GW1 - Carteret Oct-Jan 2017

flit FArrrl:
WELL CONSTRUCTION RECORD (GW-11
1. Well Contractor Information:
3M t i nbiz-1vN
Well Contractor Name
2 T 53,
NC Well Contractor Certification Number
}`1.0e ✓flex)
Company Name
2. Well Construction Permit#:
List al/ applicable well construction permits (1.e. INC, County, State, Variance, etc.)
3. Well Use (check well use):
Water Supply Well:
Agricultural Wunicipal/Public
Geothermal (Heating/Cooling Supply)sidential Water Supply (single)
Industrial/Conimercial sidential Water Supply (shared)
Irrigation.
Non -Water Supply Well:
Monitoring DRecovery
Injection Well:
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
Experimental Technology
Geothermal (Closed Loop)
Geothermal (Heating./Cooling Retum)
4. Date Well(s) Completed: 7j
5a Well Location:
Militk dA flit
Facility/Owner Neme Facility ID# (ifapplicable)
160 C.14--Fte beep C geeL ectt� t
Physical Addres, City, and. Zip
t' 4,ee4-
County Parcel Identification No. (PIN)
['Groundwater Remediation
Salinity Barrier
DStormwater Drainage
Subsidence Control
Tracer
iOther (explain under 421 Remarks)
11 Well ID#
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one let/long is sufficient)
s Ji7 67PJ o“ 3 "
6. Is(are) the well(s)Permanent
76°.50'l_?.12- "W
or Temporary
7. Is this a repair to an existing well: Yes or rho
Ifthis is a repair, fill out known well construciof i formation and explain the nature of the
repair under #1/ 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; era �-
9. Total well depth below land surface:
f 2-
For multiple wells list all depths ljd(erent (example- 30a 200' and 2©(001)
10. Static water level below top of casing:
If water level is above casing, ussee/"+)
7 11. Borehole diameter: -
12. Well construction method:
(i.e. auger, rotary, cable, direct push, etc.)
0
For Internal Use Only:
446284
14, WATER ZONES
PPP^*s
TO A
DESCRIPTION ,t
a©ft.
. — ft.
�rItat -'-' Ae z k--
ft.
ft-
1. OUTER CASING (for
multi upped wells) OR LINER (ifa 1100114 `
FROM T^
DIAMETER
THICKNESS TERIAL
ft. ti ft.
in.
..--
It. INNER CASING OR. TUBING
eatherma Tclassad-loop)
FROM
TO
DIAMETER
TTRICFNESS
`,11 vbSS
MATERIAL
Y c !' -
/ ft
/gyp fL
&
it in-
ft
ft
in.
17.SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
70II.
L� V
s70 fL
a
to in.
`(
2 a
544 v
l'
lJV 4J-
?tic
ft.
ft.
in.
111; CRODT
FROM
TOqq
MATERIAL
& AMOUNT
EMPLACEMENTJJ��
0 ft.
- ft
/� t' )"tI
(
f�1ETHOD
f zz t'v e Q /1i7?r i j4
ft.
ft.
�`
ft.
ft.
I9:SAND/GRAVEL
PACK
(if applicable)
PROM
TO
MATERIAL
EMPLACEMENT METHOD
ft
(70
g0 ft
Srwtr,
Ycu r € 6-
ft.
ft.
20. DRILLING
LOG (attach
additional sheets if necessary) ,
FROM
TO
DESCRIPTION (color, hardness, soil/rack type, grain size, etc.)
-p ft.
7 6 ft.
�S l v7 C4
Oft.
Oft'
C rrttd(t c.L torn
c /a O.
co 4' ft
` C.- ifs/Y--, x�
i/{ 4 r't �t/"
ft.
ft.
ft.
ft.�..
ft.
ft.
.
21'1gEMARKS
ocr.2 3 2017
Dfprlrl.OeiOP Pier% el 'Jill
22. Certification: -
`J'thillnT u
ure of Certified Well Contractor Date
y signing this form, I hereby cert* that the well(s) was (were) constructed in accordance
with-ISA NCAC 02C .0100 or 1SA 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 [he 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, Raleigh, NC 27699-1617
24b. For Iniection Wells: In addition to sending the form to the address in 24a
above, also submit one copy of this fonn within 30 days of completion of well
RECEIVEDiredF tyyl e following:
Division of Ater Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
eJ. ter Sunni): & 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
(ft.)
(ft.)
FOR WATER SUPPLY hWW EL S ONLY:
13a. Yield (gum) (J Method of test:
136 Disinfection type: 4 0 al.i1 Amount:
p-112, OCT
VY t
Form GW-1
9���� Operat
North Carolina DeparuaerR6TDL i. r4tM1g�
aVWirf20.. 161Pa)ed.
one Section
falbirMtf4tla)ityf 13i fliae of Water Resources Revised 2-22-2016'

WELL CONSTRUCTION RECORD (GW-1)
1. Well Contractor Information:
Bobby Allred
For Internal Use Only:
446229
Print Form
14. WATER ZONES:.:
Well Contractor Name
2610-A
NC Well Contractor Certification Number
A C Schultes of Carolina, Inc.
Company Name
2. Well Construction Permit #:
List all applicable well construction permits (i.e. U1C, County, State, Variance, etc)
3. Well Use (check well use):
Water Supply Well:
Agricultural
Geothermal (Heating/Cooling Supply)
Industrial/Commercial
'Irrigation
ElNon-Water Supply Well:
Monitoring
Injection Well:
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
LiExperimental Technology
Geothermal (Closed Loop)
lMunicipal/Public
(Residential Water Supply (single)
Residential Water Supply (shared)
Recovery
QGroundwater Remediation
Salinity Barrier
DiStonnwater Drainage
9Subsidence Control
0Tracer
I' -lGeothermal (Heating/Cooling Return) fliOther (explain under#21 Remarks)
4. Date Well(s) Completed: 7/17/17 Well ID# PW-8
5a. Well Location:
W Carteret Water Corp
Facility/Owner Name Facility IN (if applicable)
4102 Hwy 24, Newport, NC 28570
Physical Address, City, and Zip
Carteret
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
34.71 556 N 76.98 461
6. Is(are) the well(s)Sx Permanent or EpTemporary
7. Is this a repair to an existing well: [JYes or Elm.
If this is a repair, fill out known well cmisvuction Information and explain the nature of the
repair under ff2l 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: N/A
9. Total well depth below land surface: 295
(ft.)
For multiple wells list all depths ifd/ ferenr (example- 3 r@i 200' and 2®100')
10. Static water level below top of casing: 25 (ft.)
'Twofer level is above casing, use "+"
11. Borehole diameter: 23
(in.)
12. Well construction method: mud/reverse rotary
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) 1220 Method of test: Pumping
13b. Disinfection type: HTH Amount: 10 IbS
Fonn G W-1
FROM
197 ft
270 ft.
TO
237 ft'
290 ft
DESCRIPTION •
Limestone
Limestone
15. OUTER CASING (for multi -cased wells) OR LINER (if a lleable)
FROM TO DIAMETER THICKNESS MATERIAL
0 ft 50 ft• 24 In• 1-.375 steel
16. INNER CASING OR TUBING (geothermalclosed-loop).
TO
FROM
0 ft.
245 ft
197 ft.
270 ft
DIAMETER
12
in.
12 in.
17. SCREEN
FROM
197 ft.
270 R•
TO
237 ft•
290 ft.
THICKNESS
Sch 10
Sch 10
12 m r .050
DIAMETER L SLOT SIZE
12 'n .050
18. GROUT
FROM
0 ft.
TO
50 ft.
MATERIAL
cement
MATERIAL
304 SS
304 SS
THICKNESS
n/a
n/a
MATERIAL
304SS
304 SS
EMPLACEMENT METHOD & AMOUNT
tremmie
0 ft.
165 R.
cement
tremmie
245
255
cement
tremmie
19 SAND/GRAVEL PACK (if applicable)a
FROM
187ft.
255
TO
245 ft
295 ft.
MATERIAL
#3 gravel
#3 gravel
EMPLACEMENT METHOD
tremmie
tremmie
2.0 DRILLING LOG (attach additional sheets if necessary)
TO DESCRIPTION (color, hurdneaa, soil/rock type, a, ain size, etc.)
sand & clay
FROM
0 ft.
10 ft.
30 ft•
51
60 ft.
145 ft
10 ft.
30 ft
50 ft
60 "•
145 ft
190 ft
clay and fine sand
clay
sand, shells, limestone
gray clay
sand & shells
190 ft
300 ft•
limestone
22. Certification: '��r�./
ha
Signature ofC ed Well Contractor
OCT
Won.,
71 1017 ".
Date
By signing this form, l hereby certify That the wells) was (were) constructed in accordance
with 1.A NCAC 02C .0100 or 15A NC'AC 02C .0200 Well Construction Standards and that a
-copy me this retard hae been providedto the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provid p site details or well
construction details. You ma 1y;,{'rp Sty �T.�tl„ dhe* •tpnecessary.
SUBMITTAL INSTRUCTIONS
24a. For All Wells: Submit this fm(ihTw�ll3.3glays of completion of well
construction to the following:
U
Division of Water Resources, l plaIYY;11,15ytli awaking Unit,
1617 Mail Service t84B9-1617
Opera IGr���'ua�yI Office
24b. For lnieetion Wells: In arj(j(qig((ijgeOtI llj Farm 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 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Snooty & 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.
North Carolina Department of Environmental Quality - Division of Water Resources Revised 2-22-2016

WELL CONSTRUCTION REORD (GW-1)
1. Well Contractor information:
31kc O N' 9: p 12-TOIJ
Well Contractor Name
NC Well Contractor Certification Number
/4l0d %tJ .� �, Cs -
Company Name
2. Well Construction Permit#:
List altappticable well construcnon permits (Le, (/7f., County Slate, Variance, etc)
3. Well Use (check well use):
Water Supply Well:
Agricultural °MunicipaUPublic
Geothermal (Heating/Cooling Supply) esidential Water Supply (single)
Industrial/Commercial 1. esidential Water Supply (shared)
Irrigation
Non -Water Supply Wdl:
®Monitoring
Injection Well:
Aquifer Recharge
°Aquifer Storage and Recovery
°Aquifer Test
jExperimental Technology
°Geothermal (Closed Loop)
Geothermal (Reating/Cooling Return
.°Recovery
°Groundwater Remediation
°Salinity Barrier
tStormwater Drainage
ubsidence Control
Tracer
Other (explain under #21 Remarks)
4. Date Well(s) Completed: Z -!< Well ID#
5a.
Well Location:
Fec'ht}//Qwlier Naktmi Facility ID# (if applicable)
y�oWpoOlfin A D2 Alt
Physical Address, City, and Zip
County Parcel identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one !among is sufficient)
Vs'yt 193 rt N774,)o6' zy, Yen
6. Is(are) the wel(s)4Permanent or °Temporary
r
7. Is this a repair to an existing well: Yes or °No
ljthls s a repels. p!! out brown well construct, and a plant the nature of the
repair under #2l remarks section or on the ha a this form
8. For Geoprobe/DPT or Closed -Loop G$othernml'We1Is having the same
construction, only 1 GW-I is needed. Indicate TOTAL NUMBER of wells
drilled:_ 'a
9. Total well depth below land surface: 1 7
For multiple wells list all depths if different resanrple- 3©200' and 2©100')
10. Static water level below top of casing:
be water level itt above casing, use "1"
11. Borehole diameter: 1
12. Well construction method:
(i.e. auger, rotary, cable, direct push, etc.).
/es
(in.)
!{ot R
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) vs Method of test: f I
13b. Disinfection aype.ckloi I Ale Amount: /
ft.
rt.
ft.
. 20, DR1LLIN0),�}G (aHpe!additional shef N °essnr'y)
FROM TO DESCRIPTION (color, hardness, soil/rock typ
e grave aerate/
fan
,_54,0AL vz%L
REC
SEP 2 5
017
For lnternal Use Only:
14. WATER ZONES
FROM TO
1311.
ft.
gritit.
ft
OF-SCRIPON
15, OUTER CASING (for multi:tased wells) OR L
FROM TO DIAMETER
rt.
i
8
(dfA bZ010
THICKNESS MATERIAL
-i16.INNER CASING 01)TUBINU (geothermatelosed fobp)
FROM TO DIAMETER THICKNESS
MATERIAL
il
� - Y'lJ
f
17::SCR'e N:
FROM
(56R.
ft.
FROM
O ft.
11.
ft.
TO
Krfic
TO
21
ft.
ft.
ft.
ft.
it.
DIAMETER I SLOT SIZE
Lt In. If
1, in.
MATERIAL
2 fl
�THICKNESS
J e' 7V
/Dvc
MATERIAL
tvc-
EMFLACFMENT METHOD & AMOUNT
350
19. SAND1f:RAVEL PACK Of applicable)
FROM MATERIAL EMPLACEMENT METHODAU /red
et.
TO
575 ^ft.
ft.
s,n/c
/LC
ft.
350.
/ , R.
ft.
ft.
ft.
/3-P.
LS"
22. Certification:
g j7
By signing this form, 1 hereby cern& that the well(s) was (ere) consMreted m accordance
with 15A NCA( 02( U/OO or LSA NCAC 021: .0200'Well Conk!rucrmn Standards and that a
copy, aphis i record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back ofthis page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTRUCT! CEIVED/NCDEMR/Diuo2
(ft.) 24a. For All Wells: Submit this form within 30 days of completion of
construction to the following: ((��tf ((l`�, Lf�1 tt�� l!11 ]] (ft.) Division of Water ResouPeC,Tn! r%atihRljrocessing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Injection Wells: In a ra,6,6 ii(ljnig- to the address in 24a
above, also subunit one copy of tl(pgihotit4lijt(�elps of completion of well
construction to the fouowing:Wilmingt0n Regional Office. Division of Water Resources, Underground injection Control Program,
1636. Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supply R 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 theioounty
where constructed.
ell
Form] GW-1
North Carolina Department of Environmental Quality - Division of Water Resources
Revised 2-22-2016

Print Fo(tf
WELL CONSTRUCTION RECORD (GW-1)
1. Well Contractor Information:
j,eN nejtAll
Well Contractor Name
NC Well Contractor Certification Number (
five& ()taut
ti3353
Company Name
2. Well Construction Permit #:. 1
List all applicable well constriction permits (Le.' UI(i. County, .State. Variance, etc)
3. Well Use (check well use):
Water Supply Well;
Agricultural
()Geothermal (Heating/Cooling Supply)
f u1ustrial/Commercial
Irrigation
-Water Supply Well:
Monitoring
Injection Well:
Aquifer Recharge
Aquifer Storage and RecoveryAquifer Test
Experimental Technology
Geothermal (Closed Loop)
',Geothermal (Heating/Cooling Return)
ElMunicipal/Public
Residential Water Supply (single)
()Residential Water Supply (shared)
Recovery
()Groundwater Remediation
Salinity Barrier
Stormwater Drainage
Subsidence Control
Tracer
Other (explain under #21 Remarks)
4. Date Well(s) Completed: 9-is-/ 7 Well ID#
5a. Well Location:
4 ger it
Facility/Owner Name
/50 a/'c/aiutc2 /Q.
Physical Address City, and Zip
CGr e(te -
County
5b. Latitude and longitude in degrees/min
(ifwell field, one let/long is sufficient)
37/`t(l117e 77' N 76.3
6. Is(are) the weals) Permanent or
7. Is Ibis a repair to an existing well
Facility ID# (if applicable)
Parcel Identification No. (PIN)
tes/seconds or decimal degrees:
es/ /33jQ It W
Temporary
Yes or yrgNo
'phis is a repair, fill out !mown well contraction formation rid explain the nature of the
repair wider 021 remarks section or an the back o this form.
8. For Ceoprobe/DPT or Closed Loop Ge thermal Wells having the same
construction, only l GW�-tlJ i{sieeded. Indic to TOTAL NUMBER of wells
drilled: O/ _ -
9. Total well depth below land surface:
For multiple wells list all depths jdiferent (ekam le- 3 2©100')
10. Static water level below top of ease
If water level Is above easing, use ":1"11. Borehole diameter: (in.)12. Well construction method: 11 pl/°fT
(i.e. auger, rotary, cable, direct push, etc.)
easing: 18
For Internal Use Only:
'l6(e/y
(ft.)
(ft.)
FROM
/ ft.
ft.
14. WATER ZONES /(/'� .v -
4
116
FROM
70 f
To
(q°
ft.
DESCRIPTION
45.111TER CASINGIfor multi-cased'welle) OR LIStkiR(If APPlteMARMTe)7 ERIAL
THICKNESS
FROM
ft.
TO
ft.
DIAMETER
in.
1.6.1NNL"R CARING OR TUBING (geothermal olosedalboP)
TI[[CKNEESS MATERIAL
TO
OP ft.
ft.
DIAMETER
17. SC1t1.,F.N
FROM
ft
Vft
TO
(490
ft.
DIAMETER
/f in.
in.
SLOT SIZE
20
THICKNESS •
91
MATERIAL
/le
it GROUT '.
FROM
/e1 ft
.
fa
ft.
TO
a0fL
ft.
rt.
MATERIAL
nkotTivet
EMPLACEMENT METHOD &AMOUNT
*Ad' '740 /h
=15ISANOICRAYEL vACR (ff applicable) f
EMPTACEMEIT METHOD
FROM
/ 70 ft.
ft
TO
9a ft-
ft.
MATERIAL
. rd-
neceSSary)
211: pRtInNG LOG (at raph addifionnl sheets if
DESCRIPTION (color, hardness, soil/rock type, grain she, etc.)
FROM
b ft.
ft.
RIP
ft.
FOR WATER SUPPLY WELLS ONLY.
13a. Yield (gpm) ,a Method of test:
13b. Disinfection typceh/t-lt V
Amount:
ft.
21. REMARK
22. Certification:
5 4n4
err,�ysl
F EIVED
SEP 2 5 2017
ink) eon Pr 3t
of Certified Well Co
e
it 1 Wilt
114-17
Date
By signing this form, 7 hereby certify drat the welll's) was (were) constructed to accordance
with ISA NCAC 02C .0100 or 15A NCAC 02C .0200 Well Construction Standards and that a
copy aphis 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 INSTRUCT laTEIVED/ht00
24a. For All Welly Submit this form. wn m completion of well
construction to the following:
Division of Water RemaiSiss, OffrrfAfgry Processing Unit,
1617 Mail Service Center, Ra eig , NC 27699-1617
24b. For Iniection Wells: 1p""y,,annr�ddd[ }oAto Kr, the form: to the address in 24a
above, also submit one copy orrl#$ fdo 'W.yn.r@lPaIs of completion of well
construction to the followin era dons action
vvllmington Regional Office
Division of Water Resources, Underground Injection Control Program,
1636 Mail ServiceCenter, Raleigh, NC 27699-1636
24c. For Water Sunnly & 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 GW-1
North Carolina Department of Environmental Quality - Division of Water Resources
Revised 2-22-2016

WELL CONSTRUCTION RECORD (GW-1)
1. Well Contractor Information:
CA- oyv P,
Well Contractor Name
1-410 R r✓
NC Well Contractor Certification Number
Yyl®2"tbsi <`)ez,ttiNG9-
Company Name
2. Well Construction Permit #: 2 T Jr 7 b
List all applicable well construction permits (i.e. UIC, County, State, Variance, etc.)
3. Well Use (check well use):
Water Supply Well:
Agricultural Municipal/Public
Geothermal (Heating/Cooling Supply). residential Water Supply (single)
Industrial/Commercial Residential Water Supply (shared)
Irigation
Non -Water Supply Well:
:}Monitoring
Injection Welt
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
Experimental Technology
Geothermal (Closed Loop)
Geothermal (Heating/Cooling Return)
°Recovery
Groundwater Remediation
Salinity Barrier
fStormwater Drainage
Subsidence Control
DTracer
(Other (explain under #21 Remarks)
4. Date Well(s) Completed: 9 7 ( 1 Well ID#
5a. Well Location:
5tcve4 Pe 9w$ot1
Facility/Owner Name Facility ID# (if applicable)
r71 5 e/VAU ,Z) frbWfre25 d sM,4
Physical Address, City, and Zip
Ciftfetef
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lattllong is sufficient)
314 04/i t 1 le vy ,tiv, 6/3 t t w
6. Is(are) the well(s)Permanent or DITemporary
7. Is this a repair to an existing well: Dyes or �iINo
If this Is a repair, fill out known well construction Information dud explain the nature of the
repair under 02/ 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: BN w7
9. Total well depth below land surface: 0
For multiple wells list all depths if different (example- 3@200 and2@100')
10. Static water level below top of casing:
(ft.)
(ft.)
If water level is above casing, use
""+" ,r�2
11. Borehole diameter: //(YJ (in.)
12. Well construction method:
(i.e. auger, rotary, cable, direct push, etc.)
AD 7 y
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Y0//l Method of test:
13b. Disinfection type: ,(/r1 l t)/u✓t Amount:
For internal Use Only: 446540
3
FROM
TO/Jr(
DESCRIPTION
/7 '' IL
CC
7 O R.
f
/1 +19t �L-
ft.
ft.
15. OUTER CASING "(for
multi -cased wells) OR LINER (if appliable)
FROM
TO
DIAMETER
THICKNESS MATERIAL
ft.
ft.
in.
16. INNER
CASING OR TUBlNCL(geothermal
tlgsedrloop) '.
FROM
TO
DIAMETER
THICKNESS/�0%
MATERIAL
/ ft.
tt 7)fft.q
in.
r
9e4 T
P ✓ e-
ft.
ft.
in.
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
.
<C ft
QV ft.
t/ in.
zit)
+ s'(%
/' ✓C-
fl.
ft.
GROUT
FROM
FR
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
it) ft'ec>
f.
✓a,,91a,
5/ozr /j/%ftoie
ft.
ft.
ft.
ft.
t9, NAND/G'
VEL PACK
(if applicable) _
FROM
TO
MATERIAL
EMPLACEMENT METHOD
7PfL
c W R.
Card
'ow ed
ft.
ft.
30. DRILLING
LOG (attach
additional sheets if n necessary)FROM
TO
DESCRIPTION (color, hardness, soiarock type, grain size, etc.)
O ft.
:5 ft.
5 5 D.
CO ft.
f- / c. �/
/gJr,JJa`�S/C�j.�;,�
(tie(_
/\tt
1/
tie) ft.
s9. it
/`
ft.
0.
ft.
h.1
fi q...,w
1
ft.
ft.
-'yg
21. REMARKS ::: Sf
-.
'p
LUI/
yy��
Ftiol-liit2
22. Certification:
-/t 9-3-'77
Sre el -Certified Well Contractor Date
y signing this form, I hereby certfy that the well(s) was (were) constructed in accordance
with 15A NCAC 02C .0100 or 1SA 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 t)ENgp� ��pp
24a. For All Wells: Submit tit.ME[�(�lt. R,M pletion of well
construction to the following:
Division of Water Resource jofprinajyoq,PppSessing Unit,
1617 Mail Service Cent , Ie 99-1617
246. For 'election Wells: In addition to sending the form to the address in 24a
above, also submit one copy of thiWginll nit 301f(gg$G1fr'llompletion of well
construction to the following: N�'I Operations Section C
Division of Water Resources,'C1HiirQritd IrtgJe��iou Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24e. For Water Sootily & Iniection Wells: In addition to sending the form to
,t the address(es) above, also submit one copy of this form within 30:. days of
/ u S 641 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

•
Pfint E
WELL CONSTRUCTION RECORD (GW-11
1. Well Contractor Information: .�
* 'W Pl, Ino1 &)
Well Contractor Name
NC Well Contractor Certification Number
Company Nome ri 2
L. Well Construction Permit ft:
List all applicable well construction permits (i.e. UIC, County, State, Variance, arc)
3. Well Use (check well use):
Water Supply Well:
f Agneultural * Municipal/Public
Geothermal (Heating/Cooling Supply) >�C esidential Water Supply (single)
Industrial/Commercial I*Residential Water Supply (shared)
"Irrigation
Non -Water Supply Well:
Monitoring DRecovery
Injection Well:
AquiferRecharge OGroundwater Remediation
Aquifer Storage and Recovery 'Salinity Barrier
Aquifer Test DStormwater Drainage
Experimental Technology Subsidence Control
Geothermal (Closed Loop) Tracer
"Geothermal (Heating/Cooling Return) !Other (explain under #21 Remarks)
4. Date Well(s) Completed: - 6- / 1 Well ID#
5a. Well Location:
AO A-2 k fni ke- s
Facility/Owner Name Facility ID# (if applicable)
a33: Llge I/meg d 2ilatacJiatiottei /
Physical' Addd{loess, City, and Zip
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
Yy°yy'32/2alift lb°3D' di/ `97' w
6. Is(are) the wells) Permanent or Tempor,,aarry
7. Is this a repair to an existing well: Yes or p5INo
/f this ism repair, fill out known well construction information aftd`explain the nature of the
repair under It21 remarks section or on the back of this form.
8. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction, only I CJ�isypeded. Indicate TOTAL NUMBER of wells
drilled: /a
9. Total well depth below land surface:
For multiple wells list all depths if different (example- 3@200' and 2@100)
10. Static water level below top of casing: /
If water level is above casing, use
"x"
11. Borehole diameter: / e (in.)
12. Well construction method: /
(Le. auger, rotary, cable, direct push, etc.)
(ft.)
(ft.)
For Internal Use Only: 1146539 ,
14. WATER ZONEB-. i.
FROM TO
DEECR1PT
`,.q
toft.5 ft
r/L`.GSSf/fine 'r XvV
ft. tL
IE. OUTER CA 7N&(f r
muld-ans dwell) OR LINER (if apPJtcabl)
FROM
TO
DIAMETER
THICKNESS I MATERIAL
D.
ft.
in.
16. INNER
CASING OR TUBING (geothermal closed -loop)
FROM
TO
DIAMETER
THICKNESS
0r ft.
e V trl ft.
'4X in.
/. %`
/' V fi
t ft.
ft.
in.
17. SCREEN -
FROM
TO
DIAMETER
SLOT SIZE
THIKNESS
MATERIAL
6.0 ft.
so ft.
%/ in.
.L
to
V
5c y
Yjetf ii
ft.
ft.
in.
IR GROUTFROM
TO
MATERIAL
EMPLACEMENT
L�
f4
�'�'.. f
O
Wt
{ , ; t i,&e
ft.
R.
ft.
ft.
19 ND/GRAYEDPAC
K
(if applicable)
FROM
TO
MATERIAL
METHOD
— fa
fro ft.
�,,14-`71 (
EMPLACEMENT
/
. t2i 'atilt. ci
ft.
ft.
20. DRILLING
LOG Cato
h additional sheets if necessary)
FROM
TO
DESCRIPTION (color, hardness. soil/rock type, grain sae, etc.)
a ft.
36 ft.
SA--n LJ
gs ft.
5-40 ft.
Si dy c7.0,-
5 -0 ft.
Z b ft.
C. 4a4 v
pr6V rt.
Ct
Leib ft.
c% � ie Js Zh—
f
11.
ft.
ft.
ft.
21..REMARK5
SFP ? 2017
FOR WATER SUPPLY WELLS
WELLS ONLY: rIA�
13a. Yield (WO) 9) Method of test: / /2'
13b. Disinfection type hl» / tm 10 Amount:
22. Certification:
Si a' 'ie of Certified Well Contractor
Ddle' '/7
rgning this faun, I hereby tarty" that the well(s) was (were) constructed In accordance
wish 15A NCAC 02(7 .0100 or 1SA 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, Informati�onp, �Proceetstssiinz Unit,
1617 Mail Service Ce IE®1'NC- '" PPR AIR
24h. For Infection Wells: In addition to sending the form to the address in 24a
above, also submit one copy of this form within 3Q days
2of completion of well
OCTconstruction to the following: 1. v //
Division of Water Resources, Underground Injection Control. Program,
1636 Mail Service Centers glj j(� �7CC�( tiI
24c. For Water Supply & Infection We1QPQ P i r oMQSta,I,'�g the form to
the address(es) above, also submit iB'VV161, i g1s1PtT R` H'E30 days of
completion of well construction to the county health department of the county
where constructed.
North Carolina Department of Environmental Quality - Division of Water Resources
Revised 2-22-2016
Form GW-1

WELL CONSTRUCTION RECORD (GW-11
rot
For Internal Use Only:
I. Well Contractor Information: -( �
.SPc�o/� ?:Ioizl�1
Well Contractor Name
NC Well Contractor Certification Number
(Mo% i »J RI LLia &-
Company Name ,n
2. Well Construction Permit #: t (4( 1 I'
Dm all applicable well construction permits (r.e. WC, Cowry, Score, Variance, eIc.)
3. Well Use (check well use):
Water Supply Well:
jAgricultural
:Geothermal (Heating/Cooling Supply)
;Industrial/Commercial
"Irrigation
Non -Water Supply Well:
Monitoring
Injection Well:
]Aquifer Recharge
,Aquifer Storage and Recovery
Aquifer Test
jExperimental Technology
Geothermal (Closed Loop)
I'lGeothermal (Heating/Cooling Return)
unicipaVPubtic
sidential Water Supply (single)
Residential Water Supply (shared)
Recovery
DGroundwater Remediation
Salinity Barrier
£Stormwater Drainage
Subsidence Control
£Tracer
riOther (explain under #21 Remarks)
4. Date Well(s) Completed: $_9-1
5a. Well Location:
(Illto MuAtI
Facility/Owner Name
704 (.ieev P6)(11: w S7
Physidal Addmss, City, and Zip
CAR+e_Ree"-
Well ID#
Facility ID# (if applicable)
/AK 4C.
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, oneleNong is sufficient)
741°433q,N -7b`9g1' 6,1 ri w
6. Is(are) the well(s)4Permanent or £Temporary
7. Is this a repair to ail existing well: Yes or spy/�/o
lfthis is a repair, fill out known welt construe:kg information tics,1 explain the nature of the
repair under 112) remarks section or on the hack 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: ONE-
9. Total well depth below land surface: Z. ' (ft.)
For multiple wells list all depths if different (example- 3Qa 200' and 2@/00)
10. Static water level below top of casing:
If Rater level is above casing, use tI" ✓
11. Borehole diameter: (
12. Well construction method:
15
(in.)
(i7/
(ft.)
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLSxONLY: G
13a. Yield (gpm) 5 Method of test:
13b. Disinfection type (1) O I W(" Amount:
/ I1.
e446538
14. WATER ZONES les s
FROM
10
DESCRIPTnon
'Zoo ft.
zzd ft.
/z o C.
ft.
ft.
15. OUTER CASING (for multi -cased wells) OR LINER (Yap liable)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft.
ft.
in.
16.:INNER CASING OR TUBING (geothermalclosed-loop)
FROM
TO
DIAMETER
TRICKNESS
MATERIAL.
R..
(
Zeo ft.
7
gel/ 0
/a if C
T
ft.
in.
17.SCRLLR
FROM
10
DIAMETER
SLOT SIZE
'FRICKNEES
MATERIAL
cY r6..,Y
/J©C: ft.
zit,.y.
in.
rI/
(
L.5 if
Gam'
ft.
ft.
I in..
18. GROUT
FROM
10
MATERIAL
EMPI ACEM^yIENT
Pawed
METHOD &AM UNT
iced I b s
b R.
7 f.
err,
ft.
ft.
rt.
ft
19. SAND/GRAVEL
PACK
(if applicable) ..
TO
MATERIAL
EMPLACEMENT MIOD
p<e)0 R
ZZFROM
0 ft.
reE"�
+VV oo
ft.
ft.
2e:: DRILLING
LOG (athr
h additional sheets if nee scary)
FROM
TO
DESCRIPTION (color, 'artiness, soir/rock type, grain sbs, etc)
rt.
✓
3 ` rt.
! As-
ggV
37/fL
$2 <ft.
c5 -,_f_ c2-* _
JaY'aC/r rf .'`//`���+�Ln��''-f/�
5---ft.
5?
/DDO �\fL
O
G� t.
z�/© oft
TaaLe, Sal J
t.
210 ".
4frx,L V
ft.
ft.
21:.RCMARKS
SEP 9.2 2017
22. Certification:
)
SignaJddrpof Certified Well Contractor
1D-17
Date
By signing this form, l hereby certi that the wells) was (were) constructed in accordance
with 154 NC'AC 02C.0100 or 15A NCAC 02C _0200 Well Construction Standards and that a
copy, of this record has been provided to the well owner.
23: Site diagram or additional well details: •
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTRUCTIONS
24a. For All Wells:- Submit this form within 30 days of completion of well
construction to the following:
Division of Water Res y�lrJ�s�.. tra$l A Unit,
1617 Mail Service 6lfls� }+1)')'�At
24b. For Injection Wells: In addition to sending the form to the address in 24a
above, also submit one copy of this foHroithjq A(1 ggyt1f completion of well
construction to the following: oil
LU l
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Ceram), rtI lltl4lgg'`�a++®ali36
24c. For Water Supply & Iniection <31�Rf?ti��df��dlQy11��Pding the form to
the address(es) above, also suh1 IljhyrlfilKI $ With 'ARin 30 days of
completion of well construction to the county health department of the .county
where constructed.
Farm OW -I
North Carolina Department of Environmcnml Quality - Division of Wares Rcsonrce
Revised 2-22-2016

'~tint rprni
WELL; CONSTRUCTION RECORD (GW-1)
1. Well Contractor Information:
Ai Pe %Y sti--N
Well Contractor Name
.295
NC Well Contactor Certification Number
I pas_/LL/y v
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 DMunicipal/Public
Geothermal (Heating/Cooling Supply) ptesidential Water Supply (single)
Industrial/Commercial Residential Water Supply (shared)
Irrigation
Non -Water Supply Well:
Monitoring
Injection Well:
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
Experimental Technology
Geothermal (Closed Loop) 'jTracer
Geothermal (Heating/Cooling Retum) apt{Other (explain under #21 Remarks)
4. Date:Well(s) Completed: 7— ZI ^ (7, Well ID#
5a. Well Location:
Recovery
0
EIGroundwater Remediation
Salinity Barrier
Stormwater Drainage
Subsidence Control
,l nl€5 &i:Wa)#2
Facility/Owner Name Facility ID# (if applicable)
/ �f3 6-C/ hei& . lust d baark +- A!
Physical
(Add�d��resss, City, and Zip
ski"i�T
County
5b. Latitude and longitude in degrees/minJtes/seconds or decimal degrees:
(if well' field, one tat/long is sufficient) r t
31{o501If/ " N L6
Parcel Identification No. (PIN)
6. Is(are) the well(s) Permanent or I♦lTemporary
7. Is this a repair to an existing well: Yes or [j(INo
If this if a repair, fill out known well construction i formation a explain the nature of the
repair under 1121 remarks section or on the back o this farm.
8. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction, only 1 GW- I is neteded. Indicate TOTAL NUMBER of wells
drilled:
oPf
9. Total well depth below land surface:
For multiple wells list all depths if different (exam,
10. Static water level below top of casing:
If water level is above casing, use "+"
11. Borehole diameter: n/71
12. Well construction method:
(i.e. auger, rotary, cable, direct push, etc.)
ry
For Internal Use Only: 446537
14.WATERZONRB
~ROM
TO
DESCRIPTION
( -%ft.
LAY
/Q'Uft
/���y'g ,r
/ S06/t- -�' c/
f.
ft.
15 OUTER CASING(for
multi -eased 'wells) OR LINER (if anpkale)
PROM
TO
DIAMETER
THICKNESS MATERIAL
ft
ft.
16. INNEI CASING -OR TUBING
-(geothermal closed -loop)
FROM
TO
DIAMETER
T/IIICKNE�SSS)
MATERIAL
R.
f
� ft.-
rj' in•
i `I'V
P v '—
ft.
r
ft.
in,
1'.
17.SCkEE
FROM
TO
DIAMETER
SLOT SIZE
THIC ESS
MATERIAL
ft.
J00 ft.
in.
70
5C-ASid
RV
ft
ft.
in.
it GROUT
`M TO
MATE
EMPLACEMENT MET sD&AMOUNT
«.
z2fLr��oa�
Val0
ft.
ft.
ft.
ft.
19.:SAND/GRAVEL:
PACK
(if applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
fL
job R.
Syav)d- w
pDor.° d.
rt.
R.
20. DRILLING
LOG (attach
additional sheets if necessary)
FROM
TO
DESCRIPTION (color, b nines*, soil/rock type, prase sire-, ete.)
6 fL
35 ft.
. S
S ft.
i ^ 0 ft.
-/� /�/
K;a2"?7C ef..,- CL c r,----
d
,40 / r
ft.
ft.
R.
R
ft.
ft.gt'�
-
y
21 REMARKS SEP 2r;..201
C.'
)nfoffir ttinri'-rcrg, c:y.`_t i�i .,.
FOR WATER SUPPLY WELLS ONLY
13a. Yield (gpm) �v
r,i
L4
136.Disinfecfion Type�flNl�f�t�'t-gi
ethod of test:
Amount:
(.0 7
22. Certification:
e of Certified Well Contractor
7— Z f --r
Date
By signing this ,form, I hereby certify that the well(s) was (were) constructed in accordance
with 15A NCAC 02C .0100 or I5A NCAC 02C .0200 well Consruction Standout and that
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:
RECEIVF�D/NCIUNR/DWR
Division of Water Resources, n orma ton ocessrng Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Iniection Wells: In additiRe(Ts�y�•i�g 2-tit fyrm to the address in 24a
above, also submit one copy of this fonn within days of completion of well
construction to the following:
Division of Water Resources, 1341` ontrol Program,
1636 Mail Servrert
t�Rb1` II'�k99-1636
VVVV rn ngfon egional Office
24c. For Water Supply & Iniection Welts: 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.
ec
Form GW-1
North Carolina Department of Environmental Quality - Division of Water Resources Revised 2-22-2016

WELL CONSTRUCTION RECORD (GW-1)
Print Form
For Internal Use Only:
1. Well Contractor Information:
Bobby Allred
Well Contractor Name
2610-A
NC Well Cormactor Certification Number
A C Schultes of Carolina, Inc.
Company Name
2. Well Construction Permit #:
List all applicable well construction permits (t.e. U1C County, State, Variance, etc.)
3. Well Use (check well use):
Water Supply Well:
['Agricultural E31 Municipal/Public
['Geothermal (Heating/Cooling Supply) ()Residential Water Supply (single)
Dlndustrial/Commercial ()Residential Water Supply (shared)
"Irrigation
Non -Water Supply Well:
()Monitoring
Injection Well:
['Aquifer Recharge It Groundwater Remediation
['Aquifer Storage and Recovery [' Salinity Barrier
['Aquifer Test ['Stonnwater Drainage
['Experimental Technology ['Subsidence Control
()Geothermal (Closed Loop) ()Tracer
'Geothermal (Heating/Cooling Return) ['Other (explain under #21 Remarks)
4. Date Welt(s) Completed: 7/17/17 Well ID# PW-8
5a. Well Location:
W Carteret Water Corp
()Recovery
Facility/Owner Name Facility ID# (if applicable)
4102 Hwy 24, Newport, NC 28570
Physical Address, City, and Zip
Carteret
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
34.71 556 N 76.98 461
6. Is(are) the well(s)0Permanent or ['Temporary
W
7. Is this a repair to an existing well: ['Yes or I:j No
If this is a repair. fill out known well constnmrian information and explain the nature 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 I GW-I is needed. Indicate TOTAL NUMBER of wells
drilled:
9. Total well depth below land surface: 295 (ft.)
For multiple wells list all depths if different (example- 3(3200' and 2 tr100)
10. Static water level below top of casing: 25 (ft.)
If water level is above casing, use "+"
11. Borehole diameter: 23 (in.)
12. Wellconstruction method: mud/reverse rotary
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) 1220
Method of test: Pumping
13b. Disinfection type: HTH Amount: 10 IbS
446331
14 :WATER ZONES ,
FROM
TO
DESCRIPTION
197 It
237 H•
limestone
270 ft.
290 ft.
limestone
15 OUTER CASING (for
multi -cased wells) OR LINER (if ap limbic)
FROM
TO
DIAMETER
THICKNESS MATERIAL
0 R•
50' ft-
24 'n•
.375 steel
16. INNER CASING OR TUBING
(geothermal closed -loop) ,.
FROM
TO
DIAMETER
THICKNESS
MATERIAL
0 R•
197 ft-
12 'n•
sch 10
304 ss
245 ft•
270 ft.
12 'n.
sch 10
304 ss
FROMEEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
197".
237 It.
12 'a•
.050
n/a
304 ss
270ft.
290 ft•
12 'a•
.050
n/a
304 ss
IS GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
0 ft.
50 ft-
cement
Tremmie
0 ft.
165 ft.
cement
Tremmie
245 ft
255 H•
bentonite
Tremmie
19d:SANDIGAAVEC
PACK
(ifTplieame)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
187 ft•
245 ft-
#3 gravel
Tremmie
255 f •
295 ft-
#3 gravel
Tremmie
20. DRILLING
LOG (attach
additional sheets if nee ssary) `S
FROM
TO
DESCRIPTION (color, hardness, soit/rock type. grain site, etc)
0 f•
10 IL
sand & clay
10 R•
30 ft-
clay & fine sand
30 fL
51 H,
clay
51 ft.
60 ft.
sand, shells and limestone
60 ft.
145 ft•
gray clay
145 f •
190 ft-
sand & shells
190 ft.
300 ft.
limestone
2i REMAIU(S- - -
RFC
_
I
--D
A
22. Certification: J t f•'
aiF�*iliwR 9/7/17
Signature ofCified Well Contractor (Jr� Date
By signing this form, 1 hereby cert hni-jhe eec (s) was (were) constructed in accordance
with 154 NCAC 02C.0100 or 15A 1VeA0-0214.0002181217onstruction Standards and that a
copy of this record has been provided to the well owner.
23. Site diagram or additioMmel
You may use the back of this®,
construction details. Yor(
SUBMITTAL INSTRUCTIONS
s:
agHt1Uka¢al well site details or well
§SI-pages if necessary.
eglonal Office
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: 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 Mail Service 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 fonn within 30 days of
completion of well constmetion to the county health department of the county
where constructed.
Form G W-1
North Carolina Department of Environmental Quality - Division of Water Resources
Revised 2-22-2016

CONSTRUCTION RECORD (GW 1
1. Well'Contractor Information:
31r©N , `111oIZ"To,J
Well Contractor Name
NC Well Contractor Certification Number
5t » � (1_ L/N G-
Company Name
2. Well Construction Permit List all applicable well cons/ruction permits ( 1//C, County, State, Variance, eta)
3. Well Use (check well use):
Water Supply Well:
Agricultural 0Municipal/Public
Geothermal (Heating/Cooling Supply) Residential Water Supply (single)
Industrial/Commercial DResidential Water Supply (shared)
tion PP Y
Injection ell:
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
E Experimental Technology
Geothermal (Closed Loop)
N n-Water Supply Well:
Monitoring
Recovery
Groundwater Remediation
}Salinity Barrier
DStormwater Drainage
Subsidence Control
Tracer
Geothermal Heath: Coolin: Return) * Other (ex lain under #21 Remarks)
4. Date Well(s) Completed: SZB-/%
We11ID#
5a. Well Location:
Robes } IM Lr. L
Facility/Owner Name
Facility ID# (if applicable )
W a -•aria 0 .� o J/ I},
Ply IAdd City, and Zip
re; ,0G
Jf (example- 3@.200 aanppd2©100')
10. Static water level below to easing: '(J
Ifwater level Is above casing, use " (ft.)
11. Borehole diameter: B
(in.)
County
Parcel Identification No. (PM)
5b. Latitude and longitude in degrees/minutes/secondsor decimal degrees:
(ifwell'field, one lathong is sufficient)
YO r 92 Q rt r*1 TEC: 6 r S9 24 tr
6. Is(are) the well(s)5permanent or Temporary
7. is this a repair torn existing well: 0Yes or j{�.ff N If this is a repair, Jill out known well conrIrucdon information ana( o repo under 021 remarks section or on the bock of this form. explain the nature of the
9. Total well depth below land surface: % 9� Form IOple wells list all depths rfdr eras( ex (R•)
p of
er, rotary, cable, direct push, era) O
8. For Ceoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction, only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
to
d
12. Well construction method:
(i.e. auge
Division of Water Resour es, Underground Injection Control Program,
1636 Mail Serv�ce Center �R�aleeig 7799-1636
24c. For Water Su 1 & In'ection*lis: ilnad �on to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
completion of well construction IQAOre co
where constructed. I Wafer Operations
Section
of the county
Operations Section
ilmington Regional Office
For Internal Use Only:
4.. WATER'ZONE$
FROM
®
T - 111111111
ND for multi -cased wells OR E
DIAMETER ite�'. liable
DESCRIPTION
NG OR TUBING eotheema Hosed— eddy off- '
DIAMETERiv T.T/nraa,�
19. SAND/GRAVEL PAC it
FROM TO �+n
TO: DRILL!NGLEIG attach
FROM
22. Certification:
Siy�Ft�m ofCertified Well Contra
ERIAL
lint,r=oor
TaiCRNEs3
EMPLACEMENTMETHOD & AMOUNT
ad, ttiana— '" sheets 'f sat _
mPTION color, hardoe,,, soil/rock
m size, etc.
0 1 2017
,tion ProcesssIng Unit
Date
Gy signg this form, I hereby car that that the well(,) was (were) constructed in accordance
with 15A NCAC 02C .0100 or 15A. CAC 02(' .0200 Wel/ Construction Standards and that a
copy of this record has been proved d to thewell owner.
23. Site diagram or additions well details:
You may use the back of' this page to provide additional well site details or well
construction details. You inayaiso attach additional pages if necessary.
in
SUBMITTAL INSTRUCTIdNS
24a. F r All Wells: Submit/ this form within 30 days of completion of well
construction to'the following
Division of Water fiesources, Information Processing Unit,
1617 Mail Sery ce Center, Raleigh, NC 27699-1617
24b. For Inieetio Wells: Inl addition to d"
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
136. Disinfection type: -0 1-
• Amount:,_2,,
Fenn O W-i
above, also submit one copyPF this form w'thing the form to the address in 24a
onstruction to the following:: R CEWED}��D' mpletion of well
North Carolina Department of Environmental Quality - Division of Water Res lu W
Revised 2-22-2016

For Internal Use Only:
446018
WELL CONSTRUCTION RECORD (GW-1)
1. Well Contractor Information:
Sj ; NI : YVI o 2To Ni
Well Contractor Name
1S3-kt
NC Well Contractor Certification Number
R�LUtit6-
Company Name
2. Well Construction Permit 6: Z 3 5 5 7/
List all applicable well constrncnon permits (i.e. UIC, County, Slate, Variance, etc)
3. Well Use (check well use):
1aterSupply Well:
AgriculturalGeothermal (Heating/Cooling Supply)
ndutrial/Commercial
rrigation
DMunicipat/Public
DResidential Water Supply (single)
Residential Water Supply (shared)
n-Water Supply Well:
Monitoring
Injection Well:
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
Experimental Technology
Geothermal (Closed Loop)
"Geothermal (Heating/Cooling Rehm)
4. Date Well(s) Completed: id L"
DRecovery
DGroundwater Remediation
DSalinity Barrier
DStormwater Drainage
DSubsidence Control
DTracer
(Other (explain under 621 Remarks)
Well IDN
5a. Well Location:
DneS P k,jerce
Facility/Owner Name Facility ID# (if applicable)
of R5/t rmer/td De £,ineattet dell
Physical Address, City, and Zip
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one let/long is sufficient)
3y°yo'Vo.{rsjr'N 76°s� /9ezo"
6. [stare) the well(s)rtf.Permanent_ or DTempotttaraaa,rfftty
7. Is this a repair to an existing well: DYes or aoNo
Ifthis -is a repatr, fttt out known well construction information d explain the nature of the
repair under E2/ remarks suction or on the hack 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; 0 F
9. Total well depth below land surface; Z SS (ft.)
For multiple wells list all depths if different (example- 3©200' and 2(41100)
10. Static water level below top of casing: / E (ft.)
If water level is above casing, use -'4"
11. Borehole diameter: 1
12. Well construction method:
(i.e. auger, rotary, cable, direct push, etc.)
(in.)
Aeflaral
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) - Uo / I r,' Method of test: I A
13D._ Disinfection type: 110 i2-( !'r (&'. Amount: 1 . 0 o Z/
Form GW-I
14;WA1E] ZONES
FROM
TO
DF.SCRIPI'10N
,7 J
6 Lf"
1
2e ft.
G
Zerda-
ft.
ft.
15.:0UTER CASING (for
Muth -cased wells) OR ti1NER Of
Hoak),
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft.
ft.
in.
16:. INNER CASING OR TURINO
(geothermal
elesed,loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL .
/ it.
7/ .7 `R.
!/!/
in.
$c/ V
/7
Pvc
R.
D.
in.
17.SCREEN
FROM
TO
DIAMETER
SLOTSIZE
THICKNESS
MATERIAL
ZG5ft.
ZOsft.
O
y. in.
to
scXVo
^
-rvc
ft.
ft.
.
18i.GROpT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
O n.
90 fL
/jailor of to
SLw. I f/ f /.nrn At
tt.
ft.
ft.
ft.
19. SAND/C RAVEL PACK
(if aptltcable) ...
FROM
TO
MATERIAL
EMPLACEMENT METHOD
r
ft.
ft.
29r:DRILLING
LOG (alto
h additional sheets if neeesary)
FROM
TO
DESCRIPTION (color, bardeem,soil/rock type, grain size, etc)
o ft.
YDR.
Sa-N te
too R.
/et v��--ll fL
/cl y C t,(41.1
S%r-n
/ 20 It'
AO ft.
she 4- S/e d
(?0 ft-
III
7 vo ft.
L LA y
7 ��)R.
Z&S ft.
C
,.
�Nc dry l..f 121/1
i
ft.
265
ft.
Z85
,f
/ 1S
ft
ft
21. REMARKS
AUG 01 2017'
s - _,, Or"broari51tr1U UM
22. Certification:
caon
5" ore of Codified Well Comma or
DWQ/ZO G
8-30 -17
Date
u
Division of Wa der er esoesources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supply a lee1io1 VLFTrf In addition to sending the form to
the address(es) above, a o submit one copy or this form within 30 days of
completion of well construction to the county. health department of the county
where constructed,
Water Quality Regional
Operations Section
wrtfrNorth Carolina Department of Environmental Quality - Division of Wag niy){sRepjOnal Office
By signing this jam 1 hereby eery, that the well(s) was (were) constructed in accordance
with 15A NCAC 02C .0100 or ISA NCAC 02C .0200 Well Corsst-aalian Standards and that a
copy of Ilia 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 A]] 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 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:
Revised 2-22-2016

WELL CONSTRUCTION RECORD (GW-11
1. Well C ntractor Information:
(e l4C1 r
Well Contractor Name
NC Well Contractor Certification Number
Li d Well brilltn�, LG�
Company N ei n
2. Well Construction Permit 14: 23 5 l
List all applicable well construction permits (i.e. (JtC.. County. State, Variance, etc.)
3. Well Use (check well use):
Water Supply Well:
OAgicultural
❑Geothermal (Heating/Cooling Supply)
DlnduslriavCommerclal
OEMtion
°�M/�unicipal/Public
IHResidential Water Supply (single)
°Residential Water Supply (shared)
Non -Water Supply Well:
°Monitoring
Injec Well:
°Aquifer Recharge
°Aquifer Storage and Recovery
DAquifer Test
DExperimental Technology
°Geothermal (Closed Loop)
°Geothermal Heating/Cooling Return)
°Recovery
°Groundwater Remediation
❑Salinity Barrier
fStormwater Drainage
°Subsidence Control
❑Tracer
❑Oth
ain under #21 Remark
4. Date Well(s) Completed: 2 15._1 7 Well ID#
StWelllastion:
MA 6-arriee-
Facili /Goner Name• Facility IDk (if applicable)
JAY) /4a95 Rd » r Az- 2885-70
Physical Address, City, and Zip
Cgr4ent- l3360257 / eb
County Parcel Identification No. (PIN)
Six Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one IaFlong is sufficient)
3 9 tit ti35 N D76°S3r D117
6. Is(are) the well(s): BPermaaent or °Temporary
7.1s this a repair to an misting well: °Yes or 614;
If this is a repair, fill out knmvn well construction information and explain the nature of the
repair wider 1121 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:
9. Total well depth below land sdrface:
For multiple welly list all depths if afferent (example- 3@200' and 2®100')
/6 D
(ft.)
10. Static water level below lop of casing: o!L✓ (ft,)
If water level is above casing, use " . "
11. Borehole diameter:
12. Well construction method: f fiA rt/
auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLYWELLS{//
ONLY:
13a. Yield (gpm) %0 Method of test: e'(I r I(
r I
136. Disinfection type: I Amount: 319Z
FormGW-I
1 For Internal Use Only:
4459.73
14. WATER ZONES
FROM
TO
DESCRIPTION
/5o:
16 0 fr•
"��
r✓ ifYBsTfif•t_1 rod _
n.
ft
15. OUTER CASING (for
multi -cased wells) OR LLNER (if ap dicable)
FROM
TO
DIAMETER THICKNESS MATERIAL
twain
fa, ft.
a r f SA. I-,o Pvc.
16. INNER
CASING OR TUBING
(geothermal cased -loop)
FROM
TO
DIAMETER J THICKNESS
MATERIAL
ft
R
itE
ft
R
in.
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
"[WIENERS
MATERIAL
P3oft.
Hoof
d 'R
, 9,0
5d)-1-in
I Pvc
f4
fL
in.
18. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
ft
ft
ft
19. SAND/GRAVEL PACK
(if applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
PO R•
I bo ft
LOarse.sand
p®vr
fc
h
20. DRILLING
LOG (attach
additional sheets if necessary)
FROM
TO
OESCRWfON Nolen hardness, soiuroeh rape. anon. e, egret.)
10 ft
2,0 itFi^Lct
Sncl Y' 0fga.,,z_ re c rlur
y;0 ft
,So n'
Fitt Seine\ 1- btu C.
50
1g.5 B.
hr.c sty -f 51/4615
b_5ft
231ft
b1'c dasi
23 ft
13o ft
Naybj'� 's ff vaiN;ke- ror
i3o'
IVO �t
� U('-s�r 92 RAJ
w
n.
21. REMARKS
. a, i ,,, �
AUG 292O17
22. Certi ca
Signature of Certified We
ation Prof flL,,
DWO/BOG - G2-/ /
ar Date
By signing this form I hereby , that the welts) was (were) constructed in accordance
with I5A NCAC 02C .0100 or 15A NCAC' 02C .0200 Well Construction Standards and that a
copy tllhis record has been provided to the nvIl 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. 1NSTRUCTION1
24a. For MI Welds: Submit this fors within 30 days of completion of well
construction to the following:
Division of Water riQRMfpformatioa Processing Unit,
REC EMhf;Raleigb, NC 27699-1617
246. For Infection Wells: In addition to sending the form to the address in 24a
above, also submit one w o ,(}s, form within 30 days of completion of well
construction tot fc9to 'LU1
Division of Water Resources, Underground Injection Control Program,
1636 M it S g(Raleigh, NC 27699-1636
Water �uafity �t
24e. For ti'ater(�nDldoi�)t. Rt♦d fl1l In addition to sending the form to
the aForess(pg) rOR1 a 5)9fi copy of this form within 30 days of
completion poi we construction to the county health department of the county
where constructed.
North Carolina Department of Environmental Quality - Division of Water Resources Revised 2-22-2016

tint Foci
WELL CONSTRUCTION RECORD (GW-1)
1. Well Contractor Information:
`2N P `Mog tt,.)
Well Contractor Name
NC Well Contractor Certification-0Iumber
tF/7 C ., i _ ., 1
Co any Name
2. Well Construction Permit #:
'o9iD
List all applicable well construction permits (I.e. WC; County. Stale, Variance, etc)
3. Well Use (check well use):
Water Supply Well:
®Agricultural
DGeothermal (Heating/Cooling Supply)
©'lndustrial/Commercial
j(rrigalion
Non -Water Supply Well:
DMonitoring
Injection Well:
Aquifer Recharge
EpAquifer Storage and Recovery
Aquifer Test
jExpetimental Technology
jGeothermal (Closed Loop)
',Geothermal (Heating/Cooling Return)
Municipal/Public
esidential Water Supply (single)
Residential Water Supply (shared)
Recovery
EiGroundwater Remediation
ctSalinity Barrier
DStormwater Drainage
Subsidence Control
DTracer
'Other (explain under #2l Remarks)
4. Date Well(s) Completed: b-2 /' I 7 Well ID#
5a.AVell Location:
L u )A- (I c h.n—
Facility/owner Name �/ Fa "ty ID# (if applicable)
537400pRd 1�V )
Physical Address, City, and Zip
Cla r�k
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field, one lat/long is sufficient) ; y
gY 01 3Oc 93 `IN 7<, 6 /23. 4 2
6. Is(are) the well(s)Il./laermanent or Temporary
7. Is this a repair to anexistingwell: (Yes or No
If this is a moan...fill out known well construction information nd explain the nature 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 ia needed. Indicate TOTAL NUMBER of wells
drilled: (:)IAISCP �''f
9. Total well depth below land surface: ! /
For multiple wells list all depths ifdierent (example- 3Qa 200' and 2Q100')
10. Static water level below top of casing: f
If water level is above casing, us " p1
11. Borehole diameter: (in.)) _
12. Well construction method:
(i.e. auger, rotary, cable, direct push, etc.)
(ft.)
(ft.)
FOR WATER SUPPLY WELLS ONLY: �
13a. Yield (gpm) _� 0 Method of test j/L
Ai 'C 1 I
/I U ov/
13h. Disinfection typeCh (0 Amount: /
For internal Use Only:
445207
14. WATER ZONES
OM
TO
i DESCRIPTION
-hh.
ft.
77 R.
: �/e SAt cc,
ft.
15.OUTER CASING (for
multi -eased wells) OR LINER Dia Iteable)
FROM
TO
DIAMETER
THICKNESS MATERIAL
ft.
ft.
in.
16 INNER
CASING OR TUBING
(geothermal'
closed -loop) -' -
FROM
TO
DIAMETER
THICKNESS
MATERIAL
/ ft.
i,7 ft
! .sg in.
�.,i �" f� I7L�
�(f'�.
R. ft.
in.
17.:$CREEN -
FROM
TO
06�TEiRn.
E
S/
C/{OV.[
L
Ac
f lift.
(,
n/1 rt.
!
if,
$cA/_ yU
pvERS
q
ft
ft.
in.
19.;CRDUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
0 Q.
(ZR.
liSesi4TIT±-
flout d
g_Sn/
ft.
ft.
19.SAND/GRAVEL
PACK
(if applicable) +.
FROM
TO
MATERIAL
EMPLACEMENT My TROD
07 R.
07 ft
. Al—,t1 t)
Loom e °
ft.
ft.
20DRILLING
LOG (attaeh
additional sheets if necessary) '
FROM
TO
DESCRIPTION (color, hardily!, snit/rock type, grain size, etc)
Pft
2 ft.
572 rt
>b ft.
.'7 ft
te e,0-1.,
i
.fb
ge
ft
ft.
ft.
ft.
ft
k'
f t.
(qg�Oe
21-REMARIGS JUL: (d 0 201>f . _
cs?a'1tkAt
22. Certiffct(fion:
5
e lor-2A 4 -2..9 —77
/t-4-n
ofCertified Well Contractor Date
By signing this font:, I hereby test fy that the well(s) was (were) constructed in accordance
with 15A NCAC 02C .0100 dr 15A NCAC 02C .0200 Well Construction Standards and that a
copy of this record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTRUCTIONS
24a. For All Wells: S i this form within 30 days of completion of well
constriction to the follow EIVEp/yCDERR/DWR
Division of Water Resources, Information Processing Unit,
1617 MaiI Service
(JCenter,�lRaleigh, NC 27699-1617
24h. For Iniection Wells: In ad dition-tdi's21Qtlg the form to the address in 24a
above, also submit one bopy of this form within 30 days of completion of well
construction to the folloWi*ffal1ter QDauty fil3g, al
Division of Water 'eafi(]tdgg$Elrq(ilection Control Program,
1636 Mai a tl @6nRaglttplggb ` 27699-1636
24c. For Water SunnWW & 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 GW-1
North Carolina Department of Environmental Quality- Division of Water Resources Revised 2-22-2016

WELL CONSTRUCTION RECORD (GW-1)
1. Well Contractor Information:
James R. Williamson
Well Contractor Name
4251-B
NC Well Contractor Certification Number
Geological Resources, Inc.
Company Name
2. Well Construction Permit #: Not Required
List all applicable well construction permits p.e. UIC, County, State, Variance, etc.)
3. Well Use (check well use):
Water Supply Well:
Agricultural DMunicipal/Public
_ Geothermal (Heating/Cooling Supply) 0Residential Water Supply (single)
' Industrial/Commercial Residential Water Supply (shared)
Irrigation
Non -Water Supply Well:
X. Monitoring E®Recovery
Injection Well:
QAquifer Recharge Groundwater Remediation
Aquifer Storage and Recovery Salinity Bather
Aquifer Test ED Stonnwater Drainage
„Experimental Technology ID Subsidence Control
j Geothermal (Closed Loop) fl Tracer
'_iGeothennal (Heating/Cooling Return) - fOther (explain under #21 Remarks)
4. Date Well(s) Completed: 06-07-2017 Well ID# RW-4
5a. Well London:
Speedway #8268 0-0035167
Facility/Owner Name Facility ID# (if applicable)
6999 US Hwy. 70 E. Newport, NC
Physical Address, City, and Zip
Carteret
633820808532000
County Parcel Identification No. (PIN)
56. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
34.776957° N 76.872396°
6. Is(are) the well(s)Dx Permanent or OTemporary
7. Is this a repair to an existing well: (jYes or E®No
If this is a repair. fill out brown well construction information and explain the nature 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: n/a
9. Total well depth below land surface: 12
For multiple wells list all depths if different (example- 3 e@d200' and 21100')
(ft.)
10. Static water level below top of casing: 6.30 (ft.)
If water level is above casing, rise "+"
11. Borehole diameter: 12 (in.)
12. Well construction method: Rotary Hollow Stem Augers
(i.e. auger, rotary, cable, direct push, etc.) -
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm)
13b. Disinfection type:
Method of test:
Amount:
For Internal Use Only:
14 WATER ZONES.
FROM
6.30 fL
ft.
TO
12
ft.
ft.
444855
DESCRIPTION
Saturated
Print Form
OUTER CASING (for mWd-eased wells)DR LINER (if ap. Rcable)
FROM TO DIAMETER THICKNESS MATERIAL
ft. in.
It INNER CAS (geothermal closed -loop)
0 R.
ft.
CASING OR TRING
TO DIAMETER
2 R. 14 In.
R. in.
THICKNESS
Schd. 40
17. SCREEN
FROM
2 D.
ft.
TO
12 R.
IS: GROUT
FROM
0.5 R.
1
ft.
ft.
TO
0 R.
0.5 R.
ft.
DIAMETER
4
in.
In.
MATERIAL
MATERIAL
PVC
SLOT SIZE 1 THICKNESS
0.010
Concrete Grout
Bentonite Chips
.19.SAND/GRAYEL PACK (ifapplleable)
TO
FROM
12 a.
R.
1
R.
ft.
MATERIAL
#2 Sand
Schd. 40
MATERIAL
PVC
EMPLACEMENT METHOD & AMOUNT
Pour
Pour
EMPLACEMENT METHOD
Pour
20.DRILLING.LOC (atte lladditional sheetsif necessary)
FROM TO DESCRIPTION (color, hardness, soiVrock type,
ype, grain sin, etc.)
Concrete
0 ft.
0.3 ft.
2
R.
10 fL
rt.
R.
0.3 R.
2
ff.
10 ft.
12 R•
21:REMARKS
22. Certification:
h,
ft.
ft.
Brown fine sand
Black silt
Blue -grey silt
Sigfiature of Certified Well Contractor Date
By signing this form, 1 hereby certify that the well(s) was (were) constricted in accordance
with 15A NCAC 02C .0100 or 15,4 NCAC 02C.0200 Well Construction Standards and that rt 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 followi CEIVED/NCDENR/pyyR
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b, For Injection Wells: th �ddiiionto Zn2QgMe fonn to the address in 24a
above, also submit one copy of this form within 30 days of completion of well
construction to the followin
water Quaiity Reg
Division of Water II��e�s�ouQ�lfaeti Sgr &lion Control Program,
1636 Malniklillt Rt$tegeigf Ce7699-1636
ci 24c. For Water Supply & 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.
x1 0 le 2017
1rifnrm
r Proc6Syfflg Unit
06-30-2017
Fonn G W-1
North Carolina Department of Environmental Quality - Division of Water Resources
Revised 2-22-2016

WELL CONSTRUCTION RECORD (GW-1)
1. Well Contractor Information:
James R. Williamson
Well Contractor Name
4251-B
NC Well Contractor Certification Number
Geological Resources, Inc.
Company Name
2. Well Construction Permit#: Not Required
List all applicable well construction permits (r'.e. UIC County, State, Variance, etc.)
3. Well Use (check well use):
Water Supply Well:
_ + Agricultural
Geothermal (Heating/Cooling Supply)
Industrial/Commercial
Irrigation
Non -Water Supply Well:
X' Monitoring
Injection Well:
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
Experimental Technology
Geothermal (Closed Loop)
Geothermal (Heating/Cooling Return)
°Municipal/Public
°Residential Water Supply (single)
°Residential Water Supply (shared)
()Recovery
°Groundwater Remediation
°Salinity Barrier
QStormwater Drainage
°Subsidence Control
°Tracer
°Other (explain under #21 Remarks)
4. Date Well(s) Completed: 06-07-20 1 7 Well ID# RW-3
5a. Well Location:
Speedway #8268 0-0035167
Facility/OwnerName Facility Mt/ (if applicable)
6999 US Hwy. 70 E. Newport, NC
Physical Address, City, and Zip
Carteret 633820808532000
County Parcel Identification No. (PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
34.776957° N 76.872396°
w
6. Is(are) the well(s)4X Permanent or Temporary
7. Is this a repair to an existing well: Oyes or XQNo
If this is a repair, fill out known well consintction information and explain the nanrre 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-1 is needed. Indicate TOTAL NUMBER of wells
drilled: n/a
9. Total well depth below land surface: 12
For multiple wells list all depths ifderent (example-(ft.)
( p 3@200'and2t(-dlo0')
10. Static water level below top of casing: 8.14
If water level is above casing, use "+"
11. Borehole diameter: 12 (in.)
12. Well construction method: Rotary Hollow Stem Augers
(i.e. auger, rotary, cable, direct push, etc.)
(ft.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm)
13b. Disinfection type:
Method of test:
Amount:
Fenn GW-t
North Carolina Department of Environmen
For Internal Use Only:
4: WATER ZONRS
ROM TO
8.14 H•
I& OUT
FROM
6.INN
ROM
0
ft.
12
CA
TO
for lined
444854
and wells OR
DIAMETER
ft.
ER
Cab
Print Form,
in.
11111111111111111111
eottiermal¢lesed-too,
DIAMETER
R CASING OR TUB
ft
TO
2
ft.
17, SCREEN+
FROM TO
2
ft.
S. GROUT
FROM
0.5
1
12
0
0
0.5
ft.
9• SAND/GRAY
FROM
12
TO
4
iu.
In,
THICKNESS
Schd. 40
DIAMETER SLOT SIZE
4 1n' 0.010
f.
f.
ft.
PAC
R.
1 ft.
ft.
in.
MATERIAL
Concrete Grout
Bentonite Chips
cab
MATERIAL
2 Sand
INNEN
-kaTiann
-
THICKNESS
Schd. 40
EMPLACEMENT METHOD & AMOUNT
Pour
EMPLACEMENT METHOD
Pour
20. DRILLING LOG attach(addifonal'sheets If necesse
FROM TO DESCRIPTION eotor, hardness, soWrock am
0 °' ft• Concrete
0.3 .• ,¢ Brown fine sand
2
ft
ft
ft.
R.
ft.
21.REMARRS
22. Certification:
ft.
R.
t.
Blue
ature of Certified Well Contractor
0.3
2
12
a
re silt
aisa
0 2017
06-30-2017
Date
By signing this form, I hereby cer¢fj that the well(s) xis (mere) constructed in accordance
with ISA 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��re tss®
You may use the back of this p: s,: !N, , 1l(/De Il
e construction details. You may also attach additional pages if necessary. or well
SUBMITTAL INSTRUCTIONS JUL 1 7 2017
24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Resoutc
1617 Mail Service.Ce
246. For Infection Weill: In addition to sending the form to the address in 24a
above, also submit one copy of this fonn within 30 days of completion of well
construction tothe following:
Division of Water Resources, Underground Injection Control Program,
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 fonn within 30 days of
completion of well construction to the county health department of the county
where constructed.
tal Quality - Division of Water Resources
uality Regional
t78fita cititi ®Essing Unit,
FineNADDitleer
Revised 2-22-2016

WELL CONSTRUCTION RECORD (GW-1)
1. Well Contractor Information:
James R. Williamson
Well Contractor Name
4251-B
NC Well Contractor Certification Number
Geological Resources, Inc.
Company Name
Required
2. Well Construction Permit #: Not Re q
List all applicable well construction pennies 7.e. UIC, County, State, Variance, etc.)
3. Well Use (check well use):
Water Supply Well:
3Agricultural
Geothermal (Heating/Cooling Supply)
Industrial/Commercial
{Irrigation
0Municipal/Publc
Residential Water Supply (single)
Residential Water Supply (shared)
Non -Water Supply Well:
X Monitoring %®Recovery
Injection Well:
]Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
aExperimental Technology
,Geothenal (Closed Loop)
1Geothermal (Heating/Cooling Retum)
OGroundwater Remediation
o Salinity Barrier
0 Stonnwater Drainage
OSubsidence Control
0Tracer
Other (explain under #21 Remarks)
4. Date Well(s) Completed: 06-07-2017 Well no RW-2
5a. Well Location:
Speedway #8268
0-0035167
Facility/Owner Name Facility ID# (if applicable)
6999 US Hwy. 70 E. Newport, NC
Physical Address, City, and Zip
Carteret
633820808532000
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one tat/long is sufficient)
34.776957°
N 76.872396°
W
6. Is(are) the wel(s)DPermanent or OTemporary
7. Is this a repair to an existing well: QYes or X®No
If this is a repair. fill out/mown well construction information and explain the nature of the
repair under 1121 remarks section or on the back of this form.
8. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
constmction, only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled: nla
9. Total well depth below land surface: 12
For multiple wells list all depths ifd erent (example- 3@200' and 2 a.100)
10. Static water level below top of casing: 6.93 (ft)
f water level is above casing, use "+"
11. Borehole diameter: 12
(in.)
12. Well construction method: Rotary Hollow Stem Augers
(ft.)
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
Print Form
For Internal Use Only:
444853
14. WATER ZONES
FROM
TO
DESCRIPTTON
6.93 ft.
12 ft•
Saturated
ft.
ft.
15. OUTER
FROM
CASING (for
TO
multi -cased welts)
DIAMETER
OR LINER (if applicable)
THICKNESS MATERIAL
ft.
ft.
In.
1
16. INNER
CASING OR TUBING
(geothermal closed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
0 ft
2 ft.
4 i°
Schd. 40
PVC
ft.
ft.
in.
17.SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
2 ft
12 ft
4 in'
0.010
Schd. 40
PVC
ft.
ft
In.
PROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
0.5 ft•
0 ft•
Concrete Grout
Pour
1 ft.
0.5 ft.
Bentonite Chips
Pour
R.
ft.
19.I:SAND/GRAVEL
PACK
(tf appieable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
12 R•
1 ft
#2 Sand
Pour
ft.
ft.
20 DRILLING
LOG (attach
additional sheeis.Ituee scary)
FROM
TO
DESCRIPTION (color, hardness, sod/rook type, grain size, etc.)
0 ft•
0.3 ft.
Concrete
0.3 ft.
2 ft.
Brown fine sand
2 ft•
2.5 fL
Tan -grey silty clay
2.5 ft.
10 ft•
Black silt
10 ft.
12 ft•
Blue -grey silt
ft
ft.
aa gg
C: E \/ E
')
ft.
ft.
..
21.REMARKyy 11 ttq as--ss
S -... 0.7
JUIs LO,/'
;nforpnation Proc GSTIQ Jogt
22. Certification:
n 4 7Z.1/, rb e:f
S'411.392e
' ature of Certified Well Contractor
06-30-2017
Date
By signing this form, 1 hereby certify that the well(s) was (were) constructed in accordance
with 15A NCAC 02C .0100 or 15,4 NCAC 02C .0200 Well Construction Standards and that rt
copy of this record has been provided to the well owner.
23. Site diagram or af�l1� r w
You may use the backiaili Arm'(; it«3f&i well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTRUCTInt 1.7 2017
24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
,g0na1Division of Wa�n4on Processing Unit,
1617 Ma' eR7699-1617Ilminone
24b. For Infection Wells: In addition to sending the form to the address in 24a
above, also submit one copy of this fonn 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 & Infection Wells: In addition to sending the fonn 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.
Fonn GW-1
North Carolina Department of Environmental Quality- Division of Water Resources ' Revised 2-22-2016

(;1��z
WELL CONSTRUCTION RECORD (GW-1)
1. Well Contractor Information:
James R. Williamson
Well Contractor Name
4251-B
NC Well Contractor Certification Number
Geological Resources, Inc.
Company Name
2. Well Construction Permit #: Not Required
List all applicable well construction permits a.e. UIC. County, State, Variance, etc.)
3. Well Use (check well use):
Water Supply Well:
QAgricultural
OGeothermal (Heating/Cooling Supply)
E3Industrial/Commercial
fl Irrigation
Non -Water Supply Well:
Monitoring
f MunicipaVPub)ic
Residential Water Supply (single)
QResidential Water Supply (shared)
Injection Well:
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
fEz
Recovery
lGroundwater Remediaticn
Salinity Barrier
Stonnwater Drainage
perhnental Technology l Subsidence Control
RGeothennal (Closed Loop) OTracer
Geothermal (Heating/Cooling Return) nOther (explain under #21 Remarks)
4. Date Well(s) Completed: 06-07-2017 Well ID# RW-1
5a. Well Location:
Speedway #8268
0-0035167
Facility/Owner Name Facility ID# (if applicable)
6999 US Hwy. 70 E. Newport, NC
Physical Address, City, and Zip
Carteret 633820808532000
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
34.776957° N 76.872396°
6. Is(are) the well(s)Ex Permanent or CITemporary
7. Is this a repair to an existing well: EjYes or x®No
If this is a repair, fill out known well construction information and explain the nature of the
repair under #17 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: n/a
9. Total well depth below land surface:
For multiple wells list all depths if different (example- 3 a 200' and 2@100')
10. Static water level below top of casing:
If water level is above casing, use "+"
11. Borehole diameter: 12 (fn.)
12. Well construction method: Rotary Hollow Stem Augers
12
7.36
(i.e. auger, rotary, cable, direct pusls, etc.)
For Internal Use Only:
Print Form `.
444852
14. WATERZONES
FROM
7
ft
12 ft I Saturated
TO DESCRIPTION
ft.
15. OUTER CASINO (for mold -cased wells) OR LINER (Rap Reable)
FROM TO DIAMETER THICKNESS g MATERIAL
n
16. INNER CASING OR TUBING (geothermal elose4-loop) .
FROM TO DIAMETER
R.
0 B.
ft.
FROM
2 rt
R.
FROM
0.5 R.
1
fa
ft
2
TO
12 H•
ft.
TO
ft.
0 f.
0.5
ft.
4
DIAMETER
4
in.
in.
MATERIAL
In.
in.
in.
THICKNESS
Schd. 40
SLOT SIZE
0.010
Concrete Grout
Bentonite Chips
19. SAND/GRAVEL PACK(ifapplicable)
TO
FROM
12
ft.
ft.
MATERIAL
#2 Sand
MATERIAL
PVC
THICKNESS
Schd. 40
MATERIAL
PVC
EMPLACEMENT METHOD & AMOUNT
Pour
Pour
EMPLACEMENT METHOD
Pour
20.DRILLING `LOG (attach additional sheets if necessary) '
FROM TO DESCRIPTION (color, hardness, soil/rack
type, grain sift, arc.)
Concrete
0 m
0.3 rc
1 ft.
1.5 ft
4 ft
10o ft
ft
0.3 R.
1
1.5 R.
4
10 ft
12 ft'
R.
22. Certification:
Tan fine sand
Grey fine sand
Brown fine sand
Black silt
Blue -grey silt
Signature of Certified Well Contractor
IUL 0 a 2017
nagorra
Rtcuti
06-30-2017
Oral
Date
By signing this form, I hereby cert(fy Mat 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 additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTRUCTIONS
(ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
(ft.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center,ff.n�ppRl�a�le�i�g9h, NCp27699-1617
246. For Infection 4{$B ' idPg19Rh95 !lk form to the address in 24a
above, also submit one copy of this fonn within 30 days of completion of well
construction to the followinIgI:(I II yy yy (7�17
Division of Water Resd6fles,4)IAIe1�gYU nd Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water SuppWAPIttielItilidSliOlheilddition to sending the fonn to
the address(es) above, appissa)tf@W9tgegtasnof this form within 30 days of
completion of wellWPjFll'titilm11ti24(,riepaltDlPkaUh department of the count
where constructed. y
1
Fonn GW-I
North Carolina Department of Environmental Quality - Division of Water Resources
Revised 2-22-2016

WELL CONSTRUCTION RECORD (GW-11
For Internal Use Only:
•444789
1. Well �Contractor Information:�
Well Contractor Name
2-q6 it
NC,y4ell Contractor nifice i nn Num
I tip/
Company Name 2. Well Construction Permit #: 2 2_& 3 9/
List all applicable well construction permits ('.e. UIC, County, State, Variance, etc.)
3. Well Use (check well use):
Water: Supply Well:
QAgrieultural QMutricipaFPublic
['Geothermal (Heating/Cooling Supply) DResidential Water Supply (single)
j-tdustrial/Commercial DResidential Water Supply (shared)
i Tigation
(Non -Water Supply Well:
['Monitoring ['Recovery
Injection Well:
['Aquifer Recharge ['Groundwater Remediation
['Aquifer Storage and Recovery ['Salinity Barrier
QAquifer Test ['Stormwater Drainage
[Experimental Technology ['Subsidence Control
['Geothermal (Closed Loop) ['Tracer
['Geothermal (Heating/Cooling Retum) "Other (explain under 421 Remarks)
4. Date Well(s) Completed: 6-I it / I /} Wen ID#
5a. Well catiolp
r�Lx4e
Facility/Owner Name
/ =3 iSlit ckkie
Physi Add ^Ci`ty, and Zip
Faeiii ID# Of applicable)
h%- CI dui;&4. »e
County - Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwellfield,, one lav/longjis sufficient) '`� -T Ogg
3Y®`C/1/lik It N 76 8,9-4 / O.'. '% r
6. Is(are) the well(s) ermanent or ['Temporary
7. Is this a repair to a existing well: ['Yes or No
If this Isn repair, fill out known well construcdon information a d explain the nature of the
repair under #2) remarks section or an the back of this farm
8. For Geoprobe/DFT or Closed -Loop Geothermal Wells having the same
construction, only 1 GW-1 i e eee#d. Indicate TOTAL NUMBER of wells
drilled: 0A
9. Total wen depth below land surface:
For multiple wells list all depths ifdi_Qerent (example- 3Q200' and 2Q/00)
(ft.)
10. Static water level below top of casing:. C-> (ft.)
If water level Is above casing, use "+"
11. Borehole diameter: 7 .- ' b (in.)
12. Well construction method:
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm)
136. Disinfection
t4. COATRR
FROM
TO
DESCRIPFON
l f ft.)
( fL
!j( �)
fL
fL
15. OUTER CASINO (for multi -cased wells) OR MNIR (ifap &Dole)
PROM
TO
DIAMETER
THICKNESS MATERIAL
ft.
ft.
in.
16.INNNER CASING OR`fvffNG (geothermal clesedrloop) ->
FROM
O
DIAMETER
THIC„ ESS,
MATERIAL
/
1 0
L-
it
ft.
( in,
17.SCEEEN
FROM
TO
DIAMETER
SLOT SIZE
TRICCXNIp/SqS
MATERIAL
/3(?J.
/S(1ft.
P6 in.
2 t�
,C/
vL
ft.
fL
in,
18. GRPUT
FROM
TO
MATE-
L
EMPLACEMENTMTROO &AMOUNTd
i
4'
fL
ft^
i
fL
ft.
a. SAND/GRAVEL
PACK
Of applicable)
FROM
TO
MATERIAL
EMPL CEMENT METHOD
7 ft
/ r/
7
jj ft
s..
�7 iYt
(-1 (J
ft.
ft.
20, »NIt,LING
LOG(attach
additional sheets if gece Wry)
FROM
TO
DESCRIPTION (color, hardness, soil/rock type, grain size, etc.)
TA, fL
VV ft.
,-
eyt.
/ ) ft.
,oft.
(
G (ia'•k
ft.
/ 3
ffy
GI. %4T"�
f 5t•
IITYL
ptrc
ft.
ft.
> yp� 1yf F )
fL
fL
JUL 0 3 2017
2t. REMARKS
4matlOft PrOCeee&ng UM?
22. Certification:
e fin
edified Well Contactor
Date
flf signing this farm, I hereby certify that the well(s).was (were) constructed in accordance
with 15A NCAC 02C .0100 or ISA NCAC 02C .0200 Well Cans:ruction Seandankv 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, Ral46B ENR/®WR
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 following:
JUL 10 2017
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Ralei C 27699-1636
Maier Quality Regional
Method of test: /a 24c. For Water Snppiv &Iniection Wells: In ,4hstjtNfttDnSIetbfl form to
C,-y/rhe address(es) above, also submit one copWdfldeigtO>RItRLrgjfti.tannicin of
Amount: / `-%s - <.� completion of well construction to the county health department of the county
where constructed.
5
Form GW-1
North Carolina Department of Environmental Quality - Division of Water Resources Revised 2-22-2016

WELL CONSTRUCTION RECORD (GW-1)
1. Well Contractor Information:
5454c P, rrno ` ,J
Well Contractor Name
NC Well Contractor Certification Number
9-nla oat < >�t Lt i G-
Company Name ],0 2. Well'. Construction Permit /1: -17d
List all applicable well construction permits (i.e. UWC, County, State, Variance, etc.)
3. Well Use (check well use):
Water Supply Wel:
jAgrioultural
Geothermal (Heating/Cooling Supply)
D industrial/Commercial
1nigation
Non -Water Supply Well:
Monitoring
Injection Well:
QAquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
fExpdrimental Technology
DGeothermal (Closed Loop)
Geothermal (Heating/Cooling Return)
4. Date Well(s) Completed: 6.-Z2-
unioipal/Public
sidential Water Supply (single)
}Residential Water Supply (shared)
Recovery
DGroundwater Remediation
Salinity Barrier
fStormwater Drainage
Subsidence Control
Tracer
Other (explain under #21 Remarks)
�7 Well TM
5a. Well Location:
K41e) a� -n_ 1G
Facility/Owner Name Facility 1D11 (if applicable)
t 15 Nor UK Ll J wtc Bete+jet- p --
Physical Address, City, and Zip
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one latflong is sufficient)
39°I/3'149. 4/2 t' N77e03'32-1el& i I w
6. Is(are) the well(s) ermanent or Temporary
7. Is this a repair to an existing well: ties or VINo
Ifthis is a repair, fill out known well construction information a d explain the nature of the
repair under 121 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 i nee Indicate TOTAL NUMBER of wells
drilled: Z24u
9. Total well depth below land surface: 2 / D (ft.)
For muliipie wells list all depths ifdifferent (example- 3@200' and 2@1001)
10. Static water level below top of casing: /7i 0 (ft.)
lfwater level Is above casing, use "+"
11. Borehole diameter: - V
12. Well construction method:
(in.) y.,p
(i.e. auger, rotary, cable, direct push, etc.)
FOR. WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) , / Q p� Method of test:
136. Disinfection type:C�1 /O t/, t Amount:
2.0 n
For Internal Use Only:
444788
Print Form;
14.WATER ZONE'S
FROM
TO
DESCRIPTION
1 loft.
2 f 0ft.
11
�. T
ft.
ft.
is,AUTER
CASING (for nmlti-Faked wells) OR LINER (if ap Gentle)
FROM
TO
DIAMETER
THICKNESS MATERIAL
fl.
ft.
in.
16. INNER
CASING OR TUBING
: (geothermal closed -loop)
FROM
TO
WAMETER
TTRIO/QEASS
MATE IIA/L
G fL
j 9 ;7 ft'
( ii
^-./]/' in.
�)
5 C-f 7V
V C
ft.
ft.
in.
17SCREEN
..... r
FROM
TO
DIAMETER
SLOT SIZE
TRICKIVESS
MATERIAL
ig'
7(r
1f.0
2-0
504 c
p� C
in.
IP:CROUT
TO
EMPt(F(i.e
AMOUNT//
/�M ft.
�J
rc# ft.
,'--ra,-
TXNI�©%
,i d__
/�!�
ft.
ft.
D.
19:: SAND/GRAVEL.. PACK
(if applicable)
FROM
TO
MATERIAL
EMPLACES METHOD
(1011.
Z' ° ft.
,,..
-,/d riel-
(MENT 0.---
Poore
rt.
ft.
XI. DRILLING
LOG (atta
h additional sbeets if necessary)
FROM
TO
DESCRIPTION (color, hardness, soiVrok type, gin airy etc.)
0 R.
()fL
2„
/
r"1 ftt.
i3. ft.
1f�2.��L
< -ram
'r
f
b
/5
/ 9d ft.
,A.. i"'/✓J e 5Are (/y C.G
64
IQ b ft.
ft.
/
ft.
ft.
R.
rt.
RFC
®i
2L:REMARKS
JUL 0 3 2017
22. Certification:
GC.G
-01/9 f ltfti 26-/7
of Certified Well Contractor Date
By signing this form, 1 hereby carts that ibe we/l(s) was (were) constructed In accordance
with ISA 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,
1.617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Iniection.Wells: In addition to ®o c 8Lip 24a
above, also submit one copy of this form within 30rla s T well
construction to the following:
Division of Water Resources, UndergroundiWictirjn Qoa9fpl 'program,
1636 Mail Service Center, Raleigh, Nt 2169946n//
24c. For Water Supply & Injection Wells 1 addition to sending the form to
th address(es) above, also submit one coy PrtWiaip(H('Ragbag days of
completion of well construction to the COHR g t t ?Sr&e4u ad the county
where constructed. figs{(onRRegional Office
Form GW-I
North Carolina Department of Environmental Quality - Division of Water Resources Revised 2-22-2016

Print Form
WELL yONSTRUCTION RECORD (GW-1)
1. wstrantractor Information:
rfit5ex/J P. ` 460Ni
Well Contractor Name
2gi53-A-
NC Well Contractor Certificati�pn Number
1 I I�r�-fv/U k ILL I it)
Company Name
2. Well Construction Permit#:
a 3 v-i- 3 I
List all applicable well construction permits (I.e. 111C, County, State, Variance, etc.)
3. Well Use (check well use):
Water Supply Well:
Agricultural
Geothermal (Heating/Cooling Supply)
Industrial/Commercial
rrigation
Non -Water Supply Well:
1 Monitoring
Injection Well:
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
Experimental Technology
Geothermal (Closed Loop) f Tracer
Geothermal (Heating/Cooling Retum) nOther (explain under #21 Remarks)
4. Date Well(s) Completed: 6-7- 11 Well ID#
[3Municipal/Public
Residential Water Supply (single)
Residential Water Supply (shared)
DRecovery
5a. Well Location:
Groundwater Remediation
(Salinity Barrier
r3Stormwater Drainage
DSubsidence Control
P1ca/Lq�J Racie,LX.
Facility/(honer ame Facility ID# (if applicable)
9()P (? Litif CT tyP(
Physical Address, City, and Zip
GRY--Fe r
County Parcel Identification No. (PM)
5b. Latitude and longitude in degrees/minutes/secondsor decimal degrees:
(if well field, one latilong is sufficient)
3 I%n121,2-/ N7%bOli/ tSC0V li W
6. Is(are) the well(s) Permanent or Temporary
7. Is this a repair to an existing well: QYes or No
If this is a repair, fill out known well construction information d explain the nature ofthe
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 i3. seeded. Indicate TOTAL NUMBER of wells
drilled: /`7
9. Total well depth below land surface: (/5 0
For multiple wells list all depths if different (example- 3Qa 200' and2@l00)
10. Static water level below top of casing:
If water level is above casing, use'1-" 7
11. Borehole diameter: 7 4 (in.)
12. Well construction method:
(i.e. auger, rotary, cable, direct push, etc.)
For Internal Use Only: 4 4 4( 0 (
19. WATER ZONES
FROM
TO
DESCRIPTION
/
f So ft.
J
- c ,L6yg C
ft.
H.
15. OUTER CAM (for
multi -cased wells) OR LINER (if applicable)
FROM
TO
DIAMETER
THICKNESS I MATERIAL
ft.
ft.
in.
16IN
CASING OR TUBING
(geothermal closed -loop)
FROM
TO
DIAMETER
THICKNESS.
MATERIAL
/ ft
ft
16
l� in.
/
r l 1 e
r,
P�(r
( ft.
ft.
III
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MAT RIAL
/3, ft.
/5Uft.
/ ( in.
`_�
.a 0
5a'
ie
,yy L.-
ft.
ft.
in
18. GROUT
FROM
TO
IAL
EMPLACEME METHOD & AMOUNT
0 fL
.00 ft.
ppMATEE
/7`pi IGfoie---'
Post re d 30 '4
ft.
ft.
19. SANK/GRAVEL
PACK
(if applicable)
FROM
TO
MATERIAL
EMPLACEMENT METH D
o
'I'INNd
/Soft.
/52 ft.
5itNd
fR
ft.
20. DRILLING
LOG (altacp
additional shee if necessary)
FROM
TO
DESCRIPTION DESCRIPTION (color,�soilrock type, grain ¢is, etc.)
© ft.
L) ft.
E
^hardness,
SN -1 &--
von..
st, ft.
5 eri dv CZ, t4-la- -'
ft.
ft.
_
ft.
ft.
!�.?
£L
pEiv-a.
e��glg^�
1111�''
21. REMARKS `::: JUL 03'201(
- - I Iy
�, a�3binA
in+'s „,.=t'Dnti
wf46QG
22. Certification:
a/&
of Certified Well Contractor
igning this form, L hereby certt& that the well(s) was (were) constructed in accordance
with 15,4 wc:AC 02C .0100 or I5A N(]AC 02C.0200 Well constmction Standards and that a
copy af 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
constmction details. You may also attach additional pages if necessary.
SUBMITTAL INSTRUCTIONS
(ft.) 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: 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:RECEIVED/NCDENR/DWR
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Ralelilglh, NC 27699-1636-1
24c. For Water Sunni)/& Iniection We11s:J)n �dd$idri 12al ling 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 h department of the county
where constructed. to W .Y Regional
Operations Section
Wilmington Regional Qatf 22-2o16
(ft.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) 51) Method of test:
13b. Disinfection type:/ it 10 l2, i /t+ Q--• Amount:
tT I )i
rt.er
Fonn GW-1
North Carolina Department of Environmental Quality - Division of Water Resources

WELL CONSTRUCTION RECORD (GW-D
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 #:
List all applicable well construction permits (i.e. UIC, County, State, Variance, etc)
3. Well Use (check well use):
232382
Water Supply Well:
Agricultural
Geothermal (Heating/Cooling Supply)
DMunicipal/Public
Residential Water Supply (single)
Industrial/Commercial DResidential Water Supply (shared)
Irrigation
Non -Water Supply Well:
Monitoring
()Recovery
Injection Well:
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
Experimental Technology
(Groundwater Remediation
()Salinity Barrier
DStoriuwater Drainage
()Subsidence Control
Geothermal (Closed Loop) [Tracer
Geothermal (Heating/Cooling Return) . ()Other (explain under #21 Remarks)
4. Date Well(s) Completed:6/14/17 Well Mg N/A
5a. Well Location:
Kerri Quispe
N/A
Facility/Owner Name Facility 1D# (if applicable)
105 Sweet Grass Trail, Cedar Point, NC 28584
Physical Address, City, and Zip
Carteret 537411662795000
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient).
3441 16.2 N 77 04 56.0
W
6. Is(are) the well(s)JPermanent or OTemporary
7. Is this a repair to an existing well: (Yes or No
!(his is a repair; fill out known well construction information and explain the nature of Me
repair under #11 remarks section or on the back ofthisfone.
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: t
9. Total well depth below land surface: 120
For multiple wells list all depths if different (example- 3@200' and 2@l001)
(ft-)
10. Static water level below top of casing: 14 (ft.)
If water level is above casing, use "+"
11. Borehole diameter: 8 (in.)
12. Well construction method: Mud Rotary
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) 80 Method of test: Airlift
13b. Disinfection type: HTH Amount: 3% @ 10 gallons
For Internal Use Only:
444786
1 !elr,l e. V1;11,
14; WATER ZONES
FROM
TO
DESCRIPTION -
ft.
B.
ft.
ft.
15. OUtER
CASING (for
multi eased wens) OR LINER (ifa limbic)
FROM
TO
DLNIETER
TRICKINESS MATERIAL
0 tt•
100 ft'
4 'n•
SCH40 PVC
16.;INNER
CASING OR TUBING
(geothermal closed -loop) .,
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft
R
in
ft.
ft
in
17..SCREEN . '..
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
tt.
ft
in.
ft
ft
in.
18:'GROUr
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
0 fp
21 ft
Bentonite
Poured
90 ft
95 ft.
Grout
Poured
ft
ft
19. SAND/GRAVEL
PACK
(if _
FROM
TO
MATERIAL
EMPLACEMENT METHOD
95 ft
120 h•
Coarse
Poured
ft.
ft
2l).pRILL)NG.
LOG (attach
additional sheetiirnecessary) ,.
FROM
TO
DESCRIPI'ION (color, hardness, sol/roek type, gain sizes ete.)
0 ft'
15 tt.
Reddish orange sand (shells @ 10')
15 ft•
75 ft
Cray clay with shells
75 ft'
90 ft
Green Clay
90 ft.
120 tt•
Sandy limestone
ft
R•
wErEIVED
ft.
ft.
rt.
ft.
3
zI:RE ntARxs JUL- Q 2Q17
Presdin&n l IzA9
nlsvrms ten
DWQ/ICQi
22. Certification:
1Q-4A-u/(4-((°
Signature of Certified Well Contractor
06/26/17
Date
By signing this form, I hereby ceutfy that the wells) was (were) cant ,cted 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 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, Raleigh, NC 27699-1617
24b. For Infection Wells: In additi
above, also submit one copy of this
construction to the following:
•
'1
44
-10
,a*dress in 24a
n tion of well
Division of Water Resources, Undergrgpppi�d I%e I4l gntrol Program,
1636 Mail Service Center, leigh, 2- r ^ -1636
24c. For Water Supply & Infection Wells: In additiopln,,t,o,�sending the form to
rena the address(es) above, also submit onW509CaalitY lallin 30 days of
completion of well construction to the c tyataraff d t of the county
where constructed. Wilmington Regional trice
Form OW-1 North Carolina Department of Environmental Quality- Division of Water Resources
Revised 2-22-2016

WELL CONSTRUCTION RECORD (GW-1j
Print Form
For internal Use Only:
t. Well Contractor Information:
•A5.0-41 e- )n&z44
Well Contractor Name
29 53 - /44
NC Well Contractor unification umber
ft- ki 1Lg N G-
23472S
Ds( all applicable well onn,n ,,titan permlrr (,r (SC Gmniy, State Varimme, e
Company Name
2. Well Construction Permit
3. Well Use (check well use):
Water Supply WeII:
DAgricultural DMunicipal/Public
Geothermal (Heating/Cooling Supply) Dhesidential Water Supply (single)
Industrial/Commercial ['Residential Water Supply (shared)
Irrigation
-Water Supply Well
Monitoring Recovery
Injection Well:
Aquifer Recharge
Aquifer. Storage and Recovery
Aquifer Test
Experimental Technology
Groundwater Remediation
fl Salinity Barrier
DStormwater Drainage
Subsidence Control
Geothermal (Closed Loop) QTracer
Geothermal (Heating/Cooling Return) FlOther (explain under 421 Remarks)
4. Date Well(s) Completed: %6-/ 7 Well IDH
5a. Well Location:
S-1-10 0 eau 6. ei e
Facility/0 ner Name Facility !DM(ifapplicable)
5/oq "ep/IyG�t/ in /1-C N
Physical Address, Cirf> id -Lip
C-.9D240 e 'r
County - - Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds-or decimal degrets.
(if well field. one Iva/long is sufficient)
,34 ° 43 Jr 5
5ssa ItPermanent
76' Ili yl, z5 a W
6. Is(are) the weR(s)ttt���ssfPermanent or [Temporary
7. Is this a repair to on existing well: Yes or f�]yygq,�yrrj No
If this is n repair,fill aout o 11 construction information afrh rplatn rhe,lamre of the
repair der 1121 remarks section or on the back of this form
8. For Ccoprohe/DPT or Closed -Loop Geothermal Wells having the same
construction, only I GW-Iis needed. Indicate TOTAL NUMBER of wells
drilled: 0,„.; edhh
9. Total well depth below land surface: /.e
For multiple wens fist all depths if different (exempt e- 3@r 200• and 2@iMY)
10. Static water level below top of easing:
If water level is chain coxing; use "-I_"
11. Borehole diameter: / 8 (in.)
12. Well construction method: A ,,,///
CI I t_r'f �
(i.e. auger. nitary, cable, direct push, etc.) /
(ft.)
(ft.)
FOR WATER SUPPLY
WELLS ONLY:
13a, Yield (gpm✓) J/ Method of test: Z. 24c For Venter Snonly & Iniection Wells: In addition to sending the for�p
m to
address(es) above, also submit one copy of this form within 30 days of
136. Disinfection Mpe 1�- -- Amount:. / r7S completion. of well construction to the county health department of the county
where constructed.
444557
14. WATER ZONES
FROM Ir0
DESCRIPTION
/bp ft
/4°ft.
i
15. OUTER CASING (for
multieased wails) OR LINER (if ap limbic)
FROM TO
DIAMETER
THICKNESS MATERIAL
ft. fe.
in.
16. INNER CASING OR TUBING
(geothermal closed' loop).
FROM TO
DIAMETER
TIM(CI(rvESS
MATERIAL
1 fr. // rt.
W
JLJt �O
, lc/
V
rt. R.
17: SCR GEN
1 ID..
FROM
TO
OIAMET
DIAMETER
SI.OTPSIZE
THIi(CJ(NESS)4O
MATERIAL
/40f1,
lb in
18, GROUT`
FROM
TO
'&4t€/
MATE�`IIAL
EMPLACEMENT( ETIIOD & AMOONT
p,,,„, po4v2.
0 ft-W
19.SAND/G
RAVEL PACK
rfapplicable)
FROM
TO
MATERIAL
EMPLACEMENT MET OD
/6V
/ e D
a{7 5,44-
(loose ei
ft
R.
20. DI211.LINC
LOG (atta'
1/ additional sheets if necessary)
FROM
TO
DESCRIPTION (colnrh dness saiUrsck type, grain nu, etc.)
p R .
?S n.
y ft.
/D 0 rt.
)0D ft
/bpft
/b0 re.
u ft.
a IVED
ft.
ft..
a
ft
JUN 2 6 2017,
2LRCMARKS
RNa'Radon PrueA4S4`s , UM
DUvrlf' O G
22. Certifjg&tion:
Si of Certified Well ntractor
Dt
By signing this fore, I hereby cart( that the walks) war (were) constructed in accordance
with l SA NC'AG 02( 0100 or 15A NCAC 02(.0200 Well Conswncilon Standards and that a
copy of this record has been provided la 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.
SUBMITTAI INSTRUCTIONS
24a. For All Wells: .Submit this .form w( in 30 days of completion of well
construction to the following: ggECEIVE'®/OIM9fIC91p DWR
Division of Water Resources, Information Processing Unit,
Il
1617 Mail Service Center, Raleigh, NCI'276p999-1617
24b. For Injection Wells: In addition to sendingaordf 302 alth ess in 24a
above, also submit one copy of this form within 30 days of completion of well
construction to the following:
Form GW.I
Water auk p$t 6(yThm,
Division of Water Resources, Ilnderground�yYal its 1L
1636 Mail Service Center, �I in d •
n - tsOn
n •eglonal /f
North Carolina Department ofEnvironme dal Quality - Division of Water Resources
Revised 2-22-2016

Print Fbrri
WELL CONSTRUCTION RECORD (GW-1)
1. Well Contractor Information:
37a P- 1,DPdb)
Well Contractor Name
NCfWell Contractor
�Certifies ion Number
s f
Company Name _
2. Well Construction Permit N: 2 % { 7
List all applicable well construction permits' Be, IBC, County, Stale, Variance, etc.)
3. Well Use (check well use):
Water Supply Well:
(Agricultural
Geothermal (Heating/Cooling Supply)
j1ndustrial/Commercial
igation
`Non -Water Supply Well:
jMonitoring.
Injection Well:
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
Municipal/Public
DResidential Water Supply (single)
DResidential Water Supply (shared)
Recovery
Groundwater Remediation
Salinity Barrier
DStonnwater Drainage
Experimental Technology 0Subsidence Control
3Geothermal (Closed Loop) OTracer
tGeothennal (Heating/CoolingRemm) Other (explain under N21 Remarks)
4. Date Well(s) Completed: 6 3(�1 ry Well IDN ' \
5a. Well Location: ii,, Aq /� J
�� f.�.L✓/tl'L ffl l
Facility/Owner Name Facility IDN (if applicable)
{T' eRetke S
;;Qat (OLL1/1di.Lb/1 Nc /U r✓
Physical Addres ,City, and Zip
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one let/long is sufficient)
r
3rf W1, 3.g3 N7h. 53,05" w
6. Is(are) the well(s) rfermanent or Temporary
7. Is this a repair to an existing'rWeii: ()Yes or
If this is a repair, fill our Mown well construction Information a d ceplain the nature of the
repair under N21 remarks section or on the back Wads 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; ear !Z ,pp
9. Total well depth below land surface: /Z3.0
For mtdtiple welly list all depths if different (example- 3Q200' and 2Q100')
10. Static water level below top of casing:
If water level is above casing„ use "+
11. Borehole diameter: 9 "7 .v (in,)
12. Well construction method:
(i.e. auger, rotary, cable, direct push, etc.)
(ft.)
(ft.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) ✓Y-) ©!! Method of test: jJ 1 /\
136. Disinfection type:.11 IQ ediUt Amount:
For Internal Use Only:
444556
I4, WAYKR20NRS t
FROM
TO
DESCRIPTION
/60 Tt
is? ft
�CyLk
tin-
ID
rt.
1S. ONfER
CASING (for multieased Wells) ORLI NEA Of ap aeabtO
FROM
TO
DIAMETER
THICKNESS g MATERIAL
fL
H.
in.
16, 1NNER
CASING OR TUBING(geothermal
closed loop)
FROM
TO
DIAMETER
TRICC ESS
MATERIAL
i ft.?.
b0 ft.
V in.
cc o
7 V
ft.
ft-
in.
I7.:gCRREN
FROM
TO
DIAMETER
SLOT SIZE
TBIC/{cairSSS
MATERIAL
ft•
Un-
_(
ft
in.
FR.: GRObIT
FROM
TO
MATERIAL-
EMPLACEM METHOD &AMOUNT
6 n.
2-p f•
',
fie t
�otre r •ra 116.s
.
m
fL
ft
/9, SAND/CRAYEL
RACK
(if applicable/
FROM
TO
MATERIAL
EMPLACEMENT METHOD
D ft
20 it
9
9a red
ft
FGRILLING
LOG (attach
additional sheets onecessary) :
FROM
TO
naSCRIPfiOor, ha new, sail/reek ryaeranin sing etc.)
n.
j/r} ft:
rt
/)� ft.
//'
ft
/ ft.
li
/07 ,�-r�
C.(,,
jib
6 h ft.
(fi'
/ rt.
/
?
((,/iJ gt,
ti,
n,
n,
ft
D
n.
ft
R C IE
21 REMARKS
6 201
JUN u67
Inse rwl Iron Procesetng Unit
22. Certification:
Fonn GW-I North Carolina Depart eat ofEnvironme gal Quality - Division of Water Resources
DWG/BOG
Date
By signb,g this form. / hereby cerg, that the wells) was (were) constructed In acdordance
with IBA //CAC 02C:0100 or iSA Wile 02C .0200 Well Construction Standardsold that a
copy of this record hay 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: ,�p
Division of Water Resourcel Q on Processing Unit,
1617 Mail Service Center, Ra lt4 2j�69�9-1617
24b. For Infection Wells: In addition to sending the fornf resslin 24a
above, also submit one copy of this forrp/4&'3hin 30 days of co of well
construction to the following: `` 99qq
Division of Water Resources, $4a rground Injecfiddmntrol Progrgm,
1636 Mail Suva!
Ct3 RRlei h, NC 27699-1636
24c. For Water Sunuly & Iniefi r ``�'Ur'U aiL. n to sending the £Orin to
the address(es) above, also submit SrfEr2a,MMo' within 30 days of
completion of well construction to the coun46partment of the County
where constructed. Ce
Revised 2-E-2016
®a

WELL CONSTRUCTION RECORD (GW-1)
1. Well Contractor Information:
P T.bc b l
Well Contractor Name
NC Well Contractor Certification umber
noi`DN N R11 l.! IJ G-
Company Name
2. Well Construction Permit it:
22-1 'f 75
List all applicable well construction permits (l.e. UIC, County, Stale, Variance, elc.)
3. Well Use (check well use):
Water Supply Well:
Agricultural
['Geothermal (Heating/Cooling Supply)
dustrial/Commercial
igation
Non Water Supply Well:
Monitoring
Injection Well:
Aquifer Recharge
Aquifer Storage and Recovery
®Aquifer Test
Experimental Technology
Geothermal (Closed Loop)
r Geotherrnar (Heating/Cooling Return)
4. Date Well(s) Completed:-.7Z 2 -
Sa. Well Location:
['Municipal/Public
DResidential Water Supply (single)
Residential Water Supply (shared)
['Recovery
['Groundwater Remediation
['Salinity Barrier
['Storrnwater Drainage
['Subsidence Control
['Tracer
['Other (explain under #21 Remarks)
l7Well ID#
acility/Owner Name Facility ID# (if applicable)
/712- &eon be r 61)c b Jsie t
Physical A[ddresss,jCity,, and CZip
County Parcel Identification No. (PIN)
$b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one Iat/long is sufficient)
3q ° ol v3r.5z ,r N7b°56 (12,19 ,/ W
6. Is(are) the well(sOP
)ermanent or ['Temporary -
7. Is this a repair to an existing well: ['Yes or No
If this is a repairfill out known well construction information ea u. plain the nature of the
repair under 1121 temerity section or an the back of this form.
8. ForGeoprole/DPT or Closed -Loop Geothermal Wells having the same
construction, only I GW-1 is n ode Indicate TOTAL NUMBER of wells
drilled:
9. Total well depth below land surface: (.d)
For malt/plc wells list all depths if different (example- 3@200 ' and 2@100')
10. Static water level below top of casing:
(/water level rs above casing. uusse"+"fj�
11. Borehole diameter: / J>
12. Well construction method:
(i.e. auger, rotary, cable, direct push, etc.)
(ff.)
FOR WATER SUPPLY WELLS ONLY:
i' `h^^
13a. Yield (gpm) ) Method of test:
p rOr'
136. Disinfection type 1f ia(l), V Amount: jrr� /'
For Internal Use Only:
444555
14. WATER ZONES a
FROM
TO
DESCRIPTION
210ft.
'3/6 ft.
'Week
ft
ft.
15, OUTER
CASING (for
ultt-cased wells) ORLIIVER (if MS
FROM
TO
DIAMETER
TRICENESS I MATERIAL
ft.
ft.
in.
16, INNER
CASING OR` TifdNG(gnothermal
elosedrlopu)t
FROM
DIAMETER
THICKNESS
MATERIAL
( ft
/TJO
L. /3 0 ft
q in.
.cGI 0
P G
ft.
l7. SCEEEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
MOIL
La/
'7j/) f4
7
14 in,
2- 0
se 1 tie)
✓ �7 `r'
pv-
Y Y'
ft
fe
in.
FROM
TO
MATERIAL
EMPLACEMENTMETHOD SE AMOUR')
f
Lt
e D,
t F,ute,
PtreJ /(
re.
ft
19. SAND/GRAVEL PACK
(if applicable).
FROM
TO
MATERIAL
SA-nal
EMPLACEMENTME'HOD
Prr u r e
:290 R.
3/0 D:
ft
ft
20, DRILLING
LOG (atta
h addition! sheets if neees@afy) 1: '
FROM
TO
DESCRIPTION (color, hardness, soiVrock type, earn Man etc.)
7) ft.
�d
`ill ft.
Sa u- 2.:.yf
ft
/to ft
Srek74 dy CLA-l.y-
/gift
��. D,.
(J/'
Z✓ 0 D:
z%/,(2 R•
Crrf-..Cy-. - Lc//')c. SA''t ci
z ft
3/ 0 ft
ft.
ft,
ft
ft
A
21. REMARKS .�n (.
..
JUN 2 6 2617
22. Certification:
Si of of Certified Well Contractor
cf�
ion Processing Unit�..
Date
•
signing this fon& 1 hereby cart& that the well(s) was (were) constructed In ac4ordence
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. i
SUBMITTAL INSTRUCTIONS
24a. for All Wells: Submit this form within 30 days of completion Of well
construction to the following:
Division of Water Re
1617 Mail Servic se
wink,
24b. For Iniection Wells: In addition to sending the form to the address! in 24a
above, also submit one copy of this foolni Fvithin 30 davy of completion of well
construction to the following: ll1lL V L171!
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service 4W(ift�triea�ft Eyyht91g11: ff eRIM36
24c. For Water Sanely & Inieggj���Qn`rPPa��f fph�alitlsending the form to
the address(es) above, also sow/rang G1g jIl(�r4 Qliin 30 days of
completion of well construction to the county health department of the bounty
where constructed.
Form OW -I North Carolina Department of Environmental Quality - Division of Water Resources
Revised 2-22-2016

WELL CONSTRUCTION RECORD (GW-1)
For Internal Use Only:
Ltf-444
Print Form
4440g
1. Well Contractor Informa/tiiii ': ((/^�{{��I / /JqJ�
i ec) I I9 e/2
Well Contractor Name
NC Well Contractor Cenifcation^mnber
viz
Comliany Name
2. Well Construction Permit /I: 2337
LW all applicable well 01.'I otion perrnlh (Le. (/1C County, Pate, Variance, etc)
3. Well Use (check well use):
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
DRecovery
Injection Well:
Aquiter Recharge
Aquifer Storage and Recovery
Aquifer Test
Experimental Technology
Geothermal (Closed Loop)
Geothermal (Heating/Cooling Return)
DGroundwater Remediation
D Salinity Barrier
DStormwater Drainage
D Subsidence Control
DTracer
DOther (explain under 421 Remarks)
4. Date Well(s) Completed: 5-2\, (7 Well ID#
So. Well Location:
DOUL - Cep t/
Facility/Owner qs
Name Facility IDk (if applicable)
IR) mW (L1» -►>a ,fifitkeitc r9t P
Physical Address, City, and Zip
County
Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one IaUleng is sufficient)
?ye'y2fy'S ,SS N 7b°3Sb/, az"
6. Is(are) the well(s)
ermanent or QlTeniporary
7. Is this a repair to a i existing well: El Yes or .1)q}'�t.1ffINo
if this is a repair, fill out know well construction information a/Nexplain the nature of the
repair under 1121 minority section or MI the hank of this %erne lfff
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: 4e---
9. Total well depth below land surface: Z O
For multiple wells Ida nil depthv if different (example- 3 n 200' and 2@100')
10. Static water level below top of easing: 2. C7
If water level is above casing, use •';...
11. Borehole diameter: / 11-3 (in.)
githfeeif
12. Well construction method:
(i.e. auger, rotary, cable, direct push, eta.)
(ft.)
(ft.)
FOR WATER SUPPLY WELLS ONLY:
ram/
13a. Yield (gpnl) S5 Method of test: A-t iz
13b. Disinfection type,
cksr(/V t Amount: e ro O/
14r WATER ZONES
FROM
TO�yr�
DESCRIPTION
fL
BD
/r Sift.
/tea Ci
ft.
gfr
i
.D00
15. OUTER (SING (for multi -cased wells OR. LINER (if op livable) ,.
FROM
TO
DIAMETER
THICKNESS I MATERIAL
ft.
ft.
in.
11
16. INNER CASING OR TUBING (geothermal
closed -loop)
FROM
TO
DIAMETER
MATERIAL
' fL
�' `� eft.
/T'HHIICKNESS/
(fI tn. Ta' (% (�
Al -
ft.
ft.
17. SCREEN
FROM
TO
IAMETER
SLOT SIZE
THIC E55
MATERIAL
off
Sc
in,
/d
(/l
r /
R,
ft
in.
//J
AV
IS. GROUTFRO
TO `,
-
Ml
EM MEgT METHODo& AMi UNT_
aM ft.
a 1 ft-
i/VVV
A!J- /
/�/�9WY/A.'I"/
�{t/ / S
o f
n.
ft.
Y(//r�AV
ft.
ft.
19. SAND/GRAVEL. PACK
(if applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
3J. ft.)
Y/
ft.
Le GI
ft.
ft.
20. DRILLING
LOG (attach
additional sheets if necessary)
FROM
TO
DESCRIPTION (color, hardness, soil/rock type, grain size, etc.)
dft.
2' ft.
c
J
ft.
R,
ft.
�7/t/ 'i�rs ft.
e-i
•�-
0 R
f' a. t.
At A-
ft.
rt.
R.
ft.�s
t 1
21. REMARKS
&AY302017
-.1lolt
22. Certification:
OtOCi'I`.testru r,--.--
vQ/BC`a
3
Si a of Certified Well Contractor Date
y signing (his form, I hereby certify Mat rbe well(s) was (were) constructed in accordance
with 15A NCAC 02C .0100 or 15A NCAC 02C .0200 Well Construction Standards an✓ rha( a
copy of this record has been provided in Swell 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: ��pp����
Division of Water iREWCfjEO iyeitt
1617 Mail Service Center,' � IeigYr,
ng Unit,
617
24b. For Infection Wells: In adds Qipypp to sending the form to the address in 24a
above, also submit one copy of IlLi Nnai5iI239i sys of completion of well
construction to the following: U //
Division of Water Resource rµynt injection Control Program,
1636 Mail Service t511? g16fM699-I636
WilIppr1ratt@,s. Lions ectiof{
24c. For Water Snooty 4 1 nle'ejlrODef gApr tl�'tyqI7,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 G W-1
Noah Carolina Deportment of Environmental Quality - Division of Water Resources Revised 2-22-2016

WELL CONSTRUCTION RECORD (GW-1)
Print Form
For Internal Use Only:
2 f196 bZr3� frN7& 73'/s 97
1. Well Contractor Information:
�R Zo
P.
Well Contractor Name
NC Well Contractor Codification Number
♦
(ZA i 1
Company Name
2. Well Construction Permit #: �%i7i�j yJ
List all applicable well construction permits .WC, Co inty, State, Variance, eta.)
3. Well Use (check well use):
Water Supply Well:
Agricultural
Geothermal (Heating/Cooling Supply)
Industrial/Commercial
Irrigation _-
DMunicipal/Public
esidential Water Supply (single)
Residential Water Supply (shared)
f1
Non -Water Supply Well:
Monitoring
Recovery
Injection Well:
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
Experimental Technology
Geothermal (Closed Loop)
Geothennal (Heating/Cooling Return)
DGroundwater Remediation
Salinity Barrier
DStormwater Drainage
DSubsidence Control
Tracer
Other (explain under #21. Remarks)
4. Date Well(s) Completed: 7 iP/,
5a ell ocation•
•e- refit f k/�
Well ID#
Facility/Owner Name Facility ID# (if applicable)
/00 5Yr145 ecS dway & Lis s/
Physical Address, City, and Zip
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one latilong is sufficient)
rs
W
6. Is(are) the well(s)01'ermanent or DTenaporary
7. Is this a repair to an existing well: Ei Yes or $No
7jth/s is a repair, fill out known well catnractian information and explain the mature of the
repair render 1121 remarks section or on the hack of this fare.
8. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction, only I QW-1 is needed. Indicate TOTAL NUMBER of wells
drilled: 4 P
9. Total well depth below land surface:
For multiple wells list all depths ifdferem (exampl
Q�
3@200' and 214;1001
10. Static water level below top of casing: / 9
If water level is above casing, use "7
11. Borehole diameter; 7 /g (in.)
12. Well construction method:
(i.e. auger, rotary. cable, direct push, etc.)
(ft.)
(ft)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) 'S v Method of test:
13b. Disinfection type: ch Amount:
/4-I 12--
co 0-,
444001
14. WATER
FROM
TO
DESCRIPTION
elO ft.
20 ft.
./
!�� ` /C
fL
ft.
15. OUTER CASING (formulti-easedwells) OR LINER (if ap licable)
FROM
'ro
DIAMETER
THICKNESS MATERIAL
ft.
ft.
in.
16.)INNER
CASING OR TUBING (geothermal closed loop).
PROM
8T
DIAMETER
TDICJ�NESS
M`�TERIA
/ ft.
ifr'_ ft.
(((�✓��✓♦N
in.
°jf'/2v
`f f/
fJV
/If
ft.
ft,
( in,
17. SCREEN
FROM
SLOT SIZE TIC S
MATERIAL_
Go ft.
YYYY////
g(%ft.
DETER
in.
.. � /(A ! (
�/'-' 3(//t•
�/ RVr
ft.
ft.
18.CROUT
OM
TO
M4TE•Le.
EM ACEME TMETHOD&AM/OfD,ryT
ft.
zD .
2�y t
'4()roe- 01.8)8 I rc:.
ft.
ft.
19.SAND/GRAVEL PACK
(if
OM
T
MATERIAL
EMPLACEMEy( METHOD
AUr•C7
�r Q ft.
ft.
;e_-7
;end_
ft.
f.
20 DRILLING
LOG (atta
h additfo pl sheets if nece vary)
FROM
TO
DESC PTION (color, tl es, soil/rock type, grain size, etc)
ar(',(/f
D ft.
�t ft.
fan of
rvi /G� Yy/'
EtE
C]
ft.
ft.
Of1'J'�95�
tN11 kit e'yr-
21. REMARKS
iDY6f4'I 1 n-- y ..
D AC'onCX3
22. Certi
D 6t �1 9s -i7
ified Well Contractor Date
signing this form, I hereby certify that the well(s) was (were) coustnroled in accordance
with I5A NCAC' 02C .0100 or I5A NCAC 02C .0200 Well Construction Standards and thin a
copy of this record has been provider/ 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: pp�������pp
Division of 11'at ¢}113®Ip►Dt�ssing Unit,
1617 Mail S itTrr aleigh, NC 27699-1617
24b. For Injection Wells: In addition to sendin, the, form to the address in 24a
above, also submit one copy of tliihlrnp6hi ays of completion of well
construction to the following: JJU
Division of Water Resources, Undexxgr a tvalControl Program,
1636 Mail Servidf'J2tSfek$ �i l ' 7699-1636
Operations eG ce
24e. For Water Simply & I�11FIfftAih s42egichinenn.in io sending the form to
e address(es) above, also submit one copy of thts form within 30 days of
completion of well construction to the county health department of the county
when, constructed.
Fonn OW -I
North Carolina Department of Environmental Quality - Division of Water Resources Revised 2-22-2016

D)itunicipalwublic
Residential Water Supply (single)
Residential Water Supply (shared)
()Recovery
0Groundwater Remediation
Salinity Barrier
fStormwater Drainage
DiSubsidence Control
Geothermal (Closed Loop) rTracer
Geothermal (Heating/Cooling Return) Other (explain under #21 Remarks)
4. Date Well(s) Completed: . -A-11 Well ID#
5a. Well Location:
Ifehmeo L A;k
acility/Owner Name Facility ID# (if applicable)
GN Ntamifeutza
2cS Sat IZ4«
Physical Address, City, and Zip
fret -A
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one Iatflong is sufficient)
WELL CONSTRUCTION RECORD (GW-11
1. Well Contractor Information:
7,g4;v P »l2
Well Connector Name
2953
NC Well Contractor Certificdtion Number
Company Name
2. Well Construction Permit 4:
2246 7
List all applicable well construction permits (i.e. (1IC County, State, Variance, eta)
3. Well Use (cheek well use):
Water Supply WeB:
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
rf
gy'yIVDvo.7." N76"S/t V3.69"
6. Is(are) the well(s) Permanent C,orr ...fe Temporary
7. Is this a repair to an existing well: 11Yes or EJNo
If this is a repair. fill out known well construed n information and explain the nature 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 I GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled: 0A=-
9. Total well depth below land surface: _ di lei(ft.)
For multiple wells list all depths ifdi erent (example-3 0and 2@100')
10. Static water level below top of casing:
If water level is above casing, ussJe ..++1"'
11. Borehole diameter: / J48 (in.)
12. Well construction method:
(i.e. auger, rotary, cable, direct push, etc.)
/6
Rey
w
(ft.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection typed, ioklive Amount: 4 r / r /
AI1Z
Print Form
For Internal Use Only:
444000
14. WATERZONES
FROM
TO
DESCRIPTION
/k ft
fray ft.
goc
ft.
ft
15. OUTER CASING (for
multi -cased welt) OR LINER (if ap limbic)
FROM
TO
DIAMETER THICKNESS MATERIAL
ft.
ft.
in.
16. INNER CASING.
OR TURING
(geothermal closed -loop):
FROM
TO
DIAMETER
THICKNESS�7s
MATERIAL
/
/i)
V
V7
Re C
H.
ft
o.
17. SCREEN
FROM I TO
DIAMETER
SLOT SIZE
TAICKNE53
MATERIAL
/0ort. H.
, ` in.
a
/ L VD
P v ci
llr
18. GROUT
FROM
TO
MATERIAL
EMPLACEMENTS pouted M THUD&AMOUNT
Oa LBS
rt
f.
ekat
ft
ft
ft
.
19, SAND/GRAVEL
PACK
Of applicable)
FROM
TOE/'.
EMPLACEMENT METHOD
/ by ft.
V
ft.
/d V.
�VMATERIAL
j
,O.0 �',.O.. Cr
ft
ft
20..DRILLING
-LOG (attach
additional sheets If necessary) '.
FROM
TO
DESCRIPTION (rotor, haj�nen, aailrock type, grain eve, eta.)
ft.
ft.C?5
iI4
H.H.
r
c.i9!it//o
ft
ft
ft.
MAY 3 o 2n17
ft.
ft
21.:REMARKS - s -in ut ,4 r S C J M
di Ch i It —
Er MT eCeo
22. Certification:
%�f/I 2O ;�7r
ofertified Well Contractor Date
gning Ibis form, 1 hereby certf that the well(s) was (were) constricted in accordance
h 15A NCAC 02C .0100 or 15A NCAC 02C .0200 Well Construction Standards and that a
copy of this record Jul been provided to the wall 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 fC�enn�teer, pRaaleigh,eNCp2�7p69999-1617
24b. For Infection Wells: In,IdrtNA'tAi dtritghbrtbFhTltlAthe address in 24a
above, also submit one copy of this form within 30 days of completion of well
construction to the following:
������ QQ ��aa 99 77
Division of Water Resources, U-nd"eLrdlrrld Ift,Pition Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Snooty & InieWiateMGfilelitrn ::%,;rt'6ptr7jl sending the form to
the address(es) above, also {{u�b�m(t)j2ki ti6pjS Seem' !form within 30 days of
completion of well construc$WilffrB$t06 M gigaj({j Qlj(;'j rent of the county
where constructed.
Form GW-I
North Carolina Department of Environmental Quality - Division of Water Resources Revised 2-22-2016

WELL CONSTRUCTION RECORD (GW-11
1. Well Contractor Information:
5_ns©wv P. 'Mo 2-ta,J
Well Contractor Name
2At53-1�
NC Well Contractor Certification Number
niotZ4wJ DR I L ))al
Company Naine
2. Well Construction Permit 4: .237 ,/ Z 5
List all applicable we// construction permits (i.e. Inc, County. State, Variance, etc)
3. Well Use (check well use):
Water Supply Well:
Agricultural
Geothermal (Heating/Cooling Supply)
Industrial/Commercial
."Irrigation
Non -Water Supply Well:
DMcnitoring
Injection Well:
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
Experimental Technology
jGeothermal (Closed Loop)
Geothermal (Heating/Cooling Return)
DMunicipaWPublie
Residential Water Supply (single)
DResidential Water Supply (shared)
E3Reeovery
DGroundwater Remediation
Salinity Barrier
DStormwater Drainage
❑Subsidence Control
Tracer
Other (explain under # 1 Remarks)
4. Date Well(s) Completed: 5- Z /— 17
5a. Well Location:
Lt *hrr too+Le
Facility/Owner Name
berry
Physical Address, C1y, and Zip
0a2-Fert •f'
County
Well 1D#
Facility ID8 (if applicable)
Nc• Mczfa
Parcel Identification No. (PIN)
56. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one latAong ti sufficient)
7Vm fi$.7) rr N "7l9e yc/1/7r95-
rr W
6. Is(are) the well(s)93Permanent or 0Te nporary
7. Is this a repair to an existing well: DYds or fr�iNo
If this is a repair, fill out known well construction infoema ion a d explain the nature of the
repair under 1121 remarks section or on the hack of llrii fo m.
8. For Geoprobe/DPT or Closed -Loop Geother al Wells having the same
construction, only I OWL is needed. Indicate TO AL NUMBER of wells
drilled: ON
9. Total well depth below land surface: 0 (ft.)
For multiple wells IS al depths if different (example- 33.00' and 2©l00)
10. Static water level below top of easing: 1 5
If water level is above casing, use "-I "
11. Borehole diameter: 1 j8
12. Well construction method:
(Le. auger, rotary, cable, direct push. etc.)
(in.)
0
(ft.)
FOR WATER SUPPLY WELLS ONI Y'
3a. Yield (gum) 60 Method if test:
3b. Disinfection type:C(4I0►�1IU Q� Amount:
A-l2
For Internal Use Only:
14. WA'fER.ZONES
FROM
D ft.
ft.
TO
r O ft.
ft.
DESCRIPTION
Roc%
Print Form
443937
15. OUTER CASING (for multi -cased wells) OR: LINER(if apt
PROM TO DIAMETER THICKNESS
rt.
it.
in.
lieable)
MATERIAL
16. INNER CASING OR TURING (geothermal closed -loop)
DIAMETER THICKNESS MATERIAL
FROM TO
1
,a o ft. n.
ft. ft. 9 in.
ft.
17. SCREEN
501, %b
FROM TO DIAMETER sun s]ZN: 'THICKNESS MATERIAL
In. 0-2_v �V P J
in.
�i9� `t•
ISO R.
ft. ft.
GROUT
FROM
TO
MATERIAL
O ft. f. &An"%.
ft.
ft.
EMPLACEMENT METHOD & AMOUNT
Poo red Voo (6
ft.
19. SAND/GRAVEL PACK (if applicable)..
FROM TO MATERIAL
/Go
ft. (3 ✓ ,) ft.
ft. `o ft.
SGtw�
EMPLACEMENT METHOD
1) Or?
20. DRILLING LOG (attach additional sheets if nee ssary)
DESCRIPTION (color, hardness, soil/rock type, grain sire, etc.)
o `t 35� firer, die 5 ft. -1 S ft. SA-rai CCay
EN DW
/40 ft.
FROM
/GO
ft.
ft.
307
Rn
/
It.
21 ({WAi®I t9 R anal
Upe abut s Seeltui
Wjlminginn Rag'nnal Office Wormiest r
® JFtt
lure of Certified Well Contractor
MAY
2 4 2u77
Sis- r9
Date
By .signing this form, I hereby cent& that the well(s) was (were) constructed in accordance
with I5A NCAC 02C .0100 or ISA NLAC 02C .0200 Well Construction Standards and that a
copyof this record has been provided to the well owner.
23. Site diagrams 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. Far 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 Injection 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 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Simply & Iniection Wells: In addition to sending the form to
the address(cs) 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
Norel Carolina Depamnent of Environmental Quality - Division ofWater Resources Revised 2-22-2016

WELL CONSTRUCTION RECORD (GW-11
1. Well Co ctor Information:
1A(C Ser
Well Contractor Name
H2(ot- A
NC Well Contractor Certification Number
Lf(ff G(/ea101�-
1cjQ3
Company
2. Well Construction Permit#:
List all applicable well construction permits (i.e. UIC, Canary, State, Variance, etc.)
3. Well Use (checkweB use):
Water Supply Well:
°Agricultumi
OGeothermel (Heating/Cooling Supply)
Olndustrial/Commercial
°Irrigation
OM�p` cipal/Public
(Residential 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 #21 Remarks)
4. Date Well(e) Completed: ! —2 ! f Well Rl#
FROM
For Internal Use Only:
443732
14. WATER ZONES
FROM
TO
DESCRPTION
iSot
VD"
50H L;fw5fer7'C
15. OUTER CASING (for multi -eased wells OR LINER (if a livable)
THICKNESS 1MATERIAL
R
R
in.
FROM
TO
DIAMETER
16. INNER CASING OR TUBING (geothermal closed -loop)
THICKNESS
TO
DIAMETER
MATERIAL
in.
in.
17. SCREEN
FROM
TO
DIAMETER
SLAT SIZE
TmCKNESS
MATERIAL
100"
R
zrofL
R
in.
a vc-
Ill. GROUT
FROM
0
20
EMPLACEMENT METHOD & AMOUNT
MA IMUAL
bn14mi /Lapol r (....46
19. SAND/GRAVEL PACK (if applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
R
ft.
R
5a. Well Location:
ctts21 Cate- ld
Facility/OrvvuName Fity) acil(ifappleable)
niy pc•ie,'ir ti�fort MZ- 2-85G
Physical
53gS2 9139arD
39
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degreeshninutes/seconds or decimal degrees:
22. Certifica
tion:
:
20. DRILLING LOG (attach addidonal sheets if accessary)
DESCRIPTION Odor, amdkes, soiprock type, grain slim eta)
FROM
DR
/6
016
bOf`
R
145
131 R
115R
TO
ID
ft.
o R
131
11.5 "
ado ft.
21. REMARKS
Fire_ sand d- red demi
Coarse 52nea l ynt.et.. fi1,4N5
5Efnc1-4f - r %Ivt day
6-rel mac 1
‘anc154il e-
StrFA- I ins-att.
(if well field, one )Moog is sufficient) / ,�`/
3H°�I1, ?98'N -/'1 7°02-400
6. Is(are) the well(s): QPermanent or °Temporary
7. Is this a repair to an existing well: °Yes or DNo
If this is a repair, fill out known well construction information and explain the nature of the
repair under 112i remarks section or on the back ofthis fonn.
8. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
constmetioo, only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled
9. Total well depth below land surface:
For multiple wells list aft depths 3@.200. . and 2Q rr )
10. Static water level below top of casing:
If water lever is above casing. use "+"
O
11. Borehole diameter: x Li /y .r.-(KO
12. Well construction method: 1
ril
(i.e. auger, rotary, cable, direct push, etc.)
2/0
Signatwe ofCenified Well (3
By signing this form, I IerNy
with 15A NCAC 02C.0100 or, -
copy of this record has beenpia
23. Site diagram or additlrnmiw@p details:
Date
well(s) was (were) constructed in accordance
%comtruction Standards and that a
C L)
You may use the back of th' to idgO onal well site details or well
construction details. You may also attach add( pages if necessary.
in
SUBMITTAL INSTRIJ W(�/�Prixamoigunit
(fL) 24a. For AB Wells: Submit this form within 30 days of completion of well
construction to the following:
(ft.) Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
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:
FOR WATER SUPPLY WELLS ONLY: L
13a. Yield (gpm) tOC Method of test:
13b. Disinfection type: 61/ �i)flr� Amount I Z oz
Form GW-1
Division of Water Resources, UIa , -
ogram,
1636 Mail Service Center, Raleig
24c. For Water SuDDIV & Infection We Is: In addition to sending the form to
the address(es) above, also submit one Vof f thin 30 days of
completion of well construction to the county the dent of the county
where constructed.
Water Quality Region�� North Carolina Department of Environmental Quality- Division of Water Resources OpefatlDn5 Section lased2222016
Wilmington Regional Office

WELL CONSTRUCTION RECORD (GW-1)
1. Well Contractor
.Into tion:
1`r\l 1t_ Intonation:
ter
Well Contractor Name
NC Well
Contractor Certification
`ry
ertificatiio�n�Num/ber ) f
t-IcI1C-r V-tl/ l--art
elff'n�f C�Cs6o-
Company Nam_ �J% %
2. Well Construction Permit #: Z'Z'm'�+
List all applicable well construction permits 0.e. UIC, County, State, Variance, etc.)
3. Well Use (check well use):
Water Supply Well:
:Agricultural
:Geothermal (Heating/Cooling Supply)
°IndustrialCommercial
:Irrigation
OM cipal/Public
sidential Water Supply (single)
O Residential Water Supply (shared)
Non -Water supply Well:
:Monitoring :Recovery
Injection Well:
: Aquifer Recharge
: Aquifer Storage and Recovery
°Aquifer Test
o Experimental Technology
❑ Geothermal (Closed Loop)
O Geothermal(Heating/Cooling Return)
: Groundwater Remediation
:Salinity Barrier
OStormwater Drainage
: Subsidence Control
:Tracer
:Other (explain under #21 Remarks)
4. Date Well(s) Completed: t Z7-/% Well ID#
,gsWell Location:
.OAck\ci Weaver"
Facility/Owner Name r Facility IMF (if applicable)
qDH Mars( rsLLflr, (adult Pt. NL
Physical Address, City andffi8r Zip Z-1
ere_53-ly070 61/3ato
Co Parcel Parcel Identification No. (PIN)
For Internal Use Qn4 3731
14. WATER ZONES
FROM
TO
/70b•
ft.
DESCRIPTION
15, OUTER CASING (for multi -cased wells) OR LINER (if a Rca ble )
FROM
TO
R.
DIAMETER
THICKNE56 MATERIAL
16. INNER CASING OR TURING (geothermal closed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
in.
ft.
AO.
17. SCREEN
FROM
1 Hblt
TO
/-i17L
ft.
DIAMETER
a rum
in.
SLOT SIZE
.0,0
THICKNESS
64.14.410
MATERIAL
%%✓Cs
I8: GROUT
FROM
0
ft.
TO
7.0 R.
11.
MATERIAL
bent,/ de
EMPLACEMENT METHOD & AMOUNT
We)/6 -
r
ft.
19. SAND/GRAVEL PACK (if applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
ft.
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/iong issssufficient) -r7e 7,04.1 oL`
S N
6. Is(are) the well(s): BPermanent or :Temporary
7. Is this a repair to an existing well: :Yes or BC.
If this is a repair, fill out known well construction information and explain the nature of the
repair under #21 remark section or on the back ofthis form.
8. For Geoprobe/DI'T or Closed -Loop Geothermal Wells having the same
construction, only 1 GW-I is needed. Indicate TOTAL NUMBER of wells
drilled:
9. Total well depth below land surface:
For multiple wells list all depths ((different (example- 3(rp200' and 2(4100')
/70
10. Static water level below top of casing:
)(water (evens above casing. use
11. Borehole diameter: B1 ( (in.)
12. Well construction method: Thigni
(i.e. auger, rotary, cable, direct push, etc.)
(ft-)
FOR WATER SUPPLY WELLS ONLY: 1144
13a. Yield (gpm) 60. Method of test: Ceti r
13b. Disinfection type: Y rf Amount:
/Oaz_
FormOW-1
20. DRILLING LOG (attach additional sheets if nee sary)
FROM
1
D
(�fL
i00 fL
136-
ft.
TTI
I(
/cnn
135
00 ft.
DESCRIPTION (color, Denims., sei0mck type, train size, eta)
Eft. -'-t� I itartr- 1
)1 V.Q dQ yy
►. ,t` c. r Skiffs
hly ✓a 574444 € -
ft.
21. REMARKS
22. Certiftca
MAY i 5 2011 \ (Cr: )
Signature of Certified Well
0
/- Z7 17
Dare
By. signing this form. I hereby certify that the well(s) was (were) constructed in accordance
with 15A NCAC 02C .0100 or I5A NCAC 02C .0200 Well Consauction 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 fallowing:
Division of Water Resources, Information Processing Unit,
1617 Mall Service Center, Raleigh, NC 27699-1617
24b. For Infection Wefts: In addition to sending the form to the address in 24a
above, also submit one copy of this %withED/NCyENR completion of well
construction to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mall Service Center, R0e1't NCQ27699-16636
24c. For Water SuDDly & Injection Wells: (. In alifion ?iP)Zdiog the form to
the address(es) above, also submit one copy of this form within 30 days of
completion of well construction to the�cutramntt healthdeparhnent of the county
where constructed. vydie ua ity Negional
Operations Section
Wilmington Regional
North Carolina Department of Environmental Quality- Division of Water Resources gig&2-22-2016

WELL CONSTRUCTION RECORD (GW-1)
1. Well Contractor Information:
:1:A9v,t/ P- '711crd-67 i
Welt Contractor Naine <7 A.�M6
NC Well Contractor Certification Number
}H1ottc i D JL-L-!
Company Name
2. Well Construction Permit #: i
8
LW all applicable well construction permits (i.e. 111C, County, State, Variance, etc.)
3. Well Use (check well use):
Water Supply Well:
Agricultural
1 ! Geothermal (Heating/Cooling Supply)
Industrial/Commercial
Irrigation
DMunicipallPublic
ResidentialWater Supply (single)
f Residential Water Supply (shared)
Non -Water Supply Well:
Monitoring QRecovery
Injection Well:
Aquifer Recharge OGroundwater Remediation
Aquifer Storage and Recovery f Salinity Barrier
Aquifer Test fStorrnwater Drainage
Experimental Technology £Subsidence Control
Geothermal (Closed Loop) DTracer
Geothermal (Reating/Cooling Retum) riGther (explain under #21 Remarks)
4. Date Well(s) Completed: 3 '1 '- 11 Well ID#
5a. Well Location:
t1,A€ 4iC1c4. iPtlil'.It
Facility/Owner Name
n;
nC1
Physical Address, City, and Zip
('' re f -
County
Facility ID# (if applicable)
214.67:41. f /Chic✓
Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one Iat/long is sufficient)
/7jsAl9 7Grl3 N /j'c,' T'l f at ./J, /J r( W
6..Is(are) the well(s) p (/Permnnent or jTempornry
7. Is this a repair toan existing well: QYes or lrliNo
lfthis is a repair, yl out known well c nstruction (n/brr onon nhd explain the nature o/'the
repair under 1121 remarks' section or on the back oflhisJonn.
8. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction, only 1 OW-1 is needed. Indicate TOTAL NUMBER of wells
drilled: (n'af"-"
9. Total well depth below land surface: <� S
For multiple wells list all depths ifdierenl (example- 3(1)200 • and 2 G /00')
10. Static water level below top of casing:
lfwater level is above casing. use "I "
:.
11. Borehole diameter: -7`f.' (in.)
12, Well construction method: / 1 0.1
(i.e. auger, rotary, cable, direct push, etc.) - r
/../
(ft.)
(ft.)
FOR WATE.R SUPPLY WELLS ONLY:
no -Yield (um) Method of test: //7-)!1!-
13b. Disinfection type: 4/t/i:. L-l7 e. Amount: j r3
North Carolina Department c
Print Form
For Internal Use Only:
442520
14. WATER. ZONES
FROM
DESCRIPTION
R.T,i
Ir
sr ft.
A.
ft.
ft.
IS: OUTER
CASING (for
multi -cased wells OR LINER (if a p Hea de)
FROM
TO
DIAMETER
THICKNESS MATERIAL
rt.
ft.
in.
16. INNER
CASING OR TUBING
(geothermal
'closed loop)
PROM
TO
DIAMETER
THICKNESS
MATEERIAL.
7 ft.7
!
j ft.
to in.
tT
4 T c'
) vl'""
R.
ft
in.
17.SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
7{R.
(
4'S ft
ft In
L 0
5 O
�) . e-.
lt
ft.
f
ft.
18. GROUT
PROM
TO
MATEE�(}��SAL
EMPLACEMENTy�METHOD IF AMOUNT
Z fl.
2L ft-
r-',G)1*n/IC
YcE> LL £ ''I)D (7 ,1
Y,Y
.
ft.
ft.
rt.
19. SAND/GRAVEL
PACK
Of applicahle)
FROM
TO
MATERIAL
EMPLACEMENT METHOD.
•j --n.
.r j fr.
S Ff
t� z-
001, (9 S
ft
ft.
20. DRILLING
LOG (attach
additional sheets if nee ssnry)
FROM
TO
DESCRIPTION (color, hardness, soil/rack type, grain size, etc.)
,rr ft.
25 ft.
CJ. Y Y7
�G.'S ft*.7
5' ft
>,`fit__t/ c 64-
./1 ft
li ✓0 ft. .
/4, et
ft.
ft
ft.
ft.
RECEIVED
ft
ft.
ft. ft.
MAR 2017.
21.-REMARKS.' _2-7
inform) .tin Prprr-va inc Unit
DWQ/BOG
22. Certification:
(s
/ -el 7 7 cr
ture of Certified Well Contractor
Date
By signing thus form 1 hereby certify that the well(s) was (were) constructed in accordance
with 15A N(AC 02C .0100 or 154 N(A(. 02(' .0200 Well Construction .Standards and that a
copy of this record has been provided ro. 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, Raleigh, NC 27699-1617
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 following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
APR 0 3 2017
nviromne ntal Quality- Division of Water Resources Revised 2-22-2016
Water Quality Regional
Operations Section
W INCDEN ,, r. WR
24e. For Water.SuSC Infection GEAVE an Wells: In ': ,
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.

WELL CONSTRUCTION RECORD (GW-1)
1. Well Contractor Information:
For Internal Use Only:
442519
Print, Form
Well Contractor Name
�C7.5 5- A-
NC Well ContnctorCertificado2 umber
711,arc+r» R1 t--Lf )()) Cr"
Company Name.
2. Well Construction Permit#: •22' 1 G'. 1
List all applicable well cansmrclion permits (t.e. (//C, Cinnur, ,Stale, 1 ara: me, etc:)
3. Well Use (checkwell use):
14. WA'1'RI ZONES '.
FROM
TO
DESCRIPTION
Z-.ioft.
5 Jft.
ft.
t.
15.:OUTER CASING (for .multi -eased wells) OR LINER (if ap lieable)
DIAMETER 1 M
FROM
PROM
ft.
THICKNESS
A'FERIAL
16. INNER CASING OR TIRING (geothermal closed -loop)
TO
ft.
L1 ✓'^ f.
DIAMETER HIC NESS MATERIAL
2'�yo
ft.
ft.
In.
Water Supply Well:
!Geothermal (Heating/Cooling Supply)
Industrial/Commercial
Irrigation
Agricultural
on-Water Supply Well:
Monitoring
Injection Well:
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
Experimental Technology
Geothermal (Closed Loop)
Geothermal (Heating/Cooling Return)
Municipal/Public
Residential Water Supply (single)
Residential Water Supply (shared)
Q Recovery
QGroundwater Remediation
Salinity Barrier
DStonnwater Drainage
[]Subsidenee Control
DTracer
Other (explain under #21 Remarks).
4. Date Well(s) Completed:3-J t' Well ID#
5a. Well Location:
Facility/Owner
Facility IDk (if applicable)
/f/I'.. 2L'7r'f liF"Cw t c1- /YL'/.'ZC £ (-
Physical Address, City, and Zip
County Parcel identification No. (PIN)
Sb. Latitude and longitude.in degrees/minutes/seconds or decimal degrees:
(if well field, one labloug is sufficient)
6-7/33,7r) N°..3.5"1.35;/9 t W
6. Is(are) the well(s) Permanent or 3Temporary
7.1s this a repair to an existing well:. OYes or DkNo
ifthis is a rapme, fill out known well construction infimontian and explain the nice nfMe
repair under 1121 iernarks section or an iM back of thus /bnu.
8. For Geoprobe/DST or Closed -Loop Geothermal Wills having the same
construction, only I GW-I is needed. Indicate IOTA!. NUMBER of wells
drilled: Sri% .✓
9. Total well depth below land surface: G5 L�
For multiple wells list all depths if different (grumble- 3t31200' and 2 m/0(1)
10. Static water level below top of casing:
If water level is above casing, use "+"
11. Borehole diameter: 7 -6f' (in.)
12. Well construction method:
/,2
(i.e. auger, rotary, cable, direct push, etc.)
(ft.)
(ft.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (Rpm) ' /] S methodoftest:
1` 112.
13b. Disinfection type:( YA l(;Ill i./ 1, Amount: / 7..
17. S(REEN
FROM
Loft.
fL
TO
Z5t� f°
ft.
DIAM1TRR
` in.
SLOT SIZE
TntCICNPSI
Seib
MATERIAL
18. GROUT
FROM
L) ft.
TO
Ci ft.
ft.
ft.
ft.
MA'rrnls
Qcii-t
EMPLACEMENT METHOD & AMOUNT
bv; id. Olt) le
19. SAND/GRAVEL: PACE (if applicable)
FROM
�3o ft.
ft.
TO
LE0 R.
ft.
MATERIAL
EMPLACEMENT METHOD
4, re
20. O14ILLING.UOG^^ (attacb additional sheets if
FROM
�ft.
s w n.
�154
/en rt.
/Sort
24p ft.
ft.
r0
/yc ft.
/G`tis rt.
`O ft.
ft ft.
wary)
DESCRIPTION (color, kaNnw, roil/rock type, grain
J J4?'I d
Zen. e_ cm,"
ED
(
21. REMAI KS
MAR t
207
22. Certification: r J
Signs Certified Well Contractor
i0rt F't000.+smg
t
sit
cY
) 4)-/?
Date
By signing this farm,, I hereby cerl f that the wells) was (were) conun,cced in accordance
with /SA NCAC 02C .0100 or 15A NCAC 03(' .0200 Well Constructimr 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 1'rocessing tlnit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Injection Wells: In addition to sending the form to the address in 24a
Annie, also submit one copy of this form within 30 days of completion of well
construction to the tollowing: •
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, Nt /µCDENR/DWR
24. Fur We ter Supply & Inier lion 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 tq the county health depaftiHrt 0 e yp11
where constructed. B Lu
0
ft.
Fonn GW-I
North Carolina Department of En
Dine Dal Quality - Division of Water Rewire
Water fffliFi'kiNaI
Operations Section

WELL CONSTRUCTION RECORD (GW-1)
1. Well Contractor Information:
7ktso \J % fno2`7t ✓
Well Contractor Name
NC Well Contractor Certification Number
MOEJWJ a L C ins,
Company Name yy
2. Well Construction Permit #: OC S'S %
List all applicable well construction permits (i.e. 111C, County, State, Variance, etc)
3. Well Use (check well use):
Water Supply Well:
DAgricultural Municipal/Public
©Geothermal (Heating/Cooling Supply) DResidential Water Supply (single)
Industrial/Commercial - DResidential Water Supply (shared)
rogation
N -Water Supply Well:
Monitoring
Injection Well:
Aquifer Recharge
fAqui£er Storage and Recovery
Aquifer Test
Recovery
Groundwater Remediation
®Salinity Barrier
0Stormwater Drainage
Experimental Technology Subsidence Control
Geothermal (Closed Loop) DTracer
Geothermal (Heating/Cooling Rehm) nOther (explain under #21 Remarks)
4. Date Well(s) Completed: Wen % Wen 1D#
5a. Well Location:
Facility/Owner Name Facility ID# (if applicable)
/a4 ' Yfrt 9,2 13L U
Physical A dress, City, and Zip
f h°-7-te, -e ¥-
County Parcel Identification No, (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one let/long is sufficient)
3yS9 I lc,11 jl N12°O.21347,9Y tt W
6. Is(are) the well(s)Permanent or DITemporary
7. Is this a repair to an existing well: jYes or ,No - If this Is a repair, fill out known well construction information and explain the nature of the
repair under 1121 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: 671t/
9. Total well depth below land surface: /SCE
For multiple wells list all depths if different (example- 3@200' and 2Q100)
10. Static water level below top of casing:
If water level is above casing, use "+",g
eerQ
11. Borehole diameter: (in.)
12. Well construction method:
(i.e. auger, rotary, cable, direct push, etc.)
474-,z`,
(It.)
(ft.)
FOR WATER SUPPLY WELLS ONLY:
2S
13a. Yield (gpm) J`a%%`� Method of test: /"I /2
13b. Disinfection type:C*Wai t e
Amount: /• ;/
Print Form
For Internal Use Only:
442425
14, WATER ZONES
TO
DESCRIPTION
DESCRIPTION
/FROGM��
/5, t
l
/✓ ° :
72Cr �
ft.
ft.
15. OUTER
CASING (for
multi -cased wells) OR LINER (R a Doable)
FROM
TO
DIAMETER
THICKNESS MATERIAL
ft.
ft.
in.
16. INNER
CASING OR TUBING
(geothermal closed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
a/ ft.
/rAa f.
rTe in.
cei ! Tice
nv G
9-
ft.
ft.
in.
17. SCREEN
FROM
TO
.DIAMETER
SLOT SIZE
THICKNESS
MATERIAL/
-O7' fit.
J % a fit
(L7 in.
2.0
J'C7 V
9 i% ("
ft.
f .
in.
18. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
® ft.
fa
f4�11,r.;
ibi(Fc/ o i
fit
ft.
ft.
ft.
19. SAND/GRAVEL
PACK
(if applicable)
FROM
TO
MATERIAL
EMPLACEMENT MET,IOD
/33 f.
/n ft.
SAND
/Jpe.)red
ft.
ft.
20. DRILLING
LOG (attach
additional sheets if necessary)
FROM
TO
DESCRIPTION (color, hardness, mil/rock type, grain size, eta.)
e9 ft.
1+ 5 ft.
S /-Q/7,7 Gr
ft.
to ft.
5/ 1�'G/
s3S
/r� R•
0 6 ft.
C-4i
/3� R.
/A? fit.
garZ- rL--
ft.
ft.
ft.
ft.
21. REMARKS. MAR p6 2U1
22. Certification:
of Certified ell ontmelor
f-eb -/ 7
Date
.signing this form, I hereby certt& that the well(s) was. (were) constructed in accordance
with 15A NCAC 02C .0100 or 15A.NC..4C 02C .0200 Well Construction Standards and that a
copy o./ Ibis 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 INSTRUC t 5. i.`..IVED/NCDENR/DWR
24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
MAR 2 0 2017
Division of Water Resources, nformatiou Processing Unit,
1617 Mail Service�c�Center,tlRaleigh, NC 27699-1617 '
24b. For Infection Wells: In•a gron`iiSgr �+m to the address in 24a
above, also submit one co pf qY� �i& 1 it',�I'q,T',i of completion of well
construction to the f'ollowinly Amin on Regional llRlce
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Slimily & 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.
S
Fonn GW-1
North Carolina Department of Environmental Quality - Division of Water Resources Revised 2-22-2016

WELL CONSTRUCTION RECORD GW-I
I. Well Contractor Information:
CA firn 72
Well Ceara for Name
415
NC Well Contractor Certification Number
Company N
2. Well Construction Permit #:
List all applicable well construction permits (i.e tIIC County, State, Variance, etc)
3. Well Use (check well use):
Water Supply Well:
Agricultural
Geothermal (Heating/Cooling Supply)
Industrial/Commercial
rri_atinn
Injection Well;
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
Experimental Technology
Geothermal (Closed Loop)
Geothermal HeatinCoolinReturn)
n-Water Supply Well:
Monitoring
QRecovery
QMunicipal/Public
DResidential Water Supply (single)
Residential Water Supply (shared)
{Groundwater Remediation
Salinity Barrier
DStormwater Drainage
Subsidence Control
0Tracer
Other (ex lain under #21 Remarks)
4. Date Well(s) Completed: / Z-- 2
5a. Well Location:
.5c t$ A(ll`7Al
Facility/Owner Name r' Facility EDP (if applicable)
(,,e tbz. 3 1--
/li.r C
Physical AddCity:andZip
County
Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
N 77 'it
Well ID#
6. Is(are) the well(s),W�. ermanent or DTemporary
7. Is this a repair to an existing well: DYes or No
if/his is a repair, fill out known well construction information alla5;eplain the nature of the
repair under 1111 remarks section or on the back of this Ann.
S. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
constmction, only 1 GW-I is need, indicate TOTAL NUMBER of wells
drilled: � )
9. Total well depth below land surface:
For multiple wells list all depths ifdifjerent (example
2'
n200' and 2e@i100)
10. Static water level below top of casing: oe;
!f water level is above casing, use "
11. Borehole diameter: ( `fn
(in.)
12. Well construction method: P.
(i.e. auger, rotary, cable, direct push, ear.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpnl)
/ Method of test:
13b. Disinfection type C-0j ' e ; U[.
Amount:
f
(ft.)
(ft.)
Form GW-1
For Internal Use Only:
FROM
TO
wslt
Print Forry
��DESCRIPTION
llaliallalainall
f ft. MMEMEMEMEMEMIMIlliall
IS. OUTER CASING for mold -cased wells OR LINER a tlaa$1 _
FROM TO DtAcased OR LI'ER ifa
16. INNERCA$ING OR TUBING closed -kw FROOM Ti DIAMm�
SIISINSIII
%FROM TO DIA ETER SLOTSIZE Mill
lg. CROUT ®®
FROM TO EMPLACEMENT BTROD & AMO NT
,LI', �F
ft. ft. 11.1.1111....111111.11.111
ft. ft.
19.RSAND/GRAVEL PgCI(. if n livable
F
al
alla
�25
ft.
ft.
EMPLACEMENT METHOD
ginar
20. DRILLING LOG attach. additional sheetsif necessa r
WFROM TO DESCRIPTION mbr,hardness, sell/reek
aS min sire, etc.
5 ft.
Ma��`
ft.
ft.
Entnaaniesanin
EdI�
22. Certification:
fr.
ft.
J/—? ft.
ft.
SUBMITTAL INSTRUCTIONS
24a. For. All Wells: Submit t IRnr{�,Ab)I;Afpfpdays of completion of well
construction to the following: ,,UU'' Y.00""YY�I
ure of Certified Well Contractor
Date
By signing this. form, 1 hereby eerily that the well(s) was (were) constructed to accordance
wail 15A h'CAC 02C .0100 or 15A NCIC 02C .0200 Well Cons'tntction Standards and that a
copy of this record has been provided la the well owner.
23. Site diagram or additional well details:
You may use the back of r v d additional well site details or well
construction details. You rat t 'Y'i ee99�fFff.ls�°�
IReatqtnecessary.
Division of Water
''�FF�����(,fI'��??or anon� _Pjocessing Unif,
1617 Mail ServrcBlCk'¢1B 1 IAm7699
VVFP� ffuiifdOS �pq 16I7
24b. For Irrection Wells:W1111Din tbi
above, also submit one copy of this form withhiin�30 ddayyss of complettiion sof w24a
ell
constmction to the following:
Division of Water Resources, Underground Injeetimw Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24e. For Water Sunnh'---__
& I ' t' Wells: Ino f this
to sending the forams
to
the address(es) above, also submit one co
py completion of well construction to the county health sdepartmenttn of th30e countof
y
where constructed,
North Carolina Department of Environmental Quality - Division of Water Resources
Revised 2-22_2016

Print Form
For Internal Use Only:
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 14: Unknown Not listed on site
List all applicable well construction penults (t e. UJC, County, State, Variance, etc.)
3. Well Use (check well use):
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 R'ell:
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
xperimental Technology
,7t Geothermal (Closed Loop)
Geothermal (Heating/Cooling Return)
4. Date Well(s) Completed: 2/1/17
5a. Well Location:
First Citizens Bank & Trust
Recovery
°Groundwater Remediation
°Salinity Barrier
°Stormwater Drainage
°Subsidence Control
°Tracer
°Other (explain under #21 Remarks)
Well lD#See Attached
N/A
Facility/Owner Name Facility IDk (if applicable)
1505 Live Oak Street, Beaufort, NC 2851.6
Physical Address, City, and Zip
Carteret 730615731359000
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one Iadlong is sufficient)
See Attached N See Attached
6. Is(are) the weil(s)Ex Permanent or °Temporary
7. Is this a repair to an existing well: °Yes or x°No
If this is a repair, fill out known well consaxmtion information and explain the nature of the
repair under =21 remarks section or on the hack of this farm.
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: 11
9. Total well depth below land surface: 305
For multiple we/Is list all depths b.dierent (example- 3@200' and 200I00')
(ft.)
10. Static water level below top of casing: N/A (ft.)
If water level is above casing, use "-"
11. Borehole diameter: 5 7/5 (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
Form OW.1
14. WATER ZONES +.sa
FROM
TO
DESCRIPTION
ft.
ft.
ft.
ft.
15. OUTER CASING (for multi -cased wells) OR LINER (if ap Iicable)
FROM
ID
DIAMETER
THICKNESS MATERIAL
0 ft'
305 ft.
1 in•
SDR-11 HDPE
16. INNER
CASING OR TUBING
(geothermal
closed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft.
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 ft•
305 ft
Thermex
Tremmie
ft.
Ft
ft.
R.
19. SAND/GRAVEL
PACK
(if applicable).
FROM
TO
MATERIAL
EMPLACEMENT MLTROD
ft.
ft.
ft.
f.
20.:DRILLING
LOG (atta
h additional sheets if necessary)
FROM
TO
DESCRIPTION (color, hardness, soil/reek type, gram sae, etc.)
0 ft'
25 ft,
Clay some sand
25 Et
40 ft'
Sandy clay with shells
40 IL
60 ft•
Sandy shells
60 ft
210 ft
Clay, shells, & sand mix
210 ft
220 ft
Sandy clay & shells
220 R
270 ft•
Silt with fine sand layers
270 ft
305 Et
Clay and sandstone
21. REMARKS
22. Certi cation:
Ignatnf ofCerti
2/1/17
Contractor Date
By signing this form, l hereby certify that the we//(r) was (were) constructed in accordance
with 1SA 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 als rWitiCnrel P 544fjlie-e-yary.
SUBMITTAL INSTRUCTIONSpppp` Mtnn -'
24a. For All Wells: Submit this fo- AR ha 39 dAys' completion of well
construction to the following:
( .,
Division of Water Re9bllP�fstltnl'Utmgtion Processing Unit,
1617 Mail Service Center, Haleigfi'NC 27699-1617
24b. For Iniection `3WEa.1•NEa�g
above, also submit one copy o ins ARff
construction to the following:
Division of Water Re4'Rs, dlegopynd Injection Control Program,
1636 Mail Service e e , Ithieigh, NC 27699-1636
form to the address in 24a
days of completion of well
24c. For Water Sun*, II cti Wells: In addition to sending the form to
the address(es) above, UN OgLiftlaSf this form within 30 days of
where constructed. n
completion of welW n Sa8Gttolg+ health department of the county
egional Offs
North Carolina Department of Environmental Quality - Division of Water Resources
Revised 2-22-2016

\RM Project Number: 1505 Live Oak Street First Citizens Bank Pagel
Beaufort, NC 28516
Driller: Sanford Sweeting
Date Drilled: Loop No. Loop Depth
GPS Coordinates
1/24/2017 1 305 34 43 33.3361 76 38 49.0445
1/25/2017 2 305 34 43 34.0453 76 38 48.577
1/25/2017 3 305 34 43 32.6633 76 38 49.8566
1/26/2017 4 305 34 43 32.5924 76 38 46.3007
1/26/2017 5 305 34 43 32.6952 76 38 45.6258
1/27/2017 6 305 34 43 32.6592 76 38 45.1986
1/27/2017 7 305 34 43 32.7021 76 38 45.1713
1/31/2017 8 305 34 43 32.3505 76 38 44.5258
1/31/2017 9 305 34 43 32.3457 76 38 44.5279
2/1/2017 10 305 34 43 31.8016 76 38 46.9491
2/1/2017 11 305 34 43 34.9252 76 38 48.232
RECEIVED/NCDENR/DWR
MAR162017
Water Quality R
Operations Section
Wilmington Regionalegional 0ffice

1
WELL CONSTRUCTION RECORD GW-1
1. Well Contractor Information:
Well Contractor :J Mt) F� J �!
Name
24? 3^ A
NC Well Contractor Certification Number
Company Name
2. Well Construction Permit #: 2 5 3 9 G
List all applicable well construction permits p.e. U/C County
, ,Slate, Variance, etc.)
3. Well Use (check well use):
Water Supply Well:
Agricultural
Geothermal (Heating/Cooling Supply)
Industrial/Commercial
Irri_ation
IL
Non -Water Supply Well:
Monitoring
Injection Well:
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
Experimental Technology
Geothermal (Closed Loop)
Geothermal Heatin • Cooling Rehm
gi...
Municipal/public
Residential Water Supply (single)
Residential Water Supply (shared)
DRecovery
QGroundwater Remediation
rr--t{
Salinity Barrier
D Storm water Drainage
Subsidence Control
QTracer
Other (ex lain Under#21 Remarks
4. Date Well(s) Completed:
Well ID#
5a. Well Location:
0±4 ' e'er
Facility/Owner Name
/CV
Physical Address, City, and Zip
61 I+ere t
ut
Dnee
Focili`� IN (if appiicable)
Foci,'
F,t
County
Parcel Identification No, (PIN)
56. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one let/long is sufficient)
W
6. Is(are) the well(s)
Permanent or fTensporary
7. Is this a repair to an existing well t1 �,�-r�(p
this h es or QNo
repairiu' a repair,1/2/ fell out known wellon the hack /formation and explain the nature of the
repair under ll2/ remarks section or on the hack a(Salami.
8. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction, only 1 OW -I is needed. Indicate TOTAL NUMBER of wells
drilled: j J £.
9. Total well depth helow land surface: =Ly
Far multiple wells l/sa all depiln ()Afferent (example- 3(r4200and 2©700')
10. Static water level below top of easing: J_!
If water level /s above easing, use "A"
I1. Borehole diameter: ✓ /
(in.)
12. Well construction method: j4 0 i7rki2..!
(i.e. auger, rotary, cable, direct:push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test: / /p
136. Disinfection type L 7 t'�zi
Amount: �t=_
(ft.)
Ponn GW-1
North Carolina Department of Environmenta
For Internal Use Only:
TO
n.
l5. OUTER CASING for multi -cased wells OR
TO DIAMETER LINER ifri, ilieahle
16. INNER CASING
® TOEING
�atcios PR® T`_l DIAMETER THICKNESS C
ll
PROM TO DIAMETER
-- SIR®
18. GROUT®�--23K13M-
FROM TO ,.�
innitla
al t">�1� tL �rA)�p� EMPLACEMENT METHOD @AMOUNT
Allan ialliallMale
�C:��;1i�LAG
ERni® EMPLACEMENT MET OD
MUM
20. DRILI ING LOG attach additional
-sss
FROM si
TO DESCRIPTION calor, hardness, soiereehr
e, ram sae, etaalanall
ralinffirma
Print Form
22. Certificati
z
Z1 signer +. fcertined WrII Co, sIenor % D !
Date
By signing this form, 1 hereby
/
)" that the well(swas
conructed in accordance
with ISA NCAC (/2C, 0/00 or /5AN(,AC 02C.0200/W Well Const uctian Standards and that a
copy ofthls record hos been provided m the well ownec
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 RECEIVE® �e�
24a. For All Wells: Submit this form within nay3{NC s of oompYRon of well
canstnletion to the following: (J�
Division of Water Resources, Iuf.%{tat(�uVr
licg 1617 Mail Service Center, Raleigh, NC 27699-1617 nit,
24b. For Inie f wens: In additionWi1tgfd(da"'
above, also submit one copy of this fortaililt atill.O g1DUlg(letions inwell
construction to the following:@fti6(9Rmiretian of well
WIIDII!)BtOn Rpninnal Ocri..P
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Su) I & 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.
I Quality • Division of Water Resources
Revised 2-22.2016

WELCONSTRUCTION RECORD (GW-1)
ell Contractor Information:
i/A 5CAi 6 940/Z- /1)
Well Contractor Name
NC Well Contractor Certification Number
l t1 & /V/ it l % (,-/xJ &
Company Name 2 2-
2. Well Construction Permit #:0 7 LE
8
List all applicable well constr Ilion permits (i.e. UIC,, County, Slate, Variance, etc)
3. Well Use (check well use):
Water Supply Well:
Irrigation
Non-Water Supply Well:
Monitoring °Recovery
Injection Well:
Aquifer Recharge °Groundwater Remediation
Aquifer Storage and Recovery °Salinity Barrier
}Aquifer Test °Stormwater Drainage
Experimental Technology °Subsidence Control
Geothermal (Closed Loop) °Tracer
1 Geothermal (Heating/Cooling�Return)flOther (explain under #21 Remarks)
4. Date Well(s) Completed: //Y' Z/) .-.1 Well ID#
5a, Well Location:
Agricultural °Municipal/Public
Geothermal (Heating/Cooling Supply) Residential Water Supply (single)
Industrial/Commercial Residential Water Supply (shared)
Insep vlAwr7y;`
Facility/Owner Name Facility ID# (if applicable)
t /Ian &i cr Af 4..
Physical Adds, City, and Zip
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,
one IaU1ongris sufficient) .l
!AI o yO'E fr D%% r/ N7 9 6T "!Z'C'% rt w
6. Is(are) the well(s)
Permanent or Temporary
7. Is this a repair to an existing well: ° Yes or No
If this is a repair, fill out known well construction information and explain the nature gfthe
repair under 1121 remarkv section or on the back of this foral.
8. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction, only 1 Cr -1,1 eeded. Indicate TOTAL NUMBER of wells
drilled: [7
9. Total well depth below land surface:
For multiple wells list all depths ifdi/ferent (exwnple- 3@200' and 2Q1005
10. Static water level below top of casing:
If water level is above casing, use "+"
11. Borehole diameter:
12. Well construction method:
(i.e. auger, rotary, cable, direct push, etc.)
tie)
/G
(ft.)
(ft.)
FOR WATER SUPPLY WELLS
WELLS ONLY:
13a. Yield (gpm) -,J Cif Method of test:
13b. Disinfection type: YI IU(Z_i &I`JAmount: 1 r.0 u G
rz-
FROM
%D ft
ft.
For Internal Use Only:
44183 /
I Print Form
14, WATER ZONES
FROM
ft, ft.
a
TO
%'G`) ft.
ft.
DESCRIPTION
15, OUTER CASING (for multi -cased wells) OR LINER (ifap Rouble)
FROM TO THICKNESS MATERIAL
ft. JI in.
DIAMETER
R.
16.1NNER CASING OR TUB IrY G (geothermal closed -loop);
FROM TO DIAMETER
ft.
ft.
17. SCREEN
FROM
TO
?Uft.
ft
18. GROUT
FROM
TO
6 re.
ft,
ft.
ft.
ft.
f.
ft.
ft.
DIAMETER
(3 in.
in.
MATERIAL
in.
in.
THICKNESS
}1 MATERIAL
'JLK 1(
SLOT SIZE
19. SAND/GRAVEL PACK (if applicable)
TO
go ft.
ff.
MATERIAL
I v c,
THICKNESS
MATERIAL
ev
EMPLACEMENT METHOD le AMOUNT
r
EMPLACEMENT�METROfy
tv f ✓e l'✓
20. DRILLING LOG (atta h additional sheets if necessary)
FROM DESCRIPTION (color, h1 rdneas, soit/rock .. rY type, grain size, etc)
i7MV1
u ft.
t.
ft.
ft.
ft.
ft.
TO
3; ft.
70 ft.
ft.
ft.
ft.
ft.
21. REMARKS
ft.
22. Certification:
Lfa-at '! -7 62' /d - 1) -` 6
Signal of Certified Well Contractor Date
By signing this form, 1 hereby certh that the wells,) was (were) constructed In accordance
with 15,4 NCAC 02C.0100 or ISA NCAC 02C .0200 Well Construction Standards and that a
copy of this record has been provided m 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.
24a. For All WeIIsBECENf®OD'E1,gwndays o}-completion of well
construction to the following, FEB & 2017
Division of Water Resources, Information oe ssing Unit,
1617 Mail geEBe 2e0er ugh, NC 27699-1617
24b. For Infection Wells: In addition to sending the' -form to the address in 24a
above, also submit on of this form within 30 days of completion of well
construction to the foliowo r wuarity Neglonal
�,„'�,err_ations Section
Division of WatWlnesolgroeg, ®agidooldj1 ij ection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Sum*, & 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.
Fonn GW-I
North Carolina Department of Environmental Quality - Division of Water Resources
Revised 2-22-201 G

WELL CONSTRUCTION RECORD (GW-12
1. Well Contractor Information:
4410db
PrintForm
For Internal Use Only:
Well Contractor Name
.)--mot 253
NC Well Con ctor Certification Number
G1`lr>7°Z �i b /LL(/Li
Company Nmne
2. Well Construction Permit 0:
List all applicable well construction pertllils (be. (/1C C'owi, , Stale. I aria
3. Well Use (check well use):
Water Supply Well:
Agricultural 0Municipal/Public
Geothermal (Heating/Cooling Supply) Ejli.esidential Water Supply (single)
Itldustrial/Commercial (Residential Water Supply (shared)
rrigafion
Non -Water Supply Well:
Monitoring E]Recovery
Injection Well:
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
Experimental 'Technology
Geothermal (Closed Loop)
OGroundwater Remediation
I; Salinity Barrier
D'Stonnwater Drainage
Subsidence Control
DTracer
Geothermal (Heating/Cooling Return) nOther (explain under 02l Remarks)
4. Date Well(s) Completed: Well 1D0
5a. Well Location: /(qq
IPVi/✓ • a41--I"N4/
Iity/Owner Name
/31 /71/L, (vve..
Physical Al!ddes� jru ,6-1y, and Zip
Crn
County
Facility IDf (ifapplicablc)
btie' t l vz -I--
Parcel Identification No, (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
Orwell cold, one la✓Ions is sufficient)
� �3;yz93' N �2 .5s s7
W
6. Is(are) the well(s)ermanent or DTemporary
7. Is this a repair to an existing well: EYes or
If this is a repair, fill out known well construction information and explain the nature of the
repair under tl2/ remarks section or on ,he hock 'It 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:
eke
9. Total well depth below land surface:
/
For multiple wells list all depths if tlijersmt (example- 3 a200' and 2(r 100')
10. Static water level below top of casing:
/f aeler level is above casing, use "
7�
11. Borehole diameter:
12. Well eonstruction method:
(i.e. auger, rotary, cable, direct push, etc.)
c se,
(ft.)
(ft.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm)
136. Disinfection type:
Method or lest:
/t(IVr? .Amount:
2i2-
14. WAT'EI
ZONkES.
FROM
TO
DESCRIPTION
r'
15. OUTER CASING (for
multi -eased wells) OR LINER Dr ej, Doable)
FROM
'1'O
DIAMETER
THICKNESS MATERIAL
ft.
ft.
in.
16. INNER
CASING OR TUBING: (geothermal closed -loop)
PROM
TO
DIAMETER
'THICKNESS
MATERIAL
/)ft.
0 I't.
l '
in.
el C)
II v"� -
ft.
ft.
in.
17. SCREEN
FROM
TO
DIAMETER
SI.OI'SIZE
T'mCKNFSS
MATERIAI.
(t/'Zft
/'Qft.
0
r / in.
"1
I
�Gh �(J
)
)� l..f � .,
H.
ft.
in.
IS. GROAT
FROM
TO
MA'rERRrr,in,
EMPLACEMENTM TI OD&AMOUNT
U ft.
'C fh
)TLf j.�)'
r,etire - f/l
ft.
rt.
ft.
ft.
19.SAND/GRAVEL
PACK
Of applicable)
FROM
TO
MATERIAL
EMPLACEMENT ETVOD
ft.
ft.
2o. DRILLING:
LOG (attack
additional sheets if ec slaty).
FROM
'10
DESCRIPTION (color, hardness, soil/rock type, grain sue, elo)
/7 ft.
3 5. ft.
c 1
Li_. tf
/f t) fL
i, 0 ft.
) (') n.
7 0-6
ft.
n.
ft.
ft.
ft.
ft.
21.. RENIARKS
22. Certtfl Lion:
2-r � r ,
re of Certified Well Connector Dace
-/I
y signing thh form, r hereby cerlijy that the wears) was (were) constructed in accordance
with 1SA NCAC 02C .0/00 or 15A NCAC 02C.0200 Well Cnnsin,c,ian Standards and that a
copy ol'lhis record has heen provided to the well owner.
23. Site diagram or additional well details; '
You may use the back of this page lie provide -additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL LNSTRUCfIO^ CEI WAladig6
24o. For All Wells: Submit tit:s,)'prm within 30 days of completion of well
construction to the following
FEB qq 0
21117
nn
Division of Water Rem rce emote how rrocessing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Injection Wells: In adiWm$1 ttQ4l�UtggRkegj'gnB)ro the address in 24a
above, also submit one copy tt�rJJ�I7n.,iPerrfaillISISEftfluber of completion or well
eonstruction to the following: V'/Ilmington Regional Office
Division of Water Resotmees, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supply & 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.
Forte OW-1
North Corollas Department of Environmental Quality - Division of Water Resources
Revised 2-22-2016

WELL CONSTRUCTION RECORD (GW-1)
1. Well Contractor Information:
h5ON ]vLo12,--1_cN
Well Contractor Name
NC Well Contractor Certification Number
011106--oN D/211,1.-1/J6
Company Nam 77 Z
2. Well Construction Permit #: `� L J �^
List all applicable well construction permits (i. c. (IIC. County. Stole. Variance, etc.)
3. Weil Use (check well use):
Water Supply Well:
Agricultural ,
0Municipal/Public
Geothermal (Heating/Cooling Supply) 'Residential Water Supply (single)
Industrial/Commercial Residential Water Supply (shared)
Irrigation
Non -Water Supply Well:
]Monitoring
Injection Well:
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
,Experimental Technology
Geothermal (Closed Loop)
'ryGeothermal (Heating/Cooling Return)
ORecovery
QGroundwater Remedietion
Salinity Barrier
fStormwater Drainage
Subsidence Control
Tracer
Other (explain undo § #21 Remarks)
4. Date Well(s) Completed: I' � %'� / Well !DP
5a Well Location:
1114'1,3P ON a --Ret`;N�
Facility/Owner Name Facility 1UN (if applcablc)
Physical
Address,
City. id Zip
County
Parcel Identification No, (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
Of wall field, ono lar/long is milldam)
5 f `2'd 135,;77 N 7L' `-3'7 ' ce, 4 /
6. Is(are) the well(s)i/xBPermanent or OTemporary
7. Is this n repair to an existing well: D Yes or o
ff this is a repair, fill out known well construction information aAd espiain the nature of the
repair under Ill/ remark. section or on the hack of this foam.
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: f ^r/v
9. Total well depth below land surface 7Z t2 (ft.)
For multiple wells list all depths if different (example 3@200'ant/ 2©/00')
10. Static water level below top of casing:
o1 6)
If water level is above casing, use •'+H
11. Borehole diameter: •. 111 (in.)
AO -tik)E1-
12. Well construction method:
(i.a auger. rotary, cable, direct push, etc.)
(ft.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpnr) 6 J /
13b; Disinfection type: /kil9//✓ei
:Method of test: r' ` 12-
Amount: 2 a D 64—
Print Form
For Internal Use Only:
441835
-14. WATER 'LONES
FROM
TO
DESCRIPTION
c, R.
1 ft.
C. .I
7 ".
32-G`t'
11 It
15. Oft TEIt CASING (for
multi -cased wells) OR LINER (if opQRuahle)
FROM
'1'O
DIAMETER
THICKNESS I MATERIAL
ft.
ft.
in.
111
16. INNER
CASING OR TURING
(genthern
al closed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
/ rt.
. , is, ft.
.1.74 in.
5Ei1 vo
10 ii ,c
ft.
ft.
in.
17, SCItERN
PROM
TO
DIAMETER
SLOT SIZE
'THICKNESS
MATERIAL.
-Jp%(i ft,
SL 4jfr,
[. in.
Z�7
cell 90
sb. L
t
n.
tn.
It GROUT
FROM
TO
MATERIAL
EMPLACEMENT METI OD MINT
0 f1.
"C. t.
D L l:�
tcrv/LfCd %1
ft
tr.
ft.
ft.
19.SAND/GRAVEL
PACK
(if sign heable).
FROM
TO
MATERIAL
EMPLACEMENT MEMI
?FiC ft._724
ft
-``)•.a-t/ f-t't
POve
ft
a
20. DRILLING
LOG (attach
additional .sheets if nee ssarv)
FROM
'1'0
DESCRIPTION (color, har nm, soll/rock typc, grain slay etc.)
Ct ft.1'7
ft.
J -I
10
/G/
2 v ft.
/Co ft.
S/it: /l oc S ri-/z c�
2.L `L
CC'tcz.e-?.
SQL) ft
qzL-ft.
l
(3—Z / Fly
ft.
ft.
21. REMARKS-
22. Certification:
2 jo
hi
Lure of Certified Well Contractor
aZ-->r .
Date
Hy .signing this form, I hereby certi(v that the well(s) f was (were) constructed in accordance
with 15A //CAC 02C .0I00 or 15A NC'AC 02C .0200 Wc/l Conavnct on Standards and thin a
ropy of this retold has been provided to the well owner.
23. Site diagram or additional wellpal/ isik�a
VOL, may use the back of this page M1/it�19���j i� mils or well
construction details. You may also attach additional pag@F'fPMe.
S U B M FITA1. INSTRUCTIONS
24a, For All Wells: Submit this form' will) n'3(YddyWbl completion of well
construction to the following:
Division of Water Resource ' ' 'g Unit,
1617 Mail Service % • h�r, �r 9f-f 617
ino
24b. For Injection Wells: In additinN seeding Ineertdnn�to-mee:address in 24a
above, also submit one copy of this form within 30days§ of completion of well
construction to the following:
Division of Water Resources, Underground Injection Control Progra nl,
1636 NLn1 Service Center, Raleigh, NC 27699-1636
24c. For Water Simply & I nieetin n Wells: In addition to sending the form to
the addresses) above, also submit one copy of this form within 30 days of
completion of well construction RI the county health department of the county
where constructed
Ponn GW-I
North Carolina Department of Enviromne rvd Oualily - Division of \Vaicr Resources Revised 2-22-2016

WELL CONSTRUCTION RECORD (GW-1)
1. Well Contractor Information:
0 J f>. Vj2-z.'U
Well Contractor Name
a 5 " r tar
NSW, elll Contractor Certification Number
/V 4Diz.`s7U R. 11- j fV 9 "sop
Company Name Z 9
2. Well Construction Permit #: 2 ti q Winston-Salem
List all applicable well cousin:Mon permits (i.e. U/C,, County, gle, grim r) . n
RIeg on `relfnc„
3. Well Use (check well use):
Water Supply Well:
Agricultural
..1. Geothermal (Heating/Cooling Supply)
IndustriaUCommercial
Irrigation
Non -Water Supply Well:
Monitoring
Injection Well;
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
Experimental Technology
Geothermal (Closed Loop)
, Geothernal (Heating/Cooling Return)
OMunicipal/Public
esidential Water Supply (single)
Residential Water Supply (shared)
Recovery
OGroundwater Romediation
Qsatinity Barrier
fStormwater Drainage
DSubsidence Control
OTracer
' )Other (explain under #21 Remarks)
4. Date Well(s) Completed: //r Si Well ID#
5a. Well Location:
,(////l r /Mete S
Facility/Owner Name Facility IDe (if applicable)
2° I I 1e&. 4(oures.4 c PC
Physical Address, City. and Zip
CAsteR�F
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
Of well field, one lat/long is sufficient)
43' 5h.3lnffN 7b°37 6 30'f W
6. Is(are) the well(s)OPermanent or DTemporary
7. Fs this a repair to an existing well: DYes or -fX1No
If this is a repair, fill out known well conslructian informationdts explain the nature of die
repair under 1121 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 need. Indicate TOTAL NUMBER of wells
drilled:
Ok
For Internal Use Only:
14: WATER ZONES
FROM TO
NC Department of n. (7 R.
Environmental Quality ft. ft
Received
For multiple wells list all depths If different (example- 3©700 CI
0' an, 1(10')
9. Total well depth below land surface:
10. Static water level below top of casing:
If water /eve1Is above casing, use""+"
II. Borehole diameter: ( -e
12. Well construction method: O
(i.e. auger, rotary, cable, direct push, etc.)
/0
(in.)
aOrboc2y
15..OUTER CASING
FROM TO
f4
4
DESCRIPTION
for. multi -cased well:
DIAMETER
fe.
OR LINER
A.
lfa
THICKNESS
in.
liable ".
MATERIAL
f16. INNER CASINO OR TUnING eothermal doped -too
FROM TO DIAMErRR TRICpJESs MATERIAL
in.
a & I R.
ft.
17•SCREEN'
FROM TO
DIAMETER —CIA—T SIZE
V ft. / 1 ft. i Z d
ft. ((//VV ft. m.
18i GROOT
FROM
T ft.
ft.
ft.
TO
ZJ f4
ft.
ft.
MATERAL EMPLACEMENT METROD&AMOUNT
TIIICRNEss
Pint Form,
c.—
MATERIAL
a)evititw feat �{oo Ibs
19. SAND/GRAVEL: PACK (if aPpllcable)
FROM TO MATERIAL
An ft COJit. S.sn cl
2el-DRILLII
oM
ft.
25ft.
S7 ft.
CJ
go ft.
ft.
ft.
G 4.OG (attach additional sheets: if nec
TO
5E ft.
ED n.
100 rt.
ft.
MPLACEMENT METR D
�oure�
r
DESCRIPTION color, bardnm, roiU:ock type, grain SI
Sid
Se �1Q y�)C.lLn-ty
CIV
V� L�
eta,)
22. Certification:
8i ofCertifsed Well Con tor
Date
By signing this Porn; I hereby cerrijy that the well(s) was (were) consinicted in accordance
with ISA NCAC 02C.0I00 ar ISA NCAC 02C .0200 Well Construction Smndardv and dim 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 pass iif�'ecessary.
SUBMITTAL INSTRUCT ENROv
1-,tEOVEDIV4C0
(ft.) 24a. For All Wells: Submit this form withiin 30 days of completion of well
7
(ft.) Division of Water Resources, nfD mat oOniProcessing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
a.
24b. For Inieetino Wells: In ad r rt ai ttry{ ReglOtlal
above, also submit one copy of thipag1� Teswi.101111 to the address in
EECC tt1AIC�mpletion of well
construction to the following: WII61If) OB
Division of Water Resources, Underground Injection Control Program,
1636 Mao Service Center, Raleigh, NC 27699-1636
2Ire addres. For s(es) Water SARAN, Se. infection welts: in
form to
es)above, also one of this form sending
30e days of
completion of.well constriction to the county health department of the county
where constructed.
v
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) �� Method of teat:
, it2
13b.Disinfection type:rl,,)bgt&V Amount:
Faun GW-1
)tS017
construction to the following:
North Carolina Department of En
ro
entnl Quality - Division of Water Resources Revised 2-22-
2016

WELL CONSTRUCTION RECORD (GW_1)
1. Well Contractor Information:
Well Contmetor-v 1
A9 S') -
OQ'1 ijfartment of
Received
NC Well Contractor Certification umber DEC 1 9 2016
` -1-7,1l LL Zit} CY1/1/inston-Salem
Company Name.
2. Well Construction Permit #: 02. f
List all applicable well construction permits (l.e. UIC. County, Slate. Variance, etc.)
3. WeII Use (cheek well use):
Water Supply Well:
e(; Iona! Office
Agricultural
Geothermal (Heating/Cooling Supply)
Industrial/Commercial
,I Irrigation
Non -Water Supply Well:
Monitoring
Injection Weil:
Municipal/Public
Residential Water Supply (single)
Residential Water Supply (shared)
Recovery
-i Aquifer Recharge ()Groundwater Remediation
Aquifer Storage and Recovery ()Salinity Barrier
Aquifer Test ()StorrnwaterDrainage
Experimental Technology ()Subsidence Control
Geothermal (Closed Loop) ()Tracer
Geothermal (Heating/Cooling Return)
FiOther (explain under #21 Remarks)
//"/✓ -
4. Date Well(s) Completed: /f/ Well ID#
5a. Well Location:
5epl,N* 4.1)Ain S
Facility/Owner Name Facility TD# (if applicable)
Z22 bOC►-VIS 141 he'htrjur Ale
Physical Address, City, and Zip
0; Ate
County Parcel identification No. (PIN)
Sb. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one hit/long is sufficient)
319465f f/r // p N 7i7JiL IZrZe2 I1
W
6. Is(are) the well(s)Permanent or ()Temporary
7: Is this a -repair to an existing well: - ()Yes or MNu
If this. is a repair, fBl out ;mown well construction information explain the mare of the
repair under 10 remarks section or on the hack of this form.
8. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction, only I GW-1 is WISH. indicate TOTAL NUMBER of wells
drilled: fL-
ON
9. Total well depth below land surface: /t e Vt.)
For multiple wells list all depths ifdlferent (example- 3©200' and 2©100')
10. Static water level below top of casing: / .G.- (ft.)
If water level is above casing, use "i-"/
11. Borehole diameter: 7 /ff (in.)
12. Well construction method: no -jy„
(i.e. auger, rotary, cable, direct push, etc.) /
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) s. -J Method of test: 7%2—
I3b.Disinfection typetelatt 2LjA/Q Amount: 1.I( C
Form GW-1
For Internal Use Only:
44065
DESCRIPTION
IS, OBTER CASING for multi -cased wells Ott LINER if `.licable
FROM TO
THICKNESS
ft.
ft.
DIAMETER
in.
16. INNER CASING OR TIMING eothermal closed -too i. �r:rrrn�
Can DIAMETER THICKNESS """`d
mileva
17. SCREEN
Print -'Form
ft.
FROM
TO
lo0R.
TO
ft.
MATERIAL
in.
SLOT SIZE
��E /mL EMPLACEMENT METHOD&AMOUNT
Yi/7i/L/Y IE�I,.
ft. fL
ft.
FROM
ft.
19. SAND/GRAVEL PACK - if a likable
TO
.i 1 ft:
ft.
MATERIAL
-_
mia
mamma
ft.-m a EMP�'�MENTMETarD
20. DRILLING: LOG attach additional sheets if access
FROM
agnom
TO �� DESCRIPTION color, hardness, eoiVrc¢k ¢, rain size, etc.
Ealanra
Marailialera
alle
wig
ft.
ft.
lit.
ft.
ft.
21: REMARKS..
i ntocrroation ror:osririt
22. Certification:
ture ofCerttfied Well Contractor
24a, For All Wells:� Sub iVCDENRIDWR
within 30 days of completion of well
construction to the following'
Oslo
By .signing this forme I hereby cargo, that the we//(s) was (were) constructed in accordance
with ,j4 AC'02C.0100 or 1SA NCAC O2C 0200 Well Construction Standards and that a
ccopy ofdus 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
Division of Water Restopcpts,{oor�1,, `7
1617 Mail Service'Cin'fer, Raleigh, N 27699-161 Unit,
24b For Iniection Wells: In addition to_gcj�d�ire :('palm to the address in 24a
above, also submit one copy dNNBtigtt�11J>5°U, + L (slays of completion of well
construction to the following: Operation
Regional Office
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Smutty & Iniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this forrn within 30 days of
completion of well construction to the county :health departmentof the county
where constructed..
North Carolina Department of Environmental Quality - Division of Water Resources
Revised 2-22-2016

WELL CONSTRUCTION RECORD
1, Well Contractor Information:
ot,J
Well Contractor Name
N Well Contractor Certification Number
Company Name
2. Well Construction Permit #: -'
List all applicable well contraction permits (i.e. Uic Co
3. Well Use (check well use):
Water Supply Well:
Agricultural
Geothermal (Heating/Cooling Supply)
Industrial/Commercial
Irri:. tion
R.)LA—
Non -Water Supply Well:
Monitoring
Injection Well:
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
Experimental Technology
Geothermal (Closed Loop)
Geothermal (Heatin_ Coolin . Return)
Facility/Owner Nam
-partment of
nvlronmenia
Received
N, Sa
°. Grcf
municipatiiii6jional Office
�2esidential Water Supply (single)
esidential Water Supply (shared)
Recovery
QGroundwater Remediation
QSalinity Barrier
QStormwater Drainage
DSubsidenee Control
DTracer
Other ex i Jain wider 821 Remarks)
4. Date Well(s) Completed:
5a. Well °cation:
o eta
Facility IDN (if applicable)
&4et r crwl ! Q r( /2�2(t tQs Physical Address,City, andZp
NC -
County
C4)4teae i-
Panel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
?V°51136,05" .N7lo°/$' ✓rls/�
6. Is(are) the well(s)yNrpermanent or ]Temporary
7. Is this a repair to an existing well: - J Yes or ON°
If this is a repair, fill out /mown well construction information and explain die nature of the
repair wider HE 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-I is needed. Indicate TOTAL NUMBER of wells
drilled:
9. Total well depth below land surface: �� For multiple wells list all depths iifdderenl (erample-i@200 and l@I00) _r(ft)
10. Static water level below top of casing;
If water level Is above casing, use "1 " (R.)
11. Borehole diameter: /
(in.)
12. Well construction method: Q- 2i(
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gPm)
Method of test: O(
136. Disinfection types. )Kim Amount: 0 ei
Bonn GW-I
For Internal Use Only:
14
AT
R ZON
S
TO
✓ � ale1
6.1...1111
le
Is:CASINO for multi -cased wells Oft.LINEge licsbl®
a A DIAMETER �ki
16. INNER CASIN
ININal etoae
PROM TO DIAMETER
TnICR
®r
=�
FR,SCREEN
PROM TO DIAMETER
�
18,.GROUT
:
Feint FgGbfl;
MIMI
®EMI
19. SAND/GRAVEL PACK if a u in-
FROM
ft
ft.
SLOT SIZE
IMMO
ran 0 rt. I
r6
F . REMARKS
EMPLACEMENTMETROD & AMOUNT
re WI nrentriat
EMPLACEMENTMETROn
20:1)12ILLINC LOG attach additional stir
PROM TO DESCRIPTION
=oor, harsn�iVroek e rain she, etc.
22. Certification:
Ate
rxiglfatare ofCerti6ed Well Contractor
B si Date
y gning this form, 1 hereby certify that the well(i) was (um) crosmuned in accordance
with 15.4 MAC 02C.0100 ar iSA N'CAC 00 Well Construction Standards and that a
copy of this recmd well owhas 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 W Ifs: Submit this form
construction to the toliowin : within 30 days of completion of well
e
Division of Water Resources, Information Processing
Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b, For lnieells: In addition to sendingthe for m to the adin 24a
above. also submit one copy of this form withi30 days of completion resSof well
construction to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699.1636
24c. For Wn r S,cenin Wens: In addition to sending the form to
the uddress(es) above, also submit one copy of this form within 30 days of
completion of well construction to the county health department ofthe county
where constructed.
North Carolina Department of Environmental Quality - Division of Water Resources
Revised 2-22-2016

For Internal Use Only
441202
WELL CONSTRUCTION RECORD (GW-1)
1. Well Contractor Information:
R. Mark Walton
Well ContractorNaine
3062
NC Well Contractor Certification Number
Walton Engineering
company Llama
2. Well Construction Permit M:.. .
List ail applicable well consentctionpenntls 22. UIC. County, State Variance. eta)
3. Well Use. (check well use):
Water Supply Wen:
()Agricultural
JGeotltermal.(Healing/Cooling Supply)
hidustrialleorinhertial
nlrrigatiOn
Non -Water Supply Well:
[tifnnitating
Igjection Well:
Sutler Recharge
Aquifer Storage and Recovery
3Aquifer Test
jExperiinentalTechnology
Geothermal (Closed Loop) DTracer
aGeothermal (Beating/Cooling Return) ::°Other (explain under 02tReal
ts)..
4. Date Well(s).Completed:.12-20-2016 Well Ma
AMW-1. R
5a. Well. Location:.
First Base Convenience Store 6093 / 23148
°Municipal/Public
°Residential Water Supply (single)
()Residential Water Supply (shared)
['Recovery
()Groundwater Remediation
()Salinity Ranier
°stonnwater Drainage
°Subsidencc Control
Facility/OwnerName Facility/1M if applicable)
Mr. George Edward Wheatly
Physical Address, City, and Zip (� Y'S..Y.
ada cape Lookout or. fiarkefs Island 28Sst 733514252087000
County Parcel Identification No. (PLN)
h.Latitude and longitude in degreeslminutes/seconds or decimal: degrees:
(if well field, else bt/kegissufficient)
34°41'70" 76°33'75"
6. Is(are) the 'well(s)SC Permanent or E3Temporary
7.1s this a repair to an existing well °Yes or EffiNo
11 this 13 a repair, fill oat known well cOnstructtan infannarton and explain the nature of the
repair under #21 remarks section or on the back ofthis form.
8. For GeoprobeDPT or Closed -Loop Geothermal Well hatingthe same
constmction, only 1 OW-1 is needed. Indic:te TOTAL NUMBER of wells.
dolled: NA
9. Total well depth below land. surface: 5-7 _ (n.)
For mal:iplewells list all depths lfd11Thaint (erampk- 3®200'- and i@JOB)
10. Static water level a below top of sing: i}. 58 (ft)
ifwater level is above casing use'*"
11. Borehole diameter: 3•5 (in.)
12. Well construction method: Auger
(i.e. auger, rotary, cable: direct lmsh. etc.)
FOR WATER SUPPLY WELLS ONLY:
I3a. Yield (gpm) Method of test:.
13h,Diaiukectioa type: Amount:
PItUM..
TO
DEat'.RIPCION
R..
0.58 ft.
5.7
A.St73GiYnEamliL-eoi6c4't=fteiG4taEIP.)Y'?t±tY}@".a¢I"{
70
Groundwater
b1AMETER
1'llrCKNES$
a1ATERLIL
:k)vAfr#"k
PROM
{)
0:7 ft
2 .
0.154
PVC Sch.40
�I.'
FROM
TO
D6CMR'1'Ea
TBIC(.'NES$
MATERIAL
ft.
1
M.
ft.
R
ID.
=
1RtOat
TO.
DIAMCrER
1(9LOT SIZa
TOICT4YEES
MATERkiL
0.7 If.
5 g.
2 lei.
0.010
0.154
PVC Sch:40
FTiOM
TO.`a
MATEEML
&i1PLACEMEMTMETDOD &AMOUNF�
0 R.
0.5 ft•
Cement Grout
0 55 ft.
0:7. ft•
BentonitePdieis
rt...
fL
3 t N('ph`,1*1rkDk""{f.•'•
W)
ROM
- To
MATEMA&
IS OD
0.7 R-'
5.7 n.
Well Pack filter Sand
.._._. a.
R.
Cx.X:gGsaTattstb'ftilQlt7enaisbe'e"3xi[4&c.ggY
TO ..
: DESCRI%TON (color, bardear,
r-:;%u.� :.'� S:s..
sewmtk t pa, grain Da, ate)
20;>Ultllds
PROM
0
0.5 rr.
white sand
0.5 R
5,7 m
dark sand
n
fr.
t.
it
nrrTE-LtIV.;...
D
fr.
f4
a
tr sir , ... 0O
D`WQlf3t Xa
22. CCeratification:
Signature of Certified Well Contractor
Date
By signing this form, 1 hereby certify that the well(.[) was (*erg s cynsnvized in accor&mce
with 15s1 NC,AC 02C.0100 or 15A NGAC 02C.0200-Well Construction Standards and that a
u,py ofrhi-reconlhas been provided to the well owner.
23. Site diagram or additionai'wel details:
You may use the bad: 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
constructiontotter following
Division of Water Resources, Information. Processing Unit,
1617MailService Center, Raleigh, NC 27699-1617
24b. For Inieetion Wefts: In additipikai
above, also submit one copy of th $bi6!'0tl'
construction to the following Division of Water 1636MaliServiceCen ffptnc¢ni controlkeig1>NC`l -1636Program[
24e. For Water Supply & lnieetioaWe@fle,
the address(es) above, also submit
p7
completion of well construction to the wow,
where constructed. Wilmington
j address in 24a
f completion of well
ding the Ta nt to
thin 30 days of
the county
glop
Perm GW-)
Nmlh Carolina Department of Environmental Quaiity -Division of
e
Revised 2-22-2016

4" Minimum
1" Minimum
Ground Surface
/j�j:
\\f
Non —Shrink Grout Seal
2" Sch. 46 PVC Well Casing
i
Sand Pack ---__
2" Sch. 40 PVC 0.010" Slot
Well Screen
3.5" Borehole
7
\fN
Security Manhole with
Watertight Steel Cover
aterkight Well .Cop
5'
Natural
Subgrode
Sentonite Seal
5:
Figure
ANW-1R
Project -
First Base Convenience Store
Title:
AMW - 1 R Detail
W4Lraw EN-Grk7FERING
tt10/2017 I Scale:
NTS
LS
8'
_DAT
Project 4:
206257

,04fr'
®
6
Z
W
:D
J
-\C Q
A- 4^ v=(i
O0 ^ Q \
CT
cn
ce
c�
J
S
d
0
3 e
01
Q
0
jr
LDrawn by: JLW/GSF/DAT

WELL CONSTRUCTION RECORD (GW-1)
1. Well Contractor Information:
%sc' J p. 'Yt'2 lax)
Well Contractor Name
2ckS
N Well Contractor Certification Number
, /Vto/z ° s7u `I fa t LL: P G-
13b. Disinfection type:Ctl:Ibk I$.)ti Amount:
Fonn GW-1
Company Name
2. Well Construction Permit #:
List al! applicable well construction permits (/.e. 1!/C County, State, Variance, eta.)
3. Well Use (check well use):
Water Supply Well:
Agricultural
Geothermal (Heating/Cooling Supply)
Industrial/Commercial
CitIrrigation
Non -Water Supply Well:
Monitoring
Injection Well:
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
jExperimental Technology
jGeothermal (Closed Loop)
`"}Geothermal (Heating/Cooling Return)
Municipal/Public
Residential Water Supply (single)
DResidential Water Supply (shared)
Recovery
QGroundwater Remediation
Salinity Barrier
fStormwater Drainage
DSubsidence Control
QTracer
Other (explain under #21 Remarks)
4. Date Well(s) Completed: ! / 3- / (j
5a. Well Location:
M om,tS 1 t DJe
Facility/Owner Name
53i'{ Qouge Salmi Deg
Physical Address, City, and Zip
C'AISte12t-i"
County
Well ID#
Facility ID# (if applicable)
gMw2 i tist_ NC
Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one Iat/long is sufficient)
3V °y0'a6. s." N ',6 °59' 4,7
6. Is(are) the well(s)0Permanent or 0Temporary
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 1l2/ remarks section or on the back of this form.
8. For Geoprobe/DPT or Closed -Loop Geothermal Welk having the same
construction, only 1 GW--�edE. Indicate TOTAL NUMBER of wells
drilled:
9. Total well depth below land surface: /.(7
For multiple wells list all depths ifdWere,rt (example- 3@200' am/2@100)
10. Static water level below top of casing: 65
If water level it above casing, use "+"
I1. Borehole diameter:
12. Well construction method:
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONI Y.
13a. Yield (gpm) �u Method of test: /14
North Carolina Department ofE viromne nal Quality - Division of Water Resources
ff
W
(ft.)
(ft.)
For Internal Use Only:
14. WATEl ZONES
FROM
/30t.
ft.
TO
Print Form
441036
DESCRIPTION
/L /nt.
ft.
15, OUTER. CASING (for Multi -cased wells) OR.LINER (if ap'dicable)
FROM TO
/1 ft.
16. IN
FROM
/ ft.
ft.
DIAMETER
ft.
in.
THICKNESS
CASING OR TIEING"(geothermal closed+leolD
17. SCREEN
FROM
/3af.
ft.
TO
/ 3d ft.
TO
ft.
/loft.
18. GROUT
FROM
ft.
ft.
ft.
ft.
DIAMETER
in.
in.
MATERIAL
TRICKINESS MATEmAL
DIAMETER I SLOT SIZE L Tmcn NEss
�C "a'r
9/in.
in.
TO MATERIAL
zv
- D m Mate- htI.
ft.
ft.
19. SAND/GRAVEL PACK (if applicable).
TO
/SP ft.
H.
FROM
/JO R.
ft,
MATERIAL
/0VC-
EMPLACEMENT METHOD & AMOUNT
t'v w edi 1/410 !d
MATERIAL EMPLACEMENT METD/�1D
Saab-fd Pa oft d
20. DRILLING LOG (attach additional sheets if necessary)
FROM DESCRIPTION (eobr, hard esa, soiVraek type, grain afu, etc.)
35 rt.
ft.
30 fL
ft.
To
5_5- ft.
50 ft.
90 ft
/31'ft.
isp It.
ft.
�//�/"le/y C GA-z-k
?lave SA -ray CGrt-f y-
ft.
ft.
21. REMARKS
22. Certification'
_.TIED
JAN 1 1 2017
J%� ion Proceesiirg Unit
� er�et' �l " ` ®/BOG// " / 6' j' ,
e ofCertifi W Canna or Date
Dy signing this form, I hereby cent)" that the we//(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 Resou[.grsp
1617 Mail Service cams,,
it,
24b. For Infection Wells: In addition to sending the form to the address in 24a
above, also submit one copy of this form v in'f�0rrlav yypa.ompletion of well
construction to the following: �Ht ` 1 LU fI
Division of Water Resources, Underground Inketion Contra' Program,
1636 Mail Service CentdflJBteterimaYldy2 Ljl�r§6
zar. For water c n lv & , r Operations Section.0ilargdtgtftoijalstffling the form to
the address(cs) above, also submit o' co of this form within 30 days of'
completion of well construction to the county health department of The county
where constructed.
Revised 2-22-2016
f