires a variance In accor-
dance with 15A NCAC 2C 118
10. YIELD (gpm): MET(1G0�1) OFTEST
11. WATER ZONES (depth), \ LS
or
DEPTH
12. CHLORINATION: Type �AT-y Amount If additional space Is needed use back of form
13. CASING:
Depth
From 0 To
From To
From To
14. GROUT:
From
From
15. SCREEN:
Wall Thickness LOCATION SKETCH
Dlarpqlp
r or ei ht/Ft. to to (Show direction and distance from at least two State
Ft. LE. �7 � ` "L' Roads, or other map reference points)
Ft.
Ft.
Dept t L.aterlqkMethod
To Ft.
To Ft.
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
O o
C
riUJ t ii I�i I
C
Crr�
is
t
n
Z
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY %OFT CORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Quad No: SIGNATURE OF SON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Quality, Groundwater Section Within 30 days
Serial No. GW-1 REV. 12/99

212948
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] \u� U a, .D�_[ LU I
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION #: �J
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable sox): Residential 0 Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LO ATIO : (Show
Nearest
(Road Name a d umbers, C(
3. OWNER
Address Il
the location below)
County:
bd'vAsion and Lot No.) DRILLING LOG
From To
CV-1t) 1I s'
City or Town State Zip Code--r— — —
4. DATE DRILLED r
CZ TnTA1 r1CDTW rig
6. CUTTINGS COLLECTED YES F ] NO[D'
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NOE"'
8. STATIC WATER LEVEL Below Top of Casing: 46 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 .0118 ^ ,
10. YIELD (gpm): METHOD F TEST (�J�
11. WATER ZONES (depth):
12. CHLORINATION: Type Amount
13. CASING:
DEPTH
If additional space is needed use back of form
LOCATION SKETCH
Wall Thickness
Depth Cjn
Diameter o Weiflnt/Ft. a�te%� I
`U/4- I
(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
ter'teri'm Method
o
FroTo �_
m
Ft.1Y3
C=
From
To
Ft.
r
�
15. SCREEN:
N
N
Depth Diameter Slot Size Material
From
To Ft
in. in.
From
To Ft.
in. in.
N
From
To Ft.
In, In,
ICn
16. SAND/GRAVEL PACK:
"J
Depth
Size Material
From
To
Ft..!
`
From
To
Ft.
17.
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF TI IS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Quad No:
Serial No.
0
�m
oC')
crn
z—
a.�
m
m�
a
cn x
m�
��
SIGNATURE OF PaeON CONSTRUCTING THE WELL DATE f
Submit original to Division of Water Quality, Groundwater Section within 30 days
GW1 REV. 12/99

?1?947
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]��( LLt(�('� _.
WELL CONSTRUCTION RECORD WELL CONTRACTOR: W \1-LkW SS n'A� s ` 1
WELL CONTRACTOR CERTIFICATION #: �J
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: ow sketch of the location below)
Nearest Town: \a� R_ County:
(Road Name aq mbers, Comm , or Subdivi*(ortand Lot No.) DRILL) LOG DEPTH
3. OWNER '
City or Town State Zip Code
4. DATE DRILL
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑ NOQ-'
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NOd
8. STATIC WATER LEVEL Below Top of Casing: ' _ FT.
(Use '+' If Above Top of Casing)
9. TOP OF CASING ISFT. Above Land Surface -
`Top of casing terminated at/or below land surface requires a variance In accor-
d ith 15A NCAC 2C 0 1 a
From To
C) tSr
anw n ` `
10. YIELD (gpm): 112, METHOD OF TEST w-J�
11. WATER ZONES (depth): �
12. CHLORINATION: Type VVT_tA7_ Amount If additional space is needed use back of form
13. CASING: `
Wall Thickness LOCATION SKETCH
Depth pNeV W i VFt7 I tA�(al (Show direction and distance from at least two State
FromTo l=L Ft. tt�P �`P 'Hll✓ Roads, or other map reference points)
From To Ft. o
From To Ft. oo �
p
14. GROUT:
Dep alteria Metho �m,
From _ _ To Ft. .<
z
t N o
From To Ft. tV �M
�o
15. SCREEN: "L� m�1
Depth Diameter Slot Size Material NM
From To Ft in. in. N hCil
From To Ft. in. in.
From To Ft in In.
16. SAND/GRAVEL PACK:
Depth Size Material I
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 BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Quad No:
Serial No.
SIGNATURE OF P !dSON CONSTRUCTING THE WELL DyfrE
Submit original to Division of Water Quality, Groundwater Section within 30 days
GW1 REV. 12l99

212961
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699.1636-Phone [phone] �E �l LE✓ ��� J�Lku—k Krs
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential a Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL
(Road Name
3. OWNER
of the location below)
County:
or Subdivision and Lot No.) DRIL G LOG
From To
airy or i own State Zip Code t
4. DATE DRILL
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑ NO[]'
7. DOES WELL REPLACE EXISTING WELL? YES a NO[Ef
8. STATIC WATER LEVEL Below Top of Casing: (co FT.
(Use '+' it Above Top of Casing)
9. TOP OF CASING IS l FT. Above Land Surface -
'Top of casing terminated at/or below land surface requires a variance In accor-
dance with 15A NCAC 2C . 18
10. YIELD (gpm): MET OD OF TEST
11. WATER ZONES (depth): `tt�)o
Agricultural ❑ Monitoring ❑
DEPTH
12. CHLORINATION: Type Amount If additional space Is needed use back of form
13. CASING:
Depth D! aret�r
From 0 To g L) Ft. l�
From To Ft.
From To Ft.
14. GROUT:
Wall Thickness LOCATION SKETCH
or el iytlttgrl (Show direction and distance from at least two State
Roads, or other map reference points)
Depths � Ma atrial _. Method
From To
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft in. In.
From To Ft. In. in.
From To Ft. In. In.
16
17
SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To Ft.
REMARKS:
Material
OC=
�
C
=
om
C=m
N
M
—v
�
Mm
tv
r�*i
�1
! i
CJ1rni
C7%
o
�i
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF IS RECORDH/tc$$ BE N PROVIDED TO THE WELL OtDAE
Q
FOR OFFICE USE ONLY
Quad No: SIGNATURE OF ERSON CONST UCTING THE WELL
Submit original to Division of Water Quality, Groundwater Section within 30 days
Serial No. GW-I REV. 12/99

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section 0 1 A
4 J
1636 Mall Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION 0:
o2Z/0 -51
STATE WELL CONSTRUCTION PERMIT#:
sox): Residential [ t]- �Municipai [l Industrial d Agricultural ❑ Monitoring ❑,`
1. WELL USE (check Applicable
Recovery ❑ Heal Pump Water Injection E] Other [] If Other, List Use:
2. WELL LOCAT�N: (Show sketch of the locallon below)
t� rn
Town: ail d; fl County:
Nearest
(Road Name and Numbers, Community, or Subdivision and Lot No.) DRILLING LOG
DEPTH
Forrimallon Description
3. OWNER L�a C'c' Ls D� From To
Address © -
rea or ou e o. , I ? 3
cI
CA
City or Town Stale Zip Code
DATE DRILLED -2 OD
— CO
r—'— r`
4. ti
5. TOTAL DEPTH
_
6. CUTTINGS COLLECTED YES NOL-0—
DOES WELL REPLACE EXISTING WELL? YES n NO[g-
�'
C r] C-3 <:
7.
8. STATIC WATER LEVEL Below Top of Casing: �ap r FT.
; 6o
(Use +' If Above Top of Casing)
�'-
9. TOP OF CASING IS__1, FT. Above Land Surface*
C? �-_�-
'Top of casing terminated atior below land surface requires a variance In accor-
dance with 15A NCAC 2C .0118
METHOD OF TEST ?
10. YIELD (gpm): s?s.
11. WATER ZONES (depth):
12. CHLORINATION:
13. CASING:
Type Amount It additional space is needed use back of form
Wall Thickness
Depth Diameter or We�lgfiV%t. Material
6
165' Ft. 4-125— vn —
From
To
From
To Fl
From
To Ft.
14. GROUT:
Depth M lariat Method
From 1!2_ To _ate --Ft•
From
To Ft.
15. SCREEN:
Depth Diameter Slot SIZE Material
From
To Ft In- In.
From To
From To
16. SAND/GRAVEL PACK:
Depth
From To
From To—
W. REMARKS:
-
I DO HEREBY CERTIFY
CONSTRUCTION STAN
FOR OFFICE USE ONLY
Ouad No:
Serial No.
Ft. In. In. ----
Ft. In. In._�._,—.
M
T THI
i
Y _
LOCATION SKETCH
(Show direction and distance from at least two Slate
Roads, or other map reference points)
(Sci'��j t�TRUCTE} IN ACCORDANCE WITH 15A #CAC 2C, WELL
T! F THIS-RtCORD HAS BEEN PROVIDED TO THE WELL OWNER.
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
original to Division of Water Quality, Groundwater Section within 30 days OW-1 REV. 12/99

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section '2* 14 4 155
1636 Mall Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION 0:
STATE WELL CONSTRUCTION PERMIT#:
1, WELL USE (Check Applicable Box): Residential E9 Munlclpal a Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery R Heat Pump Water Injection F] Other C] If Other, List Use:
2. WELL LOCATf19N: (Shows etch of the location below) 1 �1
Nearest Town: ►4� I ro S + �� P 9—) County: .
DRILLING DEPTH
(Road Name and Numbers, Co unity, or Subdivision and Lot No.) Formation Description
3. OWNER ui� t©YZ �'�✓��c�r yr,>lrc� SfFrom To
Address � /
reo or ou e o.
to le 2
Clly or own Slate Zip Code
4. DATE DRILLED . - l nn
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES []
7. DOES WELL REPLACE EXISTING WELL? YES
8. STATIC WATER LEVEL Below Top of Casing: [��, FT. tit
(Use '+' it Above Top of Casing) t'
9. TOP OF CASING IS FT. Above Land Surface'
*Top or casing terminated atior below land surface requires a variance In accor-
dance with 15A NCAC 2C .0118
10. YIELD (gpm): V• - METHOD OF TEST
11. WATER ZONES (depth):
12. CHLORINATION:
13. CASING:
Type ���%(13�5_ Amount _'I;-- II additional space Is needed use back of form
Wall Thickness
Depth Diameter or Welpll"Fl. Material
From To - _ FL , 1- f EL --
From To Ft.
From To Ft.
14. GROUT:
Depth M terlal Method
From To 02f� Ft.
From To Fl. ----------
15. SCREEN:
Depth Diameter Slot Sizri Material
From To Fl In. In.
From To Ft. In. In. _ - From To Fl. In. In. —
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To FL
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITVI 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
=No:
"" "` v� t A R F wa N CONSTRUCTING THE WELL DATE
'cr uslity, Groundwater Section within 30 days
Gw•1 REV. 12/99

North Carolina • Department of Environment and Natural Resources - Division of Water Quality • Groundwater Section
4412
1636 Mall Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION.RECORD WELL CONTRACTOR: ,P( `J�P3 1
WELL CONTRACTOR CERTIFICATION p:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (check Appiiceble Box): Residential CL----Munlcipal [] Industrial ❑ Agricultural ❑ Monitoring
Recovery ❑ Heat Pump Water Injection ❑ Other [] If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: "� `� ` I County:
EEC, vA n DEPTH
(Road Name and Numbers, Community, or Subdivision and Lot No.) DRILLING LOG
3. OWNER W I� P t� C Ctin Sl2'^ From To Formation Description
Address _
reol or ou a o,
City or Town Stale Zip Code
4. DATE DRILLED -UU
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑ NO[ (�-�
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NOO
8. STATIC WATER LEVEL Below Top of Casing:. FT.
(Use '+' if Above Top of Casing)
TOP OF CASING IS ( FT. Above Land Surface'
9.
-Top of casing terminated at/or below land surface requires a variance In accor-
dance will) 15A NCAC 2C .0118 ,/�
METHOD OF TEST 14 2
10. YIELD (gpm): _112___
11. WATER ZONES (depth):
Its Amount—
It additional; space is needed use'back of form
12. CHLORINATION: Type
13. CASING:
- LOCATION SKETCH
Wall Thickness
Material
(Show direction and distance from at least two State
Depth Diameter or Wetpht/Ft.
® Ft.-L __
Roads, or other map reference points)
From To --�-- -[s��`�-
-
From To Ft.
From To
14. GROUT:
Deplit Material Method
C
�
c�
+
From �_ To �— Ft.
-
-: m
From To Ft.
r
ry
`=R
�`=--
15. SCREEN:
C-9
Depth Diarneter Slot SIZ9 Material
�.
m
From To Ft In. In.
rn
From To Ft. In. In.
Q
cn --
in 56
From To Ft. In. In.
o
`'4
16. SAND/GRAVEL PACK:
CD
Depth Size Material
From To —Ft.
From To Ft.
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Quad No: p=
Serial No.
OF PERSON CONSTRUCTING THE WELL DATE
of Water Qunilty, Groundwater Section within 30 days GW 1 REV. 12I99

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section `
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone] ". 1 4 41 1
WELL CONSTRUCTION RECORD WELLCONTRACTOR: 127dioP
WELL CONTRACTOR CERTIFICATION 0: o2�1D�f
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable sox): Residential Eg' Municipal [] Industrial ❑
Recovery ❑ Heat Pump Water InJectlon [] Other n If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Agricultural ❑ Monitoring d
Nearesl Town: County:
(Road Name and bars, Communit or Subdivision and Lot No.) DRILLING_ LOG DEPTH_
3. OWNER e an From To Formation Description
Address N _
yr P
Code
C y or Tziown Stale p i
4. DATE DRILLED,' -D%-DD
5. TOTAL DEPTH 3DS
6. CUTTINGS COLLECTED YES O NO
7. DOES WELL REPLACE EXISTING WELL? YES [] NO[D-
6. STATIC WATER LEVEL Below Top of Casing: /,,p! FT.
(Use '+' It Above Top of Casing)
9. TOP OF CASING IS�_ FT. Above Land Surface'
'Top of casing lerminatod at/or below land surface requires a variance In accor-
dance with 15A NCAC 2C .0110 n ,
10. YIELD (gpm): t- METHOD OF TEST J
11. WATER ZONES (depth):
12. CHLORINATION
13. CASING:
Type fD ► i cr�>�Amount It additional space Is needed use back of form
Wall Thickness
Depth r Diameter or Wel ht/Ft. Material
FromTo- �-- Ft.-L'
From To Fl.
From To ,Fl.
14. GROUT:
Depth M terial Method
From 0 To -2� Ft.
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 Size
From To Ft•
From To Ft.
17_ REMARKS:
Material
LOCATION SKETCH
(Show direction and distance from at least two Stale
Roads, or other map reference points)
c.�
CD
C^ C�, M
N '=ram
N�
orn
O n
N o
DO HEREBY CERTIFY
NDARDS THIS
AND THAT A COPY OFT H S RECORD HAS B EN PROVIDED TO THE WELL OWNER.
CONSTRUCTION STA _
FOR OFFICE USE ONLY
Ouad No: i
Serial No.
F PERSON CONSTRUCTING THE WELL
Water Quality, Groundwater Section within 30 days
DATE
GW1 REV. 12/99

North Carolina • Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section r) 1
1636 Mall Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION 0:_
STATE WELL CONSTRUCTION PERMIT#:.
1. WELL USE (check Appiiceble Box): Residential d' Municipal d industrial ❑ Agricultural ❑ Monitoring d
Recovery ❑ Heat Pump Water injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: County: CC
(Road Name nd Numbers, Communlly, or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER C %� From To Formation Description
Address
(Slre5l or ou a o.
21 Code 3- � LLL Ls L
City or Town Stale P
4. DATE DRILLED
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑ NO[D--
7. DOES WELL REPLACE EXISTING WELL? YES n NO[�
8. STATIC WATER LEVEL Below Top of Casing: t,�2p_ Fr.
(Use '+' II Above Top of Casing) +f_`
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
10. YIELD (gpm): I METHOD OF TEST il'
11. WATER ZONES (depth): -
12. CHLORINATION: Type i &Vi �r L t e_E Amount ___1__— It additional space Is needed use back of form
13. CASING:
LOCATION SKETCH
Wall Tlilckness
Depth Diameter or Welght/Ft. Material (Show direction and distance from at least two Stale
From -To -4�5'- Ft. - -�,p f-.1 - `— Roads, or other map reference points)
From To Ft.
From To FI. _
14. GROUT:
Depth Material Method
From To Ft. D
From To Ft.
o
='
15. SCREEN:
r"'
n
Depth Diameter Slot Size Material
From To Ft In. In.;
From To Fl. in. In.
57"CDD
From To Ft. In. In.
16. SAND/GRAVEL PACK:
Q
o
Depth Size Material
C3
Mn
C-)
From To Ft.
N
From To Ft.
_o
17. REMARKS:
THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 20, WELL
I DO HEREBY CERTIFY
THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
CONSTRUCTION STANDARDS, AND
FOR OFFICE USE ONLY
Quad No:
Social No.
�( »� �QNikTUME OF PERSON CONSTRUCTING THE WELL
In8ho:-DFvisl�r(of Water Quality, Groundwater Section within 30 days
t roilnd�t�ter Seclion
Ash°Yille Epgioipl Juice
DATE
GW-1 REV. 12/99

North Carolina • Department of Environment and Natural Resources • Division of Water Ouality - Groundwater Section
1636 Ntail Service Center - Raleigh, N.C. 27699.1630-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: okee oe' l
WELL CONTRACTOR CERTIFICATION if:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check applicable Box): Residontial Municipal ❑ Industrial ❑ Agricultural ❑
Monitoring ❑
Rocovery ❑ Heal Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below) 1 /
IFlpnrest Tovrn: __._ _�L��Q4° s Count: Y
—1L('���ce �eL_ wont- �
(iload Name an Nunn; �rs, c.Ionvnunity, or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER t/1h ��/(yb�ry From To Formation Description
Arldr-si
cot or
^III' or Tomi SIAte ZIP Code
. DATE
�L _
5. IUTDEPTH UEPTH
6. CUT -PINGS COLLECTED YES F__ NO0_-
�
7. ODES WFI.L REPLACE EXISTING WELL? YES NO
Cs
S. STATIC WATER LEVEL Below Top of Cnginq: D` FT.
C...
P-Isn'r' If Above Top of CAslrg)
a TOP nF RAcING IS--_.__j..___• FT. Above t.nnd
Z: �
Surface*
'Tor
ez"
of raernp tnrmin�t�rl :,1;nr hnlnw tonal tnrfare rerynire! a vnrinncp In accor• '"""—"
rri
d7r+ce with 15A HCAC 2C .0119
10 YIELD (cirri)* _f-,_-- MFT OP OF TEST -
Ab
- — —ter o
11. WATEFl ZONES ((iepth):
p cn
.. r
n;a
12.. CHLORINATION, Type _� Amount Q .f If additional space Is needed use back of form V o
13. CASING
Walr lhtckricil
Dnoth / r D'ameter pC W i Wt.
From ___ To L FT.
1'toni — To. --.-- FI.
Front To _ Ft.
14. GROUT:
LOCATION SKETCH
nterial (Show direction and distance from at least two Stale
v C Roads, or other map reference points)
U ne?r Z Materlai Method
Front To ' Ft. ZZl
r
Front U _ 1 o /4 _Ft.
15. ^rFlF�t`I:
Del-th Diameter Slot Size Material
I runt io _—_-- FT _ in. in. —
From _--- TO _--_.. __ Ft. In. _ in.
Frorn ____,__• To Ff.In. In.
15. SAND/GFlAVEL TACK:
iz Material
Front o,__--- F
1.
17. HEMAf1K _ JUN-2 .4-2000_.._. _..._..._ ._ __.
I rn HrRF' Y r IFY E 1 Fi13 WF(,. AR PONSTRIJOTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
r'01'JR I RI I TION S I @fV(PVa laktOM IAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
Asheville ionalOffice—Ij
-r-oR orrlr,E usF oftl_Y . _._
011 u1 Nei, 1 ATIME F r:n . N CONsinuCTItiG THE WELL DATE
4rr!'11 i1 ortulnal to Ur WAlpr nuality, Groundwater SarNrrin within 30 days
^) i1! fir. �-Q GW1 REV. 12/99

212959
North Carolina - Department of Environment and Natural Resources - Division of Water Quality • Groundwater Section
1636 Mail Service Center • Raleigh, N.C. 27699-1636-Phone [phone]�E`lWELL CONSTRUCTION RECORD WELL CONTRACTOR: W\—LkW 'S [OAl�71E t s
WELL CONTRACTOR CERTIFICATION #: �J
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATI : (Show ske f the location below)
Nearest T wn, County:
(Road Nam d Numbers, C nity or Subdivision and Lot No.) DRIL ING LOG DEPTH
3. OWNER From To Formation De cription
Address _
(Street or F13�r
City or To State Zip Code,
4. DATE DRIL D Db �55
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑ NO�
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
8. STATIC WATER LEVEL Below Top of Casing: QD 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 1a
10. YIELD (gpm): METHHOD O,F TEST
11. WATER ZONES (depth): ON
12. CHLORINATION: Type FIT
—_Amount
If additional space is needed use back of form
13. CASING:
LOCATION SKETCH
Deptt}
Wall Thickness
ia�et4i o i t/,t a ed I
�{
(Show direction and distance from at least two State
From To �t� Ft.
Roads, or other map reference points)
From To Ft.
—
From To Ft.
o
z
14. GROUT:
o�
Depth
acre 141 . Method
From To �� Ft.
N
o m
From To Ft.
nn
15. SCREEN:
�o
Depth Diameter Slot Size Material
N
c„:z
From To Ft
in.
in.
crt Ci
From To Ft.
in.
in.
�,
.y
�j��t�� t» C,
From To Ft.
in,
in.
16. SAND/GRAVEL PACK:
Depth
Size
Material
9 r !
�°4�_tR ti
',t 9(ii
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 OFt THISPECOR2t!AS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Quad No: SIG'
Submit original to
Serial No.
PERSON CONSTRUCTING THE WELL DATE r
of Water Quality, Groundwater Section within 30 days
GW1 REV. 12/99

212958
North Carolina - Department of Environment and Natural Resources - Division of Water Ouality - Groundwater Section \
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELLCONTRACTOR:
WELL CONTRACTOR CERTIFICATION #: �J
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (check Applicable sox): Residential Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2.
WELL LOCATIO Show ske'tc the location below)
Nearest Town: County:
—
(Road Na and Numbers, Commu or S bdivlsion and Lot No.)
DR ING LOG
3.
OWNER
From To
Address
�a
treet or u o. D
—
-,
`( ,
City or Tow Stale Zip Co de
^ / —
4.
DATE DRIL
a '-
5.
TOTAL DEPTH-
6.
CUTTINGS COLLECTED YES Q NO[+r
—
7.
DOES WELL REPLACE EXISTING WELL? YES ❑ NO[a
WE —
8.
STATIC WATER LEVEL Below Top of Casing: Go FT.
—
(Use '+' it Above Top of Casing)
-
9.
TOP OF CASING ISFT. Above Land Surface-
-Top of casing terminated at/or below land surface requires a variance In accor-
dance with 15A NCAC 2C t011 18 n', n
—
10.
YIELD (gpm): METHOD OF TEST
11. WATER ZONES (depth):
12. CHLORINATION: Type _
—Amount
13. CASING:
Wall Thickness
b
DTooth (
D'ar,�et
W i hV�Ff. at rial
From
From
To
Ft.
From
To
Ft.
14. GROUT:
Depth
M t rial I i od
From D
To (OL
Ft.
From
To
Ft. t
15. SCREEN:
Depth
From
To
From
To
From
To
16. SAND/GRAVEL PACK:
Depth
From
To —.
From
To _
17. REMARKS:
Diameter Slot Size Material
Ft in. In.
Ft. In. in.
Ft. in. In.
Size Material
— Ft.
— Ft.
DEPTH
If additional space is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least two State
Bads, or other map reference points)
O to
��
r J AtC
0
9
btu *-Oq (A
C-m
N <
N A n
� mo
Any
N M.;Q
)
on
LF
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC-, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RE ORD HAS BEEN PROVIDED TO TH WELL OW R.
FOR OFFICE USE ONLY
Quad No: SIG ATURE 0 .. RSON CONSTRUCTING THE WELL DATE
Submit original to Divisionater Quality, Groundwater Section within 30 days
Serial No. GW-1 REV. 12/99

212957
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] � � aL � LL
WELL CONSTRUCTION RECORD WELLCONTRACTOR:
WELL CONTRACTOR CERTIFICATION #: �J
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 I
Nearest
(Road N
3. OWNER
Address
of the location below)
County:
or Subdivision and Lot No.) DR NG LOG DEPTH
City or Town State up t;oae
4. DATE DRILLED 0`� 00
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑ NOED'
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO[f
8. STATIC WATER LEVEL Below Top of Casing: p _ 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 01 8
10. YIELD (gpm): �51 METHOD OF TEST 0.
11. WATER ZONES (depth):
12. CHLORINATION: Type Amount
13. CASING:
Wall Thickness
Depth I e er or ei ht/Ft. , atorrial
From b To �� Ft. ��`�( ` (v-1y=_'—
From To Ft.
From To Ft.
14. GROUT:
Depth M terial Method
From To (CO Ft.
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft in. in.
From To Ft. in.
From To Ft. in.
16. SAND/GRAVEL PACK:
From
From
17. REMARKS:
From To Form tio Des pt Lk Ma
a
C—
C=
N1
a"
r=rt
-•—C')
C�7
c.
Cn
b
If additional space is needed use back of form
(Show direction and distance from at
Roads, or other map reference F
In.
Depth Size Material,
To Ft.
To Ft.
State
4/
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 PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY���J
Quad No: SIGNATUR O ERSON CONSTRUCTING THE WELL 0 TE
Submit original to Division of Water Quality, Groundwater Section Within 30 days
GW1 REV. 12/99
Serial No.
19

212956
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] u aL, ��( (-L I
WELL CONSTRUCTION RECORD WELL CONTRACTOR: Wk- kW S`I V. �5 ` 1
WELL CONTRACTOR CERTIFICATION #: ?J
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATI : (Show sk,.4 of the location below)
Nearest T 01 NCounty:
(Road Na d Num er Communi , or Su vision and Lot No.)
D LING LOG DEPTH
3. OWNER
From To Forma on D scription
Address�
eel or outs o
r �
City or Town State Zip Code
—
4. DATE DRILLE
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑ NO[E'
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NOF71
8. STATIC WATER LEVEL Below Top of Casing: t) 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 . 18
a-
10. YIELD (gpm): METHOD OF TEST
11. WATER ZONES (depth):
5r'o0
12. CHLORINATION: Type —Amount
If additional space is needed use back of form
13. CASING:
Wall Thickness
DepthlI
lir�e(er Wgiq/FI.atgttal
FromTo Ft.
From To Ft.
From To Ft. —
14. GROUT:
Dept? _ M terial i Method
From Ti Ft.
0 AM
From To Ft. t
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft in. in.
From To Ft. in. In. 41
From To Ft. in. in.
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft. 1
17. REMARKS
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points) 0
C'3
C_
C
2
(V
ry
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 PROVIDED TO THE WELL O
FOR OFFICE USE ONLY
Quad No: I SIGNATURE RSON CONSTRUCTING THE WELL
Submit original to Division of Water Ouaiily, Groundwater Section within 30 days
Serial No.
N
tli
�J
DA
0
fl
�rn
on
4M
Q.<
Ao
M
;Ol co
M
cn x
rn�
c�
0
z
GW-1 REV. 12/99

Norin L:arolina - Uepartmcnt of tnvironmenI ana :r Alu,s! flu
1636 Mail Service Center -Raleigh, N.C. 27699-1636•Phone [phone]
J
WELL CONSTRUCTION RECORD WELL CONTRACTOR: I I n I�
WELL CONTRACTOR CERTIFICATION #: 12ell0 U
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (check Appticabte sox): Residential ®Municipal ❑ Industrial ❑ Agricultural Monitoring ❑
Pecovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: J.k-'>CAC0 'P County:
0 �1 d
(Road.Njme and Numbers. Co unity, or Su division and Lot No.) DRILLING LOG
3. OWNER S From To ,F`8rmaxn Description.A
Address �
-(Street or Houle o.
City or Town State Zip Code
4. DATE DRILLED Lj JQ -'rP
5. TOTAL DEPTH I `SL5 `
6. CUTTINGS COLLECTED YES F—] NO[
7. DOES WELL REPLACE EXISTING WELL? YES [] NO D—
B. STATIC WATER LEVEL Below Top of Casing: _ C> • 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): _6__ METHOD OF TEST /fr ✓�
11. WATER ZONES (depth):
12. CHLORINATION: Type �4h IQLME :s Amount If additional space is needed use back of farm
13. CASING:
LOCATION SK=TCH
Wall Thickness
Depth Diameter or Weight/Ft. Material (Show direction and distance it= al le=,mo S'.ate
FromJo� Ft. -61 - -0IZC_— Roads, or other trrcp refererry points!
From To Ft.
From To Ft.
14. GROUT:
Depth Mat 'al Method
From �— To -�L Ft.
From To Ft. CD
0
15. SCREEN:
Depth Diameter Slot Size Material (Der )
From To Ft in. In. N c5 1
From To Ft. in. In. 01 cri
From To Ft. In.
In. m
16. SAND/GRAVEL PACK: o u1z
Depth Size Material
o
From To Ft. — N o
From To Ft.
17. REMARKS:
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH t;A 04CAC 2C. vrELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVICED 'JO THE Yl tl OtN'%EI%,
4L
FOR OFFICE USE ONLY Os-.TE
Quad No: _. A;W F PERSON CONSTRLY.TING Tkc' WELL
j 0su t�rig)U t ' f Water Quality. Groundwater Seen within Y3 d%Yg tn.t V, 1291
Serial No. u j�j
11 1 Ju ` '110
�rn:t

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.v.t�ttt cv_P'sWG. Iblct-
WELL CONSTRUCTION RECORD WELL CONTRACTOR: VON4E .JIU W�1I -
WELL CONTRACTOR CERTIFICATION #: 01tfl(0
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (check Applicable sox): Residential Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (\Show sketkhrpf the location below)
Neare t Tpwn: County:
(R am nd Numbers, Cc ni , or Subdivision and Lot No.) ILING LOG DEPTH
3. OWNER From To Formation Description
Address
(birecK or Aquip pip.)
City or To State Zip Code
4. DATE DRIL 1's o
5. TOTAL DEPTH— ^-
6. CUTTINGS COLLECTED YES ❑ NO[f
7. DOES WELL REPLACE EXISTING WELL? YES ❑ N0EJ tam
8. STATIC WATER LEVEL Below Top of Casing: 5,LD, FT. CJ1
(Use '+' if Above Top of Casing) Mg
9. TOP OF CASING IS FT. Above Land Surface* ;
'Top of casing terminated atfor below land surface requires a variance In accor- r =;
dance with 15A NCAC 2C .0119 "r
10. YIELD (gpm): 20 METHOD OF TEST Q o
0
11. WATER ZONES (depth):
12. CHLORINATION: Type T Amount If additional space is needed use back of form
13. CASING:
Wall Thickness
Depth Dtarnler
� Y.
oC�Wetght/Ft —Mato
Q'
From
To Ft.
s� -`a -S-
From
To Ft.
From
To Ft.
14. GROUT:
Depth M to
al Method
From C) To Ft.
From
To Ft.
`
15. SCREEN:
Depth Diameter Slot Size Material
From
To Ft In.
in.
From
To Ft. in.
In.
From
To Ft, in.
in.
16. SAND/GRAVEL PACK:
Depth Size
Material
From
To Ft.
From
To Ft.
17. REMARKS:
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONXRYCTED IN
CONSTRUCTION STANDARDS, AND THAT(A COP/9FTHIS RECC
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
FOR OFFICE USE ONLY
Quad No: I G SIGNATURE,# PERSON CC
Submit original to Divislo of Water Quality,
Sedal No.
TO THE WELL OWNE
1
MAY I (20 00 X
WELL ATE
P within-8G.day
Groundwater SeCtiottc;w.t REVI 12/99

North Carolina . Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section l
1636 Mail Service Center - Raleigh; N.C. 27699-1636-Phone [phone] TLC t��2l�s �"SNG .Iblct,
WELL CONSTRUCTION RECORD WELL CONTRACTOR: WFl l-- IUL1-1 NV�
WELL CONTRACTOR CERTIFICATION #: AV9(I
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: JSIhow sk c of the location below)
Nearest Town County:
(Road (dame d tiers, om ity, r ubd ision and Lot No.) D(�ING LOG DEPTH
3. OWNER From To Formation Description
Address FV
ree ou
City or To State Zip Code
4. DATE DRIL D
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES Q NO�—
7. DOES WELL REPLACE EXISTING WELL? YES Q NO� r" 7-7 L­
8. STATIC WATER LEVEL Below Top of Casing: ")_ FT. -
(Use '+' it Above Top of Casing)
9. TOP OF CASING ISFT. Above Land Surface'
'Top of casing terminated at/or below land surface requires a variance in accor- "' M.
dance with 15A NCAC 2C .0118 CD 4
10. YIELD (gpm): 00 METHOD OF TEST a) rt7--E3
11. WATER ZONES (depth):
12. CHLORINATION: Type 7C Amount If additional space is needed use back of form
13. CASING:
LOCATION SKETCH
Wall Thickness
Depth D/�17% r M t atgd I (Show direction and distance from at least two State
From To ` 2 Ft. _ tom— ""' (Oy� Roads, or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth M t ria Method
From To �a 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. rn fa
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED CCOR CE It 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY HIS C RD BEEN IDD,''(O �HE ���8 0
FOR OFFICE USE ONLY
Quad No: SIGNA RE OF RSON CONSTR CTING TH1tWEELrb�"ater Section DA E
!! r! n ,�
Submit Mginal to 0 ision of water Quality, Groundwater Se�t�b)S W�f}li7i i 1k
GW1 REV. t2/99
Serial No.

WELL CONSTRUCTION RECORD WELL CONTRACTOR: IM1161Z IOLII
WELL CONTRACTOR CERTIFICATION N:
STATE WELL CONSTRUCTION PERMITH:
1. WELL USE (Check Applicable sox): Residential Municipal ❑ Industrial ❑ Agricultural D Monitoring ❑
Recovery ❑ Heat Pump Water injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATI N: (Show ske}ch of the location below)
Nearest Town: `+ P SV' I 1 County: C 10
(Road Name and Numbers, Community. or Subdivision nd L I ) DRILLING LOG DEPTH
3. OWNER �l`vl From To Forrraxn Des=riPGo-
Address j _ n
(street or o o. —
City or Town tale Zip Code
4. DATE DRILLED' a�-
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑ NO❑
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO��'
S. STATIC WATER LEVEL Below Top of Casing: UD FT.
(Use '+' it 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): 6 METHOD OF TEST AV
11. WATER ZONES (depth):
12. CHLORINATION: Type Amount
—
13. CASING:
Wail Thickness
Depth r Diameter or Weight/Ft. Material
From To Ft. 6 1,2 8-- --
From-- To -16 Ft. 6—
From To Ft.
14. GROUT:
Depth Ma vial
r
From _1_r2__ To _,;�2 Ft.
From To —Ft. '
15. SCREEN: '
Depth Diameter Slot Size
From —To—Ft— In.
Method
Material
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
If additional space is needed Ls,-- back of fcrm
LOCATION SK=TCH
(Show direction and d'sftance ir-m ZI leas trro S ate
Roads,.or other rra refere:r-A, points!
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDAPICE WITH tk.A pJCAC 2-.,'/✓ELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROViCED 10 THE Yl 1 Cm,%EP,
FOR OFFICE USE ONLY
Cued No:
SIGNATURE OF PERSON CONSTRLnTING 1)t yv'ELL
V-'b—,W1V ==Water puality. GroundMater Sra_cn within :0 C ✓ Y3
Serial No.� L 0 L5 b U i5
10,
1 I'
OA.'E
0
0
c_
C
(V
Ln
0
0
iV
�i
C„• 1 F c V. 11"

Notch Cnrolina - Depnrtmenl of Fnvironnrenl, I leallh, and Nalutal Ilnsourco,
Division of Environmenlal Managnmont . Groundwator Soclion
P.O. Box 29.935 - Raleigh, N.C. 27626-0535
Phone [phone]
FOIL OFFICE USE Of II yl
OUAD. NO.SEMALNq_ . 4
444
1-11. --- —Long. --- no
Minor rlasin
WELL CONSTRUCTION RECORD Mash Code
DRILLING CO14TRACTOR: , /,� �� ��� g Ileader Ent. GW-I Ent.
- STATE WELI_ CONSTRUCTION
DRILLER REGISTRATION NUMBER: PERMIT NUMBER:
1. WELL LOCATION: (Show sketch of file location below)
Nearest Town: 'VIf S V� t' —. Counly: I
�—
(flonrl, Communily, or Subdivision and I_ol No.) DEPTI I DRILLING LOG
2. OWNER -- -- —----------_—_-- Frorn — To Formalion oesrription
r
(street or noulo No)
Cily or rowan Stale Zip Codo
3. DATE Dt1ll_LED _3_ 9 - Da- USE OF WILL A�/kvo �__—
^. TOTAL DEr-TI-I - a�S -- _
5. CUTTI(JGS COLLECTED YES [ I NO[:O--
6. DOES WELL REPLACE EXIST ING WELL? YES NO
7. STATIC WATER LEVEL Below Top of Casing: 3�_� FT.
(Use, "r" it Above Top of Casing)
8. TOP OF CASING IS _l_ FT. Above Land Surface"
' Casing Terndnaled atlor below land surface Is Illegal unless a vnrinrice Is Issued
In necordanca with 1SA NCAC 2C .0110
9. YIELD (gpm):_?C? r METHOD OF -TES r
10. WATER ZONES (depth):
11. CHLORINATION: -type ,�ll1m,keks Amount —
12. CASING:
Wall 1 hirkness
Depth Dianu+ler or Weighl/R. Malerial
From. To e/, `Z r'L .a-,-.��_
rrom — To. —
From __ To Ft. --- --.-- -
13. GRour:
Depth r Material Method
From _�_ To _ice Ff.From -- To rl. — _ —
14. SCREEN:
Depth Diameter Slot Size Material
From To rt in. in. From To Ft. _— in. —__ In.
Frorn-
15. SAND/ VS %C�: Q d�
ep l i Material
FrolTl 09 _
From O Ft.
16. REMA <S: „__.:,.., _-_-
LOCATION SI<ETC1-1
(Show direction and distance from at least two Stale
Roads, or other map reference points)
M
� G
rT
DO c�=r
s�
ci
fTl
m
O -n-1
c.� o
i DO I1E1y-nY CETY- TI IAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO T1IE WELL OWNER.
s1r.,rinrt.mr Or CONrnnCTOn On AGr_mr DAFE

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwaiee Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
i 411
WELL CONSTRUCTION RECORD WELL CONTRACTOR: 'Lli I I ELL w el 1 orf lk vies
WELL CONTRACTOR CERTIFICATION #: ,` qD Q
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (check Applicable Box): Residential LEI Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Aecovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCAT19V: (Shovy sketch of the location below)
Nearest Town: bf-'Lr SS 01On County: —_I41
l7 f'EEJI LQ12 ; eJ,
(Road Name( nd Numbers, Community, or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER f10l� V1 -iC`•lh P_<- From To FomaxnDes:riptio,
Address ('� - / ` Cla I
(Street or Route o. %U
City or Town State Zip Code y`�
4. DATE DRILLED , -X7- 0
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑ NOQ--
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NOED—
8. STATIC WATER LEVEL Below Top of Casing: c;�2 ' 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): __LL_ METHOD OF TEST,
i
11. WATER ZONES (depth):
12. CHLORINATION: Type Amount
If additional s;ace is neeM tzs•e back of fce-m
13. CASING:
LOCATION SK=TCH
Wall Thickness
Depth Diameter or Wefght/Ft. Material
(Show direction and dis ante fr-n ai leas.:'rro State
From To Ft. 6, 2< - -10IX. _
Roads, or ot.w r..--? reference points!
From To Ft.
From To Ft.
14. GROUT:
Depth Mat dial Method
From _n To �1L Ft.
CD
From To Ft.
o
O
Q
15. SCREEN:
�--�
Depth Diameter Slot Size Material
cC)
From To Ft in. in.
From To Ft. in. In.
-n
From To Ft. In. In.
�[
M o
16. SAND/GRAVEL PACK:
o
ni �3
Depth Size Material
Cp
y
From To Ft.
•
N
o
z
From To Ft.
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDMICE WITH ISA DJCAC 2'.;, VfELL
CONSTRUCTION STANDARDS, AND THAT AC Y OF THIS RECORD HAS BEEN PROVICED -TOTHE 71S: t- O%+''EF•,
FOR OFFICE USE ONLY
Quad No: TA Sir'N#UhI OF PERSON CONSTRIY.'TING 1>t,nr'ELL Os.'E
' _ _- 8>J •orfg Nlon of Water Ovality, Gmyrvb«ater Srcn within Vi C�ys
a
Serial No. N
IiJ

North Carolina - Ueparlment of Envirommnnl, Ilealth, and Nalural flnsourco,
Division of Environmental Manahamenl . Groundwater Sortion
P.O. Cox 29 535 - Raleigh, N.C. 27626.0535
Phone [phone]
f on orricr IJ - Ot 11.Y
oUAD. No. --- _—_-- SEftIAL No.� 4 445
Long. _ no _
Minor Ba.^.In
WELL CONSTRUCTION RECORD Gash Code
DRILLING CONTRACTOR: I��--'L�--Ur1—n Ileader Ent. GPJ•I Ent
STATE WELL CONSTRUCTION
DRILLER REGISTRATION NUMBER: PERMIT NUMBER:
1. WELL LOCATION: (Show skelch of the location below)
(Iload, Communily, or Sub IIVIC110 and Lot No.) DEPTH DRILLIf-IG LOG
2. OWNER — ��� 5.—_ _--_—_-__ From to rorrnatiorr Desr-riplion
--------------------- _—Cam._-=--��Z------ � ' ------
(^beet or nouto No.) r --� —
-
Cily or town Slato lip Corlo �--- ---
3. DATE DRII_I_EDOb
-- USE 01= WI=1_l_
4. 101-AI_ DEPTI I------
5. CUTTINGS COLLECTED Yr_s U) NOJ_ � --- -----
6. DOES WELL REPLACE EXISTING WELL? YES [::] NO-
7. STATIC WATER LEVEL Below Top of Casing: 56 '_ FT.
(Use "C it Above Top of Casing) !
S. TOP OF CASING IS _�__— rT. Above Land Surface' nt
Casinq Terminnled nUor below land surface Is Illegal unless a vnrlarice Is Issur_d — l -
In nccordance with 15A NCAC 2C .01111
9. YIELD (gpm):__,2D METI IOD OF TES I- Ai
10. WATER ZONES (depth): --- __----
1 1. CHLORINATION: Type t 1e-65 Amount If additional space is needed use bark of form
12. CASING: ----- — -------
Depth Dianreler
From._ To _2�L'--
Front To — FL------
rrorn _. To ---- Fl. ----
13. GROU r:
Depth
From d To __?Q ' FI
From _ To _ rl
14. scREEN:
Depth
From --To
From To
From ---To —.._-
15. SAND/GRAVEL PACK:
Depth
From To —
From To _
16. REMARKS:
Wall I hirLnoss LOCA'I ION -SK-ETCI 1
or Weight/Ft. Malarial (Show direction and distance from at (past Iwo Slate
roads, or other map reference points)
Material Method
�1� d. - --
Diameter Slot Size Material
rt in. -- In. —.
i DO I IEnFPY CEn virY II`IAT V IIS
CONSTRUCTION STANARDS, AN
WAS CONSRUC ED IN ACCORDANCE WITH 15A NCAC 2C, WELL
Fi C4 fi?t Or TI II RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
SIGIJATURE or coNI TIACron oR AGENT DATE
_. . .. . . .. — . . I n. . .... .....A 0. .. .. 1 ..........

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
163E Mail Service Center -Raleigh, N.C. 27699-1636-Phone [phone] 2.
WELL CONSTRUCTION RECORD WELL CONTRACTOR: 0 ; 11 e t -) e I 1 sir_-`1I f'`7G
'WELL CONTRACTOR CERTIFICATION #: 2 yvq J
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential [E--- Municipal ❑ Industrial ❑ Agricultural El Monitoring ❑
Recovery ❑ Heat Pump Water Injection 0 Other n If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: P 14T �' S !� j e County: �Gl/
aAnr P LJc
(Road Name d Numbers, Community, or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER _ Q_ 4227e V From To /?Fonra5cn Dds ripGo-
Address
Creel or Houte No.)�/�
City or Town State Zip Code G` © '
4. DATE DRILLED - e) -M
5. TOTAL DEPTH 34S
6. CUTTINGS COLLECTED YES ❑ NO©r
7. DOES WELL REPLACE EXISTING WELL? YES[-] NO[�--
S. STATIC WATER LEVEL Below Top of Casing: / O D FT.
(Use '+' if Above Top of Casing) }; ' ? i -
9. TOP OF CASING ISM_ FT. Above Land Surface* � s
`rf
'Top of casing terminated at/or below land surface requires a variance In accor-
dance with 15A NCAC 2C.0118 ; i"
10. YIELD (gpm): �_ METHOD OF TEST Ae �+
11. WATER ZONES (depth):
12. CHLORINATION: Type Amount
—
13. CASING:
Wall Thickness
Depth n Diameter f/ or Weight/Ft.
From —Q—To Ft. 61 ­2­5_ 50rd-/
From To Ft.
From To Ft.
14. GROUT:
If additional space is needed L-s-_ back of foe-m
LOCATION SKETCH
Material (Show direction and dis--lance fr= a1 leas::rro Snate
/ Roads, or other rrcp refere:r-e points`
Depth
Ma anal Method
From To
Ft.
From To
Ft.
C3
o
-�
15. SCREEN:
Depth Diameter Slot Size
Material
r-'
M
:m
From To Ft
in.
in.
N
U7
-4= M
From To Ft.
In.
In.rn
y,
From To Ft.
In.
In.
=�
� m
16. SAND/GRAVEL PACK:
O
Depth
Size
Material
o
C-) �
-+
N
o
From To
Ft.
z
From To
Ft.
17. REMARKS:
]DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 195A r4CAC 2'.:.'/IELL
CONSTRUC71 ' NEST RD '-AND­TTHAT,,A, Y OF THIS RECORD HAS BEEN PROVICED 'TO THc VIE'rl OI��EF..
.IPi- - �"`1P IF ifs v; fa 1
FOR OFFICE �11� PNL
0vad No: a
8ddal No.
SIGNATURE OF PERSON CONSTRLI :--TING Dt vVELL 04.'E
al to Div(alon of Water Quality. Gmnb.-aler Src:cn ►within'3j crys
C. ,- c v. I_9t

North Carolina - Department of Environment and Natural Resources - Division of Water Ouaiity - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
T�4 aM�12PtzasES,znIG . `�'b�cc,
WELL CONSTRUCTION RECORD WELLCONTRACTOR:
WELL CONTRACTOR CERTIFICATION #:___ At9c,
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATIO . (Show ske I of the location below)
Near%11est w . County:
( -&2v-
ad N end umb s, murn , or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER From To Formation Description
Address �`'1
street or ou
Cl
City or Tow State zip Code C�5' r3
4. DATE DRILL �`� 0b
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑ NOL
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO ff
8. STATIC WATER LEVEL Below Top of Casing: p` FT,
(Use '+' if Above Top of Casing)
9. TOP OF CASING IS — cn
FT. Above Land Surface* ,.
'Top of casing terminated at/or below land surface requires a variance In accor- 8
dance with 15A NCAC 2C.9118 ca
10. YIELD (gpm): METHOD OF TEST
11. WATER ZONES (depth):
12. CHLORINATION: Type Amount It additional space is needed use back of form
13. CASING:
Wail Thickness
Depth 11 QQ �cll
From To _�_9 d_ Ft.
From To Ft.
From To Ft.
14. GROUT:
O Dept t( �� �eri Ad
From To ` Ft.
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft in. In.
From To Ft. In. in.
From To Ft. In, In.
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
17. REMARKS:
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCT D IN ACCOR
CONSTRUCTION STANDARDS, AND THAT A COPY OF ECO AE
FOR OFFICE USE ONLY
Quad No: 5GNATURF PER t7N
�! Submit origi al to Division of Water Quality,
Serial No. — . a
n �l'
Itl 5A NCAC 2C, WELL i
ED JJyJE WE_ WN �1
IC ING r.6L TE
wa of S@ctlOnS t 1fH 1" OC 1011
A ""WiGW1 REV. 12/99

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699.1636-Phone [phone]
Tu4 eqf112.P21S��Ib�ct-
WELL CONSTRUCTION RECORD WELL CONTRACTOR: 1k(�4E�J�U E WELI, Q�LI t
WELL CONTRACTOR CERTIFICATION #: a�Iio
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCA
Nearest Town:
(Road N
3. OWNER
Address
)f the location below)
County:
or Subdivision and Lot No.) ILING LOG DEPTH
JI1 Nv , , __ _ _ From To Formation Description
fleet Or Ro I N
City or To State Zip Code
4. DATE DRILL D �b
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑ NO[ ►�
7. DOES WELL REPLACE EXISTING WELL? YES ❑ N0OD-
8. STATIC WATER LEVEL Below Top of Casing: L.� 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 .0 Ili'
10. YIELD (gpm): METHOD OF TEST
11. WATER ZONES (depth):
12. CHLORINATION: Type Amount If additional space is needed use back of form
13. CASING:
Wall Thickness
From DToth q, Ft la e�tRr Wei �latgr�at
From To �� Ft. ,I {'V�•
From To Ft.
14. GROUT:
Depth M t HaM Method
From b To M_ Ft.
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft in. in.
From To T— 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 CERTI�tt T I A O(S>j IN
CONSTRUCTION STA A A'CCSPl' O RECC
FOR OFFICE USEONVU1 MAY I i.
Quad No:
Serial No. ,,MtiroW'alel MIC
Rshevlii' Pe,,Jnnal
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
G�
V\- i 64
CD CE WITH 1 NCAC 2C, WELL
HAS EN D TO THE WELL OWNER.
l P � rid
SON O RUCTING THE WELL DA E
Quality, Groundwater Section within 30 days
GW1 REV. 12/99

North Carolina - Department of Environment, Health, and Natural Resources
Division of Environmental Management - Groundwater Section
P.O. Box 29535 - Raleigh, N.C. 27626-0535
Phone [phone]
FOR OFFICE USE ONLY 7 h
QUAD. NO. � SERIAL NO. 1'08 7 U 2
Lat
WELL CONSTRUCTION Long RO
Minor B
RECORD asin
RILLING CONTRACTOR: Basin Code-----
,o�01. tLLE ��L� �, Header Ent
DR1111LLER REGISTRATION NUMBER: STATE WELL CONSTRUCTION
��Cv PERMIT NUMBER:
(Street or Route No.)
3. DATE DRILLE� E
zip Code
4. TOTAL DEPTH USE OF WELYESL
NGS R
6. DO SIWELL REPLACEDEXISTINGEDWELN�`_'
7. STATIC WATER LEVEL Below -Top of Casing:E� FT.
8. TOP OF CASING IS (Use "+' if Above Top of Casing)
FT. bove Land Surface
Casing Terminated at/or below land surface is Illegal unless a variance*
fis Issued
In accordance with 15A NCAC 2C .0118
9. YIELD (gpm):�_ METHOD OF TEST 6 -1-
1 0• WATER ZONES (depth):-.
11. CHLORINATION; Type 1 `-
12. CASING: Amount ________
Depth Wall Thickness
From TO -.�_ Ft. D'tpr Wv t. ate 'al
From- To--
From Ft.
13. GROUT: ---_ _
Depth a eria
From __Q__ To Ft. Ft C Method
From To Ft.
14. SCREEN:
Depth Diameter Slot Size
From To— Ft — Material
'n — in.
From
— To — Ft —
From _ To. in. in.
Ft
15. SAND/GRAVEL PACK: in. -- in. ------
Depth Size Material
From To
-_ Ft.
From To.
16. REMARKS: —'------
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCT
CONSTRUCTION STANDARDS, AND THAT A COPY OF THI
I I
'N•1 REV, 9/91 � SIGNATURE OF S
Submit original too
GW-1 Ent
DRILLING LOG
Formation Description
d
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)
ACCORD NG WITH 15A NCAC 2C, WELL
RD HA BEE P OVIDED TO THE WELL OWNER.
n =5
�1,1 vH OR AGENT

North Carolina • Department of Environment, Health, and Natural Resources
Division of Environmental Management - Groundwater Section FOR OFFICE USE ONLY V Q 1'j
P.O. Box 29535 -Raleigh, N.C. 27626.0535 F v VV II
Phone [phone] SERIAL NO.
WELL Long. RO
CONSTRUCTION RECORD Minor Basin
RILLING CONTRACTOR: +�-� Basin Code______
io�0.. �`�-�J•Itl.lE. ���.-i� Header Ent._.______.
DR LLER REGISTRATION NUMBER: STATE WELL CONSTRUCTION
�q�o PERMIT NUMBER:
I. WELL LOCATI (Show sketc the location below)
Nearest
County:
(Road, Co ity, or Suboivi ion of No.)
2. OWNER EPTH
ADDRESS From To
n (Street or Route i
City or Ton State —IU
3. DATE DRILLED La C)o Zip Cod
4. TOTAL DEPTH USE OF WELL
5. CUTTINGS COLLECTED YES[] NOEE'
6. DOES WELL REPLACE EXISTING WELL? YES r�
7. STATIC WATER LEVEL Below -Top of Casing: FT u
8. TOP OF CASING IS (Use'+' if Above Top of Casing)
• Casing TerFr. Above Land Surface
minated at/or below land surface is Illegal unless a v
In accordance with 1 A NCAC 2C .0118 ariance Is Issued
9. YIELD (gpm):METHOD OF TEST &O.
10. WATER ZONES (depth):
11. CHLORINATION: Type
12. CASING: Amount
Depth Wall Thickness
From To DiaVetgf or Wei Ft,jheri
Ft. 4
From- To ___-_-- Ft._
From ---- To Ft.
13. GROUT:
Depth 4erial4 Method From ._.Q__ To Ft.
From To Ft. _�
14. SCREEN: --------
Depth Diameter Slot Size Material
From To Ft in.
From — To In.
Ft. — in. in.
From — To _Ft _
5. SAND/GRAVEL PACK: in. in.
Depth Size Material
From To Ft.
From To Ft.
3. REMARKS:
HEREBYjCEATOYTHAT THIS WELL WAS CONST
5a1`RUCTI6N STANDARDS,`AND THAT A COPY OF
/ 1 RE i. 9/91
SIGNATURE OF
Submit original to
GW-1 Ent.
DRILLING LOG
Formation Description
o
©
O
0
--Y
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)
ACCORD E WITH 15A NCAC 2C, WELL
RD H BE P OVIDED TO THE WELL OWNER,
ACTOR OR AGENT
of Environmental Management and cars t ,..emu Al

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
Phone [phone] rLat
AD. NO. SERIAL NO. IC O H % U e
Long.RO
WELL CONSTRUCT n B '
ION RECORD r as
RILLING CONTRACTOR: �IAO > Basin Cole•__________
ELER
u E11�SE1L�j(2Il l.l�yT ��' Header Ent_-----D REGISTRATION NUMBER: r� STATE WELL CONSTRUCTION
a 09 PERMIT NUMBER:
1. WELL L CATI : (Show Sket of the location below)
t To
County:
(Road, Com nity, r Subdivisio Lot N )
2. OWNER DEPTH
ADDRESS t From To
tweet or Rou a No.)
City o To n State
3. DATE DRIL D Z �'1 pp Zip code
4. TOTAL DEPTH 51 ' USE OF WELL
5. CUTTINGS COLLECTED YES 0 NO
6. DOES WELL REPLACE EXISTING WELL?
YES NO
7. STATIC WATER LEVEL Below -Top of Casing: Q
8. TOP OF CASING IS ' (Use "+' it Above Top of Casing)
FT. Above Land Surface*
Casing Terminated atior below la ace is Illegal unless a variance is Issued
In accordance With 144 NCAC 2C .011e
9. YIELD (gPm):__-g--_ METHOD OF TEST _
10. WATER ZONES (depth): —
11. CHLORINATION: Type
12. CASING:
/� Depth Wall Thickness
From �TC _ C(,p(e �r Weight/Ft j at rial
Ft. t� l `P
From To Ft.-______
From ---_To
13. GROUT: Ft._______
Dept � ateri Method
From
From - To Ft. ¢ C
To Ft.
14. SCREEN: -------
Depth Diameter Slot Size Material
From — To Ft _ in.
in.
From To Ft.
in. — in.
From __•_____—_
To Ft._ in.
15. SAND/GRAVEL PACK: in.
Depth Size Material
From To Ft.
From To Ft.
16. REMARKS:
GW-1 Ent
DRILLING LOG
Formation Description
c
c�-
�•.t
� 4
o
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)
CONSRI DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
UCyTIQN `STANDARDS AND THAT A COPY OF THI ECORD HA
ll EN PROVIDED TO THE WELL OWNER.
r3 i7^�fl:Ii; ' IrlJ �I Z!k
GW i REV 9i91 SIGNATURE OF ONTRACTOR OR AGENT
Submit erininm t„ n „; ;__ neTC

North Carolina - Department of Fnvironrnnnl, Heallh, and Nalutal llnsomcns
Division of F-nvitonmenlal Managemnnl - Groundwater Soction
P.O. Box 29535 - naieigh, N.C. 27626-0535
Phony. [phone]
WELL CONSTRUCTION RECORD
ron ouicr_ usE orue
OIJAD. No. —_ _— SEMAL No l_ Y 4
Lat. —,—_ Lonq. — no
Minor Basin
Basin Code
l I leader Ent. G%7.I Ent.
t I
DRILLING COfJTnACTOn: %/i //� � C� �'/l C�:- i,�
�TATE WELL CONSTnUCTION
DRILLER REGISTRATION NUMBER: V PERMIT NUMBER:
t. WELL LOCATION: (Show Sketch of [lie location below)
Nearesl Town:
_
(noad, c »mun`ity, or Suhclivision and Lot No.) DEPTH I _ U-NILLIrIG LOG_-
(. OWNER _��i I R zees. __._.___—__----_ rr�to Forrnalion Desr-ription
(Streat or nouto No )
City or r('tcn Slaln Zip Conn -----'-- "---
3. DATE DRII_f_EI) _�- 41=G�._ USE OF WL=I_L.--
d. 10TA1_ DEP111 _2Q5' __-.-.--
5. CUTTINGS COLLECTED YF__S L .� NO� ---- ---
6. DOES WELL REPLACE EXIS I ING WILL? YES-
7. STATIC WAIEn LEVEL Below Top of Casing: _&o
(Use "r" it Abovn Tor of casing)
8. TOP OF CASING IS _j_— FT. Above Land Surface'
Casing Terminated aVor below Ismd surface Is Illegal unless a variarice Is issued
In accordance with 15A NCAC 2C .01 In
9. YIELD (gpm): '/ - METHOD OF TESL- �_—_-
10. WATER ZONES (depth): --_-------=-
1 i. CHLORiNA1ION: Type ���1 - � Amount _14 If additional space is needed use back of form
12. CASING: — --------------.___
Depth Diamoler
From-� To //3 F1. 6­2-
From— l o - Ft. ----
From —To--- Ft. ---
Q. GnoU r:
From 0 _
From
14. SCREE!".):
w.dt 1lticlutnss LOCA'IION SKETCH
or weighUFt, Material (Show direction and distance from at least Iwo Slate
Cs2 � _C' (loads, or other map reference points)
Depth Material
To .20 ' rt. _P� To Fl. —_--
Depth
From TO
From To
From To —__
15. SAND/GnAVEL PACK:
From lint
• !� �r
• LLL1 ;,
I DO IIEPE[34
CONST UCII
Method
Diameter Slot Size Material
Ft hi. In.
Ft. -- in. _ in.
Ft. _ in. - in. —
Material
TIT IN
-_ F L - 11rL
t3
oZE
�
n_
r
M
rn
r�
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m
m�
m
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11 F-T R914ELLIWAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
ail ,AND THAW A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNEn.
-1.1 1 n t -
OnrE
SIGNATURE OF cmIRACTOn on AGENT

North Carolina - Depaliment of Environrnnnl. Health, and Nalumi Rnsources
pivision of environmental Managwnnnt - Gloundw.-iler Section
P.O. Box 29535 - Raleigh, N.C. 27626-0535
Phone [phone]
WELL CONSTRUCTION RECORD
DRILLING CONTRACTOR: 7/Y), �� �f /,J e ZL 1)X "-?c
Fon orricE usr_ orlL l 4 4 6 9
QUAD. NO. _ __ SERIAL NO.
Lat. Long. RO
Minor 13w;ln
Basin Code -
Header Ent. GV/-1 Ent.
STATE WELL CONSTRUCTION
DRILLER REGISTRATION NUMBER: L/cj,3 PERMIT NUMBER:
1. WELL LOCATION: (Show skelch of the location below)
Nearest Town: It l4), 0 5V, d . --- County: W — —
,Qr --
(Road. Community, or Subdivision and Lot No.) DEf I l l
2. OWNER _1�0'r ) I;aYV i, IA2cic Do from To/
ADDRESS_,;2_76 1911y�L
(Street or Route No.)
city r Town Stale Zip Coda
3. DATE DRILI_ED12-on USE OF WELL %'Vc� 0— - —
4. TOTAL DEPTI I _L:;L15 _
5. CU ifINGS COLLECTED YES [_ NO(2--1---
6. DOES WELL REPLACE EXISTING WELL? YES �j tl0
7. STATIC WATER LEVEL Below Top of Casing: _fir— FT.
(Use "t." it Above Top of Casing)
8. TOP Or CASING ISM FT. Above Land Surface'
Casing Terminated atlor below land surface Is Illegal unless a variance is Issued
In accordance wllh 15A NCAC 2C .0118
9. YIELD (gptn):- cl,_ METHOD OF TEST ;)
10. WATER ZONES (depth):
r
DRILLING LOG
Formation Dgscriplion
11. CHLORINATION: Type 11 - -je8 Amount -3 If additional space is needed use back of form
12. CASING: - -- - --
Wall 1 I lickness
Deplll Diameter or Weight/FI.
rroln-1r�To rL
Front To Ft._From To Ft. -- —
13. GROUT:
_LOCATION SKETCH
Material (Show direction and distance from at least two State
f!2C_ -- Roads, or other map relerence points)
Depth Material Method
FrOtn b To _ �O rL Pol,flc4tuZ
rront To Fl. _ —
14. SCREEN:
Depth Diameter Slot Size Material
From To Fl in. In.
From To FI. --- in. In.
Frorn To Fl. in. _ Ill.
15. SAND/ Allral GI14-
Reim, Q U NSI Material
Froth to To Ft.IF I
I
Front �Ft:
16. REMA
I DO I IE E13Y
CONST
0
o
o
-=
C_
N
o
C_n
a
o
io
o
m:;,j
o
-"-I
w
WCI_LjWAS CONSTRUCTED IN ACCORDANCE WITH l5A NCAC 2C, WELL
Si1171T A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
'bV _9 - 9—
SIGNATURE Or CONTRACTOR OR AGENT DATE
r.w. 1 nry o.n 1 c,.1....11 .L6.,.J In hl,a.•i ... 1 r.1.,t.nrv..nn1•.I ! t•u, .nn...n 1 —A rn In "Al n-mim

Depth qq�� Wall Thickness rr�� eta
From --�___ To � t c-F?r
From To or we
Ft ___-_____
From To Ft.______
Ft. _
13. GROUT:
_______
--------_
Depth I M tQri I Method
From ._._�- To ,`_ Ft. t:
From To Ft.
14. SCREEN: ------
Depth Diameter Slot Size
Material
From To Ft
From in.
In.
From To Ft. — In. — in. ______---
To Ft. in.
5. SAND/GRAVEL PACK: In.
Depth Size Material
From To Ft. _
From To Ft.
i. REMARKS:
100 HEREBY'CERTIFY THAT THIS WELL WAS CONSTRUCT DIN ACCORDANCE WITH 15
CONSTRUCTION STANDARDS, AND THAT A COPY OF T A NCAC 2C, WELL
,lp ECORD H EEN PROVIDED TO THE WELL OWNER.
SIGNATURE OF NTRACTOR OR AGENT N
Submit original to Division of Environmental Manaaam—# .-A
DRILLING LOG
Formation Description
r�-
o
0
�n -
------------""'��+
to
-----------------
�,
North Carolina - Department of Environment, Health, and Natural Resources
Division of Environmental Management - Groundwater Section P.O. Box 29535 - Raleigh, N.C. 27626-0535 QUAD. NO. FOR OFFICE USE ONLY U Iw
Phone [phone] -- SERIAL NO. U
�t--------_.. Long. RO
WELL CONSTRUCTION RECORD Minor Basin
DRIL NG CONTRA TOR: Basin Code
Header En.t.
A`®q GW-1 Ent DRILL R REGI RATION NUMBER: (o STATE WELL CONSTRUCTION
PERMIT NUMBER:
1 • WELL LO ATI : (Show ket If the location below)
Nearest T ryn.
Corulnty:
(Road, Comm orSubdi io 1� "''"' ` ` ``
2• OWNER t No.
D- EPTH
ADDRESS ��oZ -) L— From To
ireet or Ro t No.)
IN
City or own—,71'
State
3. DATE DRILLED iJ� 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: --of -Casing)
FNT.
8. TOP OF CASING IS (Use "+" if Above Top
FT. bove Land Surface*
' Casing Terminated avor belowla urf8Oe is illegal unless a variance is Issued
In accordance with 1SA NCAC 2C .011a
9. YIELD (gpm): tom` METHOD OF TEST Q>�
10. WATER ZONES (depth):
11. CHLORINATION: Type__
12. CASING: Amount _______ 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)
S/60

North Carolina - Department of Environment, Health, and Natural Resources
Division of Environmental Management • Groundwaler Section
P.O. Box 29535 - Raleigh, N.C. 27626.0535
Phone [phone]
WELL CONSTRUCTION RECORD
DRILLING CONTRACTOR: r LiC-// -LJ // , /%i
FOR OFFICE USE ONLY J1 /� C
OUAD. NO. SERIAL NO. 4 U
Lat. Long. RO
Minor Basin
Basin Code.
Header Ent.
_j STATE WELL CONSTRUCTION
DRILLER REGISTRATION NUMBER: L�<j � PERMIT NUMBER:
1. WELL LOCATION: (Show skelch of the location below)
Nearest Town: i`> j"C' -`> >�-�/' l County: /bF i/
(Road, Community, or Subdivision Lot o.) DEPTH
DRILLING LOG ,
/and
2. OWNER ,4- o L '•r^7` 'L i' 1 �% _ Prot" To
Formation Description
Formation
ADDRESS &2f`," �: C�-r-f,N 4-' 0 — �d {
{� --
(Street or Route No.)r 'u `
city or Town I State Zip Codo-
3. DATE DRILLED /- /: �J=' USE OF WELL `t' '
4. TOTAL DEPTH irS'
5. CUTTINGS COLLECTED YES[:] NOL---F�
6. DOES WELL REPLACE EXISTING WELL? YES F-] NO( ,-
7. STATIC WATER LEVEL Below -Top of Casing:_p ' FT.
(Use "+" if Above, Top of Casing)
8. TOP OF CASING IS f FT. Above Land Surface`
• Casing Terminated auor 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 1,,;-)-)�) klllf1 SAmOunt If additional space is needed
use back of lorm
12. CASING:
Wall Thickness
Depth Diameter or Weight/Ft. Material
From To 5=& Ft. 25 s'
From
To Ft.
From
To Ft.
13. GROUT:
Depth Material f Method
From — To �_ Ft. 00 � , 7 d
From
To Ft.
14. SCREEN:
Depth Diameter Slot Size Material
From
To Ft In. in.
From
To Ft. in. In.
From
To Ft. in. in.
15. SAND/GRAVEL PACK:
From
From T Ft. _
I DO IIE EBY
CONST
Material
_LOCATION SKETCH
(Show direction and distance from at least two Slate
Roads, or other map reference points)
0
O
4
0
c•�
� m
n
PC"
c
ch
r� K-
'
Ao
w
o
ELL AS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
THA A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
r,w-1 nFv n,'91
SIGNATUnE OF CONTRACTOR OR AGENT DATE
6 J....�1 n.r..�r r..l In hi,.r�rnn nl Crr.rirnnrnnnl�l rA�n�nnrnnrd ..r,rl inn.• In Doll n,nrnr

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• %7 1�
FOR OFFICE USE ONLY
OUAD NO. SERIAL NO.,
Lal. Long.
Minor Basin
Basin Code
Header Ent.
ti. 1 4 `.t
ET -
GW-1 Ent.
T STATE WELL CONSTRUCTION
DRILLER REGISTRATION NUMBER: �`l' , PERMIT NUMBER:
1. WELL LOCATION- (Show s. etch of the location below)
Nearest Town: �y G' l��" County:
pt)"" l Cav e
(Road. Commuff ti1y, or Subdivision and Lot No.) DEPTH_ --DRILLING LOG _
2. OWNER /fo i1 /'/eel, e From To Formalion Description
ADDRESS —
(Street or Route No.) C kc I
c -
City or Town State rp Codo.
3. DATE DRILLED l USE OF WELL
4. TOTAL DEPTIAyo —_
5. CUTTINGS COLLECTED YES[:] NO[j-
6. DOES WELL REPLACE EXISTING WELL? YES F—] NOL:j.
7. STATIC WATER LEVEL Below Top of Casing: /S' FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS l FT. Above Land Surface"
Casing Terminated aVor below land surface Is Illegal unless a variance Is Issued
in accordance with 15A NCAC 2C .0110
9. YIELD (gpm):— —2—— METHOD OF TEST
10. WATER ZONES (depth):
11. CHLORINATION:
12. CASING:
Type Amount 'l`L If additional space is needed use back of form
Will Thickness
Depth
/�e
From
Ft.
Diameter or wet ItUFI.
�"'�1 30z
Material
�UL
--To
From
To
Ft.
G. 2j— ,/,
J�e�
From —To
—
Ft.
--
13. GROUT:
Depth
20
M Irial
at.��(
Mejhod
f/rd�c
From
To
Ft.
From
To
Ft.
14. SCREEN:
Depth
From To Ft
From To Ft
From To Ft
15. SAND/GRAVELM�IS��
Diameter Slot Size Material
From o 1-
From ;To _ F
16. REtt1ARK
I DO HERE Y CER a1
CONSTRU
In. In.
in. in.
in. In.
;e <; Material
LOCATION SKETCH
(Show direction and distance from all least two Slate
Roads, or other map reference points)
0
cn
ram---
c �>
m
N
C 1
MID
_t
Fd
q
<n �-
•
r-1 --j
O
c�
0
A
CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
OPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
GW-1 REV. 9,y1
UA
SIGNATURE OF CONTRACTOR OR AGENT
Suhrnil orir0nnl to nivision nt Ftwhorimmilal 1�.lnnnnrmnnt end cnnv jr) well owner.
DATE

North C1101ilm - OvIvirlmnrti nl rnvilnnmmill, I Ir+�IIh, null NaIu1n1 Ilnr:nutcn^,
Divtston of rit'll nnntnnl,1l M tnnclnntrnl • (.aoUnrlwdrn Pwclinn
P.O. Dox 29 5'15 - tInInigh, N.(:. 276326-05:35
Phone [phone]I
WELL Cotis-mum,mi nECO11U
-- ----I r)II (Wr:lrr I)rlr rlr iI -e
Minor rlanbi
UnILLIIIG CONTFIACTo11: I leader Eli. ---- — GS'd• I Ent
sl-A-1E wrL1. corls-rnucrlorl
nnlLLrn nmsi nnTION Nurvmr_n: q�_3 PEnmir rrumum
I. WELL_ Locn r 1011: (Show skelclr 01 11m locallon below)
rlpernsl rowrt' _ Y �? �%�-L-� - - -- - - -.. _.._._._ Corinl ---- -
(rin2rl, Cnm nt,nily, vt 5ulvlivi�inrt rind Lot Mo.) L)E_1' 111 DHILLIr IG O1_,
2. OWh1E=r1 -. ' o ' nom to rnrtn:,rnrt n�^ rirr�n
l.__Ll_�e--- U--- ._
nr Moto No
r
Oily nr I nv:n atn 7t11 Qgrlo - - --
a. PA rt- Ltlut.t_ -0 1- c : coo USE of WCL1__-
n. 1011AL UP'll1
cu f I Ir ICq COI_LFC rr_n YrS ( J 1.1ol tj-
s. UUF.S wr_ LL nE rt_nCL r-xlsl IrI�; w1=LLB YE_s---------.._.__---------------.--
7. S rn I IC WA1 Ell LEVEL Lleiow -rop or cnsin .._ o '_._ r r•
(l)sn ",' if Ahovn 'r(il, n1 Cosing)
8. 101, OF CAS11,10 IS._1___._.._ rT. Above 1-111d S(trlace* ------ ---
Cn.^.Ing lnln,b,nlnd nUor below I:trul su,loce Is Ilingnt unless if vnrinricn Is Issunrl------- -----
In nccordnncp wllh 15A IICAC 2C .01 111 — -- — --
9. Yn_Lu (gpttr) __.ILL.__ Mr- I I IOL) or- 'I rs r-
10. WAf Ell ZONES (depth): ----- ------ ------..- --- ------ -----
_.�..%!�
,
11. CI II.OnII In 11OIJ: I ype J]7 1 S1}r-Yl�ei Amount -.___-- n ,ddilinn�l st)ecn is snarled usp h rk of form
LOCn I toll SICE rCL1-
Dnpllt Oinntnlor o, weigl,t/n. Mnlorial (Show ditP.cllon and dislnrlcri Irons nt Iensi Iwo iI819
From _ __-_ 10 I-I.-�'�5----Sl�at--- I<1�-.-- clouds, or other nuip tPlerence Points)
From- — 1 o --�' rl. r a --- —r_l_ S"i _ s5.
Flom - ------ -10 -- - r I. ------- - -- -- -- -- - -
U. (311OL►I:
beplh rvlalelial Melllod
From -- - To --- rl -- - - ------ - - -------
IA. SCnEEII:
Depth Diameter
Front _-- To Ft — hi
Frortt To -- ri.
rronl
15. Snrl
From 2- 1 o __.--�•-- F I.
noill
CD
CD
O
r;_
c
r-
CA
0
O
w
e�
urounawate ot:t,,tvl,
bct I nrEIYAfff�l IF 11 IA ;�tir:�81.� r- L WAS CnNsIMIGIrU IN ACConDAMCE WI111 1.n IIGAC 20, WELL
CONS1nUc110H srnNunnuS, ANO 1I1nr A CopY or-'r111S nECollu HAS BEEN PnoviuEo 10 1I IE wELI_ owNEn.
^lrr-IA lt)nr nr CON lnncfon on Acr-Ilr DAIF

North Carolina - Departnienl of Environment, lNPallh, and Natural flnsourcos
Division of Envitonmental Managnmonl - Gtoundmile.r So..clion
P.O. Box 29535 - n iPigii, N.C. 27626-0 535
Phone [phone]
WELL CONSTRUCTION RECORD
DRILLING CONTRACTOR: _�,, I ko C I,I
ron orrict, u r or «-v r,
QUAD. 1•10. _ sFn1AL No. " I # `l
Lat. -- _ Long. — no
Minor Basin
13,13111 Code -
I leader Ent. GVJ- I Ent.
STATE WELL CONSTRUCTION
DRILLER REGISTRATION PJUMBER: (�ej� — — PERMIT NUMBER:__
1. WELL LOCATION: (Show sketch of the location below)
NParesl Town: �e_e UI �� C'----._-- County:
(noad, Comiptinily, or SufAivision and Lot No.) DEPTH I DRILLING LOG .
2. oWNER -%tl i Loner --------------------- rr�n1 —,o rnrmalion Description
(Sheet or noulo No ) —
_ r
City or rows Slate 711, Co, — ---- ----"-
3. DATE DRll-LED 00 USE oi- WI_I_L �C;U_G.�j-E? .-_
d. To rnL 0Er-TI I _��s ' _ _ - -----
5. CUTTINGS COLLECTED YES NOJ_� — -- —
6. DOES WELL REPLACE EXISTING WELL? YESNU-
7. STATIC WATER LEVEL Below Top of Casing:
(Use "Cif Above Top of Casing)
8. TOP OF CASING ISM FT. Above Land Surface'
' Casinq Terminnled nUor below land sintace Is Illegal unless a vnrintice Is Issued
In necordancp with 15A NCAC 2C .011n
9. YIELD (gpm):_I&C— METHOD OF TEST 1 ✓t --_
10. WATER ZONES (depth): --- -----
�`���-�-.row
11. CHLORINATION: -type k+k �c�_C& Amount Il additional space Is nP.eded use back of form
12. CASING:
Wall 111ir1!f mss
Depth Diameter or weighurt. Material
From_ 0 —To 10r FL -a -2-SFrom 5a ' To
From _ To------
13. GROU r:
Depth Material Method
From 0 To 9=0
r FL el -
From _ To Ft. —_
14. SCREEN:
Deplh Diameter Slot Size Material
From To Fl in. in.
From, To Ft. in, In.
From To __ Ft. _ In. In. — —
15. SAND/GRAVEL PACK, _
From
From . To
16. REMARK JUL.
I DO IiEnE$Y CERTIT'Y".TPTA'T,T
CONSTRUd1:.ION S" 'A DARDS,
Material
LOCATION SKETCH
(Show direction and distance from at least Iwo State
(toads, or other map reference points)
rD
O
0
n
c
m
c nn
xa•
0
N
..
m 5,
O
C")
W
o
'WELL WA'S CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
D'TI-in A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
DAFE
SIrNATUnE or COMACTon on AGRIT

North Carolina - Department of Environrnnnl, health, and Nalural flosourcos
Division of Environrnenlal Managnmenl - GroUndwalor Soclion
P.O. Box 29535 - Raleigh, N.C. 2.7626-0535
Phone [phone]
WELL CONSTRUCTION HEcoRD
DRILLING CONTRACTOR:
QUAD. No,
Minor Basin
Ba ,In Corte
I leader Ent.
ron or-ricr- uSr. of lt.Y ., t
1
_._ SERIAL No. 41'
no —
STATE WELL CONSTRUCTION
DRILLER REGISTRATION NUMBER: PERMIT NUMBER:
GM 1 Ent.
1. WELL LOCATION: (Show skelch of the location below)
Nearest/ Town: GSV lE _-- County:
(11nar♦, Community. or Sulyfivision and I_ol No.) DEPTH l -DR ILLIf 1G LOG
2. OWNF-11 _ I 'J7 P-4 _---- rrorn Ta rormalion Descripron
ADDRESS -- -- "-- -- ----- ---- --- - - 0 - /o -- -� / r
(Street or noulo No.)-
----- --- -- r r
Cily or Town Slalo Zip Codo -- - - 5-- --
3. DATE DRILLED —_ USE Or WEI_I_---"-
4. TOTAL DEPTH 5. CUTTII IGS COLLECTED YF_S Fj NOJ_---
6. DOES WELL REPLACE EXISTING WELL? YL=S U
7. STATIC WATER LEVEL Below Top of Casing: _50 ' rT.
(Use "C it Abovn Top of Casing)
S. TOP OF CASING IS' -_ Fr. Above Land Surface'
' Casing Terminnled nVor below Innd surface Is Illegal unless a vnrinrice Is Issued
In Accordance wllh 15A NCAC 2C .0110
9. YIELD (gpm): 5.0 _ METI-IOD OF TES r A&_e___--_-
10. WATER ZONES (depth): ---
I I. CHLORINA-I ION: -type Amount II addilional space is needed use back of form
12. CASING: ---- ---- -------_-----------
Depth bianuler
From b -To s r rt.-
From- - To Ft. ---
From ro --_ Ft.--
13. GnoUT:
Depth
From -n - To n O r rl
From _ To _ rl
14. SCREEN:
DPpIh
rrom To -
Flom To -
Fron1 — To -
15. SAN1141211AUZ h
Mill llrickness-LOC/1"1ION SKETCH
or WeighUR. Malerial (Show direction and distance from at least two Slate
-� nonds, or other map reference points)
Material Method
S;Ir i
Diameter Slot Size
Ft Ill. —_
Ft. _- In.
F1. in. __
rUs:�
11 U U N l e
Fro Ft
Fro? rlr,on Ft
16. nE
Material
cm
Q
C._
C
r--
N
c-n
0
0
ca
Mr
CD
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�m
;moo
r
;�
rrt
cn X
m :u
c-)
--i
0
z
I D t1Ef1E(,� hT,1tsY 1F.1AT rrIIS WELL WAS CONSTnUCTED IN ACCOnDANCE WITH 15A HCAC 2C, WELL
CONSTnUC lON`STANDARDS, ANIl'114AT A copy or THIS REConD HAS BEEN PROVIDED TO THE WELL OWNER.
Z L) — /-aeon
slrNnrtJnr-_ or coNI nnCTon on AGENT DATE