GW1 - Brunswick Oct-Jan 2017

WELL CONSTRUCTION RECORD
Unix Conn ca ba and fmsagte Or mu141 ewe1h
1. W eU.Qimactter lnf
Ain fatal jot-)
Well Cantor
3S'OA
NC Wall Cav n( rsrliicalwnwumGaWe/ Ail
CampazyNamc
2. W eB Constntcfim Permit%
Liu affopplkebkwdlpmaks lie. Conaty Sins. Panama. Irae.'foa.Tzl
3. Well The (shed weft use):
Water Supply Well:
O.Agicdhcnl
OGeothernint (Heatiag.Coolum Supply)
OL.daewial+Cvrnmercial
..4026tm
Non —Titer Supply Welk
Ohhiuitming ORe.•ovcry
Injection Well:
DAquifer Rethargc
°Aquifer Storage audBecowes.
°Aquifer Test
OEcperimental Teclmdnes
°Geothermal (CbmedLaop)
OGe thermal (Heatmg:r dine Baum)
Okluais ipat'Pnbtic
ORenhattial Wan. Supply tannic)
O R id til Water Supply (sharcd)
OGtomidwaterRmnediatimt
D.Sabni Ba to
°StmmnaterDtainage
O Suhcidmtcc Cunln l
°Tracer
°ath r(ccp1ain under s2l Rom)
3. DaatteWeI(s) Completed: c).— 2wcD IBB
•fel S l Triton:
__eh /
F.acilityiOwncxName
/e207 Ne- 3 i ,1-7 _aT l oyAs-
Physica A&E ra C0v, and Zm
£rvNS f all C
C°tray. Pawl Idasifivawk'o. tPik7
Sly Latitude and Ira tsdein deareednti estseeends or decimal degrees:
.twell field, one indent ssauoi imo)
3 3°5-es't' 33.0 72e7:2s€ry6f w
Faalitt ID�` (rfappliahle)
)At4 (J egt/d
6. Is (are) thewell(s): taternment or °Temporary
7_ Is this a repair to an existing well: OY es or evade
thin 'sampan; fill outttona well nsawtn aja.matian and espiam the mtrna elfin
repair under 21 mmarErseaan or on the back <O i-font
&?{umber afwrlls constructed:
F medripk i*athn or tmratermpplywrils ONLY wbh the sans c wson
mrkaitone faint ram, 3nvaus
9. Total well depth bduw hand surface: gi 7 (Q)
For midge wells lint on depths (deepen, tismnplo• 33_'tOand_:t10R5
10. Static whdow
tenter mp of easing: //
sing: (D
If 'rarer lend isobar: easing tare -a.-
!f
t&
11. Borehole mutter: G -Me �� {a)
12. Wen coortrz U:1
rn method: ) ri ii es.,
is c. augcr, mom cable, data omit etc)
Cana
FOR WATER SUPPLY WELLS ONLY:
13a.17dd (��ma) yo// // Method nf[esL��—
13b. Disinfection type tgle/7CA Amount o Z
Form GR-I
Forinlamlttx ONLY
44b81.4
ILWATERZONES
FROM =O
W w. /1 R
R Er.
IIQCRiptfa'
SAT fRNe r
Is OUTER CASING (fanno—stdwells1ORSINER ti
i�OINES )
�t )i9lD 4/ehyo
it RMannOR
r• fe. DLAMETFR g ) MATERIAL
1.
17. SCREEN
1
MATERIAL
Goa/v. STel
WM
'9 a
To
tantalite
SLOTSIpE TtnCaaass
a 7 fL
/7y'-
60014...4 917+
ru
a
in.
0
a
a
To
1
1ATtRLi
es s
[a``ltJJstettl. El1N.. t 4ErIT ?Slob eau° JCT
VeNT tavie - / tire
19. SinMDIGRAYEL PACE 6f appH ®tile)
FROM TO ( MAtERiaL
A it
rL fr.
EMPLACEMENT 3lETHof
20. DRILPSRG LOG *attsr& addisaeat sbcee tf uecemrsl
FROM DQCRIPISO? 6trdaes, sSVnd; nut. arthasac. a..)
o-N
TO
271c
a
It.
IL
rr.
IL RE(L4RRLS
fL
fu
is
rr.
rL
i CE!\:
ULI ! 0 2017
WormmtHHS PrOCOaa.'--i t...,•
Smmsctar
Dace
0y signing thisthisInnt, f krebr eerie dmr the well(si war ftrerel anmrvad u cot: wah fid 1CIL'C .o100 or 15.4]CAC 02C .woo wen cona tame srandmdn aml Nara
copy ((thin record harken pranged m the well mazer.
23. Site aware ar additional well deta.ls: You may use thc back of this page to provide adshtional vvtll site details ar well
connection details. Younny also ands additional pees ifnecessary_
SOB.\IITTALINSIBCRTOwS
Zia For All Wells; Submit this fans within 30 days of completion of well
connection to the following:
Division of Water Rasui-o s,Infnns®Bon Protease)* Unit,
1617 Mail Scniee Center, Raleieh,NC 27699-1617
24h. Far Iniecti'on Wells OlstY: tit addition to sending Om form to the addtt s in
ttla ovg, ais submit
a c y of this form Wallin 30 days of completion of Iona wail
Dirisian ofWaterRrsamme., Uodelgretlijjfj nigar3h4
1636 Ala Service Center, Raleigh, NC 27699-1636
24c For Water Supply & lnjettian arena ((l�''
Also submit out any of this foam wither 30 dayDoc l pleliyy o2QA 7
well conalmdioi to air cooly heal h eltmiman of the county where
Water (duality Regional
North Cwinu Drpatmmu ofEnvanmau and Natural Rnwrcz—Di-ssinnonlimer&aomam Opera tiopsplogth l :o13
Wilmington Regional Office

WELL CONSTRUCTION RECORD (OW-IZ
1. Wept Cause* Information:
Wel Coma me
NG' WellJ CCeunrmtwc Airimsnc Nnmge(
A""1u¢., tJ•ea/r DRr!(
Cannp. ny Nato
2, Well CortchteOon Permit ft:
Llat akapplicaNe wall gMMMu flan pelmet! pt. SEC emu*: *Yte.'Perreut r. ate/
3. Well Um (cheek ivdl nsr);
ter Supply Well:
Agricultural f MunielpaPPOlic
Gemhernusl (ifeatin@/Coniing Supply) Oft...Menlo? Was* Supply (single)
nduetrlaVGbmmoial f Re idental Water Supply.(gnared)
on,Water supply Welk
Mmi'torin%,.
eeell:
Aquifer Recharge
Aquifer Stowge and Recovery
Aquifer Test
Pnepeaimeaml teohnotoge
Geothermal (C1esed'Loop)
DOrmadwetor Rduediatitn
()Salinity Barrier
©Stomerater Drainage
QSufeaidence Control
Mama
S1 ether ex loin under 12.1 RtRuhks
4. Date WAD Completed; •L a 4'i WAIN
Se, well Locaenn:
PMtllly/(hvau Name Fa?
CA) D. tfLaasa Otte 'a,M4 AWL
etyma:al Addren, city, end Zip $ `firs i
.�� a3w tat.
C;Nmty Peueel Idea/A:Man Nit. (PIN)
Sh. LaMothe and kiiBPtadt iu degremlatinuteslsecond» or &Lie n)•degree:
Oil'wep fdd, one fa'bginseiheieni)
33a star a4In N o/S u /Oe 36 Y Yy
0. Ware) the well(a) permanent or Dlemporary
7.Isthis arepair toenabling well: Oyes or afa�y7do
(film .a a movieynlvulatimvn weltcurtaasilna Wanttile outeolaindin ealutanflho
raw wldnr a2i 'mark: &MOO or onlha beef 4rNlafars.
S.!For Geoprebe1APA' or.'CAaaod-Amp Gateman Wenshosimgnho son
consflclioa. only t G Wt is vatted. Indicate TOTAL NUMBER: of wells
9. Total well depthbelow tandeerfacer (ft,)
Forandrlple wally rayon daprbs gauuanmr(:zampra.344200'awt2@fdah'
ID. Static meter level beW* lop of casing: li
vision kvei (show aw'mf,.nre /"1
*I. Iaorekotc diameter: teem on.)
12. Will sooatruedeomethod:
1,6e;amiss'. Macy, cebiee (Pcet PM. etc.) 54.1, Wale
(RJ
POR WATER RUMS WELLS ONLY:
l3a. Veldhpm) Mottled great;
13b. Dblafeelidn We;
Amounts
wow:ofceli
ay/iO *AAR. 4' Ate m Rarest way wily (weer) mead /a vxent
copy g4ws,twor4baf duo prorated to the veil payer.
For Internal Use Only:
riYe.'rNiV6R
_ache
a.
44C77
litgrahat.
tri
NAM IIAL
put
eicnjy y Qain
.90_42 oh5 -pita
n.
22. Certigcnt)eo:
Otril
whor_ia.sepkg Lod.
ROI ( ail PICA. tt2f .0240 Weil Cutoruak t, &rags and
Office
24h. bar amiad'nn W t g to addition to sending the form to the address it
More, oho submit one copy of this form within 30 dale of completion of
cannfMetton to the foilnwing:
Division of Water Resource , Uhdpgrohud lnjeMiaa Control Program
1.6aa Mail' Santee Center, Rahlgh, NC 27d994d16
24a. Par Wll ff Ceelnta .a hissna WeNet in eddit(on to main net fen
the wdressta) above, also submit otte copy of this (pen within 30 day
conpidtoa of wail conssneino to the county health department of ale co
who" . mndml*M
23. MR diagram or Additional well derelig¢ rpAen� �11adp
You may use the bad: of this page tttp10tP�asmtiDtl�ONttlGlls'1is•
cthasbtta?on dalaile. You may also ettaahaddilionai•psges if m oesslvy,
$ttMUTALeNerivi TTONM OCT 09 2017
24a. Pc asp Submit this faro within 30 days of eempletiou of
iiossf udion lo et following:
mimeo ot Wseer Reaotrces, l
1617 Mall Senile Center,;

WELL CONSUUCTMON RECORD (GW-f
Wcit Contractor Information:
aeo $ M Thwe
wen cimmwobbinne
NC Wo1) Covladnt Ovtinote n Nteniat
Company. Nina
2, WtJI C inetruc6p0 Permit.da
Ian all epnnaable wall awnrialon praraar lab. UIC, Cowry. .Stare, Perfew::e
3. well liseldlcck wen wte):
Water $appty'Welk
geiWtfnral - - [9Mtmio(palrouotio
ea0wmia) (HeatiRp'Cooling Supply) ai�sidentiiS Waw suppry (eingla) •
ndakbialalfen l<:lat f Residential Water 3upply,(shered)
a -Water Supply We
Monitore;
Well:
Aquifer Recharge
Aqui*r Storage's Recovery
Aquifer Test
I XperiMsntal 'frebnolopy
Geothermal (Closc41oop)
(MndtermstQiealtg(Cu lin t.Retum)
Domuedweter Re ttediallow
OSalbdry Hurries
DStmmwainDraingga
f Su6siger ae Control
Ottawa
)ItI Other Rx, lain under r21 Reds
4. Date wele(a) Completed: /G" . I7 Well nor
Se. Wall Location:
rstllly our Nam, a railitylUa(itep»hetate)
Physical Ades* Chy,nd Zip
count
ve+: 33 yt
Nd- as"
Parce1'ldenn irJo;tk;,MPN)
Sb.'Ladtnde and bodltede is degretvtmihuledlKronen or, dedrneldegrecol
tefwall liana, onn Iudlennia sufficient)
390rf93N
opt.42 it • d 1 14/
6. Warr) the we U(s Permandnt or f Tetiporaty
7.1s rain a tapir to an existing went DV,es or MN°
(fMlxka repri r fanoat amnv weltcenaerivdan, a Arnie, Ian,and explaln dnr ndara<lur
repels wulxt UV raw* saa41vn If onlathalk of ay Ann,
2. For Geoprobaerf w iosod•pmap Geothermal Welk Imvbng,thc soma
consitudion.only 1 OW-1 isnesdicd.. Indicate • OTAI,NUMBBRofweb
9. Total well depth below loadaurfces 3 .Y (t)
Itormultiple wells Ito at, depths Vd{(Taren1(mai(AS MEW rod+2gtao9
10.iliac water teWUlmtop oftidog: /i- _ (ft.)
(1.war /evei lsc$ve aft* tie "it„
11.'.Bareaote diameter 4 Dna
12. Well eoastruatiaa mntRod:
(i.a. auaor. OW+ ;ON. dked oueb. aft) Saf.aaaatar
FOR WATER SUPPLY WELLS ONLY:
131. Ytetd (gpm) Method of testa
rib Disinfection type Amount:
Rif Internal tS Only:
446770
M. 710 bIAMETER
u. is. ra,
ft. R. InTr-
CV%
22. Carlifica:
WORM
er mil .....St RkAt.
04/0 �tJC
aSai
mos
Ofion lNC'WORRAik
... RMHAMAN MRIMrU
net tbs. el
imrorritakpn Pr
- ga.a
t781C
ay rla,laiR Minolta, I Men* .6rl(Ar roar Me'we're/ xwt Nano moanwrrd it txror.
wig ISA liCAC 02C.0'10aw ISA NLAC UZC,(ZM Well Canslnwtk., Saner& and
uopr Mmmkmv,W*ao bent provaird the yeam,mr.
23. rSlIc diagram or addiatuthal wdl detanas
YOa me . use the beck of this pegs to• .1, RIDENODMODENelth
construction deceits. You pray also tub slditionapigeOrneceury.
ag
nOttnei1lt41, Impit ltnotes (Il1 ,�7
24a, j Or_rdl W¢lta: Submit mia feint whh)i (�r 7 . d©9 f`aix4ectlon of
ceedruddon to the following;
DloidebofWaferResaurves, �ii .P 4r t.
1617 Mail Strike Center,
ilmtngton egiona Office
24h. per letiaebin Wad: in addition w sending On form to the addrass ie
aims; also submit ant: copy of this form within 30 dayc of completion of
col stMbtion tit the following:
DfvbWw of W.seer%soured, UBdergroeRd injedien Coated Prawns
't636 flalt.Sorvke Center, Rakigi, NC 27QJ9. f636
24e. per Wutaraillar x.tIttdadektaW4j la edditlon to sending Re far:
the addteas(es) stave, also Rub.* one copy sd this fop: within 30 day
completion 'of well construction to the comity badlh dapetbnent of the co
whom rongmtNt -

Pbystea: Address, Sty. and T.ro
Corny.
WELL CONSTRUCTION RECORD (OW-1)
1. Wen esmifnctor Information:
626 'Tn .1c
wen Cowenme
NC well Controaiar O:nineadon Numb
,A &,r Wc•/f 0 lit Ai
Comp my Nome •
2, Wall C*nstruotoa Permit 0:
tin all apt licnbfa w.N otimonvt a paanlifa pe. ()IC. C.Iwuy, Sate. YarPonw. a/a(
3. We:) Weleheek well use):
Water $apply Were
/! Andantino!
DIwnhemud (f(oatiag/Cw[Ing Supp(Y)
amm ■ lodtwtrial/Cereial
ING((or
f MunicipaitPubi'c 9 ce' 9 4 fk
Qkasiden6N Wnln:Supply (single) J n.
flresidendgi Wider $ pply(tbared).
IPot Internal Use chill: 4 4 6 7 6
ff OMR
RWM o aJ1
;damaR ll9n'°►e''�nw
MOM
1L
taatirtitiarts
int
wan
lw
Mgr
UMW
Oil
SIC
AARMAL
MATUTAL
iSTiain' n� r" arMar
0k0��
Non -Water sunkW4Ik
M, MondeS _-
)ac na
gN Aqudtar Recharge '
golfer Stomp and Recovery
f t Aquifer Teat
sY ryparimema: Trelmolnpy
of Cicodrermal ('Clasa±Loop)
(ieohermal
fiecovsty
paraunAwe:cr Ronrcdiatioa
C3306:ii:y Battier
f SWrmwaterDrainage
flsuba:denne: t%Id tol
atom
Return Othar y ' lain under N21 Rem
4 Date Wel1(s) Coug4etedr5/4'^l'i 44641 lint
• Oa. Well Location:
t.M
11Wlilyrownio • a
Molloy Mue (if eanOnsbitY
)? 9 4,4.e /(a {,L Sr OAt J r fetch
Aid- a. safes'
Parcel IdendnundonNa. (PIN)
Sh Ladluda and Ies$tude eta dtgremhoin4:es/setga6& or deelmal.digints:
(if well MM. one fa/lsonis maid*
?2° sr; 30)fN eft al. 624e y)
6. Is(are) thewail(s)twmanent
er D7'N:tperary
7. Is fhb; arep r fawn existing wit:. OW, or IdNo
?non nmat. /lllowk4Mrvnman ewmmmmMn hero lQ same explain Me name y°a
r4Iflhlrld•r n]f reaaraaaaGbnorenOho kaat nfrf4aiara. •
3, For Geoprobelalf or Closed -Loop. Wells WNW mewane
construction. only I CWl is tecdcd. h4itak TOTAL.NtIMBIIR of MILS
!. Total wall 4eplhbelottenOsutIce 3y (R.)
Par MN* way Mr aledephs fIbil rent (eamrpto. Sxg2S0'4n42gtOO)
10. Srdas aquae keel below tap of string: O at.)?/wafor lever /yang., ea..la .wa"'1''
11.'Borebolc Mamater: .. (in )
12. Well eoaa&ruotial method:
(Le. ateer. nary• whlo, dime sat att.) �t VA}•'r
PPR WATER SUPPLY WRVS ONLY'
13a. Yldd (gyro) Method of trait.
Dhtaltcedud tips: Amount: •
MA
y. r�?'A1STnatLa esi1
rt.
n.
MOM . re . - MA7r,'MM. aMSIACW6awTMa•:itOD,
n. f.
ft.
ft,
0,
fr. re.
-----� 04 2017
/PR°'MnaYnr
O. R inform Processing Mt
a
22. Cer&kali
/.v•I'll
sienaute, +-.iRdWth tract* thud
Yha ISANCAosagAC OCAS del or ISAA(X02C.240O C s rnSetad,9 d
1:00,4 ialr ravel has Seen provide Lathe wNf oxeye.
23. San 4fagram or addtdun I well Moll.:
You may use rho back of ten page
amst i*Uoa details, You may Wm
24e. For At) WO: Submit this form a9N1iA 3t days Nk1atmrpletion of
d0oe rueuan to the (glowing;
DivislonOfWater Resourna$ fr(1nff kt Ifni.
1017 Mall Service Cenra�lf rI,,lmlpkIg�bpungc��Io aI �{{7CCee��
Yob. Par.lnlsa n'. a 1n addd)ahITS' r mg laaYo9i��oare aaorss it
above, ellu submit CPC COPY of this form within 30 days of completion of
consinletioato he Mowian:
Melon of Wan Reoonrcee, Undergrahnd lo)sden Control 1Mhgrau
't 436 Mali ScrQiae Ceuitr. WOW" Nc red Q-Ida6
24e. for Entoringaufaugoasugolls M addition to seeding the p,r
the addeasa:os) about aft; submit one eupY of Mk Sn within 30 40y
completwf of well construction to the cow" health depwbnont of Mc se
WI MP ran 'lwn04

WELL CONSTRUCTION RECORD (GW-).)
1.Well ContreetertDI rmatiore
Well emoneloRalatee
PC Well Gouuadar CuniOtadon Numtet
canvu ni Noma
2. Well Cooatramina Pamela!:,-,,,__,_
tin ad/a)plc.&di well ammuclion panda. fie. UIC COS*, Stati, Vahan* etc)
S. we!) use lebeek Well else):
ater 9npplyWelk
Ap'rilUMOWtai rjhillnieipallPtibiie
Geothermal (f feetii itoOUng )iupph) QRasidetulal Water $u'pply(singie) •
tutusirieVeommerelid f Residwdoi WawrSuppfy(shafed)
Non•Water Supply We
Monitor"P
Yon
Aquila Recharge
Aqui*r Storage and Recovery
uifor Trst
:sperh icntai Technology
Geothermal (ClosedLoop)
Geothermal ,deal' ^ Chu -,Ret
A. Date Wale) Completed:
Ms. Wen tattier
D(Imuodwater.Ranedhairm
Ohmmeter
Barrier
I�pgtmrmweter Doan*
flspbsiderme.Centred
Ofraest
k(tee (datpiain under et Rabat
/9-)� wahine
•
FaeliayttTwmr Mane - °a.itity l77R.(tfanpdmaie)
!S9 uE,r" OAIL !:CAA .,c
.ah))staal Addrem, Ctrs red Zip e3-Iran a s—
ift aos w.C. K ' ' ptt .
county 1*alael ldmdRa &, No (fIN)
Sb. Witodo and tbeellade in degreedinheeti'sTece019 or dedmal.degreea:
tined" field, ono Iatbnaissuf1 sim0
33 Si: ti3).74 o)7 Tr! r s3'J
6. Ware) the weuhaerni nenf er 0114,00rary
la Odes repair to an mining well: ova. , or Eplo
¥rh� lva nlxnr.. iltaul*town well toutu roil A+namlanande,plain Ihu nD"dlrhd
'pair whiter at neMatJo SWIM urns Sheba* oflhlefinn.
8.!Fw GcoprobefAf or Closcddaap OcotbinS Welk having Cm sine
oonaatldion, Only I OWt is Deeded. k dateasiOTALNUM)1Elt of swells
•
drill'il:.,,,.,.............�.._.......
9.TOmlwed depth below Matt anthem 0? . (ad
I4rnullWe walls141 slawhs (fdd rent(emnplw FlOrOfr 00 WOO)
It Stade water levelkW lop•of cAaio : , f O (ft)
I/water Watt Av Beata Wring £#C "•I."
1 tared* diameter: (fa )
12. Wag tonetruedom method:
Waal; minor. eablei direst dish, ems) St+
flTor Internal Uae.(hlly:
446768
osscai"'-
s 9:►r
�►� n. a ia, *Y0star11Q
TO. U 141 al I -
Ala
tat
ft:
R
h.
fr.
ft-,
ih
Ta111AL-,
3`o —., ..
Btn -iaY&BP
M.
OCT e m
i00
-r
22. Cart
�R yror(i`i
/Q"3"/i
Rost oft adW .Oantaxt Doom
1Y edgnheg MY fens, I hems t vi:l , Ille`weltp) oats (Ward Caaatlwlred fr noon
I WO ISA MACOS(;.0(00 pr S C 7.+C MOO WenConnnrwkm Stasd➢rnds oaf
ropyN'dtls•mrdnd awn tovheweft moor.
23 (floe dLvgra n Or addldaaal nth deter
You may um the bath of OR page to foyi6f WbSI �5:dllaTui(s a.
ennsmirtioa details. You may also attach additional pages ifnwc say,
nisatlittalLaSlIFICTIOnth
All We* 0CT092017
y�trA , Submit this tbrnt within 30 days of ewnpletion of
%ashtiction to the fntiawi0 :
ater quality Regional
Divlel000lWaderBi�saulvas,f9 �
rdl7nfail$erviceCenter. Kin Office
t4ls tely h s Ien WeAlar In addition to sending the form to the edam it
thou, also submit one copy of this tom within 30 days of completion of
consunotion to the tbllowing:
DLvWoa of watt Aeour ces. thataroaodWeirdo Control Macao
F'OR WATRR RIPPLY WRLI S COILY2 1636 Mali Sento Contsry RMeigkt.NC 276094436
17n. Yield (gpra)— • Method or wet Mc. PInattier SnobA rain_ysnn Wnga• in eddidnn to sending the thy,
the addtats(es) above, also submit ono copy of this form within 30 day
13b. DWafeeeloa Type: Ammon:: anaptotinn of well CanStniaiai to the county hmdth deparment of the .Co
odotot on mooted
WAS

WELL CONSTRUCTION RECORD (GW-I)
1. Welt Contractor information:
G, t&' 3 T
Wd� Connuoaene
a»9
NC Mall *museum Cant tkadun Number
A Q,A..9 wt./t o PLll ifiss
Company Name
2. Well Canatructlen Permhb:
tier ell ar.11ebla wall(mnwrueelen twrwW&a.. GM C
3. Well Use neck well use);
Water Supply ea:
Agricultural ©MunieipaVAiblie
Geothermal (Pfeetingtouling Supply) ®Rceidential Water Supply (singe)
Industrial/Commercial QResidendal Water Supply (abwed).
brieasion
for Internal Use Onty,
S'Mfe. Pastanaa e'c,
Nio.Wster Supply Well:
Monitoring
anon Well:
Aquifer Recharge
Aquifer Storage lad Recovery
Aquita Test
fixperimenfal'redmoloRY
Beacham's! (Closed Loop)
Geothermal Bietaingamlitu.Retetn]
4. Date WORN Compkkted: — 3
Sa Wall t oaadoar
9allhy/ihalt7 Nem
RecoVerY
cGrouedwatcr&mediaion
Q3niinity Barrier
DStaroWsaer Drainage
f Suhai&uce Control
Miaow
(Other (oxotaia ender 121 Rethinks)
Welt 3DN /)
s
naar_dA{uTS:t3r
a1
IL:taint:a ?a
11111111,111111113
MINIM
la.
%rainy Ina (Itmnitable)
29/T A1:ta,s EAST OAK .Eder.
N m. a-rvct
Physical Addmss, City: and 7:p
eia,.+SanseeBX
(lace Peron )marimmiunNc. (PIN)
Sh Ia ode and Idigiado in degreohoimutea/aeconils or dalmal degrees:
Orwell field. ace IWl wg ti sat/dant)
33 ° Snit05 ° N 3 a° e . T 171
6. ta(sre) the wdl(s)Mpermaaent of 3Tentporary
7.10 this a repair*, an e:alednp well: rr+1Tea or Ilare0
fthts Ix a 'twain,gd sat 4Mw. well meumtasa, Wamicttan mod eapfain Me Hulas Of*
repair mar 621 ,ema4rawnn or ne rho Aaak afatwfann.
8. Ear (hoproheibYl or t`dored-,t oap Geolkermol Wegshung else Some
rconsoaaiort only 10W4 is oaded. indiateTQTALNUMfl of walls
9. Total wad depth below land ASAW:er ai: s (ft)
" al* aellslaralldepras I/Warne(aamp/a- $02170•amt 4070)
le. Static water level below top Of adage li a,)
q•rear le!et treemt Cash: deg "I.
I. Borehole diameter: 4 (in.)
12. WSI ednatrucdoo method:
Gel atoer. Hoary, aabk, direct (lub, ere.)
FOR WATER 9t)lafai,Y WTl,1-S ONLY;
13a. Vida Wog Mdbodofreal:
131A Diatntietton type: Animism .
O o
22.
ossamsik
Law -
twin Processing Unit
llhtoat
Sienet=of 'ad ,;, .. .. Mtn
ay alp* Ibt. ,.. , y ate Men der Waal was (,oy awuioratad.ln arm at° MA NCNCO2C.d(door /SA NGIC 017.00 NW Co wnwtlon Swards an
a7PY7:11141Magi M¢bait provided to Ow rnell4flaaa
23. Site *lawn Jor ad�ditloaal well detaib
You may aonsaudi0IIdelyktilbl ti)G red 1 ) alpA$es roo:ssokin* well she ry. ails a
/ae312
-
;SWDMkITAL'Df977ti1C IO(N��Sp ryr� 7
24*. Par A11 Welb: ��oettRW116 i J Within 30 days of completion of
caaatruedun to due tbllowtng:
DMatets.{ W,
7■, !'� : ,t» gallairallon Alveoing Unit,
1617IfY�ta- i tNC 2109d6/7
. tF&
2'dg. �i Cethe form tb the address i
above, also submit one copy of this form within 30 days of completion od
construction to the following:
DWldoaof Weir Itaonruet, Undegrotad Injection Cooro'Progrm
1636 Moil &Mee Qatar, Relcigb, i e27699-A04
2 e For Water Sao* & tmleaddob Welts: fit addition to seodtng die ki
the address(m) abelvet also roan* ant copy of this form witbio 30 di
campledon of wall c0nSvucdrtn to the county health department of the ct
where ennemnawt

WELL CONSTRUCTION RECORD
Ibis fain canoe rued forairuts or multiplealb
LV. omfactarinf
CP/ive � &/S0Al
Weil Contractor Name
3SyO A
NC Wedleconacor timifntianN ba
7—he wel!�r�'(�
Company Name 117issiN` pi Mtn 2.0 I'7 -0012.2.
2. Well Construction Perndt N: A t 4iv - WV Q J 0 0 no (
Lin aff applicable well itemize tit. Coma. Som. ladnnv, Infection etc,
3_ Welt Use (cheek well use):
Water Supply Welt:
°.AgricuIbual
OGcothumu (Heatingicooline Supply)
Olndastriab'Commerval
eatitnu
uMmiiipali abbe
ORcsidential Watt Supply (sink)
1Risidaa ial Wata'Supply (shared)
Nisi?- Water Supply Wen:
°Monitoring ORecomity
InjectionRell:
Mr:miler Recharge .. ..
°Aquifer Storage and Recovery
O.Aquifo Test
OEcperimadal Technology
°Geothermal (Closed Loop)
°Geothermal (Heati ngrmalins Ream)
OGmnndwat¢Readiation
OSalinityBarrier
❑SbnmwaterDounnage
°Subsidence Control
°Tracer
°Oihen (ccplain under a21 Raaati;s)
4. DateWell() Completed: /i"eB iON
FaalaciOmnerName Facility ID* ttfapplicable)
/0S". swlsT. omtc-to/mNJ atycs
PhysimlAddress, Cm', and Zip -
3WNJ'wt
County ..... .... _.. - parcelldemifcazrallo. ono
Sb. Latitude and Loruaibrde in degrteshS-uteslseronds orrdamai degrees:
kit wall rich_ on: lotion, isancient) t
33d5- %/. 334 7 f 9 inf. s W r' W
G Is (are) the wel(s))lrrerm ownt or °Temporary
7_ Is this a repair to a_n' existing NMI: °Yes or
If this is a repave, fill ma known well eonsmtuion iitfonmafion end explain the nonce of the
repaira nder 021 remarks section or on d€ backofshafamm..
8. Number of wells constructed: /
For multiple irgcxion or non -water supply welly OK' rt with the same cnpmnaf0n, you can
adsndonejbmt.
9. Total well depth below land surface: �J (IL)
• For mn)riple stets fist all depths if d rent (mange- 3:s'00' 0nd?:g100`i
IG Static water lie( below top ofrasibg:-' .
Ifteater level is obos^e us
e e `r" �.
I1. Borehole diameter: e - s'"" l (ht)
1L Weil construction method: r ( V CA)
he aiper, ratan, cabk, dhcet omit etc)
(R)
FOR. WATER. SUPPLY NWT S ONLY: 132-Yield(gpm) tsar Method aftwo: rtrhIrQ
I3b. Disinfection type: 64l /l
__mint: 'p OZ..
Faces OW-1
24c For Wain Supply & In -al
Also sttmn one copy of 0'
well construction to the mas
'msnuctai
Farlmandtbc ONLY:
446634-
1i WATERZONFS
nay
TO
DESCRIPTIONS
ft.23
b.
jef'4
R
15 OUTER
CAS!NGOormuW.
adwdW ORUNESgt bye)
FROM
TO
DIAMETER
> yy in-
THICKNESS MATFIOAL
SCA yo 45-0ilv. one,
0 ft
AS-ft-
bt1Nt€R
CASING OR TIMING
Comdata) chssdj )
FROM
TO
DUMMER
THICENESS
MATERIAL
[t
2
in
0.
R
in
17. SCREEN
PROM
To
DIAMETER
SLOTSI -
THIC!WESS
MATERIAL
/Sit
073 ft
/_%,/n.
!jo mom
jcil yo
LT,
ft
a
in
-
1S tltour
FRa31
TO
MATERIAL
EMPLICEMENT METHOD & AM OAT
o a
/o ft
�/
& rc7aCeJ
POtern.
a
ft
IS. SANWGRAVEL
PACE
fifnp$tcabi )
FROM
TO
MATERIAL
EMPLACEMENT METHOD
a
ft.
ft.
ft
2b DRII.i3NGLOG
booth
additpa l sheaf( trecemar)
FROM
TO
DESCRIPTION (color, faunas, oil/rock type.,raaabe. nc
0 =t
a 3 ft
Send CEP
m
a
1't
ft.
ft
ft.
;as _
:•
it
ft.
ft
SEP 2 9 201/
a
ft
2t. REMARi'C •t""
..�. .. ,
n ..
Sigatwe of Certified Well Coareaor
Da aS- / 7
m
&- signing aroma hnmbr certijr that the welts) was Oreme, constructed tit arerdanca
with lid WC4C 0_'C .0i00 or 13.i NC:2C 02C .0200 IVd1Commarrion Standards and ghat a
ropy of rhir record has been provided to the well owner.
13_ She diagram ar additional well donuts:
You may use the back of this page to provide additional well site details or well
ctnubuction details. You may also :mach additional paecs if necessary.
SUBMITTALINSTUCTIONS
24a. For Al Wells: Submit this face within 30 days of completion of ttell
construction to the following:
DMsion ofRater Resources, Inf
1617 it
tossing Unit,
9-I617
24b. For Iniection Wells ONLY: Li addition to sending We fans to the address in
24a above, also submit a copy of this form widgmh30 days of completion of well
coObuctiou to the following: - 0CI ®9 Zulu if
Ikeivon of Water Resources, yjo letgmmid injecdoq Control Prngrany . -
.. - 1636 Mal Service Center, 4�il�gh�2 7i99-1636
URa11tY rwe':—'
flS sectil'0(1li{ICE
pi ays at completion of
.&poement of the county where
North Carolina Detanmmt of&wvomuent and Natural Rrsamcc -Division ofwatakam,res
Rcveicd Augur 2013

It StaticMatr Iced below top of taskig:
If worth lnrl is (than .wring, are '='p/
11. Borehole diameter & y (iVata.)/d ///
'i
12. Well construction method: / - " Q. / (, ot}'} r k,(
(t e. auger,
caw)', cable. duea omit etc.) J
WELL CONSTRUCTION RECORD
ma soon can lie used has'ogle ormdfiplcwebs .
1. {SelI C_eim ctsitf
A:/'P le / f 0 yJ
! j
torbga I1 a ONLY: q q 0 04
SJ Z.
14 WATERZONES
REM
TO
DESCRIPTIOS
Mat Commnw'Namc
r YOA-
/0 "
#.3 R
r% pv'e jokes' J
s D-
7o Pr-
4p1'pes'rvN e
NC WcllCanty a.�--^fez :Nuotyo:
e vv•e �I//
Li. OUTER
CASING ear �)ORIIl�¢f� RI-)
FROM
TO DIAMETER,
+t rt
sz..'D-�-�s art vo pvc
Company Name "'Ow1N�
2. Well Colatomthm Permit l: 1 i idb 1 ? '' j 7 - cal IC
1L 1N2 R
CAS:WOO TUOII&teeaabit—..1 c p) o
I
DLAAT
Th
MATERIAL
ft.TO
ft. n.
I
FTRICOMME
List allappliasdk wdllaenms seer- Cmtmc Scat. Parlaex- (q*a ma etc)
3. (shackled! Use (shackdi tare):
rt.
It. y :a
17. SCREEN
Water Supply Well:
OAgricuIDrral OkluoidratliPnblic
OGcutltamal alcating'Cooling Supply) Olbsidurtial Water Supply min_le)
Canals: I' 1Commaeial ORcsidential Water Supply (shared)
Y_(�'�=�'`�
FROM
TO
DIAMETER
SLOTS@
l'IRC/CIESE
MATERIAL
ft.
Pre
ha.
"
R
is
1 . GRO1R
18Nt
TO
MATERIAL
E1IPL SAMOU1i
0 "
Sara"
eererec
12 4-`1 as* ✓/'/c.j
Non -:Miter Supply Welk
OMoadanug ORetmvery
rt.
InjealatWelk
Manger Range OGi mdaaterReecdini on
o agoit'vStongeandRms-ec OSalinin'Barriv
❑ayairarraT OStmmw7tcDraivagc
"
ft.
125.41w,GRAVELpAC26
taaapl abk1
FROM
To
MATERIAL
EZPLAtiatsaa-r verDOD -
"
"
fc
OE ental Tcdmal
xpvtm a^-1 OSaMidtm¢ Caauui
OGcot amal(Closedloop) OTiartr
O wit, emal(xcatmgCori._Remm) OOOnr (explain undo ill Remake)
-n�-u'G
LOG tatmd.addiriotuls2a:misave¢arp)
FROM
TO
DESCRIPTION (wM; Intdaac arilinct n➢c warm� uct
ID R-.
361t.
%c i0.e fi3d.. ei cm �tht//4
4. DateWel(s) Completed: 9 -12. 11te
Wel1.
_3
� "
7' ft-
( erlidY Clet
ao- ell Loratian:
•
ewe y Crw is
Yrrr
%0 Ic
L- A --I a sn i- L.
is
a.
it.
a.(yam
— -
FarileawOteaaName
(�(i nnn�����- Faul/ittc\JlOaritfa}pli./-3/JTe)
ft ditAiel
ft.
i-
It-
ft.IL
Physical .City.and� oVV6
p�
9 97
Cony Pvmi idaaificatian It ifl
/\ t
S4 Lanmde sad Langtt rde iu d�ares7rtmmeslstconds ordeanpl d gecec
0fwcll ridd arm la l uic N6c:an)
33°sY:46r2yy 7,P°Ys. 7a36 W
6. Is (are)thewe9(sj gPrnment or OTemparary
7.Is Wisa repair to an misting WA: Oyes or
If this is arepair,pillatu brown wallconniwz n igomatxm plabt the nature ofthe
repair wider #2I remarks scale n or m Be back fhrfonn.
S. Number of wells constructed:
For mdt ple byname or umwatermpplrwelb ONLr with the name coamnmon. _tausn
submit onc.thrni.
It
9 Total trill depth Endow land surface: D )
For mdriplc inlh lbt all dcpthr teem' laonpte--3.2'00' and 11001
/0
FORt4ATER SUPPLY 'R1.1 S OIdf.]::
}
13a.Tidd (gym) Qp 4.1 136. Disinfection type: 6ft4Ch
Method of use
Amount:
A- nr
Fun GR'-1
By signing this forth. I brit, :theft tau rbe tm0(s) teas mere) oaTmc--x3 S oronit=
with ISONEAC O_'C.0100or ISd \"CAC 02C.0200 Bell Canner.ybc Sranith3r mid data
copy M this mmN has been provided to the wall owner.
23 Sae diagram oradditiatra ader details:
You may use the back oht)Ig,ppgc t am�idc ad�tim al c11 site details or wall
cuuelim details. Ya `G7GyL1t7nYt and nnmsary.
ma
SUIODTTALINSRICflONS
yerj
24a. For AB Welts: SarniOS fghti1 itiOn, 40 days of completion of well
constitution to the following: t, r7
Division of Water Resources, Iufatamgan Processing Unit,
1617.AIM thielft3E eetnyidttAnir 2769946/7
Lib. For Ib-ecdoa W dung the firm to the Mats in
coa ahom,mmotj also submit.a copy s I� dap of completion of well
ccommotiontto the famine:
Division ofWater Resources, Undetaromtd Injection Comm! il.St.un.
IEr6 Man Srsice Center, Roicigh, NC27699-106
24e For Water Supply& injection Welk
Also submit one copy of this fain within 30 days of completion of
emntns1im to the county health depamamt of the county Mime
cunstme al
North Conlin Dgonnan ofEeshm,m, ami Natud Rwotrc -Division at Water Rtotm+e
Revisal August 2013

Parcel (dosifatiaa Na /PiN)
Sb. Latitude and L.ouginrde ha degreeshninutcrJseconds or declined draeers:
`yfwell field om tattooer issutfscicul
ft
33"SS/re,yLLt?362 rq 78'nf3 7- 68'36 W
6.15 (are) thew4l(sx.prerTm ent m °Temporary
7. Is this a rowdy to an existing well: °Yes or JT
jabs a a repay fat out known well ommat onhfolnytron and captain/he me m of Mt
repair adder .-_1 renmhrsachm or on the beck oj j®m.
Off
WELL CONSTRUCTION RECORD
This than note mod for k rutbipkwdh
1- Wall CmaaamrIufmma/tim/
J,ry r /% e,a d o n.J
Well Ca,wanarbrame
3�voA
NC Welt t ...a. nor c—t:F�r••
e 7 G'y
Company Name NVel Construction Pernik P! nJO7.%-boo/g
Z.
Lis allappliasbk roll rafts Re. Conk, Sraa. listrene. fefatioa gel
3. Well Ike (check well use)
Water Supply Welk
CIagticulh.vl
Oro-..lrhdulal (H®tiug.Cooling supply)
Ornndustziak'Commerml
dRa*+aaDon
OAlnridpalThblie
°Residvrtial Wata'Suppty (single)
ORcsi fouial Water Supply (sItatd)
94 'Mier Supply Well:
OMonitoting
Injection Well:
°AquiferRechangc
°Aquifer -Storage andRccm•¢y
❑Aquife Tcn
°Esperimentnl Tcelmnhoy
OGenthmmal (ClosedLoop)
°Geoth•—,l flcatuag:Coaling Remo)
ORanv z
Ot3muudwatcrRm ediatim
°SalinityBanitr
OStarmwatcraManc
°Subsidars Contaul
OTaaccr
°Oita (=plain under €21 RamtLt)
4. Data Willis) Completed: Ca/ 2 ell IUs
Loprtion:
brig !Trio/li
Facility/Coma Name Farlitg!Of ftfappliobblej
J/O Se / 74 a t e)A /e4 I .Vy&r
Physical lddrm4 City, and Zip
ertaa &vac /
County
111. Stadc inter level helm top of taring:
If wear lard iterate amg aa; 4 Ia
If. Borehole diameter-
8. Mutter ofwells t.m.li a-d:
Farmahp4:j rtion oryen-rraters14'welle Orer,.ab deaamc momaumt loony
mbmitaye Timm
9. Total wen depth helm land surface:
JQ
IFarlmnaIt%cONLY:
ItWA EitZONsS
FRp11
tr-
6t
44B63
TO DESCRIPTION
30 D. f/ttvd* crhefr rntk
antweRmaNGtror 'se$ookiEwitfy
FRO3I To DIAMETER THMtmiESS 1L%TEML
a tabr`To; era-Jse',$o
I&INNER MGM OR TUBING Catm
18dM TO DLi3111TE ( THIGsh' I I ELaSERIAL
R ft fit
PVC
D.
17. scREEN
ft
fie
rams I TO
eIOR
R
R
DIAMETER
STd±
THICIGCESS
en 0 _rc6 *
PVC
a GRROOT
FROM To
0 rL 15
a.
R
\LirIRML r1@LAC,.NT METHOD.t
f3�l..'rc p Pit+ -r
allotflr
D. ft
19. SAND/GRAN'ELPACE ffappEeable
FROM To MATERIAL
/ter` .3 O fp # Jits/p
ft. ft.
2O DRII.LLIM
FROM
O
f6
Ire
E1@LICEliE1T MET
LOG Imaeh addict al sheets
TO
It.
ft
octes:I v)
tfalltsutnta
fe
ft.
(L
t.
t
D.
ft.
t_
L
S�4' ?017
2I. REMARK-5
ft
Suuuuc ofCsrutied Pea Cmhartor
/ 7
by sung vizi,jmrr..1 hereby cfIlya the version: aver;! mrsmated in o ron/ancr
virh 15.4 \r4CO2C .0100 er 13.1 NCACO2C:11001felt Car -unction S,anindt and that
copy ojthis record hoseten provided to thew! Iainm.t
23. Dec dinnamat- Mditinaaladl decalls:
Yon may use the back of this page to provide additional well site details or va:II
cw,shuction details. You may also attach addaional pages ifnemeaty.
SUBMITTAL INSTUCTIONS
Permafdge wells1ShcdepthsyellItrent ramnple.3.c•260•end_3100'i (I � 24a. For �A8 'Wells:Suhmit this frnni within 30 days of completion of w•eil
(R) 'rye of Water Resmurees,infarmation Processing IAA,
1617 (fail Service Center, Rdeyh,NC 276994617
O
Ctrs)
I2. Well construction method: /// V LI (E07P,:b rt,.
A c. auger; rosy, cable tea pelt de)
ilk itmLlnikcaij aim ONLY: In addition to sadios the than to the address in
24a ahoye, also submit a copy of this form within 30 da)s of completion of well
cmwLuaion to the following:
✓Voter Qualjt y�
Oiler a�mx�, underground Injection 276n -1.536 Ptagtam,
I ice Center; &deaaiy NC 17699-1636
FOR WATER SUPPLY'%WTI S ONLY: Wf
I3a. Yield tom) dO
Method attest:
13h. Disinfection type: e/e 6, Amount
Finn OW-1
ington Regions 0 ice`r`
24e Far Water Supply & injection Welk
Also submit one copy of this farm within 30 days of completion of
well nmtstsuyian to the county health depanmat of the county where
consuv e&
North Carolina Dcpmmmt ofEmir'a,®p,t and Nattnai Realness—Dirisim, ofll'attr Resources
Rnt tedd.emt 1013

WELL CONSTRUCTION RECORD
This Elam cashes mica far Mole amuWaked/I
LW.
Cant/auk Infest_ soame
"We sorgi
o
Well ConuaaaWvme
3syv 1)
NC II'cl aa'•vWti6ovivefj G e /L/(// t-1
Company Name ,akrla, 20, i -0011V
2. WcU Construction Permit 1: &Are-Wvo8'00 /7 0
List all appl(eablendlpermits«Le. Corauu: Slam. Tinian , Lnjceaon. err/
3_ Well Ike (check well use):
Water Supply Well:
°AamicuWaul
°Geothermal gleatmg:tooling Supply)
01ndostrialICommerml
gatioo
Oh(micipeliPublic
ORoide t:-at ll'eterSLppinsinak)
°Residm4al `Pala Supply (slaved)
13.WATERZONES
FROM TO
00 R
MiSCRAlt6Y
a5 %!/✓d
.sr- to ft- i 4-1**-7-es r_ro e
li OUTERCASINGtfar malticasedwellOORLDrint or
FROM. TO DIAMETER. THICRNESS
1I ER �a ORr(IBMMestbstand a s1
16.D
mow TO ft. it I
Ina'tO;TF2t- I flfCGi6S 1 MAMMAL(a
ft 1 (o..
'TPF'�btrl
SfATIRLAL
PAC
R
17. ScREEN
FRNa
PTO�p �Ottae(ER ilL ESLOTSUE trificrtNEs3
_MAT2RL*L
18 Q(0777/'i'
2
ft.
N n-Waw- Supply Well:
olllouitoriag ORta:mm-
injection MAIL
❑AquifaRecharge
O_Aquif Storage mid Recovery
❑Aquifer Tat
°Experimental Technol V
OGeothamal (CloscdLoop)
OGeathamal (HeatingCooling Rcwnt)
OCnumdwma Rot cdiatiem
OSalarity Barrie
OsuamnmaDrainage
❑Srbsidacc Ctmuui
°Trace
°Otha(eepliin mda=21 Remarks)
lDateWell(s) Completed: 9-22 /7W en ma
aallVellLocation:
ifi•-P-R LA-Nger
FaohtciLTevertiame
iipoy E. yfYlr• �t^r
PhysicilAJdress. Cttf. anilZip
aK/NSW2ae
Comity
Faality Rig 1 rf appliobic)
2�Ybs
Paid )hmuan.tin. Na tP O
Sb. Zadmdeand Longitude in d-•^--___ - - ardcamml d�amee
iiforll fad- one iflvl .a isatifiia0
3.3S 21 y 00.8°N 78°7 i0.ssap (l
6.1s (are) theuell(s) ermmnent or OTemporary
7.Is this a repair to an essslietgare@: aIes or �14
Ifdririsarepavfiliout known wel!conera-ian infanrarion and "
repair undcr?_1 ranarlsra-ran or on 11Cbark ofrhirjons
8. NumberafuWbi constructed:
W
L(OCm/�jC
'ruUIsif Qp� diagram or additional troll details:
Yat
use the back of this page to protidc additional welt site details tic c11
emnbuetion details. ]'oar may also attach additional paass ifneeozauy.
Formultiph ngction or nos atersupplywelir 0.4$Fw3btnose rout
' ai6iaone
�n" ?,� L 1, Ur 20i7SUBIlnrflL1NsrurffoNs
For nultiple wells list all depths fd*mml (R) i8 Welts:
�It Quart canhuenan to the fo8oynug�
Submit
9_ Total well depth blow land surface: 24a.Forit this lam within 30 eraaple-3�^m=00'and days of a mplaion of wall
i
FROM
d
To
Coo' ft-
ft.
(L
EffLACEMEMOMIETHoD &MOUNT
6err e/Trio ib rtf 1, moci
19-SAMIIGRAVEL PACK (fappucabld
FROM TO MATERIAL
tEn-rMSRon
R
R R
10. DPrr T acres LOG (ate.cb>,ddiiiaai sbeas linaerasT)
DESCRIPTION task: brdnat Mika tom aci
ofeNal
FROM
p
aon-
'14 IL
it
(L
R
TO
a ft
a5 ft
Ss rL
j/' gag IL
a-l.Apdftitre
2L Crry
tL
fL
f f)A,c4 / she(/
/dent r/,sag
Lime c•poia.re
CariucdWrjl Conhaaar
Br siguiag Ibis join. Iherbr :miff dos dre Trellis) was (.rerj m smn-red is wro dmi
wilt ill A-C-1C 0_'C .0100 or ESA \C.e 022C .020010.1!CorsMaloe Srar orris adaFwa
cope of this mrord)ms been pro idedm the well away
10. Static w•eferlevel Mow top oftsdug:
grater letrl is ohm: caring.: L�
11. Batabde diameter (tar-)
17- Well cansRoetian method: / //
:t a toga, ramp. cable. .tirca push. tic.)
OPerationsy Regional
SWilmj Re Se( bn DivisionofWa4r Reourcrs,l-=-- pratearnir
n glOndt 1617 Mall Service Center, Rai
Oi`fiCe eyh,NC 27699-1617
FOR R%ATERSUPPLY WELLS ONLY
f
I3a. Iield L pm) /J
13b. Disinfection type: (%/9fiC(�/
60
Fonn OW-1
246. For Infection Wells ONLY: La additim to sending the form to the a:lams in
2aaahoro also submit a copy of this fonn nitbin 30 days of completion of well
commotion to the fofooing:
Incision ofMaterResoaa-a s, ltadetgramd iujecdon Control Pmeeram,
a,Is 1636 Alan Seam Center Rdzlgh,NC27699-I636
Afethod arrest:: Hi2-k For Water Supply& Injection Welk
also submit me copy of this form within 30 days of completion of
an.oatsr 0 wall wntiuotioa to die county health depanman of the counts where
coosuactai.
North Carotins Dcpmniair offttuemveo milNotvrat P cuwccc-➢isuion a(WmetResouces
Recited din st2b13

WELL CONSTRUCTION RECORD
This tam can 4mod to/rash a< 0.Ihi$endh
L. Weil Contractor bdta
/cTfr22lspiJ
FerfuvmlMe ONLY:
!i WATFRiOLffi
446350
Weil Cartvaeawame
3S'yo A
NC Well - eaa ban
Company Nape ^
tritar
2. Wen Cala°tuna° Psodt N' f lwn 00
3 3
Lim alf appiimWe odt paadr (ia. Corm: Sbs. I atiam.Y. t Xcoon .a1
3. Well Use (dad:welluse)
Water Supply WdM:
13AgsicWNml
DGeothamal (Hcaing.Ctmlim Supply)
Oludnstrial'Cammcoai
tinati. "on
rott-Wma Simply Welk
fthmiiditi'puhlic
ORaidattial War&apply (rmalc)
ORaidrnlht Water Supply (champ
.
Okkanitoting DRco eat
Injection Well:
❑Aquifer Recharge
Monica Storage and Recovers-
0 aquifer Tat
OExpaimentat Techuniogy
DGmrhnmal (ClosedLoop)
OCxalhamai GTmtingf Mina Return)
DGnmdnmerRrmaliatim
OSabutityBanic
OShamnuterDrainag
OSubsidacs Control
DI—'—
ClOthr(eplaiuUnder t`t1 Remarks)
d: Date Walks) Completed_ 9 / 3- /A a in
Sa�eBLocation: E.-yj•
Faatityievotiamcp]/� v
'D .yt eav tun
q 4ttlrcss. City. al Zip /
(JYUNfW (C K
Fn,urm ,dapplichle)
oft4 /J%b dt er4r
CO1°ttl' Parcel IdaeifmasanNa (PM)
Sh. Latitude and Longitudehet dwashoionussfseconds or dctimai deetxa:
(it nat tied, ors nylon%u auhcmu)
33 y'a ye 7116N 7P ° 9 6. 5-WV W
6 Is(me)the mkts): kermman or OTemponiy
7.1s this a repair to anexistingmehh OFes or 'i o
Iftha iea repah; fRamtomm reilcommamn hyamaan radcp/oathe name of Me
repair tartar =:_1 rnahss ecrienaa. slsbeSofddrfanc
ca
S. Mather unveils constructed:
Far multiple Weaior.ornon-water mpFb. O:!ZF with Mcseae amu ®' mlmitoneJ etc o.tnosn
Formrfdplanelr tutall depths- tdffena 'trample-3SC00•and _€Ifl ) (R)
9. Total well depth Minn -land smferec
Id. Stade uncorked Sdnwtop of casing:
Iftmnr level isntwr mime taw �r
I I. Burehda diameter. O )I// Cm,) �J
12 Well connection method: m VC( �Po,79 e y
+het auger, mtau-, mbbt data Pma% etc)
O O
FOR WATERSUPPLYRFT T SONLY:
I3a. Yield (gpm) ,.%/o� Method of test
I3b���
. Disinfection type: U/MCA Amok_'
I/
(R)
MUM TO . nESCRIPtrnv
e I t34 R• T esh-vi ,J .I p
e-rurI}hJ
a� it
& L/rneavore
ER01I TO OtAatETER TERMITESs MATERIAL
( >< 6.2—R /3 a.. [NI Vo 1 Pb-c
It ream CASNG tRx ruanteiatztatniidata-hm)
FROM R ft.in I TO OUMMER m iTHICERESS I MATERIAL
R R
1Z. SCREEN
PROM 1 10
ex" -
IS. GROOT
FRE1t
0I
n
To
SL"
R
mta@!ER 1 sn
tan
MATIRLAL
et3/4 rr
19. SA1 DIGtheilEL PACE EdmanexI
kRN! To
TINClGrgg
M5TIRflI.
Eadd
MPLACIMEATPRTROO S.NIOI *MOW!
MATERIAL EEMpLARRum.T T
riton
T1t ZOOTT TG LOGtameradditional shoo¢Noeegysl
FROM DESCRIPTION none sa9had
tf w�r�el( G
O
R
ft.
R
R
TO
36 R
+yacar_ -
m he trey
Fizi e �N
ifsR Alen, PI-J
�J �y
to R
R
is
SEP182017
i0flma9'')rl qa at(Slg tin
DW+zl(§rei
Dan
By sigaing Mir fora. I Ianln, car* Mar the treks) I tra (ram) comra.-red a arardana,
• rah JS7 \i 4C Or MOO er 154 At -it OS .020Mal Cormrrsuam Standards and Aar a
nappy -Mir mardharken pa nt/dm the rnfaimr.
S Sue diagram or additional well details:
Yon may use the back of this page to pmtide additional Well site dtlmis or well construction derails. You may also attach additional pasta ifnccanasy+.
SLIBMr1TALINSILTCIIONS
Lia. For iR Welk Submit this form within 3D days of completion of wall
construction to the following:
Division of Water Resource; lamination. Processin IInit,
1617 Mail Setsice Center, Rale(gh,NC 276394617
241.. For infection Wdhs ONLY: In additim to sanding the Teem
to the adzhnss in
24a about, also submit a copy of this form Within 30 days of completion of well
coostroctitn to the following:
INsadonnfWaterResmasq Undetgrmaid Injection Control A
I636 Dian Sat Cemvilyretit,NC±7699-tag rw
ate Far Water Supply & Injection Well€
Also submit one copy of this fermi within
well csustmcjm to the county health department
Noah C rohtu Dcpsmomt OtErrianwd mad
raaNa Ramnca➢i -Menial of Water Remoras
Force GW-I
WWR/DWR
of ncc county where
SEP 2 5t ZO.)L2o13
Water Quality Regional
Operations Section
Wilmington Regional Office

IFor Internal Use Only:
ammo Pared Idemi6aaovNo. MOO
db. iatitudeand longitude In degrees/mInutedsecondsordedmat degrees:
()rwe06eld, one Wong is sufficient)
N W
6. &(are) We wells) Permanent or QTemporary
T.&thisarepair toanedging well: ['Yes or aiqo
fit* Isarepain"!ant known we0roaraaettontrform+ationand die namesafrh6
repair wok. rt2I resort stilton or on the hackoj&trform.
8. For GeoprobadsT or Closed -Loop Geothermal Wells having the same
communion, only I OW-1 is needed. Indicate TOTAL NUMBER of wells
drilled: /� y/
9. Total well depth below land sodiumY
Pbrmulti* web lbtald.prhs b'47er nt (eamp/e-3@200'old 261005 ( )
10. Stade water level betow.top of casing:
inter &vetteabove eating, use "+
11.l1oreholediameter: SF
IL Well construction method:
lie. auger many. rabies dbectpab,
gt.) >umnennr-war.. a..,,lik!itialdblaftallailtietedinnhdt,
_ "enter, Ralelgb, NC 27699.1617
24b. For Iniecuan W gs:� in addition to sending the from to the address in 24a
above, also submit one copy of this foam within 30 days of completion of well
construction to the following:
Divkion of Water Resources, Undergromd Injection Control Program,.
1636 MaO SWIMS Center, Raleigh, NC 276994636
�-��---- 2AG Fer Water Sum * & Infection Wads: In addidon to sending she fun to
Ampmts ,yam(! the a of address(es)
4 also subm6 one copy of lids foam wftbiu 30 days of
camm�uotion to - comm health department of the county
wbaecrosatmted,
Prom GW-I Nato Carolina Depaeenest ofpwirwmsntQu Quagry . Division of Wat rMm ,
AggleVgayadagrG
FROM To
: BROM• . TO
ft
f.
446277 un-
DBOLW¢TTON
D
MA
� .+ . :thaw:.. aD'':?G
DIAMETER MATEEpe
LyZ rt of !u
.g2-TAUT
tROM T»
gt2.7$
a.
0 ffi ct rt
ft.
ft ft
FROM TO
tt
ff.
Mt
hot
yf
ft
tot
/3 oft
ft
R
TO
to
mat fa 13134s, Aire_
MA
ID.
SLOT
if�e-
�"U
OD
eNgmNm4mamfa4 ncl/0 G- if talon ��1 Ja
/'-t !r7P . _-Ev yt 3
afar
3 tat-/ nice.,
sr
/a
Te
jot
!:r-
FOR WATER SUPPLY WELLS a ONLY:
132. Yldd (gpm)
13b. Dhinsxdoa type:
x.Td. CONSTRUCTION RECORD (GW-n)
I: WdiContr Or"
d
WdMCon meterName
•
NC Wefcon6a Ced6attonNnmber
/ t/7e/Jfls . K/<6/ detfinq
Company ems
2. Well Construction Permit W
List ail applkabte well ewntrealsnpwm0s-Coe. UIC, Coma% &ate. raHmm ac)
3. Well Use (check well use):
Water Supply Well:
QAgdaattmal • QMrmisieeFFabiic
®OwWetmd (Aatmg/Coolio8 SD9P1Y) Eteneatuial Water Supply (single)
QlnaasbialcCommercial
Water
I'tlnia Supply(sbamd)
Nan -Water Supply Well:
DitilM ORccoeay
onitotin8
infection Wdb
QAgdfer Rectums
QAquife' Storage and Recovay
QAquifa Tat
QExpe imemelTectnology
QOeothamal (Closed Loop)
®Oeothamat(Heatmg/Codmgllfln) (ezpWatmder#21Remarks)
/V �7 WellDlf
4. Data Well(s) Completed
6a. Well Location:
inn4 . (LP
'eye
gVutgvuwfarve iD# ifapplknbk)
'e :cofa /I/ 4 kCifho
sa
Physical Ac e. ay,
Z%,
11e.
t44jwI Cie / 2/74pt'
.1lc/033wL/
QOroimdwaterRemediuim
CI&BUM Battier
QStonnwaterDtainnge
QSubsidenceControl
Maar
Method of test: A`✓
Dale
By Smg this form, I acre that the we110) non (were) eaiWmled N accordance wbb IMNCAC 0.2C.0100or13ANCAC112C.0200 Wel1ConmaeAmp &andantecad thata
ropy e%rhlr record has hem: provi&d to the well owner.
23.site diagram aradd(6onaiwell j LIVED/NCDENR/DWR
You may use the back of this page to provide additional well site details or well
cmatmtion details. You may also attach additionalif necessary.
SUBhII1'li s k:DSEP 2017
� �.�
2lin a;e; 30 gym
oommuctiamt iyl/ WaterQuaht e low
Operations Section
Revised 242-2016
•

�f?
bit
RECEIVED/NCDENR/DWR
SEP 1 8 2017
Water Quality Regional
Operations Section
Wilmington Regional Office

I1orIin:mgUse ceat
IL WATER ZONES
4 VIM
19. SAVING .VELPACKOtacd:nLlel
hBOM [70
R >G
R 1r.
MAMMAL EMPLACIATOW METUOf
2R DRIiilNGiOG /clack-+axanual sheers ifnecessary)
28s231 ngsna RTOS( bxm desdhiart mut. susve mica
O IL
.33 ft-
Coo"-
ft.
ft.
TO
3.sh-
4o-re
fe-
R
TL
(/Ac' a/ l-/n)t flood
c
IL • fl
Mb0F2017
6-13 yerr
1piQfPi'latton PfoCt% g
22. Cstiii
SiotureciCanlialOiR Ccotruior Eat.
By .signing flair fooy I lery sngy dal the nets) war kern/ .a,mmseed ie a_mao:e
rirh 114 Ards 2'C .0100 or lad NCAC OIC _ IWO rd/ Construction Srani airand thou a
copy of Mr sccard habeas beas prorNed to drawl owner.
23. Site d'ea<erantar additional well ' tile:
Yon may use the Ind: of this page to provide additional well site details ur w�dl
coustruehm details. Yon may also anal* additional panes ifateeasary.
SUBhIITTALQISItTCTIONS
24a. For 4n Welk: Submit this form within 30 days of empletion of well
emtshuetimt to the following:
Division of Water Rsou ces,Information Processing Unit,
1617 Mai Service Center, Rakich, NC 276994617
14b. For Inter tin Wills ONLY:. in addition to smiling thefaun to the address in
24a above, also submit a copy of this form Within 30 days of completion of well
constmctioe to the following:
Dvision of 3iaterResources, Under tmentijccdon Control Prigraza,
-1636 Mai Sssice Center, lightly NC 27699406
24m FnrWinsvaptySs rnici DER/RCREPNR/DWR
Also submit one cosy of this form within 30days elf completion of
writ constcmGon to the countyhiallh department of the county where
constructed_
WELL CONSTRUCTION RECORD
ibis than caste ,ail fur saskcrania* walk
1. "eU Ceatnua-
Ate
Wen CwmmntNma
3SYo4
lets u sJ
NC1ydl' aaa%aiid atimN
771 e WPC IsLi 4-%
Company Name
2. Weil ear r ~ ?/'^•, Lv/7 -do r i
Zoratlopp4ablewell permit fir.Coasn:Srar rate.hgetriaa ad
3. Well Use (cheek well use
Water Snp dyWene
OAgicufmral
OGedhamal (Bmtiag.'Cud ug Supply)
O, �/lndusbial/Cmwaual
.at[mnatitm
NotrUluerSupply NW:
Monitoring
Injection Well:
a4quiferRdemgc
()Aquifer Storage and Romney
❑Aquifer Test
OEcpa®mtal Technology
OGeontamal (ClosedLoop)
ONmsicipal`Pubtic
CIResidiattial RatcSupply tsm_ak)
I71tsalcutial Warm Supply (shared)
ORmmsur
OGromdanterR®Station
OSalmityBarrier
OStmmnulalMma_c
OSJss:dmcCtmml
OTiae=
oGeo> enuai (BmtmgCooinggReam) OOtha(csplain under 2(Rrmadml
4. DaWel(s)Ctnipkede 2075:17WeBIBg ..
era. Imxt/nn:
T,ie) +&.e9 IhA,T
ParitityfhmrrWane Fa:ditc ? 'appii al
d'V Nt yS'Msnt OA Igti-idAntr
igton en, City, and Zip J
✓ilit/ci 64-fi ch
fPoas TO DESCIOPTTON
�RI3.Rs�
foS R 7 8 R L- I nn a STOS)
Ter fra-i/c
13.OMERCISINSI6ammm.aardsmBslORLINER0[ 1
7IDWs� az4Teer.'
1 ERGOR 1m v 07 laOLORIETER.t O 1 7 .sue -y PYG..
ULMER CASEWIIII TERM fIaheemds N!S
FROM It TO DCiaorl92: I rffiCRiPg (armTOua
17. SCREEN
]Ypy
R
O.
18 GROUT
FROM
T© 1 FR81tE[E: I
9.OTSIiE 11Q +H[gpS W1CRLtL
N
0
R
TO
70 re
�aG/7EBlw fIff. nuance &AiIMT
ektnos tT I-( �w; m(A L
ft.
re.
County
Punt ldali&atianNa (PM)
Na. Iadmde and Longitude in &arem.fsnitmeceseconds ordecimal 'Iegrs.t
phvJl 0 ono bronze issthlci •
33 6s (. 3348 N 78 m7'o. 1o, a
6. 1s (are) the Walks) $Yleratmnent or Otempnlaey
7.1s this a repair to an existing we& Oyes aretilt/
IjIhie is arepti fdlaut own wdlaoamecrian aJmmoStand eaplaerh• mama: of the
repair ender 421 rrmartrsection or an the back ofehafarm
rt Number of wells constructed.
Parrmhiph injection arsa,.watersvpplyaelfO?\2Ptrills *name rmsmsadett lnu.an
submit one f .t. /
9. Tonal wen depth below Landsmface: - 6 6
For multiple wet lit era depthr ifdjfereat faampto- *taw aid 25elool
IR Static moer•level bdawmpofmaim:
Ifraar terelaabctr aging. ma 1.
/
1f. Bmthdetfmtmer: Cm-)
12. Well eammrtsim mnt.rl- .41 -tt t RO y)0'YlA
lac
aoga,saay, sable. caact psis etc)
(R)
(It)
SEPIl2017
Form GW-I North Cxartu Depmmmt otEn iroment and.
NamaiRaoncc-Division aCR'maRaonrtat Anita Alpena 2ols
Water Quality Regional
Operations Section
Wilmington Regional Office

WELL CONSTRUCTION RECORD
This Loam eabeusd fir single armd6p)e@dh
a.nceB tio Hung [-7" 2 it/ S o!✓
rarlmmlCse03iLL q ,p� j�
44 V ii 91
aiwa7EAZOIIES
FROM
rO
DESCRIPTION
Wcfl v «Name
-.
RZfr.
% R
C6r /, n -'d -
NC Well umpad rCathi/ ��
_�yij"_1 a We �V
IS. DITEITC1SD'LG tier
mo drenal OBLIl�Ba
Fen To
DIAMETER. t
aiarramr.
f 1 ft I. 1. 9 h-
i 74 `t Soh -Yo
-
Sree L
Cnutpany Name /
2. Well Coed Permittl: P�`/rn Z,O 1 7 bo (L 3
ISANIM?a CAs.tG OR TUk
G( � 1
FROM To
DIAMETER t
MATERIAL_
fr.
�
Lis a lappa-abb trail penaysfie. CoatJC Sras. PaParkawt eel
fiaori
Well L (check cell use)
ft. ft.
17. EMMEN
Water Supply Well:
0.amicallural 1hlu;cipahPah,;e
❑Gndhumat (Hettiug.Codme SLPp1S) OR id Water Supply (sidle)
❑badusttialiCmmacial ❑Resiiim4alQ:ater Supply (shard)
'''-'11OII
F6ali
TO
DIAMETER
sarsrm
TEEL/MESS
MLITERIA..
/ q I`
a 7 ft_
/Pr-
.060 /t
iC.111 sch
o Sr
R.
It GROW
Tn
M__T/_1
EMPLACEMENT SAvtiwr
O. n
/ p h
Ch/ o4
Pau re
Pion-WnterStogywd1:
Monitoring❑Rero*eta
h
ft.
Injection Well:
❑AquifrRecharge ❑u'mmdwwterRnnediatiin
❑_agnifrSrmage andRtcavav DSalmityBasrier
❑ayoii'aTdat ❑SnemwataDcama�
.attal Tndtm_ • d idaceC®md
❑Cmdhamal (CTosedLoopj ❑TraevDRI
❑Geaheamal(Hctttina oolingemlntln) ❑olha(ct%
��
pkin under =21 tomb)
n
R.
19. SAND1
tAPELPACEOrmaliabley
FROM
TO
1 MATERIAL
£a@LSCEatpl.T Vernon
n
n
ft.❑
2tIIPPOLOG(mcchadditlmalsLasifneremaal
PROM
TO
DESCRIPTION fader, havc tesah%dRxsraWmc tcl
O h
ft-
/i 4-
3. Date WAN) Completed: ..dJ-I1-ea ID3
Q
ts?)
tJh¢I�
R
fe
aallifeDLocation:
Sre e /4"0einini
ft.
ft.M
- \✓FS)
it.
.. :.
FaulkynawmsNane tafapplvaltk}
/09 -N€ yM esr. oft//e/i a,Pt s-
R
t-
AUG 0 1 2017
.. .
.0--
PhyaicaI Marco, City, ad Zip- !/
/'Jit/l�,f'WIcft-
2Luammtae - rfr93 -.
DvytN13uG
Coaml)- P.orel ldemdkatianNa tPIN)
ad Latrmde and Lasta/mde mdesaseeshmnmasfssoatds ardWard degrees
of well field, one Were is to) p
3 3 1 s 17. o 4f, 7? gay. Y 908
GIs (are) thewsl(s or ❑Temporny�
7_ Ls this a repair to an existim went ❑Y"es or (a
fits •tampoufall ant Imam trailmtmm:tma information andcaptaintha noarm of the
repair wader a3f rmrmhseemn or an the bark ofrbclronrr
IL Number of mats nested:
For m ai* lajeake or mmwmersupply wells ONLY whb On same eanmaadan.laa um
submit onefoma
9. Total well depth below load sulfate: f ? 7 (h)
For maniple wear tat at depths &Wren haumpie- 3�'00•'am1 _;stOO)
10 Static iraterlead below top ofcalm: AR
If water lard oaten: =sing. ses'+'
I I. Ro ehele dies ter: W .. . (m.)
12. Weil camtrnt8® method: sir(1%'e tar
.t a. auger, retail; cable, .tam cash etc)
(Et)
FOR WATER SUPPLY WELLS ONLY:.
I3a Yield wan) 3C/ Method attest: P
13b.Bisinfeaisn type.. eb»C/T t»c /6 'cY
Fenn GW-I
Setatere ofCadred Well Cnaaa s
-/7
ay String 1hisfanq I lruel' u 'that aha wvMki sae Orem) ormirenaed b a.,nrLr.:
with 1£-t lC4C ILC .0100 or !£i Nat 0'C MOO RellConnnemu. Standards and :tsar a
cope' ofthis record has been provdedto the well owner.
23_ ate diagea am or additiosl INCH details.
You may Inc the lack of this page to provide attati®at wail site details or well
coushaction details. Ton may ako attach additional poem if nee vsay_
SUB301T.1LINS1ITCTTONS
24a. For ail Wells: Salmi( this foam within 3D days of completion of well
enlistmetim to the following:
Divisionof WaterBesoutces,Itd'nrmation a Unit,
1617 Mail Service Center, Raleilq NC 27694-1617
236. For Infection Wells ONLY: In addition to sarfmg the form to the address in
2-la above, also submit a copy of thin form within 30 days of completion of wail
constsnaiito to t cfollowins-
/BosionofiiaterBesourtes, tjndetSmmni Injection Control Aogran,
I.06Meal Srsicc Center, Rut llneigh, NC 27699-106
.Me Per We, r SuPplv&. W tfinm with 30 dasofcR
Also submit one y of orm wSrhm 30 days of completion of
Waal awmct.n.a 00 to the chunky health dcpmmaa of Ibe county litre
ranshuaral
Monk Caroling SEP 1` 1 2017
DeFvmmtofEaviteamatandNandResurees-Division ofWanatesc ,a
Water Quality Regional
Operations Section
Wilmington Regional Office
d August 2613
ar
vo

WELL CONSTRUC IONRECORO ('GW-(Z
1, Wdl Cni*nctor Inthrmatloa:
G.c)ce.tt :Tnzit 's
cowl Coawaet ame
r2.l99
NO Well Contractor Certification Rather
A i.4e /I D god i ..v T. Urmpsny Name 2. WON Cnnswdatoa Permit d: _
/1.. Uri nj,&ehrh Wail rwnNnajwm(wpi p.e.'WI C ay, ytafe=: .Ssa a/Al
3. wail Um (ttm& well tree):
oder. upply di:
Agricudnta) �ryMuntelpol/Public
cothemtal (HeadoV.'uoIiif Supply) (jRasiduntiat Mau Supply (singe).
IndusuialfCt mmerclai ORmidentiat Water Supply (sbarod)
It-WaterSupplyW 1:
Motu • .
et
Aquila Recharge
Aquifer St.orageantl Rowvmy
Aquila Teel
C+xperin enfal Technology
Geothermal (Closed Loop)
Geothamal (Nomin#Cuotint IWwu
Dclmpndasui. Ranediatian
OSalinity Bert*
OStonoriview
OSultddenae Control
Muer
Other at= lain under el Rem
4. taste WdUs) Comdata* •) H I ` /7 Wrlt IBd
5a. Wd1 Leeetien:
((26 tore nit Mee K.r,
Paellilylfan ettl)ne Nappy IAn titheolitatu)
yo 3s fechkr 2l L 4m4 N q,
Plosion Miters dhyanit tto
dt..S3 Wigwag
Comfy Pared kdmdAsdan No, (PIN)
Sb. Ladle* and I tak fat degrterntinatestaxaands ar dedmal degre at
Orwell Sold, opt .lemon is sag7etent)
D 3' /1t. ort.o . N 0.) r • • o `. '-
6. Ware) the well(a, ermanant Or ( Temporary
7. le Miss repair to an eased well: C3Yes or ©No
Milos aetapir./ orhtwwn wrNemkdeadhtnterhmmitmandarpiairl ihatwwno1Jer
rarw.r sir elf lamadamenun or, oe the heckolaionet.
S. For (:eoproteftWfi' sr owed-ttwp Geothermal WCIk having the sane
wnsUuadtlm.oniyI OW -I is corded Indicate TCrs'ALNUMatiRof!alb
9. Total salt depth below land amp g (a)
ForruMpk wells lLtralidrpas JMfnme {aamplo- 3(daronI2@laa)
I.Q Static water keel below top ofaim
If wer(.+e•/irneoream%Stes'4.-
t I. Berndt: dhimeter:, _,..`. U •)
12. Wdl eomcraadoa method:
time, aosee®ceble, dent push, N=) ..
FOR WATER SIMPLY WELL$ ems
13a. Tieldfepn) ; %MOW of test:
131L Didafedon type: Amonatt
Fatinternal IlsaOnly:
Luz
445810
nl •ro• araCWt�7tari
2pL 0r rL cafe al
n 0.
l ftta
4m ordosontere•r.R
zerganr
`I-1 a Jo ri l ra. ay
moosan,
7O
St RFSEN... • •..
raj rV
rt.
A W I
MArmm*L
1ntKt a r CAM
eesnacrawxLte�R9£�
MA ..:., 1• EMP1ActtMr-'fjl'M69N n
-Aider14--2017
CM _ Iloae
haseatR etCenidoad W : •' //r.
av Sitsm/e/brm. I Sr
PNa 194( NCtC 02CAlen
we n% reseteharhen.
atmdn Wait) Wal (were) ct tit nosed In ewer
rd Near 01C.Oflr ma(ICnnn,vaM, Salmis and
evlat<eAte ailrnOnvr.
U. Sits diagram or Madam' well details:
YOU may use the back of MR pep to pmvida additional well site downs or
eonatruaioo Omaha YOU may also wadi additional page) ifnaaerosmy=
sraar r Ilrntr hiEIVEDcoc%%R24a. For MI Wes Subniis this (nm mm completion of
construction to theiollowing:
Dietamn etWater Reaogat.�at}m p(pna�aieg Unit.
16671Mad Service Caner, Rath . 27699-i617
26buetionnrrle detaa fWta : 1 ` m)"gon itoRnf$oeingn Il0adtya
{ios
iCeo
teem, alto to oomdre padinsorut 9a''
DkWouofWS/Rtddras,UodergoaW 6jt.CowedProgram
1636 Mall Sorrier Center. RA &NC 276994426
Me. For Wat r Smolt nothir Mo Welk: in addition to swdbrg du 4wi
dre addnws(ts) above, erbo subtaet one copy of Uds thou within 30 day
compladon of wail construction to the.wmb MIIMt deportment of the w
whommna ' IM

WELL CONSTRUCTION RECORD
Ibis toners elan Ind farah,0tc rmultiple wefts
1. Well Contractor Informal ^
�iyve /`4g2RIS o /v
Well Convincing Name
r Ss% o "1
NC Well Comets CcrtifttationNtnabol
e Weil &uy
Company Name
trfisi2. Well Construction Permit#: P/"''''r2o/7 00093
List aappSeable well Fernald (ie. Coom3: State. Variance. fnjecbon eta'
3. Well Use (check well use):
Water SupplyWdi
O.Agicultural
OGeothamal (t1catingCCooling Supply)
011nndustrialiCammereial
frfl
Nun-Water Supply
°Monitoring
Injection Well:
°Aquila -Recharge
D Aquifer Storage and Recm'a't-
C.aquilirTcst
fEAperimattal Tet hunIogy
°Gcolhamal (CloscdLoop).
DGeotherma) (Heatntg:Cooimg Reim)
4: Date Well(s) Completed: O, 7-/,
aa.�ell Lonti :
rei
Rulnyiewncrwame Facility IftrI fappliaMc)
/302 VW1q sf OA isle 2/116.
Physical AJdres, Ciw, and Zip
UMonicipalTnblic
ORcsida.tial Water Supply (sine*)
ORcsidcntial Water Supply (shared)
°Riovm•
°Groundwater Ronciliation
°Salinity Barrier
CStwmwdcrDtainagc
CSubsidatuc Control
°Tracer
ClOther (cyplain under a21 Remailn)
Well IDF
Far IetandUsc ONLY: ,•
14.19ATERZUNES
FROM
Q R
TO
a / f
DESCRIPTION
sal, f e-fal
5845
R
R
15. OUTER CASING Gar _ dwe&)ORLINER Of
To
FROM
4- /
19
DLLMETER
1s/Y
THICKNESS MATERIAL
Sc1,YO Srer/
16.INNER CASING OR TUBING (Reothesmal doted -loop)
DIAMETER
FROM
R
TO
R
in
TIRCEMESS
MATERLAL
R
ft SCREEN
FROM 1 TO
/9R
IL
1S GROUT
1L
DIAMIETER
/ 7yis
fe.
SLOT SIZE
THIORTESS
_60 sneak
MATERIAL
(S
0 R
R
TO
/ 0 fL
(g,
MATERL4L
/JFNn
EMPLACEMENT METHOD s, W MOUNT
pay,-60 d
19, SAND/GRAVEL PACK HTgnat:abl )
FROM
TO
R
MATERIAL
ENPLACENINT METHOD
R
D
10. DRILLING ING LOG (attach addidnad dues freecetarp)
DESCRIPTION (=hr. bardoet. saWradr Mt. WARant ati
J'ent✓ci
FROM
tl
TO
an"
6rIAOCA.iC4
County
-
Parcel ldcntiticsiau No. 'MW)
Sb. Latitude and Ian tide in dweeshoinuteskeconds or dechoal dtesxes:
ihwall itd.1 one lat/lona is suf iciasl
33°s Si.c/S -N 71°io"/a aiin W
6. Is (are) the. wells): »ermanent ar °Temporary
7. Is this a repair to an existing we0: OYes rill
Ifthfr ire ropey, fthlmaknown riellconsnctwn Wannation and
repair under kV rcmarkr section or an the back of ehir fomr,
8. Number et lIs constructed:
ainthe nature of the
Farmuftiple injection or nen-watersnpair irclr ONLY i hh the woe construction. you aan
mind: one form.
9. Total well depth below land surface: d 7
Far multiple welt lift aft dcpthr ffd ,rend terampko- 3f 00' and2m1OP1
10. Static water level below rep of casing: 7'
If water lend is abaft casing. ate --r"
11. Borehole diameter: t' I r �e+�d (in.)
12 Wen construction method: �) rl_tr ikai.:..
ti: a anger, rocoy, able, Sinter putt etc.)
(It)
(D.)
FOR"WATER SUPPLY
WTI 7 S ONLY:
T
1311- Yield Com) 7 l'"" .. Method attest: PU-171 jO
13k Disinfection type: ra lent in . ' Automat: ` ( 0 Z-
Fonn GW-1
It.
R
it.
ft.
RECEJ\rr'►-
R
ft.
R
ft.
11. RANTAMIN
AUG 2 1 2017
Itntormanon Miot:
DWCiacyz
:•cot•% Lel*
Sin'!tt&e at inilied Kell Contractor Date
Dr signing his fonft I7mre(m ccrhfy that the wel(s) war (were/ mnrnretcd in accordance
with 114 ACIC 02C .49100 or 114 Nc4C 02C .020017 ell Construction Standards and than a
ropy gfthir record has Men provided to the well owner.
23. Site d'ragramaraddi&nai well details:.
You may use the back of this page to provide additional well site details or well
constmction details. You may also attach additional parrs if necessary.
SUBhWITALINSrUCTIONS
24a. For All Wells: Submit this fan with n 30 days of completion of well
constwction to the foiawing:
Division of Water Raoures,infennatlan Processing Unit,
1617 Mall Service Center, Raleigh, NC 27699-1617
Ian.. For Iniection Wells ONLY: In addition to sending die limn to the address in
2-la above, also submita. copy- of this form within 30 days of completion of well
catsuuctioa to the following:
Division of Water Reso trbol Pi ntatn,
1636 hail Service Center, tg a36
24c. For Water Supple & Injection WeUv Also Mikan Onc copy of -this fob 38 d21Rto107 c�
pletion af
welica stan:tian 10 the county Ililt department o the county where
Water Quality Regional
Noah Coups Dcpumtw of Emilanuat and Nanaal Resume -Dormice or ASac6 ection Raised August 2013
Wilmington Regional Office

WELL CONSTRUCTI N RECORD
This fern carat toed f r single or muhiplc cod k
1. Well Contactor Inf ma:
�+ e 2Z,elC s o►J
Will Contractor Name
3r /Q A
NC Well Caua Catilication
-Tine we rluy
Company N.anc
2. Well Construction Permit F I on apt, - bt9u 9 /
List all applcable well penults fie. Count'; Stare. Variama, traction elch
3. Well The (cheek well use):
Fmrldaml USG ONLY:
' 945944
14. WATERZONES
FROM
TO
IV`
n
/ n
n
DFSCRDRIOM
c! err c1 I4hJd
IS. 0UTERCASINGrcarm atti•eascdselfs)°RUNE:R
fit
FROM TO DLANETER UUC&NZSS tGA+TPRL1t%L�C/
ICINNER CASING OR TOBlNGjgta&Rs Sdasd-taapl `�
DL4METFR 1 TM(IT. iESS
FROM TO
0.
n
ft
ref
MATERIAL
fit
17. SCREEN
Water Supply WeB:
D Amicolt sal.
OGcothom+d (Heating.Cooling Supply)
flndustrialfCommcrcial
�Salnn
Non -Water Supply Well:
OMoeitoriug
OhfmiicipalnPubbc
ORcsidattiai Water Supply (sm,ie)
ORcsidentiaf Brats Supply (shared)
ORccoven•
InfectionWdL:
O aquifer -Recharge
❑Aquifer Storage and Rust ay
OAquity Tat
DExperimtadnl Technology
OGeothamal (CloscdLoop)
f GoundnvmrRemediation
°Salinity Barrier
OSta mWale'Drainage
DSobsidaace Coal
°Tracer
OGeolhermal (HeatingCoelme Return) fOthx(aplain under 42I Rcmarim)
--Date WeU(s) Completed: GP- 7-1 7W:B IBR
Sa.1 d)Location:.
tey Algms
Facilityh)wnerName Facility IDS ufappliable)
/a NE h sr 044 is/»A42Piekr
Physical Address, CM-, and Zip %
County. Parcel Identification No. 4P1*0
5N. Latitude and Lomitade in ilwteaminutestseconds or decimal degrees-.
of well Geld, one lantana is sufficient)
33"SsIZltfil N 764°9 5 "4 2f�/ W
6. Is (are) the well(s): - jlPertmmem or °Temporaaryf
7- Is this a repair to an existing well: Oyes ar tl'Iruu
Iflhir is arepair. fall out known well construction information and explain the nature of the
repair under *21 remarks section or on the back fthirfomu.
S. Number afwe%s constnwted:
Far nothipte injccdan ar nan-warer ppiy wells O.•t'LP with the sane cansmaedan. rmtaan
submit one form. .
9. Tutal well depth below hind surface: 017 (0.)
For multiple wells list dt depths ifdiffereal (example. 3n ^00'and' 13•100'1
10. Static water level below cop of rasing: / 2. (O-)
If water fere, is atom many. use '•t'
IL Borehole diameter (0 'iDh /d (in.) . .
12. Well construction method
i c. auger, rum y cable, (ilea pub, dr.)
brlvr1/41.
FOR RATER SUPPLY WF-TT S ONLY:
13a, Meld(gpon) its
I31t. Disinfection e: elm4 type:
Method attest: Ptf1'vl p
Form GR-1
£ROM 1 TO
!q tt
ft
n l ft.
MalifErER
/ %y `1
to
SLOTS@
Gdmes
111ICIMESS
Se4 yo
MATERAI.
aS S.
IS. GROUT
FROM
O n
TO
/O It
MATERIAL
teoeNT
&tti'III W e MEjon A,sMOUKT
le.
n
it
n
19. SAN0/GROVEL PACK 6fmat idd )
FROM TO MATERIAL EMPLACEMFAT METHOD
n
20. DRULING LOG (attach additional sheen if necmiarr)
DESCIUMION(mhr- hardaa, satthad ape sante. act
,/'jenny
n ft.
FROM
Oft
ft.
70
2) n
ft.
ft.
ft
ft
IL
n
ft.
ft
FUG2k
2011
21. REMAREc
8--/S-/ 7
red RadF06ntvnor Dan
Br signing thic_fann. f hereby certify Isar the actin/ um- (were/ cnnrrncted ben asardanm
• with 114 ACdC 02C .0100 or list NC.0 02C .0200 Well Construction Standards and Mar a
copy ofrhir rend has been provided to the well owner.
23. Site dial no or additional will details:
You may use tltc back of this page to provide additional well site details or }call
cumauetion details. You may also attach additional pages ifnectssaiy.
SUBMITTAL INSTUCTIONS
24a. For .40 Wells: Submit this from within 30 days of completion of well
cmutmctian to the following:
IBvisionof Water Resouren,Infarmtion P aeessingg °nit,
1617 Mail Service Center, Raleigh,NC 276994617
24h. For reflection Wells ONLY: in addition to sending One form to the address in
24a above, also submit a copy of this form within 30 days of completion of well
eonstmctionto the following:
.Division M%aterRisou •.',. �!.> �Ji t'. j nat Program.
1636 Mao Service Ceuta, Raleigh, NC 27 9- : 6
24c For Water Supply i injection Wells
Also submit one copy of this form Aidhld ppyiyt injection of
wilt coustmetiaa to the county health department of the county where
constructed
Water Quality Regional
North Caralim Drpunmaa of Fswvamam and Normal Resume= -Division of Wata
WilRmf on�RegoralofficeRn•isedam rzuty

Print Form
WELL CONSTRUCTION RECORD (GW-1)
1. Well Contractor Information:
William M Wiggins
Well Contractor Name
(NCWC) 3470-A
NC Well Contractor Certification Number
Mid -Atlantic Drilling, Inc.
Company Name
2. Well Construction Permit#:
List all applicable well construction permits (i.e. UIC, County, State, Variance, etc.)
3. Well Use (check well use):
Water Supply Well:
:Agricultural ()MunicipalfPublic
jGeothermal (Heating/Cooling Supply) DResidential Water Supply (single)
Industrial/Commercial QResidential Water Supply (shared)
',Irrigation
Non -Water Supply Well:
z)Monitoring
Injection Well:
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
Experimental Technology
Geothermal (Closed Loop)
(Geothermal (Heating/Cooling Retum)
4. Date Weli(s) Completed: 7/7/17
5a. Well Location:
Town of Shallotte
Facility/Owner Name
Town of Shallotte
DRecovery
DGroundwater Remediation
()Salinity Barrier
()Stomrwater Drainage
[Subsidence Control
DTracer
(Other (explain under #21 Remarks)
Well ro# MW-1
Facility IDS (if applicable)
Physical Address, City, and Zip
126 Wall Streets'3r(.4M01fir< 8AD00305
County Parcel Identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one I,Nlong is sufficient)
33 58' 26.37" N -78 22' 54.07"
W
6. Is(are) the well(s)a%Permanent or )Temporary
7. Is this a repair to an existing well: ()Yes or ONO
If this Is a repair, fill out known well construction information and explain the nature of the
repair under #11 remarks section or on the back of this form.
8. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction, only I GW-I is needed. Indicate TOTAL NUMBER of wells
drilled:0
9. Total well depth below laud surface:
For multiple wells list all depths if different (example- 3 ,200' and 2@J00')
(ft)
10. Static water level below top of casing: 3'00 (fL)
If water level is above casing, use "+"
ti
11. Borehole diameter: 8.25(in.)
12. Well construction method: Hollow Stem Auger
(i.e. auger, rotary, cable, direct push, etc.)
For Internal Use Only:
14, WATER ZONES
FROM
TO
DESCRIPTION
3.0 it
i'
Depth of water in well 24hrs after well Installed.
ft.
15. OUTER
CASING (for muiti.eaeed ells) OR LINER Cf ap !feeble)
FROM
TO
DIAMETER
THICKNESS MATERIAL
0.0 ft
0.0 ft
in.
PVC
16. INNER
CASING OR. TUBING (geothermal closed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
0.0 f'
1 ft.
2 in.
PVC
ft.
ft.
in.
17. SCREEN
FROM
TO
DIAMETER ,
SLOT SIZE
THICKNESS
MATERIAL
1.0 ft
11.0 R•
2 it
.010
Sch 40
PVC
ft
ft.
in.
18. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
0.0 i.
0.5 ft•
CemenbaentanaeMix
Hand pour(Outer Casing)
0 5 ft,
1 ft
eemananemonaa NAM
Hand pour (Inner Casing)
ft.
ft
19. SAND/GRAVEL.
PACK
(ifappacable).
FROM
TO
MATERIAL
EMPLACEMENT METHOD
1,0 t
11.0 ft'
#2 Filter Sand
Hand pour
R,
tt
20. DRILLING
LOG (attach
additional sheets ifueeessary)
FROM
TO
DESCRIPTION (ealor, hardness, eeil/roek beet grain eive, etc.)
0.0 ft
7.0 B•
Brown, fine & medium grained sand
7.0 It
11.0 ft
Grayish brown fine & med. grained sand
0.0 ft.
0.0 ft
0.0 a
0,0 it
0.0 2
0.0 ft.
a ...,.
.0 f'
0 ft
�p p
ft
ft.
Nub is 7 20'y
21, REMARKS
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
136. Disinfection type: Amount:
8/14/2017
of = 'led Well :ntractor Date
By signing this form, I hereby Bert fy that the well(s) was (were) constructed in accordance
with ISA NCAC 02C .0100 or ISA NCAC 02C .0200 Well Construction Standards and that a
copy of this record has been provided to the well owner.
23. Site diagram or additional well de rap WR
You may use the back of tlgj td4 1tllttonnaf well site details or well
construction details. You m so attach additional pages if necessary.
SUBMITTAL Weas: INSTRUCTIONSp R 2°17
For
All Submit this loan 2thin 30 days of completion of well
construction to the following:
(�1l�lily Regional
Division of Water Res,a,Uplatrlbcessing Unit,
1617 Mail Service C ie& gB4if j lili�9hen
Wilmingt
24b. For Infection Wells: In addition to sending the form to the address in 24a
above, also submit one copy of this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mali Service Center, Raleigh, NC 27699-1636
24c. For Water Suuoly & Infection Wells: In addition to sending the fonn to
the address(es) above, also submit one copy of this form within 30 days of
completion of well construction to the county health department of the county
where constructed.
Form GW-1
North Carolina Department of Environmental Quality- Division of Water Resources
Revised 2-22-2016

03/21/2016 22:40 9103133102
.- nezvL-tcarrn Ut intro ICLCVIuo
This Ihrm can be used for sinpte nr multiple °ells
I. Wen Contractor In(drmation:
Ca/4 ri-a
0n5
Well Contractor nus
D_ 199
;cc Well Contractor Ccnifiention NmnI eF
A 8-1/4gA I st Li ii/Le LI R,An.,
Company Name
2. Well Co,struction Permit d:
laa, all apphepbk Nett perm* to a name, ,Allot 1'arrancr, harelnm
3, Well Cee (check well use):
IiJ
Water Supply Well:
CAgacultural
ooeothermal (heating Cooling Supply)
CIndustrial/C emmcresal
Irrigation
Non -Water Supply Well:
OMonitoring
GMunicipal/Pubhc
GResidenhal Water.Supply Ismgle)
1Rc&dOnual Water Supply (shared)
GRccuron
Injection Well:
OAtiur(i( Recharge
GAquifer Storage and Reco'cI)
CAquilcr Test
o 'perlmental Technalc,
c:`(ieothermal (Closed Loop)
❑Geothermal (Heating/Cooling Return)
l7(iroundwater Rcmudlatlon
C'1Salinity Flamer
❑Stnrmwater Drainage
OSubsidence Control
C:PI'racer
COther (explain under 02I Remarks)
4. Dale Was) Completed: .:', /_9 " \cell i»d
Ss. Well Location:
6•14CNv 11t.s.:1�veS
3`3s7Q
Fanhy O• Her Name Fbcilo ID. pl'appheaile I
/0 7 5'4 y 1-4 5;4' OA lc LS14A>1_ ,et/, t�
Physical address. (If. and 74!
L] rt>NJ us • C-K
l'ounp
AQUA WELL
For lntemal (9e ON y 4 5 1 7 3
PAGE 02
Parcel WcnIlCcanan No (PIN) •
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
Irf+ell field. one hn Inng i9 vnfficientl
3 3 rh ,$-9, vs,/ `N b-7 v n u t,. tl1 S \Y
6. Is (are) the well(s): Oermanent or OTempornq'
7. Is this a repair to an existing well: CI es or I20S'0
(l rhr.r rr n t pun. h// um !Filthy' ...•ll rnnxvncu°u to itrnwrmn and explain rite Horton! or the
repair under :21 romurkr nL i lti ar on OW hdRA H/'rlht' Gran
S. Number of wells constructed:
hbr hndrrplr VIM /urn nr nnn.n our, i.pph N.•//v V.v1 r N nit the some eanfnuer(n,r , m ,tow
a,hnul ore Fula.
9. Total well depth helou land surface: 3 3 (ft l
k:.r mutq,l. vat Irf'ill&Tilos tt dryeront (efamtle-foal/(! end-'"ri lrla'1
10. Static water lea el below top of colon;
L water luteha ahmvanima
I1. norehole diameter: \.O tin.)
12. Well construction method:
b e queer. rapist cabledirect pueh. etc 1
r
lP
rI I
FOR WATER SUPPLY WELLS ONLY:
13u. Yield (gpm)
13b. OiPinfectinn fype:
.Method of test:
Amount:
elm (spot'.(
II. WATER ZONE
TRDM
TO
ntNCRIPTIDN
b D•
2 a (a
5;4,r i
2,a h.
3 3 R•
C..oMP) .Ed..':
IS. OUTER CASING (far multi -coral went) OR LUNER11f a Sable)
FROM
TO
DIAMETER
THICKNESS MATERIAL.
* / ft.
'r ft.
1 In.
s c_l Y. o eJ e—
IE. INNER CASING OR TURING (geothermal claseddeap)
PROM
ID
DIAMETER
THICKNESS
!MATERIAL
ft.
ft,
in.
h.
h.
—
in.
17. SCREEN -
PROM
10
DIAMETER
SIMI SILL
THICKNESR
MATERIAL.
/5`ft.
39 ft
2\/y il.
O rlf
srd L/
f,J C-
R.
h.
in.
II. GROUT
FROM
TO
MATERIAL
,EMrLAC'EMENT MENTOR dt AMOUNT
O n.
/.. n.
Ndk AnNi
paCs:—
ft.
h.
ft.
FI
19. SAND/GRAVEL
PACK
(tfapylletbk)
FROM
TO
MATERIAL
EMPLACEMENT ME'THOI
ft.
n,
h-
R.
20. DRILLING
LOG (stmch
selditiaeal ahreb ITsemueyl
FROM
TV
oEM'NIPTION Isabr, has nem. minted* rppe.grno size. no
h.
ft.
q,�,,q,
M
fa.
\! w
R.
ft.
n.
ft..J...
G c ,• trT ... `,_.....
ft,
n.
MAY
2 v) 2016
21. REMARKS
,Icy„
22. Certification:
Data... .. .
N,t tgum/! II Hum. l F:n:ht tvritti that the telly I fa IN ere/ M11011 1d nl (1bah/ante'
k nit /5.4 NrAt' 0?1' 0/Fiat ,r (.SI .V'('d(' 02r 0200 ll.,ll ( nun Standards and 'hoot n
enp, atHut ?Abed hoot dea,.prn•xdrd w Mho . rll°miff
23. Ste diagram or additional well details:
You may use the hack of this page to provide add'uonal well site details or well
construction details You may also attach additional pages it necessary
SI'BYIITI'Al. INSTE CTIQ ? S
24a. for All Wells: Submit this formi,ippilliRA
tr aIcomNpl Lion of well
construction to the flintseep^
Division of Water kt$ourcer. Information ProwIting ( nil,
1617 Mall Service ('enter, Ralg(gh.al(47'49934417
2db. for !Meehan Was ONI.A In dddiioonniit..o sending the form to the address in
24it abuse, also submit a cops of this form within 3(1 dams n(p116ty)Ietlon of well
construction co the following Mj`)atef raic\aUap9 tt0h (Ce
Sal
Division of Water Resource,. Codergr�d f gleghhlruol Program,
1636 Nail Service ( enlelt,.gi 27699-1436
tee. Fur water Supply & Injection Wells:
Also submit one copy of this form %Whin 30 days of completion of
well construction 10 the count) health department or the count} where
connerur:('d
' orrh Carolina Depart n ii //t En urpnmeni and \ar oral Reruuxces .. pn,et0H of wan' Revuurcce an sized Auaw+ 21111

l-c c { y 33 3
u e auger, rmay. cable. .fired push. de)
WELL CONSTRUCTION RECORD
This loon can be used for n im k or multiple wills
1. Well Contractor Infontnrtionn: ,,/S
ve /:74-41) #1 , .S O si
Well Cant/actor Nome
t35vo,A
NC Will Contact v CcnifutiouNtmiber
e (re f/ - (-1
Company Name
2. Well Construction Permit it: VdV O 0 0 1 (fir
Listail applicablewelpermits lie. Counn•, rate, uriarse, Infection. etc.!
3. Well Ilse (check well use):
SVaterSltpplyV4elL-
°_Agricultural
°Geothermal (HcatingiCouling Supply)
°IndustrialCommercial
Aldtfieatio,
°Municipal:Public
°Residential Water Supply (single)
°Residential Wab7 Supply (shared)
Non -Water Supply WdI:
Monitoring °Recover•
Injection Well:
D Aquifer Recharge
°_aquifer Storage and Recovery
°Aquifer Test
°Experimental Technology
OGeothetmal (Closed Loop)
°Geothermal (Heating/Cooling Rearm)
°Groundwater Rctncdiation
°Salinity Bander
°Sto mw-aterDtainaee
°Subsidence Control
°Tracer
°Other (explain under fi21 Remarks)
4. IPate Welke) Completed: 762 0 -f QVL.1I ID#
5a We!! Location:
Facility/Owner Name
1t; ( SW s 44n. .
Physical Address, City, and Zip
1)7r(sr.;S'c l"e,%-
Facility IDR (if applicable)
&Ak isk S
County Parcel Identification No. ,PIN)
Six Latitude and Longitude in degrccsfminntcs/seconds or decimal degrees:
;if tech tidd one laulano is saticien0
33" N 7tg�C� 7.7StV
6. Is (are) the we0(s); t enmtnent or °Temporary
7. Is this a repair to an existing well: °Yes or
If this is a repair, fill out known well Construction information
repair under *21 remarks section or on the backo(thk form.
8. Number of Welk cotmuacted:
For multiple infection or non -water supply wells OAZI"with the same construction. you can
submit one firm.
d explain the name ofthe
9. Total well depth blow land surface:
6
For multiple wells list all depths if different (crumple- 3d200 • and 2:o10P1
` t r
f LL Staiw- lcr lwaterabove
level below top o!'rasitg; (L (R)
If water tort is above easing.
// c'/ ,.ry 1
•
11. Borehole diameter. in t I _ t On.)V V ` if n" 7
12_ Well construction method: .b i-) e Ail
(D)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (grim) Lt Method of ECM:
13h. Disinfection type: &Jeri �1 Aumunt:
P-- -7 in
Z
Fonn 0\V-1
North Corolla. IhRmmem of F Ivucmnent
Far Internal Licc ONLY:
44517
4
1d. WATER ZONES
FROM
TO
DESCRIPTION
fL
ft.
IS OUTER CASING (for
maM-rased was) ORLRqER bra .•..._ bit)
FROM
To
DIAMETER
THICKNESS
MATERIAL
,(- I fc
1f, ft
i yy in.
.Jci vt.7
S% obi
16. INNER
CASING OR TUBING
(geothermal dosed -loot*
FROM
TO
DLAMETER
THICKNESS
MATFar1l
ft,
ft.
is
R.
ft
in
17. s RYFN
FROOM
TO
DIAnteetee
SLOTSIZE
THCKNESS
MATER/AL
11 ft.
& % rt.
[ I in.
CA. Yo
,Ss`
ft.
R
in
_
it GROUT
FRom
To
MATERIAL
EMPLACEMENT METHOD & AMOUNT_
R
i>
lCD R
r1
V r'i...L C
Jie'3- p f>:,freJ
ft
ft.
t 0 0 1 L S
fr.
ft
j 19. SAND/GRAVEL
PACK
(if applicabk)
FROM
To
MATERIAL
EhIPLACEMENT METHo»
ft
ft.
ft
ft.
10.DRR.LLNG
LOG (ants
is additional shmtsif accessary)
FROM
TO
DESCRETtON (cake. hardecs soiaroch type, die.
',nib ctc 1
m
ft
ft.
ft
ft.
ft
ft.
\f1G
v ae,.f
APR gp
f t 2 0 2y
ft
21. REMAKES t` �n1e110f1 Cipa ",Clt
G :); of
n1AtC/Ft(, ere
22. Curt.______-.
Signature of Certified deli Contractor
Date
By signing thir form, 1 herby ccrnh that the !gills) ,tar (were) constricted in a.ccordons
with 134 ilCAC 02C .0100 or 15:1 AICAC 02C .0200 Well Commas/ion Standards and Mar a
cogs of this record has been provided to the well owner.
23. Site dtagrasn or additional will details:
You may use We back of this page to provide additional well site d<miis or well
consbuetiou details. You may also attach additional pages it necessary.
SUBMITTAL INSTUCTIONS
24a. For All Wells: Submit dtis1f tyq fyt13s fE completion of well
construction to dtc faflowineEtteivI i
Envision of Water Resources, Inibrneatio,tttf_p7_�.,,cecsing Unit,
1617 Mail Service Cen11[�et)- R �1R fit- Zttt99-1617
14Ix For Injection Wells ONLY: Is addition to sanding the tbrm to die address in
243 above, also submit a copy of this form within'.po l f completion of welt
construction to the following Uallt9 E
wice
Division of Water R <ources, UJanQ(1gg(ate t1Un5�"g„(tL,yCt` (Conte
Oval, 2v 9 -1636 f h tarn.
3636 Mail Sin -vice �11� evil, NC 17644-I Qi6
24c. For Water Supply Sr Injection Wells:
Also submit one copy of this foram within 30 days of completion of
well construction to the county health department of the county where
constructed.
Naiwal Rmurecs -thrown at Water Resources
Re dumat 2!)

WELL CONST OICTiON RECORD
This foam can be used iorcrrauitiplemak
I. Weil Cnnttuetorinfotmutinn:
a Iavaoat Oise QNLl_
4 45 1 7 4 3-4-6- —
Aire 'lee n1
Well CmtlradocNamc
�3s Yo /9
NC Welt Counacta Cetitication Nu
jet
companywame
L Well Construction Permit lb PL tfrn 20110 — 000 L Lj
Listaiapplicable well permits (Le. Corn}; State. Patience, Injection, etc.)
3. Weft Use (checkwel use):
Water Supply Well:
°_Agricultural
°Geothermal (Heating:Cooling Supply)
EllodustriaVCommacial
oMuniaipa):Public
°Residential Water Supply (single)
°Residential Water Supply (shared)
Non -Water Supple Well:
Monitoring
ORecova '
Injection Weil:
aaquifer Recharge
°Aquifer Storage and Recovery
❑aquifer Test
DEtpconentat Teclmology
DGeothamat (Closed Loop)
OGeothamal (Heating:Cooling Rama)
Dfsmndw•atcr Roocdiation
°Salinity Barrier
OStromwaterDrainagc
°Subsidence Control
°Tracer
DOtha (ccplain under 421 Remarks)
Ztaf6
4.Date Weft(s) Completed: 3
Sa. Well. Location:
Salo ac AtA i
FacdigyOa-arNamc
Yio Setters Srr
3301
{{ Facility IDk (rfap/ Roble)
!" 0F44/s/ne-c`
Pbye�ii Iwtl Address, City, and Zip
r ns i•-� I C GZ..
County
-
Parcelldentifi.:aion No. fill)
56. L.atimde and Longitude in degrees(minuteslseconds or decimal degrees:
«(well held, one Iaclong is still.iem)
"sv. 3s y[) N % V n3 3. Y462r5
6. Is (are) the well(s): xTirenreaemt or °Temporary
7. Is this a repair to an exiistitd well: Oyes or „nu
lfihir isa repair, fell out known well construction hg nnation and explain the name of the
repair under 421 remarks section or on the bock of this form..
8. Number of wells constructed:
Far multiple ige.sion or non -water supply welts ONL F with the same canmuaion, sroit can
smolt one fonn. `j
9- Total well depth below land surface: 02 f
For multiple wells list all depths ifdiffennt (example- 3200' and2.'�df00•)
10. Static water level below top of casing:
Ifwotcr level irabosv eating^
C..
II- Borehole dfatoete:
12. Well construction method:
(
t
pn) e to
rile
(it)
14. WATERZONES
FROM
TD
DESCRIPTION
a
ft.
a
ft
Is OUTER CASING (for
moYbnsedwels) ORL1NERN )
PROM TO
DLLIIPlER
THICKNESS MATERIAL
t i ft- tot a
('I 'ice-
.tined- vo sire/
I6.INNER CASING OR TIMING/geothenttal
ciaa4oup)
FROM TO
DL4MEIER THICENESS
PE.TFRLaL
a ft.
in
ftft.
in.
17. SCREEN
FROM
TO
DIAMETER
sLOT SITE
THICKNESS
MATERLSL
1 d It.
L 7 ft.
''i is
!
564,4 9d
ASS:•
a
ft.
in.
Bt. HPOTR
FROM
TO
MATERL4L
EMPLACEMENT METHOD & .4MODNT
O a
I0 ft.
Gew chp
-
Pot. re
a
a
ft.
ft.
it SAPIWGRAVEL
PACK
(if applicable
FROM
TO
MATERIAL
EMPLACEMENT METHOD
a
ft.
ft.
O.
20. DRILLING
LOG (atta
I, addidLl sheets if nennti rv)
FROM
TO
DESCRIPTION (odor. Pardee. 'entrain type main tat. etc)
0" a
2) a
SAF-4
tt
1
a
a
a
a
1VIc
fL
a
a
ft-
Mien 2 3 2016
rt. REMARKS
22. Cert tion
J l b Zl)[ 6
Simnttae orCertifed Well Contractor
Hy signing this form, I heathy cern.(i: that tha walks) was (very mnctroared in mordancy
with 15.4 ACAC 02C.0100 or I5A A'CIC 02C .0200 Well Construction Standards and that
ropy of this record has Ivan provided to the well owner.
23. Site diagram or additional well details:
You may use the back oft its page to provide additional welt site details or well
construction details. Yon may also attach additional pages if necessary.
SUBMITTAL INSFUCTIONS
(0L) 14a. For 48 Wells: Submit this fats within 30 days of completion of well
construction to the following: S
F��(ss[[�� I�fdk
liao esttbre Unit,
arcauger, rotary, cable, dimes posh eon.)
FOR WATER SUPPLY
(WFF I S ONLY:
13n. Yield (pm) I 0
Method of test:
13h. Disinfection tvpc: 6(erck-c- Amount: D 1J2,
Eons GW-)
Division of Water Resourc
1617 Mail Service Cent a3�"; I C 27699-1617
24b- For Iniecafon Wefts ONLY: In addition to saudng Viet to the address in
24a above.,also submit a copy of this farm wtitjs{�} 3(tk .s Lof completion of tell
construction to Usc following. .7U
jots
Division of Water Resources, Underground In!'S �o�rst �1 s-
ISr6 Mali Service Center, Rale�gfRZC'Y'Y40O({')C0
24c For Water Supply & injection Welts �p� 1�p0g1011 RC�'jp0a`
-Also submit one copy of this form within 30')da)s of completion of
well coasuwtim: to Use comity health department of ilia county where
consnttctcL
Noah Cvoliuu Department of Environment mud Natal of Wider Resources
Recited August 20)

WELL CONSTRUCTION RECORD (GW-1)
1. Well Contractor Information:
John Salmon RECEIVEDINCDEQ/D
JUL 5 2017
Well Contractor Name
3497-A
NC Wen Contractor Certification Number Water Quality egiona
Applied Resource Manageojentto l ection
Company Name
2. Well Construction Permit #: Could not located online
List all applicable well construction permits (:.e. WC, Camay, State, Variance, etc)
3. Well Use (check well use):
Water Supply Well:
Agricultural
Geothermal (Heating/Cooling Supply)
Industrial/Commercial
Irrigation
Non -Water Supply Well:
Monitoring
DMunicipal/Public
Residential Water Supply (single)
DResidential Water Supply (shared)
Recovery
Injection Well:
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
Experimental Technology
Geothermal (Closed Loop)
Groundwater Remediation
Salinity Barrier
oStormwater Drainage
Subsidence Control
DTmcer
Geothermal (Heating/Cooling Retum) nOther (explain under #2I Remarks)
4. Date Well(s) Completed: 06/27/17 Well ID# N/A
5a. Well Location:
Charles & Dana Reed N/A
Facility/Owner Name Facility ID# (if applicable)
808 Riverside Drive, Sunset Beach, NC 28468
Physical Address, City, and Zip
Brunswick
10540915267
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one latllong is sufficient)
See Attached N See Attached
W
6. Is(are) the well(s)JIx Permanent or OTemporary
7. Is this a repair to an existing well: fYes or x®No
If this is a repair, fill out known well construction information and explain the nature of the
repair under #21 remarks section or an the back of this form
8. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction, only 1 GW-I is needed. Indicate TOTAL NUMBER of wells
drilled: t
9. Total well depth below land surface: 2.50 (ft.)
For multiple wells list all depths if different (example- 3@200' and 2@100)
10. Static water level below top of casing: N/A (ft.)
If water level is above casing, use "+"
11. Borehole diameter: 6 (in.)
12. Well construction method: Mud Rotary
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) N/A Method of test: N/A
13b. Disinfection type: N/A Amount: N/A
For Internal Use Only:
R4: WATER ZONES
FROM TO
DESCRIPTION
ft.
ft.
ft.
15. OUTER CASING (for multi -eased wells) CPR LINER (if a Beagle)
)
FROM
TO
DIAMETER
MATERIA
L
L
0
250 ft.
1
in.
HDPE
161 INNER CASING OR TUBING. (geothermal closed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft.
ft
in.
ft.
in.
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
ft.
in.
ff.
in.
18. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
0
ft
250 ft-
Thermex
Pumped
ft.
19. SAND/GRAVEL PACK (if applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
fL
ft
f.
20 DRILLING LOG (attach additional sheets if necessary)
FROM
0 ft.
TO
10 ft.
DESCRIPTION (color, hardness, soil/rock type, grain sae, etc.)
Sand
10 ft
60 it,
60 ft.
65 R,
Clay sand
Shells sand
65 ft.
250 ft
Clay
ft.
ft.
ft.
ft.
8igbahue ofCert)fiedJWell Contractor
6/28/17
Date
igning this form, I hereby cell fy that the well(s) was (were) constructed in accordance
with ISA NCAC 02C .0100 or ISA NCAC 02C .0200 Well Construction Standards and that a
copy of this record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additioirigiAtiftpils or well
construction details. You may also attain :e..1)
SUBMITTAL INSTRUCTIONS t pp '-II
24a. For All Wells: Submit this form withAiL0 pa,}ta ox�l ftbinpletion of wen
construction to the following:
Division of Water Resources, IgRiq t�' p q itiliit,
1617 Mail Service Center, Ito f A 6>j@t pl
Rge 1pn I Office
24b. For Infection Wells: In addition t�j�iS�Q{� Ibr�i to fife address in 24a
above, also submit one copy of this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Slimily & Infection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
completion of well construction to the county health department of the county
where constructed.
Form GW-1
North Carolina Department ofE
onmental Quality - Division of Water Resources Revised 2-22-2016

ARM Project Number
Driller: John Salmon
Date Drilled: Loop No,
6/1/2017 1
6/2/2017 2
6/5/2017 3
6/6/2017 4
808 Riverside Dr
Sunset Beach, NC
Loop Depth
250
250
250
250
Whitney Blair Custom Homes
GPS
33 52 22.868
33 52 21.1512
33 52 23.949
33 52 22.9418
Coordinates
78 30 5.1134
78 30 5.593
78 30 7.6755
78 30 4.8737
Pagel
RECTAEpINCRENRICWR
3
U1- S c\``1
opeatlons 5ectiona\ e
Wilmington Regronal

Physical
Address, City, and Zip
17YvNS /tin/ c�
co,„ Pmrsildcrui{cwn Nc. fl'IN)
Sle Lndtude and Longitude in degmesind antes/seconds ar detfayal deggyeen
air welt n;'ehl onc' Ginn is sufficient)
o
33• SY SLdig/ N 7P 4 to • 3.3 a {�
6. Is (are) the well(s): ermmnem or °Temporary
7. Is this a repair to an existing well: Oyes or. Nett
if the is a repairfill oat known wolf construction infotmnnnn and explain the nature of the
repair under r1I remotkrsecrion or on the back ofthefarnt
S. Ntm,her of wells constructed:
For mnhipit injection or non-watersupply walk OATS with the same construction, 'nu can
salmit one fem.
WELL CONSTRUCTION RECORD
This fan canbeused for sitmele mtmdtiplevie1e
1. W antra -tar Information _
Ave se-9son/
Well Cwnaaor Name
35" go A
NC Well Comm a Citation
tion Nimib
Weil/ �L d
9. Total well depth below land surface: o 7 (R)
For multiple wells list all depths ifdrfereut (example. 3(4400' and71m100')
If water level n chore testing tam "> "7
fG
/ 11l -roe"(i") lL
10. Sortie water level below top of tossing:
11. Borehole diameter
12 Well construction method: ' r 11/e/./
ii a auger. ratan cable, ducat pub. etc.)
(R)
FOR W ATER SUPPLY WET IS ONLY:
I3a. Yield (gym)
3V Method of test I V_
136. Disinfection type, M!)41 _Amount: • Z .
Fenn GW-I
Company Name oAk i$//sf.'d-
2, We11 Cotnerucdon Permit #: GO/ 7 - 000 G.
List all applicabk well pennfs tie. Colmnt State. Parlance. hrtec9aq eiei
3. Well Use (check well use):
Water Supply Welk
❑Agricultiml
OCacottamal (Heating:Couline Supply)
O luddusttiallCommnaal
aQlnagad•
Non -Rater Supply Will:
°Monitoring
°Municipal -Public
°Residetial Water Supply (single)
ORcsideutial Bute Supply (shared)
Injection Well:
°Aquifer Recharge
❑aquifer Storage and Recovery
o Aquifer Tat
°Experimental Tcolmahon'
OGenrhamal (Closed Loop)
°Gcothamal (Heating/Cooling Return)
4_ Date Well(s) Completed: t - 6
era. ,VeB Location:
'lt7747 bOtrlacey
FacilitviowncrNamc
°Ra.o cry
°Groundwater R:mediation
°Salinity Barba
OStotmwaterthaioagc
°Subsitlatcc Control
°Tracer
°Other (ccplain under 421 Rauarks)
7{{m
Facility IDr (tfappli able)
C23° !erg (o0W'h sr0/9-h /J/.mod djflr
For Internal Use ONLY:
444.3
14. WATER ZONES
"
TO
"
DESCRIPTION
,SA-T, f./4A_, d
13OUTER CASING For atuk-escdstfcloRLDNERtuaa e/
FROM TO DIAMETER TE1CRNE1LATERL4L
+I " t9 "1 1 /Yia'I i yo eto(v,tree/
16,INNER CASING ORTVRIDiG(Reatbamal closed_mop) -
FROM R I TO It DIAbiLTFR fTiIICLTtE55 MATERIAL
17, SCREEN
1
tOM TO
it-
DIAMETER
SLOTHEE
TmcrciESk
4" a7
ft..
/As'
. °
5ch ye
..,,,....,.
Y7!
FROM
O R-
ft_
TO
/0te
rr.
AIaTFR1AL
I\GTERLIL
Se S�
EMPLACEMENT Amnion &AMOUNT
e141•rc inoj— Pot -re J
10. SAN71/GRAVEL HACK (if applicable)
FROM TO AtATFR1a
L E\IPLatE\IE\T METHOD
n.
20. DRILIINGLOG labiaeh additionalsLe is if ter -v)
FROM 1 OESCRIPTIO\ tedoe. hardness. sadhad:
p troy ^.jaieshe, nr_t
(3. ft
It.
IL
e.
it.
is
fc
TO
a7"
21. REMARKS
ft.
ft.
ft.
"
JUL 12 2017
w r�:,yyll(, i r: _
wer,rl1VtQg3 4a
By signing this form, l bendy cern& that the well() war liner;l ,;amvm-red m amen data
with 1Ad \CIC 02C .0100 or Ili NCAC 02C .0200 Well Construction Standards and shut a
cape of this record has been provided to the well enter.
23. Site diagram or additional well details:
You may use the back of this page to amide additional well site details or well
consbuctioa details. You may also attach additional pages if necessary.
SUBMITTAL INSTIICTIONS
24a, For All Wells: Submit this form within 30 days of completion of tail construction to Om following:
Division of Water Resources, Information Processing Unit,
I617 Mail Service Center RaIlt afiIOpy
617il "ELQ1246. For Injection t dBs 0 a t!on to sent/Ina the
forum to the address in
24aab tiou to tltcsubmitove, also olowin copy of this form within 30 days of completion of well
cons
Division of Water Resources, 'TJ 7 aground 2017
ti Injection Control Program,1636 hail Service Center, Rateiub, NC 276994636
24c. Far Water Supply 3lnjecWOtwfetiiality Regional
Also submit one copy of this forgDRi$tp;'if kfanomeetion ofwell constitution to die counWij69ingtaliagyptsa comity where eeanstuctui
Monti Cmntitw Depmmrnt of Environment and Nanaal Raorwca—Division of Water Resources
Bevis-logust 1013

WELL CONSTRUCTION RECORD
This 6nn can be used furshrele or multiple wen
1. W' tenor Intern="n,:/�p
/ Ave /2,eel s a A/1
R'dl CmmanorNamc
JL5 *O A
NC Well Conn a CertiticationNmn /
l ie Welt gay
Cotupay N:une on / 1.�%.Nd
2. Well Construction Permit #: .Y aQ / 7 — 00 on)
Lin all applicable trelperutis At. Coots; Stay rarianm, Infection eta)
.3. Well Use (check wen se):
Water Supply Well:
°Agricultural
o Gcot anal (Heating:Cooling Supply)
fDL ddustrialCommaciai
4unpotion
Nba.Water Supply Well:
o Monitoring
Injection Well:
o Aquifer Rccharyc
❑_igniter Storage and Recovery
OAqudaTst
OEtpaimental Technology
OGconhetmal (Closed Loop)
OGcothomal (Hcating:Caoiing Remm)
Fortmuml Use ONLY:
444998
14. WATER ZONES
FROM127
To
8 R 7
fc f h,
DESCRIPTION
JA-% rJ , wa-
IS. ODTER CASING normiscasedvdls)ORIEVEROfap hid
FROM TO DUMEIER TIDCKNESS )1A ,w
4-( rt j`l IL tk tn-Is4%to 'oa/iri:nee-
16.1NNER CASUSG OR ITIDDIGf ntires..,s cimsdtoepl
FROM TO DIAMETER THICETGFS3 MATERIAL
R. I R In
iG ft in I
17. SCREEN
O1unicipai=Public
ORc&but tial 8 atu' Supply (singly)
ORrsid,mtial Wata Supply (shored)
OReovcry
OCaonndwarcr Re ncdiation
°Salinity Darria
OSnamwaatcrDminagc
OSubsidatcc Control
OTraccr
OOtha (explain under 921 Ramada)
4. Date Wt41(s) Completed: O Of 9-/ Z411DN
ia. Well Location:
FaeilitylOwnaliane Facility ID# (leappli.=h1c)
go-7/04./s/91.d
PI s'on I tLh�s
ty t9 , City. and Zip c7 4
13YUNS W t c k
County
-
Parcel Identification No. iPtN)
ih Latitude and Longitude in derrees!m inredseeonds ordecinmi degrees:
(dwell field_ one Wong is sufficient)
j3°(SS2,, 734N 7S,'4'Sz-9fery
6. Is (are) the well(s): ytyermmment or °Temporary
7. Is this a repair to an existing well: OY es err
If tb this is a nepotr fill owe known wall commmkan ihiormwfon and lain the nation of the
repair ender ei_I remark section ar on the back of thisfont
8. Numberufweus constructed:
Far multipk injection ar non -water apply trelf AZT with the same cantrnafan• you can
submit one jam 1
9. Total well depth below land surface: 7 7
For multiple wells In all depths ifdrferent (example-3%200' ond':u't00'1
id Smtiewater level below cop of eying:
a /
If warn lens is ohms casing an "+"
in "
11.ILurehale diameter. G -,vp
12. Well construction method: c(] /e' j �A
h c. auger, tuna}, cable, duecr petit cn,)
(R)
FOR WATER SUPPLY WTI 1 S ONLY:
13a Yield (gpns) Jq0w Method of test: ,to
136. Disinfection type: '
Amono t•
Faun OW-1
IEM1@LOGE\(Est 11iHOD
SR DRILLNr G LOG (alto h additional sheets ifneceaarv)
FROM TO 1 IIESCRIFfION rector l an to a sa= Ooet mac Value. nch
p ft.
fig
fe
ft
fig
rt
ft.
27 fig
21. RFar• ore
22- Cerdf
ft.
ft.
ft.
fig
ft.
JUL 1 2 2O17
itTirst-t-li-vri f.Yrt�
DIN Q/Jl?s
ECEIVED/NCDENR/DWR
Siananay offer hied Well
TROM /9nia7i�� �YoITHICIGIESS \IATERIAL
�s.
i Ne.rh I
12. GROUT
1LATERIAL EMPLwcEMEM1T 11E1ffOD &AMOU T
e,,ter. ehgos— H)woea
19. SAND/GR.IV EL PACE. inapplicable)
TO
rn01r To
0 rt U h-
it. ft.
rt ft.
fR01t
a
fig
it.
MATERIAL _
JUL 1 7 2017 Date
T' signing this fann. 1 hereby cent char she weni&l was Inc.-.,) constructed in a, -co dan:
with lit KC.4CO2 Dl00 or lit NCIC 02C -0200 Well Construction Standards anti dun a
copy ofthir record hos been prorWcd,o cell
t -Quanta Regional
23. She diagram ar additional rQnfitaI1011S Section
Von may use tits back of this pgifroipiatialeq,,,,,r��
construction details. You may also attach additional4pars '�i� dy..vls or wen
pats if necessary.
SUBMITTAL, INSFUCTIONS
24a. For Ali Welk: Submit this loon within 30 days of completion of well
construction to the following:
Division of Water Resources, Infon ation Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699_1617
24b. For IOleetion Wells ONLY: In addition to scoffing We ramp to the address in
24a above, also submit a copy of this form nithia 30 days of completion of well
constitution to dry following
Division of Water Resources, Undergrntmd Injection Control Program,
1636 Man Semite Center, Raleigh, NC 27699-1636
24c. For Water Supply & Injection Wells-.
Also submit one copy of this form within 30 days of completion of
wtbl construction to the county health department of the county %s tern
consbuctcrl
iTIOUi41
7-3-/ 7
Montt Cam6nc Dcpmmml of Pn uamnent anti Normal Rcsncc -Division of Water R you ca
Revised Atmmn'_J13

WELL CONSTRUCTION RECORD (GW-1)
rint Form'
For Internal Use Only:
1. Well Contractor Information:
John Salmon
Well Contractor Name
3497-A
RECEIVEDINCDEQIDWR
JUN 2 6 2017
NC Well Connector Certification Number Water Quality Regional
ote
Applied Resource Maagemen,P.C.
Company Name
2. Well Construction Permit#: Not posted on Line
Lis/ all applicable well construction permits (te. UIC Colony, State, Variance, etc.)
3. Well Use (check well use):
Water Supply Well:
Agricultural
Geothermal (Heating/Cooling Supply)
IndustrialCommercial
Irrigation
Non -Water Supply Well:
Monitoring.
fMunicipal/Public
Residential Water Supply (single)
QResidential Water Supply (shared)
Recovery
Injection Well:
Aquifer Recharge
Aquifer Storage and Recovery
(Aquifer Test
Experimental Technology
Geothermal (Closed Loop)
Geothermal (Heating/Cooling Retum)
4. Date Weli(s) Completed: 6/15/17
5a. Well Location:
Ethan Mesmer
Groundwater Remediation
Salinity Barrier
fStomswater Drainage
Subsidence Control
fTracer
(Other (explain under #21 Remarks)
Well m# N/A
N/A
Facility/Owner Name Facility ID# (if applicable)
3696 Wingfoot Drive, Southport, NC 28461
Physical Address, City, and Zip
Brunswick 219FB026
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one 1st/long is sufficient)
See Attached N See Attached
6. Is(are) the well(s)0x Permanent or DITemporary
7. Is this a repair to an existing well: DYes or x®No
If this is a repair, fill out known well construction information and explain the nature of the
repair under 321 remarks section or an the back of this form.
8. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction, only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled:5
9. Total well depth below land surface: 300
For muliple wells list all depths if different (example- 3200' and2@100')
(ft.)
10. Static water level below top of casing: N/A (ft)
If water level is above casing, use "+'
11. Borehole diameter: 6 (in.)
12. Well construction method: M ud Rotary
(Le. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) N/A Method of test: N/A
13b. Disinfection type: N/A Amount: N/A
14. WATER ZONES.
FROM
TO
DESCRDTION
ft.
ft
ft
f.
15 OUTER CASING (for wens)OR LINER (if ap flexible)
FROM
TO
DIAMETER
THICKNESS MATERIAL
0 ft*
+/-300ft
1 in.
�HDPE
16. INNER
CASING OR TUBING (geothermal dosed -loop) '<
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft.
ft
in.
ft.
ft.
in.
17L5CREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
tt
R
in.
ft.
ft
is
IS: GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
0 ft'
300 ft•
Thermex
Pumped
ft.
fe.
ft
ft.
19.:SAND/GRAVEL
PACK
(if applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
ft.
ft.
ft.
ft.
20.DRILL ING
LOG (attach
additional sheets ifneeessary) ,
FROM
TO
DESCRIPTION (rotor, hardness, soil/rock type, grain sae, etc)
0 ft•
10 ft
Topsoil and sand
10 ft•
70 ft
Sandy clay shells
70 ft
150 ft
VVhite limestone
150 ft•
280 ft
Limestone sands clay
280 ft
300 ft
Layered limestone sandy clay
ft
ft.
ft
0.
21, REMARKS
06/16/17
Date
y signing this form, I hereby cart& that the wells) was (were) constructed in accordance
with 15A NCAC 02C .0100 or 15A NCAC 02C .0200 Well Construction Standards and that a
copy of this record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTRUCTIONS
24a. For All Wells: Submit this
construction to the following:
COVEDYNCIENFIMIr of well
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Riljkh, r0227trt,617
24b. For Iniection Wells: In addition to sending the form to the address in 24a
above, also submit one copy of this fowfp7 within 30 days of completion of well
construction to the following: vvafer Quality Regional
Operations Section
Division of Water Resources, Ullditii618 tlAnNgi micinifjtjtEgrogram,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supply & Iniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
completion of well construction to the county health department of the county
where constructed.
Form OW -I North Carolina Department of Environmental Quality - Division of Water Resources
Revised 2-22-2016

WELL CONSTRUCTION RECORD (GW-11
RECEIVED/NCDEQIDWR
1. Well Contractor Information:
For Internal Use Only:
John Salmon
Well Contractor Name
3497=A Water Quality Regional
NC Well Contractor Certification Number Operations Section
Applied Resource Management, P.C.
Company Name
JUN 2 6 2017
2. Well Construction Permit#:Not posted on Line
List all applicable well construction permits (i.e. UIC, County, Slate, Variance, etc)
3. Well Use (check well use):
Water Supply Well:
Agricultural
Geothennal (Heating/Cooling Supply)
Industrial/Commercial
(Irrigation
fMunicipal/Public
DResidential Water Supply (single)
Residential Water Supply (shared)
Non -Water Supply Well:
Monitoring
Injection Well:
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
Experimental Technology
t�IGeothermal (Closed Loop)
Geothermal (Heating/Cooling Retum)
4. Date Well(s) Completed: 6/15/17
5a. Well Location:
Ethan Mesmer
DRecovery
Groundwater Remediation
Salinity Bather
f,Stormwater Drainage
Subsidence Control
Tracer
Other (explain under #21 Remarks)
Well ID# N/A
N/A
Facility/Owner Name Facility ID# (if applicable)
3696 Wingfoot Drive, Southport, NC 28461
Physical Address, City, and Zip
Brunswick 219FB026
County Parcel ldentificalion No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
See Attached N See Attached
w
6. Is(are) the weil(s)JxPermannt or r (Temporary
7. Is this a repair to an existing well: DYes or xONo
If this is a repair, fill out known well construction information and explain the nature of the
repair under 4121 remarks section or an the back of this fann.
8. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction, only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled:3
9. Total well depth below land surface: 300
For multiple wells list all depths if different (example- 3@200' and 2@100')
10. Static water level below top of casing: N/A (ft.)
If water level is above casing, use "+"
11. Borehole diameter: 6
(in.)
12. Well construction method: Mud Rotary
(ft.)
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) N/A Method of test: N/A
13b. Disinfection type: N/A Amount: N/A
19�WATER ZANES
,
FROM
TO
DESCRIPTION
R.
ft
ft
ft
IS. OUTER
CASING(for
m11l6cased wells)OR LINER (if ap Stable)
FROM
TO
DIAMETER
THICKNESS MATERIAL
0 ft
+/-300ft
1 in
I-tDPE
16..INNER
CASING OR TUBING
(geothermal closed -loop) -
FROM
TO
DIAMETER
THICKNESS
MATERIAL
R.
ft
in.
R.
ft.
in.
17'.SCREEN
—
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
ft.
ft.
in.
R.
ft
in.
1$;,GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT'.
0 ft'
300 R•
Thermex
Pumped
Tt
ft
ft
R.
19.SAND/GRAVEL
PACK
(if applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
ft
ft
ft.
R
20 DRB.LFNGEOG
(aaanh
adilidoml sheeb H'neeessary)
FROM
TO
DESCRIPTION (color, bantaess, soiOrock type, grain size, etc)
0 ft•
10 R•
Topsoil and sand
10 ft
70 ft
Sandy clay shells
70 ft
150 ft
White limestone
150 ft
280 ft
Limestone sands clay
280 ft
300 ft
Layered limestone sandy clay
ft
ft.
R
R
21 REMARKS
27a. Certification:
06/16/17
ature of Certified We) hiinscfor Date
signing this form, 1 hereby cent!), that the well(s) was (were) constructed in accordance
with 15A NCAC 02C .0100 or I5A NCAC 02C .0200 Well Construction Standards and that a
copy of this record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTRUCTIONS
24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center,tHelniehaAr6 j7¢A$d(11.7/®WR
24b. For Infection Wells: In addition tosendingthe1�formmUto thehladdress in 24a
above, also submit one copy of this form within 30 days of completion of well
construction to the following:
JUL 1 2 2017
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
Water Quality Regional
24c. For Water Supply & Infection Wells: Qpamytq is tt i •.r the form to
the address(es) above, also submit oneWiimircitetisFfenni 6., ...t days of
completion of well construction to the county health dep`$ tment o i ee county
milere constructed.
Form GW-1
North Carolina Department of Environmental Quality - Division of Water Resources
Revised 2-22-2016

ARM Project Number: 3969 Wingfoot Drive Fulford Heating & Air Pagel
Southport, NC
Driller: John Salmon
Date Drilled: Loop No. Loop Depth GPS Coordinates
5/25/2017 1 300 33 56 45 5339 78 7 32 2425
5/30/2017 2 300 33 56 45 2908 78 7 32 7108
5/31 /2017 3 300 33 56 45 8642 78 7 32 8472
RECEIVED/NCDENR/DWR
JUL 12 2017
Water Quality Regional
OperatWilmington �RegionalOffice

Fminte nal Ilse ONLY:
443225
WELL CONSTRUCTION RECORD
This loon cantle used farsingk ar multiplewelt
1. Well star Infer/oration:
A-vae
Well Contractor Name
J$'yo A
rr/2/SoN
NC R`7_4„ ofi' atianNmn, •
6v
e{lrJ�`/�AS/�O� s
Company Nmne
TpwA.- P�v,» 201 i-DOC21 S
2. Well CotlsWedon Permit p:
List all applicnb/ewellpermiu tic. Coun0: Stare. Variance, 1njection, eta)
3. Well Use (check well use):
Water Supply Well:
°Agricultural
°Geothermal (Heating Cooling Supply)
Olndustrial!Cammercial
�_^_atttvr
OMuaicipalTublic
°Residential Water Supply (single)
OResiadattial Water Supply (shared)
N n-water Supply Well:
°Monitoring DReeoven'
Injection Well:
°Aquifer Recharge
❑Aquifer Storage and Recovery -
❑Aquifer Test
°Experimental Technology
OGeothamal (Closed Loop)
OGcothamal (Heatingtooling Return)
°Groundwater Ranediation
°Salinity Barrier
OStmmwater Drainage
DSubsidarce Control
°Tracer
°Other (explain under 1121 Rauarks)
4. Date Well Completed: ] OI - / 7\VdD U)I8
Sal Nell Location:
an-WS
FacilityfOwnerNaau
Physical Address, Cm-, and Zip
ijrevvJ (-tit eh
/4Ans
Z Z o, E . y6e%r era 044 ls/
as Vt tr
Cmmty
Parcel Identification No. /PIN)
Sh Latitude and Longlt tde in de„grecsfndnineslseconds or decimal degrees:
(dwell field, one laulan; is sufficient)
33'SS:? 7, /77G
7t 8 1/ , 122 y
6. Is (are) the well(s): *ern anent or DTempormy
7. Is this a repair to an existing well: °Yes or Ado
If this is a repair, fill autknown well construction information and explain the nation of the
repair under 021remarks section or on the back afthisf c
S. Number of welts consrcucted:
For muhiple injection or non -water supply wells ONLI with the sante cat mnalon, you can
submit one form.
75
For multiple wells list all depths i(d •red (example- 3�C00' and?@100')
9. Total well depth below land surface:
Facility 'DP itiappli able)
ID. Static water level below top of casing:
!prates faunal is above casing, tire
11. Borehole diameter: & (in.)
12. Well construction method: /%7:/CI 2Ors* r- F
ii c. auger, roll'. cable, attract push etc.) /
/0
4 Yo I IOvt
16. INNER CASING OR TUBING (geothermal clmed4nap)
➢L1MErER TIRC{ONESS
IL in
in
FROM
ft.
TO
a
ft.
MATERIAL
17. SfRFFN
FROM I TO mAMnER iTY sum. sax
rallEss
ft
1R GROUT
NEATLTDAL
FROM TO
O fL Zo
/L
fL
fL
ft.
MLATERIAL
E3Pev"T
LACEME,T MET HOD & AMIo T
C%p3 Pasred
19. SAND/GRAVEL PACK (R appicabi )
FROM TO
14. WATER ZONES
PROM
/o
YAWL
TO
2rtt-
Its
➢TSCRD'TION
S1 d
Li brie s ruts te.
It OUTER CASING (for mold.med webs) ORLR�R Sf�PQ1t�a Mel
FROM TO ➢LAMJErER TIRCXNESS I 1LATERIAL
fc
MATERIAL EMpLAcLIIR,T METHOD
2D DRILLING LOG (attach additional sheers Hneceaary)
TO
FROM
e
3S
yatL
ft.
G ft_
tf1^' ft.
ft.
2J tL
3s ft
Y-2
%St
ft
ft.
DESCRIPTION (odor Mssdaea;seittraek wise.
.S "9"-,
fAeV/ f e/r9 y
/-/entle
52-D"raLY
f D
21. REMARKS
ft.
APR 9.7 2017
i0;7,C (ili1E U/lCD (_ ti k/C
t, rngatinn Frocf'*S llg Unfl
DWQlBCP7AI ' I r'
WQROS
3i�-dn�at�? r-1cr
vtitie3lVell Contractor Dam
Br- signing this fan.,; I hereby certify that the well(s)ices (here) comrrmnad in accordance
with 114 MAC 02C .0100 or 11-11 CAC 02C.O2001iftt Construction SraMads and that a
cops of this record has been provided to the well corner.
21 Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
conshuotio n details. You may also attach additional pages if accessary.
SUBMITTAL INSTUCTIONS
(ft.) 242. For All Wells- Submit this loon within 30 days of completion o
coumtction to the following:
Dhdsion of Water Resources, Intorntatlon processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
246. For Iniection Wells ONL%D 4� (
�o}}e`iR Y'e/� b"J �S�LiO to the adduces in
construction to the following;
��'U^'r"
WR
(01)
FOR WATER SUPPLY \VBI.1 S ONLY:
13a. Yield (gpnt) / S 1- Method oftest: 4 / r L / v42T
136. Disinfection type: /411/4 G 1 _;mount. / a v irr
Fonn O1V-1
wall
24a above, also submit a copy is tam v 3 days of completion of well
Division of Water Resources, UndHrgt onildpr ari Control Program,
1636 Mali Service Cente``rr,i(Ral`i ei j 2 6y99-1636
24e. For Nicer Supply & Injection Wells. f�
Also submit one copy of this form ln�5 p� S
will construction to the comity beak Yn K2
constructed Wilmington Regional t
Nat, Carolina Depannant of Environment and Ramat Resources -Division of Water Resources
Revised August Nil)

WELL CONSTRUCTION RECORD (GW-1)
1. Well Contractor Information:
For Internal Use Only:
444770
For multiple wells list all depths if different (example- 3@200' and 2@100')
John Salmon
Well Contractor Name
3497-A
NC Well Contractor Certification Number
Applied Resource Management, P.C.
Company Name
2. Well Construction Permit if: Could not located online
List all applicable well construction permits (i.e. UIC, County, State, Variance, etc)
3. Well Use (check well use):
Water Supply Well:
Agricultural
Geothermal (Heating/Cooling Supply)
IndustrialCommercial
Irrigation
['Municipal/Public
°Residential Water Supply (single)
°Residential Water Supply (shared)
Non -Water Supply Well:
Monitoring
Injection Well:
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
Experimental Technology
x Geothermal (Closed Loop)
Geothermal (Heating/Cooling Return)
4. Date Wen(s) Completed: 06/27/1
°Recovery
°Groundwater Remediation
°Salinity Barrier
°Stormwater Drainage
()Subsidence Control
°Tracer
°Other. (explain under #21 Remarks)
7 wenw#N/A
5a. Well Location:
Charles & Dana Reed N/A
Facility/Owner Name Facility 1D# (if applicable)
808 Riverside Drive, Sunset Beach, NC 28468
Physical Address, City, and Zip
Brunswick
10540915267
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
See Attached N See Attached
6. Is(are) the well(s)1xPermanent or °Temporary
7. Is this a repair to an existing well: °Yes or x°No
If this is a repair, fdl art known well construction information and explain the nature of the
repair under 321 remarks section or an the back of this form
8. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction, only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled: 1
14 WATER ZONES
FROM
TO
DESCRIPTION
ft.
ft.
ft.
ft.
15. OUTER
CASING (for
multi -eased wells) OR LINER (ifa Doable)
FROM
TO
DIAMETER
THICKNESS MATERIAL
0 fr•
250 ft1
in.
�HDPE
16. INNER
CASING OR TUBING
(geothermal closed -loop):
FROM
TO
DIAMETER
THICKNESS
MATERIAL
fr.
ft
in.
ft.
ft.
in.
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
ft.
ft.
in.
ft.
ft.
in.
18 GROUT
FROM
TO
MATERIAL
_ EMPLACEMENT METHOD & AMOUNT
0 fL
250 ft
Thermex
Pumped
ft.
ft.
ft.
ft.
19. SAND/GRAVEL
PACK
(ifapplicable) ;
FROM
TO
MATERIAL
EMPLACEMENT METHOD
fL
t4
ft.
ft.
20. DRILLING
LOG (attach
additional sheets if necessary)
FROM
TO
DESCRIPTION (color, hardness, soilfrock type, pain she, etc.)
0 ft'
10 ft.
Sand
10 ft.
60 ft.
Clay sand
so ft•
65 ft'
Shells sand
65 ft
250 ft•
Clay
ft.
ft.
A p
REChi 1%
EC 8v'E
ft.
ft.
ft.
ft.
JUL 0.3 2017
-.21. REMARKS
aefrYBbetii
rSJ+.VSnkKj ...A Hi'
DWQ/tisOG
22. Certification:
9. Total well depth below land surface: 250 (ft.)
10. Static water level below top of casing: N/A (ft.)
If water level is above casing use
11. Borehole diameter: 6 (in.)
12. Well construction method: Mud Rotary
(i.e, auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) N/A Method of test: N/A
13b. Disinfection type: N/A Amount: N/A
Si: ature of C ell Contractor Date
• . igning this form, I hereby certify that the wells) was (were) constructed in accordance
with 15A NCAC 02C .0100 or ISA NCAC 02C .0200 Well Construction Standards and that a
copy of this record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if'necessary.
SUBMITTAL INSTRUCTIONS
24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following: gggg++FFlIuu ��((®®fi�nl�
Division of Water ResoFE3;ihY ��t7rFEs°4rUnit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Infection Wells: In addition td thditeltenrinjto the address in 24a
above, also submit one copy of this form within 3D o f completion of well
construction to the following: Cvvd,I
Division of Water Resources, Uen�dh
1636 Mail Service Civil
ona
24c. for Water Supply & Iniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
completion of well construction to the county health department of the county
where constructed.
6/28/17
lac9g' i rot Program,
(0 }lite6
Form GW-1
North Carolina Department of Environmental Quality- Division of Water Resources Revised 2-22-2016

ARM Project Number:
Driller: John Salmon
Date Drilled: Loop No.
6/1/2017 1
6/2/2017 2
6/5/2017 3
6/6/2017 4
808 Riverside Dr Whitney Blair Custom Homes Pagel
Sunset Beach, NC
Loop Depth
250
250
250
250
GPS
33 52 22.868
33 52 21.1512
33 52 23.949
33 52 22.9418
Coordinates
78 30 5.1134
78 30 5.593
78 30 7.6755
78 30 4.8737
a
RECEIVED/NCDENR/DWR
JUL 10 2017
Water Quality Regional
Operations Section
Wilmington Regional Office

WELL CONSTRUCTION RECORD (GW-11
1. Well Contractor Information:
Sanford Sweeting
Well Contractor Name
2082-A
NC Well Contractor Certification Number
Applied Resource Management, P.C.
Company Name
2. Well Construction Permit #:
List all applicable well construction permits Be. LUC, County, Stale, 4arimicc, etc.)
3. Well Use (check well use):
N/A
Water Supply Well:
Agricultural
Geothermal (Heating/Cooling Supply)
Industrial/Commercial
X Irrigation
DMunicipauPublic
®Residential Water Supply (single)
Residential Water Supply (shared)
Non -Water Supply Well:
Monitoring
Injection Well:
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
Experimental Technology
(Recovery
Groundwater Remedietion
(Salinity Barrier
DStonnwater Drainage
Subsidence Control
Geothermal (Closed Loop) f Tracer
Geothennal(Heating/Cooling Return) ',Other (explain under#21 Remarks)
4. Date Well(s) Completed: 06/21/17 Well mil N/A
5a. Well Location:
Cades Cove Homeowners Association, Inc.
N/A
Facility/Owner Name Facility ID# (if applicable)
801 Cades Trail, Southport, NC
Physical Address, City, and Zip
Brunswick
237CD00103
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one IatAong is sufficient)
33 55 5733 N 77 151 7301
w
6. Is(are) the well(s) j Permanent or Temporary
7. Is this a repair to an existing well: DYes or ®it No
If this is a repair, fill out known well construction information and explain the name of the
repair under #21 remarks section or on the back of this form.
8. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction, only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled: 1
9. Total well depth below land surface: 198
For multiple wells list all depths ifdi different (example- 3@200' and 2@I00)
(ft)
10. Static water level below top of casing: 40 (ft.)
If water level is above casing, use "+"
11. Borehole diameter: 7 7/8 (in.)
12. Well construction method: Mud Rotary
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) 30 Method of test: Airlift
13b. Disinfection type: HTH Amount: 3%@10g
1 ,n,tl VlrlI.
For Internal Use Only:
444769
14. WATER ZONES
FROM
TO
DESCRIPTION
ft.
R.
It
ft.
15. OUTER CASING (for
multi -cased wells) OR LINER (if a linable)
FROM
TO
DIAMETER
THICKNESS MATERIAL
0 it.
178 ft
4 in-
SCH40 PVC
16..INNER
CASING OR TURING
(geothermal dosed loop): `.
FROM
TO
DIAMETER
THICKNESS
MATERIAL
fL
R.
in.
ft.
ft.
in.
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
178 R•
198 R•
4 'nL
.020
SCH40
PVC
$
ft.
in.
18. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
0 ft
35 ft
Grout
Poured
155 ft
175 ft
Bentonite
Poured
H.
ft.
19.SAND/GRAVEL
PACK
(if applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
175 ft
198 ft
Coarse
Poured
ft
ft.
20.DRILLING
LOG (atta
haddifional sheets ifneeessary)
FROM
TO
DESCRIPTION (color, hardnen, soh/rock tepe, grain size, etc.)
0 ft*
10 ft•
Black sandy silt
10 ft
25 ft
Sand with shell and some clay
25 ft•
50 ft•
Clay with sand
50 ft•
65 ft•
Limestone
65 ft.
95 ft.
Clay with limestone layers
95 ft•
110 ft
Limestone
110 it
175 ft
Clay with limestone layers
IliREMARKS _
175 -198 - Sandstone
198 - Sticky clay with fine sands
22. Ce
'cation:
06/21/17
Signe of e. ; -ed We I Contractor Date
By signing this form, I hereby certify that the well(s) was (were) constructed in accordance
with ISA NCAC 01C .0I00 or ISA NCAC 02C .0200 Well Construction Standards and that a
copy of this record has been provided to the well o,9 r
23. Site diagram or additional well details:
You may use the back of this page to provide ailehtiong site details or well
construction details. You may also attach addit a saT'n�gry.
SUBMITTAL INSTRUCTIONS Information Processing UM
24a. For All Wells: Submit this form within S649%LB6Pcompletion of well
construction to the following: RECEIVED/NCDENR/DWR
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, JRale7ii Raleigh,
NC((��27699-1617
217
24b. For Iniection Wells: In addition to sndmg the onn to the address in 24a
above, also submit one copy of this form within 30 days of completion of well
construction to the following: Water Quality Regional
Division of Water Resources,*y p ntQ ttt11Iy000,}ryy,�'(ntrol Program,
1636 Mail Service t"l (�i',�7899=f11i36
24c. For Water Sunnis & Iniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
completion of well construction to the county health department of the county
where constructed.
0
EIVED
Form GW-1
North Carolina Department of Environmental Quality - Division of Water Resources Revised 2-22-2016

WELL CONSTRUCTION RECORD
This loon Gan be mcd forshile ormultiple wells
1. ' I ContractorinfontThile .�
�e
Nell CouhactorNamc
NC Well (Aim rtCtorC Ceri onN7�
Company Name
2. Well Construction Penult #:
List all applicable well permits (Le. County. State. Variance. Injection. etc.)
3. Wei Use (theck well use):
Water Supply Well:
OAgricultu al
°Geothermal (Reathtg(Cuoline Supply)
DlndustrialiCommereial
auatiwh
OManicipal/Public
°Reidentiat Water Supply (single)
°Residential Watm' Supply (shared)
Noll -Water Supply Well:
°Monitoring °Recovery
Infection Well:
°Aquifer Recharge
°Aquifer Storage and Recovery
❑Aquiferr Test
°Experime tal Technology
°Geothermal (Closed Loop)
OGcoWnmal (Hafting/Cooling Return)
°Groundwater Ranediation
°Salinity Barrier
OStormwatcrDtnnlagc
°Subsidence Control
°Tracer
°Other (explain under 021 Remarks).
4. Date Well(s) Completed: y' W s} i IO#
Sa ('ell Location:
Facility/Oa Nance Facility ID# fitapptiablc)
D?Ya 6eoryeJZ' ,4ytiwa�%
Physical Address, City, and Zip hi/ Yes cool,
art." w/e�e atPy79
County ParcelldantificaonnNo. (PIN*)
56. Latitude and Longitude in degrces/minntes/seconds ar decimal degrees:
wctt lieid, one tat/torn is sufficient) e
3Ya7 & a� 7(s zg-.i8.3z W
6. Is (awe) the wells) ntmt snt or OTemporuy
7. Is this a repair to an existing well: Oyes ur
If this is a repair, fill out known wellcensnwtion information and explain the galore of the
repair under H2l'remarks section tar an the back oj'Ihufame
8. Number anvils constructed: /
For multiple injection ar non -water supply wells ONLF with the same cmzsoauYon, vau can
submit one form.
9. Total wdi depth below land surface:
70
For multiple wells Test all depths ifd3 ,rent (example- S@200' and2nl0O')
/V
10. Static water level below top of using: /
If water level is afire casing, use "+"
11. Borehole diameter v (in.) ^
12. Well //e
construction method: (/ Gy- / `o in
fr. e. auger, rotary, cable, dnect ptnn, ere)
rj
(1L)
FOR -WATER SUPPLY NWT 1 S ONLY: ail q�
13a. Field (gpns) 7 � Method sliest: A f ✓ Lr `C'1
I36. Disinfection type: 6k ti Amount: / Q V is ►di'
Fonts G)V-t
North Cuubna Da
For TeuamlLTsc ONLY:
443224
14. WATER ZONES
FROM
/
2SR
ro
/o ft-
70
ft-
DESCRIPTION
SAth✓ta
(.../ m e r -711 e-e
IE OUTER CASING (formolScnsed wells)ORLINERCdapbkl
Moil TO DIAMETER THICKNESS5 JI MIATF.RLIL
/�
it. f./ 0 frL tn. � tic 1" V C
16 INNER CASING OR TUBING (genthe :Dal dosed -loop)
FROM DIAMETER 1 TWClelseSS
TO
R
n
ATATERLIL
a
ft.
in.
I7. SCREEN
FROM
It.
ft
1S. GROUT
TO
0?
DIAMETER t' urrevE 1 THICILSESS j.IL4TERIAL
eAt
FROM
0n
ft.
TO
aam
MATERIAL
OeNT
EMPLACEMENT METHOD St AMOUNT
/i°J— Po-.rre 1
n
19. SAND/GRAVEL PACT. Mappliable)
To
FROM
MATERIAL
ETIPLACLMlfSrT METHOD
ft.
20. DRILLING LOG (att-a It additional sheets if necessary)
DESCRIPTION teakr, hardness. salOmck Dye snits she eel
FROM
0 at
TO
/0 et -
/0 11-
a.1 fL
IL
ft.
ad' a
21. REALARICS
70 ft.
tL
tr.
fc
ft.
silly c%y t.V/sot//r
"Pyle s77.7s-te
APR? 7 2017
b,. (a IVEDINCDI
l‘)b11
Information Precessing Unit
DWQ/E3CG
WURO:
NNR/DWR
iDi ORES L. RLG1'MAL OFFICE
)
Sierann'e of Certified Nell Contractor DY /
Date
Sr signing this form, 1 hereby certifr Mat the walks) was prerei conrnlcred in accordance
with 15.4 AVAC 02C .0100 or ISA NCAC 02C .02001Fe11 Construction Standards and drat a
copy of this record iws been provided to the well owner.
23. Site diagram ar additional well details:
You may use the back of this page to provide additional well site details or well
coashudtion details. You may also attach additional pagrs ifnecssmy.
SUBMITTAL INSTUCTIONS
242. For All Wells: Submit this loon within 30 days of completion of well
construction to the following:
Division of Water Resources, Information Processing Unit,
1617 Mali Service Center, qRa�leigh, NC 27699_1617
246. For Infection Welk ONLY: In adtRECEIV OO 't /9wpsddrtss in
24a above, also submit a copy of this tors Within 30 days of camp d.on of well
conshuction to the following: II 1l
Division of Water Resources, Undergrotgttb,s@jes4i14 Nip! Rvgram,
1636 Man Smite Center, Raleigly NC 27699-`163
24e. For Water Supply & Injection Welis:wata
Also submit one copy of this form wither � Q4a1jt
well emlstrngttnn to the Comity health duet constructed �l�l
not ofEnvira intent and Natural Rsmnces -Division of Water Resources
egos a OMce
Revised August 24113

WELL CONSTRUCTION RECORD (GW-1)
1. Well Contractor Information:
John Salmon
Well Contactor Name
3497-A
NC Well Contractor Certification Number
Applied Resource Management, P.C.
Company Name
2. Well Construction Permit#:Not posted on Line
List all applicable well construction permits (i.e. LUC. County, State, Variance. eta)
3. Well Use (check well use):
Water Supply Well:
°Agricultural
°Geothermal (Heating/Cooling Supply)
flndustriaVCommercial
Irrigation
Non -Water Supply Well:
Monitoring
Injection Well:
!Aquifer Recharge
'Aquifer Storage and Recovery
Aquifer Test
Experimental Technology
DGeothermal (Closed Loop)
Geothermal (Heating/Cooling Return)
°Municipal/Public
Residential Water Supply (single)
°Residential Water Supply (shared)
°Recovery
0Groundwater Remediation
°Salinity Barrier
fStormwater Drainage
°Subsidence Control
°Tracer
Other (explain under #2I Remarks)
4. Date Well(s) Completed: 6/15/17 Well ID# N/A
Sa. Well Location:
Ethan Mesmer N/A
Facility/Owner Name Facility IDk (if applicable)
3696 Wingfoot Drive, Southport, NC 28461
IFor Internal Use Only:
Print Forth
444554
14. WATER ZONES -..
FROM
TO
DESCRIPTION
f.
15,017TER CASING (tor multi -cased wells) OR LINER (trap'Roble).
FROM TO DIARIETER THICKNESS R MATERIAL
0 ft' +/-300ft.
FROM
HDPE
16. INNER CASING OR TUBING (geothermal elesedanop)
DIAMETER
ft.
TO
THICKNESS.
MATERIAL
17. SCREEN
FROM
TO
ft
DIAMEatR
in.
SLOT SIZE
THICKNESS
MATERIAL
R.
ft.
la
FROM
0 ft-
TO
300 fL
MATERIAL
Thermex
EMPLACEMENT METHOD & AMOUNT
Pumped
iL
R.
D.
19. SAND/GRAVEL PACK (if applicable)
..:'
FROM
TO
ft.
MATERIAL
EMPLACEMENT METHOD
ft.
20 DRILLING LOG(attach additional sheets if necessary).'.
DESCRIPTION (color, bardnm, manna type. grain ahe, etc.)
Topsoil and sand
FROM
0
f.
10 D•
70 £t'
TO
10 R
70 D.
150 it
-
Sandy clay shells
White limestone
150 D.
280 D-
fL
280
300 a
ft.
Limestone sands clay
Layered limestone sandy clay
Physical Address, City, and Zip
Brunswick 219FB026
County
Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees.
(if well field, one Iat/long is sufficient)
See Attached N See Attached
6. Is(are) the well(s)0Permanent or °Temporary
7. Is this a repair to an existing well: °Yes or %®No
If this is a repair, ft!l our known well ronstractlon information and explain the nature of the
repair under 421 remarks section or on the back of this form.
8. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction, only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled:3
9. Total well depth below land surface: 300
For multiple thefts list all depths if different (example- 3©200' and 2.I00')
(ft.)
10. Static water level below top of casing: N/A (ft,)
If water level is above casing, use "+"
11. Borehole diameter: 6
(in.)
12. Well construction method: Mud Rotary
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gem) N/A Method of test: NIA
13b. Disinfection type: N/A Amount: N/A
Fenn GW-1
North Carolina Department of En
R fEIVED
JUN 2 6 2017
2j,. Certification:
Sig$atareafcertifi Welonasc
n
ntorr'natiun Processing Unit
4/BOG
06/16/17
Date
Designing this form, I hereby cent& that the well s) was (were) constructed in accordance
with 15A NCAC 02C.0100 or ISA NCAC 02C .02 0 Well Construction Standards and that a
copy of this record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provi e additional well site details or well
construction details. You may also attach add tional pages if necessary.
SUBMITTAL INSTRUCTIONS
24a. For All Wells: Submit this form within 30 days of completion of well
constniction to the following:
RECEIVED/NCD, R
Unit
Division of Water Resources, Information Processing Unit,
1617 Mall Service Center, Raleigh, NC ii27699-1617
24b. For Infection Wells: In addition to sending,plykpmmmtraheQs i4 ,s in 24a
above, also submit one copy of this form within 30 days of completion of well
construction to the following: 1/d �a111,�4``,,'�i
Division of Water Resources, Undergrounir}�yyQ����efCt!QD��'Ctld5�o
1636 Mail Service Center, R tY34 `d63'6CtIIOOnfl
vvir ington Regional Office
24c. Yor Water Supply & Infection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this fonn within 30 days of
completion of well construction to the county health department of the county
where constructed.
onmental Quality - Division of Water Resources Revised 2-22-2016

ARM Project.Number: 3969 Wingfoot Drive Fulford Heating & Air Pagel
Southport, NC
Driller: John Salmon
Date Drilled: Loop No. Loop Depth GPS Coordinates
5/25/2017 1 300 33 56 45 5339 78 7 322425
5/30/2017 2 300 33 56 45 2908 78 7 32 7108
5/31/2017 3 300 33 56 45 8642 78 7 32 8472
RECEIVED/NCDENR/DWR
JUL 0 3 2017
Water Quality Regional
Operations Section
Wilmington Regional Office

WELL CONSTRUCTION RECORD (GW-1)
1. Well Contractor Information:
John Salmon
Well Contractor Name
3497-A
NC Well Contractor Certification Number
Applied Resource Management, P.C.
Company Name
2. Well Construction Permit#:Not posted on Line
List all applicable well construction permits (Le. UIC ("omity, State, Variance, etc.)
3. Well Use (check well use):
Water Supply Well:
For Internal Use Only:
Print Form)
444553
L`
FROM
TO
DESCRIPTION
R
15: OUTER CASING (for amld-rase4'wells) ORLINER:(if ap linable)
FROM TO DIAMETER THICKNESS MATERIAL
0 rL +/-3002 1 'ti 1HDPE
16.,INNER CASINGOR TURING (geothermal dosed.loop)
i DIAMETER
FROM TO
ia.
THICKNESS
MATERIAL
rLI f.
in.
Agricultural
Geothermal (Heating/Cooling Supply)
Industrial/Commercial
Irrigation
Non -Water Supply Well:
Monitoring
Injection Well:
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
Experimental Technology
2c: Geothermal (Closed Loop)
Geothermal (Heating/Cooling Retum)
fMunicipaVPublic
Residential Water Supply (single)
®Residential Water Supply (shared)
Recovery
Groundwater Remediation
Salinity Barrier
oStormwater Drainage
Subsidence Control
(Tracer
lOther (explain under (GI Remarks)
4. Date Well(s) Completed: 6/15/17
5a. Well Location:
Ethan Mesmer
Well ID# N/A
N/A
Facility/Owner Name Facility RV (if applicable)
3696 Wingfoot Drive, Southport, NC 28461
Physical Address, City, and Zip
Brunswick 219FB026
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/secondsor decimal degrees:
(if well field, one let/long is sufficient)
See Attached N See Attached
w
6. Is(are) the well(s)jx Permanent or OTemporary
7. Is this a repair to an existing well: EJYes or ribio
ljthis is a repair,JID out brown well construction information and explain the nature of the
repair under 021 remarks section or on the back of this form.
8. For Ceoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction, only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled:5
(ft.)
For multiple wells list all depths if dj(erent (example- 3r0200' and 2@100').
9. Total well depth below land surface: 300
10. Static water level below top of casing: N/A
If water level is above casing, use "+"
11. Borehole diameter: 6 (in.)
12. Well construction method: Mud Rotary
(i.e. auger, rotary, cable, direct push, etc.)
(ft)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) N/A Method of test: N/A
13b. Disinfection type: N/A Amount: N/A
Form GW-1
7: SCREEN
FROM 1 TO
ft.
DIAMETER
in.
SLOT SIZE
R. I R
In.
THICKNESS i MATERIAL
FROM
0 ft.
TO
300 ft
MATERIAL
Thermex
EMPLACEMENT METHOD & AMOUNT
Pumped
R.
ft.
19. SAND/GRAVEL PACK (if applicable)
TO
FROM
a
MATERIAL
EMPLACEMENT METHOD
ft.
20. DRILLING LOG (attachadditional sheets if necessary)
DESCRH2JON (color, hardmess, ama/meh type. grain aae, etc.)
Topsoil and sand
FROM
0
fL
10 a
70 tL
150h-
280 ft
ft
ft
2.
TO
10 a.
70 D•
150 ft
280 ft
300 ft
Sandyclay shells
White limestone
Limestone sands clay
Layered limestone sandy clay
RE.CF1v
JUN
2 6 2017
2. Certification:
inikawation Processing Unit
USCG
06/16/17
Cerrsfli Well Contractor Date
s signing this lam, I hereby cent& that the well(s) was (were) constructed to accordance
with 15A NCAC 02C .0100 or 15A NCAC 02C .0200 Well Construction Standards and that a
copy of this record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTRUCTIONS
24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center,Nagieh 27699--11617
24b. For Infection Wells: In addition to sending the n 24a
above, also submit one copy of this form within 30 days of completion of well
construction to the following: JUL app 99
12 1-1
•
Division of Water Resources, Underground Injection uorurp Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supply & Inierfion jataillaikst Nag, the form to
the address(es) above, also submit lift Wisps? "%WSRW 30 days of
completion of well construction to the of the county
where constructed. a 7SfhCe
North Carolina Department of Environmental Quality - Division of Water Resources
Revised 2-22-2016

ARM Project Number: 3969 Wingfoot Drive
Southport, NC
Driller:
Date Drilled:
5/18/2017
5/22/2017
5/24/2017
5/25/2017
5/25/2017
John Salmon
Loop No. Loop Depth
1
2
3
4
5
300
300
300
300
300
Fulford Heating & Air
GPS
33 56 45 5309
33 56 45 528
3356452156
33 56 45 5339
33 56 45 5302
Coordinates
78 7 32 3273
78 7 32 2412
78 7 32 2132
78 7 32 2351
78 7 32 2374
Pagel
RECEIVED/NCDENR/DWR
JUL 03 2017
Water Quality Regional
Operations Section
Wilmington Regional Office

WELL CONSTRUCTION RECORW (GW-12
1. WdI Contractor Information:
Gi41fi ti . fl'rwe
Wdl (:antrum wed
a799
NC WellClonine:re Culbiaation Number
Alt,..,, UJeJI Da 1 r' .
Company Narita
2. Wdl COdatenctina Permits:
/Aar ail opMiea¢le wit mrtmemuienp'mdd fie. WC e:inwe. Slag, rmhmaa mat
3. Well Use (eheeh well use):
Water sopply weft:
Agricultural
°mat (Heaatng,Coortng Supply)
indiisttidlCommercial
f„Mueicipallnublie
QReaidaWat Water Supply (single)
f Residendd Water Supply(sheted)
NeaWaterSupply Walt
Olutenaorina
lgladen Well:
JAquifer Redmrge
Aquifer Storage and Recovery
Aquifer Test
rixperimentd Teelleology
DReeevery
DGmundwater Relnedisrion
fSdinity Barrier
f stmrnwww Dninrge
f Subsidence Control
Geothermal (Closed Loop) ®Tweet
eoa..1 al (UOSIIIWCCOliIW Rurwn) floaiw(ospirdp under#21 Rummies)
4. Datewelld) Completed: S ti-n Wae'IB#
• Sa. Wad Uw den:
Z;.UrCA (-Ai; I.DsoV
FsnirylOemtx,Name
'FAeethy TON (rfappamble)
/60I S':.IA D4 amok 2SMid 4 ,tic
Phydeel Addeo. CB%aid2in
Slt Saxek
Canny Fowl IdmmY:mion No (PIN)
SA Ladende and bitgiradc la dcpteeholeoterfaccooda or dedmsl degrees:
(irwoR &10, Ore M MairMOMS)
32° Si-Cr aV re Oltl) 10 641 w
6. Is(are) the wdis)Qermaaent or Cli emporary
7. Is tb(e a repair to as Satin well: [life or ZItto
eau ire repwln,pa amMMwn welt cotOntainn infomodm enaawfoi the oa'nafSM
nrpait 'odor ari.mnwls.wwran or on MeOde oliab/onm
S. For CseproteMPC.or dosed-LoopGoiter'mal Wdh having the serve
eousuadion. oaty 1(W-1(a needed tadia teTOTALNUMUS of SR
drifted:_,
9. Total nil depth below bad'imtaeee Se (ft.)
ForAralliple wells hnaftdaMhr 'different (rmmple. 30)200'sod 1@I170)
10. Stade water level below top 0 aadage. / 0 ((L)
Oster tad seabove entree one •••o-"
II: Borehole diameter: (in.)
12. wen coaslracdoa method: 1-370-% tOC
rte. anger, nary. mote, dbcet path, act.)
FOR WATER BUMF WELI,,SANLY:
13a. Yield (gpm) Method 'Oflest
13b.IRdnfefmo type: Amouat:
I For Internal Use (hrly:
444526
ywSM' . TO —..'l CRI, laN cr""
Sae, S-3...R.
a
C.wits'
s�q
BC 'rddd metwdli Idlea:saten Rtakl..
OM •- _gpst Rye O CNRS$ MATERIAL
er a. 2 orn. � 2 ilkOil 1a)`
JOINER Oa
FROM J TO
A
'MIQe$Ra8 r M 7ERNL
h. h. is
h. re. fa
tR56
pace
3 It
a
0
1
n
R.
n.
n. n.
R. a,
AM
/ L.I`
al
J
TO
'Ito
♦77aeraa
M,w(edpAL nmace saulaxeo:a6 ewu
.' f:
:cDIVE
UN 2 2 2017
DINnn•AQ:MtNTMelHOD
ntt
DWQBOG
22. Ccr_dneadem
S /y—':
s' of 'fed Conaaaor OEw,
By slot NISIPPIP,t**» MOW Um 0w'we/ Od wax (word c'nnrvamd <MOM
WO IM NCYC O2CAI00 nr)tt MCK:02C'.61i4600 WYW$Coverauida Swath undo
opiate* =gni kisManwov&kdepthesdlowner,
23. 5i1e disgfam er addigoasl wdl deluge: •
You may two die bat& of Ns page to. provide additional well site derails or
constmcdoa details. Yea may also: Rath additional pages if necessary.
,, entiorrrAL INS7'RUCTIOIrs
24a. Mr AB Wray SubMit this form within 30 days of completion of
c4R°6Ucgan to the tbftawing:
Miasma of Water Resoarcea. Wformadoa Framing Oair.
1617 Mad denim Center; Weigh, NC 27699-1617
20. per Iaieedea Wrier le at one ,d�(ddyi�tiioppn to weft dhQoe, formQto the edemas in
abovecensnuesiw alto to the PoFlow btIVCU/fbUtNt( 1�) Hf opmpledon of
DivWoa of WaterRaonedes.Lade eroa,d IoleeNsw Caoge& Preerwe
1636 Mail Senior. C,C1r(ar� 27d99-(06
Me. For WasNr_S utely & laiac i UU ��VV�Wedon to soedb8 Ole fan
the addeas(ca) above also submit one copy of this MEOW Aestm�1(�o&nt within 2O day
ao ere an of well constrodfvvater e1U a goner s ur Ole CO
1M" ""'n"" d Operations Section
Wilmington Regional Office

WELL CONSTRUCTION RECORD
rn
Thisto
ork mdaiplemeDs
form contractor
1.-104.700
ti
We ntnaar lstfonaRad °
Baal Lin ONL1: Z
(% iTe(S 0 A2
14.1WATER ZONES
Well C«maao Names
FROM
of d
TO
3R
DFSCRDrtfON
s � 1- SAe/(m®L
��ame
ft.
ft.
'
NC Welt Counae CeWirai�pnNmubv
IS. OUTER CASING(fnr
multi-cased®cfs) ORL� Rf • Met
/ a el y�.-{fit y/
FROM TO
nu2,IIEr'ER MUCHNESS A TERLiLy
e Vr(6 C ( �+ ' l
iv itaI aS R-
1 2 I Jet). v pv
Cum Name
Company .�-les ;�;
r xis
16 INNER CASING OR TtRRG
(Rent anal dmedduop)
�C u -% ce
'ROM TO
DIAMETER
TH/CIz'.ESS
MATFRrn,
2. Well Construction Nook #: 1 1 � -� �'
(L re
in
List all applicable well permits(ie. Conan State- f oriance. I:gentian. etei
3. Well Use (check well 16e):
rL ft.
r¢
17-SCRFpN
Wafer Supply Well:
FROM
TO
DIAMETER
SLOT SIZE THICKNESS
IATERUL
❑Agricultural - °ifunicipal:Public
O? vqq'..
3 D'
(.7/ a
1 ei 0
L SCA yo
Pv c..
DGcothamal (Hcating/Cooline Supply) ORcsidvttial Wane- Supply (simile)
re
ft.
to
Dlndustrial/Cammacial ORcsidattiat Wales Supply (shared)
1S- GRMOAT
FRO
TO
MATERIAL
FAIPLaCFAEtaT METHOD R AMOUNT
g_afltnt
Non -Water Supple Will:
0 re
20 b.
o®Nr
rr
r d
°Monitoring ORccovav
a
ft.
Injection Well:
°AquiferRccharge D3mundwater
1L
ft.
-
Ranediation
19. SAND/GRAVEL
PAt1C
tD applicable)
°Aquifer Storage and Rccormy °Salinity Barris
FROII
TO
MATERIAL
EUPLaCEMRIST M
DA uifer Test °SLUtml]IGr)laalYC
et?J n-
C.. . D'
14141/ &Pliel
OD
Pt V re
DExpmma tal Technology. °Soltsidnice Control
O.
DGeathanml(Closed Lmp) Miami -FROM
Th. DRTMENG
LOG (area
Isadditimalshe rsif necessary)
TO I
DESCRIPTIO\( harduut soak -oak type *minim. ucl
OGcothamal (Heat ng:Cool-mg Return) ClOtla (a -plain under =21 Restarts)
0 ft
R. f
at
1 AIL'S
.
j
i. Date %Yaks) Completed: v7 —ti / "ill eD Mit
.. e R.
3r. :
d Jq'� + .S/7 e7/-
a Well Location .
fL
ft.
Ave / / wM Sety
rL
2
FaciilitiOwnerNam Facility ID.# /-/ti appiiiabicj
�C
#
t71r®I. WOkr Ure &gk /S /iN.1
ft.ft.
' `1`,.,. ia.� E..... d
Physical AdJras, City. and Zip
It
ft.
MAY 9, R 2097
sru� rLA.Sd
21. Rtxf.Rx!
•J `, ik
County
Probat03,g1{1 '.)i^f>
Pared idndifiuuan No. tPihl
Ste Latitude and Longitude in degree shuinlueslseconds or decimal dean-...-
4}f(Wlrti'.inn
1 1
(dwell 6elL one nntaam is surtickna
33`5ri3aa094 ry 7r 79 y7 396
fL Is (m e) the well(s):(etmmment or °Temporary
7. Is this a repair to an existing well: °Yes ur
If this is a repair. fall au:knoarn well cansmmtion i jornmtion and explain?!
repair under *21 remarks section or on the back of this form.
S. !Umber of wells constructed:
For multiple injection ornon-watersupply iota OAZi'wah the same caaam aion, you con
submit one form. /
9. Total well depth below land surface:
For multiple wooslist all depths ifd vent (example- 3(200' and 20,1001
P
/
estrum ofthe
10. Stade water Intel below top of casing:
If water legal is above easing, tare `+"
II. Borehole diameter:
(in)
/2_ Well construction method: 1 7 1.)6 I=0 'fY±r '
o c. meet-. rolmv, cable, duce melt etc.)
(R)
FORWATER SUPPLY WFI 1 S ONLY:
13a Yield (gpm) 3 s- Method of test:
13b. Disinfection type: 8/'/Q- et, Amount_ / a•faArt
Fran OR -I
S-?3-20i7
Siemnaof Cmitied Well Contractor Dam
3r signing this font. I Frrelm :ernfo that the naaa) Was (wea:) comma_tett in accorclance
,riih 15.4 NC. -IC 02C _0100 ar )>.-i RC.IC 02C .0200 Well Constraztion Standards and that a
cape of this record has been provided to the well owner.
23- Site diagram or additional well details:
You may arse the bock of this page to pmaide additional well site details or well
consbuctioi details. You may also attach additional pages if necessary.
SUBMITTAL INSFUCTlONS
24a For All Wells: Submit this fora within 30 days of completion of aMl
ennatmction to the following:
Division of Water Resources, fulmination Processing Unit,
1617 Trail Service Center, Raleia_h, NC 27699-1617
24h. For Infection Wells ONLY: In y ``
24a above, also submit a copy of Ur
constitution to the following:
Diets -inn of Water Resmnces, Underg I e I Prcgraln,
1636 Mali S.. vice Center, , NtW7j63
2-lc For Water Supph, & Injection Wells:
Also submit one copy of this form tai(G(at2Q (atnicheiRegitshma
wen consuuction to the county hraith dcapatigti6f tem here
cnnanra red Wilmington Regional Office
Noah Cu abash nepa ntent ofFmyuoanuent and NamalRcotacc-Diyisi n of Water Resources RreucdAmin ?U13
91,a �f
c adsh-css in
ction of well

WELL CONSTRUCTION RECORD
This Mann Can be toed for sitwle or multiple melt
1. Well Contractor lnrn
on:
ftve /I et SeM
i\'ell CwnactorNamc
35l0A
INC Wentoona ar CeroticationNum
e-We// ‘t/Lj
Company Name
2. Will Construction Permit I: -------
List all opplicabk well pumas (Le. Coup; Sean. rosin,-. In/eceina etc)
3_ Well Use (check well use):
Water Supply Well:
°Agricultural
OGcothamal (Hciting:Coolint Supply)
Olndusirial/Comme rcui
ninaton
Non -Water Supply Well:°Monitoring ORceoyaay
Injection Well:OAquiferRecha gc
°Aquifer Storage and Rccovat
°Aquifer Test
°Experimental Tcehaalogy
°Geo/Tiumal (Closed Loop)
°Geolhomal (IleatingCoding Retool)
Ohltuticipa)Public
ORcsidatiial Water Supply (single)
°Residential Watt.: Supply (shared)
OGmundnatcr Rcncdiation
°Salinity Barrierum,a °St =uterDrainage
OSubsitbatoc Control°Tracer
°Othcr (e,plain motor =21 Resnais)
i. D-ate Well(*) Completed: S t'O / ?Wen DIG
3a- W'e1 Location:
Facility:ihwwrNanre
62oeft iveveygfor ciy
(5tti,u Sw,c4
corm,
Physical Address; City, and Zip
Facility Inn ttfappii.nble)
1®orr
Parcel Licraift man No. ipIN)
56- Latitude and Longitude in degte<s/tninntesfseconds ar dental d
\tii1cId one iao)a degrees:
wall . la is sufficing)
3.3° �1Sr*fre N ro 22, 93 2 W
6. Is (are) the we0(s): Permanent or °Temporary
7. Is this a repair to an existing well: °yes or
If this is arepair. fi)7 out known well construction infonnarion and explain the nanrm of the
repair under _I remarks section or an the backn)rhirfoms
8. Ntmtberofwelis constructed:
FormaRiph injection or tmmaatersupply wells OICE with the some cansaaaiort you nn
submit one form. J•
9. Total well depth below land surface: .35
For muldple wells list all depths ff'de' rent (iantriple- 4)200' and_'/¢100'j
10. Static water level below top of omit*:
Ifiater lcrrlisatare cast tta ""t"
II_ Borehole diameter Y! (R)
y�rt j
IL Well construction method: // f (pGI /20 "�')�' r i t
ti e. anger. mint cable, diner only ele)
8 s
(R)
(ft.)
FOR WATER SUPPLY \%TI 15 ONLY:
13a. Yield(gpm) 33 „ Method nftesr
13b. Disinfection typo. Ge/YCL'I Amount:
rr
Fonn GW.I
35-fr
is OUTER CASING (for multi-vud wens) ORDERER flop hte).
R
1T ft To DIAMETER .SCR ,G7FRLII.
T% I�2tS' oC id
16. INNER CASING OR TUBING t ___t .clan _
tr
FROM I TO DIAMETER TEIC13aEs MATERIAL
R R.21(n I{
R I It. ie.
0
17. SCREEN
pvc
FROM TO DIAMETER 1 SLOTS= SHICI4,'ESS MATERIAL
?PI S511-
ft.
ft.
IS. GROUT
FROM
71 R
ft.
TO
.:1 ° fig
R
fr
MATERIAL
t3e
19. SAND/GRAVEL PACT. tit atrpfcabie)
FROM TO
-2011 3r
ft. ft
MATFPIAL
PVC
EMPLACEMENT METHOD &AMOUNT
_ Poore. cl.
errilli �e,mLacE,Cr89
alere
20. NRU.LGYG LOG (atm b additional sheets if atemous)
FRAM TO DESCRIPTION molar. knelt en. Evil rt.
0 ft �y'��ft nac ar aria Y
ft.
fig
ft.
it
fa
It.
D.RE:GARBS
DWG/BOG
22.
Farintvml Use ONLY:
14. WATFRZONES
}43958 I
Taw
kR
R
To i EFSCRiPTIOyiNA /1
ft
ft.
ft.
R
lt_
J'th"ct L l5if r
MAY 2-a 21117
Date
Th- signing this fans.. 1 hereby certify that the t ei/ft) war (u ern; constructed in a:ro tncu
with 13A9"C4C 02C.0100 or 13.-1 NCAC 02C .02001fei Construction Standards and that
copy of this record has been provided to the well owner.
23. Site diagram ar additional well details:
You soy use We back of this page to provide additional wall site details or well
construction details. you may also attach additional pages if accessmy-
SUBIiIITT_aI.INSTUCTIONS
24a. For All Wells: Submit this form within 30 days of completion 01' wall
construction to the following:
Division of Water Resources, Incarnation Aucessitg Unit,
1617 Mail Screice Center, Raleigh. NC 27699-16I7
24h For Infection Wells ONLY- lit addition to sending arc form to !her adch ss in
2la above, also submit a copy of this I4If\rditlawat,e
constuctiou to the following: 1IJJ//�t�ell+ltitiGGjb�1KlJj rah of well
Division of Water Rasaurces, Underground Injection Central Pngfatm
1636 kind Service Center, R:dek Mica ppM9 -
2Je For ii/ater Suppy' & Injection Wells ly�i7ll 44 V C U l
Also submit one copy of this form ni a 0 dajg�o.fd c��am" )dime of
wail eousanetmh to the comity hello d�:tWahray,:
consbucfra. Operations Section
North Onafi nDapnmrnaolFzmuormmm;and NannalRcahoac -Division of Water ResomWilmington Regional Office
Revised August 2013
Siamesof Cmitied Well Contractor

WELL CONSTRUCTION RECORD
Tim foam cape and for cumin or multiple went
1- Well Contractor lnfortmttion- -
rmtviamt Um ONLY:
443357
�A("e 4412 t l c Cry
!"� J
ti WAIFS ZONES
}RDU
f To
➢ESCREPTION
Weil Cmmaaor Name
A
0 R.
j 02 81 ft.0
Thr�
<3S.'�°
55R
g&
t--11,-)fl e C,ILIA)
NC Welt Contrite CenitirationNtmtber
IS. OUTER CASING Bar
multi-easedwells)GRIJNSR(,I -
)
�� // / �v
FROM TO
DIAMETER THIC ILiT/EJRli
,p
C. V e/
tt ti
.+ t R. O F-
I ( 10V
-'] nk p jRNESS
OC
rdesed P%Ii /�V' �r
Cumpmg Nane litt-,0
hi !BMA CASUCG OR TUBINGjg-.:L-
n
:dosedlamo
2. wen Construction et uen — 000
FROM
DIAMETER
I➢Ict,ZNFSs
MATERIAL
Penult#: aZ.U`1) �
R Cc
in.
Liss aapplicable troll tic. Comic. Star.. isurimci. l ctiaa eta)
ro
3. Well Use (check well use):
R it.ra
17 SCREEN
Wafer Supply Well:
FROM f TO
mintETER
SLOT SIZE
TrDCIt,'FSS
MATERIAL
OlidmtictpalPobhc
D'
0peJ
m.
OGtothamnl (Heating/Cooling Supple) °Residential Water' Supply (single)
1{
ft.to
la
-
Olndustrini'Commacia( ORcsidattial Wain- Supply (shad)
1S. GROUT
ation -
fRO.0
ill
MATERIAL
Pbi(-.E�iFl•T EMMETHOD R,I,U
tc
OLmT
Non -Water Supply Well:0a
20
13el✓ro
l.ft Lox - Pay a U re j
°Monitoring ORecovav
it.
it.
Injection Welk
DaquifizRecharge
tV
it
OGmnndwvter Rnnediation
ID. BAND/GRAVEL
PAO.
(ifap➢licabe)
❑Aquifer Storage and Ra:arety °$aliniry Dania
FROM
To
MATERIAL
E}mL4cEMExi METHOD
°_aquifer Test OStommuatalhanner
n
tt
DExpetimanal Technology OSubsidatec Control
R
ft.
°Geothmmal (Cloned Loop) ()Tracer
20. DBILLMG
LOG Wits
h additional sleesifnereaarv)
FROM
TO I
DESCRIPTION( harduuPardue..suibvadc avoc main she. act
OGeothamal (HeatinRCooling Re/men) Oaths (explain under 921 Rern )
0 to
4
. to
f'An ti
3. Date Wents)Completed:570-I-teen MO
- -:
�'it
2/n /SA-P/lt
a:L�VCeII Location:J.S
fL
/ fft.R
fG7
1-**• / der) P 5 ru5 at/ Z
Sieve 1-0-Ph
2
FaciluriOowNante Facility m-hfappli.ahle)
it.
it
l 33 Kea tog Ph sr. am-h /s/ �
L
fL
3 ��
Physical Mantis. Cry-. and Zip
it.
tc
FFyy
(3rvi(.a.s earl ic
=I.REL4RI� Y 61- i 2017
c
County
Parcel Identification No. iPPi)
Ladtode and Loogitude in d �^reedndnutestseconds ordecimalAiwa-...
/9 iration rr ce-• ?..10l LinnSI.
/ 1 s DWCYJC'`_"
(if moll had,one Detour, is sufficient')
33°Ss 22,YSit /h7 7 _co?,Y/
6. Is (are) the wen(s): it ermmnent or °Temporary
7. Is this a repair to an existing well: Dyers car . Nu
If th v is a repair, fill out known uel commotion otion information and explain the natnrc of the
repair nndere21 remarks section or an Me back of this form.
8. Number (tine% consu acted: /
For multiple injection or non -water supply wells OAtr with the same coustntaiat• ton can
submitonejorm.
9. Total well depth below land surface:
(ocP
For multiple dells list dt depths ifdeirrent (example- 3:e'00' and2/g1001
10. Static water level below cop of rasing:
If water level it above casing. ten ' /
11. Borehole diameter: }t7 (in.)
1 L Well construction method: 1 f i c-nA `r lei
u.. auger, rally, cable. direct with. eteJ
i2
FORWATER SUPPLY WELLS ONLY:
13a. Yield (gpnt)
Method of test: / 1 r
136. Disinfection type: 13/OA-.CA Amount: ` Cl OVA- Yr
Farm GW-i
NorthCmJuv Depmmon ofEnvitonutc
2L Cc
Sienatizc o&Catiicd )Veil Contractor .
s-13-7
Date
7r signing this (one. 1 bendy comb' that the milks) tear /were) constructed in a:ro dan_-e
with lid \C)C D2C .0100or ISA:Wile 02C.02001rJt Casmm-tion Standads and Mar a
dopy ofthis record has been provided to the well corner.
23. Sue diagram or additional well details.
You may use the back of this page to provide additional null site details or Well
cutuhuction details. You may also attach additional pages if necessary. SUBMITTAL INSTITUTIONS
24a. For AR Wells: Submit this fours within 30 days of completion of well
consuuction to the farrowing:
Division ofWater Renoures s,Information Processing Unit,
1617 Mail Service Center, Raleth. NC 27699-16I7
lib. For Ioiection Wells ONLY: In addition to scndibe the form to the address in
24a above also submit a copy of this form mthm 30 days of completion of well
construction to the following: Divdson of Water Resources, Undergira�F(9IigQtE1p
1636 hail Service Center, Raleigh, NC 27699-1636
23e For Water Supply & Injection Welk MAY 'j O , n 7
Alto submit one cop}• o{ phis form Wilbur ill o{L�vljtlLzn i 7f
will emuuwaims to We county bcabk depattmart of the county where
cmmhuctcd
Water Quality Regional
and Natural Resaw.-es-➢vision of Water Retourc Operations Se d-,wmt,o,--,
Wilmington Regional Office

wtria
Print Form
WELL CONSTRUCTION RECORD (GW-11
1. Well Contractor Information:
Donald Cummings
Well Contractor Name
2412-A
NC Well Contractor Certification Number
Applied Resource Management, P.C.
Company Name
2. Well Construction Permit 0:
N/A
last all applicable wcdl construction pumas 1.. o, WC ()aunty. Stale, Variance
3. Well Use (check well use):
Water Supply Well:
Agricultural
Geothermal (Heating/Cooling Supply)
Industrial/Commercial
'Irrigation
Non -Water Supply Well:
Monitoring
Injection Well:
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
Experimental Technology
Geothermal (Closed Loop)
Municipal/Public
DResidential Water Supply (single)
DResidential Water Supply (shared)
DRecovery
Groundwater Remediation
D8alinity Bather
DStormwater Drainage
®Subsidence Control
f Tmeer
Geothermal (Heating/Cooling Return) Other (explain under 021 Remarks)
4. Date Well(s) Completed:3/20/17 Weil11 M W-7
5a. Well Location:
Village of Bald Head Island N/A
Facility/Owner Name Facility IDS (if applicable)
Bald Head Island 14 Fairway, Bald Head Island, NC 28461
Physical Address, City, and Zip
Brunswick 2642F00106
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
Orwell Beid, one Iattong is sufficient)
33 51 37.26
N 77 59 40.51
W
6. Is(are) the well(s)ax Permanent or ()Temporary
7.1sthis a repair to an existing well: QYes or @No
If Mrs is a repntn fih!mu known well construction information and explain the mare of the
repair under 21 remarks section or on the bock o/Mrsfarnr.
8. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction. only 1 GW-1 is needed, Indicate TOTAL NUMBER of wells
drilled:1
9. Total well depth below laud surface: 20 + 2.5 Stickup (ft.)
Farmtthtple wells fief all depths if different (example- 3(200' and 21a(00')
10. Static water level below top of casing: 9.76 (ft.)
Ifunter level a above casmg, use - "
9"
11-Borehole diameter:
12. Well construction method: Auger
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY.
13a. Yield (gpm) N/A Method of test: N/A
136. Disinfection type: N/A Amount: N/A
or internal Use Only:
443721
14. WATER ZONES
FROM
TO
DESCRIPTION
ft.
ft.
rt.
ft.
15.OUTER CASING (for mal&eased wdts)OR LINER (if a Stable)
FROM
TO
DIASIn ER
THICKNESS MATERIAL
0
5 fI•
2 1^
SCH40 PVC
it INNER
CASING OR TIRING teothermal closed -loop)
FROM
10
DIAMETER
'THICKNESS
MATERIAL
ff:
ft.
in.
ft.
fe.
in.
17. SCREEN
FROM
TO
DEAMETER
SLOT SIZE
THICKNESS
MATERIAL
5 ft
20 2
2- tit
.010
SCH40
PVC
ff.
ff.
in
15: GROUT
FROM
TO
MATF,ROAI.
EMPLACEMENT hIETROD&AMOUNT
0 ft•
1 ff•
Grout-
Poured
1 ft
3 ft
Bentonite
Poured
ft.
h.
19. SAND/GRAYELPACh.
(if applicable)
FROM.
TO
MATERIAL
EMPLACEMENT METHOD
3 ft
20 IL
Coarse
Poured
ft.
ft.
20. DRILLING
LOG (Attach
additional sheets if necessary)
PROM.
TO
DESCRIPTION (cotes bosdna%soiVrack 1ype,grain !frt., etc.)
rt.
ft.
See Attached
ft.
It.
ft
ft.
ft
ft
ft.
ff.
ft
9
/ ECc \&
ff.
it
21.REMARKS Mi 5 2017
MAY
rUnll
IDIGINVHBi L 4.Ay
nIP1G
22. Certi -,-.o
Signature of Certified Well Contractor
4/6/17
Date
As signing this forrn, 1 hereby certify that the well(s) war (were) constructed to accordance
with al NCet(' 02C'.010n or 13A NCA(' 02C ,0200 Well Construction Standen& and That a
copy oft is record has been provided to the well owner,
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTRUCTIONS
24a. For All Wells' Submit this fora within 30 days of completion of well
construction to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Iniection Wells: In additt4�yr d' the form to the address in 24a
above, also submit one copy of thiiYa N'1WNR Abtion of well
construction to the following:
Division of Water Resources, Underg�spad Jpjppscti�onn Control Program,
1636 Mali Service Center)It6ldigty.^;!L fw$% 1636
24c. For Water Sunni, & lnjection Wells: In addition to sending the form to
the address(es)ptetioabove, also submit dtis�r5ytt> hul 30 days of
completion of well construction to the.iiSSdh,'.bb.. CC�CCkk���V Ent of the county
where constructed.
Wilmington Regional Office
Form GW.l
North Carolina Department of Environmental Quality - Division of Water Resources Revised 2.22.2016

BORING LOG
VILLAGE OF BALD HEAD ISLAND
BALD HEAD ISLAND, NORTH CAROLINA
MW-7
Drilled by: Applied Resource Management
Logged by: J. Zuncich
Date: 3/20/17
Depth
(!G)
Description
Wafer `:
Content
2-4
Tan to light brown, silty to medium grained sands with some organics.
Low
5-7
Tan brown, fine to medium sands with shell fragments.
Low to
Moderate
10 - 12
Brownish gray, fine to coarse sands with shell fragments.
High
15-17
Light gray, medium to coarse sands with shells.
High
18-20
Greenish gray, fine to coarse sand mixtures with shell fragments.
High

MW-7
17' Sand
1
y
Protective Steel Standpipe
Lock'
Ground Surface
2' Bentonite
A
,.
,•�••• ••• •
,•••••%+•••-•'
!•.•••• D• •••••••
•• •l t
i•� ••�_•— D••••••
te•
e •• �� •�•�••
►�•�••�• •�•�••
i•••••i L. ••�••�
•r•( ••••
Groundwater 1•••• L_1 •••••
•
Table ••�•• •1••�•�•
L•tt •i s
t••••••• ►❖••::
'••••• iD ••••• •
1•••••�l).•IPO
•s •
��••••—-?j• ••
•�•�•!.._. �j••• •••i.
�II ••••`.l••�.��
! •%••••i 1• •• �••
• •
•••L-••!
•�•�•••f = 1••••••i
••••..-.)••••••t.
••••••LF-••••••4
t••••••~'••••••S
•••i 0•'••
►•• :04••••••••
!••••• 11%
••••••••
2.5' Stick Up
Concrete/Grout Crown
5' Riser
A
15' Screen
• 20' Total Depth
Applied Resource
Management, P. C.
Hampstead. NC 28443
TITLE:
JOB: SCALE:
17059 Not to scale
AS -BUILT
DATE: DRAWN BY:
4/06/17 KLC
WELL ID:
MW-7

APPENDIX B

ANALYTICAL & CONSULTING CHEMISTS
Environmental Chemists, Inc.
6602 Windmill Way, Wilmington, NC 28405 . 910.392.0223 Lab • 910.392.4424 Fax
710 Bowsertown Road., Manteo, NC 27954 • 252.473.5702 Lab/Fax
255-A Wilmington Highway, Jacksonville, NC 28540 . 910.347.5843 Lab/Fax
[e-mail]
Applied Resource Management
Post Office Box 882
Hampstead NC 28443
Attention: Joe Zuncich
Lab ID
17-09391
Test
Sample ID:
Site: MW-7
Revised Report: May 09, 2017
Original Report Date: Mar 29, 2017
Report #: 2017-03937
Customer ID: 08100006
Project ID: Bald Head Island Wells
Method
Collect Date/Time
3/21/2017 11:53 AM
Matrix
Water
Results
Sampled by
Joe Zuncich
Ammonia Nitrogen
Total Dissolved Solids (TDS)
Chloride
PH
Total Phosphorus
Total Organic Carbon (TOC)
Fecal Coliform
1,1,1,2-Tetrachloroethane
1,1,1-Trichloroethane
1,1,2,2-Tetrachloroethane
1,1,2-Trichloroethane
1,1-Dichloroethane
1,1-Dichloroethene
1,1-Dichloropropene
1, 2, 3-Trich lorobenze n e
1, 2, 3-Trichooropropane
1,2,4-Trichlorobenzene
1,2,4-Trimethylbenzene
1,2-Dibromo-3-Chloropropane
1,2-Dibromoethane
1,2-Dichlorobenzene
1,2-Dichloroethane
1,2-Dichloropropane
1, 3, 5-Trimethylbenzene
1, 3-Dichlorobenzene
1,3-Dichloropropane
EPA 350.1
SM 2540 C
SM 4500 CI E
SM 4500 H 8
SM 4500 P F
SM 53108
BM 9222D MF
SW 846 method 8260B/5030B
SW 846 method 8260B/5030B
SW 846 method 8260B/5030B
SW 846 method 8260B/5030B
SW 846 method 8260B/5030B
SW 846 method 82608/50306
SW 846 method 8280B/5030B
SW 846 method 8260B/5030B
SW 846 method 8280B/5030B
SW 846 method 8260B/5030B
SW 846 method 8260B/5030B
SW 846 method 8260B/5030B
SW 846 method 8280B/50308
SW 846 method 8260B/5030B
SW 846 method 8280B/5030B
SW 846 method 8280B/5030B
SW 846 method 82608/50308
SW 846 method 8260B/5030B
SW 846 method 8260B/50308
11.7 mg/L
346 mg/L
RECEIVED/NCDENR/DW({8 mg/L
7.52 units
MAY 2 2 2017 1.67 mg/L
10.4 mg/L
WOerQuality anonsSectionaz80Colonies/100mL 03/21/2017
Wilmington Regional b ftiqy5ug/L 03/22/2017
<0.5 pg/L 03/22/2017
<0.5 ug/L 03/22/2017
<0.5 pg/L 03/22/2017
<0.5 pg/L 03/22/2017
<0.5 pg/L 03/22/2017
<0.5 pg/L 03/22/2017
<0.5 pg/L 03/22/2017
<0.5 pg/L 03/22/2017
<0.5 pg/L 03/22/2017
<0.5 pg/L 03/22/2017
<0.5 pg/L 03/22/2017
<0.5 pg/L 03/22/2017
<0.5 pg/L 03/22/2017
<0.5 pg/L 03/22/2017
<0.5 pg/L 03/22/2017
<0.5 pg/L 03/22/2017
<0.5 pg/L 03/22/2017
<0.5 pg/L 03/22/2017
Date Analyzed
03/23/2017
03/22/2017
03/23/2017
03/29/2017
03/24/2017
03/23/2017
Report #:: 2017-03937
Page 4 of 6

ANALYTICAL & CONSULTING CHEMISTS
Environmental Chemists, Inc.
6602 Windmill Way, Wilmington, NC 28405 • 910.392.0223 Lab • 910.392.4424 Fax
710 Bowsertown Road, Manteo, NC 27954 • 252.473.5702 Lab/Fax
255-A Wilmington Highway, Jacksonville, NC 28540 • 910.347.5843 Lab/Fax
info ellvironmentalchemists.com
Applied Resource Management
Post Office Box 882
Hampstead NC 28443
Attention: Joe Zuncich
Revised Report: May 09, 2017
Original Report Date: Mar 29, 2017
Report #: 2017-03937
Customer ID: 08100006
Project ID: Bald Head Island Wells
1,4-Dichlorobenzene
2,2-Dichloropropane
2-Chlorotoluene
4-Chlorotoluene
Benzene
Bromobenzene
Bromochloromethane
Bro mod ich lorometha ne
Bromoform
Bromomethane
Carbon tetrachloride
Chlorobenzene
Chloroethane
Chloroform
Chloromethane
cis-1,2-Dichloroethene
cis-1,3-Dichloropropene
Dibromochloromethane
Dibromomethane
Dich lorod ifl uoromethane
Ethylbenzene
Hexachlorobutadiene
Isopropylbenzene
M+P Xylene
Methylene chloride
Naphthalene
n-Butylbenzene
n-Propylbenzene
ortho-Xylene
SW 846 method 8260B/5030B
SW 846 method 8260B/5030B
SW 846 method 8260B/5030B
SW 846 method 8260B/5030B
SW 848 method 82608/503013
SW 846 method 8260B/5030B
SW 846 method 8260B/5030B
SW 846 method 8260B/5030B
SW 846 method 8260B/5030B
SW 846 method 82601315030B
SW 846 method 8280B/5030B
SW 846 method 8280B/5030B
SW 846 method 8260B/5030B
SW 846 method 8260B/5030B
SW 848 method 8260B/5030B
SW 846 method 8260B/5030B
SW 848 method 8260B/5030B
SW 846 method 8260B/5030B
SW 848 method 82606/50308
SW 848 method 8260B/5030B
SW 846 method 8260B/5030B
SW 846 method 8260B/5030B
SW 846 method 8260B/5030B
SW 845 method 8260B/5030B
SW 846 method 8260B/5030B
SW 846 method 8260B/5030B
SW 846 method 8260B/5030B
SW 846 method 82600/5030B
SW 846 method 8260B/5030B
<0.5 pgIL
<0.5 pg/L
<0.5 pg/L
<0.5 pg/L
<0.5 pg/L
<0.5 pg/L
<0.5 pg/L
<0.5 pg/L
<0.5 pg/L
<0.5 pg/L
<0.5 pg/L
<0.5 pg/L
R<0.5 Ug/L
ECEIVED
/NCDENR, wip L
<0.5 "ILMAY 2 2 20!?<0.5 pg/L
WOaterquelity Re <0.5 pg/L
ons
Wilrningtonl Region 0 ia.5 NO-
<0.5 pg/L
<0.5 pg/L
<0.5 pg/L
<0.5lig/L
<1.o WI-
<0.5 pg/L
<0.5 OIL
<0.5 pg/L
<0.5 pg/L
<0.5 pg/L
03/22/2017
03/22/2017
03/22/2017
03/22/2017
03/22/2017
03/22/2017
03/22/2017
03/22/2017
03/22/2017
03/22/2017
03/22/2017
03/22/2017
03/22/2017
03/22/2017
03/22/2017
03/22/2017
03/22/2017
03/22/2017
03/22/2017
03/22/2017
03/22/2017
03/22/2017
03/22/2017
03/22/2017
03/22/2017
03/22/2017
03/22/2017
03/22/2017
03/22/2017
Page 5 of 6
Report #:: 2017-03937

ANALYTICAL & CONSULTING CHEMISTS
Environmental Chemists, Inc.
6602 Windmill Way, Wilmington, NC 28405 . 910.392.0223 Lab . 910.392.4424 Fax
710 Bowsertown Road, Manteo, NC 27954 . 252.473.5702 Lab/Fax
255-A Wilmington Highway, Jacksonville, NC 28540 . 910.347.5843 Lab/Fax
[e-mail]
Applied Resource Management
Post Office Box 882
Hampstead NC 28443
Attention: Joe Zuncich
Revised Report:
Original Report Date:
Report #:
Customer ID:
Project ID: Bald
May 09, 2017
Mar 29, 2017
2017-03937
08100006
Head Island Wells
p-isopropyitoluene
sec-Butylbenzene
Styrene
tert-Butylbenzene
Tetrachloroethene
Toluene
Trans-1,2-Dichloroethene
Trans-1,3-dichloropropene
Trichloroethene
Trich lorofl uoromethane
Vinyl chloride
Nitrate Nitrogen (Galt)
Nitrite Nitrogen
Nitrate+Nitrite-Nitrogen
Nitrate Nitrogen
Comment:
Reviewed by:
SW 846 method 8260B/5030B
SW 846 method 8260615030E
SW 846 method 8280B/6030B
SW 846 method 8260B/5030B
SW 846 method 8260B/5030B
SW 848 method 8280B/5030B
SW 846 method 82608/5030B
SW 846 method 8260B/5030B
SW 846 method 8260B/5030B
SW 846 method 8260B/5030B
SW 846 method 8260B/5030B
EPA 353.2
EPA 353.2
Subtraction Method
<0.5 pg/L 03/22/2017
<0.5 pg/L 03/22/2017
<0.5 pg/L 03/22/2017
<0.5 pg/L 03/22/2017
<0.5 pg1L 03/22/2017
<0.5 pg/L 03/22/2017
<0.5 pg/L 03/22/2017
<0.5 pg/L 03/22/2017
<0.5 pg/L 03/22/2017
<0.5 pg/L 03/22/2017
<0.5 pg/L 03/22/2017
0.03 mg/L 03/22/2017
< 0.02 mg/L 03/28/2017
<0.02 mg/L 03/29/2017
RECEIVED/NCDENR/DWR
MAY 217
2017
Water Quality Regional
WilrlOnerations Section
gton Regional Office
Page 6 of 6
Report#:: 2017-03937

0a;d Head Island
Approximate GPS Coordinate
Test Well Site #1 (MWV 7): 33°51' 37.26"N
Basin 4 77°59' 40.51 "W
Test Well Site #2 (MW 8): 33°51' 43.97"N
Basin 5 77°59' 30.84"W
Adapted from Earth Image 10/29/2016, accessed 3/3/17.
Goggle Earth
8:' eve VC R0
LEGEND
G Monitoring Wells Location
RECEIVED/NCDENR/DWR
MAY 2 2 2017
Water Quality Regional
Operations Section
Wilmington Regional Office
Applied Resource
Management, P. C.
Hampetead. NC 2&WA3
TITLE: Google Earth Image With
New Monitoring Well Locations
JOB: SCALE: DATE: DRAWN BY:
17059 1" = 200' I 4/20/17 EFC/JLZ
FIGURE:
1

The Village of Bald Head Island
Utility Department
May 8, 2017
NCDWR,
Information Processing Unit,
1617 Mail Service Center
Raleigh, N.C. 27699-1617
Subject: Monitoring Well Construction, Sampling and Monitoring Well
Abandonment
Dear DWR:
I have added the following information to help understand why monitoring
wells were removed and new wells were installed.
Pond #3 was removed from permit #WQ0000193 as part of that process two
monitoring wells were determined to be no longer useful due to their
locations (See Appendix C) MW-4 & MW-6 Well Abandonment Records.
During the permit modification to include, Villas Homeowners Association
to our Re -use permit WQ0000193 the Division of Water Resources
requested we replace the two monitoring wells and in install them in useful
monitoring locations, (1) to the south of small discharge pond 4 (MW-7) and
one to the east of larger discharge pond 5 (MW- 8).
Please review the package from ARM, Geothermal, Environmental & Well
Drilling and let me know if you have any further questions, comments or
concerns.
Sincerely,
RECEIVED/
NCDENR/DWR
MAY 222017
im;
Kennith D. Bowling, Director of Utilities water Quality
SReTonal
Section
Village of Bald Head Island Wilmington Regional Office
P.O. BOX 3009 • BALD HEAD ISLAND, NC 28461 • [phone] • FAX [phone]

ARM
Geothermal, Environmental,
April 20, 2017 & Well Drilling
Bald Head Island Utilities
Attn.: Mr. Ken Bowling
Bald Head Island, North Carolina 28461
Re.: New Monitoring Well Construction and Sampling
Monitoring Well Abandonment
Mr. Bowling,
The following information is provided for your review:
Figure 1 Google Earth Image With New Monitoring Well Locations
Appendix A Boring Logs, As-Builts and NC Well Construction Records
Appendix B Laboratory Report For New Monitoring Wells
Appendix C Well Abandonment Records
New Monitoring Well Construction
The two newly constructed monitoring wells (MW-7 and MW-8) were installed in the
designated locations on March 20, 2017. Figure 1 depicts the new well locations. Both
wells were constructed to a depth of twenty feet with a screened interval from five to twenty
feet deep. A 2.5' stick up pvc riser with a steel protective standpipe and concrete pad was
installed at each well. Boring Logs, As-Builts, and NC Well Construction Records are
provided in Appendix A. After construction, both wells were developed, gauged, and
purged of at least three well volumes of groundwater. Static water levels were recorded
at 8.52' belowtop of casing at MW-8 and 9.76' below top of casing at MW-7. After purging
activities, groundwater samples were collected from both wells and analyzed for Total
Organic Carbon, Chlorides, Fecal Bacteria, Ammonia Nitrogen, Nitrate, pH, Total
Phosphorous, Total Dissolved Solids, and VOC's per EPA Method 8260.
Monitoring Well Sampling Results
RECEIVED/NCDENR/DWR
Based on laboratory results, all 8260 volatile organic compounds analyzed were found to
be compliant. The following results are as follows: MAY 2 2 2017
Water Quality Regional
Operations Section
Wilmington Regional Office
Applied Resource Management, P C.
1? 0. Box 882, 257 Transfer Station Road, Hampstead, NC 28443 910.270.2919 Fax [phone]

Method
Ammonia Nitrogen
Total Dissolved Solids
Chloride
pH
Total Phosphorus
Total Organic Carbon
Fecal Coliform
MW-8
<0.2 ppm
297 ppm
69 ppm
7.87
1.54 ppm
4.6 ppm
240 Colonies
A Laboratory Report is included in Appendix B.
Monitoring Well Abandonment
MW-7
11.7 ppm
346 ppm
58 ppm
7.52
1.67 ppm
10.4 ppm
280 Colonies
April 20, 2017
On March 20 and 21 st, 2017, monitoring wells MW-4 and LM-6 were properly abandoned.
Well abandonment records for each well are provided in Appendix C.
If you have any questions or require further information, do not hesitate to call.
Sincerely,
r
Jos L. Zuncic!
Project Manager, CWD, Geologist
mes L. Corne e, , CWD
Project Manager
REWIEDINGDERRIDWR
toy 2 2 201T
Water
ons Reg.se t onal
Wilmington Reg'°nal once
2

WELL CONSTRUCTION RECORD (GW-1),
1. Well Contractor Information:
Donald Cummings
Well Contractor Name
2412-A
NC Well Contractor Codification Number
Applied Resource Management, P.C.
Company Name
2. Well Construction Permit #:
N/A
List all c01pliczMe well c nsaPmtian penman 0.c. Ul(
3. Well Use (check well use):
:-orally. State, l'ariatrce, etc)
Water Supply Well:
Agricultural
Geothermal (Heating/Ccoling Supply)
Industrial/Commercial
Irrigation
Non -Water Supply Well:
I )Monitoring
Injection Well:
jAquifer Recharge
JAquiter Storage and Recovery
Aquifer Test
JExperimental Tcchnolom
Geothermal (Closed Loop)
Geothermal (Heating/Cooling Return)
4. Date Well(s) Completed: 3/20/17
5a. Well Location:
Village of Bald Head Island
IMunicipaI/Public
DResidentinl Water Supply (single)
Residential Water Supply (shard)
IRecove
FGmundwater Remediation
Salinity Barrier
fStormwater Drainage
}Subsidence Control
DTmcer
r'IOther (explain under 421 Remarks)
wen muMW 8
N/A
Facility/OwnerNaoe Facility 1➢a (if applicable)
N. Bald Head Wynd, Bald Head Island, NC 28461
Physical Address, City, and Zip
Brunswick 2642F001
County
Parcel idend6cation No, (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one laalong is sufficient)
33 51 43.97 N 77 59 30.84
6..'stare) the well(s)RxPermanent or OTemporary
7. is this a repair to an existing well: QYes or ENo
1(das is a repay -fill out known well cmrnntction Infortnanon and explain the nature ofthr
repent* meter `21 remarks' necrton or an the hack of this form.
8, For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction, only I GW-1 is needed. Indicate TOTAL NUMBER of melts
drilled: 1
9. Total well depth below land surface: 20 + 2.5 Stickup (ft.)
For multiple wells Lst all depths ifdifferent (example- 3g}200' and 240100')
10. Static water level below fop of casing: 8.52 (ft,)
!Rater level Is above casing, use "-'
11. Borehole diameter: 9" (in.)
12. Well construction method: Auger
W
(i e. auger, rotary, table, direct push, etc.)
FOR WATER SUPPLY {YELLS ONLY:
13a. Yield (gpm) N/A Method of test: N/A
I3b. Disinfection type: N/A Amount N/A.
Print -Form
'or Internal
)nly:
443722
14. WATER ZONES
FROM
TO
DESCRIYl'ION
ff.
ft
ft.
ft
IS OUTER CASING (For multi..nud with) OR LINER (if a cable)
FROM
'ID
DIAMETER
T IICSZNESS MA. Elf
0 ft
5 ft
2 'n-
SCH40 PVC
16. INNER CASING OR'Ctt${NG (geothermal closed-loopl -.
FROII
TO
DIAMETER
TRIMNESS
MATERIAL
ft
ft
in.
EL
ft
]n.
17. SCREEN -
FROM.
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
5 ft
20 ft
2 '"
010
SCH40
PVC
g„
ft Jt
in,
itGROUT ...
FROM
TO
MATERIAL
EMPLACEMENT MEITIOD & AMOUNT
0 n.
1
Grout
Poured
1 ft
3 ft-
Bentonite
Poured
ft.
19. SAND/GRAVEL
PACK
(if applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
3
20 ft•
Coarse
Poured
rt.
rt
20. DRILLING
LOG (attach
additional sheets if necessary)
FROM
TO
DESCRIPFTON (color, hatdnns,soivreck ly ., grin size. CM)
rt
ft-
See Attached
ft
0.
rt.
0.
f�I
N.
ft.
ft.
ft.
ft
MAY 1 0 2017
ft.
21. REMARKS 9n9orma#Ian P;:',,:;t.sr o,0 ',VW
DWLN 0Ca
22.
anon:
Signature o Certified Well Co tor
4/6/17
Date
$y .tlg,dng thi% frlrni, 1 hereby certify that the nr111i) ,ra' en'! eonrmacwd ma accordance
/tub 15.4 tia AC 02c.' .0100 or 15d NC -AG' 02( .0100 Well t'ansmAfton Standards- and that a
copy of this record has been provided to the vet! invnec 23. Site diagramor additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITrTAL INSTRUCTIONS
24a For All Wells: Sub �E �t�r� 30 days of completion of well
IrClYtil DW
construction to the followin . / NR/ R
Division of Water Resources, Information Processing Unit,
1617 Mail Servicejfy yer2 lei(arih JC27699-1617
24b. For Iniection Wells: In addition to sending the form to the address in 24a
above, also submit one copy of this form within 30 days of completion of well
construction to the Mowing Water Quality Regional
Operations S od�p
Division of Water Res rqy[y (t�t,"-''on Control Program,
wvicer) l 'RMem ,. og
1636 Mail Service nter, mg �99-t636
24c. For Water Snooty. & Injection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
completion of well construction to the county health department of the county
where constructed.
Fiona OW -I
North Carolina Department of Envirom
nal Quality - Division of W ater Resources Revised 2-22-2016

BORING LOG
VILLAGE OF BALD HEAD ISLAND
BALD HEAD ISLAND, NORTH CAROLINA
MW-8
Drilled by: Applied Resource Management
Logged by: J. Zuncich
Date: 3/20/17
Depth
(ft)
Description
Water.
Content
2 - 4
Tan light brown, silty to very fine sands with some shell fragments and
root matter.
Low
5 - 7
Beige to light brown, very fine to fine grained sands with minor shell
fragments.
Low to
Moderate
10 - 12
Gray brown, fine to medium sands with some coarse sand mixtures.
High
15 - 17
Tan to light brown, fine to coarse sand mixtures with shells.
High
18 - 20
Tan to light brown, fine to coarse sand mixtures with shells changing to
greenish gray, medium to coarse sands.
High
RECEIVED/NCDENR/DWR
MAY 2 2 2011
Water Quality Regional
Wilco aerations Section
gton Regional Office

MW-8
17' Sand
Protective Steel Standpipe
Lock
Ground Surface
2' Bentonite
v
2,5' Stick Up
-Concrete/Grout Crown
5' Riser
t
rs•••• •s••••
r•.••.. •••.•.
r•❖.. •••••••,
❖ ••• ,••••••:
r❖.••-,•❖•'
Groundwater • • • —3 • • •
Table ��• I—•••••i
•tYl_rr ti,
►1•.•.: •••••.
1 0 * * r•••••�
0010 • `• • •
►eke•••0*•111•••••
•,
1••••••—•••••I
••• ►•••
•
0••••i•••••;•
RECEIVED/NCDENR/DWR
•
i + i•i s•••••• MAY 2 2 20 7
1i••••S.Z • 20' Total Dept
• • • • • • • • Water Quality Regional
Operations Section
Wilmington Regional Office
15' Screen
Applied Resource
Management, P. C.
Hempstead, NC 28443
I TITLE:
JOB:
17059
AS -BUILT
SCALE: j DATE: DRAWN BY:
Not to scale; 4/06/17 1 KLC
WELL ID:
MW-8

Environmental Chemists, Inc.
envirochem
SM
ANALYTICAL & CONSULTING CHEMISTS
6602 Windmill Way, Wilmington, NC 28405 . 910.392.0223 Lab • 910.392.4424 Fax
710 Bowsertown Road, Manteo, NC 27954 • 252.473.5702 Lab/Fax
255-A Wilmington Highway, Jacksonville, NC 28540 • 910.347.5843 Lab/Fax
info@envi ronmentalchemists.com
Applied Resource Management
Post Office Box 882
Hampstead NC 28443
Attention: Joe Zuncich
Revised Report: May 09, 2017
Original Report Date: Mar 29, 2017
Report #: 2017-03937
Customer ID: 08100006
Project ID: Bald Head Island Wells
Lab ID
17-09390
Test
Sample ID:
Site: MW-8
Method
Collect Date/Time
3/21/2017 12:57 PM
Matrix Sampled by
Water Joe Zuncich
Results Date Analyzed
Ammonia Nitrogen
Total Dissolved Solids (TDS)
Chloride
pH
Total Phosphorus
Total Organic Carbon (TOC)
Fecal Coliform
1,1,1,2-Tetrachloroethane
1,1,1-Trichloroethane
1,1,2,2-Tetrachloroethane
1,1,2-Trichloroethane
1,1-Dichloroethane
1,1-Dichloroethene
1,1-Dichloropropene
1,2, 3-Trichlorobenzene
1,2,3-Trichloropropane
1, 2,4-Trichlorobenzene
1, 2,4-Tri methylbenzene
1, 2-Dibromo-3-C h loropropane
1,2-Dibromoethane
1,2-Dichlorobenzene
1,2-Dichloroethane
1,2-Dichloropropane
1,3,5-Trimethylbenzene
1,3-Dichlorobenzene
1,3-Dichloropropane
EPA 350.1
SM 2540 C
SM 4500 CI E
SM 4500 H 8
SM 4500 P F
SM 53106
SM 9222D MF
SW 846 method 8260B/5030B
SW 846 method 8260B/5030B
SW 846 method 8260B/5030B
SW 846 method 8260B/5030B
SW 846 method 826013/5030B
SW 848 method 826013/5030B
SW 846 method 8260B/5030B
SW 848 method 82608/5030B
SW 848 method 8260B/5030B
SW 846 method 8260B/5030B
SW 846 method 82608/5030B
SW 846 method 8260B/5030B
SW 846 method 8260B/5030B
SW 846 method 82606/50308
SW 846 method 8260B/5030B
SW 846 method 8260B/5030B
SW 846 method 82608/5030B
SW 848 method 8260B/5030B
SW 846 method 8260B/5030B
< 0.2 mg/L
297 mg/L
69 mg/L
7.87 units
1.54 mg/L
4.6 mg/L
240 Colonies/100mL
<0.5 pg/L
<0.5 pg/L
<0.5 pg/L
<0.5 pg/L
<0.5 pg/L
<0.5 NgIL
<0.5 pg/L
<0.5 pg/L
<0.5 pg/L
<0.5 pg/L
RECEIVED/NebWR
<0.5 pg/L
MAY 294.91E
<0.5 pg/L
Water Qua !W ?e,Iq al
Operation ffice
Wilmington 5 kIie
<0.5 pg/L
<0.5 pg/L
<0.5 pg/L
03/22/2017
03/22/2017
03/23/2017
03/29/2017
03/24/2017
03/23/2017
03/21/2017
03/22/2017
03/22/2017
03/22/2017
03/22/2017
03/22/2017
03/22/2017
03/22/2017
03/22/2017
03/22/2017
03/22/2017
03/22/2017
03/22/2017
03/22/2017
03/22/2017
03/22/2017
03/22/2017
03/22/2017
03/22/2017
03/22/2017
Report#:: 2017-03937
Page 1 of 6

ANALYTICAL & CONSULTING CHEMISTS
Environmental Chemists, Inc.
6602 Windmill Way, Wilmington, NC 28405 • 910.392.0223 Lab • 910.392.4424 Fax
710 Bowsertown Road, Manteo, NC 27954 • 252.473.5702 Lab/Fax
255-A Wilmington Highway, Jacksonville, NC 28540 . 910.347.5843 Lab/Fax
[e-mail]
Applied Resource Management
Post Office Box 882
Hampstead NC 28443
Attention: Joe Zuncich
Revised Report: May 09, 2017
Original Report Date: Mar 29, 2017
Report #: 2017-03937
Customer ID: 08100006
Project ID: Bald Head Island Wells
1,4-Dichlorobenzene
2,2-Dichloropropane
2-Chlorotoluene
4-Chlorotoluene
Benzene
Bromobenzene
Bromochloromethane
Bro mod ich loromethane
Bromoform
Bromomethane
Carbon tetrachloride
Chlorobenzene
Chloroethane
Chloroform
Chloromethane
cis-1,2-Dich loroethene
cis-1, 3-Dichloropropene
Dibromochloromethane
Dibromomethane
Dichlorodifluoromethane
Ethylbenzene
Hexachlorobutadiene
Isopropylbenzene
M+P Xylene
Methylene chloride
Naphthalene
n-Butylbenzene
n-Propylbenzene
ortho-Xylene
SW 848 method 8260B/5030B
SW 848 method 8260B/5030B
SW 846 method 8260B/5030B
SW 846 method 8260B/5030B
SW 846 method 8260B/5030B
SW 846 method 8260B/5030B
SW 846 method 8280B/5030B
SW 846 method 8260B/5030B
SW 846 method 8260B/5030B
SW 846 method 82606/50308
SW 846 method 8260B/5030B
SW 848 method 8260B/5030B
SW 846 method 8260B/5030B
SW 846 method 8260B/5030B
SW 846 method 8260B/5030B
SW 846 method 8260B/5030B
SW 846 method 826013/5030B
SW 848 method 8260B/5030B
SW 846 method 8260B/5030B
SW 846 method 82608/5030B
SW 846 method 8260B/5030B
SW 846 method 8260B/5030B
SW 846 method 8260B/5030B
SW 846 method 8260B/5030B
SW 846 method 8260B/5030B
SW 846 method 8260B/5030B
SW 846 method 8260B/5030B
SW 846 method 8260B/5030B
SW 846 method 8260B/5030B
<0.5 pg/L
<0.5 pg/L
<0.5 pg/L
<0.5 pg/L
<0.5 pg/L
<0.5 pg/L
<0.5 pg/L
<0.5 pg/L
<0.5 pg/L
<0.5 pg/L
<0.5 pg/L
<0.5 pg/L
<0.5 pg/L
<0.5 pg/L
<0.5 pg/L
<0.5 pg/L
<0.5 pg/L
<0.5 pg/L
<0.5 pg/L
<0.5 pg/L
<0.5 pg/L
<0.5 pg/L
<0.5 pg/L
<1.0 pg/L
<0.5 pg/L
RECEIVED/NCD t(yIIR
<0.5 pg/L
MAY 2 24g jg/LL
Water Quality<FQ giYr�ia/f
Operations Section
03/22/2017
03/22/2017
03/22/2017
03/22/2017
03/22/2017
03/22/2017
03/22/2017
03/22/2017
03/22/2017
03/22/2017
03/22/2017
03/22/2017
03/22/2017
03/22/2017
03/22/2017
03/22/2017
03/22/2017
03/22/2017
03/22/2017
03/22/2017
03/22/2017
03/22/2017
03/22/2017
03/22/2017
03/22/2017
03/22/2017
03/22/2017
03/22/2017
03/22/2017
Report #:: 2017-03937 Page 2 of 6

ANALYTICAL & CONSULTING CHEMISTS
Environmental Chemists, Inc.
6602 Windmill Way, Wilmington, NC 28405 • 910.392.0223 Lab • 910.392.4424 Fax
710 Bowsertown Road, Manteo, NC 27954 • 252.473.5702 Lab/Fax
255-A Wilmington Highway, Jacksonville, NC 28540 • 910.347.5843 Lab/Fax
[e-mail]
Applied Resource Management
Post Office Box 882
Hampstead NC 28443
Attention: Joe Zuncich
Revised Report: May 09, 2017
Original Report Date: Mar 29, 2017
Report#: 2017-03937
Customer ID: 08100006
Project ID: Bald Head Island Wells
p-Isopropyltoluene
sec-Butylbenzene
Styrene
tert-Butylbenzene
Tetrachloroethene
Toluene
Trans-1,2-Dichloroethene
Trans-1,3-dichloropropene
Trichloroethene
Trichlorofluoromethane
Vinyl chloride
Nitrate Nitrogen (Calc)
Nitrite Nitrogen
Nitrate+Nitrite-Nitrogen
Nitrate Nitrogen
SW 846 method 8260B/5030B
SW 848 method 8280B/5030B
SW 846 method 8260B/5030B
SW 846 method 8260B/5030B
SW 846 method 8260B/5030B
SW 846 method 8260B/5030B
SW 846 method 8260B/5030B
SW 846 method 8260B/5030B
SW 846 method 8280B/5030B
SW 846 method 8260B/5030B
SW 846 method 8260B/5030B
EPA 353.2
EPA 353.2
Subtraction Method
<0.5 pg/L
<0.51ig/L
<0.5 pg/L
<0.5 u9/L
<0.5 pg/L
<0.5 pg/L
<0.5 pg/L
<0.5 pg/L
<0.5 pg/L
<0.5 pg/L
<0.5 pg/L
0.39 mg/L
0.34 mg/L
<0.02 mg/L
03/22/2017
03/22/2017
03/22/2017
03/22/2017
03/22/2017
03/22/2017
03/22/2017
03/22/2017
03/22/2017
03/22/2017
03/22/2017
03/22/2017
03/28/2017
03/29/2017
RECEIVED/NCDENR/DWR
MAY 222017
Wty Region
Wilco natergtonl QualiReg Operatons oRne Officeal
Page 3 of 8
Report #:: 2017.03937

ANALYSIS REQUESTED
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WELL CONSTRUCTION RECORD
Fins Rum can be used lix >inele is multiple „all,
I. Well ('outraclor Information:
Lewis LeFever
Well Corn s`;mmr Nam).
2480
NC Well Gmnoctin Lendiemon Number
Parratt Wolff, Inc.
l �nnpvnc Nonni
2. Well (0Ru:tr'octiun Permit a:
l.,.v till uppbrable roll perm,iu ti-e- f'nonn. .ti.
3. Well Use (check well use):
MEW nee. b
Water Supply Well:
❑Agricultural
❑Geothermal (Heal(nJC'oo
❑Industrial/Commercial
❑Irrigation
Supply)
❑ Municipal/Public
O Residential Water Supply (single(
❑Residential Water Supply (shared)
Non -Water Supply Well:
Mon itorine
❑Recover)
Injection Well:
❑Aqui ter Recharge
❑ Ado i ter Storage and Recover)
❑Aquifer'lest
❑Experimental Technology
❑Geothermal (Closed Loopl
❑Geothermal (Heating/Cooling Return)
❑Groundwater Remediation
❑ Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑Tracer
❑Other.(explain under IQ l Remarks)
4. Date Well(s) Completed: 1 /15/08
5a. Well Location:
Greenfield Environmental Trust, LLC
Facility/Owner Name
120 Quality Drive, Navassa, NC 28451
Well ion MW-1 7
NCD980557805
Facility tD# (if applicable)
Physical Address- City. and Zip
Brunswick
310814440336
County Parcel Identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
{if well field, one la[/long is sufficient)
34° 14' 55.269" N 77° 59' 50.887"
6. Is (are) the well(s): ©Permanent or ❑Temporary
7. Is this a repair to an existing well: JVes or 0No
11- this is.. a repair, fill nut known well construction in(onmati°n and explain the nature Lithe
repair under 421 remarks ,section or on the back o/7his Rion,
8. Number of wells constructed:
For multiple injection nr non -water supply eels ONLY mill' /A
.submit one Arun.
ame construction, you ce
9. Total well depth below land surface: 37.0 (ft.)
For multiple yells list all depths ifdi(T-rem (crumple- 3C200' and 2O, /00')
10. Static water level below top of casing: 16'S3 (ft.)
If /ere/ is above caving time "'
11. Borehole diameter: 6'0 (in.)
12. Well construction method: Rotosonic
1 i.c. auger. rotary. cable. direct push. etc.)
FOR WATER SUPPLY WELLS ONLY:
I3a. Yield (gpm) Method of test:
13b. Disinfection type:
Amount:
°°r lummal I.c VNI
443On
14. WATER ZONES
FROM
TO
DESCRIPTION
16.53 ft-
37.0 ft.
Surficial
ft.
I5. OUTER
CASING (far multi -cased wells) OR LINER (if ap linable)
FRO.I
TO
DIAMETER
TFICKNESS
b1ATERLLL.
e.
in.
16, INNER
CASING OR TUBING
(geothermal closed -loop)
FRO11
TO
DIAMETER
THICKNESS
MATERIAL
0,0 °'
27,0 R.
2 m.
0.I:3144'70
SS
ft.
ft.
n.
17. SCREEN
FRO1I
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
27.0 ft'
37.0 f-
2 in,
0.010"
01,3434 (C0
SS
ft.
ft
in,
18: GROUT
FROM
l'O
MATERIAL
EMPLACEMENT METHOD & AMOUNT
0 0 f`'
16.5 It
cement/bent.
ft.
ft.
19: SAND/GRAVEL PACK
(if applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
24.0 ft
43.0 ft
#2
ft.
20. DRILLING.
LOG (attach
additional sheets if necessary)
FROM
TO
DESCRIPTION (color. hardness, soil/rock type. grain size, elc)
0.0 IL
9.0 YL
brown tan gray silty SAND
9,0 ft
11.0 ft•
gray sandy plastic CLAY
11.0 f.
13.0 it
gray clayey SAND
13.0 It
47.0 ft'
tan orange fine SAND
ft.
ft.
ft.
ft.
rt.
ft.
2LREMARKS
Well repairs were made by Parratt Wolff, Inc. 3/25/17 by adding
3.08' of PVC stick-up to the well
22. Certification:
9-2/- /7
Date
By signing this (rum, l hereby certi(: that the rell(.s1 n .v (were) e eetrucled in accordance
with l5d NC1C 02C .0)00 or 159 NCAC 02C .0200 Well Construction Standards and that a
copy of this record has been provided in ttre well °tiny ye,- -
23. Site diagram or additional well details:
You may use the back of this page to provide adgiiipyl,'ellssit ,als or well
construction details. You may also attach addition es ace4M3,
SUBMITTAL INS /NCDEN• & 1 Frl000s •i ng Un±t
❑❑ylCD�tk4-61etion of well
24a. For All Wells: Suomi[ this form within 30 da s
construction to the follow „g^
WAY
11 77
Division of Water Resources , information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For ln'ection We t iltYn IDtt@Ro sending the form to the address in
24a above. also stllpiHn within 30 days of completion of well
construction to the roflo'v, IRjegional Office
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supply & Injection Wells:
Also submit one copy of this form within 30 days ofcompletion of
well construction to the count' health departmentof the county where
constructed
x D
Form ON, I
North Car)1ina Depe
or Ennronment
d Natural Resources-D; vismnof 'aver Rc,vourcc
Revised Arigast'_013

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
For Internal Use ONLY
1. Well Contractor Information:
Lewis LeFever
Well Contractor Name
2480
NC Well Contractor Certification Number
Parratt Wolff, Inc.
14. WATER ZONES
FROM
TO
DESCRIPTION
6.78 ft.
27.5 rt.
Surficial
27.5 ft.
Pee Dee
15. OUTER CASING '(for imulti-cased wefsjOR.LINER (Rai . ltcable)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft.
rt.
in.
Company Naine
2. Well Construction Permit ft:
Lis/ all applicable well pcaon/ts tl. e Cnuim. Slate Variance, /ejection, eft.)
3. Well Use (check well use):
16. INNER CASING OR TIRING (geothermal closed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
0.0 ft.
27.0
2
in.
SS
ft.
ft.
in.
17. SCREEN
Water Supply Well:
❑ Agricultural
❑Geothermal (Heating/Cooling Supply)
❑Industrial/Conumerc ial
❑irrigation
Non -Water Supply W ell:
17Monitoring
❑Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
❑Recovery
Injection Well:
❑ Aquifer Recharge
❑ Aquifer Storage and Recovery.
❑ Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑ Geothermal (Heating/Cooling Return)
4. DRIP Well(s) Completed: 1/27/05
5a. Well Location:
Greenfield Environmental Trust, LLC
Facility/Owner Name
120 Quality Drive, Navassa, NC 28451
OGroundwater Remediation
❑Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑Tracer
❑Other (explain under #21 Remarks)
Well ID
MW-5
NCD980557805
Facility Mt/ (ifapplicablel
Physical Address. City. and Zip
Brunswick
310814440336
County Parcel Identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
ill well field. one lat/long ,e sufficient)
34° 14' 49.729" 77° 59' 57.713"
6. 1s (are) the well(s): ©Permanent or OTemporary
7. Is this a repair to an existing well:
[/)hie is a repnlr, /fll nut knuwm wad/ I mist)vi tl
c'peir nodal 4p/rcanal Av :leaor on the ha.
S. Number of wells constructed: 1
DVS or ❑No
inlorntmlon and explain the and
of hey lnat.
For multiple /nfauion ur noieweaer suppk ens ONLY vGln the same enuslruc ioa
submit Inc limn.
9. Total well depth below land surface: 37'0
Foe multiple le n-eth, liar alI l plh, ij dflle e r example- ii r: 00 and 2,Zn l00
ID_ Static water level below top of casing: 6.78
/l weon rlcrcu.. abna pre:, h;.r r
l I. Borehole diameter: 6'0
on.)
12. Well construction method: ROtosoniC
(ft.)
e. angel reet . cuht°. direct push_ ere
FOR WATER SI PPLV WELLS ONLA:
13a. \ ield (wpm) \ tethod of test:
13h. Disinfection type: ,Amount
FROM
27.0 ft.
TO
37.0 ft.
DIAMETER
2
in.
SLOT SIZE
0.010"
THICKNESS
MATERIAL
SS
ft.
ft.
in.
1S.:GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
00 a.
21.6 ft.
cement/bent.
ft.
ft.
ft.
ft.
19. SAND/GRAVEL PACK (if applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
24.8 f`
37.0
#2
R.
ft.
20. DRILLING LOG (a
FROM
0.0 ft-
TO
13.0 fL
h additional sheets if necessary)
DESCRIPTION (color. her ness, soil/rock type. grain size, et
tan gray orange silty sandy CLAY
13.0 f6
27.5 f`
gray tan brown sility fine SAND
27.5 rc
37.5 ft.
dark gray fine SAND w/ clay lenses
ft.
ft.
ft.
ft.
ft.
R.
ft.
21. REMARKS
Well repairs were made by Parratt Wolff, Inc. 3/25/17 by adding
2.97' of PVC stick-up to the well
22. Certification:
ofcernrea
I Contractor
y-z✓ -/ %
Date
Drumming this /nna, / hereby eern/,r that the went,' was (were) co»xn-nr tad in accordance
with 15.4 NCl e 02C _n100 or 154 VC'AC 02C 0200 lull (Union teflon SYmulnrds and Thal et
copy of this record ha, been pmndad In the well owner
23. Site diagram or additional well details T y t
You may use the back 0l' this page to pl ovldeTatldiAfooal w,eW sift d44d41Yxrr well
construction details_ You may also attach additional pages if necessary.
MAY .t'"2017
SUBMITTAL. INSTLCTIONS
24a. For All Wells: Submit this fon attarar3.0ndaysTori.cornpleritinaol well
construction to the Rdlowing_ e ,
Division of Water Resources. Information Processing Unit.
1617 Wail Service Center. Raleigh. NC 27699-1617
24b. For Injection WeIRE43EIVEDMOITIENDynistoig the form to the address in
'da above. also submit a cop,' of this mm wW1Ififir days Of eumpleuun or well
construction to the following'
Division of Water Resagys/As(ld5'gzrarf7
l Injection Control Program,
1636 Afail Service Center, Raleigh, NC 27699-1636
24c. For Water Supply S t \ 'e Is:
Vf�i C1u)Iti Rq2on I
.Also subunit one Copy of IIOpvOYiatSe gii011,��'.,s ur"I"Het
will construction to IhWitrlljfgj 'k(k1011dlillffleB the 0ount
nsf ruled. 'S
of
heft
Henn CA -I
nth Gl ,1
leg -atomic(
tart :n d ?)alai a
ill lava nO.»u _e.auu.. na egw.L DOH

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
For Internal Use ONLY
1. Well Contracmr Information:
Lewis LeFever
Well Contractor Name
2480
NC Well Contractor Certification Number
Parratt Wolff, Inc.
4 4
14. WATER ZONES
FROM
TO
DESCRIPTION
7.16 ft.
28.0 fi.
Surficial
28.0 ft.
95.0 ft.
Pee Dee
FROM
15. OUTER CASING (for multi -cased wells) OR LINER (if am lie hie) -
DIAMETER -
TO
THICKNESS
MATERIAL
ft.
ft.
in
Company Name
2. Well Construction Permit N:
Lis/ all applicable well permits an Coi
3. Well Use (check well use):
Slala. Ikv•iunoe, lnJeniu
16. INNER LASING OR TUBING (geothermal closed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
0.0 ft.
85.0 ft.
2
in.
Sch 40
PVC
ft.
17. SCREEN
Water Supply Well:
❑ Agricultural
❑Geothermal (Heating/Cooling Supply)
❑industrial/Commercial
❑ Irrigation
❑Municipal/Public
❑Residential Water Supply (single)
:Residential Water Supply (shared)
Non -Water Supply Well:
❑ Monitoring
Injection Well:
❑ Aquifer Recharge
❑ Aquifer Storage and Recovery
DAquifer Test
❑Experimental Technology
°Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling Return)
4. Date Well(s) Completed: 6/27/12
5a. Well Location:
Greenfield Environmental Trust, LTC
❑ Recovery
❑Groundwater Remediafion
:Salinity Barrier
DStorntwater Drainage
❑Subsidence Control
❑ Tracer
❑Other (explain under 421 Remarks)
Well MOMW-6D
NCD980557805
Facility/Owner Name Facility ID# lit applicable)
120 Quality Drive, Navassa, NC 28451
Physical Address. City. and Zip
Brunswick
310814440336
County Parcel Identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
of ae)I field. one tat/long is sntTic bent
34° 14' 49.397"
77° 59' 56.329"
6. Is (are) the well(s): °Permanent or °Temporary
7. Is this a repair to an existing well: D%es or ❑No
// ibis is a repair, lilt out Munn well c ntvtruniun in(orniminn and ecplain the nal
repair under .21 lemur-d:r- wiener or on the back al /his Fran.
8. Number of wells constructed: 1
Ln
11r
Fur n ndriple iflecrimn (Inmu r -u? /cv.vepph with ONLY with the .mnre rnmrruetimr. .14111,ar
.arhnril mm Inrnr_
9. Total well depth helms: land surface: 95.0 (ft.)
Fof faffiliptc,rel1ss My tin (frpliI J Il/<rnr rrrungh itr 20 wire
10. Static water level helms top nfcasing: 7.16
I L Borehole diameter: 6'0 (in.)
12. Well construction method: Sonic
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
85.0 ft.
95.0 ft.
2
in.
0.010"
Sch 40
PVC
ft.
ft.
in.
18_ GROUT
FROM
00 ft-
TO
77.5 ft'
MATERIAL
cement/bent.
EMPLACEMENT METHOD & AMOUNT
ft.
ft.
ft.
ft.
19. SAND/GRAVEL PACK (if applicable).
FROM
TO
MATERIAL
EMPLACEMENT METHOD
83.0 ft
95.2 ft.
#2
R.
ft.
20. DRILLING LOG (atta k additional sheets if uecessa
FROM
0.0 ft.
TO
28.0 ft
DESCRIPTION (color, hardness. soil/rack Pipe. grain size. etc)
tan brown gray fine grained SAND
28.0 ft.
40.0
dark gray fine SAND w/ clay lenses
40.0 ft
60.5 ft.
60.5 ft
95.0 ft
gray silty fine SAND w/ limestone, clay tense
dark gray silty fine SAND
ft.
ft.
ft.
ft.
ft.
ft.
21. REMARKS
Well repairs were made by Parratt Wolff, Inc. 3/25/17 by adding
2.58' of PVC stick-up to the well
22. Certification:
7
azure of Ceit'4Ted Well Contractor
Dale
Br signing rhir tin, r, I hereby ecrabi: awl hire irolltvl u s tail o-el mnsnvLim it
will; IS4 NCiC 02C. 0100 or /SI :VC4C 02C 0200 Ifb/I Canun-nariuu S'intloielc.
eapr of this regard has been provided in lire well abaci:
23. Site diagram or additional well details:
You may use the back dllff :Nge. tp Pryn(ide;"addintmal well site details or Well
consur¢hon details Yohftay,Alko attachcadditional pages if necessary
SCBMIITTAL INSTLCTIpy8S/ j, 1 2017
24a. For All Wells: Submit[Ins firm within 30 days of completion of vv•II
construction to the Iotlttkingite)c I I _
fY r
Division of Water Resources. Information Proccssiug Unit.
1617 ('taail SSerrvvicc(e`( enter. jRaalleigh. NC 27699-1617
24b. For IniecH61ZI el s C7M1' - 00Idi0011 to xnding the )drat to the address in
24a above. also submit a copy oh this form within 30 days of completion of well
construction to (he (it) ur 1_tg-
Y
aft.)
t1.c auger. rotas alhle dimct push_ ac)
[OR WATER SUPPLI
13 . Field (gm)
(gmm)
13h. Disinfection hpc
ELLS ONLF
Method:
ethod u f test:
\moon1:
15 2017
Division of Waver Resources. nderground Injection Control Program.
1636 A tail Service Center, Raleigh, NC 27699-1636
24c. FM' \\ratersuprygtekQ- 1)1htNiRPal
1Jpe d.IOH eL1I n (�
ALu submit on�ifmin 6 itfi i3n1 J ffiC'e days r f completion of
vest) r n-Duclion n ille all Ili earth department of the enmmv vv here
con -trusted
long (.aa
NIT( lmaD
II II II
.l V:aur L. -I ,i('.A,ne. Ie.

submit one form.
9_ Total well depth below land surface: Y
WELL CONSTRUCTION RECORD
TI•h them tan be wed for single or multiple melts
I. I Contractor Infors�dttja :� - \.
/ Atte /`�xi 22/ semi
Welt CmwactorNamc
3SVo A
NC lFellCoujii cte Clieri
"rhe 1 - r 7f
Company Nmnel O(.,,,s (,.J
2, Well Constmedan Fermin!: PI.JW 201) —O 00
3e
Lien aft applicable well pemtas (Le -County. Smrc, faridmq Tryecriam. etcl
3_ Weil Use (check well use):
Water Supply Well:
°Agricul➢ra1
°Gcothamal (Heating:Cooling Supply)
Di.�indrustrialiCommercial
OMunicipat+Public
°Residential Water Supply (single)
ORcsidastial Wier Supply (shared)
Non -{cater Supply All:
Ohlouitoring ORccovcry
Injection Well:
°Aquifer Recharge
O_lq➢ifer Storage and Rccovcry
°Aquifer Test
°Experimental Technology
OGcathamal (Closed Loop)
OGeothamal (Heating:Cooling Rmtm)
°GroundwaterRan cdiuian
°Salinity Banier
°StusmwuterDrainage
°Subsidence Control
°Tracer
OOtna-(cwplain under #2I Remarks)
4. Abate WeR(s) Completed: ( o` I —/Well Ili..
era. Wefl Locafan:
�sr9i4 F1211res/Ir
FacilitYOenciName Facility ID=(ntappliable)
702/ (awn" ek br, Oak /s/vid
Physical Address, City. and Zip ., .2 it GfeJ
r
'tJ YN S Wt e
Cmmty. Patrsl!aerniecatime No-ti`IN)
511, Ladmde and longitude in degreeshainutes/seconds ar decbdecimal degrees:
(ef av-Il field, ono WL9mia issuff cimu)
0
33*St'f/. rOt N 725/ tIt 537b l
6.Is (are) the well(s):terntment or °Tempter_sty
7_ Is this a repair to an existing wen: OYes or affiti
if Air is a repair. fill out brown welleansm¢Han information and explain the nature o_i der
repair under S2l remarks section or on the back of thisform
8. Number ulnas constructed:
For multiple Injection or ran -water mpply's-ells ONLY with the same canortaion, you tin
O
For mnlriple wells list all depths ifdrjli'r nt (example-iron_^(1°' and'tdhl0d5
10. Static water level below tap of clang:
If water lctrl is atone casing, use "
I1. Borehole diameter e) On,)
12. Well construction method: in V 4 , ,TJ9 r
(s e. auger, ratmM. cable. direct petit ere)
/0 e
(R)
(ft)
FOR WATER SUPPLY \YEL S ONLY
Yield (gpm)
7St
3h. Disinfection type:
Method of test: 10 f r L ,'Y' t-
Amount: Vq rr
Fenn City-1 Noah Camlhm Depmmmt o(Fmv
Forbaenmlitse ONLY: 4 4 3 2 91
�J
14. WATERZON ES
FROM
TO
DESCRIPTION
/0 tr.
ft
f
3o
./Ag
,St) ft-
9a ft
L/nneswrf ` .
IS. OUTER
CASING Car
ronl6-essedeeps) OR LINER Oran 6fel
PROM
To
DIAMETER THICRNPss MATERIAL
'fr[ IL
6-2-IL3
t( in' j h. vo Pere
WINNER
CASUCG OR TDBING(genrh
tnral dosed4ocp)
FROM
To
➢LAMETER
MATERIAL
ft.
ft.
is
jTifCear�
IL
ft.
a
it SCREEN
FROM To�(Jt
surf ME
TFIICRRESi
MATERIAL
(
p
sDIAMEIEER/
�-
IL V
�/ ' Mtn,
1S GROUT
FROM
TO
MATERIAL
EMPLACEMENT MIETI10➢ & AiIO lT
- P(rT.re dl
0
.2,0 (L
%3er.. r chip
R
ft
ft.
{L
19. SANDIGRACEL
PaCk
taappfcable)
FROM
TO
MATERIAL
EMpWaEHEAT MLTHOn
ti
rt
ft.
D.
20. DRIESDia
LOG later
is additional sheen if nesetsaer)
FROM
TO
t DESCRIPTION utter. prdear. soiUkark tee; .min SOS net
O ft
30 ft.
JAe-fd
3 o (L
qr ft.
c/At_ r ,i A e //
VC'
90 ft
t-/tor XTv..e-e.
tL
ft.
IL
fL
R
IL
.6
¢'
ft.
ft.
APR 2 R®17
21, IlMARKS
21 Ces"uf
Si_enatwe of Ced well onoaetor
say /7
Date
Sr signing this fomt. 1 hereby cerdj- that the was) was (*ere) eonrrnarcd 9, acco ds=
with 15.43CdC OL.OIooar 15.-LF'CAC 02C-0200 Wag Construction Standards and that
caps M thin record has been prarided to the well owner.
23, Site diagram or additional well details:
Sou may use We back of this page to pmwide additional well site details or well
cunsbuction details. You may also attach additional pages if necessary.
SUBMITTAL INSTUCTIONS
24a. For All Wells: Submit this from within 30 days of completion of well
construction to the fallowing: �1 pi(s
Division of Walkaaa(tLWa R ing Unit,
1E17 Mail Service Center, Raleigh, NC 27699a6I7
24b. For Injection Wells Oii''LYi hffpa i(ito tag np the farm to the adtkess in
24a above, also submit a copy at1 tfi1 fol•Inlivighlhl SO days of completion of u-dl
conshuctioo to the following:
Djyision ofWrnerResest all (glint) lltr{n Control Program,
1636 MaU Service g iR ,kq,7699.163E
24c For Water Supply &1 A'diC Ai>;:Regional Office
Also submit one copy of this form within 30 days of completions of
well cmuauaims to the county health department of the county where
constructed,
iwntand Nanaal Resowee -Division of Water Besowm
Awned Aumnat 2013

7P
7,
it; I-
to 3
/4 7
((o
r1y
7'4
2-3z
2-39
7D
71
wZ
/03
l4/4
( 7
((0
rtvs-
7-4
2- 3 1
9-3
2-3^
r4
a- 7a
Micd
Oct S79i'-e-
ier
Come. s o.M-
dm y
£Cna_ S 7-tn.
scar
4(01y
C ST220"--
dl4.Y
Cr'Ste,
dirt
01.0(
1

WELL CON$YRUCTIo1V RECORD LGW D
1. Wen Contactor
For Internal Use Only
wenconantorxmne
411
Comm Nome
2. Wen Construction Permit#•. /�
List ail applicable weucosllactIonpermit: (.e. UIC County. gage, Partance, etc)
3. Well Use (check well use):
t�aWi �^ater_Suppty Well:
La"w"""l . `P""'wei lie
®Geothermal (Beating/Cooling Supply) dmtial Water Supply (single)
f lndusaiavCommesc(at ®Residential Water Supply (shred)
I�biinUon
Non -Water Supply Well:
EiMonitoring DRecovay
jeetioa Well:
DAguit'er Recharge
DAqutfer Storage and Recovery
("Aquifer Test
DExPerimenla►Technology
OGe the oral (Closed Loop)
13a. Yield (gpm)
9. Total well depth below land surface: AN)
Farmahlple wall its depths reiffe ens (
10. Static water level betow.top Messing:
(water level&aboveemhrg are ••+•
1L Borehole diameter:
12. Wen construction method:
de auger, runty, able, fired pmb. eau.)
oGramdwater Remediation
OSalioityamnia
OStonnwater Drainage
®subeidenceCmdrol
Drawer
f oeot iemel glmting(Coolibg Rolm) Othe•(explain undvp21 Ramada)
4. Date Well(s)Completed:y�?Other
' TWeil IDE
Se. Wen Location: ss
/Owner me Faeniylo# ftfapptiable)
9e93�i'r d. t 414 kG ?,1?W u)
Physical. City, andZp
kg R lee
Comity Panel Identification No. (PIN)
Sb. Latitude and lougitudeIn degrees(minutes(secoyds or decimal degrees:
(dwell Sold, one htl(oag is sainoien0
22. CerIB
4 3290 a—T
araDDREiVa—
= _u:—t
F
Iro
ft.
FROM' . TO
FROM I TO
iL
ft.
R
VOOSZREROUS,?.&4,
FROM TO
pe
f`
TO
DR S-�
FROM TO
l60Q 7oIi
FROM
ft. R
To
2.4ra. ;sue
3 in*
b Gp
DESMOPTION
»
n1AMSTER
in.
in.
In.
Ia.
TRIOMUaS
iitfte
MA,cr.M;r
TERIAL
o JL
PC.
amnion &AMOUNT
ell
sea
MEtROD
DESCRIPTtORaistsreh tda¢r.soBlmeatomemio ¢,Mel
Izat
414
CIA 57PaREGE1
_-re,s.(t-.F,�. Ott
Information Pfocossir.0 ONi
nu
v Cb'GU(j
1407
6.Is(are)thewdi(s)cermanent or Di enrporary Sigma=ofCddfiFdWett
Date
7.Is this a repair to an By algalag ibis farm.I hereby that the wed) war (wag) eamtnaed di&cork= .
lEirdOg well: ®�'es &t' p+�a with ISA=ICO2C.0IIDorISA N g
tfthafearspak"oat Iwoww welt construction hrfometienod*Veal She naoveaftha IPY"thtrneaordhae bin pOvided d4 dardi'and that a
repalrrader#2I rowans section or on theback°fthefont -
23. Site diagram or additional well defans:
8. For Geoprobe(DPT orChned-Loop Geothermal Wens having the same You nray use the book of this pogo to 'gggli yea site ddalis or well
consauclfon,only IOW-Iisneeded. Indicate TOTALNUMBER of wells construction details. You mayalmaOa phgEArif drilled: necemmy.
$UBMITPALINSTRUCTIONS
(ft.) 24a. For An Wens: Submit drisWater Quality R o i
emmp(e-3(a]200•md2(1�1U0yt�(aex�ng� completion of woll
comauctiontothefolbwing: Wilmington Regional Office
(D•)
FOR WATER SUPPLY WELLS ONLY: _
!0 Method of test: 17,✓
13b. Dis(nfedlon type: efithati Anoint pa
Dividon.ofwater Resources, Information Processing Unit,
1617 Man Service Center, Raleigh, NC 27 99-1617
246. For Iwiet&in Wen : In addition to sending the form to the address in 24a
above, also submit one copy of this tkin within 30 days of completion of well
constructon to the following:
Division of Waterltesources, Underground Injection Control Program,
1636 Mali Service Center, Raleigh, NC 27699-1636
24c. for Water Snooty & Iniedion Way In addition to sending the form to
the address(ea) above, also submit one copy of this font within 30 days of
where completion
of well ctee aensnuction to the county health depaament of the aowty
3E 01 33n N 71`,e 3Se ¶ /..
FarmOw.1
North Carolina Downturn of Environment Quay - Division of water Resoumos
Revised 2-22•2018

WELL CONSTRUCTION RECORD
For Internal Use ONLY:
This form can be used for single or multiple wells
1. Well Contractor Information:
Chip LeFever
Well Contractor Name
2480
NC Well Contractor Certification Number
Parratt Wolff, Inc.
443163
14. WATER ZONES
FROM
TO
DESCRIPTION
1.0 D.
20.6 ft.
Surficial
20.6 ft.
60.5
Pee Dee
15. OUTER CASING (for multi -eased wells) OR LINER (Ifapplicabie)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft.
ft.
In.
Company Name
2. Well Construction Permit #:
List all applicable well permits (i.e. Cluny, State, Variance. In/ectio
3. Well Use (check well use):
tc.)
Water Supply Well:
DAgricultural
°Geothermal (Heating/Cooling Supply)
0(ndustrial/Commercial
❑ Irrigation
Non -Water Supply Well:
aMonitoring
OMunicipal/Public
°Residential Water Supply (single)
❑Residential Water Supply (shared)
DRecovery
Injection Well:
°Aquifer Recharge
DAquifer Storage and Recovery
o Aquifer Test
°Experimental Technology
OGeothemntl (Closed Loop)
°Geothermal (Heating/Cooling Retum)
°Groundwater Remediation
❑Salinity Barrier
OStormwater Drainage
❑Subsidence Control
°Tracer
°Other (explain under (i21 Remarks)
16. INNER CASING OR TUBING (geothermal closed -loop).
FROM
TO
DIAMETER
THICKNESS
MATERIAL
0.0 D.
50.1 f°
2
in.
304
SS
ft.
in.
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATEm.AL
50.1 fit•
59.9 fit•
2
in.
0.010"
304
SS
ft.
ft.
in.
18. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
0.0 ft.
41.5
cement/bent.
ft.
ft.
ft.
19. SAND/GRA
FROM
TO
PACK (if applicable)..
MATERIAL
EMPLACEMENT METHOD
46.5 ft.
60.15
prepack +GP#1
ft
20 DRILLING LOG (attach additional sheets if necessary)
FROM
0.0 ft.
TO DESCRIPTION (color, hardness, soil/rock type, grain size, etc.)
5.0 fit. gray silty fine sandy plastic CLAY
4. Date Wen(s) completed: 3/12/17
Well ID# MW-32D
5a. Well Location:
Greenfield Environmental Trust, LLC NCD980557805
Facility/Owner Name Facility IDN (if applicable)
120 Quality Drive, Navassa, NC 28451
Physical Address, City. and Zip
Brunswick 310814440336
County
5.0 D,
46.0 ft• gray dk gray fine to med SAND w/ clay lens¢
46.0 ft.
60.5 ft• dk gray silty fine to med SAND w/ sandstone
ft.
ft.
n.
ft.
ft.
ft.
ft.
2
DNAPL measured thickness of 5.42 ft on 3/21/17
Parcel Identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22. Certitic
(if well field, one lat/long is sufficient)
34° 14' 48.841" N 77° 59' 56.383"
6. Is (are) the well(s): ©Permanent or °Temporary
7. Is this a repair to an existing well: Oyes or E1No
If this is a repair, fill out known well construction information and
repair under #21 remarks section or on the back of this form ,. 4Y V
1
8. Number of wells constructed: R ®p) ip o
For mndliple injection or non -water supply wells ONLY with the sane cdAw is r c2
submit one,finm.
9. Total well depth below land surface: 60.15 in51?rmatl0la Proett�
•
For multiple wells list all depths if different (example- 3C200 • and 2@a 100') D
10. Static water level below top of casing: 3.34
//rater level is above casing use "+"
11. Borehole diameter: 8.25 (in.)
12. Well construction method: hollow stem auger
(i.e. auger, rotary, cable, direct push, etc.)
(ft.)
tion:
-/7-i7
ture ofCertitl&Well Contractor Date
By signing this form. I hereby certib' that the well(s) was (were) constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C .0200 Well Construction Standards and that a
cap, of this record has been provided to the well owner.
P3 Si a diagram or additional well details:
Tou may use the back of this page to provide additional well site details or well
17onstmction details. You may also attach additional pages if necessary.
SUBMITTAL INSTUCTIONS
.Ss191'or All Wells: Submit this fonn within 30 days of completion of well
construction to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NCpptl2776699-1617
24b. For Injection Wells f ECEIVEQ/mC t thAgrhe form to the address in
24a above, also submit a copy of this form within 30 days of completion of well
construction to the following: nit pp�
Division of Water Resources Rd2gTbuqqpp177ZW Ujection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supply & In' fk 469QLr_Ilty Regional
f!1'tiblis3Settenf completion at
�stiRgglc©fficqounty where
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type:
Amount:
Also submit one copy of this
well construction to the c
constructed
Form GW- I
North Carolina Department of Environment a d Natural Resources- Di
ter Resources
Revised August 2013

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
1. Well Contractor information:
Chip LeFever
Well Contractor Name
2480
NC Well Contractor Certification Number
Parratt Wolff, Inc.
Company Name
2. Well Construction Permit 8:
List all applicable well permits (i.e. County, State. Variance. In/eetion, etc.)
3. Well Use (check well use):
Water Supply Well:
DAgricultural
❑ Geothermal (Heating/Cooling Supply)
❑industrial/Commercial
❑Irrigation
Non -Water Supply Well:
I7Monitoring
O Municipal/Public
❑ Residential Water Supply (single)
▪ Residential Water Supply (shared)
❑Recovery
Injection Well:
DAquifer Recharge
DAquifer Storage and Recovery
DAquifer Test
O Experimental Technology
OGeothermal (Closed Loop)
DGeothermal (Heating/Cooling Retum)
4. Date Well(s) Completed: 3/14/17
5a. Welt Location:
Greenfield Environmental Trust, LLC
❑Groundwater Remediation
❑Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
DTracer
❑Other (explain under #21 Remarks)
Well ID# MW-32
NCD980557805
Facility/Owner Name Facility ID# (if applicable)
120 Quality Drive, Navassa, NC 28451
Physical Address, City, and Zip
Brunswick
310814440336
County Parcel Identification No. (PIN)
56. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
34° 14' 48.892" N 77° 59' 56.268"
6. Is (are) the well(s): ©Permanent or DTemporary
7. Is this a repair to an existing well: Dyes or allo
(Phis is a repair, fill mu known well constriction information and explain the nature of the
repair under 621 remarks section or on the back ofthis form.
8. Number of wells constructed: 1
For multiple injection or non -water supply
.submit one, form.
For Internal Usc ONLY:
443102
14. WATER. ZONES
FROM
TO
DESCRIPTION
3.34 It
20.6 ft.
Surficial
20.6 fit.
40.0 ft.
Pee Dee
15. CASING (for multi -cased ells) OR LINER (if templet
FROM
ft.
TO
ft.
DIAMETER
In.
op
THICKNESS 1 MATERIAL
16. INNER CASING OR TUBING (geothertnal closed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL.
0.0 n.
30.06 ft.
2
in.
304
SS
It.
ft.
in.
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
30.06R'
40.2 R.
2 in.
0.010"
304
SS
ft.
ft.
in.
18. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
0.0 D.
23.0 fL
cement/bent.
ft.
rt.
ft.
19. SAND/GRAVEL PACK (if applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
30.06 rt.
39.9 et.
prepack +GP#1
ft.
20. DRILLINGLOG (attack additional sheets if necessary)
FROM
0.0
5.0 n.
TO
5.0 ft.
40.0
DESCRIPTION (color, hardness, soil/rock type, grain size, etc.)
gray silty fine sandy plastic CLAY
dk gray yellow fine to med SAND w/clay
ft.
ft,
ft.
ft.
ft.
21. REMARKS.;
well developed on 3/25/17
22. Certification:
gnature of Cettified'Well Contractor
cE /Z---/7
Dale
By signing this firm. I hereby certify that the well(s) was (were) constructed in accordance
with 15A NCAC 02C .0100 or 15A NCAC 02C .0200 Well Construction Standards and that a
copy of this record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
I I gilt details. You may also attach additional pages if necessary.
lls ONLY with the same cars ' .a'�r i�
2 �a q SS TAL INSTUCTIONS
9. Total well depth below land surface: 40'20 APR (Iy,) yxpps For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths iifdWerent (example- 3@.200' and 2 cei 100') construction to the following:
3.34 1.ri irilaticn Proces&fnJ Unit Division
Division of Water Resources, Information Prossin Unit,
ce
10. Static water level below top of casing: DvofUtjiG aMMs
If water level is above casing use "+" 1617 Mail Service C YtPC/ts
ENRAVR
11. Borehole diameter:
8.25 (in.) 246. For Injection Wells ONLY: In addition to sending the form to the address in
hollow stem auger 24a above, also submit a copy of this form within 130 days of completion of well
12. Well construction method: construction to the following: APR 2. Y 20 .7
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
1313. Disinfection type: Amount:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center.waterejRll��'+� egiOn 6
di
24c. For Water Supply & Injection Wet peE l'attiiOpfl°•S Sec5tionfr
Also submit one copy of this foririfltithT)Ih1J BIayagt4$�ipl�tlPof
well construction to the county health department of the county where
constructed
Fonn GW-I
North Carolina Department of Environment and Natural Resources - Division of Water Resources Revised August 21113

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
I. Well Contractor Information:
Chip LeFever
Well Contractor Name.
2480
NC Well Contractor Certification Number
Parratt Wolff, Inc.
Company Nam°
2. Well Construction Permit #:
List all applicable well permits (i.e. County. State, Variance. (t/ecdon, etc.)
3. Well Use (check well use):
Water Supply Well:
❑Agricultural
:Geothermal (Heating/Cooling Supply)
:Industrial/Commercial
❑Irrigation
Non -Water Supply Well:
aMonitoring
:Municipal/Public
:Residential Water Supply (single)
:Residential Water Supply (shared)
:Recovery
Injection Well:
:Aquifer Recharge
: Aquifer Storage and Recovery
OAquifer Test
: Experimental Technology
:Geothermal (Closed Loop)
:Geothermal (Heating/Cooling Return)
4. Date Well(s) Completed: 3/10/17
5a. Well Location:
Greenfield Environmental Trust, LLC
Facility/Owner Name
OGroundwater Remediation
DSalinity Barrier
❑ Stonnwater Drainage
DSubsidence Control
: Tracer
OOther (explain under #21 Remarks)
Well ID# MW-31
NCD980557805
Facility ID# (if applicable)
120 Quality Drive, Navassa, NC 28451
Physical Address, City, and Zip
Brunswick
County
310814440336
Parcel Identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one tat/long is sufficient)
34°14' 52.117" N 77° 59' 47.346"
W
6. Is (are) the well(s): OPermanent or :Temporary
7. Is this a repair to an existing well: :Yes or allo
If this is a repair.fill out known well construction information and explain the nature of the
repair under #21 remarks section or an the hack of this form.
For Internal Use ONLY:
443161
14. WATER ZONES
FROM
TO
DESCRIPTION
3.24 ft
40.55 ft•
Surficial
R.
ft.
15. OUTER CASING (for multi -cased wells) OR LINER (if applicable)'
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft.
ft.
in.
16. INNER CASING OR TUBING (geothermal closed -loop)
FROM
TO
DIAMETER
THICKNESS
MATE.RIAI.
0.0 rr.
30.4 ft'
2
in.
sch 40
PVC
FL
ft.
in.
17 SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
30.4 ft•
40.2 it
2
in.
0.010"
sch 40
PVC
ft.
ft.
in.
18 GROUT
FROM
r0
MATERIAL
EMPLACEMENT METHOD & AMOUNT
0.0 ft.
22.0 ft.
cement/bent.
ft.
ft.
19..SAND/GRAVEL PACK (if applicable). `..
FROM
TO
MATERIAL
EMPLACEMENT METHOD
27.0 ft.
40.5 ft.
prepack +GP#1
ff.
ft.
20. DRILLING LOG (atta Nadditional sheets if necessary)
FROM
0.0 ft.
5.0 ft.
TO
5.0
21.5 fL
DESCRIPTION (color, hardness, soirock type, grain size, etc.)
loose gray brown silty fine SAND
loose dense gray yellow fine to med SAND
21.5 n.
40.0 ft•
dense brown fine to med SAND w/ clay tense
ft.
n.
ft.
R.
R.
R.
'.21 REMARKS
well developed on 3/14/17
22. Certification:
ignature of Cedd Well Contractor Date
By signing this form, I hereby cert((y that the well(s) was (were) constructed in accordance
with 15A NCAC 02C .0100 or 15A NCAC 02C .0200 Well Construction Standards and that a
copy of this record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
S. Number of wells constructed: 1 FF�� yyyy s5 o (Tfli,'. aay'ri details. You may also attach additional pages if necessary.
For multiple injection or non -water supply we/Is ONLY with the same con(Z6c' tYyycc' i x..�. I.✓
submit one form. dd�� 2411
S (UBMITTAL INSTUCTIONS
9. Total well depth below land surface: 40.55 APR f(0'L9 Z4A1 For All Wells: Submitthis form within 30 days of completion of well
For multiple wells list all depths if different (example- 3@200' and 2 a 100') construction to the following:
10. Static water level below top of casing: 3.24 information Processing Unit
DVd Division of Water Resources, Information Processing Unit,
If water level is above caring. use "+" 1617 Mail Service Center, Raleigh, NC 27699-1617
11. Borehole diameter: 8.25 (in.)
12. Well construction method: hollow stem auger
(i.e. auger, rotary, cable. direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
246. For Iniection Wells ONL0.rEeh4 MAt(ri`tU'SdnFRt 4IMrm to the address in
24a above, also submit a copy of this form within 30 days of completion of well
construction to the following: ((((ppR qq, nnt77
Division of Water Resources, UfinhrgroNn4l 2h1fon Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supply & tftjectioWrYMIsQuality Regional
Also submit one copy of this form 0.1ftftratittifftleadifilinpletion of
well construction to the county t hhtlriiYt'l?nt if , 1Of18ieatiie@y where
constructed
Form G W-I
North Carolina Department of Environment and Natural Resources - Division of Water Resources Revised August 2013

tAiittnotA
WELL CONSTRUCTION RECORD (GW-1)
1. Well Contractor Information:
John Salmon
Well Contractor Name
3497-A
NC Well Contractor Certification Number
Applied Resource Management, P,C
Company Name
2. Well Construction Permit if:
List all applicable well eonctruction pennies (i. e. UIC, Co
3. Well Use (check well use):
N/A
m. Slate, Variance
Water Supply Well:
[Agricultural
Geothennal (Heating/Cooling Supply)
Industrial/Commercial
x ,Irritation
Non -Water Supply Well:
Monitoring
Injection Well:
Aquifer Recharge
.Aquifer Storage and Recovery
jAquifer Test
DExperimental Technology
R__ Geothennal (Closed Loop)
(Geothennal (Heating/Cooling Return)
DMunicipal/Public
DResidential Water Supply (single)
DResidential Water Supply (shared)
Recovery
Groundwater Remediation
DSalinity Bather
0IStonnwater Drainage
'Subsidence Control
jTracer
['Other (explain under #21 Remarks)
4. Date Well(s) Completed: 3/23/17
Well # N/A
MN
5a. Well Location: Hubbard Residence N/A
Facility/Owner Name Facility IDk (if applicable)
1007 Coralberry Ct, Leland, NC
Physical Address, City, and Zip.
Brunswick 037NJ031
County Parcel identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one /at/long is sufficient)
34 13 28.0476 N 78 1 47.8727
6. 1s(are) the well(s){}Permanent or QlTemporary
7. Is this a repair to au existing well: QYes or x©No
If this is a repair,fill ow kaolin well construction information and explain the nature of the
repair under 01 remarks section or on the back of this form.
8. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction, only I GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled:1
9. Total well depth below land surface: 55
For multiple we/le list all depths ifdfferent (example- 3@200' and 2Ia100')
(ft.)
10. Static water level below top of casing: 1 0 (ft.)
If water level is above casing, use "-
11. Borehole diameter: 4 (in.)
12. Well construction method: Mud Rotary
(i.e. auger. rotary, cable. direct push. etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) 60 Method of test: Airlift
13b. Disinfection type: HTH Amount: 3%a©10g
For Internal Use Only:
448041
Print Form
14. WATER ZONES
FROM
TO
DESCRIPTION
ft
ft
ft.
it.
FROM TO
15. OUTER CASING (for multi -cased. wells) OR LINER ('f ap)1/cable)
DIAMETER
0 ft. 45 ft,
4
in.
THICKNESS MATERIAL
SCH40 PVC
1.6. INNER CASING OR TUBING (geothermal closed -loop)
DIAMETER
FROM
ft,
TO
ft
in
THICKNESS
MATERIAL
ft.
17. SCREEN'
ft.
in.
FROM
45 ft
TO
55 ft,
DIAMETER
4
in
SLOT SIZE
.010
THICKNESS
SCH40
MATERIAL
PVC
ft.
R,
in.
18. GROUT
FROM
0 ft.
TO
45 2.
MATERIAL
Bentonite
EMPLACEMENT MEP] OD & AMOUNT
Poured
ft.
ft
ft
ft.
19. SAND/GRAVEL PACK (if applicable)'
TO
FROM
45 ft
55
ft.
MATERIAL
#2
EMPLACEMENT METHOD
Poured
ft.
ft.
20. DRILLING LOG (attach additional sheets if necessary)
DESCRIPTION (color, hardness, sail/rock opt- grain siu etc.)
Sand coarse sand
FROM
0
ft,
35 ft.
£t.
TO
35 ft.
55 ft-
Limestone sandy deposits
ft.
ft.
ft.
RECEIVED
R,
ft.
ft.
ft
APR 1.7 2017
21. REMARKS
i61111m hkl6tini ot.t,bstissp
uvvQ/E1CA,
22. Certification:
y' 5./7
Date
/3v signing this form, I hereby certify that the we/1(s) was (were) constructed in accordance
with ISA NCAC 02C .0100 or I5A MCA(' OK 0200 Well Coiutncvion Standards and that a
copy oft is record has been prodded to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTRUCTIONS
24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
Division of Water ResRfacalinglOtinn Unit,
1617 Mail Sen'ice Center, Raleigh, NC 27699-1617
24b. For Iniection Wells: In additionA�p i t th to the address in 24a
above, also submit one copy of this fdHh itilit n3041 }g 1S of completion of well
construction to the following:
Division of Water Resources, LWt��rQlk�
^'nY 1 )IU94636 Program,
1636 Mail Service CenOWilatjf 16edA3179-1636
al Office
24c. For Water Supply & IniectionWells:
Eton In aedldition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
completion of well construction to the county health department of the county
where constructed.
Fonn GW-1
North Carolina Department of Environmental Quality - Division of Water Resources Revised 2-22-2016

WELL CONSTRUCTION RECORD
This Icon calla used iorsirgie et multiple walk
1. ell Contractor lnfoen,n�tf1
L n:
RR/S0Adi
Well Contractor Name
3_3- %0 A
Company Mvne
2. VCe(1 Canst rued= Permit n_ fl/vM .2 017 1)00
Lin off app)icnble well pennds tie. Corms: Sate. Variance. Infection. ctci
3. Well Use (check well use):
NC Well Co actor CadltationNmm
Pik (,,/Gi,
Water Supply Well:
a 1guicultural
°Geotteamal (Hcating./'Cauling Supply)
OlndnstriallCommacial
,byaa2ation
OMunicipalPohlic
OResidaitial lYaia-Supply (single)
DRe.sidential Wala Supply (shared)
Non -Water Supply Well:
°Monitoring °Recovery
Injection Well:
°Aquifer Recharge
°Aquifer Storage and Rccaray
°Aquifer Tot
OExpe imattal Technology
OCcothamat (Closed Loop)
OGeothamal (Ilca1ing.Cool-mg R-mm)
°Groundwma Rmmediation
°Salinity Barrier
°Stamm= D,muagc
OSubsidatec Control
OTraccr
OOher (explain undo -21 Remarks)
a. Date Wdtts) Completed: 3 a? % //lint ID:
5a.\Vel 4ocationh
0i/*e Rdbet-TS
Facility/OsmerName
S� O 6, &nc4 or.
Ph sic dAddrazs, City. and Zip
grvNS La i f c`L
Cmmty
Facility Ma itfappIi able)
h /.r/r
02d flj
Parcel idenh.fcatian Na kPIG)
51n. Latitude and Lm4,itude in de„mees/minntes/secondsar declain degrees:
(ifwcll tiekL ant Iauk ne is sufficient)
3 3' Y`3 3,P$1 7ij06 f3 2. /76dr W'
6. Is (are) the 'velt(s): kennanent or OTemporaiy
7. is this a repair to an existing wen: OYes ur k1Qu
If this is a repave, full out [own well cans:ruaion iigivniarion and exploit thc nature of the
repair under S21 remarks section or on the backofthis firm.
S. Number of was constructed:
For multiple injection or non -water suppl irel& GHEE with the same ammtaion, you can
submit one form. �
9. Total well depth helow lend surface: J" (tt)
For multiple wells list all depths ifdrfferent (example- 3.a•200' and(41001
Ill Static water level helow cop of rasing:
!teener level is above casing, try ^+••
11. Borehole diameter CO
(in,)
m
12. Well construction ethod: Vdjj/20ner)
it c. anger,ramy. cable, data melt de
O p
(R)
PORWATER SUPPLYY V.TI IS ONLY: p�
23a Yield (gum) 51) ell
of test: girl Pc n ,o
13b. Dlsiufection type. /g if74 a 6) Amount: / 9 Cry
Fenn OW -I
For Internal Vise ONLY:
44259"/
24 WATER ZONES
FROII
(O
70
DESCRIPTION
f�Nd
J5- ft- I 70 R e-/en e_ not.-e
1S OUTER CASING tformolticosednelsl 062uNER tila1n ice rue)
FROTIMMS
-F-/A' R i 68 TO DLAMETIER nZ St® R ben
16. INNER CASING OR TURlNGje otheratat closed -leap)
THIC1Dvss
PROM TO
DIAMETER
R R in I
R
ft.
17. SCREEN
MATERIAL
FROMft.
I. TO DIAMETER. SLOTS= I TWCICCESS MI,&TFatat
ft. M - I
It GROUT
FROM
1'
IL
TO
a R
R
ft.
LAL
NIA
OF to
EMPLACEMENT METHOD &.uIOI/NT
ChLiaJ- ("6 ore J
MATERIAL EMPLACEMENT METHOD
1R. DR/LLTNG LOG tettaeb additional sheers fin e ....pl
DESCRIPTION cake modes soffit -ad; troe entrant ski
I� ec f7%
tie
z R c7/9 y
SS-t` L( t-ri e 5 7u� •-e
ao R
r
19. SAN71/GRAY'EL PACK (ifuneatable)le)
FROM TO
R.rr.
rr. rt.
PROM
0 R
1t.
R
R
TO
�® tt
-2S &.
S tc
8-0 ft.
21. REISARES
22. Ce�
Sims te ea
R
ft_
fr.
RECEIVE
MAR 302017
191fO1mWatirr Procuring
Date
3r signing thin farm:• I hcrebp certify that the 'reFl(r1 was (wee) conrrne,rcd b: a coniun_-e
with 15.4 h:CAC 02C.0,00 or ISd A'CAC 02C-020011 Well consa,¢dan Sma nda and duff a
cop-t• of this rerord has been provided to the well Dower.
23. Site diagram or additional well details:
You may use he back of this page to pmtidc additional mil site details or Well
cmatruon deta
ils. You may also attach additional patio if necessary.
SUBMITTALINSIUCTIONS
Zia. For All Wells: Submit this fora within 30 days of completion of will
construction to the fononine:
Division of Water Resources, Information Pmeessing UDii,
1617 Mail Service Center, Raletah, NC 27699-16I7
24h. For Intention Wells ONLY: in addition to sending the farm to thc address in
24aabove, also submit a copy of this form within 30 days of completion of well
combnctitan to he tollmwng:
Division of Water Resources, Undergr otmd Injection Control Program,
1636 Man Service Center, Raleigh, NC 27699-1636
24c- For Water Supph• & Injection %Felis-.
Aso submit one copy of this fans within 30 oinetlletitioolnof
well cmtsbunimt to he county heath iNEQ COOK/®WR
Jnit
'onstmctc,L
Well Contractor
Nwtb Carolina Da/tarlatan ofE war:meant and Na ne-al Rescue= -Division of Water Resources
APR 0 Seri'
Water Quality Regional
Oon
Wilmington rations l
Regional Office

WELL CDNSTRUCT1OIjncoRD (GW-1)
1. Well Contmetor Information:
Eeryy 'c%Da••S
WeN
Name
COP Mille
piss'
NO Wdl Contactor Certification vaunter
fru-, AS hJtCU •. Q0.O.s.Q
Company Nuns
2. Well Conttrucdon Permit Oh
Liu di wince* [JMY/ncm7I pw nit. (Le WC, Cmmgr Sae. Parl'(IIn% tic)
3. Well Use (check well use);
Water Supply Weir
Agticuhutal
Geothermal (Healing/Cooling SIMPLY)
Industrial/Commercial
W
Non-Watersupply WdI:
Monitorial;
latetioa Wage
Aqu(f t ReSsge
Aqutibr Storage end Recovery
AquiterTe5d
Experimmrd Technology
Gcothemmt (Cloud Loop)
Geothermal (leadnp/Coolinst Remm1
QMunicipat/Pobie
DResideabtiai. Wafer Supply (single)
['Residential Water Supply (shared)
®Recovery
Ocrou4dwater Rujuediation
E3sa(inity Ranier
['Roomer** Ontinage
f Subddence Control
Orman
parlor(mmlain underd21 Remarks)
4.Date wdi(t)Canpletede /N- 1) weft my
St Weil Location:
C.can't /ltlyel a du/5
Facility/0 mn Name Facility IDS('rfappli®bla)
r144 FerA.m0004 DK So.."%Mprt Pat
Physical Address, City. aodOp
13r.x,adtrod-A
Comity
Porael ldenlilimfon No, (PIN)
Sb. Latitude end bagitude In degrees/miausweecoada or decimal degrees:
(IfweI1 Sod, one IaNmsg is sachet)
33 ° fSe 994 N en S a CU Or 4) 3
6. le(are) the well4aRcrnutnent or °Temporary
T. fa this a repair to auWaring wdl: ®Yea, or DNo
Oils Is midi: Ali Ow blown well e.Mtryml nl mfarmetloro end expkin the=Nano o)"dro
repair under ell ,wn-or/nsealmn aeon rho oath efilikiform.
8. For Geoprobe/DET or Closed Loop Geothermal Wells helot the same
communion,only I OW-1 is ended. Indimse TOTAL Nu ER. dwells
related: _
9. Total wed der helm* laud sarfaee: 3g
Farmtddple wells Wall depths ydehreig (wimple. $4200'ald 2@100)
10. Static water level below top of enter QI
If water level lx,0ave mien uee "+'•
11. Borehole diameter. Co tit/
12. Well construction method; 'cam--iC
(i.e. auger; niwn, tab* dbeet puck de.)
(ft)
(a)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) 6 d Method ortem:
13h. Disinfection type
"—oaf
Amount:
*1
PROM TO a ` -ORS PISTRIPMe
"' it C.
er
eiW1tO6''.DRTim�' •—_•. $eA� kA p
va 7o
ft. t<
d. ft.
AT -SCREEN y,
PROM 76
ottat
R. n.
w.
PROM 7U
(L
IFor Internal Use Only.
442588
Mere tit oascannen
90R
h
3 a IL
emIntr S,o,_l.
VIA
in
le
yrSMtTER W mmn
1 tk11w oio
to
MAAIWA4
fiat pin
_7mJCiraess
Scat Leo
smanaratmlyniumin amour
paAna. "rant.
If>motda IORT;:j: },.� p}J:O../i'ny:.v ".'yl".:....iY:Sp•''� e;.:f.n.,..
aaA7a71.1L IIMPIAZxMITTMRTROD ..
0.
nbaealrlrOnlakyfnr4hm, MaAa4eraq,Q.peem aal
rt.
B
R
ft.
It.
m
R
a.
R.
ft.
RECEIVED
MAR 2 8 2017
22. Cornett'
W
Si
Omar
3^)9 7%
tote
ey sign* rMmrlium. as, comfy SIthe %eV) sus henei aapunme'd In OeraSaea
wad, 13ANC4C 01C. /000,lrq NON: OIC.0200 WO ConrtreNen yrwakide mddtrta
eepyafrhb recant has eeea pravided:omawdlowner.
23. Site diagram or addidoui well debits:
You may use die boor of this page to provide additional well site derails or well
wnsWNon(Malls. You may also attach additionei peps ink:C scary.
flue= ITTAL IN.ClRVC110N4
2/a. For All Weltae Submit this Poem within 30 days of completion of well
construction to the fultowing;
DMalaa of Wear Resource:, taformedon Procastng Volt
1617 Pall Service Center, Raleigh, NC 27639-1617
24b. For tnieedon We: In addition to sending the form to the address to 24a
above, des submit one copy of this Om within 30 days of completion of well
construction to the Mowing;
Division of Water Resources, Underground Injection Coated Program,
1636 Mai Service Cotter, Raleigh, NC 27699-1636
IA'e. War water_Suap)y R Minden Weirs: In addition to sending the ram to
the addres(m) above, also submit one o1
atmpietion of well construction to the Tiialtih' �y
hnA an IM
APR 03 2017
Water Quality Regional
Operations Section

•
WELL CONSTRUCTION RECORD (G W-11
1. Wdl CAnlsactor Information:
G_Atr c3a.nras
Weil GUMName
a194
NC Wen Contractor Crnifieadoa Number
A@r,wep
Compeer Name
2. Well Construction Permitd:
LIT( pppllraatawaN canrinelka permim (se WC. Co: tty. Rae, Fmlmtaa elea
3. Well Vse (check welt um):
Water Supply Well:
M Agricultural. QMunicipal/public
X (Reckons' (ffoating(Coofiag Supply) QResidentiai Wafer Supply (single)
■' lndusniaUCmnmtretai t]Resideneal Water Supply($hamd)
Non -Water Supply Wee:
Monitoring
Igteetioa Well:
II *Ohm Rahn*
■ Aquifer Storage ad Recovery
01 Munk Test
I Experimental Technology
1 Geothermal (Closed laep)
Geothermal (Headh%/Cueling Return)
4. Dens Well(s) Completed: 2—a ('
Set. Well Location:
P.64 GetdcS
Facility/0watt Name
®Recovery
®Groundwater Relocation
DSaldttey Barrier
©Stamwidw Drainage
DSvbsideoce Control
f Oder• Bargain under /f21 Renretks)
1" 1 welt M it
Facility ION (d•appaeable)
/a2.- w:rto.a los AA. Lietara a)c.
Physical Adana, City, mad Zip
F
County FwMl Idcndfiaadon Na (RN)
SA Ladled. and longitude in degreer/miausearmdeoodsor decimal degrees:
Orwell field. one Woes lasMUkienq
340 1, 703 N o')8° o3.. fl w
6. Ie(ara) the wdi(S)rfipernlanent or ©Temporary
7. Is thb a npatr CO err esdadog wag: OVes or eNo
(flak 4 o repoir, fdlatknown well continaerien.,bfnnimlmrwidcpiain the oaten Oleic
repair under OW remarkneaia or on Maadeae tMraarm.
8. FoeGeoprabe/DPT or Csored-Loup Geothermal Wells having the same
construction, orgy I OW-1 is needed. Indicate TOTAL NUMBER ofwelts -.
drilled:
9.Total well depth below land surfeit: �l$ r iR)
For mufti* welbliudidep s begJinni (sample-30100"eedZeldin
10. Stade water level below top orating: / i7
Intater(Feetirgfrow low ,,sae"4"
f 1. Borehole diameter: % (fa.)
12. Well commotion method: `7+311
aiwer. Mey, cable,dhea path, era,)
(ft)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield Om) di 0 Method of teat: tro e
13b. Disinfection type: Amounts
IFor internal Use Only:
442586
PROM_ TO I alrn0it
3c t eir R ( Cesaft tS
"'Di:
rI1011121C4SD1DIfai'm 1RSp�DvgRi<7r
ems) TO manna 'etSr unas_ MAITOML
r�
PR M WO DMMEIZO_
a a Is
K A
37'eG11sRN. o . ..:.
FROM I TO 1 »M1este
30n•
4 if
/ Yet,, ter.
R.I al 1a.
Yo
TOTOOPOMS
P.��,,��.�.�t
saarei AC .�
U 0.
R.
e9
n.
h.
BMnat<enmter arnmoaa AMgp ir
toe e,r —torp
BetOrt6ere> FAi,eraabFi>iWOrr.:.,: :: :•.:
FROM7S JaA1astrMto lnnrt*OMWrranrnlon
ft.
WO
a
a
0.
Ft.
a.
0.
a
R.
d
sr.
at.
A
R
IL
+ati'tlEkrelari Pr.,..,
ldbeaarbl•':'..': ".':
Juana. aarwk sea pv.R. de)
R ECEIVED.
MAR 2 , 2017
onicion9 m:.rrcrurr© i ban• .
22. CaliOpn
Sian• -of - •watt
3•a- i)
Duo
dyepntrg thbfmm. 'rarOy Menke aeilla1 was (erg eaaoaaeredrn aeco,tmr e
,.era MA NCAC 02C.0100 M ISA NCAC e.'C.OA00 Wen Cattareiltow &arlrbldr and theta
copy tor Ws reemd kae been provedelip Mewl 1 early..
23. Site dlegram or additional weal details:
You may roe she back of this page to provide additional well site details or well
construction details. You may also math additional pages if accessary.
SVDMITTAL INSTRUCTIONS
24a. For All Welk: Submit this fmm within 30 days of completion of well
wrmb alonmtheibiowleg;
Divlliaa of WaterResoarrms, foferMetion Processing Gain
1617Mef Service Center, Raleigh, NC 21699461.7 •
24A For laieetton Welk: In addition a seeding the fans a the addles in 24a
above, also Summit ono copy Of Uds form within 30 days of completion of well
construction to the tUowiag;
Division of WaterRemunasr Undeigroaod Injection Control program,
163E Mali Service Ceaten Reidgh, NC 276991636
24e. Far Water Saindv &Jniecdehilreiis• in addition to sending the fors to
(he address(a) above, also submit one copy of ithin 30 days of
completion of well mnabursioa a the aunty !teal PENRYB yR
ohm.M mamN
APR-p3 y61
Water Quality Region

WELL CONSTRUCTION RECORD
This fainwubeand for simle a multiple wells
1. Well Contractor Info on:
Ave !L[ se91vl
Wen Cmwador Name
NC Kell Ct enactor CenifieationN Hs
e �e // 6--u j
Company Nmac
7rawu - Phi d u el -coo / Ye
2. Well Construction Permit 4:
List all applicable well pem,ds fie. Court'. State, Variance, Infection, eta)
3. Well Use (check well use):
Water Supply Well:
°Agricultural
°Geothermal (Hcati ngiCooiine Supply)
OindustrialiCommacial
*initiation
For Werval The ONLY:
14. WATER ZONES
FROM
ft.
ft
442448
TO DESCRIPTION
SI /4',✓a + SA e // 1
ft.
IS. OUTER CASING tformolti.esed wells) ORLINERWan ' Mel
FROM 77
+I R Sa ft- I tl in- rich. yo Pot
TO
DIAMETER THICKNESS \L4TrDLST
16. INNER CASING OR TUBING (geothermal dosed -loop)
FROM TO DL4MIEIER THlchcwESS MATFnisr
It ft. - in
2 1 ft.
E6
17. SCREEN
OMunicipalVPublic �.
❑Residential %Vsta. Supply (single)
°Residential Water Supply (shared)
FROM
3-2 ft.
FL
1S. GROUT
TO DIAMETER SLOTSEE
e IL4,2fI in �.©/ 0
R in.
THICKNESS' MWtFRTAL
scA tic plc
Non-Rtater Supply Mill:
°Monitoring °Recovery
Injection Well:
°Aquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer Ttst
°Eeperimattal Technology
°Geothermal (Closed Loop)
°Geothermal (Heating/Coaling Rana)
OGtoundwater RemediaGan
°Salinity Barrier
OStmmwutcrDtahnagc
OSubsidatac Control
°Trace
°Owe (cepiain under 421 Raoui:s)
4. Date Well(s) Completed: , / U 47 Wen IDH
era. Well Location:
ANC R✓SA
Facility rNaue
63io 6 /Ar4rr yr
Physical Address, City, and Zip
}�rtrt'S &tile 4
✓f7y Fag®®dity 1125 Ojfappiicb7ej
K r/KIT✓ d11
County Parcel ldnaifcationNn.!PIN)
Sh Latitude and Lor4,itude in degrees/minutes/seconds or decimal degrees:
(If ftc14 one latIIona is sufficient) 0 /
33 SS`?, 352
vve I
6_ Is (are) the well(s): lBPermmnent
W
FROM
© a
ft
TO
a� a
ft.
\LATERIAL
r39e-er c
EMPLACEMENT METHOD @ AMODNT
Nos— /0D ° r^'e ei
f4
ft.
19. SAND/GRAVEL PACK Of apgieabl )
TO
FROM
R
ft.
MATERIAL
fl PLACEMENT METHOD
ft.
f6
20. DRILLING LOG (atta L addiloml sbeess H necessary)
TO
FROM
tV ft.
a20 tL
DESCRIPTION(mhr, hardness, solwwtit trye Vale Mt. act
.0ft.
ad ft.
3a
Ito ft.
iL
AQ R
350
2
61 IL
ft.
ft.
21. REMARKS
ft_
s `_4 + stie//.r
efeHJct 4 e/nL3 /f7/k
LM;in e S7LN-e_
RECEJVED
22. C
S.srul . e of enaied Well Contractor
or °Temporary
7. Is this a repair to an existing well: Oyes or iWlu
Iftbir is a weir, fill out known well consanetion information and explain the nature of the
repair under k21 remarks section or on the back ofthirform.
8. Number ofwells constructed:
For multiple injection or non -water s pplyweIIr OA.Fwith the some coumtainn. ;Ott can
submit one form f
IGfU
12. Wel construction method:
. anger, rainy, cable, faired omit etc.)
9. Total well depth below land surface:
For multiple wells het all depths fdeepen/ (example- 3%200' and 2`7100•)
/
10. Static Crater level below top of cuing: Ip
If water lord is above casing, use "*" If
11. Borehole diameter.
!4tlJ 120rnre/
OR WATER SUPPLY WELT S ONL
SO *
13a_Tield (mind
136. Disinfection type: (3 let& Cgg h Amount: / (a (at
MAR 202017
Information Processing Unit
DWQMOG
.3-»-/7
Dam
flr signing this fonn, I hereby cernfy that the well(s) war beer) communed in accordance
with 114 AZAC 02C .0100 or I3d NC.4C 02C .0200 Well Constriction Standards and that a
copy of this record hos been provided to the well owner.
23. Site diagram or additional well details:
You may use the hack of this p
construction details. You may al
tenvisig
SUBMITTAL INSTUCTIONS
24a. For Al Wells: Submit this fo4A'ftth0 .Qs17ap completion of well
construction to the following:
Division of Minter esyry o��ing Unit,1si7 Mail Service
ecion6Y
24h. For Iniection Wells ONLiiinktrba
pegimi
often to the address in
24a above, also submit a copy of this form within 30 days of completion of wail
omtstmction to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
'Method of test: M / vmp lac For Water Supply Sk Injection Wells-.
details or well
Also submit one copy of this form o thiu 30 days of completion of
tarn coustsuction to the county health department of the county where
consbustcd
Pons OW-1
Noah Carolina Depanntcnt ofEmmcmnent and Natural Resources —Division of Waltz Resources
Rniscd ivamt'JJ13

WELL CONSTRUCTIQN RECORD (GW-11
1. Well Contractornadon:
ew
Well Contractor Name
3/s,
NC fiat ateNit r { L ✓✓��//((�- a� - G%G( � tr;
Company Name
2. Well Construction Permit #:
List all applicable well construction permits (i.e. UIC, County, State, Variance, eta)
3. Well Use (cheek well use):
Water Supply Welk
®Agricultural
®Geothermal (Heating/Cooling Supply)
®Industrial/Commereial
Ilirrtgation
Non -Water Supply Well:
Monitoring
lnjection Well:
DAgnifer Recharge
f Aquifer Storage and Recovery
DAquiM r Test
DExpeeimental Technology
®Geotkerual (Closed Loop)
®Geothermal (Heating/Cooling R
4. Date Well(s) Completed✓///f7
5a. W Loca on:
5
cility/' ner a Facility JD#(ifapplicable)
gzsb Ad inn' s 7R4, Ash 2-5 qw
Physical s, City, and Zip
uAj W rCC
OMrmi " bkc
esidential Water Supply (single)
® Residential Water Supply (shared)
®Recovery
®Groundwater Remediation
f Salinity Ranier
DStormwater Drainage
[#Subsidence Control
D7kacer
®Other (explain under 521 Remarks)
Well ID#
County
Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one latflong is sufficient)
3c( 27 N 7f a/3
6. Is(are) the welI(s) rmanent or 13Temporary
7.1; this a repair to an existing well: ®Yes or 1kp^O
"this is a repair, fill out known well construction information end explain the nature ofthe
repair under#21 remarks section or on the back ofthisform
8. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction, only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled:
9. Total well depth below land surface:
For multiple wells lint all depths 'different (example-3©200' and2©TWO
,Sb
10. Statie water level below lop of casing:
"water level is above caring, use "+"
11. Borehole diameter
12. Well construction method:
(i.e. auger, rotary, cable, directpusb, etc.)
/ y
rr
(ft.)
(ft.)
FOR WATER SUPPLY�'1WEE^LLS ONLY.
13a. Yield (gum) !O
13b. Disinfeeden type:
Method of test:
Amount/fa
For Internal Use Only:
442447
Sarst:sr StY. ..1.-
FRO)
TO -
DESCRIPTION
r/ ft.l.S�n
/ 4 (
2
a-
TO
iid1 "bifsImt-iINf.`Rt(tt'l
lisigvifitsrann
FROM .
DIAMETER TfcIONFSs
MATERIAL
rt.
iD.v+
r
Mob•
MR'.7Dkt�ih
Y
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft
ft
In.
ft
in.
+��$ �{It. t
� F�.�.R'..:YfY=,(s
�ay f
"�`.iF W �"Xf i.x!IA+t
rii i'.ETER
FROM
TO
DIAMETER
(sir
SLOT SIZE THICKNESS
$ESE
MA?���
03,E
�
°. /0 I.S tO
/'lf L
R
tt
In.
I
SON. ^ .e4 •'
_ itt n+a.'iaraPi M"''t,'.U'tate--PA ,� tt:;:..W.7.
PROM TO
MA• &MPLACEaI,EN'' par seAMOUNT
ft f
zo .2m ft.'
!l""'
ein ...,.
mce
Sr
FROM
TO
r.an LIL•...-
EMPLACE/a/�/NtT METHOD
/�t�
tt Or'
n.
El[sbli§T;h101
(aDail
d (on"Sfa'k54io �10 "=`-= `gretaM., 't
FROM
TO
DESCRH'TTON(co r, hardnem garoek espy anin Mu, era)
bft
is ..
5Qn1 .
fr..jret
dill/
3sft
/ev ft
7V
SQ
ft
�' �`
tt.
ft
RE.:EIVE,r
n
"
MAR 2 0 2017
ft
.. ft.
22. Certlfcatio
Agri)
Signature of - : red Well Contractor
MAR 2 7 20177
Division of Water Resources, Information ro cessing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
ter uaii R
24b For 'Election Wells: -In to the address in 24a
above, also submit one copy 'i 186 completion of well
construction to die following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Servk Center, Raleigh, NC 27699-1636
24c. For Water Sunoly & Iniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
completion of well contraction to the county health department of the county
where constructed.
4
Date
By signing Otis form, I hereby cere that the weli(s) was (were) constructed in accordance
with 15A NCAC 02C.0100 or ISANCAC 02C.0200 Well Construction Standards and that a
copy ofthir record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
smgnrrAT_ m snRucn EIVED/NCDENR/DWR
24a For All Went Submit this form within 30 days of completion of well
construction to the following:

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2 61 1
1. WELL CONTRACTOR:
Douglas Hewett
Well Contractor (Individual) Name
Hewett's Well Drilling
Well Contractor Company Name
STREET ADDRESS 2172 Ocean Hwy West
supply NC 28462
City or Town State Zip Code
( 910- 7:5::4-,ft.528
Area code- Phone number •
2. WELL INFORMATION:
• SITE WELL ID #(if applicable) )Ty( bog 171,
STATE WELL PERMIT#(irapplicable)
D W Q or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable JBox): Residential Water Supply V
DATE DRILLED it
r7 7-/
TIME COMPLETED cJ idr'i AMID PM(Z -
3. WELL LOCATION:
CITY: , Ot )%v1 96 4
COUNTY LT r Uti1/4;'
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
p Slope ❑Valley Eybllat ❑Ridge ❑Other
(check appropriate box)
LATITUDE 3
LONGITUDE
Latitude/longitude source: ❑CPS ❑ Topographic map
(location of well must be shown an a USGS topo map and
attached to thiglorm rfnot using GPS)
4, WELL. OWNER ``" �r
OWNER'S NAME ...3CdNS r�0 vL,(a^ PrCe
STREET ADDRESS «p/ (cl5/ins rd I,17C+
Sir,Fh Pore! NC 2M/
City or Town State Zip Code
( 9/6 )- /I 3- /21/
May be in degrees,
minutes, seconds or
in a decimal format
Area code- Phone number
5. WELL DETAILS: i
a. TOTAL DEPTH: MO
b. DOES WELL REPLACE EXISTING WELL? YESNO ❑
c. WATER LEVEL Below Top of Casing: /b FT.
(Use "+" if Above Top of Casing)
d. TOP OF CASING 1S 1 FT. Above Land Surface'
*Top of casing terminated at/or below land surface may require
a variance fn accordancetr)'
with 15A NCAC 2C .0118.'
e. YIELD (gpm): the -
METHOD OF TEST V^vfl
f. DISINFECTION: Type /7I(7 Amount
g. WATER ZONES (depth):
From TS To kb From To
From To From To
From To From To
6. CASING:
Depth Diameter
From a To 7I� Ft. C
From To Ft.
From To Ft.
7. GROUT: Depth ,r�
From 2D, To 3 Ft. Rviknl-k fume
From 3 To loP Ft. p,IM, ikt. ices 128ud
From To Ft.
442396
As
Thickness/We1y
ht terial
SCL, q0 M VL
Material Method
8. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. In.
From To Ft in. in.
From To Ft. in. In.
9. SAND/GRAVEL. PACK:
Depth Size Material
From To Ft.
From To Ft.
From To Ft.
10. DRILLING LOG
From To Formation Description
8 /0 elan
/0- in k vC Z'Ay
35.- 4,6 ay a' dheiii
agar
6bC4- 1Z14,ts
76"- l0a 1rTMd.576-ie. •
RECEINEDINCDENRIDWR
11. REMARKS:
Water Quality Reg»onat
Uperailuus cction
Wilmington Regional Office
4 9 n t 7
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL CONS:' UCTION STANDARDS, AND THAT COPY OF THIS
RECORD HAS BEEN PRO Ar ED TOTH WELL NER,
SIGNATUR. CERTIF D WELL CONTRACTOR D
Douglas Hewett
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Atfn: Information Mgt.,
1617 Mail Service Center — Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-la
Rev. 7/05

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2 ti 1 1
442395
1, WELL CONTRACTOR:
Douglas Hewett
Well Contractor (Individual) Name
Hewett's Well Drilling
Well Contractor Company Name
STREET ADDRESS 2172 Ocean Hwy West
cup& y NC 28462
City or Town Futate Zip Code
( 910- 75:41-'t528
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(it applicable)
/.G 872 r
STATE WELL PERMIT#(ifapplicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box):�Residential Water Supply
7/ /`❑
DATE DRILLED /«
TIME COMPLETED 3 o0 AM PMtr
3. WELL LOCATION:
CITY: Ho lde/1 &*e A
/331 34444 rd alW
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
COUNTY
TOPOGRAPHIC / LAND SETTING:
❑Slope ❑Valleyat ❑Ridge DOther
(check appropriate box)
LATITUDE 3
LONGITUDE
6 rvn5w`c t�
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: ❑ GPS 17 Topographic map
(location of well must be shown on a USGS topo map and
attached to this form if not using GPS)
4. WELL OWNER
OWNER'S NAME AA dry,/ Koer ekf
STREET ADDRESS )331 ,S /snb•;r/ f"J
SuOPI f .NC arrvez
City or Town State Zip Code
( 9n )- 7$' $z.oz
Area code • Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: / 2o
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NOtri
c. WATER LEVEL Below Top of Casing: / 2, FT.
(Use "+" if Above Top of Casing) . /
d. TOP OF CASING 15 FT. Above Land Surface`
`Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118./
c
e. YIELD(gpm): 1 a METHOD OF TEST v ItTZ)-
f. DISINFECTION: Type F I R" Amount YL14
g. WATER ZONES (depth):
From SD To is o From
From - To From
From To From
To
To
To
6. CASING: Thickness/
From 6 DTpd- ila? Ft. Deter C4g0 f Material.
From ToFt. �rcf G-
From To Ft.
7. GROUT: Depth 7 Material
From 0 To J Ft. Ben rvv
o
From 3 To2 f, Ft. I
From To Ft.
8. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft.in. in.
From To Ft. in. in.
9. -BAND/GRAVEL PACK:
Depth
Size Material
From To Ft.
From To Ft.
From To Ft.
10. DRILLING LOG
From To
Formation Description
sa.tL
5l�etl Q-lw-•
s lie ]l Is
1 ML .T +0,e
11. REMARKS: 311A .2 1!)
Water Quality Regional
,fir' �nOpeetrnattiionss�ySenc�tiio/ntt'cn I DO HEREBY CERTIFY THAT THIS WELL WAS CNtti9} gtyen INpNGRIAAyga WITH
15A NCAC 2C, WE J CONSTRLCTION STANDARDS, /�JD THAT A COPY OF THIS
RECORD HAS B PROVI TO THE WELL OWN
STt ATURDOF CERTIFIED WELL CONTRACTOR DATE
Douglas Hewett
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt.,
1617 Mail Service Center— Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-la
Rev. 7/05

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
1. Well Contractor Information:
Well Contactor Name
N Well Contractor Certification Number
r
Company Name P� �y
2. Well Construction Permit#: L®/ / 0 qs
List all applicable well permits (.e. County, Stale, Variance, Injection, etc)
3. Well Use (check well use):
(Ate 0
Water Supply Well:
°Agricultural
°Geothermal (Heating/Cooling Supply)
❑Industrial/Commercial
°Irrigation
Non -Water Supply Well:
°Monitoring
Injection Well:
°Aquifer Recharge
°Aquifer Storage and Recovery
DAquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/CoolingReturn)
°MMu�unicipal/Public
113 sidentiai Water Supply (single)
°Residential Water Supply (shared)
°Recovery
°Groundwater Remediatioir
°Salinity Barrier
oStormwater Drainage
°Subsidence Control
°Tracer
°Other (explain under #2I Remarks)
4. Date Well(s) Completed: V/to Well ID#
5a. Well Location:
Facility/Owner Name
Facility EDP (if applicable)
271, Vcvee 11 QcL NW /4s 1,
Phgafoot Address, City, and Zip
f ihf c 4
County
Parcel Identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lal/long is sufficient)
N W
6. Is. (are) the well(s): IOPermanent or °Temporary
7. Is this a repair to an existing well: °Yes or IIt(ro
Idols is a repair, fill out known well construction information and explain the nature of the
repair under ON remarks section or on the back aphis form.
S. Number of wells constructed:
For multiple injection or non -water supply wells ONLY with the same construction, you can
submit one form.
9. Total well depth below land surface:
For multiple wellslist all depths Ifdilferent(example- 3a®200' and2(100)
10. Static water level below top of casing:
If water level Is above casing, use "�+"/
11. Borehole diameter: 6
12. Well construction method: YO'i'4 g
(i.e. auger, rot cable direct
1
o
al?
rotary, t push, etc.)
(ft)
(ft)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) /
13b. Disinfection type:
N-/i/
Method of test:
Amount:
4;f /tf
1 Ibs
For Internal Ilse ONLY:
(4. WATER ZONES
FROM
TO DESCRIPTION
93
ft. 2 /o ft.
220ft. awft.
IS. OUTER CASING (for mold -cased weds) OR LINER (if applcable)FROM . �W/ht
`9 9©ft. I TO ea ft. I DIAMETER ca_in. I THICKNESS
o/0 F MAT/Y
�1�6: INNER CASING OR TARING (geothermal dosed-l000p).
FROM TO
ft. ft.
4423941
S4°-•' e�
DIAMETER
in.
THICKNESS
MATERIAL
R.
I7 SCREEN.
FROM
22j ft.
ft.
/3. GROUT
FROM
O ft.
0
ft.
ft.
TO
7SD ft.
TO
ft.
ft.
al ft.
3
ft.
In.
DIAMETER i SLOT 512E
f7 in,
in.
19. SAND/GRAVEL PACK (if applicable)
FROM TO
ft.
ft.
ft.
MATERIAL
/0
THICKNESS
5-40)
MATERIAL
EMPLACEMENT METHOD $ AMOUNT
v 77rJ
vit
a
EMPLACEMENT METHOD
20. DRILLING LOG Cathie]] additional sheets if necessary)
PROM TO DESCRIPTION (color, hardness, soil/rock type, grain sir" etc.)
2 rrt.
so ft.
ft.
sD R.
/to ft.
/CE Sr
ft.
74e/D ft.
.22-0
ft.
21. REMARKS
/tDR.
/9( ft.
2/0 ft.
226 ft.
„Est) ft.
Ctl Fy
ci.ell roe II
-C.v.., C11—y c)oa-ci
(�. t._. / - J/viva
I\�JL
y9�1ti2
22. Certifrcationf
do
Sena o C 'Dad Well Contractor Dat�2 C./4
By signing this form, I hereby cerl.* that the well(s) was (were) constructed In accordance
with 15A NCAC 02C .0100 or 15A NCAC 02C .0200 Well Construction Standards and that a
copy ofthis'record has been provided 10 the svF(lt rygs •,
23. Site diagram or additional well details: EII(�
You may use the back of this page to provide additional well site details or well
construction details. You may also attach addi(Yprjal,paiesr.jFuppE.6spry.
SUBMITTAL INSTUCTIONS ��1/�H��(( °G� UU' LL UU�//
24a. For All Wells: Submit this form within 30,da pf n of well
construction to the following: Water V'Oanty Fi���hhd�
Operations Section
Division of Water ResourceMinMngjdlt Ilifiglidgfiatke
1617 Mail Service Center, Raleigh, NC 27699-1617
24b, For Infection Wells ONLY: In addition to sending the form to the address in
24a above, also submit a copy of this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supply & Injection Wells:
Also submit one copy of this fomr within 30 days of completion of
well construction to the county health department of the county where
constructed.
1 4 2017
ED/RCDERR/DWR
Form GWI
North Carolina Department ofEnvironment and Natural Resources —Division of Water Resources
Revised August 2013

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 7 ti 1 1
442393
1. WELL CONTRACTOR:
Douglas Hewett
Well Contractor (Individual) Name
_Hewett 's Well Drilling
Well Contractor Company Name
STREET ADDRESS 2172 Ocean Hwy West
Rif pp1y NC 78462
City or Town State Zip Code
( 91 (1- 75 • -6628
Area code- Phone number
2. WELL INFORMATION: ryry q
SITE WELL ID #(If applicable) 0l007 6 6 / 5-49
STATE WELL PERMIT#(ir applicable)
DWQ. or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply ❑
DATE DRILLED 3-30 - /6
TIME COMPLETED / i00 AMID PM®'
3. WELL LOCATION:/1
CITY: (-JI84460 COUNTY 13(Unsto;c1t
ff/ Cai50A tote rd Si 2 Qi9
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
❑Slope DValley DFIat ❑Ridge ❑Other
(check appropriate box)
LATITUDE
LONGITUDE
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: In GPS ❑ Topographic map
(location of well must be shown on a USGS tope map and
attached to this form if not using GPS)
4. WELL OWNER
OWNER'S NAME IOA a14Ab.A
STREET ADDRESS If I C4,50,1 log rr)
l.Arin Aa IMW AJC 181171
City or Town
( 9/b ). 26.Z 66R6
Area code- Phone number
State
•
5. WELL DETAILS: ei
J 1'}
a. TOTAL DEPTH:
Zip Code
b. DOES WELL REPLACE EXISTING WELL? YESe NO 0
c. WATER LEVEL Below Top of Casing: 25- FT.
(Use "+" if Above Top of Casing)
d. TOP OF CASING IS I FT. Above Land Surface'
`Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .011188f O
e. YIELD (gpm): D METHOD OF TEST '+ 4"
f. DISINFECTION: Type !/ # N Amount / /45
g. WATER ZONES (depth):
From HO To /lir From To
From To From To
From To From To
6. CASING:
Depth Dia eter
From f /O To ® Ft. a 1
From To Ft.
From To Ft.
Thickness/
Weight Material
Safe) 64014.4,24
7. GROUT: Depth Material
From 7o To 3 Ft. fl(A Ida,(c
From 3 To ;df Ft. fM104i4c
From To Ft.
Method
8. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in in.
From To Ft. in. in.
9. SANDIGRAVEL PACK:
Depth
From
From
From
Size Material
To Ft.
To Ft.
To Ft.
10. DRILLING LOG
From To Formation Description
6 - s �-ol° ro,l
15 in) 1 C/4y
(3- - 25" .CIGy
25- .- Sa San) l 6/4y
so '- 76 sti:ais
70 — yS N44.41444
9C- lob OP/A er4u,' y
/no - /Ljs-
11. REMARKS:
RECEIVED/NCDENR/DWR
D2.10402 17
WaterrQuality. Regiof a l
Operations Section
I CO HEREBY CERTIFY THAT THIS WELLWAS'ICONSTRUCTED INACCORDOAfNC e WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THATA COPY OF IS
RECORD HAS BEEN PROVIDED TO THE y[<5N`L OW NE
SIGNATU F CERTIFIEU"WELL CONTRACTOR DA
Douglas Hewett
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt.,
1617 Mail Service Center- Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-la
Rev. 7/05

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 7 61 1
1. WELL CONTRACTOR:
Douglas Hewett
Well Contractor (Individual) Name
Hewett's Well Drilling
Well Contractor Company Name
STREET ADDRESS 2172 Ocean Hwy West
supply NC 28467
City or Town btate Zip Code
( 91 n- 7&_4fi•528
Area code- Phohe number'
2. WELL INFORMATION:
SITE WELL ID #(if applicable) Qo 16 6710 412
STATE WELL PERMIT#(If applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applic le Bo : Residential Water Supply Lr "
DATE DRILLED
TIME COMPLETED 9)00 AM.D PM Er
3. WELL LOCITIION:
CITY: MA COUNTY 1311//ISWtC ‘t
t&/a° mpwIkAsJ rd Anti vino
(Street Name, Numbers, Community, SubdiNsion, Lot No., Parcel, Zip Code)
TOPOGRAPHIC/ LAND SETTING:
['Slope ❑Valley lat ❑Ridge DOther
(check appropriate box)
LATITUDE 3
LONGITUDE
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: D GPS ❑ Topographic map
(location of well must be shown on a USGS topo map and
attached to this form if not using GPS)
4. WELL OWNER
OWNER'S NAME C/4 did � 6r 45
STREET ADDRESS 0q): A-10k 4e4p /J .V41
.4511 .vt ,VrV Zo
City or Town State. Zip Code
(q/o )- 2(7.3c/97
Area code - Phone number
5. WELL DETAILS: 70
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES P. NO Elc. WATER LEVEL Below Top of Casing: 11l FT.
(Use "+" if Above Top of Casing)
d. TOP OF CASING IS P . FT. Above Land Surface'
'Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD(gpm): 60 METHOD OF TEST Ann"
442392
f. DISINFECTION: Type 17 # 11
g. WATER ZONES (depth):
From Mi9 To / 7o From
From To From
From To From
6. CASING:
Depth C./
Diafgter
From /7® To
From To
Ft.
Ft.
From To Ft.
7. GROUT: Depth
From 20 To 3
Amount 1 /,15
To
To
To
Thickness/
Wei ht Material
fe4 Put -
Material
Ft. OrnlUn
From '3 To doe Ft. Re..14pn;/e.
From To
Ft.
Method
AA"?'
C4i, l°f
8. SCREEN: Depth Diameter Slot Size Material
From /70 To /90 Ft. 2 in. .o/b In. Pin.
From To Ft. in. in.
Ft. in. in.
From To
9. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
From To Ft.
10. DRILLING LOG
From To . Formation Description
o- 10 dnv .Sai I .a- Sa
to ,A,f
2s"
y0' 6D
6o - 4d
40-42a
!za -no
130 - l3r-
l31-- /N0
! //o - 176
100 HEREBY CERTIFY THAT THIS
15A NCAC 2C, WELL CONSTRU ON
R.--+-. HAS BEEN PROVID TO
Mod 1
Aeo Ic
/si„J
took
Fat %„1
(oeve 44n¢ ,¢ rock
tlgrt h i.0elitANCE WITH
OF THIS
ice
SIGNATFIED WELL C
Douglas
Hewett
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt.,
1617 Mail Service Center — Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-la
Rev. 7/05

DATE DRILLED
RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 9 61 1
442391
1. WELL CONTRACTOR:
Douglas Hewett
Well Contractor (Individual) Name
Hewett's Well Drilling
Well Contractor Company Name
STREET ADDRESS 21 72 Ocean Hwy West
Rnpply NC 28462
City or Town State Zip Code
( 919- 71-574-'5.528
Area code- Phone number'
2. WELL INFORMATION:
SITE WELL ID #(ifapplicable) o I6714y 6
STATE WELL PERMIT#(it applicable)
D W Q or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply p-
ry
TIME COMPLETED 3.3o AM.❑ PM Er
3. WELL LOC TION: V1
CITY: -=fib COUNTY Ygr..rtiSwtCFC
a€' Ai yi/�theal r,J /U 4) ,2`rq 20
(Street Name, Nu bars, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
❑Slope (Valley pyP(at ❑Ridge DOther
(check appropriate box)
LATITUDE 3
LONGITUDE
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: ❑GPS ❑Topographic map
(location of well must be shown on a USGS topo map and
attached to this form if not using GPS)
4. WELL OWNER
OWNER'S NAME enCIA tJ (AA
STREET ADDRESS 4 o gyro. /god ri( AA)
/YS(n At gdWo
City or Town State Zip Code
( 9/0 )- ;270 3313
Area code- Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: nj
b. DOES WELL REPLACE EXISTING WELL?//YES ( NO t "
�c
c. WATER LEVEL Below Top of Casing: 5- FT.
(Use"+" if Above
Top of Casing)
d. TOP OF CASING IS / +.$✓ FT. Above Land Surface'
*Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): 26 METHOD OF TEST $unnP
f. DISINFECTION: Type OW Amount f. f- 45'
g. WATER ZONES (depth):
From 035_To 2676From To
From To From To
From To From To
6. CASING: Thickness/ Depth
Diameter I
From d To/7D Ft. .fCF Os' !VI
From /70 To 2or Ft, oZ SCA, «1 Pm:
From To Ft.
7. GROUT: Depth MateriallI Method
From 0To 3 Ft. , ib.Uk LF.QS gVrc/
From 3 To '2o Ft. t%lie•r i e Kra ft
From To Ft.
8. SCREEN: Depth _ Diameter Slot Size
From 23r To 204° FL 2 in.-0/2_ in.
From To Ft. in. in.
From To Ft. In. in.
9. SAND/GRAVEL PACK:
Depth
From To Ft.
From To Ft.
From To Ft.
16. DRILLING LOG
From To
o 075--
Z5-1'_ y5
Q3 fo
�o - / 7d
I.7r - /t
lKr- z,
Zoo— 235"
11. REMARKS:
Material
Put
Size Material
Formation Description
eAr
Ric 5<rnS
IS4 /t nue/ / Tccfr
54,Id
col
MAR 2`0'2017'
Water Quality Regional
operatic s SAction
Wilmington Regional Office
1 DO HEREBY CERTIFYTHAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTR HON STANDARDS, AND THAT A COPY OF TH
REC,COO i`HAS BEEN PROVI ` • TO THE W�LIJJW NER.
TUR, 2 r CERTIFIED rIIJECL CONTRACTOR DA
Douglas Hewett
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 clays. Attn: Information Mgt.,
1617 Mail Service Center — Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-1a
Rev. 7/05

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION
1. WELL CONTRACTOR:
Douglas Hewett
Well Contractor (Individual) Name
Hewett's Well Drilling
Well Contractor Company Name
STREET ADDRESS 2172 Ocean Hwy West
gimp] y NC
City or Town State
( 910- 75A-8528
Area code- Phone number'
2. WELL INFORMATION: �% {'�
SITE WELL ID #O( applicable) 901 d 7/f ay
211462
Zip Code
STATE WELL FERMIT#(inapplicable)
DWQ or OTHER PERMIT#(if applicable)
WELL USE (Check ApplicableprBox): Residential Water Supply EY
DATE DRILLED /d-�. (?/-2dlf
TIME COMPLETED oI.00 AMID PM ®/
3. WELL LOCATION:
CITY: S(/ l��r
99d alai. /et
COUNTY &-IIMC1C
(Street Name, Numbers, Community, Subdivision, Lot No„ Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
❑Slope DValley DTat ❑Ridge ['Other
(check appropriate box)
LATITUDE 3
LONGITUDE
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: DGPS ❑Topographic map
(location of well must be shown on a USGS topo map and
attached to this form ifnot using GPS)
4. WELL OWNER OWNER'S NAME Cl//vrt j acal5
STREET ADDRESS Y90 64 54 /a
c f/eV A/C ?Af/6L
City or Town . State Zip Code
(f/D )-zit- 5'337
Area code - Phone number
5. WELL DETAILS: a. TOTAL DEPTH: 90
b. DOES WELL REPLACE EXISTING WELL? YES D NO ❑
c. WATER LEVEL Below Top of Casing: /Z FT.
(Use "+" if Above Top of Casing)
d. TOP OF CASING IS l FT. Above Land Surface*
'Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): / METHOD OF TEST /✓M/
f. DISINFECTION: Type
g. WATER ZONES (depth):
From 60 To 7d
From To
From To From To
From To From - To
6. CASING:
Depth Diamgter
From © To 60 Ft. ${
From To Ft.
From To Ft.
442390
Thickness/ Weight
Material
7. GROUT: Depth. Material Method
From .? To gd Ft. /Tr4t 4i/c Panlio
From 0 To 3 Ft. 2t4/Oa%k arid
-
From To Ft.
8. SCREEN; Depth Diameter Slot Size Material
From To Ftin, in.
From To Ft. In. in.
From To Ft. in. in.
9. SAND/GRAVEL PACK:
Depth
From To
Ft.
From To Ft.
From To Ft.
Size Material
10. DRILLING LOG
From To
6- /0
/a 3d
30 - tiro
CAB - 5d
so - 63
6o-9d
11. REMARKS:
Formation Description .
.sane-±
"Ili
L%44/t /AV t540d
AIXG A.
RECEi FD/MtPRIR/DWR ,
M
Operations Section
Wlln(mgton Regiunai O
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
ISA NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THATA COPY OF THIS
RECORD HAS BEEN PVIDEETO THE WELL) WNER.
SIGNATU'OF CE TIFIED WELL CONTRACTOR DATE
Douglas Hewett
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt.,
1617 Mail Service Center- Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-ia
Rev. 7/05
c-ac-.n / 2cx2l

I1 ESIDENTJAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 961 1
1. WELL CONTRACTOR:
Douglas Hewett
Well Contractor (Individual) Name
Hewett's Well Drilling
Well Contractor Company Name
STREET ADDRESS 2172 Ocean Hwy West
SupCity or Town P l y State C 28462
iCode
( 910- 7.9:4-er6528
Area code- Phone number' •
2. WELL INFORMATION: ��jj //' y/ /
SITE WELL ID #(ifapplicable) /70/J O//7Q9'
STATE WELL PERMIT#(ifapplicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply RI,
DATE DRILLED //d-/- ad/kr
TIME COMPLETED s&O AM
3. WELL LOCATION:
CITY: Sv19",
990 47+l4et
COUNTY 661/44414.4.0(
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND. SETTING:
❑Slope DValley genet lot ❑Ridge ❑Other
(check appropriate box)
LATITUDE 3
LONGITUDE
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: ❑GPS ❑Topographic map
(location of well must be shown on a USGS topo map and
attached to this form if not using GPS)
4, WELL OWNER
OWNER'S NAME
STREET ADDRESS () (4 04,, P(f
414,11 • Ate a�yGt
City or own State Zip Code
(4/0 )-23a- 5137
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: 7O
b, DOES WELL REPLACE EXISTING WELL? YES ❑ NO ❑
c. WATER LEVEL Below Top of Casing: /Z FT.
(Use "+" If Above Top of Casing)
d. TOP OF CASING IS l FT. Above Land Surface`
*Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD(gpm): 9 METHOD OF TEST Rwwtel
442389
f. DISINFECTION: Type g1s7/j Amount g
g. WATER ZONES (depth):
From 60 To TO From To
From To From To
From To From To
6. CASING:
Depth / Diameter
From 0 To 66 Ft._`p4_
From To Ft.
From To , Ft.
7. GROUT; Depth
From 3 To as
From 0 To .3
From To
8. SCREEN:
From
From
Thickness/
Weight Material
ScY (id c
Material Method
Ft, n,r�c d
Ft /�Pnha/ &
Ft.
Depth Diameter Slot Size Material
To Ft. in. In.
To Ft. In. _ in.
From To Ft. in. in.
9. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
From To Ft.
10. DRILLING LOG
From To
a-10
/0 - 3d
��- 'a
40 - Sd
_So -6a
60 - 90
11. REMARKS:
Formation Description
. Sgnrr
(la y
6/F at send
54:dt. r/4r(/J .wand
SA, A.
RECEIVED/NUMDWR
MAR 1 4 2119-
MAR: °2.,0 2017
Water Quality Regional
Operations Section
I D0 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THATA COPY OF THIS
RECORD HAS SEEN Pr VIDE THE WEU WNER.
SIGNATUOF CERTIFIED WELL CONTRACTOR r DATE
Douglas Hewett
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt.,
1617 Mail Service Center— Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-1a
Rev. 7/05
care n 2Ci�>?

10. Static water level below top of casing:
If water level is above casing, use "+[" f)
11. Borehole diameter: rG (in.)��'///
12. Well construction method:
(i.e. auger, rotary, cable, direct push, ate.)
WELL CONSTRUCTION RECORD.
This form can be used for single or multiple wells
1. Well Contractor In ormation:
Well Contracto ame
A
NC Well Contractor Certification Number
(AseJ4 AJe11
Company Name
2. Well Construction Permit QO$ /6 S3S-
List all applicable well permits (.e. County, Stale, Variance, Infection, etc)
3. Well Use (check well use):
Water Supply Well:
°Agricultural
❑Geothermal (Heating/Cooling Supply)
°Industrial/Commercial
°Irrigation
Non -Water Supply Well:
❑Monitoring
Injection Well:
°Aquifer Recharge
°Aquifer Storage and Recovery
°Aquifer Test
°Experimental Technology
°Geothermal (Closed. Loop)
DMunicipal/Public
fdential Water Supply (single)
°Residential Water Supply (shared)
DRecovery
°Groundwater Remediation
❑Salinity Barrier
°Stormwater Drainage
°Subsidence Control
°Tracer
i °Geothermal (Heating/Cooling R
eturn) °Other (explain under#21 Remarks)
4. Date Well(s) Completed: OthWell ID#.
5a. Well Location:
i /
e/ ,'G I (clrr/5bsn
Facility/Owner Name
Facility ID# (if applicable)
ego 9 GJ /eaell �r Og k Mind
Physical Address, City, d Zip
ert/nsul cY.
county
Parcel identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one fat/long is sufficient)
N
6. Is (are) the well(s): IBl'ermanent or °Temporary
7. Is this a repair to an existing well: °Yes or .1516
If this is a repair, fill Out known well construction information and explain the nature of the
repair under 121 remarks section or on the back of this form.
8. Number of wells constructed: I
For mul iple infection or non -water supply wells ONLY with the same construction, you can
submit one form.
9. Total well depth below land surface: 90
For multiple wells list all depths if different (example- 3Q200' and 2@I00)
fa
For Internal Use ONLY:
14. WATER ZONES
FROM TO nsSCNPrION
p rt. 5 J ft.
t.
442388
//meJJoA
cc
..15.. - UTER CASING fdi multi -eased wells OR LINER if 5 Scab,e
FRO TO DIAMETER IC SS MATERAL
s rJ 1 SCA q Pvc
ft. 7tf ft.
16: ER CASING OR TUB
O
ft.
TO
ft.
n.
G (geothermal elided -loopy
DIAMETER THICRNE59
MATERIAL
It.
1T. SCREEN
0
TO
DIAMETER
in.
SLOT SIZE
CNN
MATERIAL
1S. GROUT
O
2.0
3 ft.
ft.
t.
in.
TO
3 ,t.
Tat ft.
R.
9. SAND/GRAVEL PAC
FROM
t.
TO
ft.
ATERIAL
Be h4Je
gm iO4,YC.
MPLACEMENT METROD&AMOUNT
Pour,/
(if applicable)
MATERIAL
PLACEMENT METH OD
R.
O.
20. DRILLING LOG (attach additional sheets if necessary),
FROM TO DESCRIPr10N (color, hardness, soil/re
O R I 26 R' Saud
lhtYP¢, grain sire. etc.)
2 a
ft.
go ft.
7r
ft.
d ft.
ys` ft.
yv
ft.
C/4y
col/ /lhrf4a-Ae. 4
tehicria to see
ft.
21. REMARKS
ft.
Date
By signing this form, I hereby cerlfy that the well(s) was (were) constructed 1n accordance
with ISA NCAC 02C .0100 or ISA NCAC 02C .0200 Well Construction Standards and that a
copy of this record hos been provided to the well owner. 23. Site diagram or additional well details:
You may use the back of this page to ovide
construction details. You may also atta
SUBMITTAL INSTUCTIONS
(ft.) 24a. For All Wells: Submit this form witIAR9 on4 pletion of well
constmction to the following:
AR I 4
(@,) Division of Water Resources, In_ _ _forma iuuigropgssina Unit,
1617 Mail Service Center i'itt41 'TT SSgq§§ ij/la'
24b. For Iniection Wells ONLY: In Opper[ga tions OCiIOD
ress in
24a above, also submit a copy of this �fo form 30 )co��iondof well
construction to the following:
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) .3' Jr- Method of test:
13b. Disinfection type: ,'i �/ / f" Amount: 1, f J6f
peimP
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supply & injection Wells:
Also submit one copy of this form within 30 days of completion of
well construction to the county health department of the county where
constructed,
017
Form GW-1
North Carolina Department of Environment and Natural Resources - Division of Water Resources
Revised August 2013

WELL CONSTRUCTION RECORD.
This form can be used for single or multiple wells
1. Well
�Co�nraactor Information:
WLl
Well ContractoFRame
NC ell Contractor Certification Number
C0../ 5 cue h I Dr; i6int I
Company Name
2. Well Construction Permit ft: a
List all applicable well permits a. e. County, Slate, Variance, Injection, eta.)
3. Well Use (check well use):
Water Supply Well:
°Agricultural
❑Geothermal (Heating/Cooling Supply)
°Industrial/Commercial
°Irrigation
Non -Water Supply Well:
°Monitoring
Injection Well:
°Aquifer Recharge
°Aquifer Storage and Recovery
°Aquifer Test
°Experimental Technology
❑Geothermal (Closed Loop)
°Geothermal (Heating/Cooling Retyrn)
4. Date Well(s) Completed:
5a. Well Location: TWey ito Pie
Facility/Owner e
Physical Address,fratty, and Zip
9/zd
°Municipal/Public
esidential Water Supply (single)
°Residential Water Supply (shared)
°Recovery
['Groundwater Remediation
°Salinity Barrier
°Stormwater Drainage
°Subsidence Control
°Tracer
°Other (explain under #21 Remarks
I' Well ID4i
Facility ID# (if applicable)
County Parcel Identification No. (PIN)
56. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
N
6. Is (are) the wll(s): Permanent or °Temporaryy 2
7. Is this a repair to an existing well: °Yes or . o
lffhis is a repair,.fill out known well construction information and explain the nature of the
repair under N2l remarks section or on the back ofthis form.
S. Number of wells constructed:
For multiple injection ar non -water supply wells ONLY with the same construction, you can
submit one form, n
9. Total well depth below land surface: /20
For multiple wells list all depths ijdi5lrent (example- 3@9200' and 2@2009
10. Static water level below top of casing: !'a
If water level is above casing use "+"3,
11. Borehole diameter: 'a i ��'(in,)
12. Well construction method: g6
(i.e. auger, rotary, cable, direct push, etc.)
For Internal Use ONLY:
14.'WATER ZONES
FROM
7f re.
ft.
FRO
0
DESCRIPTION
/2o ff.
442387
LITER CASING fbi•oiulh-eased wells OR LINER if a' .
TO THICKNESS ■Si_4Ten
ft.
18. GROUT
DIAMETER
ft.
ER CASING OR TUBING
Tor rt.
DIAMETER
DIAMETER
MATERIAL
THICKNESS
SLOT SIZE
1P.$AND/GRAVEL PACK if 4cable .
TO
MATERIAL
THICKNESS
MATERIAL
EMPLACEMENT METHOD
a . a,..hove s, ee', Ilecessa
-" •'D' mtuphn •nose, sONrec s
D ffmans'n(nu, ere.J♦
Irai
realem
I� S«
12 0 ft.
22. Certification;
for Date
By slgnlny' rs fern?, I hereby ceriity that the wells) was (Were) constructed in accordance
with 15A NCAC 02C .0100 ar ISA NCAC 02C .0200 Well Construction Standards and that a
copy ofthis record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attacRee
SUBMITTAL INSTUCTIONS
(ft.) 24a. For All Wells: Submit this form wit6vu39 dayytofacnptpletion of well
construction to the following: IVIHf(G U L1) (
(ft.) Division of Water Resources, Information Processingga�Unit,
1617 Mail Service Center; gig9-rr=51�%flai
246. For Infection Wells ONLY: In 0ppp p&p ratlr' gee
24a above, also submit a copy of this"fdrn� i({'3i':', D ip the addressowell
construction to the following: iit�'etion of well
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center,Raleigh, NC 27699-1636
24c. For Water Supply & Injection Wells:
Also submit one copy of this fort within 30 days of completion of
well construction to the county health department of the county where
constructed.
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm)
13b. Disinfection type: //y'/1
Method of test: Amount: gal
lure ofCeyt. ed ellCo .o
sti
IRERiRGVR
Form GW-I
North Carolina Department of Environment and Natural Resources —Division of Water Resources
Revised August 2013

WELL CONSTRUCTION RECORD.
This form can be used for single or multiple wells
1. Well Contractor Information:
Well Contra/tor Name
a6i/_4
NC Well Contractor Certification Number
� �eL3e14 cie l i :O;-:l lIn5
Company Name
2. Well Construction Permit #: _ Q� /n O./7P /
List all applicable well permits (.e. County, orate, Variance, Injection, etc.J
3. Well Use (check well use):
Water Supply Well:
°Agricultural
°Geothermal (Heating/Cooling Supply)
°Industrial/Commercial
°Irrigation
Non -Water Supply Well:
°Monitoring
Injection Well:
°Aquifer Recharge
°Aquifer Storage and Recovery
°Aquifer Test
°Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling Return)
4. Date Well(s) Completed: / •"/" /6
5a. Well Location:
k ;4-1 13lcf/ck:rn
Facility/Owner Name
li
b33'cs Fork rd S;
Physical Address, City, and Zip
ircki
County
°Municipal/Public
Cesidential Water Supply (single)
°Residential Water Supply (shared)
°Recovery
°Groundwater Remediation
°Salinity Barrier
DStormwater Drainage
❑Subsidence Control
°Tracer
°Other (explain under #21 Remarks)
Well ID#i
Facility ID# (if applicable)
Parcel Identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
N w
6. Is (are) the well(s):rmanent or °Temporary
7. Is this a repair to an existing well: °Yes or . p3N'o
lfth/s is a repair, fits( out known well construction information and explain the nature of the
repair under #21 remarks section or on the back of this form.
8. Number of wells constructed:
For multiple Infection or non -water supply wells ONLY with the sane construction, you can
submit one form. d / �7
9. Total well depth below land surface: / b (ft.)
For multiple wells list all depths "different (example- 3@200' and2®100)
10. Static water level below top of casing:
"water level is above casing, use "+"
'i
11. Borehole diameter: 7 ] (in.)
MUc!
12. Well construction method: ry'{{,�
(i.e. auger, rotary, cable, direct push, etc.)
(ft.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) v(I�/1 Method of test:
136. Disinfection type: !/ 1/] Amount:
"Rali P
1.S As
IFor internal Use ONLY:
14.'WATER ZONES
ROM TO
44238E
o ft. j ft.
It. rt. I
DESCRIPTION
5.. UTER CASING (for multi-cased'welis) OR LINER (if'apprrcable).
ROM TO DIAMETER THICKNESS MATERIAL
$eA 90 JPC
R CASING OR TUBING (geothermal closed -loop)'.
OM 1 TO 1 DIAMETER THICKNESS 1 MATERLAL
R.
t.
17. SCREE
ft. in.
7S ft.
t.
in.
Sch yt)
Put
FROM To
ft.
a.
1S. GROUT
0
2 v ft
ft.
ft.
ft.
DIAMETER SLOTSIZ
m.
ATER/AL
gek{d4k p011,4
CHNESS MATERIAL
MPLACEMENT
t.
19. SAND/GRAVEL PAC
OM
ft.
TO
t.
(4t' s
OD & AMOUNT
Of applicable)
MATERIAL
MP
CEMENT METHOD
ft.
t.
20. DRILLING LOG (atta
FROM 1 TO
0
a.
ft.
additional sheets if necessary),
DESCRIPTION (color, hardness, soil/rock type, grain sl
�T ft.
jS
t/O
ft.
#8 rt.
S'S
7r
t.
t.
«d
Ss
a.
ft.
7f a I ✓1'IVd
la0
21. REMARKS
a.
Sx,d State,
C/4y
Sk l
kitty /fiat_ tvcI
sof/ /?Atcf%1x -
MAR 1 4 201
ed Well Contracto, Date
By signing this form, I hereby cern * that the wells) was (sere) constructed /n accordance
with ISA NCAC 02C .0100 or ISA NCAC 02C .0200 Well Construction Standards and that a
copy ofthls record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTUCTIONS
24a, For All Wells: Submit this win, lYtEPA(7CiDaENy®yRtion of well constmction to the following: .
Division of Water Resourcespjtf('rpmgt10 p.Wpising Unit,
1617 Mail Service Center''jj�(``4b1Ikh, 2 1617
246. For Injection Wells ONLY: In addition to sending the forry to the address in
24a above, also submit a copy of thihttatteramlitto 'B Qi mpletion of well
construction to the following: Wilmington
Operationsep}}Section
Division of Water Resources, Unldergreund Injection RegionalControl
ntrOfficerogram,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supply & Injection Wells:
Also submit one copy of this fonn within 30 days of completion of
well construction to the county health department of the countywhere
constructed.
Form GW-1
North Carolina Department of Environment and Natural Resources - Division of Water Resources
Revised August 2013

10. Static water level below top of casing:
"water level is above casing, use "+"
i
11. Borehole diameter: ti 17 (in.) 5
12. Well construction method: •'1 , 4 d t?�1"lfy
(i.e. auger, rotary, cable, direct push, etc.)
WELL CONSTRUCTION RECORD
This form can be used for single or multiple webs
1. Well Contractor Information::
11 i
te
el Coniralt r Name
1010/
NC Well Contractor Certification Number
1,3techI4 fit" I6 r; I l +
Company Name j
2. Well Construction Permit#: t�(0 J 3 0 ./..)
List all applicable well permits (.e. Counry. State, Parlance, Injection, etc.)
3. Well Use (check well use):
For Internal Use ONLY:
14. WATER ZONES
442385 I
FROM
jib ft.
ft.
TO
{ 05 ft.
ft.
DESCRIPTION
54•) 1,:rme..5Yd.«
• 15.. OUTER CASING (far multi -cased wells) OR LINER (if applicable);
FROM TO DIAMETER THICKNESS MATERIAL
Syft. .T4y) ft. I. I 1
Se6 (ro
16; INNER CASING OR TUBI G (geothermal closed -loop)
FROM DIAMETER
TO
ft.
ft.
in.
in.
THICKNESS
MATERIAL
ft.
ft.
fa.
17. SCREEN'.
Water Supply Web:
°Agricultural
°Geothermal (Heating/Cooling Supply)
°Municipal/Public
°Residential Water Supply (single)
__,__._.....
FROM TO
DIAMETER
SLOT SIZE
THICKNESS
.SLh 7 C
MATERIAL
Pc.
CPC,
6es' ft. .13
ft.
(,i/
in•
,G`LO
D.
go GRO
rt.
in.
°Irrigation
upply (shared) DT
FROM
Non -Water Supply Well:
❑Monitoring
Injection Web:
o Aquifer Recharge
°Aquifer Storage and Recovery
°Aquifer Test
o Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling Return
°Recovery
°Groundwater Remediation
❑Salinity Barrier
OStormwater Drainage
°Subsidence Control
°Tracer
(]Other (explain under#21 Remarks)
4. Date Well(s) Completed: ..2.5 6 Well ID#
Sa. Web Location:
fj,= 4 i.ch (eflty' 6-,e9 11 eel'
Facility/Owner Name Facility ID# (if applicable)
3 6 Z p'a!arw 1 la Alta 9,0
Physical Address, City, and Zip
County
ZSft.
3 ft.
Tof ft.
TO
3
�1e ft.
'MP fr.
MATERIAL
P.,Tknd$�
Lzrnrn.�
19. SAND/GRAYEL PACK (if applicable)
TO
FROM
1oJ ft.
/Q ft.
MATERIAL
-tt,2yti l
EMPLACEMENT METHOD & AMOUNT
ku49
tPovrd
"NU 5 ki,
EMPLACEMENT METHOD
20, DRILLING LOG (attach additional sheets it nec'ssary)
DESCRIPTION (color, bar ness, soil/rock type. grain sire. ate.)
FROM
105 ft.
So R.
ft.
TO
_55 ft.
t/0
S ft.
j D.
ft.
Soft 11MC.i,ydAf (J few (odd
ce..4 gat./ .5lr_fl4{! %J)ttl,
V usihF ,Mt>rd
4cP .Bull . /PIL't
lac-he4
ft.
21. REMARRS
iAAR 14 21117
Parcel Identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
N W
6. Is (are) the well(s): p1 ermanent or °Temporary
7. Is this a repair to an existing web: °Yes or ONO'
ffthis is a repair, fill out known well construction information and explain the nature of the
repair under 021 remarks section or on the back ofthts form.
S. Number of wells constructed: 1
For multiple injection or non -water supply wells ONLY with the same construction, you can
submit one form.
9. Total well depth below land surface: o7r
For multiple wells list all depths if -different (example- 3Qa 200' /and2@100')
U t
1
(ft.)
(ft.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) 35—JJ
13b. Disinfection type: all/
Method of test: .44' 1t did'
Amount: / -) 1.4
22. Certification:
C. I fie°
Signature o e rfied Welltonhactor.
By srgning this form, 1 hereby cert(%y that the well(s) was (were) constructed in accordance
with 154 NCAC 02C .0100 or ISA NCAC 02C .0200 Well Construction Standards and that a
copy of this record has been provided to the well owner.
23. Site diagram or additional web details:
You may use the back of this page to provide additional well site details or well
construction details. You may also anaalaedditjpga6pegyppehnI®
SUBMITTAL INSTUCTIONS t��i7i
24a. For All Wells: Submit this form wi lMMi((ilof
0 Qay� 6g7pletion of well
construction to the following: H C. I
Division of Water Resources,fa/hag
gIn�f�ormation Processing Unit,
1617 Mail Service Center, fa/rT,,h gA$)6VEgbha(
24b. For Injection Wells ONLY: In addi}tt�s'E'rii ! �(• &Ctirasa,t(ye address in
24a above, also submit a copy of this)/1igle3 ettiption of well
construction to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supply & Injection Wells:
Also submit one copy of this form within 30 days of completion of
web construction to the county health department of the county where
constructed.
Form GW-I
North Carolina Department of Environment and Natural Resources -Division of Water Resources Revised August 2013

WELL CONSTRUCTION RECORD
This form can he used for single or multiple wells
1. Well Contractor Information:
G/ou 114.E
Well Contractor Name
De. / l
NC Well Contractor Codification Number
}�eLA, eh Welt DP; I1,,,Ly
Company Name
2. Well Construction Permit #; 1of5 ®72 A Crl
List all applicable well permits 0.e. County, State, Variance, of ectlon, etc.)
3. Well Use (check well use):
Water Supply Well;
°Agricultural DM��unicipal/Public
�
❑Geothermal (Heating/Cooling Supply) Residential Water Supply (single)
°Industrial/Commercial °Residential Water Supply (shared)
°Irrigation
Non -Water Supply Well:
°Monitoring °Recovery .
Injection Well:
°Aquifer Recharge ❑Groundwater Remedietion
°Aquifer Storage and Recovery ❑Salinity Barrier
°Aquifer Test OStormwater Drainage
°Experimental Technology DSubsidence Control
❑Geothermal (Closed Loop) °Tracer
❑Geothermal (Heating/Cooling Return) °Other (explain under #21 Remarks)
4. Date Well(s) Completed: 7 1 f'/10Wef 1D
5a. Well Location:
/K Vire IOn en/.Frl
Facility/Owner Name
# ao/5'07; 059
Facility ID# (ifapplicabip)
p SVa Address, At h,/ Ln _ e 'tjffZZ
Physiicddress, Ci6r, and Zip
iv n.Swt'ch
County
(if well field, one laulong is sufficient)
Parcel Identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
22. Certificatio
/For Internal Use ONLY:
442384
19. WATER ZONES
FROM TO
5. OUTER CASING
FROM
TO
DESCRIPTION
ft.
for I dfi-edsed wells
DIAMETER
16: INNER CASINO OR TUH1N geothermal cloossed---lop)'
FROM TO DIAMETER THICKNESS
in.
ft.
17. SCREEN
OM
R LlN R it'a.'.Iieable
THICKNESS MATERIAL
c.
MATERIAL
ft.
TO
t.
DIAMETER
le,.
SLOT SIZ
CKNESS
MATERIAL
S. GROU
FRO
0 ft.
in.
TO
o ft.
t.
19. SAND/GRAVEL PAC
OM
ft.
t.
AT REAL
(Reno% e
EMPLACEMENT METHOD & AMOUNT
ekbtey
(ifaypiicable)
TO I MATERIAL
ft.
EMPLACEMENTMETHOD
20. DRILLING LOG Canada additional sheets ifneceisaryj..
a'nOM TO DESCRIPTION color, hardness, soinrnek rain sire, et
35-
35'ft.
R.
t.
ft. R.
ft. ft.
21. REMARKS
N W
6. Is (are) thewell(s): WC:maneut or °Temporary
7. Is this a repair to an existing well: OYes or
Ifthis is a repair, fill out known well construction Information and explain the nature of the
repair under 01 remarks section or on the back of this form.
8. Number of wells constructed: '
For multiple injection or non -water supply wells ONLY with the same construction, you can
submit one form. f�
9. Total well depth below land surface: 7 D (ft)
For multiple wells list all depths ifdlerent (example- 3@200' and 2@100)
10. Static water level below top of casing:
Ifivater !evens above casing, use "+"
11. Borehole diameter:
((iin.)
12. Well construction method: %eG ! aery
(i.e. auger, rotary, cable, divest push, etc.)
(ft.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) 3o I Method of test:
13b. Disinfection type: 44 44 Amount: y y6$
nnLcsitMe a ..:.,.,.s
MAP
-c
2017
Signature edified Well Contractor t�p m /
Date
By signing this form, I hereby certhy that the well(s) was (were) constructed In accordance
with /5A NCAC 02C .0100 or 15A NCAC 02C .0200 Well Construction Standards and that a
copy of this record has been provided to thew!! owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also att¢O laMAbl'E p'
SUBMITTAL INSTUCTIONS Fi�7vG �¢
24a. For All Wells: Submit this form witluipr30tdap@ ¶typrppletion of well
constmction to the following: IVIh11C G 1/ LUII
Division of Water Resources, Information Processing Unit,
1617 Mail Service CenterAlakigelfeliO6;A.., raga
24b. For Infection Wells ONLY: Intgy(Qjyl� ratiojlS� C P n
24a above, also submit a copyof thi33 £ r 7ROd' tan offss in
to ays of completion well
construction to the following:
Division of Water Resources, Underground Injected Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supply & Injection Wells:
Also submit one copy of this form within 30 days of completion of
well construction to the county health department of the county where
constructed.
Form GW-1
North Carolina Department of Environment and Natural Resources —Division of Water Resources
Revised August 2013

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
1. Well Contractor Information:
Doug. /85 41au4uae44'
.
Well Contractor Name
Oro
NC Well Contractor Certification Number
¢1etoe4'¢ Wel
Company Name
DP 2 I I. aVIO
2. Well Construction Permit ft: t:(0/.0 7a d fq
List all applicable well permits (le. Court%, State, Parlance, Infection, etc)
3. Well Use (check well use):
Water Supply Well:
°Agricultural
°Geothermal (Heating/Cooling Supply)
°Industrial/Commercial
❑ Irrigation
For Infernal Use ONLY:
14. WATER ZONES..
FROM
90ft.
ft.
TO
96R.
ft.
442383 I
DESCRIPTION
Ptig vita&-r. Lt01.e. 0
15_OUTER CASING (for mull -eased webs) OR LINER (if hp'.Eiable),
FROM TO DIAMETER THICKNESS 1 MATERIAL
o ft. LAS I in. , I P ✓ c_
16. INNER CASING OR TUBING/ .Se%1j%
gdotherthal cloe'dd-loop)
FROM TO DIAMETER
ft.
ft.
17. SCREEN.
ft.
ft.
THICIGIESS
MATERIAL
in.
°Municipal/Public
Eli‘sidential Water Supply (single)
°Residential Water Supply (shared)
Non -Water Supply Well:
❑ Monitoring °Recovery .
Injection Well:
°Aquifer Recharge
°Aquifer Storage and Recovery
°Aquifer Test
°Experimental Technology
❑Geothermal (Closed Loop)
°Geothermal (Heating/Cooling Return)
°Groundwater Remediation
°Salinity Barrier
°Stormwater Drainage
°Subsidence Control
°Tracer
❑Other (explain under #2I Remarks)
4. Date Well(s) Completed: 7%2/"/Well ID# 20/f67o7 aft
5a. Well Location:
IOCV;A /Dm ender
Facility/Owner Nrxne
Facility ID# (if applicable)
PhysicalAddress, C;0 `A cc tt/ z z
i 0Zip
IQ /),SLJI C ft
County
Parcel Identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one latllong is sufficient)
N W
6. Is (are) the well(s): tPermanent or °Temporary
7. Is this a repair to an existing well: °Yes or VIC
If this is a repair, fill out known well construction information and explain the nature of the
repair under 521 remarks section or on the back of this form.
8. Number of wells constructed:
For multiple infection or non -water supply wells ONLY with the same construction, you can
submit one form.
I
9. Total well depth below land surface: / V (ft.)
For multiple wells list all depths ifdiferent (example- 3Q200' and2@100)
10, Static water level below top of casing: / (ft.)
If water level is above casing, use "+"
II. Borehole diameter: ( (in.)
12. Well construction method: toter��
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) 3'oMethod of test: ?U kfl P
13b. Disinfection type: 114 44 Amount: y P6 S
FROM
R.
ft.
18. GROUT
FROM
® ft.
3 ft.
R.
TO
ft.
ft.
TO
ft.
col I? ft.
ft.
f
in.
IA OMETER SLOT SIZE
MATERIAL
Poor. e
19. SAND/GRAVEL FACIC (if applicable)
TO
FROM
ft.
ft.
MATERIAL
THICKNESS
MATERIAL
EMPLACEMENT METHOD & AMOUNT
k:a
pus,....
EMPLACEMENT METHOD
20. DRILLING LOG (attachadditional sheet, if necesary);.
FROM 1 TO 1 DESCRIPTION (color. hardness, soil rock type, grain sisa, ew.)
S sow
ft. aI.) ft.
too R'
3s ft.
ft.
ft.
SS"' ft.
9'8 ft.
ft.
ft.
C /h.y A. ;Letts
tts
Stud $414.4
ft.
21. REMARRS
22. Certifieatio
ft.
ff.
Signature ofCredified Well Contractor Date
By signing this form, I hereby cert fy that the well(s) was (were) constructed in accordance
with ISA NCAC 02C .0100 or 1521NCAC 02C .0200 Well Construction Standards and that a
copy of this record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach addOEIVE111'iM RplprR
SUBMITTAL INSTUCTIONS ��77���� ,sr99
24a. For All Wells: Submit this form within 30tdaFR pf gpo p)sYgn of well
construction to the following: iVl/-If( .G 'U C U
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Ralei�l(gAegional
246. For Infection Wells ONLY: In additi µpr�55 atirns SecI�ti ggaa¢¢QQrr
24a above, also submit a copy of this form wiith'fnn ayss fr1p' U i%r well
construction to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supply & Injection Wells:
Mso submit one copy of this form within 30 days of completion of
web construction to the county health department of the county where
constructed.
Porn GW-1
North Carolina Department of Environment and Natural Resources- Division of Water Resources
Revised August 2013

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 9 611
1. WELL CONTRACTOR:
Douglas Hewett
Well Contractor (Individual) Name
Hewett's Well Drilling
Well Contractor Company Name
STREET ADDRESS 2172 Ocean Hwy West
Supply Nr 28462
City or Town State Zip Code
( 910- 75.4:=6528
Area code- Phone number-
2. WELL INFORMATION:
SITE WELL ID #(if applicable)
STATE WELL PERMIT#(irapplicable)
D W Q or OTHER PERMIT #(if applicable) /781,®/1
WELL USE (Check Applicable Box): Residential Water Supply DATE DRILLED 7- 3— J(p
TIME COMPLETED 4 DD AMP PMVe"
3. WELL LOCATION:
CITY' 015 II COUNTY 2,416#0 r %
4L73ee Four SAaeotl Wq-y W
(Street Name, Numbers, • Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
❑Slope ❑Valley ['Flat ❑Ridge ['Other
(check appropriate box)
LATITUDE 3
LONGITUDE
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: in GPS ❑ Topographic map
(location of well must be shown on a USGS topo map and
attached to this form if not using GPS)
4. WELL OWNER ,9�
OWNER'S NAME 57ei/e iihuts
STRE TAD RESS kV 1/.-//er Ett. ✓d
C' n rn fit c�7 2.7
CityTown State Zip Code
( cI/D )- 44/7-Ova '
Area code - Phone Ttumber
5. WELL DETAILS:
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YESW NO ❑
c. WATER LEVEL Below Top of Casing: 4 0 FT.
(Use "-" if Above Top of Casing)
d. TOP OF CASING IS I .,5. FT. Above Land Surface`
'Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): 9 METHOD OF TEST 4t/,
Formation Description
442382
I. DISINFECTION: Type % %J Amount I
g. WATER ZONES (depth):
From Soo To ./?%f From To
From cis- To es kr'. From To
From To From
To
6. CASING: Thickness/
From
Depth s Diameter
To Ws t eigh_ Materi G
') Ft . /f�
From To Ft.
From
To Ft.
7. GROUT: Depth Material Method
F'[
IC .✓ t. ry
From 4' Toc9 r Ft.
From rM�ti
From To Ft.
a. SCREEN: Depth From 5.0- ToDiameter Slot Size Material
/J4CFt._4_ _in. /0 in, //✓ I
From To Ft. in. in.
From To Ft. in. in,
9. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
From To Ft.
10. DRILLING LOG
From To
0-/D
'/1b(- 93-
7 S o S
r7
KECEIVEQINC©ENR/DWR
II. REMARKS; MAR 2 0 2017 . T ;:,ny,t
Water Quality Regional
wilONe�ratiuNaSiect ona on
I DO HEREBY CERTIFY THAT 6�{.GRe��'T THIS WELL WAS
CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONS - UCT1ON STANDARDS, AND THATA COPY OF THIS
RECORD HAS SEEN PR TO TOTHE WEL • NER.
SIGN OF
D WELL ONTRACTOR DATE
Douglas Hewett
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt.,
1617 Mail Service Center —Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-1a
Rev. 7/05

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION 11 9611
442381
1. WELL CONTRACTOR:
Douglas Hewett
Well Contractor (Individual) Name
Hewett's Well Drilling
Well Contractor Company Name
STREET ADDRESS 2172 Ocean HWy West
Supply NC 78462
City or Town State Zip Code
( 910- 7-5:4 28
Area code Phone number •
2. WELL INFORMATION:
SITE WELL ID *Of applicable)
STATE WELL PERMIT#(I( applicable)
DWQ or OTHER PERMIT#(if applicable)20150/2/j' Lf
WELL USE (Check Applicable Box): Residential Water Supply ❑
DATE DRILLED 7 2/ —/k
TIME COMPLETED WO
3. WELL LOCATION:
CITY: .©j7/ "
&c
(Straet Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
❑Slope °Valley ❑Flat ❑Ridge ❑Other
(check appropriate box)
LATITUDE 3
AMC PM6�✓
COUNTY Relit/S ' a
LONGITUDE_
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: MOPS ° Topographic map
(location of well must be shown on a USGS topo map and
attached to this form if not using GPS)
4. WELL OWNER �% J
OWNER'S NAME 4•t�° dlciy
STREET ADDRESSJZDi / tatl
City own State
(%/O )-4177-Of'3I
Area code - Phone number
5. WELL DETAILS: L®
a. TOTAL DEPTH:
`sna 4
'FPv'yret.s L2r'.
Zip C/orde 2
b. DOES WELL REPLACE EXISTING WELL? }YES
❑ Nair"-
c. WATER LEVEL Below Top of Casing: / v FT. '
(Use "+" if Above Top of Casing)
d. TOP OF CASING IS / FT. Above Land Surface'
*Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118. e. YIELD (gpm): / METHOD OF TESTY / / r1rft
f. DISINFECTION: Type /t / y�l Amount YG/
g. WATER ZONES (depth):
From .3,5— To S.�^
From To
From To From To
From To From To
6. CASING:
V
y Depth Diameter
From To 9 0 Ft. 4C
From To Ft.
From To Ft.
7. GROUT: Depth
From To .2
From 3 TopL7
From To
Thickness/
We�"
�1lght Mat al
Material ♦ Method
Ft.13qP.hah aGr,�
Ft. /fc m>svlr' 4" v"sue
Ft.
8. SCREEJNl: Depth,, Diameter Slot Size
From 7� Tc c) Ft. LE in. /0 in
From To Ft. in. in.
From To Ft. In. in.
9. SAND/GRAVEL PACK:
De.Gth Size Material /
From TOSS— Ft. f'2 Crq_�e/
From To Ft.
Material
la re
From To Ft.
10. DRILLING LOG
From To
�Q _is-
/c-- c25
s tG Ys�i4
Formation Description
l lid y } 4L hG
rtz Tn&c
Water Quality Regional
OperationsgtonQional Section
Office
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT COPY OF THIS
R ' -0 HAS B�N PROV DED TO THE WELL OWNER.
7—a--i
S - AT A 'E OF CERTIFIED WELL CONTRACTOR DATE
Douglas Hewett
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt.,
1617 Mail Service Center — Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-la
Rev. 7/05

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2 61. 1
442380
1. WELL CONTRACTOR:
Douglas Hewett
Well Contractor (Individual) Name
Hewett's Well Drilling
Well Contractor Company Name
STREET ADDRESS 2172 Ocean Hwy West
Rnppl y Nf'
City or Town State
( 910- 775546-5e8
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable)
28462
Zip Code
STATE WELL PERMIT#(if applicable)
DWQ or OTHER PERMIT #(if applicable)ZD/ V7 /,'Lf
WELL USE (Check Applicable Box): Residential Water Supply p
DATE DRILLED `—J
TIME COMPLETED `pDAM.❑ PM(fa/
3. WELL LLOCATI ON:
CITY:,J//.j71 1
(Sur t Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
❑Slope °Valley ❑Flat ❑Ridge ❑Other
(check appropriate box)
LATITUDE 3
LONGITUDE
COUNTY Nevi/SEA'
/7
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: ❑GPS ❑Topographic map
(location of well must be shown on a USGS topo map and
attached to this form ifnot using GPS)
4. WELL OWNER
OWNER'S NAME ti 4c/y `S
STREET ADDRESSJ'2D/e.(-AZI/reW at.
City or Town S to pCode 2
(%/9 ). Lf77^tQi?31
Area code- Phone number
5. WELL DETAILS: „lam
a. TOTAL DEPTH:J
b. DOES WELL REPLACE EXISTING WELL? jYES 0 NO"g�
c. WATER LEVEL. Below Top of Casing: / FT.
(Use "+" if Above Top of Casing)
d. TOP OF CASING IS / FT. Above Land Surface`
`Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): Ar METHOD OF TEST hey r/a Di_
T
f. DISINFECTION: Type I ` 7 --d
g. WATER ZONES (depth):
From . Zr To -.5 3 From To
From To From To
From To From To
6. CASING: Thickness/
Depth Di meter Weight
From t) To re) Ft. ,x4 ra
From To Ft.
From To Ft.
7. GROUT: Depth Material
From 0 To .7 Ft. t3rrffeg(z* Ate
From 3 Taa2U Ft. %znanrie
From To Ft.
8. SCREEN: Depth Diameter Slot Size
From �T FLL -_in. 2O in.
From To Ftin. in.
From To Ft. in. in.
9. SAND/GRAVEL PACK:
De th Size
From Toc-t Ft. %
From To Ft.
From To Ft.
10. DRILLING LOG
From To
/0
/Q.-4S-
/,S^- .2S
3s-ss�
11. REMARKS:
Amount >2./4
Mat r��—
Method
Materialvc
Material
(a Y/4Ge /
Formation Description
CV"- y 5' SA-
i//ter G
ct-t T`/=sh`1
Cr_ /en
S 4- tZ �s
MAR 202017
'alai Quellily Regional
Operations Section
IDO HEREBY CERTIFY THATTHI$/rt'�B lYt1'CFQ.ORD NC WOTI 15A NCAC 2C, WELL CONSTRU N� • YA2'OP1'
R- O HAS BINPROVPED TOTHE WELL OWNER.
7 a /6
S - AT OF CERTIFIED WELL CONTRACTOR DATE
Douglas Hewett
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt.,
1617 Mali Service Center— Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-la
Rev. 7/05

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION #, F 1 1
1. WELL CONTRACTOR:
Douglas Hewett
Well Contractor (Individual) Name
Hewett's Well Drilling
Well Contractor Company Name
STREET ADDRESS 2172 Ocean Hwy West
RI: P Y
NC
City or Town State
( Q10- 7.54=5-528
Area code- phone number'
2. WELL INFORMATION:
SITE WELL ID #(if applicable)
98462.
Zip Code
STATE WELL PERMIT#(ifapplicable)
DWQ or OTHER PERMIT #(if applicable) D0 rib 7L ZU
WELL USE (Check Applicable Box): Residential Water Supply t17.—
DATEDRILLED 3— 21 `/�
TIME COMPLETED
3. WELL LOCATION:
CITY: )v/ayJf�
3.'1,0 AM El PM LiLr
d Cc_ , d'
(Street Name, Numbers, Community, Subdi e)
TOPOGRAPHIC / LAND SETTING:
❑Slope ❑Valley ❑Flat DRidge ❑other
(check appropriate box) „
LATITUDE 3
LONGITUDE_
Latitude/longitude source: ❑GPS ❑ Topographic map
(location of well must be shown on a USGS topo map and
attached to this form if not using GPS)
4. WELL OWNER 1 ��I•
OWNER'S NAME ��rrOki / PI4h L'>>o t
STREET ADDRESS 9 / %3/,./ /tyilt IROr1 (h
COUNTY Bfl nse.o.G
Nsion, 6 No., Zip Cod
May be in degrees,
minutes, seconds or
in a decimal format
City or Town State Zip Code ,
(i/D )- �f , 7 -..1)14g
Area code - Phone number
5. WELL DETAILS: NOa. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES 0
c. WATER LEVEL Below Top of Casing: es
(Use "+' if Above Top of Casing)
*Top of casing terminat at/or below land surface may require
d. TOP OF CASING IS . FT. Above Land Surface'
a variance in accordance with 15A NCAC 2C .0118. e. YIELD (gpm): e.J 2METHOD OF TEST,grr (jj r 4
442379
f. DISINFECTION: Type ru _ Amount l
g. WATER ZONES (depth):
From SO To //0 From
To
From
To From To
From To From
To
6. CASING: Thickness/
Depth Diameter Weight M terial
From Dv Torelr Ft; Sc y y//J t✓e.
From To Ft.
From To Ft.
7. GROUT: Depth Material
FromY> To 3 Ft. Offload,Method
From 3 To ��p�7� — C �rp
Ft�l1 ur-..
From` j"_ To ..3— Ft.
sea
8. SCREEN: Depth. Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in. __ in.
From To Ft. In.
in.
9. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
From To Ft._
10. DRILLING LOG
From To
7- 02 (J
o?v- 3 v
C7- %✓p
1. REMARKS:
Formation Description
MAR 202017
Water Quality Regional
Operations Section
I DO HEREBY CERTIFY THATTHISWIthralf]'BiQj1N jr;r,, tanalllatfireDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STAN ARDS, A i THAT A COPY OF THIS
RECORD HAS BEEN ' ROVIDE. TO THE WELL OWNER,
577006
I OF CERTIFIED WELL CONTRACTOR DATE
Douglas Hewett
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
S
Submit the original to the Division of Water Quality within 30 days. Attn: information Mgt., 1617 Mail Service Center— Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-1a
Rev. 7/05

441534
This inci can be reel far siren .r mwuplewelk �•vaW
1. Well Contrccttoorrinr�(t,/o/y..
For 7memalIIae ONLY:
1w
.»
, % j ,e i s Ol
IL 1VATERZONES
cJ
FROMM
To
DESCRIPTION
Well CowactorNmm
R
Q?O R.
ire Nd
3SY0 A
i8 fL
98 f-
.ems' d SruNG
NC Well Counacipp' ntincaDan
Numbcr
1S OUTER
CASING (for
multeased wails) ORLENERWa bkk)
e
A /e / / f
67
FROM
TO
DLAMEMER TIHCIINESS }LATEPL4L
+(�V
t/ i/
We/
t
b S rL
d �- [ b yo j Pvc
Company Name I/��rr6�L J
16.INNER
CASING OR TUBING
(Rembermal dondfanp)
V/•^/.1/i4/✓te/Vat .aB'� "p00O�
FROM
To
DIAMETER
THICfOGFSs
LL4Trinat
2. Well Construedon Pernt[N: 6
D.
(r.
in.
List all applicable well permits fie. County: Score. Variance, Infection. an;
3. Well Use (check well use):
fL
f4
in.
17. SCREEN
Water Supply Well:
FROM
TO
DUMETER SLOT SIZE
Tmc Ess MSEEP��I
❑AgriculNral Ohdhmicipat•Public
D.
�eyeA's
O44
OGeothemal (lieatutgrCooling Supply) ORoidehtial %Tatu Supply (single)
fL
tr.��
Io-
❑Industrial/CommercialnORrsidmtid �'at Supply ('shared)
It GROUT
FROM
TO
MATERIAL
EMPI.ACEIMENT ?JFHO OIRtf
@.NI
n/
llon
0
ry IL
/�
etittr
Non -Water Supply Well:
Pit nvo e
OAlouitoring ['Recovery
ft.6Q
Injection Well:
ft.
ft.
['_aquifer Recharge OCroundwatu Remediatinn
19.SAND/GRAVELPACB
(it' malleable)
['Aquifer Storage and Recovery ['Salinity Barrier
FROM
TO
MATERIAL
RMPLACEMEMT METHOD
❑Aquifer Test OStomn vatcr Drainage
to
n.
°Experimental Technutogy °Subsidence Control
R.
ft.
OGeothamal Loop)
20. DPI!!
MG LOG(atta
b additiars4 stems if necessary)
(Closed ['Tracer
FROM
TO
DESCRIPTION (calor. bar het; art sae• au
°Geothermal (Heating'Cooling Remise) ['Other (explain under #21 Remarks)
U fL
a o ft-
lu
4. Date Welds) Completed: -i- /7Weli lD#
ft3�jg
a7
ff.
G f\s,
Gr /'4 /
aa.WeBLocation:
�Qr
70 it
6d I`
-L(v»esnvrJe wj C/pyL.
/e rote
(ogt ft.
98' fL
s,gNd Sro� t
soM
R
iL
Pandit_ OwncrNama Facility con Of a)pliabk)
Y�
/Oa 6. /s/m4 br °Ale tr/,mod
«
f�
�v.
Ph)Y, alliddress. City. and Zip ' dey6s
��
21-RFAf6Re•S ®7
(�jrva3CA-.rC lcCount)'Parcel
l��®®2
IdauificaionNo. (PN)1""'""8i,}n
?',n,, , ti),� l)n!i
DbwiRrd 9
>1 Latitude and Lm i sulri in degrees/minutes/seconds or dechrral degrees: ly Q,yy�jeatiu�:
61w Latitude
eat bhtaavgistude sufficient)
/�/IlI
rt
IAI
3°Cc.1 otH/N __ It. Oft 116 wipe n
n 11i\
•
♦
6. Is (arc) Me wel(s): �erntment or ['Temporary
W
7. Is this a repair to an existing well: °Yes or fVu
If this is arepoir,frll out known well consevctinn information and explain the nature of the
repair under d?I remarks section or on the bock ojthisf nu.
S. Number of wells constructed:
For multiple iryection or non -water supply wells ONLY with the same canna chary. roe can
submit oneJonn.
9. Total well depth below land surface:
For multiple wells list all depths if different (example
!fleeter level is ahoy: casing. min "y.,
11. Borehole diarmter. (2_ ((n.) To (yip
@200'and 21100) (a)
8
10. Static water level below top of rasing:
7'
12. Well construction method:AdA l e+rP r y
c. auger, rotary, cable. .Ghmn pink etc)
92
FORW.ATER SUPPLY 'WF) 19 ONLY-
13a. Yield (gpnr) / O Method of test: ,4i f
13k Disinfection type: I3/#Aer�r( Amounr: /b 0 Z
Fora, GN-I
err
Shgmnoc of Certified Welt Canhamor Date
By signing this Iona, f hereby cernjr daa the well(s) was (were) constructed in accordance
wish 1)4 NCAC 02C .0100 or lid.VCAC 02e.0200Well Construction Srandords and that a
copy o this record has been provided to the well owner.
23_ Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
constriction details. You may also attach additional pages if necessary.
SUBMITTAL INSTUCTIONS
24a. For All Wells: Submit this form within 30 days of completion of well
constriction to the following: �j��sC�
SA� Division of Water ResmhM'e4(WMCDCh(o1DItrDit
E617 Mall Service Center, Raleigh, NC 27699-1617
24h. For Injection Wells ONLY: In acklitiochto.icem ate limn to the address in
24a above, also submit a copy of this fr♦tiC{}iithjrh t306.47of completion of well
cohstuctimh to the following:
Division 1f Water of Program,
1636 Mail Serdee CanterfBf a�lt
24u For Water Supply & InjectionMiltigiOft Regional Office
Also submit one copy of Ibis form within 30 days of completion of
wet constuctanl to the cnm,ly health department of the county where
constructed.
Noah C,rohhn Dcpanmcnt of Environment and Natural Rmmwces-➢ivision of Water Resources Ranged .August 2013

WELL CONSTRUCTION RECORD
this form canto mod for single ormagpie molls
1. Well �actarin ormali
ehte RP ( s a✓
Well Camac2a Waive
3SYo A
NC Well Gunnar.;licatiaaNmWty ,'/ vey
Company Name
3. Well Construction Penang:
List allapplicable wel(pennds at. Comm; Sere. Variance, Itgectiwh etei
3. Well Use (check well use):
Water Supply Well:
DA ricultural
°Geothermal (HeatingCoolins supply)
Olndusitiattipmmcrcial
time
OldmricipaLPoblic
ORGndaltlat Waite Supply (single)
ORaidmtial Watt Supply (shared)
Non -Water Supply- Wen:
Ohluoitoriug ORecmm•
Injection Well:
❑Aquifer Recharge
°Aquifer Storage and Recovery
❑Aquifer Test
°E perimental Tcdmoloay
°Geothermal (Closed Loop)
°Geothermal (Heatine Coaling Recent)
°Groundwater Ransdiation
°Salinity Danier
DstmmwmterDrninagc
°Subsidence Control
°Tracer
OOthm (mplain under #21 Remarks)
4. Date Well(s)Completed: 1 11 Well 111i1
aa.ltidllocution:
1013 recc»rj
FaiIity/OwnerName
�a, ��Peaky IDii Ofapplicable)
✓' 7 Wesr V ea nte. .7� fovi t r
Pltysicat Address, City, and Zip
Rama w/eA
Comuy
aayc/
)areal IdauifrcabanNa WIN)
Sh. Latitude and Longitude in degcer/hmmtes/seconds or decimal degrees:
Of won 6dd, one labia isstoTi.iw)
33"sr'/b,awnn,. 71 / a3Y.S%36 \Y
6. 1s (are) the wants): Ifferimment or UTemporaty
7. Is this a repair to an existing well: °Tea err akle
Ifthir isa repair. fill out blown wdlemamm:t»n itfa nmtmn and explain the nature of the
repair under 421 remarlssection Oran the bazto"thirfana
S. Nwnhtr ofwens constructed:
For rmrl:01e igeation or am -waxer s upply ste11r ONL F with tiresome m vmuaMau, sou can
suBrniton.fame.
9. Totalwdl depth hdawlandsm• ace.
For multiple wells list all depths fd rent (example- 3.g200• and21100)
10. Static water level below tap of easing:
lfinner lerelisabove casing. use '•+
1). Borehole diameter
IL Wen construction method: /// V J /C 4%ritry
ere. auger. 'ataxy, cable, cheer push, vac.)
(It)
FOR WATER SUPPLY WFli S ONLY:
13a.17dd (pm)
1 g
13b. Disinfection type 84/2I/12
Method attest �}✓%/
/6 0 2.
Form GN-1
FE?IP6201/
IL ODTFBCASINGttermobFrasdwan ORLINERftiamanptel
DL4ID:IFB Lich
Q? LfJ'ch ro
16INNER CASING OR TURING (g eiknoal c[med400p)
FROM TO DIAMETER
For Idaml Use ONLY:
441533
14.WATERZONES
FROM
7 h
a
TO
3yh
IIFSCRRTION
FROM
4,
To
ay
R
in
THICKNESS
MATERIAL
PVC
MATERI.u.
R
rn
17 SCREEN
FROM
dirt
IL
To
3y"
R
WARDER
ain.
in
SLOTsi7E
, 0/0
THICKNESS
s�l Yo
G
18. GROUT
FROM
0 a
rt.
To
2.22‘
ft.
ft.
MATERIAL
Sew n
SCltlEffM(Ef��pp R AMOUNT
_rat(Yili'iti /0* /6J
19. S9@IDIGR REL PACK(ifapplisahle)
FROM
Z2
D.
TO
sf
ft.
6NTERSAL
W.2 6rmter/
EMPL\CLM5AAT METHOD
Ia RRltrny LOG(attach addidonIlitsdifaeccmrq)
hUOM DESCrRI-FrtOV (wfw lnrdhac.mitrert type ,or..t<r
/—/ a'e rblwN f q ts'd
IL inec 7V eoarse -ravel •_, e
0 IL
20
3r-
R
To
Zo
3y"
R
fr.
a
D.
1L
t
IL REMARKS
72. Cent.
3�nnae ofC.died Well Contractor flaw
/ 7
Br -signing Ihir_form, I her* cerdf)' that the wilts) war Orere) constructed bt acardnra
nib /14lt4C 02C.0100 or ISA ALAC 022C .0200 Trill Construction Statdardr and Hun
copy ofthirreard hasheen provided to there! owner_
23. Site diagram oradditional well decals:
You may use the Ind of this page to provide additional well site details or well
consluctim details. You may also attach additional pages ifnecensary.
SUBMITTAL INSFUCTIONS ��AA��LLaut� (u�r
24a. For All Welk: Submit this fan wim't16WE �t1O1E Bell
crostmetion to thefollowine:
Divisional -Water Resources, 1 c Unit,
1617 Mail Service Center, Re1Ka49360,70 17
24b. For Iniecdon Welis ONLY: In addition to sending the form to the address in
24a above, also submit a campy of this fsmp, they pldion of well
cnusimctim to the fullowine: d rtiudlltY onal
�����,„Operations Section
Minim of Water Resources, UndeegtvwtM
1636 Ilan SemiteCenter, lbdeigh, NC 27699-1636
24c. For Water Snnppty & Injection Wells:
Also submit one copy of this faun within 30 days of completion of
well coustra dim to the county health department of the comity where
cousuucted
North Candiru Dtp.mn ens ofEnvironment and Natural Rnaurces —Division of Wolof Resources
Reviled August_'D13

WELL CONSTRUCTION
This fmn cn be Inca foraigle or mohipicwl6 y�
1. Well Cw{L)Alte Information 4Q 0/ SOS)
cl\�/7 �-
FarlmvmlFte ONLY: /� /� �j
2
"t`jrl
bs-3
14. WATER 20NF5
FRWt
FROU
i0
DESCRIPTION
Well Cowactv Nmm
3S4/0 A
laR
35/EL
at
- S.tL#- She/7
D.
ft.
-
NCWcUCoisisaaq/� CatficationNummb/ais.
I l 1 e -V
N✓ _c/I c,
maim
ING(farmthimedwe8s)ORLUNER
p &. le)
FROM
TO
DIAMETER
TmcR NE$s
MATERIALu
+ ► t
On it
"a-
scA4 qo
PING
Company Name
1 %i N I Q©O 1 S% /
2. Well ConstruudonPenult#: w o
16.1NNEB
CASING OR TUBING
faeatbttmal ern/
FROM
ro
DIAMETER
T)Det,FEss
attiman
a
O.
In.
.
Lisr all applicable we#pnumde (ie. Cony: Stare. Pinions, Ireectioq dal
3. Well Use (check well use):
ft.
ft.
io.
17.5CRFEp7
Water Supply Well:
O agricu0urat @.fmaicipalTublic
DGeodtamal (Heatittg.Coofotg Supply) °Residential Water Supply (sinete)
OlndmttiarCmmveial °Residential Wain Supply (shared)
*Oat" en
FROM To
DIAMETER
SLOTS TITI u4Fy
MATERIAL
aYaa
YR..2
'-
.o/o VGs 1/0
f vG
R. n
in
LS GROITt
PRDM
To
MATERIAL
EMPLACEMENT METIVNI & AMOUNT
__Q n
22 ft.
(eta;
Ao✓ re al
-.•/Oo/E
Non -Water SogdyWelk
DMmitodng ORceoven
M1
2
Injection Well:
°AquifaRedsatge
ft.
fi.
UCaotmd'wter Rma)iatism
°Aquifer Storage and%irony °Salinity Hairier
Q aquif eTest °SmmnyterDrainage
QE aual Te,imobep °Subsidence Control
TA SWNWGR4W
PACK
fdappiieable)
FBOw
TOO
MATERIAL
EMPLACEMENT EMPLACEMENT MEritotl -
era •
3I R
• 142 (jar 4W
fowl.' i
OGeelhermal (Closed Loop) OT�a
°Geothermal (Heating:Coaling Return) [(Other (ctplain anda#21 Remarks)
10. nawrne&ton
(attach
FROM
TO
addidomaistaaifaeieav,,
DESCRIPTION (Wt. taedaakavitaapd trt¢ in sin. ttct
D. ft'
20 ft.
FAPi grow,' drivel
4. Dote Well(s)Compteaed: %ta73 /7Well BM
OW Q
3yR
Mg. I.Iv Court e S d W/
Sa.Wdl location:
TON 1%%/Ii(%TO
ft.
ft.
C((t°/./s
ft
.. l0
CI
ft
L
J
FacilityiOmerName - Faality IDe (.Pappiioble
ft.
t.
SO 7 earn' J..f Dfi/ hues
J& ipe /
!e
ft.
Physical Adams, City. and Ziptaint/
,Gran-. s wce%c
11. REMORSE FEB 0 6 2017
Camay Parcdldcntification No. (PIN)
^ f47Pot, u,th.114.41!, ,; ., ..
al.. Ladtttdeand LS e�aatndemdraarsefuasnrteslserondc at dwad degrees:
fit -well nerd, one button isamGeina)
33a$3 2/e/I1 78d /r3 3.w
6.I1 (are) the wef(s): Jdettonaent or OTemporny
ng
7. Is this a repair to an exdsliwell: Oyes or Ide/
gear is a repair. fill nutbrown well sonar adi w Wa nna Lion and explain the nature of the
repair tinder #21 ranmrksaedmn or on the back flak/eat
8. Number ofwe&s constructed*
Formuldple irge ion or can-warrnpplvwoHs OAT)' with die some ammuvion. lam can
subnttonefarm. e
9. Total well depth below land surface: Y : 3 (R)
Formnitipk welts liq all depths Veinal (example- 3/a200' and2e16a)
10. Stalk water level below tap of tonic:
If water le,rffroieta man sac "+"
11. Borehole than,
to 1
Cana
12. Well construction method: // / u 01 Qo7n ry
u.e. anger roam , eabte, .Eseatsnit etc)
(R)
FOR WATER SUPPLY WELTS ONLY:
13a. Yield (gpua) 22- Method of test: i" n'l�
13b. Disinfection type: BienA-
Form GWd
22.0
Sienna of he R'ell Contractor
2-3-17
Date
Ely signing this loan. 1 herelm c-enifv dnr the Ira) was (wen) mmtnated in accordance
srah 153 NOIC 02C.0100 or lid NCAC 02C .0200 Well Cmotn¢-don &m dads and that a
mayojthis record hesbeen provided to the well owner.
23. Site diagram or additional weB decals:
You may use the back of this page to provide additional well site details or well
constsuetion details. Ton may also attach additional pages if necessary.
SURARTTaLINSrUCTlONS
24a. For AB Wells: Submit this
cmutmelion to the following;
Niltign9althn of well
Divisionof Water Resources, Information Processing unit,
1617 t3Tai) Service Center, Ripen, P.y 7t76Q9r1�77
2Ah mf/For Inieon Wells ONLY: In adsltion to sanding the Itom to the address in
24aahmti; also submit a copy of this fare within 30 days of completion of well
n:anunuctioatothcfollowing: Water Quality Regional
Dhasion nfWafer Resources, 0 r��o2CCtb`i.I�,ana
1636 Mail Soviice Center, t 8� j ice
24n For Water Soppiv S Injection Wells
also submit one copy of ibis form within 30 days of completion of
well cmtstm ion to the county health department of the comity where
constructed
North C olina Damnnment of Environment and Natural Rnowces -Division ofWatcrRetamax
Reaved.,rugssn MI

WELL CONSTRUCTION RECORD
This Cann can be and for sick am thipleweUr
1. Contactor Infantti r. /
/ha/SON
Welt Connector Name
t3Sro A
NC Well Counpta' Cmi6rationN mbat
e WWelj 6u y
CmapanyNmnco» I /f/ i
2. Well Construction Perndtik: Ci piu n7 &O/ 7 -00003
List all applicable'mell pemahr (¢.Conn: State. 6arimee. t lemon, etc)
3. Well Use (check well use):
Water Supply Well:
O.gricultural
°Geothermal (Hrating:Cooli a Supply)
CliinddustriaL'C'ommcrcial
iFSwgatkn
laMmicip alPuhhc
°Residential Water Supply (single)
°Residential Watir Supply (shared)
DIWaterSuppis Wd1:
DMonitorutg
°Rcoowm
injection Well:
❑Aquifer Recharge
°Aquifer Storage and Recovery
❑aquifer Test
OExperimattal Ten/otology
°Gcnrbamal (Closed Loop)
°Gemhanml (HeatingConliva Return)
Olmmndwater Ranediation
['Salinity Barrier
OStmmwaterMhainage
OSubsidatee Contml
°Tracer
OOdur (explain under
21 Ronarks)
4. Date Width) Completed:t n?' / 7 {; idt IDS
5a.1tiell Locati'op
Coro-(y 1 ov ,erry
Facility/Owner Name Fadiw !Ott js(appiinh1cj
430 AIE qo li Sr) OAk RNJ cOa r
Physical address, Cityand Zip
,$ LA.,,a K
Coma' Parcel ldcutifcatnn No. IYIN)
Sh. Latitude and Longitude in degvxesdni mtes/seconds or declared degrees:
{if wdI Odd on.: Ln;tone is sufficient) C
3 315Tio t2 N 7 B 7'i 2.9rY
6_ Is (are) the walks): ti erne rent or °Temporary
7. Is this a repair to an existing welt: °Yes or tier
If Mir No repanr,pll out known ire; consmmefon infirmaaon and explain tlx aaatrc of the
repair under c_I remarkrrection or an she back o faun,
8. Number of wens constructed:
For multiple injection or non -water pply wcllr OAZFwith the same caastrmaian.vnu co
submit one form.
9. Total well depth below land surface: 07 7
For multiple welts lot all depths ifdi erem (+'rumple-3(2.200' and 2@MMal
10. Stroke water level hejow top of c.sitg:
If water lord is above casing. tan•
11. Borehole diameter:
12. Well construction method:
.a a miser. rnwy, cable, deco push etc.)
7
brtvem
(fi.)
FOR WATER SUPPLY WI I S ONLY:
13a. Yield (gnat) LI/O 'Method aftest: �' i 1'vt,0
13h. Disinfection type: 77�eMCI Amount: /6 O "7--
Form Guy-1
IForloternalUse ONLY:
14. WATER ZONES
FROM To
IL a
7 7
IL fc
L'SIP DES Die
r'° Cet,rse J4r✓cl
it OUTER CASING do-multlmsedsefls)ORLE&}tf:f appal• able2
�FtROM To/� nEASIET t TNtCfotESA ' MATERIAL
T t fL j 1 q fL i '/ ! i^• i �c4 yo 1 SlweL
16. INNER CASING OR TUBING fgeotbermal dosed400pl
DL&METER LTHICKNESS
FROM ft.I TO
ft.
17. SCREEN
FROM 1 TO
/i f-
18. GROUT
FROM
fL
in
MATERIAL
IL
fL
ln.
OLLMETER SLAT SRC k
HICrctrs<q hIATFar.tl
/q 60 J, tic ists.
la mesh
o f4
TO
/O ft-
IL
2LATERLAL
G'sNT
EMPLACEMENT" METHOD') Ss AMOUNT
PoorerD
ft.
10. SANINGRAVEL YACA tit apWiesblel
FROM TO
MATERIAL
EMPLACEMENT METHOO
IL fL
20. DRD.LLNG LOG (atm h additional staets if necessary)
TO I DESCRITIO\ (mbr 62t4naa aeiltrxk vvpc sato sat. cu.)
Fur ro Course Mgt./
FROM
0 n.
IL
i
fL
rL
fL
fL
fL
ft
ft_
fL
fL
21. REMARKS
fL
ft.
FEB 0 6 2U1/
44;i tic;
a-3-/7
sr�ftius ofCc¢itied bell Contractor Dam
4- signing this farm, 1 hcrelm ccrnfr that the yolks) war fuerel constructed be accord,,
with /St\C-CO_'C.0)0l0 or1St NC -K2 02C.0200 Well Comings —lion Standards and rhma
cope of this record Arts been provided to the well owner.
23. She diagram or additional well details:
You naay use the hack of this pig ctails or tell
cunshuetion details. You may alsolasi as a t t
SUBMITTAL INSFUCTIONS C[D y 9 11 7. 24a. For MI Welts: Submit this foih haidau(t33 dzg l completion of urll
construction to the following:
erg Unit,
''m' �af�,, culUD I17
24b. For Injection Wells ONLSW'Iti' `d& EtRig t� (fU &ken to the address in
24a above also submit a cops of this farm within 30 days of completion of well
cmuttuctioo to the following
Division of Water Resources, Underground Injection Control Pragrmn,
1636 Mad Service Center, Raleigh, NC 27699-1636
24c For Water Supply & Injection Wells:
Also submit one copy of this form lvidtin 30 days of completion of
well consttudion to the county health department of the county- wiaerc
constructed `
Division of Water Resatj!t
1617 Mail Service Cenflot
Nunh Gnaliam Dcp.inmmt ofE vwunncnt and Natm il Reonccs —Division of Wma Resources
Rccued.asmtm 2013

R ESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources -Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2485
1. WELL CONTRACTOR:
Sean Cropsey
Well contractor (Individual) Name
Skipper's Well Drilling & Pump Service, Inc.
Well Contractor Company Name
107 Oakland Avenue
Street Address
Leland
NC 28451
City or Town State Zip Code
910 3712770
Area Code Phone Number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT# 2006067967
SITE WELL ID# (if applicable)
3. WELL USE (Check Applicable Box): Residential well
DATE DRILLED 05/14/12
TIME COMPLETED AMIT1PM
4. WELL LOCATION:
City: 2575 River Rd County Brunswick
(Street Name, Numbers, Community, subdivision, Lot Nol, Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
nSlope nValley XX FlatnRidge nOther
LATITUDE N34"
LONGITUDE W077°
8 . 620 '
0 . 047' '
Latitude/longitude source: x GPS Topographic map
(location of well must be shown on a USGS topo map and attached to
this form if not using GPS)
5. WELL OWNER
Brunswick County
Owner Name
PO Box 249
. g. WATER ZONES (depth): is L' ~r
• Top 80 Bottom 110 Top Bottom
. Top _ Bottom Top Bottom
. Top _ Bottom_ Top _ Bottom
Thickness/
7. CASING: Depth Diameter Weight Material
Top +2 Bottom 80 Ft. 4 sch 40 pvc
Top Bottom Ft.
Top _ Bottom_ Ft.
❑.
Street Address
Bolivia, NC 28422
City or Town
( 910 )
Area code Phone number
State Zip Code
6. WELL DETAILS:
a. TOTAL DEPTH: 100
b. DOES WELL REPLACE EXISTING WELL? YES pi No
c. WATER LEVEL Below top of Casing: 25 FT
(Use "+" if Above Top of Casing)
d. TOP OF CASING IS 2 FT. Above Land Surface
Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C.0118.
e.YIELD (gpm): 20 METHOD OF TEST pump
f. DISINFECTION: Type HTH Amount cup
•
8. GROUT: Depth
Top
Top
Top
0 Bottom
Bottom
Bottom
20 Ft.
Ft.
Ft.
Material Method
cement pump
9. SCREEN:Depth Diameter Slot Size Material
Top
Top
Top
80 Bottom 110 Ft. 4 in. 20 in. SS
Bottom Ft. in. in.
Bottom Ft. in. in.
10. SAND/GRAVEL PACK:
Depth
Top 70 Bottom 110 Ft.
Top Bottom Ft.
Top Bottom Ft.
Size Material
#2 Southern Products
11. DRILLING LOG
Top / Bottom Formation Description
0 / 30 Gray sand wit some clay
30 / 45 fine yelow sand
45 / 50 fine gray sand and clay
50 / 80 fine gray sand, rock, clay
80 / 110 fine med sand and roc
/—RECEIVEQ/NCHFNR/DWR
/ JAN`23'2017
12. Remarks:
Wutei Qudlity Regiona
Operations Will ington Rego ralopfff{i�ce
1 DO HEREBY CERTIFY THAT THIS WELL WrAS CONSTRUCTED IN
ACCORDANCE WITH 15A NCAC 2C, WELL CONSTRUCTION
STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN
PROVIDEDO THE W LL OWNER.
SIGNATURE OF CERTIFIED V,j'ELL CONTRACTOR
.��cw,r� CcCi 5..�
PRINTED NAME OF PERSON
�tUCTING THE WELL
Submit within 30 days of completion to Division of Water Quality - Information Processing
1617 Mall Service Center, Raleigh, NC 27699-161, Phone: [phone] Rev. 2/09
4,/ 7/if 2
DATE
Form GW-la

NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3552
1. WELL CONTRACTOR:
VINCE FEDERLE
Well Contractor (Individual) Name
GEOLOGIC EXPLORATION, INC
Well Contractor Company Name
176 COMMERCE BLVD
Street Address
STATESVILLE NC 28625
City or Town State Zip Code
(704 ) 872-7686
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT# N/A
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable) ULCSTREM-12
3. WELL USE (Check One Box) Monitoring ReMunicipal/Public ❑
Industrial/Commercial ❑ Agricultural ❑ Recovery ❑ Injection ❑
Irrigation❑ Other ❑ (list use)
DATE DRILLED 01/26/12
4. WELL LOCATION:
NC HIGHWAY 87 28461.
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: SOUTHPORT COUNTY BRUNSWICK
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope ❑Valley ❑Flat ❑Ridge ❑Other
LATITUDE " DMS OR
LONGITUDE " DMS OR
Latitude/longitude source: [,GPS Lltopographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5. FACILITY (Name of the business where the well is located.) >
PROGRESS ENERGY N/A
DD
DD
Facility Name
NC HIGHWAY 87
Facility ID# (if applicable)
Street Address
SOUTHPORT
City or Town
PROGRESS ENERGY
NC 28461
State Zip Code
Contact Name
PO BOX 10429
Mailing Address
SOUTHPORT NC 28419
City or Town State Zip Code
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 34.0 FEET
JAN 18 2017
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
c. WATER LEVEL Below Top of Casing: 17.0 FT.
(Use "+" if Above Top of Casing)
4031
d. TOP OF CASING IS 0.0 FT. Above Land Surface*
*Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): N/A METHOD OF TEST N/A
f. DISINFECTION: Type N/A Amount N/A
g. WATER ZONES (depth):
Top Bottom Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
7. CASING: Depth Diameter
Top 0.0 Bottom 14.0 Ft. 2INCH
Top Bottom Ft.
Top Bottom Ft.
8. GROUT: Depth
Top 0.0 Bottom 10.0
Top Bottom
Top Bottom
Thickness/
Weight Material
SCH 40 PVC
Material
Ft. PORTIAND BENTONITE
Ft.
Ft.
Method
SLURRY
9. SCREEN: Depth Diameter Slot Size Material
Top 14.0 Bottom 34.0 Ft. 2.0 in. .010 in. PVC
Top Bottom Ft. in. in.
Top Bottom Ft. in. in.
10. SAND/GRAVEL PACK:
Depth Size Material
Top 12.0 Bottom 34.0 Ft. 20-40
Top Bottom Ft.
Top Bottom Ft.
m11. DRILLING LOG
Top Bottom
FINE SILICA SAND
Formation Description
0.0 / 1.0 CONCRETE
1.0 / 34.0 FINE GRAY SAND
rECE
VED
F'EB f9 9 7012
rt+vrVATER QUALITY SPC1iON
RY vinellekieb ,UNIIT
12. REMARKS: Jp Ar3?017
BENTONITE SEAL FROM 10 0 TO 12.
I DO HEREBY CERTIFY THAT THIS WELL WAN
15A NCAC 2Q, WELL CONSTRUCTION STAND
RECOeD HIrt BEEN PROVIDED T
SIGNATURE OF CERTIFIED WEL
VINCE FEDERLE
MD ACCORDANCE WITH
T EMSt THIS
onggsp�iSection
RRtonal Offfyy1/12
DATE
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality - Information Processing,
1617 Mail Service Center, Raleigh, NC 27699-161, Phone : [phone]
Form GW-1b
Rev. 2/09

NON ON RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2480
1. WELL CONTRACTOR:
Lewis LeFever
Well Contractor (Individual) Name
Parratt-Wolff, Inc.
Well Contractor Company Name
501 Millstone Drive
Street Address
Hillsborough NC 27278
City or Town State Zip Code
(919 ) 644-2814
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT#
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable) ADH-TWO1
3. WELL USE (Check One Box) Monitoring d Municipal/Public 0
Industrial/Commercial 0 Agricultural p Recovery p Injection 0
Irrigation❑ Other 0 (list use)
DATE DRILLED 2/1/12
4. WELL LOCATION:
Daniels Road NE
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: Leland COUNTY Brunswick
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope ❑Valley IjFlat ❑Ridge ❑Other
LATITUDE 34 ° 19 • 475.0000 "DMS OR 3X.XXXXXXXXX DD
LONGITUDE 78 2 116.0000 „ DMS OR 7X.XXXXXXXXX DD
Latitude/longitude source: [GPS c4Topographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5. FACILITY (Name of the business where the well is located.)
Facility ID# (rf applicable)
Dupont Facility
Facility Name
Daniels Road NF
Street Address
I eland
City or Town
NC 28541
State Zip Code
Contact Name
Mailing Address
City or Town
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 20 0'
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO al
State
w
Zip Code
JAN i 5 2017
c. WATER LEVEL Below Top of Casing: 10.0
(Use "+" if Above Top of Casing)
FT.
10363
d. TOP OF CASING IS 0 FT. Above Land Surface*
*Top of easing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): N/A METHOD OF TEST N/A
f. DISINFECTION: Type N/A Amount N/A
g. WATER ZONES (depth):
Top N/A Bottom Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
Thickness(
7. CASING: Depth Diameter Weight Material
Top 0 Bottom 10.0 Ft. Sch40 PVC
Top Bottom Ft.
Top Bottom Ft.
8. GROUT: Depth Material
Top 0 Bottom 2.0 Ft. Portland
Method
Tremie
Top 2.0 Bottom 8.0 Ft. Bentonite Tremie
Top Bottom Ft.
9. SCREEN: Depth Diameter Slot Size Material
Top 10.0 Bottom 20.0 Ft. 1 in. .010 in. PVC
Top Bottom Ft. in. in.
Top Bottom Ft. in. in.
10. SAND/GRAVEL PACK:
Depth Size
Top 8.0 Bottom 20.0 Ft. #1
Top Bottom Ft.
Top Bottom Ft.
11. DRILLING LOG
Top Bottom
Material
Sand
Formation Description
4.0 / 8.0' Brown moist fine SAND & SILT
8.0 / 12.0 Brown. wet. fine SAND & SILT
/RECEIVED%NCDENP/DWW nP
2U1t
/ IntannatlOn PtoCesslff�g unit
12. REMARKS: JAN G 2qN 3_ 2017 DWQIbutt,
Water Qnallty Ike
I DO HEREBY CERQperat
15A NCAC 2C �qr�,5�
pkbHlU
RECORD HA BE'p�l
Lewis LeFever
ONSTRUCTED IN ACCORDANCE WITH
DARDS, AND THAT A COPY OF THIS
CeINER,
y�Y /Z
WELL CONTRACTOR DATE
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality - Information Processing,
1617 Mail Service Center, Raleigh, NC 27699-161, Phone : [phone]
Form GW-1 b
Rev. 2/09 ,

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
1. Well Contractor Information:
Joseph Zuncich
Well Contractor Name
3324-A
NC Well Contractor Certification Number
Applied Resource Management, P.C.
Company Name
2 Well Construction Permit #: N/A
List all applicable lien! construction permits (i.e. Couno, State, Variance, etc.)
3. Well Use (check well use):
Water Supply Well:
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑ Industrial/Commercial
❑irrigation
Non -Water Supply Well:
MMonitoring
°Municipal/Public
°Residential Water Supply (single)
❑Residential Water Supply (shared)
❑Recovery
83
For Internal Use ONLY:
14. WATER ZONES:
FROM
TO
DESCRIPTION
ft.
ft.
Injection Well:
❑Aquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer Test
❑Experimental Technology
°Geothermal (Closed Loop) °Tracer
❑Geothermal (Heating/Cooling Retum) °Other (explain under #21 Remarks)
❑Groundwater Remediation
❑Salinity Banner
❑Stormwater Drainage
°Subsidence Control
4. Date Well(s) Completed: 12I21 /16 WellIlllt N/A
5a. Welt Location:
Milliken & Lennon, Inc.
N/A
Facility/Owner Name Facility ID# (if applicable)
4447 Main Street, Shallotte, NC
Physical Address, City, and Zip
Brunswick
1820013402
County Parcel IdentificationNo. (PIN)
5b. Latitude and Longitude in degrees/minutes/seeonds or decimal degrees:
(if well field, one latong is sufficient)
33 59 03.8 N 78 22 01.4 1
6.Is (are) the w'ell(s): °Permanent or OTemporary
7. Is this a repair to an existing well: DYes or ONo
If this is a repair, fill out lmoun well construction information and explain the nature of the
repair under #11 remarks section or on the back of this form.
8. Number of wells constructed: 1
For multiple injection or non -water supply wells ONLY with the sante construction, you can
submit one form. -
ft
ft
15. OUTER CASING (for multi -cased wells)OR LINER (if applieahle)
THICKNESS MATERIAL
FROM
0
ft
TO
2 ft.
DIAMETER
2
in.
SCH40 PVC
16. INNER CASING OR TUBING (geothermal closed -loop)
THICKNESS
FROM
ft.
TO
ft
DIAMETER
in.
MATERIAL
ft
in.
17. SCREEN
FROM
2 ft
TO
8
ft.
DIAMETER
2
m
SLOT SIZE
.010
THICKNESS
SCH40
MATERIAL
PVC
ft.
in.
It GROUT
FROM
0
TO
1
ft.
MATERIAL
Bentonite
EMPLACEMENT METHOD Sr AMOUNT
Poured
ft
ft.
ft
19. SAND/GRAVEL PACK (if applicable)'
FROM
1
TO
8
ft.
MATERIAL
Coarse
EMPLACEMENT METHOD '
Poured
ft.
ft.
9. Total well depth below land surface: 8 (ft.)
Far multiple wells list all depths ifdjfjerent (example- 3 ,200' and 2Q700')
10. Static water level below top of casing: 2.51(ft.)
If rater level is above casing, use "+"
11. Borehole diameter: 2 (in.)
12. Well construction method:
Hand Auger
(Le. auger, rotary, cable, direct push, etc.)
20. DRILLING LOG (attach additional sheetsif necessary) 7 '
DESCRIPTION (color. hardness. soil/rock type, grata size. etc)
FROM
ft.
ft
TO
ft
See attached
ft
ft.
ft.
ft.
n.
n.
ft
Wma
ft.
Siam
ft
21. REMARKS
22. C
ft
Signature o fie ell Confector
By sign' g this form, I hereby cert fy that the well(s) was (were) constructed in accordance
with A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
co ' of this record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTUCTIONS ®���.a�/tf ������tr��*Jp1r1l�C1Ir� rsf�tp,
24a. For All Wells: Submit this REbs�YIDUjNWeISIP/1/P/Y1Rtion of well
construction to the following:
Division of Water Quality, Infp atipn Processing Unit,
1617 Mail Service Center, Ma ttMt 2.1WW1617
24b. For Iniection Wells: In addition to sending the fort to the address in 24a
above, also submit a copy of this fo>f�a�v�Qisp�pletion of well
construction to the following: �/�/ Operations Secttl'Orf�l�,,,�
Division of Water Quality, Undeli tl4AtYlhle #n CNnftticfirogram,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Suooh & Iniection Wells: In addition to sending the four to
the address(es) above, also submit one copy of this form within 30 days of
completion of well construction to the county health department of the county
where constructed.
JAN 1 9-2017
hilenDelion Prner„ i:.c_r.)n:
Dlreisoc
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) N/A Method of test: N/A
13b. Disinfection type: NIA Amount: N/A
yap 7
Form GW-1
North Carolina Department of Environment and Natural Resources -Division of Water Quality
Revised Ian. 2013

auk) Ie io0a l uoi8u!WI!M BORING LOG
uoipag suogend0
ieuoi9aa men°JateM MONITORING WELL TW-1
LID? CZ NV1 MILLIKEN & LENNON, INC.
4447 MAIN STREET
MOMN3GONABAI3338 SHALLOTTE, NC
Drilled by: Applied Resource Management
Logged by: J. Zuncich
Date: 12/21/16
Depth '
(ft)'
Description
Water Content
0 - 2
Medium to dark gray fine sand with organic material. No
hydrocarbon odor.
Low
2 - 4
Brown -orange silty clay changing to light gray slightly clayey
sand. No hydrocarbon odor.
Moderate to High
4 - 8
Greenish -gray, clayey sand changing to fine sands at 7'. No
hydrocarbon odor.
High

TW-1
Lock
Ground Surface
1' Bentonite
Applied Resource
Management, P. C.
Hampstead, NC 28443
7' Sand
♦ ►. •r+.ss
)•. ••• ••••••
••••••• • •• •�
� ••••• i•!
I •°••• '•••• i
I ••• �•�• 1111100 ••
LO
I•s•••�-ii �••
�• •••. •••°•°
• • • 11••
°Ge?.e• • •.s•
0••• • '••••••
I••••• •••••i
Groundwater ►•••••• ••••i
Table •
••fit• 1••*•:
15*! Pet:
P• •• ••• ••••
►••••• '.•••••
►• •••• I•••�•
►••••• '••••••
i ••i•••••
► °•••
•• •°�°••
4
i•••••• •••:•°r
0•••••• •••°••
1
►•••••• •••°••
1
I • •••• • •• •••4
•••••• •°�°••
1
I• • •• •••••
I•• ••• ..•••4
►•••••••
TITLE:
JOB:
2' Riser
•
6' Screen
RECEIVED/NCDENR/DWR
2017
WaterLAN Quality23 Regions!
Wil inugtoni RegSemctionf `.e
. 8' Total Depth
Type II Monitoring Well Asbuilt
16289
SCALE:
Not to scale
DATE:
1/12/17
DRAWN BY:
KLC
WELL ID:
TW-1

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
1. Well Contractor Information:
Kevin White
Well Contractor Name
2973-A
NC Well Contractor Certification Number
Parratt-Wolff, Inc.
Company Name
2. Well Construction Permit#:
List all applicable well permits (i.e. County. State, Van mecc. Injection, etc.)
3. Well Use (check well use):
Water Supply Well:
❑Agricultural
OGeothermal (Heating/Cooling Supply)
Olndustrial/Commercial
Dlrrigation
Non -Water Supply Well:
▪ Monitoring
❑ Municipal/Public
❑ Residential Water Supply (single)
❑ Residential Water Supply (shared)
❑ Recovery
Injection Well:
OAquifer Recharge
❑ Aquifer Storage and Recovery
DAquifer Test
❑Experimental Technology
❑ Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling Return)
4. Date Well(s) Completed: 12/14/16
5a. Well Location:
Duke Energy Progress
❑ Groundwater Remediation
❑Salinity Barrier
❑ Stormwater Drainage
❑Subsidence Control
❑Tracer
❑Other (explain under #21 Remarks)
wen ID# ESS301-304
Facility/Owner Nmne Facility ID4 (if applicable)
8392 River Road SE Southport NC
Physical Address, City, and Zip
Brunswick
County
Parcel Identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one Iat/long is sufficient)
33.958170 N-78.008223
W
6. Is (are) the well(s): ©Permanent or OTemporary
7. Is this a repair to an existing well: Oyes or ONo
!phis is a repair, fill out known well construction information and erploin the nature Jibe
repair under #21 remarks section or on the back of this form.
8. Number of wells constructed: 4
For nndtiple injection or non -water supply wells ONLY with the saute con climb you can
submit one farm.
9. Total well depth below land surface: 28 (ft.)
For multiple wells list all depths ifdii rent (example- 3C200' and 24)00')
10. Static water level below top of casing: 17 (ft.)
if water level is above casing, use "+"
1I. Borehole diameter: 1 1
(in.)
12. Well construction method: Auger
(i e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
I3a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
For Internal Use ONLY:
440962
LT
la
14. WATER ZONES
FROM
TO
DESCRIPTION
17 ft.
28
ft.
Sand
ft.
ft.
15. OUTER CASING (for multi -cased wells) OR LINER (if apQBcaile) I
THICKNESS I MATERIAL
FROM
ft.
TO
et.
DIAMETER
in.
16. INNER CASING OR TUBING (geothermal dosed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
0 st.
18
ft.
2
ID
Sch 40
PVC
0
ft.
5
ft.
2
in.
Sch 40
PVC
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
18 ft
28 It.
2
.01"
Sch 40
PVC
5 ft.
15 ft.
2
in.
.01"
Sch 40
PVC
IL GROUT:.
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
15 R.
17 ft.
Bentonite chit
gravity
ft.
2
ft.
Bentonite chit
Gravity
ft.
19. SAND/GROVEL PACK (if applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
17 ft
28
ft.
#1 Sand
gravity
2
ft.
14
ft.
#1 Sand
gravity
20. DRILLING LOG (attach additional sheets if necessary)
FROM
ft.
TO
ft.
ft.
DESCRIPTION (color, hardness, soil/rock type, grain sire, etc.)
no samples taken - brown med sand
ft.
ft.
ft.
D.
ft.
ft.
RECEJVED
ft.
ft.
ft.
ft.
JAN 1 0 2017
21. REMARKS
hlrr°rwM4lan-R ^6-srwig UnR
DWQ/BOG
22. Certification:
Dlnllally ,lgned byTodd Mnench
To oM Cn-Todd Mum eo. o=Fananwl.-oInc.,
IVIU2t1C an-FwxC.enuil=lnaencnert....e-us 12/19/16
Dale: 2016.1219085513 05'nff
Signature of Certified Well Contractor Date
Br signing this form, 1 hereby cert& that the well') was (were) constructed in accordance
with 15A NCAC 02C .0100 or ISA NCAC 02C .0200 Well Construction Standards and that a
copy of this record has been provided to thewell owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTUCTIONS
24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Iniection Wells °RuuEItr:. ii. mama form to the address in
24a above, also submit a copy of this form within 30 days of completion of well
construction to the following:
Division of Water ResourcesikNl9erjro7rniNction Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supply & Inje ��rcW 1s:.. a 10 al
Also submit one copy of this gg}� completion of
well construction to the coy �l{n ) Cc�runty where
constructed 5�
Form GW- I
North Carolina Department of Environment and Natural Resources - Division of Water Resources Revised August 2013