Well Construction Records Transylvania CY2000

249029
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699.1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION #: z
STATE WELL CONSTRUCTION PERMIT#:
/
1. WELL USE (check Applicable sox): Residential Q Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring El
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town:
%{05 rl i County: Trt r7.J
(Road Name and Numbers. Community, or Subdivision and Lot No.) DRILLING LOG
DEPTH
3. OWNER r k i - From To Forma9on Dcscrip6o1
Address i�` Rd �� /%ry O 3L Cl, i }—
^'75treator use o. 3�
City or To State Zip Code
4, DATE DRILLED A'012?
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES 0 NN�
7. DOES WELL REPLACE EXISTING WELL? YES [] NO�
8. STATIC WATER LEVEL Below Top of Casing: FT.
(Use'+- a Above Top of Casing)
9, TOP OF CASING IS 2 FT. Above Land Surface*
Top of using terminated suer below land surface requires a varlance In accor-
dance with 15A NCAC 2C.011 118
10. YIELD (gpm): METHOD OF TEST
11. WATER ZONES (depth): '/ao
12. CHLORINATION: Type
13. CASING:
Amount If additional apace is needed use back of Icm1
Wall TNckmM
Depth
Diameter
or WeightrFt. Material
,
D 3 ('
Ft.
6
1Iry
From
To
From
To
Ft.
From
To
Ft•
14. GROUT:
Depth
Material Method
From
0 To Z"
Ft.
s
LfiP —a/'
From
To
FL
15. SCREEN:
Depth
Diameter Slot Size Material
From
To Ft
in.
_ in.
From
To Ft.
In.
— In.
From
To Ft.
in.
_ in.
16, SAND/GRAVEL PACK:
Depth
Size
Material
From
To —Ft.
-
From
To
Ft.
17. REMARKS:_
IDO HEREBY
CONSTRUCT]
FOR OFFICE t
Quad No:
Serial No. _
Submit
LOCATION SKETCH
(Show direction and distance from at least two Scale
Roads, or other map reference points)
ED IN ACCORDANCE WITH 15A NCAC 2C, WELL rn L
^Rff CO HAS BEEN PROVIDED TO THE WELL OIANEFR
/l � 12 0 e)�
OF PERSON CONSTRUCTING THE WELL DATE
of Water Quality, Groundwater Section within 30 "Y3 ow-1 RSV 1291
l u'J

n onn Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section 229644
1636 Mail Service Center • Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELLCONTRACTOR: D. Bowman well Drilling, Inc.
WELL CONTRACTOR CERTIFICATION #: 2809
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Boa): Residential D Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other 0 If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town:
Brevard County: S,ran-,vl vania
Little River Campground Ro
(Road Name and Numbers, Community, or Subdivision and Lot No.)
3. OWNER Thomas E.. StpwaS:Y-.--_ _.-
Address P.O. Blue 884
uaot or utswo-)
Pisgah Forests NC 28768
City or Town State ZJp CoOe
4. DATE DRILLED 12/08/00
5, TOTALDEPTH 80'
6. CUTTINGS COLLECTED YES ❑ NO®
7. DOES WELL REPLACE EXISTING WELL? YES M N05
8. STATIC WATER LEVEL Below Top of Casing: T-b' FT.
(Use': Y Above Top of Casing)
9. TOP OF CASING IS 1 A FT. Above Land Surface'
—'op of cuing terminated error below land surface requires a variance In accor-
dancewith l5ANCAC2C.e11a rotary air
10. YIELD (gpm): ?(,1— METHOD600F TEST
11. WATER ZONES (depth):
12. CHLORINATION: Type 1-ahla+ Amount.
13. CASING:
Wall Thickness
Depth Diameter or WeighUFt. Material
From 0To 40 Ft.6 1 I Grh Rn parr
From To Ft.
Agricultural ❑ Monitoring ❑
DRILLING LOG DEPTH
From To Formation Description
It additional space is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
From To Ft.
14. GROUT:
Depth Material Method
From 0 To 20 Fl concrete gravity flow
From To —FI.
15.SCREEN:
Depth Diameter Slot Size Material
From —To—Ft _ in. —in.—
From _ To — Ft. _ in. — In.
From To _ Ft._ In. —In.
16. SAND/GRAVEL PACK:
Depth Size Material
From To 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. 6
FOR OFFICE USE ONLY I(1NATURE OF ERSON CONSTRUCTING THE WELL DATE
Quad No:
Submt orig al to Divislon of star ouajity. Groundwater Section within 30 days GW t REV. 12M
Sena] No.
F

2231.15
North
Mal lina - Department
entofEnvironmentRaleigh.
and Natural
ne (9rce - Division of Water Quality - Groundwater Section
J
WELL CONSTRUCTION RECORD WELL CONTRACTOR: f
WELL CONTRACTOR CERTIFICATION 4
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable BOX) : Residential [�( Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring Li
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATIOq., (Show sk9tch of the location below)
Nearest Town: m •1 - Count': —
nrnciuiru DEPTH
(Road Name and Numbers. Comrwnity. or Subdivision and Lot No) From To
�'--
From To Formation Description
3. OWNER D 5
Address C/n u P i !1 i%S i1 ITD es
Dry or Town
4. DATE DRILLED I2 1� -00
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑ NO® NOOD
7. DOES WELL REPLACE EXISTING WELL? YES
e. STATIC WATER LEVEL Below Top of Casing:
(Use •,- 8 Above Top of Casing)
2
9. TOP OF CASING IS� FT. Above Land Surface'
-Top of using terminated at/or below land surface requires a vartence In accor-
dance with 15A NCAC 2C.9118 Ti m Pri
10. YIELD (gpm): METHOD OF TEST
11. WATER ZONES (depth):
12. CHLORINATION: Type
Amount If additional space is needed use back of loin z
13. CASING: f1 I P — r i 11St0.� 2f' nr e7inN cKETCH
1 Wtll Thickness
tar or Weight/Ft. Material (Show direction and distance from at least two Stale
r 1 Depth2 Duvey SD221 � Roads, or other map reference points)
From _To -30—• Ft. _LLB iLt012/V•
r
From To Ft. NUVJ� �4-UJ�St•
From TD Ft.Uat0 V-OAvo"-:0.OJWL -
14. GROUT: - r(V 2
Depth Material Method
Cross �yy) }p F-O-lrul(k`�
From nnner� l.•
Q_ To _�� FL � ,p
From To Ft._-- I�L� QiVL (2"rgcd I�L�iVim.
15. SCREEN: 3 klgtw On
Depth Diameter Slot Sae Material �OroX • If{ jX t 1 e J
From To —Ft— in. -- in. �j1lLLffNeA fd t1
From To .-- Ft. __ In. In.
From __ To Ft. In. __ In.
16. SAND/GRAVEL PACK:
Depth Sae Material
From To Ft. ---------
From To Ft.
17. REMARKS:
I DO CONSTRUCTION
TANDARTTHI�.)MPtT QOPYNOFRUCTED IN THIISREC RDCASp�EENEPROY�E TO THE WELL OWNER.
CONSTRUCTION STAN4:?ARRS'✓'�T�
- N° k
OR OFFICE USE DATE
• (, SIGNATURE OF PERSON CONSTRUCTING THE WELL
Quad No: Su pinal to Division or water Quality, Groundwater Section within 30 days
GW1 REV. 12J99
Serial No.

North Carolina • Department of Environment and Natural Resources •Division of Water Quality •Groundwater Section
248996
1636 Mail Service Center - Raleigh, N.C. 27699.1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: 1LECC"LJ )10. Jr/ Z�' J6 ""''1:57
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Boa): Residential E Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ It Other, List Use:
2. WELL LOCATIOIJ ( (Show sketch of the location below)
Nearest Town: r�-l" T> -County:
(Road Nameaj�d Numbers, Community, or Subdivision and Lot No.)
3. OWNER /4D r`h !�% ��Y r"l
Address
treat or Hauls o.
DRILLING LOG
From To
3c Sl7
Zi Code
City a Town StateD
4. DATE DRILLED) 3� 2ncJ
5. TOTAL DEPTH 3 vS
6. CUTTINGS COLLECTED YESCD NOD'
WELL REPLACE EXISTING WELL? YES ❑ NO[El�
7. DOES
8. STATIC WATER LEVEL Below Top of Casing: 9 c, FT.
(use'.' a Above Top of Casing)
9. TOP OF CASING IS .2—FT. Above Land Surface*
-Top of using terminated aVor below land surface requires a variance In accor-
dance with 15A NCAC 2C.0114
10. YIELD (gpm): i_ METHOD OF TEST r
11. WATER ZONES (depth): / 2-v
12. CHLORINATION: Type
13. CASING:
Depth Diamet r
From 0 To �© Ft.
From To Ft.
From To Ft.
14. GROUT:
DEPTH
Fomw7cn DescrIPUM
ri t' r
br^,�14 5h,,)(
jn tt. , '
Amount If additional space is needed use bade of form
LOCATION SKETCH
Wall Thickness --
or WeighVFI. Ma} arias (Show direction and distance from at least two State
2-7 Roads, or other map reference points)
Depth Material Method
From 2 To Zy FL L-A4'�efe P,..•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:
fI� 81
FOROFFICE U?ILY, 0
Wad No:
Submit ad nal to
Sedal No.
,�5•'F`.�J�L[ FrGiOtJ%,'_ OF=ICc
&Ir d"y fly
/3Y tt?.7 a�,, T l�
�cv /'�G C,-y��l o✓f
N
:m
-
l
QO
o
ORDANCE WITH 15A NCAC 2C, WELL
!qA
H EEN PROVIDED TO THE WELL 011NER.
F PERSON 0 RUCTING THE WELL GATE
Water Quality, Groundwater Section within 30 G3y3
own Irv. 12v1

P onh Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section 2 29 6 J 3
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone (919) 733-=1
WELL CONSTRUCTION RECORD WELL CONTRACTOR: D. Bowman well Drilling, Inc.
WELL CONTRACTOR CERTIFICATION Is: 2809
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Boa): Residential® Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2 WELL LOCATION: (Show sketch of the location below)
Nearest Town: Frevarr1 County: Transylvania
(Road Name and Numbers, Community. Or uOdivislon and Lot No.) DRILLING LOG
3 OWNER James Earley From To
Address P.O. Box 1427
tbe�et or� Is No.)
Mountain Homeu Nr 28758
City or Town -- Stale ^zip Coda
c DATE DRILLED 1 1 /01 /00
5. TOTAL DEPTH 260 r-
6. CUTTINGS COLLECTED YES[3 NO®
7. DOES WELL REPLACE EXISTING WELL? YES NO®
8, STATIC WATER LEVEL Below Top of Casing: _6 r) FT.
(Use'+' # Above Top of Casino)
9, TOP OF CASING IS 1 . 4 FT. Above Land Surface'
-Top of casing terminated atlor below Ian•i surface requires a varlana In accor-
d: nce with 1 SA NCAC 2C.0115
10 YIELD (gpm): 1 Q__ METHOD OF TEST rot a r3Z a i r
1 . WATER ZONES (desth): 180' - 220'
is CH!-ORINATION: Type tablet Amount 6
I:I. CASING:
Agricultural ❑ Monitoring ❑
DEPTH
Formation Description
It additional space Ls needed use back of form
LOCATION SKETCH
De th
0 p 67
Di
6
Wall Thickness
t or}yeianUF Material
�%� �0
(Show direction and distance from at least two State
From
To
Ft.
SCR PVC
—
Roads, or other map reference points)
From
To
Ft.
From
To
Ft.
14. GROUT:
Depth
Material Method
From
0 To 2Q—Ft.
gravity
flow
From
__ To
Ft.
1G. 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 FI.
l r. 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,
< 67 lUv
FOR OFFICE US
Duad No:
�/SJGNATUREJ& PERSON CONSTRUCTING THE WELL DATE
An �] .Submit original to Division of Water Duality, Groundwater Section Within 30 days
$anal No.
,; jl. ", n FIT L GW.I REV. 12199

IJorth Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699.163rrphone (919) 733.32.21 1 1 ll
'HELL CONSTRUCTION RECORD WELL CONTRACTOR CERTIFICATION 0:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable box): Residential Id Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATIO : (Show
Nearest Town:
3. OWNER
Address
of the location below)
or Subdivisiat and Lot No.)
4. DATE DRILLED r
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑ NO[7]
7. DOES WELL REPLACE EXISTING WELL? YES 0 NOt]
8. STATIC WATER LEVEL Below Top of Casing:
(Use V u Above Top of Casing)
9. TOP OF CASING IS FT• Above Land Surface'
Tap of using terminated allor below land surface requires aa'vulsnce�In accor-
dsnce with 15A NCAC 20.0118 10. YIELD (gpm): METHOD OF TEST!
,� _
11. WATER ZONES (depth):
12. CHLORINATION: Type Amount
13. CASING: (/JS�"e✓
Depth b�
C I
/ . Wall Thicckm"
(011,k�— orw VL'
From
To
Ft.
From
To
Ft.
From
To
Ft.
14. GROUT:
Depth
Material Method
From �--To ZC7
" n�xr
Ft. �Vlnr(lp re•
From
To
Ft,
15. SCREEN:
Depth
Diameter Slot Sfzfi Material
From
To Ft
in. in.
From
To Ft.
__ in. In.
T FL
in. th•
DRILLING LOG DEPTH
From To Fomation pescdpdon
If additional space Is needed use back of form
l QgATION SKETCI-
(Show directlon and distance from at least two State
Roads, or other map reference points) Ciu..h
�rot�"6revc� �Uly
Creek �{tf'CJYLCaS Vu
roaA on 1Q + C ,5pr-i j
Sitt -IridL on lot
From o
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
17. REMARKS:
1-"CAC 2C, WELL
Cp H RUC �{ �pTHATT �NSa A A OPY OWELL WAS FRTHIS E CORD HAS BEE EPRIOVI I ED �O T,H/E WELL OWNER.
15 ZJ''L1? a'
!0",d
:NO:
FICE NLY DAT
-'- I b r57GNATUREOFPERSO CONSTRUCTING THE WELLi . `._sutvnj 6jr�l to ivvWon of watt r Gush. wi1r11n ��:y�3� v.12�9

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
;...r38
1636 Mail Service Center - Raleigh, N.C. 27699.1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: wOTI'v�
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMIT#:
WELL USE (Check Applicable sox): Residential 6 Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION (Show sket of the location below)
Nearest Town: i j h Q/KO 1 /X r O J County: —
(Road Name and pumben. Comnwnity, or Subdivision and Lot No.)
3. OWNER
Address
LA treat or a o.
-
city or Town Sate Zip Code
4. DATE DRILLED ( 00
5, TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑ NO[�
7. DOES WELL REPLACE EXISTING WELL? YES 0 Not
8. STATIC WATER LEVEL Below Top of Casing: LIU_ FT.
(Use': if Above Top of Cuing)
9. TOP OF CASING IS FT. Above Land Surface-
-Top of easing terminated suor below land surface requires a variance In accor-
dance with 15A NCAC 2C .O718
10. YIELD (gpm): METHOD OF TEST
11. WATER ZONES (depth):
12. CHLORINATION:
13. CASING:
DRILLING LOG
From _ 1,3
3-Q(rs
DEPTH
Formation Description
r
CD
_
n�
v
c`;
C
-0
m
r' :U
W
Type
Amount a 3 C It additional space is needed use back of form Z
Wall Thickness
Depth Di I ter or WSW eghVFt.. terial
From + To 2 Ft. Da
R
From To Ft.
From To Ft.
14. GROUT
Depth
MaterialMetho
10 Ft.
From
To
From
To Ft.
15. SCREEN:
Depth Diameter Slot Size
Material
From
To _ Ft
_ In. _.
in.
From
To _ Ft.—
In. _
in.
From
To __ Ft.
— in. —
In.
16. SAND/GRAVEL PACK:
Depth
Size
Material
From
To Ft.
From
—TO—Ft--
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
O 0-"
6110
r1Qd bum- �
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 17� DATE
Quad No: " ✓ IGNATURE OF PERSON CONSTRUCTING THE WELL
Submit odginai to Division of Water Quality, Groundwater section within 30 days GW I REV. 12199
Serial No.

22'7524
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27e99-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: GAMEtt T?iFI? 1)EU4 TZJmP Co .
WELL CONTRACTOR CERTIFICATION 0: ' ` 2�024-
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable sox): Residential ® Municipal ❑ Industrial ❑ ElAgricultural ❑ Monitoring
Recovery ❑ Heat Pump Water Injection ❑ Other Ef If Other, List Use:
2. WELL LOCATI N' (Show ske s 1 of the locallon below)
NNeArres Town: County �`��'���1G`
�1 ��0 DEPTH
(Road Name nd Numbers mmunily, division and Lot No.) DRILLING LOG
3. OWNER I SubFrom To Formation pescdpllon
Address
res or u o.
City or Town Slate Zip Code
4. GATE DRILLEO,�/-�-��
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑ NOLK
7. DOES WELL REPLACE EXISTING WELL? YES NO® (�S — - SoL�� �7✓O^�L�a
8. STATIC WATER LEVEL Below Top of Casing: FT.
(Use'+' If Above Top of Casing)--
9. TOP OF CASING ISFT. Above Land Surface' "_-
Top of casing terminated atior below lend surface requires a variance in accor-
dance with 15A NCAC 2C.0118
10, YIELD (gpm): METHOD OF TEST At-, - -;
11. WATER ZONES (depth): "
fV c-,-
12. CHLORINATION: Type/ItFft Amount /02 d'7- If eddillonal space Is needed use back oflfcjin
13. CASING:
LOCATION SKETCH
Wail Thickness
Depth �/� C�i�r�n�e per o Wei hVFt. lariat (Show direction and distance from at least two Stale
From-�—To -�-- Ft. vG* Roads, or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth M erl (�elhod
From C�2) To
From To Ft. 1
1
15. SCREEN: `
Depth Diameter Slot Slze Material
From _ To _ Fl _ In. —In.—
From _ To. Ft. _ In. — In.
From _ To _ Ft. _ In. _ In.
16. SAND/GRAVEL PACK:
Depth Size Material
From To —Ft. —
From To Ft.
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS
CONSTRUCTION STANDARDS, AND THAT A C
FOR OFFICE USE ONLY
Quad No:
Serial No.
;ONSTT/7R,�UCTED IN ACCORDANCE WITH 15A NCAC 2C. WELL
rpy OfiTHIS R CORD A BEEN PROVIDED TO THE WELL OWNER.
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Inal",fo Division of Water Quality. Groundwater Section within 30 days
GW-1 REV. 17/99

Nona Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699.1636•Phons [phone] I r
WELL CONSTRUCTION RECORD WELL CONTRACTOR:auj1,
WELL CONTRACTOR CERTIFICATION N: __„ (1
,( STATE WELL CONSTRUCTION PERMITi
1, WELL USE (Check Applicable sox): Residential 111 Municipal ❑I(Ot In Industrial
❑
Agricultural Monitoring ❑
List .
Recovery ❑ Heat Pump Water Injection El Other
2, WELL LOCATION: (Show sketch of the location below)
-LZ.-^. , ^ v County:
Nearest Town:
(Road N and NumOars, CammuNty. O! SubaVWW and Lai No.)
3 OWNER c1�4"r'nf))Co
Address 3
tree or ou a 0. a8 t7/ O a v0
' or Town���I �Stale Lp Coda
4 DATE DRILLED J
5 TOTAL DEPTH
6 CUTTINGS COLLECTED YES ❑ NO®
7 DOES WELL REPLACE EXISTING WELL? YES ❑ FN'f0®
8 STATIC WATER LEVEL Below Top of Casing:
' a (use W If Above Top of Casing)
9 TOP OF CASING IS i FT• Above Land Surface'
'lop of using terminated avor below land surface requires a variance In sccor-
dunce with 16A NCAC 2C.0118
11). YIELD (gpm): r METHOD OF TEST
11. WATER ZONES (depth):
1:2. CHLORINATION: Type Amount
13. CASING: Q V n11 Vt/J)
I f T Wall TNcknesa
Depth �� Diameter or Weight/R. Material
From --To —51— Ft. ('1/8 - PIC,
From To Ft
From To Ft.
14. GROUT:
Depth Material Metho .
From
To ?Q- Ft. aWLEL
Q--
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft __ in. —_ in.
From To Ft. _ In. In.
From To __ Ft in* In•
1 S. SAND/GRAVEL PACK: Material
Depth size
From To Ft. ---
DRILLI�_ DES PT_TH
From To Formation Description
If additional space is needed use back of form
i n TInM SKETCH
(Show direction and distance from at least two State
Roads, or other map reference Points) le-FL
01
I urK Creek i3 Isl Church �Itii ch is old
Ne�Bo.(°o %Z Mile and+o-Y Ci- knn
TurlCe� Creek i2D0.Ll .fro %2 ynile-
LLvt�b
}o r(��Lt then o sire( ht. 1+ is be-U"d
M�y�� ,llounkLUn��S-�a-y2meln�" �S
sn� raven road about I m I k-�-
�d ,�ro�er�y is on ri�ht•
From To FL
17. REMARKS:
CO HEREBY STRUCTICERTIFY THAT THIS WELL WAS CONOSTRUC9RE RECORD HAS BEEN pROV)50 ED IN ACCORDANCE WITH
I5A TO THEW LL OWNE .
f FOR OFFICE U LY i t NATURE OF PE N CONSTRUCTING THE WELL
DAT
Quad No: '
' i '! Submt origihy,to Dtvblon of Water Oualiry, Groundwater Section within 30 days GW-1 REV. 12N9
Sadal No.

!- ... 2 117
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]
'NELL CONSTRUCTION RECORD WELL CONTRACTOR: a
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Chock Applicable BOX): ResidentialMunicipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection[] Other If Other, List Use:
2. WELL LOCATII (Show sketch of the location below)
Nearest Town
(Road Name an Numbers. Co nity, or Subdivision and
3. OWNER —�a7ILLI Ix rlttF"
Address// l) ./r?0 f/i 1---�4 IL
Ci 00, own Stale "� ""•'
4. DATE DRILLEL: D
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑ NO[]
7, DOES WELL REPLACE EXISTING WELL? YES NO[n
B, STATIC WATER LEVEL Below Top of Casing: Fr.
(use'+' u Above TOP of Casing)
9, TOP OF CASING IS FT. Above Land Surface'
-top of "sing terminated ovor below lend surface requires a valiance In actor-
dancs with 15A NCAC 2 to '�mP�
1 ). YIELD (gpm): METHOD OF TEST -
1 1. WATER ZONES (depth):
12. CHLORINATION: 1Type ins
,AImI ount
13. CASING: /`� ( (�I L y I11.s"ud er
I ( r WallTwaNeu
Depth Dkvnatef cor �W�ei�ghl/�Fl. �p�
FromTo Ft. }2_/8 1I
From To FI•
From To Ft.
14. GROUT:
Depth Material Method t .
From To 2-FI. Wut/'VP
From To Ft.
Ili. SCREEN:
Depth Diameter Slot Size Material
From To Ft _ in. in.
From _To Ft. In. —In.
From __ To FL In. _ In.
113. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
17. REMARKS:
DRILLING LOG DEPTH
From To Fomution Description
If additional space is needed use back of form
LOCATION SKETCH
(Shaw direction and distance from at least two State
Roads, or other map reference points)
OY1 fast ForK - Crosse br[dq
Ord drive onotd�ba�h-
©kt-trod[)er 2vtd of driv2waY
I DO HEREBY CER I TH ISL UCTED IN ACCORDANCE WITH 15A NCAC 2C, WE
LL
CONSTRUCTIONS ' RECORD HAS BEEN PR VIDED TO THE WELL OWNER.
FOR OFFICE USE $ - RE OF P SON CONSTRUCTING THE WELL TE
Ouad No:
Submit oripi to Didsbn of W or Oualiry, Groundwater Section within 30 days GW t REV. 12N9
Serial No. --- Croundwat z �T .

North Carolina •Department of Environment and Natural Resources -Division of Water Quality -Groundwater Section 1� h � �5 O
9 1636-Phone [phone] CJ
1636 Mail Service Center - Raleigh, N.C. 2769 - �x7
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION #: - '%�y
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential 2 Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATIC)gl: (Shgw sketc f the location below)
Nearest Town:.{,— '/A,' ^ _ County:
y
(Road Name and Numbers. Community, or SuDdivision and Lot No.)
3. OWNER /3 r9 b Sb-4-
Address �/0
�iorK /1 S e ^/ C Zip code
City or Town State P
. DATE DRILLED
5. TOTAL DEPTH .S
6. CUTTINGS COLLECTED YESQ NOM
7. DOES WELL REPLACE EXISTING WELL? YES NO®
8. STATIC WATER LEVEL Below Top of Casing:i
- _ FT.
(Use'+' it Above Top of Casing)
9. TOP OF CASING IS11 FT. Above Land Surface'
'Top of casing terminated at/or below land surface requires a variance In accor-
dance with 15A NCAC 2C .011a C
10. YIELD (gpm): —/2Z— METHOD OF TEST Z Z Jd
11. WATER ZONES (depth): 1 5 t
Agricultural ❑ Monitoring ❑
DRILLING LOG DEPTH
From To Formation Description
12. CHLORINATION: Type �� !j Amount � If additional space is needed use back of form
z
13. CASING:
LOCATION SKETCH
Wall Thickness
Depth Diameter or Weight/Ft. Material (Show direction and distance from at least two State
/1 _ G % 4, ,SO'P _'P71 1+9 1/C— Roads. or other map reference points)
14. C
17.
I DO HEREBY Cn_HIS TuT)(JELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTEAgpA�S�NPTHAT,ACOPYf1F?�I CORD HAS9Ef>�PR2iA/IDEDTOTHEWELLOW�R•H/ ,
FOR OFFICE U Lr DATE
Quad No: �INATURE OF PERSON CONSTRU TIN E WELL
F. Submit fn o Division of Water Quality, Groundwater Section Within 30 days
GWt REV. 12/99
Serial No.
Cr01A��'.• , �� N

f•-
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:- La?uFlu4_
WELL CONTRACTOR CERTIFICATION #:.2 7,W
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
Nearest
3. OWNER
Address
Agricultural ❑ Monitoring ❑
sketch of the location below)
z^� County ice,.
4. DATE DRILLED
5. TOTAL DEPTH .S rD.S
6. CUTTINGS COLLECTED YESQ NO
7. DOES WELL REPLACE EXISTING WELL?'YES,❑ NO®
B. STATIC WATER LEVEL Below Top of Casing: :yy6- FT.
,,�y. (Use'+' If Above Top of Casing)
9. TOP OF CASING ISM Fr. Above Land Surface'
-Top of casing terminated at/or below land surface requires a variance In accor•
dance with 15A NCAC 2C.9118 '
10. YIELD (gpm): LoL_ METHOD OF TEST_T -4,& •-v
11. WATER ZONES (depth): y a 1
12. CHLORINATION: Type T4 6 Amount
13. CASING:
Wall Thickness
Depth %%__iamreler or Weight/Fl. Material
FromTo � Ft.l.�-�r--- SOQ Z/yc•
From To Ft. -
From From To Ft.
14. GROUT:
DepthMaterial Met od '
From To a r ^ � Ft. ��"'%�
From To Ft.
15. SCREEN:
Depth Diameter Slot Slze Material
From To Ft in. in.
From To Ft, in. In.
From To Ft. in. in.
16. SANDIGRAVEL PACK..
Depth Jj Size Material
From To Ft.
From To Ft.
17. REMA S:
DRILLING LOG DEPTH
From To Formation Description
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS. AND THAT A COPY QF5 -�ECORD HAS BE�NOOVIDED TO THE WELL C
Quad No: U SIGNATURE OF PERSON CONSTRUCTING THE WELL uAte
P Submli odgipal to Division of Water Quality, Groundwater Section within 30 days
Serial No. _ GW1 REV. 12199
RID
5.

22367
hortn Carolina • Department of Environment and Natural Resources • Division of Water Quality • Groundwater Section
�
1636 Mall Service Center. Raleigh, N.C. 27699.1636•Phone (919) 733.=l I r
WELL CONSTRUCTION RECORD WELLCONTRACTOR:
WELL CONTRACTOR CERTIFICATION #:
/STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (CheckAppil"bls 9os): ResldenGalE Municipal ❑ Industrial ❑ Agricultural ElMonitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCA'
Nearest Town:
'2O_
3. OWNER
Address
of the location below)
Numbers, Cornrttwary, or Subdivision and Lot
r-ans v I V a.n) a
Gry or town
4. DATE DRILLED
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑ NOM y•�r11
7. DOES WELL REPLACE EXISTING WELL? YES NO[n
e. STATIC WATER LEVEL Below Top of Casing:
2 (Use Z. 9 Abm Top of Casing)
9. TOP OF CASING IS 1.33 �• Above Land Surface*
?op of "sing terminated Wor below land surface requires a variance In accor-
dance with 15ANCAC2C.011a I tYYIP�
1 C. YIELD (gpm): I_ METHOD OF TEST
11. WATER ZONES (depth):
12. CHLORINATION: �Type
1,,Amounnt
12. CASING: �j.�
pif (YLSWs e
Depth
s
Wall Thickness
ter or we t Material
era"
From ID To q,p—
From To I �t d
Ft
�_
Ft.
From To
Ft.
14. GROUT:
Depth
Mate al Method ,.
From 0— To � —Ft•
� t 1Y'P_d
From To
Ft
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft
_— in. — in.
From To Ft-
— In. In.
From To __ FL
in. In.
16, SAND/GRAVEL PACK:
Depth
Size Material
.DRILLING
From To
DEPTH
Formation Description
If additional space is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
c�en5 Auk. o post &I d d U e
I:orK c uyzh - turn r'Lt on. Payed
drive . ProPE� is first drive on
rce�
From To FI
From To Ft•
17. REMARKS:
I t)D HEREBY C PfRI (& 6LL= CONSTR TED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTI01 S,�NI�TF�T.CtPYOF ISRECORDHASBEEN VIDEDTOTHEWELLOWNER.`41—�
I°OROFFICEUS Y _ TIREOFP SON COS CTNGTHE WELL DATE
h ad No: i
r � �� submit o i .6 Division of our Oualiry, Groundwaur Section within 30 days Gw•1 REV. 1259
Serial No.
ndwater Section
blieville Regional

North Carolina - Department of Environment and Natural Resources - Division of Water Ouality - Groundwater Section
P.O. Box 29578 - Raleigh,N.C. 27626-0578-Phone [phone] /� l.r p
WELL CONSTRUCTION RECORD DRILLING CONTRACTOR:I fiLY3Yr`n�S 1 tort ✓1lPfWBi�tium;
DRILLER REGISTRATION #:
/ STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential IJ Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2, WELL LOCATIC�L (Show sket h of the location below) �����,�p7 Q��Q7
Nea)esl Town:- . �`� ' Aa, County:
or Subdivjsjon and Lot No.)
3. OWNER
(Sheet or Route No.) on r, v
or Town Stale Zip Code
4. DATE DRILLED
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑ NO[K
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO[t
8. STATIC WATER LEVEL Below Top of Casing: FT.
(Use .+'. it Above Top of Casing)
9. TOP OF CASING IS 1.33 FT. Above Land Surf ace'
Casing Terminated aver below land surface is illegal unless a variance is issuer
in accordance with 15A�N�CAC 2C .0118
10. YIELD (gpm): XZA METHOD OF TEST
11. WATER ZONES (depth):
DEPTH DRILLING LOG
From To Formation Description
If additional space is needed use back of form
LOCATION SKETCH
Depth pi�meter t r�.ial (Show direction and distance from at least two State
From QTo III — Ft. u, lQ / Roads, or other map reference points) L
From To Ft. —
From To Ft.
14. GROUT:
Depth Material Method Q
From V To _ Ft. (+�ar�r P ram_ CIiN S CJiIR1LeL �1 — TQ
From To Ft. arv_ _
15. SCREEN:
Depth Diameter Slot Size Material l 00
� _ ( —d _ �a C
From —To—Ft— In. m. L l/�C UXi
From —To .— Ft. — in. N� R in.
From _ To
16. SAND/GRAVEL P
Dept Size rial uu
From
From To Ft.
17. REMARKS:
—
I DO HEREBY CERTI C D IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION ST D RECORD HAS BEEN OVIDED TO THE WELL OWNER.
FOR OFFICE USE ON / ' DATE
Quad No: - 1t 1t,' - ^0 - URE O ONTRACTOR OR AGENT
Serial No: JVIV I 1 riginal to Division of Water Quality and copy to well owner. GW-1 REV. 1198
12. CHLORINATION: Ty e Amount _
13. CASING: �t y �f� CI y�cQ A%RQx A
0 r "=
Wall Thickness
or Welghv't.

<' 1)J7
North Carolina - Department of Environment and Natural Resources - Division of Water Duality. Groundwater Secko r)
1636 Mail Service Center - Raleigh, N.C. 276994636-Phone [phone] i l%r'�fii, L D
WELL CONSTRUCTION RECORD WELL CONTRACTOR CERTIFICATI N M: c�00
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 LOCATIqN: (Show sketch of the location below)
Nearest Town: JYPLYC�—County'�11-
i vw Qf iO V va DEPTH
(Road Name and Nup�ars. Colr-mare • or Subdl and Lot No.) DRILLING LOG
3. OWNER aid rhor c hnG/o IIlud, E. f From To Formation Descr(Ption
Address i IQ R 111,0sf 3JA Ave A:�6X•Pfi
4. DATE DRILLED
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑ NOI
7. DOES WELL REPLACE EXISTING WELL? YES El NO
8. STATIC WATER LEVEL Below Top of Casing: FT.
? (use': g Above Top of Casing)
9. TOP OF CASING ISFT. Above Land Surface*
-Top of using terminated at/or below land surface requires avulance in accor-
dance with 16A NCAC 2qp118 l I litp[1
10. YIELD (gpm): METHOD OF TEST
11. WATER ZONES (depth):
12. CHLORINATION: Ty a (Amount
13. CASING:7 pub (IWW-gV
plop T Wag TNcclvru
Depth� �'�"��°r or WsighvR. Material
FromTo Ft. gc / o— l Je JL—
From To Ft.
From To Ft.
14. GROUT:
Depth Materi M
From 'D To � Ft.
From To Ft.
16. SCREEN:
W NZ
If additional space is needed use back 0MUrrh —+
LOCATION SKETCH
(Slow direction and distance from at least two State
Roads, or other rnap reference points)
�l.cGui ram. 1Zoa-d-
Lh
Fro�x 13rp-vard - 00 Ease Cn % b
L`LII,�, a 8o a;� PrSgck (-ores+. Stay
VVI ,280 approx�-JS ry1((es , -r( S.
Imo" Jow AC Gluire� `�oa-d .-r0_te J_ef+
Depth Diameter blot bite 1 I w jkt +h Vo I -St SY ICU V
From To Ft In. In. �YIiLLI 1 0 drive -
From To Ft. In. In. `a � � rj p) 1 lr& Gh, u
From To FL In. I^' n end. w cI
16. SAND/GRAVEL PACK: C!w-
Depth Size Material
From To Ft. D (f 1
From To FL
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONST
CONSTRUCTION STANDARDS, AND THAT A COPY OF
FOR OFFICE USE ONLY
Quad No:
Submit original W
Sadal No. ! ..-
'ED IN ACCORDANCE WITH 15A NCAC 2C, WELL
RECORD HAS�BEENVI TO THE WELL OWNER.
OF PE N CONSTRUCTING THE WELL DATE
of water Quality. Groundwater section within 30 days Gw.t REV. 12N9

North Carolina - Department of Environment and Natural Resources • Division of Water Duality • Groundwater Section n 3
12
1636 Mail Service Center • Raleigh. N.C. 27699.1636-Phone [phone] t G
'VVELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applleebie sox); Residential (YJ Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other If Other, List Use:
2. WELL LOCATI N: (Show skgtch of the location balow)
Nearest Town: r `l �= rC - County. r
or Subdivision and Lot
3. OWNER
Address
City or Town State
4. DATE DRILLED
5, TOTAL DEPTH
6 CUTTINGS COLLECTED YES ❑ NOM
7 DOES WELL REPLACE EXISTING WELL? YES ❑ NOEj
8 STATIC WATER LEVEL Below Top of Casing: FT.
(Use'+' g Move Top W Casing)
9 TOP OF CASING IS 1.33 FT. Above Land Surface'
-Top of easing terminated suor below land surface requires a variance in accor-
dance with 15A NCAC 44.0118
11). YIELD (gpm): I METHOD OF TEST l m
wA
1'I. WATER ZONES (depth):
12. CHLORINATION: Type Amount
13. CASING: jr(s�+2i
�1`I P (d'1lP Wall Thickness
Depth (� tar 121212� 4 pV C
From TO � Ft. des-6--
From To Ft.
From To FL
1rt. GROUT:
Depth Materipl Method t.
From � To � Ft. TQ_Ql�PJ
From To Ft.
1:i. SCREEN:
DRILLING LOG DEPTH
From To Formation Description
If additional space Is needed use back of form
i OCATION SKETCH_
(Show direction and distance from at least two State
Roads, or other map reference points)
Frorn `ereva-rd--Ea Green-giVa
i�hwr cL� ro�ci rnatel .� rfu les .
��VoactKIVPX• (0.KG ie-q
Crops �(�eryf A-Ll� lei
pv, h J��� COrL'�IYlU&-
Depth Diameter Slot Size matenal
To Ft in. —In.
0 1 I
fD 4DP O� rl( un&ii1
From
From To Ft. In. In.
From —To __ Fl. In. In.
Oa �Y JEa.
ae
16. SAND/GRAVEL PACK:
J
Iu , nn
Sal
Depth Size Material
From To Ft.
From To Ft.
17. REMARKS:
se
auad Na
NSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
OF IS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
GNATURE OF RSON CONSTRU NG THE WELL DATE
to Division of Water Ouality. Gmundwater Section within 30 days OW-1 REV. 121"
Serial No.

North Carolina - DeParfinent of Erwironrnent and Natural Raw, rcn - Divplon of Water ouaGty . GroundwaW Section "/' U 0
16W Mad Service Center - R61N9h. N.C. 276118-1636•Phom (919) 733-Ml
WELL CONSTRUCTION RECORD wELLcoNTRACTOR:
WELL CONTRACTOR CERTIFICATION
STATE WELL CONSTRUCTION PERMITS:
1. WELL USE (chu* Appgcabls nosy Rasldsnda!EE Munkdpel ❑ Industrial ❑
Recovery 0 Heat PMV Water Injection Other 0 If Other. List Use:
2. WELL LOCATI91: (Show ske%h of the location below)
:1. OWNER
Address
4. DATE DRILLED
:i_ TOTAL DEPTH 0
fi. CUTTINGS COLLECTED YES 0 NOM
7. DOES WELL REPLACE EXISTING WELL? YES NO®
II. STATIC WATER LEVEL Below Top of Cashg: Fr.
L (the +• s Above Top of Cdno)
0. TOP OF CASING ISFr. Above Larid Surface-
•rOP of tOdM termNabd attar below land surface requtna a verWroe in aaior-
canm Was 1aA NCAC 2C A118
10. YIELDWm): /6- METHODOFTEST
11. WATER ZONES (depth): & g r "k
12. CHLORINATION: Type 7W13 Amoum_
13. CASING:
06Pw ellTh lawsa
From ToY.�_ Ft.
From To FL
From To FL
14. GROUT:
Dept Method
From _/ To Ft. t i
From To FL
15. SCREEN:
Depth Diameter Slat Shi Material
From
From In. in.
From T F In M
16. SANDIGRAVEL PACK:
Depth size Material
From Ft
From To .
17. REMARKS:
.7•
• yr
Agriculture! ❑ Monitoring ❑
DRILLING LOG DEPTH
From To Forrradm DesaWon
o_
0
o
>o
-
m
a
-r+w
GJ
o
ti addkb W spate M roaded uae back of brm
LOCATION SKETCH
(Show direction and distance from at Mast tiro State
Rods. of other nap reference PAM)
IN iccopDANCE WITH 15A NCAC 2c. WELL
Serial Na.
rw.. 9" 12m

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section , . ( 9 F
1636 Mail Service Center - Raleigh N C. 27699.1636-Prone [phone]
WELL CONSTRUCTION RECORD WELLCONTRACTOR: A.I
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 LOCATIO�N}{: (Show sketch of the location below)
Nearest Town: KrrlSYyly) n County: :r n�
(Road Nana and Numbers, Community, or Subdivision and Lot No.)
:I. OWNER ,HoroqId a�j]t�k)
Address 1) n. V,nY I I I Q
� . DATE DRILLED 10 -q -oo
TOTALDEPTH 1006
E. CUTTINGS COLLECTED YES ❑ NO®
7. DOES WELL REPLACE EXISTING WELL? YESE-]
E. STATIC WATER LEVEL Below Top of Casing: FT.
(Use Y' a Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface*
-'op of cuing terminated at/or below land surface requires a variance In accor-
dance with 15A NCAC 29plia •
10. YIELD (gpm): METHOD OF TEST Tt
11. WATER ZONES (depth):
12. CHLORINATION. Type Amount
1 3. CASING: �j &y p�� ()r
/ r Wall Thickness
Depth n r r tar «w� ehVFl Material
FromTO Ft. �L>� <i
Pl 0-
From To Ft.
From To Ft.
14. GROUT:
Depth Mate�'al Method,
From �_ To �—Ft. S:.ld� T("�'1'_f`Y'1orJ`_
From To Ft.
16. SCREEN
Depth Diameter Slot Size Material
From To Ft _ in. in.
From To Ft. _ In. in.
From To _ FL In. In.
1(;. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
17. REMARKS:
DRILLING LOG
From To
DEPTH
Fomtation Description
ra
:4
1V -"
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)
CN�r Law j( er-Ait&ell Bi.ssel)
rprx �revcud -Lade �� Wit kQ
W1e36 ForkL-oop or
fop of r"mtain ,
-be. Lc-&. me-.
rL9 all the uia�to
I DO HEREBY CEATJFY �j WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
rnN¢TAI ICTIOI.f S,TAN R[DS AT A COPY OF TftIS RECORD HAS BEEN PRQVIDED TO THE WELL OWNER.
Ouad No: ul] 13 1 &PATURE OF RkpSON CONSTRUCTING THE WELL UAI t:
Submit od fnal 1 Division of Water Duality, Groundwater Section within 30 days
GW1 REV. 12/99
Serial No. „��„ ._._.__ n=

North Carolina • Department of Environment and Natural Resources • Division of Water Quality • Groundwater Section , ..1 j Q r'
1636 Mail Service Center • Raleigh, N.C. 27699.1636-Phone [phone]
jig
WELL CONSTRUCTION RECORD WELL CONTRACTOR CERTIFICATI N r: aGU7
STATE WELL CONSTRUCTION PERMITiI:
1. WELL USE (Check Applicable Box): Residential LJ Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL
3. OWNER
Address
sketch of the location below) TranSV I ,an 1 -
p County: _TJV
and lot No,) DRILLING LOG DEPTH
From To Formation DesVVWn
4. DATE DRILLED ESL_ p:m
5. T0TALDEPTH�a�1iSf1C:JcI-�-�
6. CUTTINGS COLLECTED YES❑ N0ftt]
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NOrtl
6. STATIC WATER LEVEL Below Top of Casing: FT•
(Use •.• a Above Top of Casalg)
9. TOP OF CASING IS FT. Above Land Surface'
-Top of using terminated War below land surface requires a varlanee In actor-
dance with 15A NCAC 2C.ILI1a 'T T marl
10. YIELD (gpm): & METHOD OF TEST
11. WATER ZONES (depth):
12. CHLORINATION: Type Amount
Zy
13. CASING:
gy 1u:Laao'
' 1 Wall Thickness
Depth ter or WeighgR. t4
From TO � Ft.
From— From
To Ft.
From
To Ft.
14. GROUT:
O
Depth Material Me
y10ro,o
From
To _0—Ft.
From
To Ft•
15. SCREEN:
Depth Diameter Slot Size Material
From
To Ft In. In.
From
To Ft. In. in.
From
To FL In. In.
16. SAND/GRAVEL PACK:
Depth Size Material
From
To Ft.
From
To Ft.
17. REMARKS:
If additional space is needed use back of form
i O eTIf1N $KETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
Lj t.U, e1 •i v,er C' om m ioti y
F(cm Brevard lake
rj VLt 01 Tria�ilgL2 S�0p orli()
drab -eI( koa d , Takes rt�h on
3:sI " Cove 12oad • Go ° PProXi mafey
Y4 rxi)e •yoLL uuilt s Tj � b
eeaaF�&\If-goad -� -6 Lila& +Dp
dn�e- at tcP of h.tl l
U 1111 V IS UCTED IN ACCOflDANC ITC 2C, WELL
I DO HEREBY CE THAT
CONSTRUCTION AADS, AND THAT�A C THIS RECORD HAS BEE ROVIDED TO THE WELL OWNER. �J
Jd �'
FOR OFFICE ON SI TORE PERSON CONSTRUCTING THE WELL DATE
Quad No: ndivate• r�yyag/�
'lie englrw to'wlon o Water Duality, Groundwater Section within 30 days GW-1 REV. 12/99
So" No.

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section 1 _
1636 Mail Service Center - Raleigh, N.C. 27699.1636-Phone [phone] i _ 11 ;J D t— C
WELL CONSTRUCTION RECORD WELL CONTRACTOR: 'lnhprt �. �ll } �C�37r�
WELL CONTRACTOR CERTIFICATION #:_Q ' "1
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check applicable Boa): Residential ❑ Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATIO * (Show sk Ich of the location below) T
No est Town: County: " n s V I V Q 1
Cind Nn(tnIzzin firu
(Road Name and � Numbers, Community, or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER 1.611Icon
F n me l l From To Formation Description
Address C
� _,E u.. «N C' o. 28768
�a Townes"' State lip coft �-
4. DATE DRILLED
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES NO®
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO[o
B. STATIC WATER LEVEL Below Top of Casing: FT.
(Use •+' g Above Top of casing) _
9. TOP OF CASING IS1 55 FT. Above Land Surface' -7 -
-Tap of using terminated atror below land surface requires a variance In accor-
dance with 15A NCAC 2C. la _1'm�
1 C. YIELD (gpm): METHOD OF TEST
11. WATER ZONES (depth): r '
12. CHLORINATION. Tye Amount If additional space Is needed use back of form
13. CASING: /)Itryn inslaq-r'
r ^ Wall.rn�� LOCATION SKETCH
Depth Diameter eer or Whl/R. Material (Show direction and distance from at least two State
FromTooFt. _(Q'IT 'sWZ PV O1- Roads, or other map reference points)
From To Ft. '/i�.l� L
From To Ft.-1��L�dOUIILQI�i ram^
14. GROl1T: �(,1,�r
Depth ��l1r� MateriI Methods �Mrk 6rQgUrd lake "1 ' CgS�
From 0 To �S Ft. 0,one "e� �Fl�l/I�Gf //��
From To Fl. _— y©xenfree Roa-A orL
15. SCREEN: GO � e{'� _ n n���(m"y
Depth Diameter Slot Size Material O�� r J "`�' J
From To _ Ft in. _ in. I otS , TrR o L O U—FouLw ,I,(
From To —Ft. in. In. ^J JJ
From —To —Ft. In. In. kt)o, , Go (f�jx-tmAe ( 5 rm' )�
16. SAND/GRAVEL PACK: ��
Depth Size Material +0 e. v"1 rl J
-
From To Ft.
From To Ft.
17. REMARKS:
I DO HEREBY CERT CTED IN ACCORDANCE WITH 1SA NCAC 2C, WELL
CONSTRUCTION ST IS RECORD HAS BE.0 PROVIDED TO THE WELL OWNER.
FOR OFFICE USE 07Groundwate,Secethon
I
Oiao No: OF PERSON CONSTRUCTING THE WELL DATE
on of Water Oualiy, Groundwater Section within 30 days
Soda] No. GW-1 REV. 1Y/99

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Secllon % .3 p 2
1638 Mall Service Center - Raleigh, N.C. 27699-1636-Phone [phone] ! J
. yP ygg: 1�C(1-� �' P Cc
WELL CONSTRUCTION RECORD WELL CONTRACTOR C CERTIFICATION 4: 67T6 � 2_1q
STATE WELL CONSTRUCTION PERMIT#:
1. W ELL USE (Check Appllcabta 6ox): Residential ® Municipal ❑ Industrial
El
Recovery ❑ Heal Pump Water Injection ❑ Other n If Other, List Use:
2. WELL LOCA-
Nearest Town:
(Road N
3. OWNER
Address
of the location below)
v, County
Subdivision and Lot No.)
DAl E DRILLED
5. TOTAL DEPTH y�
6. CUTTINGS COLLECTED YES E] NO®
7. DOES WELL REPLACE EXISTING WELL? YES Q NOD
8. STATIC WATER LEVEL Below Top of Casing: FT.
(Usa -.'If Above Top of Casing)
g. TOP OF CASING IS FT. Above Land Surface'
'Top of casing terminated aVor below land surface requires a variance In accor-
dance with 1SA NCAC 2C.0118 A
10. YI,Q (gpm): �— METHOD OF TEST N iR
I it WATER ZONES (depth): 'f..1 //
02,
12. CHLORINATION Type 1 1 Tr7 Amount
13, CASING:
Wall Thickness
� -DepthL/n
.,j.,
9_Ia,% for
ar Wel edal
VC.
From l� —To FLV�!
.—
From To Ft.-,
From --To Ft
In. GROUT:
w
M
tart othod
FrFromL To
_S,
Front To Fl,
15. SCREEN:
Depth Uiarnoler
Slot Size Material
From .— To _ Ft
_ In.
_ In.
From — To _ Ft.
_ In.
_ In.
From _ To _ Ft.
_ In.
._ In.
16, SANDIGRAVEL PACK:
Depth
Size
Material
From To FI.
From To FI.
17, REMARKS:_
DRILLING LOG
From To
Agrlcultural ❑ Monitoring ❑
DEPTH
Formatlon Descdptlon
If additional space Is needed use back of form
LOCATION SKETCH ` 6J >;•tQ
(Show direction and distance from at least two Slate�
Roads, or other map reference points)
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C. WELL
CONSTRUCTION STANDARDS, AND THAT A CQ )Y OHIS A `R S BEEROVIDED TO THE WELL OWNER.
=No
DATE
SIGNATURE.OF P@RSON CONSTRUCTING THE WELL
Submit original to Division at Water Gustily, Groundwater Section within 30 days GW t nEv. 12199

North Carolina • Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section "
1636 Mail Service Center - Raleigh, N.C. 27699.163&Phone [phone] n/►
WELL CONSTRUCTION RECORD WELLCONTRACTOR: tzilflOD erg
WELL CONTRACTOR CERTIFICATI N #:CQ On "I— -
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (check Applicable Il Residential uu Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATIq N: (Show qketch of the location below)
NaarealTown: 13fe`/ f -County:
(Road Name ano NumGrs, Cormwh ry. or Sub6vlsicn and Lot
3. OWNER y
Address
City or Town
4. DATE DRILLED
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑ NOM
7. DOES WELL REPLACE EXISTING WELL? YES ❑ [�
6. STATIC WATER LEVEL Below Top of Casing:
1 (use': if Above Top of Casing)
9. TOP OF CASING IS 1, 3� Fr. Above Land Surface'
-Top of using terminated atior below land surface requires a varianu In accor-
dance with 15A NCAC 2C.0118 t h,��
10. YIELD (gpm): ~ METHOD OF TEST
11. WATER ZONES (depth):
12. CHLORINATION: Typa Amount
13. CASING: 81 p� i (
1 wall TNrkneu
Depth .�^ -o, wr�rer Sw=� V dal
From 0 Ft• b'!X
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method .t
From 0 To __aQ Ft. krtn P IN 4! TOr71(y_1lL
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft in. in.
From To Ft. in. In.
From To FL In. _— In.
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS COt
CONSTRUC=" STANDARDS. AND THAT A COPY
Quad No:
DRILLING LOG DE
- TH
From To Formation 045011990n
;z
------------
O v,
0
II additional space is needed use back of form
iOC TIO SKETCH
(Shaw direction and distance from at least two State
Roads, or other map reference Points)
2
4/),U�,
ED IN ACCORDANCE WITH 15A NCAC 2C. WELL
RECORD HAS BEEN�ROVIDED TO THE WELL OWNER.
/n_
GNATUREOF ERSONCONSTRUCTNG THE WELL
DATE
b Division of Water Quality, Gmundwater Section within 30 days OW-1 REV. 12M
Sedal No.

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
:0r.�8
N C 27699.1636•Phone[phone]
1636 Mal Service Center - Raleigh, M, r hn rC�.�" >'4--•�
WELL CONSTRUCTION RECORD WELL CONTRACTOR CERTIFICATION If: �d Ln ✓
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential R� Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATI 7p�� (Show sket h of the location below) 'j'Y n h V l !�
Nearest Town: '.r'AI'r n r / - County:
Ll rAb LYG1_l� `z� DRILLING LOG DEPTH
(Road N urroe Community, or Subdivision and Lot NoJ TO Formation Descrlplion
r
3. OWNER Q From To
Address
treat or ur0 o. 0-9 76 6
Pl`nrnS�
City or Town Sou Zip Code
4. DATE DRILLED IQ r
5. TOTAL DEPTH
S. CUTTINGS COLLECTED YES ❑ NOE
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO®
S. STATIC WATER LEVEL Below Top of Casing: FT•
I .3 5 (Use'. 8 Above Top of Casing))
3. TOP OF CASING IS FT. Above Land Surface'
'Top of using terminated at/or below land surface requires a variance In accor-
dance with 1SA NCAC 2c.0�118
10. YIELD (gpm): - METHOD OF TEST
11. WATER ZONES (depth):
12. CHLORINATION. Tynpe Amount
13. CASING: R� p11F�1/f klaws-r
wall Truduteaa
Depth r tar or • ntrFt. Material
From —To Ft. —
From To FI.
From To
Ft.
14. GROUT:
Depthss���^
Mated I
Method
0From
Y.� To �SL,_Ft.
— T!1"n"Ilr'_2oS__
From T40
Ft.
15. SCREEN:
Depth
Diameter Slot Sfzti
Material
From To
Ft _
in. _.
in.
From To
Ft.
In.
In.
From _ To
Ft.
in. _
In.
16. SAND/GRAVEL PACK:
Depth
Size
Material
From TO —FL
—
From To
Ft.
_----
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS COt
CONSTRUCTION STANDARDS, AND THAT A COPY
FOR Of
Quad No:
0
--------------
ul -,
If additional space is needed use back of form o gig..,
J
LOCATION SKETCH `
(Show direction and distance from at least two State
Roads, or other map reference points)
Fforn Ae_rLdersorulille , wept on.
}( a i L-Crfzl�CreeK T aot
AP�rox1Ylney Iz miles - Ise
cLn�euja� &C r�Wt after
I Y� -Cranny Narua CQt
ED IN ACCORDANCE WITH 15A NCAC 2C, WELL
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
0 ERSON CONSTRUCTING THE WELL DATE
of Water Quality, Groundwater Section within 30 days GW-1 REV. 12M
Serial No.

�0640
North Carolina - Department of Environment and Natural Resources - Division of Water Duality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699.1636-Pltone (919) 733-=1
�Orto
WELL CONSTRUCTION RECORD WELLCONTRACTOR: l �rinhe�Tnc�CL
WELL CONTRACTOR CERTIFICATION ll: C=
,./STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (CheckAppil"bla Box): Residential10 Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other F1 If Other, List Use:
2. WELL LOCATIO�(Show sketch of the location below) �� n 9V IVLzn I
Nearest Town: ✓r',v�4 ` d County'
(Road Name Numbom. CorrenarN ru Subdivision and Lot No.)
3. OWNER ,i5 tTe ana
Address ar
P��&Gk"
A*Sa h
" �8768
Ci r Town Y Stall Zip Code
4. DATE DRILLED
5. TOTAL DEPTH r
6. CUTTINGS COLLECTED YES ❑ NO®
7. DOES WELL REPLACE EXISTING WELL? YES F1 NOP
B. STATIC WATER LEVEL Below Top of Casing: FT.
(Use '+- k Above Top of Casing)
9. TOP OF CASING IS193 FT. Above Land Surface'
'Top of using tarmtnated stlor below land suAace requires a variance In accor-
dance with 15A NCAC 2C�.0j?s
10. YIELD (gpm): 14) METHOD OF TEST
11. WATER ZONES (depth):
12. CHLORINATION: Type Amount
13. CASING: Dy p)1YkD ins&lW
yy ll r __ r wall TniWast
Depth "Diameter or WafghVFL Material
From _S —To Ft. 10'19——
From To Ft.
From To Ft.
14. GROUT:
Depth Material bend
From .iz.— To aQ—Ft• �nCt'�iE
From To Ft.
15. SCREEN:
DRILLING LOG DEPTH
From To Formation Description
cn
Ei
..
If additional space is needed use back of lortm
LOCATION SKETCH
(Stow direction and distance from at least two State
Roads, or other map reference points)
P�Grc2eS� TI � rrvl�
Depth Diameter blot,tZe maidnarK--r-�'✓,, ,,�1_.
From To Ft in. ..._. in. T'r� Ohm 441-"^ /o "-ge .
From To Ft. in. In.
From To Ft In. In.
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF IS RECORD HAS BEE ROVIDED TO THE WELL OWNER.
[FORFFICE USE GATEad ��n,.��I� ! �S,IG�NATURE 0 ERSON CONSTRUCTING THE WELLSLU'JJodO1" 0i`rialon of Water Oualiry, Groundwater Section within 30 daysGW1 REV. 12/99. [(�•�� I�•Y�� I

L> r7(�
North Carolina - Department of Environment and Natural Resources - Division of Water Quality- Groundwater Section _, ; kV 1 :7 i 1
1636 Mail Ss"Ice Center - Raleigh, N.C. 27699-1636-Phono [phone] U �� cy k�w� / / I r „-
WELL CONSTRUCTION RECORD WELLCONTRACTOR: l [ `!\\}J\
WELL CONTRACTOR CER I ICATION #:
STATE WELL CONSTRUCTION PERMIT#:
WELL USE (Check Applicable Box): Resldentlal [�J' Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other [] It Other, List Use:
Agricultural ❑ Monitoring ❑
2. WELL LOCATIOV ((Shp�,skefch� It?g kZc�(I low)
Naarost Town: (( l` 1( CL County: l Cl
(Road Name n{1 IN b rs, o rp nl(y, p�Subdivision and Lot No.) DRILLING LOG
3. OWNER �i (%� ! i From To
Address
red Qr L e o. ) -
City or Ta,m /7 S )'I1to Zip Code
4. DATE DRILLED
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES; ❑ NO[ff
7. DOES WELL REPLACE EXISTING WELL? YES �', NOEJ
8, STATIC WATER LEVEL Below Top of Casing: ! FT.
(Use'i if Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface*
-Top of casing terminated atfor below land surface requires a variance In eysgr-I
DEPTH
Formation Descdptlon
CD
--a
r\3
dance with iSA NCAC 2C. 8 l n u;-.-
10. YIELD (gpm): METHOD TEST L9 �c,,
11, WATER ZONES (depth): 0 — R
CI+ o
12, CHLORINATION: Type If additional space is needed use back of form -
13. CASING:
Depth Diameter
From To J Ft.
From To Ft.
From To Ft.
14. GROUT:
Depth
From To —
From To _
15. SCREEN:
Wall Thickness
or Welght/Ft. Material
Mato la Moll
FL .�Ll
Ft.
Depth Diameter
From —To—Ft— in.
From —_ To _ Ft. _ In.
From __ To _ FI. _ In.
16. SAND/GRAVEL PACK:
Depth Size
From To FI..
From To Ft. .
17. REMARKS:
Slot Slz© Material
In.
In.
In.
Malarial
LOCATION SKETCH
(Show direction and distance from at least two Stale
/Roads, or other map reference points)
J
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 16A NCAC 2C, W ELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HA EEN PROVIDE TO THE WELL OWNER.
FOR OFFICE USE ONLY ��
puad Na
SIGNM7U OF P SON CON UCTING THE WELL OAT
Submit original to DIvL•Icn of Water Quality, undwater Section Wlihin 30 days GNf-I REV. 12/99
Serial Na.

i9 784
Nonh Carolina - Department of Environment and Natural Resources -Division of Water Quality •Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: &
WELLCONTRAC -- TFI ATION0:LII J
STATE WELL CONSTRUCTION PERMIT#:
WELL USE (Check Applicable Box): Residential!) Munlcipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other [] II Other, List Use:
2. WELL LOCATION'
how sket 1 oI he loc lion below)
-� L 1, l / Lill I Ci
dJl LCC
Nearest Town:
County:
�'
(Road Name No
-�j
be/�a Co
—
u , arpdivisiofl and L l No
• DEPTH
DRILLING LOG
Formation Description
. t/
i/
From To
3. OWNER
Address
/
zip Code -
city or Town
-
4. DATE DRILLED�G-/,_�, _
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑ NOQ -
7. DOES WELL REPLACE EXISTING WELL? YES [-� NO�.
B. STATIC WATER LEVEL Below Top of Casing:
c�. FT.
I (Use'✓ II Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface'
lece
'Top or casing terminated Wor below land surrequires a var! ce In sc
dance with 15A NCAC 2C ffli �C �(✓I��
10. YIELD (gpm): METHOt4QF TEST
11. WATER ZONES (depth): U-IJ
12. CHLORINATION: Type Amount
13. CASING:
Wall Thickness
Depth !i
-Fl.
Diameter ar Welghl/t.
MaterialFrom�T,
From To
Ft.
From Te
F!
14. GROUT:
Depth
�p(
,pM`L1ASIab hocLL/✓<
From To
Fl,
From To
Ft,
15. SCREEN:
Depth
Diameter
Slot Sizo Material
From ._—To_
FI
_ in. _In.
From _— To —.--
Ft. _—
In. _— In.
From _—To _—FL._
In. _ In.
16. SANDIGRAVEL PACK:
Depth
Size Material
From To
—FL
—
From To
Ft.
� �ii�
tui�
� �1111111111111
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)
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 TV R RD HASB E ROVIDED TO THE WELL OWNER. — a
USE ONLY — WELL DATE U
L
FFICE v IGN TUBEOFP SONCONSTRU 1 GTHo:Submlladq!nalG !TURF Ot, for OuallC NSTRGroundwater Secllon Within 30 ayS Cw IREV. 11JB9
o.

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
249028
1636 Mail Service Center - Raleigh, N.C. 27699.1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:" /w 7` ��"�
WELL CONTRACTOR CERTIFICATION #: �
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check applicable Buz): Residential Municipal ❑ industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other If Other, List Use:
2. WELL LOCATIQN: (Show sketc of the location below)
Nearest Town: 7'%eirrn County:
3. OWNER
Address
-r.
4. DATE DRILLED 7-11-e a
5. TOTAL DEPTH 140
6. CUTTINGS COLLECTED YES EE�' NO❑
7. DOES WELL REPLACE EXISTING WELL? YES CJ NO
8. STATIC WATER LEVEL Below Top of Casing: 7-0_ FT.
(Use'+' a Above Top of Casing)
9. TOP OF CASING IS L_ 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): 4 _ METHOD OF TEST �^-�
11. WATER ZONES (depth): /-1
12. CHLORINATION: Type
13. CASING:
DRILLING LOG DEPTH
From To Formation Descip6on
Amount If additional space is needed use back of form
Wall Tnickrwss
Depth Diameter or W 11 hVFf.
From Tom Ft. T —/
From To Ft.
From To Ft.
14. GROUT:
Depth Material
From To %% Ft.
From To Ft. —
LOCATION SKETCH
Material (Show direction and distance from at least two State
Roads, or
other
map reference points)
Method
15. SCREEN:
o
=-
Depth
Diameter Slot Size
Material
ry
o
From
in. _in.
;
—To—Ft—
From To
Ft. in. —in.
I
From To
Ft. In. —in.
U
16. SAND/GRAVEL PACK:
a
_;
Depth
Size
Material
From To
Ft.
From To
Ft.
e
fl
17. REMARKS:
FOR OFFICE U pNLY
Quad No: U
Submit o
Serial No.
'FFI�E
TRUCTED IN ACCORDANCE WITH 15A "CAC 2C, WELL
F THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
JATURE OF PERSON CONSTRUCTING THE WELL DATE
Division of water Quality, Groundwater Section within 30 "Ys GW 1 Kv. 12o"

249026
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699.1636-Phone [phone]
WELL CONSTRUCTION RECORD WELLCONTRACTOR: "'1-1 �� P�r>c
WELL CONTRACTOR CERTIFICATION A:,/f/
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Chock 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) 111� ,� oit• n ir��J
Nearest Town: -�'�'S"'��'� County: ....// �
41
(Root! Name�yut0 Numbers, Community. Subdivision and lot No.) DRILLING LOG DEPTH
3. OWNER �17; � �"'7"" �� From To Fom'aSon CescripGop ,�„
Address 5' ���/
�j Creator ute o. /y
�T .tilt ir2/� /l�e, �7/ D �' f�' 6/
City or Town State Zip Code
4. DATE DRILLED
S. TOTAL DEPTH
6. CUTTINGS COLLECTED YES Q NOd
7, DOES WELL REPLACE EXISTING WELL? YES M NOkEj�
S. STATIC WATER LEVEL Below Top of Casing: r,7_ FT.
(Use': g Above Top of Cuing)
9. TOP OF CASING IS / FT. Above Land Surface.
-Top of using terminated suor below land surface requires a variance In scoot -
dance with 15A NCAC 2C.011e
10. YIELD (gpm): METHOD OF TESL L
11. WATER ZONES (depth):
12. CHLORINATION: Type Amount
13. CASING:
Wall Thickness
Depth
- Diameter or Wei ighVFt. tp9�
From
To ��
Ft. o —
From
To
Ft.
From
To
Ft.
14. GROUT:
Dept
Material Method
From
To
Ft.
From
To
Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft In. _ in.
if additional space is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least two Stale
Roads, or other map rate )
CD
ry
From _
To Ft. In. —In.
From _To
Ft. In. —
In. =^
16. SAND/GRAVEL PACK:co
-
Depth Size
Material
From
To Ft.
From
To Ft.
17. REMARKS:
c
DO HE.
¢¢�t F Yi,FIA: S WEL' W
RUCTEO IN ACCORDANCE WITH 1SA NCAC 2C, WELL
o
I
THIS RECORD HAS BEEN PROVIDED TO THE W1 U1
CONSTRUCTI�¢J�
--;;I-ell
FOR OFFICI LY DA-TE
Quad No: a TURE OF PERSON CONSTRUCTING THE WELL
Submit odgi al to iVwon of Water oualiry, Groundwater Section within 30 Cay3 GW 1 RSV 1299
Serial No. ICr.VF1'i-- SECTION
RE&� IN! OHICE

North Carolina - Department of Environment and Natural Resources - Division of Water Duality - Groundwater Section y_ 1 B 9 5 oa
1634-Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: Lee SIywS W"t LLrrll,wn 11+C.
WELL CONTRACTOR CERTIFICATION#: a3�1J
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: eu c(e in . ��� O e-c'&C
2. WELL LOCATION (Show sketch of the location below) T 1
Nearest Town: a Ar, r c ,.ti.� i n County: I l a
/i t. n_ , n s r• I I
(Road Name and or Su�divisio+ and Lot No.)
DRILLING LOG
3.
n�Niumber(s.rCommun/itty,
OWNER ll� i rt'S l nnwtvu+a+'i'�2 S
From To
Address 3 Pa. 3 •
!l 1
,
k fir eSC 2-9
<
City or Town State Zip Code
5-1-do
S rI S�
4.
DATE DRILLED
5.
6.
TOTAL DEPTH 0 tp1/+oto LCG
CUTTINGS COLLECTED YES Q NO® 20-16e Ta Fd�(P
`S 90
80 - f405
7.
DOES WELL REPLACE EXISTING WELL? YES NO['n`�
8.
STATIC WATER LEVEL Below Top of Casing: 40 FT.
11 `r (Use •.' it Above Top of Casing)
-
9.
TOP OF CASING IS FT. Above Land Surface
'Top of Casing terminated at/or below land surface requires a variance In accor.
dance with 15A NCAC 2C 0118
Liu
10.
YIELD (gpm): METHOD OF TEST Air
11.
WATER ZONES (depth):� Z10t
W lQ 330 E
DEPTH
o --
r
12. CHLORINATION: Type 44A Amount z If additional space is needed u�- bacicf f <;
13. CASING: c
Wall Thickness LOCATIONSKE7CH `
Depth A,, Diameter or WeightfFt. Material (Show direction and des.2nce I-= a. leas: tHo Scale
From—�To A0Ft. - - vJ Roads, or rrt-�rc retere points'
From To Ft. 66
From To Ft. C,_S cCti:Q tW4-, e d _
14. GROUT:
Depth Mater al Method
From _ M To S0 Ft. d' ���_
From To Ft.
15. SCREEN: IJ'4
Depth Diameter Slot Size Material
From —To—Ft— in. _ in.
From _ To Ft. in. In.
From —To Ft. in. in.
16. SAND/GRAVEL PACK: p1 (e1
From _
From
17. REMARKS:
100 HEREB
CONSTRUC
FOR OFFICE
Ouad No:
Serial No. _
Depth Size Material
To Ft.
To Ft.
clew
C mot.
21b
I!
.rya �b
G4
M+ ��
S E ONSTRUCTED IN ACCORDANCE WITH I'A W� AC 2C, VlELL
PY OF THIS RECORD HAS SEEN PROVIDED TO THE'WcU 01t%%EF..
�n
(UoI I SIGNATURE OF PEASOM CONSTRUCTING Ttfc'/vGLI Os .: £
Subf t o?al to Dnfslon of Ware* Ouality. G.or*✓ater Se , Within ai d%TYs
_ .. G+-I irc Y. t_tf
WMA

Noah Carolina - Department of Environment and Natural Resources - Division or Water Quality - Groundwater Secuon , i 9216
16[16 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone] r--
WELL CONSTRUCTION RECORD WELLCONTRACTOR: n Bowman Well Dri 11 ingr Tnr-
WELL CONTRACTOR CERTIFICATION #: 2809
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) Transvlvania
Nearest Town: Rrava H County: —
Valley View Estates (Jeter Mtn. Rd)
(Road Name and Numbers. ComrnuNN. or Subdivision and Lot No.)
3, OWNER Glenn WAedy —
Address P.O. Box 939
Vent or u a o.
City or own Stan tip Code
4, DATEDRILLEO 9/08/00
5. TOTAL DEPTH 520 r
6. CUTTINGS COLLECTED YES 0 NO®
7. DOES WELL REPLACE EXISTING WELL? YES NO®
8. STATIC WATER LEVEL Below Top of Casing: 42()_ FT.
(UM': a Above Top of Casing)
9, TOP OF CASING IS_1 - 4___ FT. Above Land Surface*
-Tc p of casing terminated sVor below land surtus requires s variance In accor-
dance with 15A NCAC 2C.011e
10. YIELD (gpm): 1 METHOD OF TEST rgta3zy :._r-
11. WATER ZONES (depth): 480'
.2
CHLORINATION: Type tabletAmountA
13
CASING:
Wall Thickmu
Depth
Diameter or WeighVFI. Material
0
32
F11.61 /8 Sch 80 PVC
From
To
From
To
Ft.
From —TO
—Ft.—
14.
GROUT:
Depth
Material Method
From _ 0 To
Ft. Concrete Gravity flow
From
To
Fl•
15.SCREEN:
Depth
Diameter Slot Size Material
From _
To _ Ft
— )n. — in
From _____
To _ Ft.—
In. — In.
From _.
To _ Fl-
— in. — in.
1(i.
SAND/GRAVEL PACK:
Depth
Size Material
From
To
Ft.
From
To
Fl,
DRILLING LOG DEPTH
From To Fomution Description
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
17. REMAHKS:
1 CO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
FOR OFFICE USE ONLY --r NATURE OF PERSON CONSTRUCTING THE WELL DATE
Ouau Na:
Submit original to Division or water Duality. Groundwater Section within 30 days GW 1 REV. 12099
Senal NO,

Nonn Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1 Q�36 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELLCONTRACTOR: n F rn;in W. 11 n ;,, rtr tnc
WELL CONTRACTOR CERTIFICATION #: 2809
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Bo:): Residential® Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other It Other, List Use:
2.
3.
Agricultural 0 Monitoring ❑
WELL LOCATIBrevard sketch of the location below)
Nearest Town:
County: Transylvania
Lot #10 Valley View Estates
(Road Name and Numbers. Community. or Subdivision and Lot No.) DRILLING LOG
OWNER Will Lin Hall From To
Address kny—
Iraol or Is o.
Ftn h n1n 287a2ZapT " C
City or Town scale
M. DATE DRILLED 9 12/00
5, TOTALDEPTH Apr
6, CUTTINGS COLLECTED YES 0 NO®
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO[�
B. STATIC WATER LEVEL Below Top of Casing: 20 FT.
(Use ,+ M Above Top of Casing)
9, TOP OF CASING IS1-4._ FT. Above Land Surface'
-Top or cuing terminated atior below And surface requires a variance In isecor-
dance with 15A NCAC 2C.0118
10. YIELD (gpm): 100+ METHOD OF TEST r.Q4ap}-a4r
1 • . WATER ZONES (depth): 320 r
DEPTH
Formation Descdpuon
12 CHLORINATION: Type tablet Amount r If additional space is needed use back of form
1s. CASING:
Wall Thickness
Depth
Diameter or Weight/Ft. Material
From n To -29 Ft.
6q/8 Eldl 08 fTe—
From To
Ft.
From To
Ft.
14. GROUT:
Depth
Material Method
From To —29— Ft.
concrete a1~a_v? ty_f1.aw
From To
Ft.
1 5. SCREEN:
Depth
Diameter Slot Size Material
From To._._
Ft
_ in. — in.
From — To —
Ft. _.—
In. _ In.
From __ To _
Ft.
_ In. _ In.
i S. SAND/GRAVEL PACK:
Depth
Size Material
From To —Ft
--
From To
Ft.
----�---
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
1
co co
17. HEMAHKJ:
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 O=USEONLY TGNATURE F PERSON CONSTRUCTING THE WELL DATE
Quad NoSubmit original to Division of Water Quality, Groundwater Section within 3 ays
GW-1 REV. 12r99
Sanal No

'onh Carolina • Department of Environment and Natural Flowurcea . Division of Water Quality • Groundwater Section ; 9217
J6 Mall Service Center • Raleigh. N.C. 2769% 1636•Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: D. Bowman well Drilling, Inc.
WELL CONTRACTOR CERTIFICATION #: 2809
rrXX,� STATE WELL CONSTRUCTION PERMIT#:
t WELL USE (Cheek Applicable sox): Residential lJ Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other. List Use:
2 WELL LOCATION: (Show sketch of the location below)
NearestTOwn: ,a"`a County'
Valley View Estates (Jeter Mtn. Rd.)
(Road Name and Numben. Convtaniy. or Subdivteidn and Lot Flo') DRILLING LOG
7 OWNER
Glenn Woody From To
Address P.O. Box 939 —
« or
Pisgah F��aaF "'� �a
zip codo
DATE DRILLED 9/04/00�
5 TOTAL DEPTH-
3 CUTTINGS COLLECTED YES❑ NO©
7 DOES WELL REPLACE EXISTING WELL? YES ❑ NO®
B. STATIC WATER LEVEL Below Top of Casing: 1 2 o FT•
(Use': Y Above TOP of CWng)
9. TOP OF CASING IS 1 • 4 FT. Above Land Surface'
Top of casing terminated el/or befew lane surface requires a variance b aeou-
d rnce with 16A NCAC 2C.01h16
1 D. YIELD (gpm): �2_ METHOD OF TEST _XjULLJZy a i r
t1. WATER ZONES (depth): 460
12. CHLORINATION: Type tablet Amount 6
13. CASING:
DEPTH
Formation Description
If additional space dad USA ack of form CO o
Dep�f�
Wall ThcnkyrwFJu MPalVeriCal
(Show direction and distance from at leas) two State
C
gl,rmrgr J CVh*V 2i U.
Roads, or other map reference points)
From
To
Ft.
From
To
F1.
From
' To
FL
14. GROUT:
Motorist Method
0
20
Ft
concrete gravity flow
From
To
From
To
Ft.
15. SCREEN:
Depth
Diameter Slot Size Material
\ 7/
�
From —To—Ft—
In. -- in•
From —
To _
Ft..
In. — In.
From __
To
FL �
In. — In
'6. SANDIGRAVELPACK:
,.
Depth
Size Material
From
To
F4
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.
ni �.
GNATURE RO# SON CONSTRUCTING THE WELL V^lc
10 Division of Weiler quality, Groundwater Section within 30 days GW_1 REV. 12M
f

North Carolina . Department of En,lronmenl and Natural Resources - Division of Water Ountiry . Ground-wn:er Secron
1636 Mall Service Center . Raleigh, IN 27699-1636 Phone [phone] r-...
WELL CONSTRUCTION RECORD WELL CONTRACTOR: EECEN l%✓-R(UctL F t n1a
WELL CONTRACTOR CERTIFICATION 0: 2C'2-Cl-
STATE WELL CONSTRUCTION PERMITM: _
I WELL USE (Check Applicable cox): Resldentlal L71 Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, Llst Use:
2. 'NEt.I, LOCAT N: Sh sket 1 of th location below)
rInarest Town County
LS 2 * 2(0 (_��1yfP I�� U .
(Road Name and�N�u\mbers. Cc rvrn or subdldslon slid Lot No 1 DRILLING LOG _ DEP I I'_
3. OWNER tl •� �I `�00P 'N From To Formallcn Descrivinn
Address %n%<n (AUN. ---
City or Town Stale Zip Code
DA i E ORiLLED
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES F NOXI
7 DOES WELL REPLACE EXISTING WELL? YES[—] NOW1
B. STATIC WATER LEVEL Below Top of Casing: FT.
(Uso'.' If Above Top of Casing)
9. TOP OF CASING ISFT. Above Land Surface'
'Top of casing terminated at/or below land surface requires a variance In eceor.
dance with 15A NCAC 2 00.,18 ,,ff —7
10. YIELD (glom): � METHOD OF TEST / 1
11. WATER ZONES (depth):
12 CHLORINATION. Type �1 Arnoun
13. CASING:
Wall Thlcknoss
,� I Depths/-� Dli f,eI r w nv-t. aledal
FronttL To 1�V-FI. 60 4 ���
From To FI.
From _-_ —_To—_—_ F1._—
I,! GROUT.
Depth M�terla Molhod
From _�_ To .22_ FL
From __ To
1-4. SCREEN:
Depth Diarneler
From To __ FI _. In.
From To FI. In.
From —To FI. In,
16 SAND/GRAVEL PACK:
Depth Slze
Frorn To Ft. --_
From To FI.
IFMARKSI
Slot Sl7e Material
In.
In.
In.
Malarial
O,
If additional space Is needed use back orYorm
LOCATION SKETCH_ O
(Show direction and distance from al least two Stale_
o pV�41
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTnUCTED 11
CCO NCE WITH 15A NCAC 2C. WELL.
CONSTnUCTION STANDAn US, AND TI IAT ACry/ICY OF IIS REC R A 8 EN P VIDED TO THE WELL OWNED
FOR OFFICE USE ONLY O
Quad No. SIGNATunE OF PilnSlb`CONSTnuc TING TIRE W2LL DATE
Subnll original to Division of Water Gustily, Omundwamr section within 30 days
GW.I nEv 12/99
SrAal No

North Carolina - Department of Environment and Natural Resources - Division of Water Ouatiry Groundwater Section r... i�166
1636 Mall Service Center Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: �P a�✓-2 (t�=cL F (n1P C'�
WELL CONTRACTOR CERTIFICATION R:
STATE WELL CONSTRUCTION PERMITN:
Industrial ❑
I WELL USE cApplicable eMunicipal
Recovery ❑ ePurnPWater Innjection ❑ Other❑ If Other, List Use'
Agrlcullural ❑ Monitoring ❑
2. tNELf. I.00AT1�`1.� gij'sk3�pU. ���oc211on below) TR&',CVL`/ Ah('
'(-7 �i f..� County. �f YJ f V J1 I 1
Naaraat TOwn1 I '�\ � / Q
�(� CtUi )L�1lV GAP Vr DRILLING LOG DEPTH
(flood Name end N.10 s. Communlly or Subdivision and Lot NO I From To Fonnallon Desulr' n:
Tfl�v� VE�
3 OWNER /�i (ail[ l--K
Address
roe or o 1/)Q
City or Town � 2�n�� Stale Zlp bode
DA-i E DRILLED e-i� iL7 Q:Z— - Ili �'7tVt1l'L
5. TOTAL DEPTH .��(L5L— _
6 CUTTINGS COLLECTED YES❑ NOW
DOES WELL REPLACE EXISTING WELL? YES 0 NO® :
e STATIC WATER LEVEL Below Top of Casing: FT. -'p----.—
(Use'.' If Above Top of Casing) -- _-`-=----
9 TOP OF CASING IS --Z— FT. Above Land Surface' 1 ''
'Top of cuing terminated eVor below land surface requlrea a ",lance In actor- —
dencewllhlSANCAC2C.0 i6
10 YIELD (gpm): METHOD OF TEST 6pm
;vATER ZONES (depth): 10 Q
ez c (y/1
12. CHLORINATION Type UTH Amount
13 CASING'
Depth
From7o
Pror„ To
lame�lor
FI.
rl.�—
Wait Thickness
dvc-
C
l., GROUT
5
If additional space is needed use back of 11C7 Tc.
LOCATION SKETCH No(
(Show direction and distance from at least two State
Roads, or ciher rnap reference points)
Dept'�l]j� lariat Mell d
To
o.?�-- rf �--
Prom `'�
From _— To
SCRFEN.
Depth
Dlarneler
From _ To _
FI In.
From _To _
FI. _ in.
From —To _—
F1. _ In.
t6 SANDIGRAVELPACK.
Depth
Size
Slot Size Malarial
In.
_ In.
in.
Flora, To rLV---
Fron, To Ft.--
- REMARKS.
Material
l .will
i DO HEREBY CERTIFY THAT THIS WELL WAS CON RUCT IN ACCORDANCE WITH 15A NCAC 2C. WELL
CONSTRUCTION STANDARDS. AND THAT A
- THI BEEN PROVIDED TO THE WELL O`A'NCP
FOR OFFICE USE ONLY Gn)E
Ovad No SIGNATURE OF PERSON CONSTRUCTING THE WELL
Svbrnit odpindl to Divblon of Were, Oualll,. Omvndwelor Secunn within 30 days ,+ PEv t2191
Sedal No

I
r Department of
lonh Carolina • Environment and Natural Resources • Division of Water Quality • Groundwater Section
_i919r3
7 0.163&Phone [phone]-=i
1636 Mail Service Center • Raleigh. N.C. 2 6e
D. Bowman Well Drilling, Inc.
WELL CONSTRUCTION RECORD WELL CONTRACTOR CERTIFICATION #:2809
STATE WELL CONSTRUCTION PERMIT#:
1 _ aldenUal ® Municipal ❑
Industrial ❑ Agricultural ❑ Monitoring
WELL USE (Check Applicable Boa): Re ❑
Recovery ❑ Heat Pump Water Injection ❑ Other If Other. List Use:
,. WELL LOCATION: (Show sketch of the location below) Transylvania
Nearest Town:
_a County:
Lot #15 Valley View Estates DEPTH
(Road Name and Numbers. Carmrity, or Subd'WW and Lot No.) DRILLING LOG
3. OWNER
Scott GOldsmi th From To Forration Description
Address
«°r 28712
city or Town Zip Code
s. DATE DR LLED 8131 / 00
5. TOTAL DEPTH 0
5. CUTTINGS COLLECTED YES ❑ NOQX
7. DOES WELL REPLACE EXISTING WELL? YES 0 NOQ
8. STATIC WATER LEVEL Below Top of Casing: 6_ FT.
(Use': M Above TOP Of Casirq)
9. TOP OF CASING IS 1 FT. Above Land Surface.
­'P of cuing tarminated Wor below land surface reptakss a vail"As In seeor•
dancewlth l6A NCAC 2C.011e rotary air
10. YIELD (gPm): -4 METHOD OFF TTFST
11. WATER ZONES (depth):
12.CHLORINATION: Type tah'1Pr Amount-6
13, CASING:
Wall Thickness
Depth Diameter or WlriphtrFt. Material
From 0 To 37 Ft.(;1 /A S�h Rn D"C
From To Ft.
CD
CD
of form
(Slow direction and distance from at least two State
Roads, or other reap reference points)
From To FL
14. GROUT:
pgPih Material Method
From 0 70 20 Ft. concrete gravity flow
From To - Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From _. To _ Ft In. — in•
From — To —Ft. __ In. — in -
From _ To _ FL _ In. — in•
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER. �J)ATE
FOR OFFICE USE ONLY SIGNATUREOF RSON CONSTRUCTING THE WELL
Ouad No:
e�yp,ryt 'rtel W Division 0 Water Ou Iy Groundwaur Section within 30 days GW.t REV. 12N9
Sepal No.

North Carolina • Depanment of Environment and Natural Resources • Division of Water Duality •Groundwater Section
2 1 G 0
1636 Mail Service Canter • Raleigh, N.C. 27699.1636•Phone [phone] I
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (crack Applicable raoa): Residential E Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other M If Other, L)st Use:
2. WELL LOCATION:_
(Show sketcr of the location below)
Nearest Town:
4• rovn, .Pn County: l �LIL_ rl
i n ANrsrnrvri i2Q-�d DRILLING LOG
3. OWNER
Address
Gly or t own
4. DATE DRILLED
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES❑ NO[n
7. DOES WELL REPLACE EXISTING WELL? YES 0 NOLrVw
6. STATIC WATER LEVEL Below Top of Casing:
(Use'+' u Above Top Of Casing)
9. TOP OF CASING IS-1- "3 FT• Above Land SuAace'
'Top of casing terminated atior below land surface requires a variance In actor -
dance with 16A #CAC 2 0"1
10. YIELD (gpm): METHOD OF TEST
11. WATER ZONES ( epth):
12. CHLORINATIO Type __L Amount
13. CASING: � � ®�7 r/[3zter
Wall Thirkmall MateriaJ
Depth r /D* tar u Wephl/Ft.
From —To Ft. Z
From To Ft.
From To FL
14. GROUT:
Depth Mate al Me
From 0 To _g&--Ft. /p
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft In. in.
From To Ft. In. In.
From To FL In. In.
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To
Agricultural ❑ Monitoring ❑
DEPTH
Fomudon Description
If additional space Is needed use back of form
n
^r`"TION SKETCH
(Show direction and distance from at least two Stale
Roads, or other map reference points)
:r
_kourL QI/l f7 6v/MPrlooy
i.3 yrntfronL
A i ll) Ord kvus e.-
From To Ft.
17. REMARKS:
I DO HEREBY d T10 Tt#�tTtt!HIS WfiLL WAS CONSTRUCTED IN ACCORDANCE WITH 15A TO
E WELL
CONSTRUCTION TMID D5, ANDTHATA COPY OF IS RECORD HAS BEEN OVIDED TO THE WELL OWNER. _ / 7'
=FOROFFICEUSEONL,,3 DATE
SIGNATURE 0✓PERSON CGNS UCTING THE WELLSubmit original to Division of Water Oualily, Groundwater section within 30 days GW_tREV•12199

Nonh Carolina • Department of Environment and Natural Resources - Division of Water Quality. Groundwater Section ; ,
' 636 Mal Service Center • Ralaigh, N.C. 27699-16366Pncne [phone] I
WELL CONSTRUCTION RECORD CONTRACTOR: IL
WELL CONTRACTOR CERTIFICATION 0:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Boa): Resldenuatl
Recovery ❑ Heat Pump Water Injection
2. WELL LOCATIO (Show
Nearest Town: CSO
3. OWNER
Address
Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Other If Other, List Use:
of the location below) l ,Q � IQ
County: �i� n. IV
W Subdivision and Lot No.)
4, DATE DRILLED2::�
5. TOTAL DEPTH J¢=�-
6, CUTTINGS COLLECTED YES ❑ NO® �p--�
7, DOES WELL REPLACE EXISTING WELL? YES ❑ N050
8, STATIC WATER LEVEL Below Top of Casing:
2 (use `; V Above Top of Casing)
1. 5
9, TOP OF CASING IS ;2FT. Above Land Surfaces
Top of using terminated Wor below land surface requires A variance In actor•
d,mce with 15A NCAC 2C.0118
13. YIELD (gpm): METHOD OF TEST —
11. WATER ZONES (depth):
12. CHLORINATION: Type Amount
13. CASING: -4 6 puny
J Wall ThIOM"
Depth Diameter or WeighVFIL Material
From 0 To Ft. L 119 -1— �
From To Fl.
From To FL
14. GROUT:
Depth Material Method
From J0 To QQ Ft. pnnRratC From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
DRILLIOC'— DEPTH
From To Formation Description
0
cn
--------------
lDr;—
rn
II addidorld space B needed use back of lom(u
n
l OCATION SKETS'd
(Show direction and distance from at least two State
Roads, or other map reference points) _
C ra.b ereei, P0ad
1k h.,/ 4o row of �&LC zrx�s a2
IL ranee has
o erz �roa qa L' fttz noc- "I l bO� rids
P(('5h.o, 70J1S Farm`
From
—To—Ft—
in. __
in.
From
_To
—Ft.
In.
In.
From __
To
— FL
In. __
in.
16, SAND/GRAVEL PACK:
Depth Size Material
From To Ft, 1'
From To Ft.
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTR TED IN ACCORDANCE ITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY IS RECOR HAS BEE OVIDED TO THE WELL OW
FOR OFFICE USE ONLY DAT
Wad No: SIGNATURE PERSON CON UCTING THE WELL
Submit original Do Division of water Duality. Groundwater Section within 30 days GW4 REV. 12m
Serial No.

North Carolina • Department of Environment and Natural Resources • Division of Water Quality . Groundwater Section
1.'7061
1636 Mail Service Center • Raleigh, N.C. 27699.1636-Phone (919) 733'3221
'NELL CONSTRUCTION RECORD WELL CONTRACTOR •CERTIFICATION
STATE WELL CONSTRUCTION PERMIT#:
WELL USE (check Applicable Box): Residential WJ Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
,:. WELL LOCATION: (Show sk?tch of the location belo�uny T n nsy Iv Yu Q
(Road Name and NUrrlbare, mrarnitylor Subdivision and Lot
3. OWNER
Address
Ciy or Town :a+a -• ----
4. DATE DRILLED .Y/_6rLLQLL-
5. TOTAL DEPTH K L
e. CUTTINGS COLLECTED YES ❑ NO®
7. DOES WELL REPLACE EXISTING WELL? YES O NOM
F'f
8. STATIC WATER LEVEL Below Top of Casing:
2 (Up •+' a Above Top of Casing)
9. TOP OF CASING ISl 3 3 FT. Above Land Surface
•'rop of using terminated atior below land surface requires a variance In accor-
dance lSA NCAc 2c I
10. YIELD
METHOD OF TEST T meted
10. YIELD (gpm):
11. WATER ZONES (depth):
12. CHLORINATION:%Typne ____,_Amount
13. CASING: puno In er
J wau Thickness
r-, Depth Diameter or W^ e' MIFL
FromTo SO (1112 5L1J$�1
From To Ft•
From To FL
14. GROUT:
Depth Material Method
/1I
From SG.— To 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, SAND/GRAVEL PACK:
DRILLII DEPTH
From To Formation Description
CD
O m
0
0
II additional apace B needed use back of form
t nrATION SKETSJi
(Show direction and distance from at least two State
Roads, or other map reference points) I %8
t2©swLn � I -to
-
Tus befvr� (R2L ,ion- LLc.rr-L
eF� -�rc, read-30
alrxo�� -b end -burn onto
i1h1° bane- -
n0
PYdP�� iS
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 / O�
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS BECORD HAS BEEN PROVID TO THE WELL OWNER. O
FOR
Quad No: OFFICE USE ONLY DATE OF SIG NA RE PER CONSTRUCTING THE WELL
Submit original to Division of Water Quality. Groundwater Section within 30 days GW.1 REV. 171"
Serial No.

North Carolina • Department of Environment and Natural Resources •Division of Water Quality -Groundwater Section 1 t1
1636 Mail Service Center • Ralaigh, N.C. 27699-1636-Prone (919) 733.=1 �`�''�"'y`�T I r
WELL CONSTRUCTION RECORD WELL CONTRACTOR CERTIFICATION #:.
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Chock Applicable 6oa): Residentiallz/ Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other M If Other, Ust Use:
2. WELL LOCATION: (Show sketch of the location below) Tn r1 el ��O ((�(
R J P11 n r — County.
Nearest Town: _a ^
3. OWNER
Address
La o.1 DRILLING LOG DEPTH
) ) -- From To Fonrrtlon Desulplion
City or Town ��jj --11 a,an -
.i. DATE DRILLED
5. TOTAL DEPTH _qD �
ii. CUTTINGS COLLECTED YES[:) NO[a
r. DOES WELL REPLACE EXISTING WELL? YES ❑ FN"fO®
3. STATIC WATER LEVEL Below Top of Casing:
(Use': u Above Top a Casing)
9. TOP OF CASING IS► 33 FT. Above Land Surface'
'Top of using terminated atlor below land surface requires a variance In accor-
dance with 15A NCAC 2C 11a
10. YIELD (gpm): METHOD OF TEST
11. WATER ZONES (depth):
12. CHLORINATION: Type Amount
13. CASING: 14 6y Fury insk&'�
I 1 Wap Thickness
Depth piernoter or weighVFL IAalerfal
From G To Q— Ft. If Sp221
From To
Ft.
From To
FL
14. GROUT:
Depth
Material
Method
From 0 To -7.0-FL
awnrro{-e_
From To
Ft.
_---
'15. SCREEN:
Depth
Diameter Slot Size
Material
From To
Ft —_.
in. __.
in.
From To
Ft.
In.
In.
From To
FL
In.
In.
16. SAND/GRAVEL PACK:
Depth
Size
Material
From To
Ft.
f:
o -
1 --
If additional space Is needed use back of form= 2
LOCATION SKETCH
(Show direction and distance from at least two Stale
Roads, or other reap reference points)
Sep"ct • I -�I Lo+ a R A
��lcSK2 en_-er.=
J! . 'Z7b SO►, k �6 CtJhr s
��QIe
I�V15fbn• �tfSk
c�
leI�L i rl_tD �,LI Cl branch- - Lc;�: is
f��he endLh�e o(-f?�
1 4 `"
From To Ft.
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND JH�T, A4,OPY OF THIS ECORO HAS BEEN PROr ED TO THE WELL OWNER. O I
_21
FOR OFFICE USE ONLY D TE
Quad No:
SIGNATURE OF PER CONSTRUCTING THE WELL
Qu
Submit original to Division or Water Quality. Groundwater Section within 30 days GW4 REV. 12199
Serial No.

North Carolina • Department of Environment and Natural Resources •Division of Water Quality •Groundwater Section 1'706
1636 Mal Service Center - Raleigh, N.C. 27699.1636•Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
ELL CONTRACTOR CERTIFICATION#:.
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Bea): Residential [Er Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, Ust Use:
2. WELL LOCATI01(Show sketch of the location below) �� 1rIVa n is
Nearest Tow I(Ird County' —f
( Name end N re, CommuNb, or Subdv wn and Lot
3. OWNER T i C J .rnml Asheo
Address pox
.3. DATE DRILLED �r
5. TOTAL DEPTH
d. CUTTINGS COLLECTED YES ❑ NO® rr���-ll
I. DOES WELL REPLACE EXISTING WELL? YES ❑ NO[K]
d. STATIC WATER LEVEL Below Top of Casing:
(Use': d Above Top of Casing)
9. TOP OF CASING IS l • 33 FT. Above Land Surface'
'Top of using terminated atlor below land sumac, requires a variance In accor-
dancewldt 1SA NCAC 2C.018 METHOD OFTEST
-limeI
10. YIELD (gpm): �—
11. WATER ZONES (depth):
12. CHLORINATION: TYPOAmounnl
13. CASING: i� y � 'C1�Lt
WSY Thickness
Depth D',We�ghVF4
Material
From —To 567 Ft• /�..�-.- e2111'S�--1,
From To Fl•
From To Fl•
14. GROUT:
Depth �M�al�a�rl Method_
From O To Ft- s.dllJ5c=5:Ls�— 1}EHJlL"�
From To Ft.
15. SCREEN:
DRILLIR NG__ L� DEPTH
From To Formation DesMption
0
rn
-------------
cn
o -
�� —
II additional space Is needed use back of form `
t nrartON SKETCH ,
(Show direction and distance from at least Iwo State
Roads, or other map reference points)
FrorK Brevo-r& >-L� h use
e�� 0l2 L do- I..OOP
bye (se�. Ga
she v, G� I-LDf OF
(lJell
Depth Diameter Slot Size Matenal
From To Ft in. __ In. 11 r�l 17r1 it G;il 1
From To Ft in In. �O IjL ertj of k-G�e.
From To FL In. In.
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft,
From To Ft.
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL `^ 1
CONSTRUCTION STANDARDS. AND THAT A COPY OF THIS RECORD HAS BEEN PR�tlf�ED TO THE WELL OWN
ER./D U U
�i v — DATE
FOR OFFICE USE ONLY IL'SIGNATUREOFPER NCONSTRUCTINGTHEWELL
Quad NO: Submit original to Division of water Ousliry. Groundwater Section within 30 days
GW1 REV. 12199
SOU No.

North Carolina - Department of Environment and Natural Resources . Division of Water Quality - Groundwater Section � O
1636 Marl Service Canter - Raleigh, N.C. 27699.1636-Phona [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR CERTIFICATION M:-
STATE WELL CONSTRUCTION PERMITi1:
/ l ❑ Agricultural El Monitoring LJ
1. WELL USE (Check Applicable, sox): Residential Lh Municipal ❑ Industria
Recovery ❑ Heat Pump Water Injection ❑ Other rl If Other, Usl Use:
2. WELL LOCATIONf(Sh�ow sketch of the location below) —r-:�n S V VQ,n_(�
— County.
Nearest Town::..
0� —(
City or Town
4, DATE DRILLED
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑
NO
NO
7. DOES WELL REPLACE EXISTING WELL? ES ❑ �
B. STATIC WATER LEVEL Below Top of Casing:
�, (use ; ifMwvs Top of Casing)
9. TOP OF CASING ISM-- FT. Above Land Surface'
-Top of "Sing terminated over below land surface requires a variance In accor-
dance 1 NCAC 2C.9118 S�
10. (gm�--
10. YIELD (gpm): METHOD OF TEST
11. WATER ZONES (depth):
12.
CHLORINATION-
Amount
i f LS.'1ra.Ler
13.
CASING:
FF��
P'� ,,p
Depth
l �
Wall Thickness
Diameter or Weight/R. Material
yy—
To
FI.
From
From
To
Ft.
From
To
FL
14.
GROUT:
DepthMaterial
Method ,.
Q
To �-Ft•COWLn•Iro
,P01dJ3.�d
From
From
To
Ft. �—
15.
SCREEN:
Depth
Diameter Slot Size Material
From
To Ft
in. __ in.
From
To Ft.
in. In.
From
To FL
In. In. —
16.
SAND/GRAVEL PACK:
Depth
Size Material
From
To
Ft. ----�
From
To
Ft. --------_"
DRILLI� DEPTH
From To Formation Description
\ o
m
cn
It additional apace Is needed use back of K n
0
t QQATION SKETCH -
(Show direction and distance from at least two State
Roads, or other map reference points)
from 3revar6L
elm `Beh.d 4D le brti Isms
()
L.an0, OfPrc�' es) � I
tri(I,2, mod- on Le-L
up 0i -�D?
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 THI RECORD HAS BEEN PROVIDED TO THE WELL OWNER. ! a
FOR OFFICE USE ONLY SIG TORE OF PE N CONSTRUCTING THE WELL
DATE
Quad NO: Submit original to Division of Water Ouality, Groundwater Section within 30 days GW 1 REV. 12M
Serial No.

Nonh Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section . L O (} �
9 733- 3221
1636 Mail Service Center - Raleigh, N.C. 27699.1636Phcns (91 ) I_ I
WELL CONSTRUCTION RECORD WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (ChockApplicabte Box): Resldential02/Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, Ust Use:
2. WELL LOCATIQN: (Show sketch of the location below) n Y�VQYf/Q -
Nearest Town: County: r
�nyL DEPTH
(Ran
(Road Nams d Numbers. Community. or Subd,vis+on and Lot No.) DRILLING LOG Formation Description
3. OWNER-I�LYViri * �.itf �Q s/LYYt`3_ From To
Address Or) R M 2 0
City or Town Stan `"� "'•"' - -
4. DATE DRILLED jq-ro L_
5. TOTAL DEPTH �
3. CUTTINGS COLLECTED YES ❑ NOM
1. DOES WELL REPLACE EXISTING WELL? YES NO® t
3. STATIC WATER LEVEL Below Top of Casing: FT•
(use •: 0 Above Top of Casing) r _
3. TOP OF CASING IS3 FT. Above (and Surface' _-
"Top of "sing tarminated avor below land surface requires a varlencs In actor. �O — - -
,lance with 1SA NCAC 2C .011a
10. YIELD (gpm): I;?- METHOD OF TEST _/ r 29J ry
11. WATER ZONES (depth):
12. CHLORINATION: Type Amount If additional space Is needed use back of form
13. CASING: Z� QL �L(/y /I29t&Uer LOCATION —SKETCH—
JJ Wall TNckness
Depth PwIn�eiter or WeighVFL nMateerw (Show direction and distance from at least two State
From To � Ft. 61 o--•- �' ..- Roads, or other map reference points) / ere , l
From To Fl. 61tE. io C'rab G'rt!c>L �oa� /17 miles
From To FL po,,,A -)Lp h6Qrt/ /�
14. GROUT: tit!- � e /7 kl /!2 � P lr✓� ..
Depth Mate al 211 x a . � iU'P.s'OG>g ' /0 Sz<CLy �!
From � To � Ft. �d— �NC - /V r� Cj /� .�/iLJ.� �-
From To Ft, (V raye- a 0 / v (Ta GL!
,15. SCREEN: J/ �� _ /_ J � e le-9 /
Depth Diameter Slot Size Material (Jt wt �``
From To Ft in. _in. h,! (/e�%lr7
From To Ft. In. In. s I �� ��� �f! l /�/ Ue .
From To FL In. In.
'16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft
From To Ft.
7. REMARKS
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL —t
CONSTRUCTION STANDARDS, AND THAT A COPY OF THI ECORD HAS BEEN PRO DED TO THE WELL OWNER. o !J
tom✓
FOR OFFICE USE ONLY 6 DA E
Quad No: SIGNATURE OF PE N CONSTRUCTING THE WELL
Submit original W Division of Water Quality. Groundwater Section within 30 days GW1 REV. 12199
Sarlat No.

r4,.nh Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section (_ 8 4 8 7
1636 Mail Service Center - Raleigh, N.C. 27699.1636-Phone [phone]
V/ELL CONSTRUCTION RECORD WELLCONTRACTOR•CERTIFIRc),V N#: man WeJ-J�- +-c TnC.
2809
STATE WELL CONSTRUCTION PERMIT#:
1, WELL USE (check Applicable 6oa): Residential ® Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ It Other, List Use:
Agricultural ❑ Monitoring ❑
2. WELL LOCATION: (Show sketch of the location below) Transylvania
Nearest Town: Brevard County:
Crab Creek Road Lot #1
(Road Name and Numbers, Community, or subdivision and Lot No.) DRILLING LOG
v_.^..i a nn R„mhp
3. OWNER From To
Address 1002 Bales Chapel Road —
traet
Jamestown C 27282 —
Cily or Town staff Lp CoOe —
4 DATEDRILLED 7/7/00
5. TOTAL DEPTH 200 r �? c�
6 CUTTINGS COLLECTED YESQ NO®
7 DOES WELL REPLACE EXISTING WELL? YES 0 NO®
8 STATIC WATER LEVEL Below Top of Casing: FT• 1
(Use'+' 0 Above Top of Casing)
9 TOP OF CASING IS 1 - 4 FT• Above Land Surface'
'1 op of cuing terminated aUor below lend surface requires a vulenq In actor• _ _ --
d.mce with 15A NCAC 2C .011a
1 ). YIELD (gpm): A METHOD OF TEST ��... •• -� _�
11 . WATER ZONES (depth): 1 Rflr - - CO r�
12 CriLORINATION:
13. CASING:
DEPTH
Formabon Descnption
Type to h 1 Pt c Amount 6 If additional space is needed use back of form
wall Thickness
Depth
Diameter
or Weighm. Material
0
110
Ft. 6 1
Ssh—La PYG—
From
To
From
To
Fl.
From
To
FL
14 GROUT:
LOCATION SKETCH
(show direction and distance from at least two State
Roads, or other map reference points)
Depth Material Method
From n_To 20 Ft. rnnr� P+P�rh�*a {low
From To FI•
15.SCREEN:
Depth Diameter Slot Size Material
From To _ Ft _ In. _ in.
From To _— Fl. — In, — in.
From _To _. Ft. — In. —In..
6. SAND/GRAVEL PACK:
Depth Size Material
From To Ft. -
From To F1'
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELLT AAS CONSTCOPY OFRUCTED IN T ACCORDANCE I
THIS RECORD HAS BEENROVI ED TO THE WELL OWN� R.
CONSTRUCTION T 7 / v /&
FOR OFFICE USE TURF OF OERSON CONSTRUCTING THE WELL
DATE
ouaa Na. skgmit o 01 vision or water Duality. Groundwater Section within 30 days
;,. �` �;�..� GW1 REV. iMll
$endl No.

North Carolina - Department of Environment and Natural Resources - Division of Water Quality Groundwater Section 1704 1
1636 Mail Service Center- Raleigh, N.C.27699.1636-Phone [phone] �hrlti lUnherToc��or' a,—
WELL CONSTRUCTION RECORD WELL CONTRACTOR: �n
WELL CONTRACTOR CERTIFICATI N A: a00
ll
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residen8al[ff� Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below) -rn no.r/.rnn
Nearest Town: t'e %bSCQ.u1/r�A County:
1 n �__ r
(Road Name and Numb rs, Conrnuniry. or Subdivision and Lot
3. OWNER Tr a deUIICQ'412 �
�4.r�
R Address � I rx 343
City or Town z r/_ nn Zip Code
4. DATE DRILLED=._i,,.?5
5. TOTAL DEPTH �(
6. CUTTINGS COLLECTED YES ❑ NOM
7. DOES WELL REPLACE EXISTING WELL? YES [n NOr-1
8. STATIC WATER LEVEL Below Top of Casing: FT•
(Use'+' 0 Above Top of Casing)
9. TOP OF CASING IS ) 133 FT. Above Land Surface'
-Top of using terminated at/or below land surface requires a variance In accor-
dance with 15A NC AC 2C .011a
10. YIELD (gpm): Ja-- METHOD OF TEST J
11. WATER ZONES (depth):
12. CHLORINATIO Type
Amount
13. CASING:
6y
nU� ///Sayer
Depth'1�
r wall TNcknoss
D' tar Weight/Ft. Material
Df2 Z I V
To A
Ft.
From
From
To
Ft.
From
To
FL
14. GROUT:
Depth
Material M_ ethod r
From 0
To ZO
Ft. C.1121''r�e
From
To
Ft.
15. SCREEN
DRILLING LOG DEPTH
From To Formation Description
w
------------
t
-
If additional space is needed use back of form
LOCATION SKETCH
(Slow direction and distance from at least two State
Roads, or other map reference points)
FrorR- Sre\141rd qo 64w-fo KimJu ller
R / o -fa CaK Grove church anti
koaad. f oper�y Is Coc.-a-ea al
,end 6f roams �h M rid 1 42- OF
Depth Diameter slols¢e nrernuor CU�'de�aG
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:
.---- ... ...... MMAL,ne unru 4c A uRAC?C_WELL
I DO HEREBY CERTIFY THAT THIS WELL%
CONSTRUCTION STANDARDS, AND THAT
=OFFICEUSE
SIGNATURE OFFt:KWN••--
Submit original to Division of Water Quality, Groundwater Section within 30 days GW-1 REV. 12r99
I

IJonh Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section � 1. U U 3 /
1636 Mail Service Center • Raleigh, N.C. 27699-1636-Phone (919) 733.=1 I
'NELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residentialod Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
'e. WELL LOCATION: (Show sketch of the location below) I r.n n �vhla�nl�
Nearest Town: County:
C "n ire- DRILLING LOG DEPTH
(Road Namery/,W. Nu��.ro�ers,�Com'�� u�rury or Su vwon ano Lot No.)
From To Formation Description
3. OWNER
Address "SidjO DrIVP.
City or Town State 2+p Code
4. DATE DRILLED r
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES❑ NOCt
7. DOES WELL REPLACE EXISTING WELL? YES [] NOM
6, STATIC WATER LEVEL Below Top of Casing: FT.
��
(Uw'+' V Above Top of Casing)
9. TOP OF CASING IS 1,33 FT. Above Land Surface'
-i-op of "sing terminated sUor below land surface requires a variance In accor.
d race with 15A NCAC 2C_4118 I I MpA
1 D. YIELD (gpm): '-L METHOD OF TEST I 1
11. WATER ZONES (depth):
12. CHLORINATION. Type Amount
13. CASING: �. �� rimip iY,Ul`oer
!" Wall ThiCknus
Depth �D'''j"j r or WeighVFL Material
From To — Ft. (a �--
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From To 120—Ft. �h7'n0� T—rP^j
From To Ft.
15. SCREEN
fV o:.:_
If additional space is needed use back of form
LOCATION SKETSeN
(Show direction and distance from at least two State
Roads, or other map reference points) f-ro yes Ere ua-rd —
Al 976 5 Dasl eonness,�c
F, s.Turn. IG,eA A Cedes
G( fArIfCk--S D1lJiSr ZSn ,
Depth Diameter Slot Size Material
in.
From
To Ft _ in. —
In.
From
From
To _ Ft. _ in.
_To Ft. — In. — In.
I , r 0 yL
4
T/�
15. SAND/GRAVEL
PACK:
Depth Size Material
From
To Ft.
s f � �(.-d-e
A
Sac.
From
To Ft.
(✓L VYu�L
17. REMARKS
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WIT 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF IS RECORD HAS BEEN PR I ED TO THE WELL OWNER.
FOR OFFICE USE ON /
10, DA E
Quad Na �T SIGNATURE OF P SON CONSTR NG THE WELL
Submit original 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 1 ij U j 0
1636 Mail Service Center • Raleigh, N.C. 27699.1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: EME� IVEK LL)F!1-4 Ed 0F2.
WELL CONTRACTOR CERTIFICATION #: S%(o— 2-02,4-
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable eox): Residential E Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:--------r•^
2. WELL LOCAT N• (Show ske ch of the location below) --�1�Vlc f `. 1;-�-' ,2 _
Nearest Town: Countymr , ," rntc, F
Ce �- ( AUG I 8
(Road Na d mbersr Cofnni or ubdivision and Lot o.) DRILLING LOG 9 1 DEPTH
3. OWNER From To a Frornyt;on DescrryGa^
Address
City or Town le Zip Code
4. DATE DRILLED �-/q
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES Q NOE�J-
7. DOES WELL REPLACE EXISTING WELL? YES N0fq
8. STATIC WATER LEVEL Below Top of Casing: FT.
(Use '+' it Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface'
'Top of casing terminated at/or below land surface requires a variance In accor-
dance with 1SA NCAC 2C 118
10. YIELD (gpm): METHOD OF TEST A 12
11. WATER ZONES (depth):
12. CHLORINATION: Type ILI I-N Amount
13. CASING:
Wall Thickness
I
Depth"k5
kJ
9i�rV i( �l(pt, le'al
C 7
From
To
FL
From
To
Fl.
From —To
Ft.
14. GROUT:
O
Dept
M t ethod
From
To
Ft.
From
To
Ft.
15.SCREEN
Depth
Diameter
From
ToFt
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
0
r�
C7
L'
If additional space is needed use back ePaorm="`-
LOCATION SKETCH
(Show direction and distance from at least two Stag
Roads, or other map reference points)
1�I
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS,ANDTHATAC PY FTH ECQf\D HAS BEEN PROVIDED TO THE WELL(OOWNEP_
FOR OFFICE USE ONLY Cnn��ln �fI i
Quad No: SIGNATURE OF PERSON CONSTRUCTING THE WELL Ct.TE
SubrNl original to Division of Water Quality. Groundwater Section Within 30 days
Social No. Gw I FtEv. lvrr

e
North Carolina • Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section r 1 ; I CI f "I1 '...
—
3221
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone (919) 733- CONTRACTOR:
n —T�
WELL CONSTRUCTION RECORD WELL hric5nilEf IiY/.�C���-y�OttA
WELL CONTRACTOR CERTIFICATI N #: a/ /
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Chock Applicable BOX): Residential Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑/ If Other, List Use:
2. WELL LOCATION: ( S w sketch o,ftt(ppe location below)
Nearef Town: . /ip'(i— County: ��-
Rz
( sad Name n N milers. Co niry, or bdivision and Lot No.) DRILLING LOG __DEPTH�
From To Fomtaoon Description
3. OWNER
Address / Q % /
treat er��
City or Town state
4. DATE DRILLED _/
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑ NO® j r�
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO[�J r o
B. STATIC WATER LEVEL Below Top of Casing: FT. --- c rn
(use'i g Above Top of Casing)
3 FT. Above Land Surface•
9. TOP OF CASING IS � _
Top of cuing terminated at/or below land surface requires a varlance In actor-
dance with 15A NCAC 2C.0118
10. YIELD (gpm): M METHOD OF TEST S1dCLC ��
11. WATER ZONES (depth): m a
12. CHLORINATION: Typne Amount
13. CASING: ry, /)!ti-xa� L( JdaU-SR,
�7 /� - Wall Thickness
Depth Dianteter or Weight/Ft. lc-
f
From —To � Ft.
From To Ft.
From To Ft.
14 GROUT:
1
11 additional space is needed use back of for o
LOCATION SKETCH
(Show direction and distance from at least two Slate
Roads, or other map reference points)
�4j -11A7
— To
Material ��M�efthod
�1 Depth / �� //�-�•� ��
From _ Ft. Pnn�'A JELLr� J�
From To_Ft, ' " h
15. SCREEN: c
Depth Diameter Slot Sfz3 Material n ��
From To Ft in. _ in. k
From To _ Ft. in. _In. D / '4',
From _To _ Ft. in. —In.
16. SAND/GRAVEL PACK: Q /
Depth Size Material
From TO —FL —
From To Ft.-------
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF RECORD HAS BEEN PR IDED TO THE WELL OWNS. /
FOR OFFICE USE ONLY SIGNATURE OF P SON CONSTR CTING THE WELL ATE
Quad No:
Submit original to Division of Water Qualiry, Groundwater Section within 30 days GW 1 REV. 12199
Serial No.

North Carolina - Department or Environment and Natural Resources - Division of Water Oualiry. •Groundwater Section � � 47
A Y C
1636 Mail Service Center • Raleigh, N.C. 27599-1636•Phone [phone] I r V
WELL CONSTRUCTION RECORD WELLCONTRACTOR:
WELL CONTRACTOR CERTIFICATION 0:
STATE WELL CONSTRUCTION PERMIT#:
WELL USE (Check Applicable ace): Residential Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other M If Other, Ust Use:
Agricultural ❑ Monitoring ❑
2. WELL LOCATIO (Show sketch of the location below)
Nearest Town: _ County'
DRILLING LOG
(Road N N rs, ry, a SuD6vWon and tot No From To
3. OWNER
Addfess _ rc
4. DATE DRILLED
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES❑ NOF1
7. DOES WELL REPLACE EXISTING WELL? YES ❑ FTO®
8. STATIC WATER LEVEL Below Top of Casing:
I � (use': 0 Above Top of Casing)
9. TOP OF CASING IS FT, Above Land Surface'
?op of using terminated aVor below land surface requires a variance In actor-
dance with 15A NCAC 2C 0118
10. YIELD (gpm): . Y[__ METHOD OF TEST
11. WATER ZONES (depth):
12.
CHLORINATION%Type ,Amount'
��
13.
CASING:YX�
Depth
Wall Thickness
Diameter or D2hVFL Material
From• —To 2 2— Ft.
UN pV(�
From
To Fl•
From
To FL
14.
GROUT:
Depth
Material
Q
To �(L._ Ft.
dFm�
From
From
To Ft•
-------
15.
SCREEN:
Depth Diameter Slot Size Material
From
To Ft
in. —_ in.
From
To Ft.
In. — In.
From
To FL
In. In.
16.
SAND/GRAVEL PACK:
Depth
Size Material
DEPTH
Formation Description
If additional apace is needed use back of form
LOCATION SKETCH ,
(Shaw direction and distance from at least two State
Roads, or other rtaap reference Pints)
From To Ft.
From To Ft.
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15-A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF IS RECORD HAS BEEN PROVI TO THE WELL OWNER.
=OFFICEUSE DATE
SIGNATUREOFP SON CONSTRUCTING THE WELLsubmit original to Division or water Quality• Groundwater Section within 30 daysGW.1 REV. 12M

North Carolina - Depanment of Environment and Natural Resources -Division of Water Quality •Groundwater Section
1 1
1636 Mail Service Center . Raleigh, N.C. 27699.1636Phons [phone] I r
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION
/ Municipal ❑ STATE WELL CONSTRUCTION PERMIT#:
Industrial ❑ Agricultural ❑ Monitoring ❑
1. WELL USE (Check Applicable Box): Residential Lid
Recovery ❑ Heat Pump Water Injection ❑ Other rl If Other, List Use:
2. WELL LOCATION: how sketch of the location below)
Nearest Town: e r 1 A n� County:
(Road None
:3. OWNER ,T
Address
or SubdWlsion and Lot No.) DRILLING LOG
n . n ., From To
•1. DATE DRILLED
C
:i. TOTAL DEPTH
li. CUTTINGS COLLECTED YES ❑ NO®-
7. DOES WELL REPLACE EXISTING WELL? YES ❑ FNTO®
13. STATIC WATER LEVEL Below Top of Casing:
(Use': a Above TOP of Casirg)
9. TOP OF CASING IS 33 FT. Above Land Surface'
'Top of using terminated avor below land surface requires a variance In sccoa
dance with 16A NCAC 2C.0118
METHOD OF TEST
10. YIELD (gpm):
11. WATER ZONES (depth):
12. CHLORINATION: �T,lype 'A,�mou�nt, ' n,
13. CASING: /, ,(.ems �lI�yQ� /•t�'�'
/ _' Wait Thickness
Depth Pw¢wter or Wl D1�Wh�
FromTo -3•�— Ft.lsZ�—
From To Ft.
From To FL
14. GROUT:
Depth Material
Material Method
From
0,�. To Fl. A rcx r? s fit.1IQ2�
From To Ft. _---
15. SCREEN: M t en 'al
DEPTH
Fomration DesMption
0
ma
c;
tD
�
If eddidorlel space Is needed use back of form t QgATIOI SKEML
11
(Show direction and distance from at least two State
Roads, or other map reference points)
rk- ga.- 3 � a-cL ip
Depth Diameter Slot Size a ,J )
From To Ft in. __ in.
From To Ft. In. In.
From _To_ FL In. in.
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft. ---
From To Ft. ---
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL 7
CONSTRUCTION STANDARDS, AND THAT A COPY OF RECORD HAS BEEN PROVI TO THE WELL OWNER.
=No:
DATE
SIGNATURE OF PE N CONSTRUCTING THE WELL
Submit original to Division of Water Oualiry, Groundwater Section Within 30 ddye
GW1 REV. 1?/99

IJonh Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
J�2ijt 143
919 733.3221
636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone ( )
'NELL CONSTRUCTION RECORD WELLCONTRACTOR:
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable aox): Residential ad, Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other If Other, List Use:
2. WELL LOCATION: w sketch of oe location below)
Nearest Town: .�.1_PwJ/rn County:
(Road Name sad umbers, Co or Subdivision and Lot
3. OWNER //ir/i/ oii ,� �/I/if[�
Address ,P�_ .� r z a60
4. DATE DRILLED �Qo -OO
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑ NOCS�
7. DOES WELL REPLACE EXISTING WELL? YES NO[t
B. STATIC WATER LEVEL Below Top of Casing: FT.
(Use '+' V Above Top of Casing)
9. TOP OF CASING IS1 '3 FT. Above Land Surface'
-,op of using terminated at/or below land surface requires • variance In accor-
dance with lSANCAC2p.P is
1 O. YIELD (gpm): 121Z METHOD OF TEST tv�
11. WATER ZONES (depth):
12. CHLORINATION. Type Amount
13. CASING: A-hc,
Wait Tnicimss
Depth D''�"�ter or W@lghVFL Material
From —To 7 Ft.10� — sviz� l
From To Ft.
From To Ft.
14. GROUT:
DepthMaterial M�e'th'o�d,�"
From � ��1 To � Ft. D r a & Jam+ -�—
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
DRILLING G_ LOG DEPTH
From To Formation Description
r-71
If additional apace is needed use back of
LOCATION SK H
(Show direction and distance from at least two State
Roads, or other map reference points)
3xv nu Qao
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 L#ECORD HAS BEEN PROVI D TOT E WELL OWNE � /a 1 /
=OFFICEUSE SIGNATURE OF PER VN CONSTRUCTING THE WELL DA E
Submit original to Division of Water Oualiry,Groundwater Section Within 30 ay3 GW1 REV. 12r99

r • -1 :1
,_ i `s. f49
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699.1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: I
WELL CONTRACTOR CERTIFICATI N #: c2 I
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential Er Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Sy�pw sketch of the location below)
Nearest Town . , �[n�n, oi./ d. County:t�%/�
Agricultural ❑ Monitoring ❑
( oad Name afidNumbers. Compwniry, or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER eJIQAAalf Z&t ���nv)aail4j From To Formation Description
City or Town talc -zip Cede
4. DATE DRILLED
5. TOTAL DEPTH
5. CUTTINGS COLLECTED YES ❑ NO[n
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO®
B. STATIC WATER LEVEL Below Top of Casing: FT.
(Use -+' II Above Top of Casing)
9. TOP OF CASING IS l_ 33__ 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): —1j­ METHOD OF TEST
11. WATER ZONES (depth):
12. CHLORINATION: Type Amount
13. CASING: 'i` 4 a.. ,(/a;/.t7LQQf�
(/ Wall TNdmess
Depth b Diameter . V�
From To — Ft. `� SW21
From To Ft.
From To FL
14. GROUT:
Depth Material Method
From 0 To 90_ Ft. 110n��-�'
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
tj
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)
�2 i�f c Quoit 4�k
02 zw �Iajttaf . ?mco) . JbAt�
It
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 TH RECORD HAS N P IDED TO THE WELL OWN 9. ` r
FOR OFFICE USE ONLY WE / 1
SIGNATURE OF PER3�0N CONSTRUCTING THE WELL DATE
Quad No:
Submit original to Division of Water Oualiry, Groundwater Section within 30 days GW 1 REV. 12199
Serial No. -

North Carolina . Department of Environment and Natural Resources •Division of Water Quality • Groundwater Section1 t 1 5
1636 Marl Service Center • Raleigh, N.C. 27699.1636-Phone (919) 7M-3221 r
WELL CONSTRUCTION RECORD WELL CONTRACTOR CERTIFICATION 0:
STATE WELL CONSTRUCTION PERMIT#:
,1. WELL USE (Check Applicable sea): Residential 211� Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring Li
Recovery ❑ Heat Pump Water Injection ❑ Other If Other, Llst Use:
>. WELL LOCATION: (Show sketch of the location below) n AJj//�/>LiQJ
Nears To n: i County:
�1 r7i�dyJ DRILLING LOG DEPTH
(Road None and Numoan. Comn+Nty. or SubdwWon and Lot No.) --�'— From To Formation Description
;I. OWNER
Address /, 0 �9�
City or Town h Stale
.i. DATE DRILLED / -)
;i. TOTAL DEPTH 0 r
fi. CUTTINGS COLLECTED YES ❑ NO® ,y.,
7. DOES WELL REPLACE EXISTING WELL? YES ❑ FT.
El. STATIC WATER LEVEL Below Top of Casing:
(Use': a Above Top of Casing)
;i. TOP OF CASING IS FT• Above Land Surface'
•Top of using terminated avor below land au
rface requires a�vJulanu in eewr-
1 0. YIEwithLD
1(g m): 2C. 113 METHOD OF TEST 21MUd —
10. YIELD (qpm):
1 1. WATER ZONES (depth):
12. CHLORINATION:�Typa
13, CASING: /�/'
Well Thickness
Depth D'uygetar aW�e'q�nVA. P J�
From --To Ft. Y12.�
From To Ft.
From To FL
' 4. GROUT: Depth Material Method
From 0— To Q0-Ft.
From To Ft.
15. SCREEN:
If additional space is needed use back of form a
t nrATION SKETCH ,
(Show direction and distance from at least two State
Roads, or other map reference points)
le 4/ ix�_ ,�
, 7� E�
oeW�
Depth Diameter Slot Size Matenal �(A
From To Ft in. In.
From To Ft. In. In.
From To Ft In.
'16. SAND/GRAVEL PACK:
Depth Size Material
From To FL From To Ft.
' 7. 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 PROVJDED THE WELL OWNER. �/
FOR OFFICE USE ONLY 'DATE
Quad No: SIGNATURE OF P SON CUNSTRU NG THE WELL
Submit original to Division of water Quality, Groundwater Section within 30 days GW.1 REV. 121"
Serial No.

G
Vonh Carolina - Department of Environment and Natural Resources - Division or Water Quality - Groundwater Section r
1636 Mall Service Center - Raleigh, N.C. 27699.1636•Phone [phone] rt I 2 14 0 6 0
'NELL CONSTRUCTION RECORD WELL CONTRACTOR: 11 I1
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMIT#:/
1. WELL USE (Check Applicable Box): Residential T Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other If Other, List Use:
?. WELL LOCATIO Show sketch pf the location below)
Nearest Town: �0// County:
�jFiO14Nnd Numbers, 'ty, or Subdivision and Lot No.)
DRILLING LOG DEPTH
3. OWNER `L
/')'1 n n 0AL-) From To Formation Description
Address L. k
4. DATE DRILLED
5. TOTAL DEPTH �
6. CUTTINGS COLLECTED YES ❑ NOM
7. DOES WELL REPLACE EXISTING WELL? YES NO®
6. STATIC WATER LEVEL Below Top of Casing: FT.
(Use'.' 9 Above Top of Casing)
9. TOP OF CASING IS 933 FT. Above Land Surface
Top of casing terminated Wor below land surface requires a varlance In accor-
dance with 15ANCAC2C 11a
10. YIELD (gpm): J(L METHOD OF TEST
11. WATER ZONES (depth):
12. CHLORINATION: % Type Amount
13. CASING: y �j� ��� y� *;/ t�
Wall Thickness
Depth Diameter or WelghtffL tercel
From m Ft.�Ln—
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From Q To 2n Fl. eMCA OIL A=y
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From _ To _ Ft _ in. _. in.
From _ To Ft. _ In. In.
F To Ft In. — In.
If additional space is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least two Stale
Roads, or other map reference points)
rom
1 S. 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 4TH15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF IS RECORD HAS BEEN OVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY 11 it"lI I
Quad No:
2 t _ . .SIGNATURE PERSON CONSTRUCTING THE WELL DATE
'- Submit original to Division of Water Quality, Groundwater Section within 30 days GW1 REV. 12/99
Sedal No. - { .

North Carolina - Department of Environment and Natural Resources - Division or Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699.1636-Phone [phone] 214061
WELL CONSTRUCTION RECORD WELLCONTRACTOR: QnhPl fi rF�e�
WELL CONTRACTOR CERTIFICATION 0:
STATE WELL CONSTRUCTION PERMIT#:
.I. WELL USE (check Applicable Box): Residential Er Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION;,6Show sketch of the location below)
Nearest Town:
Qnt ALpI County:
(Road Nana dean Numo.rs.
;l. OWNER "
Agricultural ❑ Monitoring ❑
and Lot No.) DRILLING LOG DEPTH
/H M J From To Formation Description
City or Town aloe
A. DATEDRILLED -00
B. TOTAL DEPTH r
E. CUTTINGS COLLECTED YES[:] NO[Z]
7. DOES WELL REPLACE EXISTING WELL? YES NOP
E. STATIC WATER LEVEL Below Top of Casing: FT.
(Use'i a Above Top of Casing)
G. TOP OF CASING IS r 33' FT. Above Land Surface'
'fop of casing terminated at/or below land surface requlrsa a variance In accor-
dance with 15A NCAC 29 �plia
10. YIELD (gpm): 12.?-- METHOD OF TES1G,
11. WATER ZONES (depth):
12.
CHLORINATION: Type Amount
13.
CASING:
Wall TNdkrteu
Depth / 2 �'�`��tar
or We' hVFL Material
p
From �To �L Ft. 'L•a--
From To Ft.
From To Ft.
14.
GROUT:
Depth �M,aterlI Method ,
_g
From _iz__ To s2Q— Ft. S'�n`,`��n
From To Fl•
15.
SCREEN:
Depth Diameter Slot Size Material
From ._ To .— Ft — in.
— in•
From _To Ft. _ in.
_In.
From _ To _ Ft. in.
—In.
16.
SAND/GRAVEL PACK:
Depth Size
Material
If additional space is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least two Slate
Roads, or other tr pre w- r
r
9-.t Ox
. 2
I,� �- rxA�e
-
From To Ft.
From To Ft.
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL i
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVff TO THE WELL OWNER.
FOR OFFICE USE: p1YLY DATE
Quad i O' . A `. p SIGNATURE OF PERSO CONSTRUCTING THE WELL
i Submit original to Division or Water Quality, Groundwater Section within 30 days
GW4 REV. 12199
Serial No.
P•

lgonh Carolina - Department of Environment and Natural Resources - Division of Water Duality - Groundwater Section C- 1 `3 0 6
636 Mail Service Center - Raleigh, N.C. 27699.1636-Phone [phone] I r
'NELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable sox): Residential 011� Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION :.Show sketch of the location belo�uny
NaarestTQwn: L' r Np{i'_Cr'-cL
A[r:�(( DEPTH
(Road N and Numbers, Co um . or Subdivision and tot No.) DRILLING LOG
3. OWNER r /"y7 From To Formation Description
Address ,0/,L/l . N!/I�0/7 , n.r.M . /%/i/J/ .P
City or Town blare
4. DATE DRILLED
5. TOTAL DEPTH r
6. CUTTINGS COLLECTED YES ❑ NO®
7. DOES WELL REPLACE EXISTING WELL? YES NO®
8, STATIC WATER LEVEL Below Top of Casing: FT.
(Use'+' V Above Top o1 Casing)
9. TOP OF CASING IS I , 33 FT. Above Land Surface'
Top of casing terminated at/or below land surface requires a varlance In accor-
d rnce with 16A NCAC 2C .otte
10. YIELD (gpm): 7_ METHOD OF TEST 4;2
11. WATER ZONES (depth):
12. CHLORINATION:l -Type Amount
13. CASING: yr �tyma��;G
Wall Thickwu
Depth orWf�'
al'ghVF't. Material
F om�—To � Ft.''star �-
If additional space is needed use back of form
T�
LOCATION SKE
(Show direction and distance from at least two State
Roads, or other map reference points)
r
From To Ft. / / / 1 D
.From To Ft. Uv
14. GROUT:
Depth Material MethodOGc/
From 0_ To D Ft. 0 Wn U ° fi[
From To Ft. �J
15. SCREEN:
Depth Diameter Slot Size Material
From To _ Ft _ in. — In.
From _To Ft.— in. In.
From —To Ft. In. — In.
16. SAND/GRAVEL PACK:
Depth Size Material
From To —Ft. -
From To Ft.
17. REMARKS:
I DO HEREBY CERTIFY -THAT Ti11S WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION AND THAT A COPY OF IS RECORD HAS BEEN P IDED TO THE WELL OWNER.
FOR OFFICE USS ONLY —= DATE
qA Pr' '1 SIGNATURE OF PERSON CONSTRUCTING THE WELL
Quad No: F1 U :
Submit original to Division of Water Quality, Gmundwater Section Within 30 days GW 1 REV. 12r79
Serial No.

North Carolina •Department of Environment and Natural Resources •Division of Water Quality •Groundwater Section
�'14063
1636 Mail Service Center - Raleigh, N.C. 27699.1636-Phone [phone] r
WELL CONSTRUCTION RECORD WELL CONTRACTOR CERTIFICATION III:
STATE WELL CONSTRUCTION PERMIT#:
WELL USE (Check Applicable Box): Residential Ed Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
:2. WELL LOCAT N: (Show sketch of the location below) Tr
NearestTown:If2V�rd County:
(Road Name and Numbs Community, or Subdivision and Lot
3. OWNER q r
Address ► L4 n Fn irp si z
4. DATE DRILLED rli
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑ NOEJ]
DOES WELL REPLACE EXISTING WELL? YES ❑ NOM
I1. STATIC WATER LEVEL Below Top of Casing: FT.
(Use'.• 8 Above Top of Casing)
!). TOP OF CASING IS 1-53 FT. Above Land Surface'
'Top of casing terminated at/or below land surface requires a varlance In aeeor•
dance with 15A NCAC 2C .0118
10. YIELD (gpm): 49�_ METHOD OF TEST T Yy)
11. WATER ZONES (depth):
12. CHLORINATION: Type Amount
13. CASING: PjY Pump irt,56 1'e(
wall TNauroa
Depth ter or WeightIFL Material
From To � Ft. 17
From To Ft.
From To Ft.
14. GROUT:
Depth Material Metho .
From 0 To QO Ft. =91
From To Ft•
15, SCREEN:
Depth Diameter Slot Size Material
From
To
Ft
in.
— in.
From
—To
—Ft. _
In.
—In.
F m
To
Ft.
in. .—
in.
ro
16. SAND/GRAVEL PACK:
Depth Size Material
From _-- To Ft•
From To Ft. ------
17. REMARKS:
1 DO HEREBY CERTIU'TH
CONSTRUCTION sTAt�G
FOR OFFICE USE ONLY
Quad No:
Social No.
.DRILLING DEPTH
From To Formation Description
c
a
o
--ry
Ln
c�
r,p
�
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)
VrOm Br�var� , Nw . 6'' W - R On_.
J OVL ffForesk La
Clei�erlk load.
Te-
�'s4�r iRoad-
Proe�is 0r1
a.� �I �QJMe1r
R Mr 0 e n. hwd I b -Cedar {tiom>?
• gEU_yAa,j'rMTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
i1(IrL, q�pr0 IS RECORDHAnSBEJEN}yR�OVIJD/EDTOTHE WELL OWNER.
DATE
SIGNATURE OF PERSON CONSTRUCTING THE WELL
Submit original to Division or Water Quality. Groundwater Section Within 30 days Gw-1 REV. 12M

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
P.O. Box 29578 - Raleigh,N.C. 27626-0578-Phone [phone]
WELL CONSTRUCTION RECORD DRILLING CONTRACTOR: r "r Pr dwistni t0i) Y1�FrVllell+l`Wxp
DRILLER REGISTRATION #: IRh )
-,/ STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable sox): Residential LyJ Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATIch of the location below)
Nearest Town: _ f ree l rC� County: 7-rdngy [van t tom' -
(Road, Co ' ity, or Subdivisn and Lot No.)
3. OWNER tl ame.S /lAllY''{-I
ADDRESS 1,151 rf2envi tle-
tfJ.
(Street or Route No.) 719
City or Town -f Stale Zip Code
4. DATE DRILLED
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES E] NO®
7. DOES WELL REPLACE EXISTING WELL? YES [::] NOM
8. STATIC WATER LEVEL Below Top of Casing: FT.
(Use '+" if Above Top of Casing)
9. TOP OF CASING IS 1 33 FT. Above Land Surface'
Casing Terminated aUor below land surface is illegal unless a variance is issue
in accordance with 18 NCAC 20 .0118
10. YIELD (gpm): I) METHOD OF TEST rWy
11. WATER ZONES (depth):
12. CHLORINATION: Type Amount
13. CASING: by /)1t� n hsWter
Wall Thickness
Depth Dia eter or Weight/Ft. Material
From 0 To `a FL -—
From To Ft. -
From To Ft.
14. GROUT:
Depth Material Method ,
From � To Ft. bit ro *L�11' yp_d
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:
I DO HEREBY CERTIFY
CONSTRUCTION STAN
FOR OFFICE USE ONLY
Quad No:
Serial No:
Slot Size Material
0
in.
in.
in.
Material
DEPTH
From To
DRILLING LOG
Formation Descrintion
O
n _'
>a
C_n
La
Ifadditional space is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
buy. a76 - an;l drNe ord eR po-sf
�arcla� �Qd - o has+ house on
rl9ht - be.hini house. is proper.
IN ACCORDANCE WITH 15A NCAC2C, WELL
CORD HAS BEEEN PR IDED TO THE WELL OWNER. p
F CO RACTOR OR AGENT
to Division of Water Quality and copy to well owner.
GW-t REV. 1/98
Ashes

North Carolina - Department of Environment and Natural Resources - Division of VJa!er Oualiy - Groundwater Section 0 81
1636 Mail Service Center - Raleigh, N.C. 27699.1636-Phone [phone]
WELL CONSTRUCTION RECORD WELLCONTRACTOR:
WELL CONTRACTOR CERTIFICATION
STATE WELL CONSTRUCTION PERMITP:
1.
'' pp��
WELL USE (check Applicable oox): Resldentiai,n Municipal ❑
Industrial ❑ Agricultural ❑ monitoring ❑
Recovery ❑ Heat Pump 1Va;er Injection ❑ Other It
Other, List Use:
2.
WELL LOCATION: (Show sketch of the location be!o•,.)
rr L e�zrtE -
Nearest Town �' r•�U ,tit ^r Ccuny:
72nJ
- I AV-6 6xawA
(Road h'arre and D:unpp�S�^�_rs, C mmucl;y, or £cbdMs:cn and Lot No )
DRILLING LOG DEPTH
3.
OWNER&P, )Uy
From To Fcf-matlon Descdylon
Address Da.L�.'>< ;2}
C�itL3 Ifcp7
l[l=e cr rl J'J:^_To.f
(J� 28747.
4t� ,jU �J1N liC.
To ,arvay tit
�Ci;y or To,., - Stale Zip Cote
-- -
4
DATE DRILLED G^-7D-„o
5.
TOTAL DEPTH .7oJ F:
6.
CUTTINGSCOLLEC(ED YES NOD
7.
DOES WELL REPLACE EXISTING 1'/ELL? YES ❑ t10,FEj
8.
STATIC WATER LEVEL Bc!cr: Top of Casing: 112— FT.
o_
(Use'.' it Abcvo Top of Cac:n;J
O
9.
TOP OF CASING IS I FT. Abovo Land Surface'
Q-
9 n�
-Top
of casing tarmir.a:ed nHor bclow land surlaco raqulrea a variance In actor-
fT1 U
danco
r:::h 154 KCAL 2C .0 113
10.
YIELD (cpm): _ �= r.1ETHOD OF TEST
—CO
0
Fi
_
is is b_c': cI frig
12.
CHLOR: `:AT IOt:: Type _).jl -A:nounl
t
a.. .,c..� _, c:e naedeiL:e
--_--N-
13.
CASING:
--_---_---_-__
LOCA1m
r
�_.-•l �:o: c V Ft. r
o
(SF wd'. -r .. JcaS
Frc^1 To FI.
From- -To ___ Ft.
1,1.
GROUT:
Depth tt..la!�7rinl t.lethed
N
From To �_ Ft.
L
15.
From _ To Ft.
SCREEN:
-9
Iho
Uep:h Oiamaler Slet Siz^ td a:e ri al
—
From _ To PI in. _ In.
� I.� v.
From To _ FL In, In,
E
From . To FI. In. In.
16.
SAND/GRAVEL PACK:
Dep!n Size tda!arial
o
From To FL-
From To Ft.
17.
REMARKS:
I DO HEREBY CER T IFY THAT THIS VlELL ViAS CONSTRUCTED IN ACCORDANCE VlITH I 6 A NClC 2C, WELL
CONSTRUCTION STANDARDS, AND�T(HHAT AA C,rOfP�Y�OdF� TT S`RECGRD HAS BEEN PROVIDED TO THE NlELL 01"1 i
/'N,ER
FOR OFFICE USE ONLY p u��Ya� �-1 C S A V`A IJ IOC
Ouad No:__.."m,.,;,.,e,.,.>.;..SIGNA7L'RE OF PERSON CO;lSU;UC7U:G TF:[ ElL CATS
to ti] 11c bcri al o Di,is;cn of Plalcr CuaJty, Groucd,;atcr S=ct:cn within 3O day5
Sc^al No. (a C; �. G;1.1 REV. 1215"
S,

WUM
North Carolina - Department of Environment and Natural Resources - Division of Water Quality w
- Groundwater Section
�� `� q .y- �,
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone] C�
WELL CONSTRUCTION RECORD WELL CONTRACTOR: %-
WELL CONTRACTOR CERTIFICATI N #: W07
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (check Applicable Box): Residential IJ Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCA
3. OWNER
Address
of the location below) T a_ns` IN ay � a
County:
or Subdivision and Lot No.)
City or Town Were -. -----
4. DATEDRILLED6 SLS01[._
5. TOTAL DEPTH —ZQ5-21_
6. CUTTINGSCOLLECTED YES❑ NOCKL
7. DOES WELL REPLACE EXISTING WELL? YES NO[n
6. STATIC WATER LEVEL Below Top of Casing: FT.
(Use '+' it Above Top of Cuing)
9. TOP OF CASING IS 1.33 FT. Above Land Surface'
-Tap of casing terminated st/or below land surface requires a variance In accor-
dance with 15A NCAC 2C .0118 2 j 11ilf d
10. YIELD (gpm): In METHOD OF TEST
11. WATER ZONES (depth):
12.
CHLORINATION:1 Type
Amount
13.
CASING:
PuLmf t(Lst0.ue-(
1
Wall TNeWrcu
Depth
�'�r tter or Weight/Ft. Material
Ft..s¢ L sp--P2)-- - a«
From
To
From
To
Ft.
From
To
Ft.
14.
GROUT:
0
Depth
Material Method
i't• C tr)Y1PItie nntl
From
To —.?Q--
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
DRILLING LOG DEPTH
From To Formation Description
C3 _
If additional space is needed use back of form
LOCATION SKETCH O m
c')
(Show direction and distance from at least two Statdc;; o
Roads, or other map reference points)
ronL- Eye-\Urd
toy Wass-. - 2Y
ht on
c i k olkvch kAbout
1/2 Kilt° s OR rialtit - GCcress �Vm
S1ai(-kbler9 Lames.
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 R CORD HAS BEEN PROVI 0 THE WELL OWNER. 1 -)-1 /
FOR OFFICE USE ONLY DATE
Quad No: SIGNATU E O PERSON NSTRUCTING THE WELL
Submit original to Division of Water Quality, Groundwater Section Within 30 days GW 1 REV. 12199
Serial No.

212974
° �
North Carolina •Department of Environment and Natural Resources •Division of Water Quality •Groundwater Section g•Mi � P
1636 Mail Service Center • Raleigh, N.C. 27699.1636•Phone [phone] I r
WELL CONSTRUCTION RECORD 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)
1 n lC o T(O �i»r1CL(1 County:
Nearest Town: �u�.
fwirLaaLance DEPTH
(Road Name Numbers. Community. or bdnision and Lot No.) DRILLING LOG Formation :I. OWNER t '^'r am Pi' t�11YY�.II _ From To
Address
ri. DATE DRILLED (Q-19 -()0
!i. TOTAL DEPTH _. 2ML—
li. CUTTINGS COLLECTED YES ❑ NOR
7. DOES WELL REPLACE EXISTING WELL? ES 0 NOM
il. STATIC WATER LEVEL Below Top of Casing: FT.
(Use': a Above Top of Casing)
!3. TOP OF CASING IS I.33 FT. Above Land Surface*
'Top of using terminated avor below land surface requires a variance In accor-
dance with 15A NCAC 2C.otla - ' mp d
'10. YIELD (gpm): A.Q_ METHOD OF TEST
-11. WATER ZONES (depth):
o
12. CHLORINATION- Type Amount If additional space is needed use back of form
13. CASING: (, `�`' pw, e-p IO
IYLS f LOCATNSKETCH
777 l f ^ I wag TNdwaa
Depth Dianwttor or Welahvft Material (Show direction and distance from at least two State
From 0 To 01 Ft. (02 - Roads, or other map reference points)
From To Ft. t l �� (� 4 • o � g l
From To Ft. �Yl
JV nn I 1
14. GROUT: FlFl QpPrO %. oL Depth MaI Method ( ` I
From S[�_-To ��oFt•
From To Ft• T(Al I L �ntS Lf2h 2 q 0 (w
15. SCREEN:
Depth Diameter Slot Size Material On1° �` � — �r�PQYLUj Or-L
From To Ft in. in. 1 -lJ
From _ To Ft. in. In.
From To _. FL in. —In.
16. SAND/GRAVEL PACK:
Depth Size Material
From To FL
From To Ft,
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL /
CONSTRUCTION STANDARDS, AND THAT A COPY OTIS RECORD HAS BEEN PROVIDED � THE WELL OWNER /
FOR OFFICE USE ONLY DATE
Wad No: G TURE 0 ERSON CONSTRUCTING THE WELL
Submit original to Division of Water Quality. Gmundwaler Section within 30 days GW 1 REV. 17J99
Serial No.

North Carolina - Department of Environment and Natural Resources -Division of Water Oualiry - Ground.+a:er Section
?_150r7G
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELLCONTRACTOR: N v€ C
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential R Municipal ❑
Industrial ❑
Agricultural ❑ Monitoring ❑
Recovery ❑
Heat Pump Water Injection ❑ Other ❑
If Other, List Use:
2. WELL LOCATJ
ell
Show sketch of the location below)
r
Nearest Town:
c N
`p �k—"N ' Counry:
Siva
f r:
DRILLING LOG .' DEPTH
(Ro ama
dNumbers, nvn ni or Subdivision and Lot Nc.)
3. OW ER
r ,1 �>1
From To
Fonralion Descnplion
Address
City or Town Slate Zip Code
4. DATE DRILLED
S. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑ NO[]�
7. DOES WELL REPLACE EXISTING WELL? YES
S. STATIC WATER LEVEL Below Top of Casing:_ FT.
' (Use'+' it Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface*
'Top of casing terminated aVor below land surface requires a variance In accor-
dance with 16A NCAC 2C Tg118 /�
10. YIELD (gpm): �— METHOD OF TEST A) P-
11. WATER ZONES (depth):
12, CHLORINATION: Type T Amount
13, CASING:
Wall Thickness
,Depth r Diameter �`�W i�j'�Ft.. ,�epnal
From To Ft. �{ v�
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From �_ To ,(_ Ft.
From To Ft.
15.SCREEN
Depth
From —To
— Ft
From —To
—Ft.
From —To
—Ft.
16. SAND/GRAVEL PACK:
Depth
From
To
From
To
17. REMARKS:
Diameter Slot Size Material
in. _ in.
in. —in.
in. —In.
Size Material
Ft.
Ft.
.J q - a�
3
�m
N
r*rE
z
II additional space Is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
A
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A C Y THIS ORD BEEN PROVIDED TO THE WELL OWNER
FOR OFFICE USE ONLY —� �� A,9 ^ a E
Quad No'.
SIGNATURE OF PERSON CONSTRUCTING THE WELL
Ot.T
Submit original to Division of Water Oualily, Groundwater Section within 30 days GW 1 NEV 17113
Soda] No.
ti�

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]
♦r.,,..1 Q O
♦
WELL CONSTRUCTION RECORD WELLCONTRACTOR: r. rl<�TnQ12er QaL "
WELL CONTRACTOR CERTIFICATI N #: J 7
,.,( STATE WELL CONSTRUCTION PERMIT#:
,I. WELL USE (check Applicable Box): ResidentialLvJ Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATI N: hia
(Show sketch of the location below) I
N/e�arestTown: r1{l County: IrrziLsyrzlQ.
OjLt C'0.JIP- DEPTH
(Road Name end Numbers. Community, or subdivision and Lot No.) DRILLING LOG
9. OWNER / From To Formation Description
Address?.
NO
Liar.
IoeIt or outs
14
Cily OrTown state er o 2+p C+Mo
�. DATE OF b-b"oo
5. TOTAL DEPTHr--
6. CUTTINGS COLLECTED YES ❑ NOM
i'. DOES WELL REPLACE EXISTING WELL? YES NOM
E. STATIC WATER LEVEL Below Top of Casing: FT.
(Use'+' II Above Top of Cuing)
E. TOP OF CASING IS f U FT. Above Land Surface'
'fop of casing terminated at/or below land surface requires a variance In accor-
dance with 15A NCAC 2C�.911e
10. YIELD (gpm): I `& METHOD OF TESTTm d
11. WATER ZONES (depth):
12. CHLORINATION: Type Amount
13. CASING: Oy Punf iAspauer
Wall Thickness
Depth n1 Diartwter or Weight/Ft. Material
From To 3— Ft. (I'/r, �C
From To Ft.
From To Ft.
14. GROUT:
Depth M,a,,tirial Metho
From 0 To �fl—Ft. C�L(Jar-
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. �(j�12 2urrts r I
In. I-
Material
O
If additional space is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
(o�} East from Brevard k� `�ehrose -
- F&Trt R-/m Crab CreeK oL. iv Mon
Duf)or& RA. Oo -ID 0- tJ � road. �d
,d� Still -r I� OA- e��
tcJ V,e U. � GtDLoroy- 02 YYLileS.
�ar off C.Q.R.
t'eT � _
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL ^
CONSTRUCTION STANDARDS, AND THAT
FOR OFFICE USE ONLY
Quad No:
Serial No.
Submit original to Division of Water Quality, Groundwater Section within 30 days
GW1 REV. 12199

Nonh Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section �., 5'
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone] ,-/p"� id
WELL CONSTRUCTION RECORD W• ELLCONTRACTORCERTIFICATIONa'R3 t
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (check Applicable Boa): Residential C9 Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
Agricultural ❑ Monitoring ❑
2. WELL LOCATIO (Show sketo of the location below) ,(� A� n�
Nearest Own-.4 Counry: L/ .Y
n. d A �7 4 /) o of _ .Q
and
3. OWNER
Address
FM
4. DATE DRILLED LeZI 117CV0,00
5. TOTAL DEPTH T
6. CUTTINGS COLLECTED YES Q NOEL
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO�
8. STATIC WATE'R-L� Below Top of Casing: To Fi.
f- (Use'+' If Above Top of Casing)
9. TOP OF CASING ISir— FT. Above Land Surface'
'Top of casing terminated at/or below land surface requires a variance In accor-
dance with 15A NCAC 2C.9me
10. YIELD (gpm): METHOD OF TEST � O
11. WATER ZONES (depth): 0%60 Jl T
12. CHLORINATION: Type %� Amount 3
13. CASING
Wall Thickness
Depth Di me r or W� aighVF1 Material
From —To � 0— Ft. �L j�—
From To Fl.
From To Ft.
14. GROUT:
Depth r M� ate al Me od '
From �_ To �Ft. 1�C
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From To _ Ft _ in. in.
From To — Ft. in.
From To In. —In,
16. SAND/GRAVEL K:
Depth Size Material
From To F
From To Ft.
17
DRILLING LOG
From To
DEPTH
Formation Description
It additional space is needed use back of form=m
m�
LOCATION SK cn
(Show direction and distance fro at least two Sta R
Roads, or other map rate nce poi g'ep ,�•
r-ou r�
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED I CCORDANCE WITH 1 A AC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS O BEE PR O E WELL OWNER.
FOR OFFICE USE ONLY
Quad No: SIGNA RE OF PERSON CONSTRUCTING TH ELL 6ATE
Submit original to Division of Water Quality, Groundwater Section within 30 days
Serial No. GW1 REV. 12/99

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section r) `j /� O
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone] L 4 87
WELL CONSTRUCTION RECORD WELL CONTRACTOR: D Bowman 6101 1 Drilling.,Tnr
WELL CONTRACTOR CERTIFICATION #: 2809
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable sox): Residential E3 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: Brevard County: Transylvania
Mountain Meadows Lot #7
(Road Name and Numbers, Community, or Subdivision and Lot No.)
3. OWNER Frank Kelley
Address
Brevard"elor outs °28712
City or Town State Zip Code
4. DATEDRILLED 6/27/00
5. TOTALDEPTH 420'
6. CUTTINGS COLLECTED YES Q NOQX
7. DOES WELL REPLACE EXISTING WELL? YES NOQ
8. STATIC WATER LEVEL Below Top of Casing: 1 n n , FT.
(Use'+' II Above Top of Casing)
9. TOP OF CASING IS 1 .4 FT. Above Land Surface'
'Top of casing terminated atlor below land surface requires a variance In accor-
dance with 15A NCAC 2C .0118
10. YIELD (gpm): 1 1 METHOD OF TEST rQtarY a i r
11. WATER ZONES (depth): 320'
DRILLING LOG DEPTH
From To Formation Description
o
_
IV
ri,�
N
—+
12. CHLORINATION: Type tablet Amount 6 If additional space is needed use back of form
13. CASING:
Depth Diameter
From 0 To 67 Ft. 6118
From To Ft.
From To Ft.
14. GROUT:
0 Depth 20
From To Ft.
From To Ft.
15. SCREEN:
LOCATION SKETCH
Wall vThicktnneess
S 8 Ul pUC al (Show direction and distance from at least two State
Roads, or other map reference points)
Allt'�4ete gi�IPi`[y flow
Depth Diameter
From —To _ Ft in.
From — To _ Ft. _ in.
From _ To _ Ft. _ in.
16. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To Ft.
17. REMARKS:
Slot Size Material
in.
in.
in.
Material
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS .AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
2_7 oa
FOR OFFICE USEI 1G `�. ' —T
Quad No: 9t -NATURE OF P SON CONSTRUCTING THE WELL DATE
h s Submit original to Division of water Quality, Groundwater Section within 30 days
r tt j A 1(-:GW-1 REV. 12/99
Serial No. — - -

North Carolina -Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section gi t'a [" t
1636 Mail Service Center - Raleigh, N.C. 27699-163ri-Phone [phone] I r
WELL CONTRACTOR: WELL CONSTRUCTION RECORD WELL CONTRACTOR CERTIFICATION #: Q
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Boa): Residential ® Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other If Other, List Use:
;!. WELL
(Road Name and
,I. OWNER f,
Address AnAr
sketch qI the location below) �-
)�rrCounty:
_DEPTH
doaxmluniry,orSubdiv
i�r.No.)J2Y DRILLING LOG
Formation Das—
c iPGon
rA rn n 4 n
O
uryw rewn
a. DATE DRILLED k oh
5. TOTAL DEPTH ag
fi. CUTTINGS COLLECTED YES ❑ NO®
;'. DOES WELL REPLACE EXISTING WELL? YES ❑ NO®
EI. STATIC WATER LEVEL Below Top of Casing: FT.
(Use •: If Above Top of Cuing)
El. TOP OF CASING IS Q S FT. Above Land Surface'
•Top of casing terminated at/or below land surface requires a variance In accor-
dance with 15A NCAC 2C .011a .�-.� ✓:9
0. YIELD (gpm): i. METHOD OF TEST
- 1. WATER ZONES (depth):
' 2. CHLORINATION: Type Amount If additional apace Is needed use back of form
' 3. CASING: 1'tIrv, P 1056((E-4- i OCATIQ &USeH
1 wall Thickness Depth Show direction and distance from at least two Slate
From To % o f7 ter or Weight/A. Material
Ft. I " 5bre`2 Roads, or other map reference points)
From To Ft. rYo /�Y°(1Qf'--//---4V��/,, �
From To Ft.
'A. GROUT: / L � 4-in J'� V7 r%
Depth Malarial Method 1
From To ',7f1-•Ft. (r n 91Cr crG�-
From To_Ft. ihT �jn y1 YeJ
• 5. SCREEN: J Y1 /
Depth Diameter Slot Size Material C � rLvL /) _f �� p--J•_, `TT'�
From To_ Ft __ in. in. �r0 �12► GJ
From _ To _Ft. _ In. —In.
From — To _Ft. In. _In. f7o t I- /
16. SAND/GRAVEL PACK: �r r �tT r 'it 2-
Depth Size Material 4111.
e S
From To FL
From To Ft. — — -----
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF T IS RECORD HAS BEEN PR�V'I�ED TO THE WELL OWNER.
/ .4 1 / �C / 11"4._
FOR OFFICE USE ONLY GbATE Jr
Quad No: �, SIGNATURE OF P SON CGNSTRUC NG THE WELL
Submit original to Division of water Duality. Groundwater section within 30 days GW 1 REV. 12m
Serial No.

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section t r, r p
16:W Mal Service Center - Raleigh, N.C. 27699.1636-Phone [phone] t: 1, fJ 7 rj 9
W ELL CONSTRUCTION RECORD WELL CONTRACTOR
WELL CONTRACTOR CERTIFICATION e:
STATE WELL CONSTRUCTION PERMITC 14�?
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: _ / tu-r-� County: —
(Road Name and umbers. Co Ity, or Subdivision and Lot No.)
3. OWNER
Address D I It u
A40/JLLLd_ tiA No.)
aP7ia
City or Town Sale Zip Code
4. DATE DRILLED OS/0q l00
5. TOTAL DEPTH !O S
6. CUTTINGS COLLECTED YES ❑ NOQ
7. DOES WELL REPLACE EXISTING WELL? YES NO
8. STATIC WATER LEVEL Below Top of Casing: �_ FT.
(Use': Y Above Top of Ca")
9. TOP OF CASING IS FT. Above Land Surface*
-Top of cuing terminated atlor below land surface requim a variance In accor-
der ce with 15A NCAC 2C .011a
10. YIELD (gpm): .r S METHOD OF TEST Cc t
11. WATER ZONES (depth):
DRILLING LOG
From To
0 - t, rat
&C. IO S
Agricultural ❑ Monitoring ❑
DEPTH
Formation Description
dL
�
o
^i
b
R:
-1
z
12. CHLORINATION: Type uq�Amounl 1 C' If additional space is needed use back of form
13 CASING: lad
Wall TNUuwN LOCATION SKETCH
Depth Diameter or WephVFt. enal (Show direction and distance from at least two State
From To Ft. r�— Q�r Roads, or other reap reference points)
From To Ft. i-
From To Ft. �(L
14, GROUT: V ,n 1/
Depth Material Method k///S� t��� <J
From () To s)Q_ Ft.
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From To _ Ft _ In. _ In.
From —To — Ft. _ In. _ In.
From _ To _ FL _ In. _ in.
16. SAND/GRAVEL PACK:
Depth Size Material
From TO —Ft —
From To Ft.
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS. AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY r" r °{ A�
Quad No: "7IGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Qualiry, Groundwater Section within 30 days
GW1 REV. 12189
Soda No.

North Carolina - Deparlmeni of EriviioKiinehl acid Natural Resources - Divisiion of Water Quality - Groundwaier Section
21JO53
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 d Municipal ❑ Industrial ❑ Agricultural ,'1gn4toring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use: , "r.
2. WELL LOCAWN: (Show tch of the location below) ,_ ;;v, h-,r
Nearest Town: (prR'C, County: a 'c - .!' r •�'U
(Road Nam d Numbers. C mmu iry, or Subdivision and Lot No.) DRILLING LOG�� DEPTH
3. OWNER C ` From To
�,.. 'FQnmalion Descnpocn
Address -�� :n �c \ . i \. P>�\C)
City or Town Slate Zip Code
4. DATE DRILLED y:
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑ NOQ— l05 a
7. DOES WELL REPLACE EXISTING WELL? YES NO[a L
8. STATIC WATER LEVEL Below Top of Casing: FT.
(Use'+- If Above Top of Casing) o
9. TOP OF CASING ISFT. Above Land Surface' .3
'Top of casing terminated at/or below land surface requires a variance In accor- - -
dance with 15A NCAC 2C.0118
10. YIELD (gpm):_ METHOD OF TEST fit 2
11. WATER ZONES (depth): — -
12. CHLORINATION: Type T Amount
13. CASING:
Wall Thickness
j Depth Diarp9pr aj gi�(yF. an`
Fromm —To Ft.` — •�jYS�C 1
From To Ft.
From To Ft.
14. GROUT:
,1 Depth M t ethod
From To Q Q 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.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
17.
If additional space is needed use backrn
eQforrr{�"
TV
LOCATION SKETCH N `i
(Show direction and distance from at least tv.clSta Z
Roads, or other map reference points)
IN
1
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY O HIS RECORD HA EEN PROVIDED TO THE WELL OWNED
FOR OFFICE USE ONLY
Ouad No:
Serial No.
SIGNATURE OF PERSON CONSTRUCTING THE WELL GATE
Submit original to Divlslon of Water Duality, Groundwater Sedwn within 30 days Gw i FAEV, 12173

/' -
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwa:er Section 2 -! j YJ O
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: 1Jr C
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable sox): Residential d Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other If Other, List Use:
2. WELL LOCAT N: (Sh w sk rolf the`{I'p�cation below)
Nearest Town: �QQck �`\e `S ` County: �1/ ��
/aU I �
(Road fAme and Numbers. Communii ivisign and Lot No.) DRILLING LOG
3. OWNER From To
Address 9
Q
or Town State Zip Code
4. DATE DRILLED
5. TOTAL DEPTH 4
6. CUTTINGS COLLECTED YES 0 NO[ T�
7. DOES WELL REPLACE EXISTING WELL? YES N0[RJ_
8. STATIC WATER LEVEL Below Top of Casing: FT.
(Use'+' It Above Top of using)
9. TOP OF CASING IS I FT. Above Land Surface'
'Top of casing terminated et/or below land surface requires a variance In actor- y %'
dance with 15A NCAC 2C.011 a N ^�
10. YIELD (gpm): _ METHOD OF TEST A)
JPC �
N
11. WATER ZONES (depth):
z
12. CHLORINATION: Type T Amount
13. CASING:
• Wall Thickness
* 'Depthi eLler tV Wei hVF. at nal
From ' To .� Ft.
From To Ft.
From To Ft.
14. GROUT:
© ptt To
To M to e ethod
From .� Fl.
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From —To _ Ft in. _ in.
From —To —Ft. in. —In.
From —To _ Ft. In. _ in.
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
II 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)
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A C0�015 R ORD H sS�EEN PROVIDED TO THE WELL OWNEP_
s-�26
FOR OFFICE USE ONLY GATE
Ouad No: SIGNATURE OF PERSON CONSTRUCTING THE WELL
Submit original to Division of water ouality. Groundwater Secoon within 30 days
Gw-1 P.c`V. t7177
Serial No.

Q�l^� Co 211883
North Carolina - Department of Environment and Natural Resources - Division of Water Ouality - Groundwater Secti n
1636 Mail Service Center - Raleigh, N.C. 27699.1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: ChrIDrIL'rT C��oiin
WELL CONTRACTOR CERTIFICATI N #: a�7
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (check Applicable Box): Residential2JMunicipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sitetch of the location below)
Nearest Town: R irP VQrd County:
or
3. OWNER 11 J
G u �..,,.
Address Q ( 7 rf
$reYoLrd eee�e�87)�
City or Town J�(State lip Code
4, DATE DRILLED
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑ NO[N
7. DOES WEL REPLACE EXISTING WELL? YES [] NO®
8. STATIC WATER LEVEL Below Top of Casing: Fr.
(Use': it Above Top of Casing)
9. TOP OF CASING IS 1 • 313 FT, Above Land Surface'
-Top of casing terminated avor below land surface requires a varlance In occor-
dancewith l5ANCAC2q01/8 Tmpel 1
10. YIELD (gpm): in METHOD OF TEST
11. WATER ZONES (depth):
DRILLING LOG DEPTH
To Formation Descdption
0
CD
12. CHLORINATION: Type Amount
If additional space is needed use back of form
13. CASING: sy pt� ��p� i"f - 1"
LOCATION SKETCH
Wall Thickness
Depth Diameter or Weight/Ft. Mate
(Show direction end distance from at least two State
From Q—To �( Ft.619' SD2ir — Iat
Roads, or other map reference points)
From To Ft.
'I c�
w+)Iodloto I oof,:( I_ rla Orl
From To FL
14. GROUT:
WR�
�1 T� .J f L
Girl 30—OLd (toad. 4o T1rsl
Depth Material Method
From 0 To �0FP.A0nOyO Pull a
lefE ((`in (goods pr) Lod 1Z .
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From —To—Ft— in. —in.—
From _. To _ Ft. _ In. — In.
From —To _ Ft. In. _ In.
16. SAND/GRAVEL PACK:
Depth
From To
From To
17. REMARKS: AUG_
I DO HEREBY CERTIFY TH T T IS WELL WAS CONSTRtgCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
STAND DS, 9 C{? fi4 IS RECORD HAS BEE OVIDED TO THE WELL OWNER.
CONSTRUCTION
FOR OFFICE USE ONLY DATE
SIGNATURE PERSON CONSTRUCTING THE WELL
Quad No:
Submit original to Division of Water Quality, Groundwater Section within 30 days GW 1 REV. 121"
Serial No.

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Prone [phone]
WELL CONSTRUCTION RECORD WELLCONTRACTOR: 24I
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2, WELL LOCATIR N: (Show srketch of the location below) —T'� n I V f
oL
Nearest Town r f a s (' J31�-� County' �I(('' O
3. OWNER
Address
r ri
Nurrbers, Community, or Subdivia and Lot No.) DRILLING LOG DEPTH
1 I-ei n V7 From To FortnaOon Description
rl o a 4 un YI w" �-lt
-City or Town State
4. DATE DRILLED
5. TOTAL DEPTH ^ r
6. CUTTINGS COLLECTED YES ❑ NO®
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NOZ]
B. STATIC WATER LEVEL Below Top of Casing: FT.
� (use': II Above Top of Casing)
9. TOP OF CASING ISFT. Above Land Surface'
Top of cuing terminated at/or below land surface requires a variance In accor•
dance with 15A NCAC 2C .0118
10. YIELD (gpm): -L� METHOD OF TEST
11. WATER ZONES (depth):
12. CHLORINATION. Type Amount If additional space is needed use back of form
13. CASING: By it suaa'er LOCATION SKETCH
Wall Thickness
Depth or WeightrFl. ale" (Show direction and distance from at least two Slate
FromTo—rd i tar Ft. SDU I P'I(-' Roads, or other map reference points)
From To Ft. L% , / i
From To Ft. QSS II U
14. GROUT:
Depth Material Method d Qark - 531�, orr_ nt. l') ox
From �_To M Ft. r1nPrem poll �P _ Old ico rl . Oa left -Side-
From To Ft. lL
15. SCREEN:
Depth Diameter Slot Size Material
From —To—Ft— in. _ in.
From To _ Ft. _ in. — in.
From _ To Ft 1n.T-
16. SANDlGRAVEL P Q t
Dept D P_'_ �-----�p�nal
From To F'N__
From To a
17. REMARKS:
Groundwater Sectipn
I DO HEREBY CERTI THA CTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS PfiCORD HAS BEEN PR 3VIDED TO THE WELL OWNER.
5--19-0o
FOR OFFICE USE ONLY SIGNATURE OF PER N CONSTRUCTING THE WELL DATE
Quad No:
Submit original to Division or Water Quality, Groundwater Section within 30 days GW.t REV. 12199
Soda] No.

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone] '{n�
WELL CONSTRUCTION RECORD WELLCONTRACTOR: Iin A. ��er
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residentfal[O' Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: how sketch o the location below)
Nea�st Town: f�P� LC County: I i �V aL OL
(Road Name end Numbers, Convnunity, or $','division and
3. OWNER /Vln''r/I k_ n vl �l. (sa itoi K
Address 0 k)ohrAAti 7\r-vt10
4. DATE DRILLED ;?I
L
5. TOTAL DEPTH 4.3I'
6. CUTTINGS COLLECTED YES ❑ NOCZ
7. DOES WELL REPLACE EXISTING WELL? YES ED NOU�
8. STATIC WATER LEVEL Below Top of Casing: FT.
(UN -+ it Above Top of Cuing)
9. TOP OF CASING IS FT. Above Land Surface-
-Top of casing terminated at/or below land surface requires a variance In accor-
dance with 15A NCAC 2C 0118
10. YIELD (gpm): � METHOD OF TEST j t MPd
11. WATER ZONES (depth):
12. CHLORINATION:\ ,Type Amount
13. CASING: Jt �� n1 t yy I1 iuctabef
Wall Thickness
Depth ter Wa'pn i t.
FromTo1� Ft. 1
From To Ft.
From To Ft.
14. GROUT:
Agricultural ❑ Monitoring ❑
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 State
Roads, or other map reference points)
Depth
Material
Metho
From
To a Ft. n 60=4-A -
From
To
Ft.
15. SCREEN:
Depth
Diameter Slot Size
Material
From
—To—Ft—
in. —in
From
_ To —
Ft. _ in.
in.
From
—To —Ft.
_ in. —In
16. SAND/GRAVEL PACK:
Depth
Size
Material
From To Ft.
From To Ft.
17. REMARKS:
c-x
I DO HEREBY Miginai
STRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTI OF S RECORD HAS BEEN P VIDED TO THE WELL OWNER.
FOR OFFICE U 5
Quad No:NA RE OF P RSON CONSTRUCTING THE WELL DATE
o Division of Water Quality, Groundwater Section within 30 days
Serial No. Grottdwater Sedon GW-t REV. 12199

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone (919) M-3221 yn 1� -
WELL CONSTRUCTION RECORD WELLCONTRACTOR: !t A• +kr
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check applicable sox): Residential Lt7 Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other If Other, List Use:
2. WELL LOCATI/p� N: (Show sketch of the location below) '�
Nearest Town: �(SaCL� County:
(Road Name and Numi rs, Community, or Subdivision and Lai
3. OWNER Pnnol �a4rU flnn- X nt4
Address Oh). FZ y 1 U7 0
4. DATE DRILLED b'
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑ NO®
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO[f
8. STATIC WATER LEVEL Below Top of Casing: FT.
(Use': If Above Top of Casing)
9. TOP OF CASING IS 1,33 FT. Above Land Surface'
'Top of casing terminated at/or below land surface requires a varlence In accor-
dance with 15A NCAC �CI0118
10. YIELD (gpm): `� METHOD OF TESTTM,0A
11. WATER ZONES (depth):
12. CHLORINATION: Type Amount
13. CASING: 81 p� instauQt-
( - wall Thickness
Depth D''�"�°%fir orweighyR. Material
FromTo� Ft._-t¢ 1� NF-2 I -py 0-
From- To Fl.
From To Ft.
14. GROUT:
Depth Material Metho
From 0_ To _a0__Fl. PnnPIMi1°
From To Ft.
1S. 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
Roads, or other map reference points) Wilson iZad - Wllb*an5mOreek-
o fprox, a r lees orgy lei -%o
}� i dden Ya [ I eyy aboak .3 rnr le
_n2 4,1, on Laum I
Lane. - 6usee cn corner J
NoA[ey -- Lauld - road- be-6d
I DO HEREBY I I L KSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C, WELL
CONSTRUCTI OFTHIS ECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE U LY
Quad No: S !WkTURE OF PE N CONSTRUCTING THE WELL DATE
'girut o Division of Water Quality, Groundwater Section within 30 days
Serial No. , _ _ $eCt100 _ GW-I REV. IV%

2366
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 #: q
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
Town:
3. OWNER
Address
of the location on below) 7'ra nsIN QYl.IQ
County:
and Lot No.) DRILLING LOG DEPTH
?r _ From To Formation Descripuon
City or Town / Slate tip code
4. DATE DRILLED 6 0�
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑ NOM
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
8. STATIC WATER LEVEL Below Top of Casing: FT.
I �z (Use'+' If Above Top of Cuing)
l
9. TOP OF CASING IS . 33 Fr. Above Land Surface'
-Top of casing terminated stlor below land surface requires a variance In accor.
dance with 15A NCAC 2 a11e
10. YIELD (gpm): METHOD OF TEST TI 1Y)� CP
11. WATER ZONES (depth):
O
s
�
e9zm
_
z—
lD
�m
a
m
m_
fTt�
--1
z
12. CHLORINATION: TypeAmount If additional space is needed use back of form
13. CASING: Lly rurxn 41$� uff
/�' Wall Thickness LOCATION SKETCH
Depth �Diia` ester or Weight/R. Material (Show direction and distance from at least two State
From Q To Ft. `Pijt. ? S� I IN C1 Roads, or other map reference points)
From To Ft.
From To Ft. ttWy (o -o aP5t0±I00 . )
14. GROUT: Ill Q�Qe P1 r7YLtCt t YLurGROB. — I mlle-
Depth Material Method / Q ( ��L mtl�
From 0 To AQFt. 01710 0rdf nnN� �l Q{� G�Qldea Rd. - 9 0-4� L
From To Ft. TumerLixlailbb� w gar� banthe►� bn I+15. SCREEN:""�Depth Diameter SlotSze Material ( 2
��— d�d2i U�n1f7 on
From _ To _ Ft _ in. —in
From _ To _ Ft. — in. — in. �r0 �J �r0 p�}� (X100V2 C th
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
FOR OI
Quad No:
0
Serial No.
DNSTRU TED IN ACCORDANCE WI 15A NCAC 2C, WELL
'Y OFF S RECORD HAS BEEN PRO IDED TO THE WELL OWNER.
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
ial to Divislon of Water Qualiry, Groundwater Section Within 30 days
GW4 REV. 12799

North Carolina - Department of Environment and Natural Resources - Division of Water Duality - Groundwater Section 1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: 1\obeyt 21 tfler
WELL CONTRACTOR CERTIFICATION #: R 139
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable sox): Residential U� Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below) ._..� _ �V an I Q.�
Nearest Town: Rrcgla rd County: )
IRmindl Aqn (Road
(Road Name and Numbers. Community, or Subdivision and Lot No.) DRILLING LOG
3. OWNER A1fred -DOr r-2, From TO
Address —
1-�reVard lreetor �� nl L
City or Town Stale Zip /Code
4. DATE DRILLED Ig DO
S. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑ NO[R
7. DOES WELL REPLACE EXISTING WELL? YES NO[K]
8. STATIC WATER LEVEL Below Top of Casing: FT.
(Use': it Above Top of Casing)
9. TOP OF CASING IS 1.99 FT. Above Land Surface -
'Top of casing terminated at/or below land surface requires a variance In accor-
dance with 15A NCAC 2C .0118
10. YIELD (gpm): J_ METHOD OF TEST T m °C d
11. WATER ZONES (depth):
12. CHLORINATION. Type Amount
13. CASING: gY Pump ias-Wer
Wall Thickness
Depth Diarppter or WCTngnt. ate al
From 0 To M Ft. 6 R +zyls-.�t— Ci
From To Ft.
From To Ft.
14. GROUT:
From
From
15. SCREEN:
From
From —
From _
Depth �M�at�en�I Method,
To Ft. S�LLSIS�— � I It^2.d
To Ft.
Depth Diameter Slot Size
—To—Ft— in.
To — Ft..— in.
To _ Ft. In.
16. SAND/GRAVEL PACK:
17
Material
in.
In.
In.
Depth Size Material
From To Ft.
From To Ft.
DEPTH
Formation Description
to w
fV �
If additional space is needed use back of form o
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
Frolx�retard-TaICe wit. ��i W Pask
{R"Ra-n.. -TJ1. 0a Rua[
Go 1Z tftna . T/R W-L UcCr w)at )-
GO iUs-t �� end 0f ovemere t 4v
t2�uxtd �/lE. CTctt�- a. � h1i1&_s
Ctam
rIles i� Orxx, t jvu n .1oad. l�S
use -
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF TtJOS RECORD HAS BEEN /PF/��( VIDEO
TO THE WELL OWNER.
FOR OFFICE USE ONLY —� of "r+ ""1d�' g' ✓
Ouad No: SIGNATURE OF SERSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Ouality, Groundwater Section within 30 days
GW-i REV. 12/99
Serial No.

North Carolina •Department of Environment and Natural Resources -Division of Water Oualiry - Groundwater Section
1636 Mail Service Center • Raleigh, N.C. 27699.1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: A,I r 2' 13 1 `�
WELL CONTRACTOR CERTIFICATION #:
�} STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Boa): Residential L.bt Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water injection ❑ Other ❑ It Other, List Use:
2. WELL LOCATION: (Show skit Q h of the location below) -t J Q V an I LL
Nearest Tow n:—_c..��V/`f�h County: -
(Road Name
3. OWNER
Address 2
City or Town State L113- d00
4. DATE DRILLED 7
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑ NOM
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NOM
8. STATIC WATER LEVEL Below Top of Casing: FT.
(Use'+' It Above Top of Casing)
9. TOP OF CASING IS 1. 23 FT. Above Land Surface-
-Top of casing terminated avor below land surface requires a variance In accor-
dance with 15A NCAC 2C .0118 --r- f
10. YIELD (gpm): c2Q_ METHOD OF TEST ISM110
11. WATER ZONES (depth):
12. CHLORINATION\Tye Amount
13. CASING: U Pllt'1111-lrLS�&LL'ef
JJ ! Wall Thickness;
Depth Dia/meler or WSDQleprh1VFL Ma
terial
tonal
DRILLING LOG DEPTH
From To Formation Description
If additional space is need ad use back of form
LOCATION SKETCH
(Show direction and distance from at least two State
From To Ft. Roads, or other map reference points)
From To Ft. Fr'b-i1'>- ✓1� ��� -�- ��''
From To Ft. �✓
14. GROUT:
�1 Depth Material Metho �O /� Q
From J L— To 20 Ft. (' Q J21f, B yt C,A L�Lt 6
From To Ft. _
15. SCREEN: I - G�6 7/vd
Depth Diameter Slot Size Material q ,7
From _ To _. Ft — in. _ in. - r q
From —To _ Ft._ in. _ In. </
From — To _ Ft. L` in. — In. 0�� (( ILt'J6
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 R ORD HAS BEEN PROVID TO THE WELL OWNER.
FOR OFFICE USE ONLY Quad No: SIGNATURE OF PERSOCONSTRUCTING THE WELL DATE
Submit original to Division of Water Quality, Groundwater Section within 30 days OW-1 REV. 12199
Serial No.

North Carolina - Department of Environment and Natural Resources . Division of Water Ouality - Groundwa:er Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELLCONTRACTOR: �PFti -N l r t r
S%� �-���
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMIT#:
Industrial ❑ Agricultural ❑ Monitoring ❑
1. WELL USE (Check Applicable sox): Residential ❑ Municipal ❑ I-� S e
Other It Other, List Use: n +
Recovery ❑ Heat Pump Water Injection ❑ � r'
2. WELL LOCATION: (Show sketch of the location below) •--rnM1 , . I V AcIV IA
�. county:._-{
Nearest Town: //� �.-----
t�QY IDLI DEPTH
DRILLING LOG ----
(Road Nam nd Numbers. Community, or Subdnlsmn and Lot No) Fro-----�—' To Formation Oescnpuon
3. OWNER
Address %Q
1 zip Code
City or Town State
4. DATE DRILLED
5. TOTAL DEPTH /(08 — O
6. CUTTINGS COLLECTED YES ❑ NOa (�J(
7. DOES WELL REPLACE EXISTING WELL? YES NO
S. STATIC WATER LEVEL Below Top of Casing: FT -
(Use': it Above Top of Casing)
9. TOP OF CASING ISFT. Above Land Surface'
'Top of casing terminated avor below land surface requires a variance In accor-
dance with 15A NCAC 2C��' AL
10. YIELD (gpm): T— METHOD OF TEST 12
11. WATER ZONES (depth):
12. CHLORINATION:
13. CASING:
Type HTI4 Amount If additional space is needed use back of form
Wall Thickness
.�. -Depth Diameter or W ighVFt. I nat
From Ili Ft. —
From To Ft.
From To Ft.
14. GROUT:
Depth Material
Material elhod
From To D Q Ft.
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From _—To— Ft __ in. in.
From __To._.Ft. — in. _ In.
From _ To To._ - Ft, — in. _ in.
16. SAND/GRAVEL PACK: Material
Depth Size
From To Ft,
From To Ft.
17.
I DO HEREBY
FOR OFFICE US
Quad No: �JHIT J. 1, 1 9
LOCATION SKETCH
(Show direction and distance from at least two Slate
Roads, or other map reference points)
IN ACCORDANCE WITH 15A NCAC 2C, WELL
D HAS ,BEEN PROVIDED TO THE WELL
'1r) P-
41 URE OF PERSON CONSTRUCTING THE WELL
DATE
Divlslon of Water Quality, Groundwater Section within 30 days GW 1 l3Ev 12"i'l
Serial No.

North Carolina -Department of Environment and Natural Resources -Division of Water Quality -Groundwater Section i 9 8 fl 41
P 0. Box 29578 - Raleigh.N.C. 27626.0576-Phone [phone]
JJ . (rn ncnn f rKDRILLING CONTRACTOR:
iAn /MYItP(WellT/Lllii�
WELL CONSTRUCTION RECORD DRILLER REGISTRATION
STATE WELL CONSTRUCTION PERMIT#:
t. Monitoring
WELL USE (Check Applicable BOX): Residential Ef Municipal ❑ Industrial ❑ Agricultural ❑ ❑
Recovery ❑ Heat Pump Water Injection ❑ Other If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below) Tn ns3(y0 Rt0t
'GZ,rv>\r n � County:
Nearest Town: I 1
�Aollyll alp DEPTH DRILLING LOG
(Road, Community, or Subdivision d Lot No.) From To Formation Description
3. OWNER
(Street or gate No.) �� /
I� marsh 1`2S� C� zlppCode
r Town state
4. DATE DRILLED
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑ III
7. DOES WELL REPLACE EXISTING WELL? YES ❑ FO�]
a. STATIC WATER LEVEL Below Top of Casing:
T.
o�
(Use III if Above Top of Casing)
9. TOP OF CASING ISM 93 FT. Above Land Surface•
Casing Terminated avor below land surface is illegal unl�eess�aa variance is issuer
in accordance ce with ): AC METHOD OF TEST I .L1Lst--
10. YIELD (gpm):
11, WATER ZONES (depth):
12. CHLORINATION Type.
13. CASING: C1
Amount
PUJkL, [(LAO-ll-i
k
hh Dept h'�n i� ter
From V To �— Ft.
From To Ft.
From To Ft.
14 GROUT:
Wall This ness
or Weightl Material
5 Z
Depth Material
From 0 To o Ft. POnItP_
From To Ft.
i5 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
Metho
Material
in.
in.
in.
Material
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
(o4 W e 280
LL
��o if2betsee�ion ki
Is
0- Vi Pon- ZBO CDOL 1plr OX. a fMOU
dF Lit�fe /ll,oura�n•youcio
cLYtVc 6n�J
ri�� Q� youyo &O(AJ L lures
a �ec�©ns of ju od rail ,
Sir UR-
17. REMARKS: ��((((
DO HEREBY IF T T , W HAT NOFRU IS ED IN RECORD HASBEE
WIOVIDED TO HE WELL OWNER.
COOFFICETI S�
FOR OFFICE U t Y IGNATURE F CONTRACTOR OR AGENT
Quad No: ubmit original to Division of Water Quality and copy to well owner.
Serial No: - ^ection GW-1 REV. 1198
d Office
DATE

WELL LOCATIRRN: (Show sketch f the location below) T� 5 )aa-
Nearest Town: (1-0 n f,� , t r County ( / .
Red f1L1 �n(1{7QS DEPTH
(Road, Com�''unny, or SJbdm w and Lot NoJ
OWNER ID ��� From 70
ADDRESS I T 44"
(Streel or R{y� Nd.) Q pr
L (� t1 f i u�ut<_Lip Code
City
T or Town Slate
DATE DRILLED 9+1gt�yl, —
TOTAL DEPTH
CUTTINGS COLLECTED YES ❑ NOr
DOES WELL REPLACE EXISTING WELL? YES ❑ NOL]
STATIC WATER LEVEL Below Top of Casing: FT.
(Use ": • if Above Top of Casing)
9. TOP OF CASING ISI 33 FT. Above Land Surface"
• Casing Terminated aVor below land surface is illegal unless a variance Is Issued
in accordance with 15A 1JCAC 2C .011e
10. YIELD (gpm): METHOD OF TEST f f11P� 11. WATER ZONES (depth):
12, CHLORINATION: Type Amount
13. CASING: /) Llyf�i-(,pl''�Q
T,
Wall Thickness
Depth�(� Diamter or Weight/Ft . atrial
From Q—To �_ Ft. spe21 (:�
From To Ft.
-
From To Ft. -
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
P.O. Box 29578 - Raleigh,N.C. 27626.0578-Phone [phone] /i /J 1'f p
W1 ri70f l 'VIS 1 1017 iV�PfWL'��t►►lmw
WELL CONSTRUCTION RECORD REGISTRATIONDRILLERDRILLINGt
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other M If Other, List Use:
4.
5.
6.
7.
8.
DRILLING
� LOG
Formation Description
If additional space is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
See CAcP-Aowz►('Pad olden
1a.GROUT: 0pYY1mlIv)iW - I �� j-�p� ,I1lianL 3
Depth Material Method �� ri �� JL S, k� L�ILd 5,1,
From Q To —2� FL C mCra}e
From—TO—Ft.—'r �qq� T ��51 I� c
15. SCREEN:
Depth Diameter Slot Size Material
From —To—Ft— in. in.
From — To _ Ft. in. in.
From _ To Ft. in. in.
16. SAND/GRAVEL PACK:
Depth
From To Ft.
From To Ft.
17. REMARKS:
Size Material
I DO HEREBY CERTIFY-THATTHIS WELL WAS CONSTRUCTED IN ACCORDANCE
CONSTRUCTIOfv SAt�fAPDSt-AND THATA COPYAF THIS RECORD HAS BE�jJ
tti� 1/i so/ ��.
0
FOR OFFICE USAElONLY ' O nry� SIGNATU E OF CONTRACTOR OR
Quad No: 2.O 2 1 . ? -
Serial No: I i "" - submit original to Division of Water O
cop'yTN e I own'
GW-1

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
P.O. Box 29578 - Raleigh,N.C. 27626-0578-Phone [phone]DRILLING
Q yeri� s 1C►on ViPI WE��tilrma
WELL CONSTRUCTION RECORD DRILLER REGISTRATION CONTRACTOR: I
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (check Applicable Box): Residential Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other M If Other, List Use:
2. WELL LOCAT��pQ7N: (Show sketch of the location below)--r'arSY'V� I Ll
Nearest Town: rlr'`� dp rsoll N i I \tid County: 1 i�
RBI Y V I0to f—Qa DEPTH DRILLING LOG
(Road, Cor'(nu�nity, or Subdivision and [NO) I Formation Description
3. OWNERS6bf� F���tfe� From To
ADDRESS nY` �a5
(Sir et or Route Na.) �.B 76�'
�rrC�e 1�G Slate Zip Code —
City or Town O
4. DATE DRILLED ab 00
m
5. TOTAL DEPTH 1 CD" —
6. CUTTINGS COLLECTED YES ❑ NOM t =-
7. DOES WELL REPLACE EXISTING WELL? YES Q NO[t) ao
8. STATIC WATER LEVEL Below Top of Casing: FT•
(Use "." it Above Top of Casing) _m
9. TOP OF CASING IS l 33 FT. Above Land Surface- - F"A
• Casing Terminated aVor below land surface is illegal unless a variance is issued
in accordance with 15A N AC 2C .0118 CD10. YIELD (gpm): METHOD OF TEST
11. WATER ZONES (depth):
12. CHLORINATION\, Type Amount If additional space is needed use back of form
13. CASING: T B1 ( ury it S&dgr LOCATION SKETCH
Wall Thickness
Depth Diarpeter or WeighuFI. Material (Show direction and distance from at least two State
Frp,
From To 4 0 Ft. "if? � — 0 Roads, or other map reference points)
�.�1
_ � �z re(vCv d s
From To Ft. �jf` �p'1• E , 12�c on C�a6 ��eek .
From To Ft.
14. GROUT: _ pn JeT�( t/V�11. lJ D I o
Depth Material - Meth
o
From �_ To a0 Ft.LULLlt'I 1 �� � �(tl,/Voe( oVJ5.
From —To—Ft.
15. SCREEN: GQ •�'� �1 � -" � � 121Ve.(-
Depth Diameter Slot Size Material ^,� a1� ll _ (j �,�
From _To Ft in.—in.—� �O� 1 (,t,-j"r�I
From _To Ft. in. in. �-I' `✓Y �
�(ti Pr�P S �'
From —To Ft. in. in. (/
16. SAND/GRAVEL PACK:
Depth Size Material
From To —FL -
From To Ft.
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WLL WAS�CONSTRUCTED IN ACCORDAN H 15CAC�2CQW�EL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HA EE �
VID T E' L
4AY - 12000 kc�
FOR OFFICE USE ONLY''. Section
Quad No: _ SIGNAT RE OF CONT ACTOR AGE
Serial No: ^ i ,n �—� ` - - Submit original to Division of Wale
Gyp-1 REV. 1/98

r o
North Carolina -Department of Environment and Natural Resources -Division of Water Quality • Grqundwat�er�S/e�c�tio�n"
1636 Mail Service Center • Raleigh, N.C. 27699.1636-Phone [phone] (vY/).[O.,GO,,(,
WELL CONSTRUCTION RECORD WELL CONTRACTOR:C,
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMIT#: 17
1.
WELL USE (Check applicable Box): Residential ❑ Municipal ❑
Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2.
W ELL LOCATION: how sketcj�Jt of the tion below)
//
Nearest Town: \ /iiyl/�L.lil�..,. , i County: Jta4ua-X[J�.�,,.�.
_ `—DR'IILLING
�.. )
(Road NamejM Numbers• nity, r S givuion and lot
LOG DEPTH
3.
OWNER n( RAJ
From To FomuuonDescription
Address Su
0 — ,) O All. -
lowest or rioute NO.Jo%'
O — i�0 S GI✓!
c( VXVt &_ 7c P
City or Town Sub 21p Coe
4.
DATE DRILLED
5.
TOTAL DEPTH i0 5
^
6.
CUTTINGS COLLECTED YES ❑ NK!
0
7.
DOES WELL REPLACE EXISTING WELL? YES ❑ NO[S
C -'
6.
STATIC WATER LEVEL Below Top of Casing: FT.--
c..
(tlse'.' M Above Top of Casing)
9.
TOP OF CASING IS FT. Above Land Surface'
-Top of using terminated stlor below tend sudace requires a variance In aceor.
dance with 15A NCAC 2C.01 a
Jz
10.
YIELD (gpm): METHOD OF TEST
11.
WATER ZONES (depth):
�Cq —'
z
a
12. CHLORINATION: Type Amount /z e ' If additional space Is needed use back of form
13. CASING:
Wall Thickness LOCATION SKETCH
Depth Diameter or WeighVR. Material (Show direction and distance from at least two State
From �To �0 Ft. —6 41olz a? Caa�wr Roads, or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From To o Ft. fdi c t rs t 7'
From To FL 0
1S. SCREEN
Depth Diameter Slot Size Material
From To _ Ft _ In. —In.
From — To — Ft. _ In. _ In.
From —To _ FL In. —In.
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY `�`E1" � / � w,"
Quad No: GNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Division or Water Quality, Groundwater Section Within 30 days
SerW No. GW-1 REV. 12199

North Carolina - Department of Environment and Natural Resources - Division of Water Quality -Groundwater Section ;..
P O. Box 29578 - Raleigh,N.C. 2 7626-0578- Phone [phone] �J•T
WELL CONSTRUCTION RECORD DRILLING CONTRACTOR: �Rh)
DRILLER REGISTRATION #:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (check Applicable BOX): Residential E( Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heal Pump Water Injection ❑ Other ❑ It Other, List Use:
2, WELL LOCAT, : (Show
Nearest Town:
or
3. OWNER
of the location below)
County:
(Street or Route No.) ^^
�f1 S I r 22
City or Tow Stale zip..ude
4. DATE DRILLED
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑ NO®
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO®
B. STATIC WATER LEVEL Below Top of Casing: FT.
(Use "+" iI Above Top of Casing)
9. TOP OF CASING IS 1-33 FT. Above Land Surface•
• Casing Terminated auor below land surface Is illegal unless a variance is issuer
in accordance with 15A NCAC 2C .0118 f'1'1P 1
10. YIELD (gpm): __ -- METHOD OF TEST Lam- -
11. WATER ZONES (depth):
DEPTH
From To
DRILLING LOG
Formation Description
ci
12. CHLORINATION. Type p "Amount If additional space is needed use back of form
13. CASING: Z� (j'LsbJJ'2f' LOCATION SKETCH
I Wall Thickness y
�1 Depth a eler oar �Weft9Ghhu1Ft. terial (Show direction and distance from at least two State
s [-- To � Ft. _� —� V � 11 rr Roads,, or
other map reference points)
From �7 TJU 0 Yl �Y ewd) N
From To Ft.
From To Ft. rn tt�2(` t\S �cff')L Q-
14. GROUT:
Depth Material Method thodA —�© �(—[C52.�\l_1X� rl
From �— To � Ft. (°nnny�iv- �X11d�y1K— �II// ls; `er
From—To—Ft.—�QYl fl(IL �IICX F I i
15. SCREEN: Tin _! I Oro '—Z rN `2S L@ Frye
Depth Diameter Slot Size Material In -r^1�I `�t'C I_ f_ T> �1 4
From To Ft in. in. l�v � uLl l� oou� ChI 2d
From —To Ft. in. —in., ^^11II � _ SI�5 rio&
From —To—Ft.— in.—in.—Sy1n�{us s(qn) �nn— IQII�r0
16. SAND/GRAVEL PACK: 4t) Una cTeiAg 1ywCIti KKK 7Q7) ) ,J� _
cn ,[ '� 4 "
Depth Size Material n
From To Ft.
From To Ft. I J
17. REMARKS:
I DO HERPSTAN357AM
4L S CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTI OPY OF�FiIS RECORD HAS BEEN PR TO THE WELL OWNER. / /�
2 / �� 2
FOR NO: t -= per i_
Quad No: SIGNATURE CONTRACTOR ORAGENT
Sepal No: Submit original to Division of Water Quality and copy to well ownerGW-1 REV. 1198
at - Sactinn

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
P.O. Box 29578 - Raleigh,N.C. 27626-0578-Phone [phone]
WELL CONSTRUCTION RECORD DRILLING CONTRACTOR:UC &r &14n I An V�PrWEI�+iilma
DRILLER REGISTRATION #: IIR'I I
�STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (check Applicable Box): Residential LJ/ Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATIO : (Show ske h of the location below)
Nearest Town: //,� _ County:
'S v / DEPTH DRILLING LOG
ad, rn!nI v, or Sue, icn antl Lot No q
3. OWNER�??� _ a-�� aillin (P] /�Dwi From To Formation Description
ADDRESS'-D
(Street olhy1o/: No.) Ann 01 OA I Lit/ IX. d
C t r Town State Zip Code
4. DATE DRILLED I "al -00
5. TOTAL DEPTH �255 r
6. CUTTINGS COLLECTED YES ❑ NO[]
7. DOES WELL REPLACE EXISTING WELL? YES NOA
8. STATIC WATER LEVEL Below Top of Casing: FT.
(Use' ' it Above Top of Casing)
9. TOP OF CASING IS I, 3 3 FT. Above Land Surface'
- Casing Terminated avor below land surface is illegal unless a variance is issue(
in accordance with 15A NCAC 2C .0118 ,(7
10. YIELD (gpm): _-- METHOD OF TEST �f
11. WATER ZONES (depth):
12.
CHLORINATION: 1 Type Amount
13.
CASING:
Wall Thickness
Depth Diameter or Weight/Ft. Material
0
7 Ft. 'bi l2tc -
From
To -4
From
To Ft. —
From
To Ft.
14.
GROUT:
Depth Material Method
From 0
To 20 Ft. 0V� °i-10`
From
To Ft.
15.
SCREEN:
Depth Diameter Slot Size Material
From —To—Ft—
in. in.
From
To Ft. in. in.
From
To Ft in. in.
16. SAND/GRAVEL PACK:
Depth
From To Ft.
From To Ft.
17. REMARKS:
I DO HEREBY CE
CONSTRUCTION
FOR OFFICE USE
Quad No:
Serial No:
Cfl 1
z
If additional space is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least two Slate
Roads, or other map reference points)
t . /_J_0
at
kab- l s+ Q�cu =a Qk
Size Material --
fELkG
ACCORDANCE WITH A CAC 2C, WELL
ORD HAS BEEN PROV ED „i„ -
eie Re ional Offt e
C TRACTOR OR AGEN DA
Division of Water Quality and copy to well owner.
GW-1 REV. 1198
2 %//s,

271606
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section r�
1636 Mail Service Center - Raleigh, N.C. 27699.1636-Phone [phone] /� Cf/�rer JF/✓�c2Ci-
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential ❑ Municipal ❑ Industrial ❑ A ricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ OtherEg'lf Other, List Use: �i14 _0 le�
2. WELL LOCATI N: (Show sketch of the location below) ezj
Nearest Town:County:
(Road Name and Numbers. Community, or Subdivision and tot No.) DRILLING LOG DEPTH
3. OWNER ew.»From To Fom&5on Descnpti
AddressjJ
w tfeol Of 0 0.
City or Town State Zip Code
4. DATE DRILLED le / e,7
5. TOTAL DEPTH /i1if4
6. CUTTINGS COLLECTED YES No
7. DOES WELL REPLACE EXISTING WELL? YES NO
B. STATIC WATER LEVEL Below Top of Casing: J©v FT.
(Use •+• if Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface'
'Top of using terminated at/or below land surface requires a variance In accor-
dance with 15A NCAC 2C J03"
10. YIELD (gpm): U MEJ HOD OF TEST
11. WATER ZONES (depth):
12. CHLORINATION: Type Amount
It additional space is needed use back of fcum
13. CASING:
"
LOCATION SKETCH
Wall Thickness
DepthL, Diameter o^r W�ei�hvFt. at nal (Show direction and d""stance from at least two Slate
From !✓ To L �— Ft. r S�
j�L Roads, or other map reference points))
From To Ft.—
C:Muu/s1i/
From To Ft.—
14. GROUT:
Depth Material
M#}hod
From 1 To � Ft. Sa CaF�
ieai W o c;
_
From To Ft.
G)
—
15. SCREEN:
—
Depth Diameter SiotSize
Material t
From To Ft in. _ in.
From —To —Ft.— in. —in
:2
From To Ft. in. _ in.
w r.;;
16. SAND/GRAVEL PACK:
_ 2
Depth Size Material o _-
From To Ft.
From To Ft.
17. REMARKS:
I DO HEREBY C "1AtELL
ED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTIO itSiTT RDS, AND THATRECORD
HAS BEEN PROVIDED TO THE WELL OWNER.
4COPYHIS
FOR OFFICE US NLY 1 M
DATE
Quad No;
OF PERSON CONSTRUCTING THE WELL
Subof
Water Quality, Groundwater SeNon within 30 t12ys
fiw•1 RSV. t299
Serial No.

271605
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] / /� d�TlrrtTCC E
WELL CONSTRUCTION RECORD WELLCONTRACTOR:P�����Y'�����
WELL CONTRACTOR CERTIFICATION
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (check Applicable Box): Residential Municipal ❑ Industrial ❑ A ricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other f�( If Other, List Use:
2. WELL LOCATIO (Show sketch of the location below) /�'�
Nearest Town: W 4 d;2V = / "'G County: �'*�✓�2�;..0 '==-'� J
lei
(Road Name and Nurnbrs. Comnwnlry, or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER ' �!�, -- nwKr�x-•-r %h.�%dt.� _ From To �pmra5on Description
Address )9// y�� / y2 �i - 6 / '10I
City or Town Slue Zip Code
4. DATE DRILLED le''G< '422" h-C 9Gla
5. TOTAL DEPTH %���� /t
6. CUTTINGS COLLECTED YES Q NO❑f
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO elOG'-/UC/.y
B. STATIC WATER LEVEL Below Top of Casing: ;�7-U!/FT.
(Use'+' a Above Top of Casing)
S. TOP OF CASING IS/' FT. Above Land Surface*
-Top of using terminated atior below land surface requires a variance In accor-
dance with 15A NCAC 2C.0110
10. YIELD (gpm): Ze-1- METHOD OF TEST
11. WATER ZONES (depth): G ?_ 11
12. CHLORINATION: Type Amount If additional space is needed use back of fcrm
13. CASING:
Wall Thickness
� Der
Diameter orWeig t. Y�
S—�_
From Too
FL
From To
Ft.
From To
Ft.
14. GROUT:
Depth
Material thod
From To 1 U
Ft.
From To
Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft
in. _ in.
From —To Ft.
in. — In.
From —To Ft.
In. _ In.
16. SAND/GRAVEL PACK:
Depth
Size Material
From To
Ft.
From To
Ft.
17. REMARKS:
1 DO HEREB IQE 6ITNISWELLVJ%S
CONSTRUC Ip ' ANDARDS,AND THAT Ad(
FOR OFFICE ONL11AY1 - L "j3
Quad No:
Subm t o t
SerW No.
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
c J ---
i -
v -
TRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
F THIS RECORD HAS BEEN PROVIDED TO THE WELL O%%NER.
JATURE OF PERSON CONSTRUCTING THE WELL GATE
Division of Water Quality, Groundwater Seca'on within 30 days
Gw•i RSV. 1241
a

271603
North Carolina • Depammnt of Environment and Natural Resources • Division of Water oualtty • Groundwater Section66f
1636 Mail Service Center • Raleigh, N.C. 27699.1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTORCERTiFICATION#:
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
(Road N
3. OWNER
Address
Agricultural ❑ Monitoring ❑
(Show ekeof the locatlon below)
County:
No.)
4. DATE DRILLED/
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES NO❑
7. DOES WELL REPLACE EXISTING WELL? YES NO
B. STATIC WATER LEVEL Below Top of Casing: Lo FT.
(use Y' 9 Above Top of Casing)
9. TOP OF CASING IS r_ FT. Above Land Surface'
'fop of wing termilutwd aVor below land surface requires a vulanu In eccor-
dance with 16A NCAC 2C A TS
10. YIELD (gpm): MEYHOD OF TEST '
11. WATER ZONES (depth):
12. CHLORINATION: Type Amount
13. CASING:
-
Depth
��
Was Tnickness
piameter or weigh(fFt.
Material
"l
64
To
Ft. fL� -- -��
From
From
To
Ft.
From
To
FL
14, GROUT:
Depth
Material,
From ./_ To 2
Ft. �a�Q
From
To
Ft.
15. SCREEN:
DRILLING LOG
From To
DEPTH
It additional space is needed use back of form
LOCATION SKE—TCH
(Show direction and distance from at least two Slate
Roads, or other map ralerer" points)
C
co '
Depth Diameter Slot Size Material 70
From To Ft in.
From To Ft, In. — in. 1
From To Fl. In. —In. y
16. SANDIGRAVEL PACK:
Depth Size Material _
From To Ft.
From To FL
17. REMARKS:((
I DO HEREBM CEF�TI�Y tF T Tjil� WELL IMAA� TRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUC110N&TANDAROS ANDTHATA4Q FTHISRECORDHASBEENPROVIDEDTOTHEWELLOVdrER.
.
FOR OFFICE!USE ONLY ;.,_4 NATURE OF PERSON CONSTRUCTING THE WELL OA'7E
Quad No:
Submil original Divislon of water Quality, Grourrdwaer Section within 30 days GWI REV, 12"
Serial No.

12 71608
North Carolina • Depanment of Environment and Natural Resources • Division of Water Quality • Groundwater Section r�
1636 Mail Service Center • Ralsigtti N.C. 27699.1636•Phone [phone] p�!//,/prw _E"�c'�'��-6
WELL CONSTRUCTION RECORD WELL CONTRACTOR: __ (
/✓ WELL CONTRACTOR CERTIFICATION CONSTRUCTION WELL CONSTRUCr)naERM)T#.Y: lA SOfdoO/"'l
1. WELL USE (Crock Applicable sox): Residential El Municipal L!d Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other F1 If Other, List Use:
..2:`WELLL01
Nearest To,
..rRuad tear
3• OWNER
Address,
(Show sketch of the location below)
.�, Count:
f
or SyD�ASlon and Lot NT) DRILLING LOG
.c rii�.,..o� From To
y>� d 70
7
7Jp Coda o -YY.7
Agricultural ❑ Monitoring ❑
DEPTH
4. DATE DRILLED /X_ -/5T0
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES Er�hO❑
7, DOES WELL REPLACE EXISTING WELL? YES rl NO
a. STATIC WATER LEVEL Below Top of Casing: p�,OT FT.
(u" •+* a Above Top of Cas'unp) l/
9. TOP OF CASING IS FT. Above Land o(Casing)
'Top of assng terminated War below land surface requires a varlance In aecor•
dance with 16A NCAC 20. 11a
10. YIELD (gpm):METHOD OF TEST
11. WATER ZONES (depth);170
12. CHLORINATION: Type Amount It additional space is needed use back of loml
13. CASING:
LOCATION SKETCH
Wag Thickness 4, m at least two Slate
,
Depth Qlpwoter or ai�op��/)Ft Matelot
From-LL-�—To Ft.-R--- •�-i=- G¢
(Show direction and distance o
Roads, or other map reference points)
From To Ft.
From To FL
14. GROUT:
Material Method
Ft. Saifk---re- L4Eb
ow
From Top_h
From - To Ft.
-1
15. SCREEN:
—
Depth Diameter Slot Size Material
-1
From To Ft In. —In.—
From To Ft. In. _ In.
From .—.. To FL In. _ In.
16, SAND/GRAVEL PACK:
o
Depth Size Material
From To Ft. --.-----
From To Ft.
17, REMARKS:
1 DO HEREBY C R THIS ' WAS C . UCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUGTIO $ S Afa w A COP IS RECORD HAS BEEN PROVIDED TO THE WEiL OWNER.
11 / —� -v
FOR OFFICE U p lY
Quad No:
- 3;S ^.Y - �, _- JL� RE OF SO PERN CONSTRUCTING THE WELL kl DAB
Subnt orlginW to Di IsbSection
n of Water Ouality, Groundwater within 30 CWYs OW.1 REV. 1299
Santa No. - -- s

WELL CONSTRUCTION RECORD 293980
North Carolina - Dcpinm.ent of Environment and Natural Resources - Division of Water Quality • Groundwater Section
59ELL CONTRACTOR(INDIVIDUAL)NAME (print) 6LitChell D. Cook CERTIFICATIONS 2043
W ELL CONTRACTOR COMPANY NAiYIE Fb:yM � Ml ttmr IM i 628) 369-979�
STATE (YELL CONSTRUCTION PERSIITP ASSOCIATED WQ PERMIT#
(ifacolicable) I (ifavalicab!e)-
1. WELL USE (Check Applicable Box): Residential 6 Municipal./Public ❑ Industrial ❑ Agricultural ❑
Monitoring ❑ Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use
2, WELL LOCATI N: Topographic/Land s tt;ng
N'ear fj Town' County ❑Ridge ❑Slope ❑Vall y ❑Flct
���— .. tchecrcappraprmte bax)
(Siree: Nrne, Nuncers, Community, Su ivision, Lot No, Zip Cade) Latitude/l0 n"ilude of Well location
3. OWNER: -(degree./utlnates/seconds)
Add r• ; !� La!r,id_rlengitude source:❑GPS❑Tcpe„aphic map
/ Slrrt or Route No.) (check boa)
�1�1
( D E ?T H DRILLING LOG
' citys o n Stu: Zip Fom T FormationDescription
`7 3� 0 Clav & Ei
Area <oEe.,`E number RI'dL11 i.E
4 DATE DRILLED
5, TOTAL DEPTH: S
6, DOES WELL REPLACE EXISTING WELL? YES ❑ j O
7, STATIC WATER LEVEL Below Too cf Casing: M_Fl. --
(Use"-" i`Aoo et Top c{Casing)
S. TOP OF CASING IS 2 FT. Above Land Surface*
'Top orcasing terminated at/or Eelow land su:race requires a
variance In accordance with 15A NCAC 2C.0118. -
9. YIELD (gpm): MET IOD 0: T S� , blow
10, WATER ZONES (depth):
LOCATION SKETCH c
11, DISINFECTION: Type 8 T H Amount I6cz Show direction and distance in miles front a6ast o
12. CASING: Wa0 Thickness two State Roads or County Roads. Include tiFroad,,_;
Depth`/ Diamer or weight/Ft. Material numbers and common road names
From n Tom, Ft. la �_ �tC_,.-t
Front To - Ft. I o<
From To - Ft. W fir,
c
13. GROUT: Depth Material Method
From o c
ri To 20 Ftkaai;tE & cs[s'it
From To— FL cJ nz
Moo
14. SCREEN: Depth Diameter Slot Size
From - To Ft,
_in. ,_ in. w
. From - To - Ft. in. in..
15,'SAND/GRAVEL PACK:
Depth Size Material _ -
From To
From To
16 RFMARKS:
I. DO HERE9Y CERTIFY THAT TNIS WELL -WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CON57RUC T ION STANDARDS, AND THAT A COPY OF TH S RECORD HAS BEEN PROVIDED TO TH. W—MLL OWNER
amu
DA
TE
S,ONATURE Or PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of WaterQunlity; Groundwater Section, 1636 tYtall Service Center -Raleigh, NC l
27699.1636 Phone No, (919).733-3221, within 30 days. - GWI REV. 07/2001

2939'76
WELL CONSTRUCTION RECORD
North Ciro I ina - Dopartment of Environment and Natural Resources • Division of water Quality - Groundwater Section
WELL CONTRAC1'ORjIINDIYIDUAL)NAME (print) M'tChell D. cook CERTIFICATION x__2�Ld3
1VELL CON] R ACTOR COtM?ANY NAiNIE HB'. Fbll Q:i)lirr?r IrC PHO•.NE; 028) 369--9591
S"rATE WELL CONSTRUCTION PERMIT# ASSOCI-ATED WQ PER,MIT#
(if aoulicab l e) - (if aool icable)
I WELL USE (Check Applicable Box): Residential Cos Municipal/Public ❑. Industrial ❑ . Agricultural ❑
Monitoring ❑ Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other,List Use
2, WELL LOCAT ,(, Topographic/Landsetting
N
4M
arest—own County}„$�e ❑Ridge ❑Slop ❑Vall y ❑Flat
a!
..(check appropriate box,
(StreF Name, Nwo er,, Commun!iy, Subdivision, Lot No., 2Ip Code) 'Latitude/lon;itude of well location
3. OWNER'. - (deyrai/u,inu cs/snoods)
Address Latitudcilongitudz source:(2GPS❑Topographic map
( reet or Rovee Na.) (check tex)
DEPTH DRILLING LOG
sty�y a.eAJ{ tam U Zip Code From Forrnenon Description
Area coda Phone number y � granite
4. DATE DRILLED
5• TOTAL DEFTH .
6. DOES WELL REPLACE EXISTING WELL? YESX NO ❑
i. STATIC WATER LEVEL Below Top of Casing FT.
(Use "-" if Abcve Top eCas'ms)
8. TOP OF CASING IS 2 FT, Above Land Surface'
-Top of casing terminated aVor below land surface requires a
varlance In accordance Ith ISA NCAC 2C XI13,
_
9. YIELD (gprr) METHOD OF TEST blow
10 WATER ZONES depth):
LOCATION SKETCH
11, DISINFECTION: Type H T H Amount 1 601z - Show direction end d stance In miles f om a: least
12, CASING: Wall Thickness two State Roads or County Roads, Include the road
Depth - Di meter or WeighVFl ,Maerial numbers and comrnon road names,
From O To_�_ � `p
Ft. I Aa6up
From - To Ft.
From' To - Ft. �.
13. GROUT: Depth Material Method _<
From n To_2.Q_ FtbM&ite & Czg,kir psrgecj w S2<
From To Ft. ?�
14. SCREEN: Depth - Diameter Slot Size Material
r
From To Ft. _in. in. c
—From To Ft_in.._ in.
15, SAND/GRAVEL PACK,
W G
Depth Size Material :..
From To Ft,
—
From —To— Ft. r=—
16 REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED INACCORDANCE. WITH ISA NCAC 2C, W_t L
CONSTRUCTION STANOM THAT A COPY OF Tr CORD HAS BEEN PROVIDED TO THE
SIGNATURE Or PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Sorvice Center - Raleigh, N�j �= : ! • -
27699.1636 Phone No. [phone], within 30 days. GW"•I FTBV, 07/2Q(4

293975
WELL CONSTRUCTION RECORD
Noreh Carolina Department of Environment and Natural Resources • Division of Water Quality • Groundwater Section
VYELL CON7RACTOR (INDIVIDUAL) NAME (print) 6LtCheli D, Cook CERTIFICATIOIN>Y-2,O—d3
SYELL CON'IRACTOR CONIPANY NANH '1 Ezoth s Wall IYillem, IM PHONE Y. 823) 36—9591
: STATE IVELL CONSTRUCTION PERMITY ASSOCIATED WQ PERMITd.
(ifaoulicable) - (if applicable) -
1. WELL USE (Check Applicable Box): Residential 2; Municipal/Public ❑ .Industrial ❑ `. Agricultural ❑
Monitoring ❑ Recovery ❑ Heat Pump Were, Injection ❑ _Other ❑ If Other, List Use
2: WELL LOCAT! : ; - - / Topographic/Land s tting
Ne •cst.Tow� unt Q/X-CC,.[jjRidge ❑Slope ,❑Valley ❑Flat
� {checkapproprldte tax)
(Sire:: i nme,.N mbe Community, Subd'dvon, Lot No., Zip Code) Latitude/longitude of Well location
3, OWNER', ICLk (it jree)/m. imineslseconds)
Add r s Latinide/longitude source.❑OPS❑Topographic map
ISi«et or Rowe No,)(che:k boa)
DEP T H DRILLING LOG
a�/[(�iyarpT9en n:: / Zip cgce From To, Formation Description
(A
Area code Phone numberyy�-��������,,--yyam� 'granite
4. DATE DRILLS ,X50
5, TOTAL DEPTH:: 1��
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO ❑ _
i. STATIC WATER LEVEL B:low Top of Casing: FT.
(Use "*" if Aeove Top of Casing)
8. TOP OF CASING IS 2 FT, Above Land Surface*
*Top of casing terminated iror below land surface requires a
variance In accordance Ith I5A NCAC 2C .0119, -
9. YIELD (gpm): � METHOD OF TEST blow _
10, WATER ZONES (depth):
LOCATION SKETCH
' 11. MIN' ECTiON: Type H T H Amount 16oz Show direction and d,stance in miles from at least -
12. CASING: Wall Thickiess two State Roads or County Roads. Include the road ,
Depth Di t.r or Weight/Fe Material numbers and common road names
From To Ft✓O' - o
From To Fr. /Tje nl`'Or0 4:_
From To Ft.
13. GROUT: Depth, Materia; M:thod cm
From n To 20 Ftl:8i�1Lte & C8T6?C =102:5
- .From To Ft. J>c
14: SCREEN: Depth Diameter Slot Size Material
From To Ft. —in, in,
- - Frcm To - Ft. in. in. r^�
.15. SAND/GRAVEL'PACK: - r
Depth Size M t-riai C.J
From To Ft,
'From To Ft.
16, REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I6A N'CAC 2C, WELL
CONSTRUCTION STANDARDS, AND TH T A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636aivIall Service Center • Ralelgh, NC
27699.1636 Plsonc No, [phone], Vvlthin 30 days. : GW-I R.EV. 07i2001

293974
WELL CONSTRUCTION RECORD
North Carolina - Dcr. irtment of Environment and Natural Resources • Division of Water Quality • Groundwater Section
WELL CONTRACTOR IINDIVID'JAL)NAME (print) MitChell D. Cook CERTIEICATIOiN4-2,0—d3
WELL CON'I'Rt1 CTOR COtNIPANY NAhIE �F'�-E31.)-e-PHO:vE#523) 3C`Ur-5�9
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if apolicable) - - - (if avolicable)
I, WELL USE E(Check Applicable Box): Residential 6 Municipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring ❑ Recovery ❑ Heat Pump Water Injection ❑ -Other ❑ If Other, List Use
2, WELL LOCATIC4: i�,�,�,;��� Topograohic/Lands ttini
-. NearcfTown tntyGn(,tgf.❑Rid;a ❑Slope.❑Vzlley ❑Fri
�Qtiti l� (check approp' aie box)
(Street Nmn , Numbers, C munit -Subdivision, Lot No., Zip Ccde) Latitude/lati itude of well location
3. DOWNER: L Y (cepre<s/u•inu,es'seconds)
,Addros OL__ Latltud^_/longitude source:❑GPS❑Tonograph is mup
'(S"w ou NO) u y.. (c)e:k.ca)
DEPTH DRILLING LOG
lbooJ
i:y or' n S Zip Code From To Formation Desorption
z )- A1/-�a � & �
Area cod' Phone number D 3 G' -granite
4. DATE DRILLED
;. TOTAL DEPTH : O
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
i, STATIC WATER LEVEL Below Top of Casing, Jn FT.
(Use "-" if A'cove Top o(Casin3) -
8TOP OF CASING IS 2 FT, Above Land Surface'
-Top or casln; terminated at/or below land surface requires a
variance In accordan wlth 15A NCAC 2C,01I&
9. YIELD (gpm): METV OF TEST blow _
10, WATER ZONES (depth): 7
LOCATION SKETCH
11, DISINFECTION: Type Y T A Amount 1 6oz Show direction and distance in miles fwm a: least
12.CASING: wall Thickness two State Roads or County Roads, Include the road
c
r or Weight/Ft. Material numbers and comon road names. C=
Depth s/.. Diare!em
o
o /I r
From O To �Z(L Ft. t�
.7F1.�.
Front To Ft. _ -
�x
From- To. Ft.
13. GROUT:-. Depth. Material -. Method t
EJ
From 0 To 20 Ftlginite & CHrg:t
zto
From To
14. SCREEN: Deetn Diameter Slot Size Mai
CJ
- From— To - Ft. in
mw
—in.
From To Ft n, in, r
IS SANDiGRAVELPACK! c�
Depth Size Material -
From - To Ft.
From To Ft.
16. REMARKS: I_
1
I DO HEREBY CERTIFY THAT T H!S WELL WAS CONSTRUCTED IN ACCORDANCE. WITH ISA NCAC'2C, W7ELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THB WELL OWNF
-
CV11 lop
StNATUR^ t OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Qunlity, Groundwater Section, 1636 Mail Service Center - Ralelgh, NC
27699.1636 Phone No. (919) 733.322 I, wlthin 30 days. - - OW-1 RSV 07/2001
' -

29397"0
WELL CONSTRUCTION RECORD
North Catolina Dcoarrrientof Environment and Natural Resources • Division of Water Quality . Groundwater Section
�VELLCON7RAC9'oR(hvDIVID'JAL)NANIE (print) MitChell D. Cook CERTIFIC.4I0INA-10-43
-. WELL CONTRACTOR MNIPANYtNAbIE f� Br0ljZS F101 +->•i i-i air IM PHONE , 828) 3,6:i9591
STATE wELI. COiN'STRUCTION PERMIT# ASSOCJ'{TED }VQ PERNI [TO -
(ifauolicable) - - (ifapnliceble) -
I. WELL USE (Check Applicable Box): Residential LDS Municipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring ❑ Recovery ❑ Heat Punp Water Injection ❑ -Other ❑ If Other, List Us-
2, WELL LOCATIO ! dge0 Topographic/Land setting
Neap tTown. Count ��-a�Ridge ❑Slope ❑V211ey ❑:lit
0,M/tjd1 - (check appropriate box)
(Street Nmue, Nmnbers, Community, Subdivision, Lot No., Zip Code) Latitude/longitude of well location
3, 0WNER: Plk 1 )I.1 .4h- degres minutes/sewnds)
P.ddre Q Latitude!lengitude source❑GPS❑Tope_raphic map
is, for Routa ,'o 1 �./ - (cheek bap
p / DEPTH DRILLING• LOG
{nj�.,h o iawr nt. Z,p Code From o Formation Description
(42iil — Q 0 7 Claw & s n
Area code. Phone number ' crananite
4. DATE DRILLED.
5. TOTAL DEPTH:
6, DOES WELL REPLACE EXISTING WELL? YES NO ❑
7, STATIC WATER LEVEL BelowTop of Casing &WOO FT.
(Use"," itAoove Top ofCasing)
8. TOP OF CASING IS 2 FT, A'cove Land Surface'
-Top of casing terminaled a:/or below land surface requires a
variance In accordance with ISA iNCAC 2C A118• -
9. YIELD (gpm): //% METHOD Or TEST blow _
10, WATER ZONES (depth) /�)l5 r
LOCATION SKETCH
I I DISINFECTION: Type H T H - Amount 1 6oz - Show direction and distance in miles from at least
12, CASING: Wall Thickness two State Roads or County Roads, Include the road
Depth /Q D:� , I or Wei rJpt. N9ateriat numbers and common road names.
From Tom Ft �, s
From To Ft.
From To Ft
c
13. GROUT: Depth Material M-tr. od ro Zz
0
From_To 20 FtbEir-&i:te & MlietI
From To Ft.
14. SCREEN: Depth Diameter Slot Size Material S
From To Ft—in.1n.
From - To - Ft, —in. in.
15. SAND"GRAVEL PACK: ^'
Depth Size Material C4 y`
From To Ft. —
From —To— Ft. - o
—' —
!6 REMARKS:
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I5.A NCAC 2C, LVBLL
CONSTRUCTION STANDARDS, AND CO YOF THIS UCO N BEEN PROVIDED TO THE WflL L OWNER�Zak-� (,W, 9-�a�
SIONATUr--C PERION CONSTRUCTING THE WELL DATE
Submit the original to the Divlsion of Water Quality, Groundwater Section, 1636 Mail Service Center • Ralelgh, NC
27699.1636 Pilonp No. [phone], within 30 days. - OW -I REV 07i?Ml
I _
� �L

WELL CONSTRUCTION RECORD 293948
North Carolina - Department of Environment and Natural Resources - Division of Water Quality • Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) Mitchell D, Cook CERTIFICATION# 204_3
WELL CO.YI'RACTOR COrMI'A:9YNA,NIE P­-1-1 (37 r=, � PHoNE k g28) 36}-9591
�ASSOCM7ED
STATE WELL CONSTRUCTION PERMITk - - - -. WQ PERNITO
_(ifapplicable) (ifapoliaable)
-
- L WELL USE (Check Applicable Box): Residential 6 Municipal/Public ❑ .Industrial ❑ `. Agricultural ❑
Monitorin; ❑ Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, Lis; Us-
2 WELL LOCAT10 l: Topo rapnic/Land setting '
Nea stTo �1: Count ❑Ridge ❑Slope ❑Valley [Mat
f''ILA( ��7jJJ
(Check cppropriate aca)
(Street kAle, Nwnbers, Community, SubdiviWn, Lot No., Zip Code) LatlWde!1o9gitude of well location
ZO3. OWNER : (•araAniniiles/seconds)
:. Address L r.udu/lov�itude source: ❑GPSOTopc graphic mup
an :t e,Route No (check bay)
DEPTH DRILLING LOG
tycr ow tae Zip Code From FormahonDerription
( - 0 y�7/.
Area C1W & �i
--��p— r crran.ite
ED—nuirb
4. DATE DRILLED - � - Q
E DRILLED-
5, TOTAL DEPTH: s
6, DOES WELL REPLACE EXISTING WELL? YES P, N0
i. STATIC WATER LEVEL Below Top cfCasing:
_Q
if A'cove Top of Casing)
8, TOP OF CASING IS 2 FT. Above Land Surface*
- 'Top orcasln; Wrminared at/or below land surface requlres a
t
varlance In accordance Ith 15A NCAC 2C AI 18, -
9. YIELD (gpm)` MET�yO�t PF TEST blow
10 WATER ZONES (depth)
LOCATION SKETCH
11, DISINFECTION: Type H T H Amount L 1 6o2 -' Show direction and distance to miles front at least
12. CASING: W'al1 Thickness fvo State Roads or County Roads. Include the
road
Depth Dia zter or We:ght/Ft. Material numbers and common road names
From - 0 To FL n ✓(
Frorn - 'j`— -
To Ft
- - - From - To R.
13 GROUT: Depth Material Method
c
From_0_ To 20 FtkE'1TL'•:te & ma-m t La Cr - - b
• From - To -. F•, r
�.
ca
14. SCREEN: Depth Diameter Slot Size : Material m
-
"'•p
..From To FL_in. in. -<
From To Ft —in, in. j
o
l5. SAND/GRAVEL PACK:
Depth Size . Material - - �.
M
From To Ft.
From To Ft.
Mz
r
N
16 REN(ARKS:-------------
c
z
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL CONSTRUCTION STANDARDS, ANDTTHHAy7 ACOPY
THI
l
RECORD H APROVIDED TO BEEN PRTO THE WELL OWNER !"
/OJFF
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the theoriginnl to the Division of Water Quality, Groundwater Section, 1636Mall Service Center - Ralelah, NC
-�
27699.1636 Phorle No. [phone], within 30 days. - -
GW-I REV. 07/2001
—
E

WELL CONSTRUCTION RECORD 293945
North Carolina - Department of Environment and Natural Resources - Division of Water Quality,. Groundwater Section
14EL000N7RACTOR(fiNDIVIDU4L)NAt�IE (prim!) Mitchell D, Cook - CERTIFICATIO)N4 204_3
WELL C0.41 F A CTOR CONIPANYtNAME 4.0 a-iLLIiyr, IM -: PHONE # [phone]�
- STATE VVELL CONSTRUCTION PERMIT# ASSOCIATEDVVQ PERNIIT# -
(ifaoolicable) - (if applicable) -
I, WELL USE (Check Applicable Box): Residential LA Municipal/Public ❑ Industrial ❑ Agricultural ❑
Moniloring ❑ Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use
2 WELL LOCATI Topographic/Land setting
Neat stTown: Couny❑Ridge ❑Slope ❑Valley ❑FIaI
/h/��o a (check approprlat<box)
(Site.-: Name, Numbers, Community, Subdivision, Lot No., Zip Code) - Latitude/lonvitude of well location
3. OWNER: .(degrees/u;mutes/seconds)
- - Addre Latir,ids�longitude sou:ce:�OPS❑Topagraphic mep
Is eee Route iJoJ ../ (check boa)
i DEPTH DRILLING LOG
City y{raN;zpeode FOom to Formation
�onDescrip;ion
(
Are, code. P4one number r 0 etran.ite
4 DATEDRILtED_3'rI'fI�
- TOTAL DEPTH: ;35oe
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NQ
7, STATIC WATER LEVEL Below Top of Casing: �_ --
(Use":" if Abcve Top of Casing)
8 TOP OF CASING IS 2 FT. Above Land Surface*
'Top of casing terminated aVor below land surface requires a
variance In accordtincetillch 15A NCAC 2C .0: 18.
9. YIELD(gom): of MEJblow
10. WATER ZONES (d otn)', �J_4O,FTEST
LOCATION SKETCF' "
11. DISINFECTION: Type H T H Amount l 6oz Show direction and distance in miles from at lease
12. CASING: Wall Thick,ess two State Roads or County Roads, Include the road
Depth Q, 4 Diameor Wei ht/Ft. Material numbers and corunon road names.
-
e,ter
From To J el Ft.—
From - To Ft.
From To Ft.
11 GROUT: Depth Material Method p
c
From _ To 20 FtbErmi;te & OM -et =r)e i .c..
o
From, Ft
De
14. SCREEN: Depth Diameter Slot Size Material
�=
From To Ft. —in. if, t
o
w
- From To Ft._in. ir..
t-
>o
t5 SAND/GRAVEL PACK: _
. •Depth ..Size Material _
n.
From To Ft. - .. L?
r-tz
From To ft. - r
6, RENIARKS: _
Z
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL r
CONSTRUCTION STANDARDS, AND THAT
A COPY OF 7H15 RECORD HAS BEEN PROVIDED TO THE WELL OVYNER
1 -
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
_
Submit the original to the Division of WaterQuality, Ground}vnter Section, 1636 Mail Service Center - Ralelgh, NC
,
27699.1636 Phonc No. (919) 733J221, within 30 days. - -
G W• I R.,r V. O i /2001

111
WELL CONSTRUCTION RECORD '""
North Ca.o'uta - Dcpart meIt or Environment and Natural Resources - Division of Water Quality • Ground water Section
19ELLCONTRACTOR (IIVMYIRAL)NAME (print) James B. Brca CERTIFICATION, 2045
wELLCON'iRACTORCO:vIPANYNAn1EFedden Brothers Plell Drilling, Inc PHONE o 8229.) 36969_95 1
- STATE WELL CONSTRUCTION PERMIT? ASSOCIATED WQ PEANUT" _
(ifzonlicable)- --(ifaonlicablej
1. WELL USE (Check Applicable Box)', Residential t! Municipal/Public ❑ Industrial ❑ Agricultural ❑
_ Monitoring G Recovery.❑ - Heat Pump Water Injection ❑ Other ❑ lfCther, List Us-
2, WELL LOCATI Tupog;aohic/Land setting
N-C c,_ s,Toyn Cou �ctiE)Ridge 0Slope ❑Valley ❑Flat
--Y�14(. ,4 (check appropriate box)
(Sre . Name, Num crs, Cenw . Ity, Sabdivisioa, Lot No., Zip C e) Latitude/longitude of we!1 location
3 OW'NER', degreesh^n.neshe:-cods)
Address Latitude/longitud-source,❑GPS0Topograhhic map -
"veer or Route No.) (check box) i -
_._ _
ell
DEPTH DRILLINGLOQ__.___
C orTo•�n Stave Z:, Code From T s Formation DescrLotion
(&�) .NC- $/T / 0 clay & sand
Area coda Phone number /�o_ crra Ste _
4. DATE DRILLED 3-
5,TO' ALDEPTH:
6 DOES WELL REPLACE EXISTING WELL? YES ❑ NO —
7. ST.A'TIC WATER LEVEL Below Top of Caa,n;: FT.
(Use "-'if Above Too of Casing) -
8. TO? OF CASING IS 2 FT, Above Land Surface" -
--Top or casing terminated at/or below land surface require) a
varlance in accordancey�th 15A NC.4C 2C •0118.
9 YIELD (gpm), (Q METHOD OF TEST blow --
10WATER ZONES (d/pth): -
- LOCATION SKETCH
11, DISINFECTION: Type H T H Amount 16 OZ Show direction and distance in miles From at least
12, CASING: Wall Triokness nvo State Roads or County Roads. Include the road
Depth D: me:^r or Weight/Ft. \1ateris[ numbers and common road names,
0 To�Ft. ar
From
From - To Ft,
O
From To Ft. -c-
13, GROUT: Depth Material Method 3 n
From, 0 To ' 20 Ft. t�nnite & car, pumbed
From To Ft I
14, SCREEN: Depth Diameter Slot Size xiaterial w
' From -'To Ft. —in. in;
From To - Ft. —In. _ .in.
15, SAND/GAVEL PACK: �? r R
Depth Size .Material _ w
Co
From To Ft. rn o
From To Ft. z
16. RENIARKS
I DO HEREBY CERTIF\' THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THA COPY OF THIS RE OfLD HAS BEEN PROVIDED TO T'H•E R ELL O\WER
SIGNb.61 F PERSON CONSTROC I G THE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mall Service Center • Raleigh, NC
27699.1636 Phimc No. [phone], rrlthln 30 days. .• - GW'•1 REV. 07/2001 -