Well Contruction Records Jackson CY 2000

WELL CONSTRUCTION RECORD WELL CONTRACTOR:
' \YELL CONTRACTOR CERTIFICATION":: -- 1� 229293
to SS I STATE WL I-1- CONSTRUCTION PFRMITF:
1. IYELL USE (Clce:'a A;pliuSle eoa): Re;iden!i�. l t.IuniCi;,_t ❑ Indcslr;zi ❑ f,:i-ui:•,;rai ❑ t �oni:oring ❑
P,Oco:cry HOa' Pump 4VatOr I:I ecl:on ❑ O:h-r If OI::O,, Lis: Us
2. V;ELL LOCATION: ske: 'I o: t`^ Io:a.:on
(RoaJ Na— ntl l:cr, .ca. Cc.r,�"�w {c: S.}":vision-i�LUP
3. O'.VNE.i a SCE, u "l^il)
A,kd:ess 1/1 11 -2 M— _ �_ r _ •:� -
E 0:.1 L L E olknz ems cc I `a, a Cp>'
..
T:._..:
OTAL UEPTFI (, -6
C.
C'JITINGS COT LECTED YES , F:DI
j
7.
DOFS V, LL REPLr,-E EXiSTI:'.3 Vi"� % YES
E..
STATI-- V:ATER LEVEL E•_._.. Tcp o`�C�s':
Tzp
E.
TOP O: CAS!:J. Is i FF. Ab;:a L;,::d
Surf; c'' .
'1cp
Cc.;f::g:c.:•.: r.e:cl :c'a: :<: c':: I: :'s�::a:: rqc::<s
a vnr:...,:t In ecs:
3.
1'IcLO �L(_Tha:J O-T=$T_
l'IC
i3. Cr.SCCG
14. G:,O"'T.,
Do;.,l t.!a:oda: t.:c:hoJ
Fco::I'
Fro.il To FI.
15. SCREE?:
D_pJi D n*7sa:O: Si-1 Size
To
Ic _ FL
Tc_FL !-
F:z—. �.—.__ Tc FI.
F:-.— To Ft.
17.
DRILLING LOCI
c)
DEPTH n
,S4 Pi cv
re7
u ! y-�
_0
CD
_—._—
�
cm
z_
cn
�', t c V- C -K c c �l
ri
F3= 4-� Lem :. LAT
III I SUIIxL
G'R-I RE:'. 115i

North Carol'na - Department of Environment and Natural Resources Division of Plaler quality- Greundv.•a!er Section A n A 2I)
1636 Mail Service Center- Raleigh, N.C. 27699-1636-Phcno [phone] C `J
WELL CONSTRUCTION RECORD 1VELLCOiJTRACTOR: I�rvr-
WELL CONTRACTOR CERTIFICATION fr:W� 19-�_
STATE WELL CONSTRUCTION PERMITF:
1. WELL USE (check Appncable Box): Resldenlia1'n Municipal ❑ Induslaal ❑
Recovery ❑ Heat Pump Water Injection -❑ Other ❑ II OC.or, List Use:
2. WELL LOCATION: (Sho:v sketch of the location be!o•,v)
Neares:TOrQ� �Lt� 1)�- Ccu.1� N-CLC_ Sb/l�
Agricultural ❑ Monitoring ❑
(Road Xam n mSca C .rc , or Subc!Ms'.cn and Lot No.)
`�c`n1\�.-� 1�
a1,
DRILLING LOG
DEPTH
-
3. OWNER try ,
Q ��
From Tc
F' axon Descrpllw
Address -3 MPQ�, �� `
d- �$\�.\l
—(aveet er ou:� ao.
7.7
A-�
n S:a!o Zq Comae
ZIP
—�
:. DATE DRILLED Allo
S. TOTAL DEPTH 17 L (J
5b ',O
ft
6. CUTTINGSCOLLECTED YES�I NOD
7. DOES'.VELL REPLACE EXISTING WELL? YES NOF
s
E STATIC WATER LEVEL Bclov: Too of Casing' 0 FT
®
�— o
(U:o `.' II Abo':o Tcp of Cn:inq) T
9. TOP OF CASING IS
Fr. Above Land Surface' �p
'i op of eae:::3 lerrr.lna:ed a'lor belor:r
land Sur:.:. re qu!:es a varlanze In accor-
dance v:hh 15A HCAC 21—.0118
T
10. YIELD (gpm): 1 y2 ht
THOD 0= TEST G
11. WATER ZONES (depth):
—,A]
�q0 {^
12. CHLORINATION: Type \-j l t, Amen unl J!v_lf La&5 I:: d:!;:ienal spa_e is needed use ba_., _. ,a:m
13. CASING:
D:p:h C
From To-- Ft.-
14. GROUT:
W,stt i:dck-cco LOCATIC:d _KETCH
c (S\' ..... („�o'.� d'ca r "ds:_ c +- •.:I st lv.o S!alc
Dcplh ^M-a!orlal Molhod
Front' To ;�n F1. _S_t4]S�l 1 c>2L
From To Ft.
15. SCREEN: .
Dcplh Diameter
From=To FI i::.
From To _ Pt. _ In.
From _ To _ FI. In.
16. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To Ft.
17. REMARKS'
Slot S?,6 f.lalerial
in.
In.
_ Ln.
Ma,c:ia,
�\ s ba-r _b
IL;':-icRcoY CE4'.71='f THAT T.-:S%VELL':::-.S C0t:STij=T.-O I " I AC00=""CEP11-1H 15A NC AO 20, V/ELL
CONSTRUCTION STANDARDS, A":Demu.^r„3 c'.-iral lc(iA':.A,' TI/;R``E Gt FR'FaEt cFaiSOOuNi' iC:y0.Q0Y.6TuRr^.dUnCai:IcYr.GSciUf::cEn W�YEri LL .30 d1I/5
OWNER
[FOR _—]
Ovad G-FFICE USE ONLY
o: A
Serial lo.

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section 2 2 9 2 91
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 sox): Residential f .. Municipal ❑ Industrial ❑ '+�Icultural Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other EL If Other, List Use: ,1 /IJ IMP lye JY
2. WELL LOCATI N: (ShQw sketch of the location below) l
Nearest Town: , 1(e-�S County: v O'cLs
O 6A
(Road, Co munity, or Subdivision��"^d Lot N11o.) F �} L G I I DEPTH DRILLING LOG
3. OWNER m)ChS%)n \LJY15T. �l IAV��tS l7{�YYUf�{rom To Formation Description
ADDRESS '�Q^ 2OX ,](QC)
or
City or Town Slate Zip Code
4. DATE DRILLEDI? _19—Dt�
5. TOTAL DEPTH rZIF)
6.. CUTTINGS COLLECTED YES Q' NO❑
7. DOES WELL REPLACE EXISTING WELL? YE� NOER-
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 atior below land surface is Illegal unless a variance Is issue(
In'accorciance with 15A NCAC 2C .0118
10. YIELD (gpm): 'IVA METHOD OF TEST
11. WATER ZONES (depth):�� 1r _ cn
z
12. CHLORINATION: Type _k_"Amount dN 01115 If additional space is needed use back of form
13. CASING:
Wall Thickness LOCATION SKETCH
Depth C, D,iia--m``l�l1e11r or W lei 'UFt. Material (Shaw direction and distance from at least two State
From � To -sZL Ft. � � �i.4.Q. Roads, or other map reference points)
From To Ft. -
From To Ft.�( U
14. GROUT: IV7
`Ja,d
,
Depth
Material�� Method
From
�/�
O To Ft.
C_ Qyl—'` _
From
To Ft.
I
?QS -� ko d 5
15. SCREEN:
Y ee
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 C THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
D'DIQ Q4 f U0,
�uIFI SIGNATURE OF CONTRACTOR OR AG NT DATE
1 Submit original to Division of Water Ouali and copy to well owner.
GW-1 REV. 1/98
_�5' o

WELL CONSTRUCTION RECORD %YELL CONTRACTOR:
VIELL CONTRACTOR CERTIFICA11011
STATE NVELL CONSTRUCTION PERMITP: 929
1. WELL USE Res'd-nNa;8 Municipal ❑ I-
plecovery F-I Hunt Pum? w,!,r 1.1j,-I:on 0!',..o, Lis! U,,,:
2. V,ELL LOCATION:
Town: —
r,. 0NE.n
I,dd r c � s
of
C*- \Y.a cksh
2:,f LU r':,)
L. DOTAL DEPTH
C. G-JTTl\;GS COLLECTED YESffn-,l N-2L7
E_X7STi\'2 YES
LEV-1, Bc:ow To:) c! Cn-;: ', �j: E,. STA'i::: VVATE, I , FT , (J;c -.' i, love a T cp c:
E. TOP OF CASING IS
t,-. C
YI�2 � ti-TH-)D07TqT A 1
11. VIAl 7.0,','ES L45, '— 1.6
1 CH_0R;NATI
DNTypo
`I, V \_.
i C.41 S!.%:
To
i
----
Fro:7i _7c
Ft
e. GROUT:
Fr,.-i'
From
To —Fl.
SC7_=Et:
F., Tcr F: 1
F;o -.i Tc F:. I
F,,c m —To R. In. in.
V
D -a
T, Ff.
F:= T;, F:,
17. RE_ S:
k,,.,;:L;:IwalEl mon;tcrinjEl
CRJI-LING LOS DEPTH
h C—r
'7 3 + c) reel
A) tV
_c:)
cn
L 0 T F: 1, C
co
Ln
cr%
5C)LkA
v . (2 (ccK
IL
2 ) cfz.;s
— — — — — — — — — — — — — — —

WELL CONSTRUCTION RECORD
WELL CONTRACTOR:
VIELL CONTRACTOR CERTIFICATION
STATE SPELL CONSTRUCTION PERMITS: � (7
1. WELL USE (^nG]aF^,r.c]s!: Eoxj: ;municipal ❑ h�ai�:al ❑ A,:i:..�.ural ❑ 1.1a�i!crin� ❑
Recc:ri How; Pump Wakr It Ol:,_ , Lh! Ue_.
2. P.EII IOCATIO �'�\,(\a r • sF++ 'cl o Ih^ Ir ��n te!o'.�1
ks n�
r=.Tec:=.rieD G�6�aory
?OTAL DEPTF' k..
C. C'J, i INv'S COLLECTED YES [i—I t;,j! j
DEPTH
�i n.1
rQ ON) f�
7.
DOES VIEELL REFT-4^.= EXIST I'+ 1',_L'' YES
--
:.
STAT!C \PATE=; LE\'E,, E=10':: Tcp e.' Ces!o ��� FT.------
�.S•�:ta_?,EST
—
...ftif.]:L �._•_el].=SU::][G !]�C:GG :. •: ]: a(11C 1]G::K•
11.
VIAL r.', ZO::ES
Y� o
DebV
cill
14.
GR0JT:
D, l lsha.
FTo Ft. �tL•]LL\�. —�'�
;
From To Ft.
15. SCREEN
Si_I Sic
Frcm Tc _ Fi. In. _ in. _
—.-- c Ft.
F:.
17. fiEt.!AF.?:St
Ir�c'__ C Y� i',:' i •Err i.!�i � '.�: _ �. =Ll0-3 9_3V6/
_,
I's:
c--
-. G'Y1 REP. 13:;

North Carolina • Departmonl of Environment and Natural Resources • Division of 1laler Ouali;/ - Groundwater Section 223445
1636 flail Service Center- Raleigh, N.C. 27699-1636-Phono (919) 7333221 --�� ,yj
I
WELL CONSTRUCTION RECORD WELL CONTRACTOR: f) j02SI
WELL CONTRACTOR CERTIFICATION 11: `oi' I rF(p
' . )CA1 # I STATE WELL CONSTRUCTION PERMITR:
I. WELL USE (Check Applicable Box): Residential Municipal ❑ Industrial ❑
Recovery F-1 Heat Pump Water Wection .0 Other M If O(`or, List Use:
2. V,ELLLOCATION:
Nearest Town: _
(Road N
3. O'NNER
Address
Agricultural ❑ Monitoring ❑
sketch o lho location belov:)
Al V1 c0Uny: G�� S&AI
or
City or TIv:o Slate Zip Dote
<. DATE DRILLED eCe# _r'j;jat'od
5. TOTAL DEPTH _jnn
G. CUTTINGS COLLECTED YESMi NO❑
7. DOES Y/ELL REPLACE EXISTING WELL? YES 0 I;OV�6
E. STATIC WATER LEVEL Below Top of Cosing: /If O FT.
(Usc'.' it AScvo Top of Ca:i:rq)
9. TOP OF CASING IS ( FT. Above Land Surlace'
'Top of e03:23 terminated oYor bclovr land surfaeo requl:c, n variance in acco..
dance v:llh 15A NCAC 2c.0118
10. YIELD (gpm): 1/. METHOD OF TEST AI C
11. WATER ZONES (depth): 5/. " 3 3 D
12. CHLORINATION: Type —Anicunl
13. CASING:
Yba iltic:cr ss
Death DL-•. ", c. Y�;:--h;'i-1. cc.',.,.Ij
From CI) —To � Ft. �1,f /�---+ -
From To—_— FI. --
From To-- FI. —
1A. GROUT.
Depth Walorfal Method
From' Toc�FI.
From To Ft.
15. SCREEN: '
Doplh
Diameter
From
To
Ft — in.
From
— To
Ft. — In.
From
—To
Ft.— In.
15. SAiNDIGRAVEL PACK:
Depth
Size
From
To
Ft.
From _
To
Ft.
Slot Si:o Malorini
In.
In,
In.
Material
DRILLING LOG
From To
0-- 16`A
DEPTH
Forraaon D scrip::ca
�4,4j
rf�
I: ;AI:!%ional space L; needed us^ bag : o' form"
LOCATION S_E i-CH 2
dlrecCcn rind dis._n ce 6cm n: I_,-s. ✓ro Star^
Rca'_s, or ct:-.cr ma, r;c:cna; Ix••'s)
&1eA/a,- ,L�_skers
N v r+,a AJ' Rd
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS :/ELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY ( BE
OAF THIS RECORD HAS BEEN PROVIDED TO THE YlELL O'Nt�ER. L c
FOR OFFICE USE ONLY �!"�1-e1"E' -cos, LoC`
Ovad No: SIGNATUFIE GF PERSON CONSTRUOTING T HE WELL OATE
- - - Subma-oH.inal 10 Divls:on of Wa:or Ovally. G.cundWalcr Sccuicn wilhln 30 days
Serial r7c. GV1.1 REV. 1261
Ii`y"'!i
Croundwater Section
Asheville Re�onal Office J

North Carolina -Department of Environment and Natural Resources -Division of Water Quality- Groundwater Section 01- 2 3 4 4 4
1636 flail Service Center- Raleigh, N.C. 27699-1636-Phono (919) 7333221
WELL CONSTRUCTION RECORD %VELLCONTRACTOR: mw�4in M04hS
WELL CONTRACTOR CERTIFICATION Ik
1 Alei1,# I STATE WELL CONSTRUCTION PERUITN:
1.
WELL USE (Check Applicablo Box): Resident!WYn Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injeclion Q Othar ❑
It Olher, List Use:
2.
WELL LOCATION: (Show sketch of the location belo%v)
_
Nearest Tovm: U C`. County: ,%
a cksnnl
1I
C,4a1�e (� raNc�i, RocL.ct'
(Road t:a.rfo and Hum.bcrs• Community, or Subdivision and Lot No.)
DRILLING LOG DEPTH
3.
OWNER _ - c rr 15C, ! I P.
From To Forma:lon Descripticn ,(
"Jrp] �
Address � 0lla a �� if, it la lam"
IG r a )
(Suect ou;o 90.
� F�7
5 /ZI ctrn
Llty �c,;n Stale ZIp GoGe
�
4.
DATE DRILLED D_cC Nmbr'7y
S9 to 3
5.
TOTA!_ DEPTH 3? 0
6.
CUTTINGS COLLECTED YES MX, NOO
7.
DOES VIELL REPLACE EXISTING VIELL? YES I•!O�
S.
STATIC WATER LEVEL Bclov: Top of Casing: Fr.
_
(Uso -+- it Above Top of Cnang)
O
9.
TOP 0: CASING IS ( FT. Abovo Land Surface-
a
-Top
of lazVor below land surra<e requ::a n va ne nco In eeco:-
µ�
dan:c
with 15n HCAC 21-.0118
c-
-------
10.
YIELD (gpnt): /0 METHOD FF TEST At f.
2 s-ro*r
11.
WATER ZONES (depth): Ito) •3 ryd
12.
CHLORINATION': Tppe �'� l �� F.:nocn)1'LP
rrn
13.
CASING
---__-- --_—--__—'-N 01
Vfi! T:yckr.
LOCATION SKETCH m�
�
,.
D2put r� er u5' i°L• -'c"ai
.y
(Shoe: dv,.: Eon and dster.Ce t:crn .: Ls! !r:o Stata� CD
Fran t o FL
ads, or hcr map fetc race pc..:s)
cl
From To FI. --
14.
From To -- Ft. —
GROUT:
!
/lt�l il�NKIrN
Depth M�ato�rlll Mothod
/� %�
5 I� 13� 5 �&cj �e 'Jr•
y�
From' Tot Ft. 5�1� i'.Ll \ C>•�L
From To Ft.
15. SCREFN
Depth Dianne for Slot Site Matorial
From — To Ft In. in.
From To FI. In. in.
From —To Ft. In. —In.
16. SANDIGRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL YdAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL /G./ C� 1
CONSTRUCTION STANDARDS, AP:D THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE`�YIELL OWNER.
FOR OFFICE USE ONLY ��N C)CP-e-A+e 1.)COS u-,"_\` � I G,-,0"���A,
Ovad No: SIGNATURE OF PERSON CONSTRUCTING THE V,'ELL DATE
Submit odgiraf to Di-,k:on of Vra:cr Ovally. Grcundv:a:cr Sccr wilhin 30 days
Scrial No. G%V.1 REV. 121"
+f l
Ceoundwater Section
Asheville Regional Office

North Carolina - Department of Environment and Natural Resourcoa - Division of Water Ouali,'/ - Groundwater Soclion L 2 3 4 4 3
1036 Mail Sorvieo Cantor- Raleigh, N.C. 27699-1636-Phono [phone]
r WELL CONSTRUCTION RECORD VIULLCONTRACTOR:7Yl'a�"Yl(
F
WELL CONTRACTOR CERTIFICATION It:P) Flq�
STATE WELL CONSTRUCTION PERMITII:
1. WELL USE (CheckAppllcabla Dox): Residential Municipal ❑ Industrial ❑
Recovery ❑ Heal Pump Water Injection Other ❑ It Other, List Use:
2. WELL LOCATtg N: (Show sketch of the location below)
Naarost Towp: \ tlhr y�'� l(- County:
Agriculture! ❑ Monitoring ❑
(Road Name n d Numbers. (Go or Subdivision and Lot No.)
DRILLING LOG DEPTH
3.
OWNER ^71 YT (1 (,l'(Vr5
�(
From To Founatlon Descri tion
P
7
Address 1)1 o 7t1-Y Li7)V) 0Vo
rco or 'o`u7o-I-o'j
City or Town Zip Coda
.1.
� 1� ���S�lato
DATE DRILLED
5.
-la[—f��
TOTAL DEPTH 1 0M
G.
7.
CUTTINGS COLLECTED YES Q� NOD _
DOES WELL REPLACE EXISTING WELL? YES N0'7-'/ T_.�+j;� ]�'
C.
'STATIC WATER LEVEL Below Top of Casing: FT.
(Usa '., it Abovo Top al Casir,) -
—
y
G.
TOP OF CASING IS I FT. Above Land Surface'
'Top
of caalu9 lanuhmtad oVar blow land surface raqulraa a varlancu in actor-
dance with 15A NCAC 2CI .0,'1'1a (°P
10. YIELD (gpni): METHOD OF TEST `) l
_
11.
WATER ZONES (depth): 1)U " yFir, _—
_
3
12.
CHLORINATION: Typo JCL —Amount
1: additional space L needuv usback of corm
.0
13.
CASING:
- --
-"-_j
VJall'fhlcknass
LOCATION S"::ETCH
Depllt /) j Di Meter or Wcl,��1��/(1';�. Maledal
From To In �T L
(Shoodreclion and distance frou, a; Ieast hvo State
Ft.
RoaJ5, or other map referee -,points)
From To FI,
.
Front To-- Fl.
n
14.
GROUT:
Depth Malolial tlothod
Q>n�
From _i1— To R. _
, f
�` ; i l (1 j� cl f2
From To Ft.
j
15.
SCREEN:
Dopth Diameter
From _ To FI In.
From To Ft. In.
From To Ft. In.
1G. SAND/GRAVEL PACK:
Depth Size
From To FI.
From To Ft.
17. REMARKS:
Slot Sizo %:atorial
In.
In.
In.
Ma:urial
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRICTED IN ACCORDANCE WITH 15A NCAC 2C, :'/ELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO TI1E V. ELL O
,44.El� r.
FOR OFFICE USE ONLY ✓!- t r
Quad No: - SIONA11'RE Of PEIISON CONSTRUCTING TI IE V1 G
Submit original le 01'::.%lan of 'vlalur Quality, GrounLualcr section lvllili❑ 30 Jays
Smtal No.
J
I 6myndwater Section
z'n?iLRegional Offi�rej
DATE
GW-1 REV. IJ'19

\'JELL CONIISTRUCT(ON RECORD WELL CONTRACTOR, �-r--
PiELL CONTRACTOR CERTI; ICAl 10:i (:
STATE %YELL CONSTRUCTION PER !ITC:
%YELL USE (cneckA;; czSte Hor): E-1 In,'esl:i_I ❑
P coi_•y Ej H Pu ;lp Wale I� �cCc� ❑ O h_; I' O:-c,' LIs(,U_:
2 %VELL LO ATIO:Tkel 'i o t' c-Ir_ w^ Lr'c. )
r To.U�jQ rKSA' A)
(���'• 't:w- zCc a.,_Lc'ho.)
G_IT-iI>:SCOLLECTED YS[r:0`I
G ES',fELLREFLc.'_ErY.iSTI':_:1'i3!iYL9
ST-.,.0 IY?SER LEVEE E._:.,.: Tcn of C=s::, � F-,-
C. TOO: CAS!:.., IS
Tc Fl15
_ ---- T -- F'
-, _ -,------- Tc Ft,
Ft.
DRILLIN , LOC
—�c1 f
DEPTH
Fc1 a'-.1C:::; :'cn
Cc
tL Tl
c
�74 Braioch
5 R 1705 la t,) 4-o N
-n..-Tn 5'_L CC: ;c T:"Z'C-E_
L__.,.,=. • ..R`rnrl l�o-�S
C,
Gi.•�i.�iGiT/fa
11
TIONII
OFFICE

North Carolina - Deparlmsnt of Environment and Natural Resources - Division of Water Guam,— Groundwater Section
1636 Gait Service Center - Raleigh, N.C. 27699-1636-Phone [phone] r -1
29
WELL CONSTRUCTION RECORD WELL CONTRACTOR: k!_v in l - I, N
Y. ELL CONTRACTOR CERTIFICA1 1011 ,t: 1:9 I��o
LI:C (l # 1 STATE WELL CONSTRUCTION PERMITN:
1. WELL USE (Check Appilc.bla Pox): Res:denlialn h!unioipal ❑ Industrial ❑
Paco%cry ❑ Heat Pump %Valor In;ection -❑ Olh_r ❑ If 011-0 , List Use:
Agricullural ❑ Monitcring ❑
2. %l:ELL LOCATION: (Sho':+ske:ch of the location be!oz.)
Nearest Tovm: n >A 1 ( fl'1 ++ - - -_ Ccunry: -J CC C KS A A)
BLit r-_ Rc�
(Roa, Name tntl�'"itu�-.�ca, Cornrr.onl:y, of SvJG:vis c. an f Lcl No DRILLING LOG DEPTH
S. OVINER J} C I/lt'n u k rd we l l Fram Tc For:. on Des^r li
Address p, n x 1� G u 43 1 0 - —
CI;; or Tcv:n Sla:o Z'p Uc.-2
DATE DR!LLEDAI V&"7Lr17 -�ZCCO
S. TOTAL D E P T I I 610L _
6. CUTTINGS COLLECTED YES NO L_I
7. DOES',VELL REPLACE EXISTING 1VELL? YES ❑ I;0, -,
6. STATIC WATER LEVEL Belot': Top of Casing:
(Ucc'.' it Abc.o Tcp ct Cn:c+c)
9. TOP OF CASING IS_ I FT. A`ovo Land Surface'
'Top of coi:'9 tr. nil catcd a7C cr Colon land suoca rcqu::ca n vs;anm In accc:-
dancc wilh 51, tiCAC 2C.e113
10. YIELD (rpm): 2_ METrIOD OF TEST AI
i
11. WAIER ZONES (depth): �_`
12. CHLORINATION: Type—s1_�—\� A: 1',e;: n; �12,1/,a
11 GYBING:
(
De�;h
c: 1y�t.js:
Fronnl.
103Zr't.-lJ�--
From
To
Fl.--
--
From
To--
Fl.
—
14. GROUT:
Depth
1,!3loda! Method
From'
To �_Ft.
From
To
Ft.
15. SCREEN:
Depth Dia,ne;cr Slot Size t 3lor!ai
From To Ft — in. in. From __ To Ft. In. in.
From To Ft. . In. in. _
I6. SG.ND!GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
17. REMARKS:
O
p
o:
CC)
—
yF n1
yo
CA o
_LOCATION : i_ETCH Z
I DO HEREBY CERTIFY THAT THIS WELL \VAS CONSTRUCTED IN ACCORDANCE WITH 1SA NCAC 2C. WELL
CONS T RUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS EEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY H A fl-\ (_i Ce-e_ty e- � S r 05 � \ \ k,-� 1
0e3.1, r9o: SIG!:ATURc GF pERSOr1 CONSTRUCTitiG THE \':ELL
Subrt:6 or(.jnal to Division or Przlcr Oua l7. Groundvraer Scv.cn Within 30 da%s
Serioi No. i i
3
/!/ /SIcd
sv/otcx--
DATE
GP7.1 REV. 12'59

North Caroll:na - Doparlmenl of Environment and Natural Resources - Divislon of Waver Ouali , -Ground w a:o r 5eclion 1636 td all SeO1rvice Center- Raleigh, N.C. 27699-1636-Phc no (919) 73.3.3221 �' �' 1 Q
WELL CONSTRUCTION RECORD %YELL CONTRACTOR: ' - IL1--arrcj
WELL CONTRACTOR) CERTIFICATION
.# f STATE WELL CONSTRUCTION PERLIITN:
1.
WELL USE (check Applicable sox): ResidentI_,,,n thlunlcipal ❑
IndusLia: ❑ Agricultural
❑ t.1onitering ❑
Recovery ❑ Hea; Pump Water Injection -❑ O:her
II OC-Ic:. List Use:
2.
%',ELL LOCATION: ($Lh'ov,&etch of the location be!ov.)
N�ea:c�s: . .. .. '1J
Cl-/SnTov.
CJJN LL, nJ
(Road Name end Nurlmoc:s. Co: cr; N;y, er SutC:vis:en aLcl Nol
DRILLING LOG
DEPTH
3.
O•:^/NER A C.{7 �, /1)Q _
From
Fen rton oescrpllco
�:j—,'%n !I
Address �_,�-�l��' JC l4 r �� /S
�Tio
0 — 0 5 --
Ale
Ltlj . c,':-4 T , S:a;c Zip Comae
..
'r
D.'.TE DRi'_LEDL J 2��CCi'?
r U
_,.
TOTAL DEPTH _ o 70—
-
C.
CUTi IXI-S COLLECTED YES �j FJO
-----
--
7.
DOES %/ELL REPLACE E>JSTING WELL? YES ❑ ti02,
S.
STATIC V ATER LEVEL Below Top of Casing: /DO FT.
(ULo -,' it Abc:, Tcp cI Cc--,,G)
9.
TOP OF CASING IS I FT. A:ovo Land Surface'
-i op
of cr3::'3 lr. n-..Ina!od oYe; hole, lond scCae, royc:rca n vaxlancc In c¢or-
-�
dance
wllh IS,. HCAC 2C,.3 i13
C_> Cn
10.
YIELD (gprn): t.1ETHOD OF TEST AI r'
11.
WAl E-1 ZONES (dop;h):
o
12.
`X�'�`r-
CHLOR;NATION: Type \ F=, Arnc, nt
Epa_e s needed u.e F o. _. f'x S �o
13.
CASING: -
-
: 'r_F_ I CC'
9laa i;;d:-c:.
DIP';'.
7- V6
_LOCATION
From �� o Ft. y _ i
n o cL. mnp
From To--- Ft.
Front - To- FI. -
14.
GROUT:
t,lothod
� � I
I
/v
Depth L1a:r,Ilai
0 Ft.
Front'
From To Ft.
15.
SCREEN:
. Depth Diameter Slot Slzc Maloriai
From To Ft in. _ in.
From To FL In. in.
From _ To Fl. In. in. _
15.
SAND!, -RAVEL PACK:
Depth Size Material
Fcom To Ft.
From To FL
17.
REMARKS:
1 DO HEREBY CERTIFY THAT THIS WELL %'.'AS CONSTRUCTED IN ACCORDANCE %'iITFI 15A NCAC 2C. WELL
CONS T RUCTION STANDARDS, AND THAT A COP'f OF THIS RECORD HAS PEEN PROVIDED TO THE" LL O'NIIER.
FOR OFFICE USE ONLY
Ovad r;o:
soda) ue.
any
51G'IATU6E GF F.ERSON CONSTRUCTING THE WELL
SuSm.a on r Io:.I©i'rl 1p,ON1'lti:o:Oua:J, Gcurd. a.cr 6ccrtcn'rrit,'tin 30 days
f
DATE
GY1 I REV. 12)79

North Carolina - Department of Environment and Natural Resourcaa - Division of Water Quality - Groundwater Section . 1 ,) )) ((��
1636 Mail Servlce Canter - Raleigh, N.C. 27699-1636-Phcno (919) 7333221 i.._ J U 18
WELL CONSTRUCTION RECORD WELL CONTRACTOR: U SSe tYl / a 4 Ut-
�j2,11 V, ELL CON1 RACTOR CERTIFICATION fi: c;t I87%
_j* STATE WELL CONSTRUCTION PERLIITF:
1. WELL USE (Check Applicable Cos); Residen:ia� 1Aunicipal ❑ Industrial ❑ Agricuhural ❑ Monilcrinq ❑
Recovery ❑ Heat Pump l'Jaler In;eCtion ❑ Olh;r ❑ If OC-,or, List Use: _
2. 1VE(_L LOCATION: (Show sketch of the lo:ation bo!ov.)
Nearest Town: —. CcuI/.
CA ,Crrr
P(�Nu:uS �Lh#WSnr✓ �c'2rf
(Road N3T19 I .d NJnbcrs, Ccntrr f:y, a fr.:bd:vislcn and Lot No,)
DRILLING LOG
DEPTH_
3,
O•'NNER'1111]�-(�C�C
Fmm 7e
crra;ion Des.rip:!co
Add revs p r or a14 LA 'I
--
ite or 'o
�
�Je`o��e� NC �s78is
—
l;�
r_(I A;:'f�
Sta:o Zip Cc'e
,.
D'.iL_CUP _EO�avernbe� IO�a-ub
i y ram'_ (w
,.
"i UT_DEPTH _ U-,_
FJ
_
_---
G.
CUT-M,:GSCOLLECTED YES[%J NOL
--
--- ---
7.
DOES :'TELL REPLACE EY,ISTINC WELL? YES [_] I;0,
c.
STAI 1C 11ATER LEVEL Bclow TOP of Ca57n9' [� FT."—�ta-
(Us c'.' it A:.,c ac Top c! C,,
M O n
D.
TOP 0. CASING IS I FT. Abovo Land Surface-
-Tcp
cl casing lerminaled Door 6clmv lend surtoco raqulres a varlancc in accor-
---
�Br"
--- CO
dance
10.
will, 15A NCAC 2C.e113
YIELD (can,): __:�C>_ 61ETHOD OF TEST _GI
--�-e
11.
%VAI ER ZONES (depth):
W rn �a
12.
C; iLORiXAT13N: T v-e —�--\ I t—` —__%.a FJJni T/J /2c12
r/.di:i:: r, ni Sr,:, 1..,2Cde1',L':.0 b2z]: _. m— :j
13.
c.',slNG:
S_F F CH
1Vz9 T'L-'...-r o—LOCATION
�
F ro-n; _C:�_To Ft. - _ _ 2."— _5.
r _ s, c rap
From- To — FL —
From To-- FL
14.GROU::
Daplll raa;orlall L'othod
From' To=�1_ Fl. �tLlitl\v. 2L
i
ly� L:.S
k D )D.'AJ S 1)10
From To FI.
15.
SCREEN:
Depth Diameter Slot Sze_ Llaloriai
From To Ft _ in. in.
From To FL In. in. _
From To Ft. In. in. _
15. SAU DiGRr.VELPACK:
Depth Size fdalerial
From To Ft.
From To Ft.
17. REMARKS:
I DO HEREBY CERTIFY THAT TH:S PIELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A N-_AC 2C, WELL
CONS T RUCTION STANDARDS, AND THAT A COP'( OF THIS RECORD HAS BEEN PP,OVIDED TO THE V V ELL OWNER.
GF PERSON CONSTRUOTING THE WELL DA T E
of elatcr Qua:::y, G:cur,dralcr Sca:cn 'within 30 days
G',V.l REV. 12'51
11r j/ob

North Carolina- Department of Environment and Natural Resources - Didsion of Water Quality- Groundwater Section ` r 1 3 7
1636 Mail S�3NIce Center - Raleigh, N.C. 27699.1636-Phone [phone] ti
WELL CONSTRUCTION RECORD WELL CONTRACTOR: ALS-lip-l/ T a it,r
WELL CONTRACTOR CERTIFICATION k: o2
' STATE WELL CONSTRUCTION PERMITP:
1. WELL USE (check Appllcable Box): Residenfia3�n Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, Lis( Use:
2. WELL LOCATION: Show sketch of the location bolos•)
Nearest Tol- n: U C` County: j E� Gk S C, A6l
(Road Nam�e nd Numbers, ComrfiuNly, or Subdivision and Lot No.)
3. OWNER J V 'c\ QC S e
T
Address
lJ'C In Ca N cA V')QC c h 1- \ or � a 51_ 314 I' 1 b
Ci,y or Tcv:n slats Zip cote
4. DATE DRILLED N"eanhew lr L;LGCU
S. TOTAL DEPTH t-110
G. CUTTINGS COLLECTED YES© NO❑
7. GOES :',ELL REPLACE EXISTING WELL? YES [] N0,0
B. STATIC WATER LEVEL Below Top of Casing: FF.
(use'.' it Abovo Top of CnLinq)
9. TOP OF CASING IS j FT. Abovo Land Surface'
'Top of eaa!n, terminated et/or below land surface requif" a variance In accor.
dance with lit. NCAC 2C.e118 /1
10. YIELD (Rpm): -\_ METHOD OF TEST _AI C_
11. WATER 7.ONES (depth): 5 r -'R o 33'
\'_t�r- ILoD
12. CHLORINATION: Type�� !-,moon;'lla
13. CASING: l
V,31 Tldckncss
Dealt _ Di !or o_-1': el.;t :'F t. L:a:c.".al
From To sz( Ft. �P
From To-- FL_ ---
From To- FL —
14. GROUT:
Depth Malorlal fdothod
From' TocaaC_FI.
From To FL
15. SCREEN:
16
17
Depth Diameter Slot Size Malorinl
From To Pt in. In.
From To Ft. in. in.
From To Ft. In. In.
SAND,GRAVEL PACK:
Depth Size Material
From _ To Ft.
From To Ft.
Agricultural ❑ Monitoring ❑
DRILLING LOG DEPTH
From To Fbnca;lon Descr,p;'l,cn
U a.-, —_ C,Ick
to
- co �z
space iz needed use
-LOCATION _6_'r: E_FC H
(Sl,o,v d4ecicn r.nd Culanee' r.- '. I wo S`a;a
noads, or ether rap racrcnc:
Lv�`1NesU (1.en4
I DO HEREBY CERTIFY THAT THIS'N`e LL WAS CONSTRUCTED IN ACCORDANCE WITH 1SA NCAC 2C, V/ELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY �(' i Ce.e_t�i
Ovad No: SIGNATURE OP PERSON CONSTRUCTING T HE WELL
Submit Od.;(13110 DivL;on of Waist Qua::ty, G=nd�a;er Section within 30 days
Serial No.
i
sv/L)C--
DATE
GW-I REV. 12/53

North Carolina - Deparlmont of Environment and Natural Resocrceo - Division of Water Quality - Groundwater Section r r 1 � O � Q
163E Mail Sorvlce Center - Raleigh, N.G. 27699-1636-Phono (9I9) 733-3221 r :, ,� V
WELL CONSTRUCTION RECORD WELL CONTRACTOR: _l -
o r I oK
VlELL CONTRACTOR CERTIFICATION U:
STATE WELL CONSTRUCTION PERM;T;f:
1. WELL USE (Chock Appflcabla Box): Residential Municipal ElIndustrial ❑
Recovery ❑ It Pump Water Injection Othor ❑ II Other, List Use:
WELL LOCATIO (Show sketch of the location bo:o•.v)
Nearest Town: _ CL�SQVYI Ccu:.ty:
Agricultural ❑ Monitoring ❑
(Road Namo�rand __NUmupIS. Community, or'ubdlvLlcn and Lc'. No.) DRILLING LOG
3. OWNER �'� �1111VS�YT Rom To
Address
/1 traot�r ul�oy
,
Cify or Town Stato �Dp Code
4 DATE P r-r)
S. -1 O i AL u_,
G. CUTTINGS COLLECT ED YES [�i NO[] -
7. DOES WELL REPLACE EXISTING WELL? YES Ej N0[2� n 1-
C. 'STATIC VIATER LEVEL Below Top o' Casing: .--
(Uso '.' it Abovo Top a: Caain;;)
'J. TOP OF CASING IS FT. Abovo Land Surlaco'
'Top of easing larminated at/or below land surfaco roqulros a varlance In accor-
dance with 15A NCAC 2C .0110 (�p, ,,
10. YIELD (gpm): C) METHOD OF TEST _` 1 4 -
11. WATER ZONES (depth):-
12. CHLORINATION: Type '� Amount _I
13, CASING:
Depth GI.]]m��cicr
Front To �— Ft. `r'� 4
From To FI.
From To-- Ft.
t4. GROUT:
Depth/l
From To s � Ft.
From To Ft.
15. SCREEN:
DEPTH
Formation Doccnpllon
II additional space Is ;ceded use back of form
Vfall ihlc:;�sss LOCAT"ION SKEI"CH
or Yld;;ir°4 h'atc d;,i (Show direction and disla:•ce hotn at least two State
Roads, or other map r^;crmice points)
Malarial Method
Dopth
Diameter Slot Size
Material
From
To
. Ft In.
In.
From
To
Ft. In.
In.
Front
To
Fl. In.
In.
16. SAND/GRAVEL
PACK:
Depth
S,zo
�...:.ena•
From
To
Ft.
Front
To
Ft.
17. REMARKS:�,/YY`--(�iC9.
✓\h,
Q
O
n�
earl l�,ci� Sf210o5
LICIL �0 1� SQ Ir10(�
1 DD HEREBY CFRTIFY THATTHiS WELL WAS CO'JSi i:UCTED IN ACCORD,.NCE WITH 15A P:CAC 2C, V/ELL
CONSTRUCTION STANDARDS, AND THA�AT A CO � 01= 1"FITS RECORD HAS BEEENJ PROVIDE,
TO 1Ni4 V/ELL�O'v%NER.
FOR OFFICE USE ONLY A4 i.,�0 ✓ & n, 1�✓-r'y, , (, �(,' /L_/�'��)
Quad No SlGrviA U, iE 0i PERSON CONSTRUCTING THE 4.' .l DATE
SYJi W1Ar.�inal to U'r oion a• !'a'or Oua.ily, Ground n'alar Sec: en 1"I. `:I`. 3J days
satin No. _ v J Gsv.l n[v. 12123
it
SECil9R

North Carolina - Deparlmonl of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center- Raleigh, N.C. 27699-1636-Phono (919) 733--3221
WELL CONSTRUCTION RECORD WELL CONTRACTOR:SS�II TQyI�
WELL CONTRACTOR CERTIFICATION (1: a I F�q
STATE WELL CONSTRUCTION PERMITIF:
1. WELL USE (Chock Appllcabla Sox): Residential 11
Municipal ElIndustrial ❑ Agricultural ❑ Monlloring ❑
Rocovory❑ Heat Pump Water Injection ut Other ❑ If Other, List Use:
2, WELL LOCATIO/N:,(,S/hoe+ sketch of file location bciow) 1
Noarost Town:--`��l'�y_ Cou:lly:
Jul1 r, a.. �.
3. OWNER
Address
DRILLING LOG DEPTH
1 From To Formation Description
WI(
co or We '�Cto 0X?i (
City or Town Slato ZIP Coc��'"-
4.
DATE DRILLED _ )(]
5.
TOTAL DEPTH
6.
7.
CUTTINGS COLLECTED YES Q� NOF-1 — 11
DOES WELL REPLACE EXISTING WELL? YES ❑ NOM/_
B.
'STATIC WATER LEVEL Below Top of Casing: (-
o '
(Use'.' II i.bovo Top of Camp)
O
U
9.
TOP OF CASING IS 1 FT. Above Land Surface'
O
-Top
of enaing lennloaled iI below land surfaco reyulroa a variance In actor-
vam
dance
with 15A NCAC 2C.0110
10.
YIELD (gpm): MGTHOD OF TEST _
tV
11.
WATER ZONES (depth): —' —_
CC)
o
.�I
12.
CHLORINATION: Type Amount ) ')i5 It additional space is ne cd ed use back of form
13.
CASING:
fd
Nam_
LOCATION SKETCH
W
Wall Tlilcknoss
o
Do th DI motor W •i 0 t I la'cilal (Show direction and distance from at least two State
Z
p
From
From To Ft.
From To— Ft.
14. GROUT:
Depth Matollai Method
From To ,
Ft.
From To Ft.
IS.SCREEN
Depth Diameter Slot Size Material
From —To—Ft— In. In.
From —To—Ft.— In. in.
From To Fl. In. In.
1G. SAND/GRAVEL PACK:
Depth Size Malarial
From To Ft. _
From To Ft.
17. REMARKS:
Roads, or other map reicience points)
I DO HEREBY CERTIFY THATTHIS WELL WAS CONSTI.UCTED IN ACCORDANCE WITH 15A NCiw 2C, WGLL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED 70 THE WELL 0
FOR OFFICE USE ONLY
Ouad No:
'
enal No.
SIONATURE Of PERSON CONSTRUCTING THE'
Submit original to Oi,slon of :Valor Quality, Groundwater Section
Ski /Jva
9L -A, J/ xii
/ d DATE
30 days
GW.I nEV. 12M9

J 3A
North Carolina • Department of Environment and Natural Resources • Division of Water Quality• Groundwater Section f 2 u 1
1636 Mail Service Center- Raleigh, N.C. 27699-1636-Phcno [phone] - ` .1
WELL CONSTRUCTION RECORD WELL CONTRACTOR: (Yl01 l_ '- r-+h:S —
WELL CONTRACTOR CERTIFICATION 11: �
r'Ne11 I STATE WELL CONSTRUCTION PERMITN:
1. 1'/ELL USE (eheckAppncable Box): Residenlia;N Municipal ❑ Industrial ❑
Recovery ❑ Heal Pump Water Injection .❑ Olh_r ❑ U Other, List Use:
2. WELL LOCATION; (Srh+ov, ketch of the location below-)
Nearest Tovm: l U 10 Le_ County: , O C-k S OA)
T- n _ L..
(Road r:arne antl F:umbcrs, Conmu�q j�', or 6ubdivisicn and Lot No.)
3. O''WNER a rd,A(�
Address 2 - L r" ✓e
avect or a 'e a. ILt1_ A)c a9rf)99
ri;� or lrevn State Zip Code
At. DATE DRILLED l Mile. Cr �7 aK,C
5. TOTAL DEPTH a -1U
6. CUTTINGS COLLECTED YES�I NO❑
7. DOES :YELL REPLACE EXISTING WELL? YES NO Y
E. STATIC WATER LEVEL Belov: Top of Casing: _ j_ fT.
(Ucc'.' it Abo:o Top of Ca;i;,Q)
9. TOP OF CASING IS 1 FT. Above Land Surface-
-Top of eas!:tg lerrnlnaled oVor belowland surface req.:r. a varlanca In accor-
dance with 15A HCAC 2C.0118
10. YIELD (gpm): QLD _ METH09 OF TEST Al IL
11. WATER ZONES (depth): r' /7,�i a YZ —3_(0r
12. CHL0RINATI0N: Type _) V h Amount
13. CASING: I
Agricultural ❑ Monitoring ❑
DRILLING LOG DEPTH
From To Forraaon Description
cv— cO C 1 Ct I
(p of a-o h 1 t. rQAA) I
_ 17 t0 .�YU f1
It e.di5oral space L: needed me ties : e: f^rm
Lvaa T:iick..css _LOCATIO!d SP_EI-Cfi ,c- :4
Depths C'- c C. 'R c"al (She*,:d'recCencid dslcnee.:cri:: lets!two State Q► o
From �> To r I Ft. ,�e� Ecads, or Cther mnp Wc: ancc
From- To-- Ft. -- / //��
Front To-- Fl.A)�-! IJ
14. GROUT: / �1 3 oZ 1'k r�
Depth Nalcrlal Method S� / Li y � /'" r�s )�e✓' C ✓e�i IC
Frost" To 5a_0_ 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
Ft.
From
To
Ft.
17. REMARKS*
Slot Slzc Material
in.
In.
In.
Material
100 HEREBY CERTIFY THAT THIS'NELL WAS CONSTRUCTED IN ACCORDANCE WITH 1SA NCAC 2C, WELL /�/
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL O'NNER. /�C`-'
FOR OFFICE USE ONLY ._. _L'SS_.1,.`a..�e-g-lJ �' tit �' OS �• �' , I ,
OvadNo: tih iil ?61 n RG PE SOrrCO:ISTRUCiIr1GiHEWELL DATE
1 rlQuall:/. Grcundwa;er Secuen wil`tln 3O days
Scrial No.f GY!-I REV. 12'53
r

Nonh Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section 2 2 3 4 5 0
1 G26 Mail Service Cantor - Raleigh, N.C. 27699-1636-Phono [phone] (� / W LL CONSTRUCTION RECORD WELL CONTRACTOR: C�IUCk l `�'0' \ 1 0)1CUYN
WELL CONTRACTOR CERTIFICATION fl: I i'JiJ
}� �_ STATE WELL CONSTRUCTION PERMIT1):
1. WELL USE (ChockApplicabla Dox): Rosidontial (Municipal ❑ Industrial ❑
Recovery ❑ Heal Pump Water Injection'][ Other ❑ if C!bor, L!s'. Use:
2. WELL LOCATION: (Show sketch of the location below)
Agricultural ❑ Monitoring ❑
Nearest Town: C't°Vll)t1(E. County. ,)O.(�/,SGYl
-
_LaV,u)teL--z (�e�ahf / Whca�5klnc-yl,
(Road Name and NumSars, C6,;innuully, or Subdivision and Lot No.)
DRILLING LOG - DEPTH
3.
OWNER �.I J(J i 1 Q I Y 1
Flom To Formation Doscdptlon
Address O .1�Y .
.�aeto
or lieu o o.
'L11Ui le, e� �//LL--
_OI�ircal
.
City or Tavm� State Zip Coda ---
_
-!�—•��
1.
DATEDRILLED I1-Q`0n
o
�.�
S.
TOTAL DEPTH 9Or)-3J,oc-4- Je-E)CY _
-t-CJ .'):l _ O✓YU
., o
6.
7.
CUTTINGS COLLECTED YES Q� NO❑
DOES WELL REPLACE EXISTING WELL? YES ❑ NO Eja��
U
om
y�rL-
G.
STATIC WATER LEVEL Below Top of Casing: ;Vo nL F t.
Z m
(Uso'.' if Above Top of Casn,,7)
co
t
0.
TOP OF CASING ISFF. Above Land Suflaco'
qo
'Top
or casing terminated allor below land surface royulros a varl:mco Li actor-
dance
with iSA rJCAC 2C 111 r. Y, Ljr¢1/AcuS +1n114Me
METHOD
10.
YIELD (gpm): OF TEST
ma
11.
WATER ZONES (depth):'��ti�r�
'
� o
z
12.
n�11
CHLORINATION: Typo __Arnaunl \ 5
If additional ;pace Is needed use back of form
13.
CASING:
t7oll Th!cknacs
LOCATION SKETCH
Depth Di.�elar or 5v :VI L Ma:crlal
0
(Show direction and di;tanco (ruin at least two State
From To Ft.
Roads, or other ma, rcfercnco points)
From To Ft. ----
,
From To-- Ft. ---
��
1.1.
GITOUT:
I -
�,�t,h�C_a �t,�t tY) l�C�l kt vI�LLi
Depth Matorlal M1lolhod
�"L'' `E-'r'
From To , Ft..`T
_f
From To Ft.
1S. SCREEN
Depth
Fran
To _
From
To _
From —To
1 G. SAN Di G RAV
EL PACK:
Depth
From
To —
From
To_
17. REMARKS:
Diameter Slot Slzo Material
Ft In. in.
Ft. In. _ In.
Ft. In. _ in.
Ft.
Ft.
Sizo Ma:orial
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTt!UCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARq$w4W✓3.Z!><.LT+°.'Y'@FD Rf �TTECQRD HAS BEEN PROVIDETO ThIE WELL OWNER,
S rI`�' ./
FOR OFFICE USE ONLY D r r t'�,(fZ/� I.i�,P-�-P 1✓C-<' LQZ ,IAA l'
Cued No: SI0r1 r sion ij atjnSOtJCONSTnU water Section
W • —� DATE
$UOrlgl Tint Ia Du ion �I Tt�l r Quality. Grounawaicr Section within 30 days
Scrian No. r LU GW-t Ar V. 12/99
-/5 tX)

North Carolina - Department or Environment and Natural Resources - Division of Water Quality - Groundwater Section 223448
1636 Mail Sorvlco Cantor - Raleigh, N.C. 27699.1636-Phono (919) 7333221 (�\
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION lk rJ j:�q
STATE WELL CONSTRUCTION PERMITS:
tS 1. WELL USE (chockApplicablo ❑ox): Residential :nicipal ❑ Industrial ❑ AgrcuL'ural El Monitoring El
Recovery ❑ Fleet Pump Water Infection Other H Other, List Use:
2. WELL LOCATION: (Show sketch of the location helo�'ir
Noarost Town: 1.rJ 1 ` YY10ir1 �' Cr.un:y: _
(Road Name a//pp��tl Numbers. Cornmunily,or Subdlvisio and Lottio.; %' DRILLING LOG C[:PTH
�OR
3.
OWNER _!,1�iY� I LlV1i-(,� `i— �1 l_-1(�j Prom To Foim..tlon Doscrlption
Address
1
1
r— .+Ucol or l ou a o. n.
City or Tavm State Z!,�Codo
'
DATE DRILLED
5.
G.
TOTAL DEPTH
CUTTINGS COLLECTED YES ©� NOO
7.
DOES WELL REPLACE EXISTING WELL? YES 0 N0E2,
B.
`STATIC WATER LEVEL Below Top of Casing: FT. �
,
:o M
_
(Una'.' if Above Tap of Co;inq)
3�
yrq
0.
TOP OF CASING IS FT. Above Land Surlaco'
F
vim
•Tap
of cn9ng terminated al/or below land sorfaco roquiroa a varlan-o In a cor-
dance
with 15A NCAC 2C .elta
i�
rrt
10.
YIELD (9pin): _ MET IOOD OF TEST..`w-�i
=Mm
11.
WATER ZONES (depth):
1�,
rrnl
c-n
12.
Cl ILORINATION: Typo Arnount 1h' additional spaco I:, nocded use b:.k of form
U%
2
13.
CASING: ----
---_
�\ Depth Di,?mcler
FromTo 00 Ft. 1 L
From To FI.
From To-- Ft.
14. GROUT:
Wall Thlckncs> LOCATION SKETC, _
or WeigliyJ l'i. 61aC ledal (Show direction and distance from at lei, two State
Roads, or other map reference pair. a)
Depth Material Mothod
From To �Ft. <--�'��� — —
From To Ft.
1 S. SCREEN:
Depth Diameter
From To Ft In.
From _ To _ FL In.
From To FI. In.
1G. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From Tom_ Ft.
17. REMARKS: fQ rv1 ni-w Il l
Slot Size Llatorial
In. In.
In.
MalLmi;l
44 i -- ,1
'i Cfmco
�o�ky jar, (s2iyocj
LEA, ti��c„��h�s �4�, (s►?�`��'`
�1
CIA
II GY1(1CiLIL! S�jrl�q� I�G� r
J
I DO HEREBY CERTIFY THAT ThIIS WELLNVAS CONSTFrJCTED IN ACCORDANCE WITH 15A NCAC 20. WEL
CONSTRUCTION STANDARDS, AND TI IAT A COPY OF 7hIIS RECORD HAS BEEN PROVIDED TO TI1E WELL O'rVNER.
FOR OFFICE USE ONLY
Cuad Nu:
Serial NO.
C �Ic ;
7 f:Sueitle
CFI I
;Li l
CO'15TRUCTING THE W61 '
ty. Gmu )dwater SeCi on willtln 30 days
DATE
GW-1 I16V. 121J9
31-GU

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 WELL CONTRACTOR: 1.1 5 F i 1 TCiv�c'r
WELL CONTRACTOR CERTIFICATION 11:
STATE WELL CONSTRUCTION PERMIT/$:
�'2 ` 4 4 7
2
1. WELL USE (Chock Appllcablo Box): Residontial Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring
❑
Recovery ❑ Heat Pump Water Injection Other 0 If Other, List Use:
2. WELL LOCATION: (Show sketch of the location bolovi)
t/
Nearest Town:— County:
vl t d,
(Road Rome d Numbers, Conununily, or Subaivis�o% and Lot No.) DRILLING LOG DEPTH
3. OWNER j`IIQV� tQW"1 ��1� � /w•�C i'� 1�i7I-)ii' ; From To Fonnallon Dascdplion
_p ii),Addross Y�) .} I�DIi411 1 i)C. I,
bco(—orTi t
_
I( 11 t �cC �jI o�rn C�
Cily ar Town State zIp Code 1
4. DATE DRILLED I i -:ail i1
5. TOTAL DEPTH I':�D[�
G. CUTTINGS COLLECTED YES �� Neii U
7. DOES WELL REPLACE EXISTING WELL? YES IdO�
_
G. STATIC WATER LEVEL Below Top of Casing: �Fr.
o o
(Uso'.' It Above Top of Casin,)
_.
0. TOP OF CASING ISFF. Above Land Surface'
y om
n
'Top or cooing to nnhmlod ob'ur below rand sur(aco requires a valance In occor-
dance with ISA NCAC 2C.0110
p�
10. YIELD (gprn): �_ METHOD OF TEST
11. WATER ZONES (dopth):
;Cm
12. CHLORINATION: Type Antounl �� t y 1( additional space L^ needed use back or loon
fV ma
13. CASING: - —
n
—+
LOCATION SKFTCH
J z
Wall nccknoss
Depth ry1 DI.Co�l'er� orwair iiul9. IA"Odal
FromTo ,V() Ft.—u-1_ �/ V
From To Fl.
From 'ib-- Ft.
14. GROUT:
Depth Matodal Nlothod
Front To Q0_ FL
From To Ft.
15. SCREEN:
Depth Dianielor
Front To FI In.
From To Ft. In.
From —To—Ft.— In.
1 G. SAND/GRAVEL PACK:
Depth Size
From, To Ft.
From o Fl. _
17. REMARKS: � G W" V-) nYY
Slot Slzo Material
�Irt.
In.
In.
MatuJal
(Show direction and distance hom at least Iwo State
Roads, or other map referor,ce point;)
L4 1
Thoimts JCA. , 124 (sip i 3c1�)
Rou<y 6— (5j2-_) ) w')
UU )tiA(, ji s ►god (52) 4o I
113ano 0 plc spQ11-w S
I DO HEREBY CERTIFY THAT THIS WELL WASI&NSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF TI IlS RECORD HAS BEEEN) PROVIDED
� PTO TI1E /YdELL. OW/NCR.
FOIIOFFICE USE ONLY „12 1YI I 'i >7 1n r(JX-C'
Quid N¢ r! ppppppH I�' y$ LIISON CONSTnUCTINGTiff2 w L 'UDATE�
Submit onpinal Io L'rvrs'. pl Y a:ef Oualily, GmunbHaicr $ecllan Wllhhl 3D days
Scial N.1. 9UI

North Carolina - Department of Environment and Natural Resources - Division of Water Quality- Groundwater Section 2 23452
1636 Mail Service Cantor - Raleigh, N.C. 27699-1636-Phono [phone]
WELL CONSTRUCTION RECORD NrBLLCONTRACTOR: AL25Q—ill
V. ELL CONTRACTOR CERTIFICATION It: I Gjn
STATE WELL CONSTRUCTION PERMITS:
1. WELL USE (Chock Applicable Box): Residential Municipal Eli:ldustrial ElRocovory❑ Heat Pump Water Injection Othor M It Oth,or, List Use:
2. WELL LOCATION: (Show sketch of the location b(lcv)
Nearest Town: - `yry Q_- county:
Agricultural ❑ Monitoring ❑
(Road Name and Numbers, Community. or Subdivision and Lot No.)
DRILLING LOG DEPTH
3.
OWNER ,hrn t !A��C�
Fwm 7o Formation Description
Address,i1r+L•ti_ 1 I6
(street or au o o.
City or Town Stale Zip Code
-
4.
DA._E DRILLED ( ' •�.:• - —
n
5.
TOTAL DEPTH rJ
"T Q�n Ouyt, .l-Q
G.
CUTTINGS COLLECTED YES [j-_NO[
7.
DOES WELL REPLACE EXISTING WELL? YES [] NO[2'
8.
'STATIC WATER LEVEL Below Top of Casing: ,? F F.
CM
o
(Usa '*- It Above Top of ;rasing)
G'l
9.
TOP OF CASING IS I FT. Abovo Land Surface'
y
os
'Top
of casing terminated uVor bctow land surface rayulrus a variance In actor
Z
Zrn
dance
with 1SA NCAC 2C.0110
10.
YIELD (gpm): ( METHOD OF "- EST.1.l�,
$o
11.
WATER ZONES (depth):I" '^i w1
,1
r�1
12.
CHLORINATION; Type Amount U, ;I.
If additional space L needed use back of term ••
rn
13.
CASING:
o
LOCATION SKETCH
z
Depth r oi.�mctor
FrcmTo —� Ft. lDy L
From To Fl.
From To— Ft.
14. GROUT:
Wali Thlcknass
or W�ji h0. L Malarial (Show direction and distance from at least two State
-.Or•L -,�L£5.� Roads, or other map relcrence points)
Depth//ll Malodal Method
From To Q(D Ft.
From To Ft. _
15. SCREEN:
Depth Diamelor
From _ To _ Ft In.
From _ To _ Ft. in.
From To Ft. In.
16. SAND/GRAVEL PACK:
Depth Size
Fran To Ft.
Fran To Ft.
17. REMARKS:
Slot Size Material
In.
In.
—_ In.
M:.toriai
100 HEREBY CERTIFY THAT THIS WELL WAS CONS ERUCTED IN ACCORDANCE WITH ISA NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY C.: THIS RECORD HAS BEEN PROVIDED TO THE WELL O
FOR OFFICE USE
Quad No:
Stria! No.
12
OF PERSON CONSTRUCTING THE P9�. r
of '!later Qua!ity, Groundwater Section within 30
DATE
GW-I REV. 121J9
/r J

North Carolina - Departmont of Environment and Natural Resources - Division of Water Gualiry - Groundwater Soclion x; 123034
1636 Mall Service Con:or - Raleigh, N.O. 27690-1 636-Phono (D I D) 733-3221 - 1. ti
WELL CONSTRUCTION RECORD V"ELLCONTRACTOR: _�'rD 1Y (uC —r
WELL CONTRACTOR CERTIFICATION L': O I No
STATE WELL CONSTRUCTION PERMITS:
1. WELL USE (Chock Ap plicable Box): Residential Municipal ❑ Industrial ❑ Agricultural ❑ Moniloriny ❑
Recovery ❑ I teat Pump Water In;ecGon n Other ❑ If Other, List Use:
2.
WELL LOCATION: Show sketch of the location beto;r) ^�
Nearest Town: "l�E-n V t i Q� County:
Ci\ (_ Lson
Qe-n sy)ag S
(Road Name and Numbers, Conucnun55ily, or Sub\division and Lc1 wu.)
DRILLING LOG
DEPTH
3.
OWNER �Q'((Q�\ 5171.1.CTlAYC'S /wtlIlc f--LT/(8-11
From To
Formation Do;cdpllon
Address
cie�, C-,mmarc�
«co of rTOuI 0
3tato Zip Code
Gly or ovn�����
4.
�
DATE DRILLED- ��LAKI--)
—
_
G.
CUTTINGS COLLECTED YES [�P� NOD
u
7.
DOES WELL REPLACE EXISTING WELL? YES ❑ HO[2/
G.
'STATIC V LER LEVEL Ucicn Top of Casing: 11-)n FI
(Uso -+- II Above Top oI Casin�a)
fT
S.
TOP OF CASING IS i FF. Above Land Surlacu'
c7
cm
-Top
of eanlag Iermlr.ated nVor below land surface regalros a varla:;ce in actor-
C�!
danco
v,llh 15A NCAC 2C.0110
10.
YIELD(gpm): %(2 METHOD OF TEST
11.
WATER ZONES (doplh): _3'�r� 4 - CJQ��
Es,
m
owz
12.
CHLORINATION: Type Amount — 1(S
-
It additional space Is needed
use back of form
a
13,
CASING:
LOCATION SKETCH
Nlall iltichcc;
Dcp111
Iv:o Siote
r;, rM G �J :� Ft. -=�=;- — �' L-� -
Roe c- oiler trap ro r. G
_v pci 'sl
From To Ft. —
From To-- Ft --
Noy-�-�i`i
td.
GROUT:
Depth Material I40thod
i_ lo' d boo -
�f )
From To � Ft. C-�"m l-�" -VC)
i)
From To Ft.
C`�}� Sy10rdtS
EIUp rnkrJ
15,
SCREEN:
Depth
From
To —
From
To _
From
To
1 G. SAND/GRAVEL PACK:
Depth
From
To _
Front
To_
17. REMARKS:
Diameter Slot Size Malorial
Ft In. -In.
Ft. In. In.
Ft. In. In.
ri.
Ft.
Size Ma orial
I DO hIER%F1Y CEITT Ii Y iFi,, i THIS %.'ELL WAS COP; G TI4U CTED I?I ACCORDANCE WI F11 15A N-AC 2C, WELL
CONSTRUC1 ION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO TFIE %':ELL OWNER.
FOR OFFICE USE ONLY
Goad No:
Serial No.
SIGNAL Un5 Or / LnSON CONSTRUCTING THE
Sub 'dl O.Cinal to D-non a t tiot Gaal7ty Parounc} alcr section wtllun 30
DATE
GW 1 REV. 12/99
IQ_6_6x)

North Carolina - Department of Environment and Natural Resources - Division of Water Coati,,/ - Groundwater Section L 1 .. 3 O 3 3
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phono [phone]
WELL CONSTRUCTION RECORD V/ELLCONTRACTOR: —J' f) �LLLL��y
WELL CONTRACTOR CERTIFICATION it:
STATE WELL CONSTRUCTION PERMITN:
1. WELL USE (Chock Applicable Box): Residantiai Municipal ElIndustrial ❑ Agricultural ❑ Monlloring ElRecovery ❑ Heal Pump Water Injection Other ❑ It Other, List Use:
2. WELL LOCATION: (Show sketch
,� of the location bolov.)
Nearest Town: CUk}(n1 ,)hFk- County: — 1 _, CSC;Y-)
N/ �( iS I (Road Namo
. OWNER _
Address
w
VA ') Y �k_%( r
ar Subdivisionnnan�d� Lol DRILLING LOG - DEPTH
�1_. 1'(-ldhM �ll, � From To Founwim Desalpllon
��1e 11C1r�(9S na(_ or,`)�ll
�)I 51 L
GIy' Town Slala zlp Coco
:.
DATE DRILLED 0 _`J'OO
5.
TOTAL DEPTH Nt'y_A7
G.
CUT-TINGS COLLECTED YES EI�-_ N 0 0
_
7.
DOES WELL REPLACE EXISTING WELL? YES 0 NOE xr
ID 06) U
G.
- STATIC WATER LEVEL Belo.., Top of Caning: !k-)b FF.
(Uso b' II ASoio To, cl Cash.,)
9.
TOP OF CASING IS FT. Above Land Surfaco'
-Top
of o031119 lonnlnalad nuor below land surface roqulres a valance In otter- -
dance
with 1SA NCAC 20.0118 �"
cu_
10,
11.
YIELD (gpnl): V,4 _ MET7HOD OF TEST
WATER ZONES (dopth):
CD
li
12.
CFILORID:Ai IUfd: Type � AmountI JL 11IS
-i
I: addib:anal space is neGJ r,; use back of form
CceD
13.
CASING:
--
v
Wall Th:co-,;mss
LOCATION) SKETCH
3
L .,Pt,l GI:((,; ����^� C. 'ii f �.s.
5 6 �VC--
(5''0' df IG ,a:C I..._ Ica Il .,.e,_
w
From)T0 Ft. �=1-
Roads, or other map re c n. -�ce points)
-�
Ffo n _ To FI.
c .
From To__ Ft.
14.
GROUT:
Depth Malculal Molhod
Front To 1_�CD Ft.
From To Ft.
15.
SCREEN:
Depth Diomelor
From To Ft In
From To FL In
From To Ft. In
10. SAND/GRAVEL PACK:
Depth Size
From To Ft. _
From To Ft.
17. REMARKS: —
Slot Sizo_ Malorial
In.
In.
In.
100 HEREBY CERTIFY THAT THIS WELL WAS CON;STIIUCTED IN ACCORDANCE WITI-I 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY Of THIS RECORD HAS BEEN PROVIDE/D}�TO 1"FIE VIELL OWNER.
FOR OFFICE USE ONLY .� � ✓ ��i L�J (i' n I ,7 �J.L!' D�A4 h )o
Quad No SIGNAT URE Or) Oft CONSTRUCTING THE V/ J DATE
SWir I Gr,Oina uL; T of Quality, Groundwater Scc,icn vnL'11n 30 days
Scrial No. �Y I
I GN!-I IIflV. 12/99
4
I
rJ
/l-If-,moo

North Carolna - Deparlmont of Environment and Natural Resource3 - Division of Water Quality- Groundwater Section (+ ..r 3 2
1636 Gail Service Center - Raleigh N C 27699-1636-Phono [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: C ClL rr l
WELL CONTRACTOR CERTIFICATION U: 0 Aa'
STATE WELL CONSTRUCTION PERMITIl:
1. IYELL USE (Check Applicable Pox): Residentiakn Municipal ❑ Industrial ❑ Agricultural ❑ Monilcring ❑
Recovery ❑ Heat Pump Water Inloction ❑ Olhsr ❑ It Other, List Use:
2. WELL LOCATIO'd: (Sh v+skelc't of the location bolow) t I l ,A /
N'eares: Tovm: �� L�1�nL `L'C Couny: �1 0.L-1� xv
(Road Namq`��And Numbers, C,ommunify, or SubdM5 cn and Lot No.) DRILLING LOG DEPTH
3. OWNE.9 f) C b (JO -} -f" From To Forr-,aaon De ripacn
OC,(I Address V (u P• Qa O -- 3.3 _ SrA AJ
L rl direct or o• :A �o.
f+•X I�tL�h c,s NC_ ,;�Ftrl'Il .'�3 .5 �rrL to f-�
Clay or Torn;., - sta:a Zip Codc
<. DATE DRILLED J5(1 rr i/ .�"O
S. TOTAL DEPTH . p /)0 3 5 'AU AJ 0
6. CUTTINGS COLLECTED YES© NOD
7. DOES 'HELL REPLACE EXISTING V'7ELL? YES F-1 NOF
6. STATIC WATER LEVEL Belo:: Top of Casing: je>o FT.
(Usc'+' if Abo+o Top of Caslne)
9. TOP OF CASING IS FT. Above Land Surface'
'Top of cas!nj Icrminatcd nVor bciove land surfaca roqu!ras n variance In accor.
dance oath 1SA IICAC 2C .e 18
10. YIELD (gpn, - - METHOD OF TEST AI C_
i
11. 1'/.4TER :ONES (daplh): / Q Q 6 —
12. CHLORINATION: Type F', Amc;:n: I t(
13. CASING:
P!ffiI 1!kkncc,
From To Ft.
From To FL --
From To-- Ft. —
1A. GROUT:
r� Deplll t�:�lalorlal Method
From- To FL L.l�ltll 5��2
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Malarai
Front To Fi _. in. in.
From To FI. In. In.
From To Ft. In. In. _
16. SAND/G RAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
17. REMARKS:
O
n-
1! ,.JdiSor•.al space io needed uce L-ec.. •orm Co
m
_LOCATION SKETCH A�
(Shop: d�recl:cn end d¢tancc !rc . l 1_a;t two Statx_o
- m�
c�
Roads, or cl.`•er rap rcicrcxc I:c,• :o) -- -+
co o
z
SPeedcJe)I( cJ
C u 16wbiee- #?4W RC
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.
FHI
OR OFFICE USE ONLY I ` ` 1
Ouad No: SIGNATURE CF PERSON CONSTRUCTING THE WELL DATE
Submit orip rat to Oivlslnrt ol17a1pr OeaGty. Greundwa:cr SecEen Within 30 days
Scrim No, ,l G W A REV. 12/59
I )jb
r i
r
t
( f 1�i5�oo
vC-

North Carolina - Departmont of Environment and Natural Resources - Division of Water Quality- Groundwater Section 3031
1636 fA ail Service Center _ Raleigh, N.C. 27699-1636-Phcno (919) 7333221
WELL CONSTRUCTION RECORD WELL CONTRACTOR: _.� L_ 122C�C1u 1 f 4
WELL CONTRACTOR CER NFICATION 1.': _
STATE WELL CONSTRUCTION PERMITP:
1. WELL USE (check Appucabie Pox): ResidenliaYn Municipal ❑ Industrial ❑ Agricultural ❑ Moni!cring ❑
Recovery ❑ Heal Pump %'later Injection❑ Other ❑ If Otter, List Use:
2. WELL LOCATION: (Show sketch of the location below:) Nearest To,n: rT� tG AiD 1 C. County: �J -ram C Ck 5,> rj
(Road Narnq--_d- -Ibers, CorcmuLN;y, or Subd:Msion and Lc! No') DRILLING LOG DEPTH
3. OWNER 9, b. D' � T s From To Fomr allon Descriplicn
+ Address e/oho .,, cn. �.�r U _ '7�--- LIC,
CI ( or u o ao.�
�I c%/1 �n N'�.rocS y� '-I � 4-0 `7
Cilvrcvn 5W. Zip Code
4. DATE DRILLEDbakbi WC, y
5. TOTAL DEPTH Aq0 i4 f-G '3yU
6. CUTTINGS COLLECTED YES[X� NOD
7. DOES :'TELL REPLACE EXISTING bVELL? YES [_j 1,1015
6. STATIC WATER LEVEL Below Top of Casing: C) FT.
Abovo Top or Ca:inq)
9. TOP OF CASING IS ( FT. Abovo Land Surface'
'Top or cas!vg terrn!nalcd nJor hclow !and sur:nco roqulrco a varlanco In accor-
dance ralh 15A NCAC 2C.01J8
10. YIELD (gpm): ID . METHOD OF TEST AIG'_
i
11. WATER 7.ONES (depth): y5 --
12. CHLORINATION:: Type 1 C Anlounl-
13. CASING:
J S'rr_EI CH
Wc:I T::ic+^r.:
_LOCATIO,
Death
Di-„-.yte_r c: V,,,1 Vrl.. ;,)_'cd.-.I
(Sho'r: d;rect Ccn and rd
I'ast two S!a;o
FromTo _1Z—Ft.
--Ll.'�"�-—_stce�
Roads, or ether map r e:c:encc
pe„;s)
From- To Fr.
—
From To— Fr.
—
14. GROUT:
Depth
Matoaal f.:olhod
f1�'
From- To-3CL Ft.
From To Ft.
w �i llLJ r�
15. SCREEN:
.
Depth
Diameter
From
To
Ft in
From
To
PI. In
From
To
FI. In
16. SAND/GRAVELPACK:
Depth
Size
From _
To
Ft.
From
To
Ft.
17. REMARKS:
Slot Size Ma:oriel
in.
in.
Lt3terial
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 EF'C l—F Ceti e- T�_ 6T 05 , I,.` k\ 1\ I
Quad No: SIGtZATVRE OF PERSON CONSTRUCTING T HE WELL
Submit aA, nal to olvligh of Wa:ae.Qua My. Gr0unC'ry'a;el Seclien within 30 days
Scrial No. t i+
it-e, °1j�ld
DATE
,a=
O
M_
W
1-7
11-15_ez
s /oc.--
GW 1 REV. 12/99

North Darollna - Departmont or Environment and Natural Resources - Division of Waler OualiP/ - Greundx'a!er Section ' •�) [l (1
1636 Mail Service Center - Raleigh, N.C. 27699-1635-Phcno [phone] 4- '— V 2) J
WELL CONSTRUCTION RECORD WELL CONTRACTOR: �J) C tLrr�j
V; ELL CONTRACT OR CERTIFICATION tl:
STATE WELL CONSTRUCTION PERMITS:
1. WELL USE (Check Appllca Sla Box): Residen!L'u v Municipal ❑ Indust lal ❑ AgricuAurar ❑ Monitoring ❑
Recovery ❑ Heal Pump Wafer Wccf,).n .[] Other D If D-1-or, List Use:
2. WELL LOCATION:: (Shoe; skcicll of the location be!e•..)
Nearest Town: &JE&V,-Ile— __cc�I c,-r—ks c`, I!
(Roa9 Ramps nd 'IurJ c':jr-
jfc-f I' Cf:Fti %'CI17t, L/La. /uIrJ
3. OVVN ER �{y*_�R I, ` 1 �rhn��+-.- er
Address A ----/-
'City or Tana s:ala 21p CCG_
DSS E. L`i;ILLE0l7i i' /✓� uZert
TOTAL DEPTH --a0Q
G. CUTTI`:GSCOLLECTEO YESLI IJOL_�
7. DOES YfELL F,EPLt CE EXISTING V,ELL-, 1 LF, [::j IdOP�f,
S. STATIC WATER LEVEL Below Top of Casing: tr G FT.
(Uco'.' it AJc:. Tcp of CareC)
9. TOP OF CASING IS �_ FT. Abovo Lard Surtacc•
-Top or eao:n�, IC:minPied nvct bclo, land sur:aco rcqulrcn n varinncc 1.. tccor-
dance r:llh 1SA NCAC 20.0115
10. YIELD (rlprn): �_ GIETHOD OF TEST
11. WATE•-, ZONES (doplh): 97" 3 a U —
12. CHLORINATION: Tppe
__t
13, C?.SING:
Dcp:h _
�-�
c . �..
��-.
c 1 PI. '.a c
Frm�T0
Ft._
--
From - To ---
FI.
---
From To-
FI.
11, GROUT:
Depth
r.la;rlai
From' Q Teo 5a%F1.
_Ltolhod
From To
Ft.
_
15. SCREEN
Depth Diameter Slol Sze Mnlorial
From To Pl _ in. in. _
From To Ft. In. in.
From To Fl, In. H.
1G. SANDHI-R:WELPACK:
Depth Size tAalaria!
From To Ft.
From To Ft.
17. REMARKS:
DRILLING LOG DEPTH
Fro To Fer.T :ion Der:pC.nc
c�
c7
Q
U
I:;.�_Ci:_.,al _pae_.c n_•eJcd uc _-ta[,-; Dn6
oF�
N
rn
om
_LOCATION 6_E I CH
CD
mCa
GJ
cn2
mA -
n
�
H
O
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C. WELL 11 )1 51hd
CONSTRUCTION STANDARDS, AND THAT A COPY (HIC
OF THIS RECORD HAS BEEN PROVIDEO TO THE�V.'ELL OWNER.
� N l'
FOR OFFICE USE ONLY A a Q.e_N e 1) vC OS �t�C'.�\ S I G' (�� IL)C—
OuaJNo: -Sr' iUR OF PE RSON CO' I S TRUCTING T"_ Yl ELLS DATE
SQSF;4 on. r W D'i :on of 0a: or Oua 7. Grc undrater Sec•ron within 30 days

North Card!na - Department of Environment and Natural Resources - Division of Via! er Qua:iry. Ground n-a:er Section ' • �
1636 Mail Servlco Center- Ralei3008gh, N.Q. 27099-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: �ACCl�ll TQU /or"
Lk)C-_II \YELL CONI RACTOR CERTIFICATION h: a )Pi
41 STATE WELL CONSTRUCTION PERMITF:
1. WELL USE (CheckAppllcabla Eox): Resldenliaxn Municipal ❑ Industrial ❑ AgricuUural ❑ Moni!cring ❑
Reco•.ery ❑ Heat Pump Water In eclion ❑ Other 0 II Ol�.ar, List Use:
2. %^YELL LOCATION: (Shoe; 5kctch of lho location be!a•;:) f
Nearest Ton : Coun;7: J 0.e R .:i (°. A)
0-�(� �1�aAh��'�� 441
(Road Na.'n end t.. bars, Co. sr.uNy, e: S­Jdv�tslcn a:,C lcl No.) DRILLING LOG DEPTH _
3. O'\"iNER z e-C /Jl^C_ From To Forr.atlon Descnp;lcn
Address fie ye )u 3 (vT O— �
C\rNrC rl k1C2_e. N C� - - C—" f .� G!an ri
LL�or Tc'.-�
DATE DRILLED(2c+cbrc2K �Zc(Dc-
5. TOTAL DEPTH )'75 .rl �{ tc,G. CUTTINGS COLLECTED YESEI f40❑ —
7. DOES ;•;ELL REPLACE FY,ISTING l`: EU_? YES
S. STATIC VIATER LEVEL Belot: Tap o' Casing: FT. _ _C
Abed Tcp ct Cn:ing) C
9. TOP 0, CASING IS FT. A ;ova Land Surface- C
'top o! cml:'.3 lean In Mc3 'Jor bciow land sur;ace re qu::es nvarl.mce In ecee:-
danca nith 15A HCAC 2C.0118
10. YIELD (Cpm): _)D. ).1ETHOD OF TEST __ Air
11. tYATERzoraEs da , y"—�i5 41— /3o —'
L4 )NS
12. CHLOFJr:ATlON: -i)'pe V \_A _ ld,.�.: nt.,q. II •. �..BiOr.g spa=-.; needed use .,c:m G
13. CASING:
l'ha il;d..-.rco
HJ"
Rom—�-0S1--1—FL-IJ
— --
—
From- To FI.
--
From To-- Ft.
—
14.
GROUT:
Depth
L1 a:rrlal
From' Tot i.
_Method
From To Fl.
15.
SCR --El:
D epih DiamelCf
Silt S:2C
Ma:erial
From To Fl
in. in.
From To Pt.
In. in.
From To FL
In. In.
15.
SAi:D/3RAVEL PACK:
Depth
Size Material
From To —Ft.
-
From To Ft.
17.
REMARKS:
LOCATION ::~:ETCH
RCz_'s, or cl:.cr ru;c:cnc.:
I DO HEREBY CERTIFY THAT THIS :YELL ViAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C. WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HASBEENPROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
cuad rin: slc::AruRE cF PEFisou co:ISTRL�Gnr.G Tr:=_ WELL
Submil ori; c I to D d cn 1 c• ua, . G:eund',raeer Seet:en withln 30 days
{��
A
E
1y
DATE
w
I, 15/ C)r,
kcc
GW-1 REV. 1255

�^
North Carcli.;a - Depznment of ur Environment and Natural Resoces - DivL•ion of 6'la;er Oua;i;/ - Groundwater Section .F- �- � O y
�
m
1636 Mail S>_rvlce CeNer- Raleigh, N.C. 27699-1535-Phcno [phone] p
WELL CONSTRUCTION RECORD WELLCONTRACTOR:
VyELLcoNTRAcroRCERnFICAT[Oil fl: oil8r/
# STATE WELL CONSTRUCTION PERMITR:
1. WELL USE (Check Applicable Cox): ResidenliaYn Municipal ❑ I.;dustrizl ❑ Agrieullurai ❑ Fdoni!cring ❑
Recovery ❑ Heat Pump Water In;eclion ❑ 0111er If Othor, List Use:
2. NVELL LOCATION: (Shoe; sketch of the location be!o,) 1�
Neves: To'rrn: ( I.LC rr"rrp�' Cown?y: 0.0 1\ ( AI
�hool� C'C f� cccy
(RoaJ r4amo znd tlumbc:s, Ccn:-..un\l:y\, cr SvJd:visicn and Lcl t: o.) DRILLING LOG DEPTH
3. O,VNER -� �ic v 1 Ee t11 From To Forrraffon Descd n
Address -_ - p::c.
Q C) + (� � U— Y L — C—�--, Sr, N c
� t�T�_r_)83
,: ovy I ti' 4 3 a ton; r'tom_
_, Stc!e zit;Cc ea
Dr.TE DRILLEDQ_C� eC I dLcoo
5. TOTAL DEPTH _ r oo -- --- tt' 1 [ __ ----- I ----
6. CUTTINGS COLLECTED YES �I f:o IL
%. DOES ELL REPLACE EXISTING l', ELL-! YESS. STATIC V.tATER LEVEL Below Top of Casing: —hL. FF. O�
(Ucc'+' If AJcve Tcp of Casi:,,)
9. TOP 0:= CASING IS__I FT. Abovo Land Surface• --
'Top of eaan, Ic: m.Ir.a:cd e7ar Lela, la; d surface requlrea n v,arl nce In r.cec:- —
dance vdlh IS HCAC 2C.e 113
10. YIELD (gpn* opts_ METHODi OF TEST At
11. WATER ZONES (dep J1):
12. CHLOR:INATIONI: Type
13. CASING: I
C 2ic..aI spa2c ;L n._od0C use bay ie:M
YJa7 ih:c'<nczs _LOCATION SKETCH
e: , '��.,11 r:. ., c'cl ( t' '.-.: e' 63le l l_ o
From To �FL __ Lit_ —Ja— • rC r s, or c mTp
Rom- To R.—
Front To— Fl.-- r
1a. GROUT:
— / D Cc•.. s /�r'�.r-Q
Depth L'a toast Method
From' To Ft.
From To '—Ft.
S 1� 3S Shook Coves R
15.SCREEN:
Depth Diamelor Slot Size Ma:erial
From To Ft In. .in. _
From To Pt. In. in.
Frorn To _ PI. In, In.
15. SAND!C.RANEL PACK:
Depth Size Material
From To Ft.
From To Ft.
17. REMARCS'
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL /j 5/DC)
CONSTRUCTION STACDARDS, AND THAT A COPY OOnF THHII �S RECORD HAS BEEN PP.OVIOEO TO THE4:ELL OWNER. L
FFO,ROFFICE USE ONLY rm l-1C`"Ko: SIB::l,TL'RE GF 4'ERSON CO:ISTRUCiIt:G THE YlEII DAiE
Subw;; oh;ir.al to MvIs:cn of Vla:cr 0 a':y, Groune';ate, Secilen within 30 days
Na. ryr' OW-1 REV. 1253
t _

11,
North Carolina - Department of Environment and Natural Resources - Division of Water Quality • Groundwater Section
16361A ail SINIce Confer -Raleigh, N.C. 27699-1636-Phcne [phone] -r-
WELL CONSTRUCTION RECORD WELL CONTRACTOR: Or
WELL CONTRACTOR CERTIFICA11017 k:_— 1? _
( STATE WELL CONSTRUCTION PERIAITN:
1. WELL USE (Check Appucat9e Box): Resldentla�n
Municipal ❑
Industrial ❑
Agricultural ❑ Monitcring ❑
Recovery ❑
Heat Pump Water Injection ❑
Other ❑
It Other, List Use:
2. WELL LOCATION:
Sh w sBetch of the location thelow)
/J
s
Nearest Town:
CcunCj:
:) Cx_cA e)A,(
&S-14ers Q roe
1
k
tn/(�,
(Road Name and Numbers.
Comrcunl:y, crtauSdMsion and lot No.)
DRILLING LOG
DEPTH
3. OWNER ,17y\T9
Address 3 toy
�rJ Gyr,A '.S
Seo-V -�-S C.S'�_P i2 ��
From To
nForn-3:ion Description
�I0.V (T reu um L
_
V \ , Ca
(Strcc or ouzo
�\
o To,.,
Slot.
Zip Ccce
4. DATE DRILLEDU_AA car 1 arm
5. TOTAL DEPTH 3 'SO I "rl� }G 3 5c) 1
6. CUTTINGS COLLECTED YESF> f.0[�
7. DOES Y/ELL REPLACE EXISTING WELL? YES F10�,
S. STATIC WATER LEVEL Belov: Top of Casing: FF.
o
(Use'.' it AJovo Top of Casing) C]
9. TOP OF CASING IS I FT. Abovo Land Surface* O
'Top of ensing terminated n'Jor helm, land suCaca requlrcu a vorlance In accor-
dance wilh 15A 11CAC 2C .o111i
10. YIELD (cpm): 4 METHOD OF TEST AI C N
M
11. WATFR ZONES (depth): '— •1-O _a 1'i O _ —
12. CHLORINATION:: Type P.:neunl _12IS- I( space is needed uce !-aa: c: loan w
13. CASING:
1';ail it:ic%cxsa LOCATION:-KE I CH 47 0
Z
Depth Dlr.—^sr r_ e1" 'it. „-'c cl (S�:: ,odi;,.cCcn nd ds Lace ::cr.�.:lc rs!t,vo Sato
From To —99 Ft. — -- Jar Roads, or ether map
From - To --- Ft. -- 1 -
Frorn To— Fl. — `7 —L/!"{I
14. GROUT: //77 nn
Depth A t��a�to�r�fal1 MethodS 7� 13 � � 9�X+(!`1ei-5 C ht'e�
From' Q Too rt. t.L1111.\M —��2 I
From To _ Ft. 1 C_
15. SCREEN
Depth Diameter
From To R In.
From To FI. In.
From To FL In.
16. SANJD/3RAVEL 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
CONST.RUCTION7 STANDARDS, AND THAT A COPY I G •+� 2 [ HI
OF ATHISRECORD HAS BEEN PROVIDED TO \THE PlELL OWNER. 1 /
FOR OFFICE USE ONLY �e\ t ` ` ) `ems Q' ) C OS �%L- \�\ Y kcc
Ouad No: SIGs:ATL'RE CF PERSON CONSTRUCTING THE YELL GATE
Submit od; nal to DiAsion of Waler Oual2j, Groundt.alcr Sec6en within 30 days
Serial No. GIN-1 REV. 13'i9

91-)005
North Carolina - Deparlmont of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail S=Nice Center- Raleigh, N.C. 27699-1636-Phono [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: D m �CLLYr�
WELL CONTRACTOR CERTIFICATION 0: �
STATE WELL CONSTRUCTION PERMITP:
1. WELL USE (Check Applicable Box): Residenlialn Municipal ❑ Industrial ❑
Recovery ❑ Heal Pump Water Infection ❑ Olher if Other, List Use:
Agricultural ❑ `Aonilcring ❑
2. WELL LOCATIOt ' (Show -ketch of the location belo.v)
Nearest Town: 5 - Couny:
(tit A Rrc,K
(Road:;ame and 1:umSers, Corrrcunily, or Subdivlslcn and Lot tJo.) DRILLING LOG DEPTH
3. OWNER weMca F / 1 From To Forma:ton De crip!icn
W�Q Address a 5c, Lo cs -F arK 0— / Y
aucec or r.� ao.)
�LLhlil'I 51`ie J'JC��� )Ss h D G (aL rIf'Gil�
y o p —�
4. DATE DRILLED U_kberr.2 9010
S. TOTAL DEPTH :300 .--fir �L'O
6. CUT1I JGSCOLLECTED YES© NO[
7. DOES :'TELL REPLACE EXISTING WELL? YES 0 HO�}.
8.
STATIC WATER LEVEL Below Top of Casing: ;;to FT.
o
(Use'.' it Abovo Top of Cnclnq)
n p
9.
TOP OF CASING IS I FT. Above Land Surface'
0 n�
'Top
of eaa!ng terminated o0or below land surface roqulres n variance In aeeor-
o
dance
with 15A NCAC 21-.e118
10.
YIELD (gpnl): , 10 D METHOD OF TEST __iglL
N �`
11.
WATER ZONES (depth): hO-- r —
_--
=�Q2
72.
CHLORINATION: Type 1 \C, l.ntecn; _�I-
If rddi:icral space L- needed use tack
e!;,_rmw y_
13.
CASING:
c-a
_LOCATION SKETCHco-1
Depth Di- e e 1' ' i L Mac al
S ee-
(Shone.,directlen and d:s,_nce !:cm .-:Les! two
State z
Front C) To �h Ft. �
Roads, or ether map Wercricc po7, s)
From - To --- Fl. —
14.
From To-- Ft.
GROUT:
M (_ (3 �N
Depth I:falmlal Method
From' To _ Ft. 1 n.r2
From To __.. Ft.
15. SCREEN
Depth Diameter Slot Slzc Material
From To Ft in. in.
From To Ft. in. in.
From To Fl. In. In.
16. SAND13RAVEL PACK:
Depth Size Material
From _ To Ft.
From To Ft.
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED W ACCORDANCE WITH 15A NCAC 2C. WELL // �5—�
CONSTRUCTION STANDARDS, AHD THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER. FOR OFFICE USE ONLY �� Cee� �' S� aS �i"�' ` I�"c
�c"
Ouad No: SIGr ATURE GF `P_eRSy0tt= ST4CTING THE YELL DATE
Submit od, naltq CIMs: ;o . ua11.1,, ,=41aicr Section viilhln 30 days
Scrim Na.--���_.W� GW-1 REV. 12/53
t '

North Carofna - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section 04
1636 Mail Service Center- Raleigh, N.C. 27699-1636-Phono [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: �ir CSNr�yGL li /GF-
\'JELL CONTRACTOR CERTIFICATION t.: 01 (-_—
STATE WELL CONSTRUCTION PERMITN:
1. WELL USE (Check Appllcaela Box): Residentia1N Municipal ❑ Industrial ❑
Recovery ❑ Heal Pump Water In ection ❑ Othsr ❑ It Olhor, List Use:
2. WELL LOCATION:
Nearest Town: _ T
(Road name
3. OWNER _
Address
kelch of the location bolos;)
sSCLsc cc Caun'f:- J Ci_G,ks 1)I't
,L1LL �% I � rJ
rs, Co .m nlik, or Subd:yision and lol No.I
tiny or I ev.n - v Salo Zip Cede
4. DATE DRILLED e4c,ber/auO
5. TOTAL DEPTH .'-).'i D
6. CUTTINGS COLLECTED YES© NOD
7. DOES :HELL REPLACE EXISTING WELL? YES 0 N0,0
E. STATIC WATER LEVEL Below Top of Casing: 40 FT.
(use •,• a AJovo Taper Cn:!:,g)
9. TOP OF CASING IS r FT. Above land Surface'
'To, of eaoing tennlnaled n'Jor belor, land surtaca requ!res n varlaneo In accor-
dance will, 15A rICAC 2C .0110
10. YIELD (gpm): . 6 METHOD OF TEST — AI
11. WATER ZONiES (doplh): -5 —,qQt,
12. CHLORINATION: Type
13. CASING.'
_F.:nounl
I
Agricullurat ❑ Monitoring ❑
DRILLING LOG DEPTH
From To F rr.allon Descrip!icn
1`4 A/ , 1f G
ILb U �l
T; r
O 3 0
is c�dCiorai space L- noed.d use brie%Mo: 'o;nW r''1 �J
Ca
Y;as 1:.:cs-c _LOCATION Sr_EI-CH
Depn1 F yJ, c: Yy�y:;�h;./�t. d'v.cl:cn. r.r l C's!crc� .-c r.-� .: La;! t..o Sa,-
From—�� To FL-1r--1-_—J_.-�� needs, or c!Fzr map le!cr-nc:
From- To—__ FL_From To— FL _ .
14. GROUT:
Depth
Fdatorial
Molhod
From" «To=al�Ft.
St.L»i'_zL�
SOT�Z
From To
FI.
15. SCREEN:
. Depth
Dionle;er
Slot Size
Malarial
From To
Ft
in. In.
From To
Ft.
In. In.
From To
Fl.
In. in.
16, SAND/GRAVEL PACK:
Depth
Size Material
From To
Ft.
From To
Ft.
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED III ACCORDANCE WITH 15A NCAC 2C, Y/ELL
CONSTRUCTIOA STANDARDS, AND THAT A COPY [OjF THIS RECORD HAS BEEN PROVIDED TO THEY; WELL OWNER.
FQu
OFFICE USE ONLY r ` �� Oe-�'r �' T.>C, OS (,;� 1 I •, No: SIGr'ATUREOF M- REON CO`ISMOCTING THE YELL DATE
30 days
l tJo. G W I REV. 12/57

North Carolina • Department of Environment and Natural Resources -Division of Water Quality- Groundwafar Section r. n
1636 Mall 5=-rvice Center • Raleigh, N.C. 27699-1636-Phono [phone] i7 O
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
\YELL CONTRACTOR CERTIFICATION
STATE WELL CONSTRUCTION PERMITU:
1. WELL USE (Check Applicable Box): Rosidenlizi Municipal ❑ Industrial ❑
Recovery ❑ Heal Pump Water In;eclion ❑ Other It Other, List Use:
Agricultural ❑ Monitcring ❑
2. WELL LOCATIOV: (She v skeo r of the location bolow) `
I:earest Tovrn. - � C) n��' nn County: - �� C''k S C /V
Sne�WT'`\ I�DCa-UI
(Road Nam end; rur;.b9rs.Comr..u�y�' or Subd:vi on and Let No) DRILLING LOG DEPTH
3. OWNER Gv rG p u: iii From To Pe r
non Deseri l':
cn
Address (03 lot, C
f HOIJ:0 NO
or Town State ZippCoe
4. DATE DRILLEC115 y COD
G. TOTAL DEPTH L4 C 5'
G. CUTTINGS COLLECTED YES© NOD
7. DOES Y/ELL REPLACE EXISTING %YELL? YES NOJ�5
6. STATIC WATER LEVEL Below Top of Casing: /gyp FT.
(Usc *,'if Abavo Top of Cnomq)
9. TOP OF CASING IS ( FT. Above Land Surface-
'Top of easing lernilnaled aVor belovr land surfeca requires a variance In accor-
dance with ISAIiCAC2C.011B _
10. YIELD (gpm): 100 METHOD OF TEST AIL
11. WATER ZONES (depth): w U - 955
ip —r
12. CHLORh\'.4TIOi:. Type ti _ P,n,oun1 _ 15t1-(_ (.5 L' ai:ior.al spa_c b needed use baci. ,c:rn --
13. CASING:
Ylall I kkncso
Depth _ D�i�a.' � !Sa:cecl
Fro ToFt. -1✓ z_
From To FI. --
From To— FL_--
14. GROUT:
Depth Malorl,l L:clhod
From' Q To=za�Ft. �Y mcrt� =rrZ
From To Ft.
15. SCREEN:
Depth
Diaineler
From
To
PI in.
From
To
Pt. In.
From
To
Fl. In.
16. SAND/GRAVEL
PACK:
Depth
Size
From _
To
Ft.
From
To
Ft.
17. REMARKS'
Slot Size Ma4orial
In.
In.
In.
Material
LOCATION SKETCH
(Sher dircc.f ,, and d!s sre 6cin r i Ic ast Iwo S!a,_
Roads, or ether rap rate; crxr po„ Is)
s l0 � SPC(t, t � RC!
S q 3L9&
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER. 11141Da
FDROFFICEUSEONLY _ r� "—Cee-tv�' �OS �,iX�-1 � I G•r �� "L� �C'"
Quad No: ry'� t51GF:ATt.RE GF PER SON CO?lSTRUCTING T HE WELL DATE
t
t al Io D dalen or Pfzer Quality. Groundr.a.er Sec. en within 30 days
Scrial No. I"""` `,
GWI REV. 12159

rr•1 (� 22
North Carolina - Department of Environment and Natural Resource3 - Division of Water Quality - Groundwater Section �:. r:, J U L.
1636 (Gail Service Center - Raleigh, N.C. 27699-1636-Phono [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: IA5SC1 1 4h)r— —
WELL CONTRACTOR CERIIFICATION !::
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Appllcabla Cox): Reside ntlaYn Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heal Pump Water InjectionEl Other ❑ If Other, List Use:
2. WELL LOCA
Nearest Town:
of the location be!o,c)
County: J C, CK S
(Aoad Name end;lurnbca,Corn(r.un:y. or Scbd:Msio?r and Lct r: o.) DRILLING LOG
3. OWNER .rC4f'L'_ C1 NC� 9J4,Ck i From To
Address 11 ef--hL C:k • Qk- � U r7D
atrecl or ouzo
1,u of rV urn/ -lnr �a 3 9 q 7 0 c'7 --
-;y Zip Ccde
. SDATE DRILLED ieK / r CliC. .
. TOTAL DEPTH �Z �2
6. CUTTINGS COLLECTED YES© N4OF-1
7. DOES :'TELL REPLACE EXISTING WELL? YES-] tJO,,
B. STATIC WATER LEVEL Rel6%,. Top of Casing: r, FT.
(Use'.' if Abo•ro Top of Casing)
9. TOP OF CASING IS r FT. Abovo Land Surface'
'Top of eoa:::g lerniln.ited Wor below land suriaco roquiren n vaxlanco In accor-
dance wlth 15A IICAC 2C A118
10. YIELD (cpm): r MET110D OF TEST Alf
11. WATER ZONES (depth): .� -ia'2% -? .•;2t�D
--- 2 - y
DEPTH
orrallon Descrlpl:cn
�� rrxuz
C-\ r'cL N r if e
C:� _. �
rM 25 %i
C-3
IV c3:
12. CHLORINATION: Type __AAC )L _ Anicunl —�� 5 U au2i:ionzil _=,.ace i; needed' uce Ca_.. ,crm --
13. CASING: =__ --_------ --_'—_-----
Depth //D-iiyncicr
5�—�—
From - To — FI.
From To-- FL--
14. GROUT:
1':aa Tldckccss _LOCATIO^� KE"TCH
or iv6-1P"i'L {p.,.. aai (Shv o,din Uicn and dls.cr_c LCm._t 6_c,! hvo State
__i3—_. 5 ""C Roads, or c:hcr map ra:cr::ncc l)o,.:a)
Doplh Fdato rinl Molhod
From' To _ r 1. P�SIl 1 C " r2
From To Ft.
15. SCREEN:
Depth Diameter
Frorn To Ft in
From To Ft. in
From _— To Ft. _ In
16. SAND13RAVEL PACK:
Depth Size
From _ To Ft.
From To Ft.
17. REMARKS:
Sfol Size Matorinl
in.
In.
In. _
Material
Ctt.11vc�hCashrers /1)
5 l0c 1 Speee well Rc
s iocl F, Ile,
tI Cfeex Rj
rrc5S/� (�reelCRJ
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION 1 STANDARDS, AND THAT A COPY OF THIS RECORD HAS EEEN PROVIDED TO THE VIELL OWNER.
FOR OFFICE US nU v,. _ ' ` Quad No: i �5 m�1�(L� TUFE OF PERSON CONSTRUCTING THE WELL DATE
LS �$Uilinil �,ir bk:on of Plater OuaNty. Groundaa:er section within 30 days
Serial No.
GW-I REV. 12/57
s/o L
L)C'
t ..

North Caro!Lna - Department of Environment and Natural Resources . Division of Wa!er Qualiy- Greundwa!er Section
1636 Mail Service Center -Raleigh, N.C. 27699-1636-Phcno [phone] 229294
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION 8: �1 _
(I r \ e t `'*- I STATE WELL CONSTRUCTION PERMITH:
1. WELL USE (check Applicable eox): Resldcntialn Municipal ❑ Industdal ❑
Recovery 0 Heat Pump Water Injoction .I] Other If OI or, List Use:
Agricultural ❑ Monitoring ❑
2. WELL LOCATIO (Sho•.v ketch of the location be!o..) �—
Neares! Town: G S Ccuny: J QCx C Q P.)
S; ►_o>cr h u fJ R
3
J.
G. C'JTT!`:GS COLLECTED YES G) t,oL
7. DOES YJELL REPLACE EXISTC:G YJELL? YES �::) I IO,fr6
E. STATIC WATER LEVEL Bet5v. Top of Casing: _ V15 FT.
(Uco'.' it Adce:e Top or Cncinq)
9. TOP O: CASING IS ( FT. Abovo Land Sur lace'
'Top of ca e:n3 Icrmlaalcd a:or bciovr land sur:nco rcqu!:c3 n variance Inactor
dance va:h 15A tICAC 2^ . 118
10. YIELD (gpm): METHOD.OF TEST Air
11. WATER ZONES (depth): L ,dCi/b
(rload t.arne and::urbe\rs. Commu�nBy\, or SoIdrvisicn aid Lot No.) DRILLING LOG DEPTH
O'WNE,R _-�1CL._�'t'C \� 1�C KS From To Forrra:ion Descr►p'�fon
Address _1 I,t t- I: e 1`"a� G.te S tI'14c Its O- 3 3 act 1_
12. CHLORINATION: Type .1 _` 1 Arncunt
13. CASING:
Vrall T::fcex r.
Dea:!12 Cia n u5'fo:-;::'F:.
From �� To 3� Ft. - �3--
To
From TC..-- F:'------- '— - ----
tA. GROUT:
Oop!h I.Worlol Mothod
From' Toc; 0 F1..�1t�U:�ti
From To Ft,
15. SCREEN:
Depth Diameter Slot Sizc tGe!erial
F: a•n ------ To ----- FI - — 1:,. -__ in.
From —To _ Ft. In. —In.
From To _ Fl, In. _ In.
16. SAND/GRAVEL PACK:
Depih S:z_
From To Ft.
From To Ft.
17. REMARKS:
_!� rO A)a 3i'C—
Lk
1(
0
� O
�:23
p�
cm
T -rn
ao
I: rAdl:ioral s(.acc is nocded v:c ba : c' te:m
m
M�
LOCATION SKETCH
4Ln
(S hc.: d.;eclicn r.nd dill - ..- m r: L'c.! two SW:e
61
Rc�os. or ct.` r map r_fcco : pc„ s)
�uN
S1`IIJGir
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, VlELL
CONSTRUCTION STANDARDS, ANO THAT A COPY OF THIS RECORD HAS BEEN PROVIDEDTO THE YJELL OWNER.
�=cos ��11�IG" / c
FIRIIICE USE ONLY r Ce-e-t`) �' J�" "�/U
SIGNATURE OF FERSOU CONSTRUCTING THE WELL DATE
Su.`mit od;iral to Ci•d::en oI Vra:cr Oua:ity, Groundealcr Secl:en nrilhln 30 days
GW-i REV. I2'99

North Carolina - Department of Environment and Natural Recourcoa - Division o(Walor Quality - Groundwater Soclioa O
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phono [phone] , 4
WELL CONSTRUCTION RECORD VIELLCONTRACTOR: Ilks l ' /�1Y IL� 7-
WELL CONTRACTOR CERTIFICATION Ik r 1 1
STATE WELL CONSTRUCTION PERMITII:
1. WELL USE (ChockAppucabtlo Dox): Residential t'dunEl Induslra! ❑
Recovery ❑ Heat Pump Water Injection] Other L] If Other, List Use:
WELL LOCATI0,N. (Show sketch of file location bolow)
Nearest Town: QNlI Cc
Agricultural ❑ Monitoring ❑
(Road Namo ,6 Numbors. Comrn' nity, ar Subdivision and Lot No.) f DRILLING LOG
3. OWNERFrom To
Address
spec, or �)t o.
City or Town c,' State Zip Coda
4. DATE DRILLED 1l �I—CCY
5. TOTAL DEPTH _L_uL
G. CUTTINGS COLLECTED YES ©� NO
7. DOES WELL REPLACE EXISTING WELL? YES E) NOED'
B. STATIC WATER LEVEL Below Top of Casing: J,,() -FT.
11 (Use'+' If Above Top of Caainp)
9. TOP OF CASING IS.�J� FT. Above Land Sudaco'
'Top of easing lanninated atJor below land surfaco requlras a vadenco In accor-
danco with 15A NCAC 2C .0118
10. YIELD (gprn): -,pl_ 2 _ METHOD OF TEST
11. WATER ZONES (depth): 11) — 1 ;2 S
DEPTH
Formation Descriptlon
�IQJiLV�,
0
o
O
(b
o.
$ (rl
�o
H
S
AO
w
m
<"
c�
r� O
12. CHLORINATION: Type Amount If additional space Is needed use back of form
13, CASING: --
Wall'rhlcknoss
�\ Depth l'�(� Di.]molor ar W i hbi't. Malcdal
Front-0 To r -1 R.
`r'� L -
F-rom To F1.
From To— FI. —
14. GROUT:
Doplh Material Mothod
From To �Q FL
From To Ft.
1S. SCREEN:
Depth Diameter
From To Ft In.
From _ To Ft. In.
Front —To Pt. In.
1G. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To Ft.
17. REMARKS:
Slot Size Malodor
In.
In.
In.
idatorial
LOCATION SKETCH
(Show direction and distance Irom at least two State
Roads, or other map reference points)
Farm ed
F(rQ f (y R-J. (sR- Ic(ob)
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 20, WELL
CONSTRUCTION STANDARDS, AND TWAT A COPY OF THIS RECORD HAS BEEN PROVID,E/D� PTO THG WELL O
FOR OFFICE USE ONLY A" ( G I nlL l �'I /Q(�I.(%.P.t�.F /✓�(' (.4 A
Quad No: SIGNATURE OF PERSON CONSTRUCTING THE W G
!1101. ]�ai l,@r Gigslon b17lalor Quality, Gwund•uater Section wlthln 30 days,
Scdal No.
} (
DATE
GW I HEV. 12/99

�
North Carolina - Department of Environment and Natural Resources - Division of Water quality .3044 - Groundwater Section ') e) ..
1636 Mail Service Canter - Raleigh, N.C. 27699-1636-Phony [phone] -
WELL CONSTRUCTION RECORD WELL CONTRACTOR: J4 () fi1L(-l.tv-✓t>
WELL CONTRACTOR CERTIFICATION U:
STATE WELL CONSTRUCTION PERMITN:
1. WELL USE (Chock Applicable Box): Residential C_ Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ I -lent Pump Water Injection ❑ Other ❑ it Olhor, List Use:
2. WELL t Town C(�Sh 1y Sketch T �f the location baloC)�n �,SC�
Nearest Town: ) County: Cl
(Raid Name and Numbers. Comrnunily. or Subdivision and Lol Nu.) DRILLING LOG
3. OWNER `r� Fro:n Ta
Address L� )Q` l -\r C_ —
Iroo or it-,.ao ,o.j
DEPTH
Fonnallon Dascrfpllon
- E' co, - ) c
City or To - S;a:a Zip Gcdada
o
'
DATE DRILLED —) -VO
5.
TOTALDEPTH LEE
C.
CUTTINGS COLLECT ED YES 0� NO❑
V
7.
DOES WELL REPLACE EXISTING WELL? YES ❑ HO�
^^//A\
. Q -A-rS lD o 11
0
E.
STATIC WATER LEVEL Uclovi Top of Cn sing: F7.
CD
o
(Use'+' it Above Tc�, of Casina)
-
O
�?-�
S.
TOP OF CASING IS I FT. Above Land Suifaco'
c"')
oc n
'Top
of eoelug lounlnated at/or below land surfrcu raqulros a vn:lanca In actor-
-
N
;t
dance
with 15A HCAC 2G.0110 4
�Wl
_ �- _
�<
10.
YIELD (gpin): �_ METHOD OF TEST
_,
yo
11.
._ Ll0 '
WATER ZONES (depth):
�
r i,
__9D _�2� -�
ci"o
12.
CHLORINATION: Type Fvnocnl Jiz1_p.[11
lJ If addilional space Is needed use back of form
13.
CASING: V
—1
o
-
J
Wail Thkb,ncss
LOCATION SKETCH
=
Depth 'P.z .. C:_� ;. :,',.:;
E, i 5
(CI U ._n and C, s a: co f least two S',ale
From To _!_� Ft .. --
Ponds, or other map refs c'ce points)
From To
FL
From To—
Ft.
—�,(,(,�
LQ C.I ..
1.1.
GROUT:
Depth
Malorlal tAolhod
�LJ�05 f
From To ;)
Q FL
�)
From To
FL
Chris-�V
15.
SCREEN:
/
Depth
Diameter
Slot Size_ Malorial
From To
Ft
In. In.
From To
FL
In. In.
From To
Ft.
In. In.
16.
SAND/GRAVEL PACK
Depth
Size
From To
Ft.
From To
Ft.
17.
REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS COtdS'l FiUCTED IN ACCORDANCE WITH 15A NCAC 2C, %ELL
CONSTRUCTION STANDARDS, ANO THAT A CO Pf OF THIS RECORD HAS BEEN PROVIDED
TO THE WELL OWNER.
FOR OFFICE USE ONLY ��!-� %� h-J, Qlo
Quad No: SIGiiA1U11EOFPERSONCOPi S.RUCilN4 THE YI DATE
Scbn'il aginal .o Di,:isiml a. Ylaler Ou airy, Ground=rrater Section Yntl tin 30 days
Sadal Na. GW-I REV. 12J'Ja
#�I
S r
I

�Ak
(
North Carolina - Department of Environment and Natural Resources - Division of Wafer Duality - Groundwater Section 4_ a. 3 0 4 21
1636 Mail S=_rvlce Center - Raleigh, N.C. 27699.1636-Phono [phone]
WELL CONSTRUCTION RECORD 1VELLCONTRACTOR: lA s��� l 1a -1 0 r
VlELL CONTRACTOR CERTIFICATION G: o�ilg
STATE WELL CONSTRUCTION PERMITN:
WELL USE (Chock Applicable Pox): Residential'n Municipal ❑ Industrial ❑
Reco%ory ❑ Heal Pump Vlate, Injection ❑ Other ❑ If Olhor, List Use:
Agricultural ❑ Monitoring ❑
2. WELL LOCATION: (Show sketch of the location be!ow)
Nearest Town: County: C� -� C k S
A /\i
(Road Name and Numbers, Commun:y, or Subd:v!sion and LCI NQRR) DRILLING LOG DEPTH
3. OWNER �3thb&l 6�:L)A CjL gt, 1n. b0ocrf s From Tri/� o Forr.allon DescnpGcn
Address ('�e( 1 �-} wr. 'i y LL� _ 0 — rj _ _ 1J4u cS('v 1'-J
�SuccTor 14"', ran r
I,yh:+i,; ,/
NZ 1�11 q,'79-'/
ICi;y or Tccn -
S:ate 21;. Colic
4.
DATE DRILLED
S .9MC,
5.
TOTAL DEPTH CA, 11
G.
CUTTINGS COLLECTED
YES© NO❑
7.
DOES VIELL REPLACE EXISTING WELL? YES D I'l0j'S:<j
6.
STATIC WATER LEVEL Bcf!ote Top of Casing:.-_R 1 _ F F.
(Use',' if Abo,o Top o! Casino)
9.
TOP OF CASING IS 1
Fr. Above Land Surface -
•Top
of tn5ln9 terminated oVor below
land surr.ua requires a variance In accor-
dance
v:Ilh 1SA IICAC 2C.011a
10.
YIELD (glom): M
THOD OF TEST AI C_
11.
WATER;_
12. CHLORINATION: TypeAntic n1
13. CASING: -
V,,31 i;au-c
Dep!h Di c:cr c:5-; ci;,P"i%• !!-•:c Cal
From To hS Ft. (s-...-4 J3_ $•F re
From- To-- Ft.
From To-- Ft. _
14. GROUT:
Depu, (11,13to:lal Method
From' To acL FI. �tLlS lt� S_T2
From To Ft..
15. SCREEN
Depth
Diameter Slot Size_
Malorial
From
To
Ft
in.
in.
From
To
FL
In.
in.
From
To
Ft.
In.
In. _
SAND/GRAVEL PACK:
Depth
From
To —Ft.
—
From
To
F (.
17. REM,
Size
Material
R3 I-c 85 � CC A.',f r=
r�
-rO {,
C 5�' cm
yo
cn
If c�JiSoral space i; needed use L-ac.. _. �: rn -� y
LOCATION SKEE[CH.
(Shoff dlrec�icn cnd dis.ance .rc•m -1 Jca, f two S!a,_
ioeds, or ct.`•er map r;c: cnc,. Ix.• s)
L40) Lhr r� flee-
S i �l/�ll 3flvc,R6nG
,_5 q // (�lV '((b��ti jjl�r l� (T C-1
A Oil `- 14' I I 0 C,1
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NrAr 2C, WELL ! �l�-J/OG
CONSTRUCTION STANDARDS, AND THAT {/A�COPY (OAF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY ::.:.,...-.,» .:. ,..,.1�1 4 Yt l'1 C9e'Jii �' V.> �OS �i�., � I G •+l�� ��/(%G--
QuadNo: e , i ( jr$irS!IlTUREOFPERSONCO?ISTRUCTIRG THE WELL GATE
r r 1 n.'a a nLe,Qun r,lt.lo Division of %'later Duality. Groundea'cr Seca en within 30 days
Serial No. 'zf Gs9l REV. 12159

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 0
1
WELL CONSTRUCTION RECORD WELL CONTRACTOR: sY f�)-- c^(1 _ urr1,1
WELL CONTRACTOR CER NFICATION If: d�
_
STATE WELL CONSTRUCTION PERMITS:
1. WELL USE (Check Applicable Box): Residentiain Municipal ❑ Industrial ❑ Agricultural ❑ Menitering ❑
Recovery ❑ Heat Pump Water Injection ❑ OIM--r ❑ It Olnor, Llst Use:
2. WELL LOCATIO d: (Sho•vv ketch of the location bolow) _ '/ . /
3
Nearest Toy'�
CounDy: a-c S 0/V
,tea L�-_K
(Road Name entl r:umbea, Comrnun.Y', cr Subd:vislon and Lct No,) DRILLING LOG DEPTH
3. OWNER (.L�[',S�'�IG,r/l
Fro Fcmatl ripGcn
b)U Address go{ip j,0es+MLrK
avec; or .,_ ao.
:�bl ski Tb � "74 '/y-
'7'7 > c G ranr
Late
Ci;y or Tcwn � State Zip Cede �
<. DATE DRILLED r��+�,±.,=„''�� e--t-"��jawo
FiKV
i'O
S. TOTAL DEPTH
6. CUTTINGSCOLLECTEO YES© NOD O
9
7. DOES SPELL REPLACE EXISTING bVELL? )'ESL --.I NOJY, d
B. STATIC WATER LEVEL Bolote Top of Casing: q [) FT. rrr
(Ucc'.' if Abova Top of Casl:,g) C")
�-,.,1
9. TOP OF CASING IS FT. Abovo Land Surla ce' b
o�
'Top of easing terminated nt/or bcla,t land surfaco requires a varlance In aecor.
dance v:Ilh 15A NCC 2C.01 8 p
—'-
10. YIELD (api METHOD OF TEST /-1I V-
11. WATER ZONES (depth):
12. CHLORINATION: Type � C \� Amcun! 11I: ...,dlSe;:al space io needed lice L...... _, ,e:n'J
o_
13. CASING: - I ----__--- --_—__—_—_—_
Wall T:nkncss LOCATION SP EETCIH
Depth Or ar C.,Y' -"'1 -'•a-I (Show dyc-.!icn and dt 1r:nc_ !:C::! .l Icas! tv:o State
From �� To-4—Ft. ,1.3�� Ro:.ds, or ether map lc•_•_.•_: pc•• o)
From - To --- FI. --
From To— Fl. —
1A. GrOUT:
Depth r� Matorlal Method
���2
From' «TO-�L Ff. l
map
From To Ft. I-
15. SCREEN:
Depth Diarneler
From To Ff _ in.
From To Ft. In.
From To Ff. in.
1G. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To Ft.
17. REMARKS:
Slot Size Ma:Grim
in.
in.
In. _
Material
I DO HEREBY CERTIFY THAT THIS W'c LL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C. WELL OQ
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE SELL OWNER. /
FOR OFFICE USE ONLY
Ouad tic:
Scrial tic.
SiOt:ATURE OF PERSON COPISTRUC ntGG THE \TELL DATE
3l,tA-Ai; J gl 1(pyar Duality. Groundwater SecY.en within 30 days
GW-I REV. 12r58

North Carc%na - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section .'- •� �� ! / 4 0
1636 Mail Service Center- Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: , ✓+ / +CCLL(/ (�
WELL CONTRACTOR CERTIFICATION 0:
STATE WELL CONSTRUCTION PERMITU:
1. WELL USE (Check Applicable Box): ResidentiaYn Munkipal ❑ Industrial ❑
Recovery ❑ Heal Pump Water Infection ❑ Olhsr F-] it Other, List Use:
2. WELL LOC"ATIOS1h�,1erP_i(q e location be!ov:) `yC k <S JNearest T in: LCauny:
Agricultural ❑ Mcnitcring ❑
(Road Name' and Numbers. Corrrmuni;y or SubdMsicn and Lot No,) DRILLING LOG DEPTH
to'h. O'wNER 1, e ,)4 fnc i�k From To auec, or Porto Ion Oesc,(,p:icn
Addresars c D st U— -31 4 rC.l
/ C ao.)
/n�
City or Tc,vnr5la!a Zip Code .'J i 7�' 33 _!� rctu (,e-
4. DATE DRILLED c' -r-
5. TOTAL DEPTH &LID +
6. CUTTINGS COLLECTED YES© NOD
7. DOES :YELL REPLACE EXISTING V/ELL? YES F-1 NON
S. STATIC WATER LEVEL Bclow Top of Casing: at,,,() FT.
(Use'.' it Abovo Top o! Caoinp)
9. TOP OF CASING IS FT. Atovo Land Surface'
'Top or eas!n2 terminated n7or below land sur:aco requires a variance In accor-
dance with ISA NCAC 20.0 t1a
10, YIELD (apm): .LJL MET D OF TEST - AI
Fj9
11. WATER ZONES (depth): / '3LG_—
*Y3 -fD �0
rV
12. CHLOr;N.ATION. Type 1 \ \A r, ,cunt „::JdiSo,.al spaca;; ncaded use
LOCATION SKEVCH _
Depth DI,:.T,cr
� From (- To Ft. UN
From To FI.
From To-- FI.
14. GROUT:
15
V7a:1 Ti�iu^rs.
Deplh 1,131orlal1
From' Q To �_Ft.
From To FI.
SCREEN:
Depth
From
To
From
To
From
To _
16. SAND/GRAVEL
PACK:
Depth
From _
To —
From
To_
17. REMARKS:
tlolhod
—x�_2
Diameter Slot Sizc_ Malcrinl
Ft in. in.
Fl. in. _ In.
Fl. In. In. _
Ft.
Ft.
Size Material
(Sho,v direcCcn ecd dislcc .Ica;[ two State
Roads, or otter map rolarena: pcir'i:5)
-� 1 1 c-
I DO HEREBY CERTIFY THAT THIS WELLWAS CONSTRUCTED IN ACCORDANCE WITFI 15A NCAC 2C. WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TK�O, THE WELL OWNER.1 , /
FFOR OFFICE USE ONLY ; �'OS ` � I G •+ �/� !Y kozx_
d No: Gr T E - iSTRUCTING T HF WELL DATE
dTF'son or Walorc A�TGround,sater Sec:on within 30 days
ial No, 1 GW-t REV. 12/55

23039
North Carolina - Department of Environment and Natural Resources - Division of Water Dualiq - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phono [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: R I MLU DY-
1VELL CONI RACIOR CERTIFICATION Il: r`-�
STATE WELL CONSTRUCTION PERMIT#:
1. VIELL USE (Check Applicable Pox): AesldentlaYn Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water In;ection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION
Nearest Town: —
(Road t.
3. OWNER
Address
M
Agricultural ❑ Monitoring ❑
of the location ba!ew)
T 5C.CJkS o n,
or Subd:Msion and Lct t:o.) DRILLING LOG
(L I�to 1 1 -,j - - From 70
/� t' V e- -- U — 1 '/'-
Clay or Tcv:n - Sla:o 21p Code
4. DATE DRILLEDSC e.m t�_1'I,:2CCr,
5. TOTAL DEPTH .-g45
6. CUTTINGS COLLECTED YES © NOD
7. DOES';' :ELL REPLACE EXISTING WELL? YES NO�
B. STATIC 'ELL
LEVEL Sclov: Top of Casing: FF.
(Usc'.' it Abo•+o Top of Cacing)
9. TOP OF CASING IS r FT. Abovo Land Surface'
'TOP of enaing lannlnnled DVOr beloe+land sur(aca requ:rea n variance In eccor-
dancc vdih 1SA NCAC 2C.0118
10. YI ELD(gpm): 10 MET/HOD..O,F f
TEST AI
11. WATER ZONES (daplh):—
12. CHLORINATION: Type _�, \ E1—_!••nteu':1
13. CASING: ! 1
4Yail T'r.ci.-c ss
> Dep:!t CIO a 1" 'cr cr l•;c3r L,-•CCI
From �- To s,,A I Ft. ...�_
From' To FI. ---
From To-- Fl.
14. GROUT:
^ Depth r�.�la�to�;�lal Molhod
From' Ca— To (^) FI.
From To Ft.
15. SCREEN,
Depth Dionleler Slot Size Material
From _ To FI In. in.
From To Pt. In. in.
From To _ Ft. In. In.
16. SAND/GRAVEL PACK:
Depth Size Material
From To —Ft. —
From To Ft.
17. REMARKS:
as_kaq
9q i-o ggJj
DEPTH
�c ion OescripCcn )
_r Cr/�lu ✓t l
� t ,'fr,
-� If :..,�Ciorai spaceis noedod use bac<; c. ,,rmj o
_LOCATION SKETCH
(Sh%,, d:recicn rnd caLt two S:a,-
Roads, or clhor map re:cr cncc
S y I L)CIL
C LL [ (6j'
S� lyNl CpC� c0 ,,R A)
S R lei v List' P - .
S 3
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE vilM 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS EEEN PROVIDED TO THE WELL OWNER,
FOR OFFICE USE ONLY >I Nc 1 Oe-e-tvi P_ O�VN
Guad Nc: S(rt:l,,TL'RE C;F PEASON CONSTRUCTING THE WELL
SubW1 tid_Ira1'tofllviaen of P/elor Oualily, Ground,a:cr Section lvilhln 30 days
Serial tic. r
f {;
p
! U iAu d',5 c 'f•
m
DATE
�/is/Co
5��lC�
GW-1 REV. 12159

North Carolina - Department of Environment and Natural Resources - Division of Wa!er Qua!i; f • Groundwater Section �1_ 23151
1636 Mail Service Center- Raleigh, N.C. 27699.1636-Phcno [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACT -OR CERTIFICATION 0: a l
A' Ctk Z, STATE WELL CONSTRUCTION PERMITP:
1. WELL USE (Check Applicable Box): Reside ntiaYn Municipal ❑ indusldai ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ It Olhor, List Use:
Agricultural ❑ Moniloring ❑
2. WELL LOCATION: (Shoe ketch of tho location be!ow) +
Nearest Tovm: Ste, � U LC-.
(rtoae Nam $ynCea tt' Mb C'S, CflWgju01��, SU�divWcn aid Lot No.)
3. OWNER y I )C,-rAIer_I/ S��1nC_f rS.
Address rnr �r1,_.., C1.__..'F"
w;y or itwn - Stale Zlp Ccdc
4. DATE DRILLED S k1r;ht'✓.:2Vpa1�d
5. TOTALDEPTH •2aM
6. CUTTINGS COLLECTED YES© N0L—]
7. DOES V/ELL REPLACE EXISTING VVELL? YES IF;Co
S. STATIC WATER LEVEL Below Top of Casing: _lf� F-F.
(Use'.' it Above Top of Cain;)
9. TOP 0= CASING IS i FT. Abovo Land Surface'
'Top of erring terminated nVor below land surface requlrea a variance In ccco:-
dance v:!:h 15A NCAC 20-.0119
10. YIELD (cpm): q!5" METHOD OF TEST Air
11. P/ATER ZONES (deplh): �JY 2/OF
_ 3i 07-- I f' Aj
12. CHLORINATION: Type A:ncunt 4b p—Ji'a-
13. CASING: I
YlaA T!:ick:.r;;
Fro,n1_�—To 1Ps6_ Ft. te
From- To—_— FL From To-- Ft. —
tA. GROUT:
Deplh 1,latorlal Method
Front' To'-7.�_ FL .�ri1LLt �2_
From To —_. Ft.
15. SCREEN
Depth Diameter Slot S!zc 6lalerial
From To Ft In. .in.
From To _ Pt. In. in.
From —To _ FI. In. in.
16. SAND/GRAVEL PACK:
Depth Size Idalerial
From To Ft.
From To Ft.
17. REMARKS:
DRILLING LOG DEPTH
From c Fom-tattoo Descrip!:cn
(o 6 J-,r, 2ob
m;0
r �
z
space L: n._eded use tact, C' f.,:m _—
_LOCATION SKE FCH
(Shc;: d!rvedfcn end d!s• .cc' m.: Las! tv:o S!a._
Rcads, or c!hcr reap rt; c:enCc pa, s)
sR�yy) rce-k R&-Lcj
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED III ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTIOII STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PP,OVIDEO TO THE V/ELL OWNER.
FOR OFFICE USE ONLY
o�•aa Ire:
Sedal No.
•rATVRE OF PERSON CONSTRUCTING TFIS WELL
Ground,+alcr Sev;cn within 30 days
D
G'N4 REV. 12l99

North Caro!i.na - Depanment of Environment and Na lural Resources - Division of Vfaler Quali`y - Grcundwz:er Section ' , ,-1 ') (j [�
1636 Mail Service Canter- Raleigh, N.C. 27699-1636-Phcno [phone] a- � J V 61,,.
WELL CONSTRUCTION RECORD WELL CONTRACTOR: 1 ssel I ! Q�)�j I L)
e1� WELL CONT RACTOi2 CERTIFICATION G:
Si, STATE WELL CONSTRUCTION PERL!ITR: _
1.
WELL USE (Check Applicable Box): Residenl'a;Ln Munic:pal ❑
Industrlzl ❑ Agricuitural ❑ Monllering ❑
Recovery ❑ Heat Pump Water h;cclion ❑ O!h-r (]
If O!tor, List Use:
2.
WELL LOCATION: ( ov+ sketch of the location be!o•w)
?Li I CL,
�0-
Neares; Town, L,) Ccu: �;y: -
v ty
e- C rl �)
_(? V.'1 Gf1 c7 LC�A
(Road Narno end Nu.-.bo:s. Corcrr.uni:y, or 6ubd: ,,'on and Lcl No,)
DP,ILLINC LOG DEPTH
3.
O'tVR'ELi S-(l�,e3t
From To fenra7on De scrip: n
Address �1 ,� `Sx
[,l orh.:oTo)
C\-\\ o e-c Iy C A 7:1.3
Lt
cr Tcv:n 6: Cm � Zip Co_c
1 0 3 td / L1 s (Ya lJ
- ��-
,.
.^,ATE DRILLED 'i-a o`)CO"
..
TOTAL DEPTH-Lt)b I
6.
CU17C:GSC0LLECTED YESQ NOS
-
7.
DOES V ELL REPLACE EXISTING VlELL? YES h;0I �1
F.
STATIC WATER LEVEL Below Top of Casing: Fr.
o
--gyp-()
(Ucc '.' i! Abo:o Top c! Ca:I:i,)
c
O ~O
9.
TOP O: CASING IS ( FT. Abovo Lan.J Surtacc'
S
t7
'Top
of coa:r.g tc: min a;cd ovor hcton land sur'aco ro-y c:res a variance In ccco:-
dance
r:ah 15A NCAC 21-.e113
10.
YIELD (cpm): METH0D OF T EST _al L
N a�
11.
WATE.. 7IZONES(depth):- V-1_,S5.
12.
CHLO,'-;NATI0:: T)pes-� p
�
wM
L-
13.
GF'.SIN G:
_LOCATION SKET CH
Depth c: 5.r,.!-.•i=!. :,.•-�::
V `�
(5'._';:cl:-..`_n ccd dls•zc_c..cm.� l_cs. two S'a:^ Z
..,Plows,
,D,:-LL_^•c
Frnm _�� To �Z Ft. -lz __ (
or c[`;Lr map rc;c:once pc.:a)
From- To— F1.
From To- R.
14. GROUT:
Depth
From' To (_) Ft.
From To Ft.
15. SCREEN,
Depth Diameter
From To F( in.
From —To—Ft.— In.
From --To—Ft.— In.
16. SAt,!DJGRriVEL PACK:
Dcplh Size
From To Ft.
From To Ft.
17. REMARKS:
Slot Sizo Lta:orial
Ltaterlal
I DO HEREBY CERTIFY THAT THIS VIELL VrAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTFUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE`�V.'ELL O'NNE/R.'L 1
FOROFFICE USEONLY ���\ JC-Q�1.i �' �+�OS �'�11 y\IG��%/L) C�
Ocad No SIG::ATURE GF PERSON CONSTRUCTING THE WELLJ� DATE
Su-,11-1cri<;nal to 0bds:cn of PJa:er OuaG;y, GrcunC ra:cr Se.:en wi!hln 30 days
Serial Ne. GPh1 REV. 12'59

North Carolina - Department of Environment and Natural Resources • Division of Water Quality- Groundwater Section C- C.3UU1
1636 Mail Service Canter -Raleigh, N.C. 27699-1636-Phcno (919) 7333221
WELL CONSTRUCTION RECORD WELL CONTRACTOR: - R uS5_elI _TG-�(Iorr
\'WELL CONTRACTOR CERTIFICATION fi:
STATE WELL CONSTRUCTION PERMITl1:
1. WELL USE (Check Applicable Cox): Resldenfai'LY Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection
Other ❑ It Clhor, List Use:
Agricultural ❑ Monitoring ❑
2. WELL LOCATION: (Shoe sk lc h of the location below)
S
Neares: Town: ll ( L)Ca-- County:__']
Cyr- k S C)Aj
kC, k
C_ L. ss c- «J
(Read Kamo end Numbers, Commun?y, or Subdivision and Lcl No
DRILLING LOG
DEPTH
3. OWNER
From To
Fo alien cescri n
�(- 7
Address I ._
I i t_ rm S t-ad r, i�
U
—jatiem or ouzo aot .
-City 1 Tolln 51a:a L'If GOI^
-T�•
. DATE DRILLED cr z,�LY`C
5. TOTAL DEPTH
l I
G. CUTTINGS COLLECTED YES© N00
7. DOES'rVELL REPLACE EXISTING WELL? YES
8. STATIC, WATER LEVEL Belmv Top of Casing: _&_6 FT. _
(use'+' it Abovo Top of Caclnq)
9. TOP OF CASING IS 1 FT. Abovo Land Surlace'
'Top of eesl:ig laminated o']or below land surface requires n variance In accor.
deice with L`A NCAC 2C .0110
10. YIELD (gpm): _"- METHOD OF TEST —AI V _
11. WATER 7OPtES (dapih): - ! =1&D_ /'-7 sv_
3��_,�a /:5 l Ll25
12. CHLORINATION: Type --L-i `—\� A.mecm ...2` ff YL I: aIdai;ioral = ace L- needed use a.ac;. _. ,xm —
-F
_LOCATION : KETCH
From_1__To
/� Death
tv-5 Ft.
DL-:; :•r er V'C;l; Fl. L'a:cdcl
U 4— 1.3 Strel
(Shov: Cire:Clio,-: and dlslcnce!rCr-.,':I^as!two State
_
Roads, or ether map rote:ere: I:cins)
From
To--- Ff
---
From
To— Ft.
1A. GROUT:
Depth
Material Molhod
S , I CO (D d I 07%
From'
«To=Z. Ff.P_]1��n
I
CrC e%'� RAF
From
To FI.
—..
c_tis
c5 R 13,;2F
15. SCREEN
Depth Diameter
From To FI in.
From To Ft, In.
From To FL In.
16. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To Ft.
17. REMARXS•
Slot Size Matorial
in,
In.
In. _
Material
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE 1VITFI 15A NCAC 2C. V/ELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY �(:� rC , C�9-e-t" e 'lis C OS uyp'.J�_ t,
Ouad No SIG..ATURE GF PERSON CONSTRUCTING THE ';ELL
Submq odd 1`al (pT 0 ,}' or of V7a:er Ou a. ;y, G •oundea:cr Seaicn W iL',In 3D days
Serial No.
i
DATE
S�kc-
GWA REV. 12/53

North Carolina - Department of Environment and Natural Resources - Division of Water Oualiy - Groundwater Section �7 X` 0 6 0
1636 Mail Service Conte r - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: _RA raa"d!c�
%YELL CONTRACTOR CERTIFICATION 0: a0 / a /v
STATE WELL CONSTRUCTION PERMITP:
1. WELL USE (CheckAppllcahle Box): Resldentlain Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heal Pump Water Injection ❑ Other ❑ If Othor, List Use:
a4
2. WELL LOCATION(tShow sketch the location bo!ovv) (� 1
Neares!Tovm: 1.—�, \141 � � Coun1j: s \GCh1�1
(Road Namo end Nurrbers, Ccrr=untly, or Suodivis!on and Lcl No.)
(JUeM of
DRILLING LOG
DEPTH
3. OWNERCv
w\ K\ fV ri 'p
From To
Fonrailon Descnp:ion
Address
a Lj, �. C n ' CN
1
0 — ls�(
L L
—
T
OJ._ Jo.
a Sill 3M S--q to �( 1
'Ci;y or To•r:n 5:310 Zip Cede
<. DATE DRILLEDCU�S`it`_-'K) 2,Mb 9 1 t-o �,l
S. TOTAL DEPTH a*1 5
6. CUTTINGS COLLECTED YES© NO❑
7. DOES :HELL REPLACE EXISTING V•/ELL? YES ❑ I"Oj
E. STATIC WATER LEVEL Below Top of Casing: �(, p FT.
(Usc'.' if Abovo Top of Ceol:,q)
9. TOP OF CASING IS FT. Above land Sufface'
'Top of cos!ng lennlnaled at/or below land surfaco rcqu!res a varlanco In accor-
dance v:Ilh 15A HCAC 2C.0118
10. YIELD (gpm): q 5 METHOD OF TEST _Al f
11. WATER ZONES (depth): UQ' —
12. CHLO=IIN I01.. Tgpc e \ \� Ar.I i:icnai spa-c i; ncedv„ u.c _. .,.
13. CASINc---
l�aii TI:ICR;ra
Dep'�1 CR.-i�•cr c: 1ST-:-1::'i'L .. a:c•'..'.I
From—Q To Ft.
From To --- Ft. --
From To— FI. —
14. GROUT:
Depth Malorlal Molhod
From' To=L FI. 1ti�ti - V�,T2
From To Ft.
15. SCREEN:
Depth Diameter
From To Pt in.
From To Ft. In.
From To FI. In.
16. SAND/'GRAVEL PACK:
Depth Size
From To Ft.
From To Ft.
17. REMARKS:
Slot Sizo t.latorial
in.
In.
In. _
Material
!� y'cu��P
LOCATION SKErCH
(Shur: dircc::cn,.-d distance 6c•. .I_--::o S!a•_
Roads, or ct'cr mmp rcicrc.cc pcins)
S L,
j ran;K 1''N�
SR lyql iJu ra mite /1 ci
5�pitgL
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORGANCE WITH 15A NCAC 2C. WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE PlELL OWNER.
HI/
FOR OFFICE USE ONLY l`� C'2e43 e �' OS �i, �. 1 I0,•+
Ouad No: `� �." --=-Slfay TORE CF PERSON MISTRUCTING THE WELL DATE
I IS ;Su (r;(
Serial No, 4s;ir'pI Iq Q +L•Ien or l'!a'or Duality. G'oundea:cr Secl to within 30 days
' 11
�)3
T
GrouRdwe',er ^^ c
t Rsheulie Repine ,1
I I e I> y
S,/ A)CC
6Ph1 REV. 13'55

North Carolina - Department of Environment and Natural Resources - Division of Water Oualiry - Groundwater Section `7 U� (]
0. J
1636 Mail Sarvice Center- Raleigh, N.C. 27699.1636-Phono [phone] (.
WELL CONSTRUCTION RECORD WELL CONTRACTOR: �f (' C-L-Lrru
WELL CONTRACTOR CERTIFICATION h: ae l Ro —
STATE WELL CONSTRUCTION PERMITN:
1. WELL USE (Check Appncable sox): Residential'n Municipal ❑ Industrial ❑
Recovery ❑ Heal Pump Water Injection ❑ Olfv-r ❑ It Otbor, List Use:
2. WELL LOCA
Neares! Tom:
(Road N
3. OWNER
Address
of the location bolo,.-,,)
.'.� County:
Agricultural ❑ Monitcring ❑
DRILLING LOG DEPTH
From To
Forallon
O - aS _ rLj_'
pl:cn
V 'f Lr "[lf��r
Clry or Tcwn '5tato Zip Codes �d
4. DATE DRILLED
G. TOTAL DEPTH
G. CUTTINGS COLLECTED YES© NOD
7. DOES',VELL REPLACE EXISTING VdELL? YES [. J f•;Op—�}•
8. STATIC WATER LEVEL Be!ov: Top of Casing: �( Zl_ FT.
(U.c S' it Above Top of Casing)
9. TOP OF CASING IS i FT. Above Land Surface'
'Top of ea3!n9 terminated Wor below land surfsco requ!rca n varlance In aeeor.
dancewith 1SA NCAC 2C .011 B
10. YIELD (gpm): A-D— METHOD OF TEST AI C
11. WATER 7.ONES (daplh): ':?[0 " W15 ` _
or Subdivi.igi and Lcl No.)
e
j�-l% f4 u�L5
12. CHLORINATION: Type 1 C Fi A:nc,:rtl —f -? (F_ I! r. di:isnal space L- needed use Lo:k _• f.:m
13. CASING: i -- _--_
hail 7 hick: c.:
FromTo-'A I Ft..1.2 Y--
From To FL --
From To-- FI. —
14. GROUT:
Depth Malo:lal Method
From' Q To-�a_QZFt. L�1C�l 2
From To FI.
15. SCREEN:
Depth Di3rneter
From To FI in
From To Ft. In
From To Fl. _ In
16, SPEND/GRAVEL PACK:
Depth Size
From _ To FI.
From To Ft.
17. REMARKS:
Slot Size Matorial
in.
in.
in.
Material
_LOCATION SKETCH
(Show direcCcn end distance' m - Ica;! two Stare
Roads, or othar map rotcrenu: hu• :,)
Co
N ()r+orJ R c
I DO HEREBY CERTIFY THAT THIS WELL V,AS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, VlELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE V,'ELL OWNER.
FOR OFFICE USE. ONLY ` Ct Ce-e�+ e 1�T COS �%-�'- , � I , r �
Ouad No: � $IGP:ATL'RE GF PERSON COi15TRUC il'.G i F1`c HELL DATE
`-SuSM, on inal'lo 0Ms:on of %'later Qua::;y. Ground.aicr Seclicn within 30 days
Serial No. i i GW.I REV. 12'59
////5/M
r
()C'

North Carolina - Department of Environment and Natural Resources -Division of Water Qualir/ • Groundwater Section 2 U - U
1636 Mail S.2"Ice Center - Raleigh, N.C. 27699-1635-Phono [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: �u,n13e. �GL-Iyh
\YELL CONTRACTOR CERTIFICATION 6: 02 I fir/
STATE WELL CONSTRUCTION PERMITP:
1. WELL USE (Check Applicable Box): ResidentiaY Y Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water in;ection ❑ Other ❑ It Other, List Use:
Agricultural ❑ Moniloring ❑
2. WELL LOCATION: Sho v skelch of the location ho!ow) ^-�-- ' l
Nearest Torn: - oci_ Coun,y: - J �GR sn tiI
(load Nam and Numbers. Co.Tm..unily, or Suod!vision and Lot No.)
3. OWNER �gcat-II Prter !� 1rvc,
Address F.( CC rrVA&I/ hyll;S I
Ci:i or Town 'S;a!o Zip Cede
4. DaTE DRILLED to c Lis f / JD[d)
S. TOTAL DEPTH
B. CUTTINGS COLLECTED YESNX NOD
7. DOES :YELL REPLACE EXISTING WELL? YES
2. STATIC WATER LEVEL Below Top of Casing:.7_ FT.
(Usc','it Abovo Top of Casing)
9. TOP 0= CASING IS I FT. Above Land Sorfece-
'Top of eosins lcrrolnaled oVor hclovr land sur:aco roqu!res a varlanco In cccor-
d.ncc with 15A NGAC 2C 0118
10. YIELD (apm): - METHOD OF TEST _ AI E
11. WATER ZONES (depth): i-y6 / -k5 - 3 5O
12, CHLORINATION: Type \VV�_Amcun! —q_-( �
13. CASING: - !
1YaIl Vkkr. J
D2p1)t� . r
i.
C-�, nc:5•;
)::cr ft3'.'r� ;.'.��
From ��
To _�.�
Ft.
�+�__
From
To---
Ft.
From
To-
Ft.
—
14. GROUT:
Depth
).latorlal Molhod
From'
To-�.�L
Ft.
From __
To
Ft.
15. SCREEN:
Depth Diameter Slot Size Maloral
From To Ft in. in.
From To Pt. In. in.
From To FL In. In.
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
17. REMARKS:
DRILLING LOG DEPTH
From To Fcrr-a'lon Descri.pl:cn
3Lli-(-,
MM
1(r,'di:i:n31 spa_e i; needed lice heels' Term
LOCATION SKErCIi
(Sho,v direction a:;d d61_ncc' r-. .I_a;! l.vo S!a,_
Roads, or c!hor reap relcrcrce
S y UC-1 tfja` Nemec);toe, C
y s ✓iG
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY (OAF THIS RECORD HAS BEEN PROVIDED TO THE \\YELL O'NNER. 1 /
FOR OFFICE USE ONLY rT l-) CQPJv �' OS `t. �'.1` S\ C, -r ��J-� y l(%C"--�
Ouad tlo: SIGY.ATURE GF PERSON CONSTRUCTING THE WELL DATE
- Submknri 'rat 10 DBihlon of N; atcr Qual y. Groundv: a:cr Seu:en Within 3D days
Scrial tlo.
GW-1 REV. 12/53
LLB;
G i
L
(.'01711f1r 3 t �fC��06

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section �" Ai' 3 0 5 7
1636 Mail Service Canter - Raleigh, N.C. 27699-1636-Phono [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION
STATE WELL CONSTRUCTION PERM TIT:
WELL USE (Chock Applicable Box): Residonlial Municpal ElIndustrial El
Recovery ❑ Heat Pump Water Injoclio I Otter It Other, List Use:
WELL LOCATION: Show sketch of the location hale::)
Nearest Town: u C ,ACJ<r5' -e C -P P County:
cn r k cdc e\� •-
(Road Name and Nuhribrofs. Community, or ubdlvLaon and Lot Nu.) DRILLING LOG
3. OWNER Fran To
Address "J— V1�
�y[mTor iiou,o o.
AC;ilcultu;al ❑ Monitoring ❑
DEPTH
I'annatlon Doscripllon
CtSY,e.,l� -e, sSX �� r7L — C .Q C,,
City or Town `tale Zip Ccdu
1. TEDRILLD—yO
S. TOTAL DEPTH-J00 ��zO- y
Q
G. CUTTINGS COLLECTED YES [J�� NO❑
7. DOES WELL REPLACE EXISTING WELL? YES HO[2� L1 ;100 11
G. `STATIC WATER LEVEL Below Top of Casing: I 1p FT.
" o'
(Uso': II Abovo Top of Casir;;)
C:5 o
9. TOP OF CASING ISFT. Abovo Land Surface'
o a7
'Top of caalug lertninalod ntlor 6clow land su r(aco requires o v.+rla ncn In r.ccor-
^
dance with ISA NCAC 2C. 11a
i
2r
10. YIELD (gpm): -? METHOD OF TEST _ _
re o�
11. WATER ZONES(dopth): 14inn'bA-_
Ca
�o
'O
12. CIILORINATION: Type I I p �ArilOUrlt it additional s ace Isneeded we back of loon
m�
Mc �m
, to
13. CASING:
Wall Thlcknc.s
Do ill Di.]mctcr or Wei";; i Mao;;al
Fronl�Te `Q' FI. "'\ L �— AQCC.
From To Fl.
From To— FI.
14. GROUT:
Depth Malorial Mulhod
From 0 To QCD Ft. S—e Y Q7(LL �Q—
Front To Ft.
1S. SCREEN:
Depth
From
To
From
To
From _To_
16. SAND/GRAVEL
PACK
Depth
From
To _
From
To
17. REMARKS:
Diametor Slot Sizo IMalc6al
FI In. In.
Ft. In. in.
Ft. In. In.
Ft.
Ft.
Sizo Ma;urial
LOCATION5KETCH J o
(Sho•r, direction and distance Isom at least two State z
Roads, or otter map mienstee polcls)
I � 1000t� �Y1gC��
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTITUCTED li I ACCORDANCE W ITI 115A NCAC :'C. WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OP THIS RECORD HAS BEEN PROVIDED TO Ti It: ;YELL O
FOR OFFICE USE ONLY
Quad No:
Serial No.
�UI1G OF PERSON CONSTRUCTING THE'
ivisiun cl'aalur Quality, Groundwater Section
F
30 days
DATE
G W - 1 I lE V. 12/99
oC,i-� s o0

t
North Carolina - Departmonl of Environment and Natural Resources - Divlsion of Water Qually - Groundwater Section r � i 3 05 5
1636 Mail Service Center - Raleigh. N.C. 27699-1636-Phono [phone] �'
WELL CONSTRUCTION RECORD WELLCONTRACTOR: 0 (Y1QCLI,
WELL CONTRACTOR CERTIFICATION
STATE WELL CONSTRUCTION PERMMT :
1. WELL USE (Chock Appflcab:o oox): Rcsidonlial MGNCip31 ❑ Indu;lr,al ❑ Agricuilural ❑ Monitoring ❑
Recovery ❑ Heal Putrp V,1a:cr I,,^•jcc;ion _ 0::1Cr ❑ If Otto, _:cl Use:
�. WELL LOCATION: (Show sketch of the location bcio•w)
7aue— \ —
C�h Y\ 0 11I P County:
o" 1—
Noarost Town:
(Road Nam dNumbars, CJt ...nmity, or Subdivision and Lot No.)
DRILLING LOG
DEPTH
3. OWNER an Gi\(L.
From To
Fwmavon Doscdplion
�F_.. n
Address L��q S lCti t, ul'1 lrcl�V . r.
-
Irco or outs o.
�Llp
5arl CJ
City or Town S:ale Cold
_2f
DATE DRILLED 4i - '�O --CC
�nll e
S4 1 0 4U
��C�iLa-��
G. TOTAL DEPTH
M off;
G. CUTTINGS COLLECTED YES EI�� NO[�
7. DOES WELL REPLACE EXISTING WELL? YES
Cj b10�
8, STATIC WATER LEVEL Rclow Top of Casing: .75D
(Uso'.' it Abovo Top cl Casln,)
9. TOP OF CASING IS I FT. Abovo Land Surfacu'
'Top or casing tonnlnaled atror below land surtaca raGclroa a variance :n acccr-
dance with l SA N CA C 2G.0110
.
11. WATER ZONES (dopfh): h L. <ryl
12. CHLORINATION: Type Arneunt tf
I: additional spaco is needed use back of form
13. CASING:
LOCATICI'I
OiCETCH
Depth
Dia� or WeijbLI t.'.a;ciial
(Show direction and dlstatse
from at least Iwo Slato
�\
From _Io l TO
Pl.
L—�--%--
Roads, or other map Wero; ce poln!s)
From To
Ft.
—II,
Fro --IFI.
---- -----
V
.
14.
GROUT:
�I
��,
Uopllll
PAatorl3l t.to:hod
� '�1 U•�'`
(l
Frorn To d 0 FL--�`-nl�'-'YlL
Frorn To Ft.
�O�JIYns0-�
_ _
1S.
SCREEN:
Doplh
Diarnolor
Slot Sizb Malwial
From To Ft
From To Ft.
From _ To __ FI.
It,
16.
SAND/GRAVEL PACK
Depth
Sizo I:.alolial
From To
FL
From To
Fi.
17.
REMARKS:
MG
11S1VELL VAS.COt;ST1i1JC1ED IN ACCORDANCE WITH 15A NCAC 2C, `(JELL
AND THAT A COPY OF THIS RECORD HAS SEEN PROVIDED TO TI-IE `!/ELL O
FOR OFFICE USA ONLY _/-f`(-ri `-1 r� i! l !-t'U,k'_/�' I/✓-r-C-C /�i`-`, }J''u
Quad Na: SIGNATURE OF PERSON CONSTRUCTING TIIE V! �-
_ Sub,ni oricinal to Drdslon of w.itor Quality. G aundeatet Scct'on Yntllln 30 days
serial No. 9
DATE
GW.1 BEV. 12/99
l®-30-60

North Carolina - Depanmant of Environment and Natural Resources - DivLicn of Wa;or QualityGroundwater Soctian
23U4
1636 Mail Sarvico Confer- Raleigh, N.C. 27699.1G36-Phono [phone] `` -
WELL CONSTRUCTION RECORD WELL CCNTRACTOR: mil' D l <<uy-N
VIELL CONTRACTOR CERTIFICATION It: I ci
S T ATE WELL CONSTRUCTION PERMITtt:
1. WELL USE (Chock Applicable Don): Resideniia!y�(�, Municipal ❑ Industrial ❑
Rocovory ❑ Heat Pump %`later Injection Wit'- Ej If Olhor, List Use:
Agricuilura! ❑ Monitoring ❑
2. WELL LOCATION: (Sh w ��� -� sktc11 0l Iho location beic
Nearest Tovm: (�YS County: -
(Road Namo
3. OWNER _
Address
or Sub',visicn mtd Lnt r;o.) DRILLING LOG DEPTH
\ �_ �_ From 10 Fcnna:an Descrlptlon
uq or I own nu r ---
4. DATE DRILLED 1 -��� I �� +-0
S. TOTAL DEPTH CL--
6, CUTTINGS COLLEG I ED YES Et -- NOD 1
7. DOES WELL REPLACE EXISTING WELL? YES
D. STATIC WATER LEVEL Belo:: Top of Casing: _FI.
(Uca '.' it i,hovo l'op o: Cas:nq)
9. TOP OF CASING IS FF. Above Land Sutfaco'
'Top of eae11�9 la rtnlnalod auor below Iznd surface reyulraa a varlanca h: actor
dunce with 1SA HCAC 20 y°1, 10
10. YIELD (gpm):y METHOD OF TESTS -
11. WATER ZONES (dopth): - — —
12. CHLORINAT-ION: Typo Arno�nt
13, CASING:
Wall Th:c�r„ss
:er -
��_y
From To --- LL-� Ft.
From To FI.
Front To-- F1 --- -
14. GROUT:
/�
Doplh Malorlol M:tihod
From _0 To ,�)O Fl.
From To _—FI.
15, SCREEN:
16
17
Depth Dimnclar
From
To PI In.
From
To FL It!.
From _
To Fl. In.
SAND/GRAVEL
PACK:
Depth Size
From
To Ft.
From
To Ft.
REMARKS
In.
In.
L1.
0
C3
— O
11 addiEonal -,pace L• needed use back of form
J i
LOCATION SKETCH
(Show 1 .l Lcc.,'. I'r.o Slate
r c s, or ci.ier
I DO HERESY CERTIFY THAT THIS WELL WAS COPiS i!iUCTED IN ACCORDANCE V;ITH 1SA NCAC 20, ViELL
CONSTRUCTION STANDARDS, AND THAT A COP OF THIS RECORD HAS EEEJ PROVIDED JTO TI-' - V1ELL O'NNER.
FOR OFFICE USE ONL*, ,,�'G1�zQMiL' tom(/°n ^'��� >`-"-o L�-I A
Quad Not to 5 `` ,� IG i., fiE 0' PERSON CO`�6TRJC7 nG THE YlC�7
.- .tat i49p{jiP1I. a C` :icn c a'or Qua'u.y, Groanuxa'cr Section W It111n 30 oaYS
GVf-I REV. 12/"
Ii I)
lD - / 5 - vo

North Carof..,a - Department of Environment and Natural Resources - Division of Waler Quality - Groundwater Section �" .0053
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phono [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: _t
WELL CONTRACTOR CERTIFICATION N:
STATE WELL CONSTRUCTION PERMITN:
1.
WELL USE (Check Applicable eox): Residenti=x v Municipal ❑ Industrial ❑ Agricultural
❑ Moniicring ❑
Ross%cry ❑ Heat Pump Water Injection ❑ Oth-_r ❑
It Other, List Use:
2.
WELL '_OCATION: (Show sketch of the location beloat
_
rJeMares:Town: (' 1 County:
J GC- >C)A
i 1 `C�- GK `� u Lv N OCR t`
(Roac Name an ;lumhcrs, Cornrnunll•p or Subdivision and Lot No.)
DRILLING LOG
DEPTH
3.
OWNER C r P_ L4
Rom To
Forrr.alion DescripGsn
Address I� 4c, nrf scr xA,, u , r --
rr��
Q '- vZ vl
C�
l . 4
0 J 9 1
ucc or fouls o.
Fr ; /✓C- is 3 E
-
i o a
a el f-t .
CL; or Torn Stale Zip Cote
��' --
d.
DATE DRILLED rJulqi, 16 -.26` o
-'y
5.
TOTAL DEPTH
—
6.
CUTTIJIGS COLLECTED YES© NO❑
7.
DOES'NELL REPLACE EXISTING WELL? YES 0 N0,0
8.
STATIC WATER LEVEL Belot•: Top of Casing: 3r_ FT.
r,
(Use's' it Abcvo Top of Cnsw;)
-�
9.
TOP OF CASING IS I FT. Abovo Land Surface'
�—
'Top
o(cosic, le nnlnated o'lor below and surface ro Gu:res a variance In accor-
dance
10.
with UA NCAC 2C.0118
YIELD (epm): .;D METHOD OF TEPT AI
—r 3
_
11.
WATEP. ZOi:ES(depih):_ 0--90
o
�
12.
r-
CHLOFIN.ATION: Tppe F.lr, - QL�IJ
I;cd'.;:tonal epace �a needed uce
hair, c,',,;na �m
13.
CASING:
_LOCATIQ_i SKEF`_"_ wo S'a'— =i
�� Dopih7 �,/ Diarn 'cr tc:•t-sl'_'l., "a'c':1 (Sha.vd,reci.cn n,-:d dlst<nce..Cln .'. �_s J O
Fromm .To Ft..-�'=� 5 '� Roads, or ether r. p tutcrenc, peg. la) ..
From To--- Ft. —
From To-- FL
14. GROU-":
Depth l�hfatcdal f'oihod ��-
Front' To Ft.
From To Ft. --
15. SCREEN:
Depth
From
To —
From
To
From ---
To _
16. SAND/1-RAVEL
PACK:
Depth
From
To _
From
To_
17. REMARKS:
Ma)neler Slot Size Material
Pt 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, VIELL
CONSTRUCTION STANDARDS, AND THAT A COPY Gi- THIS RECORD HAS BEEN PROVIDED TO THE SELL OWNER.
FOR OFFICE USE -ONLY -� (—) CO -env Q' }�'r' OS �'r�'<'_ \V, I �
Quad No: DATE
J.._ SJ9taiLtiA� hJ1 to D vl lon of Plater Oua .y, Groundzn,cr Secicn within 30 days
Serial NO. �°4 r II G'N.i REV. 1:,,'�3
1',�f F'•r
� /I) PP

North CarcE-z - Deparlmont of Environment and Natural Resources - Division of Water Quality - Groundwater Section �+ J
1636 Mail Service Center - Raleigh, N.C, 27699-1536-Phono [phone]
WELL CONSTRUCTION RECORD WELLCONTRACTOR: s 1 u -
WELL CONTRACTOR CERTIFICATION if: 50kb
STATE WELL CONSTRUCTION PERMITS:
1. WELL USE (C1,eck Applicable Box): Residentlal�n Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Inicction ❑ Olh_r II Ct*.er, List Use:
2. ANELL '_CCATIQ{J: (St1ow iH,e
tJeares; Tov: n: (-
(Road Name
l
3. OWNER 1
Address
of the location be!o',v)
C' e— Counpl: 0 C, ck S G!21
or Subd:vislon and Lol No.I DRILLING LOG
Agric0ural ❑ Monilcring ❑
DEPTH
From To Form; on Descripban
_ — C»
City or Tarn State Zip Cede' / _ — �rRNJ' t t-
4. DATE DRILLED aw
5. TOTAL DEPTH S
C. CUTTI;iGS COLLECTED YES© NOD
7. DOES ",'ELL REPLACE EXISTING WELL? YES F-] td0,P�5
8. STATIC WATER LEVEL Below Top of Casing: -3_0 FT.
(Usc'.' it Abovc Tcp of Cm!nq)
9. TOP 0.- CASING IS 1 FT. Abovo Land Surface'
'Top of call:.; tern In.nted oVor below and sud.lco requires n variance in accor-
dance v,llh 1SA NCAC 2C.0118
10. YIELD ;cpm): _j4;xb METHOD OF TEST AI o
11. WATER ZONES (depul): 11
12. CHLO-IN.ATION: Type
13. C.ASIN3:
Depth Dlnr:cicr
From To FL Lr—
Frorn To Ft.
From _ To--___ Ft_
14. GROu,:
11
0
o
II :.�diflpn� _race..,.uCdCd use :.----'m
\'la:i i'.icR.x _LOC T]0-:J SKEI'_H W
(Show: dlrecl:cn r.nd c:s;once I:cc, . t u,.:: two S:d
r+cods, or clh,.r Irap rc:c:cnc•: he s) J
Depth t.lalorlal Method
Ftom' Q 1-0=�P_01 FI.
From --To FI.
15. SCREEN:
Depth
Diamo:cr
From --To
Ft in.
From _ _Ta
Ft.-_ In.
From To
FI. In.
16, SAND,%.:RAVEL PACK:
Depth
Size
From To
Ft.
From To
Ft.
17. REMA'iKS:
Slot Slzo n11:0rial
In.
In.
_. in.
Mclierial
V u C r-
(�Jay(✓h 1t�
GJc�tSG ��
F-c-l\; tic
O
I DO HEREBY CERTIFY THAT THIS WELL'NAS CONSTRUCTED IN ACCORDANCE N71TI 115A NCAC 2C. WELL
CONSTiUCTION STANDARDS, AND THAT nA CO? {(OAF THIS RECORD HAS BEEN PROVIDED TO T HE WELL OWNER.
FCu3d
FICEUSE OPII,Y ` ,' �1
.�117 1 VRc GF PEFISOV COh STRUC i ik'E Y•(-LL DATE
- ; i SQp�riO„-pn ire ®',Lion of %va ar Oca ,y. Grounde'a er Sec cn wilaln 30 days
.
gg G'N-I REV. 12/73
0,1
f

North Carel!:,a - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
16361d ail Service Center -Raleigh, N.C. 27699-1636-Phono [phone] -'�' (�
WELL CONSTRUCTION RECORD WELL CONTRACTOR: `2) D La o-L&rrG1
WELL CONTRACTOR CERTIFICATION 0:
STATE WELL CONSTRUCTION PERMITP:
l..J
.. _1080
1.
""pp��,,
WELL USE (CheckAppllcable Box): Residenlia N Municipal ❑ Industfal ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Iniection ❑ Olh=r ❑ It Othor, List Use:
2.
WELL LOCATION: (Show,skelch of the location belov;) _ I` - 1
Nearest Town:_ �_L EShtaPf ,S Couny: N
14I14 /-0YCSf U
(Road N, ms end Numbe,s, Corrr-.unRy, or Subc!MLion and Lol No.) DRILLING LOG
DEPTH
3.
1j
OWNER 1 01V14 0..Ne T(A CY i—�Ci Na.55 eL—, r 1 Fr= To Fonna;Ion Des-j��pticn
Address G, '�C�. r�i l r� /%%5 - 0 5 �
-
OtreC or fiooii, Jo.r
aPr�)V"/`r ML -2Ll
City or Tc,n Slafo Zip Ccce
5.
DATE DRILLEDLl 1U r%.;L'
5.
TOTAL DEPTH +D Si-b
tl
G.
CUTTIXGS COLLECTED YES© t"00
s
7.
DOES :YELL REPLACE EXISTING WELL? YES [::] N0,0
Q
S.
STATIC WATER LEVEL Selow Top of Casing: /Op . FT,
C:) --�
(Usc'.' if Abovo Top of Ca:ing)
9.
TOP OF CASING IS i FT. Abovo Land Surface'
or
-Top
of eas!ng terminated n'Jor befov, land surfaca requ!res a. arlance in eccor.
dance
with 15A 110AC 21-.0113
10.
YIELD (gpm): _U_ METHOD OFT EST _ 91 C_
r"o
l 1.
WATER ZONES (depth):rrr
�a
12,
CHLORINATION: Type �1 \ Fi !•,: r,�unt S r. .; ucc
ba.,., .,�;m� -�-
13.
CASING:
Depth r� Din. _tor
From S� To J 9 FL._S[L_i—
From - To--- Ft.
From To-- Ft.
14. GrOUT:
4'; ail T:ucx.-cos LOCATION SKFI-CH
c: 1 =r• r.t. <� -/I (Shc,v di: ecticn r.cd d:s,cnce .:cr-., . l Ics! two S!at
Road,, or ct',,er map ricicncc pc,. la)
Depth 1.13t0rlal Molitor]
From' ToZ �1 Fl. �r motti C�2_
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 Malarial
in,
In.
In.
Material
�01/L� Forte f y/5
Touter RCA
Chas1'fy ti����
I DO HERESY CERTIFY THAT THIS VIELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL I/ "I5 60
CONSTRUCTION STANDARDS, AND THAT A COPY (OF THHII `S RECORD HAS
QBEEN PROVIDED TO THE YELL OWNER.
FROFFICEUSEONLY r`l`�Ce-e-tie F.l�'OS �;�1 �IC�.,���-��%/L)C-
Ocad No: ----- .; :. $1GNATL'RE GF PERSON C0116TRUCTI'.G i 4'C 1b ELL DATE
M_u L t o , naf to DidYon of l'la;cr Ouaiay, G-oundn a,cr ScU cn vri hhin 30 daysSepal No.
Gw.t REV. lose

)JOlO
North Carolina - Department of Environment and Nalural Resources - Division of Water Quality - Groundwater Section
1636 Mail Sorvlce Center - Raleigh, N.C. 27699.1636-Phono [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION 0:�l
STATE \"TELL CONSTRUCTION PERMITII:
1. WELL USE (Check Applicable Box): Residents IAunicipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water injection ❑ Other ❑ If Othor, List Use:
2. WELL LOCATION: (Show sketc1h^ oaf th^e location belov+) Q.r� ^^
Neares: Town: U) 1 5 bA N' C� CounDj: �J`^-1 \e� cT )
(Roac Namo ar. tdumbcrs,7rfruni;y, or Subd:visfon and Lot No.) DRILLING LOG DEPTH
3, OI+YNE.R CCt1-�. ly, G7"1'ZcA e Z From To Fomcni n Descdp;lcn
Address C A"NAC.- Nc�rnxa ic-nst- -- 0 _ r)r)
10 Y.o 1,ox 44e� �J l`
rr �JIICC Of o'ul9 ti0 '1 11 II
2-YUT\y_1\I'1 it L ,'7t I �`i 9r) A p r)C) Y(1 /
Ci:y or To�..n Slalo Zip Ccce
4. DATE DRILLED -Tut \''1 .;�CUC: — J
S. TOTAL DEPTH 39U `VG G. CUTTINGS COLLECTED YES© NOO
7. DOES \^,ELL REPLACE EXISTING VJELL? YES[:] NO�
8. STATIC WATER LEVEL Belov: Top of Casing: 010 FT.
(U.c'.- if Above Top of Ca.in,;)
9. TOP OF CASING IS ( FT. Abovo Land Surface-
-Top of eual:,e tcrnilnated aVor bclovr land surface re Gulres a variance In accor-
dance wah iSA NCAC 2C.0118
10. YIELD (gprn): .I �Z METHOD OF TEST _ AilL
11 WAT"97O"ES d,-,1 �' J.� - r)lQrl
11
12.
CHLORINATION: Type �J'.�J Amour; )q�.Lll1�
�—
-, ' d U;e Lac.. _.! r!m
If ,.�'di;ional space i; nc a10' -
13.
CASING: =----_---
-—___-----�-_
_LOCATION _SKEI Cf'
z
Deplh Dtr,.me:cr or l'lc ,t:Si'. t(.-� ILe;c"rJ
> (�Q
9
(Show direction r.nd Cslu:ce ::cr: lI--as!two Smtl ,
From _1 To I_ I.—"1�
Roads, or ether map re;c:c..C._ ,$)
From To Ft.
From To-- FI.—
.
14.
GROUT:
Depth f:la;oslal t'olhod
141
_
From' To' , l—) Ft. �:�-Z
(j
S�
{p,
From —_ To —Ft.
11 n
I_J i'(2 JL),nngt 0-�h
�(M
15.
SCREEN:
U
Dcplh Diameter Slot Size Malarial
From To _ Ft _ in. In.
From To Ft. In. In.
From To FI. In. in.
16. SAND!,-7;RAVEL PACK:
Depth Size Material
From To Ft.
From To Fi.
17. REM Ci'KS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IIJ ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE�V,ELL OWNER.
FOR OFFICE USE ONLY �- l'SOe-e-JQ e_ 6' OS U -' `1 1, G -+ -
Ouad No: ,L.- SIGNATURE CF PCRSON CONSTRUCTING T`:E WELL e� DATE
Submit on nal to DIvlSlon of Vialor Oua sly, Ground'+: aer Sc clicn within 30 da y5
Serial No. OW-1 REV. 12/'i9
I y
r $. v✓�e.. n+ C h

93077
North Carol:, -,a - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 flail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: ii 42iZ .� ICU 0 it
WELL CONTRACTOR CERTIFICATION H: '� I-Sl'
STATE NJELL CONSTRUCTION PERMITU:
1. WELL USE (Check Applicable Box): Residential Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Reco•, cry ❑ Heal Pump Water Injection ❑ Otl17r ❑ It Other, List Use:
2. V,ELL '_OCATIC; (S"f1low
Nearest Town: � }t
skooll of the location belov:) -- - {/
UCLA Cc un:y: �, Cl Cry. j C, A!
_
r e Iry < C r& l R it
(Road Name and r'u,-nbers, lommunt, rSulc!Mslon and Lot No
(1 S �/n
3. OWNER iJ ) C � /V �%
Address ��/�/ Cr Cti a t
r(Strcco u:o � � i
DRILLING LOG
Fwm To
C) �
DEPTH
f'om'a;ion Descripticn
_
CL, or To. n* State Zip Comic
4. DATE DRILLED TLLI 660
5. TOTAL DEPTH ,3.�, ri
( �-
�� fC
6. CUTTCdGS COLLECTED YES© NO❑
7 DOESVELL REPI CE EXISTING WELLo YES "I
o
8. STATIC WATER LEVEL Below Top of Casing: FT.�
(Use's' if Abovo Tcp of C9nq)
9. TOP OF CASING IS i FT. Abovo Lard Surface'
'Top of casing tonnlnaled oVor belocr land surreca squires n variance in accor-
dance oath 15A NC:C 2C,e118
10. YIELD (gpm): METHOD�F TEST _ At C_
11. WAl ER ZONES (depth): Q— � 9�6
12. CHLOFINATION
13. CASIN3:
Type a \ V- A:neurU II ..I'_I:ioral space is needed uce `aci,r
WailTbict s
Depth pijc'cr ciV.,�i y^Ll; i'I�c�r!,-.11
From-�> To 7D Ft. �'' I .-1-1
From - To— Ft.
From To-- Ft.
14. GPOU
Depul Maloaal M.othod
From' O ToFt.
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From To Pt in, in.
From - - To Pt. In. _ In.
From __ To FL In. In.
16. SANDi,:iRAVEL PACK:
Depth Size Material
From To Ft.
From To. Ft.
17
LOCATION t;KE_LCH
(Sho,v direct:cn c^.d di:tance.c .least ;a•o State
Roads, or ether reap rul_rcn_: points)
Sy Juc�
L4 q
( rPcIVC fcr k
SRi3?
I DO HEREBY CERTIFY THAT THIS WELL 1VAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HASBEENPROVIDED TO THE \YELL OWNER.
FOR OFFICE USE Ot1LY _C�T C'R-eJv �'. Vim] nS �� ' I
Quad No ' �` $I F'. WRE GF PERSON CONSTRUCTING T HE YELL DATE
:on of %'later Quality, Grcundwa'er Sec:Icn 'within _3Q da'j s
Serial tro. j' G'N.1 REV. 12,".:7
?r clir.A j

22307
North Carol .na - Department of Environment and Natural Resources - Division of Waver Quality - Groundwater Section
1636 Mail Sondce Center - Raleigh, N.C. 27699-1536-Phone (919) 7a3 3221
WELL CONSTRUCTION RECORD VJELLCONTRACTOR:
WELL CONTRACTOR CERTIFICATION fl: CN/.AIL+ _
STATE 1"JELL CONSTRUCTION PERMITV:
I. WELL USE (Check Applicable sox): Resldentia.H Y Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Iniection ❑ Oillsr ❑ If Other, List Use:
2. WELL LOCATION: SShov+sketdt of the location below)
Nearest Town: !'ti•/!'%(III CCUny:
(Road Name j�no Numbers, Corn r, i;y, cr Su bd:v`on and Lot No.)
3. OWNER 1'l rC'N kC'
Address D ir. nV lri'7
1 C1 UC 0. j f CcL lt/V L/ 2� 6--/J �
Cip- cr To::n Sla:o - Zlp Cc.e
4. DATE DRILLED JI � 0
S. TOTAL DEPTH
G. CUTTIP;GS COLLECTED YES© NOD
7. DOES .',ELL REPLACE EXISTING bVELL? YES O 6:0�
8. STATIC WATER LEVEL Solovr Top of Casing: iito FT.
(Use'.' it Abovo Top of Cacir;)
9. TOP OF CASING IS i FT. Ahovo Lard Surface'
'Top of onsb.g terminated oVor below land surface roqutres a variance in eccor.
dance Mih PA NCAC 2C.0110
10, YIELD (ppm): ._)L— METHOD OF TEST _ i9l
11. 4,ATER ZONES (depth): 1 J-'aGC)
12. CHLORINATION: Type —r 1 t- F.;nee'; 6T(.11L5
13. CASING:
DRILLING LOG
From To
0—o2 3_
DEPTH
Fcr ,atlon Description
Al r
M
II r._lji:iGnal spa=e_Ls noodled use back c-;,rn�
SP;F__(CH
l: aA i'',Ichne ss
_LOCATION
Deplll�
.-,n^ter cr V/•_ i:','f"I. ,,,.'.al
(She;: di: ect:cn snd des;once :: a::. t I_ocl two Sia;e
From_
-To —
Fl.—�
��f��
Roads, or ctt:er ma, Ic:^_:end,
From
To
F-I.
-----
Frorn _
To _--
FI.
—
14.GROUT:
�%
From' 0
Depth
T�o-L1
Ft.
t.talorlal L",othod
_P`c_i�yS-1� —��2_
I �
beL' i f-C)l-est Il o
From
To
Ft.
/)
15. SCRE"r.td
Depth
From
To
From
To
From
To
16. SANDi,3RAVEL
PACK:
Depth
From
To —
From
To_
17. REt.LWf KS:
Diameter Slot Size Maleriai
Ft in. in.
Ft. In. in.
FL In. in.
Ft.
Ft.
Size Maierial
100 HEREBY CERTIFY THAT THIS WELL ViAS CONSTRUCTED IN ACCORGANCE WITH 15A NCAC 2C, WELL
CONST UCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE %%ELL O'NNER.
FOR OFFICE USE, Yc� I `n�- -K �1 CQ-e-it')
Ouad No: '�_. V` 1� �E 'tGNA1UFE GF PERSON CONSTRUCiIFG i`:CY.ELL DATE
r� 6ubntil od;lr'�aI tq Division of Ylai or Ouallly, Graunda: a:cr Sc U!cn Y+Ilhin 3O day5
.1 REV. 12'G9
Serial No. t„ GW
1e 1; tt

Nc'ih Carolina - Departmonl of Environment d Natural Resources - Division of Water Quality - Groundwater Section (') �.r
16„6 Mail Sarvice Center -Raleigh, N.C. 27699.1636-Phony (919) 7333221 L
WELL CONSTRUCTION RECORD WELL CONTRACTOR: iZuSzc —T-4\(LCZ
WELL CONTRACTOR CERTIFICATION #: -2-
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Appncable Box): Residentia; V Mun cipal ❑ Industrial ❑ Agricvllural ❑ Monitor,ng ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2, WELL LOCATION: (Show sketch of the location below)
b Nearest Tov.n: C'•u 1k;E CounP7: � y�
�aUa2- �,AD
(Road Na.Te and Nvrburs, Co-rr.unity, or Subdvis:on aid Lot No DRILLING LOG DEPTH
3. Ol.'NER pRT ICEEr (Z` From 'fo Fcrma!ion Deso-;p::o.�
Address moo, 3cx t3r�� 11
mee cr ,Dote m.) 41 43 /r+2'+NIr�
C,ry cr Tcv.o S:a:o Zlp Cody 43 OpOG"' GRnJt%
4. DATE DRILLED'�'D��'
5. TOTAL DEPTH may? F;
6. CUTTINGS COLLECTED YES [ NOO —
7. DOES V,ELL REPLACE EXISTING WELL? YES 0 NO�
8. STATIC WATER LEVEL Belov: Top of Casing: /To FT. p
(Usn .' it tdr:o Tep of Cas:nq) O �
9. TOP OF CASING IS I FT. Above Land Surface'
•Top of ca s!r.g le:mina:ed eJor below land surfaca regclree a vsl a nce In actor- c=
da.^.cc with 154 t ICAC 2C.0118
10, YIELD (Cpm): Z t 1ETHOD OF TEST _ CX-,r _ Co
11. WATERZONES(dapth):_ /_ZZ� ',�—,3C� /-�y�� ->
4eJ_ Z2- StS - --: 1
p �r
12. CriLORI':ATIOt1: Type hT fi A,;raont —--L4�„-r's II c,..,.,. ace is n: ed;d use b=..': o: Is.n
ci TI t. ,.a
From---
To
FI.
Fr.:an
To—
Ft.
14. GROUT":
Depth
f�:�fa�:e tint
t'etholJ
From O
To=:g1_FL
LLCl'`
n
From
To
Ft.
i5. SCREEtl
Depth
From
To Ft
From --To
FI.
From --To
FI.
16. SANDIGRAVEL
PACK:
Depth
From
To _
From
To
17. REMARKS
Dimnelar Slol Sire Llalerinl
n. in.
In. In.
In. in.
Size tl,aterial
Ft.
Ft.
�JpJ
rr Tn IM
LOCATION i S_-TGH z
(S`.o:r d!r=C,:cn cr`d Zs'a:.._c 'mn c: !was: f.vo Save
RUds, or olh_r map re:urence points) ci
I
I
— g /tier
c�ww.+vf' 20.
I DO HEREBY CERTIFY THAT THIS VIELL VrAS CONSTP.UCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COP OF THIS RECORD HAS BEEN PROVIDED TOTHEWELL OV,'NER.
FFOROFFIC_—]E USE ONLY T `! 1 f�-V�G-V`�J L�yF SliQzO: S G IATUPEOFFERSOtICO:ISTRUCTI6GTH= =LL LATE
to Eu..o.n of water Ouality. Groundn'alcr Sec, en wilh7r1 30 da/s
Nc. -��- -,) i E G•;:-1 REV. tv59
r
a
&' Ceopr F

-o74 North Carolina - Department of Environment and Natural Resources -Division of \Paler Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phono (919) 7333 221
WELL CONSTRUCTION RECORD WELLCONTRACTOR:
WELL CONTRACTOR CERTIFICATION 0:
STATE WELL CONSTRUCTION PERMITtt:
1.
qq��,,
WELL USE (Check Appllca Sle F/ox): Resldeniia;n Menictoal ❑
Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water In:ection ❑ Oltier F-1 If
Other, List Use:
2.
WELL LOCATION: (Shcw sketch of I`ie location helo',.)
Nearest Torn: Svwa• CcuaY
6
G40 wz5 CR61, Ra N I �I Top M,uT
(Rcad name cnd rbmbe:s. Co-.rr.u:.tly, cr S:Sd:vls:oI and La; ro.)
DRILLING LOG DEPTH
3,
OWNER 1SIQ. CQCGE L ArJO
FrFrccm To Fcr .arion Descrpllcn
Address 23zV-S)
0 of -4y
aet cr Imu:e .e.1
c� CD Q-1_21 �ilLbJr rc
Wa�an,Eiz ac, Zfd'�SO`�
`I' Z iGz� lvrLa.J+�y
Crty cr Tcv,n Sta!o Z'q CaG.,
4,
DATE DRILLED `�-I q_W
5.
TOTAL DEPTH (:6%2) FT
6.
CUTTINGS COLLECTED YES® NO❑
—
7.
DOES WELL REPIJICE EXISTING WELL? YES 1;0J
8.
STATIC WATER LEVEL Belo;: Top of Casing: 250 FT.
Abcvo Tcp of Ca7n,)
9.
TOP OF CASING IS FT. F:rove Land Surface'
O
'Top
et easing Icrmlr,ared aVor below land sur/ace require, a v,lanco In acccr-
1�
dance
v:i:h 1SA NCAC 20.01la
Cur
— —n->m
10.
YIELD (gpm): (21 I.'-.ETHOD OF TEST _
11.
WATER ZONES
Ts �
12.
CHLOP,.-ATION: Type �7�� \AA=Lrd _ � "-'
.. ,,,.�. ,_ ce 2dad a>o ba=?ol a:- ,CZ)
13,
CAS!NG:
nnia
LOCATtO_J SF,ETC:-i -- n
D_-.,il Di rL:1Fr"e11
:. •I�VL—
(Jhrr' -;�C IoS;c:ems
From_C� To QOZ Ft. �.9 -
t'.._..5, or Cr - -nep r .- C P�:n )
FrO,m o—__ FI.
Fr'.-ni 1o_ Ft.
d
14.
GROUT:
Dr.pth f.le:eriol 1Lcl=.+Cd
£ r
y
Flom TOc_:�;C? Ft.
From To Ft.
15.
SCR�cFI:
•�
DCPlh Diameter Slot Size Ma!eral
Frorn To Ft
--�
ly`�q
From To Ft. In. In.
q�
From To R. I.I. in.
7 2 � Sy k
16,
SAND/GRAVEL PACK:
a
Depth Size t.ta'erial
q,
From To Ft.
rr
From To Ft.
17.
REMARKS'.
� r' Y/✓G:
=�14-I- SAS
100 HEREBY CERTIFY THAT THIS P:ELL WAS CONSTRUCTED IN ACCORDANCE WITH 13A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TOTHEYs ELL 01141NER.
FOR OFFICE USE ONLYIZ-
Ocad Na' L '�':5 ^"IATUP= OF "r ERSON CC;ISTRUCTIt:G HE ' cll DATE
Subrr l oo ;_, al to i.l::en e' Water O.:a ly, Groundwater Se-:.cn wilhln 30 days
Becht No. GYM REV. 12/53
�9CiLS ,�

I',' ty
Nc :h Carolina - Department of Environment end Natural Resources - Division of Water Cluallty - Groundwater Section :..:. J �� /
1 C3o fd ail Service Center -Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION 9: Z184
STATE WELL CONSTRUCTION PERh11TM:
1. WELL USE (Check Applicable Box): Residentla;Cn Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. LVELL LOCATION: (Shea sketch of the location be!o•,
Agricuhiral ❑ monitoring ❑
Nearest Town: :54uVA count'/:
b
Pr ti /K,,­a- `=o-
(Road Na,ie and N,mbers, ComMX.;!/, cr Svbdv'sicn aid Lol No_)
DRILLING LOG
3.
Ol^.'NER Z::R. G'r "5 l7- Mc" .>C%2l6
From To
Address �2`?3
U 3•%
D,usyw -Si ZN?zr
I fcrTcr:n Slate ZipCode
4,
DATE DRILLED —;?-2.-"
750
5.
TOTAL DEPTH
G.
CUTTflNGS COLLECTED YES i` NO❑
—
7.
DOES WELL REPLACE EXISTING WELL? YES D NO' _
8.
STATIC WATER LEVEL Selow Top of Casing: 2_5 FT.
(Use'.' II Abc: i Top of Cadnp)
9.
TOP OF CASING IS FT. Above Land Surface'
'Top of casing terms :a:ed at/or below la•-.d svrtaco requires a va:lance In accor-
dance
v.ilh 15A NCAC 2C.0118
10.
YIELD (cpm): 2-0 METHOD OF TEST
11.
WATER ZONES (depth): 40 -r,>
12. CHLORI.':ATION: Type �T ti Am�unl _ZG/�'-'s
13. C.AS!Nd :
V. o T -
Deplh
gl
Dir-.- Cr v %7c F 1.
`�✓�
From
To
FI.
� 'y _
From
To
FI
---
Fr.%m
To --
Ft.
14. GROUT:
Depth
f.laferlol
L:ethcd
From C'
To Ft.
.L15:i1-y�
Q
From
To
FL
_
15. SCREEN:
Depth
Diamelar
Slot Sizo
-M.
Material
From
To
FI
in.
From
To
FI,
In. in.
From
To
FI.
In. in.
_
16. SAND/GRAVEL
PACK:
Depth
Size L1a'erial
From
To
Ft.
From
___ To _._—
Ft.
17. REMARKS:
DEPTH
Fcrr..arion Des&pl:on
E-2aivr sC
I' ,.__Ilona' ;,ace L need=_d use b^;✓ of lot.". Q1 0
LOCAT;O\' St<=TC�-I
(a dirrztcn ^d' a r .. lea st Pno S!'lT
r ,. _. S, or clhnr map r- poles)
z7
tilt
c
y Qv
1 �a
I DO HEREB'( CERTIFY' THAT THIS WELL Vi.AS COt:STRUCTED Ir,l A.000RDlviCE %'il T FI 18A NCAC 2O• PlELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO(THE \YELL OVlNER.
FOR OFFICE USE ONP \ Q
LY OO(QP_6Q '� �000 AUr )V� Sq1 UQ- _ W--- C0
Goad NJ SGNATURE OF FERSON COnsTRUCTING THE ELL
5�4n�it,o,i-:->r.11a ��Gion of t•fater Gua'ily, Ground eater Sec cn within 30 days
n r
Sedol No.
s
DATE
GY:f REV. 12,'59

' North Carolina • Department of Environment and Natural Re;ourceo - Division of Water Quail,/ 30'71 -Groundwater Section r" '"
1636 Mail Service Center - Raleigh, N.C. 27699-163G-Phono [phone] WELL CONSTRUCTION RECORD WELLCONTRACTOR: Qu5scU To,V (0yy­
W ELL CONTRACTOR CERTIFICATION It: I Q;r)
STATE WELL CONSTRUCTION PERMITN:
1. WELL USE (CheckAppdcabla uox): Residential Municipal ❑ Industrial ❑
Rocovory❑ Heat Pump Water Injection Othor ❑ If Other, List Use:
2. WELL LOCATIO U (Show sketch of lho location below)
Nearest Town: -��) Cc
Agricultural ❑ Monitoring ❑
(Road Name<a(3d Number, Cont�n,/unily, ar Su,6divi1slFon and Lot No.) DRILLING LOG DEPTH
3.
OWNER :),<uma Yl'- 1\e-ri VV i1FQA From To Formation Description
Address a � G-)0.'
S rco or ou o o.
SU1oke Q-v-N-,A r.0 atl5 n
4.
City or Town - 'tale Zip Code -
DATEDRILLED
S.
TOTAL DEPTH --
G.
CUTTINGS COLLECTED YES Q� NOD
7.
DOES WELL REPLACE EXISTING WELL? YES E:] NO[2" uU A-r1 r U
0.
'STATIC WATER LEVEL Below Top of Casing: 3CrO FT.
o..
}
(Use'.' It Above Top of Casin,)
O
O
9.
TOP OF CASING IS FF. Above Land Surface*
o
a�
'Top of casing lonnlnaled at/or below land surfaco ruqulros a variance In actor-
rn
dance
with 1SA NCAC 2 Otte
kL
10.
YIELD (gpin): METHOD OF TEST
11.
WATER ZONES (depth): Ira — ( ID
'4 — 4'S —
12.
CHLORINATION: Type IA7K Arnour,l I?-JL 011.15 It additional space L^ needed u;e back of form
W
�Co)
cnm
13.
CASING: - --
m;a
Mall Thlckncss LOCATION SKETCH
Q1
y
$
z
Depth / C4
From 0 To LQ
From To
From To-
14. GROUT
DI motor or I�hvl 1. f.talcdal
Ft. �1 L
Ft.
Ft. ---
Depth Material Material Method
Front n To Ft. �XYvQhri �Q�2
From To Ft.
15. SCREEN:
Depth Diatnetor
From To Ft In.
From To Ft. In.
From _ To Fl. In.
10. SAND/GRAVEL PACK
Depth Sizo
From To Ft.
From To Ft.
17. REMARKS:
Slot Size Material
In. In.
In.
Mulerial
(Show direction and distance from at least two Slate
Roads, or other map reference points)
441
LL, rk ck
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTi-iUCTEDIN ACCORDANCE WITFI ISA NCAC 2C. ViELL
CONSTRUCTION STANDARDS, AND THAT A CCF i` OF THIS RECORD HAS OEEN PROVIDED TO THE WELL 0
FOR OFFICE USE ONLY ,�-� 1�.,1P�'� I '1 �'4"_
Quad No: SIGNATURE OF PERSON CONSTRUCTING THE V9G
Submit onpina: to Di';Ision 0: ','late( Quality, Groundwaler Section withlll 30
Scdal No.
Zvi
DATE
GW.1 REV. Ivsu
r ,t
- 1 D L�

4.
3U70
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]
WELL CONSTRUCTION RECORD WELLCONTRACTOR:
WELL CONTRACTOR CERTIFICATION ti:
z1£ro, 1
STATE WELL CONSTRUCTION PERMITN:
1. WELL USE (Chock Applicable Box): Resldentizl�n Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Waler Injection ❑ Other ❑ It Other, Ust Use:
2.
WELL LOCATION: (Show sketch of the location below)
Nearest Town: � t-vP Count':
J-A r 2,I, 6oJ
(Road Name and Numbers, Community, or Subdivision and Lot No.)
DRILLING LOG
3.
OWNER "_C0 ro7 WOOy
From To
Address -,,I L� a5LC-TY Ste-
0 7-4
(Stre-eooru e No
CFl N- 28�/�
x{ -7w
7Co 2j�
City or Tcwn State ZIP Coco
4.
DATE DRILLED 7�27--a>
5.
TOTAL DEPTH 23: �T
6.
CUTTINGS COLLECTED YESN NOD
—
7.
DOES WELL REPLACE EXISTING WELL? YES 0 110�.
8.
STATIC WATER LEVEL Belov: Top of Casing: -36 Ff.
(Use'.' it Above Top of Ca.inq)
9.
TOP OF CASING IS FT. Above Land Surface'
-Top
or casing Icrminated odor below land surface requiros a varlance In actor.
dance
vath 15A NCAC 2C.0118
W O1C
10.
YIELD (gpm): METHOD OF TEST _
11.
WATER ZONES (depth): f 4 9 o�5
F7.------
- 43
--
DEPTH
Formation Descdpl,on
CL4 %
q.uNrrC
_J CD
12. CHLORINATION: Type Amount _ _ _ ( It :dd:Ilorai =pace is needed use back, of
13. CASING: t --- —-_-- ----
Deplll Dizmc:c�
i
From �� To ?� Ft.
From To--- FL -
From To-- Ft.
14. GROUT:
Y; all llnchness LOCATION SKETCH
liFI. t.'o:cd,-d (Sho,, d'vectien and dislanco Gem at least Mo State
13? r�E=` Rcuds, or other map reverence point;)
Depth M_a:oliat Molhcd
From To=�C-) FI.
From To ___Ft. _
15. SCREEN:
Depth Diameter
From To Ft in.
From To Ft. In.
From To Fl. In.
18. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To Ft.
17. REMARKS:
Slot Size Material
in.
In.
in.
Maleri3l
a
IMIiiiIIIIII
1 AnLUr6W 5,,le .,.--
I DO HEREBY CERTIFY THAT THIS WELL'NAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C. %VELL
CONSTRUCTION STANDARDS, AND
THAT1�A COPY OF THIS RECORD HAS BEEN PROVIDED TOTHEWELL OWNER.
OR OFFICE USE ONLY
I
r(1 . Q 6NV ��•\�`��T
wd No:S:GNATUf3E0EFERSONCOi4STRUCTINGTHEdL
DATE
los"
Submit ot�inalio Division of G10t or Quality, Ground eater Section Within 30 days
dalNo.
I GVJ.1 REV. 12/59

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section C) ti J �) (
1636 Mall Sorvice Center - Raleigh, N.C. 27699.1636-Phono [phone] 13
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION h: - ZtiSLr \
STATE WELL CONSTRUCTION PERMITN:
1. WELL USE (Check Applicable Box): Resldenila;:N Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ It Other, List Use:
Agricultural ❑ Monitoring ❑
2.
WELL LOCATION: (Show sketch of the location be!o'w)
Nearest Tov: n: Sy Cv.+ Ceun; r.
- �Lrci•-
(SAu-4- Z,-r3c 1P__J.
(Road talle and Numbers. CommurJly, or Subdivision and LDI No,)
DRILLING LOG
3.
OWNER �U` 5?wE�
From -to
Address s`(
C) -" zi-
«eot or SoueT o.)
cavJ�l+�.� Pin r 3v cQZ
Zrt -- 2-°L
Z-
3�
CI y or Tcwn Slalo Zip Code
4.
DATE DRILLED-Z.J-po
5.
TOTAL DEPTH
G.
CUTTINGS COLLECTED YES[ NOD
-
7.
DOES WELL REPLACE EXISTING WELL? YF_S F--] (10,0
8.
STATIC WATER LEVEL Below Top of Casing: 45 FT.
(Use'.' it Abovo Top of Casing)
9.
TOP OF CASING IS I FT. Above Land Surface'
'Top
of ca>Ing Iermina;ed astir below land surface requlros a variance In actor- —
danco
v.Ith 15A NCAC 2C yis
�2- METHOD TEST C7--ir
—
10.
YIELD (gpm): OF
11.
WATER ZONES (depth): 2(.ix3
12. CHLORINATION: Type «y h Amount
13. CASING:
t7aA lliiuness
��
Depth
Dixne:er uP; c:-: a. Ft.
i y
U`
p'C�_
From
To-�-Ft.
_ -
From
To
FI.
------
Fr:xn
-To--
Ft.
14. GROUI":
Depllt
Ma:anal
t.'elhod
From
-To _FI.LG]l�
From
To _Ft.
_
15. SCREEN
Depth Diameter
From To Ft in.
From To Ft. in.
From _ To Fi.4— In.
16, SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To FL _
17. REMARKS:
Slot Size Molorial
in.
Material
DEPTH
Formation Descripllon
fLW,tU
=pace Is needed use bac'v of
LOCATION SKETCH
(Sha:r direction end dLlanco from at least 1%%o Sale
PC_: ls, or other Wrap reference paints)
O—Q
O
t Od
i
_0�o
a
`j
WG4-
)J 6,3r'
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C. WELL
CONSTRUCTION STANDARDS, AND THAT A COPY �OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE 014LY N)`�, b(Q.��(}CL � "�'\�\ 1 UQ '3I UJ
Ouad No; SIGNAIUlI:OEPE{ SON CONSTRUCTING THE LL DATE
Sobmh odiijnaii 64L•lonot V7alor Ou allty, Groundwater Section within 30 days
Serial Nc. f'( E - &N 1 REV. 12/59
Z-7

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 WELL CONTRACTOR: RasSt� ca(�c•
WELL CONTRACTOR CERTIFICATION 9: 21 H-P
STATE WELL CONSTRUCTION PERMITN:
1. WELL USE (Chock Applicable Box): Resldential�n Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other (] It Other, Ust Use:
2. WELL LOCATION: (Show sketch of the location belov:
Agricultural ❑ Monitoring ❑
Nearest Torn: SYtyA County:
Colt (_wcy- 12-"7
(Road Name end Numbers. Community, or Subdivision and Lot No.)
DRILLING I.00_
3.
OWNER
From To
Address P'J" (vc3
C) 4D
uect or Houle vo.)
�P 247?q
%4N SD
g� 0-
SJ 2c;\
lily or Town - Stale Zip Dodo
4.
DATE DRILLED —
5.
TOTAL DEPTH
G.
CUTTINGS COLLECTED YES© NOD
—
7.
DOES WELL REPLACE EXISTING 'JELL? Y'ES 0 110,0
8.
STATIC WATER LEVEL Below Top of Casing: 4D FF.
(Use'.' if Above Tcp of CaL ing)
9.
TOP OF CASING IS I FT. Above Land Surface'
'Top
of casing lermIriated eVor bcfowr land surface requires n varlance In Decor.
dance
with 15A NCAC 2C.0118
4'S
10.
YIELD (gpm): METHOD OF TEST _
11.
WADER ZONES (depth): S-'75- 40- I _
12. CHLORINATION: TypeF,mount _3_tp.t0
13. CASING:
Depths Dipm_ �r
Fronh�—To Ft. y
From To--- FI.
Froc1 'To-- Ft.
14. GROUT:
I: .11:1:ona! space is reed
DEPTH
Formation Description
c�44 .
�(9aa1�[t
fA�^r'TL
%%V!Thkvno LOCATION SK=TC_H
c: 'V., !;;II t. (Show direction and dclanco Lcrn of least two State
or other nap ro;erenee poirs)
Depth Ma:ctlal Method
From To _ F1.
From To Ft.
18. SCREEN: - -
Depth Diameter
Frorn To Ft in.
From To Ft. In.
s
From To FI. In.
16. SANDIGRAVEL PACK!
Depth Size
From To Ft.
Frorn To Ft. _
17. REMARKS:
Slot Size Molerial
in.
In.
in. _
1,13!erial
A
JAZ
,.1
n
rJo Sal 4,
.
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED It ACCORDANCE WITH 1SA NCAC 2C. VJELL
CONSTRUCTION STANDARDS, AND THATy�A CCOPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWN
FOR OFFICE USE ONLY �(Qq- Q �� `�}�•\`D`�D 1 Via— 9 Z3)
Quad No: SLGnAl j iE GO PERSON CONSTRUCTING THE dL DATE
Submit odeina!'lo 67kldn o(". W'Quailty. Groundwater Section within 30 days
sedal No. GW I REV. 12/59
YJ
(ULLU✓��/

3067
North Carolina - Department of Environment and Natural Resources - Division of Water Oualiry - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phcno [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: SD mc;C��
1
WELL CONTRACTOR CERTIFICATION P: Z:it�v
STATE WELL CONSTRUCTION PERMITN:
1.
WELL USE (Check Appllcabla Boa): Resideniia;,n Municipal ❑
Industrial ❑
Agricultural ❑ M .onhoring ❑
Recovery ❑ Heal Pump Water Injection ❑ Other ❑
If Olher, Usl Use:
2.
WELL LOCATION: (Show sketch of the location be!o\v)
Nearest Town: Sy r_VA County:
f,Y r C^I ce6e (-
(Road Name and Numbers, Community, or Subdivision and Lot No
DRILLING LOG
DEPTH
3.
OWNER W,:>`a
From to
Formation Descrpt.cn
Address U'b i4w1 74 ,J
C --7C
C"I
vet or ouo +o.
7i•
(�QJ•N i-rC
V`1 k41inrtrL f.f:. ���
City or Tov+o State Zip Code
4.
DATE DRILLED '7'7f1_W
5.
TOTAL DEPTH 1y_5 G
6.
CUTTINGS COLLECTED YES© NO❑
—
7.
DOES WELL REPLACE EXISTING WELL? Y'ES O NO�
.--.
8.
STATIC WATER LEVEL Boto\v Top of Casing: 4D FT.
O �n
fsL
(Use'.' it Above Top of Casing)
o
n Crn
9.
TOP OF CASING IS FT. Abovo Land Surface'
o�
'Top
of ensln9 terminated nt/or below land surface requiros a variance In actor.
—
m
dance
valh 15A NCAC 2C .0110
METHOD OF TEST cy-1r
10.
YIELD(gpm): ._1-5
—
11.
WATER ZONES (depth): S ;ass �qL 2
1A COXX
/D f±LJ �O. i
C�
12.
CHLORINATION. Type %C ti r".:^:aunt _ 3—
!' cdd';;ional space
is ;.ended use bac'ad (o:e: �_._S
13.
CASING_--
SKEICH
Y:a:l Ihicznc s;—LOCATION
Depth
Dizm.ct c: \'; c'.-1^ I4,
fi
I,Icicdal
(Shen m direction and d.s!anco froof least t.vo Slrle
From C-) To 80 FL
G' 4 ��
t
7 `�"
P.c ads, cr other ap releret:ce pain,)
From To--- F1.
Frem To— R.
—__
14. GROUT:
rx, .
f
Depth
Ma!orinl
1,'ethcd
Fro�— To ��QFI.
Front
�1SA�--
�
C�
wtZL
;1,�
-
Front To FI.
—
C_ss1
15. SCREEN
Depth Diameter
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 Size Maledal
in.
In.
In.
Ma!orial
e"-qf \ nv
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED L^! ACCORDANCE IVITH 15A NCAC 2C. WELL
CONSTRUCTION STANDARDS, ANO,THATsA,COPY OF T HIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE
Quad No: ..{(( NJG ✓\TUBE OF PERSON CONSTRUCTING THE cLL DATE
t Sub r oriz i (o D ;Islon of P!a`or oualily. Groundaalar Sect on \within 30 days
Serial No, G`,,-I REV. I'J'i9

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: -,a. Pi
WELL CONTRACTOR CERTIFICATION 0:
STATE WELL CONSTRUCTION PERMITS:
M `Gv 2-e y
z 18ce
3065
1. WELL USE (Check Applicable Boa): Residential t,lunicipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2.
WELL LOCATION: (Show sk.9tch of (he location be!ov.)
N Vr4t
Nearest Town: Couny:
)gU,� n.N_T.
(P.oad IJa.me and Numbers, Ccmmunlly, or Sub7:vision and Lot No.)
DRILLING LOG
3.
O\VNER "M"1 LF✓E2'TY
From To
Address PC>,
U e,3
Twee or bulo fqo-1
Ary,rcavo ac. 2 }`tl
6,57
�oS 0>D
City or Town Stale Zip Core
4.
DATE DRILLED :7-5wc•
5.
TOTAL DEPTH -3r) CT
6.
CUTTINGS COLLECTED YES© NO[:]
7.
DOES WELL REPLACE EXISTING WELL? YES E] N0,0
8.
STATIC WATER LEVEL Belove Top of Casing: _ZU FT.
(Use'.' if Abevo Top of Caslag)
9.
TOP OF CASING IS FT. /,hove Land Surface'
'Top of casing terminated ouor below land surtacc rcy-ulrea a valance In accor-
dancewilh15ANCAC2C.0118
�J2
10,
YIELD (cpm): Zf _ f,1ETHOD OF TEST _
11.
WATER ZONES (depth):
12. CHLO.RINATION: Type
13, CASING: t
'J %,! T!dch^os
Depth Dia.^,a r uVici;I.LTI.
From_(:!_ Tcr GS Ft.
From To Ft. -
Frorn To-- Ft.---- -
14. GROUT:
Depth hlalerial r.lethod
Front n TocZaC Ft.
From _ To Ft.
15. SCREEN:
Depth Diameter
From To Pl in.
From _ To FL 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
DEPTH _
Fom:a:ion Descdptlon
G"2.9r.r r rc
N, fv
If add.,.,,_al s,- _e Is r. eded use ba ct n
LOCA.TIO'1 SKETCH `� o
(Shcv: di rcc.'.c.n and ron a.; least t'.vo State
Roads, or olher map r-Icrcrica pcinls) R r•top
a
4jak
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
FOR OFFICE USE ONLY nnn w uC' U' U U
Quad No: d SIGNATURE O FEi1SCN GOtJSTRUCTI6G T = YJcLL
,y,Vmit'g'rL,r"IoOivis'o.i o' YJa;er C.a i:y, Groundn a:cr Scu:on Vrtttlin 30 days
Serial uo. ter' r.
eI4IOo
DATE
GVr 1 REV, t2'S9

North Ccrolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section 10J 0 U 4
1536 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD
WELL CONTRACTOR: eu?x6 Ti4xut`�. _—__
WELL CONTRACTOR CERTIFICATION 0: Z I g
STATE WELL CONSTRUCTION PERMIT#:
1.
WELL USE (Chock Applicable Box): Residential Municipal ❑
Industrial ❑ AgricuViural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑
If Other, List Use:
2.
WELL LOCATION: (Show sketch of the location be:ov.)
Nearest Town: 5 ✓Y44 A County:
,Sl� 13S67 r,44-^t TP
(Road Name and Numbers, Commwdly, or SuCdlvisicn and Lot No.)
DRILLING LOG DEPTH
3.
h
O6A'NER CELfL n,o,D G-IN J�-eft
From To Fcr,.allon Oescd^,Len
Address
U
jSl�ec or ]owe �a.l
%G�5/ /c;e� _ A[[",
City or Tov.n Slave Zip
-Z�f'Q;
C.
DATE DRILLED
TOTAL DEPTH ZS r+
0
S.
6.
CUTTINGS COLLECTED YES© NOLJ
O
O
7.
DOES WELL REPLACE EXISTING WELL? YES 0 Noj�,
8.
STATIC WATER LEVEL Belov., Top of Casing: _5!�' FT.
(Use'.' if Above Top of Casing)
fV zo {
9.
TOP OF CASING IS F-T. Abovo Land Surface-
'Top of casing lerminated cUar below land surface requ!res n variance In sccor.
dance
with 15A NCAC 2C.0ity9
10.
YIELD (gpm): ,,jj METHOD OP_TEST _
11.
WATER ZONES (depih):
12.
CHLORINATION: Type Ameur,t
,.�dltcnal spaces necdej jsoback Cf form
13.
CASING:
— -- _-- -- ---
V1�4 Thk•.. -
Depth -.m v; L I/Wrial
r L_OC:iTiON SKETCH
(Show d!re bnd: 'ante 'w•-'at
Xr c:
From _C To /�� R. — -- - w�
,,
(j �+o
P.oads, r c:` -r map rlu: enca pcir}: ice
From To - Ft.•f�
From To— FI. --
Qa
14.
GROUT:
Depth G!a!orial t'olhod
From To=�QF1.
From To Ft.
15. SCREEN:
Depth
From
To Ft
From
To Ft.
From
To Fl.
16. SAND/GRAVEL
PACK:
Depth
From
To
From
To
17. REMARK
Diameter Slot Size Material
in. in.
In. In.
In. in.
Size Ma!erial
Ft.
Ft. _
TJc++6�U,4y-
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15.A NCAC 2C. WELL
CONSTRUCTION STANDARDS, AND THAT AAA COPY 9F THIS RECORD HAS BEEN PROVIDED TO THE WELLC0
FOR OFFICE USE ONLY 11 `�'� Y i'Q-�rCs �5-�qm - Dt )
Quad No: _ SIGNATURE OFF PERSON CONSTRUCTIM3, TH`c 14ELL r
y SObmll crli,iftaff 40 Division of Vlater Quality, Groundealcr Seclicn within 30 days
Serial Na.
t .9 L��n• P �.
' iz...-.._...'._.. ,. .. a-....,
-N trir�aGYi
NNER.
1811 W
DATE
GW-1 REV. 12/99

'
North Carolina - Department of Environment and Natural Resources - Division of Water Quality -Groundwater Section 3063
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION III:
STATE WELL CONSTRUCTION PEn MITN:
1. WELL USE (Check Applicable Box): Residential Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
Agricultural ❑ Monitoring ❑
2. WELL LOCATION: (Show sketch of the location be!ow)
Nearest Town: CAs e4tEa5 Coun?y:
Rig ,4 FFCmccc�
(Road flame and Numbers. Community, or Subdlvislon and Lot No DRILLING LOG DEPTH
3. OWNER 131l-l- pU'MA_-a From To Formatlon Descnpllon
Address /d7UGa ii­'�?OP146a 5<. 0 -qco _ `1
(—Street or fiouio .o. /{ 1,0 4 6
Mo3;t_C AI— 34lEVG '+� Cry
Cl;y or Tcvn Slate c"p Code
4. DATE DRILLED -14--co
5. TOTAL DEPTH flptt1.�7
6. CUTTINGS COLLECTED YES© NOO
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NOQ},
8. STATIC WATER LEVEL Below Top of Casing: Zy FT.
(Use 4' it Abovo Top of Casing)
9. TOP OF CASING IS , FT. Above Land Surface*
'Top of casing terminated nVor below land surfaco requlras a vndanco In accor-
dance with 15A NCAC 2C .0113
10. YIELD (gprn): METHOD OF TEST d17R'
11. WATER ZONES (depth): a rz
12. CHLORINATION: Type T FA Arneunt _ zZF''ce� ,...d:;ional_paco is needed use back of term13. CASING:
/\ Depth �j� Dinme(e:ora
Front CTO -- Ft.
From To-- Ft.
Front To— Fl.-
14. GROUT
1Va:l Tldc%nnss LOCAT'ON SKETCH
or We!:dl-lPPL Vz'ciai (Sli,cr: direction and dis!-nce from at least t+.o State
I J v Road,, or other map reference points)
Depth
Method
From 0
To-_'- Ft.
I�Matorlal
1]Si1�
(>
/n
Q -I
From _
To Ft.
15. SCREEN:
) %o
Depth Diameter
Slot Size
Material
i
From --
To Ft
in. In.
Rom
To Ft.
In. In.
..��
From
To Ft. __
In. _ In.
16. SAND/GRAVEL PACK:
Depth
From To Ft
From To Ft
17. REMARKS:
Size Material 73
aY rp
�14tr
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
Z.
FOR OFFICE USE ONLY C'1'I`Q.'� 'Q_ �'((iS(ly�, B�ei �Ob
Ouad No: - SIGNATURE OF PERSON CONSTRUCTING THE WT�C DATE
8ub!itil odp'nal_io gidd slG� of Water Cezlity, Ground Hater Section within 30 days
Scnal No. - v C!l 1 REV. 12/93
i

North Carolina - Department of Environment and Natural Resources - Division of Water Quality -Groundwater Section !.
3093
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phono [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
4'lELL CONTRACTOR CERTIFICATION Y: a112(y
STATE WELL CONSTRUCTION PERMITN:
1. W ELL USE (Chock Applicable Box): Rosldontial P,lunicipal ElIndustrial ❑
Rocovory ❑ Heat Pump Water InJectionI Othor ❑ If Othor, Llsl Use:
2. WELL LOCATIOjJ: (Show sketch of the location talc.v)
Agricultural ❑ Monitoring ❑
NearostTown: 1, n1iL1, County: S1(a( ILSCY
UO,kQ_ (,len0Ille
(Road Name and Numbers. Community, or Subdivision and Lct No.) DRILLING LOG DEPTH
3. OWNER _ Ffan-z ujhkAt rN1 re From To Formation Description
Addresss -rR
0 r or ou o o.
�alen��ll� �
City ar Town State Lip Coca
4. DATE DRILLED 6 -1(I - C)0 —
S. TOTAL DEPTHC)i�
C. CUTTINGS COLLECTED YES ©� NO
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO[�J'
0. STATIC WATER LEVEL Bolow Top of Casing:_ FT. o
(Uso . II Auovo Top o, Casing)
O
-_
9.
TOP OF CASING IS FT. Above, Land Surface'
'Top
at ca31119 terminated aVor below land surface requires n vodxnco In aces,
dance
with iSA NCAC 2C.0110
rn
on
10.
YIELD (gpm): ,�_ METHOD OF TEST
r1(�
CO
S7
11.
WATER ZONES (dopth):
Do
�
12.
CHLORINATION: Type Arnourtt
1
If additional space Is needed use back e(lorm
3
rn
re,
13.
CASING:
—
s_i
tn2
m�
VJall'fhkkncss
LOCATION SKETCH
Q1
ni
Depth Dl, meter or Wcir "U(-1. tdalcdal
p e lQ 7 ` �{,ti D�
From To T V Ft. l� LI �Ll.
(Shorr direction and distance born eI least two Stale
z
Roads, or other map reference points)
From To FI.
From To-- ) t. -----
-
14.
GROUT:
S I Ut (�. C�/
G J`
Depth
Material Method
� /-�
Front To �Ft.
C-�'-t'�1�_
From To Ft.
15.
SCREEN:
Dopth Diametor
Slot Size Malarial
From To Ft
In. In.
From To Ft.
In. hi,
Front To FI.
In. in.
16.
SAND/GRAVEL PACK
Depth
Slzo Material
From To Ft.
_
From To Ft.
17.
REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS COi•; 31.lIUCTED IN ACCORDA,gCE WITFI 1SA NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A C rOP ' CF THIS RECORD HAS B./EEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY ,(jJ.j '
Quad No: P SIGNATURE OF PERSON CONSTRUCTING THEW DATE
d '". ----- Submit on9inai to Division of Vlator Quality. Groundwater Section WWII it 30 days
Serial No. GWA REV. 121J7
L�

North Carc::na - Departrnonl of Environment and Natural Resource, - Division of Waver Cualir,, . Groundwater Section �, •� (� (�
1636 tdail Serv!ce Center- Raleigh, H.C.27699-1636-Phcno [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: j- D ' " cL (a rr
IYELL CONTRACTORi CERTIFICATION M1: S-_
(.1 0ll S"I"ATE WELL CONSTRUCTION PE-Rt,IITF:
1. WELL USE (check Applicable Box): Residen!iaYn municipal ❑ Industrlal ❑ Agricu"ural ❑ h'onlloring ❑
Recovery ❑ Heal Pump Water Injeclion Otfr_r F-1 If Olhor, List Use:
2. %VELL LOCATION: (Sho:v sketch of the location he!ow) ._
Neares: To::n:—�/e ' Cc,; n;7: �� Cl_ 4n1y
m; )I c rc'-c-K Rr,,a()(Rond Name er.d Numbers, Corernut,;,[�e( SuJd:visicn asnid Lot No DRILLING LOG_ _ DEPTH
3. OPJNE.R =t M CL/v CI LJD(C'i ))4 CX_Pr Fm:n To Forca-;�ion Dcscr,B'cn
Address < �� ` 'J O JG Lee :.
3,� o ,.�;,�t �C- rrV - -
iree:
_sr-; da- .3 Ll�-311 58-
C;; c,Te,.: L a
` alo Zp Ccc_
a, DATE DRILLE DJ r, e/C � "1 cet) -- T5. OTAL DEPTH
G. CUTTINGS COLLECTED YES [Ya NO
7. DOES';YELL REPLACE EXISTING ViELI.? YES L_I N0,�D-,
c. STATIC V,'ATER LEVEL Below Top of Casing: _-ja FT.
(Ucc'.' if Abe.c Tcp of Car-:+;) r�
9. TOP OP CASING IS I FT. Abovo Land Surta ee' O
iop of Ira, Ina!ed o'lor hcic%, land surtaco re qubes a variance In r.ecc:- - -
dnnce 1':!;h 15A NCAC 2C,e113 _ M
10. YIELD (cpnl): _2L_ to ETHOD OF T EST A CC_ _
11. 1YATER ZONES (dopth): 3 31,o -- — _ _ !i
12. CHLOR;NATION: Typeejlw
13. CASING:
cs TLk2:rsc
LOCAT�Oh_'__r
COt•;
FGH c;? tm'
/7' AT
('+,�L�U
FromC To �
IL
' 14 — . -±
From To---
FL_--
FrelTl To_—
FL_-
14. GROUT:
Depth
Llatoaoi t,',olhod
r�
From' Q To'—��_
From To
Ft.
Ft.
1
6
I I
15. SCREEN:
C`
Depth Dinmelcr
From To Ft in.
From To Ft. In.
From To Fl. In.
113. SAND!GRAVEL PACK:
Depth Size
From To Ft.
From To Ft.
17. REMARKS:
Slot Slze t.lalorial
tdalerial
I DO HEP.E o'i CERTIF'i T!1.4T T: :IS PlELI PiAS CONSTRUCTED IN F,CCO:iD:,?;CE WITR 15, NCi,C 2C, V/ELL ' ){/D (�
COlST UCTION STANDA5iDS, A,NG THAT A CC? i (CIF THIS RECORD HAS OEEN PROVIDED TO THE\,\YELL OWNER. c
FOR OFFICE USE ONLY R (� P� �� Ce-fi e V) Cos �' �'-11 S\ I G -; (-) " kocC
OCad No: SIC!:ATURE GF PERSON CONSTRUCTING T HE WELL DATE
Sobmt cri jcal is Ci,L:cn of hater Ouala7. Ground.:a;cr Seel on 'rvithln 30 days
Serial No, G'.V-1 REV. 13'59
fir