Well Construction Records Swain CY2000

North Carelina - Department of Environment and Natural Resources -Division of Water Quality - Groundwater Section
'3036
1636 Mail Sarvlce Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELLCONTRACTOR: ua—u°,I %ayln y-
\TELL CONTRACTOR CERTIFICATION 0:
STATE \YELL CONSTRUCTION PERMITN:
I. WELL USE (Check Appflcabla Box): Residentl*n taunicipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Roca%cry ❑ Heat Pump Water In;talon ❑ Ottr_-r ❑ It OI„er, List Use:
2. 1NELL LOCATIOt{,(Show sF:etchI the Iota lion Lolow)
Nearest Town: k) r`Ij S L� I d }i.l Cou, y. Sw,-C - /.i
(Road 1.'ama antlst'umbcrs, Co/%rnunily, or ,Stub,". sion and Lol
3. OWNERGAC r-iY SI UjC'-S
Addrec3 P. (, , /li v 5�r-S
'Gi;), or Yo.cn - ISta!o Zip Coca
4. DATE DRILLEDS*24_C °r qjj o2u t)
5. TOTAL DEPTH 2 7
G. CUTWI GS COLLECTED YES Q N00
7. DOES'VIELL REPLACE EXISTING VIELL? YES F-1 NO2�j
B. STATIC WATER LEVEL Belor: Top of Casing: (-) FF.
(Usc'+- it Abovo Tcp of Ca;in;.)
9. TOP OF CASING IS i FT. Abovo Land Surface'
'Top al call: , tennlnatcd avor bolom land surfaca roqulrea a vadanca In accor-
danca v:lth I A NCAC 2C. 1 to
10. YIELD (clam): METHOD OF TEST AL
11. WATER ZOINES (depth):
12. CHLO=:INATIOi.: Type \"1 i \� _Amaun;-2—�
13. CAShVG:
4SaIl 1'. �.icx.-roc;
Death
Di;, nclor cr i I �•a:c r!,-.I
,��-
From i >
To �
Ft.
-
Fro:n
- To ---
Ft.
From
To--
Ft.
-
14.
GROUT:
Depth
Alolhod
From'
To=a�..>-_rt.
l�hlatorlal
From
- To
Ft.
15,
SCREEN:
Dcpth
Dimnelor
Slot Size Malarial
From
_ To __ FI
in. in.
From
To Ft.
In. in.
From
To Fl.
In. in.
16.
SAND/,RAVEL PACK:
Depth
Sizo Gale:ial
From
To
Ft.
From
To
Ft.
17.
REMA-,KS:
DRILLING LOG
From To
0 — 5,3
S +-off2 rW
DEPTH
Ferrraflon Descrip6cn
� _.-11--11:Icrais-zu�; nc•ec4d use_--—_�-__—�__
LOCATION .SKE 1-CH
(Sho,v direct:cn rnd C'stcrrc :.an '. b: No Sta7•
Roads, or ether mep icic;ar,a:
g rf�soN L 17'
s Rii ya c�i«ik�ti R��n
R 1156 �IN.Ljol�r Rcl
I DO HEREBY CERTIFY THAT THIS WELL',VAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 20. WELL
CONST UCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO TH�E�VIELL OWNER. L C
FOR OFFICE USE ONLY � k �Cp- "tL E`oS lU \ I G•+ -)\ "yl�C''��(.
Quad No: SIC'tAf'1fA1. Cr 061Sf.'3N d.01ISTRLtC T It G : HE WELL DATE
Submit od.inal to ci l41dlt of \'fate! Qua,lly. G'ound r:a:of Seclicn 'erilhln 30 days
Serial No. "' ' {' G'.11 REV. 12/59

North Carolina - Department of Environment and Natural Resources - Division of Water Duality - Groundwater Section
236186
1636 1Aall Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: oUl �HO�
WELL CONTRACTOR CERTIFICATION 0:
STATE WELL CONSTRUCTION PERIAITM:
ntial
1 • WELL USE (Cheek Applicable Boa): Reside
[��jAunicipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heal Pump Water Injection ❑ Other I] II Other, List. Use:
2. WELL LOCATION: (Shaw skglch of the location beloCoun 5�7 ;n
Nearest Town: y:
DRILLING LOG DEPTH
_-----
(Road Name and Numhen, Community, or Subdivision and Lot No.) from To f omnaXn Dcscriptio`
3. OWNER �� f34 0 f7L --
Address
I(eetar oae a. �-�6O C
Ciry or Town
Stale zIp coda oo - 3G-D
4. DATE DRILLED
5. TOTAL DEPTH J 6 0
6. CUTTINGS COLLECTED YFS ❑ NOEJ—
7. DOES WELL REPLACE EXISTING WELL? YES 0 NOD
a. STATIC WATER LEVEL Below Top of Casing: /S7-0 FT•
y (Use't 0 Above Top or Casing)
9. TOP OF CASING IS 1 Z FT. Above Land Surface'
-Top or easing terminated elfor below land sudsce requires a variance In accor.
dance with 15A NCAC 2C.0115 �-
10. YIELD (gpm): r_ METHOD OF TEST
11. WATER ZONES (depth):
baci of lc '
12. CHLORINATION: Type
l>` Amount l{G It additional space a needed rse
13. CASING:
LOCATION SKcTCH
Wall Thickness
Material I
(Show direction and d's-ante bxn 21 Iia� re•° -�a e
Depth � v/
d
Diameter or �WeIghUFI.
�- - —
Roads, or other ne7 relert: rs fo
From To 1 t
TO.2t,2 6-
FI• —
, /
Ft.
Fromm
From To
Ft.
14. GROUT:
Depth
elhod
M d�
c7
I
c
0.-
6 To �7�
_ - -
From
To
Fl. �
From
15. SCREEN:
Diameter Slot Size Material
a?
C'3
rn
m
Depth
From —To_Ft
_- In. _In.
CD
0
From _ To _. Fl.
_ In. _ In.
In.
From _ To ,_- Ft.
In. _-
•
16. SANDIGRAVEL PACK:
Material
Depth
Size
From To Ft. I —
From To Fl. —
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL W111 AS
CONSTRUCTION STANDARDS, AND THAT A 0
=No:
ED IN ACCORDANCE WITH 15A NCAC 21.'/%ELL
RECORD HAS BEEN PRONGED 70 THE VIS!-L 011NEF..
�$IONATURE OF PERSON CONSTRII%TIf IG lYc '/YELL
a'E
bmil,040nd to Divldon of Wale(Ouallty. Groundwater Seem within h C�W Ea.l Pk V. I=11
e

North Carofrta • Department of Environment and Natural Resources _ Division of Water Quality. Groundwa!er Section
1536 Mail Service Center • Raleigh, N.C. 27699-1636-Phone [phone] J . ,- 2 3 4 4 6
WELL CONSTRUCTION RECORD WELL CONTRACTOR:1UP61I
WELL CONTRACTOR CERTIFICATION
Orn`I #' STATE WELL CONSTRUCTION PERMITp:
1. WELL USE (chock Applicebla Poo): Residenliakn Municlpat ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water In;ection❑ Other ❑ It Other, List Use:
2. %','ELL LOCATIO' \' ( how sketch of the location below)
Nearest Town: W ,+fter Coun7
e 0-r-N DOc
(Road Name and Nu. bcrs, orr .. Cnity, or Subr!Mslcn and Lot No.) DRILLING LOG DEPTH
3. OWNER y From To n FCn`r3t10n Descrp:ion
Address 1 7r- ��/f (',/"� �` .. O _ l.. lQ V Sj C+rc­
JPect or 5oXe Ol 6 /a Y•-� L r--J�
` f 7 / Ci T L) �� !b IreL 1 T
r
City or Torn stata � Zip Cove --p
4. DATE DRILLED CrCmher V .q" —
5. TOTAL DEPTH ?,'M
6. CUTTINGS COLLECTED YES© PiOL --
7. DOES WELL REPLACE EXISTING WELL? YES L tJOf�
E. STATIC WATER LEVEL Belovr Top of Casing: _b b FT.
(U.e *.'if Aboao Tcp of Cosinq) n
9. TOP OF CASING IS 1 FT. Abovo Land Surface' �-
'Top of eaa:ng lcrtnlnaled o'+'or bclovr land sur:azarcqu!:ca avarlan<a In a<eo:• F6
dance rash 15A HCAC 2M.. 1B
10. YIELD (cpm): ME THOD OF TEST7ir
11. WATE,RLOt'�:ES(depth): -.Ju< 3 -a
��� tii- .3J.S
12. CHLOAIi:ATIOi:: Type _.L4 � __A:� !unt L,�JJ_S If �dd;:ional e.. yp space i; needed uce to : �:m m
13. CASING:
IYr.i i,acx.-c:; LOCTIC,:4 SKE I OH t •�_-r
Depth
From To �El Ft. _l _ ..2.0 Roads, or other map Wercc_:
From To_ Fl.—
Front To-- FL —
14. GROUT: r
Depth I� f�a�a�td�r�lal t.:o thud n
From' 0 To'i�FI. 1tLYs�`� ��2 f �on7a$ On-Ife y A
From --To Fl. tn� Rd
15. SCREEN: - S i1 1 %7 0410 '`j
Depth Diarnoler Slot Size Malarial
From -To _ Ft in. in.
From To Pt. In. In.
From To Fl. _ In. In.
16. SAND/1-RAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
17. REMARKS: - /
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCOROANC'c WITH 15A MAC 2C, W ELL /N/ f/�
CONSTRUCTION STANDARDS, AND THAT A COPY OF THI`S RECORD HAS BEEN PROVIDED TO THE
V; ELL O'IR�ER. L� C�
OHI/
R OFFICE USE ONLY �._� l`)Ce.eJ.;e }��`'
FOS G`�'.�1 Y\I G•+ )\
Ovad No: SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
SJBNY�fL'7� n.�1,;o"l'gl '�ry o!_ ','a:er Ova' ;y. G:cundr. a;cr 5caien wilhln 30 days
scrialNo. ' Wl ,'I Gw-1REV. 12r59
` i�

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Ground Water Section c:.J 2 813
1636 Mail Service Center - Raleigh, N.C. 27699-1636 - Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: Hedden Bros. Well Drilling Inc.
WELL CONTRACTOR CERTIFICATION #: 2047
STATE WELL CONSTRUCTION PERMIT N:
I. WELL USE(Check Applicable Box): Residential 0 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: Bryson City County: Swain
Nrihols Rd
(Road Name and Numbers, Community, or Subdivision and Lot No.) DEPTH DRILLING LOG
3. OWNER Quentin Smith From To Formation Description
Address 396 Scenic Rt 0 57 ring Rr -"Ind
(Street or Route No.) 57 500 granite
Cordele GA 31015
City or Town State Zip Code
4. DATE DRILLED 12/19/00 0
5. TOTAL DEPTH 500 0 0
6. CUTTINGS COLLECTED YES ❑ NO n T
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO M o
8. STATIC WATER LEVEL Below Top of Casing: 0 FT. oc'
(Use " + " if Above Top of Casing) N o
9. TOP OF CASING IS 2 FT. Above Land Surface*
'Top of casing terminated at/or below land surface requires a variance in actor- rn o
dance with 15A NCAC 2C .0118 =
10. YIELD (gpm): 6.00 METHOD OF TEST Blow o?�
11. WATER ZONES (depth): 7?5
0 C o
12. CHLORINATION: Type H T H Amount If additional space is needed use back of form
13. CASING: Wall Thickness
Depth Diameter or Weight/Ft. Material LOCATION SKETCH
From -0 To 59 Ft. 611 nvc (Show direction and distance from at least two State
From To Ft. Roads, or other map reference points)
From To Ft.
14. GROUT:
Depth Material Method
From 0 To 20 Ft. Cement Poured
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From —0 To Ft. in. in.
From To Ft. in. in.
From To Ft. in. in.
16. SAND/GRAVEL PACK:
Depth Size Material
From 0 To Ft.
From To Ft.
17. REMARKS:
I DO HER,9BY (7-TtFY.�ii
CONSTRI�r01yS'INI�'p
FOR OFFICI ONLY-
uad No.
Serial No.
WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
'A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
L / /5Wi9
e SIGNATURE OF PERSON COISTRUCTING THE WELL Date
'.c;R Submit riginal to Division of Water Quality, Groundwater Section within 30 days

_ pivlabn of Water OwNry • Oroundwaur Sscdon f � 3 t 7 9 3
North Caroller - g C Department Iar.RaM1gh,�C. 276W,t and N 364,nons (9 ��1
1636 Mail Service Certear -Qti C ry I .,
WELL CONSTRUCTION RECORD WELL CONTRACTOR: 5-0
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE DID* Appilo$We ilox): Residentisi Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery Heat Pump Water In)Wlon ❑
Other 0 If Other, List Use:
2. WELL LOCATION: (Show sketch pf the location below)
Nearest Town: / 1' L Cti'tF __ County:
DRILLING LOSz._ DEP--- TH
(Road Name and NurtDµs. nuY gupdvleion and tat No.y •---� FormAllm DperiOO'
From To
3. OWNER ¢ �---
Aidreae (>7S 2 vvadr k'rn !Z �__
4. DATE DRILLED L 2 2 o o
S. TOTAL DEPTH NO®
S. CUTTINGS COLLECTED YES ❑
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO®
S. STATIC WATER LEVEL Below Top of Casing: �o S.
(ties 0+0 A Above Top of Casing)
g. TOP OF CASING ISFT. Above Land Surface'
'Top of *ask* Iermbm*W s0or brow h1W sudw* require$ a verlance In $eoen
denoe with taA NCAC 2C At 11
10. YIELD (gpm): �_O_ METHOO OF TEST A "
11. WATER ZONES (depth): % SS
12. CHLORINATION:
13. CASING:
0
O o
Type Amount d , 78 1f additional spat$ fa needed use back of form
J TN
Depth r
From r _To 3 Ft. b�—
From To Ft.
From To Ft.
14 GROUT:
Wall Thickness
or Weight/Ft. Material
Depth
Material Method
From
0 To 9-0—
FtftmLL, 4- v�
From
To
Ft.
15. SCREEN:
Depth
.
ize
Ft.
Ft.
S
Material
ATION SKET_
(Stow direction and dletancs from at least two State
Roads, or other map reference Points) ,J A }
pT, �wucu i
i2a-li- VrttLo„ �ir:� ��eC �p G / t, o
d•n� cr �n� � tAulC,,
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
Ouad he; E PE SON CONSTRUCTING THE WELL DATE
Submit original to DMslon of Water Carlty, Groundwater Section within 30 days
9erfal No. GW-t REV. 17/ea

NoCarolina - Departmam m of Environment and Natural Resources - Division322of Water Ouslity • Groundwater Section �23692
n"
ION Mail Service Center • Raleigh. N.C. 27694.IGWPhons (e1e)
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION #: 0 S c�
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Cheek Applicable sea): Residentlai ® Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water injection ❑ Other It Other. Ust Use:
2.
WELL LOCATION (Show sketch of the location below) '5t"
v
NewatTown: IM4- 12d= C-i. -ZI CounK
(Row Nsm��sne t�rresn Cann+MY, «SuOdNabn ►rd Lot No.) DRILLING LOG
DEPTH_
3.
OWNER Kt114 - F/1- n n�en�, From To
Fom*tw Deeatodon
Address et-_.Q ra ,r jze�-
�
--
n C m =z
Cey I~ � , , �) �, � NP Code
00-------------
.,
o
4.
DATE DRILLEDI2•
--
S.
TOTAL DEPTH 0
C_
S.
CUTTINGS COLLETOTED YESO NO®
Z-
7.
DOES WELL REPLACE EXISTINNGG WELL? YES ❑ NO®
i
B.
STATIC WATER LEVEL Below Top of Casing: jo o FT.
of
g.
(Use ••' I Ab" TOP a Cast1S)
TOP OF CASING IS�_ FT. Move Land Swfsce'
-,_-
o
T�
Top of seeby ben M aNd aria 11014901161141 SUdW* reerdree a 11811M In aeeer-
N�
, I wMISANCA025.ette
10. YIELD (gpm): �_ METHOD OF TEST R
^
o
Q_
11.
WATER ZONES (depth): 3 1
12. CHLORINATION: Type Amount O ••r It akfmtlorW ;;cote 4 needed use fuck of form
13. CASING:
LOCATION
Wag Tfrsss
Depth 011"'etsr «waighighrlFt. btebdal (dhow direction end dleWce kom at tesq two Stste
From 0 To 3-1 FI. ` ` SDtR �L l a: v c Rods. «o6»r MOP reference points)
From To FIt�t
From To Ft.
14. GROUT:
Depth Material Method aL J 5 0 /
From _SL_ To 2a FL�Q»Lj 1 Ste lJ
From To FL ��
15. SCREEN:
Depth Diameter Slot SW Material
From To _ Ft — In. _ In.
From To Ft. In. _ In.
From —To _ Ft. in. _ In.
1S. SANDIGIRAVELPACK:
Depth SW Mate"
From To Ft.
From To Ft.
17. REMARKS:
`1l"0" C to
/1M Q e r Y2VWY i'�cc nr lid
gtLF '7 cw �c� (aTf csr.i 6
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 1 SA NCAC 2C, WELL
CONSTRUCTION STANDARDS. AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Gud He. #WATIM olepgpA6N cotiSTRUCTifq THE WELL DATE
aA rna b awaien of WSW quaky, 0mur 0astar seeuon within 30 days
So" No. dW1 REV. 17n1

North Carolina - Department of Environment and Natural Resources - Division of Water Ouality, - Groundwater Section 2 3 6 9 1
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (check Applicable sox): Residential ® Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town:
1 f County:
(Road Name and tilumbers, Community, or Subdivision and Lot No.)
3. OWNER c L (44.�1 U
Address i ¢AM
rV /d LL R4
u, 01 Ou a 0. 71C
City Town State Zip Code
4. DATE DRILLED ! 3 a a
5. TOTAL DEPTH ,2 S0 '
6. CUTTINGS COLLECTED YES ❑ NO®
7, DOES WELL REPLACE EXISTING WELL? YES ❑ NO©
S. STATIC WATER LEVEL Below Top of Casing: 10 FT -
(Use '+' if Above Top of Casing)
9, TOP OF CASING ISFT. Above Land Surface'
'Top of casing terminated sVor below land surtmo requires a variance In accor-
dance with 15A NCAC 2C .0118
10. YIELD (gpm): JL-- METHOD OF TEST e�--
11. WATER ZONES (depth): 1
12. CHLORINATION:
13. CASING:
DRILLING LOG DEPTH
From To Formation Description
-------------------
Type TN Amount O•.q-7— If additional space is needed use back of Corm
From
Depth
To 5 E
Wall Thickness
Diameter or Weight/Ft. Material
Ft. — I$JD- �y--
From
To
Ft.
From
To
Ft.
14. GROUT:
From 0
Depth
To ;ka
Material Method
Ft.O- 7-1— +SOvl
From
To
Ft.
15. SCREEN
Depth
Diameter
From
To
Ft in.
From
To
Ft.— in.
From
_To
Ft. in.
16. SAND/GRAVEL
PACK:
Depth
Size
From
To
Ft.
From
To
Ft.
17
Slot Size Material
in.
in.
_in._
Material
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
ilJ.}-f/)ti/LLr.n /S.�tfi.t.,e-Y�-,1SG_I .000�e --� �� p
AA�•y�t.�i L21Jyy`. 7 W2 7-/Ltvp
CA
u� YZA, / S�lO YT-L,L"l
ar i�L1,c�ZN-/1d
cr1.L e alul -c­
I DO HEREBY CERTIFY TFIAT �I, IS WELL'WA4�0gNSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, ANI&T14AT'A661a'YOF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY DA7
Quad No: 91t3 T OF P RSON CONSTRUCTING THE WELL
Submit onginal to Division of Water Quality, Groundwater Section within 30 days
... _. _.... ,....._.... GW.1 REV. 12/99
Sena[ No.

North Carolina • Department of Environment and Natural Resources • Division of Water Oualiy • Groundwater Section
2JO61'79
1636 Mail Service Center • Raleigh, N.C. 27699.1636-Phone [phone] /t ` ,1 )
WELL CONSTRUCTION RECORD WELL CONTRACTOR: )NK/1� 17J7 a�o17
WELL CONTRACTOR CERTIFICATION M:�
STATE WELL CONSTRUCTION PERMITN:
1. WELL USE (Check Applicable Boa): Residengal LJ Munlclpal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other C1 11 Other, List Use:
2.
WELL LOCATION (Shgw sketch of the location below) SDK%�l
Nearest Town: sue. �'6 /RLL2 County:
�heun
(-,f°�
(Road Name and Numbers. orn unit , ). S_ubdlvision and Lot No )
DRILLING G LOG
To
3.
/0�,7 4n� /Z �/
OWNER �C
From
Address 5oO A), 1—
veet or ou a o.
City or Town Stale Zip Cade
//-lo
Zr — 6 7
i 7—✓fld
4.
DATE DRILLED
5.
6.
TOTAL DEPTH -570
CUTTINGS COCTED YVS C1 NOP�
LLE
:J
7.
DOES WELL REPLACE EXISTING WELL? YES
B.
STATIC WATER LEVEL Below Top of Casing:
(Use'r' N Above Top of Casing)
9.
y
TOP OF CASING IS FT. Above Land Surface*
-Top
or casing terminated stfor below land surface requires a valiance In accor-
1 (g m). 2c.21e METHOD 9F TEST
dance YIEwithLD
10. YIELD (gpm):
11,
WATER ZONES (depth): �fs
12. CHLORINATION:
13. CASING:
DEPTH
Fom'ixn Descdpti-
i
T e / " r -- Amount G It add donal s;ace is needed back of lc,m
YP
Wafl Thickness
Depth Dlameler or.7
l hVFI. Mal dal
From To lfS
FI. .;� ee/
From To
From To FI.
UT
14. GRO
Depth
/%A���t��rlal//
L/'7'Lo, !
Ihod
ressu� e
From
D To ;;-'4'
Fl.
From
To
Fl,
15. SCREEN:
Depth Diameter Slot Size
Material
From
To Ft
In. —In.
From
_ To _ Fl.
— In. — In.
From
_To_ Ft.
In. — In.
16. SANDIGRAVEL PACK:
Depth
Size Material
From
To
F)•
From
To
Ft. ---
--
17. REMARKS:
1 DO HEREBY CE
CONSTRUCTION
LOCATION SKc TCH
(Slow direction and dance Irm ed leas'U.o Sate
Roads, or other rr,7 reiennrr_ points'
RIACCOROAIICEWITFIISA NCAC?.'//ELL
CORD HAS BEEN PROVICE0 -70 THE 71=L" O NER
FOR OFFICE USE ONLY p oa'E
M I'� " 910NATUNE OF PERSON CONSTRrIanrC 1Yc 'HELL
ouad No
Submll odglr(al Id pivblon of WaNr OUNIIy, arourW�+sur Srccn within Ci>YS

h C li a • De arlmenl of Environment and Nalural Resources - Division of Water Duality • Groundwater Section
236180
Non are n p
1636 Mail Service Center • Raleigh, N.C. 27699.1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
LL CONTRACTOR CERTIFICATION q:rr�
STATE WELL CONSTRUCTION PEnMITM:
1, WELL USE (check Applicable Boa): ResldenlialLD Municipal ❑ Industrial ❑ Agrlcullural ❑ Monitodrg ❑
Recovery [j Heal Pump Water Injection ❑ Other [I II Other, List Use:
2. WELL LOCATION- (Shoyv sketch of the location below) .%wa-%2
G�iGra —
Nearest Town: 6f- County.
L
(Road Name end Numbers. Communly, or Subdivision and Lot No.)
3. OWNER
Address Lip vF/�4
oast or ou o o.
City or Town Slate Zip Code
4. DATE DRILLED
5. TOTAL DEPTH �yd
6. CUTTINGSCOLLECTED YfS❑ NOE�J­
OQ
7. DOES WELL REPLACE EXISTING WELL? YES 0 T
B. STATIC WATER LEVEL Below Top of Casing: �O FT'
(Use's N Above Top or Casing)
9. TOP OF CASING IS FT. Above Land Surface'
-Top or cuing terminated eVor below land surface requires a variance In accor-
dance with ISA NCAC 2C.e11e
10. YIELD Npm). -3 D MET HOD OF TEST
11. WATER ZONES (depth):
DRILL114G LOG
From To
DEPTH
Fomaxn Oes.dpeo'
D - 7J' by —Gee✓-v
7J /�D lr`7-1
if %/7L Amount
--
It additional s;ace is ne,,d J use back of fc�
12.
CHLORINATION: Type
_-----
13.
CASING:
LOCATION SK=TCH
Walt Thickness
Maledal
(Show direction and ds'ance frm � liaus.'` eo
Depth
698
DIJ�male1 or Wai UFt.
° �,L) , <6'Y
Sl y
Roads. or other rr<p reference Do
From D To
Fl
From To
FI.
From —To—
Fl.
14.
GROUT:
Depth
led
MelJtod
y,
_
From To ;;'�
FL
2.-------
From To
Fl•
---------
I
rn
_-
15.
SCREEN:
Depth
Diameter
Slot Size
Material
a�
From To _
FI
In.
co
From To _
FI•
— In. _ In.
w
From To
Fl.
In. _ hi.
o
0
--
16.
SAND/GRAVEL PACK:
Malarial
Depth
Size
From To
FI.
From To
Ft.
--- —
— --
17. REMARKS:
IDOHEREBYCERTIFYTFIAT;T f,,SJWELl�;WASCONSTflUCTEDINACCOnOMICEWITHISA 04CACYJ.'/'ELLs�EF..
CONSTRUCTION STANDAR d�HAY a`'Cpf Y OP THIS RECORD HAS BEEN PROVICEO 70 THE y!%-L
4".
=No:
i�r^T `
i SION unE OF PERSON CONSTRIY:TR1O lY 'HELLSubll original to Division of %valor Ouothy Qreund"2101 Sccn within h C%sys a

Nonh Carolina - Depanmenl of Environment and Natural Resources . Division of Water Ouality - Groundwater Section 236 t 8 1
1636 fAail Service Center - Raleigh, N.C. 27699.1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION 0:— a�
STATE WELL CONSTRUCTION PERMITH:
,❑
1, WELL USE (check Applicable Box): ResldenUalL'_I/ Municipal ElIndustrial ❑ Agricultural ❑ Monitoring
Recovery ❑ Heal Pump Water In(ecllon ❑ Other n 11 Other, List Use:
2. WELL LOCATION: ASho js e8Ich of the location b 0W) County:
Sr a'n
Nearest Town:
DRILLING LOG DEPTH
(Road N me and Numbers, Commnity, or Subdivision and Lat Na.) From To Fomuxn OescAP6-
3. OWNER p� rj wejt
Address r/O y/,6a/ C047
Tree Of ou o 0.
76
city orTown Stale
zlpcode _/6° —
4. DATE DRILLED
5. TOTAL DEPTH DLO ,
6. CUTTINGS COLLECTED YES ❑ NO[��
7. DOES WELL REPLACE EXISTING WELL? YES [� N E]"
e. STATIC WATER LEVEL Below Top of Casing: 3�0_
/ iL r (Use'+' If Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface*
-Top of using terminated avor below land surface requires a variance In accor.
dance with 15A NCAC 2C.011e
10. YIELD (gpm): f METHOD OF TEST __r
I I. WATER 70NES (depth):
Amount e Gym 11 additional s;,ace 1s needed ise baci of IUrn
12. CHLORINATION: Type T.---
13.
CASING:
LOCATION SKETCH
Walt Tbickness
direction and d'slance Ir n ah lias! "o
Depth
��
Diameter or WelghM. Material
(,"yI A/c,
(Slow
Roads, or other rr-7 relererre po
From
To
FI.
—
Flom
To
FL
—
From —To
FI.
14.
GROUT:
Depth
elhod
M��edal rvrt
o
c
From d
To ZO
FI.
aYh�H�
0
From
To
Ft,
__--
C=
c .
15.
SCREEN:
Diameter
Slot SIZE Material
(y)
I
`.
Depth
rn
From _To_
FI
In. _ In.
a
From —To_
F1.
In. —In.
�„
T
From
To
Ft.
In. _ In.
co
16.
_—
SAND/GRAVEL PACK:
Material
W
=
Depth
Size
From
Te
FL
—�—
From
To
FL
— ----
17. REMARKS:_
I DO HEREBY CE
CONSTRUCTION
FOR OFFICE USE
Ouad No:
Sedal No.
3i1A - EITISdAtF1 L.WRS CONSTRUCTED III ACCORDANCE WITH i5A FXAC r"..'rrELL
)ARDS. AND THAT A COPY OF THIS RECORD HAS BEEN PROVICED 10 THE YrV—L O11 EF..
StONATU OF PEFlSON ClN15TFllY%TIf101>{'/✓ELL
pA'' E
4. nawafa-= w mnal la Wilton of Water Gustily.o,"nde.alar Seem with(n:O C%?ys Ce•1"V. I_'fl
a

North Carolina - Department of Environment and Natural Resources •Division of Water Quality- Groundwater Section 2006182
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone] 'o( V
WELL CONSTRUCTION RECORD WELL
ELL CONTRACTOR ' CERTIFICATION
STATE WELL CONSTRUCTION PERMITN:
1. WELL USE (Check Applicable Boa): Residential Q—Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water In)ectlon ❑ Other El If Other, List Use:
2. WELL LOCATION: (Showw�kelch of the location below)
Nearest Town: C e' o `d 42- County: SC
Q•S (out
(Road Name and Numbers. Community, or Subdivision and Lot No.)
3. OWNER zd� GdO�`F
Address
creel of outo o.
City or Town Stale Zip Code
4. DATE DRILLED
5. TOTALDEPTH ,f9
6. CUTTINGS COLLECTED Y€S ❑ NOQ
7. DOES WELL REPLACE EXISTING WELL? YES � NOD—
B. STATIC WATER LEVEL Below Top of Casing: / FT.
� (Use'+' It Above Top or Casing)
9. TOP OF CASING ISM FT. Above Land Surface'
'Top of casing terminated at/or below land surface requires a variance In actor.
dance with 15A NCAC 2C.a1
10. YIELD (gpm): METHOD OF TEST
11. WATER ZONES (depth):
12. CHLORINATION
13. CASING:
iI
Agricultural ❑ Monitoring ❑
DRILLING LOG DEPTH
From To Fom•awn DescrIOW
b — 0 C A// -Gam; oe
Type %N Amount `f �� It additional space is needed iv baci of irtm
Depth Diameter
From To Ft. -/ A'
From To Ft.
From To Fl.
14. GROUT:
Depth t ria elhod
�srv� C'
To — FI.
To Ft.
From V
From
15. SCREEN:
Depth Diameter Slot Size
Matedal
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 —ToFl.
LOCATION SKcTCH
Wall Thickness
or Weight/Ft. Male� al (Show direction end diSance bom a� leas!,NO `ale
/?/ fie e Roads, or other rr,—a relererry points`
C
m
x.
%a
0
,1
r�
c>,
r�
Nam:
C')
0
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED
EEEE IN ACCORDANCE WITH iSA 04CAC 2c,'/lELL
CONSTRUCTION STANDARDS, AND THAT A COPY 0 THIS CORD HAS BEEN PROVICED 10 THE Ylc�m 1 D%%NEF..
FOR OFFICE USE ONLY g —T/ DATE
Quad No: ff t F )9 SIGN ATUREOFPERSONCONSTRIY.TING 1>c'N'EU.
d - • i Submit odginal to Division of Water Oualily, Groundwater Seem within :0 CifY5 Ca.l FTS Y. I171
Serial No.

North Carolina - Department of Environment and Natural Resources - Division of Water Duality •Groundwater Section 06191
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION N:,t{O�
STATE WELL CONSTRUCTION PERfAITR:
1. WELL USE (Check Applicable Box): Residential L f Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: —���� County:
CL �
(Road N me end Numbers. Communi or Subdivision and Lol No.) DRILLING LOG DEPTH
3. OWNER f k,; /I N07�e- From To Fonratcn Desui0w
Address e1/2" el 'Ct llti dc'l c�
-[btreelor outs No.
City or Town p Slate Zip Code
4. DATE DRILLED 11-A?-In)
5. TOTAL DEPTH ^C
6. CUTTINGS COLLECTED YVS ❑ NO �
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NOQ
S. STATIC WATER LEVEL Below Top of Casing: Z p_ FT.
/ (Use '+' II Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface'
'Top of casing terminated at/or below land surface requires a variance In actor•
dance with 15A NCAC 2C.0118
10. YIELD (gpm): ZO METHOD OF TEST
11. WATER ZONES (depth): S1
12. CHLORINATION: Type All % Amounl —5,-' 11 additional space is needed lse bacL of fc�
13. CASING:
LOCATION SKE=TCH
Wall Thickness
Depth Diameter or WeighVFI. Material (Show direction and disance bcm --IIeas: teo Sale
From 0 To IVY Ft. �'.ZJ Roads. or other n-,7 relererr-e points.`
From To Ft.
From To Ft.
14. GROUT:
Depth Material Mel od
From To 2--e— Fr•
From To Ft. c
O -
15. SCREEN:
Depth Diameter Slot Size Material b, n__
C
From —To_ Ft _ In. _ In, c� '
From _ To _ Ft.— in. — In. r c
To — Ft. In. _ In. rn -'
From
16. SANDIGRAVEL PACK: ZZ \
Depth Size Material CO w T
rn
From To Ft. N
From To FL t� o
17. REMARKS:
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCOROAPICE WITH 15A DICAC Y.:, vrELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS SEEN PROVIDED 70 THE YlS!-L Orr'`EF
FOR OFFICE USE ONLY,
$IaNAffUhE OF PERSON CONSTRU rTIUr It -.'WELL Os . E
Ouad No:
Submit edpinat to Division of Water Duality, Orwnd..ator Sscu+ within h
Sedai No. - ,

North Carolina - Department of Environment and Naturaf Resources - Division of Water Quality - Groundwater Section c �.
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELLCONTRACTOR:
WELL CONTRACTOR CERTIFICATION #: aO S0
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential 14 Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION (Show sketch of tLhe location below)
Nearest Town: `L Y� • C. County: _ ')'L'J fir,
(Road Name and Numbers, Community, or ubdivi4Ion and Lot No.)
3. OWNER `Y11Gct1� /yL1� ria
Address '51 14
ree or ou a o.
A,2]
City or Town State Zip Code
4. DATE DRILLED ) / J4 I'Zbo-
5. TOTAL DEPTH O
6. CUTTINGS COLLECTED YES ❑ NOQ
7. DOES WELL REPLACE EXISTING WELL? YES NO©
8. STATIC WATER LEVEL Below Top of Casing: i400 FT.
(Use'i if Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface'
'Top of casing terminated st(or below land surface requires a variance in accor-
dance with 15A NCAC 2C.0110
10. YIELD (gpm): _I& METHOD OF TEST %� V+�
11. WATER ZONES (depth): / ✓rS
12. CHLORINATION: Type -- 9721 Amount 0,30
13. CASING:
Wall Thickness
Depth Diameter or WeighVFt. Material
FromTo _ Ft. — 50R*;Lf ":OVC.—
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From O To 10 Ft. (W"A ..IN -So
From To Ft.
15. SCREEN:
Depth
From
To _
From
To _
From —To
16. SAND/GRAVEL PACK:
Depth
From
To --
From
To_
17, REMARKS.
Diameter Slot Size Material
Ft in. in.
Ft. in. in.
Ft. in. In.
Ft.
Ft.
Size Material
DRILLING LOG DEPTH
From To Formation Description
0
O
e
o co T
crn-r o�
cam.
I y M
u9spit
co
If additional space is needed use back dlbrmo
z
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
U n''�
ivy. ,��� {r S lump? 5;/'a�t•� R�!-,
UaA, h,,- �k
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT ACOPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER,
FOR OFFICE USE`O - -Qn= r Q f ZCOa
Quad No: i i �. T I I$I AOF P RSON ONSTRUCTING THE WELL DATE��SubmIJ to Division of Water 0 'J ty, Groun I_ to, Section Within 30 days
Seral No. / i GW.1 REV. 12/99

Nonh Carolina - Department of Environment and Natural Resources . Division of Water Quality - Groundwater Section I_ i 6 8 6
1636 Mail Service Center - Raleigh, N.C. 27699.1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:/LE�Q t L'�CQ )ylcfl, ;w
WELL CONTRACTOR CERTIFICATION #: e5tn-S_")
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: �` 'z �" County: �oU�}'-'7V
(Road Name and Numbers, c or $uhdlNSlon ono Lot No.) DRILLING LOG DEPTH
3. OWNER �6Y`� [' _ From To Formation Desenption
Address to le
rss or lowle Ro.
City WNW State Zip Code
4, DATE DRILLED Z 1'"0
S. TOTAL DEPTH
6. CUTTINGS COLLECTED YES[3 NOR]
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO® o p —
8. STATIC WATER LEVEL Below Top of Casing: S10 FT.
(Use'+' a Move Top of Casing) rn m
9. TOP OF CASING IS FT. Above Land Surface' n_ ;m
'Top of eating terminated aVor below land "rise* requires a vadones In seeor.
donee with 15A NCAC 2C.0118 Do
10. YIELD (gpm): JQ METHOD OF TEST 6]tiv -e—nt=
11. WATER ZONES (depth): s ccnn=
aD
12. CHLORINATION: Type Amount If additional space is needed use back of lore
13. CASING: Z
Wall T1aew wa LOCATION SKETCH
Depth D4/rMtor or WelghVR. Material (Show direction and distance from at least two State
From To 160 Ft. 6 SDK 1 i - ,J?V C �y Roads, or other map reference points)
From To FI. p llti+ t R �yp r y , � �}� CA_
From To Ft. Fy�lia8 S jam/ 1O
14. GROUT:
Depth Material Method Y) .Ga t'4,Vl IJ1744,rr, AJ�,4
From _0 To '7,2_ Ft. CSIEDW �o Sari 7 �( qt S/ p 1���y w ✓` ,
From To Ft.
15. SCREEN: G'7\ �'�""- ``• c/,—., �/d
Depth Diameter Slot Size Material
From —To—Ft— in. —in
From To — Ft. — in. —In.
From —To _ Ft._ In. —In.
1S. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
17. REMARKS:
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 OF.R E U �� aAL 4 do ll�DT Zaop
U 1
SKiNATI E C ERSO CONSTF(UCTING THE WELL DATE
t original to Division of Water Ouaury, Groundwater Section within 30 days
So" NO... �i S GW-t REV. 12t"

19�2
North Carolina - Department of Environment and Natural Resources - Division of Water Dualiry - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:•Z_l tI ')j' �` rl �11
WELL CONTRACTOR CERTIFICATION #: •-1 y �`
STATE WELL CONSTRUCTION PERMIT#:
WELL USE (Check Applicable BOX): Resl(lendal0/ - Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injeclion ❑ Other ❑ If Other, List Use:
2. WELL LOCATION:,( Show sketch of the location below) c� ,
/
Nearest Town: I`1: Counry:—J�<'C4irL�
(Road Name and Numbers. Community, or Subdivision and Lot No.)
3. OWNER I` - I v .� �-p - n <� c, _,> /J
Address 11 c f l / 6�i� � e r fuJ
tree! or outo o.
I F Y yN lMT
City or Town State Zip Code
4. DATE DRILLED
5. TOTAL DEPTH r�
6. CUTTINGS COLLECTED YES ❑ NOQ--
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NOF-1
8, STATIC WATER LEVEL Below Top of Casing: ?%r, FT.
(Use'i If Above Top of Casing)
9. TOP OF CASING ISFT. Above Land Surface -
'Top of casing terminated atior below land surface requires a variance In accor-
dance with 15A NCAC 2C.0118
10. YIELD (gpm): ! -5 METHOD OF TEST-
11. WATER ZONES (depth): ZLIL ' --
Agricultural ❑ Monitoring ❑
DRILLING LOG DEPTH
From To Formation Description
e
G-�
L n =:
12. CHLORINATION: Type %t t N Amount If additional space is needed use back of form
13. CASING:
LOCATION SKETCH
Wall Thickness
Depth Diameter or Weignt/Ft. Material (Show direction and distance from at least two State
From �� To - Ft. L—
"_ Roads, or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From To ZI, Ft.
From To Ft.
15. SCREEN
Depth Diameter Slot Size Material
From _ To _ Ft — in. — in.
From —To —Ft. — il',. — 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.
0 �— �ID j c 21
FOR OFFICE USE ONLY DATE
Quad No: SIGNATURE OF PERSON CONSTRUCTING THE WELL
Submit ohI;inal to Division of Water Quality, Groundwater Section Within 30 days GW 1 REV. 12199
Serial No.

North Carolina - Department of Environment and Natural Resources - Division of Water Ouatity - Groundwater Section Y-. i K.,
1636 Mail Service Center - Ralei;h, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELLCONTRACTOR:='+' 1 ,'ll' 'u �` 'I
WELL CONTRACTOR CERTIFICATION a: •�)
STATE WELL CONSTRUCTION PERMITU:
1. WELL USE (Check Applicable Box): Residential M1 u1 nicipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other If Other, List Use:
2. WELL LOCATION, (Show sketch of tht, location below)
Nearest Town: County: L.l
(Road Name and} Numbers, Community, or Subdivision and Lot No.) DRILLING LOG
3. OWNER l Y ;Y C-i _ From To
Address
`(Sweet or oule o.
CI�PIZbtic,tl 1-I _ �`f7�%
City or Town State Zip Code
4. DATE DRILLED..f[`
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES❑ NOE]—
7. DOES WELL REPLACE EXISTING WELL? YES NODi
8. STATIC WATER LEVEL Below Top of Casing: f L-) FT.
(Use'." it Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface -
*Top of casing terminated allor below land surface requires a variance In accor-
dance with 15A NCAC 2C. 18 --
10. YIELD (gpm): ; METHOD OF TEST '1 rri f +
11, WATER ZONES (depth): ' `7 , •�- S "C
DEPTH
Formation Description
—C
0
O
-
f:
GJi
o
12. CHLORINATION: Type t t N .—Amount '�tr h If additional space is needed use back of form
13. CASING:
LOCATION SKETCH
Wall Thickness
Depth Diameter or WeighVFt. Material (Show direction and distance from at least two State
From L� To Ft. (1- ­ ' " P di ` Roads, or other map reference points)
From To Ft. From To Ft.
14. GROUT:
Depth Material Method
From L To 2 L Ft. Ir^,,,:,",i"
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.
Matedal
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 1SA NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY S ' I� / v 47
Ouad No: SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Quality. Groundwater Section Within 30 days
GW1 REV. 12/99
Serial No.

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section r.• 19 2 Z- 7
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: 71-vr1 it ti �fr f) 'n (C'� I I L. r I n >� ��, C'
WELL CONTRACTOR CERTIFICATION #: '-7
STATE WELL CONSTRUCTION PERMIT#:
WELL USE (check Applicable Box): Residential EPMunicipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: /'J�^ r� how sketch of the location below)
t
Nearest Town: � I� �'h �' ` ! County: r
(Road Name and Numbers, Community, or Subdivision and Lot No.)
3. OWNER rr t^ rl. - L , n A
Address S
jStreet or oute o
City or Town - late Zip Code
4. DATE DRILLED
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES Q NO[D--
7. DOES WELL REPLACE EXISTING WELL? YES ❑ 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 aVor below land surface requires a variance In accor-
dance with 15A NCAC 2C.0118 ,
10. YIELD (gpm): .-:2- `r METHOD OF TEST it / i
11. WATER ZONES (depth): IrS
12.
CHLORINATION: Type /t t 14
—Amount ' t 6
13.
CASING:
Wall Thickness
Depth Diameter
or Weight/Ft. Material
From L)
To - - Ft. —L
' ' ' I> -
From
To Ft.
From
To Ft.
14.
GROUT:
Depth Material Method
From
To .:LIB Ft. (7Lill
o+�7
From
To Ft.
15.
SCREEN:
Depth Diameter Slot Size Material
From —To
_ Ft _ in.
_ in.
From —
To — Ft. — in. _—
In.
From _To
_ Ft. — In.
in.
16.
SAND/GRAVEL PACK:
Depth Size
Material
From
To —Ft. -
From
To Ft.
17.
REMARKS:
Agricultural ❑ Monitoring ❑
DRILLING LOG DEPTH
From To Formation Description
0
t�
ul
It additional space is needed use back of form `
LOCATION SKETCH
(Show direction and distance li: 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 DATE
Submit original to Division of Water Quality, Groundwater Section within 30 days
GW-1 REV. 12/99

Nonh Carefna - Doparlment of Environment and Natural Resources - Division of Wa:er Oualiq - Groundwz:er Section /, ti 3 0 3 0
1636 bail Sarvice Center - Raleigh, N.C. 27699-1636-Phc no (919) 7333221
WELL CONSTRUCTION RECORD %YELL CONTRACTOR: _17 I /L� 010A S
1vELL CONTRACTOR CERTIFICATION 2-5`f -7 _
STATE WELL CONSTRUCTION PERLIITV:
1.
WELL USE (CheckAp. llca5le Pox): Resident!&'LY Munleipal ❑ Industrial ❑ Agricullural ❑ Monitoring
Recovery F-1 Heal Pump Water hn oclion ❑ Oth;r
If 0!-or, Lls( Use:
2.
%^;ELL LOCATION: SI o•.v sPeich of the location bo!ov�)
Nearest To....: Coun:y:
l L )� 1' Al
A la r kc(�
( Road :4aT 9 C.n1tl YU-1SC15, GOmr`.UrL:y, Or S::JC.visiCO anu' Lcl i:0.)
DRILLING LOG DEPTH
3.
O', NER (�('�/ r(jNLi./�I_!
From To FCrT.a:iOn DCSC`�P:70.,
Address
)JVCCI orOr 1_TJJ:O Li O.)
So ILI 0-4) , t� Tcx�� > 7� � U
- •�— rc%;'tom
City cr Tc,n S;z 2ip Ca
•.
DATE DRILLED014-bCIr 07 9C/'n
-
..
TOTAL DEPTH __3f,D
f0 3015
G.
CUT-TiXGS COLLECTED YES Ll NO ]
_
7.
DOES '.',ELL REPLACE EXISTING %TELL? YES IdO�P.
STATIC WATER LEVEL Belov. Top of Cosing: F-T.
AJc,a Top of Cno::.;)
9.
7O? O° CASING IS (_ FT. F.bovo Lard Surface*
--O
O
'Top
of eae:n9 lerminotcd oVor bcID,v land sOCaco rcga!:es n variance In Deco:-
JbIL AI r
N
10.
YIELD (gpr1* METHOD OF TEST
_
11.
1/A] E,R 7-ONES (depth):C�
12.
CHLORINATION: Type � < <, A:r,cunl - 1/1, p-/lS
I: r....l:ie..ai s,-,ac_ ., noeded use'_ -. l,rn -
13.
CASING:
Vfc!I T:;;d.nc zo
_LOCATION !-KETCH qp
��--_To3 C7 L
�Rx
From FL-L-7�L- _� -
, cr,...._.,. np f!cr�_•,c: pc.. S)
From - To— FI. —
From To-- FL —
•I (�'/y (,�� J
�] rt S B
14.
GROUT :
_,)
RU
Depth t:fatcrlal f.lolhod
C Q 11 q U a to r kc ,
From' To-a_l_FI. �� ��tll _2
✓ 7
From To Ft.
1s.
SCREEN,
Dop!h Diamelor Slo! SLo_ tdaler. al
From To PI in.
From To FL In. in. _
Rom To Fl. In. —in.--
1-3. SAND/GRAVEL PACK:
Depth Size Material
From To FI.
From To Fl.
17. REMARKS:
I DO HEREBY C'e RTIFY THAT THIS :YELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL J
CONS T R'UCTION STANDARDS. AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE V: ELL OWNER, r
FOR OFFICE USE ONLY ��N G(-e_eU (? ,.)CG'S I'\I C),,()�-cy/oc-
OuadNO: SIGI:ATURE CF PERSON CO: I STRUCTING THE Vi ELL GATE
SuJr,;Y 0dpna: 10 Ci'l,:', oI lYa:or Ov32y. GrQvndra:cr Scu!cn withln 30 days
Serial Nc. GY1.1 REV. 12'99
,��� t

North Carolina •Department of Environment "Natural Resource• - Division of water Quality -Groundwater Section 0 5 0:0. 3
ISM Mail Service Center - Raleigh, N.C. 276MIS36-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: 1 A Q ^ -r, r > d s D �D A J P. iM,
WELL CONTRACTOR CERTIFICATION 0:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Chock Appl!oabls box): Reaidenii ® Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATIO (Show sketch o the location below)
NsareatTown: JL� County: �LUOWr�
(Road wrn�rW Nunbers, Commuryty, or SVyIvlNon and Lot No.) DRILLING LOG
3. OWNER-U�F�iry o /�/(/tf�LiU From To
Addressor rwruiv NO.)
✓ t(
t
City orTown , State C Zip Code
4. DATE DRILLED
5. TOTAL DEPTH o
S. CUTTINGS COLLECTED YES Q NO©
7. DOES WELL REPLACE EXISTING WELL? YES F] NO
e. STATIC WATER LEVEL Below Top of Casing: S o FT.
(Use'+' IIAbow Tap of C4*VO
9. TOP OF CASING ISFT. Above Land Surface -
'Top of ca"M Urrnlnal•d War below IwW surface requires a varlance In actor -
dents with 1aA KCAC 2C .011a
10. YIELD (gpm): � METHOD OF TESTA 426
11. WATER ZONES (depth): µ Vs
12. CHLORINATION: Type—/'4 Amount 0.9/
13. CASING
WON Tltckrrae
10 Depth `s/nWer 5WagIwFt. Material
From To q_ Ft. 5 OR 2.) V <-
From To Ft.
From To Ft.
14. GROUT:
Depth MatRrw Method
m)
FroTo _ X O �Ft. s+
From To Ft.
15. SCREEN:
Depth Olamater Slot Size Material
From To Ft In. in.
From To Ft. in. in.
From To Ft. In. —In.
16. SAND/GRAVEL PACK:
17
Depth Size
From To Ft. _
From To Ft._
Material
DEPTH
Formatlon Description
o
N
If additions! space is needed use back of form:
LOCATION SKETCH
(Show direction and dletance from at least two State
Roads, or other map reference points)
-7
rr C%'l �G-h,01�c1' ooc � ' g�1
�f y �G Y7 Itaw' �vvr /2 gn
e� �/0 YTu(w bl m tee- on
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
Quad No:
Serial No.
:OF PERSON CONSTRUCTING THE WELL
on Water Quality, Groundwater Section within 30 days
OW-1 REV. 12/99

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Ground Water Section `1 A 3
1636 Mail Service Center - Raleigh, N.C. 27699-1636 - Phone [phone] J / `i.
WELL CONSTRUCTION RECORD WELL CONTRACTOR: Hedden Bros. Well Drilling Inc.
WELL CONTRACTOR CERTIFICATION #: 2045
STATE WELL CONSTRUCTION PERMIT #:
1. WELL USE(Check Applicable Box): Residential ❑X 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: Bryson City County: Swain
Old Brush Crk Rd
(Road Name and Numbers, Community, or Subdivision and Lot No.) DEPTH DRILLING LOG
3. OWNER Earl Fortner From To Formation Description
Address 2020 Kirkland Crk Rd O 47 (Jay & sand
(Street or Route No.) 47 500 granite
Bryson City NC 28713
City or Town State Zip Code
4. DATE DRILLED 10/20/00
5. TOTAL DEPTH 500
6. CUTTINGS COLLECTED YES ❑ NO ❑X
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
8. STATIC WATER LEVEL Below Top of Casing: 0 FT.
(Use " + " if Above Top of Casing)
9. TOP OF CASING IS 2 FT. Above Land Surface*
*Top of casingg terminated at/or below land surface requires a variance in accor-
dance with ISA NCAC 2C .0118
10. YIELD (gpm): 1.00 METHOD OF TEST Blow
11. WATER ZONES (depth): 0
12, CHLORINATION: Type H T H
Amount
If additional space is needed use back of form
13. CASING:
Wall Thickness
Depth
Diameter
or Weight/Ft. Material
LOCATION SKETCH
From 0 To_-21
Ft. 6"
198 steel
(Show direction and distance from at least two State
Roads, or other map reference points)
From 21 To 47
Ft. �'
D VC
From To
Ft.
14. GROUT:
Depth
Material
Method
From 0 To 20
Ft. Cement
Poured
From To
Ft.
o . -
Ca
15. SCREEN:
Depth
Diameter Slot
Size Material
From To
Ft. in.
in.
I
_0
c.a
From To
Ft. in.
in.
.
From To
Ft. in.
in.
16. SAND/GRAVEL PACK:
Depth
Size
Material
71
From 0 To
Ft.
r"
From To
Ft.
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
[FORFFICE USE ONLY.
o. SIGNATURE OF PERSON CONSTRUCTING THE WELL Date
Submit original to Division of Water Quality, Groundwater Section within 30 days

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section R f
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone] '' 1 0 7
WELL CONSTRUCTION RECORD WELLCONTRACTOR: � O� ��zL� Dili Lrf 5
WELL CONTRACTOR CERTIFICATION #:,S"%
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 LOCATIQ (Show sketch of the location below)
Nearest Town: l �Q+ c County
i.� lz�
(Road Name and Numbers, Comm pity, or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER -,Cl14 ^^' to /��C Yj% From To Formation Description
Address
(street or oute o.
City or Town _ State Zip Code
4. DATE DRILLED 6 %CCC
5. TOTAL DEPTH _;'?C Y�
6. CUTTINGS COLLECTED YES[] NOT f�
7. DOES WELL REPLACE EXISTING WELL? YES F] NOLO
8. STATIC WATER LEVEL Below Top of Casing: (, G _ FT.
(Use': it Above Top of Casing)-
9. TOP OF CASING ISFT. Above Land Surface- __
-Top or casing terminated at/or below land surface requires a variance In actor-
dance with 15A NCAC 2C .0118 vD
10. YIELD (gpm): ,� METHOD OF TEST
11. WATER ZONES (depth): at_ "
-
12. CHLORINATION: Type Amount If additional space is needed use back of form.'
13. CASING:
Depth Di meter/
From I To l?D Ft.
From To Ft.
From To Ft.
14. GROUT:
____) " LOCATION SKETCH
Wall Thickness
or Weight/Fl. anal (Show direction and distance from at least two State
Roads, or other map reference points)
'iD r2d
Depth Material Method
From —L To Zb FL S%)Nr u"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:
2000
Quad No:
Slot Size Material
in.
in.
in.
Material
CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
DPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
r to - -n . I Or, _ /
GNATURE OF PERSON CONSTRUCTING THE WELL U.I.
to Division of Water Quality, Groundwater Section within 30 days
GW1 REV. 12199
Serial No.

North Carolina - Department of Environment and Natural Resources - DHtebn of Water Quality •Groundwater Section r_ 186 3
16M Mail Servlos Center - ReWah, N.C. 27699.1636•Phone [phone] -
WELL CONSTRUCTION RECORD WELL CONTRACTOR: " �`^h?` 0)
WELL CONTRACTOR CERTIFICATION 6:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (PMok Appllaable 1111*0 Residential ® Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other It Other, List Use:
2, WELL LOCATIODL: (Show sketch of try& location below)
Nearest Town: n..nJs C,c County:
(Road Name and Nu en, Communnkt ,, or Suod0fon and lot No.) DRILLING LOG
3. OWNER �_ From To
Address w� pCL
Cky or own I Stele Zip Code
4. DATEDRILLED 5 /Z Zoo _
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES Q NO®
7. DOES WELL REPLACE EXISTING WELL? YES [] NO® o _—
a, STATIC WATER LEVEL Below Top of Casing: 4 FT.
(Use •; Y Above Top a Caelnp) —' - _
9. TOP OF CASING IS FT. Above Land Surface-
-rop of oadna YmMnaMd al/or below land &urine nWAVIIe a vw%fm In lecw-
dems wish 16A NCAC 2C.e1111 METHOD OF TEST ^'L
10. YIELD (gpm): Z e ,,.
11. WATER ZONES (depth): 4 / -3
DEPTH
Formation Deception
12. CHLORINATION: Type / H Amount �' 0 additional space la needed use back of to+m o
13. CASING: ATION SKETCH
Wail Thickness
Depth Dlar]wgr or WeighVR. Material
From To — 7 Ft. 4 �4 5�1 V �'
From To Ft. --
From To Ft.
14. GROUT:
Depth Material Method
From —To—Ft.—
From To Ft.
15. SCREEN
Depth Diameter Slot Sue Material
From To Ft In. _ In.
From To Ft. in. in.
From To Ft. in. _ In.
16. SAND/GRAVEL PACK:
Depth Size Material
(Shaw direction and distance from at least two State
Roads, or other map reference Points)
Y�j
(sy.
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.
SIGNATURE OF PEN
odpinal to Division of Water
Serial No.
0 THE WELL
Section within 30 days
OW-1 REV. 12Ne
Mal

North Carolina - Department of Environment and Natural Resourcea - Division of Water Quality - Groundwater Section J O 3 8
1636 Mail Service Canter - Raleigh, N.C. 27699-1636-Phono (919) 7333221 --��
WELL CONSTRUCTION RECORD WELL CONTRACTOR: .)OLUJ o�
WELL CONTRACTOR CERTIFICATION It: 02ISo`�
STATE WELL CONSTRUCTION PERMITII:
1. WELL USE (Chock Applicable oox): Rosidonlial Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection Other II Other, List Use:
Agricultural ❑ Monitoring ❑
2. WELL LOCATION: low sketch of the location bel3,:r)
Nearest Town: n l� U'1'(-� County: ll-'�` k ✓�
c k1L'a `C,k�
(Road Name
and Numbers. Community. or Subdivision and Lcl Nu.) DRILLING LOG
3. OWNER I 1 YY1 � TY�S. S From To
Address (G( le rC S$Ir14 ��• —
Iraa or lioule 0.
DEPTH
Formation Description
�=g W rk "C C \_;111 UG f,) q13
City or Tmvn State Zlp Coda
4. DATEDRILLED
5. TOTAL DEPTH
G. CUTTINGS COLLE TC ED YES ©� NOD
7, DOES WELL REPLACE EXISTING WELL? YES NO[Ia' (1 1 -'�-1 qSn 11
6. STATIC WATER LEVEL Below Top of Casing: FT. O �'
(Uso `.' II Above Top of Casing)
9. TOP OF CASING ISFT. Above Land Surface'
'Top or casing terminated aVor below land surface raqulran n va:lance In occur- r�
dance with 15A NCAC 2C.0110 ('y, _ rn
l W l •-rn
10. YIELD (gpm): �_ METHOD OF TEST yU
11. WATER ZONES (depth):
Tn a
I .$ II additional space Is needed use back of term
12. CHLORINATION: Type ArnolT_Tq� _
—i
13, CASING:
z
Will TNcknecs
Depth Di.]mlater cr Yfci WN Ma:cdal
From 0 is l Ft. "-'� L- ' c�
From To Ft.
From To— Ft.
14. GROUT:
Depth Material DAothod
Frown 0 To DQFt. LdXI'vr2h'L ' .an�p_
From To Ft.
15. SCREEN:
Depth Diameter Slot Size_ Material
From _ToFt In. In.
From To _ Ft. In. in. _
From To Ft. In. in. _
1 G. SAND/GRAVEL PACK:
Depth Size Malorial
From To Ft.
From To Ft.
17. REMARKS:
LOCATION „KETCH
(Show direction and distance from at least two Stale
Roads, or other map rofcrcnco points)
ds
I b\(I,yi l VltW `Pi-o Y i l e5
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 I I E /WELL C
r
R OFFICE USE ONLY t (k�ZM� �� /Q� Y�A Oe�� .
ad No: ,,,GNAT URE OF PERSON CONSTRUCTING THEW G
Subr'AI onginalto Givisen of'walar Quality, Groundwater Seciion within 30 days
pal No. '-
,4
DATE
GW4 nEV. IM9
10 -15- Ud

North Carol'. -,a - Departmonl of Environment and Natural Resources - Division of Water Quality - Groundwater Section 4- • � 3 0 ,3 7
1636 Mail SnMco Center - Raleigh, N.C. 27690-1636-Phono [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: l US<S e-11 U r
WELL CONTRACTOR CERTIFICATION It:, CR
c,
STATE WELL CONSTRUCTION PERMITH:
1. WELL USE (Check Applicable Cox): ResidentiaYn Municloal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Roca%r ry ❑ Heat Pump Water Injection ❑ Olhcr ❑ It Other, Lis; Use:
2. WELL L.00ATIOi (Show sl:etctJ of the location bo!ow)
Nearer!IITov('m: " U S07J 1�1II'4//' t 1Counry: S(.>`; 2 �
r 1A S �. �N e- K t I'1 G cz r�
(Road:;ama and Numbers, Comrrun"••, or SubC:yi::on and LCl Y.o.) DRILLING LOG DEPTH
3. OWNER v r Lrc CL Ll I From ,To Fo,rro;bn Descriplion
Address U c k d-o 1 0— 45 _ L �Cl IT
�11QCL or ouzo v
Ci;� rTovm Slata Zir Colic
DATE-RILLED IC- ber,�CoC
G. TOTAL DEPTH ��s
G. CUTTIP:GS COLLECTED YES Q ('400
7. DOES ;YELL REPLACE EXISTING WELL? YES t•!025
S. STATIC WATER LEVEL BoloW Top of Casing: ZX, FT.
(Use'+' if Abovo Top of Casing)
9. TOP O CASING IS I FT. Abovo Lnnd Surface'
-Top of caaln terminated zVor bcloer land surfaeo re Gulres a vad.inco in accor-
dance each I -A NCAC 2C.0113
10. YIELD (,pm): .., �- 'JETHOD OF TEST AI C_
11. WATES', ZONES (depth): a C`. �2 90 / - —
12. CHLOr",:NATIOP.: Typo Ail "r-1
13. CASING: l
flail iLicknrs
Depth
�>
Dla.ry:•or c: 1•'•I /','��t. Ltalcc.-.I
/- , ,
From
To �-
Ft.
From
To
Fl.— .
From
To--
Fl.
14. GROU-:
Depth
Matodal 6lothod
From'
From
To
Ft.
15. SCREEN
Depth Diameter
From To Ft in.
From __ To Ft. In.
From To Fl. In.
16. SAND/1-;RAVEL PACK:
Depth SI20
From __ To --Ft.
From To Ft.
17. REMAP.SS:
Slot Sizo Malorial
in.
in. _
In.
Miaterial
> it v;di;'oral spa=c i; needed lire b,.,,. cf ;ern �' e�
LOCATION SKFFCH =
(Sho.v dire:.licn rrr.7 Cislansc :. � : , I_;a! two S!a7_
needs, ar oL`,ar rrwp tole: c::cc pCa;r)
b) I ) C' 4"V 0' * li Lt
C�, pacz-d
bee,- �11 cj,jQ.- gcc�lj
moon/ b's/4 tcd
I DO HE EBY CERTIFY THAT THIS WELL WAS COf 1STRUCTED rl ACCORDANCE WITI'1 1SA NCAC 2C, WELL
CONSTP.UCTION STANDARDS, AND THAT A COPY (OAF THIS RECORD HAS BEEN PROVIDED TO THE VlELL OWNER.
FOR OFF'CE USE ONLY [�.e N G, C QeJv e R CS �&,_ 1 V I c, -, )
Ouad No: Gl15NAl UHE CF PE RSOrt C0:1STRUC 7ING THE W C L L DATE
Submit cri,inal to D;1i':Gn. of IYater Quality. Groundwater Scclion Prilhln 30 days
Serial No. . ---
GW-I REV. 12Pi7
j1
r
1D1/51o0

Water`'"'3035
North Carolina - Department of Environment and Natural Resources - Division of Water Quality 2- Groundwater Section "'
1636 Mail Sarvlce Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: S 4 tsS i I ) a- Y
WELL CONTRACTOR CERTIFICATION N:
STATE WELL CONSTRUCTION PERMITN:
I. WELL USE (Check Appllcome Box): Residentiain Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Glher ❑ If Ci-.or, List Use:
2. WELL LOCATION: Allow skelcil o(,lt/p location belovr)
Nearest Tovm: r43G A. Lti+y _Coun;7:
DEPTH
rcar.a:ion Descriaticn
I�
r �n I iCr Doi c< f i II Rd. U)ct'lll, ll i1 n t,
(Road':amo nntl Numocrs, or .mupn::yr, oar SubdMvi cn anndd Lol r'.o.) L DRILLING LOG
3. OWNED{ i, C,_ C{ rr IQ fde Ir t cer(%�•1 From To
Address
fi, C e e t �Gn c +o a
�r,,� t c
Ci;, or Town Slab Zip Coco
r•
4. DATEDRILLED>rD}C mbuGJaLrT'
5. TOTAL DEPTH -2_t r77) —
G. CUTTIXGS COLLECTED YES© f400
CD =
O
7.
DOES V,ELL REPLACE EXISTING WELL? YES M N0_0
S.
STATIC WATER LEVEL Below Top of Casing: FT.
fT1 �gm
_(AU
n m
(Use'.' if Abcvo Tcp of Ca.inp)
9.
TOP C CASING IS FT. Abovo Land Surface'
m =_m
-Top of eo s: le nnl naiad 0Vor L•e lour land su rfaca requires n variance in accor-
d ance
10.
S
n91h liA NCi.0 2C .o 110
YIELD (cpMETHOD OF TEST AI p-
Imo
[n=
12.
CHLOI.:.INATIOt1. Type t_!„nc•ca �02_.�.1L� 5
r
II c�di:ior•.:I space : neeced uc� -.,, _.. _..ern
0 Z
13.
CASIN3: 1
.._-----
\Ya;l
Dept!) Diarr.:%� or V�' I^j�j
L ra!
(Show CirC:.!iCn End disla�^.CC ::c;:1 .. two S.'�;c
From-', To FL /�/ �' yam' —
Roads, or other map rc:crw:c :�poir';:s)
From To FI.
-
Frofn - To--- Ft.
14.
GROUT:
2 / -f-
cy
t�rys�
De Ih faa;o Fiat ;.lolhod
/
riicl. /TC®
FromQ Toparl.
S 10c�_.
/� n
From — To Ft.
FS
S R 30 (•_
I�G'
15.
SCREEN:
. Depth Diameter Slot Slzc Ma!orial
Olo4 m,'ll JC AIL
.
From To Ft in. in.
From __ To Ft. In. __ In. _
From To FL In. in. _
16.
SANDJCRAVEL PACK:
Depth Size Material
Fiorn To Ft. —
From To Ft.
17.
REMAP.'VS:
I DO HEREBY CERTIFY THAT THIS WELL WAS COIJS TIIUCTED IN ACCOROANCE WITH iSA NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY (OF -i HIS RECORD HAS BEEN PROVIDED TOTHE 1P:ELL OWNER,
FOR OFFICE USE ONLY a--ti- C-"1 C9-eJ" Q' �) OS �,->L.- + I G •' \ % /�Ci
Ouad No: SIG':Ai URE CF PERSON CONSTRUCTING THE WELL DATE
SuSrnil ori; nal la Div;;:an of Yla:cr Oua'J;y. Ground.: a:cr Scdicn within 30 days
Serial No. GWA REV. 12'5l

North Carofoa - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section J 7 O A i 3
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phono [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: R ,a sSP_l� Ta- i for
-,\ WELL CONTRACTOR CERTIFICATION C: I 7
STATE WELL CONSTRUCTION PERMIT11;
1.
WELL USE (Chock Applicable Pox): Residential Municipal ❑
IndusL•Iai ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Inicclion ❑ Other ❑ It Olhor,
List Use:
2.
WELL LOCATION, (Shover s�l�:elllch of the location beio,v)
J_`j
Clearest Town: 10 C�S�County: ct,
iv
P) ru S h reel'( Doe- J —
(Road game and Numbers, comrnun;:y, or Subdivision and Lot No.)
DRILLING LOG DEPTH
3.
OWNER P) rr + 1✓ e e
From To Fenratlon Description
Address Lj �1� eQ sae l� wrz
0 - 4 3 ('.Ie�� rc, o
I
,<`c
Clay or To,., state Zip Ccte
t•115
4.
DATE DRILLED 4� cm1�e� 1r-lr B.eGr.
y5'h='
5.
TOTAL DEPTH 35a
,35G
G.
CUTTINGS COLLECTED YES© NO❑
o
7.
DOES TELL REPLACE EXISTING WELL? YES ❑ f10,0
o
n_
8.
STATIC WATER LEVEL Belot:, Top of Casing: lip FT.
(Uco'+' if Abovo Top of Casing)
N
'--�
9.
TOP OF CASING IS 1 FT. Above Land Surface'
co
Mr
'Top
o! easing erminated nLlor below land ser!aco raqu!res a variance in Actor-
dance
oath 15A NC.0 2C d1118
(±]�
10.
YIELD (gpm): _` METFJOD OF TEST AI
�r
11.
WATER 7.0NES (depth): I- 5 _r I' - 115 _
mom',
12, CHLORINATION: Type
.t C \�
!-mot nl (O'i_v111a
I' cd..I:i-nal spa r is needed use ba_.. -. I,rn �- X
13. CASING; -
I
---__--------___-- --__ ---
;KEI CH
l';ae_LOCATION
Depth
Die--y.�!or
L,f
c; l'J•rb;{°t. 'a'cr!al
(Shmv dlrecGcn end Cis.cnce 6cm .l Ic cs! two Sta,-
��
From�—To 6{5
Ft.-,,--
fie.
Roads, 0 clhcr m.op Wc;e :cc
From To---
FI.
--
From To--
Fl.
—
U
('aI Sc�J
1 A. GROUT:
Depth
t.latorl,l
Molhod
7�
$ R ) 1 3 3I-, 'J rct5 � [ Y'C'e(�� R
From' — To=�_Ft. �L�
—.C�2
(fills r l M'VN R8
From To
Ft.
15. SCREEN:
Depth Diamelcr
From To Fl _. in.
From To Ft. In.
From To Fl. In.
16. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To FL
17. REMARKS:
Slot Size Maori al
in.
in.
In. _
Material
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED III ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE PlELL OWNER.
FOR OFFICE USE ONLY - �'� � + Cf-E'J.i el � (' OS (I _\ � I ., )
Quad No:
e'1
Serial tJa. t
Y.
OF PERSON CONSTRUCTING THE WELL DATE
or Waver Quality, Ground,eater Section within 30 days
GW-1 REV. 12.1,9
//// 51D0
OC'-

North Carolina - Department of Environment and Natural ftesaurcaa -Division of Water Quality • Groundwater Section
046
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phono [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: Imo^^ �� /or
1VELL CONTRACTOR CERTIFICATION If:
STATE WELL CONSTRUCTION PERMITIt:
1. WELL USE (chock Appucablo ooz): Rusidonlial Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water InIcclion Other 0 If Other, List Use:
Agricultural ❑ Monitoring ❑
2.
WELL LOCATION: (Show sketc I of the location bcic'a)
Noarost Town:_ County:
nn
t'�r IAS h d
,
(Road Name and Numbors. Community, or Subc!Ms•ion and Ln'. Na-)
DRILLING LOG
DEPTH
3.
OWNER �Qt-,.,-}-E''.'s'tV/ rV 1 (1 e+r
From To
Formation Doscdplian
Addressio
� 55
r e co�.
x
City or :.y or Taw - Slalo ) Cow--
-
4.
DATE DRILLED
S.
TOTAL DEPTH 051�-
'f rJ
(2n
G.
CUTTINGS COLLECTED YES ©� NOD
� o am
7.
DOES WELL REPLACE EXISTING WELL? YES NO-'�,
0.
STATIC WATER LEVEL Below Top of Casing: _6�j�,_ FT.
_m
(Usti' II Abovo Top of Casing)m
FT, Above Land Surface*
9.
TOP OF CASING IS
'Top
of eaaing lanninalod allor below land surfaco royulras a vay:lanco In accor-
dance
with 15A NCAC 2C.0110
N�
10.
YIELD (gpm): 1) 4 METHOD OF TEST vv�" l
•• na
11.
WATER ZONES (dopth): 50'E,
—�
0
z
12. CHLORINATION: Type Amount 0 121115 it additional space L^ needed use back of form
13, CASING: -- --
Deplll Di. mcicr
From0 To FL "-'�� t-
From To Ft.
Front To -- Ft.
14. GROUT
Wall Ihld.ncss LOCATION SKETCH
or Wei Material (Shoe, direction and distance Irom at least two Slate
uc- Roads, or other map ;clercnce points)
Depth
Material
Molhod
Front
To Q 0 Ft.
From
To Ft.
15. SCREEN:
Depth Diameter
Slot Size
Malorial
From
To Ft
In. In.
_
From
To FL
In. In.
From
To __ Ft.
In. In.
1G. SAND/GRAVEL PACK
Depth Size Malorial
From To Ft.
From To Ft.
17. REMARKS:
I�
�Y lRS �l ✓L�1-{-Yt � .
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/D� TO THE WCU_ 0
FOR OFFICE USE ONLY '� ✓.iv/,l'�Zi2,1Q I�I/..L'.LC- �JX,C; L9
Quad No: SIGNATURE OF 4 PERSON CONSTRUCTING THE W G
Submit-odginal to Dlvislon of Vlator Quality, Groundwater Section Wllhin 30 days
Serial No.
Croundwates Section
Pisl!01a�ceionalOffcp_ -
(S(_ I(33)
DATE
GW-1 REV. 12199
)/-/S--oa

NCnh Carows • Oeouedwu a lnraenmoM and Nak w Raaowt:u . OW4ton of W sler OwIRY • Gmumdwow section `�` J 0 / 9
taaa•F1w+. u
,r s4lw
ent br 1 We svtee Cemsr • PWWi. N.C. a7eaF%. 4A
WELL CONSTRUCTION RECORD WSLLCONMft11TRACTOR: .J " W 2 �"
WELL COACTOR CUMPICATION *:--a So
STATE WELL CONSTRUCTION PERW70:
1. WELL USE w* Arftilss6b 9@ a R411 f "M Munkipai ❑ IflduwW ❑ AWim tursl ❑ Menft "❑
meww" [5 Heat pYe'fp Weer Irt0aetion OIW ❑ If ocw, Lbt Uae:
2. WELL LOCAMM (Show skolch of too bosYon ONow) St UA r�>
Noanet Town ..,_ C� sty:
(Mat tans ado I Ow~*. or atAa imism and let Ma) DRI6" Loa DEPTH
a. OWNER Q_--=,°—^. _ Hom 7s 1antiYadOsas'0
/V C,
ft or T*M man
5. TOTAL DEPTH -2-s'S r--- — — ----
a. CUTTMIGS COLLICTED YES Q No
7. DOES WELL REPLACE EXISTING WELL? NO(
I. STATIC WATER LEVEL Sobw TOP OICf�M1E: c Fr. o <
gYa &NAW"TeloombW ncr
a. TOP OF CASING ISFT. Above Lend See uffe• ao
'Tq at asstq l Mm" BYar sWw ww anew MWAM a somm" M seen. o
OwweAalMfa0A0aa • Yf7 �7�u �nz
10. lEiO (tpsrt): METF� OF 7iET _ ,
11. WATER ZONES (depM): tV o
12. CHLORINATION: Type A =M O� I addllalY a0aaa la daaOW uu be* of form
13. CASMIO: - -
��GATION �MTCM
Oarw wwo lowwrW (chow dirudon add dtatrtoe befd a mm two awe
From _SL__TO�� Ft. _SL_ SDR 1l 'PVC lbada. «eew Pose rslandee w") l
Fforn To Ft �Slq�t L� /�� poly"
Flom To Ft
14. GROUT Depthf��
Method
From C_ To 3e Ft.
From To FL
15. SCREEN:
o.pn 04nlew sw1 sha Materw 1l^ ed ct 1
Ffem Te Ft In. _ K _
From _ To _ PL In In. 3�6 �+
From — To FL In. __ Y1
1S. SANDIGRAYEI PACK'
Depth w killo l 3 fb m (eta l,%�
From To FL
Fran To FL
17. PEW~
100 MANY CERWY TMMT THIS WELL WAS CONSIRUCTEO IN ACCCROANOE WRH 15A NCAC IC. WELL
CONMUCTION aTANOAROI. AND THAT A CO►Y OF IN* 11 OOM HAS SEEN PA0VI0E0 TO THE WELL 0WN1h.
FOR OPP= USE ONLY
Oese IYt
aw Ne.
OWAVOW Maven wwn 30 days

North Carolina - Department of Environment and Natural Resources - Division of Water Duality - Groundwater Section ? J t) 1 1
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION 9:
STATE WELL CONSTRUCTION PERMIT#:
1, WELL USE (check applicable Box): Residential `L'J Municipal ❑ Industrial ❑
Aecovery ❑ Heal Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: /(Show /pkketch of the location below) ScJ�
Nearest Town: e%e/"D"-G County:
—
1f11 Cove
(Road Name and Numbers. Community, or Subdivision and Lot No.
3. OWNER S�a�
Address Cjo quk{/4
veer or ou a o.
City or Town State Zip Code
4. DATE DRILLED 17-00
5. TOTAL DEPTH /b
6. CUTTINGS COLLECTED YfS❑ NOQ-
7. DOES WELL REPLACE EXISTING WELL? YES F1 NOe'
B. STATIC WATER LEVEL Below Top of Casing: ,r_ Fr.
(Use'✓ If Above Top of Casing)
9. TOP OF CASING IS z FT. Above Land Surface-
-Top of casing terminated atfor below land surface requires a variance In accor-
dance with 15A NCAC 2C.0119
10. YIELD (gpm): o METHOD OF TEST
11. WATER ZONES (depth):
DRILLING LOG
From To
v - G3
6 31 %o
50 - (/O
Agricultural ❑ Monitoring ❑
DEPTH
Fonri7M Des.:AAw-
L 6r/ --6/4 uc/
12. CHLORINATION: Type HL# Amount �'( It additional s;.ace 4s needrJ tse baciof rcF
13. CASING:
LOCATION SKrTCH
Wall Thickness
Depth Diameter or Weigh.11. Material (Show direction and distance b mi � leas: two Sale
From f7 To GS Ft. ' �Y� Sfee� Roads, or other rra releren� poinb`
From To Ft.
From To Ft.
14. GROUT:
Depth Ma aria) M 'hod
From To -9-0 Ft.
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From To _ Ft in. _ In.
From —To —Ft. — In. —In.
From To _ Ft.— In. — In.
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
17. REMARKS
I DO HEREBY CERTIFY THAT THIS WELL. WAS CONSTRUCTED IN ACCORDANCE WITH 15A l4CAC t:,'/rELL
CONSTRUCTION STAgDA", LAND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED -70 THE vl:� 1 011NEE.
FOR OFFICE USE ON ) -
Ouad No: STL IIrr--ni SIGMA RE OF PERSON CGNSTRIKJTING 1 c VVELL
u Inal to Divlalon of Water Duelhy, Groundrstar Sfc-A within h C;?Ys
Caw
oa c
60.1 fie v. 1:11
Serial No.

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section 14 9
1636 Mail Service Center - Raleigh, N.C. 27699.1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: - 1�11/e/_. (A.0 DyMl!:f;)
WELL CONTRACTOR CERTIFICATION P:
STATE WELL CONSTRUCTION PERfAITN:
1. WELL USE (Check Applicable Box): Residenllal L f Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other EI If Other, List Use:
2. WELL LOCATION:/(Shot'�sketch of the location below)
Nearest Town: C�+erd V-C County:
(Road Name and Numbers, Cfmmunity, or Subdivision and lot No.) DRILLING LOG
3. OWNER �6 /lcr From To
Address �� %/ Gu ��� ¢,
j5beel or,.G FTo. 0 — log
City or Town Stale Zip Code
4. DATEDRILLED
5. TOTAL DEPTH 5/25
6. CUTTINGS COLLECTED YFS F--] NOQ'
7. DOES WELL REPLACE EXISTING WELL? YES NOD—
S. STATIC WATER LEVEL Below Top of Casing: 160 FT.
i (Use'+' If Above Top of Casing)
9. TOP OF CASING IS 1 FT. Above Land Surface'
'Top of casing terminated st/or below land surface requires a variance In accor-
dance with 15A NCAC 2C.0119
10. YIELD (gpm): 3 METHOD OF TEST
11. WATER ZONES (depth): /P ' 12-
jr/G'
DEPTH
Fomasn DescdpGo�.
c%
G. e
12. CHLORINATION: Type f Amount,�v 6 ? If additional space is needed ts> baci of Item
13. CASING:
Wall Thickness LOCATION SKETCH
Depth
/Z-/
Diameter or, wt, Material (Show direction and distance Ir„m a l leas: trio Stele
�Y
From
To
FI.
SO/12 f ��� Roads, or otter rr'cp refentr4e points'
From
To
Ft.
From
To
Ft.
14. GROUT:
0
Depth
20
�ateria�l M thod
/erS✓/Q
From
To
FI.
�
From
To
FL
a
15. SCREEN:
f
Depth
Diameter Slot Size Material
rn
From —To
—Ft—
In. —in.—
From—To—Ft.—
in. — In.
ZZ
From —To
_ Ft.
In. _ In.
9?
16. SAND/GRAVEL PACK:
p
Depth
Size Material
From
To
Ft.
From
To
Ft.
17. REMARKS:
I DO HEREBY CERTI 11T,
IS-1ME4L WAS CONSTRUCTED IN ACCORDANCE WITH 15A FJCAC 27,'/JELL
CONSTRUCTION STARS,JDF?H)AT A COPY OF THIS RECORD HAS BEEN PROVIDED 70 THE 'N O shEP..
R EEE iiiiii 111III 333333 �--d
---
- ' •- . _ �
FOR OFFICE
Ouad No:
OCT 6 %' SIONAiURE OF PERSON CONSTRUCTING PIZ'N'EU. Oa'E
i Submit original to Division of Water Duality. Groundr alor Saccn within n City$
Serial No. Ge.l ptE V. I:r

North Carolina - Department of Environment and Natural Resources - Division of Water Ouality - Groundwater Section J 6 1 3 6
1636 Mail Service Center - Raleigh, N.C. 27699.1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION p: .Y7 S agcC
STATE WELL CONSTRUCTION PERMIT11:
1. WELL USE (Check Applicable Box): Residential D Municipal ❑ Industrial ❑
Recovery ❑ Heal Pump Water Injection ❑ OIherFj If Other, List Use:
2. WELL LOCATION: (Sho sketch of the location below)
Nearest Town: N�-�f12;A County:
(iUCff2!' el-e'ex
(Road Name and Numbers. Community, or Subdivision and Lot No.) DRILLING LOG
3. OWNER h5 P U 2 /ZY� /6n'i From To
Address
vest or outs o. b - ld
City or Town State Zip Code - /U /26
4. DATEDRILLED,�-02-OD
5. TOTAL DEPTH �26
6. CUTTINGS COLLECTED YFS NOQ-
7. DOES WELL REPLACE EXISTING WELL? YES Q NOL:;�-
B. STATIC WATER LEVEL Below Top of Casing: X-,n_ FT.
(Use 'i II 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.0118
10. YIELD (gpm): /5 - METHOD OF TEST ->2%/-
11. WATER ZONES (depth): SOS
Agricultural 0 Monitoring ❑
DEPTH
Fomuxn DeSCAP!,W
12. CHLORINATION: Type Amount �4` �" If additional sNce is needed cv bans of lct
13. CASING:
LOCATION SKcTCH
Walleih Thickness
Depth Diameter or Wei hr�I. material (Show direction and d'Sance kcsn � leas::rro ��le
From To '2l Ft. "S l�✓ Sfee� Roads, or otter rr�7 relertncy poin><)
From To Ft.
From To Ft.
14. GROUT:
Depth ����y1111ateqal elhod o
From �— To -Le Ft. �O/7`!n� CD o
n
From To Ft.C i✓
15. SCREEN:
1
Depth Diameter Slot Size Material
rn
From _ In. —in.—
—To—Ft
From —To — Fl. — In. —In.
z .'
From To Ft. _ In. _ In,
m
�-
_ _
16. SAND/GRAVEL PACK:
ca
Depth Size Malarial
From To FI.
From To Ft.
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 1SA D4CAC Y.,'/JELL
CONSTRUCTION STANDARDS, AND THAT A COPY OFTHIS RECORD HAS BEEN PROVIDED 70 THE VIES OWIEF..
FOR OFFICE USE ONLY --'
Oa
E
Clued No: SIGNATunfoF PERSON CONSTRU4TING 1>c KNELL
•
original to Division of water Quality. Gmrwj. slsr Se within .�7
C3lys
Submit
Fe.t GtE
V. 1271
Soda[ No.

North Carotins - Department of Environment and Natural Resources • Division of Water Oualiry - Groundwater Section 23609A
1636 Mail Service Center -Raleigh, N.C. 27699.1636•Phone [phone] GJ�
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION N:_
STATE WELL CONSTRUCTION PERMITN:
1. WELL USE (Check Applicable BOX): Residential [2 Municipal ❑ Industrial ❑
Recovery ❑ Heal Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (,Show;ketch of the location below)
Nearest Town: (- 7G�G -G'�-- County: —
`�i0 Cove
(Road Nlime and Numbers, Community. or Subdivision and Lot No.)
3. OWNER �Cr�rl� QI-rVer
Address C(>vr/la b LJ5"'9
treat or Route No
City or Town /, Slate Zip Code
4. DATE DRILLED b _30-'570
5. TOTAL DEPTH '19''5 r
6. CUTTINGS COLLECTED YFS ❑ NOD-
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 or casing terminated atior below land surface requires a variance In accor-
dance with 16A NCAC 2C.0118
10. YIELD (gpm): 6 METHOD OF TEST ^fir
11. WATER ZONES (depth): V7,'� r
�v a
DRILLING LOG
From To
Agricultural ❑ Monitoring ❑
DEPTH
Form2Sn Desaip60'
7,e-- - --
----------------
12. CHLORINATION: Type �f % Amount / 6✓ If additional s;.ace is needed tse bah, of fc m
13. CASING:
Wall Thickness
Depth Diameter or Weigh t. Material
From
�_To � Ft. M. ./b'✓ F Sfe�
From To Fl•
From To Ft•
14. GROUT:
Depth Mat vial M Ihod
From �_ To �
From To Fl.
15, SCREEN:
Depth Diameter Slot Size Material
From —To—Ft _ In. —in.-
From —To Ft.
From _ To _ Ft.
16. SAND/GRAVEL PACK:
Depth
From To
17
From To
In. — In.
In. — In.
Size Material
Ft.
Ft.
LOCATION SKcTCH
(Slow direction erd dance Ir" as leas: rwo Slate
Roads, or other rr—,—p relererrt polnlss`
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A 04CAC Y.:.'/dELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIC£D "TO Tlfi WS4 I O^"ERA If
FOR OFFICE USE ONLY
Ouad No'
Serial No.
SIG TURF OF PERSON CONSTRUCTING lit "'ELL
Submit original to Division of Water Duality. Gmvn(l` a** Se within h C : yS
00"t:
CN.I pig V. ""

;_i�8��
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELLCONTRACTOR:
WELL CONTRACTOR CERTIFICATION #: 1 �z-'J
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential W Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATIR N: (Show sketch of the location below)
Nearest Town: l I1 k,<0 c--eE mx, County:
(Road Name and Numbers, Community,
or Subdivision and Lol No.) DRILLING LOG DEPTH
3. OWNER ;.,; l a� 1�1 kc-.nif!�6i From To Formation Description
Address
beet or oute o.
City or Town Slate up ucue
4. DATE DRILLED W''
5. TOTAL DEPTHS Pt
6. CUTTINGS COLLECTED YES Q NO®
7. DOES WELL REPLACE EXISTING WELL? YES NOO
6. STATIC WATER LEVEL Below Top of Casing:_ FT.
(Use'+' it Above Top of Casing)
9. TOP OF CASING IS ! FT. Above Land Surface-
-Top of casing terminated atior below land surface requires a variance In accor-
dance with 15A NCAC 2C .0118
10. YIELD (gpm): 3 METHOD OF TEST
11. WATER ZONES (depth):
12. CHLORINATION: Type
13. CASING:
Depth Diameter�,yr
From I To 3S Ft.
From To Ft.
From To Ft.
14. GROUT:
Amount
Wall Thickness
or tWeight/R. ate
Depth Material Method
From To 2-0 Ft.-nrJ'A'4- C�m.7tsrJi4'"
From To Ft.
15. SCREEN:
Depth Diameter
From —To — Ft _._ in.
From — To _ Ft. — in.
From _ To _ Ft. _ in.
16. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To Ft.
Slot Size Material
in.
in.
_ in.
Material
o
-
0
If additional space is needed use back oflDrm c
LOCATION SKETCH
(Show direction and distance from at least two State
WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
D THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL O
Vrrna = uac .,n..r
IL
No: SIGNATURE OF PERSON CON CTING THE WELL
Submit original to Division of Water Quality, Groundwater Section within 30 days
/I
DATE
GW-1 REV. 12/99

North Carolina • Department of Environment and Natural Resource$ . Division of Water Duality • Groundwater Section 21 rl 357
16M Mail Service Center • Raleigh. N.C. 276WI S36•Phone (910) 733*=l
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION
STATE WELL CONSTRUCTION PERMIT#:
ba ResidKt6aia) Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
i. WELLUSEfzteokHeat Applicable ): p
Recovery Hut Pump Water In)eellon ❑ Other ❑ if Other, Wl Use:
2, WELL LOCATIOhI: (Show sketch of the locationbelow) .
Nearest Town: Y�-fZ"aay�County;
(PAW Name once Numbefs� 0 or suodoswin Lot No.)
3. OWNER
Address p toma or miss NA.)
C14l_1 k k n n N
City or Town „ atele =1p Code
a. DATE DRILLED'
5. TOTAL DEPTH zss
6. CUTTINGS COLLECTED YES 0 NO©
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO®
S. STATIC WATER LEVEL Below TOP Of Cuing: 26 FT•
(U" -*'I Move TOP Of Caekq)
g. TOP OF CASING M i FT- Abow Lund Sum.
-Top ar a•aing tennkraled sUer below land suit" res ukea a walrus In mow-
dense wen taA NCAC EC.0119
10. YIELD (gpm): _F?_ METHOD OF TEST [7
11. WATER ZONES (depth): 2 01
12. CHLORINATION:
13. CASING:
JP)RILLING LOG
From To
DEPIt
Fermetlon De$atvtlon
CD
Type T" Amount d LJ I— It add9brW space Is nestled use bad* of fwm
Well TNdare$s
Depth
Material
From O
To�Ft._
sD2a1 �vC
From
To
Fl.
From
To
Ft.
1 L. GROUT:
Depth
Mate1161Medved
From
To _4o
Ft. 00
From
To
Ft.
15. SCREEN:
LOCATION SKETCH
(Show direction and 04141`0e from at least two State
Roads, or other map reference Points)
j4-L'a%-t i&juj: 7 C o y,o
J� ';_�4, 1 75' llti��cvcJ404gI
Depth Diameter Sot Sae metanar -6g.� /C
From —To —Ft _ In. _ h. N`V��
3
From —To __ Ft. In. —In.
18. SANWGRAVEL PACK:
Depth Stse Material )
From To Ft.
From To FL
17. REMARKS:
I DO HERESY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCI1C 2C, WELL
CONSTRUCTION STANDARDS. AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY $J� � did
Died Ise: J K CONE THE WELL DATE
Stearn$ gyFryt'b� our ouesry, emlawwatar tedeon within 30 days
ow-1 R[v. 17/Ie
seder NO.

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27OWISae-Phone [phone] .
WELL CONSTRUCTION RECORD WELL CONTRACTOR: 1S1n 0_
Y WELL CONTRACTOR CERTIFICATION 11:OSo�
STATE WELL CONSTRUCTION ►ERMITg:
1. WELL USE Check Applloable sox): Residential ElMunicipal ❑ Industrial ❑ AgrIcultural ❑ Monitorklg ❑
Recovery L_j Heat Pump Water Injection ❑ Other ❑ It Other, Ust Use:
2. WELL LOCATI(?)X: (Show sketch of tpe location below)
Nearest Town:1�-+ County:
(ROW Name dd NW-nbers. C/lortvrrunlry. or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER /cY � 4-1 iR� From To Formation i)eteriptlon
Address 7:�L o i
or o.
CD
City OVT~ State Zip Code e3
4. DATE DRILLED 8 00 o m
5. TOTAL DEPTH 78 � _
B. CUTTINGS COLLECTED YES ❑ NOQ co _-
7. DOES WELL REPLACE EXISTING WELL? YES O NO
8. STATIC WATER LEVEL Below Top of Casing: 41 O FT. u — --
(Use '.' It Above Top of Casing) r n c
9. TOP OF CASING IS % FT. Above Land Surface* a
'Top of easing term* - st/or below land surface requires a varlarm In accor-
dance wlet 1 to NCAC 2C .011a
10. YIELD (gpm): METHOD OF TESTA
11. WATER ZONES (depth): S 41
12. CHLORINATION: Type )V�rt% Amount r) .9 7 It additional space Is needed use back of form
13. CASING:
Wag TMckness
Depth Diajnater or Walg!WR. Material
From To Ft. I I PVC-
From— To Ft.
From To Ft.
14. GROUT:
Depth Ma rtal Method
From _Z2_ To 2,2 Ft.
From To Ft.
15. SCREEN:
Depth
From
To
From
To
From —To
16. SAND/GRAVEL PACK:
Depth
From
To
From
To_
17. REMARKS:
Diameter Slot Size Material
Ft in. —In.
Ft. in. In.
Ft. In. — In.
Ft.
Ft.
Size Material
LOCATION SKETCH
(Show direction and distance from at Nast two State
Roads, or other map reference points)
f14-L�-;M.ua-j wags
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C. WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Quad No: SI TU PER N CONSTRUCTNG THE WELL DATIi
Sutlrtlta iglnal can weer Quality, GroundwaterSection within 30 days
Sariat No. OW-1 REV, 12M
7

North Caronw lina • Depannt of EnvironmarN and Natural Resouross - Oivla)on of Water Ouaiiy. • Groundwater 3trction
e19% 733.3221
1636 MLI Serviu Gnar • Raleigh, N.C. 270ee•163fLPhorks
WELL CONSTRUCTION RECORD WELL CONTRACTOR: R �Q
WELL CONTRACTOR CERTIFICATION 0:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check ApplkWMBoag Reaidentsl® Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Ham Pump Water IrOotlon ❑ Other O It Other, Ust UN:
2. WELL LOCATION: Show sketch 0f t11e location below)
NearevTown . County:
(ROW Name and �Comnrlry, or SutdVAIon and Let No.)
3. OWNER J) 10 d x )N
Acnkdrrea/.ems \ -7 TJ�v—k
.G
Cey Tom atale ap Cods
4. DATEDRILLED 8 zouo
S. TOTAL DEPTH r
a. CUTTINGS COLLECTED YES ❑ NO®
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO®
S. STATIC WATER LEVEL Below Top of Cashg: -. . FT.
lute'.• I Above Top at Casltp)
9. TOP OF CASING IS__J__ FT. Above LWW Surtat:e'
'Tap of saskp wounYM aYer #law land surface rgWrea a wrWws In seem'
eaMe wM taA NCAC aC .eNe ^
10. YIELD (Wm): 0 METHOD OF TEST s7 x-�j
11. WATER ZONES (depth): 1-9
12. CHLORINATION:
13. CASING:
DRILLING LOG DEPTH
From To Formation ossetiobw
Type r AmOunt o • r 2 It additionalepaoe Is neededuse back of tom+
WY Tlittarss
_
Depth OWnstar a
2
From
To Ft. —
From
To FI.
From
TO Ft.
14. GROUT:
Depth Mal" Method
From
To 10 Ft.Lllu
From
To Fl.
15. SCREEN:
Depth Diameter Skit Sizs Material
LOCATION SKETCH
(Show direction and distance from at local two State
Roeda, or other map reference points)
-# 7 'j 1 p� 1 t-wn
From —To—Ft—
In.
_ in.
w
From To _ Ft.
In.
—In.
From a To _ Ft. __
In.
— In.
IS. SANDIGRAVELPACK,
Depth
Size
Material
From To FL
From To Ft.
17. REMARKS:
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.
I S!`aa0o
OR OFFICE USE ONLY
FOR
Nix - D► 11a0N S THE WELL DATE
Owed pub". to of wave Ousay. Otoutdwaler sadcon w0hin 30 days
[dal No. OWt R[V. ,Nei

Nonh Cro1ro . DoprYrom of Endlonm4nl Ord NgkrW RMourcM' DivMbn W NH Ou�dY • Orardwoyr Season._ 1 1( 3 U 2
t dad Alan Meviw Conw. . PAWO. N.C. 17$WIUWPhW4 (VII) �"W LU �C�- /�� / • •"��
ACTOR:
WELL CONSTRUCTION RECORD WSLL FACTOR OR" FICATIDN 0;
STATS WELL CONSTRUCTION FERWTTO;
1. WEE �Uu�01wtANW��W°ONr ❑
Munblpsl ❑ Indwtrl0l ❑ AgeM11061rel ❑ ► "Itarlr+p ❑
Ofm ❑ It Dow. ust use:
2. WRLL LOCATION: Show o1cMOh Of b W ) --
rM
FL�S
tNt Town' �..�.�}-S �• Caumv:
V r �,�AWn am Lot NO) HYII l _ Fenn"
(ntld towns rrr rld m Oon+IM�!9r; _ A- Y ._ fi FROM To
9. OWNER
Addro00
-
4. DATE DR&LIKO 3 d o a
G. TOTAL DSPTH �— Q
0. CUTTNIOS COLLECTED EN YR ❑ NO®
7. DOES WELL RGI LACE EOUST►NO WE
f. STATIC WATER LffM Show Top of C&": -30 FT
• FT. Abend LWW Surwo 0
S. TOP CASINOt8 ovr1�Mu000-
ny M rlf! �r�0War below WA Suits" rolrMM_
1O. s wa YWDN►mn): go
oe MWT7IOD OF TEST d
11. wATEP120 ldo0r+):
If dddtbrW fpme Is rroo0o0 use book of teem 100
92. CHLORINATION: Typo ..�! AMMM o. ZJ/
13. CASINO:
Depth
Fresh © To ° Ft. /T
From_— To F1•
From To FL
1a. OP(O(JT:
0111110111
To —_
To FL
From
From
10, SCREEN:
000
From To _ Ft
From To Ft
W Woo ►moral
SD 's J! V
DIORIeW 510111" Mff N"
From — To � Ft.
br In
In. In.
In. In
1/. SANORMAVELPACK-
Ddph Ste Mew"
From TO FL
Fran To Ph.
17
1 M.1T7fYd LLTCH_
(Show d400*m Ord db. , tram r IMotl MO SMM
Ro01o. of WW m" tfists 0d per)
g
-t )2p,
\J
#7Y4'� / t4uv�-,
j� CUUJ Gr tcv✓Y, A/ 6y�
cG.n� ,,,r...�.
100 HERESY CEIITMY THAT TW WELL WAS CONETAUCTED IN ACCORDIINDE WITH 111A NCAC ZC. WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAi SW FROWDED TO THE WELL OWNKR.
c9G�
roRo� OTS
o� NSN � oowmucTw THs west` OATS
fMIrM r r aFwWw. Duwy, Orwdnow fawn wWn 00 aydow-, Rtv. tttl
flydrr Nr. ���

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section C f J U ) 0
1636 Mail So Nice Center - Raleigh, N.C. 27699-1636-Phona [phone]
WELL CONSTRUCTION RECORD WELLCONTRACTOR: S•S�J� 1 �' `j IUr
WELL CONTRACTOR CERTIFICATION lr%
STATE WELL CONSTRUCTION PERMIT!!:
1.
WELL USE (Check Applicable Pax): Residential Municipal ❑
Industrial ❑ Agt'CUL'ural ❑ Monitoring ❑
Reco. ory ❑ Heat Pump Water Injeclion ❑ O;h_r ❑ If Other, List Use:
2.
N/ELL'.-OCATION' (Show sketcla of the location helot.")
SLL)G_f/J
r
Neatest Town: Ar 1 +-`T Couny
Q1
\ PAiill AJf3 &CLC)
-Le
(Road Naamo and Numb�elr , Comrnunl:y, or Suod:vision a:id Lol f.'o.)
DRILLING LOG DEPTH
3.
OWNER �il.T Jef-A)k11VJ
From To Fcnna•IJon Desc,iiplioi
Address 3 L-
C. la��
btrec or o'J:n Vo.
/I p
'fL ci �
I']Sl
4r oOn, .i
� .� %P
Cr ShipJ�tate -ZIP c� e
�f12�
4.
l� :
DATE DRILLEDWA cvc
I o
O �' � C)
0.
TOTAL DEPTH >
—
G.
CUTTItdGSCOLLECTED YES© NOED
o
7.
DOES ':',ELL REPLACE EXISTING WELL? YES (� fJOro
8.
STATIC WATER LEVEL Below Top of Casing: —LC) FT.
Abevo Top o! Coinq)
9.
TOP OF CASING IS i FT. Abovo Land Surface'
'Top
of ensing terwirialed a7er below land surface requ!res n varinnce In necor-
dance
rvhh 15A 11CAC 2C .0118
I) METHOD OF TEST
10.
YIELD (^,prn):
11.
WATEI-: ZONES (depth): - /i)5
12.
CHLOP.INATION: Type t-_ 7.rncl;nl .�S
I! c...i:io,.al space i, necdeC u.e L.._.. _. .c: m_ __-
13. CASING
Dep!h GG.�r�,� Di.-,:I:cter
From �� To � Ft. �LQ -`—
From To--- Fl.
Front To-- Ft.
14. GROUT:
\•; ii T:dc:..-.csa _LOCAL-10:J .^__KE 1 Cf;
C: tic:-r.`i'I. ..�r�c'al (Shoe: direcLcn r.nd dstence! .:I ,c.:vro Slat..
Road: or c1hor map ra : pc s)
Depth I.talorlal.l M:olhod
From' To cao_Fl.— Pitt\r — 2
From --To Ft.
15. SCREEN:
.
Depth
Dimnetor Slot Size.
Malor.al
Front
To
Ft in.
In.
From
To
Ft. In.
In.
From
To -__
Ft. In.
In.
10. SAND/GRAVEL
PACK:
Depth
Size
Matetial
From
To
—FIL
From
To
Ft.
17, REMARKS!
I C: I�r1 SoA; � r'4-1
S t� 1 3 f {ju eECtier 131-nit- _h 00(74
G-c-P Rd
1 31 � 7}C>th7N > f rr
3c sum �kr l":5
s R 13/ 5 Mr- Jc. rry r2
S l 3.2.2 C cJ jJ ,"i< Itfs
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 1SA NCAC 2C, WELL
CONST ;UCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE P,ELL OWNER.
FOR OFFICE USE ONLY
A{� G,cer�
Ouad No: tl!1 .-rSIC�"'ATi1RE OF PERSON CONSTRUCTING T HE WELL DATE
Sbbmtt^[gnaal I y{slcn oI Plater Oua y, Greund r. a.er Seaicn 'within 30 days
Scrfal No. I 1 r GW.I REV. 12'4)

Nc n Carolina -Department of Environment and Natural Resources - Division of Water quality -Groundwater Section , j ") ,)
1626 Mail Service Center - Raleigh, N.C. 27699-1636-Phony [phone] ! 2,104 0
WELL CONSTRUCTION RECORD WELLCONTRACTOR: eu'x:Y-
WELL CONTRACTOR CERTIFICATION 0: - 21$ �-
STATE WELL CONSTRUCTION PERMITk:
1.
WELL USE (Check Applicable 13ox): Resldenlla� Municipal ❑
Industrial ❑
Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑
If Other, Llst Use:
2.
V ELL LOCATION: Show sketch of the location be!o.v)
Nearest Town: 'j ,j:w--1 ctnj Cour•y:
C
V
0A-Sv Abui?)4 o /Zo -
(.Road Name and Numbers, Cormur•Iiy, or Sub'Vslon and Lo'. No.)
DRILLING LOG
DEPTH
3,
OIVNER 5-r'V� IS CJ+N R"
Frcm To
Fcn,aiion Desc..:pl
n
Address ( �j rCC rZm,,j7 /�
Jirec: or IiJU ^ �0-1
33&dco
(p �p
�Y'�AiNlrc
-"Ti�MV•a Ft-
Cfl`i- 7Zy
c 2a,�rzc
C',y or Ta-,, Sla!e ZlpCcda
..
DATE DRILLED 0LT--W
5.
TOTAL DEPTH -7LS
o
6.
CUTTINGS COLLECTED YES NO[]
—
7.
DOES :YELL REPL4CE EXISTING V ELL? YFS O NO�l
n
S.
STATIC WATER LEVEL Below Top of Casing: — FL.
(Ucc'.' is ASc:a Tcp of Cac: ny)
9.
TOP OF CASING IS Ff. F.bo•:a Land Surface'GO
'Top cf cas!r.g Icr,mina:ad eJor below lard surfzca requires a vzrlanca In acccr-
J
do•^cc
10,
vuh 15n Nc;,c x.cna
YIELD (gpim): = F.1ETF!0D OF TEST _- �1r ---
--
a ru Co
11.
1YATER ZONES (captM
--LJ---��A
i2.CH'_O^I..ATION:
Type C !� Ar-._.�n1_ISZ �ia_.�
1:z2--t._�.__� _ei .ed .s:L--_— o
13,
CA _. ,.
LOC I! S� TGH
From To--- Fl - ---- —
Fr:'.nt To—.— FI.
14. GROUT:
Dep!h ttla!erlal tlolhcd
From O To aQ FL %b?
Fror.1 To Ft.
1S.SCREEN:
Depth Diamelar Slct Size Material
From To Ft in.
From _ To FL In.
From To _ Ft. In. _ in. _
16. SA'DIGRAVE'_ PACK:
Depth Size M,!erial
Frcm To Ft.
From To Ft.
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS V/ELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C. WELL
CONSTRUCTI0N STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO(TH1 UE %IIELL O'RNER.
FOR OFFICE USE ONLY 0 ` ' `�r� 'R� � �'����"\�\�'A 5.�Q'
Guad Nc; SIGNATURE OF FERSON =1STRUCTING THE =LL
Submit or;:ral to Di Aston of Water D"My. Ground,.aler Secl:cn within 30 days
Sedai No. -
L ntlrt6wa;�� Sic'+3n
r1 t f� aiunal uP st' E -
DATE
Z
G'f' 1 REV. 12,99
,Y
�' 1

0048 Nam Carolina - Department of Environment and Natural Resources - Division of Water Duality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: (Zu'>'3� YAV °cZ
WELL CONTRACTOR CERTIFICATION k: - ""Z41 7
STATE WELL CONSTRUCTION PERMIT#:
gam.-,
1. WELL USE (Check Applicable Be-): R^_sidentil>' !_ Municipal ❑ Industrial ❑ Agricvllural
❑ tAonitorin3
❑
Recovery ❑ Heal Pump Water In;ection ❑ Other ❑ It Other, Ust Use:
2. WELL LOCATIOt I: (Sha:r ske'ch of the location be!o•w)
Nearest To,n: QZY xra CiTy Coin'/: "4"J
b
(Rcad fame antl Numtca. -.murdty, or SoSdwislon and Lot No.) DRILLING LOG
DEPTH
_
3. OWNER M9_ URAAWA^ From To
Fc«r..a::on Descript:on
Address ?tflt SAnt/✓/Jvi:, 2D U
G-r Sc zb-;L13 S� 14S
ctznN::c
Cry cr Tc:,n &zle Tp Co'c
4, DATE DRILLED c6S''-A-coo
_,. TOTAL DEPTH 1-15_cj
6. CUTTINGS COLLECTED YES L NOD —
a
7. DOES V;ELL REPLACE EXISTING WELL? t(ES 0 NOw
$---o
8. STATIC WATER LEVEL Belo'%%Top of Casing:y0 FT.
(Ucn'.' it Abcr+o Tcp of Cncing)
9. TOP OF CASING IS FT. Abcve Land Suracc'
-Top cf eas1n9 termlaa:ed a'Jor below Iand surfeco requires a carimllca In actor-
dance v.ith 1SA fICAC 2C.C113
3� a\r
�o
10. YIELD (cpm): f.'ETFiOD OF TEST __
/?J Fr
Ao
11. WATER LOPES (dapth): -- — --
12. Cr.'_O. Tcpa
,:..ATION:
13. CP.Si:JG:
Frc-__C> To S} r t.
Frsm-- To FI.
Fr:m -To -- Ft,
—
14.GROUT:
L0C 4TI0V S-:ETC'-I
1cr„ I (S�^ / di,..Cc Ccl�o . •«s! L:o S.._ Z1��
F.: _ , or other map ra:orer.,.e polo,) ' Y
Depth
f:', a'et1al
L'.elhcd
From
ToQFt.itit�
�2
From _
To FI.
—
15.SCREEtl
Dcp!h Di2inetar
Slct Size;
Fdalelial �-
From —To
Ft __
in. in.
74
From _
To Ft.
In. in.
Frcm
To Ft.
In. !'I
_
15. SANDIGRAVEL PACK
Depth Size Ma!erial
From __ To Ft. —
Fram To Ft.
17. R-_f,IARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED lPi ACCORDANCE'?/ITH 15A NCAC 2C. WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OV,LIER.
FOAOFFICEUSEONLY Q�1(QP_nQ. VnC6, J'Qw�v�`eD� sq�vq.
Curd No
Scdal No.
S 1ATURE OF PERSON CONSTRUCTING TH z_\N4�LL
_ Sy }�}AiP. atAaDi dsien of \Ya.er Cua it/, Grourd'r.'a:er Se:. cn within 30 days
own
DATE
G'N 1 REV. 12M

N, th Carolina • Department of Environment end Natural Resources - Division of Water Quality, - Groundwa!er Section 4
1626 Mail Service Center - Raleigh, N.C. 27699-1636-Phono [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: R o" L" T/lyio;t `
WELL CONTRACTOR CERTIFICATION k: zlo T
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): ResidentlaiLY Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Irlection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Sho•,v sketch of (he location be!c•.v)
6
Nearest Town: 13Ly Sa.4 if T J Counr7:
Agricultural ❑ fMonitoring ❑
tAs, PLAV_kA '04__)-
(.goad Came and Yvmbe:s. Co.-.mu:dly, cr SuJ Vsion a,_' Lol No.) DRILUP:G LOG
3. OWNER $-tayE CS CAME. _ From To
Address ?,&% 5. f-q�cCmc. r 0.J£- U 72.
------- 7�:eelvrR—D :roI 7Z 74
—7=A'M?A FL— 3 g '74 7sS
D,:j cr TC,.a S:a!o 7p CO.:'
4. U.ATE D TILLED
S. TOTALDEPTH -765 FT
6. CUTTINGS COLLECTED YES [R NO — —
DEPTH
For;ralion Descdplicn
CQiy.k Lc
7. DOES WELL REPLACE EXISTING V:'ELL? YES [� F:O�,
o
8. STATIC !'DATER LEVEL Be!ov; Top of Casing: FT.
(Ucc'.' is AY o Tc, c(Cna:rg)
O
9. TOP OF CAS6NG IS I FT. A.`,ovo Land Sur'ace'
rn
'Top of c::!na tcrmlv.a:cd a:ar bclor•r !and su"sco rcgvlrae a n:in rre In acccr-
4;
il,,cc v,i;S 154, I;CAC 2C.0113
�-1r
-
Co rn
fIETHOD OF TEST _
_
-'a
m
Frcm S> Tr, Ft �—�� PJ�--
r .,, c h -. map r c _ puL ,
From To---- FL --
Fr^;n To—.— FL—
14. GROUT:
0..-..Am
Dep!h 1 alerial
From To��-Ft.]S-Ll\_
From To FI. --
15. SCREEN:
Dcplh Uiametar
Frog To Ft
Frcm —To—Ft.— In.
Frcrn _To FL— In.
18. SANDIGRAVEL PACK:
Depth Size
F; -rn To Fl.—
From To Ft.
17. REt.1ARri S:
Sct Size
in
it
C�7
L�(NL
f.'!!a._riel
rd
& r1v `�\''mow
E, a
C�Y
I DO HEREB'( CERTIFY THAT Ti :IS VIELL VLAS CONSTRUCTED IN P.000RDi YCE WITH 15A NCAC 2C. WELL
CONSTRUCTIO'l STANDARDS, AND THAT A COPE OF THIS RECORD HAS BEEN PROVIDED TO THE VEELL O'NNER.
FOR OFFICE USE ONLY
N)A-,r�.e;n�. "�� lOQWD\<), �4 S4) Vq. S� z31�
Cda,] No:
I
l 1
U
Srdal
OF FERSON CONSTRUCTING TH E`VkLI DATE
c Pla'er Cuality, Groundrater Sec!:on within 30 days
GIN I REV. 12159

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Ground Water Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636 - Phone [phone] Li 83 9 5
WELL CONSTRUCTION RECORD WELL CONTRACTOR: Hedden Bros. Well Drilling Inc.
WELL CONTRACTOR CERTIFICATION M: 2045
STATE WELL CONSTRUCTION PERMIT #:
1. WELL USE(Check Applicable Box): Residential 0 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: Bryon City County: Swain
Union Hill Rd
(Road Name and Numbers, Community, or Subdivision and Lot No.) DEPTH DRILLING LOG
3. OWNER Wane & Marilyn Herron From To Formation Description
Address 96 Airport Hill fl 150 rlay Rr sand
(Street or Route No.) 150 200 grnnite
Bryson City NC 28713
City or Town State Zip Code
4. DATE DRILLED 08/31/00
5. TOTAL DEPTH 2OO
6. CUTTINGS COLLECTED YES ❑ NO
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO X❑
8, STATIC WATER LEVEL Below Top of Casing: 0 FT.
(Use '•+•' if Above Top of Casing)
9. TOP OF CASING IS 2 FT. Above Land Surface*
*Top of casing terminated at/or below land surface requires a variance in accor-
dance with ISA NCAC 2C .0118
10. YIELD (gpm): 15.00 METHOD OF TEST Blow
11. WATER ZONES (depth): 163
195
t7
H
n
f`J
.n
F3=;
J
12. CHLORINATION: Type H T H
Amount If additional space is needed use back of form
13. CASING:
Wall Thickness
Depth
Diameter
or Weight/Ft. Material
LOCATION SKETCH
From 0 To 152
Ft. 6"
IRS Stems— (Show direction and distance from at least two State
From To
Ft.
Roads, or other map reference points)
From To
Ft.
14, GROUT:
Depth
Material
Method
From 0 To 20
Ft. Cement
Poured
From To
Ft.
15.SCREEN:
Depth
Diameter Slot
Size Material
From 0 To
Ft. in.
in.
From To
Ft. in.
in.
From To
Ft. in.
in.
16. SAND/GRAVEL PACK:
Depth
Size
Material
From 0 To
Ft.
From To
Ft.
17. REMARKS:
I DO HEREBY
CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRU
D,�2L�, WIOPY
OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE NLY
4AS
Quad No.
•-
Serial No.
GNATURE OF PERSON CONSTRUCTING THE WELL Date
_
.__ �__.:,,..
nal to Division of Water Quality, Groundwater Section within 30 days

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section 3 O
1636 Mail Service Center - Raleigh, N.C. 27699-163G-Phono 1919) 733 1-221
WELL CONSTRUCTION RECORD VdELL CONTRACTOR: _ �tSSt I I I o, �Gr
WELL CONTRACTOR CERTIFICATION It:
STATE WELL CONSTRUCTION PERMITII:
1.
WELL USE (chock Applicable oox): Residential Municipal ❑
Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection Other ❑ If Other,
List Use:
2.
WELL LOCATION: ('Show sketch of the location below) C
'
Noarost Town: yr\ S �.\ . County: vL"
�\1'1
`[p ,,�
�l\, yC i -i
l-l. M1U
(Road Namo((a��nd Numbors, Commu)ity, or Suhdivision LcI No.)
DRILLING LOG DEPTH
3.
1an'd
OWNER l�1�.1;t2Y �' ''i' r�\t'�C��- "Lly s-�
Frcrn To Fmmallon Description
Address �'', \�
�ttca'—CorTloula
C1�'
ll>k5At��n G1Q 33440
L (°j
City or Tmvn State sp Coda
4.
DATE DRILLED
5.
TOTAL DEPTH-
6.
7.
CUTTINGS COLLECTED YES[�NOE:] --77�� 1t
DOES WELL REPLACE EXISTING WELL? YES[-]NO� h 3 At-1 /n t r -
B.
STATIC WATER LEVEL Below Top of Casing: �0 FT.
o
K'
(Use'+' II Ahove Top of Caning)
0.
TOP OF CASING IS I FT. Above Land Surface'
m
om
'Top
or casing lanninated at/or helow land surfaco requires a vntlanca In actor-
�-
dance
with 15A NCAC 2C-.0110
1�
^'
Co
10.
YIELD (gpm): METHOD OF TEST
11.
WATER ZONES (depth): 3�d -vi4C at- %)
13 - -700 .
m
12.
CHLORINATION: Type _ Amount ( S
11 additional space L- needed use back of form
m�
13.
CASING:
LOCATION SKETCH
�
Wall Thickness
Depth Di, me or or WeiphUFt. Material
(Show direction and distance born at least two Slate
From To FI. � —�L
Roads. or olhcr map rcicronce points)
From To Ft.
From To-- Ft.
14. GROUT:
Depth Malarial Mothod
From lrl To �Ft.--�-mr`-'Yt�i'_
From To FL
1S. SCREEN:
Depth Diameter Slot Size Malarial
Front —To—FtIn. In.
From To _ Ft. in. In.
From —To Ft. In. in.
1G. SAND/GRAVEL PACK:
Depth Sim N alurial
From To Ft.
From To Ft.
17. REMARKS:
Fir�V-� se _as
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITII 15A NCAC'2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF TI-IIS RECORD HAS BEEN PROVIDED TO THE WELL,O
FOR OFFICE USE ONLY
L
L 1 j�
Quad Not -- -
-
$tGr1A1 LIRE OF
PERSON CONSTRUCTING THE W
Su6rh�l-niiginarto�DivL•ion al
`!later Quality, GmurAvratcr Secllon within 30
Smial No.
Sit �3a5
DATE
GW 1 REV. Q/77

North Carolirm - Depnlln,onl at Envho,mmnl. I-leallh. and 1•I"lurnl 17nsourcos
Divlsion of �nviron,ncrdnl Mmmgemnnl - 0mj"fIwnlet Sncllon
P.O. Box 29535 - Raleigh, N.C. 2762E-0535
Phone [phone]
WELL CONSTRUCT"ION RECORD
/lees 1 &H
ron or ricr a :r om.y
01-1AU. NO. __ SENAL t1O. — _
Lal. — Long. nO
Minor 9nnh,
Uasin Corte --- -- —
I leader rill. GY'!1 Enr
DRILLING CONTRACTOR.
TATE WELL CONSTRUCTION
DRILLER REGISTRATION NUMBER:_ J-qO _— PERMIT NUMBER:
I. WELL LOCA1ION: (Show Sketch of Ille 10cal Ofl below)
Newest Towm
2/'U[�2 z- Counly:
In""d, Cot nn,w,i,y, or Sukxlivision m,d Lo(No.)
2. OWNER rGda
ADI)nESS
(S"eel or noulo No.)
DEPTI 1
rime - to
0 — //G
//0—;00
City m Town Salo Zip Cod"
3. DATE DRILLED-��-db— USE OF WELL �/' war<e
4. TOTAL DFPTI I oo'—_
5. CUTTINGSCOLLFCTED YFSL-j NO[-J'
6. DOES WELL REPLACE EXISTING WELL? YES U 1`10[�-
7. STATIC WATER LEVEL Below Top of C151119: S—v FT. -
(lisp. -t" it Above Tnp of casing)
B TOP OF CASING IS Z _ FT. Above Land Surface'
• Caeinq Termin"led allot below land suilace Is Illogpw l ,less"v"Mince Is Issued"
In occ ordonco with 15A NCAC 2C .0110
9. YIELD (gpirl):/°-- ME I I IOD Or TEST ) r
10. WATER ZONES (depth):
I I. CHLORINA1ION:
12, CASING:
13
-DRILLIf IG LOG_
FommAnn 0e.oiplim,
Type ArnoUnd V)� II addi(ional space Is neodnd use hack oI lorm --
Depth Uiamele.,
rrom To /M FI.Flom—to - FL --
Fran --,a—
GROUT:
r-ton,
v
From
14.SCREEN:
LOCA 1_I_0I1 SKE 1 CI_I-
Wall INA11fir's or Wed Id/rt. Material (Show direction and distance Irvm al load 1•110 Stale
692 )_ '21/,- Roads, or olher map Tolorence palms)
Depth ah/rlal
To FI. 7G/unj —
To r1. —
Depth
Flom, —To—
Flom To —
rion, ----To _._
15. SANDIGRAVEL PACK
Depth
From Ia—
rlom _-- ]a-
16.REMARKS:
Diameter
Ft In.
FI. In.
r1. IN.
Size
_ FI.
_Ft. -
7 MJ� Iliad
%1-eA( vP
Slot Size Material
Malellal
W,
,a
c=
c,
1
S
00
w
C.
100 I-IEREOY CERTIFY 111AT'H ITS WELL WAS CONS TnUCtED IN ACCORDANCE WITH 15A NCAC 2C. WELL
CONSTRUCTION STANDARDS. AND IHAT A COPY OF IHIS RECORD HAS BEEN PNOVIDED 10 THE WELL OWI IEn.
Or CONTRACTOTI On AGFNt
UAQ

North Carolina - Department of Environment and Natural Resources - Division of Water Duality - Groundwater Section 0 0 C '1
1636 Mail Service Center - Raleigh, N.C. 27699.1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: Aill� L)a V1
WELL CONTRACTOR CERTIFICATION
STATE WELL CONSTRUCTION PERMIT#:
D Municipal ❑
Industrial ❑ Agricultural ❑ Monitoring ❑
1.
WELL USE (Check Applicable eox): ResldenUal
Recovery ❑ Heal Pump Water Injection ❑ Other ❑ If Other, List Use:
2.
WELL LOCATION: IShoy sketch of the location below)
Nearest Town: e-/i2ro L•C,� County:
(Road Name and Numbers. Community, or Subdivision and Lot No..
DRILLING LOG DEPTH
3.
OWNER zcr/ �L4/eS
From To FomaXn Descdptio-
Address L ""l Cods
G_ /cam 4y
veer or outs o.
City or Town State Zip Code
2`//-60
4.
DATE DRILLED
5.
TOTAL DEPTH "d
6.
CUTTINGS COLLECTED YFS ❑ NOQ-
7.
DOES WELL REPLACE EXISTING WELL? YES F--] NO�
B.
STATIC WATER LEVEL Below Top of Casing: 1.2-0 FT.
(Use'+' if Above Top or Casino)
9.
TOP OF CASING IS 2- FT. Above Land Surface -
'Top of casing terminated atfor below land surface requires a variance In accor.
dance
with 15A NCAC 2C.0119
6 METHOD OF TEST r
10.
YIELD (gpm): _t
11.
WATER ZONES (depth): u40
Amount D ba If additional space is needed baci of krm
12. CHLORINATION: Type
13. CASING:
LOCATION SKETCH
Wall Thickness
Depth Diameter or WeighVFt. Material (Slow direction end d-a'ance Irm a7 leas: -No Snare
6 116 Fl. 6'2-J� 4D2z l J�1/ Roads, or o0xr rra relenerre yoinG`
From To
From To Ft.
From To Fl.
14. GROUT:
_
Depth t nal M hod o
/esJ✓��
c
From � To Ft. °" ""
From To Ft.
15. SCREEN:
Depth Diameter Slot Size material 01
From To — Ft — In. — In.
From — To — Ft. _ in. — In, w
n.c
From — To —Ft. In. — In. w
16, SAND/GRAVEL PACK:
_
Depth Size Material
`
From To Fl•
From To Ft•
17. REMARKS:
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A p4CAC 2--, virELL
PROVICED -70 THE Y!St-l. OW%EE.
CONSTRUCTION STANDARDS; -AND THAT, ACOPY OF HIS RECORD HAS BEEN
FOR OFFICE USE ONLY lwyacwc c�
•TING D"SU Da . E
SIGNA. E OF PERSON CONSTRIYJIZ L
Ovid No:
SulxrJl original to Division of Water puelhy, Grovnd.•tler Saccrt wil)li0 :7 t:'sY�
Ce•1 V.
12"
Sedai No. -

2153'76
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
WELL CONTRACTOR CERTIFICATION #: 23 E7
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable sox): Residential X Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
Agricultural ❑ Monitoring ❑
2. WELL LOCATI N: (Show `6ketch of the I cation below)
Nearest Town: -r�SC`r" C k' County:
ALt'yiQ rdd DEPTH
(Road Name and Numbers, Community. or Subdivision and Lot No.) DRILLING LOG
3. OWNER ',2'h51yr' C —
From To Formation Description
Address
treat ar OUIe o.
City or Town State Zip Code
4. DATE DRILLED
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES Q N021
7. DOES WELL REPLACE EXISTING WELL? YES ❑ 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 aVor below land surface requires a variance In accor-
dance with 15A NCAC 2C.0118
10. YIELD (gpm): METHOD OF TEST
11. WATER ZONES (depth):
12. CHLORINATION: Type Amount
13. CASING:
Wall Thickness
Depth Qlarpeter or Weight/Ft. a eehat
From To Ft.rle—
From To Ft.
From To Ft•
14. GROUT:
Depth Majjerial Method
From To Z-V Ft. 57,4✓d A4)clw` 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:
100 HEREBY CERTIFY. TLIAS.THIS..WELL WAS.
CONSTRUCTI*ST*D ,AD,1c' AND TIHA�A Gy
FOR OFFICE U E bNLY
Quad No: . . i l [ i.
O
n
b
�l
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)
ISTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
GNATURE OF PERSON CONSTRUCTING THE WELL uni c
to Division of Water Quality, Groundwater Section within 30 days GW 1 REV. 12199
Serial No. }

North Carolina - Department of Environment and Natural Resources -Division of Water Quality -Groundwater Section
215375
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone] p
WELL CONSTRUCTION RECORD WELL CONTRACTOR: J N W OrJS 1lJU L . I r
WELL CONTRACTOR CERTIFICATION #:--1Sr�� 7.
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential [a Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2.
3
Agricultural ❑ Monitoring ❑
WELL LOCATION: how sket It of the locattiQn,,below)
Nearest Town: /I County:
j � 424-q L A-L� R �
(Road Name and Nuinbers, Community, or Subddivision and Lot No.) DRILLING LOG
OWNER 'C�1'Wtd i%�C'T (LQ-� From To
Address —
(Street or houie o. —
City or Town State Zip Code
4. DATE DRILLED 4
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES Q NO®'
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO[V
8, STATIC WATER LEVEL Below Top of Casing: D FT-
(Use'i it Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface'
-Top of casing terminated atior below land surface requires a variance In accor-
dance with 15A NCAC 2C 118
10. YIELD (gpm): W METHOD OF TEST
11. WATER ZONES (depth):
12, CHLORINATION: Type
13. CASING:
De t qa ter
P %.o
FromFtFt.
From To Ft.
From To Ft.
14. GROUT:
DEPTH
Fonnalion Description
Amount If additional space is needed use back of form
LOCATION SKETCH
Wall Thickness
or Weight/Ft. atedal (Show direction and distance from at least two State
, Roads, or other map reference points)
Depth Materi I Method
From To -2-0 Ft. �1 Le4 l' `✓
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
VP
M
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION �ITANDAR[3S•-ANOdHATA COPY
�.O THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE - f l
Quad No
"; `;i SIGNATURE OF` PERSON CONSTRUCTING THE WELL DATE
� (!9Vbmit original to Divisional Water Quality, Groundwater Section Within 30 days
d a GW-1 REV. 12J99
9
Serial No.
n

Nonh Carolina - Dparwwnt of Envirom ent and Natural Resources • Divteion of Water Quality - Groundwater Section
1 f136 Mail Service Canter - R~. N.C. 276WIG36-Phono (91 i) 733.3221
WELL CONSTRUCTION RECORD WELL CONTRACTOR: lhLet yr\ LL` Olt (�/11CCVy�1
WELL CONTRACTOR CERTIFICATION Mr.
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check APp6cable eOa): Reeldental ® Munlcow ❑ Induatral ❑
Recovery p Heat Pump Water Ir1)ectlon ❑ Other C3 It Other, List Use:
2. WELL LOCH Show ak6leh of�the, location below) s
Neanal Town: ! Coin,; L, 'y ayyv
Agricultural ❑ Monitoring ❑
(Roes Name "" Comrrunpy. or aub4Nsl and lot No.) DRIWNG LOG
3. OWNER/ L t� C}{ (/ from To
Address tivrtt c�L�',
i
Cityer een tasY VpCode
4. DATEDRILLED 7 /$ 2-61t-a
5. TOTAL DEPTH -s---
5. CUTTINGS COLLECTED YES❑ NOE
7. DOES WELL REPLACE EXISTING WELL? YES �D NO®
6. STATIC WATER LEVEL Below Top of CaNng: o 0 FT.
(Uee'e's Above TOP of Caaktq)
9. TOP OF CASING IS �_ FT. Above Land Surlee6•
'TOP Of eire" be edrraad alter variance land surface ro*dm a varoe In ooOor-
, I eMr 1tA NCAC MD is
10. YIELD (gpm): METHOD OF TEST r'1'
11. WATER ZONES (depth):
12. CHLORINATION: Type ILELd Amount
13. CASING:
Deptha, W*hlll tr Mle*"
From To 24' Ft. Off— •Sl1KA11
From— To Ft.
From To Ft.
14. GROUT:
Depth t"ermALla(arie! 9 M69hod
From n To A 0 Fl.
From To Ft.
15. SCREEN:
Depth Diameter Slot Site Material
From —To—Ft— In. _ In.
From _ To _ Ff. , in. _ In.
From —To , Ft. In. —In
10. SANO/GRAVEL PACK:
Depth size MOURW
From To Ft.
QEPTH
.pow iogn oeesrww
If additional span Is needed tide back of
LOCATION
(Show direcdon end distance from at least two Sale
M
Roads, or other mw referenoe points)
YYtt 1�v 'vti� f ��1 Wci��/�
Rcit. dse- h m�
W� ,gip �-6l , —
From To Ft.
17. REMARKS:
I DO HERESY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 1SA NCAC 2C. WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY v �Iwd71 g 2 o d
Quad No. CON TWO TIE WELL DATE
aubrm WWW ID D y"n rvafar WON Oudky. Gro nO$sown wIthin 30 day#
sow Ns. OW-1 REV. t1M

3066
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 tAail Service Center - Raleigh, N.C. 27699-1636-Phone [phone] �
4
%Ayr.(_)z
Z(V� -4
WELL CONSTRUCTION RECORD
WELL CONTRACTOR: . _1.'; SSEU-
WELL CONTRACTOR CERTIFICATION N:_
STATE WELL CONSTRUCTION PERMITN: _
1. V;ELL USE (Chl
eck Appl lcable Box): Resdantia� Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (SQho,.v sketch of the local;on below)
Nearest Town-3 Lt T7 Count':
DJ`t-/ArN
(Road Name and Numbers, Community, or SuCd:vision and Lot No DRILLING LOG
3. OWNER 4A'5ilA-/ Ati �✓m9Nii7 c,-.7fwt' �r-/ From To
Address P0, •3C/ q15- s U l:
treat or outs o.l // xS // q
City or Tc,n Safe Zip Cope
4. DATE DRILLED-y-oo
5. TOTAL DEPTH 3oc F7 —
6. CUTTINGS COLLECTED YES© NOE]
7. DOES WELL REPLACE EXISTING WELL? YES n N0_0
8. STATIC WATER LEVEL Below Top of Cabling: UO FT.
(Use'.' it Aocva Top of Cao`nq)
9. TOP OF CASING ISM_ FT. Ahovo Land Surface'
-Top of cas:rg terminated nVor below land surface requires a variance In sccor-
dance with 1SA NCAC 2C .0119
10. YIELD (gpm): 01� r.1ETHOD OF TEST _ LT'-'e _
11. WATERZONES(deplh): :�r­-1;7o S _Zoo
12. CHLORINATION
13. CASING:
Amount - 42-Q+trS
P: aO Tifskra
ss
Depth
�y7
Cia—N c: F.ei-!a i'I.
�4-
:`a'edal
`-�ex_�
From _��
To Ft.
--/'3
Frcm
To - F1
-- --
-
Frora ---
ro - Ft.
---
14. GROUT:
Depth
k.1:Jeriaf
:.jfh,od
Frcrn
To�-Fl.-J—
Frcm _
To _—FI.
15. SCREEN:
Depth Diameter
From To FI _ in.
From —To—rt.— In.
From _ To __ Ft. In.
16. SAND/GRAVEL PACK:
Depth SIZE)
From To FL -
From To FL
17. REMARKS:
Slat Size Malarial
In. _
Ma!erial
Agricultural ❑ Monitoring ❑
DEPTH
Formalion Descdplion
Sa,.ry
�r:rE
G-r2: nnr: iE
11 ad..:cnn: s ace is needed use hay:. of
O
O
_LOCATION SKETCH J
(She,v direction r ^d d's'anco from at least hvo Stale
Roads, or other map reference poirds)
41
y�
` JJ ny
�y132x
AD C-0 �S^1
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, rAA�NNDD THAT COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELLOWNER.
FOR OFFICE USE ( 0 ' -VAn r1C `\Ao0_0 I4I`�
Quad No:
Serial No.
6UDmlt on
q
OF PERSON CONSTRUCTING Tfic td__L ' DATE
of Plater Oual, y. Groundwater Section Within 30 days
GW-1 REV. 12199

North Carolina - Department of Environment and Natural Resources - Division of Water Duality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phono (919) 733"3221
WELL CONSTRUCTION RECORD WELL CONTRACTOR: 2✓s ue -TA4 -•'L-
WELL CONTRACTOR CERTIFICATION ti: 7 _
STATE WELL CONSTRUCTION PER ITN:
1. WELL USE (Check Applicable Box): ResldentiaY2�1 Municipal ❑ Industrial ❑
Recovery ❑ Heal Pump Water Injection ❑ Other ❑ It Other, List Use:
2. WELL LOCATION: (Show sketch of the location be!o:v)
Nearest Town: �3?4ia Crry County: 5.ee.9r-1
(Road Name and Numbers. Commur,ity, or Subdivision and Lot No.) DRILLING LOG
3. OWNER wO i✓NSLCi From to
Address P c� j. 32(e 0 3<{
jStrcorrT{ouial�o.) h 4
azu,-- tarry Aim 2D.7f
C,ly or Town Stale - Zip Cod. ��'( �
4. DATE DRILLED-t'j-tw
5. TOTAL DEPTH 35-0 PT
G. CUTTINGS COLLECTED YESF>� NOD
7. DOES WELL REPLACE EXISTING WELL? YES 0 NOJR3
8. STATIC WATER LEVEL Below Top of Casing: 1 Lo Fr.
(Use'.' if Abovo Top of Casing)
9. TOP OF CASING IS FT. Abovo Land Surface'
'Top of casing Icrminaled oVor belovr land surface roqulros a variance In accor-
dance v.Ilh 15A NCAC 2C.0118
10. YIELD (gprn): 4'5- METt tOD Or TEST c-lr
11. WATER 7.ONES (depth): nil o 1�:T
Agricultural ❑ Monitoring ❑
DEPTH
Formation Description
gnaN,ve
�p�wr7c'
o
O
o
�m
0
fV
pi
CO
it
0
nl A
--1
z
"
12. CHLORINATION: Type H^V ti Amount _ �,��WS If cdjilional space is rmeded use backot
13. CASING: I
Depth Dinmclor
From-> —"ro 4L Ft. G%1
From To— FI.
Franc To—" F1.
14. GROUT
\Ya!f 11Jcxness LOCATION SKETCH
c,Y;N:�11. i'L lJ_:edat (Show direction and ds:anco'rcm at least 1'.vo State
s, or other map reference points)
Depth y� M�a�.orial Idothcd
From To'—Z F1.11lS;i1�� Q7
Frorn To FI. _
15. SCREEN:
Depth Diameter
Front To Ft in.
From To Ft. In.
a
From To Ft. In.
16. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To Ft.
17. REMARKS:
Slot Size Ma!erinl
in. ---
In.
In. ----
Ma!erial
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS REC`ORRD- HAS BEEN PROVIDED TO THE WELL OWNER. i
FOR OFFICE USE ONLY! 1-r�'-� C-7\C�J �[�� &)� �iQ �IZ3 [x)
- m
Cued No: - $IGf1ATURE OF PERSON CON6TRUCTING TH- -LL
SubmO.orifinal la DivL'ien el yfalor Quality, GrounC'rra;cr Secaen vriihin 30 days
Serial No.
t
DATE
GfA'"I REV. 12157

North Carolina - Departmont of Environment and Natural Resources - Division of Water Quatit,/ - Groundwa!er Section C.,.:. 3079
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: — R SS � / AU 16
WELL COM RACTOR CERTIFICATION 1J: aIflrl
STATE WELL CONSTRUCTION PERMITR:
1.
WELL USE (Check Applicable Box): ResidentiaYN Municipal ❑ Induslrlal ❑ Agricultural ❑
Monitoring ❑
Recovery ❑ Heat Pump Water In;eclion ❑ O!Mr ❑
It Other, List Use:
2.
WELL LOCATIO' (Show sketcl of ir' location balov;)
Nearest Tov:n: S I u County:
`, 1.lkt,I kI
(Road Name d fiulmbers. Corr.!„unity, or ubdivislon and Lcl No.)
DRILLING LOG DEPTH
3.
OWNER CL 1 ^S
�j /
From To Fon-a;ton
DZs P:lcn
Address (! oC-,
(Street or qq•u�; 0.) e/ n
h��, aV d
D,i/or Tov:a - Sia!o Zip Code
r7
—�—•
l okd , Y,
4.
DATE DRILLED MX „2tvo
'7 G 3 60
5.
TOTAL DEPTH
6.
CUTTINGS COLLECTED YES© NO❑
7.
DOES WELL REPLACE EXISTING WELL? YES L-1 NO,,
8.
STATIC WATER LEVEL Belov: Top of Casing: 7C) FT.
(Use'+' it Above Top o! Casing)
O �_
9.
TOP C= CASING IS FT. Above Land Sutface'
'i op
of ea s!ng I r rr.I nated aVor beio,v land su rfaeo to quire a vadurea in acc or-
O �
m
dance
10.
with liA ti Ci.0 2C .0118
YIELD(apm): _��METHOD OF TEST __ AIC
Fla >�
�
12.
CHLORINATION: Type a j 1=—A.:ncur,l01115If cddi5enal =_pace t needed uce Lac;;r!
form ,CD
LOCATION SKETCH
-ni
Depth Din. 'cr c: 1. 1. Vatc'al
r
(Show direcCon rtnd d3lence :rem :'. Ic c.,!
two Slalc� z
From_C? —To Ft.- --K-D
Roads, or othar map rolcre^cc pci.:a)
From To-- FI. --
From To- Ft. —
14. GROUT:
Depth F.Ialorlal Molhod
From' «ToczQC-) Ft.
From To Ft.
15. SCREEN: "
Depth Dinrne!cr
from To Ft in.
From To Pt. In.
From To Ft. In.
16, SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To Ft.
17. REMARKS:
Slot Size Material
in.
in.
Malarial
g ( Se,n 01 +_I ? L/
Sal/G% �csSer0-roe RcQ
1/ CYCISsa'-", R�
S U
I DO HEREBY CERTIFY THAT THIS WELL WAS COPISTRUCTED IN ACCORDANCE WITH 15A NCAC 20. WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS EEEN PROVIDED TTO� THE %':ELL OWNER.
!F10),R:NO:
ICE USE ONLK �'
wer t'G:".l �T.'}'ja PERSONCO'iSTRUCTP.G if!`c HEll DATE
Lral to DiO, I Wafer Guai;V. Groundea'cr Section within 30 days
eo `'� GW I REV. IM3
! ,u) I s(
k
/ i 11115166

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section N
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone] S u
WELL CONSTRUCTION RECORD WELL CONTRACTOR: NIJb}' .1S t OLIt nY' tI ti
WELL CONTRACTOR CERTIFICATION #:,
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential bill 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: Ro, S t� �' " County: SL"'1q N
r Q L IV CR-kA
(Road Name and Numbers. Community, or Subdivision and Lot No.) DRILLING LOG
3. OWNER 1 4Jq, y. + From To
Address if.-KA —
'-(btreei orf HouTe o.)_
City or Town Stale Zip Code
4. DATE DRILLED
5. TOTAL DEPTH `
6. CUTTINGS COLLECTED YES Q NOM
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO®
B. STATIC WATER LEVEL Below Top of Casing: IIA — 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): I'L METHOD OF TEST
11. WATER ZONES (depth):
12. CHLORINATION: Type Amount
13. CASING:
Wall Thickness
Depth Diate'
or WeighVFt. atenat
FromToJ4— Ft. t ' /F �;—
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From To �—Ft. C�1M%1 J Ica lo-, -*
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From —To—Ft— in. —in.-
From _ To _ Ft. _ in. in.
From —To —Ft. in. in.
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
17
DEPTH
Formation Description
If additional space is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least two State
or other map reference points)
J `: NL, j C
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Quad No: SIGNATURE OF PER" CONSTRU�T91 G WE " (� � i DATE
Submit original to Division of Wear. aGly, d alrl�fa Wd days
Serial No. ) GWd REV. 12/99

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section 1 4 3 g
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone] II
WELL CONSTRUCTION RECORD WELL CONTRACTOR:WELL CONTRACTOR CERTIFICATION N: p3
STATE WELL CONSTRUCTION PERMITN:
1. WELL USE (check Applicable 90a): Residential L"J Municipal ❑ Indusirlal ❑
Recovery ❑ Heat Pump Water Injection ❑ Other n It Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: C�e,-d e e— County:
GIJ/''y//fl C/'GGVL
(Road Name and Numbers. Community, or Subdivision and Lot No.) DRILLING LOG
3. OWNER daq e Sy
v / / On From To
Address (�y£�l4 /y41JJ,4y
[5 reo or ou e o. O> — 3 D
City or Town State Zip Code
4. DATE DRILLED S- 02 2"
5. TOTAL DEPTH Err '
6. CUTTINGS COLLECTED YES ❑ NOOK
7, DOES WELL REPLACE EXISTING WELL? YES ❑ NO[�
8. STATIC WATER LEVEL Below Top of Casing: kO FT.
(Use'i If Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface'
'Top or casing lerminaled allor below land surface requires a variance In accor-
dance with l SA NCAC 2C .01la r
10. YIELD (gpm): O METHOD OF TEST
11. WATER ZONES (depth):
Agricultural ❑ Monitoring ❑
Formation OdstrYp(km
e 4y
f-e-
12. CHLORINATION: Type 17'71i AmountC
It additional space Is needed use back of form
13. CASING:
LOCATION SKETCH
Depth!!
Wall Thickness
Diameter or We hm. Material
(Show direction and distance from at least two State
From To L�
Fl.
6 - '��X C
Roads, or other map reference points)
From To
Ft.
From To
Ft.
14. GROUT:
Depth
at�ydot Ihod
From O To ;2-61
Ft,
cl!r`4n� esr✓,-e.
From To
FI.
15. SCREEN
Depth
Diameter
From
_To _
FI _ It).
From
— To _
Ft. _ In.
From
_.. To _
Fl �_ In.
16. SAND/GRAVEL
PACK:
Depth
Size
From
To
Ft.
From
To
Ft.
17. REMARKS
Slot Size Material
In.
_ in.
In.
Material
I DO HEREBY CERTIFY THAT THIS�WECLNlAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C, WELL
CONSTRUCTION STANpA DS, AND THAT A COPY Off' I RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONE UU
Quad No: SI N TUR OF PERSON CONSTRUCTING THE WELL GATE
e ion vision I Water Quality, Groundwater Section within 30 days
Serial No. aC il�e RoeinnAt RY :e m OW-1 REV. 12199
0

North Carolina - Department of Environment, Health, and Natural Resources
Division of Environmental Management - Groundwater Section
P.O. Box 29535 - Raleigh, N.C. 27626-0535
Phone [phone]
WELL CONSTRUCTION RECORD
DRILLING CONTRACTOR: � ) u
FOR OFFICE U5E ONLY r ; +
QUAD. NO. SERIAL NO. '- -" 4 O
Lai. _ Long. RO _
Minor Basin
Basin Code
Header Ent. GW I EnL
STATE WELL CONSTRUCTION
DRILLER REGISTRATION NUMBER: V3 3 PERMIT NUMBER:
1. WELL LOCATIONS (ShowXsketch of the location below)
Nearest Town: �G7'erU2�.2, County: 54v,141
(Road. Community, or Subdivision and Lot No.) _DEP LI 1 Df}1Lf.1P�G_LOG_
2. OWNER Qiane -5 11104 _ From To Formation bescrptirlyi
ADDRESS PiG> (Qva�la_ /ivu3.r19
f Stieel or Route No) O - 2S C A
City or Town Slala zip Codo
3. DATE DRILLED USE OF WELL !/alze
4. TOTAL DEPTII 600 _
5. CUTTINGS COLLECTED YES ❑ NO[---
6. DOES WELL REPLACE EXISTING WELL? YES U NOL�4
7. STATIC WADER LEVEL Below Top of Casing: FT.
(Use '+' if Above Top of Casing)
8. TOP OF CASING IS 2 FT. Above Land Surface'
Casing Terminated alJor below land surface Is Illegal unless a variance Is Issued
In accordance with 15A NCAC 2C .0110
9. YIELD (gpm): D METHOD OF TEST
10. WATER ZONES (depth): —s_
11. CHLORINATION: Type /l�Il% Amount
12. CASING:
Wall l hicknoss
Depth DiafnCler or Wei hVR. Maleriat
From b To VO FI. 6,2-(� ,W'd2/ /6-t-
From— To FI.
From To FI.
13. GROUT:
Depth MM I r'at
From To ;'o Ft.
From To Ft.
14. SCREEN:
Depth
From
To
From
To
From To
_
15, SAND/GRAVEL
PACK
Depth
From
To —
Fron1
To
16. REMARKS:
Diameter Slot Size
Ft in. In.
Ft. in. In.
Size
7nn
/"1hod
PSf Ul
Material
0
O
O
L
t' o
Ln
If additional space is needed use bacRof Itr4w
o
LOCATION SKETCH z
(Show direction and distance from at least Iwo State
Roads, or other map reference points)
I DO I IEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A HCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF T111S RECORD HAS BEEN PROVIDED TO THE WELL OWIIER.
E OF CONTRACTOR OR AGENT
DATE

North Carolina • Department of Environment and Natural Resources -Division of Water Cualiry •Groundwater Section
0' '3085
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: je�55c(- Ta7roR
WELL CONTRACTOR CERTIFICATION N: ZIF,
STATE WELL CONSTRUCTION PERMITk:
1. WELL USE (Check Applicable Box): Residentia)3N
Municipal ❑
Industrial ❑
Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Wafer Inieclion ❑
Other ❑ It Other,
List Use:
2. WELL LOCATION: (Sho.v sketch of the location belov.)
Nearest Town: 3,0Yz"1 G1T�
Ccun�':
A`,3
(L
3ZDSrt C b5Ce 'Zk`-
� o Nc,--7ri
(Road Name and Numbers. Community, or Subdivision and Lot
NO)
DRILLING LOG
DEPTH
3. OWNER -572AryJly 1-1N6 6�,'- C/0 -?OVI
?ZAAA4 A641f%
From To
Formation Descrpi.on
Address 1-1KIKecA,Jo &1
0 99
616A7
/ tree or lewd o.)
^1y aiL
' b,
:71_?�G-.2.4Nt:L-
yg 30
G,C.4/✓!7E
*CIly or Tc,,n 4 State Zip Code S
4. DATE DRILLED
5. TOTAL DEPTH-
6. CUTTINGS COLLECTED YES[X NOD —
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NOP�j _
B. STATIC WATER LEVEL Below Top of Casing: ,C, FT. _
(Uso b• if Abo,o Tcp of Casing)
9. TOP OF CASING IS % FT. Above Land Surface'
'Top of casing terminated at/or below land surface requires a variance In actor
dance with ISA NCAC 2C.0118 —
10. YIELD 13- ( ;gym : L METHOD OF TEST A " _
) —
11. WATER ZONES (depth): '7 -/ ZS /-15S' %- 05-0
qy-3oS
12. CHLO.RIN.ATION: Type r� � F� A,m.ount-
13. CASING:
Wall IIkk,-,ess
Depth Diameter or Wci;kd Ft,
FromTo—'5-�o Ft. 1� v/"i--
From To Ft. - —
Fro;n To— Ft. —
14. GRou r:
Depth Material ttc:hod
From — To—.�Q Ft.
From To _FI. _
15, SCREEN:
WE
i
�j
If ad^Llonai space L- needed use bat'
c!
0
LOCATION SKETCH // V
(She.., direcl'cn and distance from at (east lv:o Sa' L�
Roads, or other. nap refarenoe points)(/ pp
Depth Diameter Slel Size_ Malorial
Front To Fl In. In.
From To Ft. In. In,
From To _ Ft. In. In. _
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS'NELL WAS CONSTRUCTED IN ACCORDANCE WITH 1SA NCAC 2C, WELL
CONSTRUCTION STANDARDS AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE Of Yy k fu ��'�n��)V�
Curd No + U SIGNATURE` OF PER SO N CONSTRUCTING T HE*VUL I DATE
y Submit orirvnal Io;Divis:on of V,auu Qualify, Groundwater Section Within 30 days
Sedal No. - GW.I REV. 12,'S9
-r2)
1 ZA✓CG1j
y$r

North Carolina - Department of Environment and Natural Resources - Division of Water Dually - Groundwater Section �" i 1 J r-
1636 Mail Ser ,lce Center - Raleigh, N.C. 27699-1636-Phone [phone]
ll'er Lv'0
WELL CONSTRUCTION RECORD WELLCONTRACTOR:
WELL CONTRACTOR CERTIFICATION 0:
STATE WELL CONSTRUCTION PERMITO:
1. WELL USE (Check Applicable son): Residential9 Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other [l II Other, List Use:
2. WELL LOCATION: (Show sketch of the location below) ,fi„Jkii!
Nearest Town: 9 en G county:
(Hoed Name and Numbers, Corrvnunlly, or Subdivision end Lot No.) DRILLING LOG DEPTH
3. OWNER GJ l it/c, 71t C /00 From To Formation Description
Address 9 rjvS1�•
rea or oue
(co. Q
City or Town State ZI p Code
4. DATE DRILLED 5 -!Y'Od
S. TOTAL DEPTH 34 d
6. CUTTINGS COLLECTED YES❑ NO�
7. DOES WELL REPLACE EXISTING WELL? YES Q NOL�
8. STATIC WATER LEVEL Below Top of Casing: JFT.
(Use -: If Above Top of Cnsing)
9. TOP OF CASING IS FT. Above Land Surface'
'Top or casing terminated eVor below land surface requires a variance In accor-
dance with 15A NCAC 2C.0118
10. YIELD (gpm): S' METHOD OF TEST
11. WATER ZONES (depth): -3`? 6
--'cam'
fa
Al
.L_
U1
.gin
O
m
0
12. CHLORINATION: Type Amount Y.ff✓ II additional space Is needed use back of form
13. CASING:
Wall Thickness
Depth
Diameter or WelpphVFL
Material
From
To /-?7
Ft.
6_4- SO.Kz(
,pug
5
From 137
To ;2-06
FI.�
From
To
Ft.
14. GROUT:
Depllr
y,M t rial Malhod e
From 9
To �"`A
rFl.
' ` � fl�ssui
From
To
FI.
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
15. SCREEN:
Depth Diameter Slot Slzo Material
From —To _ Ft _ In. _ In.
From __ To _ Ft. _ In. _ In.
From __- To _ Ft. — In. __ In.
16. SAND/GRAVEL PACK e lid
Depth i t l ; : Size- L- fvlale�ial!
From To
From To
if
17. REMARKS: ,gpp�,,
I DO HEREBY CERTIFY HAT TF�Ir�Q�CT'�N,},+,yr;�TRUCT D IN E ORD AS B EN PROVIDED TO THE WELL OWNER.
CONSTRUCTION STAN R135-A D ff�t OOTT'T1'''
,�.,�
FOR OFFICE USE ONLY ---- o.� DATE
Ouad No: SIGNATUnE OF PERSON CONSTRUCTING THE WELL
Submit original to Division al Water Ouallty, Groundwater Section within 30 days
GW.1 REV. 12/99
Sedat No.

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Nail Sorvice Center - Raleigh, N.C. 27699.1636-Phone [phone]
WELL CONSTRUCTION RECORD
WELL I'll TRACFu
TOR: '""� TAy��
WELL CONTRACTOR CERTIFICATION fl:
STATE WELL CONSTRUCTION PERfAiT4:
1. WELL USE (CheckAppncablo Box): ResldeniiarPN` Municipal ❑ Industrial ❑
Recovery ❑ Heat Puma Water Injection ❑ Olher ❑ If Other, Lis; Use:
Agricultural ❑
2.
WELL LOCATION: (Show sketch el the location be!acv)
Nearest Torn: C3P-4 �'^s CrT7 County:
C
ye Ao�
1C l 0-9, LAM) 5 Cec
(Road flame and Numbers. Comm.urdly, or Subdivision and Lot No
DRILLING LOG
3.
OWNER K� coci"zy
Front "ru
Address 13(jq 2I-
0
(elleot or 1loule ao.)
NIL
4-7-- 4y
r,ty or Tcvm Slate Zip Coda
4.
DATE DRILLED 5-31-po
A y
5.
TOTAL DEPTH S r7- -
G.
CUTTINGS COLLECTED YES® NOD _
7.
DOES WELL REPLACE EXISTING WELL? l'F_S (-1 t10,R1
6.
STATIC WADER LEVEL Belcr: Top of Casing: To FT.
(Use -< it Abe:, Tcp of Casing)
9.
TOP OF CASING IS I FT. Abovo Land Suflacc'
-Top
of aaaing tertnfna;ed abor below laod surface requires a variance In accor-
dancevdthl;ANCAC2C.e118
/'5�
10.
YIELD(gpm): h!ETHOD OF TEST
11.
WAT ER ZONES(doplh): "8S 3-/8S A-2ZS
I
rT�t•-.� w
zt6-4
Monitoring ❑
DEPTH
Ferc.alion Description
c
o
1
1
c�=
m
m
Co
U7
—+
12. CHLORINATION: Type , T h Amount _�J%,r_L I! :d�lnor.o.! space i; reeded use bac'., of to:ri w o
13. CASCJG:
11'ail I hick, -es-,
Depth Cia.mc:�r crV/c:-ti'r 1. ;,ta:edal
From To 49 Ft. & V`_ NC
From - To--- Ff. -----
Fr,in -Io-- Ft._—
14. GRQUI
Depth taatodnl t:(clhcrJ
From -0-- To �SaCZ Ft. 1S1ti _ Q-n
Front _ To Ft. _
15. SCREEN:
Depth Diamoter
From To Ft in.
From To Ft. In.
From To Ft. In.
16. SANG/GRAVEL PACK:
Depth Size
From To Ft.
From To FL _
17. REMARKS:
Slot Size - Material
in.
In. _
In.
Ma!orial
t
ti
L0CAT:0N SKETCH
(3ho.v drect:on and dC:a-r c from :.t least k,.o Slate
cr other map rofcrcrce pu r'a)
1�1 m1L
4fgC _
Cr ¢KLAuo- C UO '4'
.sz 12
I DO HEREDY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE 1NFR 115A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO TTHE 1A/ELL OWNER.
FOR OFFICE USE ONLY 014\ �(f�-�.�,riC. "UCcr ✓� VQ /
Quad No: S GtJAI URE OF FERSON CONSTRUCTING Tf - t ELL DflrE C
Submit origins to O ,hlon of water Quality, Grounde-i or see'en "d:llr °p dhyL:.
Sedal No.
,6XI REV.Ing

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section 2 153 V1 91
1636 Mail Sorvice Center- Raleigh, N.C. 27699-1636-Phono [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: IuS£L� TPyco4
\
WELL CONTRACTOR CERTIFICATION p:-
STATE WELL CONSTRUCTION PERMITN:
1. WELL USE (Check Applicable Box): Resldenlia�n Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
Agricullural ❑ Monlloring ❑
2.
WELL LOCATION °i sketch of the location bc!ow)
Nearest Town: YEN GI TY Cow^dy:
SwAiN
W cST VeE C QjZGk 20 4o
(Road Name and Numbea, Comrnur,0y, or SubdVnion and Lot No,)
DRILLING LOG_
3.
OWNER MQ, NW3 SMILEY
Frain To
Address (D,E, 9,cx 1351
0 44
Tjrrapl ar ,ou;e vo.1
( �y o Cry IC 26-13
441 _ y�
City or Taw., Slate Zip Coda
4.
DATE DRILLED - "i-�CP
-LS
5.
TOTAL DEPTH
G.
CUTTINGS COLLECTED YES [5:Q NO❑ —
7.
DOES WELL REPLACE EXISTING WELL? YES [_-] NO
8.
_D;�,I
STATIC WATER LEVEL Belov: Top of Casing: go FT.
(Use's' if Abo+a Top of Ca:::+g)
9.
TOP OF CASING IS I FT. Above Land Surl3co'
'Top of casing termfnaled aVor below land surface roqulros a variance in accor-
danco
v.ith 15A NCAC 2C .0111i �; r
2-
10.
YIELD (gpm): METHOD OF TEST _
11.
WATER ZONES (depth): y30 /- sip
DEPTH
Formation Oeccriplicn
r1.
SA.JO
GRAeJiTE
CD
C,_-:
J
-io
y
i fn
�D
C %
c-n
it
w
z
ens
V
tYl
V
12. CHLORINATION: Type ti Amount _1.i_pu'S 1! a_'dd!onai=pace is needed use bac',of foots
13. CASING: I -__—_— --�
,.ail laic'
DL7111
From _C�L_ To Ft. 4 _-v—(�--
From To--- Ft. ----
Frx:1 To— FL___
14. GROUT:
Depth Ma:oii,l11� fdolhcd
From _0 ToFt.—19.al`_
From To Ft.
15.SCREFH
Depth Diameter Slot Size - Material
From To FI in. in. _
From To Ft. In. In. _
From To Fl. In. in.
16. SAND/GRAVEL PACK:
Depth Size Material
LOCATION SKETCH
(Silo:: dirccl:en and Cslaneo Irom at lea. '•-o State
F.c dds, or other map relcrence points)
ray t� f".%V
C d I
1
From To Ft. _ l I -TO cflG4114EC
From To Ft.
�P D uy«r i CA MAA 5-ray (zYi,� 17. REMARKS: CA
I
100 HEREBY CERTIFY THAT TF!1S W ELL WAS CONSTRUCTED IN ACCORDANCE WlTi 115A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THATyy��A COPY
YYiOF THIS RECORD HAS 1BEEN PROVIDED TO (THE WELL OV,'NER.
FOR OFFICE USE ONLY 1y )A 06(Q.+q)Q_ 6NCJ V, -�.� ���U\ �L1 UG'. , 2 Z G»
Quad No: S 3NAII JRE OF PCRSON CONSTRUCTING THE ELLL I 0
Subrr t orb:nal to D :Eton al \"a;ar Oualrl/, Graundv: a,cr Scu.cn r. tllrn a0 dyyd
Serial r7v. G'hr I REV. 1✓59

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) 73&j3221 i 15
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION #:�
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable eox): Resldentia4!!;, Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATIOfi:_(,Sliow sketch of the location below)
Nearest Town: L1.2 �7Z::,.9_ I _ County:
(Road Name lid mbors. Commun'I , or
3. OWNER
Address
Cify cr Tov;a Slate r Zip Code
4. DATE DRILLED a
5. TOTAL DEPTH '��1���
6. CUTTINGS COLLECTED YESL NOD
7. DOES WELL REPLACE EXISTING WELL? YES D NO;K�
8. STATIC WATER LEVEL Belov: Top of Casing: off— FT.
(Use `4' if Abaro Top of Cas:rg)
9. TOP OF CASING IS FT. Above Land Surface'
-Top of casing terminated ntlor below land surface requires a variance In accor-
dance with 15A NCAC ZC.0118
10. YIELD (gpm): MEfHOD OF TEST
11. WATER ZONES (depth):
Agricultural ❑ Monitoring ❑
DRILLING LOG
From ' To
C1
DEPTH
Formation Description
1
r_
W
co
Ln
12, CHLORINATION: Type \A—V N Amount '�A_ It additional space is needed use back of form
13. CASING:
%':all Thlcknoss
Depll� .� 1
From —To 1I-- FL
Diamh!Lr'
---./�—
cr%Veigh Ft. CNxedai
.� _J— \\-C��-
From To Ft.
From To Ft.
14.
GROUT:
Doplh
Material
Mothod
From TocL CL Ft.
Cf mcrv}—
\ C¢_
From To FL
15.
SCREEN:
Depth Diameter
Slot Size Material
From To Ft
In.
in.
From To Ft._
In.
In.
From To Ft.
In.
In.
16,
SAND/GRAVEL PACK:
Depth
Size
Ma'erial
From To Ft.
From To Ft.
17.
REMARKS:
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map role. ence paints)
`� S2 1 \A
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 t' ``�(Q�- l)S W Q_0'DU
Quad No: SIGNATURE OF PERSON CONSTRUCTING TJfE WELL DATE
Submit original to Division of Water Quality, Groundwater Seclion within 30 days
Serial No. GV7.1 REV. 12l09

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center- Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELLCONTRACTOR:
WELL CONTRACTOR CERTIFICATION N:
STATE WELL CONSTRUCTION PERMITN:
1. WELL USE (Chock Applicable Box): Residential Municipal ❑ Industrial ❑
Recovery ❑ Heal Pump Water Injec ion n Other ❑ If Other, List Use:
Agricultural ❑ Monitoring ❑
2. WELL LOCATION: (Show sketch of the location below) C
Nearest Town: 1- County:_
(Road N Nurnhcrs, Community, or Subdivision and Lot No.) DRILLING LOG DEPTH
3, OWNER C1`�_- From To Formation Description
Address
!reC or oule o.1�
City or To,, \ Slate — j Zip Code
d. DATE DRILLED ;
5. TOTAL DEPTH -
6. CUTTINGSCOLLECTED YESRC NO[::]
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO;�5
8. STATIC WATER LEVEL Belov., Top of Casing: FT.
(Use `4' it Abovo Top of ring)
9. TOP OF CASING IS FT. Above Land Surface'
'Top of casing terminated at/or bolo, land surface requires a variance In accor-
dance with 15A NCAC 2C .0110
10. YIELD (gpm): METHOD OF TEST
11. WATER ZONES (deplh):A--(;� c) — n
12. CHLORINATION: Type _ANiT Pi Amouni�-
13. CASING:
Wall Thlcknoss
De if—l-�Q arPe_:1er cr 1'!r. h Material
FromFrom —To —S—t- Ft. 9
From To FI.
From To- Ft. —
14. GROUT:
Depth (� Matorlal Method
From 0 To cl� C-)_Fl. n1C t6-� \C7p_
From To FL
15. SCREEN:
Depth Diameter
From To Ft in.
From To Ft. in.
From —To—Ft.— In.
16. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To Ft.
17. REMARKS:
Slot Size Material
In.
In.
In.
Material
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)
\CIX
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.
n
SIGNATURE OF PERSON CONSTRUCTING THE i'I"ELL DATE
Submil oriCinal to Division of Plater Quality. Groundwater Section within 30 days
IS t'�.) I'' FI ,
AC,'I
TM11i1` ';

North Carolina - Department of Environment and Natural Resources - Division of Water Quality- Groundwater Section 2215.113
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: RU U TLi �GY
WELL CONTRACTOR CERTIFICATION
STATE WELL CONSTRUCTION PERMTq:
1. WELL USE (Check Applicable so.): nesidentiaqV Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other If Other, List Use:
2. WELL LOCATI (Show sketch of the,..�oc lia on beio:v)
NearestTown: 1��: a County:
(Road Name and Numb rs, Communnity, dr Su dan`and Lot No.) DRILLING LOG DEPTH
3. OWNER �e� C!, _ � 5� � From To Formation Descdplian
Address
tzz�reot or Houle o.
City or Tovm State Zip Code
4, DATE DRILLED� ^- �
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES L� NO[J -,
7. DOES WELL REPLACE EXISTING WELL? YES NO,� p
8. STATIC WATER LEVEL Below Top of Casing:.- �_ FT. C � � -
(Usa'a' it Abovo 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 (gprn): 4 - METHOD OF TEST z+�
11. WATER ZONES (depth):
iD Nam:
+��
12. CHLORINATION: Type Amount I' additional space Ls needed use back of term C.ft
13. CASING: 14
z
Nall Thickness
LOCATION SKETCH
Depth
Diame!er cr 1Ye" ,VFI. Ma:clalt5A
�� 1
(Shag direction and distance fromrent of least hvo Stare
From—Cl—To
Ft.
Roads, or other map reference points)
From
From --To
To Ft.
Ft.
14. GROUT:
Depth
rnatedal Method1�\�S\n����{ap
Front o
To[ZFI
���,�n�—��
vw
From
To Ft.
-
15.SCREEN:
Depth Diameter
From To FI In.
Front To FL In.
From To _ FL In.
16. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To Ft.
17. REMARKS:
Slot Size Matoriai
In.
In,
In.
Material
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 20. WELL
CONSTRUCTION STANDARDS, AND THAT
yA�COPY OF THIS RECORD HAS BEEN PROVIDED TO THE( WELL OVINER. �
FOR OFFICE USE ONLY dJYYY 1 I�YQ'�'Yl'Q ��OS (/.. W Mc, L4 S jLa QtAy .15 C10
Curd No: SIGNATURE OF PERSON CONSTRUCTING THE w L DATE
Submit original to Divis;on of Water Ouality. Groundwater Section Within 30 days
Serial No. i AEV_12/59 .. _ .

son wu of Eve o"e N }AMWM . ONWon of WSW Gushy • Orounawaur Seaton
Rrafpf► H.C. =N MO -I a Phonoe (e 1 a) r&s. l q4 �,
WELL CONSTRUCTION RECORD WELL CONTRACTOR: k>iflat� ,Vr 1.u_LU _`bA'd�
WELL CONTRACTOR CERMwATION a: eS O
RATE WELL CONETPtUCT10N ►ERNIRa:
,. WELL wE�.kA>tsaadlaewp n W*nVWM MuNokd O )nawaW D Aprfeula,nl O Mwrco" ❑
fiery U H"l ►wnp WSW 1.1 olk o Of w p It other. Ulm Use:
2. WELL LOCAT1pf"ftw akabh of IM bOMbn below) G Near"Twin:
,. t" mw afle MMIe , aI fi1A IMin anf Lot Na.1 Doll l 1W 1 M DEMH OWNER G _
AAdi m" ,�� FNen To
Femaeon Ooonloson
or
4• DATE DRILLED S v o
S. TOTAL DE►Tt o
0
E• �E COLLECTED VES C) ND�] — ,--,
7. DOME WELL RElLACE E WELLT Tp NO©
E. RATIO WATER LEVEL Eebw Top of Cube: 100 ►T. f _
E. TOP O► CAiINp to Fr.
�'� a Maws Too of C404) m
_L_ FT. Above Land SuAm,
'►wofusimaMambdwermmIndVAAMMwAbooavwimwInwon dense No "A IN"0 ,s0 OF TUT
m
,1. WATV%ZONEE( oeprq:—S o s- -,
v
12. CHLORWATION: Type T A cunt '�'
x
13. CAER1O: �— 11 edAbf W apeee Y n "w uw beak d bnn
LO,^_ATION KEE TCH
From Ohillwal km ' L" a.n TO
.erafe awno. at 6"1M two eve.
f""R6To p, �p�Reads, w eEw fru0 relefeflae peke)
FFwn
14. To R E
Dam
MSS"
From •�� To00
� pj isvrna Sa YYu Fmm Orgy / FLU
1S. BCREEN: �f` % ��
From oeplh7 n DI""�" Met Mu 1NWrfa1 � '5")
Ffofn To Ft. __ in. h
Flan To R in. h
tE.aAWOgRA � Mse 1leletW
From To ►L 6Y\ G �
Flan T� Ft.
17. REMARICM
f DO HMVY COM" THAT 74E WELL WAS CONSTFA CTED IN ACCORDANCE W rrH I SA NM 2C. WELL
00""74JOTM ETANDMtOE. AND THAT A COPY OF Tip PROORO HAE WEN ►ROVt0E0 TO THE WELL OWNER.
POR MEOuse lle r SO MOM r /IS�d.d C'lO
•leaiR«Mww of11k11ar COMfAMIOTegToll WELL DATE
bout* 1VI f� �Y, Oielalaamw aooaan wNn 30 days
ow.fnE,,.sM

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)gI-a "`�"m
WELL CONTRACTOR CERTIFICATION
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (CheekAppllcable Box): Residential® Municipal ❑ industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water In)ection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION (Show sketch of tFya location below)f Q'
Nearest Town: I h'th County:
(Road Name and Numbers. Community, or qubdivision and Lot No.)
3. OWNER `,FAO -
Address Ja4L w
�)) roe or ou a o.
,C/YYL�s� i7 X_
City or Town State Zip Code
4. DATEDRILLED S !e ;Zoac'
5. TOTAL DEPTH 2•3 O
6. CUTTINGS COLLECTED YES 0 NO©
7. DOES WELL REPLACE EXISTING WELL? YES NO®
8. STATIC WATER LEVEL Below Top of Casing: 6o FT.
(Use'+' if Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface'
'Top of easing terminated attor below land surface requires a variance in accor-
dance with 15A NCAC 2C .0118
10. YIELD (gpm): S o METHOD OFTEST nn
11. WATER ZONES (depth): Z 1 d
12. CHLORINATION:
13. CASING:
DRILLING LOG DEPTH
From To Formation Description
Type T Amount n • 3 / it additional space is needed use back of Corm
Wall Thickness
Depth Diameter or Weight/Ft. Material
From O To Ft. 96 %u _ SDR 211 'P'V
From To Ft.
From To Ft.
14. GROUT:
Depth
From To Ft.
From To Ft.
15. SCREEN:
Material Method
Depth Diameter
From To Ft in.
From To _ Ft. In.
From To Ft. in.
16. SANDIGRAVEL PACK:
Depth Size
From To Ft.
From To Ft.
17. REMARKS:
Slot Size Material
in.
in.
In.
Material
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points) I
e� 4i/rl w C", Jag �l
� 75�!,5 -3 /,6 �
i DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONL S 0 2 0
Ouad No: D OF PERSON CONSTRUCTING THE WELL DATE
'• 'L 4' - SubrNt original to i i of Water Oual!ty, Groundwater Section Within 30 days
Serial No. I) I O „ , GW-t REV. 12/99
21?0 €,

North Carolina - Department of Erwlronmeni and Natural Resources - Division of Water Quality - Groundwater Section
1639 Mail Sarvfea Canter . Raleigh, N.C. 27E99.1E36-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION M: �I1 S Q
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE Cheat Apokaem sws): Residential® Municipal [I Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery LJ Heat Pump Water In)eetlon ❑ Otter If Other, Ust Use:
2. WELL LOCA • (Show sketch of a Wadon below) U atiry
Nearest Town: _� �- _T Courtly:
(Read Naar IeirMen. Camtun , er ek"Weion and Lot No.)
3. OWNER M-
Addrsa
e
CIy Town slam zip Coda
4. DATE DRILLED
5. TOTAL OEM 3 0
6. CUTTINGS COLLECTED YES 0 NO®
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO®
S. STATIC WATER LEVEL Below Top of Casing: 6FT.
(use'.' N Aawe Tap a CmkV)
9. TOP OF CASING IS FT. Above land Surface•
-Tep of eee' taredrteled mWer below NM eurfass tgWree a verWre In aeeer-
denee whir 1tA NCAO 96.a11a
10. YIELD (opm): METHOD OF TEST M
11. WATER ZONES (depth): 4,00
O
_
a n-
r_
C_
o
tD
�rn-
s
m�
12. CHLORINATION: Type / % Arouse Q 36 If addponal space Y nsoded use back of form z
13. CASING:
WIN TMdnew _
From—_OTO� 7 3 �zet. 9 or 110*1040R. SD R x i �,LS
From To Ft.
From To FL
14. GROUT:
Maw" Method
From �_ To ad Ft. U'm+
From To Ft.
15. SCREEN:
Depth Dlsrrteter Slat 810 Mate"
From To _ Ft In. _ in.
From _ To _ Ft. _ In. _ in.
From To _ Ft. _ In. _ In.
16. SANDAIRAVEL PACK:
Depth Size Mdww
From To Ft.
From Ta Ft.
17. REMARKS:
LOCATION SKETCH
(Show direction end dNnnoe from at Nast two State
�p Roade, or other map reference points)
R ll •' C l�r� `i Lj_. �d
C�
10
I DO HEREBY CERTIFY THAT TWS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 1 SA NCAC 2C, WELL
CONSTRUCTION STANDARDS. AND THAT A COPY OF THIS RECOjID HAS BEEN PROVIDED TO THE WELL 0
FOR OFFICE USE ONLY
Quad Me: n n.
41.
seed No.
h im " � ?To
CONa7RtlCTIN6 THE WELL
M, am simmer section within 30 days
ow-1 REV.'V"

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: to acWELL CONTRACTOR CERTIFICATION 0: Q O S 1
STATE WELL CONSTRUCTION PERMITN:
1. WELL USE (Check Appllcill 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)
6+rj
Nearest Town: ,4 v� l Gt"- County: 5-LUMiy�
(Road Name and Nurnberp, Community, or Subdivision and Lot No.)
3. OWNER an/ 41,2 L
Address 7le,Ycy„ev P Ciila�Q2
(Sree o}�r ooue, NO.)
C City or wn 'State Zip Code
4. DATE DRILLED S a°ao
5. TOTAL DEPTH o
6. CUTTINGS COLLECTED YES ❑ NO©
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO©
B. STATIC WATER LEVEL Below Top of Casing: SS FT.
(Use if Above Top of Casing)
9. TOP OF CASING IS t FT. Above Land Surface'
'Top of casing terminated Wor below land surface requires a variance In mccor.
donee with 15A NCAC 2C .011 a
10. YIELD (gpm): q METHOD OF TEST R kZ,
11. WATER ZONES (depth): 2 A0 r
12. CHLORINATION: Type IN TiJ, Amount
13. CASING:
Wall Thickness
Depth Diameter or Weight/Ft. Material
From O To Ft.— sL �p V C
From
To Ft.
From
To Ft. —
14.
GROUT:
O
Depth material Method
From
To ;10_ Ft. c
From
To Ft.
15.
SCREEN:
Depth Diameter Slot Size Material
From
To Ft in. in.
From _
To Ft. in. in.
From _
To Ft. in. in.
16.
SANDIGRAVEL PACK:
Depthz" �" " Material
From
Tot 4j
From
TN.E717t.
17.
REMARKS:
t II IM
1 DO HEREBY CE
CONSTRUCTION
FOR OFFICE USE ONLY
Quad No:
Serial No. �� 1
DRILLING LOG DEPTH
From To Formation Description
Q
a
�
o
� !
C
7i---
r
m
9C —
vD
�m
m
m�
m
c
z
If additional space is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least two State
Roads. or other map reference points)
)CO,���S
-A, 7 �` 0' 7_. raA- moo• 14 w
�a> S Y>�-- tom'
�-
RUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
SIGNATURE OF PERSON CONSTRUCTING THE WELL I 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
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: PA�Jw a):-11
WELL CONTRACTOR CERTIFICATION #: ;Z O S_ /
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: County:.
(Road Name and Numbers Community, or Subdivision and Lot No.) DRILLING LOG
3. OWNER From To
Address F 0a
13��— � (5 r or ou e
City ocrown State Zip Code —
4. DATE DRILLED 5 Soso —
5. TOTAL DEPTH (, a S
6. CUTTINGS COLLECTED YES ❑ NO❑
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO❑
B. STATIC WATER LEVEL Below Top of Casing: FT.
(use'.' it Above Top of Casing)
9. TOP OF CASING IS I FT. Above Land Surface'
'Top of taming terminated attor below land surface requires a variance In accor-
dance with 18A NCAC 2C .0118
10. YIELD (gpm): 6 METHOD OF TEST f} vL
11. WATER ZONES (depth):
12. CHLORINATION: Type
13. CASING:
Amount
Wall Thickness
Depth Diameter or Weight/Ft. Material
FromTo /6SFt. � — SW7 f
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From O To 2 e)_ Ft. C2m.u..7t-�.SAl
From To Ft.
15. SCREEN
Depth
From
To
From
To _
From —To
_
16. SAND/GRAVEL PACK:
Depth
From
To —
From
To_
17. REMARKS:
Diameter Slot Size Material
Ft in. in.
Ft. in. —In.
Ft. in. in.
100 HEREBY CERTIFY 11HA7
CONSTRUCTION STANDARD
FOR OFFICE USE ONLYr
Quad No:
Serial No.
DEPTH
Formation Description
If additional space is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
`4.xat
CL6 4 %
iIS WELL WAS CONS RUC ED IN ACCORDANCE WITH 15A NCAC 2C, WELL
AND j1�pX THIJ RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
4, d-4- 5/�
SIGNATURE OF PERSON CONSTRUCTING THE WELL DX
Submit original to Division of Water Quality, Groundwater Section within 30 days
GW-1 REV. 12/99

Nonh Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section 13 7 9 `Y
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]-c—
WELL CONSTRUCTION RECORD WELL CONTRACTOR: VIS INOS y�zA if ' ki 11: >e�_
WELL CONTRACTOR CERTIFICATION
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (check Applicable Box): Residential Q4 Municipal ❑ Industrial ❑ Agricultural ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
91
WELL LOCATIQN(Show sketch of the location below) p
Nearest Town:' 24 ; 6tJ t t:�6 County:
CA'Js a
(Road dame an umbers, Com11munJlty, or Subdivision and Lot No.) DRILLING LOG
OWNER Kt v^.iJrAd,- `,A'�AA _ From To
Address _
(Street or Route o.
City or Town tale Zip Code —
4. DATE DRILLED--fiL�u
5. TOTAL DEPTH I'
6. CUTTINGS COLLECTED YES O NO®
7. DOES WELL REPLACE EXISTING WELL? YES NOV
8. STATIC WATER LEVEL Below Top of Casing:.) n F -
(Use': it Above Top of Casing)
9. TOP OF CASING IS�_ FT. Above Land Surface'
-Top of casing terminated atlor below land surface requires a variance in accor-
dance with 15A NCAC 2C .0118
10. YIELD (gpm): ', METHOD OF TEST
11. WATER ZONES (depth):
12. CHLORINATION: Type
13. CASING:
Monitoring ❑
DEPTH
Formation Description
Amount If additional space is needed use back of form
c
O o
0
LOCATION SKETCH
Depth
Wall Thickness
Diameter or Weight/Ft. Matenal
(Show direction and distance from at least two State
From
To
Ft. �' vim'
Roads, or other map reference points)
From
To
Ft.
From
To
Ft.
14. GROUT:
Depth
Material Method
r
From j
To ZA
Ft. C'c_wv" 101'
�
From
To
Ft.
I
15. SCREEN:
an
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:
Material
Old
5�
I DO HEREBY I
CONSTRUCTION STAN� HACCORDANCE
nS ANPTHATrA COPY FTHIS RECORD HAS BENL PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLT
11
Quad No: SIGNATURE OF PER CONSTRUCTING THE WELL DATE
Submit original to Division of Water Quality, Groundwater Section within 30 days
Serial No. GW-1 REV. 12/99

North Carolina -Department of Environment and Natural Resources -Division of Water Quality -Groundwater Section 9
1636 Mail Service Center • Raleigh, N.C. 27699-1636-Phone (Sit 9) 733-3221 ,I n
WELL CONSTRUCTION RECORD WELL CONTRACTOR :Jvr't
WELL CONTRACTOR CERTIFICATION #: ) 1; '7
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)�� i
�I
Nearest Town: Y1 ���1 (-J"1 County:
VN-,C P't" 2Y 6LyP- DEPTH
(Road Name and Numbers. Community, or Subdivision and Lot No.) DRILLING LOG
3. OWNER '�,�,r �id a-L 11:L 6}rJ From To Formation Description
Address
beet or outs o.
City or Town State Zip Code
4. DATE DRILLED M0
o
5. TOTAL DEPTH rJ
6. CUTTINGS COLLECTED YES Q N07
`
` 0
p"
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO® C
pa
am
8. STATIC WATER LEVEL Below Top of Casing: G FT.
(Use'i if Above Top of Casing)
TOP OF CASING ISFT. Above Land Surface'
DomZ
9.
'Top of casing terminated aVor below land surface requires a variance In accor- b
--,.
mM
-�.m-
dance with 15A NCAC 2C.0118
10. YIELD (gpm): -]—METHOD OF TEST c
m�
11. WATER ZONES (depth):
_
12. CHLORINATION: Type Amount If additional space is needed use back of form
13. CASING:
LOCATION SKETCH
Wall Thickness
Depth Diameter or nt/Ft. maul (Show direction and distance from at least two State
AWeg!
From. To 37 FL �' �� ---u-o-- '� Roads, or other map reference points)
From To Ft. i 1i 1 v�h
From To Ft. oA a
14. GROUT: J
Depth Material Method
From I To 06 Ft. k �tL 4%
From To Ft.
-
15. SCREEN: nn q1�(1
Depth Diameter Slot Size Material
From _ To _ Ft _ in. — in.,
From _ To — Ft.— in. — In.
From _ To _ Ft. _ in. r ini'
16. SAND/GRAVEL PACK:
Depth Size Material I ,
From To Ft.
From To Ft.
17
I DO HEREBY CERTI FY THAT THIS WELL WAS CON STRUCTEDIN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
A A_ ---1�?P-1
FOR OFFICE USE ONLY
Quad No:
Serial No.
SIGNATURE OF PERSON CONSTRUCTING THE WELL
Submit original to Division of Water Quality, Groundwater Section within 30 days
DATE
GW1 REV. 12199

North Carolina - Department of Environment. Health, and Natural Resources
Division of Environmental Manngernanl - Groundwnler Section
P.O. Box 29535 - Raleigh, N.C. 27626-0535
Phone[phone]
WELL CONSTRUCTION RECORD
DRILLING CONTRACTOR:i�CC/
FOR OFFICE USE ONL I% /� /( (j
QUAD NO. SERIALNO. 2 0
Lm, Long. RO
Minor Basin
Basin Corte
Header Ent. GW 1 Enl
STATE WELL CONSTRUCTION
DRILLER REGISTRATION NUMBER:_�_122 _ _ PERMIT NUMBER:
1. WELL LOCATIO : (Shey/ sketch of file location below)
Nearest Town:: 6 2e/'02�e — County: `2 �,,-17 Y
(Road, Community, or Subdivision and col No) DEPTH LOG_
2. OWNER Jfo, From To Formation Description
ADDRESS z"/2T/''6 C'a�s
(Sheol or Routo No) — 17
City or Town Stile 1�0_1ip Code
3. DATE DRILLED f--70-06 USE OF WELL
4. TOTAL DEPTH A O _
5. CUTTINGS COLLECTED YES ❑ NO[—�--
6. DOES WELL REPLACE EXISTING WELL? YES [—] No
7. STATIC WATER LEVEL Below Top of Casing: _3;_O_ FT.
(Use'.' it Above Top of Casing)
B. TOP OF CASING IS —Z FT. Above Land Surface'
Casing Terminated aUor below land surface Is Illegal unless a variance Is Issued
In accordance with 15A NCAC 2C .0110
9. YIELD (gpm): `f METHOD OF TEST
10. WATER ZONES (defelh): /!0'
0
0
C31
O
o
�
i
11. CHLORINATION: Type 111-7'11 Amount �fG� If additional space is needed use back of form
12. CASING:
Will Thickness LOCA rION SKETCH
Depth Diameter or Weialifft. Material (Show direction and distance from at least Iwo Stale
From-0 To e`l Ft. G"- i,��e� Roads, or other map reference points)
From To Ft.
From To FI.
13. GROUT:
Depth M,t rial M Ihod
From © To 'QD FL U' `" — /eSsu�e-
Frorn To Ft.
14. SCREEN -
From
From
From
15. SANI
From 4—"-
From
s
16. REMARKS:
Depth Diameter Slot Size Material
—To—Ft— in. —in.-
-To FL In. __ in.
To rt R V1.M R rMi1 - in.
Depth a
_ To FI'
Cro�mdvr2'e- Ssction
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.
SIGNATUFIG'OF CONTRACTOR OR AGENT
DATE

North Carolina - Department of Environment. Health, and Natural Resources
Division of Environmental Management - Groundwaler Section
P.O. Box 29535 - Raleigh, N.C. 27626-0535
Phone [phone]
WELL CONSTRUCTION RECORD
DRILLING CONTRACTOR: M1_1 ea_
FOR OFFICE USE ONLY
QUAD. NO, SERIAL NO.
Lnl. Long. RO
Minor Basin 2 3 A f]
•T—
GW-I Ent.
STATE WELL CONSTRUCTION
DRILLER REGISTRATION NUMBER: PERMIT NUMBER:
1. WELL LOCATION: (Sheskelc11 of the location below)
C �e /O/L ��- Sal ii/f
Nearest Town: County:
(Road. Commu it or SuNjivision and Lot No.) DEPTH _DRILLING LOG
2. OWNER 4 $1 _ From To Formation Descdpliou
ADDRESS zh jn6�/ _Co-7s7 •-- — --
(Stiehl or Route No.)
City or Town Stale Zjp Codo —
3. DATE DRILLED �-ay 7 USE OF WELL
4. TOTAL DEPTH -?�D
5. CUTTINGS COLLECTED YES ❑ NO[-�-
6. DOES WELL REPLACE EXISTING WELL? YES NOJ�_4
7. STATIC WATER LEVEL Below Top of Casing: p _ FT.
(Use "1' it Above Top of Casing)
S. TOP OF CASING IS FT. Above Land Surface'
'Casing Terminated allor below land surface Is Illegal unless a variance Is Issued
In accordance with 15A NCAC 2C .0118
9. YIELD (gpm): Z METHOD OF TEST
10. WATER ZONES (depth):
11. CHLORINATION: Type �1 Amount �� If additional space is needed use back of form
12. CASING:
Wall Thickness LOCH VION SKETCH
Depth Diameter or Weight/Fl. material (Show direction and distance from at least two Slate
From �� To % 1-1 �' Lf sD.4'-Z/ p//G, Roads, or other map reference points)
From G 7 To �y FL"fJ
From To FI. -
O +'
13. GROUT: o
Depth ,�MJerlal thod r" n D
From To 2C Ft. / "�""s�� r�ssv r c
From To Ft. cn o
14. SCREEN: s No
Depth Diameter Slot Size Material n
0
From To — Fl In. — In. CD a
From To Ft. in. In. N o
z
From --To Ft. _ in. in.
15. SAND/GR fL3►{: R it M
ke3lFT ll 11 Material
From { ITo
From _ 11 'To -St.- I _tF1.
16. REMARI(
I DO HEREL r�oA9Pe9lIW.KCSIWi@I ,T�PI.A.� CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
CONTRACTOR OR AGENT
DATE

North Carolina - Department of Environment and Natural Resources - Division of Water Duality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELLCONTRACTOR: ASh_Yr o1-)S V)2P )) r4
WELL CONTRACTOR CERTIFICATION #: i 7T' i
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (check Applicable Box): Residential ® Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: F)Y�SPio c {* y A).C. County:
L6YpA.C4.
(Road Name and Numbers, / Community, or Subdivision and Lot No.)
3. OWNER n1�..0 It �4TS6 A)
Address
treat or Houle No
City or Town State Zip Code
4. DATE DRILLED V1 7'ATc`
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑ NO®
7. DOES WELL REPLACE EXISTING WELL? YES F-I NOQ
8. STATIC WATER LEVEL Below Top of Casing: g_ FT.
(use'+' if Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface'
-Top of easing terminated atfor below land surface requires a variance In accor-
dance with 19A NCAC 2C .0118
10. YIELD (gpm): 3_ METHOD OF TEST
11. WATER ZONES (depth):
12. CHLORINATION: Type
13. CASING:
Depth Diameter„
FromTo//0 Ft.
From To Ft.
c...... T.. Pt
i G)4 A/
Agricultural ❑ Monitoring ❑
DRILLING LOG DEPTH
From To Formation Description
Amount If additional space is needed use back of form
LOCATION SKETCH
Wall Thickness
or Weight/Ft. atenal (Show direction and distance from at least two State
, L1 CRoads, or other map reference points)
4

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: bAa ., LuW CL
WELL CONTRACTOR CERTIFICATION #: aOS /
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check applicable Box): Residential ® Municipal ❑ industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATIO (Show sketch o_ .f he location below) ` Q
Nearest Town: _,� County:
(Road Name and Numbers, Community, or §ubdvision and Lot No.)
3. OWNER T�IzU I�
Address
[�Ireqt or ou a o.
(31 u la a7 CA�r—" "A' C.
City ororown State Zip Code
4. DATEDRILLED �ao�
5. TOTAL DEPTH ? 3a
6. CUTTINGS COLLECTED YES ❑ NOFAI
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO©
8. STATIC WATER LEVEL Below Top of Casing: _ f q b FT.
9. TOP OF CASING IS / D (Use •+• it Above Top of Casing)
FT. Above Land Surface*
'Top of casing terminated st/or below land surface requires a variance In accor-
dance with ISA NCAC 2C. 11e
10. YIELD (gpm): 3 y METHOD OF TEST A w
11. WATER ZONES (depth):. 1913'
12. CHLORINATION: Type Amount o, 3
13. CASING:
Wall Thickness
Depth Diameter or Weight/Ft.
From-0 To /Ft.4-- 2 k SOR-1I
From To Ft.
From To Ft.
14. GROUT
DRILLING LOG DEPTH
From To Formation Description
If additional space is needed use back of form
LOCATION SKETCH
Material (Show direction and distance from at least two Stale
V Z Roads, or other map reference points)
Depth Material Method
From O To of O Ft. Uaytt. l- Sat .
From To Ft.
15. SCREEN:
Depth
From —To
From —To
From _
To _
16. SAND/GRAVEL PACK:
Depth
From
To _
From
To_
17. REMARKS:
Diameter Slot Size Material
Ft in. in.
Ft. in. in.
Ft. in. _ In.
Size Material
Ft.
Ft.
J /yGy� C�t�l
m r'
)),IN 3 p 21111i
i
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Quad No:
Serial No. _ '- -i- `.
SIGNATURE OF PERSON CONSTRUCTING THE WELL
Submit original to Division of Water Quality. Groundwater Section within 30 days
t7 00Ct
DATE
GW-1 REV. 12/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: ljbJQ' .__b
WELL CONTRACTOR CERTIFICATION #: ;ZO J C
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check applicable Box): Residential © Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION (Show sketch of location below) St� QAzn,
Nearest Town: County:
or Subdivision and Lot No.)
3. OWNER
Address
City or Town (State Zip Code
4. DATEDRILLED IxS Zodo
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES 0 NO©
7. DOES WELL REPLACE EXISTING WELL? YES NO©
8. STATIC WATER LEVEL Below Top of Casing: JAO FT.
(Use'+' it Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface'
'Top of casing terminated attor below land surface requires a variance in accor.
dance with 15A NCAC 2C .0118
10. YIELD (gpm): __'9E_— METHOD OF TEST A2
11. WATER ZONES (depth): � ris
r
12. CHLORINATION: Type H! N Amount 0 • S 7
13. CASING:
Wall Thickness
Depth Diameter or Weight/Ft. Material
From To ga Ft. (� /4 5D fQ J �P V c_
From To Ft.
From To Ft.
14. GROUT:
Depth Me anal Method
From To XO Ft. '#-
From To Ft.
15. SCREEN
Depth Diameter Slot Size Material
From —To—Ft— in. _ in.
From _ To _ Ft.— in. _ in.
From —To _ Ft. _ in. —in.
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
17. REMARKS:
Agricultural ❑ Monitoring ❑
DRILLING LOG DEPTH
From To Formation Description
If additional space is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least two State
�p Roads, or other map reference points)
N r 1 74
�p a �s
YYul,o t"',
.4.4. 53 m lea
% o Y1u-1-a�
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION ST IS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ON I, I q� 7
Quad No: SIQ E OF PERSON CONSTRUCTING THE WELL DATE
JUN Surfmif orfglnal t n of Water Quality, Groundwater Section within 30 days
Serial No. TIA 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: bA 11JW _2)LdLva
WELL CONTRACTOR CERTIFICATION #: 2 O S /
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential lE Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: Show sketch of the location below)��
Nearest Town: County:
(Road Name and Numbers. Co munity or Su iviSion and Lot No.) DRILLING LOG
3. OWNER A From To
Address
Ae jStr eg tgI ou/' o. _
City or Tom Topm Y f State Zip Code
4. DATE DRILLED 7 oZ600
5. TOTAL DEPTH 43 Of
6. CUTTINGS COLLECTED YES[_ NO®
7. DOES WELL REPLACE EXISTING WELL? YES ❑ N0FA
B. STATIC WATER LEVEL Below Top of Casing: 49 o FT.
(Use'+' it Above Top of Casing)
9. TOP OF CASING ISFT. Above Land Surface'
-Top of casing terminated atfor below land surface requires a variance In accor-
dance with 15A NCAC 2C.0118
10. YIELD (gpm): '9' METHOD OF TEST 6 4;1.2
11. WATER ZONES (depth):
DEPTH
Formation Description
12. CHLORINATION: Type Er 14 Amount _ 0 -4 3 If additional space is needed use back of form
13. CASING:
Wall Thickness
Depth
Diameter or Weight/Ft. Material
FromTo/! O
Ft.Z"
5o a �y <
From
To
Ft.
From
To
Ft.
14.
GROUT:
Depth
Material Method
From O
To 2-0
Ft.
ttw",:i'-r-.,"
From
To
Ft.
15.
SCREEN:
Depth Diameter Slot Size Material
From _
To _ Ft
_ in. in.
From —
To _ Ft.
in. _ in.
From _
To _ Ft.
in. _ in.
16.
SAND/GRAVEL PACK:
Depth
Size Material
From
To
Ft.
From
To
Ft.
17.
REMARKS:
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or othermapreference points)
nn p
I DO HEREBY CE�MAX4HWrDNE RUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION tIiATIID,{�iD� AU
-�iPAOFjYhQf THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE " ' v :4,
Quad No: - N I 9. �!�' TURE OF PERSON CONSTRUCTING THE WELL DATE
n .9 Submit origl vision of Water Quality, Groundwater Section within 30 days
Serial No. V GW4 REV. 12J99

North Carolina - Department of Environment. Health, and Natural Resources
Division of Environmental Management - Groundwater Section
P.O. Box 29535 - Raleigh, N.C. 27626-0535
Phone [phone]
WELL CONSTRUCTION RECORD
DRILLING CONTRACTOR: �� ^
FOR OFFICE USE ONLY
QUAD. NO. SERIAL NO.
Lat. long. RO
Minor Basin
Basin Code r—
Header Ent. _. GW I EnL
STATE WELL CONSTRUCTION
DRILLER REGISTRATION NUMBER: PERMIT NUMBER:
1. WELL LOCATION: (Show sketch of the location below)
Nearest Town: ��✓s or �'{}� County:
41e, 4 _
(Read.Comm/unityor Subiivision/and Lot No.) _D_E_PTH_ _DRILLING LOG
2. OWNER �/ Cr P_ �L/K.gs _ _ From To Formation Description
ADDRESS ___—__
(Stiehl or Route No.)
City or Town Stale —�-- p Coda
3. DATE DRILLED USE USE OF WELL ✓4
4. TOTAL DEPTH 60
5. CUTTINGS COLLECTED YES[] NO[q6, DOES WELL REPLACE EXISTING WELL? YES NO[�
7. STATIC WATER LEVEL Below Top of Casing: )— _ FT.
(Use'a' it Above Top of Casing)
8. TOP OF CASING IS FT. Above Land Surface'
Casing Terminated atior below land surface Is Illegal unless a variance Is Issued
In accordance with 15A NCAC 2C .0118
9. YIELD (gpm):_-6METHOD OF TEST �lr
10. WATER ZONES (depth): Sy"/
11. CHLORINATION: Type ljL%lr7� Amount 45 It additional space is needed use back of loan
12. CASING:
LOCATION SKETCI-1
Wit Thickness
Depth
Diameter or Wei rUFI. 5Materi1
(Show direction and distance from at least two Slate
From 0
To —5-- Ft.
Roads, or other map reference points)
From
To Ft.
From
To Fl.
—
13.
GROUT:
Depth
�}erial lhod
c
From D
To O Ft.
o
L
From
To Ft.
c
14.
SCREEN:
r—
C7 �
Depth Diameter
Slot Size Material
cN
From
To Ft
in. In.
n
From
To Ft.
in. in.
m
ant
From
To Fl._
in. in.
o
Na
m:o
15.
SAND/GAVEL PACK
N
_
Material
o
=
From
From ViTo
Ft.
16.
REMA
( )I
-
I DO I IEREBV GERS.IF•Y-FI ELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CnN9Tal ICTIDN-�T^_A1AAR54'. D THAt A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
D'ytu"' )
SIGNATURE OF CONTRACTOR OR AGENT DATE

North Carolina - Department of Environment, Health, and Natural Rnsources
Division of Environmental Management - Groundwater Section
P.O. Box 29535 - Raleigh, N.C. 27626 0535
Phone [phone]
WELL CONSTRUCTION RECORD
DRILLING CONTRACTOR: _ 7�Y,&l C
STATE WELL CONSTRUCTION
DRILLER REGISTRATION NUMBER: 7{%f PERMIT NUMBER:
1, WELL LOCATION (Sho sketch of the location below) `
Nearest Town: ch ��Ze e, —County: Jo7l ci,'rJ
(noad. Community, or Subdivision and Lot No.) _DEPTH DRILLING LOG
2. OWNER ��'+�� Crows
From To Formation Description
ADDRESS % • 6� _C!'vt.
(Street or Routo No.) Q — ��j CA-,
y
City or Town Stale Zip Carle
3. DATE DRILLED 3-a9 0o USE OF WELLP' ✓g7 E
4. TOTAL DEPTH /`/0 _
5. CUTTINGS COLLECTED YES[ NO[—}-
6. DOES WELL REPLACE EXISTING WELL? YES NOP]
7. STATIC WATER LEVEL Below Top of Casing: FT.
(Use'+' it Above Top of Casing)
8. TOP OF CASING IS .2FT. Above Land Surface'
' Casing Terminated at/or below land surface Is Illegal unless a variance Is Issued
In accordance with 15A NCAC 2C .0110
9. YIELD (glprn): .3 0 METHOD OF TEST
10. WATER ZONES (depth): 4,0 '/
11. CHLORINATION: Type l7'7'11 Amount
12. CASING:
FOR OF FICF_ USE ONLY
QUAD, NO. SERIAL NO.
Lat. _ Long. RO
Minor B.isin
Basin Corte
Header Ent. GW-I Ent
Sig ._ /yo G�u;z, ire
If additional space is
Wall Thickness
LOCATION SKETCH
-
Depth
Diameter or WeighvFt.
Material
(Show direction and distance from at least two Slate
From
To
Fl.
/"'c
Roads, or other map reference points)
From
To /oS
FL
From
To
Ft.
13. GROUT:
From
Depth
To 219
Ft.
p Material
Me,��1' od
/ressu�c
o
0
�o
From
TO
Ft.
c—
"
14. SCREEN:
C—
r
c;
Depth
From To _
From To _
From To _
15. SAND/GRAVE
From
From
16. REMARKS:
I DO I IEREBY CPR
CONSTRUCTION S
Diameter Slot Size Material vNj
_r -r
Fl In. In. a�
rn
Ft. in. In. ' m
NT
Fl. in. In.
F� l� CD
t50 Material ro i
_FI.
iA71�.NlEC4�.WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
RDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
TUBE OF CONTRACTOR OR AGENT DATE

North Carolina - Department of Environment. Health, and Nahual nonourcos
Division of Environmental Management - Groundwater Section
P.O. Box 29535 - Raleigh, N.C. 27626-0535
Phone [phone]
WELL CONSTRUCTION RECORD
DRILLING CONTRACTOR:,'���
FOR OFFICF USE Of It Y
Of1AD. NO. SE nIAL 140.
Lal. Lomg. RO
Minor ensin �. r
Dnsin code A- t
Header Ent. GVJ I EnL_ _.
STATE WELL CONSTRUCTION
DRILLER REGISTRATION NUMBER: PERMIT NUMBER:
1. WELL LOCATION; (Sho/yv sketch of the location below)
Neareest Town: �v%��'%/�� e- _ County:
(noa .Community, or SuNlivision and Lot No.) DEPTH _DRILLING LOG
2. OWNER J471ic1yo/Ft —
From To Formation Description
ADDRESS �/h 47uw//t euS1�--
(Strent or Route No.)
City or Town Stale iZip Codo
3. DATE DRILLED 3 ,?d-"o USE OF WELL / /l
4. TOIALDEPTH •zyo '
5. CUTTINGS COLLECTED YES ❑ NO[-
6. DOES WELL REPLACE EXISTING WELL? YES 0 NOJ�;]
7. STATIC WATER LEVEL Below Top of Casing: 14�1 _ F1.
(Use'a' it Above Top of Casing)
8. TOP OF CASING IS FT. Above Land Surface'
'Casing Terminoled oVor below find surface Is Illegal unless a variance Is Issued
In occordance with 15A CAC 2C .0110
9. YIELD (gpm): METHOD OF TEST /"z>
10. WATER ZONES (depth):
„7z o
11. CHLORINATION: Type Amount _V
12. CASING:
7s_-z ya U�e
If additional space is needed use back of form
Wan l ldckness LOCATION SKETCH
Depth Diameter or Weight/Ft . Material (Show direction and distance from at least two State
Front To /O f Ft. G.,LS'_ , /W St e/ Roads, or other map reference points)
From To Ft. ---
From To FL_-
13. GROUT:
Depth /� M nil M hod
From Tope FL /o ip� Yrsl'l-r o0 0
From To --Ft. _ C_ o
14. SCREEN: C ` n
Depth Diameter Slot Size Material C_n �<
err,
From To Ft in. In. T'=�
a � \ From To Ft. in. In.
m
From To Ft. in. in. `� m
15. SAND/GRAVEL PACK: 0 1
N o
�e 1 LS L; RSiynN Material z
From F"`T"o L5
From Ft.
16. REMA
I DOH REBY rU10VaWIM',*1S WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONS ILPSft97, 1ATJD..TI1L4'1 A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
r /" )'Ij C
SIGNATURE OF CONTRACTOR OR AGENT DATE

North Carolina - Department of Environment, Health, and Natural nnsourcor
Division of Environmenlal Management - Grounrlwaler Section
P.O. Box 29535 - Raleigh, N.G. 27626-0535
Phone[phone]
WELL CONSTRUCTION RECORD
DRILLING CONTRACTOR: %%%ibex"
FOR OFFICF_ USF Or iLy � /) A
QUAD. NO. SERIAL NO. _ 4 `Y
Lal. Long. RO
Minor Basin
Basin Code
Header Ent. GV1 I Ent.
STATE WELL CONSTRUCTION
DRILLER REGISTRATION NUMBER: PERMIT NUMBER:
1. WELL LOCATION: (Sho sketch of the location below)
Nearest Town. C-e/'J L e _ County:
�j Cc✓e
(Road. Community, or Subdivision and Lot No.) DEPTH _DRILLING LOG
2. OWNER A4 SCy Grp )/q �i From To Formation Description
noDREss 5'o tV�a�//< Hoy—s,�� --
(Street or Route No.)
65 — Z ZQ
City or Town Stale Zip Corlo
3.
DATE DRILLED 3'30 -y0 USE OF WELL
4.
TOTAL DEPTH 2-2-0 _
—
5.
CUTTINGS COLLECTED YES D NO[_:�-
6.
DOES WELL REPLACE EXISTING WELL? YES NO[�J-
7.
STATIC WATER LEVEL Below Top of Casing: .S-O FT.
(Use -+- it Above Top of Casing)
8.
TOP OF CASING IS 2— FT. Above Land Surface'
' Casing Terminated sUor below land surface Is Illegal unless a variance Is Issued
in
accordance with 15A NCAC 2C .0118
9.
YIELD (gprn):� METHOD OF TEST /¢/,,
10.
WATER ZONES (depth): /�'Ls
11.
CHLORINATION: Type zYZ - Amount 5/c yzg
If additional space is needed use back of form
12.
CASING:
LOCATION SKETCH
wall thickness
Depth Diameter or weight/FI. Material
(Show direction and distance from at least two Slate
From To 6 Ft. ' "LS 'iD271 �UG
Roads, or other map reference points)
From G / To `-Z FL 6.4d �b� Sfee l
From To Fl.
13.
GROUT:
Depth Malt nal Method
o
From To ' FL ©1, 2� /�ierr�r c
o
From To Ft.
r--
r-
14.
SCREEN:
r— c �,
r
Depth Diameter Slot Size Material
cNn c'{
From To Ft in. In.
ern
m m�
From To Ft. in. In.
= -m
From To Ft. in. in.
o
15.
SAND/GRAVEL PACK:
C��
N E3
.--p iz Material
=
From
Frorn To Ft.
16.
REMARK it "AC
100 HER S LL S CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION Sr3PlN� UB-IQtilD,1LIal COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
OF CONTRACTOR On AGENT
DATE

North Carolina - Department of Environment. Health, and Natural Resources
Division of Environmental Management - Groundwater Section
P.O. Box 29535 - Raleigh, N.C. 27626-0535
Phone [phone]
WELL CONSTRUCTION RECORD
DRILLING CONTRACTOR: /%il,7l
FOR OFFICE USE ONLY
QUAD. NO. SERIAL NO.
Lat. Long. nRO
Minor Basin 2144
4 5
Basin Code
Header Ent. GW-1 Ent.
STATE WELL CONSTRUCTION
DRILLER REGISTRATION NUMBER: 7{C/� PERMIT NUMBER:
1.
WELL LOCATION (Show sketch of the location below)
Nearest Town! Gyjol'i C'-- z County: .SW uA
iiwy'F
(Road, nity, or Subdivision and Lot No.) DEPTH
Comm7"
DRILLING LOG
2.
OWNER Tu Cdj 04 From To
Formation Description
ADDRESS
(Street or Route No.)
3.
City or Town Stale 1Zip Code
DATE DRILLED USE OF WELL
1.
TOTAL DEPTH -?-'0
3.
CUTTINGS COLLECTED YES ❑ NOQ'
3.
DOES WELL REPLACE EXISTING WELL? YES D NOQ— tl
_
7.
STATIC WATER LEVEL Below Top of Casing: FT. U
(Use "+" if Above Top of Casing)
f
3.
TOP OF CASING IS FT. Above Land Surface'
' Casing Terminated at/or below land surface Is Illegal unless a variance is Issued
In
9.
accordance with 15A NCAC 2C .0118
YIELD (gpm):'— METHOD OF TEST r
10.
WATER ZONES (depth):
11.
CHLORINATION: Type /fT Amount vqc If additional space is needed use back of form
12. CASING
Depth Diameter
From b To /L Ft. 1s
From To Ft.
From To Ft.
13. GROUT:
Wall Thickness LOCATION SKETCH
or Weight/Ft. Material (Show direction and distance from at least two State
SD4zt dL Roads, or other map reference points)
Depth M to ial thod
From To " Ft. e/7 ��`�
From To Ft.
14. SCREEN:
Depth
From
To —
From
To —
From
To
'15. SAND/GRAVEL
PAC
Depth
From
To
From
To_
16. REMARKS:
Diameter Slot Size Material
Ft in. in
Ft. in. in
Ft. ins-_='rr
c
0
C
r—
rV
Cfl
3y
a
0
CD
rV
�n
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.
7�
OF CONTRACTOR OR AGENT
DATE

21;)`'6b
North Carolina - Department of Environment and Natural Resources - Division of Water Quality -Groundwater Section
1636 Mail Service Center- Raleigh, N.C. 27699-1636-Phone [phone]-�/t+- �¢Z
WELL CONSTRUCTION RECORD WELLCONTRACTOR: l Alt: Q, Y
WELL CONTRACTOR CERTIFICATION #:_ I_
STATE WELL CONSTRUCTION PERMIT#:
1.
WELL USE (Check Applicable Box): Residontiall.. Municipal ❑
Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑
If Other, List Use:
2.
WELL LOCATIO ' (Show sketch of the location below)
,
Nearest Town: �+S'c��1 County:
c + >„
(Road Name andd Numbers, Community, orr Subdivisionand Lot No.)
DRILLING LOG DEPTH
3.
OWNER )�Q-Q� (1 \ a��\`�")�
From To Formation Description
Address �� LQ�S �
�'� l0� 0\ �,\L,
(Sireet or Houte No.
City or To.n STala Zip Code
4.
DATE DRILLED
5.
TOTAL DEPTH _?TAQ
s?-
6.
CUTTINGS COLLECTED YES® NOD
r'-
7.
DOES WELL REPLACE EXISTING WELL? YES D NOJ9
S.
STATIC WATER LEVEL Below Top of Casing: —)n FT.
'-
(Use **'if Above Top of Casing)
J -x
9.
TOP OF CASING IS '-JA— FT. Above Land Surface'
_
'Top of casing terminated at/or below land surface requires a variance In actor-
71
d ante
10.
with l SA NCAC 2C.e 119
YIELD (gpm): 1,0__ METHOD OF TEST
J
11.
WATER ZONES (depth): d-off\`a
c-n —+
W �
12.
CHLORINATION: Type �\ \ '�'� Amount L4
If additions! space is needed use back of form
13.
CASING:
Wall Ti!ckno ss
LOCATION SKETCH
Depth Dlame:or c'weichITI. Material
r
T`�C
(Show direction and distance from at least two Stale
From To FL .�—
Roads, or other map reference points)
From To Ft.
From To Ft.
GY, ykU
14.
GROUT:
M \ ^
Depth Material Method
From To sa_�) Ft.
From To Ft.
15.
SCREEN:
Depth Diameter Slot Size Material
From To Ft In. in.
From To Ft. In. In.
From To Ft. In. _ In.
16.
SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
17.
REMARKS:
I DO HERESY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 1SA NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A `C�OPY OF THISRECORDHAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY �.i, � 1�A Q� nQ 1.Au vS �'Q�\ YJ� \���l.r� U u
Quad No: SIGNATURE OF PERSON CONSTRUCTINGA HE WELL DATE 1
Submit original to Division of Wrier Quality, Groundwater Section Within 30 days
$cnaLNo,S GW-I REV. 12l99
L�

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section 215 ( +% 6
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: — _� L' ?AYLo2
WELL CONTRACTOR CERTIFICATION
��......,, STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (check Applicable Box): ResidentlaIN Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATI N: (Show sketch of the location below) ,
Nearest Town: 5-1 ' - � F � County: v\
e�\cAQc\
(Road Name and Numbers. Community, or Subdivision and Lot No) DRILLING LOG DEPTH
3. OWNER—\�\�4- vC-->P1C]a� C1FiyC From To Founation Description
Address yV \ \\Z lc�\1 C-\.�'-A
(blfM or HOUtO O.
\ J n C) 1
City or Town Stale Zip Coda
. DATE DRILLED^ O
5. TOTAL DEPTH �c >
6. CUTTINGS COLLECTED YESO NOD
7. DOES WELL REPLACE EXISTING WELL? YES NO`LcW�11
B. STATIC WATER LEVEL Below Top of Casing: \C�_ FT.
(Use'+' If Above Top 01 Casing)
9. TOP OF CASING IS =t— FT. Above Land Surface'
'Top of casing terminated after below land surface requires a variance In accor-
dance with 15A NCAC 2C-.01/9
10. YIELD (gpm): '� METHOD OF TEST •• ci
11. WATER ZONES (depth): V \'C CI ��'0 .�1 a-�yC� Ln
1 =
12. CHLORINATION: Type �yX7 Amount f additional space Is needed use back of form
13, CASING:
Wall Thickness LOCATION SKETCH
Depth , larr`el r or W rUR. Maledal (Show direction and distance from at least two State
From �To � Ft. Roads, or other map reference points)
From To Ft. C
From To— Ft.O C�.� -cam. S\z\\V C�
14. GROUT: \ S \\cA � X0 fit;
Depth Material Method " ��
From C To,:D-O _ Ft.
From To Ft.
15. SCREEN
Depth Diameter
From To Ft In.
From To Ft. In.
Front _ 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
Quad No: SIGI
N i Submit original to
Serial No.
C "f
e&�, A-- Y`�9A
�-- 1 Q-
OF PERSON CONSTRUCTING THE WELL
DATE
of Water Duality. Groundwater Section Within 30 days
GW-1 REV. 12199

2215
7 5Qp2
North Carolina - Department of Environment and Natural Resources - Division of Water Qualify -Groundwater Section !.. i0� Q (.,,
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: - us v_A ko \
WELL CONTRACTOR CERTIFICATION #:r9 j 9_
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Chock Applicable Box)- Residential Municipal ElIndustrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of 4h to ation below)
Nearest Town: County: 1�-a
nor c\ Ncc� li_
(Ro d Name and Numbers. Community. or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER From To Formallon Description
Address �� _ ((rC-)
tbqeotcrmout
City or Taw - ,S ato - Zip Code
4.
DATE DRILLED -T-' 1!��
5.
TOTAL DEPTH 77ZQ)ZS
6.
CUTTINGS COLLECTED YES® NO❑
7.
DOES WELL REPLACE EXISTING WELL? YES ❑ N0_0
E.
STATIC WATER LEVEL Below Top of Casing: � FT.
(Use'.' if Abovo Top of Casing)
9.
TOP OF CASING IS6- FT. Above Land Surface'
on
'Top of easing terminated attor below land surface requires a variance In accor-
O
dance
with 15A NCAC 2 0 18
10.
YIELD (gpm): METHOD OF TEST
11.
WATER ZONES (depth): Ys=;t- -
12.
CHLORINATION: Type Amount I S
If additional space is needed use back of form-
13.
CASING:
r.
VVaIi TII��%cnC55
LOCATION SKETCH ' Gnr'
� NI,J
Depth ,, Diameter cr Weight' Glalc dal
From�--To S.�! _)- FL
(Show direction and distance from at least two Stale ca
Ln
- -
Roads, or other map raerence points) N c
From To FI.
From To Ft.
14. GROUT:
Depth I�M�a�t-eri�al1 Method
From � To �Z Ft. 1 CDP_
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 FL
17. REMARKS:
Slot Size Material
In.
In.
In.
Material
z p C�vci . \ fo wu&�
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A (CHOPPY OF THIS RECORD HAS BEEN \PROVIDED TO THE WELL OWNER.
R FOR OFFICE USE ONLY V C1C��P l'�UW S W A) (Q �4 �`(�t
Quad No: SIGNATURE OF PERSON CONSTRUCTING THE WELP DATE
Submi -original to Divlsion of Plater Quality, Groundwater Section Within 30 days
Scriai Na. j G'R-I REV. 12/99
— 6-0U

' a ^iYJr"Yd-'r!V!�!_ latd"61�.JN.%..+y,_ _ - ••
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELLCONTRACTOR:
WELL CONTRACTOR CERTIFICATION C IR 0.5 /
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (check Applicable Boa): Residential © Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other M If Other, List Use:
2. WELL LOCATION,, (Show sketch of t e location below) 9I1.170-.-
Nearest Town: %.V3-rr d County:
(Road Name eCCntleeNumoers. Community, or Subdivi on and Let Na.) DRILLING LOG
3. OWNER zeC��oetFrom To
Address r q e
r or ou a qo.
City or Town State Zip Code
4. DATE DRILLED 13 -D 1000
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES Q NO X
7. DOES WELL REPLACE EXISTING WELL? YES Q NO XJ
8. STATIC WATER LEVEL Below Top of Casing: _(g0 FT.
(Use': If Above Top of Casing)
9. TOP OF CASING IS 1 FT. Above Land Surface'
-Top of casing terminated atlor below land surface requires a variance In seem.
dance with 19A NCAC 2C .0116
10. YIELD (gpm): 1_ METHOD OF TEST A L
11. WATER ZONES (depth):
DEPTH
Formation Description
C7
12. CHLORINATION: Type T Amount It additional space is needed use back of form
13. CASING:
Wall Thickness
Depth
�D'�'a`� ,c°e f or Weight1R. Material
From O
To `�7
Ft. 4 SDRR) V<,
From
To
Ft.
From
To
Ft.
14.
GROUT:
Depth
Material Method
From
To IQ Ft. 0-a-'r'r IV44��
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 f1. fi2e _' -Material
t
From
To
Ft.
From
To `
Ftasti
17.
REMARKS:
�
se
Quad NO: 9III l; 91M F 5
F"S.r1lm
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
Q&f''`j'Z;_Rom
Ql,
`I
}7r% tJo f;
/Tu((JJ(� r lln.k JJI LC/?r&
WA -LC d-Y� LLIT 1
�3 E W 1IONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C. WELL
dllt OPY A COF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
ONATURE OF PERSON CONSTRUCTING THE WELL DATE
to Divislon of Water Quality, Groundwater Section Within 30 days
GW-i REV. 121"

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: ^^�n7 ta)� �� U
WELL CONTRACTOR CERTIFICATION #: _�,, ,
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Sox): Residential® Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other F1 If Other, List Use:
2. WELL LOCATION: Show sketch of the location below)
Nearest Town: 11 u+It'4 County: '5Wat^
(Road Name�,''d Nu ers. C mmunity, or Subdivision and Lot No.) DRILLING LOG
3. OWNER l�,t.r-Vt<� � +,A(-, a� From To
Address —
DEPTH
Fomw6on Description
1� L
fee Of • 0.
a
W
WM
cm
Cityw Town State Zap Code
4.
DATE DRILLED
5.
TOTAL DEPTH
6.
CUTTINGS COLLECTED YES ❑ NOE]
r
o
7.
DOES WELL REPLACE EXISTING WELL? YES M NO©
B.
STATIC WATER LEVEL Below Top of Casing: fog FT.
(Use •i M Above Top of Casing)
9.
TOP OF CASING IS�_ FT. Above Land Surface'
'Top of using terminated stlor below land surface requires a variance In accor-
dance with 1SA NCAC 2C.0118
A A;
o
10.
YIELD (gpm): _L METHOD OF TEST -
11.
WATER ZONES (depth): .Soo
12.
CHLORINATION: Type Amount O�
If additional space Is headed use back of form
13. CASING
Wan Thickness
Depth r Diameter or WoighVFt. Malarial
From 0 To 22�1 Ft. 6 �q Shea) ']RV[ -
From To Ft.
From To Ft.
14. GROUT:
Depth Ma erial Method
From 0_ To _2 Ft. R -
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From _ To _ Ft _ in. _ in.
From _ To _ Ft. _ in. _ In.
From _ To _ Ft. _ In. _ in.
16. SAND/GRAVEL PACK
From
From
17. REMARKS:_
IDO HEREBY
CONSTRUCT)
FOR OFFICE L
Quad No:
Serial No. 5K
SIie1Vl jtgterial
1 FL I `t 'jf`'�!!
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points) I'
It /o Yrit lea., ljvvy` 0.i� Td,`
Yr L!s a� tt vt„� n tad"" ct `n an->
% L �C
R
'00
ONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
rsZ�Nt
0 X OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
3ag� o0a
n ISIGNATUREE OF PE N CONSTRUCTING THE WELL DE original to Division of Water Quality, Groundwater Section within 30 days
Gw•1 REV. 121"

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: "Yt" LOW
WELL CONTRACTOR CERTIFICATION #: a 0 S" J 0
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (check Applicable Box): Residential 6L Municipal El Industrial El Agricultural El Monitoring ❑
Recovery ❑ Heat Pump Water Injection Other ❑ If Other, List Use:
2. WELL LOCATIO (Show sketch of ythe location below)
Nearest Town: IfC`-t A44 - County: 5w mk"
(Road Name and Numbers,(ommunity or Subdivision and Lot No.)
3. OWNER Tom+', C' r ,
Address o C-t R1
r� tre or outs o.
614,laeol C- t-! YI.0 _
City or T#wn State Zip Code
4. DATE DRILLED O 2000
5. TOTAL DEPTH-5'tlr
6. CUTTINGS COLLECTED YES ❑ NO❑X
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO©
8. STATIC WATER LEVEL Below Top of Casing: ),Ia FT.
(Use'+' it Above Top o1 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 .
10. YIELD (gpm): 3119
METHOD OF TEST 6 4Z,
11. WATER ZONES (depth): A15
12. CHLORINATION: Type d7—P Amount O )
13. CASING:
Wall Thickness
Depth Diameter or Weight/Ft. Material
From4n To I Ft. 6N SDR7,1 Vc-
From To Ft.
From To Ft.
14. GROUT
Depth
From To 7-0
From, To —
15. SCREEN:
Depth
From —To
From —To
—
From —To
_
16. SAND/GRAVEL PACK:
Depth
From
To _{
From
TO,
17. REMARKS:
100 HEREBY CE
CONSTRUCTION
FOR OFFICE USE ONLY
Quad No:
Serial No.
Material Method
Ft
Ft.
Diameter Slot Size Material
Ft _ in. _ in.
Ft. in. in.
Ft._ In. _ In.
Size Material
L� I-
_ Ft.
1i,"'
DRILLING LOG DEPTH
From To Formation Description
0
o
G
c3 r�
If additional space is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
t I-
RUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
W CL� A ak-. 31Ao z0 c. a
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Quality, Groundwater Section within 30 days
GW4 REV. 12199

North Carowra • Departrrrant of Environment and Natural Resource • Divteron of Water Ourity • Groundwater Section
ION Mail Service Cerder • FWeloh, N.C. 27eW1sWPhw* [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE Chaak AnlleeUe aoa): ResdentlN® Munldpai ❑ Industrial ❑ ApftcultufW ❑ Mudtor)np ❑
RseowryU Heat Pump Water lroodon ❑ OtherE3 If Other, Lis Use:
2. WELL LOCATK)YY_(Show sketch of location below)
No~ Town: ��"��3, ; _ C ur*y: cS W
(fled Wme end Nurrtert, Ce +Ry, a SubdMal n and lot No.) DRILLING LOG
3. OWNER -7 Fran To
Address
Calf Vrown I Mar me Calls
4. DATE DRILLED ! eau
S. TOTAL DEPTHo. _s
NOM
7. DOES WELL REPLACE EXISTING ❑WELL9 YE ❑ NO®
S. STATIC WATER LEVEL Scow Top of Caft: ) 6 o FT.
Nee '•'s Abm Tap of 00b*
G. TOP OF CASING ISFT. Above Lend Surface
-rep of eeeI tarsdeeted error below tend Wkm wpdra a wsrraee te aeeaw
dears No ISA NW SO AM
10. YIELD Wm): __9* METHOD OF TEST A421
11. WATER ZONES (depth): 44 S
12. CHLORINATION:
13. CASING:
0
c�
J
o
Type htTf l Artoum "O a If alkil brW space is nasded use beck of term
Wall TRWwe
Depth
DW_ xWMprIFL McWfr
rwr
From Q
To �-- Ft. / /r .— SoR 11 4v<
From
To
Ft.
From
To
Ft.
14. GROUT:
Depth
matom Method
From 0
To a
FL Cwrna,
From
TO
FL
iS. SCREEN:
Depth Dle nwter Slot Shti Meters
From To Ft in. _ N.
(Show dkaodon and dletenos from Of 114a Iwo MW
Roo", or other Amp rewanee pokes)
From _ To Ft. _ In. _ in. V L-4, 1\
From _ To Ft In. _ in.
1S. SANO/GRAVELPACK:
D•PB+ sin M.MAaI �From To Ft&Y'_ 4*rzkW,'e,.' 'kc VzuudKXAP A44t/ In.S
From To Ft. °j -7// 0 YT-� w La dh / "
17. REMARKS:
I DO HERESY 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.
suWrt alpNrr
WILL DATE
r wMhln 30 days
ow.1 my. 12"
OF�R - 5 inn
J au�s�8
f
„, '
h, r''

Nor IIt Cmolion VerniIt? nnl of EnviroumnnI. I IpalIll. and Nahnnt IInnnacn5
Division of r11010nnlpnlal Managpnlnnl - GnnJ ndwalnr Snrlion
P.O. Box 29535 - notpigh, N.C. 27020-0535
Phoup [phone]
WELL CONSTRUCTION RECOIID
DRILLING CONTRACTOR: ; j��f
ran orrlCr U ;r or ILV
OI_IAD- NO. SE171AL NO.
lal. _-_ Lor.q. __ no
Minn, easlu _ f�
Minh, code 214 t, n 2 leader Ed. GV1 I Ent.
STATE WELL CONSTRUCTION
DRILLER nFGISTnATION NUMBER: �i� PEBMIT NUMBER:
1. WELL LOCATION: Show ketch of the location below)
Tlparasl Town!-C�x i-c' -e--u _Conly: lCC.vJ rr'</—
�l,/�r !3%car i
(nnad, Community, or SuIxIivision nod Lol No,) 2.
DRILLING LOG
G
2. OwNFn c'L'—LL'Cl— rani To - --.. _-----. _.
----.-----— rannnlion DpSeriplipn
nDDRESS, rlc T/'i'Laj ceq 57L
(Sl,00l or noon tin)
- -- ----
(:Ily pl Imvn Shle _. _ if-, cod" -- --- _____-
3. DATF DRII I ED 2 /7-° �'- usE OF WI LL-
d. TOTAL DEPTH----
5. CUTT IIJGS COLLECTED YES L j NO['r—
6. DOES WELL REPLACE EXISTING WELL? YES O
7. STATIC WAT En LEVEL Below Top of Casiriq
(U :p 'r' it Above Top nl Casing)
8. TOP OF CASING IS- ✓ __ FT. Above Land Surface'
I
' CarOriq Terminnlpd nVor below land stulace le Illegal unless a variance 19 lsnupri In nccordnnce wllll 15A NCAC 2C .0118 _
9. Ylr_LD (qpn,) _—__.__ METHOD OF TL=S r __.-->,,--
10. WATEn ZONES (depth): ____
CIILOnITIATTON: Type �f %� Amount !'Y� `� II additional space i5 neerJpd use bark of loan
12. CASING
wallTla' knms
-_LOCAIJOIJ SKETCI I__
Depth
Diamolpr or weighm Malclial
(Show direction and dislance boor at least Iwo Slale
/
From— TO FI.
G-ts >o22i sJu`
--�-- --
nOadS, Or Other slap relplpnCe POIn15)
Erom----lo FL----
--- - —
From --_"To -- FI.------
13. GROUT`.
o
Depth
Material Mplhod
od
o
From v _ ToEl.
�r�IFrom
To
_
14. SCREEN:
(-n
o?
Depth Diameter
Slot Size Material
3> o
Floor __To F(
In. _ In.
From To Ft.
In. In.
o
N?
ma
From To Pt.
In. In.
ht
—
15. snNaGRnv�.Lrrncic__...a..�....__�_._._.
0
pPtF C
izill Material
l
From �^ 0--
:j
t
From off_ FTt.
++ ter. ,,
16. REMARKS: 1
1110 NEREB CERT4j�'P`��(I're�h���j4'E�.L WASICONSTnUCTED IN ACCOn DANCE WITH 15A NCAC 2C, WELL
COTJSTRUC )M'S''JI%I An S, AND T}1ArA'COPY OF THIS RECOnD HAS BEEN PROVIDED TO THE WELL OWHEn.
SIGNAT7n,,or CONInACTOn on AGETIT DArr

Nor III Carolina . DepwIninnl of Fnvhoninnnl. I lenlllt, and NnlUrnl nnnour r.Us
Division of Envhonmonlnl Manngamnnt - CroUnrlwnler Serllon
P o. Bo. 29595 - nnlelgb, N.C. 27626 05a5
Phone, [phone]
WELL CONSTRUCTION RECORD
DRILLING CONTEIACTOEI: �/l�/
roe, orrlcr U ;r of ityr) i QUAD. No --_ --- sEIIIAL No r- I. J 4 4 8
no _ --
Miner nanln _
Ira^Lr cod"
I leader Enl. GW I Ent.
STATE W1711 CONSTRUCTION
DnILLEn nEGISTRATION PEnMIr NUMBEn:
1. WELL LOCAIIOI' (Show sketch of the location below)
�' c,' ,e �'
Nearest Town: - _. County:
hlnad. coinntt. RV f, S"NI sign �nndd yoi No.) D_E_P I I I _ DRILLING LOG
2. OWNE11 _,�Z/" le 1, �OSS.4/i rroni to Frnmalinn nnstdpYnn
--------
(gliwn "r nettle No I
Cilym lawn 5111n--- ----� -_ ip Colo
---
:1, DAIF-Linn-I_EDZ-Z2-�e - USE of-wEl_I__j�z'c%><�
ATOTAL DEPTII -/7)_ -
5. CUTTINGS COLLECTED Yr5 L.l NO[ --
6. DOES WELL nErl-ACE EXISTING WELL? YES j _ I MOu
7. STATIC WAIEn LEVEL Below Top of Casing: _ F-I'.
(Use' i' it Above Tell or Cnning)
8. TOP OF CASING IS Z _- F-1. Above Land Surlace'
'Casing Tonninnlod Pilot below Innd sm lice Is Illegal unless n vnrintice In Issued
In nccordPnce with 15A NCAC 2C .al In
9. YIELD Igpnl) _/C U —ME [I IOD OF TESTto, WATEn ZONES (depth):
II. CI-ILonlHA11014: Type if _Amount Lv
12. CASING:
D Dnplli G�2J";
Flora .—._ Io rL --
rroln__ I rl.-------
rlom ----1 o_Fl.---___
ta. Gnout:
f A y
II addilional snncr, Is nnednd use back orr';m
W:dl lldckn"".; _LOCA IION SKEI CIL
or Wei hvrl, ldnlndal (Show direclion and dislanrn front at leasl Iwo Slate
j7Z 1 wG noads, or olher Irvin ref Prellce points)
Depth',
Ze
Mal /c[III
� �
M Ihod
S1U/"e.
rrem �!
_ TO
0 rl.
D/ T,^
_____—
76
From
To __rL
14. SCREEN:
Depth
Diameter
Slot Size
Material
From
To
rt
in.
ilt.
Rom
To
rl.--
in.
in.
Front To
rl,
In. _._
in.
15. SAND/GIIAVEL
PACK:
Depth
Size
Malerlal
Front
To
r-i.
Front -__
To
rL
—
---
Dly v u u .,
M IIEnEBY CE11TIrY THIS WELL WAS CONS1nUC1ED IN ACCORDANCE WI111 15A NCAC 2C, WELL
�ONUnL1C 1gOFfAjAN S, AND IIIAT A COPY OF H its nECOnD HAS BEEN PROVIDED TO 111E WELL OWIIEIT
cineinnlnr_ .rnr.nn nrnel not Anenr nATIP

(T r 2 (�
North Carolina - Department of Environment and Natural Resources - Division of Water Quality • Groundwater Section l ..) t.:7 3
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: IZUS�
WELL CONTRACTOR CERTIFICATION If: ZI
,.7_,(STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Boa): Residential1Municipal[] Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ It Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: �-1YU-S171"l County:
I )L CV Y\Q_A �iY-0.Y_11Z
(Road Name and Numbers. Community, or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER P Cc ut—c.e, van 1 From To Formation Description
Address Ohl � �P_\c�h C, O�)P Cy� C`A ..
iq or Hours rvn.lV�
City o own sile Zip Code
4. DATE DRILLED\� — nG r7.
,
5. TOTAL DEPTH /1D5
6. CUTTINGS COLLECTED YES E�2' NOF G Mgt 76 ^'
7. DOES WELL REPLACE EXISTING WELL? YES 0 N0fff n `�
8. STATIC WATER LEVEL Below Top of Casing: Lk-)o FT. -}-(-1 r1G _
(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.0118
10. YIELD (gpm): `/4 METHOD OF TEST Ou n
11. WATER ZONES (depth):=
12. CHLORINATION: Type �AT N;:\ Amount It additional space Is needed use back of form N o
13. CASING:
Wall Thickness
LOCATION SKETCH
�To
Depth I 1
't
D/la,,me/1'er, or w vFl. Material
�—
(Show direction and distance from at least two State
From
Ft.-
Roads, or other map reference points)
From
From —To
To FI.
FL
�I I'`'n .
1,9 -
14. GROUT:
Depth
Material Method
iJ
J
�1,� VI AJY' BY S� 13 l —
I /
`� 10
From
�r�
To sr-_U_ Ft.
C •
,E
.�"—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:
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 =
Ouad No: SIGI
f ..I .. Submit Original la
Serial No. 'z
of PERSON CONSTRUCTING THEW LL CATE
of Water Ouality, Groundwater Section within 30 days
GW-1 REV. 12/99

Norlb Carolina - Deparlmotil of Envlronnwnl. I teallh, and NnInIA nnnowcos
Division of Environmental Mnnngrmmnt . (,roll nrlWnlei Snriton
P.O. Box 29535 - naleigh, N.C. 27626-0535
Phone [phone]
WELL CONSTRUCTION RECOnD
DRILLING CONTnACTOR: i- ,2sI_
ron orricr Use oriue r) 14 4'75
OU. NANO. SEnIAL NO 2__ —
1_11---___--- Long _ no
Minor Rani r
Ba shr Corte --
Itender Ent. GW I EnL
STATE WELL CONSTnUCTION
DRILLER nEGISTnATION NUMBER: rt/ PERMIT NUMBER:
1. WELL LOCATION: (Show sket I, of [tie location below)
Nearest Town:. 14119 Z County:
(nead, Community, or SuNfivvision and or No.) DEP 111 DRILLING LOG _
S�R�7oD > %%J! !� _.____—_.._ From — To ro nmtimi Description
2. owNFn __ n
-lam------ - --------- —
(Shenl or nettle Net _ C li
CiIY ar Tnrvn Slnln /7'1' Coda
3. DATF Dnll_I_FD dD USE OP WELT_ l �- �ufe — — -- -- ----- --- -- — ---
d. TOTAL_ DEPITI _ZY64 ' -_ —
5. CUT Tit IGS COLLECTED YES [ ] NO[.- {�_- --
6. DOES WELL REPLACE EXISTING WELL? YES LJ NOU —.
7. STATIC WATER LEVEL Below Top of Casinq S—D F1
(U;e' I' it Above Tnp of Casing)
B TOP OF CASING IS Z FT. Above Land Surface'
' Casing Terminaled atlor below land surface Is Illegat unless a variance Is Issued
In accordance with 15A NCAC 2C .0110
9. YIELD (gpm): ;2 ME N IOD OF TES T
to, WATER ZONES (deplh): —�]�T — -- —
IT. CHLORINA NON: Type ,�_�C, —Amount II addilionat cpaca is needed use bark or form
12. CASING: — ------
Wall , birknnss _ LOCATION SITI CII_
y� Depth Dianloler or W;21 71, Malelinl (Show direction and dislanre from at Iensl lwo Slale
rioul v TO rl. G2� - SD'C�Z�C nonds, or other mop reference paints)
From to /°6 Ft._ L 11 /� Steer/
From _— Ib-- Fl.
13. GROUT*
Depth I Fiat Me od O o
/ o
From -- To _rl. -_ 6/'`" jc ---- -- /'�tlrti^C ` �M
From _ To --rt.
14. SCREEN.
Depth
From To
From To
From _— To __
15. SAND/GRAVEL PACK:
From
From
16. nEM,
C
r—
rV
cn
Diameter Slot Size Material
rt in. In.
FL in. ITT. o
To _.r
e ' + Material
I DO 11ERE Y CEIR) E;TtWIWELL WA� CONSTnuCTED IN ACCOnDANCE WITH 15A TICAC 2r,, WELL
CONST RUC ION SF#�o 4D? 104A+* OPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWtIER.
SIGN nEOFCONInACTononAGENT DATE

WELL CONSTRUCTION RECORD 293947
Nort'n Carolina -Department of Environment and Natural Resources -Division of Water Quality, -Ground water Section
WELL CONTRACTOR (I:NDIVIDUAL)NAME IpHttt) Mitchell Q, Cook CERTIFICATION# 2Od3
WELL COSY) RICTOR COMPANYNAME �1 -"S FELL. LY7,]7,]-L:7L� IM - PN.ONE p g23' 1 y-957j
. STATE WELL CONSTRUCTION PERMIT# ASSOCMTED WQ PERMIT#
- (ifaoulibable) - (ifabolicable) - -
I WELL USE (Check Applicable Box): Residential 6 Municipal/Pu1011C 0 Industrial ❑ -.Agricultural ❑
Mcnttoring ❑ Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use
2 WELL LOC.AT10 : Topographic/Land setting
Neown County e _; ' . ❑Ridge ❑Slcpe ❑Valley ❑Flat
(Check appropriate box)
(S:ree: Nnr,te, Numbers, Ccinmu�nity, Subdivision, Lot No.; Ztp Code) Latitude/Iengitude of well location
��
3, 0WN!ER: 1S1i-G7�/f/ICQ��
(de7rees/minites/sronC>;
_ /D.`J �wiwsi>, - Latltttdo/lo,ngitude source:❑GPSOTopegraphic rnup
(Street o, Reuts No.)(check bee)
Y=-
/� D°PT!-; DRILLING LOG
,le Zip Code Front T Format ion Description,
r.., Clay & sa3
Ar--a wd. Phone number ,
4. DATE DRILLED 1granite
5. TOTAL DEPTH: Imo_
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO ❑
i. STATIC WATER LEVEL Below Top of Casing: ,95n FT. --
(Use ",, tr A'ocve Top of Caslne)
8, TOP OF CASING IS 2 FT. Above Land Surface•
-Top or casing terminated at/or below land surface requires a
varlance In accordance w th 15.A NCAC 3C .0118,
9. YIELD
(gpm) METHOD( r' TEST blow
10, WATER ZONES (depth): ��_3
LOCATION SKETCH
I 1 r DISINFECTION: Type F T H Amount 16602 Show direction and distance in miles from at least
12. CASING - Wall Thickness two State Roads or County Roads. Include the road
Depth Dt zr or We.ght/Fl. Material numbers and common road names
From 0 ToFt. 'Ile
—0"s-
From - To Ft,
From To Ft,
13, GROUT: Depth, Material Method O
z
From To 20 FtbEr= - & �;s3tt nJoea :
.From To Ft.
14: SCREEN: Depth Diameter Slot Size Material
cm
From To Ft. —in. in, t
o_
From To Ft —in. in.
c
IS. SAND/GRAVEL PACK
Depth Size Material �-
'o ^�
From, To pt, w
N-
. From To. FL - _ .€^---•�4-----.__—......
N
16, REMARKS:
r:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C
CONSTRUCTION STANDARDS, AND T 'AT A , WELL
COPY OF THIS RECORD
I
I
H.4S BEEN PROVIDE) TO THE WILL OWNER
/
i
�[1�L� 62)
SIGNATURE OF PERSON CONSTRUCTING WELL .ELL DATE
-Submit the original to the Divlsion of Water Quality, Groundwater Section, 1636 Mall Service Center - Ralel;h, INC Phone No. (919) 733-322 I,
I
within 30 days. OW-1 REV.07/2001
i
-- I

WELL CONSTRUCTION RECORD 293836
North Ca'rohna Department of Environment and Natural Resources • Division cF Water Quality • Grow ,dwater Section.
WELLCOYTRACTOR(INDIVIDV�L))Ap1E (prat) James B. Braan CERTIFICATIOY_2045
WELLCON'lRACTORCOMPAIN YNAME Hedden Brothers Well Drilling, Inc PHONE a ) 2591
STATE WELL CONSTRUCTION PER�N117A ASSOCIATED WQ PERhI17.
` (ifzo�Iicable). - - (if applicable) r- —--_.._._.-
I. WELL USE (Chick Applicablz Bc.x), Residential i Municipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring ❑ Recovery ❑ Heat Pump Wate; Injection.❑ -Other ❑ if Otner, List Use
2, WELLLOCATf Topo,raphic/Lands.ttin¢t
ounry ❑Ridge Elope ❑Va!ley ❑Flat
(check auprop•,ate box)
(Street Name, Numbers, Community, Sub/ddlilvvifloil,. Lot No., Zip Code) - Latitude/longitude of Well location
3. OWNER iQ t� �� degreesAn'mutu/seconds)
Address �d L. LatrtNdo/longltdi esource:❑GPS❑T000e;apt.tc'raap,
(Sire i or out.yya.)r7 (check box) q— —
II"ilf (; tl i4 DEPTH DRILLI(NG LOGS
a
city dr o� n �-te Z:, Code Fr T Formation Descr otion
clay &sand _
Aron cafe F'no,m nu nee• - 0 ardP.lte _
4. DATE DRILLED Yd"U/on
5. TOTAL DEFTH', 1 on
I
6 DOES WELL REPLACE EXISTING WELL? YES ❑ N0 —
7. STATIC WATER LEVEL Below Top of Ca,.ng: C410 FT. —
(Use "✓'V Above Tco of Casing),
3 TOP OF CASING IS 2 FT. Above Land Surfa:e' -
--Top at'cas:n; terrnlnated at/or below land surface requires a —
variance In accordance wlrh ISA NCAC 2C.0118. —
9.'Y(ELD(gpm):D METe9F`�--
10WATER ZONES (depth):
LOCATION SKETCH
11. DISINFECTION: Type B T H Amount 16 oz Show direction and distance in rules flair, at lead
12. CASING: Wall Thic:kre3s two State Roads or County Roads. Include the road
Depth, DI me.,r cr Weight/et�. Materialm numbers and common read nm aes.
From 0 To — Ft. _ T_ o 0
From— To h, - - .c—
From..To Ft n�
13."GROUT: Depth. tNlamrial Method
-' _...From 0 To 20 - Ft. ben=tte & cEnat pumped
From - To Ft.
>> o
14. SCREEN:- Depth, Diameler Slot Size Material
From -To Ftill in,
cr.
From To' Ft.in.in, w ma
15, SAND/GRAVEL PACK w
rn —
Depth Size btatenal-
Frorn To. Ft. —
From —To— Ft.
16, REINIARK$i
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTIONSTANDARDS, AND AT A COPY OF THIS RE RD.HAS BEEN PROVIDED TO THE WELL OWNER
SIGN RE OF PERSON CONSTRUCTING THE 7ELL DATE
Submit the original to the Division of Water Quality; Groundwnter Section, 1636 Mail Service Center- Raleigh, NC
27699.1636 Phnnc No. [phone], within 30 days. 0,4-1 REV. 07/2^01

293819
WELL CONSTRUCTION RECORD
North Carc 'rta - Departmerit of Environrre'nt and Natural Resources • Division of Water. Quality - Groundwater Section
James Be Fran w ZN5
WELGC0,1'iRACTOR(DDIYIDUaL)IINAMB (prIN) CERTIEICATI01n
Hedden Brothers We11:Drilling,
VYELL CON'IIt+1 [TOR COivIPANY NA,V1E incPHONE
STATE WELL CONSTRUCTION PERMIT# .ASSOCIATED. VYQ PERMl74
'--(Irabnlcap le). — --' (if aoolicable)
I. WELL USE (Check Applicable Bo,e):Residential tMunicipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring CD Recovery 0 Heal Pump Water Injection 0 Oilier ❑ 1f Other, List Us- _
2 WELL LOCATI Topographic/Land setting
Near?7Iown: County an,.M , ❑Ridge Slope OValley, ❑Flat
U/,1(check appropriate box)
(Street Nance 4wnbcn, Conimunity, 56bdivisiou, Lot Na., Zip Code) - Latitude/Iongitude of Welk location
-
3. OWNER, J ''(degreethn:n<,ter/s<condaj
-Address IfAf Q Lautu e/iongitudesource:CJGPSOTepographle_map_..--
'.(Street R to No,) - (check boa)
P
( (, NCDEPTH DRILLING LOG
City orT en Sere Zip code From To Formation Descr�otion
1A. L/A8-eq'58)? O clay & sand _
Area c:de. Phone vurrbe- 15n ' a 40 granite —
4 DATE DRILLED 3/-60
5, TOTAL DEPTH: n"lwI —
6. DOES WELL REPLACE EXISTING WELL? YES NO-C7 —
7. STATIC WATER LEVEL Below Top of Casing: FT. -- -
- (Use"*" i(Above Top of Casing). -
S. TOP OF CA5ING IS 2 FT. Abcve Land Surface" -
-'Top of casing terminated itlor below land surface requfrer a —
var.ence In ac-ordaw;Lilh 13A NCAC 2C.0118
5. `YIELD (gpm): METHOD OFT�y�ST blow
10. WATER ZONES (depth): 3 /7.� —
LOCATION SKETCH
11, DISINFECTION Type' H T H Amount . 16 cz Show direction and distance in miles froin at least
12, CASING Wall Thickness two State Roads or County Roads, Include the road
Depth D zmert or Wei hVF! Material numbers and common road names. '
.
From O To /:5o Ft �dL_
From, To _ Ft.
Frcm To— Ft. _.
CD
g
13,*GROUT: - . Depthd. Material ' -Metho.. -
From 0 To ' 20 Ft. b5a'2.nite & o�rert pumped s
c .•
From To Ft
. 14, SCREEN '. Depth Diamet , Slot Sae .: iVlaterial
From— �.Ft._in. in
-
a
From - To Ft
15. SAND/GRAVEL PACK i
Depth Size. Material
_Frog
- To Ft.
From To FL - J
c.
16. REMARKS..-,:
I.DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH -13A NCAC 2C, WELL
CONSTRUCTIONSTANDARDS,AN i T ACOPY OF THI RD. HAS BEEN PROVIDED TO THE WELL OWNER
SGN E OF PERSON CONSTRUCTING T HE WELL DATE
tv
Submit the orl;inal to the Division of Water Quallt -v; Groundwnter Section, iu6 mail Servlce Center- Ralelgh, NC
27699.1636 Phorc No [phone], within 30 days.- - OW-i.REV. 07/2001