Well Construction Records Yancy CY2000

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i t
22940
'nnh Cmpbna . hrpmtma-I rl rnvtrovn•rd and Natutnl ►1esotvice9 • CIvIHon of Waist Oually • Oroundweler Seclloft
,38l.lOil Snrvico Crnn,t • itnlel0h, N.C. 27899.1e38-Pl,one [phone]
WELL CUNS11MG11011 11ECO11U WFLLCONINACron: Jb�._-1.1rR9ULSanL
WELLCONInACtonCFntirICAllOtI0:,�
StATF WELL CON9iflUCTlOt1 PEI1MIt0; _i __._
1. WELL Urr (ctnck n, rti,mot, n-.v)t tlnaldnntlaf 6d Municipal Lj Industrial ❑ AlvIcullured Monitntin9 L)
(lecovrry I-) I Irnl rump Water Injection 0 Ofher Ej U 011lerr L191 U9e:
2, WELL I-OCA110 ((;hmv sketch of tthe locatlon below)
Nn: enrest tow�'� 'u•{ 7i�y—� COuny:
jnoaiii.vmoml14".0'.is,Comm mIlly. o ubdvislonendLolilo) Uf11LUNQLO(3 UEIJ11_.___
From to rom anon 0escdpnon
Address // 1
Vel or lf;uln Ro`.
l�/i1axS2L�__ !�
Cnyn, ir.,. - elnle 21p Code
4. VAIEPIII11.F1)_�a•%�-0tf
S. TOM Itfil'lll _ ..__ !2 �• R g
S. C(ITIII It's ci.3l.11"CIEO YI38—_1 NUL1%J o
7. UVES wnJ_ lU'I•lncE rXts11NG WELL? YES O
D:
B. SIAIICWAIEf1LEVEL Oelo1•Jlop o1Ca91n
(Use 1* O Above ter nl CROV) _ am
9. TOP Or CASING. L;.__ I__ . rT. Above Lend Sudnco' CO
_—
lop Pinn helow lend surface unufrn a vnlene's M aeem• a --r
.nee withIrA11Va2r.n118 _ �� r,
tO.YlE1_U(al"'+) �.T.MEIIIO0OrTEST�IJa
11.WATEfl7O1JES(tIrI+U,):— _ _ __•�_
12.CIILOItIIJAiIOtJ: lype_� z
Amount Ifaddlllonnlernr.o11oredndusnbnckatform
13. CASING:
wen 111110neee
�inmselt�er
INi xY. A fLr,,,I I Ais
ilY•' YOlr,elf(
Fwm-�Urldh
__lo'��FL�
. rtom--
rtom.
14. 1311011E
elhod
I,rrth
s�Mnl�nrinl
�� X-0-amik.
roomis.
—.------
15. sCNrI II:
1),.I,u, bian,nlor
SlotSlzb Mnlmlal
r- in
I n _ . _� I't -
— In.
_
rronl —
_ It, ------1 1. ___-
It"
rlon,
Iu. _T1
In.
to. SAiJUI(iNAVrf,
rA(II(:
Material
Url,ll,
SI28
From _—
In ---- t-1.
From ..._.
10 rt.
--
LUCAIION SKEICII
(Show dlrecllon and dlninnce from at Inas1 two Stale
floods, or olhel MAP Irlelence Points)
96t_CA5 az4& � y/
17. FIEMAIM 3:
100I,PnrnV t;Ftv�rr nJsAT(�In9 WEll NVA9 CO1JSI11VCJEtl ItJELL
/1CCol10NJCE W111115A MAC 2C, rLL
CONSII1Vr'llOal {]11t1OS`AND91IATACQPY 11119flEC0 DHA9 BEEN PIlOV10ED /O 111E WEll.OWNEn.
_ fi
ro11 Orr l(,C t)t
71ILY ; OatE
t tll(tUnE or t'En5 11 COt191nUC IA 9ecnon wllhln 30 days
Oued llr' (� t'' (.
� 6ub Av9�0 d avblon vl Weler OvelBy. brvvndn' OWI FIEV. I2J91
Setst it,
x

I,_ ,. 4,i f•r+ �M rk ..31� rf•t tlN r.t n. ...L •t j. ...
r
trlit Cnrpb�n . Itrpnrluvnl rf Il wirr•vnerd mild NnIUrnl nenmucrl • Olvlpinn OI water Quality UmUndv.nlrr Secilort 229477
,36 Mail Crrv;rn Crnlrr - f lalelgh, N.C. 27699-1e36-Phons [phone]
WELL CUNS111LIC110IJ f1EC0110 WFu.ComnAClon: —ZoE._-.Fi6.B9Lksc)a_
WELL Co111nACTonCEntirICA11U11Ir:`;
SIAIF WELL CONSIMUctloll PEnl.11ln:
1. WELL ll+;l_ Iroeck At ro•f): tlrsldontlalLid MutdCIPal L_J bldusidr,l L_J Aprlcultuml L__I Monllorhig (_
Ilrcok,my j _I 1 Irial Punill Witter h,lecllon L] Other L) If Other, Llsl Use:
2. WELL I (It tAI1Ut1: 1to�w�s,kr,r-vIfrhh� 7a11hp Igccnllon below)
Neme511own:____!•a/P/�J.Kl� .County: 7dw
Of 01-
Pyml lrvnr nnJ lLu.• i5, Ctnnw ntl,y, er vlllon snd Lot Nol UITILLINo LUG _ UE( l l l
3. cAvr1U 11 /�,� C From To rmmMlon Orfalrllnn
Addrr^n 11 dQGI/ e' d ---
-t'+rlir' m furl1�7o.TT �- ad'J_ " d - -
Ea
A. /"-61n1e Zip Code — -
A. BATE PI III.ITI 1.a�' -QC
S. TUTAI UI:I'I11
G. CUT111 (.,,1iI.LUI,,Ir;U Y15,_I NO[t7J _ .o
7. UOES bVI"L1. 111'I'IM:E EXISIINO WELL? YES FIUudo
S. SIATIC WAl Ell LEVEL Veluw loP o1 CeMblq:
(Vfe b' 9 Above TOP nl Cefingl
rT. Above Lnnd Sudnco'
Tor of eefLm I.nninnbd elf", below lend euffeee Isqulles a Yerlenee In Neer' _CO
mee tvtlh L.M ❑cAC IC AIIM f --` '—`�'— De
10.YI[I_U(ppm):
11.WATE117UNGS(tlrplh):_.— J -- �' m`
12. Cl ILUNINA 1I014: I ypr ._/ AmoUn( T'"- II eddldonal epncs h nrmind unn buck of Im14- -t
13. CASING :
O DvpIhIllmlipler
�
Prom_ ----lo -._ r1.
Fom-- — 1 n -L-
ln.__-_.- TI.
K GIIOUI:
UrPu, Mnlorinl nlhorl
rim" .._.
rroin
15. SCIIUII1:
UrPlh Utmnnter
rtorn _-_ lo_..__
• From _-_--._lo Il. In.
riot,, ..... _ lr .
16. SANUIUUMIA -PACK:
Url,lh She
Wen 11,14neill, .LUCAIIUN SKF ICH—
p
or WIIIgLVIi'llt. }Anlednl (Slaw dlrlcllon and dlnlnnce boor nt Inn+l lwd Slnle
�14J�S nR noeds, Of 01110, PPIIMP'f-ele1@11co P01 d9)
Slot SI16 Mnlorinl
From -- la__--11.
From _._ to rl.
17. FIEMAIIKS:—
no I lrl,rnV.. Crnll' A��jj
CONSIIIVCIIrgN iAllUW1O.S./(NW!IHI
rot, o�1 icr usr x)iii.Y
Oued Nr' �j Iv • Subml
Sedel Nr -
Melellnl
t$IRLICIEU IN ACCOIIOANCE WIIII I$A MAC 2C. VIELL
RECU O '" BEEN PROVIOEb 10111E WELL OWNEn.
;,,A4,T,T',E or rrnS Il Cotl6mucntro 111E PJrt I. bf1tE
to (Nvblon of Wolof Dually. broa+dwtlu $.coon Wllhhl 30 day! ow
-I Tim I2199

2294'78
it lh Cnrpl n:, . I,�i,n, I...rm of fnvlrrruoe'if and Nowtvii ►Ieeourc" • Dlvlelon of Water Ouallly • Orouodwnler Soclien
38 Mail Srrvlco Crnrrr - Ilalcigh, N.C. 27699-1638-Plane 1919) 133.3221 --tt--.
WELL CUNSINUC1loll nEcant) WELL COMTIACron: Job-__FiP.43usc)H_
WELLC0111nACT0nCEntirICANOII8:� p�
STAM WELL coN9inuCTloN mimittf:
1. WELL WIT' (ci,rclr aly.nr.I,len.,+t: IlesldonllalLi MurdcipalU IndualdnlU
Ilecovriy (_1 I lone Pump Woler In)ecllon 1] Other Lj If Other, List Use:
2. WELL /U IUI P} holy sketch "Ithe locellon below)
Nemost meel I awn: __Er,i.lp�1, County"—'(/U�4
jn�au li�nin omi i •imis. Colmh"Illy, or Sub��Jlelari aito{lio.j OI11LL114G LOO
3. OWNrfI _ Cj [�fGLff/dla A From To
Addre^e Jr
_
---I"rPFI a R�ul'n
City m IV,,, Sule zip Code -
4. OAIEhIuI.LF'rtI 1 ad
5. 701A1 Pt'1 I11 _
G. CIITIII I(:,^. CVLLF"f;ICU YI_ U-.1 N0u1j
7. UOES W( 11_ IIPI'LACE rXISI1tJ(1 WELL7 YE3.L1—t4O4
8. SlATICWAlEtlLI:VELUelov7lopofCnsing: FTr
(Vfe'.' l Abova Tap nI Cae619) '
9. TOP VF CAMI I(1 L. __ . Fr. Above Lnnd Sudncn'
'*op of caelnn 11, mhmhd rihv below lend Outlets requlHe TO vulanee In secat-
....
me a wnh t' n ,2C .911 a a�
10. YI[Lb (anmi„): .tD_. MEIIIUU OF TEST R,
—
11. WA1EN 7.OfJES (drptll);� —
Apriculturnf LI Monlloring Cl
12. CIILOfIltJAIIQI4:
13. CASING:
_ hEP-11
raln.atim vest:110an
O
---------------
typo _f_(_Il]__...Antouid Ileddlllonnlnpncnhtip orirdmifbnrktit form -_
UrpltlPininflot
From—� --_lo _Z FI. Ia.25
Rom—_— In rl.
Firm . ___
14. G110t11:
LUCAI ON SKETCH
wan ihlafneel
or WYMbVt (. IAelednl (91row direellon and dl•Ilnncn ham of lead fwo Stale
�11e.11S �nR noeda, or altar map irlererice polnU)
ItrPlll MnlnlhoutEd
Flinn
Rom
15. SCNEEII:
U,�pih bianlolor Slot Slzb Mnllnlnl
From _-----.loITI.
• From -- -- 10 ..._..— 1't. ___ In. � In.
From .. ._.le. ..__rl.--- tin. _In.
18. SANUI1,111AV1'l. PA(11(:
0r1•nr SI2e
Fiom
From to rt. —
17. nEMANKS.
Moteilal
Lh y —
1 DD I Ir nFnv Cn1aIeP'r`F1iA1' 71n9 WELL WAWcatf9 InucTED IN ACCOIIDANCE W1111 ISA NCAc 2C, v/FL
COHSIIIUr IIbl rS,1AFIUAr1D^, ANDTIIAT 0.GURV T1119 nECD OHA98EEN PROVIDED TO TIIE WELLOWf n.�d QQ
Et'll
,noatE
6ubme: dlo tNvblonM WNer Oualny.Orow+dweNl gocoon wilhln30 day1
OW1 tIEV. ILTI

a ft 1:.^.:.,..._ •1ts f0il ii N"x'Elt'} �� :�IL1S^ ---�`- 1 SiL" 3t t' 7 •n_. - -
r +
j � t
229479
'•,nh Cnrpb�u . f,np n, tow ,I rt rnAhnvM,It end Nolwol Fie ftmnoee • Dlvlelon of Well, Ouellty • b,nundwoler Section
,36 Mail Srrvlcn Crnler - lhielub, N.C. 27690-1636-Phone [phone]
WELL GUNS MILIG1101111ECO11U WFLLCONr11ACTOn; R3- "ZtL-77
WFLLcoNrnncroncmuf-ICAIlollll:
srnTE wELL CONsrnucTlon Primmil:
1. 1VFLL U!a( (ravcM n,y.nnnbl• nn.p I7rsldnnllaiLl(J Munlclpal [j Indulldtil ❑ Agrlcullurnl IJ Monliming LI
flecovrty 1 _1 1 Lnl rump Water Injection ❑ Ullw [] If Ottler, List Use:
2. WELL I.UCAIIUt ,how sketch ol.lh locallon below)
Newest Town:�Ll9gS7(®�og County:
(nestIlmun and Ihr„a--Cmmondly, of bdlvlelon end lot noT UNILUIJO LOG UEr-lll___—.
3. MUM zL /�t_ Flom to ro�n,eeen On<drllon
Address
% Q
-4• Pe1mrG�ulnRo. — rii.7_•—
�- ��40 - edc4c►s--
Cltym Ino�+ - - fitnle� zo Ootle - -
4. OAIE hilll.l.r11 ��•Qa
5. TOM 111:1 I11
G. C11T1111(:,r.C(Jl.It+Glra) YI58o tiouvj o
7. UOES Wrl.l_ IIPI'IACE rXIStINO WELl7 YESCJ IDOL
a. STATICWAIErlLI:VELETejOwlop ofCasing:
� Cc
(Vse'4' 0 Move top or Caeing)
9. TOP ('r CASII)(; 19�FT. Above Land Sullncit
Top of arid'" ,r, n,h,nhd Fist helow land surlete lequlree a Variants In attot• DC
meewlth lr.l, rlcrlC 213.01111 - fi• AC
10.YIELU(npnQ: _�_.ME111000FlESF_ /llQ� — � N�
11. WATErl701JE5 ((lrplh):� - - _ ma
12. Cl IL01111JAI1014:
13. CASING:
Typo _[ Amount II eddl9onnl epnce Is nrcdnd III" bnrk of loan -z
wen Ihrcl•neel -
Urpih�/) lemrter or�WelrliV I 1A,Dd�e�naR
r,om
Firm . _--- _-- I o
14. G110111:
f, Itrpllt n.M.nleee'nr'(,� Rom JSoulfA
Finn,
15. SCf 1L V11:
U,�ptl, blan,olor
From _-----ln_.._—It__ In.
From ____ tn-__..—rl. In.
Ron, ....-...10. .-.__rI. 41n.
19. SANUJ3,11AV171. MCI(:
Urplh SIX#
Slat Slxb Moodnl
In.
Material
LUCAI ION-Sl(F ICII
(show d6ecllon and dinlnnce from or land Iwo SII119
floods, to other mop lefelence polnls)
From _— Tn --_II.
From ...--- to rt. —•
17. nEMAIMS: - --
I V011rluny Crni lr`y, UtAttlj:u4XYF4.l6-CAB-CUf137111119 nEC0 DNA9BEEN rROVID b 70111E WELL COWNEn.
CONS11111C 11011 !:Q/tNUA71D9, ANO Tf 1A1 ACOP'�
rUil OrrICE USf O11LX ^fglla)E or rrnS IIC01ismuctlf1O/11F. VIM L DIVE
Wad Nn
6uMa loD)vlslon at Wabr Wallry,blourdwtla 9aeon Wllllhl 30 dny! oW.I NEV. ILff
Sedel

1North ere M�sna - Gnt�in ofe nvkcrw wrd and
Mob"
ix- R"Cureof
lure) 7- ONWan or WHa OuMN - ��ater section 2 2. 6 -1 0 8
WELL CONSTRUCTION RECORD WEELL
WL CONTRACTOR CERTIFICATION It:
STATE WELL CONSTRUCTION PERMrr#:
1. WELL USE (Check Appilceble sox): Residential v�- Iurllclpai industrial 0 Agricultural Cj Monitoring ❑
Recovery ❑ Heat Pump Water lr*m ton ❑ Other ❑ 11 Otter, List Use:
2. WELL LOCATI(r7N: (Show skate. (hs location below)
Nearest Town: \-�5-�'�S�
�L
(Road N e and urtben, comruNlY. or Su»al icnQ ld No)
Dom LOG
From Tc
DEPTH
Fommtlon e0 w"011
3. OWNER
D r/tiL
2
/J�l�
Address
City or T~ VP Cede
r$tale
4. DATE DRILLED
N ''
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES NOQ
o
7. DOES WELL REPLACE EXISTINd WELL7 YES [] NOrii7(
-
O
o
6. STATIC WATER LEVEL Below Top of Casing: 2 f) Fr -
of
lux" **' a Above Top of Ca "I
3'
r' • ,
9. TOP OF CASING IS Fr. Above Land
-
Topof eexirq terminated xtbr below land "uAet» wpuNes a verlente in ettory
drrce with ISA NCAC 1C.0118
-
10. YIELD (gpm): 129 METHOD OFTEST_--
---
11. WATER ZONES (depth):
12. CHLORINATION: Type �' /� f Amount
If additional spare Is needed Lae back of torrrt' •
^`
^ ^�
13, CASING:
l r1r'ATION
SKETCH
z
Wall Thickrom
Depth r rW,�a60WR ,Ua1,11" (Show direction and dbtencs kom at least two State
From S1—To Ft. D-- - —�-rl — -f-"" meads, or other map, rabrenca points)
From To Fl.
From To FL
14. GROUT:
Depth Material .Method4R
From b To Ft.
From To Ft.
15. SCREEN:
Depth Diameter Sio1 Size Material
From _ To — Ft — In. _ In.
From _To Ft. — In. —In.
From —To — Ft. In. —In.
16. SAND/GRAVEL PACK:
Depth Size Material
From To Fl.
From To FL
17. REMARKS:
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 1EA NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COP�YY F THIS R CORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY '' _
Quad No: SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
�Wri�bdpbfi Ie OhWen of Wafer QuelYy. Groundwxler SecOon within 30 days
Serial Na. OW -I REV. 12M
}
ire..

� ¢ >r y, :� •' � _. �_�iti#�ia��Td �_t>t _ ' iate it :.�fi7r�'.i�
I.: ....r . .. t d!:;- .a l•a`•�T_ t:r: �wr •...T.•. - p4!1." , e•...t t• -
V d
r I
229439
nth Cnrbbru . hrpnnnrrnl nl 1'lr0bo-mvfnl end NMumf thetmrrcel • Civlalnn of W!N(Oudity • O,nundwaler Socllon
dJ8 Meil Srrvicn Crmrr • 1lnlelph, N.C. J!7600-iSJe-Plans (91 p) 7JJ•3221 � CC
WELL CUNS1IiUC1IUIJ MGM) wrLLcolltnncfull! b�._.1.�rRSjU�So .
WELL CONinACTOnCEn11rICA110110:� p
StAJF WELL constnuclfon PEIIMItIt: __-
1. WELI. tlSl? (('heck nI pllralJe nn I: nesldonilal W
Municipal [j
Industrlal ❑ Agrlculturnl 1A Monilodng LI
Ilecovrry j _)
I Irnl Pump Water Injection
other 0
II ogler, LIs1 use:
2. WELL LOCAIIUI I:
lfilrmv sketch old a to orlon below)
Nenresi town: _�1n.cr.LZ
FS �, e j `
county:
f—
—jnoarllianmmdiiu,imis,1.7on,nomlly,otSubdv
lon.nd�ollb.l
UFIILLIWOLOO
�J f
S
P/Mn Te rormMron Oe+cdrlbn
Address —7
.1Q..
s R }-
_—
j rlml'Gvlerlo��(i
Clry n, Imm more ---
4. oAl E n11n.LEl, -_J/' �' Ob �• �:
S. TOM Irt:f-Ill L l ��
N(i xn
G. C(ITtltl(1. C(11Jf
1?IEII YISS NU .+ a
7. UVES OVrl.l- 11I'PLACF FXISIIWELL? YES IJO n^
S. S1A110WAIEnLI:VEL13001•11OPofCasing: `_•_FTs n
(Use'.' a Abore ToP nl Ces6rp) ----
9. TUP ('r CABIIJG FT. Above Lnnd 6udnce' ---- --c�
"P oT veshrl,I.rminnVd ritm below lend furlRill Hgallol a Yed; nt�hn ateol-
.enN,vhh 14A llnAC t e le & —g--
t0. YIFLU (nrllr): D- MEI I IOD OF TEst J1>t- —
11 WATEN 7L1NES (drpllh);—_ __
I Fl
J11 -
- Amount ills
If edditlonol epnce le nrednd urn bnrk al (orm
12. CI ILOItI1JAt 1UtJ: ypo _
13. CASING:
LQCAII-ON_SI(FI(:II
Wert 11110"e4l -
ImedM
(Shaw dlreellon and dlalmrce Ilom nl le+d two 5tnte
Urpul
Inmeler
awelghN 1.
JW,J T '�lUtLK
Hoods, or other mop telelerxa points)
Flom-- la -- rl.
_ /,� OVA
Firm _..--
A'
Flom .....U._lr..AQ—I'I.
rrnm .._ .._ to ._____1'1.
s
-
15. SCNLrI I:
hrplh blanwior
Slot
Slzb Mnlariol
rlom------- In _ ._� 11 -
— In.
__ In• _ ----
In.
Flom-_._ln..._..._rl•------
In.
—
rron, ._......to. ..._-rL-.—_
1
is. SANUIGNAvrI.PhCIQ
Material
Orpth
Slis
From
From--
17. F1EMAnl(s: WELL
I oo I lrrnrnY crr111rY T1 IATTIn9 WELL WAS cons ln(ICT 6"C ACC011DMEH 1`811119A I10A"'a
CONSinLrr: I loll St AlIUAl1DS, ANOTIIATACOPY T1119 REC0 OIIA9 BEEN PROVIOEO TO 111E WELL OWNEn.
ate-- DATE
fronOIrICGUSFUIILY t1ATlmEOrFETiS nCOn91nVCn SittrEWF.II
Wed ftn: Bub,Ia odY 0 to Mvlllon M wslw Minify, Dr01M'd+'Nu Secean W111dn 30 days OWI nEV. 12119

Jb ILA . ; n .
l ........ to.�1:!'.�.y.l *, ,�r.:�s•,yr.. ,...•�. .1,T�''r.,. L�•. 11• _ 11
..
229440
-'9rlh Cnrpl•nn . I1, pnr lnv nl PI rnow -vn!nl end NelvtFit fie ?ourc" • MMon at Water Quality • Oroundwnll/ Section
,38 Malt brrvirn CPnlrr • 11nlelgh. N.C. 27899-1030-Phone [phone] •-c'.
WELL CONSMUG11011 FIEC011U wl=_LLCONMACTO11- Jb�__��R9UrSa
WELL COII1nACTOn CEntirICA110tI
StATF WELL CONS MUCTIMI PFI1MII
1.
WELL tl I: (Clack nr r11nWn nP+): tlesldnnllatU(J MwdClPnl [-1
Indusillnl d Agrieulwrnl (J Monitodng
tlecovrry ( ) I lcnl Twill, Water Injection ❑ Other r] If Omer, U91 Use:
2.
WELL LOCATION/�•.s now sketch of Ilse location below)
Newest Town: _Z 4 STD J Z-1 1.—� County:
--...-----•- ---------- ---
ploedrlan�PnndNw•am11, Co,mvmlly. or SwAslon and tot lro.)
OnILUfJO LU13 __. UEf'-II_____.
3.
MUM
Address %
From to fameeon Oetcdpeen o
CD O
1 }J/y
n
pcoda
_
1
-_UEt�Lc
A.
——
City P, I V ... nis
DATE111111.1.61t_�
11G1'lll
_-
5.
G.
TOM _
CUTIl1l0.^•C(nIYI:IEU Yl.SL_I NUL�
NU4
m
7.
UOES WrU_ IIFI'I.ACE r.XIStING WELL7 YES U
a
S.
SIATICWA'IEnLt'.VELUeIowTcPolCaslnp:
�m
(Uee'd 9 Above TOP of Cesinp)
-mom
9.
TOP Or CASING L^. -__ I-.. FT. Above Land Silllnce'
'lop oft110,p l•lndnnlPd eifm below land IlUdgee requital S varlante In Steen
n. ~_-
> . YIE D (till cAC 2C .,Ise +�
10. YIELU (npm): _ f/a . ME111011 OF TEST
Z
—
11.
WATEn 70tJES (dry,llt):� - -
_
typo Amount J�
11 eddillonnl epnre isnredrd use brick of fair"
12.
CI ILOI111JA I ION: _F
13. CASING:
wen lhlcbmill *
Urpot mneler orwWujp M•niceskp
arlssal *sv� M1
Flom....__.�_10.—.— rl.
14 GIIOUI•
Urpnl
Mnladnl .
/Lt�
"
(�
glom ___.`_._ �In .oi V,rL
._S/7-1•.�•J•-•�w�I/st
-Nu
Fmn
15. SCIIEPIf:
Urpn+
binntolor
SIo1 Slzb
Mniminl
morn
• Flom _ _'I n .._.._
rl. __—
In. ----
In.
rfom le . .--
rL�._.-._
._. ..._
10. SANDIGI1AVI-1. rACI(:
Melerinl
Urpu,
Site
From T^---rl•
LUCAII00__SI(E101
(Show dllecllon Find dlelm+ce Plum nl1na11 hvo Stale
needs, or 011ie, "ISP- fellnit +ce/Potnb)
CD
o�
/
•om
Ao
a
a
;rn o
N
� b
Itoo`
.y
Z
17. nEMAIIKS
t is t" I
IbOtlPnrnYCCfHCYl11ATr,a9WELLWA9COfJ9tr1VCIEO IN ACCO11bANC8 WITH 19A NCAC 2C,WELL D
CONStnUrilotl $,IAN0All09.AN0111ATACOPY 7119REC0 o NA9BEEN 1ROYlOE010 life WELL OWNS111.
rOfl OrrILC Ll$M'OtILY DATE
Wed fJa f1AilmE Or rEfiS NCOf191nUCtIflO lilt. WF.lI
__—_--_ gubpnodp dloolvtslontf Whet WNIly.Orola+de'da 9a9on W111111130 d�y7 OWI nEV. 12101

,
I.: i .G 1::'-.'� .I !i`.y_ c!t: "t'."'1K.. !. �, r, i�( �.� a , ... L'•. T i•
a r
229437
,tlh rl rnvlartm•nl and NAlutnl Neemire" • Dlvisinn of Watar outinty • Ofoundwaltr Section
,as Mad Fprvicn Crnirr - ilnleiph, N.C. 27e90.11138.Plrone [phone] �•
WELL GONSMUC1101111ECO110 wELLcofltnnclnn: o�—_I�B�jU�4aj
WELL C0111nACTOn CEn NrICAt1011 Il:�O
SFAIF WELLCONSFnUCTION PEIIMI10!
1. WELL lhr (Cr,rc4 AI purmoo nrq, Nealdnnllaluf MunlCipal Ej Induslrlel ❑ AprlcullulAl lJ Monitorhlp LI
flecomy I _) I tent rmnp Water Injection I] Other 0 II Other, Llsl Use:
2. WELL LOCH, IUI . c,hoW sketch d the I Callon beloW)
Nemest town:
County: '
—i—' wiLLUJO loci
P1oN1 Ilanm Nut ihbrit, llonviu udly, Of SUbdlvnl r and to N0.) to ro.mnlon Otfcd�llOn
3. OIVIJFN _ �_ Fran o
_, Mob
ZE
Address ^•�
O_ _ BI-ar
uy rt in„, ---Sias ZID CaN c
A. DAIE 111111 F111_t
5. TOM LI`I:I'ill.cz�..•
6. CUiI11 Jt:,^. cvL1 YC i rt) YrS [_-1 NoL1%J '� •��
7. DOES WrU_ ItPI'L/ CF rXl$NNG WELL? YES u tJ0 •� o�
0. S1 Ai1(; WAl Eli LEVEL 0elot+Top 01 Cooing: F?f
luse'a• 0 Above top nl Ce16'0) — —N
x
9. 70P or CASING I -__ �__ . FF. Above Lnnd Sudncn' _
-?or or toolnO lot n,nnhd ritrr 6rlow lend eurleta Iniquities 11 enlnee In eteof
lane•"llh nn 2'
fO,YIELD
(e.m): a_.MEI)000F7ESr •
__..—
r .Amount .-Rs� I I epnro H I,rrdrd ma bock fit norm
-
12. CNLONIIJAIIUIJ: Iypo _
13. CASING:
DrPllt inneler
From—� _lo _A/0 Ft.
From—
From
Won ihichne.M,
of We671,11f I 'MaR
14. GIlOUI: Mnlerinl �Rlho._ J T
11ri �111 A^` Flom
Slot
15. scNl 'If:
nlnrinl
Uri+tl, bintnolor Slol Sicb M
l n r1 — 61. __
Flom------- In.
From __._ It, - In• In.
From .._..-_.lo_ .---r1.— In.
is. SANLVGIIAV(-I, rAUK: Site MelmaterialUri`II,
FromFrom-
17. FIEMAIMS:
i DOIIFn@nV crntf+,Y 111ATTI119 WELLWASCOf
CONS I nllr; 110I1 910MAI1139, AND 111A1 A COP i
roll OffICC iiSF t)h 'j/�
1
Due, Nn: _—' --- SuMnOdpIM1O
Sedni hn _
lilts
LOCA11QN_SI(F IC11
(9110" dlrecllon end dhintice Imam nl I!tAtl two Stale
lJoeds, or other "top reference Points)
tlod a4\ &�
�SzCA )�.c
VJ ACCONDANCE Wl111 15A NCAC 2C. WELL
CO_9D NAS BEEN PROVIDED lO TIIE WELL OvvN/%, �r
fU111f1E Orf FRS fl COR91nVC11f10111F.WFIL
DATE
to Division of WalNOuaOly, amunt?«aal 9ecoon will 111130 days OWI nEv. 12199

'2i9?
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh. N.C. 27699-1 fw'36-Phons (919) 733-Ml ''oo __
WELL CONTRACTOR: > > ��i��D ti �f`'�'
WELL CONTRACTOR CERTIFICATION Y:
STATE WELL CONSTRUCTION PERMITY:
1. WELL USE (Chat kApplluble eo:r Residential (Z Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATIO (Show sketch oo location below)
NearestTow-* --.�"- County; Va*cr • 7
and Lot No.)
3. OWNER
Address
cry or Town seta up k:ose
4. TOTAL DE D �
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑ NO®
7. DOES WELL REPLACE EXISTING WELL? YES F1 NO®
e. STATIC WATER LEVEL Below Top of Casing: FT.
� y (We•+•eAbonTop ofCasing)
9. TOP OF CASING IS � FT. Above Lard Surface'
•fop or cubq tarndnaW st/or below Arid surface requires a waWrn In acow-
dance with 15A NCAC 2C la
10. YIELD (gpm): /T METHOD OF TEX 7�/ Ad C
11. WATER ZONES (depth): / CJ
DRILLING LOG
From To
DEPTH
Forrr0on DeserWm
12. CHLORINATION: Type 9 )9 Amount If addNonal space is needed use back of form
13. CASING:
Was Tmcwd s
Depth orwoi:L Matadal
From —�To � Ft. �wh
6Af_,.L -��-
From To Ft.
From To FL
14. GROUT:
Depth Material
Method
From
//���
To .9�_ Ft. 11,zZ
From
To Ft.
15. SCREEN:
Depth Diameter
Slot Size
Material
From
From
/jo t _ n.
To t. in.
n.
irk.
From
� To F in.
in.
16. SANDIGRAVEL PACK:
17
Depth Size Material
From
From To Ft.� �-
.•
LOCATION SKETCH
(Show direction and ciblarm from at least two State
Roads, or other map reference points)
IN ACCORDANCE WITH 15A NCAC 2C, WELL
CORD HAS BEEIM10kiVIDW TO THE WELL O
&
Quad No:
IATURE OF PERSON CONSTRUCTWO THE WELL torte
MAslar of Wsw OuaBty, Wow4vew section within 30 days
OW-1 REV. 12099

North Carolina - Department of Environment and Natural Resources- Division of Water Quality - Groundwater Section C i
1636 Mail Service Center - Raleigh, N.C. 27699-1636 - Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: Dewey Wright Well Pump Co., Inc.
000843-2 WELL CONTRACTOR CERTIFICATION #: I&QUILeslie eece
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable' -: �): Residential ® Municipal 0 Industrial 0
Recovery El Heat Purr 'Dater Injection EJ Other El If Other, List Use:
2. WELL LOCATION: (Show skw `he location below)
Agricultural ❑ MonitoringED
3.
Nearest Town: SPRUCE PINE County: YANCEY
HALL CHAPEL RD. OFF 7 MILE RIDGE RD. OFF HWY 80
(Rued Nameand Numbers, :;orr.munity, or ubtlivision and Lot No
OWNER KENNY R. PIEPER
Address % PENLAND SCHOOL OF CRAFT, PENLAND RD.
DRILLING LOG
From To
0 72
DEPTH
Formation Description
DIRT
PENLAN1Ytree1orRuuteNo.i NC 28765
72
147
QUARTZ?FELDSPAR
City or Towu stoe Zip code
147
146
MICA
4.
DATE DRILLED 11/13/2000
148
241
FELDSPARIQUARTZ
5.
TOTAL DEPTH 265 _
241
242
QUARTZ
6.
CUTTINGS COLLECTED YES 0 NO ©
242
265
GRANITE
7.
DOES WELL REPLACE EXISTING WELL? YES EJ NO71
8.
STATIC WATER LEVEL Below Top of Casing: 50 FT.
(Use '," if Above Top of Casing)
9.
TOP OF CASING IS 1 FT. Above Land Surface*
•Top of casing terminated at/or below land surface requires a variance in accor-
dance with 15A NCAC 2C.0119
10.
YIELD (gpml: 4 METHOD OF TEST Aar
11.
WATER ZONES (depth):1 ppm 147-148 3 ppm 241-242
O o
0 ppm 0 ppm
O
12.
HTH 45
CHLORINATION: Type Amount
If additional space is needed use back of f�prn
-p_ �^
13. CASING:
Wall Thickness
Depth Diameter or Weight/Ft. Material
From 0 To 76Ft. 0118 .350 PVC
From To Ft.
From To Ft.-
14. GROUT:
Depth Material Method
From 0 To 20 Ft. Cement Gravity Flow
From To Ft.
15. SCREEN
Depth Diameter Slot Size Material W
From To _ Ft. in. in. 0-
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
Quad No:
LOCATION SKETCH a Ao
y
(Show direction and distance from at least MV St�teo
rn
Roads, or other map reference poird- y i
t
1
T I NSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
D H Y OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
y
SIGNATURE OF PER CONSTRUCTING THE WELL DATE
Sub it ori. naI to Division of Wat Quality, Groundwater Section within 30 days
GW-1 REV. 12/99
Serial No. AShrtii�-:-

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section 2 2 C r 2
1636 Mail Service Center - Raleigh, N.C. 27699-1636 - Phone [phone] "�
WELL CONSTRUCTION RECORD WELL CONTRACTOR: Dewey Wright Well Pump Co., Inc.
WELL CONTRACTOR CERTIFICATION #:
000643-1 STATE WELL CONSTRUCTION PERMIT#: Leslie Neece
1. WELL USE (Check Applicable Box): Residential D9 Municipal 0 Industrial EJ
Recovery 0 Heat Pump Water Injection 0 Other E] If Other, List Use:
Agricultural 0 Monitoring 0
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: SPRUCE PINE County: YANCEY
Hal AP RD OFF 7 MILE RIDGE RD.OFF HWY 80
(Road Nameand Numbe rs,Community, or Subdivision and Lot No,) DRILLING LOG DEPTH
3. OWNER KENNY R. PIEPER From To Formation Description
Address P% PENLAND SCHOOL OF CRAFT PENLAND RD. 0 31 SANDY DIRT
PENLANInee or Route NOJ NC 28776 31 690 FLDSPR/QRTZ/MI CA
City or Town State Zip Cars
4. DATE DRILLED 11/9120DO
5. TOTAL DEPTH 890
6. CUTTINGS COLLECTED YES E] NO FA
7. DOES WELL REPLACE EXISTING WELL? YES E] NO 0
8. STATIC WATER LEVEL Below Top of Casing: FT.
(Use'+" if Above Top of Casing)
9. TOP OF CASING IS 1 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): U METHOD OF TEST Air
11. WATER ZONES (depth):0 ppm DRY HOLE 0 ppm
0 ppm 0 ppm
12. CHLORINATION: Type HITH Amount
13. CASING:
Wall Thickness
Depth Diameter or Weight/Ft. Material
From 0 To 35Ft. 61/8 .350 PVC
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From 0 To 20 Ft. Cement Gravity Flow
From To Ft.
15. SCREEN:
Depth
Diameter
From
To
Ft. in
From
To
Ft. in
From
To
Ft. in
16. SAND/GRAVEL PACK:
Depth
Size
From
To
Ft.
From
To
Ft.
Slot Size Material
in.
in.
in.
Material
If additional space is needed use back
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
17. REMARKS:
I DO HEREBY CERTIFYTHATT)VS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION ST NDAK I TCOP
Y PY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE O
V1 iTURE OF PE N CONSTRUCTING THE WELL DATE
Quad No: Submit originoivision of Water Quality, Groundwater Section within 30 days
=._..3 GW-1 REV. 12/99
Serial No. , ,•'ourid;vat::' Secti„a

,. : ..., . .. 1, �i:::`�.4 .I r�..,_ ,.r ti1•��'1'1 �..IY M . 1�T�,.1' � ... L'•. t 1• ., ..
229466
'•fnh f: n,pl+,n - I,rpm 1, PI rrwhn-ur,enl end Nnlurfil fie snurcet • Olvl.lon of Witter Ouetity • Oroundweler Section
i30 Moil Servirn Comer - Ilnlelpl,, N.C. 27600.1039-Pl,ons 1010) 733.3221
WELL CONS] 11UC'1lot J 11ECOM WFLLcoffmAcron: b_6._-F6_R9U�Sa .
WELL CON1nACTOn CEn11rICA11011
STATE WELL CONSMUCT1017 PFItM11R:
1. WELL ll E (a,ec firrairebh n.•=le Nrsldnnll ,I L Munlclpnl LJ Induslrinl ❑ Agilcullurnl U Moulloring (—(
rlecovmy _J I Irnl rump Water Injection L] Other 0 11 other, Usl Use:
2. WELL TOGA 1101l• ;how sketch of ilia location below)
Neatest fo,vn: ZtjDOpj Count': __j� V
— --
ptoau/��]�cnn,unnuy, or S dlvisla •ndtot No.l O(11LLIIJO LOO __ UEF'_I I _._
3. O dren I _ =f�% Flan Te to,menon °e+cdnnon
------ da4lii. & ?_ - --)-;L -
Ciq r, r r. Ante zip Code
..• A• OAIE0InLl.rlI__L/�/�S-Q
S. TOM I'EI'llt _-.._..._ 10
G. CUT11110 (;(,)IJICIED YISS(__L NUL_JJ _
7. OOES Writ. NC PrtAF Exit,1IN(1 WELL? YES NO�
8. SIATICWA1Ff1LEVELEIelo,-7lopolCesing:Q_"! �--er-
(use'•' R Above Top of Ceeh,g)
9. TOP ('r CnFIIJ(; 13_—_ I _ . FT. Abovo LIM Smenco' oo^
-top or ee•L,p rrnnlnnhd m im below lend surfeee requires a eerleoes In Reel•
J•ne•wnh I'A IICAC 2C.alle _ �m
10. YIEI_U (nl'rn) --off+. MEIIIOOOFlEST �4�— b --i�
11. WATEn 7_C1NE5 ldrpllt): _� J — rq
12.CI1LOI11tJAI1UW: lypo_� ..AmoUnl Ileddltlonfilepncehnrerlydutebock ollorK3
13. CASING: z
LUCAIIQfJ 51(EICII
Wen InkVncel
Urplh imneter of webl-N 1. Iftedei (Slaw dheclton find dhim,ce born 11111,110 two Stills
Flom nR nor ddss, oorr o`llllut,r map rellueuce points))
Flom--- ln.--- rl. il�,C! r
Front
v` Itrpll, —M`nlerlorl ,- nl�O
From v._ Ir, .2rU-11. _C61& _
rion,
15. SCNEI'1I:
Urpll, Dhillolor Slot Slzb Mnlnrlol
rrorn _--_-- l o _ . --- I t _ _ In. In.
Flom u I in.
Froul _ _ _.. lI, rI._.—_ In. .—._ In.
4
JO. SANUJ13IIAVI-1. PACK:
001,111 Size Mnlellnl
From ln___rt.
From --
17. nEMAi1K5:-:...:..:_.
'q I
I OOlrfnrnYrC 4t�:-T11n�7-LNS.Wr�I•Ii"'AS IstnuottOPINCCOM)ANCEWINI 15A NCAC2C•Weu
CONSinur•t"`IAlluArI09 AND 111AT YS. f7gQY 11119 r1EC0 ON/1G BEEN PnOVIDE010111E WEI •--
roll off a.flnnmEorrrns nconstnvcnnO nrE v,Elt. DATE
Su coo .Ill lo°IvblenMwaist a.nlr.0rourdwslot secnon wnhnl 30 days OWInEV. IL91
Sedei frn C!

............ .
.I1., 1.•rlJHL�SI • LL7te 'Ti1T!':.1."ICY,n:91rl.:r'+
IT
229464
Orlh Cnrpl ne . I l.pn,hnrnl nl I'nvhavoanl end Nnlmnl Ilennu eat • Clvlann Of Wolff Outdtty • UroundNeler 9ecllon
16J6 61e11 f:rovkn Urlllrr . 11-1101911. N.C. 21600•If)J6-P11one [phone]
WELL CU14SIIMG11011 FIECOM) Wr.LLCONt11AC1011: —7:5bb.__.1FFrP-43 AC_
WrLLCVI$tnACTO"centirICANg110:•!
srnTF wELL ConsrnuCTlou rrnfana:
1. WELL Ur•l: puck nrrarrblr n.,+h Nnaldnnllal( Munlclpnl LJ Indueldnl U Agticutluffel IJ Monllnoh,q LI
tlecovrly I ) I Irnl Pump Water In)ecllott (] Other 0 It ogler, Llsl Use:
2. WELLIOCn11(11L +'howskelchotth locallonbelow)
Newest le,vle_ l-111/1 t�r2• Count': 4,"
ee-
pymtnamnnn Doti^r+,Cmr.lmnlly,ofCS,, viflenandl0lrto.) Un1ULNuIq(3 rErl(t.._
3. O1Vllr11�7 c3UL/.L�1 Iron to rmrenOnOr+cdrnan
Address —� /n G a
n, m Irv„ male zipC. p
5. TOTAI h1El'UI ._._
G. Clllllll(:,^.CVLII"CIEb _� NUL1%J
7, UOES WI -I 1_ III'1.1/10E EXI$11110 WELL? YES [L NUtjd
S. SIAM; Wn1ENLIEVELVitto-,Ioratcasing: -TjQ—rir
tufe'*e 6 Above lop of Ce/6,91 I.
Q. TOP C1r cn.^.•lu(7 I _ I__ . rr. Above Lend 6ullnco,
.top of tn+6,". lend elvlees lequllso a vorlenes In seefn•
dent ewtlh is A l n:AC2C.01 I e - e
10. YIEI_U (npno): _�,� fAE1110D OF TEST
11.WA1E117.UIIGS(tlrPlh):�_t �—'--tt;;'--
12. CI ILOIIIIJn I IUIJ: typo _/ Anlomd _ ills 11 eddl0onnl epnre It nrrdrd afn finch of brm
13. CASING:
LUCAIIUN SI(F.iCN
Mill uactnefl
brplh �',In,.n�rlrer oAwrol.)I 11. I�ud�tlednl p (91por dlrecllnn and dhlnllce how nl Inafl trro 91n1t
rlom__U _1o_ rl.S!"�.a— >ev�l)M1 deeds• of other nlepnfelencepohlb)
glom----
rlcm ...--- ._-1n.-- 11.
14.GII011I: '�A
I,rpII1 �Mnlaro►tnyth/%
i� �palyl4lot
�
room--
ts. scnlru:
Dinnlolor Slot Slrb Mnlndal
room ------- Ill- _ _.— 11 _ _ IIf.
rlom lit.
rion, le. _rL�._�. In, ht•
16. SAt4L11C IIAVPI. PnCI(:
Ur1•Ih site Malallal
From 1n 11.
-M7 �.
�,,.,•..,..v� __ _ ..
1 001 ornrnV rrfi��IrS' MAT TIB9 WF.II W1�9 QOn9inllClEb IN I1CC01IUANCE W1111 ISA 1tCAC 2C. Y/Ill
COttr.111UrilOrl ANUMlOq;ilr)D11MTACdP>( 111t911EC0 OfWOEENPnOVIDErl101116WE1
rUllOril(,rusrd)tlLy , tlAtInlEOrhrnS tlCOtt9tnUCllfroPlFwF.11. oAtE
wed Ito
6ptmtiIq rleDwI)IonMwelefOuNM.glaroMnererenonwnhln30doPs ow-1my. 12,91
serial fin _---. _-

dh -
d9 L.:,.� r _.: J�L'jitJLli$T�''�_EG`}.��JLb^�t:'S'rl�i_'C2�>t'7'. ...L ,t iR":91r1 :.n •-. .
°� ' �� 1,,.1tl.:: �.� .l � y l�r„-t•7wt1 r. « ,,I ..�, ... a+. ) �, . ..
I t
229462
'loth cmirl.nn . 1, r-grin,,w rf rnvkrvnenl and Nalurol fletou cot • bivlann of Wa1et ouallly • Ornundweler SACIlon
38 Man Srrvlcn Contor . Ilntclgh, N.C. 2F699-1638-Phone [phone] —t-.
: WELL CONS IHUCIloll IIECOf1b WFLLCOtJTNACTOfI: Zoe-_.F*&!_jUSoii
WELL cOrJTnACTOnCFnTirICAT1011
STATE WELL CONSMUCTION PFr1M1111:
1. WELL fill I` (Check Al 01r,61, p,•+): nn-8ldonllatLY1 Munlcipnf [j Induetrlef ❑ Agrlcullurnl Monitoring )_)
necovriy j_j I lent Pump Water Injection j] Other 0 If Other, List Use:
2. WELL I.00AI IUII: tnty Sketch of Ihl9lncallon below) ',{
Newest Town,_ �/�A�15?_S- II .t_ Count': 4 +dam L 4 —
Coirnnn,uy,or ebdlvlslon Lot it*,) URILUNOLO(3 _ UErIll
3. OWNr11 From To fo�mallenoescdnron
Address -�.?5
I lip 1=r llnuln/11Q-!_�.rC�
Uy nr lr,an 1.
Slnle zip C .--��—
4. DALE (t1nl.LrNL/-a[• U 0
S. TOM hG11111 .._�l��... _ "
0. Clli TII1(:,^. Cl.tl.l.f-f.:I [U YE i L_� NOL1%j ^
7. OOES WrLI_ nl'rtM:F FXISIiiJO WELL? YES 1104
S. Sl ATIC WA7 Erl LEVEL Elelow lop or Casing: — FT, �-
(Ute't' 9 Above ton of Catk,g) - _o
9. TOP C,r Cn�ING I:, I___ FT. Above Land Su11ncA' ——${
•fop or calm" trnninnl•d Him beta" land surteee taquitee a verlanee In aeeon,
dencewllh t5A IWAC 2la C. - t
10. YIELD (uwu): �. _. MEI I IOU OF TE9r q — A
11. YVATEf17_OIJES (drplh):_ — m '
m�
12. CI ILOMIJAi IUIJ: Typo —F1J. —.Amour) MfPTITS 11 eddlllonal al,nra It nredrd utn back of lomw o
13. CASING:
OrpOt p1multot
y—FI.
rl.
14. 6110111:
Ilri,ut
Flom .. _ U.. In ,asQ-11.
Font
15. SCF1L II:
WAR lhlcrne tf . - IUCA l IQN SI(F. I C11
et WeybVt 1. Mtledel (9how dlrecllon And dltlnnca ham n1 load M'o Sale
1_lWis TlUhR needs, of other map tefelence points)
MntArIAI .��V+olhod
_cin&L&_ SoAar"L
NrptFt biomolor
• Fom----le___..-1L_..—.In.
Iv. ...__rl.In.
1e. snNnlGnnvrl. rnca<:
Depth Site
From In rl.
Frew to rl.
17. FIEMAI IKS:
1 OOI IFl,fp
CONSMUC
Slot Slzb Mnlallnl
OrrIC��(.". U11LY
Mtd —�
Wad Nn
Sul
SAM no
Malerinl
-ILr
FCON91 nuC1 ED IN ACCO11DANCF WI I I I I SA MAC 2C. WELL
j
9f1EC0DSIIOVIOED 10111EWELLOWNEnAlTltteor rrn5 tt con9lnuc TltnitIF, wEtl DATE
otslon 0 Woler WN6y. 0rela,d«eNr 9rcnon Wilhbt 30 days OWIpEV. 12119

e c x T 2' rt,r�Tr
229457
o th Cnrnf i 1.•.I. nIn,r..t ,•I r rnir•vnn^nl nrld tlnitlr❑1 rtr7ntnrnv • L11v1^Inn of Welff Ounllly • nunnnl'.vnlrr .^nrab•n
r6J6 Mn!I g^:•h�r:^,Irr Il:d^IIlr,ll':. 27699�1630�r'Iwne (PIPJ 7JJ�9221
WELL ca.lrlSlr((IC:IIOr'arl,�cvrru \vr1.LCollIIIACIOil: _Li__/_�1�('_�Giis)l��_..-_--
WilCUNIItACIOrlCEmIrICATI011n. __,:_....'-_....---
rTAIrWElLCO1MMUC11OIJPppG11In:
1. WrLI. I+"I (l I rM rl n I I rv, }" nnsldnntlnl�l4 trluldc!pnl Ll InduflOrilI_� r�arlcunvrntI 1 Idonitr ing
Fleco�"r; I . I I F :d I !nnp Wntm hl)ecllon [j Olhar U II Other, Llet Usr.:
2. WFLI_ I 1' 1,r, •r nP.nlch I hfl locetlon below)
� �,� �✓
,
--- — - - UFiILLItJO l.UG
(rlrn•I nam r l n+^ a C r n,n if or Subdivision and Lot 110 I
DEr (I1
r n, snon pNrdl l nn
3. OWWr It
ZIP Code
A, DATE 11111111'11----
5. TCiIAI. III <I 11 i - " - L � IJO`✓7 .—
13. CUT11t I!: 1,( LITt-IrU YFS _-
YES [_J IJO[✓� — -C=
-- - ---a
n
7- DOES �'Jfl !. I11'I'I nr.r. ILXISIIfJCT WELL4
0. SIATICNJAtGF11.I v[LUclowloporCn.^.Ing: ��r r,_-----------
— vc
(Use•.' If Alrove lcp of Cn
rT. AboV0 Lnnd S11110C11-
9. TOP Or Cn"Int; !!. -----
-.-.�
,Top of ceslnn o-rn,h"nhd bNew I+nd nnleoe NPulree a vmlence Tit eoeor-
--
- --
- — ya
lot) OF TEST BLS (-a -----"----- -
--
10. YIELD (u!1'11)
j—_----- --
— ,——�
11. WnTEII 7S1I IFS - ---
- .._ ----w— —� —
1'
PAS II Ml----1 rfm�:f le nnnrind
u-.r hn y of Inrn�.
12 Gilt (II III LAIU It I: i}'I'"---- _. _
13. CASIIpr_
rrcm_
ITom -
I li`m
1A. GI10111'
I rr•rn ( )
from
1F, SCrll:l if
11,.I ,!Il nimnMnr
I (l1101_I S)CG I C11_
or JlllcII iIt1, s
or t'J e! M'l.1nlr,In! (Sh
ow dirfcllon rind rilvinncn If""' nl Inn�l In0 Sinln
�,�5_ rloeds, or c!hnr pmp rfinrnn^^ P'I!I�!n)
P, hl nlflinl 4,lnlimd
(? -pnUrF.�
1 r, rill
rinm n
floill ^
from I"
10. SAril+n;ilAW
I +rl'll
n
s +117 netanrn €r,E
I -��1Urr,rnnr rlrpr
CC1N$lnnr I1 II'11 n.0
OaM tin'
I+I:nnnlar Slol Sizo Idnlmlal
SILO tilnlnllal
-- --
nr,1 nue wn.L wn9 collrl Inlr.�III nCC(sl1nn11Ct W!1111^,n FICM: 71,sat.
r.nng,NNllln(ACOrV t1m is.,1nDlA OEEN rn V1U[U 10111r v,r.+l-(rrnrrn
-- I - - _. unlr
onnl 1 r or rrn;nn ronsultic In n r wn -
Subn#1 alpinsl to nl Inno f Weter Cusllly (lroundw"" E�!Ilnn Vdlhhl 3lt + Aye 6YI 11!r V, I1r71

....!!L'.T:Ms3'."..!.
.I.: ..:: ': (n. ,�.. !:::: .�.y I .�.:,1"SI .!'. `t'••'•i°f. t H•p ::,I N. r.r.u. ... t,,. ,} 1.- ..
229398
Nonh Cnrp1•nn . I lrpniliurnl of rnvinrtntenl and Netmnl Tleiaurcee - DIVWon of Water Quality • Oroundweler Section
536 Mail Srrvicn CPitt Pr - 1111elgh. N.C. 27699-1838-11fiono [phone] -
WELL CUNSIf1UC11UNRECORD WELLcoNTnncTon: �4�__FJ7RglASa
Wr:LL CONTnnCTOn CEnTIFICATION P: � p
STATE WELL cONSTnUCT10ti miMIfM:
1. WELL llcf: (check nly.ur.ble n •_): nrsldonllallJU Munlclpal Ll Industrial Agrleullurnl Monlloring C)
necovrvy [ _J I goat Pump Water In)ocilon ❑ Other [] If Other, List Use:
2. WELL MCAI1011: (511/q�sy sketch of tire location below)
Nenrosl z 0:2 County:
jrtoa l iizn+o-nnri l �•��^is. CorrtPudl at Subdlvislonand tot TO DnILLINO 1.013 __- DEPI11_-_
3. OWNFII .,( from To ro,reetfon Description
Address
c.,`('�`'�'`�'1 No.�}O �i __BLaro� —
—kk
Cl"
Zip Code
4. DATE ('fill I F O __( C)-3!:!P0 S. TOTAI.1+rllIII _._ . _ --- �� NOLyJ
6. CLITTIIIC.S CVI.LF('IFU YI_S o
7. UOES WFJJ_ NPf'LnCE rXIS111JG WELL? YES O
e. S1 ATIC WA'I En LEVEL Ltalot'1 TOP of Ceslnp: ___ FT, — —
(Usit Y 9 Above Top nl Cafing)
9. T0P OF CAFII IG IS _�_L—_ . FT. Above Land Sutlnce'
-Top of cestop 1.nnfonl.d rihn below fend surface raqulfee a eutmee In aeeor• `
mes with 15A fWAC 213.01111-
1O.YfFI-0011nt): __. ._.ME111000FTEST —
11. WATEn 7.ONES (tirplh): __
12. CIILONIIJAIION
13. CASING:
I ype _H_L.II Amount - -
OrPth Plornpair
From__—_—
Flom.___._._lO------ FI.
14 Of10U1'
II eddillonal spnce 0 1n, pd use back of IorrrN
_LOGAI ION_SI(E ICN
WAIT ihlcLnese
or We1gf'VTI 'pIftedesl (Show direction Arid dlalnnce frorn III Innsl two Srn10
'U ai * av to Floods, or other MAP felerence Points)
I trp11, Maledal elhod
From _ _ 0.. to Ao—I I. is4lT��i4Tr SA(ES�
Font
is. SCnuvii:
1)ridlt biantnlor Slot Slze Mnlmlai
rrom
• From —_.— in.._. _.__IA. In -
Front .._.._.. IL, FL_ In. In.
1e. SAND1tf1AVl7I.rACI(:
Depth Size Maledal
From _— 1n
From _.---- 10Ft. —• -
17. TIEMAI1KS; --°
1 0011r Ilrl{i' F1t1Jr '! 1N)!T 7N19 WELL WA9 CON$TTILICTEO III ACCOIIDANCE Wl111 ISA MAC 2C. WELL
CONS 111LI klilt-liltS 1 ANOAf1DS. AND 711AT ACOPY OF 7 19 FiECOn HA9 BEEN PIIOVIDEO TO 111E W ELL�ONs
Eousd
FFIL[=lASfS ONLY - oniE
So nnE or TernSO oN9TnVCTIN0111F. VIF.I Ibrn11 od91na1 IvIsIon of Waler Oastay,oroundwaUrSoctionWillIis 30 daysoW1 pEV. IL99
o •.� ,.a.n
0

.t � 1N J.i .. r•F 1 I -.rN �.! Y -.� . r.
Mb•r
n
229397
flotlh Cnrpl no _ hrlrn, Intuit r,f Fnvlrt, vnenl end Nnturol rlesnurcne • Divlelon of Water ouellty • Groundwater Sactloo
536 Mail Frivicn Crnlrr - rintelgh, N.C. 27699-1636-Phone [phone]
WELL CUNSMILIG1I014 fiECOM) WFLI.coNTnncion: o�—FlrggUSpAL
WELL CUNTnACTOnCEnTirICA110116:,�_
STATE WELL CONSTRLICTIONPEI1MIf11:
1.
\YELL 1,178 (Check its rltrnhle M,-): neslden6allid Municipal [] IrldustrlAl ❑ Agricullurnl I_J Monitoring
❑
tlecovrly I-_J I Irnl Pungl Water Injection ❑ 011ter E] If Other, List Use:
2.
WELL CUCAIIUII: w loske`lcil g111%ee location below)
Nentest lowrl:_—_�jiCLr�i/Z'i.ilLL3=-•� County:
� 1
jnonrl oil i1u'ril^I- s. Cm�nnn1uy, 0 t S VS dsion and lo111o.j DRILLING LOO __DEPT11_-_-
fo,mallon 0ordpnon
3.
OWNFrI
From Ta
..
Address 166 —
I':iirrl o1 t(i'UToI3t).n �G7 '� j.,—
Jib P_ar_oc�
City rl ir.'n. 61a1e zipC.-
4.
DATE DIuI_L17-11
5.
6.
TOTAIA11"I'i11
CIITiII!(:.^. CUI-L -C I ED YISS NO
NO ----- a"
o
7.
DOES WFU_ IIPI'I /SCE FXIS IIIJG WELL? YES U
c�
9.
S1 ATIC INA'I EfI LEVEL Lteto%" 1 op 01 Casing:
(Use b' 9 Move Top of Cashlg)
9.
TOP Cr CASItI(; I-I_ . rT. Above Lnnd Sutlnen' _
m
'
-Topof eafhlp re nnln nlr•d el4rr helow land turlaee requilee s vulanee M fteoP
to �••
Do
once
t0.
with lSA IICAC 213.01
YIELD (ninn):A..D. _. MEIIIOD OF TEST '
=o
11.
WATEn HIES (drpih):
111] 11 sdditfonnl spnre in nrerled tin" back of lordly
_t
12.
CNLOi11NA I IUN: I ypo _FL LiL-Attlounl
_
Z_
13. CASING:
_LOCAL IUN_SKE I CH
rInr.n�el�er
Wo�r W1�MIg1h�lVlrcS tae
Malednl
jj"hLR
(Slaw direction mid dinlnncA hem of Innst two State
map feference points)
�Urh11
needs, or other
From
--
o.—_..—
14. GIIOU I :
```` DrI,III ��M_nl�ollnnl
�� ol� r_'
tSL
/� n
From ._-.v
Tn a1 U.-I1, _S-Y�SJ[�iec-
_
riotn
..__.. In .__-_-1-I.
15. SCnFI"I1:
L>r•hpr binmolor
From -----_. L, _ __ 11 - — In.
• Flom --I r ..__..-1-1. _._. In.
In.
To. SANUtt;IIAVPi. PACK:
Drpll, Size
From
From
17. FlEMAIIK5:_
1 b0I Irllfny Cp
CONSI1111C11011
Slot Sl2e Mnlmini
Malellnl
TEO III ACCOt1DANCE WIIII ISA NCAC 2C. WELL
i nEConD HAS BEEN Pnov1DEO To I IE WELL OWNER
rOfl OFfILF US�'�C7NLY A .,1., „ ,-
Quad W: " Y
Subrnil
Se dal fM
or reason ❑STf1VCTIIIG 111F. WF.IL
DATE
at Water Oualily, orosodweler SaUlon Will lift 30 days GW1 IIEV. 12111

L�h•`.'t.f^1..
229394
Noah Cnrpr,n . nrynrnnrr.I of riwlrwimn iil and Nolurnl fie snurcas • Divlaton of Water Duellly - Oroundwln9t Sacuon
538 Mad Srrvirn Conlrr - IInlelgh. N.C. 27699-1838-Phone [phone]
WELL CONSMUClionnEconu WELLcoNTnnc7on: oE—EEr_EtgUSonL_
WELL coulnnc7oncEnTlrICATIOIIe:
SPATE WELL CONSTPIUCTIOTIPE11MltP:__--
1. WELI. llel; (carrk nrynr.hla n"*): flrsldonllalLlU Murdctpnl [] Indusldnl0 Agdcullurnl Monuortng
nncovrty j _J I lout Pump Water InJecllon ❑ 011ier C1 If Other, Llsl Use:
2, WELL LUCr111Urtvkelcli'Zecnllonbelow) ty --
Nemesl tor: n:_ Court ;
jnoen iiv���"nd iiJ.�is. Cmrrmnlly or Subdlvlsiog and lot tio.j UIIILLIIJO LQO ___UEr TII__-__,_
3. O%VNr11 .,QQ/�, 6� Rom To rmmnaon Oovlprlan
Address
City r, 1 m,, Stale zip Code
4. DAI E III lit 1,F1) __,Q', •D iS
G. C117T1111�S CVL1.1"ftl[D YI_o NO cY.J
7, DOES WFI 1_ IIGI•I.ACE EXISIIIJO WELL? YES U D�Y -
s. Sl ATIC WA I En LEVELEteloi'r T op of Casing: -gs
(Ufa t9' 9 Above Top of Casing) -
9. FT. Above Land Sudnco'
'Top of cee1119 Lnnrnnhd ritor helow land eurfoee requltee o vedenee In seeot-
'mee wlih 15n 111'nC 2C.j'11e `
a YIELD (nP^t): _ J _- MEI I IOU OF TEST
11. WATEn ZLIIIES (tlrpIh): _J '
12. CIILOttiIJAl1UtJ: typo _� Amount.
13. CASING:
Urldh /p_Inm"ailaat
From—O ate rl.-S�- t
From...-.__-1^._ F'1.
At n011 1 •
If additional apnr.9 is nrorind ilea bar_ .k� of 1��
LUCAI IpN_51<E I CFI
wan Tlacrnesl'
or Walgl•url. fdal9del (Show direcllon lutd dhinnce from nl land two Stnl9
, Pt"tiR needs, of outer rnaP reference Polnle)�
UrI.111 Mnlorinl nlhod
From -".Q__ I..AO_I'I.
Frnm _ -- to -—I-t. �-----
ts. scn"AI:
Urplh bi.vnMer Slot Slce Mnlorinl
From _ In _ __- FI - --- In. __- In.
From in.- —lot.
Flom.-.._1^. .___r1._ In.
1G. SAfJU/GflAVFI. rAGK( Melednl
Urltlit Size
From _ in --- I I- ------
From T^ rl. —
17. F1EMA11K9:
1 DO I IFI1rnV I1•Ir}Y 11�IATL�
CONS IIILICI IEA I•:Il�rlVAf10S,
FroOFrILr
1 Wed Nn:
I
Sednl Nn
ISTNLICTEO IN ACCOtIDANCE Will' 15A NCAC 2C. WELL
OF 711 TFCOFTD /� BEEN Ph IDF_O TO 11 IE NlEU.OW� y
O�TE
cr r.. .011E r61nucfltfcl EWF.l I.
Of Weler Welty. OroundwNet S9tllon Wilhln 30 deye OWI nEV. 17/99

... ._ Affm viJF1Y'I S'�' .?✓.^ "'..11:!L"iID'_ '.�' .?'J+L^".,.t ,r: ':T. !.., ..
2293,93
?forth rtry'ml in^nl M ruvlrn anent and Nnlurnl nesnor",I • Divlalnn of Welar Quality • Oroundwalef SPCIInrt
339 Mail Srrvlcn Cnnlrr - Ilnlclgh, N.C. 27699-1636-r'hons [phone]
WELL CUNSMILIC11011 RECOM) WFLLcomilACTon: ;�E_.F�r-RgUL54
WELL CON1nnclon cEnllncnnON
S1ATE WELLCONSTnucTloff PERMIT10:
I.
G W
WELL USE (rnnck nl pn .ble p •*) 11rsldenllal� Munlclpnl 1J
InduthIpI U Aprlcullurnl L) Monlloring U
flecovmy _) I Icnl rump Water Injection ❑ Other
If Other, L191 Use:
2.
WELL 1,0CAI1011ketch of llty ly�allon below)
iA 17571L court : �
Nenresl I n,vre _—_ b
—
---
jrtoal ti.� -n��- iui.•i'�is, crn�m��nit or Subdlvlslon end tot no)
DNILLING LO(3
_._.-. I 1EF'T11.-- —..
fo,mellon Dardpllon
3.
O:VNrfl
From la
Addre's a m ��j'�7
[
—
_ Zlp Code
.• 4.
DATE Pill 1 1-11 1b'(a•Ob_
__,_
5.
TOTALItfa'111 �, NO LVJ J
Yfi.n,
_
^
CD '�
G.
C1IT1111G.^•CUll.f(11FD _
YES
7. DOES Wfl f_ IIFI'IrCF r:XlS"llELL? _FTt
B. SIATICWAIErlL1:VELVelntvlopOICasing:
(use •+' IT Above lop of Ce91119) -4
9. TOP Or cn�lNG 1-1-__J _.. FT. Above Land Surfnen'
•Top of tesb,n trnnlnnl^d ei'or blow lend turlaa raqulrea a variance In weer•
enaewuh 1,A 11 AC?C.e11e • _ a
10, YIELD (ol'rtt): ���-- MEII IOD of 1EST
11. WATER 7011ES (tlrl,lh): __ ••
12. CI ILOI11lJA 11UIJ: Typo Amount —� Il edr)Illoml Ppnr.P It nrnrind u•.n bnrk of 106"
13. CASING:
Drpllt Inln�eltor
Flom_—O ----lo c+—'--r1. _V�•J_
Flom_— -- In---_._ rl._
Flom
14. GNOU l c Pot tod
Drl,u, Mntethtl •A&
Flom .... U.. lr, .2��__rl. --Fp
MIL
15. SCflErll:
hrplh biontnlor Slot SILe Mnladnl
From ___--- t V -
Flom __ I o- _.-- In. In.
In. In.
to. SANDIGIIAVI`I. f ACK:
Depth Size
From _-- To---fl.
From ..._ .— 1 it rl.
17, nEMAI1KS:-
1 b01 if Ilr'nV
CONSIIIur;il
Full offlCE 1
Wed No'
LOCAI ION_SKF I CFI
WAIT lhtcsncs9
or Wtdgbvt I. Mslednl (Show direction find dlslnnce [turn at Innnl two Slnle
�14,115 ktUaR floods, or other map reterenca polnb)
AND 1I IAT A
.. .... Submll,
Maletlnl
is T mic I ED IN ACCOTIDANCE WI I I I I SA li 2C, WELL
OF 1219 nECUnD ►I 9 BEEEN irnovIDED 10111E WELL OWNS o f
K^i V
DATE
I tlnE Of nE SON n91nVCI11tD 111E WF.I I.
10 Dlvblon of Water Oue91y, Groundwater Section Wllhln 30 day9 GW,1 aEV. 11e9
Sednl tin

.I.: i p.� ?(:^. , #.9 I •L..1 t�h...t.7 ',' -foil t:
, I
229390
North Carpbnn . I,ry.mrnirnl nl rnvlrnvnrnl end NMmnl flesovrcre • oivlSlon of WatU Quality • Oroundwnter Secllon
536 Mail Sr,vlcn Ceram - 11.ilelgh, N.C. 27699-1638•Phons [phone]
WELL CONS111UC110P RECOM WFLLCONTnnCTOn: o�_��iRgUtSo
WELL COIIJnACTOn CEnTIrICA110tJ
SFATFWELL CONSMUCTIOIIPEnMIIN:
1. WELL CI f: (caeck nr ratr..hle nnvl: nrsldnnllal� MunlclpAl [1 Induatrinl ❑ Agrleullurnl O Monlloring 0
rlecovrly j-) I Icst rung, Water Injection ❑ other F1 If Olhor, List Use:
2. WELL LOCAI IUI1: (,5) qt�h o111M1ipllon below) b
Nearest Tow,c__��T/1-J{ ��''((f�'' County:
jrtoe�l tl,vnn ernt am S. Co,rrr „1111', S vl Ion end toll rlo.j
UnILLINO L00 __ _UEP II I__
3. OWNrrI �I7V,,M4
From io fom ellon befcdpllon
Rp7( S75
Address /YVI
--1
Clty nr 1rv.,, Slaie ZIP Coda
0 <
4, DATE hllll.l_rll
33.
5. TOTAI. I11:1
6. Cllillll(:^C(JLI,rCIEU YISScj NclEvf �_
N0
�
�7 m
7. UOES WrU_ NrrIACE EXISTING WEI_L7 YES
— v¢
8. STATIC WAl En LEVEL Velo,•r Top of Cesing: S M
Do
(Use 4' 9 Above top nl Ce9111v)
g. TOP Or CAFIt1G 19 -__ �___ FT. Above Land 81r11nCe'
-top of eafh"n a nnm ntrd ria•r below lend eurleee, requirU a vvlenee In decor•
--
snoewllht'.AIICAC2CI.o11e
to. YIELD (gins): LS . MEII IOU OF TEST / eF
— —� o
It. WATEn MIES (drplh);
Amounl .�
It edditlonal epsre le nrrdrd uve bark of loan
-
12. C1 ILOI IIIJA 110N: I ypo _
_
13. CASING:
SKEICII_
wan ndctncS#"
IAaledel
_LOQA11OtJ
(Show dlteciton end dlalrrnce from at teat) two State
Ury,9,
smeter or Wnlgl,vrt.
�IJa,1�S
noeds, of other map refelence Polnb)
From----- Ft.
From __--lo--- Ft.
14. GNOU1:
Itrl�O, Mnledai 1�0�
fy
From .- _ U.. In .a1Q>11.
Horn .. _._.__ to ._----__t"'• ---
15. SCr1E111:
U r•p0, binnrslor Slat Slze Mntedsl
From __ _lo_ ._-1.1-- In, -- I"'
From _ -1v.._-._—I-'--.— In. In.
t , rl in. _ 111.
ra Flo . __ C
. -_
to. SIWU/GIIAW-i. rA(;K:
Ur1,ih Size
From
From _..._...—.. 10rt.
it. nEMIUJI( S:
TM WFLL WA9 CONS t nUC I ED III ACCOt1DANCF WI111 15A MAC 2C. WELL
AND 1NAT A COPYJ11n1ECOnD 11 BEEN Pt113 F0 iO 111E W FLL �NER.DATE
slor rrn. oN c sinuctma IT IF VIRL
Su1m#Iodpinelot Wetef Oval9y, Orara,dwtlu Seeoon W111dn 30 doye aW InEV. 12/99
F
b0I IF 11r ny f rlf" _"",I ,
CONSI r1UCTl flKtANUATIOS,
µ
r0110Orri(.r lI�ILI�_..
Wed Nn.
Sedal lln
Malednl

a .11 L .:i::".» �....:_)f 1[iJ 9n S >�'Y'� """'7I11E9lFS '' T r'I3". '.1. r=!M , r' r .r. ••
I.! _.. tw.�l::,'. 4.I 'y'l�µ. "t•�"iL ....�F - .:�ti1 ,.... L+. �i.
r
rlonh Cnrpbnn - tlrPmhnCnl of rnvlr^nrnenl and Nntwnl hesmuce! • bivlelon of Water Oudlly • oroundwnler Section
229388
536 Ma9 Srrvlce Ceninr - Ilnlelgh, N.C. 27699-1636•Phone [phone]
WELL 'QNSINUC11011 RECOFIU WELL CON1nnClOil: o�—�1rR U�Sa
WELL CONTnACTOn CEnTIrICA111011 0:�_ .per
STATE WELL CONSTRUCTIOII I'VIM1111:
1• WELL tlCr? (Check or lalrrhlnn,•.): nes1dantlaf5 MunICIPoI L] InduslrinlEl
necovely [J I loml Puna, Water In)ecllon ❑ Other [] It Other, List Use:
AgrlCUlturel U Monlloring ❑
2. WELL LOCAI IOIJ: ( hoj sketch of the'lo on bellow)
Nentesl Town: ____�_..�•n'M <7iC County: —
jn,n•I lionn and N o�•� is. Co;lnmidlY• o ubdlvlelon and tat t1o.j DRILLItJO Li
3. OWNrTI __ _ From to
Address y40
IRG'vrl i dUl'a No. " a
Coy rr Ir•m Sinle ZIp CoG
4. DATE h1111.I-N)_��•l OD
5. TOTAI.Iirirlil _ .._/-
6. CIITTIIII^COLLrC1EU Yf�:S--] NUM _
7. DOES Wr1 i_ IIP.f•IM:E F.XISINJO WEI_L7 YE9 1404
8, STATIC WAIEr1 Ll_VEL Ueloly ToP of Casing: S FT,
(Use'** 9 Move Tap nl Ce91119)
9. TOPOrCA!71lJGLS-__I—_.- FT. Above LendSUllnco'
'Top of ce9111p Irnnlnnl'd rVrr helow lend outface tequlale a Variance In fOtaF
once with 15A NrAC 2C .owm '
to. YIELD (nrn,): _p!- MEI I IOu OF TEST q
it. WATEn 7011ES
-- —. it
i ylio ,_ Amount .�a5 If eddlllonnl epnce Is nredad use bark of form -
12. CIILOl111JAIION:
13. CASING:
wan 1111etnefil
Drl,lh ('Imnelleer or WMghVrl Malednl
. Flom----
1^----- rl.
Flom.._--.---1^__—.—.
TI.
14. GNOUI:
I )rl•Ih
Mrileil-A olhod
From -- --U._
Flon/ .
..___--
15. SOMA 11:
I h•plh bimmalor
Slot Size Mnlorinl
Flom _ __
T o _ ___ r1 _
— In. _—_ In.
• Frorn __
_I n------- 11. ___---
In'
rionn . __..__
Iv -
to. sAw/Gnnvri.
PACT(:
Orpel
She Material
From
— in __— rl.
From _..---
T(1 r1.
-
17. nEMAI1KS:__-
1 Oo 1 trl)rny cr
CONS InUr,Ilotl
ton ornc.r usl
Ouad No:
Sedal tin
rein'ellpn Descdpllon
—_U.Ecils?fx�� --173
0
LOCATION SKEIGL
(Show dlrecllon w1d dhlnnce Itorn nt load two Slale
needs, or 0111e1 n,aP lelerence Points)
) (ry jjTIA1' TI NR WELL WA'-1 CON$ T NUC I Ep Ill ACCotIDM10E WITH I SA NCAC 2C, WELL
j%y{j1LL11yC• AND li1TAT /i`COPYOF 71 i F1ECOr1D f1A9 BEEN Pr10VIDFD i0 711E WEL D //
_ DATE
$liv 91E or rmsot! Ie1n0CNflo IIIF WFI1.
SuMrJI odpinal i vblon al Water oualtly, Detundwale, Seellon willlh) 30 dmy! OW-1 f1EV. 17191

a a t -. � � ..: Jla .lttaar >sr�-1r.>~��--�y�hn^'� �m>>:•!yt.;�;"1 r �' :t t.
.I,... ^.. _tn.l.'!,!.,�.! 1.ar..) a'I`.r:1't Yt jl,r.. ijn6,..,' .. I" `1•�I'
I0111, CID l r,^ �nrl...rnl 0 1 "0 e n 1 • t)[00,111of WeI.I (Nltlll • (Innnrhvnt•r S.01,-'2 2 9 4 4 8
r f ,• un nl end Nnlmnl (lean c^ y
,630 hlnd r:,•I v1rn IJ rninr - Il:dnlOh, rl C. 1!76pp-1630 rhorle (plp) 737 9211
WELLCU11S111UCl1011IIECU1W WCLI.CONIIIACloll!
WELT_ Cor7n1nc1On crnnnr.nnnn e� �al]� �.._-- _ __
f SIA1F WELL CON9It1UC U011 I't Ilr.tlle:
I, WEI.I Ilya; U Indoehlnl 1. _� Awirvlllnnd 1 f,1•In11116•p 1 �^
Ilncot rty _1 I hnt l'om, Witter Inieclloll U Ulller C1 It Olher, Lltl Uee:
2. V`Jr(LI(*,:nll(Ah(^ n,v^.kelcholllsnl c/1/�I,l�onbolovr)`G-
N,!mest Im•:n_-__�RCNJLi,(..�_LdL.d�.4�--�Counly:
ii„��r•n"nl +. i'rv-.ndty, of SybtpNflon 11111lnlJio) UIIILLIIJU LVt)___
- Uf l'lll
I.,.,,,nrn•, n,,..11,�:n.,
Irom to
Add n D SAS" — — j--�- (J
rtlm ,'.,lit lo. l.[= o._.... __
_ _j
{ .
IEi.
l�Fdro�l�
luLjcSlrt(.�-� ./I(f
-SI,le
17q r•� tr,,. ZIP Cod.
- _.
—.----'
5. IWAI l,t'1 111 .p7'jld.. _ _ .._
.. _ ___
n, CIII 111 It :,': 1. l,ilrttll l) Ylii1_.1 IIUI _�
WELLS YES
7. DOES W I1 III -I I nr;r. L"ISIIIIC7
—��
0. SIAIIC WAILIll.1:VCLU001-11cEo1U1111 9; ` .
(Vtt'I' it Above t ep of C 711,11
-------- —. -x_.
❑ lUf (it' CnImZ01(1 Irt._-- I___ . rt. Ahnvto Lnml Snitnco'�-
'Irr pl ne16�n 1.� ��D„I^d rl',•r hrinw lend nnla. Ngtdtis 0 redenee In wot•
— --
. ___-
- a ~\
dence Veld Inn 11 l'At: )C. Ile ' r------------
�,�_h1El11000r1ESi J3
m . -
11. WAl EI1 ZC711L5 (O, I,II,I: _—_
1�is it e•bllll ,nnl ry•m n H r��r
-- I
lr 1 n -� hn•Y^I /NT
12. CI ILOI III IA 11(111: l Jq l_I—Ll_—A11101111I
13. CASII)(',:
Wn9 111111 nn+l
1),.Igl, Nmn.lnr nr Y/rbLV, l l.17lydrl
Io
In. U110111: Inntpd
/, I a1411 Idnlnllol ti
Ir. AV._I LAUR
15. SCII(1 II: lnlminl
I t,l,lh Uinnnlnr Slot Sl.b h
g_ glom _ _. In_ _._,II---- 111. --- 111.---
• glom---
rimil
III. SAII(U(:IIAVrl.IWA': tAnlodnl
t)PI.111 SILe
h1A1 M;:
1 ttt:A111111 !10:It'It
(91tow r1llocllpo mr1 dhinn, n L.nn nl In„11«n 91n1n
lloed7, et 01,11 Innp Rlnleu n 1 •dnitl
17. r1E -
IL
UD I Ir t it V.CI:Ill n'Y 111nr Illt9 W(PCL WA9 COt101111-ICIF.IJ 111 ACCO11I/AfICF W111115A 11r;Ap Zr; YIO,
CON^•IIIUr I,tJl19'1 n11MIlU^•, AtIU111At ACOrYO 11,19 I1EC0 DIIA90EEN rRUVIUEU lU 111E W[U.OI�r�
UII Of I Il r U�Sr UIILY� - `� 1I1/1t1111E Orrrlln. It COIIe fr111r" l(' If Yrrt l---
(Nedrin j Qu r, odp(,rno 11Iv1Jlon et wllnr ay.rny,Orour,d..I11u 3.cnnn Y+IIIJn 90 Jayf
_� __-.._�L Y& �fi• . OWI IIEV. 17/91
Sednttt+ _-:rc

I pt �::..- 1 .:_JI7[^.'krla-v^�x �� ��^' �Ic�^�t��'s.r.>1xtlF:a^.'.1.' _,r �.+'..�r r.t •:�. �, .. .
229445
with Cnrpbnn . 1+^I•.•,rl,urra M I"nvkr vnr,ll end NnNrnl rwourc^q • olvinlon of Wolof quality • Omundwnl!r Serllor,
.36 f.lail Srrvlrn Crnlrr, 11otrl9h, N C. 27699-1636dfions [phone] _
WELL CUNSI RIC11011 MCMID wr-.u.colNnncton: o_E._-.� Fr-RgVSanC_
WELLCOIJInnClonCEnitrlcnnolle:`_
SIAtEWELL c01,19MucllDNTrrnf.lnn:
I, WELI- D`I; (chrck At r•nr.btr n••+p flnsldanllnlLlU Mwdclpnl U Indu�lrinl _t Aprlcullurnl �. Mnrdlad,r
llncovrry ( _I I Irnt runq, Willer In)eclion I Olhsr [] II Other, List Use. -----
2. WELL IOCAlKill l ;hotvskelrllaLit cntlonbillow)
Nemesl I e,vn: ___ County:
p
UIIILLINOLUC3 frFrf(1 lrnanninnnrr hn.,,,^rr:rurnunn•orSubdlvlrlonandloltro.) - fnnrlrlronon"4^gym,
Flom 70
ZIP Cud.
Cnr m 1 r,,•, .,Iola _-- — -
A. DALE hlUl I rll _ jpjrSQa'pa c-
5. 701AI 1Ita1111 --...o7.10zL -• "—_�—
G. ClIT11I1t:SCV1.LrnIF.0 YIS.^,L_)
7. DOES WFI.I- 111'1'IACr rX1!;111 CI WELL7 YES FL
S. S1AfICIV�Irt1L1:VELErelm•llopolCilsing: �� �.---- cn
—�-
9. 70r ur CA ING 1^.---�-- . rr. Above Llnid Sullncn' -- __---- —Am'
tnP M u.nrn r. nnhmt^d rnr•r 6dow Iand rorlaa uquhu a va,lanes In steer -
me of I011"I
�1 M[IIIOUOFIESF.Jl1-a
10. YIELD (nr ): --P�" J —
11. WAIEf17.01IF5 (tlrpill):_—
�._Anloun—f-�i�� II nddltlonnl rrncn It nrr,lnrl toil bock ill InN
12. CI IL0 IIlI4AIION: type _. _
13. CASING: LOGAII011 t3Kr.ICII_
Wall ihkt•ncrf -
llmnrler or Welnl•Nl t. 1Aaledrl (Show dlrecilon and dinlnnrn Iran At Innrl Iwo Slnln
�j(Sr_SnR noads, er olironuep lrlaanrr pnlnUl
From---
14. GIIOVI: Mnlmini
1n _II.
hem — --
15. SCM 1 11: Mnlminl
I )rpll, Uimnnlof slot Slzb
rrrnn --
rrom ----- to _.__---11._ In. _.----
rrom ....-._ Io.
10. SANDIGIIAVII.I'MM: Site Mnlollnl
Drplh
Frorn _---
l0- 11.
rrom ...._.— I r1._�------•---"_��
17. FIEMAIIK',;: r r VlELI.
1 OOI irllrny crriiu-Y MAT illl;i WELL WA9 COIr31 NlIC1 ED It ACCIAS011 S ICF. WIIII ISA IICA. 2:. �,
CONrz I IIVr;i loll grAfTUAiIOS, A110111A7 ACOPY 11119 f1ECU D NA9 BEEN pROVIUF.0 lO 111E PIER. OWNEn.
ID I 1 Of Ill: [E ItSE I))iL`Y IIA11It 0f rPnS If On91f1UC'lrSrcaon Wllldn 30 dnys
UUM011, I 6uM#1 odp 11Io Dlvl'Slon at Waist oualtl. Orourdw pW.I nEV. IL9f
Sedal trr _ _— --___.

1il lag^f 2;A: t'.".1.'71t3"!1R��'4��1t7]:: S;I t'"•,.t, r •.A 1 .'.-.'.
229442
rrlh ('nlhhn .hip nrhnnrd rd I"lm,r vn•nl And Nolurnl ne.^.nurC^e • Olvl!1'n1 of WeW OUAIIty • O'nuudwnl" Srcu-m
J9 MAII Srrvlrn Crnirr Il.ilniph, N C. 27699 1BJ8 Phorle (919) 7JJ-9121
WELL CONSl ILIG110H 11ECOM) weu.cvtlnlACTon: oE__I 6R9l
WELL Co11111ACTollCEnTIrICAI1011h:-;--- U yt,--_—
SIAIFWELL coristnUC11otlPrlif.11ls
1. \VFL1. IISI: (r l,rck nl rn rbl^ n.•.) I1r41dnnllall[J MunlcIpM U Indu thinl /1Ullcnl1nrnl ( I Mnullirhio
Ilecm rly I j I Ir,t Pump Wnlnr 1111Acllon U oth9t L)
2. WFLL 1 (`I:A I IUI1: '.how skAlr, 1 11 9locnllon bnloA - - - -
Ne m e 51 1 m•: n: _. County:
---...._ . _ .._ ....-__.._...
(Ilnp l llnnm and llur•b^i<, Cnmin ndl sub vyon And lnl
r1oT to
f mm M�pn pr l.,dp Gnn
I��rlmtt��iln tlo. -- ,j iR.T_--.--D--
ry% C
Cody _ - .-__.-_ _ -�►--��"
A. DATE ('Illl l rn -�m-
G. MII1111':SC(11,IFC1FU Y138L-_� F'U`J lrrr� -- v
7. DUES bVl-U_ 111-1.1 nrW
E rXi511110 E117 YES t10
0. SIATICWAIEll LEVEL Delo1•+lopolcm1m.: ----- 3 _�1
(Ute b' 9 Above tell ul (;we1n0) <na
P rr. Abovo Lnnd SInc mn'
9. TC1PCrCn;IIIF Li --_-I---"
toll M cANnp I^un6i rl•d rl'r, hrlon Iend surface nquhes 9 ve'IAna In raceot•----._�--C) ---
nl<A Wllh 15n IWAo ].A
10.YIr:LU(nrn,): (e�-_rAelrlouorTEsr q----------
11. WAI Ell 7011L i _ __ ___..__- ----
/j__.. Arllollnl :1--p1�� ck 11 Addlllnn;li rlmr,n H ar•rlm1 a^^ bonl Hill,�_--
12. CIILUIIIIIAIIUt1: typo _ _ _ - --
13. CASIII ,: 1_UC:A(IUII .SRFICtI_
YIeA Ihlcl•ncf�
Urlllll 11mnrlet or
Wldg1lwl c1. 'O tAtledrl^ (Slrow dlrecllon nrnl dlnlnnrn hn1^n pvIn11) 51nh
rIom--v-
�\) -"---Ir'- G �-- �l�L�A L�SZSAR nOAde, nr oll,el m,1'rflrinlP ��/J (/'
frr•rn __ .----_I n . ___._._ r-1. -- (/ /I✓/Cr p,Y�i, ,',-`�N.
14. Gn0UI:roOrTl
MnImInl lnlhotl
--
V
-
15. SClll:l ll:
II,.1,II1 bLvnMor Slat Slze Mnlodnl
In.
• rrom -.-_._-lo_
rlom
to. SAIII-IM11AVI L PA(:l(: S1Le Mnlorinl
DPplh
rrorn ___- 10 -_-- 1 1.
_____--- -- —
rrnm
17. nEMAIII(S CC
'`- r• r YlFl.l
IDO1IrIlrOVrIkI,FI� 111Ml ID^HIND 11tAiNA COPY191f'1119TIECoAO1111f9BEENrnoVIUF.V11O1IIE WE11.OWIIEn.
CON`:I rIW t101ilh�I
_sDATE
Foil p1-I II,C IIS Y� f/-.y;1?11)';A�]IIIIE Of nEn. IIC01191nUC11VO 111E Yl At
Oued pn. ? ^-I 6vbn11 olig ll to TIMslon of Water Ovelly, UMUM&CIr Srcnon willlln 9U doye oWIIIEV. 12j97
Sedalhn .-- 1

1 n (. �:.. ! .__,la^ err la.•r�z #�•;�,.u. �lJss4t ` . . _ m.>x :� t';�^ -) � , r + . � � T �, � • ..
,'•'1'1
229443
I�•I,m nnnni rl I-nvin, unnnl And Nnturnl rle.^.mac^1 • bivN,)n of WAIu Ouelily • O.aundwnVr Snclhn
.39 MAll ;:rrv7cn Crmnr " tlnlnlph, M.C. 27690"1636-rhons (910) 7333221 WELL CL)NESIMICIIUId fiECUfIU WrLI_CONtilACTUrl!
WELL COIItnACIOFI CEnul-ICAT7VH 0:�_-
SLATE WELL CONSTnuCTlorlrrrlr.tlrn:
L 1VFLL II•:I: Irlvck of e a 1. n,•I: ticsldnnllal b Murdclpnl (ndusldnl Aprlculluml Mnnllorinp
Ilocovr,y I - I I -al romp Water In)ecllon (J Olher ❑ If Other, List Use:
2. Wrlll(tCAIIfIII: ';how.^.kelrhdlly9 CnllDnbolow)
flenrecl Ia„n:__. /-44n6__.r4 County:(l/.f&aL."�'�
ptoa•Imm�n nni 7v•+^�t l'mwu��nlly'olf�S/ulbdlvl end lat Mol UI11LlIN(3l_U U-_
3. OWNI II ///r��i1Aa+ _ Flom to fromnllan D<r 4•I nn
Address
" 111rd, nr 7bkln 11 '' � __ _-- � j)l yi .l _ — -----
6-wcil, rr t I--, Slnle zip co • -
G. C(ITTIII(,':(;Cq.1.1"clrL) YF!, IJUM
7. UOrS WI I I- I IPri ACE rXIS f II ICI WELL? YES[] 1104 S. SIATICWAIErILI-VELLtelov,1opOfUll .3.0 rt,
?. 7OP Crr CA�III(I L;-__- L___ . rf. Abovo Lnnd Sullncn' _-_
rep M seat„g o-nidnm^d ni�rr bnlow lend �urlAe� nqulr�� � rnlAne� In �eeer• —
+neewith tr•A11CA02c,j1IIA Q�
fO.YlEIb(ulnn): _J�—.f�1[IIIOI30F1ESf /rlq- --
11. WATE(1 ZOUES (dridh):
12,CIILOIIIIJAIloll: lypn_.'_ - Anlobn( �Tl�� IlAddlllm,nleimcnl�nTn�dn^1u�nbnckolinrm
13. CASIIJLI:
From_—�-----Iv----"-7'rL
Urpilr
Wee lldch,eel
� tlmNter er Wny1 V11.
5-- •�l��s.
,
'i11.111edel
I1.S[�.QR
lo.._---
Frcm
14. Of IOU 1:
rlam ....
Uri41,
0_
M�nl_miarl' lnlhbrl
15. SOHL III:
Urpn, UlamMor SIo1 Slzb Mnlminl
From - -- -"—
rronl _.-.._.ln_.____.ri_.__
twill
16. SANDAMAVI-1, rAGK:
Orhllt Hite Matetinl
morn
LUCAIIOti SKF.I(JI__
(Slrow dhecllon mid dlnlnnrn bnm nl Inwl Iwo Stnln
floods, or Oil let Igor If let once pnlnb)
0 "t j U,.,d
1-2 MKS iu,� n c
17. nEMAIIK'.,:-- -
VICAL
1 DV II�nrnv r'Flll)r.K tIIAT.THrB.WELLWA9C0119fIl(ICIEU Ill ACCIAS13E to WITH1r HCAC2C.ELI-
COH^tllln 1lot r:ItlUAllb^, ANOIHAT ACOrY 11119 pECV Df1A9 BEEN r110VIDF.0 10711E WELL OWI,lnEf1J
roll UtriCr LIS�€�)1ILY IINIIIlE Of 1'Erl^, nCOtl9tb(1CInIC111lE V1E11. DATE
GU Ad No:
eB0 d la blvhlan e1 WAler WAlay, tlro,A,dwtler Salon Wtll lln 90 doy! OW,i IIEV. I2j91
_.—

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section I
1636 Mail Service Center - Raleigh, N.C. 27699-1636 - Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: Dewey Wright Well Pump Co., Inc.
WELL CONTRACTOR CERTIFICATION #: 2645
000568 STATE WELL CONSTRUCTION PERMIT#: Dewey Wright
1. WELL USE (Check Applicable Box): Residential EZ Municipal 0 Industrial El
Recovery 0 Heat Pump Water Injection 0 Other E] If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: BURNSVILLE County: YANCEY
GREEN MiFN RD OFF HWY 197 N OFF 14WY 19E
IRoatl Name and Numbers. Community, or Subtl lvision and Lot No
3. OWNER CAPI CIS .'")N'": PION
Address RT 3 ROX 21
C;RFFN . I$t[eet or Rowe No.l NC 28740
City or Town M �V State Zip Code
4. DATE DRILLED 10111120110
5. TOTAL DEPTH °RF
6. CUTTINGS COLLECTED YES 0 NO
7. DOES WELL REPLACE EXISTING WELL? YES D NO
8. STATIC WATER LEVEL Below Top of Casing: 20 FT.
(Use'," if Above Top of Casing)
Agricultural Monitoring
DRILLING LOG
From To
0 3
DEPTH
Formation Description
D!RT
3 8
SHALE
R 120
GRANITE
120 123
123 175
_QUARTZ
URA.NITE F3,
175 175
175 308
GRANITE .
GRANITE
308 310
QUARTZ
310 310
QU,AP.TZ
9. TOP OF CASING IS 1 FT. Above Land Surface* 310 333 QUARTZ _?
`Top of casing terminated at/or below land surface requires a variance in accor-
dance with 15A NCAC 2C.0118 r, co
10. YIELD (gpm): 10 METHOD OF TEST Air
11. WATER ZONES (depth): 1/2 ppm 175 9.5 ppm 310 rs, v
0 ppm 0 ppm
12. CHLORINATION: Type HTH Amount 70 If additional space is needed use back of form
13. CASING
Depth Diameter
From n To 01 Ft. R 1/d
From To Ft.
From To Ft.
Wall Thickness LOCATION SKETCH
or Weight/Ft. Material (Show direction and distance from at least two State
1RR GAL V u Roads, or other map reference points)
14. GROUT:
Depth Material Method
From 0 To 20 Ft. Cement Gravity Flow
From To Ft. _-
15. SCREEN
Depth
Diameter
From
To
Ft. in.
From
To
Ft. in.
From
To
Ft. in.
16. SAND/GRAVEL PACK:
Depth
Size
From
To
Ft.
From
To
Ft.
Slot Size Material
in.
in.
in.
Material
� b
2
r �
P .�
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONST AC Y OF THIS RECORD HAS BEEN ROVIDED TO THE WELL OWNER.
FOR OFFI NLY �(. (_ �6 — of ©00
Quad No: SI NA URE OF PERSO NSTRUCTING THE WELL DATE
�j�f t original ivision of Water Quality, Groundwater Section within 30 days
GW-1 REV. 12/99
Serial No.

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone] .. jJ F..J r, O U C7 p
WELL CONSTRUCTION RECORD WELL CONTRACTOR: — �' 1 i / ` �� 1 '�r 1 , O I
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMIT#: -
j
1. WELL USE (Check Applicable Box): Residential ❑ Municipal EY Industrial ❑ Agricultural
CI V 1—v❑
Recovery ❑ Heat Pump Water Injection ❑ Other 0 If Other, List Use:
✓City
A�
N
0. DP��. O _ i
FM
2. WELL LOCATION: (Show sketch of the location below)
/
Nearest Town: r ' _ j t County:
I l!. r
`r Aar.DE-, _. ri
PTH
(Road Name and Numbers. Community, or Subdivision and Lot No.) DRILLING LOG
i
%
R Dmcripudd i 1 C
3. OWNER - j ' �)n f. t From To
lA!rjWll94
Address _'
CitY or Town State Zip Code
(r'!L'-..:�� _ --'—
4. DATE DRILLED
5. TOTAL DEPTH—�
6. CUTTINGS COLLECTED YES Q NO[J-•"
7. DOES WELL REPLACE EXISTING WELL? YES 0 NOFL��
8. STATIC WATER LEVEL Below Top of Casing: 7/, FT.
(use': if Above Top of Casing)
9. TOP OF CASING IS_(_ FT. Above Land Surface'
*Top of casing terminated actor below land surface requires a variance In actor.
dance with 15A NCAC 2C .011a
10. YIELD (gpm): 1� METHOD OF TEST Al % rT
11. WATER ZONES (depth): lq?�,Ir- -'�''
12. CHLORINATION: Type t' j ',1'" { Amount—.,.;TL— If additional space is needed use back of form
13. CASING:
Wan Thickness
Depth Diameter or WeighVFI. Material
From To Ft.
From To_j-- Ft.=�E ` — �—
From To Ft.
14. GROUT:
Depth Material Method
From —To—Ft.—
From Q_ To Ft. �;_:� �<
15. SCREEN:
Depth Diameter
From To Ft in.
From To _ Ft. _ in.
From —To Ft. in.
16. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To Ft.
17. REMARKS: _
Slot Size Material
in.
in.
in.
Material
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference pointskA" lJ (j-Ut
/
/
C3 —
ILiJt�, t
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELU
CONSTRUCTION STANDARDS, AND THAT A COPN Ol j THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY " " L '
Quad No: TURF/OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Quality. Groundwater Section Within 30 days
Serial No. GW1 REV. 12199

., 'T. f. .i•�NTrl+,a,. r �t r•. ... .. - ..
229356
North Carol-nn . f1r•lmihornl nl Grvlronrnwtl and Natural ne^ources • Division of Water Quality • O(oundwater Section
1636 Mail Srlvice Center - flaleigh, N.C. 27699-1638 Phone [phone], C
WELL CONSIRUC1lOWRECORD WELLC0HTnnCTOFI:WELL CONTFtACTOIT CEnTIFICA110N 0:,;_-p .{l�
STATE WELL CONSTRUCTION PERMITa:
1. WELI. USF (Check ni ralrnbl, nn.): nesldenllalLlC1 Municlpal ❑ Indus El
Flecovcly (_] I Ical Pump Water Injection ❑ Other n II Other, List Use:
Agricultural (,_] Monitoring ❑
2. WELL LOCATION : ('; w sketch of the location below)
Nearest Toone—._Z�/AjiaS`C,t � County: 44 aQ�----
�noa4 rlanm andor Subdivision nd Lot No) DRILLING LOG
3. OWNFR — From To
Address
Addres
� rr�i or FTi+vin Ao`.j
City or Imo., - `�=--hale Zlp Code
4. DATE 01111 LED __7' oo__
5. TOTALDEP111
6. CLITTIN(:^COLLF(-IED YI=SL-1 NO(1%�
7. DOES WF-IA_ fiEPVtCE EXISIING WELL? YES [_] NO Y�
8. STATIC WATEll Lf-VELD to lop of Casing:- Fr.
(Use'+' 11 Above Top of Casing)
9. TOP OF CASING r �__. FT. Above Lnnd Surface' —_
-Top of casino tannin nl••d l below lend surface requires a variance In accor-
dance withIlICAC 2C.o a
10. YIELD (apllt : __. `% __ Ill 100 OF TEST � — --
11. WATEn 70NES (drpih):
12, CHLOWNA11ON:
13. CASING:
DEPTH_-_ _
rormellon Description
Amount If additional specs Is aril use bnr-k of form
Well Thickness
Dcpih
Ft.
rlam�ellor or WelghUrl.
it.
l,lalednl
From
_To _
From. --------
From _....
FT.
14. GRODI:
I7rpih
qq�^M�`ateriall ..hlelhu(��
Flom
_Ail
�sCD�!—Pr __llW.•
Fiom
15. SCREF711
Urpth Oimneter
From _—__ I o
From _—.To_—_R._ In.
From --__ To - --.--F1-_ In.
16. SAND/GRAVEL PACK:
Depth Size
Slot Size Mnlerlal
Material
_LOCAT IOI_J_51<El_CH
(Show direction and distrincei from at lensl two Slate
%noaadds,,orr Daher map
rreellyetil polln�ts/)/
From To _ FL
From ___,— to--Fl.
17. REMARKS:
DOTIFfTt"4a,V P,FDC fM T�fiST AN WELL WAS CONSTRUCTED IN ACCORDANCE WITH 1 E To 71 E WELL
CO ill gtllC'YI'QFI S�T1ANDA�RDS, AND Q;}lAT A COPY OF 1115 RECORD HAS BEEN PROVIDED TO TIIE WELL OWNER,./
Pon1 tCF. l tit ltyr L I slot. TUBE or rERSON CON nUCfINO THE WELL DATE
Submit original to ivision of Water Guellly, Groundwater Section Within 30 days GW I nEV. 17199

FI I
r)SoY1lS
North Cnrpcmn . I lrpnrunnnt of Environment and Nnbnal nesources - Divlslon of Wet), quality • Groundwater Section 3 `�
1636 Mail .•nrvicn ennier - Ilnfeigh, N.C. 27699-1636-Phone [phone] `)
WELL CONSIRLICTION RECORD WELL CONTRACTOR: 061 IL,514N
WELL CONTRACTOR CERTIFICATION N: G.
STATE WELL CONSTRUCTION PEnMittil _
1. WELL IISE (check Appncahte nos): Resldenllalu Munlcipal ❑ Industrial ❑
Recovery L_J I teat Pump Water Injection ❑ Other ❑ If Other, List Use:
Agricultural ❑ Monitoring ❑
2. WELL LOCATION: ( w sketch of thre,I�-Callon below)
Nearest Town:—_1AA1S1i1�C-1' County: --
(Road Ilamn end tluro! nr S, Comnundty, or S`}b�diyslon and Lot No.) DRILLING LOG
3. OWNER �Quo;No�v"
i�t� From To
Address
. nr
Gt11Et 7,, env
nyw lnvm State ZIP Code
4. DATE DIIILLED �>_�-n
5. TOTAL DEPIII _
R. CUTTINGSCOLLFCTED Yf:S❑ N'09
7. DOES WFI-1_ nFPLACE EXISTING WELL? YES Q _ N04
B. STATIC WATER LEVEL Below Top of Casing: , FT.
(Use'+' If Above Top of Casing)
9. TOP OF CASING IS__J _. FT. Above Land Surface -
,Top or casing lernJnnird ever below land surface requires a variance In scoot-
doncewith l5ANCAC2C 0118
'0.YIE1_D(gp:l9: � ME1110DOFTEST ��
11. WATER ZONES (dnpih):—
12. CHLORINA110N
13. CASING:
f ■i�1 u�TT R,
Wall Thickness
O--- Depth , , !omelet or
From—to-_'�/,n � Ft.
From---- Io__ FL_
From --- lb.-- Ft.
14. GROUI
_ DEPTH _
formation Description
0
O o
If additional space Is needed use back of form
_LOCATION SKETCH
;�M�aateristt pp (Show direction and dislnnce from at least two State
i143-aM1 Roads, or other map reference points)
Orynlli Material elhad
From —� _ To _a.D_Ft. Oh 2kfFL- ur+<d
From To FI.
15. SCREFN:
Depth Diameter Slot Size Material
From To Ft In. _ In.
From To __ Ft.— In. —In.
From ___ To _ __-- FI. _ In. _ In.
16.
17
%ram= `r i' 1 Size Material
From • To FL
From 1 FLr��
I DO I IE FD CFWtF Y 11 IAT THIS WELL WAS CONSTnuCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONS? UC.TI0k&Atl0ARDS, AND THAT 4h COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER. `D' -/�
FOn OFFICE USE ONLY
Gusd No:
St N TUnE OF PEnSON CON UCTIND 711E WELL GATE
Submit odglnal Ivlslon of Water Quality, Groundwater Section will fin 30 days OW i nEv. 12,99
Serial No

..... .. _.. iy. ZI�:.. .1.� I-'!""1 1.!'. �.....T,ry Na. .,L
flop lh Carph,I . 111pnrhu^rd of Fnvlrc,mad end NWuml Fle.^.ourcee - Divlelon of WSW Quellty,• Groundwater Section
1636 Mail So,vicn Cnninr - 1lnlelgh, N C. 27699-1639-Phone [phone] C
: WELL CONSTRUC11011 RECORD WELI_CONMACTOFl: �-1�R�V.SC?J1L
WELL CONTIIACTOFl CEnTIrICAT1011 M: _IqG%��
SLATE WELL CONSTnuCT10F1 PETIMI1M:
1. WELL Ulf_ pn,,k AI rair.^tde IlesldenllalR� MullICIPM 0 Industrial O Agricullurnl Monllarhhg ❑
r ecovriy 1 _1 I lrnt r'urop Water In)ecllon 0 Other [] If Other, List Use: _
2. WELL I.00A11Ui1: j51iow sketch of,t1e location below) Nenrest Iov:n: _.— `A ., County:
jnor,lnor�n��di4u.•����s,cmnnuinIt rSub vllanendLoNlo.) DFlILLIIJGLUG __ UEPTII_-_-
3. OWNFrI ��(J��y From To fa'mellon 0cxdplion —
Addre^s
In.1 r or
ity n, Invm //1� /_Stale Zlp Code
4. DAlE011JL1.Fn_7-./-_Q.D.__
5. TOTAlPf;f'ill._.a�cz�3�2—__
6. ClIT711!!:.^•OVI1FCIEU YI_S�� NOL
1
7. DOES WFIJ_ IIFr'LrCE EXISTING WELL? YES [] NOLif o
8. Sl ATIC WA I EN LEVEL Below 1 op o1 Casing: l�aT FT. zz
(Use b• 9 Above Top of C115619) a
—__ FT. Above Lnnd Surince.
9. TOP OE CnSING IS.__
-Top of celLip r^,ndn nl^d ol'or IlelOw lend aUdaee rehab*$ a verlllnes In eccor- _ V3
dance with 15a fICAC 2C A le Q •� co- oe
!0. YIELD (nlhm): �. _. ME I IOD OF TEST r 1! - — •nyo
11. WATEn ZONES (drplh):-- _
12, CIILOWHAI ION:
13. CASING:
Drell l Iorneter
_LAV FI.
From---
From
44. Gr10U1:
Mati hem. _�e�1�
G
Amount If eddillonnt RPace Is noeded uee bark of I�
Dr1,t11
Flom .. _ U__ It,
Flon,
15. SCnuf 11:
Drplll
Dlanritor
From ------To- ---f1----
In.
• Horn -----ln..__--F1._--
In.
Fmin . _ .. _.. to . - _-_
f l.._-- In.
16. SAND(G11AVUL PACK:
Drldh
Size
O
- LOpAi 10N_SI<El CH
Well TIJci•ncef
or WRIg1,111 L Matelot (Show direction and dlnlnnce from fitleast two State
;1 JIS TVS_saR Floods, or other map reference Points)
Slot SI2e Mnlatiril
From --- T o __-- 1 t. From to Ft. —
17. FlEMAIIKS:__. -
DO IIp IIF nV CF n I Ir'V MAT-"TI ITS WELE WAS- C
CONS I NIIC NOI I F 1 ANUMM, AND THAT A CO
FOII OrFII;E USE ON4Y
Quad Ncc _--. —. �_� Subrret 0091
Soda[ No
In.
Material
ED IN ACCOrwAncE WIll1 15A NCAC 2C. WELL
nECOno HAS BEEN pnOVIOEo 7o T I IE W ELL OWNEn.
� 9- //-
r-'•-�--�Y DATE
ll�`fllnE OP PEfiS l COt19it1UCTINO TI IE W F.IL
Dlvtslon of Water Ouelity, Groundwater seclon Within 30 days OW-1 IIEV. 12191

n
229408
North Cnrt ho - hnPmiu,r,q n1 rnorwiment and Natuivi rioioorcea • DMilon of Water Ousl(ty • Omundwnter Secllon
336 Mail Smvicn Cnnlnr - llnlelgh, N.C. 27699-1636-Phone [phone]
WELLCuiisii UuiimREcont) WELLCONTnnClon: JQfi��JrRgU�SanL
WELL COf1TnACTOn CEnTIrICA1101
STATF WELL CONSTnUCT1011 PF11MI111:
1.
WELL (1747 (Cbrck ill pnr.bie n ,:) Ilesldnnlleluf Munlctpnt ❑
Indushint ❑ Agricullurel U Montloring El
necove.ly j _J I lone rung, Water Injection ❑ Outer p If Other, Llsl Use:
2.
WELL LOCAT IUIP/.,,(�,,;ho%V Sketch of toAlocalion below)
Nowell town:_—, ,UAft____ S.7/�0 - County:
jnpa ltinn�n „a ru,.,t,Ms, or von or�j'bcnv/ytonAand Lot 14a
y
OnILLIWQ LO(3 UEPIN.___
3.
OWNrN �/ I�Y D /il /l Y�td _
From To rc�mallon oetu(pron
Addre^SrF of �
—I3tj
Earnck
--
Cllp n, 1 r.'m (] � 6tale zip CaN
-0�
4-
UAIE111ULLrN-j�.. yj,
—
S.
6.
TOTALIIF.I'�tl�_._
CUTiII!(:.n•CVI_LFCIF:U YESLjl NOL-4
o
7.
UOES VVFt I_ It[ I'IrCE FXISIIfJQ WELL? YES O NOL
s n.
8.
SIATIGWAIEriLEVEL OelotvlopofCesing:___ Fri
o
(Use Y 911bove Top ni Caeing)
x r
9.
T0p Or (7nFING L. ____ I__.. Fr. Above Lnnd Sudnco'
_ v_
�n
-Top of ri'm below lend surface requires a redance In Reor•
roes with 15A ❑cAC 2C. Ito QQ��
_��
rq
.0.
YIELD (trill): __ __ ME11101) OF TEST
JJ
saz
T J.
WATEn MIES (drl,ih):
n. n
Amount
11 eddltlonnl apace Ia nreded uan back or lorm" o
12.
CIILDII114AI ION: typo _!1
13. CASING:
_ LQCAT IQN_SICE 1 C)1
Wan 11110ncae
OrPlh (S
inmeler or Weig1�VT't. [d>tledal f10W direction arid dtnlnftc9 from AT tonal Iwo Stole
From —� ----I o ---�- rl. aR floods, of
other Map
lelerence Poln(s)r/'1
From---
Front._.---Io----.-- FI.
14. Griot' I:
I trPllt Mnterini othod
From ._-0_In AQ._11. ���"
rioni _._._._ In . 1.
15. SMUT l l:
I)rpih Uiamelor Slot Slze Mnlminl
From _ Io- rlIn. __-In.
From _ l o _.__..— I"1. ___ in- , In.
Flom .-. __.Io. ._—r1.In. In.
18. SANU/13,11AV11- rACK:
Urplh Size Motellnl
From In- f L
From
17. "EMATIK> j
/' !` G E I Otis InUCTEO III 11CCOrIDANCE W1111 ISA NCAC 2C.WELL
bOlrr-IVnv Crtll''!, flnliil L
CONSINUr'NON✓:=-1 �NU�r1O^, AFftj YRA PY OF 119 RECOND►1A9 ['TEEN Pilo tOEO TO 111E WEL60Wl�'`
— DATE
rO110rrIl.0 USE bfTLY - "S 1 Tl1nE OF rr sort
ISMVCTWO 111E WEtl
Quad NO: Buti rll origin Division e1 Water Quality. Oroundwsur Section will Iin 30 days
Serial tin �-i d

a li L.:Z. �.....=_)�96iJ3Yt L a 'e"']►J.i1S^ "rMTY31: v1e..:.1. L w" r 1- •: ,.
229402
florth Cnrpl�no . I,rl,mhnnid M rnAre-m,4nl end Nnluml fle.•.norces • bivialon of Water Ousllly • Otoundwnter Section
539 Mail Sorvirn Cente, - 11o1elph, N.C. 27699-1e30-Phone [phone]
WELL CONS11MG11014 RECOF L) WELLCONInnC10n: o�__�JrRgUSa
WELL CONTnACTOnCEntirICA11014II:�
(SFATEWELLcON3TnucTIONPrnmitlr:
1. WELL tl! E (Check Aty4lr.me n.,.)! flesidontlalLYJ Municipal [j Industrial ❑ Apticulturnl Moellering
necovmy (] I lonl Pump Water Injection ❑ Omar II Other, Lis[ Use:
2, WELL LOCAI I011j: 'httw sketch pl the locallon below)
Nenresllo,wc_�'L_71i�llil. County:
(nand rinnin mid Nw�a,t airnuodty or Subdivision and Lot No.) DnILLINQ LOQ __ _UEP 111___ __
3. OWNF11 Rom 10 rmmetlon oemdplion
Address/ —
J�eel or auin
/L/(l ct�t1 C
Cllp rr 1 r.n, QQ,, 61ate Zlp Coda p -
4. DAISP]III,
LFn__.'J.�S. TOTAI,PIT tll__. -- _ a ��
6. CLITTIl 10S CUL1.Ff' I EU YES L.J NO 1
7. UOES WFLI_ 11PI'IM;E FXISfIfJO WELL? YES U_ NO4 �m
B. SI ATIC WA Erl LEVEL Veto",1Oil of Caslnp:
(use'#' 9 Above Top of Ceslno)
9. TOP Or CASIr1(; L . FT. Above Land Surinco'
m
-top of casb�n t•nnlnnl^d el4rt below lend eudeN rsqulde a vedanle In aeeot• — _vn_z_
*nee wnh 15A tu:AC 2C. e - ` mz
to. YIELD (upt11): -1�1! _ MEI I IOU OF TESL J_ 1 — n
11. WATEn 7.ONES
12. CI ILOf lITIAl ION: 1 ypo _F 7R Amount 0& 11 additional epnce le nrp.ded uan buck of loan
13. CASING:
LOCAIIQN SI(EtGH_
Wes ib91,11t -
O Urplh Inrneler of W�n�lg�bVfl. •�f�daled�nh p (Show direction and dlalnnce ham nl 1n111 two Slats
From ---- t�-rl. �IY�e Li3[�u+M1 needs, or other maptefeennic/eeppoltits),,/
Flom_ In- .._ — fl.
_— La„
Flom...---�0 --- 11
14. GnO1.11: C
Flom
Is. SCnui'if:
brpul Uiantelor Slol Slze Malarial
Flom — to-. I1_.-- In.
Front _-_-1n_.._---r't._..— in. —I"'
—
Flom ._ _._. to . ..__ rL In• -- hl
16, SAND/GtIM1. PACK:
Ur1,111 Size Matarinl
From _____ Tn_ tl.
From _____ TC, rt. —
17.
1 b011rnrnV Crr1IIrV 719�
CONS 1 r1UC71ION SI MOAT
t9'CO49r ntIC f Eo IN ACCOIIOANCE Wen I SA NCAC 2C. WELL
•COPY OF }1119 iIECOR IIA9 BEEN PnOVIOFO TO 111E WELL oWNEn. �'
FO11 OFFICE IiSE (1NLY,� i-.
Oued Na _ 6ubrdl odpin'Itl
Sedel Nn -_-
I,
DATE
Or rFn501 0n91RUCTlf10 /11F. Y1r11.
MWaterpusltty,Oroundvtler3ecllonWltllin3lJd1y9 OW-Inev.1219,

i 1
229403
Ilonh Cnrpb,r, . f,^l, a1 low, 11 of rnvfnrunlnt and Nohlral fie sources - Division or Water Clusflty • Omundwftter Smollon
536 Mail service Crnler - flalelgh, N.C. 27699-1636-Phone [phone] �
o WELL C014S I11UC1101.1 nEConu Wr.LLCONTnACTOFI: -•�ofi—F1-at-3S
WELL cournnCTOn CEnTIrICA11011
STATE WELL CONSTnucT10N PEnmitl1: _
1. WELL USt_ (check ni l.ur.hle n •.): IlrsidantlalLYJ Mwdclpal D Industrial ❑ Agrleullurnl Monlloring
necovrry j ] I icnl rump Water Injection [j 011ier [j If Other, List Use:
2. WELL I OCAIIUI I:ASlfow sketch or ilia location below)
Nenrest town:--�/N.( County:
Ll
--
jnoad tia�nn m,d limo,imis, Conrnnnity, or Sub vbion end lot No.l ORILLINO LOG. UEP1_-__
3. OWNFNII
Prom to fmmaUonvescdncon
Address _ ' A -�
nr
Cuyr, Iron, .lp stale zip Code
4. DATE
S. TOTAI.IIr:r•lII __._ �•4 SCl NO C� _ B. ClIT111k;C(JI-lYCIED YL:S o
7. UOES W[I-I_ NPt'LI CE EXISfINO WELL? YES O tJ0 ► A. ��
8. STATIC WAl En LEVEL Elelow Top of Casing: _ Y o.
(Use'+' 9 Above lop of Clulrg)
9. 7OP Or CASIIJG FT. Above Lnnd Suffnco•
'Top of cellnp Ir, ndnrt^d rill" helov, load surface requires a variants In accor• A `�
once with 1^.A IWAC 2Ca Rf�.�r
(0.YIELO(upnf):—e__MEIIIODOFTEST.__l_li_�
NX
11. WATEIl ZONES (drl,lh):_ —
12. CI ILOI IIIJA I ION: I ypo _F Amount2V4 If addlllonel space b nrerled usn bark of Ion z
13. CASING:
Wee Tll_LOCAL ION SI(E 1 CII
91,vrt
Drpu,W �t Inrneler or alghUrt. fdalednl n (Show direction And dlalnnce from at tend two Suits
noeds, of other map refetance,tPolollsl)
—` I'
Flom--- TP'--- rl. Q
From.
14. Gr10D I:DVIAll
Flom _ U__ to .ciQ—Ft' 1f�Gfi�
From
15. swuviI:
ln•plh Di.infolor Slot Slze Mnladnl
From-----__lo _ .-- 11 _ _ In.
From _-- io-._.-.—f"L__— In. In.
Font .___ _.. 1 o . . __ rl. __ In. _— In.
16. SANDIC'TIAVrr-rACI(:
Drpth Size Maledel
From
From
17. TIEMAIIKr:
I OOlfrilf(1V'Cf`yl�I11?a'1. �jA its l p+9 CONS ICtro 114 ACCOMANCE Willi 15A NCAC 2C• WELL
CONSIIIIiE'IOEIvT:1lO aA;COPYO 7 n9 nECOr1[ NA98EEN PiIOViOED 70111E WELL OWNEII.
`I LGusd
lOr USE_ (21jFk�r r1 +�— OA1E
,l �l� L St f iVllrorr mso COMMUC1'riall ElI.
__- Subrrll odgln Divbton of waist Overfly, Gisfundwaler SaCttoo will fin 30 days Ow-1 IIEv.

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section i % 1 9 ty O
1636 Mail Service Center - Raleigh, N.C. 27699.1636•Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: n 'q�1D'u
WELL CONTRACTOR CERTIFICATION #: AL %`e:<z
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check applicable Box): Residential El Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: _ County:
(Road N
3. OWNER
Address
or Subdivision and
City or Town �tata w r.,w
4. DATE DRILLED
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑ NO®
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO®
8. STATIC WATER LEVEL Below Top of Casing: :Z/,� FT.
// ' (Use'+' 9 Above Top of Casing)
9. TOP OF CASING ISL_G_ FT. Above Land Surface'
-Top of "sing terminated stfor below land surface requires a variance In aeeor-
dance with 15A NCAC 2C . 1�
10. YIELD (gpm): �MEfHOD OF TEST
11. WATER ZONES (depth):
12. CHLORINATION:
13. CASING:
DRILLING LOG
From To
DEPTH
Formation Description
Type %/Q 13 Amount 3 If addidonal space is needed use back of Comp
Well Thickness
Depth � ��rrI�,, Di r w Waight[R. ttglal
.
From To ig— Ft. =
From To Ft.
From To Ft.
14. GROUT:
Depth/ /Material Methpd
From � To SY1L Ft.. �� •�J
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft _ in. :in.
From �To_t.in. From To_FL In.
16. SAND/GRAVEL PACK:
Depth Size Material
From To I.
From �To�t.
17. REMARKS:
I DO HEREBY CE
CONSTRUCTION
FOR OF
Quad No:
IN
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
HAS
F PERSON CONWUCTIN
Water Quality, Groundwater
1SA NCAC 2C, WELL
DIED TO THE WELL 0
within 30 days
Gw.t REV. 12199
v. w
wo o
Serial No.

d Natural Resources - Division of Water Ouallry - Groundwater Section
North Carolina - Department of Environment an
1636 Mail Sorvlco Cantor - Ralaigh, N.C. 27G9J-163G4'hu114J (.)19) 7J3 3L':I1
Cco-c,j.4 E,
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION
STATE WELL CONSTRUCTION PERMIT#: _
1c '
1. WELL USE (Check Applicable Box): Residential L7 Municipal ❑ Industrial ❑ Agricultural ❑
2.
Recovery ❑ -. Heat Pump Water Injection ❑ Other ❑
WELL LOCATION Show sketch of the location below)
Neares T wn. ` r/ ' r � (�f Count': —.L�'
If Other, List Use:
' c r' c
P
-
(Road Name atid Numbers, Community, or Subdivision and Lot No.)
DRILLING LOG
3.
OWNER JO e s f% le s
From To
-Address !'0aSS4m fro ,r �Ia
't j' ✓hnlra�t-/��(' t
'
n -1
jStreat or auto o._ YrS•
Cityor Town State Zip Code
C J, V
4.
DATE DRILLED -a % G C
3 - qC,
5.
TOTAL DEPTH -So0
—
6.
CUTTINGS COLLECTED YES D NO[y]-
—
7.
DOES WELL REPLACE EXISTING WELL? YES D- NOD
6.
STATIC WATER LEVEL Below Top of Casing: � FT.
(Use'+' if Above Top of Casing)
9.
TOP OF CASINGIS - FT. Above Land Surface'
ET,
-Top of casing terminated atior below land surface requires a variance In accor-
danco
with 15A NCAC 2C.011810.YIELD(gpm): �METHOD OF TEST ��'11.
WATER ZONES (depth):
*—
ein•
Monitoring ❑
DEPTH - "• r= -
Fonnation Descdplion i
- 12. CHLORINATION:. Type /`f Amount J07- It additional space fs ffilV x of 11;11
13. CASING:
Wall Thickness
Depth
Diameter or Weight/Ft. htatenal
From
To
Ft.
From
To
Ft.
From
To
Ft.
-
14. GROUT
Depth
Material Method
"From
°" " To
Ft.
From
To -
Ft.
: 15. SCREEN ..?
Depth-
Diameter
Slot Size Material
From To Ft _
in.
From '" " '" To _ Ft. _
in.
From `To Ft.—
in.
" 16. SAND/GRAVEL PACK:
kln'Depth
Size
Prom To Ft.
From To —Ft.
—
_ in.
in.
in.
Material
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
�r
��4% /t!�—
,r (I C
I'u Ir
17., REMARKS: '^
I DO HEREBY CERTIFY THATTHIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Ouad No',j,,.SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE ,...
Submit original to Division of Water Ouollty, Groundwater Section Within 30 days
Serial No. GW 1 REV 12

... .. v _ arH;jl w..
229371
North Carollnn . Ncpnrbnenl of Environment and Natural Resources • Divlslon of Water quality • Ocoundwoler Secllon
1636 Mail Service Center - Raleigh, N.C. 27699-ma-Rhone (919) 7333221
WELL CONSInUC110N RECOM WELLCONTRACTOFI:
WELL CONTRACTOR CERTIFICATION
STATE WELL CONSTRUCTION PERMITN:
J. WELL USE (check Applicable nox): nesldonllalUU Munlclpal ❑ Industrial ❑ Agricultural (J Monitoring ❑
Recovery L] I feat Punlp Water Injection ❑ Other [] If Other, List Use:
2. WELL LOCATIOWI (Show sketch of the location below) �
Nearest Town: County: 49-;nnB
(noa•l Namn and
3. OWNFf1 _
Address
lot No.) DRILLING LOG
From To
Cily or, tnr,n d Slate Zip Code
4. DATE UNILI_FD—O_
S. TOTAL IN
6. CUTTI110SCO(_LFCIEU Yf-S❑ N0 1M
7. DOES WFLI.. flr.PLnCE EXISTING WELL? YES NO[id
8. STATIC; WAT Fri LEVEL nefow Top of Casing: :5 FT.
(Use'+' It Above Top of Casing)
9. TOP Or CAMIIG I^ _.__�.__._ FT. Above Land Suffice'
'Top of rasing Irr ntln ntrd ri'm below lend surface requlree It varlance In Acew-
dance will, 15A fICAC 2C .aI Ia
0. YIELD (grm): _.57P . ME11 IOD OF TEST L4�--
11, WATER ZONES (01'th):___- J
i
---DEPTH
ramallon Description
V. CI ILOTUNAI IOLI: I ypo _mount _y �ll1] II additional space isnreded use bark of form
13. CASING: _LOCATION SKETCH
Wall 1hlct nesa
r` Urhllr ,/may/ �lametter or Wnlghl/rt. T tx. �"artedinl (Show direction and dle iSnCe I(orrl al least Iwo Stale
,
From __V I o _ `�"— Ft. Sb ,.L QR Roads, or other map reference points)
TO- --.— Fl.-//Y)�G(/n-Qi'/ ///�'•
From ...-----_10-----_._ FI.
14. GFTOLII:
I )n(rll Material._�lnlhou(EA� �y,�J•CXtiQi
Flom
to
From In
15. SCREFII:
Urplb 17iantetor Slot Size Malerinl
From In.
From _---- to -- Pt. In. —In.—
From
16. SANDIGIIAVEL rncK:
Depth Size Material
From _— To_ rl. —
From ----- to Fl. —
17. REMARKS:
1 Do tlEnrnY CEr711rY TIIAT THiIS WELL WAS
CONS TRVCTION gTANDARDS. AND THAT A C
y y r=
--+�F--r-- '1 -
FOR OFFICE U f;ONLY
Wed No:—
SuM>II Od
Serial No.
MNST ILICTEDIN ACCORDANCEWIT" ISA NCAC 2C. WELL
IPY OF I RM RECORD HAS BEEN PROVIDED TO TI IE W ELL OWNERn.
DATE
or PEnSON CONSTRU TINO TIIE WELL.
of Water Supply, Oroundwetar Season Will in 30 day9 DW 1 nEV. 12/19

North Cnrprn,i . I lrf^nrhnnnt or Pnvirnnnlenl and Natural Nesourcm • Division of Water Quality - Oioundwaler Section 2 2 9 3 66
1636 Mail Srtvicr Crntrr - Ilnlrlph, N.C. 27699-1636 Phone [phone]
WELL CONSTRUCTION RECORD WELLCONMACTON: o L tA.SQN
WELL CONTnACTOn CEITMICATION 0:,;
STATE WELL CONSMUCTIOfI PEnfAITM:
I. WELL USE (Check At rllrible no.): nes1donllal6 Municipal ❑ Industrial EJ
necovery L] I Ir.al Pump Water Injection ❑ Other ❑ If Other, List Use:
Agricultuml U Monitoring ❑
2. WELL LOCATION flow skelch of the locallon below)
Nentest Tov:_ U,442V�i '� - County:
m
rnoa^i rlonmmmmms. COM-1J lly,N o Subdivision end Lol o.) DRILLING LOG
3. OWNER From To formation Descdplion
Address0.
PP /ram
�/V_�1VA11 Ctrf.l Oa 7SS" Far k
City rr r�n� Slnte Zip Code
4. DATE (If III LED
5. TOTALDErTII__�___ o
6. CUTTIII(ISCOLLFCIED YES[J NOM p
7. DOES WFLL IIFPVnCE EXISTING WELL? YES [� NO[ ►r — —
8. STATIC WAI En LEVEL Below Top of Casing: _56) FT, —
(Uso b' II Above Top of Caslnp) _
9. TOP Or CASING I^____I _. FT. Above Land Sulfaco'
'Top or cesbtp I.ntJnnlyd rirrr helow tend surface raqutras a variance In accor-
dance with 15A 11CAC 2C.0113
Q. YIELD (gpm): RV__ I.IEI1100 OF TEST-
11. WATER 7.ONES (drplb): —
12. CHLORINA110N
13. CASING:
Typo——Amount�D16
Depth Iameter
From _O —_To -> FI.
From_---.__. 10_--- rt.--
From Ft.
14. GROUT:
If additlonat spare is nreded use back of fo00
LOCATION SI<EtCH
W nil 1 hicknc ss
o�yr1 tW'�1elg�,nUrcl ;TM��aled`nl n (Show direction mid dlatnnce born at least two Slate
41035 x S11R needs, or other map reference Points)
Drptll Maternal etlrod
From -- �-- 10 AQ—Fl• iOlT�f} 4� ...jJISA.� >�
Fr orn _ 1 -----Ft.
15. SCREFI1:
Urp111 Diameter Slot Slze Malarial
From --_ To _ _— Ft --- In. _ In.
From —_ 10 ___— FL _— In. — In.
From __..__ To _ __ _ FL_ In. _ In.
16. SAND/GnAVFL PACK:
Depth Size Material
From To_ Ft.
From _ ____ TO FL
17. nEMAnKS:
1 DO I IEnrny CEnRf-y TI IAT "r111S WELL WAS CONSMLICIED III ACCOTIDANCE WR11 ISA NCAC 2C, WELL
CONS rnUl. �10lF7STATIDARDS, AND TIIAT ACOPY OF T11 RECORD HA BEEN PROVIDED TO iI lE W WE OWNER. _O
i r Op
FOf10FFICE qy-�,Ot111f� zt DATE
Quad No' f { -r `.,SIc3r1 nE Or rEnSON COr TRUCTINO TI IF WFII.
$ubaflt odplital to TIMslon of Water Quality, Oroundwelar Section Wllhln 30 days OW-1 REV. 17J99
:—y
3edal No _

229367
North Cnrpinri . 1 rcpnoriinnt of Environment and Natural Resources - Divislon of Water Quality • Groundwater Section
1636 Mail Srrvicn Crntrr - flatelgh, N.C. 27699-1636-Phone [phone] —e-
WELL CONSIRUC11ON RECORD WELLCONTnncrOR: Jo �RgU �aoN l
WELL CONTRACTOR CEnTIFICATION M:�•-
STATE WELL CONSTRUCTION PEnMITM:
1. WELL USE (check Ar�pncebla nn.): nesldontial W Municipal ❑ Industrial ❑
Recovery Lj I lonl Pump Water In)ecllon ❑ Other [] If Other, List Use:
2. WELL LOC:AriON: ( how sketch of the location below)
Nearest iovnr. /A/1•J S/cif �D County:
Agricultural U Monitoring ❑
(noa1 Hann m,d Nu. comnuu Ity, or Subr9vlsion and Lol No.) DRILLING LOG
3. OWNFR jn� From To
Address _ 21 . _ /S/ !a/
p�S/ 1 -1Jrni or Frulo o. o /
City or To,,,, o Slnle Zip Code
4. DATE Of 111.1_171) aa%60
6. TOTAL UErIII M1�----S ❑ NO
L�
6. CLITTItIGSCOLU-CIEU Y...
7. DOES WFI_I- HFMACE FXISIING WELL? YES 0 NOLY S. STATIC WAIT En LEVEL Relow 1 op of Casing: '-55 FT.
(Use'+• If Above Top of Cash,p)
9. TOP Or CASIIJG jr; _..... - FT. Above Land Surface' ---
•Top of ceshal trrn,innl�d lfor below Will eurface requlree a verlanee In
Sleet -donee with IFA IWAC 2C.n11a
0. YIELD (gpnl): Q_ ME11 tOD OF TEST ! --
11. WATEn zorJES
12. CHLpftIIJ,41iON:
Iypo _i_i._LQ---Antounl��1��
13. CASING:
Wall 11,10ness
pnl,lh �
i'rneler
orWelolNTI. M�YCeSRR
From__Q ___lo-_FL_
From----
In--- F1._
From.------lo---
Ft.
14. GROl11:
urhpl
Material
1
etI d
From—_�--tn
aQ_PI.
C10TT[1OLiR
From _ -_--
10----rl.
Is. SCREFII:
Urplh Dianteler Slot Slze Material
From —_,To----
rt
From —_
To __ F1. _
In.
-- IrJ•
From ----
To ____ FL
In.
16. SANpJGnAVFt.
PACK:
Depth
Size
Material
From
ToFrom--
17. REMAnKs:
__ DEPTH-_—
ronnallon Description
II additional spars Is nreded use bock of tom
LOCATION S)<E1_CH
(Show direction and dI^,Innce from at least two Slate
Roads, or other map reference points)
e&4w,sb,dtQ I `X-C
0
1 DO I1EM-Fly CERI IFY TI TAT 11IIS WELL WAS CONSTRUCTED IN ACCOr1DANCE Willi M NCAC 20, WELLR.
CONS rNUC11ON STANDARDS, AND THAT A COPY OF HIS RECORD HAS BEEN PRO IDED TO T11E WELL OWN
FOjHo:
CF Li E4N1,Y DATE
Ou�' 8 ' _J.` S ATUr1E OF PERSON CON RUCTIflO TIrE WELL
Subnif odpl&4, pPDlvlslon of Water Quality, eimundeeter Section whilln 30 days GW-1 REV. 12199
Se4—'

North Carphnn . I lepnrlmnnt of Frrvirmrment and Natural nesources - Division of Water Quality - Groundwater Section 1 3 9 V
1636 Mail Srwicr Cnnler - nnieigh, N.C. 27699-1636 Phone [phone] WELL CONSTRUCI ION RECORD WELL CONTRACTOR: �''j+_ am 0F_____F &3USL w
WELL CONTRACTOR CERTIFICA11014 q:_p�J-Qo� ra-
STATE WELL CONSTRUCTION PERMITP:
1. WELL USE (cheek nt•r•Ilc:,l;le nn=): Residanlial L1C1 Municipal ❑ Industriaf ❑ Agricultural ❑ Monitoring ❑
necovpry I j r Irat Pump Water Injection ❑ Other n If Other, List Use:
2. WELL LOCATION: flow�� ��s�ke(tcti o Ile location below)
Nearest Town:___X_UA*d_ County:—✓///('%%�`'``�M��''``/�J�^��`��//���'�
(nna't Ilarnn m Nun v s, Gnomon Ily, or Subdivision and Lol o.) DRILLING LOG_ DEPTH
3. OWNER L From To f"onnation Descdpllon
Address /{/��__ ieai
.��.{/�.
Si`•,-I'�Ilor nurq rye. �O�/_1
L __—
nyorlc�•:n �i p Slate Zip Coda
4. DATE 1)f111 LFD __ 8.'_7 •_�� __ o
5. TOTALDFPiiI
6. CUTTINGSCCIILFCIED YES[ NO[JJ
7. DOES WFLL FIFfLACE FXISNNG WELL? YES 0 NOLy ___------r- --=
6. STATIC WAT En LEVEL Delow Top of Casing: --Z2jD FT. -
(Use -.- it Above Top of Cashrq) _
9. TOP OF CASING IR �____ FT. Above Land Surfaco•
-Top of casing lennlneled nt'or below lend surface requires ■ variance In actor- C-i
dance with 15A NCAC 2C.0118
N -+
10. YIELD (g{nn): Q_Q_ MET IOD OF TEST
I1. WATER ZONES (depth):--. ---
12. CHLORINATION: TypeAmount�L It additional space Is needed use bark of form - -- —
13. CASING:
_LOCATION SKETCH_
WallT rghtieas
Dppih mmeler or Welghl/fl. h�lapl�ed�al�D (Show direction and distance from ffi least two Stale
From O 1 o -4_, Ft. _J&. IS �+-sC SAR, Roads, or other map relerenso points)) I
From------- to----- Ft.
From -----To___ Ff.
14, GROUT:
Ucppt Malarial .,�tollwd Q (^
From � To �Q_FI. OhC�.f4E i'ouad
From To ----Ft.
15. SCREFN:
Uepih Diameter Slot Size Material
From 10 _.— Ft _— In• In.
From _— To Ft..J in. — In. From To --_ To _.__— FL__ In. — In.
16. SAND/GRAVEL PACK:
Depth Size Malerial
From To_ Ft.
From ___ — l-o,-T— Ft.
17. REMARKS: "
I DO IfERFRY GEM IFY TI IAT THIS WELL WAS CONS TnUCTEO IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDAnDS, AND TLIAT A COPY THIS RE RD HAS BEEN PnOVIDED TO THE WELL OWNY.'
FOR OFFICE USE CINLY DATE
Ouad No: IGNATUFIE Or rE oON CONSTRUCTING THE WELL
Submit odglnal to Division of Water Overtly. Groundwater Section Within 30 days OW 1 REV. 12/99
Seder No

North Caropnn hepnrimnnl or Environment and Natural rlesources - Division of Water Quality - Groundwater Section 1^�
1636 Mail Service Center - naleigh, N.C. 27699-1636 Phone (9 t9) 733.3221 �� 7388
NELL CONSTRUCTION RECORD WFLLCONTRACTOn: �bb__B�UseN
WELL CONTRACTOR CERTIFICATION if:_:__�?O�
,. , STATE WELL CONSTRUCTION PEntAITM:
1. WELL USE (check nrpllcable no,): nesldenfialhi( Municipal ❑ Industrial ❑ AgricUllural U Monitoring ❑
Recovery ❑ I lead Pun1p Water Injection ❑ OfliarEj If Other, List Use:
2. WELL LOCATIOt�how sketchoof the location below)
Nearest Town: _ ///iiA 5 y_.G&e - County
(noxf Nanro m the h�ts, Cam l.uJty, or Subdivlsi n /ryl lot No.) DRI`LLING LOG
—_ DEPTH__
3. OWNER OYNi9 �i r From To Fo,malion Description
Address r--
ect or n�/ —�
a t o a
City or In.... Slate Zip Code
4. DATE DRILLFD
5. TOTAL DFPTI I
6. CUTTINGSCOLLECIED YESO NOg r-, rT-
7. DOES WELL Rn REPLACE EXIS RNG WELL? YES NOd
8. STATIC WATER LEVEL Below Top of Casing: FT.
c--
(Use': If Above Top of Casing)-
9. TOP OF CASINO: IS _.—J -. FT. Above Land Surface' — Co -
-Top or casing terndnnind evor brfow land surface requires a variance In eeeor.
dance wlih iSA NCAC
10. YIELD (91,111): A4E71 IOU OF TEST-
1. WATER ZONES (depth):
N -f
12. CNLOnINATION:
13. CASING:
Type Amount .C?.�..i:5 If additional space Is needed use back of form s
Wall T hlcV,,P l l
Depth iamctor orweigwrl ;1Haatorfal D
From —Q --T ° -FSGV Fl. - �J-�, .L►��1QM1
From----- To----- FL_
From ------TO----- FI. —
14. GROUT:
Depth Material
i����ltixrFrom —To�..telhod
_
Frorn-
15.SCnEFII:
Depth DiIntotor
From In n _---_-- Fl _-- In -
From —_ — Jo __ -- f"t. _.— In.
From _--__ _ To _ __— PL__ in.
16. SAND/GnAVEL PACK:
Oepth Size.
From _— To_ FL -
From _.-- To FL
17. REMARKS: O-
Slot Size Material
In.
In.
_ In.
Material
LOCATION_SKETCH
(Show direction and dislancri from at Ieasl two Slate
Roads, or other map referen�c""e points)
, i'�lfN
t6iN
�4 ufiwi
I DO HENEPY CFIT IIFY I AT TIit9 WELL WAS CONSTRUCTED IN ACCOnDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF TI,N3 RECORD S BEEN PROVIDED TO THE WELL OWNS;
FOR OFFICE USE OIILY -
Quad No: SIGI
Submit original Ic
Serial No.
of PEnsoIJ CON9'fnUCTING THE WELL
of Water Dually, Groundwater Section will it 30 days
DATE
OW-1 fri 12J99

North Carolina . Department of Environment and Natural Resources • Division of Water Quality • Groundwater Section
1636 Mal Service Center • Raleigh, N.C. 27699.1636-Phone [phone] r_ ,L r3 4' 7
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMIT#:?"
1. WELL USE (check Applicable Box): Residential Or Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: County:
(Road Name and yvmbers. Contmunity?rpubdiision and Lot No.) DRILLING LOG DEPTH
3. OWNER _0�ZJ2�x From To G
i or � Np 1 Formation^ DescLdption
(f Address �/ � f C�lv� ��/ — C _ il�ri7
4. DATE DRILLED Z OU
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES Q NOM
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO[2�
8. STATIC WATER LEVEL Below Top of Casing: FT.
(Use': 9 Above Top of Casing)
9. TOP OF CASING ISFT. Above Land Surface -
'Top of casing terminated stror below land surface requires a variance to accor.
dance with 15A NCAC 2C .011a
10. YIELD (gpm): �� METHOD OF TEST 154 c
11. WATER ZONES (depth):
12. CHLORINATION: Type Amount 3c
13. CASING:
Wall Thickness
Depth Demeter orWeigM/R.mverial
FromTo �P Ft.�t_ Sr'2a7
From To Ft.
From To Ft.
14. GROUT:
Depth Yateriall Method
From _le� To a 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:
If additional space Is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS AND THAT AOF THIS R 0 D BEEN PR VIDEDfT1O THE WELL OWNER.
FOR OFFICE (S G1AIL....;f%zi t�
Quad No r s SIGNATUNE OF PERSON CONSTRUCTING THE WELL DATE
_ Submit bliloalto Division of Water Quality, Groundwater Sedan Within 30 days
Serial No. ` III L:, �. is t GW1 REV. t2N9

rf
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:R. CALDWELL DRILLING, INC.
WELL CONTRACTOR CERTIFICATION #?140
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential❑ Municipal U1, Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below) `/
Nearest Town: r�vhrJSUtt.`'C' County: TnN�L /
(Road Name and Nurnbe Community, or Subdivision and Lol No.) DRILLING LOG DEPTH
3. OWNER �- I �� C� V rJ i R�� L L V From, To Fonnatio(r� Description `
Address 4 - 5 0 ✓r6__)L�E�
hoe or Houle o.) Gf-A �i:
vftrJSJ r �.�L 1�C� o --
City or Town late Zip Code CIO
4. DATE DRILLED 3 1 Oc 9
5. TOTAL DEPTH '
6. CUTTINGS COLLECTED YES ❑ NO❑ cn
7. DOES WELL REPLACE EXISTING WELL? YES NO
8. STATIC WATER LEVEL Below Top of Casing: -D FT. --
(Use'+' g Above Top of Casing) N � c-
9. TOP OF CASING IS j FT. Above Land Surface' N
'Top or using terminated at/or below land surface requires a variance In actor. o
dance with 15A NCAC 2C.to
10. YIELD (gpm): v METHOD OF ST ��
11. WATER ZONES (depth): f\-) lr�
12. CHLORINATION. Type e tyU Amount tD Z' • if additional space Is needed use back of form
13. CASING:
Wall Thickness
LOCATION SKETCH
Dept
I 5
Diamp er o Weight(Ft. al `�l
� �� �( �`�
(Show direction and distance from at least two State
From
To
Ft.
Roads, or other map reference points)
From
From
To
To
Ft.
Ft.
14. GROUT:
Depth
Material elhod
ls-kZL
From f
To 2 0
Ft. i e^^FaY( c u 2 E Q
From
To
Ft.
iF�Ye1Tx�.
Depth
Diameter Slot Size
Material
\ \
From
in. —in
—To—Ft—
From —To
Ft. _ in. —In.
qq�'�
M7 k-
>4 r
From —To —Ft.
_ In. —In.
C IC G7J
16. SAND/GRAVEL PACK:
Depth
Size
Material
From To Ft.
(r,JR-NS�It��e NW
From To Ft.
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, ANO TJ A A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
SEP [ ?nnl'
FOR OFFICE USE ONLY
Quad No: SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Subrnit original to Division of Water Quality, Groundwater Section within 30 days
Serial No. GW-1 REV. 12199

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section ti l ~� 717
1636 Mail Service Center - Raleigh, N.C. 27699.1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:R.CALDWELL DRILLING, INC.
WELL CONTRACTOR CERTIFICATION #. 1 0
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (check Applicable Box): Residential ❑ Municipal R� Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heal Pump Water infection ❑ Other ❑ If Other, List Use:
2. WELL LOCAT N: (Shaw sketchonf the location below)
Nearest ow o n
(Road Name and N mbers, Community, or Su rvision a` La o.) ILLING LOG DEPTH
3. OWNER — l� F om To Fo'^�atlon Description
Address ,e 6(� OV��y�UKLb�
ZSTrea or KMIO No.y
6Pr>-
City w Town late Zip Code O -
4. DATE DRILLED r�
5. TOTAL DEPTH r" `
6. CUTTINGS COLLECTED fESF NO❑ -
7. DOES WELL REPLACE EXISTING WELL? YES NO[� T -
8. STATIC WATER LEVEL Below Top of Casing: 0_ FT.
(Use'.' a Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface'
'Top of casing terminated Wor below land surface requires a variance In actor- .. -
dance with 16A NCAC 2C.0)18
c.,
10. YIELD (gpm): METHOD OF VEST 4(
11. WATER ZONES (depth):
12. CHLORINATION: Type P 11^ L Amount D If additional space is needed use back of form
13. CASING:
Well Thickness
LOCATION SKETCH
Depth
(�
Diame r or Welgh I. Mal I
r J(F
SOfL �
(Show direction and distance from at least two State
From —TO 0
Ft.
�� a`,
Roads, or other map reference points)
From To
Ft.
From To
Ft.
W L
14. GROUT:
Q
Depth
Material Method
C
From 1 To
FL
cW`e n1"( Po .�2eY1
From To
Ft.
�I
15. SCREEN:
Depth
Diameter
From
To _
Ft _ in.
From
To
Ft. In.
From
To _
Fu _ In.
16. SAND/GRAVEL
PACK:
Depth
Size
From
To
Ft.
From
To
Ft.
17
Slot Size Material
in.
_ In.
_ In.
Material
--_.
C/A c?
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Ouad No: SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Ouslity, Groundwater Sedbn within 30 days
Serial No. GW-1 REV. 12199

North Carolina - Department of Environment and Natural Resources - Division of Water Quality
'. 1636 Mail Service Cantor - Raleigh, N.C. 27G99-1 G3G-Phono (91 e) 733-3221
218033
Groundwater Section
WELL CONSTRUCTION RECORD WELLCONTRACTOR: hJc C(
"�'` r �• WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMIT#:
. 1. WELL USE (Check Applicable Box): Residential LJ Municipal ❑
Industrial ❑ Agricultural ❑ Monitoring ❑.'
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If
Other, List Use:
2. WELL LOCATI N: (Show sketch 1 the location below)
N aresI Town: �)' Ih — I�r County:
s3� CR��k
(Road Name and Number , Commu%rty. or Sugdivision and Lot No
�..
DRILLING LOG DEPTH
3. -.OWNER ' 59[-�� �'� PC_X
From To Forma ton Descnpbon
Address ; -
CJ 3 7
'�
tree! or ouzo o. -,
% •—
City or Town State Zip Code
4. DATE DRILLED 1-7 -to
'.5...TOTAL DEPTH
I
6. CUTTINGS COLLECTED qESQ NOQ'
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NOQ-
8. STATIC WATER LEVEL Below Top of Casing: FT.
(Use'+' if Above Top of Casing)
9. TOP OF CASING ISFT. Above Land Surface*
'Top of casing terminated at/or below land surface requires a variance In accor.
dance with 15A NCAC 2C.g118
10. YIELD (gpm): /4� METHOD OF TEST
11. WATER ZONES (depth): _3
-
-' 12. CHLORINATION:Type r�-- Amount
If additional space is needed use back of term
13. CASING:'.`••'"
Wall Thickness
LOCATION SKETCH
Depth L�1 l Diamet r or We' h t. Maled I
�-►a
(Show direction and distance from at least two State
FromTo Ft. r
Roads, or other map reference points)
From To Ft,
u
From To Ft.
c
14. GROUT ':✓. ;
�
Depth Mate gal Method
6
:From � 'To 2 Fl. Lw
-. From To Ft.
:.-15. SCREEN::.:
_-
.__,
-�: Depth Diameter Slot Size Material
c.a
- From To FI in, in.
From To Ft. in.—in.'i"
From :"':To_ FL in. in.
�_ r
16. SAND/GRAVEL PACK:
d s
a.1dxi",
>rt.:1 'Depth - Size Material
v w .
From To Ft.
From To Ft.
; ru
17.,REMARKS:
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPXQF HISRECORP-HAS-BE N PROVIDED TO THE WELL OWNER. •' . _.- :'
FOR OFFICE USE OL❑—_
�"�`� 0
•- ��
Quad No ", Y Ur1E OF PERSON
CONSTRUCTING THE WELL DATE
Submit OriQlna sign of water Quality,
Gmundwater Section Within 30 days
Sedal No •'� i � C �t n,'�
U
GW i REV. 12/99 t
Croundwater Section
° i`

18034
North Carolina Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section "
1636 Mail Service Center- Raleigh, N.C. 27699-1636-Phono [phone]
WELL'' CONSTRUCTION RECORD WELLCONTRACTOR: yxx II Cif >t
WELL CONTRACTOR CERTIFICATION #: a 13 -
STATE WELL CONSTRUCTION PERMIT#: -
1�.WELL USE (Check Applicable Box): Residential Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring Recovery Heat ❑ ,: Heat Pump Water Injection ❑ Other ❑ If Other, List Use: -
2.WELL LOCATION: Show sket h of the locatio,�l�p,low L)
` Nearest Town• ' W9 0S UJ LJ� Coun I Ayk_y FBI/ - ' - -"+
t
(Road Name and
umbers, Communily, Subtlivisio and Lot No.)
DRILLING LOG
3'
OWNER
`A.Q CJ-Dt La®R-)
From T
"d :I
Address � s � :.
Q — r �
ani or cute o.
— 1
.a. r: a
City or Town Smote Zip Code
-4. DATE DRILLED L V
5.:.. TOTAL DEPTH
�6. '- CUTTINGS COLLECTED YES0 NO©-
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO©-
8. STATIC WATER LEVEL Below Top of Casing: FT.
(Use'+' i Above Top of Casing)
9. TOP OF CASING IS r 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):. , 6D 'METHOD OF TEST
11. WATER ZONES (depth): fy
DEPTH' t �" q•"
Fonnali DescnpGon f -/ ✓ �'
yn r{
se t,t
7ryi t
zr
-':-12. CH LORI NATION:'::: Type Amount := If additional space is needed use back of
13. CASING
Wall Thickness LOCATION SKETCH
Depth DDiia r` or Welyy(Fy Mate 'al (Show direction and distance from at least two
From FL. f I �S�S - Roads, or other map reference points)
From To
Ft.
From To
Ft.
14 GROUT `;
Depth
Matar�
Method
i"
pc
From To
Fl:
k„
To -
Ft.
7
" 15. SCREEN:, t
Depth
Diameter Slot Size
Material
" From To
Ft in.
in.
From ToFt.
in.
in.
i
From, TD"_
Ft. In.
in.
16. SAND/GRAVEL PACK:
iS ,.> s ��Y?Depth ''`
Size
Material
From—a wt ,
To
Ft.
.
'From ' `' To
Ft.
`.17.. REMARKS:
r
r -
`I DO HEREBY CERTIFY
THAT THIS WELL WAS CONST UCTED IN ACCORDANC WITH 1SA NCAC 2C, WELL
CONSTRUCTION STANDARDS AND THAT A COPY
F THIS R D HA EE , ROVIDED TO THE WELL OWNER.
I
FOR OFFICE USE,
Quad No r't,
t j.
TURE OF PERSON CONSTRUCTING THE WELL DATE
•.-• n 5 Y '+� -'
od0i I
ivislon of Water Quality, Groundwator Suction Within 30 days avy+ryj�
Sedal No. ^• i
T CSyY�txnit
I — 11 Ll.�nn
GW1 REV. 12
M
Y
S-roundwater Sections
-
Aa au,il.; :'eaiocal mice
+:�.Clt

North Caroline - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mall Service Center - Raleigh, N.C. 27699-1636-Phone [phone] _.. �- 1 /1 3 4 3
WELL CONSTRUCTION RECORD WELL CONTRACTOR: - S -' ezi v
WELL CONTRACTOR CERTIFICATION
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Boa): Residential Municipal ❑ Industrial (] Agricultural 0 Monitoring ❑
Recovery ❑ Heat Pump Water Infection ❑ Other M If Other, List Use:
2. WELL LOCATION: (Show sketch f the location below)
Nearest Town: �'r-r'�7 r<v��t County. �&h
(Road Namo and Numbe , Coubc[Mslon and Lot No.) DRILLING LOG DEPTH
3. OWNER iE �_l�/' Marc From To Farmalton Oescrlpeon
Address .� -9a
ate_,
( ree or ou a o.
City or Town Slate Zip Code
4. DATE DRILLED. 6:_0Oi 0V
5. TOTAL DEPTH DZ 0 ,,,a,,��r�r�------------yyyyyy 4a 2 .7 --r
6. CUTTINGS COLLECTED YES NOO o ;-
7. DOES WELL REPLACE EXISTIN WELL? YES 0 1,1000�
6. STATIC WATER LEVEL Below Top of Casing: _ V5' FT.
(Use 'i Ii Above Top of Casing) - - -
9. TOP OF CASING IS FT. Above Land Surface' - r
*Top of casing terminated attor below land surface requires a variance In actor- . _ -
dance with 15A NCAC ZC.9 a
10. YIELD (gpm): / � METHOD OF TEST-
11. WATER ZONES (depth):
w
12. CHLORINATION: Type � .- ,$ Amount ^s If additional space Is needed use back of form
13. CASING:
Wall Thickness LOCATION SKETCH
Depth Of eler or Weiphl/R. �Mna/le,daCl/ (Show direction and distance from at least Iwo Slate
From �To —9c?— Ft. .�_ %L Roads, or other map reference points)
From To Ft. _
From To Ft.
14. GROUT:
Depth �Material Method
From b To 1 �1� FI.
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:
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS
BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY />w'"'^l�y 9 %) C)d
Quad No: SIGNATURE OF PERSON CON RUCTING THE WELL DATE
Submit odginal to Division of Water Quality. Groundwater Section within 30 days
Sedal No.
GW-I REV. 12199

North Carplma - Deparimvnl of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-1638-Phone [phone]
8 5
WELL CONSTRUCTION RECORD WELLCONTRACTOR: �O1< FE-aq 014
WELL CONTRACTOR CERTIFICATION a:_Q�
STATE WELL CONSTRUCTION PERMITa:
1.
WELL USE (Check Applicable aoa): Resldenlial b Municipal ❑ Industrial ❑
Agricultural ❑ Monitoring ❑
Recovery ❑ I lent Pump Water Injection ❑ Other ❑ It Other, List Use:
2.
WELL LOCATIO (Show sketch vl lhspg location below)
Nearest Town:... ���'N'S y..1, County:
(Road Name and Nur ers. Community, or ubdivlsion and Lot No.) DRILLING LOG
DEPTH_
3.
OWNER �� /�Jl AJ From To
Formation Description
AddressQ 0q
/�� Bova o.�(,
.49 �vc ffri�0 !l7
City or T own state Zip Code
_• 4.
DATE DRILLED
5.
6.
TOTAL DEPTII _
7-T--
CUTTINGSCOLLFCTED YES] NOM
NOdY
CD
7.
DOES WELL REPLACE EXISTING WELL? YES 0
8.
STATIC WATER LEVEL Below Top of Casing: d Fr.
(Use'+' if Above Top of Casing)
9.
TOP OF CASING IS--J— __ FT. Above Land Surface-
_.� _
'Top of cuing trr min nled ellor below land surface requires a variance In aecor-
__ 3 _.-,
' dance with 15A FICAC 2C Pjlg •
MET) IOD OF TEST R�
co
10.
YIELD (gpm): -c;R --
W
11.
WATER ZONES (depth):—
o
12. CHLOITINATION: Type Amount ..1 pdh% If additional space Is needed use back of form
13. CASING:
LOCATION SKETCH
Well Thicvness
Depth plammetteer or Welghvpt. Material D (Show direction and distance from at least two Stale
From To f/f/--4— Ft.-sa--f�+— M"M1 ii:dRoads, or other map reference points)
From To FL �
From _ To Ft.��
¢%/<) V 1..
14. GROUC
Depth Material kAtilhod
From — To -2iQ _ Ft. Ohm
From _--- TO _ FI.
15.SCREEN:
Depth Di=tmeter Slot Size Malarial
From —To __— FI In. —In.
From -- To -- Ft. _— In. _ In.
From _---To Ft.__ In. —in.
16. SAND/GRAVEL PACK:
Depth Size Material
From To_ f
From To Ft.
17, REMAHKS:
1 DO I IEREPY CERI IFY TI IAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C. WELL
CONSTRUCTION STANDARDS. AND THAT A COPY AILS REC D HAS BEEN PROVIDED TO TILE WELL OW g : /I Gd
FOR OFFICE USE UNLY NATURE OF FER N CONSTDUCTINQ THE WELL DATE
Quad No'.
Submit original to Division of Water Quality, Groundwater Section Wi1111n 30 days GW 1nEV. 12/99
Serial No.

North Carpinrn - Deparhnenl of Envircnment and Natural Resources - Division of Water Quality - Groundwater Section I,.} w ,.S
1636 Mal Servico Cenler - Raleigh, N.C. 27699-1636-Phone [phone] s: 1 ( 1
WELL CONSTRUCTION RECORD WELL CONTRACTOR: JoE Fells
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMIT#:
1, WELL USE (Check AFpnrable Pox)- Residential6 Municipal ❑ Industrial Agricultural ❑ Monitoring ❑
Recovery ❑ I teal Pump Water Injection ❑ Other 0 If Other, List Use:
2. WELL LOCATION: row sketch oft location below)
Nearest Town:,5%/ County:
(Road Narno and Nu r� ens, omnnailty, or bdivision and Lo No) DRILLING LOG _ DEPTH
3. OWNER From To Formation Description
Address Q
rp rrcl or} a 7 � �1.
Hy or Tovm Slata ZIP Code 6�-
4. DATE DHILLFD 0� -
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES O NOM
7. DOES WELL nFPLACE EXIS TING WELL? YES ❑ NO[ y -�
8. STATIC WATER LEVEL Below Top of Casing: � FT, ,--...-
(Use ': If Above Top of Casing)-
9. TOP OF CASING IS __J __ FT. Above Land Surface' -
'Top of casing terminnled aVor below land Surface rSqulreS a variance In accor-
dance with 15A NCAC 2CCR b • r"'`_
m th_— ME1 HOD OF TEST
10. YIELD (gp ):
w -+
11. WATER ZONES (depth): o 0
12. CHLORINATION: Type Amount A P t II additional space is needed use back of form
13. CASING:
LOCATION SKETCH
Wall Thlckness
Depth �//�� plammetteer or W�elg�httTll. �materiiall (Show direction and distance from at least two State
From O To X 0 Ft. Sts�— aetY.i.a.i PI :-UR Roads, or outer map reference points) � J��/%
From To F. /1n .( / `C .
From To- Ftt.
14. GROUT: lll!llCCC777111 r(/(/'trJ /
Deplh Material, silted
From To AO Fl. on QLtE
From __ To _ Fl.
15_ SCREEN:
Depth Diameter Slot Size Material
From _ To _._ Ft ._._ In. —In.—
From _ To FL _ In. — In.
From _ To __— Ft. In. _ In.
16. SAND/GRAVEL PACK:
Depth Size Material
From To—rt.—
From To Ft.
17. REMARKS
'nvr
100 HEREBY CFRT IFY TI IAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF IS REC D HAS BEEN PROVIDED TO T11E WELL OWNER.
FOR OFFICE USE ONLY NATURE OF PERSON CONSTRUCTING THE WELL DATE
Quad No:
Submit odpinal to Division of Water Quality, Groundwater Seaton W(Ihln 30 days OW-1 REV. 17/99
Serial No.

North Carpllna - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center - naleigh, N.C. 27699-1636-Phone [phone] C, 1 0
7 3 O
WELL CONSTRUCTION RECORD WELLCONTRACToR: Z-ofi sag LSoN
WELL CONTRACTOR CERTIFICATION 0:_
STATE WELL CONSTRUCTION PEnMITN:
1. WELL USE (Check Applicable Pox): Residential LYl Municipal ❑ Industrial ❑
Recovery ❑ Heal Pump Water In)ectlon ❑ Other M II Other, List Use:
2. WELL LOCATION: (S w sketch of the location below)
Nearest Town: UA&S;yLI1e - County:
(noad flamo and hinhers, mmunlly, r Subdivision and Lot No.) DRILLING LOG
3. OWNER From To
Address
/J treei or ou a
l coea --—
ny or Tov�n p—' Slate ZIP
4. DATE OnILLED
5. TOTAL 1) -
6. CUTTINGSCOLLECTED YES❑ NOM
7. DOES WELL REPLACE EXISTING WELL? YES [J _ NO[y�
B. STATIC WATER LEVEL Below Top of Casing: ��� FT.
(Use Y If Above Top of Casing) -
9. TOP OF CASING IS __� _. FT. Above Land Surface*
-Top of easing lerndn nlari at/or below land surface requires a variance In accor-
dance with 15A NCAC 2C.01 e
10. YIELD (gpnl): _1— MET I IOD OF TEST
11. WATER ZONES (depth):-
12. CHLOnINATION:
13. CASING:
Agricultural ❑
Monitoring ❑
DEPTH _
Formation Description
• r
M
Type Amount Jagj)16 II additional space Is needed use back of form
Well Thickness
DPplh
FIameter or Welghl7Ft. Material
�'�
Ff.
si .z — 11�a.�1S
From
To
From
To
Ff-
From ---To
-
Ft.
14. GROUT:
Depth
, elhod
D60
Ff.
OMnerl2l
From
To
From __
To
Ft.
15. SCREEN:
Depth
Diameter
Slot Size Material
From
To _ Ff
--
In. _ in•
From _
To _ FL
— In. _ in.
From _—To_.--Ft._
In. _ In.
16. SAND/GRAVEL PACK:
Depth
Size Material
From
To
Ff.
— —
From
—
17. REMARKS:
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
v C
�19w
. n r
�.rs
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF 11S RECORD HAS BEEN PROVIDED TO THE WEL— L OW— NER. 9
FOR OFFICE USE ONLY DATE
Quad No: AN ONSTRUCTING T11E WELL
Submil origin 110 DlAslonTunE OF P RSOof Water Quality, Groundwater Section within 30 days GW 1 REV. 12f99
Serial No.

North Cnrncnn - l,rhn; Irnrnl nl rnvi,,,iruVnt and uwmal rloanu,c^s . LMv Inn el Wale' Duality - Or nnnd.vaVr Snclinn
1636 Mail S... icn Cnnlrr Ilnlnlgh, fLC. 27699.1636 Phone [phone] ,- 17405
WELLcui4sjm.imioriRECORD WELLCONInnC11011: __-FEI3glt.S4�L/
WELL CONTr1ACTOR CEnTIFICA11011 it:
�( SLATE WELL CONSTrIUCTION PEm•1ITN:
1. WELL 1J fi (chock nprnrahle ro+.): nasld^.nllal[U MWdcfpal L] Indurfinl Agacuunrnt [J Monitoring ❑
necovely Icat Pump Water Injection U Other ❑ If Other, Llsl Use:_---
2. WELL I.00A I [Or I: hnw skrict;ol lhv location below)
Nearest tcrvn: __
&4^J 1u' ! - County;
(noa•l rlan+n m Fill MILLING LOG __- DEPTH
3. OWNfn Flom To ronnatlon Desulpron
Address_2!� -- — }
oil —
City e, Ie..n Stale ZIp Code
4. DATE 111111 -1_FO_--__--
5. TOTAL PFP III
6. GUTlIr IC COI LFr IED YES❑ NOUV O
7. DOES W1.I I NPPI M F FKISIING WELL? YES[—] NO[ --- —----_—� --_---
n
B. Sl ATIC WATE11 LGVEL Elelvl•! Top of Casing: _,o7 1J FT. ----- ---- 11 — -
(Use -+- It Above lop of Casing) _--__ — _ .-.
9. TOP OF CARIrIG 1^ ---_ Fr. Above Land Srlrracn' --- —_- -- I ---
•Top of cAsl1m Irinilnnl'd rl'r, below land mrlace rerltdres a variance In accor-
dance with I!;,A M-AC 2Cto. YIELD YIELD (nrni): ___- 1,1ETI IOD OF 1EST
11. WATEII ZONES (rlcpih):--_
c�
--- — ------
12. CNLOHN I i ION: type ___ ff NIyouIlt _,%%4aS 11 adddbnal spnr,9 Is nerJ^d na^ honk n! IcuID o
13. CASING:
LQ(:ATIUIy SKEIC;N_
Wall lhlcbnces
Dr1,111 �1 J(1lamelor or YleigbVft. Maladnl (Show direction and di^.Inncn front nl tensl Iwo Slate
jl
From_--v- __---1 . _ — FI. L. a5— �'�'�5- �- - hLR Fields, or ollter nmp reference points) In
Frorn-.-_- __._ In. _ ---- 11._.
From - _-_.._in .---- Ft._
1
14. GnOUI:
i Material 1nihod
From .. U.- 1n fi. _Con1�CK.E.%. So-vi0 i
F1nol .. In r1.
15. scm n
1lrplll Diameter Slol Slzo Malarial
Flnrll r I __ -- Ill. --
Flora ._ _.._- Tn 1-t - --- In. _— In.
Frorn .. -_.._ to _ -. --Ft._.— In.
16. SAND/11,f1AM. PACi::
Depth Size Malollal
From T n ..—_ 1 I.
From 10-----PI.
17.
1 DO I tGrlr nY rrnI if I IAl-IIUS WELL WAS CONS1FilICTEO IN ACCORDANCE WI It 15A NCAC 2C, WELL
CONSi RIIt;TION Sl AtiPMD.^.•. AND TNAT ACOPY OF TIII RECORD tIAS EEN PROVIDED TO IIIE WELL OY1fIEn.
• Ste— / ��_(f[ � O�
FOIL OffiCE USE (dtILY WY al icy -- -� IIiT ------ onrE
1 SInN r nE or rrn,oN cor nucnncT 11117 wEl1.
Ovad No'.
Submit original to D vlslon of Water Ouallty, Oroundv: star Section Wilhfrl 9U aYs DW1TIEV. 12I99
_._-

North Cmol,,,n . Ihpnrtnirnl of rnvirorm,enl nod 1111ural f1C^.oUr"'I - Divlainrt of Writer Qualify - C,.oundwnlFr Secli.m
1636 flail Srrvico Crrdrr - Ilnlcigil, if 27699-1636 Phone to 19) 7333221
7 407
VVELL CONS] 11UCl[ON nECORD WFLLCoNrRACTOil:
WELL CONTMCTOR CEFlTIrICA11011 ff:
STATE WELL CONSTHUCTfoN PFn611TN:
1. WELL tl! FE (CI,r<k PI r,Ocable norz)t non1denllol Lid Municipal [j Industrial IJ AgricUllural [_, fdonitoring
El
necovery [J I Ival Pump Wader Injection ❑ Other ❑ If Other, List Use:
2. WELL I-OCA 110 J: '�h�o�w �skntch o(tho locatlon below)
Nearest invnr_ ,,4,Lc-t���,- 1 ---County: -------_.
DRILLING LOG LIE_F_TII
(n,a f f fnnm and—unP rr Commnnp %r/Su bdivl,s/ion Pnd Lot —
��-7� From To ro'rnntlon DCscdplion
Address �0 _ ----- j
/�' (eelciflculo o---
��JL<<aKG-- i �/ O�i1�--
Cityorlrv.n Sale Zlp Code _
A. DAT E 11f III 1 FU--
5. TOTAL f^Ff, II I-
6. CUl"TIIIG ol (01LFCIED ll_S NO[17 c� __-
7. DOES VJFI-L flF f'LAf F FKISTING WELL? YES �� tEJTO ►� --- - --
8. S"IATIC %VAT Eft LEVEL Elelow Top of Cnsing: _— ----
...-- (use'+' If Above Top of Caslrrp) ---------r-
9. TOP OP CAMt1P t^ rT. Above Lnnd Sarfacn•
'Top of centno t,ml ,rd,f rYrr Felow Im,d �ur6cs requlre� variance In actor•
dance w111, IrA 11"AC 2C .nt In
10. YIELD ((11'rrr) J IOU OF TEST(�4- —
J C
it. WATER ZOM--S(ticpih):_ ----- _ IV —
1''
12. CI ILOI1114A 11011: 1 ypn —1 _ Amount SiiS 11 ed idlonnl sparn Is ne erind a n hank of Inrm
13. CASRJ G: _LOCATION SREICI).-
Wall Thid�nesl
prhllr tlnrneior or Welut'Vrt. r.latelf" �O QM1 (Show directlnn mil diatnncn born nl 1^nol Iwo Stale
in-� FL "• �IY IJ� I��`Floonds, or other map lelerenre pnlnts)
Tram_-O_
F�
From.
tA. GnoUI: r
I'�rth � Matorlal I �inll wrl
F nrn _ In rt.
15. SCnEl
1 )rlrnt Ilhnmler Slot Size Mntadal
From _ -.._. In.... _.. f 1 _. _ _- In. --
From _. _._-10..-.___fl._ -- 111.---in.-----
Front .- _ to _. _._FL_-- In. _____ In.
--
16. SANDlGf1.r\VFI.I'Ar;"' bialorlal
Orplh Size
From
Front--'�'�-
17. FIEMAIIKS
TIIIS WELL WAS CONS1nuciED 114 ACCOnDANCE Willi 15A NCAGMWELL
3, /,ND Sj1AT A COPY OATE
YJA
IIS nECORO HAS BEEN/PROVIDED TO 111E W ELL OWNER.
1nEOr revs I COrISTRUCTRIp nrr wll.
Suft,, pinal to owl slon of WPler Ovellty, OroundwPler Section WlllJn 30 days DW-1 nEV. 12199
1 DO I lrnrny cmi It V
co1151n 1rTT01JS7AN
FO FI Or FILE USF ONl Y
Ovad No.
Serial No

North Carnln,n . nrr,at lmrnl nl rnvlrnrunenl rind Nal(i, al Tln^nurcns - Oivlrinn of WAIer Of-ur"Y - Crnnndwnlrr gVc.I p„ ; rrl O
1636 Mail Srrvirn Crntrr Ilalelgh, N.C. 27699.1636PI,one 1919) 733.3221
WELL CUris i [mm iorq RECORD WELL CON innCTOII: �b�-_-FESgUS4in1L/-
WELL CONTPACTOn CEPTIrICA110N 11:� 0 _
SLATE WELLCONSTnUC1ION Prim" IP: _------- __----__-_--
1.
WELL Nr.P )chrck Pr pnrablr PDX): nesldonliniu Municipal [] Industrial L-1 Agriculllnal Monitoting U
Pecovrry [_.f I Inab Pump Walor Injection ❑ Other ❑ II Other, Llst Use:
2.
WELL, I.(WA I1011: hocv Sketch Of theO location below)
Nearest lev.n:.__%�4.�. County: ------------
Inoaml rlom-1 n1, l ..... :, Cc, rnt...it (� or Subdivlyio end Lot f10
From To
Fo,rnUon Deescgfcn
3.
ONJNFn
��ti n�,Q�-._Q5!
Addnre^s ?�1S _ -- _—_Q� _--
--- r Oil
as.s'c.a.�.---- 6to %g�__
-a51((/L1L.s
O v " 1 0'..n Shle ZIP code
GO
4.
DATE 1111111.fo-,'Arri
I I I
------- =-
-o
5.
6.
TOTAL PFr _.ate --
CUTTII III`.' C 011T-I:I rI.T yl-! NOM
-- -
7.
DUES kVFI-1_ nLf•LAd F C7(I`:IIIJG WELL? YES �f fJ0[
6.
STATIC WAI En H-VEL Below Top of Cnshlg: __eJ FT. —. _--_
_----- ---:'-'-
(use •,• If Above Top of CnslnO)
9.
TOP Of- CA5!Ir1(', L^ _.._'__-- FT. Above Land SIIlfecn• ----- --
—-_----_ .--L=---
'Ton
of ceslnp ,r.... loot+d r"or hrtow bend surface requires a variance In accor- -
_ -., a7)
dencavdth
10.
ISAIAC 2C Of In
YIFLU (uc❑n): -. /0- 1:1E11 IOD OF T EST-!_�----_-
11.
WATER 70NF
v n h
ck of tom,
12. CI ILOFurJAI IUIJ: 1 ypn—�1-I.57----Amount _.—pas 11 additbmi rrace Is ncndnd o
13. CASRIG: LOCATIUN.SKFICII_-
Wall TIJCVncne
Drplh pilfflNor or We_ Ipl,b'rI. Rhlednl U (Show direction rind di^.Inr,rn front M Innel Iwo $late
Ponds, or other map Were')" polnir))//
From---
From - _.-----In.. _. - H._.-_
14. GnOtlI:
urin,
Flom _ In ___r1.
is. SGI-lu"V
Drl,Ilt Dinlllelnr
From _ _____ l r _.. __._ rl
From
From T" - ---R'- In.
16. SANDJGfI.AVEL rAOK:
Unpl7, Size
From
From
17. nEMAnlcs
Slot Size Mninlinl
In. —
In. --- —
In.
Malorlal
1 DO I
ie nGnY CFFI of"Y TI IAT 11 IIS WELL WAS CONS I PLICTED IN ACCOFTDANCE. WI Ill 15A NCAC 2C. WELL
En
CONS TDIIC110H S IANT)APDS. AND TNAT ACOPY OF TNIS PECOPD HAS BEEN PFIOVIOFO 101t IE WELL OWN
FOTI OrrICF U$F OtILY DATE
IATIIIIE Orr :..SON OtISTf1UCT1fi(1 TIIF Y1FII.
Quad No
Submit odptnal to Dlvlslon or Water Quality. omundv: star Section Wllhln 30 days oW I FIEV. IV99
Serial No. ----_-

North CnrnLno " nrl.n,nnrm of Fnvirmnnenl and Natural fle^ources - Divi^Ion of Water Quality • Gmundwaaer Secllon r.I
1636 Mail Srrvicn Crlltrr - f M1,19h, N C. 27699.1636d'hona [phone] !— �- ir 411
WELL CONSHMIC110N RECORD WFLLCONTnncron: oE__� L�guSonL
WELL CONTFIACTOn CERTIFICATION 0:�-
STATE WELL CONSTRUCTION f FRMITM:
1. WELL CISF (check AI•pnr,wo nn,r): ResldonllalLYJ Municipal 0 Industrial ❑
necovery [_ ) I Innt Pump Water Injection ❑ Other n If Other, List Use:
2. WELL LOCAI IOu tow skert�ch. D,1f t/lp/yya0 localion below)
Nearest lor,n: _�C�i�f i.G j County:
(Woad rtanm mid I m,e wrs,C. rnnrynlly, or Sub sion and of NoN DRILLING LOG
3. OWNER .tiPA From To
Address Q
h lir 3of —Frb o� �0��q
__ Ud4exo-- o ill
City o. Im�n hhta a Zlp Code
4. DATE 111111 LFD y_
5. TOTAL DEf I I I _
6. CLITTIN07COLLFCTED YIcSEl NOM _
7. DOES WFLL fIEPVACE EXISTING WELL? YES NO[ ►r
8. STATIC, WAT En LEVEL Below Top of Casing: FT.
(Lisa'+' If Above Top of Casing) -
9. Top OF cASII1G IS--_.. �____ FT. Above Land StOnco'
-TIP of Ceslnm lrrndnnlyd rDar below lend surlece requires a verfance In eccor-
donoewllh 1FA IICAC 2r.0I yis
0. YIELD ME 1 U OF TEST
11. WATER ZONES WN'th): J -
Agricultural E-1 Monitoring ❑
romtatlon Description
CD
4—=--
--
12. CNLOTtI IJAI IOtJ: 1 ype _.! AmoUlit 5 II addlflonal spnre is needed use back of to-
13. CASING:
m
LOCATIONSKEICH_
YIe11 Thict ness --
Dri�tb 7- n I' meter or s W���FIr)��bVl-1. �b�lawledenl U (Show direction and di ,lento from at toast two 91a1e o
Ft. ;fWl$ Pt"- t P% needs, or other reap rrefeellanncceeDPoh,is)
From _ lb.-"--- FI.
.
From ..--_ l o . —_ Fi.
14. GROL)1:
Nrltlll �Mal�etlitt j�l�nlhod
Front To _AQ_Fl. Pon Q.E�jr— Tuced
From - -- 10 .
15. SCREEN:
Drlrth Diameter Slot Slze Material
From ------ To __-_-- r 1 _-- In. In.
From — ------ l o _ __ 11. _— in.
Front -_—_--To_ FL__ In. —In.
16. SAND/GRAVEL pACIC
Depth Size Material
From --- — To --- I I.
From _.- ---- 10--- Fl. -- - --
17. nEMARKb:--_ —
1 DO 1IF 11F nY OFRI Ir-Y I IAl' 1111S WELL WAS CON SInVC IED IN ACCORDANCE WI111 ISA NCAC 2C, WELL
CONS IRVC TION 3l ANOARDS. AND MAT A COPY OF 09 RECORD HAS BEEN Pnov1DFD TO THE W FL�
___ yfil✓ _ __ ��
FUR OFFICE USE OtILY - DATE
OueO No' lATUr1E OP Pd I COIISInUCTtr1G 111E W F.l1.
Submit origin to Divislon of Waler Oueltty, GroundwAter Secllmn Wilhln 30 deY's G49.1 TIM 12199
--

North Carp6nn nspnrtmrvu of Environment and Natural Flesources - Division of Water Oualiry - G+oundwater Section 11 4 r) q(1
1636 flail Service Crnter - Raleigh, N.C. 27699.1636Phone [phone] �- r_ J-
WELL CONSIRUCIIO14 RECORD WELL CONTRACTOR: �oE F lx$LeN
WELL CONTRACTOR CERTIFICATION 0:_�O�
STATE WELL CONSTRUCTION PERMIT#:
1.
WELL USE (Check Applicable Pox)! Residential5 Municlpal ❑
Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery [] f feat Pump Water Injection ❑ Other n If
Other, List Use:
2.
WELL LOCATIO 1: (Show sketch of the location below)
Nearest Town: LlA.1C 7 >G- County:i/Y
(nowt flame and Nwnl,crs, Communlly, or Subdivision and Lot No)
DRILLING LOG DEPTH___
3.
OWNFFI j q_�oY1K
From To Fcm+alion Description
Address L{
_
YtSV, r1
Ci+y or T mvn Stale Zip Code
_
4.
r/
DATE DRILLED 1r---©0__
5.
TOTALDEPTIi ?>00 _
6.
CUTTltIGS COLLECTED YFS ❑ N'0M
WELL? YES N04
—
—
7.
DOES WELL f1FPLACE EXISTING ❑
— —
8.
STATIC WATER LEVEL Below Top of Casing: _3Q FT.
_
(Use'+' if Above;fop of Casing)
CD
9.
TOP OF CASING IS_--� -- FT. Above Land Surface*
-Top of <asln.1 trrminnted nVor below land surface requires a variance In actor•
:T
dance with 15A NCAC 9C .el 10
R-�--
10.
YIELD (opnt) _Zk.MET-HOD OF TEST
r 1.
WATER ZONES (depth): `_
—
12.
CHLORItJAT10N: Type Amounl _2L_�zL/�S
If additional space Is needed use bark of for cCn
13.
CASING:
cs
SKETCH 00 0
Wall Thickness
Depth Piameler or WelghVFL
_LOCATION
(Show direction find distanco from at least two Slate
;1M,ateriiall U
From 1 o 51__ Ft. -sc-�—-�1.�.��. SIS.z-�M1
Roads, or other map reference points)
From— To--- FL
From --- --- T0-- Ft.
Pons / ) TVF•
14.
GROU 1:
elhod
�To
/,/��
5�.�%1 nSV lIG I i,V .
From ---0- -AC—)FL POfLiCQEt r
From -----To ___Ft.
15.
SCREEN:
Uvpth Diameter Slot Size Material
From _—___ 10 __ —_ Ft ___ in. —in.--
From —___— 10 ---- ! t. _.— In. — in.
From -_—._ To _ ._ __ FL_ In. _ In.
16,
SAND/GTIAVEI. PACK:
Depth Size Material
From __ 1o_ Ft.
From ___ _— 10Ft.
17.
REMARKS: —
I DO HEnEEW CEn fury TI IAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION ST ANDAn DS, AND THAT A COPY
FOR OFFICE USE ONOF I IIS RECOR HAS BEEN PROVIDED TO TI IE WELL OWNER.
LY —y — DATE
Clued No St ATURE OF f ERSOICCONS
TRUCTING THE WELL.
Submit odpina o Division or Water Dusllly, Omundwaler Section Within 30 days
GW-1 nEV. 12/99
Serial No.

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section I 1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone] f, 6 0 O
WELL CONSTRUCTION RECORD WELLCONTRACTOR:i Loot
WELL CONTRACTOR CERTIFICATION Il
STATE WELL CONSTRUCTION PERMITe:
1. WELL USE (Check Applicable sox): Residentiall.-1 Municipal ❑ Industrial ❑ Agricultural ❑ _
Recovery ❑ Heat Pump Water Injection ❑ Other If Other, List Use: _
2. WELL LOCATION: (Show sketch of the location below)
Nearest�Tyown: ��'Ar-���+r-f(e County: �Annj ' V
(Road Nam�GdNumbers. Cor�v�,u�nity, or Subdivision and Lot No.) DRILLING LOG DE'''''
3. OWNER �i1 1 Cr Ref-fL'' From To Focnatrrr. _
Address
&c (St rect or 0Yo.�
� 7
City or Town State Zip Code
-/f '
---- O
-_
r�
4.
DATE DRILLED
----- CO
5.
TOTAL DEPTH
-- _------ -- 3"
6.
CUTTINGS COLLECTED ES ❑ NO©—-
7.
DOES WELL REPLACE EXISTING WELL? YES NO[EF—
8.
STATIC WATER LEVEL Below Top of Casing: FT.
(Use'.' it Above Top of Casing)
I
y
r•i
9.
TOP OF CASING IS FT. Above Land Surface'
—
-Top of casing terminated at/or below land surface requires a variance In actor-
,.''i
dance with 15A NCAC 2C.0118
10. YIELD 'iq METHOD OF TEST �rJ
(gpm):
w
11.
WATER ZONES (depth):. a W .1,
��
12.
CHLORINATION: Type Amount
II additional space is needed use back o: I
13. CASING
Wall Thickness LOCATION SKETCH
Depth Diameter or WeighVFt. Material (Show direction and distance from at least t.
--�JJ�
From To 2( Ft. G / 12 o rs_l� Roads, or other map reference points)
From To Ft.
From --To Ft.
14. GROUT:
Depth Material Method
From To - Ft.
From To Ft. _ -
15. SCREEN:
Depth Diameter
From —.To Ft in.
From To Ft. in.
From To Ft. in.
16. SAND/GRAVEL PACK:
Depth Size
From -- To Ft.
From To Ft.
17. REMARKS:
Slot Size Material
in.
in.
in.
Material
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A CO.PPYY(0 THIS RE D HAS BEEN �P-ROOVIDED TO THE WELL OW76_
FOR OFFICE USE ONLY I '�" 7_
Quad No: SIGNATURE OF PERSON CONSTRUCTING THE WELL
Submit original to Division of Water Quality. Groundwater Section Within 30 days
Serial No.

North Carolina - Department of Environment and Natural Resources - Division of Water Quality Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD
WELL CONTRACTOR:R.CALDWELL DRILLING
WELL CONTRACTOR CERTIFICATION #? 140
STATE WELL CONSTRUCTION PERMITk:
215209
INC.
1. WELL USE (Check Applicable sox): Residential Eel,, Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOC: (Show sit tch of the location below) /
Nearest Town: v+K`•y`O1S 1: Z' County: -,6*ul CGY
lRoad Nameprgl N 7ers. �mmug)ry, or Subdivision and Lot No.) DRILLING LOG
3. OWNER (JRy I ! a fYD7N��� From To
Address 2
tree or y to o. ^1 S1
City or Town state ^ ` i de
4. DATE DRILLED
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YESQ NO
7. DOES WELL REPLACE EXISTING WELL? YES NO
8. STATIC WATER LEVEL Below Top of Casing: -�n I FT.
(Use'i If Above Top of Casing)
9. TOP OF CASING IS ; FT. Above Land Surface'
'Top of casing terminated at/or below land surface requires a variance In accor-
dance with 15A NCAC 2C..118 1
10. YIELD (gpm): d- METH7D OF TEST
11. WATER ZONES (depth): &Z - Z.crpw-100-
J
DEPTH
Formation Description
0
O D
O
12. CHLORINATION: Type punt JOW If additional space is needed use back of form -
13. CASING: .402
W
Wag Thickness
�' Depth Diameter orWeI MIR
From�To _�� Ft.-i�g 7�
From To Ft.
From To Ft.
14. GROUT:
Depth Material athoc
From _� To u' Ft. P�
From To Ft.
15.SCREEN:
Depth Diameter Slot Size Malaria
From _ To FI _ In. _ in.
From To Ft. _ In. In.
From To Ft. In. _ In.
16. SAND/GRAVEL PACK
Depth Size Material
From To Ft.
From To Ft.
17. REMARKS:
LOCATION SKETCH
(Show direction and distance from at least two State
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT$44OPY OF THIS REQORO HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Quad No:
Serial No.
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Dlvislon of Water Quality, Groundwater Section within 30 days
GW-1 REV. 12199

North Carnnnn . Irrpartr;irnt of Environment and Natural Resources - Division of Water Quality - Groundwaler Suction j
1636 Mail Scrvirn Center - nnlcigh, N.C. 27699-1636 Phone [phone] -t- / , 174 32
WELL CONSTRUCTION RECORD WELLCONTRACTon: J -F SgUSaN )
WELL CONTRACTOR CERTIFICATION e:_�OA la..
STATE WELL CONSTRUCTION PEnMITM:
1. WELL tISE (check nrTur,ble nn.): nesldential R Municipal ❑ Industrial El Agricultural U Monitoring ❑
Recovery [_I I loaf Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATI(O�N'�(^how sketch of the location below)
Nearest--
(noid Name and Numbers,Community, or Subdivision and Lot No I
3. OWNFn �z� rL
jl�Q)"-1J_121�?».
Address ecl 0r ou-IngT10
cnv nr te,,n ff sale zip Code
4. DATE 0HII-LED
5. TOTAL DFPTII AW
6. CUTTIIIGS COLLECTED Yf-S ❑ NO 1g
7. DOES WEI_I_ nFPVK:E EXISTING WELL? YES [J NOdy
B. STATIC WATEn LEVEL Relow Top of Casing: J _ FT.
(Use'+' II Above Top of Caslnq)
9. TOP OF CASING IS___.-L _- FT. Above Land Surtaco'
'Top of eeshrq lennlnntrd PI/or below land surface requires a variance In ¢cor-
dance with 15A NCAC 2C .0119
10 YIELD nl)• LA METIIODOFTEST
DRILLING LOG_ DEPTH
From To Formation Desorption
r
0
va
-
- _U
r1. WATER ZONES(deplll):_— --
s
12. CHLOnINATION: Type Amount .E2�- iJ� It additional space Is needed use back of forty r,n
13. CASING: �� =
LOCATION_ SKETCH W �?
Deplh
Wall lhicl,neef
lameter or Weight/1-1 Malerial
--- -
(Show direction And distance from At leas[ two State
O
//
�o
��� PVC SQl�
Roads, or other map reference points)
From
T o
FL
From ---To---
Ft.--v,C
Q n.c.
From ---1e-
Ft
� err- yjle
14. GROUR
Depth
�Q
Material / othod
OhCpEfF �Q 1A
From __—�
_ To
Ft.
From -----
To ---Fl.
15. SCREFN
Dnpih
Diameter
From ---To
----
Ft _-_ In.
From --
To _ _
Ft..— in.
From _._----
To -.---
FT. _ In.
16. SAND/GRAVEI. PACK:
Depth
Size
From
From _—__
To
Fl.
17, REMARKS:
Slot S176 Material
_ In.
In.
_ In.
Material
I DO HERFOY CFn11FV TI IAT THIS WELL WAS CONSTnLICTEO IN ACCOnDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDAROS, AND THAT A COPY OF IS RECORD HAS BEEN PROVIDED 70711E WELL OWNER.
_ __ ___ �—-DC
FOR OFFICEUSE ONLYy:;: `�}
Quad No:
SIGN T RE OF PERSON C STOUCTING THE WELL DATE
_ Submit odglnal to Dwislon of Water Quality, Groundwater Section within 30 days
GW-I REV. 12/99
Sedal No

North Carolntn - nnpnrimnnt of Environment and Natural nesources - Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone] J- 7431
7 ^ 3 1
NELL CONSTRUCTION RECORD WELLCONTRACTOR: _ o —F- 8,43'uSaN Y
WELL CONTRACTOR CERTIFICA11014 ff:_p��
STATE WELL CONSTRUCTION PERMIT11:
I. WELL USF (Check Arrllc,hle no:): nesldentlalRf Municipal ❑ Industrial ❑ Agricultural Monitoring ❑
Recovery [] t teal Pump Water Injection ❑ Other ❑ If Other, List Use: _.
2. WELL LOCATIO Show sketch of io location below)
Nearest To _��— County:
(noa,i nanm. Uurnhnt s, Car m nIt . or Subdivision and Lot 110 I DRILLING LOG
3. OWNER From To Fomiallon Description
AddressI Or —
s6.1.[e(�$� y1 ,,I—cc� u o o.
City or 1 n,,, / State Zip
4. DATE DRILLED - p?7,,,111 e-
5. TOTAL DEPTH _ o
6. CUTTINGSCOLLFCIED YESL� NO 1�
7. DOES WELL nErLACE EXISTING WELL? YES []_ NOEi --- --
8. STATIC WATER LEVEL Below Top of Casing: FT.
(Use'.' If Above Top of Casing)
9. TOP OP CASING ISFT. Abovo Land Snriaco'
'Top of casino IMndnnted c:'nr below Iand surface requires a variance In Motor.
dance with 15A NCAC 2C to . 1
q,� r--
10. YIELD (npttl): _-�£_-- MET 110D OF TEST i
I. WATER ZONES (drpth): _
12. CHLOnINAT ION: Type Amourd�D& II additional spare Is needed use bark el loan `
13. CASING: - -- -- --- - --- --- _-- —
DP['tll iametor
From— 1 ---To --/-••+— Pt. _
From-------- To_----.— Fl.-
From------.--To--- Ft._
14. GnOU I:
0r111 Material ,41-0thod
--WSd.LE_GL-
From
FLorn -
15. ScRErrl:
Vrppl binrneter
From __--__ l n _-___- Fi _-- In.
From -- To __--- Fl. in.
From _____ To _. __—Ft._ in.
16. SANDGnAVEL PACK:
Drpth Size
From _-- To --- FI.
From _ __— 10Ft.
17. REMARKS:___
Slot Size Material
In.
It).
In.
Material
-LOCATION__Sf<E1 (;N_
Wall Thicbnees
or Welgwrt Maledal (Show direction and distance hom at lead two Slale
�jL.l]5 FV aR Roads, or other map reference points)
;LLM flit
4W , /
I Do I IEnF_nY CFn I IFY TI IAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C, WELL
CONSTnUCTION STANDARDS, AND THAT A COPY OF"IIS RECOFlD AS BEEN PROVIDED TO TIIE WELL O
FOR OFFICE USE OtiLY.
Ousd No: i IATUFlE OF PERSON ONSTFlUCTING 1HE WELL
Submit original to Division of Water Duality, Groundwater Section within 30 days
Serial No.
DATE
GW-i REV. 12/99
,J

North Carphnn Drpnrlrnont of Environment and Natural Resources - Division of Water Quality - Groundwater Section �])
1636 flail Service Canter . Raleigh, N.C. 27699-1636-Phone is 19) 733.3221 r 1 ! 4 3 4
WELL CONSTRUCTION RECORD WELL CONTRACTOR: -ToF_fiB!gu.&P /
WELL CONTRACTOR CERTIFICAI ION #:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (check Arr6cab]e nox): ResldenlialLYJ Municipal ❑ Industrial ❑
Recovery ❑ t Ieat Pmnp Wafer Injection ❑ Other It Other, List Use:
2. WELL LOCATION: 1 w sketch 111 ocalion below
Nearest Town:��ti'1 Mz� County:
(noed flame and F7umbers, Cornmmnlly Subdivision and Lol No )
3. OWNFn
Address _�/'lY d a 7
_iS.,impl pr {Toulo FYo�;-^ a87.t�
— Ciryw lnv:n Stele Zip Code
4. OATE DRILLED _ VD
5. TOTALDEPiII
6. CUTTINGSCOLLF('1ED YFSL—] NOU
7. DOES WFI_L REPLACE FXISNNG WELL? YES[—] N0
8. STATIC WATER LEVEL Below lop of Casing: _30 FT.
(Use'i II Above Top of Casing)
9. TOP OF CASING IS ___
.�__._ FT. Above Land Sullnco'
-Top of easlnp ter ndnetnd rvor below tend surface requires a variance In accor-
dance with 15A fICAC 2C . le
10. YIELD (npni): _�. _. MET NOD OF TEST _
11. WATER ].ONES (drplll): _-
12. CHLOniroMON: Type — Amount Q
DRILLING LOG
From To
o
Agricultural ❑ Moniloring ❑
__ UEPTH__
ronoallon Descdplion
c' J
_L—�JLI It additional space Is nr�eded use bark of forAP —
13. CASING:
Wall TMckneaa _
LOCATION $KE1CH
Drplh lameter or WeigbUrl. f.latedal (Show direction and distance from at least two Stale
From �_-__To Fl. 1Ld. �ue•saR Roads, or other map reference points)
From---- To--.— Fl.
From -._.--To— FI,
14. GROU f
Drpth
Malerlal
iE
elhod
in
Ft.
e;).
Flom _0
_a..
Fiom -----
to ____
Ft.
15. SCREEN:
Drpth
Diameter
Slot Size
Malarial
From
_ To __
Ft __
in. _ In.
From
_ l o _
FL
_ In. — in.
From _._._
To ___
FL
_ In. _ In.
16. SAND/GRAVEL PACK:
Depth
Size Material
From —
—_ 10 _
Ft.
From _—
— To
FL
41v. /Y-c
17. REMAnKS:
1 DO f IEREOY CEn11ry it IAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTnLICTION STANDARDS, AND THAT A COPY OF HIS RECORD H S BEEN PROVIDED TO 111E WELL OWNER.
FOR OFFICE USE OilLY DATE
Quad No: S , ATUnE of PERSON CO TnUCTIrJO TI IE WELL.
4 Submit odgln Division or Water Ouellty, Groundwater Section wllhin 30 days OW-1 REV. 12/99
Serial No.

North Carplina - nepnnment of Environment and Natural Resourcos - Division of Water Ouality • Groundwater Section
1636 Mail Service Center - naleigh, N.C. 27699-1636-Phone [phone] '�j'' = 174 3 S
WELL CONSTRUCTION RECORD WELL CONTRACTOR: +�oF_ Fe it
WELL CONTRACTOR CERTIFICATION 0:_Q�D� Iz '
STATE WELL CONSTRUCTION PERMITN:
1.
WELL USE (Check Applicable Ras): ResidentialEd Municipal ❑
Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery 0 Heat Pump Water injection ❑ Other EJ
If Other, List Use:
2.
WELL LOCATI N: (Show sketch of the location below) �/
Nearest Town: u-�'Y/ 1 County: `4-nC-sP
V
(Road Name and Numbers. Com wnity, or Subdivislon and Lot No.)
DRILLING LOG _ DEPTH
3.
OWNER
From To Formation Description
Addressq��
Q Ti oor"NNoilee No.)�Q'y �/
F1uxniyide oe ridOIO Lt7
CGry or Town ��state Zip Code
DATE DRILLED F7�_
4.
5.
TOTAL DEPTI I '
6.
.Vlq5.__
CUTTINGS COLLECTED YES ❑ NO 1M
7.
DOES WELL REPLACE EXISTING WELL? YE�NO ►�
o
8.
STATIC WATER LEVEL Below Top of Casing: FT.
(Use'+' If Above Top of Casing)
_
9.
TOP OF CASING IS__J___ FT. Above Land Surface'
---
-Top of eesing terminntnd Pi/or below find surface requires a variance In aceor•
CID
dance with 15A IICAC 2C.011e •
'.%
10.
YIELD (gpni): 17— METHOD OF TEST
_
11.WATERZONES(depth):—
12.
CHLORINATION: Type _ Amount q 1 Pill
If additional space is needed use back of Id%1 -�
13. CASING:
LOCATION SKETCH
Wall Thlcknesa
Depth U' Plameter or
W1e1g1heVFt Material
O (Show direction and distance from al least two Stale
From O To FL sr�.+— �J.Y-.>J+� I-L�-�M1 Roads, or other map reference points)
From - To Fl.
From --I o Ft. Pe
J,6r25r Or. 4 •
14. GROUT: Depth IMaterial elhod ��,�vf«� /). C,
From To AQ Ft. OhCpz�� oura:d
From ___ To FL
15. SCREEN:
Depth
Diameter
From _—To
_
Ft _ In.
From —
To —_
Ft. _— in.
From ____
To _.__—.
FL _ In.
16. SAND/GRAVEL PACK:
Depth
Size
From
To
FI.
From __--
to
Ft.
Slot Size Material
in.
In.
In.
Material
17. REMARKS:
100 I IEREDY CF.RI IFYTt IAT THUS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C. WELL
CONSTRUCTION STANDARDS. ANDTHAT A COPY n THIS RECTO HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY, F DATE
f I ATURE Or PERSOI ONSTRUCTING THE WELL
Ovid No: s Subndt origin o Division of Water Ovatlty, Groundwater Section within 30 d, GW 1 REV. 12/99
Serial No.

North Carplhia . Depnrtmrnl of Environment and Natural RCSOLIrees - Division of Water Quality - Groundwater Section
1636 Mail Servicr, Cenint - noleigh, N.C. 27699-1636-Phone [phone]
JVELL CONSTRUCTION RECORD WELLCONTRACTOR: Z-o r- -_F &S SoN
WELL CONTRACTOR CERTIFICATION If:
STATE WELL CONSTRUCTION PEr MITq:
"17437
1.
WELL USE (check Ar pucame nn.): nesidential LYJ Municipal ❑ Industrial ❑ Agricultural U Monitoring
❑
Recovory L] I lent Pump Water Injection ❑ OlherEj H Other, List Use:
2.
WELL LOCATIO (Show sketch of t location below)
Nearest To n County
(Woad namn and Inmd.i^u, Convm Willy, or hdivl9lon and _Lot tJo) DRILLING LOG_ DEPT-H_____-_
3.
OWNFR _ OIrVY/V From To rormallon Description
y� �.__� —
Address fG�J/�� /� 12q,/
_�
IM R
8 7f� -
—
Ciiy:orTo,-.,, $ia1Q Zlp Code
4.
DATE [)FULLED _ CA' ' Q
TOTAL DEP I I I
5.
6.
CUTTIMISCOLLECTED YES( NOg
YES
c>
7.
DOES WELL REPLACE EXIS FIND' WELL? [ j NO[ ►e ---- a—�.,-
8.
STATIC WATER LEVEL Below Top of Casing: FT. P.
___qg;0
(Use O' if Above Top of Casing)
_
_ - -
9.
TOP OF CASING IS __ FT. Above Land Sudaco'
-Top
of easing terminated nNor below land surface requlree a variance In aecor-
dancewlth ISA t ICAC2C.o11a
10. YIELD (gpm): METHOD OF TEST
_
r 1.
WATEn ZONES (d(lpth):_ —
12.
_
CHLOnINA110N: Type — Amount g1� It additional space is needed use back of form--
0
—
13. CASING:
Wall lLOCATION_SKETCH_
ghVI t
Dnplll Diameter or WelgnVrl. h'laledCalr, O (Show direction and distance from at least two State
From O To Ft. Sh�7-- .1.�,5. 7-�. -�-LaM1 Roads,
,or'other map reference points)
(/+
From-- To Ft —
From --I ° --- F1.
14. GROUT:
Depth n Material l ethoSd
From — C) To �D FL —s ohCp�tF OdLfr�
Frorn -- _.— To __Fl.
15.SCREEN:
Depth Diarnoter
From _ To _ — Ft _ In.
From _ To _--. FL— In.
Front _ ___._ To _.___Ft._ in.
16. SAND/GRAVEL PACK:
Depth Size
From To _ Fr.
From to Ft.
17. REMAnKS: _
Slot Size Material
Malarial
DO imnFnY CEnilFY THAT THIS WELL WAS CONSTRUCTED III ACCOnDANCE WITR 15A NCAC 2C, WELL
CONS TnUCTION STANDARDS, AND THAT.A COPY OP 11S RECOnD H S BEEN PROVIDED TO 111E WELL OW �R.
� �o e
FOR OFFICE USE (1hILY 43 DATE
Quad No
Sub
or rEnsonc NSTnUCTING THE WELL.
--i! mll original to Dlvlslon of Water ouallly, Groundwater Section wilhln 30 days
-- GW1 REV. 17/99
Serial No

North Carorno. - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center . Raleigh, N.C. 27699-1636-Phone [phone] _ 1 (1 ri 4 .4
WELL CONSTRUCTION RECORD WFLLCONTRACTOR: �O - 92Ur4Ohl
WELL CONTRACTOR CERTIFICATION[e-
STATE WELL CONSTRUCTION PERMITtt:
1, WELL USF (check Applicable no.): Resldontial5 Municipal ❑ Industrial El
Recovery 0 I Lai Pun1p Water Injection ❑ Other Fj If Other, List Use:
Agricultural ❑ Monitoring ❑
2.
WELL t_OCATI (Show sketchof the location below)
Nearest Town: ilirr l 1 jp County: 146L4"-c-J
- —
DRILLING LOG DEPTH__-
(noa,l dame an Numhers, Community Subdivlsio
and LoI Not
3.
OWNFR _ Z
From To Fomratlon Description
Address
_
- t,rei ar Our,
e. —
D 3 8
�hM�StI.A\ I or Ivc �S71 l
0- a s s
City rn 1ov, State Zip Code
4.
DATE DRILLED b-__--�%7ya'-
_=
5.
TOTALDFrIIIc_�6 _ r�
-- — u—�—
6.
CUTTINGS COLLEGIED YES L-] NOU
7.
DOES WFI_I_ nr-rlACE EXISTING WELL? YES
[J N0';-
8.
STATIC WATEn LEVEL Mori Top of Casing:
FF.-
(Use '+' It Above Top of Caship)
_ co _ - _
9.
TOP or CARING IS..__-�_—_ FT. Above Land SNtfaca•
'
'Top
of tAehrq trnnln pled eYrr below Imid surface requires ■ verlence In actor ---
- - -- -- -- --- F
di nce with lSA NCAC 2C 119
al.-
— ------ T,' =
10.
YIFLD (gp it): ..._ f.1E1T IUD OF TEST _L11
11.
�__
WATER ZONES (depth):(,.'�
—_—--_-_-_---�—o
12.
-
CHLORINATION: I ype _J-LLE1—Amounl 1ffS
It additional spac9 Is nreded nse back of form
13.
CASING:
--
LOCATION SKETCH_
Wall lhicl ness
UppIll iametar orr WeighVFL Manledeal
(Show direction find distance front at head two State
From _. O --1 o —J A— Ft.
D
� a+1a,1.+.5. IJl.Y3QM1
Roads, or other map reference points)
From----- to---- Fi.— —
From .___—.—lo-- FL
�^
�� V_.�lk 2�
14,
GnOLI1:
.
Urpth Material elhod
i L
From _--U-a(,)— In r1. coil p'�f�F
UA/V S L�-�--�,
From ---- ---- To
15.SCREFN:
Drplh Diameter Slot Size Material
From 10 -_ — Fl __— In. In.
From —___ To —_ Ft. __ In. In.
From __ To __ — Ft._ In. — In.
16.
SAND/GRAVEL PACK:
Delrth Size Material
From -- To _ FI.
From ------ To Ft.
V.
REMARKS:
I DO IIERERY CF.RT IPY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND SuTHAT A COPY OF IIS RECOR HAS BEEN PROVIDED TO TILE WELL OWNER.
CQ- a�-od
FOR OFFICE USE ONLY - —'—
Quad No SIG UnE OF PERSON NSTRUCTING T11F WELL DATE
") bon odOlnal to Division or Water Ouality, Or
a
'
ndwaler Section Wlthhl 30 days
GWI REV. 1L99
Serial No

North Carl - Deparhonnt 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: �OE (ERQl15bn/
WELL CONTRACTOR CERTIFICATION Ill li..
STATE WELL CONSTRUCTION PEFlMI IP:
1. WELL USE (Check Applicable noa): Residentlai R Municipal ❑ Industrial ❑
Recovery ❑ float Pump Water In)ecllon ❑ Other If Other, List Use:
2. WELL LOCATION: (, v sketch of The location below)
Nearest Town: —ifillsil County:
(noad name an umbers. Community, r Subdivision and Lot No DRILLING LOG
3. OWNER From To
Address p�ld
City or Tovm //""� Slate Zip Code a —
4. DATE DRILLEDQG
S. TOTALDEPTIi,_(p
6. CUTTINGS COLLECTED YES(--] NO[VJ
7. DOES WELL REPLACE EXISTING WELL? YES [a N04
8. STATIC WATER LEVEL Deloty Top of Casing: 4V FT.
(Use '+' 11 Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface'
'Tap of easing lerndnnlyd eVor below land surface requires a variance In eceor.
dance with ISA fICAC 2C A e
10. YIELD (qpni): — METIIOD OF TEST
11. WATER ZOrJES (depth):
Agricultural ❑ Monitoring ❑
DEPTH _
Formation Description
e
12. CHLORINA110N: Type Amount ll] If additlonal space is naeded use back of form
13. CASING:
Wall Thickness LOCATION SKETCH
Depth Piameter or 1w�eig�httri ,�maatteriiall p (Show direction and distance from at least two Stale
From O To _,a, FI...to. ILL_ � rY•rJ�. SJ.Y-�tM1 Roads, or other map reference points)
From-- To Ft.—,�� ,�., CC ����
From _._ To Ft. 6�w/�tJ z w"'� �C
14. GROUT:
Depth Material 11 ethod
From To -A0_Ft. (Ion
�EtE
From To FI.
15. SCREEN:
Depth
Diameter
From To _—
Ft — in.
From _ To _
Fl. _ in.
From —To —
FL _ In.
16. SAND/GRAVEL PACK:
Depth
Size
From To Ft.
From — _— To Ft.
17. REMARKS:_-_
100 IIEREDY CERTIFY T
CONSTRVCTtT.(LNO,
FOR OFFICE USOJONLY
Quad No:
Slot Size Material
In.
In.
In.
Material
IN ACCORDANCE WITH ISA NCAC 2C, WELL
'ORD HAS BEEN PROVIDED TO THE WELL O
1 n
NATURE OF PERS70N CONSTRUCTING THE WELL DATE
$UWnl1 original to Division of Water Quality, Groundwater Section within 30 days
GW-1 nEV. 12l99
Serial No.

North Carprmn I),parlrnp nt of Environment and Na lural rip sources - Division of Water Quality - G, oundwnter Section r'_} r.r sO
1636 Mail Sorvwc Center - fl nleiph, N.C. 27699-1636-Phone is 19) 733.3221 r- - . (
WELL CONSIRUCIION RECORD WFLLCONTRACTOR: �o6���tJr�47�aN
WELL CONTRACTOR CERTIFICA11014 H:-_�ISI�
STATE WELL CONSTRUCTION PERfd ITH:
i. WELL TICE (Cheek Arpl1coble Pox): Resldenlial5 Municipal ❑ Industrial ❑
Recovery [] I feel Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCAT ON: (Shaw sketch of the location below)
Nearest Town rnSV 111p County: y •nce
Agricultural ❑ Monitoring ❑
(noan dame and Nurn')7is. Community. or Subdivision and Lot No DRILLING LOG
3. OWNER
L From To
Address
1en�, oPiS R�.
as y
City or Tm•m (4/ [late Zip Code
4. DATE UTILLFID
5. TOTAL DFPII116
6, CUTTINGSCOLL.ECTED YES0 N09 _
7. DOES WELL REPLACE FXISNNG WELL? YES NO4 B. STATIC WATER LEVEL Below Top of Casing: FT.
f (Use '+' If Above Top of Casing)
9. TOP OF CASING ISJ-_- FT. Above Land Surface -
'Top of casing lPnnlnnted Prior below land surface require$ a verianee In accor-
dance ---
withlSArICAC2C.01 a
10. YIELD (gpnt): Je_ METTIOD OF TEST Rg
11. WATEn ZONES (depth):— j
_- DEPTH___
Formation Descrlplion
o
_
----- � ..
CO o
12. CHLOnlNA110N: Type Amount if additional space Is needed use back of form
13. CASING: - "- - -- -
DPpih
Wall Thicl-.nea$
Material
Pkirnear or WeighVFL ;1
_.LOCATION-_SKEI_CH
(Show direction and disiance from at least two Stale
From O
__ 1 o _
FL
am• �
_S/� e=a— =A.U. r rQR
Roads, or other map reference point;)
From ----
From.
Ft.—�L
) I;44be Creeh Rd.
14, GROU1:
Deplh
Material olhod
e0nekE ft
Bu �Vnle n.c
From
1-n ao
Fl.
-1�01-[
Fens _
To
15. SCREFII:
Drplh
Dimneler
Slot Slze Material
From -__ I n _ _-...-
PI
— In.
From .__...__ . 1 o ..__..__
Ft. _ _—
in.
From -_-_---To__---
Ft. -_.--
In.
16. SAND/GnAVEI. PACK:
Drplh
Size
From _ — T o
_- Ft.
--
From _ To
Ft.
17. REMAni<S:
Material
I DOHErTFOYCFnIIF Y TI IATTIIIS WELL WAS CONSTRUCTED IN ACCORDANCE Willi 15A NCAC 2C. WELL
CONSTnUCTIQII STANDARDS, ANO.THAT A COPY OF IIS RECORD HAS BEEN PROVIDED TO TI IE WELL OWNER.
FOn OFFICE USE Of1LY
Quad No: SI TUDE OF PERSON ONSTRUCTING THE WFU DATE
j � ubmk odglnal to Dlvlslon of Water Quality, Groundwater Section within 30 day4
--- - GW4 REV. 11/99
Serial No.

North Carplinn - nnpnrhncnt of Environment and Natural Resources - Division of Water Quality - Groundwater Section YJ A
1636 Mail Seivicn crnu•r . nnleigh, N.C. 27699-1636-Phone [phone]. / 4 5 5
JVELL CONSIRUCIION RECORD WF.LLCONTRACTOR:
WELL CONTRACTOR CERTIFICATION M:_oy
STATE WELL CONSTRUCTION PERMITN:
1. WELL LISI- (Check Appnrabte nox): Residential LYJ Municipal ❑ Industrial ❑
Recovery ❑ I feat Pump Water Injection ❑ Other if Other, List Use:
2.
3
WELL LOCATION: (� v skelch of the ocation below)
Nearest Town: —_ County:
Inc"I flame ar hinr'iws Cmnnninlly rSWdlvlslon And Lot N-o DRILLING LOG
OWNFn t�01YNOSDYy From To
Address u/1 / - _ L.n. .0 _ __ .
Code
4. DATE DRILLED _V --I vv
5. TOTAL DEP11I __- a_
6. CUTTINGSCOLLEGIEU YFSNO[-qJ
7. DOES WELL nEPLACE EXISTING WELL? YES I NOd
8. STATIC WATER LEVEL Below Top of Casing: __,�Q FT.
(Use'.' If Above Top of Casing)
9. TOP OF CASING IS __J—__ FT. Above Land Surface*
'Top of easbrg tormlimled eUor below land sudece requires a variance In aeeor.
dance with 1sA IICAC 2C .gI to
10. YIELD (gfni _I._ METI IOD OF TEST
11. WATER ZONES (depth):
Agricultural ❑ Monitoring ❑
DEPTH I___
Formallon Description
G I.�
cn --
-a
r-
W cnT_
ni 2
Co o
12. CHLORINATION: Type Amount .sT 1-�D II additional space is needed use back of form
13. CASING:
Wall Thickness
Depth ;."e5 or Wei T1Igh `I. h1a,�rC-ShD
From O _To � Ft. t�-1l.l+ea7. .Ll1�auM1
From— To FT.
-
From ____.__To Ft.
14. GROUT:
Depth Malerlal��,,�_allied
From _� To _c�.0 FL iOh p-Wutrea
From __ To _ Ft.
15. SCREFN:
Depth
Diameter
From
To _._—
Ft —_ In.
From _
10 __
Ft. _ In.
From _--To
_ __
Ft. _.— In.
16. SAND/GRAVEL PACK:
Depth
Size
From __
1o_
Ft.
From ____
I
Ft.
17. REMARKS:
Slot Size Malarial
In.
In.
In.
Material
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
1�eC-11 AI),
BU-CNsu I 11E,Nc
I DO I IEnEDY CEFII IEY'II IAT II ITS WELL WAS CONS inUCTED IN ACCORDANCE WITH 15A NCAC 2C. WELL
CONSTnUCT IONSTANDARDSS AND THAT A COPY F TI ITS RECORD HAS BEEN PROVIDED TO TI IE WELL OWNER. //]]
FOR OFFICE U$ (7NLY --�� Q+C�— --
Quad No: d ,NATURE OP FERS ONSTnUCTINO If
Quad WELL DATE
Sub 1toDivlslonoIWar"D"Ilry,DmundwalerSeUionWilltln30dey9
Serial No. ' y GWA REV. 12/99

North Carplinn . Repnrinrnnt of Environment and Natural Resources - Division of Water Quality - Groundwater Snction
1636 Mail Service Cnntrr - flnleigII, N.C. 27699-1636-Phona (919) 7333221 r{ J 1y
WELL CONSTRUCIION RECORD WFLLCONTRACTOFT:—v0�_—_��B�U.�2N `� /
WELL CONTRACTOII CERTIrICA71014 0:
STATE WELL CONSTRUCTIort PEnmim
1. WELL USE (Check Appnc,bm Fln.): Residential b Municipal ❑ Industrial ❑
Recovery [_] heal Pump Water Injection ❑ Other ❑ It Other, List Use:
2. WELL LOCATI N: (Show sketch of the location below) 1/
Nearest Town: �L!'Lt.VI� ]� County: i`ev
Agricultural ❑ Monitoring ❑
(Roil Name d flum!isrs, Cornowni. y, or Subdivlsion and Lot No) DRILLING LOG
yyj�,'
3. OWNFR �.-LV;r) �Q%� From To
Address N
'-`,� (e T4jjla T7o.
City or To,, Q �ySlate Zip Code
EU A. DATE DRIL.I__ yV _
5. TOTAL DFPIII_aa_t0_—_ -
6. CUTT111GSC0LLFCLED Yf.S[:] NO(17
7. DOES WEI_I_ nF-rt ACE FXIS TING WELL? YES NO4 -
8. STATIC WATEn I FVEL ETelocr Top of Casing: _ FT.
(Use'+' If Above Top of Casing)
9. TOP OF CAS111C; IS__J__,_. FT. Abovo Land Smfnco'
'Top of easln9 Inrrnin Mod ePor below Imrd sudsee rerlulres a variance In aeeor. —_---
dance with I S A II",AC 2C .0110 fj —
10. YIELD (gpm): —7,._._ MET I IOD OF TEST
_DEPTH _
Fermalion Description
0
VII
'I I.
WATER 7-ONES(dcpth):--
12.
CHLORINA11ON: Type —�
Amount a4- 6
If additional space Is needed use back of to"
n. c'
13.
CASING:
t
SKETCH_ =
Drpill
Watt Thicencae
FiAm.�erler or WeloW t.
_LOCATION
(Show direction and distance frorn at least two State
From __Q —_ 10 _1 0
;TMaler(al
FI, d!. �� =A.0 h-C-S- R
Roads, or other map reference points)
From----- lo-.-----
Ft._
From ---.--lb---
Ft.
14
TannDT.
Doplh Material olhod
From _U To Ft. Oh pE�
From 1-o _ Ft. _
15.SCREEN:
Depth Diameter Slot Size Material
From _ I o _ _ FI —_ in. _ In.
From --__ to __ Ft. _ In. _ in.
Front .__-___ To _ _._ Ft. ___ In. _ In.
16. SAND/(,nAVEI. PACK:
Depth Size Material
From _ Io_ Ft.
From _ —__ To Ft.
17
ttWy 8o s
MiCCt,Vi1L-e O.C.
1 DO RE.11EPY CERT If Y -it IAT THIS WELL WAS CONSTnUCTED IN ACCORDANCE WITH 15A NCAC 2C. WELL
CONSTRUCTION STANDAAr T A: A CxOPY OFT S FlECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOn OFFICE USE Orl4Y
p� SIG IIRE OF PERSON C 1S TFlUCTING T11E YlELL DATE
Quad No: n 30 days
f7Submilodolhafl ivistonof Water Quality, Omundwaler Section Wilhl
Serial No. GW1 DEV. 11199

North Carolina - Depadmenl of Environment and Natural Resources - Division of Water Quality - Groundwater Section ! 1 3 2 1 1.
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION 0:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Resldenllal LYf Municipal L1 Industrial ❑ 4g�rlcurural M nI torI I❑
Recovery ❑ Heal Pump Water Infection ❑ Other 0 If Other, List Use:
2. WELL LOCATION: (Show sketch of
(hlion below)
Ecounty: 3�RN5VI LL.IA ru LLv
fFI
oedTJame en/ eu. Community, or Subdivision end Lol No) p DRILLING LOG DEPTH
3. OWNER t ! l cf UN I lt' LJ16 From To r Fonnallon Descdp� `
Address 163 - 5 i t.3 jt X 6 N_
A-V _ .. rye r e o on o .� / V 62-A a l"T'E.
4. DATE DRILLED,=O
5. TOTAL DEPTFI
6. CUTTINGS COLLECTED YESQ NOE]
7, DOES WELL REPLACE EXISTING WELL? YES Q NO
B. STATIC WATER LEVEL Below Top of Casing: X r) FT.
(Use 'i It Above Top of Caslog)
9. TOP OF CASING ISFT. Above Land Surface'
-Top or casing terminated at/or below land surface requfreepa variance In accor-
dance with ISANCAC2C. 118 Ft� IE,ST
10. YIELD (gpm): METi IOD OF TEST
11. WATER ZONES (depth): 200
12. CHLORINATION: Type P I l-L- Amount 0 — If addlllonai space Is needed use back of form
13. CASING:
Wall Thickness
DepthDla sor gat
s-1FWtrLl_ i1VJ
From_1To
From To-- Ft.
From To-- Ft.
14. GROUT:
Depth Material olJ� ��
From To 2 0 F1. � o
From To Fr.
15. SCREEN:
Depth
Diameter
From _
To _
Fr _ In.
From _
To _
Ft.— In.
Front __
To _—
Fr. _ In.
16. SAND/GRAVEL PACK
Depth
Size
From
To
FL
From
To
Ft.
17. REMARKS:
Slot Size Material
In.
In.
In.
Material
LOCATION SKETCH
(Shaw direction and distance from at least two Stale I
Roads, or other map reference points)
e
3 I \
I DO I tEREBY CERTIFY THAT THIS WELL WAS CONS TRIICTED IN ACCORDANCE WITII 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND ^
THAT++A COPY OF TI IIS RECORD HAS BEEN PROVIDED TO THE WELL O
FFOR OFFICE USE ONLY t ilc_' Id l J �� lI t �� y� 5
Quad SIQNAI LIFE OF PERSON CONSTRUCTING TI IE WELL
SuGnit odglnp[�
,I )D,Ivlslon of Water Ouallly, Groundwater Secllon within 30 days
Sedal r t g d
DATE
0
0
Ora 6)
GW-I REV. 12/99

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section n ) 0 10
1636 Mail Seance Center Raleigh. N.C. 27699- 1636.Phone [phone] <.
WELL CONSTRUCTION RECORD WELLCONTRACTOR:R.CALDWELL DRILLING, INC.
WELL CONTRACTOR CERTIFICATION #.
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Resldentlal E� Municipal H Industrial ❑ grlc iltural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATIOp}: (Show ske the location below)
Nearest Town: A5A �^�'y County: _Y_
A
Road Name an Comm%}�;II oar Suodi sion andy,L�of No) D DRILLING LOG DEPTH
3, OWNER A�pGy'2 21w � �q�IG/1'r• y r�`L� . From To Formation scn on
Address P/ / ✓✓ g7% /�+3/
i eT ou e o. _
ily or Ifown slate ZipCode/
4. DATE DRILLED-`�
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YESQ NOQ-
7. DOES WELL REPLACE EXISTING WELL? YES n NO��
8, STATIC WATER LEVEL Below Top of Casing: _jj-_ FT.
11 '' (Use'+- II Above Top of Casing)
9. TOP OF CASING IS�I__L _ FT. Above Land Surface*
-Top of cuing terminated at/or below land surface requires a variance In accor-
dance with 15A NCAC 2C .011E
10. YIELD (gpm):_ METHOD OF TE T
11. WATER ZONES (depth): aclhMAs
12. CHLORINATION:
13. CASING:
Type Amount It additional space is needed use back of form
Depth �/ Di%� r
From�To 42.1— Ft..lt—tom
From To Ft.
From To Ft.
14. GROUT:
LOCATION SKETCH
Wall Thickness
or Weight/Fl. M tena (Show direction and distance from at least two Slate
4Q19•2`i vC Roads, or other map reference points)
Depth
Material
Method
From To 2_ Ft.
From To Ft.
15.SCREEN:
Depth Diameter Slot Size
Material
From _ io __ 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
17. REMARKS:
0
CD
c-_
tA
� N
\a kD
1v 3
I DO HEREBY CERTIFY TF(AMTHIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT norm[
�OTHIS RECORD HAS BEEN PROVI�O THE WELL 0������ peO
FOR OFFICE USE ONLY
Quad No: I' SIG URE OF PERSON cONSTRUCTING ELL DATE
SubnJl original to Division of Water Quality, Groundwater Section Within 30 days
-- GW-I REV. 17/99
Sedal No.

North Caroline - Department of Environment and Natural Resources - Division of Water Quality • Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phons [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION lf: l rL C
STATE WELL CONSTRUCTION PERMIT/:
1. WELL USE (check Applicable sos): Residential L] Munlclpat ❑ Industrlat ❑
Recovery ❑ Heat Pump Water Injection ❑ Other n If Other, List Use:
2. WELL LOCATIOJI): (Show sk@he location below) �/Y
Nearest Town: [ County:
Agricultural ❑ Monitoring ❑
(Road Name agg Numbers. Comm dly, or Subdivision and Lot No.)
DRILLING LOG
3.
OWNER
Frorn To i
� i
Address 7 %y`
ree or ou
i3 JIL L,C N l'
100
ly or Town Slate Zip Code
A
1,0 ( .- Y O `J
4.
DATE DRILLED' O O
O
5.
6.
TOTAL DEPTH
CUTTINGS COLLECTED YESQ NO❑
7.
DOES WELL REPLACE EXISTING WELL? YES 0 NO�
8.
STATIC WATER LEVEL Below Top of Casing: 30 FT.
(Use'i It Abova Top of Casing)
9.
TOP OF CASING IS FT. Above Land Surface'
'Top of cuing terminated aVor below land surface requires a variance to accor-
dance
with 15A NCAC 2C 0115
J�j OF TEST
10.
YIELD (gpm): METHOD
11.
WATER ZONES (depth): n O
DEPTH
Formation Description
„)ke-Lure bc iJ
bi AN tT tr_
:a 1�
(vl-fUr
r
12. CHLORINATION: Type p ` Amount .�° It additional space Is needed use back o(mi
13. CASING: . 1 a
Wall Thickness LOCATION SKETCH _
Depth Dlalmm�� rr a Wei rneI. ,{�1ase (Show direction and distance from at least lye
From To Cl` I FI 15J2 r t i Roads, or other map reference points) N
N
Frorn
To
Ft.
From
To
FI.
.�
14. GROUT:
,'
Depth
Material
(Method
From
To
FI.
e 6r4,C
�R-CjD
3
From
To
FI.
^2
15. SCREEN:
L,
Depth
Diameter
Slot Size
Material
i
From
To _
Ft _
In. _
In.
_
From _
To —
Fl. _
In. _
In.
i
From _
To _
Ft.
In. _
In.
C�
16. SAND/GRAVEL PACK:
Depth
Size
Material
From
To --
Ft.
From
To__
Ft.
17
�n r P P S C/Lt
0
z
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C. WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL O E
FOR OFFICE USE ONLY
OnhAlj 1✓ll�ll'(Vh� /(__�00
Quad No:
4 n '.
Serial No. r"' ' .L L y
21 ' 1 i000
3 THE WELL DATE
section within 30 days
GW.I REV. IV99

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section .. yl 469
1636 Mall Service Center . Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: { }lrPOhGAcaliY
WELL CONTRACTOR CERT�IFIVATION If: ,262aLo
STATE WELL CONSTRUCTION PERMITN:
1.
WELL USE (Check Applicable Bo)o: Residential B?r Municipal ❑
Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heal Pump Water Injection ❑ Other F1 It Other, List Use:
2.
WELL LOCATI N,: (Show sketch of the location below) v
Nearest Town: _,cr, um 5611 e_ County:_J
----
(Road llu,aud Numbars, Community, or Subdivision and Lot No.)
DRILLING LOG DEPTH
3.
^
OWNER {,lea COrl it
From To Foorquion Description
Address fA
y
�O
�—�--- —
77 vac or ou
S 7
A'� —` 2 L05
City or Toym State Zip Code
, CD
4.
DATE DRILLED BnNs_oo
r�
5.
TOTAL DEPTI-1 1106
6.
CUTTINGS COLLECTED YES LJ No
WELL? YES ❑ NO
r'-•"
7.
DOES WELL REPLACE EXISTING
-_'.^�
6.
STATIC WATER LEVEL Below Top of Casing: 70 FT.
—
(Use': if Above Top of Casing)
TOP OF CASING IS--J_ FT. Above Land Surface'
m-
9.
-Top
of casing terminmed PYor below tend surface requires a variance in actor-
•J �'-
dance
10.
with 15A NCAC 2C 11e
YIELD (gpm): `b— MET HOD OF TEST
11.
WATER ZONES (depth):_
CHLORINATION: Type W_ : Amount
if additional space Is needed use back of form
12.
_l7.1.
13. CASING:
_LOCATION SKETCH
Wall I hickne is
/,�l Depth (]� /ptarmeq�gr orf,WLeIghUF atedal (Show direction and distance horn at leas) two Slate
From __S/ To —1— FI.(. J%5 CIF.»» Roads, or other map/reference points)
From--- To-- Ft. 11 v'«>°�
From ____ Trr Ft. Norkd
14.GROUT: bufri-5vilte-, �G
Dn rtl{ �1 Materl I 4ethod�
From .� __ Toth✓ --FT.
From .- ---- 10
1r; Cf:Rr FN:
Doplh
Lliameler
From ---TO
_ __
Fr
Front _—_
l n ---
Fl.._— In.
From _
—_ To ___._
Ft.-_ In.
16, SAND/GRAVEL
PACK:
Depth
Size
From
To
Ft.
From _—
To
Ft.
Slot Size Material
_ In. _ —
_ In.
__- In.
Material
17. REMARKS:
DO HEREBY CEnT IFY, TfTAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECO D HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE U, �FjQNI "Q' V%t� 'SIGNATURE OF FER N CONSTRUCTING TIIF WEII DATE
Quad No: )
_ •�, _ Submilo nal to Division of Water Ovellty, Groundwater Section within 30 days GW T REV. 12,,99
Sar l No. -

f.l 4 t-1"
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section I 1 f /
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:A��d�-'
WELL CONTRACTOR CERTIFIIVATION 0 a ? to
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable sox): Residential Rr Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (S w sketch of the legation below)
�Z�� Nearest Town: !4"l? County:
(Road Name and Numiblers, Communi or Su divls'on and Lot No.) DRILLING LOG DEPTH
3. OWNER From To Formation Description
Address_
Ir et or Dula e.
City or Town State / Zip Code a
4. DATE DRILLED d
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES Q NO
7. DOES WELL REPLACE EXISTING WELL? YES �NOd
8. STATIC WATER LEVEL Below Top of Casing: �C �_ FT. c1
(Use '+' If Above Top of Casing) rn T
9. TOP OF CASING ISFT. Above Land Surface' -0—
*Top of casing terminated at/or below land surface requlres a variance In actor- I ,
dance with 15A NCAC 2C .01 8
10. YIELD (gpm): METHOD OF TEST o
11. WATER ZONES (depth): -'-
12. CHLORINATION: Type Amount It additional space Is needed use back of fom
13. CASING: ._
LOCATION SKETCH
Wall Thickness
/� Depth lh�QQ fppFam�e� ( r or W ht/F . ayteJn�a<l j►� Show direction and distance from at least two State
From 6 'To 2—.L Ft.W.-- d �u-�l Roads, or other map reference points)
From To Ft.
From To FL
14. GROUT:
Depths _ Mated I elhod f /�
From - To Ft.
From To — Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From —To—Ft— in. —in
From _ To _ Ft. _ in. _ in.
From To _ Ft. _ in. _ in.
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
17.
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECZL0Al2IQ&44.e_�
D HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE`ONLY `� •. G
Quad No: `IGNATURE OF PERSO ONSTRUCTING THE WELL DATE
t Submit original to Division of Water Quality, Groundwater Section Within 30 days
Serial No. GW I REV. 12199

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone] r= 17 .4 0p
- 1rl
WELL CONSTRUCTION RECORD WELLCONTRACTOR: O-e OhAbcaci�1
WELL CONTRACTOR CERTFM ATION H: nos /a
STATE WELL CONSTRUCTION PERMITN:
1. WELL USE (Check Applicable Boa): Residential G?r Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ It Other, List Use:
2. WELL LOCATION: fw eketch a( lh/gamlocation below)
Nearest Town: `J— ���"ie County:
ifty
4Tom
;Stale
, or S b ' Ision and Lot No.) DRILLING LOG DEPTH _
3. From To Formation Description
--
Zip Code
4. DATE DRILLED
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES Q NOd
7 DOES WELL REPLACE EXISTING WELL? YES NOd
8.
STATIC WATER LEVEL Below Top of Casing: FT.
_
9.
(Use': It Above Top of Casing)
TOP OF CASING IS FT. Above Land Surface-
O
Cn
-Top of casing terminated aVor below land surface requires a variance In accor-
dance with 15A NCAC 2C . 19
I
—
10.
YIELD (gpm): METHOD OF TEST —4—
11.
WATER ZONES (depth):—
,
rd
�
12.
CHLORINATION: Type Amount __Lt1�—
If additional space Is needed use back of lord
""o
13.
CASING:
ry
L'
LOCATION SKETCH ..I
Wall Thickness
De thQyn %�la.m�e� r or W i hVF I
--
( Show direction and distance from at least two State
��Jla�te7dd
J](J
From �To -�/� Ft.Wrt7�— ��"�"�
Roads, or other map reference points)
From To Fl.
From To_ FL
M�
14.
GROUT:
��,z/(GejIrc
De tl /n•,,M,at'en I elhod
From A_ Topst_ Ft. (jlA[L
From To Ft.
15. SCREEN:
Depth Diameter
From To Ft _ In.
From _ To _ Ft. _ In.
From To —Ft. _ In.
16. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To Ft.
17. REMARKS:
Slot Size Material
_ in.
In.
In.
Material
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY
OF-THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY `'�'
Quad No:
NATURE OF PERSON CONUTRUCTING THE WELL DATE
Submit od Inal to Division of Water Quality, Groundwater Section Within 30 days
0 y Y GW-i REV. 12199
Serial No.

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone] ti 17 4 8 3
WELL CONSTRUCTION RECORD WELLCONTRACTOR: EJD' %IG7tIC�GI
WELL CONTRACTOR CERTIFI ATION #: ,�20,210
STATE WELL CONSTRUCTION PERMIT#:
1.
WELL USE (Check Applicable sox): Residential Rr Municipal ❑
Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2.
WELL LOCATION: 2pow sketch of )he location below)
Nearest Town: (�f�.(li�i=Jf� County:
(Road Name end Numbers. Community, or Subdivision and Lot No.)
DRILLING LOG DEPTH
3.
OWNERwk
From To Formation Description
Address
t Mor Hout o.
11y or Town State Zip Code
4.
DATE DRILLED Oct
5.
TOTAL DEPTH
6.
CUTTINGS COLLECTED YES Q NOd
WELL? YES NOd
r�
7.
DOES WELL REPLACE EXISTING
8.
STATIC WATER LEVEL Below Top of Casing: FT.
o
9.
(Use': It Above Top of Casing)
TOP OF CASING ISFT. Above Land Surface'
T
'Top
of casing termineted aVbr below land surface requires a varlance In accor.
dance with 15A NCAC 2C.0118
10.
YIELD (gprn): METHOD OF TEST —4—
EJ
._
r -
It.
WATER ZONES (depth):
y ''
U]=YC
CJ
12.
CHLORINATION: Type 14 TM Amount
If additional space Is needed use back of 1000 1
13.
CASING:
SKETCH
Wall Thickness
., , , iame r or W ,ghVF . aledal
_LOCATION
-
(Show direction and distance from at least two State
�Depth
From— To-.��f-tU— Ft.
Roads, or other map reference points)
From To Ft.
From To Ft.
I/C.c�
qe" `a�
14.
GROUT:
Depth
��•1�M�at�eri I
ethod
From To AV
Ft. (.,Qlll�
From To _
Ft.
15. SCREEN:
Depth Diameter
Slot Size
Material
From To _ FT
__
In. _
In.
From _ To Ft.
_
In.
In.
From _ To _ Ft.
_
In. _
In.
16. SAND/GRAVEL PACK:
Depth
Size
Material
From To
Ft.
From To
Ft.
17. REMARKS:
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS CORD HAS BEEN PROVIDED TO THE WELL OWN
FOR OFFICE ONLY -
Quad No:
-) submit
Serial No.
SIGNATURE OF P SON CONSTRUCTING THE WELL DATE
at to Divlslon of Water Quality, Groundwater Section within 30 days
GW-1 REV. 12199

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699.1636-Phone [phone] r- 1 II 4 O 2"
WELL CONSTRUCTION RECORD WELL CONTRACTOR: OAA.u.AG> �1
WELL CONTRACTOR CERTIFI ATION If:aDo%
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential5? Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ II Other, List Use:
2. WELL LOCATIONJ.�;ihow sketch of the location below)
Nearest Town: dQ60' *_" County:
Agricultural ❑ Monitoring ❑
(Road Name and Nu rbers, Community, or S Adivision and Lot No) DRILLING LOG DEPTH
3. OWNER I
,/ From To Formation Description
Address Lj[_ 7�.3�
reel or Rout,
NYC-
�ity or Town State Zip Code
4. DATE DRILLED - do
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑ NO
7. DOES WELL REPLACE EXISTING WELL? YES M _ NOd
8. STATIC WATER LEVEL Below Top of Casing:
(Use'+' If Above Top of Casing) - rn
9. TOP OF CASING ISFT. Above Land Sudace' -1 =
•Top of casing terminated edbr below land surface requires a variance In accor-
dance with 15A NCAC 2C.0118
10. YIELD (gpm): _1 METHOD OF TEST D
11. WATER ZONES (depth): —A-
12. CHLORINATION: Type Amount If additional space Is needed use back of foq;>) y
13. CASING: -�
Wall Thickness —LOCATION SKETCH—
Depth , , fame r or W :ghUF . atedal (Show direction and distance from at least two Slate
From To aSLyuL� Ft. Roads, or other map reference points)
From To Ft. —
From To Ft.
14. GROUT:
De tl
��•1�Maten I
ethod
From TopFt.(jlJL
From To
Ft.
15. SCREEN:
Depth Diameter
Slot Size
Material
From _ To _ FI
_
in. —in.-
From _ To _ Ft.
_
in. _
In.
From _ To _ Ft.
_
In. —
In.
16. SANDIGRAVEL PACK:
Depth
Size
Material
From To —Ft.
-
From To
Ft.
17. REMARKS:
I DO HEREBY dri kWl AT 1 NjFdL AB CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION t7 rWhD :. 11 y _ mA'4PY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE US9ONLCI'1 ` '" ,S NATURE OF PERSONC STRUCTING THE WELL DATE
Quad No:
Submit original to Division of Water Quality, Groundwater Section within 30 days
GW-1 REV. 12199
Serial No.

North Carolina - Department or Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mall Service Center - Raleigh, N.C. 27699-1636-Phone [phone]�
WELL CONSTRUCTION RECORD WELLCONTRACTOR: T�` r%� �> W�—� L" le) Lit-iiJa
WELL CONTRACTOR CERTIFICATION 0: �, G
STATE WELL CONSTRUCTION PERMITII:
1. WELL USE (Check Applicable Boxy Residential [2� Municipal ❑
Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other
II Other, List Use:
2. WELL LOCATtQjJ: (Show sjgtt of the location below)
un
Nearest Town: jam_ l h I41
(Road Nang and Nu �be7y` or Subdivision and Lot No.)
DRILLING LOG DEPTH
'Cor/LamunIly,
3. OWNER ✓r�'✓rj"�'� rI
From To Fannallon Description
Address �`pn� �as��%1� ih11f' 1 [( 5'�
L`�'-C.`� fl e—, i�:...-,G
�-
�i e. or qy is o.
It e
.Tj GrA.�
City or Town 3 Slate Zip Coda
J
4. DATE DRILLED T-
5. TOTAL DEPTH _._lX
6. CUTTINGS COLLECTED YES ❑ NOE31__�
o
7. DOES WELL REPLACE EXISTING WELL? YES Q NO
8. STATIC WATER LEVEL Below Top of Casing: 15 FT.
C cs—
(Use'i II Above Top of Casing)
9. TOP OF CASING IS i FT. Above Land Surface'
Z cam_
-Top of casing terminated at/or below land surface requires a variance In actor-
dance with 15A NCAC 2C4416
10. YIELD (gpm): / METHOD OF TEST r
p,a
11. WATER ZONES (depth): 74 '4
t "c
gii - 14o
;
12. CHLORINATION: Type TbI¢t Amount fi11e—
If additional space Is needed use back of forrtt
13. CASING:
0
LOCATION SKETCH XtJ
Wall Thickness
Depth, Dlametar or WelghVFI. Material
(Show direction and distance from at least two St le�
From -t To Ft.
Roads, or other map reference points)
From To FI.
'"�
L✓��
From To Ft.
Y(N•I
14. GROUT:
Depth Material Molhod
From 0 To �Ft.
From To Fi.
15. SCREEN:
Depth Diameter Slot Slze Material�.
From —To _ Ft _ In. —In.
yy/
From — To _ Ft. _. in. — In.
From _ To __ Ft. _ In. — In.
-
16. SAND/GRAVEL PACK:
Depth Size Material
�CK? (2;0'-�
From To FL _
60,
0'''
From To FI.
/1e�a. l�oJcd0-
17. REMARKS:_ _
l
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 1SA NCAC 2C. WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNPER.
FFOR OFFICE USE ONLY 00A �r1 �� Vl /f/rg� (d ! LaoO
No: n ^ ' [ SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
tx�@od�alRD so T9�tare�y.Gmundwaler Section Wllhln 30 days
al Na. (LAC IIIISSSS nlf' GW-I REV. 12/99

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
NELL CONSTRUCTION RECORD WELL CONTRACTOR:�v i OU
WELL CONTRACTOR CERTIFI ATION #:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Boa): Residentialwr Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (ySgh��oov� sketch of (he I cation below)
Nearest Town: �L/d�County:
Agricultural ❑ Monitoring ❑
(Road Name and umbers. Community, or Subdivision and of No.) DRILLING LOG
3. OWNER From To
Address
--I Iryc outs
City or Own �J State �( Zip Code
4. DATE DRILLED •a '
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑ NO
7. DOES WELL REPLACE EXISTING WELL? YES Q NOIF
B. STATIC WATER LEVEL Below Top of Casing: _[49 Fr. _
(Use'+- If Above Top of Casing)
9. TOP OF CASING ISFT. Above Land Surface'
'Top of casing terminated eVor below land surface requires a variance In accor-
dance with 15A NCAC 2C. 11e
10. YIELD (gpm): METHOD OF TEST
11. WATER ZONES (depth):
DEPTH _
Formation Description
0
O
G
J
12. CHLORINATION: Type Amount It additional space Is needed use back of form
13. CASING:
LOCATION SKETCH
Wall Thickness
Depth _ �., lame r or W IghVF aled I (Show direction and distance from at least two State
From To •S % Ft. Roads, or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
�ee�r CaZ-*-4
DeplI
/??
M,aa�t,e.riiTadgi
elhod
From .� To
Ft. G—
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
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORDS BEEN PROVIDED TO THE WELL OWNER. 2 J
FOR OFFICE USE ONLY --
Clued No:
Sl,rpmil bd
3
Serial No. :
1ATURE OF PERSON CO RUCTING THE WELL
Division of Water Quality, Groundwater Section within 30 days
DATE
GW.1 REV. 12t99

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] L !�
WELL CONSTRUCTION RECORD WELLCONTRACTOR:,�cnG> ?
WELL CONTRACTOR CERTIFI ATION 0: 'tea
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential uIr Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other If Other, List Use:
2.
WELL LOCATION: J$how sketch of fhe to_cation below)
Nearest Town: II `'s� l D�� County:
DRILLING LOG DEPTH
(Road Name and u ers. Communi . r Sub ivlsion n Lot No.)
3.
OWNER
From To Formation Description
Address
r eor o
City or Town p Coda
;�-—y--
4.
DATE DRILLED Slate
5.
DEPT
TOTAL DEPTH
6.
CUTTINGS COLLECTED YES ❑ NOd �/
NO[
7.
DOES WELL REPLACE EXISTING WELL? YES a
8.
STATIC WATER LEVEL Below Top of Casing: FT.
(Use's' if Above Top of Casing)
9.
TOP OF CASING IS � FT. Above Land Surface'
'`-'
'Top of casing terminated after below land surface requires a variance In accor-
�..,
dance
10.
with 15A NCAC 2C .0118
YIELD (gpnl): A;a-METHOD OF TEST 4
^; t
r;
11.
WATER ZONES (depth):—
y
12.
CHLORINATION: Type Amount —. V—E
It additional space is needed use back of form
13, CASING:
LOCATION SKETCH
Wall Thickness
Depth_ _ s iame r or W IghUF. aie al (Show direction and distance from at least two State
From To sue!-[LL— Ft. Roads, or other map reference points)
From To Ft. /� a
From To Ft. _/
14. GROUT: �/L/ C`-"/
De t1��1 �,M,�ate'n.7a'I} elhod
From ..� To Ft. ( '---
From To Ft.
15. SCREEN.
Depth
Diameter
From
To _Ft
_ In.
From
_ To _
Ft.— in.
From _.—.
To _
Ft. _ in.
16. SAND/GRAVEL
PACK:
Depth
Size
From
To
Ft.
From
To
Ft.
Slot Size Material
_ in.
In.
In.
Material
17. REMARKS:
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS,,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER,
FOR OFFICE USE ONLY DATE
Quad No: IGNATURE OF PERSON CO RUCTING THE WELL
__�i R9 Submit original to Division of Water Quality, Gmundwaler Section within 30 days GW4 REV. 12/99
Serial No. C C i

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section 21174 9 O
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone] O
WELL CONSTRUCTION RECORD WELLCONTRACTOR:
WELL CONTRACTOR CE FICATION If: r3D l
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential Rr Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL =���
LOCATION: ow skettc�h�of the location below)
Nearest Town: JA 9i County:
(Road Name an-d N�Toers, Community, or S y division and LoI No.)
3. OWNER
Address
City or Town Slate Zip Code
4. DATE DRILLED
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES[ NO2'
7. DOES WELL REPLACE EXISTING WELL? YES Q NO[✓]'
8. STATIC WATER LEVEL Below Top of Casing: /Q_ FT.
(Use'+' If Above Top of Casing)
9. TOP OF CASING ISFT. Above Land Surface'
-Top of casing terminated at/or below land surface requires a variance In accor-
dance with 15A NCAC 2C 11a
10. YIELD (gpm): METHOD OF TEST
11. WATER ZONES (depth):_
Agricultural ❑ Monitoring ❑
DRILLING LOG DEPTH
From To Formation Description
e 6)
90 - /OS o
o
CD
_
I-r1
I
--
co
cJ
nSo
fV
12. CHLORINATION: Type _ci-/ 'Q Amount If additional space is needed use back of form
13. CASING:'
LOCATION SKETCH
Wall Thickness
Depths n Diameter or Weight/Ft. c—,n,{},atte_nal' (Show direction and distance from at least two State
From-0 To Ft. Roads, or other map reference points)
From To Ft. —
From
From To Ft.
14. GROUT:
Depth Materia ethod /
From —fD To —FL
From To Ft.
15. SCREEN:
Depth Diameter
From —To_ Ft _ in -
From _. To _ Ft. _ in.
From —To_ Ft. — In.
16. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To Ft.
Slot Size Material
in. —�—
in.
_ in.
Material
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER. r O
FOR OFFICE USE ONLY DATE
Quad No: `. Y GNATU�E��GWELL
odg al Io Division of Water Quality, Grountlwaler Section within 30 days
GW-1 REV. 12199
Serial No.

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699.1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERT ICATION #: Ci
WELL CONSTRUCTION PERMIT#:
t
2 t fr 4 9 0
,,/STATE
1. WELL USE (Check Applicable Box): ResidentialUd Municipal ❑ Industrial ❑ Agricultural ❑
Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: JJqow sketch of line 19ccation below)
Nearest Town:. County: —�—
(Road Name and Nu s, Community. qr 4divi on and Lot No.) DRILLING LOG DEPTH
3. OWNER l/(� From To Formation Description
�7
Address d —
— !
./J �ee or outs 0.0 ��iy !/ dt —
as - isGs`
ity or Town State Zip Code
90'4�
4. DATEDRILLED
_
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES Q NO[
CD
7. DOES WELL REPLACE EXISTING WELL? YES Q NO
(m
ro
8. STATIC WATER LEVEL Below Top of Casing: 15"_ FT.
�-
(Use '+' It Above Top of Casing)
9. TOP OF CASING ISFT. Above Land Surface'
'Top of casing terminated atfor below land surface requires a variance In eccor-
dance with 15A NCAC 2C 118
co
10. YIELD (gpm): METHOD OF TEST
r
11. WATER ZONES (depth):
ry
0
12. CHLORINATION: Type s.T,46_Amount _ If additional space is needed use back of form
13. CASING:
LOCATION SKETCH
Wall Thickness
Depth., �1 9iameter, or WejQ,nvFt. Ma rial (Show direction and distance from at least two State
From —To Ft. 61-25— , �xa r' Roads, or other map reference points)
From To F.
From To Ftt. -
14. GROUT:
Depth __Ma�t��e �ia�l FAe.,,tf,, thod
L 1��
From To �� FYJ14Lddal�
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From —To—Ft— in. —in.—
From —To —Ft. _ in. —In.
From _ To _ Ft. — In. — in.
16. SAND/GRAVEL PACK:
From
From _
17. REMARKS:
Depth Size Material
To Ft.
To Ft.
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECOR HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLYlYI ai J aa' a!i
Quad No:
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Divisional Water Quality, Groundwater Section Within 30 days
• GWd REV. 12N9
Sadal No.

North Carolina - Department of Environment, Health, and Natural Resources
Division of Environmental Management - Groundwater Section
P.O. Box 29535 - Raleigh, N.C. 27626-0535
Phone [phone]
WELL C S.TRUCTION CORD
DRILLING CONTRACTO
DRILLER REGISTRATION UMBER: ) %
STATE WELL CONSTRUCTION 7 n L� r
PERMIT NUMBER: 2 V U
1. WELL LOCATION: (Show sketch of the location below) t-/
Nearest
(Road,(
2. OWNER
(Street or Route
City or Town / j Slate
County:
3. DATE DRfLLED ILV
USE OF WELL
4. TOTAL DEPTH ' _
5. CUTTINGS COLLECTED YES ❑ NOLI
6. DOES WELL REPLACE EXISTING WELL? YES NO(- _
7. STATIC WATER LEVEL Below Top of Casing: FT.
(Use'+' if Above Top of Casing)
8. TOP OF CASING IS�� FT. Above Land Surface'
�te .
DEPTH ZW,14, LLIN LOG
From To /�' Formation Description
Casing Terminated at/or below land surface Is Illegal unless a variance Is Issued
In accordance with 15A CAC 2C .0118
9. YIELD (gpm): 7 METHOq 9F TEST-
10. WATER ZONES (depth):
11. CHLORINATION: Type //T fi cc77 _2�IS
yp fQ Amount ' if additional space is needed use back of form
12. CASING:
Wall Thickness
Depths Di meter or Weighl/Ft. Material
From �—� To � Ft. � �f 51pL�
From To Ft.
From T Ft.
13.GROUT: UilYf jJAIVe ) :OG
De t Material Method
P
From T �- Ft. H
From To Ft.
14. SCREEN:
Depth
From To _
From To _
From To _
15. SAND/GRAVEL PACK:
16.
Diameter Slot Size Material
Ft in.
Ft. in.
Ft. in.
Depth
From To Ft.
From To Ft.
Size
in.
in.
in.
Material
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference poinlpb
=�
Q
G
rm
w
I DO H�RE9YCERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A C,0
OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
"A VCV
unaware ` � u GW-IAE}
UI....�...-
SIGOATURE OF CONTRACTOR OR AGENT
i
Submit original to Division of Environmental Management and copy to well owner.

North Carolina - Department of Environment�Health, and Natural Resources
Division of Environmental Management - Groundwater Section
P.O. Box 29535 - Raleigh, N.C. 27626-0535
Phone [phone]
WELL CONSTRUCTION RECORD
DRILLING CONTRACTOR: R.CALDWELL DRILLING Leade�Eht�t1'rc rr&^ �rt3W-lEnt�c+Yp.
y STATE WELL CONSTRICTION
DRILLER REGISTRATION NUMBER: I,. 7. �„) PERMIT NUMBER: /II/A 7 U
1. WELL LOCATION: (Show sketch of the location below)
Nearest Town: r-ut24Syyyl, County
(Road. ommunity, or Subdivision and Lot No.) /lye T t) P1yi. DEPTH
2. OWNER /1lnuuigi FI A i 2 � - L'- From To
ADDRESS 13ukt456 (fe
(Street or Route No.)
ID ty prn State Zip Code
OT1
3.l.P am E� USEOFWELT
4. TOTAL DEPTH ��S' �ire'rx� AP, ?ZO
5. CUTTINGS COLLECTED YESD NO❑
6. DOES WELL REPLACE EXISTING WELL? YES 0 NOD 3&o'
7. STATIC WATER LEVEL Below Top of Casing: FT.sfr'
(Use'+' it Above Top of Casing) V
8. TOP OF CASING IS_1_ FT. Above Land Surface*
• Casing Terminated aVor below land surface Is Illegal unless a variance Is Issuec
In accordance with ISA NCAC 2C .0118
9. YIELD (gpm): C 17 METHOD OF TEST R
10. WATER ZONES (depth): 300' - 3 to - Jg'd dSfJ
11. CHLORINATION: Type b4r_11 Amount z Pitt
12. CASING: S-T- 49zeT&
Wall Thickness
Depth DiameI or WeighVFt. Material
m Fro" / To .- L Ft. «ef—
From To
From To
13. GROUT:
Ft. -
Ft. DAIII _510 -
DRILLING LOG
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
Depth Material ethod
From �_ To t56 Ft.&�J��"t _�
From To Ft.
14. SCREEN:
Depth
From —To-
From To -
From To -
Diameter Slot Size Material
Ft in.
in.
Ft. in.
in.
Ft. in.
in.
15. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To Ft.
16.REMARKS:
Material
0
o
L
GJT
o
N
o
HIS WELL
ONE tR GTIIOFJSTYANDAft�TAMD THAT OFT HIS RECORD HED IN OASDBE BEEN PROVIDED TO THE WELL OWNER.
SIGNATURE OF CONTRACTOR OR AGENT / DATE
GW-1 REV. 9N1 Submit original to Division of Environmental Management and copy to well owner.

North Carolina • Department of Environment, Health, and Nalural Resources Y
Division of EnmmFOR OFFICE USE ONLY
virom�ninl Managa ant • Groundwater Section QUAD No. USE N
P.O. Box 29535 - nnlnigh, N.C. 27626.0535 ,
O.
Phone [phone] tat __. - __ Lorq. no
Mirror Basin
WELL CONSTRUCTION RECORD anein Cnrin
DHILLING CONTRACTOR t Ilendor Ent.— GINA Fill.
STATE WELL CONSTRUCTION r r rl 7
DRILLER REGISTRATION NUMBER:_ �1 PERMIT NUMBER:
1. WELL LOCATION: (Silo sketch of IIhQ location below)
Nearest Town: AVA4o, County
(Road. Commur' , or Sutdivlelon nd Lot No.) DEP I I_ I_ DRIL�ING LOG
2. OWNER Flom To Formadon Description
ADDRESS lx- —
(street or Routs No.) D _
City or Town Stale Zip Code
3. DATE DRILI_EU O USE OF WELL Z203,
4. TOTAL DEPTI I _
5. CUTTINGS COLLECTED YES ❑ NO[Y
6. DOES WELL REPLACE EXISTING WELL? YES [] NO[o
7. STATIC WATER LEVEL Below Top of Casing: PS FT.
(Use'd' if Above Top of Casing)
8. TOP OF CASING IS ------ I_— FT. Above Land Surface'
• Casing Terminaled sUor below lend surface is Illegal unless a variance Is Issued
In secordanca with 15A CAC 2C .Otte
9. YIELD I till:Le METHOD OF TEST
1R. WATER ZONES (depth): ca
11. CHLORINATION: Type Amount II addilionaf <paca is needed use back ofgtm
12. CASING:
_
Wall thickness LOCATION SKETCH
D Deplll Diameter or WelghuFl Material (Show direclinn and distance from at least two Stele .
From TO �� Ft. G..�s a/G.i�.f Roads, or olhnr map reference points)
From To Ft. / (?/
From To Ft.
13. GROUT:
!1
Depth Malerl I �t�{pat�h�o�d��
From _0 To Pie - Ft.(
From To Ft.
14. SCREEN:
Depth Diameter Slot Size Material
From To PI _— In. In.
From To Ft.-- In. In.
From _—To _ _ Pt.
N ' 15. SAND/GRAVEL PACK:
Depth Size Material
From Tn Fl.
From _— T o Ft.
c-,
T
16. REMARKS:
_ I DO HEn F_RY CFITI IPY MAT TI It,; WELL WAS CONSTRUCTED IN ACCORDAHCE WI111 15A NCAC 2C, WELL
CONSTRUCTION. STANDAnDS, AND THAT A COPY OF THIS RECORD HAS BEEN PnOVIDED TO THE WELL OWNER.
Off_ J_/
! i S& ' DATE
SIGNATUnE OF C TOACTOn OR ENT
Ow-1 TTEY. 9191 Submit odginal to Divielon of Errvkor"onlol l.lae�g�mnnt end ropy M well owner.
-do

Notth Catall,,a • OnprulmmnI of Environmonl, Health. and Nalural Ro4ource9 _ v FOn OFFICE USE ONLY n r7
Division of Envirmonnnlal Mmmgnmont • Gioundwnler Section 011AU. Nf ). _ r Usi! NL G ( J
P.O. tlox 29595 - Ilnlnigh, N.C. 27626.0533 ' _-- _
Phane (919) 733-322 t 1 nt _,.. Loiq. no
Alhror 11.,;a
WELL CONSTRUCTION RECOnD Dinh
/ _ 1 EnL
_
JRILLINGCONTLIACTON - l.nir S)AI/ LAM ----llnnrinr T 13F.,,[_tI —
OW-
STATF.. WELL (:ONSIRUcNON
)nILLr=n nEGISTNA11011 N11M[iL'N:_ S PENMII NUMDEII:
I. WELL LOCAI1011: (Shoo shelCII of the I c lion below)
Nearest Town:Caunly:
(nond, Conxnunity, mnnSut.livhlAn apd Lot No) U ---III UnILLING LOG
2. OWNER (.�.u�� -- From 1,r Formation Description
ADDnESS— o
Sims.t m Floute No.)
City or l oom Slain Zip Carlo C a
3. DATE D1110 1=1J dd USE OF WELL 2)e.271 - z c
1. TOTAL Df_P T I I ---- �O7X _ _ - N v�
5. CUTTINGS COI_LFCIED YESL_I N0UVf _ 3 --Io
s, DOES WELL RFPI_ACE EXISTING WELL? YES U NOU2r
7. STATIC WATER LEVEL Below Top of Casing: Y51 FT. - Cm
(Use '.' it Above T or of C using)
8. TOP OF CASING IS _1__ FT. Above Land Surface'
• Casing Totminnfnd allot hnlow Innd euf Inc,* Is Illegal unless a vaflance Is Issued -- z
in eccordnnco vllh 15A I` C 2C .0110
9. YIELD (qpm): 92f _ ME f NOD OF TEST /�----
I 'PATER ZONES (deptll): (/
11. CHLORINATION: Type / � Amount If ndrlilionnl ^pacn is nnadod use back of lot
12. CASING: LOCAIION SKETCH
Wail I I Ockness
..
Unpilt �y D amnl� o Ylniglr^U alndnl (Show dhnclian and distancn Irom at least two Stela
From -To Ft. lioad3, of whgr map mlefence Points)
From To Ti. �ZueAC4
From To Fl.
13. GROUT: GC/%� Z' � " `
d C.
Urplh /y,�-a-learl_al, �- yyyyy¢��Ilho
From To
Front -_ To — _FI.
14. SCREEN:
Urplh D1111ieter Slot Size Matellnl
From to ---- 1 1 -- In. Ir"
Rom To---TL---- ht, In.
From --- To -Ft --- In. In. _
f 15. SAND/GRAVEL PACK:
Depth Size Material
From To --
From --- To Ft.
16. REMARKS:
OO IIE[1'.SnY CFt11 IrY-IIIAT Tlll WELL WAS COtJSInUCTEO IN ACCOnOAtICF Will' ISA IICAC 2C, WELL
CONST[) 1 ��U'TT �TANr3AnT)S;'ATID MAT A COPY OF THIS n
ECOfIU i IAS DEEJ/ PflgvtUEO l,0 111E WELL OWNER.
1, _ i - 1�J/d✓ -���� �D�
6Totindwater Section
lnr slnrunE4f(al cron en n Ern ogre
OWA REV. 9 1 Asheville P.e 'onal Office Suhmlt nriglnnl lg Milian nl Rrvlrmvngnlel r.lnn,a^m•nl nrd ropy to waa ewrrer.
_p.

North Carolina • Dnpartmonl of Environinno. Hirallh, and Nnlural Resources _ FOR OFFICE USE Mu
Division of FiMrmonmdal Mmmpnmanl • Giound•Nnlar Section OUAb. t1o. 6EDIALt ? ��
P.O. Dos 29535 • flninigh, N.C. 27926-0539 --
Phone [phone] nl _-_.. _ --__ Lorq. no
M6wr pacin
WELL CONSTRUCTION RECORD NO' r"I _
DRILLING CON I FIACT Oil: _ ( ��� liAarfnrFw GINA Ent.
/ STATE WELL MIS IIIUCIION
DnILLEn nEGISTRATIOti tTITMDL'n: ��L— _ PEFTMIr NUMDFFI:
1. WELL LOCATION: (Sjy w sketch of the localion below)
Nearest Town:County:
(Rood, Cmrnnunity, or ruivilvNion and
-Lal'No.) OF I I I 1 DRILLING LOG
2. OWNEn %�i�1—Gl^.»;P '���-,,-�r /�fGXLt�[./Y�&�_ From In Pormadon 0escripdon
AUDRESS�n�_1�� ---- — --
/� 0 (Slrnet or Flouts No.) / 9 7
City or 1 oval Stale Zip Code g
3. DATE DRILLED _ -. e USE OF WELL
4. TOTAL DEP111.__r�Qs _---
5. CUTTINGS COLLECTED YES L_I 1`102J S. DOES WELL FIEPLACE EXISTING WELL? YES Q NO0
7. STATIC WATER LEVEL Below Top of Casing: K FT.
(Use'.' it Above Top of Casing) _.
6. TOP OF CASING IS ____— FT. Above Laiid Surface' —
• Casing Teminelnd mUnr hnlow Innd smince is lilegal unions a variance Is Issued
In accordance with 15A tJCAC 717 .01 is
9. YIELD(gpin)'_—` P___METIIUUUFTEinr
HATER ZONES (deplil): --
11. CFILOnItJATION
12. CASING:
Typei� % Amount II additional epacA Ve nandnd udA back of form
DrPIII amntnr
From --To �ZrL
From To
From ---To--- - rt.
13. GROUT:
alerlal II d
Unplll
From To 3-0—rl.
From __—To ---Pl.
14. SCREEN:
LOCA_110N SKETCH
wan nunH.nean
or WeighUFt. Matedol (Show dirnclinn slid distance from at least two State
ai�r�s � Bonds, or nlhni mop reference polnts)
Unplil Ulameler Slot Size
From To --_ T 1 _._— In.
From —_ To -- rL—
From _ To _..--—Fi.--
15. SAND/GIIAVFI_ PACE:
Ueplh Size
From To---F1• .—
From —_.-- to rl.--- —
16. REMARKS
1 DO I IEnF
CONSTnUf
C oNr
oW.l nEv. e191 m+rd Mae Section
. �n �r.0 �Bfi-a
Matindrd
In.
In.
Material
AUG 1 C KP' _u
I;L wAS COIJSI FIUC T ED It ACCOnDnl Mr. WH111SA MAC 2C. WELL
1AT A COPY of TI IIS nECODO IIAS DEE1i PriOVIDED 10 111E WELL OWNER.
sir rrnnmFD orrrrin TT onA sill DATE
Suhudt orignml to Olvislon of F_rrvlrnnmrnrnl 1.Innq^mint 1,q crpy to wsa owner.

North Cetollna - Dnpmtmiu l of Environment, I leallll, And Nntutnl nesources rOn OFFICE USE ONLY r) rj C
Division of Fnm,m virmdnl Mnnngnlnnnl • Cironl,d•Nnler Section QUAD. NO. _ 6EnIALF10. (J
P.O. nox 29535 - Flninlgh, N.C. 27628.0535 — --
Phone [phone] let __. —Carp. F10
Minrn Pa^in
WELL CONSTRUCTION nECOnD Finale Cn.ln_—_
DRILLING COFIFMCTOR; Ilandn, ro _-_ 0W-1 Ent
-) SIAir. WELL CONS IIIUCFIOU
DRILLER nEGISTITAI1011 11(1MIT PERMIT HUMDFIf:
I, WELL LOCATION: ow sketch of (1he^ location below)
��lAl Y.L.f' _ COUItIY.
Nearest Town: - --
(Flood, Convnu ' Y. or Suisfivisin and Lot NODE_(',) DE_(' III DRILLING LOG
2. OWNER_ 1, prom In FormeEon Descllptlon
ADDRESSS-
-—
—
cityorlown Slain Zip Code
3. DATE DIIII-I ED 3.6' 0� USE OF WELL b6r-.
I. TOTAL DEP I I I .___ 1P �____ _ -- - o
5. CUTTINGS COLLECI FD YES o 0
6. DOES WF11 FIE PLACE EXIST It (J WELL? YES ❑ NO(�
7. STATIC WATER LEVEL Delow Top of Casing: FT. -. 2
If Above Top of Cnaing) _.
6. TOP OF CASING IS ___ PT. Above Lni,d Surface'
r�
-Casing Terrnlnnted eunr hnlow Innd eullnce is Illegal unless s vellence is Issued y�
In aacordenca wllh 19A CAC 2C .011a 3
ma
'VATER ZONES (deplll): -- ry -
Cr-
11. CHLORINATION:
12. CASING:
Type L-�-- Ar1t0Un1 $ II nddilloml porn is needed use back of (orm Z
Deplh�D nn�elnr
From dD 10 FI.
From To
From .---To--- FI.
13 GROUT•
LOCAL 101.1_SKEI_CH
vinll I hlcp.nes e
or vlelgilur Metednl (Slww dircrlinn and dislnnce hour at least two Stele
_(�•��9]2.. Floade, nr olhnr tilnp telelnnC9 points)
0('� s ' k
Un tlh Malelll M01hod
From - A 0
Flom -_ To _Ft. —
M SCREEN:
Dnllll, Diameter Slot Size Mntednl
From [ ° ---- rt -- In, In.
From --in —__-- rl.--- Ill. Ill.
From —_._ To - - - P1.
15. SAND/GFIAVEI_ PACK:
Depth Size Malerinl
From 10 --- rl.
From --- T ° Fl. —___-----
i6. REMARKS: -
WFI_L WAS CONSTRUCTED IN ACCOMMICF WIIII 15A IICAC 2C, WELL
D TI TAT A COPY OF T1ITS nECOnD IIAS BEEN Pr10vlOrD—T 70 INF WELL OWNNE11./ /]
DATE
"`�•�� SIr1NA tUr1E Op co I ACIOR AGFt1i
Groundwate* Secil n a [
OW-1 nEv. 91g1 ASieyif a tPegiot�;,al Q_fISvhnJl odghlnl to of
.Ion of Fmlromm�nlnl l.lnrnq•mmul and copy to ae Duren .

North Carolina • Dnpmlrnnnl of Env(romm"fill Nenllh, And Nnlurnl ReloUtce9 Y rOR OFFICE USE ONLY Division of Fnvironnronlnl f lnnngmm�nl • GrounrhNnlor Soda" OVAU. N(). 6ENAL Mo. 21 2 7 3
P.O. t3ax 29535 • flnlnigh, N.C. 27626.0534 ---
Phone [phone] let __._. -,__ Lmq. no
611nnr Ravin
WELL CONSTRUCTION RECORD nnnlnCnan-_
r Ilondnr F"t GWA Ent.
7RILLINGCON If1ACTUN_hnJ t�> a9�L.N�_rn—
SIAlEWELLconsinUCnoN
MILLER nEGISTnATl011 Nt1MnFR: ��- - — PERMIT NUMnFrI:
1. WELL LOCATION: (r stow sl:elch of 1 e ocalIon below)
Nearest Town: Q Q n,. County: �. __.-- - --------
(Road, Conan nity, or Sutaivlalon nn Lpl Nn.) UEI' 111 _DRILLING LOG_
2. OWNER __ Rom to Farmeion bescdptlon
-- "
(Street or nou a No.) �^ 7 q—"
City or Town Slain Zip Code o
3. DATE DRILLED 3-1- 00 USE OF WELL hn-) • O o
1. TOTAL UEP T I I
s. CUTTINGS COLLECT r_D YES D NOEY — 2
6. DOES WELL REPLACE - EXISTING WELL? YES ❑ NO[El'
o<
7. STATIC WATER LEVEL Below Top of Casing: —?5QN FT. o
(Use'i it Above Top of Cnaing) S�
0
6. TOP OF CASING IS--l— — FT. Above I -mid Surface' _ m
' Caging Term(neled nvir betow Innd our Iota is Illegal unless a variance Is Issued m�
In eccordonce wlih 15A NCAC 2C .0119
9. YIELD (gpm)'— --- M -111OD OF TEST
z
`HATER ZONES (defilh):
11. CNLORINAI ION: Typo 1' 7 k AinountLO, ILL0 If additional ^.Irnco iq nondnd u6e beck of form
12. CASING:
LOCn f 10[I_SI(Ei CN
Well ihlcMnC9!
Ueplli Ulmm�ler of yil lghttn. 'J�+11�a1nrinl (Slow dlrQf.Iinn and distance IIOm at Ieell IWO SIAIA
From O TO Ft. �.a 0—t-"'�'-'� flnnd9, of OIIIOr rnnp reference Points)
From TO---
FromVt.----
---To---- f'1.
13. GROUT: t C
A—
FF�� Ue tllk Materiel 6 n1t�R 1 � � �,y' V
From _yL_'tot dO FL
From ___ TO
14. SCREEN:
Urp(it Ulanteter Slot Sizo MalerlRl
From
From TOFrom _-.. _ To __----f l•--- In. In.
r 15. SAND/G1IAVEL PACK
Uep(h Size Material
From To __-- FI.
From — To Ft.
16. REMARKS:
DO IIE - Y� r �t �I II WFI_l WAS COtJS I nUCIED III ACCOI DANCF WI II 115A NCAC 2C, WFLL
CONS jT MAT A COPY OF 1111s nECOno 11AS.b.EErl PflOV1DEDT0 T11E WELL OWNEn.
- �I�-- BATE
4 SlrttlAlUnE-COHIriACT OItJtGFHI
OWA nEV. 9/9ai1 pGround'Reo oraeC6Oce SUhnJt nr ighml o Di,1elon 0l ErrvirnrnnnntaI Lla,��4^mint and mpy b w+ll owner.

North Cnrolinn • Dopnrlrnnnt of FnvirnnninnL Ileallh, And Nnluirll nesoutces _ ron OFFICE USE CXILY2 1 2 7 3 1
Division of Fnvironnmrtlnl Mmtnpmnnnt • Ground'Nalnr Section oUAU. Nr). 6EnIALNO.
— _
P.O. Box 29535 • 3 N.C. 27628 0533 lot. " -, Lotq. f10
Phone [phone]
(919) 7
Elinor Pa^in
WELL CONSTRUCTION RECORD nnntr, rn.in___
MILLING COIN nACTOII tir/AGCn SCA1/� /LIf 60 Ilnndnr Enr t3W1 EnL
(I S1ATE WELL CONSINUCNOIJ
7nILLEn nEGISTRA110N IlUM0f9n: S_y1 _ PERMIT NUMFiER:
1. WELL LOCATION: dhow sLelch of the loci lion below)
CCU
Neatest Town: lily: - -
It
(nond, Conxnunity, or sublivivion mI L-t Na) LIE P 11 I
DRILLING LOG
2. OWNER_ _ from )n
FormadonDescdption
ADDRESS—
(slrnnt or noule rin.)
_ N ' a �c� 7 R __a
01-14 am&
City or IV wil Slain Zip Cade _
1. DATE DniLLFl) 3_ k 66 USE OP WELL
1, TOTALDF_PTN
_
5. CUTTINGS COLLECTED YES E] NOF� _
_
a-
WELL FIEPLACE EXISTING WELL? YES NO[2
5. DOES W
7. STATIC WATER LEVEL Below Top of Casing: a - FT. _
c�
(Usa'i If Abovo Top of Cueing)
9. TOP OF CASING IS ___ j__ FT. Above Lnlld Surface'z-
' Casing Terminated sVnr below Imtd eurloce is Illegal unless a variance Is Issued
rn
O
in accordnnee will, 15A f CAC 70 .0119
z R
9. YIELD (gpnt) _ METNOD OF TEST
'VATEn ZONES (del)ill): —
c�
11. CHLORINATION:
12. CASING:
1 ype _r Amount __1J F II nddillonnl <pncn is nondnd u9A back oRtirm Z
Depth.-� 7Dimmnler
Fromlo Lam- IFL� -
From To--- FL -
From ---To----= Fl.
13. GnOUT:
Unplil alerlal tod
From -to -A Ft.
From To ___ rt. —
14. SCnEEN:
Depth Diameter Slot Sizo Mnlednl
From 10 -- -_-- t l -- In• In.. ---
From ---In ----__
From _ _ _ 10
15. SAND/GIIAVEI. PACK:
Depth Size Malellal
From - to ----- TI. -
From --- 10 Pl.
16. REMARKS:
IDO lit,/Qpg�rr�A lAil(jrljR; yyFpl WAS ror,ISInUCrED It ACCC
a rlh ncSr, uri' yOl {�U, T A COP Y OF T I its n ECOno I I/
LOG_1_IOt1_SKEi CN
Well Ih6,knees
er WcIghVFt, aleda11 (Show dirnr•.linn and diclnnre front at Ieesl two Slate
S noad,, or nlhnr mop rAlerence polnle)
rl�
W L-E wiit1 15A.-fWAr, 2C. WELL
BEEr4 MCVM11)EU TO 11IF: WELL OWNE11.
�;
f '_ — s� �,-)— -
-- -
_ bl )I lnrll -0 Ht rlArr0 nnr;fNr OATE
OW -I nEV. 9r91 Iti'2 S CilOfl y Subndl nd9%ttnl to vInton of Env ronrnm,lni ).1amq+mmil and copy M wnA awnar.

North Carolina • Dnpnrhnnnt of EnvirnnnlAnl, 11011111, And NAluml nasoulcse j
FOn OFFICE USE ONLY
Dlvfslon of Fnvironmmntal Monnpmnoot • Groundwnl"r Sectlnn Ot1AU, MI. BERInLNO. 4 n- 1 2 U i
P.O. Poll 297,15 . ltnlnlgh, N.C. 27626 0535
Fhone [phone] tat __-.. - -_ Lmq. no
f.lhlnr Do^in j
WELL CUNS TTTUC TION RECORD Minh
DRILLING CONI nACT OR r /A 4.lV Ilnn<f"r Fnt_ GINA r"L
1 Q SIATEWrl-LCOIISIIIUC11014
DnILLEn nEGISTRA11011 NUMnim: ,jL/ZL PEITMIT NUMDrn:
1. WELL LOCATION: (Sil�y�yv sketch of file locifion below)
Nearest Town: LK1i�2� ��( Counly: — -----------
---------------------- --
(nond, CounnuCnity_, or ^ubfivklnn td Lot th) U_(_ II.I I _ DRILLING _ LOG
2. OWNF.n __�XdlJ_ rm rt to FameAon Deealpllon
ADDRESS--fl-aQB--
(Sho"t or flout" No.)
1�lC'8a7�' y_AffXo
City or Ioval t� Slnln Zip Cod"
3. DATE DRILLFD -3- -'00 USE OF WELL DoM .
4, TOTALDEPIII
5. CUTTINGS COLLECI ED YFS _ �] NORf -
6. DOES WFI.L tIEPI-ACF EXISTING WELL? YES(-1 NO(�
7. STATIC WATER LEVEL Below Top of Casing: _�S FT.
(Use'l, If Abov" Top of Cashrq) _
8. TOP OF CASING IS ___� ____ F T. Ahove Lnnd Surlace' _ - C-
• Casing Terminnled at/nT b"Inw Innd eudece is Illegal unleee a vallence is lesued
in aecmdence whit 15A "CAC 2C .011R Gm
9. YIELD (9pllt)'-- __-.- ME 11 IOD OF TEST - -
a • r„ �
'NATEn ZONES (depth):-- ��
11. CI ILORRIAT ION: Typo - Amount Y/� II nrldilionnl -porn irl nnndnd us" back p(:)or r
12. CASING: z
LOCH I_ION SI<E1 CI_I
WI.ichnon7
Unpllh Diunnior orr VlelghVFL �jatnri"I (Show [fir"rains and di^Innr.a Isom M least two State
From ® —1 o �J 7 rI. ��� �—`E n ate Noat)s, or ollwr nmp inf"rnnce points) -
From -----From ----fo-
13. GROUT: A/C
_ Viol
lhl �, M— nlhud��Q/
From rt.
From __ --- To
14. SCnEE11:
Upplh
From -----
l o — --- I t
From ----
To --- T t
From --
-__ To _.-- _ PI
15. SAND/GIIAVE-I-
PACK:
Ueplh
Frorn
__- T o ---
From
16. REMAws:
(Dole
CONS
VI.
unintiler Slot SIP) Malerinl
SIZo Malednl
rt. -
r t.
1�lli 16AT 11 I^. WFLL
t•ST)CTfIJATRSSr"XTTD71 IA
rli'
JUN ' cl 21"?,1 III U
WAS CONS inLICTEO ItI ACCOd1DAf ICE Wl11 t 15A f IGC 2C, NlFLL
T A COPY OF TIits nECOnb II iAS.0 F_Erl rfi OVii)ELi 10 111 IF�WELL OWNER.
J/1-
R]
Gw-i npv.
--- _..---- VATE
glra lnlllnE OF C[ irinC l On Orl •ENr
SuhnJl orfghtal to DIviIIon of Erm"rllu'VuI'l m'd Cr ry to w"A ownac

North Carolina • Department of Environment, Health, and Natural Resources
Division of Environrrmntal Mnnagnrnant • Gioundwnter Section
P.O. Rox 29515 • Raleigh, N.C. 27626-0535
Phone [phone]
_ W FOR OFFICE USE ONLY
OUAD. NO. 6EMAL NO. t! l
Lai.___ . Long. RO
Minor Ra^in
WELL CONSTRUCTION RECORD Rain Cod,_
r Heador Enr,_ OWA Ent.
DRILLING CONTRACTOR: __
STATE WELL coNs I RUCTION
DRILLER REGISTRATION NUMDEn:'6-v/ PERMIT NUMDER:
1. WELL LOCATION: (SI w sketch of the location below)
Nearest Town: �� Z1 Zk, County:
(Road, co mmr nty, ar SuMivision and Lot
2. OWNER a= "
(Sheet or noute No.)
DEfill I DRILLING LOG
From In Formation Description
ity or Town _ " State Zip Coda �—
3. DATE DRILLFI) 3-�7 _ D O USE OF WELL FO�) —
4. TOTAL DE -Pill _l�Q
S. CUTTINGS COLLECTED YES ❑ NOUY/f
6. DOES WELL REPLACE EXISTING WELL? YES F-1 NOEV�r
7. STATIC WATER LEVEL Below Top of Casing: /,,10 FT.
(Use'i II Above Top or Casing)
8. TOP OF CASING IS FT. Above Land Surface'
• Casing Terminated atior below lend suitnce is Illegal unless a variance Is Issued
in accordance with 15A NCAC 2C .0118
9. YIELD (gprn):—�I, METHOD OF TEST
WATER ZONES (depth):
n
C
om
IV
�m
N
:*im
a r-�
pa
=
m�
m
W
!
. o
11. CHLORINATION: Type 47 Amount If additioml spnce is needed use back of form
12. CASING:
------------- — ----- -- ---- --
_LOCATION SKETCH
Wall Thickness
Depth lamater or Welght/Ft. /�JA�MOH811 (Show directirni and distnnca from at least two State -
From To 1e 2 Ft. ��' '� _ JRoads, or other map rolerence Points)
From To Ft.—Aw� r
From To Ft.
13. GROUT:
Depthalerfal [�lh�o�d /
From To Ft.
From To Ft.
14. SCREEN:
Depth
Diameter Slot Size
Material
From
-To
In.
From
To
In
In.
From
To --
r 15. SAND/GRAVEL
PACK:
Depth
From
To —
From
To-
16.
ee
ow -I n r9i
FI
rI.
Fl
In.
In.
In.
Size Material _ t
Ft. 17 i r
FL
R''Ittt:WFLL WAS CONSTRUCTED IN ACCOnDAIJCE Willi i5A NCAC 2C, WELL
O S NJ A �MD THAT A COPY OF THIS RECORD HAS DEEM PnOVIDED TO THE WELL OWNER.
y; I !,l ls' �i
SIOVIATURE CONNIA non AGENr DATE
?rm!ndwate Section Submit original to Division of Erwironmenlal 1.lnnognmenl and copy ro well owner.
section

North Carolina • Department of Environment. Health, and Natural nasoutces - rOn OFFICE USE ONLY r(2 �y
Division of Environniental Management • Groundwnlor Section QUADf10. 6EnIALNO. 2 t 2 ` 5 .
P.O. Box 29535. nalnlgh, N.C. 27626-0535 ,
Phone [phone] Lnt, __ _ Lora. RO
Minor nantn
WELL CONSTRUCTION RECORD nantn Cndn
DRILLING CONTRACTOR Haadar Ent _ GW1 Enl
�T//STATE WELL CONSTRUCTION
DRILLER REGISTRATION NUMBER: V 7 ! _ PERMIT NUMBER:
1. WELL LOCATIO Silow sketch (the location below) /r
Nearest Town: �/HQ1�� County: —
(Road. Comrnuri or Subdivlslonand LoH4o) D_E_ P I I I
DRILLING LOG
2. OWNER G�— From 7n
Formation Description
ADDRESS _..LAJ1A
Ior no
G.Cy
./
-�u
CityS/tan Zip C000�--
3. DATE DRILLED 3-23 OD USE OF WELL
--
4. TOTAL DEPTII _.30 0 —
o
5. CUTTINGS COLLECTED YES ❑ NOLVr
—
6. DOES WELL REPLACE EXISTING WELL? YES 0 NOER
o �
7. STATIC WATER LEVEL Below Top of Casing: 5- FT.
o�
_5
(use'.' if Above Top of Casing)
Z em
8. TOP OF CASING IS FT. Above Laid Surface'
N—ot
' Casing Terminnted at/or bolow lend surface Is Illegal unless a variance Is Issued
y o
In accordance with 15 CAC 20 .0110
am
9. YIELD (gpm):_ METHOD OF TEST
o
'- WATER ZONES (deplll):
N '•i
11. CHLORINATION:
12. CASING:
r o
Type �TN- Amount If arldilional space is needed use back of ormz
Wall Thickness
Deptll �(J
iamater
or_ ht/rrt. aterlal
From
From
To
Ft.
From
To
Ft.
13. GROUT:
Depth
at� erlal/ nlhod
From
12 To _¢20
rl.
—
Fron,
To
Ft.
14. SCREEN:
UPPlh
From _—To —
From To From To
"r 15. SAND/GRAVEL PACK:
Depth
From To —
From To—
Ia
I DO HE
i1•.
i
OW -I nEV. 9141 -
Diameter Slot Size Material
Ft
in.
In.
rt.
in.
in.
Fl.
In.
In.
LOCATION SKETCH
(Show direction and distance from at least two State.
noads, or mbar rnaP tolerance points)
Size Material -
Ft.
Ft. ] ��
MS CONSTALICTED IN A�COFIDh(G6i Will' ISA NCAC 2C, WELL
A COPY OF THIS nECOnb HAS ISEEN PnOVIDED TO THE WELL OWNER.
Si ,rlATunF OF COP ACTon on -tit DATE
Submit original to Divlslon of Emlronmenial 1.1anagnmeni and ropy to well owner.

North Cnrclhm • Dnpnttmnnt of Environment, Health, end Nnturnl Rnsoufcos ron orrice USE ONLY` 1 2 / 5 O
Division of Fnm viromnntal hlnnngntnnnl • Oroundwnlor Sectloo MAR, ?I(). 6ERIAlfJo.
P.O. Rox 295J5 • Ilninigh, N.C. 27626-0535 ---- ,
Phone [phone] tnl ..__ Lerq, no
- Minor
WELL CONSTHUCTLOII RECORDr Rani„cn,rn
DRILLING CON I RACTO(t S LC� II^ndnr Ent. aw-1 EnL
STATE WELL CONSILtUCTIOH
DRILLER REGISTRATIOII NIIMnL'R: _ SLI/ __-_ PERMIT NUMnEH: —
WELL LOCA I ION: (�}yOw skelch of Ilia locallon below)
Nearest Town: /a�*��-� - � — Counly: �-
(nond, Comm ,ity, or ..ulvlivlelnn and Lot o.�
2. OWNER (/ — rrom to
ADDRESSL�D7L /aG --
(Shee1 or Route No.)
-&21i1� &C -CPS
city or 1 oast Stale Zip Codo
3. DATE DR11.LFD -2 USE OF WELL —
4. TOTAI_DFPIII
S. CUTTINGS COLLECTED YES ❑ NOFI-ff B. DOES WELL REPLACE EXISTING WELL? YES F_J NO�
�
7. STATIC WATER LEVEL Below Top of Casing: O FT.
(Use'i It Above Top of Cnsing)
S. TOP OF GAS RdG IS ___f___ FF. Above Laitd Surface'
• Cneing Torminelod Prior holow Inr,d sur Inca is Illegal unless a vnrinnce In Issued
In eccotdnnce wllh 15A NCAC 2C .0118
9. YIELD (9pm):_ 4_____ ME I I IOD OF TEST 1—o
WATER ZONES (depth):— ----
11. CHLORINATION:
12. CASING:
_DRILLING LOG
Fermadoo Description
Type T _ _ Amours— II nrtditional cTmc.n in nnndod uen back of form - - -
Well 1114 knees
Ueplli Dianholer or Welghvrt. gnlednl
�/�
Fromto-�2L Ft. - a A, -`�-n""2
From To FI.
From ----To----= FI.
13. GROUT:
Un11111 aterlal lhod�
From -to
From _ --- To _—_ FI.
14. SCREEN:
Depth
From ---- I o .---- t I
Front To —_-- FI
From ___.—To____FI.
%' 15. SANDlGHAVEl_ PACK:
Depth
FromTo_ --
From __-- To
16. REMARKS:
Diameter Slot Size
In.
In. In.
Fl.
FI.
Size
LOCI1011_SKETCH
(Show rlirnclinn and disinncn from et least two SIMI@
Raisin, or oilinr amp ininrnncs paints)
/1-C .
MalerlRl
In. _
In.
In.
rN..
�1I
AUG
WASCONSInUCTEDI€1AC(.OFifSAT10E`WIf1 t'1 SA NCAC 2C, WELL
r A COPY OF Tits nECoITO IIA'9 BEEN PftO`/IOFO 1'0 11117 WELL owNEn.
Submit or lghml to Division of mmW ""If espy TO wen owns..
OW-1 REV.

t North Carolina • Dnpndrannl of Envltommonl, Health, and NAlural hosources
Division of Enviinmmnrnnl Mnnngnmanl • Groundwnlot Section foil OFFICE USE ONLY !_ 1 2 .7 5 1
P.O. nox 29535 - llnlniglt, N.C. 27626-0539 QUAD. IIt). eEnIALNO.
Plana [phone] for __-_ , ___ Lo,V. n0
Minor main
WELL CONSTFIUCTION nECORD aaeirtro,,,, _
MILLING CON TnACIon vy IlondnrEnl — -- --- OW-1Ent.
SIATr WELL COIISIFILM I10N
DRILLER REGISTRA f IOII NIR�IDEn:�� — - _ PEf1M11' NUMDEN:
--------- — ---
1. WELL LO(,A110N: ($iJow skrittch of hire location below)
Nearest Town: ���/ _-- County: ---- -----
and Lot No.)
2. OWNER
(Sham or noute tic.) -Arc —
City
.
or town Slain Zip Code
3. DATE Dnn.Lr--i) USE OF WELL n
4. TOTALDf_PrN S. CUTI INGS COLLECTED YES L] NOFv
6. DOES WELL FIEPl_ACE EXISTING WELL? YESI—] NOLj�
7. STATIC WATEn LEVEL Below Top of Casing:
(Use •i If Abovo Top of Cnsing)
R. TOP OF CASING IS __—_�___ Fr. Above Land Surface'
• Caging Tetmfrmisd eUnr hnlow load sur lnce Is Illegal unless a variance Is Issued
In accordance wish I5A NCAC 2C .011A
9. YIELD (gpnr):_�U--_ METI IOU OF TEST _.----
WATEn ZONES (depth):
DEPIII DRILLING LOG
r+mn Io Fmma9on Description
0
0
Z
cm
fV
o�
Do
3
22
O
mT
IV
---1
O
z
11. CHLOTIVATION: Type # % —Amount-- II nddilionnl ^fracn is nnndnd u9a back of form —
12. CASING:
LOOT ION_SKE-MI
W nil I hickne ss
Depth `� D amntor orWea� l V5 aladnl (Show rGrnclirnr and dislancn Nam at least two Slate
From To 6 FL �°• a flondn, or n16nr ninp rnlotence Points)
From To-- f t. — %U
From To
13. GROUT:
Unplh nlerinl hQ�l
From -10 rL
Front _—To Ft.
14. SCREEN:
UppUr Di2nlelor Slot Size Matelinl
From To —___ Ft —_ In. —
From---To---fL — — In. _
From —_-- To ___- —FL_ In. —
15. SAND/GIIAVEL PACK
Depth Size
Frorn To _ — PI.
F1om --__— To FI.
16.
GW-I My. 911
In.
In. -
hl.
Material
11S-WFLL WAS CONSTrtUCTEO It! ACCOnt%ANCE WIII.I,15A Nt AC) 2C„WELL
ktrO MAT A COPY OF I IIS nECOnu I AS DEF_N PnOVIOEl7 1.0 TI IF WELL OWNEn.
SlntlAlU it OrC Ir1nCrOn nnFNr GATE
�, Suhmit original to VNI'llon or Errvirmun�nlol t.10 .aq^mint m•d campy to rvell owner.

North Carolina - Onpnrinlnnl of Environmrint. Naallh, and Nniurnl nosourcas — ron oPPILE USE ONLY Division of Fovironrnnntal Mnnngmm�ni • Giound•water Section OIIAV. Nu. -- 6ERIAL NO. ? •— �} r �)
P.O. [lox 29535 - Ilnlnlgh, N.C. 27626-0536 — ----
Phonn [phone] lnt __- Lory. - no
Idiom na^in
WELL CO14STIIUCTIOIA nECOnD pnalnr�,ln __
DRILLING CON IfiACiON�„TtLil�nr�%�/00L A�lfljZ! IlnndnrFnt QW-1Ent
SIATF.Wrl-LCONS InuCUON
bRILLEn RE(11SInAIIOII tIIJMDER: J 7 1 PE11MIrNUMF)rn:
---------------- -
1. WELL LOCATION: (Sh skelch of I119-1a Ion below) r�JN
NeareslTown:County:_�j'l _---------
(nond. Conn pity, or Sutdlvlslor a d Lot No
2. OWNEn -51� -
ADD RE S S_1F�----_1..__
(^+honl or rloule N
City or -1 o .vn Slain Zip Codo
3, DATE DITII.LFI) „.?1:�4-5'440- USE OF WELL
A. TOTAL Dr -Pill
S. CUTTINGS COLLECT FD YES EI NO[v 6. DOES WELLW
nEPl_ACE EXIST ING ELL? YES[] NOL
7. STATIC WAT En LEVEL Below Tap of Casing: _.,s_ FT.
(Vse'i it
Above Top of C.10,q)
B. TOP OF CASING IS ___-�__-_ FT. Above Land Surface'
• Cssing Termhulod el/nr below Innd etiriacq to Illegel unless n vi tlance In Issued
h1 eccordnnce with ISM,,J� AC 2C .0110
9. YIELD(gpnl):-Lv-.__.MEIIIODOFTEST
' NATER ZONES (deplh):
it.CHLURINATIOIT: Typo N%� Amount
12. CASING:
UEI1I11
_U.f11LLINGLOG
rormxtlon Descdrtlon
0
--
C om
_.
m
r` z-
--
tV ec
on
-
c->
II mlditionnl ^.pace is nondnd Uen back Morrrg
Wall 1 hlr.h.nees
Unplh point'Wass or YldghVFl, nrinl
From--T° PL
From---
13. GROUT:
n I'°nl,l� Materiel n �u-
From
From - - - TO ----rh - -
tA. SCREEN:
Urppl Dlnnteler Slot Size Materiel
From --- To----11---- In.--In.----
From ___ fo —.-- I t.
Front
- - To F1.-
15. SAND/GIIAVI:I- PACT::
Depth
From --- T o ----
From -__— To -
16. nEMAMS:_
I DO
Size Malednl
rt.
L.00AI ION _SKETCI1
(Show (firnclinn mid Elklancrt from al laast two Slaln '-
Iloadn or other ninp rnfnranca pclnls)
• r
WAS COris in11CTEo Ill ACCOMMICP. Will I ISA -tICAG 2C. WELL
r A COPY Or THIS nEConb I IAS nFEtr rnovioro TO 111E WELL OWNEn.
_ oy�,-Z'�Z—�
SIMIATUDF Orrt trinr,On 011 ,Ern DATE
Subn Jl orlyhml In Mlslnn or Frwlromm,,,f copy to wetl owner.
OW.I nEV.

z/ 14
Division of Environmental
nvlronmental Manage
171144 l lea,uy enu lVal
• Groundwater
P-O' Box 29535 • Ralelbhr N.C. 27$29.0535
Phone [phone]
WELL CONSTRUCTION RECORD
DRILLING CONTRACTOR:
RI t r
DRILLER REGISTRATION NUMBER:.1537 STATE I
r -- PERMIT
of the location below)
County:
DEPTH
From To
3. DATE DRILLED I OD ) Z'l)Codes- 7
4. TOTAL DEPTH u6 J . USE OF WELL r 57��
5. CUTTINGS COLLECTED YES[] NO
6. DOES WELL REPLACE EXISTING WELL? YES NO , - 7o
7• STATIC WATER LEVEL Below Top of Casing: 7
8. TOP OF CASING IS fuse •,• IIAbove Top o� casing) ❑to
Casing Terminated at/or � �' Above Land Surface* —� -,, l�
In accordance with below lend surface oils,
le hlo9at untess a varlence Is lssuod
15A NCAC 2C .0119 Z 5T/
9. YIELD (gpm);_MET op OF TEST //((
10. WATER ZONES (depth):_Z - se /77, ✓g5
,(Lr?
11. CHLORINATION
12. CASING:
DRILLIN LOG
II additional space is need act- use back of term
Depth Wall Thickness _LOCATION
1 6- Dlameter or Wei hvFt. Malarial KETCH
From TO _Z Ft. 6 `�2 a� (Show direction and distance from at least two Stale
To Ft 9 Roads, or other map reference points)
From To F1. �n t�
13. GROUT: P
Type Amount _Li35
Depth Material
From To . �5-Z Ft _f Mew t
From To
14. SCREEN: Ft.
Depth AJ Diameter Slot Size From To Ft Material
From To Ft. In. In.
From In. In.
To Ft. In. "--�
15. SAND/GRAVEL PACK; In.
Depth Size
From To Ft Material
From
16. REMARKc• To. Ft
0
O
o
�
r
w
o
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDE WITH 15A NCAC
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO TH
GW.1 RE1. 9NI
� L Ot1ntl4Va t , ,�
WELL
ELL OWNER.
SIGNATURE OF i p
CONTRACTOR
npt original to Dk%lon of Ern*� AGENT Sub�...
O mental Manaent and b " !4 DATE
gem
PY )o Wet) owner:.;:.

North Carolion • Deprttlrnnni of Environment, Nenllh, and tlnturnl nasources • of F dlvisloFOn OFFICE USE ONLY 21280 ,p
rl nvirnnntrrtdnl MmtngMnenl Gioundwntnr Sectioni
P.O. nox 29535 • llnlnlgh, N.C. 27626 0539 at JAU. f1r t. 6EnIALN0.
Phona IS 19) 733-3221 1 nt __._. _ -_ rorq. no
Agnrn tia-ln �.
WELL CONSTnUCUOU FIECO1TD F1n11,t 47,1,
�y. 1 dQQ IlnnrUv Ent. OWA Ent.
DnaL1NG corllnnclon� --__-_ - . --- _ :-__--
sIATE. Wr_Ll_ C01ISn1UCTION
DnILLEn nE(:IST[IA1101111IfMnFn: Sy I---- PENMIT HUMMI:
1. WELL LOCATION: (Sho sketch of Ihg locallon below)
Nearest Town: _ I T h Ae,,SAi li Q P�_ Comdy:
(noad, Com inty, of ,;1,j ivinl7y��and*�ot Plo.) DEI' I I I UnILLING LOG_
2. OWNrn __��IYM�Mv. �)Ak Alka,ll _ —_ Fmmto Formation Descrlptlan
ADDnEf
("lied or noule flo.)
City or 1 own + Stale Zip Code
3. DATE DI11LI_EU 1 3--4-i2_ USE OF WELL
4. TOTAL DrPIII __3_'#D____ - _
5. CUTTINGS COLI_EC 1 ED YES L_] NOL1]"
6. DOES WELL nEPLACE EXISTING WELL? YES
7. STATIC WATEn LEVEL Below Top of Casing: c�� U.
(Use'*' It Above Top of Casing)
8. TOP OF CASING IS _ I___ PT. Above Land Surface'
• Ceeing Ternthtaled sUnr below Innd eurince is Illegal unless a variance Is Issued
In occordnnce Milt 15A NCAC 2C .0119
9. YIELD (gp1T1):_1!9_1_ __ MEINOU OF TEST
+" WATEn zOtJE3 (depth):
o
� o
N
11. CHLORINATION: Type iRYRAntount -� If nrhfilionnl ^pncn is needed use back or forrix
12. CASING: - --
LOC111101J_SKET CH
Wall 1 hickness -
Dopth/n � iamnior or WclghVrt. etednl (Show diraclirnt and disinnca from at least two Slate
From10 -[,— Ft. � � nonds, or nlhnr nrnp raletonce paints)
From To rt.--
From—To _— FL / l
13. GNOUR
Det tlll alerial Ihod
From To-rt. _�1P
From To
14. SCnEEN:
Dpplll Dlarllnter Slot Slzo Malerlrll
From 7o —__ T'1 -- In. In.
From To --__ rt.-- In. In.
Frorn _____ To _-_- -Ft. In. In.
r 15. SAND/GIIAVFI_ PACK:
Ueplh Size - ahM,xtel{aW
From To---- rt.
i From _— to _ rL
16. nEMAWS:
I D f1}IPIj' I A& FtL WAS ( OtJS1FlUCTF-t1.1SA:ACCOnDAt1CF WI111 15A f ICAC 2C, VYFLI_
CO )C tlorl S T ) A{ MAT A COhX QF 3t:fISYflECOnO HAS DFErJ Pn OVIDED 10 1l IF WELL OWNEn.
AN, 1 4 2000 U
GraundwaterSection Rlr;rlAT11r1EtTECOf IGclonon F.N1 DATE
OW-1 n I Asheville $egioCal Office subiolt orlginnl 10 Divblon or ,+d crpy to was o.vrter.
0

lorth Carolina'• Department of Environment, Health, and Natural Rosoumo,
Division of Environmental Management - Groundwater Section
P.O.'Box 29535 - Raleigh, N.C. 27626-0535
,,•�rrx _,�;-:�,. Phone [phone]
WELL CONSTRUCTION RECORD I Basi CodeyF"�h'�
DRILLING CONTRACTOR: IJ �_f ` we _j l _ Dn t) j; ,��� Header Ent. Ar +r?n'P+if:3bYlF
STAT� WELL CONSTRUCTION
DRILLER REGISTRATION NUMBER: L PERMIT NUMBER:
irr'G . ,.EnnnL
n O !1
G V
1. WELL LOCATION: (Show sketch of the location below)
Nearest Town: 31 4k tb f)� County: "e
~LOG
(Road, Community, or Subdivision and Lot No.) DEPTH
DRILLING
2. OWNER ( '05 From To
Formation Description
ADDRESS D rC lA5 Z - - - _— /O
4�_k
(Street or Route No
City brTown State Zip Code
3. .DATE DRILLED 1 `11-SQ USE OF WELL 3a5 e
4. TOTAL DEPTH �� --
5.' CUTTINGS COLLECTED YES ❑ NO[fr' - ---.---------
6. DOES WELL REPLACE EXISTING WELL? YES[-] NOL-�' _
o o'
7. STATIC WATER LEVEL Below Top of Casing: FT,
s -
(Uso. -.' if Above Top of Casino)
8. TOP OF CASING IS---[_ FT. Above Land Surface' --
�� 7
t - -
' Casing Terminated atlor below land surface Is Illegal unless a variance is issuedIn
accordance with 15A NCAC 2C .0118
-
(gp ) METHOD OF TEST b✓nJ
9. YIELD m : --.- —_
_ L
10. WATER ZONES (depth):
11. CHLORINATION: Type ch42A.-F.e— Amount-3ptiOs. If additional space is needed use back of foHn
12. CASING:
Wall Thickness
Frorri
Depth
To a I
Ft.
Diameter or Weight/R. Material
- 6 s/� --- ._„ f 8d - c�q �✓,
From
To
Ft.
From
To
Ft.
13. GROUT:
Depth
Material Method
From
To JO
Ft.
corKerl-7' o�
From
To
Ft.
14. SCREEN:
Depth
From
To —
From
To —
From
To —
15. SAND/GRAVEL PACK:
Depth
From
To —
From
To_
16. REMARKS:
Diameter Slot Size Material
Ft in. in. --
Ft. in. in.
Ft. in. in.
I DO HEREBY CERTIFY THAT
CFE8
7
2 8 2000
GW-1 R
Ft.
Ft.
Size
Material
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
411P
IS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
Ap, THAT A COPY OF THIS REr,ORD HAS BEEN PROVIDED TO THE WELL OWNER.
SIGNATURE OF CON TRACTOR OR AGENT DATE
Submit original to nivi"inn of Environmental Management and copy to well owner.

North Carolina- Department of Environment. Health, and N,turnl nucnurcoa +,x.,vwtVrap�
Division of Environmental Management -Groundwater Section
y v ; P.O.'Box 29535 - Raleigh, N.C. 27626-0535
FOR OFFICEME
QUAD .NO.
Phone [phone]
Let.'•' M r e✓•r 1
�;y+1i1i4v
WELL CONSTRUCTION RECORD
Duoln
BasinMlnor
code < h
DRILLING CONTRACTOR:, r-. i ` Lot j� y�^t' j <S
Header Ent "'_ t ' GIA
DRILLER REGISTRATION NUMBER:_ STATE WELL CONSTRUCTION
�� PERMIT NUMBER:
1. WELL LOCATION: (Show sketch of the location below)
NearestTown:L LlIA- ( Count 4h
y' --
(Road, Community, or Subdivision and Lot No.)
DEPTH DRILLING4LOG
2. OWNER
ADDRESS
From To Formation Description
ZR
eto
.(- mkt •. ;,2�L' 20u •Li �t r_
1 I
I
Ctry or I own State Zip Code
3. DATE DRILLED ) - % - oo USE OF WELL
4. TOTAL DEPTH. '
5.' CUTTINGS COLLECTED YES 0 NO
p
6. DOES WELL REPLACE EXISTING WELL? YES F-] NO �
7. STATIC WATER LEVEL Below Top of Casing: FT.
a —
(U:'.e. "+" if Above Top of C:etinry)
8. TOP OF CASING IS_jFT. Above Land Surface- ------
'Casing Terminated at/or below land surface Is Illegal unless a variance is issued
In accordance with 15A NCAC 2C .0116
9. YIELD (gpm):1_ METHOD OF TEST
10. WATER ZONES (depth):.6irHf i.
11. CHLORINATION:
12. CASING:
Type , Ale2R'a)e Amount
Depth Diameter
From To 3y Ft. -IS
From To Ft.
From To Ft.
13. GROUT:
Wall Thickness
or Wei0P. Mato. rinI
m i $J�-IYt
Depth Material Method
From G To 20 Ft,
From To Ft.
14. SCREEN:
Depth Diameter Slot Size
From To Ft in.
From —To —Ft.— in.
From —To —Ft.— in.
15. SAND/GRAVEL PACK:
Depth Size
From To —Ft. —
From To Ft.
16. REMARKS:
GW-1
Material
in.
in.
in.
Material
If additional space is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
i DO HEREBY C JJEy Ikigl_T+Hs WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
fi^ TIQ$! $(TFQ})D�1DFUD THAT COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FEB 2 8 2000
�y
SIGNATURE OF CON TRACTOR OR AGENT Submit originaf fo Division of Environmental Management and copy to well owner. DATE

North Carolina - Department of Environmen4ealth, and Natural Resources
Division of Environmental Management - Groundwater Section
P.O. Box 29535 - Raleigh, N.C. 27626-0535
Phone [phone]
WELL CONSTRUCTION RECORD
DRILLING CONTRACTOR: R.CALDWELL DRILLING
STATE WELL CONSTRUCTION 2 0 5 8 81
DRILLER REGISTRATION NUMBER: 1537 PERMIT NUMBER: Al 1q .
1. WELL LOCATION: (Show sk tch of the location below) # 3
Nearest Town: D �11M/w�< County: r
n 1_'A/) 10 . f)
2. OWNER
(Street or Route No.)
JI -ism-,✓N-a-.uax- 1111-o
City or Town State Zip Code
3. DATE DRILLED USE OF WELL _
4. TOTAL DEPTH 7 D.S'
5. CUTTINGS COLLECTED YES 0 NOF-1
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NOF-]
7. STATIC WATER LEVEL Below Top of Casing: _q FT.
(Use "+• it Above Top of Casing)
8. TOP OF CASING IS FT. Above Land Surface*
Casing Terminated atlor below land surface Is Illegal unless a variance Is Issued
In accordance with 15A NCAC 2C .0118 Q
9. YIELD (gpm):_ � METHOD OF TEST Te67-
10. WATER ZONES (depth): /- 90 - -1
DRILLING LOG
DEPTH
From To
11. CHLORINATION: Type %%��� • ft?- Amount 7Z Jl[%S1 If additional space is needed use back of form
12. CASING:
Wall Thickness LOCATION SKETCH
Depthr� Diameter orWeig�Weight/Ft �Mat_eriall (Show direction and distance from at least two Stale
,
From To -� Ft. 4' �— Z Roads, or other map reference points)
From To Ft.
From To Ft.-
0
13. GROUT: C>
Depth ate I I ._/. Method m oF,
From 0 To �� Ft. r nklL -�Pe
.F-rerla To Ft.� ' 9f F c
14. SCREEN/
Depth Diameter Slot Size Material
From To Ft in. in. M
From To Ft. in. in. r -"
From To Ft. in. in. `
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRI wj=W Sj"U AaQ& AUQ T+4:T A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
r. t ,
SIGNATURE OF CONTRACTOR OR AGENT
Submit original to Division of Environmental Management and copy to well owner.
GW-1 REV.