Well Construction Records Polk 1 CY2000

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section 14 r
1636 Mail Service Center - Raleigh, N.C. 27699.1636-Phone (919) 733-=1 J
WELL CONSTRUCTION RECORD WELL CONTRACTOR: �a - e5 1� • (� ntny w
WELL CONTRACTOR CERTIFICATION
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: Show skgtch of the location below) I�
Nearest Town: C LL6 County: o
1A)bI fe Oak M+h.
(Road Name anrd�Numbam,'(C�ormunity., f Subdivision and Lot No.)
DRILLING LOG DEPTH
3.
OWNER
From To Fo tlo
Dascnption
Address
3 D
ree or outs o.
s)a rtaV&
A ra 5 C.
City or Town State Zip Code
4.
DATE DRILLED 1s-I3-Oo
^
5.
TOTALDEPTH 905'
o
6.
CUTTINGS COLLECTED YES E] NO® /
c'
7.
DOES WELL REPLACE EXISTING WELL? YES EZ NOF-]
m
orn
8.
STATIC WATER LEVEL Below To of Casing: o FT.
P 9� r�o
9.
(Use'+' If Above Top of Casing)
TOP OF CASING IS � FT. Above Land Surface-
Ql
'Top
of Casing terminated atior below land surface requires a variance In accor-
^� i
dance with 15A NCAC 2C .0118 n
10.
YIELD (gpm): METHOD OF TESTA; I Y
ry
ma
11.
WATER ZONES (depth):
•i
0
12.
CHLORINATION: Type Amount I CILP—
It additional space is needed use back of form
13
CASING'
LOCATION SKETC
Wall Thickness
_ , u�
Depth
30
tar or Welght(Ft. Material
(Show direction and distance fro
least two Stale
Fromy
To
Ft.�L—
Roads, or o4epol,,Ls)
From
To
Ft.
From
To
Ft.
14.
GROUT:
Depth Mterial I M t_ p hodt
V YI2A P_ 21r
From
To
Ft. en
From
To
FL
15.
SCREEN:
Depth
Diameter SlotSize Material
From _To
Ft_ In. _InFrom
_To
Ft._ In. _in.
From
To
Ft._ in. _ in16.
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 O THIS RECORD HAS BEEN PROVIDED T THE WEIR. OWNER./
FOR OFFICE USE ONLY �Q/fV(lL 1 �1,0 !0 —d
Quad No: SI ATURE OF PERSON CONSTRUCTING fH9 DATE
Submit original to Division of Water Quality. Groundwater Section within 30 days
Serial No. GW-1 flEV. 12J99

North Carolina - Department of Environment and Natural Resources - Division of Water Quality- Groundwater Section ti 4 .l 1.
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone] p
WELL CONSTRUCTION RECORD WELL CONTRACTOR:—7�t—V(es— IXl, (any r.TY.
WELL CONTRACTOR CERTIF AIC TION #:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential © Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other 0 If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: Sa jk 3a.. Cc
(Road Name
3. OWNER _
Address
2aY
&e - KIXbtau
or Subdivision and Lot No.)
PC
City or Town �l State ap D009
4. DATE DRILLED ja- is-0
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES Q NO®
7. DOES WELL REPLACE EXISTING WELL? YES M NOF-1
8, STATIC WATER LEVEL Below Top of Casing: i -�_ FT.
(Use'i 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 .Ott8
10. YIELD (gpm): 4_ METHOD OF TEST A I Y
11. WATER ZONES (depth):
12. CHLORINATION: Type Amount CLAP
13: CASING:
Agricultural ❑ Monitoring ❑
DRILLING LOG DEPTH
From To Formaiton Description
O io qmLld 0irt
10 705 York
t7
_
o
ci _7
r�
c>
If additional space is needed use back of fora-
o
LOCATION SKETCH
Depth
Wall Thickness
Diameter or Welght/Ft. Mai at
(Show direction and distance from at least two State
From To 3D Ft.
-Lyd 1- _ - --L=
Roads, or other map reference points)
From To Ft.
�U`Ue
From To Ft.
_ --- _--
14. GROUT:
_-----�—_
Depth
Material } elho
I
From —n To 20 Ft.
nee'} Gelylenl
a�
_
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft
In. —in.—
From To _ Ft.
_ In. — In.
%' P
From _ To _ Ft.
_ in. _ in.
16. SAND/GRAVEL PACK:
Depth
Size Material
I
From To —Ft.
—
(� F
From To Ft.
17. REMARKS:
_
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY O THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USEAN)<Y,_
Quad No: "` % SIG TURE OF PERSON CONSTRUCTING T WE DATE
Submit original t Division of Weber Duality, Groundwater Seaton within 30 days
Serial No. jGW4 REV. 72/99
11

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section 7' • 1 1 ��,.
1536 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELLCONTRACTOR, Imes l w. �(wlrA T.
WELL CONTRACTOR CERTIFICATION C 13$
STATE WELL CONSTRUCTION PERMITC
1. WELL USE (Check applicable Box): Residential E Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: SShPw skr�tch of the location below)
Nearest Town: i o Putm{:1 ct5 County: P6 I k
or Subdivision and Lot No.)
3. OWNER
Address
City dr Town Stale Zip Code
4. DATEDRILLED 1)
5. TOTAL DEPTH ;I 4
6. CUTTINGS COLLECTED YES ❑ NO®
7. DOES WELL REPLACE EXISTING WELL? YES Q NO[Z
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 caiing terminated atlor below land surface requires a variance In accor-
dance with 15A NCAC 2C ,0118
10. YIELD (gpm):_ METHOD OF TEST 1 y
11. WATER ZONES (depth):
12. CHLORINATION: Type 10JAALd Y Amount Icy
13. CASING:
Wall Thickness
Depth Diisml Iller or Welght/Ft. atonal
FromTo20 Ft. —('r4 '52�a1- �C
From To Ft.
From To Ft.
14. GROUT:
Depth aterial eth d
From �' To 2z o Ft. A Ce r
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From —To—Ft— in. _ In.
From To — Ft. In. — In.
From _ To _ Ft. in. _ in.
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
DRILLING LOG DEPTH
From To Fonnatlon Oescription
h 70 )Avl
7o P,46— (.0I!6o ' E c
It additional space is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
I �,,r
I
I'
, f
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 BE N PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Quad No: „:<:.-. SIG TORE OF PERSON CONSTRUCTI G T WELL DATE
Submltoriginal l ivislon of Water Quality, Groundwater Secton within 30 days
Serial No. ' " - -- GW-1 REV. 122199

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699.1636-Phone [phone] t. 4 _l. O J
WELL CONSTRUCTION RECORD WELLCONTRACTOR: Jrtmes 0 CA I-lIF2
WELL CONTRACTOR CERTIFICATION #: 9 138
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential LVJ Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other If Other, List Use:
2. WELL LOCATION:(
OCATION::(ho etch oNe location below
ONearestTown: Co
(Road NamejInd'tlomda Conanuniry, or 1�ub ivision and Lot
3. OWNER ,tea aylle L1a R
Address Q-I-. 0
�R444 ' f- Ci,ll ii•7
" nvy,L " D J lt
City or Town 119llaate Zip Code
4. DATE DRILLED / `Za !C'
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES NOO
7. DOES WELL REPLACE EXISTING WELL? YES Q 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 at/or below land aurfaos requires a variance In accor-
dance with 15A NCAC 2C.0118 //11
10. YIELD (gpm): �Fi I _ METHOD OF TEST y
11. WATER ZONES (depth):
12. CHLORINATION: Type -Ya r Amount—LLL --
13.-CASING:
Wall Thickness
Depth Diameter or Walght/R. Material
From D To SIG, Ft. 6 /4 5 D 11 iP J G
From To Ft.
From To Ft.
14. GROUT:
DRILLING LOG DEPTH
From To Formation Description
0
90
0
t_
!M
T>tJ
N
.e
—z
cn
It additional space is needed use back of form
o
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
Depth
Material Method
P( d
From O
To 2°
Ft.
rat e l A�i
From
To
Ft.
15. SCREEN:
Depth
Diameter
Slot Size Material
From —To—Ft—
In. _ In.
I-F14)T1
From
To
Ft.
In. —In.
From —To—Ft.—
in. —in.
16. SAND/GRAVEL PACK:
Depth
Size Material
From
From
To
Ft.
Ft.
OV
To
17. REMARKS:
_
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Quad No: - S
submit original
Serial No. -
to
/-/0_0
OF PERSON CONSTRUCYING'TkA WELL DATE
of Water Quality, Groundwater Section within 30 days
GW-1 REV. 12/99

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mall Service Center - Raleigh, N.C. 27699-1636-Phone [phone] j
'��
WELL CONSTRUCTION RECORD WELLCONTRACTOR: � mp_5 �d
WELL CONTRACTOR CERTIFICATION p: STATE WELL WELL CONSTRUCTION PERMIT)
r' . r'� 1 /Y
—'—'`�1 0 3
mn k 1 ✓.
1. WELL USE (Check Applicable Box): Residential 12, Municipal ❑ Industrial ❑ Agricultural ❑
Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show s <etch of the location below)
Nearest Town: County: �n' �<
r
ahtpr06
(Road N and Numbers, Comnunli or Subdivision and Lot No.) DRILLING LOG
DEPTH
3. OWNER �2-SSC- M11�5 From To Formation
Description
AddressII
j5 ree or Dula �O s a s
V c
/SIN Ill FT G$ 2 0 7AX
City or Town State Zip Code
4. DATE DRILLED L,.Il--on
5. TOTAL DEPTH .2 ,,5-
6. CUTTINGS COLLECTED YES ❑ NO[Xf
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO®
o
8. STATIC WATER LEVEL Below Top of Casing: qa_ FT.
O
(Usa'r' If Above Top of Casing)
9. TOP OF CASING ISFT. Above Land Surface"
m ^-
-Top of casing terminated atior below land surface require* a variance In accor-
dance with 15A NCAC 2C.0115
10. YIELD (gpm): METHOD OF TEST A; y'
11. WATER ZONES (depth):
m
12. CHLORINATION: Type aye"14Y Amount j rra
13. CASING:
Wall Thickness
Depth Diameter or Waighl/FI. Material
From To 4-5 Ft. /'�j— Svc
From To Ft.
From To Ft.
14. GROUT:
Depth Material Malho
Fromy To AL 1')Ba't' Genie 0.
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From —To—Ft— In. In.
From To Ft. _ In. —In.
From —To Ft. _ in. —in.
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
17
If additional space is needed use back of form •T m x
•� o
LOCATION SKETCH z
(Show direction and distance frgm at leas(two Sta
Roads, or other map relereri�)
C.
VU
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL I
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY — %D SDI
Ouad No: SIGNA RE OF PERSON CONSTRUCTING LL DATE
Submit original to D islon of Water Duality, Groundwater Section Wllhln 30 days
Serial No. - GW-1 REV. 12/99
i J,l
�1

North Carotins - Dsparvan nof EnvironmentNatural and Rasouicae - Division of Wader �liH - Groundwater Section r_ ; 2
1636 Mail Service Carter - Raleigh, N.C. 27699-163&Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: James W. Camp, Jf.
WELL CONTRACTOR CERTIFICATION •: 2138
STATE WELL CONSTRUCTION PERMITM:
1. WELL USE (Checkapplicable eoa): Residantlal E Municipal ❑ Industrial ❑ Agricultural Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other E3 If Other, List Use:
2. WELL LOCATION: (Sh w sk�(lch of the location below)
Nearest Town:. 1t1 Y1 U 4, County: O
3, OWNER
Address
and Lot µo.) DRILLING LOG
From . To
0 3C
Uly or town auto F
4. DATE DRILLED I �- 11.61)
5. TOTAL DEPTH !�nts-
6. CUTTINGS COLLECTED YES Q NO®
7. DOES WELL REPLACE EXISTING WELL? YES [] NO®
B. STATIC WATER LEVEL Below Top of Casing: �,o FT.
(Use 'r' II AOwe Top of Casing)
9. TOP OF CASING IS 1 FT. Above Land Surface'
'Top of ;axing terminated wor below Isnd surtaca r"uk" a wrionca In acow-
danu with 15A NCAC 2C ,0115
10. YIELD (gpm): r METHOD OF TEST Air
11, WATER ZONES (depth):
DEPTH
Fomwibn DascrnpLion
di✓t clams
r, vA60j dateJ YCck
T2_ CHLORINATION: Type Gr0011101 Amount It additional apace is needed use back of form ¢
13.-CASING:
Depth Diunerer
From 0 To 130 Ft. A tea
From To Ft.
From To Ft.
14. GROUT
Wall TNcicnesx LOCATION SKETCH
SDR21�t PVC (Show dlrectbn and dstanca from at least two Stale .
,toads, or other map retereMe points)71
Depth Material Method
From 0 To 20 Ft Neat cement Hand
From To Ft.
15. SCREEN:
Depth Diameter
From —To _Ft— in
From —To _ Ft._ In
From _To —Ft. — in
16. SAND/GRAVEL PACK:
Depth Size
From To FL
From To Ft.
17. REMARKS:
Slot Size Material
in.
In.
—in.
Material
0
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Owe PERSON CONSTRUCTIN THE ELL DATE
1wuar oualtty, Orcundw"( Section within 30 days
Serial No. "' GW-1 REV. 12/99
LL .r+utator $Cc11011

`222'~g
North Carolina • Department of Environnwrx and Natural Resourcue • Division of Water Quality - Groundwawr Section
1636 Mail Service Center - Raleigh, N.C. 27699-163C •Phono (919) 793 =1
WELL CONSTRUCTION RECORD WELLCONTRACTOR: James W. Camp, Jr.
WELL CONTRACTOR CERTIFICATION S: 2138
STATE WELL CONSTRUCTION PERMIT#:
,._,J
1. WELL USE (Check Applicable 6os): Residential L21 Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other If Other, list Use:
2. WELL LOCATION: Show sketch of the location below) �o
Nearest Town: ' VIP R,) County: L\
Q1I_a �C 'e ii [ZA -
(Road Nan191 an�moars^r C—omnunity. or SuUdivisim and of No.) DRILLING LOG DEPTH
3. OWNER "t )a k, s Flom TOFonr Uon Des npWn
Address (� �� c 65 0 -35 t 0.
j or Data �`i CGS So
C-
1j;(�
!1�)l�C'V5oY(Vil e -�Z802-
Gry or sown State Zp Cade
a, DATE DRILLED - 3 DO
5. TOTAL DEPTH go s
6. CUTTINGS COLLECTED YESD NO®
aE
aE
7. DOES WELL REPLACE EXISTING WELL? YES D NO® O
CD
S. STATIC WATER LEVEL Below Top of Casing: 30 FT. O
��
(Usa'✓ II Above Top of Casing) A
9. TOP OF CASING IS 1 FF. Above land Surface' —
_-
-Top of casing tarminated Wor below land surface raqulrea a variance In scow- `�—
dancewith 15A NCAC 2C 115 yilf
10. YIELD (gpm): _ 0 METHOD OF TEST
�{m
11. WATER ZONES (depth): Ga
i2- CHLORINATION: Type SranUlar Amount 1 M Q If additional space is needed use back of lance
o
13.-CASING:
Wall ThiI�ckness
Depth3�
nw iatar wel$1 * mawrial
From O
To
Ft.
bPVC
From
To
Ft.
From
To
Ft.
14. GROUT:
Depth
Material Method
From 0
To 20
Ft
Neat cement Hand
From
To
Ft.
15. SCREEN;
Depth Diameter
From _To_ Ft — In.
From —To—Ft.— In.
From `To —Ft.— in.
16. SANDIGRAVEL PACK:
Depth Size
From To Ft.
From To Ft.
17. REMARKS:
Slot Size Material
in.
_ In.
_ in.
Material
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
r
l
OF
I
I
1
I DO HEREBY CERTIFY THAT THIS W ELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY Q�THIS RECORD HA'l1S BEEN
�PROVIDED T(/7]�ITHE WELL OWNER. ^
FOR Of
Quad No:
Sadal No. 111111
Groundwater Sec'rrn
,-__Asheville RegigL3i ise .
OF PERSON CONSTRUCTING htE Wal. DATE
of water Quality. Groundwater Section within 30 days
OW-1 REV. 12/99

North Carolina - Department of Enviroa nerx and Nauu W Resource* - Division of Water Quality - Woundwawr Section r' 2281
1636 Mail Service Canw - Raleigh, N.C. 27699.1636-Phone (919) 793-=l
WELL CONSTRUCTION RECORD WELLCONTRACTOR: James Camp, Jf.
WELL CONTRACTOR CERTIFICATION a- 2138
STATE WELL CONSTRUCTION PERMIT►:
1. WELL USE (CheckAppllcable 0ex): Residantia) Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery 0 Heat Pump Water Injection ❑ Other Ej If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below) Nearest Town: Mf1l�1 yi j County: P` k
I�fi Nel�� bane �tAYYP vlFu �o m,
(Road Nance en Cam ity.,Ior baivlsion and Lot No.) DRILLING LOG
3. OWNER /rlAyt/i rle� r�YL From .To
Address 14 r1Ll�, (—� I i-pn La ne 0 Is
/r"lill SQYrri' eaaA C. a. ,%�7S10 %� 'i5
Cary br� Tof,n Stale Zip Code
A. DATE DRILLED ti - t)D
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES M NO®
7. DOES WELL REPLACE EXISTING WELL? YES Q NOM
8. STATIC WATER LEVEL Below Top of Casing: 7iL Fr.
(Use'.' It Above Top of Casino)
9. TOP OF CASING IS 1 FT, Above Land Surface'
'Top of casing terminated atior below land suds mqulrw a vation" In "oor-
dart" with 15A NCAC 2C .011 a
10. YIELD (gpm): ID METHOD OF TEST Air
11. WATER ZONES (depth):
DEPTH
Formation Dascdpiion
c
rp Sn1 . IdafeA roc
12- CHLORINATION: Type Q�rgnUlof Amount 1 C.L1i2-_ It additional space is needed use back of form
13.-CASING:
Well T1lickness LOCATION SKETCH
Depth r�11//// Diameter or We nVR. Material (Stow direction and distance from at least two State
From 0 To �— FL b lea SDR$11 PVC Roads, or other map reference points)
From To Ft. ��a'r ✓`r`
From To FL
14. GROUT
Depth Material Method
From 0 To 20 Ft. Neat cement Hand
From To Ft,
15. SCREEN:
Depth
Diameter
From
—To _F1
in.
From
_ To
Ft. _ In.
From
—To —Ft.
_ in.
16. SAND/GRAVEL
PACK -
Depth
Size
From
To
Ft.
From
To
FL
t rt
�A C
17. REMARKS: hY f ^ a
J
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 20, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE U
Ouaa No: & - L. - `'--- NATURE OF PERSON CONSTALkilt4THE WELL DATE
@ Suomi o4sh to Oivislon of Water O"Ity, Groundwarar Section within 30 days
Sari;* No. - OW-t REV. IZ64
i (` .
Slot Size Material
_ in.
In.
in.
Material

'22North Carolina - Department of Environment and Natural Resources - Division of Water Gkiality - Groundwater Section 2 r3 0
1636 Mail Service Center - Raleigh. N.C. 27699-1636Phone (919) 793-='
WELL CONSTRUCTION RECORD WELL CONTRACTOR: James W. Camp, Jr.
WELL CONTRACTOR CERTIFICATION R: 2138
STATE WELL CONSTRUCTION PERIti
1. WELL USE (Chock Appucablo box): Rezidantla) Qz� Municipal ❑ Industrial ❑ Agriculture) ❑ Monitoring ❑
Recovery 0 Heat Pump Water Injection ❑ Other El It Other, Last Use:
2. WELL LOCATION: Show s alch of the location below) f� 1
Naarest Town: _ _0 IUm�:JG5 County:.]"O
3 �5 ge c) f� x
(Road Name and Numbers. Comrtwnrty or Suoaivlsion arw Lot NO.) DRILLING LOG DEPTH
3. OWNER •h e✓ From To Fomraaon Oowrrpdon
Address J3 �d --p X 7
n ae or Data o. 10 795- NSo �l Cie e rOc
1 ojuw 114 C 'A0
City or Town State Zip Coda
4. DATE DRILLED D- OD —
5. TOTAL DEPTH �o S
6. CUTTINGS COLLECTED YESQ NO®
7. DOES WELL REPLACE EXISTING WELL? YES Q NOM
B. STATIC WATER LEVEL Below Top of Casing: 2$5Z--Fr.
(Use '✓ II Above Top of Casing)
9. TOP OF CASING IS 1 FT. Above Land Surface*
`Top of casing terminated atior below I" surlace mqukea, a varWtu In accor-
dance with 1 SA NCAC 2C .011 a
10. YIELD (gpm): 1_ METHOD OFTEST Air
11. WATER ZONES (depth):
12- CHLORINATION: Type Grant der Amount 1 It additional space is needed use back of form Z
13.-CASING:
Depth Diameter
From-0 To _9 Ft. 6 1/4
From To Ft.
From To Ft.
14. GROUT
Depth
From 0 To 20 Ft.
From To FL
15. SCREEN:
LOCATION SKETCH
well Thliinness
awr of
(Show direction and distance from at least two State
Roads, or other map reference pouts)
Material Method
Neat cement Hand
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:
",vj IT
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 PROVI ED TO THE WELL OWNER.
n..._. 71) /__... (I. )7_�,_
FOR OFFICE U=^061LY 1' f1
Quad No: 3;,i IK tL-,, i� i l i.,
Serial No.
GNATURE OF PERSON C.ONSTRUC•ntiQ #1E WELL DATE
to Division at Walar Quality, Groundwater Section within 30 days
OW-1 REV. IZ*W

North carown - Department of Environment and Natural Resources - Division of Water Ouatity - Groundwatar Section L 2 "0 27 1
1636 Mail Service Cancer - Raleipt% N.C. 27699.1636-Phona (919) 753-=1
WELL CONSTRUCTION RECORD WELL CONTRACTOR: James W. Camp, Jr.
WELL CONTRACTOR CERTIFICATION rr: 2138
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (CheckAppucabta Box): Residential LJ Municipal ❑ Industrial ❑ Agricultural 0 Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other (:) If Other, List Use:
2. WELL LOCATION: Show sketch of the location below)
Nearest Town: 8r) l 5 f Y i ✓l . County: �J
(Road Nam1
3. OWNER _
Address
Subdivision and Lot
,2OS�_
Gfy or Town � Shale up cow
A. DATE DRILLED _rz�l—C
5. TOTAL DEPTH
6, CUTTINGS COLLECTED YES Q NO®
7. DOES WELL REPLACE EXISTING WELL? YES (1NOO
8. STATIC WATER LEVEL Below Top of Casing: �O" FT.
(Use'i It Ahova Top of Casing)
9. TOP OF CASING IS 1 FT. Above Land Surface'
'Top of casing tarminated aUor Glow land surtaca requk" a variance In eccw-
dancewith 15A NCAC 2C.9419
10. YIELD (gpm): METHOD OF TEST Air
11. WATER ZONES (depth):
T2- CHLORINATION: Type
(ter n
i� Amount 1 r'11P
13.-CASING:
Wall Thici nau
Depth
Diameter or WeuFt. Material
From 0
To 9
Ft.
b4 SDR11 PVC
From
To
Ft.
From
To
Ft.
14. GROUT:
Depth
Material Method
From 0
To 20
Ft.
Neat cement Hand
From
To
FL
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
FL
From
To
FL
17. REMARKS:
DRILLING LOG
Fmn To
0 GR
DEPTH
Fo &Lion paon
yT San
(Omcbd,le d rock
If additional space is needed use back of lornr
LOCATION SKETCH
(Snow direction end ti stanoe from at least two Stale
Roads, or other map reference points)
i
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 20, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY/�F THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
d^-- _ = a��-a.•%.J-......
FOR OFFICE USE
auad W.
Submit
Sand No. ) L"I t
iWWL1
OF PERSON CONSTRUCTING TY9 WELL
of Water ouallty. Groundwater Soeson within 30 days
DATE
GW-1 REV. 1299

NoM Carolina - Da % �% n "7
partmerlt of Envitntvnarx and Natural Resources -Division of Water - Groundwater Section ll
1636 Matt Saivice Center - Raleigh. N.C. 27699-16.9SPIwna [phone] l/' fir •K^,. �v E 4- ��. ,.p 60
James W Camn Jr
WELL CONSTRUCTION RECORD WELLCONTRACTOR:
WELL CONTRACTOR CERTIFICATION a: 2138
_._, /STATE WELL. CONSTRUCTION PERMIT#:
1. WELL USE (CtwCkApplicable 6oa): Residential to Municipal ❑ IndusVW ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other C3 It Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearast Town: 0; � 1 '5.0 4. 9. County: O 1 k
(Road Nam" an
nunity, or SUbdlVWW and Lot No.)
DRILLING LOG
DEPTH
3. OWNER 1'!{ �f1 /15
From To
Formation Dosaiption
Address r D 13C K.
�q3
0 30
, J ; ri
n ) ) 7srae of
"I o. .. ,. _ _.
.30 ,�D'h
11
/tnh6n)IClntrt{ YDcI'
4. DATE DRILLED - • - 00
5. TOTAL DEPTH 0 ti
6. CUTTINGS COLLECTED YES Q NO®
7. DOES WELL REPLACE EXISTING WELL? YES M NOE]
e. STATIC WATER LEVEL Below Top of Casing: _�4 LFT.
(Uzii'i It ADow Top of Casing)
9. TOP OF CASING IS 1 FT. Above Land Surface'
'Top or eaaing Wminatad ado, below land surtaca requlrw a Varian" In aecw-
dan" with 15A NCAC 2C .g115
10. YIELD (gpm): 1"i_ METHOD OF TEST Air
11, WATER ZONES (depth):
T2-CHLORINATION: Type GranOlar Amount 1S!IGL
13.-CASING
Depth Diameter
From 0 To ;3G — Ft. 6 V4
From To Ft.
From To Ft.
14. GROUT
It additional apace is needed use back of
Wall TNcknesa LOCATION SKETCH
Mwe�t z
Ig
$DR21WC (Show directbn and disunoa from at least two Seta
Roads, or other map reference points)
Depth Material Method
From 0 To 20 Ft. Neat cement Hand
From To Ft.
15. SCREEN:
Depth Diameter
From —To F1 — 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
J
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COP OF THIS RECO,Rqq HAS BEEN PROVID 0 TO THE WELL OWNER.
FOR OFFICE USE 0(I�9 '
ONaa No: *d-
EOF PERSON CONSTR ING WELL DATE
Submit odginal , on of Water Oualrty. Groundwater Section within 30 days
Segal No. GW-1 REV. 12/99

Nona Carolina - e Canwant or igN N.C. 27 and Natural one (919) - Division of Wafer Quality - Grourdwawr Sewion 1- 0647
1636 Mil Service Ceruar - Ralaipn, N.C. 27699-1636Pt»ne [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: James W. Camp, Jr.
WELL CONTRACTOR CERTIFICATION A: 2138
STATE WELL CONSTRUCTION PERMIT#.-
1. WELL USE (ChackAppdcabla Box): ResidantaJo Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recover
y ❑ Heat Pump Water Injection ❑ Other Fj If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: }�nY\ County: 02 �^
tn?V 1
(road N" an Nun Comnwtity. or Buooivlsion and Lot No.) DRILLING LOG DEPTH
3. OWNER I.� From To Fo�^'+Oescriprion
Addressi'rj C r ee K Dy 0 r7-4 ctnd a
C' CTll Sc tct teaw Z- o 1i D %4 51, S _ con5n I a.e Y�ck
Gty or Town State Zip Code
4, DATE DRILLED IG L I12 _ac _
5. TOTAL DEPTH S o
6, CUTTINGS COLLECTED YES Q NO® u
7. DOES WELL REPLACE EXISTING WELL? YES Q NO® -
8. STATIC WATER LEVEL Below Top of Casing: 15r;- _ FT. `--
(Use'i It Above Top or Casing) _ --
9. TOP OF CASING IS 1 FT. Above Land Surface' u1
-Top of casing 1arrNnatod Wor below, I" sedate regWree a war"" In acoor- -
danca with 15A NCAC 2C Al1a-
10. YIELD (gpm): 10 METHOD OF TEST Alf -
11. WATER ZONES (depth): -
12. CHLORINATION: Type %rarltllar Amount s r'1 RL It additional apace is needed use back of form
13.- CASING:
Wall Thlk�kness
LOCATION SKETCH
Depth
Diameter Wa$hL'FL Material
(Show direction and distarlce from at least two State
From 0
To �
Ft.
6 rya 2
Roads, or other map reference points)
From
To
Ft.
From
To
Ft.
14. GROUT:
Depth
Material Method
From U
To 20
Ft,
Neat cement Hand
(
y
From
To
Ft,
I
15. SCREEN:
-IF,J�wt
Depth
From To
From —To —
From To
16. SAND/GRAVEL PACK
Depth
From To
From To_
17. REMARKS:
Diameter Slot Size Material
FI in. —in.
Ft. In. —In.
Ft._ in. —in.
Ft.
Ft.
Size Material
u cJ�'""
N
IIwJ3
NQ-1� \-\tom
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN
/PROVIDED TO THE WELL OWNER.
FOR OFFICE US — L�4 COY I b -L
Quad No:y`NA PERSON CONSTRUCTING THE WE DATE
t islon 1 water Quality, Grourdwalar Soction within 3 days
Serial No. a GW-t REV. 12/99

North Carolina - Department of Environment and Natural Resources - Division of Water Quality. Groundwater Section C_ .r7' 1 1636 Mail Service Career - Raleigh, N.C. 27699.1636-Pnone [phone] 0
WELL CONSTRUCTION RECORD WELL CONTRACTOR: James W. Camp, Jr.
WELL CONTRACTOR CERTIFICATION *: 2138
STATE WELL CONSTRUCTION PERMIT*:
1. WELL USE (CneokAppkuble Box): Residential ❑ Municipal ❑ Ind"trial ❑ Aqriwltural Monitoring ❑
Recovery E] Heat Pump Water Injection ❑ Other It Other, List Use: _ /"]/I it rC
2. WELL LOCATION: Show sketch of the location below)
Nearest Town: Nlr)1 -Sort r141 County: �o
Cr
2 Cr 15
(Roan and tMunbers, ity, or Suodivision and Lot No. DRILLING LOG DEPTH
3. OWNER �S t' 7. 1 a. From To rmaton Descdprlon
Address f7 n CCO t?r>�a C�l. 0 IDS d
M;1I Sar"hd reedy ON NO.)
Q7�� ,os 4Dr
Ury or I own J 5tale Zip Coda
4. DATE DRILLED D
5. TOTAL DEPTH D.
6. CUTTINGS COLLECTED YES 0 NO®
7. DOES WELL REPLACE EXISTING WELL? YES 21 NOF__j
6. STATIC WATER LEVEL Below Top of Casing: 65- Fr.
(Use '✓ it Above Top of Casing)
9. TOP OF CASING IS 1 FT. Above Land Surface*
'Top of casing twfwnated War below land surtau requkea a varlwwe In accor-
dancs with 15A NCAC 2C .alla
10. YIELD (gpm): I D METHOD OF TEST Pit
11. WATER ZONES (depth):
T2: CHLORINATION: Type rr(lnitlnr Amount 1 rt10_
13. - CASING:
It additional space is needed use back of bra
Walt Thickness LOCATION SKETCH
Depth Own4wr or wettggnI/Ft. Material (Show direction and distance from at least two State
From 0 To I a h Ft, 6 'A SDR"Ll PVC Roads, or other map reference points)
From To Ft.
From To Ft,
14, GROUT: 9 . M t .-l-t- Q
Depth
Material
Method
From 0
To 20
Ft,
Neat cement
Hand
From
To
Ft.
15. SCREEN:
Depth
Diameter
Slot Size
Material
From _
To _
Ft _
in. —in,—
From _
To
Ft.
In. _
In.
From _
To
Ft. _
in. ^
in.
16. SAND/GRAVEL PACK
Depth
Size
Material
From
To
Ft.
From
To
FL
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED 0 THE WELL OWNER.
FOR OFFICE USE ONLY (i / I
Ouad No: GNATURE OF PERSON CONSTRUCTIN6 TkE&kLL DATE
Sara No. Submit dd" gto Division at Water Quality, Groundwater Section within 30 days
GW1 REV. 1299

I
North _
NoCarol- Dapefunent of Environmeru and Natural Resourcwr - Division of Water OuaGty - Groundwawr Section L' (� v 8
16W Mail Service Cancer - Raleigh, N.C- 27699-1636Ptwne (919) 733-=1
WELL CONSTRUCTION RECORD WELL CONTRACTOR: James W. Camp, Jr.
WELL CONTRACTOR CERTIFICATION at: 2138
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (catackAppucaaa Box): ResidanUal E;� Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water InjeCUon ❑ Other 0 If Other, List Use:
2. WELL LOCATION •h( ho sketch of the location below)
Nearest Town: I* t �T �P Y I yl H County: K
Col I ns'/r Ile Rj. off -* I
(Rued Name art tbera. C nanny, or Suoomwon and Lot No.) DRILLING LOG DEPTH
3. OWNER \�Ln1 C From To For'"�tintO -"ipwn
cl 0 L Ict o[_
City or Town Stale �P
4, DATE DRILLED
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: qc;- FT.
(uu ,* It Above Top of Caring)
9. TOP OF CASING IS 1 FT. Above Land Surface*
Top of caalne larminated atlor allow Land 41rr1a00 raquk" a vuianca In accw-
dana wim 15A NCAC 2C .e110 Alf
1 G. YIELD (gpm): _ (o METHOD OF TEST
11. WATER ZONES (depth):
12.CHLORINATION: Type Granular Amount I QQ
13.-CASING:
Wall Tluc nzu
Depth Diameter wale IVFI. Material
From U To 160 Ft. 6'A SDRp21 PVC
From To Ft.
From To Ft.
14, GROUT:
Depth Material Method
From U To 20 Ft. Neat Cement Hand
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.
1 S. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To FL
17. REMARKS:
CD
tv
If additional space is needed use back of form r
LOCATION SKETCH
(Show direction" dletence from at least two State
R , or other map relererae points)
tT !,
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF S RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE 0 I D b C
Quay N, ' RE OF PERSON CONSTRUCTING THEALL' DATE
Submit Original "on of watar Quality, Grcundwalar Section within 30 bays
Sarini No. II ; ! GW-1 REV. 12r99

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-16W-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: -� '_�L ✓VLF S Ltd. 1�( rnn T.
WELL CONTRACTOR CERTIFICATION #-. oZ 3
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (check applicable Boa): Residential LI Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Infection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION- (Show sketch of the location below)
Nearest Town: �' I IA 1'✓I A iA S County:
(Road Name antl ^Numbers, Communi of Subtlivision and Lot No.) DRILLING LOG
3. OWNER fl )herf 11, AX From To
Address 4
(Mraet 9r HOUle o. �i i 395
4. DATE DRILLED -q -on
5. TOTAL DEPTH 219
6. CUTTINGS COLLECTED YESQ NO®
7. DOES WELL REPLACE EXISTING WELL? YES CE/ NOr__J
8. STATIC WATER LEVEL Below Top of Casing: �a FT.
(Usa'+' If Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface'
'Tap of casing terminated allor below land surface requires a variance In accor-
dance with 15A NCAC 2C .011a
10. YIELD (gpm): 6METHOD OF TEST e I ✓
11. WATER ZONES (depth):
DEPTH
Formation Description
art
n r).
12. CHLORINATION: Type ,�.%1 n u a r Amount-1 .5U_ It additional space is needed use back of form
13.-CASING: �J
Wall Thickness
Depth Diameter or Welght/R. Material
From To � Ft. ' 4 2 Lf L
From To Ft.
From To Ft.
14. GROUT:
c7 "
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
I San�y 5�5- Rci.
Depth Material Method
From To ,2(G Ft. Ileac 4cwetJ X
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
/7 vv 7,J\
PC0. R; d
Greert�t�e�
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 CUN'lV.,tLyv a-Yvt,4 / 0
Quad No: SIGNATURE OF PERSON CONSTRU ING THE WELL DATE
Submit original to Division of Water Quality. Groundwater Secton within 30 days
Serial No. GW-1 REV. 12/99
Gree n Pr de y
�lanikl,�i1

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section 1r
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone] : i 925 15
WELL CONSTRUCTION RECORD WELLCONTRACTOR: - Sa mes Cam Ty",
WELL CONTRACTOR CERTIFICATION M
STATE WELL CONSTRUCTION PERMITC
1. WELL USE (check Appucabla Box): Residential Ep Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other If Other, List Use:
2. WELL
Nearest
(Road Name
3. OWNER _
Address
of the location below) County: f D I k
4. DATE DRILLED ') - - u
5. TOTAL DEPTH .�4 r6_
6. CUTTINGS COLLECTED YESQ NO XQ
7. DOES WELL REPLACE EXISTING WELL? YES NO©
8. STATIC WATER LEVEL Below Top of Casing: _ iTT FT.
(Use'+' If Abovs Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface -
'Top of "sing terminated at/or below land surface requires a variance In accor-
dance with 15A NCAC 2C .aW9
10. YIELD (gpm): 15 METHOD OF TEST 6 iy'
11. WATER ZONES (depth):
DRILLING LOG
From To
D 70
7 .2,ty
Agricultural ❑ Monitoring ❑
DEPTH
Formation Description
(dirt rzr_k
I cciliCual1
f(l r,)e:k
ce I W _
12. CHLORINATION: Type i Ltt a y Amount It additional space is needed use back of form
13.-CASING:
Wall Thickness
Depth
%0
Diameter or Weight/Ft. Material
From
To
Ft.
�'5�- -I
From
To
Fl.
From
To
Ft.
14. GROUT:
Depth
Material -1 elho
From 0
To �U
Ft.
d eat r' Prnea t 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:
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points) ) -v La k( kt,e r e
'�ta lllllu rH nt
Hot q N
Mc Cur rth
-k Mill 5()9
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY F THIS RECORD, HAS BEEN PROVIDED TO THE WELL OWNER,
FOR OFFICE USE ONLY `lx� "' CA0
Quad No: �IGNATURE OF PERSON CONSTRUCTI G T WELL DATE
Submit original to Division of Water Quallty, Groundwater Section Within 30 days
Serial No, I GW-t REV. 12/99

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section 217687
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone] II n/I
WELL CONSTRUCTION RECORD WELL CONTRACTOR: )AWC5 W (Liln4 �w•
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: h� v u n i i
2. WELL LOCATION• h w etch ofYl the location below) n
Neares(Town: I�� ✓ f �. County: d
(Road Name and Numbers, Community, or Subdvision
3. OWNER JT MA i'i�l_
Address P D P,ox t4 I ��
lamer or Hours No.)
SaartanbK4 -, L '7 oS
City or Town i State Zip Code
4. DATE DRILLED q-AV 190
5. TOTAL DEPTH 30.5
6. CUTTINGS COLLECTED YES Q NO®
7. DOES WELL REPLACE EXISTING WELL? YESED NO®
8. STATIC WATER LEVEL Below Top of Casing: FT.
(Use': It Above Top of Casing)
9. TOP OF CASING IS FT, Above Land Surface'
'Top of casing terminated atior below land surface requires a variance In accor-
dance with 15A NCAC 2C .0119
10. YIELD (gpm): _*C-5 METHOD OF TEST /mot l r
11. WATER ZONES fdeoth):
12. CHLORINATION: Type PFifP�Amount 1"p
13. CASING:
DRILLING LOG DEPTH
From To Formation Description
,9 as, dirt 5.14
2R 31)S Cm5yl;dotod roc
0
cn _
rTl
"
uT
-
~r
iV
171)
If additional space is needed use back of form
Wall Thickness LOCATION SKETCH
Depth Diameter or WeighuFt. Material (Show direction and distance from at least two State
From e) To 2V Ft. &A 5i)p .1-1 y Roads, or other map reference points) _.
From To Ft.
From To Ft. :X
14. GROUT:
Depth
Material
Metho
From 0 To 2DFt.
neai CeKeA
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
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY - )r
Quad No: SI ATURE OF PERSON CONSTRU ING E WELL DATE
Submit odgina o Division of Water Quality, Groundwater Section Within 30 days
Serial No. GW-1 REV. 121"
F2p

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section 217688
1636 Mail Service Center - Raleigh, N.C. 27699.1636-Phone (919) 733,1221
WELL CONSTRUCTION RECORD WELL CONTRACTOR: �a wtes W l ii T_
WELL CONTRACTOR CERTIFICATION C 02 1 3
STATE WELL CONSTRUCTION PERMITC
1.
WELL USE (Check Applicable Box): Residential ❑ Municipal ❑
Industrial ❑ Rgncultural Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other 0
If Other, List Use: / •� ,r r} r
2.
WELL LOCATION: Show ketch of the location below)
Nearest Town: County:
�� IK
L�aCe ae1`
(Road Name anddNNumb , Community, or bdivision and Lot No.)
DRILLING LOG DEPTH
3.
�1
OWNER 11 W1 Sm V F1550 C_.
From To Formation DesS5nption
Address p �ioX ���5
D 3D if'� 5ctvI
(Street or outs 0.)'fi
�pata��uyg
o `f 5 5u r d a e oc
S,C_. 29305
iry orrTown State Zip Code
4.
DATE DRILLED A-BO-
5.
TOTAL DEPTH
a
6.
CUTTINGS COLLECTED YESQ NO®
7.
DOES WELL REPLACE EXISTING WELL? YES NOQ
�o
8.
STATIC WATER LEVEL Below Top of Casing: 47o FT.
ro _ -
- (Use'+' If Above Top of Casing)
9.
TOP OF CASING IS�_ FT. Above Land Surface*
4op of using terminated at/or below land surface requires a variance In accor-
dance with 15A NCAC 2C .0118-
10.
YIELD (gpm): -In METHOD OF TEST air
N cr
11.
WATER ZONES (depth):
12.
CHLORINATION: Type sa ✓ r�Ixmount Gr'r
If additional space is needed use back of form
13.
CASING:
LOCATION SKETCH
Wall Thickness
Depth Di star or Weight/R. Material
(Slow direction and distance from at least two State
From Q To -�Q)— Ft. - -�-�- P✓L
Roads, or other map reference points)
From To Fl.
From To Ft.
_
14.
GROUT:
Depth Material Method
0_ 20 nl
i
From To Ft. Lle-feewte
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.
1
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 OFTHIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY 'o D
Quid No: NATURE OF PERSON COAST 9OCTING THE WELL DATE
Submit orgl I to Division of water Quality, Groundwater Sectlon within 30 days
Serial No. I
GW1 REV. 12199
,'rlrr,ir

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section 217689
1636 Mail Service Center - Raleigh, N.C. 27699-1636rPhone (919) 733-=1
WELL CONSTRUCTION RECORD WELL CONTRACTOR: aom i! 5 �) - (law
WELL CONTRACTOR CER (CATION #:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential ❑ Municipal ❑ Industrial ❑ �gdcultvral ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use: , >s• ++-
2.
WELL LOCATION::}(�ghow sketch of the location below)
Neares% Town: r" I l/ S4 ✓r V, e County:
iVO&L
Park La e hj} c✓
(Road Name and Numbers. omn'wlnity, or 8qVb ision and Lot No.)
DRILLING LOG DEPTH
3.
OWNER J m Smi+i I r155oL
From To Formation Description
Address P af)4 J);x
�jSr
0 a0 ,
�inarlaK
or outs o.
baQ S G a`13o�
A0 ' D o o ro c
iryor Town i Slate Zip Cade
4,
DATE DRILLED �' - O
5.
TOTAL DEPTH tlo�
O
6.
CUTTINGS COLLECTED YESQ NO®
_
7.
DOES WELL REPLACE EXISTING WELL? YES Q NO©
S.
STATIC WATER LEVEL Below Top of Casing: /,p FT.
m --
9.
(Use'i 11 Above Top of Casing)
TOP OF CASING ISFT. Above Land Surface"
_ --
-Top of casing terminated atlor below land surface requires a variance In accor-
dance
with l SA NCAC 2C.0118 1
10.
YIELD (gpm): ' 0 _ METHOD OF TEST al r
,.. �.
11.
WATER ZONES (depth):
--
N —�
12.
CHLORINATION: Type n )f—Amount
If additional space is needed use back of form =
13. CASING:
Wall Thickness LOCATION SKETCH
Depth Diameter or weighl,(R. Material (Show direction and distance from at least two. State
FromTo 12-0— Ft. 16 A— SDR.zI P Vc- Roads, or other map reference points)
From To Ft.
i
i
From To Ft.
14. GROUT:
Depth Material Method
From 0 To ,0 Ft. � a fn }� a at
From To Ft.
15. SCREEN:
Depth Diameter
From _To_ Ft _ In.
From — To — Ft. _ In.
From —To —Ft. _ in.
16. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To Ft.
17. REMARKS:
Slot Size Material
In.
_ In.
in.
Material
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY J OD
Quad No: SIG TURE OF PERSON NSTRUdTIE WELL DATE
Submit original to Division of Water Quality, Groundwater Section Within 30 days Serial No. ��ga� GW-1 REV. 12/99
'*rl 12 V
�)i
x

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section 17 69 0
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone] ` LI
WELL CONSTRUCTION RECORD WELL CONTRACTOR: ��1NP5 �. t T.
WELL CONTRACTOR CERTIFICATION #: '. 13—
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: %n rn a rr`�•/
2. WELL LOCATION:-(ghow sketch of the location below)
Nearest Town: MLl
County: r D
1 N
1
(Roatl Name and Numbers,Community, or
division and Lot No.)
DRILLING LOG DEPTH
3.
OWNER S
oG
From To Formation Description
Address i) Box 41
O 30 diYt Vac
y-1=--sGee or ut os o.
;fp �DS' Sa a d Yac
STAY IartVl �rg 6 C- a936
City or Town J Stale Zip Code
CD —
4.
DATE DRILLED a -A9 -0�
y
cn "-
5.
TOTAL DEPTH 40.h
6.
CUTTINGS COLLECTED YES Q NO®
7.
DOES WELL REPLACE EXISTING WELL? YES Q NO®
8.
STATIC WATER LEVEL Below Top of Casing: (rip FT.
(Use's if Above Top of Casing)
9.
TOP OF CASING ISFT, Above Land Surface'
-Top of casing terminated at/or below land surface requires a variance In accor-
dance with 15A NCAC 2C .0118
—�
10.
YIELD (gpm): 30 METHOD OF TEST a' ✓
—
11.
WATER ZONES (depth):
12.
CHLORINATION: Type � r, ) ount GU
It additional space is needed use back of form
13.
CASING:
LOCATION SKETCH
Wall Thickness
Depth Di ter or Waight/Ft. Mate
(Show direction and distance from at least two State
From 0 To 30 Ft — R al
Roads, or other map reference points).,.-
From To Ft.
.--_"
'
From To Ft.
14.
GROUT:
Depth Material Metho
From _L_ To -20 Ft. NleahZtIneKt
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. _) r✓
From To Ft.
17. REMARKS: f
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY C DL
Quad No: SI TURE OF PERSON CONSTRUCTI G T WELL DATE
Submit anginal t ivislo. of Water Ouality, G ourtdwator Section within 30 days
Serial No. GW-1 REV. 12r99

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section ti ) 7 6 9 t
1636 Mail Service Center - Raleigh, N.C. 27699.1636-Phone (919) 733-=l 1 ! U J J-
WELL CONSTRUCTION RECORD WELLCONTRACTOR: 6 YVIC 3 �ma '
WELL CONTRACTOR CERTIFICATION #: _
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable aox): Residential ❑ Municipal ❑ Industrial ❑ Agricultural P Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other © If Other, List Use: it ; r ;, r:.r
2. WELL LOCATIONIpw etrrh of the location below) ('�o I (`
Nearest Town: l.�,�✓IVIC(_ _ County: ii
(Road Name antl Numbers, Cammun�itry, or�SLubdi/Xyi ' n and Lot No.) DRILLING LOG DEPTH
3. OWNER —�yv� YV11 I Y\ V i I S SDC From To Formation De,yption
Address P CC BoX 4 1 �S 0 & CI"V Sand
5 � (5 me or outs o. �S r a 0') So o C
au cyi lt.tYq :i C OS
City or Town J State up �.we
4. DATE DRILLED
5. TOTAL DEPTH_
6. CUTTINGS COLLECTED YES M NO®
7. DOES WELL REPLACE EXISTING WELL? YES Q NOUD
8. STATIC WATER LEVEL Below Top of Casing: Ff.
(Use'+- It Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface*
Top of "sing terminated at/or below land surface requires a variance In accor-
dance with 15A NCAC 2C .otte
10. YIELD (gpm): A';-_ METHOD OFTEST al ✓
11, WATER ZONES (depth):
C7
G?
v
-n
---------------
12. CHLORINATION: Type i5 o JeA rarttiknount If additional space is needed use back of form
13. CASING:
Wail Thickness
Depth Diameter or WelghVFt. Material
From 0 To 120 Ft. G Y4 ` —A '� L
From To Ft.
From To Ft.
14. GROUT:
Depth Material 1Methgd
From To - 2-0— FI.From To Ft.
15. SCREEN:
LOCATION SKETCH
(Stow direction and distance from at least two State
Roads, or other map reference points)
Depth
Diameter Slot Size
Material
From _ To _
Ft _ In. —in
From _ To _
Ft..— In. —
In.
From _ To _
Ft. _ in. _
in.
16. SAND/GRAVEL PACK:
C A)" _
Depth
Size
Material
From To
Ft.
From To
Ft.
�- -- --log
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�B�EpENN PROVIDED TO THE WELL OWNER.
`-�I
FOR OFFICE USE ONLY AYN�d- r v '/ !I 42 q
Quad No: S16hATUFIE OF PERSON CONSTRU TING E WELL DATE
Submit original to Division of Water Quality, Groundwater Section within 30 days
Serial No. GW-1 REV. 12/99
SAP 2.0

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section 17 69
9 3
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Plane [phone] (! J
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION
_ STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential Ltd Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other M If Other, List Use:
2. WELL LOCATION: rS7 ho sl etch of the location below)
Nearest Town:'1 /1"i/I' I r Z it rt a County: .
SCEl1rI 0aRg
(Roatl— Nameshiot N mbers. Community, or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER ,,��I( II 50. I From To Formation Description
Address S /rIP0..Llc 1 -✓es� �rl • ) 63 al
- (SST N oats o. g �. / 3 _3l0 5 _ r25o1 rd a e
✓ �o n
ty or Town Slate Zip Code
4. DATE DRILLED g'a _00
5. TOTAL DEPTH 31 6
6. CUTTINGS COLLECTED YES NOEA
7. DOES WELL REPLACE EXISTING WELL? YES F__J NO®
8. STATIC WATER LEVEL Below Top of Casing: '70_ FT.
(Use'+' If Above Top of Casing)
9. TOP OF CASING IS f—_ FT. Above Land Surface`
Top of using terminated at/or below land surface requires a variance In accor-
dance with 15A NCAC 2C.0118
10. YIELD (gpm): '�_Cl METHOD OF TEST a i ✓
11. WATER ZONES (depth):
12. CHLORINATION:
13. CASING:
Type e e 5 Amount Ga If additional space is needed use back of forrrF o
Wall Thickness
Depth D,ia gter "Weight/R. Material
From To Ft. �Y4 15092-1 P C=
From To Ft.
From To Ft.
14. GROUT:
Depth Material �- Metho(i
From To 2-0 Ft. �7ea'F CeytieKl d
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From _ To _ Ft _ In. _ In.
From —To —Ft. _ In. —in.
From —To —Ft. _ in.
16. SAND/GRAVEL PACK:
- Depth Size
From To Ft.
From To Ft.
17
in.
Material
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
i
r
6;;
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY s"60
Quad No: SIG URE OF PERSON CONSTRUCT G THE WELL DATE
Submit odginal to ivislon of Water Quality, Groundwater Section within 30 days Serial No. GW-1 REV. 12199
.X
t

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section t_ _t / 6 4
1636 Mail Service Center - Raleigh, N.C. 27699.1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: TriteS W. �GL6HTd ✓,
WELL CONTRACTOR CERTIFICATION p: 1 ��
STATE WELL CONSTRUCTION PERMITN:
1. WELL USE (Check applicable eox): Residential WJ Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: /(�S�jhow sketch of the location below) Po
Nearest Town: r r l__,.__f+�) ri KC( County:
or Subdivision and Lot
3. OWNER
Address
4. DATEDRILLED 9-640
5. TOTAL DEPTH 7C 9
6. CUTTINGS COLLECTED YES Q NOM
7. DOES WELL REPLACE EXISTING WELL? YES [] NOQ
8. STATIC WATER LEVEL Below Top of Casing: _Tf _FT.
(Use's If Above Top of Casing)
9. TOP OF CASING ISFT. Above Land Surface -
'Top of casing terminated Wor below land surface requires a variance In accor-
dance with 15A NCAC 2C A 18
10. YIELD (gpm): ')0 METHOD OF TEST �I 1
11. WATER ZONES (depth):
DRILLING LOG
From To
�S GCS
DEPTH
Formation Description
Ci Y
G7
, T
--r
-7) r_:
12. CHLORINATION: Type I Pdlf_r�_Arnount Lu If additional space is needed use back of form
13.-CASING:
Wall Thickness
Depth Diameter or Weight/Ft. Material
From 0 To �— Ft. (I rA`-LPL PJc-
From To Fl.
From To Ft.
14. GROUT:
Depth Material Meld hqd
From 0 To 2,0 Ft. heat C emMt Kd
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
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
X
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER,
FOR OFFICE USE ONLY - D
Quad No: SiC#ATURE OF PERSON CONSTRU TIN HE WELL DATE
Submit original t Division of Water Quality, Groundwater ctlon within 30 days
Serial No. GW-t REV. 12/99
s=�k
`reFk
r

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section ,� .l ry O 1
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]nl /1
WELL CONSTRUCTION RECORD WELLCONTRACTOR: U4me5 1i, Ce tna Jr
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMITC
1. WELL USE (Check Applicable Boa): Residential LJ Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Infection ❑ Other [D If Other, Ust Use:
2. WELL
Nearest
(Road Name
3. OWNER _
Address
sketch of the location below)
w 41 IJ g County:
or Subdivision and
4. DATE DRILLED Q"� "��
5. TOTAL DEPTH o
6. CUTTINGS COLLECTED YES ❑ NO®
7. DOES WELL REPLACE EXISTING WELL? YES Q NO®
6. STATIC WATER LEVEL Below Top of Casing: /o q FT.
(Use'+' If Above Tap of Casing)
9. TOP OF CASING IS FT. Above Land Surface-
-Top of casing terminated atlor below land surface requires a Varian In accor-
dance with 15A NCAC 2C .Ot e
10. YIELD (gpm): METHOD OF TEST A I Y
11. WATER ZONES (depth):
DRILLING LOG DEPTH
From To Formation Desc PE on
i✓ a
C C D a e oG
r-�
cL�
Tt i
Crt
12. CHLORINATION: Type e s Amount It additional space is needed use back of form
13.•CASING:
Wall Thickness LOCATION SKETCH
DepthDiameter or Welght/FL Mal rial (Stow direction and distance from at least two State
—r�r^
From To _J Z- Ft. —AY4 51) P, -1l Roads, or other map reference points)
From To Fl.
From To Ft. I
14. GROUT:
Depth Ma erial
From Q_ To AL Ft. ea GP
From To Ft.
15. SCREEN: o Y '-------
Depth Diameter Slot Size Material From —To—Ft— In. _ In.
From —To —Ft. _ In. —In.
i
From —To Ft. _ in. —in. t
16. SANDIGRAVEL PACK: 1`
Depth Size Material 11
From To Ft. - -- V
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 qfi THIS RECORD /HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY l' o d l I / '4'4 c/) � 1A S D D
Quad No: - Sl ATURE OF PERSON CONSTRUCTI G Tiff *ELL 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] [: i D 671
WELL CONSTRUCTION RECORD WELL CONTRACTOR: a me s 10 • Ca m p d✓•
WELL CONTRACTOR CERTIFICATION N: �5t, 13 S
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable eox): Residential Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: h w vetch of the location below) ��/
Nearest Town: County:
ta'a DEPTH
(RoadNam and NT ers. COTmmuyN�ry. r Subd ision and Lot No.)DRILLING LOG
3. OWNER �.J e 55 e ,r
Y 111 YVLa Vl From To Fom,,von Description
� ��. e jas dt. YZ✓z
Address ree r cute o.� iaZ�i JrO S- Lty6vr"'jate j rDs
J t J or Taft Cwn Stale ZlP Lode
Ci o
4. DATE DRILLED
5. TOTAL DEPTH��+
6. CUTTINGS COLLECTED YESQ NO® o
7. DOES WELL REPLACE EXISTING WELL? YES NO[]
8. STATIC WATER LEVEL Below Top of Casing: FT. -
(Use Y It Above Top of Casing) A '�
9. TOP OF CASING ISFT. Above Land Surface*
-Top of casing terminated atlor below land surface requires a variance In actor- — 2
dance with 15A NCAC 2C ,0118
10. YIELD (gpm): � METHOD OF TEST a I ✓ -
11. WATER ZONES (depth):
12. CHLORINATION: Type
E Amount Cr,t If additional space is needed use back of form
-"
13. CASING: -
LOCATION SKETCH
Wall Thickness
Depth Diameter or Weight/Ft. Material (Show direction and distance from at least two State
From To j Ft. 111V4- 5 D P ;L1 p1f G Roads, or other map reference points)
r/1;�, -
From To Ft.
From To Ft.
14. GROUT:
Depth l4ateriall etho
02Ce —
From __�___ To o FL ea- eFrom To Ft. _—�
15. SCREEN:f
Depth Diameter Slot Size Material
From _ To _ Ft — in. —in.-
From _ To — Ft. — In. — In.
From —To _ Ft. _ in. — in. I
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.1=_c�`,-
From To Ft.
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 20, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN P OVIDED TO T E WELL OWNER.
FOR OFFICE USE ONLY DATE
Quad No: G SIN URE OF PERSON CONSTRUCTING TH WE
Submit original ' islon of Water Quality, Groundwater Section wit n 30 days GW 1 REV. 12/99
Serial No.
—�`
Ilk'
" t ✓:
t

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section f ) 15 Ct 70
1636 Mail Service Center - Raleigh, N,C. 27699-1636-Phone [phone] ' I
WELL CONSTRUCTION RECORD WELLCONTRACTOR: JaWe5 ✓,0- �-avvtD �7 ,
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential 44 Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other [] if Other, List Use:
2. WELL LOCATION^n::^(S
Nearest Town: �r.lL
LO Ke A d I e
(Road Name and NuRibe
3. OWNER I i m
Address �2 o A
of the location below) �Lk
G County:
or Subdivision and Lot No.)
N
4. DATEDRILLED " 0-6D
5. TOTALDEPTH 2D5
6. CUTTINGS COLLECTED YES Q NO®
7. DOES WELL REPLACE EXISTING WELL? YES Q NO®
e. STATIC WATER LEVEL Below Top of Casing: 5�L— FT.
(Use'+' II Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface*
-Top of casing terminated atior below land surface requires a variance In accor-
dance with l5ANCAC2C.011a LLf
10. YIELD (gpm): ac METHOD OF TEST
11. WATER ZONES (depth):
12. CHLORINATION: Type e s Amount
13, CASING:
DRILLING LOG
DEPTH
From To
Forma1.tion Descriptign
0 15
I ir` le -
`]Si
)DYES idcte
oc_
--------------
'm
rn
It additional space is needed use back of form
8
Wall Thickness
From 0
Depth
To ?g
Ft.
Diameter or WeighVFt. Material (Show
6,Y4 SDRAI PVc- R<
From
To
Ft.
,
From
To
Ft.
14. GROUT:
Depth
a
Material " Methgd
'a t Ce 0.w
From 0
To U
Ft.
y1 W e n
From
To
Ft.
15. SCREEN
Depth Diameter
From —To _ Ft _ In.
From _ To — Ft..— In.
From _ To _ Ft. _ in.
16. SAND/GRAVEL PACK:
Depth Size
From To Ft. —
From To Ft.
17. REMARKS:
Slot Size Material
In.
_ in.
in.
Material
1 and distance from at
other map reference i
�e
A.� ey
State
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: _ a+� (' I','�IG TYRE OF PERSON CONSTRU ING E WELL DATE
S IE'41 I vi210n of Water Oua ily, Groundwater nlon within 30 days
GW-1 REV. 12199
Serial No.

North Carolina . Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section I [-cry
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone] CL 1 15 J S
WELL CONSTRUCTION RECORD WELL CONTRACTOR: y�y�C5 W Ca
WELL CONTRACTOR CERTIFICATION #: 13�
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (check Applicable Box): Residential 2Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION:,( how s etch of the location below) n
Nearest Town:- 1i1 Pt`Q County:
(Road Name dN mhersL. Subtlivision dLot No.)
DRILLING LOG DEPTH
3.
OWNER
tCo�mmu^niry', /or
From To Formation Descnption
17
Address 69St' LeJe
e) po i4"Y C
ree o Data o.
I I O .305 o so o
Mil
59I,;N4 c ax�s�
4.
CityCity or�T Stale Zip Code
DATEDRILLED 2-2,5-5317
-
c�
`=-
5.
TOTAL DEPTH ADS
6.
CUTTINGS COLLECTED YES F-1 NOW
7.
DOES WELL REPLACE EXISTING WELL? YES [VJ NO[]
S.
STATIC WATER LEVEL Below Top of Casing: (vj)_ FT.
9.
(Use Y If Above Top of Casing)
TOP OF CASING IS, FT. Above Land Surface*
r-
f
r,o --
-Top of casing terminated atror below land surface requires a variance In accw-
dance with 15A NCAC 2C .0118
10. YIELD (gpm): AS METHOD OF TEST Ott
- -
rs iz
11.
WATER ZONES (depth):
12.
��
CHLORINATION: Type .�tJe r-1-i_Amount FS�
It additional space is needed use back of form
13.
CASING:
LOCATION SKETCH
Wall Thickness
Depth D�iaVm�ter orWeighVFt. Material
(Show direction and distance from at least two Slate
From © To 1I 0 Ft. -t2L4— "s - -
Roads, or other map reference points)
From To FL
From To Ft.
14.
GROUT:
Depth Meter al Metho
�Ina
From O To a° Ft..11PA Ix'
From To Ft.
�IaK t.kll
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 OWWjNER.7�
FOR OFFICE USE ONLY ,6( YY A d - �a �G
Quad No: ;r^^^---� .•.Tp..-....�.-.. SIG TUREOFPERSONCONSTRUCTI THEWELL DATE
t ; i;�uErjtil odginal to ivislon of Water Quality Groundwater Section within 30 days
Serial No. �_ --- ------ GW4 REV. 12/99

r; .f ((1� /� '1
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section G- 1 . 9 r' � )
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: 1_ m e5 �J- Cu m n, Jr.
WELL CONTRACTOR CERTIFICATION #: ._;� I3 S
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: ( ho sl etch of the location below) j�
Nearest Town: - e. County: / ,
�e Vre l
(Road Name and N er Community, or bdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER r l o From To Formation Description
Address I.0 t/C.1 (� d ✓t
treat cI\9r ute o.
'Jtrh�L � d %'DrtSDA a e Yec�.'
City or To&vn Stale Zip Code
4. DATE DRILLED —d0
5. TOTAL DEPTH O
6. CUTTINGS COLLECTED YES[:) NO®
7. DOES WELL REPLACE EXISTING WELL? YES [� N0r_�
8. STATIC WATER LEVEL Below Top of Casing: gz;- FT.
(Use': It Above Top of Casing)
9. TOP OF CASING IS_f.,_ FT. Above Land Surface*
'Top of casing terminated aUor below land surface requlres a variance In accor.
dance with 16A NCAC 2C .0118
10. YIELD (gpm): —L_ METHOD OF TEST Af ✓
11. WATER ZONES (depth):
12. CHLORINATION: Type �e/4e 5 Amount I C-4(0 If additional space is needed use back of form
13. CASING:
Wall Thickness
C
Depth
Diameter or Weight/R. �atpn.at
From
To
Ft.sc
.- 2f pVG-
From
To
Ft.
From
To
Ft.
14. GROUT:
Depth
Malarial Metho
From O
Tom
Ft.
He CCme {wn�
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)
CD
0
.
--J w-
CikDrgrLS
c�
z
SPJ �0 9 r��l
c
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY
�OIF�THIS RECORD �HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY �� � ;_ / `/0 4 O
Quad No: SI ATURE OF PERSON CONSTRUCTIN TNE E` LL - DATE
Submit original to Division of Water Quality, Groundwater Section within 30 days
Serial No. -,I _ GW-1 REV. 12/99

North Carolina. Department of Environment and Natural Resources - Division of Water Quality- Groundwater Section 13964
1636 Mail Service Center - Raleigh, N.C. 27699.1636-Phone (919) 73&3221
WELL CONSTRUCTION RECORD WELLCONTRACTOR: -1r r✓tes 0. Caw d 7r`
WELL CONTRACTOR CERTIFICATION C L;!, 13 —
STATE WELL CONSTRUCTION PERMITN:
1. WELL USE (Check Applicable Box): Residential 5?� Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION; (.I hoW sk8lch of �e�location below)
iy J
Nearest Town: Pt�tCc
(Road Name q'n Nu am. Community, or
3. OWNER
Address
r" or out o. _
M i l l SD r 95 G
City or Town j Stale Zip Code
4. DATE DRILLED _ DD
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑ NO®
7. DOES WELL REPLACE EXISTING WELL? YES NOQ
S. 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 at/or below land surface requires a variance In accor-
dance with 15A NCAC 2C .017
10. YIELD (gpm): METHOD OF TEST A) Y
11. WATER ZONES (depth):
12. CHLORINATION: Type l; � o e- Amount e
13. CASING:
DRILLING LOG DEPTH
From To FQnnallon Description
0 q1)
Go 3D5 P�rLsolte rack
It additional space is needed use back of form
WallTnickness LOCATION SKETCH
Depth Diameter or Weight/Ft. Material (Show direction and distance from at least two Slala
From D To Ft. 62 I1 .--P Roads, or other map reference points)
From To Ft.—
From To Ft.
14. GROUT:
Depth Material Melho
From — L2 To 20 Ft. Y\earCewlcnt }\grt
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
'r
t7
7 isCD
O
D
Spa,
z
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 20, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF IS RECORD HAS BB�EN PROVIDED TO THE WELL OWNER,
FOR OFFICE USE ONLY
Ouad No: SIGN URE OF PERS CONSTRUC ING THE WELL DATE
Submit original to ivislon of Water Quality, Groundwater Section with a'
Serial No. s' -GVf l fieKt11jL9y'

North Carolina - Department of Environment and Natural Resources - Division of Water Quality- Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELLCONTRACTOR: antes W- Cum- `1r. r
WELL CONTRACTOR CERTIFICATION N: ZIPS
STATE WELL CONSTRUCTION PERMITii:
1. WELL USE (Check Applicable Box); Residential Ud Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other M If Other, List Use:
2. WELL LOCATION: (Shpw ske5h of the location below)
" 4 Qgq(1
Nearest Town: J-11T D /19 County: r O 1 I\
41 11 CK .
(Road Name antl umbers, Comm iry, or Suodlvislon and Lot No.) DRILLING LOG DEPTH
3. OWNER _ n Y 7;� I� 1yP.e YL i From To onnatlon Description
Address D �0 ;
(Street or ule o. 170 40,�- rpKSQ.1J(AteT Ock
City or Tower Slate Zip Code
4. DATE DRILLED
5. TOTAL DEPTH D.5
6. CUTTINGS COLLECTED YES ❑ NOM
7. DOES WELL REPLACE EXISTING WELL? ''YES [:] NO®
8. STATIC WATER LEVEL Below Top of Casing: �Lj FT.
(Use'+' If Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface -
'Top of using twminated auor below land surface requires a variance In scoot -
dance with 15A NCAC 2C .0118 `
10. YIELD (gpm): 2,_ METHOD OF TEST
11. WATER ZONES (depth):
12. CHLORINATION: Type dellell Amount Gr,
13. CASING:
Wall Thickness
Depth ny ��,Oian list or welght(Ft. Material
FromTo20 Ft.� —,5PR 21 PVC -
From To Ft.
From To Ft.
14. GROUT:
Depth alanal echo
From _/ To �D Ft. ea Cervie 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:
a
o
T
n�
0
aT
cn ='
rv1 �
rV
y
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)
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OFT S RECORD HAS
/BEEN PROVIDED TO THE WELL OWNER,
FOR OFFICE USE ONLY—
Ouad No: SIGNAT RE OF PERSON CONSTRUCTING T E W DATE
Submit original to Divsion of Water Quality, Gropric rater Sacdon within 30 days
Serial No. - `__. GW-1 REV. 1PJ99

North Carolina - Department of Environment and Natural Resources - Division of Water Quality- Groundwater Section 2 n 1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone] ( r1
,
WELL CONSTRUCTION RECORD WELLCONTRACTOR: Mmes 0 � " YK yam.
WELL CONTRACTOR CERTIFICATION C
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box); Residential E/Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other M If Other, List Use:
2. WELL LOCATION :1�( ow sketch of the location below) (�l
Nearest Town: /"fj���"jcounty: ONK
(Road Name and
3. OWNER
Address
and Lot
1'fl ll JDyI nn NG 237-96
City or TAyn J State zip Code
4. DATE DRILLED G — IS —60
5. TOTAL DEPTH .36 S
6. CUTTINGS COLLECTED YES ❑ NO®
7. DOES WELL REPLACE EXISTING WELL? YES NO[�]
8. STATIC WATER LEVEL Below Top of Casing: _g FT.
ove Top of Casing)
9. TOP OF CASING IS I PT. Above Land Surface.
'Top of casing terminated Wor below land surface require* a variance In accor-
dance with 15A NCAC 2C.0118
10. YIELD (gpm): --ZQ— METHOD OF TEST a) y
11. WATER ZONES (depth):
12. CHLORINATION: Type Nllift5 Amount -uI
13, CASING:
DRILLING LOG
From To
O GD
to 0 3laS
DEPTH
Fermallon Description
rt
o
t
c�
Y /_t
os
jY v
---------------
s'7,
ri
W
r✓t __
m�
N
n
--r
`o
If additional space is needed use back of form
Wali Thickness LOCATION SKETCH
b
Depth
�'
Diameter w welghuFt. Malenal (Show direction and distance from at least two State
From
To
Ft. 6 `a'� VG Roads, or other map reference points)
From
To
Ft.
From
14. GROUT:
To
Ft.
y t �—
0
Depth
Material Melho J
From
To ay
Ft,
eafC!"t"t (a
From
To
Ft.
15. SCREEN:
Depth Diameter
From —To _ Ft _ In.
From _ To Ft. _ In.
From —To_ Ft- in.
16. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To Ft.
17. REMARKS:
Slot Size Material
_ In.
In.
in.
Material
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCAf;DANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF T IS RECOR HAS BEEN%PROVIDED TQ THE WELI.OWnNER.
E:::
ICE USE ONLYSIGNA, REDFPRON CONSTRSubmlloriginall9DIslon of Water Quality,Ground_... _.
GW-1 REV. 12/99

n .a 9r1
NorthCarolina - Departmental Environment and Natural Resources• Division of Water Quality• Groundwater Section/� 1 t� f a�
1636 Mail Service Center- Raleigh. N.O. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION Ill ?A ) j
STATE WELL CONSTRUCTION PERMITN:
1. WELL USE (Check Applicable Box); Residential LV Municipal ❑ Industrial ❑
Recovery El Heat Pump Water Injection ❑ Other If Other, LJsI Use:
Agricultural ❑ Monitoring ❑
2. WELL LOCATION: (S ,w sketch of the location below) �//� L
Nearest Town: (-� I bL YYL b i.15 County: —/ �'^
&11g1u f"'y
(Road Name and 'wR ers, Cc iry, or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER M From To Form Ion Description
Address D v 5( 5
/7 ree or out� s o. �',� 114 GOVL�D i a e c
le A r -� /7 2 7
City or Town �y State Zip Code
4, DATEDRILLED � (-Ol7
5. TOTAL DEPTH
6, CUTTINGS COLLECTED YES ❑ NO[K
7. DOES WELL REPLACE EXISTING WELL? YES [- NON
S. STATIC WATER LEVEL Below Top of Casing: 44_FT.
(Use 'i If Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface'
-Top of casing tarminated atior below land surface requires a variance In accor-
dance with l5ANCAC2C, tta
10. YIELD (gpm): 230 METHOD OF TEST GL I Y
11. WATER ZONES (depth):
12. CHLORINATION: Type Amount GtA it additional space is needed use back of form
13. CASING: pellc1l;
Wall Thickness
b
Depth
�S
Diac�n}g�Lar or WalghUFIL Maledal
62',Y—._ 50R9.) PVC
From
To
Ft.
From
To
FL
From
To
Ft.
14. GROUT:
D
Dept
O
M terial Metho
(
From
To
Ft.
e
From
To
Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From _ To _ Ft In. —in.
From _ To _ Ft. _ In. _... In.
From —To _Ft. ^ in. in.
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
17. REMARKS:
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, oXther map reference points)
ilaj�eiala.{. Dr.
�I
o
O
O
C,_
C
o,�
S�yyKo. Rd.�
r�
cn
�Feai �s7o�
o
z
_
Colin
Jill us
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 (tit VLEd_ it), Cajq o I/ . / - /6 -OD
Quad No: SIGNATURE OF PERSON CONSTRUCTING HE WELL DATE
Submit original to Division of Water Quality. Groundwater Section within 30 days
Serial No. OW-1 REV. 12199

212189
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELLCONTRACTOR: �� e W T.
WELL CONTRACTOR CERTIFICATION #: 11
Ed
WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable sox): Residential E Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION how sketch of the cation below) �D
Nearest Tofwn: 91 I�� l -r71N wt County: �
GCA,J—O — like
(Road Name and umbers, Croommuni or Subdivision and Lot No.) DRILLING LOG DEPTH
r� I l P a From To Formation Desf ription
3. Address l �% �nK �� j��0 `Q1 List
f I1�QPYtfI �le feet or Ui. o. `�D 31 h %n 115nlrAe L ko Ck
City Tawn Stale Zip Code
4. DATE DRILLED _ - 00
5. TOTAL DEPTH
6, CUTTINGS COLLECTED YES Q NOR)
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO®
8. STATIC WATER LEVEL Below Top of Casing: O FT.
(Use -+- it Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface-
-Top of casing terminated at/or below land surface requires a variance In accor-
dance with 16A NCAC 2C . 118
10. YIELD (gpm): METHOD OF TEST QI
11. WATER ZONES (depth):
12. CHLORINATION: Type Amount
13. CASING:
If additional space is needed use back of
Wall Thickness LOCATION SKETCH e,
Depth Dia ter or Wei ht I t, atedal (Show direction and distance from at least two State �uY
From �% To Ft. V L Roads, or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth M t� erial ethod
From �� To 2C Ft.�lL_Je elt r
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From —To—Ft— in. in.
From _ To _ Ft. _ in. _ In.
From —To _ Ft. — in. in.
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
17. REMr
X
�Atk ° ,may I
CK Rl.
t jog M�II Spy
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 1 r +d 17
)
Quad No: SI ATURE OF PERSON CONSTRUCtIN6 THE WELL DATE
Submit original to Division of Water Quality, Groundwater Section Within 30 days
Serial No. GW-1 REV. 12199

212194
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] tt
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION #: Z(30
,_.,
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): ResidentialE/Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION:
(Show sketch,of the location below)
Nearest Tgg,wn: �j
So-; Y 9 County:
Pn'K
Ri'(1ae
2� =
e0-
(Road Name and NumbeF4, Community, or Subdivision and Lot No.)
DRILLING LOG
DEPTH
3. OWNER
i L.
From To
Formation Description
Address Re
klgf
O
dI y ` +1
'3 );1 VOck
j
A,1 I �
, t5treet oVle o.
0
LLIE)19 e' t, /P
4. DATE DRILLED DEPTv
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑ NO®
7. DOES WELL REPLACE EXISTING WELL? YES NO®
8. STATIC WATER LEVEL Below Top of Casing: n , FT.
(Use '+' it Above Top of Casing)
9. TOP OF CASING ISFT. Above Land Surface -
'Top of casing terminated atlor below land surface requires a variance In accor-
dance with 15A NCAC 2C.0118
10. YIELD (gpm): rU METHOD OF TEST Q) Y
11. WATER ZONES (depth):
C3
O `p
t o
z
12. CHLORINATION: Type A-s Amount G u If additional space is needed use back of form
13. CASING:
Wall Thickness
Depth Diam ter or Weight/Ft M�aatteQaat
r From To
FL �O
From To Ft.
From To Ft.
14. GROUT:
Depth Material ethod
From �_ To 2_Ft. nP0.%CCNtentrloLwd
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From —To—Ft— in. —in
From — To — Ft. _ in. _ in.
From _ To _ Ft. _ in. _ In.
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
17. REMARKS:
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED T�OyTHE WELL OWNER.
FOR OFFICE USE ONLY 7Atf 04 j� %
� ^,' , ""
�//, y
Quad No: SIGNATUR OF PERSON CONSTRUCTING T E WELL DATE
Submit original to Division of Water Quality, Groundwater Section Within 30 days
Serial No. GW-1 REV. 12199

North Carolina - Department of Environment and Natural Resources • Division of Water Quality. Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699.1636-Ptwne (919) 733-=1 n
WELL CONSTRUCTION RECORD WELLCONTRACTOR: �A)nA5 We)) �,LW-4 CD �,
WELL CONTRACTOR CERTIFICATION #: y
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Chock Applicable Box): Residential 12' Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other rl If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below) �o'
Nearest Town: .y�/ n n County:
t _ .
t,tRrcm-e r\noaes Kd • al I_V i"L
(Road Name and Numbers, CommuN , or Subdivision and Lot No.)
3. OWNER WoLol oa ke✓
Address ( 1grertce Rho Je,, kA
orate Zip Code
4. DATE DRILLED �O -boob
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑ NO®
7. DOES WELL REPLACE EXISTING WELL? YES J[ � NOF-�
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 Dosing terminated at/or below land surface requires a variance In accor•
dance with 15A NCAC 2C.0116
10. YIELD (gpm): 15" METHOD OF TEST a I✓
11. WATER ZONES (depth):
DRILLING LOG
From o
D
DEPTH
Fonnaeon Description
cen5eltllelrock
0
4.2
c�
12. CHLORINATION: Type 4Z=Amount If additional space is needed use back of form
13. CASING:
Wall Thickness LOCATION SKETCH
�1 Depth Diamfeter orweighvFt. Mat�eJ� (Show direction and distance from at least two State
From-6�_To Ft..1R� SD^aJ. �r`_ Roads, or other map reference points) ,.r.
From To Ft.
From To FL
14. GROUT:
Depth Material r Method,
A
From [� _ To Depth
Ft. pnt GP)len�
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:
_a.
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A OPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY D
Quad No: U E U THE WELL 'DATE
Submit gi Ion WiOW-1 REV. 12/99
thin 30 days
Sena No.
MAY 3 1200[1
L
fL'

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: �, eiJctl LmI Y d — (_a W i k1e)�
WELL CONTRACTOR CERTIFICATION #: na I rg 8 �c .
STATE WELL CONSTRUCTION PERMIT#:
LJ/
1. WELL USE (Check Applicable Boa): Residential Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other If Other, List Use:
2. WELL LOCATION: hOw skejph of the location below) �D
Nearest Town: j County:
(Road Name and� umrs, Cort`v/nuniry, or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER ,j")Ybe
I R.v, KPYV From rmm To Foat on Description
Address 6 y 0 )1, d 'r
l ree or oua o. �15 14A5 LC Sa ,dn} Ycc
D LA W U 5 C, , 'I..7 1
City or Town Stale Zip Code —
4. DATEDRILLED - 7'DD —
5. TOTAL DEPTH !4 A,�- / —
6. CUTTINGS COLLECTED YES❑ NO[K �/ —
7. DOES WELL REPLACE EXISTING WELL? YENO� _
8. STATIC WATER LEVEL Below Top of Casing: FT.
(Use's' It Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface* -
-Top of casing terminated at/or below land surface requires a variance In accor-
dance with 1 SA NCAC 2C .0118 �
10. YIELD (gpm): 90 METHOD OF TEST 41l Y
11. WATER ZONES (depth):
12. CHLORINATION: Type Amount_
13. CASING:
Wall Thickness
Depth Diameter W WeIght1rL Malepai
_
From (2 TO � Ft. � 4 .5U)z.2 Pvc
From To Ft.
From To Ft,
14. GROUT:
Depth Material elho
From —� To 2_ Ft. ea t CC
e K11111,1d
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:
If additional space is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Quad No: NATURE OF PERSON CONSTR TIN HE WELL DATE
ro
o uality, Groundwater Section within 30 days
Serial No. �'-f OW-1 REV. 12/99 51
-RI.
JUN 1 9 20^t)

North Carolina • Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699.1636-Phone [phone]
WELL CONSTRUCTION RECORD WELLCONTRACTOR: _0- l,clvHn y.—('1
WELL CONTRACTOR CERTIFICATION #: �) 3 R Ct' _.1Ftc .
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (check Applicable Pox): Residential ® Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other (D If Other, List Use: _
2. WELL
Nearest
(Road Name
3. OWNER _
Address
of the location below)
5 County: PR
or Subdivision and Lot No.) DRILLING LOG DEPTH
City or Town Stale Zip Code
4, DATE DRILLED
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑ NOE]
7. DOES WELL REPLACE EXISTING WELL? YE�NOQ
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 using terminated atlor below land surface requires a variance In accor-
dance with 15A NCAC 2C.0113
10. YIELD (gpm): �[0 METHOD OF TEST A/ V
11. WATER ZONES (depth):
12. CHLORINATION: Type E ; Amount
13, CASING:
Wall Thickness
Depth Diallpter or wel0ht/Fl. Mato 'al
From f_To %'2S Ft. 'IV4
From To Ft.
From To Ft.
14. GROUT:
Depth atonal Method
From To L _Ft. 1 ct -. 'L
From To Ft.
15. SCREEN:
From To Formation Description on
O �
�m
—At c m
Cq
s am
N2
n
—r
N o
If additional space is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map teleran points)
_— W I
Depth Diameter Slot Size Material
From _ To _ Ft In. _ In.
From _ To Ft. _ In. In.
From To Ft. — in. _ in.
16. SAND/GRAVEL PACK: I/I
Depth Size Material
From To Ft.
From To— Ft.
17. REMARKS:
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY L 4'a'. LY 4 � r /J ' - 6'0
Quad No: SIGNATURE OF PERSON CON TR(UCTING THE WELL DATE
- 1) Ity, Groundwater Section within 30 days
Serial No. t I t B �j1 D GW-1 REV. 12/99
�1N 1 9 2p",11 u

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699.1635-Phone [phone] I� n
WELL CONSTRUCTION RECORD WELL CONTRACTOR-6 e5�.Cdwfn )r "�)amn5�e��tttfnpCD.
WELL CONTRACTOR CERTIFICATION #: I g T— rTnc
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 LOCATIONdStow s etch of the location below) fl
Nearest Town: n t 6t A County: O !C
(Road'Name an rurn,hers, Com wn'ty, or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER c From To Formation Description
Address p C llr it _
(birsel uxa o. ND .565 Y So -cd roc
11YcSQrz l ' q q � /,
City or Town State Zip code
4, DATE DRILLED 4 -191- D t�
5. TOTAL DEPTH 3 ( 6- '
6. CUTTINGS COLLECTED YES ❑ NOM
7. DOES WELL REPLACE EXISTING WELL? Y S E_ NOX
8. STATIC WATER LEVEL Below Top of Casing: q5 FT.
(Use'i It Above Top of Casing)
9. TOP OF CASING ISFT. Above Land Surface-
-Top of "sing terminated allor below land surface requires a variance In accor-
dance with 15A NCAC 2C.0116
10. YIELD (gpm): /0 METHOD OF TEST Q / ✓
11. WATER ZONES (depth):
12.
CHLORINATION: Type
Pe105
Amount u
It additional space is needed use back of form
13.
CASING:
Wall Thicknass
LOCATION SKETCH
Depth ,,
Diameter or Wel9ht/Fl. I�r[at dal
4D �C
(Show direction and distance from at least two State
From V
To 00
Ft...&Y4
R Y
Road or other map reference points)
From
To
Ft.
From
To
Ft.
14.
GROUT:Deh
ri hod II
M�tartd
M teelVYte
vt�
v y�
20
f
From
Topt
Ft.
From
To
Ft.
1�e"
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
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 —Jr. � - 5 - L D
Quad No: SIGNATURE OF PERSON C N TRUCTING THE WELL DATE
..�,., a o u roundwater Section within 30 days
Serial No. -j +J FV'
GW-1 REV. 12/99
JJUN 109 2000
Ili vsk� 05
(0q

North Carolina - Department of Environment and Natural Resources - Division of Water Quality. Groundwater Section
1636 Mall Service Center - Raleigh, N.C. 27699.1636-Phone [phone]
WELL CONSTRUCTION RECORD WELLCONTRACTOR: �IµmN_ s,Je Camla_sc,
WELL CONTRACTOR CERTIFICATION M: ; I � S
STATE WELL CONSTRUCTION PERMtTa ;
1. WELL USE (Check Applicable Box); Residential Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION- JS�how s etch of the location below) Jl
Nearest Town: 1.-.DI I'tP L I[5 County:
(Road Name an umbers. Coav/n�unity, or S tlti{ion and lot No.)
DRILLING LOG
3.
OWNER f WC. /-/x..i'1'L� F7 bS
From To
Address o
p S(,
City or Town Slate Zip Code
0,_0G
4,
DATE DRILLED
5.
TOTAL DEPTH `.5
6.
CUTTINGS COLLECTED YES ❑ NO®
7.
DOES WELL REPLACE EXISTING WELL? YES d NO[]
S.
STATIC WATER LEVEL Below Top of Casing: ',(o FT.
9.
(Use'+' If Above Top of Casing)
TOP OF CASING IS�_ FT. Above Land Surface'
Top
of casing terminated Ivor below land surlacs requires a variance In accor-
dance
with 15A NCAC 2C.0118
10.
YIELD (gpm): 2� METHOD OF TEST Air
11.
WATER ZONES (depth):
12. CHLORINATION: Type 6 _Amount T
13. CASING:
Wall Thickneta
Depth Diameter or WalghvFt. 1Maten ll
From —L2_ To Ft. )_ Na A
From To Ft.
From To Ft.
14, GROUT:
Depth �tatonal t�e thud(
From —0 To 20 Ft. N&ITr` _,I hand
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
Fcrtnaaon oescnptign
✓ d _ YOLK
a. D
S
It additional space is needed use back of form
LOCATION SKETCH N
(Show direction and distance from at least two State
Roads, or Titter map reference points)
1, Xp1
n
vuRI' J
9•
9 1 �
!ynn
i!
7i'�P r
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 29, WELL
CONSTRUCTION STANDARDS, AN THAT A COPY OF THIS RECORD HAS BEEN PR—OVIVIDED TO THE iWELL OLW, NER.
FOR OFFICE USE ONLY ✓✓. J —J- OD
Ouaa No: S ON CONS UCTING THE WELL DATE
f ; '� 1111 b ri I slo 1 Ouallty, Groundwater Section within 30 days
Serial No. ., 1 ' V<1
GW-/ REV. 12/99
AIN 19 2! 11

North Carolina - Department of Environment and Natural Resources - Division of Water Quality- Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699.1636-Phone [phone]
WELL CONSTRUCTION RECORD WELLCONTRACTOR: t-dm-►ps ")) Mam,j ( o.Tnc.
WELL CONTRACTOR CERTIFICA IT OIF
STATE WELL CONSTRUCTION PERMIT#:
WELL USE (Check Applicable Box): Residential 19' Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCA
(Road N
3. OWNER
Address
of the location below)
1,4 x , County: ((jj
or Subdivision and Lot No.)
gily or Town State Zip Code
4. DATE DRILLED-L� D(7
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES 0 NO[E)
7. DOES WELL REPLACE EXISTING WELL? YES NO®
8. STATIC WATER LEVEL Below Top of Casing: _4,!5' FT.
(Use'i If Above Top of Casing)
9. TOP OF CASING ISFT. Above Land Surface*
'Top of casing terminated atior below land surface requires a variance In accor-
dance with ISANCAC2C.0 78
10. YIELD (gpm): METHOD OF TEST Gi r
11. WATER ZONES (depth):
12. CHLORINATION: Type e S Amount �L
13. CASING:
Wall Thickness
Depth Oiar�atar or we_ iQhvFt., M41#691
From— 42 To A1_5 Ft. RaJ
From To FL
From To Ft.
14. GROUT:
Depth material ) ethod)
From To 20 Ft.
From To Ft.
15. SCREEN:
DRILLING LOG DEPTH
From To Forma8 Description
to 4S 1 11 5oL e mock
0
t
If additional space is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least two Slate
RD[a,�d�s, or other map reference points)
I1 r
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.
A
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. n�1
FOR OFFICE USE ONLY CA of O ov
Quad No: SIGNATURE OF PERSONtOfgTRUCTING THE WELL DATE
Serial No.
Q �airala.rlater Quality. Groundwater Section within 30 days
� R Q �i� GW-1 REV. 12/99
MAY 3 1 2000

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-1 W&Phone [phone]
WELL CONSTRUCTION RECORD WELLCONTRACTOR: L6C/rt/Js
WELL CONTRACTOR CERTIFICATION k:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential ID Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other 0 If Other, List Use:
2. WELL LOCATION: Show s etch of the location below) )/)1
Nearest Town: I, County: r O / K
.t�7
(Road Name and umbers. Coklity. or bdivision/ot N .) /1 DRILLING LOG DEPTH
3. OWNER 5 p t C.,O N.5 CD . From To Fomatlon Description
Address 1 Dwp UK �� _ 0 /,�,0 d i r, _
�lt r�l2Y Yrl rh or �1 f �5(129 /,�0 SD 1� —CQA5p1jdgFed YOc
Ciryor Town Siale - - Tp Code
_ _
4. DATE DRILLED "�°� 000
5. TOTAL DEPTH 4n 5L
6. CUTTINGS COLLECTED YES Q NO[2q
7. DOES WELL REPLACE EXISTING WELL? YES NO[X
8. STATIC WATER LEVEL Below Top of Casing: Qp FT.
(Use '+' It Above Top of Casing)
9. TOP OF CASING IS�_ FT. Above Land Surface*
'Top of casing terminated atfor below land surface requires a variance in accor-
dance with 15A NCAC 2C C. 11 a
10. YIELD (gpm): METHOD OF TEST R I
11. WATER ZONES (depth):
12. CHLORINATION: Type C 5 Amount ."J L
13. CASING:
Wall Thickness
Depth
From 12To�_Ft.
Diameter or Welght/R. Met grist
gr� �`(2 L V�
From
To Ft.
From
To Ft.
14. GROUT:
From 0
Dept
To D Ft.
Material t Method
� n u.t Cf+ �CLl
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:
If additional space is needed use back of lorm
LOCATION SKETCH
(Slow direction and distance from at least two State
Roads, or other map reference points)
t! F
V L�
j
)D
0
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 20, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY U d 6 t/
Quad No: T P U I THE WELL DATE
Submit on � Section within 30 days
Serial No.
OW-1 REV. 12P49
MAY ?00i,
Groundwater Section
a.t..,An. b.,.t.,..t Am—

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699.1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: ( i kn A5 ill Ak �� •* uric,
WELL CONTRACTOR CERTFFI ATION
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box); Residential LY) Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: S ow snatch of the location below) I Z
Nearest Town: �u>wb d S County:
(Road Name and Nurh T, Community, or Subdivision d I No.) DRILLING LOG DEPTH
3. OWNER �9a r1NN�l; a..11l nR�eal s Ale From To Fomwuon Description
Address q5 j )'.r5 / /' laivt St. n -7,7 a "t
—(SGeet or RouTe o. ^ _ /77 13 D�r_ (ro n 5oT T7 Yo ck
4. DATE DRILLED A- Ili -a000
5. TOTAL DEPTH
6. CUTTINGSCOLLECTED YES NO[�g
7. DOES WELL REPLACE EXISTING WELL? YES ® NOF__J
8. STATIC WATER LEVEL Below Top of Casing: tp FT.
(Use'i If Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface*
'Top of "sing terminated atlor below land surface requires a variance In accor-
dance with 15A NCAC 2C .011 a
10. YIELD (gpm): 10 METHOD OF TEST Q w
11. WATER ZONES (depth):
12. CHLORINATION: Type o Amount—/
13. CASING:
Wall Thickness
Depth Diameter w Weight/Ft. Material
From To 4 Ft.(414 5D9Al
From To Ft.
From To Ft.
14. GROUT:
Depth Material Metho
From _ C To �� Ft. rn' e n-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
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)
i
CNF,
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 01 —,— 4 • - GG
Quad No: SIGNA URE OF PERSON CONSTRUCFING E WELL DATE
Submit original Io . islon of Water quality, Groundwater Section within 30 days
Serial No. 1 � OW-1 REV. 12/99
J

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699.1636-Phone [phone] n n
%J k)e P &..Tvt WELL CONSTRUCTION RECORD WELL CONTRACTOR: .S � s '-c(MQ c.
WELL CONTRACTOR CERTIFIC ION #: I -af T T-
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box); Residential 10 Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: j$ho)v ske(h of the location below) �`
Nearest Town: , (� I t- b County: °
(Road Name and nN tubers. ComnuniI or Subdivision and Lot No.) DRILLING LOG
3. OWNER 1! r, 1 1s d" So K From To
Address Po Bo x q,C' D /D5-
tbireei oAmpute o. , n^ �Gh 35
City or Town State Zip Code
4. DATE DRILLED O
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑ NO®
7. DOES WELL REPLACE EXISTING WELL? YES D NO®
8. STATIC WATER LEVEL Below Top of Casing: _4&_ FT.
(Use'i 11 Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface -
Top of using terminated attor below land surface requires a variance In accor-
dance with iSA NCAC 2C .Oita
10. YIELD (gpm): 2io METHOD OF TEST GL l r
11. WATER ZONES (depth):
Agricultural ❑ Monitoring ❑
DEPTH
Formation Description
Drrt "
('°nso I; dated ?DcK
0
O
o
p
m:S
am
12. CHLORINATION: Type Amount If additional space is needed use back of form
13, CASING:
Wall Thickness
Depth
Di�am�!et�ar or Weight/Ft. Material
From-0
To ILFt.
- LY4 P-Al 0VC
From
To
Ft.
From
To
Ft.
14. GROUT:
Depth
Material Method
From
— 0 To 20
Ft.
/'�Wte vet �Q 6
From
To
Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From _ To _ Ft _ In. —in
From _ To T Ft. _ In. _ In.
From —To —Ft. _ in. _ in.
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
17.
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAA BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY Q,yYYVYWuf/ -aOUD
Quad No: SIG RE OF PE N C�UCTING THE WELL DATE
SubrNt original to Division of Water Ousllty, Groundwater Sectlon within 30 days
Serial No. OW-1 REV. 12/99
0l�id'Hatt S'v.r':n

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-163rrPhone [phone] n/J
WELL CONSTRUCTION RECORD WELL CONTRACTOR: LAM ay 14),e l 4 Co, �.
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential Eff Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other E] If Other, List Use:
2. WELL LOCATION:�} ho�' sketc of the location below)
-- I L
Nearest Town: .D „,( M pr" 5 County:
3.
4. DATE DRILLED oD
Agricultural ❑ Monitoring ❑
DRILLING LOG DEPTH
From To Fomwuon- Description
O 6-5-✓1 / -t
6"2;- fc5- rI o a e Of
5.
TOTAL DEPTH L o
6.
CUTTINGS COLLECTED YES Q NO[K]
=
7.
DOES WELL REPLACE EXISTING WELL? YENOE
o
8.
STATIC WATER LEVEL Below Top of Casing: FT.
c'
11 (Use -t If Above Top of Casing)
�6
c �,
9.
TOP OF CASING IS_1_ FT. Above Land Surface
-Top of casing terminated atlor below land surface requires a variance In accor-
dance with 15A NCAC 2C .et is
10. YIELD (gpm): 15_ METHOD OF TEST 11 r
'
11.
WATER ZONES (depth):
p
�'
12.
CHLORINATION: Type >' Amount Gll
It additional space is needed use back of form rT
o
13.
CASING:
Wall Thickness
LOCATION SKETCH
Depth {� Diameter or Weight/Ft. Material
From To » Ft. �
(Show direction and distance from at least two State
Roads, or other map reference v
From To Ft.
points�
o
From To Ft.
14. GROUT:
Depth Material Methoq k
From 0 To�Ft. (Ny eye aKA
From To Ft,
15. SCREEN:
Depth Diameter Slot Size Material
From _ To _ Ft _ In. _ In.
From —To _ Ft._ In. _ In.
From _ To Ft. in. _ in.
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
17
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY QF. IS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY L ?
J- - oZD o U
Quad No: i. + Sfbl,l.fUREOIF PER NSTRUCTING THE WELL DATE
Submit original to `slon of Water l y, Groundwater Section within 30 days
Serial No. � � � � ,j OW-1 REV. t2199

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone] I
WELL CONSTRUCTION RECORD WELLCONTRACTOR:
WELL CONTRACTOR CERTIFICA ION S: A 13 7
STATE WELL CONSTRUCTION PERMITC
1. WELL USE (Check Applicable Box): Residential Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION:( wych✓o e �— below)Nearest Town:
. County:
(Road Name and mbed, Community. or Subdivision and Lot No.)
3. OWNER ai/—F(iJ1or
Address I'7n S a.cu R� .
City or Town State zip Coae
4. DATE DRILLED-
5. TOTAL DEPTH '� nh
6. CUTTINGS COLLECT' S ❑ NO[3]
7. DOES WELL REPLACE EXISTING WELL? YES d NOr_�
S. STATIC WATER LEVEL Below Top of Casing: FT.
(Use'i It Above Top of Casing)
9. TOP OF CASING IS j FT. Above Land Surface*
-Top of easing terminated atlor below land surface requires a variance In accor-
dance with i5A NCAC 2C .011 a i
10. YIELD (gpm): D METHOD OF TEST �� I ✓
11. WATER ZONES (depth):
12. CHLORINATION: Type �l°' �� iI i�Amount Gw
13. CASING:
Wall Thickness e�
Depth Diameter orweight/Ft. � 11
FromTo Ft. �L d
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From To ,LQ Ft. L?t
From To Ft.
15. SCREEN:
Depth Diameter
From —To Ft _ in.
From _ To Ft. _ in.
From _ To _ Ft. _ in.
16. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To Ft.
17. REMARKS:
Slot Size Material
In.
_ In.
in.
Material
DRILLING LOG
From To
D 3G
DEPTH
Formation Description
�r
Y' i a
r
If additional space is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least two
Roads, or other map reference points) j
Df` taf�
I911,
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 20, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
` a FOR OFFICE USE ONLY /7 -4—� ` (-�A \ I ✓ 1 : — 1 —�Od
Quad No: SI ATURE OF PERSON CONSTRU THE WELL DATE
—: Submit original to Division of Water Quality. Groundwater Section within 30 days
Serial No. 4' l I i ,) t Ci OW-1 REV. 12/99

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699.1636-Phone (919) 733.=1
WELL CONSTRUCTION RECORD WELL CONTRACTOR: IAwt0'6 L�e01A M
A ^r.
WELL CONTRACTOR CERTFF ATION #: _�) 3 g�-
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential ff Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other r7I If Other, List Use:
2. WELL LOCATION:
Nearest Town:
Th At
(Road N
3. OWNER
Address
of the r location below)
11 � Y,e I County: D
or Subdivision and Lot
ctry or Town Stale Zip Code
4.- DATE DRILLED - Ar 6p
5. TOTAL DEPTH j
6. CUTTINGS COLLECTED YES Q NO®
7. DOES WELL REPLACE EXISTING WELL? YES EO' NOF_�
8. STATIC WATER LEVEL Below Top of Casing: --4-- FT.
(Use'.' If Above Top of Casing)
9. TOP OF CASING IS�_ FT. Above Land Surface*
'Top of casing terminated at/or below land surface requires a variance In accor-
dance with 15A NCAC 2C .011 a
10. YIELD (gpm): 10 METHOD OF TEST —GC / y'
11. WATER ZONES (depth):
Agricultural ❑ Monitoring ❑
DRILLING LOG DEPTH
From To Formation Description
q0 D' r'
o (?6- o '
0
O
U
3'.
Y
A
G�i
o
G- rn
-
rn
t�
rT1:0
12. CHLORINATION: Type C- Amount C 14 If additional space is needed use back of form
13. CASING:
Wall Thickness LOCATION SKETCH
Depth Diameter or WeightrFt. Material (Show direction and distance from at least two State
From To 10 - Ft. G, 'a D R 2 I PAL Roads, or other map reference points)
From To Ft. �--- I
From To Ft.
14. GROUT:
Depth Mateda� MathQPd
From rL To 20 Ft. GCw e1 j' l 7
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 ACOPY OFTHI�SRECORD HAS BEEN
�PROVIDE TOTHEWELLOWNER.
FOR OFFICE USE ONLY (-��& /, , f /L411U ?- 1 ab
Quad No: SIGNATI'1RE OF PERSON CONSTRUCTI G T E WELL DATE
Sulxnit original to ision of water Quality, Groundwater Section within 30 days
Serial No. r� GW-1 REV. 12199

Page 1 of 1
North Carolina Departmenr of Environment, Health and Natural Resources
Division of Environmental Management - Groundwater Section
P.O. Box 29535 Raleigh, NC 27626-0535
Phone [phone]
WELL CONSTRUCTION RECORD
FOR OFFICE USE ONLY43
Quad. No. Ser. Nory
Lat. Long. RO
Minor Basin
Basin Code
Header Ent. GW-1 Ent.
Drilling Contractor CAMP'S WELL 6 PUMP CO., INC.
Dr;IIcf Cfrl,,' ,cApor- AIIq,� as' .t138
State
Well Construction
Driller Registration Number 215
Permit
Number
1. WELL LOCATION: (Show sketch of the location below)
County
Po
Nearest Town /lei 11 Seri nq
Bi a I,e / e I R,, d
Depth DRILLING LOG
(Road', Community Subdivision and Lot No.)
From
To Formation Description
/or
2. OWNER T ✓✓� VOS$C-0
0
¢o DIRT
ADDRESS 980 Co0r-r L ne Rd.
�a
��S CONSOLIDATED ROCK
p,`f ,Y'��y,lzr NCa9:3j
—
3. DATE DRILLED 1-IQ-d000 USE OF WELL -DOMESTIC
—
4. TOTAL DEPTH�5
—
5. CUTTINGS COLLECTED? NO
6. DOES WELL REPLACE EXISTING WELL? NO
-
7. STATIC WATER LEVEL Below Top of Casing: 55 FT.
B. TOP OF CASING IS 1 FT. Above Land Surface.
9. YIELD (gpm) METHOD OF TEST -PUMP
10. WATER ZONES (depth)
11. CHLORINATION: Type CHLORINE Amount I C u
12. CASING:
Depth
From D
To 4o
ft.
From
To
ft.
From
To
ft.
13. GROUT:
Depth
From 0.
To 20
ft.
From
To
ft.
14. SCREEN:
Depth
From To ft
From To ft
From To ft
15. SAND/GRAVEL PACK:
Depth
From To ft.
From To ft.
14. REMARKS:
Wall Thickness
Diameter or Weight/Ft. Material
6 1/4 SDR 21 PVC
Material Method
NEAT CEMENT HAND METHOD
Diameter Slot Size Mat
in. in.
in. in.
in. in.
Size Material
O
— o
(Show direction and distance from at least two
State Roads, or other map r ference�pooYnxtSs)
a C OVC
1 ➢O HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
�1Ftili _ 5I6NA E OF CONT ACTDR DR GENT DATE
GW-I REa:_9191 Subei original Division of Environment Management and copy to well owner.
l _

Page 1 of I
North Carolina Departmenr of Environment, Health and Natural Resources
Division of Environmental Management - Groundwater Section
P.O. Box 29535 Raleigh, NC 27626-0535
Phone [phone]
WELL CONSTRUCTION RECORD
FOR OFFICE USE ONLY0 0 6 n ^ n
Quad. No. Ser. N647 U U
Lat. Long. RO _
Minor Basin
Basin Code
Header Ent. GW-I Ent.
Drilling Contractor CAMP'S WELL W PUMP CO., INC.
Pnllc+ d134 , 2135, di3?
State Well Construction
Driller Registration Number 215
Permit Number
1. WELL LOCATION: (Show sketch of the location below)
County PO l K
Nearest Town j,yji 1 SP✓ � e-�
Depth DRILLING LOG
si �J°✓ Ck Rd •
(Road, Community or Subdivision and Lot No.)
From To Formation Description
2. OWNER 7:i!0` U)a1-ev
0 Ho DIRT
ADDRESS S; tvev LK. Rl�
a 36S CONSOLIDATED ROCK
M ) 5 fi v%a c
—
3. DATE DRILLED (- o^ ood USE OF WELL -DOMESTIC
4. TOTAL DEPTH 3 6 S
—
5. CUTTINGS COLLECTED? NO
—
6. DOES WELL REPLACE EXISTING WELL? NO
—
7. STATIC WATER LEVEL Below Top of Casing: r/ o FT.
B. TOP OF CASING IG 1 FT. Above Land Surface.
O
o
9. YIELD (gpm) )d METHOD OF TEST -PUMP
-"
c
c'-
rri
10. WATER ZONES (depth)
-=
11. CHLORINATION: Type CHLORINE Amount OP
J
-'
T1
l
12. CASING:
p
Wall Thickness
F
�:
Depth Diameter or Weight/Ft. Material
o
From D To 11D ft. 6 1/4 SIR 21 PVC
z
From To it.
To ft.
(Show direction and distance from at least two
From
State Roads, or other map reference
points)
13. GROUT:
Depth Material Method
From 0. To 20 ft. NEAT CEMENT HAND METHOD
From To ft.
14. SCREEN:
x
Depth Diameter Slot Size Material
Si�✓er Ck,
From To ft. in. in.
in.
a
From To ft. in.
From To ft. in. in.
15. GAND/6RAVEL PACK:
Depth Size Material
From To ft.
From To ft.
14. REMARKS:
I DO HEREBYtLERTIFYJHffT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL
CONSTRUCTIOf4AND, THAT, AND 'THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
DATE
SIGNAT
OF CONTR
TOR OR A6EN
GW-1 REV. 9/91 Submi original t
ivision of Environment Management and
copy to
well owner.
,,.

Page I of 1
North Carolina Departmenr of Environment, Health and Natural Resources
Division of Environmental Management - Groundwater Section
P.O. Box 29535 Raleigh, NC 27626-0535
Phone [phone]
WELL CONSTRUCTION RECORD
Quad. No. _
Lat.
Minor Basin
Basin Code
Header Ent.
FOR OFFICE USE ONLY q 0680
Ser. N(f-
Long. RO _
BW-1 Ent.
Drilling Contractor CAMP'S WELL k PUMP CO.,
INC.
DY;
Oef A154 1I S t ,
State
Well Construction
Driller
Registration Number 215
Permit
Number
1.
WELL LOCATION: (Shea sketch of the location below)
County
P O Ik
Nearest Town /11i �1
SPA n9
- a- Lakes
Depth DRILLING LOG
(Road, Communityi or Subdivision and Lot
No.)
From
To Formation Description
2.
OWNER )_e5& PO WO V"vk5
0
So DIRT
ADDRESS Si I Jev Cve° k Rd
go
�,�- CONSOLIDATED ROCK
M II sir ng HL
-
-
3.
DATE DRILLED 1-6I-;D00USE OF WELL -DOMESTIC
—
4.
TOTAL DEPTH a95
—
5.
CUTTINGS COLLECTED? NO
—
6.
DOES WELL REPLACE EXISTING WELL? NO
a a
7.
STATIC WATER LEVEL Below Top of Casing:
GS FT.
—
S.
TOP OF CASING IS 1 FT. Above Land
Surface.
'^—
ni
9.
YIELD (gpm) _157 METHOD OF TEST
-PUMP
07 n:
-
_ L
10.
WATER ZONES (depth)
—' "C
y
IL
CHLORINATION: Type CHLORINE
Amount l
O
S:
12. CASING:
Wall Thickness
Depth Diameter or Weight/Ft. Material
From O To 80 ft. 6 1/4 SIR 21 PVC
From To ft.
From To ft.
13. GROUT:
Depth Material Method
From 0. To 20 ft. NEAT CEMENT HAND METHOD
From To ft.
14. SCREEN:
Depth Diameter Slot Size Material
From To ft. in. in.
From To ft. in. in.
From To ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To ft.
From To ft.
(Show direction and distance from at least two
State Roads, or other map peference poiFffm _
�1
�rlwfCK.
o�
14. REMARKS:
I ➢O HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL ,
CONSTRUCTION-9tAN0ADG� AKILL NAT.AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
hi S GNATUW OF CONTRACTN OR AGENT f DATE
GW-I REV. 9/91 .' Submit original to Di Wsion of Environment Management and copy to well owner.
r

Page 1 of I
North Carolina Departmenr of Environment, Health and Natural Resources
Division of Environmental Management - Groundwater Section
P.O. Box 29535 Raleigh, NC 27626-0535
Phone [phone]
WELL CONSTRUCTION RECORD
FOR OFFICE USE ONLYrJ
Quad. No. Ser. N6- t1
Lat. Long. RO _
Minor Basin
Basin Code
Header Ent. GW-1 Ent.
Drilling Contractor CAMP'S WELL h PUMP CO., INC.
Driller Ecv�'Pcai,'oA a134,.1135, a138 State Well Construction
Driller Registration Number 215 Permit Number
1. WELL LOCATION: (Show sketch of the location below) County Po/�
Nearest Town Mill
S P r i n9
(Road, Coo lunit or Subdivision and Lot No.)
2. OWNER j�cn l� W5,0vI
ADDRESS P t, Z 3 o X 10 8
Try,v� N c aR9aa
3. DATE DRILLED li-z000 USE DF WELL -DOMESTIC
4. TOTAL DEPTH % 0 5
5. CUTTINGS COLLECTED? NO
6. DOES WELL REPLACE EXISTING WELL? NO
7. STATIC WATER LEVEL Below Top of Casing: �0 FT.
8. TOP OF CASING IS I FT. Above Land Surface.
S. YIELD (gpm) 3 METHOD OF TEST -PUMP
10. WATER IONES (depth)
11. CHLORINATION: Type CHLORINE Amount I CLAP
12. CASIN6:
Depth
From 0
To 10Sft.
From
To
ft.
From
To
ft.
13. GROUT:
Depth
From 0.
To 20
ft.
From
To
ft.
14. SCREEN:
From
From
From
Depth
To
To
To
15. SAND/GRAVEL PACK:
Depth
From To
From To
14. REMARKS:
Wall Thickness
Diameter or Weight/Ft. Material
6 1/4 SDR 21 PVC
Material Method
NEAT CEMENT HAND METHOD
Depth DRILLING LUG
From To Formation Description
0 10S DIRT
lD S %D S' CONSOLIDATED ROCK
r
0 0
-= n
n L
y.
(Show direction and distance from at least two
State Roads, or other map reference points)
�afvn
X Cer er
Diameter Slot Size Material
ft. in. in.
ft. in. in.
ft. in. in.
P✓1
Size Material
ft.
ft.
i
1 DO HEREBY CERTIFY IHAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL 4-'—
CONSTRUCi0o, ST4DARDS, AND THAT AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TD THE WELL OWNER,
SIGNAiRE OF CTORWENT DATE
GW-t REV. 9/94 Submit original tbJDivision of Environment Management and copy to well owner.
n

Page I of I
North Carolina Departmenr of Environment, Health and Natural Resources
Division of Environmental Management - Groundwater Section
P.O. Box 29535 Raleigh, NC 27626-0535
Phone [phone]
WELL CONSTRUCTION RECORD
FOR OFFICE USE ONLYy J v
Quad. No. Ser. N
Lat. Long. RO
Minor Basin
Basin Code
Header Ent. GW-I Ent.
Drilling Contractor CAMP'S WELL & PUMP CO., INC.
pr
lfe+�eYf;T cop ,2I34, ai3S, a138
State Well Construction
Driller
Registration Number 215
Permit Number
1.
WELL LOCATION: (Show sketch of the location below)
County po l<
Nearest Town 141l11' rO
� r✓C io�.JE✓ .,-Cl R0
Depth DRILLING LOG
(Road, Community or $ubdivision and Lot No.)
From To Formation Description
2.
OWNER °hn15 0e,11 rnar,
0 3o DIRT
ADDRESS / U Lo k 133,z—
30 CONSOLIDATED ROCK
P,*i C✓Lr4'k V N C ;,8139
_
3.
DATE DRILLED 1-10-l000 USE OF WELL -DOMESTIC
4.
TOTAL DEPTH �45'
5.
CUTTINGS COLLECTED? NO
—
6.
DOES WELL REPLACE EXISTING WELL? NO
_
7.
STATIC WATER LEVEL Below Top of Casing: 3 S FT.
_ _ o
-"
B.
TOP OF CASING IS I FT. Above Land Surface.
_ _ =q
r
9.
YIELD (gpm) I o METHOD OF TEST -PUMP
_ _
10.
WATER ZONES (depth)
_
11.
CHLORINATION: Type CHLORINE Amount
12.
CASING:
o
Wall Thickness
Depth Diameter or Weight/Ft. Material
rj
From 0 To 3 o ft. 6 1/4 SDR 21 PVC
From To ft.
From To ft.
(Show direction and distance from at least two
tate Roads, or other map reference points)
13.
GROUT:
x
Depth Material Method
/
From 0. To 20 it. NEAT CEMENT HANG METHOD
From To ft.
14.
SCREEN:
Depth Diameter Slot Size Material
From To ft. in. in.
From To ft. in. in.
From To ft. in. in.
15.
SAN➢/6RAVEL PACK:
Depth Size Material
From To ft.
�y` (p )er ��•
From To ft.
14. REMARKS:
I DO HEREBY CERTIFY THAT -THIS WELLWASCONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTIONIJAI�AR@S, AND THAT AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
i SIGNAT E OF CONT CTOR OR A NT DATE 1—�8-oZ000
GW-1 REV. 9/91 Submit original to Division of Environment Management and copy to well owner.

Page I of 1
North Carolina Departmenr of Environment, Health and Natural Resources
Division of Environmental Management - Groundwater Section
P.O. Box 29535 Raleigh, NC 27626-0535
Phone [phone]
WELL CONSTRUCTION RECORD
FOR OFFICE USE ONLY 9 0 r' ;?
Quad. No. Ser. No.'- V
Lat. Long. RO
Minor Basin
Basin Code
Header Ent. GW-1 Ent.
Drilling Contractor CAMP'S WELL h PUMP CO., INC.
flr,-lje. d.134,ZI35? ;132 State Well Construction
Driller Registration Number 215 Permit Number
1. WELL LOCATION: (Show sketch of the location below) County Po L K
we..... T�..
(Road, Community or Subdivision and Lot No.)
2. OWNER 'fawaes perk jrEer, Reef L-k'
ADDRESS +. f B P K Y
_�aflie✓ r, rd'I 1JC
3. DATE DRILLED 1-13-,,�ooa USE OF WELL -DOMESTIC
4. TOTAL DEPTH +0 5
5. CUTTINGS COLLECTED? NO
6. DOES WELL REPLACE EXISTING WELL? NO
7. STATIC WATER LEVEL Below Top of Casing: S FT.
B. TOP OF CASING IS I FT. Above Land Surface.
9. YIELD (gpm) Io METHOD OF TEST -PUMP
10. WATER ZONES (depth)
it. CHLORINATION: Type CHLORINE Amount
12. CASING:
Wall Thickness
Depth Diameter or Weight/Ft. Material
From 0 To I/S ft. 6 114 SIR 21 PVC
From To ft.
From To ft.
13. GROUT:
From 0.
From
14. SCREEN:
From
From
From
Depth Material Method
To 20 ft. NEAT CEMENT HAND METHOD
To ft.
Depth
To
To
To
15. SAND/GRAVEL PACK:
Depth
From To
From To
14. REMARKS:
I
MAR -
GW-1 R 9/01
Diameter Slot Size Material
ft. in. in.
ft. in. in.
ft. in. in.
Qrlo�
Size Material
ft.
ft.
pND}
Depth DRILLING LOG
From To Formation Description
0 I I5 DIRT
I CONSOLIDATED ROCK
(Show direction and distance from at least two
State Roads, or other map reference points)
Cn2os.. QiatiC.n �-�
L WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER,
SIGNATUR OF CONTRAC R OR AGENT DATE
Submit iginal to D' ision of Environment Management and copy to well owner.

North Caroline - Department of Environment and Natural Resources - Division of Water Duality • Groundwater Section 2 27 492
1638 Mail Service Center - Raleigh, N.C. 27699-1638-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: (5�EFd aR ))`Eu- bmp Cv.
WELL CONTRACTOR CERTIFICATION 0: low` 2O2-4-
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residenllal UO Municipal ❑ Indusidat ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATIQQN�: (Show S
Nearest Town: �.[St� —
3. OWNER
Address
of the location below) I(
'L�) County o� `\
Of
City or To,+ SlZip Code
4. DATE DRILLED at
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑ NOE�3
7. DOES WELL REPLACE EXISTING WELL? YES 0 NOF-1
S. STATIC WATER LEVEL Below Top of Casing: --%k FT.
(Use'.' II Above Top of Casing)
9. TOP OF CASING IS� FT. Above Land Surface'
Top of casing terminated at/or below land surface requires a variance In accor.
dance with i5A NCAC 2C A 19 p
10. YIELD (gpm): METHOD OF TEST
11. WATER ZONES (depth):
12. CHLORINATION: Typo Amount
13. CASING:
Wall Thickness
Depth �n��jj m t9r / o h F. to
From] To —J—„— Ft �
From To !///�� FI. vG
From To FI.
14. GROUT:
Depth alert ethod
From To .,c Pt.
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
Agricultural ❑ Monitoring ❑
DRILLING LOG DEPTH
From To Formation pescdptlon
/; - // Y
It additional space Is needed use back of low
'3
LOCATION SKETCH c'
(Show direction and distance from at least two State
Roads, or other map reference points)
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C. WELL
CONSTRUCTION STANDARDS, AND THAT A COPY F IS RE RD HA BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY (r�'a'�`^- I C—
Quad No: SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to DIAslon of Water Quality. Groundwater Section within 30 days
Serial No. GW1 NEV. 11J99

0102 2 7493
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mall Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: GKIEW ldEF-0tl .��{ PIMP Co
WELL CONTRACTOR CERTIFICATION #: i
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable 'Box): Resldonllal (r Municipal ❑ Industrial IDAgricultural ElMonitoring ElRecovery ❑ Heat Pump Water Injectlon ❑ Other ❑ If Other, List Use:
2. WELL LOCAT1 1ghow s Iclrof the location below)
Nearest Town: \ `S t County: ESL
�IQr� C W1V�E?
(Road Nam andr1�b s, o or Sub �yIsIP and Lot No.) o.) DRILLING LOG DEPTH
3. OWNER 1�`O� `N \ From To Formation pescdptlon
Address O [�
�ilreotcrHoutg. F
City or Town Slate 21p Coda
4. DATE DRILLED�o�—ag-C�
5. TOTALDEPTH
6. CUTTINGS COLLECTED YES ❑ NOOK
7. DOES WELL REPLACE EXISTING WELL? YES NO[w'
8. STATIC WATER LEVEL Below Top of Casing: FT. O
(Use'i It Above Top of Casing) = _ _ -
9. TOP OF CASING IS FT. Above Land Surface' 3'.
'Top of casing terminated Wor below land surface requires a variance In accor-
dance with 15A NCAC 2CrqAI8
10. YIELD (gpm): METHOD OF TEST ' \ c.j _
11. WATER ZONES (depth): ?
12. CHLORINATION: Type [47Amount It additional space Is needed use back of forte ^'
13. CASING:
LOCATION SKETCH =-
Wall Thickness
Deplh, iamelar or I M e I (Show direction and distance from at least two State
From/ To FL �� rl ( Roads, or other map reference points)
ly
From TO FI."�
From To Ft.
14. GROUT:
Depth � Ma all pihod
From r\\
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:
SlotSlze Material �\
In.
In.
In.
Material
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTR CTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A CO/�/,/yJ IS RECO D HAS BE PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY ' ^
DATE
Ouad No: ? $ �Ii sl ATURE OF PERSON CONSTRUCTING THE WELL
` 'b < t S'tlWnli• 4 al pivislon of Water Quality, Omundwater Section within 30 days
Serial No. G W I HE V. 12/99
o i;.

-33
22.71)
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mall Service Center - Raleigh, N.C. 27699.1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: (REW RVFlZ ))ECL � i:zrmP Ca,
WELL CONTRACTOR CERTIFICATION #:{o�
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Resldentlai O Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL
Nearest
_1
3. OWNER
Address
sketch of the location below) f\ `
County: `3C1(F-
and Numbe(s. Communlly, or Subdivision and Lot
City or Town Slate up cone
4. DATE DRILLED ' -Cf
5. TOTAL DEPTH 4
6. CUTTINGS COLLECTED YES ❑ NOO
7. DOES WELL REPLACE EXISTING WELL? YES K) NOF-1
8. STATIC WATER LEVEL Below Top of Casing: FT.
(Use'+' It Above Top of Casing)
9. TOP OF CASING IS�__ Fr. Above Land Surface -
'Top of casing terminated at/or below land surface requires a vaAance in accor-
dance with 15A NCAC 2C��0�1-1�a A
10. YIELD (gpm): sSL.! METHOD OF TEST Jdr R
11. WATER ZONES (depth):
12.
CHLORINATION: Type !ATFi Amount 1.2
13.
CASING:
Wall Thickness
DepthDiameter grWel�hVFl. yarral
r // 9-
From .i
To J50 Ft. <<M I�' L� r —
From
To Ft.
From
To Fl.
14.
GROUT:
Depth Materl I-�Melho
From i1—_
To e-;ql "_ Ft. - - '1' A��+
From
To Ft.
15,
SCREEN:
Depth Diameter Slot Size Material
From —To—Ft
_ In. —in.—
From _
To Ft. _ In. _ In.
From _
To _ Ft. _ In. in.
16,
SAND/GRAVEL PACK:
Depth Size Material
From
To —Ft. —
From
To Ft.
17.
REMARKS:
Agricultural ❑ Monitoring ❑
DRILLING LOG DEPTH
From To Fonnallon pescripllon
i - 72
N '-
tN� �
If additional space Is needed use back of form'
LOCATION SKETCH I Vol 7`x
(Show direction and distance from at least two Slate
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 C OFT IS RE D H S BEEN PROVIDED TO THE WELL OWNER.
P//ypy,^
FOR OFFICE USE ONLY —/' "" � 'NC NST vNG`T �
Ouad No: - SIONATUFlE OF PERSON CONSTFlUCTING THE WE DATE
/Submit odeinal to Division of water ouallly. Groundwater Section within 30 days
Sedal No. - GWA nEV. 12/99

I
North Caroline - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mall Service Center . Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELLCONTRACTOR: rF1 F✓��R�)�c� �r AMP CC1
WELL CONTRACTOR CERTIFICATION 0: 2--02-4-
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential ® Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other M If Other, List Use:
2. WELL LOCATI L (ShfRw sketch of the location below)
Nearest Town: County:
(Road Na a it NuComm inily. or Subdivision and Lot No.) DRILLING LOG DEPTH
1�\
3. OWNER ` I?Rt�,t^� From To FormaOan pescdpllon
Address_J�}
City or Town rr Stale Zip Code Z,2 L 1 —
4. DATE DRILLED -
5. TOTAL DEPTH c_
6. CUTTINGS COLLIE TED YES Q NO® —
7. DOES WELL REPLACE EXISTING WELL? YES NO®� CMQaiI--
S. STATIC WATER LEVEL Below Top of Casing: FT. �—
(Use -.- If Above Top of Casing) LLI
9. TOP OF CASING ISFT. Above Land Surface-
-Top of casing terminated al/or below land surface requires a variance Ip accor.
dance with 15A NCAC 2C�0118
10. YIELD (gpm): c METHOD OF TEST AR,
11. WATER ZONES (depth):
12. CHLORINATION: Type Lr�-'j Amount If additional space is needed use back of form --
13. CASING:
Wall Thickness LOCATION SKETCH JV07' r0 xnl�
Depth//,_, lamelor o W II h,\VFL Fjlafedal (Show direction and distance from at least Iwoznrhr �
From } / To —7f— Ft. n d �' ( _ Roads, or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
f� Depth,,ff11 Materiel elho
--
From To
From To Fl.
15. SCREEN:
Depth Diameter
From To _ FI In.
From To Ft. _ In.
From _ To Ft. _ In.
16. SAND/GRAVEL PACK:
Depth Size
From To Fl.
From To Ft.
17. REMARKS:
Slot Slze Material
In.
In.
In.
Material
7
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C. WELL
CONSTRUCTION STANDARDS, AND THAT %C��jY THIS 07CSrBEr PROVIDED TO THE WELL OWNER. C
FOR OFFICE USE ONLY jVVV/'lt{'�I /IQ -
Quad No SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit od0inal to Division of Water Quality. Groundwater Section within 30 days
CW1 REV. 12/99
Sadal No.

Norlh Caroline • Department of Environment and Natural Resources - Division of Water Ouallry - Groundwater Section
1638 Mall Service Center - RaIdIgh, N.C. 27699.1636-Phonej919) 733.3221
WELL CONSTRUCTION RECORD WELL CONTRACTOR: Y�F� k%y6R11)cu4 pinjP Co
WELL CONTRACTOR CERTIFICATION #: , 0 ` 7-O2-4-
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable sox): Residential Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATIQ[y (S w sketch of the location below)
I
Nearest Town: T County:
(Road N
3. OWNER
Address
or Subdivision and Lot No.)
City or Town Stale Lip cone
4. DATE DRILLED ID',3�fA
5. TOTAL DEPTH-3a q _
6. CUTTINGS COLLECTED YES Q NO
7. DOES WELL REPLACE EXISTING WELL? YES 0 N0E—]
8, STATIC WATER LEVEL Below Top of Casing: FT.
(Use'.' If Above Top of Casing)
9. TOP OF CASING IS j FT. Above Land Surface'
'Top of cuing terminated auor below lend auhece requires a varlaTcl In accor-
dance with 15A NCAC 2C_ 119
10. YIELD (gpm): _- / METHOD OF TEST L P e
11. WATER ZONES (depth):
12. CHLORINATION: Type /'( Amount
13. CASING:
Wall Thickness
Agrlcultural ❑ Monitoring ❑
DRILLING LOG DEPTH
From To Foanallonpesc(100n
rJ �2 �' 1
0
t
If additional space Is needed use back=torm^ICD
LOCATION SKETCH- /4j l�
I I I Stale
Depth /,��?
DlameIor or WeyI h,V,FI. M�ateeripi (Show direction and distance from at eas wo
Fro,To � Ft.iQ . / J �—e- Roads, or other map reference points)
From To FI.
From To FI.
14, GROUT
r, Depth _ M tart I
From S1— To a 0 FI. C\
From To Ft.
15. SCREEN: \
Depth Diameter
From _To_ Ft _. In.
From ._ To _ Ft. _ in.
From _ To _ Ft. _ In.
16. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To Ft.
17, REMARKS:
Slot Size Material I
In. 1In.
_ In.
Material
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A C Y THIS -CORD BEEN 7VIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY DATE
Ouad No SIGNATURE OF PERSON CONSTRUCTING THE WELL
Submit original to Dtvlston of Water Duality. Groundwater SectIon within 30 days Gw t nEV. 12/99
Serial No.

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Soctlon ; _ , U 'i O Q 3
" `-1536 Mali Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELLCONTRACTOR:
WELL CONTRACTOR CERTIFICATIONII:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (check Applicable next: nesidenllal ® Municipal ❑ Industrial ❑ Agricultural El Monitoring ❑
Recovery ❑ float Pump Water Injection ❑ Other ❑ If Other, List Use:
2, WELL LOCAT!S fS1u `sk�tch of the location below)
Nearest Town: !tL )K County: t—JOLL
3. OWNER
Address
No.) DRILLING LOG DEPTH _
From To Formallon Description
Ciry or Town r Stale Zip Code
DAT E DRILLED w� = o
5. TOTAL DEPTH 3 5
6. CUTTINGSCOLLECTED YESO NO[56
7. DOES WELL REPLACE EXISTING WELL? YES Q NOXI
8, STATIC WATER LEVEL Below Top of Casing: FT.
(Use'.' II Above Tap of Casing)
9 TOP OF CASING ISFT, Above Land Surface -
'Top of casing terminated atior below land surface requires a variance In actor.
dance with i6A NCAC 2C 119 '
10. YIELD (gpm): METHOD OF TEST
it. WATER ZONES fdepih):-"QC-'� cs1e4 .5�lS �Sa�raa9
12. CHLORINATION: Type
13. CASING:
Amount
Wall Thlckness
DepthL;/� �Dlynerr r'Wji000-/����F/`_ 6"C
From } / To sL`-= Fl.l(J-tom 6
Frorn To Ft.
From To-- Ft
d. GROUT:
Dop1b M-
Frorn 0 To �� -- F I +
From _ To Ft.
is. SCREEN:
Depth Diameter
From _I o _ Ft _ In.
From —To—Ft.— In.
From ___ To _ Ft. -- In.
16 SANDIGRAVEL PACK:
Depth Size
From To Ft.
From To Ft.
.-
17.REMARKS:
�5
/S -_ 30
1
If additional space is needed use back lon
LOCATION SKETCH %Yo-� 2 .
(Show direction and distance from at least two Slate
Roads, or other map reference points)
I DO IIERESY CFRTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 1SA NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY O HIS R ORD H EEN P VIDED��QJ THE WELL OWNER.
��..nl V.c1 GM �iJ'"
FOR OFFICE USE ONLY
Quad No SIGNATURE OF PERSON CONSTnUCTING THE WELL DATE
Sutvnli original to Division of Water Guathy. Groundwater Section within 30,days
Gvl1 nEV. 12l99
Serial No.

North Cnrollna - Department of EnOronmenl and Natural Resources - Division of Were( Quality - Groundwater Section
1636 Mall Service Center - Raleigh. N.C. 27699-1636-Phone [phone] r
DER Li ACLU
WELL CONSTRUCTION RECORD WELL C-tkErd
ELL CONTRACTOR CERTIFICATION A: 6 — = O24
STATE WELL CONSTRUCTION PERMIT#:
WELL USE (Check APPllcable eos): Residential la Municipal ❑ industrial ❑
Recovery ❑ Heal Pump Water Injection ❑ Other if Other, List Use:
2. WELL LOCATION: (Show sketch of the location below) 1- 01 \'
_ County: �'h
Nearest Town
(Road r me pnnd ,ua'benl CO nunily, or Subdivlsbn and Lot
3. OWNER
Address ` e) clt'� 1 iii(0
DRILLING LOG
From To
Agricultural ❑ Monitoring ❑
DEPTH
Foanallon DescrrpJion
City or Town 111'
DAI E DRILLEDQr'�'�j --�--'
5. TOTAL DEPTH'dt�---
6. CUTTING S COLLECTED YES❑ NOW Q f
7. DOES WELL REPLACE EXISTING WELL? YES ® NOD
❑ O
6. STATIC WATER LEVEL Below Top of Casing:
(Use -.' 11 Above Tap of Casing)-
9. TOP OF CASING IS FT. Above Land Surface-
_,>Topof easing terminated eVor below land surface requires a variance In accor-
dance with 15A NCAC 2C.0118
10. YIELD (gpm): _.4-- METHOD OF TEST Z T _
l�,��1� G�a�tt w I51'
11. WATER ZONES (depth): t- , I ,el.' —`
GPI— �'- I
Qt 7
Amount It additional space Is needed use bark of lorrt�,^
12. CHLORINATION Type - ,, i
13, CASING: LOCATION SKETCH AT 157
Wall Thickness
t Depth D(llaap)elor r hUFL tedaI (Show direction and distance Irom at least Iwo State
From 71 To 70 Ft. �— �'� � Roads, or other map reference points) • ----
From To Ft.
From To _-- FI
14. GROUT:
Depth �-, Maler al
From To '- Fl. 2
From Tb FI.
t 5.'SCREEN:
Depth Diameter
From To __ FI -- In.
From _ To _ Fl. _ In.
From _To_ Ft. _ In.
16. SAND/GRAVEL PACK:
Depth Size
Fton'. To FI.
From To FL
1?.REMARKS:
Slot Size
In.
In.
_ In.
Material
Material
i DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTE IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS. AND THAT A5? Y, QFj THIS> E ,/ '�,7 ENi(ROVIDED TO THE WELL OWNER
FOR OFFICE USE ONLY
Quad No:
Serial lie.
SIONATU E OF PERSON CONSTRUCTING TFiE WELL DATE
Submit original to DMsion of Water Ousi ly. Omundwater Section within 30 days GW i nEV. 12199

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section . l �++ 1? f'
1636 Mail Service Center - Raleigh, N.C. 27699.1636-Phone [phone] t. WELL CONSTRUCTION RECORD WELL CONTRACTOR: wFF� rc v�K L -_1jL CF'
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential LJ Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use: - -
2. WELL
Town:
(Road Name
3. OWNER
Address
sketch of the location below) - -
Pd�k
>. n� County: t
AUG 1 $ 2
Rmunity, or Subdwision and Lot No.) DRILLING LOG DEPTH
a
4. DATE DRILLED
5. TOTALDEPTH
6. CUTTINGS COLLECTED YES ❑ NO[a"
7. DOES WELL REPLACE EXISTING WELL? YES ❑ N0P:J
8. STATIC WATER LEVEL Below Top of Casing: FT.
' (Use': it Above Top of Cuing)
9. TOP OF CASING ISFT. Above Land Surface'
-Top of casing terminated at/or below land surface requires a variance In accor•
dance with 16A NCAC 2C .� 1j¢
10. YIELD (gpm): METHOD OF TEST f
11. WATER ZONES (depth):
12. CHLORINATION: Type "I H Amount
13, CASING
Wall ThicWtgss
.Depth,
From � To �
Dame er ate .1
Ft. �J l/
Wel✓Q M
al
From To
for
Ft.
From To
Ft.
14. GROUT:
Depth
From �— To t�.�
oleo 1 Metho
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:
From To-1-om^aNpmmanpwu:�,
�`
/65
a.
G7
�:
N
—t
0
It additional space is needed use back of form
'z
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
I DO HEREBY CERTIFY THAT THIS WELL WAS CONST CT CCORDANCE WITH 15A NCAC 2C. WELL
CONSTRUCTION STANDARDS, AND THAT A C Y O HIS ECO D H S EEN PROVIDED TO THE WELL OWNEP
FOR OFFICE USE ONLY
Zy i
Quad No
SIGNATURE OF PERSON CONSTRUCTING THE WELL O:.7E
Subrnil original to Division of Water Gualily, Groundwater Segion Within 30 days
Gw-1 FEv. tzrn
Serial No.

North Carolina - Departtlir" Envitonment-and Natural Resources -Division of Water Quality -Groundwater Section21
1636 Mail Service Center - Raleigh, N.C. 27699.1636-Phone [phone] J V
WELL CONSTRUCTION RECORD WELLCONTRACTOR: 6ZE4 JVFK Ukdd -131mp CAE'
WELL CONTRACTOR CERTIFICATION #:
,_,
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential R( Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCA N ho ket h of the location below)nV
Neare t To v C^unN: ` -
(Road Nam and rs. Coornn ni , or Subdivision and Lot No.) DRILLING LOG DEPT11 H
3. OWNER t� From To Fora'a4on Oescnp4on
Address rr-s--� 'T �i; n.,�. a'�l_ rv,. 1. 9
(3treat or '_ JC2C o.t 3a ,� � n � n __
T�~♦1 P i'1 B
Ct� r own (� ' ^ AStatte_ Zip Code
Jk
4. DATE DRILLED 9-ra _ ter,
5. TOTAL DEPTH 59 S
6. CUTTINGS COLLECTED YES 0 NO[o
7. DOES WELL REPLACE EXISTING WELL? YES NO
8. STATIC WATER LEVEL Below Top of Casing: FT. - =
• (Use'+' II Above Top of Casing) .C7 -
9. TOP OF CASING IS Fr. Above Land Surface'
-Top of casing terminated at/or below land surface requires a variance In accor- -
dance with 15A NCAC 2C . 11 a
10. YIELD (gpm): M METHOD OF TEST A/ iZ z `J
11. WATER ZONES (depth): n- —
' c�
12. CHLORINATION: Type 14TI4Amount 1-,2v-s«. If additional space is needed use back of harm Z
13. CASING:
Wall Thickness
I- �Deplhy^ i I atedal (Show direction
From* _�— Ft. r y � Wd3,
From ToZD— Ft.
- From To Ft.
14. GROUT:
De at nal
From 0 ToPLO_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 Top— Ft.
17. REMARKS: '
Slot Size Material
in.
In.
_ in.
Material
LOCATION SKETCH
and distance from at least two State
t'r map reference points)
�'
`M
��.Q 0.R
C
4�
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COP OF IS RECORD Hl��/ EEN PROVIDED TO THE WELL OnWNEP-
FOR OFFICE USE ONLY �L� C�hpY .� 2J /l J d ��
Quad No: SIGNATURE OF PERSON CONSTRUCTING THE WELL GATE
Submit odginal to Divlslon of Water Quality, Groundwater Section within 30 days
Gw.t FLEv. tzv1
Serial No.

r
North Carolina - Department•of EnvironmentandNatural Resources - Division of Water Quality - Groundwater Section "" 2 15 U 5
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone] "
WELL CONSTRUCTION RECORD WELL CONTRACTOR: 6PFEN � VFr1LUr1iMP CE
WELL CONTRACTOR CERTIFICATION #: .S%%—
STATE WELL CONSTRUCTION PERMIT#:
1, WELL USE (check Applicable sox): Residential EO Municipal ❑ Industrial ❑ Agricuiturtin....�-..�.DA®rr'
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATI(p�N (g`h sketch of the location below) ['�©( 1�
Nearest Town: (' "i�1 {JQI a2I,3 County: \,_ \i
(Road garlie and Nu m s, unity, C �q ity, or Subdivision and Lot No.) DRILLING LOG
3. OWNER \ From To
Address
t tr t or e
el `
ity or To n`'� ,-Svtate Zip Code
4. DATE DRILLED /_
5. TOTAL DEPTH cbR--tFF7--�'�----- u
6. CUTTINGS COLLECTED YES Q NO[✓'
7. DOES WELL REPLACE EXISTING WELL? YES ❑ N0EEr
8. STATIC WATER LEVEL Below,Top of Casing: FT.
(Use'+' if Above Top of Casing)
9. TOP OF CASING ISFT. Above Land Surface'
Top of casing terminated alJor below land surface requires a variance In accor.
dance with 15A NCAC 2C 0118
10. YIELD (gpm): I — METHOD OF TEST
11. WATER ZONES (depth):
DEPTH
Formation Descnptton
9-KNE1�.l11(1
�. 4WI N �
W-1
12. CHLORINATION: Type 14TIP4Amount If additional space is needed use back of �n o
13. CASING:
Wall Thickness
' 4Dept� iamet'r ei ty �n�
From To Ft. f0
From To Ft.
From To Ft.
14. GROUT:
Depth
� ate Method
From _C') To FL
From To Ft.
15.SCREEN
Depth
From —To
_Ft
From —To
—Ft.
From —To
—Ft.
16. SAND/GRAVEL PACK:
Depth
From
To
From
To
17. REMARKS:
Diameter Slot Size Material
in. In.
In. In.
In. —In.
Size Material
Ft.
Ft.
LOCATION SKETCH
(Show direction and distance from at least two Stale
Roads, or other map reference points)
I DO HEREBY CERTIFY THATTHIS WELL WAS CONST UCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COP/Y�OF IS R C D HA EN PROVIDEDTOTHE WELL OWNER 'n
FOR OFFICE USE ONLY r N i% D �7 D Lq
Ouad No: SIGNATURE OF PERSON CONSTRUCTING THE WELL Ds TE
Submit original to Division of Water Duality, Groundwater Section within 30 days
Gw-t FtEv, tYfi
Serial No.
.14

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]
"155054
WELL CONSTRUCTION RECORD WELL CONTRACTOR: �PF6N T�vez CUeu C'
WELL CONTRACTOR CERTIFICATION p:
STATE WELL CONSTRUCTION PERMITC
1. WELL USE (check Applicable Box): Residential ❑ Municipal ❑ Industrial ❑ A r'cultural �❑,1 Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other W If Other, List Use: k, 0%,�Q, P\.O PC,- c —
2. WELL LOCAT N: (Show sl etch of the location below) ��,�k
NNe'arest Town: I County:
= '
(Road amP.�ndNumbers. omr+u,Zo Subdivision and LotNo.) DRILLING LOG-
3. OWNER .VnQ W r From To ) FonrSnbesePtpvo�n
7Y1�� ee or utgr q y�.75
n-
City or o q State Lp Code
4. DATE DRILLED /-1/' �
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES L-j NOZ
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO[✓] —— _
8. STATIC WATER LEVEL Below,Top of Casing: FT.
(Use': It Above Top of Chasing) OCZ)
N
9. TOP OF CASING ISFT. Above Land Surface-
-Top or casing terminated avor below land surface requires a variance In actor- J
G')
dance with 15A NCAC 2C -0 18
10. YIELD (gpm): Y METHOD OF TESTA) 1
11. WATER ZONES (depth): D
12. CHLORINATION: Type T Amount
13. CASING:
Wall Thickness
.Depth /D�i�a//nw'eter 1E . ` ateda
m l
FroTo � Ft. LR a[a f/L
From i Ft.
From To Ft.
14. GROUT:
Depth_, aten I (`(vlelhod
From Q— To 4X_LL_. Ft. 6� V
If additional space is needed use back glfprm
N —+
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map 71erence points) \
From To
Ft.
L
i
15. SCREEN:
7A
Depth
Diameter Slot Size
Material
From
_ in. _
in.
—TO—Ft
From _To —Ft.
— in.
In.
From _ To _
Ft. In. —
in.
15. SAND/GRAVEL PACK:
(,A•
Depth
Size
Material
From To —Ft.
-
From To
Ft.
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONj�HISR
CTED IN ACCORD CE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A (APY R HAS E N PROVIDED TO THE WELL OWNED
/� � n � �� %//-�
FOR OFFICE USE ONLY i D�,TE
Quad No: SIGNATURE OF PERSON CONSTRUCTING THE WELL
Submit original to Division of water Quality, Groundwater Section Within 30 days
Gw-1 REV, 17J99
Serial No.

North Carolina - Department of Environment and Natural Resources- Division of Water Quality - Groundwater Section
1636 Mail Service Center. Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONTRACTOR: N vE
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMIT#:
WELL CONSTRUCTION RECORD
1. WELL USE (Check Applicable sox): Residential E Municipal ❑ Industrial ❑ Agricultural ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCA
Nearest Town
3. OWNER
Address
sketch of the location below)
County:
DEPTH
Forrnalion DescdpLan
or
City or Town (' ,-State Zip Code
4. DATE DRILLED' (JU
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑ NO[]
7. DOES WELL REPLACE EXISTING WELL? YES Q" N0E-�
B. STATIC WATER LEVEL Below Top of Casing: FT.
(Use '+-1(Above Top of Casing)
9. TOP OF CASING ISFT. Above Land Surface-
-Top of casing terminated atior below land surface requires a variance In accor-
21 084
Monitoring ❑
DRILLING LOG
From To
dance with 15A NCAC 2C its /t / Q
� METHOD OF TESTA)
-- - -v r�+`
rn
10.
YIELD (gpm):
cr, s
11.
WATER ZONES (depth):
F.. c�
12.
CHLORINATION: Type
T Amount 0-
It additional space is needed use back oldorm Z
13.
CASING:
LOCATION SKETCH
r *Depth
Wall Thickness
Diarfetyf I. atenal
UC
(Sho w direction and distance from at least two State
tots)
•
`L�
Ft.
�If<
Roads, or other map reference p
From J--To
From To
Ft.
^ \
From To
Ft.
r1rE
14.
GROUT:
O Deplty
jr0
M IMetho
\fh S
From To
FL
Q
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
Fl.
17. REMARKS
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRU ED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A OPY IS ECO AS BEEN PROVIDED TO THE WELL OWNER
62 -
FOR OFFICE USE ONLY Ds.TE
Quad No: SIGNATURE PERSON CONSTRUCTING THE WELL
Submit original to Division of Water Quality. Groundwater Section within 30 days GW t REV. 12M
Serial No.

215083
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwa:er Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELLCONTRACTOR: G!'E��✓� C
WELL CONTRACTOR CERTIFICATION #: S%%—i\=�
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (check Applicable sox): Residenlial5J Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
___...._
2. WELL LOCATION: (Show sketch pp1 the location below)
//
Nearest TownfCounty:,
(Road N
3. OWNER
Address
or Subdiv' Iona dLot No..) ( DRILLING LOG DEPTH
From To Formation Descnpcon
City or Town Stale Zip Code
4. DATE DRILLED 0c)
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES 0 NOE]—
7. DOES WELL REPLACE EXISTING WELL? YES � NOE]
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 cuing terminated st/or below land surface requires a verlance In accor-
dance with 15A NCAC 2C . 16 10. YIELD (gpm): METHOD OF TEST A 12
11. WATER ZONES (depth):
12. CHLORINATION: Type —14 �H Amount
13. CASING:
N�_•m_�1r
�
o
o-
o
rn
It additional space is needed use backor
m
LOCATION SKETCH ON
o
Wall Thickness
-Dept iarmeter oorr7�y��rl�ory//1. rNatenal (Show direction and distance from at least two State
Roads, or other map reference points)
tom
9
Ft.
From To�
From To
Ft.
14.
GROUT:
Depth
V
e ethod
L
From Top�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:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C. WELL
CONSTRUCTION STANDARDS. AND THAT A CY HIS R C RDHA EN PROVIDED TO THE WELL OWNEP_'
FOR OFFICE USE ONLY '-7 SIGpfgTU�RE OF PEfl50N CONSTRUCTING THE WELL DATE
Quad No:
submit original to Division of Water Quality, Groundwater Section Within 30 days
GW-1 ftEV. I297
Serial No.

r
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwa:er Section It_`� �),R
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone] v
WELL CONSTRUCTION RECORD WELL CONTRACTOR: is! C'
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (check Applicable Box): Residential2' Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ It Other, List Use:
2. WELL LOCA
Nearest Town:
3. OWNER
Address
Agricultural ❑ Monitoring ❑
of the location below) -
county:
.rR
Community. or Sub divisio\and Lot No.)
Yi ll��
City or Town Stale Zip Code
4. DATE DRILLED 5-31 -00
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES Q NO[2
7. DOES WELL REPLACE EXISTING WELL? YES NOQ
8. STATIC WATER LEVEL Below Top of Casing: FT.
(Use': If Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface'
'Top of casing terminated at/or below land surface requires ■ variance In accor-
dance with 15A NCAC 118 A
10. YIELD (gpm): METHOD OF TEST AI 2
11. WATER ZONES (depth):
12.
CHLORINATION: Type
T
Amount ��-
13.
CASING:
�I
"Depth
To �Q
ia/ne)yr
Ft. �/9
Wall Thickness
iij I. '1.1a{erial
L�
From
From To
Ft.�D�
1==—
From
To
Ft.
14.
GROUT:
Depth ,�,,
ea
I [ e"o_d (�
From
ToiFt.
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:
DRILLING LOG
From To
J�
pro-
• ter_ r1
,fie
If additional space is needed use back dLtbrm�
LOCATION SKETCH
(Show direction and distance from at least tw�.StaUe �.,
Roads, or other map reference points) T m u
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THATA CO{d'PP�/X1(OF HIS RF`�('ORD H-� EEN PROVIDED TO THE WELL OWNEP_
FFO�RFFICE USE ONLY��: SIGNATURE OF PERSON CONSTRUCTING THE WELL 01.7E
Submit original to Division of Water Quality. Groundwater Section Within 30 day5GW-7 REV. t7fA.

North Carolina - Department of Environment and Natural Resources - Division of Water Duality - Groundwater Section '� j 0 2
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: N v' C
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential© Municipal ❑ Industrial ❑ ural
Recovery ❑ Heat Pump Water Injection ❑ Other It Other, List Use:
2. WELL LOCATION: (Sh sketch of the location below) / 0 I
Nearest Town: County
:-
:
(
(Road Nam nd Numbers, C S*imun' or S'Gdlvision and Lot No.) DRILLING LOG DEPTH-
3. OWNER \ From To Formation Description
Address C) rJyl ��
e— I —i \ (Scree: or utv .) -7
)�lllc�cy /V6_r aL�i
tale p CdeCity �
4. DATE DRILLED
5. TOTAL DEPTH L6 6. CUTTINGS COLLECTED YES ❑ NOQ-
7. DOES WELL REPLACE EXISTING WELL? YES NO[�
8. STATIC WATER LEVEL Below Top of Casing: FT.
(Use'+' II Above Top of Casing)
9. TOP OF CASING IS i FT. Above Land Surface'
'Top of casing terminated aVor below land surface requires a variance In accor-
dance with 15A NCAC 2C 11a
10. YIELD (gpm): LP METHOD OF TEST Al2
11. WATER ZONES (depth):
12. CHLORINATION: Type T Amount
13. CASING:
Wall Thickness
Clamete u')Ft/ serial
From ` To Ft.'o✓�
From To FI.
From To Ft.
14. GROUT:
Depth M t ethod
From �— To 0 Ft.
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From —To—Ft— in. —in.—
From —To — Ft. _ in. in.
From —To —Ft. — in. _ in.
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
'D m
It additional space is needed use back o m o
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map relerence points)
o�
N
CJ I� roto
17. REMARKS:
I DO HEREBY CEEiTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPS OF THIS F�tEQORDOH BEEN PROVIDED TO THE WELL OW
NER
FOR OFFICE USE ONLY \llln S
Quad No:
Serial No.
SIGNATURE OF PERSON CONSTRUCTING THE WELL
Submit original to Division of Water Ouality, Groundwater Section within 30 days
DATE
GW-1 REV.'ZM

North Carolina - Depar4ment ofl�✓ronmeni-and'Ita16ral Resources ---Division of Water Quality - Groundwater Section' 215063
1636 Mail Service Center -Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: E?EEbl JYEK it L CI
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMITq:
1. WELL USE (Check Applicable Box): Residers l LYJ Municipal ❑ Industrial ❑ Agricultural Q_- M�rh�ring b,
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATI :,(Sh w sketch of the location below)
Nearest Town: V County: O
(Road Nam �d Numbers. �°�''"'urn , or Subdivision and Lot No.) DRILLING LOG DEPTH'. .
3. OWNER Jy ' From To Foirration0escripuon
Address �� i
vCa or Town Stale Zip Code`
4. DATE DRILLED ,U
5. TOTAL DEPTH �
6. CUTTINGS COLLECTED YES Q I
7. DOES WELL REPLACE EXISTING WELL? YES [� NO�� 3 env
8. STATIC WATER LEVEL Below Top of Casing: FT.
(Use -+' If Above Top of Casing) =6,11
9. TOP OF CASING IS.FT. Above Land Surface-
r '
Top of casing terminated aUor below land surface requires a variance In actor- ,� L7
dance with 15A NCAC 2C . 1 a
10. YIELD (gpm): METHOD OF TEST A) 2 "9 �'•-�
11. WATER ZONES (depth):
12. CHLORINATION: Type T Amount ! �%L: It additional space is needed use back o rm o
z
13. CASING:
Wall Thickness
Q Depth;` - Diame e' Inl6 �jaterial
From To .�-- Ft. (�`llc_
From To Ft.—�
From To.�O Ft. 4 - �L
14. GROUT:
Depth l M to /ytelhod
From To ael—Ft. d
From To Ft.
15. SCREEN
Depth Diameter Slot Size Material
From —To—Ft _ in. —in.-
From _ To Ft. _ in. _ in.
From —To —Ft. In. —in.
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
17. REMARKS:
(Show direction and distance from at least fr State
Roads, or other map reference points) �� y
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY F T REC HAS�N PROVIDED TO THE WELL OWNED
FOR OFFICE USE ONLY
Duad No: SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Duality, Groundwater Sea= within 30 days
GW-1 HE V. IL99
Serial No.

Section North Carolina - Department of Environment and Natural Resources - Division of Water Ouai, y - Groundwater `� O "
1636 Mal Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELLCONTRACTOR: 6PFEN
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable sox): Residential m Municipal ❑ Industrial ❑ Agriculturalp, r(vto((ito`pjng
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:-
2. WELL LOCATIO• : (S w sketch of the location below)
Nearest Tow( County:
(Road N d Numbers, Cor muniry, Vubdivision and Lot No.) DRILLING LOG DEPTH -
3. OWNERa 1RV �.Qnl[ `Rc�412 From To Fonrauon Description
Address /00A cr �(, ,.,r\A tr
City or Town State Zip Code Y�
4. DATE DRILLEDSLa 1
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES Q NO[
7. DOES WELL REPLACE EXISTING WELL? YES NO[�
8. STATIC WATER LEVEL Below Top of Casing: FT.
(Use': if Above Tap of Casing)
9. TOP OF CASING ISFT. Above Land Surface'
'Top of casing terminated at/or below land surface requires a variance In accor• _> ;
dance with 1SA NCAC 2C 18 r
10. YIELD (gpm): METHOD OF TEST
11. WATER ZONES (depth): tv
0
z
12. CHLORINATION: Type LEN Amount R If additional space is needed use back of form
13. CASING:
Wall Thickness
LOCATION SKETCH
*Depth
, � Qia/nejer
I- (p
or VFt. k1ral'elnal
=
(Show direction and distance from at least two State
p
From Ft.
—
Roads, or other map reference points)
From To Ft.
From To Ft.
X
14. GROUT:
r�
Depth M�te
From _'_ To �Ft.-S-i2
I Metho
a0-
From To Ft.
15. SCREEN:
Depth Diameter
From To _ Ft in.
From _ To Ft. In.
From _ To _ Ft. _- In.
16. SAND/GRAVEL PACK:
Depth
From To Ft.
From To Ft.
17. REMARKS:
Slot Size Material
_ in.
_ In.
In.
Size Material
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS. AND THAT A% e fl HI HAF,iD1 S BEEN PROVIDED TO THE WELL NEEF'
FOR OFFICE USE ONLY
Quad No:
Serial No.
SIGNATURE OF PERSON CONSTRUCTING THE WELL
Submit original to Division of Water Quality, Groundwater Section Within 30 days
DATE
GW-1 itEV. uvi

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section r'1 155
O C 51636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone] C. J
WELL CONSTRUCTION RECORD WELL CONTRACTOR: �yEK t�)F1 " P C)E>
WELL CONTRACTOR CERTIFICATION It:
STATE WELL CONSTRUCTION PERMITA:
1. WELL USE (Check Applicable BOX): Residential Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other If Other, List Use:
2. WELL LOCATIO : (Show sketch of the location below) \� ,
Nenresl Town_ _ 'N 14L County: O
dR
(Road N N�urtlbs, gmJ(nunity, or Subdivision and Lot No.) DRILLING LOG1 DEPTH
3. OWNER Q Q \oc2 From To Fom'a6on Descdpuon
Address
(\t-Stret%moo, o.
l✓ n9 T5/U
City or Wwn State Zip Code
4. DATE DRILLEDS /9S'�
5. TOTALDEPTH a
6. CUTTINGS COLLECTED YES ❑ NO[✓]"
7, DOES WELL REPLACE EXISTING WELL? YES 7 NO[D-
8, STATIC WATER LEVEL Below Top of Casing: FT.
(Use'+' II Above Top of Casing)
9. TOP OF CASING ISFT. Above Land Surface'
'Top of casing terminated aVor below land surface requires a variance In accor-
dance with 15A NCAC 2C 113 Q
10. YIELD (gpm): � METHOD OF TEST tS^)
11. WATER ZONES (depth):
12. CHLORINATION: Type T Amount /-2 1—
13. CASING:
Wall Thckness
/
t`
Depth Diameter °Weig�hVFtt �atteena]
� 1F
From
To
Ft.
From
To
Ft.
From
To
Ft.
14. GROUT:
Depth
Metho
From
To as
,t,eri
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.
If additional space is needed use back oljormfn
LOCATION SKETCH IV ma
(Show direction and distance from at least tv_0__�tat o
Roads, or other map reference points)
to
/ tv'il
i
17. REMARKS:
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OFHIS RERD BEEN PROVIDED TO THE WELL OWNEF_
✓III ply o S-/S-00
EFO�ROFFICE USE ONLY otirE
No: SIGNATURE OF PERSON CONSTRUCTING THE WELL
Submit original to Division of Water Quality, Groundwater Section within 30 days Gw t REV. I7J91
No.

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CON TRACTOR: GZCIP-4 Eiyf-K f•L)Eu� .xP 0E'-
WELL CONTRACTOR CERTIFICATION #: S%%— 2-02-5-
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (check Applicable sox): Residential g Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
Agricultural ❑ Monitoring ❑
2. WELL LOCATIQj�: $how s tch of the location below)
NearestTown: � `1w \ cw County:
(RoptlIName Aad Numbers. Co yniry, r ubdivision and Lot No.) DRILLING LOG
3. OWNERFrom To
Address —
«eet or to o.
�l ha .C,
City or To Slate Zip Code
4. DATEDRILLED.v}-.5-�
5. TOTAL DEPTH `
6. CUTTINGS COLLECTED YES F_� NOQ `
7. DOES WELL REPLACE EXISTING WELL? YES EST 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' o
'Top of casing terminated at/or below land suAace requires a variance In accor- aM
dance with 15A NCAC 2C 01 0
10. YIELD (gpm): A -�_ METHOD OF TEST A) (Z
11. WATER ZONES (depth): fc"
12. CHLORINATION: Type____RT1J Amount
13. CASING:
Wall Thickness
Deplh„/N i�rrteder ei n� t. vc-
From To Ft.
From To Ft.
From To Ft.
14. GROUT:
Depth Mated I Metho
From Q— To Q—Ft.
From To Ft.
15. SCREEN
Depth Diameter
From —To—Ft— in.
From —To—Ft.— in.
From —To—Ft.— in.
16. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To Ft.
17. REMARKS:
Slot Size Material
In.
In.
_ In.
Material
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN AC'
CONSTRUCTION STANDARDS, AND THAT A jqOPI RF THIS RECORD
DEPTH
Fonration Descdption
If additional space is needed use back
LOCATION SKETCH
(Show direction and distance from at least t
Roads, or other map reference points)
v
�y
FOR OFFICE USE ONLY I I LeW 0
Quad No: SIGNATURE OF PERSON CONSTRUCTING THE WELL
Submit original to Division of Water Quality, Gmundwater $action within 30 days
Serial No.
BATE
Gw.I aEv. Izm

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
P.O. Box 29576 - Raleigh.N.C. 27626-0578-Phone [phone]
WELL CONSTRUCTION RECORD DRILLING CONTRACTOR: S 1 Ion V1lPr 8i�
DRILLER REGISTRATION
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential E; Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: �h 1 YY111P 1 K C� — County: _ I I-
�nrn.nf 1 -! Rd,
fRo d Community, or Subtlivision and Lot No.)
DEPTH DRILLING LOG
�� Arlhtn son From To Formation Description
3. OWNER
ADDRESS pp t h^K ItiLA
��Q(Street or,ioute No.) ����
eela �'�� L, .0 I C 2
City or Town Stale Zip
ode
4. DATE DRILLED )13 OO
5. TOTAL DEPTH %D
6. CUTTINGS COLLECTED YES ❑ NOM
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 1.33 FT. Above Land Surface'
- Casing Terminated aVor below land surface is illegal unless a variance is issuer
in accordance with 15f�� N,,,CAC 2C .0118
10. YIELD (gpm): �_ METHOD OF TEST
11. WATER ZONES (depth):
12. CHLORINATION Type Amount_
13. CASING: �� Qjv P"`�
U jYL$}1 o-l"
I.
Wall Thickness
Depth is eeter or Wei hVFt.
From Q To �— Ft. mod--
swzi
From To Ft.
From To Ft.
14. GROUT:
If additional space is needed use back of form
LOCATION SKETCH
Material (Show direction and distance from at least two State
IN (11 Roads, or other map reference points)
Depth Material Metho
From G— To 2_ Ft. Wfle
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/GRAVE
From Ft.
From t Q .
17. REMARKS:
IDO HEREBY
61+ -bwards Riney V,,OJC, `RhL
prt G'�ll�arx�i�n.Zd. F�llou�ko
-:-&opSi rL.-T'�[. Rnd�roItow (�
5Picer Coves C°all
�r Father &(bons. �ocLd is
u L6kr Un. mclioh
I
t C
E
I V E
I1
� I!
KI
IIIII
I �' � ��' "ah� v�ir�tul� • �
A NCAC 2C, WELL
D TO THE WELL OWNER.
y. p�yr
FOR OFFICE USE ONLY DATE
Quad No: SIGNATUR F CONTRALTO R AGENT
Serial No: Submit original to Division of Water Quality and copy to well owner.
GW-1 REV. 1198

UST SECTION Fax:[phone] Jul 2 '99 9:50 i
REC"IVEC
12009
North Carolina - Department of Environment end Natural Resources - Division of Water 'oualily- 6rounc6ater section
P.O. Box 29578 - Ralegh,N.C. 2762KM0 Phone [phone] FAYMEVILLE
WELL CONSTRUCTION RECORD
1. WELL USE
Recovery
2. WELL
Town:
3. OWNER
ADDRE;
M c,
I
DRILLING CONTRACTOR; t=tvMl q /m P
dRTi1 ER REMSTRATION M
STATE WELL CONSTRUCTION PERMIT/:
Appuabte sox): Residential I Municipal ❑ Induptrial ❑ Agricultural ❑ Monitoring ❑
Heat Pump Water Injection ❑ Other 0 If Other; Llat Use:
how tch otthe location below) t�
County:
n�^MCI :tNo.) DEPTH DRILLING LOG
SC :, From Tq rormailon Description
No.)
CRY or Town Sttue Zip Code
4. DATE DRILL` 3 ` 00 —
5. TOTAL DEPT
6. CUTTINGS COLLECTED YES 0 NOQ-
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NOQ—,20
8. STATIC WATER LEVEL Below Top of Casing: FT.
tuna ^:: Aboya Top of Caslna
9. TOP OF CASING IS FT. Aboee:L'and Surface• o® o
- Casing Terminated avot oelow land surtax b IIIegYt.an o varlance Is Issued
In aeartlenp wlih 15 C gC .0118 I '
10. YIELD {gpm) METHOD OF TEST a
11. WATER ZONES (death):
12, CHLORINATION: Type Amount
13. CASING:
If additional space le needed use back
T -_
m
Wall Thidtnaa
1QCATION SKETCH ry
Depth-9IL�1 ppla er C/ �hAVa+enm Show tlirnction and distance from at least t>4dStete3
From V To 4V__ Ft. � O—I�LJC` ( Roa4s, or other map reference points) z
From To FI,—
Prom To Ft.
14. GROUT:
Depth MacejIof�y 1{ethod
From To Ft. i
From To Ft,
15_SCREEN:
Depth
Olameter
From _ To _
Ft in.
From —To —Ft.—
In.
From —To—Ft.—
In.
16. SANDIGRAVEL PACK:
Depth
Size
Srot'Size Material
In.
In.
in.
Material
From To Ft.
From To. ..__ Ft.
1T, REMARKS: I
I DO HEREBY CERTIFY THAT THIS WELL WAS CONS UCTED IN
CONSTRUCTION STANDARDS, AND THAT Acgff Oj/rHIS R�,n*
0
WITH 15A NCAC 2C. WELL
PROVIDED TO THE WELL OWNI
3-
4'eY
2 V V V� 1SIGTURE OF SUDMO onglne110 ONWoR of Water
and copy to wan o. -
GW-I nEv. IM
DATE

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: EPFEN R✓sr, UJF
WELL CONTRACTOR CERTIFICATION s: 6'7(o- : -02.4
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: Si
how skeigh of the location below)
crest Town CC County:
Road,91meart Nu ers, Co ^unity, or Su ivision and Lot No.) DRILLING LOG DEPTH
3. OWNER rye L� , � A' - From To Formation Description
Address
treat or outs o c
c
Cily or Town State Zip Code
4. DATE DRILLED ,p
5. TOTAL DEPTH 2 Qpo zies ,
6. CUTTINGS COLLECTED YES Q N0[1� ono
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO[,J
8. STATIC WATER LEVEL Below Top of Casing: F7. YS — .ED_� (� °
(Use': It Above Top of Casing)
9. TOP OF CASING ISFT. Above Land Surface
'Top of casing terminated at/or below land surface requires a verlance In accor•
dance with 15A NCAC 2C 118 _ -
10. YIELD (gpm): . METHOD OF TEST A/ 2
11. WATER ZONES (depth): 0
12. CHLORINATION: Type Amount If additional space is needed use backform
13. CASING: ^•
cn o
Wall Thickness LOCATION SKETCH
From�• Depth Diameter or Weight/Ft. Material (Show direction and distance from at least two State'
To Ft. Roads, or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method II
From A To F. From To —Ft.
15. SCREEN: Z
Depth Diameter Slot Size Material
From —To—Ft— in. —in.—
From —To —Ft. _ in. —In.
From _ To _ Ft. In. _ In.
16. SAND/GRAVEL PACK: O D
Depth Size Mate
From To Ft. AY 3 1 2D
From To Ft.
17. REMARKS:
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED WITH 15A NCAC 2C. WELL
CONSTRUCTION STANDARDS, AND THAT A WPY QF THIS REWFID HAS BEEN PROVIDED TO THE WELL OWNER
FOR OFFICE USE ONLY
Quad No:?T� �
Serial No. ,,.2-tu•s,J�=.Y�J-i•
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Quality, Groundwater Section Within 30 days
Gwa REV. IZM

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,MEA1 i✓1=K ale -QP
WELL CONTRACTOR CERTIFICATION: S%(o— �2-02.4
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): ResidendalLlCl Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other M If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: C4,. M"-�'s P County: `A
Agricultural ❑ Monitoring ❑
(Road Name Numbers. Co`� niy, or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER _ e-n P l ? t�dVNnQ p From To Formation Description
Address i A1 _9 C r,
4.
City or Town �State Zip Code -
DATE DRILLED�v� cp —
5.
TOTAL DEPTH
6.
CUTTINGS COLLECTED YES ❑ NOQ-
7.
DOES WELL REPLACE EXISTING WELL? YES NO©��7 _ ,�2ti
8.
STATIC WATER LEVEL Below Top of Casing: FT.
c�
(Use Y If Above Top of Casing)
i
9.
TOP OF CASING IS FT. Above Land Surface'
-n -
'Top of using terminated avor below land surface requires a variance In actor.
dance with 15A NCAC 2C. 11a
10. YIELD (gpm): METHOD OF TEST Al P-
"
11.
WATER ZONES (depth):
v
12.
CHLORINATION: Type T Amount If additional space is needed use back o roar♦, "
13.
CASING:
♦ n
bi o
LOCATION SKETCH
=C
'•� Wall Thickness
/ 'Depth/ Q giaTr ter % WgghVlct. Material
14.
15.
16.
17
CONSTRUCTION STANDARDS, AND THAT A
(Show direction and distance from at least two State
iRD BIAS BEEN PROVIDED TO THE WELL OWNEP_
FOR OFFICE USE ONLY
Quad No:
Sadal No.
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Subrrvt original to Division of Water Quality. Groundwater Section within 30 days
Gwa REV. I7/`n

No III Carolina - Department o1 Environment and Natural Resources - Division of Water Quality - urou4yaier .tedlon
p.0. Box 29575- Ralegh,N.C. 27626-057154Phone [phone]
WELL CONSTRUCTION RECORD DRILLING CONTRACTOR: QL
DRILLER REGISTRATION N: S
STATE WELL CONSTRUCTION PERMrT#:
1. WELL USE (Ct*ea Appueapla Box): Residential Munioi0al ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Reccvery ❑ i Heat Pump Wager Injection ❑ Othor ❑ If O*.her, List Use:
2. WELL LOCATI�pryp` `now etch f the location below)
N9are5i rows ` "i\�5 1 t County: —
(Roan Jom . or Suo vision and 1 01 No.) DEPTH
3. OWNER a C, _ From To
ADDRESS `7i�-,-'e=c
'A�r Routo No.)
Car o- Town Strife Zip Code
0 727-
4. DATE DRILLEESLY.3r
5. TOTAL DEPTHI.Ses..5_ _
6. CUTTINGS COLLECTED YES ❑ NOQ
7, DOES WELL REPLACE EX STING WELL? YES ❑ NOE
S, STATIC WATER LEVEL Below Top of Casing: FT.
(Use "." Y Ab» @ Top of Casino)
9, TOP OF CASING ISFT. ADoveL'and Surface'
Casing Terminrned avor Dwow land wrfam b Ilbget emcee a vanance la leaved
in accordance with 15 AC 20 .0118
10. YIELD (0pm METHOD OF TEST
11. W A7E!� ZONES (deothl:
12. CHLORINATION, Type
Amount aZ•
13. CASING:
Wall Thloknaaa
at
FrOn1 v TO
Ft.
From To
FI.
—
=rom To
Ft.
1A. GROUT:
po
�O
athod
Frye To ck
S�
R.
From To
Ft.
15, SCREEN:
De'ptn
Diameter SfolSize Material
From _ To _ Ft
_ in. In.
From —To_ F1.—
In.— In.
F n To Ft.—
In. in.
16. S.AN'DIGRAVEL PACK
Depth
Slze Material
From To
-
Ft --Pro, To. .._
Ft.
—
17.REMARKS:
I DO HEPE6v CERTIFN THAT THIS WELL WAS CON
CONSTAUCTIGIN STANDARDS. AND THAT A COP IS C
SIG"in)RE OF CONTRACTOR OR A054T CA "a
MENIMh p7j)QO Supmn 06lnd to pNblon of WW*r Oua6ry eb=PY m""0 pv"OrGw-1REV . "Ills
DRILLING LOG
Formation Deacdptlon
It addYlorei ,pace is needed uae9eck o
OCATION SK1lC�IL�SK
(Show tliredlor and distance from at {oast I
Roads, or,'.her map'elererfca Wnta)
or Mull a ��;
IffiF+MFih'NCAG 2C. WELL
PROVIDEC TO THE WELL OwNE;:.

No-vi Carolina - Department of Environment and Natural Resources - Division of Water Quefiy - �",roun'l.+'ater.�edion
p.0 Box 29573 - Raleigh,N.C. 27626-057&Phone [phone]
WELL CONSTRUCTION RECORD DRILLING CONTRACTOR: s.7(a
DRILLER REGISTRATION N:
STATE WELL CONS`fRUCTiON PERMIT#:
,�/, ❑ Agricuttural ❑ Monrtoring ❑
1 WELL USE tCrlbck Appnoanle Isox): Residential Municipal ❑ Industrial
Recovery ❑ Heat Pump Weser Injection ❑ Other ❑ If Other, List Use:
i WELL LOCATI ha sketch of the location below) O(�
-- ` CcunN
N9areSl Tpwr' /�
f DEPTH DRILLING LOG
(Roan OCrlmu ; •. o' Sul �+s(n nd .m no.) TQ rorma'lor 0eac-.c4bn
3. OWNER
ADDRESS ` 8T2a�e�Q'7�Q2
0^Routo Np.),ic, C7 C B
Q .�%
Cdr o, Tam '—'/_ �yS-tore
4. DATE DRILLED / /y_
5. TOTAL DEPTH gD S -
6. CUTTINGS COLLECTED YE9 ❑ NO r© 7. DOES WELL REPLACE EX'.STING WELL? YES ❑ NOQ'
g. STATIC WATER LEVEL Below Top of Casing: FT.
(Uae ".' Y Atwve Tap of Casing)
9. TOP OF CASING ISFT• Above Land Surface'
• Casing Temine7ao avor oe�ow land surfs,• Is Iliegal Uhlo" as vnance le lasrrod
i . ac YIELD with ): - NCAC METHOD OF TEST ---
10. YIELD (�7pm):.�. +L. o
1, WATEci ZONES Moth)'
z
12. CHLORINATION: Type V r Anwunt t add'nlorel space la needed ua•. beck c' fog
13. CASING. I QC8jION SKETCH
Wall Thome"
Depth D11nm�er L elenai (Shaw diioctcr and distance
tom et bast n o Stm
77� Roads. c1 other map'e':ronce ports!
From To 1�Ft.�- (/L
From To �_ Ft. t � —
From To
Ft.
14.
GROUT:
Dept /2�/�
� T
n� eft
G
ethod
Fro rrl o �L—F'•�-----
From To
Ft.
15.
SCREEN
Depth
Diameter SfolSize
Material
From _ To -- Ft
— in. _— In.
From To --- Ft.
— Irl In.
Frcm lo_Ft.—
in. _in.
16.
SANDIGRAVEL PACK:
Depth
S'2e Material
From To
FL —
--
Crem -. Tn. J
Ft. —
17.
REMPas<S: (
_
e• a •.
• � q �e
prTH 15A NCAC 2G. WELL
FRDVIOED TO THc Vr-U.
�A7_
SIGNATURE OF OONTRACTOR OR AG5NT
SUnTM1 enylnaJ lD DNblOn of Y/efo OA �:Y a"C co CyM "•'i �"��0� __f ��

Carolina - Deoarma it of Environment and Natural Resources - Divisioi of watp,, Oue'i^y - Ar,1n-' •at?r Sedior
p 0 Box 29573 - Raleigh,N.C. 27626.0575-Phone 19t9) 733-3221
WELL CONSTRUCTION RECORD DRILLINGCONTRACTOP:
DRILLER REGISTRATION l;
STATE WELL CONSTRUCTION PERMRI:
t WELL USE (c-eck Appucanlf, BOX): Rosidentialg Municipal ❑ Industrial ❑
Acncuf vat ❑ n';nrtc•ing ❑
Reccvery ❑ Heat Pump Weser Injection ❑ Othor ❑ II 0-.her, Ls' Use:
2. WELL LOCAT le'Sh ketch of the location below)
M19arest Tow County : n
(Roar .. o�oia o• su Is�on ana _ot No.) DEPT'h
DRILLING LQ
3 OWNER A 6 Fror 'c
F�-a'.lon :aac-czar.
ADDRESS
1
•\)1, �]LA[`W'C� Slreal 0(R�u1a No.) as /% `�_
/� —
I l (i
Cn. v T StaleC ZipCode�
a. DOT_ DRILLED
E. TOTAL DEPTH
S. CUTTINGS COLLECTED YES Q NOQ
a ,�
7. DOES WELL REPLACE EX.STWG WELL? YES ❑ NOQ
3. STATIC WATER LEVEL Below Top o' Casing: FT.
rTT —
(Use'. I Move Top of Cnaing)
`- —
9. TOP OF CASING IS�_ FT. All Land Surface'
ra
• Caaing Terminvad avor Ja-ow land arfacel fs Illegal unless a wnance la issued
��
In accordance with 15A CAC 2C
10. YIELD 117pm): METHOD OF TEST
1 WATER ZONES iceoth):
— ==
C3
12. CH_ORINATIONType Amount It addit,ial scece a needy use oeck C-21
13 CASING
Wall Thlokneaa
Dept^ I�m eer a gnycL 1 lens.
FrM 0- To 210 FI, i
From, To FI. —
=rom To Ft.
te. GROUT:
DeD ��M erla _ elho
From -!a-
To
From To F:.
+5. SCREEN.
Dept- Dlameler Slot Size Material
From _ To _ FI _ in. In.
From To Ft. — In In,
Prcm —ToT_I
16 SAN'D/GRAVEL PACK.
Dapth- 5 ze Material
=rom To _ Ft.
- REnnaRt g:
LQCATION S{E T OH
(Skye, d:rcct'cr ail d'aranCe ion et r5ast MC Steve
Roads. e• map •e'vrCt prcU) /
I DO HEPC8y CE RTIFV THAT THIS WELL WAS CONSTRUCTED IN ACCOROANCE V117H 15A e CAC 2C
CONSTRUCTION STANDARDS. AND THAT A / IA OE THIS RECOPO HP/S,EEEN °ROV:7K 7) THE','-e LLj -e:= ^—
a1C.NATIIRa OF CONTRACTOR OR ACE D'
2 0 7 0
h ^ jU�jTh On�InN le OrI�On dl Y/OIO Fll O�.lY •Y :O�y '7 ���� J-""�

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section 223,118
1636 Mail Service Center - Raleigh, N.C. 27699.1636-Phone [phone]
WELL CONSTRUCTION RECORD WELLCONTRACTOR: w
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential10 Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other 7 If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below) ,(jam'
Nearest Town: , AG(.Q, County: [[""
Numbers, C�jVwniry, or Subdivision and Lot No.)
3. OWNER 'V I (�I NC-
-Address Qt S Sb RGy�
trees uleC °.
Sn I I J day
City or Town state Zip Coda
4. DATE DRILLEDu__D__�_
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑ NOM
7. DOES WELL REPLACE EXISTING WELL? YESED NOV]
8. STATIC WATER LEVEL Below Top of Casing: FT.
(Use •+' If Above Top of Casing)
9. TOP OF CASING IS.I.33 FT. Above Land Surface'
-Top of easing terminated at/or below land surface requires a variance In accor-
dance with 15A NCAC 2C fill
10. YIELD (gpm): ]�.L METHOD OF TEST
Mryied
11. WATER ZONES (depth):
12.
CHLORINATION: Type Amount
13.
CASING:
IriS10.-Uet`
�
I
Wall TNdmess
Depth Diameter orw, e�pn t. Material
O
r L Ft. '/4 L— —
From
To —
From
To Ft.
From
To Ft.
14.
GROUT:
Depth Mata al Method,
0
�-� Ft. C'OY1C.Y� 2
From
To
From
To Ft.
15.
SCREEN:
Depth Diameter Slot Size Material
From —To—Ft—
in. —in.-
From
To _ Ft. _ in. _ in.
From —To
Ft. In. —In.
16.
SAND/GRAVEL PACK:
Depth Size Material
From
To Ft.
From
To Ft.
17. REMARKS
Agricultural ❑ Monitoring ❑
DRILLING LOG DEPTH
From To Formation Descr ption
r
gm-
p
-
->m
co
-,m
�m
m=
—
4n
y
If additional space is needed use back of form
z
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
T((,M I eYLjersOrw)i[e- -Srt ers4D,� Z�
tO �Ight O(Z 5aAU ,
I S� ��o� st rt 4o (3a-1 ©� ro I wee
left nrL I� (17& . Cro cl,�proxORa4 1J
5 nlil�nrs r�lti� Gn {{��e �rs1 o %1
FQLI s lC o(tR . PT O C �Z )r0Y,iM e
ptii1�. Take righ�ff /nri EZlls Lsor)
sane. I:� 6X pv�- Left.
I DO HEREBY IIFY,rTL PTTHIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION' SL> 4Af6S L*NO THAT A COPY OF�iIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
,�
FOR OFFICE U LY A f DATE
Quad No: - SIGNATURE OF PERSON CONSTRUCTING THE WELL
Submit ollginal to DiAslon of Water Ouality, Groundwater Section within 30 days GW-I REV. 12199
Serial No. '-
ndwa`.e Sec,
Ash�e�iile ne�lnna ,,

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section '- 17044
1636 Mail Service Center. Raleigh, N.C. 27699-1636-Phone [phone] :�
WELL CONSTRUCTION RECORD WELLCONTRACTOR: "I�hnrC� DCrOLr`I
WELL CONTRACTOR CERTIFICATION #: n i D
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
Town:
3. OWNER %Cf°VI Il C a`
Address 91
of the location below) n� I )/
County: y iC
�n I f rrin �-Ti.rnn
or
City or Town btats zip ewe
4. DATE DRILLED g
5. TOTAL DEPTH r
6. CUTTINGS COLLECTED YES ED NOEM
7. DOES WELL REPLACE EXISTING WELL? TES NO[g]
8. STATIC WATER LEVEL Below Top of Casing: FT.
fuse'+' if Above Top of Cuing)
9. TOP OF CASING IS I.3 3 FT. Above Land Surface'
•Top of casing terminated ■tlor below land surface requires a varlance In accor-
dance with 15A NCAC 2C.0118 --�r-�
10. YIELD (gpm): � METHOD OF TEST I ,irmo d
11. WATER ZONES (depth):
12. CHLORINATIO Type- —Amount _
13. CASING: /i„�'
euty n
77 �+ "" Wall Thickness
Depth �/� l j^�ter or Weight/Ft.
From �7I Ft. 119
From To Ft.
Agricultural ❑ Monitoring ❑
DRILLING LOG DEPTH
From To Formation Description
a
c
3
Eq
If additional space is needed use back of foW CS
LOCATION SKETCH
nMaterial
(Show direction and distance from at least two State
PU L Roads, or other map reference points) C'
From To Ft.-'FY©m Nen�l4rspnc�lll,'? T�-'�(c, 4D
14.GROUT: E�{I�. �4070ne TUutt�(1�
Depth Material -Me,.rthho�Nd��J �_ t li& rm 1,,-os ' Um I i'L`ly-rs-°�-`Uo/% ' f��
From O To _ 20 Ft. 00rWrP v wS&" of I oxo Oh1`CeS • I (%a� rt ©YG{rlR(�
From To Ft. Y �t u t f
rho 15. SCREEN:
©ri- Cuwe wher�7hnmpsc�
Depth Diameter Slot Size Material s H)t)/� 17Gi -+ abb/XAe-
From _ To _ Ft _ in. _ in. —
From , OZa��+tlo�
From —To _Ft._ in. _ in. L• r(
From —To _Ft. in. —in. p - .I-_ 1_ 'I) ,J cIrL I'�6
16. SAND/GRAVEL PACK: T hI TS �L K- 4 r hill
n '��pf���jjj
Depth Size Material �[[[ pp (� fI V °tom q� ( I l I W1/ fr. ,_L
From To Ft.�/�'(j1Plr? • ��� lf7 f�(f
From To Ft.
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF RECORD HAS BEEN PRO" D TO THE WELL OWNER.
FOR OFFICE USE ONLY
Quad No: IGNATURE OF P SON CONSTRUCTING THE WELL ATE
-I
(; Submit original to Division of Water Quality, Groundwater Section within 30 days
Serial No. 1 GW-1 REV. 12/99

North Carolina - Department of Environment and Natural Resources - Division of Water Ouality . Groundwater Section
1636 Mall Service Center - Raleigh, N.C. 27699-1636-Phone [phone] WELL CONSTRUCTION RECORD WELL CONTRACTOR: ` %�
ld e- -S,40l Vk-K ft Sb n3
WELL CONTRACTOR CERTIFICATION N: ,ZLJ J0
,t STATE WELL CONSTRUCTION PERMIT#:
{�
1. WELL USE (Check Applicable Boxy Residential - Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery 0 Heat Pump Water Injection ❑ Other E] If Other, List Use:
2. WELL LOCATION:!(Shovtyf skp4ch of the location below) /)o y
Nearest Town: fig+ County: i�
(Road Name and N tubers. Community, or Subbddivision and Lot No.) DRILLING LOG DEPTH
m
3. OWNER Cr-[c L ✓ Pa K S From / To
Formation Description
Address
City or Town Slate Zip Code
4. DATE DRILLED "/-/0-e2P
5. TOTAL DEPTH - 7��
6. CUTTINGS COLLECTED YES® NO❑
7. DOES WELL REPLACE EXISTING WELL? YES 0 NO® o
8. STATIC WATER LEVEL Below Top of Casing: FT. -
(Use'i If Above Top of Casing) O O
9. TOP OF CASING ISFT. Above Land Surface'
-Top of casing terminated auor below land surface requires a variance In accor-
dance with 15A NCAC 2C.0118 t Qi
10. YIELD (gpm): 2 METHOD OF TEST
11. WATER ZONES (depth): -+
rn�
12. CHLORINATION: Type S Amount It additional space Is needed use back of fora)_ rnz
13. CASING: '3 =
LOCATION SKETCH W o
Wall Thickness ;C
Depth DllmVa or ,W�eIgghVVFt. Material (Show direction and distance from at least two Slate
From_±_L—To -1[Y— Ft. —jY —�— Roads, or other map reference points)
From To Fl.
From To Ft.
14. GROUT:
Depth Mato 181 lhod
From © To �21V Ft.
From To Ft.
15. SCREEN:
Depth Diameter Slot Slz6 Material
From _To— Fl _ In. —In.-
From —To —Ft. _ In. —In.
From —To _ Ft. — In. — in.
16. SAND/GRAVEL PACK:
Depth Size Material
From ToFl.
From To FL —
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C. WELL
CONSTRUCTION STANDARDS, AND THAT A C OF HIS RECQ)iD HAS BEEN PROVIDED TO THE WELL OWNER,
FOR OFFICE USE ONLY DATE
Ouad No: OPJ'ER30NCO Sundwat NG rsTHEWELL
/ D r 61e�0uallty,GroundvraterSedlonWilhln30days
Serial No. fIIi GW.1 REV. 12199
1 JUP1 ? 2000 U j

North Cnronnn - Drpn,hnoui of rnvlrnnmw,l and Natural ne'MUICe9 - Division of Water Quality - Oroundwnler Sncli,m r,', 1 ( 4 11
1636 Mail Scrvico CrWor - Finleigh, N.C. 27699.1636-Phone [phone]/zy/�//�.,� pp////// pp/I �
WELL CONSTHuciIOiJ RECORD WELLCONTF1fT40 �� �� p
WELL COIJTRACTOn CERTIFICA C) o: r; aD St, 6
STATE WELL CONSTnUCTION rrnfIITH:
1. Munlcipal ❑ Industrial ❑ Agilcullural ❑ Monitoring ❑
necovrry [J F Ipat Pump Water Injection ❑ Other If Other, List Use:
2. WELL LOCAHOTJ- ITow 0at� of tho location below) -
NeareslTorm:_ .r /✓. COunry:
DEP
(noa l Jinn+o s++rj.IrJm�'+cis, orrmvnlly, or u divlslon and Lot No.) DRILLIIJG LOG ____ mi;on Vj__
3. OWNFrI
!CJ From To Formation Ocscdption
Addres.n. : _
�nry a Clirr Di n/V^so'� —
Ajack X-~—SI' I Zip Code
ZIL
Ciiy r, Iev:,, // �-
A. DATE Of WILL o -(p • .4 a-_-- ._-
5. TOTAL DEr I I I _a4_5—__
6. CUTTINGSCOLI_FCIEO YES❑ NO[�f o
7. DOES WELL nEfLACF. EXISTING WELL? YES [� NO[�/
cn
a. STATIC: WAT FIT LEVEL Delow Top of Casing: FT.
(Use'.' It Above Top a1 Casing) - -
I
9. TOP Ur CASIf1C1 Is _-_�____ FT. Above Land Surface'
'Top of casino I•r ndnntml nyv, helow lend surface requires 2 variance In occur•
dance with 15A IJCAC 2C .0110
10. YIELD (qpm): _/- � ME I f IOD OF TEST —
11. WATEII ZOTJES-
-�� r -
12. Cf ILOi IINA110H: l ype _.�{.J_/.1- ArT ounl�s if eddillonal space is needed us _ bnrk of lnfF?
13. CASING: ,LOCAIIQ(J SKETCH
W All 1 hickne sf
Drl,ih �Dlamel r or Welphlirt. Mal. - ed}'h ^� (Show direction and dl5lpe born et mast two Siale
�911,+1It f- }�rF'��LrL noads, or other rna,erelevance points)
From----___._ ln..---- FL--- — — Ci' _ E •/r/ f �/r
Prom _. -----1 0 ---- ----
14. Gnoul: p� d
`l I,npth Malednl lelhoJ
I- torn ._ v_. 1,., _.p .� rl.
rion, .___ in-
15. SCRFrfT.
Ury+Ih Dimneler Slot Slzo Mnlorlal
Fron, __.--- I n ._ rl --- In.
From _ _ to ___ .-rl.-- In. In.
iron,-- ._To- ____-FI._In. _in.
16. SAND/GRAVEL TACK: Melellal
Del,ltl Size
Front In _- FI.-------
From __._— To_ --Ft.
17. REMAFII(S:_
1 DO I IFf1FDy CFf1i ITY TIIAI TIIIS WELL WAS CONSTRUCTED IN ACCOnOANCE WITH 15A NCAC 2C. WELL
CONSTnUCTION STANOMDS, AND Tf1ATACOPY 1111S RECORD HAS BEE%FFlN� TO THE WELL OWNER
^
LF(o)IJTICE USE ONLY DATEj41CtI ,nE OF P - Orl COH6TnUCTV Ir7 TIIF, WFI l lT -mlt odginsf to DWlslon of Water Ouellty.Omundwater Section Wlihln 30 daysOW1 DE`/ 12/99

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone] /
WELL CONSTRUCTION RECORD WELLCONTRACTOR:
WELL CONTRACTOR CERTIFICATION #: �52�
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) J
Nearest Town: r�6)e//f— /� S • A/C County: �
(Road Name and Numbers. Community, or Subdivision and Lot No.)
3. OWNER
Address (7/�
treat or Route o. 7zz
City or Town State Zip Code
4. DATE DRILLED /1,7o0(­
5. TOTAL DEPTH Z-6`0
6. CUTTINGS COLLECTED YES[Z] NO❑
7. DOES WELL REPLACE EXISTING WELL? YES NOQ
8. STATIC WATER LEVEL Below Top of Casing: -V 2- FT.
it Ab To of Casing)
(Use + ova p
9. TOP OF CASING ISFT. Above Land Surface'
-Top of casing terminated aVor below land surface requires a variance In accor-
dance with 15A NCAC 2C .01.1 a //�
10. YIELD (gpm): 14 METHOD OF TEST
11. WATER ZONES (depth):
DRILLING LOG
From To
90
DEPTH
Formation Description
C
_o
O
12. CHLORINATION: Type �'/%L��//✓f Amount�r If additional space is needed use back orform z
13. CASING:
LOCATION SKETCH
Depth
Wall Thickness
Diem ter or Weight/Ft.
(Show direction and distance from at least two State
+1
.
3 3
'Maat1eri`al
Ft. D / —�
Roads, or other map reference points)
From
To
From
To
Ft.
From
To
Ft.
CIJ�
14. GROUT:
Depth
From _ To —Ft.
��
Material Method
11/FA% C!f/Iif//r
�y71'
I Y' fl f %
From
To
Ft.
15. SCREEN:
Depth
Diameter Slot Size Material
From
To _
Ft — in. _ in.
C
From _
To —
Ft. _ in. — in.
4
From _To
—Ft.
— in. —in.
16. SAND/GRAVEL PACK:
Depth
Size Material
l
From
To
Ft.
f/
From
To --..FS — r
17. REMARKS:
{)
-� Ali
t-
I DO HEREBY CE ILi)GHAT THIS WELL WAS CDN.S,TRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION (1ARWi kNO THAT A CO�y'41F THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
ruff vrrN.c uQ,; Y"" , 1d14atc Sp- UAIM
i A.niSIGN/iTUR F PERSON CONSTRUCTING THE WELL
Quad No: ('. , il5ubmit originart0 Division of Water Quality, Groundwater Section within 30 days
GW-1 REV. 12f99
Serial No.

NORTH CAROLINA DEPARTMENT OF NATURAL RESOURCES C COMMUNITY DEVELOPMENT
WELL RECORD DIVISION OF ENVIRONMENTAL MANAGEMENT, GROUNDWATER SECTION
� � P.O. BOX 27687 - RALEIGH, N.C.�27611 [ ((
DRILLING CONTRACTO (J/-t /200& Lt/111 REG.NO 5 � / WELL CONSTRUCTION PERMIT NO.
1. WELL LOCATION: (Show sketch of the relocation below)
Nearest Town: ��/1/ X /CIS , Z./C County: R2Z-
IV
or f
Lot No.
z. OWNER: KFROM TO
�/�/ Y (•-rNi71�/�/t�
3. ADDRESS ''L1 4 Vei.K/�W(�-�/�2Yb/'�/vCDEPTH
4. TOPOGRAPHY: draw,valley,slope,hilltop,flat(circle one) C
5. USE OF WELL: DATE:_Tl�-i�/N.'(.'_
6. DOES THIS WELL REPLACE AN EXISTING WELL? �C
7. TOTAL DEPTH: _300 RIG TYPE OR METHOD: `fJ/2
8. FORMATION SAMPLES COLLECTED: YES � NO
O
O 8
No.
9. CASING: Depth Inside Wall thick. type
/ ?}� Dia. or weight/ft.
From to ft
10. GROUT: Depth Material
Method
,ft �i�fFrom�to ofry6 ;
11. SCREEN: Depth Dia.
From to ft
12. GRAVEL: Depth Size
From to ft
Type 5 Opening
Material
13. WATER ZONES(depth):
2. 7 • i S I'� cr
above
J
14. STATIC WATER LEVEL:- / ft. a o-top of casing
Casing is __,/ ft. above land surface ELEV7:_
15. YIELD(gpm): G METHOD OF TESTING/'/ / /
16, PUMPING WATER LEVEL: ft.
after hours at gpn.
q (
17. CHLORINATION: Typ / 66 / i�'L+mount e; 6�� "(
18. WATER QUALITY: TEMPERATURE(',)
19. PERMANENT PUMP: Date Installed
Type Capacity (gpm)HP
Make Intake Depth
Airline Depth __ >__-j
DRILLING LOG
FORMATION DESCRIPTION
It additional space is nee a use o 2 orm
T.00ATTON SKETCH
20. HE(Am4RR WEER PIV ElFfll OPY OF THIS RECORD AND INFORMED OF THE DEPARTMENTS REQUIREMENTS AND
21. HE ' -
I reby certify that this well was constructed in accordance with N.C. Well Construction
Re 1,Rions
and Standards and that his well record is true and exact.
u=' SIGNATURE CONTRACTOR OF AGENT
Form, Gw-1 Revised 11/3/77 Submit original to Groundwater Section and copy to well owner.

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] /� q L
WELL CONTRACTOR: (� LCa� �12I«/w w
WELL CONTRACTOR CERTIFICATION #: zJ�Zy
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: UL-CAAIdL/S N2 County:
(Road Name and Numbers. Community, or Subdivision and Lot No.) DRILLING LOG
3. OWNER U y�%%��.'? % From / n
Address ��� /y/�L j///✓ /C�iCL Zk2 f
n ire' or 5565 o. U
City or Town �ta�le Zip Code
4. DATE DRILLED-�OG`O
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES E NO❑
7. DOES WELL REPLACE EXISTING WELL? YES ® NO
6, STATIC WATER LEVEL Below Top of Casing: FT.
(Use'i it Above Top of Casing)
9. TOP OF CASING IS—j— FT. Above Land Surface-
-Top of casing terminated atior below land surface requires a variance In accor-
dance with 16A NCAC 2C.01
10. YIELD (gpm): METHOD OF Tf-ST
E- S d lh /1 S
11. WATER ZON ( ep ).
12. CHLORINATION:
13. CASING:
Wall Thickness
i Depth Z Diarryeter or Weight/FLMateM
From r/ To LZ Ft. Ct�
From To Ft.
From To Ft.
14. GROUT:
r-, n
4.4J595
Agricultural ❑ Monitoring ❑
DEPTH
Formation Description
C_
0
1 It additional space is needed use back of formo <
LOCATION SKETCH — C,
(Show direction and distance from at least two Slate `
Roads, or other map points)
I�9/
&I--
Depth Material Method
From To Z & 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
I DO HEREBY CE
CONSTRUCTION
Slot Size Material
in.
in.
_ in.
Quad No:
u Submit c
Serial No. .. ..
Material
S� %pLiillu
DLO
ED IN ACCORDANCE WITH 15A NCAC 2C, WELL
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
F PERSON CONSTRUCTING THE WELL DATE
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 1 r, rr-r �
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone] �
WELL CONSTRUCTION RECORD WELL CONTRACTOR: �il�F / /U ` c
WELL CONTRACTOR CERTIFICATION #: ;2.5 Z y
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 LOCATIO/",(Show sketcc of the locati below)
Nearest Town: / �iL «�;:LC! .� N County:
—7�L
(Road Name and Numbers, Community, or Subdivision and Lol No.)
DRILLING LOG
3.
OWNER . S✓,�%ii /)� f:f C / ) /L
From To
Address 601f
0 ZI�Ll L W,5/l>1-FiS L/tl
a �o /
—tSueet
%K, D,
City or Town State Zip Code
' ',7G00
4.
DATE DRILLED
5.
TOTAL DEPTH C
6,
CUTTINGS COLLECTED YES® N07
7.
DOES WELL REPLACE EXISTING WELL? YES © NOF—]
B.
STATIC WATER LEVEL Below Top of Casing: &j FT.
9.
(Use'+' it Above Top of Casing)
TOP OF CASING ISFT. Above Land Surface'
*Top of casing terminated atfor below land surface requires a variance In accor-
dance
with 15A NCAC 2C .0118
10.
YIELD (gpm): 1_ METHOD OF TEST
DEPTH
Formation Description
b/fie/31/24fi✓
C-)
0
l
11. WATER ZONES (depth):
�/ � r
c-
12. CHLORINATION: Type 7� f Amount C—T�' If additional space is needed use back tSY%rm S 1
13. CASING:
Wall Thickness
{ i Depth/ S Of eter or Wei � �. dal
FromTo12L Ft. (L'
From To Ft.
From To Ft.
14. GROUT:
Depths �� `//Material Method
From I 2 To C Ft.',OCT�/
From To Ft.
15. SCREEN
Depth Diameter
From To _ Ft _ in.
From _ To Ft. _ in.
From —To —Ft. — in.
16. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To Ft.
17. REMARKS:
Slot Size Material
_ in.
in.
in.
Material
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
___\
�ct (3liS�
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRU AT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFIC 0 °� GI C
Quad No: SIGNATUR F PERSON CONSTRUCTING THE WELL DATE
Su f ' final to Division of Water Quality, Groundwater Section within 30 days
Serial No. - GW-1 REV. 12199

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section C1-1
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone] V
.VO UlsGNs X • G /«
WELL CONSTRUCTION RECORD WELL CONTRACTOR: - D21ec /AlG w
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (check Applicable Box): Residential ® Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: Show sk tch of tF !L location below)
Nearest Town: ti County: i�OLK
(Road Name and umbers. Community, or Subdivision and Lot No.) DRILLING LOG
3. OWNER ///ISL/ S0121- D '/( From To
Address AGO Vr/r%� (�LIc/niT/L// 7
j5treeior H ule NO.
City or Town State zip Code
4. DATE DRILLED r`'1Z64`0
5. TOTAL DEPTH 3 0 0
6. CUTTINGS COLLECTED YES© NOFJ
7. DOES WELL REPLACE EXISTING WELL? YES NO®
8. STATIC WATER LEVEL Below Top of Casing: /7 FT.
(Use '+' it Above Top of Casing)
9. TOP OF CASING ISFT. Above Land Surface'
'Top of casing terminated at/or below land surface requires a variance In accor.
dance with 15A NCAC 2C.0118
10. YIELD (gpm): -5-0 METHOD OF TEST
11. WATER ZONES (depth): 2 F2 Z� r SOC@ Z&4b
DEPTH
Formation Description
1/2///3 a? 4,1,/,1
,mod`% ,2o<ic
/�2AN /72' llelC
t �. t.nwntrvN t Ivrv: t ype c- r-x-yrr f f-z Amount It additional apace is needed use back of form
13. CASING:
Wall Thickness
.-F- Depth D}i met'er or Weight/R. to alai
From To R Ft.5" 2/ err
From To Ft.
From To Ft.
14. GROUT:
Depth �'',' `, Material Method
From To � Ft /v F/%i('�/�tf� RVIN `+
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft in. _ in.
From _ To Ft. in. _ in.
From —To —Ft. _ in. _ in.
16. SAND/GRAVEL PACK:
From
From _
17. REMARKS:
Depth
_ TO-
- To_
Ft.
Ft.
Size Material
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
,AHrfWu IAQtAP)RY
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.
_7I
SIGNAT41E OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Divislon 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 0
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone] Dv tee'. 4/4S G / C 1
WELL CONSTRUCTION RECORD WELL CONTRACTOR: I/dtIl ebb_//AW/A/
WELL CONTRACTOR CERTIFICATION #: ZSZ 5�
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: H A 12- 1 fZR f Ga T/OIL
2. WELL LOCATION/N�j-. (Show sketch of the location below)
Nearest Town: LAu F !� /CT , /V G County: PL K
(Road Name and Numbers. Community, or Subdivision and Lot No.)
3. OWNER c-1 rzw izA:S w
Address &1Q 0/ Z36 le/N( iiror_A
or Town / ;State Zip Code
4. DATE DRILLED /L(JOU
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES® NOQ
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NOW
8. STATIC WATER LEVEL Below Top of Casing: /23 FT.
(Use's if Above Top of Casing)
9. TOP OF CASING ISFT. Above Land Surface'
'Top of easing terminated aVor below land surface requires a variance In accor-
dance with 16A NCAC 2C A18
10. YIELD (gpm): V METHOD OF TEST /z2
11. WATER ZONES (depth): 1160
7 7/6.
12. CHLORINATION: Type Clet k't Amount
13. CASING:
DRILLING LOG
From To
i
�. / 7z o
Ir,
DEPTH
Formation Description
c ell'auw Of/J
a,4tJ ) /77 lZdCe
If additional space is needed use back of form
Wall Thickness
LOCATION SKETCH !�
m ^'
f- Depth 7 7
�To /J J
Di meter or Weight/Ft. MM�att�edcal
�
(Show direction and distance from at least two Sty
-�-t
From
Ft.
Roads, or other map reference points)
From To
Ft.
From To
Ft.
14. GROUT:
Depth
Material Method
✓ tt E
U 20
A&24i &Ai`ctWr Dtl,'r//
From To
FL
From To
Ft./rG
15. SCREEN:
d
Depth Diameter Slot Size Material
„JQ-
�D
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.
r�✓y
fND I-LO A
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 HAS BEEN PROVIDED TO THE WELL OWN/ER.
FOR OFFICE USE ONLY
-RECORD
/(1z" 44
, zz�z 7/�7/?00
O
Quad No:
&CINATLA OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Quality, Groundwater Section within 30 days
Serial No.
Gw-1 REV. 12/99

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699.1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: M t ►D121(lt IQG C<l tuP 1gri t/
WELL CONTRACTOR CERTIFICATION #: 6 Z
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential M Municipal ❑ industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
NearestTown: �1/C° County: PoLIle
(Road Name and Numbers. Commun�ltj or Subdivision and I No.)
3. OWNER ^ZZA1011 /rO/gf/GSO
Address Y S 2J
'��(� ree or�u o.
/ VL4-
City or Town Slate Zip Code
4. DATE DRILLED DKJ
5. TOTAL DEPTH Z r7 O
6. CUTTINGS COLLECTED YES [X NO❑
7. DOES WELL REPLACE EXISTING WELL? YES ® NO❑
8. STATIC WATER LEVEL Below Top of Casing: 7- Z, Ff.
(Use 'r' II Above Top of Casing)
9. TOP OF CASING ISFT. Above Land Surface*
'Top of casing terminated stfor below land surface requires a variance In accor-
dance with 15A NCAC 2C.0110
10. YIELD (gpm): / LMETHOD_OF TEST Al
f2
11. WATER ZONES (depth): ✓lans �/ S
12. CHLORINATION: Type !7L/L0/1//✓£ Amount ✓D
13. CASING:
Wall Thickness
(� Depth _ Diameter oryyvVe�ig��ht/�Ft. Material
FromTo Ft. Ia— JL11CL/ /'Vr
From To Ft.
From To Ft.
14. GROUT:
/ Depth Material Method
1
From � To _ZQ_Ft. 10W2Wz&r >9 1
From
16. SAND/GRAVEL PACK:
I DO HEREBY CERTIFY THAT T
CONSTRUCTION STANDARDS,
DRILLING LOG
From To
el 33
3-4 JdC1
Agricultural ❑ Monitoring ❑
DEPTH
Formation Description
A / r1iActX OF✓
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)
��LCY� t Jfrt
:ORDANCE WITH 15A NCAC 2C, WELL
HAS BEEN PROVIDED TO THE WELL OWNER.
SIGNATURE OF PERSON CONSTRUCTING THE WELL
Submit original to Division of Water Quality, Groundwater Section within 30 days
,_—ZL

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699.1636-Phone [phone]
WELL CONSTRUCTION RECORD WELLCONTRACTOR: 02UtYD2lLL-II46 CrJ,
WELL CONTRACTOR CERTIFICATION #: 2S2
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 LOCATIONj(: (Show sketch of the location below) Po
K
Nearest Town: L-0L(^l'ytL C5 County:
(Road Name Numbers. Commmunitycor Subdivision and Lot No.)
DRILLING LOG DEPTH
CA 3. OWNER E Iy iFe r • v C..l wt� r W
BE
From To Formation Description
Address R.l Z 3,0 ( g q
(18J`— t!3r U.r2A8N
(Street or Oa o.
A ►o3 f�tLz�SJ Jz6cI
no Iunl.h us ►V C
10 3 I Z 5 �s2r�f�rl�TZ-p�
City or Town State LPCods
DATE DRILLED 3IZ812(X)U
IZj ZZy ,B fC01,062 ROCK
4.
5. TOTAL DEPTH
�y ZOO (LAN T�
6. CUTTINGS COLLECTED YES® NO❑
7. DOES WELL REPLACE EXISTING WELL? YES ® NOD
o
8. STATIC WATER LEVEL Below Top of Casing: cTJ4 FT.
(Use '+' it Above Top of Casing)
,
r:
9. TOP OF CASING IS FT. Above Land Surface'
ce-
'Top of casing terminated atfor below land surface requires a variance In actor-
c ^ -
dance with 15A NCAC 2C,9118
M HOD OF TEST
10. YIELD (gpm):
11. WATER ZONES (depth): E0Qr
r,
c4
12. CHLORINATION: Type L i5 Amount 1
It additional space is needed use back of o~
13. CASING:
LOCATION SKETCH
Wall Thickness
Depth Diameter or Wei hl/R. Mittenal
+ en
I
(Show direction and distance from at least two State
From To �� Ft.. la LLB
Roads, or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From To 2�Ft. IALAi Cf{kfrt� PuMpttlG
4 rtit�f5
From To Ft.
dye
15. SCREEN:
SG
Depth Diameter Slot Size Material
From —To—Ft— in. —in
From —To —Ft. _ in. —In.
From —To —Ft. _ in. _ in.
SC
16. SAND/GRAVEL PACK:
Depth Size Material
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
E�EN�PPROVIDED TO THE WELL OWNER.
CONSTRUCTION STANDARDS, AND THAT A COPY OFF THIS RECORD HAS BB'�'-
l y
FOR OFFICE USE ONLY f A
"—3 / ZQ ZO010
Quad No: SIGNATUR F PERSON CONSTRUCTING THE WELL DATE
Submit odginal to Division of Water Quality, Groundwater Section within 30 days
Serial No. n l -
GWC REV. 12199

NORTH CAROLINA DEPARTMENT OF NATURAL RESOURCES AND COMMUNITY DEVELOPMENT
DIVISION OF ENVIRONMENTAL MANAGEMENT - GROUNDWATER SECTION
P.O. BOX 27687 - RALEIGH.N.C. 27611. PHONE [phone]
WELL CONSTRUCTION RECORD
FOR OFFICE USE ONLY
((� 1y (±
Quad. No. Serial No" 6 q r
Lat. Long. Pc
Minor Basin
Basin Code
Header Ent. GW-1 Ent._
DRILLING CONTRACTOR IC Orf T2,21LL1 IVLT C'��ntr�A419
1 STATE WELL CONSTRUCTION
DRILLER REGISTRATION NUMBER zS24 PERMIT NUMBER:
1. WELL LOCATION:: (Show sketch of the location below)
Nearest Town: l2[71 [,iM B(kS I N (! County: �V�I
(Road, Community, or Subdivision and Lot No.)
2. OWNER (5FF✓F. L.BEa I
ADDRESS 7& I! 6 I L [3E (LT tZ0
C OLIA YI'l g u( treet or Route!(LNoJ Z„_, z„
CCiit'y or Town �,^ State Zip Code
3. DATE DRILLED '3 p�''�p� USE OF WELL -DOnn��MESTt C
4. TOTAL DEPTH � CUTTINGS COLLECTED 9Yes ❑ No
5. DOES WELL REPLACE EXISTING WELL? 0 Yes ❑ No
6. STATIC WATER LEVEL: FT. ❑ above TOP OF CASING,
0 below
TOP OF CASING IS FT. ABOVE LAND SURFACE.
7. YIELD (gpm): 1 Z METHOD OF TEST
TEST 1
8. WATER ZONES (depth): Z 0- l5 ! t
o (-zss
9. CHLORINATION: Type LO IWJ Amount jo Dilk .
10, CASING: 7A13Lf�T5
Wall Thickness
Depth / -� Diameter or Weight/Ft. Material
From To 2 Ft._4_ -5 21 PV I.
From To Ft
From To Ft.
Depth DRILLING LOG
From L//Ler _)My
O
c�
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)
11.
GROUT:
Depth Material Method
From i'
`I
To Ft.
From
To Ft. /
12.
SCREEN:
Depth Diameter Slot Size Material
From
To Ft. in. in.,
From
To Ft. in. in.
From
To Ft. in, in.
/
J ✓e
13.
GRAVEL PACK:
-
.
— - -
sG
Depth Size Material
From —To—
- Ft. ryryE9 _. 4
lM"f�
From
To Ft.
14,
REMARKS:
- - --
I DO HEREBY
CERTIFY THAT THIS WELL WAS CONSIlIaUGTE6111'ACCORDANCE WITH 15 NCAC 2C, WELL
CONSTRUCTION
STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PR9�VIDE TO TyE WELL OWNER.
� 411g �r�/r<a fi /,I*'/ �'/
61 ZOCJ(J
SIG0,TURE GY CONTRACTOR OR AGENT
15ATE
GW-1 Revised 6/88
Submit original to Division of Environmental Management and
copy to well owner.

To DEER DIVISION OF WATER QUALITY, GROUN[From ALAN S. GANTT 828-286-8787
Sent by the Award Winning Cheyenne Bitware
10/22/00 20'06.50 Page 10 of 11
Norlh Carohtla - Deparimenl of Envirotunent. and Natural Reources - Diction of W atnQuality'. Ground, at at Section
1636 Mail Sen ice Carter - Releiah, S.C. 2-699 - 1636 -Phone [phone]'_2I
9530
"INT1A, CONSTRUCTION RECORD 11 ELL. CONTRACTOR: CAROLINA R"ELL llRI1,LERS, INC.
11 ELL CONTRACTOR CERTIFICATION # : 25M4
STATE \FELL CONSTRUCTION PERMIT # :
I. WELL. USE vCheck Applicable Bos): Residential ❑ Llulucipal ❑ Ifltlushlal ❑ Auiculwial ❑ Molu0.nutg ❑
Recocelti ❑ Ilea( Pump AFatef Injection ❑ Other ❑ If C) ller, List Csr_
1. NVELL LACAI,I( (SIIm, ekodtafthe location be mc)
N'earca toot MILL SPRINGS ('nuns-. POLE
RADAR RD
Road. Coaununis. or Sob, icieion;md Lot No.)
1. M%NEk ALAN GONVAN
ADDRESS 116 RADAR RD
Re«t m Raw. N. I
MILLSPRI\GS tic
rnofIo,„, state ril,('ode
A. DATE. DRILLED y400 USE OF WELL RESIDENTIAL
s. TOTAL DEPTH 145
6- CUTTINGS COLLECfE.D 1ES ❑ NO ❑
-. UHI S W111, kI PI.A('I`. If a IS'I1A(I WkLI,:' )1" ^ "'
8. STATIC WAFER LEVEL Bco, Top of Ca;ins' d_
(l, ",' If Rove Top o
o 1'OP OF CASING IS 3 FT. Above Lmtd Sod
'C's- ,'l' ,.,.tnmd m:oi balowlvtd,-ntfuea Is &k,ol uuka, o,nnotua t
m a.uotdnnee with IAA NC.AC 3C.0118
to. YIELD(,ml 20 METI ICE) OF TEST
11. WATER ZONES Idcplln: 65
12. CHLORINATION'. TCpc H1'POCHLORI I Amount
11 CASING'.
DEPTH
FkOM IO
0 s5
9s Ilz
DRILLING LOG
Formation Dceaiption
CLAY
CONSOLIDATED ROCK
T OZ. Ifaddoiouid z,o,o 6- a—kdu, ba&offo l
LOCATION SKETCH
R'all TI)idatees (Site,, (Ih'egton and dlstm¢e fl-otn at le:at Imo State
Depth Dituneter or W,tOa. Ft. Mainml Roads. or other nrap reference point;)
From 0
To
60 Ft. 6 1'1 " SDR 'I PC'C
I-t. OROU-1
Depth
Material
Method
D'otll 0
To
20 FI_ SAND NIIA
GRAVITY
t3. SCREEN
Depth
Divneter Slotslze
6laterinl
Ftom 60
1"0 80
Ft. ill
in.
1ti. S: ENT) GRAA'1--I. PACK.
Depdt
Size
Material
Flom 60
T'o 110
Ft. k3
FILTER SAND
I-. RLMARIS
1 DO HERFM C'L.RIIFti I FLAT TFQS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NC.AC'_C, WELL
CO'JS'FRI'(710O ST:INDARDS,A\T)TITAT A COP) OPTI ITS RFCORD HAS FEE\PROVTDLDTOTlIITiVTLI.OW,TR-
FOR oFOFFICErsF oNLr��j�� Io _27
_ 00
Quad No. Date
Serial NU. SIGNATURE OF PERSON CONS ERUCTING TI IT WELL
Subnut nti!,nal to Di.iaon of \Corer Quality, Gonndwmnr Sretmn a-itlwt 10 Day,
GU' -I RED'. L99

To DENR DIVISION OF WATER QUALITY, GROUN(From ALAN S GANTT 828-286-8787 10/22/00 20 04:00 Page 6 of 11
Sent by the Award Winning Cheyenne Bitware
North Caillim- Department of Emiromnent- and Nat uat Resources- Limon of Water Quality- Ground)catcr Wion r' - `� 9 4
1636 Mail Sen ice Center - Raleiell" N,C. 2'699 - 1636 - Phone of l)) -33.3 '-'1
\YELL CONSTRUCTION RECORD WELL CONTRACTOR: CAROLINA IV ELL DRILLERS. INC.
N1 ELL CONTRACTOR CERTIFICATION # : 2,84
STATE \FELL CONSTRT CTION PER -Nil] # :
I. WELL USE (Check Applicable Bost: Residential ❑ Pluluciplll ❑ Indu'(11A ❑ Ap CLilwral ❑ Neluloling ❑
Recoaen❑ I Teat Pump Water Injection ❑ Othel ❑ If Oi List I se-
3. WELL LO(-ATIC)\ (SIc,,, eldi oCthe location belo<cl
Ncamal Inver. MILE SRINGS t`ounry-. POLL:
-I" PEA RIDGE RD
Road. Caauunip"or Subdr,ision mid Lot No. I DEPTH DRILLING LOG
3,OFS'NE:K LUA HOALES FROM 'CU Fotmalion Dcsliptiml
ADDRESS
(se —a ei knel<N,, 1 0 85 CL.AV'
SHELBY NC Si 610 CONSOLIDATED ROCK
A. D:\TE DRILLED 82100 USE OF WELL RESIDENTIAL
±. TOTAL. DEPl'H 640
6_ CUTFLNGS COLLECTED 1TS ❑ NO ❑
O
-.uu1!SM L,RIPPIACI I!US'I NG%VkUk' V'I!S ❑ NO ❑ CD
8,STATIC %%A FER LE\TL Beloa,'foil of Caeirar 0 FT.
(V, I(Ab—Toy of C's,IiM _
9_ TOP OF CASING IS j FT. Above Lm¢I Surface' l.J
\pQ
<_ _T<nnu loc orbda.c lw l" !,�,i.
m n..onlnn.< wirb IA NCAC' N .011ato tiEELD IL'Inn r. 0 METHOD OF TESL ARDAI e�A
OF
II- WATER ZONES l&JAI,I NA Ql --t
12. CHLORNA'IIOS' TSRc MPOCHLORHE Amount 0OZ. ifvddidonW±ync<I=n«d<J ���. boak of form
13. C ASN(I LOCATION SICFTCH
Wall 1Ii ckne,,, (Sho)c dlreclion;uld distance from at lea-1 nvo State
Depth Diaueter arWmfitFL Material Roads" or other nap reterencepoaust
From n To S- D. 6 1i 1 " SDR 1l PV'C US HAA Y 74
I -I. CiKOI'T:
Depth Material Method
From (I 'rn ,ti Ft sANDMIX (iRAAIT) PhARA)GEEli
scaem
Depth Diameter Slot S"e Material
Flom NA To Ft. HOi SF O\ LEI'
to"S:ANID ,IW El. PAC E_
Uq)th SizeAlael ,I
TO RL'IEIERFORllTOV IRCS Ills
iuw NA'fu Ft.
I-. VE\PciaKS'. DRS \YELL. SOT USED —�
I DO 1-Cc[(EB1 CF.RTIp} 'I'HAT'MIS WELL WAS CONSTRUCTED N ACCORDANCE Mill 15A NC AC ^C. WTLL
f f1NSTR 1 i1'11 ON STA1411,ik DS AND TI6\T A COP}' OF TI US RP.CORD I IAS it FT:, PRO\1DFD T011IF kb-- LL MRN Ilk.
FOR OFFICE USE ONLY / %f &ii" "f, ] 0: 22 00
Quail No.14 Date
Sel-ial No. SIGNAT -TT OF PERSON CONSTRVCTNG "11 IF t\TLL
Saaca nmcvl m Dklekn of¢'mcl Qwill, Gowid<mIm S,aln.•idw, 30 Oafs
GAl'-I 6H1'. 12 W

To: NCDEH&NR N.C. Dept. of Env. Health & Nat. Re From ALAN S. GANTT 828-286-8787 06/17/00 15 2-126 Page 2 of 10
Sent by the Award Winning Cheyenne Bitware
FOR OFFICE USE ONLY
QUAD. NO. SERIAL NO.
Lat. L�t�e.. R212 2 5 4
North Carolina - Department ofGm'iromnent. health andNmurit Resource. L.. ns Hin _ _
Division of Enviro mentil Nlanagentenl - Groundwater Section Basin Code
P.0. Bo,'_9535 . RaRiol, N.0—6'_6.0535 Head. Eni. GW-I Ent.
Phone(919) '33-3221
WELL CONSTRUCTION RECORD
DRILLING CONTRACTOR: CAROLINA NVELL DRILLERS, INC.
STATE BELL CONSTRUCTION
DRILLF;R REGISTRATION NIINIBER: 1805 PERMIT NUMBER:
L WELL LOCATION'. (Shmv,Aetd1 ofthe location belol,7
Ncarcat tonn- MILL SPRINGS Connn'- POLR
RADAR ROAD
(Road, Cotmlunin. or Subdhkionmul Lot No.) DEPTH DRILLTNG ,CG
2. UWNER HORTON HOMES, HERNANDEZ FROM l0 Pbrtnalinn Ucso ipllon
ADDRESS U^ ITWYSAA
(5u«tor Rooe< vo.l 0 140
RLTHERFORDTON NC 28139 110 2_0
Gry or 1'oan Stale Zip Co&
J. DATE DRILLED 117,00 USE OF WELL RISIDEN'I'IAL
I. TOTAL DEPTH '20
i. CUTTINGS COLLECTED YES ❑ NO
r. Dot's WI:LI. REPLACE IfXIS'I ING W'6I.I::' N'FS ❑ No ❑
'. STATIC WATER LEVEL. Below Top of Caning: SI FT. +;
(Ge" '* Ifabov<Top of CasLg)
8, TOP OF CASING IS 2 FT. Abuvc Lmtd SuBome*
'C'azu�g T,,,,., t<d aior bd... 1aW sudar<is Jlwal is isn<d
m a.<ordmu<o,uh INd NC'AC 2C.0118
CLAY
CONSOLIDATED R�1K
CD
� o
21TELD 1¢pm)10 NIETHOD OF TEST ARD%I
la. WATER ZONES (depth). 180
11-CHLORINATION-T)pc HIPOCHLORHE Amount 60Zbaakof form
12. CASING'. LOCATION SKETCH
Wv11 Tllidmeas CSWo di,emion mid diTmtce from at leaf Iwo Statc
Depth Dimnetei or W'elJlt'Ft AInlerial Road, or othennap I efeimce ponim
From 0 To 115 Ft. 61-1" SDR21 PVC
13. GKUUT'.
Depth
From 0 To
11, SCREEN
Depth
From NA To
1'. SAAND: GR-1\'EL PACE:
Oq)th
Frnm NA To
16. RE.NLARRS:
Matm'ial Method
20 Ft SAND MIX GRAA'ITY
Dimneler SlotSize Material
Ftin. in.
S17C NIMe, al
Ft.
C'HESNhE HIVI
I DO ITEREBY CERTrFY TI-LAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WTFH 15.A NCAC'C. WELL
CONSTRC(-HON ST.ANT)ARDS,.-',D TILAT A COP} Ol-'HES RPCORD IUS BEL'N PRO%'rDED TO TIIE \YELL OR'N-ER.
636
GNN'-t RE\'. 99l
SIGNATURE OF CONTRACTOR OR.AGEN"F
Snbnur .,,wO Io Elie oo of E11, bb vol Natural Rcowa<s
06' 17; OG
Dale

To: NCDEH&NR N.C. Dept. of Env. Health & Nat. Re'.From: ALAN S. GANTT 828-286-8787 03/16/00 20.17 54 Page 10 of 11
Sent by the Award Winning Cheyenne Bitware
QUAD. NO. FOR OFFICE NO
on7.2077[)
North Carolina- Department of Environment. Healthand Natural Resources Lat. Long. RO �) ` (J
Dic ision of Em ironmentnl Management - Groundrsatn' Section Minor fiasco
P.O. Boz 29535 - Raleigh. N.C. 2626.0535 Basin Code --
Phone[phone]I HraderEnt. _. OW-1 En( --
WELL CONSTRUCTION RECORD
DRILLING CONTRACTOR: CAROLINA NVELL DRILLERS INC.
STATE WELL CONSTRUCTION
DRILLER REGISTRATION NUMBER: 1805 PERMIT NUMBER:
L WELL LOCATIOX': (Show sketrh of the location below,
Nearest loon: COLUMBUS Camp" POLK
LEVISTREET
(Road. Community. or Subdivision and LOI No.}
z. OWNER HORTON HOMES
ADDRESS 342 US Hwy', 4A By -Pass
RUI'HERFORDTON INC 28139
City or Tmvn State Zip Code
3, DATE DRILLED 3'2/00 USE OF WELL RLSID6NTIAL
a TOTAL DEPTH 125
DEPTH
FROM To
0 3
12 175
DRILLTNG XG
Formation Desc.iplion
CLAP
CONSOLIDATED ROCK
5, CUTTINGS COLLECTED TES ❑ NO D
—
6. DOES W111. REPLACIS E:XISIING WELT:? %Es NO ❑`
7. STATIC WATER LEDBL Be].. Iop of Casing 20 FT.
fGa'-" I(dbove Top of C'a�tnp)
a. TOP OF CASING IS 2 FT. Above Land Sudaoe"--
'Ca,u�p Tmiuw'd ot'or below [oiM'urfaw n dl<gal udcei a vadanes"Iseaad
- -
—
no a.anrdmree gel, Is,t tccnc:c.oux
9. YIELD (gpm): 30 NIETHOD OF TEST ARD%f
to. WATER ZONES (depth): 102
r
—F10C]_
IL CHLORINATION_ Tplc
12. CASING.
Depth
From 0
To
13, Gkonnt
Depth
From 0
To
14. SCREEN
Depth
Ft'om NA
To
I5. S.A\-D/GR�INHL PACT:'.
Depth
From NA
To
16. REMARFS.
m �
Z
HYPOCHLORI I'E Amount 4 OZ. If additional spore is nxdod uae baA of farm
LOCATION SKFFCH
Wall Thiclaic" (Show direction and dislar.e from at lean nvo State
Diameter or Weight: FL Material Roads, or other map reference points)
FIWY, 74
21 Ft. 61/1" SDR 21 PVC
Material Method
20 Ft. SAND hHR GRAVITY
DianietnSlot Size Material
Ftin. in.
FL
Size Material
FO\ NIOLNTAN RD,
LM ISTREET
l\'OODLAN-D ❑
PD. g 1532
105
I DO HEREBY CERTIFY THAT TIES WELL WAS CONSTRUCTED LN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, .AND TILAT A COPY OF TIDS RECORD HAS BEEN PROVIDED TO TIR WELL OWNER.
629
03,1600
v
OW I REV, 9'91 SIGN.ATLRE OF CONTRACTOR OR AGENT Snbirur oiiy, al ro 11 N.non of &rrvvomnant, Haildi and Namril Rao, rces (),,to
1,

Nonh Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section 1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone] Z J n
,✓ g
WELL CONSTRUCTION RECORD WELL CONTRACTOR: n Rnu,man well T1ri 1 1 i nnr Tnc _
WELL CONTRACTOR CERTIFICATION #: 2809
STATE WELL CONSTRUCTION PERMIT#:
1 WELL USE (check Applicable Box): Residential® Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: Columbus County POl
25 Twin Drive/Land of Lakes Subdivision
(Road Name and Numbers. Communiry, or Subdivision and Lot No.)
3. OWNER Rclnalrl R Carman Rrnrk
Address P.O. Box 403
ueel or Houle o.
Glya own 10/02/ p
4 DATE DRILLED
5, TOTALDEPTH 99n'
6. CUTTINGS COLLECTED YES Q NOn
7. DOES WELL REPLACE EXISTING WELL? YES CI NO® _
8. STATIC WATER LEVEL Below Top of Casing: 50 FT. _
(Use': 9 Above Top of Casing)
9. TOP OF CASING IS 1 d FT. Above Land Surface' _
-Top of using terminated at/or below land surface requires a vorlance In accor-
dance with 15A NCAC 2C.0118 [�
10. YIELD(gpm): 2 METHOQOFTEST rotary air
11. WATER ZONES (depth): 180 — 220
Agricultural ❑ Monitoring ❑
12 CHLORINATION: Type f--hlst Amount 6
13. CASING:
Wall Thickness
Depth Diameter or WeighVR. Material
From 0 To 93 Ft. A 1 /R Crh Rrl plir
From To Ft.
From To Ft.
14. GROUT:
DRILLING LOG DEPTH
From To Formation Descdpuon
:r_=
o<
If additional space is needed use back of form
CO
`M
po
LOCATION SKETCH
3
rn�o
(Show direction and distance from at least two Stale
cli
rnx
Roads, or other map reference points)
W
J
o
z
Depth Material Method
Front _._Q To 2Q Ft. �nn.csat, .gr-a;x;Lt;T flow
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:
►0
��
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C. WELL
CONSTR,UPrTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFIC:IyU Ni..�:. �.. , .�D I1u�1 ��
Quad O ri ➢ SIGNATURE PERSON CONSTRUCTING THE WELL DATE
o ginal to Division of Water Quality, Groundwater Section within 30 days
Senal No ! GW-1 REV. 12/99

North Carolina - Department or Environment and Natural Resources . Division of Water Quality - Groundwater Section r.. 19 2 I 1
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Ptlons [phone]
WELL CONSTRUCTION RECORD
D. Bowman Well Drilling, Inc.
WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION p: 2809
STATE WELL CONSTRUCTION PERM(T#:
1 WELL USE (Check Applicable Box): Residential D Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ II Other, List Use:
2, WELL LOCATION: (Show sketch of the location below)
Nearest Town: Colnmhis _- County: EQ1
Old Holbert Cove Road
(Road Name and Numbers. Community. or Subdivision and Lot No.)
3. OWNER Jeffrey Ramsey
Address P.O. Box 970
treat orFT06
o.
col nmhns N
City or Town Stale Zip Cade
4 DATE DRILLED 913Q /00
5. TOTAL DEPTH n0-
6. CUTTINGS COLLECTED YES❑ NO�y)
7, DOES WELL REPLACE EXISTING WELL? YES ❑ NOO
8. STATIC WATER LEVEL Below Top of Casing: 60 FT.
(Use'+' g Above Top of Casing)
9. TOP OF CASING IS_1, 4 FT. Above Land Surface'
'Top of using terminated at/or below land surface requires a varlance In acew-
dance with 15A NCAC 2C.011e
10. YIELD (gpm): 6 METHOD OF TEST sat.ar�air
11. WATER ZONES (depth): art'
Agricultural ❑ Monitoring ❑
DRILLING LOG DEPTH
From To Formation Description
F If additional s o
1'_ CHLORINATION: Type tahlat Amount pace B needed use back form -�
13. CASING:
Wall Thickness
Depth Diameter
or Weight/Ft. Material
From 0 To _ 46 Ft. 6 118
Sch 80 PVC
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From —n To ?0 Ft. onnC*'ote
gtavTl"a
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From To _ Ft _ in.
—in.
From — To — Ft. — In.
_ In.
From —To _ Ft._ In.
_ In.
16. SAND/GRAVEL PACK:
Depth Size
Material
From To Ft.
From To Ft.
17. REMARKS:_
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
- /'g/-
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.
y131)i02->
rOR OFFICE USE ONLY IGNATURE OF RSON CONSTRUCTING THE WELL DATE
uad No:
Submit original o Division of Water Quality, Groundwater Section within 30 days
GW I REV. 1299
awl No.

North Carolina - Department of Environment and Natural Resources - Division of Water Quality • Groundwater Section 1 7045
6 M 'I S C t Rai t h N C 27699-1636-Phone [phone]
1. a aNce ener- eg . . . 1
WELL CONSTRUCTION RECORD WELLCONTRACTOR: C�ri nhPr )p C� �ona
WELL CONTRACTOR CERTIFICATI NO.: CQM r7
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 LOCATIO : (S ow ketch of the location below) On
Ne r st Town: -�(Cai - County: r -
176
jil/!M SG ILCa r�ri
(Roan and NurMers,or Su sion and tol No.) (T DRILLING LOG DEPTH
3. OWNE 1 I I to !OM a �?I12T tYnPY From To Fonnatlan Desc 1pGon
Address
City «To" state
4. DATE DRILLED
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑ NO®
7. DOES WELL REPLACE EXISTING WELL? YES NO®
6. STATIC WATER LEVEL Below Top of Casing: FT.
Q
(Use •: 0 Above Top of Casing)
9. TOP OF CASING IS_J_53 FT. Above Land Surface -
Top of casing terminated atior below land surface requires a variance In accor.
dance with 15A NCAC 2C.0110
10. YIELD (gpm): -0- METHOD OF TEST
11. WATER ZONES (depth):
12. CHLORINATION: Type Amount
13. CASING:
-
Wall Thickness
Depth iar 9ter
«Wa Mat dal
/'�
From _�L—To � Ft. t t
2vFl.
From To Ft.
From To Ft.
14. GROUT:
Depth Mated4l
Method
From 0— To 2Ft.
r ad
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.
O
fTl
Et
cn
If additional space is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least two State'
Roads, or other map reference points) c �U
From .4eridersonviLLe- I-Z(0
0 zcne (�of • tou)ard Try
i afers eC ''do • Go
pcz s iYui SQL" I l ac �l A-ce .'ass
I(Or hard _T11)' 3rd or 4-fk-cu` c
where -1"h-o son (7� ec�nes'i
t)��e us fast e b
176 , � p % 6 v drive CV-
o 4v 1p of hJ1 . Gr u�e-oq
-41tinq (here. U)eJ/ iny
nt- ard.
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH i5A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF RECORD HAS BEEN PROVIDED TO WELL OWNER.
FOR OFFICE USE ONLY -, � ,fey DATE
Quad Not SIGNATURE OF RSON CONSTRUCTING THE WELL
Submit original to Division of Water Quality, Groundwater Section within 30 days OW-1 REV. 12/99
Serial No.

, i4;754
North Carolina - Department of Environment and Natural Resources - Division of Water Quality • Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-163EPhone [phone] �1 1
WELL CONSTRUCTION RECORD WELLCONTRACTOR: I'iriLOCO
WELL CONTRACTOR CERTIFICATION p: ar7
/STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Appllcable Boa): Residential m Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCA
Nearest Town:
3. OWNER
Address
sketch of the location below) "Polk,
(�
County: 1�
and lot No.) DRILLING LOG
From To,
)
city or Town elan �'� "•'•^
4. DATE DRILLED
5. TOTAL DEPTH �
6. CUTTINGS COLLECTED YES ❑ NO®
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO®
6. STATIC WATER LEVEL Below Top of Casing: FT.
(Use'+' 11 Above Top of Casing)
9. TOP OF CASING ISI 3 FT. Above Land Surface'
'Top of casing terminated at/or below land surface requires a variance In accor-
dance with 15A NCAC 2C.0118
10. YIELD (gpm): IC METHOD OF TEST T�
11. WATER ZONES (depth):
12. CHLORINATION: j Type Amount
13. CASING: �i�y puny Ias,�&UeI�
- Wall Thickness
Depth D'iarroter or W h 1. lariat
FromCTor45 Ft. �—
01
From To Ft.
From To Ft.
14. GROUT:
Depth Matert i M� euw
.2�dl
From � To F1. �'I)I'1Cfe-
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
DEPTH
Fomtason DescdPlim
If additional apace is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least two Slate
Roads, or other map reference points)
:-?10 - IZ,t,g a GLL Saluda.
Go to eel 01 J-00A
0a V76 . Go Pas} iersorL Fall S
20a�1 On 46C�-
b i cures �h� 1���I Jug'skep
b� le i ar�d ih� l09 coJ�,,, real'{ ol.
6-10 Come. �n hear CCU -,From To FL
From To Ft.
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF IS RECORD HAS BEEN PRO IDED TO THE WELL OWNER.
FOR OFFICE USE ONLY DAT
Quad No: SIGNATURE OF ERSON CONSTRUCTING THE WELL
Submit original to Division of Water Quality, Groundwater Section Within 30 days GW 1 REV. 12M
Serial No.

�/�g�
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section 11\ ' 21335f
919 733.3221
1636 Mail Service Center - Raleigh, N.C. 27699.1636-Phone ( ) -1Q WELL CONSTRUCTION RECORD WELL CONTRACTOR: ��fISTUnhe�� Ci Lima
WELL CONTRACTOR CERTIFICATI N #: a 00 7
_ STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable box): Residential LIQ/Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other If Other, List Use:
2. WELL LOCATION: (Show sk ch of the location below) �n t
Nearest Town: - ont rf Yt,b u S County:
(Road Name and Numbers. C-oOm_��_nItY. Or Su vision and
3. OWNER inn I7/Pnh/e vision and
Address Irlc:7 i -r11 CSV 4' (�r
Gty or Iown
4. DATE DRILLED b—e rr SdL
5. TOTAL DEPTH N 6 S r _
6. CUTTINGS COLLECTED YES ❑ NO[t
7. DOES WELL REPLACE EXISTING WELL? YES ED NOM
8. STATIC WATER LEVEL Below Top of Casing: FT.
(Use •+' 0 Above Top of Casing)
9, TOP OF CASING IS `• 33 FT. Above Land Surface*
-Top of casing terminated at/or below land surface requires a variance In accor-
dance with 15A NCAC 2C .0116
10. YIELD (gpm): METHOD OF TEST-7 r? m
11. WATER ZONES ( epth):
12. CHLORINATION: Type Amount
13. CASING: e�f Plop Ir)SWQ-r
Wau Thickness
Depth 0 4vilpter or Weight/R. Material
FromTo 123 Ft.— CS D le -IL Vill (2--
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From To -XL- Ft. L _Oh to i Q r l
islij
From To Ft.
15. SCREEN:
DRILLING LOG DEPTH
From To Formation Description
r�
0
c`
C
om
,
z r"
W
sr�1
>o
bJ
r
ti
Z
If additional space is needed use back of form
I OCATION SKETCH
(Show direction and distance from at least two Stale'
Roads, or other map reference points)
q4 A - AU.�
or
�00.G�• �0.1Y'Wlr�..-�r•
Depth Diameter Slot Size matenal PQSs
From —To —Ft— in. _ in.
From To. —Ft. in. in. erLA of
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 WITH95A N, GAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS REC RD HAS BEEN PROVIDED T THE WELL OWNER.
FOR OFFICE USE ONLY DATE
Quad No: SIGNATUR9 OF ERSON C TRUCTING THE WELL
Submit original to Division of Water Quality, Groundwater Section within 30 days GW 1 REV. 1N99
Serial No.

North Carolina -Department of Environment and Natural Resources -Division of Water Quality -Groundwater Section
1636 Mail Service Center- Raleigh NC 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELLCONTRACTOR: ` �r( ' �r ITdd LOrio
WELL CONTRACTOR CERTIFICATION #: �� 0
(1
STATE WELL CONSTRUCTION PERMIT#: i7
1. WELL USE (check Applicable Box): Residential Lh Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ if Other, List Use:
2. WELL LOCATION: (Shoyv sketch of the location below)
Agricultural ❑ Monitoring ❑
Nearest Town: Le LfJLL&fM`yl I N2 V County: J L' t 11
TO.L`1Ls�ofi CrfOV� Rnclri.
(Road Name and Numbers, Commun' or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER Y `I Knd
ate ( aer 1n 9er From To Formation Description
Address .(C5✓rvr d-
City or Town Stare Zip Code
4. DATE DRILLED
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑ NO�t
7. DOES WELL REPLACE EXISTING WELL? YESED NOM
8. STATIC WATER LEVEL Below Top of Casing: FT.
1 2 (Use -: it Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface'
-Top of cuing terminated at/or below lend surface requires a varlance In accor-
dance with 15A NCAC 2C.0118
10. YIELD (gpm): �_ METHOD OF TESTEif
11. WATER ZONES (depth):
12. CHLORINATION: Type Amount
13. CASING: au puDtp iast"Pr
J I / Wall Thickness
Depth Diameter orWeighVFt. —MfAJ aterial
FromTo60 Ft. (0�-- )—
From To Ft.
From To Ft.
14. GROUT:
Depth Material Metho
From To —,QQ—FLrO n�_Imumd
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From —To—Ft— in. —in
From —To —Ft. _ in. —In.
From _ To _ Ft. In. — in.
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
17
0
o
�
L
a�
�c
"r
Ln
ON
0
If additional space is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
Easy. -b EXi-I ), LaAd-ruM -
I hn�le. UM r1/10
tors Tac)CsortGroAe 14aA ty6 l e-
house
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.
o� _1c
FOR OFFICE USE ONLY Quad No: SIGNATURE OF PERSON CONST CTING THE WELL DATE
Submit original to Division of Water Quality, Groundwater Section Within 30 days
I - GWt REV. 12f99
Serial No,

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section 1; 1
1636 Mail Service Center - Raleigh, N.C. 27699.1636-Phone [phone] A- 1 ! f
WELL CONSTRUCTION RECORD WELL CONTRACTOR: fly
WELL CONTRACTOR CERTIFICATI N #: J 00 1 J
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (check applicable Box): Residential as Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION:
Nearest Town:
(Road Nana Numbers,
3. OWNER
Address
sketch of the location below) ``�' n© n
-A..,' County:
and Lot No.) DRILLING LOG DEPTH
From To Formation Description
CitAw Town State lip code
4. DATE DRILLED----9-��0-Q�O
5. TOTAL DEPTH f
6. CUTTINGS COLLECTED YES ❑ NO®
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO®
B. STATIC WATER LEVEL Below Top of Casing: FT.
(use •; if Move Top or Casing)
9. TOP OF CASING IS 1.33 FT. Above Land Surface*
•Top of casing terminated atior below land surface requires a variance In accor-
dance with 18A NCAC 2C.0118
10. YIELD (gpm): "TQ_ METHOD OF TESLJL�
11. WATER ZONES (depth):
12. CHLORINATION: Typo / Amount
13. CASING:
Wadi Thickness
Depth Diameter or Weight/Ft. Material
From —TO 125S Ft.1,2,19 SUZ21—
From To Ft.
From To Ft.
14. GROUT:
Depth ,M�ateriI Method
From 1`9 To QQ FL iliJ1d.Ya[�--
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
J,
lD o
If additional space is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least two State (A,,
Roads, or other map reference points)
6
U
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY O IS RECORD HAS BEEN PR IDED TO THE WELL OWNER.
FOR OFFICE USE ONLY M.
DATE
Ouad No: SIGNATURE SIGNATURE OFF SON CONSTRUCTING THE WELL
Submit original to Division of Water Duality, Groundwater section within 30 days
GW1 REV. 12/99
Serial No.

.'1_ 340
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 WELLCONTRACTOR: 1'�rictlnYlPf�odCLLou
WELL CONTRACTOR CERTIFICATI N 0:
STATE WELL CONSTRUCTION PERMITO:
1. WELL USE (Check Applicable Boa): Residentially/Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ if Other, List Use:
2. WELL LOCATION: (Show sketch of the location below) �'v
Nearest Town: • (� S t)r' i County:
l (1 vLG 0' h apes
(Road Name and Numbers, Convnuniry, or suod vision and Lot No.) DRILLING LOG
3. OWNER �� Qtj .�I ' P10� From To
Address q ) FQ'r(Su or e o S> pTa"F
—'
DEPTH
Formation Description
'°
Arden ,AtC
City or Town Slate Lp rode
O C7i
4.
DATE DRILLED —00
S --
5.
6.
TOTAL DEPTH '
CUTTINGS COLLECTED YES❑ NO®
L7 c r'
n
7.
DOES WELL REPLACE EXISTING WELL? YES NO®
�" o
8.
STATIC WATER LEVEL Below Top of Casing: FT.
M
(Use Y• It Above Top of Casing)
9.
TOP OF CASING ISFT. Above Land Surface*
•Top of using terminated at/of below land surface requires a valance In accor-
dance with 15A NCAC 2C.011a
r OF TESTT_L d
v o
10.
YIELD (gpm): METHOD
11.
WATER ZONES (depth):
12. CHLORINATION:\ `Type Amount If additional space is needed use back of form
13. CASING:
LOCATION SKETCH
Wall TltiUvass ..
Depth St
Diameter or Weight/Ft. Material (Show direction and distance from at least two ate
From —To— Ft.1"/9 5De-2-1 Roads, or other reap reference points)
From To Ft. =-z(o morn )4ead emavIllin
From To Ft.
14. GROUT: �Q 1�01f�IKLIuS 2)C(T 'd-� qJ0 IL' 0l�
Depth Material Metho )4U1..tr- 74 -{-a ft(S� eY.(t t�Y 'JL pwLs O (
From 0 To _ 20 Ft. e= ra
From To Ft. C�QS �R W. 5 0/ L log UYL 1
LJ•. I - _ I
15. SCREEN: t{OU_ Gprht: to if L. 'J ec"�(OYL o� �� C1 .
Depth Diameter Slot Size Material ( L OrL q GO rox. l bl oak
From To Ft in. _ in. / p
From To _ Ft. — In. —In. TI L O(l t �VG'Y Cf�e00.c1 I (rz'6
From To Ft. In. _ In. 01 ��
16. SAND/GRAVEL PACK: 111
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 BEE ROVIDED TO THE WELL OWNtA. i
FOR OFFICE USE ONLY DA
Quad No: SIGNATURE O ERSON CpffSTRUCTING THE WELL
Submit original to Division of Water Quality, Groundwater Section within 30 days GW 1 REV. 12t99
Serial No. -