Well Construction Records Jackson 2 CY2000

Nonh Carolina • Department of Environment and Natural Resources • Division of Water Quality • Groundwater Section `- 1 8 A p 2
1636 Mail Service Center • Raleigh, N.C. 27699.1636-Phone [phone] `} O
D. Bowman Well Drilling, Inc.
WELL CONSTRUCTION RECORD WELL ELL CONTRACTOR' CERTIFICATION#: 2809
STATE WELL CONSTRUCTION PERMIT#:
1 WELL USE (Check Applicable 9oa): Residential ® Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
Agricultural ❑ Monitoring ❑
2. WELL LOCATION:
how sketch of the location below)
S Jackson -
S
Nearest Town: _
Mineral
Springs Road Lot #18
n tidy or SuDWwston u+d lot No.) DRILLING TOG
(Road Name anxd, NVIlbers
MM li 011riO ri
3. OWNER
rings oa _
Address
Sy 1Va
tresterr ua o. 28779 _
5or Town
Stale Zip Code
DEPTH
Formation Description
y
4. DATE DRILLED 7 21 zo0 0
5. TOTAL DEPTH 240
6. CUTTINGS COLLECTED YES ❑ NO®
7. DOES WELL REPLACE EXISTING WELL? YES NO®
B. STATIC WATER LEVEL Below Top of Casing: ___3-0— FT.
(Use': # Above TOP of Casing)
9. TOP OF CASING IS 1 . 4 FT. Above Land Surface' o
'Top of casing terminated allor below land aurfaca requires a variance In actor•
dance with 15A NCAC 2C.0110 r �"
: m
10. YIELD
(gp ) 4 0 METHOD OF TEST LSIt r�r
-
11. WATER ZONES (depth): 220'
12 CHLORINATION:
13. CASING:
Type tablet Amount 6 It additional space is needed use back of form
0 Depth 56 6u1/8
ter
From To Ft.
From To Ft.
From To Ft.
14 GROUT:
LOCATION SKETCH
Wall Thickness
or WaignVFl. Material (Show direction and distance from at least two State
SCh 80 PVC Roads, or other map reference points)
Depth
Material
Method
0 To 20
Ft.
rn nrrPta araviTl.ow
From
From
To_Ft.
-------
15. SCREEN:
Depth
Diameter Slot Size
Material
1'
,n
From
To __
Ft .___—.
in. _
in.
From __
To __
Ft. __
In. _—
in.
From
_ To __
Ft. __
in. _
In.
16. SAND/GRAVEL PACK:
Depth
Sue
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 OWNEF%' �U
FOR OFFICEUP;-
_A,j,rSlGNATUREq ERSON CONSTRUCTING THE WELLDATE
Quad No:o Division of Water Quality, Groundwater Section within 30 days
GW-1 REV. 12M
L�T.iN:pf� r s r
s i i t i faat]Yf�

!; d /'
North Carolina - Department of Environment and Natural Resources - Division of Water Quality •Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELLCONTRACTOR: D. Bowman Well Drilling, Inc.
WELL CONTRACTOR CERTIFICATION #: 2809
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)
Nearest Town: SVlva Counry: Tarkson
Crawford C'P__�y Read
(Road Name and Numbers, Community, or Subdivision and Lot No.)
3. OWNER HaLold p 6ett
Address Crawford Cemetery Road
trees or Frouts o.
Balsam, NC
City or To" state Zip Code
4, DATE DRILLED 6,102100
5. TOTAL DEPTH 2 n 0 '
6. CUTTINGS COLLECTED YES Q NO[o
7. DOES WELL REPLACE EXISTING WELL? YES NOE�]
8. STATIC WATER LEVEL Below Top of Casing: 60 FT.
(Use -+- if Above Top of Casing)
9. TOP OF CASING IS 1 ' 4 FT. Above Land Surface-
-Top of casing terminated atior below land surface requires a variance In accor-
dance with 15A NCAC 2C.011s
10. YIELD (gpm): 3 0 METHOD OF TEST -z _
11. WATER ZONES (depth): 2101
r
Agricultural ❑ Monitoring ❑
DRILLING LOG DEPTH
From To Formation Description
12. CHLORINATION: Type t a h 1 Pt- Amount r It additional space is needed use back of form
13. CASING:
Wall Thickness
Depth Diameter or Weight/Ft. Material
From 0 To 63 Ft. 6 1 /8 Sch 80 VC
From To Ft.
From To Ft.
14. GROUT:
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
Depth Material Method
From n_ To 20 Ft. zon—tc gar 17i ty. flow
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From —To—Ft— in. —in.-
From — To _ Ft. _ in. _ in.
From _ To _ Ft. _ in. _ in.
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTNQ 175 ANDARDS,:AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
I /
FOR OFFICE
Quad No:
SIGNATU F PERSON CONSTRUCTING THE WELL
Submit original to Division of Water Quality, Groundwater Section within 30 days
DATE
GW-1 REV. 12r99
o
Serial No.

r-,
North Carolina • Department of Environment and Nai ral Resources - Division of Water Ouaory - Ground«ater Section � •� O J
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: N LIe & C
WELL CONTRACTOR CERTIFICATION u: 1
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential [0 Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATI (Show sketch of the location below)
Nearest TowQ:�C��,1 e County:
Skmav
i 7-0-a-M-1
or Town 7 State Zip Code
4. DATy DRILLED --z>-
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES F NOQ
7. DOES WELL REPLACE EXISTING WELL? YES Q NOEJ
8. STATIC WATER LEVEL Below Top of Casing: FT.
(Use -+' it Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface'
'Top of casing terminated at/or below land surface requires a variance In accor.
dance with 15A NCAC 2C .011e
10. YIELD (gpm): .1— METHOD OF TEST A) 2
11. WATER ZONES (depth):
12. CHLORINATION: Type NTH Amount
13. CASING:
Wall Thickness
, rr Depth �Q iameter o�ei h�F� en�I
From T�To Ft. n v1As---•So�.�.�
From To Ft.
From To Ft.
14. GROUT:
Depth�/--, ate ' elho
From Q— To l FL '
From To Ft.
15.SCREEN:
Depth Diameter Slot Size Material
From —To—Ft— in. in. —�
From —To—Ft.— in. —in.
From —TO—Ft.— in. in.
16.SAND/GRAVEL PACK:
Depth Size Material
From To —Ft. -
From To Ft.
17.REMARKS:
From To
Agricultural ❑ Monitoring ❑
ADPTH,
Formation Descripbcn
r�
O
n�
4
'
-o
If additional space is needed use back of forty
N
LOCATION SKETCH CF%
o
(Show direction and distance from at least two State
Z
Roads, or other map reference poins)
(0
I DO HEREBY CERTIFY THAT THIS WELL WAS CONST UCTEPJkACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A CPIPY O HIS R O D HAS BEEN PROVIDED TO THE WELL OWNER
FOROFFICE USE ONLY
Quad No'.
SIGNATURE OF PERSON CONSTRUCTING THE Y -_v-
Os.TE
Submit original to Division of Water Guaiily, Groundwater Season within 30 days
Gwi HEv Ivr,
Sena) No.

Murat R030=63 - Division of Water Quality - Groundwater Section
i88.1636-Phone (919) 733-=11
WFE2 7777;777`1! 7- " 777
1 1­ " . -irpyn `
.ICORP WELL CONTRACTOR:
T, TJPN RE ON$ RyC
WELL CONTRACTOR CERTIFICATION
STATE WELL *. CONSTRUCTION PERMrT#3�
ji.i, USE (Check Applicable cox): Residential EY MunicipalO Industrial [3 Agricultural ❑ Monitor ing[3
Heat PUMP Water Injection [3 Other F1 if Other, List Use:
WO ATIQN: (Show sketch of the location below)
Town: County:
DRILLING LOG DEPTH
ty, vision and Lot No.)
Nwrom cpqvrmw of Swtd Forrnaton D054nPtim
^ � j I , I Vlly..-, V 0 1 / From To
)LLF.cTr;D-.YE3EJ NOLLJ-
lepLACEEXISTING WELL? YES 0 NOC2
�Ff LWEL BeipW Top of Casing: . Fr.
(Use -+9 V AfWQ Top of C&3ft)
Fr, Above Land Surface*
R"Wd a or Wlow and surface requires a variance in accor-
METHOD QFTEST
Kli, Type Amount
If additional space is needed use back of form
_LOCATION SKETCH
Q_--
Wall TWAM al least two Siale
D • 'apth plarpetar L crWaightfft Material (Show direction and dis;UMO from
Roads, or other MmP reference point,)
�To � Ft.�
To, — FL—
C=)
Material Method
Depth
77777Tq FL 177`77�
Ln
Tq, F1
Siqtsiziii Material
Ft in.
In, In.
X
Flk in. In.
Depth Size Material
V11 To F.-
WTO Ft,
gu,
WAS CONSTRUCTED IN ACCORDANCE WITH 15A INCAC 2C, WELL
Ems
-ORP, PTIV A ; COPY OF THIS RECORD HAS BEEN PROVIDED 11`0 THE WEILL OIANEA.
f
,f
OF PERSON CONSTRUCTING THE WeLL
Da
of water ouwity, omnd"er S&cwn within 30 days
Submit erlpinal to GW-I FtrcV. 12'"

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section 0434
1636 Mail Service Center - Raleigh, N.C. 27699.1636-Phone [phone]
WELL CONSTRUCTION RECORD WELLCONTRACTOR: clireenr ns t.�(t Pump
WELL CONTRACTOR CERTIFICATION 0: ?�Cy 1
STATE WELL CONSTRUCTION PERMIT#: NUM_
1. WELL USE (Check Applicable Box): Residential G / Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: —N-nrnhi t.C`V to Count': _'Pe V+Snn
n
(Road Name and Numbers. Comma , or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER Q tyft4r- From To Fonnaion Description
Address y\b aY -ym\Lf - n' n "i K r ID 1,11
is r�q or ou a o.
N ,1Y1� rr�Lr �'T1 a :Sc. 2n6uNo
City or To State Zip Code
4. DATE DRILLED 2- � DC1
5. TOTAL DEPTH -
6. CUTTINGS COLLECTED YES ❑ NO[�J--
7. DOES WELL REPLACE EXISTING WELL? YES ❑ N0n
8. STATIC WATER LEVEL Below Top of Casing: min_ FT.
(Use Y' 9 Above Top of Casing)
9. TOP OF CASING ISM_ FT. Above Land Surface*
*Top of using terminated atlor below land surface requires a variance In accor.
dance with 1SA NCAC �C.011a
10. YIELD (gpm): tJ t .d METHOD OF TEST Z 1
11. WATER ZONES (depth): pl0 - 10 N CV % r-r
12. CHLORINATION: Type I-Mi Amount �_ If additional space is needed use back of form
13. CASING:
Depth Diameter
From To 41 Ft. "
From To Ft.
From To Ft.
14. GROUT:
Wall TNcmess LOCATION SKETCH
or weight/Ft. Irlaterial (Show direction and dnaance tram a3 least bvo Stale
Roads, or other map reference points)
Depth Material Method
From To its Ft.
From To Ft.
15. SCREEN:
Depth
Diameter
From To _
Ft in.
From To _
Ft. In.
From _ To _
Ft. In.
16. SANDIGRAVEL PACK:
Depth
Size
From To Ft.
From To Ft.
17. REMARKS:
Slot Size Material
in.
In.
_ in.
Material
LD
,r
.D
w
r::
o
c;
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 1 SA AJCAC 2C, WELL
CONSTRUC Y OF THIS RECORD HAS BEEN PROVIDED SO THE WELL OWNER.
FOR OFFICE
Quad No: IGNATURE OF PERSON CONSTRUCTING #YELL 0Ai. E
" - Su to Division of Water Duality, Gnundwaler Sector within V days
Saris! No. Gvr•t R&V. 12"

1)0
North Carolina • Department of Environment and Natural Resources - Division of Water Duality • Groundwater Section oc- �- l !A 3 5
1636 Mail Service Center • Raleigh, N.C. 27699.1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:-C-srRO-ne- k .let l 4 Pt „)r, p
WELL CONTRACTOR CERTIFICATION III: 241 A
STATE WELL CONSTRUCTION PERMIT#: � ypZ
1. WELL USE (Check Applicable Box): ResidentialL_f Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other El It Other, List Use:
2. WELL LOCATIQN: (Show sketch of the location below)
Nearest Town:- AV-un County: �f�C1� Orl
-n .A
(Road Name and Numbers. Community, or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER From To FomuocnDescription
Address l7 loin
ree or HOU18 7o.j
gym I\\C_
Gty or Town State Zlp Code ,
4. DATE DRILLED \�
S. TOTAL DEPTH,
6. CUTTINGS COLLECTED YES ❑ NOQ
7. DOES WELL REPLACE EXISTING WELL? YES NO[Er
8. STATIC WATER LEVEL Below Top of Casing: �k o FT.
(Uae'+' 11 Above Top of Cuing)
9. TOP OF CASING IS FT. Above Land Surface,
'Top of cuing terminated at/or below land surface requires a variance In accor.
dance with 15A NCAC 2C .011a
10. YIELD (gpm): �_ METHOD OF TEST -2b—c-L.
11. WATER ZONES (depth): -4 Ati - 4° n nm
12. CHLORINATION: Type Amount If addroonal a
13. CASING: pace s needed use back of loan
Wall Thickness LOCATION SKETCH
Depth Diameter or WeighVFt. f4at,e,d,al (Shaw direction and distance from at least two Stale
From— To l 0 L) Ft. _ U" s'' Roads, or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
L-)
From . G _ To .2 _ Ft. 0 o fX1 I r\
a
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From 72
—To—Ft—In. _ In.
From _ To _ Ft. in. _ In.
From To __ Ft. In. _ In, o
t._
16. SAND/GRAVEL PACK:
Depth Size Material
From To FL
From To Ft.
17. REMARKS:
1 DO HEREBY
FOR OFFICE U LY _
Quad No:
Submll
Serial No.
ISTRUCTED IN ACCORDANCE WITH 15A INCAC 2C, WELL
OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OIA%ER.
1ATURE OF PERSON CONSTRUCTING THE UYELL OA7.E
Divlslon of Water Cwlily, Gmvndvntsr Seaert within 3g cl*ys
Gw.1 REV. 12"

North Carolina - Department of Environment and Natural Resources - Division of Water Duality - Groundwater Section 013733
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone] �(/
WELL CONSTRUCTION RECORD WELL CONTRACTOR: ./�I » 2"
WELL CONTRACTOR CERTIFICATION #: _44`(/ f
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable eox): Residential 14 Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATI N: Show sketc of the location below)
Nearest Town: -/=" County:
(Road NamXar�dlilumtbers. Commty, or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER 6 + uniA'Z—- From To Formation Description
Address — ;a / if . D ''//,, o
(bireei or houle NO')
ity or own Stale Zip Code
4. DATE DRILLED ^
5. TOTAL DEPTH (-
6. CUTTINGS COLLECTED YES ❑ NO®
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NOV]
S. STATIC WATER LEVEL Below Top of Casing: //)/)/) FT.
(Use'+' If Above Top of Casino)
9. TOP OF CASING IS_(_ Fr. Above Land Surface-
-Top of casing terminated attor below land surface requires a variance In accor-
dance with 16A NCAC 2C .0118
10. YIELD (gpm): gyp_ METHOD OF TEST _ af = L-2
11. WATER ZONES (depth):
12. CHLORINATION: Type W r/l Amount
13. CASING:
If add'rdonal space is needed use back of form
LOCATION SKETCH
Wall Thickness
Depth Diameter or WeighVFI. Material (Show direction and distance frontal least two Sate
From— L_To 641 Ft..—(�— �nt�r_ Roads, or other map reference points)
From
To Ft.
From
To Ft.
o
0
14. GROUT:
0
n
Depth aterial Method
c
o
From
To Ft.
o:;E
From
To Ft.
—
<rn
15. SCREEN:
p
no
m�
Depth Diameter Slot Size Material
=m
From
In. —in
tV
m=
—To
From
—Ft—
To Ft. in. _ In
"._'
_
From —To
_
—Ft. In. —In.
t7
0
z
16. SAND/GRAVEL PACK:
Depth Size Material
From
To _ F[
From
Ye`l Ft. _
17. REMARfC$`
I DO HEF)
l) L
ERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A 04CAC 2C, WELL
CONSTRUCT] AN€TTHAT A COPY OF THIS RECORD HAS BEEN -11OVIDED TO THE WELL OwhER.
Cmndwa•
na�y:
SIGNATURE OF PERSON CONSTRUCTING Tlfe YW£LL
DAY£
FF�RFFICSw
Submit odginal to Division of Water Duality, Groundwater Section Within n days
.
Go .1 Rev.
12?5

'13'734
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699.1636-Phone [phone] n
WELL CONSTRUCTION RECORD WELL CONTRACTOR: 4 I dlc,ys Aff"a,
WELL CONTRACTOR CERTIFICATION #: 4409
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (check Applicable Box): Residential1% 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 Name anj Numbers, Commu ty•, oNo.)
3. OWNER Ll nt Address
4. DATE DRILLED - --' d 0
5. TOTAL DEPTH x + 4
6. CUTTINGS COLLECTED YES F] NO[Z
7. DOES WELL REPLACE EXISTING WELL? YES N0[Z
8. STATIC WATER LEVEL Below Top of Casing: Jpp 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 1SA NCAC 2C .0118
10. YIELD (gpm):_ METHOD OF TEST
11. WATER ZONES (depth): � � - ^-1� �
ao2 I� X sue'
12. CHLORINATION: Type L711� Amount 157
13. CASING:
Agricultural ❑ Monitoring ❑
DRILLING LOG DEPTH
From To Fon :icn Description
0
7/r 4Lq4
r
i
If additional space is needed use back of loom
LOCATION SKETCH
Wall Thickness
Depth Diameter
or Weightlft Material
(Show direction and distance from ai least two Sure
From To .Z2 Ft. —�
T
Roads, or other map reference points)
From To Ft,
c
From To Ft.
`o
14. GROUT:
L
n�
Depth aterial Method
r
From 6 To .2a Ft.
_
o<
From To—Ft.o
15. SCREEN:
Depth Diameter Slot Size Material
N
rna
From —To—Ft— In.
—in
N
m�
—�+
From _ To _ Ft. _ in.
_ In.
o
0
From _ To _ Ft. _ In.
_ In.
16. SAND/GRAVEL.PACK:
1*6` ii Size
Material
From _ To' _ -Ft.
From ,° ToFt_.�T_
N IT
17. REMARKSI 3 .
I DO HEREBY 6ERI°IFY1HAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A I14CAC 2C, WELL
CONSTRUCTIOWSTANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL ON`NER.
FOR OFFICE USE ONLY
Quad No: SIGNATURE OF PERSON CONSTRUCTING THE WELL GATE
SutxNt original to Division or Water oily, Grounowuer SeC.cn within n days
Serial No. Gvr-1 REv. 1299

North Carolina - Department of Environment and Natural Resources - Division of Water Quality • Groundwater Section F- 1 5 `f 5 6
1636 Mail Service Center • Raleigh, N.C. 27699.1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: m
WELL CONTRACTOR CERTIFICATION p:� y
STATE WELL CONSTRUCTION PERMIT#:
WELL USE (Check Applicable Box): ResidenlialZ Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Sjloyv sketch of the location below)
Nearest Town: _ ^ .—Jf-- yP� County:
Agricultural ❑ Monitoring ❑
(Road Name aniftNumbeni. CO7munity, or Subdivision and Lot No.)
DRILLING LOG DEPTH
3. OWNER / J,/X ,
From To FomuSm Description
/ O� /
Address _/cam l%qn /%�]Jz.
A 44) <fl�����
's`
beet off route No.)
JKi
q ti
City or TOwn Slate Zip Code
4. DATE DRILLED
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑ NO[XJ
7. DOES WELL REPLACE EXISTING WELL? YES 0 NO®
S. STATIC WATER LEVEL Below Top of Casing: FT.
(Use'i If Above Top of Casing)
9. TOP OF CASING ISFT. Above Land Surface'
'Tap of cuing terminated ettor below land surface requires a variance in accor"
dance with 15A NCAC 2C.011e /
10. YIELD (gpm): METHOD OF TEST
_,3YL
11. WATER ZONES (depth):
12. CHLORINATION: Type Amount
If addrdonal space is needed use back of loran
13. CASING:
Wall Thickness
LOCATION SKETCH
Depth Diameter or WeighVFt. Material
From�_To .20 Ft. /- " 0 tl
(Show direction and distance from at least two hale
Roads, or other map reference points)
From To Ft. f
From To Ft.
14. GROUT:
Depth Material Method'
From To � Ft. &&_ 11L�` T
o
_41 --`--�
From To Ft.
15. SCREEN:
G'3
c
Depth Diameter Slot Size Material
From To_ Ft In. —in.—
From _ To _ Ft. _ In. _ In,
z
From _ To _ Ft. In. _ In.
%Y
FFli R
16. SAND/GRAVEL PACK:
Zj
Depth Size Material
J
o
From To Ft.
From To Ft.
17. REMARKS:
I DO HEREBY -CERTIFY THAT -THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A 04CAC 2C, WELL
CONSTRUgt01 SJA* (_tD5jAN0 THAT A COPY OF THIS RECOR HAS BEEN PROVIDED TO THE WELL QWTER.
FOR OFFICfi,IjE ONLY �.1 i�iv. �ld�jo -Sl-�
Quad No: ; f o Itj ( ; - SIGNATURE OF PERSON CONSTRUCTING THE WELL OA'E
-- �_ Submill Original to Div(sbn of Water Duality, Groundwater Semen within V days
Serial No.
Grr-t REV, 12"
,54:,12V 1P

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: milli
FOR OFFICE USE ONLY QUAD. NO. SERIAL NO,
F- 14
Let. Long. RO
Millar Basin
Basin Cade
Header Ent. GW I Ent -
STATE WELL CONSTRUCTION
DRILLER REGISTRATION NUMBER: �S� _ _ PERMIT NUMBER:
1. WELL LOCATION: [Scy,.how sketch of the location below)�
Nearest Town: kllf50ro County: SGC(LS`r1
(Road. Community or 9uMivicyyon and I -of No.)
2. OWNFR %7i:s{Y Fra;ij; — ---
(Street or Houle Net
City or Town Stale Zip Code
3. DATE DRILLED J _t6-A' - USE OF WELL ��r ✓G e
4. TOTAL DEPTH -280' _
5. CUTTINGS COLLECTED YES NOL_
6. DOES WELL REPLACE EXISTING WELL? YES r�� NOQ
7. STATIC WATER LEVEL Below Top of Casing: __G_U__ FT.
(Use'+' if Above Top of Casing)
8. TOP OF CASING IS L FT. Above Land Surface'
Casing Terminated allor below land surface Is Illegal unless a variance Is Issued
In accordance with 15A NCAC 2C .0110
9. YIELD (glom): P ME HO,D�OF TEST
W. WATER ZONES (depth)
11. CHLORINATION: Type %fit Amount
12, CASING:
Wall Ihicknoss
Depth Diameter or W t I)UFI. Material
From � To G 7 Ft. 6,2S
From To g,e Ft. 615 /y� Stee/
From To— FI.
13. GROUT:
Depth
From l7 To 2'P Ft.
From To Ft.
14.SCREEN:
Depth
From
To
Front
To —
From
To —
15. SANDIGRAVEL
PACK
Depth
From
To —
From
To-
16. REMARKS:
Material 6elhod
ifv�e.
Diameter Slot Size Material
Ft in. In.
Ft. in. in.
Ft. in. in.
_DEPTH
_DRILLING LOG_
Finn To
Formafian D¢s<ription
—
--
7f = 2 Vo
Grin. Ae
_c
@ c
L
LJ7 g r,;
a c;
Rr �
II additional space is needed use bac57-bf tort_�in
LOCATION SKETCH
Show direction and distance from at least two State
Roads, or other map reference points)
1 0011EREBY CERTIFY 141AT THIS WELCWA"S CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCI ION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
OF CONTRACTOR OR AGENT DATE

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
ILLING CONTRACTOR:
FOR OFFICE L15E ONLY; !
OUAD. NO. SERIAL NO4- 1 4-
Let. Long. RO
Minor Basin
Basin Code
Header Ent. 31,11-1 EnL
DR
STATE WELL CONSTRUCTION
DRILLER REGISTRATION NUMBER: ��J'- _ PERMIT NUMBER:
1. WELL LOCATION: dShow`sketch of the location below) 7� 6 / J U 1
Neareest Town: �-/''�-r/O7`�e County: /Z
(Read. Community, or Subdivision and Lot No.) DEPTH _DRILLING LOG _
2. OWNER LtJ(1��7�1 Y6 From To Formation Descriplion
ADDRESS S%J 4t�alla ous,l q
(Street or Route Not (J Al ,S
City or Town Slate y,,zzip Codo
3. DATE DRILLED ��-oo USE OF WELL-
4. TOTAL DEPTH S'30
5, CUTTINGS COLLECTED YES ❑ NO[�J--
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NOE-j-
7. STATIC WATER LEVEL Below Top of Casing: j O FT.
(Use '.' it Above Top of Casing)
B. TOP OF CASING IS FT. Above Land Surface'
• Casing Terminated alJor below ?and surface Is Illegal unless a variance Is Issued
In accordance with 15A NCAC 2C .0118
9. YIELD (gprn):.2—_METHOD OF TESL- h711'
10. WATER ZONES (depth):
11. CHLORINATION: Type ,n/ Amount
�«
II addilional space is needed use back of form
Q. CASING:
LOCATION SKETCH
Depth
Wall Thickness
Diameter or W�i r FL
maiv,al /
-- --
(Show direction and distance from at least two State
From �
To /�
Ft.�'��
r;
Roads, or other map reference points)
From
To
Ft.
—
From
To
FL
-
13. GROUT:
Depth
a of tat
Mekhod
:
o
From
To 2�
Ft.
""'1
etJ
0
From
To
Ft.
0
14. SCREEN:
Depth Diameter
Slot Size Material
i_
it
From To Fl in.
In.
Qn'm
.T- J
From To Ft. in.
in.
From To FI. in.
in.
o
m
15. SAND/GRAVEL PACK
o
De
-_Material
I
^�
s
From L5 t5
f
From Ft.
16. REMARKS:
I Doi jEREBY CEI
TIFY TTkn -T ff! '_� o
CO
STRUCTED IN ACCORDANCE WITH 15A
NCAC 2C, WELL
OWNER.
CONSTRUCTION;$TANDARDS,
AIZT�tKY A COP 1
OF THIS RECORD HAS BEEN PROVIDED
TO THE WELL
OF CONTRACTOR OR AGENT DATE

North Carolina - Deprnlment of Environmenl. Health, and Natural nosourcos
Division of Environmenlaf Managnmenl - Groundwaler Section
P.O. Box 29535 - Raleigh, N.C. 27626-05:35
Phone [phone]
WELL CONSTRUCTION RECORD
J RACTOR IYV& Cr
N
FOn OFFICE USE OL/ ;) 14 4 7
OIJAD. NO. SEMAL NO.
Lnt. Long. no
Minor Basin
Basin Code
Header Ent. GWI Enl
DRILLING COr T
STATE WELL CONSTRUCTION
DRILLER REGISTRATION NUMBER: �zl� _ PERMIT NUMBER:
1. WELL LOCATION' (Sh9w sketch of the location below) c /J0o
Nearest Town: /�n-0'"p e' County: R -
, /LA
jRo�rn,y,orSuMivision I'd Lot No)
D_EPTII DRILLING LOG
2. OWNER_ 11 From To Formalion Description
nDURESS�p- rr5 l so1�--I — v —
(San cel or oulo No No J
City or Town Slate ,Zip Codo
3. DATEDnILLED 2-63-06 USE OF WELL_L-
4. TOTAL UFPTI.1
5. CUTTINGS COLLECTED YES" NO(
6. DOES WELL REPLACE EXISTING WELL? YES O NO(
7. STATIC WATER LEVEL Below Top of Casing: Z 2- R-
(Use'�- if Above. Top of Casing)
8. TOP OF CASING IS Z FT. Above Land Surface'
Casing Terminated aVor below land surface Is Illegni unless a variance Is Issued
In sccondpnce with 15A NCAC 2C .0110
9. YIELD (gpn* L D METI IOD OE TEST A r
to. WATER ZONES (depth): I1 f
11. CHLORINATION
Q. CASING:
S-o /Z oi—_--
Type � Amount /`t° II additional space is needed use back of form
Depth Diameter
Frorn-0 To rl.-��-
Fron, To FL
-
From To R.
13. GROUT:
LOCATION SKETCH
I
Wall Thickness `
or W�eoig()hiFt. Sfeea/ (Show direction and distance Iron, at least two State
- 11W— _ / Roads, or olher map reference points)
Depth
Front _ 0 To ;1, 0 FL
Front To FL
14. SCREEN:
Depth Diameter Slot Size
From To rt In. _— In.
From To Ft. In. In.
From To In.
15
From t �To - -Fl.
Free., 1'D Ft.
16. FIE AJA�Xslr
_
o
—
CD
O
0
elhod
ram—
cl;
c-n
g r„
m
Material 1s
o
M
C3
,
.. W
o
Material
1 DO HEREBY CERTIFY TI IAT THIS WELL E WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF TI ITS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
ks_� 21
OF CONTACTOR On AGENT DATE

North Carolina - Department of Environment. Health, and Natural Rnsources
Division of Environmental Management - Groundwalm Section
P.O. Box 29535 - Raleigh, N.C. 27626 0535
Phone [phone]
WELL CONSTRUCTION RECORD
DRILLING CONTRACTOR: / 7;Uer
FOR OFFICE USE ONLY
QUAD. NO. SERIAL NO. 2
Lal. Long. RO
Minor Basin
Basin Code
—
I leader Ent. GW 1 Ent.
STATE WELL CONSTRUCTION
DRILLER REGISTRATION NUMBER: �/ _ _ PERMIT NUMBER:_
1. WELL LOCATION: (Show sketch of the location below)
Nearest Town: N�W e- e j
County: 7&(lum
Q•'y 6u,
(Road. Communlily or Subdivision and Lot No.) DEPTH _DRILLING LOG _
2. OWNER �!T �OSJi Fr� Fan To Formation Description
ADDRESS �/n 7-1-441 _C ,,1-6 ----
(street or Routo No.) O — 5-6 (/r4 U e C 4C
City m Town Stale Zip Codo
3, DATE DRILLED Z 0 USE OF WELL Xr" 17 5-
4. TOTAL DEPTH 1 YO
5. CUTTINGS COLLECTED YES ❑ NO
6. DOES WELL REPLACE EXISTING WELL? YES
7, STATIC WATER LEVEL Below Top of Casing: ___ FT.
(Use'+' it Above Top of Casing)
6. TOP OF CASING IS Z _ FT. Above Land Surface -
'Casing Terminated eUor below land surface Is Illegal unless a variance is Issued
In accordance with 15A NCAC 2C .0110 _
9. YIELD (gpm), 5' METHOD OF TESL
10. WATER ZONES (depth): CGS
5�0
I I. CHLOR114ATION: Type Amount �F II additional space is needed use back of form
Q. CASING:
LOCATION SKETCH
Wall Thickness
Depth Diameter or W i I UFI. Material
(Show direction add distance from at least Iwo
State
©
G j '"jJ' `�" s�Qe /
Roads, or other map reference points)
From
—To Ft. --
From
To FI. ---
0
o
0
From
To Fl.— --
o
13.
GROUT:
C
c
Depth /..M�a�nallhod
D 7
r—
N
g
From 0
To e Ft. i e' 1`� ?ieJl�`C
cn
- rn
T-
From
To Fl.
s
14.SCREEN:
cn z
Depth Diameter Slot Size Material
o
m�
From
To El in. In.
o
w
o
From
To Ft. in. In.
z
Front
To F��M in.
15.
SAND/
CE V
D
Material
From
T�go�g FIL _
—art.
From
1 -
16.
REMAR S:
Croundvate' Scene8�����
t,2jY11T TFIIS wELC AS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
I DO HER,
AND THAT A COPY OF THIS RECORD
HAS BEEN PROVIDED TO THE WELL OWNER.
CONSTRUCTION
STANDARDS,
Z GNT
SIGN TUBE OF CONTRACTOR OR AGENT
K
DATE

North Carolina - Department of Environment. Health, and Nalural Resources
Division of Environmental Management - Groundwater Section
P.O. Box 29535 - Raleigh, N.C. 27626-0535
Phone [phone]
WELL CONSTRUCTION RECORD
DRILLING CONTRACTOR: %1,%ler
FOR OFFICE USE ONLY I
QUAD, NO. SERIAL NO.
Lnt. Long.
Minor Basin
Basin Code
I leader Ent. - _ _ GW-1 EnL
STATE WELL CONSTRUCTION
DRILLER REGISTRATION NUMBER: L 43 PERMIT NUMBER:
1. WELL LOCATION: (Show sketch of the location below)
Nearest Town: s/l�/ County:
(nond, Community, or Subdivision and Lot No.)
2. OWNER TE?✓yfCl 2/,7lel�rf
ADDRESS(Street or or Route No.)
City or Town State Zip Code
3. DATE DRII-LED �2 -/0" ' USE OF WELL 1 'Ile,
4. TOTAL DEPTH
5. CUTTINGS COLLECTED YES ❑ NO[-:�
6. DOES WELL REPLACE EXISTING WELL? YES 0 NOP
7. STATIC WATER LEVEL Below Top of Casing: _/� p ' FT.
(Use'+' it Above Top of Casing)
8. TOP OF CASING IS FT. Above Land Surface'
' Casing Terminated al/or below land suriace Is Illegal unless a variance Is Issued
In accordance with 15A-JICAC 2C .011e
9. YIELD (gpnt): METI-10D QF TEST
10. WATER ZONES (depth): / �057
11. CHLORINATION: Type
1-17-
y
— Amount 'i( Cv
12. CASING:
Wall Thicknoss
C
Depth
Diar
6mete
or We�ig WI'l. Material
S�K�I /11dL
From
To/C<
FI
From
To
Ft. -
From
To
Fl. _
13. GROUT
From
Depth
To • FL
Ma}erif l
rCj��`�d
lhod
�2frb�e
From
To Ft.
14. SCREEN:
Depth Diameter
Slot Size
Material
From
To Ft
in.
in.
From
To Ft.
in.
In.
From
To Ft.
in.
in.
15. SAN(RAC nnr.K -
Material
D
From
TD Ft.
FrontTofq,(L
16. REtd
DEPTH _DRILLING LOG_
From To Formation Descriplion
If additional space is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least Iwo Slate
Roads, or other map reference points) o
O t
0
L
r\3 t —
en ==
O rn z
c�
O
W O
z
I DO ED IN
CONI ERE -ibffs IAP d:�AS WE AT A COPY OF THIWAS S RECORD HAS BEEN PROVIDED D TO THE WELL OWNER.
OF CONTRACTOR OR
DATE

North Carolina - Department of Environment, Health, and Natural Resources
Division of Environmental Managemenl - Groundwater Section
P.O. Box 29535 - Raleigh, N.C. 27626 0535
Phone [phone]
WELL CONSTRUCTION RECORD
DRILLING CONTRACTOR:
FOR OFFICE USE OrILK. 1 4 439
QUAD. NO. SERIAL NO.
Tat. Long. RO
Minor Basin
Basin Code
Header Ent. GYJ1 EnL
STATE WELL CONSTRUCTION
DRILLER REGISTRATION NUMBER: Ll92 PERMIT NUMBER:
1. WELL LOCATION: (Show sketch of the location below) _
NeareslTown- County: J6C'�fOn
(Road, Con m roily, or Subdivision and Lol No.) DEPTI-I _ DRILLING LOG_
2. OWNER l'G/bb L��t�Y — F,om To Fomialion Description
ADDRESS n,ba ConS�•
(Street or Roule No.)
yor Town Stale Zip Corlo �z �; M,"t c'
Cil
3. DATE DRILLED oo USE OF WELL "� e
4. TOTAL DEPTH
5. CUTTINGS COLLECTED YES[—] NO[%j`
6. DOES WELL REPLACE EXISTING WELL? YES NO0
7. STATIC WATER LEVEL Below Top of Casing: O FT.
(Use '+' it Above Top of Casing)
B. TOP OF CASING IS Z FT. Above Land Surface'
Casing Terminated allor below land surface Is Illegal unless a variance Is Issued
In accordance with 15A NCAC 2C .0110
9. YIELD (gpm): ZD METH09 OF TEST
10. WATER ZONES (depth):
x
3
11. CHLORINATION: Type ff% Amount Y If additional space is needed use back of to'rri 3
12. CASING:
Wall Thickness LOCATION SKETCH
Depth Diameter or Weight/Ft. Mfatat (Show direction and distance from at least two State
From To S 7 Ft. sOP, Roads, or other map reference points)
From To Ff.
From To Ft.
13. GROUT: o
Depth Ma eria M filed �
P _c
r m
From To 20 Ft. °� 4�I 71 , c r
From To FL �-c
(_n
14. SCREEN:
a m�
Depth Diameter Slot Size Material 3 �o
From To Ft In. in. E5 m
From To Ft. in. in. -
W o
From To Ft. in. In.
15. SAND/GRAVEL PACK:
�i Material
From tL55 L7 LS 1
FromR,'+ TO
16. REMAR I JUL { I �""�1 L)
I DO HE EBY C R�_flFY~, TeUK WELL AS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTR ,Mtl'$ ARf5#;D§,0 b-T44A A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
SIGNA
OF CONTRACTOR OR AGENT
DATE

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:,��Er
QUAD. NO.
Lat. _
Minor Basin
Basin Code
Header Ent.
FOR OFFICE USE ON16e-L U
SERIAL NO.
_ Lorg. RO --
DRILLER REGISTRATION NUMBER: STATE WELL CONSTRUCTION
��/ PERMIT NUMBER:
1. WELL LOCATION: (Show sketch of the location below) _
Nearest Town: G 1e�okr z County: ->k�5i 12
_(/Vv-,17. ii s/(6/1 1! -eCeel
(Road, Community, or Subdivision and Lot No.) isi
� DEPTH DRILLING LOG
2. OWNER_Cllie
From To Formation Description
ADDRESS 5�2
(Street or Route No.) i
/CA
City or Town Slate Zip Code�'
3. DATE DRILLED %S' CC USE OF WELL
4. TOTAL DEPTH / J'e
5. CUTTINGS COLLECTED YESF1 NOD-
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO[�j
7. STATIC WATER LEVEL Below Top of Casing: �f— FT.
/ (Use "+" it Above Top of Casing)
8. TOP OF CASING ISlM FT. Above Land Surface'
Casing Terminated allor below land surface Is Illegal unless a variance Is Issued
In accordance with 15A NCAC 2C .0118
9. YIELD (gpm): 2Y— METHOD OF TEST /� ✓
10. WATER ZONES (depth): I%L
11. CHLORINATION: Type /ii/> Amount 4 a
12. CASING:
Depth Diameter
From To _ Ft. 6-1'r
From To Ft.
From To Ft.
13. GROUT
If additional space is needed use back of form
Wall Thickness LOCATION SKETCH
or Weight/Ft. Material (Show direction and distance from at least two State
, /0— ifz :/ Roads, or other map reference points)
Depth o Material Method
From L^ To �2o Ft.d
From To Ft.
14. SCREEN:
Depth Diameter Slot Size Material
From To Ft in. in.
From To Ft. in. in.
From To Ft. in. in.
15. SAND/GRAVEL PACK:
From
From
16. REMA
I DO HE
Size,t,? Material
WELL 41AS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
GIN REV. 9r91
2�'t' 3
SIGNATURE OF CONTRACTOR OR AGENT
Submit original to Division of Environmental M
DATE

idorlh Cnroliun . Depa11m1-0 M Fnvhonntru,l, 110.1111, aml Nnhnal IIntmurcna
LlivisiVn of Fnvi,onn,enlal Mmmgmnnrd (:,ounrkvnlor Ser,Iloo
P.O. Box 29535 nnleigh, N.C. 2702.E 05,35
Phone [phone]
WELL CONSTRUCTION RECoRD
rl " CONITIACTOR' �/�er
ron or Tics- u�r orm TrJ t ��11 w
7
QUAD. No. SEIIIAL ItOL -L 4 `S_ �_
Minor nnehl
I leadoff Ed. Gl'J-I C...
DRILLI _ —
srn1F wr_LL colTsrrlucnorl
DRILLER REGISTRnI'ION NUMBER: �{9,� PERMIT NUMBER:_ —__ —
1. WELL LOCATION: (S7bow sketch of the location below)
title ski' TRcfcJv«
Nearest Town: G County:— -- - —
---------
(nead. Comm„..ity, or SI'MMv ;0n and Lot No) UEP rl I DRILLING LOG
2. OWIJFr1 __/ %f2 From To Fmnnurr" U srdpnon
(Slroel o' Motile No) Q — si 0—
Cil1' M rmvn - `;1'ua �plip C � In
2. PATI Dr1111ri) �`2s'CO LISFOI WIII a�7�e
d. 101Al. UEP111 _6/0____.
5. CUTTIIIGSCOLLECTED 1,FSL-� NO[--�
6. DOES WELL nEPLACE EXIST ING WELL? YL-S J NO
7. STATIC WATER LEVEL Below 7op oI Casing: FT.
(L)se ",'it Above Top o1 Cnsing)
B. 1 OP Or CASING IS -_ Z —_- FT. Above Land Surlace'
' c'InInq Tennlnnlyd nuor below Inud sVilace In Illegol uulesn It vndo,ice Is lamed
In nccoidm,ee with 15A NCAC 2C .0110
9. YIELD (gprn):_ Z ME I I IOU Or TESL—
t0. WATER ZONES (depth):----
—s—v- 610---- G_�,�,te ---
11. CHLORIHATiON: Type I"/-
— Amoulll .
II arJdilional space Is neer)ed use back of loan
Q. CASING:
Local l_OrJ SI<ETCI I__
-
Depth Uiamnlet
wnn IH'I'nnsn
or woic IT Malmial
—
(Show direcllon and dislancq Iron, 11 lead I•rm Slalq
0
PI. "=•`f -
}Vle-� �VL
Roads, or other map reference points)
Ff0111
.TO
Flom,
To- FL--
--- - ----
0 0
rtom, _
1C FT---
- -- ---
o
13, GIIOUC
_
C o%
Dpplll l la)elial M 11 old
'�
r �c
m
From, 62
To Ft. �-`"�=�--
�`�arJw=c
Front To Fl. ---- -- m�
14. SCREFN: g N
Depth Diameler Slot Size Malellal
o
Front To — rl—
z
Front To
From To
15. SA �'R�V� ep I U
e Malellal
Pros
Flbl -_ _ TO-- F1. -- -- --- ---
16 Fit- •ART — ---- ---
:min '.v
Spvvdt. Rational 01ficeC 2C. WELL
._-_•, _ I
I DO,t'r1=n€�Y CEiTTIf`V'TUFf H..ITS WELL WAS CONSInL)C IED IN ACCOnDAHCF WllII 15A IICA
cows nuc I Im SrANDARDS. AND THAT A COPY Or 11 Its RECORD HAS BEEN PROVIDED 10 111E WELL OWI IE n.
n /1�
SIMIAlU :o1rcoNmACTOnOnAGENT UAIE

North Carolina - Department of Environment and Natural Resources - Division of Water Duality -Groundwater Sectionr:. 4 14 3 9
1636 mall Service Center - Raleigh, N.C. 27699.1636-Phone [phone]
If
WELL CONSTRUCTION RECORD WELLCONTRACTOR: 1rLG 14' i�Fr'��•%r-_
WELL CONTRACTOR CERTIFICATION #: 1�1. 6 %
STATE WELL CONSTRUCTION PERMIT#:
I. WELL USE (Check Applicable Boa): Residential 0?1' Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other If Other, List Use:
2. WELL LOCATION: how sketch of the location below) JAG J/'�
a_.......� T.....n. / County.G�
(Road Name
3 OWNER <
Address
and Lot No.)
Caq or Town Ware �•v ----
4. DATE DRILLED
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES Q NOQ
7. DOES WELL REPLACE EXISTING WELL? YENOE
8. STATIC WATER LEVEL Below Top of Casing: � FT.
(Use'*' 9 Above Top of Casing)
9. TOP OF CASING IS 12 Fr. Above Land Surface'
-Top of casing terminated atfor below land surface requires a variance In actor•
dance with 15A NCAC 2C.01 8
10. YIELD (gpm): METHOD OF TEST /9r
11. WATER ZONES (depth):
12. CHLORINATION: Type Amount
13. CASING:
Agricultural ❑ Monitoring ❑
DRILLING LOG
From To
LrJ /G
/an s�52
DEPTH
Fortngllon Descnption
If additional space is needed use back of lout
cn
Walt Thickness
LOCATION SKETCH
-� 0eplh�
D�ia�me).e!r/ or Weight/R. enat
irL
(Show direction and distance from at least two State
From
To
Ft.
1lGZ
Roads, or other map reference points)
From
From
To
To
Ft.
Ft.
'7 ..1.
1 s /
ly61/
14. GROUT:
Depth
Material Method
From
-
To
Ft.
�P�+z�✓
From
To
Ft.
15.SCREEN
Depth Diameter Slot Size Material
From To Ft in. in.
From To —Ft. — in. —in.
From _ To _ Ft. _ in. — in.
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL

n
North Caeolina - Department of Environment and Natural Resources -Division of Water Ouabry -Groundwater Section 4 5 4
1636 Mail Service Center - Raleigh, N.C. 27699.1636•Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
L CONTRACTOR CERTIFICATION#: c O7
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (check Applicable Box): Residential Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other 0 It Other, List Use:
2. WELL LOCATION: (S7ow/sketch of the location below) -�
Nearest Town: � �/ S rCl� - County: —J li
(Road N
3 OWNER
Address
or Subdivision and Lot
Cay or Town Stale Zip Code
4, DATE DRILLED _17 -bvr
5. TOTAL DEPTH
6, CUTTINGS COLLECTED YES M NOM
7. DOES WELL REPLACE EXISTING WELL? YES [ ] NOr7r
8, STATIC WATER LEVEL Below Top of Casing: Z11e FT.
(Use': g Above Top of CUM)
9. TOP OF CASING IS FT. Above Land Surface-
-Top or casing terminated avor below land surface requires a variance In accor-
dance with 1SA NCAC 2C .0110 n
10. YIELD (gpm): �_ METHOD OF TEST /7 J'
11, WATER ZONES (depth):
DRILLING LOG DEPTH
From To 4�iln D scdption
� aT o Hd+'e
C—
Q. CHLORINATION: Type Amount It additional space is needed use back of 1
0
11IQ31
13. CASING:
LOCATION SKETCH
Wall Thickness
.' Depth , y Diamgtgr, or WeighUR. t nalt - (Show direction and distance from at least two State
From r� To -� Ft. i%2 Roads, or other map reference points)
From To Ft. —
From To Ft.
14. GROUT:
Depth"0�1SG_ Ft. , Material Method
From �— To OS.MP•'✓
From To Ft.
15.SCREEN:
Depth Diameter Slot Size Material
From —To—Ft— in. —in.-
From —To —Ft. _ in. —In.
From —To — Fl. _ in. —in.
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
17. REMARKS:
I DO HEREBY CERTtgY T41 THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 1SA NCAC 2C, WELL
CONSTRUCTION SiIgN A St;A��A 'ftfJA{-ASC,P,Y OF 7kUS RECORD HAS EEN`PROVIDED TO THE WELL OWNER.
FOR OFFICE USE �
Ouad No: jr N CONSTRUCTING LL DATE
- 2 - Submit Drip tN2,1,�naliy, Groundwater Senion w hin 30 days
Serial No. GW-1 REV. 12N9

Nonh Carolina - Department of Environment and Natural Resources - Division of Water Quahry - Groundwater Section `- 4
1636 Mail Service Center - Raleigh, N.C. 27699.1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: �rlC F' ^2F' lr'
WELL CONTRACTOR CERTIFICATION p:n2/i10 %
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential Rr Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other M If Other, List Use:
2. WELL LOCA
Nearest Town:
(Road Name i
3 OWNER 1
Address
of the location below)
f County:
or Subdivision and Lot No.)
Qty or 1 own
4. DATE DRILLED v7Onco
5. TOTAL DEPTH
6, CUTTINGS COLLECTED YES Q NOF_�
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO[1 '
6. STATIC WATER LEVEL Below Top of Casing: �a o_ FT.
(Use '+' if Above Top of Casing)
9. TOP OF CASING ISFT. Above Land Surface'
'Top of casing terminated attor below land surface requires a variance In accor.
dance with 15A NCAC 2C . 118
10. YIELD (gpm): p211 METHOD OF TEST
11. WATER ZONES (depth):
DRILLING LOG
From To
ya iav
Agricultural ❑ Monitoring ❑
DEPTH
Formation Descriptions
G--o
C
rri
C3M
r
am
C.fl
�m
a
m�
_m
m�
-y
12. CHLORINATION: Type Amount It additional space is needed use back of form =
13, CASING: -
Wall Thickness LOCATION SKETCH
Depth U Dfir or weghuFl. Material, (Show direction and distance from at least two Stale
From To Ft. — Roads, or other map reference points)
From To Ft.
From To Ft. A"ll J�
14. GROUT: VV 1
Depth /,Material Method
From To �Ft.
1 �^'e�
From To Ft.
15.SCREEN:
Depth Diameter
From _ To _ Ft _ in.
From To — Ft. _ in.
From To —Ft. _ in.
16.SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To Ft.
17. REMARKS:
Slot Size Material
_ in.
in.
_ in.
Material
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH i 5A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OE THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
SIGNATURE OF PERSON CONSTRUCTIN aG-AE WELL
at to Divislon of Water Duality. Groundwater Section within 30 days

220387
North Carolina - Depanmont of Envlmornenl and Natural Resources - Division of Water Quality - Groundwater Section
1636 (flail Service Center - Raleigh, N.C. 27699.1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOra: , U,U1-
WELL CONTRACTOR CERTIFICATION 0: yJ
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): nesidonUa
MUDIClpal ❑
Industrial ❑
Agricultural ❑ MonTcNng ❑
nocovery ❑ heat Purnp Water Inject I ❑
Other ❑
If Other, List Use:
2, WELL LOCATIONI
Nearest Town:—
�-i11'I 1
(Road N
3, OWNER
Address
sketch of the location below) —�'
County: 11 I , �l•L-
Domi.nnity. or Subdi,,Iscarnnd Lot No.)
191
Clty�r Town Statext,
D,^.'F DRILLED
5. TOTAL DEPTH
�-
6. CUTTIrIGS COLLECTED YES NUO
7. DOES WELL nEPLACE EXISTING WELL? YI NO
B. STATIC VlATEn LEVEL Below Top of Casing: ::�U FT.
If Abovs Top of Casing)
9. TOP OF CASING IS FT. Abovo Land Surface'
'Top of caehig terminstnd eVor below land surface requires a variance In accor-
oanco wlih 15A NCAC 2 0118
10. YIELD (grin): METHOD OF TEST
11, WATER ZONES (dOP01):
DRILLING LOG
From To
U o
�O
DEPTH
Formal to Description
, IA
12. CHLORINATION: Type DT H Amount If additional space Is needed use back of form
13. CASING.
LOCATION SKETCH
Wall Thickness
tt Depth hl tteerl�at I (Show direction and distance from at least two Slate
Fromm To J� - Ft. -"-='-"\ Roads, or other map reference points)
From—_-- To--- FT 7y� w6c4 fi
Frorn---Io--- Ft.-/ Ui /
14_ GnOUT: r I/
Dopih Malndnl Method
From S..___ To f"I.
From To
Is, SCnFFrI
Uep(h Diameter
From
To
From
_-To--Ft In.
From ___
10 _.— Pt. _ In.
10, SACID/GnAVEL
PACK:
Depth Size
Frorn
_— To -- Ft.
From
__ TO FL
17. nEMARKS
Slot Size Miatorinl
In.
In.
In.
Material
I DO i Enr8Y CERTIFY IIIAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CD(ISTnUCTION STANDAn DS, AND TI TAT A GO/PY OF HIS RECCORD HAS BEEN PROVIDED TO THE WELL OWNER.
`,—
FON NOFFICE USE ONLY
Ouaj No
Sc ial Nc.
SIGNATURE OF PERSON 6 NSTRUCTING THE WELL
Submit original to Division of Water Duality, Groundwater Section within 30 days
DATE
GW I REV. 12199

North Carolina - Department of Environment and Natural Resources - Division of Water Quality -Groundwater Section �: 1 a7 0 51
1636 fAail Service Center - Ralelgh, N.C. 27699.1636-Phone [phone] p
WELL CONSTRUCTION RECORD * C�-v
WELL CONTRACTOR CE RT FIC TON
STATE WELL CONSTRUCTION PERMIT#:
1 . WELL USE (Check Applicable 60.). Residenllal�
Recovery ❑ Fleal Pump Water Injection
2, WELL
(Toad N
3. OWNER
Address
Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Other El If Other, List Use:
sketch of the location bolow) '/ /
Q-_ County:A CSC L k
and Lot
„ „� , r _ _ _ -zip cage
Cit or TownTown ('� Slate
❑GRILLED =- t1-�7
5. TOTAL DEPTH P---- —
6. CUTTINGSCOLLECTED YESCI Nor 1
7. DOES WELL REPLACE EXISTING WELL? YES 0 NO
8. STATIC WATER LEVEL Below Top of Casing: �;�._ F-i
(Us,'a' II Above Top of C151nq)
9. TOP OF CASING IS __r_— FT. Above Land Surface'
'Top of casbrg tennhrated eUor below land surface requires a variance In eccor-
danco with ISn NCAC 2c.k1U ME
Tk IOD OF TEST Cl S �
10. YIELD (gpnt): —�
11. WATER ZONES (depth):_
12. CHLORINATION: TypeIT Amount
13, CASING:
Wall 1 hlcknes5
Depth�o��lq-=U-'L
Fromf 'To ���11- Ft. e�)r1-I��zl-e/s�d=z
-
From I o ---- Ft. -
Frorn ---10 Ft. -
n. GROUT:
Material Mothod
From O _ To 4iLl--FL
Front To—._.rt. —
15. SCREEN: !o!cral
Unpllr Diameter slot Sizd ��
From _- To FI --- In. —_- In.
From To_ - Ft, _- In. _-in.
Front To FI. In. In.
16. SArIDIGRAVEL PACK Material
Depth Size
Flom To Ft.
Front To Fl.
17. REMARKS:
DRILLING LOG
From To
DEPTH
FMIt,, Desadplion
9
L Iva -
•N
(Show
direction and distance from at least two Stale
Roads, or other map reference points)
�q /yy 7
IIAMFn
I DO I IE REGY CERTIP't TI IAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WEL
COIISTRUCTION STAIJDMDS, AND TI I LA DOPY QF THIS REC- Nz\ BEENI.-.
FOR OFFICE USE ONLY
Oaad tlo
Sciial No
SIGNATURE OF PERSON CUnb r nuU I nv
Submit cdginal to owlslon at Water oualtly, Groundwater
GWlt REV. IM9

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Sarvlce Center - Raleigh, N O. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: a ° �S P�--
WELL CONTRACTOR CERTIFICATION 0:
STATE WELL CONSTRUCTION PEFtl
WELL USE (meek Appucebla eo.): Residoflllal ) Munlcipal ❑ Industrial ❑
Recovery ❑ Heal Pump Water InjeCtlon ❑ Other ❑ If Other, List Use:
2. WELL LOCA
NeareslTpwn
(n"d Name pap,
3. OIV fJEfI 1 �
Address S
of file location below)
County: —J
or Subdivislon and Lot No I
Gl r Twin— state zip Code
CAT CIll lLED
8. TOTAL DEPTH _
6. CUT7INGS COLLECTED YES [_� NOD
7, DOES WELL REPLACE EXISTING WELL? YES D NO)]
8. STATIC WATER LEVEL Below Top of Casing: )Ou FT.
(Use'.- if Above Top of Casing)
9. TOP OF CASING IS (:)� FT. Above Land Surface'
'Top of casing termlnalad moor below land surface requires a variance In eceor-
dan10, YIELD
1 (g n* 2�.oi1s METHOD OF TEST
10. YIELD (gpm): �___
11. WATER ZONES (depth):
12. CHLORINATION
13, CASING:
Type Arnounl
Dell
Fronta— To�—Ft.
Prom. 'lo--- FL —
From —---I-o--- FL--
14. GROUT: }
_ Ivlalod�nl JL
From O
Frorn ---
is scnEr_rc
Depth
To � -Pl.
To _—_-FI.
Depth Uiemetor
From _-- To --- Ft _— In.
From--To_-FL_ In.
From _To Fl.— In.
16. SAPID/GRAVEL PACK:
Depth Size
Flom To--rt.—
From To Ft. —
17. nEMARKSt—
DRILLING LOG
Finn To
6 20
Agricultural ❑ Monitoring ❑
�r�
DEPTH
Formation Description
/'/b I,
r nv,
r-�
IV -
c>
II additional space Is needed use back of form
n
LOCATION SKETCH
Wall Thickness
(Show
or WelghUl't..i �tib�pahed�al � _w direction and distance Iron at least two tale
f L'� Roads, or other rnap reference points)
Method
Slot Slzs )�tatcrial
In.
In.
Material
I UO HEREUY CrnTIFY THAT T HIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C. WELL
cot is RUC plot STANDARDS, ANU TI AT A_ COPY OE THIS RECORD BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY DATE
O..al ho SIG NAIURE OP PERSON CONSTRUCTING TH E
sub ... it original to Division of W ate( Quality, aroundwal or Sectlen W hi 30 days G ej� t REV. 12M
Scdal No.

North Carolina - Department of Environmanl and Natural Resources - Division of Water Quality- Groundwater Section �� _[- U +J
1636 tAail Sorvice Center - Raleigh, N.C. 27699-1636-Phono [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: p�� 1
WELL CONTRACTOR CERTIFICATION #: 3 l T
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check nppuceble nos): Residential Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water InJecll n Other ❑ If Other, List Use:
2. WELLLOCAT
Noaresl Town:.
)Road IT
3. OWrdER
Address
ow sketch of the location below)
County:
Numbers, Cammm11ll olubdIvislon and i-ol
City orTown n -.
5. TOTAL DEPTI.I rA�') r
6. CUTTpdGS COLLECTED YES [_j NOL]
7. DOES WELL REPLACE EXISTING WELL? YES_0 NO
�
8. STATIC WATER LEVEL Below Top of Casing: J FT.
(Usa '.' It Abova Top of Casing)
9. TOP OF CASING IS_ 9—�— ET, Above Land Surface'
-Top of casing ter minatnd atior below land surface requires a vndance In accor-
dance I I 15A IICAC el la
10. YIELD (gpm): METFIOD OF TEST
t i. WATER ZONES (depth):
Agricultural ❑ fdonlloring ❑
DRILLING LOG DEPTH
From To
7v
12. CHLORINATION: Type -F1 1 Amount it additional space Is needed use back of form
13. CASING: LOCATION SKETCH
Wall Thickness
Dept[ lnarrle)er or Weightfl-t. M Iedal (Show direction and distance from et least hvo Slate
t—'To Cns Ft. - "--`�-i L— Roads, or other map reference points)
From
From To--- PI. `7��
From —.--To —.-- Fl.
14 GROUT:
Uepl�Material Molhod
From a__ To C>lc�G=FI.-"�-
Flom _-. — To
15. SCnEEfI.
Depth
Diameter
From
To
Ft _. In.
From
_-- To —
Ft
From —__
To _—
FL— In.
16. SAr]D/GnAVEL
F'ACK:
Depth
Size
From
To
Ft.. —
Front
— To
Fl.._
17,REMARKS:
Slot Size Matc:ml
In.
_— In.
Maiorlat
t DO IIEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
COtISTRUCTION STANUARDS, AND TI T_ACOPY 0 TFIts RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
H
9—�u-lN
OR OFFICE USE O
DATE
Ouad no
SIGNATURE of PERSON CONSTRUCTING -THE ELL
Submit original to Division of Wzrer Ouality, Groundwater Section Ihln 30 days G`N I REV. 12/99
Serial No. -

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Sectlon
1636 Idail Service Center - Raleigh, N.C. 27699.1638-Phone [phone] �� r-^ 1 `! \' `! 1
WELL CONSTRUCTION RECORD WELL CONTRACTOR CERWELL CONTRACTOR: I , TIFICATION FICAT ON 0 p
STATE WELL CONSTRUCTION PERMITi
1. WELL USE (Check Applicable Box): ResidontlalMunicipal ❑ Industrial ❑
nocovory ❑ Heat Pump Water Injectlon ❑ Other 0 If Other, List Use:
2. WELL LOCH
Noarcgrr F wn'
Mond dame
3. OWNER
Address 1
I the location below)
.Q JL- County: L \ r N I/ 5 rTlk
and Lol
Stale Zip code
City or Toc+n
4. DATE DRILLED ��-T,
—�-"1.�-
5. TOTAL DEPTH -- NO[�
6. CUTTINGSCOLLECTED YES[
7. DOES WELL REPLACE EXISTING WELL? Yi NO
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 Imminelnd eVo, below land surface requires a varied ce In accor.
dance w llh ISA II CA C QNB /­`. . .
DRILLING LOG
From To
p �1
Agricultural ❑ Monitoring ❑
_ DEPTH
Formation Descdtition
r'f
10. YIELD (gpn Q:(y METHOD OF TEST
11- A"DATER ZONES (depth): rn1
12, CHLORINATION.
13. CASING:
Ty.I>e {-iT Amount II additional space is needed use back of lcrr
0
Deptl DI:��eI r
From --To Ib-(LOLL
Rent. To---- Fr
-
From ---To-- FI.
t4 GROUT:
LOCATION SKETCH
Wall 1 hlckne s sleast
or VfelghUFl. F1 l-,Sh!oR direction and distance rentrom at points)
two tale
L. Roads, or other reap reference points)
O UeptIviatorInI
From _ lb FL ----
From To ---Ft.
15. SCREEN:
Depth Diameter
From __ To _ Ft _ In.
From To _ Ft. _ In.
Front __ To _ Ft. _ In.
16. SMIDIGRAVEL PACK:
Depth Size
Front To -- FL
From _ -To FI.
17. nEMARKS:.
Method
Material
Material
I Oct itEnc By CERTIFl TI IA.T THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITII 15A NCAC 2C. WELL
CONSTRUCTION STANDARDS, AND T A COPY OF THIS RED HAS BEEN PROVIDED TO THE WELL OWNER.
Ilk
q-ia- w
=OIFICLUOE DATE
SIGNATUne OF PERSON CONSTRUCTING THE V LLSobo9t original to DMr,lon of Water Ouallly, Groundwater Sectlon W' fin 30 days GW I REV. 12199

North Carolina - Department or Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 lAer Service Center - naleigh, N.C. 27699-1636-Phone [phone]
V-
WELLCONSTRUCTIONRECORD WELL CONTRACTORCERTIFCATIONIf:y 1
STATE WELL CONSTRUCTION PERMIT#:
1 . WELL USE (Check Applicable Be),). nesldenliat Municlpal ❑ Industrial ❑ Agricultural ❑ Monitoring El
nocovory ❑ 1-teal Purnp Water Injection Other If Other, List Use:
2. WELL LOCATIO1rd: Show sketch of the location below) r n
Nearest Town: l �' Q��� �� County: ` -\ C o'NLU
(noad Name
O'AI N E R
Address
and Lot
�G tiu ,l r� T a A.
•3 a-1 a u
C,ly or Town Stale Zip Code
n n`TC DR!', LED V-1O-CiU
5. TOTALDEPTH _
6. CUTTIIIGSCOLLECTED YES[_NOU
7. DOES WELL nEPLACE EXISTING WELL? YES Ej NO
g. STATIC WATER LEVEL Below Top of Casing: Qcl) ]
FT.
(Use -.' It Abovo Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface'
.Top or casing h,minatnd aVor below land surface requires a variance In accor-
dance wWr 15A NCAC 2C 1o11e METHOD OF TEST
10. YIELD (gpm):
11, WATER ZONES (dOPth):-
12, CHLORINATION
13. CASING:
DRILLING LOG
From To
in
_L'2_0
2r) �--
DEPTH
Formation Description
f}
� NCB
Type Amount If additional space Is needed use back of form
Depth-� Imrnrm
From _ CTo .SZ '— t
Front To --- Ft
From __-- I o1.--
14 GnOUT
LOCATION SKETCH
Wall Thickness
or WeighVFi. Material _ (Show direction and distance from at least two State
C]. C Q_ Roads, or other map reference points)
/'�
Dnplh
Malnrlal Molhod
To ��-_FI.From
Frain 51--
_—
To---
1s. scnei-N.
Deplil
Diantetor
Slot Sizd Maicrlal
From _-To_—Ft--
In. —.-In.
From _--
To _.-- FL.--
in. — In.
From _—
1-0 --- FI.
_ In. — In.
1B. S AfIDJGRAVEL PACK
Depth
Size Material
From
To
FI.
Frorn ___
To
FI.
17. nEMAnKS:_
-4 /�
I DO HEREBY CEnI IPr MAT THIS IIS WELL WAS CONSTRUCTED IN ACCOnDANCE WITH 15A NCAC 2C, WELL
COrls tnUCTION STANDARDS, AND TI IAT A COPY OP THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNE11
FOR OFFICE USE ONLY
Quad No'
6eAal No.
SIGNATURE OF PERSON ONSTnUCTItJG THE WELL
Submit original to Division of Water Oualdy, Groundwater Section wlthln 30 days
SEA 2 1
O
CD
cn
CIl --a
CO
DATE
GW.I REV. 12/99

Nonh Carolina . Department of Environment and Natural Resources - Division of Water Oualily - Groundwater Section r- 17
1636 !Anil Service Center - Raleigh, N.C. 27699-1636-Phone [phone] ((��
WELL CONSTRUCTION RECORD WELLCONTRACTOR• dACc �lR� 1 w I�'YuX�
WELL CONTRACTOR CERTIFICATION k:
STATE WELL CONSTRUCTION PERFAITX:
1. WELL USE )Cbeck Applicable sox): Resldontlayl
Recovery ❑ I -loot Purnp Water Injection
2. %',ELL LOCAT IOrI $how sk Ich of
Nearersk Town: j r
(Road rlame
3- owNER
Municipal ❑ Industrial ❑
Other ❑ If Other, List Use:
below)
— County:
Agricultural ❑ Monitoring ❑
No.)
DRILLING LOG
DEPTH
From To
DescdPtion
D /o
D 'y
is.
_,!
ZI Code
City or Iovm QQ �-�� ,rare p — p� x/ , —
DATE DR!U_ED.S�-I L� 1LL- /rc
5. TOTAL DEPTH
C. CUTTINGS COLLECTED YES NOU
7, DOES WELL REPLACE EXISTING WELL? YES NO I\/ I
8. STATIC WATER LEVEL Bolow Top of Casing: FT. Yc'
(Uso'.' If Above Top of Casing) _
9. TOP OF CASING IS � FT. Above Land Surface'
'Top of casing terminated nuor below land surface requires a variance In accor-
dance lth 15A NCAC 2C.o 10
10. YIELD (gpnt): METHOD OF TEST
i i. PLATER ZONES (deptl Q.
12. CHLORINATION. Type_' ` 1 ` ` Amount If additional space Is needed use back of form
13. CASING:
Depth 11 �Iarrfc rr�
From +—)To � 1 _ FL -4Y---s--�
Plod -to-- FI.
From To-- FL-
14 GROUT:
LOCATION SKETCH
Wall Thickness
or Welghl/Pt. aerial --(Show direction and distance from at least hvo State
(+ C_ Roads, or other map reference points)
Uapih �1 pM�alarinl Method
Frorn — To c�D Ft. �7L
From _.. To __FI.
15.SCREErr.
Depth Dienieler
Frorn --To __ Ft In.
From _- To Ft. In.
From __ To __ FL III.
18. SAf1D/GRAVEL PACK
Depth Size
From _— To __ Ft.
Flom To Ft.
17. nEt!ARKS'.
Slot Sizd Malcr.al
In.
in.
In.
Material
CD
rig
:-'l
`0
m
C!l
y
CIO
I DO I IEREBY CEFIT IF7 TI AT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND TI AT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Quad No
Se al Nc
SIGNATURE OF PER N CONSTRUCTING THE WELL
Submit adpinal to Divlslon of Water Ouality, Groundwater Section within 30 days
SEP 2 12000
DATE
GW-I F1EV. 12/99

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section 215 777
1636 Mail Service Center - Raleigh, N.D. 27699-1636-Phone [phone] ((/J�1� n
WELL CONSTRUCTION RECORD WELL CONTRACTOR: I -r 0 � I � �0 it �pp�<<� �o
WELL CONTRACTOR CERTIFICATION 0:
STATE WELL CONSTRUCTION PERMITN:
1.
WELL USE (Check Applicable Boa): Residential Municipal ElIndustrial
❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injecli n Other
If Other, Llst Use:
2.
WELL LOCATION: (SIlow sketch /ol file location below)
y `ti County: /
1 S J
Meares own
C7� I-n D
(ticad Mania C Nm ubers, corr nrrwnhy, or Subdlvlslon fand Lot NO)
DRILLING LOG DEPTH
Fro,n To Formation pasulVlion
3
owNER
,
Z`
Address Q
�fl�j(
ree or Iry1T)^—��
Gly or Town Stale Zip Code
DRI LIED �- I - Old
TOTAL DEPTH QY-
5.
0.
CUTTINGSCOLLECTED YESD NOD
7.
DOES WELL REPLACE EXISTING WELL? YES NO
a
8.
STATIC WATER LEVEL Rolow Top of Casing: FT. CCC
9.
(Use'+' if Above Top of Casin(1)
TOP OF CASING IS FT. Above Land Surface'
'Top
or casing terminated eVo, below land surface requires a variance In accor-
dance
10.
with 1SA NCAC 2�118
YIELD (gpm): MET)IOD OF TEST Q
11-
WATER ZONES (depth):-
12- CHLORINATION
13. CASING:
Type Amount it additional space Is needed use back of lorm
Depth( L�. Dla"tar
From—�'To �--U FL
From To---- Ft.
Roan._
14. GROUT'.
LOCATION SKETCH
Wall TNckness
or WeighVR. Hate(Show direction and distance from at least two Stale
Roads, or other map reference points)
Depth Malorlal
From LJ To ­1C) r1. t /1
From To -- FI.
15, SCREEN:
Depth
Diamelor
From _ To -_
FI
_ In.
From To __
Ft.
In.
Frorn __ To
rt.
_ in.
16. SAr]D/GFIAVEL PACK:
Depth
Size
Frorn To-_FL.—.-
Frorn _-- To
FL
slot Size
In.
In.
In.
O
0
Method
J
c
-
Material
:cc r-.
1.0
cn r:
ti
CD
Material
17. REt.1Afl1(S:_ __
I DO IIEnEBY CF:NTIr, TIIAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C, WELL
CONS Tf1UCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDEO TO THE WELL OWNER.
FOR OFFICE USE ONLY Ouad Nc. SIGNATURE OF ERSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Quality. Omundwaler Section Within 30 days
GWI REV. t2/99
Serial Ne.

''15778
Norlh Carolina - Department of Environment and Natural Resources - Division of Water Oualiry - Groundwater Section 4.
1636 1Aoil Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELLCONTRACToR: Kt J
WELL CONTRACTOR CERTIFICATION R:
STATE WELL CONSTRUCTION PERMITN:
t. WELL USE (Check Applicable ooa): Residential
Municipal ❑
Industrial ❑
Agricultural ❑ Monitoring ❑
Recovery ❑ Heal Pump Water In)ecti 1
Other ❑
If Other, List Use:
2. WELL LOCH
Nearest Town:
(noad Name
3 OWNER _
Address
of the location below) I _��
County:\ 1rt o L` ' ",k
OF S4'bdNlsl9n and Lot
u or 01", I Slalo Zip Code
S. TOTAL DEPTH 6. CUTTINGSCOLLECFED YES[ NOD
7. DOES WELL REPLACE EXISTING WELL? YES NO
a. STATIC WATER LEVEL Below Top of Casing: F T.
(Use'.' It Above Top of Casing)
9. TOP OF CASING ISC FT. Above Land Surface'
'Top or toeing tetminatnd at/or below land surface requires a varlanee In accor-
dance with ISA NCAC L
21fli 18 METHOD OF TEST
10. YIELD (gpnl): .S..-
11. WATER ZONES (depth):
DRILLING LOG DEPTH
rrom T
Formation escrlption
b
j
12. CHLORINATION: Type T
Amount
It additlonal space Is needed use back of form-
13. CASING:
LOCATION SKETCH
�- l
UBpil� I I D am�IF�
/
wall Tldcknoss
o NI 'yJf9. 6 ale dal i
(Show direction and distance Irorn at least Iwo Stale
Fron+ rJ
To -- Pt.
Roads, or other map relerence points)
From
To-- Ft.
l�
From _
_To-- F
14.GROUT
Dnp(ll �Maallnrlal Method
I o:�UQ_Ft._L3.T--mil
From To----
15. SCREEN'.
Uoplh
DIa1nCler
Rom —To
Ft In.
From --
To __
Ft. in.
From —To—Ft.—
In.
16. SAND/GRAVEL
PACK:
Depth
Size
Float
To
Ft.. --
Front
To
FL
17. REMARKS'.
Slot Size Material
_— In.
In.
In.
Material
O
O
A
C
G7
A
t1J
Ul
.P-
I DO I IEncoy CERTIFY HIPS I IIS WELL WAS CONSTRUCTED IN ACCORDANCE WITI-I 15A NCAC 2C, WELL
CONSTRUCTION STANOAn DS, AND I IAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
Ar n w . , , —1— 1 ;1
FOR OFFICE USE ONLY
Ouad No
Serial No
slGNnrunE of rensoN consrnucrlNc THE WELL
Submit orlpinal to Di0slon of Water Ouallty, Groundwater section witllln 30 days
DATE
O
n-
GW-I nEV. 12J99

r r 786
rtn Carolina � Department of Environment and Natural Resources � Division of Water OuaLry � Groundwater Section �;
r:civi�
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELLCONTRACTOR Q iQ U(,Yike
WELL CONTRACTOR CERTIFICATION
STATE WELL CONSTRUCTION PERMIT#:
1, WELL USE (Check Applicable Box): Residential Municipal ❑ Industrial ❑ Agricultural ElMonitoring ❑
Recovery ❑ Heat Pump Water Injection 0 Other ❑ It Other, List Use:
2. WELL LOCATION: Show sketch of the location below) ---
Nearest Town S C.- County. sjaL .,-_C�
f Road Name a umbers, Conpakn+r� or Subovislon and Lol No.) DRILLING LOG DEPTH
3. OWNER n h CJ _1k' ' Frro/olln m To Fonytion Descnp:ion
Address
po ✓
� o
�I L/LV�iSi.i7 beet p o o��, C)s 70 -7 40
City or Town / Stale Zip Code __jQ /« r N
a DATE DRILLED 'off 1r2(2 yls / N• f
5. TOTAL DEPTH —
6. CUTTINGS COLLECTED YESF7 NOM
7. DOES WELL REPLACE EXISTING WELL? AS= NO
8. STATIC WATER LEVEL Below Top of Casing: s_ FT. YYY��ttT"""
(Use'.'if Above Top of Casing)
9. TOP OF CASING IS_C2� FT. Above Land Surface'
-Top of casing terminated allor below land surface requires a variance In actor.
dance with 15A NCAC 2 0118
10. YIELD (gpm): METHOD OF TEST O i
11. WATER ZONES (depth):
12. CHLORINATION: Type Amount If additional space is needed use back of lore
13. CASING:
Wall Thickness LOCATION SKETCH
+ Dept Di mete or Weight/Ft. atenal (Show direction and distance from at least two State
From To Ft. - n Roads, or other map reference points)
From To Ft. �J
From To Ft. 70 /
14. GROUT:
Depth Material Method
From F) Toab Ft.
From To FL
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 FI. —
From To FT. _
17. REMARKS:
Material
in,
in.
in.
Material
O
O
C
A
r:
CO
Ln
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT OPY OFT RECORD HAS BEEN PEOVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Quad No. SIGNATURE OF PERSON CONSTRUC THE TELL DATE
Submit original to Division of Wale(Oualily. Groundwater Section Within 30 days
Serial No. GW 1 REV. 12/99

Nonh Carolina - Department of Environment and Natural Resources - Division of Water Quality -Groundwater Section
15'7'7 0
1636 Mail Sorvice Center - Raleigh, N.C. 27699.1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: I I'r'e
WELL CONTRACTOR CERTIFICATION
STATE WELL CONSTRUCTION PERMITN:
1, WELL USE (Check Applicable i3o+): Residontlal Municipal ❑ Industrial El
❑ Beal Pump Water h1jecilon Other If Other, List Use:
2, WELL LOCATIOr how sk tch of the location below) ��I
Nearest Town: I LL County:,,
(Road r1
3. OWNER
01
or Subdlvislon and Lot No.)
City or Tov;n ^ r,, State Zip Code
n YrE D.RILi_ED --�- I�"1-��
5. TOTAL DEPTH ySID 2--
G. CUTTINGS COLLECTED YES El NOD
7. DOES WELL REPLACE EXISTING WELL? YES NOI YI
B. STATIC WATER LEVEL Bolow Top of Casing: FT.
(Uso'.' II Above Top of Caslnq)
9. TOP OF CASING IS �3!, FT. Above Land Surface'
-Top or casing tarminalael nVor below land surface requires a variance In scoot.
dance with 15A HCAC 2C. 118
10, YIELD (gpn,): _ METHOD OF TEST
11_ `,PATER ZONES (depth):
12, CIiLORINATION
13. CASING:
Agricultural ❑ Monitoring ❑
DRILLING LOG DEPTH
From To Fo ,alion Description
d7 - fFND cN�
f.�ri SOJ — e
Type HT� Amount II additional space Is needed use back of form
Depth `'j DII.T�jI r
FromTo _ F1+L=
From To- FI.
From — To— — F't.---
la. GROUT.
LOCATION SKETCH
Wall Thickness
o tUl't, �- aleda (Show direction and distance from at least two Slate
�� Roads, or other map reference points)
(� Depth(1 Maledal Method
From sC— 10 .�f�_ FL S_Y
Front _-- To _._Ft. -
15. SCREEN.
Depth Olamelor
From To __ FT — In.
From _ To —__ Ft. ___ in.
Frorn ___ To _ _ Ft __ in.
I - SAND/GRAVEL PACK.
Depth Size
From To__FL_
Front _ To FL
17. REMARKS: -_
Slot Size Ntalodal
Irt.
In. _
Material
tJ
r
O
o
O
�l
-
�n
r
—r,
rn r.
tD
mom-
c
CJ1
--r
.G"
o
I DO t IEnEBY CERTIFY TI IAT TIIIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 1SA NCAC 2C. WELL
CONSTRUCTION STANDARDS, AND TI IAT A COPY OF TI TS RECORD HAS BEEN PROVIDED TO THE WELL O'NNEn.
FOR OFFICE USE ONLY
Ouad No
so,ml No.
SIGNAL LIRE OF rMSON CONSTRUCTING THE WELL DATE
Submit original to Division at Water Costly, Groundwater Section within 30 days
GVl�I f1EV. 12,99

Ncnn Carolina - Decanmenl of Environment and Natural Resources - Division of Water Ouaht'y - Groundwater Secoo,,
1636 Mad Service Center -Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: PI L P P,
WELL CONTRACTOR CERTIFICATION #: 3 M
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Cneck Applicable eox): Residential Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATI
Nearest Town. _
(Road N,ame li Numbers,
3 OWNER
Address SaLy^
_ o-a
sketch of the location below)
or Subdivision and Lot
City or Tow.. State Lip Code
a DATE DRILLED
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑ NO
7. DOES WELL REPLACE EXISTING WELL? � NOIY
8 STATIC WATER LEVEL Below Top of Casing: FT.
(Use'.' if Above Top of Casing)
9. TOP OF CA5,NG IS;FT. Above Land Surface'
'Top of casing terminated at/or below land surface requires a variance In accor-
dance with 16A NCAC 2 i1B //��..
10. YIELD (gpm): METHOD OF TEST C-
11. WATER ZONES (depth):
12. CHLORINATION: Type Eff L Amount
13. CASING:
+ �� Depth �� ialnkier
From `�=L--- Ft. IL
From To Ft.
From To Ft.
1». GROUT:
DRILLING LOG
From To
DoC U
�fl 36
Agricultural ❑ Monitoring ❑
DEPTH
F ation D zo'ip;io�
'4
L
7 °e
If additional space is needed use back of form
LOCATION SKETCH
Wall Thickness
or eignVFt. h1 tenal (Show direction and distance from at least two Stale
L �� Roads, or other map reference points)
Depth M,aatte�rial� -�- Method
From Cr To QC� Ft.
From To Ft.
15. SCREEN:
Depth Diameter
From —To—Ft— in.
From —To—Ft.— in.
From —To—Ft.— in.
16. SAND/GRAVEL PACK:
From
From
17.REMARKS:
I DO HEREBY CE
CONSTRUCTION
FOR OFFICE USE ONLY
Quad No: +�
Senal No. Wit/
Slot Size Material
in.
in.
in.
a
13-3 8
o
3
In7c,
m
G c�
c rn
1
oM
130
ScC7
a
S
r—i* �
Am
f/12
m�
CO
C=2
Z
3UCTED IN ACCORDANCE WITH 15A NCAC 2C. WELL
THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit engine) to Division of Water Duality, Groundwater Section within 30 days
Gw 1 REV. IZ'95

Nonh Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
163E Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: 1" Aa U ID I I f—u r-v-42
WELL CONTRACTOR CERTIFICATION #: 31
STATE WELL CONSTRUCTION PERMIT#:
1. V1ELL USE (Check Applicable Boa): Residential Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection 0 Other ❑ If Other, List Use:
2. :^JE(-L LOCATION:,(Shoyv sketch of the location below)
Nearest Town: " -)Ia-( l) a County: X
Subdivislon and Lot
3 OWNER
Address
d, DATE DRILLED 1a S�"ol7
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES[ NOQ ,d�-{{--,,
7. DOES WELL REPLACE EXISTING WELL? YES NO
IX I
8. STATIC WATER LEVEL Below Top of Casing: FT.
(Use'.' If Above Top of Casing)
9, TOP OF CASING IS c9l, FT. Above Land Surface'
'Top of teeing lerminated at/or below land surface requires a variance In accor-
dance wlih 15A #CAC 2C.0118
10. YIELD (gpm): tO METTIOD OF TEST
Qufl-
11 WATER ZONES (depth):
12. CHLORINATION
13. CASING:
Type Amount
Depth IarF to
From -
To -Ft. t�
From To Pt.
From To Ft.
1d GROUT:
Agricultural ❑ Monlioring ❑
DRILLING LOG
From To
/0
as �_
DEPTH
Formation Description
N
Ark ArID
;e
II addiflonal space Is needed use back of form
LOCATION SKETCH
Wall Thickness N
or p(ayFi. Material P I (Show direction and distance from at least two Slab
�j Roads, or other map reference points) N
Depll.
�O
Material1 Method
From
T o
Pt.�1
From
To
15. SCREEN:
Depth
Diameter Slot Size Maloral
From
To
_ PI
_ In. _ In.
From
To
FL_
In. _ In.
From
To
Ft.
_ In. In.
10. SAIID/GRAVEL PACK
T uj )07
Frorn T jn't
I- T,JFrom Tc�---"'17. REf.1ARKS: _i
1 DO HEREBY CEn71FY DRAT THIS WELL WAS C ST CTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
COHSTnUCTION STANDARDS, AND T14AT. OF HIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
°Ctirn C'
FOR OFFICE USE ONLY
Quad No.. SIGNATURE OF PE S N CONSTRUCTING THE WELL DATE
Submit original to Division of Water Ouallty, Groundwater Section within 30 days
G'NI REV. I21ii
Serial No

North Carolina - Department of Environment, Health, and Natural Resources - FOR aPFlCE Division of Environmental Management - Groundwater Section % k .-1-.,
P.O. Box 29535 • Raleigh, N.C. 27626-0535 QUAD. NO-$USEONLERIALNO
Phone [phone] Lat.<�Ad 'a ,;;"
Ml
nor an
WELL CONSTRUCTION RECORD Basin Code
DRILLING CONTRACTOR:?t 1 P p. l Y L 1 Header Ent.GW_
STATE WELL CONSTRUCTION
DRILLER REGISTRATION NUMBER: PERMIT NUMBER:
1. WELL LOCATION: (Show sketch of the location below) 11
Nearest Town: r 2 ( 1 0 ('i County: S 1 n• LC ��
(Hoag, Commu Subdivision and Lot No.) DEPTH DRILLING LOG
2. OWNER / From To Formation Description
ADDRESS 1LS9 /HJQ
(Street or Route No.)
Cary or T4Wn / State Zip Code AA laic) e
3. DATE DRILLED (� - �Q USE OF WELL IIM7YI- jc2c)
4. TOTAL DEPTH I Qr-) S'
5. CUTTINGS COLLECTED YES ❑ NO[y]
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO©
7. STATIC WATER LEVEL Below Top of Casing: /7z� FT. a c
0
(Use'+' if Above Top of Casing) `9
8. TOP OF CASING ISFT. Above Land Surface
Casing Terminated at/or below lend surface Is Illegal unless a variance Is Issued in accordance with 15p �1f2 2C .0118
9. YIELD (gpm): 1 METHOD OF TEST Q A- L -
10. WATER ZONES (depth):
m:a
11. CHLORINATION: Type I --IT ft Amount If additional space is needed use balk bf form
12. CASING:
Wall Thickness LOCATION SKETCH
} Depth -�r-� 9iarrlter or t/Ft. Material (Show direction and distance from at least two State
From �—To �-L Ft. �% Roads, or other map reference points)
From To Ft. —
From To Ft.
13. GROUT:
Dept Material Method
From s _ To C>l Ft. 01A_ QA! f'
From To Ft.
14. SCREEN:
Depth Diameter Slot Size Material
From To Ft in. in.
From To Ft. in. --in.
From T r1 RFD
15. SAND/GRAVEL
DKo�
,. , tSJ7,rr,,, Material
From - LLUU1JftI�
From
16. REMARKS: an
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.

North Carolina - Department of Environment, Health, and Natural Resources FOR aFFlD� USE ONtY,
Division of Environmental Management - Groundwater Section %
P.O. Box 29535 - Raleigh, N.C. 27626-0535 QUAD. NO. .:I SERIAL N&__
Phone [phone] LaL
Minor Basirt""�'0`, -""
WEL STRUCTION RECORD Basin Code
DRILLING CONTRACTOR:w t^l (� Header Ent
CJz. ? - VG1ti•I
STATE WELL CONSTRUCTION
DRILLER REGISTRATION NUMBER: 319 PERMIT NUMBER:
1. WELL LOCATI Show sketch of the location below)
Nearest Town: ` �%'{.I) at - County:
(Road, Cniry, or Subdivij��O1 and Lot No.) DEPTH DRILLING LOG
2. OWNERmmu1 a 1(n t I \ 1 C' R A �. From To Formation Description
ADDRESS g oI� . �COU Rd O — .21 CLgy —tg e4v-L:
Street or Route No.) g _ Si¢Ndf
1 �QI\aC�{ ll lC'FIkICCtA, Lii3MA P� _ / 8d SgNd S7aNe
City or Town State Zip Code
3. DATE DRILLED'—'' USE OF WELL ASd — 2
4. TOTAL DEPTH . 2nS
5. CUTTINGS COLLECTED YES ❑ NOT
6. DOES WELL REPLACE EXISTING WELL? YESO NO®
7. STATIC WATER LEVEL Below Top of Casing: _Q o FT.
(Use'.' it Above Top of Casing)
B. TOP OF CASING IS FT. Above Land Surface'
' Casing Terminated atlor below land surface Is Illegal unless a variance Is Issued
In accordance with 1 A NCAC 2C .0118
9. YIELD (gpm):METHOD OF TEST CIA >L'
10. WATER ZONES (depth):
11. CHLORINATION: Type Amount
12. CAT ING:
Wall Thickness
Dept iar? tGr or �e� ighVFt, aterial
From
From To Ft.
From To Ft.
13. GROUT:
Depth " Material � Method
From n To 9— Ft. YL LSX_
From To Ft.
14. SCREEN:
Depth Diameter Slot Size Material
From To Ft in. in.
From Ft. In. __ in.
From RI. W E_ tin. in.
15. SAND/
Depf�, � f Si Material
From •�Y
From In Ft
16. REMA KS: & hraoundill.pllter Section e
c
o
�
J
r- —
It additional space is needed usackv form
LOCATION SKETCH
(Show direction and distance from at least
two State
Roads, or other map reference points)
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.

230445
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 CERTIFICATION N:lt�_ 1
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box) Residential[4 Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ II Other, List Use:
2. WELL LOCATIT: (Show sketch of the localion below)
Nearest Town: `' 1 ? vo lh r County:
�i � Ltl �fC1„ �L DRILLING
(Road Name and Numbers. Community, or Subdivision and Lot No.)
3. OWNER �LG 1 ✓ From To —
Address
trees or oute o. --
City or Town Stale Zip Code
4. DATEDRILLED
5. TOTAL DEPTH OS f f
6. CUTTINGS COLLECTED YES Q NO
7. DOES WELL REPLACE EXISTING WELL? Y S ❑ NO®
B. STATIC WATER LEVEL Below Top of Casing: —71)_ Fr -
(use -+- it Above Top of Casing)
9. TOP OF CASING ISFT. Above Land Surface'
'Top of casing terminated atior below land surface requires a variance In accor-
dance with 15A NCAC 2C.0118 METHOD OF TEST
10. YIELD (gpm): �_
11, WATER ZONES (depth):
DEPTH
Formation Description
12. CHLORINATION: Type Amounl It additional space is needed use back of form
13. CASING: LOCATION SKETCH
Wall Thickness
Depth D'artleter or Wei ht/Ft. fAalleenna ,, (Show direction and distance from at least two to e
r Ft. 1 — Roads, or other map reference points)
From To r , G
From To Ft.
From -To Ft, Lti 2d
14. GROUT:
Depth Material Method
From To 2J Ft.
From To Ft..
15. SCREEN: J
Depth Diameter Slot Size Material
From —To — Ft _ in. —in.
From To —Ft. _ in. — in.
From — To _ Ft. _ in. —in.
16. SAND/GRAVEL PACK: Val 3
Depth Size Material . t, 0
From To FL ----��yy
From To
FL N ( d
17. REMARKS:
CE
I DO HEREBY CERTIFY THATTHISWELT LiAACOPY OFT THIS RECORD HAS BUCTED IN EEN PRIOVIDED TO THE WELL OWNER.
CONSTRUCTION STAN,QFyE]QS(�.�Af1ppD- / �Il rize Z)
It Il r 2
i i 1E.
FOR OFFICE U — DATE
Quad No: I '.!SIGNATURE OF PERSON CONSTRUCTING THE WELL
A If w�gullmd ongirlaj to Division of Water Quality, Groundwater Section Within 30 days GW IREV. 17199
11 11''II
Serial No.
J
grggn ate 711on t
Ashevi''

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONTRACTOR: We
---Z
WELL CONTRACTOR CERTIFICATION #: / S%
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Boxy ResidentialZ Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection L] Other M If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: CR�Pn or rii-C County: CSC
SOC6 DEPTH
(Road Name m
d Numbers. Community, or Subdivision and Lot No.) DRILLING LOG
3. OWNER
r L t From To Formation Description
h.�
WELL CONSTRUCTION RECORD
Address
trees or outs o.
City or Town State Zip Code
4. DATEDRILLEO �1`�' yZV—�7yC0
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑ NOELI 7. DOES WELL REPLACE EXISTING WELL? 'TES ❑ NOQ
6. STATIC WATER LEVEL Below Top of Casing: )-6 0 FT.
(Use': it Above Top of Casing)
9. TOP OF CASING ISFT. Above Land Surface'
-Top of casing terminated atior below land surface requires a variance In accor-
dance with 15A NCAC 2C .0118
10. YIELD (gpm): q-y4.-- METHOD OF TEST
11. WATER ZONES (depth):
12. CHLORINATION: Type
13. CASING:
Depth Qiameter
FromTo Ft. fil VA/
From To Ft.
From To Ft.
14. GROUT
Amount
220773
r-,
It additional space is needed use back of form
LOCATION SKETCH
Wall Thickness
or Weight/Ft. Material (Show direction and distance from at least two Slate
' Roads, or other map reference points)
Depth
Material Method
I
Q.D_Ft.
�LItt2C�kC4_t.,
From
To
From
To
Ft.
15. SCREEN:
Depth
Diameter Slot Size Material
From _To
_
Ft
— in. —in.—
From _
To _
Ft.
— in. — In.
From —To
_
Ft.—
in- — in.
16. SAND/GRAVEL PACK:
Depth
Size Material
From
To —FL
—
From
To
Ft.
17. REMARKS:
I DO HEREBY NSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCT Al T D D A OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER. ERi 2���
U
FOR OFFICE I N4Yl IGNATURE O PERSON CONSTRUCTING THE WELL DATE
Quad No:
JbI rn to Division of Water Quality. Groundwater Section within 30 days GW 1 REV 12I99
Serial No.

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
ort"I CNS to g-u
WELL CONTRACTOR: �
WELL CONTRACTOR CERTIFICATION If: I'52
STATE WELL CONSTRUCTION PERMIT#:
WELL CONSTRUCTION RECORD
220772
1. WELL USE (Check Applicable sox): Residential ❑ Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other 1p If Other, List Use:
2. WELL LOCATI( R. (Show sketch of the location below) ��
Nearest Town: C W!k Dk- a 0,L-- County:
(Road Namey��nd�� Ne,u1mbers,�Cpmmu tt , or Subdivision a d Lot No.) DRILLING LOG
3. OWNER F ti1J lI L� 1 �A�-1 `Sf Ut L C-1- From To
Address
(Streator oute o.
City or Town State Zip Code
4. DATE DRILLED 1 !J-3S- ul0
5. TOTAL DEPTH h b�i %d'
6. CUTTINGS COLLECTED YES ❑ N0[g
7. DOES WELL REPLACE EXISTING WELL? YES NO®
8. STATIC WATER LEVEL Below Top of Casing: �_ FT.
(Use -+- II Above Top of Casing)
9. TOP OF CASING ISFT. Above Land Surface'
-Top of casing terminated atior below land surface requires a variance In accor-
dance with 15A NCAC 2C.0118
10. YIELD (gpm): -AD METHOD OF TEST
11. WATER ZONES (depth):
12. CHLORINATION: Type Amount
13. CASING:
Wall Thickness
Depth Diameter or Weight/Ft. Material
FromTo 521 Ft. 'ON
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From �_ To —)'U Ft. SAJJd 1
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. K 4A
16. SAND/GRAVEL PACK:
Depth Size Material f l o
From To Ft. p I
From To Ft.
17. REMARKS:
Tw- WE t w S CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
I DO HEREBY CERTIFY THF��-- A
CONSTR )D(�1D6, )(�1D�{HAY A, COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER • 2 �
FOR EONLY U u s il'` DATE
Quad No: 1 i i U SIGNATURE OF PERSO CONSTRUCTING THE W Ell
RL-! S o'ginal to Division of Water Quality, Groundwater Section Within 30 days GW 1 REV. 12J99
Serial No.
DEPTH
Formation Descdption
---------------
W r;
Co
n
If additional space is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least two Slate
Roads, or other map reference points)
A�If�

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section 220774
h
1636 Mail Service Center - Raleigh, N.C. 27699.1636-Phone [phone] ! �}
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION #: t
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (check Applicable eox): Residential Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ OtherE3 If Other, List Use:
2.
3.
WELL LOCATION, (Show sketch of the location below) --l—ne-ts I
Nearest Town: F vt� ��' C - County: Yl/
g/U It) DRILLING LOG
(Road Name and Numbers, Community, or Subdivision and Lot No.)
OWNER R I ct, .sht/, * From To
Address
treat or oute o.
City or Town Stale Zip Code
4. DATE DRILLED��
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑ NO[
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NOQ
B. STATIC WATER LEVEL Below Top of Casing: _L.,) FT.
(Use'+' it Above Top of Casing)
9. TOP OF CASING ISFT. Above Land Surface-
-Top of casing terminated at/or below land surface requires a variance In accor-
dance with 16A NCAC 2C .0116
10. YIELD (gpm):::Fi) METHOD OF TEST
11. WATER ZONES (depth):
DEPTH
Formation Description
12. CHLORINATION: Type Amount If additional space is needed use back of for _
13. CASING:
LOCATION SKETCH w
Wall Thickness '--
Depth Diameter or Weight/R. alerial (Show direction and distance from at least two C Dte
From I To � Ft. i`—"— Roads, or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From _J­ To 0—Ft.
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From _ To _ Ft _ in. _ in.
From —To —Ft. in. _ in. oQ,
From _ To _ Ft. in. — in. Ur
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
17. REMARKS:
I DO HEREBY FV THAToT,I-�$„IELL WAS. CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCT T,}�JD�PD@, AINDI AT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
s V L5 Q-/ram L
FOR OFFICE NLY j�gIGNATURE OF PERSON CONST CTING THE WELL DATE
Quad No: t li r �V�(,
Submt fOGr"P'lo Division of Water Quality. Groundwater Section Within 30 days GW 1 REV. 12199
Serial No. — I

215373
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] S
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION #: Z
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 ( Orr J-­QeI , A)'C— County: -
al, �r 3 t �' Rd: DRILLING LOG DEPTH
(Road Name and Numbers. Community, or Subdivision and Lot No.) Formation Description
3. OWNER I�t'Y.y 11�'G %l-4aof_`�-Q From To
Address
(Street or Route No.)
City or Town State Zip Code
4. DATE DRILLED '0,4el
5. TOTAL DEPTH ! S J:f --
6. CUTTINGS COLLECTED YES ❑ NO®
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO®
8. STATIC WATER LEVEL Below Top of Casing: __g'_ FT.
(Use'+' it Above Top of Casing)
9. TOP OF CASING ISFT- 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): .t.Lk— METHOD OF TEST
11. WATER ZONES (depth):
12. CHLORINATION: Type Amount
13. CASING:
Wall Thickness
Depth Diameter or Weight/Ft. Male
FromTo� Ft. 74
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From _-t— To
From —
15. SCREEN:
From
To Ft.
Depth Diameter Slot Size Material
—To—Ft— in. —in.-
From —To _ Ft. — in. — in.
From _To Fl.— In. —in.
16. SAND/GRAVEL PACK:
Depth Size Material
From To —Ft. -
From To Ft.
17. REMARKS
mop
It additional space is needed use backRVorrri—,
�D ;T
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 OWN
( Xp.� �iAOOor
FOR OFFICE USE (1 hiLY DATE
Quad No: ` ' _ SIGNATURE OF P RSION CONSTRUCTING THE W ELL
Submit original to Division of water Quality. Groundwater Section within 30 days GW I REV. 12/99
Serial No.

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
SL
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION #:_
STATE WELL CONSTRUCTION PERMIT#:
n 1 i "i (�
1. WELL USE (Check Applicable Box): Residential Municipal ❑ ❑ Industrial Agricultural El
Monitoring ❑
Recovery ❑ Heat Pump Water Injection Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: r I", County:
21
(Road Namur` Numbers, Cgqommuniry. or Sugtlivision and Lot No.) DRILLING LOG
DEPTH
3. OWNER M V 1Yri�A From To Formation Desciption
Address
(street or Houle o.
City or Town Stale Zip Code
4. DATE DRILLED
5. TOTAL DEPTH 4 DO T T
o
6. CUTTINGS COLLECTED YES Q NO®
O® o
7. DOES WELL REPLACE EXISTING WELL? YES NO(P
8. STATIC WATER LEVEL Below Top of Casing: 1 FT.
(Use '+' it Above Top of Casing)
9. TOP OF CASING ISFT. Above Land Surface'
-Top of casing terminated at/or below land surface requires a variance In actor-
c
dance with 15A NCAC 2C.0118
10. YIELD (gpm): C,21 METHOD OF TEST
r
N
11. WATER ZONES (depth):
O
J
O
12. CHLORINATION: Type Amount If additional space is needed use back of form
13. CASING:
LOCATION SKETCH
Wall Thickness
Depth Diameter or Weighs/R. Material (Show direction and distance from at least two plate
l
From ( To C: Ft. o y' U C" Roads, or other map reference pointsi: I N
From To Ft. C1
From To Ft. Q nfo�p~
14. GROUT:
Depth Material ethod U(h 1 5
From �— To h Ft. �A-�-1 �� C ne 3 bf)"
From To Ft.
15. SCREEN:
Depth Diameter
From _ To _ Ft _ in.
From —To _ Ft.— in.
From _ To _ Ft. _ in.
16. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To Ft.
17. REMARKS:
Slot Size Material y�
in. �
in.
in.
Material
K
I DO HEREBY CERTIFY THATTHI$,WELtWAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDAR,06; AND 1t1AT.A COPY OnFTHIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY B
Quad No: � I I i-ttjU , (�.: SIGNAT�R@ OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Divi iorrdlWaterOualily, Groundwater Section Within 30 days
Serial No..,,,,. GW-1 REV. 12199
s
4 J.
'eM

215374
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]
56
WELL CONSTRUCTION RECORD WELL CONTRACTOR -CERIFICATION #: iCi 7 Z
STATE WELL CONSTRUCTION PERMIT#:
Residential ®
Municipal ❑
Industrial ❑
Agricultural ❑ Monitoring ❑
1. WELL USE (check Applicable sox):
Recovery ❑ Heat Pump Water Injection ❑
Other ❑
If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: P i.�l r �" County:
rI �, Saco MZA- DRILLING LOG DEPTH
(Road Name and Numbers. Community, or Subdivision and Lot No.) Formation Description
tom'
3. OWNER ' �&a 0e_V 1ri X-TJ&e-7, — From To
Address
beet or oute o.
City or Town Stale Zip Code
4. DATE DRILLED
5. TOTAL DEPTH T
6. CUTTINGS COLLECTED YES E] NOEt
7. DOES WELL REPLACE EXISTING WELL? YES NO�(]
8. STATIC WATER LEVEL Below Top of Casing: _� FT.
(Use '+' if Above Top of Casing)
9. TOP OF CASING ISFT. Above Land Surface'
'Top of casing terminated atfor below land surface requires a variance in accor-
dance with 15A NCAC 2C 0118
10. YIELD (gpm): D METHOD OF TEST
11. WATER ZONES (depth):
12. CHLORINATION: Type Amount
13. CASING:
Depth Diarr1qter
FromToFt.
From To Ft.
From To Ft.
14 GROUT:
Wall Thickness
or Weight/Ft. Material
Depth
Material Method
'�
To Ft.
4A&A 1k�Jd (.0 e
From
_�)­D
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 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
CONSTRUCTIOM,STANDA€tD% AND THAT A COPY OF THIS RECORD HASBEEN FROVIDED TO THE WELL OWNER.
FOR OFFICE U"NL DATE
§IGNATUREO PERSON CONSTRUCTING THE WELL
Quad NO:Submit gdginfdl to Division of Water Quality, Groundwater Section within 30 days Gw i REV. 17199
Serial No• ..<.....

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
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 LOCATION: (Show sketch of the location below) TMS61r�
Nearest Town: -'r Q rr i-G County:
(Road Name and Numbers, Community, or Subdivision and Lot No.)
3. OWNER i'AY-6 LI �5U-NbN
Address
(street or outs o.
-- City or Town �^/// State zip Noce
4. DATE DRILLED_, -11-
5. TOTAL DEPTH 00 Fir
6. CUTTINGS COLLECTED YES 0 NO®
7. DOES WELL REPLACE EXISTING WELL? YES NO©
8. STATIC WATER LEVEL Below Top of Casing: FT.
(Use -*' if Above Top of Casing)
9. TOP OF CASING IS � FT. Above Land Surface'
*Top of casing terminated at/or below land surface requires a variance In accor-
dance with 15A NCAC 2C .01IS
10. YIELD (gpm): METHOD OF TEST
11. WATER ZONES (depth):
12. CHLORINATION: Type Amount
13. CASING:
Wall Thickness
Depth
OjArneter or Wei ht/Ft. Material
From To Ft.�
From To Ft.
From To Ft.
14. GROUT:
Depth
Material Method
�_ Ft.
Ci7W L �!
From To ,
From To Fl.
15. SCREEN:
Depth Diameter Slot Size Material
From —To—Ft
_ in. —in.-
From _ To _ Ft.
_ in. _ In.
From —To _ Ft.
_ In. —in.
16. SAND/GRAVEL PAGKi—
,
_.. • a _..1_,
From To ° u Ft.
From To Fir
17. REMARKS:
I DO HEREBY CERTI - T
CONSTRUCTION ST
FOR OFFI�YSf Fly,
Quad No:
Serial No.
Agricultural ❑ Monitoring ❑
DRILLING LOG DEPTH
From To Formation Description
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)
iut
'k
n�
4
ED IN ACCORDANCE WITH 15A NCAC 2C, WELL
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
J
ri
SIGNATURE OF PERSON CONSTRUCTING THE WELL 'VA i t
Submit original to Division of Water Quality, Groundwater Section within 30 days GW 1 REV, 12199
Y�

North Carolina - Department of Environment and Natural Resources - Division of Water Duality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELLCONTRACTOR CERhlktA0 f5 :�(g4 7/lnvS
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residentialyu Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water injection ❑ Other ❑ If Other, List Use:
2.
a
Agricultural ❑ Monitoring ❑
WELL LOCATION- (Show sketch of the location below) �1
Nearest Town: I�� rQY}N�C• County: 1:IAlrrgl
�—
(Road Name and umbers, Community, or Subdivision and Lot No.) DRILLING LOG
l OWNER Av 1 , `3a± dbJ From To
Address b1h 4, o rt/G
tree, or Ftoutatfo. —
City or Town ,�-' �Sttate Zip Code
J 4. DATEDRILLED.._L-d�>
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES 0 NO®
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NOZ
8. STATIC WATER LEVEL Below Top of Casing: 3<— FT.
(Use'+' it Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface'
-Top of casing terminated at/or below land surface requires a variance In accor-
dance with 15A NCAC 2C. 118
10. YIELD (gpm): f METHOD OF TEST
11. WATER ZONES (depth):
12. CHLORINATION: Type
13. CASING:
DEPTH
Formation Description
Amount It additional space is needed use back of form
Wall Thickness
Depth Diameter or Weight/Ft.
From To & 3 FL L—r,,-- —
From To Ft.
From To Ft.
14. GROUT
LOCATION SKETCH
Material (Show direction and distance from at least two Slate
—5IMe Roads, or other map reference points)
Depth Material Method
From I To 2_Ft. Gd-19
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
17
From 101 W j""'"�,r
From To Ft. _
I DO HEREBY CERTIFY THAT THIS
CONSTRUCTION STANDARDS, AN
FOR OFFICE USE ONLY
Quad No:
Serial No.
CAIRz
IST{}UCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
OF THIS RECORD HAS BEEN PROVIDED TO THE WELL 0
SIGNATURt OF PERSON CONSTRUCTING THE WELL
Submit original to Division of Water Quality, Gmundwaler Section within 30 days
.S�
/�
DATE
GW4 REV. 12199

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELLCONTRACTOR: Nt-i7bAls
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:
3.
Agricultural ❑ Monitoring ❑
WELL LOCATION: (Show sketch of the location below)
Nearest Town:
1.•ii�af1-C' County: �EiC�SBh�
�hbAL- C�—`'t
(Road Name and Numbers, Community, or Subdivision and Lot No.) DRILLING LOG
OWNER n'aLit xity,-T- From To
Address < ier N•c, —
ireet or oute o. —
Cityor Town State Zip Code
4. DATE DRILLED"'
5. TOTAL DEPTH 936 A�
6. CUTTINGS COLLECTED YES Q NO®
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO®
8. STATIC WATER LEVEL Below Top of Casing: �T6 FT.
(Use'+' if Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface'
-Top of casing terminated at/or below land surface requires a variance In accor-
dance with 15A NCAC 2C . 118
10. YIELD (gpm): 1, METHOD OF TEST
11. WATER ZONES (depth):
12. CHLORINATION: Type Amount
13. CASING:
I
14.
15.
16.
17.
Wall Thickness
Depth Diameter or Weight/Ft. Material^
DEPTH
Formation Description
It additional space is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least two State
CONSTRUCTION STANDARDS, AND THAT A COPY Ot• I nls\ w, v n� ���• • -•�-• • - • - - -- �_ �i �d��1
FOR OFFICE USE ONLY
Quad No:
Serial No.
t7liGNATURE-d PERSON CONSTRUCTING THE WELL
Submit original to Division of Water Quality, Groundwater Section within 30 days
DATE
GW-1 REV. 12199

North Carolina -Department of Environment and Natural Resources -Division of Water Quality -Groundwater Section - rr I O
1636 Mal Service Center - Raleigh, N.C. 27699.1636-Phone [phone] r t
WELL CONSTRUCTION RECORD WELL CONTRACTOR: tit, n, I I �1 J) ., r10 I I C,
WELL CONTRACTOR CERTIFICATION #:_
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential 0- Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town:—--+1v:2- 2 C County:- J0
(Road Name and Numbers, Convnunity, or Subdivision and Lot No.)
3. OWNER _ d� e v.,a
Address �� L'9 rxA' / [/ -j
�5frost or ou a o.
l 2 (/(_ ) c�
City or Town S ale Zip Code
4. DATE DRILLED
5. TOTAL DEPTH /3
6. CUTTINGS COLLECTED YES Q N0E�`
7. DOES WELL REPLACE EXISTING'WELL4 YES . NOF-1
B. STATIC WATER LEVEL Below Top of Casing: zo -) FT.
(Use'': II Above Top of Cuing)
9. TOP OF CASING IS�_ FT. Above Land Surface*
'Top of casing terminated aVor below land surface requires a variance In accor-
dance with 15A NCAC 2C.0118
10. YIELD (gpm): 'L METHOD OF TEST I
11. WATER ZONES (depth):
DRILLING LOG DEPTH
From To Fonnadon Description
12. CHLORINATION: Type It t 14 Amount •- -t-'-L
It 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 Stale
From To `''
Ft. ___iL_ . lky P ciP .
Roads, or other map reference points)
From To
Ft.
From To
FL
14. GROUT:ZZ
c'
Depth
Material Method,
Cj
C
From _.(` To ,.�,_\
Ft. n rt,i, d.,�T i—
2..
c�
fir
From To —Ft.
15. SCREEN:
�
E5,
Depth Diameter Slot Size Material
�.
From —To—Ft—
in. _ in.
From To _ Ft.
_ In. _ In.
From To _ FL_
In.
w
16. SAND/GRAVEL PACK:
—in.
%.0
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 COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Quad No: SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Soria No. Submit original to Division of Water Quality, Groundwater Section Within 30 days
GW1 REV. 12/99

North Carolina - Department of Environment and Natural Resources - Division of Water Quality • Groundwater Section h .. 5 6 04
1636 Mal Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: �I1it 5
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: &) r' hi¢ P P County: C, Uh
(Road Name and�Jumbers, Communiry,or Subdivision and Lot Na.) DRILLING LOG DEPTH
3. OWNER C(9-A a4From To Fom'.aJon Description
Address ,I�,I
�twreei or 119ule o.
l�r(�hS�P✓ � G �. 87�S
City or Town State Zip Code
4. DATE DRILLED ��7,a�J
5. TOTAL DEPTH SLt A
6. CUTTINGS COLLECTED YES❑ NOEJ--
7. DOES WELL REPLACE EXISTING WELL? YES NO�
8. STATIC WATER LEVEL Below Top of Casing: .�,.'�i f1 FT.
(Use's it 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.0118
10. YIELD (gpm): _Z METHOD OF TEST h1101 r 1
11. WATER ZONES (depth): ;/
12. CHLORINATION: Type It t N Amount It additional space is needed use back of form
13. CASING:
Wall Thickness LOCATION SKETCH
Depth Diameter Diameter or Weight/Ft. Material (Show direction and distance from at least two State
From L� To 5Ft. —( ' /;-V ✓? I/? . Roads, or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From To Zlit Ft. 0 1',):. o,11
From To Ft.
15. SCREEN:
Depth
From
To
From —To
—
From —To
16. SAND/GRAVEL PACK:
Depth
From
To _
From
To_
17. REMARKS:
Diameter Slot Size Material
Ft _ in. _ in.
Ft._ in. _ in.
Ft._ In. in.
Ft.
Ft.
Size Material
O
O
S
e
rV
rV
rn
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.
/^ I
FOR OFFICE USE 6zt��.Y l I { �r�t�Cr/� 2 � 7— ov
Quad No: SIGNATURE SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
... SuLvrdl original to Division of Water Quality, Groundwater Section within 30 days
Sedal No. GW-1 REV. 12/99
v
0
c

North Carolina - Department of Environment and Natural Resources - Division of Water Qualiry, - Groundwater Section c. ,�- ) 0 3
1636 Mal Service Center - Raleigh, N.C. 27699.1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: I Pl'1 I) i4i il�
WELL CONTRACTOR CERTIFICATION #:_
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential 0- Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
RecoveryHeat Pump Water Injection 0 Other M If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: A ,
County: & (/C C o
(Road Name and Numbers. Convnunity, or Subdivision and Lot No.) DRILLING LOG
3. OWNER )L k-) r-) C From To
Address 3 L; ltle SA_ v ri h Cr /C /^
ule
treat or oo.
City r Town O State Zip Code
4. DATE DRILLED X - -/ - UZ-'
5. TOTAL DEPTH -70. 5
6. CUTTINGS COLLECTED YES Q. NOE�i-
7. DOES WELL REPLACE EXISTING WELL? YES NOF]
8. STATIC WATER LEVEL Below Top of Casing: FT.
(Use'-+' If Above Top of Casing)
9. TOP OF CASING IS�_ FT. Above Land Surface -
'Top of casing terminated at/or below land surface requires a variance In accor-
dance with 15A NCAC 2C .e11 a
10. YIELD (gpm): ,S METHOD OF TEST
11. WATER ZONES (depth):
12. CHLORINATION: Type H 1)4 Amount
13. CASING:
Depth Wall Thickness
C P Diameter or WeighvR. Material
From To 77 Ft. (,--. ,/k-y P'tiP.
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method� ,
From _� To ,Lt\ Ft. n Liiu ,.,, i -P
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From _ To _ Ft _ in. —in.—
From _ To _ Ft. _ in. _ In.
DEPTH
Formation Description
If additional space is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
Q
O
From _ To _ Ft. _ In. _ in.
16. SAND/GRAVEL PACK:
Depth Size Material N
From To Ft. N
From To Ft.
17. REMARKS:
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
FOR OFFICE USE ONLY
Quad No:
Serial No.
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Quality, Groundwater Section Within 30 days
GW-1 REV. 12199

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section 1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone] \\ L 1) p J g 7
WELL CONSTRUCTION RECORD WELL CONTRACTOR: LI:21I �''• 4
WELL CONTRACTOR CERTIFICATION #: / `7 �• a
STATE WELL CONSTRUCTION PERMIT#:
�
1. WELL USE (Check Applicable Box): Residential ET Municipal ❑ Industrial ❑ Agricultural
❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: , ✓el County: J G LI C
(Road Name and Numb:jco—uup/ity, or Subdivision and Lot No.) DRILLING LOG
DEPTH
3. OWNER �C_vJ %t" /Pubum�--eE71� From To
Fom',ation Desenp:iw
Address r Q Irrl r V
trees or oule o.
Wc, g% 3
1
City or Town Stale Zip Code
4, DATE DRILLED
2
S. TOTAL DEPTH 20?'S
n
6. CUTTINGS COLLECTED YES Q NO[D--
.
7. DOES WELL REPLACE EXISTING WELL? YES NO❑
S. STATIC WATER LEVEL Below Top of Casing: FT.
_--
(Use *.'If Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface-
ko
-Top of casing terminated atfor below land surface requires a variance In accor-
dance with 15A NCAC 2Q 118
YIELD (gpm): Qn METHOD OF TEST '� r/ ' 1
-J ES10.
11. WATER ZONES (depth): 1_� r
12. CHLORINATION: Type Jt 1` N Amount `�lr It 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 Slate
From To t" Ft. Roads, or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From _ '� To .�� Ft. 0 r',n, o ,ai
From To Ft.
15. SCREEN:
Depth Diameter
From _ To Ft in.
From To Ft. in.
From _ To Ft. In.
16. SAND/GRAVEL PACK:
Depth Size
From To Ft. From To Ft. _.
17. REMARKS:
Slot Size Material
_ in.
In.
in.
Material
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A /C�OOPPY OF THIS RECORD HAS %BEEEN PROVIDED TOO THE
�1WELL OWNER.
0
SIGNATURE OF PERSON CONSTRUCTING THE WELL
Submit original to Division of Water 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
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:lel)n -r 5lla , C/'C'il f); rilt�ai Tl1 c
WELL CONTRACTOR CERTIFICATION #: .� / %G•
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) /
Nearest Town: ry
(Road Name and Numbers, Community, or Subdivision and Lot No.) DRILLING LOG
3. OWNER hi; If-, r,ri I 0 r3 '1'S6XJ From To
Address [:�� �� 1_ C[ '7
—d—'-(Street ! lute o.
CcS7/7
City or Town Slate Zip Code
4. DATE DRILLED L = -LD
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES 0 NO[D--
7. DOES WELL REPLACE EXISTING WELL? YES NO CJ-
8. STATIC WATER LEVEL Below Top of Casing: ,Zi FT.
(Use •: it Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface'
'Top of casing terminated atfor below land surface requires a variance In accor-
dance with 15A NCAC 2C .0118
10. YIELD (gpm): METHOD OF TEST /
11. WATER ZONES (depth): 0
12. CHLORINATION: Type P-/ /V Amount
13. CASING:
Agricultural ❑ Monitoring ❑
DEPTH
Formation Description
If additional space is needed use back of form
Wall Thickness LOCATION SKETCH
Depth Diameter or Weight/Ft. Material (Show direction and distance from at least two State
From— To —1- Ft. /_ _ / Roads, or other map reference points)
From To Ft.
From To Ft.
14. GROUT
Depth Material Method
From To -f)!' Ft. 2L_U, 2
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:
! AUG 1 0
t
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.
FOR OFFICE USE ONLY ^ (J�
/'/' I ,Jr ff//J a G / 3y
Quad No: SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Quality, Groundwater Section Within 30 days
Serial No. GW-1 REV. 12/99

'12270
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: �� °nn �f ref) l //ir�ll �Y, li n�,l Tit L
WELL CONTRACTOR CERTIFICATION #: '% G-
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (check Applicable Box): Residential EZ MThicipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: (i,1f/){7<n Af0 County: k 5Lai
1
(Road Name and Numbers. Community. or Subdivision and Lot No.) DRILLING LOG
3. OWNER Me r LL From To
Address lj / `r`)igi 4-
-(Scree! or route Rom— -
City or Town State Zip Code
4. DATE DRILLED L -1 2-0-0
5. TOTAL DEPTH `
6. CUTTINGS COLLECTED YES Q NO©,
7. DOES WELL REPLACE EXISTING WELL? YES F1 NOS
8, STATIC WATER LEVEL Below Top of Casing:, Ff.
(Use': it Above Top of Casing)
9. TOP OF CASING ISFr. Above Land Surface'
'Tap of casing terminated atlor below land surface requires a variance in accor-
dance with 15A NCAC 2C .0118
10. YIELD (gpm): > METHOD OF TEST _
11. WATER ZONES (depth): %C
12. CHLORINATION
13. CASING:
Type y-t // Amount 4/ /'�
Wall Thickness
Depth Diameter or Weight/Ft.
From To 5 Ft. /- , /,F 5
From To Ft.
From To Ft.
14. GROUT:
Agricultural ❑ Monitoring ❑
DEPTH
Formation Description
If additional space is needed use back of form
LOCATION SKETCH
Material (Show direction and distance from at least two State
Roads, or other map reference points)
Depth Material Method
From To Ft. ��r—�� �/�'
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From _ To _ Ft _ in. in.
From _ To — Ft. — in. in.
From —To —Ft. _ in. in.
16. SAND/GRAVEL PACK:
17
Depth Size Material
From To Ft.
From To Ft.
n
I 1�16
17
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF HIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY /�/,n n / -cam
Quad No:
Serial No.
SIGNATURE OF PERSON CONSTRUCTING THE WELL
Submit original to Division of Water Quality, Groundwater Section within 30 days
DATE
GW-1 REV. 12/99

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: '1)61n h 1 A� ))g, ci 0; eiI
WELL CONTRACTOR CERTIFICATION #: S E `� 0
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential ❑--�Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: �) (' �% t--� Couny: ')` (-1� S t`y�
(Road Name \and Numbers, Community, or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER _ l )fC) V '(0 1" 1(! . F From To Formation Description
Address /U Q U %; 7-n l le L 19
w,y,v, J 0. Jlala L p Voue
4. DATE DRILLED •�: % 01-2
5. TOTAL DEPTH a/'
6. CUTTINGS COLLECTED YES ❑ NOEE�-'
7. DOES WELL REPLACE EXISTING WELL? YES NO©--
8. STATIC WATER LEVEL Below Top of Casing: / FT.
(Use'+' 0 Above Top of Cuing)
9. TOP OF CASING ISFT. Above Land Surface'
'Top of casing terminated at/or below land surface requires a variance In accor-
dance with 15A NCAC 2C.01/8
10. YIELD (gpm): _? 5 METHOD OF TEST 1 c a
11. WATER ZONES (depth): /7/'
12. CHLORINATION: Type // /-N Amount /' /17 If additional space is needed use back of torte -n-r
13. CASING:
x
Wall Thickness
Depth ` Diameter or Weight/Ft. Material
FromTo J/ Ft.
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From To .20 Ft. n 67) P nT I t t4
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft in. _ in.
From _ To Ft. _ In. _ In.
From —To Ft. In. —In.
16. SAND/GRAVEL PACK:
17
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
I DO HEREBY ERTL_Y TNATTHIS WEI t Wd C STRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTI N STANI 91dbIMR1311ftW A COP QF,THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY f � 4 141LL ' '� + —11
Quad No: SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
)1 Submit original to Division of Water Quality, Groundwater Section within 30 days
Serial No. I" A �' '1' J GW-1 REV. 17/99

North Carolina - Department of Environment and Natural Resources - Division of Water Duality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: J-) el)(); S 141) 11 01A ILL 11 llv, 11 1�1 L
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 LOCATION: (Show sketch of the location below) t
Nearest Town: S / v &, A. ( C - - County:
(Road Name an�Numbers, Cow i,i or Subtlivision antl Lot No.) DRILLING LOG
3. OWNER /n( G A, , Kf r r', f> i From To
Address /
(Street or oue o. ('
�i- I CA) I/. //'P 4-1/'
City or Town Slate Zip Code
4. DATE DRILLED 'Z
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES❑ NOQ-'
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO©--
8. STATIC WATER LEVEL Below Top of Casing: , ') FT.
(Use'+' 0 Above Top of Cuing)
9. TOP OF CASING ISFT. Above Land Surface*
'Top of casing terminated attor below land surface requires a variance In accor-
dance with 15A NCAC 2C.0118
10. YIELD (gpm): .3U METHOD OF TEST h 1 c u
11. WATER ZONES (depth): ( n
12. CHLORINATION: Type /'1r14 Amount r
13. CASING:
Wall Thickness
Depth /1 Diameter or Weight/Ft. Material
From To Ft.
From To Ft.
From To Ft. _
14. GROUT:
Depth Material Method
From To .(_ Ft. n (P) P nT n n,___ !_t
From To Ft. _
15. SCREEN:
Depth Diameter Slot Size Material
From —To—Ft— in. —in.-
From To Ft. _ in. _ In.
From —To Ft. In. —In.
16. SAND/GRAN .e n nn ra 11
Agricultural ❑ Monitoring ❑
DEPTH
Formation Description
If additional space is needed use back of form
LOCATION SKETCH C
2
(Stow direction and distance from at least two St
n
Roads, or other map reference points)
om
=m
1
oG
tD
yo
Mat
70m
S
fAZ
tv
cr*7A
-1
.�
o
7-
From Ft. A I
From
17. REMARKS:
I DO HEREBYJEF[TltYj�l STRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTIOF THIS RECORD HAS B N PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY C `,
Quad No: SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
f, Submll original to Division of Water Quality, Groundwater Section Within 30 days
Serial No. a" i ;, ,: iJ GW4 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: .41ni10) 5 kr Ilan 4'o!�")1 fir-, 11�� SItL
WELL CONTRACTOR CERTIFICATION #: _ 5c , '7t
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential[2 Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATIO (Show sketch of the location below)
Nearest Town: ( 1-f ,1 t, , I i r : L j� County: S r•
Agricultural ❑ Monitoring ❑
(Road Name andumbers. Communi _ or Sutxfivision and Lot No.)
DRILLING LOG DEPTH
3.
OWNER c A ,. r� t � � i r <". � f-� �
From 7o Formation Description
Address 7 �� ,U „��9-1
. (St'reel or HoutTo.
City or Town State Zip Code
4.
DATE DRILLED ^) 7- t 7
5.
TOTAL DEPTH
6.
CUTTINGS COLLECTED YES ❑ NOED-'
7.
DOES WELL REPLACE EXISTING WELL? YES NO© -
6.
STATIC WATER LEVEL Below Top of Casing: /f7, FT.
9.
(Use '+' II Above Top of Casing)
TOP OF CASING ISFT. Above Land Surface'
'Top of casing terminated et/or below land surface requires a variance In accor.
dance with 15A NCAC 2C.0118
10.
YIELD (gpm): S METHOD OF TEST (
11.
WATER ZONES (depth): -`
12.
CHLORINATION: Type <i tfF Amount 7 r
It 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 h To � Ft. — sL-.S=?L l L'
Roads, or other map reference points)
From To Ft.
From To Ft.
14.
GROUT:
o
Depth Material Method
G
o
From r) To �(" Ft. n EtnF rl -PLO 12_
Z
T �
From To Ft.
cc"i
rn
15.
SCREEN:
1
Depth Diameter Slot Size Material
Do
From —To—Ft— in. —in
_
z�
From _To Ft. in. _ in.
From —To _ Ft._ in. in.
CA
r
cli
16.
SAND/GR
CD
o
z
e Siza Material
From Fl.
�--�
From o "UI�
17.
REMARK
[DO HERE YCl (�H"LL WAS ONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRU ION S1AlA#Il± PY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY �� /�� a n "v j -� I- cn
Quad No: SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Quality, Groundwater Section within 30 days
Serial No. ' GW-1 REV. 12/99

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:) W)'If S Ifi2 i
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: r� l {ir o /l -i c 'C_ County: J t': ( k ti e) k
(Road Name and Numbers, Community, or Subdivision and Lot No.) DRILLING LOG
3. OWNER &r, .a. it tz C'OL4 From To
Address i) ;2/ SJ
r Nreetor outs o.
City or Town slate Zip Code
4. DATE DRILLED 7- 47;
5. TOTAL DEPTH 4fL L
6. CUTTINGS COLLECTED YES ❑ NOED'
7. DOES WELL REPLACE EXISTING WELL? YES NO[�r
8. STATIC WATER LEVEL Below Top of Casing:? FT.
(Use '+' II Above Top of Casing)
9. TOP OF CASING ISFr. Above Land Surface'
-Top of casing terminated at/or below land surface requires a varlance In accor.
dance with 15A NCAC 2C.0118
10. YIELD (gpm):? METHOD OF TEST bly
11. WATER ZONES (depth):
DEPTH
Formation Description
12. CHLORINATION: Type - - Amount If additional space is needed use back of loan
13. CASING:
LOCATION SKETCH
Wall Thickness
Depth
met Diaer or,aWeightt t. Material (Show direction and distance from at least two State
From To J .S
Ft. - =S pp_ - P 0C Roads, or other map reference points)
From
To
Ft.
From
To
Ft.
14. GROUT:
C
Depth
Method
C
From To
nMaterial
)1
Ft. 1• i41e'iPeCG"
y
From
To
Ft.
1
15. SCREEN:
Depth Diameter Slot Size Material
From —To—Ft—
in. —in
From _
To _ Ft.
— in. — in.
C
From —To
—Ft.
_ In. _ in.
CA
CID
16. SAND/GRAVEL PACK:
h—"--e
Material
L�
From
From
To
Ft.
17. REMARK
"i,
I DO HER
Y C RTIFY TH T
W CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRU
TIO fiflB,
HAT A Y OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
devil
�''� .CZ7
FOR OFFIC
E ONLY
Quad No:
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Quality. Groundwater Section within 30 days
Serial No. 0 1 r. "/ .1 , GWA REV. 12199
0
ze
0
c,+1
or
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=m
of
�o
m�
zom
Vfz
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0
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i
I
:onh Carolina • Department of Environment. Health, and Natural Resources
Division of Environmental Management • Grcundwater Section
P.O. Box 29535 • Raleigh, N.C. 27626.0535
Phone [phone]
WELL CONSTRUCTION RECORD
_LING CONTRACTOR:
'_LER REGISTRATION NUMBER: 4)1
WELL LOCATION- (Show sketch of the to catli
Naarast Town:_
(Road, Community, or Subdivision and Lot No.)
OWNER _7;�i?y /iI!'i c, '�,
(Street or Route No.),
n /r�
..I Il � P.
STATE WELL CONSTRUCTION
PERMIT NUMBER:
below)
County:
Ciry or Town State • I Zip Code
DATE DRILLED ' ' -,7-- e USE OF WELL
TOTALDEPTH K_t>'
CUTTINGS COLLECTED •YES❑ NO[;J�'
DOES WELL REPLACE EXISTING WELL? YES N062!
STATIC WATER LEVEL Below Top of Casing:, _�,qo Ff.
(Use 'i it AboveTop of Casing)
TOP OF CASING IS j FT. Above Land Surface'
slag Terminated allcr below land surface Is Illegal unto) s a vadanco IS Issued
accordance with 15A NCAC 20 .0118 '
YIELD (gpm): !n METHOD OFTEST 2
WATER ZONES (depth): S`� �
CHLORINATION: Type
CASING:
Depth
From To -
From To -
From —To -
GROUT:
From �—
From
SCREEN:
Diameter
S % Ft.—
— Ft.
— Ft.
DEPTH DRILLING LOG
Firm To Formadon Descripdon
It additional space is needed use back of form
WaqI'hickness LOCATION SKETCH
or NcknFt. Material (Show direction and distance from at least two State
f.c_r. Roads, or other map reference points)
Depth - Material Method
To -�, Q_Ft. C2menl IprOup
To Ft.
Depth
From
To —
Frcm
To —
From
To _
SAND/GRAVEL
PACK:
Depth
From
To —
From
To_
Diameter Slot Size Material
Ft In. In. -
Ft. ' In. _— In.
Size
FOR dPFlCE USE ONLY:';,i�,, j;'�. r
QUAD. NO.'.
y
•:�:1-::ilr•.��:
4; • SERIAL NO.UL
Minor Basin..
.:: i'.:-:-ii}a1:L�y'!L.•;..
Basin Code
Hoadortnt.
r.GW��nL;.,:.,,-..
O c
arm
:rn
r onyF
3s CD
y�
S N
�v
y2
� rnz
0
2
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
-_ONSTRUCTION STANDARDS, ANQTHATA COPY THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
11..,/7_.(..... &-Qa-07D

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mal Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: I-/�1tn C. N l n ,ra �t en
WELL CONTRACTOR CERTIFICATION #: 5 `7
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential 0�' Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town:r_Cr , i/iaz['11rf . lj�C' . County: C,rr(
(Road Name and Numbers, Community, or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER H r.r iA ern, t )L From To Formation Description
Address jC VO ,
//;�� jStreet or outs o.
�"1� Idi'1111)y'e_ A('_ -2
City or Tom State Zip Code
4. DATE DRILLED R-.'4 7-
S. TOTAL DEPTH 1'
6. CUTTINGS COLLECTED YES Q NO[�J'
7. DOES WELL REPLACE EXISTING WELL? YES ED NOEZJ-�
8. STATIC WATER LEVEL Below Top of Casing: .a an FT.
(Use'« II Above Top of Casing)
9. TOP OF CASING IS j FT. Above Land Surface'
'Top of casing terminated atior below land surface requires a variance In accor-
dance with 15A NCAC 2C.0116
10. YIELD (gpm):1,�IV METHOD OF TEST h%''
11. WATER ZONES (depth):
12. CHLORINATION: Type _Amount r It additional space is needed use back of form
13. CASING:
Wall Thickness LOCATION SKETCH
Depth c. Diameter or Weilht/R. Material (Show direction and distance from at least two State
From_To 1FL ° d e- Roads, or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Material
From L To ;�� n Ft..P r'rrl < P 71
From
To
15. SCREEN:
Depth
From
To _
From —To
_
From —To
_
16. SANDrcoevcl oQ
Ft.
Diameter Slot Size
Ft _ in.
Ft. _ in. _
Ft._ In.
Fro o Ft.
Fro%TRUC
UTJt.
17. RE
I Diln
COA
FOR OFFICE USE ONLY
Quad No:
Serial No.
Method
T
Material
in.
In.
In.
Material
WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
f A CORX OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
SubtrYl original to Division of Water Quality, Groundwater Section within 30 days
GW4 REV. 12199
0
y
D

Nonh Carolina • Department of Environment, Health, and Natural Resources
Division of Environmental Management • Groundwater Section
P.O. Box 29535 • Ralaigh, N.C. 27626-0535
Phone [phone]
WELL CONSTRUCTION RECORD
ILLING CONTRACTOR: ,12nr�, ¢ -, ` ill 1cl Wr,
Lh
ILLER REGISTRATION NUMBER:
WELL LOCATION: (Show sketch of the IOCE
NaarestTown;_ CL/�/�sf�r. ���
i U ':''._'
,FOR dF`FlCE USE ONLY':;?.^:i>;;Fr
OUAO. NO.'
SERIAL NO. •cc�.a. >': w:..:
LJL
Basin Code•
•;w�- r,
Huador Enu' ...
,.. K c^ . t.
STATE WELL UUNS IHUCTION
PERMIT NUMBER:
below)
— County: _cJ( Q i Zl 5 ex—_:,
(Road, convnd Lot No.) or Subdivision a9No.)
0`INER DEPTH
DORESS / l pX /(/ Frcm To
t [ (Sueet or Route No.)
Ciry or Town state
Zip
Code
DATE DRILLED 'VV USE OF WELL
TOTAL DEPTH O�
CUTTINGS COLLECTED •YES❑ NO[�J%
DOES WELL REPLACE EXISTING WELL? YES NO(
STATIC WATER LEVEL Below Top of Casing: �4n (T.
TOP OF CASING IS (Use '+-it Above Top of Cuing)
FT. Above Land Surface
"ng Terminated aucr below land surface Is Illegol unless a variance Is Isavud
ccordanw with 75A NCAC 20 .0119 `
MELD (gpm): <�) - METHOD OF TEST
.'ATER ZONES (depth):
-HLORINATION: Type — t-( i N Amount
.SING: I
DRILLING LOG
Farmadon Description
If additional spaco is needed use back of form
Depth
Wall Thickness
Di
LOCATION SKETCH
=rcm �To �r3
Ft'
lnetar onig t. f.ta,a aI
„.^�_ �
(Show direction and distance from at leas( two State
Roads,
-rcm To Ft.
� _
or other rnap reference points)
=rom To FI.
ROUT:
_
zz
Depth
-rcm ToFt.
Material Method
C6rn r) PDU
Op
�m
-e
o
o
rom To Ft.
C
:CREEN:
r
>m
Depth Diameter
Slot Size Material
a
—r
(Om To Ft -
In, In.
m
' nl To Ft.
In. In.
C3
AND/GRAVE
z
IF�
Material
,cm
'cm
cMARKS:
JO HEREBY C 1 STRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
INSTRUCTION STANDARDS, ANQ,THAT A COPY F THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.

North Carolina - Department of Environment, Heallh, and Natural Rosourcos
Division of Environmental Management - droundwalor Soction
P.O. Box 29535 - Raleigh, N.C. 27626.0535
Phone [phone]
WELL CONSTRUCTION RECORD
LING CONTRACTOR:
LEA REGISTRATION NUMBER:
ELL LOCATION:
:aarest To
)YVNER
.DDRES
sketch of the
(SueeI or Route
QUAD. NO.".
FOR &FILE USE ONLY
SERIAL NO.
Minor Basin
Basin Codo
Hoador Ent' ..,.:....r._,...• i'. .ri>::4r', ..
STATE WELL CONSTRUCTION
PERMIT NUMBER:
:aNgn below)
I—� -- County:
City or Town - St— at —a—"`
Zip Codu
ATE DRILLED lir,1 USE OF WELL 4Z,,�
OTAL DEPTH o fn-
UTTINGS COLLECTED •YES[]
OES WELL REPLACE EXISTING WELL? YES NO(
TATIC WATER LEVEL Below Top of Casing: s Fr.
�? OF CASING IS (Use'.' it Above Top or Casing)
FT. Above Land Surface,
g Tarminatod allor below land surtoco Is Illegal untosa a verloncu Is Isauod'
-ordance with 15A NCAC 2C .o116
=LD (gpm): --D METHOD OF TEST 1��A v� in01
ATER ZONES (depth): 0
DEPTH DRILLING LOG
From To Formadon Description
-iLORINATION: Type -i A Amount 'r
SING: _
It additional space is neadod use back of form
I
Depth Wall Thickness
LOCATION SKETCH
:m--V—To8� ° _ orb °r' t. Material�(Show
direction and distance (Tom at least two Slate
om To Ft
Roads. or othor map rolorence points)
om To FL
b
o
-TOUT:
p
Depth Mater(al M—� elho2d
'm To A-Q_ C 2lnel') j
a
c
�rn
mac,
---�— Ft.
m To Ft.
r
om
no
;BEEN:
S
�m
Depth Diameter Slot Size Material
o
mz
,m To Ft In. In.
y
;m To Ft. In. __ In.
N
_
o
;m To F In Lin
z
ND/GRAVEL P
Dep lerial
m J�N-t 9 2(P�fl
T
HEREBY CERf1P1`1 PiAj15Tt-t SI I IIe�IrRUCTED IN ACCORDANCE WITH 1SA NCAC 2C, WELL
'ISTRUCTION STANDARDS, ANQ.THAT A COPY P THI3 RECORD HAS 8EEN PROVIDED TO THE WELL OWNER.

North Carolina • Department of Environment. Health, and Natural Resources
Division of Environmental Management • Groundwater Suction FOR d!`FlCE USE ONLY
P.O. Box 29535 • Raleigh, N.C. 27626.0535 QUAD. NO..' SERIAL NO.;
Phone [phone]; Lat _
WELL CONSTRUCTION RECORD Minor Basin
Basin Code -" -
LLING CONTRACTOR: <Il n5 `� L)� •� ,t �I HuadorLnt '!.; :-GW
'_LER REGISTRATION NUMBER: q STATE WELL CONSTRUCTION
PERMIT NUMBER:
r/ELL LOCATION: (Show sketch of the
'Jaarest Town: 2
,Road, Community, or Subdivision and Lot No.)
DWNER
',DDRESS��r,. /i' nz C?L,
pN n below)
--T — County: SI, 1
�- (Suael or Route No.)
Uri ofTLwn
Stale Zip Codu
!ATE DRILLED - —.`r— 7T USE OF WELL
OTAL DEPTH _}o S
: UTTINGS COLLECTED 'YES ❑ NOQ%
OES WELL REPLACE EXISTING WELL? YES NO(
TATIC WATER LEVEL Below Top of Casing: FT.
DP OF CASING IS (Use'+' it Above Top of
FT. Above Land Surface•
•g Terminated Wor below land aurfaco Is Illegal unto a a variance Is lasuud
-ordance with 15A NCAC 2C .olle
ELD (gpm): /0 METHOD OF TEST
ATER ZONES (depth): 0
�LORINATION: Type
SING:
DEPTH DRILLING LOG
From To Formation Description
It additional space is needed use back of form
Depth well Thickness LOCATION SKETCH
P Dia Blur or Wu' y> IAa yL,(Show direction and distance from at least two State
om_�_To �� Ft.
Cm To Ft Roads, or other map reference points)
om To Ft.
BOUT: �--
Depth Maternjial I l Method
m——To=CZFt. Ceme(0U2
m To Ft.
,REEN:
Depth Diameter Slot Size Material
:m To Ft In. In.
:m To Ft. In. _
In,
;m To Ft.. in,
r:D/GRAVEL PACK
Depth D
'm To t
m To t. H IN 1 9 2ffl$n
0
O
a
1
r
a
Y
O
cn
b
0
HEREBY CERTIFY AT 7I4Zy�LR WAUhPa l l,(iTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
'.STRUCTION STANDARDS, AN(iTHAT A COPY(P/ THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.

North Carolina - Department of Environment and Natural Resources - Division of Water duality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699.1636-Phone [phone] WELL CONTRACTOR: C h✓ c t J 6A.11,14.4eR 5 j- SG Al
WELL CONTRACTOR CERTIFICA ON #: oZ 43_��1
STATE WELL CONSTRUCTION PERMIT#:
WELL CONSTRUCTION RECORD
211231
1.
WELL USE (check Applicable sox): Residentlal Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring El
Recovery ❑ Heat Pump Water Injection Other []
If Other, List Use:
2.
WELL LOCATION: ( how, s etch of the location below)
5 �-
�ia� y-
Nearest Town: � County.
(Road Name and N—u Community, or Subdivision and Lot No.)
DRILLING LOG
DEPTH
3.
tmpei{,s,
OWNER 10'l hn'S
From To 1/
+1 s7
Formation Descd�j Uon
�UG(L AG✓(lnrt✓
Address {�!.✓ft �� pleA{'s 10b
—(SiFee ar ou a o.
My or Town Slate Zip Code
4.
DATEDRILLED 5''0 -00
S.
6.
TOTAL DEPTH
CUTTINGS COLLECTED YES NO❑
7.
DOES WELL REPLACE EXISTING WELL? YES O N08'
8.
STATIC WATER LEVEL Below Top of Casing: FT.
(Use •+• It Above Tap of Casing)
9.
TOP OF CASING IS FT. Above Land Surface.
'Top of casing terminated atlor below land surface requires s variance In accor-
dance with ISA NCAC 2C.0118
10. YIELD (gpm): S METHOD OF TEST —
11.
WATER ZONES (depth):
12, CHLORINATION:
13. CASING:
Type e:D r L( S Amount- S It additional space Is needed use back of loan
Depth Dameler
From +I To L— Ft.
From To Ft.
From To Ft.
14. GROUT:
LOCATION SKETCH
Wait Thickness
or WelahVFL Mated I (Show direction and distance from at tent two Stale
/4r Roads, or other map reference points)
Depth Material Method t
From Q To 020 Ft. e`r.r�✓'A'
From To Ft.
15. SCREEN:
Depth Diameter
From _To _ Ft In.
From —To _Ft. In.
From _ To _ Ft. In.
1S. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To Ft. _
17. REMARKS:
Slot SIZE -Material
In.
In.
_ In.
Material
O
O �o
L om
rV ca n
L0
r
rn
xCD
f��
V -t
2
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH i5A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COFYOOF �THI 3 RECORD h(pSSBBEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY _�+f^�
Quad No: SIGNATURE OF PERSON CONSTWUSsTfJNG THE WELL _ DATE
Submit original to Division of Water Quality, Groundwater Seauon1vilhkl 30 Serial No. toys + -
t' 'GW-1 REV. 12ng
`.:' -:, _. :�.,. _..._ _ '

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section ,. r
1636 Mail Service Center -Raleigh, N.C. 27699-1636-Phone [phone] ,�//// ti 1 I! 3 `j 8
WELL CONSTRUCTION RECORD WELLCONTRACTOR: e1vle-
WELL CONTRACTOR CERTIFICATION #: S%3L
STATE WELL CONSTRUCTION PERMIT#:
1-
WELL USE (check Applicable Box): Residential _IyI"nfcfpal ❑
Industrial Agricultural ❑ Monitoring ❑
Recovery ❑ Heal Pump Water Injection ❑ Other EJ
If Other, List Use:
�.
WELL LOCATION(Show sketch of the location below)
Nearest Town: - Uy U a County. �) _ a
c 4%SOSN
(Road Name
N//umoera, Co or Subdivision and Lot No.)
DRILLING LOG DEPTH
3.
))and
OWNER Jf'rvLr.w j=n 0h�
From To FormallonDescripllon
Address
-f 9 D
---------- 17SIreol of Houle o.
City or Town Stale Zip Code
%— -,) 4
4.
DATE DRILLED
-
5.
TOTAL DEPTH S D-5
6.
CUTTINGS COLLECTED YES
CDNO❑
7.
DOES WELL REPLACE EXISTIN WELL? YES NOUO
B.
STATIC WATER LEVEL Below Top of Casing: 2e FT.,"_
(Use'+' If Above Top of Casing)
9.
TOP OF CASING IS FT. Above Land Surface'
CD
*Top of casing terminated attor below land surface requires a variance In accor-
dance
to.
with 15A NCAC 2.0 16
YIELD (gpm): M METHOD OF TEST
11.
WATER ZONES (depth):
12.
CHLORINATION: Type Amount
ED
It additional space Is needed use back of form
13.
CASING:
Wall Thickness LOCATION SKETCH
t / Depth of eler or Welghl/rl. Material (Show direction and distance from at least Iwo Slate
From _Z_L—To c Ft. - — 1/-V Roads, or other map reference points)
From To FL
From To FL
14. GROUT:
Depth Material Method
From To FI. Ll�+'va 6aKC
From To Ft.
15. SCREEN:
Depth Diameter
From —To _ Ft In.
From _ To Ft. In.
From _ To Ft. In.
16. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To FL
17. REMARKS:
Slot SIZE - fslaterial
_ In.
In.
In.
Material
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C. WELL
CONSTRUCTION STANDARDS, AND THAT A COPY F THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY ,rt r/ ^31^O
Quad No: SIGNATURE OF PERSON R&ST5LICTING THE WELL DATE
Submit original to Division of Water Quality, Groundwater Section within 30 days
Serial No. OW-1 REV. 12199
I H iii'

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 CONTRACTOR CERTIFICATION #:_
STATE WELL CONSTRUCTION PERMIT#: _
TA'f [a2
091
1, WELL USE (Check Applicable 80.): Residential Municipal ❑ Industrial ❑ AgricuVural ❑ Moniloring ❑
Recovery ❑ Heat Pump Water Inection ❑ Other ❑ It Other, List Use:
2.
WELL LOCATION: (Sho•r+ sketch of the location belov,)
Town: Savor County:
Nearest
L C'erT Nee v3oc p 21D- _
(Road Name and Numbers, Community, ar Subd:Msicn and Lot No.)
DRILLING LOG
3.
OWNERMAVpNVE �':/4 F�
From To
To
Address 'P.O-;5F
Duce er ou:e ve.)
5y VA Nc, Z 7�9
5y S3
laity or Town Slate Ip 'Ode
4,
DATE DRILLED
�j 'a
5.
TOTAL DEPTH 3e
6.
CUTTINGS COLLECTED YES© NO❑
7.
DOES WELL REPLACE EXISTING \TELL? YES NO;.
8,
STATIC WATER LEVEL Below Top of Casing: _ FT.
(Use '+' II Abovo Top of Cac:nq)
9.
TOP OF CASING IS FT. Above Land Surface'
-Top
of casing terminated sVor below land sur'aao requires a variance In accor-
darce
with 15A NCAC 2C .0118 -
10.
YIELD (gpm): (o NIETHOD OF TEST 1%(0
11.
WATER ZONES (depth): /-/5-G 5- cif _
12. CHLORIN.ATIOFJ:
13. CASING:
DEPTH
Fcrmalion Descr.plicn
G--^ram o
CO `p
Typeadd;aona; spice Is ne,ded use back of form
Depth Dlcmcicr
Frcm-C-) To - Ft. Gw
From To FI.
From To-- Ft.--
14, GROUT:
LOCATION SKETCH
Y!a'171Jcir.css
orl'lely"': I't. Limerizl (Shot: direc'Jcn and dis'ence Irom et least ; ..o Slala /t(.
✓� - Reads, or o:Iter me;) reference penis)
Depth f.latorlol Method
From 0 To-_Q C-)-FI. 0 -Ci�1S�a"1y L�-
Frorn To Ft.
15. SCREEN:
16
17
Depth
Diameter
From —To_
Ft _ in.
From _
To _.
FL _. IT.
From —To
FL._ In.
SAND/GRAVEL
PACK:
Depth
Size
From
To
Ft.
From
To
Ft.
REMARKS:
Slot Size Material
In.
In.
in.
Material
v
r� vhy
Cl J3/iu
1!!u c
v vcf
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. I`
FOR OFFICE USE ONLY �NQ-,i( � Q-�DS -11
-n JATURE CF PE FASO tJ CONSTRUCTING 7HE WE9_ DATE
Ouzd No: J 17 �p p�- I
��m _L. If §V'b� ony[f�. c'Divslcn of l`iator Cua:;;y, Ground.va;cr Section Within 30 days
Scdal No.
�.._ _ _� 'r i i� l - G,V-1 REV. In9
soundwi
-_,'oeeille I t^ 1 ....-

N _-th Carolina -Department of Environment and Natural Resources -Division of Wafer Ouatity - Groundwater Section r n ra (�
1695 Nail Service Center - Raleigh, N.C. 27699.1636-Phone [phone] G- •- 3 `l �`�' V
WELL CONSTRUCTION RECORD WELL CONTRACTOR: ev>seu_ 'TAj cc -a_ 1
WELL CONTRACTOR CERTIFICATION 9: 'Zt454
STATE WELL CONSTRUCTION PERMIT#:
q�.,
1. WELL USE (Check Applicable Bo-): Rardan(ia'� V Municipal ❑ Industrial ❑ Agricultural
❑ fLonLoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Olher, List Use:
2. �VELL LOCATION: (Show sketch of tie location be!mv)
Nearest Town: CA5a IC Q-5 Ccun;r
b !
WJLY kw1Z0 -
(ao?d Na:na and h'ur,.hcrs. Co-.mu-,;ty, of S::S7;v'sbn a-.0 Lol No.) DRILLING LOG_
DEPTH
3. OIVNER or"i M4� Da JA�.y Frcm 'to
Fcrr^..ation Desc.-Ipc:cn
Address P, �X $$i� U 73
- 11-.ZA✓6L
:n :0.1 T5 7T
C't Q/�,-1. L
(ct€Naruf Ali, 25 3(n 75 lac
C#¢vJ lTE
City cr Tcv,n S;a:o Zip Co.e
-
4. DATE DRILLED-
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES F;X NOD
O
7. DOES `+%ELL REPLACE EXISTING NiELI? YES [_] t10XI
-�—��
8. STATIC WATER LEVEL Below Top of Casing: 1� FT.
_
(Ucc'.' it Abcvc Top of Ca.::+g)
n
9. TOP OF CASING IS I_ F F. Above Land Surface'
'Top of casing tc:ml;:ared o7or:clove land sv-:eta requires a varlxnco in otter-
i I
2� o
dance vJdh 15A NCAC 2C.0 1 Is �1`(�
10. YIELD (rpm): _ ? f.tETFiOD OF TEST _
_--- --n
12. C=-1'_0;;,... .T'r0;.. Tpp., _�'�T Fi F.._.�_rlt_�-2•LLS .. .._.-�..,,�,... _,' _v is c_zdaC
ua_6'=': c; ;o: c,� o
Ce7:'1 "i5
Froms> To
Frc„i To --
Fr-;a To--
14. GROUT:
^ I •rc-. _ ^.I � t.':.c-._J !S r.:r_s,. n d C;c.� r -. ,� t o ._._
Ft.
Ft. /
Depth (� f��a�:a rill I. athrd
From To �L Fl. _S __ VALAS `_ l n
From To _—Ft.
15. SCREEN:
Depth Dicmetor
Rom To Ft _
Frcm _ To Ft. In.
From To Ft. In.
16. S'%ND/GRAVEL PACK:
Depth Size
From To Ft.
From To Ft.
17. REN.!AFIKS:
Slot Size Llaterinl
in.
In.
Material
I CO HEREBY CERTIFY THAT THIS VIELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C. WELL
CONSTRUCTIOil STANDARDS, AND THAT A�COP
/Y OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER. Q�� "2'
FOR OFFICE USE ONLY nCr �'J�i- S.�' UQ `�`_
Cua,1 No: 3'�G `IATURE Of PERSON CG:ISTRUCTING THE cLL DATE
(� �Sr.i� 'cn of Y; a:er OuaGry. Gmundn a:cr Sec!;on rrilhfn 30 days
Serial No. (,�' �s. GI( -I REV. 12'g9
I D��
c,o

'0089
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: ZJb`icL 1aY c0 t
WELL CONTRACTOR CERTIFICATION 9: Z_98iiL
STATE WELL CONSTRUCTION PERMIT#:
1.
WELL USE (Check Appllceblo Box): Residentiw�n Municipal ❑
Industrial ❑ Agricuitural ❑ 1donL'oring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑
If Other, List Use:
2.
WELL LOCATION: (Show sketch of the location below)
Nearest Town: r' U..W,"ur=E Coun�/:
cF I r,. cb l
m.0
(Road Name and NuMl Comr'dly, or Subdivision and Lot No.)
DRILLING LOG_ DEPTH
3.
OWNER hr-+r4 yr-A'?Ay IU"✓k
From 'to Formation Description
Address 5Z1,10 57 Nw
(1) 24 LCAY
tree orK.W. Jo.1
ZTF Cyl/!.JI Ter,
19crtTOrS FLA
7"Cn L45 liR.n..1t7E
City or To,vn Stale Zip Code
4.
DATE DRILLED (.+— I? z-
TOTAL DEPTH 2415 F7
5.
G.
CUTTWGSCOLLECTED YES[> NOE
—
7.
DOES WELL REPLACE EXISTING WELL? YES F-1 NOX
8.
STATIC WATER LEVEL Belov: Top of Casing: _2o FT.
(Use',' it Aoovo Top of Cncinp)
9.
TOP OF CASING IS I FT. Abovo Land Surfa cc'
_
'Top
of casing terminated oVor below land surtaca ra quires a varlanca In actor-
0 0
dance
with 15A NCAC 2C.0110
10.
YIELD (gpm): _ . METHOD OF TEST
11.
WATERZONES(depth): 13'"2rs
12.
CHLORINATION: Type tirC h ArnountIf c_. • ' � d Do
';:GLa. space i .eC' ed use liaci Ci iC:"�
13.
CASING:
LOCATION SKETCH W N`
rn:9
v;aaTnic.no:.
Depth Diane: r c ulve,gc!Ft. 'U;edal
Shov+di:ect.en and Ci;:ano='ten ,a least l'.vo SlL:e _-
7
From �� To 7� Ft. � Y� _ � �=
a% o
Rcdds, or other map rolerence points) .z
From To--- FI.
Front To-- FI.
14. GROUT:
Depth
Front O Toc�Ft.
From To FI.
15. SCREEN:
^^Material t.tou,rd
Depth
Diameter
From
To
FI in.
From
__ To
Fi. In.
From
To
Ft. In.
16. SAND/GRAVEL PACK:
Depth
Size
From
To
Ft.
From
To
Ft.
17
Slot Size Maleriai
in.
In.
in.
Material
5
2v
m^k'
T,j:.C�aefyco vJ.
1 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,'
Sy�Ug. P1Z3/eb
Quad No: p !Al'UR_ OF PERSON CONSTRUCTING THE ELL DATE
f ".. f 10 OrvLicn of Wa'or Quality, Grounde,a;er Seclbn % . . 3D days
Serial No. -�' I I+1i GW-I REV. 1J99

North Carolina - Department of Environment and Natural Resources -Division of Water Quality •Groundwater Section
'3088
1636 Idail Service Center - Raleigh, N.D. 27699-1636-Phona [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: 5x1 Tay
WELL CONTRACTOR CERTIFICATION
STATE WELL CONSTRUCTION PERMITIl:
1. WELL USE (Check Applicable Box): Residential Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injeclion ❑ Other ❑ It Other, List Use:
2. WELL LOCATION: (Shov+ sketch of the location belov+
Agricultural ❑ Monitoring ❑
Nearest Town: nli. a 1 rF1Z Courtly:
/I ����
4W� CO4e C/iM��;11✓r-`O �iN�"J
MN7 �.
(Road Name and Numbo,s. Comrnur.lty, or Suhd:vison and Lot flo.)
DRILLING LOG
3,
OWNER 14�L7 Ccvt; CAM,0X ttV1J6
From To
Address 341
_7(
—[Sure or iou;e No.
% i 75
(,j rkT`ri r%rL- lit:✓ ZA-?-43G
City or Tov:n Slats Zip CoCc
4.
DATE DRILLED t:P
5.
TOTAL DEPTH*r F1
G.
CUTTINGS COLLECTED YESN NO❑
—
7.
DOES WELL REPLACE EXISTING WELL? YES 0 NO�.
8.
STATIC WATER LEVEL Belo'.., Top of Casing: q D FT.
(Use'.' it Abovu Trp of Casing)
9.
TOP OF CASING IS I FT. Above Land SerfaCe-
'Top
of easing terminated oVor belot, and surfaco requlrau a Variance In accor-
dance
with 15A NCAC 2C .01 a
� cur
10.
YIELD (gpnl): METHOD OF TEST
11.
WATER ZONES (depth): 7 -14a L,_ Il �d F7_
_
12. CHLORINATION
13. CAS!NG:
Type � ti Amount_
I
W3!1 I hkb.,n-s
Depth
-7
Diame:o/ 11.
��-I
r.7a:adal
From
To
Ft.
co t3
From
To--
Fl.
----
—
From
To--
Fl.
—
14. GROUT:
Depth
M�a�!arlal
t.lolhrd
From
To �L
Ft.
y�
From _
To
Ft.
15. SCREEN
Depth Diameter
From To FI in.
From —To—Ft.— d In.
From —To FI, In.
1G. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To Ft.
17. REMARKS:
Slot Size Material
in.
In. --
- in.
Material
DEPTH
Forr..ation Description
CL
fi lC, r1 re
0
of r4irc�
® r,
INS;
=pace L: needed use back of terns Ql
LOCATION SKEICH
(Shea direcllon and d:s!anco Gem at least t.vo Sate
Re „'.s, or olher map re:crence polnts)
-�� L.y1.TE NIIV
O _
l w�
L1G''Y
C, `l 7 cue
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.
t; � � ,r��lne ,�ce� � a����,�� Sy1 vg. 81Z3100
FOR OFFICE U'>SON�L-Y E-Y E) r L 1
Ouad No: j II3 G"lA1UFlE OF I'C RSOtJ CONSTRUCTING THE cLL DATE
Submit ti;1((3l go DM:ion of Y7ate, Ouailly, Groundna;er Secllon within 30 days
Scrial No.
GW-1 REV. 12157

�23087
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1635 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
M���,1 -
WELL CONTRACTOR CERTIFICATION
STATE WELL CONSTRUCTION PERMITIt:
1. WELL USE (Chock Applicable Box): Residential Municipal ❑ Industrial ❑
Recovery ❑ Heal Pump Water Injection ❑ Other ❑ It Other, List Use:
2. WELL LOCATION: (Show sketch of the location below
Agricultural ❑ Monitoring ❑
Nearest Town: ( Ab 0I6CS County:
(Road Name and Numbers, Community, or Subdlvisicn and Lot No.)
DRILLING LOG
3,
OWNER Tjr�^^ce—! cr_
From To
Address "7 1 Zt,4'9 Cjze yG 21J
C !C o
UfCI cr aide 1,0.)
�CE,r.f Vil(.E Nc.
st Sp
)Cily or Tcv:a Slate zip Code
ZW
4.
DATE DRILLED
5.
TOTAL DEPTH 2.2P ET
6.
CUTTINGS COLLECTED YES© NOD
7.
DOES WELL REPLACE EXISTING WELL? YES 0 NQ0
8.
STATIC WATER LEVEL Below Top of Casing: 3t FT.
(Use's' it Abcvo Tep of Casirg)
9.
TOP OF CASING IS ( FT. Abovo Land Surface'
'Top
of casing terminated nVor below land surface requires a variance In actor
dance
10.
v:flh 15A NCAC 2C.e118 �f2
YIELD (gpm): �_. METHOD OF TEST
11.
WATER ZONES (depth): /46 F7
DEPTH
Formation Descr•pion
0 0
12. CHLOR!NATION: Type r H Amount 46G � Ls if addt�onai space Is needed use back of for. 1
13, CASING: I -- —
viri Tr cs "s LOCATION SKETCH
Depth Diarnclor er Plei;l.VFl. ''-'cdai (Shoe: direclion and di, ante from at least k at
From—�—To 5b Ft. � /� 9`G Roads, or other map reference points) �U�Q
From — To Ft. —
From To— Ft. Q'G£6
14. GROUT: PLA1
Depth r�Malarial Mcihod 62cct
From 0 To Ft.
From To FL _ _ tiIti Il
15. SCREEN:
Depth Diameter
From To Ft in
From To FL in
From To__ Ft. In
16. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To Ft.
17. REMARKS:
Slot Size Malaral
in.
in.
Material
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, VVELL
CONSTRUCTION STANDARDS, AN\D THAT AA• COPY OF THIS RECORDHAS BEEN PROVIDED TO THE WELL OWNER. l
FOR OFFICE USE CI
Quad No: r"I SIGNATURE OF PERSON CONSTRUCTING THE 'ELL DATE
C9 ' Suaioit origiral to Division of Walor Quality, Groundwater SecCon within 30 days
Serial Na. z Gw'i REV. 12/59

North Carolina - Department of Environment and Natural Resources - Division of Water Quality- Groundwater Section 4- � 0086
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD
WELL CONTRACTOR: wT
s�`u'`'
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMIT#
1. WELL USE (Check Appftceble Box): Residentia;Cn Municipal ❑ Industrial ❑
Recovery ❑ Heal Pump Water Injection ❑ Other ❑ It Other, List Use:
Agricultural ❑ Monitoring ❑
2.
WELL LOCATION: (Show sketch of the location below)
Nearest Toem: CI4EW ..-r-- County:
0q X Awy 441
(Road Name and Numbers. Ccmmunity, or Subdlvis:on and Lot No.)
DRILLING LOG
3,
OWNER L?E R.Ek Ruiv�/150 r`1
From 'I
Address P•u ^K SIl
Cj 139
_
CWCP,,:r-CE �trce or �oru�.cc ao.) ZE?
iY/ 297
City or Tcv:n stato Zip Code
-2Z-cci
-
4.
DATE DRILLED
5.
TOTAL DEPTH
6.
CUTTINGS COLLECTED YES© NOD _
7.
DOES WELL REPLACE EXISTING WELL? YES O NOj,�5
8.
STATIC WATER LEVEL Belo•:: Top of Casing: FT.
(Use'.' if Abava Top of Casi^,q)
9.
TOP OF CASING IS / _ FT. Above Land Surface'
'Top of casing lerminxled rVor below land surface requires a variance In eceor.
danco
wi:h 15A NCAC 2C.C118
10.
YIELD (cp,m): METHOD OF TEST .•9f2 -_
l 1.
WATER ZOtIES (depth):_ 2- /!"S -5 - /90
4- Zoo
-
DEPTH
Fcrma:ion Detce.ptien
6 OAnlr 7L-'
p_12/+N:9r' 9
O
12. CHLORIt:ATION: Type I mount ��.— !f ad!Riona! sp ece Ic ;eeCed w= bsec c4 ;crn
13. CASfNG:
Y; all Thk%ress '- �
Depth Dla.-c'c c: Yle:^,t�: FL l.:otcAal (Sh w d:reclicn and
Frcm CL —_ To /41 FL — - ✓` Roads, or other
From— — To FL -
Front To--. Ft. —
14.GROUT:
Depth Nlaterlal Mclhcd
From To�C_) Ft.
From _ To _Ft.
15, SCREEH
Depth Diameter
From To Ft __ in.
From To Ft. In.
From ___ To __ Ft. In.
16. SAND/GRAVEL PACK:
Depth Size
From To FL —
From To Ft.
17. REMARKS:
Slot Size Material
In.
In.
_ In. _.
Material f>pgyl';17
so
o trcm al least t:ro SI_-Je
derence po;ws) jO
T
--
T
�O
.�a
1
r'
(LG
T`� �ytvu
I DO HERESY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND �z\H�A^T A COPY OF THIS RECORD HAS BEEN PROVIDED TOO THE WELL 0
FOR OFFICE USE ONLY 4-V Q - pj uxyyI�� X o�- S�
Cuad Na: SIGNATURE OF FERSOtd COtaTRUCTING THE WEL
Submit on;injl to Division of Wn!or Quality, Groundaa!er section within 30 days
scnal No. t'
Fk 1
y c
Cr0undW;3i8'
ii5h2Udie rtl t tr.=..__.
DATE
Gw-I REV. 12/55

North Carolina . Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center- Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD
WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION #:_
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Resldentiai�n Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
'`'3094
Lail
L1ts
Agricultural ❑ Monitoring ❑
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: 5Vt_vA County: __>_4C
[EA5(/E .7ylJ-vim' yA-
(Road Name and Numbers, Community, or Subd:visicn and Lot No.) DRILLING LOG
3. OWNER From To
Address � .jX 0 — 69 _
-jStreot or Houto No _
s;i vV N Z ­ 9 $ r7 -
City or Town Slate Zip Code
<. DATE DRILLED 4'
S. TOTAL DEPTH :jS°
G. CUTTINGS COLLECTED YES© NO[—]
7. DOES WELL REPLACE EXISTING WELL? YES[::] P10o
8. STATIC WATER LEVEL Below Top of Casing: _ & 5 _ FT.
(Use'.• if Above Top of Casing)
g. TOP OF CASING IS FT. Abovo 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): /j METHOD OF TEST ITT
11. WATER ZONES (depth):
--Yiyo Z-�+SS
12. CHLORI1 dATION: Type A:nount _ �d»„�S II add:;ior,al space is nc eCsd use bac'r, of form Q1 z
13. CASING: ' - - -
DEPTH
Formation Descripl:on
GLA7
GIN:�c
oa
LOCATION' SKETCH
VJaa Tlaca:.css
Deplh
Diameter cr`:� ;:017, t1C;cd.-I
L
(Sha:: direc:'cn ar.d distance Ircm et least ;,.0
From ��
To 9y
/ rEGL
Ft. tG �Y /3
Roads, or cihcr map reverence points)
From
To
Ft.
From
To--
Ft.__
14. GROUT:
• \
\\
Depth
Maierlol Method
From n
—To-_-_-�Q
Ft. 0-r_"NLfA- _ \9__
From
To
Ft.
15. SCREEN:
a
Depth
Diameter
From
To
Ft in.
From
To
Ft. In.
From
To
Fl. In.
16. SAND/GRAVEL PACK:
Depth
Size
From
To
F1
From
To
Ft.
17
Slot Size Matorial
In. r}
In.
N
In. 5'
Ma!erial-'v
FS VO)
9 us3r.^L M�A`x".rs
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, NiELL
CONSTRUCTION STANDARDS, AND THATCOPYCOPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
C FOR OFFICE USE ONLY �`��� 6rC)/`''
Quad No: SIGNATURE OF PERSON CONSTRUCTING THE WEL GATE
Submityrainal to D1vlslon of Water Quality. Groundwater Section within 30 days
Serial No. GW-I REV. 12/59
I
)
N
- IfIStiZ i�...

North Carolina - Depanmont of Environment and Natural Resources - Division of Water qQuality - Groundwater Section C` 083
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phony [phone]
WELL CONSTRUCTION RECORD WELLCONTP.ACTOR: Qu556L- IpY L-O(Z'
WELL CONTRACTOR CERTIFICATiCN 1-:
STATE WELL CONSTP,U8T10N PERL:I T ;:
1. %'/ELL USE (Chock Applicable oo* ResldentiaiLy Municipal ❑ Industrial ❑ Act icuaurzl ❑ 1/.onllorn; ❑
Recovery ❑ Heat Pump Water Injection ❑ G;her I( O!her, Us; Use:
2. V;ELL LOCATIOlJ: (Sho'.v sketch cl I'1e Ioca Gen beta;:)
c
lJearest Town: (�-t't'N u 1 _Ccu:,
I- l lob
(.Road Y(Road amo and Numbers. Con'.mu:.ly, cr Scbdvlslon and Lol No. )f;umbcrs. Coal nu:.Ily, c: Scbdvision and Lo;Ito.)
DRILLING LOG_
3.
0%VNIER � AND�r4D L :c -r IN NyNy
From To
Address P,a r-W (0 :*
U /V
(r UFN. Or 1ou;e :0.
(rLErl JJrlc /�'C
/B 2G
r.iy cr To ,.I stale 2;p CO:^
—
a.
DATE DRILLED
Zo
5.
TOTAL DEPTH P(Cb F7
G.
CUTTINGS COLLECTED YES i< NOD —
7.
DOES VlELL REPLACE EXISTING V,ELL? YES FL-] NO�y
C.
STATIC WATER LEVEL Top of Casing: _,o P7.
(Use'.' it Abc:o Tep of C,,:!rq)
9.
TOP OF CASING IS FT. Above Land Sur:; ce'
'Top
ct c. eing Icrtnlnatcd nYor bci orr la,,^d so Caca ro cccr-
dancc
10.YI3LD(gpm):
v. ith liA NCAC 2C.0110
_3�> t.1ETH0 OFTEST Ci-YY'
—
11.
\`L4TER ZO?:ES (?ep;h);-�t$S 2uy—CoC6.�
--
DEPTH
Forr..ation DescrpCan
G�lfIN ('7C
0 �
12. CHL CF31NATION. Type �`�� hi Ad.tour., _ i �iel_5 L' cam_ _, is r.::eJed use
Dep lh
Fro,n_CD�To _
From To -
Fr -,in _To_
14. GR9UT:
20 Ft.
— F I. —
Dopih 16ab�tlal i:`.o!hcd
From To FI.
From To - Ft.
IS. SCR? E `J:
Depth
From
To
From
To
From --To
16. SAND/GRAVEL
PACi!:
Dcpih
From
To
From
To_
17. REM!ARKS:
Di3ln Otor Slot SI:
Ft in. M.
FL In. In. --
Fl. In. in.
Ft.
Ft.
Silo taaleria
4
N
j0
'k-tl?N K.O
'\
A O
I DO HEREBY CEP, T IFY THAT THIS WELL WAS CONSTRUCTED IN ACCOP7ANCE'NI T H !=A NCAC 2C, V/E'!
CONSTRUCT!Orl STANDARDS, AND THAT A COPY OF THIS RECORD HAS --*Et; PRO'i[DEO TO THE '.',ELL 0:4NER.
FOR OFFICE USE ONLY
Cu", Its sKsr+RrW"+, G, f r ,SQN Co "i. , r 1 ' -I I oATE
Sjhaz'a t�:�b�q(5,.sr Cualily Gr .: c: I .'..`I!r 30 days
L X G,:.l REV. 1:, i]
ypy 1;
tpp YS '
94 ":

North Carolina • Department of Environment and Natural Resources - Oivlsian of Water Quality • Groundwater Soc:ion 082
1636 Mail Service Center- Raleigh, N.C. 27699-1636-Phano [phone] In/
WELL CONSTRUCTION RECORD WFLLCONTRACTOR: �LLSSCU -1Fc�Lylor
;7 WELL CONTRACTOR CERTIFICATION It: t?1ri
STATE WELL CONSTRUCTION PERMITd:
1.
WILL USE (Chock Appnca610 Dox): Re51dOnllal Municipal ❑
Industrial ❑ Agrcullurol ❑ Monitoring ❑
Recovery ❑ Heat Pump Water In]cclionL_j Other ❑ If Other, List Use:
2.
WELL O (-h w sketch o1./t�ho location below)
Nearest Town: �` � � nQ v _County: U��
tTown:
_
,., _ ICI
(Road Namo an D rhers, Cmnnwnlly, r Subdivision and Lal No.)
DRILLING LOG DEPTH
3.
OWNER r 1tn o,
From To Fomlat.on Dascdptlon
Address eke
,)OO
1 o�Ti ul0 'a J
i A 1_: o
1 (y
City or Town state Jp Ccdo
oc)
4.
5.
DATE DRILLED
TOTAL DEPTH 1 �_ 1�
(T Py 4_0 5Q �`�—
G.
CUTTINGS COLLECTED YES EI�� NOD
7.
DOES WELL REPLACE EXISTING WELL? YES ❑ NO
OU r--)
0.
'STATIC WATER LEVEL Below Top of Casing: �. FT.
(Uso'.' II Abovo Top of Casinq)
0.
TOP OF CASING IS FT. Above Land Surlaco'
'Top of casing terminated near below land surraeo raqubos a varlanco Li accor-
rq
h
Gn
dance
10.
with 15A NCAC 2C.0113
YIELD (gpm): 4,5 METHOD OF TEST
�m
11.
WATER ZONES (dopth):
GO
T
mo
12.
CHLORINATION: TypoArttount ��<
If additional space Is needed use back of to.... LO
rn_I
13.
CASING:
—"'—
cm-��
Wall Thlcknocs
LOCATION SKETCH a%
o
DC rill Di. rnor Wci heel. Maldal
( ff77 `IIclor 11 11 p c
_ �
Front �To � 3 J Lam
($h0'�i direction AnrJ di51dnC0 11011: nl CaSI hY0 $IaIC
Z
Ft. = . -
Roads, or other map wfcmnce points)
From To FI.
From To F-l.
_
14.
GROUT:
i
()� "'"-n�l`� �VYI�
PA
Depth Material Molhod
//��
�
From 11_ To QFt.
From To Fl.
15.
SCREEN:
Depth Diameter Slot Size Maloriai
From To Ft In. In.
From To Ft. In. In.
From To Ft. In. _ In.
1G. 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 WIT11 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COI;Y OF THIS RECORD HAS PEEN PROVIDED TO TPIE WELL O
FOR OFFICE USE ONL
Coact No:
Smial No.
P@RSON CONSTRUCTING THE W5L r
':lalor GUMMY, Ground'o'e, $CClian Ynll lift 30
DATE
GW 1 REV. 1^J99
00
1 1-

21530� I
North Carolina - Departmont of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Nail Sorvico Center - Raleigh, N.C. 27699.1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: I?u5SGL1,-TA-1µaa
WELL CONTRACTOR CERTIFICATION 1�} `
STATE WELL CONSTRUCTION PERMITS:
1.
WELL USE (Check Applicabla oo a): Residentia) Municipal ❑
Industrial ❑ Agricullural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Iniection ❑ Gher ❑ If
Oiher, List Use:
2.
WELL LOCATION: (Sho.v sketch of the location belo.%)
Nearest Town: i-VA -County:
T1+oanr.� C�.(E Pt>AD
(woad Name and NurnScr s, Communly, cr SuSdwL'ion and lot t: o.)
DRILLING LOG DEPTH
3.
06)NER 2,AN r-TUEQtS� AgeQC"VAr1T
From TO For,:alion 0escripl:c.n
Address j27Z� CAm61_�tA L3�j `X, 'vE Liil
0 — 1-10 CL.AY
tree or owe To.)
!
7Ai�5 +uwt� FL 3Z223
17o iZ CEaN,iC
City or Tcvm Slato Zip Code
-'
4,
DATE DRILLED io" 30' caJ
O
-
5.
TOTAL DEPTH S(_o F-c
) 7L
G.
CUTTINGS COLLECTED YESM P400
- O c_
7.
DOES WELL REPLACE l WELL? YES i10,M
8.
STATIC WATER LEVEL Below Top of Casing: I3o Fr.
(Use'.' it Above To, 01 Cacin,;,)
9.
TOP OF CASING IS FT. Above Land Surface'
�._
'Top
of eoebrg Icrrnlna:ed a'✓or 6ciow land su r; ace ro quires a variance in actor-
n
dance
v.I:h 15A NCAC 2C .011 a
Z
10.
YIELD IhPn1): METHOD F TEnT
11.
WATER ZONES (depth):
12.
CHLORINATION: Type...,oUnl_Y3 5
II :.__ICcn:! space •edcd cse Lac%oi locr-
13.
CASING:
______-:-------_ ___— _ --_--
%Y-,1Ihzrtnas, LOCA-iOPJ S_r:TCH
D^pal
"i2
UizmNOr c: Plc:-, R, :.1a:e dal (Sho.; direel:cn and distance from :a (oast I'.vo Stale
Pre;n�—To 1— FL
Co - — P:cr� c. o; oflh._r map rcl^react poll?s)
From—— to --__ _ f'l.
From To-.— FI.
-_
1a. GROUI:
A
Depth
Ma:odal r.'.olhcd
From G Toc�2_Ft.
b
From To ._-Ft.
15. SCREEN:
t 31
Uopth Diameter
Slot Size - Material
From To Ft
in. in.
From To R.
From To 1-1.-
In. In. c
In. in.
_
16. SAPID/GRAVEL PACK:
r
Depth
Size Malerial P �
From To Ft.
S 4 TVsoa' 29. •
From To Ft.
_5� 131.E N
17. REMARKS:
.•��
-to l�"' t�r�►
1 DO HEREBY CETHFY THAT THIS
WELL Y1AS CONSTRUCTED IN AC CORDANC E'NITI 115A NC ,C 2C, Yl ELL
CONSTRUCTION STANDARDS, AND THAT A COP/Y�OF THiS RECORD HAS PEEN PROVi Du TO TH[ Vi=LL O',',NER.
FOR OFFICE USE ONLY
bl'QQV)Q. lD_YC�r, �'�"' ��. .EA '>'fW q
�-
Quad h0 - ',
�' S G'.ATL:?= OF i G ,. ON GG'.✓T.TJCTI :G if'c"f.�LL DATE
.. r
- Sub,Mod.]ina to D ,:: on of l .t er Quality Gro J'd,•a.cr Sect on V.' t l n 30 days
Serial rJa
G"1-1 FlEV.
AV-
b;�i;

Borth Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section (} (1
63G Mail SONICO Cantor - Raleigh, N.C. 27699-1636-Phony [phone] v vi
HELL CONSTRUCTION RECORD WELLGONTRACTOR: -J-10
WELL CONTRACTOR CERTIFICATION It:
STATE WELL CONSTRUCTION PERMITIt:
1. WELL USE (Check Applicable Box): ROsidOntial Municipal ❑
Industrial ❑ Agricultural ❑ Monitoring ❑
Rocovory ❑ Hoal Pump Wator Infection L� Othor ❑ 1f
Othor, List Uso:
2. WELL LOCATION: (Show sketch of the location bolow)
�CL��CSCI'1
Nearost Town: �!_'•YS County:
(Float Name a1n^d'Numbe1rs. , or Subdlvkion and Lot No.)
DRILLING LOG DEPTH
yCo�mmnunit
3. OWNER V� �5P 11 „ O,
Frain To Pomtaoon Duscdptlon
Addressarig�,S.}-j�A�(��
0.
1p
' Cily or To •rn Scala ZIp CcJa
4. DATE DRILLED -00
G. TOTAL DEPTH Q Fll
G. CUTTINGS COLLECTED YES �� NOO
YES F WO�
n
-
7. DOES WELL REPLACE EXISTING WELL?
S. STATIC WATER LEVEL Solow Top of Casing: �("`) FT.
o
O
-
c>
(Uso'1 II Abovo Top or Ca5.a9)
1
D. TOP OF CASING IS1� FT. Abovo Land Surface'
n
_cm
•Top or casing to nnl naloa ovor bctow land surrnco requlro3 a vadanc0 In cccor-
L_
o<
dmiao with 15A NCAC 2C�at1a
10. YIELD (gpm): _ METHOD OF TEST—�1�
35
11. WATER ZONES (doplh):
�M
12. CHLORINATION: Type Alnoun! I
� II additional space Is needed use back of loan
13. CASING:
LOCATION SKETCH
Wall Thickrass
Depth D1.9meler or W1e. I VI.i Maletlal
L 1s�
(Show direction and distance front at least two Slate
From �To Ft. 1
Roads, or other map relerenco 11011's)
From To FI.FL
From To-- FI.
4. GROUT:
Depth Material Molhod
//��
From _1_L_ To Ft.
From To FI._
15. SCREEN:
DOpth
From —To
From —To
From —TO _
1 G. SAND/GRAVEL PACK
Depth
From To —
From To_
17. REMARKS:
Dlalllelor Slot Sizo Ivlalodal
Ft _ In. —"I').
Ft. In. In. --
Ft. _ In. In.
Ft.
Ft.
Sizo LPalurial
I DO HEREBY GERTIFY THAT THIS WELL WAS CC;':ST RUCTED IN ACCORDANCE WITI 11SA NCAC 2C. WELL
CONSTRUCTION STANDARDS, AND THAT A COl;Y OF THIS RECORD HAS BEEN PROVIDED TO TIhIE INELLnC
FOR OFFICE USE ONLY �-t1n `�Ir tiwl-' . }--��=-
Quad No -- - S O JAl UIIC Or PERSON CONSTRUCTING TIIE YI ,
r' ml n $Rp t kmipinal to Divlsloo of `'Iator Quality Gmundwalcr section within 30 days
--- J I
$mist No �
t )•a
I.a
t
DATC
G'N.1 Iicv. 1'M

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section r.• • 1 •�0 9 `j
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phono [phone]
WELL CONSTRUCTION RECORD
WELL CONTRACTOR: _-_ IZQ SSF.,
WELL CONTRACTOR CERTIFICATION #:_
STATE WELL CONSTRUCTION PERMITq
IA�fLU1L
Zl� �
1.
WELL USE (check Applicable sox): Residenfia.�N Municipal ❑
Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑
If Other, List Use:
2.
WELL LOCATION: (Show sketch of the location be!ov.)
Nearest Town: Sy�vA County:
(
i toeFj 0-0-
(Road t:arne and Numbers. Community, or Subdivision and Lol t,o.)
DRILLING LOG DEPTH
3.
OWNER -�AMbs l{opr2T,y/�(i-GrQ-
From To Fomnallon Descripli on
Address CsX 2-14
0 7-5CI-cr
Jhfe or ouzo Jo.
_ Z8 7 S
D 11L>:3Lti'4 n CZ
-i
- % I �%l/Wl 7C
City or To,,, Slate Zip Code
4.
DATE DRILLED $-24-""
.y C_ILA a; TE
5.
TOTAL DEPTH
6.
CUTT ING S COLLECTED YES[y NO❑
7.
DOES WELL REPLACE EXISTING WELL? YES D NO $6
8.
STATIC WATER LEVEL Below Top of Casing: 4,,� FT.
(Uso'+' it Abovo Top of Casing)
O
9.
TOP OF CASING IS FT. Above Land Surface*��—
'Top of casing lenninated atior below land surlaco requires a vatlance In actor-
rn �m
dane
c with 15A NCAC 2C.0118
m
10.
YIELD (cpm): _ METHOD OF TEST /k r2
_ 7V 'L--
11.
WATER ZONES (depth): Z' s 2- /y5
_ �_-�`_
0
12.
CHLORINATION: Type A:neunl _✓?��'�
0
If addlicnai space Is needed use 6zc:: of har;;= �r.1
13,
CASING:
c-)
LOCATION SKETCH
Waa Thkkness
Dia.^,c: cr Weigt;YFl, M 'c dal
�y�
Ql co,
(Shmv d!rect:on acd ':'stance from a: toast Iwo Sale x
From �—Tod Ft. �`�'
Roads, or other map reference points)
From To Ft. -
G� -
Froin To— FL---
14.
GROUT:
Depth Malarill Molhod
From To ca Ft. _Q�— O_
Front To Ft.
18.
SCREEN:
Depth Diameter Slot Size Mldtorial
�
Frorn __To Ft In. in.
I/Jg vl
From ToFt. In. In.
-TayzY��ry
From --To _ FL In. --In.
G a
16.
SAND/GRAVEL PACK:
Depth Size Material
7d
From To Ft._
Frcm To Ft.
17.
REMARKS: _
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2Ct WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD A HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY 't.J `t,1y 4O.t`` Q dS WQ,1,,k -D,4 cf�= S4 1 Ue111Ov
Ouad No: _ iL L C2 r r SIGNATURE OF FERSOf1 CONSTRUC JG l l c VYELI DATE
_'ublrji( On7nal to Cidslcn o' Ylal or Oualiy, Groundwater Seclicn 5•rithln 30 days
Serial Na. 9 11 ; GW I REV. 12J59
Sii J'
n S,

r �rV9U
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phono [phone]
WELL CONSTRUCTION RECORD WELLCONTRACTOR: PuSSf,_ U Qy�Dr
WELL CONTRACTOR CERTIFICATION it: �I �
STATE WELL CONSTRUCTION PERMIT;!:
1. WELL USE (Chock Appilcahlo 6oa): Residential Municipal ElIndustrial ❑
Rocovory ❑ Heat Pump Water injection Othor If Other, List Use:
a
3
Agriccilural ❑ Monitoring ❑
WELL LOCATION- 'r (Show ;,ketch of the location boiow)
Noarost Town: `-a 5 h I P V t County: kC S c))
(Road Name and Numboa. Community, or Suhdivlsion and Lal No.) Aµn; DRILLING LOG
OWNER '-��l hn1611er?)�"r (2c F;om To
Address '2 /7n vnns ,n -T)_ t,...lo /&?A __
DEPTH
Formallon Description
latrcol or t m rvo.1 _
n J n to
City orrTown State cdo -
4.
�-
DATE DRILLEDL,?,CZ
S.
TOTAL DEPTH S 5
G.
7.
CUTTINGS COLLECTED YES ©� NO[:]
DOES WELL REPLACE EXISTING WELL? YES (7 NOED� �• L1 ��_ --
It
a.
'STATIC WATER LEVEL Bolow Top of Casing: 41nh FT.
o.
1 (Uso'+' II Above Top of Casino)
FT. Ahovo Land Surfaco'
O O
E2
9.
TOP OF CASING IS
'Top
of casing terminated nVor below land surface requiros a varlance to scoot-
O�
Crn
Banco
10.
with ISA NCAC 2C.0110 /"`
YIELD (gpm): �-- METHOD OF TEST Qj—_ 1
11.
WATER ZONES (depth): jo -Ex
r7
C
0
12. CHLORINATION: Typo Arnount ! I S It additional space I• needed use back or lorm
13. CASING:
Dopth Di.]meter
FromTo Ft. �1 L
Froth To Fl.
From To-- Ft.
1 4. GROUT:
Wall Thlcknecs LOCATIOfd SKETCH
or Wcl a1VF7. laledal (Show direction and dislanco from at lead two State
. 7-- � Roads, or other map re!e;crcc points)
Depth Material Mothod
Front To JFt.—
From To Ft.
is. SCREEN:
Doplh Diameter
From To _ Ft In.
From To —Ft. In.
Front —To Ft. in.
1G. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To Ft.
17. REMARKS:
Slot Size Nlatolial
in.
in.
Material
Jar)
100 HEREBY CERTIFY THAT THIS WELL WAS CONST RUCI-ED IN ACCORDANCE WITFI 1SA NCA-1 20, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF TI IiS RECORD HAS BEEN PROVIDED TO I I IE ,NELL C
FOR OFFICt=,,,�l,G,�N�Y__„ -�Ln. `d r"c-t''i u�'L6ti"J. 11VAkZ r- F
Quad No: t M I SIGI L\i URE OF PERSON CONSTRUCTING THE I16L DATE
(J m at to-0ivi:ion of 'eater Ouali ty, Groundnater Section vlIth.n 30 days
srdal No. Yf GW-1 nEV. 12199
a �s CAD

r 1
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section .0 ,)
1636 Nail Sorvice Center - Raleigh, N.C. 27699.1636-Phono (919) 7333221
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION h:
STATE WELL CONSTRUCTION PERMITP:�-
1. WELL USE (Check Applicable Box): Rosldenl _;n Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Walor Injection ❑ Other ❑ It Other, List Use:
Agricultural ❑ Misg1toring ❑
2.
WELL LOCATION: (,Ohf the location bclo.v)
Nearest Toven: C7sHA�2S Coua1/:
ZAL D �F-CJCk
(Road tame and Numbms, Com2rJly, or Sabdvision and Lot No.)
DRILU,"'G LOG DEPTH
3.
OWNER V�%t-` MAC
Alin To Pornation Descript:an
Address
0 I& __ SsiAlti
ntrec or 1ou,e :ol
Qb,i qyE I'a $C72 ZA
? - 20 G,2-f- I [G
r,:ycr Tcvm State zip Co,lc
4.
DATE DRILLED
5.
TOTAL DEPTH FT
6,
CUTTINGS COLLECTED YES[] NOD —
.
7.
DOES WELL REPLACE EXISTING WELL? YES 0 NO,K.
� u
8.
STATIC WATER LEVEL Below -Fop of Casing: 7P Fr.
(Ucc `4- it Abovo Tap of Casing)
C O'-;
G�rL-'
9.
TOP OF CASING IS I_ FT. Abovo Land Surface'
'Top of cosln9 terminated aVor bclovr land surtaca roGUlras n varla nco In occor-
danco
mth 15A NCAC 2C .01 to
-- ? r'
10.
YIELD (glom): 20 METHOD OF TEST
11.
WATER ZONES (depth): Rb FT '7p
iD r*•. -o
12.
h-c
CHLORINATION: Type Amount _
Il :_-.,.snaf =pace is needed lice Lace, d bn;1
Ln
w o
13.
CASING:
LOCAL O,`, SK;I C.-I
,. a1lliic%:re
Dol-'h Dip. —,.or I ,•c: ',:e - "t a:c a'I
(Sho'w dir.._;:on and d:..anse from st least Leo Slate
�
Fro,T1�—To 2o - Ft. C.0 5 �'
P.c , or other map re,erenco po;nts)
From— To ---Ff.
B,AC-9 DcK
From --To-- Ft.
d_
14.
GRgUh:
Depth I-la'orlal"r1J-
From To'�)_ Ft.D1S.a`�_ 1n��
Front To Ft. _
15.
SCREEN:
Depth Diameter
From To F1 in.
From _ To FI. In.
From _ To _ FL In.
16. SAND/GRAVEL PACK:
Depth Size
From To Ft. —_
From To Ft.
17. REMARKS:
Slot Slzc Idalotial
In.
_ in.
Material
d
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 N)! ` 13�cjf, �v-}QV D�<` &I Uq.
Cued No; SIGNATUR:_ OF PERSON CC::STRUCT II T H2"dLLL DATE
Submit original to Divlslon of VIner Oua'lty, Ground::aicr Section wllhin 30 days:
Serial No. Gw I REV. I:l59

' . 21?11
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699.1636-Phono [phone]
WELL CONSTRUCTION RECORD WELLCONTRACTOR: J 5 mCCkY �y
WELL CONTRACTOR CERTIFICATION ti 911
STATE WELL CONSTRUCTION PERMITlt: -
1. WELL USE (Chock Applicable So.): ResldenlialtN t iunicipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Iniection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION/:�(Show sketch of the location bc!ow)
Nearest Town: C�.5h1'2 V^ � County: �� Lk,��
13o.\ck �oc�
Agricultural ❑ Monlloring ❑
(Road Name and Numbers. Comi or Subdivision and Let No
DRILLING I-OG
DEPTH
3.
OWNER %fi 5±)'Y-)GY (_
From To
Forralion Descrprlon
Address 4015D ) '>rZ�}— ,cn-a fkc
—(atrecel"or tio—aa th I
0
Cr,y cr Tcw� .,late Zip Coda
4.
DATE DRILLED v)
a(� J 5 U'
%
5.
TOTAL DEPTH
G�)
6.
CUTTINGS COLLECTED YES � NO❑
7.
DOES WELL REPLACE EXISTING WELL? YES NO�
8.
STATIC WATER LEVEL Belovr Top of Casing: FF.
(Use'.' II Abcvo Top of Casing)
^'r^
9.
TOP OF CASING IS I Fr. Above Land Surface'
rNib
'Top
of casing Icrminaied aVor below land surfaca roqulros a varlanca In actor-
n
c
dance
with 15A NCAC 2C.0115
Tr 2
10.
,R.
YIELD (npm): l O hiET IOD OF TEST %
:-
11. WATER ZONES (depth): (n
12. CHLORINATION: Type A.nounl _I�S —II eddll!ona! space i; ;,ceded use Lack of foe
13. CASING: _---___--- —
P:as Thickness
—LOCATION SKETCH
Depilt
DI -na:ar c, i'1. E'a:c+tal
(Shan d!r^et:on and d:sta Co from at least I:co State
or othr-r nap re:orence pain,)
From To--.—
FL
Fr•. —_—To_—
,inFL_
14. GRCU]:
FL
P
�lU LDbCL
K
Depth
tdalellal f. olhod
Front To TocaCzFt.
From _ To
FL
_
15. SCREEN:
Depth Diameter
From To FI in
From —To—Ft.—In
From To FI. In
16. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To Ft. _
17. REMARKS:
Slol Size Molerial
in.
In.
in.
Material
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THATy�A COPY OF OF THIS RECORD HAS BEEN PROVIDED TO TIME<CWELL O'NNER. J�
FOR OFFICE USE ONLY �7`r! \ �lf�.:�{ll�'T(t�j-J��r1�
Ouad IJo: SIGNATURE OF PERSON COrJSTiIUCTItJG TL{� 5' clL DATE
Submit Lo 0;4L,ion of %'later Gualtly, Grounju.;cr Scc6cn vl;thin 30 days
Serial No. G117-I REV.
r T(TNf pW2'k6" `st _�

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section ..4... 10
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: `D D. Mccoq Y
WELL CONTRACTOR CERTIFICATION N:
STATE WELL CONSTRUCTION PERMITR:
1. WELL USE (Check Appucablo Box): Residential Municipal ❑ Indust al ❑ Agricultural ❑ Monitoring
❑
Recovery ❑ Heat Pump Water In;ection ❑ Other ❑ If Olhor, Ust Use:
2. WELL LOCATION: (Sho,v ske!ch of the location be!ovr)
Nearest Town: CA51 "I ) Count;:_ S.QLt YOB
3.&_-0
(Road fdamo and Numbers, Community, or Subdivision arid Lot No.) D R I LI_LVG i _O G_ DEPTH
3. OWNER WES-TMAC-IG— Frcm to Formation Oescript;o..
Address 4050 Lx_C TNIA(Lv—
Duce or 1 ou;o uo.1 r _ � ^
o
Ie lr(i Z� &a AN ItE
O C=
o
pU0—
Ciry cr Tcwo Sta;o ZI;, Coda
�
4. DATE DRILLED 5� 23--0 Z� s-pV <<
bC �), t
5. TOTAL DEPTH[•T"-
G. CUTTINGS COLLECTED YES [,:� NOD —-'
7. DOES WELL REPLACE EXISTING WELL? YES F-1 NO�-
8. STATIC WATER LEVEL Below Top of Casing: 40 FL.
—_ n•=;
(Use'.' it Abovo Tap of Casing)
V`
9. TOP OF CASING IS I FT. Abovo Land Surface'
♦D rr;.o
'Top of easbrg Iermina:ad aJor below land surtaca requiros a vartnnI co In eceor.
danco with 15A NCAC 2C.011e
10. YIELD (gpm): % METHOD OF TEST-_
x
11. WATER ZONES (doplh): 2S Pr
12. CHLORINATION: Type �l� h P.rnour;l _ 4`lra!a:ai =pace ceded u;c bac', of to:e
13. CASING:
l •.'atl thickness
Dep:h Dip..^nlcr cr Ft
1
From �> To Za FL CO74
Front To--- FI.----
Frn;t To—.— Ft.
14. GRQUI:
Depth Ma:oriel Method
Front 0 To=aQ F1.1Sil�_ Gn
Front To Ft. _
15. SCREEN:
Depth Diameter
From To Ft in
From _ To Ft. In
From To Pt. In
16. SAND/GRAVEL PACK
Depth Size
From To Ft. —
From To Ft. —
17. REMARKS:
Slot Size Material
in.
In. _
_ in.
Ma to riot
Lr'C„T'iON SKETCH
(Show di:eC,:on and dl!a f(cm at I0ast P.vo Sate
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WI T I 15A rJCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECCRD HAS BEEN PROVIDED TO THE WELL 05C'NER.
FOR OFFICE USE ONLY
Oki �reewne -`vn� lOQ `� D\< f�� �,�V�k. Z�`c�
Ouad No; S;GNATURE OF PERSON CONSTRUCTING TH 'kLL DATE
Submit ori,iwl to OivL•lon of PValor Quality. Groundwater Sccdcn wilh!n 30 days
Serial No. GVl I REV. 11-199

_ s
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Seclion
1636 tdail Sorvica Center - Raleigh, N.G. 27699-1636-Phona [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: tU55F_L my cz
WELL CONTRACTOR CERTIFICATION I": - zoa
STATE WELL CONSTRUCTION PERMIT k:
1. WELL USE (Check Applicable sox): Resfdontial'n Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Othor If Othor, Ust Use:
2. WELL LOCATION: (Show sketch of the locaticn be!ow)
Nearest Town. C(}E,w KZZ Coanfly:
_
5u NSCT rAam W.
(Rcatl game and Numbe(s, Corn nu..;iy, or Subdwslon and Lot No.)
3. OWNER .SC-cYT N)EWTO`-�
Address IOR '?,,AF- c2e:>, 92,
uT000ulo ao.
l ITT1EQ- !3L- Z$-.-4-l9
or Tcvm State Zip Coco
4. DATE DRILLED 5- LCr'cyo
5. TOTAL DEPTH 41y F-r
G. CUTTINGS COLLECTED YES NOD
7. DOES WELL REPLACE EXISTING WELL? Y'ES O N0,0
8. STATIC WATER LEVEL Below Top of Casing: -40 FT.
(Use'.' if Abovo Top of Casing)
9. TOP OF CASING IS I FT. Abovo Land Surface'
'Top or caaing Icrminaled aVor below land surfeco requires a variance in accor-
dancev.11h15ANCAO2C.0 6
10. YIELD (gpm): METHOD OF TEST
11. WATER ZONES (depth): I- 22 S I- 315
--7ALKy J
Agricultural ❑ Monl oring ❑
DRILLING LOG_
Fran To
0 1w
IG+y - 1L02
Ico2- old
DEPTH
Fc,ma:ion Desc.r pLoc
�2An1tTb
C)
c
CJ1
12. CHLORINATION Type H � ti F.:wunt _%.�_ iLL9 I' c�'d:;!onai space is ,:ended use bac'a of fore
13. CASING:
Yh!I thic.nes^. LOCATIO:N SKETCH
Depot Dlo^e:Fr c: 1: d,':! Ft. L'atn dal (Sho'.v dir^ctbn end d�5!anco from al least Ivro Slate
From _CD�—To 1 (10 Ft. co
/� PJL r z.:ds, or other m� r_:erencc pelns)
From To Ft.
From To-- FI.
14. GRQUT \\" C
Depth
From To QC > Ft.
From To Ft.
15. SCREEN:
�1.!"a:mlol I: elhod
Depth Din(netar
Fwm _ To Ft in.
From To FL In.
From —To—Ft.— In.
16. SAND/GRAVEL PACK:
Depth Size
From To —Ft —
From To FL
17
Slot Size Malerinl
In.
In.
Material
7D
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED III ACCORDANCE WI T H 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS PEEN PROVIDED TO THE WELL OV.'NER.
FOR OFFICE USE ONLY 1
IOcad No: SIGNAI URE OF FCRSON CC P CTING THc VIELL
— Submit ori�nai io D ,:on of P,a'or Gwlily Ground:a;cr Sect cn t. ,'!In 30 days
Serial t+o.
DATE
UN I TEV. 1'2/ 9-
r

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 tdail Service Center - Raleigh, N.C. 27699-1636-Phono [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: kist r" Tn-IL--IL
�'IELL CONTRACTOR CERTIFICATION P,: - 2d87-
STATE WELL CONSTRUCTION PERuMITN:
1. WELL USE (CheckAppncable Box): ResidentiaY Municipal ❑ Industrial ❑
Recovery ❑ Heal Pump Water Injection ❑ Other ❑ It Other, List Use:
Agricultural ❑ tvtonitoring ❑
2.
WELL LOCATION: (Show sketch of the location bolo%v)
Nearest Torn: CAC9.c�tz County:
w Di SPr Nis :LD, it � ` 'ZA LW �j.
(Road Name arid ttbcc s, Corn rally, or Subdivision and Lot flat
DRILLING LOG_
3.
OWNER M:� c� iEk,FN
Frcm Tu
Address 245 WtDaj-3 6R7.45
vec Fur HouiilTS.)
W HI TT)eab )J(— 2Q:;L 4
7of
Clly cc Town Slato Zip Coda
—
4.
DATE DRILLED SI24�oo
5.
TOTAL DEPTH ZZS GT
6.
CUTTINGS COLLECTED YES F;5;� NO
— -
7.
DOES WELL REPLACE EXISTING WELL? YES ❑ I10,0
6.
STATIC WATER LEVEL Below Top of Casing: QD Fr.
(Ucn '.'if Abovo Tap of Casing)
9.
TOP OF CASING IS I FT. Above Land Surface'
'Top
of casing lerminated atlor below land surface requires a vorlance to accor-
dance
with 1SA NCAC 2C.011e
10,
YIELD (gpm): ._12— METHOD OF TEST _
11.
WATER ZO\ES (depth): _ I-1aD /- 11c-
�_ e4v Z-7_05
DEPTH
Fo allon Descdplion
CLM
ll-Q-i�c'i£
AnS cT� r.
n P
i c5T_
12. CHLORINATION: Type ti F.;nounl _ Qd �lf.-3 It _-.:;:c:a; a?ace it nrrdcd u.c Lac'r.o( form
13. CASCdG:
t•:ou u,i�2r,ra
Depth o1 Di.o.m._:c� cc ','c'J: Y.t. 1.'1alydal
Prom S> To Pt. Qe f -yyc,
From-- To Ft.
From To-- Ft.
14, GROUT:
Depth ^ra_a'o;Iai f,t0ird
Flom To ll=_q_QZFt.AS;.a1_ 1 ��
From To --Ft.
_
15. SCREEN:
Depth Diameter
From To Pt in.
From 7 o _- Ft. In.
From To Ft. In.
1G. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To Ft.
17. REMARKS:
Slot Sic - tMaterie- f Materiel
n. _—
in.
Material
IOCLTIOfd SKF_TCH
(S,ho,v dirrcl:on and Cs;en:;e from at Lost 6vo Salo
P.ca c, cr other map ro:rroncc papa)
Z"1/1)
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED Ill ACCORDid1C WMH 15A N.CAC 2C. WELL \\>
CONSTRUCTION! STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL DINNER.
�1 Qree�� lJL\\17\�L� Sy�V�I. 1,2
FOR OFFICE USE ONLY ti 16 g
Quad No: SIGNATURE of FERSON CONSTnuCTMG TFIE 'eLL DATE
6obmii original to Ci�L•Ion el Ylalcr Quallly, Ground-.ra;cr SecF,cn 1•.� Yn 30 days
Serial No. G'!.'- I REV. 199

North Carolina - Department of Environment and Natural Resources - Division of Water Oue:ity - Groundwater Section ( rr
1636 Mail Sory3 lce Center - Ralcigh, N.C. 27699.1636-Phono (919) 733221 '" ,J � 9
eu55Eu To oV-
WELLCONSTRUCTIONRECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION i.: �7_
STATE P/ELL CO NSTF.0 0TI ON PERM1 r:
1, WELL USE (C he ck A, plica ble BOX): Re sldenti a;�n Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ if Olhcr, List U3c:
Agr:-u!lural ❑ tdonilorirg ❑
2.
AYELL LOCATION: (Sho:v sketch of the location bele,v)
Nearest Tov,n: SyLVA Count/:
P£ECN� LA^1G
(.9cad Name end Numbare, Cortxnu: dPy, or Sub'-.' and Lot No.)
OF.!LLING LOG
3.
OWNER�lGiT2-�5JJ'/XY-
Frcn To
Address RL),ecr` 171
C) 121
Unger Tcvro S:ata Zip Ccba
<.
DATE DRILLED---
2
5.
TOTAL DEPTH-
6.
CU Ti INGS COLLECTED YES NOF
— ---
7.
DOES %YELL REPLACE EXISTING 6`/ELL? 1'FS ❑ I:a
8.
STATIC %PATER LEVEL 6elov: Top of Cnsing:.—_ FI .
(Uce',' if AbC'+a Top of Cris r,,)
9.
TOP OF CASING IS 1 FT. A bovo Land Surface'
-Top
of ea:':'.o lerrilrata oJor bcfo.'r laid surfzca requlraa n vorl.:nco in actor
-- —
Jnnco
r.i:h iSA NCLC 2C .0110
✓ 1.+.ETHOD OF TEST Cl.,r
10.
YIELD(,.;;r:,;: _--
-
1 t.
Vi Al -EH 'O•N''ES (dap C:): E•7_ -
---
DEPTH
Focapon Dc;dpC.cn
C�fZAN 17�
12. CHLC� :!.:ATION: T)pe �i�- Fi r.rcounl — �,p''c-" — I' _a is r,_^.da L':^.ck c; f�.: c o
z
Fro-, s To i'L3 _ F!. C2=t
Fret% To—_— Ff.
From To-- Ft.
14. GRQU1:
Depth
Ftom 0 To', ) ) Ft.
From To Ft.
15. SCREEPI:
Drpih Di, meter
From To FI in.
From —_ To Ft. In.
Flora ToFI. In.
16, SAi:D;GRAVEL PACK:
Depth Size
Frorn To Ft.
From To FL
17. REl,!AKS:
Lla:axial L:ethcd
�S1LT1�_ l C�C7
P4
-6a:
Slcl Size f: a:r.ial
in.
f.ta!otial
(Dp^ %r')'.! f -:ETCH
A� i:c a s, cr o'.Pc; map r_,sencc pa:rL;)
1 DOHH_P.EB'( CERTIFYTHAT T:HISWELLVi.AS CONSTP,UCTEOItlACCORDi: CEPitIH!-A NCAC 2C, PiELL
CCNSTRUC T IC: f STANDARDS, AND THAT A COPY OF THIS RECORD HAS Pr -EN PPrO`:ID�D'i G(I'.E l'IELL G': RJER.
FOR OFFICE USE ONLY �(��'yr)C. V(l` � ��'�-`� ��-:1�•. z-A- ✓.,�;Jck I '�
\-- f
C:.,d No: -. S C:tJA1'JRE CF FERS0tI COt L,T n...,: DATE
Subwdl ori4�no:do D:vd: on oI Plater Cualily. Gre'.n•,:cater Seac.a r.1l.,in �0 days
Serial No.
F:'t Id
lov

North Carolina - Department of Environment and Natural Resources - Divlsion of Water Quality - Groundwater Section .15
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone] E
WELL CONSTRUCTION RECORD WELL CONTRACTOR: L, hi cy rr`(A'CY(q
WELL CONTRACTOR CERTIFICATION #:, Q 1
STATE WELL CONSTRUCTION PERMIT4:
1.
WELL USE (Chock Applicable Box): Residenlia� Municipal ❑
Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑
If Other, List Use:
2.
WELL LOCATION: (Sho•,r sketch of the location belmv)
Nearest Town �c r �12(� Court
Road Nava d N tubers, Qoommmu/nittt or Subdivision and Lot Ho. )
DRILLING LOG DEPTH
3.
OWNER `�41 \ j "'C'C'1 \xl\ C�
From To Fo alien Descdpion
^
Address ��i`L� - �e\`-
0 11` L'i
`\ -�(Sbeo
City cr Torm Slate Zip Code
4.
r
DATE DRILLED
5.
TOTAL DEPTH
6.
CUTTINGS COLLECTED YES® NO❑
e�
7.
DOES WELL REPLACE EXISTING WELL? YES [-] NO�o
A n-
8.
STATIC WATER LEVEL Below Top of Casing: y(x, FT.
C -=
(Use'.'if Above Top of Ca3icg)
9.
TOP OF CASING IS FT. Above Land Surface'
-Top of easing terminated atfor below land surface requires a variance in accor.
dance
10.
with 15A NCAC 2 Oils
YIELD 2ARL METHOD OF TEST
—�'-
11.
(gl '
WATER ZONES (depth):
_
cl•1
12.
CHLORINATION: Type `A�v Ni Amount _ CJ
It additional space is needed use backer form G.l o
13.
CASING:
LOCATION SKETCH_
Y4; Thickness
Depth .Tc�r or 17gigh;Ft. If I i I
J X_
(Shc" direcCen and distance from at least two State
s From ToFt.
Roads, or other map reference points)
From To Ft.
From To— Ft.
14.
GROUT:
Depth Material Molhod
From 2 To--__1QFt. O)E hl9
From To Ft.
15.
SCREEN:
Depth Diameter Slot Size Material
From To Pt In. In.
From To Ft. In. In.
From To Ft. in. In.
16.
SAND/GRAVEL PACK:
Depth Size Material
From To Fl.
From To Ft.
17.
REMARKS:
I DO HEREBY CERTIFY THAT THIS VlELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C. WELL
CONSTRUCTION STANDARDS, AND THAT A COPPY OF THIS RECORD
S HAS BEEN PROVIDED TO, THE WELL OWNER.
FOR OFFICE USE ONLY I)Jgfi CYC.QC RrDI%-Z Db c'- Jylu2f
Quad No: SIGNATURE OF PERSON COfISTRUCTING THE WE& I DATE
Subrnii original to Division of Water Quality, Groundwater Section within 30. days
Serial Na. GV1.1 REV. 12/59

North Carolina - Department of Environment and Natural Resources - Division of Water Oualiry - Groundwater Section o 44 a
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone] (1 9- 1 .i (I 9 3
WELL CONSTRUCTION RECORD WELL CONTRACTOR: _Cln lL Qlk
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (a,eck Applicable Box): Residential, Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ It Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: Counhl: ` -�--
Lot
3. OWNER
Address
City or Town Slato 41p 1.o e
DATE DRILLED _q_.�\_. c:)U
S. TOTAL DEPTH
6. CUTTINGS COLLECTED YES O NO❑
7. DOES WELL REPLACE EXISTING WELL? YES
S. STATIC WATER LEVEL Below Top of Casing: fz�,— FT.
(Use'.' L' Abovo Top of Carng)
9. TOP OF CASING IS A— FT. Above Land Surface'
-Top of easing terminated aVor below land surface requires a variance In accor-
dance with 15A NCAC 2C.0118
10. YIELD (gpm): <_:AC-j— METHOD OF TEST ipA 1'YR,
11. WATER ZONES (depth):F�-
12. CHLORINATION: Type Amount
13. CASING:
Depth Diar _cr
Fwm _C_21—To`� l Ft, yn`
-�
From To Fl.
Frorn To -- Ft.
14. GROUT
W'oll Thickness
cr W\e-L,FI. Iatcdai
Depth Material Method
From To .Z Ft. 0t- Vic VC�1_ � CIP
From To Ft.
15. SCREEN:
Depth Diameter
Frorn To Ft In.
From To Ft. In.
From To __ Ft. In.
16. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To Ft.
17. REMARKS:
Slot Size Material
in.
In.
In.
Material
DRILLING LOG
From To
U
Agricultural ❑ Monitoring ❑
DEPTH
Formallon Descdptlon
\1
Q
v
a
n.-
I: additional space Is needed use back o! form
LOCATION SKETCH
(Sho+: direction and distance from at least I::o State r
Roads, or ether 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 RECORRDc1H�AS BEEN PROVIDED TO THE WELL OWNER. r
FOR OFFICE USE ONLY nv)fi A ` "� � ` o\ " ) � �yIun �Tky �P, 0�
Ouad No: SIGNATURE OF PERSON CONSTRUCTING THE WEbo DATE
Submit odoinal to Division of Plater Duality. Groundwater Section Within 30 days
Serial No. GW-1 REV. 12/59
n Rst12>1�i1 e w :

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]. � 'a
WELL CONSTRUCTION RECORD WELL CONTRACTOR: ep�C_
WELL CONTRACTOR CERTIFICATION 0: I D"�0
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: (Show sketch of the location below)
Nearest Town: C� A���'C IV�C- Couny����' 1
'- C� \_I y1 _C ``(A
(Road Name and, lumbers, Co •munity, or Subc!Msiion and Lot No.) DRILLING LOG DEPTH
3. OWNER t--W� `V-�t'1CSUi.'� - __. From To Formation Description
CA.Pw,
\1
Agricultural ❑ Monitoring ❑
Address
City or Town State - Zip Code
4. DATE DRILLED y'-U--CCU
5. TOTAL DEPTH __�C'Y1
6. CUTTINGSCOLLECTED YES® NO❑
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO,0
=='
6. STATIC WATER LEVEL Below Top of Casing: yr, FT.
AA (Use'.- if Above Top of Casing)
C
;
9. TOP OF CASING IS Ci- FT. Above Land Surface'
'Top of teeing terminated actor bctow land surface requires a valance In eceor-
r-_
J
-
dance vdth 15A NCAC 2C .0118
10. YIELD (gprn)I \�METHOD OF TEST
_
11. V/ATER ZONES (depth):
vDCn
12. CHLORINATION: Type Amount 4.
It additional space Is needed use back of form
coo
co
13. CASING:
LOCATION SKETCH
Vla'I Thlckress
Depth L _ iarrteter or Vlei,hUFt �ldate_rffal
fJ=—Lu-
(Show direction and distance from at least two State
From -C-)—To Ft.
Roads, or other map reference points)
From To FI.
From To— Ft.
14. GROUT:
1AC) "N'Asl -
Depth Material Mothod
From To Ft. O4=nun' 1C-)7
Frorn To Ft.
15.SCREEN:
Depth Diameter Slot Size Material
From To Ft _. In. in.
From To Ft. in. in.
From To Ft. In. In.
16. SAND/GRAVEL PACK:
Depth Size Material
From To —Ft. -
From To FL
17.REMARKS:
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE
WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT AQCOOPYY OF THIS RECORD
HAS BEEN PROVIDED TO THE WELL OWNER.
���y/�I
if
FOR OFFICE USE ONLY
! "e K s V-\���1Q
aSWQ.� l&A
i ' `Q0500
Quad No:
SIGNATURE OF PERSON CONSTRUCTING THE L • L DATE
Submit original to Division of Water Quality,
Groundwater Section Within 30 days
Serial No.
G`NA REV. 12J99
I

North Carolina - Department of Environment arid Natural Resources - Division of S%ater Cuality - Groundwater Section 21. 3 2 1 I"7
1636 t.lail Service Center -Raleigh, N.C. 27699.1636-Phone [phone] �" 1 6
WELL CONSTRUCTION RECORD WELLCONTP.ACTOR: �lISxLL -TAyt_o(N
WELL CONTRACTOR CERTWICATIOII F: 2I Qj
STATE WELL CONSTRUCTION PERM!, N:
1. WELL USE (Check Applicable 50* Resldentla;LN Municipal ❑ Indusfria! ❑
Recovery ❑ Heat Pump 4Vafor injection ❑ Other ❑ If Othor, Llst Use:
Agricultural ❑ Monitoring ❑
2.
1VELL LOCATION: (Show s'r.e:ch of the IOcaflOrl be!oa+)
Nearest Town: �ti-U-'S �`" Cou^•;7: ���x�
Ra9x e5 CMS -
(Road Earns and Numbers. Cc rrnu..-;ly, or Subd:vlslJn and Lot No.) DR!i_LING _LOG_
DEPTH
3.
O.VNEF1 I( Fl�y-Ay otMG F:c:,i To
Fo,..wion DC,cdp'Jcn
Address tt.0 e R-wec:5LOF- 0
en ISAr4,D
—�33
l�Veol Of l4JJlC i0�
�^
Fo✓<-T /lL C4S t`-I- 1<v
L'dy or Tc:.n State Z,-. Cc
4,
DATE DRILLEp 4-Ib-60
3Db
7r tr
5.
TOTAL DEPTH _"5;q-. - D�
`�__�_,•
G.
CUTTINGS COLLECTED YES NO❑
7.
DOES WELL REPIACE EXISTING WELL? 1'ES ❑ tIo
E.
STATIC WATER LEVEL Belo':: Top of Casing: FF.
(Uae'.' it Abcvo Tep of
S.
TOP OF CASING IS I FT. Above Land Surface'
.• M>J
c�
'Top of cooLg lcmina:cd oVm bclevr Iand su rfate ro quirt: a •: arl:.nce In actor- —
'1
dance
v. i;h liA NCAC 2C 9110 �1r
—Ea9— O
10.
Y1rLD (c,I) : /O METHOD OF TEST _
11.
VIA] ER ZONES (dopth):
12.
CHLORINATION: Type A.raour^ .� " �—;:o::a! coact
:cdeC
13, CASING.
Sl%ETCH
Uo lh �_L
Df^/� crPlc'='ryl.s ..,:�:c:::yl _ (5�_ivr5:_c;:c;,c-dd!S.z..-c lr_rn :a lua.l;..o S'.a:c
!J •�$e`
iS>
I eI 1
Q Ft..
—LIL_ s, er o:hl.r m..a,p r ::enee po:;r 5
Fro;:,—
To-- Ft.
— �`' %/�
• Gy
Fror,
—To_— Ft.
- ------tl
a. GROUT":
n
Depth
Ha:erlal I:. e:hcd
Front
To =�_
Front __
To Ft.
_ _ „y'�
tv. SGREEfl:
Depth Diameter
Slot Size - l.later!al L'
From
To Ft
In. in. ru
From __
To - Ft.
It!. In.
From —To
FI.
In. in.
15. SAND/GRAVEL
PACK:
Depth
Size t.:ateria!
1L"
Front
To Ft
From
To Ft.
17. REMARKS:_
— �y
THIS WELLY.AS CONSTRUCTED IFI ACCORD•.NCE`:l TH 15A NCA.C2-IO L OAS �
iGITl-
I DO HEREBY
CERTIFY THAT
CONSTRUCTION
STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE V/ELL 0':111`11ER. ,1
FOR OFFICE
USE ONLY
00A Q(E'C0(,_ ' C:<-' DC S'�'
Quad No:
SIONAIUP.E OF PERSON CC:iSTRUCT I:lG TH _\ticLL LATE
Submit o i nal to Db.l:!an of VWar Cualilf. G'c undvea:Cr Sc:F: n Vrilh!n 30 days
-
S trial No.
Ga: I FIEV.I

North Carolina - Departmont of Environment and Natural Resourcao - DivL^ion of Water Quality - Groundwater Soclion 1y �
1630 Mail Sorvice Center. Raleigh, N.C. 27699-1636-Phono (919) 733--.'.221 A(.i 3
WELL CONSTRUCTION RECORD WELLCONTRACTOR: T , 0AA
WELL CONTRACTOR CERTIFICATION 0: I�— STATE WELL WELL CONSTRUCTION PERMITII:
WELL USE (ChockAppncatda Box): Residential Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection n Other ❑ It Other, List Use:
WELL LOCATIO�r1� (Shy ww kletcIt of the location below)
Nearest Town: \ -�� 111_U3.�11'Q.`� r County:
Agricultural ❑ Monitoring ❑
(Road Name and u 1, Cenlrnen , or Suhd'iv(Islon and Lot Na.) DRILLING LOG
3. OWNER 1.2_ Fiorn To
Address II0\In F qWqNo.)
C 1 �S re! oCor R I_ I No. 3 lb�
ily or To.vn / SWIo :7p CcCe
4. DATE DRILLED - _I --00
TOTAL DEPTH M CCU
3. CUTTINGS COLLECTED YES [�P� NOD
7. DOES WELL REPLACE EXISTING WELL? YES h;O� - (_-�_L4
3. STATIC WATER LEVEL Below Top of Casing: E FT.
(Uso'*' II Abuvo Top of Casing)
9. TOP OF CASING IS FF. Above Land Surfaeo'
'Top of casing lornilnetod alJor below land surface raqulres a varlonco in occorr.
dance Ylh1115A NCAC 2C.011 a
10. YIELD (gpnl): METHOD OF TEST �lJ
11. WATER ZONES (dopth): 6
DEPTH
Fonnallon Doscrlpaon
-0cc 1.0
n
It
0
rn•
12. CHLORINATION: Type _❑U Amount �_J j Vk I0 h additional space L• needed u;c back o: loran
13. CASING: ---
Wall Thickness
L.00ATIOf,i SKI- FCH
Depth
t1 Qq
Ia 1
Dl, icier or Wei I vI*1.
� `�
aledal
5 C'
(Show direction and di;anco fiur;i rd least Iwo State
From To
PL
Roads, or other map ra(cicnca poirtls)
From To
From To—
F-l.
FL
!1 'I1� r1 II
SAJ �.�dW•C.l�.. �
14. GROUT:
1VJ
Depth
')0
Matodal
Molhod
f
From To
Ft. S-�QXL-IC'
From To
FI.
1S. SCREEN:
Depth Diameter
From _To Ft In.
From To Ft. In.
Front To Ft. In.
15. SAND/GRAVEL PACK
Depth Size
From To Ft.
From To Ft._
17. REMARKS:
Slot Size lvlalorial
In.
In.
Material
I DO IiERCUY CERTIFY THAT TI IIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, 11JELL
CONSTRUCTION STANDARDS AND THAT A COPY
OF THIS RECORD HAS BEEN PROVIDED TO l'l E WCLL OWNER.
FOR OFFICE USE ONLY' G ✓•���
�
Quad No: — a}} r i n S00 lAi UIIE OF PEf1SON CONSTRUCTING THE Y/ f DATE
Lj it Lwb,d.4 qfq n&10 D r;slon ol'f/a.ur Quality, Groundwater Sc Uion Will lilt 30 dJ S
Smial No. �{ GW-1 n6V. 1^✓'J7
/
1
V50 V

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section ti i (T Vf
J
1636 !jail Service Center - Raleigh, N.C. 27699-1636-Phcno [phone] 1 0
WELL CONSTRUCTION RECORD WELL CONTRACTOR: A usa, /-/ 7—ay /o $—
WELL CONTRACTOR CERTIFICATION P: 1 E*7 _
STATE WELL CONSTRUCTION PERMITH:
1. WELL USE (CheckAppucable Bo=): ResldenfiaY� Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Infection ❑ Oth.r ❑ it Other, List Use:
Agricultural ❑ Moni!cring ❑
2. WELL LOCATION: (Show sf:e!ch of the location belov.1
Nearest TolwIn: S' I I 1 I C - Counfy:
a
/V iI f`A/ Lc K
(Road Name end L:umbars, ColmrnurPy, cr S,�{ad:visicn and Lf�ai Ko.) DRILLING LOG DEPTH
3. OWNER J rim IC I (a DG-kA Ct 11 From To 1=0r,aaonDcscripla-
Address /T"i % l Cti /�,rn b U k— ��i A/t U -V dl /ate ,f
'Dly or Tcv:n 6:alo Zip cote
4. DATE DRILLED
5. TOTAL DEPTH 3yS
6, CUTTINGS COLLECTED YES© NOD
7. DOES V/ELL REPLACE EXISTING WELL? YES 0 F10j},
B. STATIC WATER LEVEL Belot': Top of Casing: // o'( O6 FT.
(Use 4' If Abc:e Top of Casnq)
9. TOP OF CASING IS i FT. Abovo Lan J Surface'
'Top of cas!ng tennlna!ed Dvor below land surface requ:res n variance In accor-
dance with 15A NCAC 2C.0113
10. YIELD (gpm): q_ METHOD OF TEST AI C.
11. WATER ZONES (depih):-� 1'35/ /L _A/D/
12. CHLORINATION: Type
13. CASING:
lVatl i`)c%ress
From _CD_ To d—Ft. -rzu
From -io--- FI.---
From --To __ Ft.
14.GROUT:
Depllt y� Ltatrrbi1 t.".othod
From To _��. L1 Ft.
From __ To Ft.
15.SCREEN:
Dcplh Diameter
From To Ft in.
From __ To FI, In.
From ---To - Ft. In.
16. SAND/GRAVEL PACK:
Depth Size
From To Pl.
From To Ft.
17. REMARKS:
Slot Size Malerial
in.
in.
In.
Material
L{ttiU _�r6fA)itIt.
IfrdIj;!;�. al V .,ace!soed
-
_LOCATIOt !-e,' TRH
(Shov: dtrec:bn and dist_nc_ -.,� L� two 5.,.,2
Roads, Cr cl. c,r map
I DO HEREBY CERTIFY THAT THIS'NELL WAS CONSTRUCTED IN ACCORDANCE WITH 1SA NCAC 2C, V/ELL
CONSTRUCTICN STANDARDS, AND TH AT A COPY OF THIS RECORD HAS PEEN PROVIDED TO TH:E %' ELL OWNER. c
FOR OFFICE USE ONLY g(N N Gcg_e� ( 1� RC CS L\.1,VI )
Quad No: SIGs:ATURE _ CF PERSON CONSTRUCTING THE WELL DATE
. - Su^mil on;tnal to Clvlslcn of Ofalcr Oua,tty. Grvund'e'a!er Secllen vrithin 30 Gays
Sm-ial No. GW-1 REV. 12'79
L)C l o/1 s/a

>31.04
North Carolina - Departmont of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELLCONTRACTOR: _ &55ou TayLo(+
WELL CONTRACTOR CERTIFICATION #: ZI Tim
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Chock Applicable sox): ResldentlaAn Municipal ❑ Industrial ❑ Agricullurai ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Ciher ❑ If Other, List Use:
2.
WELL LOCATION: (Show sketch of the location Le'ovr)
Nearest Town: SxLV,& County:
xesc �
Yr^f C7 II'1.00• 'TAW c-5'rR TE.5
(Road Nine and Numbers. Community, or Subdivision and Lot Na)
DRiLLING LOG
3.
OWNER 2
From To
Address .J.l�>t `�
0 60 Z
lie— or au e No
L� rSC- 21�_qZ5,
2 l
City cr Tca.ro Stare Zip Code
4.
DATE DRILLED 9"
5.
TOTAL DEPTH I'T
6.
CUTTINGS COLLECTED YES© NO[:J
7.
DOES %'JELL REPLACE EXISTING WELL? YES ❑] NO�
S.
STATIC WAI"ER LEVEL Be!ovr Top of Casing: — FT.
(Use',' it Abo•:o Top of Caa!:,q)
9.
TOP OF CASING IS : FT. Abovo Land Surface'
'Top of casing Icrminalcd al.'or Eciow land surface requires a varlance In accor-
dance
wllh 15A NCAC 2C .011a AIL
10.
YIELD (gpm): O 61ETH'OD OF TEST
11.
WATER ZOF.ES (depth):_----- --- ---
DEPTH
Forr.a:fun Ge,c'.paa�
12. CHLO!I!NALION: T r w1y�T Ei A:nocni Aw�/w5 Lzddaiona!<_,^ace is nr,c?d uc e:-Act
N - — T-
13. CASING:
Wall Thrknes5
Depth Dlamc:cr cr;;ci eFl. b'a:c Cal
From -C') -To =A-F:.
From — To FI. - --
From To-- Ft. —_-
14.GROUT:
Deplh Matorlal _t.'.ethod
From To=i;;L(_ Ft.
From _ To _-Ft.
15. SCREEN:
Depth Diameter
From ---- To Ft in.
From __ To FL In
From —_ To _ Ft. In.
16. SAND/GRAVEL PACK:
Depth Size
From _ To Ft. —
From To Ft.
17. REMARKS:
Slot Size Material
In.
_ In.
Material
LOCATION SKETCH
(Show dlre_tion and distenco from at ions! I'so
Roads, or olher map reference po;nls)
r
t
U
w
0 -Yro SR J3�Jl
---
� 441 7u Sy<.�.a
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, %%ELL
CONSTRUCTION STANDARDS,,,, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED /T,O THE WELL OWNER.
FOR OFFICE USE ONLY " v� � !e�pwQ -ZCb5 ik)ell D\e v` SyIoa-U0IGl I Cc-
Ouad No I SIGNATURE OF FERSON CONSTRUCTING T .c V. ELL DATE
Submit odu;nal to Dhrslan of 4'Jalcr Dually, Groundv: atcr Se<lion within 30 days
Serial No. - GVJ.t REV. 12J59
;RI a4
R
Cratlndwa`p
F'S.^.CVi!?P, fiaa.

North Carolina - Department of Environment and Natural Resources - Division of Water Duality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD
,) q
�.. .,10 3
WELL CONTRACTOR: IZ055644-
WELL CONTRACTOR CERTIFICATION 0: Z/gam
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Dox): ResldenllaAL i Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water In;ection ❑ Other ❑ It Other, List Use:
2. WELL LOCATION: (Show sketch of the localion belov:
Agricultural ❑ Monitoring ❑
Nearest Town: .5 y1-VR County:
N C:) /1 curJ ZRr•J
(Road Name and NumScrs. Community, or Subdivision and Lot Nc) DP,IL LING LOG DEPTH
3. OWNER -76P Si-, 4J5�a From To Formation DescripUcl
Address V,J-&Ie 740 C�) SL- C"y
yieL.i Ireo ar Ae ;o.) Z� S2 c-/t (A2ANr
'City or Town stale Zip Code
4. DATE DRILLED
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES© NO[_] —
7. DOES WELL REPLACE EXISTING WELL? YES n NO� —
8. STATIC WATER LEVEL Below Top of Casing: _ / S FT. —
(We'.' if Abovo Top of Ca,inu) —
9. TOP OF CASING IS FT. Abovo Land Surface'
'Top of casing terminated odor below land surfaco requires a variance In accor-
dance with 15A NCAC 2C .e118 —
10. YIELD (apm): _ METHOD OF TEST y7L — —
11. WATER ZONES (depth):
.eAN l aG
12- CHLORINATION: Type Amount — _ �—�� I! zd'_Itior'.ai s.acc is neaded use tcckcl lo•rnZ o
13. CASI IIG: -- ___—_ — ---
1vaB Titc+-.^.e ss _LOCATIO>J SKETCH
Depth Diameter cr lvcl;,nl'i';. tale dal (Show dlrecticn and distance from at least two State
From To 5� Ft. �V r-' Roads, or other map rele;eT ce points) �r
From To Ft. —
From —To— FI.
14. GROUT: • Depth t.talerlal McL':od Q,�Y
From 0 To ca C)-. Ft. It
From To Ft.
15. SCREEN: }�r�
Depth Diameter Slot Size Malorial
From To Ft in. In.
y
3
From To Ft. In. In, 0
From To _ FI. In. - In.
16. SAND/GRAVEL PACK:
Depth Size Material � �
From To Ft. — C+r� D�f lilt.
From To Ft. `I�t"�%,a _�__.- _� ✓�'d
17. REMARKS: �
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT AA COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY 't�P-�' ` \1(Q''I us w�"�� �'�
Quad No: - SIGNATURE OF PERSON CONSTRUCTING THE 1vr: DATE
Submit orip;nal to Di• lslon of Water Quality, Groundwater Section within 30 days
Serial No+ " ` GW-I REV. 12159
a �
Gmnndvrate � '+rr
Asheville RpRo et

�1
North Carolina - Department of Environment and Natural Resources - Division of Wafer Quality - Groundwater Section �_" 02
1636 Mail Service Center- Raleigh, N.C. 27699-1636-Phono (919) 7a3-3221
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION
STATE WELL CONSTRUCTION PERfAIT#:
1. WELL USE (Check Applicable sox): Residentially Municipal ❑ Industrial ❑
Recovery ❑ Heal Pump Water Injection ❑ Other ❑ If Other, List Use:
2
3
Agricu'tural ❑ Monitoring ❑
WELL LOCATION: (She,v sketch of the localion below)
Nearest Town: 21ql T✓GY-FISEe Cour_y:
N�- mI" M-rs
(Road Name and Numbers, Communniify, or Scbd:vsian and Lol Net
DRILLING LOG
OWNER PAVrd ArJ DAV.t_-"e �J�
From To
Address 5 � (Ntr-t-% -DIL FAA
0 �l
G2@ sz^LJ alraeorr!V,071 o.l Z340
yj
-My or Tcwn Stab p Cod? -
4. DATE DRILLED q-b) _
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES© NO[_1
7. DOES WELL REPLACE EXISTING V/ELL? YES O N0,0
8. STATIC WATER LEVEL Below Top of Casing: �'YJ FF.
(U;o'+' it Abavo Top of Ca;ing)
9. TOP OF CASING IS I FT. Above Land Surface'
'Top of casing terminated eJor below land surlace requires a variance in accor-
dance with 15A NCAC 2q 4118
10. YIELD (cpnl): METHOD OF TEST Alf=c
11. WATER ZONES (depth): 4Zopr _---
12. CHLOR'N.ATION: Type �_�- y Am.cur�3
13. CASING
V;ail Thlckrrss
Depth n;,,
AO
Diameter or P:e:�—y F[
„a:edai
From—�
To Ft.
r
---
From--
To FL—
—
From
To-- FL-
14. GROUT:
Depth
f lalorint
Lf_thcd
From
C) ToFt.
<<
From
_ To __Ft.
15. SCREEN:
Depth Diameter
Slot Size
Ma:oral
From
From
To Ft __
To FL
in. in.
In. In.
From
To Ff._
In. in.
L
16, SAND/GRAVEL PACK:
Depth
Size fda!erial
From
To Ft.
From
To Ft.
17
DEPTH
Fcmation Descr:pLoo
cry _
C_V A 1
O 't
CD ' n�
s II Socai spa__ ., ceded use back,, e:'-,r,- rN*-,;M0
n—
LOCATION SKETCH a% oz
(Show direciicn and d 5:anco fron a! toast Iv.o Sale
Roads, or o"hcr map reference pc nis)
2e)
tL"�
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 RE�EC,O�-R\D HAS �BEEE�N PROVIDED T'O� THE WELL OWNER.
FOR OFFICrC U52 OEZLY 'iii -D� ic)_
Cuad No: , S U u _ SIGNATURE OF PERSON CONSTRUCTING Ti .. WELL DATE
S b 1Yrarii nal to Gv.Is on of Vlater Cuality, Groundnater Section within 30 days
GY/-t REV. i
Serial No. litL917
gr
2/99

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section r" a)
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD
WELL CONTRACTOR: _ _ jztjssfEw "T»yt-tXL
WELL CONTRACTOR CERTIFICATION R:_
STATE WELL CONSTRUCTION PERMITN:
1. WELL USE (Check Appllcabla Box): Residential Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: G�k6RG1Y.E-E County:
-1c5o.,
Agricultural ❑ Monitoring ❑
t'i D So C- _ - i1 t:> -
(Road Name and Numbers, Co.mmunl!y, or Subdivision and Lot No DRILLING LOG DEPTH
3. OWNER 5-fcy—_3 (1E4= /� From To Fo�a:lon Cescripl:on
Address ZG �is yra�3 YgQYki'J`-' • ! CL 41 Jr9N�
jStreet or au:e ao.l cj / 'J 3 e_IL�i71
GL C 2g-?zI K3 ? 0,CA^NTC
Coy 8r Tc wn Stato Zip Cole
4. DATE DRILLED 4 —co �
S. TOTAL DEPTH 7cx) CCU p
6. CUTTINGSCOLLECTED YES© NOEJ
7. DOES WELL REPLACE EXIS"NNG WELL? YES [_] NO;�3
8. STATIC WATER LEVEL Below Top of Casing: -q,, FT. n
(Use'.' if Above Top of Cos::.q) N_ M<
9. TOP OF CASING ISFT. Abovo Land Surface' jro
'Top of casing lermlr.a:ed aL^or below land surface requires a varlance In accw- --O fn�
dance Mth 15A NCAC 2C .0113
10. YIELD (apm): A_ METHOD OF TEST
11. WATER ZONES (dep;h):
- -- -_- a�
12. CHLORINATION: T•,pe Ameunt - If add'aonal space is needed use back, of fora
13, CASING:
LOCATION SKETCH
Wall Th!c#^c^ --
Dep!h cilrre!eer or Wci;f. R. Maoe.al (Shoe: dirocllen and distance from a! !cast tyro Slate
From --To Ft.. 'I- /� '5�� Reads, or other map reference points)
From To FL--�
From -To- FL--
1:.GROUT:
Depth f.1�- atoriol� Molhod
From 0 Toil Ft. _ �?
From To __Ft. _
15. SCREEN:
Doplh
From
To FI
From --To
Ft.
From --To
_ FL
16, SAND/GRAVEL
PACK,
D2joth
From
_ To
From
To
17. REMARKS:
Diameter Slot Size_ Material
in. In.
In. in.
In. In.
Ft.
Ft.
Size Material
Ap6
f
I `
1V
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 O
0
V;13 -
l.0
FOR OFFICE4�!�OMY
Quad Na: }if U 1 E r }SIGNATURE OF FERSO'7 CONSTRUCTPJG T ` '+ELL DATE
+r R Submihr)rili Pill to Dlvlslon of Water Duaiily, Groundxaler Section Within 30 days
i G'N-1 REV. 12M
serval No,s a , i r
T� :, <, ✓y

North Carolina - Department of Environment and Natural Resources - Division of Water Oualiy • Groundwater Section F! J I 00
1536 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: (1 ✓SSF1 7Ay�t
WELL CONTRACTOR CERTIFICATION 8: %-IE I -
STATE \'/ELL CONSTRUCTION PERUITP:
1. WELL USE (Ct-,eck Appllcabis Be.): Residenlie.�n Municipal ❑ Industrial ❑
Recovery ❑ Heal Pump Water Insection ❑ Othor ❑ It O:hcr, LI,! Use:
Agricu!lural ❑ monitcring ❑
2. %VELL LOCATION: (Show sketch of the location bc!o'::)
LVF Coin• S.<1CL'�"3
tJc a:eet To,­:/�.
j�lcys G¢e�- Lc�
(Road Narne and Numbor__-s.C�o. m,: ,Jty, Or S,bdlrlslon and Lot No DRILLING LOG DEPTH
3. O�o,^W
'+'NER �,/) ICI- 011 NN 17-7T1 Fran (e Fo,,,.a:ion De.cr:pllco
Address JJC4--wiuzy eo,
(tltCCl Of i1Jul 7 0
TW7 ' Rio
/tNITC
tl;ycr, Tccro E 5:alo Z'„CO i_
3. DATE DRILLED 4-3,.�-co
5. TOTAL DEPTH goy r-I
G. CUTTINGS COLLECTED YES R NOD —
7. DOES WELL REPLACE EXISTING WELL? YES 1)0
STATIC WATER LEVEL Bc!orr Top of Casing: _ FL.
o (Uc0'.' is Aoc:a T op of Cast:.;.)
9. I OP OF CASING IS I FT. Above Land Surf, cc'
-Top et easing terminaled aVOr belort lard su r;aca rsgvk.o o arlsnco in accer.
danca r.i:h 15A NCAC 2C.011e ---
10. YIELD (ypnt): 45- METHOD OF TEST CL1r
11. WAl ER ZONES (depth):_ /c)'Z-ld 35--Z-1y __--
12. CHLORI ATIOI:
13. CA.S! . is
T}p:'
From S>i oPAL----
Froni To FL --
Frer1 To _— FI. - ---
14. GRQUT:
Depth tda'.o;ial tL^a'rcd
From G To=�CF1.
From To FL
15. SCREEN:
Depth Diameter
From To Ft in.
From To Ft. In.
From To FL In.
18. SAP:D/GRAVEL PACK:
Dcpth Size
Horn To Ft. _
From To Ft.
17. R=t1J�Ri<S:
Slot She - I'ate:izl
in.
In.
_ in.
t/gale;ia!
z
l'7
r.0
_. S, or
r _.arcncc pa;: ls)
ZW
n
Y
e
I DO HERESY CERTIFY THAT THIS WELLY, -AS CONSTRUCTED 1:1 ACC0RDANCE','/ITH I -A :fCA0 2C,',',ELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORC HAS uLE:J PROVIDED TJ THE 1:ALL OY:iiER.
FOR OFFICE USE ONI-i �r)` v\" t`' 7�
Cuad No:
HATL'P.E OF FCn'O:; COr13r,tUC t IN j T: h_l:TLL
abD l: c�c :tor Cv.:atlr�. C.a .✓:: a:cr ,, ..'�', ,.�'`n :O C:js
DATE
0..-1 REV. 1-'51

Norh Carolina - Department of Environment and Natural Resources - Division of YJater Cua!iry • Groundwater Section !.
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD
WELL CONTRACTOR:WELL CONTRACTOR CERTIFICATION k: _
STATE WELL CONSTRUCTION PERMITP:
Z 18cr,_
1. WELL USE (Check Appncable f3ox): ResidenliattN Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ It Other, List Use:
2.
, TELL LOCATION: (Show sketch of the location beio'..)
Nearest Town: -tvC.J<A 559EE County:
-_Tn� r�
/jPED.1/ //'/ 4/s/ 7. /i./
(Road I:ame and Numbers. Community, or S_"oAs!cn aad Lot Ito.)
neQ--fE �TZ--
DRILLING LOG
3.
O''NNER `'fL
From To
Address /0y ecs
U riU
_I ::or route ;o.)
29�Io
�a0 C,2
/45 v �C
z �s
�iiy Ll I Cv:rl S:d:O Ly D+
4.
DATE DRILLED
5.
TOTAL DEPTH '75� C_
6.
CUTTINIGS COLLECTED YES© NOED
--
7.
DOES WELL REPLACE EXISTING DELL? YES tnp;Fj,
8.
STATIC WATER LEVEL Bo:o'.v Top of Casing: l t% FT.
_
(U.o •4• II Above Tea. of Cri '.ng)
9.
TOP OF CASINIG IS, _ FT. Above Land Surface'
'Top
of casing inminaled v!or belovr land surface requires a variance In eccor-
dan_e
e kh 15A f1'_AC 2C .C•13
/�
10.
YIELD (cpm): Z mETF OD OF TEST _-Z-q
11.
1VATER ZO;:ES (depth): :5 q0 F-
_
/y,,� CJXl lT
DEPTH
Feanalion Descnpt!On
C' a 7
12. CHLOR;...'.TIO;.. Ty r �, \ 1-1 P.: r!.c..;:� C �._,,.c..c! e- s re=_seC u's= basi c: form--
O_? 'I');f SKETCH
r CCil �-
-- p a�'
Ft. « •^/
ne3]o, J c:hCf map icferc l e
G//✓c 2-
DES'.
Fro^
-pl/J
FL
From
To—.--
Ft.-
I c7
J�7A's'd
14. GROUT:
r
Depth L1a:9rial t.1 r. "1cd
From To ,Q Q FL _2_1� � Q\
Frcm _ To Ft.
15. SCREEN:
Depth Diarn31er
From Tra Ft in.
From To FL In.
From To FL___ In.
15. SAND/GRAVEL PACK:
Depl'1 Size
From To — Ft.
From To Ft.
17. REMARKS:
Slot Size Malarial
in.
In.
Ma'erial
I DO HEREBY CERTIFY THAT THIS V,EI_L WAS CONSTRUCTED IN ACCORDANCE VdTH 15A NCAC 2C. WELL
CONSTRUCTION STANDARDS. AND THAT
A COPY OF THS RECORD HAS EEEN FP:O' VIDEO TO THE VIELL O'NNNER.
FOR OFFICE USE ONLY "�� G'�e-' Q- 'iliS WQ tt QI
Ouad No rr - -' SIC r •TIRE CF PERSON CONSTRUCTING THE /%ELL U 1�CATE
r Lj8C Sony, rat to Div:s'cn o l'la:cr Oua`:y. Gour CwCcr Seclicn within 30 d J
GW.f REV. 12'59
c<
k
Dar EJ?

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section ti
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
'moo 1,v1 `cof;Lay
WELL CONSTRUCTION RECORD WELLCONTRACTOR: _ WELL CONTRACTOR CERTIFICATION ff: 2I eta(
STATE WELL CONSTRUCTION PERMITq
1. WELL USE (check Applicable Box): Residentiall3 Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heal Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below) \
—
Nearest Town:( County: AC.0 1�1
(Road Name antl mbors. Community or Subdlvisicn and Lot No.)
DRILLING LOG DEPTH
3.
OWNER C
From To Foenallon Description
Address
C) V:�,
\��Vrj.�c�"<lt��lJ�C
e
City or Town State Zip Code
.
DATE DRILLED -
O.
5
TOTAL DEPTH
6.
CUTTINGS COLLECTED YES_IZ1 NOF
O
7.
DOES WELL REPLACE EXISTING WELL? YES NOM
8.
STATIC WATER LEVEL Below Top of Casing: �- FT.';�
hh (Use'.' it Above Top of Casing)
1
9.
TOP OF CASING IS :1 FT. Above Land Surface'
J - --
'Top
of casing terminated allor below land surface requires a variance In actor-
dance
10.
with 15A NCAC 2C .0118
YIELD (gpm): ?-IZ)— METHOD OF TEST i:� VZ
11.
WATER ZONES (depth): \aA::) A
L
12.
CHLORINATION: Type N-C- It-) Amour,.
II additional space Is needed use back of form �-
13.
CASING:
LOCATION SKETCH
Wall Thickness
Depth or Weight/Ft. Material
(Show direction and distance from at least two State
�Diam`e�ter
From To Ft. Iv1/- -N �'-- 17_:�
Roads, or other map reference paints)
From To Ft.
-
From To- Ft. --
-
14.
GROUT:
-t
'`/lG
Depth Material Malarial Molhod
G
From T,�V Ft.
From To Ft.
15. SCREEN
Depth Diameter
From To Ft In.
From To Ft. In.
From To __ Ft. In.
16. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To Ft.
17. REMARKS:
Slot Size Material
In.
In.
In.
Material
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER. 'y/
FOR OFFICE USE ONLY D� -r "
Quad No: SIGNAT E OF PERSON CONSTRUCTING S THE WELL DATE
t' Submit original to Divlsl of Water Oualiry, Groundwater Section within 30 days
Serial No. t i - - GW-i REV. 12/99
I1 AW

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: Z'T' D
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMIT#:
21:- 2 s0
Z18C�
1 .
WELL USE (check Applicable sox): Residential ED Municipal ❑
Industrial ❑ Agricultural ❑ Monitoring
❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2.
WELL LOCATION: (Show sketch of the location below)
Nearest Town: �'. ��rA CounN_���l.c
(Road Name oTnrr NNumm4ori. C`ommuunnity. or Subdivision and Lot No.)
DRILLING LOG DEPTH
From To Formation Description
3.
OWNER Jl,�-1-dG�
Address gjS�jC a .���__—
F
;T
� (StreoFrRomo No.)
n
lD-) l off— C' �lF�c��
4.
City or Town Slate Zip Code
DATE DRILLED
—a-`—�
1
r3
5.
=OO
TOTAL DEPTH
O
6.
CUTTINGS COLLECTED ES Y NOD
7.
DOES WELL REPLACE EXISTING WELL? YES jJ NO®
8.
STATIC WATER LEVEL Below Top of Casing: FT.
t
c,
9.
(Use'+' If Above Top of Casing)
TOP OF CASING ISFT. Above Land Surface'
-Top of casing terminated at/or below land surface requires a variance In accor-
;7
ram.
dance
10.
with 16A NCAC 2C.0118 1
YIELD (gpm): c_-ilO METHOD OF TEST
^�
11.
WATER ZONES (depth): dC7y�-
en
en
z
12.
CHLORINATION: Type Amount
_ If additional space Is needed use back of form
13.
CASING:
Wall Thickness
LOCATION SKETCH
Depths �Q (Diam,Gler or y`lei hVR. edaI \
(Show direction and distance from at least two Stale
From-0---.To �R -t-- FL .0 �J-- �"'--`--
Roads, or other map reference points)
From To Fl.
From To— Ft,
14.
GROUT:
Depth Material MoI
``y�
S
From To �Q Ft.
From To FL
15.
SCREEN:
Depth Diameter Slot Size Malarial
From To Ft in. In.
From To Ft. In. in.
Front _ To Ft. in. In.
16.
SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
17.
REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIEXD TO THE WELL OWNER.
FOR OFFICE USE OJ
Quad No: SIGI
Submit original to
Serial Na.
- )`_F_ 0
OF PERSON CONSTRUCTING THE WELL DATE
or Water Quality. Groundwater Section Within 30 days
GW-t REV. 12/99

21 ) 2' 99
North Carolina - Department of Environment and Natural Resources - Division of
Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR
CERTIFICATION p:
STATE WELL CONSTRUCTION PERMIT#!
1. WELL USE (Check Applicable Boa): Residenlia>l Municipal ❑
Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
NearestTown: G�i '\\�r�+ County-��0=�����
DRILLING LOG DEPTH
(Road Name and Numbers, Community. or Subdivision and Lot No.)
3. OWNER \ )���\lV �C-t`4'����
From To Formation Description
Address )i\C�\(�,
C-�Fi�
— t r o or 'IOU., o.
\ -�I e
obi oS (^ _r9,y _r57
City or Town Stale Zip Code
4. DATE DRILLED
5. TOTAL DEPTH-
6. CUTTINGS COLLECTED YESO NOE]
7. DOES WELL REPLACE EXISTING WELL? YES 0 NOJ;�a
8. STATIC WATER LEVEL Below Top of Casing: 1 FT.
C ^
(Use'+' it Above Top of Casing)
9. TOP OF CASING IS A_ FT. Above Land Surface'
t
-Top of casing terminated at/or below land surface requires a variance In actor-
o
dance with 15A NCAC 2C .0118
10. YIELD (gpm): \C_t METHOD OF TEST
11. WATER ZONES (depth): �--�IsLC} �-�y�_—�'�� -�
en
o
12. CHLORINATION: Type Amount
If additional space Is needed use back of form
13. CASING:
Wall Thickness
LOCATION SKETCH
Deplh1 ,.,e Iarpsor W l VFI. ler Inatedgl
�To i6C'\
(Show direction and distance from at least two State
From Ft.
Roads, or other map reference points)
From To Ft.
Ft.
From To—
14. GROUT:
Depth Material \ Method
0--CLIt�
FromTot�Ft. L&
From To Ft.
15. SCREEN:
Depth Diameter
From To _ Ft in.
From To Ft. In.
From _ To Ft. In.
16. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To FL
17. REMARKS:
Slot SIZE Material
In.
In.
In.
Material
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY A -
Quad No: SIGNATURE
Submit original to Division
Serial No.
SON CONSTRUCTING THE WELL DATE
Quality, Groundwater Section Within 30 days
GWA REV. 12/99

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: �>Ll
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMIT#:
11,E 78
i �Yw(Z
1.
WELL USE (Check Applicable Box): Residential K Municipal ❑
Industrial ❑ Agricultural ❑ Monitoring
❑
Recovery ❑ Heat Pump Water Injection ❑ Other
If Other, List Use:
2.
WELL LOCATION: (Show sketch of the location below)
Nearest Town: C+ C-',e County
(Road Name and Numbers, Community, or Subdivision and Lot No.)
DRILLING LOG DEPTH
3.
OWNER
From To Fonnallon Description
Address ���� F
N
—C') I y C! FP lU
(StreetA-ou a o.
- k fit f1 (
� . a v c\ � \ .� �-)
a� �\
4.
City or Town Stalls t Zip Code
DATE DRILLEDCl
5.
—CX->
TOTAL DEPTH>C'>'
6.
CUTTINGS COLLECTED YES ® NOF-1
7.
DOES WELL REPLACE EXISTING WELL? YES NOI�S�DC
a=•--
8.
STATIC WATER LEVEL Below Top of Casing:
6�[_
9.
(Use': If Above Top of Casing)
TOP OF CASING IS FT. Above Land Surface'
'Top
of casing terminated atlor below land surface requires a variance In actor-
--- —
dance
10.
with 15A NCAC 2C .0118
YIELD (gpm): [.a METHOD OF TEST
7
ram
11.
WATER ZONES (depth): \--41E'�, - WSJ ->I, `Q'AS
1C� —
lit
—r
12.
CHLORINATION: Type H�"''c'\ Amount A 11124
If additional space Is needed use back of form
z
13,
CASING:
Wall Thickness LOCATION SKETCH
Dept 1 pr isnmeeeytttccar` or Wei I Material ( Show direction and distance from at least two Stale
From � To Ft. Roads, or other map reference points)
From To Ft. -
From To-- Ft. � ,\ -
14. GROUT: (G +�`.jcl�hQs� /101\WQ
De lh Material Method
From U T F7. C`c (\ti�_C\lAC_� a
From To Ft.
15. SCREEN:
Depth Diameter
From To Ft In.
From To Ft. In.
From _ To __ Ft. In.
16, SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To Ft.
17. REMARKS:
Slot Slzo Material
In.
In.
in.
Material
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF T RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY ;
Quad No: - j - ^ SIGNATU OF PERSON CONSTRUCTING THE WELL DATE
t' 5ul [t ¢hgi;trl lo-Divlsl of Water Quality, Groundwater Section Within 30 days
Serial Na. GW-1 REV. 12199
is a

r
North Carolina -Department of Environment and Natural Resources -Division of Water Quality17 -Groundwater Section J
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELLCONTRACTOR: VU55c-LL_ T/�1�Lo12
WELL CONTRACTOR CERTIFICATION fill: Zl��
STATE WELL CONSTRUCTION PERMITq__
1.
WELL USE (Check Applicable Box): Residential [Z Municipal ❑
Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2.
WELL LOCATION: Show\ sketch of the location below)
Nearest Town: ^,� `\�'.— County:\Cc=r(1
\
�
(Road Name and Numb s, Communit , or Subdivision and Lot No.)
DRILLING LOG DEPTH
3.
OWNER
From To Fonnallon Description
Address c
0
reo ar ou o NO
4.
City or Tow State T ZIp Code
DATE DRILLED-� �_L'C�
� � C� CJ
CO
5.
TOTAL DEPTH" -lam
CO
6.
CUTTINGS COLLECTED YES [R] NO❑
7.
DOES WELL REPLACE EXISTING WELL? YES Nd'�
61 1
8.
"c`
STATIC WATER LEVEL Below Top of Casing: LAu— FT.
_
(Uso'+' if Above Top of Casing)
IS A FT. Above Land Surface
A rTr o
r
9.
TOP OF CASING
n
'Top of casing terminated aVor below land surface requires a variance In actor-
49— o
n
dance with 15A NCAC 2C.0118
10. YIELD (gpm): L_ METHOD OF TEST
o
11.
WATER ZONES (depth):
12.
cc
CHLORINATION: Type '' ... _-. ea.
II additional space Is needed use backof form
13.
CASING:
LOCATION SKETCH
Wan Thickness
Depth Diameter or W hjUFI. Maledal
(Show direction and distance from at least two State
`
From `)�—To � ( �^
Ft. �
Roads, or other map reference points)
From To-- Ft.
\y'
�S�IW��AQ\kN_ �/ �Oli�.e .
14.
From To— Ft.
GROUT:
�� \
O Depth Material Method
From To�Ft. 05F_Wk3
From To Ft.
15.
SCREEN:
Depth Diameter Slot Size Material
From To Ft In. In.
From To Ft. In. in.
From _ To Ft. in. in.
16.
SAND/GRAVEL PACK:
Depth Size Material
From To --Ft.
From To Ft.
17.
REMARKS:
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF TW RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Quad No:
Serial No.
Submit original to
F PERSON CONSTRUCTING THE WELL / DATE
Water Quality, Groundwater Section within 30 Ways
GW-I REV. 12/99
:ZI-ub

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
'1.1)_,75
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: T CAR
WELL CONTRACTOR CERTIFICATION:—_ Zlb�
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable sox): Residential Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: S, County:
(Road Name nd Numbers. Co�m�munit_y, or Subdivision and Lot No.)
DRILLING LOG DEPTH
3.
OWNER ��r \ Yr' �`C� C'ia �\
From To Formation Description
Address S-TIC) �[- V�1\
—C_T C��
Q(Street or onto o
bity or Town State T Zip Code
P
4.
DATE DRILLED�10—CX>
o--
5.
TOTAL DEPTH
6.
CUTTINGS COLLECTED YES® NOO
7.
DOES WELL REPLACE EXISTING WELL? YES LJ NO;�j
6.
STATIC WATER LEVEL Below Top of Casing:. An FT.
(Use -s' It Above Top of Casing)
�_ n c
9.
TOP OF CASING ISFT. Above Land Surface'
en:e
-Top
of casing terminated at/or below land surface requires n variance In accor-
dance
with 15A #CAC 2C .6116
—
10.
YIELD (gpm): METHOD OF TEST
eo
11.
WATER ZONES (depth):
12.
CHLORINATION: Type hT Y� Arnouni _
It additional space is needed use back of form
13. CASING
Wali Thickness
Depil Diameter or Weigl Pt. .lalcdai
From —To -FL-tlgr -'r
From To FL
From To Fl. --
14. GROUT:
Depth Material Method
From Tocz�:ZC_) FL O4E�&cC'Z- \O�:>_
From To FL
15, SCREEN:
Depth Diameter
From To FI in.
From To Ft. In.
From _ To Ft. In.
16. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To Ft.
17. REMARKS:
Slot Size Material
in.
In.
In.
Material
LOCATION SKETCH
(Show direction and distance from at least two Slate
Roads, or other map reference points)
S�Z v A O Cj
Y\
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITFI 15A NCAC 2C. WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLYftava:- ?,, ^ Ly
Quad No: SIGNAT E OF PERSON CONSTRUCTING THE WELL DATE
Submit odpinal to Divl on of Water Quality, Groundwater Section within 30 days
Scrial No. GWA REV. 12199

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section 2 .1. ) ".) 7 4
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION #: a S�CO
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable soo Residential lie Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2.
3.
WELL LOCATIO : (Show sketch of Iho location below) �QC.gCS�
Nears Town: ,�`� County:
l,l)QX A
(Road Name a r Numbers, Communityhhor Subdivision and Lot No.) DRILLING LOG
OWNER]esrie, b' l�tlY\(4, �iC�(IUVQ.IZ.PX From To
Address
reo or ou ONO.)
Agricultural ❑ Monitoring ❑
DEPTH
Formation Description
W !Jl,-_ tll6l� ()��� c ��
City or Town Stale Zip Code
4.
_
DATE DRILLED
5.
C2CU
TOTAL DEPTH F
6.
7.
CUTTINGS COLLECTED YES ED,`NO❑
DOES WELL REPLACE EXISTING WELL? YES NO[vr 3
S.
STATIC WATER LEVEL Below Top of Casing: � 7(-)O FT.-
9.
(Uso'+' If Above Top of Casing)
TOP OF CASING ISFT. Above Land Surface-
'Top of casing terminated at/or below land surface requires a variance in actor.
-=
t rt
dance
10.
with 15A NCAC 2C .0118
YIELD (gpm): i Din ' METHOD OF TEST QK rt
tU1
=t
11.
WATER ZONES (depth): n
12.
1
CHLORINATION: Type _«� Amount &5
If additional space Is needed use back of form
13.
CASING:
Wall Thickness
LOCATION SKETCH
Depth !�Diameter ar Wye' MIR. �MteIf I
9b �1�
(Show direction and distance from at least two Slate
From J�J—To Ft. �---J-T"=>,
Roads, or other map reference points)
From To Ft. —
From To— Ft.
14.
GROUT:
Method
(1
Dopl1 Material
�'eXh���
'
From To Ft. 20—
From To Ft.
//11,,
��` -' L.9L l Y-
15.
SCREEN:
Depth Diameter Slot Size Material
From To Ft In. In.
From To Ft. In. in.
From To Ft. In. In.
16.
SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To FL
17.
REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD H BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY ffig-
Quad No: SIGNAT E OF PERSON CONSTRUCTING THE WELL DATE
Submll original to Divl n of Water Quality, Groundwater Section within 30 days
Serial No. GW-1 REV. 12/99

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Sectioryt ^ -r/�-
t
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone] /
WELL CONSTRUCTION RECORD
WELL CONTRACTOR: . 'IZLJS LL —MyLo2
WELL CONTRACTOR CERTIFICATION #: ZIS$
STATE WELL CONSTRUCTION PERMIT#
1. WELL USE (Check Applicable Boxy ResidentIA Municipal ❑ Industrial ❑
Recovery ❑ Heal Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCAT how sketch of the location below) "\1�0 e\n� n
�
Nearest Town: ���� County: -�
(Road Name and Numb rs. Community, or Subdivision and Lot No.) DRILLING LOG
3. OWNER From From To
Address
reo or Maide rrb.)
c�s1�i
City or Town Slate Zip Code
4. DATE DRILLEDQ CC))
5, TOTAL DEPTH
6. CUTTINGS COLLECTED YES NOF__J
7. DOES WELL REPLACE EXISTI G WELL? YES U NOrk]
S. STATIC WATER LEVEL Below Top of Casing: FT.
(Use': If Above Top of ising)
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 .0110
10. YIELD (gpm): i 9� METHOD OF TEST
11. WATER ZONES (depth): �"� -�� �" �-� ALE
Agricultural ❑ Monitoring ❑
DEPTH
Formation Description
n
cn.
W
�
12. CHLORINATION: Type AY=H Amount It additional space Is needed use back of form
13. CASING:
Wail Thickness LOCATION SKETCH
Depot Diameter or V1eighVFl. Material (Show direction and distance from at least two Stale
From-1L_—To Ft. � — Roads, or other map reference points)
From To FL 1AL 1
14. GROUT:
U DoQI,�__ Malorlal� �M�o--lh�od � �'1 1L S3• "�J
From To Ft.
From To Ft.
15. SCREEN:
Depth Diameter
From To Ft In.
From _ To Ft. In.
From —To __ Ft. In.
16. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To Ft.
17. REMARKS:
Slot S176 Material
in.
In.
In.
Malarial
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF HIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY — d C7U
Quad No: $IONA RE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Di on of Water Quality, Groundwater Section within 30 days
Sedal No. - _ GW-1 REV. 12199

2152r72
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section 44-%r
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELLCONTRACTOR: 2V55Cc-L- _FAy(LOR-
WELL CONTRACTOR CERTIFICATION 0: ZIF t
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential LJ Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATIO (Sfto/w�s.�kelctl opf_the location below) C,�^
Nearest Town:Un�A` County:
(Road ame Au/nbers. Community. SubdlAslonand L'olt1N�o.) DRILLING LOG DEPTH
3. OWNER 1�.tc "11�011� 'F- QL_UeQ� \ -Y l��� From To Formation Description
Address (Street or Haute - O p
City or Town State Zip Cotle
4. DATE DRILLED � )
S. TOTAL DEPTH �j'S� �r 1 _-
6. CUTTINGS COLLECTED YES[Rr NOE) J `'
7. DOES WELL REPLACE EXISTING WELL? YES Q NO[ _ 7 C
B. STATIC WATER LEVEL Below Top of Casing: Sotp) FT. "' r
(Usa '+' it Abovo Top of Casing) m�
9. TOP OF CASING IS FT. Above Land Surface' T,JT —i
'Top of casing terminated at/or below land surface requires a variance In accor- CJ
_
dance with 15A NCAC 2C .0118
10. YIELD (gpm): METHOD OF TESTL
11. WATER ZONES (depth): r
12. CHLORINATION: Type N� Amount It additional space Is needed use back of form
13. CASING:
Wall Thickness LOCATION SKETCH
Depth Diameter or�V��°�hV�FI Maledal (Show direction and distance from at least two Stale
From�To � Ft. & ILA - 1A_� Roads, or other map reference points)
From To FL —
From To— Ft.
14.GROUT:�'j_
Depth Material 11olhod
From _n To CA) Ft. CW'hQX\+
From To Ft. C r bL
15. SCREEN: J\
Depth Diameter
From To Ft In.
From To _ Ft. In.
From _ To Ft. In.
16. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To Ft.
17. REMARKS:
Slot Size Material
In.
In.
In.
Material
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 1SA NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COP OF HIS R C RD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY s` A 4 2 M DQ�
Quad No: SIGNATURE OF PERSON CONSTRUCTIV TIE WELL DATE
Submit original to Division of Water Quality. Groundwater Section within 30 days
Serial No. ° <
J `I
GWA REV. 12199
ot

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section 2 15 22 7 1
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Pheno [phone] 1
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION 0:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (check Applicable Box): Residential Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: Courtly;
(Rome aantl��Nu�mbers, Cow, mu ity, or Subdivfsi and LoI IN \ DRILLING LOG DEPTH
3. OWNER�4�\<U1i7��\C�t�\\ From 7o Formation Description
Address
ocR�s Cc1� \
\\ tree or Route
n�
City or Town State - Zip Code
4. DATE DRILLED"'o�`c5-C�
S. TOTAL DEPTH�Y)
6. CUTTINGS COLLECTED YES r>7< NOD
7. DOES YlELL REPLACE EXISTING WELL? YES 0 110�
B. STATIC WATER LEVEL Below Top of Casing: ':e� FT.
(Use'.' if Abavo Top of Car.ng)
9. TOP OF CASING ISFT. Above Land Surface'
-Top of casing terminated aVor below land surface requires n variance In accor-
dance with 15A NCAC 2C.0110
10. YIELD (gpm): .-g_ METHOD OF TEST
11. WATER ZONES (depth):���—
12. CHLORINATION: Type \i Amount
13. CASING:
l'; all TI•,Ic'�.nc ss
Depth Un orWcc!'' 613tcdal
FromTo T- Ft.
From To Ft.
From --To Ft.
14. GROUT:
Depth Material Method
From Toc;QC-)_Fl. O)E 12aZ 1Q?
From To Ft. _
15. SCREEN:
Depth Diameter Slot Size_ Malarial
From To Pt in. In.
From To Ft. In. In.
From To Ft. in. In.
16. SAND/GRAVEL PACK:
Depth Size M1daleriat
From To Ft.
From To Ft.
17. REMARKS:
CD
15 If additional space Is needed use back of form G
A
LOCATION SKETCH
(Show direction and distance from at least two StEA
Roads, or other map reference points) co 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 O'WNER.`�
FOR OFFICE USE ONLY Q�tJ�� Q-y'QQ;n'E�CS �.L�u VJ\Gt. CL5. 1')C_ ��E- 9r (�L"
Quad No: SIGNATURE OF PERSON CONSTRUCTING TH :ELL f DATE
Submit original to Divls;on of Water Quality. Groundwater Section within 30 days
SerialNo GW-I REV. 12r99

2l 157 North Carolina - Department of Environment and Natural Resources -Division of Water Quality- Groundwater Section A. ry�.7 :.
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phono [phone]—t—
WELL CONSTRUCTION RECORD WELLCONTRACTOR:tl�r---
WELL CONTRACTOR CERTIFICATION It:
STATE WELL CONSTRUCTION PERMITN:
1. WELL USE (Chock Applicable eox): Resldenlia>q Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Agricultural ❑ Monitoring ❑
Nearest Town: JNs\NZS2, County: �7[ZL
-\.�i,_ 11 2�
ck._'C A
(Road Name and Numbers. Community, or Su�bdi\vi-sion and Lot No.)
DRILLING LOG DEPTH
3.
OWNER ( C—Y--\ Cl0 ��hw V'\
From To Formation Description
Address 1 � __Ci
`61�a
tree or ee:e
City or To,n c State Zlp Coder
4.
DATE DRILLED��CDCl
5.
TOTAL DEPTH
6.
CUTTINGS COLLECTED YES© NO❑
o'
7.
DOES WELL REPLACE EXISTING WELL? YES � NO�
8.
STATIC WATER LEVEL Below Top of Casing: �c_�- FT.
,
(Use'+- it Above Top of Casing)
I
i
q
TOP OF CASING IS FT. Above Land Surface*
'Top
of easing terminated nVor below land surface requires a variance In actor.
dance
with 15A NCAC 2C,0118
10.
� �
YIELD (gpm): METHOD OF TEST `OK:
11.
WATER ZONES (depth): �C 7
12.
CHLORINATION: Type Amourri,\YQ—
V addltiena! space Is needed use back of form
=-
13. CASING
Depth DiamG:er
From —To— Ft. '/U
From To Ft.
From To— Ft.
14, GROUT:
Wall Thickness LOCATION SKETCH
GighrF� Material (Show direction and distance from at least two State
Roads, or other map reference points)
Depth Matorlal Method
From C ToQC) Ft.�52?—
From To Ft.
15. SCREEN:
Depth Diameter
From To Ft in.
From To Ft. In.
From To Ft. in.
16. SAND/GRAVEL PACK:
Depth Size
From To R.
From To Ft.
17. REMARKS:
Slot Size_ Material
In.
In.
In.
Material
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH i SA NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO ITHE WELL OWNER. /\
FOR OFFICE USE ONLY `r ' �oz O S W'L l� O �U_fy, � (c) Ov
Quad No: SIGNATURE OF PERSON CONSTRUCTING THE WELL (UCl DATE
ubpiil original to Dwislon of V1.1ar Qualily, Groundwater Section Within 0 days
4 Serial No. sp } i(T L I' GVl4 REV. 12/99

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section 4.15 7 G 9
1636 Mail Service Center - Raleigh, N.O. 27699-1636-Phono [phone] 1 rn
WELL CONSTRUCTION RECORD WELL CONTRACTOR:rr�_Yl�
WELL CONTRACTOR CERTIFICATION k:l
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Chock Applicable Box): Residential-B Municipal ❑ Industrial ❑ Agricultural ❑ Moniloring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other 0 If Other, Llst Use:
2. WELL LOCATION: (Show sketch of the location below)
�Nearest Town: �x Tk�� CounDj��..�
P, f c, C' �Z �c ,C
(Road Narne and dd Numbers, Community. or Subdivision and Lot No)
DRILLING LOG DEPTH
3.
OWNER `',��C't Ci'�C1ti1C TriC1
From ToFo�r io'n Description
'2-
Address
,S_T—
�--I reel or Houte No.)
Cliy or Town State Zip Code
4.
DATE DRILLED
5.
TOTAL DEPTH
o
6.
CUTTINGS COLLECTED YES© NOEJ
—
n-
7.
DOES WELL REPLACE EXISTING WELL? YES 11 N0,0
6.
STATIC WATER LEVEL Below Top of Casing: E-10 FT.
(Use'.- it Abova Top of Casing)
9.
TOP OF CASING ISFT. Above Land Surface'
-
'Top of casing terminated aVor below land surface raqulres a variance in accor-
d 3n
10.
c e Yrl th 15A NCAC 2C.011e
YIELD (gprn): � METHOD OF TEST _FAa-\SZ
11.
WATER ZONES (depth): \ C:� 4119
C.71
w
o
12.
NN
CHLORINATION: Type �1� )AAmount —
I1 additional space Is needed use back of form
13,
CASING:
LOCATION SKETCH
WaY, Tldcknc sz
Depth�y D/iaml�c;ar or i'ielghV17L Maledal
(Show direction and dslance from at least two State
`
From To
Roads, or other map reference paints)
From To- FI.
From To-- FL���k-%'�
14.
GROUT:
Depth Material Method
From 0 To L Ft. :I= n�,l fzv� _52p
From To Ft.
15.
SCREEN:
Depth Diameter Slot Size_ Materiel
From To Ft In. In.
From To FL In. In.
From To Ft. In, In.
16.
SAND/GRAVEL PACK:
Depth Size Pdalorial
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.
Q%� I,'� 1 m r,
FOR OFFICE USE ONLY A()1 ``��'� � `^'Q-�` �\Q DUI l 1 faV� IJ u�
Quad Nc: SIGNATURE OF PERSON CONSTRUCTING THc ELL �_ DATE
Submit original to Division of Water Quality, Groundwater Seclion Within 30 days
SeriAf No. G'N-I REV, 12/59
it .r_

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section [,. 2 U Q
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phona [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION N: rI 9- r
STATE WELL CONSTRUCTION PERMITtt:
1. I'IELL USE (Chack Applicable Eox): Residential Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other M If Other, Llst Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: County: — 1VQ--tcnCl
3.
�I
a. DATE DRILLED
5. TOTAL DEPTH VC" O
6. CUTTINGS COLLECTED YES® NO❑
7. DOES WELL REPLACE EXISTING WELL? YES L] N0,0
8. STATIC WATER LEVEL Below Top of Casing:, FT.
(Use'.' It Abc•:o Top of Casi,,il)
9. TOP OF CASING IS_A— FT. Above Land Surface'
-Top of easing terminated aUor below land surface raqulree n variance In accor-
dance with 15A NCAC 2C.0 118
10. YIELD (gpm): '. METHOD OF TEST __
11. WATER ZONES (depth): � :- &TT
DRILLING LOG
From To
(-\ CJ�
fro
Agricultural ❑ Monitoring ❑
DEPTH
Formation Description
\f\ r
C7
0
as
-
:=r
r
�=
r n •:
"
r�� N
c>
cJ
c
T
12. CHLORINATION: Type Amount_— it additional space Is needed use back of form
13. CASING:
LOCATION SKETCH
Y1 l Thickness
Depth
or Yrel,h7Ft. Material
(Shoe: direction and distance from at least tyro Slate
From
To �— Ft,
Ipiemcler
v—
Roads, or other map reference points)
From
From
To Ft.—
To_ Ft.
14. GROUT:
'
Depth Matorial
Method
From
ToFt. C'4= Mt
Frorn
To Ft.
15. SCREEN
Depth Diameter Slot Sin Matorial
From To FI in. In.
From To Ft. In. In.
From To FI. In. in.
16. SAND/GRAVEL PACK:
Depth Size Ma!erial
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
RE-CORD HAS BEENPROVIDEDTOTCHE WELL OVINER. /�
FOR OFFICE USE ONLY _'r�jlk �1d��Q.�yi'.�-yal� I" ( oO
Quad No: SIGNATUFlE OF PERSON CONSTRUCTING i'c 7fELL DATE
Submil odpinal to Division of Water Ouality, Groundwater Section within 30 days
Seridt.N'o. GV14 REV. IM9
si `

7
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater SecliQn�� G �
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phono [phone]
WELL CONSTRUCTION RECORD WELLCONTRACTOR:
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Chack Applicable oox): Residenlia LZ Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: Shov+ sketch of the location below)
Nearest Town: a -,-i � � County >__ L-S_ C\
Y7
(Road Name and Numbers. Community, or Subdivision and Lot No.) DRILLING LOG DEPTH
OWNER VC From To Formation Description
Address a L rt o k le ) NO
.. _ C—\cw P k
to � \
4. DATE DRILLED 70
S. TOTAL DEPTH
6. CUTTINGS COLLECTED YESF>: NOD
7. DOES WELL REPLACE EXISTING 1AIELL? YES ❑ 1F10;5�j
B. STATIC WATER LEVEL Below Top of Casing: FT.
(Use -.' If Abovo Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface'
'Top of casing terminated nVor below land surface requires a variance In accor-
dance with l5ANCAC 0118 p
10. YIELD (gpm): W _ METHOD OF TEST
11. WATER ZONES (depth): \_. qf�) o��-\SCIN
0
�
c
3
'
�s
,tea
12. CHLORINATION: Type —)A i Arnounl _ It additional space Is needed we back of loan z
13. CASING:
V, as T h:ckne ss
From .��
Depth
To m
DiamN.cr
Ft. lol'a
c: Via ia--hV,Ft. tea:criat
From
To
Ft.
From
To—
Ft.
14,GROUT:
Depth
Material
Molhod
From 0
To�C-)
Ft. DY t\UOt
%Of-,)L
From
To
Ft.
15. SCREEN
Depth Diameler
From To Ft In.
From To Ft. In.
From To Ft. In.
16. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To Ft.
17. REMARKS:
Slot Size_ Ma;arial
In.
In.
In.
Material
_LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
'1y-mil\\ &-)�kQ,s�k )i'k�e
I DO HEREBY CERTIFY THAT THIS Vi ELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND
1THAT A(/C�Di PY OF THIS RECORD HAS BEEN
'PROVIDED TO THE WELL OWNER. � !/l %\
FOR OFFICE USE ONLY :'4"J11, 1��-e, ��ros \1 o \ 11a l�� J /V l(il I� V v
Quad No: SIGNATURE OF PERSON COi 167RUCTING T c W� DATE
,•,. ,.„.. Submit odoinai to Division of Vlaler Quality, Groundwater Section within 30 days
naidio. en r s n ❑n R (` '9 y GY1 I REV. 1259

?15k265
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Secti n
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION #: I P)CG
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (check Appncable Box): Residential Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Infection ❑ Other M It Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: �"���-n �u��A� CounNy___,K -f_'�
(Road NameandNumbers, Community, or Subdivision a`nd Lot No.) DRILLING LOG DEPTH
3. OWNER —�, AC Q From To Formation Description
4. DATE DRILLED �!--Cl�
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YESX] NO[__]
7. DOES WELL REPLACE EXISTING WELL? YES [::] NO�
8. STATIC WATER LEVEL Below Top of Casing: 5!�o FT.
(Use '+' it Above Top of Casing)
9. TOP OF CASING IS.� FT. Above Land Surface'
'Top of casing Terminated oVor below land surface requires a varlance In eccor-
danco with 15A NCAC 2C .0118
10. YIELD (gpm): Yam_ METHOD OF TEST �L`�—
11. WATER ZONES (depth):s_-_;t(j-1 A}'
1)
o
O
8
o
n
I
;-
-1
rla
f
c-n
i
12. CHLORINATION: Type Amount If additional space Is needed use back of form
13, CASING:
Mali T hick^Ass
From
Depth
To Ft.-�N
Di`a�melcr or Weighu,F9. hla:edal
� \ _�,_ :7 \
From
To Ft.
From
To-- Ft.
14. GROUT:
Depth
Matorlal Method
From O
To cs.1_ Ft.
From
To FL
15. SCREEN
LOCATION SKETCH
(Sho.v direction and distance from al least two State
Roads, or other map reference points)
Depth Diameter Slot Size Material
From To PI 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 20, WELL
CONSTRUCTION STANDARDS, AND THATnnA COPY
%OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY '�1�\"�'(E'2��Fo� WQ�� �G,V�
Quad No: SIGNATURE OF PERSON CONSTRUCTING THE LL DATE
Submit original to Division of Water Quality, Groundwater Secllon Within 30 days
scrialtir.% GW.1 REV. 12199

4
North Carolina -Department of Environment and Natural Resources -Division of Water Quality - GroundwVeeSee n
1636 Mail Service Center. Raleigh, N.C. 27699-1636-Phone [phone] (� `/
WELL CONSTRUCTION RECORD Pr
WELL CONTRACTOR: - J 1 / - Y /A C �� �' r` -
WELL CONTRACTOR CERTIFICATION p: � / 062- —_-�
STATE WELL CONSTRUCTION PERMITN:
1. WELL USE (Check Applicable Box): ResidenliaX Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Infection ❑ Other ❑ It Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: lo�.u\\sn's County: - l
i-\C• nCIC\
DRILLING LOG DEPTH
(Road Name and Num�bers. or�u6drvlsion and Lot No.)
3.
/CyLnFrtity,
OWNER �YYI(�l l `��c \�
From To Formation Descdpllon
Address
Ireo or oute o. ��Q_o��
\i
!�A�
City or Tawn Slate Zip Code
^t--�`— •—'—�"
CD
4.
DATE DRILLED
n_..
5.
TOTAL DEPTH �0-f i
6.
CUTTINGS COLLECTED YESO NOF__1
7.
DOES WELL REPLACE EXISTING WELL? YES EJ NOI
- t
-
B.
STATIC WATER LEVEL Below Top of Casing: I OC,— FT.
9.
(Use -i It Above Top of Casing)
TOP OF CASING IS�A FT. Above Land Surface'
-Top of toeing terminated nVor below land surface requires a variance In aceor-
♦p
••
m.a
n
dance
with 15A NCAC 2C.0113
10.
YIELD (gpm): ��_ METHOD OF TEST\�ca
11.
WATER ZONES (depth): \"lam
12.
CHLORINATION: Type Amount cam—
It additional space is needed use back of form
13. CASING
Wall Thickness
Depth Diameter or WcighVI'L e�Maler'ial
From —To 4Q Ft. (o YTU �'o C
From To Ft.
From To— Ft.
14. GROUT:
Depth Material Method
From To �— FI. Ste` mw� —
From To Ft.
15. SCREEN:
Depth Diameter
From To Ft In.
From _ To Ft. in.
From _ To Ft. In.
16. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To Ft.
17. REMARKS:
Slot Size Material
in.
In.
In.
fdaterlal
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 THAJT� A,nICOIIPY OF THIS RECORD AS BEEN
I PROVIDED TO THE
%WELL OWNER.
FOR OFFICE USE ONLY ?•I L Ui)�� / (Ds ��J I I & �, �)L �� Va-
Ouad No: SIGNATURE OF PERSON CONSTRUCTING THE W L DATE
Submit original to Division of Water Quality, Groundwater Section Within 30 days
GIN-1 REV. Ing
r
Ib 00

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section d n r7-
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]j-r)
WELL CONSTRUCTION RECORD WELLCONTRACTOR: �SSLLL T.4Yw1Z
WELL CONTRACTOR CERTIFICATION k: Z18 4-
STATE WELL CONSTRUCTION PERMITk
1. WELL USE (Check Applicable Box): ResidentiaX Municipal ❑ industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Infection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: — -', a 1) 1 t'\ County: , N
DRILLING LOG DEPTH
(Road Name and Numbers. Community, or SubdiWsion and Lot No.)
3.
OWNER T1C"i(`. T `QC%5ti :.Z,�,
From To Formation Description
Address
(S reo or o�0 ^0.
L ;7
City or Town State Zip Code
-S
4.
DATE DRILLED �_ ��-C^f7
5.
TOTAL DEPTH-
6.
CUTTINGS COLLECTED YESE. NO[ --I
7.
DOES WELL REPLACE EXISTING WELL? YES 0 NO�
8.
STATIC WATER LEVEL Below Top of Casing: \\� FT.
---
(Use '+' If Abova 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-
JJ
dance
10.
with 15A NCAC 2C .0118
YIELD (gpm): ].D METHOD OF TEST
^
Ut =
11.
WATER ZONES (depth):
12.
CHLORINATION: Type 'AN \A Amount _� a�Dlf
additional space Is needed use back of form
13.
CASING:
l` `� CaTtA
From�De tTo -�-_J- FL CaTA
From To Ft. -
From — To Ft.
14. GROUT:
Wall Thicknoss LOCATION SKETCH
or WeighVFl. M�ate�rfa`l (Show direction and distance from at least two State
Roads, or other map reference points)
-�� ��Depth Material Method
From5 Fro-)—Tos-_) Ft. lc_�_Oma.
From To FL
15. SCREEN:
Depth Diameter
From To Ft In.
From To Ft. In.
From To Ft. In.
16. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To Ft.
17. REMARKS:
Slot Size_ Material
In.
In.
In.
Material
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDE TO THE WELL OWNER.
FOR OFFICE USE ONLY(Rf
Quad No: SIGNATUR F PERSON CONSTRUCTING THE WELL ` DATE
nS 7¢61i final. fo DivislorW Water Quality, Groundwater Section Within 30 ays
Serial No. -I Lri !� GWA REV. 12/99

215262
North Carolina - Departmonl of Environment and Natural Resources - Division of Water Quality . Groundwater Sec' on
1636 Mail Sowice Center - Raleigh, N.C. 27699-1636-Phona [phone] AAA- �� � N 41 p ��'vA,
WELL CONSTRUCTION RECORD WELL CONTRACTOR: S' A> m CuLeF
WELL CONTRACTOR CERTIFICATION P:
STATE VVELL CONSTRUCTION PERMITN:
1.
WELL USE (Check Applicable Box): Residentiau y Municipal ❑
Industrial ❑ Agricultural
❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑
If Other, Llst Use:
2.
WELL LOCATION: (Show sketch of the location be!ot:')
Nearest Tov.n: C,-Le,JU1r.Lf—Counry:
� KS7J
C%jL :-»41:.E AcxWST
(Road Name and Numbers. Comrnunily, or Subdivision and Lol No.)
DRILLING LOG
DEPTH
�C7
3.
OWNER - �`/LE
a'C!'l
From 'ro
Formation Oescnptio.n O
p
Address (a o�611 TO OAK C AQ R.D.
0 $q -
CLAY C:)
------- —rp
ecToarl
QbULCV tLLE Z8
tAc-
S'4 '- %I
(yLAN!"rt
-•-..
Ciy or Town Salo Zip Core
4.
DATE DRILLED 3-Z9-cS%
J
s=%
5.
TOTAL DEPTH q2S FT
5.
CUTTINGS COLLECTED YES [>-Q NOEj
7.
DOES WELL REPLACE EXISTING WELL? YES F-1 NOS
8.
STATIC WATER LEVEL Below Top of Casing: COD FT.
L11
-+
(Usc -+- it Above Top of Casing)
9.
TOP OF CASING IS I FT. Abovo Land Surface'
'Top
of casing terminated nVor below land surta<o ro qulros n sa,lanco In occor-
-
dance
valh 15A NCAC 2C.011 a
10.
YIELD (gpm): 2C) h1ETHOD OF TEST
11.
WATER -ZONES (depth): -. M FT --
_--
_—
19
CHI C)Pll•IATinl4 Tvoe `tl V \1 A: nou nt PILLS
-
!' -,.'-"In:•_n! =^nrc is nm�;
13. CASING
Dcp!h Diarnc:cr
From-> To sI Ft.
From-- To-- FI.
Freres To-- FI.
14. GROUT:
Depot
From To'-_ Fl.
From _ To Ft.
15. SCREEN:
P: as ltuc%-nos LOCATION SKSI C'H
Lrn:chal (Show di..ct:cn and dis.anco Irc;n at least k o State
13 S T4y- Rc:, or other map ralerence points)
hletatbl t/.olhod 1
Depth Diameler
From To Ft in.
From To Ft. In.
From To R. In.
16, SAND/GRAVEL PACK:
Depth Size
From To Ft._
From To Ft.
17. REMARKS:
Slot SIZC Material
in.
In.
in. —
Ma!orial
ECG
I DO HEREBY CERTIFY THAT THIS''NELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C. "VELL
CONSTRUCTION STANDARDS, AND THAT A`aCOPYY OF THIS RECORDHAS BEEN PROVIDED TO THE VIULL OWNER.
FOR OFFICEUSE.DIJLY
Owd No h t 3 GNATURE OF PERSON CONSTRUCTING Tl N_LL DATE
Submit onyinal to OM: [on el V,aIor Ou alit y. Groundr,mor Sacron within 30 days
Scdal No, GV: I REV. 1-51
r
toff
GLEN dq

i
7 n7
North Carolina • Department of Environment and Natural Resources - Division of Water Oualiy -Groundwater Section <- , ,•. J .f ll 7
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELLCONTRACTOR: _ -_y, U>o pAr-cu2r-t
WELL CONTRACTOR CERTIFICATION #:_
STATE WELL CONSTRUCTION PERMIT# ZISCp
1. WELL USE (Check Applicable sox): Res',dei Municipal ❑ Industrial ❑ Agricullural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Inlection ❑ Other ❑ If Other, List Use:
2.
WELL LOCATION: (Show sketch of the location below)
GLeN V r`"4"
Nearest Town: County:
Ylt-Oi
(Road Name and Numbers, Community, or Subdivision Lot No.)
DRILLING LOG
3.
nand
OWNER chVCK Ar o SJ5-,,a
From To
Address P.O. LZ6, 38
0 r,ji�
Sine or ou:o No ��.���
GCEn ✓ytG
qP /00
/V6
/� 3eL)
City cr Tc.vn 5laio Zip Code
4.
DATE DRILLED-
5.
TOTAL DEPTHi
6.
CUTTINGS COLLECTED YES© NOO
7.
DOES WELL REPLACE EXISTING WELL? YES O 110,®,
8.
STATIC WATER LEVEL Below Top of Casing: _moo FT.
(Uso'+' if Abovo Top of Casing)
9.
TOP OF CASING IS FT. Above Land Sudace'
'Top of casing terminated at/or below land surface requires a variance In actor.
—
dance
zdth 15A KCAC 2C.011a
Zcn 1"/4
10.
YIELD (cp m): _ METHOD OF TEST
11.
WATER ZONES (depth): 21 /-_>
_-
12. CHLORINATION: Type Amount
13. CASING:
If ad : ioral spa_e is needed use back of tom -i
DEPTH
Fouratlon Desuiption
LOCATION SKETCH
1; a!I Thickrc ss
Depth
Dla.mctcr or Vlcigl CR. t.ralce.al
(Sho,+ direcllcn a,,d dis'ance from at least two Stalo
From
W
To /
FL
�y � �3 3���
Roads, or elhar map relererce points)
From
To
Pt.
From
To--
FL
� (� "---
14.
GROUT:
Depth
xlaterlal Molhod
��.•
From
­­--_-:� C-)_
To'L��s'�L,-
Ft.
From
To
Ft.
15.
SCREEN:
Dapih
Diameter
Slot Size Malarial
From
To Pt
In. In.
From
To Ft.
In. In.
From
To Ft.
In. In.
16.
SAND/GRAVEL PACT::
Depth
Size Ma!eriai
From
To
FL
From
To
Ft.
17.
REMARKS:
I DO HERESY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND TjH�AT A j PY OF THIS RECORD HAS BEEN PROVIDED TO THE %^:ELLI OWNER.
FOR OFFICE USE ONLY �C�I C-�IQ-ext�e. 11�� e � 5y-
Quad No SIGNATURE OF PERSON CONSTRUCTING T h Z WELL GATE
Submit odpinal to Division of water Quality, Groundwater Section within 30 days
Serial No. GW-1 REV. 12r'59
.[4r:"i:idtNBiB' $egtjrry

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section ep A
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone] 152192
} ) J(1 2
WELL CONSTRUCTION RECORD 4YELLCONTRACTOR: pCtLS5cm _ �!_ or
WELL CONTRACTOR CERTIFICATION #:_
STATE WELL CONSTRUCTION PERMITfi:
1. WELL USE (Chock Applicable Dos): Residenti3Lm Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other EJ If Other, List Use:
2, WELL LOCATION: (Show sketch of the location below
Agricultural ❑ Monlloring ❑
Nearest Town. -�vi�1 County: �n1`
(Road Name and Numbers, Community, or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER From To Formation Description
Address
'City or Town Slale Zip Code
S. TOTAL
DEPTH
D AKK
S. TOTAL DEPTH
6. CUTTINGS COLLECTED YES® NOO
7. DOES WELL REPLACE EXISTING WELL? YES 0 NO�
S. STATIC WATER LEVEL Below Top of Casing: C—::�, FT.
(U,e `.' it Abovo Top of Ca;ing)
9. TOP OF CASING IS FT. Above Land Surface'
'Top of casing terminated aVor below land surface requlraa a variance In actor
dance with 15A NCAC C.0118
10. YIELD (gpm): METHOD OF TEST
11. WATER ZONES (depth): �— \\C)
12. CHLORINATION: Type Amount
13. CASING:
wa'i Thickness
Dept Diameter cr 41!_i hVFt. 6f Icd.l
--To — Ft. � Frorn � Y
From To Ft.
-
From To — Fl.
14. GROUT:
Depth ^/�Material Method
From 0 To c� (_) Ft. l "E W\12A: '1 C-)7
From To Ft.
15. SCREEN:
Depth Diarneler Slot Slze Material
Frorn 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:
�l
d
It additional space Is needed use back of form
r
_ )\
r..
'
LOCATION SKETCH_ tD
rn
(Shov: direction and distance from at least two Statue
y
Roads, or other map reference paints) N
o
1j\0
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, VIELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL ONINER. r
FOR OFFICE USE ONLY 'a��'E,Yl'C U(ii� � -� , AQ C %(L-o_ Oo
Quad No SIGNATURE OF PERSON CONSTRUCTING THE Y! L DATE
Submil original to Division of Water Quality. Groundwater Section within 30 days
Serial No. Gvht REV. 12/59

North Carolina - Department of Environment and Natural Resources - Division of Water Ouality - Groundwater Section 7 ':� �i (I }
P.O. Box 29578 - Raleigh,N.C. 27626-0578-Phone [phone]
WELL CONSTRUCTION RECORD DRILLING CONTRACTOR: i"
DRILLER REGISTRATION #:
STATE WELL CONSTRUCTION PERMIT#:
1.
WELL USE (check Applicable Box): Residential0 Municipal ❑ Industrial ❑
Agricultural ❑ Monitoring ❑
Recovery ❑ Heal Pump Water Injection ❑ Other ❑ If Other, List Use:
2.
WELL LOCATION: (Sow ske ch of the locati n below)
Neeaaarrreeesst Town: e r. -z-r County:
(Head, Co uni or Subdivis n and LO No.) DEPTH
DRILLING LOG
3.
OWNER From To
Formation Description
ADDRES4i1 '/_ 4"X 4
v
( reet or Route No.) —
'7/ 7
d
f Z
--
City or Town State Zip Code
4.
DATE DRILLED 2 '� ' 6 D
5.
TOTAL DEPTH
6.
CUTTINGS COLLECTED YES � NOO
a3. '
`---
7.
DOES WELL REPLACE EXISTING WELL? YES NO[w�_
8.
STATIC WATER LEVEL Below Top of Casing: FT.
t _
9.
(Use'," if Above Top of Casing)
TOP OF CASING ISFT. Above Land Surface'
-
- Casing Terminated aVor below land surface is Illegal unless a variance is issued
rn
in
10.
accordance with 15A�N1� C�AC 2C .0118 n
YIELD (gpm): TL 2- METHOD OF TEST
11.
WATER ZONES (depth): �Ct 0
ro
12.
CHLORINATION: Type T III Amount
itional space is needed use back of form
13.
CASING:
LOCATION SKETCH
Wall Thickness
Depth Diameter or WeightlFt. at nal
(Show direction and distance from at least two State
From- To Ft. —i"/
Roads, or other map reference points)
From To Ft.— —
4
From To Ft.
14.
GROUT:
Depth Material Method
From To � Ft. n.P��P7�— y�-z,—,1,.�
�L
�' �(il�� AY
�Q(
From To Ft.
—
15.
SCREEN:
Depth Diameter Slot Size Material
From To Ft in. in.
From To Ft. in. in.
From To Ft. in. in.
16.
SAND/GRAVEL PACK:
Depth Size Material
From To —Ft. -
From To Ft.
17.
REMARKS:
I DO HER W)C'ITIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTR�IION"STANDARDS,
AND THAT A COPY OF THIS CORD
HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFI ,§USE ONLY -
. uad No: ---.
Serial No:
SIGNATUROOF CONTRACTOR OR AGENT DATE
Submit ongi al to Division of Water Quality and copy to well owner.
GW-1 REV. 1198

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section e)
P.O. Box 20578 - Raleigh,N.C. 27626-0578-Phone [phone] L 1 5) ! �f
WELL CONSTRUCTION RECORD DRILLING CONTRACTOR: / ink e �� 1/Y�Zk
DRILLER REGISTRATION #:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential E:r Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION //" Show sketch of oe location below) (/
Nearest Town: k 1p County: C�
(Road. Cc` 'unity, or S division and Lot ,No.), DEPTH DRILLING LOG
3. OWNER / _ /1From To Formation Description
ADDRESS Fj O
(Street or Route No — D —
C �1 3)
City or Town State Zip Code
4. DATE DRILLED d — 4 —DO �.5 .1 �r D C-_
5. TOTAL DEPTH . �� /J
6. CUTTINGS COLLECTED YES EZ' NOF] ozs
7. DOES WELL REPLACE EXISTING WELL? YES 0 NOO o n
8. STATIC WATER LEVEL Below Top of Casing: 3C, FT.
(Use "+" if Above Top of Casing) c_ -
9. TOP OF CASING IS� FT. Above Land Surface'
J
Casing Terminated aVor below land surface is illegal unless a variance is issued
in accordance with 15A NCAC 2C .0118
—1
10. YIELD (gpri METHOD OF TEST
m
11. WATER ZONES (depth): ��(�� •• c,
N n
12. CHLORINATION: Type _— T L4— Amount additional space is needed use back of form =
13. CASING:
Depth Diameter
From 0 To _s�� Ft. L
From To Ft. —
From To Ft.
14. GROUT
Wall Thickness LOCATION SKETCH
or WeighuFL t, terial (Show direction and distance from at least two State
Roads, or other map reference points)
De th , Material M thod
From 0 TO�Ft.
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft in. in.
From To Ft. in. in.
From To Ft. in. in.
16. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To Ft.
17. REMARKS:
Material
I DO HEREBY CERTIFY THAT, THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION aANDARIjS, ANCJTHAT A'COPY OF T LP RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE QNLY
Quad No: q ,
Serial No:,
t '7
7-(
SIGNATURE OF CONTRACTOR OR AGENT DATE
Submit original to Division of Water Quality and copy to well owner.
GW-1 REV. 1198

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section 1 5 !' 7
P.O. Box 29578 - Raleigh,N.C. 27626-0578-Phone [phone]
WELL CONSTRUCTION RECORD DRILLING CONTRACTOR: A1W
DRILLER REGISTRATION #:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (check Applicable sox): Residential LI Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION:Fhow sketch of the location below)
Nearest Town:, ,(�Z— County:
Agricultural ❑ Monitoring ❑
(Road, Comnrurfitdor
Subdivision and Lot No.)
DEPTH
DRILLING LOG
3.
OWNER 4xY./7/lis,
�iiJ.C;C — w ,P�., �'X-1
From To
Formation Description
ADDRES. 5:__�
(Street or l'i to No.)
_—
/ 0
4.
City or Town State Zip Code
DATE DRILLEDv�'�.77r
5.
TOTAL DEPTH
6.
CUTTINGS COLLECTED YES E2—NOD
a
7.
DOES WELL REPLACE EXISTING WELL? YES D NOEf[—
=�
G
8.
STATIC WATER LEVEL Below Top of Casing: /aD FT.
'
9.
(Use '+" it Above Top of Casing)
TOP OF CASING ISFT. Above Land Surface*
1
L i
_
a
' Casing
Terminated at/or below land surface is illegal unless a variance is issued
in
10.
accordance with 15A NCAC 2C .0118
YIELD (gpm): --V— METHOD OF TEST
f; a
11.
WATER ZONES (depth): %
cn
N
o
12.
CHLORINATION: Type f / /-- Amount
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
hh //
From To Ft. - C1w �� Roads, or other map reference points)
From To Ft.— —
From To Ft. -
14. GROUT: -
Depth Material Method
From To 2-7% Ft.
From To Ft.
15. SCREEN:
Depth
From
To
From
To
From
To _
16. SAND/GRAVEL
PACK:
Depth
From
To —
From
To_
17. REMARKS:
Diameter Slot Size Material
Ft in. in.
Ft. in. in.
Ft. in. in.
Ft
Ft
Size
Material
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER. ;a
FOR OFFICE USE ONLY:.
Quad No: SIGNATU OF CONTRACTO OR AGENT DATE
Serial No �• Submit on nal to Division of Water Quality and copy to well owner.
to - GW-1 REV. 1/98
k:_.n

nl '` S4
North Carolina -Department of Environment and Natural Resources -Division of Water Quality -Groundwater Section �- . •.. 2
P.O. Box 29578 - Raleigh,N.C. 27626-0578-Phone [phone] /�
WELL CONSTRUCTION RECORD DRILLING CONTRACTOR: F2?Fi>L 16"
DRILLER REGISTRATION #: 6 2--L—
STATE WELL CONSTRUCTION PERMIT#:
1.
WELL USE (Check Applicable Box): Residential E Municipal ❑
Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2.
WELL LOCATION: (Show th location below)
wssketch lnof
`_ ems ^
Nearest Town: �c County: +
C
h.
(Road, Comf�unity or Subdivi is and Lot No.)
DEPTH DRILLING LOG
3.
OWNER \..k2_141x�
From To Formation Description
ADDRESS, Jn6
(Street or Route No.)
A' CC --�1 C � F 77
Q ��
4.
City Vown l ' State Zip Code
DATE DRILLED
5.
TOTAL DEPTH O-5
6.
CUTTINGS COLLECTED YES NOF
r
7.
DOES WELL REPLACE EXISTING WELL? YES F] N01f]
CD -
8.
STATIC WATER LEVEL Below Top of Casing: (, :j>j—FT.
(Use "+" if Above Top of Casing)
9.
TOP OF CASING ISFT. Above Land Surface'
r;
' Casing Terminated at/or below land surface is illegal unless a variance is issued
1
-_ =
in
10.
accordance with 15A NCAC 2C .0118
YIELD (gpm): v?, S METHOD OF TEST A_)"-—
11.
WATER ZONES (depth): T
0
12.
CHLORINATION: Type i-i" I Amount
f additional space is needed use back oRidrm o
13.
CASING:
Wall Thickness
LOCATION SKETCH
Depth
D aameter or Weight/Ft. Material
(Show direction and distance from at least two State
From
To -ELL
Ft.
Roads, or other map reference points)
From
To
FL__From
To
Ft.
14. GROUT:
Depth,
Material Method
0
2-a-rnXmJ—
From
From
To IR
To
Ft.
Ft.
15.SCREEN:
Depth
From
To
From
To
From
To
16. SAND/GRAVEL
PACK:
Depth
From
To —
From
To
17. REMARKS:
Diameter Slot Size Material
Ft in. in.
Ft. in. in.
Ft. in. in.
Ft.
Ft.
Size
Material
I DO HEREBY CEAtIRY j'FiATHIS WELL I W.JS ONISTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
F' �A CONSTRUCTION;tjR�S, AND THAT ACIY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
g 4;
FOR OFFICE US -Y Ai (
Quad No. :1 SIGNATURE O CONTRACTOR R AGENT DATE
Serial No. Submit original to Division of Water Quality and copy to well owner.
. _. GW-1 REV. 1/98

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section e 1 -- � p
P.O. Box 29578 - Raleigh,N.C. 27626-0578-Phone [phone] J
WELL CONSTRUCTION RECORD DRILLING CONTRACTOR: �Q
DRILLER REGISTRATION #:
STATE WELL CONSTRUCTION PERMIT#:
1.
WELL USE (Check Applicable Box): Residential LJ Municipal ❑
Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2.
WELL LOCATIO 1 : Show sketch of the location below)
Nearest Town: s County:
(Road, Com unity. qSubdivisictind 'tnNo.)
DEPTH DRILLING LOG
3.
OWNER 4-U� f�1v-�"'�"'^-
From To Formation Description
ADDRESS 170 i LPN<zcR-
(Street RoVNttee,No.)
r 5?'�� ��
City or Town Stag Zip Code
E
Z - 7.3O
4.
DATE DRILLED c2 - I S) ' Lty
5.
TOTAL DEPTH 7,30
6.
CUTTINGS COLLECTED YES NOD
7.
DOES WELL REPLACE EXISTING WELL? YES NO[�]
�-
8.
STATIC WATER LEVEL Below Top of Casing: FT.
(Use 4" if Above Top of Casing)-
9.
TOP OF CASING IS�_ FT. Above Land Surface*
1
• Casing Terminated at/or below land surface is illegal unless a variance is issued
in
AC
accordance with 2C .0118
10.
YIELD (gpm)15A
:� METHOD OF TEST
_
11.
WATER ZONES (depth):
c;
12.
CHLORINATION: Type T- Amount
If additional space is needed use back of form tV
13.
CASING:
Wall Thickness LOCATION SKETCH
Depth �o Dia�mat2er� or WeighuFt. M rial (Show direction and distance from at least two State
From To 3� Ft. --� -`- Roads, or other map reference points)
From To Ft.— From To Ft.
14. GROUT:
Depth Material Method
From 0 To �2- 0 Ft.
From To Ft. /
15. SCREEN:
Depth
From
To
From
To
From
To
16. SAND/GRAVEL
PACK:
Depth
From
To —
From
To_
17. REMARKS:
t /ot,Pi
I DO HEREBY CERTIFY
FOR OFFICE
Quad No: —
Serial No:
Diameter Slot Size Material
Ft in. in.
Ft. in. in.
Ft. in. in.
Size Material
Ft.
Ft.
kT THIS WELL WAS. CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
RDs('AND THAT A COPY OF THIS RECORD
ORD HAS BEEN PROVIDED TO THE WELL OWNER.
Submit
/ 4-1O --(
iF CONTRA OR OR AGENT DATE
to Division f Water Quality and copy to well owner.
GW-1 REV. 1/98

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section ,tom. 1 .} .) 9
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELLCONTRACTOR: 2vSS�� L ?4TfZ1��
WELL CONTRACTOR CERTIFICATION. _
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residenlia�R Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Infection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: G�L�t�\-i:�-'O County:
OCATION
(Road Name and Numbers. Community, or Subdivision and Lol N\o.)
-L
DRILLING LOG DEPTH
3,
OWNER C: wC, �� 7 7 \ 1
From To Formation Description
C-3 VO4 C�\VA
Address CD
— �
reQ or ou a N o. ^�
�nU 0L0 G (J C\ %nf Z
Cily or Town Stale Zip Code
DATE DRILLED-11J <Dc)
4.
5.
TOTAL DEPTH
6.
CUTTINGS COLLECTED YES NOD
7.
DOES WELL REPLACE EXISTING WELL? YES ❑ NO�
r'-
8.
STATIC WATER LEVEL Below Top of Casing: FT.
(Use'+'Il Above opol asing)
9.
TOP OF CASING IS --A— FT. Above Land Surface'
-Top of casing terminated attor below land surface requires a variance In actor-
- —
1
dance
10.
with 16A NCAC 2C.0118
YIELD (gpm): ��METHOD OF TEST F)NNC
11.
WATER ZONES (depth):
12.
CHLORINATION: Type �-1R NA Arnounl / �.( �^�..�
use back of form D mr
II additional space Is needed u �o
13.
CASING:
(V =
SKETCH
Wall Thickness
De if Diameter or;ejghUFt. aledal
From-�TOSAD Ft. (o. - ��
From To Ft.
From To-- Ft.
14. GROUT:
Depth Material Mothod
From C)_ To ---DC)-_ FI.
From To Ft.
15. SCREEN:
Depth Diameter
FromFroTo _ Ft In.
From —To —Ft. _ In.
From _ To Ft. in.
16. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To Ft.
17. REMARKS:
Slot Size Material
In.
In.
In.
Material
L
(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 TQ THE WELL 0
FOR OFFICE USE ONLY
Quad No: SIGNATUFl F PERSON CONSTRUCTING THE WELL
Submit original to Divlsion Water Quality. Groundwater Section within 30 day
Serial No.
DATE
GW-1 REV. 12/99

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section .1_ ) ,(n� 6
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELLCONTRACTOR: -Pu, <)SGA I L.Ov\f `Cr
WELL CONTRACTOR CERTIFICATION #:11
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (chock Applicable Box): Residential. Municipal ❑ Industrial ❑ Agricultural
❑ ❑
Recovery Heat Pump Water Injection ❑ Other ❑ I( Other, List Use:
2. WELL LOCAT (Show sketch of the location below)
Nearest\T-own: n� 1 County: �—
�`lVl\i
(Road N
3. OWNER
Address
or
City or Town Slate Zip Code
4. DATE DRILLED
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ® NO[_j
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO;K�
B. STATIC WATER LEVEL Below Top of Casing: 4: X:- FT.
(Uso '+' it Above Top of Cn;ing)
9. TOP OF CASING IS_/1_ FT. Above Land Surface'
'Top of casing terminated aVor below land surface requires a variance In accor-
dance with 15A NCAC 2C .011e
10. YIELD (gprn): _"LMETHOD OF TEST�-
11. WATER ZONES (depth): )15—
12. CHLORINATION: Type T Amount S�
13. CASING:
Wall Thickness
Depth _ Diameter cr WoigA� hiatedai
From�To��-Ft. �rk1 -�'
From To- Ft.
From To— Ft.
14. GROUT:
Depth /, Material Method
From To- Ft. Own&nA7 10�
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From To Pt 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
0 _7_�l
Monitoring ❑
DEPTH
Formation Description
n
O
p
r73
c „�
I
o-
Ul
If additional space Is needed use back of form "
o
LOCATION SKETCH
(Show direction and distance from at least two Stale
Roads, or other map reference points)
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 16A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY I Ww - I UC",
Ouad No: SIGNATURE OF PERSON CONST IDATE
.�....� Submit original to Division of Water Quality, Groundwater Section Wt hin 30 days
Serial No.
GW-1 REV. 12/99
-K_o0

1
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.G. 27699-1636-Phono [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION If
STATE WELL CONSTRUCTION PERMIT#: I
1. WELL USE (Check Applicable Box): Resldentialol Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Infection ❑ Other ❑ If Other, List Use:
2. WELL LOCA(TTION: S\ho—wsk\etch of the location below) •��f� \
Nearest Town` �N 11'�J,�L�� Counly: _ �11�.c--tlV-1
Numbers. Community. or Subdivision and Lot No.)
3. OWNER
Address
City or Town State Zip Code
4. DATE DRILLED
5. TOTAL DEPTH '—
6. CUTTINGS COLLECTED YESM NOEJ
7. DOES WELL REPLACE EXISTIN WELL? YES E] NOU
8. STATIC WATER LEVEL Below Top of Casing: c- — FT.
(Use'+' If Above Top of Casing)
9. TOP OF CASING IS _. FT. Above Land Surface'
'Top of easing terminated aVor below land surface requires a variance In accor.
dance with 15A NCAC 2C.0118
10. YIELD (glem): ( oC ) METHOD OFTEST
11. WATER ZONES (depth): C4.), VQn
yx- 4.4r,
12. CHLORINATION: Type IA:t!" Amount _0*
13. CASING:
Wall Thickness
/'�
Depth �Di�a`�e�ler or WeighVFtt Maledal
From—C To� FL D—t— —
From To Ft.
From To-- Ft.
14. GROUT:
Depth Material Method
From C) To ._.Ft.
From To Ft.
15.SCREEN:
Depth Diameter Slot Size Material
From To Ft in. In.
From To Ft. In. In.
From To Ft. In. In.
16. SAND/GRAVEL PACK
Depth Size M31ofial
Frorn To Ft.
From To Ft.
17. REMARKS:
Agricultural ❑ Monitoring ❑
DRILLING LOG
From To
r�
DEPTH
Formation Description
�aL,,Sa-�d-
�'�Q_
�1
m
Z
II additional space Is needed use back of forrrW rNi�
y
LOCATION SKETCH
2
(Show direction and distance from at least two State
Roads, or other map reference points)
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TOTHEWELL OWNER.
FOR OFFICE USE ONLY ��1'l'2'e-'(1'C'.,f0_s
Quad No: SIGNATURE OF PERSON CONSTRUCTING THE WELL �J DATE
.• Spbf7i1 Original to Division of Water Quality, Groundwater Section Within 30 days
Serial Na. GW-1 REV. 12199
i nab-
rfu+ztt;- CeCtiy

North Carolina - Department of Environment and Natural Resourcoa - Division o1 Water Quality - Groundwater Soclion 0109
1636 Mail Service Confer - Raleigh, N.C. 27699-1636-Phono [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: �r
WELL CONTRACTOR CERTIFICATION It: ^{ i 3
STATE WELL CONSTRUCTION PERMITIk
1 . WELL USE (chock Applicable vox): Residonlial Municipal Industrial ❑
Rocovory ❑ Heat Pump Walor Infeclion�j El Olhor ❑ It Othor, List Use:
WELL I
Noarost
3. OWNER
Addross
of the location below) , L
County: �,, 'Son
Agricultural ❑ Monitori% ❑
or Subdivision and Lot No.) DRILLING LOG DEPTH
ex Qj __- __- From To Fwmatlon Doscrlptlon
[r a or ou o a. n
rySc �8G11� 4,
City or Toown,,n Slala ZIp CWa
4. DATE DRILLED � _�_�
S. TOTAL DEPTH 4�5 O
G. CUTTINGS COLLECTED YES ET�� NOD
7. DOES WELL REPLACE EXISTING WELL? YES 0 NO[E�
0. STATIC WATER LEVEL Bolovr Top of Casing: —�+K.J p' Fi.
(U.o 4' II Abova Top of Casing)
9. TOP OF CASING ISFF. Above Land Surl::co'
'Top of casing tonnlnaled eVor below land surlaco rcqulros a va:lam:a In occor-
dance with 15A NCAC 2C. VID
10. YIELD (9pm): JD METHOD OF TEST
11. WATER ZONES (doplh): 5M -
� o
12. CHLORINATION: Type ' 1 Amount � (0S I( additional spaco L needed use back of form
i 3. CASING.
LOCATION SKF I CH
Wall Thlckress
Depth
DiDi. Me or W6, II ��Ft. `la�l�er,:�al�
�`
(Show direction and di;tanca I:uln at lead two Stale
From
To -
Ft.
L —�—
Roads, or other Ina, rclarei,ce points)
Prom
From
To
To—
Ft.--
Ft.---
I I
0a� L.��.`�, )on1 `
14. GROUT:
Dopt'hl��
Material Mothod
1
1�U CQJ
From .11—
T-o
FL
Jre�ec�
From
To
Ft.
_
15. SCREEN:
Depth Diametor
From To Ft In.
From To Ft. In.
From To Fl. In.
10. SAND/GRAVEL PACK
Depth Size
From To Ft.
From To Ft.
17. REMARKS:
Slot Size M.a:o:ial
In.
In.
In.
Malorial
I DO HEREBY CERFIF-Y THAT THIS WELL WAS CONSI P.UCTED IN ACCORDANCE WFR 11SA 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: Ce"',
serial No.
SIGNAI UftE OP PCRSON COS ISTRUCTING TL'E W
ybni4 original to Division al `:rater Quality, Groundwater Scction wilhlll 30
DATE
GW-1 fIGV. 12/TJ
�uIY �5/Q
1

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
P.O. Box 29578 - Raleigh,N.C. 27626-0578-Phone [phone]
DRILLING CONTRACTOR: v
DRILLER REGISTRATION #:
STATE WELL CONSTRUCTION PERMIT#:
WELL CONSTRUCTION RECORD
1. WELL USE (Check Applicable Box): Residential lJ Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use::/
2. WELL LOCAT�ON: (Sh w sketch of the Iota Ion,(h)elo�w) G //
Nearest Town:( r�is-C rn �'—ir County: riUl�yn
(Road, Comrr�unitt or Sub sion and of No. DEPTH DRILLING LOG
3. OWNER, 20 tJE'61-_ From To Formation Description
ADDRESS/ 1)0 Ox / A ._
/ ISveef or Route N% J 7 7-1 /J — ��
orTow Q
[e oC o s% 5
i! or Town State Zip Code
4. DATE DRILLED I
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES L2' NOD
7. DOES WELL REPLACE EXISTING WELL? YES NO�
8. STATIC WATER LEVEL Below Top of Casing: ;1 U FT.
(Use '+" it Above Top of Casing)
9. TOP OF CASING ISFT. Above Land Surface'
Casing Terminated atlor below land surface is illegal unless a variance is issued
in accordance with 15A/IN.C//A�C 2C .0118
10. YIELD (gpm): � METHOD OF TEST
11. WATER ZONES (depth): oZU
/�
12. CHLORINATION: Type;? f�I� Amount ihonal space is needed use back SPforni,;
13. CASING: c_
wall Thickness LOCATION SKETCH
Depth Diameter or Weight/Ft, aten I (Show direction and distance from at Least twA State::
From D To 5q Ft. —{2— vRoads, or other map reference points)
From To Ft.— -�
From To Ft.
�u ~
14. GROUT:
Depth Material Method =
From D To Q U Ft. {� n/
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft in. in.
From To Ft. in. in.
From To Ft. in. in.
16. SAND/GRAVEL PACK:
Depth Size Material
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
,TOO/THE WELL OWNER.
FOR OFFICE USE ONLY � /Zc 4 ZI �?5 d �S ��
Quad No: '1 SIGNATURE OF ONTRACTOR Q -AGENT DATE
SerialNo. 1' 1 i Submit original I rvision of Water'ijuality and copy to well owner.
GW-1 REV, 1/98

North Carolina - Department of Environment and Natural Resources - Division or Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD
WELL CONTRACTOR: ?SJELc
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMITN
Z187
1.
WELL USE (Check Applicable Box): Residentlain Municipal ❑
Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heal Pump Water Infection ❑ Other ❑
If Other, List Use:
2.
WELL LOCATION: (Show sketch of the location below) C1
County: r�•��'r�n
Nearest Tow County:
C` ��N,�, �cti �4�
(Road Name and Numbers, Community, or,Subdlvision and Lot No.)
DRILLING LOG DEPTH
3.
OWNER \� l r+, , �} L T�
From To Description
1
Address-
r-F�o�rmatiion
jS
City or Town ' Stale Zip Code
4.
DATE DRILLED
5.
TOTAL DEPTH �`��.—
6.
CUTTINGS COLLECTED YES, NOD
7.
DOES WELL REPLACE EXISTING WELL? YES Q NO�
8.
STATIC WATER LEVEL Below Top of Casing: r:3Cl FT.
9.
(Use'.* if Abovo Top of Casing)
TOP OF CASING IS_j FT. Above Land Surface'
'Top of casing terminated at/or below land surface requires a variance In accor-
dance
with 15A NCAC 2C .011 a
F�\�C
10.
YIELD (gpm): (L<) METHOD OF TEST
11.
WATER ZONES (depth): �7 - 1�.h \CL 4,Q0
12.
CHLORINATION: Type Amoun:
If additional space Is needed use back of form
13.
CASING:
Depthh�1,Q �Di"al elnr
From C) To Ft. , •, /''4
From To Ft.
From To-- Ft.
14. GROUT
Wall Thickness LOCATION SKETCH
or W ' I VFt. Material (Show direction and distance from at least two State
Q— Roads, or other map reference points)
Depth Material Method
From C') TOoS2_Fl. L�'rmr= VS15,)
From To Ft.
15. SCREEN:
Depth Diameter
From To Ft In.
From To Ft. In.
From _ To FL in.
16. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To Ft.
17. REMARKS:
Slot Size Material
In.
In.
In.
Material
\ ORl L_�
SR- \ Ov %
Sao awe.
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OFT IS RECORD HAS BEEN PROVIDED TO,,THE WELL OWNER.
FOR OFFICE USE ONLY 2)
Quad No: SIGNATU OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Divlslo of Water Quality, Groundwater Section within 30 day
Sepal No. _�. t r GW-I REV. 12199
i

''1
North Carolina -Department of Environment and Natural Resources -Division of Water Quality -Groundwater Section !
P.O. Box 29578 - Raleigh,N.C. 27626-0578-Phone [phone]
WELL CONSTRUCTION RECORD DRILLING CONTRACTOR:
DRILLER REGISTRATION #:
STATE WELL CONSTRUCTION PERMIT#:
1.
WELL USE (Check Applicable Box): Residenti2l.0' Municipal ❑
Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If
Other, List Use:
2.
WELL LOCAT,_GN (Show sketch of the location below)
Nearest Towrp4�)'n County:
(Road Comm i ,orSubdivisiogand�LoyNo.I
DEPTH DRILLING LOG
1OWNER
/i z 4 a
'76?q
From To Formation Description
ADDRESS c QIi
(Street or Rea te
_
-
'
� a9('a�
City or Town stale Zip Code
4.
DATE DRILLED f - l l -0 O�-
5.
TOTAL DEPTH %.0
6.
CUTTINGS COLLECTED YES NOD
7.
DOES WELL REPLACE EXISTING WELL? YES n NO
8.
STATIC WATER LEVEL Below Top of Casing: _ FT.
(Use'+" if Above Top of Casing)
9.
TOP OF CASING IS I FT. Above Land Surface'
Casing
Terminated atlor below land surface is illegal unless a variance is issued
in
accordance with 15A NC C 2C .0118
10.
YIELD (gpm): METHOD OF TEST
11.
WATER ZONES (depth): -7
12.
L
CHLORINATION: Type "�n Amount
dditional space is needed use back of form
13.
CASING:
r.
O -
LOCATION SKETCH c1 "
Wall Thickness
Depth Diameter or Weight/Ft. Material Q
�-,�
(Show direction and distance from at least Lw State
From To FL -la—�l —-r^-�
Roads, or other map reference points)
From To Ft.—
I
From To FL
14.
GROUT:
Depth Material Method
From To a Ft.
_'
- p
From To Ft.
�`�"
15.
SCREEN:
Depth Diameter Slot Size Material
v
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
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS ORD HAS BEO PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY Z o2
Quad No: - SIGNATUREIF CONTRACTO OR AGENT DATE
Serial No: - Submit origin to Division of Water Quality and copy to well owner.
GW-1 REV. 1/98

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
P.O. Box 29578 - Raleigh,N.C. 27626-0578-Phone [phone]y./�/
DRILLING CONTRACTOR: 4AA- C+j2eP�x-�. .11J/I.�OUI/
DRILLER REGISTRATION M I q
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (check Applicable Box): Residential ET Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
215?99
Agricultural ❑ Monitoring ❑
2. WELL LOCATION: (Show ketch of thepcation below)
Nearest Town. County:
92dt 4_t�
(Road, Commniy,orSubdivisio and Lot o.) DEPTH DRILLING LOG
3. OWNER z I - (�a`From To Formation Description
ADDRESS
(street or o !e No.)
City or Town �-- Slate Zip Code _ Z/ &
4. DATE DRILLED _ _DO Z/& — �? �-
5. TOTAL DEPTH (v.50
6. CUTTINGS COLLECTED YES � NOF_J
7. DOES WELL REPLACE EXISTING WELL? YES EI NO[�!J'
8. STATIC WATER LEVEL Below Top of Casing: FT. _ a
(Use "+" if Above, Top of Casing) ra
9. TOP OF CASING ISFT. Above Land Surface' m
r
Casing Terminated at/or below land surface is illegal unless a variance is issued cm _
in accordance with 15A NCAC 2C .0118 --
10. YIELD (gpm): METHOD OF TEST
11. WATER ZONES (depth): 3lo O -
47
�o z,
12. CHLORINATION: Type ���� Amount If additional space is needed use back 'worm
13. CASING:
N o
LOCATION SKETCH z
Wall Thickness
Depth,,
UFt. ,� erial
Dia el er or W/S
From
To
Ft.
From
To
Ft.—
From
To
Ft.
-
14.
GROUT:
�
Depth
0
�
Material Method
�
From
To
Ft.i4iCiz�f
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:
(Show direction and distance from at least two State
Roads, or other map reference points)
06,
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS ECr', BEEN PROVI D TO THE
WELL OWNER,
FOR OFFICE USE billLY ._ /� % —/O
Ouad No L SIGNATUREp�r: *T CTOR OR AGENT DATE
Serial No.Submit origind, Eifvisi n of Water Quality and copy to well owner.
v". GW-1 REV. 1/98

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section r ) 1 `� 42 J 3
P.O. Box 29578 - Raleigh,N.C. 27626-0578-Phone [phone]
WELL CONSTRUCTION RECORD DRILLING CONTRACTOR: q�
DRILLER REGISTRATION #:
STATE WELL CONSTRUCTION PERMIT#:
1.
WELL USE (check Applicable Box): Residentialo Municipal ❑ Industrial ❑ Agricultural
❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2.
WELL LOCATI9(Show sketch of the location below)
Nearest Town: i.=T� �!9'�a u �'1t County:
Jam( r
YRol�.•Co munity, of S vision and Lot No _ DEPTH
DRILLING LOG
3.
OWNER _ -Q From To
Formation Description
ADDRES
Street or Route No. 4
-a- (f
4.
City or Town State Zip Code
DATE DRILLED (� 2—� Z (3
5.
6.
TOTAL DEPTH / UU
CUTTINGS COLLECTED YENO❑
_
7.
DOES WELL REPLACE EXISTING WELL? YES ❑ NOOK
o
8.
STATIC WATER LEVEL Below Top of Casing: 7?) FT.
p !
(Use "+" it Above Top of Casing)
9.
TOP OF CASING ISFT. Above Land Surface`
Casing Terminated at/or below land surface is illegal unless a variance is issued
-_
in
10.
accordance with 18A NCAC 2C .0118
YIELD (gpm): t /7 METHOD OF TEST
11.
h'1� S
WATER ZONES (depth): //
fTl .J
cs
12.
CHLORINATION: Type 7 14 Amount 6 - If additional space is needed use back of form Z
13.
U
CASING:
Wall Thickness LOCATION SKETCH
Depth Digmeter or Weight/Ft. JUL(Show direction and distance from at least two State
From 0 To Ft. --a— Roads, or other map reference points)
From To Ft.— From To Ft.
14. GROUT:
DeMaterial Method Q�,)`
From � To � Ft. (Z 4C­7'�
From To Ft.
15.SCREEN,
Depth Diameter Slot Size Material
From To Ft in. in.
From To Ft. in. in.
From To Ft. in. in.
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
17. REMARKS:
I DO HEREBY cGATIFY�THAT THIS, ,WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTIOt $iANDAFIDS� AND THAT. A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
1 SDI
FOR OFFICE US {�4LY
Quatl No: r t° SIGNAT E OF CONTR CTOR OR AGENT DATE
Serial No: '� �' } Submit original to Division of Water Ouality and copy to well owner.
GW-1 REV. 1/98

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section � 152 97
P.O. Box 29578 - Raleigh,N.C. 27626-0578-Phone [phone]
WELL CONSTRUCTION RECORD DRILLING CONTRACTOR: /� 1 L20i�P &W- I ��C4
DRILLER REGISTRATION #:
STATE WELL CONSTRUCTION PERMIT#:
1.
WELL USE (Check Applicable Box): Residential E_l Municipal ❑
Industrial ❑
Agricultural ❑ Monitoring ❑
Recovery ❑ Heal Pump Water Injection ❑ Other ❑ If Other, List Use:
2.
WELL LOCATION {Show p/f the location below
bpsketch ,
Nearest Town: ��(da1lLLZLLd-�(L County:
n
(Road, Community, or uDdivision Loot No.))
DEPTH
DRILLING LOG
3.
�d
OWNE
From To
F ation escriplion
ADDRE
(Street or Route No.)
City or Town State Zip Code
4.
DATE DRILLED - f - D L)
5.
TOTAL DEPTH IoLvu
6.
CUTTINGS COLLECTED YES[;]- NO❑
7.
DOES WELL REPLACE EXISTING WELL? YES ❑ NOo-
8.
STATIC WATER LEVEL Below Top of Casing: _rr� FT.
-,
(Use'+" if Above Top of Casing)
9.
TOP OF CASING ISM_ FT. Above Land Surface`
J
- Casing Terminated aUor below land surface is illegal unless a variance is issued
in
accordance with 15A NCAC 2C .0118
10.
YIELD (gpm): i` " METHOD OF TEST
n;J
11.
WATER ZONES (depth):
u1
N o
12.
CHLORINATION: Type ,L} 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 -� Q
Ft.
93 t/ems
Roads, or other map reference points)
From To
FL-_-�/
From To
Ft.
14. GROUT:
Depth
From -0 To 2-0
Material
Ft. -«-�
Method` l
/
From To
FL
15. SCREEN:
�/--
�LC(
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: 'vJ QAN
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 O�iLY , 0Pe -� 71(/I/ '-�'S-00
SIGNATU OF CONTRA TOR OR AGENT DATE
Serial No: Submit original to Division of Water Quality and copy to welt owner.
�,, GW-1 REV. 1/98

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Ground Water Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636 - Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: Hedden Bros Well Drilling Inc.
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMIT #:
Applicable Box): Residential ❑X Municipal ❑ Industrial ❑
Agricultural ❑ Monitoring ❑
1. WELL USE(Check
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other,List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: Whittier County: Jackson
well tee -Near Smkv Mtn Rac
(Road Name and Numbers, Community, or Subdivision and Lot No.) DEPTH
DRILLING LOG
3. OWNER Bette Thomason From To
Formation Description
Address P.O.Box396 0 159
clay & sand
(Street or Route No.) 158 450
granite
Dillsboro NC 28725
City or Town State Zip Code
4. DATE DRILLED 12/18/00
5. TOTAL DEPTH 450
❑ NO ❑X
ao y
6. CUTTINGS COLLECTED YES
YES ❑ NO
O
7. DOES WELL REPLACE EXISTING WELL?
8. STATIC WATER LEVEL Below Top of Casing: 0 FT.
m c
(Use "+" if Above Top of Casing)
znl
9. TOP OF CASING IS 2 FT. Above Land Surface*
CA �m
CO
*Top of casing terminated at/or below land surface requires a variance in actor-
dance with 15A NCAC 2C .0118
y�
10. YIELD (gpm): 1.00 METHOD OF TEST Blow
11. WATER ZONES (depth): 195
m�
0-757
r —
12. CHLORINATION: Type H T H Amount
YP If additional space is needed use back of form z
13. CASING: Wall Thickness
Depth Diameter or Weight/Ft. Material LOCATION SKETCH
From _ 0 To 160 Ft. Sj_' 189 Steel—_ (Show direction and distance from at least two State
From To Ft. Roads, or other map reference points)
From To Ft.
14. GROUT:
Depth Material Method
From 0 To 20 Ft. Cement Poured
From To Ft.
15.SCREEN:
Depth Diameter Slot Size Material
From —0 To Ft. in. in.
From To Ft. in. in.
From To Ft. in. in.
16.SAND/GRAVEL PACK:
Depth Size Material
From 0 To Ft.
From To Ft.
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUC Ste+ � COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE FSS , LY' ! {i
Quad No.
Serial No. SIGNATURE OF PERSON CON RUCTING THE WELL Date
_5qr alit original to Division of Water Quali Groundwater Section within 30 days
r. .
i

��2811
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Ground Water Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636 - Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: Hedden Bros. Well Drilling Inc.
WELL CONTRACTOR CERTIFICATION N: 2047
STATE WELL CONSTRUCTION PERMIT 11:
1. WELL USE(Check Applicable Box): Residential 0 Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: Dillsboro County: Jackson
Cagle Branch
(Road Name and Numbers, Community, or Subdivision and Lot No.)
3. OWNER Gary Melton
Address P O Box 962
(Street or Route No.)
Dillsboro NC 28725
City or Town State Zip Code
4. DATE DRILLED 12/13/00
5. TOTAL DEPTH 300
6. CUTTINGS COLLECTED YES ❑ NON
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
8. STATIC WATER LEVEL Below Top of Casing: 0 FT.
(Use " + " if Above Top of Casing)
9. TOP OF CASING IS 2 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): 4.00 METHOD OF TEST BLOW
11. WATER ZONES (depth): 115
0
12. CHLORINATION: Type H T H Amount
13. CASING: Wall Thickness
Depth Diameter or Weight/Ft. Material
From 0 To_21 Ft. 6" 188 stee)
From 2 To 78 Ft. 6 PVC
From To Ft.
14. GROUT:
Depth Material Method
From 0 To 20 Ft. Cement Poured
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From �_ To Ft. _
From To Ft.
From To Ft.
16. SAND/GRAVEL PACK:
Depth
From 0 To _ Ft.
From To Ft.
17. REMARKS:
I DO HEREI
FOR OFFICE
Quad No.
Serial No.
in. in.
in. in.
in. in.
Size Material
DEPTH DRILLING LOG
From To Formation Description
O 76 clay Rr cand
76 300 granite
O—
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)
WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
ATURE OF PERSON CO1�RTRUCTING THE WELL Date
to Division of Water Quality, Groundwater Section within 30 days

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Ground Water Section t— 4 2810
1636 Mail Service Center - Raleigh, N.C. 27699-1636 - Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: Hedden Bros. Well Drilling Inc.
WELL CONTRACTOR CERTIFICATION N: 2047
STATE WELL CONSTRUCTION PERMIT k:
1. WELL USE(Check Applicable Box): Residential 0 Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other,List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: Tuckasegee County: Jackson
Canada "Opp Oak Ridge Rd
(Road Name and Numbers, Community, or Subdivision and Lot No.) DEPTH DRILLING LOG
3. OWNER Jack Purdy From To Formation Description
Address P O Box 100 0 6R day & sand
(Street or Route No.) 68 ('Inn granite
Tuckasegee NC 28783
City or Town State Zip Code
4. DATE DRILLED 12/11/00
5. TOTAL DEPTH 600
6. CUTTINGS COLLECTED YES ❑ NO ❑X
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO X❑
8. STATIC WATER LEVEL Below Top of Casing: 0 FT.
(Use " + " if Above Top of Casing)
9. TOP OF CASING IS 2 FT. Above Land Surface*
*Top of casingg terminated at/or below land surface requires a variance in accor-
dance with ISA NCAC 2C .0118
10. YIELD (gpm): 0.75 METHOD OF TEST Blow
11. WATER ZONES (depth): '270
0
12. CHLORINATION: Type H T H Amount
13. CASING: Wall Thickness
Depth Diameter or Weight/Ft. Material
From -_ To 70 Ft. 6 PVC
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From 0 To 20 Ft. Cement Poured
From To Ft.
15. SCREEN
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)
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 0 To Ft.
From To Ft.
17. REMARKS:
I DO HEREB�C,ERTtFv TUeT 9LS WJ r W4S CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCT nSVN�41�SOA%b V )`COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE 6�ONLY �rz
Quad No. y
Serial No. t S GNATURE OF PERSO CONSTRUCTING THE WELL Date
it original to Division of Wate Quality, Groundwater Section within 30 days
c

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Ground Water Section :-�2809
1636 Mail Service Center - Raleigh, N.C. 27699-1636 - Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: Hedden Bros. Well Drillinp, Inc.
WELL CONTRACTOR CERTIFICATION H: 2047
STATE WELL CONSTRUCTION PERMIT N:
1. WELL USE(Check Applicable Box): Residential ❑X 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: Webster County: Jackson
Buchanan Loop -Webster
(Road Name and Numbers, Community, or Subdivision and Lot No.) DEPTH DRILLING LOG
3. OWNER Laurel Vartabedain From To Formation Description
Address P O BOX 1208 O 116 (lay Rr sand
(Street or Route No.) 116 450 granite
Cullowhee NC 28723
City or Town State Zip Code
4. DATE DRILLED 12/12/00
5. TOTAL DEPTH 450
6. CUTTINGS COLLECTED YES ❑ NO F
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
8. STATIC WATER LEVEL Below Top of Casing: 0 FT.
(Use "+" if Above Top of Casing)
9. TOP OF CASING IS 2 FT. Above Land Surface*
*Top of casingg terminated at/or below land surface requires a variance in accor-
dance with 15A NCAC 2C .0118
IO. YIELD (gpm): 5.00 METHOD OF TEST Blow
11. WATER ZONES (depth): 390
0
12. CHLORINATION: Type H T H Amount
13. CASING: Wall Thickness
Depth Diameter or Weight/Ft. Material
From —0 To 2] Ft. F" 188 Steel
From 21 To 118 Ft. 6 PVC
From To Ft.
14. GROUT:
Depth
Material
Method
From 0 To 20
Ft.
Cement
Poured
From To
Ft.
15. SCREEN:
Depth
Diameter Slot Size
Material
From _ 0 To
Ft.
in.
in.
From To
Ft.
in.
in.
From To
Ft.
in.
in.
16. SAND/GRAVEL PACK:
Depth
Size
Material
From 0 To
Ft.
From To
Ft.
17. REMARKS:
I DO HERH)
FOR OF]
Quad No.
Serial No.
a
If additional space is needed use back tZb1'ormo
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
r'f IIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
S,-AN6 THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
ATURE OF PERSON CONSTRf1CCING THE WELL ` . Date
to Division of Water ouality, roundwater Section within 30 days

22814
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Ground Water Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636 - Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: Hedden Bros. Well Drilling Inc.
WELL CONTRACTOR CERTIFICATION Y: 2043
STATE WELL CONSTRUCTION PERMIT k:
1. WELL USE(Check Applicable Box): Residential 0 Municipal ❑
Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other,List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: Cashiers County: Jackson
WDnlds Mtn Rd
(Road Name and Numbers, Community, or Subdivision and Lot No.)
DEPTH DRILLING LOG
3. OWNER J. Lee Fry
From To Formation Description
Address P O Box 130
0 31 rla)t Rr sand
(Street or Route No.)
33 300 granite
Union Cif IN 38261
City or Town State Zip Code
4. DATE DRILLED 12/13/00
5. TOTAL DEPTH 300
YES ❑ NO ❑X
6. CUTTINGS COLLECTED
❑ NO X❑
o-
7. DOES WELL REPLACE EXISTING WELL? YES
8. STATIC WATER LEVEL Below Top of Casing: 0 FT.
r T1
(Use "+" if Above Top of Casing)
9. TOP OF CASING IS 2 FT. Above Land Surface*
CD sr-;
*Top of casingg terminated at/or below land surface requires a variance in accor-
dance with 15A NCAC 2C .0118
10. YIELD (gpm): 30.00 METHOD OF TEST Blow
3 �m
11. WATER ZONES (depth): ?50
0
r
12. CHLORINATION: Type H T H Amount
if additional space is needed use back of form 'Z
13. CASING: Wall Thickness
Depth Diameter or Weight/Ft. Material
LOCATION SKETCH
From To 21 Ft. 6„ �j-$$__ steel
Show direction and distance from at least two State
_0
From 21 To 35 _ Ft. 6„ PVC
oads, or other map reference points)
From To Ft.
14. GROUT:
Depth Material Method
From 0 To 20 Ft. Cement Poured
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From 0 To Ft. in. in.
From To Ft. in. in.
From To Ft. in. in.
16. SAND/GRAVEL PACK:
Depth Size Material
From 0 To Ft.
From To Ft.
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CnNSTRI IC�iaN S'i ANbARbS, At4D tHAT.ACOPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
FOR OFFICE US. LY J , u � 1 A - LJ?_ O. p
Quad No. r..
Serial No.� GNATURE OF PERSON CONSTRUCTING THE WELL Date
t @�n.i , ter S=Cti;7lTSubmit on inal to Division of Water Quality, Groundwater Section within 30 days

r ,-
4�2�1;
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Ground Water Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636 - Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: Hedden Bros. Well Drilling Inc.
WELL CONTRACTOR CERTIFICATION X: 2043
STATE WELL CONSTRUCTION PERMIT #:
1. WELL USE(Check Applicable Box): Residential ❑X 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: Cashiers County: Jackson
(Road Name and Numbers, Community, or Subdivision and Lot No.)
3. OWNER Scott Sylvester
Address P O Box 2288
(Street or Route No.)
Cashiers NC 28717
City or Town State Zip Code
4. DATE DRILLED 12/12/00
5. TOTAL DEPTH 200
6. CUTTINGS COLLECTED YES ❑ NO EXI
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO 0
8. STATIC WATER LEVEL Below Top of Casing: 0 FT.
(Use " + " if Above Top of Casing)
9. TOP OF CASING IS 2 FT. Above Land Surface*
*Top of casingg terminated at/or below land surface requires a variance in accor-
dance with 1SA NCAC 2C .0118
10. YIELD (gpm): 40.00 METHOD OF TEST Blow
11. WATER ZONES (depth): 130
0
12, CHLORINATION: Type H T H Amount
13. CASING: Wall Thickness
Depth Diameter or Weight/Ft. Material
From _0 To ?I Ft. 6 188 Steel
From 21 To_68 Ft. 6„ DVc
From To Ft.
14. GROUT
DEPTH
From To
DRILLING LOG
Formation Description
If additional space is needed use back of=Dm
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
Depth
Material
Method
From 0 To 20
Ft. Cement
Poured
From To
Ft.
15. SCREEN:
Depth
Diameter Slot Size
Material
From _0 To
Ft. in.
in.
From To
Ft. in.
in.
From To
Ft. in.
in.
16. SAND/GRAVEL PACK:
Depth
Size
Material
From 0 To
Ft.
From To
Ft,
17. REMARKS:
I DO HER CE
CONSTRUCTION
6�F66
RNf T
S
NSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE
Quad No. . 1 i
Serial No.
GNA
—2 . 4-7 OG
rURE OF PERSON CONSTRUCTING THE WELL Date
n inal [
Division of Water Quality, Groundwater Section within 30 days

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Ground Water Section � 2 2 8 2 1
1636 Mail Service Center - Raleigh, N.C. 27699-1636 - Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: Hedden Bros. Well Drilling Inc.
WELL CONTRACTOR CERTIFICATION #: 2043
STATE WELL CONSTRUCTION PERMIT #:
1. WELL USE(Check Applicable Box): Residential 11 Municipal ❑
Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other,List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: Cashiers County: Jackson
404 N Norton Rd
(Road Name and Numbers, Community, or Subdivision and Lot No.)
DEPTH DRILLING LOG
3. OWNER Richard R Tyre
From To Formation Description
Address 426 Marietta St # 201
n 44 ciny Rr ¢anti
(Street or Route No.)
43 700 granite.
Atlanta GA 30313
City or Town State Zip Code
4. DATE DRILLED 12/05/00
5. TOTAL DEPTH 700
YES ❑ NO ❑X
6. CUTTINGS COLLECTED
YES ❑ NO X❑
r�
7. DOES WELL REPLACE EXISTING WELL?
8. STATIC WATER LEVEL Below Top of Casing: 0 FT.
Q +�
(Use " + " if Above Top of Casing)
C3
9. TOP OF CASING IS 2 FT. Above Land Surface*
n �n
*Top of casing terminated at/or below land surface requires a variance in accor-
dance with 15A NCAC 2C
.0118
10. YIELD (gpm): 1.00 METHOD OF TEST Blow
11. WATER ZONES (depth): iRs
A ma
0
N�
12. CHLORINATION: Type H T H Amount
If additional space is needed use back oydbrm
13. CASING: Wall Thickness
O FS
Depth Diameter or Weight/Ft. Material
`
LOCATION SKETCH
From 0 Tom_ Ft. 6" .188 steel
(Show direction and distance from at least two State
From 5 To 45 _ Ft. DVc
Roads, or other map reference points)
From To Ft.
14. GROUT:
Depth Material Method
From 0 To 20 Ft. Cement Poured
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From 0 To Ft. _
From To Ft.
From To Ft.
16. SAND/GRAVEL PACK:
Depth
From 0 To Ft.
From To Ft.
17. REMARKS:
IDO HEREBY
FOR OFFICE
Quad No.
Serial No.
in. in.
in. in.
in. in.
Size Material
CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
)PY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
OA -
ATURE OF PERSON CONSTRUCTING THE WELL Date
to Division of Water Quality, Groundwater Section within 30 days

y ry
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Ground Water Section ;' 2 4 3 5
1636 Mail Service Center - Raleigh, N.C. 27699-1636 - Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: Hedden Bros. Well Drilling Inc.
WELL CONTRACTOR CERTIFICATION N: 2047
STATE WELL CONSTRUCTION PERMIT N:
WELL USE(Check Applicable Box): Residential ER Municipal ❑ Industrial[E]
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other,List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: Sylva County: JaCkSOn
233 C estnut Cove lid
(Road Name and Numbers, Community, or Subdivision and Lot No.) DEPTH
3. OWNER Timothv Rall
Address 233 Chestnut Cove Rd
(Street or Route No.)
Sylva NC 28779
City or Town State Zip Code
4. DATE DRILLED 12/22/00
5. TOTAL DEPTH 250
6. CUTTINGS COLLECTED YES ❑ NO0
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
8. STATIC WATER LEVEL Below Top of Casing: 0 FT.
(Use "+" if Above Top of Casing)
9. TOP OF CASING IS 2 FT. Above Land Surface*
*Top of casingg terminated at/or below land surface requires a variance in accor-
dance with 15A NCAC 2C .0118
10. YIELD (gpm): 6.00 METHOD OF TEST BIOW
11. WATER ZONES (depth): 0
12. CHLORINATION: Type H T H Amount
13. CASING: Wall Thickness
Depth Diameter or Weight/Ft. Material
From —0 To 4 Ft. 6 189 Steel —
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From 0 To 20 Ft. Cement Poured
From To Ft.
15.SCREEN:
Depth Diameter Slot Size Material
From —0 To Ft. in. in.
From To Ft. in. in.
From To Ft. in. in.
16. SAND/GRAVEL PACK:
Depth Size Material
From 0 To Ft.
From To Ft.
From To
Agricultural ❑ Monitoring ❑
DRILLING LOG
Formation Description
If additional space is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USEONL `"
u1_
Quad No. 17-117,
Serial No.
` -' SIGNATURE OF PERSON CON$ CTING THE WELL Date
Submit original to Division of Water Qi , Groundwater Section within 30 days

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Ground Water Section �7 A J
1636 Mail Service Center - Raleigh, N.C. 27699-1636 - Phone [phone] F'
WELL CONSTRUCTION RECORD WELL CONTRACTOR: Hedden Bros. Well Drilling Inc.
WELL CONTRACTOR CERTIFICATION #: 204
STATE WELL CONSTRUCTION PERMIT #:
1. WELL USE(Check Applicable Box): Residential El Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other,List Use:
Agricultural ❑ Monitoring ❑
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: Sylva County: Jackson
Hannah Mtn Rd
(Road Name and Numbers, Community, or Subdivision and Lot No.) DEPTH DRILLING LOG
3. OWNER Buddy Glover From To Formation Description
Address P O Box 203 0 61 sla}r .G canri
(Street or Route No.) 61 200 granite
Dillard GA 30537
City or Town State Zip Code
4. DATE DRILLED 12/05/00
5. TOTAL DEPTH 200
6. CUTTINGS COLLECTED YES ❑ NO FV
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO X❑
8. STATIC WATER LEVEL Below Top of Casing: 0 FT.
(Use "+" if Above Top of Casing)
9. TOP OF CASING IS 2 FT. Above Land Surface*
*Top of cast terminated terminated at/or below land surface requires a variance in accor-
dance with 15A NCAC 2C .0118
10. YIELD (gpm): 15.00 METHOD OF TEST Blow
11. WATER ZONES (depth): 115
0
12. CHLORINATION: Type H T H Amount
If additional space is needed use back of form
13. CASING: Wall Thickness
Depth Diameter or Weight/Ft. Material
LOCATION SKETCH
From _ 0 To_-f 3_ Ft. 6 ' 188 Steel—
(Show direction and distance from at least two State
From To Ft.
Roads, or other map reference points)
From To Ft.
14. GROUT:
Depth Material Method
From 0 To 20 Ft. Cement Poured
0
From To Ft.
o
�
Z;E
D
15. SCREEN:
L
�'
Depth Diameter Slot Size Material
c,
From _0 To Ft. in. in.
—
Ca
'm
� <
From To Ft. in. in.
�o
From To Ft. in. in.
a.
S
�o
16. SAND/GRAVEL PACK:
m
Depth Size Material
a
From 0 To Ft.
_C-)
z
From To- Ft.
17. REMARKS:
I DO HEREBY gCE$ %)1A F>,{S-WELL.WAS CONSTRUCTED
IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUC 'IO% STA A D . A76tl][} T.A COPY OF THIS RECORD
HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE
Quad No.
Serial No.
ATURE OF PERSONP6NSTRUCTING THE WELL Date
to Division of Water Quality, Groundwater Section within 30 days

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Ground Water Section i .._ tt 3 5 4
1636 Mail Service Center - Raleigh, N.C. 27699-1636 - Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: Hedden Bros. Well Drilling Inc.
WELL CONTRACTOR CERTIFICATION X: 2047
STATE WELL CONSTRUCTION PERMIT f/:
Applicable Box): Residential 0 Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
1. WELL USE(Check
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other,List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: Sylva County: Jackson
90 Daffodil Une
(Road Name and Numbers, Community, or Subdivision and Lot No.) DEPTH DRILLING LOG
3. OWNER Eugene Husarenko From To Formation Description
Address 90 Daffodil Lane n RR Clad ,w Sand
(Street or Route No.) RR 900 ,granite
Sylva NC 28779
City or Town State Zip Code
4. DATE DRILLED 12/04/00
5. TOTAL DEPTH 800
❑ NO ❑X
6. CUTTINGS COLLECTED YES
YES ❑ NO
7. DOES WELL REPLACE EXISTING WELL?
8. STATIC WATER LEVEL Below Top of Casing: 0 FT.
(Use "+" if Above Top of Casing)
9. TOP OF CASING IS 2 FT. Above Land Surface*
*Top of casingg terminated at/or below land surface requires a variance in accor-
dance with I A NCAC 2C .0118
10. YIELD (gpm): 1.00 METHOD OF TEST Blow
11. WATER ZONES (depth): 0
12. CHLORINATION: Type H t H Amount If additional space is needed use back of form
13. CASING: Wall Thickness
Depth Diameter or Weight/Ft. Material LOCATION SKETCH
From 0 Tom_ Ft. 6' PVC (Show direction and distance from at least two State
_
From To Ft. Roads, or other map reference points)
From To Ft.
14. GROUT:
Depth Material Method
From 0 To 20 Ft. Cement Poured
From To Ft. O
0
�
15. SCREEN: L
Depth Diameter Slot Size Material ID
c
Cm
From 0 To Ft. in. in.
c�
_
From To Ft. in. in.
yo
From To Ft. in. in. 3
26
m
16. SAND/GRAVEL PACK: n
Nz
Depth Size Material
y
From 0 To Ft.
z
From To Ft.
17. REMARKS:
I DO HEREBY Gf' TI)� Y THAN THIS,WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTI(jRDS* AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE (}dtY401
dd
Quad No.
Serial No. - - - --- SIGNATURE OF PERSON C STRUCTING THE WELL
Date
Submit original to Division of Water Qu ity, Groundwater Section within 30 days

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Ground Water Section 2 Z04 2 1
1636 Mail Service Center - Raleigh, N.C. 27699-1636 - Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: Hedden Bros. Well Drilling Inc.
WELL CONTRACTOR CERTIFICATION l/: 2045
STATE WELL CONSTRUCTION PERMIT #:
1. WELL USE(Check Applicable Box): Residential 0 Municipal ❑
Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other,List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: Sylva County: Jackson
Willets Comm
(Road Name and Numbers, Community, or Subdivision and Lot No.)
DEPTH DRILLING LOG
3. OWNER Bobby Gunter
From To Formation Description
Address 93 Wind Crest Ridge
n 96 dw; Ar sand
(Street or Route No.)
26 300 granite,
Sylva NC 28779
City or Town State Zip Code
4. DATE DRILLED 11/01/00
5. TOTAL DEPTH 300
6. CUTTINGS COLLECTED YES ❑ NO 0
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO 0
8. STATIC WATER LEVEL Below Top of Casing: 0 FT.
(Use "+" if Above Top of Casing)
9. TOP OF CASING IS 2 FT. Above Land Surface*
*Top of casingg terminated at/or below land surface requires a variance in accor-
dance with 15A NCAC 2C .0118
10. YIELD (gpm): 6.00 METHOD OF TEST Blow
11. WATER ZONES (depth): 103
0
12. CHLORINATION: Type H T H Amount
If additional space is needed use back of form
13, CASING: Wall Thickness
Depth Diameter or Weight/Ft. Material
LOCATION SKETCH
From 0 To 2] Ft. 6' _ 188 steel
(Show direction and distance from at least two State
From 21 Tom Ft.� PVC
Roads, or other map reference points)
From To Ft.
14. GROUT:
Depth Material Method
From 0 To 20 Ft. Cement Poured
_
From To Ft.
15.SCREEN:
t
Depth Diameter Slot Size Material
From 0 To Ft. in. in.
From To Ft. in. in.
From To Ft. in, in.
o
16. SAND/GRAVEL PACK:
_
Depth Size Material
From 0 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 TH
AT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE uQuad No.
Serial No. ATURE OF PERSON CONSTRUCTING THE WELL Date
to Division of Wan
Quality, Groundwater Section within 30 days

220423
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Ground Water Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636 - Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: Hedden Bros. Well Drilling Inc.
WELL CONTRACTOR CERTIFICATION N: 2045
STATE WELL CONSTRUCTION PERMIT #:
1. WELL USE(Check Applicable Box): Residential EK 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: CullOWhee County: Jackson
South Wayrhutta
(Road Name and Numbers. Community, or Subdivision and Lot No.) DEPTH DRILLING LOG
3. OWNER Rick Bennett From To Formation Description
Address P O Box 541 0 44 MAY Rr 'nod
(Street or Route No.) 43 150 �gmnite
Sylva NC 28779
City or Town State Zip Code
4. DATE DRILLED 11/01/00
5. TOTAL DEPTH 150
6. CUTTINGS COLLECTED YES ❑ NO 0
7. DOES WELL REPLACE EXISTING WELL? YES El NO F
S. STATIC WATER LEVEL Below Top of Casing: 0 FT.
(Use " + " if Above Top of Casing)
9. TOP OF CASING IS 2 FT. Above Land Surface*
*Top of casingg terminated at/or below land surface requires a variance in accor-
dance with I NCAC 2C .0118
10. YIELD (gpm): 30.00 METHOD OF TEST B10W
11. WATER ZONES (depth): 110
12. CHLORINATION: Type H T H Amount If additional space is needed use back of form
13. CASING: Wall Thickness
Depth Diameter or Weight/Ft. Material LOCATION SKETCH
From 0 To9,L Ft. 611_ 188 St_rel._ Show direction and distance from at least two State
From 21 To 5 Ft. �— DVc Earls, or other map reference points)
From To Ft.
14. GROUT:
Depth Material Method
From 0 To 20 Ft. Cement Poured
From To Ft. o c
15. SCREEN:
Depth Diameter Slot Size Material C-D
From . 0 To Ft. in. in. l
�D
From To Ft. in. in. _
From To Ft. in. in. --
16. SAND/GRAVEL PACK: c.� r'--
Depth Size Material CD
From 0 To Ft.
From To Ft.
17. REMARKS:
I DO HEREBY CER 11L4. STRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTIONS aDR AIDIFHWr IC R OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ON 1 eo _oe
Quad No.
Serial No. ! SI NA RE OF PERSON CONSTRUCTING THE WELL Date
al to ivision of Water Quality, Groundwater Section within 30 days
�_�Cdi.
Office

��0'70
r ti
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Ground Water Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636 - Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: Hedden Bros. Well Drilling Inc.
WELL CONTRACTOR CERTIFICATION H:
STATE WELL CONSTRUCTION PERMIT k:
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: Glenville County: Jackson
Rd Below Pine Tine On 107
(Road Name and Numbers, Community, or Subdivision and Lot No.) DEPTH DRILLING LOG
3. OWNER Rusty Bennet From To Formation Description
Address 3124 Marshall Blvd 0 59 (Jai R ;nnti
(Street or Route No.) 59 900 granite
Sullivans Island SC 29482
City or Town State Zip Code
4. DATE DRILLED 11/06/00
5. TOTAL DEPTH 800
6. CUTTINGS COLLECTED YES ❑ NO F
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
8. STATIC WATER LEVEL Below Top of Casing: 0 FT.
(Use " + " if Above Top of Casing)
9. TOP OF CASING IS 2 FT. Above Land Surface*
*Top of casingg terminated at/or below land surface requires a variance in accor-
dance with ISA NCAC 2C .0118
10. YIELD (gpm): 1.00 METHOD OF TEST Blow
11. WATER ZONES (depth): 310
0
12. CHLORINATION: Type H T H Amount If additional space is needed use back of,71pm -�
13. CASING: Wall Thickness
Depth Diameter or Weight/Ft. Material LOCATION SKETCH
From —0 To ?I Ft. 6" _ _ 1 RR .steel— (Show direction and distance from at least two State
From 21 To 61 Ft. " DVc Roads, or other map reference points)
From To Ft.
14. GROUT
Depth
Material Method
From 0 To 20
Ft. Cement Poured
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 0 To
Ft.
From To
Ft.
17. REMARKS:
I DO HEREBY CERTIFY
THAT THIS WELL, WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
Sttfj.NP TFrA'B A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
iEr
iSIGNATURE
OF PERSON CONSTRUCTING THE WELL Date
bmit riginal to Division of Water Quality, Groundwater Section within 30 days

._ .- 0 ! 2 G
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Ground Water Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636 - Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: Hedden Bros. Well Drilling Inc.
WELL CONTRACTOR CERTIFICATION #: 2043
STATE WELL CONSTRUCTION PERMIT!/:
I . 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: Glenville County: Jackson
Well #1--Below Pipeline
(Road Name and Numbers, Community, or Subdivision and Lot No.) DEPTH DRILLING LOG
3. OWNER Rusty Bennet From To Formation Description
Address 3124 Marshall Blvd 0 51 rla� Mean 1
(Street or Route No.) 51 700 granite
Sullivans Island SC 29482
City or Town State Zip Code
4. DATE DRILLED 11/01/00
5. TOTAL DEPTH 700
6. CUTTINGS COLLECTED YES ❑ NO FRI
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
8. STATIC WATER LEVEL Below Top of Casing: 0 FT. r?
(Use "+" if Above Top of Casing) -
9. TOP OF CASING IS 2 FT. Above Land Surface*
*Top of cast ngg terminated at/or below land surface requires a variance in actor- -
dance with 15A NCAC 2C .0118 "-
10. YIELD (gpm): 1.00 METHOD OF TEST Blow
11. WATER ZONES (depth): 210
0 -
12. CHLORINATION: Type H T H Amount If additional space is needed use back of fear y -
13. CASING: Wall Thickness 4 - -
Depth Diameter or Weight/Ft. Material --
LOCATION SKETCH
From 0 Tom_ Ft. 611 188 steel (Show direction and distance from at least two State
From 3 To�� Ft. 611 Dyc Roads, or other map reference points)
From To Ft.
14. GROUT:
Depth Material Method
From 0 To 20 Ft. cernent Poured
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 0 To Ft.
From To Ft.
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUC COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE LY
Quad No. -„ - OO
Serial No. - GNATURE OF PERSON CONSTRUCTING THE WELL Date
S it od final to Division of Water Quality, Groundwater Section within 30 days

220723
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Ground Water Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636 - Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: Hedden Bros. Well Drilling Inc.
WELL CONTRACTOR CERTIFICATION #: 2043
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: Cashiers county: Jackson
High Hemlock Lot #14
(Road Name and Numbers, Community, or Subdivision and Lot No.)
3. OWNER Tyson Betty
Address 850 S Ta niami Trl Suite 328
(Street or Route No.)
Sarasota FL 34236
City or Town State Zip Code
4. DATE DRILLED 11/10/00
5. TOTAL DEPTH 600
6. CUTTINGS COLLECTED YES ❑ NO F
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO 7
8. STATIC WATER LEVEL Below Top of Casing: 0 FT.
(Use "+" if Above Top of Casing)
9. TOP OF CASING IS 2 FT. Above Land Surface*
*Top of casingg terminated at/or below land surface requires a variance in accor-
dance with 15A NCAC 2C .0118
10. YIELD (gpm): 3.00 METHOD OF TEST Blow
11. WATER ZONES (depth): 115
330
12. CHLORINATION: Type H T H Amount
13. CASING: Wall Thickness
Depth Diameter or Weight/Ft. Material
From —_ To 21 Ft. _(.188 gtee,1
From 2.1- Toni 1_ Ft.6 ,gve
From To Ft.
14. GROUT
Depth
Material
Method
From 0 To 20
Ft.
cement
Poured
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 0 To
Ft.
From To
Ft.
17. REMARKS:
I DO HEREI
FOR OFFICE
Quad No. _
Serial No.
DEPTH
From To
DRILLING LOG
Formation Description
clay Rr sand
-granite
ca
fV
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)
CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
A. omenrneRnR AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
IGNATURE OF PERSON CONSTRUCTING THE WELL Date
Su r iml to Division of Water Quality, Groundwater Section within 30 days

220 724
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Ground Water Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636 - Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: Hedden Bros. Well Drilling Inc.
WELL CONTRACTOR CERTIFICATION #: 2043
STATE WELL CONSTRUCTION PERMIT k:
1. WELL USE(Check Applicable Box): Residential FRI 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: Glenville county: Jackson
Bee Tree Rd
(Road Name and Numbers, Community, or Subdivision and Lot No.) DEPTH DRILLING LOG
3. OWNER David Schwab From To Formation Description
Address 3546 Castle Hill Way n 21 clay & sand
(Street or Route No.) 21 425 granite
Tucker GA 30084
City or Town State Zip Code
4. DATE DRILLED 11/13/00
5. TOTAL DEPTH 425
6. CUTTINGS COLLECTED YES ❑ NO EXI
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
8. STATIC WATER LEVEL Below Top of Casing: 0 FT.
(Use "+" if Above Top of Casing)
9. TOP OF CASING IS 2 FT. Above Land Surface*
*Top of casingg terminated at/or below land surface requires a variance in accor-
dance with I A NCAC 2C .0118
10. YIELD (gpm): 40.00 METHOD OF TEST Blow
11. WATER ZONES (depth): 410
0
12. CHLORINATION: Type H T H Amount
13. CASING: Wall Thickness
Depth Diameter or Weight(Ft. Material
From —0 To 5 Ft. 6' .188 steel
From _5 To 23 Ft. 6„ DVc
From To Ft.
14. GROUT:
Depth Material Method
From 0 To 20 Ft. Cement Poured
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 0 To Ft.
From To Ft.
17. REMARKS:
-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 THAr`_"� CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTITAND®R12. IINNITi& A WPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE
Quad No.
Serial No. SI ATURE OF PERSON CONSTRUCTING THE WELL Date
rigin I to Division of Water Quality, Groundwater Section within 30 days
g S 110
. _ j l)i(Ice
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 THAr`_"� CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTITAND®R12. IINNITi& A WPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE
Quad No.
Serial No. SI ATURE OF PERSON CONSTRUCTING THE WELL Date
rigin I to Division of Water Quality, Groundwater Section within 30 days
g S 110
. _ j l)i(Ice

2070L-
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Ground Water Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636 - Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: Hedden Bros. Well Drillin@ Inc.
WELL CONTRACTOR CERTIFICATION #: 2045
STATE WELL CONSTRUCTION PERMIT #:
1. WELL USE(Cbeck Applicable Box): Residential © Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other,List Use:
7
3
WELL LOCATION: (Show sketch of the location below)
Nearest Town: Glenville County: Jackson
Big Ridge -Laurel Falls
(Road Name and Numbers, Community, or Subdivision and Lot No.) DEPTH
OWNER Harold Gurganus From To
Address Rt 1 o 4T
(Street or Route No.)
Williamston NC
City or Town State Zip Code
4. DATE DRILLED 11/06/00
5. TOTAL DEPTH 350
6. CUTTINGS COLLECTED YES ❑ NO ❑X
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
8. STATIC WATER LEVEL Below Top of Casing: 0 FT.
(Use " + " if Above Top of Casing)
9. TOP OF CASING IS 2 FT. Above Land Surface*
*Top of casingg terminated at/or below land surface requires a variance in accor-
dance with 15A NCAC 2C .0118
10. YIELD (gpm): 4.00 METHOD OF TEST Blow
11. WATER ZONES (depth): 140
316
12. CHLORINATION: Type H T H Amount
13. CASING: Wall Thickness
Depth Diameter or Weight/Ft. Material
From _ 0 To_45_ Ft. Sj _ i vc
From To Ft.
From To
Ft.
14. GROUT:
Depth
Material
Method
From 0 To 20
Ft. cement
Poured
From To
Ft.
15. SCREEN:
Depth
Diameter Slot Size
Material
From 0 To
Ft. in.
in.
From To
Ft. in.
in.
From To
Ft. in.
in.
16. SAND/GRAVEL PACK:
Depth
Size
Material
From 0 To
Ft.
From To
Ft.
ffl�t7:lu!1'3.t�1
I DO HERE]
FOR OFFICE
Quad No. _
Serial No.
DRILLING LOG
Formation Description
If additional space is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other trap reference points)
IS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
ATURE OF PERSON CONSTRUCTING THE WELL Date
to Division of Water Quality, Groundwater Section within 30 days

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Ground Water Section .. �. r! 1 7
1636 Mail Service Center - Raleigh, N.C. 27699-1636 - Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: Hedden Bros. Well Drilling Inc.
WELL CONTRACTOR CERTIFICATION #: 2043
STATE WELL CONSTRUCTION PERMIT #:
1. WELL USE(Check Applicable Box): Residential 0 Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other,List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: Cashiers County: Jackson
397 Slab Town R - wrier'
(Road Name and Numbers, Community, or Subdivision and Lot No.)
3. OWNER Cecil Aiken
Address P O Box 331
(Street or Route No.)
Cashiers NC 28717
City or Town State Zip Code
4. DATE DRILLED 11/15/00
5. TOTAL DEPTH 175
6. CUTTINGS COLLECTED YES ❑ NO 0
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
8. STATIC WATER LEVEL Below Top of Casing: 0 FT.
(Use "+" if Above Top of Casing)
9. TOP OF CASING IS 2 FT. Above Land Surface*
*Top of casingg terminated at/or below land surface requires a variance in accor-
dance with 15A NCAC 2C .0118
10. YIELD (gpm): 15.00 METHOD OF TEST Blow
11. WATER ZONES (depth): 155
0
12. CHLORINATION: Type H T H Amount
13. CASING: Wall Thickness
Depth Diameter or Weight/Ft. Material
From —_ Tom_ Ft. 6 �188'Teel
From —5 To 42 Ft. 6„ PVC
From To Ft.
14. GROUT
Depth
Material
Method
From 0 To 20
Ft.
Cement
Poured
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 0 To
Ft.
From To
Ft.
17. REMARKS:
DEPTH
From To
0 40
40 175
Agricultural ❑ Monitoring ❑
DRILLING LOG
Formation Description
rla)r Rr Sand
granite
If additional space is needed use back of
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
IN ACCORDANCE
TH 15A
I DO E� Y fT S Nb THAT A COPY OF THIS RET THIS WELL WAS CORD CORD HAS BEEN PROVIDED TO CONS THE WELL OWNER.
DJ�T DS4
FOR OF SE,,}g,
Quad No.
# Serial NoSIGNATURE OF PERSON CONSTRUCTING THE WELL Date
. YY
UIV
tj011 SuQmit original to Division of Water Quality, Groundwater Section within 30 days

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Ground Water Section '- 1213
1636 Mail Service Center - Raleigh, N.C. 27699-1636 - Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: Hedden Bros Well Drilling Inc.
WELL CONTRACTOR CERTIFICATION #: 2043
STATE WELL CONSTRUCTION PERMIT #:
1. WELL USE(Check Applicable Box): Residential EM Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other,List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: Glenville County: Jackson
129 Oconee BQ11 Tr-f edarC
(Road Name and Numbers, Community, or Subdivision and Lot No.)
3. OWNER Jim Monteith
Address 129 Oconee Bell Trail
(Street or Route No.)
Glenville NC 28736
City or Town State Zip Code
4. DATE DRILLED 11/21/00
5. TOTAL DEPTH 200
6. CUTTINGS COLLECTED YES ❑ NO C
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
8. STATIC WATER LEVEL Below Top of Casing: 0 FT.
(Use " + " if Above Top of Casing)
9. TOP OF CASING IS 2 FT. Above Land Surface*
*Top of casing terminated at/or below land surface requires a variance in accor-
dance with 15A NCAC 2C .0118
IO. YIELD (gpm): 15.00 METHOD OF TEST BIOW
11. WATER ZONES (depth): so
165
12. CHLORINATION: Type H T H Amount
13. CASING: Wall Thickness
Depth Diameter or Weight/Ft. Material
From _ 0 Tom_ Ft. 6 11 188 steel__
From _ 5 To 0 Ft. 6-' Vim_
From To Ft.
14. GROUT:
Depth
Material
Method
From 0 To 20
Ft.
Cement
Poured
From To
Ft.
15. SCREEN:
Depth
Diameter Slot Size
Material
From —0 To
Ft.
in.
in.
From To
Ft.
in.
in.
From To
Ft.
in.
in.
16. SAND/GRAVEL PACK:
Depth
Size
Material
From 0 To
Ft.
_
From To
Ft.
17. REMARKS:
Agricultural ❑ Monitoring ❑
DEPTH
From To
0 19
38 200
DRILLING LOG
Formation Description
Hay k sand
granite
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. ND:THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE 050'I;ONLY
Quad No. 4
Serial No. N
ATURE OF PERSON CONSTRUCTING THE WELL
to Division of Water Quality, Groundwater Section within 30 days
Date
Submit

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Ground Water Section 2 Z 2 n O
1636 Mail Service Center - Raleigh, N.C. 27699-1636 - Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: Hedden Bros. Well Drilling Inc.
WELL CONTRACTOR CERTIFICATION #: 2043
STATE WELL CONSTRUCTION PERMIT t/:
1. WELL USE(Check Applicable Box): Residential ER Municipal ❑ Industrial ❑ Agricultural 0 Monitoring 0
Recovery ❑ Heat Pump Water Injection 0 Other ❑ If Other,List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: Tuckasegee County: Jackson
795 Trout C'rk Rd
(Road Name and Numbers, Community, or Subdivision and Lot No.) DEPTH DRILLING LOG
3. OWNER Ronald Wiggins From To Formation Description
Address 795 Trout Crk Rd 0 40 r
(street or Route No.) 40 150
�iflT11TP.
Tuckasegee NC 28783
City or Town State Zip Code
4. DATE DRILLED 11/28/00
5. TOTAL DEPTH 150
6. CUTTINGS COLLECTED YES 0 NO 0
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
8. STATIC WATER LEVEL Below Top of Casing: 0 FT.
(Use "+" if Above Top of Casing)
9. TOP OF CASING IS 2 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): 12.00 METHOD OF TEST Blow
11. WATER ZONES (depth): 5 5
C:f
a
0
try,
m
o'
z_
CO
;c rn
zm
m
ma
z
12. CHLORINATION: Type H T H Amount If additional space is needed use back of form
13. CASING: Wall Thickness
Depth Diameter or Weight/Ft. Material
LOCATION SKETCH
From 0 To_5_ Ft. 6 "_ A 88 steel (Show direction and distance from at least two State
From 5 Tom Ft. 6„ pvc Roads, or other map reference points)
From To Ft.
14. GROUT
Depth Material Method
From 0 To 20 Ft. Cement Poured
From To Ft.
15.SCREEN:
Depth Diameter Slot Size Material
From 0 To Ft. _
From To Ft.
From To Ft.
16. SAND/GRAVEL PACK:
Depth
From 0 To Ft.
From To Ft.
17. REMARKS:
I DO HER CERTIFY THAT THIS
FOR OFFICE
Quad No.
Serial No.
in, in.
in. in.
in. in.
Size Material
6 CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
ATURE OF PERSON CONSTRUCTING THE WELL Date
to Division of Water Quality, Groundwater Section within 30 days
-� Submit oril

1. '2819
North Carolina -Department of Environment and Natural Resources -Division of Water Quality -Ground Water Section 1. ti
1636 Mail Service Center - Raleigh, N.C. 27699-1636 - Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: Hedden Bros. Well Drilling Inc.
WELL CONTRACTOR CERTIFICATION N: 2043
STATE WELL CONSTRUCTION PERMIT N:
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)
Nearest Town: Tuckasegee County: Jackson
809 Trout C'rk Rd
(Road Name and Numbers, Community, or Subdivision and Lot No.) DEPTH
3. OWNER Katherine Conner
Address 809 Trout Crk Rd
(Street or Route No.)
Tuckasegee NC 28783 -
City or Town State Zip Code
4. DATE DRILLED 11/29/00
5. TOTAL DEPTH 340
6. CUTTINGS COLLECTED YES ❑ NO FRI
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO 0
8. STATIC WATER LEVEL Below Top of Casing: 0 FT.
(Use " + " if Above Top of Casing)
9. TOP OF CASING IS 2 FT. Above Land Surface*
"Top of casingg terminated at/or below land surface requires a variance in accor-
dance with 15A NCAC 2C .0118
10. YIELD (gpm): 100.00 METHOD OF TEST Blow
11. WATER ZONES (depth): 330
339
12. CHLORINATION: Type H T H Amount
13. CASING: Wall Thickness
Depth Diameter or Weight/Ft. Material
From _0 To__ Ft. 6" _ 199 .Steel
From _ 5 To 74 Ft. 6„ .pvc
From To Ft.
14. GROUT:
Depth Material Method
From 0 To 20 Ft. centent Poured
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From _ 0 To Ft. in. in.
From To Ft. in. in.
From To Ft. in. in.
16. SAND/GRAVEL PACK:
Depth Size Material
From 0 To Ft.
From To Ft.
17. REMARKS:
I DO HEREBY CERTIFY THAT
CONSTRUCTION S
FOR OFFICE USE
Quad No.
Serial No.
From To
Agricultural ❑ Monitoring ❑
DRILLING LOG
Formation Description
0 72 day k sand
72 340 granite
m N
If additional space is needed use back df jorm
v O
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
RUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
IRE OF PERSON CONSTRUCTING THE WELL Date
to ivision of Water Quality, Groundwater Section within 30 days

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Ground Water Section l) 0O
1636 Mail Service Center - Raleigh, N.C. 27699-1636 - Phone [phone] O
402
WELL CONSTRUCTION RECORD WELL CONTRACTOR: Hedden Bros. Well Drilling Inc.
WELL CONTRACTOR CERTIFICATION #: 2043
STATE WELL CONSTRUCTION PERMIT #:
I. WELL USE(Check Applicable Box): Residential 0 Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other,List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: Glenville County: Jackson
326 Trout C'rk
(Road Name and Numbers, Community, or Subdivision and Lot No.) DEPTH DRILLING LOG
3. OWNER Doyle Stephens From To Formation Description
Address P G Box 326 0 91 clay Xr Sand
(Street or Route No.) 83 450 granite
Glenville NC 2 I S!
City or Town State Zip Code
4. DATE DRILLED 11/30/00
5. TOTAL DEPTH 450
6. CUTTINGS COLLECTED YES ❑ NO 0
7. DOES WELL REPLACE EXISTING WELL? YES El NO 0
8. STATIC WATER LEVEL Below Top of Casing: 0 FT.
(Use " + " if Above Top of Casing)
9. TOP OF CASING IS 2 FT. Above Land Surface*
*Top of casing terminated at/or below land surface requires a variance in accor-
dance with 15-A NCAC 2C .0118
10. YIELD (gpm): 2.00 METHOD OF TEST Blow
11. WATER ZONES (depth): O
o
rTl
�rn
m
e� R,
�m
m
12. CHLORINATION: Type H T H Amount If additional space is needed use back of form z
13. CASING: Wall Thickness
Depth Diameter or Weight/Ft. Material LOCATION SKETCH
From 0 To 5 Ft. S ' _ t RR Steel Show direction and distance from at least two State
From _ 5 To 85 _ Ft. 6„ 12VC oads, or other map reference points)
From To Ft.
14. GROUT:
Depth Material Method
From 0 To 20 Ft. Cement Poured
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From 0 To Ft. in. in.
From To Ft. in. in.
From To Ft. in. in.
16. SAND/GRAVEL PACK:
Depth Size Material
From 0 To Ft.
From To Ft.
17. REMARKS: —
I DO HEREBY CF
CONSTRUCTION
FOR OFFICE USE
Quad No.
Serial No.
'iY-Ie�"I�IILiW 09NSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
ID1'Y OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
4 j
1
i -3o-a
_T -"`-• IGN URE OF PERSON CONSTRUCTING THE WELL Date
Submit original ttDivision of Water Quality, Groundwater Section within 30 days

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Ground Water Section 2 2 4 3 5 2
1636 Mail Service Center - Raleigh, N.C. 27699-1636 - Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: Hedden Bros. Well Drilline. Inc.
WELL CONTRACTOR CERTIFICATION #: 2047
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: Whittier County: Jackson
622 Gateway Rd
(Road Name and Numbers, Community, or Subdivision and Lot No.) DEPTH DRILLING LOG
3. OWNER Gene Corbin From To Formation Description
Address 622 Gateway Rd 0 70 r1gy Rr sand
(Street or Route No.) 70 400 granite
Whittier NC 28789
City or Town State Zip Code
4. DATE DRILLED 11/29/00
5. TOTAL DEPTH 400
6. CUTTINGS COLLECTED YES El NO E
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO X❑
8. STATIC WATER LEVEL Below Top of Casing: 0 FT.
(Use "+" if Above Top of Casing)
9. TOP OF CASING IS 2 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): 3.50 METHOD OF TEST Blow
11. WATER ZONES (depth): «-2
0
12. CHLORINATION: Type H T H Amount
13. CASING: Wall Thickness
Depth Diameter or Weight/Ft. Material
From 0 To 72 Ft. 6 nvc
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From 0 To 20 Ft. Cement Poured
From To Ft.
15.SCREEN
Depth
From _ 0 To
From To
From To
16. SAND/GRAVEL PACK:
Depth
From 0 To_
From To
17. REMARKS:
I DO HEREI
FOR OFFICE
Quad No.
Serial No.
Diameter Slot Size Material
Ft.
in.
in.
Ft.
in.
in.
Ft.
in.
in.
Size Material
Ft.
Ft.
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)
T It HLR W ,,L) WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
IS, AND THAT }A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
SIGNATURE OF PERSON CONSTR ING THE WELL Date
Submit erigihal to Division of Water Quality, oundwater Section within 30 days

=22300
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Ground Water Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636 - Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: Hedden Bros. Well Drilling Inc.
WELL CONTRACTOR CERTIFICATION p: 2042
STATE WELL CONSTRUCTION PERMIT H:
1. WELL USR Check Applicable Box): Residential 0 Municipal 0 Industrial 0 Agricultural 0 Monitoring
Recovery IJ Heat Pump Water Injection 0 Other 0 If Other,List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: Highlands County: +Jfte' t St4CKS0rJ
Highlantla Cove Well i!
(Road Name and Numbers, Community, or Subdivision and Lot No.) DEPTH
3. OWNER Highlands Cove From To
Address P O Box 550 77 74
(Street or Route No.)
Highlands NC 28741
City or Town State Zip Code
4. DATE DRILLED 11/09/00 94
5. TOTAL DEPTH 84
6. CUTTINGS COLLECTED YES 0 NO
7. DOES WELL REPLACE EXISTING WELL? YES 0 NO
8. STATIC WATER LEVEL Below Top of Casing: 70.q FT.
(Use "+" If Above Top of Casing)
9. TOP OF CASING IS 2 FT. Above Land Surface"
*top of casin88 terminated at/or below land surface requires a variance in accor-
dance with 15n NCAC 2C .0118
10. YIELD (gpm): 0.00 METHOD OF TEST
11. WATER ZONES (depth): O -
DRILLING LOG
Formation Description
hentnn4f, seal
z
12, CHLORINATION: Type
Amount
If additional space is needed use back of form
13. CASING:
Wall Thickness
Depth Diameter
or Weight/Ft. Material
LOCATION SKETCH
From To. R4 Ft.
_ "
(Show direction and distance from at least two State
From To Ft.
Roads, or other map reference points)
From To Ft.
14. GROUT:
Depth
Material
Method
From 0 To 72 Ft.
Cement
Poured
From —To —Ft.
8.5"
15. SCREEN:
Depth Diameter Slot
Size Material
From _14 To R4 Ft.
in,
in. ¢lotted
From To Ft.
in.
in.
From To Ft.
in.
in.
16. SAND/GRAVEL PACK:
Depth
Size
Material
From 74 To 84
Ft. 8.5"
From To
Ft.
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
rt1NSTRUCTt PY WHIS RECORD HAS MEN PROVIDED TO THE WELL OWNER.
FOR OFF71q
Quad No.
Serial No. NATURE OF PERSON CONSTRUCTING THE WELL Date
Submi origi al to Division of Water Quality, Groundwater Section within 30 days

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Ground Water Section �' 4' ` `7 v
1636 Mail Service Center - Raleigh, N.C. 27699-1636 - Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:- Hedden Bros. Well Drilling Inc.
WELL CONTRACTOR CERTIFICATION #: 2042
STATE WELL CONSTRUCTION PERMIT #:
1. WELL USE Check Applicable Box): Residential 0 Municipal 0 Industrial 0 Agricultural 0 MonitoringEE
Recovery i5 Heat Pump Water Injection 0 Other 0 If Other,List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: Highlands County: Weer ZrA CKS014
Highlands Cove Well #2
(Road Name and Numbers, Community, or Subdivision and Lot No.) DEPTH DRILLING LOG
3. OWNER Highlands Cove Prom To Formation Description
Address P O BOX 550 O 74 R 5" hnntnnite
(Street or Route No.)
Highlands NC 28741
City or Town State Zip Code 10 Sand gravel
4. DATE DRILLED 11/09/00 30 40 granite
5. TOTAL DEPTH 0 g
6. CUTTINGS COLLECTED YES 0 NO ® C=
7. DOES WELL REPLACE EXISTING WELL? YES 0 NO
8. STATIC WATER LEVEL Below Top of Casing: 18• 9 FT.
(Use'+' if Above Top of Casing)
9. TOP OFCASINGIS 2 FT. Above Land Surface*
f casth ts mina CAC2 att?r low land surface requires a variance in accor-
dance10. YIELD (gpni): 0.00 METHOD OF TEST Blow
I I. WATER ZONES (depth): O
12. CHLORINATION: Type Amount v adA:N .1 t
.
ace
..._.._.
15. SCREEN:
Depth Diameter
From _30 Tom Ft. 4" in
From To Ft. in.
Slot Size Material
in. Slotted
From To Ft. in.
16. SAND/GRAVEL PACK:
Depth Size
From 26 To 40 Ft. 8.5"
From To Ft.
in.
in.
Material
17. REMARKS:
I DO HE � un� CE2XLI1 Tea' WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRLI�T AT�1IBtRbS1YIt1� 7� A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR No. — Oyl x, i1I II 119 ^ p29
Quad No. f�tf3 ' L
Serial No. SIGNATURE OF PERSON CONSTRUCTING THE WELL Date
ubmi original to Division of Water Quality• Groundwater Section within 30 days

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Ground Water Section ` 22298
1636 Mail Service Center - Raleigh, N.C. 27699-1636 - Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: Hedden Bros. Well Drilling Inc.
WELL CONTRACTOR CERTIFICATION N: 2042
STATE WELL CONSTRUCTION PERMIT X:
1. WELL USE Check Applicable Box): Residential 0 Municipal 0 Industrial 0 Agricultural 0 Monitoring
Recovery P) Heat Pump Water Injection 0 OtherEl If Other,List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: Highlands County: +taCOn SAr_k50 J
a a'Elllandc (�nvn WP1I �1
(Road Neme and Numbers, Community, or Subdivision and Lot No.) DEPTH
3. OWNER Highlands Cove From To
Address_ P O Box 550 1 R 70
(Street or Route No.)
Highlands NC 28741
City or Town State Zip Code 21
4. DATE DRILLED 11! /00 71 32
5. TOTAL DEPTH 32
6. CUTTINGS COLLECTED YES 0 NO
7. DOES WELL REPLACE EXISTING WELL? YES F NO
8. STATIC WATER LEVEL Below Top of Casing: A 1.6 FT.
(Use "+" if Above Top of Casing)
9. TOP OF CASING IS 1 FT. Above Land Surface*
'Top of casingg terminated at/or below land surface requires a variance in accor-
dance with l5A NCAC 2C .0118
10. YIEI-D (gpm): 0.00 METHOD OF TEST
11. WATER ZONES (depth): O
DRILLING LOG
Formation Description
RFNTnN1TF. SEA I.
n an
12. CHLORINATION: Type Amount If additional space is needed use back ofIMm i
13. CASING: Wail Thickness
Depth Diameter or Weight/Ft. Material LOCATION SKETCH
From -V Tom,_ Ft. 411 PVC (Show direction and distance from at least two State
From To Ft. Roads, or other map reference points)
From To Ft.
14. GROUT
Depth
Material
From 0
To 18
Ft.
Cement
From
To
Ft.
8.5"
15. SCREEN:
Depth
Diameter Slot Size
From �2—
To 32
Ft.
411 in.
From
To
Ft.
in.
From
To
Ft.
in.
16. SAND/GRAVEL
PACK:
Depth
Size
From 20
To 32
Ft. 8.5"
From
To
Ft.
17. REMARKS:
I DO HERE]
FOR OFFICE NL=.JIlli�
Quad No.
Serial No. _ ..--.._aw
Method
Poured
Material
in. clotted
in.
in.
Material
CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
)PY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
ATURE OF PERSON CONSTRUCTING THE WELL Date
to Division of Water Quality, Groundwater Section within 30 days

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Ground Water Section ;1 t- 7 -r
1636 Mail Service Center - Raleigh, N.C. 27699-1636 - Phone [phone] ' : i J ,-) z. j_
WELL CONSTRUCTION RECORD WELL CONTRACTOR: Hedden Bros. Well Drilling Inc.
WELL CONTRACTOR CERTIFICATION k: 2043
STATE WELL CONSTRUCTION PERMIT k:
1. WELL USE(Check Applicable Box): Residential 0 Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other,List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: Cashiers County: Jackson
(Road Name and Numbers, Community, or Subdivision and Lot No.)
3. OWNER Lee Weisz
Address P O Box 3034
(Street or Route No.)
Cashiers NC 28717
City or Town State Zip Code
4. DATE DRILLED 10/05/00
5. TOTAL DEPTH 150
6. CUTTINGS COLLECTED YES ❑ NO F
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO F
8. STATIC WATER LEVEL Below Top of Casing: 0 FT.
(Use "+" if Above Top of Casing)
9. TOP OF CASING IS 2 FT. Above Land Surface*
*Top of casingg terminated at/or below land surface requires a variance in accor-
dance with l5A NCAC 2C .0118
10. YIELD (gpm): 60.00 METHOD OF TEST BIOW
11. WATER ZONES (depth): 1 O
12. CHLORINATION: Type H T H Amount
13. CASING: Wall Thickness
Depth Diameter or Weight/Ft. Material
From — To 42 Ft. 6 188 Steel
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From 0 To 20 Ft. Cement Poured
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From 0 To Ft. in. in.
From To Ft. in. in.
From To Ft. in. in.
16. SAND/GRAVEL PACK:
Depth Size Material
From 0 To Ft.
From To Ft.
DEPTH
From To
0 40
40 150
Agricultural ❑ Monitoring ❑
o
DRILLMG L09:
Form mn:ilrs— cr
clay R
�ranite
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)
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY.111 �' L.Oo Za - 5 - OO
Quad No.
Serial No. SIGNATURE OF PERSON CONSTRUCTING THE WELL Date
Submit original to Division of Water Quality, Groundwater Section within 30 days

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Ground Water Section t�' j J - ) ti
1636 Mail Service Center - Raleigh, N.C. 27699-1636 - Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: Hedden Bros. Well Drilling Inc.
WELL CONTRACTOR CERTIFICATION #: 2045
STATE WELL CONSTRUCTION PERMIT #:
I WELL USE(Check Applicable Box): Residential ❑X 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: Canada County: Jackson
Canada -Grays Ridge Rd
(Road Name and Numbers, Community, or Subdivision and Lot No.) DEPTH DRILLING LOG
3. OWNER Jim Loren From To Formation
Description
Address P O BOX 145 O '3R clay Rr
Rand
(Street or Route No.) 38 125 granite
Sapphire NC 28774
City or Town State Zip Code
4. DATE DRILLED 10/05/00
5. TOTAL DEPTH 125-
YES ❑ NO FRI
6. CUTTINGS COLLECTED
WELL? YES ❑ NO
7. DOES WELL REPLACE EXISTING
8. STATIC WATER LEVEL Below Top of Casing: 0 FT.
(Use "+" if Above Top of Casing)
9. TOP OF CASING IS 2 FT. Above Land Surface*
-
*Top of casingg terminated at/or below land surface requires a variance in accor-
dance with MA NCAC 2C .0118
xD -
10. YIELD (gpm): 40.00 METHOD OF TEST Blow
r
11. WATER ZONES (depth): 7090
a
12. CHLORINATION: Type H T H Amount
13. CASING: Wall Thickness
Depth Diameter or Weight/Ft. Material
From _ 0 To 40 Ft. 6" nvc
From To Ft.
From To Ft.
14. GROUT:
Depth
Material
Method
From 0 To 20
Ft.
Cement
Poured
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 0 To
Ft.
From To
Ft.
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)
17, REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Quad No.
Serial No.
AIGNATURE OF PERSON CONSTRUCTING THE WELL Date
original to Division of Water Quality, Groundwater Section within 30 days

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Ground Water Section • , . n 0
1636 Mail Service Center - Raleigh, N.C. 27699-1636 - Phone [phone] r. J- o
WELL CONSTRUCTION RECORD WELL CONTRACTOR: Hedden Bros. Well Drilling Inc.
WELL CONTRACTOR CERTIFICATION if: 2045
STATE WELL CONSTRUCTION PERMIT 1/:
1. WELL USE(Check Applicable Box): Residential 0 Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other,List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: Tuckasegee County: Jackson
992 Gray Ridge Rd
(Road Name and Numbers, Community, or Subdivision and Lot No.) DEPTH DRILLING LOG
3. OWNER Charles Donaldson From To Formation Description
Address 992 Gray Ridge Rd 0 77 clay k sand
(Street or Route No.) 72 300 granite
Tuckasegee NC 28783
City or Town State Zip Code
4. DATE DRILLED 10/04/00
5. TOTAL DEPTH 300
6. CUTTINGS COLLECTED YES ❑ NO
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO X❑
8. STATIC WATER LEVEL Below Top of Casing: 0 FT.
(Use "+" if Above Top of Casing)
9. TOP OF CASING IS 2 FT. Above Land Surface*
*Top of casingg terminated at/or below land surface requires a variance in accor-
dance with ISA NCAC 2C .0118
10. YIELD (gpm): 35.00 METHOD OF TEST B10W
11. WATER ZONES (depth): 250
0
12. CHLORINATION: Type H T H Amount If iddifi..A <nai­P i, ri,d,d ucr hack of from
13. CASING: Wall Thickness
Depth Diameter or Weight/Ft. Material
From 0 To 74 Ft. 6 p vc
From To Ft.
From To Ft.
14. GROUT:
Depth
Material
Method
From 0 To 20
Ft.
Cement
Poured
From To
Ft.
15.SCREEN:
Depth
Diameter Slot Size
Material
From 0 To
Ft.
in.
in.
From To
Ft.
in.
in.
From To
Ft.
in.
in.
16. SAND/GRAVEL PACK:
Depth
Size
Material
From 0 To
Ft.
From To
Ft.
17. REMARKS:
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
I DO HEREBY CERTIFY THAT THIS WELL WAS 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 D
Quad No.
Serial No. SIGNATURE OF PERSON CONSTRUCTING THE WELL Date
Sub it original to Division of Water Quality, Groundwater Section within 30 days

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Ground Water Section t., j !_) J
1636 Mail Service Center - Raleigh, N.C. 27699-1636 - Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: Hedden Bros. Well Drilling Inc.
WELL CONTRACTOR CERTIFICATION #: 2045
STATE WELL CONSTRUCTION PERMIT #:
1. WELL USE(Check Applicable Box): Residential FX1 Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other,List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: Sylva County: Jackson
722 Rufus Robinson Rd
(Road Name and Numbers, Community, or Subdivision and Lot No.)
3. OWNER Teresa Early
Address 722 Rufus Robinson Rd
(Street or Route No.)
Sklva NC 28779
City or Town State Zip Code
4. DATE DRILLED 10/09/00
5, TOTAL DEPTH 175
6. CUTTINGS COLLECTED YES ❑ NO 0
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO Q
8. STATIC WATER LEVEL Below Top of Casing: 0 FT.
(Use "+" if Above Top of Casing)
9. TOP OF CASING IS 2 FT. Above Land Surface*
*Top of casing gg terminated atlor below land surface requires a variance in accor-
dance with 15A NCAC 2C .0118
10. YIELD (gpm): 40.00 METHOD OF TEST Blow
11. WATER ZONES (depth): 1405
12. CHLORINATION: Type H T H Amount
13. CASING: Wall Thickness
Depth Diameter or Weight/Ft. Material
From 0 To2_ Ft. 6_ nvc _
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From 0 To 20 Ft. Cement Poured
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From 0 To Ft. in. in.
From To Ft. in. in.
From To Ft. in. in.
16. SAND/GRAVEL PACK:
Depth Size Material
From 0 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.
DEPTH
From To
Agricultural ❑ Monitoring ❑
DRILLING LOG
Formation Description
r
CO C>
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)
FOR OFFICE USE ONLY
Quad No.
Serial No.
-> z- ,e
ATURE OF PERSON CONSTRUCTING THE WELL Date
to Division of Water Quality, Groundwater Section within 30 days

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Ground Water Section i t- (�
1636 Mail Service Center - Raleigh, N.C. 27699-1636 - Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: Hedden Bros. Well DrillirH4 Inc.
WELL CONTRACTOR CERTIFICATION k: 2045
STATE WELL CONSTRUCTION PERMIT p:
1. WELL USE(Check Applicable sox): 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: SVlva County: Jackson
Tunnel Mtn Rd
(Road Name and Numbers, Community, or Subdivision and Lot No.) DEPTH
3. OWNER Sam FOWIks From To
Address P O Box 1832 n 56
(Street or Route No.) 56 200
Sylva NC 28779
City or Town State Zip Code
4. DATE DRILLED 10/10/00
5. TOTAL DEPTH 200
6. CUTTINGS COLLECTED YES ❑ NO 0
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO F
8. STATIC WATER LEVEL Below Top of Casing: 0 FT.
(Use " + " if Above Top of Casing)
9. TOP OF CASING IS 2 FT. Above Land Surface*
*Top of casingg terminated at/or below land surface requires a variance in accor-
dance with IA NCAC 2C .0118
10. YIELD (gpm): 20.00 METHOD OF TEST Blow
11. WATER ZONES (depth): 146
155
DRILLING LOG
Formation Description
0
r -}
n
--t
tv
12. CHLORINATION: Type H T H Amount tf addld„„at n,MPd uce hack of fnrm
13. CASING:
Wall Thickness
Depth
Diameter
or Weight/Ft. Material
From _ 0 To 58
Ft. 611
p c
From To
Ft.
From To
Ft.
14. GROUT:
Depth
Material
Method
From 0 To 20
Ft. Cement
Poured
From To
Ft.
15.SCREEN:
Depth
Diameter Slot Size Material
From 0 To
Ft. in.
in.
From To
Ft. in.
in.
From To
Ft. in.
in.
16. SAND/GRAVEL PACK:
Depth
Size
Material
From 0 To
Ft.
From To
Ft.
17. REMARKS:
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Quad No.
Serial No. JGNATURE OF PERSON CONSTRUCTING THE WELL Date
Sub original to Division of Water Quality, Groundwater Section within 30 days

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Ground Water Section 1 9 5- 2 1
1636 Mail Service Center - Raleigh, N.C. 27699-1636 - Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: Hedden Bros. Well Drilling Inc.
WELL CONTRACTOR CERTIFICATION #: 2045
STATE WELL CONSTRUCTION PERMIT #:
1. WELL USE(Check Applicable Box): Residential FX1 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: Webster County: Jackson
Little Savannah Comm
(Road Name and Numbers, Community, or Subdivision and Lot No.)
3. OWNER Eddie Stillwell
Address P O BOX 24
(Street or Route No.)
Webster NC 28788
City or Town State Zip Code
4. DATE DRILLED 10/10/00
5. TOTAL DEPTH 250 FV
6. CUTTINGS COLLECTED YES ❑ NO
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO 0
8. STATIC WATER LEVEL Below Top of Casing: 0 FT.
(Use "+" if Above Top of Casing)
9. TOP OF CASING IS 2 FT. Above Land Surface*
*Top of cask terminated at/or below land surface requires a variance in accor-
dance with 15A NCAC 2C .0118
10. YIELD (gpm): 15.00 METHOD OF TEST Blow
11. WATER ZONES (depth): 00
12. CHLORINATION: Type H T H Amount
13. CASING: Wall Thickness
Depth Diameter or Weight/Ft. Material
From _ 0 To 15 Ft. 611 188 steel
From _ 5 To7_ FL '6 PVC
From To Ft.
14. GROUT:
Depth Material Method
From 0 To 20 Ft. Cement Poured
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From _ 0 To Ft. in. in.
From To Ft. in. in.
From To Ft. in. in.
16. SAND/GRAVEL PACK:
Depth Size Material
From 0 To Ft.
From To Ft.
17. REMARKS:
DEPTH
From To
DRILLING LOG
Formation Description
CD
O
-a
w
�o
t
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 USE ONLY
Quad No. ' �)
Serial No. IGNATURE OF PERSON CONSTRUCTING THE WELL Date
Sub original to Division of Water Quality, Groundwater Section within 30 days

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Ground Water Section , ; 0 5 1. 3
1636 Mail Service Center - Raleigh, N.C. 27699-1636 - Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: Hedden Bros. Well Drilling Inc.
WELL CONTRACTOR CERTIFICATION #: 2043
STATE WELL CONSTRUCTION PERMIT k:
l . WELL USE(Check Applicable Box): Residential 0 Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other,List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: Cullowhee County: Jackson
3789 Pine Creek Rd
(Road Name and Numbers, Community, or Subdivision and Lot No.) DEPTH DRILLING LOG
3. OWNER Dean & Loretta Watson From To Formation Description
Address 3789 Pine Creek Rd 0 66 clad & sand
(Street or Route No.) 66 150 granite
Cullowhee NC 28723
City or Town State Zip Code
4. DATE DRILLED 10/10/00
5. TOTAL DEPTH 150
6. CUTTINGS COLLECTED YES ❑ NO 0
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO X❑
8. STATIC WATER LEVEL Below Top of Casing: 0 FT.
(Use " + " if Above Top of Casing)
9. TOP OF CASING IS 2 FT. Above Land Surface*
*Top of casingg terminated at/or below land surface requires a variance in accor-
dance with 15A NCAC 2C .0118
l0. YIELD (gpm): 40.00 METHOD OF TEST Blow
11. WATER ZONES (depth): 75
110
12. CHLORINATION: Type H T H Amount
13. CASING: Wall Thickness
Depth Diameter or Weight/Ft. Material
From 0 To 6g_ Ft. � .189 steel
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From 0 To 20 Ft. Cement Poured
From To Ft.
15. SCREEN
Depth
From 0 To Ft
From To Ft
From To Ft
16. SAND/GRAVEL PACK:
Depth
From 0 To
From To
Diameter Slot Size Material
in. in.
in. in.
in. in.
Size Material
Ft.
Ft.
W
r_
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)
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Quad No. %� LS�2Qivr
Serial No. SIGNATURE OF PERSON CONSTRUCTING THE WELL Date
Submit original to Division of Water Quality, Groundwater Section within 30 days

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Ground Water Section ` f3 /� 7
1636 Mail Service Center - Raleigh, N.C. 27699-1636 - Phone [phone] l ! (1 [.
WELL CONSTRUCTION RECORD WELL CONTRACTOR: Hedden Bros. Well Drilling Inc.
WELL CONTRACTOR CERTIFICATION #: 2043
STATE WELL CONSTRUCTION PERMIT #:
1. WELL USE(Check Applicable Box): Residential [K Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other,List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: Glenville County: Jackson
Big Ridge Rd
(Road Name and Numbers, Community, or Subdivision and Lot No.)
3. OWNER Wachovia Bank
Address 191 Peachtree St N E 24Th Fl
(Street or Route No.)
Atlanta GA 30303
City or Town State Zip Code
4. DATE DRILLED 10/03/00
5. TOTAL DEPTH 500
6. CUTTINGS COLLECTED YES ❑ NO FRI
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO 0
8, STATIC WATER LEVEL Below Top of Casing: 0 FT.
(Use " + " if Above Top of Casing)
9. TOP OF CASING IS 2 FT. Above Land Surface*
*Top of casingg terminated at/or below land surface requires a variance in accor-
dance with l5A NCAC 2C .01 IS
10. YIELD (gpm): 4.00 METHOD OF TEST Blow
11. WATER ZONES (depth): 150
0
12. CHLORINATION: Type H T H Amount
13. CASING: Wall Thickness
Depth Diameter or Weight/Ft. Material
From _0 To3__ Ft. 6 »vc
From To Ft.
From To Ft.
14, GROUT:
Depth Material Method
From 0 To 20 Ft. centent Poured
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From 0 To Ft. in. in.
From To Ft. in. in.
From To Ft. in. in.
16. SAND/GRAVEL PACK:
Depth Size Material
From 0 To Ft.
From To Ft.
17. REMARKS:
Agricultural ❑ Monitoring ❑
DEPTH DRILLING LOG
From To Formation Description
0 33 c4iy & sand
33 500 granite
Cn
r�
IV ,
If additional space is needed use back of f
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
VELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
� /a - 3 -oo
SIGNATURE OF PERSON CONSTRUCTING THE WELL Date
Submit original to Division of Water Quality, Groundwater Section within 30 days

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Ground Water Section �_ i 89 91
1636 Mail Service Center - Raleigh, N.C. 27699-1636 - Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: Hedden Bros. Well Drilling Inc.
WELL CONTRACTOR CERTIFICATION #: 2045
STATE WELL CONSTRUCTION PERMIT #:
I . WELL USE(Check Applicable Box): Residential 0 Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other,List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: Dillsboro County: Jackson
Cagle Branch Rd
(Road Name and Numbers, Community, or Subdivision and Lot No.) DEPTH DRILLING LOG
3. OWNER Doyle Buchanan From To Formation Description
Address P O Box 474 0 99 clay Rr eand
(Street or Route No.) 92 150 granite
Dillsboro NC 28725
City or Town State Zip Code
4. DATE DRILLED 10/02/00
5. TOTAL DEPTH 150
6. CUTTINGS COLLECTED YES ❑ NO 0
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO 0
S. STATIC WATER LEVEL Below Top of Casing: 0 FT.
(Use "+" if Above Top of Casing)
9. TOP OF CASING IS 2 FT. Above Land Surface*
*Top of casingg terminated at/or below land surface requires a variance in accor-
dance with 15A NCAC 2C .0118
IO. YIELD (gpm): 80.00 METHOD OF TEST BIOW
11. WATER ZONES (depth): 150
0
12. CHLORINATION: Type H T H Amount
13. CASING: Wall Thickness
Depth Diameter or Weight/Ft. Material
From 0 To_94 Ft. 6 .188 steel
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From 0 To 20 Ft. Cement Poured
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From 0 To Ft. in. in.
From To Ft. in. in.
From To Ft. in. in.
16, SAND/GRAVEL PACK:
Depth Size Material
From 0 To Ft.
From To Ft.
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS
CON 0 N Ann IgDSl2A
FOR OfilUSE ONLYDQuad Ni _�'ISerial N
CD
C� r
H
rn
+
C>
If additional space is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
T A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
%SIGNATURE OF PERSON CONSTRUCTING THE WELL Date
original to Division of Water Quality, Groundwater Section within 30 days

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Ground Water Section �189, J !�
1636 Mail Service Center - Raleigh, N.C. 27699-1636 - Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: Hedden Bros. Well Drilling Inc.
WELL CONTRACTOR CERTIFICATION N: 2045
STATE WELL CONSTRUCTION PERMIT k:
1. WELL USE(Check Applicable Box): Residential 1K 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: CulloWhee County: Jackson
2947 High Knob Rd
(Road Name and Numbers, Community, or Subdivision and Lot No.) DEPTH DRILLING LOG
3. OWNER Robert Field From To Formation Description
Address 2947 High Knob Rd O 73 rin) k ennd
(Street or Route No.) 73 300 ,granite.
Cullowhee 89 28723
City or Town State Zip Code
4. DATE DRILLED 10/03/00
5. TOTAL DEPTH 300
6. CUTTINGS COLLECTED YES ❑ NO 0
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO X❑
8. STATIC WATER LEVEL Below Top of Casing: 0 FT.
(Use " + " if Above Top of Casing)
9. TOP OF CASING IS 2 FT. Above Land Surface*
*Top of casingg terminated atfor below land surface requires a variance in accor-
dance with I A NCAC 2C -0118
10. YIELD (gpm): 10.00 METHOD OF TEST Blow
11. WATER ZONES (depth): 156
216
12. CHLORINATION: Type H T H Amount
13. CASING: Wall Thickness
Depth Diameter or Weight/Ft. Material
From To 75 Ft. _5' nvc
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From 0 To 20 Ft. Cement Poured
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 0 To Ft.
From To Ft.
17. REMARKS:
u
N
(n —i
If additional space is needed use back o4fmna r
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONST T A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
EFOROFFINLY �— . I IGNATURE OF PERSON CONSTRUCTING THE WELL Date
ubm original to Division of Water Quality, Groundwater Section within 30 days

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Ground Water Section I_; 5
1636 Mail Service Center - Raleigh, N.C. 27699-1636 - Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: Hedden Bros. Well Drilling Inc.
WELL CONTRACTOR CERTIFICATION k: 2045
STATE WELL CONSTRUCTION PERMIT 11:
1. WELL USE(Check Applicable Box): Residential 0 Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other,List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: Tuckasegee County: Jackson
Grays Ridge Rd -Canada
(Road Name and Numbers, Community, or Subdivision and Lot No.) DEPTH DRILLING LOG
3. OWNER Robert & Gall Berry From To Formation Description
Address P O BOX 424 (1 59 rlay Rr snnrl
(Street or Route No.) 59 150 �Arnnite
Placida FL 33946
City or Town State Zip Code
4. DATE DRILLED 10/05/00
5. TOTAL DEPTH 150
6. CUTTINGS COLLECTED YES ❑ NO
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO 0
S. STATIC WATER LEVEL Below Top of Casing: 0 FT.
(Use " + " if Above Top of Casing)
9. TOP OF CASING IS 2 FT. Above Land Surface*
*Top of casing terminated at/or below land surface requires a variance in accor-
dance with 15A NCAC 2C .0118
IO. YIELD (gpm): 20.00 METHOD OF TEST Blow
11. WATER ZONES (depth): 0
HTH Am
0
CD
12, CHLORINATION. Type oust If additional space is needed use back of form
13, CASING: Wall Thickness
Depth Diameter or Weight/Ft. Material LOCATION SKETCH
From 0 Tom1 Ft. 6" .188 -Teel— (Show direction and distance from at least two State
From 21 To61 Ft. 6„ PVC rcoads, or other map reference points)
From To Ft.
14, GROUT:
Depth Material Method
From 0 To 20 Ft. cement Poured
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From 0 To Ft. in. in.
From To Ft. in. in.
From To Ft. in. in.
16. SAND/GRAVEL PACK:
Depth Size Material
From 0 To Ft.
From To Ft.
Ifil RTMI/:\ti; I
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONS AT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR O LY
Quad No.
Serial No I li i SIGNATURE OF PERSON CONSTRUCTING THE WELL Date
SjrVfforiginal to Division of Water Quality, Groundwater Section within 30 days
p=

220422
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Ground Water Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636 - Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: Hedden Bros. Well Drilling Inc.
WELL CONTRACTOR CERTIFICATION #: 2045
STATE WELL CONSTRUCTION PERMIT #:
I. WELL USE(Check Applicable Box): Residential ❑X 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: Cullowhee County: Jackson
South Wayehutta
(Road Name and Numbers, Community, or Subdivision and Lot No.) DEPTH DRILLING LOG
3. OWNER Steve Yurkovich From To Formation Description
Address P O BOX 867 O 55 clay Rr sand
(Street or Route No.) 55 225 granite
Cullowhee NC 28723
City or Town State Zip Code
4. DATE DRILLED 10/30/00
5. TOTAL DEPTH 225
6. CUTTINGS COLLECTED YES ❑ NO 0
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO 0
8. STATIC WATER LEVEL Below Top of Casing: 0 FT.
(Use " + " if Above Top of Casing)
9. TOP OF CASING IS 2 FT. Above Land Surface*
-Top of casing terminated at/or below land surface requires a variance in accor-
dance with 15A NCAC 2C .0118
10. YIELD (gpm): 20.00 METHOD OF TEST Blow
11. WATER ZONES (depth): 182
0
12. CHLORINATION: Type H T H Amount If additional space is needed use back of form
13. CASING: Wall Thickness
Depth Diameter or Weight/Ft. Material LOCATION SKETCH
From �_ To 57 Ft. 6_ pvc (Show direction and distance from at least two State
From To Ft. Roads, or other map reference points)
From To Ft.
14. GROUT:
Depth
Material
Method
From 0 To 20
Ft. Cement
Poured
C-,
From To
Ft.-
15. SCREEN:
Depth
Diameter Slot Size
Material
From 0 To
Ft. in.
in.From
To
Ft. in.
in.
`=?
From To
Ft. in.
in.
16. SAND/GRAVEL PACK:
o
Depth
Size
Material-;
From 0 To
Ft.
From To
Ft.
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONL 0
A—) L-) Z Z'
Quad No.
Serial No. . IG E OF PERSON CONSTRUCTING THE WELL Date
Sub origin t i ision of Water Quality, Groundwater Section within 30 days

220424
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Ground Water Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636 - Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: Hedden Bros. Well Drilling Inc.
WELL CONTRACTOR CERTIFICATION #: 2045
STATE WELL CONSTRUCTION PERMIT X:
I . WELL USE(Check Applicable Box): Residential EM 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: Cullowhee County: Jackson
76 SDuth Wayehutta Rd
(Road Name and Numbers, Community, or Subdivision and Lot No.) DEPTH DRILLING LOG
3. OWNER Rose Mary Fuller From To Formation Description
Address 76 South Wayehutta Rd (I 50 clay & -and
(Street or Route No.) 50 300 granite
Cullowhee NC 28723
City or Town State Zip Code
4. DATE DRILLED 10/31/00
5. TOTAL DEPTH 300
6. CUTTINGS COLLECTED YES ❑ NO 0
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO 0
8. STATIC WATER LEVEL Below Top of Casing: 0 FT.
(Use "+" if Above Top of Casing)
9. TOP OF CASING IS 2 FT. Above Land Surface*
*Top of casingg terminated at/or below land surface requires a variance in accor-
dance with IA NCAC 2C .0118
10. YIELD (gpm): 60.00 METHOD OF TEST Blow
11. WATER ZONES (depth): 269
0
12, CHLORINATION: Type H T H Amount if additional space is needed use back of form
13. CASING: Wall Thickness
Depth Diameter or Weight/Ft. Material LOCATION SKETCH
From 0 To9,,1 Ft. 6 11 IRS Steej__ Show direction and distance from at least two State
From 21 To 52 Ft. 6— PVC Eads, or other map reference points)
From To Ft.
14. GROUT
Depth
Material
Method
From 0 To 20
Ft.
Cement
Poured o '
CD c
From To
Ft.
-
15. SCREEN:
o
Depth
Diameter Slot Size
Material I
From 0 To
Ft.
in.
in.
From To
Ft.
in,
in.
From To
Ft.
in.
in.
16. SAND/GRAVEL PACK:
o —
Depth
Size
Material F'
From 0 To
Ft.
From To
Ft.
17. REMARKS:
I DO HEREBY CERISTRUCTED
IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION S
)a@1)eJ
AihlnurFllAT
C�jIOF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE O Q _ �aQ
Quad No.
Serial No. I NA URE OF PERSON CONSTRUCTING THE WELL Date
riginaI to ivision of Water Quality, Groundwater Section within 30 days

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Ground Water Section - 0,13 7
1636 Mail Service Center - Raleigh, N.C. 27699-1636 - Phone [phone] r • U
WELL CONSTRUCTION RECORD WELL CONTRACTOR: Hedden Bros Well Drilling Inc
WELL CONTRACTOR CERTIFICATION N: 2045
STATE WELL CONSTRUCTION PERMIT N:
1. WELL USE(Check Applicable Box): Residential 0 Municipal 0 Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery 0 Heat Pump Water Injection 0 Other ❑ If Other,List Use:
2. WELL LOCATION: (Show sketch of the location below) Jackson
Nearest Town: CUllowhee y
1898 White Rock Rd
(Road Name and Numbers, Community, or Subdivision and Lot No.) DEPTH DRILLING LOG
3. OWNER Dou,Q�Beniarnln From To Formation Description
Address 1898 White Rock Rd 0 RR _ ]2fl i Rr Sand
(Street or Route No.) 88 300 —granite
Cullowhee NC 28723
City or Town State Zip Code
4. DATE DRILLED 10/24/00
5. TOTAL DEPTH 300
6. CUTTINGS COLLECTED YES 0 NO 0
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO F
8. STATIC WATER LEVEL Below Top of Casing: 0 FT.
(Use " + " if Above Top of Casing)
9. TOP OF CASING IS 2 FT. Above Land Surface*
*Top of casingg terminated at/or below land surface requires a variance in accor-
dance with 15A NCAC 2C .0118
10. YIELD (gpm): 25.00 METHOD OF TEST Blow
11. WATER ZONES (depth): 195
262
12. CHLORINATION: Type H T H Amount If additional space is needed use back of form
13. CASING: Wall Thickness
Depth Diameter or Weight/Ft. Material
From 0 To ?I Ft. 6_'.188 steel
From — 21— To 90 Ft. 6 ' _ PVC
From To Ft.
14. GROUT:
Depth Material Method
From 0 To 20 Ft. Cement Poured
From To Ft.
15.SCREEN:
Depth
Diameter Slot Size Material
From -- To Ft. _
From To Ft. _
From To Ft.
16. SAND/GRAVEL PACK:
Depth
From 0 To Ft.
From To _ Ft.
in. in.
in. in.
in. in.
Size Material
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
CD
0
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Quad No.
Serial No.
rSIGNATURE OF PERSON CONSTRUCTING THE WELL Date
original to Division of Water Quality, Groundwater Section within 30 days

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Ground Water Section , `f (�
1636 Mail Service Center - Raleigh, N.C. 27699-1636 - Phone [phone] iJ
WELL CONSTRUCTION RECORD WELL CONTRACTOR: Hedden Bros Well Drilling Inc.
WELL CONTRACTOR CERTIFICATION #: 2045
STATE WELL CONSTRUCTION PERMIT #:
I . WELL USE(Check Applicable Box): Residential EK Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other,List Use:
2. WELL LOCATION: (Show sketch of the location below)
oJackson
Nearest Town: Whittier y
146 ine Branch Rd
(Road Name and Numbers, Community, or Subdivision and Lot No.) DEPTH DRILLING LOG
3. OWNER Pat Nations From To Formation Description
Address 146 Joe Branch Rd n 11 clay & sand
(Street or Route No.) 1 1 i 3On granite
Whittier NC 28789
City or Town State Zip Code
4. DATE DRILLED 10/26/00
5. TOTAL DEPTH 300
6. CUTTINGS COLLECTED YES ❑ NO ❑X
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO 0
8. STATIC WATER LEVEL Below Top of Casing: 0 FT.
(Use "+" if Above Top of Casing)
9. TOP OF CASING IS 2 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): 4.00 METHOD OF TEST Blow
11. WATER ZONES (depth): 265
15
12. CHLORINATION: Type H T H Amount If additional space is needed use back of form
13. CASING: Wall Thickness
Depth Diameter or Weight/Ft. Material LOCATION SKETCH
From 0 To ?I Ft. 6-' -198 Steel— Show direction and distance from at least two State
From 21 To 115 Ft. 6„ PVC Eads, or other map reference points)
From To Ft.
14, GROUT:
Depth Material Method
From 0 To 20 Ft. Cement Poured
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material o -
From _ 0 To Ft. in. in. u
From To Ft. in. in. " 3
From To Ft. in. in. I
ca
16. SAND/GRAVEL PACK: _
Depth Size Material
From 0 To FL U r,
From To Ft. o =i
cT i=1
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Quad No.
Serial No. SIGNATURE OF PERSON CONSTRUCTING THE WELL Date
Subm t original to Division of Water Quality, Groundwater Section within 30 days

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Ground Water Section ti V 0 3 /1
1636 Mail Service Center - Raleigh, N.C. 27699-1636 - Phone [phone] V :7
WELL CONSTRUCTION RECORD WELL CONTRACTOR: Hedden Bros Well Drilling Inc.
WELL CONTRACTOR CERTIFICATION N: 2045
STATE WELL CONSTRUCTION PERMIT N:
1. WELL USE(Check Applicable Box): Residential EK Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery 0 Heat Pump Water Injection El Other ❑ If Other,List Use:
2. WELL LOCATION: (Show sketch of the location below) Jackson
Nearest Town: CulloWllee y'
23 Utopla Dr Cull Mai Rd
(Road Name and Numbers, Community, or Subdivision and Lot No.) DEPTH DRILLING LOG
3. OWNER Jeff Moses From To Formation Description
Address P 0 BOX 113 O ins . da)/ Rr Rand
(Street or Route No.) 109 150 granite
S lva NC 28779
City or Town State Zip Code
4. DATE DRILLED 10/24/00
5. TOTAL DEPTH 150
6. CUTTINGS COLLECTED YES ❑ NO FRI
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
8. STATIC WATER LEVEL Below Top of Casing: 0 FT.
(Use " + " if Above Top of Casing)
9. TOP OF CASING IS 2 FT. Above Land Surface*
*Top of casingg terminated at/or below land surface requires a variance in accor-
dance with IN NCAC 2C .0118
10. YIELD (gpm): 150.00 METHOD OF TEST Blow
11. WATER ZONES (depth): 1?0
135
12. CHLORINATION: Type H T H Amount If additional space is needed use back of form
13. CASING: Wall Thickness
Depth Diameter or WeighdFt. Material LOCATION SKETCH
From 0 Tom. Ft. _6' _ 189 ct_ee_l___ Show direction and distance from at least two State
From 21 To 110 Ft. 6„ DVC Eads, or other map reference points)
From To Ft.
14. GROUT:
Depth Material Method
From 0 To 20 Ft. Cement Poured
From To Ft.
15. SCREEN: o
Depth Diameter Slot Size Material
From . 0 To Ft. in. in. C
From To Ft. in. in. t _
co
From To Ft. in. in. -
16. SAND/GRAVEL PACK:
Depth Size Material o
From 0 To Ft. o c+
From To Ft. ct
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY � Z0
Quad No.
Serial No. SIGNATURE OF PERSON CONSTRUCTING THE WELL Date
Submit original to Division of Water Quality, Groundwater Section within 30 days

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Ground Water Section .. u !, n
1636 Mail Service Center - Raleigh, N.C. 27699-1636 - Phone [phone] V O
WELL CONSTRUCTION RECORD WELL CONTRACTOR: Hedden Bros Well Drilling Inc
WELL CONTRACTOR CERTIFICATION #: 2045
STATE WELL CONSTRUCTION PERMIT!/:
1. WELL USE(Check Applicable Box): Residential 0 Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other,List Use:
2. WELL LOCATION: (Show sketch of the location below) Jackson
Nearest Town: Cullowhee y'
64 tQp r1 ! 1 Mtn_Rd
(Road Name and Numbers, Community, or Subdivision and Lot No.)
3, OWNER Cathy Griffin
Address P O BOX 1077
(Street or Route No.)
Cullowhee NC 28723
City or Town State Zip Code
4. DATE DRILLED 10/25/00
5. TOTAL DEPTH 300
6. CUTTINGS COLLECTED YES ❑ NO 0
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO 0
8. STATIC WATER LEVEL Below Top of Casing: 0 FT.
(Use " + " if Above Top of Casing)
9. TOP OF CASING IS 2 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): 5.00 METHOD OF TEST Blow
11. WATER ZONES (depth): 1 O
12. CHLORINATION: Type H T H Amount
13. CASING: Wall Thickness
Depth Diameter or Weight/Ft. Material
From 0 To?IFt. 6' _ 1 RR steel
From 21 To 121 Ft. 6„ DVC
From To Ft.
14. GROUT:
Depth
Material
Method
From 0 To 20
Ft.
Cement
Poured
From To
Ft.
15.SCREEN:
Depth
Diameter Slot Size
Material
From _ 0 To
Ft.
in.
in.
From To
Ft.
in.
in.
From To
Ft.
in.
in.
16. SAND/GRAVEL PACK:
Depth
Size
Material
From 0 To
Ft.
From To
Ft.
DEPTH DRILLING LOG
From To Formation Description
n 119 clny_& carld
119 300 granite
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)
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Quad No.
Serial No.
'SIGNATURE OF PERSON CONSTRUCTING THE WELL Date
original to Division of Water Quality, Groundwater Section within 30 days

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Ground Water Section V 11 4 (�
1636 Mail Service Center - Raleigh, N.C. 27699-1636 - Phone [phone] '
WELL CONSTRUCTION RECORD WELL CONTRACTOR: Hedden Bros. Well Drilling Inc.
WELL CONTRACTOR CERTIFICATION #: 2043
STATE WELL CONSTRUCTION PERMIT #:
1. WELL USE(Check Applicable Box): Residential 0 Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other,List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: Cashiers County: Jackson
Agricultural ❑ Monitoring ❑
(Road Name and Numbers, Community, or Subdivision and Lot No.) DEPTH DRILLING LOG
3. OWNER Freeman Gas From To Formation Description
Address P O BOX 191 (1 18 r,12V Rr sand
(Street or Route No.) 18 150 granite
Cashiers NC 28717
City or Town State Zip Code
4. DATE DRILLED 10/11/00
5. TOTAL DEPTH 150 FRI
6. CUTTINGS COLLECTED YES ❑ NO
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
8. STATIC WATER LEVEL Below Top of Casing: 0 FT.
(Use "+" if Above Top of Gasing)
9. TOP OF CASING IS 2 FT. Above Land Surface*
'Top of casingg terminated at/or below land surface requires a variance in accor-
dance with 15A NCAC 2C .0118
10. YIELD (gpm): 15.00 METHOD OF TEST Blow
11. WATER ZONES (depth): 90
12. CHLORINATION: Type H T H Amount If additional space is needed use back of form
13. CASING: Wall Thickness
Depth Diameter or Weight/Ft. Material LOCATION SKETCH
From Q Tot. -2'-'-�— Show direction and distance from at least two State
From To Ft. Roads, or other map reference points)
From To Ft.='
14, GROUT: -.
Depth Material Method =
t
From 0 To 20 Ft. Cement Poured
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
0
From 0 To Ft. in. in. vt
From To Ft. in. in. From To Ft. in. in.
16. SAND/GRAVEL PACK:
Depth Size Material
From 0 To Ft.
From To Ft.
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY f �'_& t�0�.a P �O — //-Oa
Quad No.
Serial No. SIGNATURE OF PERSON CONSTRUCTING THE WELL Date
Submit original to Division of Water Quality, Groundwater Section within 30 days

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Ground Water Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636 - Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: Hedden Bros. Well Drilling Inc.
WELL CONTRACTOR CERTIFICATION N: 2045
STATE WELL CONSTRUCTION PERMIT X:
1. WELL USE(Check Applicable Box): Residential 0 Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other,List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: Sy1Va County: Jackson
995 Barkers Creek Rd
(Road Name and Numbers, Community, or Subdivision and Lot No.)
3. OWNER Jannieve Bradley
Address 995 Barkers Creek Rd
(Street or Route No.)
Whittier NC 28789
City or Town State Zip Code
4. DATE DRILLED 09/28/00
5. TOTAL DEPTH 200
6. CUTTINGS COLLECTED YES ❑ NO 0
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO X❑
8. STATIC WATER LEVEL Below Top of Casing: 0 FT.
(Use " + " if Above Top of Casing)
9. TOP OF CASING IS 2 FT. Above Land Surface*
*Top of casingg terminated at/or below land surface requires a variance in accor-
dance with 15A NCAC 2C .0118
10, YIELD (gpm): 30.00 METHOD OF TEST B10W
11. WATER ZONES (depth): 163
0
12. CHLORINATION: Type H T H Amount
13. CASING: Wall Thickness
Depth Diameter or Weight/Ft. Material
From 0 To 21 FL 6.199 steel
From 21 To 75 Ft. 6 Svc
From To Ft.
14. GROUT:
Depth Material Method
From 0 To 20 Ft. Cement Poured
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 0 To Ft.
From To Ft.
Agricultural ❑ Monitoring ❑
DEPTH DRILLING LOG
From To Formation Description
O 71 clay Rr sand
73 200 granite
t�
_.t
i..J
CU r�
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)
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.
✓,
Qo OR OFFICE USE ONLY (
Serial No. v%% SIGNATURE OF PERSON CONSTRUCTING THE WELL Date
Submit original to Division of Water Quality, Groundwater Section within 30 days

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Ground Water Section ,
1636 Mail Service Center - Raleigh, N.C. 27699-1636 - Phone [phone] L 1 8 99 0
WELL CONSTRUCTION RECORD WELL CONTRACTOR: Hedden Bros. Well Drilling Inc.
WELL CONTRACTOR CERTIFICATION N: 2045
STATE WELL CONSTRUCTION PERMIT k:
I . WELL USE(Check Applicable Box): Residential EK 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: Sylva County: Jackson
Parris Branch
(Road Name and Numbers, Community, or Subdivision and Lot No.) DEPTH
DRILLING LOG
3. OWNER David Sutton From To
Formation Description
Address 435 River Hill 0 43
clay & -and
(Street or Route No.) 43 800
granite
Atlanta GA 30328
City or Town State Zip Code
4. DATE DRILLED 09/26/00
5. TOTAL DEPTH 800
CUTTINGS COLLECTED YES ❑ NO ❑X
6.
WELL REPLACE EXISTING WELL? YES ❑ NO )(❑
t� ✓_
7. DOES
8. STATIC WATER LEVEL Below Top of Casing: 0 FT.
o
(Use " + " if Above Top of Casing)
'-
9. TOP OF CASING IS 2 FT. Above Land Surface*
w
*Top of casingg terminated at/or below land surface requires a variance in accor-
dance with ISA NCAC 2C .0118
—�
10. YIELD (gpm): 1.00 METHOD OF TEST BIOW
— -
11. WATER ZONES (depth): 705
fV plc:;
Crt ti
12. CHLORINATION: Type H T H Amount
If additional
4 o
space is needed use back of form =e
13. CASING:
Wall Thickness
Depth
Diameter
or Weight/Ft. Material
From 0
To 45
Ft. 6
nyc
From
To
Ft.
From
To
Ft.
14, GROUT:
Depth
Material
Method
From 0
To 20
Ft. Cement
Poured
From
To
Ft.
15. SCREEN
Depth Diameter Slot Size Material
From 0 To Ft. in. in.
From To Ft. in. in.
From To Ft. in. in.
16. SAND/GRAVEL PACK:
Depth Size Material
From 0 To Ft.
From To Ft.
17. REMARKS:
I DO HEREI
FOR USE ONLY
Quad
Serial
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
'A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
SIGNATURE OF PERSON CONSTRUCTING THE WELL Date
original to Division of Water Quality, Groundwater Section within 30 days
Asp^

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Ground Water Section f:,
1636 Mail Service Center - Raleigh, N.C. 27699-1636 - Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR. Hedden Bros. Well Drilling Inc.
WELL CONTRACTOR CERTIFICATION #: 2045
STATE WELL CONSTRUCTION PERMIT #:
1. WELL USE(Check Applicable Box): Residential 0 Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other,List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: Dillsboro County: Jackson
Nations Crk-Fred Sutton
(Road Name and Numbers, Community, or Subdivision and Lot No.)
3. OWNER Chris Queen
Address P O Box 330
(Street or Route No.)
Dillsboro NC 28725
City or Town State Zip Code
4. DATE DRILLED 09/29/00
5. TOTAL DEPTH 400
6. CUTTINGS COLLECTED YES ❑ NO 0
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO 0
8. STATIC WATER LEVEL Below Top of Casing: 0 FT.
(Use "+" if Above Top of Casing)
9. TOP OF CASING IS 2 FT. Above Land Surface*
*Top of casingg terminated at/or below land surface requires a variance in accor-
dance with 15A NCAC 2C .0118
10. YIELD (gpm): 6.00 METHOD OF TEST Blow
11. WATER ZONES (depth): 190
12. CHLORINATION: Type H T H Amount
13. CASING: Wall Thickness
Depth Diameter or Weight/Ft. Material
From 0 To 21_ Ft. 6 ' 189 steel
From 21 Tom Ft. '� pVC _
From To Ft.
14. GROUT:
Depth Material Method
From 0 To 20 Ft. Cement Poured
From To Ft.
15. SCREEN
Depth Diameter Slot Size Material
From 0 To Ft. in. in.
From To Ft. in. in.
From To Ft. in. in.
16. SAND/GRAVEL PACK:
Depth Size Material
From 0 To Ft.
From To Ft.
17. REMARKS:
IDOHE
CONST
FOR OFFI
Quad No.
Serial No.
DEPTH DRILLING LOG
From To Formation Description
n 8tl cla)l Rr cand
_80 400 granite
t�
L
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)
WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
T A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
' SIGNATURE OF PERSON CONSTRUCTING THE WELL Date
original to Division of Water Quality, Groundwater Section within 30 days

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Ground Water Section " 1 84 13
1636 Mail Service Center - Raleigh, N.C. 27699-1636 - Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: Hedden Bros. Well Drilling Inc.
WELL CONTRACTOR CERTIFICATION #: 2045
STATE WELL CONSTRUCTION PERMIT N:
1. WELL USE(Check Applicable Box): Residential 0 Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ .If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: Sylva County: Jackson
Blanton Br -Chestnut Rdg
(Road Name and Numbers, Community, or Subdivision and Lot No.)
3. OWNER Mike Haynes
Address 123 Night Hawk Drive
(Street or Route No.)
Sylva NC 28779
City or Town State Zip Code
4. DATE DRILLED 09/21/00
5. TOTAL DEPTH 350
6. CUTTINGS COLLECTED YES ❑ NO 0
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO 0
8. STATIC WATER LEVEL Below Top of Casing: 0 FT.
(Use " + " if Above Top of Casing)
9. TOP OF CASING IS 2 FT. Above Land Surface*
*Top of casingg terminated at/or below land surface requires a variance in accor-
dance with 15A NCAC 2C .0118
10. YIELD (gpm): 4.00 METHOD OF TEST Blow
11. WATER ZONES (depth): 180
0
12. CHLORINATION: Type H T H Amount
13. CASING: Wall Thickness
Depth Diameter or Weight/Ft. Material
From _ 0 To 40 Ft. 6" nvc
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From 0 To 20 Ft. Cement Poured
From To Ft.
15. SCREEN
Depth Diameter Slot Size Material
From 0 To Ft. in. in.
From To Ft. in. in.
From To Ft. in. in.
16. SAND/GRAVEL PACK:
Depth Size Material
From 0 To Ft.
From To Ft.
17. REMARKS:
I DO HEREBY
FOR OFFICE USE
Quad No.
Serial No.
DEPTH
From To
Agricultural ❑ Monitoring ❑
DRILLING LOG
Formation Description
O
i-,EJ
0
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)
iSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
TORE OF PERSON CONSTRUCTING THE WELL Date
, Division of Water Quality, Groundwater Section within 30 days

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Ground Water Section i- 181
1636 Mail Service Center - Raleigh, N.C. 27699-1636 - Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: Hedden Bros. Well Drilling Inc.
WELL CONTRACTOR CERTIFICATION #: 2045
STATE WELL CONSTRUCTION PERMIT #:
1. WELL USE(Check Applicable Box): Residential IR 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: Sylva County: Jackson
12 Hilltop Dr
(Road Name and Numbers, Community, or Subdivision and Lot No.) DEPTH
3. OWNER Clint Mathis From To
Address 12 Hilltop Dr n 76
(Street or Route No.) 76 300
Sylva NC 28779
City or Town State Zip Code
4. DATE DRILLED 09/20/00
5. TOTAL DEPTH 300
6. CUTTINGS COLLECTED YES ❑ NOFRI
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO M
8. STATIC WATER LEVEL Below Top of Casing: 0 FT.
(Use " + " if Above Top of Casing)
9. TOP OF CASING IS 2 FT. Above Land Surface*
*Top of casingg terminated at/or below land surface requires a variance in accor-
dance with 15A NCAC 2C .0118
10. YIELD (gpm): 30.00 METHOD OF TEST Blow
11. WATER ZONES (depth): 288
HTH
DRILLING LOG
Formation Description
clay Rr sand
granite r
O
rn
v
G rT', �!
O
c•
12. CHLORINATION. Type
Amount
If additional space is needed use back of form
13. CASING:
Wall Thickness
Depth
Diameter
or Weight/Ft. Material
LOCATION SKETCH
From �_ To 78
Ft. 6—
nvc
(Show direction and distance from at least two State
From To
Ft.
Roads, or other map reference points)
From To
Ft.
14, GROUT:
Depth
Material
Method
From 0 To 20
Ft. cernent
Poured
From To
Ft.
15. SCREEN:
Depth
Diameter Slot Size Material
From 0 To
Ft. in.
in.
From To
Ft. in.
in.
From To
Ft. in.
in.
16. SAND/GRAVEL PACK:
Depth
Size
Material
From 0 _ To
Ft.
From To
Ft.
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTIO W:rigina"to
Y OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE Quad No.
Serial No. ATURE OF PERSON CONSTRUCTING THE WELL Date
Sub Division of Water Quality, Groundwater Section within 30 days

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Ground Water Section a, .1, p 4 10
1636 Mail Service Center - Raleigh, N.C. 27699-1636 - Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: Hedden Bros Well Drilling Inc.
WELL CONTRACTOR CERTIFICATION #: 2045
STATE WELL CONSTRUCTION PERMIT N:
1. WELL USE(Check Applicable Box): Residential F—X1 Municipal 0 Industrial 0
Recovery 0 Heat Pump Water InjectionEl Other D If Other,List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: SVlva County: Jackson
Pumpkin Lyn Rd Chestnut C
(Road Name and Numbers, Community, or Subdivision and Lot No.)
3. OWNER Bob Farner
Address 41515 Silver Dr
(Street or Route No.)
Umatilla FL 32784
City or Town State Zip Code
4. DATE DRILLED 09/19/00
5. TOTAL DEPTH 400
6. CUTTINGS COLLECTED YES 0 NO OX
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO 0
8. STATIC WATER LEVEL Below Top of Casing: 0 FT.
(Use " + " if Above Top of Casing)
9. TOP OF CASING IS 2 FT. Above Land Surface*
*Top of casingg terminated at/or below land surface requires a variance in accor-
dance with 15A NCAC 2C .0118
10. YIELD (gpm): 4.00 METHOD OF TEST Blow
11. WATER ZONES (depth): 108
316
12. CHLORINATION: Type H T H Amount
13. CASING: Wall Thickness
Depth Diameter or Weight/Ft. Material
From 0 To 21 Ft. 6 ' _ 188 steel
From 21 Tom Ft. 6„ pvc
From To Ft.
14. GROUT:
Depth Material Method
From 0 To 20 Ft. Cement Poured
From To Ft.
15, SCREEN
Depth Diameter Slot Size Material
From 0 To Ft. in. in.
From To Ft. in. in.
From To Ft. in. in.
16. SAND/GRAVEL PACK:
Depth Size Material
From 0 To Ft.
From To Ft.
Agricultural D Monitoring E]
DEPTH DRILLING LOG
From To Formation Description
O 41 rlav & canrl
41 400 granite
o
r-n -
aa
v
o r >
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)
17, REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTIO COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE C _ _
Quad No.
Serial No. it : ATURE OF PERSON CONSTRUCTING THE WELL Date
Submitigura to Division of Water Quality, Groundwater Section within 30 days

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Ground Water Section t_ 1 D `i Oar
1636 Mail Service Center - Raleigh, N.C. 27699-1636 - Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: Hedden Bros. Well Drilling Inc.
WELL CONTRACTOR CERTIFICATION #: 2043
STATE WELL CONSTRUCTION PERMIT #:
1. WELL USE(Check Applicable Box): Residential EK 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: Cashiers County: Jackson
112 Monte Vista
(Road Name and Numbers, Community, or Subdivision and Lot No.)
3. OWNER Gray Murray
Address 1749 Mayfair Dr
(Street or Route No.)
Birmingham AL 35209
City or Town State Zip Code
4. DATE DRILLED 09/14/00
5. TOTAL DEPTH 600
6. CUTTINGS COLLECTED YES ❑ NO 0
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO 0
8. STATIC WATER LEVEL Below Top of Casing: 0 FT.
(Use " + " if Above Top of Casing)
9. TOP OF CASING IS 2 FT. Above Land Surface*
*Top of cast ngg terminated at/or below land surface requires a variance in accor-
dance with 15A NCAC 2C .0118
10. YIELD (gpm): 3.00 METHOD OF TEST Blow
11. WATER ZONES (depth): I O
12. CHLORINATION: Type H T H Amount
13. CASING: Wall Thickness
Depth Diameter or Weight/Ft. Material
From 0 To 60 Ft. _6 nvc
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From 0 To 20 Ft. Cement Poured
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 0 To Ft.
From To Ft.
17. REMARKS:
I DO HEREBY
FOR OFFICE
Quad No.
Serial No.
DEPTH
From To
0 59
58 600
DRILLING LOG
Formation Description
clay & sand
granite
r�
c7
v:
r,
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)
CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
nDf29P ;IG
Y OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
ATURE OF PERSON CONSTRUCTING THE WELL Date
o Division of Water Quality, Groundwater Section within 30 days

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Ground Water Section O 4 0 4
1636 Mail Service Center - Raleigh, N.C. 27699-1636 - Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: Hedden Bros. Well Drilling Inc.
WELL CONTRACTOR CERTIFICATION #: 2043
STATE WELL CONSTRUCTION PERMIT #:
1.
WELL USE(Check Applicable Box): Residential 1XI 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: Cashiers County: Jackson
I aueral Falls -Off Breedly
(Road Name and Numbers, Community, or Subdivision and Lot No.) DEPTH
DRILLING LOG
3.
OWNER Judith GWathmay From To
Formation Description
Address 66 Homer Ave 0 57
r1tim Rr -and
(Street or Route No.) 57 300
granite
Cambridge MA 02138
-
City or Town State Zip Code
('71 -_
4.
DATE DRILLED 09/01/00
-
5.
TOTAL DEPTH 300
❑ NO ❑X
rn '
'
6.
CUTTINGS COLLECTED YES
YES ❑ NO FX-1
r")
7.
DOES WELL REPLACE EXISTING WELL?
8.
STATIC WATER LEVEL Below Top of Casing: 0 FT.
(Use "+" if Above Top of Casing)
_
9.
TOP OF CASING IS 2 FT. Above Land Surface*_
'Top of casing terminated at/or below land surface requires a variance in actor-
dance with ISA NCAC 2C .0118
::3 IT 75
IO.
YIELD (gpm): 12.00 METHOD OF TEST B10W
1 L
WATER ZONES (depth): UO
`
12. CHLORINATION: Type H T H Amount
13. CASING: Wall Thickness
Depth Diameter or Weight/Ft. Material
From _0 To 59 Ft. _6' nvc
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From 0 To 20 Ft. Cement Poured
From To Ft.
15. SCREEN
Depth Diameter Slot Size Material
From —0 To Ft. in. in.
From To Ft. in. in.
From To Ft. in. in.
16. SAND/GRAVEL PACK:
Depth Size Material
From 0 To Ft.
From To Ft.
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS P
CONSTRUC S N S
FOR OFFICE U tLY rn1
Quad No.�'i 'llfn1ll0
Serial No.
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)
CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
SPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
ATURE OF PERSON CONSTRUCTING THE WELL Date
to Division of Water Quality, Groundwater Section within 30 days
GrounC::a'e Sectiol
Rsheviie I Offi

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Ground Water Section 3
1636 Mail Service Center - Raleigh, N.C. 27699-1636 - Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: Hedden Bros. Well Drilling Inc.
WELL CONTRACTOR CERTIFICATION #: 2043
STATE WELL CONSTRUCTION PERMIT #:
1. WELL USE(Check Applicable Box): Residential EX Municipal 0 IndustrialEl Agricultural 0 MonitoringEl
Recovery ❑ Heat Pump Water Injection 0 Other ❑ If Other,List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: Glenville County: Jackson
Well &3--Behind VFW
(Road Name and Numbers, Community, or Subdivision and Lot No.) DEPTH DRILLING LOG
3. OWNER Thomas Moore & Company From To Formation Description
Address P O Box 340 (1 47 clay Rr ennd
(Street or Route No.) 47 400granite
Glenville NC 28736
City or Town State Zip Code
4. DATE DRILLED 09/13/00
5. TOTAL DEPTH 400
6. CUTTINGS COLLECTED YES ❑ NO 0
7, DOES WELL REPLACE EXISTING WELL? YES ❑ NO
8. STATIC WATER LEVEL Below Top of Casing: 0 FT.
(Use "+" if Above Top of Casing)
9. TOP OF CASING IS 2 FT. Above Land Surface*
*Top of casingg terminated at/or below land surface requires a variance in accor-
dance with 15A NCAC 2C .0118
10. YIELD (gpm): 40.00 METHOD OF TEST Blow
11. WATER ZONES (depth): 215
320
�J
O
i
CD
0
12. CHLORINATION: Type H T H Amount If additional space is needed use back of form
13. CASING: Wall Thickness
Depth Diameter or Weight/Ft. Material
LOCATION SKETCH
From To 49 Ft. 6 nyc (Show direction and distance from at least two State
From To Ft. Roads, or other map reference points)
From To Ft.
14. GROUT:
Depth Material Method
From 0 To 20 Ft. Cement Poured
From To Ft.
15. SCREEN
Depth
From 0 To
From To
From To
16. SAND/GRAVEL PACK:
Depth
From 0 To
From To
17. REMARKS:
I DO HEREBY
FOR OFFICE
Quad No.
Serial No.
Diameter Slot Size Material
Ft. in.
in.
Ft. in.
in.
Ft. in.
in.
Size Material
Ft.
Ft.
ONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
A D H PY OF THIS RECORD HAS BEEN
NN 7PROVIDED TO THE WELL OWNER.
SIG ATURE OF PERSON CONSTRUCTING THE WELL Date
water SeCllObnit origire 1 to Division of Water Quality, Groundwater Section within 30 days

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Ground Water Section }}
1636 Mail Service Center - Raleigh, N.C. 27699-1636 - Phone [phone] ;..1 S 4 0 40
WELL CONSTRUCTION RECORD WELL CONTRACTOR: Hedden Bros. Well Drilling Inc.
WELL CONTRACTOR CERTIFICATION N: 2043
STATE WELL CONSTRUCTION PERMIT #:
1. WELL USE(Check Applicable Box): Residential 0 Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other,List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: Cashiers County: Jackson
Stillmont-221 Azalea Ln
(Road Name and Numbers, Community, or Subdivision and Lot No.) DEPTH DRILLING LOG
3. OWNER John MCCOrkle From To Formation Description
Address P O BOX 2826 0 ?') clay sand
(Street or Route No.) 22 400 granite.
Cashiers NC 28717
City or Town State Zip Code
4. DATE DRILLED 09/12/00
5. TOTAL DEPTH 400
6. CUTTINGS COLLECTED YES ❑ NO ❑X
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
8. STATIC WATER LEVEL Below Top of Casing: 0 FT.
(Use " + " if Above Top of Casing)
9. TOP OF CASING IS 2 FT. Above Land Surface*
*Top of casingg terminated at/or below land surface requires a variance in accor-
dance with IA NCAC 2C .0118
10. YIELD (gpm): 6.00 METHOD OF TEST Blow
11. WATER ZONES (depth): 115
0
12. CHLORINATION: Type H T H Amount
13. CASING: Wall Thickness
Depth Diameter or Weight/Ft. Material
From_0 To 24 Ft.6— nvc
From To Ft.
From To Ft.
14. GROUT:
I
`o
t"
r�
J
�>
If additional space is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
Depth
Material
Method
From 0 To 20
Ft. Cement
Poured
From To
Ft.
15.SCREEN:
Depth
Diameter Slot Size
Material
From Q To
Ft. in.
in.
From To
Ft. in.
in.
From To
Ft. in.
in.
16. SAND/GRAVEL PACK:
Depth
Size
Material
From 0 To
Ft.
From To
Ft.
17. REMARKS:
I HEREBY ( $,itlUIDU
CPO IN ACCORDANCE WITH 15A
t'ONSTRIICTI 6' A
ON
II
D T
OF THIS RECORD HAS BEEN PROVIDED TOTHEWELL OWNER.
FOR OFF:TL
l�/�J .�1!
Quad No.
Serial No. SI ATURE OF PERSON CONSTRUCTING THE WELL Date
water SerfiU mit origin to Division of Water Quality, Groundwater Section within 30 days

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Ground Water Section �� L 9 4 0
1636 Mail Service Center - Raleigh, N.C. 27699-1636 - Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: Hedden Bros. Well Drilling Inc.
WELL CONTRACTOR CERTIFICATION #: 2043
STATE WELL CONSTRUCTION PERMIT #:
1. WELL USE(Check Applicable Box): Residential 0 Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other,List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: Cashiers County: Jackson
High Hemlock -Breedlove Rd
(Road Name and Numbers, Community, or Subdivision and Lot No.) DEPTH
3. OWNER Ann Austin From To
Address C/O McKee Properties 0 79
(Street or Route No.) 78 400
Cashiers NC 28717
City or Town State Zip Code
4. DATE DRILLED 09/06/00
5. TOTAL DEPTH 400
6. CUTTINGS COLLECTED YES ❑ NO X
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO FXI
8. STATIC WATER LEVEL Below Top of Casing: 0 FT.
(Use " + " if Above Top of Casing)
9. TOP OF CASING IS 2 FT. Above Land Surface*
*Top of casingg terminated at/or below land surface requires a variance in accor-
dance with IA NCAC 2C .0118
IO. YIELD (gpm): 8.00 METHOD OF TEST Blow
11. WATER ZONES (depth)
DRILLING LOG
Formation Description
clay Rr snnd
granite
U "
o -1
12. CHLORINATION: Type H T H Amount v �?
If additional space is needed use back of form
13. CASING: Wall Thickness
Depth Diameter or Weight/Ft. Material LOCATION SKETCH
From 0 Togo Ft. _6 nve (Show direction and distance from at least two State
From To Ft. Roads, or other map reference points)
From To Ft.
14. GROUT:
Depth Material Method
From 0 To 20 Ft. cernent Poured
From To Ft.
15. SCREEN:
Depth
From 0 To
From To
From To
16. SAND/GRAVEL PACK:
Depth
From 0 To
From To
17. REMARKS:
1 DO HEREBY CE Y
CONSTRUCTION
FOR OFFICE USE
Quad No.
Serial No.
Diameter Slot Size
Ft. in. in
Ft. in. in
Ft. in. in
Material
Material
7STRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
F URE OF PERSON CONSTRUCTING THE WELL Date
Division of Water Quality, Groundwater Section within 30 days

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Ground Water Section !- ). O 400
1636 Mail Service Center - Raleigh, N.C. 27699-1636 - Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: Hedden Bros. Well Drilline Inc.
WELL CONTRACTOR CERTIFICATION X: 2043
STATE WELL CONSTRUCTION PERMIT #:
1. WELL USE(Check Applicable Box): Residential 0 Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other,List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: Cullowhee County: Jackson
897 Tritt Rd
(Road Name and Numbers, Community, or Subdivision and Lot No.) DEPTH DRILLING LOG
3. OWNER James & Wanda Herren From To Formation Description
Address 897 Tritt Rd 0 75 clay & sand
(Street or Route No.) 75 350 , granite
Cullowhee NC 28723
City or Town State Zip Code
4. DATE DRILLED 08/31/00
5. TOTAL DEPTH 350 -�
6. CUTTINGS COLLECTED YES ❑ NO ❑X
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO FX]
8. STATIC WATER LEVEL Below Top of Casing: 0 FT.
(Use " + " if Above Top of Casing) J
9. TOP OF CASING IS 2 FT. Above Land Surface*
*Top of cast ngg terminated at/or below land surface requires a variance in accor-
dance with 15A NCAC 2C .0118
10. YIELD (gpm): 15.00 METHOD OF TEST Blow =
11. WATER ZONES (depth): 290 _..a "
0 _
12. CHLORINATION: Type H T H Amount If additional space is needed use back of form
13. CASING: Wall Thickness
Depth Diameter or Weight/Ft. Material LOCATION SKETCH
From 0 To 77 Ft. 6 Tvc (Show direction and distance from at least two State
From To Ft. Roads, or other map reference points)
From To Ft.
14. GROUT:
Depth Material Method
From 0 To 20 Ft. Cement Poured
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 0 To Ft.
From To Ft.
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTIO PY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
FOR OFF::&Onundwatar
` ,I� -3
Quad No.Serial No. ATURE OF PERSON CONSTRUCTING THE WELL Date
Submit rigor to Division of Water Quality. Groundwater Section within 30 days
&actim

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Ground Water Section I g
1636 Mail Service Center - Raleigh, N.C. 27699-1636 - Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: Hedden Bros. Well Drilling Inc.
WELL CONTRACTOR CERTIFICATION #: 2043
STATE WELL CONSTRUCTION PERMIT #:
1. WELL USE(Check Applicable Box): Residential 0 Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other,List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: Glenville County: Jackson
(Road Name and Numbers, Community, or Subdivision and Lot No.)
3. OWNER Thomas Moore & Co.
Address P O Box 340
(Street or Route No.)
Glenville NC 28736
City or Town State Zip Code
4. DATE DRILLED 08/30/00
5. TOTAL DEPTH 800
6. CUTTINGS COLLECTED YES ❑ NO FRI
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
8. STATIC WATER LEVEL Below Top of Casing: 0 FT.
(Use " + " if Above Top of Casing)
9. TOP OF CASING IS 2 FT. Above Land Surface*
-Top of cast ngg terminated at/or below land surface requires a variance in accor-
dance with IA NCAC 2C .0118
10. YIELD (gpm): 2.00 METHOD OF TEST Blow
11. WATER ZONES (depth): O
12, CHLORINATION: Type H T H Amount
13. CASING: Wall Thickness
Depth Diameter or Weight/Ft. Material
From _0 To 95 Ft. 6" rnvc
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From 0 To 20 Ft. cernent Poured
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From 0 To Ft. in. in.
From To Ft. in. in.
From To Ft. in. in.
16. SAND/GRAVEL PACK:
Depth Size Material
From 0 To Ft.
Agricultural ❑ Monitoring ❑
DEPTH DRILLING LOG
From To Formation Description
0 23 da) Rr sand
23 800 granite
C')
rt
;•n
0
CD
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)
From To Ft.
17. REMARKS:
I DO HEREBY TI T I L CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTI PY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE US Y Q �t,. 20-10
Quad No.
Serial No. nn 8fp' CerSit;NATURE OF PERSON CONSTRUCTING THE WELL Date
Np
9%nit original to Division of Water Quality, Groundwater Section within 30 days

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Ground Water Section (�
1636 Mail Service Center - Raleigh, N.C. 27699-1636 - Phone [phone] [ .i 8 3 9 8
WELL CONSTRUCTION RECORD WELL CONTRACTOR: Hedden Bros. Well Drilling Inc.
WELL CONTRACTOR CERTIFICATION N: 2043
STATE WELL CONSTRUCTION PERMIT H:
I. WELL USE(Check Applicable Box): Residential ER Municipal ❑
Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other,List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: Cullowhee County: Jackson
155 Yonder Way
(Road Name and Numbers, Community, or Subdivision and Lot No.)
DEPTH DRILLING LOG
3. OWNER R L Byrd
From To Formation Description
Address 155 Yonder Way
fl 57 ring Rr and
(Street or Route No.)
57 175 granite
Cullowhee NC 28723
City or Town State Zip Code
4. DATE DRILLED 08/30/00
5. TOTAL DEPTH 175
❑ ❑X
6. CUTTINGS COLLECTED YES NO
WELL? YES ❑ NO
7. DOES WELL REPLACE EXISTING
8. STATIC WATER LEVEL Below Top of Casing: 0 FT.-'
(Use " + " if Above Top of Casing)
l �
9. TOP OF CASING IS 2 FT. Above Land Surface*
*Top of casingg terminated at/or below land surface requires a variance in accor-
d ance with 15A NCAC 2C .0118
10. YIELD (gpm): 30.00 METHOD OF TEST Blow
11. WATER ZONES (depth): 70
160
c,
12. CHLORINATION: Type H T H Amount—�.
If additional space is needed use back ofQm L
13. CASING: Wall Thickness
Depth Diameter or Weight/Ft. Material
LOCATION SKETCH
From �_ Tom Ft. 6" nvc
(Show direction and distance from at least two State
From To Ft.
Roads, or other map reference points)
From To Ft.
14. GROUT:
Depth Material Method
From 0 To 20 Ft. Cement Poured
From To Ft.
15. SCREEN
Depth Diameter Slot Size Material
From 0 To Ft. in. in.
From To Ft. in. in.
From To Ft. _ in. in.
16. SAND/GRAVEL PACK:
Depth
From 0 To Ft.
From To Ft.
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS
FOR OFFICE USEUtt
r
Quad No.
Serial No. JWWJ
Size Material
WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
5igma
Y OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
TUBE OF PERSON CONSTRUCTING THE WELL Date
Division of Water Quality, Groundwater Section within 30 days

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Ground Water Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636 - Phone [phone] I- 1 8 3 9 7
WELL CONSTRUCTION RECORD WELL CONTRACTOR: Hedden Bros. Well Drilling Inc.
WELL CONTRACTOR CERTIFICATION #: 2045
STATE WELL CONSTRUCTION PERMIT #:
1. WELL USE(Check Applicable Boa): Residential E Municipal El Industrial El Agricultural ❑ MonitoringEl
Recovery ❑ Heat Pump Water Injection D Other El If Other,List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: Whittier county: Jackson
Piney Mountain
(Road Name and Numbers, Community, or Subdivision and Lot No.) DEPTH DRILLING LOG
3. OWNER Carl Threadgill From To Formation Description
Address P O Box 256 O 65 clay Rr sand
(Street or Route No.) 65 200 granite
Whittier NC 28789
City or Town State Zip Code
4. DATE DRILLED 08/30/00
5. TOTAL DEPTH 200
6. CUTTINGS COLLECTED YES ❑ NO FRI
7. DOES WELL REPLACE EXISTING WELL? YES 0 NO 0
8, STATIC WATER LEVEL Below Top of Casing: 0 FT.
(Use " + " if Above Top of Casing)
9. TOP OF CASING IS 2 FT. Above Land Surface*
*Top of casingg terminated at/or below land surface requires a variance in accor-
dance with 15A NCAC 2C .0118
10. YIELD (gpm): 10.00 METHOD OF TEST BIOW
11. WATER ZONES (depth): 0
12. CHLORINATION: Type H T H Amount
13. CASING: Wall Thickness
Depth Diameter or Weight/Ft. Material
From 0 To 67 Ft. 6" P vC
From To Ft.
From To Ft.
14, GROUT:
Depth Material Method
From 0 To 20 Ft. Cement Poured
From To Ft.
15,SCREEN
. r -
J
If additional space is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
Depth Diameter Slot Size Material
From _ 0 To Ft. in. in.
From To Ft. in. in.
From To Ft. in. in.
16. SAND/GRAVEL PACK:
Depth Size Material
From 0 To Ft.
From To Ft.
17. REMARKS:
I DO HEREBY I GDTIcy L WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTIO A D Pj EFHRT PY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE US Y t,(, V l5 v�
Quad No.
Serial No. NATURE OF PERSON CONSTRUCTING THE WELL Date
..Sub origi I to Division of Water Quality, Groundwater Section within 30 days

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Ground Water Section 2.1. 3 Q
1636 Mail Service Center - Raleigh, N.C. 27699-1636 - Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: Hedden Bros. Well Drilling Inc.
WELL CONTRACTOR CERTIFICATION it: 2045
STATE WELL CONSTRUCTION PERMIT Y:
I . WELL USE(Check Applicable Box): Residential 0 Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other,List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: Sylva County: Jackson
184 Hayfield Dr
(Road Name and Numbers, Community, or Subdivision and Lot No.) DEPTH DRILLING LOG
3. OWNER Karen Ensley From To Formation Description
Address 184 Hayfield Dr 0 76 clay Rr sand
(Street or Route No.) 76 400 gr2nite
Sylva NC 28779
City or Town State Zip Code
4. DATE DRILLED 08/31/00
5. TOTAL DEPTH 400
6. CUTTINGS COLLECTED YES ❑ NO FRI
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
8. STATIC WATER LEVEL Below Top of Casing: 0 FT. 7 -
(Use " + " if Above Top of Casing) G7
9. TOP OF CASING IS 2 FT. Above Land Surface*
*Top of cast ngg terminated atlor below land surface requires a variance in actor-
dance with 15A NCAC 2C .0118 -
10. YIELD (gpm): 30.00 METHOD OF TEST Blow
11. WATER ZONES (depth): 150 - --
0
12. CHLORINATION: Type H T H Amount If additional space is needed use back oft�nn
13. CASING: Wall Thickness
Depth Diameter or Weight/Ft. Material `
LOCATION SKETCH
From _ 0 To 21 Ft. 6" _ 188 steel (Show direction and distance from at least two State
From 21 To 78 Ft. � DVe Roads, or other map reference points)
From To Ft.
14. GROUT:
Depth Material Method
From 0 To 20 Ft. Cement Poured
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 0 To Ft.
From To Ft.
17. REMARKS:
I DO HE IEVT1111— J WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTR ii'6I IO�ST11PO �ARDWA��r A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFI E ONLY OY—g/— Ue)
Quad No. t:(_i7rl�.'i
Serial No. SIGNATURE OF PERSON CONSTRUCTING THE WELL Date
Sub t or
to Division of Water Quality, Groundwater Section within 30 days

293973
WELL CONSTRUCTION RECORD
Ncrth Carolina • Dcoart rent of Environment and Natural Resources -Division of Water Quality • Groundwater Section
WfiLLCONTRACTOR(hVDIVIDUAL)NAN!E (print) Mitchell De Cook CERTIFICA7ION 4 2Ld3
WELL CON]RACTOR CON: PAN Y NAA I Br&—hP--✓ F)U D-lh V, IM HOVE a 828) 369-9591
STATE WELL COiNSTRl1CTI0N PERM IT# ASSOCIATED WQ PER,MIT# -
- (if aoolicable) - (irapolicable). - -
1. WELL USE (Check Applicable Box): Residential 6 Municipal/Public❑. Industrial ❑ Agricultural G
Monitorin; ❑ Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use
-
2. WELL LOCATI N: Topo zphic/Land s.ttine '
County
Neares Town, CV
_S Gftidge ❑S ope ❑Valley ❑Flat
(the:k appropriate box)
N[o„ Zip Code) Latitud0/lon Hilud'e of Well location
(S!rce: Nome, Nw• tiers Communit $usdivi '/n�
�Lol
3. OWNER: 6Lfi�{" (e ,,eanri-uteaneccnde>
Address Latitud,s'longiwu esource:OOPSOTepographic map
IStreet or Route . •o.) (Oeck box)
Joe A 'Air,% DEPTH DRILLING LOG
(/SiL)`�o�JlO //Str�yn ip ccd< Front_ , Fclay sarDdrription
Area sae Phon<nwnEer granite
4 DATE DRELLED
5. TOTAL DEFTH
6 DOES WELL REPLACE EXISTING WELL? YES ❑ NO
7. STATIC WATERLEVEL Below Top cfCasing: QfO FT.
(Use "+" if ASove Top of Casin;)
8, TOP OF CASING IS 2 FT. Above Land Surface'
`Top of casln; terminved at/or below land surface requires a
- varlance In accordant with I5.A NCAC 3C .0113,
9. YIELD (gom): (- ME NOD OF TEST blow _
10, WATER ZONES (depth);' CST
LOCATION SKETCH
IL DISINFECTION: Type H T H Amount -1 6oz Show direction and distance in miles fi<tm, a; least
12, CASING Wall Thlckrss two State Roads or County Roads. Include the road
Deptht I Diameter or Weight/FI. Material numbers and commco- road names,
"
From O To— L Ft.
From To " Ft. -
p
From' To Ft... 3
c•a^
13. GROUT: Depth, Material Method A.
From 0 To 20 Fl & centl tz-Ced
From To Ft.
14. SCREEN. Depth Diameter Slot Size Material
- `
From To Ft.in.. in.
- From To Ftin. in. CJ
c�z
15, SAND/GRAVEL PACK'.
�a
r
Depth - .Size
From To Ft.
z
Frcm _ To Ft.
16. REMARKS: F_
-
I DO HERESY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
--
CONSTRUCTION STANDARDS, AND THAT A/COnPQY OF THIS R.ECO RD HAS SEEN PROVIDED T07HE
SIGNATURE Cc PERSON CONSTRUCTING THE WELL DATE
Submit the ori;innl to the Division of Water Quality, CroundWater Section, 1636 Mail Sarviae Center - Ralelgh, NO
i
:7699-1636 Phonc Na. [phone], Within 30 days. GW-I REV. 0i/200I
i;-

293971
WELL CONSTRUCTION RECORD
Ncrth Carolina • Dopartment of Environment and Natural Resources Division of Water Quehty • Groundwater Section
YS'ELLCONTRACTOR(I:NDIVIDUAL)NAhIE (print) MitChell De -Cook CERTIFICATION 4.2L13
NYELL CON':RACTGR CO:NI?ANY NA,NI E "• �''� ni1 -'•'ge PHO,VE k 828) M9-959�
s'rATE WELL COiNSTRLIC71ON PER,MITO ASSOCIATED YYQ PERMI-r# -
(ifaoolicable) `(if aoolicable)
1, WELL USE (Che:KApplicable Box): Residential 6 Municipal/Public ❑ Industrial Cl Agricultural ❑
Monitoring ❑ Recovery ❑ Heat pump Water Injection ❑ -Other
❑ 1FOther, List Use
2 WELL LOCA710
Topographic/Land setting
Nz cst7o/W11: It&^County
❑Ridge ❑Slope ❑Valley ❑Flat
(ch::<appropriite box)
(Sire-t Nmn e, NunboorssCCom,muunity, Subdivision, Lot No., Zip Code)
Latit'ude,/lon Eltud'e of well location
3, 0WNER: WInIU//.). � Q�
(d ;rea/u.inutes/s<conLs)
Addicss YO DQ1L , In -
Laiiwde!lon itua source:❑GPS❑Topograchic mup
(str<.: r Rout a Np�) O /
(cheek box)
DEPTH-: DRILLING LOG
CCeyro/r�i wn Sp Z'.p csde
(lt(eX) / !? ! /
From , Formation Description
C T C13! & Si
- Area zoom Phone nwnoer ((
a Y ran.ite
4. DATE DRILLED_0
5, TOTAL DEFTH: 205
6. DOES WELL RE?LACE EXISTING WELL? YES ❑ NO ❑
i. STATIC WATER LEVEL Below Top cf Casing:,IM_FT..
(Use"r' If A'oovc Top of Canny)
8, TOP OF CASING IS 2 FT, Above Laid Surface*
-Top of casin; terminated at/or below land surface requires a
variance In accordance with 15A NCAC 2C.0113
9. YIELD (gpm): METHOD OFrTEST blow
_
10, WATER ZONES (depth) y
LOCATION SKETCH
I I. DISINFECTiO: Type H T H Amount 1 602
Show dirzction and distance in miles From a: least
12. CASING: Nall Thic;chess
two State Roads or Ca.mty Roads Include the road
Depth Diameter or Weight/Ft Material
From_ To Ft. &
numbers and com�mor. road names
From To - Ft.
. ` From To Ft.
- -
13, GROUT: Depth Material -. method
_.
: From 0 To 20 Ft�:.71�te & CSTER-t pinned
-
-!
From To Ft.
o
14; SCREEN: Depth Diameter Slot size Material.
�^
From To Ft.inin..
}
c"
From - To - Ft, in, _ in.
15. SAND/GRAVEL PACK'
o13
Depth Size Material
-o
m�
From To _ Ft.
-r
From To Ft.
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C, WELL t
'—� - j ,
CONSTRUCTION STANDARDS, AND TH A COPY F THIS RECO H
lea
BEEN PROVIDED-0 THE WELL OWNER
SIGNATLREOFPERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality, Groundwnter Section, 1636 tMailService Center -Raleigh, NC -
-
27699.1636 Phonc No. [phone], within 30 days.
- - OW -I REV. 07/2001
o
(� ULJ

293970
WELL CONSTRUCTION RECORD
Noi t'n Carolina - Dcpartment of Environment and Natural Resources -Dv is ion of Water Quality •Groundwater Section
WELLCONTRACI'OR(INDIVIDUAL)NA,NIE (prlo Mitchell D. 000k CERTIF1C'A1'ION q 2o43
WELLCOtV'I'ReI CTORCOMPANYNA�YIE ±;i'Ct '9 P,P_l). Ei7�-L7?r ZC - PHo,VBk 829) 364-5591
s"rATE 7YELL Co,NSTRUCTION PERMIT# ASSOCIATED WQ PER,VII74
(if applicable) - (if apcli<ahle)- - '
I, WELL USE (ChecKApplicable Box): Residential 6 Municipal/Public ❑. Industrial ❑.. Agricultural ❑
Monitorin; ❑ Recovery ❑ Heat Pump Water lniection ❑ Other ❑ If Other, List Use
2WELL LOCATIO Topographic/Land setting
Nea gsi own: County� ❑Rld;e OSlope ❑Valley ❑Flat
{�// (check appropriate'ooa)
eet
(StrNome,Nwrloccr,,C�,o_m_munnity^, Subdivision, Lot No., Zip Code) La LP�de/:on�ilude of well location
3. OWNER' ' I�CLf /1�G�S���XL� (de�rea,irmiaes/second)
Address PQ (�,t'3Jj JL 3qQ Latitudsrl ngitude source:❑GPS❑Topegraphic m2p
(jtrnees or Route No (cheek boa)
�7
f p , Mir. �R 73 (40 DEPTH -DRILLING LOG
Cl.y orT rn str- Zip Code From Formation, Description
( � a
Area o" . Phonewninter
4 DATE DRILLED
TOTAL DEPTH. OO
6 DOES WELL RBPL.ACE EXISTING WELL? YES ❑ NO
_
7 STATIC WATER LEVEL Below Top of Casing 100 FT.
(Use"," if AbcYe Top o. Cash;)
8, TOP OF CASING IS 2 FT, Above Land Surface*
•Top or cash; terminated aVor below land surface requires a
variance In accordance Ith ISA NCAC 2C,0118• -
9. YIELD (gpm): _ MET 'OD OF TEST blow
10, WATER ZONES (depth): a [�—
LOCATION SKETCH
11, DISINFECTION: Type H T H Amount 1 EDz-'. - Show direction and distance in miles from at leas;
12, CASING: Wall Thickness two State Roads or County Roads. Include the road
Depth _ jt Diamaler or We:ght/Ft. Material numbers and common road namesr
From 0 To Ft.
From - ,o Ft.
C-.
x
Fro in To Ft. - -�
13, GROUT: Depth Material Method
a I
From 0 To 20 Ftbte & m+. tznced -�
From To Ft I
c
Ia,SCREEN: Depth .Diameter Slot Size : Material �mE
r^•
From To :Ft.in. in.
-From ToFt.—in, — in,
15 SAND/GRAVEL FACK: w
m
Depth Size - Material.
-From To Ft. —
From —To Ft.
I
16 REMARKS: I r
-
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15ANCAC 2C, WELL
CONSTRUC i ION STANDARDS, A 'AJ A COPY OF THIS oC0 BEEN PROVIDED 70 T(Hn�- WEL/LJ 0WNFj,
_
/jHfJAtS
SIGNATURE OF PERSON CON TRUCTING THE WELL DATE
'
o
-. Submit the original to the Division of Water Quality, Groundwater Section, 1636,NIoil Service Center -Raleigh, N:Cr,
0
-�
,-i
27699-I636 Phcno No. [phone], within 30 days. GW-I REV. 0,/1Gq�L i

WELL CONSTRUCTION RECORD 2939C9
North Carolina • D cartment of Environment and Natural Resources • Division cf Water Quality • Groundwater SIction
YYELLCOiNTRACI'OR(hNDIVIDLIAL)NA,N!E (print) MitChell D. COOK CERTIFICATIOINk___ZLd3
1YELLCON'I'RACTORC06lPANYNA,NIE 21). a-iLL1 , im PHONE k e29) 369-9591
s'rATE 1v ELL CONSTRUCTION PERNIITe ASSOCIATED WQ PERM74
- (if apclicable) (if applicable)
L WELL USE (Check Applicable Box): Residential 6 Municipal/Public ❑ Industrial ❑ ` Agricultural ❑
Monitoring ❑ Recovery ❑ Heat Pump Water Injection ❑ --Other ❑ li'Other, List Use
2, WELL LOCATI Topographic/Lanasetting
Nzarc tTow "Coun❑Ridge ❑Slope ❑ ❑Flat
aLi✓V r'�(d_1i6 (cntat opprcpria!CCox)
(Stree: Nnmt, Numbers, Community, SubdivisiiQn�,�Lot Nc., Zip Code) Latitude/lonPltud9 Of Well location
3.t
. 0WNa'R: Lk I / l 'a--�� (des-to/minutes/se anCs)
,Addi,ss K 7�U0 Latitud rlen,;itude source,❑GPS❑Topaeraphic mup
($treN er out �N ) �7 (check bar)
Ay�pp 10. lV� 9R /367 - DEPTH DRILLING LOG
City or t wn t r. Z'o Code - From o Formation Description
Area c d - Phone mmlber r r 'QI'an.lte
4. DATE DRILLED 2' 30-00
5, TOTAL DEPTH: � M(
6. DOES WELL REPLACE EXlST(NG WELL? YES N'0 ❑
7. STA1'ICWATER LEVEL Be,owT000fCasin3 FT,
(Use', if Above To; ofcasing)
8 TOP OF CASING IS 2 FT. Above Land Surfa:e'
-Top or casing terminated avor below Iand rarface requires e
variance In accordance Ith 15A NCAC 3C .0115,'
9. YIELD (gpm) 0( METHOD� = TEST blow _
10 WATER ZONES (depth): %EJO r
LOCATION SKETCH
11, DISINFECTION' Type H T H - Amount 1 6oz Show direction and distance in miles tloin at least
12. CASING' Wali Thickness : two State Roads or County Roads Include the road
Depth "- D'am•1er or Waght/FL Material numbers and common road names.
.From-0—To Ft. 1r
From To Ft.-
From— - To Ft. o
13. GROUT: Depth, Material - Method _ 2 C1
'. From 0 To 20 FtbEtnLte &Ott _arm - ci
From To Ft. s or
14. 5CRE EN: Depth Diameter Slot Size Material
From To Ft. —in. in v m
From - To - Ft. —in, in.
15, SAND,/GRAVEL PACK: L? Na
Depth Size Matrrial r '�
From To Ft. -
From —To— Ft. z
16. REMARKS:
i
1 DO HERESY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND T T�A�COPY OF THIS °CORD HAS BEEN PROVIDED TO THE WELL OWNER
SI NATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mall Sorvice Center- Ralelgh, NC
27699.1636 Phonc No. [phone], within 30 days, - GW•1 REV, 07/2001
0
sv
.R
ul"

293968
- WELL CONSTRUCTION RECORD
Nett Carolina • D. pnrtreni of Environment and Natural Resources • Division of Water Quality • Groundwater Section
WELL CONTRACTOR(IVD141DUAL)NAME �prinl) PiitChell D, CookCERTIFICATION k—IL3
WELL CONTRACTOR COiYtPANY NAME� HR:FM ErCtl'G254,P�1. tri)1:'ri,. I PHONE [phone]
STATE WELL CCA'STRUCTIOiN PERMITN ASSOCIATED WQ PERMITM
- - �(ifavulicable).. - (ifapollcable)
1. WELL USE (Check Applicable Box): Residential d Municipal/Public 0 Industrial ❑ Agricultural ❑
Monitoring ❑ Recovery ❑ Heat Pump Water Injection ❑ -Other ❑ If Other, List Use
2 WELL LOCATIO j Topographic/Land setting
Nea- stow : County
❑Ridge ❑Slope .❑Valley ❑Flat
lV (check appropriie box)
(Sir Name, Nuinbers, Cemmu t , SAdlviaion, Lot No.. Zip Code) Latitude/longitude of well location
J. 'OWN ER: . (degr:ailminGt<ih «onL{)
,
Addresa. Laeirada'longitudesource:❑GPSC7Topographicmcp
(Street r cute No.) (check box)
jj BInI C DEPTH DRILLING LOG
Q� �City �]or Town State Zip Code From Formation Description
077' n i
(�'aPh93
' Are: cod: Phone numbr � y �granite
4, DATE DRILLED
5. TOTAL DEPTH:. '
6, DOES WELL REPLACE EXISTING WELL? YES NO ❑
7 STATIC WATER LEVEL Below Top of Casing: FT.
. (Use"," If Abcve Top. cf Casing)
8, TOP OF CASING IS 2 FT, Above Land Surface•
'Top creasing terminated aver belowland surface require, a
- < variance In accordance with IJA NCAC 2C.0118 -
9, YIELD (gpm): -,;?I)_ METHOD OF TEST blow
10, WATER ZONES (depth): ` e%0'�
LOCATION SKETCH
11, DISINFECTION Type H T ti Amount 166z Show direction and distance in miles ttom at least
12, CASING: Thickness two State Roads or County Roads, Include the road
.
'Wall
peptn ` ` Diatr)er or Wei; i/Ft material numbers and oommor, road names o
From To a Ft.�
0
From To Ft. a
•� From'. To _ , Ft _ ...
13 GROUT: Depth Material Method
From n Tom_ Ftk�te d css t cu rl
From To FL
f4: SCREEN: Depth -. Diameter Slot Size Material,'
From in. ca
—To—Ft,—in.
From To Ft. —in. _ in. r
—
IS: SAND/GRAVEL PACK: w
-
Depth Size Material
From To Ft. —
From —To— Ft.
i
----..---
16 REMARKS:
IRO HERESY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE,WITH I5A NCAC JC,. WELL
CONSTRUCTION STAN D,4R ,AND THAT A COPYA THIS RECORD HAS BEEN PROVIDED 70 7HE WELL 01V'NER
SICNA URE O.-PERSON CONSTRUCTING THE WELL DATE
Submit theoriginalto the Divlsion of Water Qunlity, Groundwater Section, 1636 Mall Service Center • Raleleh, NC
27699.1636 Phone No. [phone], within 30 days. GW•I REV. 09/2001
_
..
1

293967
WELL CONSTRUCTION' RECORD
North Cnrclma • Department of Environment and Natural Resources - Division of Water Qua;Ity • Groundwater Section
1VELLCONMkCTOR(INDIVIDUAL)NAME �prinp h�tchell D. Cook CERTIFICA71OV42043
1Y'ELLCON'IRr\CTORCObtPANYNAhIE MB:FM Br&jms Yi2�l i�"Ililttmr .' PHONE # [phone]�
-
s,rATE WELL CONSTRUCTION PERMITq �ASSOCIA7ED WQ PERMITS
-
(ifaoulicable) - (ifavolicable)- -
' I; WELL USE (Che.k Applicable Box): Residential 0 Municipal/Public ❑ : -Industrial ❑ Agricultural ❑
- Monitoring. ❑ Recovery ❑ Heat Pump Water Injection ❑ - -Other -❑ If Other, List Use' -
2 WELL LOCATI Topographic/Lind setting
Neares sown: County_�_tZt_GIEiO Jh _/ ❑Ridge ❑Slope ❑Valley ❑Flat
E-3-- (check appropriate box)
(Street Name, Numbers, Community, Subdivision, Loi/No., Zip Latitude/longitude of well location
�(Coocee),� `
3 GWNER L/K-(///lLi! 8%
Address - 7�o. ici' .O Latitude/fcn,i de sours ❑GPS❑Topographic mup
p (�Slree�e of Route ho) / (check box)
_�.��L. DEPTH DRILLING LCG
Cray o-T n Stae - Zip CoEe From Ta , -Lion Description
(4}) ,0 f1�`,ZZ3 0
9S�) 7 clay & Sri
clay
Are: cod Pharr number -7,15-1
e 'CiidIl.ltt?
4. DATE DRILLED %
5. TOTAL DEFTH:
6 DOES WELL REPLACE EXISTING WELL? YES ❑ 0 11
7. STATIC WATER LEVEL 6e1cw Top of Casing' �FT. _
. - (Uaa •'•" If Aocv: Top of Casing) '..
_.
8 TO? OF CASING IS 2 FT. Above Land Surface•
'Top of easing terminated XI/or below land surface req Wrefa _
varlanee In accordance with I,7A NCAC 3C,0118,
9, YIELD IS Pm) McT 0r 6FrTEST blow
10, WATER YC7
ZONES (depth): _�
LOCATION SKETCH
11. DISINFECTION: Type H T H Amount 16oz " Show direction and distance in miles from at least
12, CASING Wall Thickness two State Roads or County Roads. Include the road
Depth Dia^.e!dr or We:ght/Fl. Material .. numbers and common road names. O
From_0 To r Y
Ft. r
o
From To" Fs.
'. From.. To Ft..
c>�
='
...
13 ORGUT'.- Depth ... Material Method
ir±_t
Prom n To 20 Ftka'n 4te & Ca87st otrTca3 t
w
r'
'FromTo Ft..
_yr
14. SCREEN. Depth '. Diameter Slot Size Material - 3
From To Ft. in.
From To Ft. in. In.
c
IS SAND/GRAVEL PACK -r
Depth `.Siz: - Material -
z
From To Ft.-
From— - To`- Ft.
16 REMARKS
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE,W1TH 15A NCAC 2C,: WELL
.CONSTRUCTION STANDARDS AND THAT A COPY OF T RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SICt ATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the onQlnnl to the Divlslon or water Quality, Ground+vnter Section, 1636 Mall Sorvlee Center •Ralelith, NC
-.
27699.1636 Phone No..[phone], within 30.days. GWI REV. 07/2001
4 = -

293966
WELL CONSTRUCTION'RECORD
North Catollna • Dooartment of Environment and Natural Resources • Division of Water Qua!ity,- Groundwater Section
IYELLCONTRdC1'OR(liNDIVIDUAL)NANIE (print)'b tCheil D,'COOk CERTIEICATIONd 2043
WELL CONTRACTOR COMPANY tNAME. F3:bM Fz:t1� 401 nrUi =, I= -. PF{o:vE � E29) 369-9591
-- s'rATE WELL CONSTRUCTION PERMITO �ASSOC1ATE D WQ PERMIT#
(ifaooli<abla) - `(ifabclicablel
WELL USE (Check Applicable Box): Residential 0 Municipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring ❑ Recovery ❑ Heat Pump Water lnjection ❑ Other ❑ If Other, List Use
2 WELL LOCATION' Topographic/Land se;t.ng
Neares( n County ❑Ridge ❑Slope ❑Valley ❑Flat
(chedkapp Fopriate'oox)
(Sheer. Nnme,.NL nSers, Community, S%odivisron, Lot No., Zip Code) Latltude/longitude of Well location _
J OWNER
(Ide^art<5/u nlilea.h rondi)
Addres - Lat •udc/fonyitu e source OOPS❑Topographic I
(Street or Route No.) - (0eck:at)
tL%r mH Q�/� DEPTH DRIL IN^v
O
(v , fity orT yy,/ -6Str �— zip code From T / Formation Description
{pf[) 7
& �13
enu.�
. AreaDA Phonmber clay QT3.'lite
'
DATE ,`�Qb'
4. TEE DRILLED•
S, TOTAL DEPTH: f
6, DOES WELL REPLACE EXISTING WELL? YES ❑
7, STATIC WATER LEVEL 6elowTop of Casing;
; --
(Use ."It Abcva To, c(Casir B)
8, TOP OF CASING IS 2 FT. Above Land Surface'
*Top orcasin8 terminated atlor below land surface requires a
varlance In accordance wi h ISA NCAC SC.0118,
9, YIELD (gpm): _ ' MET Y.OD OF TEST blow
10. WAT E R ZON ES (dip th) %i10
LOCATION SKETCH
? 111. DISINFECTION: Type H T li Amount 1 60'Z Show direction and distance in miles from a! least
12 CASING Wall Thickness two State Roads or County Roads. Include the
.-
roado
m
Depth . Dta /tier or WaghUFt. Material numbers and common.road names,
- CD
From 0 To --%I
From - To" Ft.
.. -..FromTo Ft.
13. GROUT: Depth Material Methodc
o
From n To 20 FtkelTil E & cagTt an7
From - To' Ft.
f4 SCREEN Depth Diameter. Slot Size Material
From - To Ft. —in. in.
From_ To_ To.' Ft. in, in.
13.. SAND/GRAVEL PACK
oC
..Depth Size - Material.
,From To Ft. —
Fro mTo' Ft.
16 REMARKS
- —
I DO HEREBY CERTIFY THA t THIS WELL WAS CONSTRUCTED INACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCT $TA D,4R S, AND THAT 'FjOPY 0THIS R4CORD HAS BEEN PROVIDED TO TH�y�YLL OWNER
i, r 1
_
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to -the DIVIdiOn of Water Quality, Gro'andwnIer Section, 1636 Mall Sarvlce Center-Ralelgh, NC
27699.M6
Phonc No,.[phone], Within 30.days. ow -I REV. 07/2001
.
L =:-

293965
WELL CONSTRUCTION' RECORD
North'Cirolina • Ocpartmenl of Environment and Natural Resources - Division of Water Quality • Groundwater Section
WELLCOiNTRAC1'OR(lND:VIDUAL)NAh1E (print) �LitCh21_I D, Cook CERTIFICATf01Vq 3
WELL CONTRACTOR COMPANY NAME H9±3en hE"' G l a:!. ii•Tr im . P-,ion M 829) Mq-qrq�
STATE WELL COi\'STRUCTION PERM1II7d ASSOC/1TED WQ PERNIITB
(ifauulidaole) - ,
'(ifa olibable)
I WELL USE (Check Applicable Box): Residential Municipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring ❑ Re overt' ❑ Heat Pump Water Injection ❑
-Other ❑ ffOthe;, List Use'
2 WELL LOCATION
Ne'are Iown: y
County
Topographic/Land settling
❑Ridge ❑Slope ❑Valley ❑Flat
sires Nm,t,Num t;,Coinmuni Subdivision, Lo Jo.,zipeode)
.. (check appropriate box)
Latitude/longitude¢fwell location
3. OWNER.
Address
(deg:eu/inmukih«Dods)
, (Suee•o'}Rcufeho)
i /I
Latitude/fongrtuae sourc ❑O?$❑Topographic mup
///�
J n�� �r1 �� /
(�Iwcktax)
-G�P
r�,nCityo-TT fe Zip Code
(lGd) �7
DEPTH DRILLING LO^
From T Fcrmation Description
n pl:en
. Area code .•Phom nwnber
nb
c1a� &
4 DATE DRILLED
Qr crranite
6 TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? YES ❑ N0
7, STATIC WATER LEVEL Below Top of Casing: FT:
--
.. . (Use To, cf Cas rg) '
a: TOP OF CASING IS 2 FT, Above Lad Surface*
-Top of gaing terminated at/or below land surface requlres a
variant, in accordari with I5A NCAC 2C,0119,--
9, YIELD (gpm): _METE+rrOp OFITEST blow
10 WATER ZONES (depth): / �S
—
11, DISINFECTION: Type H T H Amount 1 60'Z
LOCATION SKETCH
Show direction; and distance in miles ronl at least
12 CASING Wall Thickness
two State Roads or County Roads, nclude the read CS
Depth Diameser of WeeghVFt. Material
numbers and common road names.
From: ToFt._
3
From To Ft.
From— To Ft._
zz:`
13 GROUT: Depth Material Method
t
w
From n To 20 Fti e727ite & Ca at
From _ To , Ft:
- -r
14 SCREEN Depth Diameter - Slot Size Mate•�al
W
From To Ft. -_in. in.
r
' From To FL'_in, -in.
w
13.. SAND/GRAVEL PACK:
Depth ` Sze :Material .
From To - Ft.
—
From —To— Ft:
I4. REMARKS
FDO HEREBY'CERTIFY THAT THIS WELL WAS CONSTRUCTED !N ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUC ON STAND,ARDE AND THATA OPY OF HIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
DATE i
Submit the
27699.1636 Phone No [phone], within 30 days,
original to the Division Of Water Quality, Orour,dwnter Section, 1636,VIai! Sdrvlce Centtr-Aa!aeh, NC
GW-I REV. 07/2001
n'r L
c
CD

WELL CONSTRUCTION RECORD 2939FA
North Carolina • Dcpartnert of Environment and Natural Resources • Division of Water Quality • Groundwater Section
WELL COINTRAUOR(INDWIDUAL)NANIE (print) �Utchell D. Cook CER'TIFICATION �___ZL43
WELLCON'fRr\CTOR C05lPANYivAIYIE- itKLB'1 F}. �5 P;e!1 Ii•11Lr , ?r-C PHONE. A �231 360-9591
- S'rATE WELL CONSTRUCTION PER61ITk ASSOCIATED WQ PERN1179 -
- (Ifacolicable) - '(ifaoplicable) - -
1.
WELL USE (Check Applicable Box): Residential 6 Municipal/FubHc 0 .Indllstral ❑ Agricultural ❑
Monitoring ❑ Re. y ❑ Heat Pump Water Injection ❑ Other I170ther, Lis: Use
2 WEI.LLOCATIOCf Topographic/Land setting
Nearest'ow CounlY-�l ❑Ridge ❑Slope ❑Valley ❑Flat
Ole /in (checkappropriuebax)
(Street Nnme,.Numbc:ss,Comrunity, rSubdivvi(sion, Lot No., Zip Code)Latitude/longitude Of Well location -
3 OWNERy►APd �A�OD/�irrrDw decree!m,nutea!sronds)
'.Address-^/ 03 'kP,Qld - Latitude/fongimdesource:❑GPS❑Topagraphicmep
1,q r< or.Roule tio) (check boa)
7/1�ilt,lPJy'224 /V C DEPTH DRILLING LOG
nyorra�yn Stat< Zip Code From Formation Description
(�> n=be- r�'J clay &
- Area o:d P6mm mm�be• � r - �CR•3Ll1tE
4 DATE DRILLED:-71-00
6 TOTAL D°FTH:
6, DOES WELL REPLACE EXISTING WELL? YES ❑ NO 71
7, STA'rIC WATER LEVEL EelowTop of Casing FT: -- _
(Use it A'ocrn Top o`Casm3) '.
8 TOP OF CASING IS 2 FT. Above Land Surface*
-Top orcaslnq terminated at/or below land surface requires a
Variance In eecordsnc Ith ISA NCAClC,0118
9. YIELD (gpm): METHOD OF TEST blow
10. WATER ZONES (depth):
LOCATION SKETCH
11.DISINFECTION: Type H T H Amount 16oiz Show direction, and distance in miles front a: least
12 CASING Wall Thickness two State Roads or County Roads. Include tee road
Depths «� Pia-clefor Wei;hl/Ft. Material numbers and common read names.
From O To U(J Ft. t0!P.
From To" Ft.
From To Ft.'
13 GROUT Depth Material Method Or
From n To_Q_ lot}�'a1{,te & Ce:sTt
From To - Fl:
14: SCREEN. Depth Diameter Slot Size Material `.
'From To Ft.... —in. in.
From To Ft. in, —' in. '
IS..SAND/GRAVELFACK =�
Depth Size Material
From To FL rna
r
From To' Ft, ca o
I6 .RENIARKS.
_ r
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE, WITH. 15A.NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECQR.D HAS BEEN PROVIDED TO THE WELL OWNER I i
SIGNATURE OF rKSON CONSTRUCTING THE WELL DATE
Submit the original to the Divlslon of Water-Qunlity, Groundwater Section, 1636 Niaii 5orVlce Center -Raleigh, NC
21699.1636 Pho!lo No, (919) 733J 221, within 30 days. : - GW-I REV,, 07/2001 - �-�

WELL CONSTRUCTION RECORD
Nort'r, Cirollna • Dopartnent of Environment and Natural Resources - DMSIOn of Water Qua:ity • Groundwater Section
1VEL000NTRdC1'OR(hVpNIDUAL)NAhlE (print) hLtChell D, Cook CERTIFICATIOtVd 08
WELL CONTRACTOR COMPANY NA@IE $ '�F f2-ill,rs, PHONE.A 628) 369-9591
STATE WELL CONSTRUC710N PERN1170 �ASSOCI47ED WQ PERiYtITM
1. WELL USE (Check Applicable Bex)i Residential 3 Municipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring O Recovery ❑ Heat Pump Water Injection ❑ -Other'❑ If Other, List Use
,
2 WELL LOCATIJ N Topog.aphic/Land setting
Ne stTown; ounty ❑Ridge ❑SICce ❑Valley ❑Flat
.. (chrk �pprcpriatc box)
(Street Name, Numbcfs, emmunity, Subdivision, Lot No., Zip Code) Latitude/Iongltud- o well location -
-
3 OWNER,e,•ri/n ,ulei/seconds)
Addre
i��-
s source OOPS❑Topographic mup
aSlreel v cuts a n ./ (chwk Eon)
� iXR�I / DEPTH DRILLING LOG
tyorT 5 at 2 p Code - From T f Formation Description
7�Inumber r3 0 �cr a i
- Arez<ad Phone number '�' ..gran.ite
4. DATEP LEE)
:.TOTAL'DEL'DEPTH:.
6 DOES WELL REPLACE EXISTING WELL? YES ❑ NO ❑
_
7. STATIC WATER LEVEL Below Top of Casing: FT. -
(Use "+" if A'cave Top. of Casing)
8: TO? OF CASING IS 2 FT. Above Land Surface'
'Tap of casing terminated actor blow land surface requires a .
variance in ac<ordan< Ith ISA NCAC 2C .0113,
9. YIELD(gpm): g2 METHOD OF TEST HOW _
10 WATER ZONES depth):
LOCATION SKETCH
III DISINFECTION: Type H T H Amount 1602 ' Show direction and dis!aace in miles from at least ,
12. CASING: Wall Thickness two State Roads or County Roads,Include the road
Depth Dia Iar or Wet hUFt. Material numbers and corru on road names,
p g
From 0 To oc!/ Ft. LP_
C
o Frm To . Ft
' O
• '..From.... To Ft._
13 GROUT Depth Material Method - -:
n-71
From_ 0 To---20 Ftb&'&Q4te & o3stt mznzel
From To Fi: t
,.•.t4: SCREEN i7ep1h Diameter SlotSrzehlatenal w
=>
From To Ft. —in. in.
From To Ft. in, in.
11, SAND/GRAVEL PACK to
C'ccc
Depth -' Size Material
From Ft.
—To—
From To' Ft:
z
16 REMARKS
r
fDOHEREBYCERTIFYTHAT THiSWELL WAS CONSTRUCTED IN, ACCORDANCE WITHISA.N'CAC2C,WELL
CONSTRVCTION STANDARDS AND THAT A COPY OF THIS ORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF15ERSONCONSTRUCTING THE WELL DATE
i
Submit the original to the Division of Water Quality, Groundwater Section, 1636 ,Mall Servlce Center-Ralelih, NC
27 699 .1636 Phone No [phone], within 3Q.days• G4V•1 RE.V 0i/2001
-
Lam:
I G;f;�
_

WELL CONSTRUCTION'RECORD 293962
Nort; Carolina • Deportment of Environment and Natural Resources - Division of Wate• Quality • Groundwater Section
SYELL' CONTRACTOR (INDIVIDUAL)NANIE.Iprmt) Mitchell D. Cook - ,CERTIEICATION420,13
WELL CONTSACTOR COMPANY NAME FS:FM $�'�51',�)l. QZ111iK;'r ITC PHONE k 625) 369-9591 -
S'rATE WELLCONSTRUCTIONPERMIT#ASSOCIATED WQ PERNIITel _
(ifaoUlicable) - - (ifabplicable)-
I.
WELL USE (Check Appjicablo Box): Residential 6 MunicipaVPublic ❑ Industrial ❑ Agricultural ❑
Monitoring ❑ Recovery ❑ Heat Pump Water injection ❑
Other ❑ If Other, List Use
' 2
WEI.L LOCATIO t1
t✓
Topograoht /Land setting I'.
NearAeq�� sL�owAn; County 7({[�(�K�
❑Ridge ❑Slope ❑Valley ❑Flat
�-
YlVIyjZfjli
(check appropriate box) _
fstrw Nmne,. mnbers, Community, Subdivision, Lot No., Zip Code)
Latitude/longitude of well location.
DOWNER;
3.
—
(Ce;;reei/u.im;led/srond;)
Address A
Lautud:/tongitude source❑OPSOTopographic map
nn,,,,, II ISo ee er cutV�N,y ) , /
(check boa)
(�I,fNGt (.A/y, /UC- o�-I/
DE"PTT DRILLING LOG
tyar To , 35 , Zip Code
Is 7 3 lap:l
From a Formation Description
0 & SE773
4,
Area code. Ptioue number„n_ _
DATE DRILLED 7
Crranite
5.
TOTAL DEPTH:
6
DOES WELL REPLACE EXISTING WELL? YES ❑ NO
7,
STATIC WATER LEVEL Below Top of Casing: a'5n FT
-
- (Use "+" If Above Top. of Casiq)
-
8,
TOP OF CASING IS 2 FT. Above Land Surface`
'TOP of casln Q. terminated wor below land surface require a
.....
-.
varlanceto accordance l;h I SA NCAC 2C,0 I I&
--
9.
YIELD (gpm): METHOD 9F TEST blow
_
10,
WATER ZONES (depth):
LOCATION SKETCH
11,
DISINFECTION: Type H T Fi Amount 160Z
Show direction, and distance in miles from at least ,
[2.
CASING Wall Thickness
two State Roads or County Roads. Include the road
Depth Diameter or We.ghi/Ft. Material
-.. numbers and common road names.
From" O To Ft, 0o
c4
From To Ft.— - -
p
From To Ft.'
_
13 :GROUT. Depth. Material Method
�_
:;
From n To 20 Ftka'a'1!te & mrm 0.n i
From To Ft:
"
e
w
u—
14. SCREEN. Depth Diameter Slot Sae Material
Y^
:.. From To' Ft. —in, in. ... -
3:X
From : To Ft_in, in,
w
n
LS SAND/GRAVEL FACK '
(-
Depth Sae Material
From To FL
w
z
From To Ft:
.16L RENITRKS
-
r
)
: I DO KSREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED I N ACCORDANCE. WITH I5A NCAC 2C, WELL
-
CONSTRUC7IONSTANDARDS AND THAT ACOPY OF THIS RPCORD HAS BEEN PROVIDED TO THE WELL OWNER'
S:CN ATU E OF PERSON CONSTRUCTING THE WELL DATE
Submit the orilinnl to the Divlsion of Water Qunlity, Groundevnter Section, 1636 tN1allServlce Center -Raleigh, NC
27699.1636 Phano No. [phone], within 30 :days. GW-1 REV. 07/2C;C1 '

WELL CONSTRUCTION RECORD 293960
North Carolina - Dcpar,ment of Environment and Natural Resources - Division of Water Quality • G•ourtdwater Section
IYELLCOiNTRACTOR(INDlYIDUAL)NAME (print) Mitchell"D. Cook CERTIFICA7I0INk--U-43
WELL COtVTRACTOR COMPANY NAME n31 •h='S we-11 aPHONE ,Y 625)
S"FATE WELL CONSTRUCTION PERNT17p ASSOCI',7ED WQ PERMITd
(if aottlicable) (if applicable) -
' 1. WELL USE (Check Applicable Bex)i Residential 6 - Municipal/Public 0 -Industrial ❑ Agricultural ID
Monitoring ❑ Recovery ❑ Hcat Pump Water Injection ❑ -Other ❑ If Other, List Use
2 WELL LOCATIC �
Topographic/Land setting I'
Neares Tpwnt 6��i. County
Gt_�
❑Ridge ❑Slope ❑Valley ❑Flat
s
.. (che:.k appropriate box)
($tree: Name, Numbers, Cc unity, subdivision, Loi No., ZZ''ipCoode))
Latitude/longitude of well location
3. OWNER, �.66d^�
(Jeyreei/mimi;ee/sronCt)
Address - X /.
: Latn;dclYong;tude source.❑OPS❑Topographic map
�J IStreeterRSute„Na) e/
C
eckban)
GnpfO�� /
-1 �0�(.101L4Jf /V
DEPTH DRILLING LOG
aly or Tdwn 41e Zlp code
From a Formation Description
0 L Clay & Era
Area cod Pnone nuinber p
4 DATE DRILLED
, , ..crran.ite
5.TOTALOEFTH: 50f
6 DOES WELL REPLACE EXISTING WELL? YES ❑ NO ❑
7, STATIC WATER LEVEL Eelcw Top of Casing FT.
--
., (Use "=' If A'ocya Top of Cssinp)
S. TOP OF CASING IS 2 FT. Above Land Surface*
-Top of casintI terminated atfor below land surface requlrte a
yarlanca In accordinSjtplth ISA NCAC 2C.0113,
-
9 YIELD (gpm): METHOD OF TEST blow
-
10 WATER ZONES(d:pth,);
LOCATION SKETCH
11, DIS!NFECTION: Type H T H - Amount 1 6oz
Shosv direction and distance in miles from at least -
(2: CASING Wall Thickness
two State Roads or County Roads. Include the road
Depth D; netr or Wei ht/Ft. Mat ;al
From Ko Ft.: / mQ
numbers and common road names.
.
From To" Ft.
From' To - Ft.--,
13 GROUT Depth Material Method
From n e'atLte &
To Fti cBm-a t
M
_=T:ed
From To ,FL
t4: SCREEN. -. Depin '. Diameter Slot Size '. Mate?al
From— To Ft. —in. in.
w
From : To Ft. in, in.
v
SAND/GRAVEL PACK
- `Depth Size Material
w
Frcm To , Ft. —
From —To— Ft.
ry
16 'REMARKS
I DO HEREBY CERTIFY THATTHIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C, WELL
CONSTRUCTION $TAYD 4RD$ AND THAT ACOPY OF THIS CORD HAS BEEN PROVIDED TO THE WELL OWNER
�/1/1�����/
51—GNATURE OF PERSON CONSTRUCTING THE tY DATE
Fir
Submit the originel to the Division of Waler.Quality, Groundwater Section, 1636 ,Mall Sorylce Center - Raleigh, NC —.
27699.1636 P hone No [phone], within 30 days GW-I REV: 07/2001
J

WELL CONSTRUCTION RECORD 293951
North-Cit:olina • Ddpor:ment of Environment and Natural Resources • Division of Water Quality, • Groundwakr Section
1VELLCONTRACTOR (INDIVIDUAL) NAhIE (prim!) PlitCh2Z1 DCCok CERTMCA190,N✓ 43
SVELL CON'r RACTOR COMPANY NAME ald�- 41l.. Ii1.LLL*Y7 TJ= PHONE. p E25) 36}-979)
S rATE 1YELL CONSTRUCTION PERIMITp ASSOCIATED WQ PERNiITp
f auolicaole) f abolioable)
I; WELL USE (Check Applicable Box) Residential MunicipaVPublic ❑ Indastrial ❑ Agricultural ❑
Monitoring. ❑ Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, Lis: Use
2 WELL LOCATI N Topographic/Landse,,,ng
Ned Town: ) County ❑Ridge ❑Slope ❑Valley ❑Flat
(chedkopproprmte'oox) -
(street Nan lumber$, COMM
ity, Subdivision, Lot No., Zip
/Code) Latitude/longitude Of well location .
3 OWNER
v Address —'7�- (daareet/i n,ite>/se<anC>J
od% �h�hio ,C_, Lan .da/ion;ituae source: ❑GPS❑Tcpographic map
(S4zet or Rey+ yo) - (check bon)
v a y L ff .60 t TH DRILLING LOG
(�C .y cr Town state �, Zip Code From To r forma tics Description
.-.�i/e/_) clay& ?3
Area ;ad-. PhonDRILLED
number
4. DATE DRILLED Jn-310­331 QU ' Crranite
5. TOTAL'DEPTH: a'Sr
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO A-
7. STATIC WATER LEVEL Below Top of Casing. .inn FT:
-(Use "✓' it Acave Top. er Casing)
8. TOP OF CASING IS 2 FT. Above Land Surface"
'Top or easing terminated at/or below land surface rqulrn a
variants In actardanc with ISA NCAC SC ,0118,
9. YIELD (gpm): METHOD OF TEST blow
10. WATER ZONES depth)
LOCATION SKETCH
11 DISINFECTION: Type H T N Amount 1602' Show direction and distance in mites front at least
Iz. CASING Wall Thickness two State Roads or County Roads. Inclade the road
Depth Dia mr or Weighi/Ft. "Material numbers and common road na'nes
From_ To_y
From To .. Ft. —
From To Ft. - •G'
13 GROUT: Depth Material Method �^
From 0 To 20 Fdxii=Ltte & ee>3 t and —C �`=
From _ To .Ft
14: SCREEN. Depth Diameter Slot Size Material`
From To Ft. in. in.
�c From To� Ft, in.. n
Z
I5., SAND/GRAVEL PACK: M o
Depth Size Material = -'
From -- To' Ft. —
From —To— Ft:
`T--
r-
16 REMARKS r
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I SA NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RE�HAS BEEN PROVIDED TO THE WELL ONVi ,IER t I V
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the origlnil to the Division of WaterQunlity, Groundwater Section, 1636 t`1311 Sarvlce Center •Ralelgh, NC
27699.1636 Phone Na [phone], wlthtn 30.days
OW•I F V. 0//200;
I

WELL CONSTRUCTION RECORD
2939:10
North Carolina . Department ofEnvirontnent and Natural Resources - Dlvision of waver Quality • GroundwaierSection
1YELCCOIVTRAC1'OR(6VDIVIDUAL)NAhlE Ipritto MdtChLl DO CCOk URTIFICATIOVd2043
)YELL COiV'I'R,\CTOR CONtPAN,Y NAhIE 1ji31}3k 'S %a ao1 , I7r— PHONE. A a2$) 369-959�
STATE WELL CONSTRUCTION PERIMIT# - - ASSOCIATED WQ PERhUTp -
(ifacolicable)` .- - "(ifaooli2able) —
' I; WELL USE {Check Applicable Box)r Residential Municipal/Public ❑ : -.Industrial ❑ . Agricultural ❑
Monitoring. ❑ Recovery ❑ Heal Pump Water Injection ❑ -Other ❑ If Other, List Use'
2 WELLLOCATI I
Topographic/Land setting
Near e
Mown: Count
❑Ridge ❑Slope ❑Valley ❑Flat_
( oj;propnae box)
(Street Nnine,. N'imberf Community, Subdivision, Lot No.. Zip Code) Latitude/lortr;tude of Well location -
3 OWNER-1�-`1-Garin) AVJQ (degrees/mriki/seconds)
Address b
11Latitude/longitude source ❑GPS❑Topographic map
A (Sp Oct er Rq°�+te �No
(check boa)n��DEPTH
DRILLING LOG
City T w t^ e. Zip Code - Fror- For
0 mation Description
. Ares coda Fhone nwnber s'Crian.ite
4. DATE DRILLED.
6.TOTAL DEPTH :
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
7, STATIC WATER LEVEL Below Top of Casing: F _
(Use ',' Ir A'oave Top. of Cis ir7)
S. TOP OF CASING IS 2 FT.Above Land Surface"
-Top ofeislna rorminat
at/or below land surface requlro a
variance In acrordanc
Ith 16A NCAC SC,0118, -
9. YIELD (gpm): �
METHOD OF TEST blow
10, WATER ZONES (epth)
LOCATI0
11. DISINFECTION; Type F T H Amount 1 6oz' Show direction and distance in miles f om at least
12 CASING Wall Thickness two Stale Roads or County:Roads. Include the road
Depth f Di let or WeighM M feria' numbers and corn^ Froon read names,
To Ft
From m
' To Ft.
-From To FL- r
7
�
13 GROUT:Depth Material Method�-
From n _ To 20 Ftba'dtite & CSBt at rt�
From- To FL
---
14 SCREEN Depth Diahuter Slot Size M1later.al W
CD
n`
From To 'F(._in. in.
From To Ft in,
�u
a6 'SAND/GRAV'eL PACK
N--
Depth Size Mate -fa;
From To' Ft.
—
From —To— - FL
I6. REMARKS:
I-
)DO, HERESY CERTIFY THAT THIS WELL WAS CONSTRUCTED INACCORDANCE.WITH 15A.NCAC 2C,'A-LL
CONSTRUCTION STAND.4RD5 AND THAT COPY OF THIS RECORD
L
�
HAS BEEN PROVIDED TO TH° WELL OWNER
SIGNATURE OF P.,RSON CONSTRUCTING THE WELL DATE
Submit the original to the Diylslon of Water Qunlity, Groundwnter Section, 1636 tNleil Sorvlce Center -Raleigh, INC
27699.1636 Phone No. [phone],
within 3Q.days, - OW-1 FiE.V. Oi/?OO,I
-.

22''91
WELL CONSTRUCTION RECORD
North Carolina • Dcoarimerd of Environment and Natural Resources -Div is ion of Water Quality - Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME (print) hLtfteil D. Cco,k CERTIFICATIO1N# 2043
WELL CON'I'Rr\CTOR COMPANY NA hIE Fb:EM '"B WP11 Q:i11 ram, TrG PHONE 9 628) M9-959�
STATE 1VELL CONSTRUCTION PERMIT# ASSOCIATED WQ Pf RMIT4
- (ifaoolicable) (irabolicable)
1. WELL USE (Check Applicable Box): Residential 0 Municipal/Public ❑ .Industrial 0.-- Agricultural ❑
" Monitoring ❑ Recovery ❑ Heat Pump Waver Injectionn ❑ _ Other ❑ HOther, Lis: Use
2, WELL LOCATION: I
Topographic/Land s tine
(
Neares�town:,Q, County�`� �' ❑Ridge ❑Slope ❑Valley ❑Flat
I
.e 4/hA C _ (check app opiat: box;
fSveat Naine,.Nmnber Communi y, Subdivision, Lot No., Zip Code) Latitude/lonsuude of well location
3.OWNER: (degrees/mlmitesheoonds)
- Addioss - Latinide%longitude source ❑GPS❑'epegraphic map
(atgreet or Route No.) (check box)
1/o/
/2LQA y/ NC, S DEPTH DRILLING LOG
yT Zipeode From To FormationDescription
�s ?
nael.' 0 C13V & sat-d
Are-, code Phone nu,nSer qqqq - -3 1 Q crran.ite
4 DATE
S,TOTALDEPTH: �
DEPTH:
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO }p
7. STATIC WATER LEVEL Below Top ofCasing: F --
(Use "," it A'oove Top of Casing)
- 8. TOP OF CASING IS 2 FT. Above Land Surface`
-Top of casing terminated at/or below land surface requires a
varlance In accordancWth ISA NCAC 2C.0118
9. YIELD (gpm): V2 METHOD OF TEST blow
10, WATER ZONES (deolh):
LOCATION SKETCH
I l DISINFECTION: Type H T H Amount 16Oz Show direction and distance in miles from at least
12, CASING: Wall Thickness two State Roads or County Roads Include ire road
Depth �;, Di me/ r or WeighVFt. Material numbers and common road names
Co
PicFrom �_ To . .) Ft. _ o
-.From To Ft.-
- 7C
" . From To Ft.'..
a
c'
off:
13, GROUT: Depth Material Method
`. r-i
.From n.. To. 20 Ftk�:te & tom+
<
ca
.'From - To Ft.
➢o
- 14. SCREEN: Depth Diameter Slot Size : Material- -- 3
r_7.
From To Ft.- in. in.
c„=7
From To Ft in, in.
15, SAND/GRAVEL PACK: t—
y
" Depth Size Material
"From - To Ft.
'From - To Ft.
16 REMARKS:
i
DO 1 REBY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
ONST N STIFY 16A NCAC 2C, WELL
CONSTRUCTION STAND4RDSA�N/D THAT OF TiRECORD HAS BEEN PROVIDED TO THE W:LL OWN ER j
yA�COPY
� � asas
S GNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality, Groundwnter Section, 1636 Mall Serviee Center -Raleigh, NC
_
27699.1636 Photo No. (919) 733•3221, within 30 days. -
- OW-! REV: G'7/3GG1
i -

293944
WELL CONSTRUCTION RECORD
North Carolina - Debirtment of Environment and Natural Resources- Division of Water Quality - Groundwater Section
WELL COiNTRdCTOR(INDIVIDUAL)NAN!E (print) MitChell D. Cook CERTIFICATIO)Nq2043
NYELL CO•N'IRACTOR COMPANY iNAME Hii:bm Rr&�T5 FaLl prjLja -C, PHONE p 828) 369-9591
s'rATE YVELL COINSTRUC7101N PERhtITO - ASSOCIATED YYQ P"e RN117M
(if auolicable; - (ifaocli<ablej -
I. WELL USE (Check App!!cable Box): Residential ® Municipal/Public❑ .Industrial ❑-. Agricultural ❑
_ Monitoring ❑ Recovery ❑ Heat Pump Water Injection ❑ Other ❑ II'Other, List Use
2, WELL LOCATIO,'. Topographic/Land se tine
Nea
tToyn Count ❑Ridge ❑Slope ❑Valley ❑Flat
(check appropriate box)
(5(••N�um�b/er�s�Cmninunniily, Subdi ion, LoIN Zip Ccda) Latitude/longitude of well location
3. o4a4ER: �i b///air /J
(d-irmhmi no I es/seconds)
Add ias; L _� La,mide/lowitude source 1GPS1Tcpognphi, mup
S.reet r RoutNo) (check boa)
�� 0�� ' 6)q DEPTH DRILLING LOG
yorTgr Sw Zip Code From r Formation Description
( Clay & Saril
Phone number ' � 'CR'anite
. DATEE DADRILLED
aDATE
S TOTAL DEPTH
6 DOES WELL REPLACE EXISTING WELL? YES ❑ NO
7. STATIC WATER LEVEL Below Top of Casing:
- (Use"+•• if A'oove Top of Casing)
S. TOP OF CASING IS 2 FT, . Above Land SLrface'
-Top of casing terminated at;or below land surface requires a
varlance In accordance Ith IS.A NCAC 2C.0118,
9. YIELD (spm): 4 METHOD OF TEST blow
10 WATER ZONES (ep h):
LOCATION SKETCH
11, DISINFECTION: Type H T H Amount 1 EoZ Show d!rection and distance in miles from a; least -
12. CASING: Wall Thickness two State Roads or County Roads. Include the road
Death - Diar er or We:' ht/Ft. Material numbers and co on road names,-
From ( To 0 Ft, s
From - To Ft
From - To - Ft.
c
3 GROUT: Depth Material Method Or
o
From n To 20 Ftk to & csa t
From To Ft. —G
-
^` '
c
: Id: SCREEN: Dectn Diameter Slot Size Matennl
From To Ft. in. in
ZZ,^
From To Ft in.
✓O
IS, SAND/GRAVEL PACK
Drch Size Material - tq
From To FL -
From, —To— Ft. 4r,
y
16. REMARKS:
I DO HERESY CERTIFY THAT THIS WELL WAS CONSTRUCTED 1N ACCORDANCE WITH, i5ANCAC 2C, WELL
.CONSTRUCTION STANDARDS, AND THAAT/'A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNE
79—
SIGNATURE URE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NiC
27699.1636 Phone No. [phone], within 30 days. �GW-! REV 07/�@p:I. `
L
--

293943
`FELL CONSTRUCTION RECORD
North Ciichna • Department of Environment and Natural Resources • Division of Water Quality -Groundwater Section
iYELLCONTRACTOR (INDiVIDUAL) N,VE (print) Mitchell D. CCi CERTIFICATION q--ZL43
WELL CON'IRACT O R COMPAN Y NAM H3:'fM W_� Li2.11iM 'M PHONE 8 628) 36cii
5'FATE WELL CONSTRUCTION PERMIT% ASSOCIATED W'.Q PERMITF
(ifapolicable) _ _ (ifapoticable)
1, WELL USE (Check Applicable Box): Residential 2; Municipal/Public ❑ .Industrial ❑ Agricultural ❑
Monitoring ❑ Recovery ❑ Heat Pump Water Injection ❑ Other
❑ If Other, List Use
2 WELL L I :
Topographic/Land setting
oCn;
News Town: .C�ffliLCounry
❑Ridge ❑Slope ❑Valley ❑Flat
nE'�,ean /l li.`�11.1n1-7fJ! L�✓�1
tchr-'�app•op'r<oox)
_
Sire t Name, Numbers, cominuniry, Subdivision, Lot No., Zip Code)
Latitude/lort,i a of Well Ioeatlon
3. O WNER:
.(deg;eulu•,Inutes�s<candt)
Address
Latitude/longitude souree,OGPS ❑Topegraphle muo
t ie:t or R04' 'o) -
(check box)
DEPTH DRILLING LOG
oLrTF S at Zlp cede
oC
From To v Formation Description
&
X�)Ily
Am cad Phone nwn6�r
ite
QiBSllt2
4, DATA DRILLED
5 TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? YEJ❑ NO'�
i. STA'rIC WATER LEVEL Below Too of Casing: FT.
(Use "*" if Above Top of Casing)
8 TOP OF CASING IS 2 FT, Above Land Surface^
-Top of using terminated at/or below land surface requires a
varlance In ac<ordanc�ew%t� ISANCAC2C.0118,
blow
9. YIELD (gpm): !1_ METD O�f�TEST
—
10 WATER ZONES (deoth): 9.7
LOCATION SKETCH
I . DISINFECTION; Type H T ti Amount 160z
Show direction and distance in riles from at least
12, CASING: Wall Thickness
two State Roads or County Roads. Include the road
Depth D1 meter or Weight/Ft. Material
e�Jc—
From To To Ft
numbers and conmon road names,
CD
c
ToFt.
From
From To Ft.
>
t
c -.
13. GROUT: Depth Material Method
Pt,
�^
From 0... To 20 - Ftb & carrierlit. M)TQ93
1
..From ToFt.
14. SCREEN: Depth Diameter Slot Size Material.
3
From - To Ft. in. - in.
From To - Ft_inin.
y:o
15 SAND/GRAVEL PACK:
ry
o
Depth Size Material
a
From _ To Ft. —
From —To— Ft.
f— t
i
16, RENIARKS:
_l
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE
WITH 15A NCAC 2C, WELL
CONSTRUCTION STAND 4RDS, AND THAT A COPY OF THIS RECORD HAS
BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTIpk THE WELL 4T
I\—Q,`ction,
Submit the original to the Division of Water Quality, Groundwater
1636 small Service Center- Raleigh, NO
27699.1636 Phone No, [phone], Within 30 days.
\ - GW-1 REV. 07/2001
i

293844
WELL CONSTRUCTION RECORD
-
North Caroiula - gopartmenl of Environment and Natural Resources'- Division of Water Quality - Grround,vater Section
YELL. itRACTOR(0DIYIDUAL) NAME IPrinp -James P...Brown CBRTIEICATfOiYR 20a5
wELLccwrR; croRcomPANYNAMENedden Brothers Well.Drilling, Ine P�oive a St l?Z
s'rATE WELL-CONSTRLCTION PERM ITO ASSOCIATED WQ PERiY11T:
I. WELL USE (Check Applicable Box): Residential i!� Municipal/Public ❑ Industrial ❑" Agriculbral 0
_
Monitoring Recovery 0 Heat Pump Water lnic tion.0 Oilier ❑ frOther, List Use
i
2 WELL LOCATION. Topographic/Land setting
- Near (Town:VL41yiCounty ,l..� C]Rdge OSlope. ❑Vali.,v ❑Fist
(cheek appropriate box)
�(Sveet
Nang, Nila bcrs, Conniiunnityy, SuboNir,Lon, Lot No., Zip Code) Latlfude/longitude of Weu location
3. GWNER:
(deg:eeshn inu teVse:andi)
'Add css 5 G5 A' L t'(ude/tor.gihtde source:OGPSGTapoyrepfije, map
_
Route
�J.._($lfti/e/jewOr
fi 1^S /A.YJ^, E� DRILLtNGL0G
i
G:y o•To.v State Zip Cede From , Fom,.; ion D is
cLattaa—.-.-'
_.
( r (a� clay sand
<onu m- _
Aren do- PhcneIiube' - ��} ran aLte
—
4, DATE DRILLED
T_
S,TOTAL DEPEPTH: r
M
6: DOES WELL REPLACE EXISTING WELL?; YES ❑ NO Y� —
7.STATIC WATER LEVEL Below Top of Casing: jOOFT. -- -
-if Above Top of Casing)
S. TOP OF CASING IS 2 FT. Above Land Surface* -
-Top. of aulna Iarminared atlor below land suri requires a - —
'. vorlance in arordince I)h ISA NCAC 2C.0118-�.
9. YIELD (gom): 'f METH)OOf EST blow _—
10. WATER ZONES (depth): LNg �3� _
LOCATION SKETCH
l I. DISINFECTION TypeH T H Amount 16 Oz Shoyv direction and distance in miles f.oin at least
12. CASING: Wall Thickness I two Stale Roads or County Roads. Include the road
.
Depth D arlirt or WeighvFI Malarial numbers and common road names.
From 0 ToFt-
o
CD
From Q Q To Ft 6
'.From To 'Ft.
13. GROUT: Depth Material Method
�e
Frbm 0 To ' 20 Ft, bgrnite b Pratt Pumped t
--
�<
From ` To - - Ft
14-, SCREEN ;Depth Diameter Slot Size".:- Nlateria;
,l
From ,:T.o Ft in. :.. :...�
From To Ft in. In, w
15. SAND/GRAVEL PACK w
Depth. size .Material
From To. Ft.
`
From To Ft.
16, REMARK5.
I.DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, A
THAT A COPY OF THIS REC R:CI.HAS SEEN PROVIDED TO THE WELL OWNER
_ SG-ATUREOFPERSON CONSTRUCTING THE WELL DATE
Submit the ori;inal to the Divlslon of Water Quality; Groundwnter Section; 1636 Mail Service Center- Ra:elgh, NO
. 27699.1636 Pi one No. [phone], within 30 days,. --:..., GW'•I.P=V. 07i2001 -
t

293843
WELL CONSTRUCTION RECORD
No,
III Ia • "Departmd-it of Environment and Natural Resources - Division of Water Quality - Groundwater Section d
tiYELhC0,17RACTOR(hvDIVIDU,4L11yA�1E (prim) -James B.-Brown CERTIFICAT10!YR_20_5
- WELLtoN'rRj\CTORCOivIPa,vY.NAitilv$edden Brothers Well;Drillin,9, Inc FHONE 0 F - a-9-u1
S'rATE WELL CONSTRUCTION PERMITO :ASSOCIATED WQ PER-NI170
(ii aonVlcable)
WELL USE (Check Applicable Bo,e). Residential ei Municipal/publo C Industrial [I Agricultural ❑
Monitoring ❑ Recovery C3 Heat pump Wat- Injection C Other 0 If0ther, List Usc _
2 WELL LOCATI N dge 'Craohto/Land setting
( l
Neare;tTown: County ❑Ridge CSlope. ❑ValLy ❑Flat
_ (crook o�proprime box).
i
(Street Nee; Numbers, Connnunity, Subdivifion, Lot No., Vp Code) - La! tulle/lOngltvde of well location
m-
3. OWNER I adegrees/inineneilse.onLst
'Addresa. Lat.rude/longitude s0u,cr,COPSC Iopouaphw n+ap
' (Street er RaweN ) .`
I Al
FD_pTN DRILLING LOG y;
City cr 'v. p ,.. clay
0n Der'"Ot'cn. __.:.-.._.
r. Sate Zi Cad•- Fror71 T Formanri
Area code. Phcne mmmbe•
4. DATE DRILLED-
5 TOTAL DEPTH:' _
6; DOES WELL REPLACE EXISTING W'ELL? BYES NO �S =
7. STATIC WATER LEVEL Below To of Cas n
(Ilse "*"i CAbove Top cr Casing) .
S. 70P OF CASING IS 2 FT, Above Land Surface'
-Too of casing torminated at/orbiIow land surface regvfret a —
rarlanee ln:ac:ordan a with tS,\NCAC IC.Otld
9 `YIELD (gpm): � METHOD OF TEST blow --
10. WATER ZONES (depth): l9g' Et a R l f LOCATION SKETCH,
I I, DISINFECTION. Type' H T H Amount 16 oZ Show direction and distance in miles fwir at least
12, CASING: Wall Thickness two State Roads or County Roads. Include the road .
Depth Dixme!er or WeiyhJF1 Material numbers and common road names. '
From Y To Ft �e „
From To _ Ft. —
From To _ Ft. _ O s
13, GROUT: Depth Mater.a! Method t �
From 0 To 20 Ft. kxrrnite & C8 3� PLun am
From To Ft. -<
14 SCREEN. Depth Diameter Slot Size Material <
From To Ft. in. in.
-From To Ft. - in,' in.
15 SAND/GRAVEL PACK:
�>
Depth Stu Mataia4
From To Ft. -ca
From To Ft.: o .
16. REMARKS.
-1DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND T , T A COPY OF THI R.ECO - HAS -BEEN PROVIDED TO THE WELL Ow'NE'R\
—�V
SIGN E OF PERSON CONSTRUCTINGTHEWELL DATE
Submit the original to the Division of Water Quality, Groundwater Sectlon, 1636 Mall Service Center - Rale!9h, NC
27699.1636 Phone No. [phone], within 30 days: - GW'•I.REV. 07i2001
a

293842
WELL CONSTRUCTION RECORD
(6orth.Carolina. Dcparlment of Environment and Natural Resources • Urvtsion'cf Wate Qua{ity • Creund,vzter Section.
tiYELbCOYTRAC1�Oft(IIYDIVIDU,AL)I A�1E (prinQ James B..BrO in ,' CERTIFICATI01_2045
,,,EFedde-1 Brothers Well Drilling, inc PHONE#1 1 69-s,791
WELL COiN'i R\CTOR COivIPAiNy
r ,ASSOCIATED WQ PERN117. -
- STATE IVELLCON'STRU C710iV P"eRMfTg
-
1. WELL USE (Check Applicable Box): Residential Municipal/Pi.bltc C Industrial ❑ Agricultural CD
Monitoring ❑ Recovery [IHeat Pump Water tnjectidn Other ❑ If Other; List Use —
2, WELL LOCATIO Topographic/Land settingl
Nea Town
County (
x ❑Bldg: ❑ Slone. [:Valley Valley❑Fat
(check a.progriate box)
(6treet Nainb4rs, Conniwnity/��6 division,. Lot Na., Zip Code) Latlh.tde/longitude of well location
3.OWN ER. A.(A�����"�-`� (de9re<s mm;itnshe:ondt)
-Add css T In��— Lau;udc/longitudesource.C3GPS[17opogropho map-----
k {check ball
S�tretC or R it a)
DRILLING LJiiof
y or Town state Zip Code From To r Formation Descr open
�n3( hlu9 0 clay 8 sand
($j-
Arta wda Phoi,e awn d er - r y Rranite
TE 4. DADRILLED
6 TOTAL DEPTH —
6 DOES WELL REPLACE EXISTINGWELL?. YES❑��j0
�FT.
7. STATIC WATER LEVEL Below Top o°Casing: _
.. (Use it Atove Top aC Car:na)
S. TOP OF CASING IS 2 FT. Above Land Surface*
. --Toi3 or casing terminated at/or blow land mrrace requires a —
vorlance In accordance with l7A NCAC 2C.0119.
9 YIELD(gpm): MEfHOD-OF TEST blow
10, WATER ZONES (depth): [Od
LOCATION SKETCH,
1. DISINFECTION TypeF. T H Amount16 oz Shoyv direction, and distance in miles frcin at least
12. CASING Wall Thickness two Statc Roads or County Roads. Include the read
Depth Diametet or Weight/Ft.,RMa✓te^riail nUmbers and cocmon road names
m Fro 0 To Ft "T'`'`� O
c
From To - FL
'From - To - Ft.
13. GROUT: Depth Material Method �
From 0 To 20 ' Ft. t to & C rer t . ; Ptlmged
e From ' To Fit. w
n
14, SCREENt', Depth Dia.neter Slot Size Nlaterial
From : To Ft. in in.
. From '.To. Ft. In _yin.
W
mz
15, SAND/GRAVEL PACK: cla
:Depth Sae.. Material
From `To- Ft.
„ From ` To FL
16.. REMARKS..;.
I.DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I SSA NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND; TACOPY OFT SRE sPDHASSEeNPROVIDEDTOTHF.WELLO`w':R
a
_
SIG, RE OF PERSON CONSTRUCTING 7HS'WELL, CATE -
Submlt the orl;final to the Dlvlslon of Water Quality, Groundwater Section; 1636 Nlail Service Center- Ralelgh, tN'C _
27699.1636-Phhnc No. [phone], within 30 days, GW-I.REV. M2001
,

293841
WELL CONSTRUCTION RECORD
North Carolina - Department of Envuorment and Natural Re3outces • Division of Water Quality Groundwater Section
1YELL,CONTIRACTOR(IiNDIYIDUAL)NAME (prinl) lames fi.,.Eram CeRTMCAT 104 2045
Fadden Brothers PJell:Drilling, Inc PHONE 0
wZLL
COY'r RACTOR COiNIP ANYNAIM
STATE (YELL CONSTRUCTIOtN PERIA179 ASSOCIATED NYQ PERMITk
I. WELL USE (Check Applicable Bo,e)'. Residential E}$ Municipal/Public ❑ Industrial; 0 Agricultural ❑
Monitonnio 'Recovery 17 Heat Pump watery ItnictlonG Other G If Other, List Use _
2 WELL LOCATION Topographic/Land setting
O
Near Town: Cotnty � ❑Bldgdg: GSlop: Val! y ❑Flat
v
I MA (check o�praprime 'ooz)
(suet, Name, Num'q"n, Cam] Subdi vivon, Lc No Zip Lode) Latitude!lonji.tudc of well location
3. OWNER' - (de3reeiA inntea/e:conds)
: Addrasa /PAA 41 164Latin:dc/longitud: source:GGPSGITopogaphic map,
_
or Roule No.) �./ {check box)
'
��($�ret
/1 FT ��y DEPTH PRILLiN'GtrJf
Sire Z' ip Codt From, Fojj matron Des:•LLotion
&
���e�� - D C1dcf S'''1S
Area code. Phcne nv ne<• /J cr2Sate _
4. DATE DRILLED 7(,4.1s
r— _ 5, TOTAL DEPTH: �j
6; DOES WELL UFLACE EXISTING WELL? YES G N0
X
7. STATIC WATER LEVEL Below Top of Casing
(Use "-"if AboYe Top of Caaln/)
8. TOP OF CASING IS 2 FT. Above Land Surface* —
--Tap aldaalny tarrnlnated itlor btlory land surface requlree a —
YarlAnotlnmcordete th}SA. NCAC 1C.0118 —
blow
9 YIELD (jpm) vMETHOD OF TEST --
10 WATER ZONES (d pth): -
- LOCATION LOCATIONSSSKE SKETCH,
I t.-DISINFECTION Type' H T H Amount 16 cz Show direction and distance in miles from at lease
12 CASING:. ' Wall Thickness two State Roads or County Road; Include the road
.
Depth Diameter or Wei ht/Ft Material numbers and common road names.
4
FromTO / / J Ft.
c
—0
X—
From To - Ft. r
�.
From To Ft. _;
13."G20UT: .. Depth Method
�2—c'
c^
�Material
.:.:From 0 To � 20 -Ft. berm-dta & Ce 7ert ' Pum_� `t
� m
From To Ft. w
=n
14, SCREEN: Depth Diameter Slot Size `:' Material
..--. From ''To Ft. —ill, in.
_ From To Ft._im in,
� r
15. SAND/GRAVEL PACK:` ca
Depth _ ,Size Material rn
:.Frcm-L
o
`To - Ft.
From To Ft. -
16. REMARKS`.
I.DO HEREBY CERTIFY THAT T ' WELL WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C, WELL
CONSTRUCTION STANDARDS/AN THATACOPY FTHIS CORD HAS SEEN PROVIDED TOTHE WILL O'NN=?,
ii�CJ\
. - S NATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the orl;inal to the Divislon of Water Quolity; Groundwater Sectlan, 1626 tNIall Strvlce Ctnter -Raleigh, N'C :
. 11699.1636 Phonc No. [phone], within 30 daysr GWI.PLV. 07/2,001

2�
WELL CONSTRUCTION RECORD
No rill.Caroluta • Doparlrnerit of Environment and Natural Resources • Ulvlston of titfater Quality • Groundwater Section
}YELLC0;ITRAC1'OR(ii)DIYIDU,aL)yA61e (print) James A. Brown ..' CERTIFICdTI0i1n 2045
wEtLCO,,';R,,CI'ORCOivIPANYNAh,iFeddp—n Brothers Well Drilling, Inc PNot�eg8 1 369 Qj31
- STATE WEL6-CONSTRUCTION PERMITA .ASSOCIATED, VYQ PERh117:
(ifxonlicabl:).- _ iifaobiwable)..
1, WELL USE (Check Applicable Box): Residential Municipal/Public CD lndustria! C7 AgriCullural ❑
Monitoring 0, Recovery ❑ Heat Pump Waterinjection ❑ Other ❑ 1f Other, Lis! Use
3 WELL LOCAT N. /�_ � Topographic/Land settin¢ ;
Nea((est"}'_ewn: Counly�f_f�! ❑Ridge �❑Slope. ❑Valley ❑Floc
dge
0 0 J2j _ - (check appropriate boa)
(street Nat,te; N/uml;ufl,, Comnwiuty, S� bbcivis'n, Lot No,, Zip Code) Latitude/longitude of well location
OWNER \' ,j'I JQ `.1 I.1wjvvy1 '(de; reeehr,nai $/asoonda)
Add", s `DO Ok 33 Latitudo/longitude source:CIG,PS❑Topographic map
QQ/sweet or Rowe No o J �1 (check box)
odliina� N �d C_PTH DRILLING LOG
Gry or To'an Stour
Zip Cade From 0 r Formation Descr blicn
clay &sand
Area <ed Pl,a�,en„b<• ���Q��b— r granite
Areo! n
4. DATE ll
/
QW _ S,TOTAL DEP?H.
DEPTH:
6; DOES WELL REPLACE EXISTING WELL? YES ❑ NO
7. STATIC WATER LEVEL Below Top of Casing: JCO_ T.
(Use"✓ irAbove Top cr Cerin;)..
S. TOP OF CASING IS 2 FT. Above Land Surface'
--Top of casing terminated at/or below land surface requires a
vor,ance In accordance lth lSA NCAC 2C.01 IS. —
rap blc
9. `YIELD (glom) METHQ OF EST
10. WATER ZONES (depth): q0 3T,, —
LOCATION SKETCH
1 I:; DISINFECTION TypeH T H Amount , 16 OZ Show direction and distance in miles from at least
12 CASING Wall Thickness two State Roads or Coun!yRoads, Include the road
Depth/_ Dt m :: or Weight/-t N1 to la1 numbers and cornmon road names
From 0 To-,�s�— Ft.c
From To�L.. t _,�_ 3�8 CD
From To Ft, - •� -
o
e
11 GROUT: Depth Material Method
:...From 0 ... To 30 Ft. bT=dta art ;.PllTped -
n
Frbm - To - FL f
14, SCREEN '. Depth Diameter Slot Size".> Material
' From To Ft in.
—ill.
From To Ft. in. in.
15. SAND/GRAVEL PACK: w
:Depth Size Material
From To Ft. —
:From —To— Ft.
16. REMARKS'.
100 HEREBY CERTIFY THAT THI WELL WAS CONSTRUCTED IN ACCORDANCE WITH I sA NCAC IC, WELL
CONS7RUCTION STANDARDS,
THAT COPY FT•'1 RE CORD HAS SEEN PROVIDED TO THE Ya LLL OWNER
ATURE OF PERSON CONSTRUCTING THENVELL 'DATE
Submit the orl;inal to the Divfslon of Water Quality; Groundwater Sectlor; H36 Mall Servl,4 Carer • Ralelih, NC
. 27699.1636 Phonc No, [phone], wlthln 30 days: - GW•I.R5V. 07/2001

2938.n1
WELL CONSTRUCTION
RECORD
North Calrollna • ]Department of 4 nvlronm:nt and Natural R soul,as • Division of Water Quality • Ground,vate Section
1YELL.0O3yTRAC1'OR(61DIYIDUAL)iYAD16(print) lames A..Brown. .;: CER71FICATION1 2045
Heddean Brothers -PIell Drilling;.Inc PHONE k L23 369--2591
WELL. CONT RACTOR COMPANY NAME
S'rATE WELL CONSTRUCTION PERMITS ASSOCIATED NVQ PERMITe
(if 2bolicableY :. - (ifaonlicable)-:
L -
1 WELL USE (Check Applicable Box). Residential 21 MUniCiPa{/FLIbliC O Industrial O Agricultural ❑
MorltorinjC2 Recovery.[] Heatpump WaterinJection ❑ Other O lFOthu, List Use 4—
2. WELL LOCAT N Topographic/Land setting
Near strewn:
/�n County ❑Rtage OSlope ❑Valley ❑Flat
(check oppropr:ate box)
�(S;reeacne, Num'ocrs, Community S division,. Lm No., Zip Code) La ltuoellOngltude Of well lOcatlOn
3 -OWNER:
'(degweshninutts/ae<anG) ( L
_ _
'Address
Latlnldc/longitude Sot-oe.OQPSOTopographic nap
n (slreet r Rowe No.) �l ck ba x)
A_Y OCS•^ ITil)1 %�lC dN �o�� EH P7DRILLING LdCi
_..
Cliyor T-+ S,•t Zip Code. - From T Formation Description
0 clay b: saraa
_ —
Aran cod.• Phone 01➢001 r crranite —
�0
4, DATE DRILLED 0? —
6 TOTAL DEPTH. —
6, DOES WELL:REFLACE EXISTING WELL? YES ❑ NO-
7. STATIC WATER LEVEL Below Top of Casing: � 0 FT. —
(Us<"+" if Above Top of Casing) .
S. TOP OF CASING IS 2 FT. Above Lard Surface"
of dasing terminated atlor blow land mtraee requires a ...
--Top.
rarlance In aecordan Ith ISA. NCAC 2C.0118.- —
blew
9. YIELD (gpm): METYO� QF TEST --
10 WATER ZONES (depth): —
LOC,ATfONSKETCH
it, DISINFECTION Type H T H Amount 16 cz Show direction and diswcc in miles (ruin at least
I2 CASING Wall Thickness t,vo State Roads or County Roads include the road
�
c
De th DI m.t�i or W�i h Ft Materiat numbers and common road name's oZE
l �tOQ
o
From 0 Tot Ft
From To - FL
-- From To ' Ft.
13. GR.OUT:... , Depth.. - Mahod - - I
=-
�Ma1teyr�ial
:...From �O To 30 Ft. bT= to 8 M-Sft 1-PUMPea'
From To Ft.�
. 14-, SCREEN `. Depth Diameter Slot Sae",> iMzterial _ y
^•,--,
„ From To Ft. in. in: r >
r
From To - Ft. in. _ in. w
15, SAND/GRAVEL PACK m
:Depth Size. Material
Prom To Ft.
From T6 FL .
16. REMARK$': ,
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C, WHLl.
CONSTRUCTION STANDARDS, YqV
THAT OFyTT'jISR-mCCOOPZ14A/SSEEN PROVI DIED TOTHE �VzLL OWNER
;ACOPY
SI t ATURE OF PERSON CONS T RUCTING THE WELL DATE
Submit the orlginal to the Division of Water Quality, Groundwnter Section, 1636 Mail Service Center • Raleigh, NC
27699.1636 Phonic No. [phone], within 30 days. CW:1,REV. 07/2001

WELL CONSTRUCTION RECORD 293838
North Carolina - Department cf Eryiromnnent and Natural Resources - Division of Wate, Quality - Grounc eater Section
WELLCOnTRAC1'OR(IiNDIYIDUaWi)AOIE(print) James A.,Prown CERTIF(CATI0Nk_2045
WELL CONTRACTOR COMPANY NAME Hedden brothers Well :Drilling, Inc PHONE a E . 1 36053°1
STATE NVELL-CONSTRUCTION PERMIT2 ASSOCIATED R'Q PERiN117- _
' --(ifzbnlicable) iifaonlicable). ! �..,-
I. WELL USE (Check Applicable Box): Residential in Municinal/Public ❑ Industrial 17 Agricultural 0
Monitotirr.v ❑ Recovery ❑ Hea! Pump Water Injection 0 Other ❑ if Otner, List Use l ;
i
2, WELL LOCATI Topog: Dhic/LandSetting
INcar, s'Town '. County ❑Ridge ❑Slope.❑Valley ❑:Ist
"AL 1V16 (a'ne-<appropriate box)
(Street New Nuir�uro,Community, Subdivision, Loi No.• Zlp Code) Latitude/longitude of Well location
3.
O�NtR',siw� I
(d pre a VIni n u to S/ae Cand!)
Address
Latitude/longitude sourca,0GPS0Topograpnic ntap---._,-_
/n/ (Street Re : Nc)
(check box)
¢ i
DEPTH DRILLING LOG
—
tydr—a•,vn' p oo l Z•pCoo,
�
Fror,. To e Formation Descr. onor�
clay & sand
'
Area code o,e ,e nambm
a graIIl tE —
. 4.
DATE DRILLED
5,
TOTAL DcFTH. .�
_
6,
DOES wCLL REPLACE EXISTING WELL? YES ❑ NO
7.
STA t IC WATER LEVEL Below Top of Ca;ing /On F
—
(Use '*" if Above Top at Casing) ..
8,
TOP OF CASING 15 2 FT. Above Land S mace'
—
-Top of casing tarm!nated at/or below land surface requires a
—
varlance In accordance vlth 15A NC.AC]C.0I15
—
9
YIELD (SPIT) _ METF. OF TEST blow
t
--
10.
WATER ZONES (depth): O
—
LOCATION SKETCH
11,
DISINFECTION: Type H T H Amount 16 cz
Show direction and distance in miles f om, at least
12.
CASING Wall Thickness
two State Roads or County Roads. Include the& d
g
Depth Diameter or WeighUFt, Materal
numbers and common road names.
From 0 To Ft.—_
1
- 3
= m
mo
From To— Ft,
O T
-
From - To Ft.
I
`—
13.
GROUT . Depth Material Me!hed
W
(7
From 0 To 20 Ft.b992ijte & Caret PUmPed
to
To
From ' To Ft.
—�
14,
SCREEN: Depth: Diameter Slot Size-i`laterial
'
From - To Ft.in. in.
From To Ft. in, in.
15,
SAND/GRAVEL PACK:
- Depth Size Material
-
Frcm `To Ft. —
From —To— Ft.
16.
REMARKS:
-- I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTIONS
STAN OAR DS, THAT A COPY OFT 'IS R.ZCORD HAS BEEN PROVIDED TO THE W ELL OWNER
-
SI • 'A7URE OF PERSON CONSTRUCTING
THE WELL OAT --
Submit
the original to the Division of Water Quality, Groundwater Section, 1636 bail Service Center- Raleigh, NC
- Z7699-1636 Phonc No. [phone], within 30 days
OW-1 REV.,07/1001
,

WELL CONSTRUCTION RECORD 2 9 3 8 `'
9
North Carolinas Oelau(ment of EnYlronment and Natwal ResouI'ceS Divis ontof Water Quality • Groundwate• Saction
YELL,COYTRACI'OR(IiYDIVIDUAL)NAf1G(prinp James Ae:Brown.; CF.RTIFICATfONk_2045
WELL CON11 RACTOR COiM.PAN Y. NAME Kedden Brothers We11�; Drilling, Inc PHONs $Bch ).. 369-9591
STATE WELL CONSTRUCTION PERMIT$ '' ASSOCIATED 1YQ PCRiVi IT$
I WELL USE (Check Applicable Box): Residential Municipal/Public O Industrial ❑" Agricultural ❑
Mcnitcr ng ❑ Recovery.❑ Heat Pump Waterinicction.0 Oilier ❑ IFOther, List Usc
2 WELL LOCATI N �' 'Popographo/Lanai s tine '
p,,,,
/%q,��,�, � �
Near^s;Tewn. L Crounty=.,F+•i:dtnLO— MRidge ❑Slop ❑Valley ❑Flat
\�.AA-/Y Q.., J 0 p Ae— YY (che:k app nO(a;e bcz). -
: (Street Name, Numburns, Community, Subdividou,. Lot No., Zip Code) La .tulle/lorlgitude of well location
.. 3 OWNZR Y 6100ki, )AIL (deaeees/minaiu/ae:soda
'Addt,vss sourc,:11GPS1I7c,,cgraphic map
: (Street or Route No.) ,. �--, p- (<Beek haz)
1P(9� AAl IA �L
GL to DEPTH DRILLING LOC
City orT '.�n S t Zip Code From t e Formation Descr ouon
(RZc)� 7i S o clay t sand
A:en code- Phone num'aer gprdl',1te
4,'DATE DRILLED
5, TOTAL DEPTH:
6. DOES WELL -REPLACE EXISTING WELL?. YES 0 NO
7, STATIC WATER LEVEL Below Top of Casing: �L` --
(Use"+"i f Above Top o!Caeing)., -
8. TOP OF CASING IS 2 FT. Above Land Surface" —
--Top of ming terminated at/or belo+v land rurrace requtru a -'
varlanctinaacordenctt th ISANCAC1C.0113
9 YIELD (gomy METHOD OF TEST blow
10 WATER ZONES (d oth): _
LOCATION SKETCu
11- DISINFECTION: TypeH T H Amount . 16 oZ Show direction and distance in miles from at least
12.' CASING: will Thickness two State Roads or County Roads. Include the road
Depth Dtjmefe; o• Wm h F! Mna�te�riat�numbers and commc, road names.
4
From 0 To�Ft.=
c
/`yc,
: From To Ft, : 0 :
-From� To Ft.
o
I3:'GROUT: :. Depth Material Method
From 0 To 20 Ft. bgrnitSa & t : Pumped -mac
- From To -Ft
14, SCREEN. -Depth Diameter Slot Size .� Material
,... '. From ,'To Ft. ill. in, v
r,
From To FI._in. ' in.
15. SAND/GRAVEL PACK:
c :
v
Depth S,ze Material--
lerom To Ft.
From ` To Ft. .
z
16: REMARK5. .
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 13A NCAC ZC, WELL
CONSTRUCTION STANDARDS, AT A COPY OF THIS RZCOP.D HAS BEEN PROVIDED TO THE W—LL OWNER
N URE OF PERSON CONSTRUCTING THE WELL CAT --
Submit the orl;inal to the Division of Water Quality, Grourldwnter Section,1636 tPylall SerYica Center • Ralelgh, NC
27699.1636 Phonc No. [phone], within 30 days, -. G W I REV. 07/2001

WELL CONSTRUCTION RECORD 2 9 3 8 2 4
North Carolina • Department oEEnvironment and Natural Resources • Dlvlsiodof tiVater,Qua!ity- Greund.va!er Sec:ior.
1YELLCONTRACTOR (IIYDIYIDVAL)INAM€ (prli!) Jarpes A. Frown. , CERTIFICATIOiN# 22045
}va6L COIN' (iACTOR COMPA,YY NAM E Hedden Brothers Well,Drilling,- Inc FHotYE a
ti YELL CONSTRUCTION PERMITr - ASSOCIATED N'Q PERNIM
-
'..-(iLaonllcable)-
I. WELL USE (Check Applicable Box): Residential t ' Municipal/Public G Industrial ❑" Agricu!(uraf D
Monitoring G 'Recovery ❑ Heat Pump Water lnjection ❑ Other ❑ frOther, List Use
2 WELL LOCATI Topeg;aphic/La.^,d setting
N:a• s;Town: C mty�7� ❑Ridge GSlepe GVaIlry ❑Flat
U
i (check ayprapriate box) -
(Street Name, N,un'pers, Community, Subdivision, Lot No., Zip Code) Latitude,/longitude or well location .
?. OWNER:-'(d<y;ees/inlnuteshec0nds)
-Addres Lat tudc/longitude source,,❑GPSGTopocra:i,ic map
-
(Street or Rouie No.) - . (check box) I-
- °� PTI-,,DRILLING L G
City Txn. mu Zip Code- From TO i Formation Des.rLmtion ----_
0
-- --
(�) clay & sand
Arencode Phcn<n�,nbtr _
-' a_ranite
, DATe llRILLED__
5_
. TOTAL DEPTH; —
6; DOES WELL REPLACE EXISTING WELL?, YES ❑ NO ❑ —
7. STATIC WATER LEVEL Below Top of Casing: ji'20 FT. -- —
(List '*" if Above Top of Casing) .
2
S. TOP OF CASING IS FT. Above Land Surface' —
--Top 01' Call% Iarminate5 at/or below Ian su. i requtrn a —
Yorlanct In ac;ord ant ieui SA NCAC 2C.011 S. -
9. `YIELD (gomj:: CJ(J M,ETHQD OF EST blow
10 WATER ZONES (depth): foQ' 110' --
- LOCATION SKETru
-
l1. DISINFECTION: TypeH T H Amount . 16 02 Show direction and distance in miles froim at least
12. CASING �'vall Thickness twoStat: Roads or County Roads Include fne road
Dep h Dameler cr Weipht/F1 Materia6 nLri and corm o . road names.
c
From 0 To� Ft. (/ O
�
Frori To Ft.
From To -Ft. 3
�.
J:'GR.OUT: Depth Marrial Method t
"��
From 0 To 20 F:. MM to & agrett Gtunped s
- From ... ,To Ft. ca
14 SCR EEN Depth Diameter Siot Size IMate•ial
>�
From To Ft_ill. in:
=
From —To_ Ft. in. in. (J
is
15, SAND/GRAV'cL PACK: w
Depth Sae Ma erial, s»
z
From To Ft.
Frcm ` To Ft. -
16: REMARKS.
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH IJA NCAC 2C, WELL
CONSTRUCTION STANDARDS; AND TH - -BEEN
COPY OF THIS °CO .HAS PROVIDED TO THE WILL
.0,1yVN�2R
SIGN 7 R OFPERSONCONS RUCTINGTH'c WELLDATE'
Submit the original to the Division oftiter Quality Groundwater Section, I6J6 M3BService Center -Raleigh, NC
27699.1636 Pill) no No. [phone], within 30 days. GWI.AEV,.07/2001

293vowv
WELL CONSTRUCTION RECORD
North Caroli ta> Departmant of Environment and Natural Resources - Division of Water: Quality- Groundwate, Section
WELLC011'TRA1. CTOR(IIVDIYIDU,AL)IiNAME (print) James B..Brown: CERTHICATIONe- 2045
Nedden brothers We11 Drilling, inc.
1YELL CON'i R.ICTOR COMPANY NAME grPHONEgLRL 369_Q�9 )..
STATE WELL CONSTRUCTION PERMITq ASSOCIATED. NVQ PERMIT'
''(ifaopticabl:).. .: (if aonlicable).: -
I. WELL USE (Check Applicable Box): Residential t " Municipal/Public O Industrial CJ" Agricultural ❑
Monitoring ❑:'Recovery 0 Heat Pump Wait, Injection 0 Dille, ❑ if 0ther, List Usc _
2, WELL LOCATI
T000graphlc/Lard sitting
NearestTo M County
v. []Ridge OSlope. ❑Valley, .OFlat
(check appropriate box)
(Street Na;re, Nun cn, n,n,uoity, Subdivision, Lot No., Zip Code) Latjtude/longitude of well location
�3. OWNER: - (dyreeehrinuto/Secoeds)
.Latitude/longitude source:OQPSOTepograph'Ic map
-'rpet o Ro^ e NoJ (check box) ,
-- _ -
a DEPTH
_ %7 DRILLING LOG
ClryggrT at / Zip Coal: From To , FormationDeserLation
(�)•. [a.� f - s, ' clay t sand
_
Are,,<oa< Phcnenuinaar granite
4. DATE DRILLED
5 TOTAL DEPTH:-
6: DOES WELL REPLACE EXISTING WELL? YES ❑ NO O —
7. STA'ric WATER LEVEL Below Top of Casing: .50 FT. -- —
. (LIS. "*"if Above Top or Casing).. - —
S, TOP OF CASING IS 2 FT, Above Land Surface —
-"Top ol'aasiny orminatd at/or below land Surfac,. requires a —
vorlance In accordance with ISA NCAC 2C .Oil ld. :
9, YIELD (gpm) 16 e METF:QqF"TEST blow
10 WATER ZONES .(deplh):—
LOCATION SKETCH,
L DISINFECTION: Type' F: T E Amount. b6 02 Show direction and dista1.nce In miles froin at least
12, CASING Wail Thickness hvo State Roads or County Roads. Include the road
a
De It DI m.� r or We4lv;t m Materia: numbers and common road naes.
From 0 To Ft. �I
From To Ft
From To - Ft.
J 'GROUT Depth vwcria! Method
n
From 0 To 20 Ft. he=dte & a ret Pt3InPEd 3
-
`'
Front :.. To . Ft. . ......: _ ••.�
c`-
m
14, SCREEN. Depth. Diameter S'ot S,ze SVlaterial 1
c�
:- From To Ft. -`_in, in. Lo
r
s"
From To Ft. in, in. o
15, SAND/GRAVEL PACK
Depth Ss: Mate, ia4
From To Ft. W
��-
.. From ` To Ft. - .. O?
o
16. REMARKS, ..
LDO HEREBY CERTIFY THAT THIS ELL WASCONSTR.UCTED IN ACCORDANCE WITH �I 5A NCAC 2C, WELL
CONSTRUCTION STANDARDS, A. ATACOPY OF TI�?�s F-ECAPLO HAS-BEEN PROVIDED TO TH-N/-c (,`O WN=R
✓."��U
RE.OF PERSON CONSTRUCTING THE WELL DATE
Subrnit the ori;inal to the DIYISIon f Water Quality; Groundwater Sectlon, 1636 bta!I SarYlce Canter • Raleigh, NC
. ' 27699.1636 Phorc No. [phone], NYlthln 30 days GNWI.REV. 07/2001

293818
WELL CONSTRUCTION RECORD
Nor Caroli sa,• Departi of Environment and Natueal Resources • Division of ti' ii Quality • Groundwater Section
WELD.CO;YTRACTO,R(IIYDIVIDUAL)1YADiE (prl ,) James A. Brown CERTIEIC�TIOiVR2045
WELL ICaN•rRACTOR COiwrAtvY rnAtitEHedden Brothers we11 Drilling, , Inc PHONE p 829) 369 _J ,"l
STATE WELL CONSTRUCTION PER,MITO ASSOCIATED WQ PERNIITY
- -
- - (ifabnlicablep- -- -`(ifaonlwable)-:.
1. WELL USE (Check Applicable Box): Residential el Municipal/Public 0 . Industrial O Agricultural ❑
Nlenitoriri ❑ Recovery ❑ Heat Pump Water ln)ection ❑ Other ❑ IfOthz;; List Us: _
2. WELL LOCATION ��,�{,��� Topographic/Land setting
N:aresjjj'Tow : CountYJ.:d� 1WJJXJ ❑Ridge ❑Slope ❑Valley ❑Flat
AP, - - (c'neck approprlaie box)
(Street Nan; imbcra,Community, Subdivision,. Lot Na., Zip Code) Latitude/longitude Orwell location
. �3, OWNER:. .. - (degreeshninutes/secondq
-Adds La!itudc/lonylhtdesou« e,❑GPS0Tcpogrpluc mir.
.-- -
(Siren ar e No.) (check box)
_
D PTH DRILLING 0Q
City Ta•.vnlate . SZip Code- From o Formation Description
( 0 clay &sand
Arencode. Nim,enumberI C(raZ1�tE —
4. DATE DRILLED R"
5. TOTAL DEPTH: QOn'
_
6; DOES WELL REPLACE EXISTING WELL? YES O NO/�
7. STATIC WATER LEVEL Below Top of Casing: / 0 FT.
- tUse"r" r Above Top of Casing).
S. TOP OF CASING IS 2 FT. Above Land Surface'
-'Tap of casing terminated at/or below land svrfa<e req u rra a
varlance In accordan< with ISA NCAC 2C.0113,
blow
9 `YIELD (gpm), --(Q_ M. OD OF TEST
10, WATER ZONES (depth): —s _
LOCATION SKETCH
iLs
It. ;DISINFECTION:Type H T H Amount 16 oZ Showdirectionanddistance ir frcinatleast
ds or County Roads. Include the road
12. CASING W'al1 Thickness two State Roads
Depth D' mg!e c' WeiIlht/Ft Material numbers and cormon road names
From 0 To Ft
From�To7. Ft i 9.-
- rrom - To - Ft -
-.
`o
13. GROUT: Depth Material Method o
:...Frbm 0 To `.20 Ft. he &eft . P=bed
From Tc Ft.
. 14, SCREEN: Depih Diameter Slot Size -. lvlaterial f -
' From ''To Ft_in. in. w
_r,
From - To Ft._in.in, v
m^
15. SAND/GRAVEL PACK'
�r
Depth Stze Material
From To Ft. - - .. (13
�
From To Ft. -J
o
16: REMARKS. ;
I.DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15-A NCAC 2C, WELL -
CONSTRUCTION STANDARDS; AN HAT A COPY OF T 'IS e RDHAS BEEN PROVIDED TO THE WELL OV/N,'EA
_ S N ORE OF PERSON CON TRUCTINGTHEWELL: ' - DATE
Subnilt the orl;inat to the Divlslon of Water Quality; Groundwnter Section, 1636 Mail Service Center • Raleigh. NC
27699-1636 Phorc No. [phone], within 30 days,: - GWI.REV. 07/2001

WELL CONSTRUCTION RECORD 293805
North Carolina • Deportment Of Environs=.nt and Natural Resources • Division of Water Quality • Groundwater Section
VIELL CO'•NTRACTOR(I)DIVIDU4L)NAME (prinl) James B. Brown CERTIFICATIO,N#� 2045
WELL CONa RACTOR COMPANY NA VISF9 en Brothers Well Drilling, Inc PHONE;
STATE WELL CONSTRICTION PERM170 ASSOCIATED SYQ PERMIT _
-lifzorlicable)- --(ifaonlicable).
I WELL USE (Check Applicable Box) Residential O Municipal/Public G lndustrial ❑ Agricultural ❑
.Monitoring [1 R::overy ❑ Heat Pump Water Injection G Other ❑ If Other, List Use
2. WELL LOCATI N setting'.
dge Cohic/Land
Nearc ;Town: Courr,y � ❑Ridge SIop:. ❑Valley GFIa:
.112A-(chi 6 O)proprl Ole bcx)
Strec: Name annacrs, Community, Subdivision,. Lot No., Zip Code) : Latitude/longitude Of well location
3 OW'N ER'. (d:gxeshninute:/seconds)
Address I Latilude/longitudesource. GGPSGTopographlemap
n ,,• (S.v'eej or Ro N ) (check box) :,
M,
'
. C2R7�3 DEPTH ILLL(N'C10G
a" orCode From motion Disc Iti—
o
clay &sag
—Z— _on
Areaede Phone no- granite
IO'3'C�O
4DATE DRILLED
5. TOTAL DEPTF, 2 X ' —
6. DOES WELL :REF LACE EXISTING WELL7 YES ❑ NO%e —
7, STATIC WATER LEVEL Below Top of CasingrQ00 FT -- —
(Use "+'•If Above Top of Casing) - —
8, TOP OF CASING IS 2 FT. Above Land Surface" -
- -`Top of cash, Urminated at/or below land surface regcires a —
variance In accordance)15A NCAC 2C.0115_
`Ith
9. YIELD (gm) I V MLETY OF TEST blow
10.WATERZONES (c.plh): ISrJem Iir _
LOCATION SKETCH
11. DISINFECTION: Type H T H Amount 16 02 Show direction and distance in miles from at least
12. CASING: Wall Thickness : two State Roads or County Roads. Include the road
- De't"D-arn.te: or Weigh,)F! I%lateria' numbers and cor„men road names.
C
From T0Ft
. From - To Ft CD
ZE
ZE
From To F:,
o
I=.°GROUT: Depth. ilma'erial Method - 3
From 0 To 20 Ft. baatite & cam L AUIDPed
From To FL t
14• SCREEN: Dcpih Dia ne ver Slot Sin-Nlaterial
' From - To Ft in. in:
m�
From To - Ft. In.' in.
15, SAND/GRAVEL PACK: <
x
Depth Size M.a:eraf - CJ
From _ To. Ft.
from To Ft.
z
16. REMARK$`.
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STA, RDS, AND THAT COP OF TrHIS PLE7CORD. HAS BEEN PROVIDED TO THE WILL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of NVater Quality, Groundwater Section; 1636 Mail Service Center • Raleigh, NO
27699.1636 Phonc No. [phone], within 30 days. - GW'-1 REV. 07/2001

29306
NVELL CONSTRUCTION RECORD
Forth Carolina; Department of Environment and Natural Resouiees . Division of Water. Quality • Groundwater Section
VULCONTRA C1'OR(IINDIYIDUALOAME (print) James A. Brown CERTIFICATION,-2045
- WEL,LOON'fR\Cl'ORCOhIPANYNAhtEhedderl ESOthers Well Drilling, inc PHONE # [phone]
- STATE WELL CONSTRUCTION PERNVTd ASSOCIATED NYQ PERMIT.
(if applicable) - I - - (if aonlicable)-.
1, WELL USE (Check Applicable Box): Residential 2 Municipal/Public C Industrial ❑ Agricultural ❑
Monitoring❑ Recovery.0 Heat PumpWaterI j:ction❑ -.Other ❑ If Other, List Use _
2, WELL LOCATION: _ Topographic/Land setting'
�^k��
Nearest'" wn: juzCounty CRIdge ❑Slope. ❑Valley. ❑Flat
(check appropriate box)
(Street Nan,-, N unbcn, Comm n y, Subdivision,. Lot No., Zip CCLe) - Latitude/longitude of Well loea5on
9. 0WIN .R
(degree OrInuus/secoada) -.
Add::Ss
Latkii is/longitude sou ce:CGPSCTopograohic map
-
-
(Street er Ro k No.) - (check bex) I
DEPTH DRILLING L`OG
It�dr iesan se-te zip Code From To f Formation Deserjotion
( clay sana
0�
Phv,e
Ar<nc d< Phan<mm�c.• ' granite
b0 t
_
4. DATE DRILLED
S.TOTALDE?TH: r —
6 DOES WELL REPLACE EXISTING WELL? YES C�0 CD_ —
7. STATIC WATER LEVEL Eelow Top of Casing: SM FT. -
- (Use "t" if Above Top of Casing)
S. TOP OF CASING IS 2 FT, Above Lard Surfa:e' -
--Top of casing terminated at/or below land surface requires a —
variance In accordance wl in l SA N CA C 2C.01 IS. -
9. YIELD (gprp) pF TEST blow
��METHOD —
10. WATER ZONES (depth): Jr —
LOCATION SKETCH
11, DISINFECTION: Type H T H Amount - 16 oz Show direction and distance in miles Erie:-. at lea;
12, CASING: Wall Thickness two State Roads or County Roads. Include t'ne road
- Depth - Diameter or Weight/Ft,. Material numbers and common read names.
From 0 To I Ft.to'
Fror,. To - Ft.
-
CD
ZE
. From To Ft. - �
o
13.'G.40UT: Depth ,Material Method - 3
j a
From 0 Tc 20 Ft. bE=lite & cs-,ert ' Purnoed
Fronn— To
14, SCREEN: Depth. Diameter Slot Six Material
' From "To Ft. in. in, -o
1�
From To Ft. —in.' in.
15. SAND/GRAVEL PACK: G?
Depth Size .Material co
-(7)-r
From —To— - Ft. —
From —To— Ft.
I6. 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 OWNHR
A. , fie, Q-
- S 'ATUt2E OFPERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Qualit,Y, Groundwater Section, 1636 Nlail Service Center- Raleigh, NC
-
27699.1636 Phone No. (9I9) 733.3221, within 30 days. G1'v'•I P.=.V. C3001

293804
WELL CONSTRUCTION RECORD
North Ca'iolina • Department of Environment and Natural Resources - Division of Water Quality- Groundwater Section
�YELLCOVTRAC1'OR(IIYDIYIDU.4L)IYA111E(prlat) James 13. Brown_ CeRTIFICATIOIy4_2045
WELLCON'iRnCTORCOIN; PAN YNAM EFedden Brothers Plell Drilling, Inc PHONE a 5 1 309 9�91
s'rATE WELL CO,N'STRL'CTION PERMIT: ASSOCIATED SYQ PERMIT.
(if aon I icable) (if aonlicable).:
I. WELL USE (Check Applicable Box): Residentia! i Municipal/Public ❑ Industrial ❑ Agricultural O
Mcnitoring ❑ -Recovery O Heat Pump Wat-, Injection ❑ Other ❑ if Other, List Use _
2 WELL LOCATIO 1: 1� Tupog, I/Lind setting
Near^ Town County ❑Ridge ❑Slope ❑Valley OFlat
- gnuft , (cne < xpprapr!ata box).
(Strctt Name Numbers, Connnunity, Subdivislou,. Loi No., Zip Code) Latitude/Ioncltude ofwell location
(degre eshni, aes/seaondi)
LeGiudc/longintdosource:CGPSCT000era:)Mc map
(check box) - -
DEPTH DRILLING LOG
Fr oom T ( Formation n Desc . hon
Y dd
Are, cafe P'�,o"enumber 1 - crranite
P-1 I 6Q
—
4, DATE DRILLED
5. TOTAL DE?TH: e
6. DO S WELL REPLACE EXISTING W ELL? YES ❑ NO
—
7. STATIC WATER LEVEL Below Too of Casing. F . --
—
(Use "+" If Above To; of Casing)
_
S. TOP OF CASING 7S 2 FT. Above Land Surface'
—
-!Top ofcasing terminated at'or below land surface requires a
—
variance In accordance,( Ith 15A NCAC 2C.0116,
9, YIELD (gpm) (P METHOD OF TEST blow
10 WATER ZONES (a pth):
_
LOCATION SKETCH
11. DISINFECTION: Type H T H Amount 16 Oz Show direction and distance in miles from at
least
12. CASING: Well Thickness two State Roads or County Roads. Include the
road
- Depth(v- Dia.—Iter or Wei^hVFL Materiel numbers and common road names.
From 0 To y Ft /D 'AL jab '.4_
From - To - Ft
From To Ft,
13.'Gr20UT: Depth Material Method
3
From 0 To 20 Ft. bii!zrnite & MPumped
s'
From To Ft.
14. SCREEN: Depth Diameter Slot Size - _ (Material
' From 'To Ft. in. in. -
-v
From To - Ft.in.in.
15. SAND/GRAVEL PACK
w
Dep th Size Material
w
From To. Ft,— -
J
From ` —To— Ft. -
16. REMARKS
I.DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTIO TANDARDS, AND TH T A WPY OF THIS RECORD HAS SEFN PROVIDED T O THE WELL C tN7,,i
SIGNA7UREOFPERSONCONSTRUCTING THE WELL . DATE
- Submit the orl;inal to the Division of Water Quality; Groundwater Section, 1636 Mail Service Center- Raleigh, NC
27699.1636 Phonic No. [phone], within 30 days. - GW-1 REV. 07/2001
s
c
0
n�

2 9 3 8 7
WELL CONSTRUCTION RECORD
Nvrth Cnroimd - Department of Environment and Natural Resources • Division of Wzter, Quality- Greurdwater Section:
1YELLCOYTRAC1'ORiinDIYIDUaL)iIAIIE (print Tares A..Brawr:. CERTIFICATIOI`IA_2045
`}YELLCON�IR,\CTORCOivIPA,NYNAbIEHedde.Z Brothers Well,Drilling�.Inc '
PHon p 6 91_369 95 1
- S"rATE WELL CONSTRUCTION PERMIT? ASSOCIATED )YQ PERMIT.- -
-
I WELL USE (Check Applicable Box): Residential EMunicipal/Public ❑ Industrial O Agricultural0
Monitoring ❑ 'Recovery 0 Heat Pump Water Injection 12 Other ❑ IPOther, List Use
Topographic/Land setting
2. WELL LOCATI N ol
Nearest wn: County ❑Ridge CSlope. OValley ❑Flat
(che.k appropriate box)
-- (Stree( qaine,-Nunbcn, Convnu ni", 9ubdi alon, Lot No., zip Code) Latitude/longitude ofwe!l location
-
t. OWNER ' '(degrees/ininntefhecondnJ
Add�'Css Latitu;c/longitude Sarce.OGPSOTacograpJuc mac
$tt/p�2l or oWe No.) (:ae<k :Jx) .
��.///// DEPTH, DRILLINGLO
�
(�City br ��ppyy��n /� Zip Coto From T 0 Formation Descr Lotton
f • 5�Y % (G clay & sand
_
Are, <ade. Pnmn<nu,nbar r� ' � granite
o
4, DATE DRILLED 41 —
5 TOTAL DEPTH;CQ(-)r) r
6. DOES WELL RBPLACE EXISTING WELL?, YES El NO C —
7.STATIC WATER LEVEL Below Top of Casing FT. -- —
(Use"+"ir Aeave Top of Casing),
S. TOP OF CASING IS 2 FT. Above Land Surfa..e' -
--Top of oaalnq torminated at/or below land surfacc requfrea a —
vurlancelra2ccerdanaefvlthl5ANCAC1C,0118.' -
9, YIELD (gp n): iQ0 METHOD 91FTEST blow
10. WATER ZONES (depth): 6._
LOCATION SKETCH
it. DISINFECTION: Type H T H Amount . 16 cz Show direction and distance in mils froin at least
12 CASING WaILThicknss two State Roads or County Roads. Include the road
Depth D Mete; or W.e' it, Ft Material numbers and common road names,
From 0 To 1 Ft._
g
o
: From To Ft, Y -.. X
. o
,. From- To - Ft.
I2:"GROUT: Depth Materia' IMe:hod
From 0 To 20 Ft. tsffrnite & =Est . purr -pea
From - To Ft. ca
r
14 SCREEN Depth Diameters Slot Size".; bta;ericl
From To - Ft _in. in. 3
From - To Ft. in. In. w
n
15. SAND/GRAVEL PACK ca
Depth Sae . .Malaria'
From To Ft. —
From —To— - Ft.: -
16. REMARK$.
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C, WELL
- CONSTRkTION STANDARDS, A THAT A COPY OF THIS '+(,}ORD HAS 55EN PROVIDED TO—, HS WILL O\`/YER
`STp JATURE Or PERSON CONSTRUCTING THE WELL DATE
IV
Submit the or!;Inat to the Division of Water Quality, Groundwater Section,' 1606 Nla!I Service Center - Raleigh, NC
11699.1656 Phonc No, [phone], within 70 days. ,. GWI.REV. 07/2001 -.
.; _ .v