Well Construction Records McDowell 1 CY2000

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section ti 1 O
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phono [phone]
WELL CONSTRUCTION RECORD WELLCONTRACTOR: _gms4xell Loell �R'll,'A-/g
WELL CONTRACTOR CERTIFICATION #:
,�,/STATE WELL CONSTRUCTION PERMIT#:
L
1. WELL USE (Check Applicable Box): Residential I" Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heal Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: County: !�r✓�uJ�.
-, I1,� Dec l< -i Ako aaF,
(Road Nam and Numbers, Community. or Subdivision and LO No.) DRILLING LOG DEPTH
3. OWNER I �'r .i From To Formation Description
Address C)d-��---
-7--ibireei or ouzo No.)
City or T9Wn Stale Zip Code -- -�
4. DATE DRILLED 3-
5. TOTAL DEPTH 0-----------
6. CUTTINGS COLLECTED ESQ NOQ_'
7. DOES WELL REPLACE EXISTING WELL? YES NO _
8. STATIC WATER LEVEL Below Top of Casing: ae> FT. _
(Use'+' if Above Top of Casino)
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 .011e
10. YIELD (gpm): fl, METHOD OF TEST "A10-2-0 _
11. WATER ZONES (depth): 3l�-
12. CHLORINATION: Type Amount 3. It additional space is needed use back of form
13. CASING:
Wall Thickness LOCATION SKETCH
Depth Diameter or Weighl/Fl. Materia: (Show direction and distance from at least two State
From To 61 Ft. & u`V Sall, _dC' ?V ( Roads, or other map reference points)
From To FI.
From To Ft.
14. GROUT
Depth Material Method
From To -?C) Ft.
From To __Ft.
15. SCREEN:
Depth
From
To Ft
From
To Ft.
From —To
Ft.
16. SAND/GRAVEL PACK:
Depth
From
To
From
To
17. REMARKS:
FOR OF
Quad No:
Serial No.
Diameter Slot Size Material
in. in.
in. in.
in. —in.
Ft.
Ft.
Size Material
WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
�Y OF THIS R� f EN PROVIDED TO THE WELL OWNER.
0
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3
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�/y1r1� SIGNATURE OF PERS NWRI$6TIWG I - DATE
ex+l/dub eat to Division of Water reundwaler Section Within y5
AUG 1 6 2onn GW-1 REV. 1299
ionalcOffce�

North Carolina • Department of Environment and Natural Resources - Division of Water Cualay - Groundwater Section
1630 Mall Seri Center • Raleigh, N.C. 27699-1G36-Phony (91q) 733 3221
WELL CONSTRUCTION RECORD WLLL CONTRACT011: Zg�st.�el) we I1
WCLL CONTRACTO11 CLRTIFICATION 0:
STATL WLLL CONS1ltUCTION PE-RMITN:
WELL USE (Check Applicable Box): Residontiaf E Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
Agricultural ❑
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: mA�-Rinr`-� County:
(Road Name and Numbers. Community, or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER - Forms
, !252_ c� From To Fou on Descdp
Address 4fJ- 3 ! -
«eetor ouzo o. �3 — yo —�
Cil or Town state Zip Code —
4. DATE DRILLED
S. TOTAL DEPTH` —
6. CUTTINGS COLLECTED YES 0 NOQ- —
7. DOES WELL REPLACE EXISTING WELL? YES NOET——
8. STATIC WATER LEVEL Below Top of Casing: FT. —
(Use'i If Above Top of Casing) —
9. TOP OF CASING IS 1 FT. Above Land Surface -
"Top of Casing terminated atlor below land surface requires a variance In accor-
dance with 15A NCAC 2C . 11 a ' /o r�� —
10. YIELD (gpm): METHOD OF TEST ram! —
11. WATER ZONES (depth):�
12. CHLORINATION: Type Amount - 2 ; V� If additional space Is needed use back of form..
13. CASING:
Wall Thickness
Depth yy.//� OiamNm or WoighJ(FI.
From-0—To IcnJl
� Ft. i2"—
From To FL ---
From To Ft. ---
14. GROUT:
Depth Malorial Molhod
From To a> Fl. 7 e
From To Ft.
15. SCREEN:
Depth
From
To
From —To
_
From —To
16. SAND/GRAVEL PACK:
Depth
From
To —
From
To_
17. REMARKS:
Diameter Slot Size Material
Ft _ in. in.
Ft. in. —In.
Ft. In. _ In.
Ft.
Ft.
Size Material
LOCATION SKETCH
(Show direction and distance from at least two Stela
;w`n
Roads, or other map reference points)
•F'
0
O
ZE
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C]
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I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF HIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
FOR OFFICE USE ONLY
Dead No: SIGNATUnE OF PERSON CONSTRUCTING THE WELL DATE
not Water Ouarty, Groundwater Section within 30 days
Serial No.
Join MAY 3 120M
�.
GW-f 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-Phoeo [phone]
WELL CONSTRUCTION RECORD WtLLCONTRACTOR:
WELL CONTRACTOR CERTIFICATION N:
STATE WELL CONSTItUCTION PERMITN:
1. WELL USE (check Applicable Box): Residential K Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other M It Other, List Use:
Agricultural ❑ Monitol
a
2. WELL LOCATION: (Show sketch of the location below) M '1 ht k° •y`
I r
Nearest Town: IA�6'+2' County:
�t �V� l�tJJ sal m;ar. a
(Road Name wd Nurntlars, Community, o S/ubdvision and Lot No.) DRILLING LOG DEPTH
3. OWNER �`� ��1 Ir �%� From To Fortnatlon escdpgon
Address
trees or oalo o. /Cj0 ^ ROd J"/.r a
Ct Lc -au `% 1 . L .
Cil Or Town Stale Zip Code`
j..t^r,Do
4. DATE DRILLED O
S. TOTAL DEPTH
6. CUTTINGS COLLECTED NOEE---'
7. DOES WELL REPLACE EXISTING WELL? YES NOQ� U1
8. STATIC WATER LEVEL Below Top of Casing: FT.
(Use'•• It Above Top of Casing)
9. TOP OF CASING IS I FT. Above Land Surface -
`Top of casing terminated atlor below land surface requires a variance In accor-
dance with ISANCAC 2 e a
10. YIELD (gpm): METHOD OF TEST
11. WATER ZONES (depth): , )�
.!"^' 12. CHLORINATION: Type /NO-- Amount 3 If additional space is needed use back of form
s.,
13. CASING:
Wall Thickness
Depth O/ Diameter at Weight/F. Material
From 101--g Ft. � � —
From To Ft.
From To Ft. --
14. GROUT:
Depth Material Molhod
From To �D Ft. c-ernes �R
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•
Slot Size Material
in.
In.
In.
Material
LOCATION SKETCH •,.r:•..-•�
(Show direction and distance from at least two State -
Roads, or other map reference points)
Ca
O
C
Z
1
Ln
-•O
3
N
cn
J
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OFrTHIS RECOR q±!AS_EEENI PROVIDED TO THE WELL OWNER.
IFOR OFFICE USE ONLY
Quad No:
Serial No.
SIGNATURE OF PERSON CONSTRUCTING THE WELL
Suhmil original to Division of Water Ouality. Gmundwalor Section within 30 days
_4901,v6i
1 d n
1+I
MAY 1 2001 (J
,JUN 2 8 200, ILI
DATE
GWI REV. IV99-

North Carolina • Department of Environment and Natural Resources - Dlvi :Inn of Wator Cuallty - Groundwater Section
1636 Mall Service Center • Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WE_L[-CONIHACTOR: 13Kn4.zlj
WELL CONT'RACTOI7 CERTIFICATION M:
I I L WI_LL CO N(i I IIUC I ION PBI tMITM:
"
,_, /:;
1. WELL USE (Check Applicable Box): Residential H3 Municipal ❑ Industrial ❑ Agricultural
❑ Monitoring ❑ .
Recovery ❑ Heat Pump Water Injection ❑ Other EJ If Other, List Use:
;
2. WELL LOCATION: (Show sketch of the location below)
n S A
Neara9lTown: County: Y✓ie� e-�� --
U
(Road Name and Numbers. Community, or Subdivision and Lot No.) DRILLING LOG
DEPTH?
3. OWNER 11 BeRg From To
Formation Descdp6o 1 `'-
Address I Sv,v ��-i— �Z • y ct'-"��c
.. y ,,.
—(Strea'Tor Houle IN
.
g L)fA )y 0A- NC_ 2
C yor Yom State Zip Code
4. DATE DRILLED
S. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑ NO F_'�—�
7. DOES WELL REPLACE EXISTING WELL? YES NO[
8. STATIC WATER LEVEL Below Top of Casing: FT.
(Use •+' If Above Top of Casing)
9. TOP OF CASING ISM_ FT. Above Land Surface'
'Top of casing terminated attar below land surface requires a variance In accor-
dance With 15A NCAC 2C .0118
10. YIELD (gpm): METHOD OF TEST k W^
_tom
11. WATER ZONES (depth):
12. CHLORINATION: Type Amount . ')-_ II additional space Is needed use back of form
,
13. CASING:
Wail Thickness
Depth�q Diameter or Woight/Ft.
From © To FLU
From To Ft.
From To Ft.
14. GROUT:
LOCATION SKETCH
Material (Show direction and distance from at least two Slate-
5�.. Roads, or other map reference points)
Depth Material Mothod
From To 22 Ft. r
From To Ft.
1S. 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.
Ft.
Ft.
Size Material
0
O �
CC_ �z
3 cn cM
,.m
1<
Cif 0tim
3>0
cill H
Jq .o
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 y/' �c �` �� S
Ouad No:
Serial No.
SIGNATURE OF PERSON CONSTRUCTING THE WELL
at 1n Division of water Ouahty, Groundwater Section within 30 days
MAY 12ppp UI II o I 2 8 2000 L
DATE

ANorth Carolina - Department of Environment and Natural Resources -Division of Wale, 0,1,11fity - Groundwater Section
1636 Mail Service Center - Raleigh. N.C. 27699- 1 636-Phono [phone]
WELL CONSTRUCTION RECORD WLLLCONTRACTOR:
Wf--[.L CONTRACTOR CERTIFICATION 11: 2;:!
'I A IL WELL CONSTRUCTION PEnmlT#:
1. WELL USE (Check Applicable 8-:): Residential [11� Municipal 0
Industrial 0
Agricultural ❑ Monitoring
Recovery F-1 Heat Pump Water Injection ❑ Other E]
If Other, List Use:
2. WELL LOCATION: (Show ketcb tho location below)
Nearest Town:
un
Co ty
—(Road Na
DRILLING LOG
DEPTH
3. OWNER
From To
Fomtatlon Description.
Address
r ou tree,t 9 0 0.
S.
Q or
own state, Lip Coda
is
-1 q z5o --- —
4. DATE DRILLED •
5— TOTAL DEPTH NO[9
6. CUTTINGS COLLECTED ES
7. DOES WELL REPLACE EXISTING WELL? YES r NO
B. STATIC WATER LEVEL Below Top of Casing: FF.
(Use -.- It Above Top of Casino)
9. TOP OF CASING IS Fr. 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
11. WATER ZONES (depth):
12. CHLORINATION: Type .... -3
Amount It additional space is needed use back of fOfm
13. CASING:
Wall Thickness ?�4
Depth Z�mor Weight/Ft KI" le
(�5 dal
From To '33 Ft.
From To Ft. ---
From To Ft.-
14. GROUT:
Depth Material Method
—'2C> Ft. C--er"EAJ'�- VP2L91Qe=a
From 0 To
From To _Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From _To —Ft in. —in.—
From To — Ft. in. — In.
From _ To _ Ft. In. — In.
16. SAND/GRAVEL PACK:
Depth Size Material
From To —Ft. —
From — To Ft.
17. REMARKS:
LOCATION SKETCH
(Show direction and distance from at least two state
Ronds, or other map reference points)
CM
C:)
C-
;0
Litt
=E ;­t
r
171.1
r_q
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A C THIS RECOEREAS BEEN PROVIDED TO THE WELL OWNER.
SIGNATURE OF POISON
� // Y6 7
DATE
30 days
GW-I REV. 12199

North Carolina • Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
4 ! 1636 Mall Service Center • Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WLLL CONTRACTOH;
WELL CON71lACTOR CL"IITIFICATION M: 2 33
;:I AI C WLLL CONSTN OC PION IIEIIMITM:
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) „fi •?`
Nearest Town: Mn.a�oly County:
,
(Road Name and Numbers. Community.or Subdivision ntl Lol No.) DRILLING LOG DEPTH t. t
3. OWNER, Pn�P '7'rZ%- }7AI2 From Two FomullonDescripllon'-t yt
Address
/ tr@CIOr q 0 0. J �j� r2� p. •�.IG
City or Town '� Stale Zip Coda"-
4. DATE DRILLED 6_'�ao
5., TOTAL DEPTH
6. CUTTINGS COLLECTED YES NOEE� C7 '
7. DOES WELL REPLACE EXISTING WELL? YES NOQ" y�.
8. STATIC WATER LEVEL Below Top of Casing: FT.
(Use '+' II Above Top of Casing)
9. TOP OF CASING ISFT. Above Land Surface"
'Top of easing terminated after below land surface requires s variance In actor- — - ---
dance with 15A NCAC 2C MIS
10. YIELD (gpm): vl METHO O TEST%a��
11. WATER ZONES (depth): Q
12. CHLORINATION: Type r' ORS J Amount `-��Y_bs. If additional space is needed use back of form
13. CASING:
Wall Thickness i LOCATION SKETCH
Depth `OQ D mol9r or Weighvr Mailer.,? (Show direction and distance from at least win State
From —To Ft. j `r —I �£� —5?dV,
From To Ft. ---
From To Ft. ------
14. GROUT:
Depth Material Method
From O To ­20 Ft. (——ela cv�
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
Roads, or other map reference points)
0
C
o
CD
C
of
Z
c t+1 r •
Ln
m
;
o
4
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rNn�
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1 DO HEREBY CERTIFY THATTHIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS. AND THAT A COPY 9F THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER. ,
FOR OFFICE USE ONLY '--a `J _J
W""a'�
Quad No: SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
o ,n ivisf 72M.,
ithin 30 days
Sedal No.Z114 D Iml
U GWA REV. IM9 -
��! lJ 3
7 MAY 1 2f0O .IUN 2 E
Ylollrl6r+!f 1 Groundifi ler Sac
IIIMai1a ��� ' Ashev?ile Region:. '- _..�

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: &JI/ I
WELL CONTRACTOR CERTIFICATION #: �2 1 3
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: I4plfg, '� County:
%a-F Qoc,:%rn r� 1F r
(Road Name and Numbers, C unity, or Subdivision antl Lot No.) DRILLING LOG
3. OWNER n7h '°c From To
If Address 01 tcl(� l 0-1,7af Q Z
treet or Roule No C)
�Ce-Lu..-
City or Town Stale Zip Code
4. DATE DRILLED
5. TOTAL DEPTH O
6. CUTTINGS COLLECTED Y SD NO[Et�
7. DOES WELL REPLACE EXISTING WELL? YES ❑ Nprl
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 at/or below land surface requires a variance In accor-
dance with 16A NCAC 2C.0 18
10. YIELD (gpm): METHOD OF TEST
11. WATER ZONES (depth): lag �44.
DEPTH
Formation Description
a
12. CHLORINATION: Type b Jet 1V5-� Amount If additional space Is needed me back of form
13. CASING:
Wall Thickness LOCATION SKETCH
Depth .�7 Di�ama-t➢�tp, or WeighVFl. Mate I (Show direction and distance from at least two Sra
From �To �1 Ft.->.11D- —.1 Roads, or other map reference points) C
From To FL
From To Ft. 1
Ut
14.
GROUT:
-v
Depth
c
Matena
Method
:lcFrom
To
Ft.
cne
From To
Ft.
t.J1
15.
SCREEN:
Ca
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:
0
0
c'r A
�m
o c-,
Cm
z --
ot
4,
M,:)
rn
rn�o
O
z
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION filliII1811101 11110611IMTHISREC19PNIDED TO THE WELL OWNER.
FOR OFFICE 3 -- a l -�
Quad No: IS.. N 7 FQRS -1 AN#rRW6TIkELL DATE
(,:Submit original to ivi `• _ — t ithin 30 days
Sedal No. �� i «si
GW1 REV. i2/99
.-7 LX1N 2 8 2000
Groundwa'; ._

i'- Department of Environment, Health, and Natural Rosnurcns
n of Environmental Management - Groundwater Soction
P.O.'Box 29535 - Raleigh, N.C. 27626.0535
Phone [phone]
;rJ�,�t•�r;!^;:" WELL CONSTRUCTION RECORD
DRILLING' CONTRACTOR:
STAT- WELL CONSTRUCTION
DRILLER REGISTRATION NUMBER: 16 PERMIT NUMBER: ��2-
1. WELL LOCATION: (Show sketch of the location be!nw)
Nearest Town: 11104) c40 __ - —__-_ CnunD/..
(Road, Community, or Subdivision and Lot No.) DEPTH DRILLING LOG
2. OWNER L&✓ck -�hA.., —j=VID _ _ From To �Formation Desorlptlon
ADDRESS
(Street or Route No.) _ 7 7 ,_ f y rj / _ `� /�
f1�Ct cck � . C • F G�
City or Town State Zip Code. I --
3. .DATE DRILLED 3 7'60 USE OF WELL--
4. TOTAL DEPTH 1 !6
5.1 CUTTINGS COLLECTED YES[- I NOE— _
6. DOES WELL REPLACE EXISTING WELL? YES F—NO
7. STATIC WATER LEVEL Below Top of Casing: FT. _
FT. Above Land Surface' 8. TOP OF CASING IS --
Casing Terminated al/or below land surface Is Illegal unless a variance is issued -- -__--
In accordance with 15A NCAC 2C .0116
9. YIELD (gpm):30' METHOD OF TEST
10. WATER ZONES (depth): "17_r_.11o_R-
11. CHLORINATION: TypeIf additional space is needed use back of form
12. CASING:
Depth Diampt r
From © To
From To Ft.
From To Ft.
13. GROUT:
Wall Thicknns:
or Weight/Ft. tl.vo ll
Depth
From To Ft.
Material
Ce;-(fx­'7`
Method
vheL
From To
Ft.
14. SCREEN:
Depth
Diameter
Slot Size
Material
From To
Ft
_ in.
in.
From To
Ft.
in. _
in.
From TO
Ft.
in.
in..___
15. SAND/GRAVEL PACK:
Depth
Size
Material
From To
Ft.
From To
Ft.
16. REMARKS:
LOCATION SKETCH
(Show direction and distance from at least two
State
Roads, or other map reference points)
Er
0
0
0
c—
C
2
am
cm
1.
a—
�
vo
3
�m
N
ooz
m�
..o
z
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRt1('1 l=:D IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCT ION STANDARDS AND TFIAT A COPY OF I IIS Rf Ci)I IF) I IA. [TEEN PROVIDED TO THE WELL OWNER.
IUUJ MAY 2 9 IMI IU[ " u,Nn e
GW1 REV. 9r91 ubrm i it H
and copy to well owner.
-- 7
DATE

North Caroline'- Department of Environment, Health, and Natural Resowcns
; "'I ''Dlylalon of Environmental Management - Groundwater Section
yrriivt24: P.O.'Box 29535 - Raleigh, N.C. 27626-0535
Phone [phone]
WELL CONSTRUCTION RECORD
DRILLING CONTRACTOR: �__� r__J, 6 �c 1 I% t �, ._ rS I Header
STATE WELL CONSTRUCTION
DRILLER REGISTRATION NUMBER: PERMIT NUMBER:
%ITE;Mff
1. WELL LOCATION: (Show sketch of the location b(llrnv) J
MO.-Aion') ry)c
Nearest Town: _._-----__-Crnmy.
(Road, Community, or Subdivision and Lot No.) DEPTH
DRILLING LOG
2. OWNER M n-%'e- From To
Formation Description
ADDRESS �J 4- ti`z J --- -- — O —
ar12+,
y� (Sire- or
C:_ No.) �� O vld
O
L. i nee
,
I'�C4.1�r."� ��
Ci or Town Slate Zip code. ----
3. .DATE DRILLED '3-7-061 USE OF WELL'Z�i--
4. TOTAL DEPTH -2-
5. CUTTINGS COLLECTED YES CJ NOEE-- ---_— _----
6. DOES WELL REPLACE EXISTING WELLS YES[__-
-
7. STATIC WATER LEVEL Below Top of Casing: F T.
(Ufa! "i." it Ahovo Top of Cn:.m(j)
8. TOP OF CASING IS % FT. Above Land Surface'
' Casing Terminated atlor below land surface Is Illegal unless a vnrinnca is issued' ----
In accordance with 15A NCAC 2C .0119 --. ------
9. YIELD (gpm): __:DO METHOD OF TEST __2261coN___
10. WATER ZONES (depth):_
11. CHLORINATION:
12. CASING:
Type trL19 Amount _ 3_ S If additional space is needed use back of form
Depth Diameter
From To a Ft. --�
From To Ft.
From To Ft.
13. GROUT:
Wall Thicknoss
or Weight/FL Material
Depth Material Method
From To Ft. Cri7,NN� �Ae
From To Ft.
14. SCREEN:
Depth Diameter Slot Size Material
From To Ft in. in._________
From To Ft. in. in.
From To Ft. in. in.-
15. SAND/GRAVEL PACK:
Depth Size Material
LOCATION SKETCH
(Show direction and distance from at least two'§tate
Roads, or other map reference poll IN
*`
O
�
c=
Z
cm
o�
I
cJ7
� m
�o
s
N
N'
Cil
Co
0
z.
From To Ft.
From To Ft.
16. REMARKS:
I DOH WAS COMB FRt)C"I I- it IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSI III nD rA COPY Of SI II HI C,OI1D 1IAS 1IEEN PROVIDED TO THE WELL OWNER.
MAY 2 9''2`f 3_ -7
. ATLIRF OFENTCIINrRACTO GDATE
GW-1 REV.9 1
SeCilee D($-r%i. ^ol En n nlal Management and copy to well owner.

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: 3��S�;�II liel! DR60r'�14
WELL CONTRACTOR CERTIFICATION #: r_,), 13.3
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (check Applicable Box): Residential E3Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: MtoN County: ✓✓Ie rJC'lf�
/7'- R R�) � h� -Kd
(Road Name and Numbers, Community, or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER L-----e- From To FormationDescription
Address 0 �j I f JC `
treetor outs o. �I I o�y�i( AT?fkN'tC'
�1C�tt -�n -c-
City or Town f State Zip Code
4. DATE DRILLED 3 17-06
5. TOTAL DEPTH ,_,/
6. CUTTINGS COLLECTED ES ❑ NO[
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NOED/
6. STATIC WATER LEVEL Below Top of Casing: FT.
(Use'+' it
Above Top of Casing)
9. TOP OF CASING IS � FT. Above Land of
'Top of casing terminated Wor below land surface requires a variance In accor-
dance with 15A NCAC 2C.01111
10. YIELD (gpm): _�_ METHOD OF TEST 1�
11. WATER ZONES (depth): i35�M'
12. CHLORINATION: Type Amount - If additional space is needed use back of form
13. CASING:
Depth c4/ Diameter
From e9 To '(` Ft. f_
From To Ft.
From To Ft.
14. GROUT:
LOCATION SKETCH
Wall Thickness
or Weipht/Ft. Material (Show direction and distance from at least two State
—9 / y§' —5-41/ Roads, or other map reference points)
Depth Material Method
From To ad Ft. c e%�✓r d
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:
100 HEREBY CE
CONSTRUCTION
FOR OFFICE USE JMM MAY 2 9 Quad No: 11 I'
Slot Size Material
in.
_ in.
In.
Material
O
O
L
c
z
1
Ln
'D
3
N
4Ln
Co
IN ACCORDANCE WITH 15A NCAC 2C, WELL
HAS EENPROVIDED TOTHE WELL OWNER.
6�,Irrrr42eTlli irtillimelarwki DATE
30 days
MORE
I Serial No. -
UN2N1"
1� "rotmdwate, c.. ..
GW4 REV. 12199

North Carolina - Department of Environment and Natural Resources - Division of Water Ouality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION #:
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,:.pr�C how sketch of the location below)
Nearest Town: I'1A-Pty/J County:-
Lw4 ')��
(Road Name arid Numbers, Community, or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER F-VeQb+zlt_ From To Fescdption
Address Cl) 0 ounaticn \
(Street or Route No. D - q
City or TTh" State Zip Code
4. DATE DRILLED as -moo
5. TOTAL DEPTH
6. CUTTINGS COLLECTED ES 0 NO©-
7. DOES WELL REPLACE EXISTING WELL? YES NO�
8. STATIC WATER LEVEL Below Top of Casing: FT.
(Use': if Above Top of Casing)
9. TOP OF CASING ISFT. Above Land Surface'
'Top of casing terminated atlor below land surface requires a variance in accor.
dance with 15A NCAC 2C .011
10. YIELD (gpm): / METHOD OF TEST
11. WATER ZONES (depth):•
12. CHLORINATION: Type Lh �� - Amount If additional space is needed use back of form
13. CASING:
Wall Thickness
Depth Diameter or WeighVFI. terial
From To �Ft. - 7rh., bb �UC"
From To Ft.
From To Ft.
14. GROUT:
O DepIIL _ Mated Method 1
From To oiU Ft. �e cL
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 CERTIFY
CONSTRUCTION STA
FOR OFFICE USE ON
Quad No:
Sedal No.
�/ C/
Slot Size Material
in.
in.
_ in.
MAY Zb%
Material
LOCATION SKETCH
(Show direction and distance from at least two Slate
Roads, or other map reference points)
0
o
L
A�
a
cr1l
I
f r7
om
na
rV
m
rnz
��
cn
Co
Ei
z
IN ACCORDANCE WITH 15A NCAC 2C, WELL
30[d0.dA BEE PROVIDEDTOTHE WELL OWNER. -7
_/�-�i��
ptaddN 6AN$Rdk-TWa TAF VMJ DATE
to IMs(o ' ° In 30 days
GW-1 REV. 12199
li EN ? 3 2(ttlrt
t

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: 2��Albil�e a A-)e /)
WELL CONTRACTOR CERTIFICATION #: orZ�
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential � Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
Agricultural ❑ Monitoring ❑
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town:-- MG!g"OlJ County:
C`YaO-"t CA,
(Road Name and Numbers, Community, or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER _ 1y1 A,ek _I r2tn,S From To r Formation crfption
Address
trees or Route NO.).q� TKO
:L -
City or Town State Zip Code
4. DATE DRILLED 7Y -vU
5. TOTAL DEPTH
6. CUTTINGS COLLECTED ESQ NOEZ�'
7. DOES WELL REPLACE EXISTING WELL? YES NO
8. STATIC WATER LEVEL Below Top of Casing: FT.
(Use'+' if Above Top of Casing)
9. TOP OF CASING IS�_ FT. Above Land Surface'
'Top of casing terminated attor below land surface requires a variance In accor-
dance with 15A NCAC 2C .01/8
10. YIELD (gpm): _—_ METHOD OF TESF
11. WATER ZONES (depth): �C:YJ C-
12. CHLORINATION: Type Amount
13. CASING:
Wall Thickness
Depth Diameter
`7'
or Weighl/Ft. Material
/
From
To Ft. --6-5
Y/
From
To Fl.
From
To Ft.
14. GROUT:
Depth Material Method
From
To _ 20 Ft.
a�
From
To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From
To _ Ft in.
in.
From
To Ft. in.
_ In.
From
To —Ft. in.
_ in.
16. SAND/GRAVEL PACK:
Depth Size
Material
From
To Ft.
From
To Ft.
17. REMARKS:
I DO HEREBY
CONSTRUCTI
FOR OFFICE L
Quad No:
Serial No.
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)
WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CR=M=FlTHIS RECORD.HCS_,@EEN PRO AIDED TO THE WELL OWNER.
nr. 1
Z 9 9 i� on Water Duality, Gmun
O� n
am
r >m
cn o
y rn
-4
�o
N Hi
� n�
0
2
:z:-_> 3—a9-«C
YELL DATE
within 30 days
GW-1 REV. 12199
, W-34

867
North Carolina -Department of Environment and. Nahrtal Resources - OWlslon of Watar OuaOry •Groundwater Section ;:2)2
1636 Mall Service Canter -Raleigh, N.C. 27699-1636-Piton (9191 733:=l ..-.. / ._ -
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION 0-
STATE WELL CONSTRUCTION PERMIT):
USE Applicable cos): Residential V�-, Iunlcipal ❑
Industrial ❑ Agricultural O Man(todng ❑
1. WELL (chock
Recovery ❑ Heat Pump Water Injection 0 Other [j If
Other, List Use:
2. WELL LOCATION: (Show sketch of the location below) ,1y
Nearest Town: County. /�✓�'��/�'Ts-r
(Road Name and;gUTOOM soh/dfviston and Lot No.)
DRILLING LOG DEPTH
/FCommunity, (sr
3. OWNER a-k4u l('LYCke.C-.-
From To Frnmallon Description
Address d"
557o
151roevar HMO
Town Slate Zip Code---
4. DATE DRILLED /b - 6 f- +�
5-& 7T6 �/ x
5. TOTAL DEPTH SOS
aa--55
6. CUTTINGS COLLECTED YES NO[]
7. DOES WELL REPLACE EXISTIN WELL? YES E] NOga
6. STATIC WATER LEVEL Below Top of Casing: go FT.
(Use Z' 0 Above Top of Zing)
9. TOP OF CASING IS FT. Above Land Surface.
.. .
'Top of easing terminated at/or below land surface requires a variants In "cor-�:.
dance with 1SA NCAC 2C.0113
10. YIELD (gpm): -? METHOD OF TEST ti
11. WATER ZONES (depth):
12. CHLORINATION: Type .,.-.Amount-
It additional space is needed use back of form
13. CASING:
LOCATION SKETCH
Wag Thickness
Depth D efer w welghtlR. Maledal
'To
(Show direction and distance from at least two Stale
' �-�
From-/--/ —! / Ft. ` - ' G
Roads, or other map reference points)
From To Ft.
From To Ft.
14. GROAT:
o
Depth Material L Method
b Ft.
CD
o
From To
�oF
From To Ft.
M
15. SCREEN:
N
` r
Depth Diameter Slot Size -Material
C
r,
From —To—Ft— in. —in
From — To Ft. M. — in.
3
z`Mm
From Ft. In. —In.
Co
m�
_To
16. SAND/GRAVEL PACK:
_
Depth Size Material
OD
z
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 RECOR S BEEN PROVIDED TO THE WELL OWNER
FOR OFFICE USE ONLY
Dead Na: ly' - /G - a P - o
!' SIGNATURE OF PERSON' NG THE WELL DATE
C• IiJ i'
4
. 5ohrat ori&al to Division at Water Quality, Groundwater Se Within 30 days f99
Serial No. ... j GW-1 REY. 12
q s L' '
t t'•alr dwa'e S rP-

North Carolina • Department of Environment and Natural Resources - Division of Water Guasty - Groundwater Section r .
1636 MAN SAwiall CAfl1Af : F16111pN, N.C.178991A81MMI11 pll) 7031111 4_ z 3 6'7 9
WELL CONSTRUCTION RECORD WELLCONTRACTOR: Hickory Well Drilling Co.
WELL CONTRACTOR CERTIFICATION R: 2343
STATE WELL CONSTRUCTION PERMITR:
1. WELL USE (Check Applicable Box): nesldenllel l l Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other [] It Other, List Use:
2. WELL LOCATION: (Show skelch of the locellon below)
Nearest Town: NPtxl County:
Deerpark Rd.
(Road Name and Number. Community, or Subdlvldon and Lot No.) DRILLING LOG
3. OWNER , T 1 nyd Foster/Horton Homes of Morganton From To
Address 319 Carbon City Rd. —
MorQanton N. 28655
City or Town Stale Zip Code —
4. DATE DRILLED 19-11-00
5, TOTAL DEPTH �$�
6. CUTTINGS COLLECTED YES Q NO�j
7. DOES WELL REPLACE EXISTING WELL? S 0 NOE]
6. STATIC WATER LEVEL Below Top of Casing: 60 Fr. _� m
(Use'** M Above Top of Casing)
S. TOP OF CASING ISFT. Above Land Surfaces 1 o`t
-Top of cuing terminated oVor below land surface requites a variance In scoot- ter^
dons with 1SA NCAC RC. Is
10. YIELD (gpm): METHOD OF TESTBy Air Test �m
11. WATER ZONES (depth):
12. CHLORINATION: Type —FFth Tabs Amount
13. CASING:
Wag Thickness
Deplh Dlamsler or Walght/Fl. Material
From To 109 Fl. 1" -PVC1.-- pinqt
From To Ft.
From To FI.
14. GROUT:
Ooprh Metorlel Method
From 0 To 20 Fl, Grout Poured
From To Fl.
15. SCREEN:
Depth Diameter
From To _ FI _ In.
From _ To _ Ft. — In.
From _ To _ Ft. _ In.
16. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To Ft.
17. REMARKS:
Stoll SIZE Malellel
In.
In.
In.
Material
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACC
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD
Ouad No:
Serial No. j I! 1
�s
DEPTH
Fonnaaon Desorption
II additional space is needed use back aUerm o
LOCATION SKETCH
(Slaw dlrectibn and distance from at least Iwo Stele
Roads, or other map reference points)
W
of Waist Quality.
14
/v /%%/uii4AlTO^r
'C 0p'/Gt/�G(/
�s
WITH ISA NCAC 2C, WELL -
PROVIDED TO THE WELL OWNER.
D TIIE WELL
section within 30 days
12-1
DATE
GW1 REV. 12199
. .,..,..... v.._.u:a,:.�....9ra.c:�wro::..:_=,.r2wst�+,M ...... .._,.; ..., .::-ti•�-•�..

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section ') 4 7 9
1636 Mal Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION #: 2609
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: Marion County: McDowell
(Road Name and Numbers, Community, or Subdivision and Lot No.) DRILLING LOG DEPTH
3.
OWNER Ann r'mmptnn From To Formation Description
Address 812 S Main St.
Streator outs a. 0 47' Dirt
Trnntman, NC 28166 47' 465' Rnrk
City or Town Stale Zip Code
4.
DATE DRILLED 1 1�?_nn
5.
TOTAL DEPTH 465'
6.
CUTTINGS COLLECTED YES 0 NO®
7.
DOES WELL REPLACE EXISTING WELL? YES N0F_�
8.
STATIC WATER LEVEL Below Top of Casing: FT.
(Use'.* if Above Top of Casing)
o
9.
TOP OF CASING IS 1 FT. Above Land Surface'
Top of casing terminated at/or below land surface requires a variance In accor.
.�
dance
with ISA NCAC 2C.011a
Air
10.
YIELD (gpm): i METHOD OFTEST ram-,
11,
WATER ZONES (depth): irn'
=E 20
12. CHLORINATION: Type RTA Amount II additional space is needed use back of formfV mN
13. CASING: W.
LOCATION SKr: CH c''�
Wall Thickness =
Depth Diameter or WeighUFt. Malenal (Show direction and distance from at least two State
From O To 47 Ft. PVC Roads, or cther map re.'erence points)
From To Ft.
From To Ft.
14. GROUT:
Depth
From 0 To 20 Ft.
From To FL
15. SCREEN:
Material Metho
Grout Poured exrf
p�
Depth Diameter
From —To—Ft— in.
From To _ Ft. in.
From To _ FL - In,
16. SAND/GRAVEL PACK f2
Depth D LS
From To t
From To t. MAR
17. REMARKS:
I DO HEREBY CERTIFY
CONSTRUCTION STAN!
Slot Size Material
in.
In. 3
tf•
JW,WtULWAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
AND THAT A COPY OF THIS 9ECORO HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Quad No:
Serial No.
SIG TORE OF PERSON CONSTRUCTING THE WELL
Submit original to Division of water Quality, Groundwater Section Within 30 days
DATE
GWI REV. IV99

,A'Ey, Norlh Carolina Department of Environment and Natural Resources -Division of Water Quality -Groundwater Section ,-
Box 29578 Raleigh,N.C. 27626-0578-Phone [phone]'9 Z—T. L
WELL CONSTRUCTION RECORD DRILLING CONTRACTOR: .Sov/4 e4 r /-E ; -/ w
DRILLER REGISTRATION#: 7if
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (check Applicable Box): Residential R Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below) J
Nearest Town: e✓ o rI 6 Co v -e County: A"iL ow e rJ
(Road. Community, or Subdivision and Lot No.) DEPTH
3. OWNER w / Ar
SFrom Ton,/dwG
ADDRES(,;0 d Oil _
(Street or Route No.)
DRILLING LOG
Formation Description
�0/'Ivh/ _Y 3)ot,3o
o-
so
r./< Jpvd
City or Town State Zip Code
4.
DATE DRILLED 0 0
TO -
20
( r S
5.
TOTAL DEPTH 2 V O
0vt CJ-f
6.
CUTTINGS COLLECTED YES ❑ NO❑o
7.
DOES WELL REPLACE EXISTING WELL? YES® NO❑
70
/60
Soia/ Gain P d
8.
STATIC WATER LEVEL Below Top of Casing: S n FT.
J, /r - SR P d
9.
(Use "tit" if Above Top of Casing)
TOP OF CASING IS�_ FT. Above Land Surface`
/60 _
/PO
G,'�r e,�y0g p
Casing Terminated aver below land surface is illegal unless a variance is issued
in
10.
accordance with 15A NCAC 2C .0118 -
YIELD (gpm): 1-o METHOD OF TEST 4t ^
1 yU -
' � 0 0
/
�i r e c / - S-a ti ; /
11. WATER ZONES (depth): 14P0 4hr✓ U 00
12. CHLORINATION: Type of ✓an�7A//�C Amount �0— If additional space is needed use back of form
13. CASING:
Depth Diameter
From O To y r o Ft. K:k�_
From To /moo Ft. 41
From To Ft.
14. GROUT
Depth Diameter
From 2.00 Tol)�'CJ`Ft G/ in.
From To Ft. in.
From To Ft. in.
16. SAND/GRAVEL PACK:
Depth Size
From "' To —'Ft.
From To Ft.
17. REMARKS:
Wall Thickness LOCATION SKETCH
or WeighUR. Material (Show direction and distance from at least two State
Roads, or other map reference points)
L i
Depth Material Method (� L
From o To 7 a Ft. d L(/0 "K`e
From To Ft.
15. SCREEN:
Slot Size Material
0/0 in. Pvc. (10
n.
in.
Material
6
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. V___.
FOR OFFICEUSEONLY �J
Quad No:-'-.. - ` SIGNATURE OF ONTRACTOR OR AGENT DATE
Serial No:.~�: ~ Submit origiaald6Division of Water Ouality and copy to well owner.
GW-1 REV. 1/98
3

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail S Ni a Center - Rate! It INC 27699.1636-Phone [phone] r)A 6
e s g . . .
WELL CONSTRUCTION RECORD WELL CONTRACTOR: mr)e A r u
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Boa): Residential I5 Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ It Other, List Use:
2. WELL LOCATION: (Show sketch of the location below) II em�� �/
Nearest Town: , M n r f 0 rx- _ _ County: /� lJ l
oad Name and Numbers. Community, or Subdivision and Lot No.) DRILLING LOG
3. OWNER �nd CI - AA rebel le , v�f.f rl From To
Address 'A2111 AczkIrinrl-h `Q,nItA
Clty or t owrl Dials
4. DATE DRILLED
5. TOTAL DEPTH r
6. CUTTINGS COLLECTED YES ❑ NOM
7. DOES WELL REPLACE EXISTING WELL? YES NOrt,,'.'
8. STATIC WATER LEVEL Below Top of Casing: FT.
(Use'+' a Above Top of Casing)
9. TOP OF CASING IS ► ,33 FT. Above Land Surface'
'Top of casing terminated stfor below land surface requires a varlance In accor-
dance with 15A NCAC 2 011a n ed
10. YIELD (gpm): -m
METHOD OF TEST
11. WATER ZONES (depth):
12. CHLORINATION: Type Amount
13. CASING: l Pir1s1:0. Let
Play
Wall Thickness
Depth - Diameter or Waight/Fl. Material
FromTo85 Ft.(121/5? —<D 12 2 1—No
-
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
! OI re
From � � To _Ft.0m�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
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)
s-ii © E-it 8 3 - Ashwor Read -
� brjjl v - and 33�kloA'rt
Past bn d e ort Ie�.
-}lee Y use . rvid{ Klm"o-
oA_ r'CG. bo ' bn rJ+)
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT
FOR OFFICE USE ONLY
Quad No:
Serial No.
Submit original to Division of Water Quality, Groundwater Section witmn ou uoya
GW1 REV. 11199
19

North Carolina - Department of Environment and Natural Resources • Division of Water 04aIIN - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27e99-116315-Phone [phone]
WELL CONSTRUCTION RECORD WELLCONTRACTOR:
WELL CONTRACTOR CERTIFICATION 0:
STATE WELL CONSTRUCTION PERMIT#: _
A531
I. WELL USE (check Applicable Boa): ResidentialGa Municipal ❑ Industrial Agricultural �', Monitoring ❑
Recovery 0 Heat Pump Water Injection ❑ Other C3 If Other, List Use: F — --
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: Ma r; On .— County:
#Road Nams and Numbers, Cernmunlly, or Subdivision and Lot No.) DRILLING_ OG
3. OWNER Todd Wildenhero Prom To
Address 13nj,—
ree or�Toule �—
M^ri
City or Town State Ip Code
4. DATE DRILLED _1*?-1'2-00
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES[] NOV � -
7. DOES WELL REPLACE EXISTING WELL? YES [] NO[dJ
e. STATIC WATER LEVEL Below Top of Casing: 40_ FT.
(Use': if Above Top of Casing) --
9. TOP OF CASING IS 1 FT. Above Land Surface -
'Top otcasing termina:ed aUor below land surface requires a variance In aecor-
dancewith lSANCAC2C.e11e �
10. YIELD (gpm): 30 METHOD OF TEST �a (`nnta*+ r l --
11. WATER ZONES (depth):.-80 —
12.
CHLORINATION: Type
Tahl Pt- Amount 2
13.
CASING:
Was Thickness
Depth
Dlarneler or WeighUFt. Material
From —0
--To60.—Ft.
From
To
FI-
From --To
Fl.
14.
GROUT:
Depth
Material Method
From _,-
To ___Fi.
_COXIC�— —$Gtar—
Frorn
To __—FI.
15.
SCREEN:
Depth
Diameter Slot Size Material
From __—
To __
FI _-- In. —_ in.
From _.,
To __
FL, In. _ In.
F tom _—
To —
FL _ In. ._. in.
16.
SAND/GRAVEL PACK'.
Depth
Size Malelfal
From ---
To
r l
From.. _—
TO
Ft.
_*EPTH
Fort}tallon DascdpUon
It additional apace Is needed use flack of form
LOCATION SKET H
(Show direction and distance from at ljest two State
Roads, or other map reference points)
I 40
Batcave Rd.
0
17.
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 1SA NCAC 2C. WELL
CONSTRUCTION STANDARDS. AND THAT A COPY OF THIS RECORD BEEN PRO'IDED TO THE WELL OWNER.
FOfl OFFICE USE OtJ LY - OAIE
Ouad No: S� OF PERSON C SiRUCTINO THE WELL
Submit original to Divlsicnof Water Dust 4, , Groundwater Section within 30 days (1Wd RE`J. 12199

Nand Mal Qnh Carolira —center ot ( ph, N- nI endt atural a urce 7-iINY2t of Wolof 9yN!M • �W^dwelm SscUon
WELL CONSTRUCTION RECORD WELL CONTRACTOR CERTIFICATION' i'
STATE WELL CON9TRUCTIONPERMf il"
L 4532
at [] IMustrial ❑ AgfioultUrei 0 ' Monitoring ❑
1. WELL USE (Cheek APPlkeIII9 SOaj: ReaResidentialMun IdP
Recovery ❑ Heat Pump Water Inectlon [] Other (] If Other, Uft use:
2, WELL LOCATION: (Show Sketch of the location below)
fY Memel l
Neetsst To+m:.
nra!! t IN pCi
(noed Name ana Nombws. ComrtYa+I!y, w $UbN'Mler! and Let No.f From To
3. OWNER RohP .
Address 5471 Painters Gad Rd•_.
m or ou e KT.—. Union r1ka�1a_i R 1 h 7
City a To`wi
State 21p Cea
4, DATE DRILLED
5. TOTAL DEPTH St)7
6. CUTTINGS COLLECTED YES NOU
NO[2(
7, DOES WELL REPLACE EXISTING WELL? YES
C3
8 STATIC WATER LEVEL Below Top of Casing: _3.4D FT -
IV" -, F Above Too of Caehgt
9. TOP OF CASING IS 1 FT. Above Land Surfaes'
') OP of easing taminatod atlor below land surfsea roquiros a verlance, !n eeeer•
dents;withIfANCAC2C.oife METHOD OF TEST r —�
1 o. YIELD (gpm): 1
1 t. WATER ZONES (dePth):
_--- it ed9eonsi DPW* is needled U" i off"'
(Show direction and lm,,,� ill ttua
Reed., a Ith" MAP rNennoe Afe)
i
m i ,. • _.�-----
12. CHLORINATION: 'Type
Amount
T
13, CASING:
Wall Thid"St
Depth Dis"I er WeiglMfii. Wladtl
f
Fran_0 - To 90 Ft._ -
From To FL -----
From - _ToFt.
14. GROUT'.
Mefedsf
Mettad
Depth
From --
TO ---.
Fi..S.DSLCY'Q��
-. D�>---
From --To
Fl. __----
15.SCREEN:
Depth
Diameter Slot Slze
}.fetarlal
From ___
- To _-
FI .�-
In. �
In.
In.
in.._--
From ._._.—To-----
Ft. -----
i
in.
From —___
To _.--
FI. _.--
In. -._—
16. SAND/GRAVEL
PACK:
Maletlel
Depth
Size
from
From
To___.-
Fl.
____---------'—_"
PTH —
iorr�aiks+ Daut.PVan
Hwy 70
Thru Pleasant Gardens
Roby Conley Rd.
Pleasant View
Hawk View
�D o
17. AEMARKS. — H�J s�////C��
t DO tiERSBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH t.`G14�'�' WNi_L
CONSTRVCnON STANDARDS. AND THAT A COPY OF THIS RECORD SEEN PROVIDED TO THE WE' OWNER
8 N0-0--
DATE
FOR OFFICE USE ONLY • N C STRUC71NG THE WELL
�
.s!OuEP.EdS.?Z......,......... within 30 dot's
Quad No'. _u ants aarxon 61y.l nEv. 17/99
-_- -_ Subma onotnal to a!o !!Pi 1pNr%ieulY prar,�^

North Carolina - Department of Environment and Natural Resources - Division of Water Quality- Groundwater Section 4 ,�
36 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
i6
WELLCONTRACTOR: Appalachian Well —Drilling
WELL CONSTRUCTION RECORD
WELL CONTRACTOR CERTIFICATION 0: n� L
STATE WELL CONSTRUCTION PERMIT#:
1, WELL USE (Check Applicable Box): Residential U Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heal Pump Water Injection ❑ Other (] If Other, Llst Use:
2. WELL LOCATION: Show Fort sketch of the location belowounty: McDowell
Nearest Town; G
DRILLING LOG—
(Rcad Name and Numbers, Community, or SuhdlAsion and Lot No.) From To
3. OWNER A] Ign VP¢S
Address
ee or ou o.
Old Fort
City or Town
Slate Zlp Code
4. DATE DRILLED 12-26-0�
5. TOTAL DEPTH 1R7 _—
6. CUTTINGS COLLECTED YES(] NO
7. DOES WELL REPLACE EXISTING WELL? YES NO
8. STATIC WATER LEVEL Below Top of Casing: 40
FT.
(Use'+' if Above Top of Casing)
9. TOP OF CASING IS 1 Fr. Above Land Surface -
'Top of casing terminated at/or below land surface requires a variance In eccor-
daucewith 15ANCAC2C.e1/6 Cal (Ontai ner
10. YIELD (gpm). 15 METHOD OF TEST
11. WATER ZONES (depth): 80.
12. CHLORINATION
13. CASING:
DEPTH
Formation Description
�. O
------------------
7 It additional space is needed use back of torn'
Type Tablet Amount =
Wall Thickness
Depth Diameter or WefghVFt. Material
From O To 47 Ft.
From To Ft•
From To FI.
14. GROUT: II d
From —
From _
15. SCREEN:
Depth Material Mo to
To Ft. Concrete Pour
To Ft.
Depth
Diameter
From —To --FI_
In.
From —To_ —Ft.._.
In.
From __ To _
Ft.-- In.
16. SAND/GRAVEL PACK:
Depth
Size
From T°
Ft. —
From To
Ft. —
17. REMARKS
Slot S176 Material
In.
In.
In.
Material
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
I-40
Bat Cave Rd.
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED)N ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
12-29-00
FOR OFFICE USE ONLY DATE
SI ATURE OF PERSON CONSTRUCTING THE WELL
Quad No:
Submit original Division of Water Quality. Groundwater Section within 30 days GW-t REV. 12/99
Serial No.

North Carolina - Department of Environment and Natural Resources . Division of Wale( OVallty. Groundwater Section
1636 Mail SeNIOe Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: HDoa acnla
WELL CONTRACTOR CERTIFICATION Il:,
STATE WELL CONSTRUCTION PERMiT1:
i515
1. WELL USE (check Applicable 90s): Residential Lid Municipal ❑ Industrial ❑ Agricultural 0 Monlioring ❑
Recovery Heat Pump Water Injection ElOther 0 if Other, List Use:
2. WELL LOCATION: (Show sketch of the location below) MO TIl ]
Nearest Town: Nahn County
(Rood Nama and Numoara. Community, or Subdldsion and Lnl No.) DRILLING LOG
From To
3, OWNER Darren MCCOrM'Qk___ —
Address �(1
ouleN76
bo_ --
--� ..nee ar `?$ 61
_ Ne�_N.
Cily or To-n State 21p Code
4. DATE DRILLED 12-7=�0
5. TOTAL DEPTH 12_y--
6. CUTTINGS COLLECTED YES Q NOQ
7. DOES WELL REPLACE EXISTING WELL? YES Q NOLO
8, STATIC WATER LEVEL Below Top of Casing: 20 FT. --
(use': If Aoays Top of Casing)
9. TOP OF CASING IS 1 .__ FT. Above Land Surface -
'Top of cuing i*rminat*d stfor blow land surface re9ulres a variant* In sccor-
dance with 15A NCAC 2C .011a
10.Y15LD(gpm), ,SO _METHODOFTEST rat _(nntainar —
11. WATER ZONES (depth):
nr
12.
CHLORINATION: Type Tahl Pt—Amount
—
13.
CASING:
Wag TNckneu
Depth
Diameter
or Welght/Ft. Material
From —.0—.--To --- 9-0—
Ft.
From.--- To--
FI•
�—
From To._---
Fl.--
--'
14.
GROUT:
fAelorlai
Method
Depth
From �-- To----Fl.
—C�
--�
From _.._ To _.
—Ft.
—
15.
SCREEN:
Depth
Olameler
Slot Size Material
From To _
Ft — In.
._— in.
From _ To __—.
Ft — In.
— In. _
From _— To _
Fl. _.— In.
_.. In -
IS.
SANO/GRAVEL PACK:
Size
Material
From _-- To
Ft. -
From —_ To_—_
Fl..----
.
___RE_PiH
Fwritalion Descepeon
It additional apace is needed use hack of form
LOCATION KET H
(Show direction and distance from at I ast two State
Roads, or other map reference points)
I-40
Nebo Rd.
Laurel Ridge
17. REMARKS: --
1 DO HERESY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C. WBLL
CONSTRUCTION STAIIOARDS, AND THAT A COPY OF THIS RECORD BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE OPtLY _ — �- DATE
Ouad No: —_ STUN RE 1 PERSON C 9urdwst r Section
WELL
-Submk oAQlnai tp Division of W at*r Uuellly, Umundweter Secilon within 30 days Uw I REV.12/99
sedal Na.

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section r-, . n A r'7
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]- ti C 8 `t
WELL CONSTRUCTION RECORD WELLCONTRACTOR: APP01 ^^hi Rn
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Boot): Residential Ltd Municipal ❑ Industrial ❑
Recovery ❑ Heal Pump Water Injection ❑ Other 0 If Other, List Use:
Agricultural ❑ Monitoring ❑
2. WELL LOCATION: (Show sketch of the location below)
�r —County: •- "
Nearest Town: �— o �F -- Cty' -�n- -
(Road Name and Numbers. Community, or SubdMslon and Lot No.) DRILLING LOG
3. OWNER brew Hal dman From To
Address
rea or ou a o.
Old Ferry N ZI Code
City or Town Slate P
4. DATE DRILLED 1 (1_71 -n0
5. TOTAL DEPTH 307
6. CUTTINGS COLLECTED YES[--] NOE
7. DOES WELL REPLACE EXISTING WELL? YES Q NO�-
8. STATIC WATER LEVEL Below Top of Casing: an 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 .0118
10, YIELD (gpm): 10 METHOD OF TEST Gal Container
11. WATER ZONES (depth): 1 490
DEPTH
Formation Description
12. CHLORINATION: Type TAIDIQL—Amount 2 11 additional space Is needed use back of form
13. CASING:
Depth Diameter
From. 0 To 8-0-- Ft.
From To FI.
From To FI.
14. GROUT:
Material Method
FL r Grote---D2eii-ry
Ft.
Depth
From To _
From To _
15. SCREEN:
Depth Diameter
From _To _ FI _ In.
From —To _.Fl._ In.
From _._. To _ Ft. _ In.
16. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To Ft.
17. REMARKS:
Wall Thickness
or Welght/Ft. Material
Slot Size Nlaletial
In.
In.
In.
Material
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
I 40
Old Fort Rd
Pine Cover Rd
0
O �
CD
O c
N p.�
CO n
S+o
a m=
Ns
Co MDo
W
as o
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 BEEN PROVIDED TO THE WELL OWNER.
_. All S/_ /h-3(9-00
FOR OFFICE U.SE ONLY
'QuadNo: 'ITS i I
� aria) No.
zjl
SIGN�T RE OF PERSON CAFfSTRUCTING THE WELL
Submit original to Division or water Quality, Groundwater Section within 30 days
DATE
GW-I REV. 12/99

North Carolina - Departmont of Environment and Natural Resources - Division of Water Otlaily. • Groundwater Section 8 4 6
1 e36 Meal Servloe Center • Ralelgh, N.C. 27699.1636-P1wne [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR CERT FICATION I: _r-1�
STATE WELL CONSTRUCTION PERMIT/:
Municipal ❑
Industrial ❑ Agricultural El' Monitorfng
❑
1. WELL USE (Cheek Applicable Boal: Residential LYJ
Recovery ❑ Heat Pump Water Injection ❑ Other [] It Other,
Ust Usa:
—
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: NobQ County:
(Road Name ana Numbers, Cortrnw,lry, or Subdlvlslon and lot No.)
t�EPTH
DRILLING LOG Fomretlon Oascdpdon
3. OWNER
From To ..
Address _—
.
Ciryot Town Stale Zlp Cods --
DATE DRILLED
4. _---I.Q=23-00
5. TOTAL DEPTH 6 S -
_-+--------
6. CUTTINGS COLLECTED YES 0 NO
Nod
7. DOES WELL REPLACE EXISTING WELL? YES Q
B. STATIC WATER LEVEL Below Top of Casing: Jr)() Fr.
(Use -i a Above Top of Casing)
TOP OF CASING ISFT. Above Land Surface'
.
9.
•Top or casing (rminalad allor below land surface rsqulres a varlsnce In accor-
dance with 15A NCAC 2C .011e
10. YIELD (gpm): 3 - .METHOD OF TEST gal —r—vvnza i
11. WATER ZONES (depth):? �
mab Amount
12. CHLOflMATION: Type Iei: �-
it addltbnal space Is needed use llack of form
13. CASING:
LOCATIOU,.SKETPH
Wan Thickness
Maledal
(Show direction and distance from at I ast two State
Depth Diameter w We(ghVFt.
Road@, or other map reference points)
From _.—.O--To ---3-1- Ft.
From To Fl.
From To FL
I 40
o
14. GROUT:
Depth Material Method
o
O
-E
From To __--_-Ft. r- z —'Pour
p
226 m
�s
or;
Fl.
From To --- —
c�
Lakeview Shores IV
�m
o<
15. SCREEN:
Depth Diameter Slot Slze Material
m,
From _ To —_ Ft --- In. _.— In.
a
3
MCI
m
From __ To __ Ft. _ In. —_ In.
Co
w z
m �6
From —._ To -- Ft. _ In. In.
W
-�-t
E. SANLVGRAVEL PACK:
a0
Depth Size Material
From __- To Ft.
From __ To Ft.._
17.REMARKS:
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C. WSLL
BEEN PROVIDED TO HE WELL OWNER.
CONSTRUCTION STANDARDS. AND THAT A COPY OF THIS RECORD
FOR OFFICE USE ONLY —� — -
OF PERSON
., ---
C 97RUCTING THE WELL DATE
Ouad No: 51�
Submit original to Division of Wetar Duality, Groundwater section within 30 days GW-I REV. 12J99
$edal No
Fr
( L.
3i

North Carolina - Department of Environment and Natural Resources, . Division of Water Duality • Groundwater Section 2W,79
1636 Mail Service Center • Raleigh, N.C. 27899A636-Phone [phone] \/
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELLCONTRACTORCElR,IFICAT10Na:
STATE WELL CONSTRUCTION PERMITII:
Y.
LD Municipal Indusldal 0 Agricultural IDWELLUSE(CheckAppticabieBox):Resldenllal V
Recovery ❑ Heat Pump Water Injection ❑ Other It Other, Ust U9e: /
WELL IOCATlO (Show sketch of the location below)
Nearest Town: ,�-iL-'__ County:
Monitoring ❑
meanu'./DRILLING LOG—
(Road Na
ForTadoo Description
t �f i' `� is i "3.,f From To
3. OWNER
a
Address --�
City or Town
4. DATE DRILLEO -,n-•- �---`
S. TOTAL DEPTH
6, CUTTINGS COLLECTED YES I] NOL3 ---' CD
7. DOES WELL REPLACE EXISTING WELL? YES (,_ f—N
i
8. STATIC WATER LEVEL Below Top of Casing: _ebar
(Use'.' a Abows Top of Casing) v"`r
FT. Above Land Surface-
g. TOP OF CASING IS FT. ,=
casing terminated War below land aurtace requires • variance In accor-
•Top of cdancewithl5ANCAC2C.011a
10. YIELD (gpm)! �..._ METHHOD F TEST— •• I. WATER ZONES (depth): r '-
12. CHLORINATION: Type —=
U) Gy Amount L- It additional apace Is needed use Yaek of form
13. CASING: LOCATION N SKETCH
Wall Thickness
-� Depth 7_— Diameter or Weight/Ft. Material (Show direction and distance from at Itast two State
r o �J Roads From , or other map reference points)
—� Ft ---
From To FL —
From TO---- Ft.
i � s
14. GROUT: Depth Melerlal ,Method
)
From --To o -- Fr, �f� ' (C. — — t_ ��..�'`.'� �.. t -- •-.�
From FL
15. SCREEN:
Depth Diameter Slot Slze Material
From TO Ft _— In. _ in.
From _To_ Ft- — In. —In. _--
From To _— FI.— In, _ In.
16. SAND/GRAVEL PACK: Malarial
Depth Size
From To Fl. ------
From To_— Fr..�— -- —
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCOROANCE WITH 15A NCAC 2C. WALL
CONSTRUCTION STANDARDS. AND THAT A COPY OF THIS RECORD BEEN PROVIDED
HE WELL OWNER
FDR OFFICE USE ONLY ��• DATE
: SIGN RE OF PERSON C S NO THE WELL
Ouad No
submit original to bivlsian of water Ouafity. Gmundw,1undweler sexton within 30 days G'N4 RE'r. 12/99
Sedal 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 WELLCONTRACTOR: 13Lj 1
WELL CONTRACTOR CERTIFICATION 0: 2FSI 3
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (check Applicable Box): Resldentlaffl—�r Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ It Other, List Use:
2. WELL LOCATION: (Show sketch of the location below) t n r nyo 1
Nearest Town: (h Cr 1 It County:
(Road Name and Num)a, a, Community. or Subdivision and Lot No.
3. OWNER _,\C'.rC% %a!ook
Address \
a or ou a o,
M ac- Go � �• P
zi coda,
City or Town State
4. DATE DRILLEDI'aU 'AA
S. TOTAL DEPTH e100
6. CUTTINGS COLLECTED YES D NO[9�
7. DOES WELL REPLACE EXISTING WELL? YES Q NOD
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 stfor below land surface requires a variance In accor-
dance with 15A NCAC 26,81 8
10. YIELD (gpm): a METHOD OF TEST ^
11. WATER ZONES (depth):
DRILLING LOG
From To
n - ►Q0
DEPTH
Formation Description
IJt� L�e,estone.
S•Cc�.l Mud
L.( t"f- Si 00
12. CHLORINATION: Type F ti% `E; r k'lNCbi!'Amount "IS If additional space Is needed use back of form
13. CASING:
LOCATION SKETCH
Wail Thickness
Depth Diameter or WelohVFt. Ma_ , ted�l (Show direction end distance from et least two Slate
From —44--To Ft. r l ( 5t e„ Roads, or other map reference points)
From To FL
From To Ft.
14. GROUT:
Depth Material Method
From 0_ To �FI. Getn4 5§1(
From To Ft. o
15. SCREEN: O ID
O ID
Depth Diameter Slot Size Material C—
From _. To _ Ft _ In. —In. C o'
From _ To _ Ft. _ in. _ In. = i'
s o'
From —To _ Ft. — In. —In. t:li yi
16. SAND/GRAVEL PACK:
Depth Size Material 3 ��
From To Ft. M
N en:
From To FI.
u =-
17. REMARKS: z
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
Ouad No: QNATURE OF PEON CONSTRUCTING THE WELL DATE
'i,'T�'� `�tQl
Division of waldryyyiouallty, Groundwater Section within 30 days
Serial No. ^T.•I '. I I j GW.I REV. 12/99

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section C 4If
17 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 0�—Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Shy sketch of the location below) Ito
City or Town State Zip Code
4. DATE DRILLED /" ( t
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑ NO
7. DOES WELL REPLACE EXISTING WELL? YES NO�
8. STATIC WATER LEVEL Below Top of Casing: F7.
(Use'+' If Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface'
'Top of casing terminated ot/or below land surface requires a variance In accor-
dance with 15A NCAC 2C.0118 ,f / f
10. YIELD (gpm): METHOD OF TEST �(1
11. WATER ZONES (depth):
Nearest Town: �`rt'p'1 County:
/t'rCr'')Ue-ti
DRILLING LOG
DEPTH
(Road Name an�d�umbers.
Cammnuniry, or Subdivii n and Lot No.)
3. OWNER f on.
at�l� I� VP iVS �� iM
From To
F�auongescri n f
Address
) cLk i� to (cs�c��S
l / C
N�b�
treat or to e. a � I
- 3
oc'c k
%3 f
01"C c
12. CHLORINATION: Type Amount If additional space is needed use back of form
13. CASING:
LOCATION SKETCH
Wall Thickness
Depth ? Diameter or Weig I. Material (Show direction and distance from at least two Slate
/_
From�TO Ft. — �n/—C— Roads, or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth atena� Method
a
//^^
From —�—�� To Ft. ^-� ^` }'e "� CD
0
From To Ft. r_�
m
15. SCREEN:
cm
Depth Diameter Slot Size Material
c�
From in. —in a'
�o
—To—Ft—
From To _ Ft.— in. _ in. s
�m
From To _ Ft. _ in. _ In. ry
mz
16. SAND/GRAVEL PACK:
Depth Size Material cn
z
From To Ft.
From To Ft.
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCT D IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND TIiAT,1kC,,60,Y OF THI ECORO HAS €N PROVIDED TO THE WELL qWNER.
Ile, ��
'11FOR
OFFICE USEQfWY ''
AT
Quad No: � Ili ( — U p' III , SKMA PERSO CONSTR TING THE WELL / DATE
Submit on in to 0 of Water Oualiry, Cta(o dwaler Section within 30 y3
x..... GW1 REV. UM
Serial No.
mdwale �
/
';,,�.AS hevifie RPS�n� .

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section `'J O Q
1636 Mail Service Center. Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR C RTIFICATION #: 7711 z, a --
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (check Applicable Box): ResidentialMunicipal ❑ 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"-' _- County:
(Road Name �,NYtubers, Community, or Subdivision and Lot tlo.) ,
DRILLING LOG
3.
OWNER _)nlnr n%InCAU — _
From To
C qr
Address O
-
)or (Code
A> `�3G
City Town Stater Zip
4.
DATE DRILLED IV%Y,
5.
TOTAL DEPTH
6.
CUTTINGS COLLECTED YES ❑ NOca--�
7.
DOES WELL REPLACE EXISTING WELL? YES ❑ NO
8.
STATIC WATER LEVEL Below Top of Casing: ? [) _ FT.
(Use '+' If Above Top of Cuing)
9.
TOP OF CASING IS FT. Above Land Surface.
'Top of casing terminated stfor below land surface requires a varlance In actor-
dance with 15A NCAC 2C .-V"
5 Li 4 /L/iZ
10.
YIELD (gpm): METHOD OF TEST
11.
WATER ZONES (depth):
DEPTH
Fonnation Description
R/?c;tk
✓�n</C —
^ C IT-
12. CHLORINATION: Type Amount
If additional space is needed use back of form
13. CASING:
LOCATION SKETCH
Wall Thickness
Depth Di to or Wepgn Material
(Show direction and distance from at least two State
FromTo Ft. -�-vC
Roads, or other map reference points)
From To Ft.
o
From To Ft.
o
0
14. GROUT:
a
o7O
Dept aterfaL Method
° r FL .en�^f
r,
�m
From To
From To Ft.
rn
5rn
Do
15. SCREEN:
v
M.
Depth
Diameter Slot Size
Material
3
�m
N�
From
in. —in.—
—To—Ft—
From To _
Ft. _ in. —
In.
U7
0
From To _
Ft. — In. —in.
z
16. SAND/GRAVEL PACK:
Depth
Size
Material
From To —Ft.
—
From To
Ft.
17. REMARKS:
I DO HEREBY CERTIFY THAT
CONSTRUCTION STANDARD
FOR OFFICE USE 4N'X —
Quad No: (� � i
SuTirNt orig
Serial No.
h_-u-
eundwate
IN ACCORDANCE WITH 15A NCAC 2C, WELL
DORD HAS PROVIDED TO THE WELL O
/ Z f/
SON coN$;fivanNG THE WELL
Quality, Groundwater Section within 30
DATE
GW-1 REV. 12199

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section % 14183
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CE TIFICATION #: Gr• /c f7I�
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Chock Applicable sox): Residential [I'— Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show s etch t Ahttjpcation below) /
I'County:
Nearest Town: � �G� / � I Coun ry:
Commun!pit,or Subdivision and Lot No.) DRILLING LOG
3. OWNER
Address a
iyj(_, --)6 /t1 /66• / 75
City or To State y 2ip Code
4. DATE DRILLED C,
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑ NOED--'
7. DOES WELL REPLACE EXISTING WELL? YES 0 N0ED----
B. STATIC WATER LEVEL Below Top of Casing: �;__ FT.
(Use '+' if Above Top of Casing)
9. TOP OF CASING ISs0i FT. Above Land Surface'
-Top of casing terminated at/or below land surface requires a variance In accor-
dance with 16A NCAC 2C,9118
10. YIELD (gpm): _Il 5 METHOD OF TEST'
11. WATER ZONES (depth):
12. CHLORINATION: Type Amount
13. CASING:
Wall Thickness
Depth Di ter or INig I. Matedgl
From �To 0,EFt. 7G
i
From-- To Ft.
From To Ft.
14. GROUT:
Dept
Materl�
Method
From
ToU
FL--'-.,-•.i r
-^^ r-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. SANDIGRAVEL PACK
Depth Size Material
From __ To Ft.
From To Ft.
17. REMARKS:
DEPTH
Fonn tion Description
OC i
JG �
If additional space is needed use back of form N
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
CONSTRUCTIOVS ANDAFjQS.tUNJTTTT 6 CQPY OF THIS RECORD HAS BEENH�ROVIDED TO THE WELL OWNER
l55 LL V .� t�,�v�—
FOR OFFICE US Y 7 DATE
Quad No: NAT� E OF PE N CONSTRUCTING TIE ELL
{j Submit o 1} DyvWon or W v . oualiry, Gtoundwatar Section w)ih)n 30 days
Gw-1 REV. 12/99
SeriN f:o. _�-.

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section •- 1 19 O
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELLCONTRACTOR: Lr ( "
WELL CONTRACTOR CE TIFICATION #:
STATE WELL CONSTRUCTION PERMIT#;�
1. WELL USE (Check Applicable Box): Residential o/Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch ophe location below)
Nearest Town. -, 1 • C'! County:
(Road Name and Numbers. Community, orrSS tbdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER t JIB Ubl y � I-U.t YY� From To Foonation Description
U r d
Address -1 6ii t o �< (�)Y ko '-r'� �ir� _ "A/
c 1
�D({ treetor 10No. 4C u1 itl� l 9itc. C
lV
City or Town State Zip Code '
4. DATE DRILLED C / }4'r.'
5. TOTAL DEPTH P- 1 f
6. CUTTINGS COLLECTED YES 0 NO�
7, DOES WELL REPLACE EXISTING WELL? YES ( NO[a
8. STATIC WATER LEVEL Below Top of Casing: FT.
(Use -+' If Above Top of Cuing)
9. TOP OF CASING IS FT. Above Land Surface -
'Top of casing terminated at/or below land surface requires a variance In accor-
dance with 15A NCAC 2C.01,18
10. YIELD (gpm): 1— METHOD OF TEST'
11. WATER ZONES (depth):
12. CHLORINATION: Type
13. CASING:
Amount If additional space is needed use back of form
Wall Thickness
Depth ly Di ter or4Velyrh fl, Material✓
FromTo Ft.- G' 1GPI
From To Ft.
From To Ft.
14. GROUT:
Depth atenal 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:
I DO HEREBY CERTIFY THAT THIS WELL WAS
CONSTRUCTION STAN0AR9SrANQ1b1A16Sc
FOR OF
Quad No:
SutxNl
Serial No.
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
ED IN ACCORDANCE WITH 15A NCAC 2C, WELL
RECORD BEEN PROVIDED TO THE WELL OWNER.
F REP SON C�tgTRUCTING THE WELL DATE
Water Quality, Groundwater Section Within 30 days
GW1 REV. 12199

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section ] 1 (1 q
1636 Mail Service Center - Raleigh, N.C. 27699.1636-Phone [phone] l 1 i7
WELL CONSTRUCTION RECORD WELLCONTRACTOR: PrE �Qir D'�lf._o= �^C
WELL CONTRACTORCE IFICATION#:
STATE WELL CONSTRUCTION PERMIT#:
WELL USE (Check Applicable Boa): Residential D� Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show skgtch of the location below)
Nearest Town: C let Fo r')' County: I C
(Road Name and Nu�mbers. Community, or Subdivision and Lot No.)
3. OWNER J i 11 r h j e 1 Lk r in
Address i —n �lt t 1 p 5 Orr 1n ,',i e_,
,i (street or Houle 0.
CAI f-J f"4_ h j c. „1 V7 (O
City or Town 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': if Above Top of Casing)
9. TOP OF CASING IS c) FT. Above Land Surface'
-Top of casing terminated sVor below land surface requires a varianceccor-
dance with 16A NCAC 2C .0p8 A
10. YIELD (gpm): I_ METHOD OF TEST 4 1 4
11. WATER ZONES (depth):
Agricultural ❑ Monitoring ❑
DRILLING LOG DEPTH
From To
�J M()
Fomalion Description
�L C /� o_ l u a
0
® o
12. CHLORINATION: TypeAmounl
If additional space is needed use back of form
13. CASING:
LOCATION SKETCH
Depth Diameter Wall Thickness or Wei V_Ft. Material
(Show direction and distance from at least two State
ell �� � '� VC
Roads, or other map reference points)
From To 1= Ft. —Kl— 74
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From To 20 FL �"
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From —To—Ft— in. _ in.
From —To — Ft.— in. —in.
From —To _ Ft. in. —In.
16. SAND/GRAVEL PACK:
Depth Size Material
From To —Ft. —
From To Ft.
17. REMARKS:
THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
I DO HEREBY CERTIFY
CONSTRUCTION AND THAT A COPY OF THI RECORD HAS B N PROVIDED TO THE WELL 0 NER.
�l i c (J
ff lG�-�
FOR OFFICE US
Y SIGN RE ERSC
CONS CTING THE WELL ' DATE
Quad No:
Submit origin t 'visl afar Quality, Gmundwatar section within 30 days
GW-1 REV. 12199
Serial No. f

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section 1212 0 3
1636 Mail Service Center • Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: PCO WELL CONTRACTOR CE TIFICATION #:� ,camp/�
CTATF WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential0 Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
Agricultural ❑ Monitoring ❑
2. WELL LOCATION: (Show Sketch of the location below) -"/ 2
Nearest Town: 1' 7a/'r G i � County: 6�-
(Road Name and u srs, Community, or Subdivision and Lot No.)
3. OWNER r��/�6 /)Pad � n -
Address 3 /0 7 %�O I T Ct t L
bee or outs o.
State or Toown
�r � P
` Zi Code
4. DATE DRILLED
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑ NO❑
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO[]
6. STATIC WATER LEVEL Below Top of Casing: Fr.
(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 .e11a n r {S� /
10. YIELD (gpm): 1 L— METHOD OF TEST r7 /
11. WATER ZONES (depth):
12. CHLORINATION: Type Amount
13. CASING:
Wall Thickness
Depth Diameter or Wav)gh�t Fl. Material
From To Ft.- dL
From To Ft.
From To Ft.
14. GROUT:
Depth r/vMatMethod
From 0 To �G FL l .•-=�e= m;xrd
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 Forrnationsescnption
L
oC
v_
o �
z �z
m
C c�
t� r
Do
3 "O
A
_ If additional space is needed use back of form oz
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
Ii
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCT AN9THATA.COPY OF THIS RE RD HAS BEE ROVIDED TO THE WELL OWNER.
FOR OFFICE '"v - S OF WSONCO STD TINGTHEE WELL DATE
Quad No: +' `i i
i 11 1 ILI Sub4 b���a1 to Di on o ter 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 ti 1 2 0 4
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR C RTIFICATION #: /1- i `t' 1)-7
STATE WELL CONSTRUCTION PERMIT#: —
1. WELL USE (Check Applicable BOX): Residential L`i' Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show q sketch of the location below)
Nearest Town: /�fGr rl r0k County:
(Road Name and Nurflgers. Comrtwniry, or Subdivision and Lot No.) DRILLING LOG
3. OWNER Grp IS n From T
Address L s or t U`/a� )
treat or outs o.
�nnellf,l _ U^r � nIC, L
City or TownState Zip Code
4. DATE DRILLED t
G
5. TOTAL
6. CUTTINGS COLLECTED YES ❑ NO�
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NOQ�
B. STATIC WATER LEVEL Below Top of Casing: FT.
(use -+' if Above Top of Casing)
9. TOP OF CASING ISFT. Above Land Surface'
'Top of using terminated at/or below land surtace requires a variance In accor-
dance with 15ANCAC2C,0 Al
Lr�
10. YIELD (gpm): _ METHOD OF TEST
11, WATER ZONES (depth):
DEPTH
Formation Description
�, r k
�c%_
12. CHLORINATION: Type Amount If additional space is needed use back of form .
13. CASING:
LOCATION SKETCH
Wall Thickness
Depth a Diameter or Welg L Mate at (Show direction and distance from at least two State
From —1! To Ft. /' t/77y— Roads, or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
/1 Depth /Material Method
From —lr— To -2C Ft. /r-r�••��t/ •.� rA'r'L,
From Tc 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 W HEREBY CERTt�Y;THA 'TtjIS WE
CONSTRW ONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
UCT1QU,t� SN�1RS, �1NT PY OF T RECORD H9S-BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE ON p � "'C/
Quad No: 'fa, SIG TU F F PERSON CONDUCTING THE WELL DATE
Su g at Div n of Water Quality, Groundwater Section within 30 days GW-1 REV. 12199
Serial No.
0
m
z

North Carolina • Department Of Environment and Natural Resources • Division of Water Oualiry • Groundwater Section i- 1, 729
1636 Mail Service Center - Raleigh, N.C. 27699.1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: r,'r o be.(( i n(LAi /YC
WELL CONTRACTOR CE14TIFICATION #; 1 rrV /_T tL1713
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential L= Municipat ❑ Industrial ❑
Recovery Heat Pump Water In)ection Other If Other, List Use:
2. WELL LOCATION: (S w sketch of the location below)
Nearest Town: A-IM; 0 - Count:
Agricultural ❑ Monitoring ❑
(Road Name and Numban. Comr; nlry, or Subdivision and 1 0 � 3
4-eR
DRILLING LOG DEPTH
Description
3.
OWNER + (. 116
From To F/grirauon
Address Z—
`�
nee or ou e o.
ci G, 3 /To C lc 3
--
n clan zJp Co
city or owda
-
4.
5.
,00-
DATE DRILLED —�%
TOTAL DEPTH
6.
CUTTINGS COLLECTED YES Q NO�
- -
7.
DOES WELL REPLACE EXISTING WELL? YES Q NO[Er'—
"
8.
STATIC WATER LEVEL Below Top of Casing: /L=) FT.
(Use'* B Above Top of Casing)
2
S.
TOP OF CASING IS FT. Above Land Surface-
—_ -
'Top of casing terminated stfor below land surface requires a varlan e, In aecor-
dance with 15A NCAC 2C.0110 ; ^
i METHOD OF TEST
10.
YIELD (gpm):
11.
WATER ZONES (depth):
-
12.
CHLORINATION: Type Amount
if additional apace is needed use tuck of i&r h 0
13.
CASING:
LOCATION SKETCH
Wall sa
Depth mar/wtar Of Witiownt, Material
0 3
(Show direction and distance from at least two State
From To -S` Ft. -
Roads, or other map reference paints)
From To Ft.
From To Ft.
14. GROUT
Depth G atej_W_ Method/
From To Ft. C"2" /, �e�
From To Ft.
15. SCREEN
Depth Diameter Slot Size Material
From To Ft _ in. _ in.
From To _ Ft. — In. — In.
From To Ft. In. — In.
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
17, REMARKS: _.
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTI
CONSTRUCTION STANDARDS, AND THAT A COPY OF
FOR OFFICE USE ONL
Quad No:------------
t t
SCR t b fi
Serial NO.
�c
n
IN ACCORDANCE W 45A
NCAC 2C, WELL
CORD HAS BEE OVIDED TO THE WELL OWNER.
V i
wl' i
-
DATE
ratero i,a-RUCTipE wEhin 30 daysP O ONST
aw•1 REV. 12M

North Carolina - Department of Environment and Natural Resources • Division of Water Quality •Groundwater Section r 1 �'y
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone] �_ 1 { 3 9
WELL CONSTRUCTION RECORD WELLCONTRACTOR:y/L i/cll �!r'1/;rt, 1� wC
WELL CONTRACTOR CE TIFICATION#: /_.c.w ir;s c #271j
r ,ESTATE WELL CONSTRUCTION PERMIT#:
Ea
1. WELL USE (Check Applicable Box): Residential Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Shoal sketch of the location below) n/IG 1�� j i
Nearest
Tow n1:' / fA/ '' y- County: / / C( l
(Road Name and Numbers, Community, ofr� Su��%%wsion an Lot No.) DRILLING LOG DEPTH
3. OWNER r.'iY9-�G wL'.i/'%77.OG�^/�- From To Formation Description
Address / wE I _ L �
rmo te i (�
Z_ jSneet o'& CNo.)a 0
i L ��- fl 3 iG� OTC _
City or Town State Zip Code
4. DATE DRILLED
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YESI:::] NO©K
7. DOES WELL REPLACE EXISTING WELL? YES NOD
8. STATIC WATER LEVEL Below Top of Casing: j" FT.
(Use': it Above Top of Cuing)
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/O�! �, I oce /L—
10. YIELD (gpm): T METHOD�foTEST L
11. WATER ZONES (depth): W,
o
ra _>
12. CHLORINATION: Type Z6C rr Amount 0-fi"2 61-i
It additional space is needed use back of form
13. CASING:
LOCATION SKETCH
U
Depth
Wall Thickness
-
Diamet r or W/ei nvFl. M tedai
/
(Show direction and distance from at least two State
/
From
113
To -�--=
Ft. �i , 4.
Roads, or other map reference points)
�y/� (�
From
To
Ft.
From
To
Ft.
14. GROUT:
Depth,
a G
Material Method
y F'
From
From
To
To
Ft. '21.Yrr�
Ft.
15. SCREEN:
Depth Diameter Slot Size Material Esc.:/
From —To —Ft— in. —in _
From To _ Ft.— in. _ in. ` LCu_eG GAP"'�
From —To—Ft.— In. _in.S�
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft. 3
From To Ft.
17. REMARKS:
I DO HEREBY CERT1FY.TtlAT.7H)S.WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTIONjOTANI ARI , AJD,71"T A�OOPY OF THIS RECORD HAS BEN-PROVIDED TO THE WELL OWNER.
FFOR OFFICE USE ONLY �" �G
adNo2 I /'p)i&ITU OF PEfjB NCO ST NG THE WELLDATE
S1lbrrat ongi(t�i4Q ivj on �arerOualiry, Grd ater Section within 30 days/GW-1 REV. 12199
dal No.

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section r to C) ['�
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone] r� 1 U 3 0
WELL CONSTRUCTION RECORD WELL CONTRACTOR: �r'%y !�•i,f �r ///.aT
WELL CONTRACTOR CERijIFICATION#: /.-re %�.•, 7i?
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 n 4 f
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: _,zwk,r,k•1 County:
(Road Name and Nu bars Community, or Subdivision and Lot No.) _
3. OWNER Se A
Address a
tre or o le 0.
r
City or Town State Zip Code
4.
5.
6.
7.
8.
DATE DRILLED _3
TOTAL DEPTH S c f
CUTTINGS COLLECTED YES Q NOQ�
DOES WELL REPLACE EXISTING WELL? YES NO !a
STATIC WATER LEVEL Below Top of Casing: FT. _
(Use'+' if Above Top of Cuing)
9. TOP OF CASING IS21 FT. Above Land Surface' L E'-
Top of casing terminated at/or below land surface requires a variance In accor-
dance with 15A NCAC 2C.gAla
10. YIELD (gpm): METHOD OF TEST
11. WATER ZONES (depth):
DRILLING LOG DEPTH
12. CHLORINATION: Type ( �c fc,Y Amount
13. CASING
rr
If additional space is needed use back of formO
LOCATION SKETCH
Wall Thickness
Depth ,�/ OiarTeter or qh. t. / terl (Show direction and distance from at least two State
From To `— Ft. 1 '� C Roads, or other map reference points)
From To Ft.
From To Ft.
14, GROUT:
'i
Depth Material Method
�L' .
From �� To Ft. ��Y^�• r 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:
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 RECPPRD HAS BEEN PROVIDED TO THE WELL OWNER.
me.µ_
FOR OFFICE USE ONLY
Quad No: SIGI
Submit original to
Serial No.
jWRSON CONSTRUCTING THE WELL
Water Quality, Groundwater Section within 30 days
DATE
GW-1 REV. 12199
NE!

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section r.. i �1 7 6
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: R(dhdrlJ/ S IA`� A/6PMu
WELL CONTRACTOR CERTIFICATION #: to
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential ❑ Municipal ❑ Industrial ❑ Agri igtural Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use: N "4L
2. WELL LOCATION: (Show s (etch of the location below) ,//� �'G
Nearest Town:— County: /`
_ #/zs
(Road Name and Nu tl mm ni ,�o/r, Subd'v' ion and Lot No.) DRILLING LOG DEPTH
3. OWNER i 9 � From To Formation Description
Address fY . :;t- Z y-3 /%�ilc»dlt/S�t.
4. DATE DRILLED
5. TOTAL DEPTH k-
6. CUTTINGSCOLLECTED YESQ NOQ
7. DOES WELL REPLACE EXISTING WELL? YES NOV
8. STATIC WATER LEVEL Below Top of Casing: opof 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
11. WATER ZONES (depth):
12. CHLORINATION: Type
13, CASING:
O
If additional space is needed use back of form
Wall Thickness
Depth
From QTo
Diameter
Ft. —��
or Wei hVFt. Material
y7/
how direction end distant �� asi two Slate
Roads, or o r map r rence points)
From To
Ft.
From To
Ft.—CXil
)
C RK
/NCR/Da
14. GROUT:
Depth
P
Materia
i
Me-�
From � To ;LL)
Ft.
From To
Ft.
i2
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft in. in.
From To Ft. _ in. in.
From To Ft. In. In.� 00 yy LN
16. SAND/GRAVEL PACK:
Depth,
to Size , M i
From � To Ft. ��L.
From To Fl.
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS/BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY /�I2� r.�2G� Ji tom' cl� 7, '2''%7 a��
Quad No: SI NATURE OF PERSON CONSTRUCTING THE WELL UAt t
Submit original to Division of Water Quality, Groundwater Section within 30 days
Serial No. GW-1 REV. 12t99

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center -Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION it:
STATE WELL CONSTRUCTION PERMITN:
1. WELL USE (check Applicable Box): Residential ❑ Municipal ❑ Industrial ❑ Agric[y�Ru�ra�l �❑Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION:
Nearest Town: —
(Road Name and
3. OWNER
Address
of the location below) 4
County: '/ i C 16) „7v"I-&
164, Jql)YO
or Subdivision and Lot No.) DRILLING LOG DEPTH
From To Formation Description
4. DATE DRILLED �1 �
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES Q NOF-1
7. DOES WELL REPLACE EXISTING WELL? YES F—] N
8. STATIC WATER LEVEL Below Top of Casing: A,,-- F
(Use'+' II Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface'
*Top of casing terminated at/or below land surface requires a variance In
dance with 15A NCAC 2C.0118
10. YIELD (gpm): METHOD OF TEST
11. WATER ZONES (depth):
12. CHLORINATION: Type
13. CASING:
Depth Diameter
From To �� Ft. 2117
From To Ft.
From To Ft.
14. GROUT:
Amount If additional space is needed use back of form
Wall Thickness LOCATION SKETCH
or Weight/R. ivLaterial JShow direction and distance from at least two State
—1,7-Z Roads, or other map reference points)
5 c SN�L�i
From
�( Depth es Ih2�I0n
� To
Maler'al M od .
Ft. �d
From
To
Ft.
15. SCREEN:
J�
Depth Diameter Slot Size
Material i
From
To Ft
in. in.
From
To Ft.
in. in.
From
To FL
in. In.
16. SANDIGR/AVEL PACK:
h��U
i.3 Mal�(ial
��
From
�1 L_DT
Ft..Size
From
To
Ft.
17. REMARKS:
I bl
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF TH S RECORD
/HAS BEEN PROVIDED TO THE WELL
FOR OFFICE USE ONLYu�"�w1��`�
Quad No: SIGNATURE OF PERSON CONSTRUCTING THE WELL
Submit original to Division of Water Quality, Groundwater Section within 30 days
Serial No.
6 VL'll
J'A
rr17W
GW-1 REV. 12t99
0

Narih Carolina - Department of Environment and Natural Resources - Division of Wntor Quality - Groundwater Soctinn r)
1636 Mail Service Center Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION If:
STATE WELL CONSTRUCTION PERMIT#:
1, WELL USE (Check Applicable Sox): Residential ❑ Municipal ❑ Industrial ❑ Agricglfural ❑ y�Monitoring ❑
Recovery ❑ heal Pump Water Injection D Other If Other, List U'so: r ems2 ��'
2. WELL LOCATION: (Shooww� skolcfp of the location below) I
Nearest Town: LJ L/.bti.,-.� County: �LLiC Alc"LIIC.L�
'Vatat krill,
(Road Name and Numttbers. Community, o Su.�h.�w..i•ilon and Lol No.) DRILLING LOG
3. OWNER S hMk� cyC[c+.i From To
Address
Streator 0�I K�T---- --
CityorTown Slate Zip Code —
4. DATE DRILLED __�77jt I'�
S. TOTAL DEPTH
6. CUTTINGS COLLECTED YES F-1 NOD
7. DOES WELL REPLACE EXISTING WELL? YES 2NOD
8, STATIC WATER LEVEL Below Top of Casing: _J(4() FT.
(Use'.' it Above Top of Casing)
9. TOP OF CASING IS_I FT. Above Land Surface'
'Tnp of casing terminated at/or below land surface requires a vnriance In accor-
dance with 15A NCAC 2C .0110
10. YIELD (gpm): METHOD OF TEST
11. WATER ZONES (depth):
12. CHLORINATION: Type
13. CASING:
Amount
Wall Thickness
Depth Diameter � or WeighVFl.
From To � Fl. !
From To Ft. —
From To Fl.
14. GROUT
DEPTH
Formallon Dewri0'ian
It additional space is needed use back of form
LOCATION SKETCH
Malenal �T,� (Show direction and distance from at least two Slat,
=`- Roads, or other map re ojence points)
Depth Matorial P e hod -
Front �_ To 10 FI. j�C —
From To --Ft.
15.SCREEN:
Depth Diameter Slot Size Material
From To FI in. in.
From To ___ FL in. In.
From To __ FL In. in.
16. SAND/GRAVEL PACK:
Depth Size _ Material
From G ToFt.�
From To Ft.
17.REMARKS,
'#ZLG
RrA.
4t 7- �XllN
v
T 'yx
:f F IS P{'tK
11rt T Nw�y
+{brlv�f t' fit 1 r✓t!!
LI�rK1ViiS�{
C
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 THE WELL OWNER.
FOR OFFICE USE ONLY �/'j 1 �LCz� 4 'I )(Ll ya.-A. 6 L 0 0
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 rl 12/99

North Carolina - Department of Environment And Natural Resources - Division of Water Quality - Groundwater Section 1 4 77 U
1636 Mail Service Center - Raleigh, N.C. 27699.1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: 2(JrWt % tJJ r�,Lr LL-?�i .
WELL CONTRACTOR CERTIFICATION #: )© 7
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable sox): Residential ❑ Municipal ❑ Industrial ❑ Agr}'It al ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (She sketctl of the location below)
Nearest Town: �y(i(.C-c-�.. (i;c
(Road Name an u tiers, Co�`'1)unity, or ubdi ision and Lot No
3. OWNER Cl� �G
Address /, /, D_> - �" G?/ ✓ )
City or Town 'State Zip Code
4, DATE DRILLED I zul?Q
5. TOTAL DEPTH J-�-i-i
6. CUTTINGS COLLECTED YES Q NO❑
7. DOES WELL REPLACE EXISTING WELL? YES ZNOM
6. STATIC WATER LEVEL Below Top of Casing: ttj_ FT.
(Use'.' If Above Top of Casing)
9. TOP OF CASING ISFT. Above Land Surface'
'Top of casing terminated aUor below land surface requires a variance In accor-
dance with 15A NCAC 2C .011a
10. YIELD (gpm): METHOD OF TEST
11. WATER ZONES (depth):
DRILLING LOG DEPTH
From To Formation Description
O
O
O
e
c
�
Ur
O
o
12,
CHLORINATION: Type
Amount
If additional space is needed use back of form
13,
CASING:
Wall Thickness
LOCATION SKETCH
Depth ,
From �To --/-�-
Diameter or W ighVFt. MMatte�riaal� (Show
Fl. r7 .-(�C'
direction and distance from at least two Slate
Roads, or other map reference points)
From To
FI.
b 6m�r�)D�
From —To—
Fr.
14.
GROUT:
-tifil�
Depth-
Material hr 0
r�
2
From _i! To .O
Ft. �s� -
From To
oS�
Fl.
_Lfly�, TiZZ
15,
SCREEN:
J
PC iGRf
Depth Diameter Slot Size Material
From To Ft
in. in.
�f
From To Ft.
_ in. In.
From _ To Ft.
In. in.�
t ��
16.
SAND/GRAVEL PACK:
try �so:l�
%1 �� rh
Depth
From To__�rj
Size M terial
Ft.%--IbC�11��1k
_IL_
G?r
From To
Ft.
�+/y1cRf.=ANiO/U
17,
REMARKS:
f
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BE PROV ED TO T WELL OWNER.
7 70L p
FOR OFFICE USE ONLY �vr 6� /
Ouad No: SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Duality, Groundwater section within 30 days
Serial No. GW-1 REV. 12199

NC DEHNR
DEM - GW SECTION
P.O. BOX 29535
RALEIGH, NC 27626-0535
( 91 9 ) 733-3221
WELL CONSTRUCTION RECORD
DRILLING CONTRACTOR: PITTMAN WELL BORING, LLC
22341.9
QUAD NO. SER. NO. _
LAT LONG
BASIN CODE
HEADER ENT. GW-1 ENT.
STATE WELL CONSTRUCTION
PERMIT NUMBER:
DRILLER REGISTRATION NO: 2567
-----------------------------------------------------
1.
WELL LOCATION: (SHOW SKETCH OF THE LOCATION BELOW)
NEAREST TOWN MARION COUNTY: MCDL
AUSTIN DR.
(ROAD, COMM., OR SUBDV. & LOT NO.) DEPTH
DRILLING LOG
2.
OWNER FROM TO
FORM. DESC.
__KENNETH_HOLLAND
ADDRESS 41_AUSTIN_DR.
MARION NC 28752_
CITY OR TOWN STATE ZIP CODE
3.
DATE DRILLED: 12-12-00 USE OF WELL: HOUSE
—
4.
TOTAL DEPTH: 42'
5.
CUTTINGS COLLECTED: YES NO XX
6.
DOES WELL REPLACE EXISTING WELL? YES NO XX
m
7.
STAT. WAT. LEVL. BEL.TOP OF CASING _30_FT.—
(USE + IF ABOVE TOP)
S.
TOP OF CASING IS 18" ABOVE LAND SURF.*
s ��
9.
YIELD (GPM): 12' METHOD OF TEST -STEEL TAPE
10.
WATER ZONES (DEPTH):
pa `n�
11.
CHLORINATION: TYPE HTH AMOUNT
—
12.
CASING:
W. THICK.
DEPTH DIA OR WT/FT. MTL
FROM _0_TO_42_FT. _24"_ _CONC_
FROM TO FT.
13. GROUT.
DEPTH
MATERIAL
METHOD
FROM_O—TO_20_FT.
_CEMENT_
_POURED_
FROM TO
FT.
14. SCREEN:
DEPTH
DIA SLOT
SIZE MTL
FROM TO
FT.
IN.
IN.
FROM TO
FT.
_ IN.
IN.
FROM TO
FT.
IN.
IN.
15. SAND/GRAVEL
PACK.:
DEPTH
SIZE
MATERIAL
FROM_30' _TO_42'
_FT.
_NO. 6M_
STONE
16. REMARKS:
LOCATION SKETCH
HWY. 221 N. FROM RUTHERFORD
TON. LEFT ON MUD CUT RD. RT
ON DINK CANNON. STAY
STRAIGHT WHEN TURNS TO SU-
GARHILL. LEFT ON ZION HILL.
RT. ON NIX CREEK. LEFT ON
WESTWOOD. RT. ON AUSTIN.
LEFT BETWEEN 1ST 2 TRLRS.
SINGLE -WIDE ON HILL.
I DO HEREBY
f�C'ER'TT-T© trHEIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
aadla) rrZVttD�DIUWELLLNOWNER.lSTANDARDS,AND THAT A COPY OF THIS RECORD
OF CONTRACTOR OR
n n ( A "

NC DEHNR 2 2 3 4 3
DEM - GW SECTION Y
P.O. BOX 29535 QUAD NO. SER. NO.
RALEIGH, NC 27626-0535 LAT LONG
[phone] BASIN CODE
HEADER ENT. GW-1 ENT.
WELL CONSTRUCTION RECORD
DRILLING CONTRACTOR: PITTMAN WELL BORING, LLC STATE WELL CONSTRUCTION
PERMIT NUMBER:
DRILLER REGISTRATION NO: 2160
1.
2
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
------------------------------------------
WELL LOCATION: (SHOW SKETCH OF THE LOCATION BELOW)
NEAREST TOWN NEBO COUNTY: MCDL
GUFFEY DR.
(ROAD, COMM., OR SUBDV. & LOT NO.) DEPTH DRILLING LOG
OWNER AMELIA_FOX FROM TO FORM. DESC.
ADDRESS GUFFEY-DR.
NEBO NC 28761_
CITY OR TOWN STATE ZIP CODE
DATE DRILLED: 12/08/00 USE OF WELL: HOUSE
TOTAL DEPTH: 6051
CUTTINGS COLLECTED: YES NO XX
DOES WELL REPLACE EXISTING WELL? YES NO XX C `o
STAT. WAT. LEVL. BEL.TOP OF CASING _600_FT.
(USE + IF ABOVE TOP) z
TOP OF CASING IS 18" ABOVE LAND SURF.* : o
YIELD (GPM): 0 METHOD OF TEST-ARD �e
WATER ZONES (DEPTH):
CHLORINATION: TYPE HTH AMOUNT
d,-
i■TeTyl►Ll
W. THICK.
DEPTH DIA OR WT/FT. MTL
FROM _0_TO_50_FT. _6-1 /4" _PVC_
FROM TO FT.
13. GROUT:
DEPTH
MATERIAL
METHOD
FROM_0_TO_20_FT.
_CEMENT_
_PRESS_
FROM TO
FT.
14. SCREEN:
DEPTH
DIA SLOT
SIZE MTL
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.
16. REMARKS:
LOCATION SKETCH
HWY. 226 N. FROM POLKVILLE.
LEFT ON VEIN MTN. RD. LEFT
ON GUFFEY DR. 1ST DOUBLE -
WIDE ON LEFT.
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL COZSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD
HAS- Iiti"' i UTIIED Th `THE WELL OWNER.,
m
SI TURE CONTRACTOR OR AGENT
�Q Q � 2�
DATE

NC DEHNR 8 A
DEM - GW SECTION ~ 3 `Y
P.O. BOX 29535 QUAD NO. SER. NO.
RALEIGH, NC 27626-0535 LAT LONG
[phone] BASIN CODE
HEADER ENT. GW-1 ENT.
WELL CONSTRUCTION RECORD
DRILLING CONTRACTOR: PITTMAN WELL BORING, LLC STATE WELL CONSTRUCTION
PERMIT NUMBER:
DRILLER REGISTRATION NO: 2160
1.
---------------------------------------
WELL LOCATION: (SHOW SKETCH OF THE LOCATION
BELOW)
NEAREST TOWN MARION COUNTY:
MCDL
W. CASCADE DR.
(ROAD, COMM., OR SUBDV. R LOT NO.)
DEPTH DRILLING LOG
2.
OWNER BRIAN_RICKER _
FROM TO FORM. DESC.
ADDRESS
_144_W._CASCADE_DR.
MARION NC 28752
_
CITY OR TOWN STATE ZIP CODE
3.
DATE DRILLED: 11/02/00 USE OF WELL: HOUSE
4.
TOTAL DEPTH: 205'
5.
CUTTINGS COLLECTED: YES NO XX
6.
DOES WELL REPLACE EXISTING WELL? YES NO XX_
7.
STAT. WAT. LEVL. BEL.TOP OF CASING 50 FT.
C
—m
(USE + IF ABOVE TOP)
B.
_
TOP OF CASING IS 18" ABOVE LAND SURF.*
n_
9.
YIELD (GPM): 15 METHOD OF TEST-ARD
n
10.
WATER ZONES (DEPTH):°-'
11.
CHLORINATION: TYPE CLOROX AMOUNT 1/2 GAL
s
12.
CASING:
W. THICK.
�� y
DEPTH DIA OR WT/FT. MTL
FROM _0_TO_60_FT. _6-1/4" _PVC_
LOCATION SKETCH
FROM TO FT.
13.
GROUT:
HWY. 221 N. FROM RUTHERFORD
DEPTH MATERIAL METHOD
TON. LEFT ON MUD CUT RD. RT
FROM _PRESS_
ON DINK CANNON -TURNS INTO
_0_TO_20-FT. _CEMENT_
FROM TO FT.
SUGARHILL. LEFT ON ZION
14.
SCREEN:
HILL RD. RT. ON NIX CREEK
DEPTH DIA SLOT SIZE MTL
RD. LEFT ON LYTLE MTN. RD.
FROM TO FT. IN. IN.
RT. ON CASCADE RD. LEFT ON
FROM TO FT. IN. IN.
W. CASCADE RD. 5TH MOBILE
FROM TO FT. IN. IN.
HOME ON RT.
15.
SAND/GRAVEL F'ACK:
DEPTH SIZE MATERIAL
FROM —TO —FT.
16.
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
S [PEFN7 PROVIDE TO THE WELL OWNER. `
IGNATURW
OF CONTCRA�CT`�GENT DATE
alai'-_'( Y

NC DEHNR
DEM - GW SECTION
G.O. BOX 29535
RALEIGH, NC 27626-0535
[phone]
WELL CONSTRUCTION RECORD
DRILLING CONTRACTOR: PITTMAN WELL BORING, LLC
184�
QUAD NO. SER. NO.
LAT LONG
BASIN CODE
HEADER ENT. GW-1 ENT.
STATE WELL CONSTRUCTION
PERMIT NUMBER:
DRILLER REGISTRATION NO: 2160
------------------------------
1. WELL LOCATION: (SHOW SKETCH OF THE LOCATION BELOW)
NEAREST TOWN : MARION COUNTY: MCDL
2
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14
TATER TOT RD.
(ROAD, COMM., OR SUBDV. & LOT NO.)
OWNER TERRY_BARTLETT
ADDRESS TATER-TOT-RD.
MARION NC 28752
CITY OR TOWN STATE ZIP CODE
DATE DRILLED: 11/28/00 USE OF WELL: HOUSE
TOTAL DEPTH: 425'
CUTTINGS COLLECTED: YES NO XX
DOES WELL REPLACE EXISTING WELL? YES NO XX
STAT. WAT. LEVL. BEL.TOP OF CASING 80 FT.
(USE + IF ABOVE TOP)
TOP OF CASING IS 18" ABOVE LAND SURF.*
YIELD (GPM): 2 METHOD OF TEST-ARD
WATER ZONES (DEPTH):
CHLORINATION: TYPE CLOROX AMOUNT 1/2 GAL
CASING:
W.
DEPTH DIA OR
FROM _0_TO_80_FT. 6-1 /4"
FROM TO FT. _
GROUT.
DEPTH MATERIAL
FROM _0_TO_20_FT. _CEMENT_
FROM TO FT.
SCREEN:
THICK.
WT/FT. MTL
PVC
DEPTH
FROM TO
DRILLING LOG
FORM. DESC.
LOCATION SKETCH
HWY. 226 N. FROM POLKVILLE.
METHOD LEFT ON TATERTOWN RD. LEFT
_PRESS_ ON TATER TOT RD. OLD SINGLE
WIDE APPROX. 4/10 MILE ON
LEFT.
DEPTH DIA SLOT SIZE MTL
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.
16. REMARKS:
I DO HEREBY
15A NCAC 2C,
CERTIFY THAT THIS WELL WAS CONSTRUCTED
WELL CONSTRUCTION STANDARDS, AND THAT
TQNTHE WELL OWNFA.
SIGNATURE
OR AGENT
am
IN ACCORDANCE WITH
A COPY OF THIS RECORD
aWINE
DATE

NC DEHNR
DEM - GW SECTION
P.O. BOX 29535
RALEIGH, NC 27626-0535
[phone]
WELL CONSTRUCTION RECORD
DRILLING CONTRACTOR: PITTMAN WELL BORING, LLC
�845
QUAD NO. SER. NO. _
LAT LONG
BASIN CODE
HEADER ENT. GW-1 ENT.
STATE WELL CONSTRUCTION
PERMIT NUMBER:
DRILLER REGISTRATION NO: 2785
--------------------------------------------
1. WELL LOCATION: (SHOW SKETCH OF THE LOCATION BELOW)
NEAREST TOWN : MARION COUNTY: MCDL
2.
3.
4.
5.
6.
7.
8.
9.
10.
il.
12.
13.
TONEY RD.
(ROAD, COMM., OR SUBDV. R LOT NO.)
OWNER CLYDE_HOLLAND
ADDRESS 462_TONEY_RD.
MARION NC 28752
CITY OR TOWN STATE ZIP CODE
DATE DRILLED: 11/02/00 USE OF WELL: HOUSE
TOTAL DEPTH: 445'
CUTTINGS COLLECTED: YES NO XX
DOES WELL REPLACE EXISTING WELL? YES NO XX
STAT. WAT. LEVL. BEL.TOP OF CASING 30 FT.
(USE + IF ABOVE TOP)
TOP OF CASING IS IS" ABOVE LAND SURF.*
YIELD (GPM): 3 METHOD OF TEST-ARD
WATER ZONES (DEPTH):
CHLORINATION: TYPE CLOROX AMOUNT 1/2 GAL
CASING:
W.
DEPTH DIA OR
FROM_0_TO_30_FT. 6-1 /4"
FROM TO FT.
GROUT:
DEPTH
FROM_0_TO_20_FT.
FROM
TO
FT.
14. SCREEN:
DEPTH
FROM
—TO
—FT.
FROM
—TO
—FT.
FROM
—TO
—FT.
15. SAND/GRAVEL
PACK:
DEPTH
FROM
TO
FT.
16. REMARKS:
THICK.
WT/FT. MTL
PVC
MATERIAL METHOD
_CEMENT_ _PRESS_
DIA SLOT SIZE MTL
IN. IN.
IN. IN.
IN. IN.
SIZE MATERIAL
DEPTH DRILLING LOG
FROM TO FORM. DESC.
o a
0
LOCATION SKETCH
HWY. 226 N. FROM POLKVILLE.
GO UDNER I-40 R RT. ON FAIT
VIEW DR. LEFT ON TONEY RD.
APPROX. 3/4 MILE ON LEFT.
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT
HAS BEEN PROVIDED T THE WELL OWN�R�i�J`,
1//��((II
SIGNATURE OF CONT�R CTOR AGENT
JAN 1 9 : � � L��, �
Groundwate, Section
IN ACCORDANCE WITH
A COPY OF THIS RECORI
DATE

NC DEHNR
DEM - GW SECTION
G.O. BOX 295.5
RALEIGH, NC 27626-0535
[phone]
WELL CONSTRUCTION RECORD
DRILLING CONTRACTOR: PITTMAN WELL BORING, LLC
QUAD NO. _ SER. NO. _
LAT LONG__
BASIN CODE _
HEADER ENT. GW-1 ENT.
DRILLER REGISTRATION NO: 2160
------------------------------ -
1. WELL LOCATION: (SHOW SKETCH OF THE LOCATION
NEAREST TOWN MARION COUNTY:
HUSK.INS RD.
(ROAD, COMM., OR SUBDV. K LOT NO.)
2. OWNER __LORA_HANEY _
ADDRESS HUSKINS_RD.
MARION NC 28752
CITY OR TOWN STATE ZIP CODE
3. DATE DRILLED: 10/26/00 USE OF WELL: HOUSE
4. TOTAL DEPTH: 245'
5. CUTTINGS COLLECTED: YES NO XX
6. DOES WELL REPLACE EXISTING WELL? YES NO XX
7. STAT. WAT. LEVL. BEL.TOP OF CASING __50_FT.
(USE + IF ABOVE TOP)
B. TOP OF CASING IS 18" ABOVE LAND SURF.*
9. YIELD (GPM): 40 METHOD OF TEST-ARD
10. WATER ZONES (DEPTH): _
11. CHLORINATION: TYPE CLOROX AMOUNT 1/2 GAL
12. CASING:
W. THICK.
DEPTH DIA OR WT/FT. MTL
FROM __0_TO_167_FT. _6-5/8" _STEEL_
FROM TO FT.
13. GROUT:
DEPTH MATERIAL METHOD
FROM _0__TO_20 FT. _CEMENT_ _PRESS_
FROM TO FT. _
14. SCREEN:
DEPTH DIA SLOT SIZE MTL
FROM TO FT. IN. IN.
FROM TO FT. IN. IN. _
FROM TO FT. IN. IN.
15. SAND/GRAVEL F'ACK:
DEPTH SIZE MATERIAL
FROM —TO —FT.
16. REMARKS:
STATE WELL CONSTRUCTION
PERMIT NUMBER:
BELOW)
MCDL
DEPTH
FROM TO
0
0
DRILLING LOG
FORM. DESC.
i
�o
-ra -
co
ca �,
LOCATION SKETCH
HWY. 221 N. FROM RUTHERFOR
TON. GO PAST SCOTTY'S HOME
& LEFT ON HUSKINS RD. GO T
TOP OF HILL R RT. AT GROUP
MAILBOXES. STAY TO LEFT.
LOT ON TOP OF HILL ON LEFT
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL NSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECOR
HAS BEEN PROVIDED 0 THE WELL OW R
(1 'x ( , i A --A
SIGNATURE �vCONTR@CTOR OR AGENT DATE

NC DEHNR
DEM - GW SECTION
P.O. BOX 29535
RALEIGH, NC 27626-0535
[phone]
WELL CONSTRUCTION RECORD
DRILLING CONTRACTOR: PITTMAN WELL BORING, LLC
QUAD NO. SER. NO.
LAT LONG
BASIN CODE
HEADER ENT. GW-1 ENT.
....liilt7J
STATE WELL CONSTRUCTION
PERMIT NUMBER:
DRILLER REGISTRATION NO: 2785
----------------------------------------------------------------------------
----------------------------------------------------------------------------
1. WELL LOCATION: (SHOW SKETCH OF THE LOCATION BELOW)
NEAREST TOWN : MARION COUNTY: MCDL
OFF SEAGLE RD.
(ROAD, COMM., OR SUBDV. & LOT NO.)
2. OWNER EDDIE_HENSON
ADDRESS OFF-SEAGLE-RD.
MARION NC 28752
CITY OR TOWN STATE ZIP CODE
3. DATE DRILLED: 10/31/00 USE OF WELL: HOUSE
4. TOTAL DEPTH: 2255
5. CUTTINGS COLLECTED: YES NO XX
6. DOES WELL REPLACE EXISTING WELL? YES NO XX
7. STAT. WAT. LEVL. BEL.TOP OF CASING 60 FT.
_ (USE + IF ABOVE TOP)
8. TOP OF CASING IS 18" ABOVE LAND SURF.*
9. YIELD (GPM): 7 METHOD OF TEST-ARD
10. WATER ZONES (DEPTH)-
11. CHLORINATION: TYPE CLOROX AMOUNT 1/2 GAL
12. CASING:
W. THICK.
DEPTH DIA OR WT/FT. MTL
FROM_0_TO_90_FT._6-1/4" -STEEL-
FROM—TO—FT.
13. GROUT -
DEPTH
MATERIAL
METHOD
FROM_0_TO_20_FT.
_CEMENT_
_PRESS_
FROM TO__FT.
14. SCREEN:
DEPTH
DIA SLOT
SIZE MTL
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.
16. REMARKS:
DEPTH DRILLING LOG
FROM TO FORM. DESC.
0
iJ
wT
LOCATION SKETCH
HWY. 226 N. FROM POLKVILLE.
RT. ON BUS. 2221 IN MARION.
RT. ON BALDWIN AVE. RT. ON
MATILDA AVE. RT. ON YANCEY
ST. LEFT ON SEAGLE ST.CROS£
RR R RT. ON IST DIRT RD.
SINGLE WIDE AT TOP OF HILL.
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C7 WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORL
HAS BEEN PROVIDED/Tb THE WELL OWNER
GNAT7UURE Z17
TORR OR AGENT DATE

NC DEHNR
DEM — GW SECTION
P.O. BOX 29535
RALEIGH, NC 27626-0535
[phone]
WELL CONSTRUCTION RECORD
DRILLING CONTRACTOR: PITTMAN WELL BORING, LLC
QUAD NO. SER. NO.
LAT LONG
BASIN CODE
HEADER ENT. GW-1 ENT._
STATE WELL CONSTRUCTION
PERMIT NUMBER:
DRILLER REGISTRATION NO: 2567
1
WELL LOCATION: (SHOW SKETCH OF THE LOCATION
BELOW)
NEAREST TOWN MARION COUNTY:
MCDL
MUD CUT RD.
(ROAD, COMM., OR SUBDV. & LOT NO.)
DEPTH DRILLING LOG
2.
OWNER JOHN_HOOPER
FROM TO FORM. DESC.
ADDRESS MUD _CUT _RD.
MARION NC 28752_
CITY OR TOWN STATE ZIP CODE
3.
DATE DRILLED: 09-18-00 USE OF WELL: HOUSE
4.
TOTAL DEPTH: 53'
5.
CUTTINGS COLLECTED: YES NO XX
6.
DOES WELL REPLACE EXISTING WELL? YES NO XX_
7.
STAT. WAT. LEVI. BEL.TOP OF CASING _33_FT.
a —
(USE + IF ABOVE TOP)
8.
TOP OF CASING IS 18" ABOVE LAND SURF.'
9.
YIELD (GPM): 20' METHOD OF TEST —STEEL TAPE
—
10.
WATER ZONES (DEPTH):
—
11.
CHLORINATION: TYPE CLOROX AMOUNT 1/2 GAL
'
12.
CASING:
ui g
W. THICK.
DEPTH DIA OR WT/FT. MTL
FROM _0_TO_53_FT._24"_ _CONC_
LOCATION SKETCH
FROM TO FT.
13.
GROUT:
HWY. 221 N. FROM RUTHERFORD
DEPTH MATERIAL METHOD
TON. LEFT ON MUD CUT RD. GO
FROM FT. _POURED_
PAST BIG RED BARN & TURN RT
_0_TO_20__CEMENT—
FROM TO FT.
BETWEEN 2 BRICK PILLARS. RT
14.
SCREEN:
ON 1ST GRAVEL DR. 1ST DR.
DEPTH DIA SLOT SIZE MTL
ON LEFT.
FROM —TO —FT. IN. IN.
FROM —TO —FT. IN. IN.
FROM —TO —FT. IN. IN.
15.
SAND/GRAVEL PACK:
DEPTH SIZE MATERIAL
FROM_33'_TO_53'_FT._NO. 6M_ _STONE
16.
REMARKS:
I DO HEREBY CERTIFY
ELL C
DED /F
THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
NSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD
�`�—I AGENT DATE

NC DEHNR
DEM - GW SECTION
P.O. BOX 29535 QUAD NO. SER. NO.
RALEIGH, NC 27626-0535 LAT LONG
[phone] BASIN CODE
HEADER ENT. GW-1 ENT.
WELL CONSTRUCTION RECORD
DRILLING CONTRACTOR: PITTMAN WELL BORING, LLC STATE WELL CONSTRUCTION
PERMIT NUMBER:
DRILLER REGISTRATION NO: 2785
------------------------------------------------------------
1.
WELL LOCATION: (SHOW SKETCH OF THE LOCATION
BELOW)
NEAREST TOWN MARION COUNTY:
MCDL
YANCY RD.
(ROAD, COMM., OR SUBDV. & LOT NO.)
DEPTH DRILLING LOG
2.
OWNER _JERRY_WILLIAMS
FROM TO FORM. DESC.
ADDRESS YANCY—RD.
MARION NC 28752_
CITY OR TOWN STATE ZIP CODE
3.
DATE DRILLED: 09/11/00 USE OF WELL: HOUSE
G
4.
TOTAL DEPTH: 505'
5.
CUTTINGS COLLECTED: YES NO XX
6.
DOES WELL REPLACE EXISTING WELL? YES NO XX
t�
7.
STAT. WAT. LEVL. BEL.TOP OF CASING _60_FT.
(USE + IF ABOVE TOP)
8.
TOP OF CASING IS 18" ABOVE LAND SURF.'
_-
9.
YIELD (GPM): 5 METHOD OF TEST-ARD
_
N
10.
WATER ZONES (DEPTH):
11.
CHLORINATION: TYPE CLOROX AMOUNT 1/2 GAL
co
12.
CASING:
W. THICK.
DEPTH DIA OR WT/FT. MTL
FROM _0_TO_80_FT._6-1/4" _PVC_
LOCATION SKETCH
FROM TO FT.
13.
GROUT:
HWY. 221 N. FROM RUTHERFORD
DEPTH MATERIAL METHOD
TON. GO PAST WAL-MART & RT.
FROM 20 FT. _CEMENT_ _PRESS_
AT NEXT LIGHT. LEFT ON HAN-
_0_TO
FROM TO FT.
KINS RD. GO PAST CHURCH &
14.
SCREEN:
RT. ON LENTZ RD. RT. ON
DEPTH DIA SLOT SIZE MTL
YANCY RD. AT STOP SIGN. 1
FROM TO FT. IN. IN.
MILE ON LEFT, TURN INTO DR.
FROM TO FT. IN. IN.
1ST DR. ON RT.
FROM TO FT. IN. IN.
15.
SAND/GRAVEL PACK:
DEPTH SIZE MATERIAL
FROM —TO —FT.
16.
REMARKS:
Y THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD
TQ�IHE WELL OWNER.(l_
IGNAT Of TO AGENT DATE
)� 7M

NC DEHNR 1_ 8 6 G
DEM - GW SECTION
P.O. BOX 29535 QUAD NO. ------- SER. NO. _-____
RALF_IGH, NC 27626-0535 LAT LONG-
[phone] BASIN CODE_____
HEADER ENT..___GW-1 ENT._
WELL CONSTRUCTION RECORD
DRILLING CONTRACTOR: PITTMAN WELL BORING, LLC STATE WELL CONSTRUCTION
PERMIT NUMBER:
DRILLER REGISTRATION NO: 2785
1.
WELL LOCATION: (SHOW SKETCH OF THE LOCATION
BELOW)
NEAREST TOWN MARION COUNTY:
MCDL
LOT 11
(ROAD, COMM., OR SUBDV. & LOT NO.)
DEPTH DRILLING LOG
._.
OWNER WILLIAM_WARF______
FROM TO FORM. DESC.
ADDRESS _LARHAN_DR._-
MARION__ NC _28752
_
CITY OR TOWN STATE ZIP CODE
3.
DATE DRILLED: 09/27/00 USE OF WELL: HOUSE
4.
TOTAL DEPTH: 205'
_-
5.
CUTTINGS COLLECTED: YES NO XX
6.
DOES WELL REPLACE EXISTING WELL? YES NO XX
7.
STAT. WAT. LEVL. BEL. TOP OF CASING __60___FT.
+ IF ABOVE TOP)
8.
_ _(USE
TOP OF CASING IS 18" ABOVE LAND SURF.*
_- _n._T__-_
9.
YIELD (GPM) : 0 METHOD OF TEST-ARD
10.
WATER ZONES (DEPTH): _ _-
11.
CHLORINATION: TYPE CLOROX AMOUNT 1/2 GAL
12.
CASING:
W. THICK.
DEPTH DIA OR WT/FT. MTL
---___________
-----
FROM FT. PVC--
LOCATION SKCCCh--
_-0_-TO_40_._6-1/4'_--
FROh1TOFT. _______
m
13.
GROUT:
HWY. 226 N. FROM PQgKVILLE.
DEPTH MATERIAL METHOD
LEFT ON MARLOW RD. GO 3/10
FROM
MILE & LEFT INTO BLUNK HENS
_S__TO__20_FT. _-CEMENT __PRESS____
FROM TO T. _ _
ACRES. LEFT ON LARHAN DR.
14.
__-
SCREEN:
1ST DRIVE ON LEFT.
DEPTH DIA SLOT SIZE MTL
F R 0 M ______T 0 __F T. -_- IN. __IN.
FROM _TO FT. ____IN. IN.
FROM__TO_-FT. ___IN. __IN. _
15.
SAND/GRAVEL PACK:
DEPTH SIZE MATERIAL
FROM TO -_FT.
16.
REMARKS: ---
I DO HERESY CERTIFY THAT THIS WELL WAS CONSTRUCTED
LL CONSTRUCTION STANDARDS, ANI) THAT
ED T q- HE WELL OWNFP. rA L ,
AT
(URE
V-L
R AGENT
IN ACCORDANCE WITH
A COPY OF THIS RECORD
DATE

NC DEHNR
DEM - GW SECTION
P.O. BOX 29535 QUAD NO. SER. NO.
RALEIGH, NC 27626-0535 LAT LONG
[phone] BASIN CODE
HEADER ENT. GW-1 ENT._
WELL CONSTRUCTION RECORD
DRILLING CONTRACTOR: PITTMAN WELL BORING, LLC STATE WELL CONSTRUCTION
PERMIT NUMBER:
DRILLER
REGISTRATION NO: 2160
-----------------------------------------------------------
1.
WELL LOCATION: (SHOW SKETCH OF THE LOCATION
BELOW)
NEAREST TOWN MARION COUNTY:
MCDL
LOT 10
(ROAD, COMM., OR SUBDV. & LOT NO.)
DEPTH DRILLING LOG
2.
OWNER TOM_BOSWELL
FROM TO FORM. DESC.
ADDRESS ASHE_BRIGE_RD.
MARION NC 28752_
CITY OR TOWN STATE ZIP CODE
3.
DATE DRILLED: 09/12/00 USE OF WELL: HOUSE
4.
TOTAL DEPTH: 245'
5.
CUTTINGS COLLECTED: YES NO XX
6.
DOES WELL REPLACE EXISTING WELL? YES NO XX
7.
STAT. WAT. LEVL. BEL.TOP OF CASING 40 FT.
o
(USE + IF ABOVE TOP)
8.
TOP OF CASING IS 18" ABOVE LAND SURF.'
9.
YIELD (GPM): 50 METHOD OF TEST-ARD
10.
WATER ZONES (DEPTH):
°
11.
CHLORINATION: TYPE CLOROX AMOUNT 1/2 GAL
s
12.
CASING:
='t
W. THICK.
;;—
DEPTH DIA OR WT/FT. MTL
FROM _0_TO_70_FT._6-1/4" _PVC_
LOCATION SKVTCf
FROM TO FT.
13.
GROUT:
HWY. 64/74A W. FROM RUTHER-
DEPTH MATERIAL METHOD
FORDTON. RT. ON COVE RD.
FROM FT. _PRESS_
CROSS INTO MCDL. CY. & RT.
_0_TO_20__CEMENT—
FROM TO FT.
ON TIGHT RUN RD. GO 1/2
14.
SCREEN:
MILE, CROSS BRIDGE. LEFT AT
DEPTH DIA SLOT SIZE MTL
END OF BRIDGE ONTO ASHE
FROM TO FT. IN. IN.
BRIDGE RD. RT. AT FORKS.
FROM TO FT. IN. IN.
LOT 10 ON LEFT.
FROM TO FT. IN. IN.
15.
SAND/GRAVEL PACK:
DEPTH SIZE MATERIAL
FROM —TO —FT.
16.
REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED
L CONSTRUCTION STANDARDS, AND THAT
D TO -THE WELL OWNER.r,
GNA-TuftOF
a,\,
OR AGENT
IN ACCORDANCE WITH
A COPY OF THIS RECORD
-i�-w
DATE

NC DEHNR
DEM - GW SECTION
P.O. BOX 29535
RALEIGH, NC 27626-0535
[phone]
WELL CONSTRUCTION RECORD
DRILLING CONTRACTOR: PITTMAN WELL BORING, LLC
' 7302
QUAD NO. SER. NO. _
LAT LONG
BASIN CODE
HEADER ENT. GW-1 ENT.
STATE WELL CONSTRUCTION
PERMIT NUMBER:
DRILLER REGISTRATION NO: 2785
1.
-----------------------------------------------------------------
WELL LOCATION: (SHOW SKETCH OF THE LOCATION
-
BELOW)
NEAREST TOWN MARION COUNTY:
MCDL
YANCY RD.
(ROAD, COMM., OR SUBDV. & LOT NO.)
DEPTH DRILLING LOG
2.
OWNER _CLARK_WALKER
FROM TO FORM. DESC.
ADDRESS YANCY-RD.
MARION NC 28752_
CITY OR TOWN STATE ZIP CODE
3.
DATE DRILLED: 08-16/00 USE OF WELL: HOUSE
4.
TOTAL DEPTH: 225'
5.
CUTTINGS COLLECTED: YES NO XX
6.
DOES WELL REPLACE EXISTING WELL? YES NO XX
r7l <,T_
7.
STAT. WAT. LEVI. BEL.TOP OF CASING _50_FT.
(USE + IF ABOVE TOP)
Co
8.
TOP OF CASING IS 18" ABOVE LAND SURF.`
9.
YIELD (GPM):20 METHOD OF TEST-ARD
--
10.
WATER ZONES (DEPTH):
E5 `''='
11.
CHLORINATION: TYPE CLOROX AMOUNT 1/2 GAL
w
12.
CASING:
W. THICK.
DEPTH DIA OR WT/FT. MTL
FROM _0_TO_50_FT._6-1/4" _PVC_
LOCATION SKETCH
FROM TO FT.
13.
GROUT:
HWY. 221 N. FROM RUTHERFORD
DEPTH MATERIAL METHOD
TON. GO PAST WAL-MART & RT.
FROM _0_TO_20_FT. CEMENT— _PRESS_
AT NEXT LIGHT. LEFT ON HAN-
FROM TO FT.
KINS RD. GO PAST CHURCH &
14.
SCREEN:
RT. ON LENTZ RD. RT. ON
DEPTH DIA SLOT SIZE MTL
YANCY RD. AT STOP SIGN. 1
FROM TO FT. IN. IN.
MILE ON LEFT.
FROM TO FT. IN. IN.
FROM TO FT. IN. IN.
15.
SAND/GRAVEL PACK:
DEPTH SIZE MATERIAL
FROM —TO —FT.
16. 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 REE'N PROVIDED rO THE WELL OWNER
NZ2\' ALL(/ 1, (
O
U SIC NATU %F�CONTRI OR ACTO�AGENT
ff` OR
-uo
DATE

1215087
NC DEHNR
DEM - GW SECTION
P.O. BOX 29535
RALEIGH, NC 27626-0535
[phone]
WELL CONSTRUCTION RECORD
DRILLING CONTRACTOR: PITTMAN WELL BORING, LLC
QUAD NO. SER. NO._
LAT LONG
BASIN CODE
HEADER ENT. GW-1 ENT.
STATE WELL CONSTRUCTION
PERMIT NUMBER:
DRILLER REGISTRATION NO: 2785
-----------------------------------------------------------------------
1.
WELL LOCATION: (SHOW SKETCH OF THE LOCATION
BELOW)
NEAREST TOWN MARION COUNTY:
MCDL
CALIFORNIA AVE.
(ROAD, COMM., OR SUBDV. & LOT NO.)
DEPTH DRILLING LOG
2.
OWNER FREDDIE_SEAY
FROM TO FORM. DESC.
ADDRESS _CALIFORNIA_AVE.
MARION NC 28752_
CITY OR TOWN STATE ZIP CODE
}
3.
DATE DRILLED: 07/28/00 USE OF WELL: HOUSE
o
4.
TOTAL DEPTH: 265'
o
5.
CUTTINGS COLLECTED: YES NO XX
6.
DOES WELL REPLACE EXISTING WELL? YES NO XXn�'
7.
STAT. WAT. LEVL. BEL.TOP OF CASING 60_FT.
-To
(USE + IF ABOVE P)
8.
TOP OF CASING IS 18" ABOVE LAND SURF."
= �r
9.
YIELD (GPM): 9 METHOD OF TEST-ARD
N==
10.
WATER ZONES (DEPTH):
�+
11.
CHLORINATION: TYPE CLOROX AMOUNT 1/2 GAL
rn O
12.
CASING:
W. THICK.
DEPTH DIA OR WT/FT. MTL
FROM _0_TO_90_FT._6-1/4" _PVC_
LOCATION SKETCH
FROM TO FT.
13.
GROUT:
HWY. 221 N. FROM RUTHERFORD
DEPTH MATERIAL METHOD
TON. LEFT AT LIGHT IN MAR -
FROM FT. _PRESS_
ION ON HWY. 221/226. GO 2.5
_0_TO_20__CEMENT—
FROM TO FT.
MILES TO DOWNTOWN MARION &
14.
SCREEN:
HOSPITAL & EXIT. LEFT AT
DEPTH DIA SLOT SIZE MTL
BOTTOM OF EXIT. LEFT ON
FROM TO FT. IN. IN.
CALIFORNIA AVE. 3/10 MILE
FROM TO FT. IN. IN.
ON LEFT IN SHARP CURVE.
FROM TO FT. IN. IN.
15.
SAND/GRAVEL PACK:
DEPTH SIZE MATERIAL
'
FROM —TO —FT.
16.
REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN AdCORDANCE WITH
15A NCAC 2C, WELL PQNSTRUCTION STANDARDS, AND THAT A COPY"OF THIS RECORD
HAS BEEN PROVIDED TO HE WELL OWNER.
SIGNREE OFVO(
DATE
o
�F'
ILlI✓nt�

NC DEHNR
DEM - GW SECTION
P.O. BOX 29535
QUAD NO.
SER.
NO.
RALEIGH, NC 27626-0535
LAT
LONG
[phone]
BASIN CODE
HEADER ENT.
GW-1
ENT.
WELL CONSTRUCTION RECORD
DRILLING CONTRACTOR: PITTMAN WELL BORING, LLC STATE WELL CONSTRUCTION
PERMIT NUMBER:
DRILLER REGISTRATION NO: 2567
----------------------------------------------------------------------------
1. WELL LOCATION: (SHOW SKETCH OF THE LOCATION BELOW)
NEAREST TOWN
NEBO
COUNTY:
MCDL
HARMONY GROVE
RD.
(ROAD, COMM.,
OR SUBDV. & LOT
NO.)
DEPTH DRILLING LOG
2.
OWNER _WAYNE_PITTMAN
FROM TO FORM. DESC.
ADDRESS —HARMONY-GROVE-RD.
MARION
NC
28752
_
CITY OR TOWN
STATE
ZIP CODE
3.
DATE DRILLED:
07-05-00 USE OF
WELL: HOUSE.
4.
TOTAL DEPTH:
62'
5.
CUTTINGS COLLECTED:
YES NO
XX
o
6.
DOES WELL REPLACE
EXISTING WELL?
YES NO XX
C �-
7.
STAT. WAT. LEVL.
BEL.TOP OF CASING
_47—
==m
( USE + IF
ABOVE TOP)
8.
TOP OF CASING
IS 18" ABOVE
LAND SURF.'
9.
YIELD (GPM):
15' METHOD OF
TEST -STEEL TAPEr'
10.
WATER ZONES
(DEPTH):
11.
CHLORINATION:
TYPE CLOROX AMOUNT 1/2 GAL
12.
CASING:
ems—
W.
THICK.
DEPTH
DIA OR
WT/FT. MTL
FROM _0_TO_62_
FT. _24"
_CONC_
LOCATION SKETCH
FROM TO
FT.
13.
GROUT:
HWY. 226 N. FROM POLKVILLE.
DEPTH
MATERIAL
METHOD
CROSS INTO MCDL. CTY. &
FROM
FT. _CEMENT—
_POURED_
TURN RT. ON GADDY RD. FIT.
_0_TO_20_
FROM TO
FT.
ON HARMONY GROVE RD. 2.1
14.
SCREEN:
MILES ON FIT. JUST BEFORE
DEPTH
DIA SLOT
SIZE MTL
NEW BRIDGE.
FROM —TO
—FT. IN.
IN.
FROM —TO
—FT. IN.
IN.
FROM —TO
—FT. —IN.
—IN.
15.
SAND/GRAVEL PACK:
DEPTH
SIZE
MATERIAL
FROM 47' TO 62'
FT. NO. 6M
STONE
16. 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. n
I G�N`ATURE F C TRACTOR
n,ORrA EN� DATE

NC DEHNR n 13464
DEM - GW SECTION
P.O. BOX 29535 QUAD NO. SER. NO.
RALEIGH, NC 27626-0535 LAT LONG
[phone] BASIN CODE
HEADER ENT. GW-1 ENT.
WELL CONSTRUCTION RECORD
DRILLING CONTRACTOR: PITTMAN WELL BORING, LLC
STATE WELL CONSTRUCTION
PERMIT NUMBER:
DRILLER
REGISTRATION NO: 2567
1.
WELL LOCATION: (SHOW SKETCH OF THE LOCATION
BELOW)
NEAREST TOWN MARION COUNTY:
MCDL
HWY. 226
(ROAD, COMM., OR SUBDV. & LOT NO.)
DEPTH DRILLING LOG
2.
OWNER _CLAUDE_LEDBETTER
FROM TO FORM. DESC.
ADDRESS
—HWY.-226
NC 28752_
_MARION
CITY OR TOWN STATE ZIP CODE
3.
DATE DRILLED: 06-01-00 USE OF WELL: HOUSE
o
4.
TOTAL DEPTH: 47'
e
5.
CUTTINGS COLLECTED: YES NO XX
'
6.
DOES WELL REPLACE EXISTING WELL? YES NO XX c �'
7.
STAT. WAT. LEVL. BEL.TOP OF CASING _32_FT.
i e
(USE + IF ABOVE TOP)
rn m
8.
TOP OF CASING IS 18" ABOVE LAND SURF.*
9 -
9.
YIELD (GPM): 15' METHOD OF TEST -STEEL TAPE
10.
WATER ZONES (DEPTH):
m O
11.
CHLORINATION: TYPE CLOROX AMOUNT 1/2 GAL
o
12.
CASING:
W. THICK.
DEPTH DIA OR WT/FT. MTL
FROM_0_TO_47_FT . _24 "_ _CONC_
LOCATION SKETCH
FROM
13.
—TO —FT.
GROUT:
HWY. 226 N. FROM POLKVILLE.
DEPTH MATERIAL METHOD
CROSS INTO MCDL. CTY. &
FROM FT. _POURED_
TURN LEFT ABOUT 100' PAST
_0_TO_20__CEMENT—
FROM TO FT.
HARMONY GROVE CH. RD.
14.
SCREEN:
DOUBLE -WIDE IN BOTTOM ON
DEPTH DIA SLOT SIZE MTL
POWER LINE RIGHT OF WAY.
FROM —FT. —IN. —IN. --
—TO
FROM —FT. IN. IN.
—TO
FROM —TO —FT. IN. IN.
15.
SAND/GRAVEL PACK:
DEPTH SIZE MATERIAL
FROM_32'_TO_47'_FT. _NO. 6M_ _STONE
16.
REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC_2C, WELL CON TRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD
HAS BEEN PROVIDED TO THE WELL OWNER.
SIG TNTRAC� R OR, AGEPT DATE

NC DEHNR
DEM - GW SECTION
P.O. BOX 29535
RALEIGH, NC 27626-0535
[phone]
WELL CONSTRUCTION RECORD
DRILLING CONTRACTOR: PITTMAN WELL BORING, LLC
QUAD NO. SER. NO.
LAT LONG
BASIN CODE
HEADER ENT. GW-1 ENT.
DRILLER REGISTRATION NO: 2785
1 WELL LOCATION (SHOW SKETCH OF THE LOCATION
NEAREST TOWN : MARION COUNTY:
PINNACLE CHURCH RD.
(ROAD, COMM., OR SUBDV. & LOT NO.)
2. OWNER _ROSETTA_HOLLIFIELD
ADDRESS _PINNACLE_CHURCH_RD.
_MARION NC 28752_
CITY OR TOWN STATE ZIP CODE
3. DATE DRILLED: 05/08/00 USE OF WELL: HOUSE
4. TOTAL DEPTH: 165'
5. CUTTINGS COLLECTED: YES NO XX
6. DOES WELL REPLACE EXISTING WELL? YES NO XX
7. STAT. WAT. LEVL. BEL.TOP OF CASING _30_FT.
(USE + IF ABOVE TOP)
8. TOP OF CASING IS 18" ABOVE LAND SURF.*
9. YIELD (GPM): 12 METHOD OF TEST-ARD
10. WATER ZONES (DEPTH):
11. CHLORINATION: TYPE CLOROX AMOUNT 1/2 GAL
12. CASING:
DEPTH
FROM _0_TO_40_FT.
FROM
TO
FT.
13.
GROUT:
DEPTH
FROM _0_TO_2
0_FT
.
FROM
TO
FT.
14.
SCREEN:
DEPTH
FROM
-TO -FT.
FROM
TO
FT.
FROM
TO
FT.
15.
SAND/GRAVEL PACK:
DEPTH
FROM
TO
FT.
16.
REMARKS:
W. THICK.
DIA OR WT/FT. MTL
_6-14/" _PVC_
STATE WELL CONSTRUCTION
PERMIT NUMBER:
BELOW)
MCDL
DEPTH
FROM TO
DRILLING LOG
FORM. DESC.
O O
O
----------------
LOCATION SKETCH
HWY. 226 N. FROM POLKVILLE.
MATERIAL METHOD RT. ON PINNACLE CHURCH RD.
_CEMENT_ _PRESS_ 3RD DRIVE ON LEFT PAST
ISAAC DR.
DIA SLOT SIZE MTL
IN. IN.
IN. IN.
IN. IN.
SIZE MATERIAL
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CA,NSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD
HAS BEEN R OVIDED O`:THE WELL OWN R.
N�ATU CON T R O AGENT DATE
:�:J' L;
o triwa'p CCA:QO

NC DEHNR
DEM - GW SECTION
P.O. BOX 29535
RALEIGH, NC 27626-0535
[phone]
WELL CONSTRUCTION RECORD
DRILLING CONTRACTOR: PITTMAN WELL BORING, LLC
SER. NO.
LONG
QUAD NO.
LAT
BASIN CODE
HEADER ENT. _GW-1 ENT.
STATE WELL CONSTRUCTION
PERMIT NUMBER:
DRILLER REGISTRATION NO: 2785
-------------------------------------------------------------------------
1. WELL LOCATION: (SHOW SKETCH OF THE LOCATION BELOW)
NEAREST TOWN MARION COUNTY: MCDL
HWY. 226
(ROAD, COMM., OR SUBDV. & LOT NO.) DEPTH
2. OWNER BETTY_SPURLIN FROM TO
ADDRESS HWY _226
MARION NC 28752
CITY OR TOWN STATE ZIP CODE
3. DATE DRILLED: 05/19/00 USE OF WELL: HOUSE
4. TOTAL DEPTH: 205'
5. CUTTINGS COLLECTED: YES NO XX
6. DOES WELL REPLACE EXISTING WELL? YES NO XX
7. STAT. WAT. LEVL. BEL.TOP OF CASING _40_FT.
(USE + IF ABOVE TOP)
8. TOP OF CASING IS 18" ABOVE LAND SURF.*
9. YIELD (GPM): 10 METHOD OF TEST-ARD
10. WATER ZONES (DEPTH):
11. CHLORINATION: TYPE CLOROX AMOUNT 1/2 GAL
12. CASING:
DEPTH
FROM _0_TO_80_FT.
FROM
TO
FT.
13. GROUT:
DEPTH
FROM _0_TO20FT.
_
FROM
TO_
FT.
14. SCREEN:
DEPTH
FROM
-TO
-FT.
FROM
-TO
-FT.
FROM
-TO
-FT.
15. SAND/GRAVEL
PACK:
DEPTH
FROM
-TO
-FT.
16. REMARKS:
W. THICK.
DIA OR WT/FT. MTL
_6-1/4" _PVC_
MATERIAL METHOD
_CEMENT_ _PRESS_
DIA SLOT SIZE MTL
IN. IN.
IN. IN.
IN. IN.
SIZE MATERIAL
DRILLING LOG
FORM. DESC.
-----------------
LOCATION SKETCH
HWY. 221 N. FROM RUTHERFORD
TON. TAKE I-40 E. GET OFF
ON HWY. 226. LEFT AT LIGHT.
GRAVEL DRIVE ON RT. APPROX.
2 MILES. (NEXT TO OLD STORE
BLDG.) HOUSE ON LFET AT END
OF DRIVE.
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
"A_NC C 2C. WELL� NSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD
He ($EWI�jIJ�PROjTBOED I o THE WELL OWNER. .
9 9M0 � �� � SI, GNATI
OR AGENT
��:�'Js
-/q -c-0
DATE

NC DEHNR
DEM - GW SECTION
P.O. BOX 29535
RALEIGH, NC 27626-0535
[phone]
WELL CONSTRUCTION RECORD
DRILLING CONTRACTOR: PITTMAN WELL BORING, LLC
DRILLER REGISTRATION NO: 2785
QUAD NO. SER . N2Q "
LAT LONG `
BASIN CODE
HEADER ENT. GW-1 ENT.
STATE WELL CONSTRUCTION
PERMIT NUMBER:
-------------------------------------------------
1 WELL LOCATION: (SHOW SKETCH OF THE LOCATION BELOW)
NEAREST TOWN : MARION COUNTY: MCDL
HENSLEY RD.
(ROAD, COMM., OR SUBDV. & LOT NO.)
2. OWNER _KENNETH_FREEMAN
ADDRESS 110_HENSLEY_RD.
MARION NC 28752
CITY OR TOWN STATE ZIP CODE
3. DATE DRILLED: 03-11-00 USE OF WELL: HOUSE
4. TOTAL DEPTH: 325F
5. CUTTINGS COLLECTED: YES NO XX
6. DOES WELL REPLACE EXISTING WELL? YES NO XX
7. STAT. WAT. LEVL. BEL.TOP OF CASING _60_FT.
(USE + IF ABOVE TOP)
8. TOP OF CASING IS 18" ABOVE LAND SURF.*
9. YIELD (GPM): 5 METHOD OF TEST-ARD
10. WATER ZONES (DEPTH):
11. CHLORINATION: TYPE CLOROX AMOUNT 1/2 GAL
12. CASING:
DEPTH
FROM_0_TO_90_FT
.
FROM
-TO -FT.
13. GROUT:
DEPTH
FROM_0_TO_2
0_FT
.
FROM
-TO -FT.
14. SCREEN:
DEPTH
FROM
-TO -FT.
FROM
-TO -FT.
FROM
-TO -FT.
15. SAND/GRAVEL
PACK:
DEPTH
FROM
-TO -FT.
16. REMARKS:
DEPTH
FROM TO
DRILLING LOG
FORM. DESC.
W. THICK.
DIA OR WT/FT. MTL
_6-1/4" _PVC_ LOCATION SKETCH
HWY. 64/74A W. FROM RUTHER-
MATERIAL METHOD FORDTON. RT. ON COVE RD. GO
_CEMENT_ _PRESS_ THUR MONTFORD COVE & RT. ON
HENSLEY RD. 1ST DRIVE ON RT
DIA SLOT SIZE MTL
IN. IN.
IN. IN.
IN. IN.
SIZE MATERIAL
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCT A
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND TH A
HAS BEEN PROVIDED HE WELL OWNE .
- SIGNATURE OF CONTRAC OR OR AGENT
K� TOS RECORD
DATE

NC DEHNR
DEM — GW SECTION
207590
P.O. BOX 29535 QUAD NO. SER. NO.
RALEIGH, NC 27626-0535 LAT
LONG
[phone] BASIN
CODE
HEADER ENT. GW-1 ENT.
WELL CONSTRUCTION RECORD
DRILLING CONTRACTOR: PITTMAN WELL BORING, LLC
STATE WELL CONSTRUCTION
PERMIT NUMBER:
DRILLER REGISTRATION NO: 946
1
-------------------------------------------------------------------------
WELL LOCATION: (SHOW SKETCH OF THE LOCATION
BELOW)
NEAREST TOWN MARION COUNTY:
MCDL
HAYNES RD.
(ROAD, COMM., OR SUBDV. & LOT NO.)
DEPTH DRILLING LOG
2.
OWNER BILL_MCCULLOUGH
FROM TO FORM. DESC.
ADDRESS HAYNES—RD.
MARION NC 28752
CITY OR TOWN STATE ZIP CODE
3.
DATE DRILLED: 02-26-00 USE OF WELL: HOUSE
—
4.
TOTAL DEPTH: 33'-
5.
CUTTINGS COLLECTED: YES NO XX
6.
DOES WELL REPLACE EXISTING WELL? YES NO XX
A
7.
STAT. WAT. LEVL. BEL.TOP OF CASING _21_FT.
(USE + IF ABOVE TOP)
S.
TOP OF CASING IS 18" ABOVE LAND SURF."
T
9.
YIELD (GPM): 12' METHOD OF TEST —STEEL TAPE
10.
WATER ZONES (DEPTH):--
11.
CHLORINATION: TYPE CLOROX AMOUNT 1/2 GAL
o
12.
CASING:
T
W. THICK.
DEPTH DIA OR WT/FT. MTL
FROM_0_TO_33_FT._24" _CONC_
LOCATION SKETCH
FROM TO FT.
13.
GROUT:
HWY. 64/74A W. FROM RUTHER—
DEPTH MATERIAL METHOD
FORDTON. RT. ON COVE RD.
FROM_0_TO_20_FT._CEMENT_ _POURED_
LEFT ON HAM CREEK RD AT
FROM —TO —FT.
DONNA'S STORE. LEFT ON
14.
SCREEN:
HAYNES RD. ON LEFT AT DEAD —
DEPTH DIA SLOT SIZE MTL
END.
FROM —TO —FT. IN. IN.
FROM TO —FT. —IN. —IN.
FROM —TO —FT. —IN. —IN.
15.
SAND/GRAVEL PACK:
DEPTH SIZE MATERIAL
FROM 21 TO 33' FT. NO. 6M STONE
16. REMARKS:
ITH
[lj ��— I---�&A".kA� kjC WELLFY THAT THIS WCONSTRUCTEDELL WAS N CONSTRUCTION STANDARDS, AND THAT ACOPY OFATHISACCORDANCE wRECORD
�� HAS BEEN PO�DED =ERP /�
— �6 V
IGNATURE OF CONTRACTOR OR AGENT s
ira•aat � on � "
t •Door was> Section
. AshoureFionalOt re
.gym.-a.e.._:ti...�...... v...a....

�j,. .�. ,fir. •.-� „Sw,��.. q 'n
229410
forth carnii ,n . f ,,p, l,,,w ni r wi,nnniew and IIntural IlenowcPs - Divt^Inn of Water Ouellty • Dinundwnicr Seclion
630 Mail S,wicn (>,,wr " flnlr•Ioh, If U. 27699AI536-Phone [phone] -
WELL cros i wic i im nECOM WELL cONTnnC1On: �L� 4
IO M gj 9
WELLCOIJTTIACTOnCEnTIriCAT
ST"ATF WELL CONSTITUCTION IPF"ITat _.
1. \YELL r ISF. (awck nl rllrnldn nn<): nesldenllnl L7CJ Munlclpnl ❑ Indushlal ❑ Agliculwrnl U Monitoring ❑
nocovpty [ I1^nl Pump Water Injecllon ❑ Other f—] II Other, LIlt Use:
2. WELL LOC:AI IUf l: (SI ry ^kglch of he lo-Ig-allon below) �f` 0
wnt
Nearest lo_—_
�� a county: �lS�
(Woad Ilan,n and I I h,rs, Conmwi,ity, or �1{bdivlslo and Lnl No.)
UnILLI140 LOG
d-h Flom TO
3. OWNErI
Address
riic,T o. w,c- ,Y
City o, lnwn � �stile Zlp Coda
4, DATE NMI-ED L'l
5. TOTAL DFI'111
6. CUTTIN(:SCOLLECIED YES ❑ NO(�j
7. DOES WELI_ IIFp'LACE EXISTING WELL? YES FT.
8. STATIC WATER LEVEL Below 10P 01 Casing: _�
(Use's' a Above Ten of C"I'll)
9. TOp Or C/nSIrIG IS____ �___ rT. Above Land Surface'
'Top of ceslna let ninelnd el'" below land surface raqulres a variance In aeeen-
dancewith Irk nCAC 2C of la r
10. YIELD (gptl)): -- METHOD OF TEST _
11. WATEfI ZONES (drptll): ----
12. CHLOT11HATION
131. CASIN(3:
�J��Amount T'
I)rplh I!Dla�nnielrrnr
Ffom_-0---10 11 r-L t
From---
From.-__----10----- rl._
FO.Allm Descdplion
a
O �
II addillnnal epaca I! needed u^.e back of lour+
LOGAIJO1 SKFTCH_
wall 1111chle»
n, ylnipilviriI. bla�edal (Show, direction and dislnnra h0ln aUonsl two Stale
F-ay c DR ndade, or other niap reference points)
14. GROU1: UMalorinl Molhod
nl,lh•n
From-- 0._--.1n _AU_f'1.__iAliGfE�� _�plsL
Front .- ---- 10 -._---rL ----- —_
15. SCnEFtI:
Url.11t Irinnrotar
In.
In.
Horn _. _.. _ to .. __ FL__.-- In,
18, SANU/Gf IAVFL TACK:
Unpin SIZO
SI01617e Mnlelial
Mnlelinl
old �-w�
From _—_.---
-----
Ftnnt
(7VIF-LI.
t tISTr1Ll IF[ tt ACCDnOAtICE WITII 15A NCA, 2C,
UO lrr nrnV (� Iry 1TKl-1T11q Wrt"Y VUp 9 CURD HA BEENP OVI)ED TU 111F. WFLI.UWl1Er1CcL
� 10
CONSfrnlCl JItj jIPNOMID3 AIto THAT 9
�.J� '. ..-. Q OATE
FOIL OT FICF D111(111_Y IOIIATIIIIE rPFDSon COtlSTnuCTIIO TtIF WFLL
Wad No' Submp odpl Ito Division of Wafer Ousllly, Oroundweter Section within 30 Llny! OVI 1 rIEV. 17/91
..
sedpltfo

North Carfolotn . Nnpnrt(nnnt of Environment and Natural nosoirrces - Division of Water Quality - Groundwater Snclion
1636 Mail Srrvwn Cooler . Raleigh, N C. 27699-1636 Phone [phone]) i
WELL CONSTRUCTION RECORD WELLCONTnACIOR:
WELL CONTRACTOR CERTIFICATION 0:
STATE WELL CONSTRUCTION PFRh11Tfl:
1, WELL USE (Chrck, f,ru,abL rrn=): nesldenlial LY) Municipal ❑ Industrial ❑ Agricultural ❑ Moniforing ❑
necovrry U I lean Purnp Water Injection ❑ Other ❑ If Other, List Use: ____
2. WELL LOCATION: (Shho'w'�'�sketch of the location below) �� I
Nearest Town: (� _ /Tr4 _ County:.090 i LM«I—
(noa,l nano and Nonei rshConmiunity, or Subdivision and Lot No )
3. OWNFn
Address
—"1'+ueci air TT-"ula- o.
City or imvn State Zip Code
4. DATE 011ILLED _
DRILLING LOG
From To Formation Descdplion
i 1 r
5. TOTAL DFPT11
6. CUTTINGS COLLECTED YESQ NOM
7. DOES WELL nFPLACE EXIS I-ING WELL? YES[—] NO( r^ "--
8. STATIC WATER LEVEL Below Top of Casing: ��p FT. _ r _ -
(Use'.' Ir Above Top or Casing) 1 --
9. TOP OF CASING V, _- FT. Above Land Surface* CD
'Top of castnq triroln Mrd rt'nr below Imtd surface requires a variance In actor- -p — -
dance with I5A HCAC 2C 0118
10. YIELD (gpn)):.-_ METIOD OF TEST
11. WATER 70NES (depth): ___ •i -- r�
12. CHLOnINAT ION: Type h / N Amount [7 D.11S It additional space Is needed use back of form
13. CASING
Drplit
WallThicDnres
lomeler or Weigwrt. Material
_LOCATION _SKETCH
(Show direction end distance from at least two State
From O
T o 110 Ft.
O
-I&. m5 ��� UP,
Roads, or other map reference points)
From-----
To _-- Fl._
From --_----
To _ FL—
1 1 I
CCtiI Rd
14. GROU R
Depth
Materiel othodtdF
�ouced
O j� /`
r l�
From ---
o To _a_ FI.
CJOI%�.E1
/ .
From _._
___ To -Ft.
15. SCREFfI
Drplh Diameter
From
To _ _— FI _ In.
From _
— To _ .__ Ft. _ in.
From __--
To _ _.---- Ft. __ In.
16. SAND/GnAVEL
PACK:
Depth Size
From —
._ T o -- Ft.
From
__— To Ft.
17. REMAnKs
Slot Size Material
in.
In.
In.
Material
I DO NEnEnY CF.n IiFy IIIAI-TITIS WELL WAS CONSTnUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONS I nUCTION STAfJOAn DS, AND TtfAT A COPY OF T IS RECORD HAS BEEN PRO IDED TO 711E WELL OWNER.
FOR OFFICE USE OId�'„� j f=-, - ---��
Quad No'. - - SIG URE or PE SON tis TnUCTING THE_ WFIL DATE
Submit odglnal to iviston of Water Quality, Groundwater Section within 30 Lin ys
-- - - GW-1 REV. 12/99
Selo? No

Noilh Carolina • Dernrhnnnl of Environment, Heallb, And Nntural nasource9 j
Division6m of ,virvna,dnl Mnm nngnnnl • Groundwnlnr Section FOR OFFICE USE p1JLY 2 1 2'7 5 9 ;
P.O. Rax 29535 • Ilalnigh, N.C. 27628 0533 OItAU. tfo ernIALNO. _
Phone [phone] or . _—_ Lmq. no
6Unnr ha^in j
WELL CONSTRUCTION NECOnD
DRILLING CONI (1AC1011 ��'����a,,..r`, (,¢Q tiendnr Frrl __- --_-_ GW-t Ent
O �J SIA]EWELL CallsIHUCnorJ
DnILLEn nE(',ISTRA HOII tIt1MDf-SR:_— j��PEIIMIT NUMRER:
----------- — -- —
1. WELL LOCATION: , low SIP.lc of 1t e locallon below)
Nearest Town:_41 ._ Counly: _Av -
10
( — y, I Is nn mid Lot Hn.) UEI' 1 I 1 _ DI11Ll.ING ,OG_
Wend, Conn nnul nr ..uld __ -
2. OWNER/tiLSL� Frmn to Fwmatlon bescriptian
or flouto
City or 1 o myj ? '` ^ Slit" u�p,.000
3. DATE DRILL : ? az`/ram• V� USE OF WELL
A. TOTAL Dr_P111-__A8�___ _
5. CUITINGSCOLLECTED YESL_� NOL
6, DOES WELL nEl'l_ACE EXISTING WELL? YES U NOL-0
7. STATIC WATER LEVEL Below Tap of Casing: rT.
(Use'*' If Above Top of C-1019)
8. TOP OF CASING IS __ FT. Above Laltd Surface'
• Casing Termineled suor below Innd slit lets is Illegal unless a vntinnce Is Issued
In accordance with 19A HCAC 2C .0119
9. YIELD (gpm):—,.?,Q MEIIIOD OF TEST
YATEn ZOtdES (depth):
II. CHLORINATION:
12. CASING:
O
zm
N
SM
Met
Im
m�
11
n�
—
z
Type %Y1 %� An,oUnl It nrhhlion,1I ^rnCn la nanded u9a back of form
Depth OjI m�nle�r
From 10 9_4�2 Ft. 1¢ 5
From To 1-
1-From ---10-- FL-
13. GROUT:
pib 0 Maly -rinj' nlhod
v_i—D _ rt. 1�---
!l Do
From -to
From —_— To
14. SCREEN:
rL
DPplll Dlan,eler
From __ To ---- FI
From To —.---- R. ___-- It"
* From — -- 10
° r 15. SANDIGIIAVFL PACK:
Depth Slze
From to --- rL
From _ 10 rt.
'G BEM
Too
LOCH i_IOtJ_SI<E T CFt
Wnll 1ldckness ..
or vlp giwrl nlmini (Show dirnrlinn nncf dill anr.n Iron AI Iaaet two Slale
ai4. Roads, or oihnr map lAleranco points)
Slot Size Malellnl
-
-
tvlatellal !"
AUG I A 2Gnn
T 1111S WFLL WAS C0rJS1rv.ICTEO It, ACConhAtif-F vvl III 15A IICAC 2C, WFLL
IS: Arm MAT A COPY OF MIS nECono I IAS MEN PfJOVIDED 10 111E WELL OwtJEn.
$If1t1AiURF OF Cc. If1AC10R Cn Ff11 GATE
Ow.I nEv: 191 Croundetater Section Submit original to bivlelon of Frrvir onnm 'lilt nd c�pY to waA awner.
sheviile Reginn41 Office

North Carolina - Department of Environment and Natural Resources - Division of Water Quality- Groundwater Section f w0. 4 1 1 J
3-
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Prone (919) 733221
WELL CONSTRUCTION RECORD WELLCONTRACTOR: - Jaynes � mn S
WELL CONTRACTOR CERTIFICATION o: 13 E
STATE WELL CONSTRUCTION PERMITM:
1. WELL USE (Check Applicable Boa); Residential ❑ Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other M If Other, List Use:
2. WELL LOCATION: (Shows etc of the location below) , 1
Nearest Tow U) A r County: t` I C 110 Iki P j
(Road Name an tubers. Convrunity, or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER 2 Le L L1-�K F E ri lIetI From To Formation Description
Address '�-�, -3 7'>6 X `15 O q3 (� Vc ,
O,tj rt—(Sraeort C o. �$%(p �13 (vDh CcYISv a nc.
Crry or Town Slate Zip Code
4. DATE DRILLED j S D D o
5. TOTAL DEPTH 8 5 CD r
0
6.
CUTTINGS COLLECTED YES ❑ NO[']
1 ^�
7.
DOES WELL REPLACE EXISTING WELL? YES M NO❑
8.
STATIC WATER LEVEL Below Top of Casing: &o Ff.--------------
9.
(Use': If Above Top of Casing)
TOP OF CASING IS ) FT. Above Land Surface'
pN
'Pop of waing terminated actor below land surface requires a variance In actor-
0 1
dance with 15A NCAC 2C .0119
10. YIELD (gpm): METHOD OF TEST Al"'
r*ra
11.
WATER ZONES (depth):
12.
CHLORINATION: Type y-a t k a✓ Amount _)CLA. i YJ
z
It additional space is needed use back of form
13. CA$ING:
Wall Thickness LOCATION SKETCH
Depth q2 Diiarngtter orwelght/Fl. Material (Show direction and distance from at least two State
From t)_ To �_ FL —6 Y4 -5C Roads, or other map reference points)
From To Ft.
From To Ft.
14, GROUT:
Depth Materialethor7l
From U To .20 Ft, beai CeWtpK� V0, y�d
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.
T In.
in.
Material 1�
phi r.,,,,, 0
'�995'_13,
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 B EN/PIOVIDED TO THE WELL OWNER.
[FORFFICE USE ONLY _ ,,VE.G'L C.iLo:SIGN RE OF PERSON CONSTRUCTING T E WELL DATE
Submiloriginal to Division of Water Quality, Groundwater Section within 30 days
o. -_ - - GW-t REV. 12199
.l
i
t Cr0t1 n tcdf=: , i

North Carolina - Department of Environmeru and Natural Resources - Division of Water Quality - Groundwater Section ' .. i r)
1636 Mail Service Carter - Ralaigh, N.C. 27699.1636-Phone [phone] r_ :1 n_ 273
WELL CONSTRUCTION RECORD WELLCONTRACTOR: James W. Camp, Jr.
WELL CONTRACTOR CERTIFICATION R: 2138
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (CrtaokApplicable sox): Residential Municipal ❑ Industrial ❑ Agricultural C1 Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other E3 II Other, List Use:
2. WELL LOCATION:r�(/glhow sketch of the location below) j�l 1'�
Nearest Town: I' Idl
A✓ 10 ✓>, County: ( 1G 1J0 I�
(Road Narne and
3. OWNER
Address
and Lot No.) DRILLING LOG
City or Town Sure zip coda
A. DATE DRILLED 00
5. TOTAL DEPTH o ti
6. CUTTINGS COLLECTED YES Q NO®
7. DOES WELL REPLACE EXISTING WELL? YES ® NOQ
8. STATIC WATER LEVEL Below Top of Casing: 3 � FT.
(Use'i It Above Top of Camp)
9. TOP OF CASING IS 1 FT. Above Land Surface'
-Top of casing Wndnated Wor below Land aurtaea racluk" a varlanu In acew-
dance with 1SA NCAC 2C .011 s
10. YIELD (gpm): /p'5'— METHOD OF TEST All
11. WATER ZONES (depth):
DEPTH
From To Formation Dasaiprion
0 /5 Jfr e
h.5 ao5 rnck_
12. CHLORINATION: Type
GCODACIE Amount 1 CHP
It additional apace is needed use back of form
13.-CASING:
LOCATION SKETCH
Depth
Wall Tlxcfiness
Diameter lght. Maw"
(Show direction and distance from at least two Sate
From U
To d
SW
Ft. 6 '4 21 PVC
Roads, or other map reference points)
From
To
Ft.
From
To
Ft.
14. GROUT
Depth Material Method
From 0 To 20 Ft. Neat cement Hand
From —To Ft.
15. SCREEN:
Depth Diameter
From _To_ Ft — In.
From To _ Ft. T In.
From _ To — Ft. ` in.
16, SANDIGRAVEL PACK:
Depth Size
From To Ft.
From To Ft_ _
17. REMARKS:
Slot Size Material
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 ROVIDED TO HE WELL OWNER.
FOR OFFICE US L �11/iYL�
Quad No: u i G IURE OF PERSON CONSTRUCTING Tf E W L DATE
Submit od�ividon of water puallty, Groundwaar Socdon within 30 days
r ` GW-1 REV. IWW
Sand No. I i 11 +

North Caro" - Deparunent of Envirorarrent " Naa.ral Resoweee - Division of Water O"'Y - Groundwater Section � �
1636 Mail Sorvica Cerwu - Raleigh, N.C. 27699-/ri3irPtane (919) 793-=1 or)
WELL CONSTRUCTION RECORD WELL CONTRACTOR: James W. Camp, Jr. f) U
WELL CONTRACTOR CERTIFICATION •: 2138
STATE WELL CONSTRUCTION PERMITI►:
1. WELL USE (ctm* AppaeaWa 8"): Residential Municipal ❑ Industrial ❑ Agricuitural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other 0 if Other, List Use:
2. WELL LOCATION: ( h w sketch of the location below) },n I`
Nearest Town: County: ,Y I C_ Do we II
D
(Roatl Nartw anc , C nunAy. or S ooivi "*n atv] t NoJ T DRILLING LOG DEPTH
3, OWNER tit o y WIf5 From .To Formation Oa peon
Address 5 Mhl . �r 0 3v iY an i _ YaJej
V t^ f outs o. 10 1/ f 30 4125 a o c
p
Qly or Town Saul* Zip Cods
a, DATEDRILLEO
5. TOTAL DEPTH L%a5
6. CUTTINGS COLLECTED YES Q NO®
7. DOES WELL REPLACE EXISTING WELL? YES M NO®
B. STATIC WATER LEVEL Below Top of Casing: /',�_ FT.
(Uso'r' II ADow, Top of Caning)
9. TOP OF CASING IS 1 FF. Above Land Surface`
'Top of wing tannlnatsd War 6alow Land sur(aca aquk" a vatianq In accor-
dana with 15A NCAC 2C,0114 I
10. YIELD (gpm): 410 METHOD OF TEST Ail
11. WATER ZONES (depth):
i2, CHLORINATION: Type Q-1001,110C Amount 1 CUP It additional apace is needed use back of loan
13.-CASING:
Wall This eaa
Depth Duv wr or WelghMaterial VFL (Show dlrectio a nest two Sure
From 0 To �_ Ft. 6 t/^ SDR21 PVC Roads, oUlar map reterence pouts)
From To Ft.
From To Ft.
14. GROUT
Depth
From 0 To 20 Ft.
From To Ft.
15. SCREEN
Material Method
Neat cement Hand
Depth Diameter
From To Ft In.
From —To Ft. In
From _ To _ Ft. in
16. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To FL
17. REMARKS:
is
Slat Size Material -
—in
Material r,
r
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF HIS RECORD HAS
, Bf BEEN ROVIDED TO THE WELL OWNER.
EQUaCNO:
FICE U NLY '(/ G[i
TUBE OF PERSON CONSTRUCTING W DATE
dI
DivL"l orWateraramy,cimundwalerSoalcnw in30days
GW-1 REV. 121"
t40V 1 �nnl)

North Carolina - Department of Environmanl and Natural Resources - Division of Water Quality - Groundwater Section Z 6`
1636 Mail Service Canter - Raleigh, N.C. 27G99-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: James W. Camp, Jr.
WELL CONTRACTOR CERTIFICATION aY: 2138
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (check Applicable Box): Residential hJ Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery 0 Heat Pump Water Injection ❑ Other 0 If Other, List Use:
2. WELL LOCATION: ( how sketch of the location below)
Nearest Te%n: r�a Y i D rt County: I r1C D6 tU e-
(Road Narrw and Com^y, or Suotlivialon arc Lot No.) DRILLING LOG DEPTH
3. OWNER G�Lt Vt.AYGl ['11tiY�11 rl Fran To Forms Dawiption
Address )7 n)?,) >)I 0 0'
f l 0 nc
City or Town Stale Zip Coda
A. DATE DRILLED 10j I'1' OD
5. TOTAL DEPTH 5
6. CUTTINGS COLLECTED YES CJ NO®
7. DOES WELL REPLACE EXISTING WELL? YES NO®
8. STATIC WATER LEVEL Below Top of Casing: ' 1 FT.
(Use'.' It Above Top of Caving)
9. TOP OF CASING IS 1 FT. Above Land Surface
'ToP of �Ing tvminated Wor below Lend surtsea regWk a varience In ecoa-
danu with 15A NCAC 2C.011 a
10. YIELD (gpm): 14� METHOD OF TEST Air
11. WATER ZONES (depth):
0
J
v
Q. CHLORINATION: Type GrOD far 1 n
yp U Amounl IdL— If additional span o needed use back of for rr
t 3.•CASING:
Depth Diameter
From U To —�° _ Ft. b 1 .
From To Ft.
F
14.(
Wall Thi kness LOCATION SKETCH
"we �gnVFL Malarial (Stow dlraction and distance from at least two State
SDR ' 1 PVC Roads or other map reference pouts)
z
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 U L GV " G l -to - UC
Quad No TORE OF PERSON CONSTRU NG ;ELL DATE
Submit u Divisian of Water Quality, Groundwater Section Within 30 days
Serial No. ,�,; �. OW-1 REV. 12M
f

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section 1VIC!_ 0652
1636 Mail See Center - Raleigh, N.C. 27699-1636Phone (919) 793-=1
WELL CONSTRUCTION RECORD WELL CONTRACTOR: James W. Camp, Jr.
WELL CONTRACTOR CERTIFICATION •: 2138
STATE WELL CONSTRUCTION PERMIT#-
1. WELL USE (Check Applicable Box); Residential ED' Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other 0If Ofher, List Use:
2. WELL LOCATION: (Show sketch of the location below) y,
Nearest Tow : I /a y n County: i Y I c' Do1e.1
IR Cr2eK Ch FN _
(Road Marne ano rs. Comrwnily, or Sulei�?y�o Lot No.) DRILLING LOG DEPTH
3. OWNER .� )I yyl ry�2YY I r'_ C )/ll, j�j yr, t` �S From To Formation pnscnpWn
Address o 0 I1,5 ✓i
rea or a Q. ye ek
lily or Town SWe --- Zip Code
4. DATE DRILLED w' 16 - DO
5. TOTAL DEPTH 31,S
6. CUTTINGS COLLECTED YESE] NO®
7. DOES WELL REPLACE EXISTING WELL? YES Ej5� NOQ
8. STATIC WATER LEVEL Below Top of Casing: FT.
(Use'.' II Above T o Casrne)
9. TOP OF CASING IS 1 Fr. Above Land Surface*
-Top of casing tarndnated Wor below land aurtea mqukea a variance In accor-
dance with 15A NCAC 2C,0118
10. YIELD (gpm): 10_ METHOD OFTEST Air
11. WATER ZONES (depth);
12. CHLORINATION: Type rranulor Amount 1 UIP
13. - CASING:
Wall Tnicknem
Depth DWfnewr or Wett��nuFL Malertal
From 0 To Ft. 6 1/4SDR21 PVC
From To Ft.
From To Ft.
14. GROUT
Depth Material Method
From 0 To 20 FL Neat cement Hand
From To Ft,
15. SCREEN:
Depth Diameter
From —To _Ft! in.
From _ To FL _ In.
From , To _ Ft. in.
16. SANWGRAVEL PACK
Depth Size
From To Ft.
From To Ft,
17. REMARKS:
Slot Size Material
in.
In.
_ in.
Material
fS�
It additional spars is needed use back of WW
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference polnLs)
IM tt'ULCr
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF IS RECORD HAS BEEN PROVIDED TOT WELLOWNER.
FOR OFFICE USE NLY - D
Qum No: I .` �{ V j SIG UHE OF PERSON CONSTRUCTING Tqk WELL DATE
(q Serial No. of water Oualily, Groundwalar Section within 30 days
U
GW-1 REV. 12199
Uti C ,LUtiU i.:.. n

North Carolina - Dopanment of Envonmant and Natteal Resources - Division of Water Oualiity, - G W dwaac Section 1636 Mail Service O Service Center - Raleigh, N.C. 27699.1636-Phone (919) 733-=l
WELL CONSTRUCTION RECORD WELL CONTRACTOR: James W. Camp, Jr.
WELL CONTRACTOR CERTIFICATION a: 2138
STATE WELL CONSTRUCTION PERMITar:
1. WELL USE (crack Appilcable Box): Residential ❑ Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other © 11 Other, List Use: —L 11 it r k
2. WELL LOCATION:_W sketch of the location below)
Nearest Town: j V G1 Y 1 C ri County: M � i06• i,L1 E' l
11„x C YCfCK C61 2a
(Road Name anINumDu/ Com raid, r Subdivision and,-Lqt No. I DRILUNG LOG DEPTH
3. OWNER �IX ( YFF•k rPrl,iJll) Y7ar1 's Ch. n From To Fonnaaon Dascnpr;on
Address �K� SI ��^ 0 125
Gtyor Town Stale Zip Coda
4. DATE DRILLED LD ` -60
5. TOTAL DEPTH �3Z
6. CUTTINGS COLLECTED YES 0 NO
7. DOES WELL REPLACE EXISTING WELL? YE [v7l NOE] S. STATIC WATER LEVEL Below Top of Casing: _>�> FT. o
(Usa'.' If Above Top of Casing) -
9. TOP OF CASING IS 1 FT. Above Land Surface* "-
'Top of wing terminaud atior below land sunace requiraa a vartance In actor- -
dance with ISA NCAC 2C .O113 — 10. YIELD (gpm): -D METHOD OF TEST Air
11. WATER ZONES (depth): -� -
i2. CHLORINATION: Type (,rnnulnr Amount 1 (1(p__
13.-CASING:
Depth Diamefsr
From 0 To r s F1. S f�^
From To Ft.
From To Ft,
14. GROUT
Depth
From 0 To 20 Ft.
From To Ft,
15. SCREEN
II additional space is needed use back of
Wall TNIgknees LOCATION SKETCH
SWe FL a " (Show direction and distance from at least two State
Roads, or other map reference points)
Material Method
Neat cement Hand
Depth Diameter
From —To _ Ft In.
From To Ft. In.
From _ To _ Ft. _ in.
16. SAND/GRAVEL PACK
Depth Size
From To FL _
From To Ft.
17. REMARKS:
Slot Size Material
in.
In.
in.
Material
%�1Y CR'?P u Qy1vRC�
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 0 7L11 ft
Ou" No: y� - SIC TIt1RE OF PERSON CONSTRUCTING fHE W& DATE
L S` Drrit origina�t�pryjslon Of Water Quality, Groundwater Section within 30 days OW-1 REV. 1299
Serial No. U I

North Carolina - Department of Environrrwru and Natural Rasotueee - Division of Wa[er Oua6ry - Groundwater Section r_ �} �' C
1636 Mall Service Cartier. RaleiyL N.C. 27649-163Pr22 Phw (919) 793{i1 U
WELL CONSTRUCTION RECORD WELL CONTRACTOR: James W. Camp, Jr.
WELL CONTRACTOR CERTIFICATION is 2138
STATE WELL CONSTRUCTION PERMIT►:
I. W ELL USE (ch.ck Appbcabta 9ox): Residentia) 02" Municipal ❑ Industrial ❑ Agricultural 0 Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other If Other, List Use:
2. WELL LOCATION:
Nawast Town: _
(Road Name and
3. OWNER _
Address
sketch of the location below) /,c��
r !Ott _ " r— county: - L' c no iye ))
or Subgrvisim and Lot No.)
uty or town Suw Zip Code
4. DATE DRILLED D _ 31 -O0
5. TOTAL DEPTH kLo ij
6. CUTTINGS COLLECTED YES F-1 NO®
7. DOES WELL REPLACE EXISTING WELL? YES [EJ NOO
S. STATIC WATER LEVEL Below Top of Casing: !ZI FT.
(Usa',' It Above Top of Casino)
9. TOP OF CASING IS 1 FT. Above Land Surface'
'Top of a ing wrtu atsd ad" bet" Wad audt requk" a vat W tc. In adoor-
danu witn 15A NCAC 2C .011a
10. YIELD (gpm): -_3 METHOD OF TEST fur
11. WATER ZONES (depth):
12- CHLORINATION: Type Srannlar Amount 1 rn10
13.-CASING:
DRILLING LOG DEPTH
From 'To For don D. prion
0 /.'1�.5 raIle /
0 5- 505 s e rocl
-D
N i=
If additional space is needed use back of form
Wall Tltic zu
LOCATION SKETCH
0
Depth
/as
Dianwtur or walahYFt. Material
6 1A SDR21 PVC
(Show direction end distanoa from at least two State
From
To FL
Roads, or other reap reference points) n `8-
From
To Ft.
From
To Ft.
14. GROUT:
Depth
Material Method
From 0
To 20 Ft,
Neat cement Hand
From
To Ft.
1%n-J.
15. SCREEN;
Depth Diameter
From — To Ft In.
From _ To _ Ft., In.
From —To —Ft. in.
16. SANDIGRAVEL PACK
Depth Size
From To Ft.
From To FL
17. REMARKS:
Slot Size Material
in.
In.
_ in.
Matenal
r 1 W
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTIONS HIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE l - /D - U D
Quad No. RE OF PERSON CONSTRUCTIN LL DATE
jute*l igin• on of wat.r Q auty. Gw ndwat.r 9ocWn within 30 days
Sarial No. f,"�`�
OW-1 REV. 12/9Y

Nonh Carolina - Dapan,nent of Environment and Naurar Resources - Division of Water OtraGly - Groundwater Section C_ ) 0 6 6 0
1636 Mall Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELLCONTRACTOR: James W. Camp, Jr,
WELL CONTRACTOR CERTIFICATION M: 2138
./ STATE WELL CONSTRUCTION PERMIT#.
1. WELL USE (COO" Appil"Wo Box): Residential LI Municipal ❑ Industrial ❑
Agricultural ❑ Monitoring
Recovery❑
❑ Heat Pump Water Injection ❑ Other E] If Other, List Use:
2. WELL LOCATION: (Dhow sketch of the location below) I,O
Nearest Town: // P h D [l County: — (� /
5
(Roau tvame a" t/y oars, C°��ity. or Subdvision ana Lot VQ) DRILLING LOG DEPTH
3. OWNER / 9Yl7( l Off' ' �e/�+& J'(oMP5 Fran .To Formation Wscnprion
Address NII 5: n Flo i✓ ✓eAJ
L a
(Stnicit or pule qO (2 per_ "O V A e
City or Town Suite --- Zip Coo*
4. DATE DRILLED � I�O-/�-OD
5. TOTAL DEPTH .---.4-C-�0
5. CUTTINGS COLLECTED YES M NO®
7. DOES WELL REPLACE EXISTING WELL? YES Q NO®
8. STATIC WATER LEVEL Salow Top of Casing: GJa FT.
(lJsa't' II Above Top at Casing)
9. TOP OF CASING IS 1 FT. Above Land Surface'
'TOP of cuing terrntnated Wor below land suHece raquaw a varian" In eocor
dams *rlth 15A NCAC 2C .0114
10. YIELD (gpm): --.40— METHOD OF PEST Au
11. WATER ZONES (depth):
i2. CHLORINATION: Type C7onUlnr Amount I Qi 11.L
13.-CASING:
0
- r)
II additional space is needed use back of lon ,3 rD
wall Tnaxnase
LOCATION SKETCH
0
Depth p,,
Diameter a We lg MR. Material
1A SDR21 PVC
(Show direction and diAartce from at least two State
From
To
Fl.
b
Roads or other reference points)
From
To
Ft.
From
To
Ft,
' U
14. GROUT:
Depth
Material Method
From 0
To 20
Ft,
Neat cement Hand
From
To
Ft.
15. SCREEN
Depth Diameter
From To _ Ft , In.
From —To _ Ft. T in.
From _ To _ Ft. _. in.
16. SANDIGRAVEL PACK --
Depth Size
From To Ft.
From To FL
17. REMARKS -
Slat Size Material �s \
in.
_ In.
in. X
Material Wr
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, �AND THAT A COPY OF IS RECORD HAS BEEN
PROVIDED TO/THE WELL OWNER.
FOR OFFICE UZUB 6 l'1 _ _/. (,6lilvrA /✓1 /I ' /D
0"0 No:
Serial No, -t]UN L
OF PERSON CONSTRUCTING kHE WEL&4 DATE
N wMer O"ItY, Greur &Ier section within 30 days
GW-1 REV. 12/W

Nowt Carolina - Depanment of Envinanmenl and Nears, Resources • Division of Water 0,46 - Grayndwaier Section G � G U F 4.
1636 Mail Service Center - Raleigh, N.C. 27699.1636-Frans (919) 753-=,
WELL CONSTRUCTION RECORD WELL CONTRACTOR: James W. COmp, Jr.
WELL CONTRACTOR CERTIFICATION a: 2138
STATE WELL CONSTRUCTION PERMIT*.:
1, WELL USE (CrtackAppucable s"): Residontial E2/ Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other M If Other, list Use:
2. WELL LOCATION: S w sketch of the location below) Nearest Town: GI YI'n yl County: /y l/�
r
�38 Trns CYetk pd.
(Road Name watkunawit. Com^ra�/u-')yl'Iy, or SrYboivWon and Lot No.) DRILLING LOG DEPTH
3. OWNER l74(h'IIIYI From To IFormaYm Dasuipaun
Address o- 5 CY e e li Dd. 0 1 .3
.0 f" 01 gate No.)
1-/� �a 3 0�85 C so a e v
Gry or Town Stale Zip Cow
4, DATE DRILLED /O- -00
5. TOTAL DEPTH �2 2 5
6. CUTTINGS COLLECTED YES Q NO®
7. DOES WELL REPLACE EXISTING WELL? YES 0 NO
8. STATIC WATER LEVEL Below Top of Casing: ,j FT.
(Ilse'.' II Above Top of Casing)
9. TOP OF CASING IS 1 FT. Above Land Surface*
-Top of cuing wmlnatad auw below land surface requk" a variance In acoor-
dance with I5A NCAC 2C ,011 a - >
10. YIELD (gpm): 10 METHOD OF TEST fur _
11. WATER ZONES (depth):
T2- CHLORINATION: Type Granular Amount 1 r't IR If addfdoaal apace is nodded use back of form
13.-CASING:
LOCATIQN SKETCH N
Wail Tlticwneas
Depth Diameter or WaI�nuFt. Material (Slow direction ere" distan from at least two State t '
From O To 63 Ft. 6 i/a SDR21 PVC R�ads, orother map feleremepoints) ry o
From To FI.
From
To
Ft.
14. GROUT:
Depth
Material
Method
T
From 0
To 20
Ft.
Neat cement
Hand
From
To
Ft.
15. SCREEN:
Depth
Diameter
Slot Size
Material
From _
To
Ft —
in.
in.
From —To
—Ft.
Im
In.
From _
To —
Ft.
_ in. —in
u.
�(
16. SAND/GRAVEL PACK -
v
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
CONSTRUCTIONtSTIAN1014ARD$, AND THAT A COPY OF HIS RECORD HAS BEEN PROVIDED TO T WELL OWNER.
FOR OFFICE USEO"No: RE OF PERSON CONSTRUCTING W GATE
't g'vislcn cr wuer quulty, Groundwater Sowwt within 30 days
Sand No.
_ GWf REV. tT/99

North Carolina - Department of Environment and Natural Resowoee - Division of Water Quality - GrourWWalar Section
1536 Mail Sarvica Carter 3 . RaLoigA N.C. 27699.1636-Phone [phone] " 2 0 6 6 n
WELL CONSTRUCTION RECORD WELL CONTRACTOR: James W. Camp, Jr. ll tI \S
WELL CONTRACTOR CERTIFICATION #: 2138
STATE WELL CONSTRUCTION PERMIT#:
W ELL USE (C lookApphcsble eoa); RosidenUal LY1 Municipal ❑ Industrial ❑ Agriculture! ❑ Monitoring ❑
Recovery 0 Heat Pump Water injection [] Other If Other, List Use:
2. WELL LOCATION: ow sketch of the location below) �n ��\\
Naafi est Town: A ✓ t o r" . r _ County: / Y ! C Jo I'o e II
IRoa(l warrw and nears. cone unify. or uboivlsion and Lot No.) DRILLING LOG DEPTH
3. OWNER 0 V, r, h h5,[. I`// ! j� From To ,FJo'rmation Dauripaon I
Address �g5a1't( �n �l l�� 0
raa or uta"Aa}----- 49 /'oyso% aft e Vo c�l
Aiyi' 9r �Qr7�a
try or Town Stale Zip Coda
4, DATE DRILLED J0--,)` -.0 &
5. TOTAL DEPTH �aalzfi-
6. CUTTINGS COLLECTED YES[--] NO®
7. DOES WELL REPLACE EXISTING WELL? YES O NO�
S. STATIC WATER LEVEL Below Top of Casing O FT.
(U" '.'it Above Top of Casing)
9. TOP OF CASING IS 1 FT. Above Land Surface'
'TOP of rasing tvmloalsd :Uor below Land aurtana rar(ukw a variant In aCow-
dansa with I M NCAC 2C .011 B
10. YIELD (gpm): � METHOD OF TEST Air
11. WATER ZONES (depth):
12CHLORINATION: Type rranUlar Amount I MIQ
13. - CAST NG:
wall TNcincss
Depth
Diameter or Welghl/R. Malarial
From 0
To /19_ Ft.
6 '/4 SDR21 PVC
From
To Ft.
From
To Ft.
14. GROUT:
Depth
Material Method
From 0
To 20 Ft.
Neat cement Hand
From
To Ft.
15. SCREEN
Depth Diameter
From To _ Ft in.
From — To Ft. in.
From —To —Ft. in.
16. SANDIGRAVEL PACK
Depth Size
From To Ft,
From To Ft
17. REMARKS:
Slot Sire Material
_ in.
In.
_ in.
Material
r
_i
It additional apace is needed use back of brm ry
LOCATION SKETCH tV n
(Show difection end distance from at least two State
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, ANDTHATA COPY THIS RECORD HAS 8 EN P VIDED TO THE WELL OWNER.
FOR OFFICE Q V LS D
auad RE OF PERSON CONSTRUCTING WE DATE
Submi#210 'vision of water quallry. Groundwater Section within 3D days
Sand No. ! i� { i,' GW-1 REV. Iz*W

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section L r 6 9 [J
1636 Mall Service Center - Raleigh, N.C. 27699.1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: GlCAtyLpTr
WELL CONTRACTOR CERTIFICATION
STATE WELL CONSTRUCTION PERMITC
1. WELL USE (Check Applicable Box): Residential E Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other If Other, List Use:
2. WELL LOCATION: how sketch of the location below)
Neare�nslt Town: /� ✓/i1n v� County: McDrtint01
/I PLd f uJ Lancet.
Agricultural ❑ Monitoring ❑
(Road Name and Numbers. Cortmunity, or Subdivision and Lot No.)
DRILLING LOG
DEPTH
3.
OWNER l
From To
Formation Description
Address 3
�- o
e� '%o
i
1wreet or out o.
Ali, nu ( ��7J�c2-r�U��
? c �� 5
a
-
City or Town Stale Zip Code
J
(77)
4.
DATE DRILLED h - '0
rn
5.
TOTAL DEPTH
6.
CUTTINGS COLLECTED YES NO©
7.
DOES WELL REPLACE EXISTING WELL? YES O NO
CT1 - -'
8.
STATIC WATER LEVEL Below Top of Casing: J4a, FT.
--
9.
(Use'+' If Above Top of Casing)
TOP OF CASING ISFr. Above Land Surface*
N
'Top or casing terminated at/or below land surface requires a variance In actor-
N -4
dance with 15A NCAC 2C .011a
10.
YIELD (gpm): r'r METHOD OF TEST a-i r
-"
11.
WATER ZONES (depth):
12.
CHLORINATION: Type t2dift5 Amount C UO
If additional space is needed use back of form
13.-CASING:
LOCATION SKETCH
Wall Thickness
1
Depth
Diiarg9ter or Welght/Ft. Material
(Show direction and distance from at least two State p r
From— JL TO 20
Ft. u'L'I '�C
Roads, or other map reference points)
From To
Ft.'s
From To
Ft.
14.
GROUT:
Depth
Material Metho d's
From 0 To �_FL
—
Neat Cemex alt�
From To
Ft.
15.
SCREEN:
Depth Diameter Slot Size Material
From _To_ Ft
In. _ In.
From _ To Ft.
_ In. _ In.
From FL
in. —in
i o
16.
—To
SAND/GRAVEL PACK:
Depth
Size Material
`
From To
Ft.
— 1'
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 CONSTRICTING THE WELL DATE
Submit odginal 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 L. i t'7 (T
1636 Mail Service Center - Raleigh, N.C. 27699.1636-Phone [phone] ! 0
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) 1� ll
Nearest Town: A, y 1r,, _ County: L D 61% C
Agricultural ❑ Monitoring ❑
(Road Name an{tl Numo . Co inity,, o+r�Subdivl ion and1Lp�t Np,J J
DRILLING LOG DEPTH
3. OWNER 1\IP 0- :5 (G (.._L11A✓( O 1 LSO r+
From To Fonnatlon Description
— II
Address e e LLTC K ,
D Io
ree oula o. p �r
�o^r
C- �D%S;L
70 �5 LDI a r
a YLntn 1\
City or Town Stale Zip Code
4, DATE DRILLED
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES 0 NO
ES d NO�
7. DOES WELL REPLACE EXISTING WELL?
_
o
B. STATIC WATER LEVEL_ Below Top of Casing: t,,'g FT.
r�
(Use '+' If Above Top of Casing)
Cn = -
9. TOP OF CASING ISFT. Above Land Surface -
'Top of casing terminated atlor below land aunace requires a varlanca In accor-
dance with 15A NCAC 2C .et 18-
10. YIELD (gpm): _�O_ METHOD OF TEST
11. WATER ZONES (depth):
.. -
12. CHLORINATION: Type I toe e 5 Amount Gu
_a
If additional space is needed use back of lorrrj,�
13.-CASING:
LOCATION SKETCH `
Wall Thickness
Depth D/i�'.'tar w WeighVR. t"epal
'YVC,
(Show direction and distance from at least two State
NI
From To Ft. - x-- .1
Roads, or other map reference points) n r I D r
From To Ft.
From To Ft.
14. GROUT:
Depth M terlal {- ethod
From _9 To AQ Ft. Y1a 1N'd'
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
�d
From _ To _ Ft _ In. In.
i
From _ To Ft. _ In. _ In.
From —To Ft. in. —in.
Y _-
16. SAND/GRAVEL PACK:
(�
Depth Size Material
From To Ft.
From To Ft.
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD H BEEN)PROVII ED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Quad No: SI ATURE OF PERSON C.ONSTRUCTIN FiE ELL DATE
Submil original Division of Water Duality, Groundwater Sedio within 30 days
Serial No. GW-1 REV. 12/99

North Carolina - Department of Environment and Natural Resources . Division of Water Quality • Groundwater Section ti l 7703
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone (919) 733-W21
WELL CONSTRUCTION RECORD WELLCONTRACTOR: �)fLes W• C wi0 �i✓•
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check applicable Box): Residential t Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION�:^(Show sketch of the location below) /� 1
Nearest Town: , MAY cry � o N- County: ( • IG ()D Lt) E / 1
(Road Name an N am. Cornawnnilry• or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER /— .A.A/r I - 0 11 15 From To Formation Description
Address fQ d jpK cVc5 Dr. `3'S —
M �75�'ie or yule o. �1 Onf '1 3�
Ciry or Town Stake up cooe
4. DATE DRILLED )5 `DD
5. TOTAL DEPTH 9,05
6. CUTTINGS COLLECTED YES 0 NO
7. DOES WELL REPLACE EXISTING WELL? YES Q' NOD
8. STATIC WATER LEVEL Below Top of Casing: _t 5_ FT.
(Use'i If Above Top of Casing)
9. TOP OF CASING IS�_ FT. Above Land Surface-
-Top of casing tuminated atlor below land surface requires a variance In accor-
dance with 15A NCAC 2C .0116 I-
10. YIELD (gpm): L-30_ METHOD OF TEST a) r
11. WATER ZONES (depth):
12.
CHLORINATION: Type C 8 5
Amount_
13.•CASING:
Wall Thickness
Depth Di?''j3!er
From —To 35 Ft. A ZV—
or Welght/Ft. Material
5DR21 ✓c-
From To Ft.
From To Ft.
14.
GROUT:
Depth 14ateriaI
Metho
From To .AQ Ft. 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
From To Ft.
From To Ft.
17.
REMARKS:
G
CID
-
rTl i
�v
It additional space is needed use back of for
ni
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other reap reference points) V 1
I (/
d
e ,
Ur,
ft,ra:,
r,,r
�r I
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Quad No: SI TURE OF PERSON CONSTRUCTIN HE WELL DATE
Submit odginal I Divislon of water Quality, Groundwater Section within 30 days
Serial No. I GW-1 REV. 12/99

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section L. 13 9 6 5
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELLCONTRACTOR: Trwes h). (blwln ,)r.
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential [a Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: o srtketch of the location below) I
Nearest Town: County: { 1' I C' `w to t
(Road Name and Numbers, Community, or Subdivision and Lot No.)
3. OWNER �,'7 ii"illpa ri
Address-� , 4 Bb X
(Street or K91.118 o.
�o Nr. I
City or To" State Zip Code
4. DATE DRILLED 4 -OC
5. TOTAL DEPTH 15 5
6. CUTTINGS COLLECTED YES 0 NO®
7. DOES WELL REPLACE EXISTING WELL? YES [2f NOF_�
8. STATIC WATER LEVEL Below Top of Casing: _j r,` 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 1SA NCAC 2C'j0�1�1a
10. YIELD (gpm): = METHOD OF TEST My'
1`
11. WATER ZONES (depth):
12. CHLORINATION: Type e s Amount I CLIO
13. CASING:
DRILLING LOG DEPTH
From To Formation Description
<� 1 o S t
IoS j$rl- con5olidatcdo�
If additional space is needed use back of form
Wall Thickness LOCATION SKETCH
Depth _
Diameter or WelghVFt. Material (Show direction and distance from at least two State
From
To
Ft. (" A 51DK.21PVC- Roads, or other map reference points)
From
To
Ft.
From
To
Ft. 7---
14. GROUT:
o
Depth
atenal
elho 00
0
From O
To AD
Ft. 'A
en
a 1
From
To
Ft,
C
oC'
15. SCREEN:
SC;n ���--r
%y
Depth Diameter Slot Size Material
Ni
From From
To Ft
in. in.
!� i��
a.
r.,
xo
From
To Ft.
in. —in
V-.
�
1 0 ��
„
z
From
To Ft.
In. in.
16. SAND/GRAVEL PACK:
o
Depth
Size Material ©
z
From
To
Ft.
From
To
Ft.
17. REMARKS:
1 DO HEREBY CERTIFY THAT
THIS WELL WAS CONSTRUCTED IN ACCORD CE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS,
AND THAT A COPY OF THIS RECORD HAS
BJ EN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
(jlL vV
—yo y U'o
Quad No:
SIGNATURE OF PERSON CONSTRUCIllihilk A4CV8LL
"s - GATE
Submit original to Division of Water Quality, Groundwa44edtion within 30 days
Serial No.
f'��J6". GW4 REV. 12/99
7r';

or 4
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section o i j 9 6 01636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: TIYVlP5 w1/I1T
WELL CONTRACTOR CERTIFICATION #:
,..
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (check Applicable Box): Residential E_,( Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Sb ow sketch of the location below) l
Nearest Town: MA rt ran County: lVJ4�V'l
d LL)e'I
606 Ma1';oit. 1 "t
(Road Name and N bers, Co�m�1munity, or Subdivision and Lot No.)
3. OWNER /l ac %'' I, C 1, /"e
Address 6C)6 Y AYr51
treet or uleNO.)_
MAYln A C ALS)�
City or Town State Zip Code
4. DATE DRILLED 1,�!, - U D
5. TOTAL DEPTH -Z '1 4,._
6. CUTTINGS COLLECTED YES Q NOE]
7. DOES WELL REPLACE EXISTING WELL? YES d NOF_�
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 .011B
10. YIELD (gpm): � . METHOD OF TEST Ll i
11. WATER ZONES (depth):
12. CHLORINATION: Type l 5 Amount Z
13. CASING:
Wall Thickness
Depth Diameter or Weight/Ft. Material
FromTo 620 Ft. 21 �L
From To FL
From To Ft.
14. GROUT:
Depth Material -y- Metho
From C To 20 FL k1 Cement "oyl
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
DRILLING LOG
From To
© lv U
DEPTH
Formation DescnPLion
Clr l'I `JG(Yl0
00yus1/'1Lfrd (VJ
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)
MA✓lor1 I� /A
� CD
L I
J -
�ul\rub
v f}tr 1
3 �'rn
ern
.. moo r";o
� o
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 i141�1(� t .4 �4 / -/4)-U6
Quad No: SIGP{fyTURE OF PERSON CONSTRUCTIN6 ilfWELL :' DATE
Submit original to bivision of Water Quality, Groundwater Section withirL'I0, days
Serial No. {I GW.1 REV. 12199

212196
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] , 11
WELL CONSTRUCTION RECORD WELL CONTRACTOR: lUmes W �aw�A . fir.
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: ( how sketch of the location below) \n j�
Nearest Town. 0.Y/�I1 County: f ✓IC DD'�)�-'I
/s ���
(Rbad Name and Numbers, Community, or Subdivision and Lot No.) DRILLING LOG DEPTH
3. %ir(
4.
5.
6.
7.
B.
OWNER _�l15 Lkl_oKV From To FonnationDescription
Address �gf. EoX (0 3 D _� I ift L)av
tbireetoqU1 o. �gr� 317 Sri,;CD so JZ e rock
e o r
City or Town State Zip Code
DATE DRILLED - S- 00
TOTAL DEPTH
CUTTINGS COLLECTED YES 0 No /g
DOES WELL REPLACE EXISTING WELL? YES® NOEJ 1 ''
STATIC WATER LEVEL Below Top of Casing: _ram FT. ")'a��,
(Use'+' II Above Top of Casing) _z;�
9. TOP OF CASING IS_ I FT. Above Land Surface'
'Top of casing terminated at/or below land surface requires a variance In accor-
dance with 15A NCAC 2C .011a
10. YIELD (gpm): • L METHOD OF TEST ai 1"
11. WATER ZONES (depth):
12. CHLORINATION: Type e a Amount If additional space is needed use back of W,
13. CASING:
Wall Thickness
Depth Diameter or Weight/Ft. atenal
�
FromTo12 Ft. al
Pvc—
From-To Ft.
From To Ft.
14. GROUT:
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
tI�AL)°�
Depth
Materal Method
From
0 To 20 Ft.
}.
Heat Cew exl
From
To
Ft.
15. SCREEN:
J
-
Depth
Diameter
Slot Size Material
.---------
From
To
Ft
in. in.
From
_ To
Ft.
_ in. In.
From
To
Ft.
_ in. in.
16. SAND/GRAVEL PACK:
2(K
Depth
Size Material
i S
bane
From
To
Ft.
n
From
To
Ft.
17
�ySnrlJ��le
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS JCORD HAS BE/�
EN PROVIDED TO THE WELL OWNER,
FOR OFFICE USE ONLY YtLcA_ i " a'Y� I - /" -� -- C
Quad No: SIGNATURE PERSON CONSTRUCTING TH WE DATE
Submit original to Division of Water Quality, Groundwater Section within 30 days
Serial No. GW-I REV. 12/99

2.12200
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: te5 l J' (aMO T
WELL CONTRACTOR CERTIFICATION #: 3
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential LJ Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: M11 r I 0 r county: V—)c
111/SaY� I fl P_ J-
(Road Name and NumbeJrsLCommunity, or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER �GC 11 m 1 '''�. From To Formation Descd Lion
Address o Sg D r�9 dIY 5a
lye � 0 treat or ut _ o. %eo Aaled I
City or Town State Zip Code e9
4. DATE DRILLED " «_U C c
5.
TOTAL DEPTHr 5
6.
CUTTINGS COLLECTED YES Q NO®
_-z
cm
7.
DOES WELL REPLACE EXISTING WELL? YES ❑ NO®
8.
STATIC WATER LEVEL Below Top of Casing: r1p FT.
kD
zEm
9.
(Use': it Above Top of Casing)
TOP OF CASING ISFT. Above Land Surface'
f Me
3
=f
;0m
-Top of casing terminated atfor below land surface requires a variance in actor-
dance with 15A NCAC 2C.0118
10.
YIELD (gpm): �2n METHOD OF TEST
11.
WATER ZONES (depth):
2
12. CHLORINATION: Type 5 Amount 1 C-" If additional space is needed use back of form
13. CASING:
Wall Thickness LOCATION SKETCH
Depth Diameter or WaighuFt.a(erial (Show direction and distance from at least two State
From /—To � Ft.=,�=12� VV�" Roads, or other mip reference points) ^�
From
To
Ft.
MA1lo1`
From
To
FL
I 1
14. GROUT:
Depth
Matedal + etho
chi
From D
To 2 Ft.-RCai
Cemen 1 a
From
To
Ft.
15. SCREEN:
Depth
Diameter
Slot Size Material
\1
lJi tie
SaY
From —To—Ft—
in. —in
From
To —
Ft.
_ in. _ in.
Co
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 Q/ �� /
-� 1y " ' ? _ �-"C
Quad No: SIGNATURE OF PERSON CONSTRU ING E WELL DATE
Submit original to Division of Water Quality, Groundwater Section within 30 days
Serial No. GW1 REV. 12199
E

2.12203
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699.1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION #: 19138,
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (check Applicable sox): Residential1a Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: Pow sketch of the location below)
Nearest Town: Iy10.rIovL rr ,r n County: ///1VIc1/oie?ell
'r06WA. ey oft I)V5Av1Vt)1e `cmn .
(Road Name and Numbers, Community, or Subdivision Lot Lot N� DRILLING LOG DEPTH
3. OWNER VA MI,erK 11E� From To Formation DescnpUT
Address —� �JoX �� pa 0 (oo 54n
kn (Streetor,puce o.) No 3?5' roc -
City or Town State Zip Code + .
4.
DATE DRILLED •-- 1
5.
TOTAL DEPTH
6.
CUTTINGS COLLECTED YES ❑ NO®
7.
DOES WELL REPLACE EXISTING WELL? YES ❑ NO a
rn
8.
STATIC WATER LEVEL Below Top of Casing: qc) FT.
,
(Use'+' It Above Top of Casing)
9.
TOP OF CASING IS FT. Above Land Surface-
3
�o
Top of casing terminated at/or below land surface requires a variance In actor-
O
m?
dance with 15A NCAC 2C .0118
10.
YIELD (gpm): METHOD OF TEST air
11.
WATER ZONES (depth):
F
o
12. CHLORINATION: Type e I a_ s Amount Cu It additional space is needed use back of form
13. CASING:
Depth Diameter
From To o Ft. "
f
14.(
16.
17
Wall Thickness LOCATION SKETCH
or Weight/Ft. Material (Show direction and distance from at least two State
`� �' Roads, or other map reference points) vA'loY�
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 hJ14G Ca'n TY G - S' -D O
Quad No: SIGfJ#URE OF PERSON CONSTRUC ING THE WELL DATE
Submit original to Division of Water Quality, Groundwater Section within 30 days
Sedal No. GWl REV. 12/99

2t2202
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: JatneS 11i. lam�jjTy
WELL CONTRACTOR CERTIFICATION ff: ;2 3
STATE WELL CONSTRUCTION PERM[TJI:
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) �� l�
Nearest Town: n v I'- h County: G o ��-
(Road Name and Numbers, Community, or Subdivision add Lot No.)
3. OWNER __�i teue. Sr 1v'C✓5
Address 1)- 1-7-2
4. DATE DRILLED - - D D
5. TOTAL DEPTH & 0 5
6. CUTTINGS COLLECTED YES Q NOZ
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO®
8. STATIC WATER LEVEL Below Top of Casing: 104,o 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.0118
10. YIELD (gpm): �L METHOD OF TEST Ot I ✓
11. WATER ZONES (depth):
12.
CHLORINATION: Type e a s Amount cu
13.
CASING:
Wall Thickness
Depth
Diameter or Weight/Ft Material
From 0
To 4 0
Ft. - 5 D R -)i �1 L
From
To
Ft.
From
To
Ft.
14.
GROUT:
Depth
Material Method
From U
To Zo
Ft. hea�Ctiy � Z'
From
To
Ft.
15.
SCREEN:
Depth
Diameter Slot Size Material
From —To—Ft—
in. —in _T
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
C 40
Al O boy
DEPTH
Formation Description
—A)'VA 5"ff rock
Cons I dntrd roel
C �
o—�
If additional space is needed use back of form '
LOCATION SKETCH
(Show direction and distance from at least two State C
Roads, oruler map reference points)
1-1 a,,1'%rs:rze
Mar;
I
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.
// DO
FOR OFFICE USE ONLY CIA ^" A) / 6 a^^^ �' � ✓ �" _
Quad No: SIGNATUK� OF PERSON CONSTRUCTING THd WELL DATE
Submit original to Division of Water Quality, Groundwater Section within 30 days
Serial No. GW-1 REV. 12/99

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: 1AMe; �� ' C4( M4 0101+P14me
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check applicable Box): Residential10 Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ It Other, List Use:
2. WELL
(Road Name
3. OWNER _
Address
sketch of the location below)
1 V� County: M Cho We
Subdivision and Lot No.) DRILLING LOG
From To
I - obi 1 `7y AX5-
City or Town State Zip Code
4, DATE DRILLED
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑ NO®K
7. DOES WELL REPLACE EXISTING WELL? YES NO�
8. STATIC WATER LEVEL Below Top of Casing: FT.
(Use'i If Above Top of Casing)
9. TOP OF CASING ISFT. Above Land Surface'
-Top of "sing terminated at/or below land surface requires a variance In accor-
dance with 15A NCAC 2C .0119 1
10. YIELD (gpm): _5� METHOD OF TEST 41 1 Y
11. WATER ZONES (deolh):
12. CHLORINATION: Type G- 5 Amount LU
13. CASING:
Wall Thickness
Depth D�i�9eter or welght/Ft. Taal
FromToFt.L-5722t Py7_
From To Ft.
From To Ft.
14. GROUT:
Depth M to ial M thod
From _ y To AQ Ft, E C� t°rLfi�
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
Formadon Dascnp0on
Ayrt C a
rock
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'Y
� c-
X
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A/C/+Q,� 0,F THIS)IREC1/ORD HAS BEEN PROVIDED TO TH/E'WIELL OWNER.
FOR OFFICE USE ONLYr rtvea w,
Quad No: OF PERS N CONSTR CTING THE WELL T
�u a In to iwz o��Vatpr,� fly, Groundwater Section within 30 days
Serial No. ' J 1 \ l I i 111 GW-1 REV. 12/99
JM 1 9 Kf!0
5-5-Do
It,

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: i /A WIPsk). 61t kitt, (A)M4Ot��
WELL CONTRACTOR CERTIFICATION #; S Sr
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential LIJ Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other 0 If Other, List Use:
2. WELL LOCATION:
Nearest Town: T
3. OWNER
Address
of the location below) n I,
County: /`�Ic Do Vic I
or
DRILLING LOG DEPTH
From To Formation Description
D eAl"'t C a
STD G, C t- D
catty or Town I / Stale Zip Code
4. DATE DRILLED `"T 1 on
5. TOTAL DEPTH 3
6S_
6. CUTTINGS COLLECTED YES ❑ NOW
7. DOES WELL REPLACE EXISTING WELL? YES Q NO®
S. STATIC WATER LEVEL Below Top of Casing: �r _ FT.
(Use'+' II Above Top of Casing)
9. TOP OF CASING IS�_ FT, Above Land Surface'
'Top of "sing terminated Wor below land surface requires a variance In accor-
dance with 15A NCAC 2C.0115
10. YIELD (gpm): 6 METHOD OF TEST Gt-I Y
11. WATER ZONES (depth):
12. CHLORINATION:
13. CASING:
Type Amount u II additional space is needed use back of form
Wall Thickness LOCATION SKETCH
/1 Depth Diamete�r or Weight/Ft. Mara 'al (Show direction and distance from at least two Slate
From6"V'
To �� Ft. -�1L 712P 11 Roads, or other map reference points)
From To Ft.
From To Ft. I`r 1I
14. GROUT:
Depth
�—
M tonal Method
A
From To
Ft..�PCri_
From To—Ft.Ae
j
15. SCREEN:
Depth
Diameter Slot Size Material
r
From —To—Ft—
in. _ In.
From _ To _ Ft.
In. In.
ia..
From _ To _ Ft.
_ in. _ in.
/
16. SAND/GRAVEL PACK:
- Depth
Size Material
c-
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 ✓ - 5 - Od
Quad No: N CO S CTING THE WELL DATE
—r- - .S-.r3 ` ), D ulauAloivioa ality, Groundwater Section within 30 days
Serial No. / r R�__� I+ GW1 REV. 12/9e
JUN ! <, ;

North Carolina - Department of Environment and Natural Resources . Division of Water Quality- Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699.1636-Phone [phone] /,� n
WELL CONSTRUCTION RECORD WELL CONTRACTOR: `-"4)nA We 1) iuln� �o T c
WELL CONTRACTOR CERTIFICATION p:
STATE WELL CONSTRUCTION PERMITN:
1. WELL USE (Check Applicable Box):Residents) L12 Municipal❑ Industrial❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION (how sketch of the location below) „ A n if
(Road Name and Numbers, Comriuoi or subdivision and Lot No.)
3. OWNER
Address
n/1 yree ormute o.
uy we
4. DATE DRILLED
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES Q NO
7. DOES WELL REPLACE EXISTING WELL? YES NO�o
8. STATIC WATER LEVEL Below Top of Casing: FT.
(Use'♦' It Above Top o Cesk ill
9. TOP OF CASING IS FT. Above Land Surface'
'Top of using terminsted at/or below land surface requires a variance In accor.
dance with 15A NCAC 2C .0118
10. YIELD (gpm): ' 10 METHOD OF TEST �h Y
11. WATER ZONES (depth):
DRILLING LOG
From To
In J .X� uJ
Agricultural ❑ Monitoring ❑
DEPTH
Formation Description
Cbm5chda`i`-e YDck
W
12. CHLORINATION: Type ae� Amount L u p It additional space is needed use back of tomes
13. CASING:
m
Wall Thickness LOCATION SKETCH N y
Depth Di t r orWelghtrFt. Matedal (Show direction and distance from at least two SIA o
From To-s'a..Z Ft. 41) P a Me— Roads, or other 'c map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method,
From To .�Ao_FL YlEai" Cemenj
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:
Di ugh"" Stza Material
From CC a DL�
From Ft
17. REMARKS: n us y
I DO HEREBY C TI THAT THI„L F urns cON RUCTED IN ACCORDANCE WII 'H 15A NCAC 2C, WELL
CONSTRUCTIO ST d1t9@!rSf.011sp, COPY OP THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
Ash 'It Re tonal Ofe j
FOR OFFICE USE ONLY d
Quad No: SIGNATURE OF PERSON CO ST CTING THE WELL DATE
Serial No.
1--A Submit o ginal to Division of Water Quality, Groundwater Section within 30 days �,S j J ; 7 1 '}
OW-1 REV. 12/99

Page I of I
North Carolina Departmenr of Environment, Health and Natural Resources
Division of Environmental Management - Groundwater Section
P.O. Box 29535 Raleigh, NC 27626-0535
Phone [phone]
WELL CONSTRUCTION RECORD
Drilling Contractor CAMP'S WELL L PUMP CO., INC.
FOR OFFICE USE ONLY 2,0GS3
Quad. No. Ser. No.
Lat. Long. RO _
Minor Basin
Basin Code
Header Ent. GW-1 Ent.
D,i)ItV Cer�'4RCAApbo 01134, aIIsr Z138
Driller Registration Number 215
State Well Construction
Permit Number
1.
WELL LOCATION: (Shoo sketch of the location below)
County M L Va C !I
Nearest Town M�rcovL-
Depth DRILLING LOG
(Road, Community or Subdivision and Lot No.)
From To Formation Description
2.
OWNER Cvey
0 qo DIRT
ADDRESS Ri. 1 Bax 5' q
Ro CONSOLIDATED ROCK
Ne6, N1 L a?l1.1
— —
3.
DATE DRILLED 1-* 0 - "— USE OF WELL -DOMESTIC
—
4.
TOTAL DEPTH 5a 5
5.
CUTTINGS COLLECTED? NO
o
6.
DOES WELL REPLACE EXISTING WELL? NO
7.
STATIC WATER LEVEL Below Top of Casing: 1 a0 FT.
G.,
o
B.
TOP OF CASING IS I FT. Above Land Surface.
9.
YIELD (gpm) METHOD OF TEST -PUMP
'z
10.
WATER ZONES (depth)
~ 5
m
1t.
CHLORINATION: Type CHLORINE Amount 1 C kp
r
c-
12.
CASING:
—
Wall Thickness
—
Depth Diameter or Weight/Ft. Material
—
From D To 90 ft. 6 1/4 SDR 21 PVC
From To ft.
From To ft.
(Show direction and distance from at least
two
State Roads, or other map reference points)
13.
GROUT:
14
Depth Material Method
From 0. To 20 ft. NEAT CEMENT HAND METHOD
From To ft.
I
14.
SCREEN:
�
Depth Diameter Slot Size Material
/
From To ft. in. in.
From To ft. in. in.
n
;
From To ft. in. in.
' -
15.
SAND/GRAVEL PACK:
Depth Size Material
From To ft.
From To ft.
14. REMARKS:
I,11OHAT, THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONsAUCOOk Sr 9NN gANND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
fi Ml MAR SIGNATURE OF, ONTRACTOR AGENT DATE c�� ",26
6W-1 R�V 9591 Submit origi�at to Divi on of Environment Management and copy to well owner.
1
r
x

1
11636 Mail eervlce Ce ter nt of Environment and Natural Assourcem - Raleigh, N.C. 27990 638 Phone [phone]n of Water Quality • Groundwater Section 'A g 10 4
WELL CONSTRUCTION RECORD WELL CONTRACTOR: Hickory Well Drilling Co.
WELL CONTRACTOR CERTIFICATION N: 2343
STATE WELL CONSTRUCTION PERMITII:
1. WELL USE (Check Applicable Box): RBaldentlal® Munlclpal ❑ Industrial ❑ Agricullural ❑ Monitoring ❑
Recovery ❑ Heal Pump Water In)ecllon ❑ Other [] It Other, List Use:
2. WELL LOCATION: (Show sketch of fire location below) IDS Q11
Nearest Town: Nebo County:
_ hs1 (LmDRd
(road Noma andd Numbers, Community. or Subdldsion and Lot No DRILLING LOG
3. OWNER Ned McGimpsey From To
Address Rt. 4 Box 113 —
ree or ou e o. 28761
Nohn NC
City or Town Slala zip Code
4. DATE DRILLED 08-17-00
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES NOm _
7. DOES WELL REPLACE EXISTING WELL? YES j� NOL)
8. STATIC WATER LEVEL Below Top of Casing: 8U F F.
(Use': It Above Top of Casing)
9. TOP OF CASINO 1972 FT. Above Lend eudece'
'Top of cuing terminated Wor below land surface require$ a votlence In accor-
dance with 115A NCAC 2C.0110
10. YIELD (gpm): _ 8—_ METI IOD OF TEST Ry Air TPSt
I I. WATER ZONES (depllr):
12. CHLORINATION:
13. CASING:
DEPTH
Formation Description
Type h th Tabs Amount 93-- II additional space Is needed use back of form
Wen 1hicknus
Depth Dlamelor or WeIghVFI. Material
p 21"
From �—To �-- Ft. .--- PyC_--- 'Plat'C— S �
Flo[" To Ft.
From —To Pl.—_
14. GROUT:
Depth Malarial Molhod
From 0 To 20 FL . Crout
Flom ---To ----FI' ----------- ----------
IS. SCREEN:
Depth
Diameter
From —To _
Ft _. In.
From —To—Ft.—
In.
From __.. To _
FI. _ Irr.
16. SANDIGRAVEL PACK:
Dept,
Size
From
-
From _— To
R..__
17. REMARKS:_
Slot SIZE Material
In. _
In.
_ In.
Material
LOCATION SKETCH
(Slmw direction and distance from at least two State
Roods, or other map reference points)
41100, N �
y
RV) IZb
NEt10
wl /(w
S
�u� IfuG
cueFEt
pp'
90 �
1 00IIEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITI1 ISA NCAC 2C. WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF TIIIS RECORD HEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY DATE
Ovad No: slot TUnE OF PE SON CO TING TIIE WELL
SvbrrJl original to Division or Water Oueilly roundweler Secllon Wllllln 30 doy9 OW-1 REV. 17/99
Sedal No.

North Carolina - Department of Environment and Natural Resources - Division of Water Duality - Groundwater Section 2 131 85
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELLCONTRACTOR: Hickory Well Drilling Co.
WELL CONTRACTOR CERTIFICATION N: 2306
STATE WELL CONSTRUCTION PERMITrf:
i. WELL USE (Check Applicable Box): Residential® Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ It Other, List Use:
Agricultural ❑ Monitoring ❑
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: Nebo County: McDowell _
John Swafford Road
(Road Name and Numbers. Community. or Subdivlelon and Lot No.) DRILLING LOG DEPTH
3. OWNER John Gillurn/Horton Mottles of 1,101"ga rW To Formation Description
Address PO Box 1837
(Streetor ou a o.
Drexel NC 28619
City or Town Stale ilp Code
4. DATEDRILLED 04_Q0
5. TOTAL DEPTH 245
6. CUTTINGS COLLECTED YES 0 NO®
7. DOES WELL REPLACE EXISTING WELL? YES Q NO®
B. STATIC WATER LEVEL Below Top or Casing: �_ FT.
(Use *.'it Above Top of Coming)
9. TOP OF CASING IS 2 FT. Above Land Surface -
'Top of cuing terminated at/or below land surface requires a variance In accor-
dance With 15A NCAC 2C.0 19
10.YIELD (gpm): METHODOFTEST By Air TeSt
11. WATER ZONES (depth):
12. CHLORINATION: Type HTH Tabs Amount It additional apace Is needed use back of form
13. CASING:
Depth Diameter
From 0 To 9_ Ft.. 61"—
From To Ft.
From To Ft.
14. GROUT:
Wall Thickness LOCATION SKETCH
or Welght Ft. Material (Show direction and distance from at least two State
G a l y• te 1 Roads, or other map reference points)
Depth Material Method
From _0 To 20 Ft. Grollf pollrt—d
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
( lb
/+U/ 7 , 10
C
I DO HEREBY CERTIFY'THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C, WELL
CONSTRUCTION STANDARDS, 7Cty0 THAT A COPY OF THI C(]j#D kA5 rM660 , D TO THE WELL OWNER.
FOR OFFICE USE ONLY 34014f) ACCESS ROAD 05-08-00
Qv#4 No; §IANATVRE OFFE�SC�fft4SWINCTING THE WELL DATE
submit original to Dlvldon)yually„tt agndy9l�r 9eellon wl1h6130 days
6edill No. ` t'., AW-I nEy: t7/ii

North Carolina - Department of Environment, Health, and Neutral Resources
Division of Er virp„ifilnental.Menagement - Groundwater Section
P.O gK*'!95W • Raleigh; N.C. 2702"535
`%��. P, jwna (g18) 733.3221
WECL;CONSTRUCTION RECORD
DRILLING CONTRACTOR: Hickory Well Drilling? Co.
STATE WELL
DRILLER REGISTRATION.NUMBER: 718 PERMIT NUMERNSTRUCTION 208805
:
1. WELL LOCATION(Show sketch of the location below)
Nearest Town: Marion County: - McDowell County
Patton Valley Drive
(Road, Community, or subdivision and Lot No.)
2. OWNER _Neal Mauna
ADDRESS Rt, 3 Rnx 399G
(Street or Route No.)
Nebo NC 28761
City or Town State zip Code
3. DATE DRILLED 03-09-00 USE OF WELL Domestic
4. TOTAL DEPTH JK7—
5. CUTTINGS COLLECTED YES Q NO[n
6. DOES WELL REPLACE EXISTING WELL? YES F--] NO®
7. STATIC WATER LEVEL Below Top of Casing: 50 FT.
(Uso •+' If Above Top of Cuing)
8. TOP OF CASING IS 2 FT. Above Land Surface -
'Casing Terminated at/orbellow land surface Is Illagsl unless a varlonce Is Issued
in accordence with 15A NCAC 2C'.0118
9. YIELD (gpm): JJ METHOD OF TEST By Air Tes t
10. WATER ZONES (depth):
11. CHLORINATION: Type HTH Tabs Amount 54
12. CASING:
Wall Thickness
Depth . Diameter or WeighVFL Material
From 0—To 47 Ft. 6k_ PVC Plastic
From To Ft.
From To Ft.
13. GROUT:
DEPTH DRILLING LOG
From To Formation Description
c:
t�
U
n'
N o
if additional space Is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
N
Depth Material Method
From 0 To 20 Ft. Grout Poured S Lifl
From To Ft.
14. SCREEN: d wv
Depth Diameter Slot Size Material
From To Ft in. in. G s�
From To Ft. In. In. �4E
From To Ft. In. in. /
15. SAND/GRAVEL PACK: U a�� plx t2,9
Depth Size Material
From To —Ft.—
From To Ft.
16. REMARKS:
I DO HERE Y CERTIFYTHAT- SWELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
TION STANDARD ' NO TH�TdSff �Tt{LS RECDRDrHAS BEEN PROVIDED TO THE WELL OWNER.
NAY I U ZLJU 340 1-4J0. ACCESS ROAD INt
P. 0. BOX 4216 03-16-2000
CroundwsixE OR OR AGENT DATE
GW1 REV. Shevd!e• ReRQ�al� Submit original to Division of Environmental Management and copy to well owner.

North Carolina - Department of Environment, Health, and Natural Resources
Division of Environmental Management - Groundwater Section
P.O. Box 29535 - Raleigh, N.C. 27626-0535
Phone [phone]
WELL CONSTRUCTION RECORD
DRILLING CONTRACTOR: Hickory Well Drilling Co.
STATE WELL CONSTRUCTION n R n A
DRILLER REGISTRATION NUMBER: 718 PERMIT NUMBER: , . °4
1. WELL LOCATION• (Fw sketch of the location below)
Nearest Town: 0Y� ort County McDowell
117 Pink Hemphill Rd.
(Road, Community, or Subdivision and Lot No.)
2. OWNER Ralph & Ruth Brown/Salem Homes
ADDRESS 117 Pink Hemphill Rd.
(Street or Route No.)
Old Fort NC 28717
City or Town State Zip Code
3. DATE DRILLED 03-14-00 USE OF WELL Domestic
4. TOTAL DEPTH 325
5. CUTTINGS COLLECTED YES 0 NO®
6. DOES WELL REPLACE EXISTING WELL? YES Q NO®
7. STATIC WATER LEVEL Below Top of Casing: 52— FT.
(Use '+' if Above Top of Casing)
8. TOP OF CASING IS 2 FT. Above Land Surface*
• Casing Terminated alJor below land surface Is Illegal unless a variance Is Issued
In accordance with 15 NCAC 2C .0116
9. YIELD (gpm): t METHOD OF TEST By Air Test
10. WATER ZONES (depth):
DEPTH DRILLING LOG
From To Formation Description
o
r,
r.:
11. CHLORINATION: Type
HTH Tabs
Amount 57
If additional space is needed use back of form
12. CASING:
Wall Thickness
LOCATION SKETCH
Depth
Diameter
or Weight/Ft. Material
(Show direction and distance from at least two State
From 0 To —97 Ft. 1"
PVC: Plastic
Roads, or other map reference points)
From To
Ft. —
From To
Ft.
N
13. GROUT:
3
Depth
From 0 To 20
Material Method
Ft. Grout Poured
`
From To Ft.
14. SCREEN: / ZI
Depth Diameter Slot Size Material w F
cn J(/AI'
From To Ft in. in.
From To Ft. in. in. a Q
From To Ft. in. in.
15. SAND/GRAVEL PACK: all Cr/�GL
Depth Size Material
From To Ft.
From To Ft.
16. REMARKS:
s; `1 DOjHE EBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
STANDARDS, AND �Yvc��F�I���RBPS BEEN PROVIDED TO THE WELL OWNER.
NAi 10 2OW 340 Y1.40 ACCESS ROAD
P. 0. BOX 4216
KC 2M 03-23-00
r ,r, ° coon ORE OF CONTRACTOR OR AGENT DATE
3 -1 ...; � 1 : _ i', Submit original to Division of Environmental Management and coov to well owner.

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section s /" .
1636 Mail Se.vfze Center - Raleigh, N.C. 27699-1636-Phone [phone] Q `� V
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION #: Lk S15
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: (Snow skStch of the location below)
I
Nearest Town: �f �L�'r/ County:
,
Sung' If --Road
(Roadf,lameCommunity, or Subdivision and Lot No.)
DRILLING LOG DEPTH
3.
—annd^Numbers,
OWNER _ l orn fY)
I11cwoe
From To Formation Description
Iq,
Address l`..1G0.•^1iQQ�
—2—.-5� F. _ ,._i_��d Clau
treat or outs D.
Ma( -Ior, N C a8 15a
CSC)
City or Town State Zip Code
cos i 3� ELnn a�
4.
DATE DRILLED to Ito-oo
5.
TOTAL DEPTH 13 a R,
6.
CUTTINGS COLLECTED YES NO[Er
7.
DOES WELL REPLACE EXISTING WELL? YES Q NO[-]
8.
STATIC WATER LEVEL Below Top of Casing: S Q FT.
CE
9.
(Use'.' II Above Top of Casing)
TOP OF CASING IS i In • FT. Above Land Surface'
•� -
_
Top of casing terminated at/or below land surface requires a variance In eccor-
dance with 15A NCAC 2C.0118 y,
161'
.l
10.
YIELD (gpm): 10 METHOD OF TEST �{ /��
-�
11.
WATER ZONES (depth):
12.
CHLORINATION: Type �Table15 Amount • I`'+ I bs
If additional space is needed use back
13.
CASING:
Wall Thickness
LOCATION SKETCH
Depth Diameter or Weight/Ft. Material
(Show direction and distance from at least two State
From O To (P 5 Ft. -(" Q• 31lo )'C-
Roads, or other map reference points)
From To Ft.
From To Ft.
14. GROUT:

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section `- ' 0 ,8 3 7
1636 Mail Seiv.ce Center - Raleigh, N.C. 27699-1636-Phone [phone] J I
WELL CONSTRUCTION RECORD WELLCONTRACTOR:
WELL CONTRACTOR CERTIFICATION #: 30LIS
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: rho,icr� County: mellow ill -
6v40nwood bri.(e
(Road Name and Numbers, Community, or Subdivision and Lot No.) DRILLING LOG DEPTH
3, OWNER From To Formation Description
Address F� iic nim c 7�; v C C) y O V-2c1 LdA `r-`i
beet or Floya o. aC 40 lad blue gr3n142.
Uck lr,-r t1C ba
City or Town State Zip Code
4.
DATEDRILLED
5.
TOTAL DEPTH tea
6.
CUTTINGS COLLECTED YES ❑ NOEEI'
7.
DOES WELL REPLACE EXISTING WELL? YES Er N07
8.
STATIC WATER LEVEL Below Top of Casing: a'g FT.
(Use *+ II 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
(_ METHOD OF TEST 1e
10.
YIELD (gpm):
11.
WATER ZONES (depth):
cn
12.
CHLORINATION: Type Amount-'RS 1b
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
FromTo 45 Ft. 0 31ta `e 0 °s{'G
Roads, or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth
Material
Method
From C To Q0
Ft.
rhea}
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 aO To Lis
Ft.
—
From To
Ft.
17. REMARKS:
I DO HE T YEA T S E S CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTR 0 COPY 0 THIS RECORD HAS BEEN PROVID D WELL OWNER.
-d6
FOR OFFI E Qbl�Y I �('p' l j
Quad No: �r''tt GNATU OF PERSON CONSTRU NG THE WELL DATE
S bmit ginal to Divi on of Water Quality, Groundwater Section within 30 days
Serial No. _ at r section GW-1 REV. 12/99

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section •- LI J v
1636 Mail Sep rice Center - Raleigh, N.C. 27699.1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATI #: e��7
STATE WELL CONSTRUCTION PE IT#:
1. WELL USE (Check Applicable Box): Residential D_�Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
Agricultural ❑ Monitoring ❑
2. WELL LOCATION: how sketch of the location below) �/f
Nearest Town: M/-/ �/d County: - / , ` e iLw J,
a mS2U I ri j f.
(Road Name and Numbers, Community, or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER i •C1�ne( i�[]MSe� From To Formation Description
Address Rnm�E� 3d 4. Re'a Clay
—�5trw a or outs 38 F4. Sand
tAQ-bc V,c. ap,i 38 sR 1:4. Sarcls4cNf,
City or Town State Zip Code
4. DATE DRILLED 16-a_-L p
5. TOTAL DEPTH 126 E4.
6. CUTTINGS COLLECTED YESFI NOD-
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NOD
8. STATIC WATER LEVEL Below Top of Casing: _6Q 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): I q METHOD OF TEST LQ A PE
11. WATER ZONES (depth):
5% lay F+. rarL{2
Ia5 lack F{- G n 4ra� vel
0
M -
12. CHLORINATION: Type "`t` kkf s Amount 13 (cIbL If additional space is needed use back of (oryn � � -
13. CASING:
Wall Thickness
LOCATION SKETCH
Depth Diameter or Weight/Ft. Material (Show direction and distance from at least two State
From �_ To Ft. �,. Cl. 3110 'E`C Roads, or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From To 3,C Ft. r',enT Ctmer<1 2rc_.
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 QO To r g Fl.1ioc �
From To Ft.
17. REMARKS:
X
well
I DO HEREBY CER CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRU S'I±ANDAIIbS T PY O THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFIC ONLY n
Quad No: 11t {' ,,� ?Ou0 SIGNATU OF PERSON CONSTR TING THE WELL DATE
l Su orig at to Divis n of Water Quality, Groundwater Section Within 30 days
Serial No. GW-1 REV. 12199

Nc:rth Carolina - Department of Environment and Natural Reso9rc9e) - D-3221n of Water Quality - Groundwater Section O p 9 9
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone
11 get�
WELL CONSTRUCTION RECORD WELL CONTRACTOR: ghl
WELL CONTRACTOR CERTIFICATION #: �045
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)
fYlal�owe��
Nearest Town: Maa;or'X
County:
rns
✓<ve-
Community, or Subdivision and Lot No.)
DRILLING LOG
DEPTH--
(Road Name and N
ers,
From To
Fonnalion Description
�<zmm�al"'i=�--� _
3. OVJNER --
Address
�v J
}.
Sond
tree 9ut�e o.
City or Town
State Zip Code
S
+�
4. DATE DRILLED 10-;LE-9
5. TOTAL DEPTH 13 1
6. CUTTINGS COLLECTED YES ❑ NO[]a
7. DOES WELL REPLACE EXISTING WELL? YES [✓]� NO[-�
8. STATIC WATER LEVEL Below Top of Casing: FT.. ,r
(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 lSANCAC2C.0118 METHOD OF TEST b¢`12r
10. YIELD (gpm):
11. WATER ZONES (depth):
cn
0
Amount 65 1105- If additional space is needed use back of forrrc
12. CHLORINATION: Type z
13. CASING:
Wall Thickness
Depths Diameter or Weight/Ft.
From To
From To Ft.
From To Ft.
1,
LOCATION SKETCH
Material (Show direction and distance from at least two State
41he,— {+C Roads, or other map reference points)

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
WELL CONSTRUCTION RECORD WELLCONTRACTOR:
WELL CONTRACTOR CERTIFICATION If: a
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (check Applicable sox), Residential Lam" Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ II Other, List Use:
2. WELL LOCATIOM (Show sketch of file location below)
Nearest Town: Z �''� �} - County:
(Road Name anddNumbers. Corn, nity, or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER X Q From To Formation Description
1
Address J ✓O" li-d'�h-n sf � J� It --
-�f-�(STree or ou e o.
City or Town � Slalom Zip Code
4. DATE DRILLED
5. TOTAL DEPTH
6. CUTTINGS COLLEC ED YES CD
7. DOES WELL REPLACE EXISTING WELL? YES r � NO[—]
8. STATIC WATER LEVEL Below Top of Casing: 1 FF. _
(Use'+' If Above Top of Casing)
9. TOP OF CASING IS _ FF. Above Land Surface' t
-Top of casing terminated atlor below land surface requires a variance In accor-
dance with 15A NCAC 2 �0J 18
10. YIELD (gpm): T� METHOD OF N ST 2� _
11. WATER ZONES (depth): N
12. CHLORINATION: Type )A Amount It additional space Is needed use back of 1 ;
13. CASING:
LOCATIOIJ SKETCH
VYall Thickness
Depth OI ele� or VveignVFl, Material (Show direction and distance from at least two Slate
From- c�._TO �`' �'' Ft. c` 'JQ-'—�C- Roads, or other map reference points)
(L�
From To FL^
From To Ft.
14. GROUT:
p©ppt jvlalerlal Method
From To -Ft. �e_!,✓ca,-
From •y To FL
15. SCREEN:
Depth Dlarnelor Slot Size Matorial�Lt-+-d�
From —To _FI In. _in.
From —To _ Ft. _. In. _ In.�/
From _ To _ Ft. _ In. _ In. ;? I (//� z.E
16. SAND/GRAVEL PACK: (!�c-
Deplh Size Material
From To F!.
From To Ft.
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND TIIAT A COPY OPT S RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE IJSE ONLY
Quad No: SI RE OF PERSON CONSTRUCTING THE WELL DATE
fiAjjjbm d al Ion of Water Quality, Groundwater Section within 30 days
Serial No. GW-i REV. 12/99
,'_jl .. '1> 111

North Carolina - Department of Environment and Naluml Resources - Division of Water Quality - Groundwater Section y...i.
1636 Mail Service Center- Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION nECORD WELL CONTRACTOR: A14,
WELL CONTRACTOR CERTIFICR TION R: _
STATE WELL CONSTRUCTION PERMITM:
1. WELL USE (Check Applicable Box): Residential E / Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: fSite w ;; etch of the location below)
Nearest Town:1�-t;�v County: 72lLCJ-.,r;J
(Road Name and Numbers. Community, or Subdivision and Lot Na.) DRILLING LOG - DEPTH
3 OWNER __ �__ ___ From To Formation ()ascription
Address _
—=—�--jg i o or ou a 11
�.ti, c_
City or Town ' / t t' tal�e� Zip Code
A. DATE DRILLED
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES O NULvj
7. DOES WELL REPLACE EXISTING WELL? YE�NO�
B. STATIC WATER LEVEL Below Top of Casing: FT. - -
(Use '+' if Abova Top of Casing) O - -
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.0110 -
10. YIELD (gum): 2 METHOD OAF TTfiST..,yZ-- -
11. WATER ZONES (depth):-
--5
12. CHLORINATION: Type —Amount If additional space Is needed use back of hEhn
13. CASING: — w
Wall Thickness LOCATION SKETCH CD
L_ Depth Diarnelor orweight/Ft. Material
(Show direction and distance from at least two State --]
From L" To -- Ft. fir—_ 1— Roads, or other map reference points)
From— To
From To FL
14. GROUT: /,z,Q,
r; Depth f.laloilai Method (ti� Z-� p� 2
From =-o To 1 Ft. _ �,d-. ti'�•LL' 000
From To Ft. _
15. SCREEN:
Depth Diarnelor
From —To _ F1 _ In.
From To Ft. _ In.
From —To _ Ft. It1.
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 CONSTRUCT
CONSTRUCTION STANDARDS, AND TI IAI A COPY OF THIS
Quad No:
Serial No.
-Jl
to
Zi �
IN ACCORDANCE WITH 15A NCAC 2C, WELL
'ORD HAS BEEN PROVIDED TO THE WELL O
OF PERSON CONSTRUCTING THE WELL
of Water Duality, Groundwater Section within 30 days
DATE
GW 1 REV. 12/99

North Caroline - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mall Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION #: �d 3
STATE WELL CONSTRUCTION PERMIT#:
WELL USE (Check Applicable Boxy Residential (� Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other If Other, List Use:
2. WELL LOCATION: (Sh sketch of the location below)
Nearest Town: , 1 aA� County: Zzz.
Numbers. Cor�,Tunlly, or
3. OWNER
Address
4. DATE DRILLED
5. TOTAL DEPTH
6. CUTTINGS COLL CTED YES ❑ NOQ--
7. DOES WELL REPLACE EXISTING WELL? YES Q ; NOE]—
8. STATIC WATER LEVEL Below Top of Casing:t fyt� FT.
(Use -: it Above Top of Casing)
9. TOP OF CASING IS___/_— FL Above Land Surface'
'Top of casing terminated attor below land surface requites a vedance In accor-
dance with 15A NCAC 2C 119
10. YIELD (gpm): METHOD OF "(E$T
11. WATER ZONES (depth):�,/.
12. CHLORINATION:
13. CASING:
Agricultural ❑ Monitoring ❑
DRILLING LOG DEPTH
From To Formation Description
TypeAmounK� it additional space Is needed use back of
Wali Thickness
r-. ___ Depth ..�� Dla`�wler cr WeighVFL
From",�F 2To — 1 Ft.
aledal
From To Ft.
From To Ft.
14. GROUT:
Depth talorial
Melhod
From •�— To �Ft.
From To FI.
15.SCREEN
Depth
Diamatar
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
Slot Sizr' Material
In.
_ In.
_ in.
Material
GO
LOCATION SKETCH
(Show direction and distance from at least two Slate
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 05THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FFOR OFFICE USE:ONLY]
ad No:rial No. )
S ATURE OF PERSON CONSTRUCTING THE WELL DATE
JI p o n o v silly, Groundwater Sectlon within 30 days
I GW.I REV. 12r99

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mall Service Center - Raleigh, N.C. 27699-1636-Phone [phone] t
WELL CONSTRUCTION RECORD W
WELL CONTRACTOR CERTIFICATION
/
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): ResidenllalEr Municipal ❑ Indusirlaf ❑
Recovery ❑ Heat Pump Water Injection ❑ Other rl If Other, List Use:
2. WELL LOCATION:(S how skgtch of the location below)
Nearest Town: I County -�
(Road Name and Numbers, Cornrnu,nu or
3. OWNER
Address
2
City or Town State Zip Code
4. DATE DRILLED
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES F—] NO[E�y
7. DOES WELL REPLACE EXISTING WELL? YES NOQ
6. STATIC WATER LEVEL Below Top of Casing: M_ 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 2CA118
Agricultural ❑ Monitoring ❑
DRILLING LOG DEPTH
From To Formation Description
C7
J.7
-
10. YIELD (gpm): 2 k)_ METHOD OF
11. WATER ZONES (depth): rE-2 y "�
12. CHLORINATION: Type—AmounIf additional space is needed use back of form
13. CASING: _
Wall Thickness LOCATION SKETCH
Depth DIelar or Welghttlft MateAyl (Show direction and distance from at least two Stale
From —To — Ft. Roads, or other mama re polnis)
From To Ft. —
From To Ft.-
14. GROUT:
Depth �-1Ma�tterial ,, Method
From To �Ft.
From —ToFI.
15. SCREEN:
Depth Diameter
From _ To _ Ft _ In.
From _ To _ Ft. _ It'.
From _ To _ Ft. _ Lt.
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 ISA NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY- - - • - - b` C- ��'P� ��
Quad No: n 0'(1 n v �� i! SIpNA RE OF PERSON CONSTRUCTING THE WELL DATE
4' O —Subnll original to Division of Water Quality. Groundwater S a S
Serial No.
APR 10 2000 (; D
asnTsxt:

NORTH CAROUNA DEPARTMENT OF NATURAL RESOURCES AND COMMUNITY DEVELOPMENT
DIVISION OF ENVIRONMENTAL MANAGEMENT - GROUNDWATER SECTION
P.O. BOX 278117 - RALEIGH,N.C. 27611, PHONE [phone]
WELL CONSTRUCTION RECORD
FOR OFFICE USE ONLY
Quad. No. Serial N"p.
Lat. Long. PC —
Minor Basin
Basin Code
Header Ent. GW-1 Ent.
DRILLING CONTRACTOR L C - /<
STATE WELL CONSTRUCTION
DRILLER REGISTRATION UMBER PERMIT NUMBER:
1. WELL LOCATION: (Show sketch of the location below)
Nearest Town:`'
(Road, Community,
or
Subdivision and Lot
No.)
2. OWNER
ADDRESSi
(Street or ?- C.
'�9 fl7�Z
City or Town State Zip Code
3. DATE DRILLED 6** USE OF WELL � ',
4. TOTAL DEPTH �n CUTTINGS COLLECTED ❑ Yes 8-No
5. DOES WELL REPLACE EXISTING WELL? 'Yes ❑ No
6. STATIC WATER LEVEL: FT. ❑ above TOP OF CASING,
❑ below
TOP OF CASING IS FT. ABOVE LAND SURFACE.
7. YIELD (gpm): Ak pMET/IJOD OF TEST 4J
8. WATER ZONES (depth): O QLC;
9. CHLORINATION: Type Amount ==�/
10. CASING:
Wall Thickness
Depth Diameter
or Weight/Ft. Material
From � To Ft. -L�C
From To Ft.
From To Ft.
11. GROUT:
Depth Material Method
From To,2 O Ft.
From To Ft.
12. SCREEN:
Depth Diameter Slot Size Material
From To Ft. in. in.
Fr,1m To Ft. in. in.
From To Ft. in. in.
13. GRAVEL PACK:
From
From
14, REMARKS:
I DO HER
STANDARI
GW-1 Revised 11/84
Material
GEB1LEY .THA.T_IriSS WELL WAS C,
AND THAT'A COPY:OF. THIS RECORD
Fst„
County:'tek µ"' 4d&
Depth DRILLING LOG
From To Formation Description
7;
CD
If additional space is needed use back of form.
LOCATION SKETCH
(Show direction and distance from at least two State Roads,
or other map reference points)
�� O - j�
TED IN ACCORDANCE WITH 15 h
V PROVIDED TO THE WELL OWNER.
0 JLXLM�R-nL
11
SIGNeURE OF CONTRACTOR OR AGENT DATE
Submit original to Division of Environmental Management and copy to well owner.

North 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: 4 n z",
WELL CONTRACTOR CEATION #:
STATE WELL CONSTRUCTION PERMIT#: J? ef
1. WELL USE (Check Applicable Box): Residential0" Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: SS qw sk tch of the location below)
Nearest Town:— [ -BEd, County:
Agricultural ❑ Monitoring ❑
(Road Name and Numbers, Commu dry, or SubdiNsion and Lot No.)
DRILLING LOG DEPTH
3.
OWNER
From To Forma:m Description.
Address ,Z
c
trees r use
—-"
City or Town Statef Zip odZ a
4.
5.
DATE DRILLED 22-_ \�
TOTAL DEPTH K,3-
--_
6.
CUTTINGS COLLECTED YES Q NO[`�
7.
DOES WELL REPLACE EXISTING WELL? YES NOEr
-'
8.
STATIC WATER LEVEL Below Top of Casing: �— FT.
�
o
m
(Use'+' It Above Top of Casing)
C_n
-i
9.
TOP OF CASING IS�_ FT. Above Land Surface'
o
'Top of casing terminated at/or below land surface requires a variance In accor.
dance
with 16A NCAC 2C 011e
10.
YIELD (gpm): 1� METHOD OF TF�ST
11.
WATER ZONES (depth): t¢
12.
CHLORINATION: Type CC22z� • Amount
It additional space is needed use back of fcum
13. CASING
Wall Thickness
Depth
Fromm To 2
Diameter o WeighVFt. Material
Ft.
From To
Ft.
From To
Ft.
14. GROUT:
Depth
Material Method
From �� To ?—Ft.60AAZ--�-
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.
LOCATION SKETCH
(Show direction and distance from at leas: two Sale
Roads, or other map ree`erence points)
All"
J���' �� all �2
r;t
16. SAND/GRAVEL PACK: (p? a 17
Depth Size Material
From To Ft.
From To Ft. 1AM - 3 W
17. REMARKS: I J
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC PC,
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO TH-
--
FOR OFFICE USE ONLY e_ , //G� 1 3-,24_ 6--�
Quad No: 19IGNATURE OF PERSON CONSTRUCTING THc WELL Os.1E
Submil original to Division of Water Duality. Groundwater Sscon within 30 d2ys
Serial No. , .) /L Gn.l F�ev. 12v3

NORTH CAROLINA DEPARTMENT OF NATURAL RESOURCES AND COMMUNITY DEVELOPMENT
DIVISION OF ENVIRONMENTAL MANAGEMENT - GROUNDWATER SECTION
P.O. BOX 27687 - RALEIGKINLC. 27611. PHONE [phone]
WELL CONSTRUCTION RECORD
FOR OFFICE USE ONLY[lp.(� p (� (?
Quad. No. Serial l l () 0 0
Lat. Long. Pc —
Minor Basin _
Basin Code
Header Ent. GW-1 Ent.
DRILLING CONTRACTOR ) C . �L �W
yp� STATE WELL CONSTRUCTION
DRILLER REGISTRATION NUMBER �/J �� PERMIT NUMBER:
1. WELL LOCATION: (Show n sketch of a allocation below)
Nearest Town: Jll3'L7- County: Ael' �;2 t`Jd_z6
(Road, Co unity, or Subdivision and
� Lot No
2. OWNER ��-?.�Glta , a- AC- &d)
ADDRESS '6� X (;
3 i (Street or Route �)
City co�r Town State Zip Code
3. DATE DRILLED 3 d , n T� USE OF WELL
4. TOTAL DEPTH ? SIX CUTTINGS COLLECTED ❑ Yes BTdo
5. DOES WELL REPLACE EXISTING� WELL? ❑ Yes 9-iTo
6. STATIC WATER LEVEL: FT. O above TOP OF CASING,
❑ below
TOP OF CASING IS-L FT. ABOVE LAND. Uff ACE.
7. YIELD (gpm): A�; METHOD OF TEST
8. WATER ZONES (depth):
Depth DRILLING LOG
From To Formation Description
O
O
n
c"
<ri
ID
r-i�
N
i
W
o
9. CHLORINATION: Type "-"knn�� Amount /tor
10. CASING: ' If additional space is needed use back of form.
Wall Thickness
Depth Diameter or Weight/Ft. Material LOCATION SKETCH
From To a56- Ft. !�__-_�.. � (Show direction and distance from at least two State Roads,
From To Ft. or other map reference points),c. &.1-Cy��/
From To F t.
11. GROUT: Depth Material Method
From L-C� To,-:?-LFt. 1 _ ��
From SSS To Ft. (/�/��,
12. SCREEN: P
Depth Diameter Slot Size Material
From To Ftin. in. /� ✓ / /�
Fr3m To Ft. in. in. y �g �f�.�J,-��-�/�t� CI�L
From To Ft. in. In.
1
13. GRAVEL PACK: -d-
Depth Size Mated;
From To Ft. n.
From To Ft. IUJI
14. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTR E $pANCE-Wil 15?NCAC 2C, WELL CONSTRUCTION
STANDARDS, AND THAT A COPY OF THIS RECORD HAS N P OVIDED1T04jHE,WELL OWNE
Ash?v l!
SIGNATU4 OF CONTRAC OR OR AGENT DATE
GW-1 Revised 11/84 Submit original to Division of Environmental Management and copy to well owner.

NORTH CAROLINA DEPARTMENT OF NATURAL RESOURCES AND COMMUNITY DEVELOPMENT
DIVISION OF ENVIRONMENTAL MANAGEMENT - GRWNDWATER SECTION
P.O. BOX 27687 - RALEIGH,N.C. 27611, PHONE [phone]
WELL CONSTRUCTION RECORD
FOR OFFICE USE ONLY (n�
Quad. No. Serial
Lat. Long. Pc
Minor Basin
Basin Code
Header Ent. GW-1 Ent.
DRILLING CONTRACTOR d • C . LC e eCAJt _
STATE WELL CONSTRUCTION
DRILLER REGISTRATION NUMBER 3 PERMIT NUMBER:
1. WELL LOCATION: (Show sketch
�
sketch of the location below) )�//�
Nearest Town: CS�f � -L' �.) County: h /��� (-'�
(Road, Community or Subbddiyiission and Lot No.) �+J
2. OWNER A w (�LO�'J9.', f._� �/%''
ADDRESS �. - gyp Id %
Street or Route No.)
" �594e-
C Town 7� State Zip Code
3. DATE DRILLED '� d - USE OF WELL
4. TOTAL DEPTH _�G _ CUTTINGS COLLECTED ❑ Yes EffNo
S. DOES WELL REPLACE/ EXISTING WELL? ❑ Yes B-No
6. STATIC WATER LEVEL: �� a FT. ❑ above TOP OF CASING,
❑ below
TOP OF CASING IS FT. ABOVE LAND SURFACE.
t
7. YIELD (gpm): --E3 / 1METHOD OF TEST
8. WATER ZONES (depth): D)f� A
9. CHLORINATION: Type C- T Amount
W. CASING:
Wall Thickness
Depth Dia/meterr or Weight/Ft. Material
From 96-- .� Ft.
�1 �
From To Ft.
From To Ft.
11. GROUT:
Depth Material Method
From To.,-IFt. e �
From To Ft.
12.SCREEN:
Depth Diameter Slot Size Material
From To Ft. in. in.
FrJm To Ft. in. in.
From To Ft. in. in.
13. GRAVEL PACK:
Depth Size Material
From To -Ft. -
From -To- Ft.
14 REMARKS:
Depth DRILLING LOG
From To Formation Description
0
0
�r
�
c-
If additional space is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least
two State
SttaatteJRoads,
or other map reference points)
C
rWR2 0 loon 1 i IJ
4z 'Q
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15rNCAG- gWWELL"CONSTf 1C:iION
STANDARDS, AND THAT A COPY OF THIS RECORD HA� BEEN PROVIDED TO THE WELL OWNER.
SIG TURF OF C6NTRACTOR OR AGENT DATE
GW-1 Revised 11/84 Submit original to Division of Environmental Management and copy to well owner.

NORTH CAROUNA DEPARTMENT OF NATURAL RESOURCES AND COMMIRMTV DEVELOPMENT
DIVISION OF ENVIRONMENTAL MANAGEMENT - GROUNDWATER SECTION
P.O. BOX 27687 - RALEIGH,N.C. 27611. PHONE [phone]
FOR OFFICE USE ONn ry 9
Ouad. No. Serial No.
Lat. Long. PC
Minor Basin
WELL CONSTRUCTION RECORD I Basin Code
Header Ent. GW-1 Ent.
DRILLING CONTRACTOR C
STATE WELL CONSTRUCTION
DRILLER REGISTRATION NIJMBER ,�8 PERMIT NUMBER:
1. WELL LOCATION: -(Show� sketch of the location below)
Nearest Town: .fli(i Ca%L!�z- _ County: ,
(Road, Communit Yor Subdivision and Lot No.)
2. OWNER
ADDRESS
(Street Q940ut
City or Town State Zip Code
3. DATE DRILLED USE OF WELL q if
4. TOTAL DEPTH CUTTINGS COLLECTED ❑ Yes ❑ No
5. DOES WELL REPLACE EXISTING WELL? ElYes '8-No
7
6. STATIC WATER LEVEL: r7 22 FT. ❑ above TOP OF CASING,
❑ below
TOP OF CASING IS FT. ABOVE LAND URFACE.
7. YIELD (gpm): � /METHOD qF TEST
8. WATER ZONES (depth):
9. CHLORINATION: Type Amount
r
Depth DRILLING LOG
From To Formation Description
10. CASING:
�z"
Wall Thickness
If additional space is needed use back of fern.
Depth Diameter
or Weight/Ft.
Material
From
j— To '2-L Ft. l@
LOCATION SKETCH
(Show direction and distance from at least two State Roacs,
From
To Ft._
or other map reference points)
From
To Ft.
11. GROUT:
Depth Material
From
'T*—Toyztll Ft.
From To Ft.
12. SCREEN:
From
From
From_
13. GRAVEL PACK:
14.
GW-1 Revised 11/84
Depth Diameter
- To Ft.
_ To Ft.
_ To Ft.
Method
Slot Size Material
in. in.
in. in.
in. in.
�otlj R I�� Size
Al {,aP
THAT THIS WELL WAS
Y OF THIS RECOI
Material
TNCTED IN ACCORDANCE WITH 15 NCAC 2C, WELL CONSTRUCTION
EN PROVIDED TO THE WELL OWNER.
24
JRE OF C�& AGENT DATE
original to Division of Environmental Management and copy to well owner

NORTH CAROLINA DEPARTMENT OF NATURAL RESOURCES AND COMMUNITY DEVELOPMENT
DIVISION OF ENVIRONMENTAL MANAGEMENT - GROuNDwATER SECTION
P.O. BOX 27687 - RALEIGH,N.C. 27611. PHONE [phone]
WELL CONSTRUCTION RECORD
FOR OFFICE USE ONLY
Quad. No. Serial K10 O 7'0
Lat. Long.
Minor Basin
Basin Code
Header Ent.
DRILLING CONTRACTOR LI C do
STATE WELL CONSTRUCTION
DRILLER REGISTRATION NUMBER z k-n 3 PERMIT NUMBER:
1. WELL LOCATION: (Show sketyh of the location below)
Nearest Town: _/�iLr) County:
(Road, Community. or Subdivision and Lot Neon)
2. OWNER /�LC CM j// 0 - i _W �I '.,04
ADDRESS le?7
[Street or FIT No
O�le�st 1/
City or
Town State Zip Coae
3. DATE DRILLED �r�- / \ USE OF WELL I-n jaLe _,/Z
4. TOTAL DEPTH CUTTINGS COLLECTED ❑ Yes G-No
5. DOES WELL REPLACE EXISTING WELL? Et -Yes ElNo
6. STATIC WATER LEVEL: FT. FT. ❑ above TOP OF CASING, -
❑ below
TOP OF CASING IS FT. ABOVE LAND SURFACE. -
7. YIELD (gpm): G METHOD OF TEST
8. WATER ZONES (depth): 6 t'� a ./e�
Depth
From To
Pc
GW-1 Ent.
DRILLING LOG
Formation Description
8
G
N
c
ra
9.
CHLORINATION: Type h=F Amount
10.
CASING:
Wall Thickness
If additional space is needed use back of form.
Depth Diameter or fight/Ft. Material
e- "" �� ff r
Fromt� To � Ft.�._ L,P' -�_C
LOCATION SKETCH
(Show direction and distance from at least two State Roads,
From To Ft.
or other map reference points)
From —To—Ft.-
p
11.
GROUT:
7 A111
-{. Depth Material Method
From To-21—Ft.��
From �TTT To Ft.
12.
SCREEN.
Depth Diameter Slot Size MaterialFrom
To Ft. in. in.
(/ 1✓-�"� „" r/.1
From To Ft. in. in.
From To Ft. in. in.
13.
GRAVEL PACK:
Depth Size Material
From To Ft.;:.
p
(u� R M j, FL
au Lam: I
A
EMA . -U
MI
���,nprV�Ae 8uu
' THAT THISCAC 2C, WELL CONSTFA)CTION
UCTED IN ACCORDANCE 'EO
--STANDAA 1 I T A
OF THIS RECORDOHS BEEN
COPY PROV
THE WELL OWNER.
Croundwater Section SIGN URE OF CONTRACTOR OR AGENT DATE
Asheville Regional Once
GWRe4ise�t
T 1—" /84- Submit original to Division
of Environmental Management and copy to wer owner.

To DENR DIVISION OF WATER QUALITY, GROUNIFromALAN S. GANTT 828-286-8787 12/26/00 7'. 2028 Page 6 of 10
Sent by the Award Winning Cheyenne Bitware
North Carolina- Department of Environment. and Natural Resources- Division of Wahr Quality- Groundwater Section z' `i 2'7'7f
1636 Mail Service Center - Raleielk N.C. 27699-1636- Phone [phone]' 1
g'•'" 1 c7
WELL CONSTRUCTION RECORD NVELL CONTRACTOR: CAROLINA WELL DRILLERS- INC
WELL CONTRACTOR CERTIFICATION # : 2584
STATE WELL CONSTRUCTION PERMIT # :
L WELL USE (Check Applicable Box): Residential ❑ Nfurucipal ❑ Industrial ❑ Agicullmal ❑ Monitoring ❑
Recovery ❑ I [eat Pump Water Injection ❑ Other ❑ If Other. List Use
1, WELL LOCATION- (Show sketch of the location below)
N.icst lawn: NEBO Cm ... 0, NeDOW'LLL
RT I BOX 388G LIS IIWY r'b
(Road, Commumtrc, or Subdivision and Lot No.l
3, OWNER JAMES KIRBY
ADDRESS RT 1 BOX 388G
(Sa—t o, Rowe No.)
NEBO NC 28761
GO' ar Taa.+t state ZiP code
4. DATE DRJLLED 11/ti/00 USEOFWELL RESIDENTIAL
5. TOTAL DEPTIJ ISO
6. CUTTINGS COLLECTED YES ❑ NO EJ
7. DOES WELL HTPI.ACE P:XIS'I ING WELL? YFS ❑ NO ❑x
I. STATIC WATER LEVEL Below Top of Cain, 41 FT.
(Use If Above Top or C'sitgl
9. TOP OF CASING IS ? FT. Above Land Smfare'
`Casing Tcnrwutad mior bdo.v Ivul nu face i, Jlegal mJsu a vmimuc is issued
m amordvtca w flt 15A NC AC 2C' .0118
to. ATELD (Rpm): 20 NIE LIOD OF TEST ARDM
ii. WATER ZONES Wtjah)- 41 152 170
DEPTH
FROM U
0 24
21 ISO
DRILLING LOG
Formation Description
CLAP
CONSOLIDATED ROCK
0
CD
p
r
rn
n
ern
N
c<
t/r i
O
Z
12. CHLORLNAT[ON'. T.1 FD POCHLORI I'E Amount 5 OZ. If add'nionW sya.. is naad<d n,e back of form
13 CASING : LOCATIONSKETCH
Wall Tllickrless (Show direction and distance from at least two State
Depth Dimneter of Weight Ft. Material Roatls_or other neap refem\ce Points)
From 0 To
la. GROUT:
Depth
30 FI. 61/4" SDR21 P%C
From 0 To 20 Ft.
15. SCREEN
Depth Dimneter
From NA To Ft.
R,SAND:GRAVEL PACK:
Uryth
Front NA To P.
I7. RENLd S —
Afita ial McWod
SAND MIX GRAVITY
Slot Size nUterial
n. in.
Size Material
TO RUTHERFORDTON
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED LN ACCOR.DANCE WfIH 15A NCAC 2C. WELL
COYSTRUC`ITON STANDARDS, ANT) TI IAT A COP}- OF TI RS RECORD i IAS BLEN PRO\TIDED TO TTIT WTLi. OW'NT.R.
FOR OFFICE USE ONLY
Quad No. I, J:A_.___...._
Serial No, li fi L� I.
6S�
PERSON CONSTRUCTING T[IE WELL
nsion of Wma Quality, Grow1ds10¢1 Senion witUt 30 Days
US 226 1 j MI
US 64
11114f00
Date
GNI ItEV. ❑.99

To. DENR DIVISION OF WATER QUALITY, GROUN[From: ALAN S. GANTT 828-286-8787 12/26/00 7'.19:44 Page 5 of 10
Sent by the Award Winning Cheyenne Bitware
' !_ `/ %�
North Cir olina -Department of Environment. and Natural Resources - DNlblou of WmaQuality- GroundwaterSection
1636 Mail Service Cents' - Raleigh, N.C. 27699 - 1636 - Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: CAROLINA «'ELL DRILLERS. INC
WELL CONTRACTOR CERTIFICATION # : 2594
STATE WELL CONSTRUCTION PERMIT # :
1. WELL USE (Check Applicable Box) : Residential ❑ Municipal ❑ Industrial ❑ Agiculluial ❑ Nfolliholing ❑
Recovel}. ❑ I feat Pump Water Injection ❑ Other ❑ If Other, List Use'.
2_ WELL LOCATION- (Show sketch of the location 1I
Nona,'t town: MARION Cmmh': McDOWLLL
68' HIDDEN. ACRES RD.
(Road, Couummity, or Subdivision and Lot No_) DEPTH
3. OWNER JERRY GENTRY FROM TO
ADDRESS 687 HIDDEN ACRES RD
61-1 o Rm1<N..1 0 102
MARION NC
City or lbwn Stalc 7.ip Code
4. DATE DRILLED 10/24/00 USE OF WELL RESIDENTIAL
S. TOTAL DEPTH 340
6. CUTTINGS COLLECTED YES ❑ NO (]
Z UUI!R WI'.LI. ILP:PLACP: FXIS'I'IN(1 lvliLl:? YES Q NO
8, STATIC WATER LEVEL Below Top of Ciiing'. 80 FT.
(LT, v" If Abov< Top of Cesar,)
9. TOP OF CASING IS 2 FT. Above Land Swface'
'Cas61g Tartmmmd ar., bdow Ivtd sudaw is Jkgil mdaac a vamm� is issu<d
in accordmm<with 15A SCAC 2C 0118
10, YIELD(apm): 20 =0D OF TEST ARD%f
LI. WATER ZONES QIeIIlIQ: I2: 335
12-CHLORINATION: T)pc
13 CASING
Depth
From 0 To
W. GROUT:
u
102
DRILLING LOG
Formation Description
CLAY
CONSOLIDATED ROCK
V
O
�
cry
J
o<
= m
Sao
r0
m�
M
cf1
+
Z
HYPOCHLORI I Amount 8 OZ. If oddltional spea< a n«d<d „< 8e<k uffom,
LOCATION SKETCH
Wall TLicknese (Shmc direction and diataae from at least two State
Dianeter or WeiyJNFt. Nlatu'ial Read,, or other nrap ret'erencepointsl
112 FL 61;-I " SDR 21 PVC MONTFORD
COVE RD
Depth
From 0 To 20 Ft.
I5, SCREEN
Depth Dianeter
From NA To Ft.
16. $.A:NEGRAVEL PACT::
Depth
From NA To Ft,
1-. RE\!ARKS:
Nlaterial Method
SAND NTIS GRAVITY
Slot Size Material
in. in.
Sire Mmcrial
SLGAR HILL PD
NDF,N ACRES RD
F687
1-40
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC X. WELL
CONSTRUCTION STANDARDS, AND TT IAT A COPY OF THIS RECORD I FAS BEEN PRO%TDF.D TO TIFF WT.I J, OW NT.R.
FOR OFFICE (
Quad No.
Serial No. - _ 8
6S4
CONSTRUCTING 7111E WELL
ate Qtu6ty. Grotmdwater section widw 30 DO,
I2/26100
Date
cw_I Rev. t2 v9

To. DENR DIVISION OF WATER QUALITY, GROUNIFrorn ALAN S. GANTT 828-286-8787 12/04/00 20 28.16 Page 4 of 11
Sent by the Award Winning Cheyenne Bitware
North Cant ina - Dgmrtuent of Erin ottmmilt. and Natural Resources -Division of WatnQuality - GroundwaterStation �. 21254
1636 Mail Setcice Center- Raleivft, N.C. ]'699 - 1636 - Phone [phone]
KNELL CONSTRUCTION RECORD WELL CONTRACTOR: CAROLINA IN -ELL DRILLERS, INC.
WELL CONTRACTOR CERTIFICATION M : 2584
STATE IN -ELL CONSTRUCTION PERMIT N :
I. WELL USE (Check Applicable Box) : Residential ❑ hlmuciPul ❑ Indushial ❑ AiziculturM ❑ htolutotutg ❑
Recoeeq ❑ I feat Pump Water Injection ❑ Other ❑ If Other, List Use.
2i WELL LOCATIOS_ ( Show slarh oC the loration below)
Ncarc.t¢awn' NIARION tbunty'. klcDO\4'ELL
SPRING HILL RD. TRACT bl
(Road, Cotmnunity, or Subdivieion mid Lot No)
3.OWNER PIKE DAMS
ADDRESS 119 LOCUST COVE RD
6ea1ai Ruute No_)
MARION NC 28'S2
City of Tmra State %ip Code
J. DATE DRILLED 9,'l 00 USE OF WELL RESIDENTIAL
3. TOTAL DEPTH 160
6, CLRTNNGS COLLECTED TITS ❑ NO Ftj
'_D(WS WOT, RI`:PIACI`: P:AS I NO%V[fH,I T'hS ❑ ]O ❑
8. STATIC RATER LEVEL Below'fop of Casing: 'I FT.
(Lv, *' IfAb ,v Top or C'a,utg)
9. TOP OF CASING IS I
2 FT. Above Lund Swfoce'
-Csos Tanww¢d of., b&,v Iwtd.... Jl,zd,.Jere_ a wnmxa a eamd
to o.wrdvta< will 13A NCAC' SC .0118
to. 1-IELD(eptru 25 METHOD OF TEST ARD%T
it WATER ZONES (delaln. I ij
DEPTH
FROM U
s2
160
u.CHI.ORINATION'. Type HT'POCHLORI'I'E Amount 4 OZ. If.adaeionw.ya<.i: �t«a.a ��;, bo.k of ro..
13. CASING' LOCATION SKETCH
Wall Tllickttess (Show direction and distance from at least live State
Depth Diuneter oiReiWaTt. Material Roods_ al other nwp refa'encepoiursl
DRILLING LOG
Formation De,nriplion
CLAY
CONSOLIDATED ROCK
C2
O
�
m
n
Cn
zt m
From 0
14 GROcr:
To
g; Fr 6 I' l SDR 21
PVC
1-40 FAST
Depth
Material
Pfethod
From 0
To
20 Fr SAND MIX
GRAVITY
'_ N4I.
I,, SCREED:
SUGAR HE RD
Depth
Diwne(er Slot Size
blarerial
Frotn NA
To
Fr. in.
in.
SPRIING InL RD.
16, SAND-GRAbEL PACE:
Depth
Size
Material
From NA
To
Ft,
I7. RENIAMZ1 S'
1 DO HEREBY CER'FIFT' THAT THIS WITLL 16'AS CONSTRUCTED LN ACCORDANCE %4TFH ISA tN'CAC'C. W'ELI.
CONSTRI:(TION STANDARDS, AND TI CAT A COPY OF TTUS RECORD HAS BEIN PROWTDRD TO TI M WELL OWNER.
a
r
im�
nlueeen
,,
LI 9�� i�� 12,04'00
.SIGNATURE OF PERSON CONSTRUCTING TI Is WELL Date
ppb6m a' d ro Diri.iou of W e,, Quality G d arcr Sca..n will., O Da..
673
ndwder Section
Asheville Repionsl 0ffce_�

To DENR DIVISION OF WATER QUALITY, GROUN(From. ALAN S. GANTT 828-286-8787
Sent by the Award Winning Cheyenne Bitware 09/25/00 20.52:06 Page 4 of 11
North Darohria - Doj,a ... mt ofnvirorrriert. I Iealtli and Natrtal Rewourre,
Division of Ems m miol 1fanagernertl- Groundwater Section
P. O. Box 29535 R,doodr.S.C. 26'_6-053s
Phase(919)-11;-3 21
218014
FOR OFFICE (lSE ONLS
QUAD. NO. _ SERLV. NO. _
Lat. Lon..
\lira, Basin _
Basin Code--' --
Haado'EW. G4b'd
IN ELL CONSI RI CTION RECORD
DRILLING CONTRACTOR: CAROLINA WELL DRILLERS INC.
STALE IITLI, CONSTRUCTION
DRILLER REGISTRATION NUMBER: 180-
PERMIT NUABER:
I. WELL LOCATION: (Show sketch of the location bdow9
h'cm'est trnm- MARIOS County
\IeDO\NELI.
KNOB HILL ESTATES LOT L
(Road Corruminiry, or Subdivision mtd Lol No.)
z. OWNER RILL FEI2ASZOC
DEPTH
'.
DRILLING CGIZ
FROM TO
Pmnlahor, DC Cuphon
ADDRESS19_0 US IRl } ; a R} PASS
15rc<n ar Rance Fa)
0
FOREST CITI" NC 2801Z
_g
SO
cL.AY
—
—0Cf
Uip,all own State
�50
CO\SOLIDATEU
Zip Code
—
3. DATE DIULLED 6;'8'00 USE OF WELL RLSIDENI'LAL
—
I TOTAL DEPTH ;50
_
s. CUTTINGS COLLECT ED }ES ❑ NO
—
6. DOES WALL RrPI,A('F kXIS'I'INd WFIJA ) I'.S ❑ AO ❑`
—
T.STATICWATERLIBelowTopofCa,ins gi FL.
—
ICs< - Il LLoee Top o(C'asinel
_
e. TOP OF CASING IS _ FT. Above Loral Surl"W
—
"Cbehig Tonwoat,d actor LAo.v taut aulm<i, iaa¢d wdaz a uyiame it iss,u
to a.co,dmte<with Im 6(AC' _'C'.or 16
9- YIELD (gprn)'. _i }[ETHOD OF TEST ARMI
1o.WATER ZONES Ideptbl:
_
—
D. CHLORIN.ATION. Type
HIPOCHLORI'1'E .-\swum (O[,. II addGtiond eyaa is n<nkdtv<bock of fors
u
L. CASING.
C�1
_
LOCATION SI:ETCH
,Fall
—
Deptll
IShom direction mid d"Imco from ar least two State
�
i Wi,ijit
Dimneler or WeiariR- afalennl Roads-o, other map refn'nlce polntsl
fV --_
From 0 To
ASHII'URl'1-t RD.
80 Ft- 6 I' l SDR 21 PVC
�' �.--j
-
19. GROUP:
r-.'-
Tooth
Material Method—
y
From 0 To
20 Ft. SAND MIA GRAN IT}'
14. SCREEN
� --1
Depth
Diwnetei Slot Size nlatedal
Fmrt NA To
Fti
]!1KNj0R1JTTR
U. S',ND/GRAIF.L PACEDepth
JVC \latn'i alFrom
NA To
FL MOD
DR.
16. RENL1RKS.
I DO HEREBY CERTIFY THAT
THIS WELL WAS CONSTRUCTED LN ACCORDANCE WTI{ 15A NCAC'_C, WELL
CONSTRUCTION STANDARDS.
A]T) 71 EAT A COP}- OF'IT US RECORD I LAS BELT PROITDED TO TI E wELL OWNER.
653
0925K
j„IY `
1
NATLRE OF CONTRACT OR OR AGENT
V E Stut otwWt D' 6an aC&rvuomn<m HadO mid ]on wl R<ww., Dalc

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section `T
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELLCONTRACTOR:t�—�/�c�✓d71
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMIT#:
c�CU L 1
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) M
m�C. `
on r
Nearest Town`: County: o \ IJ�jyJf
n 1
�ry X + nsl c to Ph (S, cl _
(Road Name a d Numbers, Commmunity, or Subdivision and Lot No.) DRILLING LOG
DEPTH
3. OWNER " C From To
Formation Description
`
Address �' 1 u,)C t\ tt V nS -
(Street or Houle o.
rN DI-c 216_WN
City or Town State Zip Code
a
o
4. DATE DRILLED
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES Q NOQ'
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO�
8. STATIC WATER LEVEL Below Top of Casing: a,q FT.
fV zm
(Use'+' it Above Top of Casing)
9. TOP OF CASING IS 1., .S FT. Above Land Surface'
Top or casing terminated at/or below land surface requires a variance In accor-
dance with 15A NCAC 2C.0118
10. YIELD (gpm): A 6 + METHOD OF TEST
11. WATER ZONES (depth): ,C, - .7 5
to --
_6 e - ( S' _ z
12. CHLORINATION: Type C Amount ( 1 If additional space is needed use back of form
13. CASING:
Depth
From —To
Diameter
Ft. '-;)
Wall Thickness
or Wei n t.
Material
(((xc
From`; To
Ft.(1 -5)
From To
Ft.
14. GROUT:
DeP t
G
Materia
Ce'
Method
From To
Ft. f1'1 f
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
CONSTRUCTION STANDARDS, AN
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
C�
-Y
N
C)
C
0
k
us �c� wes
CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
rOF THIS RECORD HAS BEIE\N�PROVIDI�D TO THE WELL 0
FOR OFFICE USE ONLY 111 ° 1 I
Quad No: , SIGNATURE OF PERSON CONSTRUCTING THE WELL
Sub t dpi. at to Division of Water Quality, Groundwater Section within 30 days
Serial No.
DATE
GW-1 REV. 12/99

2231.83
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 flail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION k:
WELL CONSTRUCTION PERMIT#:
.,/STATE
1. WELL USE (Check Applicable Box): Residential LJ Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: Show sketch of the location below)
Nearest Town: -- C C 1cO�f-� County:
V r \(,)CQp-C\ �cce5
(Road Name a umbers, Com((�'n'p'nity, or fg'ubdivi1siQn and Lot No.) DRILLING LOG
DEPTH
3. OWNER �e Cc)I lli: II � i-1 N- �" From To
Formation Description
Address (r (� n �� 6�
Street or out o,
r�
(�
City or Town $tate Zip Code
4. DATE DRILLED
5. TOTAL DEPTH
0
6. CUTTINGS COLLECTED YES F-1 NOQ
e ��
7. DOES WELL REPLACE EXISTING WELL? YES O NOa
C
8. STATIC WATER LEVEL Below Top of Casing: LT7 FT.
F9 �Q
(Use': if Above Top of Casing)
/, S
n =11
9. TOP OF CASING IS FT. Above Land Surface*
o.0
'Top of casing terminated at/or below land surface requires a variance In actor-
]o
dance with 15A NCAC 2C.0118
10. YIELD (gpm): %F) METHOD OF TESTt?
11. WATER ZONES (depth): � &_,O
N coz
rn si
cn
12. CHLORINATION: Type S < - Amount It additional space is needed use back of loan z
13. CASING
Wall Thickness
Depth/ G Diameter or Weight/R. Material
From�To (t 0 Ft. U.�S
From To 73 Ft.
From To Ft.
14. GROUT:
Depth r�� ,Material ) Method
From ��('�--� To �n Ft. O .y1 P 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:
I DO HEREBY CERTIFY THAT THIS V
CONSTRUCTION STANDARDS, AND
FOR OFFICE USE
Quad No:
Serial No.
Slot Size Material
in.
in.
in.
Material
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
9d-,)>�
vb�>Ow
UQ
KJ I
Sf°7�7
/aM
t�
i6 iOD Pow
ti
@J
CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
DRY THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
GNATURE OF PERSON CONSTRUCTING THE WELL DATE
to Division of Water Quality, Groundwater Section within 30 days
GW-1 REV. 12/99

,; r)
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: �O�O�(\�" ' ( 0,r_{r
WELL CONTRACTOR CERTIFICATION #:(.r
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential ED� Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ It Other, List Use:
2. WELL LOCATION: (SlIcw sketch of the location below)
Agricultural ❑ Monitoring ❑
Nearest Town: \ I\1 \'1C tO''l County:C
1-RA
(Road Name and Numb- &s, Community, or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER Le Le From To Formation Descriptiai
Address rP A - \ \_ 1 1
City or Town Stale Zip Code
4. DATE DRILLED I / O�
5. TOTAL DEPTH r
6. CUTTINGS COLLECTED YES F_J NOQ_
7. DOES WELL REPLACE EXISTING WELL? YES F,� NO❑
8. STATIC WATER LEVEL Below Top of Casing: .?O FT.
(Use'+' if Above Top of Casing)
9. TOP OF CASING IS 10 5 FT. Above Land Surface'
'Top of casing terminated atfor below land surface requires a variance In accor-
dance with 15A NCAC 2C.0118 `
10. YIELD (gpm): � METHOD OF TEST �, 1 O C
11. WATER ZONES (depth): LS _7L
12. CHLORINATION: Type SrAec 5CV2eC Ll Amount
—
13. CASING:
Wall Thickness
Depth
From — Tom_
Ft.
Diameter
V�
or WeighVFt Material
['� �s n )`cam'
From .S 5 To ITC'
Ft.
L
cL
From To
Ft.
14. GROUT:
Depot,
Material
Method
From 7 To )
From To _ _Ft.
_...
15.SCREEN
Depth
From
To
From —To
From —To
16. SAND/GRAVEL PACK:
Depth
From
To —
From
To
17. REMARKS:
Diameter Slot Size Material
Ft in. in.
Ft. in. in.
Ft. in. in.
Ft.
Ft.
Size Material
Ta a�
N �—'-
G1
� o
If additional space is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION Sj"/,INDARQ$, AND THAT ACOPY OF��EEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE r ��'
Quad No: i )GNATURE OF PERSON CONSTRUCTING THE WELL DATE
' Sub d ri rial.lb Division of Water Quality, Gmundwaler Section Within 30 days
Serial No. r Gw-t REV. 12/99

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section r' `) i r % e)
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: n me_S C-1 cac �1
WELL CONTRACTOR CERTIFICATION#: _ QQCr
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: IN.-: c „- o County: — E\ r D , s,JL V
(Road Name and Numbers. Community, or Subdivision and Lot No.) DRILLING LOG
3. OWNER /�l�, ���-�jCcn���-� From To
Address
(Street or outs o.
City or Town / Stale Zip Code
4. DATE DRILLED 1 ' 7O
5. TOTAL DEPTH G <'
6. CUTTINGS COLLECTED YES 0 NO�
7. DOES WELL REPLACE EXISTING WELL? YES NOD
8. STATIC WATER LEVEL Below Top of Casing: 1 t-, FT.
(Use'+' if 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 .011e
10. YIELD (gpm): .r L METHOD OF TEST
11. WATER ZONES (depth): —?) t
12. CHLORINATION: Type �' /' Amount c2.
13. CASING:
Wall Thickness
Depth Diameter or Weight/Ft. Material
From To-FLU
�--
From -?O - To Ft. /.
From To Ft.
14. GROUT:
Depth; Mate' I Method
From �� To elFt�<'/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
From To
17. REMARKS: rr
ritI, I i'
I DO HEREBY CERTIFY TH WELL WAS 1
CONSTRUCTION STANDAR S.
FOR OFFICE USE ONLY
Quad No:
Serial No.
Agricultural ❑ Monitoring ❑
DEPTH
Formation Descriptioo
CJ —
v
V r..
J
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)
ACCORDANCE WITH 15A NCAC 2C, WELL
RD HAS BEEN PROVIDED TO THE WELL O
SIGNATURE OF PERSON CONSTRUCTING THE WELL
�d g.
Submit onmal to Division of water Quality, Groundwater Section within 30 days
DATE
GW-1 REV. 12/99

North Carolina - Department of Environment and Natural Resources -Division of Water Quality -Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELLCONTRACTOR: r%T1CF- Gn4 1'\ -5-
WELL CONTRACTOR CERTIFICATION #: QCa U \
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other 0 If Other, List Use:
Agricultural ❑ Monitoring ❑
2. WELL LOCATION. (Shgw sketch of the location below) 1 ' tC Nearest Town: ff \O+C 10,E ryW C o
—
1�C'nC Cr c. T�,
(Road Name and Numbers. Community, or 1S1ubtlivision and Lot No.) DRILLING LOG
3. OWNER cJ� s/ UC, d C\ From To
Address "�
($trees or outo o.
M C./vf.0
City or Town ate Zip Code —
4. DATE DRILLED
5. TOTAL DEPTH S -
6. CUTTINGS COLLECTED YES Q NO�
7. DOES WELL REPLACE EXISTING WELL? YES_W NOD
8. STATIC WATER LEVEL Below Top of Casing: ��33�X FT.
(Use '+' if Above Top of Casing)
9. TOP OF CASING IS 1-5 FT. Above Land Surface'
-Top of casing terminated at/or below land surface requires a variance In accor-
dance with 15A NCAC 2C .011 a
10. YIELD (gpm): an+ METHOD F TEST �
11. WATER ZONES (depth):_
—. /ri.S L C7 _
12. CHLORINATION: Type
yp Amount If additional space is needed use back of form
13. CASING:
DEPTH
Formation Descriptioo
Wall Thickness LOCATION SKETCH
Depth Diameter or WeighVFI. Material (Show direction and distance from at least two State
From To Ft. (%. _-� 5 a -� Roads, or other map reference points)
From To �_ Ft. �5 - D 1�I� cc e
From To Ft. I I
14. GROUT:
^ Depth
T
From � To O Ft.
Material Method
C e m e_
f
W
From To
Ft.
15. SCREEN:
Depth
Diameter
Slot Size Material
t
From To
Ft
in. —in.—
From —To
Ft.
in. in. _
o
From _To
Ft.
in. _ in.
16. SAND/GRAVEL PACK:
{-)
Depth
Size Material
w
From To —Ft.
—
From To
Ft.
17. REMARKS:
I DO HEREBY
FOR OFFICE 11ANLY
Quad No: ..' Bl3
M.I si
ED IN ACCORDANCE WITH 15A NCAC 2C, WELL
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
at 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 p 21636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone] J
WELL CONSTRUCTION RECORD WELL CONTRACTOR: T(1 Me S (ca d, n
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: (S,h�pw sketch of the location below)
Nearest Town: I " , C t G 1 County:
L,itl e f'(1�-n ��
(Rod Name and Nu`�'bers\Community, o^r Subdiv'p`ion and Lot No.) DRILLING LOG DEPTH
3. OWNER uiYEN-?tiD1 4 \ From To Formation Description
Address 6-7. PD
(bireetor outs o.
on S2 SJ
City or Town state Zip Code
4. DATE DRILLED Qv
4J _.
5. TOTAL DEPTH ---
6. CUTTINGS COLLECTED YES Q NOQr '
7. DOES WELL REPLACE EXISTING WELL? YESEJ N00— as -
8. STATIC WATER LEVEL Below Top of Casing: _a FT. CJ
(Use'+' if Above Top of Casing)
9. TOP OF CASING IS %,5 FT. Above Land Surface'
'Top of casing terminated atlor below land surface requires a variance In actor. N
dance with 1SA NCAC 2C.011 ••
10. YIELD (gpm): _ `� 6 METHOD OF TEST n ; ? O _
11. WATER ZONES (depth):
12. CHLORINATION: Type Amount f It additional space is needed use back of form
13, CASING:
Wall Thickness
LOCATION SKETCH
Depth Diameter
From 9 To Ft JI-5
or Weight/Ft. Material
-P7, 6 �//JJ�,,�T-
(Show direction and distance from at least two State
From To1�=�—
7.
Roads, or other map reference points)
Ft.
n`
From To Ft.
3
14. GROUT:
DepthMaterial Method
'l
From To �b Ft. 6men�
From To Ft.
15. SCREEN:
Depth
From _
To
From —To
From _
To _
16. SAND/GRAVEL PACK:
Depth
From
To
From
To
ill
17. REMARKS:
Diameter Slot Size Material
Ft in. in.
Ft. in. in.
Ft. in. in.
I DO HEREBY CERTIFY
ERTIF THaT
CONSTRUCTION STA DA
FOR OFFICE USE ONL
Quad No:
Serial No,
THIS WELL WAS CON TR TED IN ACCORDANCE WITH 15A NCAC 20, WELL
it- ApIl-r undwa e€ ec Ion F S RECORD HAS BEEN PROVIDED TO THE WELL O
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
al 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 WELL CONTRACTOR: SaMe,S
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential ff 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: �a D n (y� County: — I t � C 17(lu: C�
(Road Name and Number Community, or SSuubdivis�° and Lot'No.) DRILLING LOG
3. OWNER �'1 t TSU (\ ' ``- —E'Q I ��s( From To
Address h ( '1 'D
I')QC%0fN &f.L 146 /Jo/
City or Town tale Zip Code
4. DATE DRILLED ' U
5. TOTAL DEPTH IQ3
6. CUTTINGS COLLECTED YES 0 NOQ
7. DOES WELL REPLACE EXISTING WELL? YES NO�
8. STATIC WATER LEVEL Below Top of Casing: 0 1 FT.
� � (Use '+' if 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): /.S METHOD OF TEST
11. WATER ZONES (depth): S5- lbo r
12. CHLORINATION: Type Amount - OZ
13. CASING:
DEPTH
Foncalion Descnptioo
If additional space is needed use back of form ==
Wall Thickness LOCATION SKETCH
Depth c Diameter or Weight/Ft. Material (Show direction and distance from at least two State
From —TO SO Ft. `—"'ram a,TrC- / Roads, or other map reference points)
From 66 To S5 Ft. (a ,+ee l
From To Ft.
1n r_onllr-

23
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section ~ ~ 0
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: L'MF5 �- Gam' A
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMITH:
1. WELL USE (Check Applicable Box): Residential LD Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (/S1h�1ow sketch of the location below) ,n
Nearest Town: !_1-lr�� t r" County: ' 1�� C- � /
(Road Name and Nu(nbers, Comm ry, or �jubdivision and Lol No.) DRILLING LOG
3. OWNER W����.C�1 tc(E G,f N From To
Address
jSueetor '; tCo
Mac ion )
City or Town Slate Zip Code
4. DATE DRILLED
5. TOTAL DEPTH I
6. CUTTINGS COLLECTED YES Q NOQ
7. DOES WELL REPLACE EXISTING WELL? YENO�J
8. STATIC WATER LEVEL Below Top of Casing: r Fr.
(Use'+' it Above Top of Casing)
9. TOP OF CASING IS i-5 Fr. 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 � 2C
11. WATER ZONES (depth): 90r z60
Agricultural ❑ Monitoring ❑
DEPTH
Formation Descdptloo
12. CHLORINATION: Type Amount O 7 If additional space is needed use back of formes -
J
13. CASING: _-
Wall Thickness
Depth -7 Diameter or WeighUFt. Material
From TC' To 3 Ft. I-1.:IS a7.
From ' , To `�'� Ft.(I -D,5 2 ,#` z�L
From To Ft.
14. GROUT:
Depth AA Material Method
From )� To my FL Gemen'i'
From To Ft.
15. SCREEN
Depth
From
To
From —To
—
From —To
_
16. SAND/GRAVEL PACK:
Depth
From
To —
From
To_
17. REMARKS:
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
Diameter Slot Size Material
Ft in. in.
Ft. in. in. —
Ft._ in. in.
R
l5
C
�
�
A
V
l5
�1
C
— Ft.
I DO HEREBY CERTIFY THAT 7
CONSTRUCTION STANDARDS,
FOR OFFICE USE ONLY
Quad No:
Serial No.
:ORDANCE WITH 15A NCAC 2C, WELL
HAS BEEN PROVIDED TO THE WELL OWNER.
GNATURE OF PERSON CONSTRUCTING THE WELL DATE
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 '.) f) �` n
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone] ^- '- 0 J 2 6
WELL CONSTRUCTION RECORD WELLCONTRACTOR: %— MP 5
WELL CONTRACTOR CERTIFICATION #: n G (+
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential0 Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: , C � F,5� County: < \\
(Road Name and Nu,mmSDRILLING LOG DEPTH
l, n, (K�j3. OWNER r From To Formation Descriptio,t
Address
City or Town State Zip Code
4. DATE DRILLED O/JOD
5. TOTAL DEPTH I (� L'
6. CUTTINGS COLLECTED YES F NO�
7. DOES WELL REPLACE EXISTING WELL? YES [� NOF-]
8. STATIC WATER LEVEL Below Top of Casing: (,5 • FT.
(Use'.' if Above Top of Casing)
9. TOP OF CASING IS �_J� FT. Above Land Surface'
'Top of casing terminated at/or below land surface requires a variance In accor-
dance with 1 NCAC 2C 119 _
10. YIELD (g (gpm): METHOD OF TEST
11. WATER ZONES (depth): I. 257 — 145
12.CHLORINATION: Type 14 T 14 Amount -0Z
13. CASING:
Wall Thickness
Depth Diameter or WeighVFt. Material
From � Ft. �*' I - I1 1 ��
0
Fa
rn
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)

. Q Q
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: S Q rn"5 E (f�,OLJI
WELL CONTRACTOR CERTIFICATION #: a (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 of the location below)
Nearest Town: mGft +^ County: I'`L I /O C I
Ccc55 Ccce ��
(Road Name and Numbers, Community. or Subdivision andlI Lot No.) DRILLING LOG DEPTH
3. OWNER '1 �:: IdpC From To Formation Descriptioo
Address- �� •'��, PC �at Nxf
(Street or Houle 0.
City or Town p State Zip Code
4. DATE DRILLED / 10106 Q
5. TOTAL DEPTH 730 -
6. CUTTINGS COLLECTED YES Q NO� `� r
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO[E- t
8. STATIC WATER LEVEL Below Top of Casing: :70 FT.
(Use '+' if Above Top of Casing) N
9. TOP OF CASING IS4,5 FT. Above Land Surface --
'Top of casing terminated at/or below land surface requires a variance In actor- —' -- ---
dance with 15A NCAC 2C.011 _
10. YIELD (gpm): 1.� METHOD OF TEST
11. WATER ZONES (depth):
12. CHLORINATION: Type Amount S It additional space is needed use back of form
13. CASING:
Wail Thickness LOCATION SKETCH
A DepthC��� Diameter or W Thickness
Material (Show direction and distance from at least two State
From n/_To �— Ft. � = � - Roads, or other map reference points)
From R() To IS Ff. -�-5 - �-
From To Ft.
14. GROUT:
Depth
,{vlaterial(
Method
From To 20
Ft.
emen
T
From To —Ft.
15. SCREEN:
Depth
Diameter Slot Size
Material
From —To—Ft—
in.
in.
From To Ft.
in.
in.
From To —FL
_
in.
in.
16. SAND/GRAVEL PACK:
Depth
Size
Material
From To
Ft.
From To
Ft.
17. REMARKS:
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONST COPY OF THIS RECORD HAS BEEN P OVIDED TO THE WELL OWNER.
D
FOR OF UNILT
Quad No: IGNATURE OF PERSON CONSTRUCTING THE WELL DATE
?l, i', ginal to Division of Water Quality, Groundwater Section within 30 days
Serial No. - PU 1 GWA REV. 12/99

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section -;� (� r' 4N
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: 1drnP5 ��a/Cc4��
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: Sow sketch of the location below)
Nearest Town: McS v D r, Co ly:
A (JJW
(Road Name and \\Num Reis, Commupr�l)��or division antl Lot No.) DRILLING LOG DEPTH
3. OWNER (A/ Cfi0h 1\K'\JV From To Formation Description
Address �k- '!2L �o
«, ,„ ,o� a'� _73�
City or Town State Zip Code
4. DATE DRILLED T ��
5. TOTAL DEPTH -1
6. CUTTINGS COLLECTED YES F� NO[El-
7. DOES WELL REPLACE EXISTING WELL? YES NOQ
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 accor-
dance with 15A NCAC 2C .011a
10. YIELD (gpm): In METHOD OF TEST aw, 2C
11. WATER ZONES (depth): -35 - /y-5
12. CHLORINATION: Type T Amount — 6
13. CASING:
cD
—
�y
N
c,.
r =:
U1
—�
If additional space is needed use back of form
Wall Thickness LOCATION SKETCH
Depth Diameter or Weight/Ft. Material (Show direction and distance from at least two State
From 76-1—To —37 Ft. 6 � a� ,��1`c Roads, or other map reference points)
From.— Tom Ft. 5 — 3)oc=� -s��!
From To Ft.
14. GROUT:
Depth Materi I Method
From To � Ft. em rt
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.
Ft.
Ft.
Size Material
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIPED TO THE WELL 0
FOR OF U L r '
Quad No: - ni 1 NATURE OF PERSON CONSTRUCTING THE WELL DATE
r
naf to Division of Water Quality, Groundwater Section Within 30 days
Serial No. __ii`• L _! )(111i GW.1 REV. 12/99

Nonh 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: spa rrme- 5
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 ❑ If Other, List Use:
2.
WELL LOCATION: (Show sketch of the location below)
�
Nearest Town: 1 1 r` "+ O�'� County:
1
`7tlgp, N, t1ri
(Road Name a Numbers, Community, or Subdivision and Lot No.) DRILLING LOG
DEPTH
3.
OWNER From To
Formation Descnptio.r
Address �d
—�Streetor out o.j— C1
1nn /1
City or Town 'State zip Code
4.
5.
D/3
DATE DRILLED �a
TOTAL DEPTH �O
6.
CUTTINGS COLLECTED YES f NOF=I—
r--,
7.
DOES WELL REPLACE EXISTING WELL? YES NO[Er
o -
S.
STATIC WATER LEVEL Below Top of Casing: 63 FT.
9.
(Use'+' it Above Top of Casing)
TOP OF CASING IS 4 FT. Above
_5 Land Surface•
•Top of casing terminated at/or below land surface requires a variance In accor.
dance with 15A NCAC 2C .011e
--, -- -
10.
YIELD (gpm): 1_5 METHOD OF TEST
11.
WATER ZONES (depth):
12.
O
CHLORINATION: Type Amount ° t If additional space is needed use back of form ._
13. CASING
Wall Thickness
LOCATION SKETCH
Depth Diameter
From r p To O Ft. �*-a5
or Wei ht/R. Material
(Show direction and distance from at least two State
Roads,
/NFL�.�
�O 15
From To `
ioc c c —
or other map referent points)
From To Ft.
14. GROUT:
Dept Materi
I Method
From � To ,-�.D Ft.
From To Ft.
\
15. SCREEN:
Depth Diameter Slot
Size Material
/ v'P
��
From —To—Ft— in.
From To
—in.—
Ft. in.
From To Ft. in.
—in.
in.
16. SAND/GRAVEL PACK:
Depth Size Material h7
From To FL (`d
From To Ft. c`X
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH '15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY
/nOF THIS RECORD HAS BEEN PROVIDED TO THE WELL C
FOR OFFICE USE ONLY
Quad No:
ns
Serial No. i U
SIGNATURE OF PERSON CONSTRUCTING THE WELL
alto Division of Water Quality, Groundwater Section Within 30 days
DATE
GW-1 REV. 12l99

N1636 Mail Service Center orth Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section 1...1 �) O
- Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELLCONTRACTOR: !'neS (� <a�^
WELL CONTRACTOR CERTIFICATION #: Q(. u
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential Er Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below) ^r�
Nearest Town: i1�Cl ��.� County:. `' \Ll:�}"e Il
(Road Name and Numbers, C mmuniry, or Subdi�yjision and Lot No.) DRILLING LOG
3. OWNER {y!j;.'s-,r1 IZPaIi From To
Address `�� uX, I C'6I
—(Streel or o""us�e o.
CJ IC
City or Town_ /( State Zip Code
4. DATE DRILLED
5. TOTAL DEPTH ( (e'?
6. CUTTINGS COLLECTED YES Q NOd
7. DOES WELL REPLACE EXISTING WELL? YES NO�
8. STATIC WATER LEVEL Below Top of Casing: ,C� r FT.
(Use'+' if Above Top of Casing)
9. TOP OF CASING IS 11 i Fr. 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): __7_ METHOD OF TW I P C
11. WATER ZONES (depth): 1,35
12. CHLORINATION: Type T" Amount i az
13. CASING:
Agricultural ❑ Monitoring ❑
DEPTH
Formation Description
o
='
r-)
m
If additional space is needed use back of form
Wall Thickness LOCATION SKETCH
T Depth{ Diameter or Weight/Ft. Material (Show direction and distance from at least two State
From To l l s. Ft. Q -2 S S>D ].k To,yc_ Roads, or other map reference points)
FromToFt.y�
M;�es
From To FL
14. GROUT:
_ Depth Mater �l Method
From To DO Ft �r'mtn'
From To Ft.
15. SCREEN:
Depth
From
To
From —To
From —To
_
16. SAND/GRAVEL PACK:
Depth
From
To
From
To_
17. REMARKS:
Diameter Slot Size Material
Ft in. in.
Ft. in. in.
Fl. in. _ in.
Ft.
Ft.
Size Material
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND PiI�T AQORY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL 0
FOR OFFICE USE ONLY,
Quad No: ,7 ''rr IGNATURE OF PERSON CONSTRUCTING THE WELL
Snbm�J rlq nal to Division of Water Quality, Groundwater Section Within 30 days
Serial No.
'II
DATE
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 WELL CONTRACTOR: .�R(YME.5 ��c�ec�
WELL CONTRACTOR CERTIFICATION #: QG(J
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) nM
Nearest Town: I 1 Q (-• Ot, County: - 1 1 \ Dn W Q �\
(Road Name and
3. OWNER
Address
State
Agricultural ❑ Monitoring ❑
Lot No.) DRILLING LOG DEPTH
From To Formation Description
Zip Code
4. DATE DRILLED
5. TOTAL DEPTH Ili
5
6. CUTTINGS COLLECTED YES Q NO[E!I'
7. DOES WELL REPLACE EXISTING WELL? YES NO�
8. STATIC WATER LEVEL Below Top of Casing: FT.
(Use'+' if Above Top of Casing)
9. TOP OF CASING IS Lf 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): L) METHOD OF TEST
11. WATER ZONES (depth): I C -
12. CHLORINATION: Type Amount -!5-�
13. CASING:
Wall Thickness
Depth Diameter or WeighVFt. t n-I
From �� To -5-5 Ft. 6 - 2 51fC—
Frorp-25 Tom Ft. = z5-
Fro/rr,I' To -'� Ft. L" S l ( JLCL
14. GROUT
i Depth Mated Method
From / <' To 06 Ft. 0
From To Ft.
15. SCREEN:
From
From
From
Depth Diameter Slot Size Material
-To—Ft— in. in.
To Ft.
To _ Ft.
16. SAND/GRAVEL PACK:
Depth
From To Ft.
From To Ft.
17
in. in.
in. —in. _
Size Material
tL1 r,
If additional 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[, ANP THAT A COPY OF TAiIS RECORD HAS BEEN PROVIDED TO THE WELL 0
FOR OFFICE USE ONLY
Quad No: C('I r` NATURE OF PERSON CONSTRUCTING THE WELL
LP ,
lubmit o9trisfil to Division of Water Quality, Groundwater Section within 30 days
Serial No.
DATE
GW-1 REV. 12/99

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section 'i i r'1 C1 �'1
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone] r" I I
WELL CONSTRUCTION RECORD WELLCONTRACTOR: \nips C- CA C�
WELL CONTRACTOR CERTIFICATION #: c(zL 1
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Bo:): Residential E Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2.
3.
4.
5.
6.
7.
8.
WELL LOCATION:
(Sho�wl sketch of the location below)
Nearest Town: -
I)I(\C�r`r� County:- 1 �/\ ( I,ru'-12��
A/;N
Cree K
I�j_
(Road Name and Numb11ers, or S�ubdivis'oIn and Lol No.) DRILLING LOG
1rv�,
OWNER Lt�V1s
`C`ommunity,
T.Sb1'r 1< V From To
Addressl'l—
j5treet or outs o.
TS2
\1(-, i t La"1
/� 1 (
City or Town
State Zip Code —
DATE DRILLED
DEPTH
Formation Descnptioo
TOTAL DEPTH I a U
CUTTINGS COLLECTED YES 0 NOE]— o `
DOES WELL REPLACE EXISTING WELL? YES[] NOa
STATIC WATER LEVEL Below Top of Casing: r-I U FT.
_ (Use'i if Above Top of Casing) -- -_ --
9. TOP OF CASING IS Ih 5 FT. Above Land Surface- �a
'Top of casing terminated atlor below land surface requires a variance In accor. _ r.;.
dance with 15A NCAC 2C .0118 - ,
10. YIELD (gpm): JS METHOD OF TEST - tL t `e S c-, --
11. WATER ZONES (depth):
Cn cS
12. CHLORINATION: Type Ii Amount I S a z. It additional space is needed use back of form
13. CASING
Wall Thickness
Depth r Diameter or Weight/Ft. Matedal
To F. _, C�From
From To c s— Ft.
From To Ft.
14. GROUT:
Depth /Mattma� Method
From 1 To 20 Ft. ( e"Je,)
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) --2 _
l
s 73�
L'
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 BEENIPROVIDED TO THE WELL O
FOR OFFICE USE ONLY _
Quad No: "
is
'...�, �t Submit
Serial No.
GNATURE OF PERSON CONSTRUCTING THE WELL DATE
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 i
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone] ; 1
WELL CONSTRUCTION RECORD WELL CONTRACTOR: iMl OINP.S C\
WELL CONTRACTOR CERTIFICATION
r��STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (check Applicable Box): Residential 01 Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below) �l�n
Nearest Town: \\ I' n,<"J-County:. 1 t 1 c �Ovde
�lP�a�nv\T \1,ew/
(Road Name and Number@\, Community, or $ubdivi on antl Lot No.) DRILLING LOG DEPTH
3. OWNER W�.` r�C� n Kpp` From To Formation Description
Address _ 1 c")e I lob
Cotreet or Auto o.
City or Town /Stale Zip Code
4. DATE DRILLED % a 'P/ Ov
5. TOTAL DEPTH /13
6. CUTTINGS COLLECTED YES 0 NO
7. DOES WELL REPLACE EXISTING WELL? YES (J NO�'
8. STATIC WATER LEVEL Below Top of Casing: — FT. 1-T '--
(Use '+' if Above Top of Casing) '
9. TOP OF CASING IS / .S FT. Above Land Surface' -�
'Top of casing terminated aVor below land surface requires a variance In accor-
dance with 15A NCAC 2C.011 —
10. YIELD (gpm): 45 METHOD OF TEST aj er-
11. WATER ZONES (depth): 1,60 1,51 ^°
12. CHLORINATION: Type Amount If additional space is needed use back of form
13. CASING:
Wall Thickness LOCATION SKETCH
Depth L/� Di�`` der or Wei h ,R Material (Show direction and distance from at least two State
FromT,)-To Ft. —L,L_ a (, J^n0c. Roads, or other map reference points)
From � _ To� Ft. / AL
From To Ft.
14. GROUT:
Depth Yaleial 1 Method
From To 06 Ft.
From To Ft,
15. SCREEN:
Depth
From 9EIPILTo_
From To
From _ To _
16. SAND/GRAVEL PACK:
Depth
From To
From To_
17. REMARKS:
Diameter Slot Size Material
Ft in. —in.
Ft. in. _ in. .
Ft. in. in.
Ft.
Ft.
Size Material
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.
f
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
aI 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 14068
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELLCONTRACTOR: lames
WELL CONTRACTOR CERTIFICATION #:
WELL CONSTRUCTION PERMIT#:
E G c1, �
,�,/STATE
I. WELL USE (check Applicable Box): Resideritial L�J Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery
Heat Pump Water Injection ❑ OtherEJ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: nC ',etch
County: l rl C LJ,-1i.✓P
(Road Name and umbers. Community, or Subdivision and Lot No.) DRILLING LOG
DEPTH
3. OWNER — , C
Address From To
Formation Descriptioo
Ireat or to
age
City or Town State Zip Code
4. DATE DRILLED �GO
5. TOTAL DEPTH //.S
6. CUTTINGS COLLECTED YES[] NO
7. DOES WELL REPLACE EXISTING WELL? ES 0 N00'
O d
8. STATIC WATER LEVEL Below Top of Casing: IYO FT.
(Use -+ it Above Top of Casing)
9. TOP OF CASING IS /� .5 FT. Above Land Surface-
C _�
cr"
'Top of casing terminated atior below land surface requires a variance in actor-
dance with 15A NCAC 2C.0118
W oT
—
10. YIELD m : r
(gP ) L� METHOD OF T?T I Ff
7.(�r
11. WATER ZONES (depth):- BPS-' Sio
1 . CHLORINATION: Type Amount Oz
y�
If additional space is needed use back of form
13. CASING:
Depth ?� 13'ameter
From D To __�iL Ft.
From To 13T Ff. 6
From To Ft.
14. GROUT
Wall Thickness
Or Wei$ Material '
% ��p Depth Material
From I To ! Ft. CemNn_Y"
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 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 r CONSTRUCTION STANDAR♦D-ANDTHATA COPY OF THIS RECORD HAS BEEN PROV EDT THE WELL OWNER.
FOR OFFICE USE ONLY' ' /�/ h �✓Yl1?/J y/ _ y—CMG
Quad No: SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Original to Division of Water Quality, Groundwater Section Within 30 days
Serial No.
GW-t REV. 12/99

North Carolina -Department of Environment and Natural Resources -Division of Water QualityGroundwater Section 214069
1636 Mail Service Center - Raleigh, N.G. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: �n1rP-sc� n
WELL CONTRACTOR CERTIFICATION #:
WELL CONSTRUCTION PERMIT#:
1.
r��STATE
WELL USE (Check Applicable Box): Residential tJ Municipal ❑ Industrial ❑
Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2.
WELL LOCATIOI�J;(Show sketch of the location below)
n/I
Nearest Town: � j' �(Ini o'1 County: I , f c Do �a;e
1c m a ' 'Pn<a d;:se � ce K L61 /0
(Road Name and Num/pers, Commu/ry'ry. or Subdivision and Lot No.) DRILLING LOG DEPTH
3.
OWNER fY 4 l.Gi(Y'!7 From To
Formation Descriptioo
` n I
Address + , 'Row 900L �CCMy Kd.
!� veelor 00tJ1NO.)
I ri4 Cr �� Alec ca
City or Town Stale Zip Code
4.
DATE DRILLED L ' 13-00
5.
TOTAL DEPTH _ /0 G
O -
6.
CUTTINGS COLLECTED YES Q NOQ-
O
7.
DOES WELL REPLACE EXISTING WELL? YES 0 NO[a-
C m
8.
STATIC WATER LEVEL Below Top of Casing: c%6 FT.i
9.
) � (Use '+' it Above Top of Casing)
TOP OF CASING IS FT. Above Land Surface'
co
-- c
'Top of casing terminated at/or below land surface requires a variance In actor-
dance
10.
with 15A NCAC 2C .0119
YIELD (gpm): /0 METHOD OF TrTf_�a�
%S -
11.
WATER ZONES (depth): e "
-+
t9
0'
a
12.
CHLORINATION: Type Amount 0Z If additional space is needed use back of form
13.
CASING:
Walt Thickness
LOCATION SKETCH
Depth �q Diam ter or Weight/Ft. Material (Show direction and distance from at least two Stale
From To Ft. �O 5 97-6.1D LAG Roads, or other map reference points)
��'�
From To Ft. (, - a S
_9
From To FL
C 5
14.
GROUT:
Depth Mated I Method
From �n� To �0 FL �v"rtq'
t 1
From To —Ft.B'en
15.
SCREEN:
Depth Diameter Slot Size MaterialKd-
From To Ft in. —in.—
From _ To Ft. in. in.
16.
From —To Ft. in. _ in.
SAND/GRAVEL PACK: AcrcS
�!
on G,rv,ewl
L)-
Depth Size Material
J
From To Ft.
!_) On 1�- urnq
From To FL
� �c lsc �cceS(L� 10 on�jZ�
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 �P/RPVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY -� o
Quad No: SiGNANRE OF PERSON CONSTRUCTING THE WELL DATE
ell i i g 'original to Division of Water Quality, Groundwater Section Within 3D days
Serial No. GW-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: _Tnmei &gZa,N
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential E Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below) ,fin I
Nearest Town: _ r1r, e n _ County: I r I r, n4W r e
(Road Name
3. OWNER _
Address
Agricultural ❑ Monitoring ❑
and Lot No.) DRILLING LOG DEPTH
From To Formation Description
ru E vn/V. c.. I b/ 4 I
City or Town State Zip Code
4. DATE DRILLED _ J -0
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES 0 NOEr
7. DOES WELL REPLACE EXISTING WELL? YES Q NOQ'
8. STATIC WATER LEVEL Below Top of Casing: .50 FT.
(Use '+' it Above Top of Casing)
9. TOP OF CASING IS (,S _ FT. Above Land Surface-
-Top of casing terminated avor below land surface requires a variance In accor-
dance with 16A NCAC 2C .0118
10. YIELD (gpm): _6 METHOD OF TEST
11. WATER ZONES (depth): / 60- //()
z
12. CHLORINATION: Type-779 Amount 16 0 If 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
FromTo 715 FL G 1SC Roads, or other map reference points)
From To 5_ Ft. LL5 21,, k 5 «
From To Ft.
14. GROUT: ?
Depth Material Method
From I o o To -2 0 Ft. Zem en
From 1 To Ft.
15. SCREEN:
Depth
From
To
From
To
From
To _
16. SAND/GRAVEL PACK:
Depth
From
To _
From
To
17. REMARKS -
I DO HEREBY CE
CONSTRUCTION
FOR OFFICE USE ONLY
Quad No:
Serial No. L
Diameter Slot Size Material
Ft _ in. —in.
Ft._ in. _ in.
Ft. in. in. _ _—
A.�
i
M nccl ok �
PIcce5
R&DWORMCTEDJJ ACCORDANCE WITH 15A NCAC 2C, WELL
r COPY F THIS RECORD HAS BEEN P OVIDED TO THE WELL OWNER.
o1 1- X�T c -.)- 00
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
original to Division of Water Quality, Groundwater Section within 30 days
GW-1 REV. 12/99
Q

North Carolina - Department of Environment and Natural Resources -Division of Water Quality -Groundwater Section GA1h+-�.�
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: �� m s �czc�: (� 214 U 6 r
WELL CONTRACTOR CERTIFICATION M: r)
STATE WELL CONSTRUCTION PERMIT»:
1. WELL USE (check Applicable Box): Residential E Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show ketc o t location below)
Nearest Town: 0 1 hCe County: t t < ��•"� z I'
(Road Name and Numbers, Commuu or Subdivision and Lol No.)
3. OWNER rn
Address rl,7,f,
�/ 7D(` treetor outp' R Q ?7
G?
City or Town state CJ Zip Code
4. DATE DRILLED
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES Q NOE]'
7. DOES WELL REPLACE EXISTING WELL? YES NO❑
8. STATIC WATER LEVEL Below Top of Casing: FT.
(Use': if Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface'
-Top of casing terminated at/or below land surface requires a variance In accor-
dance with 15A NCAC 2C.0118
10. YIELD (gpm): P5 METHOD OF TEST 'Le
11. WATER ZONES (depth): '76 - gG -
0 - //D
12. CHLORINATION: Type �i Tip Amount
13. CASING
Agricultural ❑ Monitoring ❑
DRILLING LOG DEPTH
From To Formation Descdptioo
0
O
If additional space is needed use back of form
Wall Thickness LOCATION SKETCH
Depth / or Weight/R. Material (Show direction and distance from at least two State
From To Di meter Ft. C Roads, or other map reference points)
From To 65 Ft. 6-25 � 1}� 2r L
From To Ft.
14. GROUT: gy
De tth��r}'''�' Materi-8I Method
From L TopFt. �Pm enl`
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
From To Ft.
From To Ft.
17. REMARKS:
Size Material
I DO HEREBY CERTIFY THAT THIS WELL WAS CON RUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPWOF THIS RECORD HAS BEEN PRPVIDED TO THE WELL OWNER.
In
FOR OFFICE USE ONLY
Quad No: I
Serial No. —
—AU I r
SIGNATURE OF PERSON CONSTRUCTING THE WELL
original to Division of Water Duality, Groundwater Secion within 30 days
LC _old
DATE
GW-1 REV. 12/99