Well Construction Records Madison CY2000

229438
North Cnrnh-,l . I,.•I•n,lm. �,,i nI F,.dend Nnlulnt fle-ourcn+ - Divl^ion of Water Duality • O+waniwnter Secti^n
t636 f.lail':^,•i, , t•.^N,•, - IL,Wuh, I I.C. 27699-1636•Phonn [phone]
WELL (.;(JIISIIlIICIlO1J RECORD WELLCOIJTRACTOR:
W FLL CONTRACTOR CERTIf IC AT I(I n:_����1-----
S1-AIF WFLLCONSTRUCTION PEfll'AlFit:
1, VIFLI Ilgr['Ir,,.�6rl�•m,ldnnnq:flesldantlall]7 Muldclpnt❑ InduslrlalU Agdcuhur�I�.. hlonitorinp -�
h,nl r'onu, Water In)ectlon ❑ other IJ It
other, List Use: - __.__----�-----
2. W[LI 1 +1i'AI I0t7. ;'ar,.� skr9ch of Iho lOcallon brloW) _Lj�t ��-4
Idiom-)
--
._. .._._-_-.---------- DRILLING
DEPTH
cn,n,mnn' or Subdivision end Lc, o DRILUJOLQG --_--
- - -
From To r-o,+naOonVcScdpPnn
W 3. ONt'rl /u,/Ff/GGLY
Addir - --
�9P, - t - -
c:ny r, Inv:.,/ C:,ab 21p Code
4. DATFI'rlil-ILfI_�a �_oa '-_----- -----
s. Tornl.i�rr iu l85 - -- -----
6. CUTI li l( t;Ut l.[ ! I FD YFS [_� NO t9
7. DOES VIF I I Nr 1'1 Ar r r-.XWTING WELL? YES [ ] NO[V74 -- o
8. STATIC Vdn1!_r1 LEVEL ❑clew Top oI Casing: - FT.
(Use T n above Tor or CaflnO)-
c
9, lUP (.1F nASIIiG Is___ ��_-- FT. Above Lend Sullnco'
Qp c
•Tap of ea+,nq nhd ct'cr below Innd surface requlna a vadmes In eecor•
donee with 154 Ur,nC 2Cen �_ —
tO.YIELO(ut+m) _ - METIIODOFTEST
t1.WATEf[7.OIlES(r.lrpih):—_ J "'- �'z
12. Cf ILOTtII JAl IOIJ: 1 r Amount 1 S 11 additional space Is needed tilebnck o » m
Y'T' -
13. CASIIIC;: LOGA11ON-SKETC11
Wen l hlc6na+e
lamer o Wef91'Yr1. nlednf (Show directyn and dlaanrs Irom nl Innsl two SInIP
'Aas Roads, or
otherll,nptPlerencePoint,)
From------- lee
from—Aw.
14. Gl1011 I: Method /
/ L C,
15. SCNGr I P. Material
t lry,lh Dimneler Slot Sizo
Flom It, -_ _. FI _ In.
10 1-1. In. __- In.
rron, - _ TO . - .--_
16. SAIJDlGNAVFL VMM: Malednl
Url•ul Size
Front--
17. REh1A11KS:_,-_
bO I,I-IIr PV Clrlll IrY TIIAl wi ri WFLL WAS CONSTr1UCTED IN ACConoaf CF. WITH 16A FICAC 7.C, WELL
I ONc, i flUc i lilt i lnF1OAr1Di, ANOIHAT A COPY OF T1113 R CORD I1AS BEEN/rnOVIDFO TO T IIF VIT-1_L OV'I/r1�En'
FOIL OI I IC:F USIS DIILY --�--" OnIE
S (31T11fUrlEO P SOtI CONS nUCTIIrOIIRwnI-
Oued Nc Submit odpinanlo Olvteton o1 aler Duality, Omundwribu Section wltidn 30 days

,?3969
NonhCaroMal &m . DeperWant of
WCr27W&1 aaurW R a (u 7- Onas d Water Ougft • Groundwater Section
WELL CONSTRUCTION RECORD WELLCONTRACTOR: S '� Lea = �' �"`
WELL CONTRACTOR CERTIFICATION #: a % Y
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (CIm*Appawbb80* RaddW"(3 Municipal ❑Inchwillil
at 0 AWicx� ❑
MWAMN
Raoovary [] Heat Pump Water ht)eOWn ❑ Other If Other
4. DATE DRILLED SZ ,
5. TOTAL DEPTH _
0. CUTTINGS COLLECTED YES NO®
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO®
8. STATIC WATER LEVEL Below Top of Collin . /,�)_ FT.
ttrae'.' b AbM Tep a Carsp)
8. TOP OF CASING IS-Lt- FT. Above Larid SW%W
'foparee•bptwmku •dattar' k Imadwhaeraqube-e/awir�ceInamar-
aanee wee 15A NCAC SC AM JJ Ad r
10. YIELD (ppca): l eMET
11. WATER ZONES (depth)' o OF TEST Zznn t
12 CHLORINATION: Typo -n ktourd 3
13. CASING:
vvdyhkimm
Depth ykqow er WMp tlR sell"
FmmTO a 6?,C>2- PVL
From— To Ft
From To Ft
14. GROUT:
Depth n MetablMethod
From �_ To �Q_FL / Ila
From To FL
15. SCREEN: FFromm
�j2-DeTpt,"t��/�FtDkrrrter SbtSizw MaWial
From T:Z
13. SANDIGRAVEL PACK
Depth She Material
From To
-
From To e— r r
17. REMARKS:
M.
If addOW101 apaoa Ia nm
(Show dkeetbn
Roads, ofc
tNam+oe P*45)
4
Li et 0
Oadft P &6" o wr b o k4don dwaaa aueft GatatemmMr 8ecoon witldn 90 deya
1

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section 229643
1636 Mail Service Center - Raleigh, N.C. 27699.1636-Phone [phone]
WELL CONSTRUCTION RECORD WELLCONTRACTOR: D. Bowman well Drilling, Inc.
WELL CONTRACTOR CERTIFICATION #: 2809
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (check Applicable Boa): Residential© Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: ___Ma r4_-.Idi1.1._ __County. Madison
Cl i ndon C ova 17 _d
(Road Nana and Numbers. Community. or Subdivision and Lot No.)
3. OWNER Mark & Latrella HigAina
Address P.O. Box 1274
treat or Houle 0.
Mar¢ Hill Nr 28754
City or Town State Lp Code
4. DATE DRILLED 12/14/00
5. TOTAL DEPTH 400' `
6. CUTTINGS COLLECTED YESQ NO®
7. DOES WELL REPLACE EXISTING WELL? YES 0 NOE]
B. STATIC WATER LEVEL Below Top of Casing: 80 FT.
(Use': 0 Above Top of Cuingl
9. TOP OF CASING IS 1 . 4 FT. Above Land Surface'
'Top of cuing terminated aVor below land surface requires a variance In accor.
dance with 15A NCAC 2C.011e
10. YIELD (gpm): 11 METHOD OFTEST rnt=_ ..ter
11. WATER ZONES (depth): 240' — 380'
12 CHLORINATION: Type tablet Amount 6
13. CASING:
Agricultural ❑ Monitoring ❑
DRILLING LOG DEPTH
From To Formation Description
It additional space is needed use back of form
IV
Wall Thickness LOCATION SKETCH "
Depth Diameter or Weigti Material (Show direction and distance from at least two Slate"
0 60 6 1 /8 Sch 80 PVC Roads, or other map reference points)
From To Ft. Po )
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From n_ To ')Q_Ft. concrete gravity flow
From To Ft.
15.SCREEN:
Depth
Diameter
From
To _
Ft _ in.
From _
To _
Ft. _ in.
From —To
_
Fl. _ In.
16. SAND/GRAVEL PACK:
Depth
Size
From
To
Ft.
From
To
Ft.
17.REMARKS:
Slot Size Material
in.
In.
In.
Material
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.
=No.
GNATURE C
Suomi, odgi al o Division of
SON CONSTRUCTING THE WELL
Quality. Groundwater Section Within 30 days
GW-I REV. 121"

??9'?89
North Cnrvl,, I1,1,T Ins - n of I nab •rlrnent end Nalural tlasowc^s - Division of Water Quality • Oimu,dwaLr Srclb•n
163611a4 .f Cnu^• Il:d^�uh, II.C. 2.7699 1636d'honn [phone]
WELL l:Ul l5 l I111C i 10(d nECOnt) wELL CONITIAcron:
WELL CONTHACTOnCEnTIr1CAlR I N:_�,_�D�Il _
SIME WELL CONSMUCT1011 r'EMAITh:
1. Wri-I MunlClpnl ❑ industrial ❑
Ilecovrry. _) I I^nl Pump Water Injection ❑ Other ❑ It Other, List Use:
Agrirulluml L.J Monlinring LJ
2. WELI I()CAIK1rl lmvskrI I onrlhelocallonbelow)
N^nre�l 1,,,. n-. Lp-� County: ---
(nonCnnnnn,i , or Subdivision and Lai No.I--
3. ow r1
Addrr � s
Alm-
oi, -o 0
rInr: •, 61r1e ZIP COde
a. omE rnu 1 rt) _lag',ra /oab
6. 10TAI. UCI•III
6. CUrlll!(1 C(tiLPGIFN YFS❑ N09
7. DOES,'jFLL tirrl nr,F FXIS IINC, WELL? YES ❑ NO[1_7J
8. STAIicVJA]FIILrVFL.nclowlopolCnsing: _��rT,
(Use': a Above IOP of Ca slap)
S, lop (it- CASII I , I" .�_____ Fr. Above Land SUHACO*
•ToP of cas4?n I•, nd,mh,l ri'rr below I+nd surface requires a valiance In eccor-
dance with 15rt NCAC 2C n 118
10. YIELII (opm) 10 _ METI too OF TEST iQ
11. WA1FIl 70NES (cl^plh): �. •J!
12, CIII-01111JA110N:
13. CASIIJ ,:
lype�. Nnounl�i
Wall liddnces
PrvIll /�,lameler orwelphUr6 KIWI,
/)nt]
From_.....-- l^ __...._ r1.
Flom. ..-____..I >-.____ FI.---
1A, GROU1:
`l
I,�rul Malollat jM�opt�h�o�d�Q/
rmnl U _.U^V_
rrom . 1, ., -.___rl. _ -
15. SCRrF n
1), himnrler Slol Sizo Mnledal
rlol„
From
I n,lul Size Malnilal
From ... _. 1„ _ ___.... Ft.
Rom
17 REh1A1lKS- — ---
DRILLING LOG
From To
UEr ii _
rmmallon Orsolnlion
o
if additional sparo b n4ednd a-e bock
LOCAI ION SKF 1 C11
(Show direction rind dl ,Mien born At Inasl two SI019
noads, or other maP relerence p0I111s)
I DO 111-1It'll ,' r rn 1 It N 11 w, it u3 WELL WAS COI $ f flUCf rD III ACCOFIDAMCF. WI111 I5A N(;AC 2r . WFt.L
COI i^.I fit ir.Iir,lI la Al i1+Art1,,. At 1D l 1 IAT A COPY OF 1111S f1Econui RAS BIErN rnow FD TO II IF v/ElL OvINFn.
f Ofl (+1 I K r IISI'. t,tll:Y -- DAIE
Quad llc IJ FICr1A1fISOtI COt131OUClltrrl IOp t7n 1.
lRubmlt odpinal to Division of Walef Ouelily. DNundwaler Snction Ylhl till 3l1 rl',y, ow I flEv. 1211,

x'v i.'^7'.�.1. ' r C 1" a" -z, r 7..
I :.: ...... 1 v t :' 4 .I •�` .T I'f:...,�•.+.Yt ss p : , �f �' • ... L Y ,) • • ..
229485
•„Ih enrol" r, l nnn,rnt M rlmbnvniir,l and Nelurnl fie . ovrcos • blvblon of Water Ouatity • OroundwAler Secllon
,39 Men Srlvicn Cr11I01 - 11-ie1911, N.C. 21690-1636.1"I,ons [phone]
WELL DUNS MUC11U1J hECOIi[l wrLLcoNTnnclon: b_fi.__��rR jtxSa 7
WrLl-comi1ACi0nCri tirlCAIION11:_
STAIFWELLCOtJ9inUciiuttPFllt4fto: __
1. WrLL Uc(_ (Cl,rck n1 pnrntde nrvl: I1rsldnnllalU(J Municipal (nduslrinl ll Agticullural Monllnring 1_J
nocovrIy I _J I Irnl 1'unq, Water Inlecllon ❑ Olhet ❑ If Olhet, List Use:
2. WELL IOCAIIUI1• Sl o,v skelc of ibe locallonbelow)
Nenrest town: County:
jnona ii„„� and li i��iw H. Con -m—oK. or Subdlvislon end -Lot Ilo.j URILLIIJG LUG
3. OWNrn __A A�� -- Fran To
Address ! —
1��/A/L - �1,rr IF, rr,ar Io -�2f"7�S�
C>rrr I` ---Into Zlp Code
.,• 4. UAIE(11U1I-r-1)___�fry_/�,/�_01�
S. TOM llf:1'ill _ .
0. CLIT111l0r..CVL11"CIrU Yi.-r,o NUL1j
7. tJOES wrla_ nPf'IrCE rxitimt(T WELL? YES LJ 140Lif
8. S1Ai1C WARM LEVEL Elelor•r lop of Casing: A&S-- rl" ---
(Use'.' 0 Above Top of (:e111191
9. TOP Or CAS111(; M __ I—_ . FT. Above Land Stnfnca' —
top of utsh,n 111ndnnl•d ri,rr below lend au,lace t@nubet a vulenes In secot-
mcewllh 15A IWAC 2c.0110
10. YIEI-b (al'11')' �. _. MEII101) OF TESF.._L.LL —
i 1. WATEn 7.Of 1ES (tlrp111): ___ —
_ UErJ-p-___ _..
rolmMl" Vescdrllnn
— �edcnc-k
12. CI 1lOI111JAi IUtJ; i ypo _F AnoW d pJ� II eddlllonnl epnre is nre,led usn beck of lotm..
13, CASING: .r
- IUCA 1 �UN_SI(E 1 CI I
wen V,tcsnrse
O Urf,lh Inmeler a WelgbVr t. Nstedrl (91aw dlrecllon and dlslnncA born nl IAtsl Ivro Stale
From—. — --la_ Ft. axis 1IR floods, orolhe,Mop Welencepobds)
flan._.----lo.--.—
14. 6I10111:
`` llrpll, Mnlerinl nlhod ��
V 'InSA.Lft� //
Flom
15. SOBLr1I:
Url,O, Diameter Slot Sl26 Mnlaflnl
rlorn-_-._--t„_..._—It_ In. _---In.
Florn _ .In..._._-11. In. In.
rlonl It, -- FL-- In. In.
IS. SAfJL)IGFIAVrL rAGK:
Urldlt Slte Malelinf
From 11n---_11.
From ....- -- 10 rt. --
17
1 OOI IFI1rnY Crnl,rY 111AT 71119 WELL WA9
CONS I I1u011011 S I AMOA1109, A1,10 MAT AC
Fvli oFrice iisi=_
Oued No
o
:ONsni(ICIEO IN ACCOnOANCF Willi 16A IIcAC 2C. WELL
pY 111119 NECO O NA9 BEEN PROVIOEb 10 TIIE WELL
Q D
t1All01E Or rF11S fl COtl9TflVCllt1411 iF YlF.11. DATE
d to tmvlslon of Weler ovolly, oralndwoun Srcnon will dn 30 days ow-1 nt:v. 121111
Sed1111n

...: 1.�y1• A..
w,.,e,l..
•�nt+wlr��lnr-�
'.Y'w �� i ..
. ..
229482
North Cemt� n . I t^rmin....I ,I F.M; nmanl and Natural Necovrcrn . Diviaion of Water Quality • otnundwater Settee
1636 flail Ilnlrlgh. I1.C. 2. 7699.1630411 lone (off)) 733-3221
WELL G0115IIII ICIION RECORD WELLcorJlnncron: �_ �R�--
WELLCONMACTOTICETITIrICAII( 1 A:�_
SIMEWELL CONSTFIUCTIOfl11E11MIlh:
--
I. WELI I ISr I 1,•rk r Ll.n, a.h r1nq nPSldnn111Il .l Munlrlpal ❑ Industrial El Agrlculllnal 1. j Monlindliq 1J
Noct""'y j .) I I,•nl Femn Water Injection ❑ Other Ll II other, List Use:
2. W r_ Ll L(Icn l l(uJ:(:hn�: �L/'r., Jr. It of Ilia 1pcatlon b Plow)
Nrnrr•I I•� n .. _-l/!/-.Eil/�/w/ fz —Cc vily:
rnc, t tt. ,, n mrxrv,dly, a O.&IIlon end Lot No )
3. OWNIII JLI{ �
1�-
(aY ot ........ Slate Zip Cads
A. DATE hltll I FI) % � /�-C6
5. 10TAI_ Or I I l
6. CUT111 (:()tIr! IFit ESNo
7. DOE^ v.frI l 11111 rv;F FXISIINC WELL? YES F fJO�
8. SIATI(: WAIFIIII:VEI r1elorr101101C1111119: _ _FT.
Above Top of CealnQ)
9. lop la- r.nBING I':Fr. Above Land Sartace'
'TIP of ca•tnp below Iend surface requires a valiance In actor•
dance with IFA I1IAC 7C title
10.YIELIt(gl`if) _I,J _METIIODOFTEST__RL�
11. WATEfl70HE5
12. CHLOr1trJATION: ly)1e _.1�-LLL—Mtount of//S
13. CASING: a
Well lblctmoae
U Oridh Viarniffier or WeJph^1. Malefill
Front
Front -
Frerlt
14. GFlOtII
- 0/l- -" (relit / Material , Mo11C/!�
Flom V to ,�� FI. _Uv_��rG�
15. $CIIFrII
I trltih Dinnlelar Slot Slzo Mr lal
in.
...___FI._.._ In. _In.
From - Tn rl._ In. _In.
16, SANUfGfInVFI.I'nCIC
Urplh Size Malallnl
DFIILL1140LUG UEr1II
From To rmn.alton USscdpllan
C- -
If additional space b 1-1-0d"ll u^e hank of
_ LOC/111-ON_SKE 1 CFI
(Show direction rind dlnlnncn from at Inno two Stela
Floads, or �otherr nuip reference PoloU)
� nC.
rrom — 1 r, ----- rt. —
From _ _-_-- lo-_----_ T-L
17.
I DO I It"I lI n� F1"7d I Ir ls' IN1A�I 1111E WEL 'WAS Cot IS r MIC T EO It ACCOnomcF. WITI 115A N7. CAC ,), WELL
Cous l 111 Jr. I III r,TA h1 _Q3' AND TH T A COPY Or line mconD HAS BEE r IDED TO IIIF NIELL OwIlrn. D�
FOIL llr rll r li �f1NL{y1 -pP ,±Stclr A IJf1E0 Er1SOtICOn. inUCTIIlO jur We.I L GATE
Oued Nc�j3'.. >
a Subme odpbla, to 0103101110 Water Outlay. Orouedwaler Section within 30 rinYs Ow l nEV. ,7/aa
Sndat fl^ _: i

�'?ffil'Ji337""±�t`?---v-T:`._-_-•-
.. Of py,r..l..ti rl,q Mrw1M+Yt.. •. -9 yn n:. a ..
229481
f Io,lh Cnrrr,n . rhl-mtm •,d nl r"rn4r nun^nt find flnturnl fle-1,vrcn1 • Illv1?Ion of Water Ouatity • Dlou+dwN1 er Sectl•a,
16Ja l.lnd ,'1..n•ir� Cnntnr Ilnlrlolt, l l.(:. 21699-163edrhona (919) 7�3�9221; '
WELL GUI IS] I it K; 11014 nEconu Wr.LLCONInnCIOff!�-
WELL CUNinACTOnCEn11FICA11tI rr:__oiJQ
St AIEWELLCONS1nUCT10flt'FNfAllo:
1. YlELI Irgr lrh�rl: rl,•n ,l�h fin.): rl9sldcnllnll]� Mllnlcipnl D Induslilal❑ AgHcullm-11I) Monllndno (__)
Ilern,n y _I 11••,11 rump Writer In)ectioil U , other Lj If Other, List Use: ---
2. WELI. I(ICATKMI I^I skr IcI, oflbee location below)
Neale•-1 Inr.n:.. _- . /—/ '�-County: "1�-----_
(nep I ll:vi�n n,g1l fin d�n�!, Ilnnp,UnlY.
3. 0WN7 rl
Addle:^
iofNoj DRILLINGS L LG
.From To r o, ma lion Ur, ry 1pll on
--
4. DATE hllllllI'll �d
S. Iorrt1. L rr II I
6. CUillll(:^ r 11lLr'GIEII Yr-S _) Nog
7. bOE VdrLC NGrI ACF rXI5I1NC7 WELL? YES 0 N0 j!f
6. STA11G WAI EN LEVEL Mow TOP of Cnsing: a FT•
(use •#' 11 Above Top or Clulnvl.
9, lOP Or CASnJ(: IE:___L rr. Above Land Surface' i
'Top of ur+ng brml,mhd enrr below land surtaee tequlree a vedente In actor.
dent► wllh l.'• 1,11C A 2 nl e ,
10. YIELII (arn+)t _ ME!II IOU Or TEST
11. WA1ER ZONES (rlcpllQ:-._
Jo?�I��j7
! Amount i •., 11 eddlllonfil npara b needed usa bark of lolm
i12. CIILOI11t1A7101J: Typo i 1 � _ __ ..
. 13. CASING: j
i LUQAIIONSI<F.1CN_
Wen 1111cVneef
Urplh I ppplameI or Welahtyl, nlednf (Show d(r!clbn mid dlalnnrn from At Infitl two Stale
rlom-_✓___-1 r -e�31 rl. Floods, or other "top referat" polnls)
Front ----
now. ..-- lr-- —j Ft• �UIV�EJC /��dL .
14. G110111:
1+, plh ,r M_alod�al� Method g n A
—
15. SCNr-FrL i
I,nl,u, ' Dinnleler Slot Slze Mnlednl
viva' 'I n _ rl
Flom _ _.. I o
From ._.. to
r '
10. SAND/GRAVEL l'ACK:
bCI UI Size Mnlellnl
rronl
i -
front
17. F1E61A1l1Cs -
100 nrllrn� l: `'Itl`'�r t')Ijn ?ll�ilyl l'Lt"-WAB COfISTNUC1Eo IIIACCOnDAfICE WII1116A IICAO 2C, WFLL
IItIlr 1�5�1 Mtf)AfiB3(•AfTD TII%1T/1 CdPY OF 11119 nE00nDNAB BEEN PnOV10ED1Cr TIIE WELL OWNEn.
CDNSa
F UI11,111Cr U^iT f111LY P OAIE
{ SInNAT UIIE OF BNSOII COt19inVCT"In E Wrt 1.
Dued Nc LI '-r
_. Svbmk odpineNo bbtslon of uer Duasty, Dlota,dwaur 3ncnon within 30 doys ow.l nr.v. 12,71
Cndaltl

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) 7W3221 --' WELL CONSTRUCTION CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION 0: y�fj�
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Boa): Residential0.— unlclpal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other [j If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
NearestTown: MQCt3ti,\\ County. M24tsor
(Road Name and Numoers, Carn mmily, or Subdivision and Lai No.)
DRILLING LOG
3.
—
OWNER A,, Allis
From To
Address �—
•` •�-`�
l reet or Howe o.
Clly or Town Slate Zip Code
4.
DATE DRILLED 0-OG'cn
7S 2C)$
5.
TOTAL DEPTH 2n5
6.
a,,ee---,55
CUTTINGS COLLECTED YES NOQ
7,
DOES WELL REPLACE EXISTIN WELL? YES N054�
8.
STATIC WATER LEVEL Below Top of Casing: —60 FT.
(Use'i II Above Top of Cooing)
9.
TOP OF CASING IS FT. Above Land Surface'
-Top of casing terminated site, below land surface requires a variance in accor-
dance with 15A NCAC 2C.0118
10. YIELD (gpm): _ 5 _ METHOD OF TEST
11.
WATER ZONES (depth):
DEPTH
Fonnalion Descrlpdan
D (/e/L /3e/dQ7
12. CHLORINATION: Type Amount .7 If additional space Is needed use back of form
13. CASING:
..�L // Depth DI yr
Frorfl_-� / To 79 Ft. x--
From To Fl.
From To Ft.
14. GROUT:
Wail Thickness LOCATION SKETCH
or WeiOhtr`L Material (Show direction and distance from at least two Slate
C_ Roads, or other map reference points)
Depth Material Method
From 6 ToaP
Ft. c`CC/ZC
From To Fl.
15. SCREEN:
Depth -Diameter
From _ To _ Ft _ In.
From _ To _ Ft. In.
From _ To _ Ft. In.
16. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To Ft.
17. REMARKS:
Slot Size \datedai
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 OFTHIS RECORD HAP BEEN PROVIDED TO THE WELL OWNER.
OF PERSON CONSTRUCTING T—MgWELL DATE
of Water Quality, Groundwater Section within 30 days
O
O
rrI
r*i
n
IV
O
GW-I REV. 12199

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section- r • '� (� 1 J
1636 Mail Service Center --Raleigh, N.C. 27699-1636-Phone (919) 7W3221 `-- / r_ �"
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION It:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential R"unicipei ❑ Industrial EJ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other E] If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: MQraklu County. /ACkJ;'k-r,
(Road Name and Numae s, Canvmrndy, or Subdivision and Lai No.)
DRILLING LCG DEPTH
3.
OWNER %0_a�gef
From TO, Formation Description
Address
/3Pidaz"
ISIreet or Routs o.
City or Town State 21p Cade
4.
DATE DRILLED /-2-06-00
5.
TOTAL DEPTH 205
6.
CUTTINGS COLLECTED YES NOD
7.
DOES WELL REPLACE EXISTIN WELL? YESEJ N057L
8.
STATIC WATER LEVEL Below Top of Casing: -60 , FT.
(Use 'a' 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 actor-
dance
10.
with 15A NCAC 2C.0118 _
YIELD (gpm): /O METHOD OF TEST ti
11.
WATER ZONES (depth):
12.
CHLORINATION: Type :�_Vw S Amount 7
If additional space Is needed use back of form
13. CASING:
�LL // Depth Of I r
From �1.—To 6y Ft.of
To Ft.
From To Ft.
14. GROUT
Walt Thickness LOCATION SKETCH
or Weight/R. Material (Show direction and distance from at least two Slate
' G Roads, or other map reference points)
Depth Malarial Method
od
From b To Ft.
From To Fl.
15. SCREEN:
Depth -Diameter
From _ To Ft _ In.
From — To Ft. _ In.
From —To FI. 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 qF THIS RECORD, jAS BEEN PROVIDED TO THE WELL I
FOR OFFICE USE ONLY "
Quad No: SIGNATURE OF PERSO N�EWELL
Pb4it oidpinal to Division of Water Quality, Groundwater Section Within 30 days
Serial No. <.:..
i-
O
O
O
m
C)
N
Co
a
3
Co
W
Ca
0
s
GW-1 REV. 12199

North Carolina - Department of Environment and Natural Resources - Division of Water Ouanty, - Groundwater Section_ t_ 2 2 9 14
163e Mail Service Center -Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFiCAT10N p:
STATE WELL CONSTRUCTION PERMIT#:
WELL USE (Check Applicable Box): Residential 0---Munfcipai ❑
Industrial ❑ Agricultural ❑ Monitoring ❑
1.
Recovery ❑ Heat Pump Water Infection ❑ Other ❑ if
Other, List Use:
2.
WELL LOCATION: (Show sketch of the location below)
Nearest Town: Ifcf - AIQC(
r -
(Road Name and Numbers. Can,nunlly, or Subdivision and Lai No.)
DRILLING LOG DErTI H
3.
OWNER ('Aar/CS %4%
From TO Famullon Description
70 O i�r�
/3eiJak.�
Address
L51reet or a o.
City or Town State Zip Cade
4.
DATEDRILLED /�?"oS_
-70 0 ,�G+
5.
TOTAL DEPTH 3 e
YES NOQ
6.
7.
CUTTINGS COLLECTED
DOES WELL REPLACE EXISTING WELL? YES ❑ NOGa
8.
STATIC WATER LEVEL Below Top of Casing: C-)u FT.
(Use's' it Above Top of Casing)
-
9.
TOP OF CASING IS FT. Above Land Surface'
'Tap of casing lerminstad atlor below land surface requires a variance In accor-
dance with 1SA NCAC 2C.0118
10.
YIELD (gpm): � METHOD OF TEST 4
11.
WATER ZONES (depth):
12.
CHLORINATION: Type /Zf Amount g
If additional space is needed use back of toms
13.
CASING:
LOCATION SKETCH
Walt ThItkeightwss
Diameter or WelghtA"L Material
(Show direction and distance from at least two Stale
It/ 7 ` Ft.
Roads, or other map reference points)
From To
From To Ft.
'
From To FL
14.
GROUT:
Depth Material L Method
b r.,,T QUiZC
'o
From To Ft.
From To Ft.
m
oR�
15.
SCREEN:
n
�_
Depth -Diameter Slot Slze Nlalerial -
W
o�
t
From —To—Ft— in. _ In.
ZC
�o
rn \
From — To _ Fl. In. in.
ZC
r—t
From —To _ Ft. In. In.
m
m
16.
SAND/GRAVEL PACK:
c.a
Depth Size Material
m
o
From To Ft.
z
From To Ft. —
17.
REMARKS:
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH iSA NCAC 2C. WELL
CONSTRUCTION STANDARDS, AND THAT ACOP�Y/QF THIS RECOR HAS BEEN PROVIDED TO THE WELL OWNER.
/1'.... _ i 7-
-
SIGNATURE OF PERSON CC
nitbdginal to Division of Water Quality,
)ar
)lp
rr
o '
THE WELL
Icuan within 30 days
DATE
GW.1 REV. IMS

North Carolina - Department of Environment and. Natural Resources - Division of Water Quality - Groundwater Section. T 2 " 13
1636 Mail Service Center --Raleigh, N.C. 27699 1636-Phone (919) 7W-3221 --- �-
WELLCONSTRUCTIONRECORD WELLCONTRACTOR:
WELL CONTRACTOR CERTIFiCATiON A: oZy�f-
STATE WELL CONSTRUCTION PERMfT#:
1. WELL USE (Check Applicabfa sox): Residentlal59 --Mun(c:pal ❑
Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water In)ectlon Other M If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: /iCf S fr'n County. MOOTS,=n
(Road Name anq NN�umm bers, Corrumity, or Subdivision and Lai No.)
DRILLING LOG DEPTH
3. OWNER 1.uYd 6VAet'
From To Fomnatlon Description
Address
-G 67 D Vie
ffe'44
(51reet or Rauto o.
287v_3
City or Town State Zip Code
4. DATE DRILLED
5. TOTAL DEPTH 5
6. CUTTINGS COLLECTED YES NOQ
7. DOES WELL REPLACE EXISTIN WELL? YES 0 NO JJ
8. STATIC WATER LEVEL Below Top of Casing: 66 FT.
(Use's It Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface -
'Tap of casing terminated after below land surface requires a variance In sccor-.
... .. -
dance with 1SA NCAC 2C.0119
10. YIELD (gpm): 5 - METHOD OF TEST
11. WATER ZONES (depth):
12. CHLORINATION: Type Amount 5
It additional space is needed use back of form
13. CASING:
LOCATION SKETCH
Wall Thickness
Depth I e)er or WeighVFL Material
67
(Show direction and distance from at least two Stale
From _7_/ To Ft. —!M - 9��S,<'�
Roads, or other map reference points)
From To FL
-
From To Ff.
14. GROUT:
Depth Material L Method /
li �Ff. l'v�"Wi.zta d4Rt' (
OO
o
�>
From To
From To Ft.
n
cr
15. SCREEN:
IV
ems_'
Depth -Diameter Siol Slze - "Material
co
'="n
vo
From -To-Ft- In. in.
y
rn �
From — To _ Ft. In. In.
-�
M
From Ft. In. In.
Ili
�55
—To
16. SAND/GRAVEL PACK:
W
'y
Depth Size Material
i
From To Ft.
From To Ft. —
17. REMARKS:
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH iSA NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS REGO
HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Quad No: SIGNATURE CF PERSGI
CONSTRUCTING THE WELL DATE
ulloAnAalnr;I.lo Divisional Wafer Quality, Groundwater Secllon within 30 days
Serial No.
GW-1 REV. 12M9

North Carolina - Departmont of Environment and Natural Resources - Division of Water 04atity • Groundwater Section 2 4- 2 p 2 `)
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: AppgI arhi nn T 1 n,-; ,
WELL CONTRACTOR CERTIFICATION R:
�STATE WELL CONSTRUCTION PERMITJI:
1, WELL USE (check Applicable Boat: Residential IF( 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: Barnard cViI I P _County: Marl' nnp
(Road Narne .it Numbers, Convnunity, or SubdIAMon and Lm No.I DRILLING LOG
3, OWNER Kevin Vinez From To
Address �����
!ta Of VU a rvv.r
City or Town Slate Zip Code —
4. DATE DRILLED 12-1-00
5. TOTAL DEPTH 4 n 7 -
6. CUTTINGS COLLECTED YESQ NO(&
7. DOES WELL REPLACE EXISTING WELL? YES[] NOd
8. STATIC WATER LEVEL Below Top of Casing: 40 FT.
(Use's' II Above Top of Casing(
9. TOP OF CASING IS 1 FT. Above Land Surface'
-Top of casing terminated atior below lend surface (squires a variance In accor-
dance with leA NCAC 2C.011e
10. YIELD(gpm): 50 __METHOOOFTEST ('AT f nnt-ainpr -
11. WATER ZONES (depth): 1 A 7
12. CHLORINATION: Type Taj e - Amount— 9
13. CASING:
Wall Thickness
Depth Olamater m Welght/Ft. Material
From 0 To 80 Ft. --
From To Ft.
From To FL -
14. GROUT:
Depth
From To —
From __ To _
IS.SCREEN:
Material Method
Fi. _ rnnrrat-a pn=
FI. ---
Depth
Diameter
From
_ To _
Ft _ In.
From
_ To —
Ft., in.
From
_ To _
Ft. — In.
16. SAND/GRAVEL
PACK:
Depth
Size
From
To
F!.
From
To
Ft..�
17
Slot Size Material
In.
In.
in.
Material
DE—rEPTH —
Fonitallon Oescrripdon
C3
L_
t-rT
�F`k
CD
�o
�m
C
0
It additional space is needed use [tack of form
LOCATION SKETCH
(Show direction and distance from at Ijast two State
Roads, or other map reference points)
19-23
Barnardsville Hwy
Holcombe Br.
Seven Glens
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 1SA NCAC 2C. WOLL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD BEEN PROVIDED TO THE WELL OWNER.
12-11-00
FOR OFFICE USE ONLY DATE
SION RE OF PERSON C09STRUCTING THE WELL
i' SuLm I orighai to Division of Water pusilly, Omundwsrer, Section within 30 days DW 1 REV 12lS9

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section t. r} 373
1636 Mail Service Center - Raleigh, N.C. 27699.1636•Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: l b�r�w��
WELL CONTRACTOR CERTIFICATION #: Q
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (check Applicable Box): Residential � Municipal ❑ Industrial El
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: Show skgtch of the location below) y�
Nearest Town: /lil,LokAlu _ __ County: �' ✓` ���
(Road Nana an N ars. Commune or Subdvlsion and Lot No.)
3. OWNER
Address
IOU or e�t, eer (2 - = 3
G y or Town Sty Zip Code
4. DATE DRILLED 2
5. TOTAL DEPTH UQ
6. CUTTINGS COLLECTED YES ❑ NO
7. DOES WELL REPLACE EXISTING WELL? Y S 0 NOR
8. 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 stror below land surface requires a variance In accor-
dance with 15A NCAC 2C� .q1�1e
10. YIELD (gpm): =4z— METHOD OF TEST
11. WATER ZONES (depth):
12. CHLORINATION: Type Amount I ZC
13. CASING: 0
Wall Thickness
Depth r Diameter or Weight/Ft. atonal
FromTo J VZ Ft.!^ N Sift �.7.�
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From To �Q Ft. C13 t
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From —To—Ft— In. —in
From _ To — Ft. _ In. — In.
From —To —Ft. _ In. _ in.
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
17. REMARKS:
Agricultural ❑ Monitoring ❑
DRILLING LOG
From '2T,o�4
�� / //�
DEPTH
Formation Description
It additional space is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
CD
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION. STANDARDS, AND THAT A Y�OF THIS R ORD H BE-E�NJPR�VIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY a r�� +� �`�
Quad No: SIGNATWi E GF PERSON CONSTRUCTING THE WELL DATE
Subalitgr)ginal to Division of Water Quality, Groundwater Section within 30 days
Serial No. f - E E,..,r GW-1 REV. 12199

North Carolina - Department of Environment and. Natural Resources - Division of Water Quality- Groundwater Section- !_2 8 5 7
- 1636 Mail Service Center -Raleigh, N.C. 27699-1636-Phone (919) 7wm=l J/ ----
WELL CONSTRUCTION RECORD WELL CONTRACTOR: &,,e_ tr s/ ��
WELL CONTRACTOR CERTIFICATION p: y3�
STATE WELL CONSTRUCTION PERMrr#:
1. WELL USE (Check Applicable Boxy Residential VL—htun(c!pal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection 0 Other 0 If Other, Ust Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: Mo�cS tiAI County. AQ IIN' —%
(Road Name and Numbers, Community, or Subdivision and Lot No.) ORILUNG LOG DEPTH
3. OWNER ,� har l.r.< &iWac m
r From To Formation Description
Address—`T 2/
tZilreet or Houte o.
City or Town Stale Zip Code
4. DATE DRILLED I1'or—O°
5. TOTAL DEPTH ��
6. CUTTINGS COLLECTED YES NOQ
7. DOES WELL REPLACE EXISTIN WELL? YES 0 N05a
B. STATIC WATER LEVEL Below Top of Casing: � FT.
�
(Use'i (I Above Top of Casing)
9. TOP OF CASING IS Fr. Above Land Surface*
-Top of easing terminated st/or below land surface requires a variance In accor-
dance with 15A NCAC 2C,e118
10. YIELD (gpm): 20 - METHOD OF TEST
11. WATER ZONES (depth):
12. CHLORINATION: Type / r1 L_f Amount q If additional space is needed use back of form
13. CASING:
.,�L // Depth tiler
From_ /� TO Q( Ft.
From To Ft.
From To Ft.
14. GROUT
Wall Thickness LOCATION SKETCH
or We(ghuFI. Material (Show direction and distance it= at least two Stale
,�G S i'G Roads, or other map reference points)
.r,
From v
Depth
To oz�
FI.
Material
Method
From
To
Ft.
15. SCREEN:
Depth -Diameter
Sidi 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 IS RECORD HAS-BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Wad No: SIGNATURE OF PERSON CO STRUCTING THE WELL DATE
-Soterit original to Division of Water Oualily, Groundwater Section within 30 days
9
Co
�10
Serial Ne!..y I e Q i GW-I REV. 12/99
0
s_
o "
cr"
rn n
ran �
c-r
O
z

1
North Carolina - Department of Environment and Natural Resources • Division of Water Quality - Groundwater Section , ,v � 2 3
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELLCONTRACTOR:R.CALDWELL DRILLING, INC.
WELL CONTRACTOR CERTIFICATION #2140
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential B Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ It Other, List Use:
2. WELL LOCAT/�p��N1 (Sho%'/�tk" h of the location below)
Nearest Town:/l //t y^S /'C-I County: �SL�'^
Road Na d tubers, C ',, j y, or Subdivision and Lot No.
="`�"'� )
DRILLING LOG
DEPTH
'on
3. OWNER
Address
S
From To
0'"Z'3 OU7
j Form Description
1�114V5
ireeior e o.
c�C 5
City or Town State Zip Code
4. DATE DRILLED 1 Z / L00U
5. TOTAL DEPTH gad
6. CUTTINGS COLLECTED YES ❑ NO[�
7. DOES WELL REPLACE EXISTING WELL? YES_Q„ o
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 .g1 to
10. YIELD (gpm): G- METHOD OF TEST
11. WATER ZONES (depth): Z- -9;� 1
12. CHLORINATION: Type Amour
13. CASING:
Wall Thickness
, ( Depth � D'am ter or t. Material
From. To � F
From To Ft.—
From To Ft.
14. GROUT:
Depth Material Method
From To 2/ Ft.
From To Ft.
15. SCREEN:
From
From
From
Depth Diameter Slot Size Material
-To—Ft— in. —in.-
-To—Ft.— In. —in.-
-To—Ft.— in. In.
16. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To Ft.
17. REMARKS:
-
I DO HEREBY
CONSTRUCTI
FOR OFFICE L
Quad No:
Serial No. _
Y _
—'-- Submit
Material
If additional space is need_
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
23
ISTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
tATURE OF PERSON CONSTRUCTING THE WELL DATE
Division of Water Ouality. Groundwater Section Within 30 days
GW1 REV. 12199

.l M 1:•::»r.» A _. �_1LL. fJYs !,f :>I3L1S"R
.If ! i w M X. rr ,e ,;
229435
'irth h-pnatwo rl rnvin•vne it end Nelurol Neenurces • bivblon of Water Quality • Otoundweler Seetlon
38 Mail ar,vico Crntrr • Ilnlelph, N.C. 21699-1638-Pbons 1919) 733-3221 —c-
WELL CONS11MG1101111ECOflV WFLLCON7nAC1OII: Jb-,.—FELt5",PtC
WELL Co117nACton CEn71rICA11011 0:,� p�Z.
SIATEWELL CON9MUCTIOIIPFIIMIIM:
1. WELL (ISI: Icbeck At rur.bre a„vlt nrsldonllalR Munlclp it u lodushlnl d A(7rlcullurnl LJ MOnllOrh,q 0
nocovrty 1 _J I loal I'ungt Water h,locllon ❑ Other ❑ 11 Other, List Use:
2.
WELL LOCH I'll, c' O,v sketch I he to Ilon below) /�'^y/^/% '
Nenrest Iown:_ County: / a
jno ii,„e iuliiu��•imis.i7m mi ty,orrub vl lonand-LotItol UnILLINGLOG
__, UEF'J11_._
3.
Owfir11 From To
reimatlen Oeecdpnen
Addre^t
I;F@.
"or ..��n �
�z
171.1f _._
4.
a,tk r / . Bt le zip Cori*
VAT EhIULLEN__-1��5.�P•Qa
o
-%ZX
S.
TOM
YL:so NOLvJ
C'r
S.
Cllllllll:^C0111-CiED
WELL? YES NO ►�
--
7.
GOES WFI i_ IWTI ACE EXIS ZING
.� zr
0.
S1AFICWA'IEnLIEVELDelor7lopolCeslnq:a M'
$^_
(uee 1410 Above top AT Cesh"91 _
FT. Abovo Land SmInco'
m\
,Top of Colt,,",•mdnnl�d rim, below lend eurlec* requires a variant* In Kea•
7nre*with 15A tWAC x5q al Q r
10. YIELD (PICA): L_ ME11100 OF TEST _& —
�A
—"-----"�
N
11.WATEn7_C71JES(llrplh):�_
.r
__ x
Ji� II eddlllonnl apnre is nrrdrd u+n bock of form
12.
C11L011INA11UIJ: typo _F_L._Lu-----•Antounl
13. CASING:
Orpll, terneler
From
Flom--
Flom. _--.--1°---- 11.
14 G110U1'
LQCA1IQN_SKF 1 CIO —
won ihtcVnelf
or Wetgl•Vl t. M*ledrl (9trow directionand dlalnr,ce from om At Innal two Stale
ZL1eJ1S I.t"DiR floods, or 011,e1 "lop lelelenee poled)
hrpllt MnlprMlnlhout�d
From
From
15. SCnEI 11:
Urpth biamotor Slot Slzb Mnlmla)
From _ ___ Io
From
—
10. SANLVCMAVIT PACK:
Orp1l, Site
From lnFL
From
17. nEMAIMS:
1 DO I,Ftlrnv Crnl,ry 711AET►Jl9 WEL 0
CONS 1I111C11011 F t AFfUA11169, AND Tt1AT'AC
IOII OFIICE USE ONLY, -I;. - '-"^
wed ftn:
SuM�I or
Serial Ile _—_—_—..+-+• tr ,
Material
tnLICtEU aI ACCOIIDANCE W1111 ISA IICAC 2C. VIFLL
9 T1Its 11EC011a NAs BEEN PIIOvicro -to 111E W Ell �/n /n
NATImE OF rFOS 11 COt191nUC I1110111� WF.lL
GATE
to Division el Wolof overtly, Oreundwner Salon will 111130 doye Ow-1 aEV. I2191

?�T:>111T.�J � � � fR�.TI�L"IJ'�.J...:rfiin'9E�7:n•.
-
` + ..
' 229434
"oilh Cmhb,n I,•pnrtIt, 0 rf rnvlrr-un!nl and Nelnr nl fie lourcef • Divlelnn of Wolof Qually, • Omundo,m!r Sactlon
38 Mad Setvlco Cemrr • Ilafelph, N.C. 21699-1638-Phons [phone] —ems
WELL COWS111UC1IOId IIECOIIU WELLcoNtnncTOn: Jbfi--��rBgUSanL
WELL C0111NACTOr1 murimilutJ 0:,, J�-
SrA7E WELLCONSIMUCTIO11 PRI 110:
1. WELL tl$Ii ((:heek nr'pilraldenn.):llealdnnllnljl(1 MUIIICIPAl1_.l Indmhlald
llecovrry [ _j I lent I'unq, Water Inlecllon [j outer j] 11 Olher, List Use:
AprlcullurAl U MonitoTb,q U
2. WELL LOCA I IUI l how skelclJ ql Wa Iocelion below) a� n m�
A w C/ 11 _ County: „ ` ?
Nemafl Town:_., a.w
0
jnoe liia„m midi „imn, c01rmm11lly, o ibOvhlon a d Lot llo.l UIIILLING LUO ___UEf'J11_�_ o
rrom in fo.mellon Defc tpl bn
3. OVVNrII __ t m �m
Address 1 �
UUU �l
y r. i r,n, TMIe Ilp C 9 T'
A. DAIE011111.r11-j
S. TOTAI iIf: rnl Cj Nv[17J = NZ
G. COTT"A"SCUOYCIED YI.-S ,_,../ n —
LJY `_---------T
7. DOES Wrl 1_ Ilrl'LhCF E)(15IING WEl-L7 YES IJO akJ o _
a, SIATICWAIUnLEVEL DeIot•rlop ofCasing: 'FTv
(Ufa'.' 9 Above top nl Cefln9l
9.
(.:, —_ �__ . rT. Above Lnnd Smince'
TOP C r CA$IIIG
-Top of eefh,p tFlndnnlmd el"', betow land audace raquIles a vino nea In aceat•
lone• Willi 15A III -AC 20.011 —
10. YIELU (nt'+++) _f- MEI I IOU OF TEST _
[j'j j]'Amomd If eddlllonal epnre is nrcdrd van back ollvrm
12. CItLOlU1JAt10tJ: lypo _
13. CASING: LQQAIION SKE.IC11
Wed IhlcVneft
Ur(,Ih nmeler a Webf'W 1. tmedst (BIIOW fill
end dlalnnce ho n n11o1 i171 vd SIR"9� �ja,��s �rs�snR rloeda,orothermaplelete„cep 1
Flom_-
Flom—__._ In------ rt. �A -
Flom
14. GIIOUI: Mnle,lnl nlhod /
rlom ......v --ln .�Q,T1. .�i-T'1>s+'s�`�• -T.11 IL0.
hnm-
15. SCNEI ll:
Ucplh Uiau,olor slot Slzb Mnlnrinl
riot"
1e. SAMLVGIIAVrI.I MM: She
Url.11l
From
From-
17. nEMAIIKV:
i DO l,p r,f nv CrrylerYl�'ll 11�' T��19
CONS i III -MI lot I Sf AtIt7A1109, AN
roil OTf ICE USE ONLY
puad Non
Sarlel tie —�.- e#+
Maledril
1U 'tro IN ACCONDANCE Willi 15A NCAC 2C, WELL
71119 TIECO_9O NMJ BEEN PROVIDFD 70711E WELL OW1J/' `
rsG. al DATE
IMImE Or rEnS f1 C01191nVCI1tK1111F. Wfal
Divisional Wolof 01101,OMW4,61e 9eo9on Wlll lilt 30 days DW.1 IIEV. 12117
I

_.. —t
.I .!i L.:;.:.� � ... _ lla�sCt,a-��s �'Y:� j.'1l:!6^ffi '�T�L *3".:..). C • ,,• :, . �
229432
'IOtlh Cn(pl „a . I o-lmrh„rnl nl fnvlrovnenl and Nolutal Nesources • Divl.lon of Water Ouellly • Omundwllter Secllon
J36 Mail SPtviro Crntrr • Ilnlolgh, N.C. 27699-1636-Phone [phone]
WELL CUNSMUC1ION nECO11D WFLLcoNTnnclolu �o-E_F�R4-3ULSonL7
WELL CDIIInACT011CEnTIrICA7loll 0:�
STATF. WELL cOnstriu oti PFI1MIts:
1. WELL 1. 111t_ (check It r•n,wo o"v): flosldnntlal[i Municipal L-1 InduslrinlEj
rincovrty j ] I Irnt Pmnp Water Injection ❑ other E] It other, List Use:
2. WELL LUCAI IU how sk Ich I to low)
Newest to,wl: court locallon bety:
Agilculluml E) Monilnring LJ
inoa,ni.I... o m, lu,�i,^, s. corlmmdly, or bdlvlslon atd Tonto_) DnILLItJD LOl3
3. owfirrl From To
Addle=s
Cry rr I tn'm , II -ryry $hale ZIP COM
4. DATE11I1n.Lr17__r1•'I��
S. TOTAI. 11r1•III
6. CkJTIIIIGS c(II.LF'(1 VD YI SE-j NOLd 7. DOES WFI t_ IIt-I.1ACE FXISIIIM WELL? YES_ NoLj4,
8. SIATICWATEf1LEVEL Erelowlop olCasing: _& F
(Use'd 9 Above TOP of Cws1119)
9. Top Pr CASIf)(l I;-__ I__.. FT. Above Land Sullnce' _
-Top of cosh,p 1,wdnnlyd Prot helow lend eerleee requfrU a vedenee In it"O"
nice svllh 15A 1n'AC 2C.�t 1�I
18. YIFLO (ui,rn): _1J_. MEII IOD OF TEST —
I t . WATEII ZOIJES (tIr P11Q: _
12. CI I1-Or1114A I TUN:
13. CASING:
I ypn _[LIU—Amounl - ills If eddlllonat ePnce Is tlPertrd It" bark of 'arm =
__-UEPI11_ _--
rolmntion DesrdrGon
Ea -Qc —
Wee Thlcknese
DrPlhr�
PInt.n,elter or1 W09i,ttrl. I�-w,.er�IPI�p
Flom------lo------rl.
Flom .. _._.
_--- l o
14. GIIOUI:
NrP111
Malarial
o1hoJ
From .. _
0._
F1on1 - _.-
_..
I Jrhu1 bi.vnoler
Slot Slze Mnlndnl
From --
- In -- r t -
— In. _ _ in.
From _-_.-
to _.__-__ 1 L _..—
In. __ In.
Front . __..__
Ie - ...__ rL_.—
In• ---- in.
18. SANDlGr1AVF1.
PACK:
Drpu,
Size Material
From
Ta _-_ rI.
From--
_ LOCATION_SKEICH
(Show direction Auld dhllnnce from At least two Stnie
Floods, or olller MAP Weronce Polnb)
�11�5
17. nEMAIIKS:_
1 DO I IFnrnV Crn I lr Y.1:ITAT Tlllr. WFLL WA9 CONSInUCTED 9I ACCOIIDANCF W1tII 1SA NCAC 2C. VIELL
CONS I rIUC I IOf I S I ANVAnDS, AND TIIAT A COPY OF 71119 FlEcon0IIA9 BEEN movioFD 10111E W ELL OWNEn• U-1
F
FFY grOpATi1t1QOrPEDSOII CON9TDUCtIf1O 111F. wFlL OAfE
6ubm11 odglnel to Division of Willer Dustily- Or011ndwUeSecllonWilhln30daysOW.111EV.1N91
drl No -_--'

.7 11- L ...Z � ...: jt3 !CTJ'1.4t S, i T 'Y_W .. SS^
.I ..: � ... .. i !: H � a I .}•t-n�,-Y, `t.1"1'1 ... �r',w :.,( „r,l a.t.0. �. L' } i -
ii 229470
North Corpbnn . I Irp a, it nr I It n1 I -I Mrn-unenl and NWin at tie eourcce • Dlvlelon of Weler ourdlty • Oroundwaler Sacllon
iJe Meil $nrvicn Cnntnr Ilnlelph, N.C. 27699-18J8PIrone (B10) 7Jj•3221 - CC
WELL CUNSIMIG11U11RECOnD wELLCONinnclOn: o�_LlrRgl>Sa
WELL CUNTNACTon CEnvi-ICA71011 R:__L—
SrATEWELLCONSTnucTlollPrimto!
1. WELL USG (cheok nly,llr.btn n.•*): NesldnnlialLYJ MUnICIPnI (] Industrinl ❑
Flecovrily I Iral 1'unip Water Injection ❑ OIIIer [j If Other, LlstUse:
Agdculluml JJ Monitoring
2. WELL LU(-,AI IUI1: ° low ske h of the location below)
��nASd�
Newest irnvn:_ -County:
1 i4r1.•i., S. Cmmomlty, or SubdlWslon e d LoUfo.j DnILLINo 1.00
3. OWNrn �,�b4 Q % pGL� From To
UEF'_i l
ro mason bacdpnan
Addresr•_61
LZ o
_
- edtlx ►�
-- Zlp Cad.
01, 1 r,a I S111ir
4. DAIEVIULLfn_j/' 3'�D
5. TOTAL 1,r1' 111 _ _
0. CLIT11I R171 VLI,f C I EN YhS �j NU�
7. DOES Wr1J- I1FrIACE FXISfilM WELL? YES[:]
8, SIATICWA'1Er1LEVELEIeIoIyToPofCesing:
(Use b' 0 Above Top 171 C+91np)
9. TOP (+r CABIN( L:,-___I__.. FT. Abovo Lnnd Smincn'
-top of I,neing I.mdnIII yd ri4n below lend turlaee requires it varlanee In Actor-
dancewith IrA In'AC 2c-eI le
to. YIELU (ol+nI): __ . _- MEII IOU OF TEST
11. WATEn 7-OIIES (tiniAI9:
12. CIILOIIINA11014: typoAmounitt--�-
13. CASING:
W84 lhtchnesl
Dr1+lit I,rneler
rt.
orWlltglV I IA,,,,�llrlaA�
�14J VYGSK
rlom_�
----le -�
From---
la------ rl.
F,rm .-_.
--- lo.-- r1.
14, GHOUL
Itr1�Il,
Malo,lal
olhod
Flom -...
Flom
Is. SCIIUTA1:
(!rptll biamolor
Slat Slze MnInrlAl
riom
It,- --- 1 I -
— In.
___ In.
------.
• From --
— I o ___--
In.
r, o,n . - -.
- _ to . . __ r l.._—
In•
18. SANLIAMAVr1. PACK:
Material
UrPll1
Size
from ---
In
From _._.�
Io rl.
17. nEMA11K e _ ..._ r{'• II '
l oo I Ir nr n v ci rl 1 IYv it in71 T1 dh V(IELL7WA`r Co
CONS I IIUr I IOrI S YANMAIMS. ANO111AT A
roll OrrlCE lt$Ei OtILY 6.:-
Quad iln. -.� . Subrtil(.odgln�
Serial tin -.
II 1 dd111onn1 epnce la nrerled u•,n bank of
LOCA114100SKEWL
(Shiow direcllon And d1alnno9 from fit meat two Stale o
needs, of 011,91 map WeieltcceAPohdf) a ��
o o$n
� �m
�o
m
co y
o
z
ntIc IED Ill ACCO11DANCE Will' 15A NCAC 2C, WELL
Tills negpnt) IIA9 BEEN PnOVIDFO TO 111E WELL OWNER
DAZE
IA11111EnrrrnS tICO1Js1nUCTIt101IIFWEIt-
DlVbtone, weleroualy, DrowdwaUr Srcnon WOhin 30 days oWI IIEV. 12199
0
0

]ltL �_.�Ji3 teEL =
I: ! , .... 1,,.C1::" '! .I •!`'1. 19M.19
.« ::,1. ,.Y r . ,. L' •. Y !'
2-29456
'vih Cnrt,tnn . 1+^pm it ww rl rmlrovnenl and Neturnl fie nourdet • 0M.00111of Waist Quaety, • Oroundweler SAC11011
,39 Mail brrvicn Critter - Itnlelph, N.C. 27999.1939-r1+one [phone]
WELL CUWS111UC11UN NEC0111) WFLLCONtnnCloth
WELL CoutnACTonCEntirICA110110:�
SFATF WELL CON9inuCTlou mimllll:
1. WEU. Uclt (Check nlpMehten.,l: NnsldanllnlUU Muulclpnl [j Induslrinl❑ Alldcullural[J Monllodn9 L[
recovery [ _J I Icnl rump Water Injection [j olhet E] It Other, Llsl Use:
2. WELL I.00AIIUt1: Sh W sketch t 19•Ioc IonbeloW)
Newest Town:_.. - County:
jnona lin...m ml ii}}%''``````_wie. Cori, filly. or Subttl1G)slon and ioll No- Is URILLI499 LPO
3. 0WNrt1
Address
zipp C.
4. OAlErIi11l,r- l-i66
s. 7QTA1 t+r:rnl ... moo Ll L�
O. C(IT1111(7, CVL11'CI EU Yle.> NO
7. DOES WI'I L ItFrI.A(:E FXISIIfill WELL? YES
8. SIATI(;WAlEr1LI:VELOel0,+lcpolCesln9: p FTr
(Ute'4.9 Above Ter of Ca16"9)
r f FT. Above Land Sullnce'
9. TOP OF CA.,INR I:^,---. -- . —
•or er cetl,�n +•��ninnl^d ri4•t below land sudaee requbU a vu'anN In eea•
weewith fan 111'2C .9tla
10. YIELU (nl""): _L . _. MEII IOU OF TEST
11. WATEn 7.OtJE9 Idrrlh):
II addlifonnl ernce 11 nrorled Plot of
typo._.f
Amould�•-�
12.CIILOttIIJAIIOtJ:
r
13. CASING:
Wee ihkkneel
Urpi11 Inmeter a�w�1S I'1•ry,r,, �nR
rev
Flom—-lo„r2�F1.
Fwm--�_
14. GI10111:
itrinh
Mnlerlal .Vol to
F,om-._.U._lr..alV._1'I.
(IOhnQs1�
1S. SCIIE I'1I:
Ilrpn, bi.raolor
Slot Slzb M nlmlol
From ------- Io_._.__I�!--
In.�--
In. —
From __.—'In_._.-1'1._.—
In. _In.
In —
—
18. SANL /GRAVIT rACK:
Url.l1, Size
From
From.__.— l('
17. FlEMAIIKS: . .
r TIIn9 WECL WA9
39. ANO MAT A C
JR .
1 OO I IFl,rny I
CONS I IWr,.il(
r011 OFrICG U
wad flit:
Molollnl
_.UErIN--_--
roM'etlon OOc,lpeon
a
O
LUG AI IONS KF ICIL
(91aw dlreclbn and dlnlm+ce hoar ni Io1/1 two Stale
floods, of othol mop Ielelence polnb)
7*,° g,t , -.0
COf19tnLICtED IN ACCOIIOANCE N/IIf115A fICAC 2C. WELI
i11,19 WLL O,'En'
IRy0a "FCOnONA9 BEEN nov0 E
-- OAIE
Pr,nS f1C011slnuCl1f10111FWF.t1.
Watef wa91y, OretaIII etH Sacnon within 30 drys OW-1 nEv. iLll
swill (lit

°I 11 ' _: ..- —� Ir�{'.IeE�r'°��_.w•-:1��"�".."�_'_'"Tr �`�iSS `y - - -- -- -- --
I �. '. � �. I � � {,., f�'r' , 1! R�• u.'ir'1{:' � ♦ere Yr .:.,, ," .., .. ..
�l I 229441
NOrtb V IWh Mn,!nl and NOIt"nI Ne v,,rCr7 • L7Ivlslon of Water OHlllly • (310un I%vAI t Src11
16Ja IAntl F^.�•Ir^ c^n,rr Itnlr•InF, I1.C. 276?9�1698�f'Ironr i91e) 73,1�322( .
WELL cuir im.mori nECOfiU WeLLcorNnnClDn: I P,0A,—
WELLCUN1nACToncEnlirlCAl1( 1 0:_y,
Sr AtEWELL CUNSrnumofl"FlIrAlfe: _-----.-------_-_-:-
1. YJELI Ilcr' rrn"r Y. r11•w ,m" n^.): Ilesldenlinl lYJ Mrn lcipnl [� h,duclrinl ❑ Agrlcvtlurnt � J Monitnrinp �.�
Ilecrvr,y I b•nl f umP Wilber Injection 1_1 Ulher (J If Othet, List Use: ---
2. WEU.I(tcnllUtr�:y(�hn^t�^sk�l (Ihe location brlow)
county:
— -- - — ,_DnILLI1J(3L(a
(n0•" r lrau•.^ m Ill ri r^r-.. Ilnn nn Jly, Or Subdlvl Dlon and lot No) -
FtOrn TO r o.mapon Urwlpllon
3, OWNI I1 _.
Addre^r. -- T— _ 7
1.•In Olnnlll 0 -- ,�••//jam�
(:ay�� c,ele 21p Code _.-.
4. DA1F hnn I r u II -
s. lornl.Drr nl
6. Curl NIII.,If. ,IT t IFNog _
7. DUES VJFLL In"I,I nr,F r:XhIINC1 WELL? YES
U NO1�1 0 ^
e. SIMIOWAlE11LEVEL Dclowlopofcnsing:�rt. _ Zm
`` (Use •s' ll Above top Of Casb,p) UD fam
9. TOP Ur Cn51N(; IS L1__ rr• Above Land Surlece a. y`
'irp of rJrh,n ,^r nrL mlml nt'rr FnIoW land surface socialise a valiance In accaf•.
Bence with l'41ICt1C 2Cn 1e � , nT
-_ ME'111UU OF TEST
1O. YIELf? 011MY JJJ —
11.Wnlenzoucs(d^puq:_ — —__-- '"--fir----
_j Z
A2, CIILCH1111A11011: lype
Atllounl II addlllonal apnre 19 n^wind vea bock of Iom, .
13. CASING;: : LOLAI ION SICEICFI_
Weu 11dcVnns7 nled0l (Show dll!ctlon Slid dNIfuir l floor Of lnall two Slnl!
Urpll, � 1 rL or Wa- f9hVfly
'7 I a �(� Hoods, or oncOr map lereto"Ce polnl7)
Flom.___....__ lr _. ._.
rrcn,
14. G110111: 11,1011 Matollal jM�ethod � !
rlont _ "---- -L, vev�.fl. -� , Y� 1 0
to _ rl.
,
15. SCDrcrr
nrpH, Uimnoler ' Slol Slze MnImIAI
In. ----
Flom _.._._ _ to In..
Ron,
Ir rl.�Itln. 1n. —
18. SAND113,I1AVUL I'Ar,IC Melellnl
br)dh I Size -
rrom------1n......
rt.
------------
17. REhinI11<st____I -
VIOFO t Cr TIIE VI[LL UWtlrn.
CDO O I I nl lr' 11(,I e•KTAI HYAR03'ANO I Mr A COFYIOFITU119 nEcOno 111 BEE FrLL
11 viti11 r NOI1C 2r;, w L
son sir tic s Usi=.T(� itY I IQO
,'•stnrintunE rrensoucot srnucnrrrl 'fir WIT
OUR(,tlr Submit oASp,al to bivB!On of Welet Ovalay, tlrpVnrlweter $aceon WI1111,13p riny7 oWInEV. 17171
j
1 Srih, rl^
_ e

North Carolina • Department of Environment and Natural Resources •Division of Water Quality -Groundwater Section
24397
1636 Mail Service Center - Raleigh, N.C. 27699.1636-Phone [phone]
WELL CONSTRUCTION RECORD WELLCONTRACTOR: ���'14Q`
WELL CONTRACTOR CERTIFICATION N: b 2 S§s
STATE WELL CONSTRUCTION PERMITN:
1. WELL USE (check Applicable sox): Residential I Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, Ust Use:
2. WELL LOCATION: Show sketch of thelocation below)
Nearest Town: cyr�al c & 91 County: y ► t� 'fin"
(Road Name and Numbors, Community. or Subdivision and Lot No.) DRILLING LOG
3. OWNER From To 3
Address
� l3 -
t 1 1ct v tree or � eC 3 J Os
City or Town State . IIP Code
4, DATE DRILLED (( /01 ka
5. TOTAL DEPTH /OS
6. CUTTINGS COLLECTED YES[:) NO[2]
7. DOES WELL REPLACE EXISTING WELL? YES NO[t
B. STATIC WATER LEVEL Below Top of Casing: FT.
(Use'+' 0 Above Top of Cuing)
9. TOP OF CASING IS 1 FT. Above Land Surface'
'Top of casing terminated ■ttor below land surface requires a variance In sceor-
dance with 15A NCAC 2C.011e
10. YIELD (gpm): SOS METHOD OF TEST iQ.I A-
11. WATER ZONES (depth):
DEPTH
Fomtation Description
E
r n1
=ri
r
eb
12. CHLORINATION: Type P�Ytd. Amount f �- ' It additional space is needed use back of form
Z
13. CASING:
Wall Thickness
LOCATION SKETCH
Depth /� D,�i�T����ter or WeighUFt. ,�,,m�,a�tt-ee�ci„„al0p (Show direction and distance from at least two Stale
From * To &2 Ft. -l.S� ram— SDK' �)Fail.` Roads, or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
/nfin^
From � To s�_ Ft. 1.Jr 'b0`7_n'4'1
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From —To—Ft— In. _ in.
From To _ Ft. _ In. — In.
From —To _ Ft. _ In. —In.
16. SAND/GRAVEL PACK:
Depth Size Material
From To —Ft. —
From To Ft.
17
I
e e f — • �e
r/
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
T-*4R%M0F THIS RECORD HAS BEEN PRQVIDED TO THE WELLIC
FOR OFFIC ONLY C
Quad No: _ SIGNA E OF PERSON CONSTRUCTING THE WELL
t - _ SuWnN giml to Division of Water Quality, Groundwater Section within 30 days
Se(W No.
lse 1
DATE
GW-1 REV. 12M

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section II � �j 3 9 G
1636 Mail Service Center • paleiph, N.C. 27699-1-6-Phone [phone] �/�y�J��,� ../_ '' )� Q e
WELL CONSTRUCTION RECORD WELL CONTRACTOR: 1�wr`•t•�A`J 0'a �L � C_
WELL CONTRACTOR CERTIFICATION #: b 6- 2 585—
STATE WELL CONSTRUCTION PERMIT#: a
1. WELL USE (check Applicable eox): Residential M Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
Agricultural ❑ Monitoring ❑
2. WELL LOCATION:,(,Sbow sketch of the location below)
Nearest Town: ' ' 1 a �'``c"-County: rf�c'�'P "'' -
(Road Namearid N mbem Cormunity, or Subdivision and Lot No.)
3. OWNER
Address To orivi(streeta� t C �d
/laid atPiS�
City or Town Slab Zip Code
4. DATE DRILLED I) 'UO
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑ NOEt
7. DOES WELL REPLACE EXISTING WELL? YES Q NOE]
8. STATIC WATER LEVEL Below Top of Casing: XO FT.
(Use'.' It Above Top of Casing)
DRILLING LOG
From
To
DEPTH
Fonnalion Descdption
QnC
9. TOP OF CASING IS I FT. Above Land Surface*
-Top of casing terminated atlor below land surface requires a variance In accor-
dance with 16A NCAC 2C,.AA11a
10. YIELD (gpm): 1ST METHOD OF TEST Q N
11. WATER ZONES (depth): w -
N o
12. CHLORINATION: Type Q�adU&Liii Amount f d C • It additional space is needed use back of form
13. CASING
Wall Thickness LOCATION SKETCH
1I Depth /_^ Di ter or WeighVFt. atonal (Show direction and distance from at least two State
From _J_To «. ) Ft."�Zc' Roads, or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Material �����^� Mew
From � To Ft. �i"
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From To _ Ft _ in. _ in.
From To — Ft. — In. — In.
From —To —Ft. _ In. —In.
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THATAPOPY)OF THIS RECORD JrA BEEN PROVIDED TO THE WELL,IO
FOR OFF19 WMN I5 u v u � I �-
Quad No: t 9 !! SIGNA E OF PERSON CONSTRUCTING THE WELL DATE
c S t ` gIginal to Division of Water ouslity, Groundwater Section within 30 days
Serial No. ) , - -' , 1, g98 GIN REV. 12M

/; i
North Carolina - Department of Environment and Natural Resources - Division of Water quality . Groundwater Section i [1 9
1636 Mail Service Center - Raleigh N.C. 27699.1636-Phone [phone]
WELL CONSTRUCTION RECORD WELLCONTRACTOR: ` l ynn r) t JI I d 04�
WELL CONTRACTOR CERTIFICATION #: /J. b R5
a_ et -
STATE WELL CONSTRUCTION PERMIT#: T
1.
WELL USE (check applicable Box): Residential 1� Municipal ❑ Industrial ❑
Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2.
WELL LOCATION: ( how sketqh1 of the location below) l
Nearest Town: ,i.1.0 fVlk..� County: macbl �
(Road Name and Numbers, Cc m unit, or Subdivision a d Lot NO.-)� c -- DRILLING LOG
DEPTH
3.
-pp
OWNER G UA4& From To
Formation Description
Address o Q TT�TT—��� n- a0
4 l fi-
tree o Otte O.
. city or Tovinj sun Zip Code
4.
DATE DRILLED ( U
5.
6.
TOTAL DEPTH
CUTTINGS COLLECTED YES ❑ NO[g
7.
DOES WELL REPLACE EXISTING WELL? YES [:] NOM
S.
STATIC WATER LEVEL Below Top of Casing: 4400 FT.
=S"
9.
(Use': a Above Top of Cuing)
TOP OF CASING ISFT. Above Land Surface'
a
ry
z'
v c
-Top of easing terminated at/or below land surface requires a variance In accor-
dance with 15A NCAC 2C.0118
10. YIELD (gpm): METHOD OF TEST CAAAL
IV
o
11.
WATER ZONES (depth):
12. CHLORINATION: Type -Amount rJ C • If additional space is needed use back of form
13. CASING:
Wall Thickness LOCATION SKETCH
Depth Di;
DiIrter or Weight(Ft. Material (Show direction and distance from at least two State
From To a0 Ft. rza� nRoeds,orothermapreferencepoints) I'' n
From To Ft. i� p� �Qi W� JcC�1(llX
From To Ft. � h U C,� 140 up lW .
14. GROUT:
Depth Material Method
^C�
From �— To T 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
From To Ft.
From To Ft.
e0
FOR OFFICFAJJE ONLY
Quad No:
SerW No.
Material
&naz " rn" CL.� "
becu dd".0 2d .0 60o7-i
l� e a.( 0 l kbQ , Gvecu e
CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
OPY,OF THIS RECORD W BEEN PRQVIDEO TO THE W ELLjC
GNATUF(E OF PERSON CONSTRUCTING THE WELL
to Division or Water Quality, Groundwater Section within 30 days
DATE
GW4 REV. 12199

North Carolina - Department or Environment and Natural Resources - Division of Water Quality - Groundwater Section
h .I 27 9.1636-Pho 919%733.3221
1636 Mal Service Center - Ralelg , . . 69 no (
WELL CONSTRUCTION RECORD WELL CONTRACTOR: i`QOrtn(1Yi�tiIL �kS�
WELL CONTRACTOR CERTIFICATION N: b 7
STATE WELL CONSTRUCTION PERMITa:
1. WELL USE (check Applicable Box): Residential & Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use: 1
2. WELL LOCATION: Show sketc f lheJocalion below) U`-I
Nearest Town: � L9-3-- County: UUU
(Road N nd Numbers. Community, or Subdivision and Lot No.)
DRILLING LOG DEPTH
3.
OWNER
From To Formation Description
Address
City or Town state Zip Code
4.
DATE DRILLED I I Io
5.
6.
TOTAL DEPTH
CUTTINGS COLLECTED YESQ NO[k
WELL? YES NOFAJ
o
7.
DOES WELL REPLACE EXISTING
y
8.
STATIC WATER LEVEL Below Top of Casing: FT.
(Use': 0 Above Top of Casing)
9.
TOP OF CASING IS I FT. Above Land Surface'
co
-Top of casing terminated at/or below tend surface requires a variance In accor-
dance with 15A NCAC 2C .011a
10, YIELD (gpm): _Q METHOD OF TEST
S
c_
_
11.
WATER ZONES (depth):
ca
w
mN
tea---�-
—,
12.
CHLORINATION: Type Amount
It additional space is needed use back of form
z _
13. CASING
Depth n�'' Di,�tter
From_ —TO Ft.kk,.4
1—
From To Ft.
From To Ft.
14. GROUT:
LOCATION SKETCH
Wall Thickness
or weight/R. Material (Show direction and distance from at least two Slate
c� Roads, of other map reference points)
Depth Material
From To Fl.
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
Cwc.�
O0.-b 9_� Earl - J c)O k 1
Lot hou.�
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A �OF THIS RECORD W BEEN
JPR VIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY 1.11.��+' r `--} �.- - ✓� l��c"��
Quad No: SIGNATW➢1E OF PERSON CONSTRUCTING THE WELL DATE
Subrnit odginai to Division of water Quality, Groundwater Section within 30 days
- Serial No. GW.t REV. 12/"

C..24228` 6
North Carolina - Deponment or Environment and Natural Resources - Division of Water 014811ty • Groundwater Section
1636 Mail Service Center - Rsleigh. N.C. 27679.1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:—a..)TT ah'
WELL CONTRACTOR CERTIFICATION a:,
STATE WELL CONSTRUCTION PERMtTN:
1. WELL USE (check Applicable Box): Residential Uri Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other (] If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: MiqrglaAl1 County:
Agricultural ❑', 1 Monitoring ❑
(Road Name and Numbers, C,unlry, or Subdlvislon and Lot No.) DRILLING LOG
3. OWNER Chad & Steph^ni a Fran To
Address
or
MarshalI N C. z�Sz
City or Town Slate flp Code
4. DATE DRILLEDO---DO
S. TOTAL DEPTH
6. CUTTINGS COLLECTED YES Q NOd
7. DOES WELL REPLACE EXISTING WELL? YES 0 NOID
e. STATIC WATER LEVEL Below Top of Casing: /gin — FT.
(Use': N Above Top of Cssingf
9. TOP OF CASING IS FT- Above Land Surface'
•Top of using terminated st/or below land surfats requires a variance In decor. _
dance with ISA NCAC 2C.0111
10. YIELD (gpm): 3_ METHOD OF TEST G 1 rQ� na —
pEPTH
Fonpetlon Descdpdon
11. WATER ZONES (depth): 1 S(1 O o
12. CHLORINATION: Type Ohl of Amount
13. CASING:
Depth Diameter
From — To —2L1— Ft. ---
From To Ft.
From To FI,
14. GROUT:
Material Method
Ft.
Depth
From To —
From To —
15. SCREEN:
Depth
Diameter
From _To _
FI _._ In.
From __. To —
Ft. — in.
From __ To __
Ft. — in.
16. SAND/GRAVEL PACK
Depth
Site
From To FI,
From To Ft-
17. REMARKS.
Wan Thiclmess
or WeighUFt. Material
Slot Site Materlel
In.
Material
It additional space is needed use ►ark of form
LOCATIO�H
(Stow direction and distance from 01 least two State
Roads, w other map reference points)
25-70
Walnut Mtn. Rd.
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C. WBLL
CONSTRUCTION STANDARDS. AND THAT A COPY OF THIS RECORD BEEN PROVIDED TO THE WELL OWNER.
FOR-0
12T4---
FOR OFFICE USE ONLY DATE
Ouad No: SIGN RE Of PERSON C S7RVCTINO THE WELL
Submli original 1e Division of Water Quality, amundwatat Section within 30 days Q V-I REV. 12199

North CardUia Dopenmsnl of FrnAronunant and Natural Resogie T33-7221 of Water OgaUry • Groundwater SacUon I,'I :y ti 2 O p ,r 3
1836 Midi Sarvlu Center • Ratalgh, N.C. 27a79•la9bPfbne ( i [�
WELL CONSTRUCTION RECORD WELL CONTRACTOR CERTIFICATION 1:.�a--
STATE WILL CONSTRUCTION PEIIMff"t
Agricultural Cl: Monitoring L
t . WELL USE (cr*ck Applieeote aoe). Residential Municipal
�er 0 If Other, LlbatuUf�a
Recovery ❑ Heat Pump Water Inlecllort ❑
2. WELL LOCATION: (Snow ek•Ici, of the location belowCoun? — Mq d, c �n
i Nearest Town:. M"'-"'—
_ neat 1NG LOO —pTM
(Rood hertz ono Mwroeii, Com^uM'y. u S�bG�sbn a+d Lot No.l Ird Fort}NUon pe c0c"n
3. OWNER Ja '_Brazil ---
Address
Ns, Fi---
Slate zip Cod
Cay a ro«n _
a. DATE 0RILLED—J-1 Q9
5. TOTAL DEPTH __-24: �-- �,/
6. CUTTINGSCOLI.ECTED YES0 NOE
7. DOES WELL REPLACE EXISTING WELL? YES [] NO��,__
8. STATIC WATER LEVEL Be" Top of Caaktg: _/, o FT.
(Us*,,* a Above Top W CI*V)
g. TOP OF CASING IS
IT. Above Lind Surface'
.Top et easing lot winatod atfor Below Und euAsce reVutru a vortonoo in oeetx•
de-ice with leA NCAC 2C.0118 METHOD OF TEST "1 Container
10. YIELD (9pm)' -
11. WATER ZONES (depth):^-
--'— ---- alto
U additlortai spa" b needed use t�aelt rm
h 1_ __Z�— -
12. CHLORINATION: TYFa--r�-�- Amount r.e•� �-
13. CASING: t wit e And ereIa aw Eial•
Depth Dtemsi.r erWolght/F• 1tndkbna ifornat Net two
Rood•, or other trap ratereroe Prints)
From ---0--To .-ZQ— Ft. --- o
From _ To Ft.__. - O x
Ft...�_-- --- - o
From _---To 151
14. GROUT: Orn om
Depth Material Method c7 zm
Ta Ft Concrete Pour panther Br. tv o <
From _sCO {r'^
From -- TO F1. Dc
Lower Flat Crk. ? m�
15. SCREEN: Material �rn*rn
Depth Diameter Sim Size � rn�
--To n. _ _ In Flint Hill c,
From in.._---- W —t
From ----To -- Ft. t,p o
From -- To _._.--
Ft.In. _—in - Grandview Rd.
t6. SANDIGRAVEL PACK: SI=® PAatedal
Depth
Fromr.---
To _-Ft. From __ To Ft..---_.-- -- ___--__--;�---------
17. REMARKS.,--------
CONSTRUCLvJN STANDARDS. AND THAT A COPY Or 'THIS RECORD BEN PROVIDED TO THE
WEIx .
I DO t1EREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED E
1N ACCORDANCE WITH 15A NCAC EG. W11LLOWNER
_ 11-14 _��
70NLYpAtE
FOR OFFICE USIaN E OF pERSON C STf1UCT1NG THE WELLongInor to pvhlon or water Oualay, aNu+dwaur Salon within 90 dsya pW l REV17191
..

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section 2 8 5 5
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR-
WELL CONTRACTOR CERTIFICATION #: y —
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Appllcable sox): Residential1"un)clpal ❑ Industrial ❑ Agricultural ❑ Monitering ❑
Recovery ❑ Heat Pump Water Injection 0 Other E] if Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: _Nn1"5A2I County. 'i»>M_ /" �t LNa
(Road Name and Numcers, Canmunity, or Subdivision and Lot No.) DRILLING LOG
3. OWNER -arnej Roht't l3 From TO
Address
(streetistreet or Houle o.
city or To— State ZIP Code
4. DATE DRILLED H-29 g3 /15
5. TOTAL DEPTH /25
6. CUTTINGS COLLECTED YES NOQ
7. DOES WELL REPLACE EXISTIN WELL? YES Q N05a
8. STATIC WATER LEVEL Below Top of Casing: �(d_ FT.
(Use'+'If Above Top of Casing)
9. TOP OF CASING IS / FT. Above Land Surface-
-Top of casing terminated allot below land surface requires a variance In accor-
dance with 15A NCAC 2C.0118
10. YIELD (gpm): 30 METHOD OF TEST--
11. WATER ZONES (depth):
12. CHLORINATION:
13, CASING:
DEPTH
Fonmffon De talc lfon /
lI !e _ �P%GQ21-1
Type l'Z S Amount S If additional space is needed use back of form
Depth DI I r
From�To �:; FL r
From To Ft.
From To Ft.
14. GROUT
LOCATION SKETCH
Wall Thickness
or Weight/Ft. Material (Show direction and distance from et least two Slate
'0 2/ _$&ibe Roads, or other map reference points)
Depth I) Material Method
7�
From b To CFI.
From To Ft.
15. SCREEN:
Depth .Diameter Slot Size Material
From _ To _ Ft _ In. _ in.
From —To —Ft. _ In. —In.
From —To Ft. — In. —In.
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft. —
17. REMARKS:
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OFFIS RECORD H(Q./$ BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Quad No:
Serial t i�1 L4 („
_ t
Sec)li)n
e7kjpal office
SIGNATURE OF PERSON CONSTRUCTING THE WELL
original to Division of Water Quality. Groundwater Section Within 30 days
O
O
O
rn
C-7
IV
m
a
3
co
W
DATE
GW-1 REV. 17199
0

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section ti 2 7 C X
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone] C/ '3
WELL CONSTRUCTION RECORD WELLCONTRACTOR:R.CALDWELL DRILLING, INC.
WELL CONTRACTOR CERTIFICATION 02140
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Boa): Residential ❑ Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ It Other, List Use:
Agricultural ❑ Monitoring ❑
2. WELL LOCATION: (Show sketch of the location below)
Nearest T wn: County:
( Name Number Co Iry, ar Subdivision and Lol No.) DRILLING LOG
3. OWNER From To
Address
_ ! IreeI orIlTouts 0.)6 0% �1�--
City or Town Zip Code f`—'--+�—�--
4. DATE DRILLED (4fo toS-
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YESM NOO —
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NOD —
8. STATIC WATER LEVEL Below Top of Casing: er FT. —
(Use'i Y Above Top of Casing) _
9. TOP OF CASING IS__�_ FT. Above Land Surface'
'Top of using terminated attor below land surface requires a v lance In occor- —
dance with 15A NCAC 2C .etta
10. YIELD (gpm):/� METHOD OF TEST —
11. WATER ZONES (depth): iC ( —
12. CHLORINATION: Type DAmount�
13. CASING:
Well Thickness
Depth Dljt"�ter or elghtfft lode
From To � Ft. _T�
From To Ft.
From To Ft.
14. GROUT:
Depth --Material Metho
From �— To Ft. ^ 1
From —To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From _ To _ Ft _ In. in.
From —To Ft. In. In.
From _ To _ Ft. _ In. In. _
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
17
DEPTH
If additional space is needed use back
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
5 �j,;, �2
w
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STBNR.ARDS.AND THAT A COPY OF THIS FIEC RD HAS BEEN PROVIDED TO THE WELL OWy ER.
RR;OFFICE
gadpip; GNATURE.OF PERSON CONSTRUCTING THE WELL DOE
Submit (I to Division of water Quality. Groundwater section within 30 days
r- j p GW.1 REV. 12("

''2591
Nosh Carolina - Department of Environment and Natural Resources - Division of Water Quality �,;_ ` -Groundwater Section
fi36 19) 733-=1
n
1636 Mali Service Center - Raleigh. N.C. 27699.1 Pha( 9
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (CMekAppliable Noa): Residential Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water injection ❑ Other 0 If Other, List Use:
2. WELL LOCATION: Show o/��� location below)
Nearest Town:l%L�A/ County:
and Lot No.)
3. OWNER
Address
coy or Town —�
4. DATE DRILLED
5, TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑ NO®
7, DOES WELL REPLACE EXISTING WELL? YES C1 NO®
8. STATIC WATER LEVEL Below Top of Casing: FT.
y (LNe'+' g Above Top of Casing)
9. TOP OF CASING IS 1— FT. Above Land Surface'
'fop at c abq trminated suor below land stelaee n9uina a vrlance In seow-
dance wab 15A NCAC 2C4114 '
10. YIELD (gpm):METHOD OF TEST TJ Ai) r
11. WATER ZONES (depth): O S r ' � S6
12. CHLORINATION:
13. CASING:
DRIWNG LOG
From To
DEPTH
Foarawn Description
Type _2�,Q Amount it additional apace Is needed Lao back of Conn
Wag TNtlawas
or WaVdIFL. Mabdal
From eo Depth
Ft. — -VL
From To Ft.
From To FL
14. GROUT:
Depth
Materiel Meftkod
From _ 0 To -zZQ_ Ft. rl
IAO
From To Ft.
16. SCREEN:
Depth Diameter Slot Size Material
From �o�n•
From To Cy_—/— Ft. In.Zin.
n•
From To F in.In.
18. SAND/GRAVEL PACK:
Depth Size Material
From TO
From To FL
17. REMARKS:
I DO HEREBY
THIS
L OO rION SKETCH
(Shaw direction and distance from at least two State
Roads, or other map reference poirda)
W ACCORDANCE WITH 15A NCAC 2C, WELL
rv.. W........r 1 U WELL yMc
Quad No: TORE OF Wale, ON THE
( _ b Olviabn el Wstsr Otrsgty, finotardaaMr Section widlln 90 days
suss REV. 12199

, c t �::. ' .. =_JLa ltnar�u �l.-t•rr^}^2 �tma ,n^t : t�+!'r^ • I • r , � •. a ' I
Ins
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1630 t.l nil r;r rvlrn Cry 11 r, IlalrIV? • N C. 17699-10J0-1'llarig to 19) 793 322, _
WELL (;l)115I IItic I IUI I IIECUIIU Wru. CUNIIIACIOil!
II CUNIIIACIUIICrt111tWAIII)II►:__;_r�U�G1.____
!:Intewel.t.cortstrluctarrlrnlrnln,
�( rduntdpnl U_� Induelrinl I. _I Aorb-unn,nl I I Idr,rdl^rp,e I
1. 5VF1.1 If':Ii p 1rrc4 nr 1 n�-1�In n ••) Ilenldnnll;,I�yCI
Ilecovrly I I I I^nl I'unq, Writer bQecllon U UIINr LI II Olhef,
2, WFU I (`I:A l It 111. (•'hawv n .Icl, of life tocnllon below) !j//l /�•
��" Calmly: ------
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_ UI11llIIJci1S)13 hrr111
II, I llinm Nnl Ilr ^a^re ('mnp U v— tnlllar bld Lol II01 - - �- 1 -rPnn l`^„•rl r
.. -' /iyi/ Ilan in
addle n 10 OF.
--- I' FFlinrl•iln I"i _ .- .. `)) CIz
+� �,�,,-, ►'J, �.��7s`�-- __�.�4 +-ill �' _ �l r r-o
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It1.16.F, N,OFF irO rl CnOr'p) .. o
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d.nte r,lh I'.n 111'nl: 7C D
11, WAIEII--
___.' i__t�.,t_.. AIIIeUf11 .tY—P—�llls II NIQIII vrnl rl m�n It r rn4n.l m 1 n -4'ynl l•,r n =—`-
12.^~--
M CASMO: i.tn;nlnrll F11TI( 11 .
Wen Ihlc4 nrd'
,Innvinr nr VIe191N, 1 1.l nlnlrl (Silo" fill IImrd dhlm„ n hrrn nl In.d Iwo Slnln
l)rl,ll,
� �'rc�s4R tlonde, ar on,nl nrn , Irin,nn-^ p.
veal.
rwril
1A. GI1Vt11' 1.1n1n11 n) , hlnlhwl
CIP
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I)rl,lll
17. FIEh1AI11C9:—, `. r• tarn
0 �CUtl$ItItK7tEU RI �CCp1117N ICf'W111115A NCAr: ...
1 UU I IF itfly G7"!l1❑ v'l 1 IAr 1111n wr!(. WA- 11119 IlECOr UIIA9 BEEN moviorU lU 111F. YIE(1. Ov711Etn1. �{
COI!^.1I IUr 7Ir�11 ^• 1 AI It, nl llln.-. At U l I IAt A Cory
jam- (..Cr
IUII OIIIIrtI$r:(It AIfIt �, nlnnnlr Or rr n^r nCOn9tttUcnnrt nlF v,nl
Wed Nn I (3mw 'r jI( Sn ceon wllllh19l1 dnlUW,I nrV. 12177
r.1 Subn#1 IF el to blvltlon e1 w11ur Weny,
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It
IorTit CnrrJ.n 1,•1,n0Fnn rd ,d 1 n•d,I, Im•r,l A, III tInlul l,l tldrn„, rq1 • bh, 1+Iv1 at Wnlu ut,p • (lr nnn•I„nl•r ^•n01
,639 Mmilt, I vlrn Cr'"Tot . 11.10gl1, ti C. 2I699-1036 Phone [phone]J221
WELL C(MIS11111C1101111ECU11U wn.t.cut lIll AcIoil: __3�T: I IrR4jU�<»J
WrLI.C()IIIiACIGnCrnllt117AIIWIF!.-.
r1111EWFLLCOrr91nllCllt)lll'rnrlllr .
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rircovrryI I I11n1l'un111WnlerinlxllonLj Ull,drL111Will, LletUlr;
2. WGLI. 1 (`('\11011: (^hnw c�kefl h of the locnllort bnlow)
f�L t aesD�O unty:
Ilanln5l lc..rc_ _ Co
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rn
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Or1111, nnuvinr m Y n 7 V 1
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rinl„_—� _._ In _S� rl. l�r:��-- �J�•laS �'VGSAR n��a1.
tA. G110111: tAnlrrinl . Mnlharl , ��,/] A A <OL� ��• `"
rinl„
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rinr„ _ .. ..-In.---11--- _ h,. ----- b,. —
rinvt In ..11.._.—.--
10. SAII01 11MV1'I.I'A""! Slie Mctlallni
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CON^11111r IIUII „i N1i,f,1111^ nNU lll/,i HGVPV ) ff �O.,�p _QU
'----- pnlE
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Ih 't suyp#lodprfidlaUlvlJlonWllhln 9U dnY�lhn-__ --_--_

229382
1JOIth .114 !: n I,^I mo •,d r`I rnvl N.G. 2 l and Natural neaourc^1 - 3-32Ion or Water Ouelity • Oimrndwmnr S c /1
1636 f.1a11 '�^I1r,�^ ('. ^..II•. Nnl^ipl,, IL(:. 27699-I63&rhona (gig) 79T3221
WELL C01151fit 1CI1OIJ RECORD WELL CON Tnncron:
WELL CONTFIACTO110EnurICATIr 1 R:�_ _
SIAIFWFLLCOtISTnUCTIONt'EnMltd:
,/ CJ
J. WFLI Munlrlpal ❑ Industrial❑ Atlrlcullurnl Monitoring
Itecn%,,,y I ) I b•nt Pump Water Injection U Other Lj II Other, List Use:------
2. WELLI(n'AIRVI 1,n•.vsl;''•I//rh'b'llAholocallonbelvw) '
Nenrr•I Il.A(jA_ ,.n - _J�F�6�—-----'__--
InO, i n.n•unli rS tdlvIslontind10140) onILUm_u_-__
3. OWNI it From To
Add r -
,jj � Iff Or Im-ji O � -
-. !1 2 off__"_
(;ny r„ v Siala 21p
4. DATE I`n111 I-U.1o`-lb' 06 _—_--
5. TOTAI.I'r-r'11I LI _
6. CUrt IrJr,t: r(,I Lr r�I r.N r S NO rJ0[✓j
7. DOE^ 1'"'r IT. III"r-I nrr rXl`;IINC WELL? YES (] NO
8. SIATICWAIFit II-:VFI.-nelcwTop ofCMI119: �!� --
rta'.'"Above TOP Of CA0,91 -
9. TOp lt1" rnFR i , I �_._ __ (rr. Abovn Land Surface'
'TOp al ce.hn, I••nn,rhll rrrr 101000 Isnd furface requires a vedence In sceor-
dlnclvdlh 1'4IL^.AC 9C .n I1fl
METIIOOOrTEST
rb mallon 0,i inl an
-Type
—.__
Amount�W.1
It additional apar.O Is neadrad u;a bark of form
12.
011-0111IJAI ION:
—
m
CASING:
SKEICFI-
Well lhlckness
ateder
-LOC(1110N
(Show direction and diclnnro born nl matt two Slate
Url�liv,�/1
tlamel r or1I •.m
iY w
needs, or other map relerence rolnls)
Front - -.
_ lr ___..—
Ft.
,
from . - _-----11,-----
FL.
14.
Gf10UT'
11 pill
Mathod
t
T•-��` 4
Flora fl.-.
__ In
-FI. ..-i
wont
15. SCIIIJ I I
I,rl.lh Uimneler SIo1 Size Malarial
morn .. ._.._ T„ .. rl In.
rfont _ _. _ I o _..- _ f-1. _ In. ._— In.
From _ ID
16. SANUK,11AVF1, r'ACK: Size Malodal
prl,lll
From
---'�-
17. FIEMAIMS
1 DV I If In PY Cr"vll ll TIIAI NUR WELL WAS COIIStr1UCTED Ill ACCONDNJCF WI1111SA Nf:AC 2C, WELL
Cot rl I NI IC. I I()N S I ANNAn US, AND TIIAI ACOPY OE 7NIs necono NAS BEEN PROVIDED TO TI IE WELL OwNrn.
r I-1----�'. ---- -�� °
►oni;i r If r ils`� xnnr oAJE
sloNnn eorrensoncolstnucnnnlurWnl.
ound 11
6ubm11 odpinel to Division ar Weler Quellly, Oroumlweler Snconn wlihln 30 rinys UNI nEV. I211
Snda, Ito _ —

229383
I forth Ca t-1 - 1,^I.ml,,, • )i r,l flndr mim,4 and Nalulaf Ne aourcra - Divi^.Ion of Water Quality • Or oundrvatr!t Sncti•v
1636 fdall 1:1­ A-^ n:nrluh, 11 C. 2769916381'honn (9I9) 793-3221
WELLcoir;lll(Iciioii nEconD WFLI_CONinncron: ! , 't� �11 9__
Wrt_LCONIFIACTon CEn TIriCAll(1 R:_i gDg3�.__--..
STA1EWELLCONstnuciloNf`EnMI1M:
WELI I ISn (( n^r1t r i rn, Mr nn.): flesldenlfnlLYJ_ Municipal 0 Industrial ❑ Agdcullutal El Monllnlinq U
Ilecovnly 11 11,•nl rump Water Injection Lj other ❑ If Olher, Llsl Use: ---
2. WELLLUCAIIOrI(J9horvskIlrlocallonbelow)
Neared 1,,,.u:--_/J(4�Q J4f County:--
-- -- - -- DRILLING LOG
(rlon nn,� nn In n' ^Is. t'onn1ull Y.p r Subdivision end Lol No.)
To
-- - - -
rolmallonbreeriplion
�✓,/��� From
ao - az (9
---
Gey ^, in,.,,1 S,r1e 21p Cade
_
---_.
4.
DATIFPtillIIt)_-�p��a�'rQG
__--
S.
6.
TOTALPF-I'lll---
CUT11IIrSCULLrc;)EI.) YES❑ N09
YES [] NO[V
o
-- -- p o
7.
DOES VII- 11 I1(41I Arr EXISTING. WELL?
6.
STATICNJAIEIILEVELFl010w Topot Cnsing: _,;t D FT. _
-- --�--
a �-
(Use': a Above Top of Casing)
---
9.
TOp (>l- (IASni , I^•__- -__._ FT. Above Land Suflnce'
'Top
of cestm, o-1 od•Int^d rt'or hrlaw innd eudees requires A vedfinee In eteor•
Sc m
donee will, 151 IICAC 2 .ni in
r4ET11OU OF TEST
a-
10.
YIELf I (al`nl)'-ri--
-
11.WAM170NES(d^plh):—_
---
-
AfnOUn1�wi II eddlflornl spare Is naednd vae bark of ffm =1
12, CNLC111111A110N: lyp0
13. CASUKI: LOGAIII N_SKF.ICFI-
Ylell 1111-wl"I
/) Urf`Ih /piametar of WalgbVfi. alalle'd�eCt/j- (Show dilacllon and dl<Wncn Irem of Inasl two 91nte
rwm __ Y-.___ 1 - � rl •" needs, or
ol�herr�Inap rplarence pol^nl5)
riom- lr' _- rt.
Wont __.._.__l,._.—.— n.
14. GnotI l: � . e �C.
/� I+1'rn1 Malodal Method ( /
rionl _. O _ 1„ A(2 rI. �• Q (,�/
r(�
1-1011) _ _ In ---__._R.
15, ScriPf tl
I lrl,ih Ilintneler
morn
_ 11• _. rl ,_.___ In.
From
16. SANU4;11AVrl,
11rl,lh Size
Slot Slzo Mntarlal
_ In.
_-
- 61.
Malelinl
From_. _._ In ...... rl.
From----__-_--'---------------
i7. FlEM1tAnI __-_
I b0 1 ❑ nr n y ('t'.It 111 y' I I IA:I 11113 WrI.L WA9 COf l9 T(111C1[D III ACCORONICE WIIII ISA f 1f:AC pr7. r,
Got ISl nl lr iltlfl 1tnllAnh;, AND IMF A COPY Or T11I5 nRCOf1D HA9 BEEN PnOVIDFU TO Ii IF WFtL O---/---� �-
rUfl Ill I IC r ll f411N1 Ypf._/ Dn1E
- "_SIMIAT F_ Or PF.n_ oirl Cofl. inUClll Ir1111r, 47f1). _
Ound tL -• Subndl dq,,at to blvislon of Water ounilly, amundwelef Soa'on v+llhhl 3q rlay9
�� _ ow.111rY. 17173

' JLa kt fa to fi W.4'n- u 7jtr'to}IF Q�••'n,•l.,,H F.•,•• • I • r ,• 7 F ..
YtHpq
n � r
2293'76
�rhn�r 1 rd 1 fJl,l!blrl of Wela Ou, lly • Linmm6enn•r Snrll.•n
n,h Cmpbn 1,•,,.
r636 Mntl Frrvirn I;nnlrr Ilnl rinh, N C. 27690-IeJO r'hon/ (P10) IIJ-3221 _
WELL(:(IIlSIIilIC11UI111CCU1{U wrL1.00UnlACIUn: __�b1 frRSjl)S��tJ j
W17.1.1_ CON IIIACIOil CrIIIIt ICA11011 e1
rIAIE WELL C01MIlUellotlrrm111N:
{ f.lunlclpnl L� Infhln6lnll".I A(irlr:nllvrnl� 1.1nnlP�rirwl
1. 1'Jrl.l U':I: 1' Irrc,r nl 1 n,•1,1. n••.I. (Ingitlnnllsl1
hnco,�nry j..l 11'•nl I'ongr WMnr Inl9cllon LJ UIINt [) II OIh61, ---
7. Wri.L 1 t•CN p tt l: (';I,r Iv ekelrl of lim locnllon Wow)
Counly:
DI11L(IIJU LVt3 Ilr1'11l
In 1lron m Ilh r..r^n l'rvmnnJly, of 5 11Ion AtA III01
_ r10T
3, Ol'lllrll 7
_!r(11.1..S.ita.Q-�rinrrt,n`r� _ l�ErlF'4rIc
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• ^. bAIE 1`I Ul l rlt.ID 3
5, 1OJAI I'll 111 _/.4. - _ .- a -�m-
r. Uttnu: I.u1.1.rC11I! Yf-^.[ .� IIV�V� flU _ ----- - C,
C
7. U(JEF WI 11. III"I.1 nl.r h'!ISIIIo Wrl(7 YE9 �J _ _ _ .. - --" . _ _._- _ =h;
r r,
C1, SIAIIGWAIF:Il1.I:VELUelocrlcpolCn^,h,p: �_-•.— cor
nI Ce101
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nn)'
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1Jr1.1[I1lot) or1ESr �� ---N- ---r
to. Ylr1 Jt (fit
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11. WAl EII 7VIIr3 idrl,lll): — 1,n Mrd h„n,
17. CI ILOIIIIlAI IL!II.
13. CASIIR::
'` 111,1011 �pp I,Imnrinr
rinn,.-O-----'c _`--
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wo 1111cHmd IlUndrl ISI,0, Ah ecp•v, nm1 dhlnn n bon, nl l,n+l lnn Slnln
nrr(YI101111 VI 1. 2y.' 11 ,rnlydl)
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rwm
ripm
rinn,
In. _.I
.
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AVI'l TW:K:
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Site
non
17. FIEMAIIK!,:_,.-
r,0I1bAlICP WI If I I;A tu; N'2r;, WCl L ��
y 11119 nECOnv fins oEBN rnovluro 10 nIF. Yrr LL OwnC: n.
10o Irr,-fly cr Ill,, v IIInr TV WrI L WAo CVlrvtllrJc:Ir.0 Irl AC'�'
Cott.nnJxncnl^Inrn,nnU^•.At,
1ul11AlACPP;$
l
CI L,r I ICE USCIITtft.Y f ILINIIIIE Or rrfln, 11 YOlinIIlU��la 9^cnon will lldn 3U linyl
W�A Ifn_—_—' ---�..� 6vbrn6 odp/1d Ia,Dlviplonet Weltr Ovellt .Orour,dv nwl ifrv. lirot
} r

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section l n
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone] �• •> V
WELL CONSTRUCTION RECORD WELL CONTRACTOF"
WELL CONTRACTOR CERTIFICATION #: b 258�
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Cheek Applicable Bo:): Residential ( Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch t the location below)
Nearest Town: +r..(S.rTCounty:Qn/w�f�/
(Road Name and Numbers, gonwnurdty. or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER From To Fommeon Dgsoription
Address C ' &6 u
"'Y"at Or
City Town Stab Zip Code
4. DATE DRILLED -06
5. TOTAL DEPTH Ar/S o
6. CUTTINGS COLLECTED YES ❑ NO[;J
7. DOES WELL REPLACE EXISTING WELL? YES NOE] "-
6. STATIC WATER LEVEL Below Top of Casing: AST FT. _ --
(Use •.• a Above Top or Caung)
9. TOP OF CASING ISFT. Above Land Surface' _ G
m
-Top of using terminated atror below land surface requlms a variance In accor-
dance with 16A NCAC 2C.0113
10. YIELD (gpm): / 2- METHOD OF TEST
11. WATER ZONES (depth): t,
W H
12. CHLORINATION: Type v Amount 3 c" If additional space is needed use back of form Z
13. CASING:
Wall Thickness LOCATION SKETCH
Depth m
�/ /,�I Diameter or WeighVFL Material (Show direction and distance from at least two State
FromTo 6— Ft. &
Yf Sim a% 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. SANDIGRAVEL 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$TANDARDS. AND THAT A foe"OF THIS RECOEID HA BEEN PRgVIDED TO THE WELLJO
FOR OFFICE UIa ` LY` "
Quad No. ,e�,�, $�IONA E OF PERSON CONSTRUCTING THE WELL DATE
w Submit l' to Division of water Quality. Groundwater Section within 30 days
Social No. GW-1 REV. 12M
. ah
1

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section '' 4 3 9 9
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELLCONTRACTOR �02�""'T+
WELL CONTRACTOR CERTIFICATION#: 7.b R �53s
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (check applicable Box): Residential d Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other If Other, List Use:
2. WELL LOCATION: (Show sketch gfthe location below)
Nearest Town: 144(&, n Ur-.� ; County:
(Road Name and Numbers, Community, or Sub Ivlslon and Lot No.)
DRILLING LOG DEPTH
3.
OWNER A,
From To Formation Description
Address o!
/�,� tr..0 ?a ��/So
fir, - 3a.S �r
—'City or Town d, State Zp Code
4.
DATE DRILLED /0 i/-6o
5.
TOTAL DEPTH 31-3-S
o
6.
CUTTINGS COLLECTED YES[:) NO
7.
DOES WELL REPLACE EXISTING WELL? Y S NO
0-
8.
STATIC WATER LEVEL Below Top of Casing: FT.
(Use'.' g Above Top of Casing)
—
�--:
9.
TOP OF CASING ISFT. Above Land Surface-
-_
0
'Top of cuing terminated aVor below land surface requires • variance In aceor•
dance with 15A NCAC 2C.0118
10.
YIELD (gpm): METHOD OF TEST �-
ma
11.
WATER ZONES (depth):
N
-
12.
CHLORINATION: Type a 011AI-1AA- Amount l C '
If additional space is needed use back of form
�
13. CASING:
WWI Thickness
From
Depth Di to or WeighVFt. Material
7 To Ft. & 4 l�
From
To Ft.
From
To Ft.
14. GROUT:
Depth Method
From
dal
Q To _�Ft. dal 9 f&Z ,
From
To Ft. 0
15. SCREEN:
Depth Diameter Slot Size Material
From
—To—Ft— In. —in
From
To — Ft. _ In. — In.
From
—TO—FL— in. —In
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
17. REMARKS:
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
O fie_
A0
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTI =AND Tj9ATAOF THISZRO D Fj6S BEEN PR9VIDED TO THE WELL OWNER.
FOR OFFICE U LY !�
Quad No; 'z ":SIGNA E OF PERSON CONSTRUCTING THE WELL DATE
Submit o l "to Division of Water Quality, Groundwater Section within 30 days
SsAaI No. GW-1 REV. 12I99
� e

North Carolina - Department of Environment and Natural Resources - Division of Water Oualiry -Groundwater Section ? 4 4 04
1636 Mail Service Center - Raleigh, N.C. 27699.1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: urCv7� try
WELL CONTRACTOR CERTIFICATION #: &b _ RAT ZSKS
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable sox): Residential Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other[:] If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: County:
(Road Name and NurCoommuniry, or S40vlaon and Lot No.)
3. OWNER d/A L%)
Address / aig Gr2�
ree or � o. EGG PG
City or Town State Lp Cade
4. DATE DRILLED /d"Zt1-00
5. TOTAL DEPTH 10 0S
6. CUTTINGS COLLECTED YES ❑ NO
7. DOES WELL REPLACE EXISTING WELL? S NOM
B. STATIC WATER LEVEL Below Top of Casing: —00 FT.
/ (Use'+' 9 Above Top of Casing)
9. TOP OF CASING IS _1— FT. Above Land Surface*
-Top of casing terminated atior below land surface requires a variance In accor-
dance with 15A NCAC 2C .011e,
10. YIELD (gpm): 4_ METHOD OF TEST
11. WATER ZONES (depth):
12. CHLORINATION
13. CASING:
Type G I�Amount
_
Depth D"ter
From f" r To 33 Ft. 7—
From To Ft.
From To Ft.
14. GROUT:
DRILLING LOG
From To
/) - 33
_33 - 46 S
DEPTH
Formation Descdptlon
0
n
0
c�
N
cr-
If additional space is needed use back of form C
z
LOCATION SKETCH
Wall Thickness
"We phVFt. erfal (Show direction and distance from at least two State
Ia� G� Roads, or other map reference points)
Depth Material Method
From 0_ To %O 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 CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C. WELL
,.a,.,Rc•�1:SYlit:a ceaA OF THIS RECORD HAS BEEN PRgVIDED TO THE WELLIO
FOR OFFICE U ,4NLY
SIGNA E OF PERSON CONSTRUCTING THE WELL DATE
Quad No: ) " Submit original to Division of Water Quality. Groundwater section within 30 days
Ssdal No. * OW-1 REV. 12M
R L:.a

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section I
2 4 4 0 2
1636 Mail Service Center - Raleigh, N.C. 27699.1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION
STATE WELL CONSTRUCTION PERMIT#: it
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 thlocation below)
Nearest Town: "'"� Count':
(Road Name and Numbers. Community, or Subdivision and Lot No.) DRILLING LOG
3. OWNER %/�� " �yAe� From To
Address . , 5eal.
'"`—'`t(Strae or Due C, . S,
G'ry 6r Town Stan Zip Code
4. DATE DRILLED 2O ' ,�7-00
5. TOTAL DEPTH ays-
6. CUTTINGS COLLECTED YES ❑ NO
7. DOES WELL REPLACE EXISTING WELL? ES NOE]
6. STATIC WATER LEVEL Below Top of Casing: ACd FT.
(Use'+' g Above Top of Casing)
9. TOP OF CASING IS_�_ FT. Above Land Surface*
-Top of using terminated at/or below land surface requires a variance in accor-
dance with 16A NCAC 2C.0119
10. YIELD (gpm): 7 METHOD OF TEST
11. WATER ZONES (depth):
12. CHLORINATION:
13. CASING:
DEPTH
Formation Description
Type ftuasearaa-�-Amounf 3 If additional space is needed use back of form
Wall Thickness
From DToth Diameter or material
/rZ Ft. yo aZ °.
From To Ft.
From To Ft.
14. GROUT:
Depth Malarial Method
U
From (9 To -26 Ft.
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From —To—Ft— in. _ in.
From To — Ft. In. _ in.
From To Ft. In. _ In.
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
17. REMARKS:
_LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
AwnTHAT A ODP'AOF THIS REf.ORD W BEEN PR9VI0ED TO THE WELLIO
FOR OFF DATE
Quad No: ? S SIG OF PERSON CONSTRUCTING THE WELL
Submit original to Division of Water Ousliy, Groundwater Section within 30 days Gw-I REV. IV"
Serial No.

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section �'- 'j ri T 17
1636 Mail Service Center - Raleigh, N.C. 27699.1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:(2ly����
WELL CONTRACTOR CERTIFICATION
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check applicable Box): Residential Municipal ❑ Industrial ElRecovery [—IHeat Pump Water Injection Other ❑ It Other, List Use:
2. WELL LOCATION: Show sketch of a location below)
Nearest Town: unty:��-��
Agricultural ❑ Monftoring ❑
(Road Name and Nuum+bers, Community, DdiNs'on and Lot No.)
DRILLING LOG DEPTH
3.
OWNER T �a� �� �/. �i�iisi F1'
From To Formation Description
c
Address
_
ree or ou o.
�-
-
CitV,orTomSun Zip Codi
4.
DATE DRILLED /U'10�00
5.
TOTAL DEPTH
6.
CUTTINGS COLLECTED YES 0 NO
QS
7.
DOES WELL REPLACE EXISTING WELL? NOf]
o
8.
STATIC WATER LEVEL Below Top of Casing: FT.
`
(use'; a Above Top of casing)
-
a
; M
9.
TOP OF CASING IS__�_ FT. Above Land Surface
'Top of casing terminated at/or below land surface requires a vsrunm in accor-
Co
w
dance with 15A NCAC 2C .0118
r^
10.
YIELD (gpm): Q0 METHOD OF TEST _ 1241
s
o
11.
WATER ZONES (depth):
�m
m�
12.
CHLORINATION: Type 44ddL�. Amount 2/3 c
If additional space is needed use back of form
13. CASING
Wall Thickness
Depth Alt_ Diameter or WafghtIFl. Material
FromTo Ft. (o L LW-,Q—Z
From To Ft.
From To Ft.
14. GROUT:
Depth nn^ __M��a^ter�i,al,,-- Me
From � To � FL i
From To Ft.
15. SCREEN
Depth Diameter Slot Size Material
From —To—Ft— In. _ In.
From To — Ft. _ in. _ In.
From To _ Ft._ In. —In.
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
17
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
I DO HEREBY CERTIFY THATTHIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A Fs Is OF THIS RE,CPD BEEN PRgVIDED TO THE WELL O
FOR OFFICE USE ONLY
Wad No: t_- SIGNAT E OF PERSON CONSTRUCTING THE WELL
Sid original to Division of Water Quality, Groundwater Section within 30 days
Soria] No. k }
dun wa Seclidn
{ $asilaui!le Ra',�iolral Q"i:^c .._.
DATE
GW4 REV. 12/"

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section 4'2 �'d (?
I
1636
Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
p
WELL
CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION
STATE WELL CONSTRUCTION PERMIT#:
Industrial ❑ Agricultural ❑ Monitoring ❑
1.
WELL USE (Check Applicable sox): Residential Municipal ❑
Recovery ❑ Heat Pump Water Injection Other ❑
If Other, List Use:
2.
WELL LOCATION:Mow ow sketch of the location below)
Nearest Town: �-r- County:��'r/�/��
DRILLING LOG DEPTH
(Road Nam and Numbers. Co unity, or SubtlivLvon and Wt No.)
3.
OWNER J
From To Formation Description
33 �A
Address ,�1�
.(Af
2% .4 notan
ritJ or Town Stale Zip Cods
4.
DATE DRILLED
5.
TOTAL DEPTH
6.
CUTTINGS COLLECTED YES ❑ NOP
7.
DOES WELL REPLACE EXISTING WELL? E NOM
8.
STATIC WATER LEVEL Below Top of Casing: FT.
o
9.
(Use': a Above Top of Casing)
TOP OF CASING ISFT. Above Land Surface'
a
'Top of using terminated stior below land surface requires a variance In actor-
dance with 15A NCAC 2C .011a
10. YIELD (gpm): a� METHOD OF TEST �-
tb on
11.
WATER ZONES (depth):
- —`
o
12.
CHLORINATION: Type Amount 73 C
If additional space is needed use back of form
13.
CASING:
— o
LOCATION SKETCH z
Wall Thickness
Depth Diameter or WagnVFt. Mpatsda�l
(Show direction and distance from at least two Slate
From—�To �3 Ft. .(016( �
Roads, or other map reference points)
From To Ft. v
To Ft.—�(
^ 7� �a �D
G{
From
14.
GROUT:
.
Depth /J Matedall Method
From /— To � Ft. LX!!1
15.
From To Ft.
SCREEN:Co7?G�
3 3
�//•
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 CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
rnuerai immnet _crealnA_smA Ab=,THAT A GOPXOF THIS RECORD HAS BEEN PROVIDED TO THE WELLJOWNER.
FOR OFFICE 1 — - "" e S GNA E OF PERSON CONSTRUCTING THE WELL DATE
Quad I i t original to Division of Water Quality, Groundwater Section within 30 days
�� GW1 REV. 12199
Serial No. ,
4 i

H
_ North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section_'Z g 5
1636 Mail Service Center -Raleigh, N.C. 27699-1636-Phone [phone]/ -'
WELL CONSTRUCTION RECORD WELLCONTRACTOR: /�� 5��1 4
WELL CONTRACTOR CERTIFICATION #: �ZYdL
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (check Applicable Box): Residential—Munic!pal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other M If Other, List Use:
Agricultural El Monitoring ❑
2.
WELL LOCATION: (Show sketch of the location below)
r
Nearest Town: 44 c e S A,2 Fr— County. Al(
DRILLING LOG DEPTH
(Road Name and Numoers. Community, or Subdivision and Lai No.)
3.
OWNER 4,, I�S�]j IT OEM CS
From To Fortnallon Description
V-7-
Address
151reet or H a a.
City or Town Slate Zip Cade
4.
DATE DRILLED
5.
TOTAL DEPTH a o S
6.
,r-5
CUTTINGS COLLECTED YES NOD
7.
DOES WELL REPLACE EXISTIN WELL? YES NOf47(
8.
STATIC WATER LEVEL Below Top of Casing: FT.
(Use 'i if Above Top of Casing)
9.
TOP OF CASING IS FT. Above Land Surface*
-
'Top of casing terminated utter below land surface requires a variance In accor-
dancewith
10.YIELD(gpm):
15A NCAC 2C.0118
/,. METHOOOFTEST
i
11.
WATER ZONES (depth):
12.
CHLORINATION: Type �% / '� f Amount
It additional space Is needed use bark of form
13. CASING:
.. �/ Depth��� Dl eter
From 71—To'-_ Ft.
From To Ff.
From To Ft.
14. GROUT:
Walt Thickness LOCATION SKETCH
or Weight/#. Matedal (Show direction and distance from at least two State
_4e&L& C Roads, or other map reference points)
Depth Material Method
From b To .2� Ff. dccRr
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 trtatedai
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.
Quad No: ..
Serial No.
Cp
O
O
71
C7
N
m
A
Z
tb
%D
SIGNATURE OF PERSON CONOfRUfMtfG THE WELL DATE
gat to Division of water Ouallly, Groundwater Section within 30 days
GW-I REV. 17199

` North Carolina • Department of Environment and. Nature[ Resources - Division of Water Quality - Groundwater Section l.. 21 Z S 6 6
1638 Mail Service Center -Raleigh, N.C. 27699-1636-Phone (919) 733'3221WELL CONSTRUCTION RECORD WELLCONTRACTOR:
WELL CONTRACTOR CERTIFICATION 0: Y3�
,tom STATE WELL CONSTRUCTION PERMrTY:
1. WELL USE (check Applicable Hasp Residentlal [L� _— un(cipal ❑ Industrial ❑ Agricultural (] Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other [1] If Other, Ust Use:
2. WELL LOCATION: (Sh�oyyv sketch of the location below)
Nearest Town:—/1"5.Lue �� County. 11_11..t_11,561,
(Road Name and Numcers. Community, ar a'ubdiviston and Lai No.)
DRILLING LOG
3.
OWNER C c, r,\1 P
From To
'G Ile
Address
Itilrem or Houte o.
City or Town Stale Zip Cade
4,
DATE DRILLED - -00
5.
TOTAL DEPTH ,,aa--��
YES NOO
6.
7.
CUTTINGS COLLECTED
DOES WELL REPLACE EXISTIN WELL? YES Q NO(Ta
8.
STATIC WATER LEVEL Below Top of Casing: _ O FT.
(Use -+* li Above Top of Casing)
9.
TOP OF CASING IS FT. Above Land Surface.
'Top of easing terminated st(or below land suAscs requires a variance In actor-..
dance with 15A NCAC 2C.011e _
10.
YIELD (gpm): 3 METHOD OF TEST y
11.
WATER ZONES (depth):
12. CHLORINATION:
13. CASING:
DEFT
Formation Oesc ipllon
d �/C/L 21_,
Type LA Amount D If additional space Is needed use back of form
.. �L// Depth D alr
7 From _L�To L K Ft. -
From To Ft.
From To Ft.
14. GROUT:
LOCATION SKETCH
Wall Thickness
or WeighVFL Material (Show direction and distance from at least two Stale
—' 6 Roads, or other map reference points)
Depth Material Method
From b To Ft. _� EkRC
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 - "idaterial
_ In.
In.
_ In.
Material
O
O
O
rn
f7
tV
m
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C. WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD AS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY ..Q �) C
SIGNATURE OF PERSON 460NUCTING THE WELL DATE
Submll original to Division of Water Quality, Groundwater Section Within 30 days
h n
GW-1 REV. 12199
SeLbl
otindwate Section
:h2 [tile Rs lgnal Office_

• North Carolina
- Department of Envirrment and. Natural Resources - DivisionotWaler Quality - Groundwater Section. r- ti V 3
1636 Mail Service Center - Raleigh, N.C. 27699A7636-Phone (919) 73 m=l "- -
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION 0: of r%.3>!
STATE WELL CONSTRUCTION PERMfT9:
1. WELL USE (Check Appuc.,bb go): Residential �—{Municipal Q Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water injection Other [] If Other, List Use:
2. WELL LOCATION: (Show sketch of the iocallon below) r
f<y L S e
Nearest Town: '' 15 S County. A', Fr 11
(Road Name and N/Iumden, Caavrsrrdty, or J'ubdlvislan and Lot No.j DRILLING LCG
3. OWNER sr--Y e (7 �o �.i,�SC From To
Address
e at HoWe
City or Town Slate Zlp Cade
4. DATE DRILLED
5. TOTAL DEPTH ,aaa,..----��555 %C
6. CUTTINGS COLLECTED YES NOQ
7. DOES WELL REPLACE DOSTIN WELL? YES NOf1(
8. STATIC WATER LEVEL Below Top of Casing: ru _ FT.
(Use -+' 8 Above Top of Caskp)
9. TOP OF CASING IS FT. Above Land Surface' -
-Top of casing terminated atfor below land satiate requires a vartm" in actor-
dance with ISA NCAC 2C.0118 _
10. YIELD (gpm): I METHOD OF TEST � ti
11. WATER ZONES (depth):
DEPTH
Formation Oesutpeon /
D (/CiL �P/OQ7i
12, CHLORINATION: Type �% �� i Amount If additional space is needed use back of form
13. CASING:
Wall Thickness LOCATION SKETCH
L / Depth CM or WeIOVR. Material (Show direction and distance from at least two Stale
From To Ft.-' G Roads, or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From b To � Ft. �t G4RC
From To FI.
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:
Sic! Size Material
In.
_ In.
In.
Material
O
O
O
r*1
n
(V
CO
s
O0
w
00
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH iSA NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF IS RECOR EEN PROVIDED TO THE WELL OWNER
FOR OFFICE USE ONLY / -� ��
Quad No: SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
d IS�uo� R�L inal to MvWon at water Qual8y, Groundwater SecBon
Serial No, within 30 days
tl LLSS ` GW-1 REV. 12199

North Carolina • Department of Environment and. Natural Res turcas - Olvislon of Water Oua9ty -.Groundwater
Grmdwater Section. - 0 71636 Mail Service Center- Raleigh, N.C. 27699-163&Phone-(919)7=3=l - '— `
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION 11: 0ZYJf-1
STATE WELL CONSTRUCTION PERMrrlt:
USE Applicable sax): Residential R - Municipal ❑ Industrial ❑ Agricultural El Monitoring ❑
1.
WELL (chock
Recovery ❑ Heat Pump Water injection [j Other M
If Other, List Use:
2.
WELL LOCATION: (Shays Aelch of the location below)
to So%1
n�u--s
Nearest Town: c.%� County.
(Road Name and Numbers. CarmmNty, or Subdivision and Lot No.)
DRI WNG LOG- DEPTH
3.
OWNER I •t LkfC� (�rr�!-h
From To y Fomrasort Oesulpdan
Address
151reet or Route c.
Gty or Town Slate Zip Cade
4.
DATE DRILLED ZU ' � _
5.
TOTAL DEPTH Ll L/U
6.
CUTTINGS COLLECTED YES NOQ
7.
DOES WELL REPLACE EXISTING WELL? YESEJ NO(P7(
8.
STATIC WATER LEVEL Below Top of Casing: / o o FT.�
of
(Ilse' 0 Move Top of Casing)
-
9.
TOP OF CASING IS FT. Above Land
. .
•Top of casing terminated at/or below land surface requires a vartance In occor-�.
-.:. , _ ...:.... ..
dance
10.
with 16A NCAC 2C.0116 _
YIELD (gpm): METHOD OF TEST ti
i
11.
WATER ZONES (depth):
12.
CHLORINATION: Type �% f Amount
If additional space Is needed use back of loan
13. CASING
LL// Depth ?r
From �,L�To Ft. —
From To Ft.
From To Ft.
14. GROUT:
LOCATION SKETCH
Wall Thickness
or Weight/Ft. Material (Show direction and distance from at least two Stale
'��& S f'G Roads, or other map reference points)
Depth Material , Method
From b To Ft. Lr$'=vrA-t• EuRC
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:
Slat Size ` -Material
In.
In.
In.
Material
e]
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF IS R(/ D-FjA BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY `` - /, J22 /� ^/�
Quad No. - SIGNATURE OF PERSON CON3TRtlCTIKG1TMWE1L- DATE
� j� TI Sy It;pigtnal to DhWon at Water Quality. Groundwater Section Within 30 days
Serial No. L5. �., �„„„�L a, GW-i nE'L 12199
S-
0

North Carolina - Department of F_rtvimnment and. Natural Resources - Division of Water Quality - Groundwater Section �. Z $ 6
-- 1636 ne Mail Service Center - Raleigh, N.C. 27699.1636-Pho(919) 7==1 "
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION S:
STATE WELL CONSTRUCTION PERMITS:
1. WELL USE (check Applicable ao:): Residend2l P_ v unlcipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other M If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below) ,
Nearest Town: P4 112=;. i County:
Agricultural ❑ Manftoring ❑
(Road Name and Numaen, Canm�luNly, or Subd(vistan and Wl No,) DRILLING LOG- DEPTH
3. OWNER ) �e U P I /:.� �(o L S P From TO Formaaon Oescdpaan
Address 'G
re or H=e
--ay or Town Scale Zip Cade _-
4. DATE DRILLED `�J —GO : V a
5, TOTAL DEPTH -2ee--55 '
6. CUTTINGS COLLECTED YES —NO�
7. DOES WELL REPLACE EXISTIN WELL? YES 0 NOaa
8. STATIC WATER LEVEL Below Top of Casing: ^& FT,
(Use Z 0 Above Top of Casing)9. TOP OF CASING IS FT. Above Land of
-
-Top of casing terminated at/or below land surface requires a "dance In accor-
dance with 15A NCAC 2C.0113 _
10. YIELD (gpm): __ METHOO OF TEST
r
11. WATER ZONES (depth):
12. CHLORINATION:
IS. CASING:
Type - L i Amount Z If additional space Is needed use back of loan
LL // Depth c der
From Jl�To 23 Ft.1,
From To Ft.
From To Ft.
14. GROUT:
LOCATION SKETCH
Wall Thldarss
or WeighuR. Material (Stow direction and distance from at least two State
' G Roads, or other map reference points)
Depth Material Method
Fromy To FI. 6t1/ZC
o
From To F1:
Q
15. SCREEN:
rri
::0:o
o T
Depth Diameter Slot Size ` Material
17
From —To—Ft— In, —in
co
_o<
From —Ft. In. - _ In.
3> o
—To
From _ To _ Ft. in- In.
3
z o
16.SAND/GRAVEL PACK:
CO
rnz
Depth Size Material
c..)
~A
From To—Ft—
From— To Ft.
x
17. REMARKS:
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C. WELL
CONSTRUCTION STANDARDS, AND THAT A COPYOFTHISRECORDHAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFF)CE-YS . (:�
SIGNATURE PERSON CONS CTiNG THE WELL
DATE
Ou}d N ( 1 OF
I': J_ 1f1! i�
i
y - Sub:rdt original to Division at Water Oualfty, Groundwater Secdan within 30 days
Serial I 3 j "
GW-1 REV. 12199
I�
__.
an

North Carolina •Department at t_mkonment and Nature! Resources - Oivialort of Water Duaery - GrourxfWater Section -
22859
- i W6 Mail Service Center -Raleigh, N.C. 27699-1636-Ptwne (919) 7=3 =l
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION 0:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Cheek Applicable Box): Residential P_ a Unic:pal ❑
Industrial 13 Agricultural Monitoring ❑
Recovery ❑ Heat Pump Water Injection 0 Other E] If Other, Ust Use:
2. WELL LOCATIO''NNJJ ('Taw sketch of the location below)
,
Nearest Town:?J County.
(Road Name and Nu{tra%ts. CommuNly, at ''uball 5fort and La! No.)
DRILLNG LOG DEPTH
3. OWNER ii I -1 >_r (,r t1
Front To Famudon Casalptlon
Address
'4-
ree or Houte
Uy or Town Slate Zip Cade
4. DATE DRILLED )- -O6
u 3 a ;re-,
5. TOTAL DEPTH G
6. CUTTINGS COLLECTED YES NOQ
7. DOES WELL REPLACE EXISTINLL? YES 0 NOaa
8. STATIC WATER LEVEL Below Top of Casing: ( F r.�
of
(Use -+' 8 Above Top of Cankp)
9. TOP OF CASING IS FT. Above Land
*Top of aaefng terminated at/or below land surface requires a vartanee In scow-...
dance with iSA NCAC 2C.0118
10. YIELD (gpm): _&_ METHOD OF TEST 4
11. WATER ZONES (depth):
12- CHLORINATION: Type �•. L f Amount
If additional space is needed use back of form
13. CASING:
Wan ThIcknew
LOCATION SKETCH
LL // Depth D efer or Wefght/R. Material
�'
(Show direction and distance from at least two State
From J1—To Ft. -��& S
Roads, or other map reference points)
From To FI.
-
Fmm To Ft.
14. GROUT:
Depth Material L Method
From To FL Lrt9�.e� d[cRC
From To Fl.
15. SCREEN:
Depth Diameter
From _ To _ Ft In.
From — To _ Ft. In.
From —To _ Ft. In.
16. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To Ft.
17. REMARKS:
Slot Size -Material
In.
In.
In.
Materfal
a
3
CA
LJ
%D
U
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 1SA NCAC 2C. WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OFRECORD
REEN PROVIDED TO THE WELL OWNER.
7OR OFFICE USE ONLY
NSd4la „ "' "I "' ' p SIGNATURE OF PERSON CONS QJNG THE WELL DATE
V r, A I Sub uit original to DfvWon of Water Quality, Groundwater Section within 30 days
e (iN a GW-1 REV. 12M9
1 r'79t+wa Secr un

_ North Carolina - Department of Environment and. Natural Resources - OMslon of Water Quality - Groundwater Section 22 2 _� 5 �'
1636 Mail Service Center -Raleigh, N.C. 27699-1636-Phone [phone]=l - '-,.
WELL CONSTRUCTION RECORD WELL CONTRACTOR:/��%��
WELL CONTRACTOR CERTIFICATION A: 0,7y3jl
STATE WELL CONSTRUCTION PERMfT#F:
1. WELL USE (G" rack Appilceble Box): Resldendal v�-Hiunfc!pal ❑
Industrial 13 Agricultural ❑ Monitoring ❑
Recovery ❑ Heal Pump Water Injection ❑ Other If
Other, List Use:
2. WELL LOCATION: (Show sketch of the location. below)
f
i{ rl )- n n o S county.
Nearest Town: ��.T h' � �'
S !
c ' 1
(Road Nants and Numbem Cammntly, ar S/^ubalvisfan and Lot No.)
DRILLING LOG DEPTH
3. OWNER �! �` kin�no F Y
From To Fannatlan Oawlpdan 2
Address
'� '�� ��`L /✓`�r�dk�
isireet or HMO
City or Town Slate Zip Code
4, DATE DRILLED
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES NOQ
7. DOES WELL REPLACE IXISTIN WELL? YESEJ NOfaa
e. STATIC WATER LEVEL. Below Top of Casing: /(p_ FT.
(Use's' 9 Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface'
-
'Top of easing terminated attar below land surface requires a variance In accor-
...: ..,,,_ �..:. ..
dance with 1SA NCAC 2C.0113 _
10: YIELD (gpm): _/ o. METHOD OF TEST y
i
11. WATER ZONES (depth):
12. CHLORINATION: Type �• �� S Amount-
It additional space Is needed use back of form
13. CASING:
LOCATION SKETCH
Wall TNckmas
Depth � D eler of WeighUR Material
�'�'G
(Show direction and distance from at least two Stale
From _/1_/ To Ft. --
Roads, or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From b To Ft. d[1RC
r
CD
O �
From To Ff.
O E
15. SCREEN:
n c;
Depth Diameter Sic! Siz6 - Material -
r'3 a _
From In. —in
O ��-
—To—Ft—
From _ To _ Ft. In. In.
S-c
m
From —To Ft. In. —In.
= x
16. SAND/GRAVEL PACK:
en _'
Depth _ Size Material
C -+
From To Ft.
_
From To Ft.
17. REMARKS:
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY Of THIS RECORD BEEN PROVIDED TO THE WELL OWNER
FOR OFFICE USE ONLY`�j'
Quad �, _ SIGNATURE OF PERSON STRUNG THE WELL DATE
t Submit original to Division al Water OualOy, Groundwater Section within 30 days
Sedai �. _. GW-1 REV. 12199

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section 2 5 9 7
3221
1636 Mail Service Center - Raleigh, N.C. 27699.1636-Phone (919) 733-
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable IBM): Residential (Z Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sKetch I the location helow)
Nearest Town: //// -
Lot
3. OWNER
Address
4. DATE DRILLED/
5, TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑ NO®
7, DOES WELL REPLACE EXISTING WELL? YES ❑ NO®
8. STATIC WATER LEVEL Below Top of Casing: /Z-,> _ FT.
L (Use': 8 Above Top of Casing)
9. TOP OF CASING IS� FT. Above Land Surface'
'Top of using tsrminatad suor below land aarfaCe requires a vwlwce in aeeor-
dance with 16A NCAC 2C)e118
10. YIELD (gpm): :!2 METHOD OF TEST
11. WATER ZONES (depth): `3 -s
12. CHLORINATION: Type -2�A913 Amount 3
13. CASING:
Wall Thickness
Depth � er or Welght' t. Material
From —To �1 Ft' fp—
From To Ft.
From To Ft -
-
14. GROUT:
Depth Material M� et(to�d*^�'
From �_ To _ Ft. �p r"r � �'y
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From Jo t in. Z in
•
Fromo�tzin. in.
From To/ Ft in. in.
16. SANDIGRAVEL PACK:
Depth Size Material
From To
From To Ft.
17
DRILLING LOG
From To
DEPTH
Formation Description
if additional space Is needed use_ back or iorm,
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
46T, # 9 /
ol—
"`PlD yes ,4f`�
I DO HERE ONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUIS T PY ECORD HAS
OVIDEDTOTHEWELLOWNEnR.
v
FOR OFFIC ONLY t, SIGH OF PERSON CONSTRUCTI THE WELL DATE
Quad NO: �:, - G
Subt on ny to pivWon of Water Quality, Groundwater Section within 30 days cw•i REV. 12r99
Serial No.

22596
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center - RaleWh, N.C. 27699-1636-Phone (919) 733-Ml Q
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (check Applicable Box): Residential ® Munk:ipa1 ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
Agricultural ❑ Monitoring ❑
2. WELL LOCATIO : (Show sk/a�ch of the Location below) y �%
Nearest Town: �r+r Q �pp County:
�iltlV 2.5i`7CU (d .LRe1rn fu'r )
(Road -Name a� Nymbe�. Co�quWy, txlMSlon and Lot No.) DRILLING LOG
3. OWNER �� �j From To
Address 111.)X ag:�//D —
1r t r Roule o.
City or Town State Zip Code —
4. DATE DRILLED Irm-
5. TOTAL DEPTH —
6. CUTTINGS COLLECTED YES NO® —
7. DOES WELL REPLACE EXISTING WELL? YES NO® S. STATIC WATER LEVEL Below Top of Casing: L FT. —
S. TOP OF CASING IS v- FT. AboveTLnanTSurface') —
'rop of casing terminated atfor below land surface requires a varlance In soeor. —
dence with 1SA NCAC 2C.9115 —
10. YIELD (gpm): METHOD OF TEST 7 , —
11. WATER ZONES (depth): IQ D
12. CHLORINATION: Typo Amount
13. CASING:
Wall TNeknass
Depth/ ^ r or WeightlR. Material
FromTo �/J Ft.S-L �L
From To Ft.
From To Ft.
14. GROUT:
Depth �-MateriarylMethod
From � To � Ft. _-L.P�
From To Ft.
15. SCREEN:
Depth Diameter Slot Slur Material
From To Ft In, in.
From �To YE Ft. in. � In.
From To FL in. h1.
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
17. REMARK
(Show direction and
Roads, or othef
• r: Ml �r�.<�1.7:1•;:�y\{�• 1'J '4' �:•i • 49
-
DEPTH
Formation Description
Is needed 49 back of forr/M4
nce from at least two Stale
reference points)
N61'St
Quad No: Submit�h . kl oiviawn of wa er Quality. 0tou4waw section within 30 days DATE
Serial No. i I cw-1 REV. 1211119

Nonh Carolina • Depanment of Environment and Natural Resources - Division of Water Quality - Groundwater Section 2 Z 8 8 3
1636 Mail Service Center - Raleigh, N.C. 27699.1636-Phone [phone]
WELL CONSTRUCTION RECORD WELLCONTRACTOR: D. Bowman well Drilling, Inc.
WELL CONTRACTOR CERTIFICATION #: 2809
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable BOX): Residential I -r 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: *"^aA R^^
1247 Lorien Lane
(Road Name and Numoars, Community, or Subdivision and Lot No.) DRILLING LOG
3. OWNER Reinhold Lind From To
Address 4818 Pig Pine Road _
Creel or Routs o.
mla i1311 NC 38793
City a Town State LP Code
4. DATE DRILLED 1 0/ 1 7/ 0 0 ' __
5. TOTAL DEPTH �dN
6. CUTTINGS COLLECTED YES ❑ NO[J
7. DOES WELL REPLACE EXISTING WELL? YES EJ NO[J
8, STATIC WATER LEVEL Below Top of Casing: 41.1 FT.
Luse': If Above Top of Cuing)
9. TOP OF CASING IS 1 d FT. Above Land Surface*
-Top of cuing terminated Wor below land surface requires a varlance In accOr-
dance with 15A NCAC 2C.0118
10. YIELD (gpm): 1r METHOD OF TEST3;e � TQ>«
11. WATER ZONES (depth): 1Rn '
DEPTH
Formation Description
12. CHLORINATION: Type tahl Pt Amount F It additional space is needed use back of form
13. CASING:
Wall Thickness
Depth Diameter or WeighVFl. Material
From. To 45 Ft 6 1 /8 Sch 80 PVC
From —TO —Ft.—
From —TO —Ft.—
14. GROUT:
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
Depth Material Method
From 0 To 20 Ft concrete gravity flow
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 C
FOR OFFIGt uaa� 1)+Nt.l ( II U -
Duad No: l --•-• NA E OF PERSON CONSTRUCTING THE WELL DATE
— Submil o i Division of Water Quatily. Groundwater Section within 30 days
Serial No. II t l r y'( GW-1 REV, 12199

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section 222884
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELLCONTRACTOR: D. Bowman well Drilling, Inc.
WELL CONTRACTOR CERTIFICATION #: 2809
STATE WELL CONSTRUCTION PERMIT#:
1 WELL USE (check Applicable BOX): Residential® Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ It Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: M 14 @ 1 1 County: Madison
1222 Lorien Lane
(Road Name and Numbers. Community. or Subdivision and Lot No.) DRILLING LOG
3. OWNER Christina Strand From To
Address 1222 Lorien Lane _
(street or Houle o. _
Marshall NI -)87-1
City or To" State zip
4. DATEDRILLED 10/16/00 r--�
DEPTH
Formation Description
5.
TOTALDEPTH 360' -
6.
CUTTINGS COLLECTED YES Q NO®
�
rn
7.
DOES WELL REPLACE EXISTING WELL? YES ❑ NO®
or"
6.
STATIC WATER LEVEL Below Top of Casing: g _ FT.
7, ;==
(Use': # Above Top of Casing)
CC) ern
9.
TOP OF CASING IS 1 . 4 FT. Above Land Surface'
—tom
'Top of cuing terminated at/or below land surface requires a varlan" In accor-
rn
dance
10.
with 15A NCAC 2C.011E
YIELD (gpm): 1 � METHOD OF TEST ram+ �
Co
'
11.
WATER ZONES (depth): 300'
4
~
-edw
12. CHLORINATION: Type
tablet Amount 6 It additional space is needed use back of form
13. CASING:
SKETCH
Depth
Wait Thickness
Diameter or WeighvFl. Material (Show direction and distance from at least two State
From 0
To 20
Ft.6 1 8 S Ch 80 PVC Roads, or other map reference points)
From
To
Ft.
From
To
Ft.
14. GROUT:
n
Noce,
Depth
Material Method
From
0 To20
Ft, cone lrav; 1-17 flow rti �.
From
To
Ft.
15.SCREEN:
Depth
Diameter Slot Size Material
From
To _ Fl
_ in. —in �
_
From —To
— Ft.
__ In. _ In.
From _
To _ Ft.
_ In. — In.
16. SAND/GRAVEL PACK:
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 OWN R.
UQN ' I'
♦tNATURF PERSON CONSTRUCTING THE WELLDATE
o:
[F�RFFICE
p
Subnvl o Division of water Quality. GroundwaterSection within 30 dayso.
GWf REV. 12/99

�u,01b
North Carolina - Department of Environment and. Natural Resources - Division of Water Cually - Groundwater Section.
1636 Mail Service Center -Raleigh, N.C. 27699-1636-phone (919) 733:=l
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMIT#:
I. WELL USE (check Applicable sox): Resfdenllal p- N unlcipal ❑ Industrial 0 Agricultural ❑ Monhoring ❑
Recovery [:1 Heat Pump Water Injection 0 Other E] If Other, List Use:
2. WELL LOCATIC , `Show sk It 4Lof the location belowDun �Q.�
NeareJst TUWn: /�� 'S l // t)r
T%tt Z
(Road can Canv,�SutMlwsfao dLo1No.) DRIWNGLOG DEPTH
3. OWNER N- Foarmtlan Oesalpdan
Address TCI Jc� C/tz" �e=la v
I nee of outs
City or Town State Zip Cade —
4. DATE DRILLED /C�� �-� %Da� 7-575 t� S" —
5. TOTAL DEPTH ,,ee��--{{ii
6. CUTTINGS COLLECTED YE
SNOQ
7. DOES WELL REPLACE EXISTIN WELL? YES—
e. STATIC WATER LEVEL Below Top of Casing: FT. —
(Use •s' 0 Abme Top of caskq) -
9. TOP OF CASING IS FT. Above Land of
—
'Top of easing terminated stfor below land surface requires a variance In aeeor- ..:. .. .,
dance with 1SA NCAC 2C.0118
10. YIELD (gpm): '-- METHOD OF TEST—
i
11. WATER ZONES (depth): —
12. CHLORINATION:
13. CASING:
Type :;a /C S Amount l If addMonal space is needed use bark of form
L / Depth C r
From 7 L-/ I To J?— Ft.
From To Ft.
From To Ft.
14. GROUT:
LOCATION SKETCH
Wall Thldvass
or WefOhUR Material (Show direction and distance from at least two Stale
JI�W'n/,. �S f'G Roads, or other map reference points)
Depth Maler(al l Mdu.Xt
From b To � Ft.
From To Fl:
15. SCREEN:
Depth Diameter
From _ To — Ft In.
From — To _ Ft. In.
From _ To _ Ft. In.
16. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To Ft.
17. REMARKS:
Sici Slze Material
In.
_ In.
In.
Material
1 00 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDA CE WITH iSA NCAC 2C. WELL
CONSTRUCTION STANDARDS, AND THAT A COY THIS REC0 HAS B PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY /
Quad No: NATURE OF PERSON CONSTRUCTIN HE WELL DATE
Subndl odginal to Dtvisfon of Water Ouallty. Gmundwater Section within 30 days
Serial Na. GW-i REV. 11199
r
O

- 'M2
North CamBne - Department of Environment and. Natural Resources - DMsbrt of Water OuaBry - Cvoundwatar Section
- 1638 Mail Service Center -Raleigh. N.C. 97699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION 11
STATE WELL CONSTRUCTION PERMIT'#:
1. WELL USE (Check Applicable BOX): Residential unlc;pal ❑ Industrial E3 Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection 0 Other M If Other, Ust Use:
2. WELL LOCATIC (Sho ✓ sketch of the location below) n
Nearest Town: /r/�aCounty. 1�
(Road Name an Numoars. Co rr((��yy<<����ar�`y\hdih jton amend Lot No.) DRIWNG LOG DEPTH
3. OWNERT �Co �- lJ�'��C�-'�� From To Formadon Desafpdcn 2
Address 'G / TO -�-� D (/,'2 /✓`�/41.'-�
151reet or Houte
City or Town /Slate Zip Cade
4, DATE DRILLED I L 1J �� TTS
5. TOTAL DEPTH ee--55
6. CUTTINGS COLLECTED YES NOQ
7. DOES WELL REPLACE EXISTIN WELL? YES 0 NOaa
8. STATIC WATER LEVEL Below Top of Casing: FT.
(Use -+' ti Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface.
*Top of easing terminated stfor below land surface requires a vartanee In accur c.:. .. ..
dance with 1SA NCAC 2C .0118
10. Y1ELD (gpm): r. � METHOD OF TEST
11. WATER ZONES (depth):
12. CHLORINATION:
13. CASING:
Type �r: I L Amount If additional space Is needed use back of torn
Depth 3 C �r
From 7 '-L/ 'To Ft.
From To Ft.
From To Ft.
14. GROUT:
LOCATION SKETCH
Wail Thlduess
or weighUR. Material (Show direction and distance from at least two Stale
' Z- Roads, or other map reference points)
Depth Material Method
From !% To Ff. 6ccRC
From To Fl.
is. SCREEN:
Depth -Diameter
From — To _ Ft _ in.
From _ To _ Fl. In.
From —To —Ft.— in-
16. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To Ft.
17. REMARKS:
Sla( Size ` "Aalerial
In.
_ In.
_ in.
Material
I DO HEREBY CERTIFY THAT THIS WELL WAS CON UCTED IN ACCORDANCE WITH 15A NCAC 2C. WELL
CONSTRUCTION STANDARDS, AND THAT A CO QFTH FIE G t EEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Ouad No: SIGNATuR OF PERSON CcNsTRu&nliG THE WELL DATE
Submit original to DtvWon of Water Quality, Groundwater Section within 30 days
Serial Na. GW-1 REV. 12f99
7-
0

North Caroline - Department of Environment and. Natural Resources - Division of Water Quality - Groundwater Section
1636 Mini Service Center-Flalelph, N.C. 27699-1636-Phone [phone]:'i221 - ,//_
WELL CONSTRUCTION RECORD WELL CONTRACTOR: eZSou
WELL CONTRACTOR CERTIFICATION it: r oZY36
STATE WELL CONSTRUCTION PERMIT*:
1. WELL USE (check Applicable Boa): Residential o"unicipal ❑ Industrial F-1 Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other M If Other, Ust Use:
2. WELL LOCATIC, (p�%(S%cw sketch�./p��UT at�tion bekrw)
Nearest Tawn: t^ / ���s i " ! Cotmty.
(Road arcs a.��e/{ Nurtaen, C , tSubdlvislon and La! No.] DRILLING LOG DEPTH
3. OWNER //�O�P=�Otyar 4J From To Fom+adon Oesalp6on
Address /-
t Meet or Howe
City or Town Slate ZIP Cade
4. DATE DRILLED -
S. TOTAL DEPTH : 31K5 ,aa----555
6. CUTTINGS COLLECTED YES — 00
7. DOES WELL REPLACE EXISTIN WELL? YES Ej NOga
B. STATIC WATER LEVEL Below Top of Casing: FT.
(Use'+' tt Above Top of Casbp)
9. TOP OF CASING IS FT. Above Land Surface'
-Top of casing terminated atior below land surface requires a variance In actor ,. , .. ..
dance with 15A NCAC 2C.911e �7
10. YIELD (gpm): ,% METHOD OFTEST • 5
r
11. WATER ZONES (depth):
12. CHLORINATION: TypeAmount I'D If additional space Is needed use bads of form
13. CASING:
Walt Thickness LOCATION SKETCH
L / Depth / 11 r or weighuR. Material (Show direction and distance from at least two State
FromTo .,� Ft. -- ' G Roads, or other map reference points)
From To FL
From To Ft.
14. GROUT:
Depth Material Method
From b To �Ft. C d[[/ZC
From To Fl.
15. SCREEN:
Depth Diameter
From —To—Ft— In.
From _ To _ Ft. In.
From _ To _ FL in.
16. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To Ft.
17. REMARKS:
SIa(Size `;vlaterial
_ in.
In.
_ In.
100 HEREBY CERTIFY THAT THIS WELL WAS
CONSTRUCTION STANDARDS, AND THAT A C
FOR OFFICE USE ONLY
Quad No:
Sedal No.
Material
VSTRU ED IN ACCORDANCE yfrH 15A NCAC 2C. WELL
'RECORDfW EN FrOVIDED TO THE WELL OWNER.
GNANRE OF PERSON CONSTRUCTING THE DATE
to Division of Water Quality, Groundwater Section within 30 days
GW-1 REV. 12MS

North Carolina - Department of Environment and Natural Resources - Division of Water Quality • Groundwater Section n 322-) r O 3 1636 Mail Service Center - Raleigh, N.C. 27699.1636-Pha(919) 733.1
WELL CONSTRUCTION RECORD WELL CONTRACTOR: LSD
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable BOX): Residential W Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL
3. OWNER
Address
of the location below) A J
County: A ack n —
0rkbdivislonand Lot No.) DRILLING LOG DEPTH
I From To Fomtation Description
City or Town Sun
4. DATEDRILLED
5. TOTAL DEPTH )SO'
�
6. CUTTINGS COLLECTED YES Q NO®
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NOW
B. STATIC WATER LEVEL Below Top of Casing: FT.
(Use'+' 9 Above Top of Casing)
9. TOP OF CASING IS 1 33 FT. Above Land Surface'
'Top of using terminated at/or below land surface requires a variance In accor-
dance with 15A NCAC 2 110 T m,ed
10. YIELD (gpm): METHOD OF TEST
11. WATER ZONES (depth):
12. CHLORINATION: Type --� 'Almount
13. CASING: �V nuf 1rlS1or
W/all Thickmu
Depth 'I ter )00.( or 7pVG_
From Q TO Ft.
From To Ft.
From To Ft.
14. GROUT:
Depth Mated aLl� MethodA
From SL_— To :)0—Ft. J.dQJLlr�—
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft in. _ in.
From To _ Ft. _ In. In.
From To __ FL In. —in.
16. SAND/GRAVEL PACK:
Depth Size Material
— r�
-------------
If additional space is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
+23 North of Ashevitte .TaKe-
L"Xis 4tq . Take ri( ht ort A�w,{ # )q Cro
"Proy. 4 milers mn 4tku f � a ' Ta.ke
ri l2t PR�ufh Circ1� - cwra. `/2 r0e.
OrL
Gi-O 0-proX �/� m t
From To Ft.
From To Ft.
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONS UCTED IN ACCORDANC WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY THIS RECORD HAS BE ROVIDED TO THE WELL OWNER. r
FOR OFFICE USE ONLY DATE
Quad No: GNATURE F PERSON CONSTRUCTING THE WELL
Submit original to Divwon of Water Duality, Grouridwalar Section within 30 days Gw-1 REV. 12199
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] �" •"' Fl
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION #: 2477Z
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (check Applicable Box): Residential Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injectlo� Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sk ch oe location below)
Nearest ,Town: •%i'72t- I County:
/
(Road Name and t(mby� ommuniry, or Subdivision antl Lot DRILLING LOG
3. OWNER / f! f�:,� . / From To
Address g� treat or old 02-�n7
A2_ /J lo
City or Town late Zip Code
4. DATE DRILLED O S
5. TOTAL DEPTH o S
6. CUTTINGS COLLECTED YESQ NO[Z
7. DOES WELL REPLACE EXISTING WELL? YES NO®
8. STATIC WATER LEVEL Below Top of Casing: 1— FT.
(Use': II Above Top of Casing)
9. TOP OF CASING ISZ 1:_ FT. Above Land Surface'
'Top of casing terminated atfor below land surface requires a variance In accor-
dance with 15A NCAC 20.0118
10. YIELD (gpm): _ 2 METHOD OF TEST _ �
11. WATER ZONES (depth): y lam'
12. CHLORINATION: Type T—
� 41 Amount
13. CASING:
Wall Thickness
Depth t Diameter or Weight/Ft. Material
From 19 To —11L Ft. � SJ" -11
From To Ft.
From To Ft.
14. GROUT:
Depth �Matena�l� Mejhod
From To n2n Ft. r� 9isX �o�T,r
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft in. n.
From To F In. In.
From To F In. tn.
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From � To Ft.
17. REMARKS:
DEPTH
Formation Description
If additional space is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
rnracroi rcrl OF -THIS RECORD HASJ1EEN P86VIDED TO THE WELL OWNER.
FOR OFFICE U LY -
Quad No: GNATURE OF PERSON CONSTRUCTING T WELL DATE
— " Submit to Division of water Quality, Groundwater Seaton within 30 days
G
Serial No. p W1 REV. 12N9

North Carolina - Department of Environment and Natural Resources - Division of Water Duality - Groundwater Section L j 9835
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:R. CALDWELL DRILLING, INC.
WELL CONTRACTOR CERTIFICATION #. 140
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' (Sho sketch of the location below) 1
Nearest Town: r' w`*'a� County.�' S 0 11
(Road Name and Numbers, Comrn7njtY o bdivlsion nd L- ot . DRILLING LOG DEPTH
3. OWNER �S�-�� /B/o4-✓L W '� u ') From To Formation Descd lion
Address _�1i -)IuZ � r Cr-a C7— S5 L�e —
13irft or MOU18 o.) 3 o tS" Rc�c--lc
City or Town State Zip Code
4. DATE DRILLED Jo - /i —Z.c� o
5. TOTAL DEPTH 152f 1 _
6. CUTTINGS COLLECTED YES ❑ NO[�J' c�
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO2r
B. STATIC WATER LEVEL Below Top of Casing: 1-15- FT. _ .r
(Use'.' if Above Top of Casing) -mot
9. TOP OF CASING IS+ FT. Above Land Surface'
'Top of casing terminated atfor below land surface requires a variance In accor-
d ance with 1SA NCAC 2C .0118
10. YIELD (gpm): *20 METHOD OF TEST?-
11. WATER ZONES (depth): (Ob— LO
12. CHLORINATION: Type 14r_k1f Amount It additional space Is needed use back of form
13. CASING:
Wall Thickness
Depth DI ter or Welght/Fl. Malaria
From D To _� Ft. 1, '4 p U
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From To Zo Ft.
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From —To—Ft— in. _ In.
From —To —Ft. _ In. —In.
From —To —FL _ In. In.
16. SAND/GRAVEL PACK:
17
Depth Size Material
From To Ft.
From To Ft.
I DO HEREBY CERTIFY THAT THIS
Quad No:
LOCATION SKETCH
(Show direction and distance from at least two State
2s
Roads, or other map reference points)
70
ISTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WEl
OF THIS RECORD HAS BEEN PROVIDED TO THE WELL
SIGNATURE OF PERSON CONPJAUCTING THE WELL
al to DlWslon of Water Ousllty, 016undwater Section within 30 days
Serial No.
GW-1 REV. 12199

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section 2-1 9 -7 Qo
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone] +,[.y
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (check Applicable Box): Residential L]J Municipal ❑ Industrial ❑ Agricultural ❑ Monlloring ❑
Recovery ❑ Heal Pump Water Injection ❑ Other If Other, List Use:
2. WELL LOCATION: how skelcl oLl a location below) / I / r a -7,(_
Nearest Town:.. {�,%1t 6 County: / Y1�`-' -� —
(Road Name n Nu bm o s, Como,
3. OWNER)Ur L
Address --, ( " -) ,
City or Town "! (/ Cave
4. DATE DRILLED
5. TOTAL DEPTH
6. CUTTINGS COLLE TED YES Q
7. DOES WELL REPLACE EXISTING W'.
8. STATIC WATER LEVEL Below Top of
(Use'+
9. TOP OF CASING IS_�_ FT. At
'Top or casing terminated at/or below land surfac
dance with 15A NCAC 2C.0118
21 METHOD F
10. YIELD (gpm).
11. WATER ZONES (depth):
12. CHLORINATION: Type c�.J iC Amounl _" It additional space Is needed use back of forna-i -
13. CASING:
and Lot No.) DRILLING LOG DEPTH
✓` i From To Formation Description
C
/,/II Depth L' Diameter
From-( ) To - - Ft.
From To Ft.
From To Ft.
14. GROUT:
Dept,
From To _
From To _
15. SCREEN:
Wall Thickness
or Welght/FL Material
Mat nulpd,V(
FL !i(i
Ft.
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 %Iaierial
In.
In.
In.
Material
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
CONSTRUCTION STANDARDS. AND THAT A COPY OF THIS R59�
FOR OFFICE USE ONLY C
Quad No: SIG TUBE PER
Submit original to Division I Water
Serial No. :::_=:_=_J
LOCATION SKETCH
(Show direction and distance from at least two Slate
Roads, or other map rplerence points)
Cd
V-�o
t,
Coje/CCi( rd
)ANCE WITH 1SA NCAC 2C, WELL
BEEN PROV DED TO THE WELL OWNER.
INSTRUCTING THE WELL DATE
Groundwater Section within 30 days
GW.I REV. i2A9

M
229428
`oilh Cnroli ,n ,f r,io,, nrtnt find Nelurnl Rennurree - DivkInn of Witter Ouellly • Oroundwaler Seclion
636 Mail Srwk:e Cenlrr - Itnlrlph, N.C. 27699.1636-Phone [phone]
WELL CUIJS i flU(1 IUW RECORD WELL coNlnnclon: C�Ry��Ba�-
WELLCUNTFIACTOnCEnTIrICATI011 ^,r
STALE WELL COI1STnUCTIOf1 PEn611TM:
J. WELL 11! [ (Cbrck Al lamelar fie,): nesidentln6 Municipal ❑ Industrinl ❑ ngrieullurst U Monitoring ❑
necovnry [_ I i I.mt Pump Water Injection ❑ Other ❑ II Other,
Llst U/sye:
2. WELLLO(IALI(M) " 5wsknlrh I `Se cation below)
Noisiest Iown:- ,i county:
(noad rlmmn
3. OWNER _
Address
rms, Communlly, or Subdlvislon and
DNILLING LOG
From To
>J
F=f?•�
Fonoeeon Description
Ciry o�pn
'�cws�'s'a.=".__ - zip Code - -
w l- Slale -
4Q. DATE URILLr:ry �' O0Q0
5. TOTAL UFP III __. 4- ' CD - -
6. CUTTItIGSCOLLFCIED YES❑ NOM
7. DOES WELL fiEPLncE EXISTING WELL? YES [_]_ IFJTO[
0. STATIC WATEnLEVELBelow lop
olC9slnp:�
(use's "Above top or Cnslrp)
9, TOP Or CASUiG IS--___�____ rT. Above Lend Suflnce' _
•Tap of ceth,n Inndn^Ind aPvr below land surface requires a vedanea In aeeor-
dmaeWith l5nIIC1C2C. to
10.YIELD (CuIn _�QMETNODOFIEST
11. WATER ZONES (dcpllr):— p
12. CHLORINATION: type — 11_L�--Amounl -0-- �T' 11 additional Rpnce b nendnd ti.n back or form
13. CASING:
Urt�lh '�/�,,�Q /Dlnm�etrnr
Front_ ---In __7 a FI.4�-�--
From------ l o ..---- rl.
From._.-----lo.--- FI._
I•
LOCI1110N SKFTCU_
well IhIC Less
Orr97W"e1pn1,=1. Merin? (Show direction and dislnncn born It Innsl two Stnle
{tne•j.e1:l- i�e�SR needs, or other map ielerence Points)
14. GF10U Method
Rnl�llt Mnlerinl
NOT"
alf�_rl. _C,E,zLell Froin ._ __. To-
15. SCnErn:
ltrpth Dlmnninr Slol Slre Mnlminl
riorn In _ F I _ _ _. In. ____ III.
Prnrn _-- _ _._ I ' -
1 L In. — In -
Front __ -_. .
. l o .. --- f 1.-- In.
16. SAND(GIIAVFI. PACK: material
Size
Ftorn ----- -- In -- Ft. -
Finns _ ...-_ 1 n - Ft.
17. FIEMARVS.---- -.--
1 UO ItFfir n, <.1-n Nr \ lit%V lien WELL WI
CON91 r11A. 11('II S1 PI )MID9, AM TIIATA
FOIL Ur rIGF- USr: (!(1`Y-�
Oued No: i'. Submit
Sedel 140
OIP-45
A&X,11
P do
1!:11hUr IN /jCCOnOANN no IS. IICAC2C,WFII.�-
$)Plt, EC T7DHAS S.EN PTlO IOF.D to 711E WELL OWfIE
_ FL
DATE
ONAIUnEO 1nS011 COf19Tr1UC 11 TIIF. Sa<Ilan wllldillI
Io Divillon of Writer Ouelily, Oroundwster n 30 dnys OW 1 my. 12199

229422
North Careen❑ . Drpmt.... nO of F!rvL orn!,11 rind Natural Re-ourcrs - Division of Water Quality - G!oundwnter Suction
1636 Mail Srrvice Crntrr - nnlrlgl,, N.C.. 27699-1636-PItone [phone]
WELL CONSII1UC110N RECORD WELLCONTnncroR:
WELLCONTTIACTORCERIIFICATII
STATE WELL CONSTRUCTION PEFlMITM:
1. WELL tISF no.): Nesldenllalb? Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Flecovrty l-) I Inat Pump Water Injection ❑ Other ❑ II Other, List Use: _
2. WELL 1.9CAT ION: (Shoal skelch of the location below)
Nearest Trnln _r(\a C AA County:
(non•! namr rind tdnnull <, Co , u p7Ily, Or Subdivlslon and}ot I DRILLING LOG
3. OWNFFl _-�-'- J •0 �///// -/-y--Froom To Addle, _ -�U. L Obi �� call
(Gill r•S or frula L
Cily nr lawn Sale zip Code
4. DATE1)1111LED
5. TOTAL UFt' 111 cz7. 1Q�.__ -
6. CUT] If1c;SCOLLFCIEO YES[ N01�
7. DOES WFI_L f1EPl ACF. EXISTING WELL? YES 0 NO 1M --
8. STATIC WAT ER Lf.VEL Below Top of Casing: ,P!2 FT•
(Use'.' 11 Above Top of Casing)
9. TOP OF OASiNG IS ___-L_._ FT. Above Land Surface'
'Top of ca11110 trrmbinlrA ""I hrlow trod turfaee requlrat a Vedarlee In accor-
dance with 151k IICAC 2C .011a
10. YIELD (g{,m): METE IOD OF TEST
11. WATER ZONES
12. CHLOf11NA11ON:
13. CASIIIG:
_--DEPTH
Formation De5crlplion
I ypo —� Amounl S It edditlonal spare Is marled use hark of form
Ylall T hlcl%ness
/�
Drl,lll
�
Diameter
Ft. J
o� I'1/F' Maledal
,. ---- , n
� L�YL>>LT't.
From_ S/
--lo
From-- -...---
1 ^ ----
Ft.
--
From _.----'Io._--
Ft.
14. GFOU I:
Drplh
n-M_at�eri�al_� Method
�___
to �Y
Ft.
From __
—
Frorn _._--
lo----_Ft.
15. Scurf I.
Drpih
Diameter
Slot
Size Material
From ---
_ I o _ ---- 11
__
In.
_ in.
From —
.To___— Ft._—
In.
In.
Front _.__
_ To _ -_— Ft,
—
In.
_ In.
16. SANDIGRAVEL
PACK:
Depth
Size
Material
From —_—
In
Ft -
From ___
— To
'FL
- - ----
LOCAIION SKEICH-
(Show direction m,d di stm!cu from nl Inast two Stale
Roads, or other amp reference points)
17. FlEMAIIKS:
I DO I IPRF RY CFTTI]j1",'fHAT fiHi3-WELL WAS COIJSTRUCTED IN ACCORDANCE WITH 11SA NCAC 2C, WELL
CONSInucTIOf151111 i)ARDS, AND TfiATACOPV OF/THIS RECORD HAS�EEN ED TO THE Y/ELL OWNER.
Is. el
IT
rosoo.
R OrrICE USF1 Y DATE
ad flo , SIONAIU EOFf ERSON CONSIRVCTINR TIIF. WFILSubrallor101naltoDlvlslonof Waler Dustily.(3mundwaler Snclion WIIIdr130 days ow IREY IV99
rial IIo

.1. ' .., . .. J e.4�?::.".. �.y I .k..1.,�•`h..,t""1•f^ ...' ` : ,,( ,.Y n. ... L., Y 1
i
229423
4onh Cmph,m - tlrpnrwww m r mft,unenl and Nnlumi ►lenoancee - Dlvlelon of Water Quality - Oroundwoler Section
630 Mail Snrvirn Cower - Ilntelgh, N.C. 27699-1636-Phone [phone] --ce--'�
WELL CUWS1)(UCIIOFJ RECOflb WELLCOfJTnnCTOn: JD-E—F�RgtxSa
WELL CONTnACTOn CEnnrICATIOIT P:�
STA1F WELL CONSTPIUCTl011 PEt1MIT11:
J. WELL Usr: (Check At pnr.hle Pow). nesldnnllaihd Municipal L-1 Industrial ❑
(lecovriy j _] I Irnl runup Water hijecllon ❑ Otller F] If Other, Llsl Use:
,
2, WELL LOCA I IOIJ: (9�1ynw skelF11 0l 1he tocallOn below)
Nearest town: _ /{�(d l' «Id County:
Agrlculturnl U Monitoring
jnold tiara- and 1 ,f, cos -cum" -it y, or Subdwislon and Lot No.) DnILUNO LOG
3. OWNTII Rom io
Address r
.,rr or ,quo o. �prj
1 (MAO_
Cnym to.,.. - time Zip coda
4. DAIEIII III LED
S. TOTAI.IIt: 1,111
G. CUTI N(:. COU TC I ED YES O NO[ 1%
7. DOES Wrl I_ IIPI'111CF EXIS11IJ0 WELL? YES u,IJO
8. SIATIC WAIEn LEVEL Delow lop of Casing: /L'ei FT,
(Use'+• 9 Move top of cash,g)
9. 70P Or FT. Above Lend S1ldnea•
-Top of Cash,!, lemilnnl�d e1411 below land eurlses taqultai a vaslanes In secat-
ance with 15A IWAC 2C A a `
18.YIEI.O(nPr,1) __O�.MEIII000FTEST g ---
11. WATEn 701JES (drplll):_
ypo Amould sI�S II addlllorMl apace b nrerind usn bock of loan —
12. CIIL01111JAIION
13. CASING:
Wall tldc4nese'
O
Urrlh
p
P101wer or Wplgr,V,7,14. Me�V�Sd1t
Flom ---
14. GnOD 1:
Ur1.111
olhod
77``
p,Mnlarinl
rrom
rrom
15. scnrrn:
Urpih Dian,Fllor
Slot Slie Mnlarinl
• Flom ---1n-.__.—rl._._In'
rrom .__.
_.. To . ..__ rL__
In.
J8. SAND/C;TIAWA.
rACK:
Material
Derth
Size
From
lo-
rrom ..----
to rl.
—
17
IoofirllrtlyCrAH yJill
CONSTIIU�IIOI�f' F{
rOTI Off ILr LISF <)JILY
Oued Nn:
sedat ftn
__. UEP111_— _
rowwion DemlOan
_
_ Btaroc�--o—
. LOQA110N SKE 1 CII
(Straw direction rind dlitmlca Imm at Ieul two $tale
noads, or other map tolerance polnu'
AaU'j4P led
I TA �Er OF 111419 I'EC0 o/CTED It, IA sm'pnIQVIDFOI 111E WELL OWNEn.
�()rr`�-�� - oa
. tNATI10 ON9Tf1UCTINO 111E YJF.II
DATE
9ubnll oll1 Iq Dlvlllon 0 Water Ovatlty, 1t3MWK caner Section Wllidn 30 days OW1 NEV. 12r99

J.
229417
North Carol -,a . l7cpminv nl nl rnvironm?nl end Natural Flesources - Division of Water Ouarity - Cioundwater Srctlon
1636 Mail Fr•rvirn Conlnr - rlalnigh, 11. C. 27699.1636-Phone [phone]
WELL COIJS1IiUC1lOIJ RECORD WELL CONTRACTOR: &
WELL CONTRACTOR CEF1TIrICAII( 4 It y'l
STATE WELL CONSTRUCTION PFFIMI IN: --_--- -
1. WEII. USF tclre[l: nl.l.u.:anl,. n�.); Fle.^,Idenlial LY Municipal ❑ Industrial ❑ AgrlcUMIl l ❑ Monitoring ❑
Fleco.r,y j_) I I^N r'UUtI` Water Injection ❑ Other ❑ If Other, List Use:
2. WELL. LOCAI ION: (SI, rl� nlch o I! a loc tlon below)----
NeareM l or.n: ---___- ,1�, - County: �c LLI.O
---- -
(nomr ilanw Ned Ilnnh c, Contn¢mily r b ' ISlon a d I No -DRILLING_---
3. OWNFFI _ _ From To
Addl 1
1"V
or $late Zip Code
4. DATE UFIll-I ED
5. TOTAL UGP if I
6. CUT1IH(V7GOI_LFCTED Y'ES❑ NO[o
7. DOES WFI-I_RXISFTING WELL? YES ❑ NO[l4 B. STATIC: WAl Ff1 Lf_VEL Below Top of Casing: FT.
(Use'+' If Above 70p of Caslnp)
g. TOP Or CASIIJG 17 _J ___ Fr. Above Land Sultoce'
-Top of ca III to nnln ntod aver betow lend euriece requires a valiance in aoaor-
l0. IEU15A rm): 2C. 1B
10. YIELU (grnt)t � - METIJOD OF TEST
11- WATER ZONES (deplh):-
12. CHLUMIJANON:
13. CASING:
_ _UEPTII_____
r ormation Description
rS _ Amount s11 eddl9onai spare is needed rise back of Ivan
1 YPe - -
Well llkl,nces
((�� Drlrih �q lamer or Wef11hML d^I
Flomy lei-/1-Ft. 0���� L'j'LtilL1C
From-- 10
From .- -To - -- Ft
14. GROUT:
Urpih �M,at�arhal�.%.� Method
From __ O l o .� Ft.--C.��"-'�'"_PQa red
From
15. SCHFFN:
Urpih Uinaleler Slot Size Material
Frorn ----- To _ _.—. rl In. -- in.
From _ _ 10 - _-- Ft. In. _ In.
From lo..------la.__ In. --In.
16. SANOIGIIAVEt_ rACK:
Depth Size Material
FromFrom-
17. REh1Ams:
DOIlrnf Pv Crilllry NIA1 T'lug WELL Il c
CON S I DI )r'l lOt l$ l ArmAnOS, AND T I IAT A
40
FO—no f FI(,F USF'(ItiLY
Submit jdpl
Sadal fto
_LOCATION SKETCH
(Show direction and distmrce from el Inast two State
Reeds, or other map reference points)
IALW �U�
IUCTEO III ACCOnOANCE Willi 15A HCAC 2C, WELL
1111S nECORO HAS %EEN PROVIDED TO 111E WELL O
OF DATE
pEDSON ONS1nVCTVa3 lilt WFIL
of Water Oustlly, Groundwater Sacllon within 30 days OW.1 nEV. 12199

_ 229418
North Camivm - I,rparhnnrml of Fnvironin wl end Nalurai nesources - Divi.^.Ion of Water Duality • Groundwater Section
1636 Meil Snrvirn Corti, - ftnlnigh, If.C. 27699-1636 Phone [phone]
WELL CONS-IIIUCUON RECORD WELLCONTnncron:
WELL CONTnACTOnCERTIFICATI P1�.1�4o'3JQ _
STATE WELL CONSTRUCTION PEnMIT11:
1. WELL tISF (ch"Ir nprlh t,tn no,q: nesidentfall,/Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring U
necovnry I loll Pump Water Injection ❑ Other Ej If Other, List Use:
2. WELL L(1CAT ION: (Show sknicll of the location below)
Nearest lowri__v� County:
(noa'I nan,^ I�ifn. nl�rre. 0omm�7rr{Iy, or Sub ivlslonend Lal No.) DRILLINQ LOG
3. OWNFn ll- _t( From To
Addivqs
or
Lip de
city ry lows Slate p
4. DATE Dft11.LrU_9-15.00
5. TOTAL UrrIN_._c��-_
6. CUTTfII(',SCOLLF(_'IEN YES❑ NOsg
7. DOES WFLL riGrl ACF FXISTING WELL? YES 0 NO t�
6. STATIC WAJ Efl LEVEL ©nlow ToP of Cnsing: 36-a FT.
(Use'+' 11 Above lop of Casing)
9. TOP Or CASING 15—_[—__ FT. Above Lend Sulfnce' -
-Top of casing rri nilnatrd nVnr below land tudece @quires a variance In accor-
dance with i5A IICAC 2C .0118
10. YIELD (mm* A %-_ METI IOD OF TEST _ ---
11. WATER ZONES
12. CHLOMIJATION:
13. CASING:
__ UEPTII_
ronnalion Description
e 5 —
Type Amount L ,5-PLhS It additional spare Is needed asa back of form
well 1 hlt4ne se
Url,lh
plam^eler or WetghUft, Material . „
rt..ft�
r,om�n
_-10
From------
From -------
1„ .----
Fl.
14. GROLII:
t,rl,g�^,1M_aleri`nl_�
Method
la pf.V—Ft.
From__. ✓_._.
Front _._—
10— ____
Ft.
15. SCRFiFt1:
Ury,d)
Dimneter slot Slze Material
From -----10
— ---- FI
-- In. — in.
From ----10
-----I I._
it" _ In.
r
To R.
_ In. —.Ill.
. LOCAT ION SKE.7 CH_
(Show direcllon and dislmicn from nl lensl two Slate
needs, or other map reference Points)
rom _.------ -
16. SAND/GRAVEL FACKC
Depth Size Material
From ---- 1n Ft.
From
17. nEMAnICS:
I DO I IFnrDV Cril I1[VI I61...TIII�4`NEf.L WA>J COI ISTRUCTED Ill ACCOnDANCE WNN ISA NCAC 2C. WELL
CONSrnl)C11011 S11cNDAn0S, ANDTIIATAC0gy07H1S FlEConDHASBEEN PnovIDED TOTHE VJELL OWNER)
Fort OFFICE USE O� Y DATE
DeaelloIDNIu rrensoncorf6rn cnnnnreweir
---- d Submilodif", to Dlvlslan of Water Quality. Groundwater Section within 30 d0ys DW_1 IT V. 12799
-c—
Se dal No

a ff L:.::,..' ._ � ...._ )�91.riI'lrfl S � 1:x1."� diiE'90t� '147�.'Cd;IL' `3"....1. f y`.+r". ,� r 7 . � •- ,.
-
229419
floe I Cerhl„n . r,^pm in,rnt nl rnviro-vnenl and Nnlwal rlesnvrces • Divlelon of Walar Quality • Oroundwaler Secllon
636 Mao Soivlcn UP, In - IInlelgh, N.C. 27699-1630-phone [phone]
WELL CONS] HUM 101111ECOfiD WFLLcomnnCTOn: �o�_��rRgUSa
WELL COrlTnncrOncEnTincATlOr16:�
STATE WELL CONSMUC71011 PFRMIt#:
1. W FLL USE (amck nt rnr.me n,•*): tlrsldnntlalLil MunlCtpsl [] Industrial ❑ Agricultural LJ Monitoring EJ
Recovrly _J I irnl pump Water In)ecllon ❑ Other 0 It Other, Llsl Use:
2. WELL LUCAI I011 (°: ww sk II o111Ja location below)
Nenrestlown:_ County: 7!'(
jnonl frnmm� �� .n^i s. Conan u,lly, Sub Ivl la and lot No.) URILLINO LOO
3. OWtJFII _ CQ,,_ From To
Address
--�`— I .jirri or IT;; 5 T '�
Ct—f �?ir�b a zip ode
4. DATE (1011 -1)
5. TOTAI, 111:1 11I L� L�
6. Y
CUrTux:.^•CVILFI�IEU L•S NO
7. DOES WFIJ_ IIEpIM:E EXISIING WELL? YES L7JIJO[►
B. STATICWAIEnLEVELEIelorvlcpolCosing:FTr
(use'f' 9 Move Top nr Cash"g)
9. Top Or CASING IS --_ I—_.. FT. Above Land Smince' _
-top of eesl11n I•nnlnnl^d rih.r blow lend eurfaee raqultes a varlanee In aeeot•
anca with I'A IICAC 2C .a l ae '
to. YIELD (a1`m): jo _ MEII1000FTESL
11. WATER 7.ONES (drplh):
__- UEPT11___ —
rormeltM oesr-dplion
(JpC—k-
12. CI ILOMNAi IUN: type
_I_L Amoun( 11 eddltlonnl epnce isnreded nvn bark or
13. CASING:
Uri,g„ � Ierneler
From._.__.—_lo---.-- I't.
ROU I'
_LOCATIQIJ 51<E1C�L
Wes ihlcS'nesa
or Welr)1-M lAntedel (Show direction end dlnlnncM hem fit IAAtI two Stale
=Was. �nR
needs, or other map fetelence points)
14. G
I,rl�llr
Ma1a1101
From
�oll
15. SCrlGrll:
Urplh
Dimnalor
Slot Slze
MnImIn1
From
_---
In.
• From
- l o .-_-_—
t-L _..—
In. .--
In.
rrom ...
-_. Io. ..__rL_.�
to. SANUIGRAVEI. PACK:
Material
Urplll
Size
From
From
17. REMARKS: gp
I bD 1IFIlEnV crnnrv,llnT^IN4 l'�REkI "W DtE FN 1,19 nECO C1Ar9 BEEN PnAMCP IOVIDFD TIOT I IE WELLL0
C0NSIrILlpT101l SIMIUARDS.AND:'E1J I9 =,..7:
rOIIOrrICEU$r•OIILV 11 (", It Tl1nEOrrERSOq fl91nVCTINO/11F.1'IF.II.
Dued Nn: — --- _ ...-...
Submit odWlnd 1 -Division M Waw OvNlty, Orpta,dwNer Secnan Wilhln 30 days
Sadal tM ----- [.
DAIE
aWI REV. 121t

—. .: �' ._._ Jr� vn i� C.&r�d'fN`.a�''�+Y-.-:'1'`3.'.aL" .,t•�'v�.:Ci'""�,.. � ?:: J � .._..
1. .. Y. .. ... ...� R�•1n.Yfi'f 1 �YV.aid'; 'ail tali ^i..il ,,.
229420
North Carl - Dernnnlcnt of Environment and Natural Resources • Divislon of Water Quality • Groundwater Section
1636 Mail Service Center - Ilalelgh, N.C. 27699-1838-Phone [phone] '"�
WELL CONSTRUCTION RECORD WFIL CONTRACTOR: TOO- ��R4U 5oN
WELL CONTRACTOR CERTIFICATION n:�O� L.
STATE WELL CONSTRUCTION MINI p:
1. WELL LISE (Check Applicable Box): Residential6,( MunlCipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ I leal Pump Water injection ❑ Other O If Other, List Use:
2. WELL LOCATION: I w skotcf} of the I cation below)
Nearest Town: - W4 171- County:
(Bond I lamp end Norot rs• Comnlurlty, or Subdivlsl and Lot No DRILLING LOG
3. OWNFn From To
Address ',1�1A/�
IieCl Of Hou o
Ceya Town state Zip Coda
4. DATE MULLED �-
S. TOTAL UFrtll
6. CUTTINC.SCOLLFCIED-YE_S[ NOg
7. DOES WELL REPLACE EXISTING WELL? YES N0
[�
S. STATIC WATEn LEVEL Delow Top of Casing: �6? FT.
(Use'a' It Above Top of Cesmg)
9. TOp Or CASING IS FT. Above Land Surface' _
'Top of cask,p tennlnnled ever below land surface requires a variance In accor•
dance with I nCAC 2C bl *
�0. YIELD (Qrnl): _ MET11013 OF TEST
11. WATER ZONES (depth):—_
__DEPTH--
Formation Description
� ME
12. CHLoniI,1A1ION: Type — Amourd It additional space Is needed In," bank of form —
13. CASING:
_LOCATION SKETCH
Well 1lickness
Depth /1 pla- te
m�eter or Wa1g1,VFt. Material D (Show direction and dislnnce from at least two Stale
From O To . 36 Ft. It1_�.1--- M1 Roads, or other map reference points)
From----- To F1.
From_._—.—ln..-- Fl.
14. Gn011 l:
Urpllt Material elhodCC%�ASN
From lo_aIQ_FI. i10h
Flom - --_-- 10----,—rl.
15. SCREFr1:
Depth Diameter Slot She Material
From —_ 1n ----- FT _— In. _ In.
From _—To—rt.— In. —In.
From ____ To _ _.— Fl. In. — In.
16. SAND/GRAVEL PACK:
Depth Size Material
From To _ rl.
From _—_— lb Ft.
17. REMARKS:
1 DO IfERr RY CF.RI IFY 11,1AT-1 I IS VMLIL YVJ
CONSTRUCTION STA"DrAnDi. AND`T"AT-a
FOR OFFICE UfILY —
Guild No: tl.
Submit
Serial No. +;i:7r
9TRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
,1F T IS RECORD HAS BEEN PROVIDED TO THE WELL OWgj� _p d
URE OF PERSONCONST "Na THE WELL GATE
"Division or Water Duality Omtxtdwaler Section Wllhln 30 days DW 1 REV 12l99

229404
'orlh CnroOn..1. r'ryn,l...rnl ,I rnvLnnm^nt rind Natural ne.".nmee! . D1v1,Inn of Writer Ouellly • Omundwatrr Serli n
.636 Mail SIrvice Crrnlrr Ilnlrigh, N.C. 27699-ismPhone [phone]
WELL COIJSi11UC1IOIJ FIECOFiU wELLcolrrnnclon:-P-Rj—'F
WELL CONTIIACTOn CEFlTlrlCATIOr1 A. PG7_L--
STAIEWELL COr1STFlUCTlOr1PENMi9a:
nnsldnnllnlL'1CJ Municipal ❑
Induslrinl ❑ Agricultural A Monitoring U
1. WELL I1^.t: (Check Arrnr,N,I
[_ I b,nt rump Water Injection ❑ Other ❑ If Olher, Lisl Use: _
necovmy
2. WELL I OCA t l0t l: nw ak .lr:h/o1 Ule location belov+) N/fQ
/n��
Nearest lown: --['�. �'ehfp--� County:
(noad Min'. rind nh�is/. �ComnnmtlY. or Su division end Loll fro.)
3. OWNFfI O-�L•[_�/ J _
UnILLING LOG-Foimatlon DeudpUon
From 70
Addres G�--SjamITT
of—o—r cu e
y
f—Jc
Zip Code
City
-IfZ
O
A. DATE DniLLFI:7-9'a��a
n n
5. TOTALDrrlll _.
6. CUTTOIGS COLI.FC1 F0 YES E] NO[V
IMPLACE FXISIIIJG WELL? YES 0NO
rn
•� 2—
7. DOES WFI_I_
LEVEL Below 1opofCasing:
na-
e. STATICWATEn_,I1ZFT.
(use'+'aAboveTopol(3eltnp)
9. TOp or CA -it IG r; _I—__ FT. Above Lend Surface'
___---
'Top of cellnn rennTnalnd el'or below lend autfees requires a vedanee In aeeor-
a
dmce wllh 15A tICAC 2C .0110 .
i2 ACC-- METHOD OF TEST
0
`
10. YIELU (gprlr)
JJJ
z
11. WATEt1701JES (drplh):_—
—
)r�Amounl
---�
UG
If additional space is neriOnd usa brick of loan
---
- "-
12. C)ILOrtIIJA1IOtJ; type _
13. CASING:
A� Urplh ����J Inlan,elm
From _ "-- 10A.e--
From-----
From ----To -- Ft._
I'
LQCIITIQN_$KFTCH_
WAIT TMapne!!
or yJetgnb'� Mat„-_^!r'1 „ (Show direction and dlslonre Iron a1 Ian>t Two Stale
j& U PW_SQ Floods, or olher nlnp reference points)
14. GIIOU .
Mnlellnl
Method
Itrldh
U
_-Pam a
Frcrn __.U__
to _
Ff0111
15. SCFlErt,
D�ppl
Illanlctor Slol Size
Mnlminl
In.
Frrnn
lo_ _ ---11.---
In.
—
FI
In. — In.
Fron, _.-_._lo-
16, SANDIGIIAVFI_ m3l': o materialUr{'nl Size
Frcrn _ -- T n --- Fl.
Front _.. _.._ T o -
17. FlEMAI11:3._--_—_---
I UO In-nr p, Cr r, tit Y II 'AT Tl%In WELL WAS CQIjisII �vtIr
CONS; 11,1(-.11(711 SIA.111?Af1T71, Ar1V 111ATA COi(Yfv/ Iil
r01T OT l l(,r U E:(IIII Y �
Wed No: Subn9t o In!
Sedet No _ =.i3n
111 ACCOMMICF W1111 ISA NCAC 2C, Wrl.l.
Cono it 513EEN P VID[D lU 111E Nlfa L. UWNEn.
DATE
I1NUI OF rrnSOtl Co"STDUCIIr . T,IE V+r(L
OlvTlIon of Welet Ouelily, Orolmtfweler Secllon wltllin 30 dny9 Ow 1 nEV. 12/91

229405
North Caroler - e pnrter nt of igh, N.C. 27 and Natural Resources - Division of Water Quality •Groundwater Section
1636 Mail Service Comer -Raleigh, N.C. 27699-1638-Phone [phone] ___�i/•N//• I�///�
WELL CONSTRUCTION RECORD WELLCONTRACTOn:
WELL CONTRACTOR CERTIFICATI N:!ZW,2B _
STATE WELL CONSTRUCTION PERMITN:
1. WELL USE (Check Applicable nok): Resldentialoi Municipal ❑ Industrial ❑
Recovery ❑ 1 feat Pump Water Injection ❑ Other (j If Other, List Use:
2. WELL LOCATION: (Sh�oyw�Eketch ol,lll� Iota Ion below) a.r/J4 J
Nearest Town: //r � i �7 County: 17
Agrlcullural ❑ Monitoring ❑
(noad Name an mnbeis, Comrtwnily, or bdivlslon and Lol No.) DRILLING LOG
3. OWNFR S " t From To
Address
1NiLYW{J.VW TSt ou/ o 6-4 Z IT, 1 34�-
City or Iovm State zip Code
4. DATE DRILLED
5. TOTAL DEP111 _
6. CUTTINGS COLLECTED YES ❑ NOg
7. DOES WELL nErl ACE EXISTING WELL? YES n NOg
B. STATIC WATER LEVEL Below Top of Casing: _�J _ FT.
(Use -+' If Above Top of Casing)
9. TOP OF CASING IS-- FT. Above Land Surface'
'Top of casing tnrntlnatnd stfor below land surface requires a variance In accor-
dance with 1SA fICAC 2C. Ila ,
10. YIELD (qpm): METHOD OF TEST
11. WATER ZONES (depth):_,__
12. CHLOnlNATION:
13. CASING:
__ UEPTH
Fonnallon Description
Type Amount ,l1lS II additional space Is needed use back of form
Well Thickness
U5,1 lamer or We_ !ghJ/Ff; Mat' ��dal
To ^A
From To _, Ft.
From To FL -
From To Ft.
14. GROUT:
DepthMalarial
Method
2.9.5P— FI. 6JOAC&AC
From _- /S('� __ To �
--jP212C�Q
From _— To __FI.
15. SCREEN:
Depth Diameter Slot Size
Material
From --_ To _ — Ft _ In. _
In.
From - To _— Ft. _ in. _
In.
From --To __— Ft. _ In. —In.
16. SAND/GRAVEL PACK:
Depth Size
Material
From To —FL -
From To Ft-
17. REMARKS
_LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
Ato' 0� .
100 111 V Ffi47PLSrl 'qg�- WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSIT�NDARDS, AND #.p'TA COP OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
9
FOR OFF`' �la4tP s DATE v
Oasd No:
-!` v k SIGNAT nE OF PERSON CONSTRUCTING THE WELL
Submit original to DI slon of Water Cruelly, Groundwater Section within 30 days OW-1 REV. 12199
Serial No. ------
M

North Carolina - Department of Environment and Natural Resources - Division of Water quality - Groundwater Section 4 A 2 J
1636 Mail Service Center - Raleigh, N.C. 27699.1636-Phone [phone] �J—��' `t
WELL CONSTRUCTION RECORD WELL CONTRACT R_��<�C �.
WELL CONTRACTOR CERTIFICATION #: �b RS
STATE WELL CONSTRUCTION PERMIT#: '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: (Sh ketch of tth location below) c�
Nearest Town: a�,�e County: 4'Z'5K',a�-%
(Road Name and Numbers, Commun ry, or Subdivisi3in and LQt No.) DRILLING LOG DEPTH
3. OWNER : 4/'ti1 /J From To Formation Description
Address Od 3 7U d 7
—(S es or e o.
Dry or Town State Zip Code
4. DATE DRILLED
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES NO
7. DOES WELL REPLACE EXISTING WELL? YES NOZ c� c
8. STATIC WATER LEVEL Below Top of Casing: It FT. _
(Use': 8 Above Top of Cuing) j :T
9. TOP OF CASING IS Fr. Above Land Surface*
'Top of casing terminated sVor below land surface requires a variance In actor-
dance with 16A NCAC 2C .e118 co
10. YIELD (gpm): METHOD OF TEST — J
11. WATER ZONES (depth):
m
12. CHLORINATION: Type -Amount !/z If additional space Is needed use back of form C'3 -4
13. CASING:
Wall TAfduwN LOCATION SKETCH
Depth Diameter or WaphVFt. ladal (Show direction and distance from at least two State
From �To Ft. le L4 �QQ�V L Roads, or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
D Depth Material Method
From To W Ft.
From To Ft. U
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 NAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C, WELL
CONSTRUCTION i•q¢jDgTIDB, ID OF THIrR7DnSEEN PR VIDED TO THE WELL OWNER.
FOR OFFICE ONLY 11t , Jg
Quad No " r, 4) y` SIGNA E Section
PERSON CONSTRUCTING THE WELL DATE
Su nglnal to Division of Water Quality, Groundwater Seon within 30 days
T„.. •• GW1 REV. 12J99
Sedal No.

North Carolina - Department of Environment and Natural Resources - Division of Water Quell Groundwater Section , i R ,�
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone] �- ^�• 2) 4
WELL CONSTRUCTION RECORD WELL CONTRACTOR: 4ele2 r'c'e �� ��
WELL CONTRACTOR CERTIFICATION N: b ZSSS
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: IIShhoow sketch 91 !pe location below)
Nearest Town: ,//YL/aW/)1Z444 County:lC(�����
(Road Name and Nu bars, Co"71 or Sub6Wston and Lot No.)
DRILLING LOG
3.
OWNER/d�
From To
—/
Address
City Town state LP Code
4.
DATE DRILLED
5.
6.
TOTAL DEPTH O
CUTTINGS COLLECTED YES ❑ NOftJ
7,
DOES WELL REPLACE EXISTING WELL?" YES E3NO
o
8.
STATIC WATER LEVEL Below Top of Casing: FFII``
(Use'+' 9 Above Top of Casing)
9.
TOP OF CASING IS FT. Above Land Surface'
-Top of using terminated at/or below land surface requires a variance In accor-
dance with 1SA NCAC 2C.0115 '
30
10.
YIELD (gpm): METHOD OF TEST
11.
WATER ZONES (depth):
DEPTH
Formation Description
CCGc�
0
12. CHLORINATION: Type Amount 7 If additional space is needed use back of form
13. CASING:
LOCATION SKETCH
wall Thickness
Depth ' ! Dianngter orwaighVFt. Material (Show direction and distance from at least two State
From4-11 To Ft. Ca rr Roads, or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method11
From 0 To 2-0 FL /1'2'4�
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From —To—Ft— in. —in
From To — Ft. _ In. _ In.
From —To —FL in. — In.
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To I'L
17. REMARKS:
I DO HEREBY GERT4rY-- 4T THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUI It
1 g4J3SF ANO THAT A �OF THIS RECORD BEEN PR VIDED TO THE WELL OWNER.
FOR OFFICI WM ONLY , �, ^.. E 'e DATE
Quad No: ��:.+.. i SIGNA OF PERSON CONSTRUCTING THE WELL
Subrt{a"nw to Divwon or Water Duality, Groundwater Section within 30 days
GW-1 REV. 12199
Sedal No.
S

North Carolina - Department of Environment and Natural Resources - Division of Water 0 'ty - Groundwater Section
'2 >i4,29
1636 Mal Service Center - Raleigh, N.C. 27699.1636•Phons [phone]
WELL CONSTRUCTION RECORD WELL CONTRACT .ice i
WELL CONTRACTOR CERTIFICATION #: b
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential ❑ Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION* how skgtch of the location below)
Nearest Town: _ County: oMa a-(' e��
(Road Name and ygmherc, Cortarwplty, Subdivision and Lot No.)
3. OWNER ��� � 07Cc, b(1i
Address C9
—(oweel or a o.
-Cityor.Town State Zip Code
4. DATE DRILLED d -Z? -GYJ
5. TOTAL DEPTH as T
6. CUTTINGS COLLECTED YES ❑ NO
7. DOES WELL REPLACE EXISTING WELL? YES NOt]
8. STATIC WATER LEVEL Below Top of Casing: FT.
(Use Y' a Above Top of Casing)
9. TOP OF CASING ISFT. Above Land Surface*
'Top of cuing terminated stfor below land surface requires a varlance In accor-
dance with iSA NCAC 2C .Oita
10. YIELD (gpm): I METHOD OF TEST
11. WATER ZONES (depth):
12. CHLORINATION: Type . CQ4�-Amount Vz c-
13. CASING:
WWI Thickness
Depth / /^ Diameter or WeghtJR. Material
From To � Ft. —J2( S 2 -1) r
From To Ft.
From To Ft.
Mw49:T411111lf
Depth 40 Material Method
From � To � FL - .�—
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From —To—Ft— In. _ In.
From To —Ft. _ in. —In.
From —To —Ft. _ in. —In.
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
17. REMARKS:
DRILLING LOG
From To
1/0 - DS
DEPTH
Formation Description
If additional space is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTR ION craruneone AND THAT AfiOP1(OF THIS R�D Ij6� BEEN PR VIDED TO T� H O
FOR OFF &4GWILY
Quad No: SIGNATUKE OF PERSON CONSTRUCTING THE WELL
} Submit original to Division or water Quality, GmundwWer Sodom within 30 days
Serlat No.
k
LrJ i J't!
-- =
DATE
OW-1 REV. 12199

North Carolina • Department of Environment and Natural Resources - Division of Water liry Groundwater Section
S�ecti/on�_ � 'y 4 ? $
1636 Mail Service Center •Raleigh, N.C. 27899-1638-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACT
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMIT#: J-V1a==—
1. WELL USE (check applicable Box): Residential Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injectior�o Other ❑ If Other, List Use:
2. WELL LOCATION: Sh w sketch of the location below) Nearest Town: County: /yyyy77. 'a /i1.-21�'
(Road Name and Nu
rs. Comrnmlry, or ubdivialon a
Lot No.)
DRILLING LOG
3. OWNER
Address
From To
-40
�
.q �a
e
City or Town
SWe
LP Code
4. DATE DRILLED O F- ZG -on
5. TOTAL DEPTH -Ua C
6. CUTTINGS COLLECTED YES ❑ NO
7. DOES WELL REPLACE EXISTING WELL? ES NOZ
8. STATIC WATER LEVEL Below Top of Casing: FT.
(Use '+' M Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface'
-Top of casing terminated al/or below land surface requires a variance In accor-
dance with 15A NCAC 2C .01 a
10. YIELD (gpm): METHOD OF TEST Z�
11. WATER ZONES (depth):
DEPTH
Formation Description
= rn
CO „c r�i
.7
T �\
� �fl
7—"m A
W
12. CHLORINATION: Type � Amount �} c If additional space is needed use back of form z
13. CASING:
LOCATION SKETCH
Wail Thickness
., / Depth Dii�ter or Weight/Ft. aced (Show direction and distance from at least two State
From �To Ft..�_ 37 Roads, or other map reference points)
From To Ft. —
From To Ft. / CJ
14. GROUT: �lJ �c 0-&Z /'Y-C �J
Depth Material Method
!1
From _Q To ' 0 Ft. nO�
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 CF 'R+AT Tole weLL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRU 10 I SIFANQARBS jplJ�TF AT `�OF THIS RE �� 7D FjA� j/�,fj BE� VIDED TO THE WELLOWNER.
FOR OFFIC OISNLYU uy
Quad No: r _ SIGMA E OF PERSON CONSTRUCTING THE WELL DATE
submit oripmal to Division or water quality, Groundwater Section within 30 days
GW1 REV. 127fN
Serial No.

North Carolina - Department of Environment and Natural Resources - Division of Water D - Groundwater Section L 2 414 3 21
1636 Mail Service Center - Raleigh, N.C. 27699.1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTO
WELL CONTRACTOR CERTIFICATION
STATE WELL CONSTRUCTION PERMITII:
1. WELL USE (Check Applicable aox): Residential[p- Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: S w s etc a location below
Nearest Town: (li:P2 County:�L�IL/��
(Road Name and NUQjrbe83Mty. or Subdivision and tot No.)
3. OWNERS 7
Address �� / da2C &
/usel or Routs
o Town tab Zip Code
4. DATE DRILLED/2
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑ NO
7. DOES WELL REPLACE EXISTING WELL? ES ❑ NOO
6. STATIC WATER LEVEL Below Top of Casing: � FT.
(Use': 9 Above Top of Cuing)
9. TOP OF CASING IS FT. Above Land Surface'
-Top of casing terminated Wor below land surface requires a variance In accor-
dance with 15A NCAC 2C.P118
10. YIELD (gpm): METHOD OF TEST r� -
11. WATER ZONES (depth):
12. CHLORINATION: Type �%�sL Amount 4c
13. CASING:
Agricultural ❑ Monitoring ❑
DRILLING LOG DEPTH
From TO Formation Descdption
_
_
x
_
yo
~o
3
m�
w
If additional space is needed use back of form
i
Was TNcknus
Depth Diameter or WeighVR. MjterW
From -tl To 13 Ft.str
From `To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From l] To 20 Ft. /h!a4t--L JJrn�n^._�J�c_,
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From —To—Ft— in. —in
From To _ Ft. _ in. _ In.
From To —Ft. _ In. —In.
16. SAND/GRAVEL PACK:
Depth Size Material
From To —Ft -
From To Ft.
17. REMARKS:
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS AND THAT A OF THIS RE,COPD F BEEN PR VIDEO TO THE WELLIO
'! .; 6/fG /ufj Git.j/ry
)R OFFIC, USE ONLY a/ r r
Ouad No:
GNATUPTE OF PERSON CONSTRUCTING THE WELL
to Division of Water Quality, Gmundwater Section Within 30 days
DATE
OW-1 REV. 12M
Sedai No.

North Carolina -Department of Environment and. Natural Resources - Dhdsion of Water 0msty - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27659-1636-Phone (919) 733 =l
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION A:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Appifoble sox): Residential4—Municipal ❑ Industrial E3 Agricultural ❑ Manftodng ❑
Recovery ❑ Heat Pump Water Injection 0 other[—] if Other, List Use:
2. WELL LOCATION: how katch (�f the location below)
Nearest Town: County: y/I
�Av� 5 1�0.� V 1 l 6,< I
t, -
(Road Name and�7,Nurnber CartmuNly, ar Sp�lvi ion and Lot No.) DRILLING LOG DEPTH
3. OWNER r `=1C �- N i � From To
Foimeaon 0esvlpdm 2
Address ,G % U _22�� _ D �/C/L✓r'��aa�
tsIfeei or lictua
CRy or Tovm � � State ZIP Cade
4. DATE DRILLED _ ;iOq
5. TOTAL DEPTH U 2 5; - aa--55
6. CUTTINGS COLLECTED YES NO❑
7. DOES WELL REPLACE EXISTIN WELL? YES Q NOf (a
8. STATIC WATER LEVEL Below Top of Casing: Fr.
(Use's if Above Top of Casing) -
9. TOP OF CASING IS FT. Above Land Surface' -
'Top or c*eing terminated *flat below land sudaee raquhes a vedance In *pcar
dance with iSA NCAC 2C.0115 _
10. YIELD (gpm): 112 METHOD OF TEST y
i
11. WATER ZONES (depth):
12. CHLORINATION:
13. CASING:
Type / % �� i Amoun! If additional space Is needed toe back of form
L / Depth �J L C elan
From 7'1 To —L Ft..
From To Ft.
From To Ft.
14. GROAT:
LOCATION SKETCH
Well Thidvrss
ar WelghtIR. Material (Show direction and distance from at least two Stale
0.? f_&G S bC Roads, or other map reference points)
Depth Material Method
From b To �Ft. 77
daRC
From To Fl:
15. SCREEN:
Depth -Diameter Sint Slze Material
From — To _ Ft In. _ in.
From _ To Ft. in. — In.
From —To _ Ft. in. _ In.
1S. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
17, REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CO WITH
15A NCAC 2C. WELL
CONSTRUCTION STANDARDS, AND THAT A C TH)S AEC BEEN PROVIDED TO THE WELL OWNER.
�
FOR OFFICE USE ONLY t r Ot r
Quad Na: SIGNATURE OF PERSON CONSTR&CTING THE WELL DATE
Submit original to Division at water Quailly, Groundwater Section within 30 days
Serial No. GW-1 REV. 12199

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mal Service Center - Raleigh. N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: ✓ ' ez�L Q-A
WELL CONTRACTOR CERTIFICATION #: wI
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (check Applicable Boa): Residential M Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCAT below)
Nag;tTown:.'�� county:
(Road Name
3. OWNER _
Address
Lot
urry or 1 own slam up liOOe
4. DATE DRILLED
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES [D NOE]
7. DOES WELL REPLACE EXISTING WELL? YES NOrM
S. STATIC WATER LEVEL Below Top of Casing: y3r FT.
�11-- (Use': s Above Top of Casing)
9. TOP OF CASING ISM FT. Above Land Surface`
4op of "sing terminated attar below land surface requires a variance In accor-
dance with 15A NCAC 2C .01 a
10. YIELD (gpm): METHOD OF TEST T�rl�rJ
11. WATER ZONES (depth): ADD 1_9.2.7 r
12. CHLORINATION: Type 7-� /� Amount
13. CASING:
Wall TNckness
Depth DI er or Welght/Ft. �/
an o
FromTo �� Ft. S� 1C-
From To Ft.
From To Ft.
14. GROUT:
Depthh Malaria Meth r
From Q To �.lL Ft.
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft in. n.
From To Ft. In. In.
From To FL ln, in.
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To� Ft.
17. REMAR S:
IDO HEREBY
Quad No:
DRILLING LOG
From To
DEPTH
Fom+aaon Description
It additional space Is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
s
IN ACCORDANCE WITH ISA NCAC2C, WELL
ARD HA MR111 PRQWDED TO THE WELL O
GNATURE OF PERSON CONSTRUCTING THE WELL
to Divielon of Water Oualiy, Groundwater Section within 30 days
Serial No.
GW-1 REV. 1=9

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section �- i D C ,3 1
1636 Mail Service Center • Raleigh, N.C. 27699-1636-Phone [phone] O U 1
WELL CONSTRUCTION RECORD WELLCONTRACTOR:R.CALDWELL DRILLING, INC.
WELL CONTRACTOR CERTIFICATION #2 14 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: M A 1=- . 1I A )_ \_ County:
(Road Name apdfNumbers. Coo ity, or bd' isionon a> o.) DRILLING LOG DEPTH
3. OWNER Fro To FomWtion Descd
Address
ptlon
o ` ,
a eIor Houle o. —1 C 1 CDP(r"
c�} / .5 z n / _ 4-_o G �_A N I i C.
City or Town State Zip Code Cl (a)
4. DATE DRILLED 4-0 A
5. TOTALDEPTH ISC
6. CUTTINGS COLLECTED YES Q NO❑
7. DOES WELL REPLACE EXISTING WELL? YES L��l NO ✓�
8. STATIC WATER LEVEL Below Top of Casing: (4 C, FT.
(Use'+' if Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface' LD 7-
'Top of calling terminated atfor below land surface requires a variance In accor- C-)
dance with 15A NCAC 2C .0118
10. YIELD (gpm): 22 METHOD OF TEST-
11. WATER ZONES (depth):—
0
12. CHLORINATION: Type d Q ��--- Amount `� If additional space Is needed use back of forri ��'...
13. CASING:
Wall Thickness LOCATION SKETCH U1
Depth Diameter or Weightlft Mat al (Show direction and distance from at least two State
From—'� To 1 Fl. �= S1— �- Roads, or other map reference points)
From To Ft.
From To FL —�
14. GROUT: I y 75 ncH �A
Depth Material Jylethod
From -i— To a l FL
From __ To Ft. O
15. SCREEN: N
Depth Diameter Slot Size Material C
From —To—Ft— In. —in
From To _ Ft.— In. In.
From _ To _ Ft. _ In. In. S
16. SAND/GRAVEL PACK:
Depth Size Material
From To —Ft. —
From To Ft.
17. REMARKS: pp MM
I DO HEREBY CERTI T I 1� `i4jC ED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION ST A COPY O ORD HAS BEEN PROVIDED TO THE WELL OWNER.
UCW
FOR OFFICE USE ONL
Quad No: SIGN uR F PERSON CONSTRUCTING THE WELL DATE
slon I Water Quality. Groundwater Seaton within 30 days
Sedal No. _ nV's GW-1 REV. 12199

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section s,� ^ �
_ 19. 1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone] L 2
WELL CONSTRUCTION RECORD WELL CONTRACTOR:R. CALDWELL DRILLING, INC.
WELL CONTRACTOR CERTIFICATION #2140
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (check Applicable Box): Residentiaf E Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATI(Show sketch of the location below)
NearestTown: /►IA✓5k14_1 County:
Agricultural ❑ Monitoring ❑
(Road Name an�umbers, Community, or Subdivision and Lot No.)
DRILLING LOG DEPTH
3.
OWNER
From To ff Formation Description
Address s (
0Ue✓&t✓ce".�
reef or
City or Town State Zip Code
f Z""
4.
DATE DRILLED
5.
TOTAL DEPTH 56,`3
6.
CUTTINGS COLLECTED YES Q NOQ'
o
7.
DOES WELL REPLACE EXISTING WELL? YES NO�
S.
STATIC WATER LEVEL Below Top of Casing: Tf , Fr.
(Use Y II Above Top of Casing)
9.
TOP OF CASING ISFT. Above Land Surlace'
N -
'Top of cuing terminated atfor below land surface requires a variance In actor-
--� =-- -
dance with 15A NCAC 2C.4 19
10.
YIELD (gpm): 11Z METHOD OF TEST rT
11.
WATER ZONES (depth):
y"
sr,
12.
CHLORINATION: Type Amount OtJI
�
If additional space Is needed use back of form
13.
CASING:
LOCATION SKETCH
/
Well Thickness
Depth Diameter or Weight/Fl. Material
(Show direction and distance from at feast two Slate
/1
From + To Ft.
Roads, or other map reference points)
From To Ft.
From To Ft.
14.
GROUT:
Depth Material Method
From To yC' Ft.
(,D
From To Ft.
15.
SCREEN:
Depth Diameter Slot Size Material�i
.
From —To—Ft— In. —in
in. In.
PO,
From _ To Ft. — —
�r t✓ IA
I
_ To _ Ft. _ In. _ in.
16.
SAND/GRAVEL PACK:
Lc.vw f� Pa
���,�
Depth Size Material
F✓`h
From To Ft.
C✓�
vY`
From To Ft.,�
17.
REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS. AND THATCCf/ OF THIS REC9FIOHASPEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE O#Y.< ��/��✓/
Clued No: tS� t } , SIGNATURE F PERSON CONSTRUCTING THE WELL DATE
.::Submit original to Division of Water Ouallty, Groundwater Section within 30 days
Serial No. GW4 REV. 12f99
mrs �eyildanal

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section r'7 1 9 3 A
1636 Mail Service Center - Raleigh, N.C. 27699.163a-Phone [phone] I )
WELL CONSTRUCTION RECORD WELL CONTRACTOR-R. CALDWELL DRILLING, INC.
WELL CONTRACTOR CERTIFICATION #. I
40
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable tom: Residential Munlolpal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other If Other, List Use:
2. WELL LOCATIOy; (,Show a the location below) �,�/
Nearest Town: /F'� County: !/�;(b,• ��
(Road Name and f umbers. Comne oy Or Su skin sn ) DRILLING LOG DEPTH
3. OWNER / From To Fomution0 erlpu
Address * 0
4�a �zS
City or Town State Zip Code
4. DATE DRILLS I X o C - -
5. TOTAL DEPTH -
6. CUTTINGS COLLECTED YES ❑ NO�
7. DOES WELL REPLACE EXISTING WELL? YES NO -_ -
8. STATIC WATER LEVEL Below Top of Casing: 15 FT. o
(Use': I Atims Top of Casing) N
9. TOP OF CASING IS_�_ FT. Above Land Surface'
'Top of "sing terminated at/or below lend surface requires a variance In accor-
dance with 15A NCAC 2C 0 /s r
10. YIELD (gpm): METHOD OF TEST ��
".� M 7 u
11. WATER ZONES (depth):
12. CHLORINATION: Type Amount Ee It additional apace b needed use back or form `
13. CASING:
Wag Thickness
LOCATION SKETCH
,,L, Depth D/W,r�t r of WslghVFI. MI (Show direction and distance from at least two State
Froml-To Ft. J�[,1�_ 1- Tforerrce
From To Ft..From To Ft.14. GROUT:
DepthFrom — To 2_ Ft.From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From To_Ft_ In. _InFrom _ To — Ft. — In. — In.
From _To _ Ft. _ In. In.
16. SAND/GRAVEL PACK:
Depth Size MaterialFrom To FtFrom To Ft.17. REMARKS:
ere
Quad Na
THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
BAND THAT
Submit odp4W to Uvialori of water Dually, Groundwater Section within 30 days
GW1 REV. 12/89

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section 18 3 217
1636 Mail Service Center - Raleigh, N.C. 27699.1636-Phone [phone]
WELL CONSTRUCTION RECORD WELLCONTRACTOR:R.CALDWELL DRILLING, INC.
WELL CONTRACTOR CERTIFICATION #2140
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Resldential [J' Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery[] Heat Pump Water Injection ❑ Other If Other, List Use:
2. WELL LOCATIOf�: ($flow ske location below)
Nearest Town: C/i1X County:,
(Road Name an Numbers, Cc u '1 a Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER From To Formatio escdphon
Address � D
or o f
City or Town �,� ,gale Zip Code
�
L1 L
4. DATE DRILLED —0
5. TOTAL DEPTH ;4 �— o
6. CUTTINGS COLLECTED YES ❑ NO o
7. DOES WELL REPLACE EXISTING WELL? YES NO
8. STATIC WATER LEVEL Below Top of Casing: 00
(Use': 9 Above Top of Casing)
9. TOP OF CASING IS4_ FT. Above Land Surface' w
-Top of casing terminated avor below land surface requires a varlancs In accor-
dance with 15A NCAC 2C,,.¢¢11,,to
10. YIELD (gpm): ESL_ METHOD OF TEST
11. WATER ZONES (depth): 7 ©D —
12. CHLORINATION: Type _ Amount if additional space is needed use back of form =_
13. CASING:
LOCATION SKETCH
Wall Thickness
L / Depth �j Di ter or We� tedal (Show direction and distance from at least two Slat
From �= Ft. � C' Roads, or other map reference points)
From To Fl. 2 f d 7
From To Ft.
14. GROUT:
Depth Material ethod
From To Q Ft. a
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From To _ Ft _ In. —in.—
From To —Ft. _ in. —In.
From —To —Ft. _.—. In. —In.
16, SAND/GRAVEL PACK: lit
Depth Size Material',
From To Ft.
From To Ft. i
r
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 OWWV R,
t , I 1 1 R �/ 2 D. J-00 r
FOR O=USEONLY DATE
Quad NSIGNATURE OF PERSON CONSTRUCTING THE WELLSubmit original to DlvWon of Water Quality, omundwater Section within 30 days GW-1 REV. IV"
Serial N

375
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:R.CALDWELL DRILLING, INC.
WELL CONTRACTOR CERTIFICATION #, 140
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential 2 Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATIQJJ�St s0etch of the location below) n� { r,
Nearest Town: II County: /G J!((S
(Road N and Nu"'tters. Corgmuniry, of Subdivision and LotNo.)
3. OWNER��'U
Address
tree or U o.
City or Town �� srai• Zm Code
4. DATE DRILLED 9 I
5. TOTAL DEPTH 7G-
6. CUTTINGS COLLECTEI
7. DOES WELL REPLACE
B. STATIC WATER LEVEL
9. TOP OF CASING IS h
-Top of casing terminated at/or b,
dance with 15A NCAC 2C Otta
10. YIELD (gpm):�32
11. WATER ZONES ( epth)
12. CHLORINATION: Type Amount 1 It additional space Is needed use back oISrm r
13. CASING:
DRILLING LOG DEPTH
From To Formation Description
(D t w4d_
�- 7cn �oc1C
Wall Thickness
Dept , , r «we-'2 % M
terial
From ( To ��- Ft. 5"
From To Ft.
From To Ft.
14. GROUT:
Depth Material thod
From _� To 2" Ft. /'o s/PvT `°r' t
From To Ft.
15. SCREEN
Depth Diameter Slot Size Material
From To — Ft _ In. — in.
From _ To — Ft. — In. —In.
From _ To _ Ft. _ In. — In.
16. SAND/GRAVEL PACK:
Depth
From To Ft.
From To Ft.
Size Material
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
Al I.W( 9S-70
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.ffCORD HA�ENIs VIDED TO THE WELL OWNER. /
FOR OFFICE USE ONLY SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Ouad No:
Submit original to Division of Water Quality, Groundwater Section within 30 days GW.1 REV. 12r99
Serial No.
r

North Carolina - Department o1 Environment and Natural Resources - Division of Water Quality- Groundwater Section
1636 Mall Service Center - Raleigh, N.C. 27699-1636-Phone [phone]/�-
G�lb�
WELL CONSTRUCTION RECORD WELL CONTRACTOR: ..i
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Appticable Box): Res'denlial EZ1 Munlclpal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other 1] It Other, List Use: /
2. WELL LOCATION: (Show ketcl of the I at)gn below)
Nearest Town:rGt & )l ') // (� County: i(Ll Lf o V
(Road Name and n, e(s, C unity. ojj(Supbd � ton and Lot No.) DRILLING LOG DEPTH
3. OWNER � L� &t— / From To Formation Destdplion
Address ;, k ti , _)r 7-0
c3
ily or Tovm `SI le Zip Code----------------
--
4. DATE-
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YESQ NOE!]/ _
7. DOES WELL REPLACE EXISTING WELL? YES NO[Ej nJ S. STATIC WATER LEVEL Below Top of Casing: (.Cr _ FT.
(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 eccor-
dance with 15A NCAC 2C .01L s �'ol�(`l�'� tom_ "��; �✓
10. YIELD (gpm): _2— METHfJ„D-QF TEST
11. WATER ZONES (depth): --
12. CHLORINATION: Type _
-Amount II additional space is needed use back of form
13. CASING:
Depth Diameler
From To i O Ft.
From To Ft.
From To Fl.
14. GROUT:
Mal 5�j/ Method i
F1 U f C
F.
Depth
From To —
From To —
15. SCREEN:
Depth Diameter
From _To —Ft— in.
From __ To _ Ft. _ In.
From __ To _ FL In.
16. SAND/GRAVEL PACK:
Depth Size
From To Fr.
From To Ft.
17. REMARKS:
Wall Thickness
cr Welghl/Ft. Maledal
Slot Size Material
In.
In.
in.
Material
LOCATION SKETCH
(Show direction and distance from at least two Slate
Roads, or other map reference points)
Z-
d
v 1, off
l�
-7 le �
pu 3 1 ?non
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OP THII-S RECO�AS BEEN PROVIDED TO THE WELL OWNER.
F
ORFICE USE ONLY DATE
S ATURE 0-ERSOt ONSTItUCTING THE WELLSubmit original to Division of Water Quality. Oroundwaler Section within 30 daysGW I REV. 11199

229368
North Carolina - O^pnrin+enl of Fnvlrinment and Natural rlesourcrs - Divinion of Water Quality . Groundwnler Sncli,�n
1636 Mail Srrvice Crnrer rinlrigh, N.C. 27699-1636-Phone [phone]
WELL CNSfIMCI
ION RECORD WELL CONTRACTOR: _j�1
WELL CONTRACTORCERTIFICATI p: ✓ �R _
STATE WELL CONSTRUCTION PE IMITM:
1. WELL llSt. (Check Al•pacable Pill): neSldentiaf ld Municipal ❑ Industrial ❑ AWIcullural ❑ Monlloring ❑
Flecovrry [) I Ical Purnp Water In)ecllon ❑ Other (_j If Other, List Use:
2. WELL LOCATION: (SI ow sk ch oflhe location below) -
NeareN l ov: n: ---- - County:
--- DRILLItJO LOG
IPond Pamr and pnher3. Cu
or Subdivn and Lot No.)
�(l1` To
3. OWNrn From
Addle",pJ0-ZocFf-nA�/7
Cily or i own TWO
4. DATE UfllLt1-1)-
5. TOTAL UFrI11-
6. CUT11I!(1SC01._LPCIED 'ES NOLO-
7. DOES WFLI- Firl i ACE EXISTING WELL? YES-
6. STA11C WAl En LEVEL Below Top of Casing: -tj -
/ "a .'. 9 Above lop or Casing) -
9. TOP OF CASING I. _-_C_-_ FT. Above Land Surface' -
'TIP of ee9ng ler nlnalyd ntfrr bntow land $urf$ee require$ a variance In aeeor-
danee will, 15A IICAC 2C III ie
10. YIELD (aPIII)' - 1--- ME1fI00 OF TEST -
11. WATER ZONES (depth): _ -
12. CNLOnIIJAlION: 'Type -Antou�nt R
13. CASUIG:
wall I Ilene. f
(� DrPih Iamel� a or W_ l91,Vf1• Material
From- 11--1c- 7-112NOr1. J p •.��
From------- lo____- FI.
From._.---1°_.--- Ft.- --
14. GROU I: Ma1911ai Molhod
Drpl)r r
Flom __Q--- I,, _AO 1 I.
From o f 1.
16. SCREFI7: Ur1dh Diameter Slot Slze Mniedal
l In. --- in.
In.
From -.- __ln-..___-FL--- Itt. _-In.
Front -_.____ I....--PL_.-_ In. _-
16. SAND/GFIAVEI_ rA(-'1C: Malellal
Depth Size
From ---- l n _--.- FL - —_
From - to—._TL ------
-_ 11EPTH---
Fom+allon Description
If additional space is needed use bark of
I.00AI IUN_SKETCH_
(Show direcllon and dl5lnnre from nt Inasl two Stale
Roads, or other rnDap reference Polnls)
17. nEMAnKS:
I DOIlrrlpny CF;JIIIFY'INAT TI IIS WELL WAS CONS IRUCT ED VInD HAS AtJCE WITVDE TOIL FC.WELL R .
CONS I fit ICT IEtIr�o; IANDAnt)% AND I IAT A COPY OF THIS RECORD HAS BE PROVIDED TO It IF WELL OWNER.
E,,Ild
1 nTE
SIOVATU E OF PERSON Corr 1RUCTIIIO 111F: WELL PVo: Subrril�odglnigtoDivlstonofWaterOusllly,oroundwaterSection Within 30 days DW1 nEv. 17J99
al Ito. -

229364
North Carpko - nrypnrlmrnt of Fnvlroriment and Natural Resources - Division of Water Quality • Groundwater Section
1636 Mail Spivico Centnr - flnlelgh, N.C. 27699-1636 Phone [phone]
WELL CONSIRUCIIONRECORD
WELL CONTRACTOR CERTIFICATION
—
STATE WELL CONSTRUCTION PERMITM:
1. WELL USE (check aprncable nnx): Residanlial[i Municipal ❑ Industrial ❑
Recovery L I I lent rump Water Injection ❑ Other 0 If Otter, List Use:
Agricultural ❑ Moniforing ❑
2. WELL LOCATION: n;hf ow sketch g7f,lhe localion below)
Nearest 7ovm: LOCATION:
! 1 1 � County:
)Woad llnnm
3. OWNFn _
Address
Tr
or Subdivision and Lot No)
J .-
DRILLING LOG DEPTH___
From To rormatlon Description
Ftnulo o --���-
8�
slate zip Code
Cilym tlnvn dv
4. GATE DRILLED _9 V
S. TOTAI. DErIII .
6. CUTTIN!TSCOLLFC1ED YES❑ NO[J
7. DOES WFIL- 1IFFLACE FXISNNC WELL? YES []_ NO
8. STATIC WATER LEVEL Below Top of COSing: �P
(Use's If Above Top of Caah,g)
9. TOP OF CASING L^., ___-_�_.._. FT. Above Land Surface'
-Top or easinn b•rnrinnird Pifer below Will surface requires a vedenee In accor-
dance wllh tsA ICl1C 2r•.a11fl
0. YIFt_D (9rt11)� �- Mill OF TEST —
11. WATEn 7.0NE-5 (dei,llt):..—_-
12. CIILOr1111MION:
13. CASING:
typo _l�l�_fa--Amounl�2��
Dop11t �j � inm�eter
From __O _lo_J- —Ft.
Fom--- -- 10--.— FL_
From ....-----'lo--- FI.
14. GRONI: atlwd
n Material •.
uc(?Ih
Flom ...... to .21U_rl.
Flora - _ __.._ In ___ _Fl.
15. SCREFII:
If additional space Is nredrd use back of for,*
_LOCATION SKETCH_
Wen Thlorlees
orwelgtNN. Material D (Show direction slid dlslance train at lead two State
IlUa5 Au hk Roads, or other map reletence points)
Depth Dimnelor slot aae
Material
Flora ---_l0 11 In. In.
- From---TO--r(,__ It" _In.
From - --TO --FL�_ In. _In.
16. SANDIGRAVFI- PACK: Material
Dr),Ih Size
From
From
17. REMAnIcs:_
1 DO I IEnFny QF^. , IIFY TI IAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC E WELL
CONSTRUc,TIOII STANDARDS. AND THAT A CQPY OF jj11S RECORD FIA9 BEEN PROVI ED TO VIE WELL OWNER. G
FOn OFFICE UtllY DATE
Ouad No:
Of PERSOIJ CONSTR nN0 THE WEII.
O
of Water Ouallly, omundwaler Section will iln 30 days ow-1 REV. 12199
Sedal No.

North Carolina - Department of Environment and Natural Resources - Division of Water
1636 Mail Service Center - Raleigh, N.C. 27699.1636-Phone [phone]
ti r A 5 nn
- Groundwater Section `' 1 `' `) U
WELL CONSTRUCTION RECORD WELLCONTRACTOR
WELL CONTRACTOR CERTIFICATION #: b
STATE WELL CONSTRUCTION PERMIT#: tly 9
1. WELL USE (Check Applicable Box): Residential Munk ipal ❑ 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 Nu M. Community, or Subdvisbn and,, l/nI No.)
DRILLING LOG DEPTH
3.
OWNER a �u LtJJ
From To Formation Description
Address
— d6Lf
tree or e o.
'Z9
City or Town p sun Zip Code
O
f-,
4.
DATE DRILLEDnD
5.
TOTAL DEPTH 3S'5-
6.
CUTTINGS COLLECTED YES ❑ NO[;�
7.
DOES WELL REPLACE EXISTING WELL? YES NO��
8.
STATIC WATER LEVEL Below Top of Casing: ° O FT.
- -^
(Use'.' 0 Above Top of Casing)
_M
9.
TOP OF CASING ISFT. Above Land Surface'
rn 1
'Top of easing terminated aVor below land surface requires a variance In accor-
ns
m A
dance with 15A NCAC 2C.0118
—+
10.
YIELD (gpm): Z METHOD OF TEST �! -
z
11.
WATER ZONES (depth):
12.
CHLORINATION: Type �, �" G-�� Amount 2 c
If additional apace is needed use back of form
13. CASING
Wall Thickness
y/ Depth
'
Diameter orwaighVFt. aterW
FromTo
Ft.
From To
Ft.
From To
Ft.
14. GROUT:
Depth
Method
�/
From � To �r�
/��Material 1_
Ft. 1.�-�a, D
From To
Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From —To—Ft—
In. —in
From To —Ft.
_ In. _ in.
From To _ FL._
In. _ In.
16. SAND/GRAVEL PACK:
Depth
Size Material
From To Ft
From To Ft.
17. REMARKS:
LOCATION SKETCH
(Show direction and distance from at least two Slate
Roads, or other map reference points)
t/", ; azw W
XY y2"k&
I DO HEREBY CERTIFY THAT THIS WFi i was CnNATRtIr:TFD IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND 1
FOR OFFICE USE ONLY
OuadNo:11 !i i,'. r .,
Seri No
C.

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section !- ti 4 A
1636 Mal Service Center. Raleigh, N.C. 27699-1638-Phone [phone] / WELL CONSTRUCTION CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMIT#: LLF�
1. WELL USE (check Applicable Boa): Resldentialo- Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
Agricultural ❑ Monitoring ❑
2. WELL LOCATION: w sketch f the location below) /
Nearest Town: GM�— County:
(Road Name and mbers, CommuN . or Subd vW= and Lot No.) DRILLING LOG
3. OWNER From To
Address WPLz '
or o e
C40 or Town Stew apt
4. DATE DRILLED 00
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑ NORY
7. DOES WELL REPLACE EXISTING WELL? YES NO
8. STATIC WATER LEVEL Below Top of Casing: FT.
(Uae'+' 8 Above Top of Casing)
9. TOP OF CASING IS__Z_ FT. Above Land Surface*
Top of casing terminated atior below land surface requires a variance In accor-
dance with 15A NCAC 2C.0/18 '
10. YIELD (gpm): LE METHOD OF TEST
11. WATER ZONES (depth):
12. CHLORINATION: Type gV111�az&'1'_Amount zc
13. CASING:
Wall Thickness
s Depth /// /� — D,�� 'er or Weight/Ft. Material
From �t� Ft. C —
From To Ft.
From To Ft.
14. GROUT:
Depth Material� Method
From � Too FL
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From To _. Ft _ in. —in
From To _ Ft.— In. _ In.
From To _ FL_ In. —in
16. SAND/GRAVEL PACK:
Depth Size Material
From To —Ft -
From To Ft.
17. REMARKS:
DEPTH
Formation Description
o
z
If 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)
ar3
��Z N L) Q ti
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Quad No: ? , ,! ,..,. �,..... - - GNATURE OF PERSON CONSTRUCTING THE WELL GATE
Su
to Division of water Quality, Groundwater Section within 30 days
Serial No. GW-1 REV. 12/99

ell
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section G ti 4 4 V
1636 Mail Service Center - Raleigh, N.C. 27699-1636-12hone (919) 733-=1 -
WELL CONSTRUCTION RECORD WELL CONTRACTOR: ' - —
WELL CONTRACTOR CERTIFICATION #: b
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: (Shpw sketc(t of the jocation below)
Nearest Town: County:
(Road Name and N rs, Commpniy, or dvlsion and Lot No.)
DRILLING LOG DEPTH
3.
OWNER
FomutionDescription
From TO Formation
d
Addr�e�sys'rbtr�r
/J — o` 7"
o a o
'y Town State 7JP Code
.
4.
DATE DRILLED 92 oo
0�'
5.
TOTAL DEPTH S
6.
CUTTINGS COLLECTED YES ❑ NOEff
YES N00
-
7.
DOES WELL REPLACE EXISTING WELL? O
8.
STATIC WATER LEVEL Below Top of Casing: S'D FT.
C _
9.
(Use'.' g Above Top of Cuing)
TOP OF CASING ISFT. Above Land Surface*
om
-Top of easing terminated aUor below land surface requires a variance In actor-
nt
dance with 15A NCAC2C.0115
10. YIELD (gpm): METHOD OF TEST'
CO
11.
WATER ZONES (depth):—
.
12.
CHLORINATION: Type i%�l� ount r z C
If additional space Is needed use back of form�_n
13.
CASING:
o
LOCATION SKETCH
Wall Thickness
,- Depth �Dian i, tier or WeightlFt. renal
� 1�! �
(Show direction and distance from at least two Slate
From To Ft. i--'
Roads, or other map reference points)
From To Ft.
14.
From To Ft.
GROUT:
�)
-kc")
Depth atenal Method
go
From � To X Ft.
From To Ft.-�/O-
15.
SCREEN: -
�o � ��"�� •(�/. ��"4-�-�
Depth Diameter Slot Size Material
D
From —To—Ft— in. —in
From To _ Ft. — in. — In.
16.
From To _ Ft.— in. —In.
SAND/GRAVEL PACK:
Depth Size Material
D�Y�
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 AfioP'r;lOF THIS RFf'.O'PD �AkBEEN PROVIDED �O THE WELL�O
SIGNAT4KE OF PERSON CONSTRUCTING THE WELL
- " Submit original b Division of water Quality, Groundwater Section within 30 days
a,er Sec-
?prtinmil r=E:....

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section 4 6 J
1636 Mail Service Center - Raleigh, N.C. 27699.1636-Phone [phone] n l l n
WELL CONSTRUCTION RECORD
WELL CONTRACTOR.
WELL CONTRACTOR CERTIFICATION a:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable eoa): Residential, Municipal ❑ Industrial ❑ Agricultural ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: Zow sketc f the location below)
Nearest Town: i '� �-ce County:
(Road Name and Nun a , Community, ubdNa on and Lot No.)
3. OWNER
Address �O
r or e `ALI C sq
'ty or To" state Zip Code
4. DATE DRILLED
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑ NOZ
7. DOES WELL REPLACE EXISTING WELL? YES NO�
8. STATIC WATER LEVEL Below Top of Casing: FT.
(Use -+' If Above Top of Casing)
9. TOP OF CASING ISFT. Above Land Surface*
-Top of easing terminated at/or below land surface squires a variance In accor-
dance with 15A NCAC 2C
10. YIELD (gpm): METHOD OF TEST
11. WATER ZONES (depth):
12. CHLORINATION:
13. CASING:
DRILLING LOG
From To
r�
Type �ount 3 C. If additional space is needea use oaca m roan
Monitoring ❑
DEPTH
Formation Description
fr,
Wall Thickness LOCATION SKETCH
Depth �p Diameter or weightfFl. /"arlal (Show direction and distance from at least two State
FromTo _E.0_ Ft. 12 'Ii_ SP2.a / -f,cG Roads, or other map reference points)
From To Ft. —
From To Ft.
iCI[H:Ifl9E
Depth �nMaterial Mathop-
From To Ft. 1C�
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 ISA NCAC 2C, WELL
nnusTwt tcTloN STANnawn�3HAT-s,QQPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELLIO
Quad No: ;3� iAlGNATUlAi0F PERSON CONSTRUCTING THE WELL DATE
_ Sulu poq to Division of Water Quality, Groundwater Section within 30 days
Sedal No. ,� , � y ; GW1 REV. 12r99

cry
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section �- 4 [)
1636 Mail Service Center - Raleigh, N.C. 27699.1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION e: b
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: ow sketch pf the location below)
Nearest Town: County: �22&z6��12c)
(Road Name and is. Community, r S division and Lot No.)
3. OWNER
Address Q
v or mute mi
Chy or Town State Zip Code
4. DATE DRILLED 0 OU
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑ NO
7. DOES WELL REPLACE EXISTING WELL? E� NO�
B. STATIC WATER LEVEL Below Top of Casing: FT.
(Use'.' 0 Above Top of Cuing)
9. TOP OF CASING ISFT. Above Land Surface*
'Top of using terminated stfor below land surface requires a valanu In scow.
dance with 15A NCAC 2C .01
10. YIELD (gpm): METHOD OF TEST 1112_14�_
11. WATER ZONES (depth):
12. CHLORINATION: TypeAmount dC
13. CASING:
Agricultural ❑ Monitoring ❑
DRILLING LOG DEPTH
Fro To Fomu6on Desoliptim �
0
U
_
—
,c
0
0
If additional space Is needed use back of form
Wall Thickness
Depth D' ter
FromTo714_Ft.
or WeightIA. Material
SE3�'L /Zl
From
To Ft.
From
To Ft.
14. GROUT:
Depth aloneI
426
�,Met�ho"d" y
From
To Ft.
From
To Ft.
y
15. SCREEN:
Depth Diameter Slot Size Material
From
—To—Ft _ In.
_ in.
From
To _ Ft.— in.
_ In.
From
—To —Ft. _ In.
_ In.
16. SAND/GRAVEL PACK:
Depth Size
Material
From
To —Ft -
From
To Ft.
17. REMARKS:
LOCATION SKETCH
(Show direction and distance from at least two Slate
Roads, or other
rr map reference
points)
a LL
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT AS.OP`ROF THIS RECORD W BEEN PRgVIDED TO THE WELLIO'
FOR OFFICE USE ONLY _ '
MA E GF PERSO
Quad No: SIGN CONSTRUCTING THE WELL DATE
Submit odglnai to Division or Water Quality, Groundwater Section within 30 days
SeAal No. GW-1 REV. 12199
.,_ ✓J !t°.'Bit _...,_

North Carolina - Department of Environment and Natural Resources - Division of Water 7ye-"�
- Groundwater Section 1, J r4 4 C
1636 Mal Service Center - Raleigh, N.C. 27699.1636-Phone [phone] l)
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION
STATE WELL CONSTRUCTION PERMIT#: 4
1. WELL USE (Check Appliuble Boa): Resldentiait Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
Agricultural ❑ Monitoring ❑
2. WELL LOCATION: sketcb of the location below) _� J
Nearest TowCounty:
(Road Nana and Numbei
3. OWNER
Address `33 3
CAy or Tom State Zip Code
4. DATE DRILLED O 0 DO
5. TOTAL DEPTH v 3 ('
6. CUTTINGS COLLECTED YESQ NO®
7. DOES WELL REPLACE EXISTING WELL? YES 0 NO®
8. STATIC WATER LEVEL Below Top of Casing: 6 FT.
(Use': 9 Above Top of Cuing)
S. TOP OF CASING IS FT. Above Land Surface'
'Top of casing terminated at/or below land surface requires a variance In eccor.
dance with 15A NCAC 2C.011a
10. YIELD (gpm): 21/a, METHOD OF TEST
11. WATER ZONES (depth):
12. CHLORINATION: Type Amount /C
13. CASING:
DRILLING LOG DEPTH
From To Formation Description
D- 1196
�O- 33S
o
c
zm
CI
--m
S
ter,
If additional space is needed use back of form
z
Wall Thickness
Depth
Diameter WWeighVFl. aria
rI 1�
From
To —IL
FL
From
To
Ft.
From
To
Ft.
14. GROUT:
From
Depth
To
Ft.
Ma�ter_ial Method
G.ru
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 HERE6Y.C�oriry
riser rui
CONSTRU-AfA(S�iA
FOR OFFIC
ONLY
Quad No: � f � �
�a,
I 1 °;
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
31 2
�z�- GaX 333
NELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
THAT AfAP`F�OF THIS R70ORD FjA� BEEN'PR7VIDED T,O THE WELL]C
` SIONATWHt OF PERSON CONSTRUCTING THE WELL
Subrait original to Division of Water Quality, Groundwater Section within 30 days
DATE
Serial No.
GW-1 REV. 12/89

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section c: 6 3 3
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION #: te2 %may
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residendal Ste+ Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: Q% sketch of the location below M
Nearest Town:1" ���-✓�-J N� C. County:
- n_ - -
(Road Name and
3. OWNER
Address /J
City or TdWn v State Zip Code
4. DATE DRILLED
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑ NO(a
7. DOES WELL REPLACE EXISTING WELL? YES Q NOCR
6. STATIC WATER LEVEL Below Top of Casing: 2_ FT.
(Use': it Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface'
'Top of casing terminated at/or below land surface requires a variance in accor-
dance with 15A NCAC 2C. 118
10. YIELD (gpm): METHOD OF TEST -Z01d c
11. WATER ZONES (depth): 170r f /9C
12. CHLORINATION: Type %/l%A Amount _
13. CASING:
Wall Thickness
Depth Di mejer or Wei ht/Ft. Maattriaall
FromTo Ft. -1-
From To Ft.
From To Ft.
14. GROUT:
Depth A Material Method
From To -aO— Ft. I-ac►Ler� 'i`, ).]'Q'c'sr.7i
From To Ft.
15. SCREEN
Depth Diameter Slot Size Material
From To _ Ft in. —in.
From in.
From To Ft. in.
16. SAN /GRAVEL PACK:
17
Depth Size Material
From —�
From To Ft.7G�
Agricultural ❑ Monitoring ❑
DRILLING LOG DEPTH
From To Formation Description
If additional space is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
'L-_
v�
1 DO HEREBY QaTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCA>; 2C, WE11
rnnierci irTlAwsii5TiXMrvrV"Fl7MAMA_COPY OFIMISaECORD HAS BEENi)BOVIDW TO THE WELL OWNER.
FOR OFFICE NLYZZ-M
Quad No: IGNATURE OF PERSON CONSTRUCTING THE WELL DATE
�pbmi to Dlvislon of water Quality, Groundwater Section within 30 days
Serial No. GW-1 REV. 12f99

North Caroline - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mall Service Center - Raleigh, N.C. 27699-1636-Phone [phone]r� ^
12
WELL CONSTRUCTION RECORD WELL CONTRACTOR: �/� '''YZ1 v S� J 3
WELL CONTRACTOR CERTIFICATION #: S:�L
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential 0"unlcipal ❑ industrial ❑
Recovery ❑ Heal Pump Water Injection ❑ Other 0 if Other, List Use:
2. WELL LOCATIOAN.: (Sho`ow// jket/¢h of the location below) ,,rr,� J,/,�
Nearest Town: /✓t /4 �d4 /�/ CountT.. A'01111d04
Agricultural ❑ Monitoring ❑
(Road Name and Numbors, Con// nn.1y, or Subdivision and Lot No.)
DRILLING LOG DEPTH
3.
OWNER _nni/` /E d(� I').Sl��
From To Farallon Description
Address
lbifeet or Houle o.
City or Town Stale Zip Cade
.
DATE DRILLED OV
— —
S ell S /'"
5.
6.
TOTAL DEPTH
CUTTINGS COLLECTED YES NOFj
7.
DOES WELL REPLACE EXISTIN WELL? YES Ej NOfC7(
-'
8.
STATIC WATER LEVEL Below Top of Casing: FT,
r-� -
_(1Q
(Uso'ti If Above Top of Casing)
r/j `_'--
9.
TOP OF CASING IS FT. Above Land Surface'
- --'
'Top of casing terminated al/or below land surface requires a variance In actor-
dance
10.
with 15A NCAC 2C.0118 n
YIELD (gpm): METHOD OF TEST
11.
_�
WATER ZONES (depth):
12.
CHLORINATION: Type i` Amount _
If additional space Is needed use back of lone
13.
CASING:
o
LOCATION SKETCH
Wan Thickness
LL // Depth L of eler or Welght/Ft. Material
From _Z_L�To Ft. NoI/ -
(Show direction and distance from at least two State
Roads, or other map reference points)
From To Ft.
From To Ft.
1A.
GROUT:
Depth Material , Method /
From 0 To e� Ft. ('$%!vx✓ l4RY f
From To Pl.
15.
SCREEN:
Depth Diameter Slot Size - Material
From To Ft In. in.
From _ To _ FL In. - _ In.
From _ To Ft. In. In.
16.
SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft. _
17.
REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY�G<
Quad No: SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit odginal to Division of Water Quality. Groundwater Section Within 30 days
Serial Na. GW-I REV. 12199

North Caroline - Department of Environment and Natural Resources - Division of Water Quality - Groundwater SectIon Ity rJ �
1636 Mall Service Center - Raleigh, N.C. 27699-1636-Phone [phone]- r- 173 4 7
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION 0:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable a..): Residential p"unlcipal ❑ Industrial 0
Recovery ❑ Heal Pump Water Injection ❑ Other 0 If Other, Ust Use:
2. WELL LOCATION: (Show sketch of the location below)
flearSM Town:_ �C�tb �� County.
Agricultural ❑ Monitoring ❑
(Road Name and N tubers, Commynily, or Subdivision and Lot No.)
DRILLING LOG DEPTH
3.
OWNER ' lints✓5"
From To Fonnallon Description
Address Jf
4.3
(S nee or ou a No.
Cily or Town Stale Zip Code
4.
DATE DRILLED.-
5.
TOTAL DEPTH
-
6.
CUTTINGS COLLECTED YES NOD
7.
DOES WELL REPLACE EXISTIN WELL? YES 0 N057(
J
8,
STATIC WATER LEVEL Below Top of Casing: &y FT.
_
rn -
(Use'.' If Above Top of Casing)�-
9.
TOP OF CASING IS FT. Above Land Surface'
'Top of casing terminated attor below land surface requires a variance In accor-
dance
10.
with 1SA NCAC 2C.0118
YIELD (gpm): METHOD OF TEST`
11.
WATER ZONES (depth):
o-
c�
12,
CHLORINATION: Type Amount
If additional space Is needed use back of tone o 0
13, CASING
Wall Thickness LOCATION SKETCH
Depth Di 4star or WelghUFt. Material (Show direction and distance from at least two Stale
From .f / To &3 Ft. -� 1 ,-& - f , S:' 6 Roads, or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Material 1 Method
From b To �Ff. � 4'r„r 'ruRC
From To Ft.
15. SCREEN:
Depth
From
To
From —To
_
From
To
16. SAND/GRAVEL PACK:
Depth
From
To _
From
To_
17. REMARKS:
Diameter Slot Size Material
Ft In. In.
Ft. In. _ In.
Ft. in. In.
Ft.
Ft.
Size Material
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY 51- 31 t
Quad No: SIGNATURE OF PERSON C0fiS'rRb1TRNG THE WELL DATE
Submit adgina_l to. Division of Water Quality, Groundwater Secaon within 30 days
Sedal No. i GW-t 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] _. ti 1 r1354
WELL CONSTRUCTION RECORD WELL CONTRACTOR: /C�{ ��" rY1 v 5, 'A �
WELL CONTRACTOR CERTIFICATION #: I-X1
STATE WELL CONSTRUCTION PERMIT#:
1.
WELL USE (check Applicable Box): Residential,X--Munlclpel ❑
Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other 0 If
Other, Ust Use: '
�.
WELL LOCATION: (Shows tch of the Iccallon below)
Nearest Town: Ma'% ��� County: l e.
/
�ya,�
(Road Name and Numoers, Community, or Subdlvislen and La1 Ne.)
DRILLING LOG DEPTH
3.
OWNER �%;. r;.P Si r�/ /iir9 [T/'C
From To Farmallon Oescdpilon
Address
IStreet or Houle a.
City or To. State Zip Code
4.
DATE DRILLED S' aS-yd
-
-3
5.
TOTAL DEPTH ;2 & s-
d 2 6 J� ; s k"
6.
CUTTINGS COLLECTED YES NO❑
7.
DOES WELL REPLACE EXISTIN WELL? YES 0 NOETJ
�
B.
STATIC WATER LEVEL Below Top of Casing: /a FT.,
r� c
(Use': If Above Tap of Casing)
C7
9.
TOP OF CASING IS FT. Above Land Surface'
'Top or casing terminated atlor below land surlace requires a variance In actor-
_
dance
10.
with 15A NCAC 2C.0118
YIELD (gpm): A METHOD OF TEST
11.
r
WATER ZONES (depth):
=`
_
m�
12.
CHLORINATION: Type �f7- �� 3 Amount —2
It additional space Is needed use back of form 0 r=i�j
13.
CASING:
w -,
LOCATION SKETCH o
Wall Thickness
_L / Depth DI�`�'ela' or Welghr/FI. Material
From'f To 30 FL '-W
(Show direction and distance from at least two Stale
Roads, or other map reference points)
Front To Ft.
From To Ft.
14.
GROUT:
Depth Material Method
Front To r� FI. eey,-Vr. f[tRC
From To Ft.
15.
SCREEN:
Depth Diameter Sin! Size Interial -
Front To Ft In. _ In.
From _ To Ft. In. In.
From To Ft. _ In. In.
16.
SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
Front 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 9-3I'Qi
Quad Ho: .SIGNATURE OF PERS N ONSTRUCTING THE WELL DATE
Submit original to Division of Water Quality. Groundwater Section within 30 days
Serial No. GW-1 REV. 12199

.::..::. .: ..ter_.. ..ii 1..� _—.... _.... ..... ..a.. _ _....
North Carpinin - nepnrtment of Environment and Natural nesources • Divlelon of Witter Quality • Groundwater Section '�' 7 3 7,)
Me Mail Envier, Crntrr - rlaleigh, N.C. 27699-1636-Phons (919) 7333221
WELL CONSTRUC1101JRECORD WELL CONTRACTOR:
WELL CONTRACTOR CEFIVnCATION M: D�
STATE WELL CONSTRUCTION PERMITII:
1. WELL USE (Check Aprlir.able Pox)! nesldenbalb MunlCipal ❑
Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery [] I jell Pump Water Injection ❑ Other n If Other, List Use:
2. WELL LOCATION: (Show sketch/pJ tthe 10 tlon below)
71
4 �'A 40—
Nearest Town: ���'-A � County:
"�"
(noal nano and�rr/ynr!�ers Comnnmll or Subdivislo, and Lot Not
DRILLING LOG _ DEPTN_—_
3. OWNFn (/ _,
From To Formation Descdplion
Addr s GGR
ily Pr rrvm �S�ile p Code
�•��.
• 4. DATE 01111.LED ___ _�-•a_
S. TOTAL PEPIII
6. CUTTINGSCULLFCIED YESO NOM
NOER(
7. DOES WELL nFPLACE EXISTING WELL? YES
B. STATIC WAI ER LEVEL ©elow Top of Casing: _ FT,
IOse *+" 11 Above Top of Casing)
I
9. TOP OF CASING IS, __I _. FT. Above Land Surface'
-Top of cesinn,Pnnlnnird Prior below lend surface requlrrs a valance in aecor•
• dance wllh 15A frCAC 2C,e11II
_ -
`
f.1E1110D OF TEST _�
-
10. YIELD (9t'hn). -L s/__ _R
cs �
11. WATEn ZOtdES (drpth):_—_-
c
If additional space le ne eded use back of Ion
12. Cnt-OVIINA1ION: Typo _� _Amount
- —
13. CASING:
_LOCATION $i<ET_CH
Wall 11doness
Drpih/� i. melor or WoIghVFt. Material
h shM1
(Show directlon end dislance from nl least two Stale
reference Points)
Q 11L.1�i
O Ft.
Roads, or other map
From -----To-.
Four---- TO--._ F1.
�(� CJLrLGF— •
From-----lo..—.— FL
!N
1,�l,eh Malarial othod
Fern To _a0_FI.
From _._.-__ 10 -
15. SCREFII:
Depth Diameter slot size Material
From __ To _ __ I l -- In.
From --- l o _---_— FL _ in.
From ---- to - --- FT. -- In. _ In.
16. SAND/GRAVEI. PACK:
DrPth Size Material
From To _----- FI.
From
17. REMAnl<S:
I DO itE NF RY CIfnl'IFV 7.11/�jL THIS E(1� WAS CONS IRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION SI ANQ4\1AES,'IS'N[ TO' T ACOPY OP 7HIS RECORD HAS BEEri PROVIDED 1071IE WELL OW R.
L),IICE USE-0flLV DATE
S ATUnE OF PER N CONSTRUCTING THE WELLSubmit odpin to Division of Water Quality, Omhmdwelsr Section Within 30 day9OW1 REV. 17/99

r rt rt
North Carolina - Repnrtnrrnl of Environment and Natural nesources - Division of Water Quality • Groundwater Section '•- 1 l
1636 Mail Servico Cenlor - rlalelgh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WFLLCONTnnCTOn: Job �E �USt2N
WELL CONTRACTOR CERTIFICATION M: ��D� li..
STATE WELL CONSTRUCTION PERMITO:
1. WELL USE (check Ar r,nc,hle Ros): Residentlal R Municipal ❑ Industrial ❑
Recovery [J I lent Pump Water In)ectlon ❑ Other If Other, List Use:
2. WELL LOCAL ION: (�Shs�'W skelcl of the localion below)
Nearest Town:_ LLB_ County:
(nowt Ilnme mid
3. OWNFFI
Address ,
IJo.) DnILLING LOG
From To
4. DATE Df111.I FD ,y(.8'UV_
5. TOTAL DFPtII __-)��__
5. CUTTItMSCULLFCIED YESL NO9
7. DOES WELL rIFPMACF FXI0jI114G WELL? YES 0 NOL ►v
8. STATIC WAJ En LEVEL Below Top of Casing: FT.
(Use'+' 11 Above Top of Casing)
9. TOP OF CASING M ___�__ . FT. Above Lend Surfaco'
'Top of ceshrp 1^r,nhinlyd rPrr below land surface requires a variance In aceor-
dencewlth 15A It CAC 2C.0119
10. YIELD .;'I'__ MEIT IOD OF TEST L
11. WATEII 70HE5
12. CHLOr11NA11ON:
13. CASING:
Drpth Iametor
From O --Io -3-3- Fl.
From----- IQ--- FI.
From _. _---T o
14. GROUI`:
15
Agricultural ❑ Monitoring ❑
DEPT H__—
Formatlon Description
M
z—T—
U,',
---------------
o `
Amount r D,1�5 If additional space Is needed use back of form
well ihlct,neii
or We�115 „'., KMaerlAl_
De1,61 Material' �elI d
Flom —_—� to _Q_FI, i70hh�tG
Flom _ ._— to _—_Fl.
SCREF_I1:
Depth Diameter
From ---To _---- Et In.
From -- To _ F1. _ in.
From To _ __— F1. _ In.
16. SAND/GnAVEI. PACK:
Drpth Size
From --- Io EI.
From ___— To FI.
17. REMARKS:
Slot Size Malarial
In.
In.
_ In.
Material
_LOCATION SISETCH
(Show directlon end dtslance from at leul two Stale
Roads, or other map reference polnls)
1 DO I fEnr ny CER'11FY THAT "[NIS WELL WAS CONSTRUCTED IN ACCOnDANCF WITH 15A HCAC 2C. WELL
CONSTRUCTION 9TANDAOOS; ANDTHATA COPY 111E REC no HAS BEEN PROVIDED TO TI IE WELL OWNER.
F
ORFIC F. USE ONLY, ,I _a i ,NATURE or rEFl oN CONSTRUCTING 711E WEM DATE
7L7SUMraIodglnalla Dtvlslan or Water Ovellly, Omtlndwslar Section within 30 daysGW 1 REV. 1L99
-

.. ...". � .. .. .. - 71 L:... ;'.*'n'r'rt�j 1�i.� -.:i1 n• .�I:. t.
North Cnrp6nn - f lepmin to tit of Environment and Natural nesources • Divlslon of Water Quality • Groundwater Section ti 17 3 8 C').
1636 Mail Sorvico Cool or - naleigh, N.C. 27699-1636-Phone [phone]
WELL CONSI RUCI ION RECORD WFLLCONTFlACTOR: ��&5LLsQN �
WELL CONTRACTOR CERTIFICATION
STATE WELL CONSTRUCTION PERMIT#:
1. W ELL USE (check Ar,pucabla nox)I nesldentlal LYJ Municipal ❑ Industrial ❑
Recovery [j I Ieal Purnp Water Injection ❑ Other (j If Other, List Use:
2. WELL LOCATION: sketch of the location below) �(� , ��
Nearest Town: County:
(Woad tlanm nn NwN,,rs. ' ton rnity, or ubdlvlslon e d Lot Lot N
3. OWNER
Address�_�L,/►7/./-r�
42;iTrVITT
%%//����jjA(+ua1 7S`=-l—� 1/ Li Coda
nr Tmrn GG Slate D
4. DATE D111L1_17---
S. TOTAL D[Plll__�62 -.
6. CUTTIt1GS COLLECT ED YES Nog
7. DOES WELL REPLACE EXISTING WELL? YES 0 NOEY
8. STATIC WATFn LEVEL Delow Top of Casing: FT.
(Use'+' It Above TOP of Casing)
g. TOP OF CASING I^ ___� _. FT. Above Land Suffice'
'ToP of resln.1 tennlnmrd enrr below land surface *quitei, a variants In actor
dance with 15A NCAC 213.0119
'0. YIELD (grnl)--./,�%_ METI IOD OF TEST 14—
11. WATER 7.ONES (drplh):._ J
Agricullurat ❑ Monitoring ❑
DRILLING LOG DEPTN_—_
From To Fonnallon Description
CD
CD
c�
12. CI ILORINAT ION: Typo _. Amount .--��-If additional space is needed use back of form
13. CASING:
_LOCATION SKETCH
Wall ThicPne ss
O Drplh �1 � i, rnetor or WaIgbVR. Makdal n (Show direction and dlslnnca from at leas) two Slate
- - Ft. - r'�u••�� ~ Floods, or other map reference points)
From - -To- -/f''�
From--- -- 1n-- - F
From -_—.- 10 .--._ FL-
- —
14. GROU1: �/l17/IIG�C�
Dcplh Malarial KIalhod
From .—_k _ To-2,0__FI, POA11"114
Flom _..____ To
15. SCREELI:
Drp11t Diameter Slot Slzri Material
From ___To _-- f t In. _ In.
Flom To — — Pt. In. _In.
From _-- To - -- — F1. __— In. .— In.
16. SANDIGRAVEL PACK:
Depth Size Material
From To _ FT. —"
From ---- To Fl.
17. REMARKS:
1 001IEREDY CEnI IFY I IAT THIS WELL WAS CONS TnUCTEO IN ACCORDANCE WITN 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF IS RECORD HAS BEEN PROVIDED TO THE WELL OWNEFL
EnoCE USF OHLY Da1E
SI JATunE OF PEAS N CONSTRUCTINU Ttlh WELL.Submll original to Divlslon or Water Quality. Gmundwalar Section Within 30 days OW1 REV. 1�9

North Cmol .I .......l Id r td finimnl Ilr^mncnl . Ltivl^.Inn of Wnlrr (hlnlny . (I... (v,Nrr Sn,:6-•„
'636 Mail E^• •nl^r rl.nl^iuh• if C. 27699 1630.r ilonn [phone] "D
WELL (' .4SIIiUC11011 RECORDWELLCONMACTOfl:—
WrLLCONMACTOncrnTlrlCAr1 Off
n:__;..-.r;._o?1J_ ---
STATE Wrl_l. cousinucliold Prll r.11lX: ._,-_ _____—___ _..__
I WrLL lfgr (rhr,4 nrrn�,ln^ nn.)� flesldm,linl L�J A1unl,;lpM Lj IndunItlal Anrhllllul nl L—� Monllnrin0 �_�
Flecavnly j _ I I I^N romp wator Injection (—] Other Ll II Olher, List Usr:
2. WELL I.(u'AIIMfI (°:I I(1`v'^Hrlch o the locnllnn b(low) ,
- -----
Courtly:
Inc I rlo•n� n .I Nn •^I< 1. , „Indly, of 51 divl<lon end-
1 nor" to
3. O1 I'lI-11
Addlo
��. 10' ZI(. Code
_.._..X _
Q a
4. DAIr Illllllf -lt..O Q--------
5. 10TAI. Itr-r• 11I
G. CUT III Ill" C(ll -I r r:I r.0 1'ti.^, �_ FJO� t10�
7. DOES L ftrl'I A,;E rXIS 11t1G WEI1.7 YES
B. SWIG WAIF-11IFVELOelowlof' elCnsing: rT• _------------
(use .
.' If Above tOP of Cminp)—_.-----
9. TOP or CASII IG 1^ _-- r-T. Above Lnnd Snlincn' _--,__---
•Tor, of caalnq 1•1 .nln,1_1 rl4•r bNow end tutface requital a valiance In actor, --
_
ro Mallon Ur ar II I�en
o _-
----- Fri t
---- -0
dance wltlt Icrt uCnC 2C .pt� . 1aFdE1I IOD OF T EST �— --
---------
10. YIELN
it. WATEIIZUITES(d^I,III):--_.— _-- __._ r.2---
-- _ 11„r}it
12. Cr1L0I11ti"MU I:
13. CASIIaC::
_ .._
Ali,ollnl Is II eddllloner
nl Ppn Is nnrdn,l ucn laN c n �-�
��ll
Wall lhld+nraa ,Aalydnl
�1YL..125. 1rS-
n.�el�n�
Fom_ --v
_.zD
- —1^ . _
from---
__ - 1,,__ — rI.--
Flom-
1d. Gfick,I:
Matodnl otI Tj '
I trlill, �C�d
rrom
---
rinm'-
15. SGFlI:I-II:
I limnoler Slol SI7,i MnlndAl
tlrl•ll,
-----
Tlnln
from __..._.
lo-----rl.----
Fon1
1n. -
1G. SANOIGf1AVE1_t'ACKt
Mnlerinl
Urhlh SI70
.—.—
rinm _
--- lrt ----', L--------
From
l-------
i r�r
LOCAI IUN-SKE1_Ctl—
(Show ditnclion mud d"d'"wa from of lend I" Slnln
nOnd" or OIIIN mnP lefrlell" Poln11)
/•.
v
OO I IPttrP / C1111I Ir Y ll IAI TI119 WEl L WAS COt1S rIlUCI C_O Itl ACCOf1DAI10E WI111 ISA TO1I 2C, YlFU. reV
COIISinllC ilnl l 5 tAIMAlit1;, Ali[) TIIAT A COPY 1111E f1ECOr1/HASB EN PROVIDE. TO 111E YlElIO �� ----
_____ vi OA1E
FOR OF FICE USE (ICILY— -.I !:Inrint IEOr rr lwj cousinUCnrn� rnr v+n 1.
OUR d na IIJI rpb,n,l alQtnal to nlvlslan or Water Ouallly, Oroundwala, $nrlinn WIII IIn 30 tf �l•9 awi nrv. I2r97
Srdal lh

North Cnrrl 1'•-pi nn•vd of r n-Innunnnl end Nnitunl rle^...ur nnn - Llivi^.lore of Wnler Oualily . (Irrnunfwnl^r Srcll n
1636 Mail S rn I nlr+r - flnlnitl r%11 C. 27699-1638 monn (91917333221
JVELL ,UIJS-j nuci iori REconD WELLCOHMACTON:--
WF-LLCONTMCTOFICEnrIflCArl011a: ;_,j :510
SIATEwr_LI.COflstnucnoupenr,life:
WELL 11ME (check nr nn•): ner.1001111d Muldrlpnl ❑ Indusllbll 11
flecovnly I -I I Innl pump Writer In)ecllon 0 Olhor F_j It Other, List Use:
Agrlctrhurnl U Monllnring Ij
2. WFLL I.('(-A11011 (f,I I��.V� r1,C�rl/0/ of Ilia ocalion below)
Nimerl/ YIIK� —_- county.------
(nPo l rl1m0and rl.rrn• •vc Con
Addrr�n i_�
rally, or Subdi,10on And lot No )
A. AJE
S. IOTAI err III ..3 k - _
0. CUT 111p ^f,l,l.lr'('IrD 1P.^�.-1 t40uv:f
7. DOES 1r,r"I I. Ilrl'I nr t r`!ISfill(1 WELL? YES L� PIULJ
8. S1A11C1'JAIFrILI:vFLnclowlopolCn^.Ing: �QFL
(Use'✓ If Above Tor of C"Inp)
o TUp Or CAMR I . Iq _ _ FT. Above Lnnd SiOncn'
•Top of cefhnl I'r minnl^d r•Irrr h^Inw land eurlace requires a verlence In accor-
dance yrlth ISe IInnr 2C nl le `
0. YIELD (m,m) 30 hlEt t IOD OF TEST
11. WA7EIliUIIES(d�plh):__-.- - •J —"'
12. CI ILOI III UOlUII
13. CASIIIf',
DFIILLIIJO LOG- _ DErnl... _._
_-rrom to ronnallon ncurlpinn
___
YI Ar110U n1 sG7 II eddlllonnl 5pnr;n h needed u-^ bnrk nl in""
1to r__.__r_�- _... - -
well
!` I�nlrlh ,t)Inmol r or W-nlprNrl.
v %• alb-�2.'i.
-
rlorn__..___ _ In.IL-
n011t
A GllUll l'
LOCAI_IpW SKFICLI_
;�1.lalrrlet (Show direction and (llvinncn I'm',M 1en51 IvIo Slele
c--$w nosdl, or other rrrnp relernure fiolnle)
1 .
` I,r-I rlh
Malnrlal KIVIlwd
15. SGrlf-r-I 1.
Lrr l+Ili
I �ianlnlor
Slot S176 MnImIAI
hnm _
n.
----
rl(nn _...__.
In
Tom ._
In
it,. SAt1U/(,ftAVrl.
I'ACR:
UPI+III
Size Mntarinl
Ft.
------ ---
From1('----R.--
17 nEhIAFIKS:
I DO It('tlrnV CF.nllrl' TIIAI 71 IIS WELL WAS CODSrFlijejE_O IN ACCunDA110E will, ISA NCAC 2C. VIFLL
CONS F fHK; I lorl S TANnAr101. ArIO TI IAT A COPY OF Tr IIS nECOf10 HAS BEEN PROVIDED TO lI lE WELL 0-----
DATE! --�
Fun OrrICE USE VFILY y-1--IIF OntE Q
_---_ --- _� 811,Al ll EOr fterOU1CONSTnUCimO llio W11_
Oued tlo'
Submit orlQlnal to Dlvlllon or water Ouellly, Oroundweler section Wllllltl 30 dny9 OW InFV. 12/73

North lire nt of Environment mid Natural nenources . Division of Water Quality - Groundwnter Seclion 'j 17
q 91
1636 Mail Swvice Crntrr - flnlnlgh, N C. 27699-1636 Phone [phone] G..
NELLCONSIHUG] [ON RECORD WELL CONTRACTOR: Z-Ofi__EiBgUV'aen/
WELL CONTRACTOR CERTIFICATION 0:�_D� Ia..
STATE WELL CONSTRUCTION PERMIT#:
2.
WELL USE (Check Aprucoble no.): nesldenlial5(J Municipal ❑ Industrial ❑ Agricultural ❑
Recovery' (] I lent Fumy Water Injection ❑ Other n If Other, List.Use: _
WELL LOCATION: (S sketch f theQJp/gation below) �1
Nearest Town:— ��� n�^ - County:
Monitoring ❑
)Woad flame nn f m hors, Communll , or Su division and Lot No.)
DRILLING LOG __ DEPlIi
3.
OWNFR `/7-l/ltilt _
From To Formation Description
_%L�,
Addres 30 /, �/
-
- (�Frcct o2 f r ✓
Ci or lo,•.n Stale Zip Code
4.
dd p
DATE DIIILLED _Q.' 4r__
5.
TOTAL DFrIII __ I A5L _
YE.S[_� N09
p =`
6.
CUTTIrIOSCOLLECTED
FirrLACE FXISTING WELL? YES [] N04
7.
8.
DOES WELL
STATIC WATER LEVEL ©elo%v Top of Casing: FT.
—=c---c_-=-
(Use '+' If Move Top of Casing)"-
_
g.
TOP OF CASIrJG IS__.� ___ FT. Above Land Surface'
_ co
'Top
of ea stnn 1ennio nted eVor below land surface requires a variance In actor-
dance with 15A NCAC 2C.0110
OF TEST
10.
YIELD (gynt):.Q MET IHOD
11.
WATEn ZONES (depth):—
-- N 1
Amount
If additional space Is needed use back of form
12.
CHLOnINA11ON: Type
13. CASING:
_LOCATION SKETCH_
Wall I hicknc ss
Drylh • izmeler or WatgnUTT �T,A'l�artedCal O (Show direction and distance from at least two Slate
From O —To Q FI. --�++--- �°L4' r r� 'hk Roads, or other map reference points)
From--- T° Ft. --
From -----To _--- Ft.
Dcpfh Material elhod l� Q/f
From -_-p_ To _LkLG_) FL P011� F ourEd l.(•t-ram/
Frorn _ __._— To _--FI. -
15. SCREFtJ:
Dopih Dianreler Slot Size Material
From 10 ---- FI --- In. — In. --
From To _._-- rt. __— In. _ In.
Front _._-...._ To _ PL_— In.
16. SAND/GnAVEI. PACK:
Depth Size Material
From"°- FI.
From --__-- To Fl.
17. REMARKS:_-_
I DO H6RFPY CEnI frY TI IAT T HIS WELL WAS CONS I FILICTED IN ACCORDANCE WIT II 15A NCAC 2C, WELL
CONSTRUCTION STANDAn DS, AND THAT A COPY OF IIS RECOR/-qHAASS BEEN PROVIDED TO THE WELL OWNEn.�,
FOR OFFICE USE OtILY�-----'2 LC---
Sf ATUnE Or r'EnSol DNSMUCTING IIIF WELL DATE
Quad No:
Submit origin o Division of Water Quality, Omundwater Section within 30 ay9 GLV.1 REV. 12/99
Serial No.

North Cnrp6nn - Drrn,lment of Environment and Natural Resources - Division of Water Quality - Groundwater Section (; 17393
1636 Mail Service Crntnr - flnleigh, N.C. 27699-1636-Phone [phone]
NELL CONSTRUC1[ON RECORD WELLCONTRACTOR:
WELL CONTRACTOR CERTIFICATION 4:_,�0� lo..
STATE WELL CONSTRUCTION PERMIM
1. WELL USE (Check Aprllcablo nox)t nesidential L1LI Municipal ❑ Industrial ❑ Agricultural U Monitoring ❑
Recovery ❑ tleaf Pump Water injection ❑ Other Ej If Other, List Use:
2. WELL LOCATION: S sketch I thle/I/Qcation below)
Nearest Town: _ � ��Q =- c= County: —
moat Marne and Numticrs, Cam. ,rnmunl or ubdivlsion end Lot No.) _DRILLING LOG
3. OWNFn _�fT- From To Formation Description
Address12
vent or ou o o
it or Tmvn p'---State zip Code-�
4. DATE DHILLFD 11.E 9• V G
5. TOTAL DFPTI I--
6. CUTTINGSCOLLECTED YF:S❑ NO 1M
7. DOES WFI-I- FIFPLACE EXIS TIFJG WELL? YES NO4
8. STATIC WATER LEVEL Below Top of Casing: Fr -
(Use '+' If Above Top of Casing)
9. TOP OF CASIN_G FT. Above Lend Suffnco'
'Top of eaalnq re nnhmlvd al'rr helaw land surface requires a variance In actor- _ -=
dance With 1sA fICAC 2C.ta /9 Q - --
10. YIELD (gl'Ir): Q`- -- ME11IOD OF TEST �(.�14--- ------ ----- --
0.WATEn70NES(drpth):___. ------""- •• �,
n,
12. CHLOMNAT ION: Typo � Amount � � It additional space Is needed use back of IorhP--
13. CASING:
Drpih lameter
From- -----T o -J_ Ft. _
From------ To----- Ft. --
From ----- --to---- FI.-
14. GnOUI:
-LOCATION SIETCH_
Wan T hicl-.ne"
or Weigr,Vrt Maledal (Show direction and distance from fit least two State
�1.4das. s?"DLR Roads, or other map reference points)
Drpih �Material II
From ___U-_ In _.kil OACJL�T
From ----__ To
15.SCREFN:
Drpih Diameter Slot Size
Material
From _-- To _--
Ft --
In.
_. In.
From --To --.
Ft. _--
In.
_. in.
From _--___ To _
FL__
In.
— In.
16. SAND/GnAVEL PACK:
Depth
Size
Material
From To:
Ft;
From ___-- To
Ft..
17. REMAnKS:
I DO IIErtEPY CFnt IFY TI IAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C. WELL
CONSTNUCTION STAtJUMDS, AND 'COPY OF HIS RECO HAS BEEN PROVIDED 70711E WELL O`NNER'
on OFFICE USE ONLY ,rJ 1[�JYDyATE
Oaed No: s ATUnE OF ENS CONSTNUCTIr1G 1nF WELL
Submit origin oDivtslon of Water Quality,Omundwaler Section Wilhlrl 30 days NWI NEV. 12199
serial No.

North nl Of rnvironn,wd and Naturat Fle!'WCn9 - Civi^.ion of Water OUAlity • otmindWnter Srr.11on ..�. ) r'1 (1
1636 Mail SrrviCr Crnlrr flNrigh, itC. 276c9-1638-Phone [phone] (. 'j.�/'ONf 9)
WELL CONSMUC11ON RECORD WELLCONTI ACTOTI: - IC 71
WELL CONTnACTOn CEnTIrICA
STATE WELL CONSTTIUCTION PEI I41TH: _
1. \VELF. IISf (check nppnranle noa)t nesldenllalLll Municipal ❑ Industrial ❑ Agrlcull'IMI ❑ Monllnring ❑
necovrry ]_] I Ien1 Pmnp Water Injection ❑ Other ❑ II Other, List Use:
2. WELL I-OCATIOI•L (rl o ssk�elccl I11,e topLation below)
m N,rareslT-:n:_--/ •��•'-=-----County: --- -
Inca nainn IN vm!wi S. Connnuon ,or ubdivision and Lot tJo.) DHILLIfJG LOG DEPTH_
3. OWNrn _ _
From To ronmallon Descdplion
AddN•es — —------�z--
//� C4 fnc_rS..—
(-Ty rr I own
4. DATE UItH I T[)S. TOTAL DFPIII
6. CUTTRI1 COI_LECIED YESQ NO[r /� — u
7. DOES WELL nFri ACE EXISTING WELL? YES
I-rl
B. STATIC WAIEIILEVEL Below Top olCnsing: _�FT•
(Vse'+' If Above Top or Casing) —_
9. TOP Or CASING IS _ FT. Above Land Surface'
�-
'Top or eesbitl lerndnalmt aver below land surface rerfulres o verlanee In occur.
dance with JrA IICAC 2C.TJ 1e • J
10. YIELD (gpm) _P MET HOD OF TEST —
11. WATEn ZONES
— rr/
12. CHLOTIII JA11ON: Type Amount II additional space Is nrterind use back of term
13. CASTIG:
Wall lhlcw"lls
O
Drpth Dlamel r or weig�h�Ur�l, Al dal
rl.�
Flom
—lo
From----
From -.--le-----
rt.
14. GnOUi:
Ma
terialFrom
Unpih
� rl.
_
_ In _aQ
Flora .___
Tn____ _.____ Ft.
Is. SCnEFII:
I,trplh 0imneler SlolSlzo
Mnlerinl
rron, .__----
1 n__..-. rl --- In. —in
From __.__—_
10 ___.__-. rl. _-- It"
Rom __.__.Io-
___Ft._--- In. _In.
16. SANDIGHAVEI. PACE:
Uepill Size
Material
Front —_---
1 ° ----- n.--------
Front _ _.
_— l o _— rt.------
LOCA110N SKETCH
(Show direction rurzf dislnnca from at laasl two State
noads, or other map reference points)
17, nEMAl11c5:__
I DO I IF IrDy CF.f111Fy 111A1 I Its WELL WAS CONST wis riE IN noA(CHAS
DNJCE WITI 115A NCAC 2C. WELL X l
COrIS1FlVCTIOIISTANDAFIF?S, ANO Tf1AT ACO�PYjO/FJTI115 nECOr1D HAS BE PFlOVIDED 70 THE WELL OWNEFl. D
FOn OFFICE USE ONLY DATE
SIOrIATU EOF PE SOLI COHSIFlUCTINC11nF.WPI
Ovad fin'
Submit alglnsl to Dl sion of Water Oueilly.Omundwater $nc!bn Wllhht 30 days ON f nEK 17J33
Sadal 110

NnrTh rnrur rant rind Natural rin-nwr ". bivl^.Inn of V✓aler ounlily. - Oraund•.vntnr Sn.ai•:rr s_ 17396
1636 Mal B; rmo:n Cnnlnr Ilal^Iuh, I1.(;. 276991636-r'hone (919) 733322,
WELL CUIJSIfIM3110IJRECORD WFLLcorlrnnClon: FE-P-5uSc)N------------
YJFLI.COFIrrlACTOn CEnTIF ICAIION
SrArE WELL COUSMUCT1ON rrIVd1I
._,{ Munic(pal [_, Induslrinl Agricullm nl L_l Monitoring ��
1. WELL W;V (chrck Pt v11-1 , nn�): nesid I110al [1LI
necovely [_ I Icnl rump Water Injection [J Olhor ❑ If Otlmr, List Use:
2. WELL LO('^ ITOr I: "/jn,W{,�skp,141,0/I llh000 lo�calian belov:)
((
------------ -- --..- ---- DEr II I. _...._
(nen•1 rla:n^ m+d�r7j nrn^is. y, or SubcITvllion e d Lnl No) DRILLING L_OG— _ -
(/� Prom 70 rbnnNlon Daluq+l'an —
Addres _ 77
"i r nr ncu i
—city r+In,'.�r p Sale zlp Code - --'--- —.—..
4. DATE(Ifill I.EO B' -00 _---------
5. TOTAL DEI' 11I _... I -
6. CLIFTIIIGSGOLI.FI�IEI) YES[] NOL -
-------------------
7. DOES WFI_I_ IIrrLACF FXISIING WELL? YES [—� NO( 1�------- ------
B. STATIC;T'JAIEnLEVEL Eleloc7IOFF orCnsing: --&V FT. ---- -----------
(Use'+' II Above Top of Ce11n9)
FF. Above Lnnd Sndnc0- _--- ---_--._ --
'Tor of cm 0i9 rrn+rb,nlyd rl':-r hnlow In rid eurlece requires a vmlence In eccor-
I
denco 1111 15A Ac 2c
10. YIELD (q!`n+)'. _,:} _ MU IUD OF TEST
o _
I1. WATEII 70tIFS (dr•l+lh):_— _ — "' — _ _ C�
r
12. GHLOf IIN.t\ i ION: l Yl,e.ItAmoUn( S��.S II ndddionnl .pane I nrndnd a^n hnrk of Inr
13. CASIN9: LOCAIION SICEICII_ -!
YJell 7lacHnelf �?
Dr!•III // /f-Immler or 1W11elo,hvi-t tdalnrinl O (Show dirncllrnt rind di^Inncn Irnm nI Imct IvrO 5.71 ,. -
Frorn___O_.__ Tn_.[_._FI. _e+L' 1IY.1'����S QR Roads, or other mnp felmencn pnhrt;) N yQ
From--
Frorn
14. G1101.1I: inlhod
I,rl•Ih Mnlerlal -� / .
(> ,r, �,v _Ft _�psssa•�4�_ _:}�o_u[f:_d_ � ��Q,Q ll
Fnm - r
-
15. SCn[r(I
I?rplh Diomolnr Slot Sl7e Mnlodol
From _.._...__ I n _. PI -_ In._-_--
Frorn -_ ___ T o ._. -. __ FL _._— In. --- In. —.
From ._____To. _FL-.--
16. SANUIGnAVFL rASICt Malnrini
Uep111_ _ Size
From
---
Frorn.- - �------.-----.'
17. nEMA11KS:___-__--_-
1 DO I IEnrnY cen t Ir'Y 11 TAT T1 ITS WELL WAS CONS rnLICTED IN ACCORDANCE WI III ISA NCAC 2C, WFLL
COIlSTI1lICTION S1 AfInANO.^.+•AND TIrAT ACOPY Or NISr1ECOn HAS BEEN moVIDED TOlNE WELL OWNE+.��
FOrT orFICE ll$F: (ttILY DIE
$I r ATUf1E Or PrnSO CONmundU ter S coon will
Oued No: Jj Submn vd0lna o Divislon of Weter ousllty, Oroundwe,er 5^ctinn Wlll lln 30 day4
DW1 nEV. t2/93
Sedal No. -

North Carolina - Department of Environment and Natural Resources - Division of Water Quality . Groundwater Section ; ; 1 6 ,t`f 5 R
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone] `S
WELL CONSTRUCTION RECORD WELL CONTRACTOR:R.CALDWELL DRILLING, INC.
WELL CONTRACTOR CERTIFICATION M. 140
STATE WELL CONSTRUCTION PERMITII:
1. WELL USE (Check Applicable Goa): Residential Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATIO� N: (Show sketch of the location below)
Nearest A t'' Tttown: iY1f4Y ea•,( County. �ASD ✓1
`a
Dvi
Road Name and NurAlbers ommu y. or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER 1.f .-KnVN� From To � Formation Description
Address (pr) I 411c-
ree or a o. — 3S
/M�4rs ,al i t y
ity or Town 3 Slate Zip Code
4. DATE DRILLED
5. TOTAL DEPTH O
6. CUTTINGS COLLECTED YES ❑ NO�
7. DOES WELL REPLACE EXISTING WELL? YES NO
8. STATIC WATER LEVEL Below Top of Casing: IQ FT.
(Use Y II Above Top of Casing)
9. TOP OF CASING IS ( FT. Above Land Surface' o
-Top of casing terminated at/or below land surface requires a variance In accor.
dance with 15A NCAC 2C.0118
1. YIELD _100— 39OF TET
11. WATER ZONES (depth):�3IoOSal,
JJ w r-,--
o -_
12. CHLORINATION: Type AmountIf additional space Is needed use back of �:
13. CASING: JJJJJJ
LOCATION SKETCH
Wall Thickness C.It
..j.1-- Depth Diameter or WelghVFt. Material (Show direction and distance from at )east two Stale o
From—f--_To / a`= Ft. Roads, or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From To Zy Ft.
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Malarial
From To _ FI _ in. —in .
From To _ Ft.— In. In. n '
From _ To _ Ft: _ In. _ In. 11 u
16. SAND/GRAVEL PACK: f_
Depth Size Material
From To Ft. Cl
From To Ft.
17. REMARKS: AA
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECO AS MEEN PRO IDED T THE WELL OWNER.
FOR OFFICE USE ONLY
Quad No: SIGNATURE OF PERSON C91NSTRUC NG THE WELL DATE
Submll original to Division of Water Qual , OmuMw er Secilon Wlthln 30 days
Serial No. GWI REV. 12199

..;.:.�:, .: :- _.._ .I'�-�.xJi :. ' Gi '17.,f=•: � I Y 9�gyr�'+„�.G, �. -'.�;..,.� . :- 6!ti. � -. .'. .:..
2293f?2
North Carpli m heT.anmenl of Environment and Natural nesources • Divlslon of Water Ouslity • Groundwater Section -
1636 Mail Service Center - flnlclgh• N.C. 27699-1636-Phone [phone]
WELL CONSTRUCI1014 RECORD WELL CONTRACTOR:WELL CONTRACTOR CERTIFICATION
STATE WELL CONSTRUCTION PERMIT#:
WELL USf_ (check Avrneable Dnz): nesldenll84 Municipal ❑ Industrial ❑
Recovery L I I loat Purnp Water Injection ❑ Other (] II Other, Llst Use:
Agricultural ❑ Moniloring ❑
2. WELL LOCATION::JJ'Ilow skel It f the location below)
Nearest Tcwn: ///�%dd -(- County: oa -
Inoa4 rlanm and r u 'tars, Comqundty, or bdlvisian and lot No.) DRILLING LOG
3. OWN E From To
Addr ..S L D _—
�liee
Zip Coda Sa - 3 b 0
Cliy nr imvn Stale p
4. DATE DI111.1_ED _T _-lg. C 6
DEP
5. TOTAI. 111 _M¢-+• E--
6. CUTTINGSCOI-LECIEU YES[_] NO
7. DOES WELL TIEPLAGE EXISTING WELL? YES 1-71,NOd
8. STATIC WATER LEVEL Beloty Top of Casing: - , FT -
(Use '+' If Above Top or Casing)
9. TOP OF CASING IS J--_. FT. Above Land Suriace'
-Top of caehtg Pei mbtAlyd rirnr below land surface requires a variance In accor-
' dsnca with lfin tlCAC 2C. e
10. YIELD (gplri): _ — IdET11OU OF TEST 1-�L--
11. WATER ZONES (depth): — J
12. CHLOnIfJA1ION:
13. CASING:
_ DEPTH--
Farmallon DescOlion
WOO
_ r
.I We — Amount l0 II additional spare isncedod use back of form
Depth lameler
From-0 _—_10 � Ft.
From----- to Ft.
Flom-.-----10.--- ft.
14 GnOU 1
_LOCATIONE7 SKCH
Well Thickness
or W'Ielghvrtmaterial nD (Show direction and distance from At least two State
JW& P&Y3QM1 Roads, or other map reference points)
OVI'lli material ethod
From ---� _ toFrom To
.. _..--- To ---Ft.
15. SCREFtl
Depth
Diameter
From __To ---
FI-- In.
- From ___—_ To ___—_
Ft. __ In.
From --- To ---
FI. In.
16. SANDIGRAVEL PACK:
Depth
Size
Slot Slzb Material
_ lit.
In.
In.
Material
From TO fl'
From _--- to FI.
17. REMAnKS:
I DO I lEnrBy CF61 IFY TI TAT THIS WELL WAS CON
CONS TnUCT ION ,$TAW ONAPS, AND THAT A COPY
T{i<I-
Es'dal
R OffICE USy(MLY
ad No'.mit o No -s.--
IUCTED IN ACConDANCE WITH 15A NCAC 2C, WELL
THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER;
y r r GATE
of PERSON CO Tnuctrwa 711E 9yELL
of Water ouality, Dmundwaler Section within 30 days OW I nEV. I2/99

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section 4' "' ' 4 / v
1636 Mail Service Center - Raleigh, N.C. 27699.1636-Phone (919) 733-=l
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION #:_�—
STATE WELL CONSTRUCTION PERMIT#:?
1. WELL USE (Check applicable Box): Residential Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION:�_(�j�how sk¢tch of the location below)
Nearest Town: � ki /; County:
(Road NaffT ends mere, Comm)Inity, or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER From To Formation Description
Address 7J4104-I_� x1L _ y }
A,.4.�� �t C ���f<3
Ci or Town U state 7Jp Code
4. DATE DRILLED
5. TOTAL DEPTH a
6. CUTTINGS COLLECTED YES ❑ NO
7. DOES WELL REPLACE EXISTING WELL? S NO� CO
8. STATIC WATER LEVEL Below Top of Casing:_ FT. .,
(Use'+' 8 Above Top of Casing) a
9. TOP OF CASING ISFT. Above Land Surface* fV
-Top of casing terminated at/or below land surface requires a variance In actor. GJ
dance with 15A NCAC 2C .0118
1 D. YIELD (gpm): J C"' METHOD OF TEST CI-Le--
11. WATER ZONES (depth):
12. CHLORINATION: Type ount ) .3 C - If additional space is needed use back of form
13. CASING:
Wall Thickness LOCATION SKETCH
Depth DiarPeter oo�-r, WW��eig�hh�tr/F�t. I1l��laa.t-ee�riall�� (Show direction and distance from at least two State
From�TO —— Ft. lc ls� }a�3 c ry(ar1.a� Roads, or other map reference points)
From To Ft. VV
From To Ft.
14. GROUT:
Depth //y}��� _'M�a�t�ed��a Method
From � To ,� Ft. JJJJ.dJLC�—
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
Serial No.
fELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
THAT A COPY OF THIS
RECORD
HAS BEEN PROVIDED TO THE WELL OWNER
��.ri''.'✓AIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
t5tltdtbrlginal to Division of Water Duality, Groundwater Section within 30 days
_ GW4 REV. 12199
M
az
r :;

North Carolina - Department of Environment and Natural Resources - Division of Water Ouafity - Groundwater Section �,: ;: t1
4 79
1636 Mail Service Center - Raleigh, N.C. 27699.1636-Phone (919) 733.=1
/ ,{//1 ,�
WELL CONSTRUCTION RECORD WELL CONTRACTOR�` � 221'ty J11ZY4 "
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: sketchAt the location below) %
%(Show
Nearest Town: -7"0'� 4 /-Q - County:
(Road Name and NuTibers. Community. or ubdivison and Lot No.) DRILLING LOG DEPTH
3.
OWNER From To Formation Description
Address ����,
r s or ou o. 7�y/
Ci or Towff Stab ZIP
4.
DATE DRILLED��0
0
5.
6.
TOTAL DEPTH JL1L ZL� o
CUTTINGS COLLECTED YES ❑ NOM
7.
DOES WELL REPLACE EXISTING WELL? YES Q NOM
o�
B.
STATIC WATER LEVEL Below Top of Casing: 20 FT. z
r-�
,
9.
(Use'.' 0 Above Top of Casing) —
TOP OF CASING ISFT. Above Land Surface'
om
s>
'Top of casing terminated atlor below land surface requires a vsrbnm in actor-
dance with 15A NCAC 2C .0115 J
10. YIELD (gpm): -,Z_ METHOD OF TEST
n
11.
WATER ZONES (depth):
12.
CHLORINATION: Type Amount C. If additional space is needed use back of form
`
13.
CASING:
LOCATION SKETCH
WallThicknau
Depth ter or Weight(R. erfal (Show direction and distance from at least two State
FromTo- Ft. Gin Roads, or other map reference points)
From To Ft.
From To Ft.
14.
GROUT:
Depth Material Method
From To W 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 Af.OPV1OF THIS RECORD F AkBEEN PF19VIDED TO THE WELLJOWNER.
FOR OFFICE USE ONLY Y
Ouad No; SIGNA EF P OERSON CONSTRUCTING THE WELL DATE
Subrnil original to Division of water Quality, Groundwater Section within 30 days
G
Sedal No. W1 REV. 12r89
r;.
( f

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section z 43 U
1636 Mal Service Center - Raleigh, N.C. 27699.163e-Phone (91 e) 733.3221 n
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION#: �b
STATE WELL CONSTRUCTION PERMIT#: ll
1. WELL USE (Cheek Applicable cox): Resldendalft Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATI N• Shaw sketch o the location below)
Neareat Town: ,�1r �L-t,2 t O-P County: /-L��� "J
Agricultural ❑ Monitoring ❑
(Road Name end N rs, Commnu I or Subdvision and Lot No.) DRILLING LOG
3. OWNER ����/ii�r�yC s✓ _ From To
Address (- 7/
(51roat or Routi o. r// — la2 S_
Gty or Town State LP Code
4. DATE DRILLED l �15)
5. TOTAL DEPTH /o O L
6, CUTTINGS COLLECTED YES ❑ NO
7. DOES WELL REPLACE EXISTING WELL? EASE ❑ NOO
e. STATIC WATER LEVEL Below Top of Casing: FT.
(Use '+' 0 Above Top of Casino)
9. TOP OF CASING ISFT. Above Land Surface-
-Top of cuing terminated stfor below land surfs" requires a varlsnee In aceor-
donee with 16A NCAC 2C .0115
10. YIELD (gpm): / Z, METHOD OF TEST
11. WATER ZONES (depth):
12. CHLORINATION: Typerl Amount o2 e .
13. CASING: a
Wall Thickness
/ Depth Di r ter or we phV1Ft. tech
Fromm -To � Ft. S
From To Ft.
From To Ft.
14. GROUT:
Depth ����Material I/ M
ethod
From � To s1[nnLFt. 1
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From —To—Ft— in. _ in.
From To Ft.— in. — In.
From To _ Ft. _ In. _ In.
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
17. REMARKS:
DEPTH
Formation Description
Owl
It additional space is needed use back of
LOCATION SKETCH �o z
(Show direction and distance from at least two State
Roads, or other map refere'ncee/ points
( /A/�� ��
/� c1 lL �
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A,PWI�OF THIS RF2COfiD FAkBEEN PR9VIDED 110 THE WELLI'
USE ONL
Quad No:
. SIGNATUA OF PERSON CONSTRUCTING THE WELL
SubrNt De4na to Oivislon of water Quality. Groundwater Section within 30 days
GW-1 REV. 121"
Selo No.

Nonh 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:( ' -_
WELL CONTRACTOR ERTIFICATION
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): ResidenUal� Municipal ❑ Industrial ❑ Agricultural ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: `�%�� /p County: �24 % 'J
(Road Name and WArbers, ComrruNry, ubdiWsim and Lot No.)
3. OWNER
Address
toweet or a 0.
YJ
e- S
City hr Town Stab ZIP Coda
4. DATE DRILLED 07 r 00
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑ NOEY
7. DOES WELL REPLACE EXISTING WELL? YES ❑ N0[ff
8. STATIC WATER LEVEL Below Top of Casing: FT.
(Use'+' k Above Top of Casing)
9. TOP OF CASING ISFT. Above Land Surface'
-Top of casing terminated atfor below tend surface require a vartance In actor.
dance with 15A NCAC 2C.0118
10. YIELD (gpm): /2 METHOD OF TEST /L�
11. WATER ZONES (depth):
12. CHLORINATION:
13. CASING:
DRILLING LOG
From To
�-a s
Type Amount L e It additional space Is needed use Dacx or rorm .r., o
4485
Monitoring ❑
DEPTH
Forma Description
WWI Thickness
Depth Diameter or WWghtIF4 ateda
From To � Ft /� SP�2/
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method�7
From L To Ft. ���
From To Ft,
15. SCREEN:
Depth Diameter Slot Size Material
From —To—Ft— in. _ in.
From To _ Ft. _ In. _ In.
From _ To _ FL_ in. _ In.
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
17. REMARKS:
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USEIDMI.V
Quad No: € r IGNATURE OF PERSON CONSTRUCTING THE WELL DATE
SuWNt odgfnatto DivWon of Water Quality, Groundwater Section within 30 days
SedW No. — ( = GW.1 REV. 12199

North Carolina - Department of Environment and Natural Resources - Division of Water Duality - Groundwater Section
1636 Mal Service Center - Raleigh, N.C. 27699.1636-Phone [phone] n
.,4 434
n A �
WELL CONSTRUCTION RECORD WELL CONTRACTOR: _ �s
WELL CONTRACTOR CERTIFICATION #: b
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 LOCATIOrn1� ow sketc the location below)
Nearest Town: ;/ .i0 � County: _1LL7<��/���
(Road Name and umbers, Cont unity, or Sult9ivWon and Lot No.) DRILLING LOG DEPTH
3. OWNER ILG+� Frommn To Fomwson Dascrip0on
Address 41n 4 S�
'^j5 ale or a o.
City or Town Stab Zip Code
4. DATE DRILLED �� o
5. TOTAL DEPTH ya S
6. CUTTINGS COLLECTED YES 0 NOO
7. DOES WELL REPLACE EXISTING WELL? YES 0 NO,Et
e. STATIC WATER LEVEL Below Top of Casing: _O_ FT.
(Use Y' 9 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.0116
10. YIELD (gpm): /-9- METHOOOFTEST C� tip
11. WATER ZONES (depth): C
0
12. CHLORINATION: Type aID� Amount / %z e . If additional space is needed use back of form
13. CASING:
Wall Tnidutem
Depth _ Diameter or We' htIR. Material
FromTo �L Ft. ° ` SW � I G
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From To � Ft. �����
From To Fl.
15. SCREEN:
Depth Diameter Slot Size Material
From —To—Ft— In. —in
From To _ Ft. — In. _ In.
From —To —Ft. In. —In
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
17. REMARKS:
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT MAOFS2!�/ORDnBEEVIDED TO THE WELL OWNER.
FOR OFFtI`:..0 (Al�LY -
Ouad NO: - SIGNA E OF PERSON CONSTRUCTING THE WELL DATE
(? Submit original to Division of Water Quality, Groundwater Section within 30 days
Sedal No.
�.i 3, _.._ - i GWt REV. 12199
LS<

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 ERTIFICATION #:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (check Applicable Box): Residentiao- Munlcipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, Ust Use:
2. WELL LOCATION: (Shpw sketch f e location below)
Nearest Town: ��-/ 6 l�� county:
(Road Name small
3. OWNER _E
Address <
or Sybdivlalon and Lot No.)
4. DATE DRILLED U//i//ov
5. TOTAL DEPTH `f 2 S_
6. CUTTINGS COLLECTED YES ❑ NOQ�
7. DOES WELL REPLACE EXISTING WELL? YES NO)
8. STATIC WATER LEVEL Below Top of Casing: I V UD FT
(Use'+' M Above Top of Casing)
9. TOP OF CASING IS_�_ FT. Above Land Surface -
'Top of casing terminated st/or below land surface requires a variance In adcor-
dance with 10A NCAC 2C .0110
10. YIELD (gpm): f_ METHOD OF TEST �u
11. WATER ZONES (depth):
12. CHLORINATION:
13. CASING:
Type � V Amount r 2 e ' If additional space is needed use back of form
L244�3
Agricultural ❑ Monitoring ❑
DRILLING LOG DEPTH
From To Fomution Description
/l l 5//!f
IV - go 5
Wall Thickness
Depth
Dfameter
urn_
orweightlFt. �Maateriall-�"
From
_�To
Ft.
�a+-
From
To
Ft. —
From
To
Ft.
14. GROUT:
D
tAMethod
��v
From
,a�n�al�
_l2 Too A2 � Ft. Ft.
From
To
Ft.
15. SCREEN
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
Depth Diameter Slot Size Material s /" ;� -
From —To —Ft— In. —in / / dk
From To — Ft. _ in. — in. yQ/2CC�C� GZ�
From To _ Ft. _ In. _ In.
16. SAND/GRAVEL PACK: o
Depth Size Material V6 411K�
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 1jOF THIS REFO(iD BEEN PR VIDED TO THE WELL
OWNER.
FOR OFFICE 5 LY
Quad No: - "_ SIONATWIE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Ousliry, Groundwater Section within 30 days
G
Sedal No. W1 REV. 12/99

North Carolina - Department of Environment and Natural Resources - Division of Water Quality- Groundwater Section 24492
1636 Mail Service Center - Raleigh, N.C. 27699.1636-Phone [phone] n
WELL CONSTRUCTION RECORD WELLCONTRACTOR '%
WELL CONTRACTOR CERTIFICATION: *,b R.S�
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential IdJ Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (S ow sketch Of a location below)
Nearest Town: ��� County:
(Road Name and Nu bars, Community, or Subdivlsion and Lot No.) DRILLING LOG DEPTH
3. OWNER From To Formation Description
Address Sl7 ryry�ijLfa"�, r �/2T llut
or our C C
City wn State Zip Code
4. DATE DRILLED 10 60 p
S. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑ NO C
7. DOES WELL REPLACE EXISTING WELL? ES ❑ NO[b
6. STATIC WATER LEVEL Below Top of Casing: FT. z `=
(Use': M Above Top of Casing) _ CO $ v
9. TOP OF CASING ISFT. Above Land Surface*
'Top of using terminated aVor below land surface requires a variance In sccor- `r
dance with 15A NCAC 2C .0118 N
10. YIELD (gpm): Ile METHOD OF TEST Fa
m
11. WATER ZONES (depth):
12. CHLORINATION: Type4r11ALL&Z= Amount J c.
13. CASING:
Wall Thickness
Depth 04vMter or Wa phVFL
From�T/�
o � FL
From To Ft.
From To Ft.
14. GROUT:
Depth atonal
From ...1[_ To­�v Fl.
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
z
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
CONSTR GllOOLST.riJIJAR9E'r— fh OF THIS O D BEENPR VIDEDTOTHEWELL�OWNER-
FOR
OFFI
Quad No: + i I SIGNA E OF PERSON CONSTRUCTING THE WELL DATE
( Su„' final to Division or Water Quality, Groundwater Section within 30 days
GW4 REV. 1V"
Sedal No. {

x
North Caroli"n - mnnl of Fnvin,nm^nl and Natural nPrmurcrq - Divl^Inn of Water Ouallly • Groundwnter Secli-,n k-1 �1 ((''��
1636 Mail Smvicr Crnlnr 11,,tMah, IJ C. 27699-1636-Prone (919) 7333221 ti 1 if JlAA 0 0
WELL CONS f RUC 11014 RECORD WELL CONTnnCIOn: _�L� L�2_y ����� i,/
VJFI.L CONTflACTon CEnTIFICATIOtI
STATE WELL CONSTRUCTION CFRh111M:
WELL NSF (speck Arlalcaao m.): flesld�nllolL'YJ Munlclpal ❑ Industflal Ej
Flecovcry [ I I h,lt r urnp'Watnr Injection ❑ Other F j If Other, List Use:
Agilcultural 1_l Monlloring ❑
2. WELL LOCA I I!) Aho1v sCke h of/l/�.�g location beloYI)
Nearest To,tiar.. Gy[f�b���`------
(load nano and
3. OWNER
Address
lind
Cay o, 1"", ,lace
A. DATET��
5. TOTAL 1)EI'111
6. CUTTIIIGSCOLLECTED YES[ NO[kf —
7. DOES WFLI_ IIEFLACE EXISTING WELL7 YES NOL-0 _
8. STATIC WATEn LEVEL 13elow Top of Casing: FT,
(Use'+' II Above Top of CAelnp) _
9. TOP OF CASIr,G IS—L_. FT. Above Land Surface'
-Top of ce51r19 ter ndoelyd e1'01 below land anrfso* raqulfss ■ verlanea In aeeor-
dance with 19AMAC 2CAI a j�
'0,YIELD (gpt _. _ MET HOD OFTEST� _
r 1. WATER ZONES (dvpltl): J
DRILLING LOG __ DEPIIT___
From To roonatlon Descdplion
N
N=r— c;
12, CHLOPINAT ION: 1 ype Amount vplcg is nenctnd u-,o back of form --
13. CASING:
Wall Tldaknas
A� Depth tar at F1nt
FromvTo � Ft. If�-;L.a— Viet
F^—Sn
From---- To--.--- Ft. —
From _—_ —lo. Ff.
14. GROUP:
15
Ur1r111 MaI991l1n_1' Mothod
From .__O__ totry —
Front _. To
oonGFrl'
Unplh
Dlnmelor
From _._.__._ In _..._._
Ff __ -- In.
- From -- -- 11t — -.--
Ff. _.— in.
From __. _-lo ___.
Ft._— In.
16. SANDIGFlAVFI_ PACK:
Drplh
Size
From
Ftent - _...__._ l o _ .__._
Ff. _
17. REMATII<S
Slot Sl2e Mniolinl
In. _
In. In. _
Malmlrll
100 M-11roy crn l v Y MAT 11119 WELL WAS CONS Tr1LiC
CONS InIIS I loll SI r.NOPd ID3. AND MAT A Cory Or
_ — LP,
FO11 OFFICE -USE UtILY SIDNATunt;
Oued No:
Submll original to Division
Serial No
LOCATION SKETCH_
(Show direction and distance from at Irasl two State
Fl�o/ands, or other map//'reference points)
dMe
TPtM ;jW,
I14 AgCOnt)ANCF WI111 1SA1 jICAr 2C, VJFLI.
CD IIAS 13EF,N rnoVlD - TO TI lF. WELL O
SON COt7S TnuC r ltlo 151E WFLI DATE
ouellly, 1) oundweter Section wlihln 30 ctny9 DW 1 DEV. 12199

North CNnllnn . flop-Irhnnnt or Fnvirnmm�nt end Nnitnel nc".nulCrq - Divlainrl of Water Ounlily - Crrnmdwnler SnClino i
1636 Mnil Srrvirn Crnlrr - flnleloh, N.C. 27699-1636 Phone [phone]
WELL CUtJSTf1UClION FiECORU WELLcomi-TACTOn:
WELL CONTFIACTOn CERTIFICA11011 M: -, (� _
STATE WELL CONSTRUCTION MIMI10:
1. WELL USE puck rr•rflrnbtr non)! nesldenllalLYJ hlunlclpnl U Induslrlal FJ
necovnry LJ I Inal Pump Wnlor Injection ❑ Other ❑ II Other, List Use:
2. WELL LOCATION: �(SI1 tv skehtcof 1he IocaliOn below)
Neatest 7mm:-__4yh A,& Le County:
c
(IlOa'l rl.vn tlunrh"r •, onto iu 1lty o/ uubdwlssllon end I,qI No I
3. OWNFn /ASS /L+1,1R.1./�wll �'rj•(JYA e-
or
A. DATE UNII.LFO _7/_%0. -
5. TOTAL PF-r III -,VY< --
6. CUTTIII(}`_'CULT .FCIFU YFSL� N0 1�
7. DOES WFI l NFPLAr F rKL!',IIiJG WELL7 YES �[/] tJ0[
S. SIATIC1VATf_nLEVELD IocrTopolCnsing: -ZS FT.
(Use •.' If Above lop of Casing)
9. TOP Or CASLIIG I ___L__-.. FT. Above Lnnd Smlarn•
•Top of caetnp I"nnbml"'I rl'r•r brlow Lnnd eurrece requital a varlance In accol-
dancnwith 1<A tICAC )C .o I I n
10. YIFLU ((iprn): jo _ t.lEl I IOD OF TEST !_q _-
Agricullural L) Monitoring ❑
L.O_G_ _ DEFTII_--_---
To rormallon Descrlplion
It WATER ZONFS
12. CNLONIN.AILON
13. CASING.:
�4_—Arnount ---��u - II eddillnml apace 1. nnndnd n^n hock of lorf*U -I_
t`)l . (1rl-Ih �11""to,
From _. V_ ln-S�._rI + •]
From _._ ln..__..___ rL-
From--_.___in ------ FL_--
14. G110111:
I,�I'n1 Material lotIod
U_ Ire _ta
AO_rl _'�o1�C11E%_ _4tCEd_
rtnm .
rrnm
15. SCnFFif'.
Itrplh ITimttnlef
Flom .. . _.__ 1 n _.. _ FT
From ____._To ._. _.__I"L-_— in.
From _. _.__ To. -..-_Ft.-____ in.
16. SAND/Gf1AVEL PACK:
(lnirlh Size
From ---_-- In- r1.
From _._. To- Ft.
17. FlEMAIII(S:___
LOC A T IQN-Sf CE I C1 i_.
Wt111111r-I•nesl _ - -
or WnIQIV[ I. l.falydnt DD (Show dirncllon and diclnnrn IInn1 Fit Innst I" Slnle
noade, or olher mop letelen" points)
Slnl Sbp Mnlmial
In.
Malarial
I DO 1 irnroy CEni lrY TI TAT 111t5 WELL WAS CONSTnIICTED ITT ACCOnDANCE W1111 15A NCAC 2C, WELL
CONSI n11CTION SI ANDAROS. AND THAT. A QDPY OF 11 RECOnD NAS 13EEN PROVIDED TO 111E WELL OWNS �—
FOn OrrICF LI$F: (111LY SIGN 1RE Or PERSOtIC STRUCTVIG 111E WELT. DATE
Ouad No:
Submit odpinal to Ivlalon o!Water OuaIlly, Groundwater Section Will do 30 day9 G\Y-I REV. 1?l99
Sedal No.

North CnroB-m . hnh min it nl nF rnvirnnrngnt find Netmal fle^.ourcrn - UivHon of Writer Quality - Oiouridwnler $rctinn 17419
J
1636 Mail Srmwi Crnlrr Ilnlnlgh, N.C. 27699-1636 Phone [phone] / 4 1 9
WELL CONS] RUCT ION RECORD WFLLCONTRACTon: ESgU�4o/�1L_l_
WELL CONTRACTOn CERTIFICA11014 I1:;. Qa -
STATE WELL CONSTRUCTION PF11MI14:
1. WELL USF (ctn•ck nl'f•IlraLln nor)ne51dentirdb Munldpal U Industrial ❑ Agricullurnl Monitoring ❑
necovrip-_.butt Pump Water Injection [j Other If Other, List Use: 2. WELL WELL I.00A11011 `; a skCrlrQI� of the locatlon below)
Nearest Iornc .__d/1'LQ �p - _County:
(non•I tlann mid rmi , cmnm r y. of S ihdivls on an I Ita) D11ILL IIJG LO0 _- _DEPTH
3. ONJmE ft From To rmrnailon Cress�l[`lian
Address -- ?- 1
Ci rr loran �l Slain zip coax — --
A. DATE DIIILLEU-.
5. TOTAL PFP 111 _._- ----
6. CUTT It Kl- CULL F(:I FITYLSL] NOM _ ----
7. DOES WGI.(. 11P11 ACF FXISIfRJ(; WELL? YES [ tJO ------
6. STATIC WA MIT LEVEL Uelol•r Top of Casing: Jar% FT. --_---
(Use'+' II Above lop of Casing)
9. TOP OF CASING ri _..__ �PT. Above Land Sat face*
'Top of eaainp I"oih,mrd r!'or brlew Iand surface requires a variance In accor-
dance with 1'n il_nC 2o_.0I In
10. YIFLD (ul,rii): __ _ L9EI I IOD OF TEST----
O -'
11,
WATEII7-OtIES (If11,lh):_—_
--
--' -
1
Amount ��
II additional spare Is nned�d ace nark of bra, ',_]
12.
CNLQfIIIJAI ION: pp9
—�
13.
CASRIC,:
-
- -_-- P0 -+
LOCATION SIC _
_E ICII'.0
DPhlli�J
Vlap lhlcitneaa
Inn,etor or w1elg1hlir1. Mnlrant p
(Show direction and dislnncn hnnl nt tend two Stale
�_� �Y�I,'4' J-�S`-�0.M1
needs, or other map reie,ence Points)
1, _ ..�
-FI. -
Flom- -
TP------
FL-- --
From ...----._To...-_—
FL_ -- --
14.
GMT.11:
I,r)'Ili
n M:,latlol
SAL�01�
VV•_"
From ...--.ii--_
Tn i�.._Vt.
—�p�$1LE4
is.
Scnei rr
Urpp,
Dimneter Slnl Slze Malarial
From - ----
1 n......._
rl __. __— In.
From -----
1n ._- ._--rt.
___ — In.
From
To . -- --
rl. _— In. _ In.
16. SAND/GIIAVFL
PA(;K:
Depth
Size Material
From
—
From
17.
I Do I Ir-lirny CGni it V it IATlllv?q WELL WAS CONSIPUC1ED IN ACconDANCE WIIN 15A NCAC 2C. WELL
CONS 1 UCTION S IANDAM)', A"D r!"'AT A COPY OF ITS RECOno l S BEEN PnOV1DED TO TIIE WELL 0���• O
FOn Of rICF: USE UfILY I' $I(`, TtinE Or rrnSON nSMUCTING 111E WF.11, DATE
Ound No
Subndt original l' OivlsJon of Water Ouallly, Oroundwaler Seciinn within 30 Boys GW-1 nEV. 17J99
Sedai No —_ __-

North CproPmn . Dnrnrinwnt of (rnvin.nn,ont and Natural nesourees - Divinion of Wpter Ouaiity - Groundwater Srction / . , -t r7
1636 Maii Sclvico Ceninr - nnicigh, 11. C. 27699-1636-Phono [phone] [ s_ 1 IT, 420
WELL COIJSTRUCTION RECORD WELLCONTn� . FI: L b
WELL CONTRACTOn CEn TirICA 1104 If: =?
SI-AIE WELL CONSTnUCTION 1'FnMiTH:
1. WELL ISr (Check nr•r lcaf la noa)f nesidentiai Muniripal ❑ Industrial ❑
necovrry LI 110,11 Pwnp Water Injectlon ❑ Other ❑ II Other, List Use:
Ag0r-ullure1 ❑ Moniloring ❑
2. WELL LOCAT ION r low skrlrh of lh location below)/. SO�
Nearest lm�: n:.-. If�,tQ'�__woll-l--_—__—County: dF' �-------
_ _ Lot No DEPTH -
Inon I rIm„n ni d Ilun,',ris, Cnmrnuna o Subdivision and Lot Na) DRILLING _LUG --- —
� s rom+alion Drscdplion
3. OWNFFI From To
Addres.-
Code ZIP 21a1e �.
Ciy rn 1 awn r�
A. DATEDIIU.LEN_./-��"Q_
5. TOTAL DrP1I1
6. CUTIRIGSCOLLFCIEO )'ES ❑
7. DOES WELL t1EPt ACE EXISI ING WELLS YES ❑ NO tL/ --- B. STA11C WAIEn LEVEL Oelow Top of Casing: b_FT•
(Use'+' 6 Above OP 01 Casing)
FT. Abovo Lnnd Surlace' o `
9. TOP OF (:ASING IS-_ -- -._ -- _. -
'Top of Caning Iorminntnd etfrr below land sudaoe requhea a vprlenee In �eeor- donee with 15A fICAC 2C "I To " r
MET'riOD OF TEST
11. WATEII ZONES (drplh):._ N -+
-'kff cl
12. CHLOI11N A110N: Type � AmoUIt S It additional space Is neertal use bprk of form
13. CASING: LOCA1-ION SKETCH_
Well 1lkc ,,CAf
Urlllh Iamelor or Welght/rI. Mnledal G (Show direction pad distnit from pl Inasl two Stole
Roods, or other map reference polnls)
/^�
From--- Tn-- FI. ,r U/'e
From __--. -lo-- Ft. L'1 &c-tu J
14. GROUP. t d
I1rl,lh
n
Mvl ro
From - Q._ In si d
Ft.
_Material
�N/'!�-�
From ..._---- 1 ° _
FT.
-
15. SCnEF.IT
Urpih
Diameter
Slot Slze
Material
Rom -_----- Tn ____ r1
---
In.
in.
Prom _ -_- 1 ° ------
—
In.
Prom ---_-- 1 ° _.._.._ PL--
16. SAND/GnMri. PACK
nnpih
SIZe
Material
Front _--- 1 ° ---
FT.
------
From-----
17 REMMI<S:
I DO IlFnrny CEn1Iry 11IAI THIS WELL WAS CONSTnUCTED IN ACCOnDANCE W1111 15A NCAC 2C, WELL
FOOuafdI NOor: rIC—E -US-E U-N—LY_ - ANOTHAT ACOPSYIOOtF THIS HAS
PnOVIDED 111E WELL OWNE�
/.Q6
DATE
CONS1nUCTION STANDAnD3, :46OUIF L
�U�intz Or NCSTftC
oundwA11, spistion within 30dny6
Submit original to Dlviaton of Wrifir Ouetlly,O
aw-1 nee. Iv79
snaal f to

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mai) Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
26
WELL CONSTRUCTION RECORD WELLCONTRACTOR: L/le- S/LG atlej v 3
WELL CONTRACTOR CERTIF16ATION0:__
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (check Applicable Boa): Residential V"unlclpel ❑ Industrial ❑
Recovery ❑ Heat Pump Water Infection ❑ Other ❑ If Other, List Use:
Agricultural ❑ Monitoring ❑
2. WELL LOCATION: (Show sketch of the location below) ,l
Nearo,s]]t /+ Town: - _e l
1 ? pt�,,'\\n. S County: - /vl6 r 1
y O'AC,y\
(Road Name a1n'd,Numblors, Community, or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER yZye'f y1 6K From To (reo or Route o. Q Famallon Description ,��
Address / / in >` >3 4 r%- %- /Ja-'/,ipj
L
Clly or Town State Zip Code
a,
DATEDRILLED 7'oiaOv
---
5.
TOTALDEPTH
_
6.
CUTTINGS COLLECTED YES tE9--NOQ
7.
DOES WELL REPLACE EXISTING WELL? YES 0 NO j(
o
B.
STATIC WATER LEVEL Below Top of Casing: V i) Fr -
(Use '.' II Above Top of Casing)
_
9.
TOP OF CASING is FT. Above Land Surface'
_-
'Top
o(casing terminated atlor below tend surface requires a variance In actor-
_
dance with 15A NCAC 2C
10. YIELD (gpm): METHOD OF TEST
_-
11.
WATER ZONES (depth):
-
0
12.
CHLORINATION: Type /�y. ��S Amount
If additional space Is needed use back of form C&�
13.
CASING:
Walt Thickness
LOCATION SKETCH
Depth Diameter or Welght/Ft. Material
(Show direction and distance from at )east two Stale
From To FL C
Roads, or other map reference points)
From To Ft. —
From To Ft.
14.
GROUT:
Depth Material Method
From To Z�' Ft. Lr�y+'4'e•-1 feeRC
From To Ft.
15.
SCREEN:
Depth Diameter Slat 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 CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C. WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF TlotlS RECORD BE ROVIOEO TO THE WELL OWNER.
FOR OFFICE USE ONLY - 3 O
Quad No: SIGNATURE OF PERSON CO TRUCTI G THE WELL DATE
Submit original to Division of Water Quality. Groun ter Section within 30 days
Social No.
GW.1 REV. 12/99

North Carolina - Department of Environment and Natural Resources - Division of Water Ouallry - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-1638-Phone [phone] ;7 r� r�
WELL CONSTRUCTION RECORD WELL CONTRACTOR: dc S .°rzr v �
WELL CONTRACTOR CERTIFICATION 0: y,�L
STATE WELL CONSTRUCTION PERMIT#:
i. WELL USE (Check
Applicable aoa): Residential V"unlclpal ❑
Industrial
Agricultural ❑ Monitoring ❑
Recovery ❑
Heat Pump Water Injection ❑ Other M If Other, List Use:
2. WELL LOCATION:
(Show sketch of the location below)
�
Nearest Town: 44
�/,/
�Q r; hat County..—/ a
d /r flo 0')
r
�
(Road Name and NumIbers, Cammuniiy% or Subdivision and Lot No.)
DRILLING LOG
DEPTH
3. OWNER _ J Oa's
N �gire rfON
From To
Formation Oascdpllon
Address
�.-g
D'C/L
_
(Sties(Stiest or Hoots o.
City or Tavm Stale Zip Cade
4. DATE DRILLED _-6 K- 6
5. TOTAL DEPTH �J r -Y - & g % 9�_S
6. CUTTINGS COLLECTED YES NOD
7. DOES WELL REPLACE EXISTIN WELL? YES 0 NOL
S. STATIC WATER LEVEL Below Top of Casing: O Fr.
/ (Use -+' If Above Top of Casing)
9. TOP OF CASING IS ` FT. Above Land Surface'
'Tap of casing terminated etior 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 f %W s Amount
13. CASING:
If additional space is needed use back of form
Wall Thickness LOCATION SKETCH
-�
{
Depth' o
IN Bier of WefghUFt. Matedal (Show direction and distance from at least two Slate
From 1
To
Ft.
Roads, or other map reference points)
From
To
Ft.
From
To
Ft.
14. GROUT:
b
Depth
Material Method
From
To .
Ft.
if NWr,.f 1, aRC
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 fdalerial
_ 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 F THIS RECORD S BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY I e -.3I �(
Quad No: SIGNATURE OF PERSON 96NSTftTtNGTF1E-WELL DATE
Submit original to Division of Water Quality, Groundwater Section Within 30 days
Sedal No. GW-I REV. 12J99
1� a : 1

-72�1'q Z--r,-7
North Carolina - Department of Environment and Natural Resources - Division of Water duality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone] /
WELL CONSTRUCTION RECORD WELLCONTRACTOR:
WELL CONTRACTOR CERTIFICA ON #: r c71r,
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (CheckAppitcsbte Box): Resldentia unicipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other If Other, List Use:
2. WELL LOCATION: (Sh skgtchthe location below)
Nearest Town: �1i �>� County-
(Road Name and Numoels. Con�-u--nily, or Su��bdi--vi ion and Lot No.) DRILLING LOG DEPTH
3. OWNER From To 7 Formation Descdpeonn
Addresses 6 r/ r .�/� t
I ree or ou a o.
City or Town �7 /Slate Zip Code
4. DATE DRILLED
S. TOTAL DEPTH
6. CUTTINGS COLLECTED YES NOQ ,L[
7. DOES WELL REPLACE EXISTIN WELL? YES Q NOt'!xl
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 be ow land surface requires a variance In accor-
dance with 15A NCAC 2C .9I.
10. YIELD (gpm): METHOD OFTEST
—
11. WATER ZONES (depth): (/
12. CHLORINATION:
13. CASING:
Type Amcunl If additional space is needed use back of form
Depth D m�19r
From--�-To h Ft. /- -�
From To Ft.
From To Ft.
14. GROUT:
LOCATION SKETCH
Wall Thickness
or ig t/Ft. Mate al (Show direction and distance from at least two State
G Roads, or other map reference points)
Depth Material Method
From V 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 HERESY CERTIFY THAT THIS WELL WAS COI
CONSTRUCTION STANDARDS, AND THAT A COPY
FOR OFFICE USE ONLY
Quad No:
Serial No.
JUL 1 3 ?nq!I
O
O
C
r—
rV
O
)IN ACCORDANC WITH ' 15NCAC 2C, WELL
ECORO� E PROVIDED TO THE WELL OWNER.
��i
F PERSON CONSTRUCTING T \ WELL DATE
Water Quality. Groundwater Section within 30 days
GW.I REV. l2f99

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: /Y
WELL CONTRACTOR CERTIFICA ON #: aL�
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable sox): Res)dentlaitlz"unicipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water injection ❑ Other D if Other, List Use:
2. WELL LOCATION:: (S�f the location below)
Nearest Town: ,9c—L= County:.
Agricultural ❑ Monitoring ❑
(Road Name and Numb unity. or S bdivi Ian and Lot No.) DRILLING LOG DEPTH
3. OWNER ��OrL A- Y ��/1 S �1� / From To Formallon Descripllan
Address <'St�LT�" //(ter-L� -�.�. �i?.GZ Olrtit
(Street or Mou19.NO.
I
City or Torn State Zip Code
4. DATE DRILLED 0�-� Y
S. TOTAL DEPTH
6. CUTTINGS COLLECTED YES NOD
7. DOES WELL REPLACE EXISTIN WELL? YES Q NO
8. STATIC WATER LEVEL Below Top of Casing: FT.
(Use '4 It Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface.
'Top of casing terminated alter below land surface requires a vadance In accor-
dance with 15A NCAC 2C.01P
10. YIELD (gpm): —12 METHOD OF TEST
11. WATER ZONES (depth):
12. CHLORINATION: Type KAmount _�._ if additional space Is needed use back of form
13 CASING:
LOCATION SKETCH
Depth v
DiametHr
Wall Thickness
or Welgh t. Material /
(Show direction and distance from at least two Stale
From To o
Ft. � Y
Z2 l Sf e—
Roads, or other map reference points)
From To
Ft.
From To
FI.
14. GROUT
From zl�
Depth
To �Ft.
Materialy
Method /
From
To
Ft.
15. SCREEN:
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:
1 DO HEREBY CERTIFY THAT THIS WELL WAS C STRUCTED IN
CONSTRUCTION STANDARDS, AND THAT A P OF IS RECk
FOR OFFICE USE ONLY
Quad Na: p;', " - - - _ GNATURE OF PE
j fSub; login 0 .1 13 o� at
l9 v 1
Serial No.
JUL. 13 ?p911 1
)ANCE WITH 15A NCAC 2C, WELL
BEEN PROVIDED TO THE WELL OWNER.
---4� 7_v-ea
-NSTRUC 1G THE WELL DATE
Groundwater Section within 30 days
GW.1 REV. 12/99

North CarpPnn - U,,pmhnntn of Environment and Natural nenourcee • Divir Ion of Water Quality • Oroundwnter Section
1636 Mail S,,mcn Crnlnr - flalnlgh, N.C. 27699-1636 Phone [phone]) 17443
WELL CONSIRUCIfONRECORD WFLLCONTnncron: C1ti�� U.�S7,�r1N
WELL CONTRACTOn CEnTiFiCA11014 0:Q,tf�zo _14
STATE WELL CONSTRUCTIOt1 PEHMITM:
1. 1YEL1. USE (Check nfrurabla nn=): flesldonllalLYJ MunlCipal ❑ Industrial ❑ Agricultural [J Monitoring ❑
necovwy [] I lent Pump Water In)eclion ❑ Other F1 IF Other, List Use:
2. WELL I OCA11011 ('/ iowsketc of tit ocation below)da
Neatest lov,n: ___�/� /� fl - County: /`�-----
(no1�f rinn n01 t-hur com -1, "-it ry, of dl is on end Lol No) DRILLING LOG
3. OWNFFT From To formation Desrdptlon
Address
Gtym Imv„ - ginte Zlp Code �Y ^ 206
4. DATE DIIII.I.FO SfI'!• �._
S. TOTAI.DEPitI---
6. CUTTpI(`iSC(KLF(:TEU YES0 NO 17
7. DOES WFL.F_ III?Pt nCF FXI S I1NG WELL? YEN04
S J — _ -- -- --tom--
B. STATIC lVA1FR LEVEL F!elovi Top of Cost g: FT. CZ)
If Above Top of Cnslog)
9. TOP OE CASIN(; ---- FT. Abovo Lnnd Surfacn• - --
'Top of eeslnn III tnlnnt"d eVnr hrlow Iend surface requires a verlenee In aeeor•
dance with 1 ,A 11l'AC 9C .j� I/
0.YIELD(glint). _.(MMFII1ODOFTEST-----
11.WATEf17-OFJES(dnI•lli):_— -- ---
12. CI ILOM14AT ION: Typn —8, Amount If addlllonsl spnce Is needed usn bnck of forrq) y
13. CASIPJG _ -- --
Well Tltict-nees _LOCATION SKEICN
(� Dnpllt plarneter or W/olghYrt. ;TM�aatedinll (Show direcllon and distance from nt Inast two Stale
From_-1!-.---lo -49 rL' - F1..Is. ae.lua��s- .T-&SAR Roads, or other m�a1p relet^ence polnts)
From- ---- ---- 10----FI.- M`//q/// X,C.
Flom ...._____I 0----- FI.- �/IfMJ'
14. GNOU1:
Urplh —e ��� _VOAA_ �d
kimho
Flom ___O _ 10 _�sQ_PI. �
Frorn _.__.__ to __--_ FI.
15. SCREm J:
Umplll Diamoler
From -- I n VI In.
From-----1°-__FL_— In.
Front -- _-- To - FL_ In.
16. SAND/G(UWFI- rACK:
Dnplh Size
From ___._ 10 --- FI.
From 10--FI.
17. REMARKS:
Slot Slze Mnlolinl
Malerlal
I DO I IERf-Py CFn I try 11 IAT TI IIS WELL WAS CUP
CONS T r1UCTRYI Sl ANOAnDS, AND THAT A COPY
FOR OFFICE USF UNLY -
Oued No
__--_-.-- Subrolt
Serial No
CTED IN ACCONDANCE WI1H 1SA NCAC 2C, WELL
IIS FECOVID HAS BEEN PilovIDED TO TI IE W ELL OWN n.
� i %. nL Uv
DATE
Ml)nEOFFEns iCOPISTnucnNGTI1FWFll.
to CIA Blon of Water Ouetlty, Groundwater Section Within 30 dny9
OWi nEV. 12/99

Norm Carnlinn - Depnrbn"nl of Pnoironrnent and Natural nonouroes - Division of Water Quality - Groundwater Section
1636 Mail Service Cnnler - naleigh, N.C. 27699-1636 Phone [phone] i)
_a4N�
WELL CONSTRUCTION RECORD WELL CONTRACTOR: I7445 �ofi s
WELL CONTRACTOR CERTIFICATION 0:`QdT re -
STATE WELL CONSTRUCTION rFRMITN:
1.
WELL USE (check AT•r8cohle tin*): nesldential5 Municipal ❑
Industrial ❑ Agricultural U Monitoring ❑
Recovery [ I f Teat Pmnp Water Injection ❑ Other
If Other, List Use:
2.
WELL LOCAT IIOOrrJl. (Show sketch of the location below)
Nearest Town: rC.LTG X-5haA — County: MQ
;50n
(no.', Ilanw anNun,!m� d �ers. Cmmniry, or 6ubdivlsion and -Lot- No I
DRILLING LOG
3.
OWNFR -.p-fin
From To Fo,mallon Description
nddre^s C 1 1,5 o�Rcuin a.
29
- _ [iL Z 3
36 - 226 EriC gLk
.M4�had
Cilvor Ir,", Style Zip Code
—
4.
DATE DRILLED 1410--QLZ._
5.
TOTAL PEP I I I -020-6.——
--
-- —
6.
CUTTINGSCOLLFCIED YFSL N09
7.
DOES WELL RMAc.F EXISTING WELL? YES [_] NO y�
--- —
8.
STATIC WATER LEVEL Delow lop of Casing: Q— FT.
_-
o
0
(Use'i it Above Top of Casing)
rn ---
9.
TOP OF CASING IS_—_� _- Fr. Above Land Surface'
m
'Top
of easing to nnlnnlod Prior below land surface requires a variance In actor
1
dance with 1SA I CAC 2C gi 18
CD
10.
YIELD (gpm): METI IOD OF TEST
11.
WATER ZONES (depth):
12.
C1-iLORIr,1A1ION: 1 ype -- Amount
If additional space Is needad use bark of form
13.
CASING:
T -
LOCATION _SKETC --
Drrih
Wall Thlcrness
Prayjr or Welghvrt. Material
(Show direction and distance from nt least two Stale
From _
_l o _�5
Ft.
(j
-SLl�7— ' `
Roads, or other map reverence points)
From-----
From.-----1°---
To
FI.-
FI.
Fitynn 'Pranch
14. GnOUT:
I -
Depth
Malarial ,method
DG� J30wC-d
Mar6.62A rn.G.
From --�
To o
R.
[Ton
Frorn _.-_
— to -Ft.
15. SCREFN:
Orpth Diameter Slot Size Material
From ___ To _ --- Ft ---- In. __ In.
From _— To ._— Pt. _—_ In. _ In.
Frorn -- To _ — Fl. --- In. _ In.
16. SAND/GRAVEL PACK:
Depth Size Material
From --- To _-- FI. From — __— to Ft.
17. REMARKS:
I DO I1Bn FRY CFnT IFY TIIAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 1SA NCAC 2C, WELL
CONS TnUCTION. STANDARDS, ANQ THAT COPY OF/HIS REGOf} HAS BEEN PROVIDED TOIHE WELL OWNER,
�,�j
FOR OFFICE USE ONLY f DATE
Quad No: SI ,t TunE OF rEnS N CONSTRUCTING THE WELL
Submll original Dlvlslon of Water Ouality, Groundwater Section will ln 30 days GW-1 nEV. 12199
Serial No.

North Carplinn - Department of Environment and Natural nesources - Division of Water Quality - Groundwater Section
1636 Mail Snivico Cenl nr - ri.iieigh, N.C. 27699-1636-phone [phone]
1NELLCUNSTRUCTIONRECORD WELL CONTRACTOR: �ob I�
FER4liSoNl �}�}6
WELL CONTRACTOR CERTIFICATION ft:
STATE WELL CONSTRUCTION PEnMiTM:
1. WELL USE (check Aprucabte no.): Residential LYJ Municipal ❑ Industrial ❑ Agricultural Monitoring ❑
Recovery U I lent Punip Water Injection ❑ Other If Other, List Use:
2. WELL LOCATION:( h vskelch of Ilia localion below)
Nearest Town: _fa County: —
ll (nvarl ama an Ili aunts, Common it yr Subdivision and Lot No.) DRILLING LOG DEPTH_
3. OWNER From _ 7o Formation Description
Address
��ret or o a �8953 � �0.—
o,lm•rn Stale pode
4. DATE DRILLED _ Q_
5, TOTAL DEPII I
6. CUTTINGS COLLECTED YFS❑ NO[_17_J o
7. DOES WFI_L nFrLtCE EXISTING WELL? YES NOEj-
8. STATIC WATER LEVEL Below Top of Casing: Q FT.
(Use •+• If Above Top of Casing)
9. TOP OF CASING IS _- FT. Above Land Surface*
*Top of easlnq trrndnnlnd ntrm betow land surface requires a variance In accor-
dance with I5A NCAC 2C A11e rc-
10. YIELD (qpm): _ METI IOD OF TEST
ra -
11. WATEn ZONES (depth):— — •• �,
12. CHLORIWAIION: Type
Amount A— -P46 it additional space Is needed use back of forTrP 2 13. CASING:
_L.00ATION SKETCH_
Wall Thickness
Depth primeler or WelghVFL hdlaaledSall (Show direction and distance from at least two State
From —O —To Ft. - -�+--- '� `ems '-`�" noads, or other map reference points)
From_---- T°--- FL ///jjj. �• F--lti, .
From--------1 ° ---- Ft."
14. GROUT:
Drppr Malarial ci elhodFlomi�/�y__ 1° _L7r0 TI. Ofl�Q�iF ��-(bj-�
From to ._.__—F1. —
15.SCRErn.
Urpd1 Dimneter Slol Size Material
From ---- 1 ° --_--- FI In. If"
From -- _ T ° ----- Ft— In. _ In.
Front ----_- To _ __ __ FL ___ In. — In.
16. SAND/GRAVEI. PACK:
Depth Size Material
From
From __ _ — I - Ft.
17. REMAnKS:
I DO N[NFnV CF.R HEV IIIAT.THIS WELL: -WAS CONSTRUCTED IN ACCOnD"ICE WITH 15A NCAC 2C, WELL
CONS InUCTION ST ANDAnoS, AND TTIAT A COPY OF TIIIS RECORD HAS BEEN PROVIDED TO 711E WELL OWNER. ,
FOn OFFICE LISE ONLY (, f(�1 $ ATURE or PERS O TfI C INO ,NE WEII. (/DAATE ]�J /JrJj'
Quad No'.
$ubmllorl0tna to Dlvlslon of Water Ovality, Groundwater Section Wllhlrl 30 daYs GW 1 nEV. 12/99
Serial No

North Carol,nn - Repm mvud of Environment and Natural Resource9 - Divislon of Water Quality - Gioundwnter Section �) (� 4
1636 Mail Service Centrr - Nnlelgh, N.C. 27699-1638-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: 'bi lit"
WELL CONTRACTOR CERTIFICATION M: ODD
STATE WELL CONSTRUCTION PF IMITH:
1. WELL USf (Check Appacable Flax): nesldenllal Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
necovery ❑ I teat Pump Water In)ectlorl ❑ Other It Other, List Use:
2- WELL LUCA110N; how skettclly'of Ih location below)
Nearest Town:_ d/�iLa .Q� County: -
fnon-I Nnme and I'nn!�rr5. Contnvni or Suhdwl}yIo/nand Lol No.) DRILLING_LOG ___f)EPTH___
3. OWNFR(„-/�� From To ronnaOon Description
Address----
-�D CI rcl or 1T0 Rof ----
__ij - -So - 665
'
Ciy er lover Stale zip Code
4. DATE InM_LFD
5. TOTAL DEPIiI
6. CUTI I IC,7 COLLFC I ED YES D NOV
7. DOES WFI-L nFf I ACE EXISTING WELL? YES [_] NO o
8. STATIC WAl En LEVEL Below Top of Cnsing:'/o D FT. -
// (Use'+' if Above Top of Casing)
9. TOP OF CASItJG IS._ L-_ FT. Abovn Land Surface'
'Tap or caflnn bNow land furl¢arequireu variance In actor- n -:
dance wlth IsA II CAC 11) ..2C .a is
10r YIELD (or, _. METHOD OF TEST _ll-/5—
T-
11. WATER ZONES (dol,lh):__
12. CHLOfIMAI ION: T ype: I Amount S 11 additional space 19 needed use brick of lorrrt'--
QJ o
13. CASING: _
LOCATION SKETCH
__
Well Thicken V
n poltlh lamget�e-r or WelphU�t. ley
�(Show direction and disinncn from at 19ast two Slate
From__t------1 o — J 1-1. ([-�:.+— �a6 ley ,p noad9, or other rnnP reference points)
From--�----__ To-._-- Ih- /nI �yI /�/, 7,��ilJ. � /
From --- ---lo—.-._ F L l edoota U f
14. GROU 1`:
0011111 material Method �
From —p--- 1, SO-- Ft. CIO /✓/�/S,�'-7�'b`!r<—rP�—
Ft0fn In -_- -FT. —
15. SCREF-ri..
Doplh Dinmoter
From _..---_Tn_.._-_FI._— In.
From — __-- 10 __._-.- Ft.
Front -- Io _..___FT._—
16. SANDIGRAVEI. PACK:
Depth Size
Slot Size Material
Material
Fran, —_— In Ft. -------
Front _. _ — l o-- Ft.
17. REMAnKS:
' DO I IFRrnV CrnTnry TA IA1 THIS WELL WAS CONSTRUCTED IN ACCORDANCF WIN' 15A NCAC 2C. WELLEn
CONS MICTION STAIIOAnOS, AND THAT A -COPY Q THIS RECORD HAS BEEN D TO TItE WELL OWN
FOR FFICE OUSF Od1LV , ' ,Star TunE or p - sot' CONSTnUc Rrvi 'IF wet L DATE
Ouad Ito
Submit orlpir,af to Oivls1on 01 Water Ouellly, Oroundwaler 5otlion Wilhln 3U day9 ow -I TIM 12/99
54,131 Ito.

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section 1 C `� i
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone (919) 733-Ml l) J 1
WELL CONSTRUCTION RECORD WELLCONTRACTO
WELL CONTRACTOR CERTIFICATION M: 6
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Boa): Residential ❑ Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATI N: 7ow aka h of the location below
Nearest Town: n L% County:
Agricultural ❑ Monitoring ❑
(Road Name and ben.ComninrSubdivision and Lot No.) DRILLING LOG DEPTH.
1OWNER aa From To For77 Deperipuon
Address
fN Of — 5A/XJ AL'
Caykor Town Stater 71p Code o
4. DATE DRILLED 1)6lot, 1p2
5. TOTAL DEPTH q4/ Y
6. CUTTINGS COLLECTED YES FI NOQ
7. DOES WELL REPLACE EXISTING WELL? YES NO[D
8. STATIC WATER LEVEL Below Top of Casing: /(0 FT.
(UN'.' If Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface'
-Top of casing terminated of/or below I" surface rpWns a varlarwe In accor-
dance with 15A NCAC 2C o la '
10. YIELD (gpm): METHOD OF TEST w
11. WATER ZONES (depth):
LNG---:
w
12. CHLORINATION: Type�416 Amount /'j} e. If additional space Is needed use back o1 form --
13. CASING:
.y � Depth �1� Diameter
Fromm —To 3_7 Ft. rL 64
From To Ft.
From To FL
14. GROUT:
LOCATION SKETCH
Was Thickno"
or Weight/Ft.. �M�ue"" (Show direction and distance from at least two State
Roads, or other reap reference points)
l &�,k Qua �Y-70 V"zjaw�
Depth Material Method
From To 20 Ft.
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From —To—Ft— In. _ in.
From To Ft. — in. _ in.
From —To —Ft. _ In. _ in.
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
17
4� IrA . O/C)f
`xa�
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A�NC/AC E2CW, EWEELLL
CONSTRUCTION STANDARDS, AND THAT�THIS R D BEEN PR VIOED TO T( o� HE0
FOR OFFICE USE ONLY `µ
Wad No: SIGNATIAEOF PERSON CONSTRUCTING THE WELL
Submit original to Division of water Quality. Groundwater Section within 30 days
Serial No.
DATE
GW-1 REV. 120"

North Carolina - Department or Environment and Natural Resources - Division of Water Quality - Groundwater Section-1 6 614
1636 Mal Sam" Cantor - Raleigh, N.C. 27599­1936-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTO .
WELL CONTRACTOR CERTIFICATION #: b
STATE WELL CONSTRUCTION PERMIT#: / Y77
1. WELL USE (check Applicable Boa): Residential ❑ Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other It Other, List Use:
2. WELL LOCATION�: ( rowak*tCp of the location below)
Nearest Town: aAgAd hw County: ��?dz�
(Road Name and
3. OWNER
Address 1,
and tat No.) DRILLING LOG
From To
D - /30
7Jp Code
4. DATE DRILLED Ur0/dr9/d a
5. TOTAL DEPTH TO S
6. CUTTINGS COLLECTED YES ❑ NO[a
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NOQ
8. STATIC WATER LEVEL Below Top of Casing: F7.
(Use'.' # Above Top of Casing)
9. TOP OF CASING ISFT. Above Land Surface-
-Top of casing terminated Wor below land •uAso• reVulna a vartenw In asoor-
dance with 19A NCAC 2C.0/18
10. YIELD (gpm): _.? METHOD OF TEST a-ii-
11. WATER ZONES (depth):
12. CHLORINATION: Type AL�� Amount
13. CASING
Was Thickness
/ Depth
From�TO -
Darrister orWpnVFt. one
Ft. /V Y S6K- �/ 06,24
From
To
FL
From
To
FL
14. GROUT:
Depth
Material Method
From
� To �V Ft.
From
To
Ft.
15. SCREEN:
Depth
Diameter Slot SW Material
From
To _ Ft
_ In. —in.
From
_ To _ Ft.
_ In. _ In.
From
_ To _ FL
_ In. —In.
16. SAND/GRAVEL PACK:
Depth
Size Material
DEPTH
Formation Deschption
CD
)---------------
0
—
m
I�
3
�r'rl
m�
w
0
If additional space is needed use back of form
LOCATION SKETCH
(Slow direction and distance from at least two State
Roads, or other reap reference points)
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 AfiOP'(iOF THIS RE/COjiD FBEEN PRYVIDED T0 THE WELLIO
FOR OFFICE USE ONLY
Quad No:
S•dal No.
SIONATYO(E OF PERSON CONSTRUCTING THE WELL
Submit original to Division of Water Quality. Groundwater Section within 30 days
GW-1 REV. 12/99

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section 7 i `V7,�
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone] --
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICA ON #:
STATE WELL CONSTRUCTION PERMIT#:
1.
WELL USE (Check Applicable Box): Residential W Municipal ❑
industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heal Pump Water Injection ❑ Other if Other, Ust Use:
2.
WELL LOCATION: (Show A,/,�kkk-e ch oft eGlg�Cation below)
/�
Nearest Town: Qi "`( County.
(Road Name an mbars, Community, or Subdi�vii an and Lot No.)
DRILLING LOG DEPTH
3.
//
OWNER it k- _Z/ �'7
From To FmUtfi� Description
1-v
Addresso1s c 'A2�c
•SG'
/e a%L2
'/L
City or wState Zip Code
�Gs y �✓� -�-��
4.
DATE DRILLED
5.
6.
TOTAL DEPTH
CUTTINGS COLLECTED YES C�q— NOQ
7.
DOES WELL REPLACE EXISTING WELL? YES NO�
8.
STATIC WATER LEVEL Below Top of Casing: FT.
(Use'i It Above Top of Casing)
9.
TOP OF CASING ISFT. Above Land Surface'
-Top of casing terminated ador below land surface requires a variance In actor-
dance with 15A NCAC 2C.,6118
10. YIELD (gpm): l a METHOD OF TEST —
11.
WATER ZONES (depth):
12.
CHLORINATION: Type �0, / 5 Amount
If additional space is needed use back of form
13.
CASING:
LOCATION SKETCH
Wall Thickness
Depth D a afar or We1ghUFt. Material/
(Show direction and distance from at least Iwo Slate
Ly
From f / To Ft.- #c2l G
Roads, or other map reference points)
From To FL —
From To Ft.
14.
GROUT:
Depthq Material Method
12 To �C) Ft. 0ealell
O
`
From
From To Ft.
om
15.
SCREEN:
+ _-_ _ .- ; N
o c
Depth Diameter Slot Size ,Material
CD
From _To_FI_ In. _In.
m
From _ To _ Ft. _ In. —In.
From — To _ Ft. — In. _ In.
1 G.
SAND/GRAVEL PACK:
Depth Size Material
x
From To —Ft. -
From To Ft. —
17.
REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CO UCTED IN ACC
DANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A CO THIS REG
!
H S BEEN PROVIDED TO THE WELL OWNER. —
^'\
QL.
FOR OFFICE USE ONLY
Quad No: (� G'��SpTUbF PERSON CONSTR ING THE WELL DATE
' 30 days
au
EG Iltnll 1 to gjvision or Water Quality,
tall
Groundwater Section within
._._..._! .''
GW-I REV. 12/99
Serial Na.
1
Croundwate- Scru.
Asheville Fe, ior.;; :"'"•

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section �, .• r�
1636 Mail Service Center - Raleigh, N,C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: ad.,= ��1 �
WELL CONTRACTOR CERTIFICATION #: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
Town:
(Road Name and
3. OWNER
Address
the location below)
County:
or Subdivision and
4. DATE DRILLED .24,1 G�,07/
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: _,Z!— FT.
(Use'+' if Above Top of Casing)
9. TOP OF CASING ISt.7-- FT. Above Land Surface -
'Top of casing terminated atlor below land surface requires a variance in accor-
dance with 15A NCAC 2c .ett
10. YIELD (gpm): METHOWF TEST
U
11. WATER ZONES (depth): ! D t e.=r,20 t
12. CHLORINATION: Type —72YA Amount_
13. CASING:
Wall Thickness
Depth � Di mejer or Weight/Ft. tedal
From To Ft. _
gZJFrom To Ft.
From To Ft.
14. GROUT:
Depth �JnMateral` , M`ethqd
From _f 1 To 2 Ft.
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From To — Ft _ in. —in.
From To in. rr!—
From _ Ft. _ in•
16. SAND ;;RAVEL PACK:
Depth Size Material
From To
From Ft.
17
DRILLING LOG
From To
ig El
e
r
G`r
Na
e-m
-
Ql
=_
If additional space is needed use back of form
�
LOCATION SKETCH
N
m
n
(Show direction and distance from at least two Stai,6;
o
Roads, or other map reference points) _ /
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COP ECORD HAS B I OVI TO THE WELL OWNER.
FOR OFFICE USE ONLY
Quad No: SIGNATURE OF PERSON 450NSTRUCTING THE WELL 6ATE
Submit original to Division of Water Quality, Groundwater Section within 30 days
Serial No. GW1 REV. 12199

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section 213263
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR- R.CALDWELL DRILLING, INC.
WELL CONTRACTOR CERTIFICATION #2140
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicabi6 sox): Residential Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: -r1 N 12S VA 1 LL County: cy\ A
(Road Name and Numbers. Community, or Subdivision and Lot No.)
3. OWNER o- 1'o2D
Address N t 1 a 3
jSuee or ou e o. 01 S Y
MAfZ5 1�1 l rJC Y
City or Town State Zip Code
4. DATE DRILLED 6 - a 0-O O
5. TOTAL DEPTH _1T0_9 '_
6. CUTTINGS COLLECTED YES Q NO❑
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NOg
8. STATIC WATER LEVEL Below Top of Casing: J:� FT.
(Use Y # Above Top of Casing)
9. TOP OF CASING IS FT. Above Land of
-Top of casing terminated allor below land surface requires a varlence In ■ccor-
dance with 15A NCAC 2C .0110
10. YIELD (gpm): 5 METHOD OF TEST ZS
11. WATER ZONES (depth): �+ n
12. CHLORINATION: Type P t L. L- Amount X o z
13. CASING:
Wall Thickness
Depth Diame er or WeighVFt. Material
From To A4 Ft. - $Ma , P y C'
From To Ft.
From To Ft.
14. GROUT:
DRILLING LOG
DEPTH
Fonpatlon Description ,
If additional space is needed use back of form
LOCATION SKETCH td
�D
(Show direction and distance from at least two State
Roads, or other map reference points)
Depth
jGaT
etho
From (
To -ZL_ Ft.
Cbl1
f�pJKF.
f'O
—�
From
To
Ft.
15. SCREEN:
Depth
Diameter Slot Size
Material
From _
To _
Fl _
in. —in.—
From _
To _
Ft. —
In. In.
From _
To _
Ft. _
in In,
16. SAND/GRAVEL PACK:r-
Depth
Size a'Ntateria�
From
To
Ft.
From
To
Ft.
1
17. REMARKS:
Y
3
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 original to Division of Water Quality, Groundwater Section within 30 days
Serial No. GW-1 REV. 12l99

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section r
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELLCONTRACTOR: D. Bowman Well Drilling, Inc.
WELL CONTRACTOR CERTIFICATION #: 2809
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential10 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. Marshall County: Mad Son
Potters Branch Road
(Road Name and Numbers, Community, or Subdivision and Lot No.) DRILLING LOG DEPTH
3, OWNER Lewis & Linda Santiago From To Formation Description
Address Potters Branch Road
(Street or Route o. _
Marshall NC 28753
City or Town 6 / 01 / 0 State Zip Code c
0
4. DATE DRILLED
5, TOTALDEPTH 2601
6. CUTTINGS COLLECTED YES ❑ NOM _
7. DOES WELL REPLACE EXISTING WELL? YES q NO®
8. STATIC WATER LEVEL Below Top of Casing: ''Rj 0 rFT.
(Use': it Above Top of Casing)
9. TOP OF CASING IS 1 n FT. Above Land Surface'
'Top of casing terminated stfor below land surface requires a variance In actor.
f� S'
d ante with 15A NCAC 2C.0118 rotary air —
10. YIELD (gpm): �.-- — M 3004 OF TEST roay o
11. WATER ZONES (depth):
12, CHLORINATION: Type a e Amount It additional space is needed use back of form
13. CASING:
LOCATION SKETCH
Wail Thickness
Depth Diameter or WeighVR. Material (Show direction and distance from at least two State
From 0 To 40-- FL 61 / 8— S-Ch-8-0 PVC Roads, or other map reference points)
From To Ft.
From To Ft.
14. GROUT: r—�10,
Depth Material
From 0 To 20 Ft concrete
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
gravity flow
Slot Size
in.
_ in.
in.
a
Material
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: - - IGNATURE PEflSON CONSTRUCTING THE WELL DATE
.{ Submit original to Dwislon of Water Quality, Groundwater Section within 30 days
GW-1 REV. 12/99
Serial No.
fE

North Carolina . Department of Environment and Natural Resources - Division of Water Ouailty - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: ` lifidif S 41W ea 5t 56 n,
WELL CONTRACTOR CERTIFICA ON p: c2 y3�
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residen118I Municipal ❑ industrial ❑
Recovery ❑ Heat Pump Water Injection 0 Other If Other, List Use:
Agricultural ❑ Monitoring ❑
2. WELL LOCATIO�1. Show sl(etch Qlrthe location below)
Nearest Town: 0.�5 �O` County.
(Road Name and N bars, or Subdlwislon and Let No.)
DRILLING LOG
3.
/�Omrrrunlly,
OWNER t1 L���'-/ S7l���F /�'eZe
From To
Address
°2
(Street or Houle o.
5�
City or Town // Slate Zip Code
4.
DATEDRILLED
5.
TOTAL DEPTH •�o7,i
6.
CUTTINGS COLLECTED YES 14 NOD
7.
DOES WELL REPLACE EXISTING WELL? YES NO()4-
8.
STATIC WATER LEVEL Below Top of Casing: FT.
of
/ (Use '+' if Above Top of Casing)
9.
TOP OF CASING IS FT. Above Land
'Top of casing terminated atfor below land surface requires a variance In accor-
dance with 15A NCAC 2C .
10.
YIELD (gpm): METHOD OF TEST )
11.
WATER ZONES (depth):
12. CHLORINATION:
13. CASING:
DEPTH
Fomlallon 0 Lion J
oue2 �ty(1yrL.
Type �) L_ I� 5 Amount- If additional space Is needed use back of form
� Depth n Diameter
j— From-7 —TO Ft.
From To FI.
From To Ft.
14. GROUT
Depth
From To 2�
From To
15. SCREEN:
LOCATION SKETCH
Wall Thickness
or Weiqhl/FL Material (Show direction and distance from at least two State
'*�d� d1 • C Roads, or other map reference points)
Materiel Method
Ft. Cement
Fl.
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 idaledal '
_ In.
in.
_ In.
I DO HEREBY CERTIFY THAT THIS WELL WAS
CONSTRUCTION STANDARDS, AND THAT A C
FOR OFFICE USE ONLY
Quad No:
Serial No.
Material
Ik
I_Ljubl aHtlinat to Division of Water Quality,
JUL 13 9T, I LJ j
0
O
0
O
n�
C
�m
M3
O
<
I' c+
3
�m
m�
c-r
Ca
o
WITH 15A NCAC 2C, WELL
PROVIDED TO THE WELL OWNER.
within 30 days
61 /
DATE
GW-1 REV. 12199

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section ( 1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: �rrya A-s0 A L7,(.c,a
.y
WELL CONTRACTOR CERTIFI ATION N: aD�? to
,..,/ STATE WELL CONSTRUCTION PERMITN:
L.I�J
1. WELL USE (Check Applicable Box): Residential Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATIO : SI w c ch Gf the location below) �^ J
Nearest Town:.,,�..--.�. ���� County:c�F�
(Road Name an )bers, ommunity, or S 'vision and Lot No.) DRILLING LOG DEPTH
3. OWNER From To Formation Description
Address 8y-,-y----
veetor 9 0.
City or Town Slate Zip Code 'T� _ cn _.
4. DATE DRILLED- s n2l/:
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YESQ NOd co r"
7. DOES WELL REPLACE EXISTING WELL? YES NOd
8. STATIC WATER LEVEL Below Top of Casing: FT.
(Use'+' If Above Top of Casing) v "'
rn
9. TOP OF CASING ISFT. Above Land Surface'
-Top of casing terminated etfor below land surface requires a v^arlence In actor- t
dance with 15A NCAC 2C.o1 9
10. YIELD (gpm): __ METHOD OF TEST ALV
11. WATER ZONES (depth):
12. CHLORINATION: Type Amount It additional space is needed use back of form
13. CASING:
LOCATION SKETCH
Wall Thickness
nn De th � lame r or,W Iig/hV�FLS ateit I (Show direction and distance from at least two State
From �SLTo �-= Ft. Roads, or other map reference points)
From To Ft. —
From To Ft.
14, GROUT:
Depth � Materi I /Q� elho�d�J
From To Al2— Ft. l a
From To Ft.
15. SCREEN:
Depth
Diameter
From
—To _
Ft — in.
From
_ To —
Ft.— In.
From
—To _
Ft. in.
16. SAND/GRAVEL
PACK:
Depth
Size
From
To
Ft.
From
To
Ft.
Slot Size Material
In.
In.
In.
Material
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 AS BEEN PROVIDED TO THE WELL OWNER.
IFOR OFFICE US:E:01:J'LY �dDATEd No: , j SIGNATURE OF PERSON C STRUCTING THE WELL
Submit original to Division of water Quality, Groundwater Section Within 30 days GW 1 REV. 12/99
dal No.

North Carolina - Depnrimpril or Environment and Natural Resources - Division of Water Quality - Groundwater SectionFir , 01636 Mail Service Center . Raleigh, N.C. 27699-1636-Phone [phone] ////����jjjj
WELL CONSTRUCTION RECORD WELLCONTRACTOR: -An-fe (cafih�
WELL CONTRACTOR CERTIFI ATION M:_. nDa
STATE WELL CONSTRUCTION PE IMITN:
1. WELL USE (Check nppllcable Do.): Resldentlalo?r Municipal ❑ Industrial ❑
Recovery ❑ I leaf Pump Water Injection ❑ Other 0 If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below) /�/�
Nearest Town: i d 7(^ t-------Counly: �loLA Oil
Agricultural ❑ Monitoring ❑
(Road Name and Numbers, Cgmmunity, or Subdivision and Lot No.l
DRILLING LOU _DEPTH _
3.
OWNER `+eadQi' 14ome& _
From To Formation Descdpllon
Address 111►_uo
1 IreCl or nu o. � np��I,
i--�-
Circa—�� I state ZiippCoda
att
4.
DATE DRILI.FD:W—�
5.
_
TOTALDEPTII6. CUTTINGSCOLLo NOLvll*�
7.
DOES WELL REPLACE EXISTING WELL? YES
8.
STATIC WATER LEVEL Below Top of Casing: _c��_ Fr•
cg ;;�,
rr (Use'+' 11 Above Top or Casing)
TOP OF CASING IS FT. Above Land Surface-
9. —f__
•Top of ceslog terndnelnd error below lend surface requires a variance in actor•
�� «
deucewIlhl5ANCAC2C
0118
19j.a,5 MEN HOD OF TEST
10.
YIELD Win):
11.
WATER ZONES (depth):
w
7 (
Type L� Amount
If additional spare Is needed use back of to"
=1_
12.
CHLORINATION: _
13.
CASING:
LOCATION SKETCH
Wall Thickness
Deplll e gr or �Atte�da`all
(Show direction and distance from at least two State
/Wgg1Q1Yr
From � To 11PO Ftppplam"� �—
Roads, or other map reference points)
From To Ft.
From --I or Ft.
au re1 m
C
14.
GROUT: DPA nMaleralelhod
From n— To o Fi.DN&--
From To ___ Ft. _
15. SCREEtJ
Depth Diameter SlolSize Material
Frorn _--To -- Ft _ in. _ In.
From _—To Ft. __ In. _ In.
From _ ____ To __.-- FL In. _In.
16. SANDIGRAVEL PACK:
Depth Size Material
From To —Ft. —
From To Ft,
17, REMAHIcs:
I DO I IERFDYICERTIFY TI IAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECO D HAS BEEN PROVIDED TO THE WELL OWNER.
LonO,,1FICE1J:SE ONL.4J DnTE
- IGNATUREOF FER N CONSTRVCTQJO TNF WSubmit o nal to Division o1 Water Quallry,OmundweterSectionwithin30day9 DW 1 REVi7199

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section 213085
1636 Mail Service Center - Raleigh, N.C. 27699.1636-Phone [phone]
WELL CONSTRUCTION RECORD WELLCONTRACTOR:-,L.�/_.
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Boa): Residential® Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection
❑ Other ❑ If Other, List Use:
2. WELL LOCATICI (Show sket9h of the location below)
Nearest Town: County:
t�G�s1r (Xd T.> - y'1 Jy z 4 £I
(/(RoaYName V Numbers Commonlry, orlvlskm and Lot No` /d DRILLING LOG DEPTH
3. OWNER
Address / , i - _ /I From To Formation Description
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 NO®
6. STATIC WATER LEVEL Below Top of Casing: FT,
9. TOP OF CASING IS / r (Use •+s Above Top of Casing)
.Lrl, F7. Above Land Surface•
'Top of casing terminated at/or below land surface requires a variance in accor•
dance with 15A NCAC 2C .0119
10. YIELD (gpm): �7h METHOD OF TEST Y.� ,
11. WATER ZONES (depth):frcf)
12. CHLORINATION: Type mount.._
13. CASING:
Wall Thickness
Depth Diameter of W.ig M le al
From To � Ft. `/, .i{;__
From To Ft.
From To Ft.
14. GROUT:
Depth (MaMethod
ethod
From _Q_ To QW20 Ft.
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft in. ri
From To Ft. n. in.
From To In. In,
16. SAND/GRAVEL CK:
Depth Size aterial
From To F
From Ft,
17
t=,
If additional apace Is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least two
Roads, or ot1jW map
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY O I RD HAS BE VIOED TO THE WELL OWNER.
FOR OFFICE USE ONLY
9/
Quad No: - - i SIGNATURE OF PERSON CONST NO THE WELL DOE
Submit 40hal 10 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 2_ 13 '" 8 8
1636 Mail Service Center - Raleigh. N.C. 27699.1636-Phone [phone]
WELL CONSTRUCTION RECORD WELLCONTRACTOR: 1( ccG2v J tJ-ew 1-42 7 c
WELL CONTRACTOR CERTIFICATION 0: r_I % /a U
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (check Applicable Boa): Residential CK Municipal ❑ industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ I(Other, List Use:
2. WELL LOCATION' (Show sl tchy.1he location below) //
Nearest Town: .. Coun /1.LA d-i1.�-
.t C.
(RoagAame
,/and �N/um rs. Community,or Suppol sk+n d Lot No.) DRILLING LOG DEPTH
3. OWNER l �iN 7710-G+J From To Formation Description
Address - 9 c-/,7., r% . 0 )
City or Town Stale Zip Code
4. DATE DRILLED S//G/ill
5. TOTAL DEPTH .34 S
6. CUTTINGS COLLECTED YES 0 NO®
7. DOES WELL REPLACE EXISTING WELL? YES M NO®
8. STATIC WATER LEVEL Below Top of Casing: 516 Fr.
(Usa'i II Above Top of Casing)
9. TOP OF CASING IS� FT. Above Land Surface'
'Top of casing terminated nVor below land surface requires a variance In scoot-
dance with 15A NCAC 2C 011e
10. YIELD (gpm): = METHOD OF TEST T-ex9
11. WATER ZONES (depth): 112D k - 300 1
12. CHLORINATION: Type T/! Amount .-
13. CASING:
Wall Thickness
Depth DIer WaIghVFI. Mptadal
FromTo A2 L_ Ft.
From To Ft.
From To Ft.
14. GROUT:
Depth
Maw lariat
Method
From To Ft.
From
To
Ft.
15. SCREEN:
Depth
Diameter Slot S--Material
From
To
Ft
In.
From
To
in.
In.
From
To
Ft. in.
In.
16. SAND/GRAMPACK:
Depth
Size
Material
From
To
FF
From
To
Ft.
17. REMARKS:
11 additional space Is needed use back of form
LOCATION SKETCH
iw dirtAn n and distance from at least two State
Roads, or other map reference points)
I DO HEREBY CERTIrr)�T'�', l L C 3{R[- UCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION S7 F D HAS BEEN PR 0 THE WELL OWNER.
AOL
FOR OFFICE USE:ONnLyi� At 5 Quad No: SIG, TONE OF PERSON CONSTRU O THE WELL DATE
Submit original to Division of Water Quality, Groundwater Section within 30 days
Serial No. �_., . _ OW-1 REV. IV"

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section ? .1076
1636 Mail Service Center - Raleigh, N.C. 27699.1636-Phone [phone]
WELL CONSTRUCTION RECORD WELLCONTRACTOR: t ' 1 -'V�' �/J " 42.14 7Z,
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMIT#: 77,3
1. WELL USE (Check Applicable Box): Residentlal ® Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ It Other, ,List Use:
2. WELL LOCATION: (Show ket f the location below) Nearest own: unty:
(Roa ame an Npu e�f C�ommynlry, or Subdivision d Lot No.) DRILLING LOG DEPTH
3. OWNER ;7/, y-,t/�fiGrr,•r Yi%iL(,w1 x4rn 0 From To Formation Description
Address . 7 �7. i O w r r
4. DATEDRILLED,y�00c'
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES Q NO®
7. DOES WELL REPLACE EXISTING WELL? YES Q NO®
8. STATIC WATER LEVEL Below Top of Casing: ;? n FT.
(Use': II Above Top of Casing)
9. TOP OF CASING IS,-//_�_ FT. Above Land Surface -
'Top of cuing terminated at/or below land surface requires a variance In mccor•
dance with 16A NCAC 2Ch011a
10. YIELD (gpm` � r � ): METHOD OF TEST
11. WATER ZONES (depth): IZZ r / _S '
12. CHLORINATION: Type Amount
13. CASING:
Wall Thickness
Depth Diam9ter or WeighVFI. Material
FromTO //D Ft. :12 PU.C"
From To Ft.
From To Ft.
14. GROUT:
Depth Mate�rial�/ Method
From JLL To � FL 1
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft ID_
From To Ft In. _ in.
From To Ft. In. in.
16. SAND/G EL PACK:
From
From
17
Depth Size Matedal
_ To Ft
_ To Ft.
h�. >_it�
If additional space is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map
H/VL/#
ES 7$7cS
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A AC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY D HAS BEEN PR THE W ELL OWNER.
S
FOR OFFICE USE ONLY
Quad No: SIGNATURE OF PERSON CONST9UOTI O THE WELL DATE
Submit original to Divislon of Water Quality, Groundwater Section within 30 days
Serial No. GW1 REV. 11/99

North Carolina - Department of Environment and Natural Resources - Division of Water Quality • Groundwater Section 2 1. 2 9 9 [ )
1636 Mail Service Center - Raleigh, N.C. 27699.1636-Phone [phone]
WELL CONSTRUCTION RECORD WELLCONTRACTOR: D. Bowman We11 Drilling, Inc.
WELL CONTRACTOR CERTIFICATION #: 2809
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (check Applicable Boa): Residential® Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, Ust Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: Walnut County: Mad' Gon
U.S. 25-70 t1yy (RoadN Natau alaC0utd,orSubdivisionandLotNo.)
3. OWNER oor Center
Address P.O. Box 398
(Street or Houle o.
Hot Springs NC 28743
City or Town 5 / 1 1 / 0 0 zip Code
ft
4. DATE DRILLED
5. TOTAL DEPTH r n 0
6. CUTTINGS COLLECTED YES ❑ N05
7. DOES WELL REPLACE EXISTING WELL? YES NOO
8. STATIC WATER LEVEL Below Top of Casing: 3 FT.
(Use'+- If Above Top of CWing)
9. TOP OF CASING IS 1 ' 4 FT. Above Land Surface*
?op of casing terminated atlor below land surface requires a vartanw In accor-
dance with l5ANCAC2C.e11a rotary air
10. YIELD (gpm): 5 — METHOD OFOT€ST
11. WATER ZONES (depth): 20
DRILLING LOG DEPTH
From To Formation Description
12. CHLORINATION: Type t a h 1 o t Amount 6 If additional apace is needed use back of form
13. CASING:
Wall TNckneu
Depth Diameter or Welghi/Ft. Malaita
From 0 To 20 Ft. 6 1 /8 $G.h 80 PVC
From To Ft.
From To Ft.
14. GROUT:
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other reap reference points)
Depth Material Method
From 0 To20 Fl. C.Q1L Xt �ravit., flow
From To Ft.
15. SCREEN:
O
Tm
o<
ZEM
41
mo
=m
mw
n
Depth Diameter Slot Size Material tV
From —To—Ft— In. —in
From_To_Ft._ In. _In.
From —To —Ft. in. _ in. -
16. SAND/GRAVEL PACK:
Depth Size Material ` 3
From To Ft.
From To Ft.
17. REMARKS:
r
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Quad No:
Serial No.
si6NATuRE of ERSON CONSTRUCTING THE WELL
Sutxrit original to Division of Water Quality, Groundwater Section within 30 days
DATE
GW-1 REV. 12N9

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]
21 )587
WELL CONSTRUCTION RECORD WELLCONTRACTORI,cr�Tcv�c
WELL CONTRACTOR CERTIFICATION
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable aoa): 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 Number. Comm ity, gr Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER From To Fomallon Qoscriplion
Address l IF
/ N 00
Code
4. DATE DRILLED U_-; /3 /Ou
5. TOTAL DEPTH 'rJS
6. CUTTINGS COLLECTED YES [:D NOQ-
7. DOES WELL REPLACE EXISTING WELL? YES NO['f'
8. STATIC WATER LEVEL Below Top of Casing: _S— FT.
(Use'.' V Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface*
'Top or casing terminated eVor below land surf&« rpuk« a varlsn« In socm-
dance with 15A NCAC 2C .0118 '
10. YIELD (gpm): / S- METHOD OF TEST -
11. WATER ZONES (depth):
w
-
----vim
t
-�
—
12. CHLORINATION: Type Amount '1A ¢ ' It additional space is needed use back of form `
13, CASING:
LOCATION SKETCH
Wall Thickness
y Depth,., p 91arrt��,eter w WsighVFt. Material (Show direction and distance from at least two State
From. —To �•�-- Ft. '`a �C Roads, or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From 0 To >� FL
From To Ft.
15. SCREEN:
Depth Diameter Slot Sizo Material
From To _ Ft — In. _ In.
From —To—Ft.— In. _ In.
From —To _ FL _ In. —In.
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
17
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT AfAP`�OF THIS RE
/CO,PO F,6�BEEN PROVIDED �O THE W ELL,IO
FOR OFFICE USE ONLY
Quad No:
Serial No.
SIGNATU$(E OF PERSON CONSTRUCTING THE WELL
suOrnit odglnat 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 U J O
1636 Mal Service Center - Raleigh, N.C. 27699.1636-Phone [phone] �•
WELL CONSTRUCTION RECORD WELL CONTRACTOR_L`�
WELL CONTRACTOR CERTIFICATION #: 7. 6 R
STATE WELL CONSTRUCTION PERMIT#: 11129
1. WELL USE (Check Applicable Box): ResidentialMunicipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATIOt ,. (Show sketch, of the location below)
Nearest Town: County: f
' c' a A a V'
(Road Name ty, or Subdv(tlon and Ln1 No.)
DRILLING LOG DEPTH ,
3.
OWNER (( �7/ �r �c �. nJ
From To Formation Dow plioFormation.s
D
Address-
( 2« mac• e • caFZ-3
�� - �.�r
Ciyor Town state ZJp Cade
D
4.
DATE DRILLED
5.
TOTAL DEPTH S
6.
CUTTINGS COLLECTED YES ❑ NOC9
7.
DOES WELL REPLACE EXISTING WELL? YES ❑ NOQ
B.
STATIC WATER LEVEL Below Top of Casing: FT.
(Use'.' If Above Top of Casing)
9.
TOP OF CASING IS FT. Above Land Surface'
w `-
'Top of using terminated at/or below land surfaoa requkea a varlenw In socor-
--
dancewith15ANCAC2C.011a
10. YIELD (gpm): _�_L_ METHOD OF TEST
,
11.
WATER ZONES (depth):
0
12.
CHLORINATION: Type 414z&62a t � Amount —
If additional apace is needed use back of form -ic- o
13. CASING
Wall Thickness
Depth Diameter orwegnuFt. y�eria
FromTo39 Ft. Y/s y
From To Ft.
From To FL
14. GROUT:
Depth Material Method
From Q To -20 Ft.
From To Ft.
15. SCREEN
Depth Diameter Slot Size Material
From —To—Ft— In. _ in.
From _ To Ft. _ in. — In.
From _ To _ FL _ In. _ In.
16. SAND/GRAVEL PACK:
Depth Size Material
From To —Ft —
From To Ft.
17. REMARKS:
LOCATION SKETCH
(Show direction and distance from at least two State
s, or other map reference points)
d a
w C�_ cam- der. w�1
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.
Submu original to Division of water Quality. Gmundwatsr Section within 30 days
GWA REV. 12t99

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mal Service Center - Raleigh, N.C. 27699-1636Phone (919) 733.=l n
21.6584
WELL CONSTRUCTION RECORD WELLCONTRACTOR:
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMIT#: /e/77
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. '�a��� -
(Road Nurse and Numbs s, Comimutity, of SubdlWp. and lql NoJ
3. OWNER
Address 3
tweeto . o
City or Town /� State Zip Code
4. DATE DRILLED / !a�
5. TOTAL DEPTH 2A 5'
6. CUTTINGS COLLECTED YES ❑ NO[�J-
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NOD
8. STATIC WATER LEVEL Below Top of Casing: FT.
(Use'.' g Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface-
-Top of casing terminated at/or below land surface require& a varlan« In accor-
dance with 16A NCAC 2C .011a�
10. YIELD (gpm): _4�._ METHOD OF TEST
11. WATER ZONES (depth):
12. CHLORINATION: TypeaAmount_
13. CASING:
Wul Thickness
Depth /Diameter or WefghVFl. Material,
From '2 Ft, /I 4e �{
From To FL --
From To FL
14. GROUT:
Depth MaUrW M��
From _Q To -V_ 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:
DRILLING LOG DEPTH ,
From To Formation Description
U _ 3 i,.?
0
0
w -
p' ri
-1
r —
If additional apace is needed use back of form '-
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other reap reference points)
I DO HEREBY CERTIFY THATTHIS WELL Wes rrnNSTRIu:TFD IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT
FOR OFFICE USE ONLY
Quad No:
Serial No.
Subrra orlon& to Dlvblon of water Quality, Groundwater Section within 30 days
OW-1 REV. 12M

` North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section 213221 '
1636 Mail Service Center - Raleigh, N.C. 27699.1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: II/d>• S A, L7 u eA s t SQ A-,
WELL CONTRACTOR CERTIRCA ON #: c2 43 6
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (check Applicable Box): Resldentlal Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection Other 0 If Other, List Use:
Agricultural ❑ Monitoring ❑
2.
WELL LOCATION: ( how f the location below)
_ketch
Nearest Town: County.
(Road Name u ers. Co��m//munity, or subdivision and Lot No.)
DRILLING LOG DEPTH
3.
OWNER 's T4� /\
From To Formation Desal eon lJ
UGR �G✓QOrL
Address C 02J OR ;' /�[✓
�/ .J r7
ree ar ou a o.
JDr'Kss Ile
City or To mr State Zip Cade
4.
DATE DRILLED 3G6r7
5.
TOTAL DEPTH /G S
6.
CUTTINGS COLLECTED YES E-. NOQ
7.
DOES WELL REPLACE EXISTING WELL? YES NOJ5J_
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 cuing terminated atfor below land surface requires a variance in actor.
_.
dance with 1SA NCAC 2C.0113
10. YIELD (gpm): 1� METHOD OF TEST _
11.
WATER ZONES (depth):
12.
CHLORINATION: Type :]� r L( s Amount
It additional space Is needed use back of form
13. CASING:
Wall Thickness LOCATION SKETCH
Depth DI me er or Wei hVR Malgdal (Show direction and distance from at least two State
From 7To Ft.—— G Roads, or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
--t�`�
From � To 2�Fl. Cm0
From To Ft.
15. SCREEN:
Depth
Diameter
From
_ To _
Ft In.
From
_ To _
Ft. In.
From
_ To _
Ft. In.
16. SAND/GRAVEL PACK:
Depth
Size
From
To
Ft.
From
To
Ft.
17
Slot Size ` Material -
_ In.
In.
In.
Material
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN f
CONSTRUCTION STANDARDS, AND THAT A COPF IS RE (9F
FOR OFFICE USE ONLY
Ouad No: SIGNATURE OF PEP
Submit odginal to Division d Water
serial Na.
N
RDANCE WITH 16A NCAC 2C. WELL
1S BEEN PROVIDED TO THE WELL OWNER.
DATE
iy uY s cuak� w '90 days
GW4 REV. Ung

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone] WELL CONTRACTOR: e l//aJ
C S q eR 5 t- SG A.
WELL CONTRACTOR CERTIFICA ON #. a 43 6
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): ResidenflaillSr Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection 0 Other If Other, List Use:
213222
Agricultural ❑ Monitoring ❑
2. WELL LOCATION;.(§how sketcW the location below)
"•[ d' Vd a Coun 0.'A r C� r.J
Nearest Town:-� lY:
(Road Name d Numberrss, Commey, or Su division and Lot No.) DRILLING LOG DEPTH
3. OWNER �6 G(J O6d T'Q� From To Fotmallon Descd%�uon
Address � / 3 z- (0 V e AG ✓ d A_
(Streal or Route o.
City or Town State Zip Code 3 3 d v`
4. DATE DRILLED S '..?e9-�
5. TOTAL DEPTH -ro•%
6. CUTTINGS COLLECTED YES [KJ NOQ
7. DOES WELL REPLACE EXISTING WELL? YES Q NO —
e. STATIC WATER LEVEL Below Top of Casing: FT.
(Use '*'It Above Top of Casing)
9. TOP OF CASING ISFT. Above Land Surface'
-Top of easing terminated eVor below land surface requires a variance In actor- .. _.. . .
dance with 15A NCAC 2C .a 19
1 o. YIELD (gpm): METHOD OF TEST-
11. WATER ZONES (depth):
12. CHLORINATION:
13. CASING:
Type fD; L( 5 Amount 7_ It additional space Is needed use back of form
Depth Oi meter
From s —L—To '3O2 Ft. 2—
From To Ft.
From To Ft.
14. GROUT:
LOCATION SKETCH
Wall Thickness
or Weight/FL Material (Show (Show direction and distance from at least two State
4'0�✓-1 ,/az1 Roads, or other map reference points)
Depth Material MelTntwLO"
From Z, To 626 FL
From To Ft.
15. SCREEN:
Depth Diameter
From _ To _ FI _ In.
From —To —Ft. _ In.
From—To_Ft. _ In.
16. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To Ft. _
17. REMARKS:
Slat Size 10alarial
_ in.
_ In.
In.
Material
o_
0
ate m
0
cM
2 rn
v<
s_ m
�o
rnp
=m
m�
c�
0
Z
100 HEREBY CERTIFY THAT THIS WELL WAS CON,5.TSUCTED IN ACCORDANCE WITH 15A NCAC 2C. WELL
CONSTRUCTION STANDARDS, AND THAT ACOy'YQ.,F TH S RECO O 4S BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY— r 4�
Quad No: SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit odginal to Division of Water Quality. Gmundealer.Sec9nn within 30 days
Sedal No. _ ._ GW.I REV. 12fg9

213212
North Carolina - Department of Environment and Natural Resources - Division of Water Quality -Groundwater Section /' 'L
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone] i
WELL CONSTRUCTION RECORD WELL CONTRACTOR: C) h/dr S 1"/eR 5 t- SC)A-
WELL CONTRACTOR CERTIFICAilON
STATE WELL CONSTRUCTION PERMIT#:
1.
WELL USE (check Applicable Boa): Residential Municipal ❑ industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection Other p
If Other, List Use:
2.
WELL LOCATION ow sketch ( edgcallon below)
--
-
Neares3Town: O.'�S i County:
-
DRILLING LOG DEPTH
Formation Descrl tlon
(goad Name an Numbers, Community, ar Subdivision and Lot No.)
1—u ✓ li
3.
OWNER n rA e S
From To /
f1 M 6ye- ✓�0�
Address I..�
S6n A6
—(STree or ou a o.
L
My or Town State Zip Cade
4.
DATEDRILLED ,5-03-00
5.
TOTAL DEPTH aBS
6.
CUTTINGS COLLECTED YES ® NOQ
7.
DOES WELL REPLACE EXISTING WELL? YES F-1 NO�C]
B.
STATIC WATER LEVEL Below Top of Casing: FT.
9.
(Use -i If Above Top of Casing)
TOP OF CASING IS FT. Above Land Surface'
-Top of casing terminated otter below land surface requires a variance in accor-
dance with 15A NCAC 2C.01� e
10.
YIELD (gpm): ! METHOD OF TEST
11.
WATER ZONES (depth):
12.
CHLORINATION: Type �; L( 5 Amount s
It additional space Is needed use back of loan
13. CASING:
Depth /' or
�� P U
From / TO Ft. a t
From To Ft.
From To Ft.
14. GROUT:
Wall Thickness LOCATION SKETCH
or We!PhVFL M]teda) (Show direction and distance from at least two Slate
Q4S1' C- Roads, or other map reference points)
Depth Material Method ,
From To OV Ft.
From To Ft.
15. SCREEN:
Depth Diameter
From _To _ Ft _ In.
From —To —FL _ in.
From _ To _ Ft. _ In.
16. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To Ft.
17. REMARKS:
Slot Slze ` 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 C9P CODF THIS R EC.ORD�AAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY _ - G�
Quad No: �' Ir ra ' tf ne5-4 OrRSON CONSTJ3 CTING THE WELL GATE
op R Water Quality. Groundwater Section within 30 days
Serial No. GW-1 REV. 12199
� r
t

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section r1 �1
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone] //(`t 9
NELL CONSTRUCTION RECORD WELLCONTRACTOR:
WELL CONTRACTOR CERTIFI ATION 1f:
STATE WELL CONSTRUCTION PERMIT$t:/
1. WELL USE (check Applicable Box): Residential W Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Sh w ketch�l llge location below)
Nearest Town: . Countyarc
ers, Commun r Subdivision n Lot No.) DRILLING LOG
(Road Name and rivers'
DEPTH
3.
OWNER From To
Formation Description
Addres
—
e or C
Ci or Tovm Slala Zip Code
4.
GATE DRILLED f g
-;
5.
TOTAL DEPTH AGO
1
6.
7.
CUTTINGS COLLECTED YES[--] NOd
DOES WELL REPLACE EXISTING WELL? YES ❑ NOd
e ,
8.
STATIC WATER LEVEL Below Top of Casing: �?O FT.
'
(Use •+' If Above Top of Casing)
9.
TOP OF CASING ISFT. Above Land Surface*
-o i;
-Top of casing terminated atlor below land surface requires a variance In actor-
dance with 1SA NCAC 2C.011
na
10.
YIELD (gpm): METHOD OF TEST
-t
i 1.
WATER ZONES (depth):
12. CHLORINATION:
13, CASING:
Type Amount If additional space Is needed use back of form
Wall Thickness
Depll %dame r or WelahVFL ldaledal
From6—To A FI.4! +
From To Ft.L
From To Ft.
14. GROUT:
Dept�I n /n• �M�at�e�nyBl ethod
From .� To a --Ft. t�LU[Ce�C
From _— To Fl.
15. SCREEN:
Depth
Diameter
From
_ To _
Ft In.
From
— To
Ft. In.
From
_ To _—
Ft. __ In.
16. SAND/GRAVEL
PACK:
Depth
Size
From
To
Ft.
From
To
Ft.
17
Slot Size Material
_ In.
_ In.
In.
Material
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECO D HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Quad No
SIGNATURE OF PERSO ONSTRUCTING THE WELL DATE
Submit o gloat to
Division of Water Quality, Groundwater Section within 30 days
1 ` GW-1 REV. 12199
Soda[ No.

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section r— 1 r• 4 9
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
NELL CONSTRUCTION RECORD WELLCONTRACTOR: D-C
WELL CONTRACTOR CERTIFI ATION #: 0 n012 1(0
STATE WELL CONSTRUCTION PERMIT#:
WELL USE (check Applicable sox): Residential Z Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION; (2how sketcjl of the cation below)
fl/(/1/Cf{CL� Counry:� GILIJ
Nearest Town:. -
Agricultural ❑ Monitoring ❑
(Road Name and N tubers, Communlry, r Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER From To Formation Description
Address
beet or ou a o
Gity or Town State Zip Code
4. DATE DRILLED % d0
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES F--] NOEFr
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NOd
8. STATIC WATER LEVEL Below Top of Casing: /� FT. _
(Use'.' It Above Top of Casing) -
9. TOP OF CASING ISFT. Above Land Surface -
'Top of casing terminated atfor below land surface requires a variance In accor-
� n,
r;o
dance with 15A NCAC 2C . 11 a —
10. YIELD (gpm): METHOD OF TEST
11. WATER ZONES (depth):
12. CHLORINATION: Type Amount II additional space is needed use back of lord o
13. CASING:
LOCATION SKETCH
Wall Thickness
/� Depth lame r or W IghUF , ��Jp�a{te7d�a(l JJ(i (Show direction and distance from at feast two State
From —To -1Sr FI. �'�-�°^� Roads, or other map reference points)
From To F�� /Jwt
From To Ft.L l//,
14. GROUT:
De tl
p
) M,aatterly8h
ethod
From .� To
Ft.(il[1--
From To
Ft.
15. SCREEN:
Depth Diameter
Slot Size
Material
From To _ Ft
_.
in. —in.-
From _ To _ Ft.
_
in. _
In.
From _ To _ Ft.
_
in. —
In.
16. SAND/GRAVEL PACK:
Depth
Size
Material
From To —Ft.
-
From To
Ft.
/Yc
17. REMARKS: -
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECO7 HAS BEEN PROVIDED TO THE WELL OWNER.
='NLY DATE
F PERSON NSTRUCTING THE WELLSubmit original to Division o1 Water ouality, Groundwater Section Within 30 days
GW-1 REV. 12199

A
North Carolina -Department of Environment and Natural Resources -Division of Water Quality - Groundwater Section r_ 174
r.j 9
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone] fffjjj
NELL CONSTRUCTION RECORD WELL CONTRACTOR: ��sOhGccaGt
WELL CONTRACTOR CERTIFI ATION #: �lJato
�,/STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential5? Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ II Other, List Use:
2. WELL LOCATION�(Skelct f the location below)
Nearest Town: lL4i�.Ct�. County: tQ1�a�`•�
(Road Name an rnbers, Co tunny, or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER From To Formation Description
Address J fj-an/� f',
ree o oule o ^^�
City or Town State Zip Code
�J• T�LS
4. TOTAL DE ED .125 d
5. TOTAL DEPTH � _
6. CUTTINGS COLLECTED YES Q NO
7. DOES WELL REPLACE EXISTING WELL? YES Q NO[Z(
8. STATIC WATER LEVEL Below Top of Casing: gip_ Ff.
(Use'+' It Above Top of Casing) -
9. TOP OF CASING ISFT. Above Land Surface' co ;
'Top of casing terminated at/or below land surface requires a variance In actor-
dance with 15A NCAC 2C.0118 .M
10.YIELD(gpm): aO METHODOFTEST _
11. WATER ZONES (depth): ca !•�
N -4
0
12. CHLORINATION: Type Amount If additional space Is needed use back of form
13. CASING:
LOCATION SKETCH
Wall Thickness
/� Depth iame r orr W llg/h.V�Flq, ,�pa�ted�a(l JjQ (Show direction and distance from at least two State
From —To Ft. U- Roads, or other map reference points)
From To F.
From To Ftt. 11 nx L 7 �.f�5
14. GROUT:
From To
AV—Fl. Materi I ethod
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From —To—Ft — in. —in.-
From — To — Ft. — in. — In.
From —To — Ft. In. —In.
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
17. REMARKS:
-
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 1SA NCAC 2C, WELL
CONSTRUCTION STANDARDS. AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE',�1LY DATE
'NATunE OF PERSON CdASIMUCTING THE WELL
Quad No:
;Submit original to Division of Water Ouallty, Groundwater Section within 30 days
a r - GWA REV. 12199
Serial No.

Nonh Carqlina - Department of Environment and Natural Resources - Division of Wale( Quality - Groundwater Section - r)
1636 Mail Service Center - Raleigh, N.O. 27699-1636-Phone [phone] ti 1 ! ) l ' !.
JVELL CONSTRUCTION RECORD WELL CONTRACTOR-.DeGfcarx '
WELL CONTRACTOR CERTIFI ATION #:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (check Applicable Box): Residential0./Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other F1 If Other, List Use:
2. WELL LOCATION: Show sk(elcch�offtthe location below)
Nearest Town: x��(-sha_ Y County:
fRoad Name an Numbers. Communl y, or Subdivision and Lot No.) DRILLING LOG
3. OWNER u's,/ From To
Address z/]
*oy'n
state Zip Code
4. DATE DRILLED 1J
5. TOTAL DEPTH -
6. CUTTINGS COLLECTED YES Q NO
7. DOES WELL REPLACE EXISTING WELL? YE�NdO
6. STATIC WATER LEVEL Below Top of Casing: FT.
(Use's' If Above Top of Casing)
9. TOP OF CASING IS. FT. Above Land Surface'
'Top of casing terminated suer below land surface requires a variance In accor.
dance with 15A NCAC 2C. le
10. YIELD (gpm): 7 METHOD OF TEST
11. WATER ZONES (depth):
DEPTH
Formation Description
12. CHLORINATION: Type Amount If additional space Is needed use back of form
13. CASING:
LOCATION SKETCH
Wall Thickness
Depth (y DDiame r or W igliVF atenaI (Show direction and distance from at least two State
From —Sl—To —ll— Ft. Roads, or other map reference points)
From To Ft. —
From To Ft.
14. GROUT: 7E�
From TDopA� Ft. MateraL
19
From To Ft. T
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft In. In.
From —To _ Ft. In. In.
From To _ Ft. _ In. In.
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY I
Quad No: SIGNATURE OF PERSON FONSTnUCTING THE WELL DATE
I CSubmilprigns! 11 Division of Water Quality, Groundwater Section within 30 days
Serial No. 64 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]
: f / Sly r t1 � �
WELL CONSTRUCTION RECORD WELLCONTRACTOR: Y _ ,
WELL CONTRACTOR CERTIFICATION
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (check Applicable Sea): Residential W_ Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heal Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: Show sk t �yy }ha location below)
Nearest Town: Cl ✓.S // County.
0 tic lerP -
(Road Name and �N—umbers, LCommuniittyy, or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER //Zf IJA/Cc"From To Fomullon Description
Address eeeO f� f P
eat or Houte o. S
City or Town Slate Zip Code
4. DATE DRILLED
S. TOTAL DEPTH
6. CUTTINGS COLLECTED YESg NO❑
7. DOES WELL REPLACE EXISTING WELL? YES NOgg-
8. STATIC WATER LEVEL Below Top of Casing: FT.
(Use'i If Above Top of Casing)
9. TOP OF CASING IS / FT. Above Land Surface'
-Top of casing terminated atlor below land surface requires a variance In accor-
dance with 15A NCAC 2C.910
10. YIELD (gpm): METHOD OF TEST U
11. WATER ZONES (depth):
,, �e� ----ar
12. CHLORINATION: Type A, °; ° Amount �— It additional space is needed use back of lorry
13. CASING:
LOCATION SKETCH
Wall Thickness
Depth DI me r or Wei ht/Ft. Mal dal (Show direction and distance from at least two Slate
From -To —a Ft. � G Roads, or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth
Material
Method
From
To
Ft.
(,eA/
From
To
Ft.
15. SCREEN:
Depth Diameter
SloiSlze
`-ldateriai
From
To _ Ft
_ In. _
In.
From _
To _ Ft.
— in. —
in.
From _
To _ Ft.
_ In. _
In.
16. SANDIGRAVEL PACK:
Depth
Size
Material
From
To
Fl.
From
To
Ft.
—
17. REMARKS:
_.
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCOROANCE WITH 15A NCAC 2C. WELL
CONSTRUCTION STANDARDS, AND THAT�OF THIS yECO D HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY """ /11
/�
Ouad No: GF(#ITl,(FiEDF PERSON CONMRUCTING THE WELL DATE
D u61t �i ginto givlitgn of Water Quality. Groundwater Section within 30 days
Serial No. F GW.1 REV. 12/99
I
.JUN
Groundwat c.,0h

_.. .... ._��..�— ..
North Carolinn • Dnpm6rlm,t of Envirmlrnenl. Health, end Nalurnl nasoutces ron OFFICE USE ONLY0 1 2'7 �` vp.
Division of rovironmmdal Mnnngnmrtnt • Groond,Nnior Section OI1nU. NI). 6ENALfJO.
P.O. Pox 29515 • flnlnlgb, N.C. 27626 0535 --_---
Phone [phone]
Mltmr nrin 1
WELL CONSTRUCTION RECORD ❑aelnre,re,
_
DRILLING CON RACTOR ` FA Ilnndnr Ent.__ OW t Ent.
SIATF. WELL C0115IIlUCJ1014
DRILLEnnEGISTRATIO11tIUMDER: ,j�l ____—PERMIFNUfdDFN -- _
1. WELL LOCAIION:,(.�Siioow she ch of the location Uolow)
Nearest Town: Counly: L1 -
(nond. Corrnnr ,ity, or ..^.uL.11vlr m, mul Lct Nn.) _—
2. OWNER _ --- --
ADDRESS- -
(Slrnel or flouts wo.)
City or lo'Nn Stnln -T�Zip Code
3. DATE DIIILLF.D 'L DD USE OF WELL DQM .
4. TOTAL DE_PIII -
5. CLI VTINGSC01_LECTFL) YES(_] NO��
6. DOES WELL nEPLACE EXIS11t1G WELL? YES [ ] Nog
7. STATIC WATER LEVEL Below Top of Casing: —2;5- FT.
(Use ?^ If Above Top of Casing)
e. TOP OF CASING IS --__' _.-- FT. Above Lal,d Surfaco'
"Cesing Tetmineled nVnr below lend emb,ce is lilegol unless a verlence Is Issued
In eccotdencn Mil, I5A If AC 70 .0110
9. YIELD METHOD OF TEST
VAT ER ZONES (deplh):
11. CHLOFIRIATION:
12. CASING:
UEP' I I I _-DRILLIN-G LOG_
From In Formndon Description
LIQ
T VI)0 _AUIOUfIt' II nddilionnl cp:rcn is needed 0n back of form
UnI)IIl
V1.1ointor
23
FromTo -55-
EL '
Frorn To---
Ft.
From---10-----
rt.-
13. GROUT:
LOGAJ-IONS KETGIT_
Well Ildol:ness
o{,rwei Ja 5 alnrinl (Show diroclinn mid diNancn horn et least two Stele
o�JWX--5jx noad?, or ollwr mnp tnfninnce Points)
n [,oI,I MalerinI �olh
od
From c� Io 0 _Tl. 1ddL
From - --- To _ _.--FL
14. SCnEEN:
Url)th Diameter Slot Size Malerinl
From —_-- 10 —_- I 1 --- in. --
From To --------
From 10 _P1.----.— 111, In.
r 15. SAND/GIIAVFL PACK:
UeI)III Size
From _ 10 ___-- 1I. --
From ---- To ---- Ff.
—
d r,_
Do I1Er].Ci1
CONS Il'TI
(
UU
GWn nEV. `, ,Lj
)IT�� 111�J17�rJ�, PBrJr
,ju uu LS
¢a�3Alcl
Malerinl4 �j- L iJ LEi
r
I
WAS cows l nllCI ED IN ACCOr1Dht ICF Will:I rrA 'fTC- AC?C, W rLL
T A COPY OP Tins nrconO I IAS nEEtJ ntloVluCO to ll IF WELL OWNEn.
su:rinTUnFOFCr IrtnClOnorl •Ern DATE
Submll ndglnnl to Divlelon or 6rvlronmenlnl FI-m'.q'n�e•a erd �er•y M w"� nwrr"r.

North Cnrolinn • Dnpnrinrrrnt of Environrnenl, Health, and Nnlumi nasources ron orriCE use o11LY
Division of riMionmmnlnl Mnongnmont • Gtound•wnlar Section OIJAD. M). 6ENALNO. !�a
P.O. nox 29515 . nnlnlgh, N.C. 27626-0535 lnt _ --Lora noMons(919)733-3221 ,--
Moor Paain
WELL CONSTIlUC11014 nECOnU annlnCrdn—__
MILLING CONFnACI II^ndnr Fni __ oW t EnL
�1 SIAM Wr_LL coils IIlucIlot$
DRILLEn nEGISTnAHQ? I fIUrAnf_n: Jry % PEnMIr t1UMnrn:
1. WELL LOCAL ION: (-I ow sLelc I of the Callon below)
Nearest Town:--/// A_S'A� —County:
(nand, Cn,rV"U ity, or Sutdivl^.I r Mid Lo Nn.)
2. OWNEn _ or,
-
ISt,on pule NO.)
City or 10vnr Slain ^►� zip Code
3. DATE DnillI-D 31�0>o USE OF WELL JJO/n .
4. TOTAL DEPIII �(
5. CUTTINGS COI_LECIEU YES L_I NOL-
6. DOES WEI L FIEPI_ACE EXIST ING WELL? YES
7. STATIC WATEn LEVEL nelow lop of Casing: __jd FT.
Into'i If Abovn Top of (3Msh,g)
S. TOP OF CAS ItIG IS FT. Above Laird Surface'
• Casing Tarnh,nlyd nUnr hnlow Innd amino, is Illegal uniess a variance Is Issued
In ercordonce with 13A tjjCAC 2C .0118
9. YIELD (gp111):—SI?_—_ ME IOD OF TEST
VATEn ZONES (deplit):
U_EI'lll
Uf11LLit_4G LUG
rormadon Descripdon
o
M3
11. CHLOFIINAT 101J: Typo � Amount SAE tl n,lJilian,l sp,rn is nnndnd usn back Moray
12. CASING:
t.00Ai_IOt!_SI<ET CI I_
wan add -erne
Depth D'iamnln�r Of WrlghUF1. nindnl (Show Jirnnlinn and distnnr,n hom at leael two State
From O To Ft. /Q.2 floaJn,einlhnrmaprM(Mrnncepoints)
From TO rt. — - A
From ___To--- rt.-. - -- JJI ram, n,, j%ltaJL�
13. GROUT:
Urpth /l�M�alerhEnl nlhod
From —Q -to A4 rt.5..6�KdL�C+---
morn ___.__.-to-
14. SCREEN:
Dnplli Uiantet0r Slot Size Maledal
From 10 ---- f l — hl, In.
From -- to — --1 1. --- in. In. —
', From — __ To - — Ft.-- In. -- In. f�
^ r 15. SAND/13HAVEL MCI': 12 `vJ
Ueplh Size Malelial
Front To-- —ri. —
i
From — _— To Ft.__
,^ REMARKS.Fr -
DO LIAr 1111S WFLL WAS COr1SinUCTED Ill ACCOnDANCE Wld.l"1rrA IICAO 2C, WFLL
CONS TION STANDAIIus. MID TIIAT A COPY OF 11iIS necono HAS OEErf PnOVn)FD TO TI IF WELL OWNEn.
ij
cry
Croundwate] Section slrrinlunr: of cc I ItACIOn OiI ,FNt
GATE
GINA nEV. pshev1ile 1te onal Office Suhmil 01lg41-11 In Divlelon of Frrvlronmmrtat 1.1vna^rn�ni mid Crpy M wnA nwrur.
0

North Caronm - no ow,r)l of Fnvirnninnni, Heallil, And NAlurol lineoulceA � roe orrlcE usE «rLv21 �'� 4-�2)
Dlvfsion nta
of ' Mronm.nl Monngmnent • Groundwolor Sectlort
r J. Doa 29S:15 - llnlnlgh, N.C. 2.7626-0539 o11Au. tit). ____-- 8E11IALNO.
Phone [phone] r^r _... . _._ Loiq. no '
' Minor 11n^in
WELL—CONSTRUCrIOrr nECOnD nnni„ante
DRILLING C' .1 TITACTOTI d Nnndm Eel -__ -- OW-r Ent
(j �/ / S SIATE WFI-L CONSIItl1CHON
DRILTr' ,iFG!STnATIQIINl1M11nFn: PETIMITNUMAEri:
ELL LOCH I ION (Sh�o"wAp ketch of the locallon bolow)
Nearest Town: ._Ijff,4AS1d_aQCounly:—&A�C1— - .-_-_------
(Woad, Conrcnwi , m ^ul-livlslnn and LOINO.) U_F_I'_I_I 1
t)nILLING LUG
2. OWNEn _ �✓ From In
formation Description
—
(Sheet or Pours No)
�7
City orlown sial" Code
'-t�Zip
3. DATE Dn1LI_F.0 �� USE OF WELL D2rr) . —
4. TOTAL DFP I I I
5. CUTTINGS COLLFCI ED YES[ No v l
B. DOES WELL nErl_ACF_ EXISTING WELL? YES
o�
LNO�
7. STATIC WATEn LEVEL Below Top of Casing: FT.
��
(rise': If Above Top of (3nninq)
C or^
8. TOP OF CASING IS Fr. Above land Surface'
zM
• Casing Tertnirmled over hnlow Inod iodate is Illegal unless a vailence Is lssuad
(V m
In accordance with 15A NCAC 717 .0118
A ne
9. YIELD (gpnl):-Z.p _ ME I I IOU OF TEST —
O
oO
1' YATEnZONES (depth): ----- —
m�
---its----
11. CHLORIrTATIOfJ: Type % Amount If ndwitlonnl ^pncn is nnndnd use back oINm j
12. CASING:
Ylnli lhfckness -
LOM lON-SKE T CIS
Unptll inmelor or welghUrt. Malarinl (Show diroctirnt mid distance from at lenst two Stale
From4910 � rI. � �8 �j/C-S[J2 llonds, or oilwr nine talaiince Points)
Frorn To-- H.—
From --To------=
U. GROUC /V Drpill Milerllil d� /%
From Q '10 A42 rl.nn `p �j(�0
From _.__ To ____ rI. —
14. SCnEEN:
n Slot Sl7r) Malerinl
brplll Ulamn
.l.r
S
From ---
ToFrom
--
To
From —____
To __ __
_ rl.__ In.
15. SANDIGf1AVFl_ PACK:
Doplh
SI70
From
Te
_-- rt. —
—
From
lo__Ft.
—
16. nEMARKS:
t oo _ F It nryrr a I-C WAS coN.^, tnuCIED It ACccAiteAijjj, I;i4l t rA ern 2C, wr_LL
CON ki All HAT A COPY Or TI IIS nEC� 4 DEErI PrtOviopD To 11 IF. WELL owriFn.
Ls� a gas
slnrlAtunr:or Cr TrinClonon .rrlr DATE
OW-1 J. ;: , Croundwa;e! Sectlell SuMnll odglnal to D!vieion of piwironn owil tl,, ­q�nwnt and c�rr to wen owner.

Norm Carolina . Dnpn of or r.mimornnrd. 11011111, and NnfUral Rasource9 Q�
Division of End ,„„nr,; �Irnnpmmont • Ground'Nnlnr Section ron orRCE U9E ONLY ! u r'.r' ,t,x 29571. Ilnlnlgh, N.C. 27626-0535 OUAI7. NU. ___ 6En1ALW,
Phone [phone] t at _ Lo,q. no
Minor 11,1 ih
WELL CONSTNUCTION RECORD n1n61rn.ln
DRILLIfTG C iI RACTOR r ���.ljD nnndnr 6d_-- - ow-1 Ent
�J SIATeWELL CONS MUCnoN
DRILLF1 iEGISTRATIoNN1IMDf=R: ,j�l _PERMtT'NIIMUER:
1. ._LL LOCH I ION: ow shelcl o the locallon below) �/% -/• -
Aearest Town:_— � ✓/ -- County: _96, l/ -------
(nond, Cor9rnnun4y, or Su1.11yftort and Lo�{lo.)
2. OWNERL��
ADDRESS_fL_
) �� ���,�/J� (Stinnl or floouto No.) fl
City or l ovm Slnln Zip Code
3. DATE DRILIFI) 3' • 66 USE Or WELL _ZPD .
A. TOT ALDFPIII y�_rL_, LA,
CUTTINGS COLLECT EU YEo NO
6. DOES WELL f1EPl_ACE_ EXIST IIIG WELL? YES O NOLO
7. STATIC WATER LEVEL Below Top of Casing: qdj� FT.
(Use's' It Abovo Tor of (3nsing)
S. TOP OF CASING IS __j__ FT. Above Land Surface'
-Casing Ter mineled aVnr bolow Iand eurfnca Is Illegel unless a vnrlence is Issued
In accordance with 1SA N AC 2C .01 is
9. YIELD (gpm): W__ MET I IOD OF TEST
11' _VATER ZONES (depth):
UE-- -- --
I' I I I ILLING- L
- -- ---- DR-- ---- - OG -
rrmn 1 o rormation oescrrpenn
c
�
O—a
nv
zm
N
sm
ya
cr
N.
o
11. CHLORINATION: Type II ndditionil -.Inca is nnadnd uAn back of form
12. CASING: - ----
LOCA_IION SKETCLI
Wnir IIIIf.1.rIP.9e
Unplll.�2 9ia^nlnCter or v�itolg�iw�rti �Wittorrini (Show diroctinn and disianco from of loest two Slate
From O To L3 Ft. IG�+5 dL�. Q 'PK" k Boada, nr oilmr om/p roloroncs points) From —To- Ft. —
From ---To ---= FI.
13. GROUT:
Drplll n MalerlEnl nlhod �/f� //V l
-
From -�— r1.L To ��
From _ _— To rt.
14. SCREEN:
Urplh
rrom To _____ rl
From To ____ _ rt
From ___ _To Fl
15. SAND/GRAVEL. PACK:
Deplh
From T o --
From ___-- to
16. REMARKS:
r Do IiFnrnV Crilll
COrTSTnUC T toil SI-
t]
OW-1 nEV.
Diameter Slot Size Materinl
In. in.
— In. Io.
In. In. --
Size
rL
Ff.
Material
r.5 .
a, AU_
WAS COris I nUC 1 ED If l ACC
TA Cor'Y Or TI ITS mconD f
Pj[JAC 7C, WELL
TO 111F_ WELL owuEn.
-- aw_ __W-7 3 Sao
su;rinrunr:orcr lrincronon ,rnr onrE
Strbndi migL,nl In pivinlon of 6rvhonn,ental l.1oi�q^nmrd and c�rY M wnA owner.

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section c 1636 Mail Service Center - Raleigh, N.C. 27690-1636-Phone [phone] _ .1
w) ? 4
WELL CONSTRUCTION RECORD WELL CONTRACTOR: Lt 1 l)
WELL CONTRACTOR CERTIFICATION If: b
STATE WELL CONSTRUCTION PERMIT#: / 79
1. WELL USE (check Applicable Box): Realdenbal B Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other If Other, List Use:
2.
WELL LOCATIO how qketc��of the location below)
Nearest Town: (r/OL4. Couny:- �WaO�,&J
(Road Name en mbers, Commu Ity, or Subdivision and Lot No.)
DRILLING LOG DEPTH
3.
OWNER L
From To Fonnayoi Description
Address o�
~
cuo�,�I �_e- ae7-3
City or Town State ZIP Code
4.
DATE DRILLED o B O7100
5.
TOTAL DEPTH toa.C'
6.
CUTTINGS COLLECTED YES 0 NO[J-
7.
DOES WELL REPLACE EXISTING WELL? YES NOD
c
B.
STATIC WATER LEVEL Below Top of Casing: FT.,.
cn-;
(Usa'Y' 9 Above Top of Casing)
--1
9.
TOP OF CASING IS FT. Above Land Surface'
w
-
-Top of casing terminated at/or below land surface requim a vartence In actor-
—
`--- m
dance with 15A NCAC 2C .Otte
10.
YIELD (gpm):1 21 METHOD OF TEST I-u-
11.
WATER ZONES (depth):
02
12.
CHLORINATION: Type 4n �h- 4�, Amount 0 C -
If additional space is needed use back of form rV
o
13. CASING
Wall Thickness
Depth Dter o W� hu_Fl. enal
1l—Fromql' Fl,iVSteFrom To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From d To 4-0 Ft. (i[� 71q_t'a,LZ2�,c_
From To Ft.
15. SCREEN:
Depth Diameter
From —To _ Ft _ in.
From _ To _ Ft. _ In.
From _ To _ FL _ In.
16. SAND/GRAVEL PACK:
Depth Size
From To FL
From To Ft.
17. REMARKS:
Slot Size Material
In.
_ In.
_ In.
Material
LOCATION SKETCH
(Show direction and distance from at least two Slate
Roads, or other �mjap reference points)
a"
�d -k, 'Yq - " (110y, 01 JA_
1W_z �c vA arLt ,
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT AA OF THIS R D BE,ENN PRR VIDED TO THE WELLf OWNER.
FOR OFFICE USE ONLY i. <�
Quad No: SIGNATUA OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Quality, Groundwater Section within 30 days
Serial No. GW-1 REV. 12W

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: 6 JuQe Siau/cti es .S�J
WELL CONTRACTOR CERTIFI ATION
STATE WELL CONSTRUCTION PERMIT#:
1.
WELL USE (Check Applicable Box): Resldentlal Municipal ElIndustrial ❑ Agricultural El monitoring ElRecovery
❑ Heat Pump Water Injectlo 1 Other n
if Other, List Use:
2.
WELL LOCATIOt�,,�Show sketcrpt)tte location below)
/ ,
Nearest Town. /. /ti ��!'e/ County.
.Ltni
(Road Name and Nu erg, Commu, or Subdivision and Lot No.)
DRILLING LOG DEPTH
3.
OWNER r /ll e,kS67—�
From To Formation Description
t l rs 1911{2 !'��2�%
Address u) y/ y
—T( reeT r ou e o.
Cilyor Tovm Slate Zip Code
4.
DATE DRILLED
5,
6.
TOTAL DEPTH
CUTTINGS COLLECTED YES® NOO
7.
DOES WELL REPLACE EXISTING WELL? YES Q NO6?J_
B.
STATIC WATER LEVEL Below Top of Casing: FT.
9.
// (Use 'i if Above Top of Casing)
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.011e
10. YIELD (gpm): _21)_ METHOD OF TEST
11.
WATER ZONES (depth):
12.
CHLORINATION: Type .S Amount
If additional space Is needed use back of form
13.
CASING:
LOCATION SKETCH
Wall Thickness
Depth Diameter or WeIghVrI. Ma dal (Show direction and distance from at least two Slate
FromToS`� Ft Le Roads, or other map reference points)
From To Ft.
From To Ft.
14. GROUT: O
Depth �m Material Method
From Q_ To /�-V/ .Ft. off#1 z e C
From To Ft. x
1
15. SCREEN: fV
Depth Diameter
From —To _ Ft _ In.
From —To —Ft. — in.
From _ To _ Fl. _ In.
16. SAND/GRAVEL PACK:
Depth Size
From To Ft. —
From To Ft.
17. REMARKS:
Siol Size ` "laterial
In.
In.
_ In.
1 DO HEREBY CERTIFY THAT THIS WELL WAS
CONSTRUCTION STANDARDS, AND THAT A C,
FOR OFFICE USE ONLY
Ouad No:
Serial No.
Material
JUN 2 8 2000
IN ACC RDA CE WITH 15A NCAC 2C. WELL
AS B EN PROVIDED TO THE WELL OWNER.
PERSON CONSTRUCTING**_WELL-'DATE
'ilor Quality, Groundwallij,.Satifen within 30 days
l
�m
o�
c
om
y0
mC3
Ao
Nx
C�
—i
O
"I
GW.I REV. IV99

North Carolina - Department or Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: S6�
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 how sl etcl 9f the location below)
Neares Town: G,R 5 I I County:
�u 1
(Road Name and Num,(pers, Comnunll , o/S Subdiv/fslon end Loi No.) DRILLING LOG DEPTH
3. OWNER S / eoe- Y �7 From To Formation Description
Address
f / 3 Odell Sexalm—
tsireet or HOU a o.
/o
City or Tovm Slate Zip Code SEX
4. DATE DRILLED 3-03-00
S. TOTAL DEPTH
6. CUTTINGS COLLECTED YES® NO❑
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO(].
8. STATIC WATER LEVEL Below Top of Casing: FT.
(Use'.' If Above Top of Casing)
9. TOP OF CASING is —I— FT. Above Land Surface'
-Top of casing terminated otter below land surface requires a variance In accor-
dance with 1SA NCAC 2C . 1
10. YIELD (gpm): METHOD OF TESTT
11. WATER ZONES (depth):
12. CHLORINATION:
13. CASING:
Type Amount II additional space Is needed use back of form
Depth ��/ O am ler
From To �— Ft.
From To Ft.
From To Ft.
14. GROUT
LOCATION SKETCH
Wall Thickness
or We» VFt. M ly od?I, _ (Show direction and distance from at least two State
L— I/GStr - Roads, or other map reference points)
Depth
Material
Method /
D �
Fl.
d�
From
To
From
To
Ft.
15. SCREEN:
Depth Diameter Slot SI20
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
FOR OFFICE USE ONLY
Quad No:
Serial No.
JUN 2 8 2000
-aL
07,
IN ACCORD"
E WITH 1SA NCAC 2C. WELL
COS YEAS BE PROVIDED TO THE WELL OWNER.
r c)
PERSON CONSTRUCTING LL DATE
later Quality. Groundwater Section within 30 days
GW-I REV. 12/99

North Carolina - Department of Environment and Natural Resources - Division of Water Guanty - Groundwater Section
1636 Mail Service Center- Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELLCONTRACTOR: GGr�
WELL CONTRACTOR CERTIFICATION #: a S 6
STATE WELL CONSTRUCTION PERMIT#:
WELL USE (Check Applicable Box): Residential sy Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other E] If Other, Ust Use:
Agricultural ❑ Monitoring ❑
2. WELL LOCATION;.,,ow kelc 2ri ocation below) /}�%Q _10
� _
i
//�� County. /,ryv
DRILLING LOG DEPTH
Fom+atim Description
3. G'" UE/k From Ta y /
Address
t/ �� odt2 Ur/r7ilt�
ree or ou a o.
City or I awn Slate Zip Cade
4. DATE DRILLED
5, TOTAL DEPTH 821
6. CUTTINGS COLLECTED YES [0 NO❑
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO©
8. STATIC WATER LEVEL Below Top of Casing: FT.
(Use'i If Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface*
-Top of casing terminated etfor below land surface requires a variance In accor-
dance with 15A NCAC 2C .0118
10. YIELD (gpm): _ 6 METHOD OF TEST-
11. WATER ZONES (depth):
r
If additional space is needed use back of torn
12.
CHLORINATION: Type ills
Amount
13.
CASING:
LOCATION SKETCH
Wall Thickness
WeIghVFI. Material
(Show direction and distance from et least two Stale
Depth p Diameter
1 / To a v� — Ft *
or
�`�/ �/ ��iG
Roads, or other map reference points)
From—L--
From To Ft.
�p
o
From To Ft.
a"
14.
GROUT:
Depth Material
Method
Z
t
c
CD<
�— To �— Ft. dePI0
—ram`
N
bo
From
From To Ft.
_
`^o
Am
15.
SCREEN:
Depth Diameter Slat Size -Material
=
••
"'_
rq=
From _ To _ Fl _ 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. REMAHKJ:
I DO HEREBY CERTIFY THAT THIS WELL WAS CO RUCTED IN ACC DANCE WITH i5A NCAC 2C. WELL
CONSTRUCTION STANDARDS, AND THAT A C Y F IS D H S BEEN PROVIDED TO THE V E i0W`N�ER�
=No:::
J DATE
CuedIGNATURE OF PERSON CONSTR TING 7HE WELLub(Qll0 na �ivisTfi btWaleroualiry.GmundwaterSection within 30 days GWt REV. I2M
D �L22
I
Croundwate• Section
h= n �' cIonal Office 11

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1638 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone] ,,/ ��'
WELL CONTRACTOR: _,(Z °t— a w��� s saw
WELL CONTRACTOR CERTIF CATION #:
STATE WELL CONSTRUCTION PERMIT#:
WELL CONSTRUCTION RECORD
1. WELL USE (check Applicable sox): Residential 1E
Munlclpai ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injectlon, Other E] If Other, List Use:
2. WELL LOCATION: Sh w etch of the location below)
ue�.oer Tnwn• 0♦ : &4 S County: !/ I ($ 6 �-
rr DEPTH
(Road Name and Nu hers, Communit/y,;r S start and Lat No.) DRILLING LOG
3. OWNER /! y�`- From To Form atlm Description
Address dw
tbiree,or Houle o.
,s� 3oS �ti
City or Town Stale Zip Code
4. DATE DRILLED
S. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ®" NO❑
7. DOES WELL REPLACE EXISTING WELL? YES O 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 easing terminated atior below land surface requires a variance In accor-
dance with 15A NCAC 2C .g)18
10. YIELD (gpm): J METHOD OF TEST
11. WATER ZONES (depth):
12. CHLORINATION: Type r S Amount S It additional space is needed use back of form
13. CASING:
LOCATION SKETCH
Wall Thickness
Depth q� � D�a�ieler or W�e/Ig�hUFt. �Ma��ed�al� � (Show direction and distance from at least two Slate
From.--�--To —L— Ft. —(I -V 10'& = Roads, or other map reference points)
From To FL rb -
From To Ft. OO ME
14. GROUT:
Depth Materia Method
o
�qq!!ll Z �
From �— ToFt.
1 2m
From To Ft. fVm
15. SCREEN: Dv
Depth Diameter Slot Size AMateriai ~.,
3 2o
From _ To _ Ft
_. In. _ In. — rn m
From _ To _ Ft. _ In. _ In. ti
From —To _ Ft. _ In. —In. V7 0
s
16. SAND/GRAVEL PACK:
Depth Size Material
From To FL
From To Ft. —
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CO CTED IN A COR NCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A C Y O T IS RE HAS EEN PROVIDED TO THE WELL OWNER.
3�y- ov
FOR OFFICE USE ONLY """—
Quad No: N U O��yp E CONSTRUCTING THE WELL DATE
#late Ily, Groundwater section within 30 days
Serial No. .2 GW-1 REV. 12199
JUN 28-)-n

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: &ut e_ )L S�
WELL CONTRACTOR CERTIFICATION 0:y� l0
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residentlalz Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATIO ' how sketcl fj ocatlon below) i a�
Nearest Town: a f // Count': A� r
(Road Name endCyum�er , Commuunity, or SyY(Jlvislon and Lot No.) DRILLING LOG DEPTH
3. OWNER / �e /" �i /�rf h�// /`-� From TO Fom+atlon Descdptlon
Address f SY Q//Y� ��rr1l1•v
(street or Route o.
City or Town Stale Zip Code
4. DATEDRILLED 3-lb-IT
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ® NOO
7. DOES WELL REPLACE EXISTING WELL? YES Q NO®
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 atlor below land surface requires a variance in accor-
dance with ISA NCAC 2C .0118
10. YIELD (gpm): .1• ' METHOD OF TEST
11. WATER ZONES (depth):
12. CHLORINATION: Type r Amount It additional space Is needed use back of form
13. CASING:
Depth O�aXmelor
From -t / To —L— Ft. -V!
From To Ft.
From To Ft.
14. GROUT
Wall Thickness LOCATION SKETCH
or We10hVFl. Material (Show direction and distance from at least two State
>U/ rtiis �G Roads, or other map reference points)
Depth Material Method
From _t Torl. e B
From To Fl.
15. SCREEN:
Depth Diameter
From _To _ Ft _ In.
From _ To _ FL _ In.
From _. To _ Ft. In.
16. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To Ft.
17. REMARKS: _
Slot Size -Material
In.
In.
In.
1 DO HEREBY CERTIFY THAT THIS WELL WAS
CONSTRUCTION STANDARDS, AND THAT A C
FOR OFFICE USE ONLY
Ouad No:
Serial No.
Material
JU►V 2 8 2000
o•
C c
n
t out
N rn
Do
rn
S �o
c,o 2
rnm
_ c:1
tJ1 CD
Z
IN ACCOR ANCE WITH 15A NCAC 2C, WELL
OR HA AEEN PROVIDED TO THE WELL OWNER.
MrON CONSTRUETING THE WELL DATE
uality, Groundwater Section within 30 days
GW-I REV. 12199

North Carolina • Dnpmlmnnl of Fnviro inlonl. Healer, and Nnlurnl Resources Y FOn OFFlCE USE dJLY
Division of ElMlommnnlal Mnnngmmnnl. Gioundwaler Section OIIAIJ fnl _ FERIAE tJL C ! I
P O Oox 29515 • llnlnl h N C 27626 0535 ----
9 .
Phone [phone] lot. _ Loog. no
Mlllnr Pavia
WELL CO TSTf1UCTION RECORD nnnin Cmrn __
--� C Ilnnrinr GINA EnL Pal.. ,_.
MILLING CUNTMCTUft•
SIATE WE1_1_ Collslflue n014
URILLERnimnistRAIIOffflumnf_R: �� _PErimirtiUMnir
1. WELL LOCATION: I w sketcl all I callon below)
Nearest Town: .— County:
(nond, conwrnn ity, r Sul<Jivlrlon and L I No DEP I I I _ DRILLING LUG
2. OWNER_ Foin In rbrmnaon Description
ADDRESS_-7e/
�) (Shinl or ule No.) 0 „ S
Ciry or lown Stalo Zip Cade ID
3. DATE DRILLED L 'UU USEOF WELLJ%
4. TOTAL DrP I I I _ -- '
5. CUTTINGS COLLECTED YES L_] NOL✓J —
6. DOES WELL REPLACE EXISTING WELL? YES � NoZ
7. STATIC WATER LEVEL Below Top of Casing: �__ Fr.
(Use'.' it Above Ter of Caslnq)
S. TOP OF CASING IS ___J__ rT. Above Lind Surface'
' Cesing Trrmlimlod of/nr bolnw Innd surinee is Illegal unless a variance is Issued -
M eccardnnce rrllh 13 JJ_CAC 2C .ol1e ----
9. YIELD(gpnQ�___MEIHObOFTESi ---.
' 'NATEll ZONES (deplh): -----
11. CHLORINATION:
12. CASING:
jype _ Amount II additional ^.pacn is nand
Will 1 hrakness
Doplb Olanlnfer or WelyhUFt, ntminl
From-- Tb Ft.
From ---To----- Fl. —
13. GROUT:
Dopel Malerlal Method
From -A rl. From ____ To
14. SCREEN:
o �,
LOGAI ION SKEI Gil
(Show dirnclirm and disfanca frorn et lensl two Slate -
Ronds, or mbar ntap refnrnnce po nls)
Drplll Diameter Slot Size Matednl
rrom --To _ rt -- in. In.
From To rt. In. —
From --___ To — Ft. In. In.
15. SAND/GRAVEL PACT(:
Depth Slze Malerlal (_ I5 it
From To_—_ rt. I1
rfoln __— Ta Ft. ] pUC l r
16. REMARKS: _ t
loonrnr--�� -rr Ir tff"r;�ii wETI'WASCOtJS1nUCTED NAc df)akk+TieslialsIA nC/jr2C.wELL
COtJSTntJ g r� GA�L7AT1r.�_Lyt4t ')I IAT A COPY OF TIIIS nE IrE WELL OWNER.
Slrr lAtUnr or OrJIftA0lr pn AGrrtl DATE
Ow.1 nEv. gig I Croundwat Section Submit orl nnl to Divielon of Emirnnrrwnhl nd c ry lo wea n+me•.

North Carolina • Depnrtrnont of Environment, Health, end Nalurnl Resources
Division of Envirommnntal Manngnment • Groundwater Section
P.O. Box 29535 - nafnigh, N.C. 27626-0535
Phone [phone]
FOR OFFICE USE ONLY 2 1 2'7 i 6
QUAD. No. 6ERtAL NO.
Lot _ Lmq. - no
WELL CONSTRUCTION RECORD Minor Ba-in6nghr cn.ln_
DRILLING CONTRACTOR: ` Hnndor Fnl _ OW-1 Ent
STATE WELL CONSTRUCTION
DRILLER REGISTRATION NUMRL"R:�/ _ PERMIT NUMRER:
1. WELL LOCATIONryh of the location below)
Nearest Town:- 19-PCounty: /ya
(Rand, Conanoni or SuMivielon od Lot No.)
2. OWNER
ADDRESS-981
(Sheet or Ro le No.)
AP7sy
City or Town Stalo Zip Code
3. DATE DRILLED,2-aka o USE OF WELL Ddj_
4. TOTAL DEPTI I _��__
5. CUTTINGS COLLECTED YES[—] Ill
6. DOES WELL REPLACE EXISTING WELL? YES 0 li
7. STATIC WATER LEVEL Below Top of Casing: 2-:k FT.
(Use •i if Above Top of Cashig)
S. TOP OF CASING IS �_ FT. Above Land Surface'
• Casing Terminated xUor bolow land surface Is Illegal unless a variance Is Issued
In accordance with 15A CAC 2C .0119
9. YIELD (gpm):METHOD OF TEST
'' WATER ZONES (deplh):
11. CHLORINATION
12. CASING:
DEP 11 I_ _DRILLING LOG
From To Formallon Description
lip
Type Amount If additional -pats is need
LOCATION SKETCH
Wall Thickness ----- _—
Deplll DI meter or Welght/Ft. Material (Show dirpctinn and distance from at least two State
From lo � FL &a•. .4A.,2 nonds, or ollmr map reference points)
From To rt.
From To Ft. ��P�Gt/f/J�/i • �/
13. GROUT: /� `
Depth Malerlal&- elhod �4 0, �LGC� �� A/ 7.
From To _QFt.
From __ To FL
14. SCREEN:
Depth
Diameter
From
To
Fit In.
From
To
rt. in.
From
To _--
Ft. In,
r 15. SAND/GRAVEL
PACK:
Depth
Size
From
To
Ft.
From
to
Ft.
16. REMARKS:
I Do HEn
Slot Size Material
In.
In.
In. _
Material
LL WAS CONSTRUCT
MT A COPY OF THIS
101� p 7
2C, WELL
E WELL OWNER.
I
CroundwaAWs tt--;d IGNATUnE OF NTr1ACT0 n AGENr DATE
OW-1 REV. 9NL-'
heville Regional Offire. I Submit original to Division of Emlronmemal 1.larngomenl and copy to wall owner.

_ .1_
- North Carolina • (lnnnrfmnnl of Envlronrnnnt, Nanllh, and Natural Ilasource9 rOn OFFICE USE ONLY 21 2'1 9
Division of FrMrommnnlnl Mnnngnmant • Groundwnlnr Section (31MD. ta1. _ _ CEnIAI NL P.O. Box 29515 - Ilninlgh, N.C. 27626-0535 --
Phann [phone] tnt. _ _ Lotq. no '
Mltim flncin
WELL CONSTnUCT10r4 nECOfiD / Mints",o
DnILLING cONInACTOn: 31 0 1 0 llnndnt F3o_ GW-f Ent
Q SIATF Wr_LL CONSI VILICI[Oil
unILLEn nF(',IST(1A11011 NtJMBL'n: PEITMII NUMRFFT:
1. WELL LOCAiION�(�,]Sh/o/w� sketch of the location below)
Nearest Town _J/1�L'— n 0-� County:
(nond, Connn�ufr'{y, or SIIIYIIviglon Id Lot No.)
2. OWNEn i(/.Pt wo R'ilAAc-
ADDness-15�Q---Ca1+�. �._ C�ixa, z z� I
(Sunni or noula Noll
City or Iowa Slaln Zip Code
a
U_EP_111 ORILLlt4G LOG
From In Formmoon Descdrtlon
3. DATE DRILLED t-uu USE OF WELL
4. TOTALDf-Pill
S. CUTTINGS COLLECT[D YES[_] N0Uvj
6. DOES WELL REPLACE EXISTING WELL? YES 0
NOU
C_
7. STATIC WATEn LEVEL Below Top of Casing: FT.
x
(Use': If Above Top of Casing)
N
8. TOP OF CASING IS �._--_ FT. Above Lnhd Surface'
no
• Casing Tetminelnd ntlnr bnlow Innd imfnce Is Illegal unless a variance is Issued
- —
3
m
In secordnnea Milt 15A NCAC 7C .0119
9. YIELD (gent)--3Q--_ METHOD OF TEST
o
mz
' WATER ZONES (depth):
0
11. CNLOMMATION: Type ? 4 �!s—Amount
I( nddilion,I cpncn Is nnndad use back of form
12. CASING: ----
_
LOCAL 1011 S.KETCFI
Will thickness
Drplila gm010r 0(W0� J ,IgIrVFt. alerinl
S
-
(Shaw (fir nrlion and distinc0 from at Inait two Slat@
From�10 rt. �[SL
no8d7, or olhnr mop rsiorance points)
From To Pt.
From --I o
13. GnOUT:
Urp111 alerlal Ihod
From _V___ -to A
From _— To _—_Ft.
14. SCnEEN
Drpih
From _—Io--rt
From To — rt
Florn _ To --_ __Ft
r 15. SAND/GMVFL PACK:
Depth
From To --
From ___ To
16. nEMAM(5-i .—
Diameter Slot Size
rL
Ft.
Size
Do NFnrj� - - -
CONSTR j ! STAfJDAr1US, ANU
ow-f nrv. gm I ..
Malednl
In.
In.
In.
Matelial
S CONS MUCTED IN
COPY Or I IIS rIECC
sIOUATunr or cot
Subndt orlghml to Dlvl
1 AU.T ,
r i nc tc, WELL
IIto WELL OWNER.
clonon .-ttr DATE
oI Frwhor,mmitni t.lnrr1q^moot w,d copy to w,11 owner.

North Cerrlion • t �,mimmil of Fnvi,mnnnni I-Ienhil. end Natural Basoutces _ FOR OffICE USE OtrLY
Division ,. miromi, Almmpninont • Gioundmilar Section 2127
i
1.0. Rox 295 - ftninlgh, N.C. 27629-0535 OIJAII. Nu. ___ SERIALNO._
rhona [phone] lot. __ Lniq. F10
Minor main !
WELL CONS IIIUC11014 RECORD
DRu.I coNrnncTon•
Ilonrly_rill _____ Ow -I Ent
�/ SIATE wELL C011SIIIUC11014
ITLEnnEGIST11AIloll f111rd01_R1 ,jZs'_ PERMIrNUMMI!
WELL LOCH [ION: (SIT w sllelch of IITT- lo 9lion below)
NenrestTown:—_/i�•.,�C.1/`�—Cnunly:
(B(ind, Community, Of ^ul. vl^.Tent and of N"
2. OWNER_ 1` t
ADDRESS_
(Sire of or IT Pu 'to No.)
City or town Slain Zip Cad"
3. DATE D111LLF1) USE OF WELL DOM .
4. TOTAL DFPIII _
5. CUTTINGS COLLECTED YES L_1 NO1;io�
B. DOES WELL REPLACE EXISTINC WELL7 YES NOL�o
7. STATIC WATER LEVEL Below Top of Casing: S_- rT.
(Use*** it Above Top or Casing)
8, TOP OF CASING IS ___ FT. Above Lnnd Surface'
• Cssing Torminn led mUnr h"low Innd mill Inca Is illegal unless a vnllnnce Is Issued
In accordnnee with 17A I C 2C .01 to
9. YIELD(911111)'-__ME1110DOF7ESi
x' WATER ZONES (depth):
11. CHLORINATION:
12. CASING:
Url'_1_1I UrIILLING LUG_
r,on, In ratmallon Description
Tyl,e i7 / �j AtttoUn II orhfilioml ^Fncn iq nnndnd ON back of lorm
vJnli lhlokness
61
Depth
1�
Ulanmler arvJnighvri.-Naindnl
rl. �
From
To
From
To--
rt.
-
Frorn--To-.-=
FL--
-
13. GROUT:
to Al
rl. 62 Mat
lthod
From
-
From _.—_
To __R.
14. SCREEN
Drplh
Prom
To _--__ I
From ___
To _--___. I-1
From —
---To ___..._ Ft
15. SANDIGIIAVEI_
PACK:
'
Dehth
rroin
_____ To ----
From -----
10--
16. REMARKS,
JUC ilOtl S I AUIDAr
Dlameler Slot Sizo Malerinl
Irl. -
--- In. h1. --
_ In. In. -
LOCH I ION SKE I CH
(Sliow dirnrtion mid dishnca from at halt two Slate
Ronda, or nlhn, amp relaranca points)
X, .iw/1V
Size rvl4im:smCo
H. --Ft.r��;ELL WAS COIJS L1J.-15A.-rl¢AC 7.C, WELT
TIIATACOPYOAFQ?IHhIt�,'81f3`?,�9�`1` 11O II IF WELL OWNEFl.
TOM
SI(VIAIung OF Cr. I1IACTOFl Ott &FUT DATE
Submit orighml to piv!slon of rill,...... ,"I r.1i.,,r-r mn1 n„•1 < 'y To IN owner.

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Grpundwater Section r
1636 Mail Service Canter -Raleigh, N.C. 27689-1836-Phone [phone] / I '. n7, J • ' 1 65 3 6
WELL CONSTRUCTION RECORD WELLCONTRACTOR:
WELL CONTRACTOR CERTIFICATION #: b
STATE WELL CONSTRUCTION PERMIT#: q'7
1. WELL USE (Check Applicable etc:): Residential 19� Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other 0 If Other, List Use:
2. WELL LOCATION: ( how sketch of the location below)
Nearest Town: � - -rn—o County:_
(Road Name and,�++umbem, Comnatly, or SubdvWon and lot No.)
3. OWNER kd}paj: w // axe_
Address / 5 9� � 2 o y
—jSuTal'oi •
Goa. e�J.�,r,�,o -yr.e -
City or To State 7Jp Code
4. DATE DRILLED -/S'00
5. TOTAL DEPTH .990 S— '
6. CUTTINGS COLLECTED YESD NO�
7. DOES WELL REPLACE EXISTING WELL? YES NO[g
8. STATIC WATER LEVEL Below Top of Casing: /5-_ FT.
(Use'.' # Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface*
'Top of casing terminated st/or below land surface requires a valance In sccor-
dance with 19A NCAC2a.011e
10. YIELD (gpm): 15 METHOD OF TEST
11. WATER ZONES (depth):
DRILLING LOG
From To
I%
J ? - aos
Agricultural m Monitoring ❑
DEPTH
FomWt�io,//n Description
/A Uf_
o
2=e
co
m
rn
—
rV
o
12. CHLORINATION: Type Amount r/a c . If additional space is needed use back of form
13. CASING:
WSW LOCATION SKETCH
Depth �1 .� Diameter or WeighVR. Material (Stow direction and distance from at least two State
From +To Ft. 6 YV S�Ge .07Viu,6U Roads, or other map reference points)
From To FL
From To FL
14. GROUT:
Depth Material Method
From 1�1 To �ZFI.
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From To _ Ft _ In. _ In.
From —To —Ft. _ In. —In.
From —To _ FL _ In. _ In.
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT AA OFTHISRj/[,��'
ORDFjd$B:�RQVIID���`E`WELL iOWNER.
FOR OFFICE USE ONLY j� �- `L 7L/ 1/J
Quad No: SIGNATU4 OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Duality, Gmundwater Section within 30 days
Serial No. OW-1 REV. 12/"

o_i6532
North Carolina - Department of Environment and Natural Resources - Division of Water Quality . Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phono [phone]/[I.
L
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION #: b
STATE WELL CONSTRUCTION PERMIT#: /'Y717
1. WELL USE (Check Applicable Box): Residential 0MunIcipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: Sow sketch of the location below) '�/ '
Nearest Town: / r a,li . e ? County: - `z u' &� nor l
1�
(Road Name and Nymbers. CormkaNry, or Subdivision and Lot No.)
3. OWNER ,t & 1.sc i C4
Address
r
City br Town state Ap Cads
4. DATE DRILLED 43 "a a`0
5. TOTAL DEPTH 30
6. CUTTINGS COLLECTED YESF NO[3'
7. DOES WELL REPLACE EXISTING WELL? YES NO[!
8. STATIC WATER LEVEL Below Top of Casing: FT.
(Use': 9 Above Top of Casing)
9. TOP OF CASING ISM_ FT. Above Land Surface*
-Top at cuing terminated War below land surface requires a variance In acow-
dance with 15A NCAC 2C.0118
10. YIELD (gpm): L4_ METHOD OF TEST
-
11. WATER ZONES (depth):
12. CHLORINATION: Type i&8a `^+ Amount e_
13. CASING: //
Wall Thickness
Depth D r or WeighVFI. Material
FromToI Z Ft.
From
To Ft. !
From
To Ft.
14.
GROUT:
Depth Material Method
From
To s20 Ft. �� y
From
To Ft.
15.
SCREEN:
Depth Diameter Slot Size Material
From
To _ Ft _ In. —In.
From
To Ft.— In. _ In.
From —To
_ FL _ In. —in,
16.
SAND/GRAVEL PACK:
Depth Size Material
From
To FL
From
To Ft.
17.
REMARKS:
DRILLING LOG
From To
Agricultural ❑ Monitoring ❑
DEPTH
Formation Description
n
CD
W
c 22
co
If additional space is needed use back of form N
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
60
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A OF THIS R ORD BEEENN/PRR IDED�TTO THE WELL OWNER.
FOR OFFICE USE ONLY Me�i-< � e/yc i j z QAllI �
Quad No: SIGNATtdi OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Quality, Groundwater Section within 30 days
Serial No. GW4 REV. 12199

North Carolina • Department of Environment, Health, and Natural Resources
Division of Environmmnial Managnmant • Groundwater Section
P.O. Box 29535 • rialnigh, N.C. 27626.0535
Phone [phone]
FOR OFFICE USE ONLY #J 1 O
OIIAD. NU. 6EnIALN0, 1
RO
Minor Ruin
WELL CONSTRUCTION RECORD Daaln cndn_
r Itondor Ew _ OW-i Ent. DRILLING CONTRACTOR://I(/{l5 %AIDS L 0, C� __ ____
STATE WELL CONSTRUCtION
DRILLER REGISTRATION NUMBL"R: PERMIT NUMBER:
1. WELL LOCATION: (nS,how sketch of the location below)
Nearest Town: /�1�h Q Q > p County:
(Road, Conmjju�nIty. or Subdivl Ian and Lot No.)
2. OWNER
ADDRESS _
(Street or r Houle No,)
City or Town State Zip Code
3. DATE DRlt.l_FD - -OD USE OF WELL )26,0)1 .
4. TOTAL DFP N1 __L[ r __
5. CUTTINGS COLLECTED YES ❑ NOUJ
6. DOES WELL REPLACE EXISTING WELL? YES [] NOE
7. STATIC WATER LEVEL Below Top of Casing: -- FT.
(Use'i If Above Top of Casing)
8. TOP OF CASING IS FT. Above Land Surface'
• Casing Terminetod aVor below land surface Is Illegal unless a variance Is Issued
In accordance with 15A NCAC 2C .0118
9. YIELD (gpm):—Z,�--_ METHOD OF TEST
1n WATER ZONES (depth):
11. CHLORINATION: Type ? Amount A4 ILIA
12. CASING:
From
DPplh / Diameter
To Cuomo Ft. /0 ­2 5-
Wall Thickness
or WeIghVFt. Material
121h'1 '15 2VC-SZ�'-
From
To
Ff.
From
To —=
Ft.
13. GROUT:
From
Depth
_/0_ To aO
Material shod
Ft.
From
To
Ft.
14. SCREEN
Depth
From To _
From To From To —
'r 15. SAND/GRAVEL PACK:
Depth
From To From To-
16. REMARKS:
Diameter Slot Size Mater101
Fl In. In.
rt. In. In.
Ft. In. In.
J119 1 9 2000
D_E_ P I I_ I DRILLING LOG
Fmm In Formation Description
0
K
0
If arlditionnl ^.pace is neaded use back
w o
LOCATION SKETCH Z
(Show direction and distance from at least two State
Roads,�,//oor�r other map reference points)
21
Size a f I T F
FL
WAS
rAC
)ANCE WIN[ ISA NCAC 2C, WELL
BEEN PROVIDED TO THE WELL OWNER.
5 Z
r
G oundwates $action sirt ATunE OF Cot ACTOR a� nGENr
Gw 1 nE Ash' le Re ional Office Submit original In Dtvinton of Erwironmvrtnt f.lanag-meet and cnpy to well owns/.
DATE

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section Ll
1636 Mall Service Center - Raleigh, N.C. 27699-1636-Phone [phone] �- ')
l
WELL CONSTRUCTION RECORD WELL CONTRACTOR: WELL CONTRACTOR CERTIFICATION: 1,e'7q
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (check Applicable BOX): Residential E( Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heal Pump Water Injection ❑ Other n If Other, List Use:
2. WELL LOCATION: (Show skelclt I the location below)
iYl�rclnlq\� Couny:{}LiIS„f�,
NearestTown:
�VvZPP� �c DRILLING LOG DEPTH
(Road Name and Numbers. Community. or Subdivision and Lot No.) -- Formation Descdp lon
a. OWNER
Address
City or town —
4. DATE DRILLED
5. TOTAL DEPTH ,
TT
6. CUTTINGS COLLECTED YES ❑ NOn _-
7. DOES WELL REPLACE EXISTING WELL? YES 0 NOnl----- C:l
8. STATIC WATER LEVEL Below Top of Casing: Fp. m
' (Use'i II Above Top of Casing) _
9. TOP OF CASING IS FT. Above Land Surface' n __
•Top of casing terminated aVor below land surface requires a variance in accor-
N
dance with I SA NCAC 2C.01 18
METHOD OF TEST
10. YIELD (gpm): 7 --A
11. WATER ZONES (depth): -_
/� 6 / e t Z--.
12. CHLORINATION: Type Amount
_.-,—��-
13. CASING:
Wall Thickness
Depth Diameter or Weight/Ft- Maled
From- In To Ft.
Front To FI.
From To Ft.
14 GROUT:
Depth
Mal/ rlal 1
Method
From 4 To ,1rJ
PI.
��
� .�4;C�C
--,%P✓Iti-.
From To
Ft.
15. SCREEN:
Depth
Diameter
Slot Size
Material
From _To _ Ft
_
in. _
In.
From __ To — Ff.
—
in. —_
In.
From __ To _ Ft.
_
In- _
In.
16. SANDIGRAVEL PACK:
Depth
Slze
Material
From To —FL
-
From To
Fl.
N
If additional space Is needed use back of lon-Lin
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
13
17. REMAKNZI:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C. WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER y G/
�- ���'� -J5
FOR OFFICE USE ONLY TURF u� DATE
FOR
SIGNATURE OF PERSON CONSTRUCTIMU THE WELL
Quad Submit original to Division of Water Quality, Groundwater Section within 30 days GW I REV. 12I99
Serial No.