Well Construction Records Macon 1 CY2000

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section " 7 2 r� 8 0
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone] S
WELL CONSTRUCTION RECORD WELL CONTRACTOR: d°tt n ,� /� I) 4 O0 t I Lt-. /I a e
WELL CONTRACTOR CERTIFICATION #:S
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION
,:�(Show sketch of the location below)
Nearest Town:k I 1_ ) i County: /)')o t ��
(Road Name and Numbers. Community, or Subdivision and Lot No.)
3. OWNER I -'n,dr-J1(" 1A -
Address �f),1y%r_r< ir1
(Street or Route o.
V
City or Town State Zip Code
4. DATE DRILLED
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑ NO❑--
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO[�]
8. STATIC WATER LEVEL Below Top of Casing: ! ; FT.
(Use's' if Above Top of Casing)
9. TOP OF CASING ISFT. Above Land Surface*
'Top of casing terminated aVor below land surface requires a variance In actor -
dance with 16A NCAC 2C,9118
10. YIELD (gpm): -)C METHOD OF TEST
11. WATER ZONES (depth): (r-�L
DRILLING LOG DEPTH
From To Fonnation Description
12. CHLORINATION: Type H t 14 ._Amount
r t If additional space is needed use back of form
13. CASING:
LOCATION SKETCH
Wall Thickness
Depths Diameter or Weight/Ft. Material (Show direction and distance frorn at least two Slate
C
From To =1-Z Ft. —��
'— Roads, or other map relrrence points)
From To Ft.
From To Ft.
pO
o
14. GROUT:
rn
om
Depth Material Method
c>
cm
From C' To 21\ FL �.=
+'I / n�'� '
—'
o•c
From To
xm
2> o
—Ft.
15. SCREEN:
--r
a�
Depth Diameter Slot Size Material
From —To—Ft— in.
—in
y
From To in.
—in.
'r
o
—Ft.
z
From —To _ Ft. _ in. _—
in.
16. SAND/GRAVEL PACK:
Depth Size
Material
From To Ft.
From To Ft. _
17. REMARKS:
100 HEREBY C
IN ACCORDANCE WITH 15A NCAC 2C. WELL
CONSTRUCTIC 6 A A S7sea�li
'OF THIS RECORD HAS BEEN PROVIDED TO Th-7 %VELL OWNER.
FOR OFFICE U LY�
°" ✓�
Quad No: FE.GNATURE
OF PERSON CONSTRUCTING THE WELL DATE
to Division of Water Quality, Groundwater Section within 30 days
GW1 REV.
12/99
Serial No.
.
Asheville Re Tonal Office

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: 1).Ell n 5 LO ,t Wo Ill } t . / I >� �" C'
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential 0- Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: tShow sketch of the location below)
Nearest Town: 7 �t I -�r !�' �— County:
(Road Name and Numbers, Community, or Subdivision and Lot No.) DRILLING LOG
3. OWNER �"c , _ P*" II G7 -e1._ 9 From To
Address % 47',t £'!/ %
!' (Straet a: outs o.
City or Town Stale Zip code
4. DATE DRILLED 7-r' z'
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑ t4OE]--
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO©
8. STATIC WATER LEVEL Below Top of Casing: -3 ��, FT.
(Use',+' if Above Top of Casing)
9. TOP OF CASING ISFT. Above Land Surface'
-Top of casing terminated at/or below land surface r"ulres a variance In accor-
dance with 15A NCAC 2C .0118
10. YIELD (gpm): ;' L METHODOFTLST
11. WATER ZONES (depth): fir- r? /.S L ' —1'r) '
12. CHLORINATION: Type /t f 14 .—Amount r�ti
13. CASING:
DEPTH
Fonnalion Description
It additional space is neode:', use back of form —
Wall Thickness LOCATION SKETCH
Depth Diameter or Weight/Ft. Material (Show direction and distance from at least two State
From C To - � FL L— , !kL— P Roads, or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From To -LL'_Ft. (7Pa11 +'1
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft in. _ in.
From To —Ft. _ in. —in.
From To _ Ft._ In. .—in.
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
17
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION VANDARS� .. - F THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
i 11 io1 � FOR OFFICE USE ONLY
Quad No: NATURE OF PERSON CONSTRUCTING THE WELL DATE
Subo i t Division of Water Quality, Groundwater Section within 30 days
mit
Serial No. —
GWA REV. 12/99

North Carolina -Department of Environment and Natural Resources -Division of Water Quality •Groundwater Section !� 22234
1636 Mail Service Center . Raleigh, N.C. 27699.1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: LL11 /1 4, � ' L) ,1
WELL CONTRACTOR CERTIFICATION #:- FrS siT :� /-7
STATE WELL CONSTRUCTION PERMIT#: _.
1. WELL USE (Check Applicable Box): Residential El ---Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: SShow sketch Of the location below)
Nearest Town:
vt l� liD.c.; "I ( _ County: 11 r.-
Agricultural ❑ Monitoring ❑
(Road Name and Numbers, Community, or Subdivision and Lot No.) DRILLING LOG
3. OWNER �1iG�^c /77' e> c'_I- z __ From To
Address —
treat or outs o.
City or Town State Zip Code
4. DATE DRILLED-
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES 0 NO❑--
7. DOES WELL REPLACE EXISTING WELL? YES NO
B. STATIC WATER LEVEL Below Top of Casing: / tom, FT.
(Use'i it Above Top of Casing)
9. TOP OF CASING IS--,L_ FT. Abo1 e Land Surface
-Top of casing terminated aVor below land surface rmluires a variance In accor-
dance with 15A NCAC 2C.0118
10. YIELD (gpm): Ir METHOD OF TEST 1 1
11. WATER ZONES (depth): 2
1 is / t
DEPTH
Formation Description
12. CHLORINATION: Type f 14 Amount ' (/ additional space is needed use back of form
13. CASING:
Wall Thickness LOCATION SKETCH
Depth Diameter or WeighVFt. Material (Show direction and distance from at least two State
From C To , r 2 Ft. L— ' 6�V P I " Roads, or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From To m Ft. (7'72l a.111 ) "
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:
FOR OFFICE IfNLY
Quad No:
Serial No.
Slot Size Material
in.
in.
_ in.
Material
4STRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
2 1f /JYt;'0A ,l BEi '),%
GNATUR OF PERSON CONSTRUCTING THE WELL DATE
to Division of Water Quality, Groundwater Section Within 30 days
GW1 REV. 12199

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Se,:tion t. "212 2 3 3
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: 1112t'111�Ir + 1 Lc)� t-. 1 a T11 U
WELL CONTRACTOR CERTIFICATION #: ti-.S-iiT- ,k /7(.�
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check applicable Box): Residential n- Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town:�ri'R-rr 1l I r'� A/<!., County: 40r9 TN
(Road Name an/d �Numbers, Community, or Subdivision and Lot No.)
3. OWNER
Address 7L, A/
A rest or KOU10 NO.)"?SI/ //
City or Town State Zip Code
4. DATE DRILLED J 0 - 5 -ram
5. TOTAL DEPTH 5 G Z:
6. CUTTINGS COLLECTED YES 0 NO©�-
7. DOES WELL REPLACE EXISTING WELL? YES Q NOE
6. STATIC WATER LEVEL Below Top of Casing: , �'..! FT.
(Use',+' if Above Top of Casing)
9. TOP OF CASING ISFT. Above Land Surface'
-Top of casing terminated atfor below land surface requires a variance In accor-
dance with 15A NCAC 2C .0118
10. YIELD (gpm): _ METHOD OF TEST
11. WATER ZONES (depth):
DRILLING LOG DEPTH
From To Formation Description
12. CHLORINATION: Type /f f N Amount ` t If additional space is needed use back of form
13. CASING:
LOCATION SKETCH
Wall Thickness
Depth / Diameter or Weight/Ft. Material (Show direction and distance from at least two Slate
From 0 To L1— Ft..--L —' /kv 0 Roads, or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From To Lit Ft. n P" t,
From To Ft.
15, SCREEN:
Depth Diameter Slot Size Material
From To _ Ft .— in. —in
From To —Ft. — in. — in.
From To — Ft.— in. —in.
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft. .
From To Ft.
17.
0
o�
I DO HEREBY C 0 THAr1H &-yVELLWAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTI M ANBAleS,�,N(q THI T X COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOROFFICEU LLLYSS vv` ��'r��
Quad No: - its NATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit o l Division of Water Quality, Groundwater Section within 30 days
Serial No. ; GW4 REV. IZt99

22231
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:. r1 11 i�z^ I) + Wg I I �Lv / I )r! Tli C�
WELL CONTRACTOR CERTIFICATION #: )/ 71
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential LLB' Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: /,r,121r/, l/"2 C- County:
Agricothual ❑ Monitoring ❑
(Road Name and %y7bers, Community, or Subdivision and Lot No.) DRILLING LOG
3. OWNER SCr.%�2�c.w .k�c1 From To
Address—
i street or HoUte o.
r 1 , ) A/P_ .�2 k'73 S�
City or Town State Zip Code
4. DATE DRILLED Vl
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑ NO❑`
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NOQi
8. STATIC WATER LEVEL Below Top of Casing: j Li FT.
(Use'.,+' II Above Top of Casing)
9. TOP OF CASING IS _ FT. Above Land Surface-
-Top of casing terminated avor below land surface requires a variance In accor-
dance with 15A NCAC 2C.0118
10. YIELD (gpm): _:3_ METHOD OF TEST 12121
11. WATER ZONES (depth): c2 3 n
DEPTH
Formation Description
W
12. CHLORINATION: Type /t 14 Amount lit If additional space is needed use back of form fl
13. CASING:
LOCATION SKETCH
Wall Thickness
Depth C Diameter orwelght/Ft. Material (Show direction and distance from at least two State
From C To 1- Ft. fr ­— ' /k t l -P I ', Roads, or other map reference points)
From To Ft.
From —To Ft.
14. GROUT
Depth Material Method
From To .Z\ Ft. (f r'r„
From To Ft. .
15. SCREEN
Depth Diameter Slot Size Material
From To— Ft _ in. .._ in.
From To — Ft. — in. _— in.
From _ To .— Ft. _ in. _ in.
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft. .
From To Ft.
17. REMARKS:
DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTIOAND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE
Quad No: I(1 SI NATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit odic t"Divislon of Water Quality, Groundwater Section within 30 days
i a GW-1 REV. 12199
Serial No.

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 WELL CONTRACTOR: T�II I L) 1 iOP II �`` /I a TJ1
WELL CONTRACTOR CERTIFICATION #: -7
STATE WELL CONSTRUCTION PERMIT#:
WELL Box): Residential © Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
1. USE (check Applicable
Recovery ❑ Heat Pump Water Injection ❑ Other If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: r`.2 �r /,' !.I County: �j )« C h
(Road Name and Numbers. Community, or Sudl;vision and Lot No.) DRILLING LOG DEPTH
l
3. OWNER / [' t � � I � I , >> <� I <- r � I E� -t From To Formation Description
Address
jSueetor Data o. _.
l lv„i-1,i i-t_ ,J,t ") V q
City or Town State Zip Code
4. DATE DRILLED i t� - / I - I
5. TOTAL DEPTH - -� O `"
6. CUTTINGS COLLECTED YES ❑ NOQ--
7. DOES WELL REPLACE EXISTING WELL? YES NO©/
S. STATIC WATER LEVEL Below Top of Casing:[? FT.
(Use': if Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface'
'Top of casing terminated atlor below land surface requires a variance In accor.
dance with 15A NCAC 2C .0118
10. YIELD(gpm): Q (`, ME-rHODOFTEST hb))/'• '
11. WATER ZONES (depth): A-Z 7C,
12. CHLORINATION: Type f 14 Amount VL 16 It additional space is needed use back of form
13. CASING:
LOCATION SKETCH
Wau Thickness
Depth Diameter or Weight/Ft. Material (Show direction and distance from at least two Slate
From To / Ft. L" ' L L P I L Roads, or other map reference points)
From To Ft.
From To Ft.
cE
14. GROUT: O
o
Depth Material Method
oT
To
From _�_ To .2L Ft. 0 r ,,, �
c�
From To Ft. —
�D
or
Km
15. SCREEN:
Ts
Depth Diameter Slot Size Material S
mD
::oo
From _ To _ Ft _ in. —in vn
m
From To — Ft.— in. in. tr
From _To _ Ft._ In. —in. ►�
o
16. SAND/GRAVEL PACK:
Depth Size Material
From To —Ft. —
From To Ft. _
17. REMARKS: —.
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION ST M - X OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE US
Quad No: ,jf I MATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit orl ip (Division of Water Quality, Groundwater Section within 30 days
Serial No. i °' GW1 REV. 12/99

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section 223275
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: �r1n I) A (0'?11 1�r. n k,� ��1c,
WELL CONTRACTOR CERTIFICATION If: S7� ,k /-7(
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (check applicable Boa): Residential Il Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water In!eclion ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: ,Cr.7-„ f" Its' //C - County: / 220
(Road Name and)Numbers, Community, or Subdivision and Lot No.) DRILLING LOG
3. OWNER 7 s' i G :._ , / Ci !l - From To
Address
(Street or outs o. '
f A/C. a f/
City or Town State Zip e
4. DATE DRILLED / 1 -2 L— L '
5. TOTAL DEPTH = sr''
6. CUTTINGS COLLECTED YES❑ NO❑--
7. DOES WELL REPLACE EXISTING WELL? YES NO[D,-
8. STATIC WATER LEVEL Below Top of Casing: ! - a FT.
(Use'+' If Above Top of Casing)
9. TOP OF CASING IS_J FT. Above Land Surface*
'Top of casing terminated atlor below land surface requires a variance In accor-
dance with 15A NCAC 2C .0118
10. YIELD (gpm): /.5' METHOD OF TEST Z
11. WATER ZONES (depth): 11r I ") t
12.CHLORINATION: Type ltt14 ,_Amount r v 6
13. CASING:
Wall Thickness
C Depth Diameter or Weight/R. Material
From To Ft. L, - I
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From To 2 L Ft. 0 r'11,
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From —To—Ft— in. _ in.
From _ To _ Ft. _ in. in.
From —To —Ft. In. —in.
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft. From To Ft. _
17
Agricultural ❑ Monitoring ❑
DEPTH
Formation Description
If additional space is needed use back of form
LOCATION SKETCH
(Show direction and distant a from at least two State
Roads, or other map re?ere nce points)
I DO HEREBY CE�iFFFA`TbiATT#IIS-W ooU WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION AID fl-Igif A COPY OF THIS RECORD HAS BEEN PROVIDED TOTH:-. WELL OWNER.
FOR OFFICE USE
Quad No: t SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to (livision of Water Quality, Groundwater Section within 30 days
Sedal No. Gwa REV. l2t99

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section 223276
1636 Mail Service Center - Raleigh, N.C. 27699.1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: LIEr1 n 'J 1 I 1� 1/)' I) �t' / I �1t C
WELL CONTRACTOR CERTIFICATION M 5_� /76
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential 0--Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water lr;eclion ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
. Nearest Town: P/C' - County:
DRILLING LOG DEPTH
(Road Name anq Numbers, Community, or Suodivision and Lot No.)
3. OWNER �), 11_��?r; r�i°! _
From To Formation Description
Address �'�r<.;' f /?
) (Stre'ei or ou a o:-
City or Town state" ° Zip Code
o
4. DATE DRILLED
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑ NO©- '
o
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
8. STATIC WATER LEVEL Below Top of Casing: Zr) ) FT.�
f c
(Use'+' f( Above Top of Casing)
'>o
9. TOP OF CASING IS FT. Above Land Surface*
s rno
T
'Top of casing terminated atlor below land surface requires a variance In accor-
r
y
dance with 15A NCAC 2C.0116
1
10. YIELD (gpm): /C', METHODOF-ICST u 1
n•
11. WATER ZONES (depth): / 5i"
rn o
12. CHLORINATION: Type N Amount r 6
if additional space is neeued use back of form
13. CASING:
LOCATION SKETCH
Wall Thickness
Depth Diameter or WeightlFt. Material
(Show direction and distance from at least two State
From C To ILL Ft. (r • • � � `' /P r ? ,
Roads, or other map reference points)
From To Ft.
From To Ft.
M&UT01116
Depth Material Method
From To ._-ULI Ft. 0 C i), a-,� �
From To Ft.
15. SCREEN:
Depth
Diameter
From
To _
Ft _ in.
From
To —Ft.
— in.
From —To
—Ft.
_ In.
16. SAND/GRAVEL PACK:
Depth
Size
From
To
Ft.
From
To
Ft.
17. REMARKS:
Quad No:.
Slot Size Material
_ in.
_ in.
In.
Material
WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
r A COPY OF THIS RECORD HAS BEEN PROVIDED TOTHE WELL OWNER.
i, -r . / n'rNnn r I.'? _ i1 .9 -[-L
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
mll original to Division of Water Quality, Groundwater Section within 30 days
GW4 REV. 12/99

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section 132
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: < /4, 1) t 1 ") �` "' �11 C'
WELL CONTRACTOR CERTIFICATION #:�-`�'�
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable eoz): Residential r❑/unicipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
Agricultural ❑ Monitoring ❑
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: r - County:
(Road Name and Numbers. Community, &Subdivision and Lot No.) DRILLING LOG
3. OWNER c 1 ("'-- I From To
1
Address ,f
treetor outs o.
City or Town State Zip Code "
4. DATE DRILLED
5. TOTAL DEPTH Y `
6. CUTTINGS COLLECTED YES Q NOQ--
7. DOES WELL REPLACE EXISTING V'ELL? YES ❑ NOD
8. STATIC WATER LEVEL Below Top of Casing: �, , FT. _
(Use'. - it Above Top of Casing) _
9. TOP OF CASING IS Z Fr. Above Land Surface'
'Top of casing terminated atlor below land surface requires a variance In accor-
dance with 15A NCAC 2C.0118
10. YIELD(gpm): /_ METHOD OF TEST
11. WATER ZONES (depth): /L e
DEPTH
Formation Description
0
® o
O
a o
12. CHLORINATION: Type /t f N Amount / i 16
It additional space is needed use back of form
13. CASING:
LOCATION SKETCH
Wall Thickness
Depth Diameter or WeighUFt. Material (Show direction and distance from at least two Stale
From L To Ft. L-- ' ��'.t P r ` Roads, or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From P_ To 21" Ft. /t ,: -„ ­ ; ' - "' 1
From To Ft. _
15. SCREEN:
Depth Diameter Slot Size Material
From _ To _ Ft _ in. _ in.
From _To —Ft. _ in. _ in.
From _ To _ Ft. _ in. — in.
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft. From To FL
17
A �1-H Ny'LAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
A (COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE Jf"NL�Y
Quad No: �l�ujj
4,
-- ' SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
m4riginal to Division of Water Quality, Groundwater Section within 30 days
-- GW-1 REV. 12199
Serial No.

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
16,36 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: LY 11 n 5 ! 1 (i1? I I �, . I <� �'1 C'
WELL CONTRACTOR CERTIFICATION #: -7
STATE WELL CONSTRUCTION PERMIT#:
1.
WELL USE (Check applicable Box): Residential 0---Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water In;ection ❑ Other
If Other, List Use:
2.
WELL LOCATION: (Show sketch of the location below)
Nearest Town: `")��, r, %' County:)
(Road Name and Numbers, Community, or Sut,divisi/gn and Lot No.)
DRILLING LOG DEPTH
3.
OWNER I , r'-� 1 L< ; '� -„ /i • I I�- , �i (�' l l
t` From To Formation Description
Address-
(9treet or outs o. /
17
City or Tow",- Slate Zip Code
'
4.
DATE DRILLED
5.
TOTAL DEPTH
6.
CUTTINGS COLLECTED YES[—] NO©--
7.
DOES WELL REPLACE EXISTING WELL? YES ❑ NO©—
8.
STATIC WATER LEVEL Below Top of Casing: FT.
(Use -: it Above Top of Casing)
O
9.
TOP OF CASING IS FT. Above Land Surface'
n oC-i
'Top of casing terminated at/or below land surface requires a varlance In accor•
`
dance with 16A NCAC 2C .011 a
10.
YIELD (gpm): METHOD OF TEST 7 /n/ 1, U
o
11.
WATER ZONES (depth):
12.
CHLORINATION: Type Amount r/L 6
It additional space is needed use back of form
13.
CASING:
x
LOCATION SKETCH
Wall Thickness
Depth Diameter or Weight/Ft. Material
(Show direction and distance from at least two State
_.
From � To ' Ft. L • . _ r / '(' %) l
Roads, or other map reference points)
From To Ft. _
From To Ft. _
14.
GROUT:
Depth Material Method
From To —Ft. 0 ("1), t+117 0 '
From To Ft.
15.
SCREEN:
Depth Diameter Slot Size Material
From —To—Ft— in. in.
From —To —Ft. in. in.
From —To —Ft. in. in.
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
17. REM.
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTIONSTANOA€IDS; AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
Quad No: i SIGNATURE OF PERSON CONSTRUCTING THE WELL
Submit original to Division of Water Quality, Groundwater Section Within 30 days
i
DATE
GW-1 REV. 12/99
Serial No.

North Carolina - Department of Environment and Natural Resources - Division of Water Duality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: r�r1 n ') <<f) �'" " El, el C
WELL CONTRACTOR CERTIFICATION #:_,_ 5- 4--4 ,r /7(
STATE WELL CONSTRUCTION PERMITA: .,
1.
WELL USE (Check Applicable Box): Residential / Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other If Other, List Use:
2.
WELL LOCATION: (Show sketch of the location below)
Nearest Town: / '- I i' ' County:
(Road Name and Numbers, Community, or Subdivision and Lot No.) DRILLING LOG DEPTH
3.
OWNER t- ) n rFrom To Formation Description
Address ! I
9cuie
beet or o.
City or TownStateState zip Code -- ---
4.
DATE DRILLED i - -
0
5.
TOTALDEPTH
6.
CUTTINGS COLLECTED YES 0 NO[_;�-- a
7.
o
DOES WELL REPLACE EXISTING WELL? YES NOQ— — rTi
8.
STATIC WATER LEVEL Below Top of Casing: Y: FT. c�
chi
(Use': i' Above Top of Casing) N
�-
9.
TOP OF CASING IS FT. Above Land Surface-
s
-top
of casing terminated at/or below land surface requires a variance In accor- -p
Rt
dance
10.
with 15A NCAC 2C .011 a
YIELD (gpm): METHOD OF TEST ')/ut/f.
11.
WATER ZONES (depth):
12.
CHLORINATION: Type /1 t f4 Amount 4ZL6 It additional space is needed use back of form
`
13.
CASING:
LOCATION SKETCH
Wall Thickness
Depth � _ Diameter or Weight/Ft. Material (Show direction and distance from at least two Slate
1
From C To -� Ft. —L— , /s, r, P I ' Roads, or other map reference points)
From To Ft.
From To Ft.
14.
GROUT:
Depth Material Method
From To L— Ft.
From To Ft.
15.
SCREEN:
Depth Diameter Slot Size Material
From —To—Ft— in. —in.—
From To _ Ft. _ in. in.
From _ To _ Ft. _ In. in.
16.
SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
17. REMARKS:
I DO HEREBY C
FY THATTHIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION
&i4IHA-COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
( Y 'ir,. - �'i lr nr , . � ../iY �i��
- ATURE OF PERSON CONSTRUCTING THE WELL DATE
FOR OFFICE US
Ouad No:
tt:{{{
Su unit Onrpinal t Division of Water Ouality, Groundwater Section within 30 days
GW4 REV. 12199
Serial No.
�(
ndtk;: S .
'd`

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section 7- f n/ 5 92
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: f1
WELL CONTRACTOR CERTIFICATION Z:Z
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (check Applicable Box): Residential �" Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring
EJ
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town:. 1h li (,,J %r✓ County:
(Road Name and Numbers. Communjty/, or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER .m jC -C �c rn S 1 t% From To Formation Description
Address L� �. J��G✓ cam, jL�J ,
'(Street or oufa o.
�i; �tlrl ,) It, � " f'(q3 c/
City or Town State Zip Code
4. DATE DRILLED
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑ NO©--
7. DOES WELL REPLACE EXISTING WELL" YES ❑ NO J
S. STATIC WATER LEVEL Below Top of Casing: ,�/'. Fr.
(Use'+' if Above Top of Casing)
9. TOP OF CASING ISFT. Above Land Surface' -
*Top of using terminated at/or below land surface requires a variance In actor- -
dance with 15A NCAC 2C.0116 "
10. YIELD (gpm): -� METHOD OF TES'
11. WATER ZONES (depth): �Sr� ' rl _
12. CHLORINATION: Type It '� /4 Amount '/C / _ If additional space is needed use back of form
13. CASING: - _ —
LOCATION SKETCH
Wall Thickness
Depth << // �7 Diameter or Weight/Ft. Material (Show direction and distance from at least two State
From L To � Ft. L" , P l Roads, or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From L _ To -2 (" Ft. 0
From To Ft. —
15. SCREEN:
Depth Diameter Slot Size Material
From —To—Ft— in. —in.—
From To — Ft. _ in. — in.
From —To _ Ft. _ in. —in.
16. SAND/GRAVEL PACK:
Depth Size Material
From To —Ft. —
From To Ft. _
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STAN r RECORD HAS BEEN PROVIDED TO THE. WELL OWNER.
FOR OFFICE USE ONL l'�i't �L 3-0
Quad No: SIGN OF PERSON CONSTRUCTING THE WELL DATE
Submit original to of Water Quality, Groundwater Section within 30 days
GW-1 REV. 12/99
Serial No. a

r:l0
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699.1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: L� t,t' ij'I) ' r1 "' �`
WELL CONTRACTOR CERTIFICATION #: c •;-, 7L
STATE WELL CONSTRUCTION PERMIT#:
OP 0F
93
/ ❑
WELL USE Applicable Box): Residential � Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring
1. (check
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: c'-m /i (L- County: 7i ('J1 -
(Road Name and yumbers. Community, or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER /£ f �1 <t �-r�- ��) r F t� l� t From To Formation Description
Address
--(Svicet cr . o�uto No.
City or Town State Zip Code
Ij".'�- t` 0
4. DATE DRILLED
TOTAL DEPTH C7
5.
6. CUTTINGS COLLECTED YES ❑ NOE�-
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO[r}-
S. STATIC WATER LEVEL Below Top of Casing: 1�� FT. �`_
(Use'+'. it Above Top of Casing) -^^
CASING ISFT Above Land Surface' o
-Top of casing terminated at/or below land surface regrilres a variance In actor- — -
dance with 15A NCAC 2C .0118 4
10. YIELD (gpm): 'i-(-_ METHOD OF TEST ') /n 1 FI —
11. WATER ZONES (depth): > d —
12. CHLORINATION: Type 1¢ '/ 14 .. Arnounl '/`1 16 If additional space is needeG use back of form _
13. CASING:
LOCATION SKETCH
Wall Thickness
Depth �', Diameter or WeighVFt. Material (Show direction and distance from at least two State
From �, To Ft. —' r �i- t' A 1 Roads, or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From From To �_ Ft. Y '» ' 1 i T—
From To Ft.
15. SCREEN
Depth Diameter Slot Size Material
From —TO—Ft _ in. --in.-
From To — Ft..— in. _.— in.
From —To —Ft. _ In. —in.
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
17
100 HEREBY CERTIFY THAT THIS WELL WAS ONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION Y OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE A
Quad No: y��t1}
IGNATURE OF PERSON CONSTRUCTING THE WELL DATE
r r';ISUbmi to Division of Water Quality, Groundwater Section within 30 days
GW-I REV. 12t99
Serial No.

North Carolina - Department or Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: L "' ' f)
WELL CONTRACTOR CERTIFICATION #: G44•,�- -Q /'7
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (check Applicable Box): Residential ❑� - Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: (r1'/i7- d/ L County:
(Road Name antl Numbers, Community, or Subdivision an, Lot No.) DRILLING LOG DEPTH
3. OWNER f^�' 'c crCJ�°r'f `' From To Formation Description
Address J'� 'L l <'�tr".rir F .Z C4.
(Street
City or Town Stale Zip Code
4. DATE DRILLED
5. TOTAL DEPTH 312
6. CUTTINGS COLLECTED YES ❑ NO0--
7. DOES WELL REPLACE EXISTING WELL. YES F NOQ
8. STATIC WATER LEVEL Below Top of Casing: . � rl FT.
(Use'+'.if Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface'
'Top of casing terminated attor below land surface rec Ares a variance In actor.
dance with 15A NCAC 2C.0118
10. YIELD (gpm): —' METHOD OF TES
11. WATER ZONES (depth):r�--
12. CHLORINATION: Type ft t 14 Amount `/t If additional space is needed use back or form
13. CASING: -
LOCATION SKETCH —
Wall Thickness
Depth Diameter or Weight/Fl. Material (Show direction and distance from at least two Slate
From L� To '-�, Ft. ' ' /� n f ` Roads, or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From L To •�J L Ft. 0 1-1» : , t % �=
From To Ft.
15. SCREEN:
Depth Diameter SW 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 CE ATTHIS WELL WAS CONSTRUCTED IN ACCORDANCE W!TH 15A NCAC 2C, WELL
CONSTRUCTION D D�Aftlp T THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
LL�S / � )
FOR OFFICE USE
Quad No: I TURE OF PERSON CONSTRUCTING THE WELL DATE
Submit origi o ivislon of Water Quality, Groundwater Section Within 30 days
GWa REV. 12/99
Serial No.

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section ti
1636 Mail Service Center • Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: 1'tt„ Ij + t('ff rino���1c
WELL CONTRACTOR CERTIFICATION #:7,
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable sox): Residen'ial ❑' _ Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
Agricultural ❑ Monitoring ❑
2. WELL LOCATION/: �(�S,how sketch of the location below)
Nearest Town: /_ " le �r County: �� (�l --7�g, ; .—
(Road Name d Numbers, Community, or Subdivision and Lot No.) DRILLING LOG
3. OWNER 7r.» c-j L— ,S� -/ �f�G G/cam From To
Address '/D� ����� /ute�p�•� ,
i �SVeet or. o.
City or Town State Zip Code
4. DATE DRILLED-
5. TOTAL DEPTH `b
6. CUTTINGS COLLECTED YES 0 NO©i
7. DOES WELL REPLACE EXISTING WELL? YES NO[�a
B. STATIC WATER LEVEL Below Top of Casing: —i� FT.
(Use's if ACove Top of Casing)
9. TOP OF CASING IS Fr. Above Land Surface' ---
'Top of casing terminated aVor below land surface requires a variance In accor•
dance with 15A NCAC 2C.0118 --
10.YIELD(gpm): -S' METHOD OF TEST /24+r +'�(---
11. WATER ZONES (depth): Xo O ..33s `
DEPTH
Formation Description
cn
_. CD
12. CHLORINATION: Type 14 f �' . Amount 'fir_,_—� r7 If additional space is needod ose back of form
13. CASING: = --
Wal; Thickness LOCATION SKETCH
Depth Y.� Diameter or WeighvFt. Material (Show direction and distance from at least two State
From (- To Ft. —?L— r /5" r' I 1 ` Roads, or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From To .� L Ft. (r
From To Ft.
15. SCREEN:
Depth Diameter
From To Ft _ in.
From To Ft. _ in.
From To —FL in.
16. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To Ft.
17. REMARKS:
Slot Size Material
in.
in.
_._ in.
Material
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Quad No:
Serial No.
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Quality, Groundwater Section Within 30 days
GW-1 REV. 12199
0

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Sectionr-
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone] rti �- U 1. J 0
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION #: 44•b=r''- /'1/
STATE WELL CONSTRUCTION PERMIT#:
/ ❑
1. WELL USE (check Applicable Box): Residential ❑ � Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: /�l i'r /� /r , , '11' Count/:
(Road Name and Numbers, Community, or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER : /] : e e-1 ke (�' _ From To Formation Description
Address , �✓ c;X O.) N
trees or outa o. _
City or Town State Zip Cod
4. DATE DRILLED /- / - Z' i
5. TOTAL DEPTH ` _
6. CUTTINGS COLLECTED YES Q NOQ�
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NOQ-- _
8. STATIC WATER LEVEL Below Top of Casing: -SF; FT. ice_
(Use': ff Above Top of Casing) -
9. TOP OF CASING ISFT. Above Land Surface'
'Top of casing terminated attor below land surface roquires a variance In actor•
dance with 15A NCAC 2C d1119-
10. YIELD (gpm): L METHOD OF TEST
11. WATER ZONES (depth):
c
w
r;
12. CHLORINATION: Type Id t N .—Amount ;/ tr n_ If additional space is needed use back of form
13. CASING
Wall Thickness LOCATION SKETCH
Depth �, Diameter orweigh�JR. Material (Show direction and distance from at least two State
From 0To r* Ft. —ii> I Roads, or other map reference points)
From To Ft.
From To Ft. --
14. GROUT:
Depth Material Method
From To ,:L1 Ft. (f i -,ti .- : r _ 1
From To Ft.
15. SCREEN:
Depth Diameter
From _To_ Ft in.
From _ To _ Ft. in.
From —To Ft. _ In.
16. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To Ft.
17. REMARKS:
Slot Size Material
in.
in.
_ In.
Material
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY '' 'l" - per✓
Quad No: SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Quality, Groundwater Section within 30 days
Serial No. GW-I REV. 12199

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section :•Y '[ (�
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone] ll 1 v
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION #: 4.•e-'i'- /�7/0
STATE WELL CONSTRUCTION PERMIT#:.-
I
1. WELL USE (Check Applicable Box): Residential ❑ Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection [] Other ❑ If Other, List Use:
2. WELL LOCATIONyJShow sketch of the location below)
t
Nearest Town: 12 % /v /'' n'.�--County:
(Road Name and Numbers. Community, or Subdivision and Lot No.) DRILLING LOG
3. OWNER //G' -'%/ C( , //: c From To
Address
(Street or Route No. ,
City or Town State Zip Code
4. DATE DRILLED Z'
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES[D NOD%
7. DOES WELL REPLACE EXISTING WELL? YES D NOL]_
8. STATIC WATER LEVEL Below Top of Casing: _ � FF.
(Use'+' it Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface' -
'Top of casing terminated allor below land surface requires a variance In accor-
dance with 15A NCAC 2C .0118
10.YIELD (gpm): �C'' METHOD OF TEST'�i'"''`+��—
11. WATER ZONES (depth): —t
Agricultural ❑ Monitoring ❑
DEPTH
Fonnation Description
CD
------------
`o'
12. CHLORINATION: Type —Amount If additional space is needed use back of form
13. CASING: --'
Wall Thickness LOCATION SKETCH
Depth Diameter cr WeighVFl. Material (Show direction and distance from at least two State
From L To Ft. ti ' P l ' Roads, or other map reference points)
From To Ft. From To Ft.
14. GROUT
Depth Malar al Method
From LTo •1" Ft. 0
From To Ft.
15. SCREEN:
Depth
From
To _ Ft
From —To
Ft.
From —To
—Ft.
16. SAND/GRAVEL PACK:
Depth
From
To
From
To
17. REMARKS:
Diameter Slot Size Material
in. in.
in. in.
In. in.
Size Material
Ft. _
Ft. _
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
l l ,
FOR OFFICE USE ONLY ,. . . - ��,,"�' ,, , �' //-/- u`J
Quad No: SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Subn;t original to Division of Water Quality, Groundwater Section Within 30 days
Serial No. GW.1 REV. 12/99

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section !., ' 0 1 4 O
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMIT#:
i
1. WELL USE (Check Applicable Box): Resldentlal El " Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: �'i� %r �� �a r' /" P� County: C2 C' GK-
(Road Name and Numbers. Community, or Subdivision and Lot No.)
3. OWNER
Address_ SA <rV.c.(.-
—J511eet or MU10 M.J7
/cCn lC/«<.
City or Town State Zip e
4. DATEDRILLED11 1 e'
-
5. TOTAL DEPTH "f r r'
6. CUTTINGS COLLECTED YES Q NOE]/
7. DOES WELL REPLACE EXISTING WELL? YES 7 NO Q-
8. STATIC WATER LEVEL Below Top of Casing: ,:4` FT.
(Use'✓ it Above Top of Casing)
9. TOP OF CASING IS� FT. Above Land Surface -
'Top of casing terminated atlor below land surface requires a variance In accor-
dance with 15A NCAC 2C��.01�1�8
10. YIELD (gpm): �t-a-=- METHOD OF TEST /1r)�,�--
11. WATER ZONES (depth):
12. CHLORINATION: Type p t N —Amount
13. CASING:
Wall Thickness
Depth
Diameter or Weight/FL Matenal
From
To
Ft.
.—iL_._ r 4-•'_�'_E_�
From
To
Ft.
—
From
To
Ft.
14. GROUT:
Depth
Material Method
From
To -� i�
Ft.
R / ;1, < , nn r
From
To
Ft.
_
15. SCREEN:
Depth Diameter Slot Size Material
From —To Ft in. . in.
From —To _ Ft. in. in.
From —To —Ft. — in.
16. SAND/GRAVEL PACK:
From _
From _
17. REMARKS:
Depth
To Ft.
To _ Ft.
Size Material
Agricultural ❑ Monitoring ❑
DRILLING LOG DEPTH
From To Formation Description
O
I
--o
If additional space is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least two Slate
Roads, or other map reference points)
J r
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY •� � "' ' ' : rl r," r — f Z�
Quad No: SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Quality, Groundwater Section Within 30 days
Serial No. GW-I REV. 12/99

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section 1. (} (1 r7
1636 Mail Service Center -Raleigh, N.C. 27699-1636-Phone [phone] ! _
WELL CONSTRUCTION RECORD WELL CONTRACTOR: %_I) J�'I) �' �' 171t ,
WELL CONTRACTOR CERTIFICATION #: r=r /'-7
STATE WELL CONSTRUCTION PERMIT#:
1.
i
WELL USE (check Applicable sax): Residential El ,Municipal ElIndustrial
❑ Agricultural ❑ Monitoring El
Recovery ❑ Heat Pump Water Injection ❑ Other
It Other, List Use:
2.
WELL LOCATION: (S�h1ow sketc�r h of the location below)
Nearest Town: l^f/% County:;
(Road Name and Numbers, Community, or Subdivision and Lot No.)
DRILLING LOG DEPTH
3.
OWNER S o '_-
From To Formation Description
Address 1 • (a- `i /
i '(Street or HOU10 No. t
l�..i 71 I i e-, .2 C_ L�
City or Town State Zip Coda
—
4.
DATE DRILLED I -_I `> i'•1"�
5.
TOTAL DEPTH
6.
CUTTINGS COLLECTED YESQ-
7.
DOES WELL REPLACE EXISTING WELL? YES NO©-
8.
STATIC WATER LEVEL Below Top of Casing: e FT.
�..
9.
(Use'+' if Above Top of Casing)
TOP OF CASING ISFT. Above Land Surface'
--
-? -
*Top of casing terminated at/or below land surface requires a variance In actor.
dance with 15A NCAC 2C .0118
10. YIELD (gpm): _�� METHOD OF TEST
11.
WATER ZONES (depth):
12.
CHLORINATION: Type —,Amount s-.
It additional space is needed w6 back of form
13.
CASING:
LOCATION SKETCH `
Wan Thickness
Depth Diameter or Weight/Ft. Material
(Show direction and distance from at least two State
From L To I P S Ft. —L-- ' L f '---L-��
Roads, or other map reference points)
From To Ft. —
From To Ft.
14.
GROUT:
Depth Material Method
From ._% To •:-i `` Ft.—0 -n ,,
From To Ft.
15.
SCREEN:
Depth Diameter Slot Size Material
From —To—Ft _ in. —in.-
From To _ Ft. in. in.
From —To—Ft.— In. ..— in.
16.
SAND/GRAVEL PACK:
Depth Size Material
From To Ft. ._
From To Ft. _
17.
REMARKS:
—
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2r: , WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFI71rJAN
` f ' '` ' �1
Quad No: qqq OF PERSON CONSTRUCTING THE WELL DATE
Sutural original to !If
q of Water Quality, Groundwater Section Within 30 days
Serial No. `Jl I GW-1 REV. 12/99

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section I-i. l! 9
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELLCONTRACTOR:-L ') /4.11., ."+ 1i),fl �)i fin T11C,
WELL CONTRACTOR CERTIFICATION #: G•.i- - / -7
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential ❑ Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: C /./ C' 1/Z , ( County:
(Road Name and Numbers, Community, or Subdivision and Lot No.)
3. OWNER
Address
(Street or outs o.
Ci y Town " 1 State Zip C e
4. DATE DRILLED j -f
5. TOTAL DEPTH � A C,
6. CUTTINGS COLLECTED YES[::] NOED "
7. DOES WELL REPLACE EXISTING WELL? YES N0E-
6. STATIC WATER LEVEL Below Top of Casing: i FT.
(Use'+' if Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface'
'Top of casing terminated atlor below land surface requlres a variance In accor.
dance with 16A NCAC 2C .0118
10. YIELD (gpm): _ t METHOD OF TEST�-
11. WATER ZONES (depth): •-J ��' / y/-�r r
12. CHLORINATION: Type _Amount
13. CASING:
Wall Thickness
Depth
Diameter or Weight/Ft. Material
From
To -LLLY-
Ft.
L o,
From
To
Ft.
From
To
Ft.
14. GROUT:
Depth
Matedlil Method
From LTo ,21�
Ft.
RI';), -
From
To
Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From —To Ft _ in. —in.
From —To Ft. in. in.
From —To —Ft. — in. --in.
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
17. REMARKS:
DRILLING LOG
From To
Agricultural ❑ Monitoring ❑
DEPTH
Formation Description
C]
cn -
If additional space is needed use back of form
LOCATION SKETCH
(Show direction and distance fi um at least two State
Roads, or other map refers^..'a points)
100 HEREBY CERTIFY THAT THIS WELL WA 3 CONSTRUCTED IN ACCORDANCE WITH 15A NCAC b_. ,NELL
CONSTRUCTION STAND - ECORD HAS BEEN PROVIDED TO THE WELL OWNER.
r � �
FOR OFFICE USE ONLYFub§rniferigir
S
Quad No: IGNA F PERSON CONSTRUCTING THE WELLE DATEat to Di I Water Quality, Groundwater Section within 30 days
Serial No. GW-t REV. 12129

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section �. �� 1� 1 7
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: L\ I 1 'II �' �'F ;' C
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMIT#:
1.
WELL USE (Check Applicable Box): Residential El Municipal ❑
Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ It Other, List Use:
2.
WELL LOCATION: Show sketch of the location below)
Nearest Town: )L 'i )I (: 1 -r t. - A. l.- County: nI
(L
(Road Name antllJumbers, Community/, or Sutxlivision antl Lot No.)
DRILLING LOG DEPTH
3.
OWNER I 1 �� t"- / t �Z:
From To Formation Description
^�
Address
ZSueet or outs o.
City or Town State Zip Code
o
4.
DATE DRILLED ��—•-� %-C`L`
Q
5.
TOTAL DEPTH 6'
O
6.
CUTTINGS COLLECTED YES Q NOM�—
n
�m
7.
DOES WELL REPLACE EXISTING WELL? YES NO©,
B.
STATIC WATER LEVEL Below Top of Casing: _- !" FT.
(Use': it Above Top of Casing)
�o
9.
TOP OF CASING IS FT. Abcve Land Surface'
3
�o
'Top of casing terminated atlor below land surface requires a variance In actor.
dance
10.
with 15A NCAC 2C.0118
YIELD(gpm): METHOD OF TEST LLO/+ L
—
11.
WATER ZONES (depth):
12.
CHLORINATION: Type /i t h"f Amount t' / n
It additional space is needed use back of form
13. CASING
LOCATION SKETCH
Wall Thickness
Depth Diameter or WeighVR. Material (Show direction and distance from at least two State
From L To 1,2 --)- Ft. L ' ' r /` ' Roads, or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From L To -)-+"' Ft.
T"
From To Ft.
15. SCREEN:
Depth Diameter
From To _ Ft in.
From _ To _ Ft. _ in.
From —To —Ft. _ in.
16. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To Ft.
17. REMARKS:
Slot Size Material
in.
in.
in.
Material
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
cnNSTRUQTION STANDARDS. AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER,
FOR OFFICE US
Quad No:
Serial No.
I1, ,. 0 / 9n:,,: n nr , -
VGNATURE OF PERSON CONSTRUCTING THE WELL
Submit 060ino to Division of Water Quality, Groundwater Section Within 30 days
DATE
GW-1 REV. 12199
3
Groundwater Section
AshevilleR 'onal Office
I1, ,. 0 / 9n:,,: n nr , -
VGNATURE OF PERSON CONSTRUCTING THE WELL
Submit 060ino to Division of Water Quality, Groundwater Section Within 30 days
DATE
GW-1 REV. 12199
3
Groundwater Section
AshevilleR 'onal Office

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section t.:.. 1. 4 1 U
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: 111,", /�,-'') mil'' "II L',rI I T)1c
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMIT#:
i 1. WELL USE (check Applicable Box): Residential ❑" " Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring El
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATI J (Show sketch o(the location below)
Nearest Town: V"/v,11.' I ' /.( County:
(Road Name and Numbers, Commum , or Subdivision and Lot No.) DRILLING LOG
3. OWNER i,^ i C- �c, C 4lQ 11\ From To
Address '�� �l • r,� C� k •�- 3
tbtreei or ho
to o.
1'I,a1lLit%�-) 41PC9��
City or Town State Zip Code
4. DATE DRILLED 1 I- 1 (,, - c't�
5. TOTAL DEPTH 7M
6. CUTTINGS COLLECTED YES 0 07-- —
7. DOES WELL REPLACE EXISTING WELL? YES NO©i
8. STATIC WATER LEVEL Below Top of Casing: FT.
(Use'+' it Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface'
'Top of casing terminated aVor below land surface requires a variance In accor.
dance with 15A NCAC 2C .0118
10. YIELD(gpm): L-2 METHODOFTE;ST '7/:ni'. r� �l-
11. WATER ZONES (depth): h IF
12. CHLORINATION: Type 0114 Amount
13. CASING:
W ali Thickness
Depth Diameter or Weight/R. Material
From �� To `L Ft. t,- P 1
From To Ft.
From To Ft.
14. GROUT
Depth Matorial Method
From L To .�_Ft. 0r';1,,L:r; i),�-
From To Ft. ._._
15. SCREEN;
Depth Diameter Slot Size Material
From To Ft in. in.
From —To —Ft. in. —in.
From —To Ft. in. in.
16. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To Ft._
17. REMARKS:
Material
DEPTH
Formation Description
It additional space is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRU T A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFIC
Quad No: SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Subfrit dapinal to Division of Water Oualily, Groundwater Section Within 30 days
Serial No. GW-1 REV. 12199

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-1536-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: - / !1 _+ (l)' I) ht 1 7 ^� T1t c,
WELL CONTRACTOR CERTIFICATION #:5;
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (check Applicable sox): Residential EK Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (.Show sketch of the location below)
Nearest Town: 4-1 % , /"�+- ; , / : , - County:
(Road Name and Numbers. Community, or Subdivision and Lot No.)
3. OWNER mac.
Address
C_ -�! t C_u' ti,
treat or outs NC.
City or Town Stale Zip Code
4. DATE DRILLED j _ ) ` _ 12
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑ NO❑J
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO❑
8. STATIC WATER LEVEL Below Top of Casing: EL FT.
(Use **'It Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface'
-Top of casing terminated attor below land surface requires a variance In accor.
dance with 15A NCAC 2C.0119
10. YIELD (gpm): • 2 METHOD OF TEST ') / 1 v
11. WATER ZONES (depth): J- r
12. CHLORINATION: Type Amount t
13. CASING:
Wall Thickness
Depth Diameter or Weight/Ft. Material
From C To �= Ft. L • . &— P t ; 7
From To Ft.
From To Ft.
14. GROUT:
Depth
Material
Method
From To 21"
Ft.
_ n
From To
Ft.
15. SCREEN:
Depth
Diameter Slot Size
Material
From —To—Ft—
in. —in
From To —Ft.
_ in.
in.
From To —Ft.
— in. —
in.
16. SAND/GRAVEL PACK:
Depth
Size
Material
From To
Ft.
From To
Ft.
17. REMARKS:
DRILLING LOG DEPTH
From To Formation Description
II additional space is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCT J ,QQPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE
V �} ,In i.•, �'ii ter.-.� I—���
Quad No: = i SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Subma b4linal to Divislon of Water Duality, Groundwater Section within 30 days
Serial No. , - GW-1 REV. 12199

North Carolina - Department of Environment and Natural Resources - Division or Water Quality - Groundwater Se::tion I I .-) 7
1636 Mail Service Center- Raleigh, N.C. 27699-ti.36-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: )mil I n 1) A Wo f f _)1 . If �� �i1 C'
WELL CONTRACTOR CERTIFICATION #: - z�
STATE WELL CONSTRUCTION PERMIT#:
1, WELL USE (Check Applicable Box): Residential 0---Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch o1 the location below)
Nearest Town: " t -) n I'� I i't,i "/� _ County:
(Road Name and Numbers, Community, or Subd.vision and Lot No.)
DRILLING LOG DEPTH
3.
OWNER (� i'f Y '1� i L lC I C O
From To Formation Description
Address '%�`l_"� �7t . �+f« —
, (Street or Route No.
City or Town State Zip Code
4.
DATE DRILLED I1 -J6 -Ot`
5.
TOTAL DEPTH S/e' `;
6.
CUTTINGS COLLECTED YES Q NO❑--
7.
DOES WELL REPLACE EXISTING WELL? YES ❑ NOQ
^
B.
STATIC WATER LEVEL Below Top of Casing: 3 FT.
c
(Use '+' it Above Top of Casing)
C cow
9.
TOP OF CASING IS FT. Above Land Surface'
Fn or�i
-Top of casing terminated atlor below land surface requires a variance In accor.
2=
dance with 15A NCAC 2C.0118 -
10. YIELD (gpm): -,2— METHOD OF TEST
"-�
W
11.
WATER ZONES (depth): (^ f —
m_
12.
CHLORINATION: Type Amount t
It additional space is needed use back of form
13.
CASING:
n a
LOCATION SKETCH Z
Wall Thickness
Depth Diameter or WeighVR. Material
(Show direction and distance from at least two State
� f�
From C To J- 7- Ft. ( -, /�V— n 0
Roads, or other map reference points)
From To Ft.
From To Ft.
14.
GROUT:
Depth Mate ial Method
From � To ylL Ft. 01j2L:r,-i
From _— To Ft. _
15.
SCREEN:
Depth Diameter Slot Size Material
From To _ Ft _ in. — in.
From To — Ft, _ in. _ in.
From To _ Ft. _ In. _ in.
16.
SAND/GRAVEL PACK:
Depth Size Material
From To Ft. _
From To Ft. .
17.
REMARKS:
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTIO-N cTas ANDAa Q.AAIO OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
�b
FOR OFFICEUB V �,ltf+.,:G'z�
Quad No: 9r �' NATURE OF PERSON CONSTRUCTING THE WELL DATE
Subm: orjq(dal Yo Division of Water Duality, Groundwater Section Within 30 days
Serial No. GW-1 REV. 12199

,
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section r., 1 .7
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: 4L1 t, n � ' )1 (/)<, I) �! , n, ,.� �i1 C,
WELL CONTRACTOR CERTIFICATION #: -7
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential /- Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: �r-/:2.;Ik /,1 i .4 County:
Agricultural ❑ Monitoring ❑
(Road Name and Numbers, Community, or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER Z�/�l/v': .r ,�={'�� From To Formation Description
Address / Si 7 -)
(bireet or Route Noq
City or Town State Zip odd e
4. DATE DRILLED /_Z"
5. TOTAL DEPTH � 7-;
6. CUTTINGS COLLECTED YES Q NO©�-
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO�
S. STATIC WATER LEVEL Below Top of Casing: _ Fr. CD
(Use's . it Above Top of Casing) _-1
9. TOP OF CASING IS FT. Above Land Surface' 1�_a _
*Top of casing terminated aVor below land surface requires a variance In accor-
dance with 16A NCAC 2C .0116 '
r —=
10. YIELD (gpm): j L METHOD OF TEST h4)/ r 7 n(--
11. WATER ZONES (depth): '� _ e _d C9-=
12. CHLORINATION: Type N Amount t If additional space is needed use back of form N
13. CASING:
Wall Thickness
Depth Diameter or Weight/Ft. Material
From To Ft. —L'
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From To • 2 i� Ft. R r'111
From To Ft.
15. SCREEN
Depth Diameter Slot Size Material
From —To —Ft— in. --in.
From —To Ft. in. —in.
From —To —Ft.— In. --In.
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
17. REMARKS:
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
. , I (-1
FOR OFFICE USE ONLY
Quad No:
Serial No.
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Quality, Groundwater Section within 30 days
GW-1 REV. 12199

l r r, 0
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center -Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELLCONTRACTOR:11-'tt11 5 /4-)) � Lt)?II �r If C,
WELL CONTRACTOR CERTIFICATION #: <-S= .2 /'7/_
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (check Applicable Box): Residential 0---Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION Show sketch of the location below)
Nearest Town: County:
(Road Name and Numoers, Community, or Subdivision and Lot No.)
DRILLING LOG DEPTH
3.
OWNER Ucd a'r.S tl,
From To Formation Description
Address
Street or HOUIO o. '7 I I f /�7 i %L �C — . -�-CLI /
City or Town State Zip Code
4.
DATE DRILLED _//% 4 r= - 2 3
5.
TOTAL DEPTH . 1%
6.
CUTTINGS COLLECTED YES [:J NOE]i'
^ .J
7.
DOES WELL REPLACE EXISTING WELL? YES NOED—
CD
8.
STATIC WATER LEVEL Below Top of Casing:..-2Ir FT.
_-
(Use `41 if Above Top of Casing)
9.
TOP OF CASING IS IFT. Above Land Surface'
-Top of casing terminated atlor below land surface requires a variance In accor-
dance with 15A NCAC 2C .0118
10. YIELD (gpm): METHOD OF TEST h/W/ 1 7 —
11.
WATER ZONES (depth):
Cr1
12.
CHLORINATION: Type �f t N L
yp _Amount
1,0 L-�
1t additional space is needed use back of loan
13. CASING
Depth Diameter
From �� To 4 L Ft.—L(
From To Ft.
From To Ft.
14. GROUT:
Wall Thickness LOCATION SKETCH
or WeighVFt. Material (Show direction and distance fiom at least two State
r r ' P t Roads, or other map refere::ce points)
Depth Material Method
From To .;) L' Ft. 0 Pa» r ,TT n
From To Ft.
15. SCREEN
Depth Diameter
From —To—Ft— in.
From —To—Ft.— in.
From —To IFt. _ In.
16. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To Ft.
17. REMARKS:
Slot Size Material
_ in.
in.
in.
Material
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2c,'VVELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Quad No:
Serial No.
DZ�
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Quality, Groundwater Section within 30 days
GW-1 REV. 12199

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section `., 1. 9 F! " 6
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:.tiL7L , /4-))r > (I,9I) �\I. ,I r�-of T)iC
WELL CONTRACTOR CERTIFICATION #: '7/<.
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (check Applicable Boa): Residential Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town:"217 // �rJ`Counry:
(Road Name and Numbers, Community, or Subdivisslon and Lot No.) DRILLING LOG DEPTH
/�
3. OWNER , I<<cFrom To Formation Description
Address
treet or Route o.
j�l L6h l( l �
City or Town State Zip Coda
4. DATE DRILLED A %
5. TOTAL DEPTH �7`2
6. CUTTINGS COLLECTED YES ❑ NO©—
7. DOES WELL REPLACE EXISTING WELL? YES 7 N00--
B. STATIC WATER LEVEL Below Top of Casing: �? �. FT.
(Use'+. it Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface'
-Top of casing terminated aVor below land surface requires a variance In accor-
dance with 15A NCAC 2C.0116
10. YIELD (gpm): METHOD OF TEST hlnl
11. WATER ZONES (depth): t
�J
i
crt
12, CHLORINATION: Type /t t J4 .-Amount If additional space is needad use back of form
13. CASING:
LOCATION SKETCH
Wall Thickness
Depth Diameter or WeighVFt. Material (Show direction and distance from at least two State
From L� To Ft. (C . r /'V P t Roads, or other map reference points)
From To Ft.
From To Ft.
14. GROUT
Depth Material Method
From V To .:� l'� Ft. 0 ,-7 i A —
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From —To—Ft _ in. —in.—
From —To _ Ft.— in. — in.
From _ To — Ft.— In. —in
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
17. REMARKS
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 1SA NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY L`
Quad No: SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Quality, Groundwater Section Within 30 days
GW1 REV. 12/99
Serial No.

t 'q �t
North Carolina - Department of Environment and Natural Resources • Division of Water Quality - Groundwater Section r., j_ ( �
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone] I
WELL CONSTRUCTION RECORD WELL CONTRACTOR: cL1 t, n �}r 11 Lf )" f ` ' I c'
WELL CONTRACTOR CERTIFICATION #: -7
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: _,�-r'ii "f ll lilt' �'C County:.��C'�F"
(Road Name and Numbers. Community, or Subdivision and Lot No.) DRILLING LOG DEPTH
i Formation Description
3. OWNER �� »L� _. From To
Address L :r(
treetor out '
Zip
Cily or Town Stale Co e
4. DATE DRILLED
5. TOTAL DEPTH _ CD
6. CUTTINGS COLLECTED YES f__j NO[Z]--
7. DOES WELL REPLACE EXISTING WELL? YES NO L[�— o ,'1-`
B. STATIC WATER LEVEL Below Top of Casing: i— FT. --1 _
(Use •+.If Above Top of Casing) N
9. TOP OF CASING IS FT. Above Land Surface'
'Top of casing terminated eVor below land surface requires a variance In actor-
dance with 15A NCAC 2C.0118 _
(gp )_ METHOD OF TEST h%Ind r 11 n
10. YIELD m : � •• � =-
r
11. WATER ZONES (depth): ._
N �
12. CHLORINATION: Type /t t /-/ Amount 'ICZ.16 It additional space is needed use back of form
13. CASING:
LOCATION SKETCH
'Nall Thickness
Depot—_,, Diameter or WeighVFt. Material (Show direction and distance from at least two Stale
From �� ToFt. —L% -- ' /f v 11 f Roads, or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From To —L-L Ft. n r-a„ o
From To Fl.
15. SCREEN:
Depth Diameter Slot Size Material
From —To—Ft— in. —in.—
From—TO—Ft.— in. —in.
From —To _ Ft. _ in. —in.
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
17
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Quad No: SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Quality, Groundwater Section within 30 days
GW-t REV. 12199
Serial No.

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section r, -L ij �1 0
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: -L,-t 1 r1, �h I l . A ( 02 f I � r, r I L
WELL CONTRACTOR CERTIFICATION #: _ .5--`�- <Q /-7
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (mow sketch of the location below)
Nearest Town: "r % -7 4' 1 r County: M ,;� <r
(Road Name ana Numbers, Communiry} or Subdivision and Lot No.)
3. OWNER FtN( I`rs,,C,u 7`N'P_�t lei
Address S -
i(Street or off ula hoFj' r/
City or Town State Zip Code
4. DATE DRILLED Ir aL
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑ NO�`
7. DOES WELL REPLACE EXISTING WELL? YES NO[_
8. STATIC WATER LEVEL Below Top of Casing: ,r� FT.
(Use'+,if Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface -
'Top of casing terminated at/or below land surface requires a variance In accor-
dance with 15A NCAC 2C.0118
10. YIELD (gpm): , '5- METHOD OF TEST '> n/ i —
11. WATER ZONES (depth): r
12. CHLORINATION: Type /f 7,14 Amount '/cl n
13. CASING:
Agricultural ❑ Monitoring ❑
DRILLING LOG DEPTH
From To Formation Description
n
r\1
-
Ul
If additional space is needed use back of form
Wall Thickness LOCATION SKETCH
Depths f� , Diameter or Weight/Fl, Material (Show direction and distance from at least two State
From l,� To Jam— Ft. —((— PLi— Roads, or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From To - Z� L_ Ft. 0 ("1),
From To Ft. _
15. SCREEN:
Depth Diameter Slot Size Material
From To _ Ft in. in.
From To Ft. in. _ in.
From To Ft. In. __ in.
16. SAND/GRAVEL PACK:
Depth Size
From To Ft. —
From To Ft. _
17. REMARKS:
Material
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Quad No:
Serial No.
—/ —Z'2�'
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Quality, Groundwater Section within 30 days
GW-1 REV. 12199

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section , . _LI 2 3 6
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:.1'r11 ��Z•! 1 tl'' I I �• �'1 c.
WELL CONTRACTOR CERTIFICATION #: '7/:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: ��1 < 1( l County: "0 , `cam
(Road Name and Numbers, Community, or Subdivision and Lot No.)
3. OWNER 4
Address I.,,r_=; �a"ui
—J— «ejS�ec or F�oo-ole o.
c, o r C�
City or Town State Zip Code
4. DATE DRILLED /'_
5. TOTAL DEPTH -> ")
6. CUTTINGS COLLECTED YES ❑ NO❑-
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO❑
B. STATIC WATER LEVEL Below Top of Casing: 4):> FT.
(Usa'.:if Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface'
-Top of casing terminated atlor below land surface rewires a variance In accor-
dance with 15A NCAC 2C.0118
10. YIELD (gpm): --� C METHOD OF TEST 7 r/ r "r
11. WATER ZONES (depth): 2'LL
12. CHLORINATION:
13. CASING:
Agricultural ❑ Monitoring ❑
DRILLING LOG DEPTH
From To Formation Description
0
to r•,�:
Type /t f 14 Amount 'fit /'r It additional space is needed use back of form W c;
Well Thickness
Depth
Diameter or Weight/Ft. Material
From L
r
To
Ft. if , r
From
To
Ft.
From
To
Ft.
14. GROUT:
Depth
Material Method
From
To .2(
FL R e"1,
From
To
Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From —To
_ Ft
_ in. _._ in.
From —To
—Ft.
_ in. -- in.
From _
To — Ft.
_ In. _— in.
16. SAND/GRAVEL PACK:
Depth
Size Material
From
To
FL
From
To
Ft.
17. REMARKS:
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Quad No:
Serial No.
SIGNATURE OF PERSON CONSTRUCTING THE WELL
Submit original to Division of Water Quality, Groundwater Section within 30 days
C" L
DATE
GW-1 REV. 12/99

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Sec:ion J 2 3
1636 Mail Service Center - Raleigh, N.C. 27699-16:t6-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: t 11 5 /)T I j i t 'g l l hi, ' I C,
WELL CONTRACTOR CERTIFICATION #: <-A,� .,Q /-7
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable sox): Residential 0-Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: �rA NI (/ I h i d 1 i - County:
(Road Name @nd Numbers, Community, or Subdivision and Lot No.) DRILLING LOG
l /1 _
3. OWNER ) [� "C' v-C`Pl _ From To
Address
creel or Ho.te o. —
City or Town State Zip Code
4. DATE DRILLED^Ib-
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES Q NOED,-
7. DOES WELL REPLACE EXISTING WELL? YES NO[��
8. STATIC WATER LEVEL Below Top of Casing: l ,//fin FT.
(Use'+at Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface-
-Top of casing terminated at/or below land surface requires a variance In accor-
dance with 15A NCAC 2C .0118
10. YIELD (gpm): - Q _ METHOD OF TEST 21 n1 f • L n� —
11. WATER ZONES (depth): /r�
Agricultural ❑ Monitoring ❑
DEPTH
Formation Description
—. o
l
_t
12. CHLORINATION: Type /t t 14 Amount ' 16 If additional space is needed use back of form
13. CASING:
Wall Thickness
Depth Diameter or Weight/Ft. Material
From �� To S1 Ft.—�L "/ —
From To Ft.
From To Ft.
14. GROUT:
Depth Materi;:,l Method
From To Ft.
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From To _ Ft _ in. --in.
From —To —Ft. — in. in.
From _ To _ Ft. — in. in.
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft:
From To Ft.
17. REMARKS:
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Quad No:
Serial No.
SIGNATURE OF PERSON CONSTRUCTING THE WELL
Submit original to Division of Water Quality. Groundwater Section within .0 days
DATE
GW-1 REV. 12f99

North Carolina - Department of Environment and Natural Resources - Division of Water Ouahry - Groundwater: ec;.dn r., i 9 23 V
1636 Mail Service Center - Raleigh, N,C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: n, �, IJ�' j I CC/�� I I I ! I n- e� 11 G
WELL CONTRACTOR CERTIFICATION #: -7r�_
STATE WELL CONSTRUCTION PERMIT#:
1.
WELL USE (Check Applicable sox): Residential lL Municipal ❑
Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2.
WELL LOCATION:
OCATION:,(Show sketch of hfcation below)
LGtilINearestTown: County: C�"1
r. spry
(Road Name and Numbers, Community, or Subdivision and Lot No.)
DRILLING LOG DEPTH
3.
OWNER ! (t 1 i i .� I1 P (� e I I
From To Fomnation Description
Address
'fMreet
7� or HOU10 No.)
L2
City or Town Stale Zip Code
4.
DATE DRILLED//,-II-C7�
--
5.
TOTAL DEPTH S
6.
CUTTINGS COLLECTED YES NOE]--
7.
DOES WELL REPLACE EXISTING WELL? YES NOQ/
8.
STATIC WATER LEVEL Below Top of Casing: < FT.
9.
(Use's: it Above Top of Casing)
TOP OF CASING ISM— FT. Above Land Surface*
O
-
'Top of casing terminated atlor below land surface requires a variance In accor.
ecl
dance
10.
with 15A NCAC 2C .0118-
YIELD METHOD ') W 1,
(gpm): -) OF TEST
11.
WATER ZONES (depth): / 70 0-
12.
CHLORINATION: Type It t N r r.
yp Amount _�
'V -
It additional space is needed use back of loan-
13.
CASING:
Wall Thickness
LOCATION SKETCH
Depth Diameter or Weight/Fl. Material
L�
(Show direction and distance from at least two Stale
From To _LL�L Ft. —L r /S-V
Roads, or other map reference points)
From To Ft.
From To Ft.
14. GROUT
Depth Material Method
From �— To •2L Ft. __0
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From To _ Ft in. _ in.
From _ To _ Ft. in. _ in.
From _ To Ft. _ In. —in.
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A. COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Quad No:
Serial No.
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Quality, Groundwater Section within 30 days
GW-1 REV. 12199

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section �� i 9 2 21
'I S Cent r - Ralei h N C 27699.1636-Phone [phone]
1636 Mat erwce e g , .
WELL CONSTRUCTION RECORD WELL CONTRACTOR:•L t 11 ` � 'I) �' �f)'II �`' /17), C'
WELL CONTRACTOR CERTIFICATION #: •-� 7
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: n(JO LC_ County:
(Road Name umoers, Community, or Subdivision and Lot No.) DRILLING LOG
3. OWNER )( c) U I�(r 1I Un>7 From To
Address
treelof oule o.
City or Town State zip Code
4. DATEDRILLED lU—-071
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES❑ NOD--
7. DOES WELL REPLACE EXISTING WELL? YES NO
B. STATIC WATER LEVEL Below Top of Casing: C,r_ FT.
(Use'+- it Above Top of Casing)
9. TOP OF CASING ISFT. Above Land Surface-
-Top of casing terminated eVor below land surface requires a variance In accor-
dance with 15A NCAC 2C.0116
10. YIELD (gpm): 6 _ METHOD OF T EST ? ^ f
Agricultural ❑ Monitoring ❑
DEPTH
Formation Description
e
o
O
11. WATER ZONES (depth).
12.
CHLORINATION: Type H I- N _Amount
rr
13.
CASING:
Wall Thickness
Depth Diameter
or Weight/Ft. Material
��
(42(-' Ft.—L
' "z '
From
To
From
To Ft.
From
To Ft.--
—
14.
GROUT:
Depth Material Method
From To 1('� Ft. RrgT1
cnl --P-"�,i1'—
From
To Ft.
15.
SCREEN:
Depth
Diameter
From
_To_
Ft _ in.
From
—To —
Ft. _ in.
From
—To _
Ft.— In.
16. SAND/GRAVEL
PACK:
Depth
Size
From
To —Ft
—
From
To
- Ft.
17. REMARKS:_
Slot Size Material
_ in.
_ in.
in.
Material
If additional space is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY ' , / '^' t " /t GATE
Quad No: SIGNATURE OF PERSON CONSTRUCTING THE WELL
Submit original to Division of Water Quality, Groundwater Section within 30 days GW 1 REV. 12199
Serial No.

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section f- i 9 2 2
1636 Mal Service Center - Raleigh, N.C. 27699.1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:.Lip-r1n �h'II ° �1)O11 �` n �" T"c'
WELL CONTRACTOR CERTIFICATION If: -7
STATE WELL CONSTRUCTION PERMIT#:
WELL USE (Check Applicable Box): Residential - Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
) A! C' County:
NearestTown:�%_i —T-
(Road Name and Numbers. Community, or Subdivision and Lot No.)
3. OWNER
Address �� (�1C X % 'j j
/ _ j5«eel v,oute Ro`.7—
4. DATE DRILLED
5. TOTAL DEPTH n
6. CUTTINGS COLLECTED YES ❑ NOE]--
7. DOES WELL REPLACE EXISTING WELL? YES N07
8. STATIC WATER LEVEL Below Top of Casing: .5�1 FT.
(Use"✓ if Above Top of Casing)
9. TOP OF CASING IS _l _ FT. Above Land Surface'
'Top of casing terminated at/or below land surface requires a variance In accor-
dance with 15A NCAC 2C.0118
10. YIELD (gpm): In METHOD OF TEST '> pt/ I 1
11. WATER ZONES (depth): 11:QC r f
Agricultural ❑ Monitoring ❑
DRILLING LOG DEPTH
From To Formation Description
rtt
12. CHLORINATION: Type 1ffi4 —Amount '�L/ It additional space is needed use back of form —
13. CASING:
LOCATION SKETCH
Wall Thickness
Depth [ / Diameter or WeighVFt. Material (Show direction and distance from at least two Stale
From—�� TO 7 () Ft — -- ' � L 1) il'�' Roads, or other map reference points)
From To Ft. —
From To Ft.
14. GROUT:
Depth Malarial Method
From L To MI" Ft. 0 r1121 4 ,-D
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From —To —Ft— in. —in.
From —To —Ft. — in. — in.
From _To Ft. — In. _ in.
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft. —.—
From To Ft.
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
I 1 �
FOR OFFICE USE ONLY
Quad No: SIGNATURE OF PERSON CONSTRICTING THE WELL DATE
Submit original to Division of Water Quality, Groundwater Section within 30 days
GW-1 REV. 17199
Serial No.

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section 1 9 2 2 3
1636 Mail Service Center - Raleigh, N.C. 27699.1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: 4��I"1 tt 5 I) 1 �1J"'
WELL CONTRACTOR CERTIFICATION #: •� y 7�0
STATE WELL CONSTRUCTION PERMIT#:
Municipal ❑
Industrial ❑ Agricultural ❑ Monitoring ❑
1.
WELL USE (check Applicable Box): Residential
Recovery ❑ Heat Pump Water Injection ❑ Other ❑
If Other, List Use:
2.
WELL LOCATION: (Show sketch of the location below) M
Nearest Town: m �! I I / County: �! /1
/ 0 /
(Road Name and Numbers, communitySubdivision and Lot No.)
DRILLING LOG DEPTH
3.
7or
y,
OWNER r` S f t Cti f� 12- 5
From To Formation Description
Address
treetor houle o. r
City or Town State 41P Cade
4.
DATE DRILLEDy
5.
TOTAL DEPTH _Sm)
6.
CUTTINGS COLLECTED YES ❑ NO❑-�
7.
DOES WELL REPLACE EXISTING WELL? YES ❑ 1,102
_ .
8.
STATIC WATER LEVEL Below Top of Casing: _ F r.
(Use'+' II Above Top of Casing)
--
9.
TOP OF CASING ISFT. Above Land Surface'
o�
*Top of casing terminated at/or below land surface requires a variance In accor•
_
dance with 15A NCAC 2C .0118
10. YIELD (gpm): 1 METHOD OF TEST r f
11.
WATER ZONES (depth): � JS-,r. �� c;
12. CHLORINATION: Type t t N —Amount It additional space Is needed use back of form =-
13. CASING:
LOCATION SKETCH
Walt Thickness
Depth Diameter or Weight/Ft. Material (Show direction and distance from at least two State
From L2 To _2�_ Ft. L . '-1�"-L'-- P � ' Roads, or other map reference points)
From To
Ft.
From To
Ft.
14. GROUT:
Depth
Material
Method
From _t� To 2 L Ft.
R r:111 d n i
.P 91s-1-=
From To
Ft.
15. SCREEN:
Depth
Diameter Slot Size
Material
From —To—Ft—
in. —in.—
From — To _.
Ft. _
in.
in.
From —To _
Ft. —
in. —
in.
16. SAND/GRAVEL PACK:
Depth
Size
Material
From To
Ft.
—.—
From To
Ft.
17
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY �r ' rr r
Quad No: SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
SubMl original to Division of Water Quality, Groundwater Section within 30 days
GW1 REV. 12199
Serial No.

North Carolina - Department of Environment and Natural Resources - Divis:_ n of %,+ater Quality - Grour. water Section (_ ,� g 2
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: L'111r`` / �''I) (I)'ll �` it n'."C
WELL CONTRACTOR CERTIFICATION ft: �) / 7C' "
STATE WELL CONSTRUCTION PERMITd:
1. WELL USE (Check Applicable Box): Residontial❑- Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Omer, List Use: _
2. WELL LOCATION: (Show sketch of the location below)
n 1
Nearest Town:..—l`
(Road Name and Numbers. Community. or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER is LZIO, 0 S LOck L C? YT�n-t'l From To Formation Description
Address , 6 D X c,
rr rl,act or oute 'o.
A/
City or Town State Zip Code
4. DATE DRILLED
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑ NO[D--
7. DOES WELL REPLACE EXISTING WE'.-L? YES [] NOIi I CD _-
S. STATIC WATER LEVEL Below Top of Casing: l � FT.� -
CD
(Use'+' If Above Top of Casing)-
9. TOP OF CASING IS FT. Above Land Surface' 1 ` -
'Top of casing terminated aVor below land surface requires a variance In accor. _
dance with 1SA NCAC 2C.0118 v-..
10. YIELD (gpm): METHOD OF TEST
r�
11. WATER ZONES (depth):
12. CHLORINATION: Type t t N ._Amount ��t, If additional space is needed use back of form d1 ='-
13. CASING:
LOCATION SKETCH
Wall Thickness
Depth Diameter or WeightlFt. Material (Show direction and distance from at
least two State
From L, To Ft. L. — "i" L P dl'" Roads, or other map reference points)
From To Ft. —"-
From To Ft.-- — —
14. GROUT:
Depth Material Method
From To -'IL Ft. 0 i rn e 2.17- T
P 1, i
From To Ft. �
15. SCREEN:
Depth Diameter
From _ To _ Ft _ in.
From _ To — Ft. _ in.
From —To — Ft. _ In.
16. SAND/GRAVEL PACK:
Depth Size
From To —Ft. --
From To Ft._.
17. REMARKS:
Slot Size Material
_ in.
in.
in.
Material
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
LFOR OFFICE USE ONLY h 'f l _ J LTL
-�- DATE
Cued No: SIGNATURE OF PERSON CONSTRUCTING THE WELL
Submit Original to Division of Water Duality, Groundwater Section Within 30 days
GW-1 REV. 12/99
Serial No.

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section f. rT n
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone] ...). J • 1 qW
WELL CONSTRUCTION RECORD WELL CONTRACTOR: '� r t1 i fr /) . t (C)� I I �' r l n, e �11 C'
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMIT#:
1,
WELL USE (Check Applicable Box): Residential �� Municipal ❑ Industrial ❑
Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other If Other, List Use:
_
2.
WELL LOCATION (Show sketch of the location below) /�
Nearest Town: --/ter-�2 L l' `L -' L - County: //11�(
(Road Name and Numbers, Community, or Subdivision and Lot No.) DRILLING LOG
DEPTH
3.
OWNER &J k%, 7r-' C LiFrom To
Formation Description
Address >� L{ I A
—
Creel or oma o.
_
City or Town State Zip Code
-
4.
DATEDRILLED /D'�(-. -�'✓
u .._
5.
TOTAL DEPTH !i
-
6.
CUTTINGS COLLECTED YES ❑ NOQ�
—
7.
DOES WELL REPLACE EXISTING WELL? YES ❑ NO�
3
8.
STATIC WATER LEVEL Below Top of Casing: ;� , FT.
— - -
(Use'+' it Above Top of Casing)
-n =
9.
TOP OF CASING ISFT. Above Land Surface'
-
'Top
of casing terminated atlor below land surface requires a variance In actor-
dance
10.
with 15A NCAC 2C.0118
YIELD (gpm): / .2_ METHOD OF TEST
O
1
11.
WATER ZONES (depth): , j •j2= r.-
12. CHLORINATION: Type If Y- N Amount ;i It additional space is needed use back of form
13. CASING:
LOCATION SKETCH
Wall Thickness —'
Depth Diameter or Weignt/Ft. Material (Show direction and d'stance from at least two State
Roads, or other ma reference points)
From � Tom Ft. , ��i p P )
From To Ft.
From To Ft.
14. GROUT:
Depth
Material
Method
From C_ To .'1 t � Ft.
Ir i U - 2 r �
_
From To
Ft.
15. SCREEN:
Depth
Diameter Slot Size
Material
From —To—Ft—
in. —in.—
From _ To —Ft.
_
in. _
in.
From _ To _
Ft. _
In. _
in.
16. SAND/GRAVEL PACK:
Depth
Size
Material
From To
Ft.
From To
Ft.
17. REMAHK5: ,_. —
100 HEREBY CERTIFY THAT THIS WELL WAS COY OF THIS RECORD HASED IN BEENPROVIDED TO THE WELL OWNER.
CONSTRU
FOR OFFIC ONL
Quad No: SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Su nal to Division of water Quality, Groundwater Section within 30 days
GW-1 REV. 12J99
Serial No.

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:-, 4
WELL CONTRACTOR CERTIFICATION #: k•�i—- /`7(�
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable sox): Residential ❑ PAunicipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION:_ (Show sketch of the location below)
Nearest Town: County:
(Road Name and Numbers, Community, or Subovision and Lot No.) DRILLING LOG
3. OWNER �_ {1 { T � G II felt From To
Address _(I ;4-
75tree-t{�r oWe o.)
City or Town Slate Zip Coda
4. DATE DRILLED
5. TOTAL DEPTH-/'l-
6. CUTTINGS COLLECTED YES ❑ NOD---
7. DOES WELL REPLACE EXISTING WELL? YES NOED�
8. STATIC WATER LEVEL Below Top of Casing: i FT.
(Use'+' it Above Top of Casing)
9. TOP OF CASING ISFT. Above Land Surface'
'Top of casing terminated atlor below land surface requires a variance In accor-
dance with 15A NCAC 2C.0118
10.YIELD (gpm): Z METHOD OF TEST 12
11. WATER ZONES (depth): L `(2
12. CHLORINATION: Type i+ h14 ._Amount '/�, /ri
13. CASING:
Depth Diameter
From To /' -� � Ft. L
From To Ft.
From To Ft.
14. GROUT:
Agricultural ❑ Monitoring ❑
DEPTH
Formation Description
O
rS
c.�
if additional space is needed use back of form
Wan Thickness LO CAT-10 N i3KETC H
or WeighVFt. Material (Show direction and distance from at least two State
'!( — Pt Roads, or other map reference points)
Depth
Material
Method
From
To ILL Ft.
(r
From
To Ft.
15. SCREEN:
Depth Diameter Slot Size
Material
From _
To Ft
in. _
in.
From _
To Ft. _
in.
in.
From —To
Ft.
in.
in.
16. SAND/GRAVEL PACK:
Depth
Size
Material
From To Ft.
From To Ft.
17. REMARKS:
41 0
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS /BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE US Y J?
Quad No: TURE OF PERSON CONSTRUCTING THE WELL DATE
Submit on ivision of Water Ovality, Groundwater Section within 30 days
Serial No. N V b L11�0 GW-1 REV. 12/99
0
`:f

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section 1 J 9"
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: •tin 11 ' I) i )v I) r rl"� �1t C'
WELL CONTRACTOR CERTIFICATION #: -7
STATE WELL CONSTRUCTION PERMIT#:
1.
WELL USE (Check Applicable Box): Residential El- Municipal ❑
Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other M
If Other, List Use:
2.
WELL LOCATION: (Show sketch of the location below)
�1
Nearest Town:- ,/ ir' "Z"-"/'L- County:
(Road Name _and Numbers, Comaturlity, or Subdivision and Lot No.) c
/ S'f
DRILLING LOG DEPTH
3.
OWNER I ` 17/7 (c 1P 1`6_,
Its From To Formation Description
Address C?��1 I•rr 6x� �,T�;-vr 7r��,
(Sire or m o j--
iaflyer,', 22
�3L
City or Town Slate Zip Code
�-
4.
DATE DRILLED 4` - 1 3 - 1 2)
5.
TOTAL DEPTH L 2 `j
—'
6.
CUTTINGS COLLECTED YES ❑ NO❑/
o
7.
DOES WELL REPLACE EXISTING WELL? YES ❑ NOI
S.
STATIC WATER LEVEL Below Top of Casing: FL) FT.
CD -
(Use'+: it Above Top of Casing)
—I -
9.
TOP OF CASING IS FT. Above Land Surface*
-Top of casing terminated atlor below land surface requires a variance In accor-
dance with 15A NCAC 2C.0118
10. YIELD (gpm): METHOD OF TEST / l '
-�-- -.
11.
_,LL1_
WATER ZONES (depth):
12.
CHLORINATION: Type -Amount '�tT! F�
If additional space is needed use back of forma o
13.
CASING:
LOCATION SKETCH
Wall Thickness
Depth Diameter or Weight/Ft. Material
(Show direction and distance from at least two Slate
_ ,_„
`,
From To �7 FI. (,- .,— —'
Roads, or other map reference points)
From To Ft.
From To Ft.
14.
GROUT:
Depth Material Method
From L To • 2l" Ft. 0 r ,,yam ,a iP "'� I `
From To Ft. —
15.
SCREEN:
Depth Diameter Slot Size Material
From —To _ Ft _ in. _ in.
From —To _ Ft. — In. in.
From —To _ Ft._ In. —In.
16.
SAND/GRAVEL PACK:
Depth Size Material
From To —Ft. —
From To Ft.
17.
REMARKS:
I DO HERE B ONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUC S N RS, T Y OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE NLY
Quad No: '10 IGNATURE OF PERSON CONSTRUCTING THE WELL DATE
;V
Sub , pi to Division of Water Quality, Groundwater Section within :;O days
GW-1 REV. 12/99
Serial No.

North Carolina - Department of Environment and Natural Resources -Division of Water Oualiry -Groundwater Section 1 (1 [t J
Si C t . Raleigh N C 27699-1636-Phone [phone] J J
1636 Mail eN ce en er
WELL CONSTRUCTION RECORD WELL CONTRACTOR: ��P"It �z't)�
WELL CONTRACTOR CERTIFICATION p: ":' " ",/7(a
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (check Applicable Box): Residential ID Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other It Other, List Use: —,
2. WELL LOCATION: (Show sketch of the location below) �"?
Nearest Town: —,(I"��'tom-- , I County:. Ll
(Road Name and Numbers, Community, or Subdivision and Lot No.) DRILLING LOG
3. OWNER _J 1 1,-l n d � lFrom To
Address
beet or cute o. L
City or Town State Zip Code
4. DATE DRILLEDS. TOTAL DEPTH
6. CUTTINGS COLLECTED YES-
7. DOES WELL REPLACE EXISTING WELL? YES NO©�—
B. STATIC WATER LEVEL Below Top of Casing: I[! FT. —
(Use '+' it Above Top of Casing) _
9. TOP OF CASING ISFT. Above Land Surface* —
'Top of casing terminated atior below land surface requires a variance In accor.
dance with 15A NCAC 2C.0118
DOFTEST h/orl" I' % I'
DEPTH
Formation Description
10. YIELD (gpm): 4 METHO
11. WATER ZONES depth): ` — —
0
.i i fS CSl c.
12. CHLORINATION: Type �t t N Amount '� ' It additional space is needed use back of lorm =
s=-
13. CASING:
LOCATION SKETCH
Wall Thickness
Depth ''yDiameter or Weight/Fl. Material (Show direction and distance from at least two State
From To •-27 Ft. ( r Roads, or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From To
'-IL Ft..-i %' )-
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.
Slot Size Material
in.
in.
in.
Material
17. REMARKS:
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUANDTHAT 11SIb
OPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFIC DATE
Quad No: SIGNATURE OF PERSON CONSTRUCTING THE WELL
;. ,nat to Division of Water Quality, Groundwater Section Within 30 days GW 1 REV. 12/99
Serial No.

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section r 14
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: L--11 A-0 a W,I) III /I :) ,, -7/I c
WELL CONTRACTOR CERTIFICATION #: 4..—�'- /7G, J
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential ❑ Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: I f . i- I County: � I Cl (,, I _
(Road Name and Numbers, Community, or Subcivision and Lot No.)
3. OWNER C�r,(��.
Address,�--j /' ` hET.)
City or Town Slate zip Cod
4. DATE DRILLED (b'_J%- w
5. TOTAL DEPTH I'1",
6. CUTTINGS COLLECTED YES ❑ NO[3
7. DOES WELL REPLACE EXISTING WELL? YES NOF__j
8. STATIC WATER LEVEL Below Top of Casing:_ FT.
(Use '+' ii Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface'
'Top of casing terminated aVor below land surface requlres a variance In eccm-
dance with 15A NCAC 2C.0119
10. YIELD (gpm): V-C? METHOD OF TEST 'L_
11. WATER ZONES (depth): h` '
12. CHLORINATION: Type It y N _._Amount
13. CASING:
DRILLING LOG DEPTH
From To Formation Description
0
0
1
-
r
U
It additional space is needed use back of form
Wail Thickness LOCATION SKETCH
Depth Diameter or WeighUFt. Material (Show direction and distance from at least two State
From To 4- FL L ,!; � — r, % Roads, or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth
Material
Method
From To
Ft.
0 (n) .r
11", 1
From To
Ft.
-_
15. SCREEN:
Depth
Diameter Slot Size
Material
From To Ft
in. _
in.
From To Ft.
in.
in.
From To Ft.
in.
in.
16. SAND/GRAVEL PACK:
Depth
Size
Material
From To
Fl.
-
From To
Ft.
_
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A /COPY OF THIS RECORD HAS /BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY�'''�-
Quad No:
Serial No.
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Quality, Groundwater Section Within 30 days
GW-t REV. 12r99

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section ' ti U 46
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential ❑" Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: �) .)`I f' lti�' ,�1:. county:
(Road Name and Numbers. Community, or Subdivision and Lot No.)
3. OWNER
l /
Address c) '_`�-
jStreee qY Houle , o.
4 c, �r��.3
City or Town State Zip Code
4. DATE DRILLED L -�4` ' '
5. TOTAL DEPTH /.5 �'
6. CUTTINGS COLLECTED YES ❑ N00— _
7. DOES WELL REPLACE EXISTING WELL? YES [:] NOE�
S. STATIC WATER LEVEL Below Top of Casing: /4S FT.
(Use '+' if Above Top of Casing)
9. TOP OF CASING IS----/— FT. Above Land Surface'
*Top of casing terminated atior below land surface ruqulres a variance In accor.
dance with 16A NCAC 2C .0118
10. YIELD (gpm): -/ r? METHOD OF TEST
11. WATER ZONES (depth): h"I ,
12. CHLORINATION: Type t N ._Amount
13. CASING:
Agricultural ❑ Monitoring ❑
DRILLING LOG DEPTH
From To Formation Description
c�1 r
0
1
------------
_r
If additional space is needed use back of form
Wan Thickness LOCATION SKETCH
Depth/ Diameter or Weight/Ft. Material (Show direction and distance from at least two State
From To "' Ft. —iC L ' %' f Roads, or other map reference points)
From To Ft.
From To Ft. ..
14. GROUT:
Depth Material Method
From L To .�) L Ft. l)�_
From To Ft. _
15. SCREEN:
Depth Diameter
From —To—Ft— in
From To —Ft. in
From To _ Ft._ in
16. SAND/GRAVEL PACK:
Depth Size
From To Ft. —
From To Ft. _
17. REMARKS:
Slot Size Material
_ in.
in.
in.
Material
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Quad No:
Serial No.
-'3O — 'IfLr
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit original 10 Division of Water Quality, Groundwater Section withir 30 days
GW-1 REV. 12199

North Carolina - Department of Environment and Natural Resources •Division of Water Duality -Groundwater Section
0 145
I ' h N C 27699-1636-Phone [phone]
1636 Mail Service Center - Ra erg \
WELL CONSTRUCTION RECORD WELL CONTRACTOR: ��ZiC,
_!' 1 5 2 I )'
t /)III F)s' /I >�
WELL CONTRACTOR CERTIFICATION N: �-�'•'� y7(�
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential F/ I' Municipal ❑ Industrial ❑ F,gricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other If Other, List Use: —,
2. WELL LOCATION;:,(Show sketch of the lo,alion below)
Nearest Town: I r/'4 h I "" ' �� L, County: .
(Road Name and Numbers. Community, or Subdivision and Lot No.) DRILLING LOG
3. OWNER (A-� ^L f i i:�,, i From To
Address;--
\ trees or cuto o. a . �,
City or Town State
4. DATE DRILLED I- ' c 1L'
5. TOTAL DEPTH .i<%.S 1
6. CUTTINGS COLLECTED YES ❑ NO©�
7. DOES WELL REPLACE EXISTING WELL; YES NOM
8. STATIC WATER LEVEL Below TOP of Casing: zl�­, FT. _—
,Jsj 'i it Above Top of Casing)
9. TOP OF CASING IS---/— f=T. Above Land Surface' - -
-Top of casing terminated at/or below land surface requires a variance In accor-
dance with 15A NCAC 2C .0118
DEPTH
Fonnation Description
ra
-'
------------
c�
10. YIELD (gpm): 44r — METHOD OF
//'�,' G' u
11. WATER ZONES (depth):
12. CHLORINATION: Type 11 t N Amount �� rt if additional space is needed use back of tom -+
13, CASING:
LOCATION SKETCH
Wall Thickness
Depth Diameter or Weight/Fl. Material (Show direction and distance from at least two Slate
From L, To Ft. �% -- ' 1.4 [ " P I L Roads, or other map reference points)
From To Ft.
-
From To Ft.
14. GROUT
Depth
Material
Method
From
To 1.Li ^
Ft.i—L—
From _—
To
FL
—.--
---
15. SCREEN:
Depth Diametor
Slot Size
Material
From _
To — Ft
_.
in. —in.-
From —To
—Ft.
_
in. —
in.
From _
To _. Ft.
_
in. _
in.
16. SAND/GRAVEL PACK:
Depth
Size
Material
From
To —Ft.
-
From
To
Ft.
17. REMARKS:
—
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS %BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY GATE
Quad No: SIGNATURE OF PERSON CONSTRUCTING THE WELL
Submit original to Division of Water Quality, Groundwater Section within 30 days Gw-1 REV. 12199
Serial No.

North Carolina • Department of Environment and1636-Phone [phone]n of Water Quality - Groundwater Section
( 144
1636 Mail Service Center - Raleigh, N.C. 27699- (f i I I . .�.� -T/7 C l
WELL CONSTRUCTION RECORD WELL CONTRACTOR: (RTI 5 ��z f) t F) t. 71,
/ I ;)-
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERI.IIT#:
- ❑ Agricultural El Monitoring
❑
1, WELL USE (Check Applicable Box): Residential 0� Municipal ❑ Industrial
Recovery ❑ Heat Pump Water Injection ❑ Other If Other, List Use: -
2. WELL LOCATION: (.Show sketcl- of the location below)
county:Nearest Town:
DRILLING LOG.
(Road Name and Numbers. Community, or Subdivision and Lot No.) From
- ).l From To
3. OWNER
Address ILL
-
Sueet
1 ✓, f �kJ A'r a
City or Tawn
State Zip Cod
4. DATE DRILLED - Zr
5. TOTAL DEPTH S
6. CUTTINGS COLLECTED YES ❑ NO©�
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO© -
8. STATIC WATER LEVEL Below Top of Casing: - sT-= FT.
(Use '.• it Above Top of Casing) .--
9. TOP OF CASING ISFT. Above Land Surface'
'Top of casing terminated at/or below land surface requires a variance In accor-
dance with 15A NCAC 2C .011 a
10. YIELD (gpm): /,Q— METHOD OF TEST L' ' 1' -
11. WATER ZONES (depth):
12. CHLORINATION: Type t i L- / Amount 'fit n
DEPTH --
Formation Description
o_ --------------------------
-
o
It additional spaces is needed use back of forte r:
13. CASING: LO(. ATION SKETCH
Wall Thickness
Material (Show direction and distance from at least two Slate
Depth Diameter or Weight/Ft.
From
To Ft. (-- r " t Roads, or other map reference points)
From To Ft,
From To Ft.
14. GROUT:
Depth Material Method
From - C . To 1i` Ft. Ct i ; i,, --I
From To Ft. -- --""
15. SCREEN:
Depth Diameter Slot Size Material
From —To—Ft— in. _ in.
From _ To — Ft. — in. _ in.
From _ To __ Ft. _- in. — in.
16. SAND/GRAVEL PACK: Si Matedal
Depth Size
From To —Ft. —
From To Ft'
17. REMAHIcb: -
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.
d c
FOR OFFICE USE ONLY �� % -
DATE
SIGNATURE OF PERSON CONSTRUCTING THE W ELL
Quad No:
$UDmil original to Division of Water Quality, Groundwater Section Within 30 days GW 1 REV. 12/99
Serial No.

North Carolina - Department of Environment and Natural Resources - Division of Water Duality - Groundwater Section r,,. 0 1 4 3
C 27699-1636-Phone [phone]
1636 Mail Service Center - Raleigh, N.
WELL CONSTRUCTION RECORD WELL CONTRACTOR: L WELL CONTRACTOR CERTI�FICA 0)V#:I
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (check Applicable sox): Residential 0� Municipal ❑
Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: I- ) 41 L i /✓ L County:
(Road Name a/nd� Numbers, Community, or Subdivision and Lot No.) DRILLING LOG
3. OWNER { 1 i, I c� ; e t ll �0"inSiT1 n From To
Address (�, ` of
—jSueet or onto o. ,�� l/ _
��IJ41 jC ( +✓ / L ! Zi Code
City or Town Scale D
4. DATE DRILLED — CZ I
5. TOTAL DEPTH •-2r' S '
6. CUTTINGS COLLECTED YES ❑ NO[D�
7. DOES WELL REPLACE EXISTIN', WELL? YES ❑ NO©, —
8. STATIC WATER LEVEL Below -"op of Casing: �41-_) FT. —
'Use'r' it Above Top of Casing) _-
9. TOP OF CASING ISFT. Above Land Surface- _
-Top of casing terminated atfor below land surface requires a variance In actor•
dance with 15A NCAC 2C .g118
10. YIELD (gpm): METHOD OF TEST h/o''
11. WATER ZONES (depth):
DEPTH
Formation Description
tV
12. CHLORINATION: Type /t t 14 Amount ' t r' It additional space Is needed use back of form
13. CASING:
Wall Thickness
Depth Diameter or Weight/Ft. Maf 1 tedal
From
To t"2 Ft. L" , /h t
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From To '- i� Ft. Cf(',21 _ I ,
From -- Tc FL -- ----
15. SCREEN:
Depth Diameter Slot Size Material
From _ To _ Ft in. —in.-
From _To Ft.— in. —in.
From _. To _ Ft. _ In. _. in.
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
17
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY
Y OF THIS RECORD HAS BEEN PROVIDED TO THE WELL 7WNER.
FOR OFFICE USE ONLY
Quad No:
Serial No.
SIGNATURE OF PERSON CONSTRUCTING THE WELL
Submit original to Divislon of Water Quality, Groundwater Section within 30 days
DATE
GW1 REV. 12/99

North Carolina - Department of Environment and Natural Resources -Division or Water Quality •Groundwater Section _'� Q O O O 6
1636 Mail Service Center - Raleigh, N.C. 27699.1636-Phone [phone] _ v
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: T I � - I '('t - County:
(Road Name and Numbers. Commu ity, or Subdivision and Lot No
3. OWNER �� r`It n I'Z"
Address -7 rv,
.(Street or KOUIO o.
City or Town State Zip Code
4. DATE DRILLED
S. TOTAL DEPTH
6. CUTTINGS COLLECTED YESQ NO[Ii-
7. DOES WELL REPLACE EXISTING WELL? YES NO©
B. STATIC WATER LEVEL Below Top of Casing: —i FT.
(Use -: it Above Top of Casing)
9. TOP OF CASING IS itFT. Above Land Surface'
-Top of casing terminated at/or below land surface requires a variance in accor-
dance with 15A NCAC 2C.0118
10. YIELD (gpm): /0 METHOD OF TEST 1112011,11
11. WATER ZONES (depth): ­D -
Agricultural ❑ Monitoring ❑
DRILLING LOG DEPTH
From To Formation Description
12. CHLORINATION: Type t t t`4 _ Amount ^ 4 / 6 If additional space is needed use back of form
13. CASING:
Wall Thickness
Depth _ Diameter or Weight/Ft. Material
From C 70 � FL /r,. —&V—
From To Ft.
From To Ft.=-
14. GROUT:
Depth Material Method
From To LI, FL 0 rbo, �' n
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From —To—Ft— in. —in.-
From —To _ Ft. _ in. _ In.
From _ To _ Ft. _ In. —in.
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
17. REMARKS: -
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY ^ ' '` �kcl+(+�
Quad No:
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Quality, Groundwater Section within 30 days GW 1 REV. 12199
Serial No.

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section ', 18087
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: t t, r, g I t 02 I f �` r l �" C'
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMIT#:
Municipal ❑ Industrial ❑
Agricultural ❑ Monitoring ❑
1.
WELL USE (Check Applicable sox): Residential
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2,
WELL LOCATION: JShow sketch of the location below)
-
Nearest Town: County: 1
(Road Name and Numbers, Community, or Subdivision and Lot No.) DRILLING LOG
DEPTH
3.
OWNER - - From To
Formation Description
Address 'T5 / /r , C /Z
beet or Rout-o.
l-' i ) 11
—
Cily or Town State Zip Code
O =
4.
DATE DRILLED
- - _
5.
TOTAL DEPTH
n
6.
CUTTINGS COLLECTED YES ❑ NO0--
Q _
7.
DOES WELL REPLACE EXISTING WELL? YES ❑ NOQ--
6.
STATIC WATER LEVEL Below Top of Casing: _ i? FT.
- (Use 'r' II Above Top of Casing)
�O `\-
9.
TOP OF CASING IS FT. Above Land Surface'
-Top of casing terminated at/or below land surface requires a variance In accor-
dance
10.
with 15A NCAC 2C .0118
YIELD (gpm): 0_ METHOD OF TEST /2/0?0,12
-
11.
WATER ZONES (depth):
12. CHLORINATION: Type t t /-! —Amount ' If additional space is needed use back of form
13. CASING:
LOCATION SKETCH
Wall Thickness
Depth � Diameter arweighVFt. Material (Show direction and distance from at least two State
From C To 2 S Ft. L Roads, or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From To ,;Lid Ft. (r��� �. i 17s1i
From To Ft. _
15. SCREEN:
Depth Diameter Slot Size Material
From To _ Ft _ in. —in.
From —To —Ft. _ in. — In.
From _To _ Ft. — In. — in.
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
17
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Quad No:
Serial No.
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Quality, Groundwater Section within 30 days GW 1 REV. 12/99

North Carolina -Department of Environment and Natural Resources -Division of Water Quality -Groundwater Section c-.,
1636 Mail Service Center. Raleigh, N.C. 27699.1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
ELL CONTRACTOR CERTIFICATION -JZZk a
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch o1 the location below)
Nearest Town: i I ,i ;, I , County:
(Road Name and Numbers. Community, or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER x/ t From To Formation Description
Address
tree, or moulu o.
City or Town r State Zip Code
4. DATE DRILLED-
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑ NO�� CD
7. DOES WELL REPLACE EXISTING WELL? YES NOQ-
8. STATIC WATER LEVEL Below Top of Casing: FT. r 1
(Use'✓ It Above Top of Casing) 4 - -_
9. TOP OF CASING IS FT. Above Land Surface' �0
Top of casing terminated atlor below land surface requires a variance In actor.
dance with 15A NCAC 2C .0118 fir:
10. YIELD (gpm): METHOD OF TEST
11. WATER ZONES (depth): ry
12. CHLORINATION: Type t )'14 —Amount 'A41ri If additional space is needed use back of form .-
13. CASING:
LOCATION SKETCH
Wall Thickness
Depth Diameter or WeightJFt. Material (Show direction and distance from at least two State
From C To Ft. It . I Roads, or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From To L, Ft. (1 r'121
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From —To—Ft _ in. —in.—
From —To —. Ft..— In. _ in.
From —To —Ft. _ in. — in.
16. SAND/GRAVEL PACK:
Depth Size Material
From To - Ft. From To Ft.
17
D W R
Groundwater Section
tle"Wille R 'final pfrice
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Quad No:
Serial No..
SIGNATURE OF PERSON CONSTRUCTING THE WELL
Submit original to Division of Water Quality, Groundwater Section Within 30 days
DATE
GW-1 REV. 12/99

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section A, O $ 9
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: I, i1 4i I )' > Wg I I D"� �" c
WELL CONTRACTOR CERTIFICATION #: yay
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check applicable sox): Residential Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below) 01
Nearest Town: f(i.ar �� �' f-' �'� - - County:
(Road Name and Numbers, Community, or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER �'�! /vi:'f sir !.'/��>": ,� From To Formation Description
Address � J� //� iiJ k
«eet or out o.
City or Town State Zip Code
4. DATE DRILLED
5. TOTAL DEPTH-nn
6. CUTTINGS COLLECTED YES ❑ NOE]!
7. DOES WELL REPLACE EXISTING WELL? YES NO
8. STATIC WATER LEVEL Below Top of Casing: ,,-� 42 FT.
(Use's If Above Top of Casing) 1
9. TOP OF CASING IS FT. Above Land Surface' a
'Top of casing terminated at/or below land surface requires a variance In accor-
dance with 15A NCAC 2C.0118 '
10. YIELD (gpm): I METHOD OF TEST r _
Y r;.
11. WATER ZONES (depth): v
c;
12. CHLORINATION: Type t t J4 _Amount 04 16 It additional space is needed use back of fo m --�
13. CASING:
LOCATION SKETCH
Wall Thickness
Depths Diameter or WeighVFt. Material (Show direction and distance from at least two Slate
t—
From (� To ` L Ft. L-- ' Roads, or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth
Material
Method
From To yai`
Ft.
�
From To
Ft.
15. SCREEN:
Depth Diameter
Slot Size
Material
From _ To _. Ft
_
in. —in.—
From _ To _ Ft.
_
in. —
In.
From —To _ Ft.
In. _
in.
16. SAND/GRAVEL PACK:
Depth
Size
Material
From To —Ft.
—
From To
Ft.
17. REMARKS:_
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
�lp ai t f � r n "7 /t ��� i
FOR OFFICE USE ONLY DATE
Quad No: SIGNATURE OF PERSON CONSTRUCTING THE WELL
Submit original to Division of Water Quality, Groundwater Section Within 30 days GW-1 REV. 12199
Serial No.

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section 4_I g 4 51
1636 Mail Service Center - Raleigh, N.C. 27699.1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: �of"1 n � ' f) rn'� WO 11 �1 r1 r1 e C
WELL CONTRACTOR CERTIFICATION N:
STATE WELL CONSTRUCTION PERMITN:
1.
WELL USE (Check Applicable Box): Resl&:ntial Municipal ❑
Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injaclicn ❑ Other ❑
If Other, List Use:
2.
WELL LOCATION: (Show sketch of the location below)
Nearest Town: 0 ff7) A/ County:
(Road Name and Numbers, Community, or Subdivision and Lot No.)
DRILLING LOG DEPTH
3.
OWNER A 1l1 f(,.y ] rv�n i
From To Fomtaion Descriptlon
Address JrIS . Od
o10.
trees or outs o.
r� j Z/L 4.
4.
City or Town State Zip Co e
DATE DRILLED
5.
TOTAL DEPTH .-2 7
6.
CUTTINGS COLLECTED YES[::] NOQ�
7.
DOES WELL REPLACE EXISTING WELL? YES F�f-1 NO[ZZ-
8.
STATIC WATER LEVEL Below Top of Casing:Y(/1 FT.
(Use'+' if Above Top of Casing)
9.
TOP OF CASING IS FT. Above Land Surface'
'Top
of casing terminated aVor below land surface requires a variance In accor.
dance
10.
with 15A NCAC 2C.0118
YIELD (gpm): _ METH OF TL-ST Y m r 1 '
11.
WATER ZONES (depth): "�
12.
CHLORINATION: Type f 14 Amount 'fir
If additional space is needed use back of form
13.
CASING:
LOCATION SKETCH
Depth
Wall Thickness
Diameter or Weight/Ft. Material
(Show direction and distance from at least two Slate
From
C,� To 4
Ft. (r , , 1�" 1, P 6/ 0 .
Roads, or other map reference points)
From
To
Ft.
From
To
Ft.
14. GROUT:
Depth
Material Method
C:)
From
To ,1\
Ft. 0 r'" = ,E� P ?I 1�
o
c�
From
To
Ft.
15. SCREEN
Depth Diameter
From —To _ Ft _ in,
From _ To — Ft. _ in.
From To Ft. — In.
16. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To Ft. _.
17. REMARKS:
I DO HEREBY CE
CONSTRUCTION
FFORd OFFICE USE O JWJ IQuaNo: r i
Slot Size Material
in.
_ in.
in.
Material
RUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
1,hn61%1?, l / _
OF PERSON CONSTRUCTING THE WELL
of Water Quality. Groundwater Section Within 30 days
CD
J
DATE
OW-1 REV. 12199
Serial No.

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section i_ 1 8 �) J 0
1636 Mail Service Center - Raleigh, N.C. 27695-1636-Phone [phone] :J `f
WELL CONSTRUCTION RECORD WELL CONTRACTOR: l r'n 5 i+rii . lmjo+) fir. 1 "C'
WELL CONTRACTOR CERTIFICATION #: *,----f-J •� /`7/c
STATE WELL CONSTRUCTION PERMIT#:
i
1. WELL USE (Check Applicable Box): Residential ❑Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION• Show sketch of the location below)
Nearest Town: «/J / County:
(Road Name an umbers, Commum or Subdivision and Lot No.) DRILLING LOG
3. OWNER 7w�''1'-Cr-t---,-'- From To
Address
CC// ee (street or oouts o. Cu 0 0. r L. % 1) • i2 c�
%0
City or Town _ Stale Zip Code
4. DATE DRILLED
5. TOTAL DEPTH /7
6. CUTTINGS COLLECTED YES ❑ NO0--
7. DOES WELL REPLACE EXISTING WELL? YES NO©/
8. STATIC WATER LEVEL Below Top of Casing: _�c� FT.
(Use': it Above Top of Casing)
9. TOP OF CASING IS ' FT. Above Land Surface'
-Top of casing terminated at/or below land surface requires a variance In accor-
dance with 15A NCAC 2C .0118
10. YIELD (gpm): I METHODOFTEST Lit/i- "1 /'
11. WATER ZONES (depth): 70 r
Agricultural ❑ Monitoring ❑
DEPTH
Fom:ation Description
12. CHLORINATION: Type If t N Amount t' If additional space is needed use back of form
13. CASING:
Depth? Diameter
From C To. Ft.
From To Ft.
From To Ft.
14. GROUT:
LOCATION SKETCH
W ali Thickness
or WeighVFt. Material (Show direction and distance from at least two State
-f' P 7 Roads, or other map reference points)
Depth Material Method
From V To .:)L' Ft. ni n'"1r,1 `—
From To Ft.
15. SCREEN
Depth Diameter
From To _ Ft _ in.
From _ To _ Ft. _ in.
From To —Ft. — in.
16. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To Ft.
17. REMARKS:
I DO HEREBY
FOR OFFICE
Quad No:
Serial No.
Slot Size Material
_ in.
in.
in.
Submit
Material
CD
J
TRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
F THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
IATURE OF PERSON CONSTRUCTING THE WELL DATE
Division of Water Quality, Groundwater Section within 30 days
GW-I REV. 12199
',•n

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section I. i O ^ ^ 9(�
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone] 'J `f `Y
WELL CONSTRUCTION RECORD WELL CONTRACTOR: c'%Pt In, 5 ��r J) 3 ll'? I1 L/I rl�_ < Tit ( ,
WELL CONTRACTOR CERTIFICATION #: /7/�,
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): ResidentialD- Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: � � >Q/W - County: / %CI Ltl- i
(Road Name and Numbers. Community, or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER cec : ly1 : q- From To Formation Description
Address (v Le A
�(Street or Route M,)
�/An Q�0, �-2 L17 6 _3
City or Town State Zip Code
4. DATE DRILLED �'sa�- cd
5. TOTAL DEPTH ^i/) 0
6. CUTTINGS COLLECTED YES M NOES
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NOD
S. STATIC WATER LEVEL Below Top of Casing: FT.
(Use '+' if Above Top of Casing)
9. TOP OF CASING ISt_ FT. Above Land Surface'
'Top of casing terminated at/or below land surface requires a variance In accor.
dance with 15A NCAC 2C.0118
10. YIELD (gpm): - METHOD OFTEST 1212011,21
11. WATER ZONES (depth): -3 70
12. CHLORINATION: Type 11 N Amount 'Al 16 If additional space is needed use back of form
13. CASING:
C DepthDiameter From To Ft. —_
From To Ft. -
From To Ft.
14. GROUT:
Walt Thickness LOCATION SKETCH
or Weight/Ft. Material (Show direction and distance from at least two State
r /1, L' 1L2— Roads, or other map referance points)
Depth Material Method
From To Ft. (1 /'011
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 Ta Ft.
17. REMARKS:
Slot Size Material
_ in.
in.
in.
Material
CD
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2..C, WELL
CONSTRUCTION TAKIDARQS AN A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WEELL'L OWNER.
FOR OFFICE USE - ^'r r / '" Z-Z)
Quad No: TURE OF PERSON CONSTRUCTING THE WELL DATE
- Sub ongi ivislon of Water Quality, Groundwater Section within 30 days
Serial No. I' f GW-1 REV. 12199

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section i 8 4 4 8
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: IiEl I n1 5 )4' LLB > �I )' I I L L
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (check Applicable Box): Residential ❑/nicipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town:(�) H/' /' C— Counry:.
(Road Name andfumbers, Community, or Subdivision and Lot No.) DRILLING LOG
3. OWNER ) e//a ,)/)3: A—, From To
Address _
(street or Houle 0.
City or Town 3 Stale Zip Code
4. DATE DRILLED ! . �) (^ —L"Z
S. TOTAL DEPTH • 20 `-
6. CUTTINGS COLLECTED YES[] NOEJ--
7. DOES WELL REPLACE EXISTING WELL? YES NO
B. STATIC WATER LEVEL Below Top of Casing: i- FT.
(Use -+' if Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface'
-Top of casing terminated et/or below land surface requires a variance In accor-
dance with 15A NCAC 2C .0118
10. YIELD (gpm): r - METHOD OF TEST hblli' • 7
11. WATER ZONES (depth): Sn
Agricultural ❑ Monitoring ❑
DEPTH
Formation Description
12. CHLORINATION: Type H t 14 —Amount ' f If additional space is needed use back of form
13. CASING:
Depth Diameter
From L To c r Ft. "
From To Ft.
From To Ft.
14. GROUT:
Wall Thickness LOCATION SKETCH
or Weight/Fl. Material (Show direction and distance from at least two Slate
r /kt, Roads, or other map reference points)
Depth Material Method
From V To 2-1 Ft. R r o, 1a n,
From To Ft.
15. SCREEN:
Depth Diameter
From To _ Ft _ in.
From To —Ft. _ in.
From _ To _ Ft. — in.
16. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To Ft.
17. REMARKS:
Slot Size Material
in.
in.
_ in.
Material
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER,
C`
FOR OFFICE USE 0 vol" 4 r " / - ?
Quad No: S RE OF PERSON CONSTRUCTING THE WELL DATE
_Subr; M final i Ion of Water Quality, Groundwater Section Within 30 days
Y�I'I'
Serial No. GW-1 REV. 12/99
-'

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section 4 8447
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: I'lt1 t1, `, 14• 1) A it j9 11 Lit-, rl >� -TJ1 C'
WELL CONTRACTOR CERTIFICATION #: <:4-� -7
STATE WELL CONSTRUCTION PERMIT.p:
1. WELL USE (Check Applicable sox): Residential LLB Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ OtherEj If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: l'il nl �' ) A- r - County: ��� �-r i � 1 ti7
- (Road Name and Numbers, Community, or Subdivision and Lot No.) DRILLING LOG
3. OWNER I"ill1? From To
Address—
jWreetof to o.
ityor Town State Zip Code
4. DATE DRILLED Z
5. TOTAL DEPTH / ' 7 S
6. CUTTINGS COLLECTED YES [D NOE]-
7. DOES WELL REPLACE EXISTING WELL? YES NOM-
8. STATIC WATER LEVEL Below Top of Casing: �n FT.
(Use'+' if Above Top of Casing(
9. TOP OF CASING IS FT. Above Land Surface'
-Top of casing terminated atlor below land surface requires a variance In accor-
dance with i 6A NCAC 2C .0118
10. YIELD (gpm): S ?_ METHOD OF TEST '/'
11. WATER ZONES (depth): '/2 ' / `/ c'
Agricultural ❑ Monitoring ❑
DEPTH
Formation Description
12. CHLORINATION: Type L f N _Amount ` n It additional space is needed use back of form
13. CASING:
Wall Thickness LOCATION SKETCH
Depth Diameter or Weight/Ft. Material (Show direction and distance from at least two State
From L To 7) Ft. —(t— ' (- f ' Pi Roads, or other map reference points)
From To Ft.
From To Ft. _
14. GROUT:
Depth Material Method
From To ,0j1 Ft. r'^;i 1L_ n
From To Ft.
15. SCREEN
Depth Diameter Slot Size
From —To—Ft— in.
From To Ft. _ in.
From _ To _ Ft. _ In. _
16. SAND/GRAVEL PACK:
Depth Size
From To Ft. —
From To Ft. _
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL W,
_ t
ae.. a. Iflltlly
Material
in.
in.
In.
Material
9UCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
0
0
0
C-D
—1
I
CD
J
TURE OF PERSON CONSTRUCTING THE WELL DATE
vision of Water Quality, Groundwater Section within 30 days
Serial No.
GW-1 REV. 12/99

North Carolina - Department of Environment anti Natural Resources - Division of Water Quality - Groundwater Section 2 18 4 4 U
^
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: cr1 n 5 !) f'' I I t r I �i1 C,
WELL CONTRACTOR CERTIFICATION #: -7
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable sox): Residential f- Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: I'1 �1 ��4' I � , A'("_ County: 'L) i Q C cz, i
Agricultural ❑ Monitoring ❑
(Road Name and Numbers, Community, or Subdivision an Lot No.) DRILLING LOG DEPTH
3. OWNER LJ I (� r2nn d �{ O Q,.- From To Formation Description
Address
(Street or oute o.
_%'.a t- I N c—
City or Town State Zip Code
4. DATE DRILLED C7i-.17 o%_')
5. TOTAL DEPTH ••=; �/5
6. CUTTINGS COLLECTED YESQ NOQ
7. DOES WELL REPLACE EXISTING WELL? YES NO©�
8. STATIC WATER LEVEL Below Top of Casing: /0 FT.
(Use'+' it Above Top of Casing)
9. TOP OF CASING IS ' FT. Above Land Surface -
'Top of casing terminated atlor below land surface requires a variance In accor-
dance with 15A NCAC 2C .0118
10. YIELD (gpm): 5 G METHOD OF TEST LVOV 1, "' I'
11. WATER ZONES (depth):
12. CHLORINATION: Type ft f N Amount —:fir It additional space is needed use back of form
13. CASING:
LOCATION SKETCH
Wall Thickness
Depth
Diameter or WeighVFl. Material
(Show direction and distance from at least two State
From
(, To L-2L
Ft. L . , — ' �`"' '!
Roads, or other map reference points)
From
To
Ft. —
From
To
Ft.-- —
14. GROUT:
o
Depth
Material Method
o
From
To 2ttL
Ft. 0C,;1, 71
From
To
Ft.
i
15. SCREEN
Depth Diameter
From _ To _ Ft _ in.
From To _ Ft. _ in.
From _ To —Ft.— in.
15. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To Ft.
17. REMARKS:
Quad No:
Serial No.
Slot Size Material
In. _
_ in.
0
_ in. �
Material
kS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 20, WELL
COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
original to Division of Water Quality, Groundwater Section within 30 days
GW-1 REV. 12l99

r
'r_-9
North Carolina • Department of Environment and Natural Resources •Division of Water Duality -Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699.1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: lel'111 f IL f I � � I r � ' ' C,
WELL CONTRACTOR CERTIFICATION#: •�y7�a
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (check Applicable Box): Residential D- Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION,: (Show sketch of the location below)
Nearest Town: "� �"r .. f< I,v� i'. County: thud d
(Road Name and Numbers, Comrmunity, or Subdivision and Lot No.) DRILLING LOG
3. OWNER %�< C-� —�c�/xc!-!' From To
Address-1 �- ���� l,, le-rtn//
(Slreetor outs o� 3 V
City or Town State Zip Code
4. DATE DRILLED
5. TOTAL DEPTH
6. CUTT ING S COLLECTED YES❑ NOE]--
7. DOES WELL REPLACE EXISTING WELL? YES NO
S. STATIC WATER LEVEL Below Top of Casing: 1,fe) FT.
(Use'+' It Above Top of Casing)
9. TOP OF CASING ISM_ FT. Above Land Surface'
Top of casing terminated allor below land surface requlres a variance In accor.
dance with 15A NCAC 2C -Q71p.
10. YIELD (gpm): a - METHOD OF TEST
11. WATER ZONES (depth): r
Agricultural ❑ Monitoring ❑
DEPTH
Formation Description
N
r
w
--,
12. CHLORINATION: Type H t N —Amount r/4 16 If additional space is needed use back of form
13. CASING:
LOCATION SKETCH
Wall Thickness
Depth Z Diameter or Weight/R. Material (Show direction and distance from at least two Slate
From L� To f '�—Ft. — — v P Roads, or other map reference points)
From To Ft.
From To Ft.
14, GROUT:
Depth Material Method
From To ,OL Ft. (7r'�>1 r-�� P
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From —To—Ft— in. —in.—
From —To —Ft. _ in. in.
From _To Ft. — In. —in.
16. SAND/GRAVEL PACK:
Depth Size Material
17
From To Ft.
From To - Ft.
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Quad No: ti `P
Serial No.
SIGNATURE OF PERSON CONSTROCTING THE WELL
Su"toffgihal to Division of Water Quality, Groundwater Section within 30 days
DATE
GW.1 REV. 12/99

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section ti 1 rf (1
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone] ( J
WELL CONSTRUCTION RECORD WELL CONTRACTOR: I� I) ^ 3
WELL CONTRACTOR CERTIFICATION #: .=� 7C
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential [D__�Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
�/ t! "' � County: GZ ( c"7l
Nearest Town:�hr C^
(Road Name and Numbers, Community, or Subdivisiond Lot No.)
3. OWNER ` , t ':-�-h Ci �,In a
Address
(greet or bide p
City or Town State Zip Cod
4. DATE DRILLED
5. TOTAL DEPTH r'%L
6. CUTTINGS COLLECTED YES ❑ NO©i-
7. DOES WELL REPLACE EXISTING WELL? YES [] NOF_�
S. STATIC WATER LEVEL Below Top of Casing: �(_ FT.
(Use': If Above Tcp of Casing)
9. TOP OF CASING IS FT. Above Land Surface'
-Top of casing terminated at/or below land surface requires a variance In accor-
dance with 16A NCAC 2C-.e118 _
10 YIELD (gpm)' y METHOD OF TEST /2)"1�r- f'
Agricultural ❑ Monitoring ❑
DRILLING LOG DEPTH
From To Formation Description
o_
C/n
11. WATER ZONES (depth):--t
_ lid
12. CHLORINATION: Type lit 14 .--Amount r�t� �' If additional space is needed use back of form r' �
13. CASING:
LOCATION SKETCH
Wall Thickness
Depth l Diameter or WeighVFt. Material (Show direction and distance from at least two Slate
From (� To `�- Ft. if • ' rs" f r Roads, or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From L To Q L Ft. 0 1-1')-`---�—
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From —To—Ft— in. — in.
From —To _ Ft. — In. in.
From —To _ Ft.— in. in.
16. SAND/GRAVEL PACK:
17
Depth Size Material
From To Ft. From To Ft._ _-
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY '"
Quad No: I �,I?(jf1, SIC
T }ffi�inal!I
Serial No.
OF PERSON CONSTRUCTING THE WELL DATE
of 'Nater Quality, Groundwater Section within 30 days
GW-1 REV. 12/99

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section I
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone] II 62 i
WELL CONSTRUCTION RECORD WELL CONTRACTOR:.tir ' �h' f) f) i7C L.?
WELL CONTRACTOR CERTIFICATION p:
STATE WELL CONSTRUCTION PERMITA:
1. WELL USE (check Applicable li Residential ❑/nicipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION,- (Show sketch of the location below)
Nearest Town: �' �� ZI' r �� County:-
(Road Name and Numbers, Community, or Subdivision and Lot No.) DRILLING LOG
3. OWNER LA Y Ra From To
Address
i q (Streal or cute o.
City or Town State Zip Cod
4. DATE DRILLED 4-
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES I::] NO©--
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NOM/
8. STATIC WATER LEVEL Below Top of Casing: j S FT.
(Use'+' if Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface'
'Top of casing terminated aVor below land surface requires a variance In accor-
dance with 15A NCAC 2C 4118
10. YIELD (gpni METHOD OF TEST L),711r0
11. WATER ZONES (depth):
DEPTH
Formation Descnption
u
N
12. CHLORINATION: Type t t N "_Amount '/tr I: additional space is needed use back of form
13. CASING:
LOCATION SKETCH
Wall Thickness
Depth Diameter or WeignVFL Material (Show di(ection and distance from at least two Slate
From �� To Ft. L' ' /� V .j'-4.Gi- Roads, or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From To Z L Ft.
From To Ft. _.
15.SCREEN:
Depth Diameter Slot Size Material
From _ To _ Ft _ in. in.
From —To —Ft. — in. in.
From —To _ Ft. _ In. in.
16. SAND/GRAVEL PACK:
Depth Size Malarial
From To Ft. —.—
From To Ft. _.-
17. REMARKS:
I DO HEREBY CERTI
CONSTRUCTION ST
FOR OFFICE USE ONLY•,
Quad No: SEP 1 8 )D[_IGI
Submit Original 10
Serial No.
9UCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
O——
OF PERRSONSON CONSTRUCTING THE WELL DATE
of Water Quality. Groundwater Section Within 30 days
GW1 REV. 12/99

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section L i 7 7 J
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: .(1-Qn, �Ir 1 nz, A 01011 /1a,, T,1c,
WELL CONTRACTOR CERTIFICATION #: /-7
STATE WELL CONSTRUCTION PERMIT#:
1.
WELL USE (check Applicable Box): Residential 0- Municipal ❑
Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other If
Other, List Use:
2.
WELL LOCATION: (Show sketch of the location below)
Nearest Town: t"Y' 9 <, V I ->, ( _ County: m
<'r- r- J
(Road Name and Numbers, Community, or Subdivision and Lot No.)
DRILLING LOG DEPTH '
3.
OWNER _f'1 04.t
From To Formation Description
Address `E �). S
(5treet or houlp 0.)'1 /7 J /
4.
City or Town fate Zip Code
DATE DRILLED 2- -GZ "
5.
.
TOTAL DEPTH <G0e)
-
6.
CUTTINGS COLLECTED YES ❑ NOE�-"
c
7.
DOES WELL REPLACE EXISTING'WELL7 YES ❑ NOQ
to =
S.
STATIC WATER LEVEL Below Top of Casing: /D FT.
_
(Use': If Above Top of Casing)
- �-
9.
TOP OF CASING IS FT. Above Land Surface-
-- -•
'Top of casing terminated st/or below land surface requires a variance In accor-
—7 r_-,, 7
dance
10.
with 19A NCAC 2C.0118
YIELD (gpm): `/) METHOD OF TEST '> r f
11.
WATER ZONES (depth): %5 v
c
12.
CHLORINATION: Type H t N —Amount r
If additional space is needed use back of form!
13.
CASING:
-
Wall Thickness
LOCATION SKETCH
DepthDiameter or Weight/R. Material
L_
Pi/l°_
(Show direction and distance from at least two State
From —To, Ft., I;-(,
Roads, or other map reference poins)
From To Ft.
From To Ft.
14.
GROUT:
Depth Material Method
From To L Ft. n r'11, o.,o-i P
From To Ft.
15. SCREEN
Depth Diameter Slot Size Material
From —To—Ft— in, —in.-
From —To —Ft. _ in. —in.
From To —Ft. — in. —in.
16. SAND/GRAVEL PACK:
Depth Size Material
17
From To Ft.
From To Ft.
I DO HEREBY CERTIFY THATTHIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 20, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Quad No:
Serial No.
Mm
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
'StAwnit original to Division of Water Quality, Groundwater Section Within 30 days
GW-1 REV. 12199

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section - +_ 1 (753
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: dot, 111� I) r , A Wo I I -�) v 11 c:
WELL CONTRACTOR CERTIFICATION #: - y7�o
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable sox): Residential Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: ($how sketch of the location below) �1
Nearest Town: or t(' 1'-�IJ �'�C County:'v-
(Road Name and Numbers, Community, or Subdivision and Lot No.)
DRILLING LOG DEPTH
3.
OWNER ho h-' G 1"n n Lll i cL
[
From To Formation Description
Address q S t :5,- t e'K Z�-1
--(Street or HouleNo.)�%3
I t' lr� : �E �r�' —
City or Town C Mate Zip Code
4.
DATE DRILLED 1 C4.)
TOTAL DEPTH S
5.
6.
CUTTINGS COLLECTED YES ❑ NO❑--
7.
DOES WELL REPLACE EXISTING WELL? YES ❑ NOED_
c�
S.
STATIC WATER LEVEL Below Top of Casing: 10=, FT.
(Use'+' II Above Top Of Casing)
r�
9.
TOP OF CASING IS FT. Abcve Land Surface'
S
'Top
of casing terminated avor below land surface requires a variance In scoot.
Co - --
dance
10.
with lsA NCAC 2C.0118
YIELD (gpm): METHODOFTEST '> n f t
: - f,
11.
WATER ZONES (depth):�-
cnr-
T_
12.
CHLORINATION: Type it Amount '4116
It additional space is needed use back of formC
13.
CASING:
LOCATION SKETCH
Wall Thickness
Depth - Diameter or Weight/Ft. Material (Show direction and distance from at least two Slate
From L2 To Ft. L' P ri? . Roads, or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From To ..,-L' Ft. �
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From —To—Ft— in. —in
From _ To — Ft. _ In. — In.
From —To Ft. _ In. —in.
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft. From To Ft. _-
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY F ''�'n ' ^ ' �� �)
Quad No: 110 �1 jj SIGNATURE OF PERSON CONSTRUCTING THE WELL �Ubmil original to Division of Water Quality, Groundwater Section Within 30 days
Serial No.
DATE
G'W.i REV. IM9

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section r" / 7 5
1636 Mail Service Center- Raleigh, N.C. 27699.1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: d -PI,11, 5 1 � 1) ,,, A (0,? f I C,
WELL CONTRACTOR CERTIFICATION #: .0 / 76,
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check applicable sox): Residential 0_ Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
Agricultural ❑ Monitoring ❑
2. WELL LOCATION: Show sketch of the location below)
Nearest Town: f . IC J ,�%l�_ County: ,62 (a,1�y�y
(Road Name and Numbers, Community, or Subdivision and Lot No.) DRILLING LOG DEPTH -
3. OWNER A'e G{ �C",(L.P .-S From To FonnaGon Description
Address 0 Z) IV,L
—Street or houte No.j
�. L2�V_ 1,2j /V-C� 02 f %7-3 V
City or Town nn State Zip Code
4. DATE DRILLED 1
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES O NOE]-- _ - o
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO J
8. STATIC WATER LEVEL Below Top of Casing: lc; FT.
(Uw'+ Ii Above Top of Casing)
9. TOP OF CASING IS�_ FT. Above Land Surface' a
'Top or casing terminated aVor below land surface requires a variance In actor•
dance with 15A NCAC 2C.0118
10. YIELD (gpm): METHOD OF TEST hm f 1
11. WATER ZONES (depth): -F2 n
C.PI
12. CHLORINATION: Type /f f N Amount `1 /" If additional space is needed use back of loan
13. CASING:
Wall Thickness LOCATION SKETCH
Depth Diameter or Weight/Ft. Material (Show direction and distance from at least two State
From 2 To / J Ft.Roads, or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From To •:2 fL Ft. — (7Pao, o.,o i P1,171,1
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From —To—Ft— in, —in.—
From —To —Ft. in. —in.
From _To Ft._ in. —in.
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 213, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ON' Fp _p !^ r r - /hnir(iA�r.0
Quad No: SIGNATURE OF PERSON CONSTROCTING THE WELL DATE
SUL )II original to Division of Water Quality, Groundwater Section Within 30 days
Sepal No.
OW-1 REV. 12199

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 WELL CONTRACTOR: 4W1911,'J l�I ,A (c1oII�1
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMIT#:
"
rI Ti1C,
1. WELL USE (Check Applicable Boa): Residential 0- Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: SShow sketch of the location below)
Nearest Town: ` i'J ten. l/.1 • i1% 4,1 C. County: -,//1 0
(Road Name and Numbers, Community, or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER _��j�tih>r)7.c1 PFryv,Lj From To Formation Description
Address
/� 'rest q cute
I nn-J
City or Town State Zip Code
4. DATE DRILLED
5. TOTAL DEPTH .3Q12 p
6. CUTTINGS COLLECTED YES NOED ' o
7. DOES WELL REPLACE EXISTINGWELL? YES E NO m
8. STATIC WATER LEVEL Below Top of Casing: —0 — FT.
S.
(Use'+' II Above Top of Casing) Co
9. TOP OF CASING IS �_ FT. Above Land Surface'
"•_-
-Top of casing terminated auor below land surface requires a variance In accor-
dance with 15A NCAC 2C .0118
10. YIELD (gpm): METHOD OF TEST m/
11. WATER ZONES (depth): aiS'
0
12. CHLORINATION: Type It t N Amount '�4 If additional space is needed use back of form
13. CASING:
Wall Thickness LOCATION SKETCH
,1 Depth ['� Diameter or Weight(Ft. Material (Show direction and distancu :rom at least two State
From To Ft.Roads, or other map reference points)
From To Ft.
From To FI.
14. GROUT:
Depth Material Method
From To 2("� Ft. n r'r+ � ,T _ n r
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From —To—Ft— in. —in
From _ To — Ft. _ in. _ In.
From —To _ Ft. _ In. _ in.
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft._._
17. REMARKS:
I DO HEREBY CERTIFY THATTHIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Quad No: J`. 2
Serial No.
2(.`U SIGNATURE OF PERSON CONSTRUCTING THE WELL
Sutmil original to Division of Water Oualily, Groundwater Section Within 30 days
c1 <
DATE
GW-1 REV. 1259

North Carolina • Department of Environment and Natural Resources • Division of Water Quality • Groundwater Section �; 1 1 { v_ 6
1636 Mail Service Center • Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: /� I) A 119 f I � t• f 1 7-1 , Y- i1
WELL CONTRACTOR CERTIFICATION #: - '0 y 76,
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (check Applicable Box): Residandal0_ Ivtunicipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other F1 If Other, List Use:
2. WELL LOCATION• Show sketch of the location below) /y�
Nearest Town: i%-11 %' 1 i7✓ Z1 County: � f 6L Gim J
(Road Name and Numbers. Community, or Subdivision and Lot No.)- DRILLING LOG
3. OWNER L1 rLA From To
Address
treet or cute o.
i A1P � :;?f �
city or Town State Zip Code
4. DATE DRILLED 9-/ `P -?)?7
5. TOTAL DEPTH 41012
6. CUTTINGS COLLECTED YESQ NOEJ--
7. DOES WELL REPLACE EXISTING WELL? YES EJ NO��
8. STATIC WATER LEVEL Below Top of Casing: Qj7 FT.
(Use'i If Above Top of Casing)
9. TOP OF CASING IS�_ FT. Above Land Surface'
'Top of casing terminated atlor below land surface requires a variance In accor.
dance with 15A NCAC 2C .0118
10. YIELD (gpm): S METHOD OF TEST n f
11. WATER ZONES (depth): % ti '2
12. CHLORINATION: Type H t N Amount 'err
13. CASING:
DEPTH
Formation Description
��
CT
rrl171
'
CO
rn
It additional space is needed use back of form
Wall Thickness LOCATION SKETCH
Depth .,, /'� Diameter or Weight/Ft, Material (Show direction and distance from at least two State
From �� To .—_2 0 Ft. _. _- -P ti? . Roads, or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From To 2-LFt. n r'.,-, o.,�T
From To Ft.
15. SCREEN:
Depth Diameter
From To _ Ft _ in.
From _ To _ Ft. _ in.
From —To—Ft.— In.
16. SAND/GRAVEL PACK:
Depth Size
From To Ft. —_
From To Ft.
17. REMARKS:
Slot Size Material
in.
in.
_ in.
Material
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
1
FOR OFFICE USE ONLY
Quad No:
Serial No.
Sr;I" G rU ' � SIGNATURE OF PERSON CONSTRUCTING THE WELL
SubrNI original to Divislon of Water Quality, Groundwater Section wilh.n 30 days
DATE
GW-1 REV. 12199

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section -. 41 1 / 5.7__ _
1636 Mail Service Center - Raleigh, N.C. 27699.1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION #: 71"
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential 0- Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCAT10N., (Show, sketch of the location below)
Nearest Town:n I' �/� ti�V County: m L-c E-t*vr )
(Road Name an Numbers, Couniy, or Subdivision and Lot No.)
I
DRILLING LOG DEPTH
3.
OWNER /� C4 771)ye�r''%-�.'Tl " _
From To Formation Description
Address '3LO_5 Lre A1)1'e4
tStreet or Fouie No.)n
161' Jw h e c /.i'�� �! . 23
City or Town State Zip Code
4.
DATE DRILLED - 13 -'
5.
TOTAL DEPTH 7 D r/
6.
CUTTINGS COLLECTED YES ❑ NO❑/cD
7.
DOES WELL REPLACE EXISTING WELL? YES ❑ NOE9--
8.
STATIC WATER LEVEL Below Top of Casing: _�_ FT.
fT1
(Use'+* If Above Top of Casing)
9.
TOP OF CASING IS FT. Above Land Surface'
co = -
'Top of casing terminated at/or below land surface requires a variance In accor-
dance with 15A NCAC 2C.0113
10. YIELD (gpm): 2 _ METHOD OF TEST / / /
_ _-
11.
WATER ZONES (depth):
12.
CHLORINATION: Type H t N Amount ^ 4
If additional space is needed use back of form
13.
CASING:
LOCATION SKETCH
Wall Thickness
Depth Diame:er or Weight/Ft. Material
' � -
(Show direction and distance from at least two Stale
From C To `5 Ft. fl— P t P .
Roads, or other map reference points)
From To Ft.
From To Ft.
iMC10419E
Depth Material Method
From To 211 Ft. 0 r'11, — i
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From —To—Ft— in. —in
From To — Ft.— in. — In.
From To _ Ft. _ In. _ in.
16. SAND/GRAVEL PACK:
Depth Size Material
From To - Ft.
From To Ft.
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Quad No: 2 nn ultkulOrigiSIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
{Snal to Division or Water Quality, Groundwater Section Within 30 days
Serial No. GW-I REV. 121"

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section " .�_ r- p 6 6
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone] a, 0 p
WELL CONSTRUCTION RECORD WELL CONTRACTOR: • n 5 IL I) , A 01911 Lr If D-
WELL CONTRACTOR CERTIFICATION #: 5 d l L
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Bo:): ResidendalEl- Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: Show sketch of the location below)
Nearest Town: � 12'n P/r7<i r�i'1 _ County: M0 GtTYL,
(Road N d Numbers, Community, or Subdivision and Lot No.) DRILLING LOG
3. OWNER NS(/_ l-'IQ.g3-S/TP) -P Y'y From To
Address
Street or outs 6
City or Town State Zip Code
4. DATE DRILLED
5. TOTAL DEPTH �� S
6. CUTTINGS COLLECTED YES NOED--
7. DOES WELL REPLACE EXISTING WELL? YES NOQ_
6. STATIC WATER LEVEL Below Top of Casing: i FT.
(Use': it Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface -
'Top of casing terminated atlor below land surface requires a variance In accor-
dance with 16A NCAC 2C .0119
10. YIELD (gpm): ` METHOD OF TEST hu I , 1
11. WATER ZONES (depth): /i/'h ' `
12. CHLORINATION:
13. CASING:
Type It t l-1 Amount 6
Depth Diameter
From 0 To FL � '
From To Ft.
From To Ft. _
14. GROUT:
Agricultural ❑ Monitoring ❑
DEPTH
Formation Description
If additional space is needed use back of formt-O
Wall Thickness
LOCATION SKETCH
or Weight/Ft. Material (Show direction and distance from at least two State
i /k.(• P I �°— Roads, or other map reference points)
Depth Material Method
From To L t"' Ft.
From To Ft.
15. SCREEN:
Depth Diameter
From To Ft in.
From _ To _ Ft. _ in.
From —To—Ft.— In.
16. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To Ft.
17. REMARKS:
Slot Size Material
_ in.
In.
In.
Material
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Quad No:
Serial No.
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Subrnil original to Division of Water Quality, Groundwater Section Within 30 days
GW-t REV. 12199
0

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] - r- -15865
tt rl `t LI)�- t il)PII ht'. /I �>� Th C
WELL CONSTRUCTION RECORD WELL CONTRACTOR: •�"
WELL CONTRACTOR CERTIFICATION #: •, I •�
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable 600 Residential Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other If Other, List Use:
2. WELL LOCATIOfX(Show sketch of the location below) /}
Nearest Town: / )-aJ9 /' I'`h ) Azli2 County: r fl�
(Road Name and Numbers, C��i`�uniry, or Subdivision and Lot No.) DRILLING LOG
3. OWNER l/J en C11 (v%S E'n �1 -PY��1p __ From To
Address
i—j5treat Of outs o. - 3 y
I (ihlC/r� A- —
City or Town Stale Zip Code
4. DATE DRILLED -U12
5. TOTAL DEPTH -9,-0-5
6. CUTTINGS COLLECTED YES ❑ NOQ-
7. DOES WELL REPLACE EXISTING WELL? YES NO©�
8. STATIC WATER LEVEL Below Top of Casing:_ FT.
(Use'.' it Above Top of Casing)
9. TOP OF CASING IS—�-- FT. Above Land Surface-
-Top of casing terminated at/or below land surface requires a variance In accor-
dance with 15A NCAC 2C.0118
METHOD OF TEST
10. YIELD (gpm): �� r
11. WATER ZONES (depth): 70
Agricultural ❑ Monitoring ❑
DEPTH
Formation Description
c.
0
0
r n
-�
J
o
12. CHLORINATION: Type If t 1-! Amount ` t If additional space is needed use back of form
13, CASING:
LOCATION SKETCH
Wall Thickness
Depth Diameter or Weight/Ft. Material (Show direction and distance from at least two State
From ( To -sLJ-- FL - -- ' /.(- V 1-1-C-= Roads, or other map reference points)
From To Ft.
From To Ft. —
14. GROUT:
Depth Material Method
From To :-L_ Ft. —2-ILI
From To Ft.
15. SCREEN
Depth Diameter Slot Size Material
From —To—Ft _ in. —in.—
From —To _Ft. _ in. —in.
From —To _ Ft. _ in. — in.
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft. —.—
From To Ft.
17
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 LEI " �^fO''I`/� A� Sf ZZ —U'J
Quad No:
SIGNATURE OF PERSON CONSTRUCTING THE WELL OATE
Submit original to Division of Water Quality, Groundwater Section Within 30 days
GW-1 REV. 12199
Serial No.

North Carolina - Department of Environment and Natural Resources - Division of Water Duality - Groundwater Section ' 5 8 6 4
1636 Mail Service Center - Raleigh, N.C. 27699.1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable sox): Residential El/nicipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other M If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below) ,
Nearest Town: �t-f — Z- __ Counry:
(Road Name and Numbers, Community. or SvAivlsion and Lot No.) DRILLING LOG
3. OWNER PoZ'I L � �_ —�1 From To
4
Address �,
;)�14F
City or Town Stale 'P Code
4. DATE DRILLED
5. TOTALDEPTH
6. CUTTINGS COLLECTED YES ❑ NO©--
7. DOES WELL REPLACE EXISTING WELL? YES [] NO[a
8. STATIC WATER LEVEL Below Top of Casing: 142 FT.
(Use'i If Above Top of Casing) _
9. TOP OF CASING ISFT. Above Land Surface-
-Top of casing terminated aVor below land surface requires a variance In accor-
dance with 16A NCAC 2C.0118 n�
10. YIELD (gpm): METHOD OF TEST 101f
11. WATER ZONES (depth):
Agricultural ❑ Monitoring ❑
DEPTH
Formation Gescrip:ion
0
CD
O
•�
N
--
J
-4
12. CHLORINATION: Type f t N —Amount `� ' If additional space is needed use back of form
13. CASING:
LOCATION SKETCH
Wall Thickness
Depth Diameter or Weight/Ft. Material (Show direction and distance from at least two Slate
From �� To 2:27 Ft. L—'/-4-- ,, Roads, or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From To -'LL_ Ft. /r 111Lr' +'
From To Ft.
15. SCREEN
Depth Diameter Slot Size Material
From _ To _ Ft _ in. —in.—
From —To —Ft. — in. —in.
From —To —Ft. — in. —in.
16. SAND/GRAVEL PACK
Depth Size Material
From To Ft. From To Ft._..-
17. REMARKS:
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Quad No:
Serial No.
SIGNATURE OF PERSON CONSTRUCTING THE WELL
Submit original to Division of Water Quality. Groundwater Section within 30 days
DATE
GW-I REV. 12J99

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section %V
1636 Mail Service Center - Raleigh, N.C. 27699.1636-Phone [phone]b
.z 'i /� f) r- ` L.9 11 �t l l 1
WELL CONSTRUCTION RECORD WELL CONTRACTOR: •I
WELL CONTRACTOR CERTIFICATION #: -5 tf -I %L
STATE WELL CONSTRUCTION PERMIT#:
WELL USE (Check Applicable Box): Residential Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: jShow sketch of the location below) M
Nearest Town: /�✓i7m l(l A.��% County: ! ! I Ct Cfa2i i
(Road Name and Numbers, Community, or Subdivision and Lot No.) DRILLING LOG
�._����•�
3. OWNER ref Ijy1 -P '♦- ly r� ,Trl ' T-tn'l � From To
Address / (2� A
treet or oute o. A / / '/ 1On44 A. �! 3.�7
City or Town State Zip Code
4. DATEDRILLED
5. TOTAL DEPTH :4n
6. CUTTINGS COLLECTED YES ❑ NOED--
7. DOES WELL REPLACE EXISTING WELL? YES 0 NOI I
8. STATIC WATER LEVEL Below Top of Casing: i,yj Fr.�
(Use's it Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface'
-Top of casing terminated at/or below land surface requires a variance In accor-
dance with 15A NCAC 2C .011a ,
10. YIELD (gpm): _ METHOD OF TEST
11. WATER ZONES (depth): �/ L7 1) � (c (��„_LJ. ,
12. CHLORINATION: Type /f t N Amount —/L_-
13. CASING:
Wall Thickness
Depth Diameter or Weight/Ft. Material
From �� To �162) Ft. (r • — "'— P r ,0
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From To aiA Ft.
From To Ft. _
15. SCREEN:
Depth Diameter Slot Size Material
From _ To _ Ft _ in. —in.-
From — To — Ft. — in. — In.
From —To —Ft. _ in. —in.
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
17
Agricultural ❑ Monitoring ❑
DEPTH
Formation Description
O
-
fV
It additional space is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A (C)OOPPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY ^ rJ ' ' L 41("` L
Quad No: SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Quality, Groundwater Section within 30 days
Serial No. ) j! GWA REV. 12199

North Carolina -Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section Y; _1 r")
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
1ELL CONTRACTOR: nn �r
I il),9ll . /I -en. 7�'�<.
WELL CONSTRUCTION RECORD WELL CONTRACTOR CERTIFICATION#: —') j-I& 11
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION:,(Show sketch of the location below)
Nearest Town: 4d%yl,�' /(' County:
(Road Name and Numbers, Co `�'�`�unity, or Subdivision and Lot No.) DRILLING LOG
3. OWNER �' C-2 `-' a r-� S �t"' From To
Address j /) • _
«eet r oute o.
-7
City or Town State Zip Code
4. DATE DRILLED
5. TOTAL DEPTH '
6. CUTTINGS COLLECTED YES ❑ NOE]--
7. DOES WELL REPLACE EXISTING WELL? YES NO[D�
8. STATIC WATER LEVEL Below Top of Casing: �_ FT.
(Use -+" It Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface-
-Top of casing terminated atior below land surface requires a variance In accor-
dance with 15A NCAC 2C.0118
10. YIELD (gpm): METHOD OF TEST11V011,1
11. WATER ZONES (depth): 3 3 �n
DEPTH
Formation Description
0
O "p
J o
1
12. CHLORINATION: Type If t 14 Amount ^ 4 / If additional space is needed use back of form
13. CASING:
LOCATION SKETCH
Wall Thickness
Depth �% Diameter or Weight/Ft. Material (Show direction and distance from at least two State
From �� To —Le Ft. t"— —, Ikv — P1 P= Roads, or other map reference points)
From To Ft. —
From To Ft.
14. GROUT
Depth Material Method
From 6_ To ("' Ft. R r'11, o.,1% -P,"?� 1 2
From To Fl.
15. SCREEN:
Depth Diameter Slot Size Material
From _ To _ Ft _ in. —in.-
From _ To _ Ft. _ in. — in.
From _ To —Ft. _ In. —in.
16. SAND/GRAVEL PACK:
Depth Size Material
17
From To Ft.
From To Ft.
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Quad No:
Serial No.
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Quality, Groundwater Section within 30 days GW4 REV. 12/99
t.x

21'7596
North Carolina - Department of Environment and Natural Resources - Division of Water Duality • Groundwater Section
I e36 Mail Service Center - Raleigh, N.C. 27699.1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: I ^'111) ' L!
WELL CONTRACTOR CERTIFICATION #: ? y 7G•
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential ❑/nicipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: H I G-m L 4AD A/C County: 01 r•C�v
(Road Name and Numoers, Community, or Subdivision and Lot No.)
3. OWNER I✓ 1 4 0. A -e
Address o - k5�, � D ct.
—��(street or oulo o.
City or Town State Zip Code
4. DATE DRILLED '3f-CO
5. TOTAL DEPTH r' `7
6. CUTTINGS COLLECTED YESQ NOQ
7, DOES WELL REPLACE EXISTING WELL? YES NOF-]
8. STATIC WATER LEVEL Below Top of Casing: _,1 L FT.
(Use'+' if Above Top of Casing)
9. TOP OF CASING ISM_ FT. Above Land Surface'
'Top of casing terminated allor below land surface requires a variance In actor•
dance with 15A NCAC 2C .0118
10. YIELD (gpm): y (^, METHOD OF TEST 2/11?/ f l 1
11. WATER ZONES (depth): t
12.
CHLORINATION: Type t t N _Amount
13.
CASING:
Wall Thickness
Depth Diameter
or Weight/Ft. Material
From
To Ft. ( —
' 6=
From
To Ft. --
From
To Ft.
14.
GROUT:
Depth Material
Method
From
To :� LFt. /f r'121
a,EL_ _P_2_L_]
From
To Ft.
15.
SCREEN:
Depth Diameter Slot Size Material
From —To—Ft—
in.
—in.—
From
To —Ft. _ in.
in.
From —To
_ Ft. _ In.
in.
16.
SAND/GRAVEL
PACK:
Depth Size
Material
From
To Ft.
From
To Ft.
17.
REMARKS:
_
1 DO HEREBY CERTIFYTHATTI
CONSTRUCTION STANDARDS,
FOR OFFICE USE ONLY
Quad No:
Serial No.
Agricultural ❑ Monitoring ❑
DRILLING LOG DEPTH
From To Formation Description
CD
cn
J
eD
It additional space is needed us"ackR form
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
✓AS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
AORY,OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
L',nli SIGNATURE OF PERSON CONSTRUCTING THE WELL
Submit original to Division of Water Quality. Groundwater Section within 30 days
6
DATE
GW1 REV. 12/99

�t
r
_f_'7
North Carolina - Department of Environment and Natural Resources - Division of Water Cuality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone] I
WELL CONSTRUCTION RECORD WELL CONTRACTOR: 'L1st111}z' I )' WD I I
WELL CONTRACTOR CERTIFICATION It: -7
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (check Applicable Box): Residential I. Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ It Other, List Use:
2. WELL LOCATION: (Showsketch of the location below)
Nearest Town: _
�� I ' W L A.c f-�) �7� Alc— County:
(Road Name and Nurr�ers, Com Imunity, or Subdivision and Lot No.)
3. OWNER 7 ) (3 r, II-r't'cot'�-� —
Address }�, �j �� n d
trees or opto ^0. •7
City or Town State Zip Coda
4. DATE DRILLED Y "3 D -Lyo
S. TOTAL DEPTH (0 0 cr
6. CUTTINGS COLLECTED YES Q NO©--
7. DOES WELL REPLACE EXISTING WELL? YES N0E-j
8. STATIC WATER LEVEL Below Top of Casing: -,�'r Ff.
(Use'+" II Above Top of Casing)
9. TOP OF CASING ISFf. Above Land Surface'
-Top of casing terminated aVor below land surface requires a variance In accor-
dance with 15A NCAC 2C.0119 _
10. YIELD (gpm): METHOOOFTEST Llrnrl-
11. WATER ZONES (depth): —Lb b 5'
12. CHLORINATION:
13. CASING:
Agricultural ❑ Monitoring ❑
DRILLING LOG DEPTH
From To Formation Descnption
Cil
Type t t N .—Amount ei If additional space is needed use back of form
Wall Thickness
Depth
Diameter
or Weight/Ft. Material
�� `♦
� Ft. (L—
From To
From To
Ft. —
From To
Ft.---
14.
GROUT:
Depth
Material
Method
From To .�)lL
Ft. 0 ('22)
r.,vi O
From To
Ft.
15.
SCREEN:
Depth
Diameter
Slot Size Material
From —To—Ft—
in.
—in.—
From _ To —
Ft. _ in.
— in.
From —To _
Ft. _ in.
—in.
16.
SAND/GRAVEL PACK:
Depth
Size
Material
From To
Ft.
From To
Ft._._
17.
REMARKS:
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 20, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
=OFFICEUSE
-.30 -cry
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Quality, Groundwater Section within 30 days GW l REV t2/99
1-1

North Carolina •Department of Environment and Natural Resources -Division of Water Oualie Groundwater Section
1'7213
1636 Mail Service Center - Raleigh, N.C. 27695`-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION N: y 7
STATE WELL CONSTRUCTION PERMIT#:
Lei' Industrial ❑ Agricultural ❑ Monitoring ❑
i. WELL USE (Check Applicable Box): Residential Municipal ❑
Recovery ❑ Heat Pump Water Injection ❑ Other If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: / ! &/'o County:—n�� 1 t
(Road Name and Numhers, Community, or Subdivision and Lot No.) DRILLING LOG
3. OWNER �L7 (�(1 �i i Y r1�( _ From To
Address
treet or outs 9.F—
r P lip Coda
City or Town State p _
♦_
4. DATE DRILLED � —
5. TOTAL DEPTH Sn —
6. CUTTINGS COLLECTED YES ❑ NO©-- ^/
7. DOES WELL REPLACE EXISTING W2LL7 YES l
S. STATIC WATER LEVEL Below Top of Casing: —
(Use •., It Above Top of Casing) _
9. TOP OF CASING IS j FT. Above Land Surface' _
'Top of casing terminated aVor below land surface requlres a variance In accor-
dance with ISA NCAC 2C.0110 �lpi / 1 1
10. YIELD (gpm): _—METHOD OF TEST 1�=— —
11. WATER ZONES (depth):
12. CHLORINATION:
13. CASING:
14
15
DEPTH
Formation Description
Type + t N ._ Amount `its It additional space is needed use back of form
Depth Diameter
From—�� To Ft. L
From To Ft.
From To Ft.
GROUT:
LOCATION SKETCH
Wall Thickness
or Weight/R. Material (Show direction and distance from at least two Stale
, !' 11 d/? . Roads, or other map reference points)
Depth Material Method
From To ,�I(I Ft. 01.-" ''"'7 1 �
From To —Ft.
Sr,RFFN:
Depth Diameter
From _To_ Ft — in.
From _ To —Ft. _ in.
From _—To_Ft._ In.
16. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To Ft.___
17. REMARKS:
Slot Size Material
in.
in.
in.
Material
CD
0
cn
r+�
f
0
cn
rn
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
a
=OFFICEUSE ' DATE
SIGNATURE OF PEfiSON CONSTRUCTING THE WELLSubrnfl original to Division of Water Duality, Groundwater Section within 30 daysGW1 REV. 12/99

;1'7?14
Nonh Carolina • Department of Environment and Natural Resources - Division of Water Quality • Groundwater Section
o. ie;,.t. u n 97eeo.1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: L tt' (1).'II �` )I L
WELL CONTRACTOR CERTIFICATION W: '0171"
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential ©Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heal Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: � /
) ..A � C- County:
(Road Name and Numbers. Community, oIr Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER l 'tl v I-/t-V t[�Ya't -� From To Fomraucn Description
Address
treet or outs 0.
City or Town State Zip Code
4. DATE DRILLED
5. TOTAL DEPTH �ii1n
6. CUTTINGS COLLECTED YES[1] NO©--
7. DOES WELL REPLACE EXISTING WELL? YES D NO�I
8. STATIC WATER LEVEL Below Top of Casing: /.?� FT.
(Use'i if Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface'
-Top of casing terminated avor below land sudaco requires a variance In accor.
dance with 1SA NCAC 2C .0118 —
10. YIELD (gpm): ,-L_ METHOD OF TEST ' iml1 -1t
f
11. WATER ZONES (depth): 24t` -
12. CHLORINATION: Type ilt t 14 —Amount
'L tf
It additional space is needed use back of form
13. CASING:
LOCATION SKETCH
Depth Diameter
Wall Thickness
or Weight/Ft. Material
(Show direction and distance from at least two State
��
Ft. L - -
' rS-f'P I`L' -
Roads, or other map reference points)
From
To
From
To Ft.
From
To Ft.
14. GROUT:
Depth Material Method
From To .1 f"� Ft. 0 r1111
From To Ft.
15. SCREEN:
Depth
Diameter
From
—TO _Ft
_ in.
From
_ To —
Ft. _ in.
From
_ To _Ft.
_ in.
16. SAND/GRAVEL
PACK:
Depth
Siva
From
To
Ft. -
From
To
Ft. —
17. REMARKS
Slot Size Material
in.
_ in.
in.
Material
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY r ^' ` ^ r r
Quad No:
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
submit original to Division of Water Ouaiity, Groundwater Section within 30 days GW 1 REV. 12/99
Serial No.
C7
O
1
v
T1C
I

North Carolina - Department of Environment and Natural Resources - Division of Water Qualiry - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699.1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: •�ftr1 �hI) �t -717C
WELL CONTRACTOR CERTIFICATION N: / % G•
STATE WELL CONSTRUCTION PERMITN:
1. WELL USE (Check Applicable sox): Residential / Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION- (Show sketch of the location below) ^�I
Nearest Town:?4i(-`'lz 4--th 4�( County: ,!`l�iA
(Road Name and Numbers, Community, or Subdivision and Lot No.) DRILLING LOG
3. OWNER _ Pe -C tie _ From To
Address jD
•
City or To Slate 7-ZZiip Code
4. DATE DRILLED
5. TOTAL DEPTH LLD
6. CUTTINGS COLLECTED YES ❑ NOED--
7. DOES WELL REPLACE EXISTING WELL? YES D NO�
8. STATIC WATER LEVEL Below Top of Casing: �� FT.
(Use': If Above Top of Casing)
9. TOP OF CASING ISFT. Above Land Surface -
'Top of casing terminated aVor below land surface requires a variance In accor-
dance with 15A NCAC 2C.0118
10. YIELD (gpm): L2 METHOD OF TEST � pi t 1
11. WATER ZONES (depth): -7n / -
12. CHLORINATION: Type 14 Amount ' t/ 6
13. CASING:
Wall Thickness
Depth Diameter or Weight/Ft, Material
From t To C Ft. f" ' _ r ILL P ti?
From To Ft. -
From To Ft.
14. GROUT:
Depth Material Method
From To :1 l" Ft. 0 ('121
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From To _ Fl _ in. —in.—
From —To — Ft. _ in. — in.
From —To —Ft. — In. in.
16. SAND/GRAVEL PACK:
From
From _
17. REMARKS
Depth Size Material
To Ft. _.—
_ To Ft.
Agricultural ❑ Monitoring ❑
DEPTH
Formation Description
If additional space is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
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'�/�� �`� GZ
Quad No: SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Quality, Groundwater Section Within 30 days
Serial No. GW-t REV. 12/99

; 1_7216
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699.1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: •r1 n �� )) �f )' I I �'' �' ° �" �'
WELL CONTRACTOR CERTIFICATION #: i7G•
STATE WELL CONSTRUCTION PERMIT#:
WELL USE (Check Applicable Boa): Residential - Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other M If Other, List Use:
Agricultural ❑ Monitoring ❑
2. WELL LOCATION: ( how sketch of the location below)
a1 12 L r_10 � ' county:
M
Nearest Town: � � � �' �'�
(Road Name and lumbers, Community, or Subdivision and Lot No.) DRILLING LOG
3. OWNER G��'i` . : (� r From To
Address i-S%1 P'SQ1L-•➢Q'b i( �+tri —
�twreeVof Route No.
S. ,Code
Cny or TP �� ,,��,, �� "" State Zip Code
4. DATE DRILLED '�� _
5. TOTAL DEPTH • RCCI
6. CUTTINGS COLLECTED YES NO©-
7. DOES WELL REPLACE EXISTING WELL? YES F] NO[F4,—
8. STATIC WATER LEVEL Below Top of Casing: --2�-- FT. —
(Use -.' If Above Top of Casing)
9. TOP OF CASING ISFT. Above Land Surface-
-Top of using terminated aVor below land surface requires a variance In accor-
dance with 1SA NCAC 2C.0118
10. YIELD (gpm): _(-_ METHOD OF TEST �7
11. WATER ZONES (depth):—.J 7h
12. CHLORINATION: Type f t N --Amount 4/ r
13. CASING:
Wall Thickness
Depth Diameter or Weight/Ft. Material
From—�� To '7' Ft. ( P il ��=
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From To ,1) L Ft. n r'�,: - +, i f
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From —To—Ft— in. in.
From —To —Ft. _ in. —in.
From —To _ Ft. _ in. —in.
16. SAND/GRAVEL PACK:
17
Depth Size Material
From To Ft.
From To Ft. _-
DEPTH
Formation Descripticn
If additional space is needed use back of form
LOCATION SKETCH -
(Show direction and distance from at least two State!
Roads, or other map reference points)
77- r
_ rr
o r
U7 -+
CT o
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 1SA NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Quad No:
Serial No.
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Quality, Groundwater Section within 30 days
GW-t REV. 12/99

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section 1 6 3 ,
41636 Mail Service Center - Raleigh, N.C. 27699.1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: •'lPr)i) !) 6 A IL9I) /I ,L.> �, c
WELL CONTRACTOR CERTIFICATION #: • 7 / 7 E-
STATE WELL CONSTRUCTION PERMIT#:
WELL USE (Check Applicable Box): Residential l[k Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: l �a� .<l County:
(Road Name and Numbers, Community, or Subdivision and Lot No.)
3. OWNER C tit rS H73 �7� G
Addressi
(reel Or Oule 0. �f p
) j(i.r�c A 7 q
Cny wn State Zip Code
4. DATE DRILLED
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES[] NOEJ,-
7. DOES WELL REPLACE EXISTING WELL? YES F-I NOF-]
8. STATIC WATER LEVEL Below Top of Casing: /,52,-, FT.
(Use'+' If Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface -
'Top of casing terminated atlor below land surface requires a variance In accor-
dance with 15A NCAC 2C.0118
10. YIELD (gpm): METHOD OF TEST '> ))'r _.1
11. WATER ZONES (depth): �� n
12. CHLORINATION: Type If t N ._Amount V�Z/6_
13, CASING:
Wall Thickness
Depth Diameter or Weight/Ft. Material
From �� To � Ft. /PV 10Al�0.
From To Ft.
From To Ft.
14. GROUT:
Depth Material
From V To .:2 L Ft. 0 +213, e �^ i
From To Ft.
15. SCREEN:
Method
Depth Diameter Slot Size Material
From —To—Ft— in. in.
From To _ Ft. in. _ in.
From To Ft. In. in.
16. SAND/GRAVEL PACK:
Depth Size
From To Ft. —.
From To Ft._
17
Material
DRILLING LOG
From To
Agricultural ❑ Monitoring ❑
DEPTH
Fonnation Description
4J
o
tV -
C'i
O v.,
r -
t c_>
It additional space is needed use back of form co
z
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDAR_ AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE,
Quad No: SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
p ^ mil original to Division of Water Quality, Groundwater Section Within 30 days
Serial No. ! GW-1 REV. 12/99

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section e C C C
1636 Mail Service Center . Raleigh, N.C. 27699.1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: 11 5 Il ,-. (/ICI) �)r. )I D )1 C
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential 0- Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heal Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: �%/���/�.4ahS County
(Road Name and ynwers. Community, or Subdivis nn and Lot No.) DRILLING LOG DEPTH
r/
3. OWNER #j,� ro I'f n t•�From To Formation Description
Address jb?; Lat/l� 51_J1l1
t— (Street or Route o.)
lI X 1. , . ): , /- L
City or Town State Zip Code
4. DATE DRILLED
5. TOTAL DEPTH"/'r
6. CUTTINGS COLLECTED YES ❑ NOE]— o
7. DOES WELL REPLACE EXISTING WELL? YES 0 NOF__J O
8. STATIC WATER LEVEL Below Top of Casing: �� FT.
(Use'i II Above Top of Casing) .^
9. TOP OF CASING IS�_ FT. Above Land Surface'
'Top of casing terminated aVor below land surface requires a variance In actor- CJ -
dance with 16A NCAC 2C.01/8
10. YIELD (gpm): - — METHOD OF TEST h) m// 1 1
m�
11. WATER ZONES (depth):
•• ri=u
12. CHLORINATION: Type H t N —Amount `�v /" It additional space is needed use back of form CD o
13. CASING:
Wall Thickness LOCATION SKETCH
Depth Diameter or WeighVFt. Material (Show direction and distance from at least two State
From L� To -�7 Ft. (f . ' - Roads, or other map reference points)
From To FL
From To Ft.
14. GROUT:
Depth Material Method
From To .�) Ft. 0 "1),
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From —To—Ft— in. —in
From —To —Ft. _ in. in.
From To Ft. In. in.
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.___
From To Ft.__._
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
f
FOR OFFICE USE ONLY
Quad No: SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
p Stf" original to Division of Water Quality. Groundwater Section Within 30 days
Serial No. J GW-1 REV. 12/99

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section (; C
1636 Mail Service Center. Raleigh, N.C. 27699-1636-Phone [phone] �- 6 3 J `J
WELL CONSTRUCTION RECORD WELL CONTRACTOR: .1ar1 n �' I I !((loll
WELL CONTRACTOR CERTIFICATION #:7G-
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (check Applicable Box): Residential /. Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the l/ocaation below) /�
Nearest Town: i (d-�7 �Q�k-jo ��_County: ' ' `�
(Road Name and Numbers, COrnmunily, or Subdivision and Lot No.) DRILLING LOG
3. OWNER �J�/L/�-£�/r1 �1.1, EMI From To
Address 7! L� / /rQ(lL I )f Z<�yr -
—(stt7l or Route o.
/4 i 2h 10,11 s
City or Ttb State Zip Code
4. DATE DRILLED _ 0 U
5. TOTAL DEPTH _27S
6. CUTTINGS COLLECTED YES ❑ NOM--
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NOQ_
8. STATIC WATER LEVEL Below Top of Casing: /0 FT.
(Use': if Above Top of Casing)
9. TOP OF CASING IS �_ Fr. Above Land Surface -
'Top of casing terminated eVor below land surface requires a variance In accor-
dance with 15A NCAC 2C.0118
10. YIELD (gpm): METHOD OF TEST _ n 1,
11. WATER ZONES (depth): 1.25
Agricultural ❑ Monitoring ❑
DEPTH
Formation Description
C]
C
—e
^i
-
:n
-
12. CHLORINATION: Type /f t N _ Amount r 4 If additional space is needed use back of 10,711M o
13. CASING:
Wall Thickness
Depth Diameter or WeighVFl. Material
From L' �Ft.= Pillf
From —To —Ft. -
From To Ft.
14. GROUT:
Depth Material Method
From To .L (" Ft. R r'no, o ..1T .'n r
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From —To—Ft— in. —in
From _ To _ Ft. _ in. _ in.
From —To —Ft. _ In. —in.
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft. —._—
From To Ft.
17. REMARKS:
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY (� ' _e-v
Quad No: SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
galSubmit original to Division of Water Quality, Groundwater Section within 30 days
Serial No. GW-t REV. 12199

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section 15 ?_ 1.1 6
1636 Mail Service Center - Raleigh, N.C. 27699.1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: •1_\�11 ) n 5 �+r I) (/J,21l �t n ,-� J- 11
WELL CONTRACTOR CERTIFICATION #: / 7 G�
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential El- Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town:✓lm (� �,� �n,[� _ County: M'l-rrz-.J
(Road Name and Numbers, Community, or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER _ T nt S 4 At nx - From To Formation Description
Address -S�-C) 0e j fi
1 /kwreei or Houle o.
Illny n"r- cl S '13 V
City or Town State Zip Code
4. DATEDRILLED
5. TOTAL DEPTHS-'
6. CUTTINGS COLLECTED YES ❑ NOE�i
7. DOES WELL REPLACE EXISTING WELL? YES NOF__j
8. STATIC WATER LEVEL Below Top of Casing: ,Q_ FT.
(Use '.'If Above Top of Casing)
9. TOP OF CASING ISI_ FT. Above Land Surface -
•Top of casing terminated Wor below land surface requires a variance In accor.
dance wlth 16A NCAC 2C.0118
10. YIELD (gpm): 5_0 METHOD OF TEST ht f 1
11. WATER ZONES (depth): a )OO ?�O
12. CHLORINATION: Type - /t t N Amount ' v If additional space is needed use back of form
13. CASING:
Wail Thickness
LOCATION SKETCH
Depth
Diameter or WeighVFt. Material
(Show direction and distance from at least two State
From L'
To 72
Ft. P ;Z'�
Roads, or other map reference points)
From
To
Ft.
From
To
Ft.
14. GROUT:
O
Depth
Material Method
A
From
To .1.1L
FLCZ
From
To
Ft. 7�
t
15. SCREEN:
v
Depth Diameter
From _ To _ Ft _ in.
From _ To _ Ft. in.
From To —Ft. In.
16. SAND/GRAVEL PACK:
Depth Size
From To Ft. —.
From To Ft.
17. REMARKS:
Slot Size Material sa
1�
— in. �o
— in. w
in. to
Material
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Quad No:
Serial No.
G'D
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Quality, Groundwater Section Within 30 days
GW-1 REV. 12/99
0
0
0

North Carolina - Department of Environment and Natural Resources - Division of Water Quality- Groundwater Section 16348
1636 Mail Service Center - Raleigh, N.C. 27699.1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: •1ar1 n 11 C
WELL CONTRACTOR CERTIFICATION #: •? / 7 G-
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (check Applicable Boa): Residentially— Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: Show sketch of the location below)
Nearest Town: r"CJnk I nJ /r/Ci County: 1711k
(Road Name _ 'Number o nity, r S bdivision and Lot No.)
3. OWNER ///!,0
Address /-') a —IL 2,
(wrest or HOUIO o.
City or Town r State Zip Code
4. DATE DRILLED X -IV
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES[] NOQ--
7. DOES WELL REPLACE EXISTING WELL? YES [] NO[]
6. STATIC WATER LEVEL Below Top of Casing: .?jj•. FT.
(Use'i If Above Top of Casing)
9. TOP OF CASING IS�_ FT. Above Land Surface -
'Top of casing terminated aVor below land surface requires a variance In accor.
dance wlth 15A NCAC 2C.0118
10. YIELD (gpm): METHOD OF TEST
11. WATER ZONES (depth): Z S r
12. CHLORINATION: Type It 14 Amount t r)
13. CASING:
Wall Thickness
Depth / Diameter or WeighVR. Material
From—�� To x Ft. —
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From _ L To 2 fA Ft. 0 I'll, o s1 �
From To Ft.
15. SCREEN
Depth Diameter Slot Size Material
From —To—Ft— in. in.
From _To Ft. — in. in.
From _ To _ Ft. _ In. _ in.
16, SANDIGRAVEL PACK
Depth Size Material
From To Ft. �—
From To Ft.__
17. REMARKS:
Agricultural ❑ Monitoring ❑
DRILLING LOG DEPTH
From To Formation Description
Cq
If additional space is needed use back otTdlm
LOCATION SKETCH .tc" --'
c n
(Show direction and distance from at least two State ==
Roads, or other map reference points)
I DO HE REBYC ERTIFVjHAT THItS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDAADS::AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE O' m
Quad No:
Serial No.
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Quality, Groundwater Section Within 30 days
OW-1 REV. 12/99

North Carolina - Department of Environment and Natural Resources - Division of Water Quality L - Groundwater Section �' I ) 3 4 J
I S Center - Ralei h N C 27699-1636-Phone [phone]
1636 Mi aervwe 9 1_
WELL CONSTRUCTION RECORD WELLCONTRACTOR:
WELL CONTRACTOR CERTIFICATION
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential r. Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water lirjeclion ❑ Other M If Other, List Use:
2. WELL LOCATION;(Show sketch of the location below)
Nearest Town: / I IC i •-),J �411 " County:
(Road Name d Numbers. Community, or Subdivision and Lot No.) DRILLING LOG
3. OWNER ��Y(3a- l J6_L^ ��.� From To
Address S- 3 ��G
treet or oute o.
City or Town State zip Code
4. DATE DRILLED -0
5. TOTAL DEPTH .? 5
6. CUTTINGS COLLECTED YES❑ NO©-
7. DOES WELL REPLACE EXISTING WELL? YES ❑ N0�
S. STATIC WATER LEVEL Below Top of Casing:-_U -
(Use'+' If Above Top-
ap of Casing)
9. TOP OF CASING IS FT. Above Land Surface'
-Top of casing terminated at/or below land surfaot requires a variance In scoot.
DEPTH
Formation Description
dance with 15A NCAC 2C.0118 _
10. YIELD (gpm): _�- METHOD OF'1'EST '�^'r• i - r•
11. WATER ZONES (depth):
�l CO o
12. CHLORINATION: Type rf 1'14 ..—Amount � If additional space is needed use back of form
13. CASING:
Wall Thickness
Depth Diameter or Weight/Ft,
From �� To FL --
From To Ft.
From To Ft. -
14. GROUT
LOCATION SKETCH
Material (Show direction and distance from at least two Stale
P d/ ' Roads, or other map reference points)
Depth Material Method
From /i To - 11 Ft. 0 ��' •,1, t-.
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From — To _ Ft _ in. _ in.
From _ To _ Ft.— iI':. _ 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 IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTIONS:i RpAlclgg.ANG, THAT A:COPYOFTHIS RECORD HAS BEEN PROVIDEDTOTHE WELL OWNER.
FOR OFFICE USE ONLY DATE
Quad No: AA �ry�ry7rt1��',SIGNATURE OF PERSON CONSTRUCTING THE WELL
f 3 Wit original to Division of Water Quality, Groundwater Section within 30 days GW 1 REV. 12199
Serial No.

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section a � r-
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone (919) M-3221 � 1 U 3 5 0
WELL CONSTRUCTION RECORD WELL CONTRACTOR: LLEI I n 'J L 1 , A (/1191) r'1- f I T r1 C
WELL CONTRACTOR CERTIFICATION #: / -7C
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential lld- Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: Show sketch of the location below)
Nearest Town: 1 '121 L County: - I-rl n t• (-'. 1
(Road Name and Numbers, Community, or Subdivision and Lot No.) DRILLING LOG
3. OWNER _ �Cr 1,1 / C. Q,11 From To
Address i ( 5
�— (wreel or HOUIG o.
YQ.n.(L.I,raJ .1%r �fi�3k
Cary or Town State Zip Code
4. DATE DRILLED
5. TOTALDEPTH 36_5 `
6. CUTTINGS COLLECTED YES�OEJi
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO©_
8. STATIC WATER LEVEL Below Top of Casing: 4_ FT.
(Use -+- I: Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface-
-Top of casing terminated allor below land surface requires a variance In accor-
dance with 15A NCAC 2C.0116
10. YIELD (gpm): /i_ METHOD OF TEST /Y/00,11
11. WATER ZONES (depth): /O2 3_9n r
12. CHLORINATION: Type H t N Amount 'fit
13. CASING:
Wall Thickness
Depth Diameter or Weight/Ft, Material
From �� To ! Ft. _ , /k V �°—
From To Ft.
From To Ft. _
14. GROUT
Depth Material Method
From — To _ Ft. (I /^g ,I = 0 I( ?f !I`-
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From —To—Ft— in, —in.-
From To Ft. in. in.
From —To Ft. _ In. in.
16. SAND/GRAVEL PACK:
17
Depth Size
From To Ft. —,
From To Ft. _
Material
DEPTH
Formation Description
0
F5'_J
fV
-
:=r.i
rr —
If additional space is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE O ` � /ten^ +sr' • UmN)/inr,Ir X —17` C2]
Quad No: _. SIGNATURE OF PERSON CONSTRUCTING THE WELL
Supmil original to Division of Water Quality, Groundwater Section Within 30 days
Sedal No. �— In r,
x-,u"9V to ri, r
DATE
GW-1 REV. 12199

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section 1 y± rD J
1636 Mail Service Center - Raleigh, N.C. 27699.1636-Phone [phone] l) J
WELL CONSTRUCTION RECORD WELL CONTRACTOR: 41011 n, ` � � I) ,t
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential El- Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: how sketch of the location below)
Nearest Town: l 2, c i.' County: ,191)1,'
Agricultural ❑ Monitoring ❑
(Road Name and Numbers, Community, or Subdivision and Lot No.)
DRILLING LOG DEPTH
3.
OWNER .Tra ✓L<, %ll vl.,^tt
From To Formation Description
Address ���` <r 'A e
or to o.
�—�Streat
og7
4.
city or Town Slate Zip Code
DATE DRILLED ;2 -D71
5.
TOTAL DEPTH 61 c-,
6.
CUTTINGS COLLECTED YES F-1 NO❑�'
7.
DOES WELL REPLACE EXISTING WELL? YES [] NOF-]
G
8.
STATIC WATER LEVEL Below Top of Casing: f1 FT.
e o
(Use'+' If Above Top of Casing)
9.
TOP OF CASING IS�_ FT. Above Land Surface
'Top of casing terminated al/or below land surface requires a variance In actor-
=
dance with 15A NCAC 2C.e118
10.
YIELD (gP m) : ­20 �'r METHOD OF TEST 2 f 1
%= �
11.
WATER ZONES (depth):
12.
CHLORINATION: Type It t N r%
Amount �
If additional space is needed use back of form �
p r
13.
CASING:
o
LOCATION SKETCH `
Wall Thickness
Depth Diameter or Weight/R. Material
(Show direction and distance from at least two Slate
From To '21 Ft. (L.- I ILL
Roads, or other map reference points)
From To Ft
From To Ft.
14.
GROUT:
Depth Material Method
From L To Ft. 0 1, e 1 P ,?I I
From To Ft.
15.
SCREEN:
Depth Diameter Slot Size Material
From To Ft in. —in
From To Ft. _ in. —in.
From —To Ft. — In. in.
16.
SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft. _
17.
REMARKS:
_
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER,
FOR OFFICE USE ONLY a u�?' 11h1LP2J r 0
Quad No: - 3CWi SIGNATURE OF PERSON CONSTRUCTING THE WELL
Submit original to Division of Water Quality, Groundwater Section within 30 days
Serial No.
DATE
GW4 REV. 12/99

s ['�
North Carolina •Department of Environment and Natural Resources •Division of Water Quality - Groundwater Section . 1 V 3 J
1636 Mail Service Center • Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: •�1a1"1 f j .- t (f l,� I t fit' C
WELL CONTRACTOR CERTIFICATION #: •? y 7 �i
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Boa): Residential ET- Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: how sketch of the location below) I
Nearest Town: —Kd ),.y I'uL` X - C- County:
Agricultural ❑ Monitoring ❑
DRILLING LOG DEPTH
(Road Name and Numbers, Community, or Subdivision and Lot No.)
3.
OWNER 0-1. LA
From To Formation Description
Address -{ r -r^ c. - cL
��0 i) h treat ar outs o. �-Cs• ��. _ c
4.
City or Town Slate - Zip Code
DATE DRILLED 2-1 Z
5.
TOTAL DEPTH ,E1` '>
6.
CUTTINGS COLLECTED YES ❑ NO❑--
CD
7.
DOES WELL REPLACE EXISTING WELL? YES [] NOQ,
---
6.
STATIC WATER LEVEL Below Top of Casing: , 3 C-)_ FT.
J
(Use'.' it Above Top of Casing)
9.
TOP OF CASING ISM_ FT. Above Land Surface'
Co c "
-Top
of using terminated avor below land surface requires a variance In actor-
_ `-
dance
10.
with 15A NCAC 2C .0118
YIELD (gpm): V METHOD OF TEST '> Pl r i Ll?•V
11.
WATER ZONES (depth): (o
12.
CHLORINATION: Type %i N Amount
0
If additional space is needed use back of form
13. CASING:
LOCATION SKETCH
Wall Thickness
Depth Diameter or Weight/Fl. Material (Show direction and distance from at least two Stale
From—�� To ,72') Ft. L . —' //kv P fZ' Roads, or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From 6' To J- LL Ft. 0
From To Ft.
15. SCREEN:
Depth Diameter
From —To _. Ft in.
From _ To _ Ft. _ in.
From —To — Ft. _ In.
16. SAND/GRAVEL PACK:
Depth Size
From To —Ft.—.-
From To Ft. _.
17. REMARKS: _
Slot Size Material
_ in.
in.
_ in.
Material
I DO HEREBY CE THAT Th11S WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION: OARC(S 40jTHAT ACOPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY - A-'mac-+�--�'�'2
Quad No: 13 1)1 vrt SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Subkt original to Division of Water Quality, Groundwater Section Within 30 days
Serial No. GW-t REV. 12199

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section � 1
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone (919) M-3221
WELL CONSTRUCTION RECORD WELL CONTRACTOR: .1a1, n 5 I)es
WELL CONTRACTOR CERTIFICATION #: , 0
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ It Other, List Use:
2. WELL LOCATION: ShoVkelch of the location below) �Y1
Nearest Town:-12CPm N"��_� ,'U �County:l
(Road Name
3. OWNER _
Address
Subdivision and Lot No.) DRILLING LOG DEPTH
t ? tL> From To Formation Description
City 06own State Zip Code
4. DATEDRILLED [1Z�
S. TOTAL DEPTH
6. CUTTINGS COLLECTED YES[:] NOQi'
7. DOES WELL REPLACE EXISTING WELL? YES [] N0F__J
B. STATIC WATER LEVEL Below Top of Casing:.' -? C� FT.
(Use': If Above Top of Casing)
S. TOP OF CASING IS _ FT. Above Land Surface -
'Top of casing terminated aLlor below land surface requires a variance In accor-
dance with 15A NCAC 2C .0118
10. YIELD (gpm): METHOD OF TEST ') U I 1
11. WATER ZONES (depth):
o
�
r
N
r�
�
W
L
r
rn
12. CHLORINATION: Type f t N _Amount ^111/ 6 If additional space is needed use back of form
13. CASING:
Wall Thickness
Depth Diameter or WeighVFt. Material
From To `� Ft. L P ti?
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From _i•' _ To -'� L_ Ft. 0 ('11, >-J i P"I
From To Ft.
15. SCREEN:
Depth Diameter
From —To—Ft— in.
From —To—Ft.— in.
From —To—Ft.— In.
16. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To Ft. .
17. REMARKS:
Slot Size Material
in.
in.
in.
Material
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTI Ir +�1 2 I) 1TA' X� (COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE U
Quad No: 1 rSIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
1 - 81iFk it original to Division of Water Quality, Groundwater Section within 30 days
Serial No. GW-I REV. 12199

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section 15 2 0 J
1636 Mal Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: .1'1P11 IF 5 �h I 11, A W 9 11 �r N
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential D- Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ It Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: -� 1 �� /'� L � d-_2S ,lJi(' County: d] .l (/4i )
(Road Name and Numbers. Community, or Subdivision and Lot No.) DRILLING LOG
3. OWNER _ \I )P 4) l� i 4 nrn -4From To
Address /pry cj �i ((CS 2,4 —
Sireel or MOUIO o.
'71 IRAs C-�-
City or wn State Zip Zip code
4. DATE DRILLED%)
5. TOTAL DEPTH /yJ ':;
6. CUTTINGS COLLECTED YES Q NO©-
7. DOES WELL REPLACE EXISTING WELL? YES NOD,
8. STATIC WATER LEVEL Below Top of Casing: Fr.
(Use "i It Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface -
'Top of casing terminated et/or below land surface requires a variance In accor-
dance with 15A NCAC 2C.0118
10. YIELD (gpm): / _ METHOD OF TEST
11. WATER ZONES (depth): r
12. CHLORINATION: Type — (t t 14 Amount '& r�,
13. CASING:
DEPTH._.. -
Formation Description
If additional space is needed use back of form
Wall Thickness LOCATION SKETCH
Depth Diameter or WeighVFt. Material (Show direction and distance from at least two State
From � To -21 Ft. —% r /S ?' ,j 0/ �)_ Roads, or other map reference points)
From To Ft.
From To Ft.
14. GROUT: O
O
Depth Material Method
From _� To i-L_ Ft. 0 ('1)1r i
From To Ft. t
15. SCREEN:
Depth Diameter
From —To _ Ft in.
From —To —Ft. in.
From _ To _ Ft. In.
16. SAND/GRAVEL PACK:
Depth Size
From To Ft. —.-
From To Ft. .
17. REMARKS:
Slot Size Material
_ in.
in.
_ in.
Material
a
lSJ
co
vD
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 20, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Quad No:
Serial No.
SIGNATURE OF PERSON CONSTRUCTING THE WELL
Submit original to Division of Water Quality, Groundwater Section within 30 days
DATE
GW-1 REV. I2r99
0
0

�1 iJIUP
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center- Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: _11c0r1t s dy 110 a CL'c l) hr. )j",L? e
WELL CONTRACTOR CERTIFICATION #: & t
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check applicable Box): Residential D Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: / / � �� L 2 .1 L_ /y County: /�)l
(Road Name and Numbers, Community. or Subdivision and Lot No.) DRILLING LOG
3. OWNER J) Pit n r. F - A, C07, From To
Address 1017 / , c
II (S� et or ou a o.
�I n
City or To State Zip Code
� I 4. DATE DRILLED �- nJ
5. TOTAL DEPTH 414 cS
6. CUTTINGS COLLECTED YES ❑ NOQ-�
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO©�
8. STATIC WATER LEVEL Below Top of Casing: FT.
(Use'+' II Above Top of Casing)
9. TOP OF CASING IS— FT. Above Land Surface'
'Top of casing terminated allor below land surface requires a variance In accor-
dance with 16A NCAC 2C .0 18
10. YIELD (gpm): METHOD OF TEST 1 C u
11. WATER ZONES (depth):
12. CHLORINATION: Type (+_'1"/4 Amount
13. CASING:
Wall Thickness
Depth Diameter or Weight/Fl. Material
FromTo .2Z Ft. (I _' ., / . f- r"'
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From To .2) Ft. o e,m p n` — pnuo
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft In. _ in.
From To _ Ft._ in. _ in.
From —To —Ft. _ in. _ in.
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
17. REMARKS:
DEPTH
For n. !cn Descriptiicn
If additional space is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF -THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Quad No:
Sedal No.
0
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Quality, Groundwater Section Within 30 days
GW4 REV. 12199

1,!.Q75
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699.1636-Phone [phone] II
WELL CONSTRUCTION RECORD WELL CONTRACTOR:LLzon n-, s
WELL CONTRACTOR CERTIFICATION #: —,7 1 76-
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential M-- Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: [// ILL L 4 A 1)C /L(- County:40CC (rrh
(Road Name and Numbers, Community, or Subd/i'v+ision and Lot No.)
DRILLING LOG DEPTH
3.
OWNER .1Gr1 n, C- r�0 IBC (_R) n �.�-r
From To Formation Description
Address J 11 ;� i 4
(Street or mouie o.)�y
L/
/U C, /
4.
City or own State Zip Code
DATE DRILLED
5.
TOTAL DEPTH fi "
6.
CUTTINGS COLLECTED YESQ NOQi"
o
7.
DOES WELL REPLACE EXISTING WELL? YES Q NO D� —
— ° —
8.
STATIC WATER LEVEL Below Top of Casing: FT.
,spy
(Use'+' if Above Top of Casing)
9.
TOP OF CASING IS FT. Above Land Surface'
'Top of casing terminated sUor below land surface requires a verlance In accor.
dance with 15A NCAC 2C.0118
m
10.
YIELD (gpm): IQ. METHOD OF TEST
11.
WATER ZONES (depth): c 15
r
y
12.
yp ("Lf f/ Amount
CHLORINATION: Type
�n
If additional space is needed use back of form
13. CASING:
Wall Thickness
Depth Diameter or Weiyhht/R, Malerial
From To / Ft.6— //W
From To Ft.
From To Ft.
14. GROUT:
Depth Material �Method
From m Tom) Ft. G' em P» 7—`�
From To Ft.
15. SCREEN:
Depth Diarmter Slot Size Material
From To _ Ft— in. —in.
From —To — Ft.— in. _ In.
From —To —Ft. _ in. _ in.
16. SAND/GRAVEL PACK:
17
Depth Size Material
From To Ft.
From To Ft.
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPYAF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Quad No:
Serial No.
SIGNATURE OF PERSON CONSTRUCTING THE WELL
Submit original to Division or Water Quality, Groundwater Section within 30 days
—c
DATE
GW-1 REV. 12/99

4574
Nonh Carolina - Department of Environment and Natural Resources - Division of Water Oualiry - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: 1 1111 ti '1) �117fI �1 rtn
WELL CONTRACTOR CERTIFICATION #: .? / `/C•
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential0 Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: Fi I , kl L'1 C. 1'(^- County: /Y1Q Le t,
(Road Name and Numbers, Community, or Subdivision and Lot No.)
3. OWNER J)enn,S Poh1c'
Address 1 D 0 c3 1 ISS
(Streator Dula o.
I ,AS 'C_
City or To Stale Zip Code
4. DATE DRILLED -aS-rho
5. TOTAL DEPTH /
6. CUTTINGS COLLECTED YESQ NOED--
7. DOES WELL REPLACE EXISTING WELL? YES NO
B. STATIC WATER LEVEL Below Top of Casing: FT.
(Use "i if Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface'
•Top of casing terminated aVor below land surface requires a variance In accor-
dance with 15A NCAC 2C.0116
10. YIELD (gpm): -�P_ METHOD OF TEST
11. WATER ZONES (depth): 'F 4 n r' _
12.CHLORINATION: Type 1ttN _Amount
13. CASING:
Wall Thickness
Depth --}�1 � Diameter or WeighVFl. Material
From L� To �J— Ft. L , . r /L' (' P E"'
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From _ — To .-Z t� Ft. 0 (21), > n i -
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From —To—Ft— in. —in
From —To —Ft. _ in. —in.
From _ To _ Ft. In. —in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To - Ft.
17. REMARKS:
Agricultural ❑ Monitoring ❑
DRILLING LOG DEPTH
From To Fonnauon Description
If additional space is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
c
i'-
CCa
0
r,-
i
fV
m�
`
Z
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Quad No:
Serial No.
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Division of water Quality, Groundwator Section within 30 days
GWA REV. 12199

Nonh Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section ZI
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:(Lifflal5 1�011071dO)n1) hr; llE-zwC_
WELL CONTRACTOR CERTIFICATION #: ,L
STATE WELL CONSTRUCTION PERMIT#:
1.
WELL USE (check Applicable Box): ResidentialM-­-M—unicipal ❑
Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2.
WELL LOCATION: (Sh w sketch of the location below)
Nearest Town:County: ice_
rv�
(Road Name and Numbers, Community, or Subdivision and Lot No.)
DRILLING LOG DEPTH
3.
OWNER C J mu te-If
From To Formation Description
Address 13 ,:� ) D R i W } -e C-t
trees or�u/ o. 3(/
4�-
City or Town State Zip Code
4.
DATE DRILLED % / 2-uz�
5,
TOTAL DEPTH SO `>
6.
CUTTINGS COLLECTED YES Q NOED�-
7.
DOES WELL REPLACE EXISTING WELL? YES NOEZJ—
8.
STATIC WATER LEVEL Below Top of Casing: a O Fr.
(Use'+' If Above Top of Casing)
9.
TOP OF CASING IS� FT. Above Land Surface -
'Top of casing terminated atlor below land surface requires a variance In accor-
dance with 15A NCAC 2C.0118
10.
YIELD (gpm): /-5 METHOD OF TEST i
11.
WATER ZONES (depth): la.S r - /f-5 - y t0
12.
CHLORINATION: Type Y 1 Amount Ci //✓3
It additional space is needed use back of form
13.
CASING:
Wall Thickness
LOCATION SKETCH
Depth Diameter or WeighVFt. Material
(Show direction and distance from at least two State
From To "U Ft. 6 ". —'/ 5�h�
Roads, or other map reference points)
From To Ft.
From To FL
14.
GROUT:
Depth Material Method
o
From To 2e) Ft. 01" ."r ; 2elU c-_
o
From To Ft.
L M 1
15.
SCREEN:
r
Depth Diameter Slot Size Material
--;-
From —To—Ft— in. —in
?- G
From To Ft. _ In. —In.
a:.�- a
From To _ Ft._ In. —In.
lO cn "
16.
SAND/GRAVEL PACK:
Depth Size Material
—�
From To Ft.
_
From To Ft.
17.
REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY 'n v�c� i"l"n` / - / .�2 -Uil
Quad No: SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Quality, Groundwater Section Within 30 days
Serial No. GWA REV. 12/99

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699.1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: I) et) 11 ; 4 1ar, 11 ra ni Cu P II Dri7/
WELL CONTRACTOR CERTIFICATION #:G_-
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential unicipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: 4- /'/,7v L /C� I /l-�r County: ITO CIr1 1
Agricultural ❑ Monitoring ❑
(Road Name and Numbers. Community, or Subdivision and Lot No.) DRILLING LOG
3. OWNER /? ' From To
Address
i «eetor ute o.
City or own State Zip Code
ry —
4. DATE DRILLED /-12-OZ2
5. TOTAL DEPTH �n S
6. CUTTINGS COLLECTED YES Q NO[D--
7. DOES WELL REPLACE EXISTING WELL? YES NOf� 1
8. STATIC WATER LEVEL Below Top of Casing: � FT.�
(Use •+' if Above Top of Casing)
9. TOP OF CASING IS_-�__ FT. Above Land Surface'
'Top of casing terminated at/or below land surface requires a variance In accor.
dance with 15A NCAC 2C.011¢
10. YIELD (gpm): ,z2, METHOD OF TEST hlol
11. WATER ZONES (depth): .�? O
12. CHLORINATION: Type /L/ Amount ZZZ Z6
13. CASING:
Wall Thickness
Depth Diameter or WeighVFl. Material
From To 3-1 Ft. L w
From To Ft.
From To Ft.
14. GROUT
Depth Material Method
From l) To -4k-' Ft. 2 0��,
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From —To—Ft— in. _ in.
From —To Ft._ in. in.
From To —Ft. _ In. _ in.
16. SAND/GRAVEL PACK:
17
Depth Size Material
From To Ft.
From To Ft.
DEPTH
Formation Description
It additional space is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY QE,THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Quad No:
Serial No.
/ -
SIGNATURE OF PERSON CONSTRUCTING THE WELL
SubMl original to Division of Water Quality, Groundwater Section within 30 days
) - Uzi
DATE
GW4 REV. 12199

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section 2' ��
1636 Mail Service Center - Raleigh, N.C. 27699.1636-Phone [phone] C�
WELL CONSTRUCTION RECORD WELL CONTRACTOR:,JLf )n e )t IIa,,,A We II der.,1 F -;,
WELL CONTRACTOR CERTIFICATION #: 7L V
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential ET —_'Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION fShow sketch of the location below)
Nearest Town: rjg // t rz% z� County: LLD %
Agricultural ❑ Monitoring ❑
(Road Name and Numbers, Co riry, or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER L P V i V �.. /' Ct From To Formation Description
Address ?� IILI 0 e
(Scree or flute c.
Arc, 3 V
°State
City orTom Zip Cod
4. DATE DRILLED %—// —07D
5. TOTAL DEPTH S-/)
6. CUTTINGS COLLECTED YES Q NOE3--
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NOE3-
8. STATIC WATER LEVEL Below Top of Casing: S� FT.
(Use'+' ll Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface -
'Top of casing terminated at/or below land surface requires a varlance in accor-
dance with 15A NCAC 20.0118
10. YIELD (gpm): - 0 METHOD OF TEST
11. WATER ZONES (depth):
12. CHLORINATION: Type p _Amount If additional space is needed use back of form
13. CASING:
LOCATION SKETCH
Wall Thickness
Dept �- Diameter or Weight/Ft. Material (Show direction and distance from at least two Stale
% L
From To FL—-..-1�� Roads, or other map reference points)
From To Ft. o
From To FL C—
C
n,
oM
r—
14. GROUT:
c
Depth Material Method
From tit To V) FL
a
From To Ft.
15. SCREEN:
m ,a
Depth Diameter Slot Size Material w
From —To—Ft— in. in.
x
From —To —Ft. _ in. _ in.
From —To _ Ft. — In. —in.
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
COPY
FOR OFFICE USE ONLY I 7—//�7)
Quad No: SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Quality, Groundwater Section within 30 days
Serial No. GW-1 REV. 12/99

2118'75
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR1,210 S 16,AA/ 0I ) J
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential ❑—M I"nicipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below) m
Nearest Town: r'r 4h County:l'
(Road Name and Numbers. Community. or Subdivision and Lot No.) DRILLING LOG
3. OWNER /U ZIL S�9 nii 7 From To
Address _ C!J !C L� ,�
UM or outs o.
City or Town State Zip Code
4. DATE DRILLED C' l ' Uy
5. TOTAL DEPTH '
6. CUTTINGS COLLECTED YES Q NOQ
7. DOES WELL REPLACE EXISTING WELL? YES NOo-
8. STATIC WATER LEVEL Below Top of Casing: Sj d FT.
(Use'+' ll Above Top of Casing)
9. TOP OF CASING ISFT. Above Land Surface'
-Top of casing terminated at/or below land surface requires a variance In accor-
dance with 15A NCAC 2C.0118
10. YIELD (gpm): rV—` METHOD OF TEST
11. WATER ZONES (depth): S
Agricultural ❑ Monitoring ❑
DEPTH
Formation Description
12. CHLORINATION: Type /4--1tv Amount r113 If additional space is needed use back of form
13. CASING:
Wall Thickness LOCATION SKETCH
/.� Depth Diameter or WeighVFI. Material (Show direction and distance from at least two State
From —To l3 U Ft. /2"_ J/ W Roads, or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
DepthMaterial Method
From C) 26 To � Ft. i�� �/nrti
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From _ To _ Ft _ in. _ in.
From _ To _ Ft. _ in. in.
From _ To _ Ft. _
16. SAND/GRAVEL PACK:
DepthiS
From To
From To-44
17
in. —in.
Material
I DO HEREBY CERTIFY THAT 4HIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT CCiP�Y OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Quad No:
Serial No.
SIGNATURE OF PERSON CONSTRUCTING THE WELL
Submit original to Divislon of Water Quality, Groundwater Section Within 30 days
DATE
GW-t REV. IV99

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section rat 1 ' 2 6 9
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: I1'vin r s
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable 6ox): Residential ❑---Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: ,�-�/G-!J C 4i[ �� ,���� - County:.-_'��'l7
(Road Name�° tl Numbers. Community, or Subdivision and Lot No.) DRILLING LOG
3. OWNER l `CI Yb / li �/ From To
Address /lfO-�Vc'Y�nw Sf
—(Sree—to r outs No.
i In-tl� Cl- 3D3L� �7
City or Town State Zip Code
4. DATE DRILLED h -'L dL
5. TOTAL DEPTH • 3 r7
6. CUTTINGS COLLECTED YES 7 NOm�
7. DOES WELL REPLACE EXISTING WELL? YES NOQ
8. STATIC WATER LEVEL Below Top of Casing: gl�, FT.
(Use'+' if Above Top of Casing)
9. TOP OF CASING IS
FT. Above Land Surface'
'Top of casing terminated atlor below land surface requires a variance In accor-
dance with 15A NCAC 2C .0118
10. YIELD (gpm): 1'�; METHOD OF TEST
11. WATER ZONES (depth):
Agricultural ❑ Monitoring ❑
DEPTH
Formation Description
12. CHLORINATION: Type 14 Amount If additional space is needed use back of form
13. CASING:
Wall Thickness LOCATION SKETCH
Depth Diameter or Weight/R. Material (Show direction and distance from at least two State
From To �// — Ft. 6". —✓ - c Roads, or other map reference points)
From To Ft.
From To Ft.
14. GROUT:'
Depth Material Method Ft.
�jt�a
d th 's �• _J
From To
_ w
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From —To—Ft— in. in.
From — To Ft. — in. in. P '
From _ To _ Ft. _ In. in.
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
17. REMARKS: -
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY C/�� ore a � GAD 6 � —"w
Quad No: SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Division of water Quality, Groundwater Section within 30 days
Serial No. GW-1 REV. 12/99

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section 211878
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTORk
WELL CONTRACTOR CERTIFICATION #: /
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable sox): Residential Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (S/how sketch of the location below)
y Nearest Town: �//a R Z /Z,? 16 A/C - County:
(Road Name and umbers. Community, or Subdivision and Lot No.) DRILLING LOG
NER / 3. OWC From To
Address
'-`—`- trees or Houle o.
4/O— �,� J
City own State Zip Code
4. DATE DRILLED - xz'
5. TOTAL DEPTH 0_5
6. CUTTINGS COLLECTED YESQ NOQ_
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO�---
8. STATIC WATER LEVEL Below Top of Casing: ,,Vo FT.
(Use '+' it Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface'
'Top of casing terminated attor below land surface requires a variance In accor-
dance with 15A NCAC 2C .0118
10. YIELD (gpm): •E METHOD OF TEST '/
11. WATER ZONES (depth): 3
DEPTH
Formation Description
0
12. CHLORINATION: Type ,2�z�/v Amount ` 4 //S If additional space is needed use back of form
13. CASING:
Wall Thickness LOCATION SKETCH
Depth ,-� Diameter or Weight/Fl. Material (Show direction and distance from at least two State
From--4-To A-2 Ft. --4,1 — ' (--Q-/ Roads, or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From To A2Ft. !7-�m��
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From —To—Ft— in. —in
From _ To _ Ft. _ in. in.
From _ To _ Ft. _ in. _ in.
16.SAND/GRAVEL PACK: ---
Depth �iz@ �MaC2rial
From To.
From To_� Ft;
17
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPYHIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY ^
Quad No: SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Quality, Groundwater Section Within 30 days
Serial No. GW-1 REV. 12179

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section 00611877
1636 Mail Service Center - Raleigh, N.C. 27699.1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: "JLt
WELL CONTRACTOR CERTIFICATION
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: kit G_ a t A n to 4 County: 40 J (-ice �
(Road Name and Numbers, Community, or Subdivision and Lot No.) DRILLING LOG
3. OWNER i 1 rte- it 1 I�- . From To
Address '�zI a I N' E' L 3 CDu ri
7Street or oute o.
City or Town State Zip Code
4. DATE DRILLED
5. TOTAL DEPTH S
6. CUTTINGS COLLECTED YES Q NOEg---
7. DOES WELL REPLACE EXISTING WELL? YES NOE3—
8. STATIC WATER LEVEL Below Top of Casing: 1L— FT.
(Use '+' it Above Top of Casing)
9. TOP OF CASING IS / FT. Above Land Surface-
-Top of casing terminated at/or below land surface requires a varlance In accor.
dance with 15A NCAC 2C.0118
10. YIELD (gpm): 2L METHOD OF TEST _
11. WATER ZONES (depth): 4- '7n
12. CHLORINATION: Type /-/7`/% Amount
13. CASING:
Wall Thickness
Depth Diameter or Weight/Ft. Material
FromTo Ft. L '/'N�
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From To A2 Ft. �s>�
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From _ To _ Ft _ in. _ in.
From —To Ft.
From —To —Ft.
16. SAND/GRAVEL PACK:
Depth
From To
From To
17. REMARKS:
1 DO HEREBY CERTIFY
CONSTRUCTION STANDA 0
FOR OFFICE USE ONLY
Quad No:
Soda] No.
in. —in.
in. in.
�iSitp t> Material
d.
---s-zrT
wU'~
DEPTH
Formation Description
If additional space is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
Wi;¢yljSTRUCTE IN ACCORDANCE WITH 15A NCAC 2C, WELL
'F M. F'TN1S ORDI HAS BEEN(PPROVIDED TO THE WELL OWNER.
L 6
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Quality, Groundwater Section Within 30 days
GW-t REV. 12/99

2118'76
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:'�)?H h, 10"IAW 01 IN'-) r=
WELL CONTRACTOR CERTIFICATION #: "? / G+
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable 6ox): Residential m---I(vfunicipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: 14 / 61 Z a-,<n q V 0- County: -L2)Q. l.rrr( 1
(Road Name and Numbers. Community, or Subdivision and Lot No.) DRILLING LOG
3. OWNER PO.I1Pr7— vn7 �44_� From To
Address (.�� jj liltLI
p'✓ 11
j5tteet or o.
/ IlJ Al f 7 -3 t-/
City or Town State Zip Code
4. DATE DRILLED (7 -L 62)
5. TOTAL DEPTH -225
6. CUTTINGS COLLECTED YES ❑ NO��
7. DOES WELL REPLACE EXISTING WELL? YES M NO[71-
8. STATIC WATER LEVEL Below Top of Casing: _�2 -5 FT.
(Use': II Above Top of Casing)
9. TOP OF CASING IS__z_ FT. Above Land Surface'
'Top of casing terminated at/or below land surface requires a variance In accor-
dance with 15A NCAC 2C .0118
10. YIELD (gpm): L— METHOD OF TEST SLR
11. WATER ZONES (depth):
12. CHLORINATION: Type /ftH Amount r
13. CASING:
Wall Thickness
Depth Diameter or WeighNFt. Material
From To •S { Ft. —/- - , 4�d
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From b To q) Ft.
From To Ft.
15. SCREEN
Depth Diameter Slot Size Material
From —To—Ft— in. in.
From _ To _ Ft. — in. In.
From —To Ft. In. —in.
16. SAND/GRAVEL PACK:
Depth y t;:. Size Material
From To(i • ' ,z Ft.
17
From Tb.' Ft.
I DO HEREBY CE
CONSTRUCTION
FOR OFFICE USE ONLY
Quad No:
Serial No.
Agricultural ❑ Monitoring ❑
DEPTH
Formation Description
If additional space is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
L6aNACCON RUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
�,�,�OPY THIS RECORD HAS BEENPROVIDEDTO THE WELL OWNER.
r=n nr, �,w%pia-L G -�% -aD
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Quality, Groundwater Section within 30 days
GW-1 REV. 12/99

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section 213340
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:, eV) n', S �i, )l n,4 1(11� j ) jl
WELL CONTRACTOR CERTIFICATION #: -7 16- U
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (check Applicable Boa): Residential ❑_­kunicipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other If Other, List Use:
2. WELL LOCAShow sketch of the location below)
Nearest Town:TION: ✓D� l _ l r �41(' - County: l) ) O l er s >
(Road Name an�Numbers, C rpmuniry, or Subdivision and Lot No.) DRILLING LOG
3. OWNER o From To
Address �e h� a ✓ ��c1
ireet or gouts o.
f= lam 1/C C�/3 �l
City or Town State Zip Cod
4. DATE DRILLED
5. TOTAL DEPTH 2-ram '
6. CUTTINGS COLLECTED YES[] NOOK
7. DOES WELL REPLACE EXISTING WELL? YES NO[/3. i
S. STATIC WATER LEVEL Below Top of Casing: .de, FT.
(Use': If Above Top of Casino)
9. TOP OF CASING IS FT. Above Land Surface*
-Top of casing terminated atlor below land surface requires a variance In accor.
dance with 15A NCAC 2C.0116
10. YIELD (gpm): / D METHOD OF TESTLc}LGl`
11. WATER ZONES (depth):�L' /75 O
12. CHLORINATION: Type �L�lf Amount LQ
13. CASING:
-_
Wall Thickness
Depth Diameter or Weight/Ft. Material
FromTo 'L5 Ft.—L -,/S;'�' QG C
From
To Ft.
From
To Ft.
14. GROUT:
Depth Material Method
U
From
To 20 FL h a
From
To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From
—To—Ft— in. —in
Agricultural ❑ Monitoring ❑
DEPTH
Fonration Description
It additional space is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
From _ To _ Ft. _ In. _ in.
From —To —Ft. _ In. _ in. µ
16. SAND/GRAVEL PACK: C {� t6IL
Depth Size Material
From To Ft. _mot ,jE^
From To Ft.
17. REMARKS:
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY,QF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Quad No:
Serial No.
ti7J
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Quality, Groundwater Section Within 30 days
GW-1 REV. 12199

213944
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mal Service Center - Raleigh, N.C. 27699.1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: t,LPMn A 13 LL1)(21'1 /r(0 1/ d)r: I "12
7 ,t C__.
WELL CONTRACTOR CERTIFICATION #: nZ / '7�
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential ❑—Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town:---� 1 cZoi l'l.��) County: / I LC.0 C(y1
(Road Name and Numbers, Community. or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER M" 1 J (C It 9 f)c _ From To Formation Description
Address i1 rl (/, i
e4,i
(Street o ute o.
P c
)��� (r ln�) WIC- U
City or Town St toZip Code
4. DATE DRILLED 61,
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES❑ NO©,
7. DOES WELL REPLACE EXISTING WELL? YES NOED_
B. STATIC WATER LEVEL Below Top of Casing: f/J r� FT.
of
(Use'.' it Above Top of Casing)
9. TOP OF CASING IS FT. Above Land
'Tap of casing terminated atlor below land surface requires a variance In accor-
dance with 15A NCAC 2C.4118
��t� /
10. YIELD (gpm): �'- -0 METHOD OF TEST 7 l
_
11. WATER ZONES (depth): /av „ 7p, _2
12. CHLORINATION: Type Al Amount It additional space is needed use back of form
13. CASING:
Wall Thickness LOCATION SKETCH
Depth Diameter or WeighVFl. Material(Show direction and distance from at least two Stale
From To Ft. tl
Roads, or other map reference points)
From To Fl.
From To Ft.
14. GROUT:
Depth Material Method
From Td�L)Ft.. o
Z-
O
From To Ft. f_
O
n
15. SCREEN: c
Depth Diameter Slot Size Material r—
c_
From —To—Ft— in. —in
From —To _Ft. in. In. a
r-o
m�
From To _ Ft._ In. _ in. s
�o
16. SAND/GRAVEL PACK: N
�r
m
Depth Size Material N
_
From To Ft.
o
z
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 COPY�THIS RECORDHAS BEE PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY = �L'p
Quad No: SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
- Submit original to Division of water Quality, Groundwater Section within 30 days
Serial No. GW-1 REV. 12199

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section 213343
1636 Mal Service Center - Raleigh, N.C. 27699-1636•Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOw�be-QM g 4V 1112,71A 106711' II ,L _77)1 C,
WELL CONTRACTOR CERTIFICATION #: ,j
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Boa): Residential ❑—vlunicipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Stlpw sketch of the location below)
Nearest Town: `I Qnt LI,-rj ,A"r • County: ,,Mr? Cc,, 1
(Road Name and Numbers, Community, or Subdivision and Lot No.) DRILLING LOG
3. OWNERVI" I! From To
tbireet orflaute o.
Cit or Town ! State Zip Code
4. DATE DRILLED ^ -2 -ell
5. TOTAL DEPTH /"S'��
6. CUTTINGS COLLECTED YES Q NO©.,
7. DOES WELL REPLACE EXISTING WELL? YES NOI I _
8. STATIC WATER LEVEL Below Top of Casing:.:?n FT.0
(Use'.' it Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface'
'Top of casing terminated allor below land surface requires a variance In accor-
dance with 15A NCAC 2C .0118 t f
10. YIELD (gpm): .=90 METHOD OF TEST
11. WATER ZONES (depth): I
12. CHLORINATION: Type %/ Amount
13. CASING:
Wall Thickness
Depth ? c Diameter or Weight/R. Matedal
FromTo Ft. ^ 1/4L i
From To Ft.
From To Ft.
14. GROUT:
From n
From
15. SCREEN:
Depth Material
To '9-tt Ft. 4fl' Lz,,
To Ft.
Method
C2r;tJ
Depth Diameter Slot Size Material
From —To—Ft— in. _ in.
From —To Ft. _ in. —in.
From To _ Ft. _ In. —in.
16. SAND/GRAVEL PACK:
17
Depth
From To Ft.
From To Ft.
Size Material
DEPTH
Formation Description
If additional space is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
0
0
0
o
�
C
t—
c
W
o
�
xm
N
rn
..
r
N
o
7
t;. ,
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Quad No:
Serial No.
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Subrit original to Division of Water Quality, Groundwater Section Within 30 days
GWA REV. 12199

North Carolina •Department of Environment and Natural Resources -Division of Water Quality -Groundwater Section 213342
1636 Mail Service Center. Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: j: Cod- , S 1� III ll/ln II liV: l f x�a Th L
WELL CONTRACTOR CERTIFICATION #: / 76,
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential ©—MGnicipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ if Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: 4 Vl�317 I- /: a J 41 C, County:_ t' eLs
(Road Name and Numbers. Community, or Subdivision and Lot No.) DRILLING LOG
3. OWNER ��'v>n �r-t-ca�� _ From To
Address Oh A ) (c L I)
3
City or Town State zip Cadez/
4. DATE DRILLED 44L -Z
5. TOTAL DEPTH f/Oo `
6. CUTTINGS COLLECTED YES ❑ NO[TL_�
7. DOES WELL REPLACE EXISTING' WELL? YE� N0�
8. STATIC WATER LEVEL Below Top of Casing: p FT.
(Use'it Above Top of Casing)
9. TOP OF CASING IS
:FT. Above Land Surface-
-Top of casing terminated et/or below land surface requires a variance In accor-
dance with 16A NCAC 2C.0116 / !/
10. YIELD (gpm): --�L— /l METHOD OF TEST
11. WATER ZONES (depth): —90 -`
12. CHLORINATION: Type Amount Z'
13. CASING:
Wall Thickness
Depth 21 Diameter or Weight/R. Material
FromTo Ft.—L _/ , / "� L'�
From To Ft.
From To Ft.
14. GROUT
Depth Material Method
From To A' Ft.
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From —To—Ft— in. _ in.
From —To Ft. _ In. —In.
From —To —Ft. _ In. —In.
16. SAND/GRAVEL PACK:
17
Depth Size Material
From To Ft.
From To Ft.
Agricultural ❑ Monitoring ❑
DEPTH
Formation Description
If additional space is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points) O
C3
L
C
r
W
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC ZC, WELL "
CONSTRUCTION STANDARDS, AND THAT A COPY OF TgIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Quad No:
Soda] No.
N
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Oualily, Groundwater Section within 30 days
GW-1 REV. 12'99
0

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section 213,241
1636 Mail Service Center- Raleigh, N.C. 27699.1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: • h`n471 5 14/101',/1 WJ/1 01-) C,
WELL CONTRACTOR CERTIFICATION #: / -7 (<
STATE WELL CONSTRUCTION PERMIT#:
1.
WELL USE (Check Applicable sox): Residential 0--gu-nicipal ❑
Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑
If Other, List Use:
2.
WELL LOCATION: Show sketch of the location below)
Nearest Town:County: 1422
/J
(Road Name and Numbers, Community, or Subdivision and Lot No.)
DRILLING LOG DEPTH
3.
OWNER 1 =w / - _
From To Formation Description
Address ", Pie
ireet or KOUle o. �J
City or Town State Zip Code
4.
DATE DRILLED (o - 2 l
� 2
5.
TOTAL DEPTH ih
6.
CUTTINGS COLLECTED YES F� NO©---
7.
DOES WELL REPLACE EXISTINGWELL? YES 0 NOM
8.
STATIC WATER LEVEL Below Top of Casing: ;,,-, FT.
9.
(Use -r' If Above Top of Casing)
TOP OF CASING IS FT. Above Land Surface'
'Top of casing terminated aVor low land surface requires a variance In accor.
dance
with 15A NCAC 2C.01/8
10.
YIELD (gpm): 15 METHOD OF TEST v') L nZ/.aZ6�-
11.
WATER ZONES (depth):-
12.
CHLORINATION: Type - ff f Ff
yp Amount
It additional space is needed use back of form
13.
CASING:
Wall Thickness
LOCATION SKETCH
Depth Diameter or Weight/R. Material
(Show direction and distance from at least two Stale
From 2 To 3 .S Ft. —(�._ ., s r '
Roads, or other map reference points)
From To Ft.
From To Ft.
0
14.
GROUT:
CD
Depth Material Method
c
From To Ft. In 2 l
t—
n
From To Ft. /
I
= ZE
15.
SCREEN:
3:0
Depth Diameter Slot Size Material
From —To —Ft— in. —in
N
;u�
m
From To —Ft. In. —in.
• r-
From To —Ft. _ In. _ In.
N
z
16.
SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
17.
REMARKS:'
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEENPROVIDEDTO THE WELL OWNER.
FOR OFFICE USE ONLY �� 1� x• - ;;2 3 - -n
Quad No: SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Quality, Groundwater Section within 30 days
Serial No. GW1 REV. 12/99

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section 13 " 2 O
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: Pl)1 e Ja il, ,.a fJc)1 fir, rl r,l '-r)2
WELL CONTRACTOR CERTIFICATION #: a / 7/�
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (check applicable Box): Residential unicipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show '' sketch of the location below)
Nearest Town: Cy,��,/l' i County: /,�� I'("
(Road Name and Numbers, Co unity, or Subdivision and Lot No.) DRILLING LOG
3. OWNER _ L. .L./Q'T �Q 72.r�'Y(n From To
Address �C�. S %��Q1y7 ri r ithJ lC
($treat or MOUL8 o.
-f!VZ11b)L-1 (7. .-�D.1. `1J
City or Town r State Zip Code
4. DATE DRILLED
5. TOTAL DEPTH 44_2 <
6. CUTTINGS COLLECTED YES 0 NO©i'
7. DOES WELL REPLACE EXISTING WELL? YES NOS
8. STATIC WATER LEVEL Below Top of Casing: fib, FT.
(Use'i II Above Top of Casing)
9. TOP OF CASING ISFT. Above Land Surface*
'Top of casing terminated atlor below land surface requires a variance in accor.
dance with 16A NCAC 2C.011e
10. YIELD (gpm): �_ METHOD OFTEST
11. WATER ZONES (depth): LS21
Agricultural ❑ Monitoring ❑
DEPTH
Formation Description
12. CHLORINATION: Type Ad 9 P Amount _4//� If additional space is needed use back of form
13. CASING:
Wall Thickness
/, Depth �. Diameter or Wei hVFL Matenal
From Ft._� i=
From To Ft. —
From To Ft.
14. GROUT:
Depth Material Method
From D To �1 Ft. 4 Pm if�
From To Ft.
15. SCREEN
Depth
Diameter
From
To _
Ft _ In.
From —To
—Ft.
in.
From —To
_
Ft. _ In.
16. SAND/GRAVEL PACK:
Depth
Size
From
To
Ft.
From
To
Ft.
17. REMARKS:
Slot Size Material
in.
in.
In.
Material
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
0
O
O
L
n
o rn
=; rn
Do
yo
rn
Q1
Y
p
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A Y OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY�7t-au�
Quad No:
Serial No.
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Quality, Groundwater Section within 30 days
GW-1 REV. 12/99

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699.1636-phone [phone] j
WELL CONSTRUCTION RECORD WELLCONTRACTOR: d)enn;S Ito, 1ILel) Pn:11tjLLaInc
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMIT#:
WELL USE (check Applicable Box): Residential m—­Municipai ❑ Industrial ❑
Recovery ❑ Heat Pump Water injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below) n�
Nearest Town: �J1�4/ C� County: _L / / O 6-,,
(Road Name and Numbers, Community, or Subdivision and Lot No.) DRILLING LOG
3. OWNER _11�;4 /)I p From To
Address t117a ( I
—j5t eet or u o. c1
�'
Cary or Town State Zip Code
4. DATE DRILLED S- S4-4 7"
5. TOTAL DEPTH 11�)7 _5
6. CUTTINGS COLLECTED YES NO[3-'
7. DOES WELL REPLACE EXISTING WELL? YES NO©-
8. STATIC WATER LEVEL Below Top of Casing: - CZ FT.
(Use': If Above Top of Casing)
9. TOP OF CASING ISFT. Above Land Surface'
'Top of cuing terminated at/or below land surface requires a variance In accor-
dance with 15A NCAC 2C.0118
10. YIELD (gpm): L'-,- METHOD OF TEST i c ul
11. WATER ZONES (depth): _ %S
12. CHLORINATION: Type Z�tfi Amount ` y
13. CASING:
Wall Thickness
�� Depth Diameter or WeighVFl. Material
From TO a Ft.-'- , r ems/
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From To *n Ft. neI-nPn_Ti nl1
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From _ To _ Ft _ in. _ in.
From _ To _ Ft. _ in. In.
From _ To _ Ft. _ In. _ In.
16. SAND/GRAVEL PACK:
Depth Size Material'
From To v L� ,
From TO
17. REMARKS: � Bute d
I DO HEREBY CE
CONSTRUCTION
FOR OFFICE USE ONLY
Quad No:
Serial No. 1� I _5 I _L 0
Agricultural ❑ Monitoring ❑
DEPTH
Formation Description
, O e
If additional space is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
IN ACCORDANCE WITH 15A NCAC 2C, WELL
OORD HAS BEEN PROVIDED TO THE WELL OWNER.
lriFKn / v-o JV 1""y v
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Quality, Groundwater Section within 30 days
GW-1 REV. 12199

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699.1636-Phone [phone]
�nnl5 fella d lJe)! 1rr /I;y_� 1 nC
WELL CONSTRUCTION RECORD WELL CONTRACTOR: J,1
5 �
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other M If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: .r/C County: ma te'-Y`1
Agricultural ❑ Monitoring ❑
(Road Name and Numbers. Community, or Subdivision and Lot No.)
DRILLING LOG DEPTH
3.
OWNER
From To Formation Description
Address/�� J r�
—Street
or ou a a `
iinz // /dhJ Ai"(' ey 3 Ll
C�
City or Town State Zip Code
4.
DATE DRILLED 3 - C70
S.
TOTAL DEPTH
6.
CUTTINGS COLLECTED YES ❑ NOQ-'
7.
DOES WELL REPLACE EXISTING WELL? YES [ NO©-
8.
STATIC WATER LEVEL Below Top of Casing: p FT.
CD o
9.
(Use's' d Above Top of Casing)
TOP OF CASING IS if FT. Above Land Surface*
G1A
= oC'
-Top of easing terminated suor below land surface requires a variance In accor.
-1! �<
dance with 15A NCAC 2C. tta
10.
YIELD (gpm): METHOD OFTEST
11.
WATER ZONES (depth): —2.ft)
�o
r m
12.
CHLORINATION: Type Amount ��
If additional space is needed use back of form
_ Ny
��
W
13.
CASING:
o
2
Wall Thickness
LOCATION SKETCH
-
Depth Diameter or WeighVFI. Material
FromTO /15L FL 6 - / 19
(Show direction and distance from at least two State
, .�
Roads, or other map reference points)
From To Ft.
From To Ft.
14.
GROUT:
Depth Material Method
From �_ To .212 Ft. O emP,n`1— nnfr 0
From To Ft.
15. SCREEN
Depth Diameter Slot Size Material
From To _ Ft _ in. _ in.
From _ To _ Ft. _ in. In.
From _To —Ft. _ In. _ In.
16. SAND/GRAVEL PACK:
Depth tie l_ ateriar t
From To lU—J— —'
From To t.
17
I DO HEREBY CE
CONSTRUCTION
FOR OFFICE USE ONLY
Quad No:
Serial No. r.� _L 0 '. 1 1
ffli
PFECORD
D IN ACCORDANCE WITH 15A NCAC 2C, WELL
HrA/SBEI/ENPROVIDEDTOTHEWELL,OWNER.
2
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
SubrnII original to Division of Water Quality, Groundwater Section within 30 days
GW4 REV. 12199

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699.1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: 7i-eil n I S
WELL CONTRACTOR CERTIFICATION If: �d 7
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential D_ Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION• (Show sketch of the location below)
Nearest Town: _,�� ��� !�_ / r7-i .n/C'� County:
(Road Name and Numbers, Community, or Subdivision and Lot No.) DRILLING LOG
3. OWNER k' �P U i n fl) a t Y 1' From To
Address p i S a,
(busel orRoute o. _
/ ,., Ie 1 tiJ n/ Ci 0 fi '7
City or Town State Tip Code
4. DATE DRILLED 5 - 2— ciz)
5. TOTAL DEPTH E a �-
6. CUTTINGS COLLECTED YES ❑ NOOK
7. DOES WELL REPLACE EXISTING WELL? YES NO©--
8. STATIC WATER LEVEL Below Top of Casing: -7 0 FT.
(Use': If Above Top of Cuing)
9. TOP OF CASING ISFT. Above Land Surface'
'Top of casing terminated at/or below land surface requires a variance In accor-
dance with 15A NCAC 2C.0118
10. YIELD (gpm): METHOD OF TEST I 1 c u t
33 '
DEPTH
Formation Description
11.W ATER ZONES (depth): n
. Z
12. CHLORINATION: Type P> /-/ Amount It additional space is needed use back of form
13. CASING:
Wall Thickness LOCATION SKETCH
Depth Diameter or Weight/Ft. Material (Show direction and distance from at least two Slate
FromTo Ft. /I " / �-k P" e' Roads, or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From To .-') n Ft. n er11 P nT to n
From To Ft.
15. SCREEN
Depth Diameter Slot Size Material
From To Ft _ in. _ in.
From To —Ft. _ in. — In.
From —To —Ft. _ In. _ In.
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From TO L fl
17. REMARKS: "
1 DO HEREBY CERTIFY T,T IS WELL WAS CONSTR TE IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTSTAND IS R
RUCTION CORD HAS BEEN PROVIDED TO THE WELL OWNER.
pshevil Re 'oral 1 , ,
FOR OFFICE USE ONLY 4r5
Quad No: SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit original 10 Division of Water Quality, Groundwater Section within 30 days
Serial No. � 4 � � s .r GW1 REV. 12/99

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: -ADnn; It. 1)4.,,, (II'd II br;J) rw_VL I" e
WELL CONTRACTOR CERTIFICATION #: , 2 / % r-
STATE WELL CONSTRUCTION PERMIT#:
1, WELL USE (Check Applicable Box): Residential Lam' Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: (�) 1�7T= /i (- - County: M
(Road Name and Numbers, Comm
or Subdivision and Lot No.) DRILLING LOG
3. OWNER L l /2 FI �li YL'_7 _ , From To
Address 17 /_ or No.)
treat or outste�o.)
City or To Stale Zip Code
4. DATE DRILLED J - �— 7 i
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YESQ NO[9—�
7. DOES WELL REPLACE EXISTING WELL? YES NO[ I
6. STATIC WATER LEVEL Below Top of Casing: SL; FT.
(Use'+' if Above Top of Casing)
9. TOP OF CASING ISFT. Above Land Surface -
'Top of casing terminated at/or below land surface requires a variance In accor-
dance with 15A NCAC 2C .0)18
10. YIELD (gpm): _77— METHOD OF TEST
11. WATER ZONES (depth):
DEPTH
Formation Description
12. CHLORINATION: Type-'/ u Amount YL zza'If additional space is needed use back of form
13. CASING:
Wall Thickness LOCATION SKETCH
Depth Diameter or Weight/Ft. Material (Show direction and distance from at least two State
From- �To 1 / Ft. —ia— , -v pv P " Roads, or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
O
Depth Material Method CO
From To 2 Ft.
From To Ft.
15. SCREEN:
Depth
Diameter
Slot Size Material
From To
Ft in.
_ in.
A
3
From To
Ft. _ in.
_ in.
From
_ in.
_ in.
N
—To —Ft.
16. SAND/GRAVEL PAWF'T
Dept19iZ'
15--_L'
n ,1rr
If
From Tol�
From To17.
REMARKS:JUT
: i117
I DO HEREBY CE
CONSTRUCTION
FOR OFFICE USE ONLY
Quad No:
Serial No.
o , u�ec TRL1TED IN ACCORDANCE WITH 15A NCAC 2C, WELL
XT *I . , e .ONdOF TH RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Quality, Groundwater Section Within 30 days
GW-1 REV. 12/99

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone] _
WELL CONSTRUCTION RECORD WELL CONTRACTOR: 'T�P n n ; s LUaA
f n
WELL CONTRACTOR CERTIFICATION #: -;2/ 7 (I
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable sox): Residential Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: .Ff-✓'1 r1 iLi':;" 1 IL County: Z%)/1 r+`,1
(Road Name and Numbers, Communiry�or Subdivision and Lot No.) DRILLING LOG
3, OWNER 7-A F f1l7cJ I d"I i t. / 4 From To
Address L CKSl��!/t
// Street or oute o.
/C� �'73 L/
City or Town State Zip Code
4. DATE DRILLED 5-22-crzJ
5. TOTAL DEPTH -2--l25 '
6. CUTTINGS COLLECTED YES Q NOE2_-
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NOfi 1
8. STATIC WATER LEVEL Below Top of Casing: -O - FT.
(Use': it Above Top of Casing)
9. TOP OF CASING IS_�_ FT. Above Land Surface-
-Top of casing terminated atfor below land surface requires a variance In accor-
dance with 15A NCAC 2C .0118
10. YIELD (gpm): _V METHOD OF TEST L/G17/i
11. WATER ZONES (depth): M
12. CHLORINATION: Type ALL# Amount Z� Z
13. CASING:
Wall Thickness
Depth Diameter or WeighVFl. Material
Fromm —To L_ Ft. & 11S-k PkIL'
From To Ft.
From To Ft.
14. GROUT
Depth Material Method
From 0 To 26 Ft. /rd4t 111 4Z �1p1
%"a2
—
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From —To—Ftin. —in.-
From To _ Ft. _ in. _ in. _
From _ To _ Ft. (_ In. _ in. _
16. SAND/GRAVEL
Depth lJ u n(�"N',"'�•,�,@'.���t
From To O Ft.
From To FL rw.•
17. REMARKS:
I DO HEREBY CERTI
CONSTRUCTION ST
FOR OFFICE USE ONLY
Quad No:
Serial No.
Agricultural ❑ Monitoring ❑
DEPTH
Formation Description
If additional space is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
0
C
O
co �
Co
cm
?
.rn
�o
S
;10m
rrnn ;;o
N
s
ED IN ACCORDANCE WITH 15A NCAC 2C, WELL
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
. /J.®') r � 5'-�'_v=
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Quality, Groundwater Section within 30 days
GW-1 REV. 12/"

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: ?nn;� olla-nrJ Cl1ePi/I;)t�/
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable sox): Residential0--v—uricipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION:,(Show sketch of the location below)
Nearest Town: k- County:
(Road Name and N mbers. Community, or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER c_�to O y1 h From To Formation Description
Addressr
,� trees or outs o�—
l��O�d'73
City or Town State Zip Code'
4. DATE DRILLED S - 19 -LrO
5. TOTAL DEPTH /O S
6. CUTTINGS COLLECTED YES ❑ NO®/
7. DOES WELL REPLACE EXISTING WELL? YES EJ N023_-
8. STATIC WATER LEVEL Below Top of Casing: -o - FT.
(Use '+' if Above Top of Casing)
9. TOP OF CASING ISFT. Above Land Surface -
•Top of casing terminated at/or below land surface requires a variance In accor•
dance with 16A NCAC 2C .0118
10. YIELD (gpm): / .S METHOD OF TEST
11. WATER ZONES (depth): /f 2
12. CHLORINATION: Type 1Z LLAmount If additional space is needed use back of form
13. CASING:
Depth Diameter
From _ Ft. L -'
From To Ft.
From To Ft.
14. GROUT
Wall Thickness LOCATION SKETCH
or Weight/Ft. Material (Show direction and distance from at least two State
i
LL� ' Roads, or other map reference points)
Depth Material Method
From U To - 20 FL (6'-in Lz,
From To Ft.
15. SCREEN:
Depth Diameter
From To _ Ft in.
From —To—Ft.— in.
From _ To Ft. _ in.
16. SAND/GRAVEL PACK:
It (. 1111111.71wUA
Slot Size Material
in.
_ in.
in.
O
O
G
Z
I
0
0
ao m
o c'
cc'
rn
o<
>o
--tom
mo
;am
m�
Ct,
0
Z
I DO HEREBY gTlkvAT T�((,S WELL WAE CO STRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTITANF4hRDS'C1ATlCA3Qifidff A COP F THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
1s � iMil office
FOR OFFICE USE ONLY
Quad No: SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Quality, Groundwater Section within 30 days
Serial No. �GW1 REV. 1219

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELLCONTRACTOR: t/Jt°nnr�-
WELL CONTRACTOR CERTIFICATION #: .:/17�-
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (check Applicable Box): ResidentialElk—NiTnicipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Sflow sketch of the location below)
Nearest Town: =y'62 1 P County:
(Road Name and Numbers. Community, or Subdivision and Lot No.) DRILLING LOG
3, OWNER GL Ll! 1 From To
Address / cf
(btreet or moute o.
City or Town State Zip Code
4. DATEDRILLED
5. TOTAL DEPTH ";2 7 `i
6. CUTTINGS COLLECTED YES Q NOED—_
7. DOES WELL REPLACE EXISTING WELL? YES NOE—
8. STATIC WATER LEVEL Below Top of Casing: _/ S FT.
(Use '+' it Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface'
-Top of casing terminated at/or below land surface requires a variance In eccor-
dance with 15A NCAC 2C .0118
10. YIELD (gpm): , 5 0 METHOD OF TEST /J 72
11. WATER ZONES (depth): 90 " /SD' _ LI Q
12.CHLORINATION: Type LiYfl Amount
13. CASING:
Wall Thickness
Depth Diameter or WeighVFt. Material
From 12 To Ft. (, "" .I /.i S _
From To Ft.
From To Ft.
14. GROUT
Depth Material Method
From l) To -0 Ft.
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From —To—Ft— in. —in.—
From To Ft. _ in. _ in.
From _ To _ Ft. _ In. in.
16. SAND/GRAVEL
17
From —Ft.
From Tjlllli ft
100 HEREBY CE
CONSTRUCTION
FOR OFFICE USE ONLY
Quad No:
Serial No.
Agricultural ❑ Monitoring ❑
DEPTH
Formation Description
If additional space is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
L $ CONS UCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
Pj-BHIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Quality, Groundwater Section within 30 days
GW-1 REV. 12/99

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:. Pfnn, y 111a„rl &fell
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential © --Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: 0 7%- 0 County:
(Road Name and Numbers, Community, or Subdivision and Lot No.) DRILLING LOG
3, OWNER L, -J am %YI P S From To
Address l/ 3 9 3G/ 4V6rbde /,?/✓-I, `a5,;�
(Street or KOUta o.
City or Town slate Zip Code
4. DATE DRILLED L'.36 -90?, J
5. TOTAL DEPTH 545_6
6. CUTTINGS COLLECTED YES ❑ NO�
7. DOES WELL REPLACE EXISTING WELL? YES ❑ N0ED--
8. STATIC WATER LEVEL Below Top of Casing: •S• p FT.
(Use': it Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface -
'Top of casing terminated atlor below land surface requires a variance In accor.
dance with 15A NCAC 2C 118
10. YIELD (gpm): METHOD OF TEST
11. WATER ZONES (depth): L 5 /
12. CHLORINATION: Type �17'/l Amount �(
13. CASING:
Wall Thickness
Depth Diameter or Weight/Ft. Material
FromTo .5 , Ft. l pl"2
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From 0 To - 0 Ft. /L-irn-e4l
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From —To—Ft— in. —in
From _ To _ Ft. _ in. in.
From —To _ Ft. in. —in.
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
17. REMARKS:
Agricultural ❑ Monitoring ❑
DEPTH
Formation Description
It additional space is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STq ILlAF3[7&AUP THAT -AA COPY �OFF�THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
OL
FOR OFFICE USE Of!)
IL^f N
Quad No: SI RE OF PERSON CONSTRUCTING THE WELL DATE
.�Supm1 inal on of WaterQuali Groundwater Section Within 30 days
YY IUN L' " _ "' y
Social No. c I `� if � GW-1 REV. 12/99

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELLCONTRACTOR: Aenn, S Ayo m 0121) l)o
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable sox): Residential❑ unicipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: - I' Jar k' I i--i j �,t2 — County:
(Road Name and Numbers, Community, or Subdivision and Lot No.) DRILLING LOG
3. OWNER M Vr2. J L1iM. 5n From To
Address I I
i—(Sveet or�tTfoute o.
Z')
City or Town State Zip Code
4. DATE DRILLED `S ' /
5. TOTAL DEPTH :2n
6. CUTTINGS COLLECTED YES ❑ NOED--'
7. DOES WELL REPLACE EXISTING WELL? YESF7 NOCDi
6. STATIC WATER LEVEL Below Top of Casing: — 0_ FT.
(Use': it Above Top of Casing)
9. TOP OF CASING IS� FT. Above Land Surface'
-Top of casing terminated at/or below land surface requires a variance In accor-
dance with 15A NCAC 2C .0118
10. YIELD (gpm): -15y- METHOD OF TEST 7?
11. WATER ZONES (depth): 2 L S
12. CHLORINATION: Type
f%-7 b1 Amount
13. CASING:
Wall Thickness
Depth Diameter or Wei ht/Ft. Material
Fromm —To �Ft.L r
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From Tom Ft. ("P , ,, 71212d,�iL
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From —To—Ft— in. in.
From _ To Ft. _ in. in.
From _ To _ Ft. in. _ in.
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
17. REMARKS:
Agricultural ❑ Monitoring ❑
DEPTH
Formation Description
If additional space is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STA T A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ON Lb 1 S-3,1—oZ_)
Quad No: 'SIGgiln
E OF PERSON CONSTRUCTING THE WELL DATE
II'�I Ljubmitgrigigal to of Water Quality, Groundwater Section within 30 days
Serial Na. �""" `' " - GW.1 REV. 12199

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
_T
T I ti. L
WELL CONSTRUCTION RECORD WELL CONTRACTOR:�Dph h'i '3 �� hl',(A L 101 / �Y-;/( LU-1-.I
WELL CONTRACTOR CERTIFICATION #: �'7C-• U
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential ❑ unicipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: r1� Zt / -/ < — County: --
(Road Name andNymbers, Community, or Subdivision and Lot No.) DRILLING LOG
3. OWNER % /d r l I i a-yY i c� From To
Address / n f f �tre0-1 ,_ p� _
et or Houle 0.
City or Town State Zip Code
4. DATE DRILLED c) a�
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑ NOQ--'
7. DOES WELL REPLACE EXISTING WELL? YES N0Eg/
8. STATIC WATER LEVEL Below Top of Casing: 1 (-1 FT.
(Use `l It Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface'
'Top of casing terminated aflor below land surface requires a variance In accor-
dance with 16A NCAC 2C .011a
10. YIELD (gpm): /0 0 METHOD OF TEST /
11. WATER ZONES (depth): !�! 75 r
12. CHLORINATION: Type Y-L /L Amount /
13. CASING:
Wall Thickness
Depth Diameter or Weight/Ft. Material
From —To 71 Ft. 6 _ 11SiL
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From r) To 20 Ft.
From To Ft.
15. SCREEN
Depth Diameter Slot Size Material
From To _ Ft _ in. —in.
From — To _ Ft. _ in. _ in. -
From —To Ft. _ in. in.
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
17. REMARKS:
DEPTH
Formation Description
If additional space is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
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 OFF7;JE
15 v _ `� S Uzi
Quad No: E OF PERSON CONSTRUCTING THE WELL DATE
Submit odginal t i n of Water Quality, Groundwater Section within 30 days
Serial No. 2 O 2non ! GW-1 REV. 12t99
c,

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699.1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: _�)ell hi S �y II fir: C_
WELL CONTRACTOR CERTIFICATION #: EZ
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential 0/Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION (Show sketch of the location below)
Nearest Town: r—Y/i'm V / �' n/ i) — County: —,M
(Road Name wdNymbars, Community, or Subdivision and Lot No.) DRILLING LOG
3. OWNER _ l /ate 1A (',I .m ()it.'�1 n i From To
Address
r (Street or Roule o.
City or Town State Zip Code
4. DATE DRILLED
5. TOTAL DEPTH r/ '
6. CUTTINGS COLLECTED YES ❑ NO[a'
7. DOES WELL REPLACE EXISTING WELL? YES NO©--
6. STATIC WATER LEVEL Below Top of Casing: (_ r FT.
(Use'+' It Above Top of Casing)
9. TOP OF CASING ISFT. Above Land Surface'
Top or casing terminated atlor below land surface requires a Varian" In accor.
dance with 15A NCAC 2C.0118
10. YIELD (gpm): METHOD OF TEST h 1 c u
11. WATER ZONES (depth):
12. CHLORINATION: Type Amount
13. CASING:
Wall Thickness
Dept Diameter or Weight/Ft. Material
From To I Ft.
From To Ft.
From To Ft.
14. GROUT:
Depth Material
From To Q 0 Ft. n L21-U P n`)-
From To FL
15. SCREEN:
Depth Diameter Slot Size
From —To—Ft— in. —in
From —To _
From —To
16. SAND/GRAVEL PACK:
Dept
From To
From To
17. REMARKS:
UL
100 HEREBY CER
CONSTRUCTION S
FOR OFFICE USE C
Quad No:
Serial No.-L_S-L1�
Ft._ in. —In
Ft._ In. —In.
DEPTH
Formation Description
If additional space is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least two Slate
Roads, or other map reference points)
Method
t3
ZEE
a
�m
—t
crn
Material
o
F
Dv
a
m�
m2z
tJf
—�i
1Sepal
z
THIS WELL WAS CO STR CTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
IS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
,hev��ille l nal,Office
SIGNATURE OF PERSON CONSTRUCTING THE WELL _ DATE
Submit original to Division of Water Quality, Groundwater Section within 30 days
GW-1 REV. 12199

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699.1636-Phone [phone]
WELL CONSTRUCTION RECORD WELLCONTRACTOR: �fnhi 5DIJa G1ell der; 11 r nL
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential E STMunicipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: /'✓ / /L-A i n, C County: - '02 6 M
(Road Name and Numbers, Communi , or Subdivision and Lot No.) DRILLING LOG
3. OWNER •-eo r a c , rT From To
Address
(Street or Kom Nol
%vJM i /yc� :;� 9S °73 cZ
City or Town State Mp Code '
4. DATE DRILLED // - -7-.2 t 2&-)
5. TOTAL DEPTH 3 ZS
6. CUTTINGS COLLECTED YES ❑ NOQr
7. DOES WELL REPLACE EXISTING WELL? YES 0 NO©--
8. STATIC WATER LEVEL Below Top of Casing: FT.
(Use'+' 0 Above Top of Cuing)
9. TOP OF CASING ISFT. Above Land Surface'
'Top of casing terminated Wor below land surface requires a Variance In accor-
dance with 15A NCAC 2C .0�1/a
�j�
10. YIELD (gpm): �L METHOD OF TEST f
11. WATER ZONES (depth):
12. CHLORINATION: Type H-fk Amount r
13. CASING:
Wall Thickness
Depth Diameter or Weight/R. Material
From To 1 " Ft. 6� ' 1,(-L J
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From To 217—Ft. n eMP nT nnrf t4
From To Ft. i��
15. SCREEN
Depth
From To
From —To _
From —To
16. SAND/GRAVEL PACK:
17
Depth
From To -
From To_
I DO HEREBY CERTIFY
CONSTRUCTION STAN
FOR OFFICE USE ONLY
Quad No:
Serial No.
Diameter Slot Size Material
Ft _ in. —in.
Ft._ in. — In.
Ft._ In. —in.
Material
DEPTH
Formation Description
If additional space is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
IN ACCORDANCE WITH 15A NCAC 2C, WELL
CORD HAS BEEN PROVIDED TO THE WELL OWNER.
4-,%_
0
CD
C o
= cr
o
-t c
1 0
'� yl
sae rn,
z i
_
Orn:
N -1
CJ) c
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Quality, Groundwater Section within 30 days
GW1 REV. 12J99

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
V 1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: �)ell hi 1�IlQnJ tie)) Tr: )I
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMIT#:
1.
WELL USE (Check Applicable Boa): Residential M Municipal ❑
Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2.
WELL LOCATION: (Show sketch of the location below)
Nearest Town: G✓nn/i�r-zri /�^i County: '22'
x J
(Road Name and Numbers. Community, of Subdivision and Lot No.)
DRILLING LOG DEPTH
3.
OWNER C(.!-!Ne4
From To Formation Description
Address (� - am /2:
/ treat or ou e o. ✓� �yq —
/l'
city or 1 own State Zip oCp —
4.
DATE DRILLED-/ -(2)
5.
TOTAL DEPTHS 7S S
6.
CUTTINGS COLLECTED YES ❑ NOQ-'
7.
DOES WELL REPLACE EXISTING WELL? YES ❑ NO©-�
8.
STATIC WATER LEVEL Below Top of Casing: FT.
9.
(Use'+' 0 Above Top of Casing)
TOP OF CASING IS_L_ FT. Above Land Surface*
'Top of casing terminated at/or below land surface requires a variance In accor-
dance with 15A NCAC 2C.0118
10.
YIELD (gpm): 10 METHOD OF TEST h 1 c u
11.
WATER ZONES (depth): / n
12.
CHLORINATION: Type _f1 ffG Amount r
If additional space is needed use back of form
13.
CASING:
Wall Thickness LOCATION SKETCH
Depth Diameter or Weighl/Ft. Material (Show direction and distance from at least two State
From To � Ft. 6 - r / Roads, or other map reference points)
From To Ft.
From To Ft..
14. GROUT:
Depth Material Method
From n To .20 Ft. n e)-n P nT n l�
o
From To Ft.
c
o
15. SCREEN:
z
Depth Diameter Slot Size Material
z
cm
From _ To _ Ft _ in. _ in.
1
zo.<
From —To —Ft. _ in. In.
r
ao
From _To _ Ft._ In. in.
=
Aa
16. SAND/GRAVEL PACK:
,'
u+i
Depth Materia(
N
C)
leli7
From To - '
From To IFI
Cn
0
z
17. REMARKS: ) 7
I DO HEREBY CERTIF1� �RSTRU ED IN ACCORDANCE WITH 15A NCAC E WELL
CONSTRUCTION ST,.ee�-nnhhL�''���cccc�..�_I,�_!-- 066 tWOFTHI RECORD HAS BEEN PROVIDED TOTHEWELL OWNER.
FOR OFFICE USE ONLY 7777 4 14 CC"'t,,li , ki _ / ;� mp
Quad No: SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Quality, Groundwater Section within 30 days
Serial No. 4,3' "r -Y ? GW-1 REV. 17199

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699.1636-Phone [phone]
WELL CONSTRUCTION RECORD WELLCONTRACTOR: Pnhi S �alla•, ! &Sell 'fir' 11 ThL
WELL CONTRACTOR CERTIFICATION #:'%
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (CheckApplicabla Box): ResidentialL/KMunicipal ❑
Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: �j'�1,++ E' t T A 'n County: ,�t2fEr�"
(Road Name and Numbers, Communi , or Subdivision and Lot No.)
DRILLING LOG DEPTH
3. OWNER
From To Formation Description
Address
beet or ouie o.
Ci or Town Slate Zlp Code
4. DATE DRILLED 4-17 n�
S. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑ NOED-'
7. DOES WELL REPLACE EXISTING WELL? YES NO©--
8. STATIC WATER LEVEL Below Top of Casing: 916 FT.
(Use •t 0 Above Top of Cuing)
9. TOP OF CASING ISFT. Above Land Surface -
'Top of easing terminated atfor below land surface requires a varlanee In accor.
dance with 1SA NCAC 2C.0118
10. YIELD (gpm): --� METHOD OF TEST
11. WATER ZONES (depth): / 0'
/u///
12. CHLORINATION: Type _fff{G Amount .
YP h
If additional space is needed use back of form
13. CASING:
Wall Thickness
LOCATION SKETCH
Depth Diameter orweight/ft. Material
From 0 To Ft. 6 ` / / i� P L-1 (2
(Show direction and distance from at least two State
Roads, or other map reference points)
From To Fl.
From To Ft.--
o
14. GROUT:
o
CD
Depth Material Method
3
s=
From _0 To .*n Ft. nernPnr nl1�`
C�m
From To Ft.
�o<
15. SCREEN:
Dmo
Depth Diameter Slot Size Material
MCAo
From _ To _ F(_ in. _ in.
rn
From _ To _ Ft. _ in. —in.
zo
From _ To _ Ft. _ In. —In.
CA
cn
c
16. SAND/GRAVEL PA & -- -._.
From To
From To
17
I DO HEREBY CERTI Q mit' STR CTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION ST ' (16hAJpp R TIA IS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
a
FOR OFFICE USE ONLY �Nt1au IC<t ru�1 �f — 1 i — OD
Quad No: SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Quality, Groundwater Section within 30 days
Serial No. i„ ) GW4 REV. 1219

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699.1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:.* Pnn, 5 �a116^tea LSel1 fir. 11TnL
WELL CONTRACTOR CERTIFICATION #:_/
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (check Applicable Box): Residential M/Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: �—I %� �� is l n, J /L C . County: �'7 Q Crn t r
(Road Name antl Numbers. Community, or Subdivision and Lot No.) DRILLING LOG
3. OWNER % C From To
Address Snr%ltcn- 1" ,2c-(_
ee ) �(Stror pule
i�I'd211A/r,
City or Town State Zip Cod
4. DATE DRILLED elf
5. TOTAL DEPTH 3 7. S
6. CUTTINGS COLLECTED YES ❑ NOQ-'
7. DOES WELL REPLACE EXISTING WELL? YES NO©�-
8. STATIC WATER LEVEL Below Top of Casing: FT.
(Use'+' 0 Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface'
-Top of casing terminated at/or below land surface requires a variance in accor-
dance with 15A NCAC 2C.0118
10. YIELD (gpm): 15 METHOD OF TEST 1 C
11. WATER ZONES (depth):
12. CHLORINATION: Type /H/E Amount cc{Ar=
13. CASING:
Wall Thickness
Depth Diameter or Weight/R. Material
�%/' � � From To Ft. -r '(2--
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From 0 To _M) Ft. QIT1 B nT 2L1ui_
From To Ft.
15. SCREEN:
Depth Diameter Slot Size
From To _ Ft _ in. _ in.
From —To — Ft._ in. _ In.
From —To _ Ft._ In. _ in.
16. SAND/GRAVEL PACK:
Depth
17
From To
From To
I DO HEREBY CERTIFY
CONSTRUCTION STAN
FOR OFFICE USE ONLY
Quad No:
Material
DEPTH
Formation Description
If additional space is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
IN ACCORDANCE WITH 15A NCAC 2C, WELL
'ORD HAS BEEN PROVIDED TO THE WELL OWNER.
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Quality, Groundwater Section within 30 days
C3
O
O
a CD
< =n
4 �n
Do
a r„ �
3 =m
O NZ
ma
Cfi -n-t
O o
z
Serial No.
OW-1 REV. 12/99

North Carolina - Department of Environment and Natural Resources - Division of Water Duality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699.1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: '1)ellm S_�VIIQ•.j 1Liell
WELL CONTRACTOR CERTIFICATION #: �_ _rl
STATE WELL CONSTRUCTION PERMIT#_,
4)1; 111�Kg,
%
Z-h C_
1. WELL USE (Check Applicable Box): Residential 0 STMunicipal ❑ Industrial ❑ Agricultural ❑
Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, Ust Use:
2. WELL LOCATIONS (Show sketch of the location below)
y1
Nearest Town: r�t'/�� G,L d l' Count': __ fir'
(Road Name and N tubers. Community, or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER From To Formation Description
Address `
treat or Houle o.
City or Town State Zip Code
4. DATE DRILLED !Z—S /77
5. TOTAL DEPTH 1/� I
6. CUTTINGS COLLECTED YES❑ NOE '
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO©�
B. STATIC WATER LEVEL Below Top o1 Casing: f�� FT.
(Use'+' a Above Top of Casing)
9. TOP OF CASING IS i— FT. Above Land Surface'
'Top of casing terminated attor below land surface requires a variance In accor-
dance with 15A NCAC 2C.0118
10. YIELD (gpm):_ METHOD OF TEST f
11. WATER ZONES (depth):
12. CHLORINATION: Type Htw Amount r yp ��,/h If additional space Is needed use back of form
13. CASING:
Wall Thickness LOCATION SKETCH
Depth Diameter or Weight/Ft. Materi I (Show direction and distance from at least two Stale
27 FromTo Ft.
Roads, or other map reference points)
From To Ft.
From To Ft.—
14. GROUT:
Depth Material Method
Cl)
From To M) Ft. n C ITl p n7— n ( I f 1.
_
i—
From To Ft.
�
c�
zrn
15. SCREEN:
J-
ao
Depth Diameter Slot Size Material
a
��
rn
From _ To _ Ft _ in. —in
_
rn
From _ To _ Ft. _ in. _ In.
m�
From _ Ft. In. In.
—"i
—To _ _
16. SAND/GRAVEL PACK:
_
SI i, ;Material
Dept417i
From ToFrom
To
17. REMARKS: I 'j
I DO HEREBY CERTIFY WR1;Iil1CT IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STAND ,'A� e E • '�' ��iIS CORD HAS BEEN PR VIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY l/O29Z` ' d,
Quad No: SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
SubrNt original to Division of Water Quality, Gmundwater Section within 30 days
Serle No. t- GW1 REV. 12199
t i

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 2769e-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: '!)ellll nl�a �l 7�ell fir+ II��TnL
WELL CONTRACTOR CERTIFICATION #: 1 %�o
STATE WELL CONSTRUCTION PERMIT# r.�
1. WELL USE (Check applicable Box): Residential LJ Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION/ (w sketch of the location below)
Nearest Town: /�✓ShoI' % "J /iC— County:
(Road Na; "d Numbers, Community, or Subdivision and Lot No.) DRILLING LOG
3. OWNER On ro f4 !4 - L i y n a Sfr From To
Address 0. A A a 9
✓a i- I rl�-J treat o �i ° a e �/3 Li
City or Town 1- S State Zip Code
4. DATEDRILLEDt-�n
S. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑ NOO-
7. DOES WELL REPLACE EXISTING WELL? YES NO©-�
8. STATIC WATER LEVEL Below Top of Casing: FT.
(Use': g Above Top of Casing)
9. TOP OF CASING IS�_ FT. Above Land Surface*
?op of casing terminated st/or below land surface requires a variance In accor-
dance with 15A NCAC 2C.0116
10. YIELD (gpm): O METHOD OF TEST c r
11. WATER ZONES (depth): �� ^
Agricultural ❑ Monitoring ❑
DEPTH
Formation Description
12. CHLORINATION: Type H'fk Amount r yp If additional space is needed use back of form
13. CASING:
Wall Thickness LOCATION SKETCH
Depth Diameter or Weight/Ft. Material (Show direction and distance from at least two State
From O To _t24— Ft. �n ," i P ✓C Roads, or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From To .2 0 Ft. n eM P nT �7 /1�_! l 0
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From —To—Ft— in. _ in.
From —To _ Ft. in. —In.
From —To _ Ft. — In. _ In.
16. SAND/GRAVEL PACK:
Depth Size Material.'
From To
From To l
17. REMARKS: t I !! � t3 tiU , %4 kill!
I DO HEREBY CE
CONSTRUCTION
FOR OFFICE USE ONLY
Quad No:
'�
Soda] No.
CT IN ACCORDANCE WITH 15A NCAC 2C, WELL
F THIS CORD HAS BEEN PROVIDED TO THE WELL OWNER.
Ce n �t �11a IaJ 6 U7�
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Quality, Groundwater Section Within 30 days
GW-1 REV. 12199
CD
0
Air
ss.
S
0
C71
Co

i
:onh Carolina • Depanment of Environment. 1­1e4h, and Natural Rosourcos
Division of Environmental Management • Groundwater Soction
P.O. Box 29535 • Raloigh, N.C. 27626.0535
Phone [phone]
WELL CONSTRUCTION
.LING CONTRACTOR:
LER REGISTRATION NUMBER:
e/ELL LOCATION: (Show sketch of the loc
NaarestTown: IL, h%I i n'/l
(Road. Community, or Subdivision and Lot No.)
OWNER .5fC : /.v„ MrF S'e
($Veit of Route No.).
ORD: .
175,11 '•1 11 '% r. •
FOA a01b� USE
QUAD. NO. ^ • SERIA
UL
Minor Basin i•: ;
Basin Code
Hoadorint'' iSs• 'ti:
D. "v:'1.ti)"SC
STATE WELL CONSTRUCTION 2n} '.
PERMIT NUMBER: V
)n below)
— County:
DEPTH DRILLING LOG
From To Farmadon Desetipdan
216
City of Town State IZip Codo
LATE DRILLED < -�2 /'(") USE OF WELL
TOTAL DEPTH
CUTTINGS COLLECTED •YES ❑ NOQ—•
DOES WELL REPLACE EXISTING WELL? YES NO
STATIC WATER LEVEL Below Top of Casing; ,_ FT.
(Use '+' B Abova'l.Top of Casing)
TOP OF CASING IS FT. Above Land Surface'
sing Tarminatod aVor below land aurdaco Ia Illegal unlol a a votlancu Is Issuud
accotdance with 15A NCAC 2C .0116 r
YIELD (gpm):/(2 METHOD OF7EST in a
WATER ZONES (depth): -:-,
CHLORINATION: Type t I + F�, A punt ��—
II additional space is needed use back of form
CASING:
LOCATION SKETCH
Wall�hicknoss
Depth Dla eter or eighVFL Material
r
(Show direction and distance from at least two Slate
From —!0—To Ft. f-•Ra-- .r—I?C
Roads, or other map rolorence points)
_T—
From To Ft. I -- -'
o
o
From To Ft. —
GROUT:
Depth Me Brief Method
From To .20 Ft. *Cpl C'T_ Ipoup"
r
From To Ft.
_
SCREEN: i
o
Depth Diameter Slot Size Material
en
From To Ft In.. IIn.
-
From To Ft. In. _ In.
From 1.In,
To Ft. in.
SAND/GRAVEL D
G
PACK:
Depth Size Materlai
jLIN)
From To Ft.
From To FL
ndwatecSection
REMARKS:
affiw
100 HEREBY CERTIFY THAT THIS WELL WAS CO STRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
:ONSTRUCTION STANDARDS, ANQTHAT A COP THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.

i
North Carolina - Department of Environment. Hea,6, and Natural Resources
Division of Environmental Management • Groundwater Section
P.O. Box 29535 - Raleigh, N.C. 27626.OS35
Phone [phone]'I
WELL CONSTRUCTION
L LING CONTRACTOR:
LLER REGISTRATION NUMB
WELL LOCATION:
Naar a at Town:
or
OWNER
3w sketch of the Id
division and Lot No.)
/ems �-r1�,r •
(Street or Route No.).
RD,
FOR d(`FlCE USE ONLY'''••>�if ;,
i°::
QUAD. NO, :
SERIAL NO.=+��+�'
Lai
�. Long: ;i'-. .;5cdi7•:C: "i _
i•
Minor Basin
: -ai:;�`L•:^•b4.
Basin Code
:.:a7%t �.."'`�•
Header tnt. `
`x'• =" •GVFt�nt,.;v:'s'.'
STATE
PERMIT L CONSTRUCTION 210754.
all n below)
_ County: n ri
City if Town State • I Zip Cody
DATE DRILLED ` -;Q f zel USE OF WELL
TOTAL DEPTH lh
CUTTINGS COLLECTED •YES ❑ NOOK
DOES WELL REPLACE EXISTING WELL? YES NO
STATIC WATER LEVEL Below Top of Casing; FT.
(Use's gAbove'!,TopofCasing)
TOP OF CASING IS FT. Above Land Surface•
:sing Terminated aVor below land surface Is Illegal unlol s s variance Is Issuod
accordance with 15A NCAC 20 .0118 / r
YIELD(9pm): METHOD OF TEST I/ 01.
WATER ZONES (depth): `3 3
CHLORINATION: Type
CASING:
Depth Diameter
From To -71 Ft.
From To Ft,
From To Ft.
GROUT:
DEPTH
From To
DRILLING LOG
Formation Description
Ai ount 'r_, II additional space is needed use back of form
Wall1hicknoss LOCATION SKETCH
orV(eighVFL. Material (Show direction and distance from at least two Slate
Roads• or other map roforence points)
Depth Material I Method
From To Q Ft. :�e� a(0u_�_
From To Ft.
SCREEN:
Depth
From
To
From
To
From _To_
SAND/GRAVEL PACK:
Depth
From
To —
From
To_
REMARKS:
'
Diameter Slot Size Material
Ft In,. In.
Ft. In. _ In.
FL In. _;.In.
Ft.
FL
Size 1 Material
i M ! 9 2000
C-7
a
a
Z
O
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, ANQTHATA COPYPIVHIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.

Car c'Ina - De pannsent cl Environmont, Haa['h, and Natural Ra ,.,.secs
Division c( Environmantal Managamont - Grcjnc'Nalor Soctio.l
P.O. Box 29535 • Raleigh. N.C. 27626-0535 O.,J.7. S=P ' AL N,0.
Phone[phone] __ Lcn KO
77_
WELL CONSTRUCTION RECORD
ING CONTRACTOR: r11�nn', C )��rn1l� �,I (1 )) LS �';1 r'.ch ErG .ficn
STATE WELL CONSTRUCTION ���,��
? _-ER REGISTRATIONNULISER: j', �� PE'13MITNUMDER: 11 5,
- ----- ----
ELL LOCATION: (Sho';,t sketch of the loc�li r half r
uafas; Tc'Nn:�
.:_ad. Corrm.cnirt. cr °ubC;vls i-,'1 s�nd/Lc1 No.;
ii
I' 1 (Saoel cr Rou:a No.) ✓� /' /_
=.q Qr Q .n Sta to Zip CuJj —
__.ATE DRILLED a7!Q� - D USE OF WELL
-CTAL DEPTH ��--
:'JTTINGS COLLECTED YES ❑ NO❑--
=JES WELL REPLACE EXISTING WELL? YES ❑ O�;f _.
TIC WATER LEVEL 6EIc':r Top of Casing;
(llse *.' it Abo,a
_ P 0= CASING IS FT. Abcva Lanc Su:
._ Torminat;d z'Jor bo low land su,riz-a Is Ill a^y al unless a varinn cu is Is -
.[c_rCzncc wilh 15A NCAC 2C .711a -_.
D (gpm):_l6 — `AETHCD OF TEST _� �! r i a_q— -
I
rATER ZONES (depth.
rr
_-:LOnIP;ATICN: Type Amour
WL:lT ..'�n ...
Depin :mta .:r !„; a'r Fi. !,�_;
To 12
To Ft.--- ---- --
To Ft. _—._--
CUT:
DEpth Material
-• Q To �Ft. (Z(?rn of r rtp
To Ft. - ---- —
_ N:
Depth Diameter Slo( Sze
..•n To Ft In. in. _—_—__--
To FL In. __ in.
_ To Pt. In. in..
-RAVEL PACK:
Depth Size Material
To Ft. _
To Ft.
9 L� U 1J IS (�
jum ! 9 200o i
co
O�
A C, rrn
� Cn
� om
r Yc7
Arn
�\
_ pom
m�
U1 C)
'4 o
x
_O HEREBY CERTIFY THAT THIS V,ELL WAS CON3TRIUCTEU IN ACCCF.DA:; __
_r,STRUCTICN STANDARDS, AND. THAT A COP r
=7 TO O
`,�rrr; , ��rlG'n,� �3 0 - tTD

Carolina • Dapanment of Environrnunt• Hoalm, and Natural Ru;ourcu> FCP CFF,CEJSE CNLY
Division of Environmontal Mana omant • Ground•:ratar Socicn
P.O. Box 25535 • Raleigh, N.C. 27626.0535 I i , 90- I
Phone [phone]?21. -'- - -- c WELL CONSTRUCTION RECORD co,,,,
'LING CONTRACTOR: rllJnn`, C .Q7 r l �) \i �Rs r En
'_G .tEnt�
��: ) S I1� r.aX
R REGISTRATION NUMBER:STATE WELL CONSTRUCTION jj ((jj _
< " EPMI r.:.:n 210"�.)
LOCATION (Show sketch of the IccaGor. ' belo:•/i
I:aa: as. Town: 2"" k/,D_J /./C
-„d Cc wr,.riry or S �vis/�i o77n ano Lot No.) ---� --
A �0 RE SS r/ ----
(S'raet or Rcuie No
V_Pry_! 3_/U _
Cirj or Tr;,n Slcio Zip
_A T E DRILLED n USE OF WELL
-0TAL DEPTH Sr c
:'JTTINGS COLLECTED YES ❑ NO J'"
_E34VELL REI LACE EX!STIL WELL?—'E [ 1;IL_i'
-ATIC WATER, LEVEL Eeloar Top of Casing: P?
(Uso'.' II ASovo Tcp of Casin;)
P OF CASING IS r FT. Above Lanc Surface'
-.; Tarmina:id et/cr balow and scricco Is Illo551 unlosa a vorianc.- le
__c_rdanccwlm1:ANCAc2C .Qile -
,ELD (gpm): METHOD OF TEST
ATER Z0\'ES depth):----------
0 , 1 }J,
_F;L nlNnTlO.":: Typ6 — ntil�
..III Tb.c'.r_ .
�m n To 137 FI
=rim To Ft.—— --- ------
Depth Material Mcthcd
: m Pm 2 Q_Ft. Cemenl P 0Ur<—
m To Ft. — --
�nEENf
Depth
:m To Ft
To Ft.
:-:I To F;.
-:;D/GRAVEL PACK:
Depth
—_ To ---
= To
�.tARKS:
Diameter Slot Slze h1a!er
in.
2 1
O
O
c
O
Z
�a
m
c�'
-at
m
om
t
rr m
Do
a
'ate
AM
Q
CA
Ln
1
co
o
2
LO HEREBY CERTIFY THAT THIS VIELL 5'.AS CON 3TRJCTED I I 0 r
;';5TR' CT1O , STANCARDS ?..",D THAT A CCF ' S rr r,c; : n _ , r i' cL'_

..^^ Carolina • Department of Environment. Heal:h, and Natural Rasourcus iFCn Ur f .. L'SE CNr Y
Division of Environmental Management • Groundwator Suction - •. '"
P.O. Box 29535 • Raleigh, N.C. 27626-0535 ^- "C ' S_R!AL NO - 'r�=�•
Phone [phone], (-� - u- ,j -F4•
WELL CONSTRUCTION RECORD
LINGCONTRACTOR: s1P n'i _ )��1.nh 1I O I��fS jli. r.'-� L' 'urE•r G�
STATE WELL (7CNSTRUCTION _'_ER REGISTRATION NUMBER: J ,� Z% PERC,IT NU'.1G_R: 21075 7
vcLL LOCATION�jShow sketch of the location belovr)
'.oarest Town: A/("__ Cc�_�rd y;� � �117v._...__--
,pcad, Ccmmuniry, or Subdivision and tat No.)
CL"Ff Fi D^rJLLIi�,'G LOG'
C.'P/NER ./. %�I S Goo,
Tc Fcmraccn Cascrip.an
,DORESS L �� /�
------
�� (Sweat ar Rou;o No.'
1' Y Ll �1 % �: rt /�i P Q7 ---------
--
�/L
CFrr or Town Slalo Zip Codo--------
_ ATE DRILLED USE OF `WELL--
-^_TAL DEPTH SnS -
, TTINGS COLLECTED YES ❑ NODi
- -- ----
_OES WELL REPLACE EXISTING WELL? YES Ej 1110�%-_______________—
_
-ATICWATER LEVEL Below Top of Casing: p Fr.
- (Use'.' it Abovo Tcp of Ca.ir,;l
T-P OF CASING IS FT. Above Lanc Surlace*
.. -.; Tarminarod aUcr balow lend wrioao Is Illagol ur,lasa a vorlancu Is Is aa��
=:=c rc enca wllh 15A NCAC 2C .0119---
_D (gpm): L� METHOD OF TEST _6/,)12(
--
ATER ZONES (depth): - -_
---- -- -- -- _--
_ 'LORINATION
:.,SING:
Type w -� 0 Amount 1 — _ .... -..... ace is ndadod usu back of fCrrn
Depth Dia otar
rCm_�To � Ft. ,r
=. To Ft.
=r,m To Ft.
FOUT:
\Null Th,:cknuss
or Wui�hVFI. 1.lmarlul
r —P V�C_
Depth Material Method
r_To 0 FL.CifMCM C�LlR -
_.,, To Ft.
Depth
rrom
To —
_m
To —
_ _:n
To —
_.,'1D/GRAVEL PACK:
Depth
cm
To—
=,C.
To —
A' RKS:
Diameter Slot Size I,!Zt rlal
Ft In. in.
Ft. In. __ in. _
Ft. in.
Size t�2;o'lal
_ Ft. _
_ Ft. --
LOCATION SKETCH
distancu from a: leas)
Iv:c
,_„__, .,r :nap rloronCa points)
CC
p
a m
m
t
o<
�
Do
-a
3
Am
�?
m�
ci
CA
-'
C
o
z
D HEREBY CERTIFY THAT THIS WELL WAS CON3TRUCTEp IN ACCORCANCE V11TH 1;A NCAC 2C, /ELL
':STRUCTION STANDARDS, ANQ•THAT A COPY THIS RECORD HAS 9HN PRO`/ICED TQ THE YELL
/4/J/!lL-�t-J�C , a „a/c3-- / 3 -

"donh Carolina • Department of Environment. Health, and Natural Resources
Division of Environmental Management • Groundwater Suction
P.O. Box 29535 • Raleigh, N.C. 27626.0535
Phone [phone];,
WELL CONSTRUCTION RECORD
BILLING CONTRACTOR: ` 1 (-1 •'111* P.
O'744
. FOR FlCE USE
QUAD. NO.�
'SERIAL
NO.
Lai
..'.(�•.. �.,.;,i;. ,.•'§:dd :1J.c?_
Minor Basin
Basin Codo
HoadorEna
•s.
KILLER REGISTRATION NUMBER: q STATE ELL CONSTRUCTION
J �i / PERMIT NUMBER:
------------------------------------
------------
WELL LOCATION: Show sketch of the Iolzatl n below)
Nearest Town: + � County: �� Ccl�p
(Road, community, or Subdivision and Lot No.) DEPTH
DRILLING LOG
OWNER �`t' �� 1 2-�... _&. From To
Formation Oescri Von
ADDRESS_ 0�r/ �7r��/rr �" / p
(Street or Route No.)
Cary or Town State Zip Codo
DATE DRILLED � USE OF WELL lj1�4z'r-1_
TOTAL DEPTH _ ! 7
CUTTINGS COLLECTED •YES 7 NO( L�. �'
COES WELL REPLACE EXISTING WELL? YES NOCD!
STATIC WATER LEVEL Below Top of Casing: /r, FT.
TOP OF CASING IS (Use 'a'ifAbove TopofCasiog)
FT. Above Land Surface -
ulna Terminated at/or below lend aurfaco Is Illegal unlol s a variance Is Issued
accordance with 15A NCAC 2C .Oita
YIELD (gpm):*_ METHOD OF TEST
WATER ZONES (depth): `7 T to0 T
CHLORINATION: Ail oust �r
-> It additional space is needed use back of form
CASING:
Wall7Ncknoss LOCATION SKETCH
Depth Dia afar or aighVFL Material (Show direction and distance from at least two Slate
From ID _To Ft.—(X— y iStfY -Pvc— -- Roads, or other map rolorenca points)
From To Ft.
From To Ft.
GROUT:
Depth �1^ Material Method
From �To=�S1_Ft, Cernc�r)( P(0U,R
From To Ft.
SCREEN:
Depth Diameter Slot Size Material
From To Ft In. in.
From To Ft. In. __ In.
From To Ft. In. '.In. _
SAND/GRAVEL PACK:
�l
Depth Size '� I lI
From To FL U
From To Ft. 9 2000
O o
:a= M
n rn
= m o
xo
o r`nn =
Cn C-j A
V
0
x
I CO HEREBY CERTIFY THAT THIS WELL WAS COI, 19 4b ° fFice Yyl H 15A NCAC 2C, WELL
--ONSTRUCTION STANDARDS, ANQ.THATA COPY F,THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
3-3—E0

rlonh Carolina • Department of Environment. Health, and Natural Resources
Division of Environmental Management • Groundwater Soction
P.O. Box 29535 • Raleigh, N.C. 27626.0535
Phone [phone]
WELL CONSTRUCTION RECORD
BILLING CONTRACTOR: <X �, .,
BILLER REGISTRATION NUMBER: <
WELL LOCATIONS (Show sketch of the local
Nearest Town: r-Al�fe I L�,,
r) .4
.FOR dF`FlC� USE ONLY'
QUAD. NO. SERIAL NO,
Lai
Minor Basin '
Basin Code
.I ]I � A I Hoador tIm.^!:'
STATE WELL CONSTRUCTION
PERMIT NUMBER:
below)
— county: —n'1 er Coo
r- w„.nurury,or5ubdivisfohandLotNo.) - DEPTH
OWNER �i gicJ
ADDRESS Frcrn To
(SU'at or Route No.)
�V' 0« Ic I • ,y q /L , h! c_'% 3 L
Cry or Town State Zip Codo
DATE DRILLED 5-3—r12:) USE OF WELL
TOTAL DEPTH 3.sn
CUTTINGS COLLECTED -YES[]
DOES WELL REPLACE EXISTING WELL? YESO NO(
STATIC WATER LEVEL Below Top of Casing; FT,
TOP OF CASING IS (Use'+' it Above Top of�rg)
FT. Above Land Surface-
3atr.a Terminated &Uor below lend surface Is Illegal unto a a variance Is Issuud
accordance with 15A NCAC 2C .0115
YIELD(glom): L5 METHOD OF TEST �nr�� )n f.
WATER ZONES (depth):. 3 (
CHLORINATION,: Type
CASING:
Wall �'hicknoss
From Depth q Dia 'tor or Wei9hVFL Material
— !_To / Ft. _ P K fY _P_Lc
From To Ft. _T_
From To Ft. _
GROUT:
Depth Material Method
From rZ To = Q_Ft. -Cefnr (OhL
From To Ft.
SCREEN:
Depth Diameter Slot Size Material
From To Ft In. In.
From To - Ft. In. __ in.
From To FL In. In.
SAND/GRAVEL PACK:
Depth Size Maleri n
Frcm To Ft R l
From To Ft.
FEMARKS JJJ
DRILLING LOG
Formation Description
It additional space is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least two State
Roads• or oihor map roforence points) o
C a
_,C o�
� zm
3iCn
y 0
Z �o
4 rnA
c —1
v o
z
I � n�ry �aherillt: Rexiotiil Nke I
CO HEREBY CERTIFY THAT THIS WELL WAS CO NSTRUC7l!t`Ytftl'RCCOROARC j —H 15A NCAC 2C, WELL
:ONSTRUCTION STANDARDS, ANO,THATA COPY THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
L3-3 ov

i
Nonh Carolina • Department of Environment. Health, and Natural Rosourcos
Division of Environmental Management • droundwalor Section
P.O. Box 29535 • Raleigh, N.C. 27626.0535
Phone [phone]
WELL CONSTRUCTION RECORD
BILLING CONTRACTOR:
'.t 11 *� P.
FOR Cl�FlCE USE ONLY':.^:?r'r'•
QUAD. NO.
LaL
$EAIAI NO. �=c::,: •'.:r.;��,•
Minor Basin �
: i'=oi•�•+�r•�-�':
Y'
Basin Code
Header6m.'
:x•- '. Lr'^.�:r+,
FILLER REGISTRATION NUMBER: STATE WELL CONSTRUCTION
Ag / PERMIT NUMBER:
WELL LOCATION: Show sketch of the lorati n below)
Nearest Town: k z
Caunly; la") li.-cony
(Road,Communiry,ofSubdivision and Lot No.) DEPTH DRILLING LOG
OWNER S'elL `Le Ficm To
ADDRESS C . /36� M1 Formation Oescripucn
(Streator Roule No.)
Al a _ &'7.3 z/
City or Town State Zip code
DATE DRILLED,3-USE OF WELL
TOTAL DEPTH
CUTTINGS COLLECTED •YES❑ NOQ�
DOES WELL REPLACE EXISTING WELL? YES NO(D!
STATIC WATER LEVEL Below Top of Casing: _ cfn FT,
TOP OF CASING IS % (Use'.' it Above Top of Casing)
FT. Above Land Surface'
331ng Terminated aUor below land surface Is Illegal unlo� s a variance Is Issued
accordance with 15A NCAC 2C .0118
YIELD (gpm):_-2 - METHOD OF TEST ,1 a
WATER ZONES (depth): 00
CHLORINATION,: Type ) F) Amount 114 116.. CASING: It additional space is needed use back of loan
I _
Depth
Wall Thickness LOCATION SKETCH
— �
From. —L�' Ft.
Oia etar or WeighuF`, Malarial (Show direction and distance from at least two Slate
r I
y �'
o
From 7c Ft.
�g+;y-- ,1^ Roads, or other map reference points)
pc
c
From To Ft.
GROUT:
Z
�A
nh Depth�l �,
From L_ To O
Material Method
Cgmen j
1
,
cm
=
<
.,.�rn
no
_ Ft.
From To Ft.
rp U
=
1�
A�
SCREEN:
o
ma
Depth Diameter
Slot Size Material
~
From To Ft
In. In.
r
o
_
From To Ft.
In. _— In..
From 7o Ft.
SAND/GRAVEL PACK:
In.fi ii
U —
Depth
Size } t tat
From To Ft.
€ Ir:J
From To Ft.
REMARKS:
GroundwaW Section
100 HEREBY CERTIFY THAT THIS
WELL WAS CONSTRUCTED
IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, ANp•THATA COPY
F THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
1712,

North Carolina . Department of Environment, Health, and Natural Resources
Division of Environmental Management . droundwater Section
P.O. Box 29535 • Raleigh, N.C. 27626.0535
Phone [phone] i
WELL CONSTRUCTION F�ECORD
R I L L I N 0 CONTRACTOR: r1 �, 1, rl �)) "t �� �•c
'
QUAD. NO.:
FOR dOlCE USE ONLY",^i";;'1'•.. .
SERIALNO.=:'.:d-Ykr..:
Lau
Minor Basin
Basin code
_ ;,:`,rY-....., •m;
RILLER REGISTRATION NUMBER: q STATE WELL CONSTRUCTION
/ PERMIT NUMBER:
WELL LOCATION Show sketch of the IoSatlfn below)
Nearest Town:'
County; m 4� (»
(Road, Community, or Subdmsmn and Lot No.)
DEPTH
OWNER J�r, , e DRILLING LOG
ADDRESS From To Formation Description
(Slreai or Route NO.)
City ar Town State Ziljlp Cade
DATE DRILLED
USE OF WELL
TOTAL DEPTH 3 7 �
CUTTINGS COLLECTED •YES ❑ NOEt �'
DOES WELL REPLACE EXISTING WELL? YES NO(
STATIC WATER LEVEL Below Top of Casing: _ ?/i FT,
TOP OF CASING IS (Use's' it Above Top of Casing)
Fr. Above Land Surface'
aalr.g Tarminatad attar below lend surface Is illegal unlol s a variance Is Iaauud
•. accordance
with 15A NCAC 2C .011e
YIELD(gpm): S('' METHODOFTEST �n(Jllna
WATER
ZONES (depth): I 0
CHLORINATION:
' If
.—Amount.CASING:
additional space is needed use back of form
Wall1hickness LOCATION SKETCH
Depth
Dia etor or WeighvFt. Material (Show direction and distance from at least two State
From--!0 To '
to
— _ Ft.— —' j a. eye
From To Ft Roads, or other map tolerance points)
O t
From To Ft. _
O
=
GROUT:
C')
a< cm
hh Depth Material . Method
From _SL To O FL CgmenjP fps
=m
ao
From To Ft.
_ ��
SCREEN:
ma
Depth Diameter Slot Size Material
cn
o
From To Ft In. In,
z
From To Ft. In. __ In.
From To Ft. In. In.. P,II,
SAND/GRAVEL PACK: _. ,_ ....
D To Size FAa
From JUN LI
FL
From To Ft.
REMARKS: I ndwater Section
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
ONSTRUCTION STANDARDS, ANQTHAT A COPY QUHIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.

i
;tonh Carolina - Department of Environment. Health, and Natural Resources ? n •y r 9
Division of Environmental Management • Groundwator Section
P.O. Box 29535 - Raleigh, N.C. 27626.0535 OUAO. NO.'
. FOA a>`FlCE USE ONLY''=�'r:.' "r''i'• .
"•+•SERIAL NO. �wv`_'.
Phone [phone]' =
tat. _p—
WELLCONSTRUCTIONFSECORD r.+lnoreasin'..'
RIL_INGCONTRACTOR:<1 Basin code ....., _-;;• 'r•.r t._,.
I �11 1 �..._::..,�.,
n`r ••t Huador LnL''`.-'.:^":z`:.;:.)i
31LLER REGISTRATION NUMBER• r q STATE WELL CONSTRUCTION
4, / - PERMIT NUMBER:
----------------
WELL LOCATION: (Show sketch of the local l n below)
Naarest Tor wn'_ Lom /V r �i y
s County: 61 �
i
„' ..v:vnurury, or Subdivision and lot No.)
OWNER 6-c;- r • DEPTH DRILLING
ADDRESS From To Formadon Oescripdon
(Sueet or Route No.) i
Ciry or Town Slate
DATE DRILLED .'S - %- oz� Zip Code
TOTAL DEPTH �S� USE OF WELL
CUTTINGS COLLECTED •YES D NO[Di
DOES WELL REPLACE EXISTING WELL? YES NO
STATIC WATER LEVEL Below Top of Casing: —2 n FT,
I (Use's it AboveTopof Casing)
TOP OF CASING IS
sing Terminated Wor below lend suriaco Is Above
unlanaa varlano Is Issuvd
accordance with 15A NCAC 2C .0119
YIELD (gpm);--z ZMETHOD OF TEST
WATER ZONES (depth):—L 2c r
CHLORINATION.: Type
CASING:
Depth Wall hicknoss
P Dia elor or Weight/FL rdaterial
Frcm--%_70 p.� FLU _ ( plOC
From To Ft. _
From To Ft.
ROUT:
Depth Material Me —a up,
rorn To—F1..6rn lj COU
'on To Ft.
SCREEN:
Depth Diameter Slot Size Material
-rcm To Ft In. I In.
=rcm To Ft.
= In. in.
rcm To
Ft. In. LIn,-
SAND/GRAVEL PACK: G
Depth Size Maier 0
:rcm To Ft.
Lr
"rcm To FL
MAR KS•
If additional space is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least hvo State
Roads• or other map retorence points)
v
O
O
d
�a
c�
�m
r
>o
a
rn
rrnn
- v
o
z
70 HEREBY CERTIFY THAT THIS WELL WAS
ONSTRUCTION STANDARDS, ANQ,THAT A C
STRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
DE THIS RECORD HAS BEEN PR?OVIDED TO THE WELL OWNER.
`� % - e-zn

North Carolina • Department of Environment, Health, and Natural Resources
Division of Environmental Management • Groundwater Section
P.O. Box 29535 • Raleigh, N.C. 27626.0535
Phone [phone]•
WELL CONSTRUCTION f ECORD
KILLING CONTRACTOR: <1 nS I L)I
RILLER REGISTRATION NUMBER: `
WELL LOCATION: (Sh w sketch of the
Nearest Town: � ?1 (/ ram,
toad, community, or
OWNER — SGL
QUAD. NO.'
SERIAL.
NO . =•.: _.ti:.
Vt.
%Long, -'t' �.ab
Minor Basin..
Basin Codo
• :;��-r, ..• �,-•
Head
STATE ELL t.;UN5TRUCTION
PERMIT NUMBER:
below)
=County: CACe
DEPTH DRILLING LOG
Flom To Formadon Description
� (Sueed6r Route No.) r/ tiles
City or Town Slue Zip C do
^ATE DRILLED USE OF WELL
TOTAL DEPTH -,I Sr
CUTTINGS COLLECTED •YES O NO[].
COES WELL REPLACE EXISTING WELL? YES NO(D%
STATIC WATER LEVEL Below Top of Casing: FT.
TOP OF CASING IS � (Use 'a' it Above Top of Casing)
FT. Above Land Surface
Jain; Terminated allor below land surface la Illegal unlol a e vmlanco IS Isavud
accordance with 15A NCAC 2C .0118
YIELD (gpm): ,I11
_METHOD OF TEST_
WATER ZONES (depth) r,''
7
CHLORINATION: Type Amount-'
CASING: If additional space is needed use back of form
Depth Wall Thickness LOCATION SKETCH
P (� � Dia star �r or Weighvft. Material (Show direction and distance from at least two Slate
Frcm—%_To —�L Ft. ° —r $�_ e
From To Ft.
Roads, or other map reference points)
_
From To Ft.
GROUT:
h Depth Material7 Method
From —sue To .) O Ft. C2mc�nj rely
From To Ft.
SCREEN:
Depth Diameter
From To Ft In.
From To Ft. In.
From To Ft. In.
SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To Ft.
EMARKS:
Slot Size Material
In.
In.__
=. In.
0
O of
O
_ n70
t Qm
*M
nCD
A MCD
= Am
C ma
tn �1
J o
z
CO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
ONSTRUCTION STANDARDS, AND,THATA COPY,PETHIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.