Well Construction Records Graham CY2000

North Carolina - Department of Environment and Natural Resources - Division of Water quality - Ground•,vater Section
1636 Mail Service Center - Raleigh, N.C. 27699.1636-Phone [phone] 042815
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION H:
STATE WELL CONSTRUCTION PERMIT#:
1, WELL USE (Check Appilcableeox): ResldenUalU Municipal ❑ Industrial ❑ Agricultural ❑ Monllorirg ❑
Aecovery ❑ Heat Pump Water Injecllon ❑ Other ❑ II Other, List Use:
2. WELL LOCATION,Show sketch of the location below)
�.. )-I /lam County:
Nearest Town:
C/1 e O & /t lle/
(Road Name and Numbers, Communily, or Subdivision and Lot No.)
DRILLING LOG
DEPTH
3. OWNER l] f �i'^Lff ,3ei'v'c�
From To
Forna�on Des-ripGo'
Address pQf- / &o /� /'�-
�,
'Z
beet or Houle o.
pf7(�i rlfv//� �1/ C. . �
Z5--
City or Town T^Stale Zip Code
1/2 _ ( G)
" A
4. DATE DRILLED /� '� �"° �'
,�`�j _ '2
s�
5. TOTAL DEPTH
-?aU
6. CUTTINGS COLLECTED Y f S L-
7. DOES WELL REPLACE EXISTING WELL? YES [NO❑ B. STATIC WATER LEVEL Below'Top of Casing: >-0 FT. —
(Use '+' N Above Top of Casing) _
9. TOP OF CASING IS / FT. Above Land Surface' —
,Top of casing terminated al/or below land surface requires a variance In actor-dan
—
10 cYlELDe with SA Nmnc 2c%olte METHOD OF TEST 11. WATER ZONES (depth): —
12. CHLORINATION: Type ��r Amount mac{ ��' If additional space is needed L--e back of fclm
13. CASING:
Wall Thickness
Depth Dlamoter or Welght/Ft. Material
From To /O Ft.
From To
,z s� Ft.
From To - Fl.
14. GROUT:
Depth Mal Hal M,91hod
From
From To Ft. --- --
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft In. In.
From To Ft. In. In.
From To FI. In. In. --
16. SAND/GRAVEL PACK: _
Depth
From To — Fi.
From To Ft. —
17. REMARKS:
I DO HEREBY CERTIFY THAT THI
CONSTRUCTION STANDARDS, A
FOR OFFICE USE ONLY
Quad No:
Serial No. ,
LOCATION SKc fCH
(Slow direction and d:�ance IMM � loan :no •`-'.alo
Roads, or other rrr� relerc:ree Pointe'
WE ,IL WAS CONSTRUCTED IN /ACC ROANCE WITH I5A 04CAC ?^.'/�L
4." S;RF�GO D H BEEN PROVIDED -70 THE Y/�:10+��>=F•
THAT�A)COP,Y OF H,
s11
Vil0 FFI(; E1
SI ATUnE OE PERSON CONSTntY:TIfIG 1>x 'N ELL Os E
submit original to Divtelon of Water Dudlly. orouno"Ier Seem within Yi C%sYS Cn.f FtE v, 071

223689
II • pepartment of Environment and Natural Resources • Division o1 Water Quality • Groundwater Section
North Caro na
if3'i�6 I„ I Service Grttsr -Raleigh, N.C. 27BSi4.1t336-Pitons (fi11i) 7 11) 1 b
WELL CONSTRUCTION RECORD
WELL CONTRACTOR:
"ZO S 4
WELL STATE WE CONTRACTOR
PE MIT11:
1. WELL USE Check APO"ble �z): Residential ® Municipal ❑
Industrial Agricultural ❑ Monitoring L.1
Recovery E5 Heat Pump Water Injection ❑ Other
ther ❑ If Other, List Use:
2. WELL LOCATi N {J�I��ppW sketch of the location below)
Nearest Town:, " '(�' y �" '� 11 a County:
DRILLIN LO D--- ma -
(Road Narns + , Nu trttbsrs, Cc unity, or Subdivhlon and t oc No.) From To Forgon DWripticn
3. OWNER s
Address 1g. A
or
21
tie
Cloy or Town State da
O�
.,
4. DATE DRILLED
5. TOTAL DEPTH
8. CUTTINGS COLLECTED YES (� NOCE
DOES WELL REPLACE EXISTING WELL? YES � NOQ
-- c
�`T'
7.
8. STATIC WATER LEVEL Below Top of Casing: jQ FT.
'
(Use '+' N Ab" Top Of Casing)
o
9• TOP OF CASING IS _ FT. Above Land Surface`
M
''TOP Of ca&V tarminaMd sVor Below land surface regulm a vadanoe In accor-
dance wfth I&A NCAC IC .f111t
1 METHOD OF TEST A L'-L,
z
10• YIELD Wpm): _
.70
—--
th
11. WATER ZONES ( p )•
12. CHLORINATION:
13. CASING:
Amount n • 1.3 It additional apaCo is naad+d uae book of form
Type
wan ThIrAm s
Depth Diameter or WeiQttt/Fl. Material
From __Q_ To _-U- Ft. --- 5-- -
From To -- Fit. —
From -------To----- Ft._-••---- ------
14. GROUT:
Depth Material Method
From O To -1 ej Ft. C01Lnt4 ,1�
From To —Ft. -
15. SCREEN:
Depth Diameter Slot Size matenar
From To Ft in._in.
From To Ft. In. in.
From To Ft. In. In.
16. SAND/GRAVEL PACK:
Depth Size Material
ATION SKETCH
(Show direction and distance from at I0ast two State
Roads, or other map reference points)
it. -A Lc&;, -,t"L'-vP, LL y— c)n l
-,v'-If'1:3 vY Lill
�V .0y- ' l31 At 9
// d 7i"CL
t
• r
pie_ Z_J IRA
From To —Ft. D
From To Ft.
17. REMARKS:
100 HEREBY CERTIFY THAT THIS WELL WA'
CONSTRUCTii STANDARD �N(`�\ jjii T A„�
��
FOR OFFICE U>'
Quad No:
l Ml�i� ')Il$,Dmlt c
Serial No.
ISTRUCTED IN ACCORDANCE WITH 15A NCAC 20, WELL
OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER,
3 RE CfF PERSON CONSTRUCTING THE WELL DATE
to Division of Water Guaft, Groundwater Uorlon within 30 days
GWt REV. 12rii4

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1t336 Mail Service Center - Raleigh, N.G. 276W1836-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: .QL•
WELL CONTRACTOR CERTIFICATION #: O 5 b
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential ® Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other [] It Other, List Use:
2. WELL LOCATI ,�j `( h w sketch o the location below)
Nearest Town: _ ^ram _ 6 . - Le County t1 _I im
(Road Name and Numbers, Community, Suadivtslon and Lot No.) DRILLING LOB
3. OWNER C ; Z % From To
Address i'
Cky or Town State Zip Code
4. DATE DRILLED�.�/; d00
S. TOTAL DEPTH 1 f'o '
6. CUTTINGS COLLECTED YES [] NO®
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO®
8. STATIC WATER LEVEL Below Top of Casing: 10 FT.
(Use 1+1 9 Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface*
'Tap of es," terminated sVor below land surface requires a valiance in accor-
dance with I$A NCAC 2C .011a
10. YIELD (gpm):_ METHOD OF TEST >�
11. WATER ZONES (depth): Gd
DEPTH
Formation DescripUon
12. CHLORINATION: Type d Amount 0. 19 It additional apace is needed use back of form
13. CASING:
Wall Thickness
Depth Diameter or Weight/Ft. Material
From To 55 Ft. _ 6 Y4 U A- I V L
From__,____. To Ft.
From To Ft.
14. GROUT:
Depth M terial Method
From To ;. Q Ft,N'�5c;v
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft in. In.
From To Ft. In. In.
From To _._ . Ft. In. In.
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
17. REMARKS:
J "ATION SKETCH
(Show direot:on and distance from at least two State
Roads, or other map reference points) p
;o
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STi'NDi tD(�'-AAIIND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE QIVIY"~''
Clued No: i 4 I Os144TURE 6F PERSOk CONSTRUCTING THE WELL DATE
SObrtilt origl4 "to Division of Water Ovailty, Groundwater Sec:ion within 30 days
StAal No, a ' 1
GW-1 REV. 12/99
n

North Carolina - Department of Environment and Natural Resources - Division of Water quality - Groundwater Section (-' 2 1 1 3 5
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: -C"Xw- "// �/!/,-) 9
WELL CONTRACTOR CERTIFICATION #:_ `)) e E .
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential I Municipal C] Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection [] Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: V I LL9_ County: _
(Road Name and Numbers. Community, or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER sic°� �.J R. ST; From To Formation Description
Address 2 GLxIDbC'^JS' c > l`i ' S C.y : •r
b?(NIreet or Roble N
/'b L r �`1 C
City or Town I G tate Zip Code
4. DATE DRILLED - D • 0 0
5. TOTAL DEPTH _S (; ) ' o
6. CUTTINGS COLLECTED YES O NOM-• CD
7. DOES WELL REPLACE EXISTING WELL? YES NOp"
8. STATIC WATER LEVEL Below Top of Casing: os ,, I FT.
(Use '+• II Above Top of Casing) Wes_ —
9. TOP OF CASING IS FT. Above Land Surface' r-T=
*Top of casing terminated atfor below land surface requires a variance In accor• \
dance with 15A NCAC 2C .0118
10. YIELD (gpm): `I METHOD OF TEST - ✓,' �� ar
11. WATER ZONES (depth): o t./ J 0 h=
12. CHLORINATION: Type y Amount a �s If additional space Is needed use back of form z
13. CASING:
Wall Thickness LOCATION SKETCH
U Depth =13 Qianpter or Weight/Fl. M�lertal (Show direction and distance from at least two Stale
From To Ft. (— _�i d) U I f �' Roads, or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth , Material Method
From `' To _ Ft. _ _xIAVI h�
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From To FI in. in.
From To Ft. in. in.
From To Ft. In. In.
16. SAND/GRAVEL PACK:
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 T ACDRY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE U � V t �• 1'' • C_
Ouad No: S ATUR6 F 10RSON CONSTRUCTING THE WELL DATE
Serial No. Submit o Io Division of Water Duality, Groundwater Section Within 30 days
OW-1 REV. 12199

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section �' 14 14
1636 Mail Service Center - Ralelnh N C 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: 0-110"
WELL CONTRACTOR CERTIFICATION N: Z (, .r'~ ol
STATE WELL CONSTRUCTION PEAMITN:
1. WELL USE (Check Applicable Box): Residentlal L'! Municipal ❑ Industrial d Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below) /' �, I��
Nearest Town: 5 @-co H County: G-AA
I7
trP-J'e2 7-usl��,C,-�H`
(Road Name and Numbers, Community, or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER L y q- F=1$ W F ,§ L41 S From To Formation Description
Address yC) Z.t /'/:: ,e �c< ,5 G� z /2 b /t^ .5' S c !� s
j9-ireetor ou a o, j 0
/10 G d,� s�,, // /V e �� 21
City or Town State Zlp Code
4. DATE DRILLED
U. TOTAL DEPTH
6. CUTTINGS COLLECTED YES [D NO❑--
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NOQ-
8. STATIC WATER LEVEL Below Top of Casing: �— v FT.
(Use '+' If Above Top of Casing)
9. TOP OF CASING IS _ I 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): 16- METHOD OF TEST
11. WATER ZONES (depth): & C '2
12. CHLORINATION: Type -/ Z / Amount `� �� If additional space Is needed use back of form
13. CASING:
�+ o
LOCATION SKETCH
Depth
Wall Thickness
Diameter or Welght/Fl. Material (Show direction and distance from at least two State
From
12'
To /0-L Ft.
L 7 _6") & a 1 10-e- Roads, or other map reference points)
From
To Ft.
From
To Ft.
14. GROUT:
C
Depth
!"-O
J Material Method
From
To Ft.
?-IU
From
To ZOL Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From
To Ft
In. in.
From
To FL
in. In.
From
To Ft.
In. In.
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
17. REMARKS: --
I DO HEREBY CERTIFY, THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION TANn'An S qND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
ib
FOR OFFICE US Y
Quad No: RFIi Q lATUR F PgA_S ►rCONSTRUCTING THE WELL DATE
u6r fort tyisl6n of Watk uality, Groundwater Section within 30 day6
Serial No. GW-1 REV. 12M
i

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section cc
1636 Mail Service Center - Raleigh, N,C. 27699-1636-Phone [phone] . 6 8 9
WELL CONSTRUCTION RECORD WELL CONTRACTOR: � A�—
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 LOCATIWN: („S ow sketch of the location below)
Nearest Town:` County:
(Road Name and Numbers, Community, or Subdivision and Lot No.)
3. OWNERS'
Address �
(Street r Route o.
' ' --h Z 7 ?
City or Town State Zip Code
4. DATE DRILLED 7
5. TOTAL DEPTH 40 d'
6. CUTTINGS COLLECTED YES ❑ NO®
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NOE)
8. STATIC WATER LEVEL Below Top of Casing: %;zo 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 ISA NCAC 2C .0118
10. YIELD (gpm): 60 METHOD OF TEST 4
11. WATER ZONES (depth): o
12. CHLORINATION: Type jlTh( Amount O..So
13. CASING:
Wall Thickness
Depth Diameter or Weight/Ft. Material
From C— To —2112 Ft. e N_ SiDi? 2_1 v'C
From To — Ft.
From To Ft.
14. GROUT:
Depth Material Method
From 0 To Ft. C emcg4--1 i
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft in. in.
From To Ft. in, in.
From To Ft. in. in.
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
17. REMARKS:
DRILLING LOG DEPTH
From To Formation Description
0
d
p
y v
C�
C
m
z� c�
rn
t�D
P11:1. c
tlf
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)
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 UUM Q
Quad No: L5 1 i � GN RE O PERS CONSTRUCTING THE WELL DATE
Submf goripipial to Division of Water Quality, Groundwater Section within 30 days
Serial No. ' p ]f10I i { � I GW-1 REV. 12199

North Carolina - Department of Environment and Natural Resources • Division of Water Quality - Groundwater Section
Me Mail SaMoo Center - Raleigh, N.C. 27699-1636-Phone [phone]
68�
WELL CONSTRUCTION JECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION
STATE WELL CONSTRUCTION PERMITN:
1. WELL USE Chock Applicable sox): Residential � Municipal ❑ Industrial ❑
Recovery Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Stew sketch of the location below) Q p
Nearest Town %l -C County, J �1yr
(Road Name and Numbers, Community, or Subdivision and Lot No.) DRILLING LOG
3. OWNER Q,4,1VrmU 1
D "I From To
Address
c2.i�ry..l.) - L" o`J2 .outG
City or Town State Zip Code
4. DATE DRILLED t j S ;ZDOJ
5 TOTAL DEPTH ,-C:y5
Agricultural ❑ Monitoring ❑
DEPTH
Formation Description
Q
6. CUTTINGS COLLECTED YES ❑ NO[K]
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO® n---
8. STATIC WATER LEVEL Below Top of Casing: I_ FT.
(Use '+' R Above Top or Casing)
g. TOP OF CASING IS�.` FT. Above Land Surface* ,� o
`Top of casing terminated War below land surface requires s vrlence In accor- y
drwe with 15A NCAC 2C .C11/
10. YIELD (gpm): 2-C, METHOD OF TEST R T
11. WATER ZONES (depth):
12. CHLORINATION; Type Amount 0 3?
13. CASING:
Will Thickness
Depth Diameter or WeighVFt. Material
From .� . _ To 3 3 Ft. E� 5,129 21 -�!Y C--
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From To ...--),Q Ft. Uri *54L
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft In. In.
From To Ft. From To Ft. _
16. SANDIGRAVEL PACK:
Depth
From To Ft.
From To Ft.
17, REMARKS;
In. in.
In. In,
Size Material
rn Cl),-r
If addition&! apace is needed use back ofig m
LOCATION SKETCH
(Show direction and distance from at least two State
Road#, or other map reference points)
�ZZVL'j_'Q l
—tc- � fit,, t�u�� -W! P 9 IV
t1'L'V" L�
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 7C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OF.FICE.USE=ONVY---�-�— 1
Quad N c""' du j
'Cl�r�� SONAT/[JNfE OF PERSON bONSTRUCTING THE WELL DATE
Submh original to Division of Water Quality, Groundwater Section within 30 days
y
Serial P ; Cie-1 REV. 12M
JOAN T 81WLD
(wills Peginnmi

North Carolina - Department of Environment and Natural Resources - Division of Water Ouality - Groundwater Section
Ion Mail SWAM Center - Raleigh, N.C. 27OWIon-phone (919) 733,3221
WELL CONSTRUCTION RECORD WELL CONTRACTOR: ba: - rr,
WELL CONTRACTOR CERTIFICATION M: AO S-o
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE Check Applicable aox): Residential M Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery (5 Heat Pump Water injection ❑ Other If Other, Ust Use:
2. WELL LOCATI (Sh w sketch of the location below) Q, p
Nearest Town: � ) p I o ­►'l C- County: _f�Ylf�h�d'tnr
(Road Name and N rs. Com•nuniy, or S vision and Lot No.) _ DRILLING L�i DEPTH
3. OWNER %e� t �'1�C ��� From TO Fomtiatlon Desuiption
Address
AA1fW
n ,
GL/vr aJ AX (Jr a O.
Ciy or Town to Zip Code
4. DATE DRILLED /i d 00
5. TOTAL DEPTH 1 9 0
6. CUTTINGS COLLECTED YES ❑ NO® _
7. DOES WELL REPLACE EXISTING WELL? YES [] NO©
S. STATIC WATER LEVEL Below Top of Casing: (�-d FT.
(Use's' It Above Top of Casing)
9. TOP OF CASING IS _ / FT. Above Land Surface*
'Top of casirto termlraded at/or below land surface regtdree a valance in accor- - -
dance with 15A t1CAC 2C .01IS
10. YIELD (gpm): •-o METHOD OF TEST
11. WATER ZONES (depth): / 2-2
0
12. CHLORINATION: Type —J4 7-14 , Amount �• If additional space is needed use back of orm z
13. CASING:
Wall Thickness
Depth Diameter or Weight/Ft. Material
From �— To _ Ft. �� 'Mj ' Py c.
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From -e_ To as Ft. bn,,r4,4} $cab
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:
Depth Size
From To Ft.
From To Ft
17. REMARKS:
In.
Material
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
toj� 1 ,-u ��9 M
i
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 OFFICIEUSII
Ouad No: 8 T E PER N 061SISTRUCTING THE WELL DATE
' I � ` 's' original to DMslon of Water Ousiiy, Groundwater Section within 30 days
Serial No, 1p�i « l '� I
GWA REV. 112l119

North Carolina • Department of Environrnent and Natural Resources • Division of Water Quality • Groundwater Section ' % -e C
16M Mail Servios Center • Raleigh, N.C. 2T6WI636-Phone (oto) 733.3221 '- �- .16 8.4
WELL CONSTRUCTION RECORD WELL CONTRACTOR: �'��� u!.ai � ' ;,per
WELL CONTRACTOR CERTIFICATION 0: „A%J
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Cheek APpllcable Box): Residential ® Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCH (Siqw, akeich qI the location below)
!dearest Town ,.°t4 t�Yt n �14, C' � n `fl. C r�,rn
County:
tRwd Name ~`—
3. OWNER C0" ' or W
and Lot No.) DRINQ LOG DEPTH
AL 1'1 a' ems' From To Fomutbn Deecrwom
Address
City w Tour WAN ZIP Cods
4. DATE DRILLED P/ 7 dJ o
5. TOTAL DEPTH „ S;
6. CUTTINGS COLLECTED YES 0 NO®
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO[K] Pq -7—
6. STATIC WATER LEVEL Below Top of CaaktQ: 6o FT. p p
..
• M Aloe Top of Caskq) O 55 :;o
6. TOP OF CASING IS FT. Above Land Surtwo'
'TOP Of OesAy brRdnetied eMw below land surfam requires a vwUnoe M a000r.
dance wMb ILIA NO" SC .011a
10. YIELD (ppm): .�, METHOD OF TEST --A �-o
11. WATER ZONES (depth):f;;
12. CHLORINATION: Type = Amount Q $
13. CASING:
Wall TNdmes
From _._ 0 __ _ o 10 6 Ft.. or �
From► To— Ft.
From —To_ Ft.
14. GROUT:
Depth Material Method
From _.�To _212 Ft. Q4.1rr.¢'nL S-4,Z
From To Ft.
IS. SCREEN:
Depth Diameter Slot Stzi Material
From To Ft in. in.
From To Ft. In. In.
From To Ft.._� in. In.
1S. SANDJGRAVEL PACK:
Depth Size Material
If sddbonW space Is needed use tuck of to .�
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
o
s C� ,���31-1
From To_ Ft.
From To Ft.
17. REMARKS:
t DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF TENS RECORD HM BEEN PROVIDED TO THE WELL OWNER.
FOR of3FICE USE oNLY 1kLAP. 1 //i %mod u o
Ouad NW.
seals! No. t x ' r4,___� 0 DMeion of Water QUa ty, Omw0watsr Ilealon whhln 30 days DATE
it
JAN 1 19, til(l1

From_._.___.
To —
FL
—
From
To_
Ft.�
14. GROUT:
Depth
M101110dal Method
From ,
err To —aO
Ft.
I44 5c,?"�
From
_To _
Ft.
IS. SCREEN:
Depth Diameter SW St" Material
From
To Ft
in. in...s
From
To Ft.
In. In.
From
To ,_..` Ft,
In. In.
18. SANOd'GRAVEL PACK:
Depth
Size Material
From To Ft.
From .�.. To_ Ft.
I?. REMARKS:
North'ON nt of Environment and Hakwel p wwo" • Division of Water OuaHy. • GrounQwat�r $*odor 4 2 `� - '
Raleigh. N.C. 279MIM41t" (919) 733•.i221
WELL CONSTRUCTION RECORD WELL CONTRACTOR: .---'A!L°= W,dk - -b� =�
WELL COMMACTOR CERTIFICATM 0: nS'rt? .r_.
STATE WELL CONSMUCTION PtRMi'T1:
1. WELL USE Apoweate a"): RegdeytlM 0 Municipal ❑ Industrial ❑ Agricultural MWA* Mp
Recovery ff Heat Pump Water Injection ❑ Other p If Other, List use:
2. WELL LOCA =(*kq1jch
of the location below)
NearestTown:N1-) ($Couny,
(Road Nems Hunters, a "y twttdf4w" and Lot No.)
3. OWNER gran To
Address
City or Town tltaee ap Code
4. 0ATE 0 A I LLEO � a
S. TOTAL DEPTH - :X Q -5;-
S. CUTTINGS COLLECTED YES ❑ NO®
7. DOES WELL REPLACE EXISTING WELL? YES [] NO
S. STATIC WATER LEVEL Below Top of Caaing: an FT.
ti. TOP OF CASING I$ % tUn V M Aft" Top or CaNnp)
FT. Above Land Surfaoe
'TOP Of 08*4 1e '1 Ul0100 sVW Below tanr eurleoe reQ **s s vertmea M a nor-
rMnao lritA taA tICAC aC A11a
Id. YIELD (gprn): 7_ METHOD OF TEST
DEI•T
Fomwow Daerlptlon
11. WATER ZONES (depth):
rt -:
12. CHLORINATION: Type Amount L� 3 ft addWonol epsce is needed use back of forff L
13. CASING:
WON TlIkknese LOCATION SKET H
Depth OialFeMr or Wefyhm. Malenal (Show direction and distance horn at Neat two State
From � r. To - 4 9 Ft, r� w Ronde, or other map referso points)
TJ,jI�
go S r + at/u b-vv, ,
l// v c —e
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTEO IN ACCORDANCE WITH 1SA NCAC 2C, WELL
C"TRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HI,S BEEN PROVfpED TO THE WELL OWNER,
or Water Ouatit . Grawxmsw aecoon within 30 days

North Carolina - DepotTont of Environment and Naboal Rro ceoucc - Dtvlclon of Wster OuaRty Grounowatar $*don �2�2. V )
1836 MmU SoMos Csntw - Raleigh, N.C. 27EM1SWIShone (e1 s) 733.3221
�'
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
�
WELL CONTRACTOR CERTIFICATION N:-
8TATt WILL CONMUCTION PERMITe:
1. WELL Ulzl�aMMr Apploa�b son): Residerttlal
Municipal 0 tndustrtal ❑ Agricultural ❑ MoNtaring ❑
Recovery Heat Pump Water Injeadon ❑ Other ❑ If Other, Ust Uar:
2. WELL LOCAl"NOw skelfth of the locatlort below)
No~ Town- County: • w
(Road We and Number. Communfty, W tilubdNNlon and lot Noe DRiLLINta1 L04 _ DEPTH
3. OWNER From To FomlaNan Dccorlp m
Address
.� . C --
C1ty or Town a"
ZIP QXIM
4. DATE DRILLED / r4 / : � a o o
$. TOTAL Dg"M o S'
a. CuTTINOS COLLECTED YES ❑ NOQ
7, DOES WELL REPLACE EXISTING WELL? YES ❑ NO®
S. STATIC WATER LEVEL below Top of Casing: / ? a FT-
(Um'+'s Above Top of Caeinp)
S. TOP OF CASINO Is f FT. Above Land Surface* C
wrop of s Osrrrrit- I a WW below lasoda w rMome a variance to s000r,-
MAC
;Z = _
Arose watlr tsA IC Aits -
10. YIELD (Vat): / U. METHOO OF TEST �----�
11. WATER ZONES (&pth): 4 A7
12. CHLORINATION: Type % Amount if &WRIOMI apace is needed use beck "rm
r-,
13. CASING:
WON Th Cimso
Depth e OWnMr w WNpl+UFL AAa*AW (Show direction and dblte xe from at bast t"aia l
From ___S____ ToR'1 Ft. D v c Roads or other map retsreraa polnte)
From To Ft.
From To Ft.- ------
14. GROUT:
Depth Malmial Method
From . a To a a FL
From To Ft.
15. SCREEN:
Depth Di meisr got SIZe Material
From To Ft in. In.
From To Ft. In. In.
From To Ft. in.-._._o,.In,
16. SANO/GRAVEL PACK:
Depth Size Material
From To — Ft.
From To Ft
17. REMARKS:
5 Yr� `'tZ4 . /1-Ap
t'il.-c-t.s�, -fc v7,y. crr, 1�
Cr �
/�tt!Y- Ito, 0-" S-�'9 2
� y�
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCOROANCE WITH 1 SA NCAC 2C. WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
%a Affa m I nee u _ _ 10_�A o n A4 Ata rL / 6 / 1 -2 /A o d ,3
Oued No:
SWW No.
2 12000
10F rEROON CONSTRUCTINO THE WELL
of WaW Ouswy, QmwAmwr tlaotlon within 30 days
OW-1 REV. I
Groundwater
:ha -

IJcrth Caroline • Department of Environment and Nnlurpl Resovrcea - Division of Water t]uallty • Groundwater Section
r" 9499
1636 Mail Service Center • Raleigh, N.C. 27699-1030"Phono [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: `0191�DkQ-Q I l L�P,i II'A; --f
WELL CONT"ACTOn GERTIPICATI'ON A: 7-
STATE WELL CONSTRUCTION P01MI'tN:
I. WELL USE (Check applicable sox): Flestdontlal a_ MuniefpA1(l InduSblal ❑ Aprieullural d Monitoring [�
Flocovely EJ Heal Pump Water In)ecllon [] Other [, it Other, Llsl Use:
>. WELL LOCATIUW: (Show sketch of the location below) � d
Npnrnnt Tov n �0_0 C.}{ - ----_. County: l �► P-6 N ir/"
bo _2 C
Ilload Name and Nv„ as, CarvnuNty, or Subdivision and Lot Ne.)
3. OWNER -- �C�E oXn 0
Addr-sn •��S W• kj^j �i1r(��li /4(%-
�••r-- S rnl crt'or FJOGiVFlo.
_� de
r0y or T, G. t $Inly Zlp Code
a. DATE DRILLED /J '
5. 101 AL DEPT 11-_ )02 '
6. CUri'lNUS COLLEC I ED YES n NOCr
7. DOES WEI.L FIFPI.ACE EXISIING WELL? YES �] NOD
8. STATIC WATER LEVEL Below Top of Cna►nq: PT,
(115a'4' It Ahovo Top of Cnslnd)
n TOP nF r,AGING IS._��FT Above (.rind Surface'
'Tnp nr rngln[, forminnrml nl;nr holnw I+n(f trlrfo" torinlr44 o vridrince In Pecor•
dinar, wlth 19A NCAC 2C, Olin
1n YIFI.r) (arm)• -___ METHOD OF TEST ✓> d
11. WAT En ZOfJE3 (depih): "). 4 u
12. CHLORINATION: Type
13 CASH IG.
INnlr 1 h1rimrB3
UQplil• Diameter or welahl/M Materiel
From 1. —.—To � �' r rl. 6 ' J •� ) l � �'�
From 10 _--_.___ Ft.
1A. rRO111:
Dcr~Ill Material_ Method
rlom To I rt. Co,
Front �O„ to--
� 5. fiCf1Ct?�d�
IJrhlh hi7rnnl4r Siol Slzti Matetlal
Frunl __.. fo .-._-•-- rl
F1. _-- In. In,
Fr-m
15. SANDIGr1AVLL TACK:
Dahill Size Material
rrnrl _------ To -- .._ ..__.._ Pt........._..
FIon1
IT HEMAI-W&
DRILLING LOG D9PTH
From To Formation Deeortption
t _z
---1 '
If additional space Is needed use back of form -�
LOCATION SKETCH
(Show direotlon and distance from at tonal two 13tate
Roads, or other map reference points)
I no I frncpy r.r-nTlrY TNnT M9 WELL WAS CON9TRUCtED IN ACCORDANCE WITH 15A NCAC 20, WELL
rnN91 RI 01,11 IONS I ANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
rOR OrFICF USF. ONLY �'� .._J
Ot 't No. SIONATU"S Or Pr , ON CONS MUCTING THE WELL DATE
—•• Submit nrt01n71 to Ui•rlslon of Wnlar Ountily, Croundwaler "Ct!(In wlthln 30 days �!�i�l No.GWI Il&V. 12/49

North Carolina • Detrartrnent of Environment and Natural Resources • Division of Water Quality • Groundwater Section
1636 Mnil Service Center • flaieigh, N.C. 27699-1030•Phono (9111) 733.3221
WELL CONSTRUCTION RECORD WELL CONTRACTOR: eituc' c -
WELL CONTRACTORt CERTIFICATION 0:
STATE WELL CONSTRUCTION PERMITN:
1. WELL USE (Check Applicoblo Box): Residentiald Municipal ❑ (ndustflal ❑ Auricultural ❑
Mor111orinq ❑
Recovery ❑ Heal Pump Water Injeclion ❑ Other ❑ If Other, Lisl Use:
2. VVELL LOCAL 1014: (Show sketch of (he location below) �^
1•ln'IrnSI T-nn• P�,Bi136$ "I-LL-E? County: L 4�N jib•-✓l
l.1RIL.L. S-kp-Wrp-c I-e
([load (Jame and Nun>Vois. Community, or Subdivision ruid Lot No.) DRILLING LOG DEPTH
:3. UWNER _ �E�•�a I F` /V jj t t C.IFrom To Formallon besodption
Arlrlrn�z hA.fu., (' C�,,12-c' Le/7
(�T, FT I C/ ltoulo F O.) 1 1.i I } t �-
C.
r0v nr T rr.•, — clniv Zip Codo
d. DATE DRILLEu /� )_--------- -
5. 101 AL UEPII I
6. Ca) f I INOS COII,I.FCI EU YES n NO[__r
r —'
7. DOES WELL RFpIACF EXISIING WELL? YES wo
q -
A. STATIC WATER t_FVE.L 6clow Top of Cnaincl: - ` _- RT.
(I!^rr',' It Ahovo Top of Cnllrq)
P TnP nr nAq?N(; IS - FT Above I. and Surface'
'Tnp Mr -trip lnrrnrnnl—i nWor hninw lend 4tnr1er`* roryntre+ o vnrinnev In arcor•
dtncn with IFA W 7AC 7C .0110
in Ylr•I n (,,pm). ' _ ._ -. MFTHOO OF TF5T _ ✓� __— _-. _ _.
= «_ —
1. VIA IEll LOVES (depth): y9'' _ _....__ _._.._-----•
''
U7 ,
12. CHL(1r.11HATION• TYpp %...__Amnon[ �' i' %/-`_, _
- .. 11 edditionet space Is needed use beck of form
13 GASIf C,
,•,, LrQnllt binmoter
_�—
i'ro:n FI.
From 10 ___-_-- Ft.
id GROUT:
Yvn1, lhfclrnn4! OCATIO SKf_TCH .
or Welphl/Fl. M)Itednl (Show direction and distance from at least Iwo State
,�.J- 1�1-),1 t " ` Roads, or other map reference points)
Cr �llr Material Mothnd
rrnnl --- lci
i5 S!'Rrf'11•
Dr•1,II1
rl
FMrT1
I r;. S)Al ID URAVET. f ACK:
Orplh
Pinimilor Slot Sl:.e Material
In. _. In. -
in.--- in. -- _
In. ---- In. --------
Size Moterlal
Fr^r-i ....,... To .. ...__.. rl
F:cnt ---._. f0.... ri.-
17. REMAHKS-
1 rn F frricny nrnTIFY TF IAT T14IS WELL WA3 CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
(Y.)NR I F-11 Ir,TI(-)N F; I ANDARDS. AND THAT A COPY OF TFIIS RECORD HAS 13EEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USF. 011LY
ou��l r:n• � - 9iril�n� 1f�pdbtr�IsorJ GON TTiuCTINO 7H�l.L DATE -- --
-•.. Su!•m t wi,lrmf to OiArtfon of Wnler Quality, GmundWAler Snct!rin Within 30 days
GW1 fTEV. 12/99

236096
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
lle� IJJ�
WELL CONSTRUCTION RECORD WELL CONTR ACTOR:
- ,r
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (check Applicable Box): Residential � Municipal ❑ Industrial ❑ Agricultural ❑ Monitorirg ❑
Recovery ❑ Heal Pump Water Injection ❑ Other ❑ It Other, List Use:
2. WELL LOCATION- (Show sketch of the location below)
Nearest Town: A ✓ l�'itf v, ll County:-
0 /J f h /ee/a
(Road Name and Numbers, Community, or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER /S26e (ry�c�u ctia From To ForrraScn Description
Address cl0 gyall J��t-pry
�j8treet or Route o.
5 z - /,z o-'-
City or Town State Zip Code
4. DATE DRILLED
5. TOTAL DEPTH l�0
6. CUTTINGS COLLECTED YFS ❑ NOD'
7. DOES WELL REPLACE EXISTING WELL? YES F] NO[�
S. STATIC WATER LEVEL Below Top of Casing: )- 6) 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 it variance In accor.
dance with 15A NCAC 2C.0118
10. YIELD (gpm): 7 METHOD OF TEST
11. WATER ZONES (depth): Z° 0
12. CHLORINATION
13. CASING:
i
Amount— If additional spare is needed' back larn c
Type 1717 74
Wall Thickness
0
Depth
Ft.
Diameter or Weight/Ft. Material
G,f S�" r �dc.
From To
Fromm To 65� Ft.
From
To Ft.
14. GROUT:
0
Depth
atonal M,91hod
% �� e_
From
To Ft.
o���
From
To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From
To Ft
In. —in,—
From
To Ft.
In. Jn.
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',-ance tr7n ;EJ leas::Ho Smote
Roads, or other rrip relere:rx_- points
0
q CD
o F
cr,
CO cn
W
rV p
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A P4CAC ?',:. YfELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEff PRO%ACED 10 THE W5�!­L D%%NEF-
FOR OFFICE USE ONLY
Ouad No:
Serial No.
SIGN T IRE OF PERSON CONSTRlY3TING I)*--- 'WELL
Submil original to Division of Water Millity. Grvandxater S*cn within Vi C%�ys
DA.�'£
C.".1 Pj9 V. 1171

236093
North Carolina • Department of Environment and Natural Resources - Division of Water Quality • Groundwater Section
1636 Mail Service Center -Raleigh, N.C. 27699-1636•Phone [phone] (i nVA�ll , 1
1) -
WELL CONSTRUCTION RECORD WELL CONTRACTOR: z��
WELL CONTRACTOR CERTIFICATION N: C
STATE WELL CONSTRUCTION PERMITN:
1, WELL USE (Check Applicable Box): Residentfal[9----municlpal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery[] Heal Pump Water InjectionEl Other 0 11 Other, List Use:
2. WELL LOCATIO (hp!! sketch. of the location below)
NearestTown: GIS(/f."� County:
j�C �zsc3<?jd^�as� DEPTH
(Road Name and Numbers, community, or Subdivision and Lot No.) DRILLING LOG Fonncxon Descripuw-
3. OWNER ��rd/�%L o'Z� �� C �JO.G! _ From To
Address<��� L'�,�s�`: b- o e K y
treet or ou o o.
City or Town State Zip Code
4. DATE DRILLED l'12-/ DD'
5. TOTAL DEPTH -� oy
6. CUTTINGS COLLECTED YFS ❑ NO[
7. DOES WELL REPLACE EXISTING WELL? YES n NO
S. STATIC WATER LEVEL Below Top of Casing: FT.
(Use •+' II Above Top of Casing)
9. TOP OF CASING IS l Z FT. Above Land Surface'
'Top of casing terminated aVor below land surface requires a variance In actor -
dance YIELD (gpm) c zc
M SOD OF TEST /1.0118 ���
10
11. WATER ZONES (depth):
12. CHLORINATION: Type Amount 11 additional space is needed tse baci of faun
13. CASING: LOCATION SK= fCH
Wall Thickness
Depth Diameter or Wetght/Ft. Material (Show direction and dunce from leas! S' a e
From To Ft• � ,�/V.Z / ©�G Roads, or other n-r--p refere:ce Po
From — To Fl..— -
From —To Ft. ---
14. (ROUT:
��rfal M
clj c� / e od""/ �
Depth
From 49 To ,"-0 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, Material
Depth Size
From ._-- To _Ft. —
From To Ft. _
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDRICE WITH 15A ??CAC ?',:.'//ELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVICED 'TO THE Yl=t.L Ot��>=F•
FOR OFFICE USE ONLY
Quad No: StON TUBE OF PERSON CONSTRIY.%TING 1> t /++ELL
Submit original to D;vltlon of Water puailty. Groundorater Srccn Within :ri C%rYs CM,I Fig V. 12t1
ifi t
Serial No. !r

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section 236092
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone] / l /fir ww
WELL CONSTRUCTION RECORD WELLCONTRACTOR:
!
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): ResidentialE Municipal ❑ Industrial ❑ Agricultural D Monitoring ❑
Flecovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2, WELL LOCATIO�jUMow sketch of the location below) /
�r�ih2
ii
Nearest Town: County:
�fiow�,7•G (�
(Road Name and Numbers, Community, or Subdivision and Lot No.)
DRILLING LOG DEPTH
3. OWNER Wk /? e (f4rve�^
From To Forrna�cn DescsipUo1.
Address
(Street or Houle o.
cc) -" eY_ C14�
5V_
City or Town State Zip Code
4. DATE DRILLED 2-2-�- v0
5. TOTAL DEPTH 200
6. CUTTINGS COLLECTED YFS [Q NO[a-----
7. DOES WELL REPLACE EXISTING WELL? YES [] NOED--
8. STATIC WATER LEVEL Below Top of Casing: 6 0 FT.
y (Use '+' If Above Top of Casing)
9. TOP OF CASING IS 1' FT. Above Land Surface*
'Top of casing terminated attor below land surface requires a variance In accor-
dance with 15A NCAC 2C.01)e
10. YIELD (gpm): f METHOD OF TEST
11. WATER ZONES (depth): 1S
12. CHLORINATION: Type ..—Amount
If additional space is needej L:5? backoI fcrm
13. CASING:
LOCATION SK=TCH
Wall Thickness
Depth Diameter or Wei ht/Ft. Material
(Show direction and d-cstance fr^m teas :rro Smote
From�_To 4o Ft. 6-2S' SO�'21 /OyG
Roads, or other rrr� referer�ce points!
From To Ft.
From To Ft.
14. GROUT:
Depth a al M hod
�p
From To F1.
From To Ft.
�
�-
`-
15. SCREEN:
Depth Diameter Slot Size Material
'� v
From To Ft In. in.
r .
r-
From To Ft. in. In.
From To Ft. In. In.
w
`-)
16. SAND/GRAVEL PACK:
N
Depth Size Material
From To Ft.
From To F1.
17. REMARKS:
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDRICE WITH 15A f4CAC 2r, ,trELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROViC£D -To THE ,?/S t- 0�%'rzF..
FOR OFFICE USE ONLY✓22L
Quad No: SIGNAT E OF PERSON CONSTFIL ,TING 1> t iv ELL D� r E
Submit original to Division of Water Ovalfty, Groun4Kater Soccn within :ri C%lys
CK.I F'EV. I.ri
So dal No.

North Carolina • Department of Environment and Natural Resources - Division of Water Duality • Groundwater Section 236091
1636 Mail Service Center • Raleigh, N.C. 27699.1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION 0:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential Municipal ❑ Industrial ❑ Agricultural ❑ Monitorir:g ❑
Aecovery ❑ Heat Pump Water Injecllon ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (S ow sketpP of the location below)
0
Nearest Town: County:
�,�fleSi»w
(Road Name and Numbers, Community, or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER Z ✓G�& it 4 (tia Ch 4 Cl --c From To Fonraxn Des_fiPU-
Address
treet or Route o.) V c
City or Town State Zip Code
4. DATE DRILLED 9) /,<''a
5. TOTAL DEPTH 2W
6. CUTTINGS COLLECTED YFS ❑ NOF-3---
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 FT. Above Land Surface -
'Top of casing terminated aVor below land surface requires a variance In accor-
dance with 15A NCAC 2C .01A
10. YIELD (gpm): VS METHOD OF TEST r
11. WATER ZONES (depth): 22 b
12. CHLORINATION: Type Amount �`� �� It additional space is needed t--s-- back of fr--
13. CASING:
LOCATION SK=TCH
Wall Thickness
Depth Diameter or Weight/Ft. Material (Show direction and dis.-..ance Iran ad leas' ,,vo Snate
From D To ' 0 Ft. G 22- sDe �� Roads, or other r,� refererrxe points
From To Ft.
From To Ft.
14. GROUT:
Depth �M,terial Method
l`iess���
l�
From b To ;,' Ft. �0�' "``I� q
From To Ft. x„.
t-� -
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft In. -in.-
From To Ft. In. In.
From To Ft. In. In.
C„ �i
16. SAND/GRAVEL PACK: C,,)
Depth Size Material N
o
From To Ft.
z
From To Ft.
17. REMARKS:
I DO HEREBY CERTIFY THAT,THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A DJCAC ?1, VtELL
'.
CONSTRUCTION STANDARDS, AND THAT ACO.PY OF,THIS RECORD HAS BEENI PROVICED TO THE Y!�". l Ot
FOR OFFICE USE ONLY pf'E
Quad No: SIGNAT RE OF PERSON CONSTRL rTING 1> c N ELL
to Divlttlon of Water ovatity, Gmr4w-alar Seam within C%Ys
SubrNl odpinal v.
GK,1 �
1:91
Sedal No.

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section 236090
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION 0: d.
STATE WELL CONSTRUCTION PERMITH:
1. WELL USE (Check Applicable Box): Residential[9-'� Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATIO J(�how sketch of the location below)
Nearest Town: "�4r`'`County:
10t, 71,9 127
(Road Name and Numbers, Community, or Subdivision and Lot No.)
3. OWNER r%?Y[ r�-/vG/'S
Address Cow 5?`'
greet or Roule o.
City or Town State Zip Code
4. DATE DRILLED
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑ NO[D--
7. DOES WELL REPLACE EXISTING WELL? YES 0 NOQ-
8. STATIC WATER LEVEL Below Top of Casing: _9 FT.
(Use '+' II 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 20 . ] 18
10. YIELD (gpm): METHOD F TEST /Zfy
11. WATER ZONES (depth):
Ir It4 9
DRILLING LOG
From To
0 - /
// zoo .
DEPTH
Forrrazn Desu l)60o-
C �y
v II additional space is needed ts•e back of form
12. CHLORINATION: Type �'� Amount �
13. CASING:
LOCATION SK-TCH
Wall Thickness
Depth Diameter orWeighVFI. Material (Show direction and distance from al leas: ;Ho S to
From To �— Ft. 6 Z 7 �yL Roads, or other rr—�? refere: point!
From To Ft.
From To Ft•
14. GROUT:
Depth jy)atega� Method
From
To 21— Ft.
From To Ft.
15. SCREEN:
Depth Diameter Slot Size
From —To—Ft— In.
From To Ft.in.
From To Ft. In. _
16. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To Ft. —
17. REMARKS:
Material
In. In.
In.
Material
W,
c�.
I
rn
:�:t•
ZZ
co
w
N
c7 ,.
M
'4
c->
CD
:e
DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDMICE WITH t5A P4CAC rL, VrELL
CONSTRUCTION STANDARDS,.AND THAT A COPY OF THIS RECORD HAS BEEN PROVICED 70 THE Yl=':L Ot%,%FF.•
FOR OFFICE USE ONLY•..
Quad No:
SIGNA RE OF PERSON CONSTRU:TING 'IXE owELL D� T£
Submit brlytnal to Division of Water Ouattty. Groun6walar Sracn within :ri C%rYs
Serial No.

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section 2360,37
1636 Mail Service Center - Raleigh, N.C. 27699-1636•Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION 0:
STATE WELL CONSTRUCTION PERMITN:
1. WELL USE (Check Applicable sox): Residential [�� Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
recovery ❑ Heat Pump Water Injection ❑ Other n If Other, List Use:
2. WELL LOCATIO�I ``how sketch of the location below) /
o County: l��
Nearest Town: L/
%,11 CleelC
(Road Name and umbers. Community, or Subdivision and Lot No.) DRILLING LOG
3. OWNER �Y h�y�a� _ From To
Address
(street or HoUte o.
City or Town State Zip Code /1<D 3 G p
4. DATE DRILLED q.00
5. TOTAL DEPTH ADD
6. CUTTINGS COLLECTED YVS ❑ NO❑-
7. DOES WELL REPLACE EXISTING WELL? YES [] N0D-
8. STATIC WATER LEVEL Below Top of Casing: 2-0_.FT.
(Use '+' If Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface -
'Top of casing terminated attor below land surface requires a variance In accor-
dance with 15A NCAC 2C .D118
10. YIELD (gpm): , '/D METHOD OF TEST /2 '
11. WATER ZONES (depth): 50
DEPTH
Forra5un Descripuo-
Clci
12. CHLORINATION: Type 1�%lf Amount It additional space is needed L­,e back of fc-cm
13. CASING:
Wall Thickness
Depth Diameter of l i ht(Ft.
From O To Ft.
From To Fl•
From To Ft.
14. GROUT:
LOCATION SK=TCH
Material (Show direction grid d-es~ance fr,,m a:I le= royo Stele
Roads, or other n~.--p refere:ce points`
r�
a CD
Depth a, e at NJqthod
From © To Ft.
From To Ft.
15. SCREEN:
Depth Diameter Slot Size
From —To—Ft— In.
From To Ft. in. —
From To Ft. In. —
16. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To Ft.
17. REMARKS:
DO HEREBY CERTIFY THAT.THIS WELL WAS
CONSTRUCTION STANDARDS, AND:THd�f A'C
i
FOR OFFICE USEONLYi1 1UH
Quad No:
Submit orl(
Serial No. s �
Material
In.
In.
In.
Material
C
c-�
t
cr,
ate•
C17
CA3
Na
CONSTRUCTED IN ACCORDANCE WITH 15A 04CAC?'.:, YELL
ORY OF THIS RECORD HAS BEEN PROVICED 'JO THE '!l=°—t Q%% %EF-
GNATURFOF PERSON CONSTRIY.%TING 1>t w'£LL
Io Divltdon of Water puality. Groundwater Se=n within :4 C;srys
p`.'r E
C.K•I FigV. 12?1

North Carolina - Department of Environment and Natural Resources . Division of Water Quality • Groundwater Section 7 3 t) l) $ 3
1636 Mail Service Center • Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELLCONTRACTOR:
WELL CONTRACTOR CERTIFICATION N:
STATE WELL CONSTRUCTION PERMITN:
1. WELL USE (Check Applicable Box): Residential3 Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Aecovery ❑ Heat Pump Water Injection ❑ Other E] It Other, List Use:
2. WELL LOCATION}}• ( 77ow sketch of the location below)
Nearest Town: /14��'i/tyiA County:
Gre. l4 m
(Road Name and Numbers, Community, or Subdivision and Lot No.)
DRILLING LOG DEPTH
3. OWNER "r077 P1I/ 62122/9LL __
From To Forraxn DescriPt;o'
Address
trees or Route o.
zs--_
City or Town State Zip Code
4. DATE DRILLED
5. TOTAL DEPTH 26
6. CUTTINGS COLLECTED YFS ❑ NO[D-
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NOEa
8. STATIC WATER LEVEL Below Top of Casing: ZD FT.
(Use '+' if Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface'
'Top of casing terminated eVor below land surface requires a variance In accor.
dance with 15A NCAC 2C .0118
10. YIELD (gpm): _?0 METHOD OF TEST �r
11. WATER ZONES (depth): ,2Sb
12. CHLORINATION: Type Yry Amount
It additional space is needed tse back of form
13. CASING:
LOCATION SK= fCH
Wall Thickness
Depth Diameter or Weight/Ft. Material
(Show direction and dunce lrxn ;E.1 leas 'feo S:.ate
From To 'i Ft. -2r si,42l ',41'�C'
Roads, or other rr.---p relere:ce points`
From To Ft.
From To Ft.
14. GROUT:
`='
Depth Material Method
o
c
From D To ,26) Ft
From To Ft.
15. SCREEN:
� r
Depth Diameter Slot Size Material
J
From To Ft In. in.
!"
r''
From To Ft. In. In.
CO
..
«'='
m-�
From To Ft. in. In.
c
"
16. SAND/GRAVEL PACK:
`D
Depth Size Material
From To Ft.
From To Ft,
17. REMARKS:
100 HEREBY CEF
CONSTRUCTION F
FOR OFFICE USE
Quad No:
r THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A f 4CAC Y,:,'/fELL
)S,,AND'THAT A COPY OF THIS RECORD HAS BEEN PROVICED 'TO THE VIV-L 01%*'EP-
SIGNAT RE OF PERSON CONSTRIY:TING 1rE ,WELL
Submit original to Division of Water Ovalily, Grovn Walar Sracn within Vi C%Ys
DA-' E
601.1 PIS v. 1:91.
u-:
Serial No,
<au

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section 36082
21
1636 Marl Service Center - Raleigh, N.C. 27699-1636•Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: o%`le l
WELL CONTRACTOR CERTIFICATION P:
STATE WELL CONSTRUCTION PERMITN:
1. WELL USE (Check Applicable Box): Residential Municipal ❑ Industrial ❑ Agricultural 0 Monitorir g ❑
Aecovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2.
3
WELL LOCATIO (,S//how sketch of the location below)
Nearest Town: D O��S�/< County: ''
f/Are-3 Geed
(Road Name and Numbers, Community, or Subdivision and Lot No.) DRILLING LOG
OWNER 7e7E� So��ww From To
Address
4
(Street or Route o.
City or Town Slate Zip Code
4. DATEDRILLED
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑ NO[
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NOE�
8. STATIC WATER LEVEL Below Top of Casing: C Q FT.
(Use '+' if Above Top of Casino)
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): 3 METHOD OF TEST��
11. WATER ZONES (depth):
DEPTH
Forrrabn Description.
12. CHLORINATION: Type lV7* Amount ��" If additional space is needed rye back of fcirrn
13. CASING:
LOCATION SK=TCH
Wall Thickness
Depth Diameter or Wet h t. Material (Show direction and d's ance trcm ;�i leas: tNo -s:tale
From To 105— Ft. 6' 2;— lRoads, or other n-rGp relererrry points!
From To Fl.
From To Ft.
14. GROUT:
Depth�ria Method?
a
From To ;B' FL / esSur�
From To Ft. C
15. SCREEN:
Depth Diameter Slot Size Malarial
From To Ft in. In.
From To Ft. in. In.
From To Ft. In, In.
16. SAND/GRAVEL PACK: N
Depth Size Material
From To Ft.
From To Ft. --
17. REMARKS:
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCOROANCE WITH 15A PJCAC ?r,'/rELL
CONSTRUCTION $TAN,DARDS AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED 10 THE 'N 0t%'1EF-
,,A 3 I1'. Ii � ..
FOR OFFICE USE ONLY
OF PERSON CONSTFILnTING t'"'ELL
SIGNA URtat "'ELL
Quad No:
Y i original to Divfslon of Water Ovality. Grw r4w&tar Sr= within :ri C%ry3
CM•1 PigV. 1271
Serial No.
ril't', 10PIV 4j

Oft" COMWN
Sarv- Cam . of Env�ro wwwd and Natural Pasourm • DK4W*n of Water Ouauy • Qroundwaar Socdon �, _L t l 3
Aalatph, N.C. Z7490-16364ftrw (91 t) 7 -MI
WELL CONSTRUCTION RECORD WILL CWELL ►CTo :c RT � CATiON A: �� 5-�__
STATE mu CONSTIIucnoN Popimmo.
1. WUL.L USE Apokabio Soak Pissidtnild ?O MuniNpal ❑ lmw' svw ❑ Agricultural ❑ MONtorinp ED
Pleoovery Meat Pump Water 1f-0c bn © OOW ❑ If Other, Litt Utt:
Z. WELL LOCA'I'IQ�: okMoh of We bn*m below) a
Ns omet Tewn: �,:{:Z�3 4' � .� l c� CotettY /_ e,-1 tt err
(Flap 1io
Marnaa,cf.«
dRlL11i�® LOEP'1_'�I
S. OY1oNi1�1 �
V C
Prom To lraar+atan OSSrlpSmn
P
Addeen
4. DATE DFULLED .3 tza a o
S. TOTAL. DEPTM _ I -
-
S. WTTMI COLLECTED YES M "0 '
7. DOES WELL PWLACE EXiSTI WEL.L'P
,......�_.
0 NOEM
_-
S. STATIC WATM L.lNEL Seiow Top of Ca*q: 4b FT.
o�
h). TOP OF CASING FT. Above Land Stxitoe•
'Tap of lead, Wor below WW owlemerstpAw a verlsi m In mama+•
dm�sa ailM 1SA 14" to m tit
io. Y11MO (own)• ...ISM METVM+j OF TEsT
11. WATRPI ZOMM (depm):... 7
12. OKORWATION: Type M"nt ©. /3
P ed0ldorW @pow 1s needed use be* d loran
13. CASM:
Depth as t#aM 7htlslrtmas Isom"
From To Ft.. 6 V-4 Y 4
(Show dh soft ®nd dltlanoe km at 16M two SWS
.
Pbeds. or other flop roWenoo pok ft)
Frorn� TO..eMM.. Ft. -..a....,.. ............ M..M_...M
Frey»
14, ciw+OLJT:
Depth MphOd
-C., i�c-� c��� Z g N � e 3-3
From ..MQ To � Ft. (.,L� 5 Frost
_To _ Ft.
Depth Dianteltr Slot Sine Me*"
From ,_,..,,, To ..o.� Ft in. _ _,. in.
pow"
TO Ft. - in. ...._... in.....�.
irtoott To
� - Ft. - In. -In.
1 S. SA1D011AVft PACK:
(ram
DOPM spSO Mau"
eld
id
Ftorrt ........_ To - Ft...�....,,..
From To PR.
�„�„� _
100 Ht1M@y CtS1T1FY THAT THIS WELL WAS COW I FVXTt1;0IN ACCOPMANCE WITH 111A NCAC IC, WELL
OONS i MUCTION STANOAPIOSI AND THAT A COPY OF TM PMOORD MM ti M PhOVIDED TO THE WELL OWNED!
o()
ShQMAIWOF MOM CONSTW=NQ T!# Wg" DATE
OOW to Cmftm of Wow Ou ft. Oraw+dsew Soevom Within 30 days
aw-S P&V. IV"

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone] i 8 6 3 9
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION #: O S
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Cheek Applicable Box): ResidentialEl Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery [] Heat Pump Water injection ® Other M If Other, List Use:
2. WELL LOCATION: (Sh w,sketch of the location below)
Nearest Town: �i va 1 elele County: Coun
(Road Name and Numbers Community, or Subdivision and Lot No.) DRILLING LOG
3. OWNER _��1� c��, �.� yL� �-p From To
Address •-D � 1
�--� reet Or HOUtO o.
City or Town State Zip Code
4. DATE DRILLED a
5. TOTAL DEPTH / .g"el'
6. CUTTINGS COLLECTED YES M NOE]
7. DOES WELL REPLACE EXISTING WELL? YES NOE]
S. STATIC WATER LEVEL Below Top of Casing: 1 d FT.
(Use '+• If Above Top of Casing)
9. TOP OF CASING IS�FT. Above Land Surface*
`Top Of casing terminated at/or below land surface requires a variance In accor-
dance with 16A NCAC 2C .0116
10. YIELD (gpm): / 0- METHOD OF TEST
11- WATER ZONES (depth): 1 %
DEPTH
Formation Description
n
1
c;�
r
•
c-i
CO
O
12. CHLORINATION. Type Amount , a ®
If additional apace Is needed use back of form
13. CASING:
Wag Thickness
Depth r Diameter or WeighVFt. Material
From-0 To 4/ Ft. _ SDI a } c
��--
LOCATION SKETCH
(Stow direction and distance from at least two State
From
_
To Ft.
Roads, or other map reference points)
`Q-�'
From
To Ft,
0��
14. GROUT:
�.a-� 1 `.
From
Depth Material Method
To _ Ft. �rnk f 5c
YY� " t � �e � 1 or, � ,ILI"
d
From --To
15. SCREEN:
Ft.
3 cJ
�L'�✓` 1�
Depth Diameter Slot Size Material'
From
To Ft in. _ In,
From
To Ft. _ In. _____ In.
From
16. SAND/GRAVEL
To Ft. In. In.
PACK:
3/ r
From
Depth Size Material
From
To Ft.
To . Ft.
17. REMARKS:
tl
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.
J
SI"TUAE10F PERSON CONSTRUCTING THE WELL DATE
ON" to Division of water Ouslity, Groundwater Section within 30 days
Gw•I REV. 12t99

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section p
16M Mail Service Canter - Raleigh, N.C. 273t? I63d-Phone (tit E) 733.3221 6 40
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION 0:
STATE WELL CONSTRUCTION PERMIT#:
- rrarrerrorrrrr�r
irrw�rw uorrrev, �.�orsrrr�rr,ri��rrrrrr�rrrs�i r - __ - --_ -_
1. WELL USE (cheek Applicable sou): Residential ❑ Munlclpal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, Ust Use:
2. WELL LOCATION: (Show sketch �� a location below) ¢�� o �
Nearest Town: - nty: z �-W
(Road Name and Numbers, or tSub&Aslon and Lot No.) DRILLINg LOG DEPTH
3. OWNER RFrom To Formation DeserWon
(arm or now 0.1
City or Town stale ZIP Cods ------ ---�"
r�
4. DATE DRILLED x; 2 a a -
S. TOTAL DEPTH `Litz'
6. CUTTINGS COLLECTED YES NO® ----- --;� - ., -
7. DOES WELL REPLACE EXISTING WELL? YES M NOM
S. STATIC WATER LEVEL tWow Top of C"ng: a FT.
IV" '+'MAbove Top OlCaft)
9. TOP OF CASING is FT. Above Land Surface•,'
`TOP Of O"hV ar+nlnabrd atlor below tend outlaw requlree a veriamw in aeeor-
dance with 15A NCAC aC .011e Y
10. YIELD (Wm): _ METHOD OF TEST 6qr-
11. WATER ZONES (depth): 370
ee
12. CHLORINATION: Type ITN Amount 7 If additional space is needed the Deck of form
13. CASING:
Wag Thickness
Depth DlajneW or WO#*TL MaterialFrom 0 To 53 Ft. 6 Y49 -Pvlc-_
Front To Ft.
From To- Ft.- ..�
14. GROUT:
Depth
Maprial Method
'
From
To 2-0
Ft. Cem�
S'
From
To
Ft.
11S. SCREEN:
Depth
Diameter
Slot Stu Material
From
To ___._ Ft
In.
In.
From
To Ft.
In.
In.
From
To Ft.
In.
in..
16. SANO/GRAVEL PACK:
Depth
Size
Material
From
To
Ft.
From To Ft.
17. REMARKS:
LOCATIQU 3Kt ?CH
(Show dIrWlon and distance from at least two $tat@
Roads, or other map reference points)
p t, �Lk� .� %-c /.
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I BA NCAC 2C, WELL
CONSTRUCTION STANDARDS. AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OF N % d
Ouad No: E OF RWN CONMUCT1Nd THE WELL DATE
OrfOW to Dfrtslon of Water ouaBty. Groundwamr 111soon within 30 days
sow No. 4w-1 AEV. IV"
7
�f I �001)

North Carolina - DOPM r»nt of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 MaN Service Center. R"O. N.C. 276WIG36-Phone [phone] .� 8 6 41
WELL CONSTRUCTION RECORD WELL CONTRACTOR: ' �-
WELL CONTRACTOR CERTIFICATION 0: o? O Sa
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Appocabte Max): residential® Municipal ❑ Industrial Q Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection [] Other (3 It Other, List Use:
2. WELL LOCO ( ow sketch Of the ktcatlon tWm) Courtly.
Nearest Town.��� � t vLLp lam.
(Reed Name Comm. *- Of SubdMsion and lot No.) DRILLING LOG
3. OWNER ,u- Fran To
Addrllee . Z
297 7 I
CNy or Tewn drab ZIP Cods
4. DATE DRILLED 4 fi zL a ) n
S. TOTAL DEPTH --ao S
6. CUTTINGS COLLECTED YES M NO®
7 DOE
ED PTH
Formation Description
S WELL REPLACE EXISTING WELL? YES [] NO©
8. STATIC WATER LEVEL Show Top of Cata ft: 40 FT. Q
(UN •.' 1 Above Top s(Caalrp)
9. TOP OF CASING IS
.___�_:. _ FT. Above Land Surface'
'TOP Of 6281"1 MrWnaMed *Vor b0ow land surtaoe
dance wftl� tiA NCAC aC .41is ro**" a vaAarm In a000r- - _--
10. YIELD (gpm): METHOD OF TEST
11. WATER ZONES (depth):
12. CHLORINATION: Type Amount 0.3o It eddltiorlal ape« Is needed use back of form c>,
13. CASING: --4
�p v
Depth ThIcI m
Dta br or Wev*7t. mwerlal
From ,. To - 3 v Ft. _ SbC12 all - vc
From TO Ft.
From -----.To— Ft..�._.,
14. 13ROUT:
Depth M dw Method
From _,, a- To —:11:1
From To Ft.
1S. SCREEN: —�—
Depth Diameter Slot Size Material
From To _ _ ., Ft in. In.
From To Ft. In. In.
From ......._. TO Ft In. In.
10. SANDIGRAVEL PACK:
Depth sin Material
From ....._... To .._.__ Ft.
From To_ Ft._
17. REMARKS:
6Wkd1I$m KS EYCN
(Show dkeoWn and distarim from at least two State
Roads. or Other map refersrce prints)^
T� I-Y 3�VI�
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 1 SA NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
ouad No.
SOW No.
OF PSRWN CONmucma THE WELL DATE
a Dlvislon of water Ouellty, GrOwwwaler Section within 30 days
GW-.1 REV. t2Htl
M
ro,andwater Section
�xiile Re f n I Ofii

North Carollna - Deparmwnt of Environment and Natural Resources - Division of Water Quality - Groundwater Section p rc
16W Mail Service Center - Raleigh, N.C. 270W1ON-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: �''�'
WELL CONTRACTOR CERTIFICATION N: c� O
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE Check Applicable sox), Residential 0 Municipal [I Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery Heat Pump Water Injection ❑ Other ❑ if Other, Ust Use:
2. WELL LOCATIX: (Dow sketch of the location below) Q
Nearest Town: }{ X"Ac-&, county: '►`+L l rt
(Road Name and Numbers, Corrvrumity, or Subdivit Ion and Lot No.)
DRILLING LOG DEPTH
3. OWNER ,fi t ��`Ywy
From To Formation Description
Address
�—(SE ore 4109 No.)
City or Town State Zip Code
4. DATE DRILLED / Zo
5. TOTAL DEPTH 2, 8 a'
t� - -
6. CUTTINGS COLLECTED YES [] NO®
-
7. DOES WELL REPLACE EXISTING WELL? YES [] NO[Z] -
--
B. STATIC WATER LEVEL Below Top of Casing: / ti e FT.
(Use's' N Above Top of Casing)
,
8. TOP OF CASING is FT. Above Land Surface'
'Top of Casing terminated st/or below land surface requires a valance In accor-
= c
denoe with 11A NCAC ZC .01 i I
10. YIELD (gpm): —d METHOD OF TEST Jq/i/t-,
11. WATER ZONES (depth): / 8 4
... c�
12. CHLORINATION: Type Amount 0,
If additional space is needed use back of form
13. CASING:
Wall Thickness
Depth DiarJvtsr or Weight/Ft. Material
From © To _ 13 Ft. —"'V_ app L V L
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From © To ;- 9 Ft. U�
From To Ft.
15. SCREEN:
Depth Diameter Siot Size Materlal
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:
ATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference o points)
xS%�'
Cal L-Z (P 0pk2 l 'L (l\&'U" o L"/,`-
YYu-�-•t,ti�.,�-.,
j Y3
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.
`J / a a".)
SIGNATURE OF PER N ST CTING THE WELL DATE
original to Division of Water Quality, Groundwater Section within 30 days
GW1 REV. 1M

Nonh Carolina - Depanment cf Environment and Natural Resources - Division of Water Quatity - Groundwater Section � � Q C '� t`
1636 Mail SsrA* Ceruer • Raloo, N.C. 27699.1t'l36-Phone [phone] v U .) U
WELL CONSTRUCTION RECORD WELL CONTRACTOR: SA�
WELL CONTRACTOR CERTIFICATION 0: gR0
STATE WELL CONSTRUCTION PERMIT#:
�. rrrrr�u�.r r, s.r�rr.r.rrrs.r�rr�, I. WELL USE (Cho" Appkewe Sort): Residential Ej Municipal ❑ Industrial ❑ Aprbcuitural ❑ Monftoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCH (Show sketch of the location below) p�
NCO~ Town: _�Pp o County:
(Road Name and Numbers nnurVty Cor, or and Lot No.) OR LUNG
LOG t�E_PTH
3. OWNER o 1 r c r . �A� JL�' From To Fom+ation DWrtptte++
Address Z ..
�a- '7 `?
r-,
My or Town awe Zip Code :
4. DATE DRILL.EO
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES,❑ NO® ,
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NOEI
8. STATIC WATER LEVEL blow Top of Casft: Se� FT.
) B. TOP OF CASINO 13 FT. Above Land Surface•
-rep of e"Wo eerr"Med Myer below ea+d a wfm requires a vularras M spoor• — r
denm v*b 1aA NCAC aC A114 _
10. YIELD (gpm): METHOD OF TEST ..-L-
11. WATER ZONES (depth): IS" 3
12. CHLORINATION: Type % Amount ©s ff addlSenaf spans is needed us* back of form
13. CASING:
from O To - 5-2- Ft..� _ 2Vj
From To-----.- Ft.
From To FL
14. GROUT:
Depth � M�tefhf Method
From ._ To �_ Ft.Q��7� t S
From To Ft. -
1 S. SCREEN:
Depth Diameter Slot Side Material
From
To
Ft
in.
in.
From ._
_..,. To
Ft.
In.
In.
From
To
FL
In.
In.
16. SM01GRAVEL PACK:
Depth size Material
From To Ft.
From To Ft.
17. REMARKS:
LOCATION SKETCH
(Show diwcWn and distance from at least two State
Roads, or outer map reference points)
o Yruj.ea.
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 1 SA NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFI 9
MASON C&STRUCTINQ THE WE" DATE
Cued No: 6e of weer ouslMy, aroa+dwaar seamn within 30 days
so" No.
�' "�. 9f
ow-1 rsv. tans

North Carolina . Department of Environment and Natural Resources . Division of Water Ouality • t3roundwater Sst:t]on �� B 6 ? 50
4
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town:' ^ `a' ` r County:
(Road Na end Nu s, corn", or au Ivtston Lot No.) DRII.LINQ LOCI _ .DER K-----
3. OWNER )4A -- 4,41 (3
Frorn To Fom+stlon O*WtVUW
Address _ 2-------
'ZS 7 t -
Cay W Town sb4e ZIP Cods
4. DATEORILLEO �/� ��`� _
5. TOTAL DEPTH Q Z '
6. CUTTINGS COLLECTED YES ❑ NOQ - C).-.-
7. DOES WELL REPLACE EXISTING WELL? YES [] NO© -
a. STATIC WATER LEVEL Below Top of Casing: 14 t3 FT•
(toss'.' 1 Apow Top of Caeing)
Q. TOP OF CASING is FT. Above Land Sumacs' r„
-Top of caelrKl tenvanoW Wor Wow land surface requlrae a vertenoe In after• _ =,
serves w *h I &A HCAC 2C .t111 •
10. YIELD (pm): .. METH OF TEST 61�
11. WATER ZONES (depth): % S _ o c
12. CHLORINATION:
13. CASING:
Type r Amount 0 .3 d If additional space is needed use back of 10iW
Watll THakron
Depth Dtart�eeer or WeIpMfFt. material
From�.,...To .—.. - Ft..�.—
From To Ft.
From To Ft.— ------
14. GROUT:
Depth Material Method
From To 2-G, Ft. (-1Qru=i% LQ
From To —Ft.
15. SCREEN:
Depth Diameter Slot Sits Materw
From To Ft In. in.
From To Ft.In. In.
From To Ft. In. In.
td. SANDGRAVEL PACK:
Depth Size Material
From — To Ft.._._._.,..._
-LnrATtot SKETCH
(Shaw direction end distance from at ]east two State
Roads, or other mep reference points)
dk
From — Toe Ft.
17. REMARKS: - - - —
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 1SA NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER,
FOFR OFFICE O M
Clued No: O u �
U E 6F PEMON CONSTRUCTM THE WELL DATE
to Division of Water Otwttty, OmwWwaler Sm*on within 30 days
se" No. 71 ? tiWt qEV. t2/M

North Carolina - Department of Environment and Natural Resources Division of Water Quality Groundwater Section 2 . C C�
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 ❑ Heat Pump Water Injection ❑ Other [] If
Other, List Use:
2. WELL LOCAT (how sketch of the location below)
Q ' County:
Nearest Town: °r--�
DEPTH
DRILLING LOG Formation Description
_
(Road Name Nu ers, Corr}munity, or Subdivision and Lot Na.)
3. OWNER 11I�_�_��-
From To
Address ,'Z
._ re or
City or Town State Zip Code
CD '
4. DATE DRILLED
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑ NO
7. DOES WELL REPLACE EXISTING WELL? Y S ❑ NOM
u
8. STATIC WATER LEVEL Below Top of Casing: 4 O FT.
(Use '+' if Above Top of Casing)
9. TOP OF CASING ISFT. Above Land Surface`
„
CD rn�
*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): P,::Z©
—
12. CHLORINATION: Type Amount
If additional space is needed use back of form
13. CASING:
LOCATION SKETCH
Wall Thickness
Depth Diameter or Weight/Ft. Material
(Show direction and distance from at least two State
From To Ft.
Roads, or pother map reference points)
From To Ft.
t11 J a -A- -
From To Ft.
J4„ a,�o l trl �5 / d
09�2
14. GROUT:
Depth Mate ia! Method
) �"�� /
C�1 op-g
4P d ,/}�
From 0 To �_ Ft. U,)-Sd�
�
From To Ft.
15. SCREEN:
�
t "�' �aQ'
Depth Diameter Slot Size Material
From To Ft in. —in.—
✓�'
From To Ft. in. in.
in.
From To Ft. in.
16. SANDIGRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft. --
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 20, WELL
COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER,
CONSTRUCTION STANDARDS, AND THAT A
FOR OFFICE USE ONLY
DATE
Quad No:
SIG TU F PER N CONSTRUCTING THE WELL
Submil original to Division of Water Quality, Groundwater Section within 30 days
{
raj
GW1 REV. 12/99
Serial No,

North Carolina • Department of Environment and Natural Resources - Division of Water Ou0j. - Groundwater Section O
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]?21
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION M:
STATE WELL CONSTRUCTION PERMIT*:
1. WELL USE (*wok Appiltabis Box): Residential[ Munkipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water in}ectlan ❑ Other ❑ If Other, List Use:
2. WELL LOCH ( h w aketch�of/the location below)
Nearest T01Mn: i ' �`—"^> a—z COouw. J t ►'� ��n,nnry�
(Road Kama and tHwmm, Coniffounity or Sub*AWw and tot No.) DR16WN La OG
3. OWNER ,jC J;a;;!j Yyyc S0 From To
Addraaa�w--
�._ ` 177�, -
CMy or Town etaN Zip Code
DEPTH
Fom)adon DeeerfpOW
4. DATE DRILLED �' i0 010
1:-
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑ NOQ
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO©
1-1 L }
-0
S. STATIC WATER LEVEL Below Top of Casing: 6�O FT.
(u'a' I AboMe Top of CAWQ)
ee
9. TOP OF CASING ISLFT. Abow Land Sudwe'
'Top of eastry WwAielled alder below land aarfaoe n"Wires a varlanae In soda•
r-i
dense wMA 1&A NCAo *C M 1a
METHOD OF TEST
. " r7l
10. YIELD (gpm):
r
11. WATER ZONES (depth):.2 0�"-
12, CHLORINATION:
13. CASING:
Type I7'- Amounts 4 It additional space Is needed use back of form "
Wag I'Mol tsse
Depth or WNgWR. Ma* ta!
From © To9 Ft. 5i -
From To_._-.- Ft. -------
From To Ft.
14. GROUT:
Depth Method
From To .;5`,Q Ft, a�._...._
From To Ft.
15. SCREEN:
Depth Diameter Slat Size Matartal
From To Ft In. In.
From To Ft. o._-__ In. In.
From To Ft...._.r, In, In.
IS. SANDIGRAVEL PACK:
Depth Size Material
From To Ft.—
From To Ft.
17. REMARKS:
LOCATION SKETCH_
(Show direction and distance from at Nast two State
Roads, or oftrr map referenoe Onto) _
ej
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
0ONSTRUCT10N STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
AuW No:
Ssdal No.
r r �
it;oc" OF PEMm CONSTRwrime THE WELL DATE
mah-A oftgfrW io Division of water Oja ty, Omw4wetar $*Won within 30 days
777
GW-1 REV. IV"

nt of Envlronmant and Natural Resources • Division of Water OusHty • Groundwater Section (� � �� r1 j !?
North Carolina • Departure J c7
1636 Mail Service Cartter • Raleigh, N.C. 27699.1636-Phone (g19) 733-3221 A n
OR-
1PVELl CONSTRUCTION RECORD WELLACT
CONTRACTOR CERTIFICATION M: EZ o s
STATE WELL CONSTRUCTION PERMITC
Municipal
1. WELL USE (Ch*ok Applicable Box): Residential ❑ ❑
Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water In)ection ❑ Other ❑ If Other, List Use:
2. WELL LOCAT{t�N: ($w sketch (A the location below)
�(/� , ,�
Nearest Town: County:
No DRILLING LOB
(Road Name and�Nut'c Comm�u� r Su'!� s'^ Lot y From To
3. OWNER It c� Y tu,
Address q AA* ,') Cu ! �
� arC_aY,L-T77, --n L -
a or Town State Zip Code
4. DATE DRILLED /D-O a"
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑ NOW
7. DOES WELL REPLACE EXISTING WELL? YES ❑ No
S. STATIC WATER LEVEL Below Top of Casing: /9_ FT.
(rise'+• M Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface'
'Top of casing lerminaled *Vor below land surface r"ulres a varlanes In accw-
data* wtitb 14A NCAC 2C .011e
10. YIELD (gpm): 7 METHOD OF TEST �._-ti'" --
11. WATER ZONES (depth): �.d
12. CHLORINATION
13. CASING:
DEPTH
Fomulton Dacrtption
t
co
N
--+
0
Type /7 �� -Amount If additional space Is needed use back of form
Walt Thickness
Depth DIalrnater or WeighVFt. Material
From To 5 7 Ft.------`�--- bra- vL
From To Ft. —
From To — Ft.
14, GROUT:
Depth Material _ ,� Method
From 15 To .2, 0 F02&�
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 referenosLPoints)
o� Crr'
(J ,
aup
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
Ouad No:
Subrni) orl
Serial No.
3
j
%( C
l PER N CONSTRUCTING THE WELL DATE
o Dms(on of Water Quality, Groundwater S*otion within 30 days
GWt REV. 12M

North Carotins - apartment of Environment and Natural Resources . Division of Water Quality - Groundwater Section
16M M" Service Center • Aalelgh, N.C. 276WIS36-Phone (E19) 733.3221
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION 0: 0 o
STATE WELL CONSTRUCTION PLrFimrr#:
1. WELL USE (ChOGIC APOIoeble Box): Flosidentlal ® Municipal[] Industrial ❑ Agricultural Monitoring ❑ Recovery ❑ Heat Pump Water Injection ❑ Other ❑ if Other, List Use:
2. WELL LOCATION�: Sh�,w sketch of the location below)
Nearest Town:. __��t�� o i / County: _
(Plow HaR+s
3. OWNER ' Of &MOvision and Lot No.) DRILLING LOG DEPTH
Address 1W From To Fomoatiort Dwription
Cly or Tewvt _
tilalaCD
4. DATE DRILLED, v �o Code f
5. TOTAL DEPTH a 0-5;_ cry
5. CUTTINGS COLLECTED YE -So NO
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO] t
B. STATIC WATER LEVEL Below Top of Casing: FT.
B. TOP OF CASING IS / (Us@'+* M Above Top of Csafnq)
_ FT. Above Lane! Surface.
'Top N easing UrrnMaled War below land surface
dames uglify tiA WCAC 30 A11 fi dukes • varlsnse M aoeer•
10. YIELD (gpm): .LS _ MtTHODOF TEST - 64 "
11. WATER ZONES (depth): -
12. CHLORINATION: Type --ITN Amount o - 2 3 tf additional space Is n*Wsd use back of form
13. CASING:
Well Thlohrms LOCATION SKETCH
DepthDlaf++sta► or WeiipWA. Lute" (Show direction and distance from at least two State
Froft►-- 6 To S3 Ft. S.1 R_*2_1 ?..V c Roads, or other map reference going)
Frofn� To - Ft.,._..
From -To FL_.._....
14. GROUT. -
Depth Maternal Method
From ._.0r__ To .0 Ft.5a,Ty�+ C rtL j 1
4 a j PV--/ 41 S
From To Ft. o 'f� orly1�rir� 1
15. SCREEN:o
Depth Diameter Slot Stafi Material /�•l From To Ft M. ______ in. �
From To ._.r. Ft. In, in.
From To FL in. In. �yYu,%v� e r ��• �` fZ yr'
1 S. SANDMIRAVEL PACK: _i, t)LZ- )IA
Depth Sias Material
From To .._.__... FL -
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 OFF= USE ONLY L6 q 3 a '.-_0 a 0
Ousd Woe CF MRAON CONSTRt1Cwi THE woo DATE
tieAal P10. suW*rt Wgi w WMAWOM W water Ouelity. Omunftwer tieWon within 30 days
QW-1 REV. 12M

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section s O
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone] r
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (check Applicable eox): ResidenUalLld Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below) /�R�
Nearest Town: R0 klo s %j l �'- County: (9
.T
L I.- u L.A d
(Road Name and Numbers, Commune , or Subdivision and Lot No.)
*act
DRILLING LOG DEPTH
3. OWNER u)P.✓ 4TT-e0—SL')
From To
Address �7
/oS• C5ForrmationDescripgon
� `
S
ree or ou a o.
,L:2
a v� OA)
City or Town 81ale Zip Code
4, DATE DRILLED 2-5 .d, v
5. TOTAL DEPTH Y�
6. CUTTINGS COLLECTED YES 0 NOE3 —
7. DOES WELL REPLACE EXISTING WELL? YES F-1 NO�
S. STATIC WATER LEVEL Below Top of Casing: J " FT.
(Use '+' It Above Top of Casing)
9. TOP OF CASING is FT. Above Land Surface•"--,•:
•Top of casing terminated sVor below land surface requires a valance In accor-
dance with 15A NCAC 2C .0118 ll
10. YIELD (gpm): �_ MET OD TEST
;
QF
11. WATER ZONES (depth):
12. CHLORINATION: Type 7/ Amount
It additional space is needed use back of rm
13. CASING:
LOCATION SKETCH
Wall Thickness
-) Depth D ameter or ei ht/Ft. /I taterial
From �' To Ft. L * �.Z,L L
(Show direction and distance from at least two Stale
Roads, or other map reference points)
From To Fl.
From To Ft.
14. GROUT:
Depth Material Method
From To 20 Ft. i
From �n To ZO,_�_ Ft.
15. SCREEN: L
Depth Diameter Slot Size Material
From To Ft in, in.
From To Ft. in. In.
From To Ft. in. In.
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS; AND THAT A COPY OF THIS RECORD H EEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Quad No: SIG RE
R N NSTRUCTIN THE WELL DATE
Sutxnll orlpiri>SI to Dt r W. Groundwater Section within 30 days
Serial No. GW4 REV. 12199

North Carolina - Department of Environment and Natural Resources - Division of Water Quality • Groundwater Section O 3 6 1213
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone] C.
WELL CONSTRUCTION RECORD WELLCONTRACTOR:
WELL CONTRACTOR CERTIFICATION #: ��03
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: XA22, jlr'`lle County:
GoId �W,
(Road Name and Numbers. Community, or Subdivision and Lot No.) DRILLING LOG
3. OWNER E o-' e,24 /10we l/ From To
Address
IS —
(Street or Houle o. S
City or Town tale Zip Code
S s �rVU
4. DATE DRILLED 2 —2-0 - 00
5. TOTAL DEPTH 3-00 '
6. CUTTINGS COLLECTED YFS ❑ NOEE---
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO�—
B. STATIC WATER LEVEL Below Top of Casing: 1.2-y FT.
(Use '+' If Above Top of Casing)
9. TOP OF CASING IS ! FT. Above Land Surface -
'Top of casing terminated at/or below land surface requires a variance In accor-
dance with 15A NCAC 2C .01 IS y� j�
10. YIELD (gpm): & METHOD OF TEST 4
11. WATER ZONES (depth): DES
DEPTH
Forra5an Description
C
12. CHLORINATION: Type �- Amount �� �� It addWonal space is needed ts-e back of fcrm
13. CASING:
LOCATION SK=TCH
Wall Thickness
Depth Diameter or WeighVFt. Material (Show direction and dis- ance from aI leas::Ho Stale
From O To G L Ft. 6- 2 5' 5W21 Roads, or other rrrcp relere:ces points`
From To Ft.
From To Ft.
14. GROUT:
Depth erial lhod
From To Zd Ft. �/Tlasz� lr�ss�re
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft in. in.
From To Ft. in. In.
From To Ft. In.
16. SAND/GRAVEL PACK:
Depth Size
From To_ Ft.
From To Ft. —
17. REMARKS:
In.
Material
ysw
C
G7
I
o,
90
c-a
c:
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCOROMICE WITH 15A P4CAC PC, virELL
CONSTRUCTION STANDARDS, AND THAT COPY OF THIS RECORD HAS BEEN PROVICED -TO THE VIS!.l O %%NEF•
FOR OFFICE USE ONLY
SIGNATU OF PERty
SON CONSTR:TING llc fv ELL
Quad No:within
0� �1
Submit 6 ginai to Division of Water C3ualfty, Grpund.�7ttor Srrtn withinh C%sYs tK•t Gss; V. 12>'1
Serial No. -- i
S

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] 236134
.
WELL CONSTRUCTION RECORD WELL CONTRACTOR: /i' /"'- <
WELL CONTRACTOR CERTIFICATION N:
STATE WELL CONSTRUCTION PERNIITN:
1. WELL USE (Check Applicable Box): Residential 0 Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Aecovery ❑ Heat Pump Water Injection ❑ Other ❑
It Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
4,
Nearest Town: ste �L` County:
v �GL
Srti�vye�s Cr'��li"
DRILLING LOG DEPTH
(Road Name and Numbers, Community, or Subdivision and Lot No.)
3. OWNER 61V r 110//—ASS 2./l
From To Forrraxn Desc ipGo'
Address
(Street or Houle o.
City or Town State Zip Code
4. DATE DRILLED L,2Y-eD
5. TOTAL DEPTH 3 20
6. CUTTINGS COLLECTED YES F] NO[
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NOD-
8. STATIC WATER LEVEL Below Top of Casing:, L_ __- FT.
(Use '+' If Above Top of Casing)
l -
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 .01111
10. YIELD (gpm): METHOD OF TEST /fir
11. WATER ZONES (depth): 2O12
12. CHLORINATION: Type �'�T - Amount ���`'
It additional space is needed tsse baci of team
13. CASING:
Depth . Diameter
From To �� Ft.
From To Ft.
From To Ft.
14. GROUT:
Wall Thickness LOCATION SK_ fCH
or ighyFt. Mate/ (Show direction and distance hm rzi leas: too Sate
jV?, Roads, or other rr�p relere:r-e- points?
Depth rid
From To _ Ft.
From To Ft.
15. SCREEN:
Depth Diameter Slot Size
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:
gethod
Material
Material
3-IN
C
G7
�
pI
V
CO
w
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDAPJCE WITH 15A DJCAC r..'/✓ELL
CONSTRUCTIONSTANDARO.S, AND THAT A COPY OF THIS RECORD HAS BEEN PROViCED 70 THE YID L 0+�`Es✓.
FOR OFFICE USE ONLY
Quad No:
c
CD
! SIGNATURE OF PERSON CONSTRLY-TING 1x-c ,"IELL
56W(orfglrW to Divltlon of Water Ouality, Groundwater Srccn within 1.0 C✓: ys
kri.I (•SirV. 12Yf
Serial No.
1

-I8647
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION
STATE WELL CONSTRUCTION PERMIT#:
i
1. WELL USE (Check Applicable Box): Residential Municipal ❑
Recovery Heat Pump
Industrial E] Agricultural ❑ Monitoring ❑
Water Injection 0 Other M
If Other, List Use:
2. WELL LOC TIO ho Retch of t o ation below)
Nearest own: County:
Y _
(Road ame ers, Com I , or Su (vision n Lo No.)
3. OWNER
DRILLING LOG DEPTH
�S
AddressJDq
From To t Fo ation Des riptio
or u
O '
City r ToState Zip Code
4. DA RIL5.
TOTAL DEP
6. CUTTINGS COLLECTED YES 0 NO[D'
N0�
7. DOES WELL REPLACE EXISTING WELL? YES I;1C)
8, STATIC WATER LEVEL Below Top of Casing: FT.
(Use '+' II Above Top of Casing)
9. TOP OF CASING IS ' FT. Above Land Surface -
'Top of casing terminated at/or below land surface requires a variance In accor-
dance with 15A NCAC 2C g11e
10. YIELD (gpm): 2lo-. METHOD OF TEST
11. WATER ZONES (depth):�t `
/
12. CHLORINATION: Type __ AmAnt
It additional space is needed use back of form
13. CASING:
From D
Depth
To �
Ft.
Wall Thickness
Dla �r or We I. ateri I
0
From
To
Ft.
From
To
Ft.
14. GROUT:
Depth
SS
trial Method
From
To
Ft.
s
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:
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
I DO HERE @RTlF�L 1Nd CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRU Iup A A S A T T PY OF THIS RE ORO S BEEN PROVIDED TO THE WELL OWNS
FOR OFFICE11�LY /<�s ✓P410i � G
Quad No: SIGNATURE OF PERSON CONSTRUCTING THE WELL DA
SubFI on nal to Division of Water Quality, Groundwater Section within 30 days
Serial No. I GW-1 REV. 12/99

f/,<�gh
North Carolina - Department of Environment and Natural Resources - Division of Water Quality . Groundwater Section '0' 1 "`�
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: " J ff __bA1.Q `
WELL CONTRACTOR CERTIFICATION #: d
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 LOCATIE: S ow sketch of the location below)
Nearest Town: l�.�% ` " LtLo- County: �Jlly` y
(Road Name and Numbers, Cgqo.�rnmu/nity, or Subdivision and Lot No.)
3. OWNER?�vLti�
Address
(Street or Route o.
C 8771
City or Town State Zip Code
4. DATE DRILLED -71 -7 2,6 aoo
5. TOTAL DEPTH 20 -S
6. CUTTINGS COLLECTED YES [] NO�
7. DOES WELL REPLACE EXISTING WELL? YES C] NO
8. STATIC WATER LEVEL Below Top of Casing: 40 FT.
(Use +' It 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): .F METHOD OF TEST 14 A-�
11. WATER ZONES (depth): 146'
12. CHLORINATION: Type T)4 Amount 4�
13. CASING:
Wall Thickness
Depth
Diameter or Weight/Ft. Material
From
D To 619
Ft. �— ZI VC
From
To
Ft.
From
To -----
Ft.
14. GROUT:
Depth
Material Method
From
0 To 2-0
Ft. C•�yy Sa
From
To
Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft in. in.
From To Ft, in. __ in.
From To Ft. in. in.
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
17. REMARKS:
DRILLING LOG
From To
Description
t' cm
a
ray
�3M
�r
-v
r7
Ai—
r
N d
-- —
0
i
Ci
U7
0
If additional space is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
�-�- k,4i,,,
qF
Gr sctrnrzn�. i�Z t D - o/d t2�
Yru-icy
Ail
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 0
Ouad No: SIGN#URP& PER ON CO STRUCTING THE WELL DATE
Submit original to Division of Water ouafity, Groundwater Section within 30 days
Serial No. GW1 REV. 12/99

r•
North Carolina • Departrrwnt of Environment and Natural Resources • Division of Water Quality -Groundwater Section
16W Mail Service Center -Raleigh, N.C. 27OW 1636-Phone (p1 O) 733.3221
WELL CONSTRUCTION RECORD WELL CONTRACTOR: b',0' j_L1.LQ _J1)^L--t'
WELL CONTRACTOR CERTIFICATION 0:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE SC,heck Applicable sox): Residential I] Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ff Heat Pump Water In*tlon ❑ Other ❑ if Other, List Use:
2. WELL LOCATION: (S,h w sketch of the location below)
Nearest Town: — ;-Lot _ County: --
(Road Name Numbers, Community, or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER From To a.scrip %y , eon
Address %�� v
istr"I of NOUSS NO.)
City or Town Suue
Zip Code �
4. DATE DRILLED d7 $ 20 a
5. TOTAL DEPTH o
4 _
6. CUTTINGS COLLECTED YES ❑ NOF71
7. DOES WELL REPLACE EXISTING WELL? YES NOM cz
S. STATIC WATER LEVEL Below Top of Casing: © FT.
(Use '+' H Above Top of casing) G-)
n-t
9. TOP OF CASING IS FT. Above Land Surface"
'Top of casing termhmftc! aWor below land surface requires a variance In accor-
dance whh 18A ICAC 2C .011s
10. YIELD (gpm): METHOD OF TEST
11. WATER ZONES (depth): 076 N cn
12. CHLORINATION: Type If 2-1 Amount d 3 / If additional space is needed use back of lofrril y'
13. CASING:
Wall Thickness CATION SKETCH
Depth Olameter or Welght/Ft. Material (Show direction and distance from at least two State
From To % Ft. 6-4_ ;�P_ 811 1 U S- Roads, or other map reference points)
From To Ft. —
From To Ft. t
14. GROUT: (J vthl2l{
Depth Material Method
From To .,26 Ft. QQ.73-4-f `•�o'!�
From To Ft,
15. SCREEN: 11
Depth Diameter Slot Size Material 3ld �` ���� � cry--,c14
From To Ft in. In.
From To Ft. In. in.
From To Ft. In. In.
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
17. REMARKS:
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY 1 'jes_ > i lark o
Owed No: S T OF PE SOt} STRUCTING THE WELL _)ATE
Serial No.
Submit original 131 of Water Quality, Groundwater Section within 30 days
ow•t REV. tv>asa

.: 'r954
North Carolina • Department of Environment and Natural Resources • DM"n of Water OuaUty • Groundwater Section
1636 Mail Service Center • Raleigh, N.C. 27OW1634-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR;
WELL CONTRACTOR CERTIFICATION:., R-O` c�
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Cho& Appitcabte sox): Residential ED Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (�jh� w sketch of the location below)
Nearest Town: c11/s+-/rill-AA,) A 1 ; .r t� County:
(Road Name "Numbsrs. Conxrmrft r Subdvlslon and Lot No.) Ur1u_
3. OWNER From
Address _ Z,
CIry or Town , State Z'ip .Code
DEPTH
For AUM Descriptlon
1 ,:✓' sI f�S\.
�-a OCR a>
4. DATE DRILLED N'` >>' `_ ©=
5. TOTAL DEPTH 6S ` E s,
6. CUTTINGS COLLECTED YES ❑ NO®
7. DOES WELL REPLACE EXISTING WELL? YES M NO
S. STATIC WATER LEVEL Below Top of Casing: FT.�'
(Use'+' U Above Top of Casing)
S. TOP OF CASING IS__.LFT. Above Land Surface'
'Top of easing terminasad Wor below had surface requlrse a vertancs In aocor•
dance with 1$A N"C 0 16
10. YIELD (gpm): METHOD OF TEST 1Z
11. WATER ZONES (depth):
12. CHLORINATION: Type Amount N additional space is needed use back of form
13. CASING:
Wad ThOmoss
Depth Diameter or WsiWt. Matedat
From To Ft.
From—____.._.- To Ft. --
From —To ._-- - Ft.
14. GROUT:
Depth Material Method
From To Ft.
From To Ft. . _ �-�-
15. SCREEN:
Depth Diameter Slot Size Material
From _ To Ft in. In.
From To Ft. __a_ _ In. In.
From To Ft.— in. — In.
16. SAND/GRAVEL PACK:
Depth Size Material
From _______ To Ft.
From To— Ft.
17. REMARKS:
LOCATION SKETCH
(Shaw direction and distance from at least two State
Roads, or other map reference points) p
41
Ll ��Ib
�K02 tx/1/ry eeL; (/Y\
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Quad No: Sid TU PEA N CON TRUCTING THE WELL DATE
Submitoripk+&Ito Isfon of Water Quality, Groundwater Section within 30 days
$eria{ NO. GW.1 REV. 121"

North Carolina - De
parttnent of Environrrwunt and Natural Resources • Division of Water Quality - Groundwater Section
18M Mail Service Center - Raleigh, N.C. 276tii I We -Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:_AJ
WELL
CONTRACTOR CERTIFICATION #: �Q S
STATE WELL CONSTRUCTION PERMIT#:
1 • WELL USE Check Appiloabts Box): Residential E1 Municipal ❑ Industrial ❑
Recovery U Heat Pump Water Injection ❑ Other [] If Other, Ust Use:
2• WELL LOCAT N: ( ow sketch of the location below)
Nearest Town: County:vLyrn
Agricultural ❑ Monitoring ❑
goad Name a�n��i• Numbers, Community, or Sutxllvision and Lot No.) DRILLING LOG DEPTH
3. OWNER 4Y LLJ1,CGS� From To Formation Description
Address ;z
(5 roe or-RCLAS 5.r - �:\
• • - ` l/mot l l / V
City or Town State 4 cc"
4. DATE DRILLED -7/CD
5. TOTAL DEPTH _2.3 ©
6. CUTTINGS COLLECTED YES ❑ NO® '
7. DOES WELL REPLACE EXISTING WELL? YES [7 NO© =j
S. STATIC WATER LEVEL Below Top of Casing: f _o FT.
(Use + N Above Top of Geeing) a -c
9. TOP OF CASING ISSurface-
'TOP
._..�....._ FT. Above Land
Of casing tartnbtated Wor below land surface r"ulree a variance In accor-
dance wNh 1fA NCAC 1C .0111
10. YIELD (gpm): I 6_ METHOD OF TEST _ AA��
11. WATER ZONES (depth): 17,0 o 4
Ul
— - o
12. CHLORINATION: Type h6%il Amount 0, .3 % if additional space is needed use book of form x
13. CASING:
From
Depth
To 1 _
Wall Thickness
in+eter or Weight/Ft. Material
Ft. S b JQ 11 V G
From
To
Ft.
From
To
Ft.
14. GROUT:
Depth
Material Method
From O
To --_
Ft.z'+5�
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:
ATION SK
(Show direction and distance from at least two State
Roads, or other map reference points)
P-Lh-,
PLO
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: 310 U F PER N-CbNbTRUCTING THE WELL DATE
Sudmit original to slon of Water Ouality, Groundwater Section Within 30 days
wal NO. GWt REV. 12199

al tr+�wn� •nr Nstw� Plaaewow • arlaMn j# waMr A►►ewY . O►wr'+�+N O'0r0"
, MOM t�ta%ovvw"o«wa. c.�trx uqppwrwwowm�h103
WELL CONSTRUCTION AECOR® WMA. Ow"ACT";
pc0:t
$RAT$ WmLL plTfluem
I. WILL -----Apowwom* smolder" "I
11216
1Maaasr�r MOM"Wow tnjaew I
uw+ E3 M Wot mom D wlot+Mo++r+0 E3
cww p It 01Pw, Lm Use:
2. WM.L LocAT
�,al! ► wtl 11�A rim
WIN= Momp and Let M) No" Ts — /attnaitta 0
/Y� O
a. vwa" _ -
Ad*4n $.-z P'(
O
4. cAT* DRUM
O. TCTAR. *am � a\�
• CUiTMMfi OOLLM110 Yn IrO(�
7. Dom WILL VuWn 1 0 Mom y y � c_ o m
L. �
I. iTAM WATO MIL OWN TOP Of O k**:-----�=- �-"= ^.
!. Tc' COP CA&" a.1_ PT. *a*" Lww t+trlrta•
iwi gid UM&Sbd
Ww bdM leaf awOt" "NOW s tulow In ass"`
1C. YID®{�pMk , MtTf'IVO OM' 7w - -- - --
11. WATIM! 90HO 1.W---
it. C AT*I* TyPM ff A 4 '
I& CA11Mlo:
Depth WSW"
14. 40cu .
PeMtt � To � PI.
1i. M:
ohmmomIra tt i moo"
Pratt ..,,.,oTo. Pt . VL In.._...._._
Pm" � To � PR. . In. ...._ In......_..._,__
Poem K
�.
M iUi►v�L PACK:
Dom an
ft" TO ......... PI.. ....
rpm TO..l� PL
17.
K at3lMnat >Mtw M rtaaNr taw OMM +N Ia*+ _�
TM 29UM
Pt»w dkoom at++ AMr+aa —1. at mw wes��r
Flomft or ww mo aq w w Pam)
1 o b-";
it -
Pei, ��
vo o �
o`a � 24 w
I Co m~ 0011p v rMlr TIN WILL WM QQtOM== IN ACCCPIWM MH 1 LA MAC IC. MU
0CNrTflYCiIh113TAN"MC MC THAT A CC" Cf TIN MOM MAM IIMII PMION M TO"WVLL OWNOR.
1 aO 60
*Aye
o� � sM� oar ww�r► O�seAp, reeN+Awnr � w�M+1� �0 dorit
-1 Fail
e� Oar•, owv. tare

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section ti 1. ! ;) !,
18M Mail SarvicoCenter - Raleigh, N.C. 270W 16W-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:���'
WELL CONTRACTOR CERTIFICATION 0: o S b U
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Cheek Applicable Sox): Residential ® Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery [I Heat Pump Water injection ❑ Other ❑ It Other, Ust Use:
2, WELL LOCATION: Show sketch of the location below)
Nearest Town: County:
(Road Name \an/d Numbers, Community, or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER V &-- 1 �� .`, i c . _ � a-LLn From To Fonnatlon Description
Address R' _ 'z .
or Re• ` o.
Q.
City or Town State Zip Code '
4. DATE DRILLED
5. TOTAL DEPTH 2-CL
6. CUTTINGS COLLECTED YES Q NOO
7. DOES WELL REPLACE EXISTING WELL? YES Q NOQ
S. STATIC WATER LEVEL Below Top of Casing: .4 o FT. -
(Use's' H Avow Top of Casing)
9. TOP OF CASING IS_L_ FT. Above Land Surface*
'Top of casing terminated aVor below land surisos requires a valence in accor-
dance whh 15A NCAC 2C .011a--
10. YIELD (gpm): / 0- METHOD OF TEST
11. WATER ZONES (depth):
Q
z
12. CHLORINATION: Type r Amount O' 3 2 If additional space is needed use back of form
13. CASING:
Wall Thickness LOCATIONSKETCH
Depth Oiamster or Wef�htiFt. Malarial (Show direction and distance from at least two State
From �� To �� `� Ft. 'C %« .�'_.j �Y� ` _ Roads, or other map reference points)
From To Ft.
From
14. GROUT: , ; '
Depth Material Method
From O To 210 Ft. ' r i;
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. ;tt• _ 1. (%
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft. rr•. �1_.
17. REMARKS: i
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 Q,1,t 1 < (c 7 -2 y 0 C;
Quad No: IG�IXTURFE 6F PERSON CONSTRUCTING THE WELL DATE
Submit ortg nai to Dlvfsion of Water Quality, Groundwater Section within 30 days
Seriat No. OW-1 REV. IZV9

f4 1(-,
MOO C&M** * DeparUnent al' Enylromw*nt and Nakwal Rgsourc" . DM610m of Wear OLWlty - Groundwater SOW" � - !;J49
IM MOM IM60 Censer - Pla"Jah N C 27424LIMP?ws 19111 7'33-SUI
I . .
WELL CONSTRUCTION RECORD WILL CONTRACTOR:
WELL CONTRACTOR CNVMPICATIONO:._- 050
STATE WILL CONSTRUCTION PERMITC. -
1. WELL USE tftmm& ApO" k9010: R98160ftel IM municiow C3 IftAWAIC3 AgMultUMI M mwtioitv C3
Pwovy" tff— bleat Pump water I*cftn 13 00w C3 if 09w. List Use,
2. WELL LOCA Tewm sk~ of the l0vadon belo 0
(PAW Nwm and NLwtmn, Conwu* gub*AWw and Lot No.)
3. OWNER From To
,%*ftn U)
j;u
Aigng� "T777"
alv or Tvm
4. DATE 011111UM,
S. TOTAL CWPTH --a6S`
4%
6. CUTTINGS COLLECTED YES
7. DOES WELL REPLACE axiirmTwuff `QS No=
6. STATIC WATER LEVEL Ulm, Top of CM!": PO FT.
9. TOP (W CA09W 4 FT. AboVo UWld ftftft*
dwome Ift I" MAO W."Is
10. YEW (Wn): ME' WMCWTUT .
11. WATER ZONES (dopft-
12, CHLORINATION: Type T
AnWin! Q,A If addlicow speft is asedw Use beck of wm
13. CASINO:
0"m
W07111110mm"
DISMASIN Of MOO"
From
Tod
Ft. 6 PV S v C.
Fran.._.._
To
FL-
Fmr" -To
-
FL
14. OF%=:
D"M
Mel?"
From
To Ft. cfww +7sal:�01
From
To
M.
13. SCAUK,
Deplh 01111mew sm 81t6 Mob"
Front To Ft in. -In.
From To Ill. In. In.
From To Ft in. In.
IS. SANDA31PAVIL PACK-
Devilli Ske mdww
From To..,.._..�PL_
From To PL
17. REMARKS:
C-)
Nam I
Wow direv"m and distance from at NNW two Stars
Roads. or oftr map re"mcs Points) L 0
Rzu,�--c cRa- /41x," Taix-el
� ),o
0
100 MONEY CERTIFY THAT THIS WELL WAS -'-- I I= I ID IN ACOOPA#A= WITH I 5A NCAC 2C, WILL
CONSTRUCTION STANOMIX AND THAT A COPY OF THIS RECORD HAS SEEN PF4VID90 TO THE WELL OWNER
Pjddja!�
ON OPP= an airy, 2 7/,! 4
Owed "m sgkok** ap P-d%wN dowftxym Tmv waLL DATI
within 30 days
Is" No. Qw-j my. I IV"

North Carolina - Department of Environment and Natural Resources - Division of Water Quality • Groundwater Section Iw 4
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone] I
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION 0: t1l "
STATE WELL CONSTRUCTION PERMITP:
1. WELL USE (Check Applicable soxy Residential e Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ II Other, List Use:
Agricultural ❑ Monitoring ❑
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: ROWws Q I, F' County: H� M
ApAH
(Road Name and Numbers. Community, or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER %0-R Wl e "ev_
From To Formation Description
Address R- 1 !-Yl ( f 5- �1 1 1 O
—'-j'STreeior Route o. j�
�01& 1,D5y IL Lr4 NC_ �S77
City or Town Slate Zip Code
4. DATE DRILLED
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES [] NO❑�
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NOa
8. STATIC WATER LEVEL Below Top of Casing: 'Jo FT.
(Use '+' II Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface -
•Top of casing terminated otlor below land surface requires a variance In accor-
dance with 15A NCAC 2C .0118
10. YIELD (gpm): 1 D ' METHOD OF TEST ��
11. WATER ZONES (depth): %Co ' / 20
12. CHLORINATION: Type Amount If additional space Is needed use back of form
13. CASING:
Wall Thickness LOCATION SKETCH
Depths ?motor or W hm. aleriai (Show direction and distance from at least two Slate
From To [ Ft. / Roads, or other map reference points)
From To a -- Ft.� I100 uC
From To Ft.
14. GROUT:
De Material Method
From 0 To p1� 0 Ft. -�
From To A0 � 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
CD
0
L
C
r
A'
x
N
Cn
0
0
h rn
7,
� r7r
M
CD
MCD
�v ri
v0 :
m
n
a
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY � S' n � n 0 Ile ^/ � _Zl - 0 -9
Quad No: SIGNATURE OF PERS NSTRUCTI G THE WELL. DATE
Submit original to Division of Water Ouall►y, Groundwater section within 30 days
Serial No. OW-1 REV. 12/99

Nalth Carolina - 0epmbnenl of Environment artd Natural Resources • DIvidlon of Water Quallty • Groundwater SeCtlon
1636 Mnil Service Center - Flafelgh, N.C. 27699-1030•Phono [phone]
WELL CONSTRUCTION RECORD WELLCONTHACTOA: 0 Q 1
WELL CONTRACTOrt Ct"TIFICATiON N:
STATt WELL CONSMUCTION PEAMITN:
1. WELL USE (Check Appileeblo Box): nesidontial rg MunIcIpai ❑ induattlal d Agricultural d Monitorinp ❑
nocovery Cj Floal Purnp Water Inleollon ❑ Other ❑ II Other, Ust Use:
2. WELL LOGA 1101�4:: ,(Show sketch of the location below) L �H �1
Nnnrn�t Tnwrt• ___-_ilV J.. -� 1/ County:
— /1-7L
(Iloail Name and Numbe s. Com(nunity, or Subdivision end Lot No.) DnILLING LOG DEPTH
3. OWNER o IJO From To Fom-AtionNsodptlon
I ZIT cot Or r1nVi- 10. Q^ _� �-� (� 1 Y Y r/T %l. /
",It• of rout-t Zlp Code
,1. DATE DRILLED U -----
5. 101AL UEPTII
6. CUI-IINOSC(71.I.ECIEU YESn NUCr
7, I.1()FS WFI L RFPI ACE EXISTING WELL? YES ❑ NO[��'
8. STATIC WATEFI l FVEL Below Top of Cnalntl: PT.
Ws9 ',' N Abovo Top of Crolnp)
o TOP nr- r.AgING IS ._. �..___. FT Above Land Surface•
'Ton of rngln(i fnrrnln:,lnri nl;nr hninw find snrlpiae Mnnire k It vnrinnce In Prcor-
dincn wlth 1FA NrAC 7C .0118 /> —
1n Ytr-1 n (ryrnt) _._. M1=THQD OF- Tt-Sr
11. WA1 Ell ?OrJE 3 (depth):
12. (lHlO(11MA i InN
Tyr—/ -..__ Amotrnl - 0 �6 It additional span, b nerded use bAck of form
13 GASIIIG.
yVglt Thlr Mnn4S
IlAnll>t� ;_ binn�9r �wSlf- l�ll
Tn -1_-? rI.
To------- FI.
Front l o __—.—._ Ft.
1A. (;F101fi
J rr,ru,-FAatnrlal
r lonl Tv �J rl.
From v 1
1 , �icnr--r:ri �J
Dr-1•Ih
Ftom ---Io
_-.rl
I'rorrt ._..._..--
'1 r, FI
rmm -._. _.
_ ,rn ... _ .. _ FI
N. SANCYG tAVCl.
f ACK:
uppnl
rr-r-t .._._....
To _ -
Florn
17 FIEIv1AnKS,
LocATI sK M -
Mf Ie.rlitl (8how direollon end dbtartoe Irom at least two State
(' `- Roads, or other map telerence points)
Method
Viprnpler Slot Si;, h4eterlal
In. In.
Size Material
rl.
i rn f irnrnt r.rnTirY TI1AT Tf llgi, 4L ?Agjr o J9TF
Rr AMR 10 Ir 1 HiN S I ANf 1AF1()S, AND-Tr1AT A COPY 0 it
ron orricr- usF ONLY 91„L
t7n.trl i.'n� � $iT1Nh'
_. StO,iNt orig1mil to bit
CD
CD
C
co
N
O
fl
1CTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
HIS RECORD H gEEN PROVIDED TO THE WELL OWNER.
OI]
ME Cr nI�n N CU STnUCTIN`G THE WELL DATE
ilon of Witter Ouallty, GroundWAlff Sectkin Wllhln 30 days
GW.I nEV. 12199

214055 �
North Carolina - Ueparlmenl of Environment and Natural Resources • Division of Wataf Ouallly' Groundwater Section
1636 I'Anil Service Center • flalolgh, N.C. 27699.1036-Phono [phone]
WELL CONSTRUCTION RECORD WFLL CONTnACTOR:
WELL CowmACTOM CF-gTIPICATION U:
STATE WELL CONSTRUCTION PEAMITN:
WELL USE (Check Appl+cable Bolt): nealdontlal0 Municipal ❑ Indotrlal d Adrioultural ❑ Monllorinq ❑
fiocovery U Heal Pump Water Injection ❑ OIII®r ❑ 11 Other; List Use:
2. WELL LOCAI 101`4: (Show sketch of Ilia location below)
Nnnrpnl Tovrn' -- KU I �?S ✓r.��. E-_ County
(Road r1amA and Nwltbors, ConmurJrx� r Subdlvlalon and Lot No.) DnILLING LOG DEPTH
3. OWNER - r`i'RT VIVO KI From To Fo )0on Nsorlptlon
Arlrlrncq .._
�Si oot er f6515,Flo.)
r,tp or Tnwi Srnto Zlp Code
a. DATE DRILLEU `9 0 —T
,. 101 AL DEP I I I
6. CU r,l INGS COI.I.FC 1 ED YES n NO
7. DOES WEI L RFPI AGE I--XISI ING WELL? YE8 ❑ NO[--:J—
8. STATIC WATER LEVEL Below Top of Cegin(j:
(I )sf)'4' N Above Top of Cnstrp)
o TOP OF r.A'�ING IS rT Above Lnnd Surface'
•Tnn of ri3O"ji lnrmtnnr—1 nVnr hnlnw knef 4rrriara Ngnlroi or vnrinneo In Pecor•
dince wllh 15A NCAC 7C .0tIll In YIPI n (ripnt)- .'� MCTh1Ob OF TFST
I I. WAIEn.'_OPIF3((leplh):
12. CHLO RINAIION Typo ��. . �'_ _�_ Amcrunf �,� 11 eddlllonrl space Is needed use back of Iorm
13 GASI11G.
Ws+P IhiC1,nn-71
r UQPih 0nrster of weellph/ rlegftl
rrr)rn __ U.— To __�� r1. s/_ -�L— \<��.L� ! I ✓G
('role--- To------ FI.
From rt.
1�. Gnot1T:
hr i, Malotlall Method
rlonl To L' f 1.17JAILIl
Front
1r, �:rnr--rrl:
Url,tlt [7i7rrrnler
17rvnn _-- to._-__.rl
1"torn •- - - 'In - ... Ft. --._ In.
rrnrTI .-- To ._......_ r1.: In.
10, SAND,GRAVE=L TACK:
Opplh Size
rrr,rt .-_-- -- Tn-. ....__.. rl. .
Flcrnt —___-- to ___......__. rt.
17 nEN1AMS-
Slot Sl:.e Material
(rt.
Material
LOCATION SKETCH
(Show dtreotlon and d1stance from at least Iwo Stele
Roads, or other map relerence points)
c�
C: o
CD
c�
C_ m
I•C- � c7
�rn
tv v
CD
CD O
l rrn 1Ir-rZcnv rrnTIrY T1 EST THIS, / -LL WA9 CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 9,C, WELL
crtr.tc 1 nt W,, l 10.N `S I ANOARUS, AND THAT A COPY D
1119 RECOR A9 BEEN PROVIDED TO VE WELL OWNER.
-1- -
roR orrice u1q bhL - —
rnrs t l:n Si�,IF7 njnE br r: So I tISTAUCTINO THE WELL ME
Surrrrrl orit,lnat to t)ivlsln-rvvnlef Ily, Croundwaler Section within 30 days r. f^ rr� ��fw
GWI nEV. 12/A9

L
North Carolina - Department of Environment and Natural Resources - Division of Water Ouality - Groundwater Section
4- 0 t-
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
Kid {y
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION N:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential El Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Aecovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2
M
WELL LOCATI/O�,N: ( how skf Ich of the location below)
Nearest Town/: o °`.s4, /`/C County:—
(Road Name and Numbers, Co nurity, or Subdivision and Lot No.)
OWNER
Address
treet or Route 1161
City or Town State Zip Code
4. DATE DRILLED a0 -00
5. TOTAL DEPTH 2d0
6. CUTTINGS COLLECTED YVS ❑ NO(D�
7. DOES WELL REPLACE EXISTING WELL? YES Q NOQ�
B. STATIC WATER LEVEL Below Top of Casing:�2_ FT.
i (Use'+' If Above Top of Casing)
9. TOP OF CASING IS ` v FT. Above Land Surface'
`Top of casing terminated aVor below land surface requires a variance In accor-
dance with 15A NCAC 2C .0118
10. YIELD (gpm): 3 METHOD OF TEST
11. WATER ZONES (depth): Z 1
DRILLING LOG DEPTH
From To Forrna:�on Descdp6w-
12. CHLORINATION: Type
l`l
—Amount Y
It additional space is needed L-se bac�of fcrm
13. CASING:
LOCATION SK=T'CH
Depth
Diameter
Wall Thickness
or Wei hVFt. Material
y7r
(Slow direction and distance tr.,m ad leas: two S-we
To V-
FI.
0/" ZS
","7
Roads, or other rr-7 reference floints!
From ---
Fromm To d
Ft.
K- ;;4L
From
To
Fl.
14. GROUT:
Depth
M�terial thod
'essyr
From
To .�2�
Ft.
1r77���
CD
From
To
Ft.
o
ZE
ca
15. SCREEN:?-,
Depth Diameter Slot Size Material
c=
From
To
--
From
To Ft.
in.
in.
Cn
`
From
To Ft.
In.
in.
16. SAND/GRAVEL PACK:
co
Depth
Size
Material
rn
CD
From
To
Ft.
—
From
To
Ft.
—
17. REMARKS:
DO HEREBY CERTIFY THAT THIS' WELL WAS.(
CONSTRUCTION STANDARDS, AND THAT A CC
FOR OFFICE USE ONLY;;
Ouad No:
Subr!?ll oiigl
Serial No.
NSTRUCTED IN ACCORDANCE WITH 1SA 04CAC 2^,'/fELL
OF THIS RECCOno HAS BEEPI PROVIDED 70 THE. 7/5....1- () %%NEF-
GNAT E OF PERSON CONSTRLYYTING i)-c^ vv ELL
to Divltlon of Water Ovaiity. Gmund"ter Srr-cn yvilhin Y4 C%lYs
D$.�'E
6K•i /.t�V. 12"

North Carolina • Department of Environment and Natural Resources • Division of Water Oualiry • Groundwater Section 4.13 515 9
16M Mal Service Center . Rdelph, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: �Ai, �h`a�_
WELL CONTRACTOR CERTIFICATION E:
STATE WELL CONSTRUCTION PERMITP:
I. WELL USE (ate"Appocaw sox): Residential® Municipal ❑ Industrial ❑ Agricultural ❑ Monitodnp
Recovery ❑ Heat Pump Water I*ction ❑ Other ❑ If Other, List Use:
2. WELL LOCA ow stretch of the location below)
Neareat Town � r r) Sap County bL"X
Mood NWM and bdvlaon and Lot No.) ORILUN_, f3 LOC
3. OWNER From To
Address
Ciro or own Stan � ZIP Code
4. DATE DRILLED ` o00
5. TOTAL DEPTH _.j'b, 0
6. CUTTINGS COLLECTED YES ❑ NOE]
7. DOES WELL REPLACE EXISTING WELL? YES M NO
S. STATIC WATER LEVEL Below Top of CaWN: ;)o_ FT.
(Use II AWx Top of
s. TOP of CASING IS__.____ FT, •;Above Land Surface•)
lop of Casing Mnnineled atttor tulow tend surfooe nmpd es a varlarm In 0000r•
donee vft 1gA N?AC 30 At18 n
10. YIELD (ppm): v� M OF TEST (� nU
11, WATER ZONES (depth): D
DEPTH
Fom+ation Dewript1 n
12. CHLORINATION: Type Amount If addltlonal
apace Is deeded the tuck of form
13. CASING:
Wall TNokr"
From DTo ,... .. Ft. th a krrow or AAsNdal
FromTo Ft,
From To Ft.
14. GROUT:
Method
From Q To9•
From -To Ft.
1S. SCREEN:
Depth Diameter Slot Slzs Material
From To Ft
in.
in.
From To Ft.
In.
In.
From To _., _ FL
in.
in.
1S. SANDIGRAVEL PACK:
Depth
Sin
Mall"W
From To Ft.
From To Ft.
17. REMARKS:
LOCATION SKETCH
(Show direot and dtstarm from at Nast two State
Roads, or other map reference polrus)
-,I
' //Z j lY ��a fey
i,ti� JZ<gl `- ,
, q ?/,d Q 2.a lt-c ,
fig.-�-�-'�.d�`�• � � ,� rn•�•L�' �<-'t'>ti
!i iwt to CLO .
t DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 1 SA NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS EEN PROVIDED TO THE WELL OWNER.
FOR ONCE UM ONLY , -a 0 <
Quad No: t3luw► 'PF PAWN CONSTRWTINo THE WELL DATE
subnrt o�pkyl I® of VJ8W Oualny. Gm ndwatsr Section within 30 days
so" No.
OW-1 REV. 12M
F
, iei
__

North Carolina - Department of Environment and Natural Resources - Division of Water (duality - Groundwater Section
16M Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:``—�'"
WELL CONTRACTOR CERTIFICATION
STATE WELL CONSTRUCTION PERMIT#: --
1. WELL USE (Check Applicable Sox). Residential Municipal ❑
. industrial ❑ Agricultural ❑ Monitoring
Recovery ❑ Heat Pump Water Injection ❑ Other ❑
If Other, List Use:
2. WELL LOCATION: (Show sketch t the location below)
Nearest Town: �'"` `� , r LL County: /
-
(Road Name and N mbenn, Co unity, or, Subdivision and Lot No.)
DRILLING LQ!Q DEPTH
3. OWNER S 1r\ ,�
From To Formation Descrlptbn
Address ram--
City or Town State Zlp Cod&
4. DATE DRILLED3
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑ NO®
7. DOES WELL REPLACE EXISTING WELL? YES NOE]
S. STATIC WATER LEVEL Below Top of Casing: 646 FT.
(Use -+- M Above Top of Casing)
9. TOP OF CASING ISFT. Above Land Surface'
o ``
p
'Top of osatnp termWAW at/or below land surface requires a vartartee In accor-
— - C_
dance wMh 15A NCAC 2C 11s
10. YIELD (gpm): METHOD OF TEST 09
11. WATER ZONES (depth): /ern
12. CHLORINATION: Type T Amount
If additional space is needed use back arm Ma
13. CASING:
n,,W
Wall Thidcnees
Depth D/ia��,1�►ter or W ' t. Materfal
LOCATION SKETCH cn
(Show direction and distance from at least tad 6tettZ
/
From _ To ..�=' Ft. — :� 21.40 V 4-
Roads, or other map rsferenbe point•$)
From To Ft.
From —To-- Ft.
14. GROUT:
4, �# /a � � `�' � i►u'l'`�
Depth Ma nisi Method
From To d
�..:�._ Ft.
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft in. in.
tA-yL,�
From
To Ft. in. in.
From To Ft. in. in.
/
� )
�L__.�'
IS. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
0
'TO PERSdN CONSTRUCTING THE WELL r DATE
of Water Quality, Groundwater Section within 30 days
Gw_1 REV. 12M

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section ry f"
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 ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: / 4 t_, n t 1 t 4 County:
(Road Name and N mbers, C mmunity, or Subdivision and Lot No.)
3. OWNER Ct titi►lJur,Zr
Address ;� wydtLy" xU
ree /� oou't/0.e �j +-7 J
2 C. l! r� ,}+ice L 1
City or Town State Zip Code
4. DATE DRILLED 61 9 a 6 ao
5. TOTAL DEPTH -!5
6. CUTTINGS COLLECTED YES ❑ NO©
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NOW
8. STATIC WATER LEVEL Below Top of Casing: _ '2 0 FT.
(Use'+' if Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface'
"Top of casing terminated aVor below land surface requires a variance In accor-
dance with 15A NCAC 2C ,011 I
10. YIELD (gpm): METHOD QF TEST-�
11. WATER ZONES (d pth):
12. CHLORINATION: Type17�7_H Amount O-M,>
13. CASING:
Wall Thickness
Depth Diameter or Weight/Ft. Material
From b To 61 Ft.��1�
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From To • -0 Ft.41l-A+7►
From
15. SCREEN:
From
From _
To Ft,
Depth
—To Ft
_ To Ft.
From
To Ft.
16. SAND/GRAVEL PACK:
Depth
From
To
From
To
17. REMARKS:
Diameter Slot Size Material
In. In.
in. _ in.
in, _ in.
Ft.
Ft.
Size Material
DRILLING LOG DEPTH
From To Formation Description
0
o
�3
r.._
y rh
O s
a
3
r
t:T1
- +
a
z
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)
) �]A
a
V
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS ANY 1;HATjA O+OPY THIS RECORD HASPEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Quad No: Aue SIG R ERSON COTRUC G THE WELL DATE of ulioriginalto isionater Quality, Groundwater Section within 30 days
Serial No. GW-1 REV. 12/99

NOM Caro" - DOP&Vr*M of Environment and Natural R***uj_.@s . 0jvWom of Wow Duality- Growidwatat .3acdr) on 13 55
IS* Mag Sol Woe 0~ - P~. N.C. 276wifts~m (sit) 733-Ml
WELL CONSTRUCTION RECORD WaLL CONTRACTOR:
WELL CONMACTOR CUMPICATION 0: Q "S cD ------
STATE WELL CONSTRUCTION PERM(TO: ovmmmw�
1. WILL USE smo- Reside WO munl*W C3 Inctuaw M Awtuftral C3 MO"fto&v Co
RecoveryHOW " Water I r*MftMC3 00W 0 It OM , ust use:
Z. WELL LOCATIQI(Sk— at of the lonlon below)
, Nearest Town:c4w*
irmad Names WW Corm"Wk 'o, ten and tot No.) WHO 60
3. OWNER &,f) To
Addrm
v awn
4. DATE
S. TOTAL DIM
6. CUTTMI COLLECTED YES M NOM
_Vft
7. DOES WELL REPLACE VUSTINT-WELL? [3 NOM
S. STATIC WATER LEVEL Bela a Top of C4LW4: 4� 0 FT.
June 0#0 1 Me- 0 T" at cub*
-
__j
9. Top or cAsms ts�/ FT. Above umw surom-
'Tap at—
;,urn
don" mis
10. YIELD _L� men4op opt TEST
- - __J.
11. WATER ZONES (dep4h): Z V2
_6
CD
12, CHLORINATION: Type AMUM 01N athM , ep" I@ nesdo use bm* of fam
13. CASM:
W4117mowaft
Depth D*MMW Wow*^ maw%(
From _2T.
ILL'-
From_
TO Fl.—
Fmm —To
FL_
14. OMIT'
000 huft" Method
From To
From
To —Ft
13. SCPAMN:
D"6 DWffwW IW Sku MOWW
From —76—
F1 Im — K
Frei —To
Pt. In. —In.
From —
To PL In. — bv
IS. $ANDIOPAVIL PAM
osplh sm Maw"
TO_FL�
From To Pt
17. Milhi~
- LWAMQN amm I
(41how direallom VW daWM from Ot Mast two Stara
Roads, or Dow neap m*~ Poku)
7 PIC)
'b-n-t'A 6-nLI
100 MMW CERTIFY THAT THIS WEU WAS CONSTRUCTED IN ACCOROAN09 MTH I $A NCAC 2C, WELL
00NITRUCT110H STANOVIDS, AND THAT A COPY OF Ff1pO hh PFAMMO TO THE WELL OWNER.
Q A610-ta 1=17=7-1 4)1,-
WN GMSTMUCTOG THI WV.L OATS
Cwft. OwA%kxw %~ wNhin 30 days
aw-i mv. is%

4-13555
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27599-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: ,- (i' df' ).tif L-ram,
WELL CONTRACTOR CERTIFICATION it: 7_S- t�
STATE WELL CONSTRUCTION PERMIT#:
- 1
1. WELL USE (Check Applicable Box): ResidentialEl Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATI • (Show sketch_ of the location below) W. ,
Nearest Town: r�6" , �� +,'rvs-, ' i-1-( t County:
(Road Name and Numbers, Community, or Subdlylslon and Lot No.) DRILLING LOG
3. OWNER ��c%� 2.�1 f—l2 •L_�`-"\ _ From To
Address Z �vz /t•��,,��.
'(bir"t r Rouutes Nod
City or Town State Zip Code
4. DATE DRILLED .3 _. 0,PY0 ---
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑ NO[
7. DOES WELL REPLACE EXISTING WELL? YES 0 NOQ
8. STATIC WATER LEVEL Below Top of Casing: '3 o FT.
(Use'+' If Above Top of Casing)
9. TOP OF CASING I5 FT. Above Land Surface'
'Top of casing terminated atlor below land surface requires a variance In accor-
dance with 15A NCAC 2C .011t1
10. YIELD (gpm): .�' METHOD OF TEST
11. WATER ZONES (depth): J S' `3
DEPTH
Formation Description
M
12. CHLORINATION: Type f 7' f� Amount '' J,% If additional apace is needed use back of form
13. CASING:
Wall Thickness
Depth Di ter, or Weight/Ft. Material
From �? To's Ft.
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From _ 0 To
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft In. in.
From To Ft. _ In. In.
From To Ft In. in.
16. SAND/GRAVEL PACK
Depth f t 9� a �� i� - I�t t�lat9 a
From _— To
From . To -------' ` „Ft. °
17
I DO HEREBY CERTIFY THAT
CONSTRUCTION STANDARD
FOR OFFICE USE ONLY
Quad No:
Serial No.
AM 1 0
0
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other reap reference points)
i
s L l + �'`n
l
L ��
R �
<L '1 t.c_ C'
c.tJ.L"ram..' cry -«.z.` 1jcLI'4 jD
�'T-\ �.J S-=Ll,% �J�� C!-LS'. L-/"-Z/.l��t; 1"•C''
YyA$ CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
1EiAT'A COY OF THIS RECORD AS BEEN PROVIDED TO THE WELL OWNER.
A �3 a
SIG ' PERSON tONSTAILICTING THE WELL DATE
Submit original to vision of Water Quality, Groundwater Section within 30 days
GW-1 REV. 12/99

54
North Carolina • Department of Environment and Natural Resources - Divieton of Water Quality - Groundwater Section 42„
t e36 Mail SeMce Center . Rai l9h N C 27699.1 Q36-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION 11:
STATE WELL CONSTRUCTION PERM(TMt
1. WELL USE (Check ApplN "sox): Residential® Municipal ❑ Industrial ❑ Agricultural E Monitoring ❑
Recovery ❑ Heat Pump Water Infection [] Other Ej If Other, Ust Use:
2. WELL LOCAne w sketch f the location below)
Nearest Town: /�- '`�'=' y_— County: E
iiloio Name and Numbers, , or Sub&Asiw and Lot No.) DRI�N{� 62G
3. OWNER From To
Address '-g&to _p,,) OX%V4U -
Cay or Town State Zip Code -
, 2EF—
TH
Fonnas on pgorlptwn
4. DATE DRILLED Z -ZO
S. TOTAL DEPTH
S. CUTTINGS COLLECTED YES 0 NO®
7. DOES WELL REPLACE EXISTING WELL? YES [] NO® — -i
S. STATIC WATER LEVEL Below Top of Casing: U' FT.
(Use V Nf ANt M Top of Cssinp)
6. TOP OF CASING lS % FT. Above Land Surhtce°
O
"Top of 0"W4 wodnated aUor below tared suffew ►eqY M a YarW" In after- m
denoe wOh 1sA NCAC 9C 011a Ft
10. YIELD WM): _,.[,._ METHOD OF TEST -- rn
11. WATER ZONES (depth): 9 ,
12. CHLORINATION: Type %f Amount 71 If additional aP is needed use back of form z
13. CASING:
_j„ OCATION SKETCH
hkknm
O Depth�> wo Welpn*VL Maoeetal (Show dirootton and diatanoe from at least t+vo State
From To Ft. L Roads, or other msp reference points) -
From— To Ft.------� --- � arm �-„� 1� �� 'LC�.
From To FL
14. GROUT: 7�Li� L_ f kws cwf � t
v
From _._. To Aa Ft.
From To Ft. Ltd,
15. SCREEN:
Depth Diameter Slot $izi Material
From To Ft In. In.
From —To —Ft.— in. —in.
x
From To Ft. In. In.
16. SAND/GRAVEL PACK:
Depth Size Material
From To FL ----
From To Ft.
17. REMARKS: -- -
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 1SA NCAC 2C, WELL
CONSTRUCTION STANDARDS. AND THAT A COPY OF THIS RECORD KAS.AEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE UN ONLY � �O
Quad No: r t't E i i a1tiNA 5 UCTINO THE WELL
L
SubnitN'odpkw fs w r CuaNry. Owatx
, Otouniedlon within 30 days
low No. I i `' QW.1 REV. IV"

North Carolina - Departrnent of Environrnent and Natural Resources - Division of Water Quality - Groundwater Section .i �}
16M Mail SdrAce Center - Raleigh, N.C. 27d9i1.1ta-Phone (919) 733.=l
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION #: 0
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE C1aek A"lleable sox): Reakleri lal �] Municipal ❑ lnduatdal ❑ Agricultural ❑ Monitoring ❑
Recovery �j Heat Punt Water Injection ❑ Other ❑ If Other, List Uss:
2. WELL LOCAT: ( w sketch Q location below) 9
Nearest Town: County:
(Road Name and Numbers, Co pity, o ;SubdlvWon and Lot No.) _ DRILLING LOG DEPTH
3. OWNER 0,V (g 1� + From To Formation Description
Address FLU
o. -
or Town State Zip Code
4. DATE DRILLED G 2-a o,�
5. TOTAL DEPTH aS'
B. CUTTINGS COLLECTED YES 0 NO® �--,
7. DOES WELL REPLACE EXISTING WELL? YES 71 NO® C)
8. STATIC WATER LEVEL Below Top of Casing: 416-- FT. o r^
(Use'+' N Above Top or Casing)—Tm
9. TOP OF CASING IS__.� FT. Above Land Surface' --�•=
`Top of oeslne terminated aft below land surface requilm a variance in accor- _J
dense with 1 iA NCAC 011 i
10. YIELD (gpm): METHOD OF TEST 21-ru
11. WATER ZONES (depth):—
c n —+
12. CHLORINATION: Type Amount O if additional apace Is needed use back of form x
13. CASING:
Wall Thickness LOCATION SKETCH
Depth Diarretsr or Welght/Ft. Material (Show direction and distance from at least two State
From ___ ___ To 2 7 Ft, _ C Roads, or other nxp reference points)
From To Ft.—Jle
From To Ft.
14. GROUT: takr Depth mat d
�`� � Ft �e rr��► I Method �,�. Ct��i
�
From ._ To r
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material , p
From To Ft In. in. tLVL'r1'
From _.— _ To Ft. In. In.
From To Ft. in. in.
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To______ Ft.
17. REMARKS:
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HA�Sf BEEN PROVIDED TO THE WELL OWNER,
FOR OFFICE USE ONLY Q l GC- la a o c7
Quad No:',Uq T F PERSO CONSTRUCTING THE WELL DA E
t _Subrrtli oAq� Diviiion of Water Quauty, Groundwater Secton within 30 days
So" No. GWA REV. t2/99
f

2t3298
Nuith Carolina . 0eparirr,eni of Environment aril Natural Resources • Division of Water Ouallty • Groundwater Section
1636 Moil Service Cenlor • Raleigh, N.C. 27699-1638-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CEhfIFICATION M:
STATR WELL CoNStF OTION PINIMITN:
I . VIELL USE (Check Applicable Pox): llesidenllal t_1 MunIcIpal 0 Indd0lal rl Aprleultural d Mor!Itorinq ❑
riocovery [] Heal Pump Water Injectlot► [] 00ior II Other; List Uss:
2. WELL LOCAT IUN: Show sketch of tlto location below)
Nnnrnnr Tovin- _— O� I:� .V I.L1-F County: 11d A-/✓\
(!load Nanrt and Nuribois, Golnrrrurity, or Subdivision mid Lol'No/.) DnILLING LOG QPTH
3. OWNER _'S��iy S. (fir Co^�NE (�., From To FonnANonbeeorlp!lon
.r
Aclydrngn % �Oic >l
ao(er fa`oulo 17o-j—
Qg1�INS� 1�� ^) C :as-rz I
riq• or Tnwr SIM Zip Code
d. DA•I E OFIILLEU r O U--------
5. IOTAL UEPII 112--)'
6. CUTTINUS COLLEC1El) YES NoE- —
7 ODES WEI I R(:PI ACE EXiSVING WELL? YES NO('t—
S. STATIC WATEFI LEVEL Below Top of Cnsinq: _ —` FT.
(l!sa'+If Abovo Top of Ctolnp)
o Tnr� f 11 r,nSIN(; IS F1 Above I. And Surface,
nr rnglnn lormlrum-1 nr/(,r hnlnw I+nd titan" toelrrirot o Vnrinner In Mrcor•
dirier, with 15A N^.AC 7C .etln
in YIFI D (nf m)' �5 .--- MFTHOD OF TFS7 _L ' •li ----- -- _ -•---
II.
12. CHLORINATION: TYrp / . f/...__Amnon( C ��� Il edditbnill space b netded use bock of form
13 CASINCo.
Will 1hIcimcQl
Vnpllt Diameter or Welphl/rl. Maledill
Fmm_ To Fl.
1'rorn J _ ro F1.—, �)/-�y `'C
From —�—lo I t. —
14. GROUT:
►`cru, Material Method
Horn To r�y rI.
rrrnn �� to .•��_.�'-_1=t. _G�� _.. ____._
lri. �rf1rC�1:
LIr hqt (7icurwler Slot Size Mnlerlhl
171 __--- in. in,
In. _—_ In.
1'3. SAND;GrlAVE-I.. rnCK:
Dpoth Size Material
rr-r-t .... Tn .. .- .._... rt..-------- — —
Ficirl
17. REMArIKS'
LOCATION SKt:7CH
(8how dir"don and distance from at least two (31ate
Roads, or olhor map telerence points)
C3
4
C
1--
I
w
N
N
0
�c
cow
a�
�o
rn
:;0 (=)
m
rM
h
--r
C`
r rt, I IFncnY r:rnTIFY TI IAT TN19 VIELL WA9 CONSTRUCTED IN ACCORDANCE WITH 15A' NCAC 20, WELL
Cf"NS I RI IGMON S i ANDARUS, AND THAT A COPY OF THIS RECORD HAS 13EE OVIDED TO THE WELL,OWNER,
rOR OrrICE USF ONLY-
0111d r:n• SICINATI mit Or, r r, nPI STA TING THE WELL DATE
Suhllwt orlQhtar to Divl-1lon of Willer y, cM'U" ndwaler Sacf!an Wllhin 30 days
ill V0. GWI nGV. 12/99

21329 1
Nclth Carolina - Depaltmenl of Environment and Natural Resources • Division of Water Ouallty • Groundwater Secllon
1636 Mnil Service Center • Ralelgh, N.C. 27699.1030•Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: C1. .k"- ��_ 0-// A/.
l��S
WELL CONTAACTOFI CEIITIFICATION N: `1,,1—
STATE WELL CONSTRUCTION 0191MITM:
f"
1. WELL USE: (check Appucable gox): nesidential u Munleipal ❑ Indu9hial d Agricultural ❑ Monitoring ❑
Flocovery U Heal Pump Water Injection [] Other ❑ If Olher; List Use:
2. WELL LOCA HOW: fShow sketch of the location below)
N-nrnnt Town• _ QINS 111.1_L--- County:+�t ►7�'�'
;fir hylFr AL -CD.
(road Name and tlunlbors. Community, or Subdivision and Lot No.) WILLING LOG UPIL
3. QWNER — — /gQ ( From To Formation bosodpflon; —�
ArlrfrnSs J - t� G 5L� �—
^sty rn Tmtin Slnle Zip Code
4. DATE DRILLED coo
5. 101AL DEPTFI l
6. CUTTINGS COLLEC I ED YES [� NoF
7. DOES WELL F1EPLACE EMS TING WELL? YES ❑ N0
8. STATIC WATER LEVEL Below top of Cnalnq: PT.
(IM • /' N Above top of Cosirg)
o Tnp nF r•ASINr IS _ FT. Above Land Surface*
'Tnp nt rnglrlp Inrminm-1 nl;rr hntnw bnd-tmiAno rAr)ulre4 a Vrtlinnee In Mreor•
d•lncr. with 151k NCAC 7C 0119 —
1n YlrLD (flan)' %�:ME=THOD OF TFST__-_--
WATEn Zor1E3 ((iepin):
12. CHLOnINAT ION: Tyre / �/ __ AmhuM 0 i/S - 11 eddltbnal spsCe Is nettled use bsck of form
13 GASIr IG
Well 'I hic1'nS4s
O�plh- b'nmelor or-WNphVFI. erfel
) l ✓ L
Violrl - To------- FL
—
From To -_—.— FL
14. GROUT:
rlr.plh atonal Method
from L l to �� rI. w __
From -. t o
r
15. �cnrerl
Url'ill I7i7rnr19r
non, --- I o .-.-_.-._-- rl In.
rrrnn _.-•-_-- fp _....__ Fl. _ In.
15, SAI iwoi-IAVCl_ I ACK:
Unpin Size
rr^rl Tn rt
rlC1111 ---- r� _----- --- rl.
17. REMAFIKS:
Slot Size Material
In.
In.
Material
_ LQCATIQN SKETCH
(ghow dlreotbn end distanes from at beet two State
Floads, or othet map telerence points)
i rrq t irncpv r.rnTirY TIIAT THI9 WELL WA9 CON3TRUCtED IN ACCont)ANot WIfiH 16A.,NCAC 2C. WELL
r()Ne r 1al ICTION 91 A140ARUS, AND THAT A COPY OF TI 3 RECORD HAMIEEk PROVIDED TO THE WELL OWNER
ron orricE USf. Oiil-Y
Otmi r:n• slra An7 or PCns d CUM TT1t1CTlt THE WELL DATE
—_ Suhmrl oritrMtl to Div sloe of Wale uall�; roundvvAI#r Secllnn wIIhIn 30 days
�,•i�t r,o. _ GW4 nGv. f2/99

21301.9
North Carolina • Department of Environment and Natural Aesouresd - Division of Water OuelltY • Groundwater Skilon
1636 Mail Service Center- Raleigh, N.C. 27699.1636-Phono [phone]
WELL CONSTRUCTION RECORD WELLCONTAACTOH: 3a�iee
WELL eoNTAArmn C18.gtIlkiCAtION lie
STATE~ WELL COMIAUCTION pNgMltn:
WELL USE (Check Applicable Box): nesldenlial ttK Municipal 0 Indubtflal b Agricultural d Monitoring d
nocovery U Heal Purnp Water Inleellon Other 0 If Other; List Use:
2. WELL LUCA 11014: (Show sketch of (tie location below) n e
Nanrnrt Town- __� 1NS I/IG,L -- County: GP4q-tV,4/Yl
(road Name and Nuribors, Corrunurdty, or Subdivision i tid Lot No.) UnILLING LOG E)Ef TH
3. OWNER ---, Ajbl-F e-I_L \/ From TO l //porn-49onWsoription.
Arlrlrnan i-2
—�riri4n; er riouio`f o. �� (W)
.COI, nr Tnwi S1e19 Zip Code
d. DATE DRILLED -� v
5. 1 U IAL DEPHI
6. C%UrTINGS CC11.I.ECi ED YES NOD,
7. nOES WEI..L FIrPLACE EXISiIN(3 WELL? YES NO(
8. STATIC WATER LEVEL Below top of Cnslnq: _ ` � FT.
11!sn',' H Ahovo Top of Ct►sing)
o TOP OF r,AGiNG IS ._ �_! h t. Above (_nnd Surface*
•Tni, nt rnOno fnrminnrmi nr/nr hninw liner our A" ►oryrdrert o vnrianev In 0ccor-
111ncn with 1F4 NVAC?C pie _
10 Ylrl.n (nrm,)' -._ Mr_THOD or- TEST
t. WAIEn ZOPIt=.3 ((lepii►):
12. GHLORINAI ION: Type .��/._._l Amount ( D YU It Additiorilif so&" I! ne@ded Use bilek 01 torn
13. CASiNG.
wnn lnlcrnens LOCATION SKETCH
L)nP(l , dl n I9r or 1p VFI. Melerial (Show dirtrotbn and distance from at beat two glals
From �� To —� _ Ft. P� Aosds, or olher map telerence points)
1'1o111'10-----_ FI.
Front io�—__ FL
iA. GROAT: o
O ZE
�`rFlti aterlaf Method o I=)
rTv ra0 ri. — c
l C
N c7 rn
cnrr:rl W A y�
Urpol t)i,.irnrel;)r Slot SIz9 Malarial
rrunl 10 .- —• _-• rt a
` Cj err
From ----- .t r, �._... _ Ff. In. In.
rr,,rrt _ To -- Fi - In. —In.
Ili, SAiIU.Gr1AVuLrACK:
�4
Uat►th size Material
rrr,rn ----- To..
F1ar11
17 REMAFIKS
I rn i irnvriv t7rnTir-Y TI IAT TI-119 WELL WA9 CON9TRUCtED IN ACCORDANCE WIN 15A NCAC W. WELL
r-r►Ne I RI Ir,1lnN S VANDAnOS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER,
rOn OrrICF U5F. ONLY
0ii.1,11 ern• Ur• St7N NSMUCT1NG THE WELL DATE
----- SuNNI oriptnnl to D1•rk1on o aler Oualily, Cmundwnler 4. eilen within 30 days
r?'i1I No. GW-I M. 121"

P-13018
tJollli Carolina • Department of Ellvlronmenl and Natural Resources • DIvlaton of Water OualltV • Groundwater Sactlon
1636 Mnil Service Center • Raleigh, N.C. 27699-1030-Phone [phone]
WELL CONSTRUCTION RECORD WELLCONTRACTOR: _�'-ao WL°-�`rLlt•y
WELL CONTAACTOM CEpTIPICATION N: 25(�S
STATE WELL CONVAUCTION ppgMITN:
WELL USE (Check Applicable sox): neslden11aI8 Municipal(] IndUblfla) d Adrlct,llural Monitorino d
Recovery U Meal Pump Water Injection [] Other C] If Other; List URa:
2. VVELL LOCATIUW�("S�hbow sketch of (lid location below)��
NPnrnal Tows ___ wS?�1 �S �JfLL� Coun� `c}K
(ftoad Hanle and Numbers. Co munlly, or Subdivldon and Lot No.) DRILLING LOG QRPTH
3. OWNER -- _ — (u 6 k0 L oQ I Front To Forrr+etton beeortprton
root or Itouio o' _ Z 7 � �•7 t!J• /��l>. `r -tom
511r nr TiAl, SIPIe ZIP Code
d. DATE URILLEU 00
5. 101ALDEP111 _So.)
6. CU r1INGS COLLEC1 ED YES NoC}--
7. DOES WEI.L RFPI ACE E.XIS1INL1 WELL? YES 0 No ff
8. STATIC WATER LEVEL Below Top of CnevInq:
(IJO'Off Ahovo top of cnslnp)
4 TOP nF rACING IS / _—_ r-'T Above I.nnd Surldce•
'Tnn of rnglnp Inrm1,rni­1 ritinr hoinw land -mr-fried terynirot A vrvfrnnev In rrecor•
tf,ncn with 161% WrAC 7C .d11A
1n Ylri.n (9pn,)' 1__-- ME-T _HOD of TEST
It. Y1A1En zot)F3 (dei�llt): pry
12. CHL1tFt NA T ICON: Tyr- Al%/� .__ Amnunf L; It Additional apace h needed use back of form
13 CASING,
W:,n Ihicknos!
!/�, Clnnlh br rp -gl or W� 761'rl.
I'rorflTo----_-_ Fl.
Front To __ rl.
1 d. GROUT:
_ LOcATION_5KETCN
MAlerlal (81ww direotbn and di6tanCe, from MI beet two 43tate
-sir- c /
Reeds, or other map Ieterdrtee points)
F�''rtlt o
alnrlal Method
Atom O To '2 D rt. y o 2E
From m 'Io Zi.,r=1. _ C_ M�
rn
Url•th r7iamr..ior Slol Si,-6 Material
� ac
rlulu -- lu ---- rl rTt _ Irt. In. I'+ —AIM
.�
rem ._ 'I r• _--.-. - FI. ---� In. In. .. , a
rr�m re Mrs
FI. In. In. n� f' o NT
13. SAI10,GRAVE:L rACK: i.r,_„ n�
Uphill Size Material f o
To_ ._ .__... rL
Fruit,TO
17. REMARKS
I rn I IF"CnY rr-nTIrY T1IAT TI4I4 WELL WAS CON9TRUCTP IN ACCOMDANCF_ WITH 1SA Nick w. WELL
r1nNs I NI Ir, I ION S rANUARUS, AND THAT A COPY OF T1 ECORb HAS BEEN OVibl:D TO THE WELL OWNER.
r0R orricp USE oiiLY _ `/ - a0
otn't r:o siaK4,lne or- pr 1 cq581FnUCTltM 114E WELL OAtF
-•-- su"rrtit ortuinal I ivislon o1 Wnl Ouallly, Groundwater Section within 30 days
GWt REV. 1?/99

2.1.2209
Noah Carolina - OnpAdment of Environment and Natural Resources . Division of Water Qusllly • Groundwater Section
1636 Knit Service Center - Ftaleigh, N.C. 27699-1038-Phono [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: C LA-& kA-,L W'_m
WELL CONTRACTOR CF-hTIPICATION 11: (4 __i G- 5-
STATE WELL CONSMOTION p11MIT0: �
1. WELL USE (check Applicable Box): (lesldenlial ld MunlclpA1 ❑ (ndusblal ❑ Apriculfurdl d Monitoring ❑
flocovery ❑ Heal Pump Water Injection ❑ 011isr C] It Mari List Use:
2. WELL LOCAI 1014: (Show skglcll of (he location below) GSA
N�nrnntTown: _ Qo� �^^?`?. e County: -4 A—"\
(need 11anw and tlun�ars, coltmuNly, or Subdlvlslon end Lot N9. W e,•-P OHILLINO L00
3. OWNER(�rJK,rJ, �wJr.) �.9N'�-- /O K�^^"'`� From To
f
j � t'•T no; Or rlttUlO rl—v.j� Lf � ���_�
q• nr Tnvrt $Isle Zlp Code
4. DATE DNILLEU n'
G. 101ALUEPIII 60'>
6. CUT-11NCIS C(II.I.EC1 EI) YES(--) NOCj'
7. f)OES WFI L RFPI.ACE EXISIIN(3 WELL? YES ❑ NO[—
9. STATIC WATER t_EVEL Below Ton of Cnglnq: _ ��_ FT. - -
(l)ao Is I It Ahovo Top of Cnelnp)
o Tnn Or- r.AeING IS � FT Above Lnnd Surface*
•Tnr, nr rn�lr+n Inrmin�lml a,;nr h�lnw I+nd t+ni�n.ra r�nnire� A onrinnC♦ In t•ccor• "-•`"—
dinco with 1¢A NrAr; 7C•. 1111 ,))
10 Ylrt h (qrn*. _ M[THnb QF TF5T _ V<
If. VJA1Erl zom-.3 (depth): b
12. CHLORINAMIN:
13 CASING.
DEPTN
Formation Dowrtption
49
Z
o
�44­
�m
O
frl
Tyre O 5 It additional Apace b needed use beck of form
Wnu 'l hlcknrgq
IIn 11 inmel9r or I /Fl. lednl
prom _ �'� .__ To �7_ FI. _ QC ( L'i L
Ciorn- 'To—•----- Ft. -
From To __ _ rt.
14. GROUT:
Pr r h v Matorlal/ Method
rlotn L' Try (�� u rt.
From T— .I" .7. _�._._FI.
in. srr1t=GN:
Of-1,111 Di:ltnrhr Slot Size Material
f nnn — -_ t o _-- _-- rt -___ In. In.
1•rom ------ -In .._.. _ __ Ft ___
From .--- - -'To --- FI
P3. SAIJU;Gr1AVEt. rACK:
uannt
rrnr-, •_-- _._ _ To_ _ .___... r- t.
Flc,nl -- _ IO - - rl.
17. nEMAl`IK3
In, _ ht.
In. In.
Size Moterial
„J OCATI SKETCH
(13how dlreolbn and dletance from at leaet two 91als
Roads, or other map reference points)
'A
Y ,
w,
i rrq i iKricnv rr-nTIFY T1 IAT TH19 WELL WA8 CONITAUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
rnNfi I nl IMI(IN S I ANI)ARUS, AND THAT A COPY IIS RECORD HAS 13ESN PROVIDED TO THE WELL OWNER.
roR orrlCl± usF oaiLIF �—
6.0. n4,
SIONA`I ME t7rf!n-,w) 4 CONSTFIUCTIr1O VE WELL VATE
SV!+rrtit orIVInal to Uivlslon of nler Owilily, Croundwaler Saclian WIIhIn 30 dayo
GW.t nm 12(go

21.2208
North Carolina • Department of Environment tired Natural Resources • division of Wa(er OualitV • Qrotnldwetdr Section
1636 Mail Service Center • fialaigh, N.C. 27699.1038•Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: �� ILe �rz�l//tip
WELL CONTFIACTOM WITIFICATION 0: c —�
STATE WELL CONStnUCTION PEMMITll:
1. WELL USE (Check Applicable Box): Resldentlal 1�r Municipal C] Induetllal El Apr)ouilural CJ Monllorino
Rocovery [] Heal Pump Water Inlacllott 0 Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
plpnrnnt Town ghs�'!_.—�'_ . County (ter
—��A Ll
(rload Name and Numbors. Community, or Subdivision and Lot No.) DRILLING LOG Off jH
3. OWNERR -- � (()S Krorn To l Fam+adonbesotpilon
A(lrlrn9s j 7� ,�`cJocJ�rfLv C) zoo'
r ni M rlavio r o. 2g C) 6-1 is -
Rile nr Tw n Srara Zip Code
4. DATE DRILLED r ' /(/'GC)
5. 101AL DEPTFI / k- >'
6. currlNUS COLLECT ED YES NUC-
7. DOES WEI L RFPi ACE F-XISTING WELL? YES Q NO�
S. STATIC WATER LFVEL Below Top of Crrginq: Q — F'1.
(rJW0 E Ahovo top of Castnp)
o TOP OF r.AglNG IS -_ lF'T Above l-nnd Surface*
•Tnr nt ­grntr lnrminnM.t Wor hninw Innd 0,1Ace ►ertnlre} a vndrince In rrccor•
dvnco with IFA NCAC 7C.Olin _
1n Ylrt.n (9pri). 1.2__- MFT Ob QF TEST _
If. WATEn ZOP•IE:S ((iepth);
r )
Iv
0
12. CHLORINATION* Ty p
p .
�
/.��1�.__ Amnunf < <� ''
?
It additional Apace b nrtrded use beck of Iorm
13 CASIr Ic:
Wnln Tntcrrnes!
LOCATION SK�tCH
UnnlhD nret9r or Veto M. Maiedal
Frnm.-0 .—Tn �IlC/ Ft. (�Jc ;fir
(show direction and dletanco from of least two State
Roads, orothetmap telerencepoints)
FI.
From —To __—.—
Ft.
14. GROUT:
\`s.
rr ru,
To
yatcrial Method
iron, �rt.��T
From to l.(1l1_:..F=1.
)
Ur htlr
Diamr..ter Slot Slze Material
_ Q'
rroNn —� To .- - -- rt
_—_ In.
Fl._
In.
113. SANWGRAVL•1_ rACK:
URIrIh
Size Material
rrrm -- To..—_—
r•luill
17. r1E1v1AF11<S
I ro I IrnCnv r.rFITlr-Y TIMT THIS WELL WAS CONIML►CTED IN ACCORDANCE WItH 15A NCAC 2,0, WELL
CONS I rat IGI ION S 1 ANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
roe orrice usF otiLY ^��,=ram, Jr
r]u.'I�s rf t:n• R )n rJ CC1NSTflUCTIN(3 THE WELL DATE
Suhrrvt oriprrrit to VNIMon of Waler Ouasty, Groundwater Sacflon within 30 day9
i:rl t!o. GWI nGV. 121"

2t2207
I
Noith Carolina - Department of Environment and Natural Resources • Division of Water Quality • Groundwater Section
1636 Mail Service Center • Raleigh, N.C. 27699.1036-Phono [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: t rL!'oAse_� �rUQi�liNg
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check applicable sox): Residontial [!I Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heal Pump Water Injeclioli ❑ Other ❑ I( Other, List Use:
2. WELL LOCAVION: r'how sketch of the location below)
NPnrpnt Town _—. � %N�I/IL.LC._._ County.
(noad game and Numbers. Commurdly, or Subdivision and Lot No.) / DRILLING LOG DEPTH
3. OWNER _--,/ �/ 1= SrJOlJk/Qrfl C'� u�c�. From To Formation Description
V or Tnv.n Slalc Zip Code
`)
4.
_ Ur U
UA'I E DRILLE0
5.
IUTAL UEPTFI -2-•
6.
c;uT-ZINGS C(-)I.I.EC I ED YES n NO[a—
7.
DOES WEI.L FTFPI.ACE EXISIING WELL? YES ❑ NO[—
8.
STATIC WATER LEVEL. 8t low Top of Cetka: a tro r FT.
(U,;e •.r• it Above Top o1 Castrp)
J
- —- — 0
-
o
TOP OF r.A' lING, IS __- FT Above 1-nnd Surface'
�r r
•rnp
nr rnatnp Irnnlnnt-f ,Nr+r hPlnw Iind emriinm rorinlrwe n vnrinnep In arcor•
'_"'-" -���
d'tni:p
tvirh 15.4 FIrAC 2C .e1111
7
in
Yif-1_Ci CTHo n OF TEST
11.
VVAIEn 7o,iE 3
12.
CH L Q R 11' 1 A T 10 N Type /... i___ Amount � �
if additional space Is needed use back of form Q
N
M;
13.
GASIf IG.
wnlr 1h1 Vnr�
Cn
LOCATION SK-U2
�
„ I1nntl?. r in voter
Front To Ft. -
From 1 o __ —._ Ft.
id- (;ROL1l':
C ... 4
or yVr•Vh1/F•t.'Material (Show direction and distance from at least two State
dRoads, or other map reference points)
�) rIcj-tlI �,latcrial
morn _!%____ To r Ft. _
From Ste' 1o�J,..,_1=I. - _
15 scnr-1-i•I'
L?r h!h 17iiamPter Slot Si; 9
to . _-- Ft __---- In. __ _. In.
1'r trT1 --- Ir' FI -- -- In. --- In. _
Fr^m .-- To ----- FI.--- In. _---- In. _
trs. ':)AHD,GI`1A E-_ SACK:
Method
�1�i 6is
Material
upr ll Size Material
Fmrt-__--_-- To_
Ftcnt
17. REMAFTKS:
1 rn r1rRgRY CrFITIFY THAT THIS WFLL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C. WELL
(Y)NR I HI ► 7110r) S I ANpARDS. AND TI IAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
6 . . E,
FOR orrice use oI`iLY-----
rntra,i Nn• Mi slar�Jtlti'— FF_PF:ns N UCTING THE WELL DATE
�;r•ndt orir�inal to Dr• ...on of VVn1ei Orintity, Groundwater Section Wlihln 30 days
I!a GIN-1 REV. 12/99

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mall Service Center - Raleigh, N.C. 27699-1636-Phone [phone] _ 1 4 4 0 9
WELL CONSTRUCTION RECORD WELL CONTRACTOR:'�`��
WELL CONTRACTOR CERTIFICATION p:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable 8ox): Residential L`�! Municipal [� Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other [j If Other, List Use:
2. WELL LOCATIOl($how sketch of the location below)
Nearest Town: O °�/6 County:
/�%o/yH �v��0 DEPTH
(Road Name and Numbers. Community, or Subdivision and Lot No.) DRILLING LOG
3 OWNER ,7"e�f �fC2y llfJS From �_e
To Formation Description
Address / -
reo or ou a o. �'D — j� Q Gi- 11, I-e-
City or Town Slate Zip Code
4, DATE DRILLED
5. TOTAL DEPTH /LV t
6. CUTTINGS COLLECTED YES ❑ NO�
7. DOES WELL REPLACE EXISTING WELL? YES[-1 NO[
8. STATIC WATER LEVEL Below Top of Casing: /s' FT.
(Use '+' If Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface*
'Top of casing terminated eVor below land surface requires a variance In accor-
dance with 15A NCAC 2C.o118
10. YIELD (gpm):_ METHOD OF TEST
11. WATER ZONES (depth): lD0
12. CHLORINATION
13. CASING:
Type �{%lf Amount 6116" It additional space Is needed use back of lorm
Depth Diameter
From To c—L 3 — FL G 2S
From To Ft.
From To Ft.
14. GROUT:
LOCATION SKETCH
Wall Thickness
or Weighvrt. Material (Show direction and distance from at least two State
//(j.J 51ee / Roads, or other map reference points)
Depth
�i'�M orl I
Method
jSSOrc'
From
o To 1d
Ft.l�/T1��J�
From
To
Fl.
15. SCREEN:
Depth
Diameter Slot Slze
Material
From
To
Fl In.
In.
From
To
Ft. In.
In.
F
To
Ft in.
In.
rom . --
16. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To Ft.
17. REMARKS:
Material
CD
CD
C-_.
C=
r'—
rV
ul
M"
0
CD
N
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 USE ONLY 'Yl]
Quad No: "—SiONATU, - OF PERSON CONSTRUCTING THE WELL GATE
a.� x Srnl.Podal lR'DI Ioslos of Water quality, Groundwater Section within 30 days
Serial No. � t , OW-1 REV. i2/99

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section ',
1636 Mail Service Center - Raleloh, N.C. 27699-1636-Phone [phone] / 2 14419
WELL CONSTRUCTION RECORD WELL CONTRACTOR: �w/lle
WELL CONTRACTOR CERTIFICATION 0: 3
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential e m—unicipal 0 Industrial ❑ Agricultural ❑ Monitoring
Recovery ❑ Heat Pump Water Injection [] Other [] If Other, List Use:
2. WELL LOCATION:�,Slw,w sketch of the location below) �
/j 6di/if u
Nearest Town: D County.
Grans l✓PIAaCle, 04,—/
(Road Name and Numbers, Community, or Subdivision and Lot No.)
3. OWNER
Address
ree or ou a o.
City or Town Stale Zip Code
4. DATE DRILLED , IL` 00
5. TOTAL DEPTH 2L
6. CUTTINGS COLLECTED YES ❑ NO❑''
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NOD
8. STATIC WATER LEVEL Below Top of Casing: /00 FT.
/ (Use **'If Above Top of Casing)
9. TOP OF CASING IS / �� FT. Above Land Surface*
*Top or casing terminated at/or below land surface requires a variance In accor-
dance with 15A NCAC 2C .0118
10. YIELD (gpm): METHOD OF TEST
11. WATER ZONES (depth): 32d
DRILLING LOG
From To
_ DEPTH
Formation Description
C �y
Type ��T Amount
It additional space Is needed use back of form
12. CHLORINATION:
13. CASING:
LOCATION SKETCH
Wall Thickness
Depth ' Diameter orwelgl,vrt. material
(Show direction and distance from at least two State
G
Ft. 6' 2X— Z/ RUC.
Roads, or other map reference points)
From To —
From To Ft.
From To Ft.
O
c=)
M
14. GROUT:
r a
Depth Ma rlal M Illod
ram—
o
From �— To � FI. � j`faigll
fv
r*r
From To Ft.
Ln
15. SCREEN:
a"
='�
r- i
Depth Diameter Slot Size Material
11
From To Fl In. In.
o
M;0
�''O
From In. To Ft. In.
o
From To Ft. in. In.
.w r
z
16. SAND/GRAVEL
'� S Y�Iz� l'I
at
Depth �. _ I
D
From To t•
From To Ft.n
i
17. REMARKS:
I b0 HEREBY CEFlTIfY HA 4 STRUC DIN ACCORDANCE WITH 15A #CAC 2C, WELL
CONSTRUCTION STAN AlDS, j(� , jA+!:®F ECOR HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY DATE
Quad No: SIGNATU OF PERSON CONSTRUCTING THE WELL
Submit original to Division of Water Quality, Groundwater Section Within 30 days GW 1 REV. 12/99
Serial No.

North Carolina - Department of Environment, 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: 1 /1_
FOR OFFICE USE ONLY
OUAD. NO. SERIAL NO.—" 4 41
Lat. Long, n0
Minor Basin
Basin Code
Ileader Ent. GW-1 Ent.
STATE WELL CONSTRUCTION
DRILLER REGISTRATION NUMBER: �j� PERMIT NUMBER:
1. WELL LOCATION* ( �Ip'w skelp i of the location below)
Nearest Town: ilD��'//s �' (� County:
(Road, Community, or ubdiv�r ion nd Lot No.) _DEPTH _DRILLING LOG _
2. OWNER �e�G "� _ From To Formation Description
ADDRESS Ti'�dk------
(Sheol or Route No.) ? Z
iz — ,2 ZD
City or Town State ip Code —
3. DATE DRILLED Sal O0� USE OF WELL /2'/ �
4. TOTAL DEPTH
5. CUTTINGS COLLECTED YES ❑ NO[_q—
6. DOES WELL REPLACE EXISTING WELL? YES F—] N00'
7. STATIC WATER LEVEL Below Top of Casing: FT.
y
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS 2— FT. Above Land Surface'
• Casing Terminated aUor below land surface Is Illegal unless a variance Is Issued
In accordance with 15A t CAC 2C .0110 ' s'
9. YIELD (gpm): & METHOD qF TEST _
10. WATER ZONES (depth):
11. CHLORINATION: Type l T/f _ Amount l� cv
12. CASING:
Wall Thickness
Depth Diameter or Wei hUFI. Material
From To 7S� Ft.
From S-" To Ft.
From To Ft.
13. GROUT:
Fromy
Frorn
14. SCREEN:
Depth
To 26P Ft,
To Ft.
Depth
From
To
From
To —
From
To _
15. SAND/GRAVEL
PA(
Depth
From
To _
From _
To_
16. REMARKS:
a(.erial
Me,.t�iod
Diameter Slot Size Material
Ft in. in.
Ft. in. In.
t n.i
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)
n
c �
r � n
� 7 0
--a
ZC ;;Q o
`rn
0 -t .o
r r;v
Cj
C3 -i
0
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.
SIGNATUR9�& CONTRACTOR OR AGENT DATE
r;w.1 RFv Q1Q1 4. n;..,..— M

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section � Q
1636 Mall Service Center - Raleigh, IV.C. 27699-1636-Phone [phone] �. 14417
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (check Applicable Box): Residential L Municipal [1 Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery EJ Heal Pump Water Injection [] Other EJ If Other, List Use:
2. WELL LOCATtO,� ( how sketch of the location below)
Nearest Town: „u6��' County:
Road Name and N bars, Comm`�yyrill fr Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER e,04Ci7From To Formatlon0escrlplion
Address 5:;'
--(,51reot or Houle o.
City or Town Stale Zip Code
4. DATE DRILLED
5. TOTAL DEPTH /o d
6. CUTTINGS COLLECTED YES ❑ NO[;
7. DOES WELL REPLACE EXISTING WELL? YES M NO�
8. STATIC WATER LEVEL Below Top of Casing: /SJ FT.
(Use '+' II Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface*
*Top of casing terminated aVor below land surface requires a variance In accor-
dance with 15A NCAC 2C .011t1
10. YIELD (gpm): Zb METHOD OF TEST
11. WATER ZONES (depth):
12. CHLORINATION:
13. CASING:
Type 6T14f Amount Cv
Depth Diameter
From To 'Z� Ft. -Le
From To Ft.
From To Ft.
14. GROUT:
If additional space Is needed use back of form
Wail Thickness LOCATION SKETCH
or WeIpIiVFt. Material (Show direction and distance from at least Iwo Stale
Roads, or other map reference points)
Depth MaI [lot thod
From To zO F1. �/ '�� d essu� 2
From To FI.
15. SCREEN:
Depth Diameter Slot Size Material
From
To Ft
In. _
From
To Ft.
In. _
From
To Ft.
In. _
16. SAND/GRAVEL PACK: '
Depth
Size
From
To Ft.
From
To Ft.
17. REMARKS:
in.
In.
In.
Material
0
G
t-"
tv
c17
xw
0
0
0
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER,
-------, mil./✓� .. ��i� sue- � � � •7-,
FOR OFFICE USE ONLY
Quad No:
Serial No.
PERSON CONSTRUCTING THE WELL
later Quality. Groundwater Section within 30 days
DATE
OW-1 REV. 12/99

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section f) 4
1636 Mall Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTORLL . CERTIFICATION 0:
STATE WELL CONSTRUCTION PERMIT#:
1, WELL USE (Check Applicable Box). Residenllal Er--Munlcipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heal Pump Water Injection ❑ other[—] If Other, Llst Use:
2, WELL LOCATIO�j�Tiow sketch of the location below)
Nearest Town: d r�91y� ll� County:
S,- "ui DRILLING- LOG DEPTH
(Rood Name and Numbers, Cm omunity, or Subdivision and Lot No.) Formation Description
3. OWNER S../oil ���i of �� From To
Address
— ree or ou e o.
ZV0
City or Town Stale
Zlp Code
4. DATE DRILLED ��
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES O NOD'
7. DOES WELL REPLACE EXISTING WELL? YES [] NOe'
B. STATIC WATER LEVEL Below Top of Casing: -s'-O FT.
(Use '+' II Above Top of Casing)
9. TOP OF CASING IS 2— FT. Above Land Surface'
'Top or casing terminated atlor below land surface requires a variance In accor-
dance with 15A NCAC 2C .0118
10. YIELD (gpm): 3 METHOD 9F TEST
11. WATER ZONES (depth):
12. CHLORINATION:
13. CASING:
Type /�T Amount 7 It additional space Is needed use back of form
Wall Tlrlckness
d
Depth
��
Diameter
6:27-O.Q,ZI
or Weight/Ft. Material
,Or.-
From
To
Ft.
From
To
Fl.
From
To
Fl.
14. GROUT:
Depth
ajgrial ,l}Aolhod
,
From
To
Ft.
!ll
From
To
Ft.
15. SCREEN:
Depth
Diameter
Slot Slze 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.
LOCATION SKETCH
(Show direction and distance from at least two Stale
Roads, or other map reference points)
17. REMARKS:
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY 05�0IS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY :SIB
�.�-..
Quad No: r Ivis
Serial No.
c
SON CONSTRUCTING THE WELL
Quality, Groundwater Section within 30 days
M
C7
C_
omM
r-- C: rn
C!1 . = rn
cz)
cn a_
c? m
p
-- o
z
DATE
OW-1 REV. 12/99

North Carolina • Dopartment of Environment and Natural Resources . Division of Water Quality - Groundwater Section
1636 Mail Service Center - Ralelph, N.C. 276W1036-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION M:
STATE WELL CONSTRUCTION PERMITM:
1. WELL USE t2wakApplloablesox): Residontial® Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery t Heat Pump Water InJectlon ❑ Other ❑ It Other, Ust Use:
2. WELL LOCATION: (She sketch of tho location below)
Nearest Town: �y"� L County: 1b -
(Road Nara sr4 uft, or and tot No.) , DRILLING LOG DEPTH
3. OWNER l Frorn To Formation Deurtpuom
Address fqeL
C D-9 '7
Cey or Town itfau Zip Code
DATE
E DFULLEo as ° - — S. TOTAL DEPTH o S Ca
6. CUTTINGS COLLECTED YES ❑ NO®
7. DOES WELL. REPLACE EXISTING WELL? YES ❑ NOE] �— ---
S. STATIC WATER LEVEL Below Top of Casing: 2c) FT. a
(t,1es '.' It Above Top of Caekp) rn
s. TOP OF CASING Is FT. Above t.rutd Surface*
'Top of ca0v /annlnated Wor below land surface requires a verlertce In scoor• `
denoe wMh 1sA MCAC 20.0118 � m
10. YIELD (gpm): ;7-0 METHOO OF TEST AA1L'
11
/ 71— WATER ZONES (depth): � �
gild 15
12. CHLORINATION: Type 97-77 Amount 0if Additlond space Is needed use beside of loan
13. CASING:
Depth
Dlsrneter
4g Th to matedal
From TO -.1
Ft.
From
To
Ft.
---
From
To._.._
Ft.
14. GROUT:
Depth
Material Method
From To a d
Ft. r1
From --To
Ft.
15. SCREEN:
Depth Diameter Slot Site Material
From
To Ft
In.
In.
From
To Ft.
in.
in.
From
To Ft.
in.
In.
1 S. SANOJGRAVEL PACK..., . -
_ -(�(►
f4 - p
From
Atterial
From Td`,I101.1 2000—
' ��,
17. REMARKS: _
y
I DO HEREBY CER FjDAFA.., 1HAM
Kl� brt, r .,v� S
S ANCONSTRUCTION„' �Q TaM,i TiA`iA43F'Y C
FOR 0MCE USE ONLY
Quad No: ltKll
SL&M orlpkut to
Sedsl
LOCATION SKETCH
(Show direotlort and distance from at least two State
RoadsW other map reference points)
Vzj�z � e(-� -tr>~ g '
'ED IN ACCORDANCE WITH 15A NCAC 2C, WELL
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
A'j )4 r d'. s/ -� I 1 z'�
pF(-ERION CONSTRUCTIrq THE WELL DATE
of Water OtWlty. Groundwater illiman within 30 days
QW-t AEv. IV"

North Carolina • Depamvent of Environment and Natural Resources • Division of Waler Quality . Groundwater Section
1636 Mail Service Center. Raleigh, N.C. 276W1636•Phone (919) 733-Ml
WELL CONSTRUCTION RECORD WELL CONTRACTOR: �Aa,
WELL CONTRACTOR CERTIFICATION 0:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Cheek Aapikebos Box): Residential® Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Ir*wtlon ❑ Other (, If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below) 9 ,
Nearest Town: 1` c , '� . , �it� ,iL4n . Cody.
(Woad Nww end numbers, or 6ubdtvfsim end Lot No.) DRILUNG LOG
3. OWNER ', _Z,� ry l_ FMM To
Address '_.j� rct
0et or mom n .c- ��77 /
Clly or Town 840 ttp Cods
4. DATE DRILLED is ao
Agricultural ❑ Monitoring 0
DEPTH
Fometlon Descrlvtim
5. TOTAL DEPTH o
o
8. CUTTINGS COLLECTED YES ❑ NO
7. DOES WELL REPLACE EXISTING WELL? YES [] NO®
...r.._ C-a"
S. STATIC WATER LEVEL Below Top of Casing: _ g'�-o FT.
�
-m
(Uee'+' If Above Top of Casir+p)x-
9. TOP OF CASING tS_._J _ FT. Above Land Surbrtte•
co
ern
'T" of sealing tsradna mil at/or batow Land awrface PpWres a varhanes In saw.
min
—tom,
canes whh 15A NCAC SC .N1&
10. YIELD (gpm): 5' METHOD OF TEST A ^'i a
�. r
11. WATER ZONES (depth):
12. CHLORINATION: Type 7- Amount O S
—j
If adMonaf &pact is needed use back of form
e
13. CASING:
wag Thlow"
From_. 0 Tom, � Ft. 6 77._ sic
From To ----. Ft.
From To FL-
14, GROUT:
Depth me dal Method
From . n To J Ft.
From To Ft. _
15. SCREEN:
Depth Diameter Slot Stri Material
From To Ft In. In.
Fmm To Ft. In. In.
From To FL in. In.
1 S. SAND GRAVEL PACK:
17.
From Tip`
From Tb1I T.�.. Ft.
I DO HEREBY CE
CONSTRUCTION
FOR Owl Use ONLY�x —
Owsd Na
SsAal
LOCATION SKETCH
(Shaw dirsodon and distan" from at least two State
Roads. or other map reference points)
vj--C��& e �� a �. 'C ' �.
br��,1
.& f,3
AZ�����
ItAA-2.
;UCTED IN ACCORDANCE WITH 1 SA NCAC 2C, WELL
THIS RECORD HA$ !BEEN PROVIDED TO THE WELL OWNER.
OF PERSON CO*STRUCTWO THE WELL ' DATE
of water Ouslky, t mw4wster Section within 30 days
t3W1 REV. 12H11

North Carolina • Department of Environment aril Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail $ervim Center • Raleigh, N.C. 276WI63a-phone (E1 O) 733.3221
WELL CONSTRUCTION RECORD WELL CONTRACTOR: 94wet
WELL CONTRACTOR CERTIFICATION M:
STATE WELL CONSTRUCTION PERMIT#:
I. WELL USE CMok Applkabis Box): Resldentlal ® Munlclpai ❑ Industrial ❑ IndustrAgricultural ElMonitoring ❑
Recovery Heat Pump Water Injection ® Other ❑ If Other, List Use:
2. WELL LOCATIO • (8hqjN attach of th* location below) D
Nearest Town: yl,Ce CourAy: Za -�FVrn
( +Yams ►+. a SubdMelon and Lot No.) �RILUNG LOG
3. OWNER " From To
Address
7
Cly wn or To0
t!� Y Zip Code
e. DATE DRILLED 5 a as
S. TOTAL DEPTH
6, CUTTINGS COLLECTED YES 0 NO
7. DOES WELL REPLACE EXISTING WELL? YES NO®
B. STATIC WATER LEVEL Below Top of Caring: FT.
ti. 70P OF CASING IS / Na *y r Above Tap or Caalrq)
FT. Above Land Surbm
'TOP Of G"WV "raVfeled SOW below band surfaoc requires a variance in racoon
dance NO 11" NCAC 11C ."Is
10. YIELD (ppm): —19— METHOD OF TEST .
11. WATER ZONES (depth): -- o
,p,EPTt-i
Fomwdon Deeodptlon
a
12. CHLORINATION: Typo r Amount 0 , G If additloinal space is mKied Use tack of form
13. CASING:
From —
Depth
TO
W-new
FL 6_
Woo Thialoges
or WSVM. material
S. R 5�
From-------
To
Ft.—_.__--
_�.�..
From —To -
- To
Ft.
14. GROUT:
Depth
Method
From To .P.c?
Ft.
.._._.___.�..
From —To
Ft,
11S. SCREEN:
Depth Diameter Slot Slav Material
From •
To Ft
_ . in.
in.
From
To _._ _. Ff. ,_._..._ in.
In.
From —To
Ft.
in.
—In.
1S. SANWGRAVEL PACK
From
Depth
To
u
�
From —To, I I " Ft.
17. REMARKS:_-_- 1 w .• 8 �,
LOCATION SKETCH
(Show direction and diewice from at least two State
Roads. CW other map reference points)
\� �p yrl .
1 DO HEREBY CERTICONMUCTONFY .,TtiJ(T 1 {j ;j ; j�;c.,V ► „ oNiTR�LICTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
BTA T I;+Un OF T�8 RECOR HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE UN ONLY 4 Ova
!load No PERSON 0ONSTRUCT04 THE WELL DAT
So" No. ub Smit ofl ?w b Dlviolon of Waist Ou& ft. Gmundwater SoWon within 30 days
ow•1 Rev. tam
ii(�a

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: f(1ele�
WELL CONTRACTOR CERTIFICATION #: �5 J
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (check Applicable Box): Residential Municipal ❑ Industrial ❑ Agricultural El Monitorir:g ❑
Aecovery❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2.
3.
WELL LOCATIOShow sketch of the location below)
Nearest Town: ``/1 �'�b �7> �' �1� County:
(Road Name an��JJNum¢ers, Community, or Subdivision and Lot No.)
OWNER
Address
(Street or Houle o. — ✓r'O �1�
City or Town State Zip Code
4. DATEDRILLED
5. TOTAL DEPTH ZOG
6. CUTTINGS.COLLECTED YES❑ NO[
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO[ —
8. STATIC WATER LEVEL Below Top of Casing: _r FT.
i (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'S
11. WATER ZONES (depth): /Y1
�n-
DRILLING LOG DEPTH
From To Formazm Descrip6W
12. CHLORINATION: Type 1I %lf Amount l �� If additional spoe is needed Ls-- back of fccm
13. CASING:
LOCATION SK=TCH
Depth
Wall Thickness
Diameter or Weight/Ft. Material (Show direction and dance tr= aI leas::No Stele
From
To ��
Ft. "f'" -21 Roads, or other n—.--p refere:cxe- points!
From `{�
To 6
Ft. G,�f- I/y sr4ee/
From
To
Ft.
14. GROUT:
Depth
at al Method
o
From 0
To
Ft.
From
To
Ft.
rrr
15. SCREEN:
ry
'
Depth
Diameter Slot Size Material
From
To Ft
In. in.
rn
From
To Ft.
in. In.
o
ern
From
To Ft.
in. In.
�j
kn z
r-'';0
16. SAND/GRAVEL PACK:
raj
a
Depth
Size Material
From
To
Ft.
From
To
Ft.
17. REMARKS:
DO HEREB
VMT A
S -L Wes` ONSTRUCTED IN ACCORDANCE WITH 15A 04CAC 2`:. vtELL
CONSTRUC
Y OF THIS RECORD HAS BEEN PROVICEO 70 THr_ YlS�_L a%*%EP.
FOR OFFICE
N.
I '' , I
Quad No:
SIGNATbRE OF PERSON CONSTRL CTING I-< vVELL
Do-rE
Su t odgl to Division of Water Quality. Gmur4water Sracn within n c:; ys
Serial No.
C in.
crate- S'K ien tN•1
Fc'cv. t2Yi
.
1 S'^ I;
t^Aginnrjl J'iS`_:%,

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 #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: ( ow sketch of the location below)
Nearest Tow n:Q . County:
(Road Name anA Num ers, Community. Subdivision and Lot No.)
3. OWNER
Address YR.
Z
4'S rye or ou e o.
(.c t __. �l • C. 7 ? /
City or Town ,r/, State Zip Code
4. DATE DRILLED � 7 2,0 o �
5. TOTAL DEPTH 4 _
6. CUTTINGS COLLECTED YES [7 NOO
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO[Z]
8. STATIC WATER LEVEL Below Top of Casing: 3 _ FT.
(Use '+' if Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface'
'Top of casing terminated attor below land surface requires a variance in accor-
dance with 15A NCAC 2C .0118
10. YIELD (gprn): ! METHOD OF TEST 19 nz
11. WATER ZONES (depth): �J W7
12. CHLORINATION: Type Amount O• g o
13. CASING:
Wall Thickness
Depth Diameter or Wefght/Ft. Material
From D To 2- O Ft. 6 �V -1 2-1 V_
From To Ft. —
From To Ft.
14. GROUT:
Depth Mmatiprial Method
From __Q__ To 2-0 Ft. a
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft in. in.
From To Ft. in. in.
From To Ft. in. in.
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
17. REMARKS:
DRILLING LOG DEPTH
From To Formation Description
O
a=
A
o r't
"'
to M
Wt
c�
z
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)
�cr_k�kj
l a ' L " (F MJJ_, UU
6 _ ul-11" 0'>
ow
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 /Ji a_ L1 t} 1 f -7 a O
Quad No: SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
-? �} Submit original to Division of Water Quality, Groundwater Section within 30 days
Serial No. ,f;� GW-t REV. 12/99

North Carolina • Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center • Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: w Q , J �
WELL CONTRACTOR CERTIFICATION #: 2 O S' /
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): ResidentialEl Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection [] Other If Other, List Use:
2. WELL LOCATI (S ow sketch of the location below)
Nearest Town; County;
(Road Name SgNumbers, Community, or Subdivision and Lot No.) DRILLING LOG
DEPTH
3. OWNER From To
Formation Description
Address
(315ael or RoUt* No.)
City or Town State Zlp Code
4. DATE DRILLED -;o
CS
S. TOTAL DEPTH %
6. CUTTINGS COLLECTED YES ❑ NOO
7. DOES WELL REPLACE EXISTING WELL? YES [] NO[]X
r �
8. STATIC WATER LEVEL Below Top of Casing: J a FT.
ern
(Use '+' II Above Top of Casing)
9. TOP OF CASING is FT. Above Land Surface*
_—
`Top of casing terminated atfor below Land surface regWres a variance, In actor.
..
dance with 15A NCAC 2C.0118
10. YIELD (gpm): / 2, METHOD OF TEST __64
,
zj
11. WATER ZONES (depth): - 9-5-
IaE
12. CHLORINATION: Type 147-J —Amount 0,917 If additional space Is needed use back of form
13. CASING:
Wall Thickness LOCATION SKETCH
Depth Diameter or Welght/Ft. Material (Show direction and distance from at least two State
From To Ft. L'�L f .Z Y-!6._ Roads, or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth4 Ma edal Method
From __t2__ To Ft.tO Q
From To Ft.
IS. 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.
JUN 3 0 20011
From To Ft. $ C fJr1rr194d,�. `:erfi, n�
17. REMARKS:
t DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 1SA NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Quad No: �► 4 p o et
Serial No. i , f : aJ
SIGNATURE OF PERSON CbNSTRUCTING THE WELL DATE
Submit original to Division of Water Quality, Groundwater Section within 30 days
Gw•i REV. 12/99

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: to� Lid e A jL/'-�- ^^�►
WELL CONTRACTOR CERTIFICATION #:
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 : (Sh w sketch ofe the location below)
Nearest Town: County:
(Road Name and Number , omm nity, ivision and Lot No.)
3. OWNER
Address
tr et or Route o.
City or Town ` Stale Zip Code
4. DATE DRILLED �/ a o�
5. TOTAL DEPTH 4-S 5'
6. CUTTINGS COLLECTED YES ❑ NO©
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO©
B. STATIC WATER LEVEL Below Top of Casing: / 4 o 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): 3 I S
12. CHLORINATION: Type T Amount 0-27
13. CASING:
Wall Thickness
Depth
Dl5meter or Weight/Ft. Material
Fromm —To q
Ft.1_
From
To
Ft.
From
To
Ft.
14. GROUT:
Depth
Ma edal Method
From n
— To 2-0
Ft.
From
To
Ft.
15. SCREEN:
Depth
From
To Ft
From
To Ft.
From
To Ft.
16. SAND/GRAVEL PACK:
Depth
From
To
From
To
17. REMARKS:
Diameter Slot Size Material
in. in.
in. in.
in. in.
Size Material
I DO HEREBY CERTIFY THAT
CONSTRUCTION STANDARD:
FOR OFFICE USE ONLY
Quad No:
Serial No.
Agricultural ❑ Monitoring ❑
DRILLING LOG DEPTH
From To Formation Description
Jai
Cr-
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)
yy,�� ef-y\ /44_t�' a-1
> �"o S' Yru.�n� , 4 A_zter�
R�4 At
-1-MAt CONSTRUCTE `IN CCORDANCE WITH 15A NCAC 2C, WELL
T HAT A COPY OF HIS_R CO D HAS BEEN PROVIDED TO THE WELL OWNER.
ndwatee Sction i!) l� �e / / / a o e
jjo�{g Rel>ional Offic
SIGNATURE OF PERSON CONSTRUCTING THE WELL DAfE
Submit original to Division of Water Quality, Groundwater Section within 30 days
GW-1 REV. 12/99

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
P.O. Box 29578 - Raleigh, N.C. 27626-0578-Pho a [phone]
WELL CONSTRUCTION RECORD DRILLING CONTRACTOR:
DRILLER REGISTRATION #: 9 O
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 LOCATION: (Show sketch of the location below) 4
Nearest Town: � t A,,, County:
(Road, CoD3 unity, or Subdivision and Lot No.)
3. OWNER W CLL.An to
ADDRESS !i
(S et or Route No.)
City or Town State ' Zip Code
4. DATE DRILLED ai{J:
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑ NO
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
8. STATIC WATER LEVEL Below Top of Casing: , Zo FT.
(Use "+" if Above Top of Casing)
9. TOP OF CASING IS �_ FT. Above Land Surface
' Casing Terminated at/or below land surface is illegal unless a variance is issued
in accordance with 15A NCAC 2C .0118 +
10. YIELD (gpm): "— METHOD OF TEST A
11. WATER ZONES (depth): 140
12. CHLORINATION: Type Amount 1 ?-
13. CASING:
Wall Thickness
Depth
Diameter or Weight/Ft. Material
From
O To A i
Ft. % SD K 11Py
From
To
Ft.
From
To
Ft.
14. GROUT:
Depth
Material Method
From
To 1_
Ft.
From
To
Ft.
15. SCREEN:
Depth
From
To
From
To
From
To
16. SAND/GRAVEL PACK:
Depth
From
To —
From
To
17. REMARKS:
I DO HEREBY CE
CONSTRUCTION
Diameter Slot Size Material
Ft in. in.
Ft. in. in.
Ft. in. in.
Size
Ft.
Ft.
Material
Agricultural ❑ Monitoring ❑
DEPTH DRILLING LOG
From To Formation Description
n
a n
C1 �07
CDff,
CO
cn
N
�-
v
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)
TRUCTED IN ACCORI
F THIS RECORD HAS
FOR OFFICE US Y 3 U 1&r - Alp
Quad No: S GNATURE OF CONTRAC'
Serial No: S bmit original to Division of
III A
DATE
and copy to well owne'1e.
GW 1REV. 1/98
�t+illy t,��rciit,3�

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
P.O. Box 29578 - Raleigh, N.C. 27626-0578-Pho a [phone]
WELL CONSTRUCTION RECORD DRILLING CONTRACTOR: W
DRILLER REGISTRATION #: 969
L'
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential l] Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: County:
(Road, Community, or Subdivision and Lot No.)
3. OWNERp
ADDRESS 14-,./ 11V 1i n--il , ;' '2 2 0 . 1)
/ (Street or Route No.)
City or Town State Zip Code
4. DATE DRILLED a A a v
5. TOTAL DEPTH IDS-
6. CUTTINGS COLLECTED YES ❑ NO
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NOX]
8. STATIC WATER LEVEL Below Top of Casing: ao FT.
(Use "+" if Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface
Casing Terminated attor below land surface is illegal unless a variance is issued
in accordance with 15A NCAC 2C .0118
10. YIELD (gpm): L— METHOD OF TEST AA^'..,
11. WATER ZONES (depth): IRa-
12. CHLORINATION: Type 24T9 Amount CUS
13. CASING:
Wall Thickness
Depth Diameter or Weight/Ft. Material
From ® To �_ Ft. 9b A V e -
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From 6 To Z O Ft. N"-1,5
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. SANDIGRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
17. REMARKS:
Agricultural ❑ Monitoring ❑
DEPTH DRILLING LOG
From To Formation Description
C.
ca
:'5 -,
7a
Si
7
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)
N, c , �-
e•
-�'�,1� 4J
I DO HEREBYPI T�I=T= L OF THICS RECIN ORD HOA8 ' N
CONSTRUCTI -.A, �jbPjY
FOR OFFICE U LR _ 3 ZOOO I I i�
Quad No: SIGNATURE OF CONTRAC
Serial No: Submit original to Division of
E WITH 15A` NCAC 2C, WELL
I.,PRO, IDES TO THE WELL OWNER.
i7 l
RACihENNAR 2 �, lil
&bu ,ity and copy to well owner.
�� GW-1 REV. 1/98
rya a
DATE

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
P.O. Box 29578 - Raleigh, N.C. 27626-0578-Pho a [phone]
WELL CONSTRUCTION RECORD DRILLING CONTRACTOR: " to
DRILLER REGISTRATION #: g O q
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: R i)4 County:
(Road, Community, or Sub(: vron and of No.)
3. OWNER �, '�'� 1�
ADDRESS S"� _� Al
(Street or Route No.)
City or Town State Zip Code
4. DATE DRILLED 4,o
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑ NO®
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
8. STATIC WATER LEVEL Below Top of Casing: 4 p FT.
(Use "+" if Above Top of Casing)
9. TOP OF CASING IS _� FT. Above Land Surface
Casing Terminated at/or below land surface is illegal unless a variance is issued
in accordance with 15A NCAC 2C .0118
10. YIELD (gpm): _6 METHOD OF TEST
11. WATER ZONES (depth): / ! -°
12. CHLORINATION: Type—AmountQ 6
13. CASING:
Wall Thickness
Depth Diameter or Weight/Ft. Material
Fromm —To 10 Ft. VC,
From To Ft. —
From —To— Ft.
14. GROUT:
Depth Material Method
From To 10 Ft. (',arrte4-4-56TQ
From To Ft.
15. SCREEN:
Depth Diameter
From To Ft in.
From To Ft. in.
From To Ft. in.
16. SANDIGRAVEL PACK:
Depth Size
DEPTH DRILLING LOG
From To Formation Description
ca
-
d
J
rn
-
�: o
-A;
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)
/ 2q A/
From To Ft. G�„ I
From To Ft.
17. REMARKS:
Slot Size Material
in.
in.
in.
Material
I DO HEREBY CERTIFL WAS-GONSTRUCTED IN ACCORDAN(fE WITH 15A NCAC C,.WELL
CONSTRUCTION S A4F54N8rTo:A'1� 0P";THIS RECORD HAS BEEN OVI pEt T;TIIY LtrOWNF'R.TP
�FOR OFFICE USE �
Quad No: I�j NATURE OF CONTRACTOR q r� GENTM(�� �nn(n� $ r +' DATE
Serial No: _ �000 °Sub it original to Division of Water of ity and'ti2ldyoII o�`rie'r.
--
___ GW-1 REV. 1/98
Cr,xindwate- onaSection
-
iii
Ashe,;'lls �{"QII10,"
_ �,giiCe_� .� -3 r G

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
P.O. Box 29578 - Raleigh, N.C. 27626-0578-Pho a [phone]
WELL CONSTRUCTION RECORD DRILLING CONTRACTOR: C AA-" w UA
DRILLER REGISTRATION #: 9 O�
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 LOCATION: ( Sh w sketch oft a location below
Nearest Town: - ) 4 o County: bi—A "ti'�
(Road, Community, r Subdivision and Lot No.)
3. OWNER
ADDRESS 2— t_ D�
`I� J 14ib(Street `-M or No.) U a M? 7
T1C�Ciity or Town State [SZip Code!
4. DATE DRILLED —� 04, a
5. TOTAL DEPTH SS—"
6. CUTTINGS COLLECTED YES ❑ NO®
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO®
8. STATIC WATER LEVEL Below Top of Casing: ;,O FT.
(Use 'Y' if Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface'
' Casing Terminated attor below land surface is illegal unless a variance is issued
in accordance with 15A NCAC 2C .0118 N
10. YIELD (gpm): DA METHOD OF TEST A'­�
11. WATER ZONES (depth): 33S
Agricultural ❑ Monitoring ❑
DEPTH DRILLING LOG
From To Formation Description
c:)
C�o
rn
12. CHLORINATION: Type —Amount 40, f o If additional space is needed use back of form
13. CASING:
Wall Thickness LOCATION SKETCH
Depth Diameter or Weight/Ft. Material (Show direction and distance from at least two State
From n_ To ) O Sr Ft. b /-th Sb R 2) :4? V C,_ Roads, or other map reference points)
From To Ft. —
From To Ft.
14. GROUT: l V
Depth Material Method C y
From To "2Z Ft.
From To Ft.y�
15. SCREEN:
Depth Diameter Slot Size Material A
From To Ft in. in. C U CY, 0? -k-.0"qk
From To Ft. in. in. _ , • / . ��� / e,(�
From To Ft. in. in.
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
17. REMARKS:
DO HEREBY CERTIf.:Y_TBAI T.IiIS WELL•WASCON_STRUCTED IN ACCORDANCE WITH<15A NCAC 2C, WELL
CONSTRUCTION S �aiV AI Np TOT A COPY OF THIS RECORD //HAS `BEEN P ROYIDffp 70 THE WELL OWNER.
FOR OFFICE USE O
Quad No: J 2000 S G TURE OF CONTRACTOR'dt2 AG (j ) DATE
MAR — ,".' R spy _ elf)
Serial No: 80 it original to Division of WI t n: uali a o to well owner.
i 4GW-1'�REV. 1/98

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
P.O. Box 29578 - Raleigh, N.C. 27626-0578-Pho a [phone]
WELL CONSTRUCTION RECORD DRILLING CONTRACTOR:
DRILLER REGISTRATION #:
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:�t ^�`�»'t��� I County:
(Road, Co munity, or Su divi i and t No.) DEPTH
DRILLING LOG
3. OWNER From To
Formation Description
ADDRESS U w'i'
(treet or Route No.)
City or Town State Zip Code
4. DATE DRILLED � .cb t4 A
5. TOTAL DEPTH i 20
6. CUTTINGS COLLECTED YES ❑ NORI
o _
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO ®
8. STATIC WATER LEVEL Below Top of Casing: FT.
-,M,
(Use 'Y' if Above Top of Casing)
9. TOP OF CASING IS �_ FT. Above Land Surface
CO-�;
Casing Terminated attor below land surface is illegal unless a variance is issued
in accordance with 15A NCAC 2C .0118
A rn 3
10. YIELD m : I Q METHOD OF TEST AIL
(gP )
11. WATER ZONES (depth):
cr -w
a "'
12. CHLORINATION: Type All 2 Amount �Z � 'r_
YP If additional space is needed use back of form
13. CASING:
Wall Thickness
Depth Diameter or Weight/Ft. Material
From To A7 Ft. S `�
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From t To 10 Ft.'+`�"�
From To Ft.
15. SCREEN:
Depth
From
To
From
To
From
To
16. SANDIGRAVEL PACK:
Depth
From
To —
From
To_
17. REMARKS:
I DO HEREBY CERTIFY
CONSTRUCTION STANI
FOR OFFICE USE
Quad No:
Serial No: G (1 f
Diameter Slot Size Material
Ft in. in.
Ft. in. in.
Ft. in. in.
Size Material
— Ft.
_ Ft.
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
iv
IIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
OP OF THIS RECORD HAS BEE4N PRbVI.DIEDIT0. THE:WELL OWNER.
W 7
� �d �! M/
������pp
SI1 NATURE OF CO CTOR ORA'GE� 1i
MAR3 2000 sub m 'ginal to Division of Water Quality and copy to well owner.
' G`/V 1 REV. 1198
_ I ^r`ound� wzite- Section { uavA -0Sn :1ElIIF ° a 7�rtii S9t �€
n
h viie n? irn
Z v V 0
DATE

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
P.O. Box 29578 - Raleigh, N.C. 27626-0578-Pho a [phone]
WELL CONSTRUCTION RECORD DRILLING CONTRACTOR:
DRILLER REGISTRATION #:
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) Q� A (�
Nearest Town: f'. � lf7ti ^ ') , . �..o _ County: k"►•/ 4Cort,
(Road, Co unity, or Subdivision nd Lot o.)
3. OWNER F
ADDRESS
(Street or Route No.)
City or Town State Zip Code
4. DATE DRILLED 2 2-O0
5. TOTAL DEPTH J 86'
6. CUTTINGS COLLECTED YES ❑ NO
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 *
* Casing Terminated at/or below land surface is illegal unless a variance is issued .
in accordance with 15A NCAC 2C .0118
10. YIELD (gpm): & METHOD OF TESTA �
11. WATER ZONES (depth): / SO
12. CHLORINATION: Type Amount 0 +
13. CASING:
Wall Thickness
Depth
p
Diameter
Gam—
or Weight/ t. Material
From
To
Ft.
V G
From
To
Ft.
From
To
Ft.
14. GROUT:
Depth
Mat 'rial Method
From
e�l_ To 2_ Ft.
From
To
Ft.
15. SCREEN:
Depth
From
To Ft
From
To Ft.
From
To Ft.
16. SAND/GRAVEL PACK:
Depth
From
To
From
To
17. REMARKS:
I DO HEREBY CERTI
CONSTRUCTION ST
FOR OFFICE USE
Quad No:
Serial No:
Diameter Slot Size Material
in. in.
in. in.
in. in.
Size Material
Ft.
Ft.
DEPTH DRILLING LOG
From To Formation Description
a
r.
cn
—CO
tad -ni—
If additional space is needed use back-toforr[10
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
MEU..U, AS.C.ONST.RUCTED IN ACCORI
D Wgl NX:OR' OF THIS RECORD HAS
.. 2�0� � TURE OF CONTRAC
ub it,original to Division of
'off' Z..7_/ZOQ0
AR 2 K) a'.�� DATE
copy to well owner.
k
GW=.1 REV: 1/98
ndwatq`
— n__:_

Divl$ion of Water Dusk • Groundwater Seallorl , `
North CaRAM& • DepartmeM of Environment and Natural Reaourooa • i .: i 6 .9 0
1i3e Map Servioe Cer"r • Raleigh, N.C. 27flY♦143-Fhor+a teal) 7 .M, t
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICA�MN'TSs
STATE WELL CONSMUCT�ON P
MONO-00-- MI MUNCIPal C7 Industrial E3 ASfiCulb�ral 10 MonWdr* G
1. WELL USE�cfnelt APOW"ia Noe): Reuel Other ❑ If Other, List UN:
Recovery Feat Pump Water In)eation
Z. WELL LCCATII ( sk.*Wh of the location below)
Nearaat Town: �r{{ ``
(Road Marna and Nurnbara, , or subd sjon and tat No.) QRILLIN LC __
3. OWNER Z Fmm To
Addreea 4,4
n
Cup or Town Stake zip Coda _
4. DATE DRILLED-
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑ N071
7. DOES WELL REPLACE EXISTING WELL? YESNO
S. STATIC WATER LEVEL Below Top of Casirp: FT•
(Uw'+' I AbWe Top at C 0111)
9. TOP OF CASING is__[___ FT. Above Land Surfeoe•
*Top of eadgwwrrww dbr wow WA wRlaaa raaulraa a vanlanaa In toner- --
atanae wO 1SA WCAC 3C .011E —
1 M YIELD (gprn): SO METHOD OF TEST 44jL
11. WATER ZONES (depth): I E0 — —
12. CHLORINATION:
13. CASING:
DEPTH
Fonwtia+ Deaalpuon
a
o
Type Amount d , 2 7 h addtUonal apace Is nsaded we back
Wab Thlokm"$
Depth
Dtasrew
W W*k0%Ft. Mawrlal
From 0 To . 6
Fl. 6 yfj
shg�kl ��-
From
To
Ft.
------
From
—To--
Ft.
14. GROUT:
Depth
Ma
rice! 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, SAN04RAVEL PACK:
Depth Size Material
From .._. To Ft.
From .� To Ft.
17. REMARKS:
cut
_14 amQu aK-rCH
(Show direction and distar4a tmm at Isaat two Stab
Roads, W other map room" point)
100 HERESY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 1 SA NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS SEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Ouad NO: �+.. —� - TINI!° F PER�N CtN MUCTINO THE WELL D�►TTe -
nVa a DM&Ion of Wowouaaty, Groundwater Saeuon within 30 days
scene" No. u � y f; 1 SW.t REV. 17/99
JAN 1 8 &01

North Carolina - Department of Environment and Natural Rseources - Division of Water Civality - Groundwater Section '. Q
1636 Mail Service Center - Raleigh, N.C. 27d99-1eWPhone (919) 733-W21 v j
WELL CONSTRUCTION RECORD WELL CONTRACTOR: LAC- ';n~,
WELL CONTRACTOR CERTIFICATION N: ;;-Zr7
STATE WELL CONSTRUCTION PERMITN:
iay.rreo,��,rrrtr.rr. rrorra�
1. WELL USE (Check Appllcable box): Residential M Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch.of the location below)
Nearest Town: �dd ti' . M --� County:
(Road Name and Numbers, or Suvlslon and Lot No.)
3. OWNER '/ csYt.11 C���i t�l�
Address -�T
Cky or Town State tip Code
4. DATE DRILLED Zo�a
5. TOTAL DEPTH O
6. CUTTINGS COLLECTED YES ❑ NO®
7. DOES WELL REPLACE EXISTING WELL? YES [] NO®
S. STATIC WATER LEVEL Below Top of Casing: :Lo FT.
(Use •+• a Above Top a Casing)
9. TOP OF CASING IS / FT. Above Land Surface'
'Top of casing terminated st/or below land sumacs, requires a variance In accor-
denoe with tiA WAC 2C .0116
10. YIELD (gpm): aS METHOD OF TEST 6 M�
11. WATER ZONES (depth): A 4-0
DRILLING LOG DEPTH
From To Forrnatlon DeecripWn
da
C3
ern
r7
c C'
en
�o
;0
n
t_cn
o
W -
12. CHLORINATION: Type I �rii Amount 0.4-1 If additional apace is needed use back of form
13. CASING:
wan Thickneas
Depth Diarnster or Weight/Ft. Material
From O To ._:�O Ft. "'44 5 R i.) Iy e
From To Ft.
From To _ Ft.
14. GROUT:
Depth Material Method
From _- 92 To - 2-0 Ft. i.LZiXL S
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.
Ia. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To Ft.
17. REMARKS:
Material
LOCATION SKETCH
(Show dirWlon and distance from at least two State
Roads, or other map reference points)
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF Ti•iIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
///a/;z a o
SI TE OF PEf SON CONSTRUCTING THE WELL DATE
Submit original Division of Water Ouality, Groundwater Section within 30 days
GW-t REV. 12/N