Well Construction Records McDowell 2 CY2000

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: .TAmPZ 11rocL� C`�15
WELL CONTRACTOR CERTIFICATION #: in I,p
STATE WELL CONSTRUCTION PERMIT#:
WELL USE (Check Applicable Box): Residential lJ Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: Mc, < " cot\ County:
3. OWNER
Address
Agricultural ❑ Monitoring ❑
Lot No.) DRILLING LOG DEPTH
From To Formation Descriptico
uity or I own state up cone
4. DATE DRILLED S- I - 00
5. TOTAL DEPTH '130
6. CUTTINGS COLLECTED YES Q NOQ
7. DOES WELL REPLACE EXISTING WELL? YES F-j NOa
8. STATIC WATER LEVEL Below Top of Casing: Cf FT.
/ (Use't if Above Top of Casing)
9. TOP OF CASING IS S FT. Above Land Surface -
•Top of casing terminated atlor below land surface requires a variance In accor-
dance with 15A NCAC 2C-.0118
10. YIELD (gpm): 1� METHOD OF TEST �Ae <
11. WATER ZONES (depth): 110 /
12. CHLORINATION: Type lr_' } kA—Amount I6 e r-
13. CASING
If additional space is needed use back of
Wall Thickness LOCATION SKETCH
_ Depth Diameter or Weight/Ft. Material (Show direction and distance from at least two State
From, n To � Ft. 61-2�5 a�i �� -y— Roads or other map reference points)
From + To Ft. — _
From To Ft. _ O
¢� l-0 2 .tea„-,e5 C.k0'
14. GROUT:
Depth Materi I Method n
From To Ft. _ereelk
From / —To—Ft.-7
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft in. in.
From To FL in. in. 9z)
From —To Ft.— in. in.
16. SAND/ _ __ _ — n
ryry t4 15 U U ISiz I Material
From U To FL
From T }) 'Piri
17. REMA
I DO HE IEBY�� WELL AS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONS COPY OF THIS RECORD HAS
�BEEN
,.(PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY i 4
Quad No: "ff SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Sir onginal to Division of Water Quality. Groundwater Section Within 30 days
Serial No. -Z 5 GW-1 REV. 12199
4e1
30

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: 1 V08.5
WELL CONTRACTOR CERTIFICATION #: rVW �Z!G L I
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATIOI/: (Show, sketch of the location below) T
Nearest Town: 1 ' \ 'Dt County.
aeKjnu� Om k -�__.cse-La ".33
(Road Name and Numbers, Commu'y1�,y or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER I,t�I\��_S KQ,l�,1 From To Formation Description
Address 91 ' " 1A
Maf�0r. ,-----..W.U_
City or Town State Zip Code
4. DATE DRILLED .- a QO
5. TOTAL DEPTH a(L_
6. CUTTINGS COLLECTED YES FI NO�
7. DOES WELL REPLACE EXISTING WELL? YES NO[�:r
8. STATIC WATER LEVEL Below Top of Casing: )_'�O FT.
(Use 'i it Above Top of Casing)
9. TOP OF CASING IS6QI. FT. Above Land Surface'
'Top of casing terminated atlor below land surface requires a variance In accor-
dance with 15ANCAC2C.01 a
10. YIELD (gpm): IAP, METHOD OF TEST 1?3�,AeC
11. WATER ZONES (depth): I(�5� - 17Sr __ o m�
co
12. CHLORINATION: Type f Amount t'c O Z if additional space is needed use back of fora* =
13. CASING:
Wall Thickness
Depth Diarrieter or WeighVFl. Material
FroTo -2f— Ft. 25
a� aiL_
From To r" d— Ft. 5—
From To Ft.
14. GROUT:
Depth // MaIa I Method
From To FL C-fir, �^
From To Ft.
15. SCREEN
Depth Diameter
From To Ft in.
From To Ft. — in.
From _ To Ft. _ in.
16. SAND/GRAVEL PACK 16-
Depth 1? Sloe
F T
Slot Size Material
_ in.
_ in.
in.
rom o I.
—
From To
17. REMARKS:
I DO HEREBY CERTIFY `-TH �Iml'iIE
CONSTRUCTION STAND
FOR OFFICE USE ONLY -
Quad No:
_;� ����� Submit
Serial No. � —
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
f✓e6o L9K� -39mes
3
0
3
0
ri
11STRUCT tD IN ACCORDANCE WITH 15A NCAC 2C, WELL
I ECORD HAS BEEN PROVIDED T% THE WELL OWNER.
T 1,7? U !/ K�(� S -
GNATURE OF PERSON CONSTRUCTING THE WELL DATE Ce/33
to Division of water Quality, Groundwater Section within 30 days
GW-1 REV. 12199

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELLCONTRACTOR: ,�ar-Ne,5
WELL CONTRACTOR CERTIFICATION #: Q&(2 I
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, Mnr'or\ County: mr'k)e' -c ll
IAAesl r A 6Q k •I r•Cesy- Loy �
(Road Name and N `mb rs, Community,�''r Subd''vision and Lot No.) DRILLING LOG DEPTH
3. OWNER ��h. �n KC9A,t+! From To FormationDescdptiou
Address C-).✓ lmt)
4. DATE DRILLED -6 -
5. TOTAL DEPTH 150
6. CUTTINGS COLLECTED YESF NOQ
7. DOES WELL REPLACE EXISTING WELL? YES NOQ
8. STATIC WATER LEVEL Below Top of Casing: .Sc� • FT.
C/" (Use'+' it Above Top of Casing)
9. TOP OF CASING IS� FT. Above Land Surface'
'Top of easing terminated at/or below land surface requires a variance In accor.
dance with 15A NCAC 2C A18
10. YIELD (gpm): y5_ METHOD PF TEST
11. WATER ZONES (depth): 160
12. CHLORINATION: Type CIOUX' AmountLf) Qel
13. CASING:
If additional space is needed use back of form zz
Wall Thickness LOCATION SKETCH
Depth Diameter or Weight/R. Material (Show direction and distance from at least two State
From To 73 Ft.. ' J5 � a � Roads, or other map reference points)
From To ? 3 Ft. L-15 Z L
From To Ft.f
14. GROUT: 3 Nebo t.oke Jar+�a5 tXIT
e
7� Depth Material Method
From 7'" _ To -)Q Ft ClZg
From To Ft.
15. SCREEN: ^
Depth Diameter Slot Size Material 7ZJ
From
To Ft—
in. in.
From
To —Ft. _
in —in. 4
From
To — Ft._
In in.
16. SAND/GRAVEL PACK('
Depth P�7 LS
®
bl�tB �I Gni
�\
From
To ". Ft.
"
Mid
N°
From
To 9 Pt.
17. REMARKS:
,
d
I DO HEREBY CERTIFY tATTtj�� ���( TRUC'�ED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STAND, nra RECORD HAS BEEN PR VIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Quad No: IGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submi ginal to Division of Water Ouality. Gmundwaler Section within 30 day5
Serial No. �� � ) L GW1 REV. 12/99

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: aivmeS i)�CLII
WELL CONTRACTOR CERTIFICATION#:
STATE WELL CONSTRUCTION PERMIT#:
WELL USE (Check Applicable Box): Residential [E Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL I
Nearest
and
3. OWNER
Address
sketch of the location below)
;n County:. C 06
Agricultural ❑ Monitoring ❑
Lot No.)- �- DRILLING LOG DEPTH
From To Formation Descriptio-i
City or Town ,,State Zip Code
4. DATE DRILLED '' 3JJ ,,,,St�
5. TOTAL DEPTH -70
6. CUTTINGS COLLECTED YES Q NO�S 7. DOES WELL REPLACE EXISTING WELL? YENO[�
8. STATIC WATER LEVEL Below Top of Casing: alj� FT.
(Use'+' if Above Top of Casing)
9. TOP OF CASING ISFT. Above Land Surface-
-Top of casing terminated atfor below land surface requires a variance In accor-
dance with 15A NCAC 2C.0118 !�
10. YIELD (gpm): )St METHOD OF TEST 2a'A? C
11. WATER ZONES (depth): Lis - (06 (
12. CHLORINATION: Type Amount 0- cZ.
13. CASING:
Wall Thickness
Depth- Diameter or WeighVFt. Material
From-4—To 170 " Ft. (a�,5 �I TVC
From —Tom -Ft. rr -aS lurk .5�cc�
From To Ft.
14. GROUT:
T Depth Material Method
From 12 _ To 2 Ft. eme,�
From To Ft.
15. SCREEN
Depth Diameter
From To Ft in.
From To Ft. in.
From To Ft. in.
16. SAND/GRAVEL PACK:
From 0 t fat �
From l�J I Ft
i n r 777
17. REMARKS:
ST
FOR OFFICE USE ONLY
Quad No:
Serial No.
O o
o r,
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)
3
0
5
1
Slot Size Material G'�
in. o.I
_ in. �y
In.
Material
ISTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
OF THIS RECORD HAS BEE PROVIDED TO THE WELL OWNER.
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
al to Division of Water Quality, Groundwater Section within 30 days
GW-1 REV. 12M
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 WELLCONTRACTOR: y_o,TV-e-N Gocatr. i &L 65�st)
WELL CONTRACTOR CERTIFICATION 0: is Ca�
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Appilcoble Box): Residentlal ® 'Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other F1 If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below) " ``
Nearest Town: County: �M i;,�0 W Q.1`
(Road Name jL4 Numbers. Communll , or Subdivision and Lot No.) DRILLING LOG
3. OWNER K�cu��n0� :� elv From To
Address LQ Y; y� �C C. _
(Stieel or Iou e o.
City or Town ny� late Zip Code
4. DATE DRILLED of —'sad
5. TOTAL DEPTH
—
6. CUTTINGS COLLECTED YESQ NOE
7. DOES WELL REPLACE EXISTING WELL? YES f__I NOQ'
B. STATIC WATER LEVEL Below Top of Casing: _ 13FT.
(Use'+' II Above Top of Casing)
9. TOP OF CASING IS I,. J FT. Above Land Surface*
-Top of casing terminated at/or below land surface requires a variance In accor-
dance with 15A NCAC 2C .011e
10. YIELD (gpm): QOZ METHOD OF TEST
11. WATER ZONES (depth): V' } 0 7
12. CHLORINATION: Type C QCt0( Amount J If additional space Is needed use back of form
13. CASING:
DEPTH
Fonnallon Description
o—
O
LOCATION SKETCH
Wall Thickness
Depth Diameter or WelghVFI. Maledal
FromTo FI. 6O--�!5 5 al 1`
, 1�—
(Show direction and distance from at least two State
Roods, or other map reference points)
�
From To Ft. (0.�5 3kaQCK
From To Ft.
14. GROUT:
Molhod
,/ i
�O-
j�I I
Me'lil
/1 o�e''llC fPPI�
(�
From TToplt�_Fl. ll
From To Ft.
�
VgKW�
15. SCREEN:
7
\51J
ceS'
Depth Diameter Slot Size Material
\\
From _ To _ Ft _ in. _. In.
r �t
From _ To _ Ft. _ In. _ In.
.0 ( L
From _ To _ Ft. _ In. _ In.
16. SAND/GRAVEL PACK:
E'
Depth Size Material
From To FL
From To Ft.
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH i5A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A CO Y
OF THIS RECORD HAS BEE PROVIDED TO THE WELLL OWNER.
FOR OFFICE USE ONLY d —/S—O�
Quad No: GNATURE OF PERSON CONSTRUCTING THE WELL DATE
!_-L—`+.1 , .. y- mil odgtnal to Division al Water Ouallty. Groundwater Secllon Within 30 days
Serial No. GW4 REV. 12/99
U
-onndwaie' Sectlaa
sl_Oiloe

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: ,i* -v 0- IEAA� ����ISo.
WELL CONTRACTOR CERTIFICATION#: c�iilf�
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: ($how sketch of the location below) /�1
Nearest Town: - nr o ✓` county:. I I I r J e)QdJe ( 1
Numbers, Community, or
3. OWNER
Address
uty or Iown State Zip Code
4. DATE DRILLED
5. TOTAL DEPTH b4c) r
6. CUTTINGS COLLECTED YES NO[7—
7. DOES WELL REPLACE EXISTING WELL? YES NOC3"
8. STATIC WATER LEVEL Below Top of Casing: AS' FT.
(Use'+' it Above Top of Casing)
9. TOP OF CASING IS _S FT. Above Land Surface'
-Top of casing terminated atlor below land surface requires a variance In accor-
dance with i NCAC 2C.011
(g�
10. YIELD (gpm): ;h METHOD OF TESJ
11. WATER ZONES (depth): Ll5r — SO
12. CHLORINATION: Type _Clorox' Amount. �!
13. CASING:
Wall Thickness
Depth Diameter or We1'phVFl. Material
DRILLING LOG DEPTH
From To Formation Descriptioo
O
_,
r..
n
�
r
J
o
-Y
c
If additional space is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least two State

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 WELLCONTRACTOR: SMQ6 (— iLr. �c�t.�Sot.Co?'J)
WELL CONTRACTOR CERTIFICATION #: QG(.A
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:
Nearest Town: _,
and
3. OWNER
Address
sketch of the location below) /}'�
D County: + e 'Dowe l�
and Lot No.) DRILLING LOG DEPTH
From To Formation Descnptioa
City or Town tale Zip Code
4. DATEDRILLED
5. TOTAL DEPTH 1011
6. CUTTINGS COLLECTED YES Q NO©�
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NOa
8. STATIC WATER LEVEL Below Top of Casing: .{g FT.
(Use'+' if Above Top of Casing)
9. TOP OF CASING IS to S FT. Above Land Surface'
'Top of casing terminated attor below land surface requires a variance In accor.
dance with 15A NCAC 2C.0118
10. YIELD (gpm): _Z METHOD OF TEST ;�er
11. WATER ZONES (depth): 9d t > r
�— laar
12. CHLORINATION: Type �-' �nrn1! Amount
13. CASING:
Wall Thickness
Depth �-1 Diameter or Welght/R. Material
From To Ft. R 27.G
From To L5 Ft.6­25_
From To Ft.
14. GROUT:
Depth Material Method
From 1.2�o � To 526 Ft. Omen
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:
From �F
From F
17. REMARKS: n"
I DO HEREBY ER
CONSTRUCTI N STA
FOR OFFICE USE ONLY
Quad No:
Serial No.
Material
O o
: `1C
�r
r r_
O N
fl 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)
2q
4/
ISTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
OF 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

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:(L_ ICA:M�5o� C0(15y) 7TQmP.t,
WELL CONTRACTOR CERTIFICATION #: is ( o ,
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ OtherE3 If Other, List Use:
2. WELL LOCATION: Sow sketch of the location below) �y1
Nearest Town: IL1ltoe, County:- t' 1 c !ir'weI
(Road Name and Numb rs, Communl or Sjivision and Lot No.)
DRILLING RILLING LOG DEPTH
3.
�
OWNER _ 1�4
From To Formation Description
Addre�sss�
f-tree or ou/ C 6l%s a
City or Town State Zip Code
4.
DATE DRILLED
5.
TOTALDEPTH
6.
CUTTINGS COLLECTED YES ❑ NOD—
o_
7.
DOES WELL REPLACE EXISTING WELL? YES 0 NOEE�-
8.
STATIC WATER LEVEL Below Top 9� of Casing: ipS 63 FT.
S?
9.
(Use'+' if Above Top of Casing)
TOP OF CASING IS /. S FT. Above Land Surface'
—
-=
'
'Top of casing terminated attor below land surface requires a variance in actor.
dance
10.
with 15A NCAC 2C .0110 r
YIELD (gpm): METHOD TEST 2G
n_ _
11.
9F
WATER ZONES (depth):J
12.
CHLORINATION: Type CIolOiC Amount %
If additional space is needed use back of form
13. CASING
Wall Thickness
✓ Depth / � Diameter or WIRat.
FromT/�,�,To �25L Ft. �� .s�L
plTo2100k
Material
From S� �a3 Ft. 11_2_S
QLv�
From To Ft.
14. GROUT:
Depth Meter I
Method
From To i1Ft.
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
Oep -Size Material
From I �:F
From - t FL _
17. REMARKS: II .. r n
FOR OFFICE USE ONLY
Quad No:
Serial No. t
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
LI 11/eb� Lvk� .SM�s Ex��
ISTRUCTED IN ACCORDANCE WITH 16A NCAC 2C, WELL
OF THIS RECORD HAS BEEJ PROVIDED TO THE WELL OWNER.
n.� < /-/7-
n L4.1 .
GNATURE OF PERSON CONSTRUCTING THE WELL DATE
to Division of Water Quality, Groundwater Section within 30 days
GW-1 REV. 12/99

228962
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mal Service Center - Raleigh. N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CE TIFICATION #:
STATE WELL CONSTRUCTION PERMIT#:
WELL USE Applicable sox): Residential ❑ Municipal R
industrial ❑ Agricultural ❑ Monitoring ❑
1. (Check
Recovery ❑ Heat Pump Water Injection ❑ Other 0 If Other, List Use:
2. WELLLOCATION: (Show sketch of the location below) M C D 61,e X� 0
Nearest Town: M i_ �-tn. County: —,
(DL
(Road Name and u Community. o�r1Suriatillist* Q Lot No.)
DEPTH
DRILLING LOG
Formation DesuipGon
3. OWNER �'t="'= N (' �^ �l' �' '% `'R"K!w"
From To
Address p 1S p � I � / O
rr �---�(Sbeet or ute o. L
City or Town Stare LD
4. DATE DRILLED a10
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑ NO[2'
REPLACE EXISTING WELL? YES Q
7. DOES WELL
8. STATIC WATER LEVEL Below Top of Casing: •a p FT -
(Use *.. it Above Top of Casft)
9. TOP OF CASING ISFT. Above Land Surface'
----
'Top of acing terminated at/or below Land curiae nqulra a variance In aeeor-
;' o
„• �_ ,__
danawlth 15A NCAC 2C.0118
METHOD OF TESTA I
.._�
c
10. YIELD (gpm): -1�1_
11. WATER ZONES (depth):".Cf.)6.,ra-�.�¢-•
I
N o
A ,,
12. CHLORINATION: Type CM LAN' ---Amount
if additional space is needed use back of form
13. CASING:
LOCATION SKETCH
Wall TNciness
Depth Diameter m weighvFt. Material
(Show direction and distance from at least two State
From To Ft.
From- - To 123 Ft. ° ( -
Roads, or other map relerencee points)
��tl✓✓✓
From To Ft.
UX
14. GROUT:
Depth Material Method
0
From To Ft.
From _� To 012—Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From —To—Ft— in. — in.
From —To —Ft. in. —in.
From —To _. Ft. in. —in.
16. SAND/GRAVEL PACK:
Depth Size Material
From To —FL —
From To Ft.
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CON UCTED IN ACCORDANCE WITH 15A NCAC 2C. WELL
CONSTRUCTION STANDARDS. AND THAT A CO THIS RECORD HAS EEAOVtDED TO THE WELL OWNER.
FOR OFFICE USE ONLY GATE
Quad No: SIGNATUR OF N CONSTRUCTING THE WELL
Submit original to Division of Water Duality. Glourdwater Section within 30 days Gw.t REV.'2199
Serial No.

228964
North Carolina - Depanment 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:"J�,
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable sox): Residential Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery n Heat Pump Water Injection ❑ Other It Other, List Use:
2. WELL LOCATION: (Sgow sketch of the location below) ��� �✓ _ /J /1
Nearest Town: /elr'""""' County.
(Road Name and ttuem. Cora+- - y. of +hdivision and Lot No.)
DRILLING LOG DEPTH
3.
OWNER (fJ /%A an �/JOt�(/�.Cs
From To Fomvation Descdpwn
Address
Cityor Town Stare Tip Code
4.
DATE DRILLED of f� CPO5.
TOTALDEPTH -Q-2J
n
6.
CUTTINGS COLLECTED YES ❑ NO[�
7.
DOES WELL REPLACE EXISTING WELL? YES
6.
STATIC WATER LEVEL Below Top of Casing: 40 FT-
c' —
(Use'+ it Above Tap—Fol=CaAnG)
9.
TOP OF CASING IS FT. Above Land Surface'
-Top of casing terminated atior below land surface requires a variance in actor-
O t
dancewlth
15A NCAC 2C 0118
X�L METHOD OF TES{T/
10.
YIELD (gpm):
11.
WATER ZONES (depth): �.�A "' l�2 f7C0
If additional space is needed use back of ford o
12.
CHLORINATION: Type Amount
13. CASING:
LOCATION SKETCH
Depth Diameter or WeigM(FLMaterial
(Show direction and distance from at,east tyro State
From To Ft.
From�To_14- Ft.
From To Ft.
14. GROUT:
Wall
Depth Material Method .
From To Ft.
From /D 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
I DO HEREBY CERTIFY THAT THIS WELL WAc
CONSTRUCTION STANDARDS. AND IHAT AC
FOR OFFICE USi~''ONLY }
Roads, or other map reference points)
RUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
THIS RECOM HAS BEEN PROVIDED TO THE WELL OWNER.
Ouad No: qq:��t��stwv+stunc
Sub"ll R!!P"W to Division
Sadai No. s
OF CONSTRUCTING THE WELL DATE
)I W Duality. Growidwater Section within 30 days
GWI REV. t2199

North Carolina - Department of Environment, Health, and Natural Resources FOR OFFICE USE ONLY
Division of Environmental Management - Groundwater Section R
P.O. Box 29535 - Raleigh, N.C. 27626-0535 QUAD. NO. ' 'SERIAL NO
Phone [phone] 'Lat ' Long. RO
Minor Basin
WELL CONSTRUCTION RECORD Basin Code
DRILLING CONTRACTOR: Header Ent. GW-1 Ent,
STATE WELL CONSTRUCTION 4 Q 3 2
DRILLER REGISTRATION N MBER: - f J PERMIT NUMBER:
1.
WELL LOCATION, (ShoNcsketch of the location below) b o
,
Nearest Tow n:�JT4 /(.�'2�-f/z County: r
f
tL-y JOI
(Road, Community, Subdivi/y"pnandLotNo.)
DEPTH DRILLING LOG
2.
OWNER �C
From To Formation Description
ADDRESS4 ?
(Street or Route No.)
/uC zS �s-z
N
City or Town State Zip Code
_
3.
DATE DRILLED /%- USE OF WELL
4.
TOTAL DEPTH 17 5,
5.
CUTTINGS COLLECTED YES ❑ NO©�
6.
DOES WELL REPLACE EXISTING WELL? YES NOQ,
7.
STATIC WATER LEVEL Below Top of Casing: FT.
(Use '+" if Above Top of Casing)
8.
TOP OF CASING IS FT. Above Land Surface*
• Casing
Terminated at/or below land surface is Illegal unless a variance is issued
in
9.
accordance with 15A NCAC 2C .0118
YIELD (gpm): . -0 METHOD OF TEST
10.
WATER ZONES (depth): Z�W 220
11.
CHLORINATION: Type s'' ' Amoun %$
If additional space is needed use back of form
12.
CASING:
LOCATION SKETCH
Wall Thickness
Depth Diameter or Weight/Ft. Material
(Show direction and distance from at least two State
From TO Ft.
Roads, or other map reference points)
From Tos-�L- Ft.
From To Ft.
13.
GROUT:
o c
Depth Material Method
a
From To —Ft.—�p
z
From To Z Ft.
\; J'
_
14.
SCREEN:
lly {jU0
Depth Diameter Slot Size Material
L
From To Ft in. in.
From To Ft. in. in.CD
c
From To Ft. in. in.
n
15.
SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
r4
,
From To Ft.I�
16.
REMARKS:
AO,HERUYtgRTIFYTHAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
NSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
ri,
4 lam- I
''� v SIGNATURE CONTRACTOR OR AGENT DATE
GWY RBV�`4N51 �,. 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]
' , FOR OFFICE USE ONLY
QUAD. NO. SERIAL NO.
Lat Long.`, ' RO
Minor Basin
WELL CONSTRUCTION RECORD Basin Code'
DRILLING CONTRACTOR: G� Header Ent. GW-1 Ent.
STATE WELL CONSTRUCTION A /1 0
/ `3 0
DRILLER REGISTRATION NUMBER:--),C PERMIT NUMBER:
1. WELL LOCATION: (Show sketch of the location below)
Nearest Town: Y1lLULac County:
ii�ly� 611 / <
(Road, Communiry,pi bdivifion ynd Lot No.) DEPTH DRILLING LOG
2. OWNER � )yy2 fir. r
From To Formation Description
ADDRESS
(S reet or Route o.) er') _. o i, l/1ce
City or Town State Zip Code
3. DATE DRILLED ZA± /S Z'' ' USE OF WELL
4. TOTAL DEPTH GJUS"
5. CUTTINGS COLLECTED YES ❑ NO©�
6. DOES WELL REPLACE EXISTING WELL? YESF7 NO©— o
7. STATIC WATER LEVEL Below Top of Casing: !ko FT. c— u
(Use'+" if Above Top of Casing)
8. TOP OF CASING IS ' FT. Above Land Surface' Ei
' Casing Terminated at/or below land surface is illegal unless a variance Is issued yo
in accordance with 15A NCAC 2C .0118 e
9. YIELD (glom): 4, METHOD OF TEST 1412 zE
10. WATER ZONES (depth): 61�z z e 43661 N
ca
11.
f
CHLORINATION: Type � E��-/� �� Amount `Zct
O
if additional space is needed use back of forrtft
12.
CASING:
LOCATION SKETCH
Depth
Wall Thickness
Diameter or Weight/Ft. Material
(Show direction and distance from at least two State
From To
From To --
Ft. y w
Ft.—sL
Roads, or other map reference points)
From To
Ft.
13.
GROUT:
Depth
Material Method
s
From To
20
Ft.
From (_ To
Ft.
£fir
14.
SCREEN:
Depth
From
To
From
To —
From
To
15. SAND/GRAVEL
PACK:
Depth
From
To —
From
To_
16. REMARKS;
Diameter Slot Size Material
Ft in. in.
Ft. in. in.
Ft. in. in.
Ft.
Ft.
Size Material
n n:
I DO HERESY GETIFY THAT THIS CALL
CONSTRUCTION STAPDARDS, AND THA
7Lo
WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
rA COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
�Jt ytM-/cd
SIGNATURE ONT�CTOR OR AGENT DATE
GW-1 REV. 9/91 Submit origin Divisi n 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]
�. FOR OFFICE USE ONLY
QUAD. NO. SERIALNO.
Lat. Long. RO .
Minor Basin
WELL CONSTRUCTION RECORD Basin Code
DRILLING CONTRACTOR: Header Ent.
1 STATE WELL CONSTRUCTION
DRILLER REGISTRATION NUMBER: <�E ir, C i i PERMIT NUMBER:
GW-i Ent.
r ^ n
- 1 '-
1.
WELL LOCATION; how S�k�et/Qh of the location below)
e Ir !
Nearest Town: County:
J
Road,CcWoily, or Subdivision/ nd Lot No.)
�
DEPTH
DRILLING LOG
2.
OWNER W r (J f� e} w-—
From To
Formation Description
ADDRESS /I.� 7 R C- P
(Street or Route No.)
nn
11 & P .---- P C_ i k\ !' �----
City or Town State Zip Code
Z— 2 - WELL
3.
DATE DRILLED USE OF
4.
TOTAL DEPTH Z'90
5.
CUTTINGS COLLECTED YES ❑ NOEe—
6.
DOES WELL REPLACE EXISTING WELL? YES NO
r_T12
7.
STATIC WATER LEVEL Below Top of Casing: go FT.
v or
(Use "+" if Above Top of Casing)
c3 G
8.
TOP OF CASING IS/ FT. Above Land Surface'
>c
- Casing Terminated at/or below land surface is illegal unless a variance is issued
In
accordance with 15A NCAC 2C .0118
A I y 7-
9.
YIELD (gpm): ) METHOD OF TEST
p� r
10.
C
WATER ZONES (depth): �✓�G� g
c
-+
o
11.
CHLORINATION: Type L• i'"� Amount .�V
CD
If additional space is needed use back of form
12. CASING
Wall Thickness
Depth
Diameter or Weight/Ft. Material
From
tJ
To
Ft.
From
To
Ft.—
—
From
To //////
Ft.
13. GROUT:
%�
Depth
Material Method
From
To
'c
Ft.
From
To G'
Ft
14. SCREEN:
Depth
From
To —
From
To —
From
To
15. SAND/GRAVEL
PACK:
Depth
From
To —
From
To-
16. 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 State
Roads, or other map reference points)
r'
r
yd/ n
5 C_ �C
I DO HEREBYCEATIFY 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.
SIGNATURE OF
GW-1 REV. MI Submit original to
ACTOR OR AGENT DATE
of Environmental Management and copy to well owner.

North Carolina - Department of Environment and Natural Resources - Division or Water Quality - Groundwat action Z 4 0 28
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone] F-
W Li
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION
STATE WELL CONSTRUCTION PER N:
1. WELL USE (check Applicable sox): Residential© Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other If Other, List Use:
2, WELL LOCATION: (Shpw sketch of the location below)
Nearest Town:._.JAAo4l County:
(Road Name and Numbers,�j�Ortapnuni_ty, or uhdivl iy/nand Lot No.) DRILLING LOG
DEPTH
3. OWNER �9--Q) From To Formation Description
Address 2 , 13 'j 4 H J
(street or flol
f`1 rJl� 0 Q
City or Town State Zip Code
4. DATE DRILLED 12 - iJ-Z`'V
5. TOTAL DEPTH a`Z � S ) — ---
6. CUTTINGS COLLECTED YES ❑ NO[a-' �` S--�s f r
7. DOES WELL REPLACE EXISTING WELL? YES Q NO��
S. STATIC WATER LEVEL Below Top of Casing: j & FT.
(Use'* it Above Top of Casing)
9. TOP OF CASING IS FT. Above land Surface' ` G7t,_
*Top of casing terminated atior below land surface requires a variance In accol Sa prr_
dance with 1SA NCAC 2C.0118
10. YIELD (gpm): _,l METHOD OF TEST A tK _ x
11. WATER ZONES (depth):._.1M�a-x-�=.� 2 'ram B
12. CHLORINATION:
13. CASING:
Type AmountWW
if additional space is needed use back of I
Wall Thickness
Depth Diameter or Weightl Material
From To Ft.� �-7y-y-.r,-
From�To� Ft. N
From To Ft.
14. GROUT:
Depth Material Method
From To Ft �
From � To Ft.
15. SCREEN
Depth Diameter Slot Size Material
From —To— Ft in. —in.-
From _ To _ Ft. in. —in.
From —To _. Ft. in. _ in.
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
17
I DO HEREBY CERTIFY THAT THIS WELL WAS
CONSTRUCTION_ STANDARDS, AND THAT A C
FQaR OFFICEU5@Q
ud No -
Serial No. it i 7 r dM� 11
,n t fpt
LOCATION SKETCH CD
O
(Show direction and distance from at least two State
Roads, or other map reference points)
1 \p
Lc T S ie
=a
RUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
THIS RECQR6R*S BEEN_F%4DWEED TO THE WELL OWNER.
Submit original to Division
INSTRUCTING THE WELL DATE
Groundwater Section within 30 days
GWA REV. 12l99

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section O L
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone] i
WELL CONSTRUCTION RECORD WELL CONTRACTOR: ATION #: eV'
WELL CONTRACTOR CERT IC (-)
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential L Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other EJ If Other, List Use:
Agricultural ❑ Monitoring ❑
2.
WELL LOCATION: (Show sketch of the location below)
Nearest Town: County:
1��
(Road Name and Numbers. Community.%r S bOvision and Lot No.)
DRILLING LOG
DEPTH
3.
OWNER �%%:JZ'"r
From To
Formation Description
Address
—(S
c r
Ch"� D Ci
reet o oute o.
A/dKr YL/a✓=
_ l
ilk;
A u
City or Town State Zip Code
4.
DATE DRILLED IZ—,Y—
S.
TOTAL DEPTH •-2•945_
i yb
6.
CUTTINGS COLLECTED YES ❑ NO�
7.
DOES WELL REPLACE EXISTING WELL? YES NOQL
6.
STATIC WATER LEVEL Below Top of Casing: 'Sc, FT.
to S
(Use '+ if Above Top of Casing)
O
9.
TOP OF CASING IS FT. Above Land Surface'
n-
-Top of "sing terminated at/or below land surface requires a varlance In accor.
p. oFn
dance with 15A NCAC 2C .0118
i TEST AJ /r 'S
� m
10.
YIELD (gpm): METHOD OF
11.
WATER ZONES (depth): /x,44- /..._ ILO,
12.
CHLORINATION: Type Amount �¢.�
If additional s f form ace is needed use back o
P tV mi
13. CASING:
Wall Thickness
Depth
Diameter or Weight/R. Material
From
To
d
Ft.
From
Tom=;+—
FLU
From
To
Ft.
14. GROUT:
Depth
Material Method
From
To
Ft.
From
df`�)— To 7-z—Ft.
--�Z 6' "—
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
co
LOCATION SKETCH
O o
(Show direction and distance from at least two State z
Roads, or other map reference points)
_ in.
in.
in. I
Material
r
. r
�f i�If f
till
FL�cr.IJ" �
I DO HEREBY CERTIFY THAT THIS WELL WAS CO STRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS. AND THAT ACO OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY -- DATE
Quad No: SIGNATURE OP#ERSON CONSTRUCTING THE WELL
Submit original to Division of Water Quality, Groundwater Section Within 30 days
GW-I REV. 12/99
Serial No.

24020
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]
NA
WELL CONSTRUCTION RECORD WELLCONTRACTOR:
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMIT#'. 1r-�
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: r(Show sketch of the location below) % Q�
Nearest Town:/�_��td" County:
(Road Name +And�Nu ers, Community, or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER /` i�iT'f/>h �L o12 f From To Formation Description
Address
(street or Route o.
c�
City or Town State Zip Code
4, DATE DRILLED r'Z •!;' �
5. TOTAL DEPTH :02
6. CUTTINGS COLLECTED YES ❑ NO❑1}
7. DOES WELL REPLACE EXISTING WELL? YES ❑
8. STATIC WATER LEVEL Below Top of Casing: _-yo FT.
(Use '+ it Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface'
-Top of casing terminated atlor below land surface requires a variance In accor-
dance with 15A NCAC 2C.0118
10. YIELD (gpm): 12 METHOD OF TEST i
11. WATER ZONES (depth): 1Z�.?,,
12. CHLORINATION: Type
13. CASING:
----------------------
_ K
Amount if additional space s needed use back of 1o4r11 1
y
LOCATION SKETCH
Wall Thickness
Depth Diameter or weight/A. Material (Show direction and distance from at least two State
From To Ft. Roads, or other map reference points)
From To
From To Ft.
14. GROUT:
Depth Material Method
From / To FL_�
t '•- 5��
From _fL_ To 11.E-Ft. � /rc4
15. SCREEN:
Depth Diameter Slot Size Material
From —To— Ft in. —in.-
From To_Ft_ in. in.
From —To—Ft.— in. . in.
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To FL
17
1 DO HEREBY CERTIFY THAT THIS WELL WAS COP
CONSTRUCT ,STAAID.ARDS iiNDTKATACOPY
it 1 ,
_ t
�-J
IN ACCORDANCE WITH 1/A NCAC 2C, WELL
r-?t a S BEEN PROVIDED TO THE WELL OWNER.
t-OR OFFICE r Q DATE
Quad No: 1 SIGNATUR OF SON CONSTRUCTING THE WELL
r
�" ' Submit origintNal to Division of ter Quality. Groundwater Section within 30 days
- GW-1 REV. 12/99
Serial No. tI"

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section 2 4 023
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CER F ATION #: �-
STATE WELL CONSTRUC N PERMIT#:
1. WELL USE (check Applicable Box): Residential LDS111' Municipal 0 Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other 0 If Other, List Use:
Agricultural ❑ Monitoring ❑
2. WELL LOCATION: (Shovi sketch of the location below)
Nearest Town: ---Al 6 " ^� County:
--Z- �7 15
(Road Name and Numbers, Community. or Subdivision and Lot No.) DRILLING LOG
3. OWNER a {may/ e-f= •n &=y%<'✓� From To
Address Z j _
/ "trees or a o. ��%�!
l� u � I�J.� ? Y "� 1�.-
City or Town State
4. DATE DRILLED "Z� - CX =6
S. TOTAL DEPTH `> 002
6. CUTTINGS COLLECTED YES Q NOQ-'
7. DOES WELL REPLACE EXISTING WELL? YES Q NO
8. STATIC WATER LEVEL Below Top of Casing: -C- FT.
(Use `.• it Above Top of Casing)
9. TOP OF CASING ISFT. Above Land Surface'
-Top of casing terminated at/or below land surface requires a variance In accor-
dance with 16A NCAC 2C.0118
10. YIELD (gpm): ` — METHOD OF TEST if
11. WATER ZONES (depth): 4 '� `1 CE 3 zo
DEPTH
Formation Description
12. CHLORINATION: Type
Amount
If additional space is needed use back of form
13. CASING:
LOCATION SKETCH $
Wall Thickness
direction and distance from at least two% to
Depth
Diameter
or Weight/Fl. Material
(Show
From To
Ft.
--,-,—
Roads, or other map reference points) fl
From�To___qF�S
Ft.
—emu
From To
Ft.
14.
GROUT:
Depth
Material Method
From To
From V To Z�
Ft.
F -
SCREEN:
15.
Depth
Diameter Slot Size Material
From To _ Ft
— in- —in.—
From —To _ Ft.
in. — in.��•
From —To _. Fi.
in. —in..
16.
SAND/GRAVEL PACK:
Depth
Size Material
From To —Ft.
-
From To
Ft.
17.
REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS COfjWUCTE'
CONSTRUCTION STANDARDS, AND THAT A CO F THIS R
FOR OFFICE 051761
Quad No: SIGNA E C
Aft; Submit original to Division of
IN ACCORDANCE WITH 15A N ' C 2C, VELL
-ORD HAS BEEN PROVIDED TO ISEWELL OWNER
P SON CONSTRUCTING THE WELL DATE
later Quality, Groundwater Section within 30 days
GW-i REV. 12199
Serial No.
I

I•UH OFFICE USE ONLY
Division of Environmental Management -Groundwater Section
.�,: -; �• . .
P.O. Box 29535 - Raleigh, N.C. 27626-0535
QUAD. NO..
- - SERIAL NO.,
Phone [phone]
LaL
Long.. - fici
-
Minor Basin
WELL COLISTRUCTION RECORD
Bask Cods
~ 1 ^_;
DRILLING
CONTRACTOR:
HeaderEnc
•; %GW-� �nE`.1
STATE WELL CONSTRUCTION
DRILLER REGISTRATION NUMBER: �d��l� PERMIT NUMBER:
1.
WELL LOCATION: (Show sketch of the location below) A
�c
Nearest Town: DArj,. ,,, County: l
1'
(Road. ComrAunity, or Subdivision and Lot No.)
DEPTH
DRILLING LOG
2.
OWNER —jUa
From To
Formation Description
ADDRESS j0 - i1:
(Street or Route No.)
(D
12nnk—
3.
Cyty or Town , '' `` -- ��11 ��,,hn'',,S,ia a Zip Code
DATE DRILLED/iLaa . USE OF WELL fjDUSVE
4.
TOTAL DEPTH (025
5.
CUTTINGS COLLECTED YES ❑ NO�
Q
6.
DOES WELL REPLACE EXISTING WELL? YES NO
7.
STATIC WATER LEVEL Below Top of Casing: FT.
(Use",' it Above Top of Casing)
1
--j
B.
TOP OF CASING IS i FT. Above Land Surface'
' Casing Terminated alfor below land surface Is Illegal unless a variance Is Issued
�\
In
accordance with 15A NCAC 2C .0118
9.
YIELD(gpm): U METHODOFTEST
10.
WATER ZONES (depth): llk 1A0�
ui o
11.
CHLORINATION: Type `- L1V'lr'p Amount
If addtional space is needed use back of form
12. CASING:
Wall Thickness LOCATION SKETCH
Depth Diameter or WeighVFt- Material (Show direction and distance from at least two State
From To Ft. �/� O Roads, or other map reference points)
From To I Ft.—L1L%�—
From To Ft.
13. GROUT: �JV
Depth Material Method
From To Ft. r¢—
From �_ To FL
14. SCREEN:
Depth
From To
From To
From To _
15. SAND/GRAVEL PACK:
Depth
From To —
From To
16. REMARKS:
D)0n r rY.0
IH 3ERTIFY;
U 117TIM--STRUCEBTION STAN[
Diameter Slot Size Material
Ft in. in. /
Ft. in. __ in.
Ft. in. in.
wA 4 5e,V
n 'Y'3
ED IN ACCORDANCE WITH 15A NCAC 2C, WELL
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
APR - 4 2000
SIGNATURE OF CIONTRA7FR OR AGENT PATE l
Submit oficinal to Division ironme.ntal Mnnanomcnt =n.l rn— r^. n i

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section `r O
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): Resldenbal ❑ Municipal U
Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection El Other If
Other, List Use:
2.
WELL LOCATION: �Jghow sketch of the location below)
.
Nearest Town: .1 • 9-f, r,, County: !
—j;, r n /
.,; -1- 5-
le
(Road Name and Numbers, Community. or Subdivision and Lot No.)
DRILLING LOG DEPTH
3.
OWNER
From To Formation Description
Address
beet or Houia� o.
City or Town State Zip Code
4.
DATE DRILLED
5.
TOTAL DEPTH
6.
CUTTINGS COLLECTED YES ❑ NOD--- -
7.
DOES WELL REPLACE EXISTING WELL? YES Q NOE�3---
8.
STATIC WATER LEVEL Below Top of Casing: ; ) FT.
(Use': it Above Top o) Casing)
9.
TOP OF CASING IS FT. Above Land Surface'
'Top
of casing terminated at/or below land surface requires is variance In accor-
dance with 15A NCAC 2C A11e
10. YIELD (gpm): Il METHOD OF TEST
11.
WATER ZONES (depth): Z ;
12.
CHLORINATION: Type Amount
If additional space is needed use back of form
13.
CASING:
LOCATION SKETCH
Wall Thickness
Depth Diameter orweight[R. Material
(Show direction and distance from at least two State '
From To Ft.
Roads, or other map reference points) CO
cD
From To 3 Ft. �- i<i =
_` -
From To Ft.
'--
14.
GROUT:
Depth Material Method
From To Ft.
From To lc• Ft. 7•' �
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.
I DO HEREBY CERTIFY THAT THIS WELL WAS
FOR OF
Quad No:
Serial No.
12 t
Material
r
ED IN ACCORDANCE WITH 15A NCAC 2C, WELL
RECORD HAS �EEN PROVIDED TO THE WELL OWNER.
JATURE qd% P�ERSON' NSTRUCTING THE WELL DATE
Division oIM1Naterilualily. Groundwater Section within 30 days
GW-1 REV. 12/99

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 flail Service Center - Raleigh, N.C. 27699-1636-Phone [phone] /
WELL CONSTRUCTION RECORD
WELL CONTRACTOR: �'-- 4` -t/
WELL CONTRACTOR CER IFICATION ft:
STATE WELL CONSTRUCTION PERMIT#
WELL USE (Check Applicable Box): Residential ®,�, Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other If Other, List Use:
20F85
Agricultural ❑ Monitoring ❑
2.
WELL LOCATION: (Show sketch of the location below)
Nearest To.wn: --1 /,-,.-•- County:
�� n
f
(Road Name and Numbers. Community. or Subdivision and Lot No.)
DRILLING LOG
3.
OWNER ' 1` " '"""" `'°'"
From To
Address i" �� ^.--_�_.,.,.r /Zct
C'
o.
ueet or puts , C
,
City or Town State Zip Code 7C y, _
4.
DATE DRILLED - it
5.
TOTAL DEPTH = `"
6.
CUTTINGS COLLECTED YES Q NO[J_�
7.
DOES WELL REPLACE EXISTING WELL? YES [� NOE7__
8.
STATIC WATER LEVEL Below Top of Casing: -`� -' FT.
(Use '+ it Above Top of Casing)
9.
TOP OF CASING IS If FT. Above Land Surface'
-Top of casing terminated at/or below land surface requires a variance In accor-
dance
with 15A NCAC 2C. 118
10.
11.
YIELD (gpm): METZHOD OF TE T
WATER ZONES (depth): " G
-71
DEPTH
Formation Description
12. CHLORINATION: Type " "_KAmountIf additional space is needed use back of form
13. CASING:
Wall Thickness
Depth
Diameter
or WeighVFI. Material
FramTT—
To
Ft.
--{�,-y-r-
—
From
To
Ft
From
To
Ft.
14. GROUT:
Depth
Material
Method
From
To
Ft.
From r =
To _Ft.
i
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
cnrucTal ICTION STANDARDS. AND THAT A C
Quad No:
Serial No.
LOCATION SKETCH
(Show direction and distance from) at least two State
Roads, or other map referent a points)
o
0
c�
O
r,-)
-i
TTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
F THIS RF76CFFIOHAS BEEN PROVIDED TO THE WELL OWNER.
IATURE OF RSON CONSTRUCTING THE WELL DATE
Division of Water Quality, Groundwater Section within 30 days
GW-I REV. 12l99

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
224031
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: 61
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMIT#: 441�2:-
1. WELL USE (check Applicable Box): ResidentialEr Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other F1 If Other. List Use:
2. WELL LOCATION, (Shoal sketch of the location below)
Nearest Towwn:: %p/ County:
/(..e-u �.XJwC-K
KoLC^ /�A DEPTH
(Road Name and Numbers. Community, or ubdivision and Lot No.) DRILLING LOG
3. OWNER From To Formation Description
Address r Di2
trees or me o.
AAA..... 1 , 2P1-3
City or Town State Zip Code
4. DATE DRILLEDa"
5. TOTAL DEPTH Zo
6. CUTTINGS COLLECTED YES Q NOQ� ..
7. DOES WELL REPLACE EXISTING WELL? YES Q NOQ� O
8. STATIC WATER LEVEL Below Top of Casing: �?O FT. -C--
(Use '+ if Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface'
-Top of "sing terminated atior below land surface requires a variance In actor- ^ m
dance with 15A NCAC 2C.0118 — =� m`
10. YIELD (gpm):_ METHOD OF TES001 IS I"
11. WATER ZONES (depth):
�U/� �—f AQT i!:J"O —ice
12. CHLORINATION: Type Amount ��- It add'rlrontal space is needed use back of Mom
13. CASING: O o
LOCATION SKETCH �
Wae Thickness
Depth Diameter or WeQWFL. Material (Stow direction and distance from at least two State
From To Ft. � —T— t r loads, -or other map reference points)
From—Q— To �Z- Ft. � �
From To Ft.
14. GROUT:-- A L/
Depth Material Method . /der go -eta`
From To Ft.
From f7 To 2,9 Ft.
15. SCREEN: V
Depth Diameter Slot Size Material Q
From —To—Ft— in. —M.-
From To _ Ft. in. _ in_
From To —Ft. in. _. in.
16. SAND/GRAVEL PACK:
Depth Size Material
From To —FL -
From To Ft.
17. REMARKS:
I DO HEREBY CERTIFY THAT. THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTIOWSTANOARDS. AND TkfAT A COPY OF RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY DATE
Ouad No: SIGNATURE OF RSON CONSTRUCTING THE WELL
Submit oglg4lat to Division of ater Quality. Groundwater Section within 30 days
GW-1 REV. 12/99
Serial No.

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELLCONTRACTOR:
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential Er Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other If Other, List Use:
2. WELL LOCATION:: (Show sketch of the location below)
Nearest Town: n4rilufiN County:
f(A /2d
(Road Name and Numbers, Community, oummsion and Lot No.) DRILLING LOG DEPTH
r
3. OWNER From To Formation Description
Address
(street or Houle o.
MA dAA4A1� c 2�7SZ
City or Town State Zip Code�-
4. DATE DRILLED ' 0U
5. TOTAL DEPTH —,io k'
6. CUTTINGS COLLECTED YES 0 NOE:��
7. DOES WELL REPLACE EXISTING WELL? YES Q NOQ�
6. STATIC WATER LEVEL Below Top of Casing: _90 FT.
(Use': it Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface'
*Top of casing terminated atfor below land surface requires a variance In actor.
dance with 15A NCAC 2C A71e
10. YIELD(gpTi _AL_METHOD ;O/FTEST
11. WATER ZONES (depth): �UUr r`5�V-,Qk!!
12. CHLORINATION: Type Amount If additional space is needed use back of form
13. CASING:
LOCATION SKETCH
Wall Thickness
Depth Diameter or WeighUFt. Material (Show direction and distance from at least two State
From To Ft. —T— Roads, or other map reference points)
From10 To -2 Ft. (�YK
From To Ft.
14. GROUT: , kW
Depth Material Method If✓u`rn"f_/"
From To Ft. / 7.
From To 24 Ft. 7 q
15, SCREEN: V o
Depth Diameter Slot Size Material
From —To— Ft in. in. a
From To Ft. in. _ in.
From —To _ Ft. in. in.
16. SAND/GRAVEL PACK:
Depth Size Material
From To —Ft. —
From To Ft.
17. REMARKS:
I DO HEREBY C IS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTIO N R F RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE US Y
Quad No: TURF OF RSON CONSTRUCTING THE WELL DATE
NC f j t o Division of ater Quality. Groundwater Section Within 30 days
Serial No. GW-1 REV. 12199
,50

72 North Carolina - Department of Environment and Natural Resources - Division of Water Ouality - Groundwater Section /-- '.7 3
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CER' IFICATION #:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential El Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
Agricultural ❑ Monitoring ❑
2.
WELL LOCATION: (Show sketch of the location below)
Nearest TowCounty:
eIU 2A
6
(Road Name and Numbers, Communi or Subdivision and Lot No.)
DRILLING LOG
3.
OWNER
From To
Address ru�-t rC d
Street or Route o.
— % - 7 C`
_
1I L-n.-... IItZ-
,/
City Or Town Stale
4.
DATE DRILLED-
/C
5.
TOTAL DEPTH yr'f
6.
CUTTINGS COLLECTED YES Q NOM-
7.
DOES WELL REPLACE EXISTING WELL? YES NOE]
`
8.
STATIC WATER LEVEL Below Top of Casing: o FT.
(Use'+' if Above Top of Casing)
9.
TOP OF CASING IS / FT. Above Land Surface*
-Top of casing terminated at/or below land surface requires a variance In accor-
dance with 16A NCAC 2C.011e
10.
YIELD (gpm): / Z METHOD OF TEST r
11.
WATER ZONES (depth): /? 4
DEPTH
Formation Description
'
12. CHLORINATION: Type /tea-«��= Amount If additional space is needed use back of for
13. CASING:
Wall Thickness
Depth
Diameter
or WeighVFt. Material
From To
From �' To My
Ft.
Ft..�
From
To
Ft.
14. GROLIT:
Depth
Material Method
From
To
Ft.
From /.)
To Z c
Ft. 2F1
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 CERTI WS'A
CONSTRUCTION S1
FOR OFFICF PSE 0
Quad No:
Serial No.
Slot Size Material
in.
in.
in.
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points) c (�
,1
il�1t—� II
Material
I
,Irirla„
ED IN ACCORDANCE WITH 1SA NCAC 2C, WELL
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
OF PERSON CONSTRUCTING THE WELL DATE
of Water Quality, Groundwater Section within 30 days
GW-1 REV. 12199

228959
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] ' OeV /(/((
j
WELL CONSTRUCTION RECORD WELL CONTRACTOR: 'Z
WELL CONTRACTOR CERTI ATION M:
STATE WELL CONSTRUCTI N PERMrT1f:
1. WELL USE (Check Applicable Boa): Residential unicipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other It Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: - County:
(Road Name and%Numbers, Community, ar Subdivision and lot No.) DRILLING LOG DEPTH
3. OWNER From To Formation Description
Address
(Sweet or uta
City or Town Slare LP Code �-� '® 8—
4. DATE DRILLED 25 _2-_(0 >
5. TOTAL DEPTH 120s__ 'A __-
6. CUTTINGS COLLECTED YES ❑ NO� _
7. DOES WELL REPLACE EXISTING WELL? YES Q NOCD/'
8. STATIC WATER LEVEL Below Top of Casing: J o FT- ^'
(Ilse': it Above Top of Casinp)
9. TOP OF CASING IS ! FT. Above Land Surface' o
-Top of casing terminated atior below land surface requlres a variance in actor-
dance with 15A NCAC 2C .011e�
10. YIELD (gpm): _(6 METHOD OF TEST I K 3
0
11. WATER ZONES (depth):
W �O t
__ p o
12. CHLORINATION: Type np^^-"�'� AmounLSL�-- it additional space is needed use back of form
13. CASING: / - -
LOCATION SKETCH
Wall Thickness
Depth Diameter or WmdghtlFL Material (Show direction and distance from at least two State
From To -T� Ft. Roads, or other map reference points)
From ®— To �� Ft.60 1 From To FL
14. GROUT:
Depth Material Method .
From To Fl.
From To`g—Ft. ZC/ j&
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: L
Depth Size Material
From —To—Ft—
From To Ft. `L
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTE IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS. AND THAT A COPY OF
CORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY '
Wad No: TORE OF PERSO TINE THE WELL DATE
Subrral origiasito Division W Water Quality, G undwater Section within 30 days
GW-I REV. 12/99
Serial No.

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N,C. 27699-1636-Phone [phone] k
r�:�364
WELL CONSTRUCTION RECORD WELL CONTRACTOR: zt'
WELL CONTRACTOR C IFICATION #: /O 6
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Bo:): Residential Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other 0 If Other, List Use:
2. WELL LOCATION:
(Show sketch of the location below)
,f� ,^1 G �( O
Nearest Town: I
A6bl.uan County:
AA
Road Name an�ry�ge_rs,
(14
communi or Subdivision and LoI No )
DRILLING LOG
DEPTH
3. OWNER o
L(H-cv (J-/1��
From To
Formation Descripticn
Address
�.
IreeluOr Route o:)Sr'
p �t
e.
IQ 2 g—s �_
—
,e .
City or Town State Zip Code
! �5 ^ 7i ��
L
ice^
4. DATE DRILLED
5. TOTAL DEPTHS `7
6. CUTTINGS COLLECTED YES ❑ NO[✓]
7. DOES WELL REPLACE EXISTING WELL? YES NO[2/
8. STATIC WATER LEVEL Below Top of Casing: !a (O FT. -
(Use '+' if Above Top of Casing) n
9. TOP OF CASING IS I FT. Above Land Surface' —Z�—
•Top of casing terminated atlor below land surface requires a varlance In actor. �--�
dancewith 15A NCAC 2C'.0118
10. YIELD (gpm): �IMETHOD OF TEST R) YL- let trttc� —
11. WATER ZONES (depth): 0) 9_ 4 to t .1�Re :.o
12. CHLORINATION: Type Amount If additional space is needed use back of loan
N
13. CASING:
Wan Thickness LOCATION SKETCH01 --
Depth Diameter or WeighVFt. Material (Show direction and distance from at least two State =-
From To � Ft. T,-Ar u )U✓� Roads, or other r>tap reference points)
From —� To FL �D�/L
From
To
Ft.
14. GROUT:
Depth
Material
Method
From
To c1 �1 Ft.
k�
T
Z
From
To
_Ft.
_
15.SCREEN:
Depth
Diameter
Slot Size
Material
From
—To—Ft—
in.
in.
From
To
Ft.
in.
in.
From
To
Ft.
in.
in.
16. SAND/GRAVEL PACK:
Depth
Size
Material
From
To
Ft.
From
To
Ft.
17. REMARKS:
I DO HEREBY CEIRr" it T`�'c kern i wet r N RUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION #rA�ID�RiDOAN) fii�A N3F"THIS RECOR9.bA"EEN PRC)VIDED TO THE WELL OWNER.
FOR OFFICE USE
Quad No: f RE O ER STRUCTING THE WELL DATE
submit origi ivision of Vale ality. Groundwater Section within 30 days
Serial No. GW-1 REV. 12199

,19366
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]
FOR drF10S USE ONLY' '''
QUAD. NO. <- SERIAL NO
Lat. Long.
Minor Basin - - -
WELL CO STRU TION RECORD I Basin Code
DRILLING CONTRACTOR. I Header Ent GW
STATE WELL CONSTRUCTION
DRILLER REGISTRATION NUMBER: ���J(� (� PERMIT NUMBER:
1. WELL LOCATION: (Show skett h of the location below) cyn
Nearest Town: O Lb l'6w County: iv
(Road,Commlunity, or Subdivisiopnn and Lot No.) DEPTH DRILLING LOG
2. OWNER %.t/!w Qu.CA✓t From To Formation Description
ADDRESS
(Street or Route No.I
�vye--r 1%) < /
City or Town State Zip Code
3. DATE DRILLED y -0 USE OF WELL /ElCitt.d e
4. TOTAL DEPTH BOSS'
5. CUTTINGS COLLECTED YES ❑ NOO--
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO�
7. STATIC WATER LEVEL Below Top of Casing: 02fj FT.
(Use't it Above Top of Casing)
8. TOP OF CASING IS FT. Above Land Surface'
Casing Terminated atlor below land surface Is Illegal unless a variance Is Issued
In accordance with 15A NCAC 2C .0118
9. YIELD (gpm):—,11 METHOD OF TEST Pf
10. WATER ZONES (depth):
11. CHLORINATION: Type
��A oun�
12. CASING:
Wail Thickness
Depth Diameter or WeighUFt. Material
From To Ft. �T�
From---Q-- To y62 Ft. I -T
From To Ft.
13. GROUT:
Depth Material Method
From To Ft.
From �_ To �—Ft.
14. SCREEN:
Depth
From
To Ft
From
To Ft.
From
To Ft.
15. SAND/GRAVEL
PACK:
Depth
From
To
From
To
16. REMARKS:
Diameter Slot Size Material
in. in
in. _ —in
in. in
Size Material
Ft.
Ft.
,: _
It additional space is needed use �1ack otforin
cn --
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
GaQj*jP"`
VAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.

:-i3369
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]
FORdrRct=USEONLV''':-': "'•`.
QUAD. NO. --SERIAL NO
lac' -
Minor Basin -
WELL CONSTRUCTION RECORD Basin Code -
DRILLING CONTRACTOR: Header Ent
STATE WELL
_1DC r CONSTRUCTION
DRILLER REGISTRATION NUMBER: PERMIT NUMBER:
1. WELL LOCATION: (Show ketch of the location below) ��J e
Nearest Town: ©L A t0d6-+ County: —✓ bt; �
+7
(Road, Community, or
OWNER M.n.
ADDRESSS
(Street or Route No.)
_ nj ford }I� 76
City or Town Stale Zip Code
3. DATE DRILLED USE OF WELL jJaLzi.9-
4. TOTAL DEPTH U
5. CUTTINGS COL CTED YES ❑ NO��
6. DOES WELL REPLACE EXISTING WELL? YES F__j NO[g-
7. STATIC WATER LEVEL Below Top of Casing: /OQ FT.
(Use -.' it Above Top of Casing)
8. TOP OF CASING IS FT. Above Land Surface'
Casing Terminated atlor below land surface Is Illegal unless a variance Is Issued
In accordance with 15A NCAC 2C .0118
9. YIELD (gpm): ?_ METHOD OF TEST
10. WATER ZONES (depth): S .� mac. 700
11. CHLORINATION: Type Amount
12. CASING:
Wail Thickness
Depth
Diameter
or Weight/Ft.
Material
From—ToT
From—� To
Ft. r
%� FL--/�+ /
From To
Ft.
13. GROUT
Depth Material Method
From To Ft. n,A, �'/�q
From To � Ft. A�
14. SCREEN:
Depth
From
To Ft
From
To Ft.
From
To Ft.
15. SAND/GRAVEL
PACK:
Depth
From
To
From
To
16.
Diameter Slot Size Material
in. in
in. --in
in. in
Size Material
Ft.
Ft.
DEPTH DRILLING LOG
From To Formation Description
v r
If additional space is needed use 11 gk ofTdrm
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
;Oe'4
WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
) THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.

93
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]
FOR dFFICE USE ONLY
QUAD. NO. - SERIAL NO
Lac Land: PO
Minor Basin
WELL CONSTRUCTJPN RECORD I Basin Code
DRILLING CONTRACTOR: Header Ent r GW fi€ht"
n STATE WELL CONSTRUCTION
DRILLER REGISTRATION NUMBER: /_ 'g PERMIT NUMBER:
1. WELL LOCATION: (S ow sketch of the location below) ,
Nearest Town: i d6y l County: ���L/4/ .l�ueff
T-a4,--r{;t , ,mot tl,2-4
(Road, Community, or Subdivision and Lot No.) DEPTH DRILLING LOG
2. OWNER L From To Formation Description
ADDRESS *yt9-+r ice. LoQe
(Street or Route No.)
City or Town State Zip Code
'/ 'O
3. DATE DRILLED y i mo USE OF WELL h�OlJt F
4. TOTAL DEPTH �o�
5. CUTTINGS COLLECTED YES ❑ NO[
6. DOES WELL REPLACE EXISTING WELL? YES NO�
7. STATIC WATER LEVEL Below Top of Casing: Y o FT.
(Use'+" if Above Top of Casing)
8. TOP OF CASING IS FT. Above Land Surface'
Casing Terminated atfor below lend surface Is Illegal unless a variance Is Issued
In accordance with 15A NCAC 2C .0118
9. YIELD (gpm):I V& METHOD OF TEST 1411Z
10. WATER ZONES (depth): yn
11. CHLORINATION: Type Amount If additional space is needed use back oEform
12. CASING:
Depth Diameter
From To Ft.
From-0.— To !O Ft.�
From To Ft.
13. GROUT:
Depth
From To —
From To _
14. SCREEN:
Depth
From
To
From
To
From
To
15. SAND/GRAVEL
PACK:
Depth
From
To —
From
To_
16. REMARKS:
rn -
Wail Thickness LOCATION SKETCH
or Weight/Ft. Material (Show direction and distance from at least two State
-P � e Roads, or other map reference points)
—��— �—vim
Material Method
—Ft.
—Ft. rVo
Diameter Slot Size MaterialFt in. in.
Ft. in. __in.
Ft. in. in.
Ft.
Ft.
Size
Material
WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
;hevi
ON STANDAR D. THAT A COPY OF THIS RE ORD HAS BEEN PROVIDED TO THE WELL OWNER.
� / (1 nl
dwater SeCfb�( Re onel

"7 ,
North Carolina - Department of Environment, Health, and Natural Resources .. FOR 6FRi;t= USE ONLY `
Division of Environmental Management - Groundwater Section _ -
P.O. Box 29535 - Raleigh, N.C. 27626-0535 QUAD. NO.. - SERIAL NO
Phone [phone] Lar -- L.onj. ""- RO -o"
Minor Basin
WELL CONSTRUCTION RECORD Basin code
DRILLING CONTRACTOR:
Header EnL-GW-fight
STATE WELL CONSTRUCTION
DRILLER REGISTRATION N BER: r��C� PERMIT NUMBER:
1. WELL LOCATION: (Show sketch of the location below)
Nearest Town: e)&Ofokt� County:
(Road, Comm iry, or��G-ubdiwsidn d Lot No.) n I DEPTH
2. OWNER ��-"-p_ �.�1 Pad C2 6'sO From To
ADDRESS
(Street or Route No.)
rot &C
City or Town �,r_. State Zip Code
3. DATE DRILLED 4C4A �,..w USE OF WELL _ZIQCIJF CPU- 32
4. TOTAL DEPTH o f
5. CUTTINGS COLLECTED YES ❑ NO[� —
6. DOES WELL REPLACE EXISTING WELL? YES NOE: -•
7. STATIC WATER LEVEL Below Top of Casing: /j�Cq FT.
(Use','if Above Top of Casing)
8. TOP OF CASING ISFT. Above Land Surface'
Casing Terminated atfor below tend surface Is Illegal unless a variance Is Issued
In accordance with 15A NCAC 2C .0118
9. YIELD (gpm):_L6_ METHOD OF TEST
10. WATER ZONES (depth):A�
DRILLING LOG
Formation Description
r z
11. CHLORINATION: Type Amount r& T If additional space is needed use Keck of`iorm
12. CASING: rn
Wall Thickness
Depth Dia= or W Mac
FromToElm--b.0 FL
From To / j Ft.
From To Ft.
13. GROUT
Depth Material Method
From To Ft.
From _� To 7-0 Ft.rl
14. SCREEN:
Depth
From
To
From
To
From
To
15. SAND/GRAVEL
PACK:
Depth
From
To —
From
To_
16. REMARKS:
Diameter Slot Size Material
Ft in. in.
Ft. in. __ in.
Ft. in. in.
Size Material
Ft.
Ft.
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
HIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
AND_ THAT A COPY OF THI RECORD HAS BEEN PROVIDED TO THE 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] f n t,�
WELL CONSTRUCTION RECORD WELL CONTRACTOR: -( y
WELL CONTRACTOR C_. TIFICATION a:—//�Y.,
STATE WELL CONSTRUCTION PERMIT#:
1, WELL USE (check Applicable sox): ResidentialD Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other If Other, List Use:
2. WELL LOCATION: (Show,sketch of the location below)
Nearest Town: �% % 0_16�—County.
/"C its o
(Road Name and Nunfiefbl, Cortxnunity. or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER /N 6- From To Formation Descopticn
Address A424-c1rt,_
(street or RouIe1To7
AL,
City or Town States Zap Code
4. DATE DRILLED 4
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑ NOQ_,--'
7. DOES WELL REPLACE EXISTING WELL? YES Q NOQI i
8. STATIC WATER LEVEL Below Top of Casing: & FT. _
(Use'.' if Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface* o
-Top of casing terminated aVor below land surface requires a variance In accor-
dance with 15A NCAC 2C.011e -
10. YIELD (gpm): J_I�_ METHOD OF TENT 14
11. WATER ZONES (depth): �� ✓l✓H r y y�
12. CHLORINATION: TypeP,mount If addit pace is needed use back of lean
13, CASING: r —+
LOCATION SKETCH
Wall Thickness —
Depth Diameter orweightl t. Material (Show direction and distance from at least two State
From To Ft. Roads, or other map ret Fence points)
From-- To Ft.JU�
From To FL /
14. GROUT:
Depth Material Method D
From �'1 To Ft. ��
From �L To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From —To—Ft— in. in.
From —To Ft. in. in.
From —To _ Ft. in. in.
16. SAND/GRAVEL PACK:
Depth Size Material
From To —Ft. —
From To Ft.
17
I DO HEREBY CERTIFY THAT THIS WELL WAS
FOR OFFICE
Quad No:
Serial No.
ED IN ACCORDANCE WITH 15A NCAC 2C. WELL
R£CO PR(6mDED TO THE WELL OWNER.
OFP NSTRUCTING THE WELL DATE
of Wate Q ty. Gmundwaler Section Within 30 days
GW-1 REV. 12/99

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center . Raleigh, N.C. 27699-1636-Phone [phone] i Q Q
WELL CONSTRUCTION RECORD WELLCONTRACTOR i�
WELL CONTRACTOR ERTIFICATION #: /nn, ./
STATE WELL CONSTRUCTION PERMIT#:
WELL USE (Check Applicable Box): Residential 2_�' Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other El If Other, List Use:
Agricultural ❑ Monitoring ❑
2. WELL LOCATION: (Show sketch of the location below) G�r
Nearest Town: A1aAt A!-_ County:
6h -,f( iC
(Road Name an ers, Convnunikor Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER , 1 �' J.S/� From 7o Formation Description
Address 2f (� '
—T�Street or ome o. — Dip
��I,xh,. ) r �Lz
rty or Town State ZiD Codo
4. DATE DRILLED--
5. TOTAL DEPTH r` Q
6. CUTTINGS COLLECTED YES Q NO��
7. DOES WELL REPLACE EXISTING WELL? YES Q NO[D
6. STATIC WATER LEVEL Below Top of Casing: , .-,QF7.
(Use '+' it Above Top of Casing) — -
9. TOP OF CASING IS FT. Above Land Surface'
-Top of casing terminated atfor below land surface requires a variance In actor- _O -
dance with 16A NCAC 2C .d11e
10. YIELD (gpm): r METHOD OF TEST�-
r.,
11. WATER ZONES (depth): `-
12. CHLORINATION: Type Amount
13. CASING:
Wall Thickness
Depth Diameter or WeighVFI. Material
From To Ft.
From( FL
From To Ft. ,, //
14. GROUT:
Depth Material Method
From n_ ToFt.
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
itionai 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 HEREB O ST UCTED IN ACCORDANCE WITH 1 NCAC 2C, WELL
CONSTRUC S N R N T IS RECOR HAS BEEN P ED TO THE WELL OWNER.
FOR OFFICE ONLY
Quad No: !Jt� i 9�, li SIGNATURE O PE N CONSTRUCTING THE WELL DATE
Su al to Division of Wat r ualiry, Groundwater Section within 30 days
GW-1 REV. 12/99
Serial No.

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:
WELL CONTRACTOR CE IFICATION #: �O
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: JShow3ketch of the location below)
Nearest�T—o{d' wn: Azzgt County: Yl
TT
(Road Name Iand Numh Community, or S bdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER h i From To Formation Description
Address,R N )
//
M n veer or A)
City or Town Stale Zip Code !n �i A� Q
4. DATE DRILLED � -0-c)
5. TOTAL DEPTH /AO
6. CUTTINGS COLLECTED YES ❑ NOQ--'
7. DOES WELL REPLACE EXISTING WELL? YES Q
8. STATIC WATER LEVEL Below Top of Casing: &A3 FT.
(Use •.' if Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface' CD -
-Top of casing terminated at/or below land surface requires a vartance In eccor. --t
dance with 15A NCAC 2C .0118 — -
10. YIELD (gpm): __d1_ METHOD OF TEST
11. WATER ZONES (depth): �I ---
n .
12. CHLORINATION: Type
13. CASING:
Wall Thickness
Depth Diameter or WeighVR. Material
From To Ft. r _2=(f From�To�- FL� �-r /C
From —To —Ft.—
14. GROUT
Depth Material Method
From To FL/ 7'--
From - eC To2O 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.
I DO HEREBY CERTIFY THAT THIS WELL WAS
CONSTRUCTION
USE
Quad No:
Serial No.
Material
V If ddifionai space is needed use back of 100it
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
Ifie-/Vr
Z-17 t�
ak '-+0 r1
tD IN ACCORDANCE WITH 15A NCAC 2C, WELL
RECORD H 8.6EEN PROVIDE LL OWNER.
OF PER UCTING THE WELL DATE
of Water Qualit-fAvridwater Section within 30 days
GW-I REV. 12/99

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone] ^
WELL CONSTRUCTION RECORD WELL CONTRACTOR: f#o `-y363
WELL CONTRACTOR CoTIFICATION N: l0(�, V
STATE WELL CONSTRUCTION PERMITA:
WELL USE (Check Applicable Box): Residential EK Municipal Q Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other 0 It Other, List Use:
Agricultural ❑ Monitoring ❑
2.
WELL LOCATION: (Show sketch of the location below)
f
9-Y/,
�
Nearest Town: Mn-�z2- County: Z,f
^>'�y/J
7"�l /Z,1
(Road Name and Numbers, Convnurrr4�//try. or Subdivision and Lot No.)
DRILLING LOG DEPTH
3.
OWNER LJ �.G
From To Formation Description
Address �L #'lo
-(Sveet or
1%'9aj.y : rU
City or Town State Zip Code
4.
DATE DRILLED V-/0^6C7
5.
TOTAL DEPTH ays-
6.
CUTTINGS COLLECTED YES Q NOE2
7.
DOES WELL REPLACE EXISTING WELL? YES Q NOQ—_
�a
8.
STATIC WATER LEVEL Below Top of Casing: fdV FT.
(Use': if Above Top of Casing)
9.
TOP OF CASING ISFT. Above Land Surface
o
-Top of of casing terminated at/or below land surface requires a variance In actor-
T T-
--i
dance with 15A NCAC 2C .0118
(o -' 2
10.
YIELD (gpm): METHOD OF TEST
-CST
11.
WATER ZONES (depth): Zc,y / //t2
12.
CHLORINATION: Type Amount r "ZLY
If additional space is needed use back of lom
13.
CASING:
LOCATION SKETCH ct1
Wall Thickness
Depth Diameter or Weight/R. Material
(Show direction and distance from at le t two State
From To Ft. f
Roads, or other map reference p nts)
From To Ft. �—
b t
From To Ft.
1
14.
GROUT:
Depth Material Method
From To Ft.
From To Ft.
15.
SCREEN:
Depth Diameter Slot Size Material
From To Ft in. —in.—
From To Ft. in. in.
From —To Ft. in. in.
16.
SAND/GRAVEL PACK:
Depth Size Material
From To —Ft. —
From To Ft.
17.
REMARKS:
1 DO HEREBY S UCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCT T D D OF IS REPEITO
HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE LY
-
Ovatl No: U,`
NATURE OF PE
ON CONSTRUCTING THE WELL DATE
Submit 'ginal o Division of Wat
Quality. Groundwater Section within 30 days
Serial No.
,__� ..,,�
GW.I REV. 12199

:_i9365
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]
FOR OPRCE USE ONLY';"
OUAD. NO.. - SERIALNO.
LaL - - Long:
Minor Basin - - - '%I'_
WELL CONSTRUCTION RECORD I Basin Code
wM
DRILLING CONTRACTOR: Header Ent { GW-f �hL.,.,;:.;
STATE WELL CONSTRUCTION
DRILLER REGISTRATION NUMBER: /©& 4/ PERMIT NUMBER:
1. WELL LOCATION: n(Show sketch of the location below)
Nearest To n: /�CICA,I�/N County:
4 �.- A
(Road, om (y, or Subdivision and Lot No.) DEPTH DRILLING LOG
2. OWNER ; r•������i�'` From To Formation Description
ADDRESS A ` A&.ei elieAs 'u _
(Street or Route No.) 0� A
City or Town State Zip Code r
3. DATE DRILLED_ USE OF WELL
4. TOTALDEPTH 4(,0'
5. CUTTINGS COLLECTED YES ❑ NO❑e_ _
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO[a— _
7. STATIC WATER LEVEL Below Top of Casing: 4_�D FT.
(Use -i if Above Top of Casing) _
8. TOP OF CASING IS FT. Above Land Surface'
• Casing Terminated atior below land surface Is Illegal unless a variance Is Issued
In accordance with 15A NCAC 2C .0118
9. YIELD (gpm):._(a MET/HOD OF TEST
10. WATER ZONES (depth): 'P aOA, Q_ /SO
rry _
11. CHLORINATION: Type Amount
12. CASING:
Wall Thickness
Depth Diameter or WeightiFl. Material
From To Ft. o
From-40 To Z ? Ft-� — From To Ft.
13. GROUT
Depth Material Method
From To Ft. -
From _5a To _2-0 Ft. 7 t 4'e
14. SCREEN:
Depth
From
To
From
To
From
To
15. SAND/GRAVEL
PACK:
Depth
From
To —
From
To
16. REAAA24a.
=
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 State
Roads, or other me '§q points)
'al
WELL WAS CONSTRUCTED IN ACCORDANCE WITH 1SA NCAC 2C, WELL
). THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.

North Carolina - Department of Environment and Natural Resources - Division of Water Quality Groundwater Section r r
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
K
WELL CONTRACTOR COKTIFICATION #: /0(�
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: —p,, � County:
(Road Namew an N1 eerrss C uniry. or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER /�. From To Formation Description
Address (Dzn 2 —
^�r��// (Sweet orRooute o.)--
~ City or own State Zip Code
4. DATE DRILLED
S. TOTAL DEPTHn
6. CUTTINGS COLLECTED YES ❑ NOQ�—
7. DOES WELL REPLACE EXISTING WELL? YES[] NO©--
8. STATIC WATER LEVEL Below Top of Casing: $,,c— FT. -
(Use'*' it Above Top of Casing) CD
9. TOP OF CASING IS FT. Above Land Surface'
-Top of casing terminated attor below land surface requires a variance in actor- C-)
dance with 16A NCAC 2C .a11 a
10. YIELD (gpm): _(�_ METHOD OF TEST ?i� /ti2 -
11. WATER ZONES (depth):F.indwallet
_ Asheville -� _
12. CHLORINATION: Type Y Amount !/, It additional space is needed use back of f r�r r.
13. CASING:
Wall Thickness
Depth
Diameter or WeighVFt. Material
From
O
To
12
Ft. _
From
To
Ft
From
To
Ft.
14. GROUT:
Depth
Material Method
From
To
Ft.
From = To .2 0
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
s- —
LOCATION SKETCH C —
(Show direction and distance from at least two State '-
Roads, or other map reference points)
1 ter,
I DO HEREBY 2C, WELL
CONSTRUCTION $jNy T T i L A UCTRECORD HIN ORDANCE WITH AS BEN PROV115A NCAC E WELL OWNER.
FOR OFFICE USE I DATE
Quad No: RE OF P SO CON CTING THE WELL
l to ivision of Water O ality, ndwaler Section Within 30 days
GW-1 REV. 12/99
Serial No. %'"dwatr:t_:�7j...

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Maii Service Center - Raleigh, N.C. 27699-1636-Phone [phone] !., 1 9
WELL CONSTRUCTION RECORD WELLCONTRACTOR:
WELL CONTRACTOR CE IPICATION #: /O 6 U
STATE WELL CONSTRUCTION PERMIT#:
WELL USE (Check Applicable Box): Residential LD Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other If Other, List Use:
2. WELL LOCATION:: (Showsketch of the location below)
Nearest Town: nIC-1.," `_ T1—county:.1J r J UGCI�SU
(Road Name and Numbers, Community. or SuMivision and Lot No.)
3. OWNER
Address
City or Town State Zip Code
�
4. DATE DRILLED �Z'd2 0
5. TOTAL DEPTH �:3&ar
6. CUTTINGS COLLECTED YES ❑ NO®
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO[jJ
8. STATIC WATER LEVEL Below Top of Casing: /0(�) Fr.
(Use'*' if Above Top of Casing)
9. TOP OF CASING IS Fr. Above Land Surface'
-Top of casing terminated actor below land surface requires a vartance In accor-
dance with 15A NCAC 2C.0118
10. YIELD (gpm): _V_ METHOD OF TEST 4 /re
11. WATER ZONES (depth):
12. CHLORINATION: Type
13. CASING:
Wall Thickness
Depth Diameter or WeighVFt. Material
From To Ft.
From To Ft.—(, — �--5
From To Ft.
14. GROUT:
Depth Material Method /�yy From To Ft. I
_ �3T
From � To 5-9 Ft. Z ��
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:
Quad
No
Serial No.
Agricultural ❑ Monitoring ❑
DRILLING LOG DEPTH
From To Formation Descdpticn
I f addig nal space is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
4STRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
0
-)FftHIS RECORD BEEN PROVIDED TO THE WELL OWNER.
GNATURE OF PeRSONV
ONSTRUCTING THE WELL DATE
to Division of Water Quality. Groundwater Section Within 30 days
GW-1 REV. lZ199

North Carolina - Department of Environment, Health, and Natural Resources - FOR (�PFlC� USE ONL'!?}'.
Division of Environmental Management - Groundwater Section
P.O. Box 29535 - Raleigh, N.C. 27626-0535 QUAD. NO.: - - SERIAL NO
Phone [phone] - LaL Lnrxj: Fi0 %%'•f:" -
Minor Basin - ' WELL CONSTRUC ION RECORD
Basin Code - - - —
DRILLING CONTRACTOR: Header Ent.GYV-f€ht
STATE WELL CONSTRUCTION
DRILLER REGISTRATION NUPERMIT NUMBER:
1. WELL LOCATION: (Show sketch of the location below)
Nearest Town: _MaAA.Onti.� County
(Road, Community, Or Sybdivisi-5� nd Lot No.) DEPTH DRILLING LOG
2. OWNER i(/Lc. / AV&44glj From To Formation Description
ADDRESS
(Street or Route No.) ! /]
City or Town State Zip Code
3. DATE DRILLED —00 USE OF WELL 0 — 110
4. TOTAL DEPTH ybS�
5. CUTTINGS COLLECTED YES ❑ NOOK
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NOEL�_—
7. STATIC WATER LEVEL Below Top of Casing: 6 e9 FT.
(Use': it Above Top of Casing)
8. TOP OF CASING IS FT. Above Land Surface'
• Casing Terminated atfor below lend surface Is Illegal unless a variance Is Issued
In accordance with 15A NCAC 2C .0118 ✓�
9. YIELD (gpm): 2 METHOD OF TEST
10. WATER ZONES (depth):— V /�' '. G, 3 40
11. CHLORINATION: Type P e4&!weVn0 Amount �'s�
12. CASING:
Wall Thickness
Depth Diameter
or WeighVFt. Material
From
To Ft.
From o
To 9— Ft_.�o
From
To Ft.
13. GROUT:
Depth Material Method
From
To Ft.
From O
To c240 Ft.
14. SCREEN:
Depth
From To
From To
From To
15. SAND/GRAVEL PACK:
Depth
From To —
From To_
16. REMARKS:
APR 2 8 20N `i ,
Diameter Slot Size Material
Ft in. in.
Ft. in. _— in.
Ft. in. in.
If additional space is needed use b= of
(Show direction and distance from at least two State
Roads, or other map reference points)
Zy0
AUCTYD IN ACCORDANCE WITH 15A NCAC 2C, WELL
THIS CORD HAS BEEN PROVIDED TO THE 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]
FOR d FICI= USE Otq n
QUAD. NO.: - - §ERIAL Now'' t -.
71
Lat Long.-
Minor Basin -
r
WELL CONSTRUCTION RECORD Basin Code
DRILLING CONTRACTOR: ' Header Ent t GW-{ @hi
STATE WELL CONSTRUCTION
DRILLER REGISTRATION NUMBER: /Q 6 (� PERMIT NUMBER:
1. WELL LOCATION: (Show sketch of the location below)
Nearest Town:County: Nl��«�✓�
(Road,(
2. OWNER
ADORE;
Lot
DEPTH DRILLING LOG
From To Formation Description
C (Slreel o ou No.) 6'—
r-_ Jl
City or To tale Zip Code '
3. DATE DRIL D 4-�/-d0 USE OF WELL FioXa.C.
4. TOTAL DEPTH 5V4Z
5. CUTTINGS COLLECTED YES ❑ NO[�-
6. DOES WELL REPLACE EXISTING WELL? YES Q NOQ-
7. STATIC WATER LEVEL Below Top of Casing: &,,n FT.
(Use'.' it Above Top of Casing)
8. TOP OF CASING IS FT. Above Land Surface'
Casing Terminated atlor below land surface Is Illegal unless a variance Is Issued
In accordance with 15A NCAC 2C .0118
9. YIELD (gpm):ZZ,_ METHOD OF TEST /4/1'Z
10. WATER ZONES (depth): /Z 7,aei2
11. CHLORINATION: Type {:mount
12. CASING:
Irr—
Wall Thickness
Depth Diameter or Weighl/Ft. Material
From To FL
From42To--&-4_ FL- Z�w —2�2_
From To Ft.
13. GROUT:
mnwl�__-w
MW
If additional space is needed use
(Show direction and distance from at least two State
Roads, or other map reference points)

North Carolina - Department of Environment, Health, and Natural Resources FOR dfFlcE USE ONL'r
Division of Environmental Management - Groundwater Section n
P.O. Boa 29535 - Raleigh, N.C. 27626-0535 QUAD. NO - - SERIAL NO
Phone [phone] Lat.-) long'
Minor Basin
WELL CONSTRUCTION RECORD Basincode - :- --_
DRILLING CONTRACTOR: Header Ent t GW-f EhC
STATE WELL CONSTRUCTION
DRILLER REGISTRATION NUMBER: /061/ PERMIT NUMBER:
1. WELL LOCATION: (Show sketch of the location below) p�
Nearest Town: K, � �[1w M County: —.L olrf_ -
(Road. Community, Subdivision and Lot No.) DEPTH DRILLING LOG
2. OWNER :5 C-4 r. �,f •w�--� /A/n(�i.y J From To Formation Description
ADDRESS a
(Street or Route No.)
2,0 - yr
aA- tw N 2 ,P Z�
City or Town Slate Code
3. DATE DRILLED - Z-00 USE OF WELL / �(' - �(OO
4. TOTAL DEPTH /Go
5. CUTTINGS COLLECTED YES ❑ NOQ�
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO®/
7. STATIC WATER LEVEL Below Top of Casing: _z/_ FT.
(Use '+' if Above Top of Casing)
8. TOP OF CASING IS FT, Above Land Surface'
Casing Terminated atlor below land sudaoe Is Illegal unless a variance Is Issued
In accordance with 15A NCAC 2C .0118
9. YIELD (gpm):._ V METHOD OF TEST
10. WATER ZONES (depth):
11. CHLORINATION: Type Amount -" 1
12. CASING:
Wali Thickness
Depth Diameter or Weight/Ft. Material
From To Z- o Ft. � Flo J�
From To!V 6 Ft..�f�
From To Ft.
13. GROUT:
Depth Material Method
From To Ft.
If additional space is needed use
e o
O
O
LOCATION SKETCB(
(Show direction and distance from at least t
Roads, or other map reference points)
P�

i 3367
Division of Environmental Management - Grouncwater Section
P.O. Box 29535 - Raleigh, N.C. 27626-0535
Phone [phone]
FUH UFFICE USE ONLY -'-
QUAD. NO. - - SERIAL NO. -
Lal. Long. Ad
Minor Basin
WELL CONSTRUCTION RECORD Basin Coda -
DRILLING CONTRACTOR: I Header EnL - GW ant
STATE WELL CONSTRUCTION
DRILLER REGISTRATION NUMBER: Lf) (o el PERMIT NUMBER:
1. WELL LOCATION: (Show sketch of the location below)
Nearest Town: MQwCount l
(Road, Community, or 5ubdivisinon an/�6ud1 Ldl No.) DEPTH DRILLING LOG
2. OWNER XA60A (O`f'From To Formation Description
ADDRESS Cain
(Street or Route No.) O —
City or To — - Katy rp Code
3. DATE DRILLED O USE OF WELL _/ �f _ -- 0 Zt/O
4. TOTAL DEPTH 2 9(4
5. CUTTINGS COLLECTED YES ❑ NOOK
6. DOES WELL REPLACE 1
7. STATIC WATER LEVEL 1
8. TOP OF CASING IS_j
Casing Terminated al/or below lay
In accordance with 15A NCAC 2C
9. YIELD (gpm):_I7_ N
10. WATER ZONES (depth):
11. CHLORINATION: Type
12. CASING:
Depth Diameter
From To Ft. �—
From Tom Ft.
From To Ft.
13. GROUT:
Depth
From To Ft.
From To Ft.
14. SCREEN:
Wall Thickness
or Weigh9Ft. Material
Material
Depth Diameter Slot Size
From To Ft in. in.
From To Ft. in. in.
From To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size
From To Ft.
Method
Material
Material
1 l7
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
6/Ly
Q
W , C q/ e
HEREBY CE�i-i;tFY HIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
sotB C�ION STAND AND THAT A COPY OFnTHIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
. /, r
SIGNATURE OF CCbf YRACTOR OR AGENT PATE
GW-1 REV. 9r91 Submit wiainal to Division of Environmontal

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone] '
WELL CONSTRUCTION RECORD WELL CONTRACTOR: —�
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMIT#: /C16 (Z
1. WELL USE (Check Applicable Box): Residential P Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
Agricultural ❑ Monitoring ❑
2. WELL LOCATION: (Show sketch of the location below) a^
Nearest Town: M cl bt 72-- County: �'� - kJ O c✓ee-!�
/1tt / t / 70 1,--' 67 vary L[ ,.
(Road Nameand Numbers, Convnuniry, or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER From To Formation Description
Address -2cqc,/
­ 15treetor oute o.
t/>i �Fnrfd /C e'J 76
City or Town tale Zip Code
4, DATE DRILLED -&C
5. TOTAL DEPTH 6,GS-
6. CUTTINGS COLLECTED YES ❑ NO[:}
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO[>}-
8. STATIC WATER LEVEL Below Top of Casing: /{i0 FT. CZ) _
(Use '+' if Above Top of Casing)
9. TOP OF CASING IS / FT. Above Land Surface'
'Top of casing terminated atfor below land surface requires a variance In accor. _
dance with 15A NCAC 2C .0116 _
10. YIELD (gpm): 1,52 METHOD OF TEST 21/ /f
11. WATER ZONES (depth): /.' our$alon --
30/,,. (7S� isheville e 0 ry
12. CHLORINATION: Type aAi.a,-le Amount Y44 If additional space is needed use back of loiM -�
rn
13. CASING:
Wag Thickness
Depth Diameter
or Weight/Ft. Material
From To Ft. , -
From—Q— To
C
From To Ft.
14. GROUT:
Depth Material
Method
From To Ft.,/7
/1 -2
From To 0 Ft.�
L- t-
15.SCREEN
Depth Diameter
From To _ Ft _ in.
From To Ft. in.
From ._ To _ Ft. _ in-
16. SAND/GRAVEL PACK:
Depth
From To Ft.
From To Ft.
17. REMARKS:
a•
Slot Size Material
in.
in.
in.
Size Material
Cell
FOR OFFICE ¢j NLY
Quad No: UIUI i._ii,i I , %�1{J�� IGiJATURE OF
Submi gin Io Division of V
Serial No.
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
IN ACCORDANCE WITH 15A NCAC 2C, WELL
MRD HAS13EEN PRI34DED TO THE WELL OWNER.
NSTRUCTING THE WELL DATE
Groundwater Section within 30 days
Gw-I REV. 12r99

:, 193 75
North Carolina - Department of Environment. Health, and Natural Resources FOR afFlC1= USE ONLY
Division of Environmental Management - Groundwater Section -
P.O. Box 29535 - Raleigh, N.C. 27626-0535 QUAD. NO. - - - SERIAL NO
Phone [phone] Lat. RO_�""--•=`-
Minor Basin
WELL CONSTRUCTION RECORD Basin Code
DRILLING CONTRACTOR: Header Ent f GW-f Ohl
STATE WELL CONSTRUCTION
DRILLER REGISTRATION N 1SER: / �C/ PERMIT NUMBER:
1. WELL LOCATION: (Show sketch of the location below) � � �%fn
Nearest Town: Z2:" iL� County: l� � b/12<)`('iv-J'
(Road, Community„ or ubdiv,sion an of .) DEPTH
2. OWNER —QM From To
ADDRESS zedT rLt1 %'u r G
al){2f fit
(Street or R/ ou No.) /'_
7�2
City or Town Slate ip Code
3. DATE DRILLED /b O USE OF WELL
4. TOTAL DEPTH mi15-
5. CUTTINGS COLLECTED YES ❑ NO�'
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO[gi
7. STATIC WATER LEVEL Below Top of Casing: �� FT.
(Use'+' it Above Top of Casing)
8. TOP OF CASING IS FT- Above Land Surface'
Casing Terminated atlor below tend surface Is Illegal unless a variance Is Issued
In accordance with 1sA C 2C .0118 jp0
9. YIELD (gory: METHOD OF TEST b� GtoW^ e'ona
10. WATER ZONE (depth): �2,412! INw SOo
11. CHLORINATION: Type ��� Amount
12. CASING:
DRILLING LOG
Formation Description
If additional space is needed use b& c of J arm
Wall Thickness
LOCATION SKETCH
Depth
Diameter
or Weight/Ft. Material
(Show direction and distance from at least two State
From
a
To
1;X
Ft.
Roads, or other map reference points)
From
To
Ft.
From
To
Ft.
t
13. GROUT:
Depth
Material Method
/
From
To
Ft.
From _
To 26
Ft.
-4_
14. SCREEN:
V 1
Depth
From
To
From
To
From
To
15. SAND/GRAVEL
PACK:
Depth
From
To —
From
To_
16. REMARKS:
Diameter Slot Size Material
Ft in, in.
Ft. in. _ in.
Ft. in. in.
Size
Ft.
Ft.
Material
T THIS WELL WAS CONSTRUCTED IN ACCORDANCE
DS. AND THAT A COPY OF THIS RECORD HAS BEEN
15A-I'1ftdC-2C, WELL
DIED TO THE WELL OWNER.
Groundwater Section

North Carolina - Department of Environment, Health, and Natural Resources- -
FOR OFRCE USE ONLY `' ?:
Division of Environmental Management - Groundwater Section QUAD. NO.. - SERIAL NO
P.O. Box 29535 -Raleigh, N.C. 27626-0535 - �.r :_r 0
Phone[phone] Lat
Minor Basin - -
WELL CONSTRUCTION RECORD Basin code --
DRILLING CONTRACTOR: Header Ent
STATE WELL CONSTRUCTION
DRILLER REGISTRATION UMBER: /Q(� PERMIT NUMBER:
1. WELL LOCATION: (Show sketch of the location below)
Nearest Town: 44aA4" a. County: de7d�' �•t/4'rCJ'
Subdivision
2. OWNER
(Street or Route No.)
e?doIt,in1. N.6 aps-z.
City or Town State Zip Code
3. DATE DRILLED 3-0-I-O92 USE OF WELL NO2A.
4. TOTAL DEPTH / SO
5. CUTTINGS COLLECTED YES ❑ NO[�'
6. DOES WELL REPLACE EXISTING WELL? YES NOF__j
7. STATIC WATER LEVEL Below Top of Casing: /0 FT.
��
(Use'.' if Above Top of Casing)
XZ
8. TOP OF CASING IS / FT. Above Land Surface'
Casing Terminated at/or below lend surface Is Illegal unless a variance Is Issued
In accordance with 15A NCAC 2C .0118
9. YIELD (gpm): Z L METHOD OF TEST R/
10. WATER ZONES (depth): �2y f' "f 0 90
11. CHLORINATION: Type (—Amount
12. CASING:
Wail Thickness
Depth Diameter or Weighl/Ft. Material
From d To 21— Ft. t
From —To FI.G — From To Ft.
13. GROUT:
Depth Material Method
From To Ft.
From --4�)— To Ft. Z E/
14. SCREEN:
Depth
From To -
From To -
From To -
15. SAND/GRAVEL
From —
From _
16. REMARKS:
r IROMEREBY
CONSTRUCTI
.1
!; APR 2 620i)li
Diameter Slot Size Material
Ft
in.
in.
Ft.
in. __
in.
Ft.
in.
in.
Ft.
ft ! 9 200n
DEPTH
From To
Of 2q
3S 50
If additional space is needed
DRILLING LOG
Formation Description
(Show direction and distance from at least
Roads, or other map reference pas)
A Fw �° 'ej
Can^f-
/<G
ZZ�
CER�IFY T�e®aelot- —"'dTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
ON STANDARDS, AND. THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
V 1
Tian;

North Carolina - Department of Environment. Health, and Natural Resources FOR 8PRCE USE ONL';
Division of Environmental Management - Groundwater Section, 1
P.O. Box 29535 - Raleigh, N.C. 27626-0535 QUAD. NO. - - SERIAL NO,
Phone [phone] Lar -Loeg-
Minor Basin
WELL CONSTRUCTION RECORD Basin Code -•
DRILLING CONTRACTOR: Header Ent GW-i @hL
STATE WELL CONSTRUCTION
DRILLER REGISTRATION NUMBER: e J (o PERMIT NUMBER:
1. WELL LOCATION' (Show sketch of the location below)
Nearest Town: /�1 j � County:
(Road, Community, or Subdivision and Lott No.) DEPTH DRILLING LOG
2. OWNER 7aNAJr C m �CTC+Q From To Formation Description
ADDRESS. :xka h _
(Street or Route No.) ^ 7rL
City or Town Slate Zip Codo--�--
3. DATE DRILLED 3--9-.15040 USE OF WELL
4. TOTAL DEPTH VC
5. CUTTINGS COLLECTED YES ❑ NO[�
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO©-
7. STATIC WATER LEVEL Below Top of Casing: dcyy_ FT.
(Use -i it Above Top of Casing)
8. TOP OF CASING IS FT. Above Land Surface -
Casing Terminated at/or below land surface Is Illegal unless a variance Is Issued
In accordance with 15A NCAC 2C .0118
9. YIELD (gpm): q METHOD OF TEST f{ 1 YL
10. WATER ZONES (depth): Sq.4G1S
11. CHLORINATION: Type Amount 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 To Ft.
From-0 Tom Ft.:CLY 8.0{
From —To Ft.
13. GROUT:
Depth Material Method
From To Ft.
From Q_ To i� Ft. I
14. SCREEN:
Depth
From To _
From To _
From To _
15. SAND/GRAVEL
From
From
16. REMARKS:
11D( HEREBYCE
^" CONSTRUCTION
J. ��
t
Diameter Slot Size Material
Ft in. in.
Ft. in. _ in.
Ft. in. in.
Ft.
Roads, or other map reference points)
Q•
-04,I't �G4r-iow
.eaeeea;aMil MIN nnnicrRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
DS, AND. THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.

North Carolina - Depariment of Environment, Health, and Natural Resources FOR aFFIbE USE ONL'tj r n
Division of Environmental Management - Groundwater Section r r9 •�
P.O. Box 29535 - Raleigh, N.C. 27626-0535 QUAD. NO. - SERIAL NO.�
Phone [phone] Lat �n9 " RO
Minor Basin
WELL CONSTRUCTION RECORD Basin Code
DRILLING CONTRACTOR: Header Ent ' GW�I ht
STATE WELL CONSTRUCTION
DRILLER REGISTRATION NU BER: PERMIT NUMBER:
1. WELL LOCATIO (Show $ketch of the location below) ��G� �/�C.Y NearestTown: A4A,L1r-' County:
(. C
(Road, Comm nity, or ubdiw}ion an Lo o.) DEPTH DRILLING LOG
2. OWNER .G. �� From To Forma don Description
ADDRESS
�7l (SI et or Route No.) O ��
/iaA4;rn-' A JC o?R7f L
City or Town State Zip Coda
3. DATE DRILLED ^ oo USE OF WELL f iz2ttle
4. TOTAL DEPTH yOS
5. CUTTINGS COLLECTED YES ❑ NO[j?f
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NOCP--
7. STATIC WATER LEVEL Below Top of Casing: qo FT.
(Use",'if Above Top of Casing)
8. TOP OF CASING IS FT. Above Land Svface'
' Casing Terminated atlor below lend surface Is Illegal unless a variance Is Issued 0
in accordance with 15A NCAC 2C .0118
9. YIELD (gpm):�Z— METHOD OF TEST Q— c2
10. WATER ZONES (depth): VZ.7,/m Imo/ 3J0 1 0
90
11. CHLORINATION: Type Amount C5L� If additional space is needed use bid& of
12. CASING:
Wall Thickness LOCATION SKETCfA
•--1
Depth Diameter or Weight/Ft. Material (Show direction and distance from at least tw�late
From TO Ft. Roads, or other map reference points)
From-115 - ToFt�fpE
From To Ft. IMOl }ter
13. GROUT:
Depth Material Method
From To Ft. r z lap
From 6_ To 2A Ft. f%r
14. SCREEN: �� � SV�jrtYL
Depth Diameter Slot Size Material
From To Ft in. In.—/7J
From To Ft. in. __ in. �"
From To Ft. in. in.
15. SAND/GRAVEL
D �i2W R Material
From Ft.
From Fl.
16. REMARKS: `
I� I.DOIOEkEBY D STRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
COTSRUCTO}a�OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
i
APR 2
h
��nzti

North Carolina - Department of Environment, Health, and Natural Resources
FOR C3RFICS USE ONL'r - '
Division of Environmental Management - Groundwater Section
QUAD. NO.
,.. ''.
- SERIAL NO
P.O. Box 29535 - Raleigh, N.C. 27626-0535
_
Phone [phone]
tat.
- Long
Minor Basin
-
WELL CONSTRUCTION RECORD
Basin Code
-- ---. •-.::
-,i.
C
DRILLING ONTRACTOR:
HeaderEnt.
^t-
°'GW-ttht
STATE WELL CONSTRUCTION
DRILLER REGISTRATION NAM ER! �Q(p(� PERMIT NUMBER:
1. WELL LOCATION: (Shgw sketch of the location below) a `
Nearest Town: `Y, 9AG,tY' County: ••"
%ZQO ✓)77 &j ads
DEPTH
DRILLING LOG
(Road, Community, o ubdiw i nand of No.)
',/
2. OWNER !Q44: i�,r(.C/ili3rc
From To
Formation Description
ADDRESS A.✓s��C.vC�
n (Street or Route No.)
A1rad
_
/ Q
Ii/ l' "Pe
City or Town late ip Code
6
r ��
3. DATE DRILLED 3-5_� USE OF WELL �=
4. TOTAL DEPTH f/09'
5. CUTTINGS COLLECTED YES ❑ NOQ-
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO(g'
7. STATIC WATER LEVEL Below Top of Casing: SO FT.
(Use •i if Above Top of Casing)
B. TOP OF CASING ISFT. Above Land Surface'
' Casing Terminated at/or below land surface Is Illegal unless a variance Is Issued
In accordance with 15A NCAC 2C .0118
9. YIELD (gpm):A— METHOD OF TEST F� /
10. WATER ZONES (depth): L/ POIEZ o .4s0
11. CHLORINATION: Type Amount
12. CASING:
Wail Thickness
Depth Diameter orWeight/pt. Material
From—To—Ft.—,,,�
From To� FL — 'C) 3�
From To Ft.
13. GROUT:
Depth Material Method
From To Ft. (—
From _� To _24) Ft. ZEl
14. SCREEN:
Depth
From To _
From To _
From To _
15. SAND/GRAVEL
16.
I?
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)
Diameter Slot Size Material
Ft in. in.
Ft. in. __ in.
Ft. in. in.
Depth 0
From To
From To
jjR;;MjE�jAF ._
kfl RAJY C£R!TIF
CONSTRUCTION STAI OAR
P;A,K —
ED IN ACCORDANCE `/JITH 15A NCAC 2C, WELL
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.

Za >z
North Carolina - Department of Environment, Health, and Natural Resources FOR dFFlcE USE ONLY
Division of Environmental Management - Groundwater Section -,
SERIAL NO. NO. -
P.O. Box 24535 -Raleigh, N.C. 27626-0535 QUAD. _
Phone [phone] - Lau - Long -.-
Minor Basin
WELL CONSTRUCTION RECORD Basin Code
DRILLING CONTRACTOR: Header Ent
,I�y STATE WELL CONSTRUCTION
DRILLER REGISTRATION NUMBER: 166 7 PERMIT NUMBER:
1. WELL LOCATION- (Show sketch of the location below) S
Nearest Town:-;W County: P
terra. 1201
(Road, Community, or Subdivision and Lot No.) DEPTH DRILLING LOG
2. OWNER From To Formation Description
ADDRESSU
�(Street or Route No.) 7a
��
Z 47S2
City or Town State , /Zip Coda
3. DATE DRILLED —60 USE OF WELL '
4. TOTAL DEPTH 2 5�0
5. CUTTINGS COLLECTED YES ❑ NO©— c
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NOOK 8
7. STATIC WATER LEVEL Below Top of Casing: _go FT.
(Use'.' if Above Top of Casing)—or*r
8. TOP OF CASING IS : %2 FT. Above Land SuHace' i
1
• Casing Terminated al/or below land surface Is Illegal unless a variance Is Issued :;.—Ca.<
In accordance with 15A NCAC 2C .011e , 46
9. YIELD (gpm): 15 METHOD OF TEST ao
Ir
10, WATER ZONES (depth): = T?
11. CHLORINATION: Type Amount If additional space is needed use back of ?um
12. CASING:
Wail Thickness LOCATION KETCH
Depth Diameter or Weight/Ft. Material (Show direction and distance fr m at least two State
From TO Ft. Roads, or other map refer nce points)
From Cam_ To Ft.—
From To Ft.— J_
13. GROUT:
Depth Material Method
From To Ft. Y°
From Q_ To 20 FL ZE/
14. SCREEN: ZZi 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 — ial
From To LS U L5
From To Ft.
16. REMARKS: KIT�',� C��iPEBY QERTIF STR CTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
{IQ STRUCTION STA Y OF IS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
j 1 t APR 2 '

P.O. Box 29535 - Raleigh, N.C. 27626-0535 QUAD. NO.. -
- SERIAL NO. -a•:{...•-;_ t' `
Phone [phone] Lat. Long,
` FIC
WELL CONSTRUCTION RECORD Minor Basin
_
eosin coda - -
DRILLING CONTRACTOR: Header Ent - -
-GW-)'@tit.'^:;;:.
STATE WELL CONSTRUCTION
DRILLER REGISTRATION NUMBER: 106 C' PERMIT NUMBER:
1.
WELL LOCATION: (Show sketch of the location below)
Nearest Town County: ,,/) County:
(Road. Comm%u %" or Subdivis�ion� and Lot No.) DEPTH
DRILLING LOG
2.
OWNER jrCQ /(/ From To
ADDRESS G.+ ell AOi
Formation Description
/ /t&-3 (Street or Route No.) ^
c29� / 41
r
City or Town State Zip Cod
3.
DATE DRILLED ' —00 USE OF WELL Am,-2.4�-
4.
TOTAL DEPTH 8 2
5.
CUTTINGS COLLECTED YES ❑ NO[�
6.
DOES WELL REPLACE EXISTING WELL? YES ED NOE9,—
7.
STATIC WATER LEVEL Below Top of Casing: ,Q FT,
8.
(Use'." it Above T_op of Casing)
TOP OF CASING IS
FT. Above Land Surface'
G
• Casing
Terminated atfor below land surface is Megal unless a variance is Issued
CD
In
accordance with 15A NCAC 2C .011B
9.
YIELD (gpm):_�_ METHOD OF TEST o4
10.
WATER ZONES (depth): 7
r,2aw
F :rem
11.
CHLORINATION: Type .(Uilll Amount �Q If additional space is
needed
use b of fQHq
12.
CASING:
_ - ma
Wall Thickness
Depth Diameter or Weia_hVFI. Material
From To Ft. -T L
From_ 0— ToFt.��l�
From To Ft.
13. GROUT:
Depth Material Method
From To Ft.
From fn To 20 Ft. 2 /
14. SCREEN:
Depth
From
To
From
To
From
To
15. SAND/GRAVEL PACK:
Depth
From
To
From
To_
16. REMARKS:
100 HEREBY CERTIFY 1
CONSTRUCTION STANC
Diameter Slot Size
Ft in. in.
Ft. in. in.
Ft. in. _ in
1�i7p M,
t 4.1.
'Mau I
IqT HIS WELL WAS CONS-
. Ashevi
2 8_>1�� i it i
Material
LOCATION SKETCe
(Show direction and distance from at least two
Roads, or other map reieregce points)
��
I�� �►Iri
Cal
e- ( A/i r-
ED IN ACCORDANCE WITH 15A NCAC 2C. WELL
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
SIGNATURE OF COKTRACTOR OR AGENT PATE
Submit original to Oivkion of Errvironnwnfal Manannmont —n

North Carolina - Department of Environment. Health, and Natural Resources
Division of Environmental Management - Groundwater Section FOR dFFlCE USE ONLV:+��I,
P.O. Box 29535 - Raleigh, N.C. 27626-0535 QUAD. NO.: - §EAIAL NO
Phone [phone] L.at Long,.`
Minor Basin
WELL CONSTRUCTION RECORD Basin Code
DRILLING CONTRACTOR: Header Ent t GW-t€h`t
STATE WELL CONSTRUCTION
DRILLER REGISTRATION NUMBER: /QG y PERMIT NUMBER:
1. WELL LOCATION: (Show sketch of the location below)
Nearest Town: 444A4�, County:
(Road. Community, or Subdivision and Lot No.)
2. OWNER Z�_ p
ADDRESS— j=
beet or Route No.)
161 _<17
City or Town Stale Zip Code
3. DATE DRILLED _9 i0 _'00 USE OF WELL
4. TOTAL DEPTH
5. CUTTINGS COLLE TED YES ❑ NOffl'
6. DOES WELL REPLACE EXISTING WELL? YES Q NOQ
7. STATIC WATER LEVEL Below Top of Casing: ion FT.
(Use'i if Above Top of Casing)
8. TOP OF CASING IS FT. Above Land Sutface'
• Casing Terminated atlor below land surface Is Illegal unless a variance Is Issued
In accordance with 15A /CAC 2C TH /�
9. YIELD (gpm):.�L—METHOD OF TEST
10. WATER ZONES (depth): _16fM(/ P �y� 99�
11. CHLORINATION: Type Amount 7(A9t
12. CASING:
DEPTH
From To
If additional space is needed
DRILLING LOG
Forma don Description
Wail Thickness LUUA I IUN JKtMH
Depth Diameter or WeighuFt. Material (Show direction and distance from agDast
From To Ft. Roads, or other map reference poo points:
From tQ—_ To— Ft.
From To Ft. rr �'
13. GROUT
Depth
From
To —
From
To _
14. SCREEN:
Depth
From
To
From
To
From
To
15. SAND/GRAVEL
PACK:
Depth
From
To —
From
To_
16. REMARKS:
100 REBY CERTIFY TF
I I .�,
HjUCTION STANDA
\t
IN ACCORDANCE WITH 15A NCAC 2C, WELL
-ORD HAS BEEN PROVIDED TO THE WELL OWNER.

Division of Environmental Management - Grouncwater Section - FUH OFFICE USE ONLYF%'1-;^. H1
9 - -
P.O. Box 29535 - Raleigh, N.C. 27626-0535 QUAD. NO. - 'SERIAL NO. _
Phone [phone] Lat.
Minor Basin -
WELL CONSTRUCTION RECORD Basin Code _
DRILLING CONTRACTOR: HeaderEnr ---GW-�nt:'`>>;_
STATE WELL CONSTRUCTION
DRILLER REGISTRATION NUMBER: P06 4i PERMIT NUMBER:
1.
WELL LOCATION: sketch Of the location below)
,(Show
Nearest Town: �.� Counly: lov
c/�
(Road, Cam unity, or Sufxlivisio-o ao'/ldC'ILot nNo.�
1
DEPTH
DRILLING LOG
2.
OWNER 1+(Llut /MC�t.-4
From To
Formation Description
ADDRESS c6.&t c
(Street or Route No.)
�L� Fink- 1-e-
3.
City or Town Star Zip Code 0
DATE DRILLED ;Z —Otl USE OF WELL
4.
TOTAL DEPTH / 'yo
5.
CUTTINGS COLLECTED YES ❑ NOO--
6.
DOES WELL REPLACE EXISTING WELL? YESO NOQ,
o
7.
STATIC WATER LEVEL Below Top of Casing: _V FT.
o p
(Use -.'if Above Top of Casing)
e
8.
'
TOP OF CASING IS F r. Above Land Surface'
cm
Casing
Terminated at/or below land surface is illegal unless a variance Is Issued
In
accordance with 15A NCAC 2C .0118
r O<
9.
YIELD (gpm): 20 METHOD OF TEST 4 / ✓Z
_
�o
10.
WATER ZONES (depth): 7-0p!e a,. P t dci
11.
CHLORINATION: Type Amount
ma
If additional space is needed use baE?of fcgn
12.
CASING:
—
Wall Thickness
Depth Diameter or WeiahUFl.
Material
From To Ft. / ,/
From—C2 To � Ft. 6 kz n
From
To Ft.
13. GROUT:
Depth Material
Method
From
To --Ft.
From (_ To -2 0 Ft.
14. SCREEN:
Depth
From To Ft
From To Ft.
From To Ft.
15. SAND/GRAVEL PACK:
From To
From To
16. REMARKS:
-190 HEREBYICEAl) Y.
CONSTRUCTION STN
GW-1 4EV-9rbi` - --
Diameter Slot Size Material
LOCATION SKETCH
(Show direction and distance from at least two State
Roads- or other map reference points)
6 C,5 fbl�_
in. in. % O
in. __ in. 6
in. in.
ED IN ACCORDANCE WITH 15A NCAC 2C, WELL
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
SIGNATURE OF CONJRACTOR OR AGENT PATE
Submit oriainal to Division of Environmental Manannmonr

Division of Environmental Management - Grouncwater Section
P.O. Box 29535 - Raleigh, N.C. 27626.0535
Phone [phone]
FUH OFFICE USE ONLY 2 �f:Q-1:•i3 3
QUAD. NO. - - SERIAL NO. - -
Lat Long. FO
Minor Basin
WELL CONSTRUCTION RECORD
f
Basincode '
DRILLING CONTRACTOR: Q f
Header Ent - -J •
- GW-1 I_nt
(/7J STATE WELL CONSTRUCTION
DRILLER REGISTRATION NUMBER: LQ6 S/ PERMIT NUMBER:
1. WELL LOCATION: (Show sketch of the location below)
Nearest Town: _DILoA0 ACe't-If County: 0(0 0bQ1xAe_n
—
/
` eA lw A Qom*=
(Road, Communiry,_or/$/-ub-division nd Lot No-) DEPTH
&949pWr
DRILLING LOG
2. OWNER � From To
Forma on Description
ADDRESS O 0- 0 Lcn7� t .it �a �
(Slreel or Roule No.) Q Q
`
/IIT-ZkV7_
��2
C) NC_ --tY
City or Town Slate Zip Code
3. DATE DRILLED Z - l(o'UO USE OF WELL - �C3 �pd
�'�•
4. TOTAL DEPTH /Is e3_
5. CUTTINGS COLLECTED YES ❑ NOOK
6. DOES WELL REPLACE EXISTING WELL? YES NOEJ�-
7. STATIC WATER LEVEL Below Top of Casing: ;to FT.
(Use'•1- it Above Top of Casing)
B. TOP OF CASING IS40/ FT. Above Land
rp CD
Surface'
Casing Terminated at/or below land surface Is Illegal unless a variance is Issued
MC za
In accordance with 15A NCAC 2C Ml 18
—t Cn
9. YIELD (gpm):0110_ METHOD OF TEST R /2
r of
10. WATER ZONES (depth): ZOer®A. /YS
�o
11. CHLORINATION: Type Amount
12. CASING:
Wall Thickness
Depth Diameter or WeiohVFL Material
From
_45�
To Ft.
From
To Ft..
From
To Ft.
13. GROUT:
Depth Material Method
From
To Ft. r --et
From O To f-d Ft. 2 G�
14. SCREEN:
Depth
From
To
From
To
From
To
15. SAND/GRAVEL PACK:
Depth
From
To _
From
To _
16. REMARKS:
Diameter Slot Size Material
Ft in. in.
Ft. in. __ in.
Ft. in. in.
-- Size_..._.. ___.Material
111�1 OOl IEREBYf�ER? IHhI^ AT HIS WELL WAS CONS RU
CONSTRUCTION STAND f, A THI
{oft[
SIG ATURE O
GW-1 REV. 9/91 Submit original to
If additional space is needed use bac of
LOCATION SKETCH z
(Show direction and dstance from at least two State
Roads, or otherga e rejoereMe points)
f% f
IA
/01/E/
ED IN ACCORDANCE WITH 15A NCAC 2C, WELL
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
1CTOR OR AGENT PATE
or Environrtwnial

Division of Environmental Management - Grouncwater Section FUH OFFICE USE ONLY-0- :lJ
P.O. Box 29535 - Raleigh. N.C. 27626-0535 oUAD. NO. - SERIAL NO.",.*r=�`Z.: L,J"
Phone [phone] lac. Lond. AO
Minor Basin -
WELL CONSTRUCTION RECORD
DRILLING CONTRACTOR: 4_ Header EntGW-(�nt:'^:;r;_..
STATE WELL CONSTRUCTION
DRILLER REGISTRATION NUMBER: /Qb if PERMIT NUMBER:
1.
WELL LOCATION: (Show sketch of the location below)
Nearest Town: _ OLD Fob County:
al�O3Cb�
5SLL11r tJ&k4,,(,
(Road. Community,o ubdivi5ion an�d lDt�o.)
1
DEPTH DRILLING LOG
2.
OWNER �.e�q ,Q LV� �.6GYc.
From To Farmauon Description
ADDRESS S: I- L. .A_.A-.
(Street or Route No.)
90 i2r-
MIj ford- tA+ N
City or Town Male Zip Code
p
3.
DATE DRILLED 2- /y USE OF WELL
4.
TOTAL DEPTH La43'
5.
CUTTINGS COLLECTED YES NO©�
6.
DOES WELL REPLACE EXISTING WELL? YES NO54—
T
STATIC WATER LEVEL Below Top of Casing: &40 FT.
3
8.
(Use'.' if Above Tap of Casing)
TOP OF CASING IS FT. Above Land
_0
C_
Sufface'
�A
' Casing
Terminated at/or below land surface Is Illegal unless a variance is fssued
In
9.
accordance with 15A NCAC 2C .0118
YIELD (gpm):METHOD OF TEST Al r2-S*r9N
Cm
fm
F
10.
WATER ZONES (depth): t qlp is C�--
Z A m
11.
CHLORINATION: Type Amount 0-*-y
If additional space is needed use back of io�
12.
CASING:
^
Wall Thickness
o
LOCATION SKETCH
Depth Diameter or Weicht'Ft. Material
(Show direction and distance from at least Two State
From To Ft. yQ G
From-& To—� Ft
Roads, or other map reference points)
.��
From To FL
13.
GROUT:
Depth Material Method
From To Ft.
From _# To �Ft.
14.
___
SCREEN: (�
Depth Diameter Slot Size Material
L
From To Ft in. in.
From To _
From To _
15. SAND/GRAVEL PACK:
From To
From To
16. REMARKS
i; tt
7 'DO EREBY CEP
CONSTRUCTION;
3r
Ft. in. __ in.
Ft- in. in
THIS WELL WAS
v1-o
'5'u
aUCTED IN ACCORDANCE WITH 15A NCAC 2C. WELL
THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
SIGNATU E O ONTRACTOR OR AGENT PATE
GW-1 REV. 991 Submit original to Division of Environrrnnlal Mnnanemom —4,­

Division of Environmental Management - GrouncwtUH UFHCE USE ONLY ater Section - ,:
P.O. Box 29535 - Raleigh, N.C. 27626-0535 OUAD. NO. - - SERIAL NO --
Phone [phone] Lai Long AO _
Minor Basin - -
WELL CONSTRUCTION RECORD Basin Code
DRILLING CONTRACTOR: Header Ent-
STATE WELL CONSTRUCTION
DRILLER REGISTRATION NUMBER: 16 tG( PERMIT NUMBER:
1. WELL LOCATION: (Show sketch of the location below)
Nearest To n: /ir /I/Y%O.a/ County: j4A
(F$Wad. Comm try, or Subdivision and Lot No.) DEPTH DRILLING LOG
2. OWNERGFrom To Formation Description
ADDRESS
(Street or Route No.J n O Z �/ K
�.Y%�? 77
City or Town Tale i/tip ode
3. DATE DRILLED 7-//-USE OF WELL HdL- o 2
4. TOTAL DEPTH dWQ
5. CUTTINGS COLLECTED YES ❑ NOOK
6. DOES WELL REPLACE EXISTING WELL? YES NOE]j�-
7. STATIC WATER LEVEL Below Top of Casing: —Ld FT.
(Use -.- it Above Top of Casing)
B. TOP OF CASING ISFT. Above Land Surface'
Casing Terminated atlor below land surface is Illegal unless a variance Is Issued
In accordance with 15A NCAC 2C .0110
9. YIELD (gpm):-7 METHOD OF TEST /V/ /L
10. WATER ZONES (depth): 7So.a P 3 S F0
11. CHLORINATION:
12. CASING:
Type Amount — If additional space is need
Wall Thickness
Depth Diameter or Weight'Ft. Material
From To Ft.
From To �� Ft.-
�—
From To Ft.
13. GROUT:
Depth Material Method
From To Ft.Q
From To 2'0 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:
Dept 5 I size
From To
From To FL 16. REMARKS: '^'j ��-
I DO HEREBY CERTI�
`CONSTRUCTION ST
AW 28-tUf)
GW-1 REV. 9'�91 -
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
t xJ.�Sa� &awr 4
/2Zt
tA AO
IUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
SIGNATURE OF[CONTRACTOR OR AGENT PATE
Submit original to Division or Environrrwntat Manannmenr —i rn^u t., wall ,...,.

Division of Environmental Management - Groundwater Section FUH OFFICE USE ONLY - .0.-1-';(}^n...�
P.O. Box 29535 - Raleigh, N.C. 27626.0535 OUAD. NO. - SERIAL NO.
Phone [phone] tat Cnng. Fi0 _
-
WELL CONSTRUCTION RECORD Minor Basin
Basincude .
DRILLING CONTRACTOR: Header Ent
lD� r STATE WELL CONSTRUCTION
DRILLER REGISTRATION N MBER: SI PERMIT NUMBER:
1. WELL LOCATION: (Shop sketch of the location below)
Nearest Town: -.064(21j4-&. County:.
OL&Ail
(Road, Commum ,or Subdrvisio and lnWo. DEPTH DRILLING LOG
2. OWNER From To Formation Description
ADDRESS
(Street or Route No.) y /
ly or own Slate ip Code
3. DATE DRILLED2 -'G' PO USE OF WELL eyC&c,._ C_ �0 _ �f3 4�&
4. TOTAL DEPTH 9 3lD
5. CUTTINGS COLLECTED YES NO[e-' `74/40 f p�
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO©/
7. STATIC WATER LEVEL Below Top of Casing: �� Fr.
(Use',' if Above Top of Casing) -
8. TOP OF CASING IS / FT. Above Land Surface'
'Casing Terminated atlor below land surface Is Illegal unless a variance Is Isdued i
In accordance with 15A NCAC 2C .01 to O
9. YIELD (gpm):�_ METHOD OF TEST 4/i@ 3� =_
10. WATER ZONES (depth): _ /Sfr►A2_0
t aE
11. CHLORINATION: Type O,Y Amount If additional space is needed use ba4f f�b
12. CASING:
Wall Thickness
Depth
Diameter
or Weicht'Ft.
Material
From To
From C2 Toqe
FL
Ft.--�--
From To
FL
13. GROUT
Depth Material Method
From To Ft.
From 49 To .�O _FL (1TlA O
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
From To -
From To_
_w 16„,REMARKS:
�r
°',I; �1001HER��YICERTIFYTI
I�I 1 I CONSTRUCTION STANDf
�V PtPn 2 dry 7 U
GW-I REV. 9191
LOCATION SKETCH_
(Show direction and distance from at least i o
Roads, or other map reference points)
76) E'
IN ACCORiSANCE WITH 15A NCAC 2C, WELL
;ORD HAS BEEN PROVIDED TO THE WELL OWNEP..
SIGNA I UR& OFRONTRACTOR OR AGENT PATE
Submit oriainai to Division of F,rwironnwntal Manaaemam a..d �..,.,, �.. Wen .......e.

Division of Environmental Management - Groundwater Section
P.O. Box 29535 - Raleigh, N.C. 27626-0535
Phone [phone]
WELL CONSTRUCTION RECORD
FUH UFFICE USE ONLY '=
QUAD. NO. - - - - SERIAL NO._,-'_ 1 '
Lat - Lorxj.- fl0
Minor Basin
m/ Basin Code --
❑BILLING CONTRACTOR: l`f� t° ( Header Ent 'GW-) �ht 1^`:',• ?.
STATE WELL CONSTRUCTION
DRILLER REGISTRATION NUMBER: PERMIT NUMBER:
1. WELL LOCATION: (Show sketch of the location below)
Nearest Town: _. n zi) 6y&-4- County:
ca=m
n
(Road,Communi ,orS bdivisianandLo o.) DEPTH DRILLING LOG
2. OWNER From To Formation Description
ADDRESS 4, 041 11
OLD Far�f (Seeetorl'i le Ng) d) l / a— ci7oGiQ,
�v C 2PC,
City or Town Slate Zip Code
3. DATE DRILLED Z^ Z-80 USE OF WELL _ 720
4. TOTAL DEPTH 110
5. CUTTINGS COLLECTED YES ❑ NOEj;j-
6. DOES WELL REPLACE EXISTING WELL? YES NOEe— v
7. STATIC WATER LEVEL Below Top of Casing: pp FT. a
(Use'," it Above Top of Casing) _
8. TOP OF CASING IS / d FT. Above Land Surface' ino,
Casing Terminated atlor below land surface Is Illegal unless a varian<o Is Issued
In accordance with 15A NCAC 2C .0118 t OC
9. YIELD(gpm):_METHOD OF: TEST /4irl'SiNwi yo
10. WATER ZONES (depth): /t�/Asa P
11. CHLORINATION: Type Amount ���
12. CASING:
Wall Thickness
Depth Diameter or Weicht'Fl. Material
From To FL O �_
From. To �Z— FL� �--
From To Ft.
13. GROUT:
Depth Material Method
From To Ft.
From _e5 To Z'0 Ft.
14. SCREEN: i
If additional space is needed use
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
Depth Diameter Slot Size Material
From To Ft in. in.
From To Ft. in. __ in.
r
From To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth e 2 �,{ ateria(
From To L5 '
From To
16. REMARKS: I W G `.i 6
IZdHEREBY CERTIFY T}{
CONSTRUCTION STAND
APR 2 8 2090
Cro,mtl•.va, r=,� i
95J
Vft+0-
IN ACCORDANCE WITH 15A NCAC 2C. WELL
'ORD HAS BEEN PROVIDED TO THE WELL OWNER.
SIGNATURE OF CONTRACTOR OR AGENT PATE
Submit original to Division of Environrrwnw Mannnomonr 2nA r,.,,,, r.. ­n .....

North Carolina - Department of Environment, Health, and Natural Resources
Division Environmental Management
_ FOR (SPFlC� USE ONLr! n;
of - Groundwater Section
r.
P.O. Box 29535 - Raleigh, N.C. 27626-0535
QUAD. NO.. - -- $£RIAL NO.-•
i.L._r�; I
Phone [phone]
tat- Long.' RO
WELL CO STRUCTION RECORD
Minor Basirt - :
Basin Code
DRILLING CONTRACTOR:
Header Ent
STATE
WELL CONSTRUCTION
DRILLER REGISTRATION NUMBER: /06 Y PERMIT NUMBER:
1.
WELL LOCATION: (Show sketch of the location below)
Nearest Town: ♦ County:
DEPTH DRILLING LOG
(Road, Community, or Subdivision and Lot No.)
2.
OWNER
From To Formation Description
ADDRESS -
(Street ar Route No.)
,A�n Lt/ C
4jQ
City or Town Stale Zip Code
d 20r
3.
DATE DRILLED 2c5!f:Q USE OF WELL � ��
_
�Z
4.
_
TOTAL DEPTH 203--
5.
CUTTINGS COLLECTED YES ❑ NOQ/
6.
DOES WELL REPLACE EXISTING WELL? YES Q NOQ--
7.
STATIC WATER LEVEL Below Top of Casing: K p FT.
(Use'i if Above Top of Casing)
o
; G
8.
TOP OF CASING IS FT. Above Land Surface'
C
' Casing Terminated at/or below land surface Is Illegal unless a variance Is Issued
In
accordance with 15A NCAC 2C .0118
C6
9.
YIELD (gpm):._(p_ METHOD OF TEST 72
r oc
10.
WATER ZONES (depth): _Ae v,.aQ rG o
ao
11.
CHLORINATION: Type LAmount
If additional space is needed use U47M ofinazq
12.
CASING:
Ca
LOCATION SKETCH
Wall Thickness
Depth Diameter or Weight/Ft. Material
.x
(Show direction and distance from at least two State
From TO Ft.
Fromdo/T2_ Ft.
Roads, or other map reference points)
From To Ft.
13.
GROUT:
Depth Material Method
From To Ft.
From d To Z-0_ Ft.
14.
SCREEN:
^ I
Depth
From To _
From To _
From To
15. SAND/GRAVEL PACK:
Depth
From To _
From To _
q _0I 1 HEREBY CERTIFY TF
CONSTRUCTION STANDA
APR 28tCil
4
t
i hro2Yd dar' Sec`on I
L. ���l'e �4ionE!
Diameter Slot Size Material
Ft in. in.
Ft. in. __ in.
Ft. in. in.
6� � ZZ 1
/ Lv'
IN ACCORDANCE WITH 15A NCAC 2C, WELL
,ORD HAS BEEN PROVIDED TO THE WELL OWNER.

Division of Environmental Management - Groundwater Section
P.O. Box 29535 - Raleigh, N.C. 27626-0535
Phone [phone]
tUH OFFICE USE ONLY?_ 0:f r't
QUAD. NO. - - - - SERIAL NO.
Let. Lond. "i-p0
Minor Basin . ` >-
WELL CONSTRUCTION RECORD Basmcada
DRILLING CONTRACTOR: _ Header Ent- ` -t •-GIN-( ItinC +
STATE WELL CONSTRUCTION
DRILLER REGISTRATION NUMBER:_,®6 (�/ PERMIT NUMBER:
1. WELL LOCATION: Show sketch of the location below)
Nearest Town: _ GL'D:64� County:
(Road. Community, or Sivision and Lot No.) /� DEPTH DRILLING LOG
2. OWNER 0" 1/s+Z `5�y1.- o'6' From To Formation Description
ADDRESS A t 15e
(Street or Rowe NO.)
City or Town late ip Code
3. DATE DRILLED 2 /O- 00 USE OF WELL S0O G
4. TOTAL DEPTH roa'
5. CUTTINGS COLLECTED YES ❑ NOD/
6. DOES WELL REPLACE EXISTING WELL? YES NO[ as
7. STATIC WATER LEVEL Below Top of Casing: _&4_ FT. d
(Use's it Above Tap a( Casing) p
8. TOP OF CASING IS III Above Land Surface' CD CD G3
' Casing Terminated atfor below land surface Is illegal unless a variance Is Issued
In accordance with 15A NCAC 2C .0118
9. YIELD (gpm):_nZ—METHOD OF TEST .!V&?
10. WATER ZONES (depth): iphl 4,V4•" yP,o
11. CHLORINATION: Type Amount
12. CASING: _
Wall Thickness
Depth Diameter or WeiahVFi, Material
From To Ft.
From to To7}S Ft.�
From To Ft.
13. GROUT
If additional space is needed use
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
Depth
Material
Method
From
To
Ft.
From m
To _ _?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:
/fZGj
Depth
n 14l e
911
From
To
IP=--
� 1
From To _
16. REMARKS
j' I DO_f-IERE8Y'CERT)FY TH
6 CONSTRUCTION STANDAif i
j APR 2 8 2000 '
i L'roanrl.eat� Section
lj64
Z Z/
,CRDANCE WITH 15A NCAC 2C. WELL
HAS BEEN PROVIDED TO THE WELL OWNER,
SIGNATURE Op C�(J'tRACTOR OR AGENT PATE
Submit original to k.n or Environn emial Manan<_, , —A

_
Division of Environmental Management -Groundwater Section rUH OFHCE USE ON + (n� (n-. 11
P.O. Box 29535 - Raleigh, N.C. 27626-0535 QUAD. NO. - - - SERIAL N .J --0
Phone [phone] tat. Lnrg: pp ;.r -
Minor Basin
WELL CONSTRUCTION RECORD Basin Code
DRILLING CONTRACTOR: Header Ent.'GW-i€n'c`�'^>�!_�
STATE WELL CONSTRUCTION
DRILLER REGISTRATION NUMBER:-�Q�p� PERMITNUMBER:
1. WELL LOCATION: (Show sketch of the location below) (p
NearestTown: _Q 6 4 f County:
At ILL
(Roe, Community, or Subdivisio and Lot No. DEPTH DRILLING LOG
2. OWNER From To Formation Description
ADDRESS
(Street or Rcute o.l
1 D IL A I- Nr3 G V`/Z-2
'City or Town '/ State Zip Coda L
3. DATE DRILLED 2-q- 00 USE OF WELL ��/J PLC_ p�—/n�1
��
4. TOTAL DEPTH (o O S
5. CUTTINGS COLLECTED YES ❑ NOC. --
6. DOES WELL REPLACE EXISTING WELL? YES NOQ._
7. STATIC WATER LEVEL Below Top of Casing: &gor) FT.
(Use'+' it Above Top of Casing)
8. TOP OF CASING IS FT. Above Land Surface'
Casing Terminated atlor below land surface Is Illegal unless a variance Is Issued
In accordance with 15A NCAC 2C .0118
9. YIELD (gpm):RMETHOD OF TEST
10. WATER ZON {L depth): a7,QA' 5"SO r
11. CHLORINATION: Type _a Amount
12. CASING:
Wall Thickness
Depth Diameter or WefahVFt. Material
From To Ft.
From.]— To Ir to Ft.-4 X1$4
From To Ft.
13. GROUT:
Depth Material Method
From To Ft.
From 0 _ To Z O Ft. 2
14. SCREEN:
Depth Diameter Slot Size Material
From To Ft in. in.
From —To—Ft.—in. --in.—
From —To—Ft.—in. —in.—
Depth
From To
From To_
16. REMARKS:
�un�
N2u!
ini
�wF
:s
'r1 DQ,'HEREBY.CERTIF
+ {;ONSTRUCTION S7A'1v[7xrrvs: xtvv
+
jj
it
OR ?
rial
If additional space is need
LOCATION SKETCH
(Show direction and dstance from at least two State
Roads, or other map reference points)
6 140r
ONST UCTED IN ACCORDANCE WITH 15A NCAC 2C. WE]
HIS RECORD HAS BEEN PROVIDED TO THE WELL
yry
GW-1 REV, 9191
Submit original to Division of Enviromm.wAt Man aanm.m anA r^nu r.. , F1 ......,a.

Division of Environmental Management - Grouncwater Section
P.O. Box 29535 - Raleigh, N.C. 27626-0535
Phone[phone]
WELL CO
DRILLING CONTRA
FUH OFFICE USE ONL
QUAD. NO.: - - SERIAL NO.
Land. f
Minor Basin
Basin Coda _
Header Ent.
�O !� STATE WELL CONSTRUCTION
DRILLER REGISTRATION BER: (ff PERMIT NUMBER:
1. WELL LOCATION; jShow sketch of the location below) CO
Nearest Town: �Drw County:
(Road, Commumry,oc- M., and tNo.) DEPTH DRILLING LOG
2. OWNER .l) /%_-A L From To Forma don Description
ADDRESS
�X" (Street or RoulNo.)
City or Town late./- �p
3. DATE DRILLED %J 7 2� USE OF WELL
4. TOTAL DEPTH
5. CUTTINGS COLLECTED YES ❑ NOE9i
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO q- o 0
7. STATIC WATER LEVEL Below Top of Casing: FT. m ?_
;. r.
(Use'+' if Above Top of Casing) C.T
8. TOP OF CASING IS�_ FT. Above Land Surface'
• Casing Terminated allor below land surface Is illegal unless a variance Is Issued
In accordance with 15A NCAC 2C .0118
9. YIELD
(gpm ):�`�METHOD OF TEST �_ ...r;
10. WATER ZONES (depth): �d (� /tin o rc
N —I
�, ,/ fdi e
11. CHLORINATION: Type Amount c-s,L If additional space is needed use back of fc?r�m
12. CASING:
Wall Thickness
Depth Diameter Wall
We/ ighVFl" Ma erial
From 119 To —42 . Ft.� rUA
From �— To C9 Ft.f 80 'C
From NM To 5 Ft.— _ /
13. GROUT:
Depth Material Method
From To Ft.
From _[Q_ To 2SL_Ft.
14. SCREEN:
Depth
From
To
From
To
From
To
15. SAND/GRAVEL PACK:
Depth
From
To ---�
From
To
16. REMARKS:
El
YK
+Ur�J AIR — 4 2000
Diameter Slot Size
Ft in. in.
Ft. in. in.
Ft. in. in.
Size
THIS WELL WAS CON
OF
Material
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
�l✓�e�y j b Lj
0
�f
IN ACCORDANCE WITH 15A NCAC 2C, WELL
CORD HAS BEEN PROVIDED TO THE WELL OWNER.
PATE

0
Division of Environmental Management - Groundwater Section
P.O. Box 29535. Raleigh, N.C. 27626.0535
Phone [phone]
t-UH OFFICE USE ONLY'0- " o
QUAD. NO.
Let . -Lor5.
WELL CONSTRUCTION RECORD mor Barn
Basin Coda
DRILLING CONTRACTOR: HeaderEnL �A- ~<{• - GW-)�n�%.!^`:`t._
/ STATE WELL CONSTRUCTION
DRILLER REGISTRATION NU BER: 106 y PERMIT NUMBER:
1. WELL LOCATION: (Show sketch of the location below) Nearest Town: eb'0 County:
.
(Road.Com''99��u, , or Subdrvslon aryd Lol No.) DEPTH DRILLING LOG
2. OWNER �C l A-)
nnnoccc From To Formation Description
(Street or Route No.)�py/��
)eho 6) C
City or Town tate. Zip Code
3. DATE DRILLED USE OF WELL 1100S
4. TOTAL DEPTH lalO�_
5. CUTTINGS COLLECTED YES NOE4
6. DOES WELL REPLACE EXISTING WELL? YES NOF]
7. STATIC WATER LEVEL Below Top of Casing: FT.
(Use'.' if Above Top of Casing)
8. TOP OF CASING ISFT. Above Land Surface'
Casing Terminated atlor below land surface Is Illegal unless a variance Is Isauad
In accordance with 15A NCAC 2C .0118
9. YIELD (gpm): a METHOD OF TEST /4 / 12
10. WATER ZONES (depth): o ,
1/o o
11 CHLORINATIO
N. Type Amount X41 I If addlional space is needed use
12. CASING:
Wall Thickness
Depth Diameter or WeighVFt. Material
From To Ft.
From—S2— To 92 Ft.—�;� LIt
From To Ft.
13. GROUT:
Depth Material Method
From —To Ft. �—
From 0 To .Kc' Ft. zp_
14. SCREEN:
Depth
From
To
From
To
From
To
15. SAND/GRAVEL PACK:
Depth P
From
To
From
To
16. REMARKS-
Diameter Slot Size Material
Ft in. in.
Ft. in. in.
Ft. in. in.
Ft.
Material
o
0
� c _
—n � m
N —
LOCATION SKETCIffn z
(Show direction and distance from at least two Slate
Roads, or other map reference points)
f�o fs%, -tulu
p CLIM L
YU�
6
P D �lql d9r,a�J
ED IN ACCORDANCE WITH t5A NCAC 2C. WELL
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
APR - 4 2000
GWA1
OR AGENT
nnrt�entel IA
PATE

Division of Environmental Management -Groundwater Section FUH OFFICE USE ONLY�d _";:",�•
P.O. Box 29535 - Raleigh, N.C. 27626-0535 OUAD. NO.. - - SERIAL NO. -
Phone [phone] Lai --Lon§ - ? RC` ;,y,:L,.�- _
Minor Basin - - . , :•.6..:...,.
WELL CONSTRUCTION RECORD Basin coda
DRILLING CONTRACTOR: S -
HeaderEnc
STATE WELL CONSTRUCTION
DRILLER REGISTRATION NUMBER: Zorr PERMIT NUMBER:
1. WELL LOCATION: (S�W Sketch of the location below) �h
Nearest Town: ,I County:
(Road,Com.ty, rSubdivisio//ny�aandl-olNo.) DEPTH DRILLING LOG
mun
2. OWNER — Qr la/r�/Jlilt From To Formation Description
ADDRESS i LJ do p
reet or Route No.) _
&(Ste 2�7Sz
City or Town SI 1,
Zip Code
3. DATE DRILLED /- Y-QUSE OF WELL
4. TOTAL DEPTH c+� 96
5. CUTTINGS COLLECTED YES ❑ NOED--- ao - r ?0
6. DOES WELL REPLACE EXISTING WELL? YES NOQ/
7. STATIC WATER LEVEL Below Top of Casing: g;o FT. O . �?�p�_ 6
(Use'.'if Above Top of Casing) B. TOP OF CASING IS FT. Above Land Surface'
' Casing Terminated el/or below land surface Is Illegal unless a variance is Issuod
In accordance with 15A NCAC 2C .0118
9. YIELD (gpm):49-_ METHOD OF TEST
10. WATER ZONES (depth): _A-Z ,seN
i -
O n c
11. CHLORINATION: Type Amount If additional space
12. CASING: is needed use b-N of fops
�
wall Thickness LOCATION SKETCH
Depth Diameter or Weight/Fl. Material (Show direction and distance from at least two State
From To FtRoads, or other map reference points)
From _ To:Z�7� - Ft.-44- _ —Ape
From To FL t/
13. GROUT: _
Depth Material Method
From To Ft.
Z
From �_ To 6 Ft.
14. SCREEN: J
Depth Diameter Slot Size Material
From To Ft in. in.
From To Ft. in. in.
From To Ft._ in. in.
15. SAND/GRAVEL PACK: ��
f
Depth a—> !2 ¢g ?Material
From To 1
From To ,'FL
16. REMARKS: '
I D-1HF�PE�Y (vERTIFY� AT R t{( WA%;PT STRt TED IN ACCORDANCE WITH 15A NCAC 2C, WELL
i --CONSTRUCTTONZT RDS,AAW0iMR fiJn, a PyOF Tt_.jIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
J,j APR - 4 2000 ( n
SIGNATUVeOF CONTRACTOR OR AGENT PATE
Submit original to Division of Environmental Mananoment ,.,en .......e.

Division of Environmental Management - Groundwater Section FUH OFFICE USE ONLY01/-
P.O. Box 29535 - Raleigh, N.C. 27626-0535 QUAD. NO. - SERIAL NO:%�_7•
Phone [phone] - !at - Long* qQ
Minor Basin
WELL CONSTRUCTION RECORD Basin Coda --
DRILLING CONTRACTOR, Header Ent {• %GWfi tnL..
r STATE WELL CONSTRUCTION
DRILLER REGISTRATION NUMBER: lbcisl PERMIT NUMBER:
1. WELL LOCATION: ketch of the to below)
Nearest Town: 4 Nti A V County: heft')rg
(Road,C muni , or Subdivision and Lot No.) DEPTH DRILLING LOG
2. OWNER �/al From To Formation Description
ADDRESS f
Fn (' (Street or Route No.)
—Q �u l %G Z ESQ— G
Cary or -Town I ate . Zip Code
3. DATE DRILLED N-20tao USE OF WELL
4. TOTAL DEPTH 0196
5. CUTTINGS COLLECTED YES ❑ NO�
6. DOES WELL REPLACE EXISTING WELL? YES NO©/
7. STATIC WATER LEVEL Below Top of Casing: to FT.
(Use'.' if Above Top of Casing)
B. TOP OF CASING IS FT. Above Land Sufface'
Casing Terminated attor below land surface Is Illegal unless a variance Is Issued
In accordance with 15A NCAC 2C .0118
9. YIELD (gpm):15'_ METHOD OF TEST A117-
10. WATER ZONES (depth): 9'Z&
11. CHLORINATION: Type Amount
12. CASING: 7-
Depth
Wall Thickness
Diameter or WeighVFI- Material
From To Ft.
From Q— To air FL_
From
To Ft.
13. GROUT:
Depth
Material Method
From
To Ft.
From 49
To 000—_ Ft.
14. SCREEN:
Depth Diameter Slot Size Material
From To Ft 4" in- in. e_y-d
From Z�(, To 2� C� Ft. _!j�_ in. _� in. &&-
From To Ft. in. in,
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From _� To Ft.
16.. REMARKS:._-.
'I 0O-HEFk8sCEAT� �A}E k d�fF!
CONSTRUCTION Sl• DS, AND. T��HyyA+qT�A �<
APR — 4
i.
Cra;mdvva;e• Section - r..,...
® c
0
If additional space is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points),
cxC) -k)
D-G
ED IN ACCORDANCE WITH 15A NCAC 2C. WELL
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
OR AGENT
nnrnaml l U
PATE

Division of Environmental Management - Groundwater Section tuts OFFICE USE ONLY i
°jy�%
P.O. Box 29535 -Raleigh, N.C. 27626-0535 QUAD. NO.' - - - SERIAL NO,, i ?,
Phone [phone] Lat Long*.
Minor Basin
WELL CONSTRUCTION RECORD Basin Code -
DRILLING CONTRACTOR. Header Ent. t GW ght
STATE WELL CONSTRUCTION
DRILLER REGISTRATION NUMBER: t(()(p(t PERMIT NUMBER:
1. WELL LOCATION: IShow Sketch of the location below) Q�
Nearest Town: m County:
n1 +�
—
(Road ,`eblrtmuniry,or bdivision and LotNo.) DEPTH
2. OWNER &ft-j1: Sk,�L ( LiL�o, C, c�2 DRILLING LOG
From To Formation Description
ADDRESS
(Street or Route NNo.) / FI
City or Town Slate Zip Code
3. DATE DRILLED -zecv USE OF WELL 14al, ,Lp
4. TOTAL DEPTH 113u
5. CUTTINGS COLLECTED YES ❑ NO[��'
6. DOES WELL REPLACE EXISTING WELL? YES NO©-
7. STATIC WATER LEVEL Below Top of Casing: I FT.
(Use'.' it Above Top of Casing)
8. TOP OF CASING IS FT. Above Land Surface'
Casing Terminated at/or below land surface Is Illegal unless a variance Is Issued
In accordance with 15A NCAC 2C .0118
9. YIELD (gpm): ? METHOD OF TEST 4 /2
10. WATER ZONES (depth): -39P M 0 CiOo /, . - -
11. CHLORINATION: Type Amount " 0 If additional space is need
12. CASING:
Depth
Diameter
Wall Thickness
or WeighuFt. Material
From
From O
To
Ft. ����—�'�
Ft.—�—
To 11
From —To
Ft.
13. GROUT:
Depth
Material
Method
From To
From �_ To ZJ
Ft.
Ft.
14. SCREEN:
Depth
From
To _
From
To _
From
To
15. SAND/GRAVEL
PACK:
Depth
From
To —
From
To _
16. REMARKS:
Diameter Slot Size Material
Ft in. in.
Ft. in. in.
Ft. in. in.
0
o a
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
V /1
ACCORDANCE WITH 15A NCAC 2C, WELL
RD HAS BEEN PROVIDED TO THE WELL OWNER.
APR - 4 2000
t9t'

223249
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] So 4 0/ 644 r (.L, / A/ 5
�
WELL CONSTRUCTION RECORD WELL CONTRACTOR: 1 O
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: Al4� ,ro'v County: mC'06,; �
isi- vWl, 14444oci nd
(Road Name and Numbers, Community. or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER ZJ_D/7N OPPUS From To Fonnation Description
Address oFr /7f+ 96r' �'o�i✓�/>� /lW
M Creel o oyyto o. o� y
City or Town State Zip Code
4. DATE DRILLED /_ 0
S. TOTAL DEPTH
6. CUTTINGS COLLECTED YES 0 NOW
7. DOES WELL REPLACE EXISTING WELL? YES n N0Fi�]
8. STATIC WATER LEVEL Below Top of Casing: '3�4 FT.
(Use'+' it Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface -
•Top of casing terminated at/or below land surface requires a variance In accor-
dance with 15A NCAC 2C .0118
10. YIELD (gpm): l,--b_ METHOD OF TEST CAr F_ h
11. WATER ZONES (depth):
12. CHLORINATION: Type Amount If additional space is needed use back of form
13. CASING:
Depth Diameter
From To Ft.
From To Ft.�
From To Ft.
14. GROUT:
Depth
From To Ft.
From To Ft.
15. SCREEN:
Wall Thickness LOCATION SKETCH O
or Weight/Ft. Material (Show direction and distance from at least two Slate —
I t
Roads, or other map re erence pom s)
2TT
I
W
Material Method
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
Quad No:
Sedal No.
Slot Size Material
in.
in.
in.
Material
CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
DPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
CI
JATURE Cd; PERSON CONSTRUCTING THE WELL DATE
Division of Water Quality, Groundwater Section within 30 days
GW-i REV. 12/99

223251
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: /`)Cih/'/✓G�
WELL CONTRACTOR CERTIFICATION #: O G
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/r:�(Show sketch of the location below)
Nearest Town: County:
Road Name tl umbers, Community. or Su/btl-ivr�is/ion an<d Lot No.)
DRILLING LOG DEPTH
3.
OWNER �'i`N,�/N /%
From To Formation Description
_
Address
d/V eel or '6NO.).�k>S
City or Town State Zip Coca
4.
DATE DRILLED
5.
TOTAL DEPTH
6.
CUTTINGS COLLECTED YES Q NOd
7.
DOES WELL REPLACE EXISTING WELL? YENOF-1
8.
STATIC WATER LEVEL Below Top of Casing: FT.
(Use'i it Above Top of Casing)
��
9.
TOP OF CASING IS /� FT. Above Land Surface'
'Top of casing terminated allot below land surface requires a variance In accor-
dance with 15A NCAC 2C .0118
10. YIELD (gpm): /D tf METHOD OF TEST �C N
11.
WATER ZONES (depth):
12.
CHLORINATION: Type Amount
If additional space is needed use back of form
13.
CASING:
Wall Thickness
LOCATION SKETCH
o
Depth -�/ Diameter or Weight/R. Material
�� H ST iL
(Show direction and distance from at least two Sp1e
`
Roads,
From To —Y Ft.
or other map reference points)
n T
From To Ft.
Z
From To Ft.
i
c<
14.
GROUT:
W
yo
Depth Material Method
m
From To Ft.
rT`
From To Ft.
c.n
y "`
15.
SCREEN:
N
o
Depth Diameter Slot Size Material
From —To—Ft— in. —in
From To Ft. _ in. in.
From To Ft. in. _ in.
16.
SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
17.
REMARKS:
100 HEREBY CERTIFY
CONSTRUCTION'WANO,Afi, S,-_ND1THfkT A;COPY OF T)1
-
FOR OFFICE USE
Quad No: J ' t IGNATU
j l a Submit onpnallo iDMsi
Serial No.
No.
'ED IN ACCORDANCE WITH 15A NCAC 2C, WELL
(RECORD HAS B N PROVIDED TO THE WELL OWNER.
OF PERSON CONSTF6CTING THE WELL DATE
of water Quality, Groundwater Section within 30 days
GW-1 REV. 12199

223252
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: Zi6 n6111/O'
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMIT#:
it, 4I,
1. WELL USE (Check Applicable Box): Residential02 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: //1h/ d i,/ County:
v�Ty��y FSFS 4,7�
(Road Name an/d/Numbers, Community, or /S/ubPivision and Lot No.) DRILLING LOG DEPTH
3. OWNER yC�C�%110/LCiO'r15s From To Formation Description
Address
�1—jbtreei or o tg o. G
City or Town State Zip Code
4. DATE DRILLED I� - ' - )U 0
5. TOTAL DEPTH L
6. CUTTINGS COLLECTED YES Q NOE�Jx
7. DOES WELL REPLACE EXISTING WELL? YES NO0_
8. STATIC WATER LEVEL Below Top of Casing: FT.
(use '+' if Above Top of Casing)
9. TOP OF CASING IS /5��� FT. Above Land Surface'
'Top of casing terminated odor Wow land surface requires a variance In accor-
dance with 15A NCAC 2C. 18
10. YIELD (gpm): 0 METHOD OF TEST
11. WATER ZONES (depth):
12. CHLORINATION: Type
13. CASING:
Depth i / Diarpeter
From To (,, J Ft. G�
From To Ft.
From To Ft.
14. GROUT:
Amount It additional space is needed use back of form
Wall Thickness LOCATION SKETCH
or WeighVFt. ('M,aterial (Show direction and distance from at least two State
Roads, or other map reference points)
Depth Material
From To Ft.
From To Ft.
15. SCREEN:
Depth Diameter
From To Ft in.
From To Ft. _ in.
From To _ Ft. _ in.
16. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To Ft.
17. REMARKS:
Method
Slot Size Material
in.
in.
in.
Material
t__.
a
1
W
m
t�
cry
N
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTI �} Rp�p� 7'A COPY OFF THIS RECORD HAS B ENnPROVIDED TO THE WELL OWNER.
�li i'c i; 11f I � �-�0 UU
—�
ra•_.
Quad No: ' �+ NATURE F PERSON CONSTRUCTING THE WELL DATE
s
- Submit bholnal to Division of Water Quality, Groundwater Section within 30 days
Serial No. . ' 3 GWt REV. 12/99

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section 2 2 32 4 6
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: _Lj o�'�Ilval i- /, ' `' Z''F's
WELL CONTRACTOR CERTIFICATION #: -Z5 G I
STATE WELL CONSTRUCTION PERMIT#:--r�i
1.
WELL USE (Check Applicable Box): Residential ❑ Municipal ❑
Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other Eff Other, List Use: C FlyF A'y 4 S7o%- C-
2.
WELL LOCATION- (Show sketch of the location below)
04,Y o-T
D0WF44'
Nearest Town: County: /M /S
(Road Name and Numbers. Community, or Subdivision and Lot No.)
DRILLING LOG DEPTH
3.
OWNER t%//VL-S /? ''W%/'KTA
From To Formation Description
Address ,IT x fjcX //,�_
Q i d /-Ui treetor �l� C Route o.
4.
City or Town / State Zip Code
DATE DRILLED
5.
TOTAL DEPTH
6.
CUTTINGS COLLECTED YES 0 NOQ
7.
DOES WELL REPLACE EXISTING WELL? YESES
8.
STATIC WATER LEVEL Below Top of Casing: Fes'.
9.
(Use'+' it Above Top of Casing)
TOP OF CASING IS /" FT. Above Land Surface'
'Top of casing terminated at/or below land surface requires a variance In accor-
dance with 15A NCAC 2C.0118
10. YIELD (gpm): � METHOD OF TEST P14
11.
WATER ZONES (depth):
12.
CHLORINATION: Type Amount
If additional space is needed use back of form
13. CASING
LOCATION SKETCH
Wan Thickness
Depth /
Diartyeter or WeighUFt. ateriat (Show direction and distance from at least two State
r G
From
To '�J
Ft. lr r Roads, or other map reference points)
From
To
Ft.
From
To
Ft.
0
14.
GROUT:
O
o
Depth
Material Method
`
E7
From
To
Ft.
p"
of
From
To
Ft.
1n,
15.
SCREEN:
CA
L
Depth
Diameter Slot Size Material
a.
From
To Ft
in. in.
�r
From
To Ft.
in. in.
r,z
From
To —Ft.
in. in.
cn
N
16.
SAND/GRAVEL PACK:
o
Depth
Size Material
From
To
Ft.
From
To
Ft.
17.
REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION
STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY ��4 Ile. Ci �a ^� l/' /G- - v O
Quad No: SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Quality, Groundwater Section within 30 days
Serial No. ; GW-1 REV. 12199
i'QfifldWBte?—•.�-10fl
- a �,a�ril a re�onal

2?1241
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: QSA/Vc �%%ih4y^
WELL CONTRACTOR CERTIFICATION #: ~
STATE WELL CONSTRUCTION PERMIT#: ---
1. WELL USE (Check Applicable Box): Residential [9 Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: r4, N County: �y�1 ed `V '`- AL'
/? / /1 Ad bYs6a7y/r 47; �a[
(Road Name and/ Numbers. Community, or Subdivision and Lot No.)
3. OWNER /7tiOAc✓ ,f?�o��
Address
l�T L o fax /Ltus
(street or Rputs o.
22, /h /o/y NC. o?8?SeC
City or Town Stale Zip Code
4. DATE DRILLED -/� - O
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES F-1 NO❑
7. DOES WELL REPLACE EXISTING WELL? YES NO�
S. STATIC WATER LEVEL Below Top of Casing: FT.
{ (Use'i if Above Top of Casing)
9. TOP OF CASING IS /o( FT. Above Land Surface -
'Top of casing terminated at/or below land surface requires a variance In accor-
dance with 15A NCAC 2C .0 18 r
10. YIELD (gpm): METHOD OF TEST
11. WATER ZONES (depth):
12. CHLORINATION: Type
13. CASING:
Depth Diameter
From To 9 Ft.
From To Ft.
From To Ft.
14. GROUT
Depth
From To _
From To _
15. SCREEN:
Depth
From _To
F1
From _
To Ft.
From
To Ft.
16. SAND/GRAVEL PACK:
Depth
From
To
From
To
17. REMARKS:
Agricultural ❑ Monitoring ❑
DRILLING LOG DEPTH
From To Formation Description
It additional space is needed use back of form
Wall Thickness LOCATION SKETCH
or Weight/Ft. alenal_ (Show direction and distance from at least two State
4S L Roads, or other map reference points)
Material
.Ft.
Ft.
Diameter Slot Size
in. in.
in. in.
in. in.
Ft.
Ft.
I DO HEREBY CERTIFY THAT THIS
CONSTRUCTION STANDARDS, AN
Method
Material
Size Material
FOR OFFICE USE ONLY
Quad No:
Submit orc
Serial No. „:...a_.._.._�.,.._:
L
a
Z
1
W
3>
a
Cb
Cn
rV
ISTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
VATUAE OF PERSON CONSTRUCTING THE WELL DATE
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 7 34
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 M. 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 Tow %' r UAI County: /'�%
I,%l/ 2aG S !J/Sr1-7"5 Ur .t,<r�_
(Road Name and Numbers, Community, or Subdivision and Lot No.)
DRILLING LOG DEPTH
3.
OWNER bu, 1v
From To Formation Description
Address /fir �
—�Sneet or outs o.
l//YroN Mr�AS i>/C 2�/G i
City or Town state Zip Code
4.
DATE DRILLED
5.
TOTALDEPTH
6.
CUTTINGS COLLECTED YES 0 NOQ
7.
DOES WELL REPLACE EXISTING WELL? YES ( NOF_�
S.
STATIC WATER LEVEL Below Top of Casing: ,i o 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): _Z__ METHOD OF TEST
11.
WATER ZONES (depth):
12.
CHLORINATION: Type Amount
If additional space is needed use back of form
13.
CASING:
LOCATION SKETCH
Wall Thickness
Depth Diameter or Weight/Ft. Material
(Show direction and distance from at least two State
From To Ft.. F/ AS it
Roads, or other map reference points)
From To Ft.
From To Ft.
14.
GROUT:
Depth Material Method
From To Ft.
From To Ft.
15.
SCREEN:
Depth
Diameter Slot Size
Material
From —To—Ft—
in.
in.
p
From _To —Ft.
— in.
in.
Z
From _ To _
Ft. _ in.
in.
a
16. SAND/GRAVEL PACK:
I
C (
Cz
Depth
Size
Material
From To
Ft.
a
_--
From To
Ft.
3
ao
17. REMARKS:
n,
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT AOOPY OF THIS REC� g/D HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Quad No: JATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit on risi"ivislon of Water Quality, Groundwater Section within 30 days
Serial No. GW-1 REV. IV99
C rhar

22342
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: tiA�^�
WELL CONTRACTOR CERTIFICATION #:� L y
/STATE WELL CONSTRUCTION PERMIT#: "
1. WELL USE (check Applicable Box): Residential l 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: 42f /, / ON _ County:
(Road Name and Numbers. Commuu'nity, or Subtlivision and Lot No.) DRILLING LOG DEPTH
3. OWNER A,A4/-j' ,t7 h/-SI%/t'iN5h%V From To Formation Description
Address .4 c i 11 �� 5 c'�dirr S
7Su"t or oule o.
City or Town _ State Zip Code
4. DATE DRILLED /'�) 5 `"
5. TOTAL DEPTH l C"q
6. CUTTINGS COLLECTED YES F_� NOQ
7. DOES WELL REPLACE EXISTING WELL? YES E] NOF-1
8. STATIC WATER LEVEL Below Top of Casing: c1 FT.
(Use': it Above Top of Casing)
9. TOP OF CASING IS /3 ,/ FT. Above Land Surface'
-Top of casing terminated at/or below land surface requires a variance in accor-
dance with 15A NCAC 2C.9118
10. YIELD (gpm): C5 f METHOD OF TEST
11. WATER ZONES (depth):
12. CHLORINATION: Type
13, CASING:
Depth Diameter
From To "5 z' Ft. L
From To Ft.
From To Ft.
14. GROUT:
Depth
From To Ft.
From To Ft.
15. SCREEN:
Amount
Wall Thickness
or Weight/Ft.
Material
If additional space is needed use back of form
_ c
LOCATION SKETCH
r
Material (Show direction and distance from at least two Sta�-.
Roads, or other map reference points) 2
1
c
W
1-.
a
3
r
Method co
c.
N
c
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 CEK
CONSTRUCTION T O RJ
FOR OFFICE USE Y
Quad No:
Serial No.
WAS: CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
(AIGOPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
le..-S--_ cd
A'
GNATURE OF PERSON CONSTRUCTING THE WELL
to Division of water Quality, Groundwater Section within 30 days
DATE
GWA REV. 12199

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section ` rJ r) A I
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone] // t- r.• r3
WELL CONSTRUCTION RECORD WELL CONTRACTOR: �6 6/iNci
WELL CONTRACTOR CERTIFICATION #: �S G
STATE WELL CONSTRUCTION PERMIT#:yy -r-
1. WELL USE (check Applicable Box): Residentialn__*�_Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: N�/�/•%�''�' County: ��� (�"""` tr<L
(Road Name and Numbers, Community, or Subdivision and tot No.)
3. OWNER 4kIVA111 1 r PIVII✓Kti%/✓
Address
jS eat or oute o.
�Y�/�Alc�v /YC• ,�� %S 2
City or Town State Zip Code
4. DATE DRILLED
5. TOTAL DEPTH /'f 7
6. CUTTINGS COLLECTED YES NOD
7. DOES WELL REPLACE EXISTING WELL? YES [�:] N0E-1
8. STATIC WATER LEVEL Below Top of Casing: Tkz_ 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): V METHOD OF TEST
11. WATER ZONES (depth):
12. CHLORINATION: Type
13. CASING:
Depth Diameter
From To ; /; Ft. �—
From To Ft.
From To Ft.
14. GROUT:
Depth
From To Ft.
From To Ft.
15. SCREEN:
DRILLING LOG DEPTH
From To Formation Description
If additional space is needed use back of form
Wall Thickness LOCATION SKETCH
or Weight(R. Material , (Show direction and distance from at least two State
P4 ap5 c- Roads, or other map reference points)
Material Method
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
L
a
1
c.�
v
3
CO
cn
IV
o
c-r
o .[
�r c
I DO HEREBY I T I W L A STRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL OF THIS HIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
u.11f
FOR OFFICE USE NLY ( E��
Quad No: : al to Division
OF PERSON CONSTRUCTING THE th DATE
Submit tiiiginal to Division of Water Quality, Gmuntlwater Section Within 30 days
Serial No. I GW-1 REV. 12/99

223244
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 #: SG
STATE WELL CONSTRUCTION PERMIT#:
ny
1. WELL USE (Check Applicable Box): Residential E Municipal ❑
Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injeclion ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show ¢ketch of the location below)
Nearest Town: !`/ON County:
04d a� �aG/i 6"i r'ilss co/�/Ml
(Road Name and�j umbers, Community/, or Subdivision and Lot No.)
DRILLING LOG DEPTH
3. OWNER //i� OGr f%N c� dJ !a S 5
�(
From To Formation Description
Address f lylVaN Qi
�tSueet or outs o.
�13tiiav /VC-
City or Town State Zip Code
4. DATE DRILLED
�/a �-"?K
5. TOTAL DEPTH _--lam
6. CUTTINGS COLLECTED YES F-1 NO❑
7. DOES WELL REPLACE EXISTING WELL? YES N07
8. STATIC WATER LEVEL Below Top of Casing: _A 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.0))8 //II
/ A
10. YIELD (gpm): METHOD OF TESTli�?
11. WATER ZONES (depth):
12. CHLORINATION: Type Amount
If additional space is needed use back of form
13. CASING:
LOCATION SKETCH
Wall Thickness
Depth Diameter or Weight/Ft. (Material
G C
(Show direction and distance from at least two State
From To Ft. �nnr'
Roads, or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
O
From To Ft.
'
From To Ft.
C_
15. SCREEN:
G"
=7 P?
Depth Diameter Slot Size Material
j oT
From To Ft in. —in
-y
From To Ft. _ in. in.
a o
From —To Ft._ in. in.
m rn
16. SAND/GRAVEL PACK:
N C7i
Depth Size Material
o
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' /O1F� THIS RECORD
�IHAS
/9BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY )' CJ t/ r � a_461 2 ZG 2 , [3 v
Quad No: SIGNATUFt OF PERSON CONSTRUCTING THE WELL DATE
Submit otjflilraf to Division of Water Quality, Groundwater Section within 30 days
Serial No. y ` "- GWl REV. 12199

223238
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: / I b (/ I'Jd �r , H l ,v
WELL CONTRACTOR CERTIFICATION #: : D
STATE WELL CONSTRUCTION PERMIT#: _7L
1. WELL USE (Check Applicable Bo:): Residential LJ Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below) y1
n k' ,/✓/_ y�Or ✓I_�L.
Nearest Town: �%� / County:
/{r .rya & s
(Road Name and Numbers, Community or Sub/tlivision and Lot No.)
3. OWNER /VI/, 94.,,-7 %�, rf15�
Address P� ' /�rj( 7 �-3 If
NF , (Street o�tTo. G City or Town State Zip Code
4. DATE DRILLED' /2. 0 0
5. TOTAL DEPTH /00
6. CUTTINGS COLLECTED YES F__J NO❑
7. DOES WELL REPLACE EXISTING WELL? YES E] N0F__J
8. STATIC WATER LEVEL Below Top of Casing: _4L� FT.
(Use 'i if Above Top of Casing)
9. TOP OF CASING IS 1/2 FT. Above Land Surface -
•Top of casing terminated attor below land surface requires a variance In accor.
dance with 16A NCAC 2C.0118
10. YIELD (gpm): 9 S-' METHOD OF TEST�� L N
11. WATER ZONES (depth):
12. CHLORINATION: Type
13. CASING:
Depth�n Diameter
From To _L? v Ft.
From To Ft.
From To Ft.
14. GROUT:
Agricultural ❑ Monitoring ❑
DRILLING LOG DEPTH
From To Formation Descnpfion
Amount If additional space is needed use back of form
Wall Thickness LOCATION SKETCH
or Weight/Ft. yatenal (Show direction and distance from at least two State
1 G Roads, or other map reference points)
Depth Material
From To Ft.
From To Ft.
15. SCREEN:
Depth Diameter
From To Ft _ in.
From ToFt. in.
From —To —Ft. — in.
16. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To Ft.
17. REMARKS:
IDO HEREBY
Method
Slot Size Material
in.
in.
in.
FOR OFFICE USE ONLY —
Quad No:
Submit
Serial No.----
._ a't ti 'tr,n
Material
ED IN ACCORDANCE WITH 15A NCAC 2C, WELL
RECORD HAS BER4 PROVIDED TO THE WELL OWNER,
IATURE OF PERSON CONSTRUCTING THE WELL DATE
Division of Water Quality, Groundwater Section within 30 days
GW-1 REV. 12199

223230
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: �1�7o 4 /-1/L/d 0_,,
WELL CONTRACTOR CERTIFICATION #: 5 G !
rr
STATE WELL CONSTRUCTION PERMIT#: yL
1. WELL USE (Check Applicable Box): Residential ErMunicipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other 0 If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: r �' r ° ^' County: ," ��' f,' �' t'
I'l 0- Cony 1, y 117�
(Road Name and ers. Commun or Subdivision and Lot Nc.) DRILLING LOG DEPTH
/n
3. OWNER ._ ���� /7�!°�t�J _ From To Formation Description
Address 1 F� /1 � 01 C 0 ✓y (- % {�(
beet or o to o.
City or Town Stale Zip Code
4. DATE DRILLED G — a v
5. TOTAL DEPTH 1/2
6. CUTTINGS COLLECTED YES Q NO❑
7. DOES WELL REPLACE EXISTING WELL? YES U NO�
8. STATIC WATER LEVEL Below Top of Casing: � FT.
(Use': it Above Top of Casing)
9. TOP OF CASING IS /2 // FT. Above Land Surface-
-Top of casing terminated at/or below land surface requires a variance in accor-
dance with 15A NCAC 2C .0118 _
10. YIELD (gpm): 70 METHOD OF TEST
11. WATER ZONES (depth):
12. CHLORINATION: Type
13. CASING:
Depth Diameter
From To D Ft. 6
From To Ft.
From To Ft.
14. GROUT:
Depth
From To Ft.
From To Ft.
15. SCREEN:
Amount If additional space is needed use back of form
Wall Thickness LOCATION SKETCH
or Weight/Ft. Material (Show direction and distance from at least two State
h pS%/G Roads, or other map reference points)
Material Method
Depth Diameter
From To Ft _ in.
From To Ft. in.
From _ To Ft. _ in.
16. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To Ft.
17. REMARKS:
Slot Size Material
_ in.
in.
in.
Material
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUq�491`STANDARDS)AND THAT ACOPY �THIS
-RECORD
/HAS
)BEEN PROVIDED TOTHE WELL O
FOR OFFICEU E ONC1° �
Quad No: ? i i ^ SIGNATURE OF PERSON CONSTRUCTING THE WELL
Sub6tbQginal to DivWon of Water Quality, Groundwater Section within 30 days
Serial No.
GroundvraterSacti"r 6
Asheville Ppeinlml1 1 c
�%.1 a a
DATE
GW-1 REV. 12199

223240
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:
WELL CONTRACTOR CERTIFICATION #: �6
STATE WELL CONSTRUCTION PERMIT#
1. WELL USE (check Applicable Box): Residential l Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION
Nearest Town:
VIK 2 °1
(Road Name and ray
3. OWNER
Address
Ah�H
sketch of the location below) f1
on1 count': hF+
D 0-)
or Subdivision and Lot No")
)vn;F _ //oN/-,5
o-1
City or Town / -(} �-State Zip Code
4. DATE DRILLED
5. TOTAL DEPTH .
6. CUTTINGS COLLECTED YESQ NOQ
7. DOES WELL REPLACE EXISTING WELL? YES O NOQ
8. STATIC WATER LEVEL Below Top of Casing: _�FT.
(Use W it Above Top of Casing)
9. TOP OF CASING IS / 2 !/ FT. Above Land Surface -
'Top of casing terminated atlor below land surface requires a variance In accor-
dance with 15A NCAC 2C . 118 ,
10. YIELD (gpm): METHOD OF TESTS '
11. WATER ZONES (depth):
12. CHLORINATION: Type
13. CASING:
Depth Diameter
From To — Ft.
From To Ft.
From To Ft.
14. GROUT:
Depth
From To Ft.
From To Ft.
15. SCREEN:
Agricultural ❑ Monitoring ❑
DRILLING LOG DEPTH
From To Formation Description
Amount If additional space is needed use back of form
Wall Thickness LOCATION SKETCH
or Weight/Ft. Material (Show direction and distance from at least two State
�G" Roads, or other map reference points)
Material Method
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
0
0
0
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS
%BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Quad No: !:SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
_ Submit (nal to Division of water Quality, Groundwater Section within 30 days
Soda] No. s ` GWA REV. 12t99

223241
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: 'gAld �h 4, /A/ �j"
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 i,(Show fetch o1 the location below)
Nearest Town: County:
(Road Name an//tl��Numbers, Comm�/uyr�'ry, or Subdivision and Lot No.)
DRILLING LOG DEPTH
3.
OWNER yJ/307 74A/CE
From To Formation Description
Address /12s,
Aga �tu/yi A C_X j� c�
—(Street or Houle NO.),,
City or Town State Zip Code
4.
DATE DRILLED '��� U o
5.
TOTAL DEPTH
6.
CUTTINGS COLLECTED YESM NO❑
7.
DOES WELL REPLACE EXISTING WELL? YES0NO�
8.
STATIC WATER LEVEL Below Top of Casing: 2 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 C .0 18
10. YIELD (gpm): � METHOD OF TEST PI? / 4 Er
11.
WATER ZONES (depth):
12.
CHLORINATION: Type Amount
If additional space is needed use back of form
13.
CASING:
LOCATION SKETCH
Wall Thickness
Depth Diameter or Weight/Ft. &4pterial
(Show direction and distance from at least two State
From To q0 FL :e �. "Pi
Roads, or other map reference points)
From To
Ft.
From To
Ft.
o
14.
GROUT:
O
Depth
Material
Method
t_
C'
From To
Ft.
a
oM
From To
Ft.
I
`o�
15.
SCREEN:
Depth
Diameter Slot Size
Material
�o
From To
Ft in. —inco
3
From To _
Ft. _ in.
in.
r
From _ To
Ft. _ in.
in.
Cil
N
-i
o
16.
SAND/GRAVEL PACK:
'-
Depth
Size
Material
From To
Ft.
From To
Ft.
17.
REMARKS:
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS,. AND THAT A C. , PY OF. THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Quad No: Rd)OF PERSON CONSTRUCTING THE WELL DATE
(Submit origin i Division of Water Quality, Groundwater Section within 30 days
Serial No. I �: GW-1 REV. 12199
7`i=

223235
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 #: 5_6
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) r
Nearest Town —/'�' T' � bH'� County: A)
b CKW sT
(Road Name and Numbers, Community. or Subdivision and Lot No.)
3. OWNER
Address err" 1� a
.—jSueet ors� ule o.
A, 6,V W7 -
City or Town State Zip Code
4. DATE DRILLED 3 ' 6y0�
5. TOTAL DEPTHl'
6. CUTTINGS COLLECTED YES Q NO❑
7. DOES WELL REPLACE EXISTING WELL? YES NOM
8. STATIC WATER LEVEL Below Top of Casing: FT.
,-� (Use'+' if Above Top of Casing)
9. TOP OF CASING IS AI 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): /Ot METHOD OF TEST
11. WATER ZONES (depth):
12. CHLORINATION: Type Amount
13. CASING:
Wall Thickness
Depth Dia ter or Weight/Ft, Material
From To Ad Ft. meKU ln7_/L
From To FI.
From To Ft.
14. GROUT:
Depth Material Method
From To Ft.
From To Ft.
15. SCREEN:
From
From
From
Depth Diameter Slot Size Material
_ To _ Ft _ in. —in.-
-To—Ft.— in. in.
To Ft.
16. SAND/GRAVEL PACK:
17
Depth
From To Ft.
From To Ft.
in. in. _
Size Material
DRILLING LOG
From To
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)
a
O
o`
nm
A
om
:2=
cm
W
CD
o
m�
CO
y='
mz
C_n
y
fl
o
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.
g•-3.-ov
FOR OFFICE USE ONLY
Quad No:
SIGNATURE OF PERSON CONSTRUCTING THE WELL
Submit ptiginal to Division of water Quality, Groundwater Section within 30 days
DATE
GW-1 REV. 12M
Serial No.

232
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] ,2 y7
WELL CONSTRUCTION RECORD WELL CONTRACTOR: ' (� ��/1�� ,y/A_
WELL CONTRACTOR CERTIFICATION #: 043 Gg
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:1 Show sketch of the location below)
Nearest Town: 0 4 d /C�e h County: A/ Alt %• `'
r
r_"ni4 a /l d 9G V,',-V
(Road Name and Numbers, Communi , or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER / 1 O h xw'y /� T S From To Formation Description
Address L" d i d
/ytMreet or PiOLSto o.
//AArO✓✓ /t ,C, ��%��
City or Town Slate Zip Code
4. DATE DRILLED —�/- Od
5. TOTAL DEPTH /
6. CUTTINGS COLLECTED YES Q NO❑
7. DOES WELL REPLACE EXISTING WELL? YES [] N0F_�
8. STATIC WATER LEVEL Below Top of Casing: FT.
(Use'.' it Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface'
'Top of casing terminated at/or below land surface requires a variance In accor-
dance with 15A NCAC 2C .etta
10. YIELD (gpm): /L5� METHOD OF TEST
11. WATER ZONES (depth):
12. CHLORINATION: Type Amount If additional space is needed use back of form
13. CASING:
Depth � Diameter
From 6To —6 Ft. 41
From To Ft.
From To Ft.
14. GROUT:
Wall Thickness LOCATION SKETCH
or Weight/Ft. M to .at / _ . (Show direction and distance from at least two State
/.1- Roads, or other map reference points) O
Depth Material
From To Ft.
From To Ff.
15. SCREEN:
Depth Diameter Slot Size
From —To—Ft— in.
From To _ Ft. _ in.
From —To Ft. in.
16. SAND/GRAVEL PACK:
Depth Size
From To Ft. —
From To Ft. _
17. REMARKS:
Method
Material
in.
in.
in.
Material
0
I DO HEREBY CERTIFY S CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C, WELL
CONSTRtiCTI6N S I�d,N(;#1.FUSNET COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
UU LLSS till uu 15//—
FOR OFFIC SE ONLY =l
Quad No: 9p SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
LLoriginat to Division of Water Quality, Groundwater Section within 30 days Sedal No. "�. _ _�_ GW-1 REV. 12199

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section\ 223237
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone] r
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential Ell Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: ( h/o sketch of the location below) If
Nearest Town: Xj �j' ' 0 /L/ County:
crack/-Y /'1455 C4ur,C4
(Road Name an Numoers, Community, or Subdivision and Lot No.)
3. OWNER 16o I 1*9 / � aFj S:
Address e xQvIv6 H p1d
veei or glrte o. _
C. T/$i52
City or Townr- State Zip Code —
4. DATEDRILLED-
5. TOTAL DEPTH —
6. CUTTINGS COLLECTED YES 0 NO❑ —
7. DOES WELL REPLACE EXISTING WELL? YE N07 _
8. STATIC WATER LEVEL Below Top of Casing: FT.
(Use's if Above Top o 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 29,0118-
10. YIELD (gpm): 20t METHOD OF TEST-
11. WATER ZONES (depth): —
12. CHLORINATION: Type
13. CASING:
Depth Diameter
From To 20 Ft..
From To Ft.
From To Ft.
14. GROUT
Depth
From To Ft.
From To Ft.
15.SCREEN:
Agricultural ❑ Monitoring ❑
DRILLING LOG DEPTH
From To Formation Description
If additional space is needed use back of form
Wall Thickness LOCATION SKETCH
or Weight/Ft. Material (Show direction and distance from at least two State
AA= i/C Roads, or other map reference points)
0
c�
Material Method
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:
L
a
Z
1
W
m
Slot Size Material 3=
_ in.
in. to
t�
in.
100 HEREBY CERTIFY THAT THIS WEL4'
CONSTRUGTIONSffNFOR OFFICE RQuad No:
SubSerial No.
Material
ISTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
OF THIS RECO HAS BEEN PR QVI TO THE WELL OWNER. — Q
)NATURE OF PER60N CONSTRUCTING THE WELL
o Division of Water Quality, Groundwater Section within 30 days
GW-1 REV. 12/99

223229
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 WELLCONTRACTOR: )Q� �A1y/ �f '��'�
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMIT#:
1.
WELL USE (Check Applicable Box): Residential oll^ Municipal ❑
Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2.
WELL LOCATION: ( ow sketch of the location below) �,�7 p
� b 'V / /
Nearest Town: /" r County:
STf cy N, 4
(Road Name an umbers, C�om`%unity, or Subdivision and Lot No.)
DRILLING LOG DEPTH
3.
OWNER ('7 O S/1 'W / 1-1. i A M S
From To Formation Description
Address /17 7-/ njo ff( 46-,>
(Street or oute o.
/ /-4 A i one MIC -
City or Town State Zip Code
4.
DATE DRILLED -/ ' 6 U
5.
TOTAL DEPTH _ Z!2
6.
CUTTINGS COLLECTED YES 0 NO K❑
7.
DOES WELL REPLACE EXISTING WELL? YES0NOF
8.
STATIC WATER LEVEL Below Top of Casing: FT.
(Use 'i it Above Top of asing)
9.
TOP OF CASING IS FT. Above Land Surface'
'Top
or casing terminated at/or below land surface requires a variance In accor.
dance
with 15A NCAC 2C At 8
✓3 r �' y= N
10.
YIELD (gpm): METHOD OF TEST
11.
WATER ZONES (depth):
12.
CHLORINATION: Type Amount
If additional space is needed use back of form
13. CASING
LOCATION SKETCH
Depth
9s
Wan Thickness
meDiater or Wei alerial Show direction and distance from at least two State
Weight/Ft.
9 tild 5 y y C(
From
To
Ft.
� Roads, or other map reference points)
From
To
Ft.
From
To
Ft.
14. GROUT:
o
Depth
Material Method L
From
To
Ft.
:c.
11
From
To
Ft.
f
i,o
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.
I DO HEREBY CERTIFY THAT THIS WELL WA
CONSTRUCTION STANDARDS, AND THAT A
Quad No:
Siu •t'n i
Serial No. i
1,
i�F:
Material
RUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
THIS RECORD HAS 8 EN PROVIDED TO THE WELL OWNER.
GNATUFk OF PERSON CONSTRUCTING THE WELL DATE
to Division of Water Quality, Groundwater Section Within 30 days
GW4 REV. M'99

223230
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] e' /,-///
WELL CONSTRUCTION RECORD WELLCONTRACTOR:
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�DlyY�sketch oA(t/he location below)/'�
Nearest Town: �'/L.� H cl '" County: (✓GALL' r'
(Road Name and Numbers, Community. or Subdivision antl Lot No.) DRILLING LOG DEPTH
3. OWNER Oly�i/ �. _ �L. C lFrom To Formation Description
Address A- / C✓
treat or o le o.
/�G
City or Town State Zip Code
4. DATE DRILLED �G' r' O
5. TOTAL DEPTH _ ��
6. CUTTINGS COLLECTED YES 0 NO❑
7. DOES WELL REPLACE EXISTING WELL? YE�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): /,/- METHOD OF TEST
11. WATER ZONES (depth):
12. CHLORINATION: Type
13. CASING:
Amount If additional space is needed use back of form
LOCATION SKETCH
Depth R
Wall Thickness
Di7eter or Weight(Ft. f4aterial
fr G
(Show direction and distance from at least two State
From
To 35
Ft.
'" x/y
Roads, or other map reference points)
From
To
Ft.
From
To
Ft.
14. GROUT:
Depth
Material Method
From
To
Ft.
a
From
To
Ft.
1
15. SCREEN:
W
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 a
_ in.
_ in. c.rf
in. CD
Material
r,
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THATA COPY OF THIS RECORD HAS B_E/EN/ PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY �+SO`
Quad No: ' jE NATO OF PERSON CONSTRUCTING THE WELL DATE
Submit o t� Division of water Quality, Groundwater Section within 30 days
Serial No. ., GWA REV. 12199

2 3 2 31
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Gro_u water Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone] a , /��� n ,
WELL CONSTRUCTION RECORD WELLCONTRACTOR:
WELL CONTRACTOR CERTIFICATION #:
S'TATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential LvJ Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ED If Other, List Use:
2. WELL LOCATION: (S ow sketch of the location below)
Nearest'.."... County:
oF� 'l7-c.,vs rid- ZL%o d S:&V5 nd
(Road Name an Numbers, Community, or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER _&/V/y/S 1" From To Formation Description
Address A4, 13o)( //LdS,/1 Y--zi„d/✓9 d
Vi.41 /=o IhT trees 0ee' o. _T?„`Z0.
City or Town State Zip Code
4. DATE DRILLED 7— �V
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES F-1 NO❑
7. DOES WELL REPLACE EXISTING WELL? YES © NOF_�
8. STATIC WATER LEVEL Below Top of Casing: FT.
,, (Use'+' if Above Top of Casing)
9. TOP OF CASING IS /1i . 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): u Y METHOD OF TEST
11. WATER ZONES (depth):
12. CHLORINATION: Type Amount if additional space is needed use back of form
13. CASING:
Wall Thickness LOCATION SKETCH
Depth (�'` Dia ter or Wei hUFt. JAatteerialy�. Show direction and distance from at least two State
From To 2 Ft. = 9 L ( Roads, or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth
From To Ft.
From To Ft.
15. SCREEN:
Material Method
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
L
Z
t
Ca
3
3
W
Cn
0
0
ZZE
n�
o01
c-�
o.,
�rn
yc
n�
^ern
<n:z
mz
n
H
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTff STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOROFFICE xONLY��
Quad No: ) , i `;. _ . SIGNATURE OF FFERSON CONSTRUCTING THE WELL DATE
9 Submit original to Division of Water Quality, Groundwater Section within 30 days
Serial No.u,.
GW-1 REV. 12F99

223232
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:
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (check Applicable Box): Residential flEr Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: Show sketch of the location below)
Nearest Town: ��i h ' a i'�j County:
(Road Name and Numbers. Community, or SUDtlivision antl Lot ru
3. OWNER ���%/Si �'�lUt,
Address Aj') /66X
City or Town State Zip Code
4. DATE DRILLED 10
5. TOTAL DEPTH /3 /ffl
6. CUTTINGS COLLECTED YES Q NO❑
7. DOES WELL REPLACE EXISTING WELL? YES � NO�
8. STATIC WATER LEVEL Below Top of Casing: e, FT.
/ (Use'+' it Above Top of Casing)
9. TOP OF CASING IS/ FT. Above Land Surface'
'Top of casing terminated at/or below land surface requires a variance In accor.
dance with 15A NCAC 2C.0118
10. YIELD (gpm): /jD f METHOD OF TEST,�%�/�E�"
11. WATER ZONES (depth):
12. CHLORINATION: Type
13. CASING:
Agricultural ❑ Monitoring ❑
DRILLING LOG DEPTH
From To Formation Description
Amount If additional space is needed use back of form
LOCATION SKETCH
Depth /�
Wall Thickness
Diaater or Weight/Ft.)ytatedal
L'
(Show direction and distance from at least two State
From
To -lam
Ft.
/ X�
Roads, or other map reference points)
From
To
Ft.
From
To
Ft.
14. GROUT:
o
Depth
Material Method
From
To
Ft.
b'
From
To
Ft.
1
15. SCREEN:
W
Depth Diameter
From To _ Ft _ in.
From To Ft. _ in.
From —To Ft. in.
16. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To Ft.
17. REMARKS:
Slot Size Material
in.
in.
in.
Material
A
CJ7
O
0
D
'Qr1
o�
r»
I DO HEREBY CF"TIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
FRECORD HAS COP
_LD TOTHE WELL OWNER. a
FOR OFFICE U NLY-
Quad No: '-�'a SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit @dginal to Division of Water Quality, Groundwater Section within 30 days
Serial No., ., -
GW-1 REV. 12199
,�.e..: wai6 Seth R

223233
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: Al,%��� �ii1 h ti
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMIT#: "ice
1.
WELL USE (Check Applicable eox): Residential Municipal ❑
Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑
If Other, List Use:
2.
WELL LOCATION:�}ISho sketch of a location below) )
(l %OO
Nearest Town: lCounty:
(Road Name and umbers. Community, or Subdivision and Lot No.)
DRILLING LOG DEPTH
3.
OWNER o / AN /JOSS
From To Formation Description
Address L41//j/u/V /9ZQz
N�/1h/Ohl ZStreet or Rome /VC- , t > S
City or Town n State Zip Code
4.
5.
DATE DRILLED
TOTAL DEPTH
6.
CUTTINGS COLLECTED YES 0 NOQ
7.
DOES WELL REPLACE EXISTING WELL? YE�NOF
S.
STATIC WATER LEVEL Below Top of Casing: FT.
(Use': if Above Top of Casing)
/�� -
9.
TOP OF CASING IS FT. Above Land Surface
'Top of casing terminated at/or below land surface requires a variance In accor-
dance with 15A NCAC 2C . 118 r,
>
10.
//A
YIELD (gpm): Z METHOD OF TEST
11.
WATER ZONES (depth):
12.
CHLORINATION: Type Amount
If additional space is needed use back of form
13.
CASING:
LOCATION SKETCH
Wall Thickness
Depth Diameter or Weight/Ft. Material
(Show direction and distance from at least two State
16
From To 15_�, Ft. L 1 ANS 7'Roads, or other map reference points)
From To Ft.
From To Ft.
14.
GROUT:
Depth Material Method
O
o
From To Ft.
—
From To Ft.
a
cn
m
15.
SCREEN:
E: ti
Depth Diameter Slot Size Material
W
of
From —To—Ft— in. —in
m
From To _ Ft. _ in. in.
From —To Ft. in. in.
M
n55
16.
SAND/GRAVEL PACK:
C_n
Depth Size Material
z
From To Ft.
From To Ft.
17.
REMARKS:
-
I DO HER6Y.CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPAOF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
GNATURE OF PERSON CONSTRUCTING THE WELL
to Division of Water Quality, Groundwater Section within 30 days

223234
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:
WELL CONTRACTOR CERTIFICATION #: m ��
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential LE" Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below) y/ r
Nearest Town: e;Ay' 1 0 /1/ County:
(Road Name�(��ndr Numbers Co unity, or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER Y�//����/7JL/ y From To Formation Description
AddressC/;r/3 —hr� /?0h7— /fC/
tw,eei or ouie o.
/V r
City or Town State Zip Code
4. DATE DRILLED o O
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YESQ NO❑
7. DOES WELL REPLACE EXISTING WELL? YE� NO�
8. STATIC WATER LEVEL Below Top of Casing: FT.
� I (Use '+' it Above Top of Casing)
9. TOP OF CASING ISIV 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): /Z 2' METHOD OF TEST X/.//4—J--
11. WATER ZONES (depth):
12. CHLORINATION: Type
13, CASING:
Depth �} L Di a eter
From To Ft.
From To Ft.
From To Ft.
14. GROUT:
Amount If additional space is needed use back of form
Wall Thickness LOCATION SKETCH
or Weight/Ft. IV14dal (Show direction and distance from at least two State
571G Roads, or other map reference points)
Depth Material
From To Ft.
From To Ft.
15. SCREEN:
Depth Diameter
From _To Ft in.
From —To Ft. — in.
From _ To _ Ft. _ in.
16. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To Ft.
17. REMARKS:
Method
Slot Size Material
in.
in.
in.
Material
IDOHEREBY O 19TIF'P fiIS� OL1
CONSTRUCTION 3 bAbAidB'TFIRT'7C
p r
FOR OFFICE US LY
Quad No:y 4 4 SI
Submit original
Serial No.
-------------
5
r_
m
t
Ca
co
cn
CD
0
NSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
'OF TH S,RECORD
7HASr EEN PROVIDED TO THE WELL OWNER. \
U1 ,r1J4 7—"�!-0J
ONATURE OF PERSON CONSTRUCTING THE WELL DATE
to Division of Water Quality, Groundwater Section Within 30 days
GW-1 REV. 12199

North Caroline - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
223228
1636 Mail Service Center- Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION 0:_,��5"G
STATE WELL CONSTRUCTION PERMIT#: a 7
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) c
/"�
Nearest Town, H r ti� County:
�'ti%YM/CiaA C hLr,Gry ��
(Road Name and Numbers. Comm u ill, or Sub�d_l,d)Sion and Lot No.)
DRILLING LOG DEPTH
3. OWNER � y5 t 4+ I U--f� HUi
From To Formation Description
n _
Address" -3 JJC'K 3 7 d
rea or 0u a o.
NFb� Nc, __? l
Cily or To" Stale Zip Code
DATE DRILLED
4.
S. TOTAL DEPTH /
6. CUTTINGS COLLECTED YES L] NO©
r p
7. DOES WELL REPLACE EXISTING WELL? YES F-1d� NO®
6. STATIC WATER LEVEL Below Top of Casing:]✓ FT.
(Use •+' It Above Top of Casing)
+
9. TOP OF CASING IS �75t // FT. Above Land Surface
1
*Top of casing terminated at/or below land surface requires a variance In actor-
�+•�
dance with 15A NCAC 2C.0118
METHOD OF TEST
10. YIELD (gpm): 1A_ _
11. WATER ZONES (depth):
it additional space Is needed use back ofgm
12. CHLOR I NATION: Type Amount
13. CASING:
LOCATION SKETCH
Wall Thickness
Depth Diameter or WeighVFt. Material
(Show direction and distance from at least two State
�/� F �Si C
Roads, or other map reference points)
From To — Ft.
From To FI.
o
From To Ft.
O
o
14. GROUT:
Depth Material Method
From To Ft.
t
o<
From To Ft.
vc
15. SCREEN:
3r
m�
Depth Dlatoctar Slot SIZE Material
z�
From _To _ Ft — In. —In.
Co
ma
From _ To _. Ft. _ In. _ In.
Ln
1L
From _ To _ Ft. _ In. _ In.
16. SAND/GRAVEL PACK
Depth Size Material
From To Ft.
From To Ft.
W. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF TH RE RD HAS BEEN PROVIDED TO THE WELL OWNER.
� � /fig-D C� -.> - ;265v0
FOR OFFICE USES2ULY.
Quad No
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Ovallty, Groundwater Section within 30 days
GW-1 REV. 12/99
Serial No.

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
4- ?_ 2 7
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: �/� �/al✓d �F'l L
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMIT#: 4231 1
1. WELL USE (Check Applicable Box): Residential Rr Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show skptch of the location below)
Nearest Town: iq�M A //�/6 A( /1 County: - N� �G w' h A 4 -
l9//���% �G VS7Cfi(_/ V G`H$5
(Road Name a��j Numbers, Cornmuniry, or Subdivision and Lol No.) DRILLING LOG
3. OWNER /SO /�//� /? S S From To
Address C/V h//✓G a f d —
treet or oute o. _
—' City or Town State Zip Code
Q —
4. DATE DRILLED / - 'y a
5. TOTAL DEPTH h —
6. CUTTINGS COLLECTED YESQ NO®
7. DOES WELL REPLACE EXISTING WELL? YES Q NO©
8. STATIC WATER LEVEL Below Top of Casing: �"A, FT. n x'
(Use 'i if Above Top of Casing) r
9. TOP OF CASING IS FT. Above Land Surface'---
(-`) y -.
'Top of casing terminated at/or Wow land surface requires a variance In accor. D c.
dance with 15A NCAC 2C .011e 7 ' i rr-
10. YIELD (gpm): 10 METHOD OFTEST
11. WATER ZONES (depth): Cal ne-
m r.
12. CHLORINATION: Type
13. CASING:
DEPTH
Formation Description
Amount If additional space is needed use back of form =
LOCATION SKETCH
Wall Thickness
Depth
Diam ter or Weight/Ft. Material
(Show direction and distance from at least two State
From
To
Ft.
�'�'�'�
Roads, or other map reference points)
From
To
FL
From
To
Ft.
14. GROUT:
Depth
Material Method
From
To
Ft.
From
To
Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From —To—Ft— in. in.
From To Ft. 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 WEU,,.WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRC;7j 3- (¢JDIT %NDf H JT, A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFIC EON
LY
ll U L
Quad No: a i P SIGNATURE F PERSON CONSTRUCTING THE WELL m DATE
S ' °original to Division of Water Quality, Groundwater section within 30 days
Serial No. GW-1 REV. 12199
riwae Secti

19
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section "- �' 21+
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: A/ 'P'I� �" rr/,4 v
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMIT#:Q-�
1. WELL USE (Check Applicable Box): Residential [�!( Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below) �.
Nearest Town: ��'r'�4� / County: = J?0 cU Af-
(Road Name aan/ndd+ Numbers. Community, or Subtlivision and Lot No.) DRILLING LOG DEPTH
3. OWNER W", So^/ /_P/9 5 From To Formation Description
Address �f�7/-� 7"N 611'1d xt. Cy
/V4 r6t.�ZStreeto 1-e No.)L,�'�_�
City or Town / �,Srrtate •� Zip Code
4. DATE DRILLED -115- 7`e"
5. TOTAL DEPTH 1 � 1
6. CUTTINGS COLLECTED YES Q NOEFf
7. DOES WELL REPLACE EXISTING WELL? YES NO®
8. STATIC WATER LEVEL Below Top of Casing: p v FT.
(Use': if Above Top of Casing)
9. TOP OF CASING ISM Fr. Above Land Surface'
'Top of casing terminated aVor below land surface requires a variance In accor-
dance with 15A NCAC 2C.0118 _
10. YIELD (gpm):_ METHOD OF TEST
11. WATER ZONES (depth):
12. CHLORINATION: Type Amount It additional space is needed use back of form
13. CASING:
Wall Thickness LOCATION SKETCH
Depth Diameter or WeighVFt.[�1,aterial (Show direction and distance from at least two Stale o
From To -!� 'J Ft. —(�— ' "'r�s' �G Roads, or other map reference points) n`
From To Ft. C_ om
From To Ft. �m
14. GROUT: 1
V
W zm
Depth
From To Ft.
From To Ft.
15. SCREEN:
Material
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
in.
in.
in.
I DO HEREBY CERTIFY THAT THIS WELL
Method
0
0
�
NZ
�
H
Material O
o
Material
CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
SPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
Quad No: V 1 , '..SIGNATURE OF PERSON CONSTRUCTING THE WELL
SuAOV'iythal to Division of Water Quality, Groundwater Section within 30 days
DATE
GW-1 REV. 12199
Serial No.

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section 229777
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 2 Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ It Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
�'
y' `'
Nearest Town: ���%` -01V /VG% County: v J ✓ r1 u" /=
GarrNr.rioCq 4--x P,yS,3
(Road Name and umbers, Co/mmuniity. or and Lot No.) DRILLING LOG
DEPTH
cSubdivision
3. OWNER M,Af1-i4 [GJ ✓�JS From To
Formation Description
Address i,ANN(,/✓ ��
pA/ (Street orA .0 o. C
City or Town State Zip Code
- - �)d
4. DATE DRILLED
:r:
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES Q NOE�Zj
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO®
om
8. STATIC WATER LEVEL Below Top of Casing: 1S r) FT.
n>,
=M
(Use'+' it Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface'
Fm
m�
'Top of casing terminated attor below land surface requires a variance In eccor.
�m
dance with 15A NCAC 2C.01)8 r
10. YIELD (gpm): v_�2 7' METHOD OF TEST
11. WATER ZONES (depth):
z
12. CHLORINATION: Type
13. CASING:
Depth Diameter
From To � L' Ft. — 6
From To Ft.
From To Ft.
14. GROUT:
Depth
From To Ft.
From To Ft.
15. SCREEN:
Depth
From
To _
From
To
From
To _
16. SAND/GRAVEL PACK:
Depth
From
To —
From
To_
17. REMARKS:
Amount If additional space is needed use back of form
Wall Thickness LOCATION SKETCH
or Weight/Ft. tenat _ (Show direction and distance from at least two State
AA. y Cl Roads, or other map reference points)
Material Method
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 THAT
FOR OFFICE USE ONLY
Quad No:
Serial No.
o gubr t original to Division of Water Quality. Groundwater Section Within 30 days
GW-1 REV. 12/99

North Carolina - Department of Environment and Natural Resources - Division of Water Quality . Groundwater Section ? �— 9778
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: /,A
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential Lr 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: �M4{> r o /IG /Y � � County: /V y ii-o
6j�"d ��cri6yG1ps- ✓'7W N ew U700c-/1
(Road Name andflpmbers, "Comm nay, or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER �f6��ry � From To Fonna:ion Description
Address
r faucet or nqura rvu.l
City or Town _ Stale Zip Code
4. DATE DRILLED -5 &'y
5. TOTAL DEPTH v
6. CUTTINGS COLLECTED YES Q NOE�
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO[K
6. STATIC WATER LEVEL Below Top of Casing: �7, 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.0J1e
10. YIELD (gpm): 5 METHOD OF TEST
11. WATER ZONES (depth):
12. CHLORINATION: Type
13. CASING:
Amount
v
O o
If additional space is needed use back of form
Wall Thickness LOCATION SKETCH
Depth �fy/ S� Dia eter or Weight/Ft. /M_y��edal _ (Show direction and distance from at least two State
From To"
" Roads, or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From To Ft.
From To Ft.
15. SCREEN:
Depth Diameter
From To Ft in.
From To Ft. _ in.
From To —Ft. in.
16. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To Ft.
17. REMARKS:
Slot Size Material
in.
in.
in.
Material
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY L S c 3
Quad No: SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
`,( '1 Submit original to Division of Water Quality, Groundwater Section Within 30 days
Serial No. sJ GW-1 REV. 12/99

North Carolina -Department of Environment and Natural Resources -Division of Water Duality •Groundwater Section 2�9779
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELLCONTRACTOR: J 4,olycl Jj+/Lti/�✓�
WELL CONTRACTOR CERTIFICATION #: _,:SL
STATE WELL CONSTRUCTION PERMIT#:
0
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 ow sketch of the location below)
Nearest Town: 4111, r " County:
P1_'w1I/z «ti /1. •9XiT_S
Road Name and Numbers, Com(nuni Db-WSubdivision and Lol No.) DRILLING LOG
3. OWNER /_�/ %%U/?,A6 lye /Y(/—�5 From To
Address 451y 76) •�L)/.5
Mireetor ouie o.
4�1 s,i oil/ N_c.: d?> —
City or Town _ State Zip Code
4. DATE DRILLED
5. TOTAL DEPTH DY
6. CUTTINGS COLLECTED YES Q NOQ
7. DOES WELL REPLACE EXISTING WELL? YES N0�
8. STATIC WATER LEVEL Below Top of Casing: AFT.
�/ (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 .4 8
10. YIELD (gpm): /2 METHOD OF TEST
11. WATER ZONES (depth):
12. CHLORINATION: Type
13. CASING:
DEPTH
Foanalion Description
Amount If additional space is needed use back of form
Wall Thickness LOCATION SKETCH
Depth �n Diameter or Weight/Ft. renal (Show direction and distance from at least two State
From To —(�= Ft. �� 7"'�r riC' Roads, or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From To Ft.
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft in. in.
From To Ft. in. in.
From To Ft. in. in.
16. SAND/GRAVEL PACK:
17
Depth Size Material
From To Ft.
From To Ft.
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Quad No: .,
Serial No.
rY C'l
r� SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
U Submit odgidal 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 Duality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone] -'7
WELL CONSTRUCTION RECORD WELL CONTRACTOR: /��r�'�'�r��`
WELL CONTRACTOR CERTIFICATION #:,
STATE WELL CONSTRUCTION PERMIT#:
2.29780
4A/AVi7
WELL USE (Check Applicable Box): Residential 01/1�
Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCA
Nearest Town:
(Road Name,
3. OWNER 1
Address /?I
nd Numbers, Com
nni11
G A, c
of the location below)
/VC, county*.
SS
and Lot No.) DRILLING LOG DEPTH
From To Formation Description
City or Town State up code
4. DATE DRILLED `7 -�� Luc• a
5. TOTAL DEPTH / S
6. CUTTINGS COLLECTED YES ❑ NO❑
7. DOES WELL REPLACE EXISTING WELL? YE�NO�]
8. STATIC WATER LEVEL Below Top of Casing: FT.
1 (Use -+' if Above Top of Casing)
9. TOP OF CASING IS A: / FT. Above Land Surface'
'Top of casing terminated attor below land surface requires a variance In accor-
dance with 15A NCAC 2C .011 e
10. YIELD (gpm): 2— METHOD OF TEST ��/� /4r�
11. WATER ZONES (depth):
12. CHLORINATION: Type
Amount If additional space is needed use back of form
13. CASING:
LOCATION SKETCH
Depth
Diameter
Wall Thickness
or Weight/Ft. renal (Show direction and distance from at least two State
From
To L
Ft. /0
Roads, or other map reference points)
From
To
Ft.
From
To
Ft.
14. GROUT
Depth Material Method
From To Ft.
From To Ft.
15.SCREEN:
Depth Diameter
From To _ Ft _ in.
From —To—Ft.— in.
From —To—Ft.— in.
16. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To Ft.
17. REMARKS:
Slot Size Material
in.
_ in.
in.
Material
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HA/S- BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY �J esI7
Quad No: SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Stub %it original to Division of Water Quality, Groundwater Section within 30 days
�; v GW.1 REV. 12/99
Serial No.

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section 229776
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION #: C
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Bo:): Residential Da Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
Agricultural ❑ Monitoring ❑
2. WELL LOCATION: (Show sketch of the location below) V �- s.
��/0/t{ County:d
Nearest Town: //
(Road Name antl Nurnt,7 Co�"'unit . or Suodivision and Lot No.) DRILLING LOG
3. OWNER f7Cl,�--'/✓an/%5� From To
Address(street or Route o.
/r''/�.Cr'v�✓ice r�ir%� -/
City or Town _ State Zip Code —
-��1 `' o
4. DATE DRILLED � 5. TOTAL DEPTH /� o
6. CUTTINGS COLLECTED YES F-1 NOD
7. DOES WELL REPLACE EXISTING WELL? YES [�J NOQ
6. STATIC WATER LEVEL Below Top of Casing: FT.
(Use'+' if Above Top of Casing)
9. TOP OF CASING IS->? FT. Above Land Surtace'
'Top of casing terminated atior below land surface requires a variance In accor-
dance with 15A NCAC 2C .0118
10. YIELD (gpm): �U>' METHOD OFTEST
11. WATER ZONES (depth):
DEPTH
Formation Description
12. CHLORINATION: Type
Amount
If additional space Ls needed use back of form
13. CASING:
LOCATION SKETCH
Depth Diameter
Wall Thickness
or weight/Ft.
Material . (Show direction and distance from at least two State
From
q
To 1" Ft.
o
s,//3 i� C Roads, or other map reference points)
From
To Ft.
From
To Ft.
14. GROUT
Depth
Material Method
From
To
Ft.
From
To
Ft.
15. SCREEN:
Depth
Diameter
Slot Size Material
From
To
Ft
in. in.
From
To
Ft. _
in. in.
From
To —Ft.
—
in. in.
16. SAND/GRAVEL PACK:
Depth
Size Material
From
To
Ft.
From
To
Ft.
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OFT IS R CORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Quad No: - SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Quality, Groundwater Section Within 30 days
Serial No. GW-1 REV. 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:
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMIT#:
WELL USE (check Applicable Box): Residential03 Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
Agricultural ❑
2. WELL LOCATION how Sketch of the location below) C
Nearest Town: ��,�wh / P/-V C County: �� �✓ CLi �'
OZd ,W TeC ram/" Y P,4 5S
(Road Name and Numbers, Compni , or S bdivision and Lot No.) DRILLING LOG
3. OWNER From To
Address (2,z of SS —
treetor
City or Town State Zip Code -
4. DATE DRILLED 6
5. TOTAL DEPTH / 46-S
6. CUTTINGS COLLECTED YES Q NOD
7. DOES WELL REPLACE EXISTING WELL? YE�NOPP
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 .Otta
10. YIELD (gpm): �_ METHOD OF TEST 4/ f
11. WATER ZONES (depth):
12. CHLORINATION: Type
13. CASING:
Depth L/2 Diameter
From To Ft. 0
From To Ft.
From To Ft.
14. GROUT:
Depth
From To Ft.
From To Ft.
15. SCREEN:
212210
�L 44 fv
Monitoring ❑
DEPTH
Formation Description
O
Amount If additional space is needed use back of form
Wall Thickness LOCATION SKETCH
or WeighVFt. renal (Show direction and distance from at least two State
r Roads, or other map reference points)
Material Method
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. -
Material
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF TTHHHIIISS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY e�
Quad No: SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Quality, Groundwater Section within 30 days
Serial No. GW-t REV. 12199

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section If
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELLCONTRACTOR:
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMIT#: �/:7n
1. WELL USE (Check Applicable sox): Residential ll�Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch o1 the location below) /YJ
Nearest Town: h "6141 County,
(Road Name and Yumbers, Comb
3. OWNER C«
Address ,2/ V ' %O
i Lot No DRILLING LOG DEPTH
From To Formation Description
2,
City or Town State Zip Code
4. DATE DRILLED--y�l—�
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES M NO®
7. DOES WELL REPLACE EXISTING WELL? YES �C]r N0E]
8. STATIC WATER LEVEL Below Top of Casing: e_•'FT.
// (Use': if Above Top of Casing)
9. TOP OF CASING IS1Fr. Above Land Surface'
'Top of casing terminated at/or below land surface requires a variance In accor-
dance with 15A NCAC 2C.998
10. YIELD (gpm): METHOD OF TEST
11. WATER ZONES (depth):
12. CHLORINATION: Type Amount
13. CASING:
Depth Diameter
From To Ft. -
From To Ft.
From To Ft.
14. GROUT:
Depth
From To _
From To —
15. SCREEN:
Depth
From
To _
From —To
—
From —To
16. SAND/GRAVEL PACK:
Depth
From
To —
From
To_
17. REMARKS:
M
If additional space is needed use back of forn
Wall Thickness LOCATION SKETCH
or WeighttFt. Material (Show direction and distance from at least two State
y1e' Roads, or other map reference points)
Material Method
—Ft.
_Ft,
Diameter Slot Size Material y
Ft._ in. _ in.
Ft._ In. in.
i
Size Material
— Ft.
Ft.
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY ' ',A
Quad No:
Serial No.
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Quality, Groundwater Section within 30 days
GW-1 REV. 12r99

212212
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: v/ �/✓�7 �i h� 'h
WELL CONTRACTOR CERTIFICATION
STATE WELL CONSTRUCTION PERMIT#:
LI _
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: 1Town: HIV Af, o M � �'' County:
(Road Name an in ers.Comm ni or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER ��/�� 5-% From To Formation Description
Address Z7 1A11A1
A/ , 3AI
City or Town State Zip Ccoe
4. DATE DRILLED
5. TOTAL DEPTH v
6. CUTTINGS COLLECTED YES 0 NOE�
7. DOES WELL REPLACE EXISTING WELL? YES NO[ZJ
8. STATIC WATER LEVEL Below Top of Casing: (, FT.
(Use'+' it Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface'
'Top of casing terminated atlor below land surface requires a variance In accor-
dance with 15A NCAC 2C.1118
10. YIELD (gpm): 2 METHOD OF TEST /7
11. WATER ZONES (depth):
12. CHLORINATION: Type
13. CASING:
Depth Diameter
�„ r
From To � Ft. G
From To Ft.
From To Ft.
14. GROUT
Depth
From To Ft.
From To Ft.
15. SCREEN:
rn e
Amount If additional space is needed use back of form Z
Wall Thickness LOCATION SKETCH
or weighuFt. /M�a�terial - (Show direction and distance from at least two State
" Roads, or other map reference points)
Material
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:
Method
U
Material
e�
Material
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.. %-
FOR OFFICE USE ONLY
Quad No:
Serial No.
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Quality, Groundwater Section Within 30 days
GW-1 REV. 12199

212213
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 #: G
STATE WELL CONSTRUCTION PERMIT#:
2.
3.
4.
5.
6.
7.
8.
WELL USE (check Applicable Box): Residential L!q Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
WELL LOCATION: (S iow sketch of the location below) �, �
Nearest Town: %� / County: �_ 176 wf4 A
Y3�c✓G /l�crCY�55
(Road Name antl umbers. Co uni , or Subdivision and Lot No.) DRILLING LOG
OWNER ivn,./N7 5s From To
Address /Ilwo/V ""La, _
rt trees or oT✓ J.
City or Town State Zip Cccie —
DATE DRILLED '2� 19 - e'—
TOTAL DEPTH
DEPTH
Formation Description
CUTTINGS COLLECTED YES Q NOE o
DOES WELL REPLACE EXISTING WELL? YE� NO©
STATIC WATER LEVEL Below Top of Casing: FT. C �n
/� (Use'+' it Above Top of Casing) ter+
9. TOP OF CASING IS— FT. Above Land Surface*
-Top of casing terminated at/or below land surface requires a variance In accor. yC
dance with 15A NCAC 2C.0118 3 rvC
10. YIELD (gpm): 16 7' METHOD OF TEST
11. WATER ZONES (depth): rye
en
12. CHLORINATION: Type Amount If additional space is needed use back of form z
13. CASING:
Wall Thickness LOCATION SKETCH
Depth �7 Diameter or Weight/Ft Material (Show direction and distance from at least two State
From To Ft. -9 Z 4' �'V 50 e Roads, or other map reference points)
From To Ft. —
From To Ft. —
14. GROUT:
Depth Material Method
From To Ft.
From To Ft.
15. SCREEN
Depth Diameter Slot Size Material
From —To—Ft— in. in.
From _ To _ Ft. _ in. in.
From —To —Ft. _ in. —in.
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF TAIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Quad No:
Serial No.
SIGNATURE OF PERSON CONSTRUCTING THE WELL
Submit original to Division of Water Quality. Groundwater Section within 30 days
�5-19- 6b
DATE
GW-1 REV. 12199

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section 212214
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]�q
WELL CONSTRUCTION RECORD WELL CONTRACTOR: 4 Al
WELL CONTRACTOR CERTIFICATION #:_�i S—lr
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential 121�'
Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
Agricultural ❑ Monitoring ❑
2. WELL LOCATION: (Show sketch of the location below) ,�/r ,(%
Nearest Town: 3 h , .0 N /VcG County: / G Q1 c) LU
(Road Name and umbers, Commune , or Subdivision and Lot No.) DRILLING LOG
3. OWNER vhA.^/[r�Ss From To
Address
uee oroute oo.
CA/
City or Town state Zip Code —
4. DATE DRILLED 15 41 ' ()O —
5. TOTAL DEPTH y 1 —
6. CUTTINGS COLLECTED YES Q NOF. —
7. DOES WELL REPLACE EXISTING WELL? YES(—] NOEg CM
8. STATIC WATER LEVEL Below Top of Casing: t!n FT.
(Use '+' if Above Top of Casing) = C�
9. TOP OF CASING IS. FT. Above Land Surface' =a!
-Top of casing terminated aVor below land surface requires a variance In accor-
dance with 15A NCAC 2C .0p 9 �-
10. YIELD (gpm): METHOD OF TEST 61'7411'
11. WATER ZONES (depth):
12. CHLORINATION: Type
13. CASING:
Depth Diameter
From To 1�r v Ft. —
From To Ft.
From To Ft.
14. GROUT:
DEPTH
Formation Description
Amount If additional space is needed use back of
Wall Thickness LOCATION SKETCH
or Weighl/R. Wienal .(Show direction and distance from at least two State
Roads, or other map reference points)
Depth Material
From To Ft.
From To Ft.
15. SCREEN:
Depth Diameter
From To _ Ft _ in.
From _ To _ Ft. _ in.
From _ To _ Ft. _ in.
16. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To Ft.
17. REMARKS:
Method
Slot Size Material
in.
in.
in.
Material
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS
BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Quad No: SIGNALIRE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Quality, Groundwater Section within 30 days
Serial No. GW-1 REV. 12/99

North Carolina - Department of Environment, 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: A'o1_f.-2 Pd -A 4 r
. FCR OFFICE USE ONLY -'
QUAD. NO. SERIAL NO,
Lac Long.SO
Minor Basin
Basin Code -
Header Ent. t - : G.V-i Eni.:.'
STATE WELL CONSTRUCTION
DRILLER REGISTRATION NUMBER: aj�7 PERMIT NUMBER:
9
1. WELL LOCATION: (Show sketch of the location below) O
A,
✓7 _
Nearest Town:_ / l/ aN County:
h
(Road, Community. or Subbdiivvisioon� and Lot No.)n
DEPTH
DRILLING LOG
2. OWNER
From To
Formation Description
ADDRESS_
r (Street or Route No.)
Al/c -
City or Town State Zip Code
3. DATE DRILLED ° USE OF WELL /76S
4. TOTAL DEPTH
5. CUTTINGS COLLECTED YES ❑ NO❑
6. DOES WELL REPLACE EXISTING WELL? YES ❑ . NOD
x
7. STATIC WATER LEVEL Below Top of Casing: �t 2 FT.
�
(Use'.- if Above Top of Casing)
8. TOP OF CASING IS FT. Above Land Surface'
ter,
' Casing Terminated st/or below land surface Is Illegal unless a variance Is Issued
fm
In accordance with 15y NCAC 2C .0119 _
2t
9. YIELD (gpm): METHOD OF TEST
10. WATER ZONES (depth):
anz
11. CHLORINATION: Type Amount
If additional space is needed use bARof fFm
12. CASING
Wall Thickness LOCATION SKETCH
Depth
�`3
Diameter or Weight/Ft. yaterial (Show direction and distance from at least two State
From
To
Ft. ,aSTiC� Roads, or other map reference points)
From
To
Ft.
From
To
Ft.
13. GROUT:
Depth
Material Method
From
To
Ft.
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:
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.
i
ter- a v
SIGNATUPE OF CONTRACTOR OR AGENT PATE
G'* I REV, 9,91 Snhmit M

North Carc:ir.a - Department of Environment. Heaith, and Naturai Resources - FCR CFTC= USE CNLY
Divisicn of Environmental Management - Groundwater Sec:icn `
P.O. Box 29535 - Raleigh, N.C. 27626-0535 CLAD. NC. - SERIAL NO. -
Phone [phone] Lat
.Minor Basin
W9LL CONSTRUCTION RECORD Basin Code DRILLING CONTRACTOR: ll�oz%n/Cl Ppr`a.</%vS Header En
STATE WELL CONSTRUCTION n .y c
DRILLER REGISTRATION NUMEER:q� PERMIT NUMEER: J f V
1. WELL LOCATION' (Show sketch of the location be!aw)
MCh`Q
Nearest Tc._n County:
G/=/' Ad
(Road. Corr, unity, or Suborn/s/1cn Lot No.) DEPTH
DRILLING LCG
/and
2. OWNER rL f Cl Qj a p / j1/4 a ' F From To
Formation Cescr;_=cn
ADDRESSlycx;Ad rFA
M (Street or Route No.) _
(�7I- /V /V_C.
City or Town Slave Zip Coce
3. DATE DRILLED3--/6--2"C USE OF WELL lfcs
4. TOTAL DEPTH //Sr
5. CUTTINGS COLLECTED YES ❑ NOF—I
6. DOES WELL REPLACE EXISTING WELL? YESEI NOEj
7. STATIC WATER LEVEL Ee!ov+ Top of Casing: Fi T.
o
�/ (Use'+' it Above Too of Casing)
A3
o"'��
S. TOP OF CASING IS FT. Above Land Surface*
'casing Terminated at/or JJaIOW land 9Urfa@ IS Illegal unless 8 variance I9 Issued
E�
2m
In accordance with 15A NCAC 2C .0119 <
9. YIELD (gpm):>�S* METHOD OF TESTS ��
N ra--
—� o
10. WATER ZONES (depth):
r^o
11. CHLORINATION: Type Amount If additional space
.7 RI ri
is needed use beck of .arm
12. CASING
Wail Thickness LOCATION SKETCH
Depth Diameier or Weight/n Ft. teal (Show direcon and distance from at !east two State
From To � Ft. 6 f S/ / L' Roads, 'or other mac reference points)
From To Ft.
From —To Ft.
13. GROUT:
Depth Material Method
From To Ft.
From —To Ft.
14. SCREEN:
Depth Diameter
From —To—Ft— in
From To Ft. in
From To Ft. in
15. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To Ft.
16. REMARKS:
Slot Size Material
in.
_— in.
in.
Material
100 HERE:Y 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 WE i OWNER.
GN.1 REV 9111
SIGNATURE
OF CCNTRACTCR CR AGENT
DATE

North Carciina - Department of Environment. Health, and Natural Resources - p.�R OFFC= USc CML.
Division of Environmental Management - Groundwater Section
P.O. Box 29535 - Raleigh, N.C. 27625.0535 CUAO. NO. - SERIAL NO" -
Phone (919) 733"3221 Lac Lc-n9..
Minor Basin
WELL CONSTRUCTION RECORD easinCode -
DRILLING CONTRACTOR: /7QX/gNyj4",r�4f/'"a HeaderE.t { GW-)Enr.`".__.
� /1 STATE WELL CONSTRUCTION 2 2 9 7 l7 C A
DRILLER REGISTRATION NUMBER: 1 PERMIT NUMBER: 3
1.
WELL LOCATION: Show sketch of the location below)
Nearest Tc-.vn: /V %? A O IV County: IVC
n O W I_� I—
pcw�r�, c Hti , ,,q �Ts
(Roan, Communiry, or Subdivision and Lot No.)
DEPTH DRILLING LOG
2.
OWNER _ ,�/�h% f% 1, C0 4 / e k
From To Formation Cesaip:ian
ADDRESS_1P666f-f( 9 <7
(Street or Route No.)
/1/C 6 n h/.0 -
City or Town State Zip Coca
3.
DATE DRILLED 3-,1D•2000 USE OF WELL Z1125
4.
TOTAL DEPTH /0b-
5.
CUTTINGS COLLECTED YES ❑ NOF)C_I
6.
DOES WELL REPLACE EXISTING WELL? YES ❑ NOE]
a
7.
STATIC WATER LEVEL Be!c%v Top of Casing: 6o FT.
CD `c
C
(Use'.' if Above Top of Casing)
a
8.
TOP OF CASING IS/1�� FT. Above Land Surface'
a Sam'
• Casing Terminated atror below land surface Is Illegal unless a variance Is Issued
N =_
In
accordance with 15: NCAC 2C .0118
o
o
9.
YIELD (gpm): METHOD OF TEST
10.
WATER ZONES (depth):
s ao
11. CHLORINATION: Type
12. CASING:
Depths Diameter
From To � Ft.
From To Ft.
From —To Ft.
13. GROUT:
Depth
From To —
From To _
14. SCREEN:
Depth
From
To
From
To
From
To
15. SAND/GRAVEL
PACK:
Depth
From
To —
From
To_
16. REMARKS:
Amount If additional state is needed use baet of
Wail Thickness
LOCATION SKETCH
or WeighVFt. Material (Show direction and distance from at least two Sate
L q 57/1- Roads. or other mac reference points)
Material Method
—Ft.
—Ft.
Diameter Slot Size Material
Ft in. in.
Ft. in. --in.
Ft. in. in.
Size Material
Ft.
_ Ft.
I DO HEREBY CERTIFY THAT THIS WELL WAS CONS T RUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND.THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
SIGNATU4 CF CCNTRACTOR OR AGENT
G'N I Rod 9,9t
DATE

North Carolina - Department of Environment, Health, and Natural Resources
Division of Environmental Management - Groundwater Section
P.O. Box 29535 - Raleigh, N.C. 27626-0535
Phone[phone]
FCR OFFICE USE CNLY'' •.`:,. S�
QUAD. NO. - SERIAL NO. - --.
Lat Long.
Minor Basin - - -
W,ELL CONSTRUCTION RECORD Basin Code -
Header Ent - .L :. _ ... _ .. ..-......f.. �..:'
DRILLING CONTRACTOR: 106X A /IJ VAIN 4 1V 5 GWA l2nt17
STATE WELL
'.:•::_.
DRILLER REGISTRATION NUMBER: 7; as( 1PERMIT NUM EANSTRUCTION
1. WELL LOCATIO : (Show sketch of the location below)
Nearest Town: l / Hid n% County: IA� C 12, W CA F`
(Road, Commu or Subdivision and Loth/a) DEPTH DRILLING LOG
2. OWNER ICE /E//,- �%fj/L)6 1VO1'jk S From To Formation Description
ADDRESS20 W �j S
�y/j //„r�/ G� (SVeelor�;le Na.)d 7S <
/Ciityyoor Town //IYStlate vC 2ip Code
3. DATE DRILLED v USE OF WELL
4. TOTAL DEPTH 777 S
5. CUTTINGS COLLECTED YES ❑ NOS
6. DOES WELL REPLACE EXISTING WELL? YES NO®
7. STATIC WATER LEVEL Below Top of Casing: 5 FT.
j (Use'.' it Above Tap of Casing) o,-^
8. TOP OF CASING IS J3 FT. Above Land Surface' Nim
' Casing Terminated atlor below land surface Is Illegal unless a variance Is Issued
In accordance with 15A NCAC 2C .0119 r m
9. YIELD (gpm): ZO 4 METHOD OF TEST ��✓>'y � L �^ � m�
�n
10. WATER ZONES (depth): Ca yZ
1n
11. CHLORINATION: Type Amount If additional space is needed use back 40rm
12. CASING:
Wan Thickness LOCATION SKETCH
Depth ,i or WeighVFt aterial (Shaw direction and distance from at least two State
From To Ft. Dia eter AA 6 iy G Roads, or other map reference paints)
From To Ft.
From To Ft.
13. GROUT
Depth Material Method
From To Ft.
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:
I DO HERE3Y 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.
r
GW-1 REV. 9,91
—,� u - D CD
SIGNATURE OF CONTRACTOR OR AGENT DATE
Suhmil nrinlml In nF.teinn of Frni.n..mn..ml rI __I_...__-

Nona Carciina - Department of Environment. Health, and Natural Resources
Division of Environmental klanaeement - Groundwater Sec:ien FCR CFFiCE USE CNLY SERIA
-
NO. L NO. -
P.O. Box 29535 - Raleiga, N.C. 27o"25.0535 CUAD. -
Phone [phone] Lat Long.,' -
Minor Basin - _
W,ELL CONSTRUCTION RECORD Basin Code -
DRILLING CONTRACTOR: Dh H�/� /r�4 r r�i/ Header E^. ; <G:V-{ EnEr.'` ..:;_.
d STATE WELL CONSTRUCTION
DRILLER REGISTRATION NUMBER: \ PERM IT NUMBER:
1. WELL LOCATION: Show sketch of the location be!ow)
Nearest To," P�� �Oh � County: /V1
1VE"-11
(Roaa. Comm---u��m�� or Sucdivision anc No.)
DEPTH
DRILL!NG LOG
/L�ot
2. OWNER _L-"dd .S /%/%
From To
Formation Ce<_crip;ion
/
ADDRESS CoHTrfS C'I•e "_�a[
(Street or Route Na_)
/J A/t/.C-
City or Town State Zip Coco
3. DATE DRILLED USE OF WELL Z/ S
4. TOTAL DEPTH GL�
5. CUTTINGS COLLECTED YES ❑ NOF-I
6. DOES WELL REPLACE EXISTING WELL? YES NOD
7. STATIC WATER LEVEL Below Top of Casing: 1S'FT.
o
(Use'J if Abave Top of Casing)
8. TOP OF CASING IS FT. Above Land Surface'
_2
' Casing Terminated at/or belaw land surfacs Is Illegal unless a variance Is IssuedCm----
own
In accardanoa with ISA WAC 2C .0118
ml of
9. YIELD (gpm): P METHOD OF TEST
10. WATER ZONES (depth):
= To
rat
(� N2
11. CHLORINATION: Type Amount
If additional space is needed use hate of fe1itm
12. CASING
Wail Thickness LOCATION SKETCH
Depth
Diameter or Weight/Ft Material (Show direction and distance from at least two Slate
From
To 36'
Ft.
Z IV4 Roads, or other map reference points)
From
To
Ft.
From
To
Ft.
13.
GROUT:
Depth
Material Method
From
To
Ft.
From -To
Ft.
14.
SCREEN:
Depth
Diameter Slat 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:
I DO HERE_Y CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND. THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
/t_S - G C)
SIGNATURE CF CCNTRACTC^n CR AGENT DATE

Ncnh Carmir.a - Department of Environment, Heaith, and Natural Resources
Division of Environmental Manacement - Grounawater Section
P.O. Sax 29535 - Raleigh, N.C. 27626-0535
Phone[phone]
FCR OF'nCE USE CPtLY '- ' -
CUAD. NO. - SEnIAL NO. --
Lac
Ninar Basin
W,FLL CONSTRUCTION RECORD Basin Cade
DRILLING CONTRACTOR: 1 41-71yel &'2/ / 44 /rHeader Er. f
/ L� STATE WELL CONSTRUCTION
DRILLERREG;STRATION NUMBER: �514 \ PERMIT NUMBER:
GW-{ Entr..:-..['
`9 7 5 9
1. WELL LOCATION: (Show sketch of the location below)
��7G
Nearest Town: Did /`e, L• / County: / �/
w J `, CIF(' 4
C0hF/'s5 Rd
(Road, Ccmm�uun;rry, or Subdivision and/Loot No_)
DEPTH
DRILL!NG LOG
2. OWNER �%q /'VjY
From To
Formadcn Descriccn
ADDRESS 0"i-7_/ SS (kF_GK Yti�
(Street or Route No.)
AZ A/.<f, %5'2
City or Town State Zip Coca
2—IS
3. DATE DRILLED ' e ° USE OF WELL
_71V-
4. TOTAL DEPTH
5. CUTTINGS COLLECTED YES ❑ NO[\ZI
6. DOES WELL REPLACE EXISTING WELL? YES NO©
7. STATIC WATER LEVEL Be!cv,, Top of Casing: / FT.
// (Use'i if Above Too of Casing)
TOP !i
-�
8. OF CASING IS FT. Above Land Surface'
' Casing Terminated at/or below land surface Is Illegal unless a variance Is Issued
m
In accordance with 15 NCAC 2C .Otta
9. YIELD (gpm):METHOD OF TEST LA
® E
a�rmi
10. WATER ZONES (depth):
11. CHLORINATION: Type
12. CASING:
Depth Diameter
From To 2D Ft. —�
From To Ft.
From To Ft.
13. GROUT:
Depth
From
To —
From
To _
14. SCREEN:
Depth
From
To
From —To_
From
To —
15. SAND/GRAVEL
PACK:
Depth
From
To —
From
To_
16. REMARKS:
Ft.
Ft.
Amount
If additional space is needed use
Wail Thickness LOCATION SKETCH
or Weight/Ft. Atiterial (Show direction and distance from at least twin State
'/.4S� / L Rcads, or other map reference points)
Material Method
Diameter Siot Size Material
Ft in. in.
Ft. in. __ in.
Ft. in. in.
Ft.
Ft.
Size
Material
I DO HERE?Y CERTIFY THA7 THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS SEEN PROVIDED TO THE WELL OWNER.
W
SIGNATURE OF CCNTRACTOR CR AGENT DATE

North Carolina - Department of Environment. Health. and Natural Resources FOR OFFICE USE CNLY
Division of Environmental Management - Groundwater Section
P.O. Box 29535 - Raleigh, N.C. 27626.0535 CUAD. NO. SERIAL NO
Phone [phone] Lot -Long. FO -
Minor Basin
W,ELL CONSTRUCTION RECORD Basin Code
DRILLING CONTRACTOR: p r ✓ i6l i6 Header Ent.
/ / ' ^� G STATE WELL CONSTRUCTION O e) n .-1 � r+
DRILLER REGISTRATION NUMBER: 1 PERMIT NUMBER: 4. `7
74
3.
4.
5.
6.
7.
F7
WELL LOCATION: (Show sketch of the location below) /nG
Nearest Town: ��%�-�h 'l9 R/ County: � ,,/
//% K,',v/✓r_ y 1�'d
(Road, Community. or Subdivision and Lot No.) DEPTH
OWNER /J:Jd / fA11'A//✓(—_'_lr From To
ADDRESS /-`K/ n,F� 294 _
(Street or Route No.)
City or Town '' __ State Zip Cade
DATE DRILLED/� USE OF WELL ,/�/=5
TOTALDEPTH /22
CUTTINGS COLLECTED YES ❑ NO❑
DOES WELL REPLACE EXISTING WELL? YES NOf_]
STATIC WATER LEVEL Below Top of Casing: ��_ FT.
(Use'.' if Above Top of Casing)
TnP nF r1ARINr, tS FT Ahrnrc I and Siirfaro•
• t:asing terminated at/or below land surface Is Illegal unless a variance Is Issues
In accordance with 15A NCAC 2C .0118
9. YIELD (gpm):A22t METHOD OF TEST
10. WATER ZONES (depth):
11. CHLORINATION: Type
12. CASING:
Amount
Wall Thickness
Depthn^ Diameter or WeighVFt. Material
From To L Ft. G hJJST C
From To Ft.
From To Ft.
13. GROUT:
Depth Material Method
From To Ft.
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
From To Ft. —
From To Ft.
16. REMARKS:
Material
DRILLING LOG
Formation Description
If additional space is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
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.
00
oIGNATURE OF CONTRACTOR OR AGENT PATE
GW-1 REV. g.91 Suhmit nrinlnal n. of ..-n

North Garonne - Department of Environment. Heaith, and Naturai Resources FCR OFFtC- USECNL.
Division of Environmental Manacement - Grcunowater Section v
P.O. Box 29535 - Raleigh, N.C. 27825-0535 CLAD. NO. - - SERIAL NO. _
Phone [phone] Lat-
Minor Basin
W,ELL CONSTRUCTION RECORD Basin Code
DRILLING CONTRACTOR: /jd{,/ar1/ vaAr Header Lit
✓ 7 R STATE WELL CONSTRUCTION 22
DRILLER REGISTRATION NUMBER: t-) PERMIT NUMEER: J
1. WELL LOCATION: (Show sketch or the location below) y� C
Nearest Town: —6/�( Pn G-T County: 114 (/62,0_J-
✓/4-X/'y , /_ a/ d5J /)/- V
T (Roao, Community, or Subaivisicn anc Lot No.)
/S 2. OWNER _,�O+ Z A A(C1 9A 5.5
ADDRESS1A-A/A/vN R&
(Street or Route No
o'v A/C,
City or Town Slate ip Coca
3. DATE DRILLED ^ �9'�soe USE OF WELL fSES
4. TOTAL DEPTH /54�
S. CUTTINGS COLLECTED YES ❑ NOF71
6. DOES WELL REPLACE EXISTING WELL? YES ❑ . NO©
7. STATIC WATER LEVEL Be!cw Top of Casing: 2 FT.
(Use': it Above Top of Casing)
8. TOP OF CASING IS FT. Above Land Surface'
Casing Terminated at/or below land surface Is illegal unless a variance is Issued
In accordance with ISA AC 2C .0118
9. YIELD (gpm): r METHOD OF TEST
10. WATER ZONES (depth):
11. CHLORINATION: Type
12. CASING:
Depth b
Frcm
To
From
To
From
To
13. GROUT
Amount
DEPTH DRILL!NG LOG
From To Formaccn Descnc:ion
If additional space is needed use baek of
Wail Thickness
LOCATION SKETCH
Diameter or WeighvFL Material (Show direction and distance from at least twc Slate
Ft. 6 tiA s/16 Rcads, or other mac reference points)
Ft.-
Ft. -
Depth Material Method
From To Ypep Ft.
From —To Ft.
14. SCREEN:
Depth
From
To
From
To
From
To
15. SAND/GRAVEL
PACK:
Depth
From
To
From
To
16. REMARKS:
Diameter Slot Size Material
Ft in. in.
Ft. in. --in.
Ft. in. in.
Size Material
_ R.
Ft.
I DO HERESY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WE;
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
r.
SIGNATURE OF CCNTRACTOR OR AGENT
G'w-1 REV a,gt
DATE

North Carciina - Department of Environment. Health, and Natural Resources
Division of Environmental Management - Groundwater Section
P.O. Sax 29535 - Raleigh, N.C. 27626 0535
Phone [phone]
FCR OFFICE USE CNLY' '
CUAD. NC. - SERIAL NO. '-- ---_ r
Let. IX_ng.
Minor easirt
W,ELL CONSTRUCTION RECORD Basin Cade -
DRILLINGCONTRACTOR: �d��^�d Frtii/n�� Header Ea GW-{Batt"._:_.
�. STATE WELL CONSTRUCTION 229 ? 57
DRILLER REGISTRATION NUMBER: / / `' PERMIT NUMBER:
1.
WELL LOCATION: Show, sketch of the location below) ,��//
��� �
V
Nearest Town: / n/ County: /'�C
Zii/�tll-zy //SF7Fe1�d L'o�Mb/JI}%
(Road. Community, or Subdivision and Lot No.)
DEPTH DRILL!NG LOG
2.
OWNER 1 %A y Cy�% x%IWS
From To Forma cn Dzsc-ic;ion
ADDRESS T3 P6 .3.710
(Street or Route No.)
City or Town State Zip Coco
3.
DATE DRILLED ,-9-2G`'USE OF WELL XES
4.
TOTAL DEPTH _fdq
5.
CUTTINGS COLLECTED YES ❑ NO
6.
DOES WELL REPLACE EXISTING WELL? YES . NO[E
Co
7.
STATIC WATER LEVEL Eelow Top of Casing: 71. FT.
9
8.
(Use': if Above Top of Casing)
TOP OF CASING IS /311 FT. Above Land Surface'
32M �m
' Casing Terminated at/or below land surface Is Illegal unless a variance Is Issued��
In
accordance with 15A.UCAC ZC .0118m
9.
YIELD(gpm): METHODOFTEST
10.
WATER ZONES (depth):
ins
11.
CHLORINATION: Type Amount
If additional scace is needed use b9a of Eim
12.
CASING:
z
Depth
From
To %
Ft.
From
To
Ft.
From
To
Ft.
13. GROUT:
Depth
From
To
Ft.
From —To
Ft.
14. SCREEN
Wail Thickness LCCATION SKETCH
Diarr/eter or WeighaFL Material (Show direction and distance from at least the State
G [sstri
Lr ---- Roads, or other map reference pants)
Material Method
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:
I CO HERE_Y 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.
G'.V t REV D 11
.1
SIGNATLYRE CF CONTRACTOR OR AGENT
1 .._.._.._.__.._- .r c_,:.,.__,,..._: I-._____._.
1 0
DATE

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section 213087
1636 Mail Service Center - Raleigh, N.C. 27699.1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
c
WELL CONTRACTOR CERTIFICATION #: e�
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check applicable Boa): RealdentialO Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring IT Recovery ED Heat Pump Water InjectionE3 Other 0 If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
nIT n County:
r• • - ­- -w mumoers.tiommunity, or Subdivision and Lot No.)
3. OWNER
Address` �r T
ibireatofou Q.)-
lxy
City or Town I Slats wa e)
Zip Code
4. DATE DRILLED SZ1
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YESO NO®
7. DOES WELL REPLACE. EXISTING WELL? YES NO®
6. STATIC WATER LEVEL Below Top of Casing: FT.
(Use': If Above Top of Cuing)
9. TOP OF CASING ISFT. Above Land Surface'
'Top of casing terminated aVor below land suttee* requires a variance in accor-
dance with 16A NCAC 2C . 118
10. YIELD (gpm): 0,40 METHOD OF TEST T�>�
11. WATER ZONES (depth): _ %O
12. CHLORINATION: Type Amount
13. CASING:
DRILLING LOG DEPTH
From To Formation Description
If additional space is needed use back of form
Wall Thickness LOCATION SKETCH
D Depth t�---.^ Diame of or W*IghvFL Material (Show direction and distance from at least two State
From To �.G�G Ft. $'PV # 1 / , P1//1T_ Roads, or other map reference points)
From To FL
From To Ft.
14. GROUT:
Depth nMaterial-/ Meth d
From -2 To 125Q_Ft. �W
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft In.
From To Ft. In,
From To F In. _ In.
16. SAND/GRAVEL P
Depth Size *lariat
From To Ft,
From To Ft.
17. REMARKS:
I DO HEREBY CE
CONSTRUCTION
FOR OFFICE
Quad No:
Serial No.
5u8
US WELL WAS CONSTRUCTED IN ACCORDANCE WITH 1SA NCAC 20, WELL
�ND, T R-COPY CORD HAS BE VIDED TO THE WELL OWNER.
5 SIGNATURE OF PERSON CONSTRUCT)86THE WELL DATE
6u"
T...=.,....�...._ _ .
GW-I REVIV"
1 original to Division of water Quality, Groundwater section within 30 days

North Carolina - Department of Environment and Natural Resources - Division of Water 213093
1636 Mail Service Center . Raleigh, N.C. 27699.1636-Phone [phone] Quality .Groundwater Section
WELL CONSTRUCTION RECORD WELLCONTRACTOR: ,O
WELL CONTRACTOR CERTIFICATION #: el
STATE WELL CONSTRUCTION PERMIT
1. WELL USE (Check Applicable Boa): Residential Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection Agricultural ElMonitoring ❑ ❑ Other ❑ if other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
fires Tow Z�z!, r
County:lL! C lZf1C
(Flo Nam toner , rrynunl��r $upumsion and Lot No.)
3. OWNER ✓/ ,f/ DRILLING LOG DEPTH
Address`From
I _ b ra �i,,J' �; �,h TO Formation DeacdpUon
ury or Town Stars
4. DATE DRILLED 21P Code
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YESQ NO®
7. DOES WELL REPUtCE,EXISTING WELL? YES 0 NO CO
8. STATIC WATER LEVEL Below Top of Casing:. _ Yn FT
9. TOP OF CASING IS �'�L (Dee *'- If Above Top of Casing)
bove Land Surface -
Top of using terminated at/or below lands Kace `quires • variance In actor.
dance with 15A NCAC 2C
10. YIELD (gpm): METHOD OF TEST
11. WATER ZONES (depth) At
12. CHLORINATION: Type %d R Amount._
13. CASING:
Depth Wall Thickness
P DI a er or We, hvFl. Material
From A _ To i� 4- FL _ U-4, _ �yC
From `I_ — To k-b Ft.-c+,.
From To Ft
14. GROUT:
Depth
From Q- To Ft.
Material
Metho
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:
r
O
C_
rT O�
J�t7
If additional space is needed use back of form W Ln L
m70
LOCATION SKETCH C► o
s
(Snow 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
CONSTRUCTION STAN4AE}I)S, ANO THAT A COPY�1 BEEN PRp�
FOR OFFICE USE O
Quad No: 5; SIGNATURE OF PERSON CONSTRUCTING
Serial No. ubmil odglnaHto bivlelon of Water ouality, Gmundwstsr Se
Wn
AC 2C, WELL
THE WELL OWNER.
WELL
within 30 days
OW.
OW-1 REV. 12r9+

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:
WELL CONTRACTOR CERTIFICATION #: e2 ~fG y
IF
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)
N rest Tow Al. C. County: 1�}'Ot.tJ-GGf
(Road Whe
1an/p Numbers, Community, or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER y6 !,& From To Formation Description
Address _ ���� � l,;_.j
City or Town
Zip
4. DATE DRILLED v
5. TOTAL DEPTH -
6. CUTTINGS COLLECTED YES Q 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 IS1=4 FT. Above Land Surface'
Top of casing terminated at/or below land surface requires a variance In accor.
dance with 16A NCAC 2C .0118
10. YIELD (gpm): 7 METHOD OF TEST E_o-k
11. WATER ZONES (depth): �� f
12. CHLORINATION: Type Amount
—
13. CASING:
Wall Thickness
Depth Diarnettir or Weight/Ft. F4qtenal
FromToZ020— Ft. 4�L
From To Ft.
From To Ft.
14. GROUT:
DepthMaterial Met od
From � To _S2V_ Ft.
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From o Ft _ In.n.
From To _ Ft. in. In.
From To _ Ft. -In. In.
16. SAND/ RAVEL PACK:
Depth Size Material
From � To Ft.
From To Ft.
17. REMr
If additional space is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT
FOR OFFICE USE ONLY
Quad No:
Serial No.
Submit original to Division of Water Quality, Groundwater Section within 30 days
Ln
GW-1 REV. 12199
EN�
-Av?�k,
41.
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] F. 1 5 (�
WELL CONSTRUCTION RECORD WELL CONTRACTOR: a,lae-jIz -s Liam&"OJ z i
WELL CONTRACTOR CERTIFICATION #: 112 %9-3 v V
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: (Shoye sketch of the location below)
3. OWNER
Address
City or Town State Zip Code
4. DATE DRILLED
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑ NO[
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO[Z
B. STATIC WATER LEVEL Below Top of Casing: _yam" FT.
l (Use': it Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface'
'Top of casing terminated aVor below land surface requires a variance In accor-
dance with 1SA NCAC 2C .0118 —t-
10. YIELD (gpm): � MET OD OF TEST - >� c
11. WATER ZONES (depth): s�s'0T_
12. CHLORINATION: Type 7_2YR Amount —
13. CASING:
DRILLING LOG
From To
Agricultural ❑ Monitoring ❑
cn
If additional space is needed use back of form z
Wall Thickness LOCATION SKETCH
Depth r�ann D'am ter or Wei hVFI. Meal ( Roads, or other map a erencShow direction and distan from
at least two State
From ep To L Ft. e om
From To FL
From To Ft. east` A
14. GROUT: y}
Depth Material Meth of I:
From To 20 Ft. 114w S 6
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From To _ Ft _ "n.
From To — F in. — in.
From To Ft._ in. —In.
16. SAND/GRA PACK:
Depth Size aterial
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 THAT A COPY OF T C HAS BBEE�EN PR TOT WELL OWNER. tlelx�/�,
FOR OFFICE USE ONLY p�� (/ I
Quad No: SIGNATURE OF PERSON CONSTRUCTING THE W -LL DATE
Submit original to Division of Water Quality, Groundwater Section within 30 days
Serial No, GW4 REV. 12199

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section} �+ O ai ry
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone] _ > 1 l.' /
WELL CONSTRUCTION RECORD WELL CONTRACTOR: &)A - W dd:_
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (cheek Applicable Boa): Residential Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other M If Other, List Use:
2. WELL LOCAT�ION:1(Show,sketch of the location below)
7
Nearest Town, ��i'D7i Al County: X�
(Road 6ime�° 'tl Numbers Como&ty. or Subdivision and Lot No.)
3. OWNER
Address (I.�j 1 9IV I,. Al" X ,. j
City or Town 5tate up 600e
4. DATE DRILLED
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES F-1 NO[f
7. DOES WELL REPLACE EXISTING WELL? YES 0 NO®
B. STATIC WATER LEVEL Below Top of Casing: %J� FT.
L (Use'+' It Above Top of Casing)
9. TOP OF CASING IS / 2—' FT. Above Land Surface*
'Top of using terminated at/or 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): `/ S r .-7
12. CHLORINATION: Type _7_9 95 Amount _
13. CASING:
Depth D' I
From 19 To � Ft. —
From To Ft.
From To Ft.
14, GROUT:
DRILLING LOG
From To
Agricultural ❑ Monitoring ❑
DEPTH
Fomation Description
0
It additional space is needed use back of form
Wall Thickness LOCATION SKETCH
-or Weight/R. werial (Show direction and distance from at least two State
Roads, or Other map reference points)
Depth MaterialMeth d -
From To � Ft. L
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From —To _ Ft _ n. in.
From o Ft. in. In.
From To, I _ I
16. SAND/GRAVEL PACK:
17
Depth
Size
Material
From
From
To t.
To Ft.
D.u>,
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.l_. II
SIGNATURE OF PERSON CONSTRUCTING THE WELL UAt C
Submit original to Division of Water Quality, Groundwater Section within 30 days
� ... GW-1 REV. 121"

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section r; i 4546
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELLCONTRACTOR: 1� �-- -P-q/Z�T_A
WELL CONTRACTOR CERTIFICATION III:e2 % g 3
STATE WELL CONSTRUCTION PERMITi
1. WELL USE (Check Applicable Box): Residentii Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
Agricultural ❑ Monitoring ❑
2. WELL LOCATION: (Show sketch of the location below) L// C ,' (�(�/�
N rest Town: County:
(Roa aim an Numbers, o'mmunity, or subdivision ind Lot No.) DRILLING LOG DEPTH,
3. OWNER �1' �� �121K21� _ From To ..Fotrgation Description
Address
4. DATE DRILLED IIF./ 7 2 6/0O
5. TOTAL DEPTH 7
B. CUTTINGS COLLECTED YES E) NO®
7. DOES WELL REPLACE, EXISTING WELL? YES NO®
B. STATIC WATER LEVEL Below Top of Casing: / FT.
(Uee': If Above Top of Casing)
9. TOP OF CASING IS Z- FT. Above Land Surface•
Top of casing terminated atlor below land surface requires a variance In accor-
dance with 15A NCAC 2C. 118
10. YIELD (gpm): METH D OF TES�/�•a*-!
11. WATER ZONES (depth): - ��S 1
12. CHLORINATION: Type Amount
13. CASING: (
Wait Thickness
Depth/� ,, or Waigh t. Matti
From 0 ToPo FL Diter
From TiFt.
From To Ft.
14. GROUT:
Depth Material Method °
From To ;�20 Ft. P�1�+�
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft . _ In.
From o Ft. in.
From To t. In./ in.
16. SAN GGRAVEL PACK:
17
Depth Size Material
From
From To Ft.
r7FM RKS
0
It additional space is needed use back of forri
LOCATION SKETCH rn
(Show direction and distance from at least two Stapr
Roads, or other map reference points) 7
J
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT ACOPY OF 0
HAS � BEEN P TOTHE WELLOWNER.
FOR OFFICE USE ONLY
Quad No: VIGNATURE OF PERSON CONSTRUCTIN6 THE WELL GATE
Submit original to Division or Water Quality, Groundwater Section within 30 days
Serial No. GW1 REV. 12l'99

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section j r
1636 Mail Service Center - Raleigh, N.C. 27699.1636-Phone [phone] Q U J
WELL CONSTRUCTION RECORD WELL CONTRACTOR: Yi-- o� • r���/a�i�w� J,
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential ra r Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, list Use:
2. WELL LOCATION: (Show sketch of the location below) In/ //
Nearest Town: ZWI:? Lm f County: � C ld
or
3. OWNER
Address
City or Town State Zip Code
4. DATE DRILLED�'1
S. TOTAL DEPTH 134-2
6. CUTTINGS COLLECTED YES ❑ NO®
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NOLO
8. STATIC WATER LEVEL Below Top of Casing: _---5' FT.
(Use'+' 0 Above Top of Casing)
9. TOP OF CASING ISFT. Above Land Surface'
'Top of casing terminated at/or below land surface requires a vadenc- In accor-
dance with 15A NCAC 2C .011
10. YIELD (gpm): METHOD OF TEST Timex.+
11. WATER ZONES (depth): _,� D_T
12. CHLORINATION: Type _7_/VQ Amount L
13. CASING:
Wall Thickness
Depth „� dame?-- SoresNZ I . tedal
/ From � To �� Ft. �j7;--
From To Ft.
From To Ft.
14. GROUT:
Depth pp Material' Method
[,w
From To �-2 Q Ft. (livrztfdTl
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From ZTo
o Ft � — n. Z
�
From Ft. in. Fromo FL In.
16. SAND/GRAVEL PACK:
Depth
From To t.
From �To Ft.
17. REMARKS:
Size Material
DRILLING LOG
From To
DEPTH
Formation Description
it additional space is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other reap reference points)
ri►I°�
I DO HEREf1FRTIFY THAT TH WELL LL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRU TION STAMIAIRD 30ANp T&TP1eGDPYAF THIS RECORD}IAS J(EEN PROWDED TO THE WELL OWNER.
FOR OFFIC1111�11ONLY
Quad No: i SIGNATURE OF PERSON CONSTRU NG THE WELL DATE
sut(i iI net to Division of water Quality, G ater Section within 30 days
Soda] No. GW1 REV. 12/"
0
eoipnal0f " - __ _.

North carom - tAparemam of EMinnrrnt OrdNamrat Rooiaaa - Dw:tan of Watw GLOW+ ' 23974
uae MM SwAcm Cnrw - F Wbh N.C. 216ti1e36Phm PM* n3-=
WELL CONSTRUCTION RECORD wmLcowrRAcToR: l g- o
WELLCONTRACTOR cERT mATION I _ n.Z % X y
STATE WELL CONSTRUCTION PERMTTA:
1. WELL USE ApOkOW �k ReMdwt Cl ❑ wdoom ❑ AwkukuM ❑ Morttb i ❑
oa Raaery How Pump WMer uocdm ❑ Ovw ❑ It Otm. Wt Uaa:
2.
dp" of Ow looe5an Miss) M C
. - --
(�OfTOIM �P��
4. DATE DRILL® le
air
& TOTAL DEPTH
a CUTTWGSCOLLECTED YES❑ NOW
7. DOES WELL REPLACE EOSTMIG WELL? YES ❑ NO®
a STATIC WATER LEVEL Show Top of Ow": r FT.
ttta + tAuw 7aµQf CwW
9. TOP I� OF CASING LS� Fr. Abase LMW SuimW
RapdasWetarw' ' rawbdmddAtwra*Awaavarlrrm,arawm-
ta YT9D (ppm): Lf Tr1ETHo�o D 0f TEST
of Ad r-
11. WATER ZONES (dap"! i
12.CHLORINATNW. TwP �,t?B Mwwt `y■addttaWpaoalarwadadtaebaakdlorm 00
I& CASING:
/., wdTaidnaw _
From �_DToh.Ls.2-�FL�v-LPl�L-
From--- To R
From To FL
14, GROUT:
DOM n
AN0*W
From To -4.0-PL
Form To FL
15. SCREEN,
Oplh�7�/�R_DbWnM/W Slot Ski MlaarW
FromFrom
SM Z'
lot
From ,�Ta� Fes„
I& SANDKiRAVE LPACK
Daplr Sfru �McM�Y---
Frain To
From To.G._ R:=—
17
CONSTRUMMWAHMMANOTMT
MR OFFICE USE ONLY
Oud rtx
_ LOCATION SICK
om d rwftn and dMwroa tram M Maatlwo!iota
Raad4 ar ~ map rIa palm)
c,J�OGk' �LLL
p, w
MH 15A NOW 9C, WELL
RROIIAEDTOTIE WILL OWNER
M 4.�

North Carolina •Department of Environment and Natural Resources -Division of Water Quality -Groundwater Section
2604
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: IL J���.Jo7l !x»10k ALA_,
WELL CONTRACTOR CERTIFICATION #: e2 r7fr-V
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
3. OWNER
Address
of the location below) C
—11-11 ! County:
and Lot No.)
City or Town Slate Zip Code
4. DATE DRILLED O �4/&ip
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑ NOO
7. DOES WELL REPLACE EXISTING WELL? YESED NOO
8. STATIC WATER LEVEL Below Top of Casing: L,L FT.
(Use'+' it Above Top of Casing)
9. TOP OF CASING IS/ FT. Above Land Surface'
'Top of casing terminated atlor below land surface requires a variance In accor-
dance with 15A NCAC 2C .0118
10. YIELD (gpm): '— MET OD OF TEST
11. WATER ZONES (depth): n d
12. CHLORINATION: Type —7-141/3 Amount z-
13. CASING:
Wall Thickness
Depth sDiameter or Wei hVFt. �k4a-tedal
FromTo Ft. I�—Sul.2J VC
From To Ft.
From To Ft.
14. GROUT:
Depth Material Methiod .
From To 1�2 152 Ft.
From To Ft.
15. SCREEN
Depth Diameter Slot Size Material
From F In
nFrom To Ft. nFrom To Ft. in.
16. SAND/GRAVEL PACK:
Depth Size Material
From From Too�t.t.�`
17. REMA KS:
Agricultural ❑ Monitoring ❑
DRILLING LOG DEPTH
From To Formation Description
(Show direction and distance from at
Roads, or other map reference r
411,
K
v Ct
r 0
two State ,.k
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTIQ"' %1AUDARDS. AND THAT A COPY OF-rdhS,RECORD H6"E)i! PROVIDED TO THE WELL OWNER.
Quad No: ! v J + t_;7� ,�'I'pfGNATURE OF PERSON CONSTRUCTIO(G THE WELL DATE
ubm to Division of Water Quality, Groundwater Section within 30 days
Serial No.+U8fth6't ' GW-1 REV. 1?J"
ZiJV
5

r ..'1 h r+ �'y
North Carolina -Department of Environment and Natural Resources •Division of Water Quality - Groundwater Section ,� t1 J
1636 Mail Service Center - Raleigh, N.C. 27699-1636•Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: I���-��- a�� tJY��.
WELL CONTRACTOR CERTIFICATION
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (check Applicable Box): Residential U Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL
3. OWNER
Address
sketch of the location below)
!P-- tI, n County: &C
or
aty or i own State Zip Code
4. DATE DRILLED
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑ NO®
7. DOES WELL REPLACE EXISTING WELL? YES Q NO®
8. STATIC WATER LEVEL Below Top of Casing: 5/ FT.
// .�/-. (Use'+' it Above Top of Casing)
9. TOP OF CASING IS Li 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): —,2-- METHOD OF TEST Teti/ C
11. WATER ZONES (depth): %` O ' A2 S '
12. CHLORINATION: Type Amount _3
13. CASING:
Wall Thickness
Depth �O Diam�r S r Wean ighUFr 1. Ja /c
FromTo Ft. (4i.�c7 C6 9fL
From To Ft.
From To Ft.
14. GROUT:
Dep_th�^ Ma ria Method
From � To �(L Ft.
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From in. in
From To Ft. in. In.
From To Ft., in.
16. SAND/GRAVEL PACK:
Depth Size Mate
From o t.
From T Ft.
17. REMA KS:
DRILLING LOG
From To
If additional space Is needeu use ueca ui win)
DEPTH
Formation Description
(Show direction
Roads, or c
u
N ,
4 C
at least two State
t points)
I DO HEREBY C TRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTIOI I NRA1fS,PTT1tTEC ECORDH N PROVIDED TO THE WELL OWNER.
FOR OFFICE US
Quad No: " - -? _ NATURE OF PERSON CONSTRUC ING THE WELL DATE
t Submit o t Division of Water Quality, Groundwater Section Within 30 days
Serial No. GW-1 REV. 12199

North Carolina - Department of Environment and Natural Resources - Division of Water Cuality - Groundwater Section 9885
1636 Mail Service Center - Raleigh. N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION #: e 2 75?,5 6
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (check Appocaws Box): Residential ❑ Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATI.ON: (show sketch of the location below)
7N st Tpwn:�I I r1unty.
3. OWNER
Address
4. DATE DRILLED
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES NO®
7. DOES WELL REPLACE EXISTING WELL? YES NOW
S. STATIC WATER LEVEL Below Top of Casing: .1, L FT.
1 (ties'.• 9 Above Top of Cuing)
9. TOP OF CASING IS Lam_ FT. Above Land Surface*
Top of using terminated aVor below lead surface requires a variance In aewr-
dance with 15A NCAC 20.411a
10. YIELD (gpm): METHOD OF TEST T��
11. WATER ZONES (depth): ADz> r 2 e�e>,
DRILLING LOG DEPTH
From To Formation Description
c3
'�
0
a
-
c.
no
12. CHLORINATION: Type Amount _7y� if additional apace Is needed use back of form
13. CASING: '
Wail Thickness LOCATION SKETCH
Depth /D"Lpr or Weight/R. Material (SJor
ion and distance from at least two State
From �.—To -sue Ft. '�� _4E2� . other map reference points)
From To Ft.
From To Ft. /
14. GROUT: D0
Depth A Material Method
From To Q Ft. I v-sy/o�..l� '/`.' L]��c 9+7
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft In. in.
From -2 To Ez Ft. � In. In.
From To Ft. in. in.
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.�
From To Ft.
17. REMARK _-
1 DO HEREBY STRl1CTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTI AI��IA�A OF RD P IDEDTOTHEWELLOWNER.
FOR OFFICE U LY
Ouad No: NATURE OF PERSON CONSTRUCTM THE WELL DATE
Submit DivWon of water Duality. Growmwater section within 30 days
Setal No. GW-1 REV. 12M

Nosh Carolina • Department of ErwironmaM and Natural Resources - Division of Water ouarny -Groundwater Section
2f 2587
C le N C 276WI636•Phons [phone]
1636 Mad Semu an r. Ralegh• . . Q D
WELL CONSTRUCTION RECORD WELL CONTRACTOR: mil• '' !' L� WELL CONTRACTOR CERTIFICATION
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (rhaeh Applicable 8"): Residential (S Municipai ❑ Industrial ❑
Recovery ❑ Heat Pump Water injection ❑ Other 0 If Other, List Use:
2. WELL
3. OWNER
Address
of the location below) C J��
County:
and lot No.)
. City or Town state Lw �
4. DATE DRILLED
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑ NO®
7. DOES WELL REPLACE EXISTING WELL? YESED NO®
a. STATIC WATER LEVEL Below Top of Casing: FT.
l (Use 'i a Above Top of Casing)
9. TOP OF CASING IS Z FT. Above Lard Surface'
'Top of eedn9 twminaaad alfor blow WW fahee fogefns a varlarea In aeca-
duree with 15A MAC 2C / '
10. YIELD (gpm): METy�OD OF TEST 7'/ Ad
11. WATER ZONES (depth):—G0'4-- //25^ t
12. CHLORINATION: Type 721!3 Amount
13. CASING:
Wall Thidawes
n Depth ,+ , WaighM Maledd
FromTorues Ft. �a6ge'2 —F-VL
From To Ft.
From To Ft.
14. GROUT:
Depth Materiel Meftiod
From 0 To .�tZ Ft. Pd �
From To FL
15. SCREEN:
Depth Diameter Slot Size Material
From �o �-- �n. Zin:
inFrom To Ft. in.From To F in.in.
16. SAND/GRAVEL PACK
DRI W NG LOG
FMM To
Agricultural ❑ Monitoring ❑
DEPTH
Fomaam Dascdption
it additional apace Is needed the back of form
LOCATION SKETCH
(Shaw direction and distance from at least two
Roads, or other map reference pdnfa)
Depth17. REMARKS- TOr �•
From
From
�,
CON
11M.100 HEREBY CERTIFY THAT TH UCTED WITH 15A NCAC 2C, WELL
less. •i,
Cq

North Carolina - Department of Environment end Natural Resources - Division of Water Quality - Groundwater Section
�"25g1
63o Mal Service Center - RaM'D h. N C 276WI636-Phone (919) 733-=1
1 t
Q
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (ChaekApplieable lboxY Residential ER Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other If Other, List Use:
2. WELL LOCATION: (Show 1lketch of the location below)
Nearest Town: 717aa ram' a County:
totter.)
3. OWNER
Address
4. DATE DRILLED ////��
5. TOTAL DEPTH 36 f
6. CUTTINGS COLLECTED YES ❑ NO®
7. DOES WELL REPLACE EXISTING WELL? YES 0 NO®
B. STATIC WATER LEVEL Below Top of Casing: ! FT.
,. (Use '4 a Above Top of Casing)
9. TOP OF CASING ISFr. Above Land Surface'
'Top of wkq isrtdnsied aYor t•Yow Mad stshee wquirea s vrluta In a000 -
dance wish 15A NCAC x.mta '
10. YIELD (gpm): / METHOD OF TEST T/ Al r
11. WATER ZONES (depth): 110
12. CHLORINATION: Type %f!13 Amount �-
13. CASING:
Wail Twduleas
Depth
orwelp )R Matalal
Fro O o76 Ft. & 6ge 21— PV L
From To Fl.
From To FL
14. GROUT:
Depth Materiel Meftiod
From _ iL To jl�,?Q Ft. 11
From To FL
16. SCREEN:
Depth
—y��Diameter Slot Size Material
From
Fro TO Ft In. In.
From Ta F In. in.
16. SAND(GRAVEL PACK:
Depth Size Material
From To --��-
From To
DRIWNG LOG
From To
DEPTH
Fort alien 13e
If additional Space is needed ties back of Corm
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or otter map reterenoe points) .
rT•t'
..
9

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section � 16 O J J
1636 Mail Service Center- Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELLCONTRACTOR: Lt) a44&�� 74
WELL CONTRACTOR CERTIFICATION If:.� �Jk�%
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (check Applicable Box): Residential P Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATI � sJ{etch o the
Nearest Town: i--�-
or
3. OWNER
Address
below) y-�l/
_ C,ounty: Ju
and Lot No.) DRILLING LOG
From To
4. DATE DRILLED oP
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑ NO�
7. DOES WELL REPLACE EXISTING WELL? YES NO[Z]
8. STATIC WATER LEVEL Below Top of Casing: 15:: FT.
,L�. (Use'+' II Above Top of Casing)
9. TOP OF CASING ISM FT. Above Land Surface'
Top of casing terminated at/or below land surface requires a variance In accor.
dance with 15A NCAC 2C .0118
10. YIELD (gpm): AV METHOD OF TEST T-�
11. WATER ZONES (depth): /d a r -1 3 n'
12. CHLORINATION: TypeAmount-
13. CASING:
Agricultural ❑ Monitoring ❑
DEPTH
Formation Description
If additional space is needed use back of form
Wall TMckrwss LOCATION SKETCH
Depth D' ter orWelghliftMatilda! (Show direction and distance from at least two
FromTo 15 C' Ft. Roads, or other map reference poin> n
From To Ft.
From To Ft.
14. GROUT:
Depth �Materiala od
From To :�Ft. 1 3
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From _To �- Ft _
From ETo� in. in.
From _ To F . _ in. _ In.
16. SAND/GRAVEL PACK:
17
Depth Size Material
From
From TO
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A CO",W RECOP"AA BEE,r)f PROVIDED TO THE WELL O
i.t: e.CQ
S GJ
FOR OFFICE USE ONLY 4�-r L� (' �/Y!Y lri/f�/ '4z GA— {E �L
Quad No: SIGNATURE OF PERSON CONSTRUCTING THE WELL
Submit original to Division of Water Ouality, Groundwater Section within 30 days
Serial No. GW-1 REV. 12199

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section "- 6052
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone] �x1
WELL CONSTRUCTION RECORD WELLCONTRACTOR: dF �� «����
WELL CONTRACTOR CERTIFICATION
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check applicable Box): Residential Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other List Use:
2. WELL LOCATION: (Show sketch of the location below) Cj
Nearest Town: &C I County:
(Road Name and Numbers, Community.` r Subdivlsioryand Lo�No.)
3. OWNER Lrt Lygs (b/�__
Address I
�) tor ufe 407
'�n zt z-
City or Town State �p C0ID
4. DATE DRILLED JT�
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES 0 NOCa
7. DOES WELL REPLACE EXISTING WELL? YES NOCK
8. STATIC WATER LEVEL Below Top of Casing:_ FT.
(Dse'+- II Above Top of Casing)
9. TOP OF CASING IS 7 FT. Above Land Surface*
-Top of easing terminated atfor below land surface requires a variance In accor-
dance with 16A NCAC 2C .0 18
10. YIELD (gpm): METHOD OF TFST T!�
11. WATER ZONES (depth):-5 Ze'n I
12, CHLORINATION: Type %%/? Amount =
13. CASING:
Wall Thickness
Depth / D�§meter or Weight/FL ,�Materiaall,
DRILLING LOG
From To
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 mao reference points)
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:
Sedal No.
SIGNATURE OF PERSON CONSTNuc:I IrvQ I Kh W LLL
lillubmil original to Division of Water Quality, Groundwater Section within 30 days
GW-1 REV. 12199

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section 6051
1636 Mail Service Center -Raleigh, N.C. 2769e-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: 'Z-�—rYv
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (check Applicable sox): Residential ® Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL
Nearest
(Road Name and
3. OWNER
Address 771
sketch of the location below)
y� L
or
City or Town Sate W
4. DATE DRILLED
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES Q NO($
7. DOES WELL REPLACE EXISTING WELL? YES 0 NOE
8. STATIC WATER LEVEL Below Top of Casing: 1,0 FT.
(Use's 8 Above Top of Casing)
9. TOP OF CASING IS� FT. Above Land of
Top of casing terminated at/or below land surface requires a variance In accor-
dance with 18A NCAC 2C . 118 '
10. YIELD (gpm): MF77HOD OF TEST
11. WATER ZONES (depth): / -S t
Agricultural ❑ Monitoring ❑
DRILLING LOG DEPTH
From To Formation Description
12. CHLORINATION: Type T/�� Amount _ If additional space is needed use back of form
iz
13. CASING:
Wall Thickness
Depth Di I r arW ntlFt. edal
From —To �L Ft. C
From To Ft.
From To Ft.
14. GROUT:
Depth Material I�Met dC�
From 12 To Ft.
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From _
From , To Ft. — In. — fn.
From To F I
16. SAND/GRAVEL PACK:
Depth Size Mate
From o
From To Ft. _
17. RE RKS:_
LOCATION SKETCH
(Show direction and distance from at least t
Roads, or other map reference
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY Of-THI)9ZE
RD HAS BE]FN P�9VIDnP TO THE WELL 0
146T�S
E
FOR OFFICE USE ONLY ��0� `� L (-.'7 sty 1 X e r
Quad No: SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
hnpmy�� riginal to Division of Water qualiry, Groundwater Section within 30 days
Serial No. V &`-`^�tr GW-1 REV. 12199

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section 2 1 V 1 C 055
0
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: IJ-zJ41CKU t-tJ.'-ay.
WELL CONTRACTOR CERTIFICATION #: ejL �G y
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable sox): Residential [9 Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
NtTown: 'w ? �� C ° County: iz
77#_ �fz �/IV
(Road Name and Nu rs, Camu9ty, or Subdivision and Lot No.) DRILLING LOG
m
3. OWNER ����` 1,111� %c h �11 % S:l� _ , From 70
Address
City or Town State Zip Code
4. DATE DRILLED
5. TOTAL DEPTH •-'S
6. CUTTINGS COLLECTED YES[—] NO®
7. DOES WELL REPLACE EXISTING WELL? YES NO®
8. STATIC WATER LEVEL Below Top of Casing: Jam_ FT.
i (use •; 11 Above Top of Cuing)
9. TOP OF CASING IS / 2___ FT. Above Land Surface -
'Top of casing terminated atfor below land surface requires a variance In accc r-
dance with 16A NCAC 2C.01 1 .mil
10. YIELD (gpm): METjiOD OF TEST
11. WATER ZONES (depth): 62 S f Z,2 5 i
Agricultural ❑ Monitoring ❑
DEPTH
Formation Description
12. CHLORINATION: Type Amount_ If additional space is needed use back of form
13. CASING:
WWI Thickness OCATION SKETCH
De th Disme er or WelphtlFt. Militarist
From— To Ft.
From To Ft.
From To Ft.
14. GROUT:
DepthMaterialMMaterial tbqd
From � To Ft.
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From n
. From /o n.
TFrom, o—ln.
IInn
,—
16. SAND/GRAVEL PACK:
17
Depth Size Material
From
From >,�ETo FL
(Show direction and dials
0"�tloads, or other map
points) ice%
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:
ad
Serial No.
SIGNATURE OF PERSON CONSTRUCTING THE WELL
+.,,J SubrAl original to Division of Water Quality, Groundwater Section within 30 days
GW-1 REV. 12M

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section 4216 O 4 9
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELLCONTRACTOR: 1.4
WELL CONTRACTOR CERTIFICATION #4'2
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (check Applicable sox): Residential CS Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: Show sketch of the location below)
Neese gst Town: u County:
(Road Name and Nu`pben, Community, or Subdivision and tot No�j DRILLING LOG
3. OWNER/`Q27A (, �(�LUN/!�/I%f✓r/i %/✓ S/- irJlr%�%Z From To
Address /,/� 961 -4 z:z
set ormoulo e No.)
�,t�//iLLc %�GLS N C. 4a
Ci y or Town Stale Zip iode
4. DATE DRILLED ol6 rdD
5. TOTAL DEPTH '3n ,S-
6. CUTTINGS COLLECTED YES 0 NO[5a
7. DOES WELL REPLACE EXISTING WELL? YES 0 NO®
8. STATIC WATER LEVEL Below Top of Casing: r FT.
l (Use'+' 1f Above Top of Cuing)
9. TOP OF CASING IS / � FT. Above Land Surface*
'Top of easing terminated atlor below land surface requires a vs_rlance In accor-
dance with 15A NCAC 2C .01 8
10. YIELD (gpm): METHOD OF TEST l�
11. WATER ZONES (depth): P r ';z ?� t
12. CHLORINATION: Type r1a /i Amount 3
13. CASING:
Wall TNcknen
Depth D111" or or el hl/Ft. enal
From-0To Ft. �t�-L -�
From To Ft.
From To Ft.
14. GROUT:
Depth s7� Mate ' Me od '
From To S;(L Ft.
From To Ft.
15. SCREEN
Depth Diameter Slot Size Material
From _To Ft In. In. —�
From /
From To Ft._ in. In.
16. SAND/GRAVEL PACK:
From
From
17
Depth Size Material
Ft.
Agricultural ❑ Monitoring ❑
DEPTH
Fonnadon Description
LOCATION SKETCH
(Shaw direction and distance from at least two State
Road, or ther map reference points)
�Vv ruAlle i!o �S C
Ne,ry1/ S.r a4re./2
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A=COPCORD HAS PRO ED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Quad No: SIGNATURE OF PERSON CONS7RUqTING THE WELL CIAE
Submit original to Division of water Qualiry. Guru ter Section within 30 days
Serial No. Gw.i REV. 12199

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section 216048
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: , , LldgvjI
WELL CONTRACTOR CERTIFICATION #: nz%rYy
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (checkApplimble Boa): Residential M Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
Agricultural ❑ Monitoring ❑
2. WELL LOCATION: Show gkelch of the/ location below)C,
Near Town? ����-�< <� �' County:
jq
(Road Name and Numbers, Community, or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER A&R%A /-' 1'l P.),,,,ymt : Y ayilDLA/ ,5, 2(!l4,rc/LFrom To Formation Description
Address
City or Town �/ e up �ooe
4. DATE DRILLED '�
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑ NO[
7. DOES WELL REPLACE EXISTING WELL? YES [] NO[R
8. STATIC WATER LEVEL Below Top of Casing: /0 FT.
(Use 'i 0 Above Top of Casing)
9. TOP OF CASING IS 1 FT. Above Land Surface -
'Top of casing terminated atror below land surface requires a variance In accor-
dance with 15A NCAC 2C Otte T
10. YIELD (gpm): :2�L METHOD OF TEST / o
11. WATER ZONES (depth): �© /�`� r
12. CHLORINATION: Type -%V13 Amount —
13. CASING:
Wall Thickness
Depth �- ' or W ' hl/R. M edal
From —To Ft.Dto
From To Ft.
From To Ft.
14. GROUT:
DepthQ��.� Mate�1a(� Met ad
From To Ft. �p-vic �!
From To Ft.
15. SCREEN
Depth Diameter Slot Size Material
From o i
From To Ft. in. In.
Frommm/T _F._ Inr
16. SAND/GRAVEL PACK:
17
Depth Size
From To
From T�.
REMARKS:
Material
If additional space is needed use back of form
LOCATION SKETCH
and distance from at least two State
Roads, or other map reference points)
,y,c. rnTS.R w�r�2
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPP)GOFj-ZWJJECORD HA§AE5 jROV D TO THE WELL 0
FOR OFFICE USE ONLY L--
Quad No: SIGNATURE OF PERSON CONST CTING THE WELL
,i- Submit original to Division of Water Duality, Groundwater Section within 30 days
Serial No.
GW-1 REV. 12r99

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section _( 1
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION #: Z 2aYz
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., 7�. N: (Show sketch of the location below) 1� e ,' 1 ��
Nearest Town: all! County:— tfy
(Road Namq*d Numbers, C u 'ty, or Subdivision and lot No.) DRILLING LOG
3. OWNER 5W_7 From To
Address
City or Town State Zip Code
4. DATE DRILLED Rio- . an
5. TOTAL DEPTH rV P.T
6. CUTTINGS COLLECTED YESQ NO®
7. DOES WELL REPLACE EXISTING WELL? YES NO®
8. STATIC WATER LEVEL Below Top of Casing: /,q�> FT.
(Use'i It Above Top of Casing)
9. TOP OF CASING IS— FT. Above Land Surface'
'Top of casing terminated attor ba oow—land surface requires a variance In accor.
dance with 15A NCAC 2C.0138
10. YIELD (gpm): METHOD OF TEST7&-�A
11. WATER ZONES (depth): - -/L'2 b r
12. CHLORINATION: Type Amount
13. CASING:
Agricultural ❑ Monitoring ❑
DEPTH
Formation Description
If additional space is needed use back of qRn
Wall Thickness LOCATION SKETCH
Depth D�'or � W�ei99,h,t/R. Material ( ow direction and distance from at least two Slate
FromTo �_ Ft.._L�1._ #e�.L_ eve • Roads, or other map reference points)
From To Ft. -
From To Ft.
14. GROUT:
Depth Material Met/ Shp
From To -s-1-2 Ft. A,le>V
From To Ft. IG
15. SCREEN: JSd
Depth Diameter Slot Size Material
From To t in. n.
From To Ft. in. In.
From , To Ft In. in. 0'
16. SAND/GRAVEL PACK:
Depth Size Material y,
From To � Ft.
From To Ft.�_-' tt? (
N4
17
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS-AND.VAAK A=YVJDF3Ji UECORD HAS BFAN PIOVII)ED TO THE WELL OWNER.
Quad No:
-T�Vlffl�
GNATURE OF PERSON CONSTRUCTING THE WELL
to Division of Water Quality, Groundwater Section within 30 days
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 #: A.G 7ii'y
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable sox): Residentiai g Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: ( t c tch t e location below)
y/C n
Nearest Town: Counry: Z �/
Woad Name Number mmuni , or Subdivision and Lot No.) DRILLING LOG
3. OWNER From To
ArirlrAee rii//
or
Zip
4. DATE DRILLED d//!o/ o/0 a0
5. TOTALDEPTH-19,5-_
6. CUTTINGS COLLECTED YES D NON
7. DOES WELL REPLACE EXISTING WELL? ES E3 NO®
8. STATIC WATER LEVEL Below Top of Casing: ��_ FT.
(Use'+' it Above Top of Casing)
9. TOP OF CASING ISA— 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): y3 METHOD OF TEST Tau
11. WATER ZONES (depth): �� T
12. CHLORINATION: Type Amount.-
13. CASING:
Wall Thickness
Depth Di eter or Wei hVFI. Mtitenall
FromToFt.
From To Ft.
From To Ft.
14. GROUT:
DepthVI Material Meth
To From _1Z Ft.
From To Ft.
15. SCREEN
Depth
Diameter
Slot Size
Material
From
From
To Ft
To Ft.
ZTOZFt.z
in.
In.
in.
From
In.
in.
16. SAND/GRAVEL PACK:
Depth
Size
Material
From
To -- Ft.
=
From
Toyer
Ft.=
17
Agricultural ❑ Monitoring ❑
If additional space is need
DEPTH
Formation Description
LOCATION SKETCH
(Show direction and distance from at least two State
Roads,
`oorrroo`thee`r�r map reference points)
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
..r..,�ro, ,r•Ti OF THIS PACORD HAS BEEN-PROMEDIO THE WELL O
FOR OFFICECE—Up��1LY
Quad No: 1I''1flf II�nI(l,(,1L� IGNATURE OF PERSON CONSTRUCTING THE WELL
"' ;$libmit to Division of Water Quality. Groundwater Section within 30 days
GW-i REV. 12/99
Serial No.

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELLCONTRACTOR: ✓�1�/�-� einY 1C2y2rVf
WELL CONTRACTOR CERTIFICATIONIII:
STATE WELL CONSTRUCTION PERMIT#:
WELL USE (Check Applicable Box): Residential ® Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION:
Nearest Town: _/191
3. OWNER
Address
the location below) 'n
County:C nw%iLJ'
or Subdivision aryg Lot No.)
Z—
City or Town State Zip Code
4. DATE DRILLED
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES Q NO®
7. DOES WELL REPLACE EXISTING WELL? YES Q NOF71
8. STATIC WATER LEVEL Below Top of Casing: !Zn FT.
// J�� (Use '+' II Above Top of Casing)
9. TOP OF CASING IS_[_2FT. Above Land Surface -
'Top of casing terminated aVor below land surface requires a variance in accor-
dance with 15A NCAC 2C-Li 18
10. YIELD (gpm): METHOD OF TEST
11. WATER ZONES (depth): �'0-n
12. CHLORINATION: Type -7W S Amount,3
13. CASING:
DRILLING LOG
From To
DEPTH
Formation Description
If additional space is needed use back of to
Wall Thickness
LOCATION SKETCH
Depth , _
Q
DlymAter
(p
or Wei h t.
term
(/
(Show direction and distance from at least two State
FromTo .L
Ft.
Roads, or other map reference points)
From To
From To
Ft.
Ft.
14. GROUT:
n�1/1
Depth Material Met
From To � FL
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft in. in.
From To Ft. In. In.
FromZTO Ft. � In. in.
16. SAND/GRAVEL PACK: VVVYYY
Depth Size Material ti
From To Ft.
From � To Ft.�
17
I DO HERE NP�M'� DTIj>44T;�MIa�'W I OCO OF�OTED IN ACCORDANCE WITH 15A NCA0 2C, WELL
S.6 WORD H BEEWPROVID D TO THE WELL 0
C(INRTRII 1 .4Ya 9� A1�6
FOR OFFIC
Quad No: 9 11 SIGNATURE OF PERSON C9 STRUCTING THE WELL
Su final Io Division of Water Ouallly. Groundwater Section Within 30 days
Serial No. _. GWa REV. 12199
(1)'J4
O

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section - 1 J 883
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION #: a %SI3
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residentialp Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection Other ❑ If Other, List Use:
2. WELL LOCATION:
Nearest Town:
3. OWNER
Address
location below)
C¢wnH:
Lot
City of Town _ taro Zip Code
4. DATE DRILLED o2
5. TOTAL DEPTH -1a S
6. CUTTINGS COLLECTED YES NOJM
7. DOES WELL REPLACE EXISTING WELL? YES NOE]
8. STATIC WATER LEVEL Below Top of Casing: / i Fr.
/ (Use -e it Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface*
'Top W cuing terminated sifor below land surface requires* variance In aceor-
dance with 15A NCAC 2C . 11e
10. YIELD (gpm): 60 METHOD OFTEST
11. WATER ZONES (depth): PS'
DRILLING LOG
From To
Agricultural ❑ Monitoring ❑
DEPTH
Fonn"on Description
12. CHLORINATION: Type 7:2�. ; ount 7 If additional space Is needed use back of form
13. CASING:
Wall Thickness LOCATION SKETCH
De th r crr WalghM lNeriaal ( Stow direction and distance from at least two State
From �_TO Ft.LS' Roads, or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth�/ Mat Method
From To Ft. 1dLHi^7
From To Ft.
15. SCREEN: D
Depth Diameter Slot Size Material n
From To Ft in. in.
From To Ft.� In. T In.
From To Ft. in. —In.
16. SAND/GRAVEL PACK: Q�
Depth Size Mated c
From To Ft.
From � To= Ft.
17. REMARKS:
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTI OF D P DED TO THE WELL OWNER.
FOR OFFICE U
Ouad No: NATURE OF PERSON CONSTRUCTING THE WELL DATE
Subnit DivWon of water Duality, omundwaler Section within 30 days
Ssdal No. GW-t REV. 17/99

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] V.
WELL CONSTRUCTION RECORD WELL CONTRACTOR: �� n� ulawld.6!���
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Boa): Residential Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ It Other, List Use:
2. WELL LOCATION.JShow sketch
the location below) {y/ C J�
Nearest n: `//// County:
iN - 4 - - � 7`6 Y ,.ter_.)
(Road Name and Numbers. Comn0tity. or Subdi gion d'Lot No.) DRILLING LOG DEPTH
3. OWNER From To Fonnation Description
Address
ire or a o.
City or Town rate Zip Code
4. DATE DRILLED
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑ NO®
7. DOES WELL REPLACE EXISTING WELL? YES Q NO 0
8. STATIC WATER LEVEL Below Top of Casing: //n FT. o
(Use'+' 0 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 l5ANCAC2C.0118� --
10. YIELD (gpm): METHOD OF TEST
11. WATER ZONES (depth): -
12. CHLORINATION: Type Amounl If additional space is needed use back of torrtt
13. CASING:
r
Wall Thickness LOCATION SKETCH --
/� Depth Di ter or Wa' ht/FL a al (Show direction and distance from at least two State
From 1L—TO -[1tt Ft. L �C- Roads, or other map refer points)
From To Ft.
From To Ft.
14. GROUT:
Depth `))�� /1 Material Method ,
From � To .�S1LFt. L o-�L�� fw� tU
From To Ft. tj
15. SCREEN:
Depth Diameter Slot Size Material TJS 7-/f,
From /To -Ft � n. �In..
From To Ft. in. 7L�
From To —Ft. In.
16. SAND/GRAVEL PACK:
Depth Size Material I 1
From To t. nil
From TO Ft. �/
1/7
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONST E71
COP isbTHIS RECORD EEN P OVIDED T THE WELL OWNER.
FOR OFQuad No: SIGNATURE OF PERSON CONSTRUCTI HE WELL DATE
ginal to Divn of water Quality, Groundwater Section within 30 days
Serial No. OW-1 REV. 12/99

-
North Carolina -Department of Environment and Natural Resources -Division of Water Quality -Groundwater Section ;_ .� 2 O8
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: n-e' 1a le4" 4-
WELL CONTRACTOR CERTIFICATION #: t..L
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (check Applicable Box): Residential [Z] Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
Agricultural ❑ Monitoring ❑
2. WELL LOCATIQN.' (Show.sketch of the location below)
Nepprest Town: �Jl��� �County:r
7 LV
(Road Name arVtd Nu s. Community, or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER ✓tn'� J�����i«� From To Fonnation Description
Address
City or Town
Zip Code
4. DATE DRILLEDLU/.3dU
5. TOTAL DEPTH �Z
6. CUTTINGS COLLECTED YES ❑ NO®
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO®
8. STATIC WATER LEVEL Below Top of Casing: a_ FT.
v (Use'+' it Above Top of Casing)
9. TOP OF CASING IS % z— FT. Above Land Surface'
'Top of casing terminated attor below land surface requires a variance In accor-
dance with 15A NCAC 2C .0118
10. YIELD (gpm): s�METHOD FTEST Tlsics
11. WATER ZONES (depth): T y 1,2 a
12. CHLORINATION: Type -7 413 Amount
13. CASING:
Wall Thickness
Depth 2,,�� Di meter orWeight/Ft. M tten.aal
FromTo �!L Ft.� toR al r—`=
From To Ft.
From To Ft.
14. GROUT:
DepthMaterial Method
?
From _� To �Ft. 61.1,ey
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From To _ Ft— in. I
From ZTo-Ft.�in. in.
From To _ Ft. In. In.
16. SAND/GRAVEL PACK:
17
Depth Size Material
From To t.
From To Ft. �/
REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS
FOR OFFICE
Quad No:
Serial No.
If additional space is needed use back of to"
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
ED IN ACCORDANCE
RECORD }jWBEEN,
IATURE OF PERSON C(
Division of Water Quality,
15A NCAC 2C, WELL
DED70 THE WELL OWNER.
WELL ' DATE
within 30 days
GWd REV. 12199

r7C
North Carolina •Department of Environment and Natural Resources -Division or Water Quality •Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: XJ-jIto?&—k% 1A����
WELL CONTRACTOR CERTIFICATION #: lt,2%L3
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: CShow sketch of the location below)
Nearest Town: County:
and Lot No.)
3. OWNER
Address
wy v, rem, �� � amro cry i.oce
4. DATE DRILLED
!l�l1
S. TOTAL DEPTH oS
6. CUTTINGS COLLECTED YESO NOCK
7. DOES WELL REPLACE EXISTING WELL? YES NOZ
8. STATIC WATER LEVEL Below Top of Casing: /L,1Ef> FT.
(Use *+ II Above Top of Cuing)
9. TOP OF CASING IS Fr. Above Land Surface'
'Top of casing terminated aVor below land surface requires a variance in accor-
dance with 15A NCAC 2C ills
10. YIELD (gpm): METHOD OF TEST
11. WATER ZONES (depth): /0-5— 3c-122
12. CHLORINATION: Type Amount �L
13. CASING:
Wall Thickness
Depth Diameter or Waight/R. Material
Froml>To /o?D Ft. SOe 1/ yC.
From To Ft.
From To Ft.
14. GROUT:
Depth Material Methpd
From 19 To _1=2tiL 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, REMAR
DRILLING LOG
From To
DEPTH
Formation Description
If additional space is needed use back of form
(Show direction and distance from ai I t two State
Roads, or other map refer points)
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTED F THIS BEAORD HAS-6EXN PROVIDED TO THE WELL OWNER.
Quad No: _ NATURE OF PERSON CONSTRUCTING THE WELL DATE
`Submit o' i Division of Water Quality, Groundwater Section within 30 days Serial No. GW1 REV. 12/99
I

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section ti :-J') r (1 n
6 Mail S 'ce Center - Raleigh N C 27699.1636-Phone [phone] G 0 V
1. a ern
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION #: 1 %69!� --
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: County:
(Road Name and umbers, rnrr Cowniy, or on and Lot No.)
3. OWNER ��� J nk 02s
Address `7 A ✓7 / o�
4. DATE DRILLEDG
5. TOTAL DEPTH -Z �
6. CUTTINGS COLLECTED YES ❑ NO®
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO®
e. STATIC WATER LEVEL Below Top of Casing: /p.5'FT-
(Use (Use'+' g Above Top of Casing)
9. TOP OF CASING IS / ;- FT. Above Land Surface-
-Top or casing tarminatad aVor below land surface requim a variance in accor-
dance with 15A NCAC 2C .0 s �
10. YIELD (gpm): METO�OD OF TEST /—
11. WATER ZONES (depth): b — r Z'L %
DRILLING LOG
From To
DEPTH
Formation Description
12. CHLORINATION: Type T013 Amount It additional space is needed use back of form
13. CASING:
Wall Thickness
nn Depth D er or WSOR ai'V/R
FromTo Ft.
From To Ft.
From To Ft.
14. GROUT:
LOCATION SKETCH
Material (Stow direction and distance from at least two State
/! C , Roads, or other map reference points)
DepthMaterial
nh Material 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
From To Ft.
17
I DO HERESY I TF� .(�! S I MUCTED IN ACC�OraRcDANCE WITH 15A NCAC 2C, WELL
,nmayol V .'n Agn D�A '(�i1{11 OF THIS RECORD •/I"' BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE LY--{ GNATURE OF PER ON CONSTRUCTING THE WELL DATE
Quad No:
Submit n to Division of Water Quality, Groundwater Section within 30 days GW-1 REV. 12199
Serial No.

� :z599
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mal Service Center - Raleigh, N.C. 27699.1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: 12�
WELL CONTRACTOR CERTIFICATION 0: e2 %
STATE WELL CONSTRUCTION PERMITS:
1. WELL USE (check eoxy Residentiai13 Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other 0 If Other, List Use:
2. WELL LOCATION: (Sho1Y sketch of the location below)
Nearest Town: 7?1 G tla vc County. C 6 ).Zie�7
OAS �r t�L LG
(Road Nana and Nmrt ConsnuYly. or Su6r8Wdon and lot No.)
3. OWNER 'U 1—•7a�1L1��.�
Address 7JJOitG�vc
city or Town Stan Zip Code
4. DATE DRILLED
5. TOTAL DEPTH yr
6. CUTTINGS COLLECTED YES 0 NO[M
7. DOES WELL REPLACE EXISTING WELL? YES NO®
8. STATIC WATER LEVEL Below Top of Casing: 1,Z__ FT.
(Use'.' N Move Top of Maine)
9. TOP OF CASING IS_L FT. Above LandSurface
'fop of wing tererHased eLor IWaw lernd surhee n rAm a variance In accor-
dance with 1SA NCAC 2C 1a
10. YIELD (gpm): ,_ METHOD O ST ��irsr
11. WATER ZONES (depth):- X5
12. CHLORINATION: Type Amount,
13. CASING:
t� , ownew / Wall ThicThicknessoa_�DTo��SGFt. « From� UC
From To FL
From To Ft.
14. GROUT:
Depth Materiel (Methgd
From To � � Ft.
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From To t In. ---777 In.
From TOO
Ft.� in. In.
From To FL in. In
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft
From = To�FL�
17. REMARKS:
Agricultural ❑ Monitoring ❑
DRILLING LOG DEPTH
From To Fomadon Description
LOCATION SKETCH
(Stow duedion and dlstence hart at IeeN 1
Roads, or other map reference points)
Ef]
Omdrr« f Ip i P, _ 8 mTtAiE OF PEReOM (bl/nuSTRUCIW6THE WEIl DATE
t.lu SnA Division of Water Owft cwwater Section Within30 days
saw No. OW-1 REV. 12M

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] (X� f % '! C 4 A 8
WELL CONSTRUCTION RECORD WELLCONTRACTOR: �� / If w0.1..)� ,QF G
WELL CONTRACTOR CERTIFICATION #: a '7&
STATE WELL CONSTRUCTION PERMIT#:
WELL USE (Check Applicable Box): Residential Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection Other 0 If Other, List Use:
2. WELL
-(Road Name
3. OWNER
Address
sketch of the location below)
c County:
or subdlvislon✓a��dLotNo.) DRILLING LOG
From To
4. DATE DRILLED lo�eLlv�n/�IJ1J
5. TOTAL DEPTH %L T
6. CUTTINGS COLLECTED YES NO®
7. DOES WELL REPLACE. EXISTING WELL? YES
8. STATIC WATER LEVEL Below Top of Casing: F r.
'' L_ (Use'+' II Above p of Casing)
9. TOP OF CASING ISM FT. Above Land Surface'
'Top of casing terminated &Vor below land surface requires a variance In accor.
dance with 15A NCAC 2C..9%,118
10. YIELD (gpm): —L_ METH ry1}p OF TEST
11. WATER ZONES (depth): !`5 ( -y rr) t
12. CHLORINATION: Type _ 46 Amount --
13. CASING:
Wall Thicknew
Depth 10 Di er or W_ _ aiy� t. t9dal
FromTo � Ft. .7�PZ _VC,
From —To —Ft. -
From To Ft.
14. GROUT:
DepthMat�erial� Mel od
From To Ft.. IG�7dddd_
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From o Ft In.
From To7- Ft. In.
From To Ft. In. In.
16. SAND/GRAVEL PACK:
17
Depth Size Material
From To Ft.
From T� Ft.
c ❑nsea ��/
Agricultural ❑ Monitoring ❑
If additional apace r9 needs..
FomuGopDgst�(plion-
locilibn and distance from at least
Me
r map reference points)
Owl
Cd.Z
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPS_,JXCORD H.A - E"TIOVIDED TO THE WELL O'
FOR OFFICE USE ONLY
Quad No:
Serial No.
C,
SIGNATURE OF PERS NSTRUCTING THE WELL
Submit odginal to Division of WalgrOuality. Groundwater Section within 30 days
GW-1 REV. 121"

North Carolina • Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section , .r 1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone] f:..j. 4 5 4 7
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION #: o.Z �Ifr
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) ,fin �(/J �1�
Nearest Town: ,cam,/ lgeL�� �• County:.Il e �`" /�-P-`-10
(Road Name
3. OWNER _
Address
No.) DRILLING LOG
From To
4. DATE DRILLEDIu
6. TOTAL DEPTH
6. CUTTINGS COLLECTED YES Q NOO
7. DOES WELL REPLACE EXISTING WELL? YES [] NO®
S. STATIC WATER LEVEL Below Top of Casing: FT.
L. (Use'r' it Above Top of Cuing)
9. TOP OF CASING ISFT. Above Land Surface'
'Top of casing terminated at/or below land surface requires a variance In accor-
dance with 15A NCAC 2C 1
10. YIELD (gpm): MET OD OF TEST 7rG4�
11. WATER ZONES (depth): .S 4- .1ep
12. CHLORINATION: Type Amount
13. CASING:
If additional space is nee
Wall Thickness LOCATION SKETCH
Depth �/w�-�,, Di/Nnett rr or Wei ht/Ft. al9dal (Show direction and distance from at least two State
From 0 To !M Ft. __� _cam 2 V Roads, or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth�7�, 0 Material A Methpd
From _� To �LS._ Ft. ',_r'1`.D`(`iA.i�_/
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material L+�
From To Ft in. in.
From To Ft. in. in. tfr�+so
From � To Ft.- in. in. D
16. SAND/GRAVEL PACK:
Depth Size Materia 5
From T.�
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 AS BEEN P D TO THE WELL OWNER.
FOR OFFICE USE ONLY zi
Quad No: SIGNATURE OF PERSON CONSTRUCTING T 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 213086
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELLCONTRACTOR:
WELL CONTRACTOR CERTIFICATION
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Resldendal�4 Municipal ❑ Industrial ❑ Agricultural 0 Monitoring ❑
Recovery 0 Heat Pump Water Injection [] Other If Other, List Use:
2. WELL LOCATION: (Shovy sketch of the location below)
Nearest Town: County: C
(Road Name an umbers. Co niry, r ubdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER
Address bow a/_ ✓I i. From To Formation Description
1Otreei or Houle No.)
C,ry or Tovm �V ^��.. fc7
State .Zip Code
4. DATE DRILLED 3 , oil
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES Q NO®
7. DOES WELL REPLACE. EXISTING WELL? YES NO®
8. STATIC WATER LEVEL Below Top of Casing: FT,
9. TOP OF CASING IS 2, (Uu -✓ 0 Above Top of Cuing)
FT. Above Land Surface -
Top of cuing terminated aVor below land surface requires a variance In accor.
dance with 15A NCAC 2C .0118
10. YIELD (gpm): - R METHO OF TESTT,.�.. .
11. WATER ZONES (depth): �/%
12. CHLORINATION: Type—%—r1/-� Amount . _ If additional space Is needed use back of form
13. CASING:
Depth Wall Thickness,DI P site" or Welght/Ft. MAJerial
From To ` Ft. 4 _
From To Ft,
From To Ft.
14. GROUT:
Depth Mata ' I Method
From To �� Ft. L&cj IA-y
From To Ft. -----� 7-
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft In. From To Ft.
From To In. _ In.
16. SAND/GRAN ACK:
Depth Material
From To
From Ft.
17. REMARKS.
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map tolerance points)
9
5 p
a r----- I
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT CO itECORD HAS §6EI$PWVIDEO TO THE WELL OWNER.
FOR OFFICE USE ONLY
Quad No: SIGNATURE OF PERSON CONSTR NG THE WELL DA'
Serial No.
ubmil original to Division of Water Quaint, Gmundwatar Section Within 30 days
_�
.. GW-1 REV. 121"
a

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section 213094
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone] A
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION 0:_ s7 7
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential D Municipal ❑ Industrial ® Agricultural ❑ Monitoring ❑
Recovery ❑ Heal Pump Water Injection E3 Other ❑ If Other, List Use:
2. WELL LOCATI N• (Show sketch of the location below) C
Nearest Tow V r County:
r
(Road Name N o uni yt Subdlvlsion and Lot No.) DRILLING LOG
3. OWNER �gJ� luniPyN• Q DEPTH
S � IAJ;E� 74de From To Formation Description
Address n_ r2 __ . � o • _ ..,, .f ,n
City or Town State Zip Code
4. DATE DRILLED A ,
S. TOTAL DEPTH
6. CUTTINGS COLLECTED YESQ NO®
7. DOES WELL REPLACE EXISTING WELL? YES :j NOM
8. STATIC WATER LEVEL Below Top of Casing: —'n FT.
(Use': 11 Above Top of Cuing)
9. TOP OF CASING IS—_ FT. Above Land Surface'
-Top of casing terminated avor below land surface requires a variance In accor-
dance with 1SANCAC2C. 1 e
10. YIELD (gpm): , METH D OF TEST
11. WATER ZONES (depth):
12. CHLORINATION: Type 7_Amount
13. CASING
Wall Thickness
Depth 0 Dam ter or Walon�l. 'ovic
FromTo�_ Ft. 'li��L
From Tom FL P L STc6L
From To Ft.
14. GROUT:
Depth,Material Method
From To e.20 Ft.
From To Ft.
15. SCREEN
Depth Diameter Slot S t3---Mateffal
From To Ft _ In.
From To in. _ In.
From To Ft. in. —In.
16. SAND/ L PACK: _
Depth Material
From To t.
From o Ft.
17. REMA
O
n
a=
ni
zm
a%
sn
A r*i
m�
C:)
ti
z
If additional space U needed use back of form
LOCATION SKETCH
(Show direction and distance from at least two Stale
Roads, or other map reference points)
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTI CSTAri1D f S.ANDTHAT200
0/R/D/�]HASBE V DT EWELL 0
• t U !/►��.�ii�
FOR OFFICE U!t,
6]CV
Quad No: +' SIGNATURE OF PERSON CONSTRUCTING THE WELL
5 '7 Ubmil crI01nal to Division of water Quality, Groundwater Section within 30 days
Serial No.
DATE
GW-1 REV. 12199

213092
Department o1 Environment and Natural Resources - Division or Water Quality - Groundwater Section
North Carolina •
1636 Mail Service Canter - Raleigh, N.C. 27699.1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION #:�!f 3
STATE WELL CONSTRUCTION PERMIT#:
r
1. WELL USE (Check Applicable Box): ResidendalM Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION- (�Shovi sketch of the location below)
Nearest Town:.!!z� „_
3. OWNER
nxnuniry. or DUDDIVISIon and tot No.) DRILLING LOG DEPTH
Address '? / is � / _ /j 1.7 - From To Formation Description
[, .j
City or
Zip
4. DATE DRILLED
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YESQ NOMI
7. DOES WELL REPLACE. EXISTING WELL? YES ❑ NO[o
8. STATIC WATER LEVEL Below Top of Casing:�FT,
�(�. (Use •.• a Above Top of Casing)
9. TOP OF CASING IS � i Fr. Above Land Surface,
'Top of casing terminated at/or below land surface requires a variance In accor-
dance with 16A NCAC 2C 0 to
10. YIELD (gpm): MET OD OF TEST 7,-/a e
11. WATER ZONES (depth): ,A
12. CHLORINATION: Type 7�iS1,� Amount _
13. CASING:
11 additional space is needed use back of form
Wall Thickness LOCATION SKETCH
Depth D er o,rr,,�W,e,�' h �/FL Material (Show direction and distance from at least two State
FromTo � Ft. � Aye- Roads, or other map reference points)
From To Ft. A&Z4d&AI Srr ra I
From To Ft.
14, GROUT:
Depth Material Moth
From To .&2.Q FL
From To Ft. —__-
15. SCREEN
Depth Diameter Slot Size Material
From To Ft In. _ in.
From To Ft. In, 1'
From Ft. In, _ In.
16. SAND/G VEL PACK: 5 ��
Depth Size Material
From To Ft.
From To y
17. REMARKS:
—
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C, WELL
CONSTRUCTION,ST/,Iry.aAFlDS, AND THAT A COPY OF THIS RE N PROVIDED 7aOWNEFI.
FOR OFFICE USE,
,.._�_ [: b/
Quad No: ` `'` SIGNATURE OF PERSON CONSTRUCTING THE WE DAT
Serial No.Submit original to Division or Water Quality, Groundwater Section within 30 days
�. i
OW-1 REV. 12l99

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636-phone (919) 733-=1 '
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION 0:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Cheek Applicable Boa): Residendaig Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
El Heat Pump Water Injection Other If Other, List Use:
2. WELL LOCATION: (Show asketch of the location below)
Nearest Town: �`"—' County.
1�7',df a1.2
(Road Name ppd Numbers. Com uOWNER nity. orSu/pdiv an and (.ot�°.) DRILLING LOG DEPTH
3. Address I - 11�Rs�w�rFrom To Formation Description
a ae or no.l -_---
e2A''jf'Z
City or Town taco Zlp Code
4. DATE DRILLED o
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑ NO®
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO[R Q o
8. STATIC WATER LEVEL Below Top of Casing: oI- C2_ FT. f -
�LL (Uss'+ it Above Top of Casing)
9. TOP OF CASING IS. L� FT. Above Land Surface* m
'Top of casing terminated Wor below land surface requires a variance In aeeor-
danca with 16A NCAC 2C .e11a
10. YIELD (gpm): aT&:� METHOD OF TEST
11. WATER ZONES (depth):
12. CHLORINATION: Type =—/fA' Amount...3._
13. CASING:
Wall Thickness
Depth DiVneler341, oryyS TeSGL From_0 Tofpf Ft.
From To Ft.
From To Ft
14. GROUT:
Depth l "Mate l Mettpd .
From �_ To s>zz Ft. - C"i /
From To Ft.
15. SCREEN:
Depth
From To _
From To
From To _
16. SAND/GRAVEL PACK:
Depth
From To _
From TA_
17
Diameter Slot Size Material
Ft In. —in.
Ft. in. —In.
FL In. —In.
Size Material
Ft.
Ft.
m �
[mil ti -
0
It additional apace is needed use back of form
LOCATION SKETCH
(Show direction and distance from at leant two State
Roads, or other map reference points)
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH ISA
CONSTRUCTION STANDARDS, AND THAT A COPY OF =k:*qr—
BEEN PROM
FOR OFFICE USE
Quad No: siGNATUAE GF PERSON coNsmucTiNdTHE,
Submit priginal Dlvisigrt or water Quality, Groundwater Section
sadm No. — 3 2000'
C o!nd va' Secua
R h rLl�o� irldl ^y1.8 ) t _
WELL
WELL OWNER.
30 days
G
Gw-I REV. 12M
K

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699.1636-13lane (919) M-3221 4 _L
WELL CONSTRUCTION RECORD WELL CONTRACTOR: SAL ;6 �� a •�*�
WELL CONTRACTOR CERTIFICATION #: wI
STATE WELL CONSTRUCTION PERMIT#: '
1. WELL USE (check Applicable Box): ResldentialO Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show. sketch of the location below)
3. OWNER
Address
city or Town State Zip Code '
4. DATE DRILLED $/ AZ4-6D
5. TOTAL DEPTH � Z -5—
6. CUTTINGS COLLECTED YES❑ NOCj�_
7. DOES WELL REPLACE EXISTING WELL? YES Q NO[Z
8. STATIC WATER LEVEL Below Top of Casing: ,der FT.
y (Use'.' 9 Above Top of Cuing)
9. TOP OF CASING IS� FT. Above Land Surface'
Top of "sing terminated at/or below And surface requires a variance In aceor-
dance with 15A NCAC 2C 0118
10. YIELD (gpm): METHOD OF TEST 1:2M e'-
11. WATER ZONES (depth): ZDO
DRILLING LOG
From To
DEPTH
Forttution DesMption
12. CHLORINATION: Type —1Q a _ Amount It additional space is needed use back of form
13. CASING:
Wall TNcknew
Depth oQ,/DI t or We hM. r(ai
From 0 To Tb Ft. (/
From To Ft.
From To Ft.
14. GROUT:
Depth ��//,, Materi Me o
From �— To � Fl.
From To Ft.
15. SCREEN
From
From
From
16. SAN[
From
From
17. REM,
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
I Do HEREBY CE iffRUCTED IN ACCORDANCE WITH OA NCAC 2C, WELL
CONSTRUCTION �O�"r T D HAS BEEN FAjb ED TO THE WELL OWNFIR.
Quad No: ELI' i TURE OF PERSON CONSTRUP16NO THE WELL Suhrnit orlpi o n of Water Duality, Groundwater Section within 30 days
Sedal No. _ GW-1 REV. 17/99