Well Construction Records Rutherford 1 CY2000

North Carolina . Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section (. , 0 1 7r7
1636 Mall Service Center - Raleigh, N.C. 27699.183E-Phone ($19) 733-9821 l
WELL CONSTRUCTION RECORD WELLCONTRACTOR:
WELL CONTRACTOR CERTIFICATION 0:
STATE WELL CONSTRUCTION PERMITII:
1. WELL USE (Check Appuceble tloz): Residential Municipal El Industrial El Agricultural ❑ Monitoring ❑
Recovery ❑ Boat Pump Water InjectloNj Other
(n0II IIf lOther, List Use:
2. WELL LOCnT&�(SIE� sk@' the location bolo County:
Nearest Town: (( ,, ((++ 11''�,
(Flood Nam4_end Numbers.. Comraurrl
3. OWNER ``lC//rWrVDYc-'A3• Tt 17�17kA�1n n
Address �� 1C&Nl= I j
iilikfi
Cilyor Town q ^( Stale Zip Code
4. DAi-E DRILLED 6—�J -OD5. TOTAL DEPTH 4yS —
6. CUTTINGS COLLECTED YES[_j NOLK
7, DOES WELL REPLACE EXISTING WELL? YE�NO❑
6. STATIC WATER LEVEL Below Top of Casing: FT.
(Use'.* If Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface'
*Top or casing terminated aVor below land surface requires a variance In accor-
dance with 15A NCAC 2C. 11a n�T
10, YIELD (gpm): METHOD OF TESTA i R
11. WATER ZONES (depth):
12. CI-ILORINATION Type Amount
13. CASING:
Wall Thickness
1 Deplitlh�nn Diameter el VFL Naledal
From m4( To—TomFI.
7
`
1.S^ G� FI. «
Fro
From --To-- Ff.-
14, GROUT:
Doplll Ahal Molhod
From To �-Ft. �qc/�--
From To FI
15.SCREEN:
Depth Diameter Slot Size Material
From _ To _— FI — In. _ In.
From _ To _ FI. _ In. _ In.
From To _ Ft. _ In. _ In.
16. SANDIGRAVEL PACK:
Depth Size Malarial
From To Ff.
From To Ft'
17. REMARKS:
DRILLING LOG DEPTH
From To Formation DescHpllon
4J
II additional space Is needed use back ol3orm--
LOCATION SKETCH o _
(Show direction and distance from at least Iw6State`
Roads, or other map reference points)
.4W4(,
I DO HEREBY CERTIFY THAT THIS WELL WVSIGNA=TunEOFPFRS
RDANCE WITH 15A NCAC 2C. WELL
CONSTRVCTION STANDARDS. AND THAT S BROVIOED TO THE WELL/OWNER.
FOR OFFICE USE ONLY DATE
Quad Na. ONSTRUCTING THE WELL
Submit original to Division of Water Dually, Groundwater Section within 30 days GW I REV. 12199
Serial No

North Carolina - Dapartment of Enylronment and Natural Resources - Division of Water Duality - Groundwater Section - r7
1636 Me11 Service Center; Ralelgh, N.C. 27699-1638-Phone (%19) 733.3221
WELL CONSTRUCTION RECORD WELL CONTRACTOR: G7JMF"7 /wF-rr ))aU-- �^1a Ctr.
WELL CONTRACTOR CERTIFICATION 0: S'%(� — 2-11024-
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (check Applicable Do.): nesldenUal x Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other 0 If Other, List Use:
2. WELL LOCATION �(S I� t��`tion below) "VTaIRF, 20— ,
Nearest Town' (�T y:
fkrwl 1� jn�� fZ n of 'A y
(Rosa Name and NuAAmbers. Community. or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER n�11'1 AS a7 From To Formation Descdpllon
Address T\
POl, !u6
C lL
City or Town State Zip Code`-TT7SC'7sJ�jr—
DAi-E DRILLED��Yv���Jl of et_
5. TOTAL DEPTH-3Sh--L
6. CUTTINGS COLLECTED YES ❑� NON r;
7. DOES WELL REPLACE EXISTING WELL? YES O NOW O -
8. STATIC WATER LEVEL Below Top of Casing: FT.
(Uso'.' 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. 1a ' —
10. YIELD (gpm): I METHOD OF TESTAO —
11. WATER ZONES (depth):
r
It additional space Is needed use back IorrrT'
I
12. CHLORINATION: Type 1 .__Amount:- 07
13. CASING:
Wall Thickness
� Depth , • la e�r or Wei I iFI. Material
From To ��� FI. we
Froth To-- FL -
From To-- Ft.
IA. GROUT:
�— Depth _ cA,,RMaterL- Moth
From 0 R. ��c Ic (�j�:_
From To FL
15. SCREEN:
Depth
Diameter
From
To
Ft — In.
From
_ To _
Ft. In.
From
To _
Fl. In.
16. SAND/GRAVEL
PACK:
Depth
Size
From
To
Ft.
From
To
Ft.
17. REMARKS
Ca
LOCATION SKETCH ffOT7'"t"E
Show direction and distance from at least two State
Roads, or other map reference points) 1_�
S
Slot Size Material 0 r
In. 1
In. -
In. A
Material I\I
I DO HEREBY CFRTIFY THAT THIS WELL WAS CONSI RUCTED IN ACCORDANCE WITH ISA NCAC 2C. WELL
CONSTRUCTION STANDARDS, AND THAT A C PY OF IIS RE D HAS PRO ED TO THE WELL OWNER,
FOuad
FFICE USE ONLY
' SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Quality. Groundwater Section within 30 daysGWI nEv 17199
o.

215 O r�
North Carolina - Department of Environment and Natural Resources - Division
of Water Quality - Groundwater Section
1636
Mail Service Center • Raleigh, N.C. 27699.1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: ��N yr C'
WELL CONTRACTOR CERTIFICATION a:
STATE WELL CONSTRUCTION PERMIT#:
1.
WELL USE (Check Applicable sox): Residential Municipal ❑
Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑
If Other, List Use:
2.
WELL LOCATION: (Show ske ch f the location below)
�
!`� ( 1
y
Nearest Town: "\
yt,`�
Cou : j
`�e>Z�d1�y
`i
`
I:i erz IiA. C1 wec _ K) y
I AUG
(Road Name and Numbers, mmun1iry, or Subdivision and Lot No.)
DRILLING LOG °DEPTH
3.
OWNER L JO�QCaL
From To F .: Oescnpncn
Address
�t�c
I 1� .�.�iSletor Dote o�
�1(�7
4.
City or Town State Zip Code
DATE DRILLED in _r2D—M
5.
TOTAL DEPTH �g e)
— —
6.
CUTTINGS COLLECTED YES NO[/'
>6S ���
7.
DOES WELL REPLACE EXISTING WELL? YES N0O-
2
S.
STATIC WATER LEVEL Below Top of Casing: FT.
(Use '+' it Above Top of Casing)
9.
TOP OF CASING IS FT. Above Land Surface'
o 0
'Top
of casing terminated etror below land surface requires a variance In accor.
dance
with 16A NCAC 2C 3gV8
10.
YIELD (gpm): METHOD OF TEST
11.
WATER ZONES (depth):
12.
CHLORINATION: Type —N N Amount
It additional space is needed use back Xm;;
13.
CASING:
' Wall Thickness
LOCATION SKETCH IV
' Aepth��f,..,� iameter o
ei h .edai
(Show direction and distance from at least ly"Statg
From To �.— Ft.
� (/
Roads, or other map reference points)
From To Ft.
From To FL
14.
GROUT:
/
Dept alert I CjAethod
From To l�Ft. WD Rcl
From To Ft.
C
15.SCREEN:
Depth Diameter Slot Size Material
From —To—Ft— in. in.
V �t C3,o
From _ To Ft. in. In.
L.l
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 CONSTRUCTE IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A C Y THI2REORD S BEEN PROVIDED TO THE WELL OwNEP_
FOR OFFICE USE ONLY
Quad No: SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Subadl original to Division of Water Quality, Groundwater Seaton within 30 days Serial No. Gw.1 REV IYs

North Carolina - Department of Environment and Natural Resources - Division of Water Ouahry - Groundwater Section rri O O
1636 Mail Service Center • Raleigh, N.C. 27699-1636-Phone (919) 733G.
.3221 1 0
WELL CONSTRUCTION RECORD WELL CONTRACTOR: GEME6i vE C
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable sox): Residential ❑ Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ It Other, List Use:
2. WELL LOCATIO� (Sh w sketch of the location below)
N(p�) rest Town: — -KJ,(c.I��L'� County: \RU2�lLiCrJI�CY�
(Road Namrtrtrt���pga���nnnn�Nf1umcp�y\.�\o^m�m,�uniry, or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER l_.G�)LJ Ir`IC.7 S From To Forma:ion Description
Address
or
City or Town
Zip Code
4. DATE DRILLED v"
5. TOTALDEPTH
6. CUTTINGS COLLECTED YESQ NOF
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO[Er
8. STATIC WATER LEVEL Below Top of Casing: FT.
I (Use'+' If Above Top of Casing)
9. TOP OF CASING ISFT. Above Land Surface -
'Top of casing terminated attor below land surface requires a variance In actor•
dance with 15A NCAC 211
10. YIELD (gpm): METHOD OF TEST A 12
11. WATER ZONES (depth):
12. CHLORINATION: Type HrN Amount S ca-•
13. CASING:
Wail Thickness
*
Depth4/6 Di�rnetar or W i ht/Ft. Matenil
From'-F _ITO FL
From To Ft. � , ,tome
From To Ft.
14. GROUT:
Depth ate Metho
From 0 To
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From To FI 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:
O �
A r'
TTJ
If additional space is needed use back Norma �
---
971 o
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 ACC RDANCE WITH 15A NCAC 2C. WELL
CONSTRUCTION STANDARDS, AND THAT A C O THIS E ORD A BEEN PROVIDED TO THE WELL OWNER_
FOR OFFICE USE ONLY �—
Quad No: SZiNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Quality, Groundwater Section Within 30 days
Serial No. Dw.1 F1Ev. 12N3

Nonh Carolina - Department o(EnVirCn--e d Natural Resources - Division of Water Quality - Groundwatersection G j 5 0 g 6
1636 Mail Service Center - Raleigh, N. -1636-Phone [phone]
WELL CONSTRUCTION ORD WELL CONTRACTOR: N �€ C
WELL CONTRACTOR CERTIFICATION p:
STATE WELL CONSTRUCTION PERMITa:
1. WELL USE (Check Ap,.licable e_ :un'ial0 Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pum;-ection ❑ Other ❑ If Other, List Use:
2. WELL LOCATIO, ': (Show sket_ - :location below)
Nearest Town: - County: ��
(Road Name apd Nurr:,. S. CoMmr.. _ rislon and Lot No.) DRILLING LOG - DEPTH
3. OWNER /{- ` From To Formation Description
Address c— 6;ZzVti `G��•i
t_Vuet D!
City or Town , _ Zip Code
4. DATE DRILLED
CC
5. TOTAL DEPTHd
6. CUTTINGS COLLE� _D •OE21,
7. DOES WELL REF! %+C.L EXIC _'-.? YES [✓] NO El n
B. STATIC WATER LE,.-t. Bela.sing: FT. -"
I !.dove Top of Casing)
9. TOP OF CASING IS a Land Surface' I cam:
'Top of casing lerminat, - Gulres a variance In actor-
dance with 1SA NCAC 2C -�_ _T .
E f�12
10. YIELD (gpm): r,
cn --
11. WATER ZONES ,_>. -- - ..
12. CHLORINATION: Pe
—Amount It additional space is needed use bawl tor® —
13. CASING: r
C_
FromT
From Tc - —
From Tc - —
14. GROUT:
Ce
From 0 Zia -
From
15. SCREEN:
Dena.
From _To—
From _
Tc
From _
Tc
1 S. SAND/GRAVEL
From
From
17. REMARKS:
—
I DO HEREBY C=.
CONSTRUCTIO::
FOR OFFICE USE
Quad No:
Serial No. -
Wall Thickness
t. t teal
tonal Method
_. t Size Material
in.
in.
in.
Material
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
.,AS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
-, ' A C{�PY� TH}S. :ORJjHAS BEEN PROVIDED TO THE WELL 05vNEP
SIGNATURE OF PERSON CONSTRUCTING THE WELL D,,.TE
original to Division of water Quality. Gmundwater Section within 30 days
Gwa REv t:rgl

UST SEC I1'-N rax:_t7-roe-yvio
North Carolina - Department of Environment and Natural #sources - Division of Water."lity - 6rounr%vater gedion
P,O. Box 29576 - Relegh,N.C, 27626-0578&Phone (919) 73M221
G-r� - verzltl�u ALMP
WELL CONSTRUCTM RECORD DRILLING CONTRACTOR: 7
pR1L`LCR REwSTf ATION /t
j STATE WELL CONS'rRUCTION PERMIT*:
1, WELL USE ( K Appheaole soa): Residential Municipal Industrial ❑ Agricultural ❑ Monitoring ❑ -
Recovery0 Heat Pump Water Injection ❑ Other Q II Other; List Use:
2. WELL
Town:
(Ro8o, C
3. OWNER
4. DATE DRILLE?Z a9L_
DEPTH
From To
DRILLING LOG
ronfri Descipbr.
5. TOTAL DEFT
6, CUTTINGS COLLECTED YES Q NOQa-TCF�'--
7. DOES WELL REPLACE EXISTING WELL? YES [✓7 NO[]— '�-
9. STATIC WATER LEVEL Below Top of Casing:. . Fr. O
twee "+" If Above Too of Casing)
9. TOP OF CASING ISFT. Above Land Surface'
• Casing Terminvisd Ivor Delow land sumacs Is Illegal.an " s VIM.ame Is Issued '
In accordance with 15A NCAC 20 .0118 �D o
10. YIELD (Dpm): _� METHOD OF TEST
11. WATER ZONES (depth):
12. CHLORINATION: Type Amount tL'
13. CASING:
Wall Thlcltnese
Dep�t�1•���� �II'I"Vef UL
Frorn�To2-=—Ft. .�
From To Fl.
From To Ft,
14. GROUT:
DepthM Ida Meth
From Q— To '90
From
To
Ft.
15. SCREEN:
Depth
Diameter S[ot'Size 'Material
From _
To --
Fl -- in. In.
From —To
.�,--T-Ft
� -. Jti
f t
;u
From _._To
—Ft--
e*-(3
16. SANDIGRAVEL
PACK
Depth
S'ze 7 nt h Mi{e) &I
From
To
Ft.' -----
From
To. .
— Ft. _.
It addalonel space Is needed use beckTRTosr1 a
C
I OCATION SKETCH ?
(Show diiection and distance from at Nast two Sere
17, REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE V/rtH 15A raCAc 2c. rlEtl`
AND THAT A COPY F T S RECQRQ HAS FEN PROVIDED TO THEW ELL CVVNEF-/,
CONSTRUCTIrjN STANDARDS, py -
a.
_ pATi
jIICiNA-RIRE OF OONTRACTOR OR AGENT ro w.n o,+r..
2 0 f'1 O �S joma oa0lnel le Ot✓Won or Wp.r Oue:ry a:d copy 0vr1 REV. 1r0a

Carolina - Deovrnent of Environment and Natural Resources - Division of Wat , QDa'i^r - AeClbn
DOBox 29573-Ralegh,N.C.27626-D57&°hme(9'9)733-3221
WELL CONSTRUCTION RECORD DRILLING CONTRACTOR:
DRILLER REGISTRATION M; S , (0
STATE WELL CONSTRUCTION PERMITR:
1 WELL USE Khans Apphcaola aox1: ResidentialEK Municipal ❑ Industrial ❑ AGncu Rural ❑ Monitoring ❑
Reccvery ❑ j Heat Pump Waver Injection ❑ Other 0 If Qher, Lis! Use:
2. WELL LOCAT`OGf�{: (Show s�c�h of the location "low) (yJ�
ti _aresi Torrr. �p 1•• r� County:
(Roa0. �om++vnfr. o•.5 aa"' 2 _ 1No.) DEPT-�: DRI.LLING _OG
3. OWNER C J , �� Frpr To Fo+na,me Darren7be
(Srreal or Romo No.)
Crryo To, Sm:e Zip Coda
—
a
CATEDRILLED
_
5.
TOTAL DEPTH
6.
CUTTINGS COLLECTED YES ❑ NO❑v' �0CM
_
4
7.
DOES WELL REPLACE EX STING WELL? YES ❑ NOR-
^
S.
STATIC 'HATER LEVEL Below Top or Casing: FT.
I Vae "-" a ADWe Top of Caelnp)
-'�
9.
TOP OF CASING IS FT, Above Land Surface'
.,
• casing Terminnaa avot oe.ow lane anal Is Illegal un a WHance la Issued
>`
in
accordanoa win to AC 20 .0118 O
Y
10,
YIELD GOON): METHOD OF TEST
T^
11.
WATER ZONES (deothi:
C3
12.
CH_ORINATION: Type Amount dZr
It addalorm! space Is needed use oec� o'
loz
1a .,AeING
Wall ThokMaa
O DepthI"or ar h t We'll!
From To Fl. V
From, To Fl. —
=Tom To FI.
14. 3ROUT:
Depth Ma rlal-{J.ethod
From TO 0 F!.
From To F:.
15. SCREEN. -
Dept-. Olaniver Slot Size Ma:erlal
From _ To FI _ in. _ in.
From —To , F(~_,T In T—
Frcm —To rleeFt. =,-jy--.--
16. SAND(GRAVEL PACK );
09otn i �1 �+pfMatpr bl
=rom To FI.miot n.'
Tn Ft.
i- REMARKS:
LOCATION SKETCH
(Show director and distance from at least two S!e-e
Roads, or other map ,e'erenca points)
I CO HERESY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE V/TTH 15A NCAC 2C. WELL
CONSTRUCTION STANDARDS, AND THAT A COPY QF,Tj S RE70 HAS EEN PROVIDEC TO THE WELL/ %G _
SIG wTURE OF CONTRACTOR OR AGFgT D� -
207084
0 ►j 0 8 4 Suora anymN 17 DNwon of wmv Ovan!r ene coCY'o wru ow",
n

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: Appalachian Well -Drilling
WELL CONTRACTOR CERTIFICATION #: n ? (6, :;
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Cneck Appilcoble Boat: Residenllal (l Munlcipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other [] If Other, List Use:
2,
WELL LOCATION: (Show sketch of the location below)
Nearest Town: Rntharfnrdtnn -County:
(Road Nams and Wumbera, Community, or .Svodlvisbn and Lot No.)
DRILLING LOG QEPTH
3.
OWNER grzg p e i s �rLran g —,_
From To Fomquion DosMPtlon
Address Poorer'--
`----j5lree or ou a o.
V Cods
City or Town State ZIP
4.
DATEDRILLED 19-29-00
5.
TOTAL DEPTH ---A n 7
---�
6.
CUTTINGS COLLECTED YES [ j NO®
7.
DOES WELL REPLACE EXISTING WELL? YES [D NO®
--t--
6.
STATIC WATER LEVEL Below Top of Casing: 1 n() FT.
ss--:
�'
(Uee': #Above lap olCulnp)
�
9.
TOP OF CASING IS FT. Above Land Surface'
...
'Top of-cesinq terminated ever below land surface requires a variance In actor-
tD m
dance with 15A NCAC 2C .a116
10.
YIELD (gpm): �_ METHOD OF TEST GA T nGr
ate.,
11,
WATER ZONES (depth):. 400
-=
ma
12.
CHLORINATION; Type T a h l Q t Amount ?--
If additional specs Is needed use brlf k of term im
13.
CASING:
OI
I0CATION SKETCH
Was Thickness
Depth Diameter ar WaWhM. Material
(SMW direction and distance from at least two Stale
From __—.Q-- To —58 Ft.
Roads, or other map reference Points)
From Tc-- Ft.-- -
From To Ft. — _-_—
Hwy 74
14.
GROUT:
Depth Material Method
Hwy 221
From __ To Ft. -- —
POoreS Ford Rd.
15.
SCREEN:
Depth Diameter Slot Size Material
From —To — Ft _ in. _— In. _.
From .--- To _ FI..^ In. _._ In. _
From _—_ To _-- FI. -- In. In. -
1S.
SAND/GRAVEL PACK:
Depth Size Material
From -- To —_.Ft.
From To FI.--
J
17. REMARKS:__. -- —
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OFT IS RECO , HASEEN PROVIDED TO THE WELL OWNER.
-8-01
FOR OFFICE USE ONLY DATE
Quad No: SI NATUR OF PERSON CONSTRUCTING THE WELL
Sutwo original to Dtvislo of Water Duality, Gmundwats: Section within 30 days ow-1 REV. ling
Serial No. -

"
J4v) 11
North Carolina - Departmont of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
tao11—Drilling
WELL CONSTRUCTION RECORD WELL CONTRACTOR CERTIFICATION 4: 13 [ G•i' S
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable sox): Residential U Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other[] If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below) RuthPrfnrd
Nearest Town: Rutherf0_ ton County:
(Road Name and Numbers, Community, or Subdivision and Lot No.) DRILLING LOG
3. OWNER Norma Coffin From To
Address 606 Hester H' 1 d
Rutherfordton 0eB oNC 28139
Cily or Town Stale zip Code
4. DATEDR11-LED
5. TOTAL DEPTH 947
6. CUTTINGS COLLECTED YES Q NO[
7. DOES WELL REPLACE EXISTING WELL? YES NO®
8. STATIC WATER LEVEL Below Top of Casing: _60 FT.
(Use': 11 Above Top of Casing)
9. TOP OF CASING IS__I-- FT. Above Land Surface'
'Top of casing terminated attor below land surface requires a variance In eccor-
dance with 15A NCAC 2C .8118
10. YIELD (gpm): 6 METHOD OF TEST GA r nt iiTlar
11. WATER ZONES (depth): 160
12. CHLORINATION:
13. CASING:
DEPTH
Formation Description
CD
O p
Type Tablet Amount 9 It additional space Is needed use back of form
Depth Diameter
From 0 To 80 Ft.
From To Ft.
From To Fl.
14. GROUT:
Depth Malodor Molhod
To Ft. Concrete Pour
To Ft.
Frorn
From —
15. SCREEN:
Depth
Diameter
From
_To_
FI _ In.
From
_ To ._.—
Ft. — In.
From
—To—Ft.—
In.
16. SANDIGRAVEL
PACK:
Depth
Size
From
To
Ft.
From
To
Ft. _.
17. REMARKS
Wall Thickness
or WeighUFl. Material
SIOI S176 Material
_ In.
In.
In.
Material
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
CONSTRUCTION STANDARDS, AND THAT A COPY OF�IS RECC
FOR OFFICE USE ONLY
Quad No: SI NATURE
Submit original to Divislo
Serial Na. y F
LOCATION SKETCH
(Show direction and distance from at least two Slate
Roads, or other map reference points)
I 26
Hwy 74
Poores Ford Rd.
Hester Hill Rd.
;ORDANCE WITH 15A NCAC 2C. WELL
HAS �EEN PROVIDED TO THE WELL OWNER.
J�) 5— 12-29-00
OFOF PRS�RUCTING THE WELL
of Water Duality, Groundwater section within 30 days
DATE
GW-t REV. 12/99

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 2769e-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: 5 ^�" `t ram""""+
WELL CONTRACTOR CERTIFICATION #: %
STATE WELL CONSTRUCTION PERMIT#: 3 5 3
1. WELL USE (Check Applicable So:): Residential ❑ Municipal ❑ Industrial ❑ Agr�c,ultural Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use: e
2. WELL LOCATION: (Shov4sketqL9f the location below)
Nearest Town: County: �( /ti-•,�V --
J;;: 15 b -7 �c+�x� ✓lob.
Road Name and hers, Communi 0 SI ubdrvisi and tot No. DRILLING LOG
3. OWNER ➢+— From To
Address .—
(Street or o e Not,
_
City or Town ,.y Sta a Zip Code
4. DATE DRILLED ZUUU
5. TOTAL DEPTH "}+
6. CUTTINGS COLLECTED YES ❑ NO❑
7. DOES WELL REPLACE EXISTING WELL? YES NO❑
S. STATIC WATER LEVEL Below Top of Casing: FT.
(Use'+' it Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface'
'Top of casing terminated atlor below land surface requires a varlance In accor-
dance with 15A NCAC 2C.0118
10. YIELD (gpm): METHOD OF TEST
11. WATER ZONES (depth):
DEPTH
Formation Description
12. CHLORINATION: Type Amount It additional space is needed use back of form
13. CASING:
LOCATION SKETCH
Wall Thickness
Depth Diameter or WQight/Ft. Material (Show direction and distance from at least two State
From To J Ft. ,� // Roads, or other map reference points)
From To Ft. IJ o_1j)iZ �y
From To Ft.
14. GROUT:
From
From
15. SCREEN
Depth D (, MateriI— Meth
To Ft.
Depth Diameter Slot Size Material
From _ To _ Ft _ in. _ in.
From —To —Ft. in. In.
From —To _ Ft. in. _ In.
16. SAND/GRAVEL PACK:
17
Depth Size Mated
From To _� Y) Ft.
From To Ft.
r�
n
7rFgRa
#156b
A ! ,
t967 �faosv ill AV,
r #I U)r"0-s m
�rpD sf>;
r1 goY
is yyly
� ompAIC4
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE US
Quad No: #A�,RE OF PERSON CONSTRUCTING THE WELL DA E
N ! y $Wpnyt onon of water Quality, Groundwater Section within 30 days
Serial No. J- GW-1 REV. 12/ff

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] Li 9 8 53
WELL CONSTRUCTION RECORD WELLCONTRACTOR: A.I r
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Boa): Residential ❑ Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATI N: Sho sketch of the location below)
Nearest Towpn,: R . �e— County:
-�-���
a of k5iS on-eE rani
(Road NameV Nj�mbars, niy, or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER KI-1ln�rCl Y11Z� From To Formation Description
Address P.O. I:-1.OX oC (a
I A dye. ��nt� 2Rh10
City Town Sine Zip Code
4. DATE DRILLED 10-17-00
5. TOTAL DEPTH 4 65'
6. CUTTINGS COLLECTED YES❑ NO(R
7. DOES WELL REPLACE EXISTING WELL? YES NO® `
8. STATIC WATER LEVEL Below Top of Casing: FT.
(Use '+' # Above Top of Casing) c�
9. TOP OF CASING IS1133� FT. Above Land Surface'
'Top of "sing terminated at/or below land surface requires a variance In accor• -
dance with 15A NCAC 2C.0118�
10. YIELD (gpm): IS-_ METHOD OF TEST Ti mP�
11. WATER ZONES (depth):
12. CHLORINATION, Type —Amount— If additional space is needed use back of form w ='
13. CASING: y y k&& -
1 Pur5a' LOCATION SKETCH WallTM�u
Depth Diameter or WeiphVI t. Material (Show direction and distance from at least two State
From To Ft. J2[_a_ v'QalJ_QV 0- Roads, or other map reference points)
From To FC O FF OF lot i 11s Creek Vol D
From To Ft.L r7LL I ) ('
14. GROUT: �Lll(J, / 7 past �� LLLM to le-4 On
Depth ,� �, M_at`ad�I- Method _ �J ) � ('1
From L_ To Q0Ft. S.L1Y1L:t� nl j lS (fiek �0 4 i'Yi l -es I -A
From To Ft.
15. SCREEN: uR Oe-d-o.r (2reeV-1 �oaA 3, '/
Depth Diameter Slot Size Material (I S {0 n dye m erLL ,
From To Ft _ in. _ in. 1 2
From —To —Ft._ in. —in. omtt Qr , et ry6 je on Gi TL roaA,
From To Ft. In. In.
16. SAND/GRAVEL PACK: CYOSS Le 6rl e ea GrL
Depth Size Material Co eek ot.
From To Ft.
From To Ft.
17. REMARKS:
I DO HEREBY CE IFY UCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION DA�i0 A A RECORD HAS BEEN PROD D TO THE WELL OWNER.
FOR OFFICE USE �D U7J
Ouad No: TURE OF P SON CONSTRUCTI G THE WELL DATE
Submit origi 'vis
ion of Water Quality, Groundwater Section within 30 days
Serial No. _ - GW4 REV. 12M

North Carolina • Department of Environment and Natural Resources • Division of Water Quality • Groundwater Section
tiii'748 -
1636 Mail Service Center • Raleigh, N.C. 27699-163&Phons (919) M-3221 � I
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION
/STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable aoa): Residential LJ Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ IIfLLOther,
„„Ust.Use:
2. WELL LOCATI (Show ketch of the location below) Rl lTI11?ri��C�
Nearest Town: Al K - County.
0-1a �� DEPTH
(Road N N rs. � R ism and Lot No.) DRILLINGFrom T LOG FomW on Da u dpt on
3. OWNER
Address n (�X l�p -
City or Town QQQ ��_ rrr777��—�MM�aw • —'—
4. DATE DRILLED
6. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑ NO®
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO[Z
6. STATIC WATER LEVEL Below Top of Casing: FT.
2 (Use'.' u Above Top of Ca")
9. TOP OF CASING IS 1 33 FT• Above Land Surface -
?op of using terminated allor below land surface requires a valence In accor-
dance with 15A HCAC 2G,0113
lo. YIELD (gpm): %. SL METHOD OF TEST
11. WATER ZONES (depth):
12. CHLORINATION, Type 1 Amount
13. CASING: C2y t�)t►')(J) Jrtsia - Wall 1 N
Deplb^' I/ (�`� �T r orwegn u a�
From �L- —To} — Ft. SD
From--� r- To I O � Ft.� 2
From To FL
14. GROUT:
n Depth Materi MnCaTl
From To ' Ft. Oonr
From —To—Ft.—
is. 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
------------
o
-
r:n
-
If additional space is needed use back of form
I ocATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
R�hk VrL
roew gravel road
S.1�e is orL khe- r(AW
From To Ft.
From To Ft.
17. REMARKS:
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTR TED IN ACCORDANCE WI 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF IS RECORD HAS BEEN P DED TO THE WELL OWNER.
FOR OFFICE USE ONLY ti z �i (SIGNATURE of RSQN CONSTRUCTING THE WELL DATE
Quad No:
Submit original to Division of water Quality, Groundwater Section Within 30 days GW1 REV. 12f99
Serial No. -

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
P.O. Box 29578 - Raleigh,N.C. 27626-0578-Phone [phone]
DRILLING CONTRACTOR:
WELL CONSTRUCTION RECORD Lln iPrCb 4 1(+ilOn VKPfWB��tittnt�
DRILLER REGISTRATION #: Mill 1
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable BOX): Residential U Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other E It Other, List Use:
2. WELL LOCAT (Sho sketch of the location below) , t,/u11_"rd
Nearest Town:, ra—! ay Q. County: /l LPL IIVV
(Road, community. or Subdivision and Lot No.)
3. OWNER �ld ��( f1l IAtLS
ADDRESS
,� (Slreel or Oule No.) ! Z�
L. V ty of Town ZI Code
City or Town Stale P
4. DATE DRILLED ^, I
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑ NOW
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NOV,]
8. STATIC WATER LEVEL Below Top of Casing: FT.
(Use "+" it Above Top of Casing)
9. TOP OF CASING IS 1,.33 FT. Above Land Surface*
Casing Terminated at/or below land surface is illegal unless a variance Is issued
in accordance with I q,NC��C 2C .0118
10. YIELD (gpm):d•5 METHOD OF TEST tYY1�
11. WATER ZONES (depth):
12. CHLORINATION. Type ' Amount
13. CASING: `(�� QlL1N!) Iy1.. taller
Wall Thickness
Depth ameler or Weight/A Material
+''t�
From i�—To � FL r l — "Are —I
From To Ft. —
From To Ft.
14, GROUT:
Depth Material Method
From d To �2 _ Ft. Onoomfe- From —ToFt•
15. SCREEN:
Depth Diameter Slot Size Material
From —To—Ft— in. in.
From —To Ft. in. in.
From — To Ft. in. in.
16. SAND/GRAVEL PACK:
Depth Size
From To Ft. —
From To Ft.
17. REMARKS:
I DO HEREBY CE
CONSTRUCTION
FOR OFFICE USE OI SAYS
Quad No:
Serial No: A *HvhvaL-
Material
DEPTH DRILLING LOG
From To Formation Description
It additional space is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
Gror, AeIr1i4 -sonxille-><CtKe ?r
b 4 Easy -Fo'6' ave . ^1 urn ri It
on 7q-- Go past Mori
O�A q lyprox. miles.-u.rrl-
OeA 10 we-ei wkile cwc- sYear
5h-oed col wjyu s T i3 k's Wend
)401mes Drive,,—qL a�- Rf-X}drive
"Jo i s end of .spree-� on teA.
ED IN ACCORDANCE WITH 15A
RECORD HAS BEEN PF VIDEL
rURE OVONTRACTOR OR AGEN I
original to Division of Water Quality and copy
- I
1
WE11�tf&f,t' II
GW-1 REV. 1198

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section !_ 18481
1636 Mail Service Center - Raleigh, N.C. 27699.163&Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
D. Bowman Well Drilling, Inc.
WELL CONTRACTOR CERTIFICATION #: 2809
STATE WELL CONSTRUCTION PERMIT#:
1 WELL USE (Check Applicable BOX): Residential ® Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other It Other, List Use:
2. WELL LOCATION:
(ShowMarion etch of the location below) Rutherford
Nearest Town: County:
Plemmons Place
(Road Name end Numbers. Community, or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER H.M. Glenn From To Formation Description
Address
treet0 ua o. 8805
Asheville 1V
City or Town Su1a Zip Code
4 DATEDRILLED 7/28/00
5. TOTAL DEPTH 140'
6, CUTTINGS COLLECTED YES ❑ NO®
7. DOES WELL REPLACE EXISTING WELL? YES EI NO[Z] o
8. STATIC WATER LEVEL Below Top of Casing: 4Uj FT. _
(Use': 9 Above Top at Casing)
9. TOP OF CASING IS 1 _ 4 FT. Above Land Surface'
-Top of using terminated atlor below land surface requires a varianp In actor-
danco with 15A NCAC 2C.01118
10. YIELD (gpm): 19 METHOD OF TEST _ _ # r
it. WATER ZONES (depth): ' 1�'
12 CHLORINATION: Type t a h 1 P♦• Amount ---6 II additional space is needed use back of lorm --
rn— —
13. CASING.
LOCATION SKETCH
Depth
Wall Thickness
Damear or Weights. Material
(Show direction and distance from at least two Slate
0
92
Ft. 6 1 : Sch
80 PVC
Roads, or other map reference points)
From
To
From
To
Ft.
From
To
FL
14. GROUT:
Depth
Material
Method
)1-j
From 0
To 20
Ft. rnnrrata
aracr LL1;Y_f1Ow
From
To
Ft.
15.SCREEN:
Material
Depth
Diameter Slot Size
From —To—Ft—
in. —in.—
From
To — Ft.
Ft.—
— In. _
in.
In.
�
✓/ �s
From —To
_
—in.
S ,
16. SAND/GRAVEL PACK:
1
1
Depth
Size
Material
�\
From
To_Ft*
From
To
Ft,
17. REMARKS:
TH 15A NCAC2C, WELL
I DO HEREBY CERTIFY THAT THIS WELLTNe We rna AS NSF THIS RECORD HAS B NED IN EPRIOVI PROVIDED TO THE WELL OWNER..
CONSTRUCTIO OS�CtO MAR ,/ � .. �i e'v
FOR OFFICE US I ATURE OF PE N CONSTRUCTING THE WELL ATE
(),,id No:
$pOntil on Division of water Duality, GrounOwatar Section within days
O -I GW-I REV. 12M
$anal No.

North Carolina - Department of Environment and Ftawral Rr sn:vcas - n,;_i,n of W,:nr rT ml�y - Groundwater Section 2 2 6 53 5
1636 Mail Service Center - Raleigh, N.C, 27699-1636-Phonn in 19) 7:0 3; 21
WELL CONSTRUCT ION RECORD WELL CONTRACTOR: G ��lLr-1)C'j/' �i;r l/IAJQ
WELL CONTRACTOR CERTIFICATION N:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential D Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
Agricultural ❑ Monitoring ❑
2. WELL LOCATION- (Show sketch of the location below)
Nearest Town: ✓�'. em i r-c county: A u� 6 r .�i'N e
(Road Name and Numbers, Community, or Subdivision and Lot No.) DRILLING LOG
3. OWNER _ l I �r r{� - lhi-e - �r/' From To
Address r •- j �;
trect or ouT07T0_F—
City or Town SL=.le Z,p rnrlr
4. DATE 1)RILLED / ` � r' in
5. TOTAL DEPTH / y D _
6. CUTTINGS COLLECTED YESEJ NO[c}-
7. DOES WELL REPLACE EXISTING WELL? YES NO[tJ
S. STATIC WATER LEVEL Below Top of Casing: _L FT.
(Use'+' it Above Top of Casing)
9. TOP OF CASING IS 1 FT. Above Land Surface'
'Top of casing terminated attor below land surface requires a varinece In accor-
dance with 15A NCAC 2C .0118
10. YIELD (gpm): /G METHOD OF TEST "
11. WATER ZONES (depth):
12. CHLORINATION: Type 'y /-{ Amount 5' el
13. CASING:
Wall Thickness
Depth
Diameler
or WeighUFl. Matenal
From
To To
Ft.
f I
From
To
Ft.
From
To
Ft.
14. GROUT:
Depth
Material
Mnlhod
From
_ 6 To fir"`
Ft.
Y ny_L-
From
To
Ft.
15. SCREEN
Depth Diameter Slot Size Material
From To Ft in. in.
From To Ft. _ in. _ in.
From _ To FL in. in.
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
17. REMARKS:
__1 S /C
__ , 173
i7 / 9 0
DEPTH
Formation Description
Y.
o
n
m
•�
It additional space is needed use back owerm
o~
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Quad No:
Serial No.
- " SIGNATURE OF PERSON CONSTRUCTING THE WELL
Submit ongingalptoo Division of Water Quality, Groundwater Section within 30 days
I'4f�t'`
DATE
GW-1 REV. 12/99

North Caroline - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1638 Mall Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
22.75)35
WELL CONSTRUCTION RECORD WELL CONTRACTOR: (9-MF4 Ri IF -Ile WEU4Tbmp Co
WELL CONTRACTOR CERTIFICATION #: ' 2�JZ4-
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential ® Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Infection ❑ Other ❑ If Other, List Use:
Agricultural ❑ Monitoring ❑
2. WELL LOCAT,'IOzNi,, #tC/S�.how sket h of the location below) C j
Nearpgt Town: T' 1`` ,� e <, -County: .��-• \ "� Alci` \ 1
(Road Na rnb or Subdlvlslon and Lot No.)
DRILLING LOG
3.
;Community,
OWNER\t(2.-
From To
Address
r Houle yy
e or \ AC . JC
� �--� %, r
City or Town State Zip Code
DRILLED
4.
5.
DATE
TOTAL DEPTH I -`)
6.
CUTTINGS COLLECTED YES NOZ
7.
DOES WELL REPLACE EXISTING WELL? YES ❑ NO®
8.
STATIC WATER LEVEL Below Top of Casing: FT.
(Use'*' If Above Top of Casing)
9.
TOP OF CASING IS FT. Above Land Surface'
*Top
of casing terminated aVor below (and surface requires a ver)ance in accor-
dance
10.
with 15A NCAC 2C.0118 sl-
YIELD (gpm): JPQ_ METHOD OF TEST
11.
WATER ZONES (depth):
12. CHLORINATION: Type
13. CASING:
Amount
Wall Thickness
Depth L c- Pla mel7y �w � h F+. Material
From�To —� Ft. `�—�5� _ t C
From To FI.
From To Ft.
14. GROUT:
Depth Ma erial, /Method
From To Ft.
From To Ft.
15. SCREEN:
Depth Diameter Slot SIZE Material
From _ To _ FI _ In. In.
From _ To Ft. In. _ In.
From —To _ Ft. In. —In.
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To FI.
17.
DEPTH
Fonnatlon j)escdpllon
r-.
s C'
If additional space Is needed use back of form
LOCATION SKETCH /t6_f'(D
(Show direction and distance from at least two Stale _
Roads, or other map reference points)
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C. WELL
FOCONSTRUCTION
R OFFICE USE ONLY STANDARDS, AND THAT A CQ,P NP/THISTCOF� HAS Q$� N� OVIDEO TO THE WELLOWNER.
^T
Ouad No: I� r.. / SIGNATURE OF PERSON CONSTRUCTING THE WELL �DATE w
!Submltudglnal to DlAslon of Water Quality, Groundwater Seclion within 30 days
Serial No. GWA REV. 12/99

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
34
1636 Mall Service Center - Raleigh, N.C. 27699.1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION II:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable ao%): Residential NJ Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other M II Other, List
Use:
2. WELL LOCAT Show;helFh of he location below) it ����
"Lear tTow� _ L �� County: 1. y
DEPTH
(Road Name nd Nu Q+b s, CoaLn unily, �or�Sub�dl sion and Lot No.) DRILLING LOG
�� E : t 4 � From To Formation pescdptlon
3. OWNER ✓
Address _ i CJeEj(L.Lc, `�C�tIf',10[)
City or Town Slate Zip Code
4. DATE DRILLED
5. TOTAL DEPTH —
6. CUTTINGS COLLECTED YES ❑ NO®
7. DOES WELL REPLACE EXISTING WELL? YES NOVI
8. STATIC WATER LEVEL Below Top of Casing: FT.
(Use -+' if Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface -
.Top of cuing terminated eVor below rand surface requires a valance in accor-
dance with ISA NCAC 2C,o119 �1
10. YIELD (gpm): ._(.^» METHOD OF TEST A I R
11. WATER ZONES (depth): n '.,�'
12. CHLORINATION: Type - Amount
13. CASING:
Wall Thickness
Depth/r{ lam tar or'rWelgKL I led
al
To �- FL-�[-- �%
From-`
From To Fl.
From To Fl.
14. GROUT: Do �11l�' �l M terlai, allied
From � ToP! L FL C r P_
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From —To—Ft _ In. —in.—
From —To _ Ft. _ In. —In. —
From _ To _ Ft. _ In. In. —
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
17. REMARKS:
r,
If additional space Is needed use back gf.Jgrm o
LOCATION SKETCH /;bj�`
(Show direction and distance from at least two Stale! —
Roads, or other map reference points)
> !
a �t
1
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED I ACRDANCE IT 15A NCAC 2C. WELL
CONSTRUCTION STANDARDS, AND THAT A C OF S RE O D COHA B EN PR VIbED TO THE WELL OWNER. /
FOR OFFICE USE ONLY DATE
Quad No: SIGNATURE OF nS N CON UC71N HE WELL
P Submit original to Division of Water Quality. Groundwater Section within 30 days GW 1 FIFV. 12199
Serial No.

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section r,i 1 /' 1 1, 1 7
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELLCONTRACTOR: :JLAa5 k) �nfna S.
WELL CONTRACTOR CERTIFICATION #: ag
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box):Residential LW Municipal❑ Industrial
Recovery ❑ Heat Pump Water Injection ❑ Other (] If Other, List Use:
2. WELL
Nearest
3. OWNER rVLl tl /1',
Address L)�'3 1'}e
of the location below) /7 �y
County: f� U � keV ✓
N
City or Town Stale Zip Code
4. DATE DRILLED -DD
5. TOTAL DEPTH -f� tT
6. CUTTINGS COLLECTED YES[] NO®
7. DOES WELL REPLACE EXISTING WELL? YES [(� NO[]
B. STATIC WATER LEVEL Below Top of Casing: r FT.
(Use': II Above Top of Casing)
9. TOP OF CASING IS�_ FT. Above Land Surface*
'Top of using terminated atlor below land surface requires a variance In accor-
dance with 15A NCAC 2C .0118
10. YIELD (gpm): METHOD OF TEST -/ r
11. WATER ZONES (depth):
12. CHLORINATION: Type 'T(alnll Amount I C"P
13.-CASING:
Wall Thickness
Depth
II
D�iam�je �r or Waight/Ft. Material
SDR 21 PC=
From
ToIP -
Ft.
From
To
Ft.
From
To
Ft.
14. GROUT:
Depth
M lariat -{ Melho�
N1e0..
From D
To 0Ft.
e- ettl
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
Agricultural ❑ Monitoring ❑
DEPTH
Formation Description
Y Sa crd
O1.a ; ruc
If additional space is needed use back of lorm
LOCATION SKETCH .r_ ==i
(Show direction and distance from at least two State
Roads, or other map reference points)
I�I\itOiic�<�i.
C ��.'
I f7T i 2
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY O� F THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY a,1, L l,d , ( pil-d wit
Quad No: - $ NATURE OF PERSON CONSTR Cf It# THE WELL DATE
Submit original to Division of Water Quality. Groundwater Sactlon within 30 days
Serial No. ( GW-1 REV. 12/99
I�
1

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
02
WELL CONSTRUCTION RECORD WELLCONTRACTOR:
WELL CONTRACTOR CERTIFICATION Ir-o�138
STATE WELL CONSTRUCTION PERMITC
1. WELL USE (Check Applicable Box); Residential LJ Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION:
Nearest Town:
3. OWNER
Address
Agricultural ❑ Monitoring ❑
of the location below) ( I
�--- County: �B ' Y"ho y
Subdivision and Lot
,F—lle)Lbora'- 13 G ago+o
City or Town State Zip Code
4. DATE DRILLED 1 o1-a.l -oo
5. TOTAL DEPTH a15
6. CUTTINGS COLLECTED YES❑ NON
7. DOES WELL REPLACE EXISTING WELL? TIES ❑ NO❑
8. STATIC WATER LEVEL Below Top of Casing: ,�� FT.
(Use'+' It Above Top of Casing)
9. TOP OF CASING ISFT. Above Land Surface`
'Top of casing terminated atior below land surface requires a variance In accor-
dance with 15A NCAC 2C .0118
10. YIELD (gpm): Inn METHOD OF TEST A I Y-
11. WATER ZONES (depth):
12. CHLORINATION: Type YayLµ. cL1' Amount �Gld�L
13, CASING:
DRILLING LOG
From
To
D
9D
5?o
aas
Wall Thickness
Depth
g0
Di star or Weight/Ft. Material
SDR2t PVc-
From
To
Ft.
—
From
To
Ft.
From
To
Ft.
14. GROUT:
Depth-
MY1P ft �a�l�` etho
From f/
To L
Ft.
A lHat KA
From
To
Ft.
15. SCREEN
Depth Diameter Slot Size Material
From —To—Ft— In. in.
From _ To Ft. — In. — In.
From —To _ Ft. _ in. —in.
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
17
DEPTH
Formation Description
a
It additional space is needed use back of form
LOCATION SKETCH
(Show direction and distance from at east two State
Roads, or other map relevance p lnts)
may`
v _ v
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY THIS REG D HAS BEEN PROVIDED TO THE WELL OWNER,
FOR OFFICE USA E w
Quad No: C ^� �+ Y ; ;' SIGNATUR O P SON CONSTRUCTING THE WELL DATE
r, 2 I Et .Sutimil original to Division of W er 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 Mall Service Center - Raleigh, N.C. 27699-1636-Phone (919) 733-=1 —� / rZ A 1 0 6
WELL CONSTRUCTION RECORD WELLCONTRACTOR: J01Mes �O (shall Tr. Y 1 ll
WELL CONTRACTOR CERTIFICATION p: )310 t
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential 121 Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION• Show sk ch 4( he location below) Qfr
Nearest Town: - {.L LP✓ '✓il I��ti County: �U+11 e✓Tc'✓
(Road Name
3. OWNER _
Address
City or Town State Zip Code
4. DATE DRILLED -�020- DD
5. TOTAL DEPTH 14-5
6. CUTTINGS COLLECTED YESQ NO® �-✓
7. DOES WELL REPLACE EXISTING WELL? YE�NO❑
8. STATIC WATER LEVEL Below Top of Castng: FT.
(Use'i II Above Top of Castng)
9. TOP OF CASING IS FT. Above Land Surface*
-Top of casing terminated at/or below land surface requires a varlance In accor-
dance with 15A NCAC 2C . 118 r
10. YIELD (gpm): METHOD OF TEST r
11. WATER ZONES (depth):
12. CHLORINATION: Type CrArta ar AmountI CLAP
13.-CASING:
Wall Thickness
Depth M
Di e r or walght/Ft. Material
From D To Ft, 48 5, O R 11 PVC
From To Ft.
From To Ft.
14. GROUT:
DRILLING LOG DEPTH
From To Fennatlon Descripttion
D 7 •f 5uccd
c47 45 OI15obdafed rc'k
0
O
o
Cn
n_
—0
rl
m�
.y
It additional space is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least two Stale
Roads, or other map reference points)
Depth Material Metho
From U To 20 Ft. A e e r
From To Ft. L
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
T'
I DUJ (, - .
X
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 BEE/N1 PROVIDED TO
THE WELL OWNER.
FOR OFFICE USE ONLY �1 /i)
Quad No: SIGNZfiE OF CONSTRUCTI T E ELL DATE
_ SubMt odglnal to isfon of Water Quality, Gmundwater SecBon within 30 days
Serial No. w 7 r GW-1 REV. 12/99

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section 6J Ai A i (1 (}
1636 Mall Service Center - Raleigh, N.C. 27699-1638-Phone (919) 733-=l i 1 0 O
WELL CONSTRUCTION RECORD WELLCONTRACTOR: :T4y s Ltd. `atvt , .Tr WELL CONTRACTOR CERTIFICATION C 131,
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential [VZ Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other If Other, List Use:
2. WELL LOCATION: ,Show sketph o the location below)
Nearest Town: � RtP✓ �r� ` C'}1 County:
(Road Name andCCNumbers, Community, or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER Je )i r e P) U tK �1 1 N Af From Ton Formation Description
Address � �,y Sip O DD /tiro 9t'a✓eI
I/ i; (Sr1Tr outs o. ,1� �O �L�� L�l'(S��lCfeA
4. DATE DRILLED -IgCG
5. TOTALDEPTH _365
6. CUTTINGS COLLECTED YES Q NOM
7. DOES WELL REPLACE EXISTING WELL? YES NOa]
8. STATIC WATER LEVEL Below Top of Casing: 41 FT.
(Use'i If Above Top of Casino)
9. TOP OF CASING IS�_ FT. Above Land Surface'
'Top of oising terminated atlor below land surface requires a variance In acoor-
dance with 15A NCAC 2C .011a
10. YIELD (gpm): —1-0 METHOD OF TEST Al Y
11. WATER ZONES (depth):
12. CHLORINATION: Type-YAYLN. a Y Amount (+ If additional space is needed use back of form
13.-CASING:
Wall Thickness LOCATION SKETCH
Depth Di)e%�r or Weight/Ft. Material (Show direction and distance from at least two State
From �_ To —?i_ "— Ft. I-'+— ` 2 1— Py c- Roads, or other map reference points)
From To Ft. -
From To Ft.
14. GROUT:
Depth Mkateri�al ..}_ Methorpl
From CJ To 2Z0 Ft. 3L rnr k6knA
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 20, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THI,$ RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Quad No: SIGI
i �c i 91/Dm1(odpirwllo
Serial No. "
k
,( J, Caju ( . 1-l0-0
OF PERSON CONSTRUCTING T E W DATE
N water Quailty, Groundwater Section within 30 days
GW-i REV. 12/99

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section i2 Z 4 I V 1
1636 Mail Service Center - Raleigh, N.C. 27699-1636rPhone (919) 733-=1
WELL CONSTRUCTION RECORD WELLCONTRACTOR: - O_WLL'A
WELL CONTRACTOR CERTIFICATION #: � L3S y
STATE WELLCONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable box): Residential Ltd Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below) J f I
Nearest Town: �yt P ✓:.��11A in.4 County: � u Th C Y 1� t rl
(Road Name an Numbers. Community, or Subdivision and Lot No.)
DRILLING LOG
DEPTH
3.
OWNER / Y
From To
Formation Des c{ipticn
Address '� 5
U 50.
5an
r u
50 585
tSd
o
g e✓�� C, aff I.i9
City or Town State Zip Code
4.
DATE DRILLED D
5.
TOTAL DEPTHS
6.
CUTTINGS COLLECTED YES❑ NO®
o
7.
DOES WELL REPLACE EXISTING WELL? YES 0 NO[X]
r�
o
8.
STATIC WATER LEVEL Below Top of Casing: ) 1 S FT.
n _.
(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 .011a
10.
YIELD (gpm): METHOD OF TEST Aix'
o
11.
WATER ZONES (depth):
_
rn a
12.
CHLORINATION: Type k OLV` Amount G tL 0
It additional space is needed use back of form
o
13.
CASING:
Wall Thickness LOCATION SKETCH
Depth ``,^, D''ian"3flar or Weight/Ft. Materiel (Show direction and distance from at least two State
From To_.60 Ft. /nA SnRzl Pvc Roads, or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Material elhof
From 0 To � Ft. drL I,LA
From To Ft.
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
t n p
From To Ft.
From To Ft.
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY _
Quad No:
Submit
Serial No.
GNATURE OF PERSON CONSTRUCT&G'THELL
to Division of Water Quality, Groundwater Section within 30 days
DATE
OW-1 REV. 121"

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section r 1636 Mall Service Center - Raleigh, N.C. 27699.1636-Phone [phone] i 1 rl
WELL CONSTRUCTION RECORD WELL CONTRACTOR: G( L(� �h �r 1 1
WELL CONTRACTOR CERT FICATION g—�
STATE WELL CONSTRUCTION PERMITt ;
1. WELL USE (Check Appflcable Box); Residential 41 Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑ Recovery ❑ Heat Pump Water Injection ❑ Other 0 If Other, List Use:
2. WELL LOCATION:-{ hor(sketc; of!helocation below) �Lt� �Y'k+Ya
Nearest To/nw�n: 11 jj iAii""i)l Pt �t tc `i I r• County:
I' a R 31), Nu! t,-rl5 l - 1--4f v2o2
(Road Neme andf ,Numbers CCoonmuniry, or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER Ki111 �IPc\4\ �J �NFrom To ttFomwUon Description
Address D 'i,F• ^a, LtP, lvS" CJiV� c14
C'aYLT l ee or oC o. �(p SQY1 tcj ✓n k
Lary or 1 own State Zip Code
4, DATE DRILLED !2' i3 -00
5. TOTAL DEPTH -24 5
6. CUTTINGS COLLECTED YES ❑ NOWE
7. DOES WELL REPLACE EXISTING WELL? E"S [� NO[K]
8. STATIC WATER LEVEL Below Top of Casing: _i o FT.
(Use W It Above Top of Casing)
9. TOP OF CASING IS�_ FT. Above Land Surface -
Top of casing ttrminated auor below land surface require* a variance In accor-
dance with 15A NCAC 2C .0118 r1
10. YIELD (gpm): -1D_ METHOD OF TEST
11. WATER ZONES (depth):
12. CHLORINATION: Type -era vI u 1 a r Amount
13. CASING:
If additional space is needed use back of form
Wall Thickness
LOCATION SKETCH
Depth
From fi To_
Di Ianneter or WeIghUFI. �Malitnal
Ft. S li%IY V<-
(Show direction and distance from at least two State
_
Roads, or other map reference points)
From To
From To
F.
Ftt.
14.
GROUT:
--- —------- —
Depth
From �_ To a0
Material Melho
Ft. )"IPai et""t
i
From To
—�
Ft.
,t
i'------ ---I
15.
SCREEN;
Depth
Diameter Slot Size Material
From —To—Ft—
In. In.
Li I! `(.
From _ To _ Ft.
_
In. In.
/
16.
SANDIGRAVEL PACK:
Depth
Size Material
From To —Ft.
—
From To
Ft.
17.
REMARKS•
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD /HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY Rw va Cl Q n
Quad No: SIG6ATUFIE OF PERSON CONSTRUCTIN THE &LL DATE
Sepal No. Submit original Io Division of Water Quallly, Groundwater Section Within 30 days
GW-i REV. 12/99
i
...,4 1 Una .. ........_:......�..*

North Carolina - Department of Environment and Natural Resources - Division of Water Quality • Groundwater Section r� ti 1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELLCONTRACTOR: 171t)ne5 lO. Cam[1 Jr
WELL CONTRACTOR CERTIFICATION C:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Appllcabia eos): Residential Ltd Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ED If Other, Ust Use:
2. WELL LOCA'
Nearest Town:
, I , 1
3. OWNER
Address
location below)
Counti• t b'tey rn V b
or SuCdivision and Lot No.)
Kaci ot tl)-T. ' Lj_3 + (515-
City or Town Stale Zip Code
4. DATE DRILLED 2-I,?-DD
S. TOTAL DEPTH 36 5
6. CUTTINGS COLLECTED YES ❑ NO [XI
7. DOES WELL REPLACE EXISTING WELL? YES O NO®
0. STATIC WATER LEVEL Below Top of Casing: � FT.
(Usa'i II Above Top of Casing)
9. TOP OF CASING IS_�_ FT. Above Land Surface -
'Top of caslns terminated at/or below land surface requires a variance In accor-
dance with 15A NCAC 2C .0118
10. YIELD (gpm): METHOD OF TEST f r
11. WATER ZONES (depth):
12. CHLORINATION: Type r2rl Amount Ic1,t
13. CASING:
Walf Thickness
Depth
D�iia__rn�° cr WeighVFt. Material
From
O To b—
Ft.
- >D R a 1 Ply C
From
To
Ft.
From
To
Ft.
14. GROUT:
Depth
��� M� to� ia,�l�� Method(
hanr�
From
_0 To �,Ft.
10CA CS MeeCI�
From
To
Ft,
15. SCREEN:
Depth Diameter Slot Size Material
From —To _ Ft _ in. —In.
From To Ft, _ In. — In.
From _To _ Ft.� in. — in.
16. SAND/GRAVEL PACK:
- Depth Size Material
From To Ft.
From To Ft.
17. REMARKS:
DRILLING LOG
From To
D 55
h5 3�
DEPTH
Formation Descnplicn
If additional space is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points) n
i
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF IS RECORD HAS 87,N PR VIDED TO TH WELL OWNER,
FOR OFFICE USE ONLX (--,,.,,:_ . _- p-o
Quad No: �� SIGN , RE OF PERSON CONSTRUCTING TH E OATE
enpinal l© Islon of Water Quality. Groundwater Section wilhl 30 days
Sepal No. GW-1 REV. 12199

North Carolina . Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section 2 Y /f
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone] ,—, /� Z
WELL CONSTRUCTION RECORD WELLCONTRACTOR: `Jr%CYY(Es l(i. C-ILm )r
WELL CONTRACTOR CERTIFICATION #: a )3
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (check Applicable Box): Residential NYJ Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use: _
2. WELL LOCATIONL(Show sketch of the location below)
NearestTown: — - G N' I 1 rl b o r o County: —K tC0f e rIn ✓Cf
Y)E2 WL5 i`'nII/I Q
(Road Name and umbers• Cortmunity, or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER ,�/l71CJ 1011 ` From To Formation Description
Address �u t�N0. {Nf 5
1 "�'jS rea or o toNO.)'�jG ,SOS
l u V Jn I�rf 2gf)4A brl5a i e oc
Lary or I own Stale Zip Code
4, DATE DRILLED l!' I) -DD
5. TOTAL DEPTH %L)`7
6. CUTTINGS COLLECTED YES ❑ NO[K
7. DOES WELL REPLACE EXISTING WELL? YES M NO❑
8. STATIC WATER LEVEL Below Top of Casing: — Gin FT.
(Use'+' II Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface'
-Top of casing twminated auor below land surlace raqulrea a variance In accor-
dance with 15A NCAC 2C,e118
10. YIELD (gpm): :�U METHOD OF TEST ,A ✓
11. WATER ZONES (depth):
12. CHLORINATION: T e < Amount )) c
YP If additional space is needed use back of form 4 o
13. CASING:
x
Wall Thickness LOCATION SKETCH
O L Depth Diiernolor WelghuFt. ,Mai at (Show direction and distance from at least two State
From To 2 Ft.. Z Z� 1517) Q ;0 _C_Y_= Roads, or other map reference points)
From To Ft,
From To Ft. LI
Fri r �^ _- �,)t'''__-
14. GROUT:------.--"7—
Depth
From �_ To _-90 Ft.
aterial Method
e �t d n A
From To
Ft,
15. SCREEN:
Depth
Diameter
Slot Size Material
From —To
Ft
In. —In.
From _ To _
Ft.
In. In.
From _ To _
Fl.
_ in. _ in.
16. SAND/GRAVEL PACK:
Depth
Size Material
From To
Ft.
From To
Ft.
17. REMARKS:
{ fa m'2' '
— n
A
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- 1i1 Yf 2 r1- • �wyy �
Wad No: } ;( p`) SIGNATUR F PERSON CONSTRUCTING THE WE DATE
t �_SF+Dmit original to Division of Water Duallly, Groundwater Section Within 30 days
Serial No. ,
GW-1 REV. 12/99
�.,4

North Carolina . Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section 224111
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone (919) 733-=l —7-�
WELL CONSTRUCTION RECORD WELL CONTRACTOR: —lAmes CtwW T.
WELL CONTRACTOR CERTIFICATION
STATE WELL CONSTRUCTION PERMITC
1. WELL USE (check Applicable Box): Residential hC1 Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other 0 if Other, List Use:
2. WELL LOCATIONj.jShoy,� sk,,r o�lhe location below)
Nearest Town: h �.L,}-�t �''� `Io r Y" County:
(Road Name and Numbers. C , or ub ivlsion and Lot No.)
mmuni
DRILLING LOG DEPTH
3.
OWNER \ C FYI'N.
From To formation Description
Address ,!� _r tuY` �,n ��
D q0 in c a'E
ae or out o.
�L � Co So ' a rock
l3 1
—Lail
City or Town Stale Zip Code
4.
DATE DRILLED Id -�'-oo
5.
TOTAL DEPTH �tn5
6.
CUTTINGS COLLECTED YES ❑ NO®
7.
DOES WELL REPLACE EXISTING WELL? YES NO®
_
8.
STATIC WATER LEVEL Below Top of Casing: 7,j- FT.
(Use'i It Above Top of Casing)
9.
TOP OF CASING IS�_ FT. Above Land Surface -
'Top of casing twminated atror below land surface requires a variance In accor-
y. p
dance
10.
with 15A NCAC 2C.e119
YIELD m :
(gp ) � METHOD OF TEST I ✓
--- 2
-�
—'-
rn"
11.
WATER ZONES (depth):
r
2
12.
CHLORINATION: Type LILr tl a Y Amount ! (� O-i—
If additional space is needed use back of form'
?
13.-CASING:
LOCATION SKETCH
Walt Thickness
Depth O'am tar or W aight/Ft. Material
(Show direction and distance from at least two State
From To '70 Ft. —rC.l�— -'; )2_C3.'21 ---c--
Roads, or other map reference points)
From To Ft.
/
From To Ft.
14.
GROUT:
Depth ,,I M terial ..{- Mathgd
A
From �_ f) �a'cemPr\l
To Ft.
/
From To Ft.
15.
SCREEN:
/
Depth Diameter Slot Size Material
'
From —To—Ft— In. —in
From _ To _ Ft. — In. — in.
j
From —To Ft. — in. _ in.
i
16.
SAND/GRAVEL PACK:
1
-
Depth Size Material
From To Ft.
/
From To Ft.
I n It
17.
REMARKS:
siren tit'
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
Quad No:
Serial No.
I;i
SIGNATURE OF PERSON CONSTRUCTIN
ipinal to 0ryiskri of Water Guallty, Groundwater
-Id—ol
VELL DATE
within 30 days
GW-1 REV. 12/99

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section 2 42) 4
1636 Mall Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: �✓Y185 0 rawtp .T ,
WELL CONTRACTOR CERTIFICATION N: )3�T
STATE WELL CONSTRUCTION PERMITN:
1. WELL USE (check Applicable Box): Residential C9 Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION:�jS'h ske h o l e location below)
Nearest Town: ! , tU P f 2 county:
(Road Name Numbers, Crgrirt,vnuniy, or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNERyQ,' Pj Ua 1E L.0 AG 1 From To Formation Description
Address Ljv/3rglri C{ICV, -16I6 0e,k5t. LI, d Y
j5 rea or to o. l
r r15f C1 7C 2a
a.uy ur r uwn saw �,p mow.
4. DATE DRILLED a- G
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES[] NO[,�]
7. DOES WELL REPLACE EXISTING WELL? YES EJ NOF-1
8. STATIC WATER LEVEL Below Top of Casing: -�eD FT.
(Use -ti If Above Top of Casing)
9. TOP OF CASING ISFf. Above Land Surface'
'Top of cAsing terminated ador below land surface requires a variance In accor-
dance with 15A NCAC 2C .0118
10. YIELD (gpm): j , METHOD OF TEST Y
11, WATER ZONES (depth):
12. CHLORINATION: Type Amount
13.-CASING:
Wall Thickness
0
Depth Diameter or Welght/Ft. Material
S n R 21 v=
From
To .�- Ft. -�
From
To Ft.
From
To Ft.
14. GROUT:
Depth aterial Metho
From —CL
To 20 Ft. ea e r� 'Kra
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•✓
If additional space is needed use back of form r-
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 0 THIS RECORD HAS B EN PROVIDED TO THE WELL OWNER.
FOR OFFICE f91g1_Yt SIGTu EO 7
Quad No: § il,. y F PERSON CONSTRUCTING E WELL DATE
Submit original to Division of Wale(Quallty, Groundwater SecUon within 30 days
Serial No.
GW-1 REV. 12/99

" ina 4'4_7
NOM Carol - Department rneM weee t of Environand Natwal Raso-Division of Water OwGry ou - Grrldwaw2
( Section r) Q a.
16W Mail Service Cantar- Raleigh. N.C. 27699-1e3fiPlwne (919) 733-221
WELL CONSTRUCTION RECORD WELL CONTRACTOR: .lames W. Camp, A
WELL CONTRACTOR CERTIFICATION 6: 2138
STATE WELL CONSTRUCTION PERWTir:
1. WELL USE (cttackApplIcable 6oa): Residential LY1 Municipal ❑ industrial ❑ Agricultural ❑ Monitoring ❑
Recovery M Heat Pump Water Injection ❑ Other C3 If Other, List Use:
2. WELLLOCATIO S�hlowsket(�_ho thlelocationbelow)(-
Ndarest Town: i 1 L Y L�' Y TO Yt Counly: U I i�1e ✓ `{-p ✓ [(_
tl
[Road Nam, aptCty,urtuars. Cwnrparily or $UbdIVI51pf1 ano Lot
3, OWNER t r A. i 11)0 kt'✓
Address %L 0,; I //)VIQ✓PS5 61,
b-astoI,I i'------ -- L" �)_90t t­1
Gry or Town $Late Zip Coon
a. DATE DRILLED 11 -0o
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES [:] NO®
7. DOES WELL REPLACE EXISTING WELL? YES ® NOD
S. STATIC WATER LEVEL Below Top of Casing: Qq Fr.
(Use'i II Abe Top of Casing)
9. TOP OF CASING IS 1 FT. Above Land Surface'
Top or �Ing terminated aVor below land surface regtdree a varlanu In aeoor-
danu with 15A NCAC 2C Atla
10. YIELD (gpm): _ 10 METHOD OF TEST Air
11, WATER ZONES (depth):
12. CHLORINATION: Type Crnnnlnr Amount 1 G11P
13.-CASING:
Depth Diameter
From 0 To �� Ft. 6'A
From To Ft.
From To Ft.
14. GROUT
DRILLING LOG
From To
0 35
17 n`)
DEPTH
Fomescri ulton Dption
j 7 Y+6i V a J,
777
If additional space is needed use back of tonrT—
Wall Thicinesa LOCATION SKETCH
V%$tI FL PVt � (Show direction end distance from at least two Slate
Roads, or oilier map reference points)
Depth Material
From 0 To 20 Ft. Neat cement
From To Ft.
15. SCREEN:
Depth Diameter
From —To Ft — ln.
From To _ Ft., In.
From _ To — Ft. — in,
16. SAND/GRAVEL PACK -
Depth Size
From To Ft. T
From To Ft._
17. REMARKS:
Slot Size
1
Method 1 �
Hand
Material
r p ,
In. �,-T<0.1.. o .
in.
Material ------_ -
l
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 1SA NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE US �lC/YrI P d l � L_ Ml Lo ) � � _ lJD
auad No: LS `&GNAT#EOF PERSON CONSTRUCTING THE4VELLO DATE
Submit o4in toiDwlslon of water Guellty. Gwunowater Section within 30 days
Sa"No. 0 '11 11 GW-i REV. 12W

North Carolina - Department or Environnwru and Natwal Resou oas - Division of Water Quality - Groundwater Section
1636 Mail Service Cancer - Raleigh. N.C. 27699-1636-Phone (919) 733-=1
WELL CONSTRUCTION RECORD WELLCONTRACTOR: James W. Camp, Jr.
WELL CONTRACTOR CERTIFICATION 0: 2138
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (ChackAppdcabta Box): Residentfald Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring
❑
Recovery ❑ Heat Pump Water Injection ❑ Other It Other, List Use:
2. WELL LOCATIO��j (S,h�Qw sk tch pf the location below) [J
'1"c
Nearest Town: 1�1 l l'�P V : Y rl Yl. County: l \ N I'(e Y'Fn r tJ
oo );YLq ln>~ RA. cff
[Road Name And NWT" . Colnf u` iiy. or Subdivision ano Lot No.) DRILLING LOG DEPTH
3, OWNER O to a I f �r I k w c -, From 'To Formation Description
Address P r 41 0 ° D , Ytl G Yau— I
P,"
�G�
C�i�fS�tie �roaoriowwe o. �gp�� ^1n CDK5o��dated
r uck
City or Town Suie Zip Code
4. DATE DRILLED
5. TOTAL DEPTH �(o
6. CUTTINGS COLLECTED YES} NO® o
7. DOES WELL REPLACE EXISTING WELL? YES NOW
B. STATIC WATER LEVEL Below Top of Casing: L y FT. m
�m
(Use ^1 It Above Top of Casing)
C m
9. TOP OF CASING IS 1 FT. Above Land Surface'
o�
-Top of casing tarminated Wor Wow land suit c requires a vartanu In accor-
O
dams wiM 15A NCAC 2C .e115
10. YIELD (gpm): L METHOD OF TEST All
11. WATER ZONES (depth):
rnz
i2_ CHLORINATION: Type Gfant tQ1 Amount .1 c'.IJ )_ It additional space is needed use back of form
Z
13. - CASING:
Wall Trtcicness LOCATION SKETCH
Depth Di imawr w wa�g VFt. Material (Show direction and distance from at least two State
/h
-��
From 0 To '.70 FL 6 '4 SDR21 PVC Road&, or other reap reference points)
From To Ft.
From To Ft,
14, GROUT:
Depth Material Method
From 0 To 20 Ft. Neat Cement Hand
^
From—To—Ft.—j
. D 1'rl rill15.
SCREEN; -
t
Depth Diameter Slot Size Material
From _To Ft in. —in.
From _ To Ft. In. ._ In.
From To _ Ft. in. in. l —� P
16. SAND/GRAVEL PACK <p
Depth Size Material j
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 COPOF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER. h
FOR OFFICE USE
Quad No: SIdNAhURE OF PERSON CONSTRUCTI ELL GATE
u -r i" tprvislon of Water Quality, GroeMwater Socoon within 30 days
Serial No.
froundwake°Section j
AshevilleRegionalJ;,,a,
OW-1 REV. 1264

North Carolina - Dapervnent of Envirorvnent and Natural Resowees - Division of Water Quality - Groundwater Section
1636 Mail Service Center • Raleigh. N.C. 27699-1636Phone (919) 793-=1
WELL CONSTRUCTION RECORD wELLcoNTRACToR: James W. Camp, Jr.
WELL CONTRACTOR CERTIFICATION is 2138
STATE WELL CONSTRUCTION PERMITir:
,�,/
1. WELL USE (Check Applicable Box): Residential LW Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring
❑
Recovery [3 Heat Pump Water Injection ❑ Other If Other, List Use:
2. WELL LOCATION: (SI oj khofYhe location below)
Fs
Nearest ydD county: e Y
!o�w)nM: QP 61
mDEPTH
(Raatl Name d umoers. Corwnity. or Suodivision and Lot No.) DRILLING LOG
3. OWNER I K . ^_ Frwn _To Fomuaon Descripriwt
Y7
Addre5s Ca 'e� gd. 0 45 C�IY'}. 0.Yavc j
C �o D
Cary or Town State Zp Coda
4, DATE DRILLED
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YESC} NO® p
o
(�V
7. DOES WELL REPLACE EXISTING WELL? YES NOM
8. STATIC WATER LEVEL Below Top of Casing: o FT.
r^
m
(Use'✓ II Aboos Top of Casing)
9. TOP OF CASING IS 1 FF. Above Land Surface'
om
-Top of caeing tuminatsd Wor below land surlace requ4ea a varianr:e In accor-
—�
dance with 15A NCAC 2C ,0110
10. YIELD (gpm): METHOD OF TEST Air S
Nz
__4i-- C4
11. WATER ZONES (depth):
c1"
C--rnnulnf Amount 1 GUQ It additional space is needed use back of tor'(;'ice-CHLORINATION: Type
Z
13.-CASING:
LOCATION SKETCH
Wall Tigoicnew
Depth O'�"tar SDR�21�t p1%C (Show direction end distance from at lass( two State
�� �
U Ft. 6 /a Roads, a other map reference points)
From To -�-5
From To Ft.
From To Ft.J. I
14. GROUT:
Depth Material Method V
From 0 To 20 F. Neat cement Hand
From To —FI. i
15. SCREEN:
Depth Diameter Slot Size Material H i
From —To _ Ft _ In. —in.
From To _ FL_ In. ` In.
From _ To — Ft. — in. _ in.
16. SAND/GRAVEL PACK: Y `-;.,
!7
Depth Size Material LL fj
From To —Ft. —
From To Ft.
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR Of
Quad No:
Serial No.
0
iATURE OF PERSON CONSTRUCTIN
on,won of water Quallty, Groundwater
4. M -
YELL DATE
within 30 days
-OD
GW-1 REV. 12JW

North Carolina - Deparunent of Environn,iont and Natural Rasotacea - Division of Water Ou4ty - Groundwater Section r-i •,) r1 9A
1636 Mail Service Carter - Raleigh, N.C. 27699-16366Phone (919) 793-=1 2 F. /
WELL CONSTRUCTION RECORD WELLCONTRACTOR: James W. Camp, Jr.
WELL CONTRACTOR CERTIFICATION tic 2138
STATE WELL CONSTRUCTION PERMITC
1. WELL USE (CheokAppeeaWe Box): Residenb t) [21 Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other If Other, List Use:
2. WELL LOCATIO : (Show etch of the location below) 1,J /' I
Nearest T?wn: pa Ke u 1 P County: �U Z it C Y 4 Y !f
?aYden LarC
Road Nanw anT1aQ1lNuntoers. C° 'it sir bolvision ano Lot No.) DRILLING LOG DEPTH
3. OWNER F7 ,ii7e JWtt Fmm .To FrormWm pl;on
Address 190Q 22 I C V0 y 0 b g
1 fIwfwlw odte o. 5-0 So rowsc,lldajed r,ck
rKI t-auLiPr a e 3h i30
City or Town Stale Zip Code
4, DATEDRILLED -IS-OC —
5. TOTAL DEPTH —
6. CUTTINGS COLLECTED YES Q NO[o —
7. DOES WELL REPLACE EXISTING WELL? YES (] NO® —
8. STATIC WATER LEVEL Below Top of Casing:-�T-A°—FT. —
(U" -.- it Above Top of Casing)
9. TOP OF CASING IS 1 FT. Above Land Surface'
-Top of casing tuminated Ww below land surface requires a vuianw In accw- _
dance wlth 17A NCAC 2C ,e la —
10. YIELD (gpm): METHOD OF TEST Fur _
11. WATER ZONES (depth): _
12-CHLORINATION: Type SE0171111flL
Amount.l G1JIL
13.-CASING
Wall TNIdcckness
Depth
D6iarnetar WelahUR.
PVC
From O
To 5 9
Ft.
1/4 SDR21
From
To
Ft.
From
To
Ft.
14, GROUT:
Depth
Material Method
From 0
To 20
Ft.
Neat cement Hand
From
To
Ft.
15. SCREEN
It additional space is needed use back of for
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
warnr,
Depth Diameter Slot Size Material
From To _ Ft — In. _ in,
From _ To Ft. — In. In.
From —To —FL _ in. _ in.
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To FL
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,VsE ONLY �' Lo
Quad No: ! I: : - 51. TUAE OF PERSON CONSTRUCT WELL DATE
Suom)t origin- o Division of water Quality, Gmunowater Section within 30 days
84ndi No. ' GW-i REV. 12/93

North Carolina - Depannlent of Environment and Natural Rasourcae - Division of Water Quality - Groundwater Section ,; ' ) 7 "?
1636 Mail Service Center - Raleigh, N.C. 27699-16366Pftona (919) 793-=1 �' F- f 6
WELL CONSTRUCTION RECORD WELL CONTRACTOR: JOmes W. Camp, Jr.
WELL CONTRACTOR CERTIFICATION R: 2138
STATE WELL CONSTRUCTION PERMITN:
1. WELL USE (Cheek Applicable Box): Residential Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery E] Heat Pump Water Injection ❑ Other E] If Other, List Use:
2.
WELL LOCATION: Show sketch of the location below)
Nearest Town: Y F(15 q C i County: V
.1�
l ll� 1� Y
,k) 10 CO )15yY1T, — I DYYt5 [­,tkf R(1-
(Road Nanw and Numows. Community, or Suboivision and Lot No.)
DRILLING LOG
3,
OWNER U—e yI, q 1-CC
From To
Address 2// 'cM5 1 aKC Rd
0 lam
te«
Yo CI r�o e d.
3W5
rest �So 3
Gty or Town ) State Zip Coda
4,
DATE DRILLED
5.
TOTAL DEPTH (✓
6.
CUTTINGS COLLECTED YES C} NO®
7.
DOES WELL REPLACE EXISTING WELL? YES O NOO
S.
STATIC WATER LEVEL Below Top of Casing: 4c�_Fr.
(Ursa '.' it Above Top or Casing)
1
9.
TOP OF CASING IS FT. Above Land Surface'
`Top of wing UrrNnatad Wor below land surtace raqukaa a variwl" In accor-
dance with 15A NCAC 2C .e110
10. YIELD (gpm): _Z METHOD OF PEST Alf
11.
WATER ZONES (depth):
DEPTH
FO
Irmation Des ption
An
12- CHLORINATION: Type 0001110r Amount .1SS.43—. It additional space is neaded use back of form
13.-CASING:
Wall Triclmosa
Depth Diameter orwe hVR. Material
s From U To1; Ft. b'A< S. tli PVC
From To Ft.
From To Ft,
14. GROUT:
Depth Material Method
From U To 20 FL Neat cement Hand
From To Ft.
15. SCREEN
Depth Diameter Slot Sizo Material
From _To Ft _ In. _ in.
From To Ft. In. In.
From _ To Ft. in. _ in.
16. SANDIGRAVEL PACK
17
Depth Size Material
From To Ft.
From To Ft.
1:�9
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 DF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
YGNATURE OF PERSON CONSTRUCYING -()4E WELL DATE
A[ to Division of water CK&Wity, Groundwater Section within 30 days
L}}};' i GW-1 REV. IZ'W
j
I

Noah Carolina - Deponent of Envirorvnent and Naurra, Resouresx - Division of Water Quality. Grour dwawr Section 2 0 U 6 2
1636 Mail Service Canter - Raleigh, N.C. 27699.1636-Plwna (919) 7933221
WELL CONSTRUCTION RECORD WELL CONTRACTOR: ,lames W. Camp, A
WELL CONTRACTOR CERTIFICATION #: 2138
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Appbcabis Box): Residential 0 Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other [ter If Other, List Use: Cy h ✓e)1 t Cnc e C (aMie✓
2. WELL LOCATION: �Show sketch of a location below)
Nearest Town: F-O 1'N 5-% County:
61 I /1',.,, w _ �?,f. T 1,.
(Need u Nun Crxylity, or
3. OWNER a P✓ r a. _`
Address
Gg or Town Suite Zip Code
4. DATEDRILLEO 10- 6--�
5. TOTAL DEPTH 5%5
6, CUTTINGS COLLECTED YES[] NO®
7. DOES WELL REPLACE EXISTING WELL? YES NOE]
8. STATIC WATER LEVEL Below Top of Casing: _FT.
(Usa'i If Abov Top of Casing)
9. TOP OF CASING IS 1 FT. Above Land Surface'
-Top of oasing ruminated Won allow land su(tace saquk" a ration" In "cu-
dan" with 15A NCAC 2C ,011 a
10. YIELD (gpm): 50 METHOD OF TEST Fur
11, WATER ZONES (depth):
12. CHLORINATION: Type Grant llnr Amount 1 f:LIP
13.CCASING:
Wall Thickness
Depth Diarnotar awellggnaFL Malarial
From 0 To %8 Ft 61/4 SDR21 PVC
From To Ft.
From To Ft.
14. GROUT
Depth Material Method
From 0 To 20 Ft. Neat cement Hand
From To Ft.
15. SCREEN
Depth Diameter
From _To Ft in.
From —To Ft. _ In
From To — Ft. in
16. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To FL
17. REMARKS:
Slot Size Material
in.
In.
_ in.
Material
DRILLING LOG DEPTH
From .To FornWlon Dascrip4on
n %s da
98 1¢S cons°b' a z roc
4 �
It additional space is needed use back of loan
-rl
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
9to -
1�
1
�L a.Y
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL /
CONSTRUCTION STANDARDS, AND THAT A COPY THIS RECORD
/HAS
l BEEN PROVIDED T THE WELLOWNER.
FOR OFFICE USE ONLY 6 �L� 11 - fD - Or'
Ouaa PERSON CONSTRUCTING LL DATE
Submw
it origin., to Div ate( Quality, Groundwar Sociion within 30 days
s��w No. fJ"'V cw-I REV. ttiv�

North Carolina . Depanment of EnviroreneM and Natural Rasowcee - Division of Water Ou"ry - CxourWwawr Section " {J .� 1636 Mail Servic:a Cerwu - Raleigh, N.C. 27699.1696-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: .lames W. Comp, if.
WELL CONTRACTOR CERTIFICATION •: 2138
,�! STATE WELL CONSTRUCTION f ERMITK:
1. WELL USE (ChaokAppil"We Box): Residential lJ Municipal ❑ Industrial ❑ Agricultural 0 Monitoring ❑
Recovery [] Heat Pump Water Injection ❑ Other If Other, List Use:
2. WELL LOCATION: ( how, aetch f the o ation below)
Nearest Tow`j _ e✓ R County:
k e✓ Y
I/L/esttvtiY�iSter ! 'c, gI RP
(Road Nartw and 10K C°�Mtarnily, or suooivisim arw tNo.)^_T DRILLING LOG DEPTH
3. OWNER L-1Ay \l ( q D
From To Fomtaiiol Oescriprion
Address _fix 14�5- q T 0 110 �ALJ, York
r15y"I or outs Q. c 1 10 6 Cori o r a e Yo
K te✓ ✓ C a8131
Crry or Town Sine Zip Coda
4, DATEDRILLED D-23-0a
S. TOTAL DEPTH
6. CUTTINGS COLLECTED YES 0 NO®
7. DOES WELL REPLACE EXISTING WELL? YES Q NO©
6. STATIC WATER LEVEL Below Top of Casing: 5-S FT.
(Use'✓ II Above Top of Casing)
9. TOP OF CASING 13 1 FT. Above Land Surface'
'Top of o ing ruminated &Uw Glow Lend suaa requew a variance In a 0,
dams with ISA NCAC 2C ,011a
10. YIELD (gpm): 30_ METHOD OF TEST Air
11. WATER ZONES (depth):
i2_ CHLORINATION: Type Granulnr Amount 1 Q 10
13.-CASING:
Depth Diamaief
From 0 To I I D Ft. 6 '/4
From To Ft.
Fran To Ft.
14. GROUT
From 0
From _
15. SCREEN:
II
r
If additional space is needed use back of lormN
Walt 1Tic 0" LOCATION ,SKETCH
o welI�dhVR. Malarial (Show direction and distan from at least two State
SDR21 PVC Roada, or other map reterence potrus)
Depth Material Method
To 20 Ft, Neat cement Hand
To Ft,
Depth Diameter
From —To Ft in.
From _ To Ft. in.
From _ To — Ft. _ in.
16. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To Ft.
17. REMARKS:
Slot Size Material ]� \
_ in.
_ in.
Material
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 1SA
CONSTRUCTION STANDARDS, AND THAT A C*THISD HAS BEEN PROVIDED T(
FOR OFFICE USE ONLY zo
Ou" No:: - - -SON CONSTRUCTIN THE
.9"mil origO"Ity, Groundwatr Sealer wl
Sadal No.NUV 6 1 2
6Q J. _,Qq fj
i lf2Yln
AC2C, WELL
THE WELL OWNER.
DATE
iin 30 days
GW-1 REV. IDW

206: 4
North Cato"• Department of EnvirprvrieM and Naturat Resources •Division of Walter O r uaGry -Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: James W. Camp, Jr.
WELL CONTRACTOR CERTIFICATION 0: 2138
STATE WELL CONSTRUCTION PERMITC
1. WELL USE (Cheok AppkcaNe Box); Residential L Municipal ❑ industrial ❑
Recovery ❑ Heat Pump Water Injection El Other If Other, List Use: Agricultural Monitoring ❑
2. WELL LOCATION:
Nearest Town:
(Road Name and � cg_nunity, or
1 /P. Y/ YI 3. OWNER i e Vja
Address %& D C2YI r 5
r o o o.
YVC)t !rl, n C
location below)
Coutty.
are Lot No.) DRILLING LOG
From To
0 h�
�53 Cos
A. DATE DRILLED )O -,L- Dc
5. TOTAL DEPTH . 4 n 5
6. CUTTINGS COLLECTED YES Q NO®
7. DOES WELL REPLACE EXISTING WELL? YES [yx NOE]
8. STATIC WATER LEVEL Below Top of Casing: If, S FT.
(use': 11 Above Top of Casing)
9. TOP OF CASING IS 1 FT, Above Land Surface'
Top or casing Wave aced Wor below land surtaca raqulrea a varkmi" In accw-
danu with 15A NCAC 2C .ells
10. YIELD (gpm): METHOD OF TEST All
11. WATER ZONES (depth):
i2. CHLORINATION: Type Granular Amount I r-I IQ
13.-CASING:
Walt Ttw i css
Depth
13
Diameter or WeiiggnI/Ftt. Malarial
SDR21 PVC
From 0
To
Ft.
6 V.
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
Slot Size Material
From —To
Ft
In. —in
From —To
Ft.
In. —In.
From —To
—Ft.
in. —in.
16. SAND/GRAVEL PACK:
Depth
Size Material
From
To
Ft.
From
To
Ft.
17
DEPTH
,)7nnatl Dascria(�n
k Sand
60NS0a e Y, .
C
It additional space is needed use back of Corm
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
V� y
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF HIS RECORD HAS BEEN PROVIDED TO T E WELL OWNER.
FOR OFFICE T1�j�
Quad O L fnI G AE OF PERSON CONSTRUCTING WE r DATE
. LI- .5uumt`r to Divislon of water Quality. Groundwater section within 30 days
�Mr.%. IUJ

NOrth Carolina - Depanment of Envirortmant and Natural Rasewcee - Division of Water Duality - Groundwater Section 0 "
1636 Mail Service Center - Ralailk N.C. 27699.1636-Phone [phone]=l
WELL CONSTRUCTION RECORD WE" CONTRACTOR: James W. Camp, Jr.
WELL CONTRACTOR CERTIFICATION !h 2138
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Crack Appucable Box): Residential ya Municipal ❑ Industrial ❑ Agricultural Monitoring ❑
Recovery Q Heat Pump Water Injection ❑ Other If Other, List Use:
2. WELL LOCATION: ROW skel�(h of the location below) yI-II J
Nearest Town:- -�1 'FS/c�� County: gu IYCir �Ylj
(ftuad Name and Numbers. Community, of Subdivisionnd aLot No.)
DRILLING LOG DEPTH
3. OWNER Ar
H e G0-
f T
From To Form iim p4on
Addrfess /(poi{
S 'pptPast
R
0 f I S RRd, G a
'7 C k/
rae or T C
d a 1n 1 Gi a
I S .305 e p L
4. DATE DRILLED
5. TOTAL DEPTH _3o.5i
6. CUTTINGS COLLECTED YES D NO ,�/
7. DOES WELL REPLACE EXISTING WELL? YES I ✓I NOD
S. STATIC WATER LEVEL Below Top of Cluing: `�' FT.
(Use '.* It Above Top of Casing)
9. TOP OF CASING IS 1 FT. Above Land Surface'
'Top of cuing terminated actor below land surlace requkea a variance In sccor-
dance with 15A NCAC 2C .e11a
10. YIELD (gpm): O METHOD OF TEST Air
11. WATER ZONES (depth):
Q2 CHLORINATION: Type GE0011101 Amount 1 c110
13.-CASING.
FCD
=i _-_
It additional space is needed usa back of forml`�
Wall 1-mckness
LOCATION SKETCH
Depth
t 5
Diameter or waVFL Malarial
1/4 SDRZI
(Show di(ectbn and distance from at least two
From U
To
Ft.
6 PVC
Aoads, or other map reference of us)
From
To
Ft.
"
From
To
Ft.
14. GROUT:
\�
Depth
Material Method
f
Y�
From 0
To 20
Ft.
Neat cement Hand
From
To
Ft.
15. SCREEN:
2.�-�
, t
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
" w L i
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY Or THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE US Y
Quad No: D L -. Sa TUflE OF PERSON CONSTRUCTING WELL DATE
Submit Ong al to Division of water Ouallty, Gmundwater Section within 30 days
Serial No. l'LJ U' Gw-I )REV. tu99
-V j a._
_/�

NoM Carolina - Dopanrnant of Envimrvnent and Natural Resources - Division of Watar Quality - Groundwater Section " 2 l'' J G' AA
1636 Mail Service Cant- Raloigh, N.C. 2769E-I W&Phone [phone] `3 8
WELL CONSTRUCTION RECORD WELLCONTRACTOR: James W. Camp, Jr.
WELL CONTRACTOR CERTIFICATION a: 2138
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Chock Appacabta ls")a Residential 2l' Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION:
Nearest Town:
(Road Name
3. OWNER _
Address
of the location below)
comfy: n IA I VIeY`f oyu
ano Lot No.)
PG57)r /V C ;A,6VI'A
City or Town stall Zip Coda
a. DATE DRILLED 0t>
5. TOTAL DEPTH v.S'
6. CUTTINGS COLLECTED YES Q NO®
7. DOES WELL REPLACE EXISTING WELL? YES NOQ
S. STATIC WATER LEVEL Below Top of Casing: G Fr.
(Use'.' II Abova Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface'
-Top of casing tarminaud auor "ow land surteu tequkaa a wrlanu In accor-
dancs with 15A NCAC 2C .011s
10. YIELD (gpm): 3 METHOD OF TEST Air
11. WATER ZONES (depth):
DRILLING LOG
From To
0 yv
4-0 `✓ro S
DEPTH
F�om�u,�e�on Description
yavej
Cvn�pfftdckfed
k
T2. CHLORINATION: Type GIC1011101' Amount 1 n If•)_ It additional space is needed use back of form
13.-CASING:
Depth m Diaetsr
From 0 To `�Q Ft, 6 ''A
From To Ft.
From To Ft.
14. GROUT
Wall ThIwi�kneas LOCATION SKETCH
SDR11/Ft pt%C (Show direction" distance from W least two State
Roads, or other map reference points) r
Depth Material Method
From 0 To 20 Ft Neat cement Hand
From To FL
15. SCREEN:
Depth
Diameter
From
_To_
Ft — in.
From
To _
Ft. T In
From
_ To —
Ft. in
16. SANDIGRAVEL
PACK
Depth
Size
From
To
Ft.
From
To
Ft.
17
Slot Size Material
_ in.
In.
—in.
Material
XLl
5unsh�nf=t
5�k��1 LJ
5'urt5 uric
c'vh,tm .
�1 c
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH i 5A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ''" d JZ
Quad No: flE Of PERSON CONSTRUCTING WELL DATE
Submit origin on of Walar Wality, Groundwater Section within 30 days
serial No. GW-1 REV. 12M
L Ju

�20F^9
North Carolina - DaparUnent of EnAmnrteru and Natural Resources - Division of Water Quality - Grarndwawr Section
1636 Mail Service Canisr - Raleigh, N.C. 27699.1636Prwne (919) 793-=l
WELL CONSTRUCTION RECORD WELLCONTRACTOR: JameS W, Camp, Jr,
WELL CONTRACTOR CERTIFICATION a: 2138
STATE WELL CONSTRUCTION pERWITII:
I. WELL USE (ChookAppllcab" 6ox): Residantlal L Municipal ❑ Industrial [] Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other E3 If Other, Ust Use:
2, WELL LOCATION,-(ShiP�`� skel.(r,,,� o the location below) `1� (' 1
Nearest Town: u T i-tC' y �" County: RU 7 Dl e Y 7c y d
n L
(Road Name rs, Comrwnity, or Subdivision and Lot I") DRILLING LOG DEPTH
3, OWNER V, Fr«n To FO tion Da ption
Addres`s�I ter 45- 61,1V d, � 0 )o � 5'Glttd. C a
1 6 la d` b e R-)` 100 3G c roc.
� r � t�P r .fir l z�l
City or Town Stale Zip Coca
4, DATE DRILLED D
5. TOTAL OEPTH
6. CUTTINGS COLLECTED YES( NO®
7. DOES WELL REPLACE EXISTING WELL? YES Q_ NO�
6. STATIC WATER LEVEL Below Top of Casing: t 4 FT.
(Use '.'It Abova Top of Casino)
9. TOP OF CASING IS 1 FT. Above Land Surface'
'Top or casing wrnlnawd W« Wow lane such raquk" a varlan" In dance with with 15A NCAC 2c,oll4
10. YIELD (gpm): 30 METHOD OF TEST Air
11. WATER ZONES (depth):
0
G)
i2. CHLORINATION: Type
Gram
llnr Amount 1 M IQ
II Addtr)onal space is needed use back of tt m;
13. - CASING:
���
Wall TNc:ness
LOCATION SKETCH
Depth
Diameter of We UK MaVarial
(Show direction" distance from at least two State
From 0
To 106
Fl.
6 tea SDR21 PVC
Roads, or other map reference points)
From
To
Ft.
From
14, GROUT:
To
Ft.
�
Depth
Material Method
From U
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
1 S. SAND/GRAVEL PACK
Depth Size
From To Ft.
Fram To Ft_
17. REMARKS:
Slot Size Material
_ in.
In.
in.
Material
i�Q
x
zj,
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD �H,A) BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USEU'V
Ti " !/(/. - I i - Jp -
Quad No: LS TURE DF PERSON CONSTRUCTIN LL DATE
SuoMt odo' on w water Duality, Groundwater Section within 30 days
Serial No.
_,GW-tREV. 12/99
Lv.j

North Carding - Department of Environment and Natural Resorucee - Division of Water Duality. -Groundwater Section r t- 0 0
1636 Mait Serviea Carter - Raleigh, N.C. 27699.163E-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: James W. Camp, Jr.
WELL CONTRACTOR CERTIFICATION *-_ 2138
STATE WELL CONSTRUCTION pERMirr#-
1. WELL USE (Check applicable Box); Residential Gj/ Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery [D Heat Pump Water Injection ❑ Other If Other, List Use:
2. WELL. LOCATION:
w sk tch of the location below)
y{�q,, j
Nearest Town:
County:
kU� 6.V
_3SD _
�((��.M
w 7�eII
t✓V �7
(Road Name and Numbers. dmn ly. or rS"dwision and Lot No.)
DRILLING LOG
DEPTH
3. OWNER t
1. �Q e h_ M uY ✓0'\l
Fran - To
Fomuuan Dazc iption
Address .7`�C
10 '}t e �� �` (2d.
n 2.0(
5An
<c �Cvt
�7oro
roe a a o.
n C "2?4D4o
'g,o '�ia�
T!iYSo i a ✓tic
tuy or Iown State Zip Code
4. DATE DRILLED�-
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES 0 NO®
7. DOES WELL REPLACE EXISTING WELL? YES NOF_�
B. STATIC WATER LEVEL Below Top of Casing: FT.
(Usa'✓ a Above Top of Casing)
9. TOP OF CASING IS 1 FT. Above Land Surtace'
"Top of oruing wininated Wor below Land surf'^— requlr" a variance In "cwr
dance with 15A NCAC 2C .o11a
70. YIELD (gpm): r METHOD OF TEST Air
11. WATER ZONES (deolhl:
rV o
i2: CHLORINATION: Type Grnni Aar Amount 1 Ct IID If additional space is needed use back of form
13. - CASING:
Wall Thickness
0
Depth
aV
Diameter awe nVFL Malarial
SDRp21
From
To
Ft.
6'A PVC
From
To
Ft.
From
To
Ft.
14. GROUT:
Depth
Material Method
From 0
To 20
Ft.
Neat Cement Hand
From
To
Ft,
15. SCREEN
Depth Diameter
From _ To Ft in.
From —To Ft. In.
From — To _ Ft. _ in
16. 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 relerertCa points)/
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF T S RECORD HAS BEEN PROVIDED TO T E WELL OWNER.
FOR OFFICE US Y G(i I D UD
Quad No: RE OF PERSON CONSTRUCTING Tinfil DATE
Submit odg Talon Of Water (hefty, Gtourdwater Section wi in 30 days
Setial No. 't / ', c.,'1, GW-1 REV. 12/99
AL,

North Carolina - Dapa ntn t of Enwrartrnerlt and Nalwal Rds wces - Division of Water Quality-:NWndwawr Section L 2 0 6 5 9
1636 Mail Service Canter - Raleigh, N.C. 276eS-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: .lames W. COMP, Jr.
WELL CONTRACTOR CERTIFICATION N: 2138
STATE WELL CONSTRUCTION PERMIT+►:
1. WELL USE (Check Applicable Box): Residential ET Munlcipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery F] Heat Pump Water Injection ❑ Other 13 If Other, List Use:
2. WELL LOCATION:
Ndwast Town: —
(Rudd Nano and
3. OWNER
Address
of the location below) �A �� e r)�a y
'1 County:
Or puooivli"n ano
f efloc'Ho---,-,mac;,..., 250?l'
Gty or Town State Zip Coda
a. DATE DRILLED J ' I3 "OU
5. TOTAL DEPTH 61�L
6, CUTTINGS COLLECTED YES [1 NO®
7. DOES WELL REPLACE EXISTING WELL? YES Q NO®
S. STATIC WATER LEVEL Below Top of Casing: 14 FT.
(Ilse'? It Above Top ofCasing)
9. TOP OF CASING IS 1 FT. Above Land Surface*
'Top of casing terminated avor below land surtace raqurrw a varlanaa In aacwr
daft" with 15A NCAC 2C ,d ltl
IQ. YIELD (gpm): METHOD OF TEST Ail'
11, WATER ZONES (depth):
DRILLING LOG
Frorn To
0 3�
3o Sat
r-,
0
`d
12- CHLORINATION: Type SmnUlnr Amount 1 CUj2__ It additional space is needed use back of form �
13.-CASING`.
WallTrx k ass LOCATION SKETCH
Depth . Dianwwf or wet�hVFt. Material (Show direction and distance from at least two State
From O To -3 D FL 6 tea $DR21 PVC Ftoa s, or other map reference points)
From To Ft.
From To Ft.
14. GROUT
Depth
From U To 20 Ft,
From To Ft,
15. SCREEN:
Material Method
Neat cement Hand
Depth Diameter
From —To Ft T In.
From —To Ft., in.
From —To —Ft. — in
16. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To FL
17. REMARKS:.
Slot Size Material 1^ 1 \
in.
In.
_ in.
Material
Qvew��r>12
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 1SA NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY O;�R
HIS RECORD H)A�SBEEN PROVIDED TO THE WELL OW.INER.
FOR OFFICE USE ONLY ! (/
+lied Np: St E OF PERSONoriginof Water Duatlty. Grourdwatnr Secdpr within 30 days
Sarial No.
GW-i FiEV, 1264
12- CHLORINATION: Type SmnUlnr Amount 1 CUj2__ It additional space is needed use back of form �
13.-CASING`.
WallTrx k ass LOCATION SKETCH
Depth . Dianwwf or wet�hVFt. Material (Show direction and distance from at least two State
From O To -3 D FL 6 tea $DR21 PVC Ftoa s, or other map reference points)
From To Ft.
From To Ft.
14. GROUT
Depth
From U To 20 Ft,
From To Ft,
15. SCREEN:
Material Method
Neat cement Hand
Depth Diameter
From —To Ft T In.
From —To Ft., in.
From —To —Ft. — in
16. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To FL
17. REMARKS:.
Slot Size Material 1^ 1 \
in.
In.
_ in.
Material
Qvew��r>12
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 1SA NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY O;�R
HIS RECORD H)A�SBEEN PROVIDED TO THE WELL OW.INER.
FOR OFFICE USE ONLY ! (/
+lied Np: St E OF PERSONoriginof Water Duatlty. Grourdwatnr Secdpr within 30 days
Sarial No.
GW-i FiEV, 1264

North Carding - Depanmant of Enviroma" and Narural Resources - Division of Water au-ality - Groundwater Section 22 " 6 4 4
16W Mail Service Carter - Raleigh, N.C. 27699-163frPflone (919) 733,141
WELL CONSTRUCTION RECORD WELLCONTRACTOR: .lames W. Camp, A
WELL CONTRACTOR CERTIFICATION F: 2138
�STATE WELL CONSTRUCTION PERMITi:
1. WELL USE (chackAppucallo e"): Residantial G,/ Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: ($ho# sketch of the location below)
Nearest Town: :H t) ✓ r 5 Cc
(Road Nanva an9'M pr}, Com'"�'�ly, or subdivision and
3. OWNER I gY(i�')l I-TAY Y)S
Address -go / 2 P" . —I
try 0( town State Zip Code
4. DATEDRILLEO -13-DL)
5. TOTAL DEPTH
6, CUTTINGS COLLECTED YES Q NO®
7. DOES WELL REPLACE EXISTING WELL? YES [3 NOM
8. STATIC WATER LEVEL Below Top of Casing: 3 S FT.
(Use'i li Above Top or Casing)
9. TOP OF CASING IS 1 FT. Above Land Surface"
'Top of oasing twminatad actor blow land surface requk" s vwlanca In accor-
dana with 1 M NCAC 2C ,011e
10. YIELD (gpm): 100 METHOD OF TEST Air
11. WATER ZONES (depth):
T2. CHLORINATION: Type GrG01117r Amount 1 (a lfl_
13. - CASING;
Wali Thickness
Depth Diwnewr or We nVFL Matanal
From 0—To 8.5 Ft. 61/4 SDR�21 PVC
From To Ft.
From To Ft.
14. GROUT
Depth
From 0 To 20 Ft.
From To Ft,
15. SCREEN;
Material Method
Neat cement Hand
Depth Diameter
From —To Ft _ In.
From —To Ft. In.
From _ To — Ft. in.
16. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To FL
17. REMARKS:
Slot Size Material
in.
In.
in.
Material 6I
DRILLING LOG DEPTH
From To Fonnauon oascnpion
0 FPS 5,RAj 1)e 1 att.501(,(a e ✓o Ck
LD
N r�
_3
N o_
It additional space is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least two Site
Roads, or other map reference points)
nA
�� tl j{tori�n
a
�aYyl 5
c � N1r V61 K Cy Rd
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE 0 i G(/VV(e d_ tO. 11 - / D -
Quad Non RE OF PERSON CONSTRUCTING WGL DATE
v L, t ` on of Walar Duality, Gmurdwatar Sgco n within 30 days
Sand No.
GW-1 REV. 1299
NU

North CanQI" - Depanment of Environment and Natural Resources _ Division of Water Ouayty. . Groundwater Section 2 0 t1 `.f 5
1636 Mall Serviea Center. Raleigh, N.C. 27699.1636Phone (219) 793.=1
WELL CONSTRUCTION RECORD WELLCONTRACTOR: James W. Camp, Jr.
WELL CONTRACTOR CERTIFICATION 9: 2138
,.,( STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Chock Appll"Wo Box): Residantia! LYJ Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery 0 Heat Pump Water Injection ❑ Other If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below) ��CY 7
Nearest Town: �.ctkC L.ri.Yp county; IA cV d
(Road Name anarNurtbgrs! ci-rwni1 gu0divlaion ux1
3. OWNER e, )e1' li IYIi -�CSiC
Address Fq ') i _-Fa-' .... ..._
V
4. DATE DRILLED ID- pC
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: 5 Fr.
(Use'i If Abova Top of Casing)
9. TOP OF CASING IS 1 Fr. Above Land Surface
'TOP Of casing tarminatad at/or below land surface mqultw a varlonu In accoh
dams wiN 15A NCAC 2C.011G
10. YIELD (gpm): _3 METHOD OF TEST Air
11. WATER ZONES (depth):
i2. CHLORINATION: Type
Gfanitlar
Amount 1 r'tlj.?_
13. - CASI NG;
Wall Thickness
Depth
3�O
Dianw(W w Wetghtl t. Malarial
SDR21
From 0
To
Fl.
6'A PVC
From
To
Ft.
From
To
Ft.
14. GROUT:
Depth
Material Method
From 0
To 20
Ft.
Neat cement Hand
From
To
Ft.
-._...
15. SCREEN
DRILLING LOG DEPTH
From To Formation Desaiptiun
0 !1O C eI
,I0 b�5 60 K(0. eC c
Cn
O
='I
7
It additional space is needed use back of lorib
c�
LOCATION SKETCH
(Show direction and distance from at Isasl two State
Roads, or other map reference points)
Depth Diameter Slot Size Material
From _ To Ft in. in.
From —To _ FL In. In.
From _ To _ Ft. in. _ in.
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
17. REMARKS:
11
Rocv'Spy. ck.Zd.
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 Qt x 'D(
Chad No: U I E OF PERSON CONSTRUCTING WELL DATE
Submit Onginal of Water Gushy, Groundwater Section within 30 days
Serial No. 1 GW-1 REV. 12199
r

NOM Carolina - Daparonant of EnAtararrent and Natural Rasourcee • DivIsion of Water Qtwkry - Groundwater Section d-
Q
l ti36 Mail Service Canwr - Raleigh, N.C.27649.163ti-Pf»ne (979) 793�3221 665
WELL CONSTRUCTION RECORD WELL CONTRACTOR: James W. Camp, Jr.
WELL CONTRACTOR CERTIFICATION R: 2138
,.,/STATE WELL CONSTRUCTION PERMIT►:
I. WELL USE (Chaak ApPlicabla 6oa): Residential L)4 Munlcipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other If Other, List Use:
2. WELL LOCATION: W skesch of the location balow `��J-./I I
Naares[Townnn: ( O✓e 5T CI' County; WatAf ✓`�pY 61
l Ycwle �rT ry /Zci
(Ruaa Nanw Ana NuJr roar., Cam Ity, ar SuodvlsIM WW Lot No.1 DRILLING LOG DEPTH
3. OWNER Y(-YL Frorn .To Formation cis ption
Address 1f6 J_Awhea a��/ 0 13S Cla ue
(STieo t or outs o. 2_5 I{+-f-5 e KOCT
A 7442.,
Gty or Town Stale Zip Cod
4. DATE DRILLED 0 0
5. TOTAL DEPTH y L 5
6. CUTTINGS COLLECTED YES Cj NO®
7. DOES WELL REPLACE EXISTING WELL? YES Ea NOO
8. STATIC WATER LEVEL Below Top of Casing: /o q FT.
(Use ', • II Above Top at Casing)
9. TOP OF CASING IS 1 FT. Above Land Surface*
'Top at casing tarmrnated War beaow land surface raquirw a varianas In accor-
dance with 1SA NCAC 2C ,011 a
10. YIELD (gpm): _5� METHOD OF TEST Alf
11. WATER ZONES (depth):
i2" CHLORINATION: Type Q001 Ij nr Amount .I >:11R.--^. It additional apace is needed use back of torm
13.-CASING;
Wait Tni k ess
LOCATION SKETCH o -
Deplh
Di *Ldr or WalchvFr.
Ma+erial
(Show direction end distance from at hest two State_,. 1-
From U
To 13,5
Fl,
6 1/4 SDR21
PVC
Roads, or other map reference points) -? ,
From
To
Ft.
—
From
To
Ft.
_-
14. GROUT:
Depth
Material
Method
From 0
To 20
Ft.
Neat Cement
Hand
v
From
To
Ft.
15. SCREEN:
N o
'(J IL_ , �=
Depth
From To
From —To _
From —To
1 B. SANDIGRAVEL PACK:
Depth
From To _
From To_
17. REMARKS:
Diameter Slot Size Material
Fit In. _ in.
Ft. In. —In.
Ft.in. —in.
Ft.
Ft.
Size Material
0
7W
I DO 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.
FOR OFFICE USE 0 vV jj G'
Quad No: RE OF PERSON CONSTRUCTING &EWEVLDATE
an at Water Quality, Gmandwater SeNan within 30 days
Serial No. GW1 REV. 12195

Oepanment 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: ,;- Me S W ��z nl r1 iy
WELL CONTRACTOR CERTIFICATION
STATE WELL CONSTRUCTION PERMITif:
1. WELL USE (Check applicable Boa); Residential ET Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below) �,j r
Nearest Town: � ii K P L-q ✓a County: RUT t P ✓ 7n ✓ d
(Road Name and 7Numbers. Conanum or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER V 11I5 IV/I rt 2. From To Formation Description
Address jfi3 P✓✓AGP � � I('S �✓t Ycc
I,� i11 tN v ree orl�o ule o. ' 2 cl '1 Sr o rJ ,�/ �i' 'D c-. G
Uay or 1 own State Zip Code
4. DATE DRILLED r�-��"I'D
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES F-1 NO[Z
7. DOES WELL REPLACE EXISTING WELL? YES [:j NO[g]
8. STATIC WATER LEVEL Below Top of Casing:-4z.`1— FT.
(Use'i It Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface'
'Top of "sing terminated al/or below land surface requlrea a variance In accor-
dance with 15A NCAC 2C .0118 r
10. YIELD (gpm): W METHOD OF TEST a l ✓
11. WATER ZONES (depth):
12. CHLORINATION: Type J)'� U r Amount C''-t
13.-CASING:
Wall Thickness
n Depth Diameter or Welghl/Ft. Material
From To U-5 Ft, ✓IA SQB.dL VL
From To Ft.
From To Ft.
14. GROUT:
Depth Material etho
From —� To 20 Ft. Vle.i [r "'f
From To Ft,
15. SCREEN:
Depth Diameter Slot Size Material
From —To—Ft— in. _ in,
From _ To Ft. In. _ In.
From To Ft. in. _ in.
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
17. REMARKS:
it additional space is needed use back of form N
LOCATION SKETCH 1 I 1
(Show direction and distance from at least two State 1- K
Roads, or other map reference points) ✓e
� X
ar<�
Le Dr.
L,CL ✓e
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY, THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONL Mn a A JJ D ' / -40
Quad No: ' nfj OF PERSON CONSTRUCT G THE WELL DATE
Ilbm0lody�ial D' O Serial No. 1 Water Quality. Groundwater Section within 30 days
I'
GW1 REV. 12/99

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section 1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELLCONTRACTOR: �ctmes W ✓.
WELL CONTRACTOR CERTIFICATION p:
STATE WELL CONSTRUCTION PERMITC -'
1. WELL USE (check Applicable Boa): Residential R Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ED If Other, List Use:
Agricultural ❑ Monitoring ❑
2. WELL LOCATION: (Show sketch of the location below)
%
Nearest Town: L^4✓� County:
4j C e n f .
ni
(Road Name and Numbers. Commu, or Subdivision and Lot No.)
DRILLING LOG
DEPTH
3. OWNER
From
To
Formation Description
Address {3. Trrace N
7,;tll
D
1(G S
' r t ;-_ c
—T,.,.+, _� ree ori!�uta No.) 22 A')V
'dos
,2A
_ C
City or Town Stale Zip Code
4. DATE DRILLED
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES 0 NO®
7. DOES WELL REPLACE EXISTING WELL? YES [:j NO[K]
8. STATIC WATER LEVEL Below Top of Casing: 6,q_ FT.
(Use': I(Above Top of Casing)
9. TOP OF CASING IS FT, Above Land Surface"
'Top of using tarminated at/or below land surface requires a variance In accor-
dance with 15A NCAC 2C .0118 t
10. YIELD (gpm): 11) METHOD OF TEST A l Y
11. WATER ZONES (depth):
12. CHLORINATION: Type jy 1 VLulct ✓ Amount I �t If additional space is needed use back of form
13.-CASING: -
Wall Thickness
From—�To
Depth
11'5
Ft.�zC�_
Di eelar orwelght/Ft. Material
?C2&dL J h
From
To
Ft.
From
To
Ft.
14. GROUT:
Depth,
Material etho
From
To 2C
Ft.
�1 Pal ({°YY(Fnt ZLK
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) ,
3�;10.r<d
CK. Pa.
?q 4
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY,QF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER,
FOR OFFICE USE ONLY
Quad No:
Serial No.
LLu VIP
LC DY-
WQr
S#JNATURE OF PERSON CONSTRUCTIAlG THE WELL DATE
Submit odginal to olvislon of Water Quality, Groundwater Section within 30 days
OW-1 REV. 12/99

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section �, 1 s. ? A
4
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone (919) 733-U21
WELL CONSTRUCTION RECORD WELL CONTRACTOR: + zme5 L/0' akma' K.
WELL CONTRACTOR CERTIFICATION #: I3 S
STATE WELL CONSTRUCTION PERMIT#:
WELL USE (Check Applicable Box): Residential m Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery EJ Heat Pump Water Injection ❑ Other E3 If Other, List Use:
2. WELL LOCATION: h w s etch of the location below) ��``
Nearest Tow f 1� ,. 0 (l yl_ County: Ruff P y 7 Y�
(Road Name and NUm1bars, Cro�mmunity,
Suh9rvision and Lot No.) DRILLING LOG
DEPTH
3. OWNER
C' Yl
I /','
(yr
CYCS From To
Formation Description
Address
J�G7
) K V1+Yt • Rd • �) 1;�0
d if t, 5A IL d
A/1111jSGeef
or ula o. Dili �1 1
/_�.DIISn �"d'g-h-d C4
City or To n Stale Zip Code —
4. DATE DRILLED - -.-, - D tJ —
5. TOTAL DEPTH 'L-25 —
6. CUTTINGS COLLECTED YESD NO[Z
7. DOES WELL REPLACE EXISTING WELL? YES D NO® 1M It_
8. STATIC WATER LEVEL Below Top of Casing: FT. 1191
(Use'*' It Above Top of Casing) HIM
9. TOP OF CASING IS FT, Above Land Surface' i
-Top of casing terminated at/of below lend surface requires a variance In accor-
dance with 15A NCAC 2C .0119 ,
Y 0. YIELD (gpm): __4— METHOD OF TEST 14 ,1 K ndNeM9.
11. WATER ZONES (depth): _
12. CHLORINATION: Type -a Lut-i1 IA L E Amount IMP It additional space is needed use back of form
13.-CASING:
WallThicknesa LOCATION SKETCH
G
Depth
or WelghuFl. M*�e�n�al (Show direction and distance from at least two State
D/�4
From
To l2 0
Ft.
S Aiiameter
r
_4R ,a l ._LY _ Roads, or other map reference points)
From
To
FL
From
To
Ft.
14. GROUT:
Depth
1 I
Material Method
LL
From
To ._r,2O
Ft.
L a CP eel
From
To
FL
15. SCREEN
Depth
Diameter
From
_ToFt
In.
From
To
Ft, In.
From
To _
FL _ in.
16. SAND/GRAVEL
PACK:
- -
Depth
Size
From
To
Ft.
From
To
Ft.
17
Slot Size Material
In.
_ In.
_ in.
Material
Ra
R
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY.7 THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY t ` '9 - oD
Quad No: SIGNATURE OF PERSON CONSTRUCTI TH ELL DATE
Submit ongina"o Division of Water Quality, Groundwater Sectlt within 30 days Serial No. 13W-1 REV. 12/99
4iq y
IO 8
spy;n�
Drys

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section / i 9253
1636 Mail Service Center - Raleigh, N.C, 27699.1636­Phone (919) 733-=1
WELL CONSTRUCTION RECORD WELLCONTRACTOR: e5 1/0- 6'z m'o, r
WELL CONTRACTOR CERTIFICATION #: 1a l
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential IJr Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other (3 If Other, List Use:
2. WELL LOCATION' (Show sketch of the location below)
Nearest Town: I U ffi 12 ✓'{c rr) in Yl County: R1,( I Ael' 1" y
r•vdRAI 1Ewl 1�3+IJe5 6ff ID•�
(Road Name antl umbers.Cammu/n�ity, or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER YA Yt C i s l le we rit From To Formation Dascnpti1on
Address , �' qq t`ft, Sq n�
G5 11 c iYrtk �)✓c
NiNYVr I'S Sn raaj or o�s NO. -LI`2 7& a4 Jv/i_S' �'DVL;c }id.tt rri ✓nt�
City or Town Slate Zip Code
4. DATE DRILLED C�'. D - 1:0
5. TOTAL DEPTH -4/-S_
6. CUTTINGS COLLECTED YES 0 NOE]
7. DOES WELL REPLACE EXISTING WELL? YES Q NO®
B. STATIC WATER LEVEL Below Top of Casing: 7,q' _ FT.
(Use '✓ II Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface'
'Top of using terminated Wor below land surface requires a variance In accor-
dance with 15A NCAC 2C.0118
10. YIELD (gpm): 10 METHOD OF TEST CL i ✓
11. WATER ZONES (depth):
12. CHLORINATION: Type C Oa Amount
13.-CASING:
11 additional space is needed use back of form
Wall Thickness =
Depth Diameter or WelghlrFt. Material (Show direction and
From-0 To Ft. - (' Y4 6) DR.R 1 P ✓C Roads, or other
From To Ft.
From To Ft.
14. GROUT:
Depth Material + Metho
From C To �Lp Ft. h t? 0.t E Vvlen I �l0. K
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
from at ieilist two State
wrylll}e S
I/Lht CK Ka.
o
4u)I 16Y
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY�'JF THIS RECORD HAS BEEN PROVIDED O THE WELL OWNER.
FOR OFFICE USE ONLY �—�I/h 4j, to L �� ' �G � � - o6
Quad No: SI NATURE OF PERSON CONSTRUCTINd THE ELL DATE
Submit originailio Division of Water Quality, Groundwater Section within 30 days
Serial No. GW-1 REV. 12/99
(�AN

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section r ) I
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: -- j1•(e5 • (a yK it Dr•
WELL CONTRACTOR CERTIFICATION #: � IJS�
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable eox): Residential 10� Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other If Other, List Use:
2.
WELL LOCATION: skVe'Q
odhe location below)
�
J
NearestTown: U
yi, County:
V--urr
1'
Cf4_ 1�8
(Road Name and
mbers, Comm7unity, or Subdivision and Lot No.)
DRILLING LOG
DEPTH
3.
OWNER
�0.K t'C Yy
From To
Formatlon Description
Address) ��i G C 16
D /,�O
d( art SA rt d
�.(%"
re for oute
0.)
jx0 445
/Cn. sc1) c ed Ycc�
(t ✓io✓a
City or Town Stale Zip Code
4.
DATE DRILLED
5.
TOTAL DEPTH
6.
CUTTINGS COLLECTED YES Q NOM
a "-
7.
DOES WELL REPLACE EXISTING WELL? YES NOM
''� i?
i;.." ,
8.
STATIC WATER LEVEL Below Top of Casing: q q FT.
- - —mooInil
`� --
1 (Use's If Above Top of Casing)
1101
1101i
9.
TOP OF CASING ISFT. Above Land Surface'
-
-Top of casing terminated atior below land surface requires a variance In accor-
_
dance with 15A NCAC 2C.0113
10. YIELD (gpm): t' METHOD OF TEST A) ✓
--
11.
WATER ZONES (depth):
.IGGGGGlill.
MAI
12. CHLORINATION: Type ✓ahtA AY Amount
13.•CASING: �T
Wall Thickness
Depth Din,Cer or WalghvFt. Matpdal
From C To /�L Ft. 6 Y4 ShR,21
From To Ft.
From To Ft.
14. GROUT:
Dept M1aterial M Aho
From �� To AV Ft. I' if r'PvVic
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From —To—Ft— In. —in.-
From To Ft. In. _ In.
From To Ft. _ in. —in.
16. SAND/GRAVEL PACK:
- Depth Size
From To Ft.
From To Ft.
17
Material
It additional space is needed use back of forrlr'
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
I
H-WY j0s�
� \'
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARD$, AND THAT A COP/Y,�`I F THIS RECORD HAS B/F�EN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY / ZZ
Quad No: SONATURE OF PERSON CONSTRUCT G THE WELL DATE
Submit original to Division of Water Quality, Groundwater Section within 30 days Serial No. GW-1 REV. 12/99
�f�

North Carolina - Department of Environment and Natural Resources - Division of Water Quality • Groundwater Section 9 n ) -
1636 Mall Service Center - Raleigh, N.C. 27699-1636-Phone [phone] ir, r--1 ! .
WELL CONSTRUCTION RECORD WELL CONTRACTOR: 1 . ( w e s l�, elf- l J r
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 sketc of the location below) �(
Neare�stTown: � ��ILNy,✓/��/L County: her / 3eI,g "A
(Road Name and t umbars, CdnxrYl 9ity, or Subfdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER 5 I ✓ t'.. I . YD t1� 1PV '\ From To Formation Description
Address ' �-- U �' y„ a ,r8 i o c s
rea or outs o. 78 49" ('p✓t5cl,.ic.fryock
l�Y,I i)t.l MI' s
City or Town State Zip Code
4. DATE DRILLED 2Oo
5. TOTAL DEPTH !4 q - '
6. CUTTINGS COLLECTED YES Q NO®
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO�
S. STATIC WATER LEVEL Below Top of Casing: � FT.
(Use'i If Above Top of Casing)
9. TOP OF CASING ISFT. Above Land Surface-
-Top of dosing terminated at/or below land surface requbea a variance In accor-
dance with 15A NCAC 2C .0119 _
10. YIELD (gpm): —�_ METHOD OF TEST A I
11. WATER ZONES (depth):
0
12. CHLORINATION: Type e'1- t U' - Amount I bl It additional space is needed use back of form
13.•CASING: "—
Wall Thidmess LOCATION SKETCH
Depth Diem ter or wet vF,(, Material (Show direction and distance from at least two State
From To -5 Ft. ° I s )� .—P Vc-- Roads, or other map reference points)
From To F1 -
From
To
Ft.
14. GROUT:
Depth
Material
ethod
From i,�
1
To .,ZD
Ft.
_
;�IPa'f CzIv1Nn Y
� �
From
15. SCREEN:
To
Ft.
Depth
Diameter
Slot Size
Material
From —To—Ft—
In. _
In.
From
To Ft.
In.
In.
Lanz CK (yj}K R�
From —To
Ft.
_
in. —
in.
15. SAND/GRAVEL PACK:
Depth
Size
Material
na )i�l�s
r
From
To
Ft.
From
To
Ft.
X
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 1SA NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY W 0 �- THIS RECORD HAS BEEN PROVIDED ITOO _THE WELL OWNER.
FOR OFFICE USE ONLY ` zzinz l Jan Q `71 M 0- e o
Quad No: Slgf ATURE OF PERSON CONSTRUCTING iHe4LL DATE
Submit original to Divislon of Water Quality, Groundwater Section within 30 days
Serial No. GW-1 REV. 12/99

212
North Carolina - Department of Environment and Natural Resources - Division of Water Quality- Groundwater Section 'r- 285
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CE TIFICATION #: I -A-6 79
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (check Applicable sox): Residential ❑ Municipal [] Industrial ❑ A,g�cultural Q Monitoring ❑
Recovery❑ Heal Pump Water Injection❑ Other [-N If Other,LlstUse: �jL'Iker+662 ce,5 ©a�S
2. WELL LOCATION: (Show sketch of the lot lion below ,Pe'�-�.
f1ti-
) S<'f' beF"C
Nearest Town: E JN - e 14, • l %5 County:
(Rood Name and�Ny/rpbers. Community, or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER L2 t hc'r -�a �' -S z7yl LC�S From To Fcanallon Description
Address v/v; el >✓ ih�! l S
TS tee or ou a o,
City or Town / z ✓State _ Zip Code
4. DATE DRILLED
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES Q NOE�'
7. DOES WELL REPLACE EXISTING WELL? YES QNO[.?
8. STATIC WATER LEVEL Below Top of Casing: FT.
--V (Use'i I(Above Top of Casing)
-'
9. TOP OF CASING ISFT. Above Land Surface*
-Top of casing terminated atlor below land surface requires a vsr/ nce In actor- ^
dance with 15A NCAC 2C .01 a
10. YIELD (gpm): METHOD OF TEST W� r yCN
11. WATER ZONES (depth): �Z C/
12. CHLORINATION: Type amount if additional space Is needed use back of form
13. CASING:
LOCATION SKETCH
Waif Thickness
n Depth 2Un Diameter or WeIghVFI. Material (Show direction and distance from at least two Stale
From !/ To Ft. Roads, or other map tolerance points)
From To FL n -
From To Ft.
14. GROUT: / J
Depth Mat la}r/t Method
From To Ft. G L
From To Ft. rTt c:,
15. SCREEN:
Depth Diameter Slot Size Maledal m =-z,
-y+l,
From _ To _ Ft _. In. —in.—
From _ To _ Ft. _ In. — In.
From _ To _ Ft. _ In. In. m'c
16. SAND/GRAVEL PACK:
Depth Size Material ?
From To FI.
From To Ft.
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED 1N ACCORDANCE WITH 15A NCAC 2C, WELL G V
CONSTRUCTION STANDARDS, AND T14AT A COPY OF THIS RECORD H BEEN PROVIDED TO THE WELL OWNF. / . V
FOR OFFICE USE ONLY
� z B I,
Quad No: ❑ SIGNATURE OF ERSON C STRUCTING THE WELL DATE
d I� S brill original to Division of Water Quality, Groundwater Section within 30 days
#j s ( GWA REV. 12199
serial No. ! i 1

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mall Service Center- Raleigh, N.C. 27699-1 &1&Phone [phone] g g
WELL CONSTRUCTION RECORD WELLCONTRACTOR: �Qri�PS k� l amnTy-
WELL CONTRACTOR CERTIFICATION #: 55 -21
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Boa): Residential LY.1 Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other 0 If Other, List Use:
2. WELL LOCATION• S.�{.°� w sl f ch f,Ithe location below r
Nearest Town: r__11 �� t'\ {' r ✓ TRA County:
13� r-0 I ACW -'150� Kr)
(Road Name and Numbers. Conimunity. or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER 'iCot IONCS From To Formation Description
AddresLs- ( 1 t O �5
�r-tl dtPr% d. re or (�I(° 5o afj��9 iS 7{oS
City or Town Stale Zip Code '
4. DATE DRILLED
5. TOTAL DEPTH C r�
0
6. CUTTINGSCOLLECTED YESQ NO® _
7. DOES WELL REPLACE EXISTING WELL? YES F__� NO[� _
S. STATIC WATER_ LEVEL Below Top of Casing: _[' FT. - --
(Use'✓ If Above Top of Casing)-
9. TOP OF CASING ISFT. Above Land Surface'
'Top of casing terminated atlor below land surface requires a variance In accor- —
danca with 15A NCAC 2C .0118
10. YIELD (gpm): —1,2— METHOD OF TEST N
11. WATER ZONES (depth):
0
12. CHLORINATION: Type i L5 Amount C u It additional space is needed use back of form
13.•CAR I NG-
Wali Thickness LOCATION SKETCH
Depth D�iam�itar or Welght/Ft. Material (Show direction and distance from at least two State
From To'25 Ft, se1�-- 6D R AI - PVC Roads, or other map reference points)
From To Ft.
J N`
From To Ft. �
14. GROUT: -Wm.
Depth Depth material i Melho
From _� To 2_Ft. ne0. E rt �""v`
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 TJ�IS RECORD HAS )BEEN /PRROVIDED TOOTHE WELL OWNER.
FOR OFFICE USE ONLY L(�7I�G<( �- Vl/ - C�a4ytj jr�J Y q
Ouad No: SIGNAFNRE OF PERSON CONSTRUCTING T E WELL DATE
Submit original to Division of Water Quality, Groundwater Section within 30 days
Serial No. GW-1 REV. 12/99
1_�_
0

North Carolina • Department of Environment and Natural Resources • Division of Water Quality - Groundwater Section ti 17704
1636 Mail Service Center- Raleigh, N.C.27699-1636-Phone [phone] WELL CONSTRUCTION RECORD WELL CONTRACTOR: `�45 Jar rim•
WELL CONTRACTOR CERTIFICATION #: a I3 8
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable eox): Residential E Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION:
Nearest Town:
(Road Name
3. OWNER _
Address
of the location below) r 1
)YCounty: 14 'PY Y
subdivision and Lot No.)
Uiry, or I own State up cone
4. DATE DRILLED
5. TOTAL DEPTH 34 S
6. CUTTINGS COLLECTED YES 0 NO® �.__,/
7. DOES WELL REPLACE EXISTING WELL? YES 53 NOQ
8. STATIC WATER LEVEL Below Top of Casing: %p0 Ff.
(Usa'Y If Above Top of Casing)
9. TOP OF CASING IS�_ FT. Above Land Surface -
'Top of casing terminated atior below land surface requires a variance In accor-
dance with 15A NCAC 2C .0119 1
10. YIELD (gpm): ..7 0 METHOD OF TEST 0.) Y
DRILLING LOG DEPTH
From To Formation Dascn tion
c_o)13DlidaleJ rock
CD
r*1
-e
=
cn
11.
WATER ZONES (depth):
12.
CHLORINATION: Type flPtS—Amount
TJ
It additional space is needed use back of form •• F_`�'
13.-CASING:
w o
LOCATION SKETCH
Depth Diameter
� /- A
Wall Thickness
or weighuFt. Malerial
5D R ✓c
(Show direction and distance from at least t o State
From12To Ft.
p
Roads, or other map reference points)
From To Ft.
n
From To Ft.
-
yP�i
14.
GROUT:
L .In
M�
�thod
1
From a Topih�_Ft. 0.teCe
Y!Q A
From To Ft.
I
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:
^/�pl
IF�J-t ,r
q,f��P� �oYo
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OFT S RECORD HAS BEE PROOV'IDED TO THEWELL OWNER.
FOR OFFICE USE ONLY `' 1 j( iYY1.o� W. �� L. '� n " ' L — 6
Quad No: SIGNAtME OF PERSON CONSTRUCTING THE ALL! DATE
Submit odginal to Division of Water Quality, Groundwater section Within 30 days
Serial No. 't,l 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. 27699-1636Phone (919) 733-W-21 —�' • .ir�
f O t'
WELL CONSTRUCTION RECORD WELLCONTRACTOR: L mes CAM
WELL CONTRACTOR CERTIFICATION
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (check Applicable Box): Residential E2 Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ OtherE3 If Other, List Use:
2. WELL LOCATION,•yS how sketch of the location below) R�eYTo Ytl
Nearest Town: f-t^Ye5-C �d County:
Si to �\
(Road Name and Numbers. Community, or S hdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER r NJ AK From To Formation Downpaon
Address S G>'A7�3 C�eeK C�, Rd. D — ,—�A"
7 _u P 1 t(S rae or, ute o. n� nn %f0 COVISoha-te_d Yo
�1'y or I own n Jmte �y Iwo
4, DATE DRILLED a - �? 0 D
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES[:] NO�Z
7. DOES WELL REPLACE EXISTING WELL? YES ® NOF_�
B. STATIC WATER _LEVEL Below Top of Casing: g- FT.
(Use'i 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 .0119
10. YIELD (gpm): _,:2�_ METHOD OF TEST e -r ✓
11. WATER ZONES (depth):
12. CHLORINATION: Type e 5 Amount . G-�"
13."CASING:
Wall Thickness
Depth ofarn§tar orw 24 1 veal
FromTo � Ft.
From To Ft.
From To Ft.
14. GROUT:
Depth Matenal Matho
From To 20 Ft. UELL C e, 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
CD
`J'
c;
If additional space is needed use back of fornC4 F
LOCATION SKETCH
(Show direction and distance from at least two SI
Roads, or other map reference �points) , I , k;
X G✓a,�s C �� 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 PROVIDE TO THE WELLOWNER.
FOR OFFICE USE ONLY 9 6
Quad No: SI ATURE OF PERSON CONSTRUCTINKG 71r4 WELL DATE
Submit odginal Division of Water Quality, Groundwater Section within 30 days
Serial No. GW-i REV. 12/99
t

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section j 7 C yn 7
1636 Mail Service Center - Raleigh, N.C. 27699.1636-Prone [phone] 1 L7
WELL CONSTRUCTION RECORD WELLCONTRACTOR: _nWIP5 k)
WELL CONTRACTOR CERTIFICATION M:
STATE WELL CONSTRUCTION PERMIT#:�
1. WELL USE (Check Applicable Box): Residential LJ Municipal ❑ Industrial [3
Recovery ❑ Heat Pump Water Injection ❑ Other E] If Other, List Use:
Agricultural ❑ Monitoring ❑
2. WELL LOCATION _,AS�ho sketch of the location below)
Nearest Town: !-�5�r�i6 —County: kN- iPY i�✓!(
� C �I r2OIJev( �AllPU
(Road Nam. Conmuni , or Subdiv' ion and Lot No.) DRILLING LOG DEPTH
3. OWNER 5 e r e Y1II From To Formation DesQp lion
Address < (1' e5`de 19 ja,Drt 5an.d
(Strea or Houle o.) Y.
05 rC. cn
City or Town State Zip Code
4. DATE DRILLED _1_ IT-
5. TOTAL DEPTH 314 ci -
6. CUTTINGS COLLECTED YES ❑ NO® -o _
7. DOES WELL REPLACE EXISTING WELL? YES M NO® S. STATIC WATER LEVEL Below Top of Casing: _ o FT.
(Use'✓ It Above Top of Casing) - J
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): a METHOD OF TEST Ali'
11. WATER ZONES (depth):
12. CHLORINATION: Type C e Amount Gu It additional space is needed use back of form
13.•CASING:
Wall Thickness LOCATION SKETCH
Depth Diameter or Weight/Ft. Material (Show direction and distance from at least two State
From To L Ft 6 yt-_ -S-Q-R 7k —PVC Roads, or other map reference points)
From To Fl. - "
From To Ft.
14. GROUT:
Depth Material Meth d
From To AC Ft. heat Celnenl_—
From To
Ft.
_
�0 r
15. SCREEN:
Depth
Diameter Slot Size
Material ,,,de
r
From —To —Ft—
In. —in.-
-}W'-'!
From _ To _
Ft. _ In. _
In.
From —To —Ft.
_ in. —in.
II
16. SAND/GRAVEL PACK:
Depth
Size
Material
From To
Ft.
From To
Ft.
I
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 � /1/l l"_ W C� Q ` S UD
Quad No: SI ATURE OF PERSON CONSTRU IN HE WELL DATE
Submit original to Division of Water Quality, Groundwater Section Within 30 days
Serial No. GW-i REV. 12/99

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section " 1 7 P
1636 Mail Service Center - Raleigh, N.C. 27699.1636-Phone [phone] I iT 9 2
WELL CONSTRUCTION RECORD WELLCONTRACTOR: 1aIY1e5 lt�• �a"toJ✓,
WELL CONTRACTOR CERTIFICATION #: A l sg
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential LYJ Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
Agricultural ❑ Monitoring ❑
2.
WELL LOCATION: (Show sketch of the location below) 1
r
1
Nearest Town: L-,tke--I�✓e-f County: L`0tflie1
Rf CI
�
R 01, CACc I1tmt,I.Iti
y
DRILLING LOG
DEPTH
(Road Name and Numbers, ( or Subdivision and Lot No.)
3.
t�Community
OWNER �—! S 0— I ° I A Y_ A h J
From To
Formation Desc
ption
Address ti�;C, �. Ra.
/lo
—dirt,
art3
Tree or
%0.Ke �t.t✓e
we o.
C, 2U44
IIO �vS
CDVvSolirin
r Yoc
IV
City or Town State Zip Code
c _.
4.
DATE DRILLED
S.
TOTAL DEPTH '� `�
—o -
6.
CUTTINGS COLLECTED YES ❑ NO®
_
7.
DOES WELL REPLACE EXISTING WELL? YES Q NO®
' ^ -
8.
STATIC WATER LEVEL Below Top of Casing: L D Fr.
'-
(Use': if Above Top of Casing)
9.
TOP OF CASING IS FT. Above Land Surface*
^_
I 1 t d V r below land surface re uires a variance In accor-
t�
'Top of oas ng term na e a o q
dance with 15A NCAC 2C.0118 —
10. YIELD (gpm): o METHOD OF TEST alI'
11. WATER ZONES (depth):
12. CHLORINATION: Type Se Je ✓Anu f Amount G L If additional space is needed use back of form
13. CASING:
Wall Thickness LOCATION SKETCH
Depth 1 1 �n Diameter or welght/R. Material (Show direction and distance from at least two State
From— � Tod Ft. (— F'Vr— Roads, or other ap reference points)
From To Fl. y
r;
From To Ft. �yltorn `
14. GROUT: 1
DepthMaterial /Method
s
From ToFL hFafrr'VAP.nfi
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
7 f
J_yr:
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: SIGN RE OF PERSON CONSTRUCTINd THE#VELL GATE
Submit original to ivalon of Water Quality, Groundwater Seaton within 30 days
Serial No. GW-1 REV. 12/99

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section J C (1
1636 Mail Service Center - Raleigh, N.C. 27699.1636-Phone (919) 733-=1 ''l (6 9 9
WELL CONSTRUCTION RECORD WELLCONTRACTOR: - J 0tirles Came'T•
WELL CONTRACTOR CERTIFICATION #: .."Z I13�
STATE WELL CONSTRUCTION PERMITC
1. WELL USE (Check Applicable Box); Residential [2 Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other If Other, List Use:
Agricultural ❑ Monitoring ❑
2. WELL LOCATION�-t SSho sk tch of the location below)
Nearest Town: l I r s r �e County: �t t P' g Y d
(Road Name and NurMlrtvnniry uor Subdivision and Lot No.) DRILLING LOG DEPTH
l
3. OWNER ,12„ f, IZ0.0 n1�ee/ p1 From To Formation Description
Address �n�� v �e r�kin5 KA, l] .;2o di✓t
KA _ ZS ree or u e o. h r.I t ,�` h C0 00 Yy 50� I c a'�e ✓o c-k
City or Town Stale Zip Code
4,
DATE DRILLED Q' -Po
5.
TOTAL DEPTH `i 50
6.
CUTTINGS COLLECTED YES ❑ NO® r�
7.
DOES WELL REPLACE EXISTING WELL? YES lZ l NO❑
8.
STATIC WATER LEVEL Below Top of Casing: Ff.
o -
(Use •: It Above Top of Casing)
rn
9.
TOP OF CASING IS�_ FT. Above Land Surface-
m
?op of casing terminated auor below land surface requires a variance In actor-
dance with 15A NCAC 2C .0118
Ul _
10.
YIELD (gpm): DD METHOD OF TEST �l ✓
11.
WATER ZONES (depth):
-T3 �--,-_
12.
CHLORINATION: Type et5 Amount
It additional space is needed use back of form
••''
r.�
13.
CASING:
—
ca o
Wall Thickness
LOCATION SKETCH
—
Depth or Wslghl/Ft. Material
(Show direction and distance from at least two State
,D,iafneter
From To 10 Ft. 9;1'4 5 al P v c—
Roads, or other map reference points)
From To Ft.
From To Fl.
14.
GROUT:
/ I
r = .p
+ ,
Depth Material + Mel�h
From U To 20Ft, t1ea� CC Wtenl
From To Ft.
f v n
15.
SCREEN:
Depth Diameter Slot Size Material
From —To—Ft— in. In.
From _ To Ft. _ In. — In.
7F, :: i - X
From —To _ Ft. _ in. -..— in.-
16.
SAND/GRAVEL PACK:
-
Depth Size Material
From To FL
r, _
Js� r ^ ✓ k-
I
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 RECORDHIAS BEYN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY W 5 - D 0
Quad No: SI ATURE OF PERSON CONSTRUC ING T W ELL DATE
Submit odginal I Division of Water Ouellly, Groundwater Se Ion Within 30 days
Serial No. GW-1 REV. 12/99
0

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section � 1 9 5
1636 Mail Service Center - Raleigh, N.C. 27699.1636-Phone [phone] -
WELL CONSTRUCTION RECORD WELLCONTRACTOR: f --�0.MF5 ]Tr.
WELL CONTRACTOR CERTIFICATION p: ;5� 1 ,
( STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential LI Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATIONIo how sk tch Pf the location below)
Nearest Town: r(-�' `\ ui'�te ✓ri �c v` County:
niF 1J rD Y e 5 t
(Road Name an umbers, (C�onvnuni,, or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER P Yl , I !a YwPyb h From To Formation Description
Address
M tbir"i or NOU10 o. 3 �{ iL_ D y O
Ay L
10/ N l
City or Town Slate Zip Code
4. DATE DRILLED �9 ` j6 _tC' -
5. TOTAL DEPTH �VP
6. CUTTINGS COLLECTED YESQ NOW
7. DOES WELL REPLACE EXISTING WELL? YE�NO� _
S. STATIC WATER LEVEL Below Top of Casing: Ff. _ -
(Use'+' 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 116 , r
10. YIELD (gpm): METHOD OF TEST 01 ✓ rv— 17s
11. WATER ZONES (depth):
r c�
12. CHLORINATION: Type ijMe 15 —Amount Gu If additional space is needed use back of form
13.-CASING:
Wall Thickness LOCATION SKETCH
Depth Diiarnater w WelghVR. Malenal (Show direction and distance from atleast two State
FromTo6 s Ft. 6 4 _15)) F-�— �L Roads, or other map reference points)
From To Ft.
From To Ft. ;'� IrOrq�.Rnrl t
14. GROUT:
Depth Material + Melh4d �I
From O To AR Ft. he,+ f.etne.tl
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From _To Ft in. _ In. -
From To _ Ft. _ In. _ In. K? \
From _ To _ Ft. _ in. _ in.
16. SAND/GRAVEL PACK: i
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 h
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY �. O6
Quad No: NATURE OF PERSON CONSMUCtIO& THE WELL DATE
Submit originalto Division of Water Quality, Groundwater Section within 30 days
Serial No. GW-1 REV. 12/99
4

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section ') '
1636 Mail Service Center- Raleigh, N.C.27699-1636-Prone [phone] 1 4.15 6'7 8
WELL CONSTRUCTION RECORD WELLCONTRACTOR: Lnles Ca )Y.
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Chock Applicable Box): Residential ❑ Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: Show ketch of the location below) ('
Nearest Town:il-SI E County: tti e✓ Y
fL
and Lot
3. OWNER
Address
1(t51 LlYj NC g3
City or Town Slate Zip Code
4, DATE DRILLED - -D
5. TOTAL DEPTH Y R 5
6. CUTTINGS COLLECTED YES ❑ NO
7. DOES WELL REPLACE EXISTING WELL? YES j j7 NOE]
8. STATIC WATER LEVEL Below Top of Casing: f�i5' FT.
(Use'i If Above Top of Casing)
9. TOP OF CASING ISFT. Above Land Surface'
'Top of casing terminated atlor below lend surface requires a variance In accor-
dance with 15A NCAC 2C .01 t e
10. YIELD (gpm): 2 � METHOD OF TEST Q f I
11. WATER ZONES (depth):
12. CHLORINATION: Type P s Amount I Cu
13, CASING:
DRILLING LOG
From To
© if o
Ito 4.), S'
DEPTH
Fonnadgn Description
Sri
-n
m�
U
c�
It additional space is needed use back of form
Wall Thickness
LOCATION SKETCH
O
Depth
I 10
Di teror weightlFt. M"?nlet
�-
(Show direction and distance from at least two State
From
To
Ft.
-u--�`=
Roads, or other map reference points)
From
To
Ft.
From
To
Ft.
I'
14,
GROUT:
Depth
Material ethod 11
From —0 To 20
Ft,
Vle4 f e.nnen� n.d
15.
From
SCREEN;
To
Ft.
Depth Diameter Slot Size Material
�I e'er e r,kt n S
From —To
—Ft—
In. —in
�d
From
To _ Ft.
_ In. — In.
From _ToFt,
in. — in.
16.
SAND/GRAVEL
PACK:
{-o
Depth
Size Material
From
To
Ft.
From
To
Ft.
17.
REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 20, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY QF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Quad No:
S ATUI
Submit odglrlal Qrvls6
Serial No.
- -
rlj(
LQA. LPL-tt�YY�A . Li 1 , _ D _ 6 p
OF PERSON CONSTRUCTING TH9 ViELLYDATE
of Water Quality, Groundwater Section within 30 days
GW-1 REV, 12/99
z

1
North
Carolina - Department of Environment and Natural Resources -Division or Water Quality •Groundwater Section 5 U 6
1636 Mail Service Center - Raleigh, N.C. 27699-163612hone [phone]
WELL CONSTRUCTION RECORD WELLCONTRACTOR: TIG rnea r Jr�
WELL CONTRACTOR CERTIFICATIONS: 1
STATE WELL CONSTRUCTION PERMITS:
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: I t Fv r`ko W County: ^ � ✓ Y a
(Road Name and Uumbers, ommuniry, or Subdivi on and Lot No.)
DRILLING LOG
DEPTH
3.
1
OWNER V)ArJ L. He I✓1
From To
Formation Description
Address S t . ,�
a 48
' 0.Ka
orlmoufNo.
f S �{oS
c�nsolldw
yoc�
RIAAtzZgeei
dg 3
r.
City or Town Stale Zip Code
CD
4.
DATE DRILLED-
5.
TOTAL DEPTH u_ /.,
6.
CUTTINGS COLLECTED YES[] NO
--
7.
DOES WELL REPLACE EXISTING WELL? YES (—I N05�
8.
STATIC WATER LEVEL Below Top of Casing: 5b 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.01118 ,
—.
10.
YIELD (gpm): 1' METHOD OF TEST ell v
11.
WATER ZONES (depth):
12. CHLORINATION: Type
13. CASING:
Depth,' m Diam ter
From D To FL
From To Ft.
From To Ft.
14. GROUT:
Amount It additional space is needed use back of form
Wall Thickness LOCATION SKETCH
or Weighl/Ft. Material (Show direction and distance from at least two State
SDK a I PVC _ Roads, or other map reference points)
Depth Material l etho
From O To 20 Ft. Ea CCV✓�et� n
From To Ft.
15. SCREEN:
Depth Diameter
From —To _ Ft in.
From _ To — Ft. _ In.
From _ To _ Ft. _ in.
16. SAND/GRAVEL PACK:
Depth Size
From To Ft. —
From To Ft.
17. REMARKS:
Slot Size Material
_ in.
In.
in.
Material
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY(/p���THIS RECORD HAS BEEN
N PROVIDED TO THE WELL OWNER.
RJR OFFICE USE ONLY *LL'med— 4d ` a4"l2JI `� 1 ,5 6 0
Quad No:
Serial No
- St ATURE OF PERSON CONSTRUCTIfi. THE WELL
Submit original to Division of Water Quality, Groundwater Section within 30 days
DATE
OW-1 REV. i?J99

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section 2 15 675
5
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELLCONTRACTOR; S �J Cam r T .
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Boa): Residential56 Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: Sh`oV sket ofltlhe location below) ��
Nearest Town: IA rr'tP� ro YO ✓� County: Ru PY YL{
(Road Name antlLJurtlhers, Ctommuni��r Subdivision and Lot No.)
3. OWNER 0 Yb Y'—
Address �2� D� - I _.. _.. P I
City or Town Stale Zip Code
4. DATE DRILLED I _X -DO
5. TOTAL DEPTH Q�S
6. CUTTINGS COLLECTED YES NO©
7. DOES WELL REPLACE EXISTING WELL? YES [0 NOF-1
8. STATIC WATER LEVEL Below Top of Casing: '75-_ Fr.
(Use's if Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface'
-Top of casing terminated allor below land suAace requires a variance In accor-
dance with 18A NCAC 2C .0118
10. YIELD (gpm): 20 METHOD OF TEST a 1 r
11. WATER ZONES (depth):
Agricultural ❑ Monitoring ❑
DRILLING LOG
From To
o III
Ilo�9.5
DEPTH
ormalion Description
s
O
v
n�
N
m:�
o
zr
-+
0
12. CHLORINATION: Type PdletS Amount r;w It additional space is needed use back of form
13. CASING:
Wall Thickness LOCATION SKETCH
Depth D�i�amoter or Weight/Ft. Material (Show direction and distance from at least two Stale
From �% To 1 10 Ft.-G�Gy-- S pp -Al -P V C_ Roads, or other map reference points)
From To Ft. X
From To Ft.
14. GROUT:
Depth Material Metho po
From _p To 2,12 Ft. V�e"t �-PMek"
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. I d 9
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
I H��L- AS BEEN PROVIDED TO THE WELL OWNER.
/^ oil /N
FOR OFFICE USE ONLY k Y - 4k J) gn �' % 0-OD
Quad No: - - SIC#ATURE OF PERSON CONSTRUCT114G. t4 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 Sacco i'i5680
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone] _0-
—L
WELL CONSTRUCTION RECORD WELLCONTRACTOR: __jMf)5 Pe � �
WELL CONTRACTOR CERTIFICATION —: z j a g
STATE WELL CONSTRUCTION PERMITC
1.
WELL USE (Check Applicable Box): Residential EY Municipal ❑
Industrial ❑
Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other
If Other, List Use:
2.
WELL LOCATION/Y SShQ�} sjc tch of the location below) '�
�e
f
Nearest Town: 1 -r I TTsr County: '�`
v<tFr 1�v 9 a
iilniy
(Road N and Numbers, Cy nvnunity, or Subdivision and Lot No.)
DRILLING LOG
DEPTH
3.
OWNER ter% W S cy LlA Q S
��
From To
ort+, Dascnpti1on
Address
O Li S
i r� 0.nd
Cll�f�5; �e Streetcr C o. �qo oz�}
14 36S
cr nso ' a d r�
City or Town �1 Stale Zip Code
4,
DATE DRILLED ! —aY
5.
TOTALDEPTH t
6.
CUTTINGS COLLECTED YES Q NO®
o
7.
DOES WELL REPLACE EXISTING WELL? YES No[:]
r— _
B.
STATIC WATER LEVEL Below Top 9� of Casing: lori FT.
9.
(Use'✓ It Above Top of Casing)
TOP OF CASING IS FT. Above Land Surface'
rn -
'Top of casing tuminated atior below land surface requirea a variance In accw-
rq
dance
with 15A NCAC 2C .0119
im
10.
YIELD (gpm): _2, METHOD OF TEST ct t v
11.
WATER ZONES (depth):
M
cJ7 u
12.
CHLORINATION: Type s Amount
It additional space is needed use back of form
13. CASING
Depth Di etar
From U To � FL low
From To Ft.
From To Ft.
14. GROUT:
Wall Thickness LOCATION SKETCH
or w9IghVFt. Material (Show direction and distance from at least two State
SD)2P,1PVC_ Roads, or other map reference points)
Depth Material Method
From O To ao FL PtfcC� C Evne r a v
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
CI
1 `e 1 5 C Y"
_ _x
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPYDf THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER,
FOR OFFICE USE ONLY LZlyted -
Ouad No: SI,ATURE OF PERSON CONSTRUCTIN THE WELL DATE
--- -#. _ Submit original to Division of Water Quality, Groundwater Section within 30 days
Serial No. ,�;
OW-1 REV. 12199

North Carolina - Department of Environment and Natural Resources - Division of Water Quality- Groundwater Section r t~ C
1636 Mail Service Center- Raleigh, N.C. 27699-1636-Phone (919) 733-U91 --� A, j 0 U
WELL CONSTRUCTION RECORD WELLCONTRACTo Cs to 7Y -
WELL CONTRACTOR CERTIFICAY10140:
STATE WELL CONSTRUCTION PERMITN:
1. WELL USE (Check Applicable Box): Resldential Ea� Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION Sow sketch Q( the location below)
NearestI�mn P V {or d_`�o v County: _Rail e V'(o ✓(i
(Road Name drid NurnoeM. Co unity, or Suhdivision and Lot No.)
DRILLING LOG
DEPTH
3.
OWNER .2t
From To
Fo'(''anon
Dascnplion
Address (� O I
D 45
Y't.
0. V e'
ff
L'I f r51(�e , IV C outs d. a9n;_4
-r �j r-/Dj
Z�nSo I a nC
City or Town n �} State Zip Code
4,
DATE DRILLED
5.
TOTAL DEPTH
"-_
6.
CUTTINGS COLLECTED YES❑ NO®
='c
7.
DOES WELL REPLACE EXISTING WELL? YES D NO®
"--
8.
STATIC WATER LEVEL Below Top of Casing: FT.
fz rm
-�Z
(Use'*' It Above Top of Casing)
1 -
9.
TOP OF CASING IS FT. Above Land Surface
'Top
of casing terminated at/or below land surface raquirea a variance In accor-
--
N
dan
dance
with 15A NCAC 2C ,e 18
m
10.
YIELD (gpm): METHOD OF TEST Q I ✓
t=) "
11.
WATER ZONES (depth):
12.
CHLORINATION: Type —Ae
l l e1 s —Amount C u
If additional space is needed use back of form
13,
CASING:
Wall Thickness
LOCATION SKETCH
Depth
� 5
Diameter or Wel hl/Ft. Malenal
(Show direction and distance from at least two State
From
To
Ft.
L Z4 Q P, Al PV t-
Roads, or other map reference points)
From
To
FL
From
To
Ft.
14.
GROUT:
z J
M trial Motho \
/ x
YDepth
From�
To ao
Ft
hCe
-heat
�
From
To
Ft.
15.
SCREEN:
Len -I rn 611 ��
Depth
Diameter
Slot Size Material
\
,'
({
From —To—Ft—
In. _ In.
From
To Ft.
In. In.
�
From —To
FL
in. _ in.
16.
SAND/GRAVEL PACK:
Depth
Size Material
\ �"
From
To
Ft.
From
To
Ft.
17.
REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY F THIS RECORD/HAS BEE PROVIDE \ 0 THE WELL OWNER.
FOR OFFICE USE ONLY //t/ • f! n 4, �' [o - 00
Quad No: I NATURE OF PERSON CONSTRUCTING HE'�&- DATE
Submit origlnal to Division of Water Quality, Groundwater Section Within 30 days
Serial No. I L .. OW-1 REV. 12199
l'`I(_

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section !- ,i 5 6 ( 2
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone] WELL CONSTRUCTION RECORD WELL CONTRACTOR: f �a M e 5 (�. �0.m4 J r.
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential 19 Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other If Other, List Use:
2. WELL LOCATION: (Show ��kettchof the location below) k T`ie ry-e ✓d
Nearest Town: County:
IdB i ke P?IdJ-
(Road Name and umbers. Community, or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER Ay 2naan From To Formation Description
Address D CA 5-6
/4s�e ;Ile realer eC NO.)av18 8
City or Town �y Slate Zip Code
4. DATEDRILLED
5. TOTAL DEPTH C S
6. CUTTINGS COLLECTED YES Q NO[M o
7. DOES WELL REPLACE EXISTING WELL? YES E] NO[K B. STATIC WATER LEVEL Below Top of Casing: 1[5 FT.
(Use -+' if Above Top of Casing) ')
9. TOP OF CASING IS Fr. Above Land Surface- — o
m
-Top of casing terminated error below land surface requires a variance In accor-
dance with 15A NCAC 2C .011a I-�
10. YIELD (gpm): JU METHOD OF TEST at ✓
11. WATER ZONES (depth):
n
I o
12. CHLORINATION: Type Amount J GT If additional space is needed use back of tormpq 3
13. CASING:
Wall Thickness LOCATION SKETCH ---
Depth Diametar "Weight/Ft. Mat rial (Show direction and distance from at least two State t
From D To f_ Ft. '1 '4 5�_I ` Roads, or other map reference points) 1O
From To Ft. -
From To Ft.
i
14. GROUT: r e
Depth Material Method_-
From (9 To Ao Ft. t' 111 K
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft In. In. c.
�G +'
From To Ft. _ In. — In. ! �,
From —To Ft. in. in. /
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
i
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
S BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY 71 . c UU
Quad No: SIG ATURE OF PERSON CONSTRUCTING T E WELL DATE
Submit original t ivislon of Water Quality, Groundwater Section Within 30 days
Serial No. GW-t REV. 12/99

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section 4 I j 3
1636 Mail Service Center - Raleigh, N,C. 27699-1636-Phone (919) 733-=t
WELL CONSTRUCTION RECORD WELL CONTRACTOR: J es �- Caws t�✓
r�
WELL CONTRACTOR CERTIFICATION #: Z 1,35
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Boa): ResIdenbai 03 Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other If Other, List Use:
2. WELL LOCATION: (Show sk lch} of the location below)
Nearest Town: VkAllP✓ Yn'i'Oh County: 'y I)L 1t2Y r
4qo ays C✓eek (t'� Ra -Slbiln
(Road Name antl Nu ers, Co"�' nity, or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER N)e✓ l From To Formation Description
Address L}qp (�✓AJS C�. �� D '%C I aJe
T7 .0 ( I t1(8iree oorrib�ldo. n I a D �r;.7� CD Sn c c
City or Town Stale Zip Code
4. DATE DRILLED
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES Q NON
7. DOES WELL REPLACE EXISTING WELL? YES E;;� NOF-1
8. STATIC WATER LEVEL Below Top of Casing:_ FT.
(Use'+' If Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface.
'Top of casing terminated actor below land surface requires a variance In accor-
dance with 15A NCAC 2C .0118
10. YIELD (gpm): -;20-METHOD OF TEST C"
11. WATER ZONES (depth):
12. CHLORINATION: Type I 6cdlet Amount —
13. CASING: a�
Wall Thickness
Depth Diameter or Weight/Ft. Material (St
From. To 90 Ft. &A �- -
From To FL
From To Ft.
14. GROUT:
Depth
Material
Meth
From - f9
To Ft.
Nfa e- Wye
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
CI^µ1` w
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 ri �}a4W_A_ 40- � r OT- 1 on
Quad No: $I TURE OF PERSON CONSTRUCTIN E WELL DATE
Submit original to Division of Water Quality, Groundwater Section within 30 days
Serial No. rv_ GW-1 REV. 12199

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section I"' 1 J 6 G U
1636 Mail Service Center - Raleigh, N.C. 27699.1636-Phone (919) 733-=l
WELL CONSTRUCTION RECORD WELLCONTRACTOR: JiXWleS (wirnl�..�1
WELL CONTRACTOR CERTIFICATION p:
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: '/ (Showsketch of the location below)
Nearest Town: /' kA. r(e L!Are_ County:
)8,3 SuLSei I-amC.I iPY OIV 11
(Road Name and
Nu ers. C nity, or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER l')D 1 \SOVdII- From To Formation Description
Addressg�
8 �j �j v Yt5 I A{'t �' 0 Yt 0.
City or Town Slate Zip Code
4, DATE DRILLED
5. TOTAL DEPTH Z4E
6. CUTTINGS COLLECTED YES NO®
0
7. DOES WELL REPLACE EXISTING WELL? YES E] NO® ,
8. STATIC WATER LEVEL Below Top of Casing: 41�' FT.��:
(Use'+' It Above Top of Casing)77
9. TOP OF CASING IS FT. Above Land Surface*
T -
-Top of casing terminated attor below land surface requires a variance In acoor- _1
dance with 15A NCAC 2C .yy1�19 s c
10. YIELD (gpm): /L) METHODOFTEST mil✓
11. WATER ZONES (depth):
O -+
12. CHLORINATION: Type Amount L u It additional space is needed use back of lorm
13. CASING:
LOCATION SKETCH
Wall Thickness
Depth _ Diameter or waighUFt. Material (Show direction �and distance from at least two State
From - (2—To 1t)- Ft. -11 Y4— -5PP.2,L Roads, or other m 1p reference points)
From To Ft, r�
D
From To Ft. �12S.-��
14. GROUT: ,
Depth M terial Method
From To 21L9 Ft. Yle0. Ce nwtl� (tan �)��4` _
From To Ft. -
15. SCREEN: x
Depth Diameter Slot Size Material
From —To—Ft— in. _ In. —
From —To —Ft. — In. —In. �o`XO L rV_
From —To —Ft. in. —in. I,a
16. SAND/GRAVEL PACK: \
Depth Size Material µsT `^ 1d
From To Ft. r
From To Ft.�— i
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER,
FOR OFFICE USE ONI Y . .. `q L �' i 10 U
Quad No: i[ i {� 1 1 i s SJ�T;+N?l'A RE OF PERSON CONSTRUCTING T E W L —DATE
�;...$uWrrllan�rtg11Q.1'lision of Water Ouality, Groundwater Section within 30 days
GWA REV. 12199
Serial No. ; I

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section 1 J 6 V
1636 Mail Service Center - Raleigh, N.C. 27699.1636,Phone [phone] ff 11
WELL CONSTRUCTION RECORD WELL CONTRACTOR: a es w• Cam T
WELL CONTRACTOR CERTIFICATION p: ;;z 13
r, STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential Lfa Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: Sho sketc of the Vocation below) 7 { ('
Nearest Town: a ^ e �' Y d i��^-- County:
n f��✓� PY iD r
N164Ie rYe�k a - Gre�� l nWlvtA.
(Road Name And Numbers, Cc"�"�nity, or Pubdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER F i A F I SeI�Y From To Formation Description
Address �(t.((A �1�AYYtr7Y Y. D )2-5 SA.n IfAVC1
Dote o. a g I.2 3
Yd >1 IV �Q - -—
C or Town State Zip Code
. DATE DRILLED (7
--%5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES Q NO®
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NOF c,
8. STATIC WATER LEVEL Below Top of Casing: fps, FT. o
(Use Y 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): _1IQ METHOD OF TEST eA l ✓
11. WATER ZONES (depth): v rr
12. CHLORINATION: Type PC llot6 Amount If additional space is needed use back of form
13. CASING:
Wall Thickness LOCATION SKETCH
Depth �
Dialm/,e�ter orWeight/Ft. Material (Show direction and distance from at least two State
From _--�—To _J ZL Ft. Buz-- < D P_.�2,1 —R-y Roads, or other map reference points)
From To Ft.
From To Ft. f1K
14. GROUT: /vr ,� 7I
Depth Materialetho L� eew d_ mm J--�-- ---
From To —,L—Ft. )'rd f CPV41el ) t�
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From _To_ Ft in. —In. 1e
From _ To Ft. _ In. _ In.
From —To —FL _ in. in. }e C
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 0 THIS RECORD HAS BEE PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY G' -OD
Quad No: - $IG I TURE OF PERSON CONSTRUCTIN THE VELL DATE
Submit drfginal ivisfon of water Quality, Groundwater Section within 30 days
Serial No. GWA REV. 12/99
y

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
r'156'74
1636 Mall Service Center - Raleigh, N.C. 27699-1636-Phone (919) 73S-3221
WELL CONSTRUCTION RECORD WELLCONTRACTOR: GTmeS W Caw p T✓
T-+-
WELL CONTRACTOR CERTIFICATION#: 'RI��
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential6_( Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (S''hplw sk/e1tch of the location below) .�% r
Nearest Town: +Ile ^r-^ � �++t�F County: p'a r n e Y h' ✓
(Road Name and Numbers. Community. or Subdivision and Lot No.)
3. OWNER &IeT i.J;vte-
Address IhnA " tN urns
City or Town' Slate zip ucce
4, DATE DRILLED �-00
5. TOTAL DEPTH o—T 5
6. CUTTINGS COLLECTED YES❑ NOQ
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO[2g
8. STATIC WATER LEVEL Below Top of Casing: -z_ Fr.
(Use'✓ II Above Top of Casing)
9. TOP OF CASING IS Fr. Above Land Surface.
'Top or using terminated at/or below land surface requires a variance In accor-
dance with 15A NCAC 2C .011 a
10. YIELD (gpm): AT METHOD OF TEST Q-I Y
11. WATER ZONES (depth):
12. CHLORINATION: Type-I"""-AmountI cap
13. CASING:
DRILLING LOG
DEPTH
From To
Formation Description
b 40
A Ir t. q re")-
f{-O (o 015
D vt'; a eel
r c r-
CD
a> _,
n
�c
(71
r_fTt
ma
O
—r
It additional space is needed use back of form
Wall Thickness
Depth oiiam�r or WeighVFt. Material
From-0 To —Ft. —per— p P, _� I — G
From To Ft.
From To Ft.
14. GROUT:
Depth Material Metho
From To .20_ Ft. joe-af CtfWf.-s1
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From _ To _ Ft _ in. —in
From —To _ Ft.— In. — In.
From _ To _ Ft. _ in. _ in.
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
17. REMARKS:
LOCATION SKETCH
(Show direction and distance from at least two
Roads, or other map reference points)
74A
V_� ,
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COP(YY JQFF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY y' A' r�a4 n g 10
Quad No: - S ATURE OF PERSON CONSTRUCTIN HE WELL DATE
Submit original to Division of Water Quality. Groundwater Section within 30 days
Serial No. GW-1 REV. 12/99
[_µYZ

t' A it [ pp n
North Carolina - Department of Environment and Natural Resources - Division of Water Quality. Groundwater Secti 6 n 1. 3
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone] ) T"t Me 5 m r,
WELL CONSTRUCTION RECORD WELL CONTRACTOR: A S , ac ne.
WELL CONTRACTOR CERTIFICXTION k: 13
STATE WELL CONSTRUCTIONPERMIT1i:
1. WELL USE (Check Applicable Box): Residential Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection Other If Other, List Use:
2. WELL LOCATION- S w
f� NearestTown: ly%l}n,
kl_ County: i?u �4 e ✓
(Road Name and Numbers, Co��I unity, or Subdivi�and Lot No.) DRILLING LOG
3. OWNER To_Me5 /r/u rAkY From To
Address .BOX
�rfp_U)V, �IPSrea or45 o. �`i a�{S
4, DATE DRILLED 7' l9-OD
5. TOTAL DEPTH 2 H 5'
6. CUTTINGS COLLECTED YES ❑ NOO
7. DOES WELL REPLACE EXISTING WELL? YES Q NO®
8. STATIC WATER LEVEL Below Top of Casing: J-5' FT.
(Use'+' If Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface'
-Top of casing terminated ador below land surface requires a variance In accor-
dance with 15A NCAC 2C .0118
10. YIELD (gpm): 15- METHOD OF TEST 6r i ✓
11. WATER ZONES (depth):
DEPTH
Foron Descriptlon
SA -ill, & 16L
l�'11 Sc /�,dafeci !'oe
0
C1 --
D
-71
rn _-
a
u1
r,
12. CHLORINATION: Type 5 Amount jam_ It additional space is needed use back of form
13. CASING:
Wall Thickness
Depth Diameter or Welght/Ft. Material
FromTO 'S Ft M 5 D P q Jc.
From To Fl.
From To Ft.
14. GROUT:
Depth Material Method
From To 90 Ft. A eat C' N hie n�AOD
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From —To—Ft— In. _ in.
From To Ft. _ In. — In.
From _To Ft. — in. _ in.
16. SAND/GRAVEL PACK:
- Depth Size Material
From To Ft.
From To Ft.
17
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, dr other map reference points)
t'
�.� (Oxe Rj .
�u'n 1C' 9 1
.I of
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF TNIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY `
Quad No:.....-oSiGNI�
Poll In �di
Serial No. I
AUG
OF PERSON CONSTRUCTING T E W L DATE
of Water Quality, Groundwater Section 1t ithln 30 days
GW-1 REV. 12/99

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699.1636-Phone [phone] II r_ ,-_C UC� Q
WELL CONSTRUCTION RECORD WELL CONTRACTOR: es W- amn �✓ V
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential OLl Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show s etch
Nearest Town: aP It n r
9oq Race PeL
(Road Name and Nu om Commu ity
3. OWNER
Address qo 6l Race
of the location below) r7u��e✓'IvYY4
n County: KK
or,Subdivision and Lot No.)
city or %own oram `•v "---
4. DATE DRILLED 7_ /.9 - D C)
5. TOTAL DEPTH 14h
6. CUTTINGS COLLECTED YES ❑ NOF)Q �---y
7. DOES WELL REPLACE EXISTING WELL? YES Lb NO[]
8. STATIC WATER LEVEL Below Top of Casing: iko FT.
(Use'i II 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 ISA NCAC 2C. 116
10. YIELD (gpm): O METHOD OF TEST Al ✓
11. WATER ZONES (depth):
12. CHLORINATION: Type - e 5 Amount Oct
13. CASING:
DRILLING LOG DEPTH
From To Formation Description
Q J, Y
SrD I 5nDnsob'da-ted cock
L7
O
fJ
cn..
O
—i
It additional space Is needed use back of form
Wall Thickness
Depth
Dill am is or WaghVFt. Material
/ 0
Ft.
5 D R �L ✓C
From 19
To
-
From
To
Ft.
From
To
Ft.
14.
GROUT:
Depth
Material Metho
a K
From
To 90
Ft.
)1ecL _
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 I �j leK.XlOYD
Roads, or other map retererx:e points) GG,
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THISRECORDHAS BEEN PR VIDEO TO THE WELL OWNER.
/ I , . - . _ . ) / � l a A V - m
FOR OFFICE USE ONLY
Quad No: SIGI
--.__ Submit original to
Serial No. tt 33y�
OF PERSON CONSTRUCTING THE WELL
of water Quality, Groundwater Section within 30 days
DATE
OW-1 REV. 12/99
14 A

North Carolina • Department of Environment and Natural Resources - Division of Water Quality. Groundwater Section I 1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone] r,
<.13 970
WELL CONSTRUCTION RECORD WELLCONTRACTOR: _ �JAYVtr'_S W, l 'Y1,1 n �Y
WELL CONTRACTOR CERTIFICATION C
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Chock Applicable Boa); Residential 13al Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑ Recovery ❑ Heat Pump Water Injection ❑ Other 0 If Other, List Use;
2, WELL LOCATION: ho sket�+h of t'hfe location below)c , �,t
Nearest Town: U� IP r'7vyo Y r7�_County: !\�NlheY�YQ
(Road Name andrNumbers, C n munn , QrlSyhdlvWon and Lot No.)
3. OWNER�P.�S77ie zli/ddYS
Address D no X
City or Town Stale - Zip Code
4. DATE DRILLED G �� l " 00
5. TOTAL DEPTH —4�06----
6. CUTTINGS COLLECTED YES❑ NO®
7. DOES WELL REPLACE EXISTING WELL? YES O NO®
S. STATIC WATER LEVEL Below Top of Casing: �7,5-_ FT.
(Use': If Above Top of Casing)
9. TOP OF CASING IS�_ FT, Above Land Surface'
Top of using twminated ador below land surface nquiroa a variance in occwr
dance with 15A NCAC 2C .oils
10. YIELD (gpm): /2 METHOD OF TEST ar -
11. WATER ZONES (depth):
12. CHLORINATION: Type e 5 Amount C-ter
13, CASING:
d
Depth L�
' Wall Thickness
Diameter or Welghtt t. IviglanaJ
From
To
Ft.
46DP�2 VC
From
To
Ft.
From
To
Ft,
14. GROUT:
From 0
Depth
To 20
Ft,
V� atenal � -{ Malhoq
1JErif enl %Iq nA
From
To
Ft.
15. SCREEN
Depth Diameter Slot Size Material
From —To —Ft— In. —in.
From _ To _ Ft. In. _ _ in.
From _ To _ Ft. _ in. _ in.
16. SAND/GRAVEL PACK:
Depth Size Material —
From To Ft,
From To Ft.
17. REMARKS:
DRILLING LOG
From To
0 go
qD '210s
DEPTH
Formation Description
dirt C a
CO 50 JcLd %OGk
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)
Karl o
L
C
r—
"O
.a
w
_a R)Vcy
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:
Sena) No.
SIGNAMFIE OF PERSON
Submit original to Division of Water Dual
WELL
within 30 days
DATE
GW-1 REV. 12/99
O
fl

North Carolina • Department of Environment and Natural Resources - Division of Water Quality- Groundwater Saction
1636 Mail Service Center- Raleigh, N.C. 27699-1636-Phone [phone]
4.397$
WELL CONSTRUCTION RECORD WELLCONTRACTQR:
WELL CONTRACTOR CERTIFICATION 0: )
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Appilcabie Box); ReSldentfal Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, Usl Use:
2. WELL LOCATION:-rpGho�w,lsketch of +he location below) `r Jj
Nearest Town: ^kT`searlth rl,r11`-;l �7 County: ,`IA.�K�>'Tc (1
1\ VCf Ri ae �a Af l )ayk h.11
(Road Nameand mbrs. Co ily, or Su IvWon and Lot No.) DRILLING LOG DEPTH
r+
3. OWNER I l I Z From To Fonnatlon Description
Address � ' C I' M /J 57O J;dYotkr Sa n c�
,y) rea or os 1eC. as, j, ('c>a5o)1—ed Yo or\
1E
Lary or Town Stale Zip Code
4, DATE DRILLED � —AY - 0 O
5. TOTAL DEPTH 75300
6. CUTTINGS COLLECTED YES❑ NO[]
7. DOES WELL REPLACE EXISTING WELL? YE�NO®
8. STATIC WATER LEVEL Below Top of Casing: FT.
(Use'.' It Above Top of Casing)
9. TOP OF CASING ISM_ FT. Above Land Surface'
-Top *(casing terminated ■Nor below land surface requires a variance In accor•
dance with 15A NCAC 2C
10. YIELD (gpm): METHOD OF TEST !l f ✓
11. WATER ZONES (depth):
)) f nl
12. CHLORINATION: Type !e- 5 Amount II additional space 4s needed use back of form Ul c
13. CASING:
Wall Thickness
Depth
fiO
Diameter or Welght/Ft. Nalonal
/I P4 ✓r%
From
To
Ft.
-oRAl V
From
To
Ft.
From
To
Ft,
14. GROUT:
Depth
�O
M trial Metho
Vlea
From
To
Ft.
Cfhlrr
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. SANDlGRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
17. REMARKS•
LOCATION SKETCH
(Show direction and distance from at least two State
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OATHIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY 1,
Quad No: SIGH
Submit original to
Serial No.
UL e
L_
.� W. Lgj214 �kl - 2-/D - DO
OF PERSON CONSTRUCTING H LL DATE
of water Quality, Groundwater Section within 30 days
GW-1 REV. 12/99
0
ra
19

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section L. 1 j 9 6
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELLCONTRACTOR: 7u-4,'eJ5 I'j C�LW �•
WELL CONTRACTOR CERTIFICATION
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential E3 Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION (Show sketch of the location below) (� r
Nearest Town: r^�-he ut 1 E-- County: r\ �1 t eY fo Y
(Road Name and Numbers, Community, f�orr+ Subdivision and Lot No.)
3. OWNER SGLYVW yt_'�"6 I Y" j 012
Address I / /' I I. _... , _ 171
City or Town Stale Zip Code
4. DATE DRILLED
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES 0 NO[K
7. DOES WELL REPLACE EXISTING WELL? YES F-1 NO®
8. STATIC WATER LEVEL Below Top of Casing: FT.
(Use'.' It Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface -
'Top of casing terminated at/or below land surface requires a variance In accor-
dance with 15A NCAC 2C .0116 I
10. YIELD (gpm): 100 METHOD OF TEST A) ✓
11. WATER ZONES (depth):
Agricultural ❑ Monitoring ❑
DRILLING LOG DEPTH
From To Formation Description
D 'JD U'I0.yt Iff
tiG 24s P�✓Tlso/ dafe� rock
12. CHLORINATION: Type
e 5 Amount _� 1:45� It additional space is needed use back of form
13. CASING:
—
Wall Thickness LOG�AT,, N SKETCH
Depth
From To L� Z) Ft.
Diameter or Weight/Ft. Material (Show direction ;ddistance from at least two Slate
6A4 50U I PVC Roads, or over map reference points)
From To Ft.
` ¢
-
From To Ft.
14. GROUT:
% C
Depth
U
feral Method r_ Ma
From ToFt.
YlPli C erg ty
From To FL
:'� ,; -_ . _ .�
15, SCREEN:
Depth Diameter Slot Size Material
Ma
From —To—Ft—
in. ! ry
From To Ft.
—in.—
is
in. In. _ ,
�'� �'�' r
E3
z
From _ To Ft.
16. SAND/GRAVEL PACK:
_ In. _ in. • rf
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 OFF RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
THIS
Quad No:
SIG ATURE OF PERSON CONSTRUCTIN T E ELL
—
Submit original to Division of Water Quality, Groundwater Section within 30 days
Serial No.
awo REV. jtt/09

North Carolina - Department or Environment and Natural Resources - Division of Water Quality - Groundwater Section 213968
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELLCONTRACTOR: iEwe-s (� ����n -.T•
WELL CONTRACTOR CERTIFICATION
STATE WELL CONSTRUCTION PERMIT#:
1.
WELL USE (Check Applicable Box): Residential5/Municipal ❑
Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑
If Other, List Use:
2.
WELL LOCATION: (,Show ketch of the location below)
f
�I J
Nearest Tow 15ldC- County:
u l�r DY
(Road Name and Num77 hers, c-o-mom—unity, or Subdivision and Lot No.)
DRILLING LOG DEPTH
3.
OWNER wlbLL .J ,rule S((�
From To Formation Description
�7
Address 19,20 / e rlUun YD - l t'VL✓iC�c� /��
D DAD
00 O.
�D ?iG� /1UYt5olit�afe Yo ck'
go'/�
eve cY� 7
City or Town state Zip Code
4.
DATE DRILLED ,
5.
TOTAL DEPTH
6.
CUTTINGS COLLECTED YES Q NO[�Q
7.
DOES WELL REPLACE EXISTING WELL? YES Q NO
8.
STATIC WATER LEVEL Below Top of Casing: &�;- FT.
9.
(Use': if Above Top of Casing)
TOP OF CASING IS FT. Above Land Surface'
'Top of casing terminated atlor below land surface requires a variance In accor-
dance with 15A NCAC 2C .011 a ,
10.
YIELD (gpm): 10 METHOD OF TEST _ Z"L 1 Y
11.
WATER ZONES (depth):
12.
CHLORINATION: Type e 5 Amount tl
It additional space is needed use back of form
13. CASING
Wall Thickness
LOCATION SKETCH
D
Depth q
Dia ter or WelghuFl.
(Show direction and distance from at least two State
From
To I0
Ft.
VC,
-r�`i-- L VC
Roads, or other map reference points)
From
To
Ft.
x
�?
From
To
Ft.
C
C
ti
14.
GROUT:
_..
Depth
lanal { etho
ri
I
From O
To ,o
Ft.
MCI CemerU
5� y0J
From
To
Ft.
15.
SCREEN:
s
zo
Depth
Diameter
Slot Size Material
w
�z
rn-c
From —To—Ft—
in. in.
/r�
ry
From
To Ft.
in. _ in.
1 V `
C17
0
z
From
To _ Ft.
_ In. In.
16.
SAND/GRAVEL PACK:
t
Depth
Size Material
From
To—Ft.�
j 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 RECORD HAS BEEN PROVIDED TO THE WELL OWNER..
FOR OFFICE USE ONLY AJ'1LU- �dZdrtll
Quad No: SIGNATURE 11 PERSON CONSTRUCTING THEW LL
Submit original to Division o Water Quality, Groundwater Section within 30 days n y
Serial No. ��jiul?tREV.d�alb9
_ r}-'.,_. it 77tt
R

North Carolina - Department of Environment and Natural Resources - Division of Water Quality- Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699.1636-Phone [phone]
/1 ��
me19%�
WELL CONSTRUCTION RECORD WELL CONTRACTOR: _��a s It�, larvi0 IT.
WELL CONTRACTOR CERTIFICATION#: vi138
STATE WELL CONSTRUCTION PERMIT#:
WELL USE (Check Applicable li Residential W Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2.
WELL LOCATION: (Show sketch of the location below)
I
NearestTown: e- County:
bt- C Y
��
V Cj
II
`1�t7n�VYfrook oA edaYCK.
(Roatl Name an mbers,Corrvttunity, orlSubdl/y,�'6ion and Lot No.)
DRILLING LOG DEPTH
3.
OWNER 1, J r" j 0.I•t_ Lt � (t l f e lJo yt5t
•
From To Fonnadon Description
Address D)( Sf
tFD ;"r't
ree or outs o. y� o /
D t S Cc i a e
Yca,
ILY—
c�
4,
City or Town S5Zip Code
DATE DRILLED=4U
^
n
n�
5.
TOTAL DEPTH
C
c '
6.
CUTTINGS COLLECTED YES ❑ NO[ZJ
i ..
7.
DOES WELL REPLACE EXISTING WELL? YES NOCK
y
o
x�rr
8.
STATIC WATER LEVEL Below Top of Casing: FT.
(Use's If Above Top of Casing)
_
r
9.
TOP OF CASING IS I FT, Above Land Surface'
W
'Top of casing terminated aUor below land surface requires a variance In accor-
dance with 15A NCAC 2C,0118
10.
YIELD (gpm): 30 METHODOFTEST QfY
11.
WATER ZONES (depth):
12.
CHLORINATION: Type 5 Amount GN
If additional space is needed use back of form
13.
CASING:
Wall Thickness
LQC.ATION SKETCH
Depth Di tar a waighuFl. Material
�_
(Show direction and distance from at least two State
�)-r� V�
From To - .— Ft, -. DZI PVC
Roads, or other m
o J e-
From To Ft.
/ A,
From To Ft.
14,
GROUT:
Depth Material Malhop
From To , Ft, tie evt ky.0
15.
From To Ft.
SCREEN:
fo ay� rDO K
Depth Diameter
From _ To _ Ft In,
From To _ Ft, In.
From _To_Ft. in.
16. SANDIGRAVEL PACK:
Depth Size
From To FL
From To Ft,
17. REMARKS,
Slot Size Material,_
_ In.
In.
— in.
Material
4,1
Y
CK,
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF T IS RECORD HAS BEEN PROVIDED TO THE WELL OW�yNER.
FOR OFFICE USE ONLY (- �O -O D
Quad No: SIGN RE OF PERSON CONSTRUCTING HE LL DATE
Suomi) anginal to isio'of
Water Qu
Serial No.
ality, Groundwater Sadlon 30 days Within GW-1 REV, 12/99
L
i 0.P3 tit°/3t. �-

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Secgon
1636 Mall Service Center - Raleigh, N.C. 27699-1636-Phone (919) 7a3-=1
CONSTRUCTION RECORD WELLCONTRACTOR: .JL(Wte9 w• �amn JY.
WELL CONTRACTOR CERTIFICATION C
STATE WELL CONSTRUCTION PERMIT#;
Cr.. 4 3WELL
1. WELL USE (Check Applicable Box): Residential E� Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery C-] Heat Pump Water Injection ❑ Other If Other, List Use:
2. WELL LOCATION:L1Shgv,sketgtl of the location below) � �� r
Nearest Town: tCe`C'sjfoCounty:— k :� e✓'fat'
�\u
7�-� 6�erA 9// C'm,".
_
(Road Name and Num1 ,ham, Co/nvnuni y or Su Ivislonand LNo.) DRILLING LOG DEPTH
mol
3. OWNER hC5"�1pE ,Cjµ/��e Y3 From To Fprallon Description
Address `� f
(� D f 2 D CJi /
/� D b X S`E
or/Vt� %io�J .O i u r? YDC-
1-ltkC. l� h Tic
- L(✓Cjsree
City or Town / State Zip Code
v -'�3 - 00
4, DATE DRILLED
5. TOTAL DEPTH OS
6, CUTTINGS COLLECTED YES ❑ NO®
0
n
7. DOES WELL REPLACE EXISTING WELL? YES M NOF—_1
S. STATIC WATER LEVEL Below Top of Casing: 73 FT.
C ''
(Use'+' It Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface'
E; _-
'Top of using twminated atior below land surface roqulroa a variance In accor-
�
dance with l SA NCAC 2C,
10. YIELD (gpm): METHOD OF TEST _ a r v
11. WATER ZONES (depth):
W F11
rn�
12. CHLORINATION: Type e- 5 Amount Grt II additional space is needed use back of form
Z
13. CASING:
Wall Thickness LOCATION SKETCH
Depth 1� O olia filar W WeIghVFt. mattonal (Show direction and distance from at least two State
From—� —
To Fl. Roads, or other map reference points)
From To Fl.
_
From To Ft.
14. GROUT:
Depth Me Melho
fanal
n
From 22 To AQ, Ft. A C - t1C-L11L-
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material LLII
I
co min
From —To Ft in. —In. f^L' yl
,
From —To Ft,_ in. —In.
From _To FL_ in. _ in.
16. SAND/GRAVEL PACK: �1(
C �7 A
Depth Size Material
5e�
?j9rcP
From To Ft. Ca,e
From To Ft.
17. REMARKS:
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL, OWNER.
FOR OFFICE USE ONLY
Quad No:
Sena) No.
SIGNVURE OF PERSON CONSTRUCTINCITHE WELL
Submit original to Division of water Quality, Groundwater section within 30 days
- 45 -oo
DATE
ow-1 REV. 12/99

North Carolina - Dapanment of Environment and Natural Resources - Division of Wafer Quality - Groundwater Section
1636 Mall Service Center - Ralaigh, N.C, 27699-1636-Phone [phone] � } rD sr .r
WELL CONSTRUCTION RECORD WELL CONTRACTOR: rne5 w C'Al Ot—'�----_�
WELL CONTRACTOR CERTIFICATION p•. J
STATE WELL CONSTRUCTION PERMITN: '-
1. WELL USE (check Appllcabie Box): Residential Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑ Recovery ❑ Heat Pump Water Injection ❑ Other If Other, List Use:
2. WELL LOCATION: ho�j sketch Qf he location below)
Nearest Town: u76t eC `�Yri I vv County: U 4C'Y Y
) L� rtVh,ai42it-, Pa
2:A
s,Commw, ity,oS bdivislo�q/Jand Lot No.) DRILLING LOG DEPTH
3. YV1C Yl C �i'YL' o` atlo Dascn tlon
,,t1Fram To 7("" PLiI�
ree or o le
+�. E a91 z'g 5 CoYtsnl k>c d ror
City orTown Stale
4, DATE DRILLED l _2 1 - C 0
5. TOTAL DEPTH 20 ti
5. CUTTINGS COLLECTED YES ❑ NO®
7. DOES WELL REPLACE EXISTING WELL? YES O NO®
S. STATIC WATER LEVEL Below Top of Casing: _� FT.
(Usa'.' If Above Top of Casing)
9. TOP OF CASING lS FT. Above Land Surface'
Top of casing twminsted atior below land surtace requires a variance In actor.
dance with 15A NCAC 2C ,0118
10. YIELD (gpm): LLD METHOD OF TEST 4,11 Y
11. WATER ZONES (depth):
12. CHLORINATION: Type mount C,u
13, CASING:
Wall Thickness
/1 Depth Diameter or Wolght1l t. Material
From To Ft..(� 14 5PPAI •pvc-_
From To Ft.
From To Ft. _
14. GROUT
If additional space is needed use back of lorm O
LOCATION SKETCH C—
C
(Show direction and distance from at least two State r
Roads, or other map reference points) v
1
Depth Material atho
��'', ,LL,
From To �.F[. l Gem �YCC'YYtarl(� 'K C.I) ti
From To Ft. �d ?
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
x
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 20. WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF HIS RECORD /HASH BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Quad No: SIGN. URE OF PERSON CONSTRUCTI G THE WELL DATE
Serial No. Submit original to ivislon of Walar Quality, Groundwater Sedlon Within 30 days
OW-1 REV. 12/99
e Litye

North Carolina - Department of Environment and Natural Resources - Division of Water quality -Groundwater Sectyon s: 1 95 f(
7636 Mail Service Center •Raleigh, N.C. 27699-1636-Phone [phone] Ca nip 5 itii Fj,
WELL CONSTRUCTION RECORD WELLCONTRACTOR: IA)I`te5 fit) Cayy(/p Jr
WELL CONTRACTOR CERTIFICATION If: 21 -3 o
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential U Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below) Iy'�I
Nearest Town, - ✓ cL County: 4 vl ' I (e � L r
liy k oy- C'_K. �Inrn_ off lrerry R
(Road Name and umbers, Community, or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER = ieL!^A�- t`J , a-k From To Formation Descdptiop
Address 3� ) iti`}tP r K Dr. _ U 7� i/ 5An 1
n/1 nv,=jwiaeto` oule FT. �G t i.1 'fJ el OG
n,.,�✓r, I�
City or Town State Zip Code
4. DATE DRILLED
5. TOTAL DEPTH
—
6. CUTTINGS COLLECTED YES 0 NO®
7. DOES WELL REPLACE EXISTING WELL? YENO®
8. STATIC WATER LEVEL Below Top of Casing: 17o FT.
(Use': it Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface'
'Top of casing terminated atlor below land surface requires a variance In accor-
dance with 15A NCAC 2C .0116
10. YIELD (gpm): 1_ METHOD OF TEST a I V'
11. WATER ZONES (depth):
12. CHL'ORINATION: Type l"I(' e _ Amount _
13. CASING:
Wall Thickness
Depth Diameter or WeighVFt. Material
FromTo Ft. �� �D t f
From To J Ft.
From To Ft.
14. GROUT:
Depth Mate al Method I
From 0 To 2QFt. ✓IeGi ('PVYIPh� (/tatrld
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 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 � ��%✓li rf l�• 4t4nfl F �
Quad No: SIGNATURE,& PERSON CONSTRUCTING THE E �
Submit original to OivisI6 of Water Quality, Groundwater Section within 30 day
Serial No. 1 fl .
?i1}2/99
_(
,,

C 1 0 ri
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: Ja vaej IZZ194 1 7y,-
WELL CONTRACTOR CERTIFICATION
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION• how ket i ,q(f the location below) (`
Nearest Town: �'Yec I County: �7U (CV oY
196 }i-cr`rc.ilins
(Road Name an—drN—umbers, Communi'tyf orj�uhdivlsion and Lot No.) DRILLING LOG DEPTH
3. OWNER _ ti1'1G ip Cili, , From To FonnationDes Snption
Address 'JA;i1 M /0
MI.,) 2d. 0 a Cil/t Sand
,.J� n (Street or outs o. (�C t OS [.DrvKo a e[ ✓oc-K
rt1DYe5i ! l� i\ r JRDg9
State Zip Code
4. DATE DRILLED
5. TOTAL DEPTH
—
6. CUTTINGS COLLECTED YES Q NO®
7. DOES WELL REPLACE EXISTING WELL? YES [0/ NOF_�
8. STATIC WATER LEVEL Below Top of Casing: k 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 varlance In accor-
dance with 15A NCAC 2C .011a
10. YIELD (gpm): � METHOD OF TEST 111 ✓
11. WATER ZONES (depth):
12. CHLORINATION: Type __ 62.Ile S Amount , rT If additional space is needed use back of form
13. CASING:
Wall Thickness
Depth Diameter or Weight/R. Material
From G To sPO Ft.
From To Ft.
From To Ft.
14. GROUT:
Depth I atenal Method
From To20 Ft. za zn cup
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 Slate
Roads, or other map reference eoints)
v
�
MO
n
ti
\
O
z
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Quad No:
Serial No.
sIG6ATURE OF PERSON CONSTRUCTRIG THE WELL ' i% tt3`ATr"
Submit original to Divislon of Water Quality, Groundwater Section within 30 days '- ..
OW-1 REV. 12199

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section 2, 13 9 ) 3
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: J_a hLeti (11W4 r r
WELL CONTRACTOR CERTIFICATION #: 2 l g
,.,
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential C,( Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION:,(Srhow sketch of the location below)
Nearest Town I: mt✓ tt Vie #C� County: t'✓�I'
Nt,e Cki- CowtviL, off`yir'Vv R
(Road Name and N�C
Numbers, Community, or Subdivision and Lot N ) DRILLING LOG DEPTH
I
3. OWNER _ IL{" ✓a U 1 % a From To Formation Description
Address cCk. RJlf/ ,�O
lreet r Mopte o. D �p`) enVlSo(,ria-ed Kock UDVES`Inin (,
City or Town / State Zip Code
4. DATEDRILLED
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: _o FT.
(Use': it Above Top of Casing)
9. TOP OF CASING IS _( FT. Above Land Surface -
'Top of casing terminated atlor below land surface requires a variance In accor-
dance with i5A NCAC 2C.0118
10. YIELD (gpm): :20 METHOD OF TEST Gi f ✓
11. WATER ZONES (depth):
12. CHLORINATION: Type PLIPt,Amount I Cut 1 If additional space is needed use back of form
13. CASING:
Wall Thickness
LOCATION SKETCH
Depth
or WeighVFt. Material
(Show direction and distance from at least two State
/l
From To 2
�Diameter
Fl..r zf--z—S 0 IZ 2l PVC
Roads, or other map reference points)
From To
Ft.
From To
Ft.
14.
GROUT:
o
Depth
l
MateriaMethod
pO
o
From �/ To ,20
Ft. Y e it Cewtertl�A fa n rl
e_
c N
C
O Y
From To
r—
cn
—Ft.
15.
SCREEN:
o.=
Depth Diameter Slot Size Material
From —To—Ft—
in. _ in.
v
x-
From To Ft.
in.
From To _ Ft.
—in.
in. In.
N
16.
SAND/GRAVEL PACK:
�
x
Depth
Size Material
From To
Ft.
From To
Ft.
17.
REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD �H`AS/ BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Quad No: SIG TURE OF PERSON CO Q�TH 'iVv LL DATE
Submit original to Division of Water Quality, ( w r �ycadd within 30 days
Serial No. OW-1 REV. 12199
11
AT
ga

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section J 9 5 V
1636 Mail Service Center • Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: )"tYVI e 5 LJ ( ct yv n r '.
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (check applicable Box): Residential [E Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELLLOCA'
Nearest Town:
(Road Name and
3. OWNER
Address
of the location below) County: U to If, 4V
Agricultural ❑ Monitoring ❑
or Subdivision and Lot No.)
DRILLING LOG
A Yt M
From To
c 55
Lt
e o.
G o l'tS
City or Town // State Zip Code
4. DATE DRILLED
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES 0 NO[4
7. DOES WELL REPLACE EXISTING WELL? YE�NOW
8. STATIC WATER LEVEL Below Top of Casing: FT.
(Use'.' it Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface'
'Top of casing terminated at/or below land surface requires a variance In accor-
dance with 16A NCAC 2C 0119 1
10. YIELD (gpm): ;rc> METHOD OF TEST a l K
11. WATER ZONES (depth):
DEPTH
Formation Description
5AAJ,An dirt
con5o dale L ZL
12. CHLORINATION: Type � e Amount LL If additional space is needed use back of form
13. CASING:
Wall Thickness LOCATION SKETCH
Depth //'' ,�, Dim ter or Weight/Ft. Mat rial (Show direction and distance from at least two State
From To .--6) 0 Ft. = .S.F)R.zt -a L Roads, or other map reference points) %
From
From
To
-To -Ft.-
Ft.
14. GROUT:
Depth
Materal Method
L ✓%=' '"
r C �F
From
To �D
Ft.
x� < Plrolert
v
r �_ ;
From
To
Ft.
-� J c�<
15. SCREEN:
D
Depth
Diameter
Slot Size Material
From
—To—Ft—
in. in.
\ t^?� rn
From
To _ Ft.
in. In.
T\3
From
Ft.
In.
—To _
_ —In.�-
16. SAND/GRAVEL PACK:
" I
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 HASBEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY / i D rl b) //""" /0 GO
Quad No: SIGNATURE OF PERSON CONSTRUCTIN THE WELL DATE
Submit original to Divislon of Water Quality, Groundwater Section within 30,days
Serial No. jl GW-1 REV. 12/99

,
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section < 1 3961.
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELLCONTRACTOR: 1prttyles 0. caW7a,Ty.
WELL CONTRACTOR CERTIFICATION
r—,ESTATE WELL CONSTRUCTION PERMIT#:
LY 1. WELL USE (Check applicable Box): Residential J Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ OtherEJ If Other, List Use:
2. WELL LOCATION: (Show
C"rsrkfmwlocation below)
NearestTowe
County:
�ov n
(Road Name and dNNumbers, Community, or Sub( Ision and Lot No.) DRILLING LOG DEPTH
3. OWNER I k(- r n r1 46iY ( i " II From To Formation Description
Address 401) � ight Rely, I oop
/ (Street or o to NO.
�Aninrt ��I;lls h��,
City or Town State Zip Code
4. DATE DRILLED � " GO
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES Q NOCK
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO[K
8. STATIC WATER LEVEL Below Top of Casing: p FT.
(Use'+' it Above Top of Casing)
9. TOP OF CASING ISFT. Above Land Surface'
?op of casing terminated at/or below land surface requires a variance In accor-
dance with 15A NCAC 2C.0118
10. YIELD (gpm): r METHOD OF TEST i
11. WATER ZONES (depth):
12. CHLORINATION: Type &J121S Amount _ If additional space is needed use back of form
13. CASING:
Wall Thickness
Depth
Diameter or WeighVFt,
Material
From
To .�.D
Ft. 4, �tP
L
From
To
Ft.
From
To
Ft.
14. GROUT:
Depth
Material Melho
From U
To 2-O
Ft. Yh,,roChtenfi
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:
LOCATION SKETCH
w direction and distance from at least two
Roads, or other map reference points)/�
�d
oo
\
L
�eJL _o`-
>
n "u
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY _ g �9 d 1_0
' Cw� A / " /0 `'9b
Quad No: Slfq ATURE OF PERSON CONSTRUCTI THE WELL DATE'
Submit original% Division of Water Oualily, Groundwater Section within 30 ii yS
Serial No. t t . GW-1 REV. 12199
LR,.

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section 13 9 G
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELLCONTRACTOR: Ian2e5 lit). (L T•
WELL CONTRACTOR CERTIFICATION #: �2 1 38
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential1i[I Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION -.,(,Show sketch of the,localion below)
Nearest Town: �a� (-d -to h County: I-\ to T IV Y` r: r(
�,;rc1Y1 ♦riPvt) ifz5 1 UNion RA
(Road Name and FFNumbers. Commjj��pity, or Subdivi ion and Lot No.) DRILLING LOG DEPTH
3. OWNER L.J bI ll l'. I (�YC d From To Fonnatippn Description
Address 61ert Dr1i✓C' 0 I�0 5ayt L{;;
_f (. tree[orhrfute. ' �•�D �3w5 (�/i Y15o �rtin to ci ✓n�k
City or Town Slate Zip Code
4. DATE DRILLED o C'
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES Q NO(]
7. DOES WELL REPLACE EXISTING WELL? YES 0 NO®
8. STATIC WATER LEVEL Below Top of Casing: 5�()— Fr.
(Use'+' it Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface'
'Top of casing terminated atlor below land surface requires a variance In accor-
dance with 15A NCAC 2C .0118 t
10. YIELD (gpm): METHOD OF TEST cl t r
11. WATER ZONES (depth):
12.
CHLORINATION: Type e ' Amount a
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 f210
Ft. (�n JDR D't tr L
Roads, oFelerenceomts
From
To
Ft.
v
From
To
Ft.
—�-
o
14.
GROUT:
`
�T
Depth
Material Metho
r—
From
To �Ft.
nJ
_Q
From
To
Ft.15.
SCREEN:Depth
Diameter Slot Size Material�?
From
To Ft
in. in.NFrom
To Ft.
in. in.N
From
To _ Ft._
In. in.16.
SAND/GRAVEL PACK:Depth
Size Material�{
- La yr e
From
To
Ft.
From
To
Ft.
17.
REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY JAoyy,4 �, ' as L o -
Quad No: SIG URE OF PERSON CONSTFIUCTI Ti­!ELL DATE,'_
Submit original to ivislon 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 13 9 6 `) 1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELLCONTRACTOR: iTArne6 1J. (?n wt n . I r.
WELL CONTRACTOR CERTIFICATION #: .�) 3 R
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential L.YJ Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Agricultural ❑ Monitoring ❑
Nearest T:
owre
l LL. ✓1 i D rL M 1 1 5 County: l\ K
j LI if Y
'f-o Y d
r"r
A iU A 1L'-
(Road Name an
Numbers. Commun�i�"" or Subdivision and Lot No.)
DRILLING
LOG
DEPTH
3. OWNER
}Nu�Ogey
From
To
Fonnadon Description
Address
�d}�JvX 11'ti`J
l]
AD
c'�irt.0
I
hn A
Snee or \rim S' 2 -) I
�
"��
iiG'YLSLIr �a �zd ✓UGk
City or Town State Zip Code
4. DATE DRILLED 6 -7-GD
5. TOTAL DEPTH 9l,05-
6. CUTTINGS COLLECTED YES ❑ NO®
7. DOES WELL REPLACE EXISTING WELL? YENO®
S. STATIC WATER LEVEL Below Top of Casing: D 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 .0119 r
10. YIELD (gpm): _1 METHOD OF TEST a l V
11. WATER ZONES (depth):
12. CHLORINATION: Type y) C lC Amount I ()-to If additional space is needed use back of form
13. CASING:
Depth Dianngtor
From To '32 Ft. & YU
From To Ft.
From To Ft,
14. GROUT:
Wall Thickness LOCATION SKETCH
w Welght/Ft. Material (Show direction and distance from at least two State
tip R 1t
1 e Roads, or other map reference points)
Depth
Material
Melho
From
To 2-0
Ft. 11LF l Ccmesll
1a
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
0
p
0
o
c
�> Ila'i3O
to
o
From To Ft.
From To Ft. -F a
17. REMARKS: n X
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF TfAS RECORD HAS B /
BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY LLL4i1 A VJ 1 cLWL11 I - ID -D n
Ouad No: SIGNATURE OF PERSON CONSTRUCTING T14E.Vy...._,.GATE
Submit original to Diwslon of Water Quality, Groundwater Section W(Ih Jl 3)tpay,Is
Serial No. n. I... GW it flEVi 12/0f. ! !
•�! a r;f Ij Ill 1
t

212192
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (check applicable Box): Residential ff/ Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATIO Sow S"tc of the location below
Nearest Town: /�2✓7a Y� �v ✓L County: LLLLLY
4731 L.D Ile_ Rol .
(Road Name and N/u/tubers, Community, or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER Kc el P.Y moo Ye From To Formation Description
Address )/' j) cove_ Rd. n 5� "rt
//_tilrou ��'1i/lf5tor o7VL A)/orl _�iR 'doe C�riso e Yoc-r�
City or Town Stale Zip Code
4. DATEDRILLED-40
5. TOTAL DEPTH ono
6. CUTTINGS COLLECTED YES ❑ NO®
7. DOES WELL REPLACE EXISTING WELL? YE�NO®
8. STATIC WATER LEVEL Below Top of Casing: FT.
(Use '+' II Above Top of Casing)
9. TOP OF CASING IS�_ FT. Above Land Surface'
'Top of casing terminated atlor below land surface requires a variance In accor-
dance with 15A NCAC 2C .0119
10. YIELD (gpm): _,L METHOD OF TEST Al Y
11. WATER ZONES (depth):
12. CHLORINATION: Type �JN-U13.ha Amount cu
13. CASING: I
Wall Thickness
Depth Diapter or Weight/Ft. Material
From G To 3 _ Ft. � c-
From To Ft.
From To Ft.
14. GROUT:
Depth N�aten Meth d
From �_ To _� Ft. / c�-t "LT
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
n
It additional space is needed use back of
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
X CJe-o
II16 Ck.pj.
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL 7
4/ ITtK
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Quad No:
Serial No.
r! -F'
SIGNATiAE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Quality, Groundwater Section within 30 days
GW-1 REV. 12199

Nonh Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section 212190
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: �w(ES �` �u t"�� '�✓
WELL CONTRACTOR CERTIFICATION #: aIJ
./
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) � 1
Nearest Town: e- "tv e- County: KL L`l "teY A
(Road Name and Numbers. Community or ubdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER qGt_O.mp S ("2f t -(-(i ✓- From To Formation Descn. tion
Address 4�7 0 u b �� © RC> `5rt
f )r I = (Street or ute o. n T w I qD �6 S' Co 5 D n e
City or Town State Zip Code
4. DATE DRILLED - DO
5. TOTAL DEPTH �/ S
6. CUTTINGS COLLECTED YES Q NO[K
7. DOES WELL REPLACE EXISTING WELL? YES Q NOFX]
8. STATIC WATER LEVEL Below Top of Casing: '3 o 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 surface requires a variance In actor.
dance with 15A NCAC 2C.0118
10. YIELD (gpm): r0 METHOD OF TEST al Y
11. WATER ZONES (depth):
12. CHLORINATION: Type e- l0 s Amount I CUP
13. CASING:
Wall Thickness
Depth Di er or Wei httR Mat rial
From O To 0 _ Ft.I `DK 11 ryc
From To Ft.
From To Ft.
14. GROUT
Depth M terial Method
From To _ U Ft. e e
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
O g
It additional space is needed use back of form
XLOCATION SKETCH
(Show direclio and distance from at least two State
Roads, or of . map reference points)
1�14A
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 TOO —THE WELL OWNER.
FOR OFFICE USE ONLY t +�) �''A [4) • c4tt � ,TA • Ca 51" G D
Quad No:
Soda] No.
SIGN URE OF PERSON CONSTRUCTINGfTH6 WELL DATE
Submit original to Division of Water Quality, Groundwater Section within 30 days
GW-1 REV. 12/99

1.12191i
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: �GIYylC5 bJ ^na.K, if Jr.
x WELL CONTRACTOR CERTIFICATION #: r9,13 S
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (check Applicable Box): ResidentiialLta Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION:
Nearest Town: —
location below)
V\� County: u f 6te Y y-o i
(Road Name and rmbe , Commpnity, qr Subdivision and'Lot No.)
3. OWNER 1 0.�I L11P5T
Address r, zI 1 ,,,.i;.', M:II RI
City or Town _ State Zip Code
4. DATE DRILLED S-aS-CD
5. TOTALDEPTH `-ZS
6. CUTTINGS COLLECTED YES 0 NO®
7. DOES WELL REPLACE EXISTING WELL? YES NOF-1
6. 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 15A NCAC 2C .0118
10. YIELD (gpm): ;aLMETHOD OF TEST a I r
11. WATER ZONES (depth):
12. CHLORINATION:
13. CASING:
Type __ 0011L Amount If additional space is needed use back of form
DRILLING LOG DEPTH
From To Fonnation Descnp'on
—T�/� qs d��t s�, I'Ll
"!S OS ('n YtSo i�r�a fe ri fOL
Wall Thickness
Depth
qS_
Diameter or Weight/Ft. Malgrial
From
() To
Ft. < SnRa) VCV —
From
To
Ft.
From
To
Ft.
14. GROUT:
Depth
L
MMaterfal Metho
T-Hea C
From
To _ ,0
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
LOCATION SKETCH )
(Show direction and distance from at least two State l
Roads, or other map reference points)
ir`�M',1�
Xn(ldkI L"w e"
C=-ivc� lothm.
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 I - 6,
Quad No: SIGNATURE OF PERSON CONSTRUCTINd TH . ELL DATE
Submit original to Division of Water Quality, Groundwater Section Within 30 days
Sena] No. GW-1 REV. 12199

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section 212187
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: 17AWes �J CA W p J ✓.
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (check Applicable Box): Residential [d Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ It Other, List Use:
2. WELL LOCATION: (Show
sketcnh I f�t5hefOcribelow)
Nearest Town: IDh TII
County:
CevL�eKn E- I RA .
(Road Name and Nu`'�ers, Co7unity, or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER T 1611 s l D Vl It e Y From To Formation Descnpt n
Address r �C, � ��.�a.0 (Ii✓t,)aK�
—(Street r outs o. j�0 �(oj �nfl5o�r �afcd ✓o L
S�IrICIaIE C �4Ilco
Ci y or Town Stale Zip Code
4. DATE DRILLED DO
S. TOTAL DEPTH (o
6. CUTTINGS COLLECTED YES Q NO®
7. DOES WELL REPLACE EXISTING WELL? YES NOM
8. STATIC WATER LEVEL Below Top of Casing: /n` FT.
(Use'+' it Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface*
'Top of Casing terminated atlor below land surface requires a variance In accor.
dance with 15A NCAC 2C A 1e
10. YIELD (gpm): METHOD OF TEST All'
Agricultural ❑ Monitoring ❑
11. WATER ZONES (depth):
12. CHLORINATION:
13. CASING:
Type NI a 5 Amount If additional space is needed use back of form =
Wall Thickness
LOCATION SKETCH
Depth n
Diameter or WeighVR. a nal
4 C �C'
(Show direction
and distance from at least two State
From
To --LC"'—
Fl.
Roads, or other
map reference oints)
From
To
Ft.
From
To
Fl.
I-(V� tiolt
14. GROUT:
From
Depth
To2,G1
Ft.
MethoQp
2aTckFne �laltcl
/
From
16. SCREEN:
To
Ft.
C�P Oef
pH�I�I l-e�CttVile
Depth
Diameter
Slot Size MaterialP
VV� Icy
From
To Ft
_ in. in.
From
To Ft.
in. — in.
From —To
—Ft.
in. —In.
16. SAND/GRAVEL PACK:
Depth
Size Material
14w t'
From
To
Ft.
From
To
Ft.
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY j W � � `+1 4 ' u? - 6 D
Quad No: SIGWkURE OF PERSON CONSTRUCTING(TFIE VIELL DATE
Submit original to Division of Water Quality, Groundwater Section within 30 days
Serial No. OW-1 REV. 12/99

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section 212186
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone] ll //��
WELL CONSTRUCTION RECORD WELLCONTRACTOR: Jc2VYlP5 W LaPl
WELL CONTRACTOR CERTIFICATION #: oZ I S
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (check Applicable Box): Residential u Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
Agricultural ❑ Monitoring ❑
2. WELL LOCATION: Shqw sk tch of the location below
Nearest Town: �-aKe �tiYc County: KA C,Y, Ic YJ
91Ld f`ak Drirf_
(Road Name andtubers, ComlmIuri , or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER Y� I G�qY O `A�!' 10. WlS From To Formation Description
Address) ! 0. 5cal l'LL S r. C� ( 0 dirt
u f �eY�arN neetor� C_ e. ASS 1' 9 COD 05 Gonso rock
4. DATEDRILLED 9-00
5. TOTAL DEPTH 0 5
6. CUTTINGS COLLECTED YES Q NO®
7. DOES WELL REPLACE EXISTING WELL? YES NO®
8. STATIC WATER LEVEL Below Top of Casing: � FT.
(Use'+' if Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface'
'Top of casing terminated attor below land surface requires a variance In accor-
dance with 15A NCAC 2C .0119
10. YIELD (gpm): 2D METHOD OF TEST A I r'
11. WATER ZONES (depth):
12. CHLORINATION: Type
Amount I LIAO
If additional space is needed use back of form
�m
13. CASING:
'•
LOCATION SKETCH Iv
!J7
Depth
Wall Thickness
Diameter or Weight/Ft. Ma`lf rial
(Show direction and distance from at least two Stale
i
From ��To (0D
,lt . c
Ft.� SIi12`
Roads, or other map reference points)
From To
Ft.
From To
Ft.
14. GROUT:
Depth
Material Metho
From �_ Top 20
Ft. eaf c ie
From To
Ft.
15. SCREEN:
Depth
Diameter Slot Size Material
�a o IlZ
L�
u
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:
X i7 le;�k y �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 Qlau CA / - LJJ� a G' g 12,
Quad No: SIGNA RE OF PERSON CONSTRUCTING THE WtLL 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 212198
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: awtes [4j . Canso ; Jr.
WELL CONTRACTOR CERTIFICATION #: .- 2I3 g
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential1 Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: i$U
V I Ihe, location belo)
�FoCounty:
i�.
Nearest Town: K ct
4rr,PrvL,.rLto,)y. �l- ALIA Coco cK
(Road Name and Community, or Subdivision and Lot No.)
DRILLING LOG
T �Nu�mb,,ers.
3. OWNER I�Dl11erf Vnoyin
From To
11
Address—
�� Creel orC o. s Aq l 76
City or Town State Zip Code
4. DATE DRILLED
5. TOTAL DEPTH
—
—{
6. CUTTINGS COLLECTED YES ❑ NO[Z]
—
7. DOES WELL REPLACE EXISTING WELL? YES NO®
S. STATIC WATER LEVEL Below Top of Casing: 5 o FT.-
—
(Use'.' if Above Top of Casing)
9. TOP OF CASING ISFT. Above Land Surface-
-Top of casing terminated atlor below land surface requires a variance in accor-
dance with 15A NCAC 2C.011e
10. YIELD (gpm): �C METHOD OF TEST a i r
11. WATER ZONES (depth):
DEPTH
Formation Description
011
12. CHLORINATION: Type 2 Amount "10 If additional space is needed use back of form
13. CASING: 11
Wall Thickness
Depth Diameter or Weight/R. Material
From To � Ft.- `L Pk=
From To Ft.
From To Ft.
14. GROUT:
Depth Mater al MethoSi C
From D To Ft. en_ Ce { L l 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:
17
Depth Size Material
From To Ft.
From To Ft.
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
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.
- on
SIGNATUR�,F1F PERSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Quality, Groundwater Section Within 30 days
GW-1 REV. 12199

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section 212188
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELLCONTRACTOR: jaYVLes 0. CC1{nPJT
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential d Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (S ow sketchof the location below) p
Nearest Town+ LIA OR I'lv�i L County: L�l,, teY� V
P.YLI eYLnj 0- IAA
(Road Name and Numbers, cc unity, or Subdivision and Lot No.)
3. OWNER (0 e Y
Address 4
City or Town ,S,tate Zip Code
4. DATEDRILLED .�-/1-1)
5. TOTAL DEPTH 3 o "5_
6. CUTTINGS COLLECTED YES Q NO®
7. DOES WELL REPLACE EXISTING WELL? YES Q NO[R]
8. STATIC WATER LEVEL Below Top of Casing: 15-5- 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): '^ METHOD OF TEST A l ✓
11. WATER ZONES (depth):
12. CHLORINATION: Type P 1I 0.15 Amount I C­klp
13. CASING:
Wall Thickness
Depth
Diameter
or Weight/Ft. Va�eenal
From
y To�
Ft.
4 /v
SDRaI —YY=
From
To
Ft.
From
To
Ft.
14. GROUT:
Depth
Material
Methgd
From
_ 0 To TO
Ft,
a�
1'1eCtme.r�
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
DRILLING LOG
From To
O 110
)10 _107r
DEPTH
Fo,l1nnation Description
❑irf 1 {—
�fill50 (O C.K
o
L �z
L
v+ve m
is r� Ai T
cil 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)
Npitlrj q N)�11
�ii(IJIGt
1 J.
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 HASBEENPROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY Vv ' COLA Y
Quad No: SIGN URE OF PERSON CONSTRUCTING HE WELL DATE
Submit original to Division of Water Quality, Groundwater Section Within 30 days
Serial No. GW-1 REV. 12/99

212197
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: )arne5 1�. �an1 T.
WELL CONTRACTOR CERTIFICATION #: 13
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) (` I
Nearest Town: �� k t/ �- County: tti le 1' Y �J
(Road Name an Numbers,�rommunity, or Subdivision and Lot No.)
3. OWNER Yec ( c o k
Address Ill�r.f / 1 ")\/
4. DATE DRILLED — -
5. TOTAL DEPTH %L
6. CUTTINGS COLLECTED YES 0 NO[Z
7. DOES WELL REPLACE EXISTING WELL? YES QV NO�
8. STATIC WATER LEVEL Below Top of Casing: is FT.
(Use '+' it Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface'
-Top of casing terminated attar below land surface requires a variance In accor.
dance with 16A NCAC 2C .0118
10. YIELD (gpm): r METHOD OF TEST 421, Y
11. WATER ZONES (depth):
DRILLING LOG DEPTH
From To Formation Description
D 2S G a
A5 &C) Ca nso I' d r c.
12. CHLORINATION: Type e I o-Ts Amount If additional space is needed use back of form
13. CASING:
Wall Thickness LOCATION SKETCH
Depth Diameter or Weight/Ft. Material
From To Ft. 1,144 21) A =A) P V C-
From To Ft.
From To FL
14. GROUT:
Depth Material Method
From —To 0 FL t9ea( eVYWr� n
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From —To—Ft— in. in.
From —To _Ft. _ In. In.
From —To _ Ft. _ in. in.
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
17
(Show direction and distance from at least two State
Roads, or other map reference points)
c - S�rns�line. �`7i _ Cx
C-1e t lord
CD
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF T IS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY ` � � � L l
Quad No: SIGNAT E OF PERSON CONSTRUCTINd THE WELL DATE
Submit original to Division of Water Quality, Groundwater Section Within 30 days
Serial No. GW-1 REV. 12199

2.12195
North Carolina - Department or Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699.1636-Phone IS 19) 733-3221
WELL CONSTRUCTION RECORD WELL CONTRACTOR: t T r"me
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 ❑ It Other, List Use:
2. WELL LOCATIONi: how sketch of the location below) D (`
Nearest Town: r l0 5+� e- County: r, VACY-le Y a
a Ce
(Road Name an tl Numbers, Co munniitty r Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER i- uc NiA ✓ !' r, it t't S /n� From To Formation Descldption
Address � `J�, �p a R, due. /24 - tJ $3 d i t C. l a 11�
eat or oute O.)� ; 3 p 5 ocK
,5
City or Town State Gip t:ode
4. DATE DRILLED 51�'00
5. TOTAL DEPTH 306
6. CUTTINGS COLLECTED YES[:) NOO
7. DOES WELL REPLACE EXISTING WELL? YES [2" NOD
8. STATIC WATER LEVEL Below Top of Casing: e - FT.
(Use -: It Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface -
'Top of casing terminated aVor below land surface requires a variance In accor-
dance with 15A NCAC 2C .0118
10. YIELD (gpm): tO METHOD OF TEST AI ✓
11. WATER ZONES (depth):
r-,
CD
or-
1'.
tD ��
12. CHLORINATION: Type I I ats Amount ) KAA, It additional space is needed use back of form Z
13. CASING:
Wall Thickness LOCATION SKETCH
Depth Diameter or Weight/Ft. Material (Show direction and distance from at least two State
FromTo 113 Ft. 11 A SDR 2_I p J c_ Roads, or other map reference points)
From To Ft. S'kV,v re
From To Ft. A �,J
14. GROUT: R v"
Depth Material Metho }
From _0 To 22Ft. �,e
From To Ft.
PA-
15. SCREEN:
Depth Diameter Slot Size Material \
From —To—Ft— in. in. 1
From To Ft. _ in. _ In. \ b 5 It L
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 COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY �iL P L �� '��� ' T`I
Quad No:
Serial No.
SIGNATURE OF PERSbN CONSTRUCTING THE WELL
original to Division of Water Quality, Groundwater Section within 30 days
DATE
OW-1 REV. 12199

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section 212185
/+
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone] '-"-��C), f11 u,) to cw,J po wit l O
WELL CONSTRUCTION RECORD WELLCONTRACTOR: Varney Iti, alyl,A :/1.
WELL CONTRACTOR CERTIFICATION
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential Eg� Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
Agricultural ❑ Monitoring ❑
2. WELL LOCATION:
Show ketch of the location below
�P Kih� �n ptJkt
9 f
Nearest Town:
Yo County:
DnYI l �
A
(Road Name and N�^umfbe�rs, Comm`f pity, or Subdivision and Lot No.)
DRILLING LOG
DEPTH
3. OWNER (�S
I ty�P h o L,J tUt
From To
Formation Description
Address P
L) k� o X e� 7 p
r) 63
I t
C)I_
�_ _
ISlreetor�oNte o. �r T t r
(p3 605
o a e Oc
City or Town State Zip Code
4. DATE DRILLED Dl � - DO
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES[] NO®
7. DOES WELL REPLACE EXISTING WELL? YE�NO�
8. STATIC WATER LEVEL Below Top of Casing: FT.
(Use -+' If Above Top of Casing)
9. TOP OF CASING ISFT. Above Land Surface'
-Top of casing terminated at/or below land surface requires a variance In accor-
dance with 15A NCAC 2C.02118
10. YIELD (gpm): METHOD OF TEST Gf I Y
11. WATER ZONES (depth):
12. CHLORINATION: Type Pe 111L Amount I GT If additional space is needed use back of form =
13. CASING:
LOCATION SKETCH
Wall Thickness
Depth
Diameter or Weight/Ft.
Mat9d'al (Show direction and distance from at least two State
2
From 1)To —6 3
Ft.
�- A
pyc' Roads, or other map reference points)
From To
Ft.
From To
Ft.
14. GROUT:
Depth
M1� serial Methqd
From To a °
Ft.
eaT Celt el�
KOM
From To
Ft.
15. SCREEN:
Depth
Diameter
From
To
Ft in.
From
—To—Ft.—
in.
From
—To—Ft.—
in.
16. SAND/GRAVEL
PACK:
Depth
Size
From
To
Ft.
From
To
Ft.
17
Slot Size Material
in.
in.
_ in.
Material
un
XL -A
wt-5 Mfl Ril.
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.
SHOW
i
SIGN,CTLRE OF PERSON CONSTRUCTING YHE WELL DATE
Submit original to Division of Water Quality, Groundwater Section within 30 days
GW-1 REV. 12199

212201
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Sellction
1636 Mail Service Center - Raleigh, N.C. 27699.1636-Phone [phone] ,AI't'lC5J)''`P �Jr
WELL CONSTRUCTION RECORD WELL CONTRACTOR: wtn 5 �� f'� .I � 01 Tylr .
WELL CONTRACTOR CERTIFICA 10 3 g 7—
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (check Applicable sox): Residential Gjl� Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION:
Nearest Town: _ I
(Road Name and Numbers.
3. OWNER f5.
Address ALi d
of the location below) ��� �eryor
County:
Agricultural ❑ Monitoring ❑
and Lot No.) DRILLING LOG DEPTH
City or Town State Zip Code
4. DATEDRILLED—OD
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: (�,o FT.
(Use '+' if Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface*
'Top of casing terminated at/or below land surface requires a variance In accor-
dance with 15A NCAC 2C.0118
10. YIELD (gpm): 6 METHOD OF TEST Al Y
11. WATER ZONES (depth):
From To Formation Description
go - 5an
5?o a8s IAYL5ol"date Yo4
12. CHLORINATION: Type Af ILIts Amount-1 C,4 If additional space is needed use back of form
13. CASING:
Wall Thickness
Depth Di���/eler or Weight/Ft. Material
From-10 To g� Ft. 3.D919-I
PVC -
From —To Ft.
From To Ft.
14. GROUT:
Depth Material Metho
From 0 To ao Ft. l FnfeemelU n
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From —To—Ft— in. —in
From To Ft. in. —in.
From —To _ Ft. — in. in.
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
17
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
,,
1,,Gt�
IJ
5�art� �rrl
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: SIGNA IRE OF PERSON CONSTRUCTlk4G THE WELL DATE
Submit original to Division of Water Quality, Groundwater Section within 30 days
Serial No. OW-1 REV. 12/99

212199
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: �rnE S tA_) CavK0 i Jy'
WELL CONTRACTOR CERTIFICATION #: 1 3 8
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 sket � of the location below)
yL
Nearest Town: k`� ✓ vA County:
de y k_)i dge �o'� ba
(Road Name and Numbers, C uni , or Subdivision nd Lot No.) DRILLING LOG DEPTH
3. OWNER Y blU 110. k -Fur A From To Fonnation Description
Address 0.L' f) Q 3 Ji r t
(Street or pule o. 43 �iL � _ CPA SoI'He �ock
n:,.. ... T....,.. Rmm WE) Code
4. DATE DRILLED 5— - a O
5. TOTAL DEPTH f 6 5
6. CUTTINGS COLLECTED YES ❑ NO®
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NOO
8. STATIC WATER LEVEL Below Top of Casing: 17o FT.
(Use'.' if Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface-
-Top of casing terminated at/or below land surface requires a variance In accor-
dance with 15A NCAC 2C .0118 I
10. YIELD (gpm): AO METHOD OF TEST Air
11. WATER ZONES (depth):
12. CHLORINATION:
13. CASING:
Type Te a 5 ----Amount=-F-- If additional space is needed use back of forte o
Wall Thickness
Depth Diameter or Weight/Ft. Matedal
From D To S Ft. � I'll —
From To Ft.
From To Ft.
14. GROUT:
Depth Material Metho
From L To 20 Ft. n eat Ge_ 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
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
[,le9iwrn�
C'�n .I
clwb
�Xe
/ GlPp horh M* 11
1.7
��J "�I.rr Zed 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 "e� `J C�!W I - ('
Quad No: SIGNA RE OF PERSON CONSTRUCTIN T E ELL DATE
Submit original to Division of Water Quality, Groundwater Section within 30 days
Serial No. GW-1 REV. 12199
I

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699.1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: h-{1L5 0, �mrA� )e- ( a✓vt.os Oe-1 t) ,Qw
WELL CONTRACTOR CERTIFICATION #: i�C j 3 l.cc
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box); Residential Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: ✓Gs tom! County: �Ll. T kerYvr�
(Road Name and Numbers, Co�nilmunity
�Gl-C I( M.
rS� Ibdl is ion and Lot No.)
DRILLING LOG
DEPTH
3. OWNER _
lLr HIS
From To
F mwtlon Description
Address J9� ct� Uri5
I/1'1
ry AO u) RA
/ DYesf ri�wrval orvia
o ���/�
t
�?ri c ✓o
4, DATEDRILLED
5. TOTAL DEPTH •5-05
6. CUTTINGS COLLECTED YES ❑ NOZ), �/
7. DOES WELL REPLACE EXISTING WELL? YES [✓� NOF]
8. STATIC WATER LEVEL Below Top of Casing: � FT.
(Use'+' II Above Top of Casing)
9. TOP OF CASING IS�_ FT. Above Land Surface'
-TOP of caslns twminated auor below lend surface requires a variance In accor-
dance with 15A NCAC 2C 119 1
10. YIELD (gpm): METHOD OF TEST 51 K
11. WATER ZONES (depth):
12. CHLORINATION: Type e e _Amount I Gia
13. CASING:
If additional space is needed use back of form
Wall Thickness LOCATION SKETCH
Depth m
n Diameter or welghl/R. Material (Show direction and distance from at least two State
From To 107 Ft. G 14 ? b P 2i .--1 r � Roads, or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth
Mater al Metho
1
From
To 20
Ft.
j L.4=R-
i
From
To
Ft.
15. SCREEN;
Depth
Diameter
Slot Size Material
From _ To _ Ft _ In. _. In.
From —To
—Ft.
_ In. —In.
From —To
_
Ft-
in. _ in.
(i 1
16. SAND/GRAVEL PACK:
jyy c��r v)
11
Depth
Size Material
From
To
FL
From
To
Ft.
-� C'•�
17. REMARKS:
r'
N
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A CQPY OF THIS RECORD HAS BEEN PRJVD TO THE WELL OWNER.
FOR OFFICE USE ONLY �1 r - U [
Quad No: kT F PERSON CONSTFk6TIV& THE WELL DATE
Serial No. n
1 water Quality, Groundwater Secllon within 30 days
GW-1 REV. 17/99
JUN 1 9 2000

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 meeW,Cam T "�trn4s We�� 4Pull,
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (check Applicable Box): Residential E Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCA
Nearest Town:
(Road N
3. OWNER
Address
the location below) 1� J
County:0. / n e ✓7D Y
and
F-0rea (' /Y,i 0
. City or Town Slate Zip Code
4. DATE DRILLED m-pD
5. TOTAL DEPTH 505
6. CUTTINGS COLLECTED YESD NO©
7. DOES WELL REPLACE EXISTING WELL? YE�NO�
B. STATIC WATER LEVEL Below Top of Casing: FT.
(Use'+' II Above Top of Casing)
9. TOP OF CASING IS�_ FT, Above Land Surface*
-Top of casing terminated atior below lend surface requires a variance In accor-
dance with 15A NCAC 2C .tit s
10. YIELD (gpm): METHOD OF TEST A I ✓
11. WATER ZONES (depth):
12. CHLORINATION: Type Amount r
13. CASING: '
Wall Thickness
Depth Diameter or Welght/Fl. Material
From TO L12 Ft. 5 D R a l (YP VC-
From To Ft.
From To Ft.
14, GROUT:
Depth Material M thod
From —6 To 20Ft. VIPaf C-CN1eK
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From —To—Ft In. _ in.
From _ To _ Ft. _ In. in.
From —To _Ft, _ in. in.
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
17. REMARKS:
DRILLING LOG DEPTH
From To Fomution Description
/
D / k 1' t r 4
i 4c, 5b5- ey R6c);0. ✓o
If additional space is needed use back of form N
LOCATION SKETCH
(Show direction and distance from at least two Stets
Roads, or other map reference points)
C kV fcr X
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.
l 7L4r8M I
Quad No:
n
Serial No.
F PERSON 001`1$iR(1aING THE WELL DATE
Water Quality, Groundwater Section within 30 days
GW-1 REV. 12/99
c 1,
JUN 1 9 2000

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center - Ralegh, N.C. 27699-1636-Phone [phone]
�
T
JTY�- 5 W , - r, 1 I� I f�
WELL CONSTRUCTION RECORD WELLCONTRACTOR: _UI F•1 u Cantfl= AT"5 We )) 4 6 MP
WELL CONTRACTOR CERTIFICAilONff:�I�g
STATE WELL CONSTRUCTION PERMITS:
1. WELL USE (Check Applicable eox): Residential)
Recovery ❑ Heat Pump Water Injection
2. WELL
3. OWNER n
Address CZ 9
Municipal ❑ Industrial ❑
Other ❑ If Other, list Use:
of the location below) y1 ,1• l/
-County: I.l. l Yl er Icy
or Subdivision and
/--j feKhnVO NI C AKvttD
City or Town Slate Zip Code
4. DATE DRILLED - VD
5. TOTAL DEPTH 14 1'
6. CUTTINGS COLLECTED YESD 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 ISFT. Above Land Surface-
-Top of casing terminated atlor below land surlaca requires a variance In accor-
dance with 15A NCAC 2C .0118
10. YIELD (gpm): 15 METHOD OF TEST A l Y
11. WATER ZONES (depth):
12. CHLORINATION: Type ^k Gr"Vke Amount GLL 1
13. CASING: pcil�
Wall Thickness
Depth Di tar or Welght/Ft. Material
4 From To D Ft. 7 A[ P _
From To Ft.
From To Ft.
14. GROUT:
Depth Material Mpthodl
From —4 To 2 V Ft. a 'C e' K k1la Rd
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 Description
n SAn L
v
O p
L o�
=m
orn
m
a0
a mCD
0
m
rn--
rn
C3
If additional space is needed use back of form N o
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points) n (e KL
61 t
�?9 Pjusrr,
La`^e
Rai P YV (1
P
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY 5 S-DD
Quad No: URE 016PERSON CO STRUCTING THE WELL DATE
4,brW o#nal to Islon of Water Quality, Groundwater Section within 30 days
Serial No.
GWA REV. 12/99
JUN 1 9 2000

North Carolina - Department of Environment and Natural Resources • Division of Water Quality- Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699.1636-Ptlone (919) 7333221 /1
WELL CONSTRUCTION RECORD WELLCONTRACTOR: _ Lamps
WELL CONTRACTOR CIE TIFICAT ON #• r I3 a r
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (ChackApplicable Box): Residential IZ/ Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑ Recovery ❑ Heat Pump Water Injection ❑ Other If Other, List Use:
2. WELL LOCATIO Sh'o1 sketc of the ocation below)
Nearest Tow11 n:k T Lt 2 tK ^ r /I `�„ dunity:
r
me Lf elf K
(Road Name and N rnbars� Co�•ry, o(Sut)d iipn and Lot No.)
3. OWNER - M(. I/lJ Its
Address ') n n lit i ),;, I —
up uoce
4. DATE DRILLED 4 600
5. TOTAL DEPTH
6. CUTTINGSCOLLECTED YESQ NO[Z
7. DOES WELL REPLACE EXISTING WELL? ES EZ/ NOED
B. STATIC WATER LEVEL Below Top of Casing: FT.
(Use'.' if Above Top o Casing)
9. TOP OF CASING ISFT. Above Land Surface'
Vop of casing terminated allor below land surface requires a variance in accor-
dance with 15A NCAC 2C .0119 ,
10. YIELD(gpm): l5r7 METHODOFTEST 0.1 V
11. WATER ZONES (depth):
12. CHLORINATION: Type � � r rye.ys _Amount CU
13. CASING: 1
Depth p
�_To
Wall Thickness
t
Di r or Wei hVFt. Material
From o
Ft.
Dt/c
From To
Ft.
From To
Ft.
14.
GROUT:
Depth
From _2 To _a0
Ft.
M trial ethod
)�('a t' '�,.rLd
From To
Ft.
15.
SCREEN:
Depth Diameter Slot Size Material
From —To _ Ft
_
In. —in.
From —To —Ft.
In. —In.
From _To _ Ft._
in. _ in.
16.
SAND/GRAVEL PACK:
Depth
Size Material
From To
Ft.
From To
Ft.
17.
REMARKS:
— —
DRILLING LOG
From To
g
:4g 310
DEPTH
Formation Description
(' 11s-1,�1 Yoe
0
0
—
--------------
c
-r�
c.o —
If additional space is needed use back of form ` LOCATION SKETCH
(Slow direction and distance from at least two State
Roads, or other map reference points)
9 fr�
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY L� Op- b 6
Ouad No: ( f. q �" `"" _ p51tovislon
TURE OF PERSON C NS UCTING THE WELL DATE
Submit odgidai of Water Quality, Groundwater Section within 30 days
Serial No, 9 r',+,Li`Ij,GW-1 REV. 12/99

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELLCONTRACTOR: - 2QMO; f fixm d Lo_T .
WELL CONTRACTOR CERTIFICATI N #: 13 B
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Chock Applicable Box): Residential ❑ Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketrh of the location below)
Nearest Town: F )Ie it n Yn County: U f Y
(Road Name(
and rNnuumb1e1 Commune orISubdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER lJbbn1/ 1P KKiYIS From To Formation Description
Address 0 Q D x o 9 g _ D 60
(� rue or e o. T1-�.S
.112)et o r '74nI f- 4o(�
City or Town Slate Zip Code
4. DATE DRILLED� OO
5. TOTAL DEPTH 2.:;__
6. CUTTINGS COLLECTED YES ❑ NO®
7. DOES WELL REPLACE EXISTING WELL? YES NOD
6. STATIC WATER LEVEL Below Top of Casing: --,g c�- FT.
(Use'+' If Above Top of Casing)
9. TOP OF CASING IS�_ FT. Above Land Surface'
'Top of using terminated auor below land surface requires a variance In accor-
dance with 15A NCAC 2C .011a
10. YIELD (gpm): —15' METHOD OF TEST a i r
11. WATER ZONES (depth):
12. CHLORINATION: Type 4d1ift5 Amount .l.Qa,4_
13. CASING:
Wall Thickness
Depth Diameter or Weighi/Ft. Meerial
FromTo_ Ft. �—'_
From To Ft.
From To Ft.
14. GROUT:
Depth MateriaPhYI
l Method I
From Q To �_Ft. ViPAtGm � An�
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
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points) )
51C'ttS W
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT (A�COPY
O(F THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER. C1
FOR OFFICE U661 N(t,Y lb/d/.IAN) t fl/IYb y (- )d pl Q Q
Quad No: U 0SIGNATURE OF PERSON cbN RUCTING THE WELL DATE
Submit original to Division of Water Quality, Groundwater Section Within 30 days
Sedal No. t ^ GW-1 REV. 12/"
'a,eM. c.m!1

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) 733,1221
WELL CONSTRUCTION RECORD
WELL CONTRACTOR: — (� W2 yn p Cd T
WELL CONTRACTOR CERTIFICATION A:
STATE WELL CONSTRUCTION pE,,j n :
1. WELL USE (Check Applicable Box): Residential [,E Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other 0 If Other, List Use:
2. WELL LOCATION: (SJt qw ¢ketc h lhe, location below)
Nearest Too n: Y ri `�o K
i / _ _ 1 n County: i, i V
..v'ry. or sum,vision and Lot No.)
3. OWNER _ T YY \ YV' 5
Address Cf n n I V., IJ 17
4. DATE DRILLED .�o�)_�p00up cone�
5. TOTAL DEPTH
6. CUTTINGS COLLECfgD YESO NOCE
7. DOES WELL REPLACE EXISTING WELL? YES ® NO[:]
8. STATIC WATER LEVEL Below Top of Casing: FT.
(Use's' If Above Tong)
9. TOP OF CASING IS�_ FT. Above Land Surface'
'Top of using terminated atior below land surface requires a variance In accor-
dance with 15A NCAC 2C .0118
10. YIELD (gpm): .';iP- METHOD OF TEST Ell ✓
11. WATER ZONES Ideothl
12. CHLORINATION: Type. be[FeAmount Gil
13. CASING:
Depthcc�,CC D��iarn� fi�sr Orel gh�t� Material
From �_ To 1L L FL Se,L(_ S 1) R 2) �q)�
From To Ft.
From To Ft,
14. GROUT:
Depth M trial Me— th,MJ
From _� To �� Ft. h Ca_ � CF)1a�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:
DRILLING LOG
From To
Ff Jr
DEPTH
Formation Description
1
i a ed
c
o �
� n
r ED
T_
W O
It additional space is needed use back of form
LOCATION SKETCH
(Shaw direction and distance from at least two State
Roads, or other map reference points)
6k
k
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>, lO b V
Quad No: IGNATURE OF PERSON rONSTF(UCTff4G THE WELL DATE
Serial No.
Submit od to Division of Water Quality. Groundwater Section within 30 days
•( or,
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: `tea 5 ft/e'I cc�n—'T—
WELL CONTRACTOR CERTIFICATION 8: _ .Z 13
STATE WELL CONSTRUCTION PERMITM:
1. WELL USE (Check Applicable Box): Residential Eir Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other 0 If Other, List Use:
2. WELL Aandumbe
sketch of the location below)
NearestYY15 County: [��I f'LeYT0Yr1
(Road o nt , r Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNEAddfe3' I IIIFrom TT Formation escripdon
s�ow• V• 0Wl o Q. 45-
�I/TheyY-drQyor�ute e1JC_u139.• )ac,�
Guy Or Town ✓y�6 State Zip Coda
4. DATEDRILLED ——a000
5. TOTAL DEPTH �
6. CUTTINGS COLLECTED YES[] N0[g
7. DOES WELL REPLACE EXISTING WELL? YES [Er NOr_�
S. STATIC WATER LEVEL Below Top of Casing: F('.
(Use': it Above Top of Casing)
9. TOP OF CASING IS �_ FT. Above Land Surface -
'Top of casing terminated at/of below land surface requires a variance in aocor-
dance with 15A NCAC 2C.011a
10. YIELD (gpm): _Z4(L METHOD OF TEST AI r
11. WATER ZONES (depth):
12. CHLORINATION: Type l—p S A r 1(A
13. CASING: —�—
O
If additional space is needed use back of form
Wall Thickness LOCATION SKETCH
Depth �, r. Diameter or we_ ighuFt. er" (Show direction and distance from at least two State
From To
Ft, SJ�R21 V[
Roads, or other map reference points)
From To Fl.
From To Ft.
14. GROUT:
Dept— Material ethodj
From �_ To O Ft. 2 U
From To Ft.
15. SCREEN:
Depth Diameter
From —To _ Ft _ In.
From —To —Ft. In.
From _ To _ Fl. _ in.
16. SAND/GRAVEL PACK:
Depth Size
From To Ft,
From To Ft.
17. REMARKS -
Slot Size Material
In.
In.
in.
Material
100 HEREBY CERTIFY THATTHIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
I
FOR OFFICE USE,ONLY
Quad No:
2 i Submits
Serial No # i
ai
OF PERSON CONSTRIIfdTING THE WELL DATE
Of water Quality, Groundwater Section within 30 days
GW-1 REV. 12199

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699.1636-Phone (919) 733-=1 �1
WELL CONSTRUCTION RECORD WELL CONTRACTOR: &M45 �ufK Lo• �Y1c
WELL CONTRACTOR CERTIFIC TION C. W S'
STATE WELL CONSTRUCTION PERMITC,
1. WELL USE (Check Applicable Box): Residential M/Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION• Sh M ske sh of location below) '� r
Nearest Town: r'Y Counly: ^IT er`}OYd
ufL i.f n
(Road and mb , Commu ' or Subdi lion and Lot No.) DRILLING LOG DEPTH
3. OWNER tI.LY P_Y Y'A From To Foonall ascription
Address
or mum, It A-e t)C
?I i' ey r 13
City or Town State Zip Code
4. TOTALDRILLEDDEPTH
� 00
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES Q NO®
7, DOES WELL REPLACE EXISTING WELL? YES NOO
8. STATIC WATER LEVEL Below Top of Casing: j�jj—FT.
(use': it Above Top of Casing)
9. TOP OF CASING ISFT. Above Land Surface.
-Top of "sing terminated at/or below land surfaos requires a variance In accor-
dance with 15A NCAC 2C .0 19
10. YIELD (gpm): METHOD OF TEST a l Y
11. WATER ZONES (depth):
use
A
c �
v
x
••
mti
ded back of form
12. CHLORINATION: ype u It additional space us nee
13. CASING:
Wall Thickness LOCATION SKETCH
Depth D' r aweight/Ft. Material (Show direction and distance from at least two State
From To � Ft. - ' a-- -al--l--ral= Roads, or other map reference points)
From To Fl.
From To Fl. S
14. GROUT:
Depth material -L. Mith,,od
From Q_ To0 Ft. —Z^= y&
From To Ft. .,J /x
15. SCREEN: �y
Depth Diameter Slot Size Material f , Y`
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. I
From To Ft.
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Quad No: G PERSON STRUCTING THE WELL `DATE
ef.Water Quality. Groundwater Section Within 30 days
Serial No. j i '" ',. GW.1 REV. 12199
r
0

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Prone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: _0cl 0n Gt/r✓���3Cf/'UIt(
WELL CONTRACTOR CERTIFICATION fS
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Boa): Residential Ltd Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL
(Road Name and ethers. Commu ty
3. OWNER C
Address 147 L; e r
location below) ] )� ('
County: j(� I.A ey ` Ylj
Urlinh Mi'T s"""'TIL a5167-752
City or Town ..II State Zip Code
4. DATE DRILLED 3- 1 Y —too-o
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES 0 NOM ,.�,//
7. DOES WELL REPLACE EXISTING WELL? YENOF__J
8. STATIC WATER LEVEL Below Top of Casing: FT.
(Use Y' 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 .0116 c
10. YIELD (gpm): -to— METHOD OF TEST d I Y
11. WATER ZONES (depth):
12. CHLORINATION:
13. CASING:
DRILLING LOG DEPTH
From To Fo aIlan Description
" n
TO
0
Type e 5 Amount +A If additional space is needed use back of form x
Wall Thickness LOCATION SKETCH
Depth qq cc Di r or WeighUFt. MAat1aq�al (Show direction and distance from at least two State
From-0 TO � Ft. 5D R 2 _�-[ `= Road,, or other reap reference polnts) �u-.n+ r"
From To FL
From To Ft.
14. GROUT:
De t Ma erial j M thod `
From _� TO 10 Ft. a )v(e11 aKd
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
(,_ P "S' r
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY....- - t
Quad No: ° -(� N T{1RE OF PERSON CON T UCTING THE WELL OATE
link eloo or 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. 27699.163i5­Phone [phone] r I /� /I
WELL CONSTRUCTION RECORD WELLCONTRACTOR: - &1yLa5' We I) *Pi mA6 , Tnc.
WELL CONTRACTOR CERTIFICATION M: aI ,3R
STATE WELL CONSTRUCTION PERMITC
1. WELL USE (Check Applicable Boa): Residential G/Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other [1 If Other, list Use:
2. WELL LOCATION., how sketch of the location below) I%�`eY (D Y Nearest Town: County: III\
Haylm CYeeK Rj -—
(Road Name anj NVmbars. Co mun ry ar Subdivision end Lot No.) DRILLING LOG DEPTH
3. OWNER C t✓ From To Fortran nDescription
Address 0. e e 'Cg h✓
nee er` lit o. �R75� , s l�n �-
Mal io><
City W Town Slate Zip Code
4. DATE DRILLED oZpOU
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES F-1 NO® a
7. DOES WELL REPLACE EXISTING WELL? YES NO®
8. STATIC WATER LEVEL Below Top of Casing: 1,22 FT.
(Use'+' It Above Top of Casing) V
9. TOP OF CASING ISFT, Above Land Surface•-c,
Top of casing ttad 0Vor below land surface rsqulrea a variance In actor -
dams NCAC with 15A NCAC 2C .0118
10. YIELD (gpm): 0 5: METHOD OF TEST _ CA I r'
11. WATER ZONES (depth): rV
12. CHLORINATION: Type ts Amount Cu If additional space is needed use back of form
13. CASING:
Wall Thickness LOCATION SKETCH
n Depth Oia /m%ter or Weight/Ft nal (Show direction and distance from at least two State
From-0 Ft.7L Roads, or ther map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth M terial Me hod
From t9 To AD Ft. 11eA� �- e1tT a,'J C clr
From - To Ft.
15. SCREEN:
Depth Diameter SlotSize 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 HASBEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY I /SON (0hS y- / E � I
Quad No: t5 SIGNATURE OF PERSON dONSTRUCTiNG THE WELL DATE
_ twhi 'gkul to Division of Water Duality, Groundwater Section within 30 days
Serial No. GWf 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: C arnDS We i �ufv ►� �' �s ��
WELL CONTRACTOR CERTIFICATION #: ) 3 g
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check applicable Soz): Residential Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other rl If Other, List Use:
2. WELL LOCATION: Shoyuy skke�t of Fh location below) 1
Nearest Town: .{4 ✓C County: 1�1� C✓ Y
}��! ID8 - Coun�1 Line 5,
(Road N an Numbers, Co ity, r Su 'vision and Lot No.) DRILLING LOG DEPTH
3. OWNER eYim PY From To Fom,aaon Description
Address D Prt�
JJ L o e f l iYle YOrI<
4. DATE DRILLED�000
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES [D NOM
7. DOES WELL REPLACE EXISTING WELL? YES M NOE]
8. STATIC WATER LEVEL Below Top of Casing: b o FT.
(Use -: if Above Top of Casing)
9. TOP OF CASING ISFT. Above Land Surface-
-Top of casing terminated atlor below land surface require$ a vOrl$ncs In accor-
dance with 15A NCAC 2C 0116
10. YIELD (gpm): V� METHOD OF TEST ✓
11. WATER ZONES (depth):
12. CHLORINATION: Type S Amount I C''A
13. CASING:
C)
-=
n
T
r✓ �'
J
rim
It additional space is needed use back of form
Wall Thickness
Depth
Diiametor er weiyhl/Ft. AQpt
SDK I J_ Z_
From— To �
Ft.
�`f_
From To
Ft.
From To
Ft.
14. GROUT:
Depth
material I- Mew thud I
ilLL
From 0 To �—
Ft.
- Qt1-
r 1=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
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
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.
v
FOR OFFICE USE ONLY - DATE
i' i' SI�iJA�!q OF PERSON CO ST UCTING THE WELL
Quad No: rrs g c`v� . �i 16 nlJlsvJ�or water Quality. Groundwater Section within 30 days
Sedal No.
OW-1 REV. 12199
N
G
MI. 1 0 7.000

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699.1636-Phone [phone] /� /n�
WELL CONSTRUCTION RECORD WELL CONTRACTOR: . ` S e.)( d'pic [-o-.TM
WELL CONTRACTOR CERTIFICATION #: 39
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential LR1 Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other [J If Other, List Use:
2. WELL
3. OWNER
Address
ke ch a location below)
County:y�
L-of S4'
or
ury or town Slate Zip Code
4. DATE DRILLED.'-1-5-a000
5. TOTAL DEPTH
6. CUTTINGSCOLLE TED YESF NO®
7. DOES WELL REPLACE EXISTING WELL? YES NOO
8. STATIC WATER LEVEL Below Top of Casing: yz FT.
(Use'i if Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface
'Top of casing terminated Wor below land surface requires a variance In scoot.
dance with I SA NCAC 2C .0 1 B
10. YIELD (gpm): / METHOD OF TEST A i y
11. WATER ZONES (depth):
12. CHLORINATION: Type Amount CT
13. CASING:
Depth�++ ,,,, Diameter
From To to Ft. Z
From To Ft.
From To Ft.
14. GROUT:
DRILLING LOG DEPTH
From To Fomutlon Descriptlon
0 do ^rt
90 _ S D D l a e YDC
It addNonal space is needed use back of form
Wall Thickness LOCATION SKETCH
or w5 D K tom.' Ma)gti;alG (Show direction and distance from at least two State
f�V Roads, or other map reference points)
Depths�,,
0
aterial
Method
From _ To �.
Ft.
From To
Ft.
15. SCREEN:
Depth Diameter Slot Size
Material
From —To Ft
_ in. _
In.
From —To _ R.
In. —in.
From —To _ Ft.
_ in. —in.
16. SAND/GRAVEL PACK:
Depth
Size
Material
From To
Ft.
From To
Ft.
17. REMARKS:
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY. I \
Quad No:
Serial No.
_)A Llo60
JATURE DF PERSOA CbNSTRUCTING THE WELL DATE
Division of water Quality. Groundwater Section within 30 days
GW-1 REV. 12/99
Sq

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699.1636-Pflons [phone] n
WELL CONSTRUCTION RECORD WELL CONTRACTOR: I dmbOe �kntA �o Inc
WELL CONTRACTOR CERTIFICATION a: 5 13 g
STATE WELL CONSTRUCTION PERMITO:
1. WELL USE (Check Applicable Box): Residential LO Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show so tc(t f the location below)
Nearest Town: Y w County: k e Y
bey i e LD-F 5-5-
(Road Name and Nu - Communii yubd' Ision and Lot No.) DRILLING LOG DEPTH
3. OWNER fi Q V �.� j A„ b0 From To F rmatlon Description
Address LA DaK rYee. 0 )5 G a
(streetor o to o. f �� ,�6 S ck
gel w10 rtf �� [ 7 Q A Ix 1 0. 0
City or Town Slate - Zip Code
4.
DATEDRILLED 0—a°OD-
3L
5.
TOTAL DEPTH
6.
CUTTINGS COLLECTED YESQ NOZ
t�
7.
DOES WELL REPLACE EXISTING WELL? YES ❑ NO❑
8.
STATIC WATER LEVEL Below Top of Casing: _ s `FT,
9.
(Use Y' 11 Above Top of Casing)
TOP OF CASING IS�_ FT. Above Land Surface*
GT
_,
-Top of Dazing terminated aVor below land surface requires a variance In accor-
dance with 15A NCAC 2C .01 IS
10.
YIELD (gpm): __j METHOD OF TEST /1 I ✓
—
11.
WATER ZONES (depth):
r*,
12.
CHLORINATION: Type lkbf5 Amount IGu
If additional space is needed use back of form
13.
CASING:
Wall Thickness
LOCATION SKETCH
Depth' C Diameter "Wetj(hl/R. Material
From 5 D R al V(—
(Show direction and distance from at least two State
To Ft. -..�O6
Roads, or other map reference polnts)
From To Ft.
From To Ft.
14.
GROUT:
Depth Material Methoo
From To 0_ FLR. e e1tt �
From To Ft.
15.
SCREEN:
Depth Diameter Slot Size Material
A
From _ To _ Ft _ in. _ In.
Lam(
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
r/�\,,LLT
ACOPY
• Al O F, THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
L
FOR OFFICE USE ONLY �11G) CA AW C)i, 1/0 �) QQ U
Quad No: SIGNATURE OF PERSON CON TR TING THE WELL DATE
8gb*'oriykul O,ivislon or water Ouality, Groundwater Section within 30 days
Serial No. I i r : OW-1 REV. 12/99
�r n• i ri ')i? 1 l

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-Ml
WELL CONSTRUCTION RECORD WELLCONTRACTOR: ( MDs r of r pa mo Co.Sjl.
WELL CONTRACTOR CERTIFICATION #: J3fl
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check applicable Box): Residentlal92 Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCA
Nearest Town:
and Numbed.,Conmunttv. or
3. OWNER
Address
location below)
L r County: ✓ d
L(s A- L30 701
Ciry or wn State Zip Code
4. DATE DRILLED .3—q-�oo0
5. TOTAL DEPTH -96)457'
6. CUTTINGS COLLECTED YESQ NO®
7. DOES WELL REPLACE EXISTING WELL? YES NO®
8. STATIC WATER LEVEL Below Top of Casing: :LT FT.
(Use '+• if Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface -
'TOP of casing terminated atior below land surface requires a variance In accor-
dance with 15A NCAC 2C Al 9
10. YIELD (gpm): METHOD OF TEST d l ✓
11- WATER ZONES (depth):
12. CHLORINATION: Type a 5 Amount cu
13. CASING:
Wall Thickness
Depth Dfame r or Weight/Ft. Material
D
From
To ��
FL
SDP 2J _PV
From
To
Ft.
From
To
Ft.
14. GROUT:
Depth
AO �_ To _
Ft.
M e ial { Method
0-KI L�
From
To
Ft.
15.SCREEN
Depth Diameter Slot Size Material
From —To _ Ft _ in. —In.
From —To —Ft. _ In. —In.
From —To _ Ft-_ in. —in.
16. SAND/GRAVEL PACK:
Depth Size Material
From To —FL —
From To Ft.
17. REMARKS:
DRILLING LOG DEPTH
From To Fomueon Description
n ?a rt c a
r12= 3UE
—O —G --
c�
o.r
=i c
0
s
If additional space is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACtIORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD AS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY , C �- Q.
Quad No:GNATURE OF PERSON CONSTIAUCANG THE WELL DATE
-Submit original to Division of Water Quality, Groundwater Section within 30 days
Serial No.7 Q ayyz
K,!eir I i) 's 11„
Bata- Section
GW-1 REV. 121"

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699.1636­PFone [phone]
WELL CONSTRUCTION RECORD WELLCONTRACTOR: L- M 5 ��ixmp o. nc .
WELL CONTRACTOR CERTIFIC TION #:
J STATE WELL CONSTRUCTION PERMIT#:
_
1. WELL USE (Check Applicable Box): Residential L� Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, L)st Use:
2. WELL LOCATION: (Show ske h �}f t e location below) ��JJ j,L�� (�
Nearest Town: gT�1{,AP✓YQ K County: ht(! ILe-r yv Yt�
River Kfd4P- [o'f 4b
(Road Name and N rs, C Iitv1 or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER Y t 9 teIl From To Fomwtion Description
Address f.�.fq I'veal qY5 —Dr. /0.5
L( r a ar oWe o. If Je2o34 10�44!E ia e roc
1
!`gin, ,., r,.w.,
Gip lip{le
4. DATE DRILLED
5. TOTAL DEPTH n ti
6. CUTTINGS COLLECTED YES 0 NO®
7. DOES WELL REPLACE EXISTING WELL? YES NOM
8. STATIC WATER LEVEL Below Top of Casing: �!,q FT.
(Use'.' if Above Top of Casing)
9. TOP OF CASING IS ' FT. Above Land Surface'
Top of casing terminated aVor below land surface requires a variance In accor-
dance with 15A NCAC 2C.0118
10. YIELD (gpm): 5 METHOD OF TEST Q I r
11. WATER ZONES (depth):
Pa n
12. CHLORINATION: Type n. _Amount Cu� If additional space is needed use back of idnd o
13. CASING:
Wall Thickness
Depth oei —r _Material
�a1 PVC —
From Q To 05Ft. , _
From To Ft.
From To Ft.
14. GROUT:
Depth M terial M thod
From d To Ft, P_rL nt�_
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
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 OAq-
Quad No: U10I��'n�;31TVRE OF PERSON CO T CTING THE WELL DATE
' Su"b1i1n'dtf{) Aril OWialon of water Duality, Groundwater Section within 30 days
Serial No.
OW-1 REV. 12/99
L -7
a1� ! .:roar;-,:cectign
q ,,t.:; r

UST SECTION Fax:[phone] Jul 2 '99 9:50 P.01/01
Nonh Carolina - Department of Envlronment and Natural Resources - Division of Water 0uatity - Grouncl raler Section
P.O. Box 29578 - Raleigh,N.C. 27e26-0576&Phcne (919) 73M221
WELL CONSTRUCTION RECORD
1. WELLUSEi
Recovery [
2. WELL LOCA
XtT
(Road, C
3. OWNER
ADDRES
DRILUNG CONTRACTOR: G2FEIJ 12tUE 2 LU6Li PUMP
DRILLER REGISTRATION Y:
STATE WELL CONSTRUCTION PERMIT#:
Applicable cox): Residential CT Municipal Irldustlial ❑ Agricultural ❑
Heat Pump Waier Injection ❑ Other Q If Other, Ust Use:
� i?S sketh qt the location below
(o
ece Csuntv:�zu'k rx k ltoh
(Street
Lot No.)
a. DATE DRILL_
5. TOTAL DEPT
6. CUTTINGS COLLECTED YES ❑ NOFL-r
7. DOES WELL REPLACE IXISTING WELL? YES D Noa
8. STATIC WATER LEVEL Below Top of Casing: (nO FT.
(Use "." i Above Top of Casing)
9. TOP OF CASING IS— FT. Above Land Surface-
- Casing Terminated aver oe,ow land surface is Illegel.unlees a variance Is Isaur
In acoordanoe with 15A NCAC 2C .0118
10. YIELD (gpm): -_ METHOD OF TESTAA
11. WATEP ZONES (depth):
12. CHLORINATION: Type r({- Amount
13. CASING:
Wail Thicknese
Depth Dlamoter a el hUFC +brim
From � To r rn
Monitoring ❑'
DEPTH DRILLING LOG
From To Fornailon loss
(J / 1
/ _ 7
rj 'J
If additional space Is needed use cack.%f fom(_:ic-'
LQCATION SKETCH ry
(Shaw cirectlon and distance from at leatar w St6te
Roads, or other map reference polntsi n o
2

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: 5 die lI �umJ (0.1nc .
WELL CONTRACTOR CERTIFICATI N #: A 3 $
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Cheek Applicable Box): Residential Lid Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show ske h the location below)
Nea/,r@�st Town:Count':
/+ t,�. eY ✓
In yl P l V' e e
(Road Name and Numbers. Cornrnuniry, orS iviaion and Lot No.) DRILLING LOG DEPTH
3. OWNER e5 Yt' From To Fo adonfescription
Address Sons oft LoD
o e ea o C o. 10 . / — n50 e Yo
_. _.. _.... up cote
4. DATE DRILLED 0
5. TOTAL DEPTH�
6. CUTTINGS COLLECTED YES Q NOM
7. DOES WELL REPLACE EXISTING WELL? ES _ NOZ
8. STATIC WATER LEVEL Below Top of Casing: _ FT.
(Use'.' it Above Top of casing)
9. TOP OF CASING IS FT. Above Land of
'Top or casing terminated attor below land surface requires a variance In accor-
dance with /SA NCAC 2C.9415
10. YIELD (gpm): A METHOD OF TEST LA ✓
11. WATER ZONES (depth):
12. CHLORINATION: Type e 5 Amount ( rJA
13. CASING:
If additional apace is need
Wall Thickness LOCATION SKETCH
Depth Dianle r a WeighVR. jai (Show direction and distance from at least two State
From-�—�—To Ft.. SDR �1 r C- Roads, or other map reference points)
From To Ft.
From To Ft.
14. GROUT: � _p � $-�
Depth M anal -( thod 1 � uv'"4 � M (� µ`^•
From — To -Ft. �iU M �r � © � Q (1n
From To Ft. _0• r✓a F�
15. SCREEN:
Depth Diameter Slot Size Material
From _To_ Ft in. _ In.
From —To —Ft. _ In. , In.
From — To _ Ft. _ in. _ in.
16. SAND/GRAVEL PACK:
Depth Size Material
From To —Ft. —
From To Ft.
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
tFOROFFICE USEO('LY q.Z
No: SIGNATURE OF PERSON CONST U THE WELL DATE
al to Division of Water Quality, Groundwater Section within 30 days
No.
OW-1 REV. 12/99
b,h2v

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: Caj`V 9 Oe N + Pa mp Po- � c -
WELL CONTRACTOR CERTIFICATION #: a I3 P—�I
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box); Residential ❑ Municipal le Industrial ❑ Agricultural El Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other Er If Other, List Use: U � I 1 c
2. WELL LOCATION: ho sketch of the location below) I j f
Nearest Town: D5m r- County: 1+�le Y; ✓d
(Road Name end er ,Co unity. or Subdivision and Lot No.)
DRILLING LOG DEPTH
3.
OWNER 0.1 Yterr ✓ - -Roo 16
From To Foanallon Dascripdon
Address I ,�q rAI Yq r o lI o_ I il •
D l2et� i' I ate_
jbiree r to o.
Su.��0.1z C_ ry
.
6-
�2S I o
o, araR e
o
Gry br Town Slate Zip Coda
T CD
4.
DATEDRILLED 23-Asoo
CD
5.
6.
TOTAL DEPTH
CUTTINGS COLLECTED YES Q NO[n
c"
7.
DOES WELL REPLACE EXISTING WELL? YES [Zf NOF-1
8.
STATIC WATER LEVEL Below Top of Casing: 5v FT.
(Use'✓ If Above Top of Casing)
9.
TOP OF CASING ISFT, Above Land Surface
`E
'Top of easing terminated atlor below land surface requires a Mariana In accor-
O
r,n
dance with 15A NCAC 2C.0118
10. YIELD (gpm):1 _ METHOD OF TEST
11.
WATER ZONES (depth):
12.
CHLORINATION: Type �- I oY Ina Amount au
It additional space is needed use back of form
13.
CASING:
e� p I
Wall Thickness
Depth Material
LOCATIONS T - ��
(Show direction and distance from at least
Diwn r or Weight/Ft.
6a
From _ To Ft.
Roads, or other map reference points)
From To Ft.
I I
Icy
From To Ft.
!�
14.
GROUT:
(�
Depth Material Method
From To Ft.-_rVLe)t-1` Ltm 'i I
From To Ft.
15.
SCREEN:
Depth Diameter Slot Size Material
�ja vt5 �11 c
From —To—Ft— In. —in
Sckoo�
From _ To — Ft. _ In. _._ In.
From —To—FL— in. ` in.
15.
SAND/GRAVEL PACK:
�,(�oC51�e5 Yid -
Depth Size Material
From To Ft.
From To Ft.
J
17.
REMARKS:
}ra l
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Quad No: SIGNATURE OF PERSON CONSTRUCTI THE WELL DATE !
Submit o ginal to Division of Water Quality, Groundwater Section within 30 days
Serial No. �• ( � �},i GW1 REV. 17199
S
�o6fic

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: (,Q u -p fl 1�Q I � nA � C"y—
WELL CONTRACTOR CERTIFICATION
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential E Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCAT(IpZ N: Show sketch of the location. below)
Nearest Town: V� County:
(Road Najd Numbers, Community. or Subdivision and Lot No.) DRILLING LOG
3. OWNER---«<lllCiQa� (A �� r^ From �To
Address t ^� ,(�,-�,, _ ._
City or Town qq r�� State Zip Code
4. DATEDEPTDRILLED , UT U
S. TOTAL DEPTH �����-
6. CUTTINGS COLLECTED YESD NO®
7. DOES WELL REPLACE EXISTING WELL? YES NOF-1
S. STATIC WATER LEVEL Below Top of Casing: _A,() FT.
(Use'+' if Above Top of Casing)
9. TOP OF CASING IS 1 FT. Above Land Surface*
-Top of using terminated atior below land surface requires a variance In accor-
dance with I SA NCAC 2C .0118
10. YIELD (gpm): —.)_METHOD OF TEST O A-k
11. WATER ZONES (depth):
DEPTH
Formna�Bm Description
O
12. CHLORINATION: Type Amount l� 0 It additional space is needed use back of loan
13. CASING:
Wall Thickness LOCATION SKETCH
Depth Diameter or weighVR. ���r�i�all� pp�� (Show direction and distance from at least two State
From To Ft. � ._L.dXJ.EXx Roads, or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Dept Malaria eth d
From _�� Top& Ft. r� 5�,,
From To Ft. q
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 Q
From To Ft.
From To Ft. 0
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
PR"^O(V^IIDD,E,D TO THE WELL OWNER.
FOR OFFICE USE ONLY Ct1 bE '-2 �M- O i
Quad No: I NATURE O� NSTRUaNG TIDE WELL DATE
Submit origiri o Divislon of Water Quality, Groundwater Section within 30 days
Serial No. �' GW-1 REV. 12/99
4 8I,M1 r : e
.. i rol ndwaler SSc110n l
havilfe Regonal 1)ff-e _ 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]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: (A M2,P4/ ,^) P �Q �F cr-
WELL CONTRACTOR CERTIFICATION C: a \ 9 V
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 LOCATI N: ($how ketch of the location below) (� \
Nearest Town: !1„ -\) (i.P County: `\� 1�1� �' �� (�� ID
(Road N
3. OWNER
Address
or Subdivision and Lot No.j DRILLING LOG DEPTH
4. DATE DRILLED
5. TOTAL DEPTH � 2 "�--
6. CUTTINGS COLLECTED YES ❑ NOM
7. DOES WELL REPLACE EXISTING WELL? YES M NOF_]
8. STATIC WATER LEVEL Below Top of Casing: 2, C) FT.
(Use'+' If Above Top of Casing)
9. TOP OF CASING ISFT. Above Land Surface*
-Top of easing terminated atior below land surface requires a variance In accor.
dance with I SA NCAC 2C .011 a `
10. YIELD (gpm): _�iL METHOD OF TEST QM
11. WATER ZONES (depth):
From To Fonnatlon Description
D;r
D o c eWccp-
C:)
u
�o
�c
n
N'
m
o
12. CHLORINATION: Type
Amount
It additional space is needed use back of form
13. CASING:
Wall Thickness
LOCATION SKETCH
Depth��y1 rr ``
From- To
Diameter
Ft. —4--
or�w�i}hVFtt. �}i�at --(Show direction and distance from at least two State
- `-+t\ -Mom""' Road,., or other reap reference p ints}, A
From To
Ft.
From To
Ft.
14. GROUT:
Depth
Mateda ethod C.
From �_ To �
Ft.�
From To
Ft.
, 17
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 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: 1 GNATURE OF PERSON CONSTR CTI G THE WELL DATE
r OSu�roit7agl lo?Division of water Quality, Groundwater Section within 30 days
Serial No. �. OW-1 REV. 12)99
A ?1T(`r

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] / n
WELL CONSTRUCTION RECORD WELLCONTRACTOR: bo
`amps l �
WELL CONTRACTOR CERTFFI ATION 1f: ! 3 9
STATE WELL CONSTRUCTION PERMIT►:
1. WELL USE (Check Applicable sox): Residential 03/ Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other If Other, List Use:
2. WELL LOCA'
Nearest Town:
(Road Name
3. OWNER
Address
location below) U P
County: U 1 Y1.2Y 7�Y 0
or Subdivision and Lot No.) DRILLING LOG
From To
�d
°.
4. DATE DRILLED D DD
5. TOTAL DEPTH lb
6. CUTTINGS COLLECTED YES Q NO®
7. DOES WELL REPLACE EXISTING WELL? YES E] NO®
8. STATIC WATER LEVEL Below Top of Casing: q t� FT.
(Use'+' If Above Top of Casing)
9. TOP OF CASING ISFT. Above Land Surface'
'Top of easing terminated at/or below land surface requires a variance In accor-
dance with 15A NCAC 2C .et/a
10. YIELD (gpm): 10 METHOD OF TEST a I Y
11. WATER ZONES (depth):
12. CHLORINATION: Type oA Amount 1 C u
13. CASING:
Agricultural ❑ Monitoring ❑
DEPTH
It additional space is needed use back of form
Wall Thickness LOCATION SKETCH
Depth DDiiame�ter or Welght/R. Material (Show direction and distance from at least two State
From— iZ To'.
o �2 Ft..-u2�
,c�— `
J) K2 I � Roads, or other map reference points) Z(1y'ka 1
From To Ft.
From To Ft.
14. GROUT: ()
Depth Material {� ethol 1 J
u1
From To AOFt. � VAMI _E14b1_
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. S. C J f ,)\
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 T S RECORD HAS
BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY w' 00
Quad No: 41J;IGF)r'q E OF PERSON CONSTRUCTING E WELL DATE
d i-�SuGYnii Loon of water Quality, Groundwater Section within 30 days
Serial No. w GW-1 REV. 12J99
—A &0n

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:
WELL CONTRACTOR CERTIFIC ION #: J 3 8
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (check applicable Boa): Residential Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: IS w s vetch
f the I�o livv below) ,f
Nearest Town:
P V
E
� County: IA T {1 e V ✓ d
4
� o'/ S rn
I`Ll
(Road Name and Numbers, c�o;"�runi.ty,
( Subdivision and Lot No.) DRILLING LOG
DEPTH
3. OWNER a N'l
d1 A From To
Formadon Description
Address pooYS i'�✓Gr
ra-t4111
r ,A- O wD
Dlr+
V f' 1 (5 ree qr
ou a
o.) ,i t Q /o O 14`7
CGYLSD Li da'f"r d ro r11
uty or sown State zip Uwe
4. DATEDRILLED,A-),Z-oZooc%
5. TOTAL DEPTH 1 14ti
6. CUTTINGS COLLECTED YESQ NO®
7. DOES WELL REPLACE EXISTING WELL? YES NO�
B. STATIC WATER LEVEL Below Top of Casing: FT.
(Use': If Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface*
'Top of casing terminated atlor below land surface requires a variance In accor-
dance with 15A NCAC 2C .0118
10. YIELD (gpm): �� METHOD OF TEST _zL I
11. WATER ZONES (depth):
01010101Fem
12. CHLORINATION: Type
CkloYiW2 Amount c
It additional space is needed use back of form
13. CASING:
Wall Thickness
LOCATION SKETCH
Depth
Diameter or WeightrRt. Material
s
(Show direction and distance from at least two Stale
From To 6
Ft., R 2,
Roads, or other map reference poll i )
From
To
Ft.
From
To
Ft.
14. GROUT:
Depth
Materi I Metho
w
From
To �s'^Ft.
From
To
Ft.
15. SCREEN:
Depth Diameter Slot Size Material
X
From
To Ft
In. In.
From _ To _ Ft. _ In. — In. PO p 15 : r
From —To _ Ft. _ in. —in.
16. SAND/GRAVEL PACK:
Depth Size MaterialFrom To Ft.
From To Ft. 3
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF IS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY "-'qu kJ i
Quad No: - • S] E OF PERSON CONSTRUCTING THE ELL DATE
SW1mitNdyfHW-Id iviblon of Water Quality, Groundwater Section within 30 days
Serial No.2 GW-i REV. 12/99
r a:jfl'1

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: 0amA5' OePuWt4
WELL CONTRACTOR CERTIFICA iON a: 13 8 (—_—�—
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: f§how sketch �+ ch o the location below) Q
Nearest Town: Aw,/e ` ±j County: I \ � e Y
key'/v St.
(Road Name and Numbers, Community. or Subdivision end Lot No.) DRILLING LOG DEPTH
3. OWNER From To Formation Description
Address Q
D D 5i,
ree or ou e o. 0 o Ada fc cK
h>e5� C. C' �80 3
City or Town State Zip Code
4, DATE DRILLED — D - a,o DO
5. TOTAL DEPTH o S
6. CUTTINGS COLLECTED YES[:) NO® �p o
7. DOES WELL REPLACE EXISTING WELL? YESED NO -' ��
8. STATIC WATER LEVEL Below Top of Casing: FT. a oc
(Use'r' If Above Top tif Casing)
9. TOP OF CASING IS FT. Above Land Surface* c
'Top of using terminated at/or below land surface requires a variance In actor-
dance with 15A NCAC 2C .0118 _
10. YIELD (gpm): 4L— METHOD OF TEST 41) Y
11. WATER ZONES (depth):
12. CHLORINATION: Type e e Amount _L� If additional space Is needed use back of form --
13. CASING:
Well Thickness LOCATION SKETCH
Depth Di;n r or�aight/Ft. Trial (Show direction and distance from at least two State
From _.L� To � Ft. t R 2I i' V L Roads, or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Mateda� Method, --
From � To �D Ft. Cewter\, _I/lsl.wd
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 ate'
Quad No: „,_Sl REAF PERSON CONSTRUCTVG' WELL DATE
Submit ongirlal t ition of Water Quality, Groundwater Section within 30 days
Serial No. _.. '.. F1 , AI GW-1 REV. 12/99
4I 6E

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 WELLCONTRACTOR: -� �mp5 �� l� NMA �D­ lnc.
WELL CONTRACTOR CERTIFICATION #: 2 138
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Boa): Residential ❑ Municipal j Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use: u ti I
2. WELL LOCATION: (ShQw sketch of the location below) I{{- I
Nearest Town: —r Ot t1'e County: Rt4,I�1 Ke✓�YA
(Road N
3. OWNER
Address
0
raj
4. DATE DRILLED
5. TOTAL DEPTH 4,0 `5 # i
6. CUTTINGS COLLECTED YES ❑ NOPD
7. DOES WELL REPLACE EXISTING WELL? YES NOF_�
8. STATIC WATER LEVEL Below Top of Casing: 6V FT.
(Use'+' 0 Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface*
Top of casing terminated at/or below land surface requires a variance in accw-
dance with I SA NCAC 2C .0119
10. YIELD (gpm): It METHOD OF TEST D I,l�—
11. WATER ZONES (depth):
DRILLING LOG
From To
O Io
S1�I (00�
DEPTH
Formation Description
1:e� CIaV
5an�5'i� h
G ✓a ru +� O P
12. CHLORINATION: Type ell e Y i kte Amount It additional space is needed use back of form
13. CASING:
Wall Thickness
Depth Diameter w Welght/R. Material
From-0 To �� Ft. (;-,%4 tog CAI -
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From O To S` Ft. C e w c r t : rLJc
From To Ft.
15. SCREEN:
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
well IV'
U eYti nb j.µnt r�+Ve,rt (`�
�t,ns IM1L
Depth
Diameter Slot Size
Material
From _ To _
Ft _ in. _
in.
Ry%+
— -
From —To —Ft.
in. —In,
wh;}-6iJes WA
From To —FL
in. —in.
16. SAND/GRAVEL PACK:
Depth
Size
Material
5�\0
From To
Ft.
From To
Ft.yb
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Quad No: - GNATURE OF PERSON CONSTRU TING HE WELL DATE
Sut3l(1it o Serial No. to Division of water Quality, Groundwater Section within 30 days
it
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: 1 QIA-�-nPrJ) c t'
WELL CONTRACTOR CERTIFICATION 1f:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential E3� Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCAT(ipNN- ( how ket It f the location below)
.(%
Nearest Town: �-Hx �,�'�- County: --
(Road Name d Numbers. ConFirAy. or Subdivision and Lot No.)
3. OWNER �' L L' &r
Address <IF
eet or Hqui
Cityor Town �State Zip Code
4. DATE DRILLED v
S. TOTAL DEPTH (j20s
6. CUTTINGS COLLECTED YES ❑ No
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO[J]
8. STATIC WATER LEVEL Below Top of Casing: Sj If FT.
(Use '+' 11 Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface*
'Top of casing terminated atlor below land surface requires a variance in accw-
dance with ISA NCAC 2C . 119
10. YIELD (gpm): METHOD OF TEST Q A ;,
11. WATER ZONES (depth):
12. CHLORINATION: Type t/,YA X Amount
13. CASING:
DRILLING LOG DEPTH
From To Fomwllon Description
qo
�rr?
�or5o),'doY2�c,IC
If additlonal space is needed use back of form
Wall Thickness LOCATION SKETCH
Depth ,, Dipa�rrleetter W_eipht//Ft. e�nal(Show direction and distance from at least two State
FromTo =1 Ft. �11� ><\ d lJs�1 t Roads, or other mapk_sW4n1vpoint
From To Ft. —
From To Ft. n
14. GROUT: ��,�,ty
Depth1� Material M thod (�
From �L To �SLFt. 'y
From To Ft.
15. SCREEN
Depth
Diameter
From
—To
Ft in.
From
_ To _
Ft. _ In.
From
_ To _
Ft. in.
16. SAND/GRAVEL
PACK:
Depth
Size
From
To
Ft.
From
To
Ft.
17
Slot Size Material
In.
In.
in.
Material
W W4A�
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 1 SA NCAC
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY �.
Quad No: .)
Sulxnd gpir
Serial No.
4W
11
WWE OF PEhSON CONSTRICTING THE WELL
M116n or water Quality. Groundwater Section within 30 days
DATE
GWA REV. 12199

Page I of 1
North Carolina ➢epartmenr 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 �+ r
Quad. No. Ser. Na l'1 U
Lat. Long. RO
Minor Basin
Basin Code
Header Ent. GW-I Ent.
Drilling Contractor CAMP'S WELL k PUMP CO., INC.
pri!(eeCer7;F'cA{'�n ,)34 a135 ,113V State Well Construction
Driller Registration Number 215 Permit Number
1. WELL LOCATION: (Show,sketch of the location below) County R,a,q er , r d
Nearest Town �0.rr15
(Road, Community or Subdivision and Lot No.)
2. OWNER ClyJr De w or
ADDRESS / o I C F- S C i rc l e
P"o rs'r Cifv AJC aS'04?
3. DATE DRILLED I - I8-a,000USE OF WELL -DOMESTIC
4. TOTAL DEPTH 3 o 5
5. CUTTINGS COLLECTED? NO
6. DOES WELL REPLACE EXISTING WELL? NO
7. STATIC WATER LEVEL Below Top of Casing: 50 FT.
B. TOP OF CASING IS 1 FT. Above Land Surface.
9. YIELD (gpm) 3 0 METHOD OF TEST -PUMP
10. WATER ZONES (depth)
11. CHLORINATION: Type CHLORINE Amount I c- op
12. CASING:
Wall Thickness
Depth Diameter or Weight/Ft. Material
From D To 5S ft. 6 114 SDR 21 PVC
From To ft.
From To ft.
13. GROUT:
Depth DRILLING LOG
From To Formation Description
0 SS DIRT
55 3o5 CONSOLIDATED ROCK
o
r p
N
o
(Show direction and distance from at least two
State Roads, or other map reference points)
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.
— fie,
14. REMARKS:
;,:I
I ➢O HEREBY CERTIFY THAT THI¢ VJ)}LL.gAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCT I01iSTfNDgDgWAIQ TPWONO3HAT,A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
MR SIGNORE OF CON CTOR OR Afi NT DATE
GW-I REV. 9/91 '; Submit original to Division of Environment Management and copy to well owner.
A`.?,.

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
Drilling Contractor CAMP'S WELL h PUMP CO., INC.
FOR OFFICE USE ONLY 1 Of 0 )-
Quad. No. Ser. No.
Lat. Long. RO _
Minor Basin
Basin Code
Header Ent. 6W-1 Ent.
Or�![e✓ Cc, y-J41'ca}iar< ;, 134, At 35, 39 State Well Construction
Driller Registration Number 215 Permit Number
1. WELL LOCATION: (Show sketch of the location below) County ui( er a,
Nearest Town H0,rr;fl
(Road, Community or Subdivision and Lot No.)
2. OWNER ,6'mLer
ADDRESS Iqo yJ ✓ 7%0 .Psi IZ�
�. u`i�'r"nr��V�tJ C d2139
3. DATE DRILLED I-13 ✓goo 'USE OF WELL -DOMESTIC
4. TOTAL DEPTH 2 YS
5. CUTTINGS COLLECTED? NO
6. DOES WELL REPLACE EXISTING WELL? NO
7. STATIC WATER LEVEL Below Top of Casing: 40 FT.
B. TOP OF CASING IS 1 FT. Above Land Surface.
9. YIELD (gpm) 30 METHOD OF TEST -PUMP
10. WATER ZONES (depth)
11. CHLORINATION: Type CHLORINE Amount ) r--p
12. CASING:
Wall Thickness
Depth Diameter or Weight/Ft. Material
From D To S5 ft. 6 1/4 SDR 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.
K
15. SAND/GRAVEL PACK:
Depth Size Material
From To ft.
From To ft.
14. REMARKS:
Depth DRILLING LOS
From To Formation Description
0 DIRT
55 CONSOLIDATED ROCK
(Show direction and distance from at least two
State Roads, or other map reference points)
I DO HEREBY CERTIFY-THAT,THIS WELL W9 CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2N WELL
CONSTRUCTIO14jrAADA40S,(AND(4HAT ARID THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
SIGNATURE CONTRACTO OR AGENT DATE
GW-I REV. 9/91 yr Submit original to Division of Environment Management and copy to well owner.
ice..:.:......-.. °. ;

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 ONLW] () C 9'7
Quad. No. Ser. too `�
Lat. Long. RO _
Minor Basin
Basin Code
Header Ent. GW-1 Ent.
Drilling Contractor CAMP'S WELL S PUMP CO., INC.
0riiler a13L41
State Well Construction
Driller Registration Number 215
Permit Number
1. WELL LOCATION: (Show sketch of the location below)
County f2 lti e r-; r d
Nearest Town r re sf C,iy
- k � C
Depth DRILLING LOG
(Road, Community
or ubdivision and Lot No.)
From To Formation Description
2. OWNER Fi' 1
fa Ada rv,5
0 4S DIRT
ADDRESS 513 E�p le
{S 5A5 CONSOLIDATED ROCK
R,t*I,,cK- -h t, L :C'1719
—
3. DATE DRILLED I 13-ao00USE OF WELL - DOMESTIC
—
4. TOTAL DEPTH S 85
o
5. CUTTINGS COLLECTED? NO
_
6. DOES WELL REPLACE EXISTING WELL? NO
r"
7. STATIC WATER LEVEL Below Top of Casing: l5o FT.
— —
B. TOP OF CASING IS 1 FT. Above Land Surface.
— —
9. YIELD (gpm) I METHOD OF TEST -PUMP
— —
le. WATER ZONES (depth)
— — 3
r
tl. CHLORINATION: Type CHLORINE Amount C z/
r
N
12. CASING: —
Wall Thickness
Depth Diameter or Weight/Ft. Material
From O To 45- ft. 6 114 SDR 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 reference points)
f
�e 1 „f \t'
14. REMARKS:
I ➢O HERft6E(T4W-U9 T.WiS-WELL, WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCT SIItDWDS'40f TWT AD THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
r
NIAR _ ° SIGNATL# OF CONT CTOR ftRENT ENT DATE
GW-1 REV. 9A1 Submit original to Division of Environment Management and copy to well owner.

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
Quad. No. _
Lat.
Minor Basin
Basin Code
Header Ent.
FOR OFFICE USE ONLYr) 0
Ser. No.
Long. RO
GW-1 Ent.
Drilling Contractor CAMP'S WELL & PUMP CO., INC.
Qr;qer 2-135'
State
Well Construction
Driller Registration Number 215
Permit
Number
1. WELL LOCATION: (Show skgto chh of the location below)
County
R u e r r
Nearest Town k Ev 4 v w
Lake, Cv¢ev ce,N .
Depth DRILLING LOG
(Road, Community or Subdivision and Lot No.)
From
To Formation Description
2. OWNER LoWell Fv- i3
0
3 S DIRT
ADDRESS 5q1l focus r R lse
$5
�oS CONSOLIDATED ROCK
L�Klow Miller Nc- a1167
_
3. DATE DRILLED [-4-; 000 USE OF WELL -DOMESTIC
4. TOTAL DEPTH 606*
e3
0
5. CUTTINGS COLLECTED? NO
6. DOES WELL REPLACE EXISTING WELL? NO
7. STATIC WATER LEVEL Below Top of Casing: 80 FT.
-
B. TOP OF CASING IS 1 FT. Above Land Surface.
-_
9. YIELD (gpm) to METHOD OF TEST -PUMP
Y
10. WATER ]ONES (depth)
11. CHLORINATION: Type CHLORINE Amount I c kP
N
�
12. CASING: —
Depth
From o
To 35" ft.
From
To
ft.
From
To
ft.
13. GROUT:
Depth
From 0.
To 20
ft.
From
To
ft.
14. SCREEN:
From
From
From
Depth
To
To
To
15. SAND/GRAVEL PACK:
Depth
From To
From To
14. REMARKS:
Wall Thickness
Diameter or Weight/Ft. Material
6 1/4 SDR 21 PVC
Material Method
NEAT CEMENT HAND METHOD
Diameter Slot Size Material
ft. in. in.
ft. in. in.
ft. in. in.
Size Material
ft.
ft.
(Show direction and distance from at least twol
State Roads, or other map reference points)
�LlnavcN f
I DO HERRY,CERTtFYjTHAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CON$}RUGT#ON➢AR kAMBS, AND THAT AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
MAR —
I ; SIGNAT & OF CONTR TOR OR AGEWr DATE A 4" o O:
661-1 qEV. U0 ., Submit original to -Division of Environment Management and copy to well owner.
9