GW1 - Columbus 2017

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,1: Well Contractor Info tlon:
0-
Will Contractor Name
For Internal Use Only:
446300
i arra+asow�ilMaI:.lar,r,S: a Ss g ialt_;ti'-."�-s= -
TO
FROM
DESCRIPTION
3/3,
Com N
NC Wet Contractor tionNumber
Z?a•- Bell O t7 j 1maY erne
2. Well Construction Permit #:
List all applicable well construction penes (Le. VIC Cmady, Slate Parhmee, etc.)
3. Well Use (check well use):
Water Supply Well:
DAMMultuml
DGeothetmal (Heating/Cooling Supply)
DInduetrial/Commercial
11bn:ration
Non -Water Supply Well:
Monitoring
jettion Well:
3Agnifer Recharge ®Groundwater Remediaton
DAquifer Storage and Recovery OSalioity Barrie
DA/Plifer Test QstormwaterDrainage
()Experimental Technology DSubsidence Control
InGeothermai (Closed Loop) DTracer
,Geothermal (Heating/Coolin,) Other (explain under #2l Remadm)
4. Date Well(s) Completed: GG(((//// l 7 Well MN -
0MtmicipavPublic
Residential Water Supply (single)
Residential Water Supply (shared)
51041 pardon:
Noah. 01
DR.ecoveri
Pack' /DwcerN me / •a Of apwtabt )
{W r o1 ti Da 4PI( Wkelva4,401-14. Physical Aiessinty, aadzig
County Parcel IdeeificatioUNo (PIN)
5b. Latitude and longitude in degrees/minutes/seconds
Orwell field. one latdom is sufficient) s� ('@ 2.
•
N
ft
ft
°�eDN33L'R'Gd1SR'f4"dtaF`tisYa fR o la S FROM TO DIAMETER TTFICKNES .L
ks-^„ sel�..
TO
ft
n
FROM TO
p3m
ft.
ft.
ft
DL4METER THICKNESS MATERIAL
in.
to
Ia1@I'RR I SLOTSIZE TIDG¢eas MATERIAL
te la
FMMA r>BN'r_ MBTHtm&AamONT
:D. ft . « V
FROM
FROM
0
TO ' MATERIAL
fit
Lti
'oft
fft
ft
ft
Fa1ELAceA16NTMETHOD
TO DESCRRTDNteam horde Rareatr�aardeshe. eta)
Sebtd- cal a y
eft
7o rt Sg4.1
tow
ft
Lm�
t
64.
6. Is(are) the weU(s)gP®Permmnent or DTemporary
�C M.formation Proci,.::-v`gt
7.Isthis arepair toanmisting well: Yes or 0No DWG/BC/3
Ift81s isarepair,fdlominown well co
silencedoplam fienatere ofdse
repair under a21 remark rscales or on the backofthis fo m.
8. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction, only 1 GW-1 is needed. Indicate TOTALNUMBER of wens
drilled:
SEP 1 1 2Th7
9. Total well depth below land surface: ` (fit)
Formuh(ple welb ilstall depths ifdtfferem (emmple-3(t1200'and 21 u@100)
10. Static water level below.top of casing: eel (ft)
lfwater level is above casing, use "+" or J
It Borehole- '
otebole diameter: (/
A4,7
12. Well construction method:
(Le. auger, rotary, cable, divert push, etc.)
FOR WATER SUPPLY WELLS ONLY: _
132. Yleld (gpm) r llgethod of test:
13b. Disinfection type: _ 4 - i r'Amounts
nos
S3(mLaeo
5y signing this farm, / hereby are that the well(s) our (were) conflicted in aacanfanee
with LTA NCAC DSC.0100or lid NC4GOAG
copy ofthir record has been provided hal
tient
tractor Da
1 a
Y
.. rdards and shay a
23. Site diagram or additional well details:
You may use the back of this page to • •([Irnq{fggp site details or well
construction details. You may also a Vage& ffnecessary,
SUBMITTAL INSTRIICF1ONS
Water quality Regional
24a. For AD Wdis: Submit this fonpliAmpnsdggeMgNompleion of well
commtction to the following: Wilmington Regional Office
Division ofWater Resources, Information Processing. Unit,
1617 Masi Service Center, Raleigh, NC 27699-1617
24b. For Irritation Vella. _ In addition to sending the from to the address in 24a
above, also submit one copy of this form within 30 days of compleion of well
construction to the following:
Division of WaterResouras, Underground Injection Control Program,
1636 Mall Service Center, Raleigh, NC 27699-1636
24c. For Water Smash & Ibjection Wells: In addition to sending the form to
the addtess(es) above. also submit one copy of this fonts within 30 days of
completion of well combustion to the county health department of the county
where constructed.
Form GW-1
North Carolina Department of Environmental Quality - Division of WaterResources Revised 2-22-2016

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RECFIVFp/NCDENR/9WR --
SEP I-m 2017
Water Quality Regional
Operations Section
itmi ngtorsR4onsTOffice

1. Well Contnctorinformado
Well ComtacOtName
To big/
446299
FROM
TO
DFSCROI'ION
3`f,
NC WeB ctos'A honNumber
CompaoyName
2. Wei Construction Perndt#s
meta applicable wellamamrdlou panda 4 (Le. WC. Coxn%. State, Variance, eta)
3. Well Use (check well use):
Water Supply Well:
Agricalittrai
Geothermal (Heating/Cooling Supply)
lndustaal/Commocial
Irrigation
Non Water Supply Well:
inhering
Injection Well:
Aquifer Recharge
offer Storage and Recovery
Agwfr Test
Experimental Technology
Geothermal (Closed Loop)
DMlmicipal/Poblic
'denial Water Supply (single)
Residential Water Supply (shared)
E3Recovery
®GmnndwaterRemed;aation
®Salinity Barrier
Dstomawater Drainage
subsidence Control
DTracer
ft.
ft..
PROM
do
TO
DIAMETER
In.
irriPlayom
rSe-Yo
FROM TOD ymrxnoea .eel a pc_
, :Lt.;2 5i z:jorrt. Tate .1-Y0 M
_it.
trit
ft.
in.
PROM
1O
3iP
is
Mamma
2_.�
tu.
?is
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fa
ff.
n
xr_-:ii
/r7
peg
&ave
inaratamaxermarnon&AM aglow
bar -4
FROM
Ma
4:
ft.
Surma (tHeatiug/coolingflpu_mm)/ nOHier(explaiunnder#21 Rom)
4. Date Wallis) Completed, ',' 7 Wellffi#
sa. Laegflpn:
Faoility/OwnerWame Facility r($
.73 7 Qiuec tJa✓d W et
Physical A GSty, and Zip
do (kmint,
County
linable) ge-
t •Zirrie
Parcelldentifio'ationfo. (PIN)
Bb. Latitude and 4ongltude In degreestminatesIsecoada or decimal degrees:
(if well Seal, one IaUlong is sufficient) y�
t �,,,r
FROM TO
0
/0a 17 ft
"fir Weal=
Di ScRonIONealae. bantam Ram* true nobadc.ere)
D o SMbJ&.. —Jam4
4,4
"Oft. 7 ! L(:s4-_ S 7'»r c.
rft g oft a t
• • 6o�-f` eZs Safi
sue, ipa ,i.u�-�'v`�%'-`-}R-it's' ice' p$' t 'G;ysy,'*,s'
6.11(are)the well(s)WPermanent or QTemporary SEP 1 A 2017s
igiocueofCadfieft Well Canvastor Data
Ry signing this tom t hereby certify that the welt(s) was (were) constructed in accordance
7. btldse repair to an existing well: ayes or 1 518tmtl `'r` °'.helthl'3ANC4CO2C.0100 orISA NCAC 02CA2000'el Cousoucdou Standards and thola
if this Lea repan•.jiltaedhaoxw snrl/conabattsianf�brmalTan curtain 1PrjItaefdte copy gflhkreeardhas hen provfdedto the wdtoroner.
repair wader #21 remorta sectionor an the bait of chi s form
S. For Geoprolse)DPT or Closed -Loop Geothermal Wells having the same.
construction, only 1 GW-I is needed. IadicatoTOTALNUMBERofwells
drilled: -
9. Total well depth below land surface: 3/ p (ft.)
Formdtrple wells Asian cloths{idi$aene(eseninte-3@200'and *NO
10. Static water level below.top ofeasing:
70
treater level kahaveousfeg use"-,"
11. Boreholediameter: 0 Qp��((3..)yn)
12. Well construction metbod: /"a "t%
(ie.apge , sonny, cable, dinar push, ex.)
(th)
FOR WATER SUPPLY WELLS ONLY: _. ,
13e. Yield (gpm)
13b. Disinfection type: )/ 'hate Amounts
7 b Method °Rest: /et/ re
[.f
23. Side diagamoradditonalweudetaR€CEIVED/NCDENR/DWR
Yon may use the back oftbis page to provide additional well site details or well
construction debits. Yon may also attach additional pages if necessary.
SUBMITTAL INSTRWCIIQNS SEP 18 2017
24a. For AD Welfp: Submit dsis from within 30 days of completion of well
construction to the tollowing: ' Water Quality Regional
Division of Water Resources, n t !
1617 Mall Service Center, x 4 }"'•ef.�'- e
24b. For 'election Welly: In addition to sending the form to the address in 24a
above, also submit one copy of this form wlthm 30 days of completion of well
oonstmetion Io the folbwing:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Weigh, NC 27699-1636
24e For Wylie SLaoI, & Intxdon Welly: In addition to sending the form to
-the address(m) above also submit one copy of this four within 30 days of
completion of well consmmtion to the county health department of the cowry
where conau eted.
Form GW1
North Carolina Department efEnvironmental Queity- bivisionofwaterResources - Rev ed2-22-2oI6

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5tr 18 2017
Water Quality Regional
Operations Section
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446298
`1. Well Contractor Info
Ia 0 jiv#
Well ContmctorNeme
3, 51
NC ei Couramor CrtilatiooNut /
Clilli✓Oic &d( Dui lA
Company Name
2. Well Construction Permit 91:
List all applicable -well cortroodion permits(Le. WC, County, State, Variance, eta)
3. Welt Use (check well use):
Water Supply Welk
Agricultural - ©MtmicipaVPublic
Geothermal (Heating/Cooling Supply) BResidential Water Supply (single)
mdustdal/CommacialResidential Water Supply (slated)
hdgttion
Non Water Supply Well:
Monitoring
DRecovery
rejection Walls
AquiferRecharge
Aquifer Storage and Recovery
■ .- Test
tt ExperimentalTeohnology
Geothermal (Closed loop)
Carthamel (1iealmg/Coolmg
Domnodwater Remodiafioo
©Salinity Barrie
Dstonnwater Dra(mge
©Subsidence Control
DTI
Other(explaintmdertal Remarks)
4. Date Well(s) Completed: f i 7 Well MN
Well Location: /
Qf(,A, /is 6u%l-
FaciliryR)wnetName Facility grapy la) Mt
g7.59 Aniertoef f 7$ v * uwo
rhysiest Ad4ps,(any, and Zip
Bute ti-7
County
5b. Latitudeand longitude indegrees/about
Orwell field, onelatileag is soavieat)
Is( ) wellO o...,,.,...
6. are the s Permanent or -k1 �'O"
7.1sthis arepair toanexisting we& Mies or DNo
Ifthis is a repairfillOle bwwa NelconrtruiIwm rmadonenderpkh: the nature afthe
reeair.wrder#21 remarkssecfmnorem the back *hit form. .
S. For GeoprobetDPTorClmad•Loop Geothermic)/ Wells having the same
construction, only 1 GW-1 is needed. Indicate TOTALNUMBER of wells
drilled:
11
9. Total well depth below land surface: ' (ft.)
For multiple wells Ea alIdepths fattens (example- 3(r)2O Ofl 2@i009
10. Static water level below top creasing:
lfwater level is above cashtg, use +h
11. Borehole dilatator:
12,Well constnieionmethod: )lye fr
(Le.avge , Maly, able, dhatpusb, eta)
(L)
FOR WATER SUPPLY
//WELLS ONLY: .
(oO
^BROM
70
DESORPTION -
O.
ft.
ft.
— -
;3:11nE Rims
_ . mai nat2amreR
;:.
• FROM
TO
DIAMETER
au eS MAL''����nR�sAAIt..
o
��dA[rldiiga7f_
Rh
L 0 Cs
a
MR
-,
FROM
march DR
TTDDICNNNEESS
MATBRML
/��'
+�/¢�
501-
2tin
)_G/ 7
Q(/C-
it."
ft
ht
/
.. A .''v ..
-' +��L3+�iu
i`Y''A ..: ic-i:..
''''(tl
ff.
io
f
Yt� �9yty,
tl$�ilR"�. :.v"s �t aF3._..;...#fu,
MOM
TO
MAIEI
b rt.
M r.
•AC'IId4ENYME'IH6II&AMOUId7
e
77-41 J 41.441u
ft.
ft
Deer"
rw
ft
,
DaQLACSMENTAMETROD
MOM
TO
MAMMAL -
n
ft.
O
ft
r
FRO.!
70
DESCRPATT trier Matmrs,$wrutki,ae.Min'm"etc)
f /
OB°-
Ci is t -
!
it
5AA,c'— - t /1
1fr
0
414
ft.
IE
,
f
ib
e� 74/
,54/70
i
�
6/
U %
Date .
m signing MIs farm I herby cue that the walls) was *re) coas,wied b accordance
with ISA NCAC OIC.0100 or HA MAC 01CA200 Well Contraction Slandevds and that a
copy oats record Aar been provided to Ike welt owner.
23.Sitediagram oradditional wd UED CDENR/DWR. You may tree the back of this page to provide one w a or well
construction derails. You rosy also attach additional pages ifaecr:wary.
strBMItFAL INSTRUCTIONS S E P 1 8 2017
24a. For AB Wallet Submit this fain within 30 days of completion of well
constuctiontothefoiltowing: Water quality Regional
Division ofWaterReno gyp,(,, :'' ;; __$gffit,
1617Mail SenkeCaner,'<:,", is
246. For hdee ilo0 Welk,: In addition m send ngthe form to the address in 24a
above, also submit one copy of this fmw within 30 days of complefon of well
constmcdantothe following:
Division of Water Resources, Underground Injection Control Program,
1636 hied Servtce Center, Raleigh, NC 27699-1636
24c. Far Water Snook & intention Wells: In addition to sending the form to
-the address(es) above, rho submit one copy of this fort within 30 days of
completion of well tmnsbuetion to the county health dent of the comgr
whiecoastnmted,
Form OW.I North Carolina Depraaentof
vhommeotalQuality - Divisionof Water Resources - Revised2-22-2016

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SLP 1 8 2017
Water Quality Regional
Onerations Section
Wilmington Regional Office
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1. Weil Contractor Info 4Ion:
o l
a w....w...m. vas vu j.
44b"co I
WellCanaamorNeme
3/"
NC Wel ctorCAutifladonNumbar
/l t e Jo+,. - lit GL(
Comps Name
2. Well Construcdon Permitt
List all applieabkvelI coronation anion permits fie. WC, Canny, State, 8arlana, etc)
3. Well Use (check well use):
FROM
7D
ft.
a/MENTION
fl &IY1.1RN e9SQif+"([M?duld sad 1. i y-.
;F$OM To D T'w
'� 7 Oft coo
09 spa c' d�4a4oda� x ;- . .
FROM
TO
tt.
Z6La
".
la.
la
TmCKNes$
rib
ater Supply Wen:
Agricultwal . Municipal/Public
Geotbemial (Ilesting/rnoling Simply) Residential Water Supply (single)
MdosniaUCommeroiel DResidential Water Supply (share!)
Non -Water Supply Well:
Monitoring
Injection Well:
Aquifer Recharge
niter Storage and Recovery
Amen Test
Experimental Technology
Geothermal (Closed Loop)
eothc mal(Resuag/CeolmgR
4. Date Well(s) Completed
Well Location:
ea % f 1 /Crete' IA-.
'Faoility/thmerNeme Tuft JEW Of le)
N C 6044, tog. A T boref mcilv0
®Rercye y
riGmnndwater Remediation
®Sallni6y Balder
QStormwatermainage
Subsidence Control
ofracer
f other(explainunder#21 ReasS)
!'r /-7 WeO1D#
Physical Address, coty, and Zip
A 44
61(4
County
5b. Ladtude and longitude in degrees/mindtesisewads ordeelanYdggeeat:
Orwell field, one ladlongis sufficient)
SEP 1 b 201
W
6.Is(are)the weu(s) Permanent or empdr
7.1s this a repair to an existing well: Ares or Na
rats tea repaa•,fillant lawn well QMrtructionhglannatlon esplabzthe nawresfthe
repairwrder#2l remathssection oronthe back01Mrfarm. .
S. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction, only 1 GW-I is needed. Indicate 7t)TALNUMBER of wells
drilled: �/
9. Total well depth below land surface: I9
7 (B.)
For muhiple wet& lint aidepths if different(exanpole- 3(§200'w plan)
10. Statiewater level below top of casing:
ffwwrer kved ft above casing, use ,•+"
11.Borehole dianietera (/ Oft)
12. 12. Well consteuetion method:
(0.)
(Le.moor, rotary, cable, dfreetpmb, oft..)
POR WATER SUPPLY WELLS ONLY:
t -
13a. Yldd (gpm) 1 0 ' • / Method attest:
13b. Dlstbfecdon typa,� ,LL(..FL Amount:,
FROM
t
TO
ft.
lo.
MATS ze
Yu 76
MA
14f,
b ft•
ft.
n
EMPLAC EMENf METHOD & AMOUNT
77r4111t,2
TL
ft.
MAfERWE •
EMI'LACIMENtMEtrOR
ft.
' rriRRsY]a:e G(i
FROM
TO
6
0
(eo)er.imams. Wealth Noa eratasbaetel
/0
itt
Z.►''t.
(v f4
rit
sr
r7 n
7
Nl4
rums.' 57VM-1--
etc
By signing this farm, I hereby are that the wetttes) was (were) constructed in accordance
with 15ANCAC 02C.0100or ISA NCAC 02C.0200 Wen Construction Standards and that
copy Oft retard has heen pov6ird to the well owner.
23. Site diagram or additionalwelldetails:
You may use the back of dais pang details or well
construction details. You any also
$UBMIDFAI. HNSrRUCt1ON4 24a. For ABWenn Submit this foe Eivp iWpbt 70 47of completion of well
construction to the following: -
Division ofWater
erRea� pkowon
n 1617tit,
1617 Mali
m on egionalOffic
24b. For lnieedou Wells• In addition to seadbig the form Office
24b. address in 24a
above, also submit one copy of this form within 30 days of completion of well
tonsbacfion to the tolbwing:
Division of Water Resources, Undergrommd Injeedon Control Program,
1636 Mad Service Center, Rakish, NC 27699-1636
24e. For Water thumb & Infection Weller In addition to sending die form to
:the address(es) above, also submit one copy of this rams within 30 days of
.completion of well construction to the county health department of the county
where constructed.
Form GW.I
North Carolina DepaanentofEaviroomental Quality- Division ofWater Resources - Revised2-22-2016

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SEP 1 8 2017
Water Quality Regional
Nm1M1e1'9 rdeet;ea
Wilmington Regional Office
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1. Well Contractor Info on:
p/ at 0
Well Contractor Name
MOM
TO
DFSd EPTION
/S�
NCWESCooaaetrcrrtifimftouNumber •
C� /tI0Lte WM Mabel
ConrpmryN e
2. Well Construction Peamit#r
List alI a pacablewel rntutntelion permks (Le WC, Corm¢; State, iearian04 roc)
3.Well Use (check Well use):
ft
ft
it.
ft
g1rb[5ididsadl'J3% :.
D
mAMETTEa
TRIMNESS Me
ttaiimitwzg,i4
r
TmcxnEss
ft
Ja.
it
ft.
ie4
Water Supply Well:
CiAgricuimmt - itloaioipaVpubnc
®Geothemlal (Heating/Cooling Supply) 'daida' Water Supply (single)
D6uluavisUCommetcial Residential Water Supply (abated)
nbristation
Non -Water Supply Well:
®Monitoring
Injection Wells
alAquiferRecbmge
Aquifer Storage and Recovery
DAquifer Test
DExpeeimental Technology
QGeothenmai (Closed Imp) Meaner
Geothermal (Heating/Cooling Return) fOaher(eaplain under #2J Remarks)
4. Date Well(s) Completed:! f7 /it / WeUDO#
Se. Well ceilen:
G>i/�i4 WoOei IT
FacfdylOwnfl ewe Pseilityllp. (If applicable)
Physical
awe* gaw &cci
QReoovay
QGmmdwata Remedietion
QSa1mity Denier
Qstovnwater Drainage
Qsubsidence Control
‘7479 5e t Le kin rca
c�_ 'L Aa mmj i'ff
Canny PelEde16cetioh'ifo! (PRO
5b.Ladtudeand longitude indegrees/min s ,,,detetideetmal l
Orwell field, one latfing is sufficient),... ,pg(n}?l, y
3st° i✓'55/r N 7er°rr _/T',
4
W
6.Ware) the well(s)Permanent or CiTemporary
7.1sibis arepair toanSating wenb QYes or No
"this ire MetavjdlOat haawn null consoactionfa�rmation erpkbithe naaveafthe
repairewder#21 remarks -section or an Mebackeat farm
B. For Geoprebe/DPTor aused-Loop Geothermal Wells having the same
constmction, only 1 GW-1 is needed IndicateTOTALNUMBER of wells
dri led:
9. Total well depth below land surface: z/0
Formula* wells list elldepths 'Winne (monde-3q®200'mtd2 )00)
10. Static water level belowtop erasing: . 0
betater fend isabovecasing, tete
11. Borehoiediaweter:
12. Well construction method:
(ft.)
(Le.anger, nanny, cable, sleet push, wt.)
FOR WATER SUPPL WELLS ONLY: _-
13e. Yield (ppm) �� Method of test:f,�1
13b. Disinfection type' . "t - Amounts
Signature ofCertified Well Grammers-A:7
Data
By signing this foes, I hereby unify that the mike) war (were) contracted is accordance
with 13ANCAC 02C.0100 or ISA RUC 02C .0200 Well Cotutraaian Standards and Ma/ a
copy efthirrecord hateeen provided to Me well owner.
23.sitediagramoradditionalwa L iIVED/NCDENR/DWR
You may use the back oft6is page to provide additional well site details or well
uonsauraiondetaiis. You may also attach additirmalpapsifnecessary.
SEP
SUBMITTAL INSMUC17Ole j 8 2017
24a. For All Wait Submit ibis fo 3D days of complaLim of well
consnucfoa to the following: win fuality Regional
Operations Sectio
Division ofWater Reo131giOnijii $I,
1617MAR ServiceCenter, RaWgh,N 27699- �``
246. For taingoo Wolin In addition w sending the form to the address in 24a
above, also submit me copy of this form within 30 days of completion of well
constsucion to the following:
Division of WaterRe:Doren, Undergromid Injection Control Program,
1636 Mali Service Center, Raleigh, NC 27699-1636
24e. For Water Sanely & [nlactlou Wells: In addition to amdamg the form to
:the addresses) about also submit me copy of this from within 30 days of
completion of well coasbuction to the cottnly health dtpattment of the cam
whereconsWcted.
t$oM
TO
oziat
6
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t
in.
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22. Cerfifica
Faun OW.1
North Carolina Department ofEnvimomeatalQuality- Division of Water Resources - Revised2-222016

, 1. Well Contractorinformp4on:
Welt Contactor Name
446295
FRO Tn DESEMPTION
3-9
xC Commcror tionNumher
GP*WOrt_, wan �/-
Compare, Name /7l
2. Well Construction Permitik W I / 7 - (00 6 f /
List all applicable weUronrin than pernls(Le. WC, County,State, Variance, ere.)
3. Well Use (check well use):
Water Supply Well:
CiAgricuitural
®oeothermal (Beang/Cooling Supply)
DIndusufal/Commemial
flu
Non -Water Supply Well:
*'Mouitoriog
Injection Well:
Aquifer Recharge
%Aquifer Storage and Recovery
Aquifer Tea
]Experimental Technology
]Geothetrnal (Closed Loop)
"Geothermal (Heatmy/Coolmg
MuniclpaFPubh'c
deadal WaterSupply (single)
Residential Water Supply (shared)
©ery
Q Groimdwatet Remadiatioa
CPO* Bather
QgmrmwaterDrainago
©Subsidence Control
althea
Other (explain =der P21 Reunite)
4. Date Well(s) Completed: 2/// /, /Well IDP
Se. ell Location:
at- r 7raeo 4J
757t 4/614 Al, 00/7Dt Arc ( 7� if $` L3
BMA and Zip
County
5b. Latitude and longitude In degrm/minuteWseco p�crpe.d elfr?
(Ewell firm, one laltong is sufficient) i 9- + LUit
N :�a(�_..R®t qn %tar.?�; tf: Srtt`
6.lsare thew (j`)d°tc,',Cr3
( ) ell(s)ermanene or �'1'emporary
7.lands arepair toart emitting well: es or No
If this is a repair,fellant Brawn wellmnstne:An Mnfarmationcadexpidothe nature of the
repair alder#21 remarks section or an Mebackofthisfarm. .
B. For Geoprobe/DPToranged-loop Geothermal Wells baying the same
construction, only 1 OW-1 ieaeeded. Indicate TOTAL NUMBER of wells
drilled:
2 'AtME11'C648It t6 (t bddsiii7l4ga
an
0it-
FROM
DIMMER I SmCwTart5
salami/GC
ialfirc'( `i!"tiie&1' „j
ft.
TO
DIAMETER
to.
Tortoess
MATERIAL •
MAISWAL
ft.
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MATERIAL
poi/G
m:oS 1F-r.E ��^ 1 ....[ FS''�`h *-T#L`Fl 'Sv % ';tlZie.•
DfAT6gNL ��. EMELACEMMTMErnOna AMOUNT
4 ' Q�d�6-
/�ft
To
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OL
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it mon %r Ai
FROM
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amp 7;ff.
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f Z f' (Car 57h/sl,
7rn
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z.3g
cp
9. Total well depth below land surlbee Dt.)
For multiple well list all depths if different (ample- 3Q200' mid 2Q100 )
10. Stade water level below top of ming: (h.)
renter level it above casb,g use "+ .
11. Borehole diameter:
12. Well constntedon method:
(Le -ergo , muse, mbk, d'aeetpush, etc.)
FOR WATER SUPPLY WELLS'ONLY:
{
13a. Yield (gpm) v © ,I'Methodten: of te
13b. Dlsbifeetiou type: 44Q,NAmount / 4/
Out
06
O.
iRDM
Sf'e7a 7dfd7
Siamese ofGratified Well Contm:ter Date
9y signing Mr form. I hereby cat) that de wee) was (were) consoeded in accaalance
with 154 NCAC OIC .0100 or15ANCAC 02C.0200 Well Construction Standmdt and that a
rope afth&record has been prodded to Martell owner.
23.sbediagram oradditional well ,i CEIVED/NCDENR/DWR
You may use the beck of this page to provide additional well site details or well
manakin details. You may also attach additjgga> ges,tfueceastry
SUBMITTAL INSTRUCTIONS j �t F' 1j ii55 L[ U�j ��
24a. For AD Wells: Submit this form wfte3rOcgantyrggp4r, of well
construction to the following Operations Section
MAIM ofWiner Resources, I J,Ce
1617 Mall Service Center, Ralelgb,NC 27699-1617
24b. For lnieedoa Weller In addili®m 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:
Divislon of WatsIthsourcea, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24e. Fer Water Bundy & Inleedon Welly In addition to sending the firm to
-the addras(es) above, aim subndt one copy of this form within 30 days of
completion of well wnstuetion to the country heath' department of the county
where constructed.
22. Cetif
2.w
Form OW t
Nosh Carolina Depmtmem ofEonenmentet Quality- Division ofOates Resources - Revaed2-22-2a16

7S712
o/., f,f
AJw
To
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/JD
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;.tt S 72zett-,
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trio
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RCCCNED/NCDENRIDWR
SEP 1 8 2017
Water Quality Regional
Operations Section
.. N
t _S +L S
Wilmington Regional Office
\,
�. .

•
1. Well Contractor
44R294
Well Conlractorwame
55 NCLjeULo �(eCati6ea
In6a N:whWr
ta Oulu
CotopanyName
2. Well Construction Permtit& &C® 77—�
List all applicable well rnrtwctlon perm!' ts(Lk we. Cmmry, Stare, grime, etc)
3. Well Use (check well use):
an: ,��� ; 42/0
dater Supply Well:
Agdcoitutai - 14famicipmYPublic
Geothemal (Heating/Cooling Supply) gResidendal Water Supply (single)
MdusttiaUCommaacial Residential Water Supply (shared)
Non --Water Supply Weil:
whoring
Injection Well:
Aquifer Recharge
ails Storage and Recovery
Test
DRecovay
0
QGroindaater Remediadon
Qselinily Barrier
Qstmmwater Draimgo
Experimental Technology QSubsidence Control
Geothermal (Closed Loop) placer
..'.o�.thermal (fleatmg/Cooingg /aom)//�()Other(explainmtder#21Remarks)
4.004 WeiI(s) Completed:7 /2 C , WeilIDd
Sa.W cation:
Aftro y . Ain f
Faegiry/Owner sma Frail R�: (if'applkablc)
47J'Dete f%vveat � eo lfc 210
Physical G3ty, aodrap
OOP f(t(w%(ti
County Paned ideadfistioaNu. (EN)
Sb. Latitude and longitude in degreesiminutesii a - o•;�„3
(ifWell fleld. onela06ug u =Wcient} ., - "��"'I""'e
„ SE13.1 As 7017 w
S.Worn} the wedgs)WPermanent er , ,?n ProcIcaang usert
7. Is this a repsirto anexisting we& QYes or ®No
Ijrhfa isarepavilloaknown wallconsauctioninformationan explain the nature ofthe
repair arder#2I Tema issecrionoran deabarkafthisfara.
S. For Geoprobr/DPTorClosed-Loop Geothermal Wenshaving the same
constmction, only 1 OW-1 isneeded. 1ndioateTOTALNUMBER of wells
ddSed: 9. Total well depth below land surface: 2-if tr
Formulsiple welts list aft der* ((diferent (rampie-3Qa 200•and2Qi00)
10. Static water level belowiopofcasing: 30 (�)
()Neter level is above easaag, vse "+
it &reko diameter:
I2. Well construction method:
(Le.OW, tonry. cable, divctpanh. etc.)
/j-
(D.)
.( FOR WATER SUPPLY WELLS ONLY: :
Yield (gpm) 3�
Mmethod of tech
i4f e
•feednntype: raft Qr InsoMntt ` ^''
MOM
To
DSSC IPDON
It
ft.
A.
ft.
MA
FROM
70
D2-
D ft.'
3.Stt
id
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9C.
Male
a r --
FROM TO
DIMMER
METER
TEICRNESS MAIWAL
ft ft�
in.
Sf. fL
in.
SLOTSIZE
R
R
in.
a't#0R0T1iMt .)::.`_ b F-._
Vac2.. L+5}.y.':f%S�
PROM
TO
MATERIAL
EMPLA METHOD AAMMO;
ft.
(` ft
.f
fJpOm
.`.
FROM
TO
MA
DhgLA METHOD
/Oof
Z4cfl.
'# afro/Vet.
0kr
ft.
ft
FROM
TO
DEMAWITON (teat madam nithretionitnmtadu.me)
1L/0
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175- -iti
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GO i4t 57N-e-,
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d 14 it
r
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in 2-97
SP Ptei e
22. Certification:
&' thL/7
St oi 6ell (rector Date
by signing this jorm, I het* cen(z that the weit(s) was (were) eonsnTated in accordance
with Uri MUG' 02C.0100or ISA MAC 02C .0200 Well Cmaaaadon Standards and thata
copy gfthisrecord hasbeen providedto the well owner.
23.Site diagram oradditional wed IJEf/NrnFAlp)1)wpD
You may use the back of this page to provide rdarfortif ellIttbl or well
constmction damns. You wry also attach additional pages ifnrcrettry.
SUBMITTAL INSTRUCTIONS
24a. for All Welly Submit this
emanation to the foilowiag:
Divisional Water Reso.
1617Mall Service
SEP 1 8 2017
form within 30 days of completion 0f well
Water Quality Regional
etaliStwantatitifin Unit
Iffilatelversinite
24b. Par Inietdoa Wolk: In addi@en 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 tothe following:
Division of Water Resources, Underground hnjeexlon Control Program,
1636 Mali Service Center, Weigh, NC 27699-1636
24e Per Water Snooty & fnlection Weds. 10 addition to sandhog the item to
-the address(e) abovq also submit one copy of the lbmt within 30 days of
covlpletion of well combustion to the county health dent of the canny
where
North Carolina Department ofEavimnmeaml Quality- Division of Water Resources - Revieed2-2.2016

1. Well Contractorinftio
n:
446293
Welt ContrmaorNatne
3/5
go
NC Wel/Contactor tenNumber
ConpaayN
2. Well Construction Permit#:
List ell applicable well constnetlon permits(le. VIC. Comrry, State, Variance, arc)
3. Well Use (check well use):
Water Supply Well:
rAgaenhuml _
Geotham at (Beatiog/Ceolmg Supply)
Industrial/Commercial
flirtation
Non -Water Supply Well:
Monitoring
YnjeNton Wells
"Aquifer/Itchiest
uiferStomp andRecovery
Test
]ExperimerualTechnology
]Geothermal (Closed Loop)
"Geothermal (Heating/Cooling R
MemicipaPPublic
gltesidendal Water Supply (single)
Residential WaterSvppby(shared)
©Recovery
©Grouodwata Remediation
Dllalinity Barrie
DStormwater Drainage
©subsidence Control
©Trace
11other(explamunde cal Remarks)
4. Date Welk(s) Completed
Well Location:
It colt DdcNti
I.r t,4k kiinet,
Physical Addreas ty,andZip
go az At 4u,
Well
impity1Dit Efappiicable)
W ilifrdith. tic Z%'
County . lfo. (#
Sb. Latitude and longitude Indegrees/wiautest wi3l faydear
Orwell field, ate lat/Sg is sufficient)
,. SEP. 1 A 2017
N W
4¢ ctmMlon f . e i:;:,.;.y.,�
6.1s(ere)the well(s) ermanent or LiZemporarafda OG
7. Is Bits a repair to an existing walk DYes or o
phis Ira repah;fdlant blown wsiconsintaionkubnnatbn =plain the nature ofthe
repairunder1121 remarks sectl rnoron the back alibis film, .
B. For Geoprobe/DPT or aosed-Loop Geothermal Wells having the. same
construction, only 1 OW -I is needed. Indicate TOTALNuMBfRefwells
drilled.
Z/.o
9. Total well depth Wow land surface:
For multiple welts jLrt ufl depths ifd(ffpma(eznnpfe-3Q200'and 2Q1009
10. Static water level below top of easing:
Ifaoterlevet isabove =eta,, tse;,
11. Borehole diameter:
qO
12. Well construction method:
(1e.auger, nary, able, sliestpmb, etc.)
FROM
TO
DESOIWIIO.
IL
0.
a.
re
-
totlnRC
RI'cf
"' ` 1
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22. C
741 7
Sigmas ofCezRHedWeil Contactor Data
9y signing this form, I herby avatlf' that the wells) was (were) mmhrated in accordance
with ISA NCAC 02C.0100or ISA NCAC 02C.0100 Well Corutrtxdon Standards and that a
copy eole. record hat Iran provided to Me 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
consuttiRion details. Yon may also
SUBMITTAL INSTRUCTIONS
construction to the foliowmg:
(ft) Divi1617Ma ateniceResources,Center,
R pro� Nt,
1617 Malt Service Center,
pe ations Section
24b. For Iaicclioa Wells: In sadititaireigtorialeM44gress iv 24a
above, also submit one copy of this form within 30 days of completion of well
construction to the folbwing:
FOR WATER SUPPLY WELLS ONLY: -
13a. Yield (gpm) 'j® Method of tat: .'ir
r�
13b. Dian' faction type Qti� Amount:
DMslon of Water Resources, llndergmmtd Injection Control Program,
1636 Mali Service Center, Raleigh, NC 27699-1636
24e. Far Water Snook & Infection 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 to the county health department of the county
where constructed.
(t) 24a. For All Wells; Submit this form wt5f30'lap 2forpletion of well
Form GW.1
North Carolina Department of Environmental Quality- DivisionofWater Resoumes • Revised2-22-2016

NC ell or Certifit himi utobn /
dt
'c cki We a7 G nt
CompatyNama
2. Weil Construction Permit&
List all mplicabte weaemutmerioa peani/s(La iAt . Cowi4 .State, Variance, ere)
3. Well TM (check well use):
ater Supply Well:
Agricultural - M:micipeUPublic
Geothermal (HrctinglCooling Supply) litesideatial Water Supply (single)
Industrial/Commercial Residential Water Supply (t tired)
Isrigatica
on.WaterSupply Well:
Monitoring
Injection Welk
Aquifer Recharge
utter Stotageand Recovery
Aquifer Test
Experimental Technology
Geothermal (Closed hoop)
Gotha-mai Coo
Recovery
Groundwater RemediatioD
Saiinity Battier
Stosmmatarlhainage
Sobsideoce Conical
__..Other explamumder#21 Rwinks)
IDate_ Well(s) Completed)
l7 Well We
5a. Well.bneafl a: ,
/Grit k4 4 IC (4110r1 )
Facility/Ownn'c core Redly lD fapplvabie)
30
07 (gir%,s,wae,,,r H 1of A urea
Pnyst�j ddrps L I
/lW! iP
Pang
•
County
i�l H
5b. Latitude and longitude indcgrtatminutes/seconds ,S tx l--* 97
(if well field, de latilong is nificiem)
For Internal Use Only:
446292
FROM
'PO
Memnon ' -
ft.
fG
ft.
Ft
-" .. .
FROM
1O
m&MEI'ER 1 MAffin4L
Q L/Da
'a°
eye V G
gsZ3.
TO
DWIEI6R
TWCIQ1ESS
rMA1ERNt. .
PROM
ft.
ft
ia.
ii
ft
is
-...
—
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rec-
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SLOTS1Et
eacEss
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13
-yo
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io.
d'arOVA
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gr i7:drst S-.At ;ir -
FROM
70
Mersat i.
ENPLA ME=ROD@AMOUNT
0 in
C
ter
rt.
ZD14
`-
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se
FROM
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MATERIAL
2MPLAt. smaiMET 0»
bit_rl!lulu
`reSts Mir
:EMI-1..vn Y*'3. ti71.
FROM
TO
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p. ft
it..
c,►e'C�,e
1 rail;
t/s—
o O'
thick-J�I'te
30ft.
"r.
JQ
91's'
70'
dl4yr
7 oft
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•rah4
7 tit
'of
cla-r
/Oft
/bt-
Qi-se- y Tnet-e>.
Ara
gifit
a irt 4, ,.. Seat'
N kt.hr tiSBion procese mpl t
Dkikaatiltt}ay
6, Is(are) the weM(s) 4armanent
7.1s this a repair to an misting well rites -er o
rats lsa reratfdlomhnawn weltansnuatianmformationan explaintheaaateopts
repair trader 421 remarks section ar on the back ofthisfaren. .
S. For GaeoprobefDFT or Closed -Loop Geo#itermal Wells having the same
construction, only 1 GW-1 is needed. Indians TOTALNUri1BERofwells
tided:
or emporary Mgmoaeu.`Ct
9. Total well depth below land surface: 2 0 (ft.)
For mebiple wells listatf depths ,dierent(=male-3@200'ard2@100)
Z©
10. Static water bevel below top of easing:
((wafer Level is once coring, use
I1.Borehole diameter:
12. Well construction method:
(Lc. auger, rotary, robie, d'vectpusb, etc.)
40n�.tYyy
(f.)
FOR WA'FRII SUPPLY WELLS ONLY: _
13a. Yield(gpm) 3o Method oftest: A/ir
In. Disinfection typey„P 14444441 Amon f Lv
eel Well Contactor
for
gl' sl1niag Mir foan, / herby cet( that the weft was &ere) easamwed ter accordance
with 154 MAC 02C.0100 or 15A NCAC 02C.0200 Well Cans ream Srundwt and that a
copy ethic record has bean providedto ilia well owner.
23. Site diagram or additional well details: •
You may use the back of this page to provide additional wed site details or well
rmramrsion details. Too may also attacb additional pages ifnecessary.
SUBP3DTIALINSIRECf!@NS RECEIVED/NCDENR/DWR
24a. For Alt WeUct Submit Ibis form within 30 days of completion of well
conswicion to the %Rowing: S E P 1 8 2017
Divisional Water Resources, Information fretmlag Unit,
1617 Mail Service Center, Haugh, NC 27699-1617
Water.Qu lit Re io
24b. fur Injection Welk. In addition to a address in 24a
above, also submit one copy of this Omani goo of well
construction to the folbwing:
Division of Water Resources, Underground Injection Control Program,
1636 Mali Service Carter, Raleigh, NC 27699.1636
24c. Far Water Sonuly & Infection Wen: In addition to sending the ibim to
-dte addrms(es) above, also submit one copy of this form within 30 days of
completion of wall contraction to the county health department of tie county
where constructed.
)41
Form GW-1
North Carolina Department of EnviroammtalQualiry- DivisionofwaterResources - Revised2-22-2016

lvi r,�-w „twat.,
70
(ir
/Yr
/s®
'57
!do
Lao
Ski
57l..-cam
4 s -4a
44 nose ,
1
RECEIVED/NCDENR/DWR
t_tt t
u �
SFP 1 8 21117
Water Quality Regional
Operations Section
Wilmington Regional Office

W g,A, lAtleM atcua-JJSt1 zcma,.vacv %NW-11
1.,Well Contractor Info OR:
For !Mensal Use Unly:
446291
®MmicipaVPublic
Residential Water Supply (single)
dcanal Water Supply (skated)
DReenvesy
®GrotmdwaterRemediaiion
DSalhaity Bonier
DStommater Drainage
Well ContacwrName
7/Se,
NC WsllComa CanteatiomNumber
Vid
Company Name
l7-oa4
2. Weil Construction Permitil:
16ta *pliable well earewntioe pemOs (De, TAG Co m% Stale. Par. wcA clod
3. Well Use (check well use):
Water Supply Well:
Agaeuitursl
Geothermal (Heating/cooling Supply)
)hdusuial/Commacial
Irrigation
Non -Water Supply Well:
dwhoring
eeltoa Well:
Aquifer Recharge
Aquifer Stooge and Recovery
Test
Experimeota1 Technology ©Subsidence Control
Geothermal (Closed Loop) ©racer
..,., eeothermal(Heating/Coolmg ) fGiber(explain under #2I
554. Date Well(s) Completed: 6 ill% f Well IDS
C. 01.1- 5
1leotadss)
Pacility/OwnerN cd' ID#(dapp7Fabte)
Lj0L7 ��f � -1 fs wxh1'Ht 21
P VAal k5 { �ry,
county
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5b. Latitude and longitude In degrees/mautes/jecouds or decimal degreesC E P s v rf
(if well field, out Wong bracing) 22. Covvoia
ettiP n:
N InferF%Ston Proc•V- ill[
6. Ware) the well(a)pPermanent or Q temporary
7.Isdeb arepair toanahtingwetie ©Yea or No
IfM s is repaiRfdlowbrown well mroeucilonWertheim ' the mauve ofthe
repair tether f2l remarks -action oron the beck oath form.
S. For CeoproheIDPf or Closed -Loop Geothermal Wells having the same
construction, only 1 GW-1 is needed. indicate TOTALNOMBER of wells
drilled:
9. Total well depth below land sorbet: /la 7 Jet)
For multiple wells list all depths lidfrferent @Meee- 3(o)200'mrd2©100')
10. Static water level bdewlapofeasing: 449 (fs.)
(Jeweler Wens above eosins ara"+" p
11. Borehole.diameter: Gv g/'xna c,/
IL Wen construction method: /
(Le. tiger, rotary, able, directpwl4 etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) so,, ���,r�,Method of test: A- /
136d
. Disinfection types —'m""'1"/Amount
SigmoneofCaiffied Wel
Ofti
Date •
Dy signing this Tama f hereby cent$ that the wells) was (were) constructed in accordance
with 134 NCACO2C .0100 or 154 NC4C 02C.0200 Well Cotum+dimt Standards and Mat
copy gftht record has ban 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 ifnecessary.
SUBMITTAL eismCITONS
Zia. For Alt Wells: Submit this form widen 30 days of completion of well
construction to the following:
Divia(oaof Water Resources, Information Processing Unit,
1617 Mail Service Cuter, RaEggIWNR/DWR
24b. Por Infection Welk In addition to sending the form to the address in 242
above, also submit one copy of this form witbhi 30 days of completion of well
constnwdon to the following: S E f 1 8 2017
Division of Water Resources, Underground Injection Control Program,
1636 Moll Service Center, Ralel FB�9-1fi76
dy regional
24o Far Water Sunk & function Well ,,��1PQ11G i9@`uitibl he fbrm to
-the address(es) above, also submit one copy 9t�S)Mt rh>mltaffilms of
completion of well constitution to the camly health depanmeat of the county
whore constructed.
Fenn GW-1
NorthCarolina Department ofEnvironmental Quality - Division of water Resources - Rov :42-2'2m (

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SEP 1 8 2017 -
Water Quality Regional
Operations Section
Wilmington Regional Office
_—s."...
_ i-2-4; 2

For Lit real Use only:
446290
WELL CONSTRUCWIN RECORD (OW--1)
1. Well Con Informations �%
Well Contractor Nona
/0 NCMepze 6mnd ndi
l
Company Name
2. Weil Construction PflIt#:
LietalI wilcable well cmrtrambn pmnls(Lt WC. Counry,aate, rarhmce, ewj
3. Well Use (check well use):
Water Supply Well:
f..sgdcukaal , ®Mucicipal/Pablic
OGeothamel (Heating/Cooling Supply) Sltesidential Water Supply (single)
D f Resideadal Water Supply Mated)
Iihttaatlan
Non -Water Supply Well:
clivionitodng
njedlon Well:
3AgmferRecharge
DAquitin Stodge end Recovery
AquiferTest
Experimental Teclmology
jOeotthamal (Closed Loop)
"%aeattamal
4. Date WeB(s) Completed-
®Reomvay
DOrosadwata Remediation
®salinity Barrier
OStormwaterDainago
®SubsideaeeControl
Th Q�
(flcetmg/Caohog Daher(captain under 1 Rem)
7 Wen IDS
l7
7tl
e8 o ;7 %m,
cility/owcerN a Iznik Me (if applicaKO
?333 Q alac'd /ti Oenm (9104C Zeg3o
sfitta
Physical Aninp. OCT. emdzip
dui &uS
County Patel idemitbadonNo. (PIN)
Sb. Latitude and longitude in degrnsiminutes4ecends or decimal degrees:
(linen field, coo Inflow is sufficient) 22. Certification.
N W
Is(are)thewell(s)OPermanent or' Temporary
7. Is Ililo a repair to no Sating welh !Yes or ®No
ratstrarepaii.JNloutbranweicanuMmtio *formation and rapbb,the Ware ofthe
repaironder#21 remarks section oron thebaceofthitform.
B. For GeoprobelDPTorClosed-Loop Geothermal Wells baying the same
construction, only 1.OW-I is needed Indicate1flTALNUMDERofwens
drilled:
9. Total well depth below land surhsee: ofiel
For rmdtipie well:ltrt all dep drs pWhffen a (esetapfe- 3@200' and 4WD)
10. Static water level below.top of casings
router lewd iabove wing, are'•+/"
11. Borelrolediameter:
12. Well censtrseden methods
On. auger, nmry, cabb, &rat push, eta)
ty
FOR WATER SUPPLY WELLS ONLY: ,
13a. Yield (gpn� .10 Method of teas
13b. Dldafeddoa typal' 6 Amounts,
Air
at
Signature ofteadged Wdl Contractor
Ley dgning tbls jbna, I hereby tern), that the weer) war (Were) constructed in accordance
with 13A NCAC 02C.0I0O or ISA NCAC 02C.0200 Well Cmtsm, aien Standards and that a
copy eftharecord has been provided to the well comer.
23. Site diagram or additional well details:
Yon may use the back of this page to provide additional well site details or well
nmatimrion details. You may also attach addition' pages if necessary.
....
TO
Alsat fllnN
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7/rl7
EGRUIMALLINRERMERR
() 24a. For Alt Wells: Submit this form within 30 days of completion of well
construction to the following:
(fL) DMdonef Water Resources, Information Frowning Unit,
1617 Mall Service Center, Raldgb,NC 276994617
24b. For Inleedon WeB4• in addition to seocktowite
above, also submit ono copy of this font widistai� l ;r. • ;fif".1
convection tonic Mowing:
Division of WaterResourees, Undergroaud lnCEg ,
1636Mai Service Center, Raleigh,
24c. For Water Sanely & lnleaion Wells: In addition to sending the form to
the address(es) abovq also submit one copy OMPftrftgftbft(iStOteporbafte of
completion of well construction to the county halt) glsoftentongeakpootmty
where connoted, Wilmington Regional Office
Perm OW-1 Norm Carolina
of Environmental Quality• Derision of WeterResources Revised 2-22.2016

WALL a.APISD_1ll411t:11S919 ILISC RD (6WW-1)
1. Well Contractor emotion:®A I",
PP
For Tntemal Use Only: 446289
Well Coe —tisane
NC -Well Coat CatifiaationNumber
pi eido. Wei D, ir//^
tf
Company Name
2. Well Construction Pandit
Lim a::applicable well emanationpamits (La WC, Comity, state, ParioncA alt)
3. Wen Use (cheek well use):
Water Supply Well:
®Agrkeltmai - ®Muvicipal/Public
®Geothermal(Heating/Cooiicgsupply) �Raidtndai Water Supply(eagle)
®>adtnnrie1/Commemiet Residential Wawa Supply (shared)
iiuiiNtloa
Non -Water Supply Well: iiiMonitoring ®Recovery
'3ajetdloa Wells
gAquiferRecii e
Aquilbr Stooge and Recovery
tAquifer Test
'Experimental Tebnology
®Gmuadwater Remcdiadon
fSalnity Banat
®Stozmwater Drainage
:Dsubsidense Control
jGeothermal (Closed Loop) Q1aacer
j oeotbemal iReadng(Ccoiing /9 fl7 her(eaple� user el Remits)
*Lugo Wells) Completed: ?fill? / 4 WeB ID#
55aa�Well Location:
W fo(c' di
dy/ Nwa focifitY1W ffapplieable)
der S cct &FNy. /-4.1 Vocal? „nG LScf3
PhysicalA s, sad Tap
fumy
County Parcel ldemificetioa Wo. (PEO
5b. Latitude and longitude In degreedmintstesTeeonds or decimatdegrees:
Orwell geld, ore latibog is mfeeiem)
aa�gge� N W
6. Ware) the welks)�gPermanent or QTemporary
1.Isthisarepair toanexisting well: ®Yes or No
$ehts is arepab;Jtilout hwt.e weimtuauction information as®ktn the nature ofthe
repair metal rmarkmdonoronthe back ofthtrfarnt.
8. For GeoprabelfPT or Closed -Loop Geothermal Wdlsbavingthe same
construction, only 1 GW-1 is needed Indicate TOTAL NUMBER of was
drilled:
9. Total well depth below land surface:
FormuMple wells Rif all depths fdgteraa (esampla-3(g200'atd2@MT)
10. Static water lead betowtop of eosiogs 30
laaterAwe: irdove eating use "+"�
11.Borehelediameter:
12. Well construction method:
(Le. Leger. mnry, cable, eked pod%es.)
5-
FROM
ft
ft --
t nD t 1
EEatltRDON -
R.
MOM
or
90
SEMI
rt
ft.
DIAMEIET
DIAMETER
tn.
lo.
ie.
MA
tirG
co
n4LA a.. MRtWOOLAN'UI)t
©a ICS ft ,( d er
/D R. / 2-0 ger-Au feaa c .
R. ft
„"!
cm or
ft
r:
NM to
ft ft.
lter. 30a
ost 60ft
of'. 9011
Soar, /24*
//7.dt lLr
car
/7r /as-
/cr. z/r Sa.d .
22. Cestifeauon:
70
ft
ft
11'Cater,
dose
JCd-
aS4q. SEP 1 -jai
7
r
tor ii'!aei0.t Pttsri, 9!T i'
LAN -
lie
ie t 7/4//7
Sigatom of Crianea Watoms Date .
By slgaieg this form l hereby ea* that Me weak) was (were) conmreted in acto dance
with NCAC 02C.0100orl3A NCAC 02C.0200 Wen Canrinatlon Swamis wed Mat a
copy (Phi s mord has ben provided to the well owner.
23. Site diagram er additional well details:
You may use the bank of ids page to pmvide additional well she details or well
co struaron details. You ay also attach additional pages ifnecessarys.
ataKin -rNCrat•iBGNs
(R.) 24a. For AB Weis: Submit this form within 30 days of completion of well
oonsouction to the following:
(rt) Dislsioaof Water Resource; inferamtlonProeesbtgUaft,
1617 Malt Service Center, Raleigh, NC 27699.1617
24b. For Iniettioa Wass: in addition to yg� 4a
above, also submit erne copy of this from catdays of m ell
construction to theMbwiag:
FOR WATER SUPPLYWELLSONLY:
13a. Yield (gm) Method attest: acre
13b. ➢1dafeedan type:
X ere Amount: / ' 41
Division ofWaterRemarw®,Underground Inis[etjan m,
1636 Mold Service Center, Rakgh, NC 276994
24e. For Water San1Av & Ialedion Wails:
the address(es) above, also submit one copy
con 10ion of wdi construction to the coax i
whore constructed.
r.iii�it •�; • a.
onal1 ice
ys of
Fong ow-1
North Carolina Department cif Environmental Quality • Division of Water Resource
Raviced 2-22-2016

awXa.a. tAirlaxxul.latur ialli W (GW-1)
1. Wdl Contractor fuforegoibn: D� '
zJ/1ft if,ivy'
Well CoatraclorNa 0
For internal Use Only.
446283
FROM
TO
D
For multiple wells lir:alfdepth rdrerent (eteaple- 3@200•and2®100)
NC wed Contractile CestificalonNwuber
company Name
2. Wen Construction Permit&
Liunllgoplimbtewefcwvrmaaionp nnu,(Le. WC Canty, State, Parlance' etc)
3. Well Use (check well use):
Water Supply Wen:
DAgricaltural bide ieipaVPublic
®Geothermal (Heating/Coolmg Supply) gtesideutial Water Supply (tingle).
OmduatriaVCommeseial Resideodel Water Supply (shared)
nrmigaticn
Non -Water Supply Wen:
QMonttoriog • ®Recovery
Injection Well:
j:AgoiferRecharge
°Aquifer Storage and Recovery
jAquifer Test
MERperimeaal Technology
-]Geothemal (Closed Loop)
DGmundwater Remediation
°SennityBanier
f StormwaterDrainage
°Subsidence Control
°Tracer
10eotbenuel (Hwtmg(Caol ugg )un 0ther (explain der #Z1 Remarks)
4. Date Wells) Completed: / f ' " / 7 Wen DIN .
se. Well oe*lon:
H •flf•/•►f.
d / dox.
Facility/Owner Frca DMfgpprrable
7.-tl�//au( / A(lv4if(7Wie Afc
Pbyskat aatmtZ'
an i o
County Parcel IdengfichtbnNo. (FD)
5b. Latitude and longitude In degrees/minutes/seconds or decimal degrees:
Of well field, one IaUiong is minded)
N W
6. ls(are) the wens) Fermanent or °Temporary
7.Istithe repair toanSating well: ®Yes or Na
rat: isa repair,RllaWbmwn welcaalnwlionb{farmatim lain she nave oldie
repair under al remarksseetioa or an the backoftkrform. .
S. For GeoprobefDPTor ©owed -Loop Geothermal Wens having the same
construction, 1 OW-1 is needed Indicate TOTALNUMBERofwells
drilled:
9. Total wen depth blow land surface: - 07. (ft.)
10. Static water level below top of agog: Co (ft)
ff%ater level isabovecasing, use "+••_
IL Borehole diameter: /T/� (ID.)
12. Wen construction method:`��j
(I.e. auger, ronry, ably dbeetpast:, etc.)
7
FOR WATER SUPPLY WELLS ONLY: - ,�j
13a. Yield (gam) Method of test: ' I a
136. Disinfecdon type: PO4 a/Amount:
lr41
Form OW -I
ft.
ft.
AETORTERS
0a �
MOM
f.
Ta
TO
DI*MEIER
r
Jens
SOBBfC my1:1(i
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tn.
MA
MATERIAL
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PROM I TO DIAMETER 1
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c !/� ,14-
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$Oct Fet bey
4.4./ SD)
-a �' x ri,
/to 1907 ?l
North Carolina Department ofEavironmentalQuality - Division of water Resources
/ 2, Z/5' S�Os?
22. Certification:
Stamm of edWdl reeler Dam
By slgmng This farm, I hereby amyy alas the well(s) wer(hrre) computed i accordance
with 11A NCAC 02C.0I00 or Ile NCAC 02C.0200 Well Caanucdan Standards and that a
copy oats recanihar been provided Jo the cell owner.
23. Site diagram or additional wen details:
Yon may use the back of this page to provide additional well site details or well
con details. You may also attach additional pages if necessary.
SUBMITTAL INSTRUCTIONS
24a. For An Weller- Submit ibis fora within 30 days of completion of well
construction to the following:
Divisionof Water Resources, Information Processing Unit,
- I6171Nan Service Center, Raleigh, NC 27699-1617
24b. Par blecdon Wells In addition to sending the form to the address in24a
cons vicc'on also two the fmit ollowing: copy of this farm within lleaea. TP/uYYR
Ridden of Water Resources, Undergromnd Injection Control Program,
1636 Man Service Center, Raleigh, NC$ -1P 2017
24e. Far Water Suede & Injection Weill:
In addition sead'atg the foam
-the ad& $era) abovq also
submit one copy of -d It wi.,,'I. ,1(1 drys of
completion of wen concbucdoa to the couary h-> Y,S}Y_E$t6iShgly
wbanwnsmmtcd. e.F'`- Ions action
Wilrmngton Regional Office
Revised 2-22-2016
.fire
sarvrgatK)n F''11�;:a*3i
)Dt`('(:?.
pc

L Well Contractor Informs
IFor Internal Use Only:
446287
adonNmnbr
P P Weil ptt;1 o*
2. Well Construction Permit #:
List angopncONe wenconvtnuxion pnmDt(Le. WC County, State, Variance, eta)
3. Well Use (check well use):
Water Supply Well:
DAgriookurei . • DMuuicipal/Pubhc
2Geothemial (Heafing/Cooling Supply) ®Residential Water Supply (single)
7ndustrial/Comotacial ®Residential Water Supply (shared)
"Irrigation
Non -Water Supply Welk
Monitoring DReoovery
lnjeetien Well:
f%Aquifer Recharge ®Gmhmdwater Ranediation
DAgmfer Storage and Recovery De Salioity Barrier
C3Aquifer Test fStormwater Drainage
3ExperimentalTechnology ®Subsidence Control
'Geothermal (Closed Loop) Tracer
'Geothermal (Iieatmw(Cooling/Risen) 9Olher(exphrmunder #21 Remarks)
4. Data Wells) Completed: &/L3 // 7weu Ill!
Sa. W tom$on: /,J GI�
Fa /OwnerNeme FaciltyIDA(ifapplicable)
303 1341 "pP �r(4cWOZs
Physical Addaeas, r`ity,/ua�n-ddZ jt
County Parcel bienifiddonNo. (PIN)
5b. Latitude and longitude In degrees/minu(a(seconds or decimal degrees:
Orwell field, one latlong is sufficient) - 22. Cati8
MOM TO
MOM TO
PROM
:33
TO
Weft
ft.
DESCRIPTION
DIAMETER
zta
In.
N
MURAL
137
G
a
a
ft.
TO
1z.
a
DLMmrM
In.
SLOT
TO MATERIAL , EMPLA
data �r1M.c
lD "L
1.
MATERIAL
tit.
PROM 10 MATERIAL
a
M M
Da
Gb
/PLO.
fr
tit
TO
�o
f Zell
/zit
*AMOUNT
EMPLACERENTMETfOD
DESCDIP71O (err,tMrien,"WrearbooerNasloe.ae)
S4L/G�L
(4-/1J/er2- S 7D 3)EP i a 207
t:a ye
// V . 1 _rl ITV-: rabn Pr,SL'i'N
Int. 3 Q
N - W
6. Is(are) the well(s)QPermanent or Dren porary
7.1s this a repair to an existing well: a or ®No
Ifthis is a repair, fillout &own wenronrmxtion ormationandespial: the natureofthe
repair under ell remarbseedonoron the back ofthisform.
S. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction, only 1 OW-1 is needed. Indicate TOTALNUMBER of wells
drilled:
9. Total well depth below land surface: L 1 0 (g)
For mantel'? wells listen depths jfdfrerent (example- 4)200'and 20100')
10. Static water level below top of easing: .7? (ft,)
(water level is above casing, use "i."
IL Borehole diameter. I
12. Well construction method:
(Is- augers mluy, ask, dimetpush, eta.)
Itigi
FOR WATER SUPPLY WELLS ONLY: _
13a. Yield (gpm) Method of test:
13b. Disinfection type type: 434PS6n' Amount: �r
Form GW-1
Noeth Carolina Department ofEavEonmental Quality- Division of Water Resources
LAB-47
Date
SY stgnlag this form, I hereby are chat den well(s) was (were) constructed in accordance
with ISA NCAC 02C.0IW or iSA NCAC 02C.0200 Wen Construction Standards and thata
copy of this record has been provided to the welIowner.
23. Site diagram or additional weB details:
You may use the back of this page to provide additional well site details or well
construction detail. You may also attach additional pages ifaecess ry.
SUBMITTALINSTRUC7IONS
24a. For Ail 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 foam to the address in 24a
constructionabove, also to
to following: �
of this Form within eFgp r,(hpA Q/ry R
Divisionaf Waterliemurea, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NCp 1636,
2 e
24e. For J
Water 3unoty & Infection Wells: In addition to sending
form
g the orm to
the address(es) above, also submit one copy of this form within 30 days of
completion of' well construction to the county heddiabgatitnealtptHhgtent90
where constricted. Operations Section
Wilmington Regional Office
Revised 2.22-2016

Water SIPply Wdl:
QAgricultutal , QMunicipal/Pubfic
]Geotke:mal (Heating/Cooling Supply) 3Residential Water Supply (single)
03Indusbial Commercial ®Residential Water Supply (shared)
lhrrigation
Non -Water Supply Well:
Monitoring ®Recovery
Injection ell:
Aquifer Recharge
gAquilbr Storage and RecoveryAquifer Test
DExperimental Technology
3Geotitamal (Closed Loop)
)Geothermal (Eleatmg/Coo
4. Date_Well(s) Completed:
li
WY Jar 21.44011.11.41LALIF aiDALIUMLIO►yW-1)
I. Well Contractor Info
77t jQ
cif?",
Well (.00tractor�,
Nlame
31 ✓}
NCi ,1 l ✓06d i061 n'1C6.
CompaayNahe
2. Well Construction Permit Ft
List alIapplcabe well conservation permits (i.e. U16 Coonly, State, Variant* eta)
3. Well Use (check well use):
®Groundwater Remediafon
Salinity Barrie
Dstonnwater Drainage
QSubsidence Control
Min"!
ng Retain) �Other (explain under #21 Remadcs)
5tl ,1;:f ##ilk )
FaN
i( '
1
1
01//4lifi Gi L
scuff
Physipi Slily, and WIZ
O
County Parcel identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell Said, one latdoag is sufficient)
N W
6. 11(are) the well(s) Permanent or E3Temporary
7.1s this a repair to an existing well: ®Yes or j3No
(rib& lea repair, Jill oa/aowm welleoaauet/on informatinandexplain the nature ofthe
repair tauter 021 remart ration or on the back g faa& form.
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:
9. Total well depth below land surface: 2/5— (R)
Formnidple wetb It l aUdepths tfdd :rent (example-3(§200• and2Qloo)
10.Static water level betowlop ofcasing:
ri werlevel is above easing, nee + `
1L Borehole diameter: /Y_ (m,)
12. With constrnedon method:
(ter. auger. rotary, able, direct path. etc.)
38'
•
(ft.)
FOR WATER SUPPLY WELLS ONLY: -
13a. Yield (gpm)
13b. Diainfecdon type:
Foss GW-I
Method of tech 4 /
Amount: % d I"—
Nortb Carolina Department ofEnvimumeatal Quality _ Division ofwato-Resources
t 4
22. Certification:
Signs Ceatraator
Date .
By signing Ms jam, 1 hereby cams that the weff(:) wet (were) consbnted in accordance .
with 1SA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and maia
ropy ojthir 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 alsoattach additional pages ifnecessary.
SUBMITTAL INSTRUCTIONS
24a. For All Wally Submit this form within 30 days of completion of well
coastructiontothe t%Rowing:
Division of Water Resources, Information Processing Unit
1617 Mail Service Center, Raleigh, NC 27699.1617
24b. kbr Inieedon Wells: In addition to sending the fors to the address in 24a
above, also submit one copy of this fonm within
consnuc6on to the following:
'1dP �10ynMaria
lf%ut'YR
Division of Water Resources, Underground Injectincontrol Program,
1636 Mali Service Center Raleigh, NC ti.M-trei 2017
24c. For Water Suooly de luiec ion Weller In addition to sending the form to •
the address(es) above, also submit one copy of "...0 tier of
completion
of � constitution to the county h-y. .. sY ec tonwhere ty
Wilmington Regional Office
Revised 2-22-2016

woo" W asr VI 11
For internal Use Only: 4462
462
5
12. Well instruction method:
tie. auger, rotary, cable, direct push, eta.)
Well Contactor Name
NC W/C&� JvkkWeit,41/Nl
Company Name 2. Well Construction Permit #:
LW allapp!cable nil construction permas(La U/G County, Nave, Variance, eta)
3. Well Use (check well use):
Water Supply Well:
C3Agricohual . DMrmit ipaUPublia
®Geothermal (Heating/Cooling Supply) ®Rmidealial Water Supply (dusk)
DIndustriai/Cotmndciai rsi�Il,Resideal Water Supply (shared)
ribitration
Non -Water Supply Well:
fal�,Monitoriug Recovery
Infaction Weil:
DAquiferRechage ®GrormdwaterRemediation
Aquifer Storage and Recovery QSallnky Barrier
°Aquife' Test DStonnwater Drainage
f E7rymimaotalTechnology ®SubeidenceControl
DGeotbermai (Closed Loop) place
['Geothermal (Heating/Cooling Rglum))®Olhc(explain uader#21 Remarks)
4. Date Well(s) Completed! z-I. 7 Well JD#
%ell
G axd. ,�a�7-'
��r{ae-ili /�Ow{nIer Name Ip(fs le,49ra✓_alen(e4145/ n
e
Phys' p(4' Cky, $tit
Igo4
County Parcel Identification No. (PIN)
5b. Latitude and longitude In degrees/minutes/seconds or decimal degrees:
Orwell geld, one lat./long is sufficient)
N W
6. Is(are) the we1I(s)elfermanent or f Temporary
7.1s this a repair to an existing well: ®Yea or SKr
(Phis irarepafr.Ialoabrown mei1constamton *formation and explain the natureVibe
repair fordo'#21 remark; section or an the boat ofthirform.
B. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction, only 1 OW-1 is needed. Indicate TOTALNUMBER of wells
drilled• 9. Total well depth below land surface: n T ✓i" (ft.)
For multiple wells list all depths ?differed (example- 31.2001 a nd 2 t(�100)
10. Static water level below.top ofeasing:
-
((waer level if above caring, true "+^i
11. Borehole diameter: /Y /O'r��r (�
/ r
(a)
FOR WATER SUPPLY WELLS ONLY: _
13a.-Yield (gpm) 242 Method of test: 4! r
13b. Disinfection type�l#�/4f Arnow*: jet
/^�
Form GW-I
Noah Carolina Department of Environmental Quality. Division of Water Resources
S '. a v`'
�
1ir ...'2nO aef :�ti d�nSY:'..x?C.t'3".
MOM
To
MSHr@ItON
R
ft
ft.
-
y`�gy�
A.1/a✓76WI
�.y...�.y. �fy.
--
�y�
--Is
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:FROM
TO
nalet17ae
=cMOiasS MA
`tc,
D
1
2 la.
c. V _
a L0115 P:.
,py 1('P.
a
.
4:':
'�•",•'� tr..s.T,--.,
PROM
TO
DIAMETER
YAJ
TM NA77WAi,
fL
fn.
2
ft.
in.
..r
70 ➢MMRTER
FROj�G)
MAMMAL
^M
�ta
`L3
7=
°t
efe..
" T= F�
FROM
70
MA7RRUL
8I18r,AFl)n
rt
ft
fMEI80o�� &AMOUNT
rt
Sftb
n."
�
t9
ft
d
-
?Ow ft.
?
l l
� r /# Vt
J
71 a V
ft
7Nriatntra'.
ft
,
DPSCRIPTION(epalarh --- __...._._.._.._.
"A f oa/rm'k eve aatua enl
atty.Sigia lay
Ptak" -cl67-
tsesi
S€
22.Certifcation: iniorntsitivnProcu.:s ciUnit
r Bi%.'aG3li:s
G/z9/7
Signature of Certified Well Conti r Date
By signing this lona. / hereby certify that the welt(s) war (were) conravcted in accordance -.
with 1.54 NCAC 02C.0100or ISA NCAC 02C.0200 Well Constnction Standards and that a
copy (Phis record has ben: 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. Ton may alsoattach additional pages ifnecessary.
$UBMI7TAL INSTRIIC77ONS
24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
Dlvidonof Water Resources, Information Processing Unit
1617 Mail Service Center, Raldgh, NC 27699-1617
246. For Infection Weds: 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 folbwing: �r
Division ofWaterResources, Undergre Rd°�nfeci ertitiB
1636 Mali Service Center, Raleigh, NC 27699-1636
24e. ;For Water Suoaly & !Median Wells: In aiOt t fit 4 s891 clie form to .
the address(ea) above, also submit one copy of tluss limn MOW( 30 days of
whcompletion
ceoonsuof wted. ell conebuctiee to the valet'
heahb derettmwt of the eovaty
t , Water Quality Regional
Operations Settle
Wilmington RegittfY1P
R

1: Well Contrac0o� rmatlon: 0 I
4 _6784
Well Coonactorlame
NC wiell_ComiatoriCaddcadonNomher
Ge iradv co& O°
CompanyN ..
2. Well Constmcdon Permit*
List alIapplrable well co attraction innate (te. UIG Corm% State, Hata etc)
3. Well Use (check well use):
Water Supply We&
®ABticokmal QMmioipallpabtic
3Geothermal (8eatingg/CoolingSt ply) R idenlialWaterSupply(»gle),
IndusfiaiCo mercial 13Rtaide6AWater Supply (shared)
ikriftation
Non -Water Supply Well:
ring
eeflon Well:
)AgldferRecb c 13GroundwateRemediatim
'Aquifer Storage andRecovay ®Salinity Barrier
Aquifer Test DStonnwaterDrainage
BxpeimentalTechnology ®Subsideace Control
3Geotbaii (Closed loop) Chats
laced:amal(Hetthm/CoolingReetn Gt er(explainunder#21 Remade)
4. Date Weti(s) Completed: 4/ (6 wen cam
5�9J7/�'eB Location:
t ttrt<..
f Rweray
Facility/OwnerNameFacility IDS Ofappliwbte)
I / /11 k; COLA Aftsr
4
County ParcelIdead6celknNo. (PIN)
6b. Latitude and longitude In degrees/minutes/seconds or decimal degrees:
(if well field, one let/long is sufficient)
6.Is(are)the wdl(s) amnent or DTetmt y./ 1,.'2m7
7-Istblsarepair toanmisting well: Crites or lialllli
Oa irarvpair.,RRawhow well mnsmrcdonaforo#_AtyPAPAih oJrl'ee
repair tattier d2lremotssection or on the betake tigiLitA. Dwell .6
8. For Geoprobe DPT or Closed -Loop Geothermal Wells having the name
construction,only l GW-1 is needed. Indicate TOTALNUMBBRofwells
drilled:
9. Total well depth below land surface: `
For multiple wells list al depths f�erest (sample-3@200 andl@100)
10. Static water level belowtop of casing: / O
(voter level tsabove casleetwe 4.
11.11oreholediameter: (in.)
FROM
FROM
29
FROM
FROM
3
FROM
TO DFS�'RON
ft
R ft
R
ft
-1L
R
To
/77 it
TO
ft
ft
TD
if
DIAMETER �I TRRIAL
Ion ctea
DIAMETER
Alra
in.
ft
fi.
SLOT SI2S
To MATERIAL •
vc,
MATERIAL.
TRRIAL
aueIBODLAMOUNT
ft ( gr.
tom® .legeditte, 7frost 1_
ft
To MA
//Pf• r2 14N riv
R
FROM
O. R
Lift
soR
7ra
DINA
TO _ DISCRRfmNCott loraam..•.,. oramin OMera
/o fti dap
zs ft SQL O 1,74
loft ;�doges,
?r - d/CY
7‘. IG,'fit: 0770, --
t. 9ei4—7g4r.4,
/3
/3r /6G let7 - 7z /r7 fah,'
/IL /7Z etrc,.
22. C
cation:
a
SigmaneofCwdfied Well Contractor
l ``/ 7
Ale
By rigtdng this form, I lardy cc* that the well(r) was (were) constructed in accordance
with MA NCAC 02C .0100 or ISA NCAC 02C.0200 Well Construction &anderdrand theta
calve thirre dherbeenprovidedmthewdlowner.
23. Site diagram or additional well details:
You may use the back oldie page to provide additional well site details or well
consuvction details. You may also attach additional pages ifnecawary.
SUBMITTALINSTRIJCi7ON$
(ft) 24a. For AB Wdts: Submit this form within 30 days of completion of well
cunstractiontothe following
Division of Water Resources, Infopmden Procuring Unit,
1611 Mad Service Center, Raleigh, NC 27699-1617
24b. For Iniadon Wello: 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
amsuuctionto the toibwing: RECEIVED/NCDENR/DWR
Division of Water Resources, Undergroundlnjeedon Control Program,
1636 Mail Service Ceuta, Raleiglj,NC27699-1636
24c. For Water Smaly & Iuieetion We: InaliditPio ito8se the form m
the address(es) above, eke submit one copy of this ibm within 30 days of
completion of well construction to the county wmty
etonal
t of the
��
(ft)
12. Well wnrtraeton method:
(i e. auserac h, able, d reetpwb etc.)
FOR WATER SUPPLY WELLS ONLY: .
13a. Yield (gpm) Ye' Method of tesh Ai /
13b. Dis ufee ion types es,�,{�(.i�i/ Amonue _% f �^7
Form GW-1
North Carolina Department or
where constricted. Operations Section
Wilmington Region Iegg
FhvaoamenmlQmfib-]Naisi000fwaterRaamea 11eltote

1. Well Co
r fn2rmaHon:
Well ComataorName
3/s1
NC will mber
Kamr1M. WfC Sri! a
Coma nvNaampeA
//
2. Well Construction Per* it:
Liatailapplfmble neamrotrucompermas(Le. WC Conan kam Parlance. etc.)
3. Well Use (cheek well use):
Water Supply Wen:
Agticultura(
Geothermal (licetingiCaoUng 8upp4') QResidential Weer Supply (single)
®Nduatrial/Coamaciat ®Residential Water Supply (shard)
relni
Non-Water Supply Wd):
rLMcnitwing
sedan Wells
°AqudeRecharge
f Aquifer• Storage and Recovery
DAquiferTest
°Experimental Technology
Doemharnai (Closed Loop)
f oeodtanaa) (fiealmg/Cco1,R
®MuoicIpaYPublic
®may
®Groundwater Reanediatim
®Salinity Barrie
f StormwaterDtainage
®SUbsi&mce ControlO(her(arplainwider#21 Remelts)
Iran AILVIAllitlM
ft.
ft.
FROM TO
446283
fa.
PS. ; 7ft Z to
cow
IM
ft brri-
ft. ft
3i1
It,
MATUW.
a
iu' 'AMU"; _'�:=�"•;fir„
ego
%�trMaxnonALbmanT
ft.
"TR
ft
R }Q/p�,f[�i
(it
acuity /Uwaar a tt---_ �--� psalm le)�r.,3 4 Tit
I y [p . Wlvclee r S kgG Ann 2-, 5Zfr.
/54); Well ID)#
4. Date Well(s) Completed: /
Well LoeadP°
Phyakai. ty, eatnd ZTipp
County
Sit. Latitude and longitude in degrees/minafesAeco
Orwell field, an atama is sufficient)
aeamal aegme:
SEP.1 1 2017
N
Ksstion Proof>3Y
6.Is(are)the weH(s) ermanent or emporarjVWGlir,LX
7.Lthis arepair toanmisting well: °Yes or De
IJtdp tea repas.,ABout Imam well construction b{(wtaaaonold egbbe the nature afthe
repair tinder AN rends section or on the back oft hplbr s.
8. For GeoprobdfPT or Cloaed•Laop Geothermal Wells having the same
construction only I OW1 is needed Indicate TOTALNUMBER of wells
drilled.
9. Total well depth blow land surfaces
For nuftWe wells Aft ell depths rani Priam l t[3100)
10. State water lead below top of easing:
Atwater levetfaboe easing we *7
12. BorebSlediatneten
12. Well construction method:
(Le. auger, rotary, able, directors)]. et)
/Z
FOR WATER SUPPLY WELLS �ONLY: .
13a. Yield (gpm) !/q/ Method wins:
13b. Dlsinfeedoa typed frewau(.�'i' Amount
R • . ft
•' {aerraw fen* 44110LSIMIUeta
efts
Sand
eat ir
22. C
SignatureofCkrdfad Wd1t Gaaetor
By string rip. font I betty err* that the weft(s) xna (were) ooraaraled is acardance
with ISANCACO2C.0100 or ISA RCAC 02C .0200 Well Construction Standards and thata
crop, ¥this recordhearbeen provided tothe tellowner.
13. Site diagram or additional wdl details: RECEIVED/NCDENR/DWR
You may use the back oftbis page to provide additional well site details or well
contraction details. You may also attach additional pages Rosemary.
7' 1ATUCUOP SEP 1 8 2017
e-S 200'a»d2 Cat•) 24a. For Ail Wes: Submit this form within 30 days of completion of wen
construction tothe tbnowing: Water Quality Regional
0
Division of Water Itmourca,InfetwiNdq eratio s Ion
1617bail Service Center,Rddgh,NC I Office
()
yt
24b. For Inleed= Web: 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
consanclion to the following:
DMvfdonef WaterRtsources, Underground Injection Control Program,
1636 Mali Service Center, Raleigh, NC 27699-1636
24e. For Water Soule &lnlecton Wells: In arwmon 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 scurry
where constructed.
Form GW-1
North Carolina DepartnontofEnvironmenial Quality- Division ofwater Resaumes Revised 2-22.2016

VY Lt Li, LUEN J I I(Ut I ION KLCUKD (GW-1)
1. Well Contractor Information:
Justin Radford
For Internal Use Only:
14. WATER ZONES
Well Contractor Name
3270-A
NC Well Contractor Certification Number
Geological Resources, Inc.
Company Name
2. Well Construction Permit #: NA
List all applicable well construction permits (i. e. UIC, County. State. Variance, etc.)
3. Well Use (check well use):
Water Supply Well;
Ir Agricultural DMunicipal/Public
ll Geothermal (Heating/Cooling Supply) DResidential Water Supply (single)
(fi Industrial/Commercial DResidential Water Supply (shared)
aIrrigation
Non -Water Supply Well:
Monitoring
Injection Well:
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
Experimental Technology
Geothermal (Closed Loop)
Geothermal (Heating/Cooling Return)
Recovery
Groundwater Remediation
0 Salinity Barrier
fStomiwater Drainage
Subsidence Control
OTracer
Other (explain under #21 Remarks)
4. Date Well(s) Completed: 06/08/17 WellID# MW-1
5a. Well Location:
George Taylor Tract
N/A
Facility/Owner Name Facility JD# (if applicable)
Intersection of Mollie Road and Hwy 701, Whiteville, NC
Physical Address, City, and Zip
Columbus
17015
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
34.204167 N 78.762500
w
6. Is(are) the wel(s)Ox Permanent or (Temporary
7. Is this a repair to an existing well: OYes or E No
If this is a repair,,fill out known 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-I is needed. Indicate TOTAL NUMBER of wells
drilled:
9. Total well depth below land surface: 10
For multiple wells list all depths ifd�erent (example- 3(a)200' and 2Q100')
10. Static water level below top of casing: 5' 12 - (ft.)
If water level is above casing, use "+"
n
11. Borehole diameter:
12. Well construction method:
(in.)
hand auger
(ft.)
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm)
13b. Disinfection type:
Method of test:
Amount:
FROM
5
ft.
TO
10
DESCRIPTION
445S33
ft.
16. OUTER CASING (Inc multi cased welts); OR LINER (if apblitable)
FROM THICKNESS 1 MATERIAL
0
ft.
TO DIAMETER
2
ft
2
in,
sch 40 I pvc
16. INNER CASING OR TUBING (geothermal closed -loop)
DIAMETER THICKNESS
FROM
ft.
TO
ft.
ft.
17. SCREEN
FROM
2
ft.
TO
10 ft.
ft.
in. f-
_ MATERIAL
DIAMETER
2
in.
SLOT SIZE
0.010
THICKNESS P MATERIAL
sch 40
pvc
ft.
in,
1& GROUT
FROM
0
ft.
TO
0.5 ft.
MATERIAL
concrete
EMPLACEMENT METHOD & AMOUNT
tremmie
ft.
ft.
ft.
19. SAND/GRAVEL PACK (if applicable)
TO
FROM
ft.
0 ft.
MATERIAL
42 sand
EMPLACEMENT METHOD
pour
ft.
ft.
20.::DRILLING LOG (atfach addidhnai sheets if necessary)
DESCRIPTION (color, hardness, soiVrock type, grain size, etc)
FROM
0 ft.
TO
2 - ft.
Brown silty sand
2 ft.
6 ft.
Tan silty sand
ft.
10 fh
Grey silty sand
ft.
ft.
ft.
ft.
ft.
ft.
ft.
AUG 25
2017
21. REMARKS
Il
<mcasng
OWQ/t4DG
Ur18
22. Certi cation:
Signs N R ertified Well ntracto
By signing this form, I hereby certi$ that the well(s) was (were) constructed in accordance
with 15A NCAC 02C .0100 or ISA NCAC 02C .0200 Well Construction Standards and that a
copy of lhis record has been provided 10 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 Amrs. of completion of well
construction to the follow': •
E9NEQ/NCDENRID
Division of Water Resources, Information Processing Unit,
1617 Mall ServiceC Center,C[pRRaleeii *(WC 27699-1617
24b. For Injection Wells: In addit[on 4o S'end 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: IOD81
Water Quality Reg,
Division of Water Resource IQ'gp;Control Program,
1636 Mail Sdj�jire161�f4P, Wisgh, C 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.
Form GW-1
North Carolina Department of Environmental Quality - Division of Water Resources Revised 2-22-2016

1. Well Contractor Informatinny
1 ror internal Use Unly:
444380.
Well ContactorName
NC Well Contractorration Number -
cde ,n C'G� Ott
CompmryName
2. Well Construction Permit #:
Listail applicable well construction pant (Le vz County, Stoic Ttrionce, era)
3. Well Use (check well use):
Water Supply Well:
DMuoicipavPublic
Geothermal (Heating/Cooling Supply) ®Residential Water Supply (single)
Indushial/Comme cial ®Residential Water supply (shared)
abrigatioa
1 Non -Water Supply Wen:
C3Monitoring Injection Well: ®�el•
- -
AlnderRecbmge ®GrouadwaterRmediadan
A
quifer Storages end Recovery°Salinity Barrier
` Aquifer 'Test DStomwater Drainage
,ExpeimentalTechnology [Subsidence Control
3Geothamal (Closed loop) QTmea
10eot iamal (Heating/CoolinggRrRenp))Glber(explain under #21 Remarks)
4. Date, Wells) Completed: ✓ "i 17 Well ID#
5 /¢d ILoopon.rc1�1
Facility/ Name Facility IDS (if applicable)
ao- DPP Neg,;w kc 2ty5y
Physical �, City, and Zip _
County Parcel Identification No. (MN)
5b. Latitude and longitude in degrea/rtdnates/saonds or decimal degrees:
Of well field, one iat0ag is sufficia0
3y°518.41" N It IZT:.'4
FROM TO .
ft ft
DESCRIPTION
f4 ft.
it
R
ft.
DIAMETER
PRO7 M Toqq
o//5k l!
n.
SLOTSIM
4.440
Seto
TRIOOMIss
10
10
0 C.
v Z.
MRThOD&AMC
o'er -
5-A F*,7
Dale
6.Ia(are)the wdl(s) P'ermoneot or O'1'empbrary N2017 isolators of - edtW&Contractor -
T. Is this a repair t0 an By stake this form, I Meby arij(y that Ne was) was (were) aaotn1aed to accdManee
existing well: Yee or . a, with 45A NCAC 02C.0100 or ISA MAC 02C.0200 Weil Comamdfon Standards and iha a
rjrhir wi repair,,l0fotahxo:m Iva commie/ion wornmlkncaff j7`ltiinpdie` ba+✓a "'l`la olihk record has been provided to thewelfawner.
repair twofer remarhssecaonorenthe badrojihisAnt Ei i, d?'_3i 0G pp��
23. Site diagram or addIflokECE V r(/� �tn
8. For Geoprobe/DPT or Closed -Loop Geothermal Wills having the same Yon may use the back of this page to prone �l site derails or well
construction,only1GW-I is needed. IndicateTOTALNUMBERofwells construction details. You may also attach additional pages ifnecessay.
drilled: / smirrrALSN977tUCflorvgUN
9.Total wellde th6elowl a rrZ S� 9 2017
Farnudttple welts list all depths 'Wrens (erample-3(§200'm42810011 (rt) 24a. For An Wells: Submit this form within' 30 days of completion of well
amsnuction to the fob owiagNa(er Quality Regional
10. static water level be ow.op of casing: (R.) Divides of Wai4t(N er, ' o (IRq Processing Unit,
IL keens above easing, aw'+^
1617MailSernce � e jj �yg94617
11. Borehole diameter: O /
12. Well construction method:
(is. auger, rotary, cable, direct push, ern.)
7
FOR WATER SUPPLYWELLSONLY:
13a. Yield (gpm) Iv/1y✓� Method of tat:
13b. Disinfection type: pee Amount:.
A' ✓
zl
246. For Infection Welts: fa 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
construct/on to the lain/ins:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Suooly & Infection Wdle: In addition to sending the form to
the addtas(es) above, also submit one copy of &IS famr within 30 days of
completionere constructed.construction to the county health department of the county
Form OW -I
North Carolina Department of Environmental Quality • Division of Rates Resources Revised 2-22.2016

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.1. Well ConGacto ormation:
fc O.0t-'
ror Internal Use Only.
444379
Well Contractor Name
l ,ff
NC Wen tractorCeni6cationNumber
6 ration
Company Name
2. Well Construction Permit #:
Liatall applcable wellmnslnrstioa permlts(xe. UIC County, &ore Torrance, eta.)
3. Well Use (check well use):
P�
Water Supply Weld:
DA&icuhutal _ - ®Muuicipal/Public
Geothermal (Heating/Cooling Supply) gireildeatial Water Supply (single)
Industrial/Commercial QResjdeatialWater Supply (shared)
Irrigation
PROM
A
ft
DESQUPIION
ft
FROM . TO
It.
flit sett
DIAMEIER ;T>` s TERML
EMIEMTIEWAIDNIVDETWORMg
FROM
TO
R
ft.
DIAMETER
b. e4e vc
in.
Non -Water Supply Well:
whoring ©Recovery
Injection Well:
Aquifer
Aquifer Storage and Recovery
Aquifer Test
DExperimental Technology
'Geothermal (Closed Loop)
'Geothermal (Heating/Cooling R
4. Date Well(s) Completed
Sa.WevLocation:
OW
DGrotmdwater Remediatioa
DSaiimity Bonier
oStormwaterlhaiaage
®Subsidence Control
()Tracer
Other (explain under #21 Remarks)
z- 7 weums
©er-
Facility/GwaerName Facility DIM (ifapp0®ble)
/ 7Y36 ! elate% 974[ (f use Qv ok Me an7
Physical City, and Tap
(Fo/wba y
County Parcel iden66cadonNa. (PIN)
5b. Latitude and longitude In degrees/minutes/aeconds er decimal degrees:
(if well Seidl one Tat long is sufficient)
N
6.1s(are) theweil(s))P€rmanent or DTenrpormwl ,t 2017
7.ls this a repair to an Existing well: graor {3No Z
pais is a repot"?omlmown wdlmmoadlon ir(fofnjplionni4wlo riketletrdis_elie"I
repair rmderk21 remark section or on the backoflhfrform. D4 Oj icC;
B. For GeoprobelDPT or Closed -Loop Geothermal Wells having the same
construction, only 1 GW-1 is needed. Indicate TOTALNUMBER of wells
drilled;
9. Total well depth below land surface:
Formuhfpte wells list al depths ij'd4 erem (example- 3@200'and 2@100)
10. Stadc water Level below.tep of casing: Io (ft)
'water level it above casing. use ".
IL Borehole diameter. (i On.)
12. Well construction method:
Zr
(:L)
(Le. auger, rotary, cable, direct pusb, etc.)
ASETMEttiorir
f•
MOM
bn
S ft.
ID.
FROM
ft.
Im
TO DIAMETER
TO
4-- ft
'4' fi
TO
IODa' 17.E
R
R
4'H THICKNESS
-;a:A° S• ;"z=:SS
THICKNESS MATERIAL -
I
suIsrze
Se- VD
MATERIAL
iif� G
---_..._.MOUNT
MATERIAL slta'LAtaireNramTsoneAMODNT
MATERIAL
EMPLA . (c METBOD..
,4rce . frier
1/03it5 Gi1'UMe
FROM TO
Zrft $-Sift
DESCRIPTION (mkt Ardour, soot ,ype, solo Manta
Xis( •,c
eh y .
.7%"*.1
Bracy
70ft 7/ fc
7ift..)f rt
y ft. / 7-n-
"rr"i:AiP:
C. KC- 57'1it.c_.
S�
22.0 /C//�D'
B au6edWdIKC7Contractor
dOII:
Date
By signing this form. I hereby ten* that the we0(s) was (wore) commuted ed as accordance
with 15.t NCAC 02C.0.100or ISA MAC 02C.0200 Well Construction Standards and thet a
copy oft is record has been provided to the well owner.
- 23. Site diagram or additional well
You may use the track of this page
construction details. You may also attach addition
SUBMITTAL INSTRUCTIONS ((����1t pp qq
24a. For All Wells: Submit this form ea ilia 20(0a completion of well
construction to the Mowing:
Wa
Division of WaterResourcee& g rot,
.m U
1617MaS Service ro., -i619
if
246. For Injection Welts: In addition to 2g shin 30 o the aletion in well
above,4a
also submit one copy of this form within 30 days of completion of well
constitution tothe folbwing:
Division of WaterResources, Underground Injection Control Program,
1636Mail Service Center, Raleigh, NC 27699-1636
24t» For Water Snooty & jniection We11g: 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 censmmtion to the county health department of the county
where constructed
FOR WATER SUPPLY WELLS ONLY: _
13a. Yield (gpm) 70« Method of test: A I
13b. Disinfeeion type: 714444, Amount: lira
/7j"D' J Z.
R In.
Form GW-I
North Carolina Department of Environmental Quality - Division of WaterReaources Revised 2-222016 -

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1. Well Contractor rmation:
Well Contactor Name
IFor Internal Use Only.
444378
PROM
DIStmerfoN
Of' tut
en5Y / IM°ee er r
Physical Address. City, and Zip
hale 004
County Parcel Identification No. (WS)
Sb. Latitude and longitude in degrees/mina(eslseconds or decline' degrees:
(if weft Se(d, one lat0ong is sufficient)
l W
2017
7.lsthis arepair toanexisting well: I(0'+";1pD14-d-''".. s"}`7 ;,';,iC
Ilshit isarepair,*amknown welennranmlan WSmmadan 6
repair:8*HLremade:sedan or an the backojthirjarm. erpra/n9id nature ajthe
N
6. h(are) the well(shrifrermanent or CiTellyi
S. For Geoprohe/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 /73
For multiple wells itet a0 depths it'd(!erent (example- 3%200' 0nd 2©1001
(ft)
10. Static water feud below top of casing: .7°
'water level aabove awns, use °y (D)
1L Borehole diameter: (/
12. Well contraction method:
(i.e. auger, rotary, able, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY: . �1
13a. Yield (gem) 30 Method Idlest:
?p
136. Disinfection type 4te. Cie' Amount: Ai.
Pr/
NC Well Contra r CerDDcalionNmoher
krc�'deant Wiel fa4efr4
CompeerName
•
2. Well Contraction Permit#:
List allapppicable we0eoastnemion permfs (xe. IBC Cormry, State, Ymjonee, etc)
3. Well Use (check well use):
Water Supply Well:
®Agticuhuml - adtmicipdmaida
Geothermal (Heating/Cooling Supply) WResidential Water Supply (single)
7udusuial/Commercial f Residemial Water Supply (shared)
',irrigation
Non -Water Supply Well:
QMonitomg ®Recovesy
eedonWel:
3AquiferReeoharge
3Agnifer Storage and Recovery
()Aquifer Test
()Experimental Technology
tGeothermal (Closed Loop)
®GmundwdeFRemediation
®Salinity Senior
DstonawaterDminage
®Subsidence Control
amerce
jGeothem al (Heating/Cooling Return) ®Other(explem under #21 Remarks)
4. Date WeB(s) Completed: / 7 WeB ID#
Sa. WeB potation: /
Gv//!i ih Kam/ f
Facility/OwserNeme Facility IDe (ifappl cable)
"WA. se #V z y
ft.
ft.
It
PROM
0
17f1
DI&MEIER
2-
In.
GejeD I P(!G
FROM
ft.
D.
TmCBntess
in.
18RLtL
DFS mg me(color,roan®,Mike*caom..c>i.erct
P / C a_ 5 e--69i
elet-y
3 t1 goo. 3 �`'7 Sal
/PR' zo
jt- 3f
fof<.. got
9 n . /<!'7f
fir
594.1
�zs ,s,Q Aly
,s-1 /do tateinutc
22. Certifies
o �I
Signature ofCmr�ed Wdt contractorr
/-GO / 73 SQn,(
CA47
Date
By signing this lam I hereby' crosa that the we ,ag9 - in ecconfance
with ISA NCAC 02C 4100 or .15A !CAC 02C.0200 Wet!.thatn
copy ((this record has ben proalded to the well owner.
23. Site diagram or additional well details: J(UN pp o
You may use the back of this page to provide addition& t l/,,,�, Retails or well
conshucion details. You may also attach additional pages if necessary.
SUDMITTALINSTRUCIIONc WUaterClualitYke
Wil Perations g tit-
24a. FerFor�Welta: Submit this form w21 0'1 (�plesion of well
construction to the following: nit ice
Dhision.of Water Resoarees, Information Processing Unit,
1617 Mali Service Center, Raleigh, NC 27699-1617
24b. For 'election Wells: In addition to smdmg 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 folbwing:
•
Division of WaterRemurces, Underground Injection Control Program,
1636 Mail Service Center, Ralegh, NC 27699-1636
24c. For Water Seeds & Infection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 coof
completion of well construction to the county health dent of the county
where constucted
Foam OW -I
North Carolina Department of Environmental Quality- Division of Water Resources Revised 2-22-2016 -

• �..vti.vaW 1 W 11
1.Wed Contractor lofo on: �y
4fd . F/A�`�O
Well Contractor Name -
For Internal Use Only:
444377
FROM
345',
NC Well CeMeactafCettificatIonNumbez
c4 at_ 411 0477 -
CompauyName
2. Well Construction Permit #:
Lfrf all applicable well construction permits (la WC Coanry, State• Variants, etc.)
3. Well Use (check well use):
Water Supply Well:
DAgricultwal . - DMmicipal/Pubic
®Geothermal (Heating/Cooling Supply) QResidential Water Supply (single)
. QItdustriawCommetcial DResidential Water Supply (shared)
"knead=
Non -Water Supply Well:
iIllvionitoring ®Recovery
Igjet en Well: -
Q NifeTRecharge ®OrouudwaterRemediation
DAquiter Storage s Recovery ®Salinity Barrier
fAquiferTest ®Stormwater Drainage
QExperimental Technology DSubsideace Control
®oeothamal (Closed Loop) space
oGoothemtel(HeatngjCooling �) O(her(cxphtmunder#21Remarks)
4. Data We11(s) Completed:rei Wed mg
5 . WeH Location:
efPt€ 44n {f!goy
FacilWinerName ileellky RIP Of applicable)
/ l04A' link
i 4- eAtien . ac 21c133
?kirk":
AYaka k art �f
County Parcel Identification No. (PIN) ie7r-
Sb. Ladtude and longitude in degree/minutes/rieconds or dedmaldegrees: (D - f
Orwell field, one Wiens h sufficient) '
a ,� 22. CertificadoD:
B. For Geoprobe/DPT or Closed -Loop Geothermal Weds having the same
construction, only 1 OW -I is new. Indicate TOTALNUMBER of wells
drilled:
9. Total well depth below land surface: 2/ 4
Formuhtple wells list el depths#'d09erem
10. Statde water level below lop of casing. T
(water level is above easing ore "+"
11. Boreholediameter: er
(example
12. Well construction method:
(le. auger, mm4; cable, Shut Rusk etc.)
TO DESCRIPTION
ft.
ft.
A.ae' itrtFav - v . .yell fl .,.
DIAMETER
PROM
tt
ft.
as
t1
ft.
TO
TO
?.,
ft
ft.
mane n st
ID.
MATERIAL
Trs0
MATERIAL
0/0
Ma1EOD
ft.
ft
FROM
O " &Sr
Z J "• 33'"
37' Stir
DESCRIPTION (ee r, beetles. soffiwekrncaoiadr.ete)
S /la//C.
-re? /Ie
7Sf 7tj-f
N
6. Is(are) the well(s) ermanent
/f'O
/5o
or O'femporarJN '& a 2017 Signe=ofC
4 3 7r .c
S4$.r'
e/4
rto[ 11- ',Pe drat/
c '� (Fr r 2/5 - Sehtei.
Well
�`�
VED/NCDENR/DWR
Eftft
By sfgning Mb form• I hereby are Mat the wags) mar (were) contacted in acetate e
7.1s this a repair to anexisdng well: ®Yes 1y}:, n arc✓.:c:snAWI UNt_ with ISA NCAC 02C .0100 or ISA NCAC 02C.0200 IVe0 CCnstrrhtiwl Sanded* and that
)titbit )s a repab; f it on blown well construction bfo ntatfon and toaabllld'67uv"tise ofthe copy e(thfs record her been pooidej 7pvnq
17 repair under #L remark section or on the baetofthtrf inn. D L D
- 23. Site diagram or additional well details:
You may use Ore back of this page to provide additional well site details or well
construction details. You mayddiemianh' ' if necessary.
SVB ALIN�U�_Opeton e Secain
(it) gton Regional Office
-3�100'mW2@199) 24a. For All Wells: Submit this form within 30 days of completion of well
(ff.)
FOR WATER SUPPLY WELLS ONLY: _
13a. Yield (gpm) 2,11 /D, /MMfethod often: �� 1T/
13b. Disinfection type: ieleil filAmount:_% 44
construction to the following:
Divisionof Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Infection Wells: n addition to sending the form to the address n 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
24e. For Water Suoaly & Infection Wells: In addition to sending the form to
the address(es) above, also submit me copy of this within 30 days of
completion of well conabnction to the county health department of the county.
where consmmted.
Form OW -I
North Carolina Department of Environmental Quality -Division ofwaterResources Revised 2-22-2016

vvaw tv Tr aI
1: Well Con
orlmbrma 106E - •- /
tor Internal Use Only:
444368
Well CantraetorName
NC Well CommAemr4y( Jow ton eE oce `( i i
CompanyN e
2. Well Construction Permit#:
Lir tall applicable well c w:rudion pam0r (le UIC, Covey. State Fariance, etc)
3. Well Use (check well use):
Water Supply Well:
®Agricultural
"Geothermal (Heating/Cooling Supply)
"ktdu sidaYComMelciai
" Itrlration
1 Non -Water Supply Well:
Monitoring
In eetlon Well:
'Aquifer Recharge
,31Agnifer Storage and Recovery
3AguiferTest
'Experimental Technology
3Geothamal (Closed loop)
,Geothermal (Heatmg(Cooling Rana)
®Mtmioipal/Public
tuidentiat Water Supply (single)
®Residential Water Supply (shared)
®Recovery
®Gmtmdwater Remediation
DSalmity Barrie
DStormwaterMminage
®Subsidence Control
['Tracer
f Othet (explain ande#21 Remarks)
4. Date Wells) Completed: Well IDS
Sa. Welt Location:
Facility/Owner H e FactiM (ifapplicable)
mt.. o/af4ait; T dein ire ZSSt 1
Physical ACity, and Zip
$c/4nq
County Parcel ldontfidationNo. (PIN)
5b. Latitude and longitude In degreWminutes(secends or dedmal degrees.
(ifwell geld, one af/iong is sufficient)
ir0117* N 7fd p
6.Ware) the weiI(s)DP&manent or Qfemper y
7.Isthis arepair toanmisting well: ®Yes or-�,xL
I¥thb is a repair,"Iout keen well construction bybrmationand castle o} 4 copy �'fia romrdOos Brea�(
repair under WTMremerkrsccaor or on the bucket:kirform, [(19 @(
23 Site diagram dd[ti aal m
S. For Geoprobe/DPT or ©osed loop Geothermal q�p • thesaxe_+ n ll;y'pu may tree the back of this page to Provide additional well site details or well
contraction, only l OW-1 is needed. Indicate TOTAL TOMB)) ,tr}'PYFiis,-3 amenctiondetaia. You mayalsoatmcha ppalpenes ifneceMMy.
drilled. �7 JUU�iVV 11 [CuW�f( _-
9. Total wen depth below land surface: Z Sir
For multiple wells iistaUdepths Vd�enm
D1p� /'�� flESs MA
r /(a. �i y0 � V
D.2. tn. TglCaegzss Mpg
in .
s-x•, err+. - r Nt s"' i'Y"y`'"4"
TO �_: SLOTS== TRICKINESS MAMMAL
in.
fL
PROM
TO
DESHnWIION
ft
ft
ft.
PROM'.. TO
ft art
FROM TO
�s net
ft
ft
MOM
bft
tt.
ft ft.
ft. ft.
MATERIAL
RMPLACRIIMM''METHOD a
ICar
FROM TO (toter,bNness,segketatme.mo trheMel
aft£o°
zee 3sr ass, &1
3 CI 7 ft S nn-e-
3 7ft C. ft
73 `t /Lod sGiry
ft Z. ft
L,ek•e- T�•t-�
22. C
Lion:
ha
Signature of Certified Well Contractor
10. Static water level below top of easing:
(jwmer/ewlbabove cesteg,use "+
11. Borehole diameter
12. Well contraction method:
(ie. auger: rotary, able, directpvsb,
FOR WATER SUPPLY WELLS ONLY: _
13a.Yield(gpn>) Method of test:
136. Disinfection type. Amount:
-
ft
. shaming Mb Jbrm, 1 hereby are Mat Me wags) was (were) cominmed in accordance
WM 15ANCAC OTC.0100 or BA NCAC 02C.0200 Well Construction Standards and that a
CNNR/DWR
or a o w details:
SUBMITTAL INSTRUCTIONS
S 24a. For Alf Wong: Sub
exempla i@20D'mu(TQIOIrI °�lr `i."`�Irey�4fbtimts of compleion of well
at.)
censmmdn theeounwmgOperationnsSection
DividonofWatmti; g���alisa6o
to ing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Infection Weil: In addition to sending the form to the address in Zia
above, also submit ono copy of this form within 30 days of completion of well
constriofiontothe following:
Division of Water Resources, Underground Injection Control Program,
1636 Mall Service Center, Raleigh, NC 27699-1636
24e. For Witter Suede & Infection Wen{: In addition to sending the form to
the address(a) 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 Caroline Department of Environmental.
Quality- Division of Water Resources Revised 2-22-2016

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1. Well Contr ctor Inform on:
+W lv rr II
For Internal Use Only:
10, Static water level below.top.of casing:
fluter level is above casing use "+"
11. Borehole diameter:
12. Wen construction method:
(i.e. auger, rotary, cable, d rectpush, etc.)
Well Contractor Name
NC Well Contor Certification Number
,t1/ '✓a / 4
Company Name
2. Well Construction Permit #: W.- // �m62,Y
List all applicable well construction permits i.e. UIC, Connty, State, Variance, eta)
3. Well Use (check well use):
Water Supply Well:
Agricultural Dq�Municipal/Public
1f�"`ra
Geothermal (Heating/Cooling Supply) identiat Water Supply (single)
Industrial/Commercial ®Residential Water Supply (shared)
Irrigation
Non -Water Supply Well:
Monitoring ®Recovery
Infection Well:
Aquifer Recharge Groundwater Remediation
Aquifer Storage and Recovery ®salinity Barrier
Aquifer Test DStormwater Drainage
Experimental Technology ®Subsidence Control
Geothermal (Closed Loop) DTracer
Geothermal (Heating/Cooling Return) ®Other (explain under 921 Remarks)
//''f
4. Date Well(s) Cempleted2A Wei IDq
SaAvell Location��
ta
Facility/Owner SName Facility 1D# (if applicable)
2.573n{-41/044 /4/ Gdr�/otres gF3o
Physical Address, City, and Zip
zip/4 at 4 In
County Parcel IdentificetionNo. (PIN)
Sb. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one tat/long is sufficient) - ^
N W,
6. Is(are) the well(s) rmanent or DTemporary
7. Is this a repair to an existing well: fYes or Eggr
lfday is a repair, fill ont known well construction information and explain the nature of the
repair under #.21 remarks sectlon or on the back of this form.
8. For Geoprobe/DPT or Closed -Loop Geothermal Wells
contraction, only 1 GW-1 is needed. Indicate TOTAL NUM
drilled: 7 APR
9. Total well depth below land surface: 2 Z O Ai" R 2 8' 20
For multiple wells list a!(de the lf� (Zl%
el 8
TTOIS
;R: ONES-:
OM TO
DESCRIPTION
Jft. sat 4
Slip 2:ER CASJrYC instrnlileee l&%,el(�;URtINEtotinMlle
ROM _TO.. DIAMETER Ta,CE:NESS RIAL
FROM
n
TO
Loa
tc
DIAME
to.
in.
SLOT.IZE
FROM TO .,.. MATERW, EMP
FROM
e H.
rt.
)fn.
LIftt.
rill.
.- ,._Wroek type, drain ma etc
G4 'it- /83 L4x r72,
3 f fh / r3 2-on SaNd er
v r. 4 Zbo ZZo Jess./
drft Jas'
/57
/flt.
"-r aoer-
/ ts-b ,54
S/G
rr ar
Pi'
22. Certifi
To
9, ft.
CRNESS
MA RIAL
C MENT METHOD&AMOUNT
MP EIVIHNT METHOD
Qee .--
DES ION (color, hardness
Signeit6e ofCerti Weil et r
P different(example-3@200 and4100') 1MAY 0 2011
n o e owm
o/ 7
a
By signing this form, 1 hereby cent& that the well(s) was (were) constructed in accordance
with 15A NCAC 02C .0100 or 15A NCAC 02C .0200 Well Construction Standards and Mat a
copy of this record has been provided to 0m 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
fiction details. You ma also attach additio al ges if necessary.
{S�UBMrrTAL INST1(>() C � D/NCDENR/LiV
2'4a. For All Wells: Submit this for within 30 days of completion of well
construction t
OnfOrMatVJn P C/Ci tll foil
rill r i/14ft.) Division of Water Resources, Information Processing Unit,
1617 1Vlailfticoftwo9Raidia C 27699-1617
443299
se
/fs-/fb s4
ZJJD -.2. -Jo
FOR WATER SUPPLY WELLS ONLY: 13a. Yield (gpm) Ao Method of test: 4
(
13b. Disinfection type: ay.if u arimount:
24b. or n'ect on W : ytr a . st§ ° i. a form to the address in 24a above, also submit on s RI) ' Hays of completion of well
construction to the following:
1 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 contraction to the county health department of the county
where constructed.
Form GW-I
North Carolina Department of Environmental Quality - Division of Water Resources
Revised 2-22-2016

I. Well Contractor 1 . o , ation:
well ConnactorNeme
NC W- I Contractor C cation Number
Company Na
Ca
2, Well Construction Permit #N _�7.00*6 %% List all applicable well conr(nm(ion pe I (.e. WC Cmmry, State, Valiance,
3, Well Use (check well use): ate)
Water Supply Well:
Agricultural
Geothermal (Heating/Cooling Supply)
Industria1Commerciat
Irri.ation
Non -Water Supply Well:
Monitoring
Injection Well:
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
Experimental Technology
Geothermal (Closed Loop)
Geothermal (Heating/Coolin, Return)
4. Date Well(s) Completed:
Saa. Well Location:
Facility/Owner Name
$7Z7Z a lc�s
Physical ,APddresss fity, and
/Zip
count
Dm pal/Public
esidendal Water Supply (single)
DResidential Water Supply (shared)
Recovery
®Groundwater Remediation
®Salinity Barrier
,QStonuwater Drainage
®Subsidence Control
oTmcer
Other (ex , lain under #21 Remarks)
Facility EDO (if applicfl f v t9a
ACealeeCaJlctd'telMC
Parcel Identification No. (PIN)
56. Latitude and longitude in degrees/minutes/Seconds or decimal degrees:
Orwell field, one lat/ong is sufficient)
22. Certificati
N
W
10.S level below.top of easing.
ffwater level is above casing use "+
6. Is(are) the wel(s) . ermanent or Temporary
7. Is this a repair to an existing well: f} BIC
flits is a repair, Jill out known well construction information andteexplain the nature ofthe
repair wider 021 remarks section or on the back ofOnsform.
well depth below land surface: �Jer ee
Far me '
rucievai DIAME B... i rs*4
/i
(:Farah sUddt"'T j ,„
FROM rTO
r� rift. r
'' :' aP.n e �
EMPLACEMENT METHOD
Signature ofCeni Well Con eto
Date
By
g this tthat
0lll SisnthacANCAC 0C.0100 or15ANCACO2C .200WeConstruction ndardad that
copy ofthis record has been provided to the well owner.
8. For Geopro6e/DPT or Closed -Loop 23. Site diagram or additional well details:
construction, only1 G1y_ Geothermal Wells NI s gyy use the back of this page to drilled: 1 is needed, indicate TOTAL in'p, rahon devils. You may also attarP,6 add'tionatr noel well site details or well
9. Total pages if necessary.
multiple wells list all depths afdierent (example- SQ200' cord 12100'j
Static water
APR 2 b 20 BMIT7'sf TV
V N
j25 E t t 3vvoi r� SECE{VED/NCDENR/DW
11. Borehole diameter: A .. lD Mall Service Cent Rai
In d6'd'(i ion % y$nSJt
12. Well construction method:
Division of Water Resources, Information Processing
,� 4// 1617 Center, sigh, NC 27699 1617
/9 24b. F r InieI 't 7
(i.e. auger, rotary, cable, direct push, etc) above, also submit one copy?he form to the address in 24a
construction to the followinof this form within 30 days of completion of well
FOR WATER SUPPLY WELLS ONLY; Water Quality Regional
Division of Water Re�hl� �Sqg i o- . tion Control Program,
1636 Mao
24c. or Water Water Suoolv�.
R�®f 4a iC1�99-1636
the address es In'ectson Wells: In addition to sending
address(es) above, also submit one copy the fags of
.
completion of well construction to the county of this epa. wits o 30 days county
where constructed, health department of the county
North Carolina Department of Environmental Quality - Division of Water Resources
Unit,
13a. Yield (gpm)
—�� Method of test:
13b. Disinfection type:
Form GW-1
Amount: l y
For Internal Use Only:
443298
DESCRUPTION
1R011iM CASING dccastd iYe Rif:`
FROM DrAME , lIs 6R+.G ie dk"111e ,�
o
ev
NMI
Lava ktEMr,:i
FROM -
(R') 24a. c 1 W s:
CSSS'm9rlii^u9tio It tlr ll Howubmit this form within 30 days of completion of well
Revised 2-22-2016

WELL CONSTRUCTION RECORD (GW-ij
1. Well Contracyr Information:
Well ContmctorName
tizai
NC Well Contra for Certification Number
ire' 61 eilvt. C &d 4// / %R j
Company Name
2. Well Construction Permit #:
List allappltcabk well construction permits (i.e. WC, County, State, Variance, etc.)
3. Well Use (check well use):
Water Supply Well:
Agricultural ®Municipal/Public
Geothermal (Heating/Cooling Supply) WitEsidential Water Supply (single)
Industrial/Commercial ®Residential Water Supply (shared)
Irritation
Non -Water Supply Well:
Monitoring
Injection Well:
■!Aquifer Recharge
Is :Aquifer Storage and Recovery
MI Aquifer Test
A' Experimental Technology
®Recovery
®Groundwater Remediation
Salinity Barrier
DStormwater Drainage
®Subsidence Control
Geothermal (Closed Loop) ®Tracer
Geothermal (Heating/Cooling Retain) Other (explain under 821 Remarks)
4. Date Well(s) Complete.' r ' I'7
r Well ID#
5a. W Locafion:
a j/4 &enc4
Facility/OwyrNisme Facility ID# (if applicable)
,04 (4414 pn Cite& i l� Bri t ,kcldY;
Physical Addre rCity, and:
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/ieconds or decimal degrees:
Orwell field, one laVlong is sufficient)
N W
6. Is(are) the wel(s) ermanent
7. Is this a repair to an existing well: ®Yes orO By signing thus form, I hereby cent 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
(phis is a repair, fill out known well construction Information and explain the nature oftre copy of this record has been provided to the well owner.
repair under tt21 remarks section or on the back of this form. -
g Site diagram or additional well details:
8. For Geoprohe/DPT or Closed -Loop Geothermal Wells 1
33.,\�a:okmay use the back of this page to provide additional well site details or well
construction, only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:
For Internal Use Only:
44397
7:orr aR;GA'SDXG(ff4tyl`o'[tDIMeEFd era),.—..- ,,,...:..
D6� 0 2- ETER
I�a
o in. �
FROM
/Pot
OM
ft.
ft.
Oft.
lo+L
22.
TO
ft /7‘ort
0f110131870e
TO
( I PL
ft
a
TO
Sort
4' ik'.,.(
t/4t
//ofL _S Goord
.3 St" 'ley_ rgs.,
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D
DIAMRTsng€v3nslTmCK1vESS PeMA
'd11t1r-xfta"tc,
CMP
o ft
ON (color, harem
e— /70-7/lc So
poWroch type, groin size,
Mention:
or °Temporary Signature o citified
9. Total well depth below land surface:
For multiple wells list all depths ifdterent (example- 3Q200 • curt ton Pro(, ft
4B;-For All Wells. Submit this form within 30 days of completion of well
DUM]BCr§ construction to the foiltEIVED/MCDENR/DWR
10. Static water level below top of casing:
limiter level is above casing, use "-E"
11. Borehole diameter: (//
GOva
/anCr
I Dam
3MMMA7
12. Well construction method:
(i.e. auger, rotary, cable, direct push, etc.)
APR GOI�UBMITTAL INSTRUCTIONS
(ft)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) 3° Method of test: Sr
13b. Disinfection typtt1it4G Amount:. j/ Li
Division of Water Resources, Information Processing Unit,
1617 Mail Service
A CCVentter, Raleigh, NC 27699-1617
Ifivk'ddh
24b. For Infection Wells: ietpt8 sag 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:
ater Quality Regional
Division of Water Resouf2Bel ijiattif tiMIClfl,(ection Control Program,
1636 Maik41lin j nt gai ¢I4 27699-1636
24c. For Water Simply & Infection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
completion of well construction to the county health department of the county
where constructed.
Form GW-1
North Carolina Department of Environmental Quality - Division of Water Resources
Revised 2-22-2016

. WELL CONSTRUCTION RECORD (GW 1)
1. Well Contractor Irf'or/nation:
C,e/aI.
IFor Internal Use Only:
4432
Well Contractor Name
3 /CI
NC Well `ontractor Certification Number
eithedf0b ill etc- `rat
Company Name
2. Well Construeton Permit #:
List all applicable well construction permits (l.e. U1C, County, State, Variance, eta)
3. Well Use (check well use):
Water Supply Well:
Agriculttunl
Geothermal (Heating/Cooling Supply)
Indu a r: al/Contntercial
gation
Non -Water Supply Well:
Monitoring
Injection Well:
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
Experimental Technology
Geothermal (Closed Loop)
Geothermal (Heating/Cooling Return)
DMunicipaVPublic
®Residential Water Supply (single)
DResidential Water Supply (shared)
®Recovery
®Groundwater Remediation
®Salinity Banter
oStormwater Drainage
®Subsidence Control
DTracar
/Other (explain under #2I Remarks)
4. Date Well(s) Completed: - Well ID#
��5 We�}} oeaton:
,but �d€0, (cs
Facility/Owner Name
-Etc Sc4rv/
Facility MP (if applicable)
Physical Ad as, City, and Zip
County Parcel Identification No. (PIN)
513. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one let/long is sufficient)
N
6. Is(are) the well(s)anent
CPI
O
fi
13idiYn"d1;Ep�eis
crr0
ter
DFScR1PrTIQN (color, hardness, col/rock type, Brain
L,6 � �f72)i�4
7 J C-- CF. I4r it
y
/yet glair_ V 4.RK
/%oft ,26rr iw
2. 7r- fond
x7r 2 77oAV_ zpf- ales—s
22. Certilicaton:
Err,
x v® vmv Viva b Y
or DTemporary n ture of Certified Well Contractor Date
7. Is this a repair to an existingwell: �y�,,� ° °PR 2 8 2017 By signing this form, I hereby eery that the well(s) was (were) contrasted in accordance
IBses or ®No with l5A NCAC 02C .0100 or 75A NCAC 02C .0200 Well Construction Standards and that a
(this is a repair, fill ant known well construction information nature orrrcopy oafs record has been provided to the well owner.
repair under ION remarks section or on the back of this form. Seethe
then!?li�", (N�
st.n>
8. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction, only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled:
9. Total well depth below land surface:
13a. Yield (gpm)
136. Disinfection type:
10. State water level below top of casing:
((water level is above casing, use "+"
11. Borehole diameter:
12. Well construction method:
(i.e. auger, rotary, cable, direct push, etc.)
33s (lot.,
For multiple wells List all depths 'dierent(examiple- 3Q200' and1u3100') 24a. For All Wells: Submit this form within 30 daysof completion of well
7® construction to the following: Q�
(ft.) Division of Water Resourccees, Informaatio OProcessing Unit,
1617 Mail Servlee Center, Raleigh, NC 27699-1617
PROM
ft.
ft.
TO
S
ft.
ft.
DESCRIPTIO
+DYfTdtRASI1YG,([or;'miilII
OM I TO
ft.
FROM
/7©
OM
On
ft.
40 ft.
OM
OM
ft
ft
ft
let ft
TO MATERIAL
® ft S 9J
'tart
In. Se-1/0
vulva. g'i+naataai,`cl 014
DIAhfSTER 1 THICKNESSS
Zin:
to,
.S
< ", f ; it-1 618
To
6'17t"r,`(i
TO
ft.
ft
O .J .
74
rft
/nit
/—vn•r 4 "".
FOR WATER SUPPLY WELLS ONLY:
Method4
of test: ,
digte t " thAmount: 714 GJ/
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.
sUBMIflAL INSTRuencilECEIVED/NCDENR/DWR
24b. For Infection Wells:. In adtiitlii
above, also submit one copy oftbt
construction to the following: rt'iimiflgFoil
"fo the address in 24a
!"b' pmpletion of well
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Sunaly & Infection Wells: In addition to sending the font to
the address(es) above, also submit one copy of this font: within 30 days of
completion of well construction to the county health department of the county
where constmcted.
Form GW-1
North Carolina Department ofEnviromnental Quality - Division of Water Resources
Revised 2-22-2016

For Internal Use Only:
443295
.�, .... ..�. ..z,, v ..va .....0 tVW LI
a
1. Well Controctorn(orynafD ©fte,-:=
Well Contractor Name
NC W 1 Contracto CettificadonNumber
itieniria ti aft t/ eteltep.
Company Name
2. Well Construction Permit#:
Lfrt allapplicable well construction permits (Le. UIC Cow* State Variance, etc)
3. Well Use (check well use):
Water Supply Weft:
A Agricultural . ®Mimicipal/Public
• Geothermal (Heating/Cooling Supply) alteidential Water Supply (single)
A Industrial/Commercial ['Residential Water Supply (shared)
R lnh-tion
Non -Water Supply Well:
■'Monitoring
ejection Well:
Aquiferkecharge
Aquifer Storage and Recovery
Aquifer Test
Experimental Technology
Geothermal (Closed Loop)
Geothermal eaten_ Coolin
Recovery
®Groundwater Remediadon
®Salinity Bonier
DStonnwater Drainage
®Subsidence Control
®Tracer
(,� ther 'Maunder #21 Remarks)
4. Date Well(s)°CCompletteeedd: / 4.? // /�7 Well 1Dq
nt �J a
U� 4� {4dL r'
Facility/OwnerName Facile
ty (ifappfiable)
Diu uy
10? iiu. .A&es? Kc
Physical Cit and Zp
de 4104,94
County Panel IdeotfioetionNo. (PIN)
Sb. Latitude and longitude in degrees/minutes/Seconds or decimal degrees:
(if well field, one lat/long is sufficient)
N W
6. Is(are) the well(s)manent or Temporary
7. Is this a repair to an existing well: or ®No
lfddr is a repah;Tilton !,own well construction igfarmalion andary)ab, the noire afire
repair under #21 remarks section or an d,e back afthfrform.
S. For Geoprobe/DPT or Closed -Loop. Geothermal Wells having the same
consistence, only I GW-1 is needed. indicate TOTAL NUMBER of wells
drilled:
9. Total well depth below land surface: /""Y Z (}t,)
Par meditate wells list oil depths ifdfffereat (example-30 200'.and2©1005
10. Static water level below .top of casing: Z $ r (ft.)
lfwater level's above casing, use '4 "_ 11. Borehole diameter: � ,
12. Well construction method: °14
(i.e. auger, rotary, able, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY: -
13a.Yield (g)m) 3 a Method Wiest:
13b. Disinfection type: 66/N('�4 Wfr Amount: pyti
•,14r�.`Mau\'
Ali "{{S Ai i." : ie,', :k:5
PROM
TO
DESCRIPTION ..
ft
ft
ft.
ft
FROM m:
11f7:(f "'mild
d IGya'"iaq .. �,r,-',.1 gel .'.,x.,T.,
FROM/���.
TO
DIAMETER THICKNESS
MA
OM
!
zGCrt
in.
'Y v ttiaiA�Lltsb
ill q"n*i t".M':',i;y,. •:
FROM
TO
DIAMETER
THICKNESS
MATERW.
zS
Lie.
/7r is
54�'b
roc.
it
ft.
in.
rx +
„K.d t
.axis srs v
FROM
TO
D
OTSIZE:ryRI4Lr,3
SIATSIEE
TIR
MATE".
OZft
t:
Man. .
'
s o
far
ft ft.
In
O ` g—gr as
E= ;;.3t :,.3 y rd_. >? �k%. -.F7` "sties -`s,:: d:;rFE`
-
FROM
TO
MATERML EY>PI.ACBY�NT METHOD& AMOUNT
v7
re
Sy
estarath,Oar
fin+ft
2
,a.
W,7fi
f
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ft.et.
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TO
TERML
EMPLAC�"�` METHOD -.
<�'m
z7z�'
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ftf/
ft
ft.
/
FROM
Ti
r''''yv
DESCq�T$pt(mb.YaNane, pE/nrktvPe,Enim
tUreekye
6 ft
y ft-
malleke
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g
v -eMX
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y
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not
/port
d m tfonRnation Pr, (?:, ; ,;
rc
22. Certifi/`�`
Signatum off CptifiedWell Contractor
Da
By signing this fore, I hereby ter* that the well(s) was (were) constructed h, 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 diagtt, DR
You may use MP o 's page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMIfTAL1N$1$slhbl�s 2017
24a. For AB Wells: Submit this fort within 30 days of completion of well
construction tothef i uglity Regional .
Diva i of s SeCtlon
ter, Raleigh, NC 27699-1617
s on o��( fiDmdon Processing Unit,
16Yo i(fi�
24b. For "election 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 Man Service Center, Raleigh, NC 27699-1636
24c. For Water Suaaly & Injection Wells: In addition m sending the form to
the address(es) above, also submit one copy of this form within 30 days of
completion of well construction m the county health depatmrent of the county
where contented.
Form OW-1
North Carolina Department of Environmental Quality - Division of Water Resources Revised 2-22-2016

tit?it?? C r754 4.-- ,,ma�yy
Se? hot
$Ctd.

1. Well Control Mr Information;
14or Internal Use Only:
443294
Well Contractor Name
3is-�
NC ell Contra CedifationNumber
le9Zieioc. fa// ri n'�a//"
�
Company Name
2. Well Construction Permit#:
List all applicable well animation permits (Le. WC, Conn%, State, Pariancc, eta)
3. Wen Use (cheek well use):
Water Supply Wen:
DAw ukaml
®Geothermal (Heating/Cooling supply)
DinduslriavCommercial
1lhrigatian
Non -Water Supply Well:
fMouutoring
Injection Well:
DAgnifer Recharge ®Groundwater Remediation
DAquit'er Storage and Recovery OSalinity Berner.
®Aquifer Teat DStomnwater Drainage
DExperimeatal Technology QSubsidence Control
DGeothetmal (Closed Loop) DTTaeer
®Geothermal (Heating/Cooling Return) ®Other (explain under 921 Remarks)
4. Date Well(s) Completedebh 7 Well IDN
erg i{irsilEEIE S%ET P,:.£h4 'rye l
DESCRIPTION
FROM
ft
7O
ft
ft
Giulia efi1 b 01anni316
.TD DIAMETER THICKNESS l
FROM
PROM
ft.
TO
ft
DIAMETER
in.
it SpER
THICKNESS MATERIAL 'y
ft
ft.
In.
®M '' ' dUPublic
eardential Water Supply (single)
®Residential Water Supply (shared)
,Well Lo don:
DRecovery
Facility erName Facility JD# (itapplicable)
4 L am S&b.q, r fl u.KL 7-Igt3
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 lat/long is
(pn
// e 1-0 774 f N 7t1 • t j- fI Cr
1 W
6. Is(are) the well(s)�manent or Temporary
7. Is this a repair to an existing well: QYes or Mir
r
Ifdm is a repay, illootknown wen cementation information and explain the nature ofihe
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:
9. Total well depth below land surface: Z Z0 (ft.)
Fornmhtple wells list ad depths IIfdj&rent (example- WOO' and 2QI00)
10. Static water level betow.top of easing:
Ifwaler (evens above casing, use "+'_
11. Borehole diameter: 6 (ht)
12. Well construction method: A nvi
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WF.Lf S ONLY:
13a: Yield (gpm) Method of test: 44/
13b. Disinfection type: %4/Elli Amount:
r
DESCRIPTION (color, badness, saamek type, mobilize, etc-)
°K y
�i 4. am
erAe r
&Age_ f7o
SSf
FROM
010-
H.
FROM
To
=�
TO
DIAMETER
Z
lo.
SIATSIEE 7IyTRICxNE88
S115e-4�
I
MATERIAL
11
3- ftrr
.. R' -�S fttie ^V
0 rt
ft /29 ft
PROM
/Zpft 22o ft
MATERWL
Saeaseir
EMPLA INERT METHOD & AMOUNT
A
EMPLACEMENT METHOD
ft
FROM
v_ ft
lift
SR
D
7Lft.
ray
To
S
raft
7Z !�
Po
el ft
rr
APR 2 a 2017
22. Certification:
Information Procerash-) UnU
©WOIBCG
Signature ofCertiled Well Contractor Date
Hy signing this form l hereby writ* that the weals) was (were) anetrocied In accordance
with ISA NCAC 02C .0100 or ISA NCAC 02C .0200 Well Construction Standards and that a
copy ethic record has been provided to Me 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 additionalpages if necessary.
SUBMITTALINSTRUCFIONS
24a. For Ali Wells: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Information Processing Unit,
161 - RajgjgjyNC 27699-1617
24b. For Injection Wens: In addition to se/aesetularnng the fonn to the address in 24a
above, also submit one copy of this form within 30 days of completion of well
construction to thefhllovgY 0 8 2017
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
Water Quality Regional
24c. For Water Sa,W dpIaitati, m.0 jdigm In addition to sending the form to
the address(es) atkisitinalargisubrtikogamispgregfethis from within 30 days of
completion of well construction to the county health deputment of the county
where constructed.
Fora: GW-i
North Carolina Department of Environmental Quality- Division of Water Resources - Revised 2-22-2016

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1. Well Contractor o motion:
tairn
Well Contractor Name
44329
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DESimurTION
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NC W 1 Coouzctor r..calionNumbertue //
U Name
Company
2. Well Construction Permit #:
List all applicable well construction permits at DIG coun(V, State, Variance, eta)
3. Well Use (check well use):
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DIAMETER
THICKNESS
MATERIAL
C.
MATERIAL
ft
ft
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Water Supply Wed:
,Agnoultmel ,
Geothermal (Heating/Cooling Supply)
Industrial/Commercial
irrigation
Non -Water Supply Wed:
Monitoring
Aquifer Recharge
Injection Well:
Aquifer Storage and Recovery
®Aquifer Test
jBupeimental Technology
,Geothermal (Closed Loop) DTTacer
]Geothermal (Heating/Cooling Return)
Other (explain under #21 Remarks)
4. Date well(s)Completed:% /�/ ?well IMF
Well Locatjtp:
7Prlo
QMunicipal/Public
esidemiai Water Supply (single)
',Residential Water Supply (shared)
®Recovery
®Groundwater Remediation
',Salinity Hattie
DStotmwate• Drainage
®Subsidence Control
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MATERIAL EMP MENT METHOD&AMOUNT
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County Parcel Identification No. (PIN)
5b. Latitude and longitude in degreea/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
N
W
6. Is(are) the well(s) manent or',Temporary
Lle1O
if this is a repair, fill out known well cananuedon information and explain the nature of the
repair under #11 remarks section or on the back of this form.
7. Is this a repair to an existing well: ®Yes or
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Date
By signing this form, I hereby enmfy that the well(s) was (were) constructed in accordance
with ISA NCACO2C .0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
copy ((fhb record has been provided to Me well owner.
ite-0iagrem or additional well details:
8. For Geoprobe/DPT or Closed -Loop Geothermal Wells haviaB th8 elms back of thus page to provide additional well site details or well
construct
consmuction, only I GW-I is needed. Indicate TOTAL NUMBER of ° ion details. Yon may also attach additional pages if necessary.
drilled: ""° k 2 O SWIMArt.INSTRUCTION
9. Total well depth below land surface: � ;„,In,F.,,, ilECEIVED/NCDENR/DWR
9.or taiple nwlls belll ow
ijd s r fant ceromple-3�100'mrd2®lOn� iC "r�}atlgun:rAR Welis: Submit this form within 30 days of completion of well
L DWQ/BC69nstmction to the following: 10. fl
10. Static water level below. top of casing: T (ft.) Division of Water Resourcki folinaiaZ a cessing Unit,
flitter (evens above casing. ace "+" 1617 Mail Service Center, Raleigh, NC 27699-1617
11. Borehole diameter: 24b. For Intection Wells- In adr 8)i20b Qeinklg % the address in 24a
12. Well construction method: fj above, also submit one copy of tiosCi gtanidbjg $@�o completion of well
(Le. auger, rotary, cable, di,ectpusb,eMJ aonsimction to the following: Wilmington Regional Office
FOR WATER SUPPLY WELLS ONLY: - Q
Method of test: !' f t'
13a. Yield (gpm) /1 13b. Disinfection type:.. V 1/ ,, Amount: _OIL_
?a
Division of Water Resources, Underground injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c, For Water 3mmale & Injetion Welk: 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 depamnent of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality - Division of Water Resources
Revised 2-22-2016

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1. Well Comm nformation:
�o IAA
Wejl Conuac rName
NC Wen Centre Certification Number
/4CNattLff t2th ©t'46�,
Company
•
2. Well Construction Permit #:
Last all applicable well construction permits (La WC, County, State, Variance, etc.)
3. Well Use (cheek well use):
Water Supply Wen:
°Agricultural , •
®Geothermal (Heating/Cooling Supply)
®Iudustrial/Commercial
flIrrigation
Non -Water Supply Well:
QMonitotiug
Injection Well:
°Aquifer Recharge
°lAquifer Storage and Recovery
°AquiferTest
°Experimental Technology
®Geothermal (Closed Loop)
f Geothermal (Heating/Cooling Return) Other (explain under MI Remarks)
4. Date_Welke)Completed: il%Wen DM
5a yyaacagqnDn:
(OxIY—(Oitl%hfol.)
Facility/Owner Name /�Facility tDk (ifappliceble)
i
®MtmicipaVPubtic
denial Water Supply (single)
®Residential Water Supply (shared)
°Recovery
°Groundwater Remediation
®Salinity Barrier
DStormwater Drainage
°Subsidence Control
®Tracer
9��pe 4'iraaK G�Kace.", 3 (
Physical
� s, City, an/
4J0 4/6/i
County Parcel IdentifrcationNo. (PIN)
5b. Latitude and longitude in degrees/minutes/Seconds or decimal degrees:
Orwell field, one lat/long is sufficient)
N W
6. Is(are) the well(s)Of ermanent or °Temporary
7.15 this a repair to an existing wen: ®Yes or ®Ittf�
If dab is a repay,air of (mown well construction information and explain the nature ofthe
repairwder #2l rattans section or on the back°fads form. - 23. Site diagram or additional soil 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.
SUBNH'1TALINSTRUCTIONS
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9WCIVI:SC FL"
•
8. For Geoprobe/DPT or Closed -Loop Geothermal Wens having the same
construction, only I GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled:
9. Total well depth below land surface Z t
For multiple wells list all depths ifdtferent (example-3@200•mid 2Q(00)
10. Static water level below.top of casing: Go (ft.)
lfwater level is above caring, use "4'
11. Borehole diameter:
12. Wen construction method:
(ie. auger, rotary, cable, direct push, etc.)
74f
FOR WATER SUPPLY WELLS ONLY: - - 0�
13a. Yield (gpm) t7 !/ Method of test:
p
�
136. Disinfection type:a/k^®-f Amount: �� 4-4
7//7
Date
By signing this form, I hereby certify mat the walks) was (were) constructed in accordance
with JSA NCAC 02C .0100 0715A NCAC 02C.0100 Well Constrnrsi0n Standards and that a
copy ofthis record has been provided to the well owner.
(rt•) 24a. For All Weni:'[}g3`
construction to the following:
tans of completion of well
Division of Water ¢psp rcgps, huformation Processing Unit,
1617 Mail S e NC 27699-1617
24b. For Infection Wells• In addition to sending the form to the address in 24a
above, also submit one copgatt Ultinjgov qdkitbadays of completion of well
construction to the following:Operations Section
Wilminpp((nnn Re ionk�II ntf e
Division of WaterResourcer,IInder un3 pee"? Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Sunaly & baiection Wens: 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 censuuotion to the county health department of the county
where constructed.
Form OW-1
North Carolina Department of Environmental Quality - Division of Water Resources Revised 2-22-2010

WELL CONSTRUCTION RECORD (GW-D
1. Well Contractor
Well Contractor Name
NC Wel Connac r rtification Number
G��ri,� ���1 �u
Company Name
2. Well Construction Permit #:
List art applicable well constriction permits (Ie. 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:
Monitoring
Injection Well:
Aquifer Recharge
°Aquifer Storage and Recovery
®Aquifer Test
Experimental Technology
]Geothermal (Closed Loop)
3Geothermal (Heating/Cooling Return)
4. Date Well(s) Complete! a
®Mimicipal/Public
rerrsidential Water Supply (single)
® Residential Water Supply (shared)
®Recovery
®Groundwater Remediation
® Salinity Barrier
oStormwater Drainage
®Subsidence Control
® Tracer
[Other (explain under #21 Remarks)
��' /Well ID#
5a. Well Loc on:
f/Ili S l 2;n�
nor
Facility/Naar Name Facility MN (if applicable)
e2cn7 ?ine/rhEV LO�,A"4011% MY7L
Physical A dress, City nd Zip
County
Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/Seconds or decimal degrees:
(if well field, one laV1ong is sufficient)
N W
6. Is(are) the well(s)1rmanent or DTemporary
7. Is this a repair to an existing well: ®Yes dr BC
If this is a repair, frill out known well constriction information and explain the nature of the
repair under #21 remarks section or on the back of this form.
S. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction, only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled: 9. Total well depth below land surface: t924 0 (ft.)
For multiple wells list all depths leant (example- 3Q200' and I(31001)
10. Static water level below top of casing: (D•)
If water level is above casing, use "+"
11. Borehole diameter: T (in.)
12. Wen construction method:
(i.e. auger, rotary, cable, direct push, etc.)
/07417
FOR WATER SUPPLY WELLSQONLY:
13a. Yield (gpm) 3 0 Method of test: Ail
Ple-
13b. Disinfection type�4r/KG&ti Amount: Ail
For Internal Use only: 442456
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22, Certification:
. 4
17/019
Signature of Certified Well Contractor
• 7yit/ 7
Date
By signing this form, I hereby earth" that the well(s) was (were) constricted in accordance
with 15A NCAC 02C .0100 or 15A NCAC 02C .0200 Well Conshvction Standards and that a
copy of this record has been provided to the well owner.
23. Site diagram or additional we�,M� I•.
You may use the back of this page ' ll site details or well
construction details. You may also attach additrona a 'g3ary.
SUBMITTAL INSTRUCTIONS AlA/1 77nn
24a. For All Wells: Submit this fonn�lwithm g0'a4 of completion of well
construction to the following: wafer Q a
Division of Water $�pjd.pi ri. t@oJ W6l ssing Unit,
1617 Mail Serviia/ �ficfi76999-1617
Ion24b, For Infection Wells: In additionitonto sending the foiiit Y6 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 Sanely & infection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
completion of well construction to the county health department of the county
where constmcted.

WELL CONSTRUCTION RECORD (GW-1)
For Internal Use Only:
Company ame
1. Well Contractoy Iytormation:
Weg.Contractor Na)}ie
..,. tonuactor Certification Number
e 4etp oad Vol 7
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
Geothermal (Heating/Cooling Supply)
Industrial/Commercial
Ini ation
Non -Water Supply Well:
Monitoring
Injection Well:
•'Aquifer Recharge
X:Aquifer Storage and Recovery
II Aquifer Test
A: Experimental Technology
KGeothermal (Closed Loop)
A Geothermal (Heating/Cooling Return)
°Municipal/Public
esidential Water Supply (single)
Residential Water Supply (shared)
4. Date Well(s) Completed.
5a. Well Location:
®Recovery
®Groundwater Remediation
®Salinity Ranier
®Stomrwater Drainage
®Subsidence Control
®Tracer
Other explain under #21 Remarks
L742 WeB um
W fe /t4
Facility/OwnerName
Physical Ad as, City, and Zip
County
. Fa ility ID# (if applicable)
s e 60t4,,t mc f9
Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,
one lat/lonng iiss ?sr sufficient) �[
J7 loni( N 7 1 //Q
6. Is(are) the weB(s) . Permanent or °Temporary
7. Is this a repair to an existing well: es or ®No
"this is a repair, fr/l out /mown well construction information and explain the nature of the
repair under 0/21 remarks section or an the back alibis 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 surface:
For multiple wells list all depths ifdierent (example- 3Q200'and 2Q100)
V
10. Static water level below top of casing:
"water level is above casing, use "+"
11. Borehole diameter:
v
0
12. Well construction method:
(i.e. auger, rotary, cable, direct push, etc.)
(ft.)
ift.)
(in.)
FOR WATER SUPPLY WELLS ONLY: j
13a. Yield (gpm) ` O Method of test: 4/ e
,- / I
13b. Disinfection type: iG�•�"' Amount: /r hf
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22. Certific
Si re of CettSed
ctor
Date
By signing this form, I mreby cern& that the well(s) was (were) constn,cted br accordance
with 15A NCAC 02C .0100 or ISA NCAC 02C .0200 Well Construction Standards and Mat 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 th I r , 1 site details or well
constriction details. You maP ecessary.
SUBMITTAL INSTRUCTIONSpp�� pp pp qq yy �n
24a. For All Wells: Submit thitili tln 4vit7int3N1daysof completion of well
construction to the following:
Division of Water RWedetesjUafii9441jgjr)igjcessing Unit,
1617 Mail Service@jdaretjd97de1 ( 27699-1617
24b. For Infection Wells. InadditionRegional atb Office
gtae fic 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 Suooly & Infection Wells: In addition to sending the fonn to
the address(es) above, also submit one copy of this form within 30 days of
completion of well construction to the county health department of the county
where cnnemmted

V0,177Z lac ,(LC-
c\N,

WELL CONSTRUCTION RECORD (GW-1)
For Internal Use Only:
cipal/Public
°Residential Water Supply (single)
®Residential Water Supply (shared)
Recovery
®Groundwater Remediation
®Salinity Barrier
oStormwater Drainage
®Subsidence Control
°Tracer.
Other (explain under #21 Remar:
Well ID#
Facility !DP if applicable),p.'L
�f LL )Gntm (f 01,4:4 ! (n%t1 tdj%it'tcYr
Physical Address, City, and an Zip
00/11
1. Well Contractor In ation:
i 9
e/t�Od
Well Contractor Name
3/0
ATNCC ell Con'r4`tor Certification Number��l�r//
i l �t(0 it-,
Company Name
2. Well Construction Permit if:
to,
List all applicable well construction permits (Le. UIC, County. State, Variance, etc.)
3. Well Use (check well use):
ater Supply Well:
r, Agricultural
Geothermal (Heating/Cooling Supply)
Industrial/Commercial
R! Irri _ation
Non -Water Supply Well:
Monitoring
Injection Well:
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
Experimental Technology
Geothermal (Closed Loop)
Geothermal (Heating/Cooling Re
4. Date Well(s) Completed: J3
5n. Well Location:
0 it
acility/Owner Name
County
10. Static water level below.top of casing:
If water level is above caring, use '4 •'
11. Borehole diameter:
12. Well construction method:
G
(i.e. auger, rotary, cable, directpush, etc.)
Parcel identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/Seconds or decimal degrees:
(if well field, one llat/long is sufficient)Q� ? �J
Yy. l/ •• V N 7U. q/ • «/ W
6. Is(are) the well(s) ermaneat or °Temporary
7. Is this a repair town existing well: Dreror ONO
If this is a repair, fill out !mown well construction information and explain the nature ofthe
repair under #21 remarks section or on the back ofthu 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: ��r
9. Total well depth below land surface:
For multiple wells list all depths ifdi ferent (example- 3 r@7i 200' and2(3100')
7C
//non.)
/"ter/
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ire
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MATERIAL •
IEN'P,METHOD & AMOUNT_
EMPLAC/F/y�
0 ft /0'
(r
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-•�
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FROM TO
MATERIAL EMPLACEMENT METHOD
ft. ft.
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-
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FROM
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DESCRIPTION Kolar, hardness, eel/reek type,, grainsineetc.),,
O• ft.
/r'ft.
54J� 1%P.2Pr e/c
5-t1.
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. e Ay aor,.24-v tic
S-lD ft.
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/7 — ft
gray
RECEIVE!
/Tr ft
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Pertsaataing U
iit4afmg(ion
GWQ/BCG
22. Certifica 'on:
Signatui ofCertiEed Well"(Sontractor
1///1/
Date
By signing this form, 1 hereby rectify that the well(s) was (were) conshweted in accordance
with ISA NCAC 02C .0100 or ISA NCAC 02C .0200 Well Construction Standards and that a
copy ofthir record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
suurITTAL Bvsnuctio1 wCEIVED/NCDENR/DWR
(fk) 24a. For All Wells: Submit this firm within 30 days of completion of well
construction to the following:
(ft.)
FOR WATER SUPPLY WELLS ONLY: Q
13a. Yield (gpm) OMethod of test: ^ /' r
/�
13b. Disinfection type: K%G/Lfj &or Amount: �/r
Division of Water Resour elss,, Inf nfanon rrocessing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Infection Wells: In a
above, also submit one copy M
construction to the following:
)WflDM
ti
I to the address in 24a
9Otillgs of completion of well
on egiona I Office
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 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 Conto nformation:
For Internal Use Only:
�453
Well Contractor Name
NC Well Conl,etor Certification Number
9¢ w.ro44- tad? )re//i t;
Company Name
2. Well Construction Permit #: w t f/ 7 040.07
List all applicable well construction permits (i.e. WC, County, State, Variance, elc)
3. Well Use (check well use):
Water Supply Well:
®Agricultural
fGeothennal (Heating/Cooling Supply)
fIndustiiaUCommercial
f Imgatioa
Non -Water Supply Well:
®Monitoring
Injection Well:
DAquifer Recharge
Aquifer Storage and Recovery
DAquiferTest
®Experimental Technology
Doeothennal (Closed Loop)
®Geothermal (Heating/Cooling R
4. Date Well(s) Completed: `/ZrID#
®Mesiunicipal/Public
dential Water Supply (single)
®Residential Water Supply (shared)
®Recovery
atom
®Groundwater Remediation
°Salinity Harrier
®Stonnwater Drainage
®Subsidence Control
QTmcer
) Other (explain under RI Remarks)
13 W�
Well Location-
. ( imnty Steve'
Fatality/Owna6Name Facility DM (if piicable)
Z97o Maw In aer,(y &A yl,ycz .s
Physicaliddrys, City, and Zip
County
Parcel Identification No. (PIN)
Sb. Latitude and longitude in degrees/minutes/ieconds or decimal degrees:
(if well field, one let/long is sufficient)
3Y. /4.R N 78.4'1.33-
6. Is(are) the weil(s) ermanent or DTemporary
7. Is this a repair to an existing well: ®Yes or Ile+`v
!phis is a repair, fill out imown well construction information and explain the nature of the
repairwWer #21 remarks section or on the back ofthf 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 surface:
For multiple wells list all depths ifd 'erem (example-3@200' and 2@l00)
10. Static water level below top of casing:
If water level is above casing. use "+" .
11. Borehole diameter: y/
12. Well construction method:
(Le. auger, rotary, cable, direct push, ere.)
(fro
(In.) [
1/40
(ft.)
(ft.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) 3 0 Method of test: 4 f
136. Disinfection type: .Amount: A
-`4aA",�sTERtTAlIE3 tx
NE,'r,:L.��.�
TO -
DESCRIPTION
IMIRLCDJG'¢or-m
Ili
iikgr rsTR, .., ..: r'S1
igs. a ;2e.
PROM .'
TO
DIAMETER
THICKNESS
MATERIAL
0It
itra
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e o
lae.
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FROM
TO
DIAMETER
THICKNESS
MAT➢IWL
fL
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it.
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TO
DIAMETER
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THICKNESS
MATERIALAA
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MATERIAL •
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!®P
arrt'
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tiaaiRalits
FROM
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•DEScR1TTTON(Ccior, Stardom, ;Wrack type, underlie,, esa)
b ft
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elan
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ft
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f
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• i o 11 r J a : ialcon0(Wn ,nrarnl6ii
22. Certifacad)*:
•
Signature ofCent fied Well`ontrac
By signing this form, I hereby certify that the well(s) was (were) constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Consauoion 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.
r4UBMt7TAL INSTRUCTIONS
24a. For Alt Welly Submit this form within 30 days of completion of well
construction to the following: pqp����ss���'�'�ICCf111 d�uunn .
Division of Water ResoWMe@ScHM1Tbrmmto)alnit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Iniection Wellg: In additionpp,cgd'big4te.,i'gyty to the address in 24a
above, also submit one copy of this fOSiiPWithbt 10 &44(of completion of well
consnuction to the following:
Division of Water Resources, li�6dudlhjd3tlg(GFRlptrol Program,
1636 Mail Service ttai ldighytr (1'(( -1636
Wilmin (Gn Reienal o a
24c. For Water Sunoly & Iniection Welts: In al • atson o awning the fours 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.
?omit GW-1
Nora Carolina Department of Environmental Quality - Division of Water Resources Revised 2-22-2016

WELL CONSTRUCTION RECORD (GW-1)
For Internal Use Only:
1. Well Contractor Ipfgfmotion:
0
0 ?pin
Well Contractor Name
5/5 7
NC Comet r Certification Number
kellcp or/aa, c(4// O.r?7a r
Company Name
2. Well Construction Permit #: (PC i- / 7 - 00 4 / 7
List atiapplicable well construction permits (i.e. UIC, Carroty, State, Variance, etc)
3. Well Use (cheek well use):
Water Supply Well:
®Agricultural
Geothermal (Heating/Cooling Supply)
Industrial/Commercial
Irrigation
Non -Water Supply Well:
Monitoring
®Municipal/Public
esidential Water Supply (single)
°Residential Water Supply (shared)
®Recovery
Injection Well:
Aquifer Recharge
Aquifer Storage and Recovery
�Aquifer Test
3Experimental Technology
,Geothermal (Closed Loop)
]Geothermal (Heating/Cooling Return)
®Groundwater Remediation
®Salinity Barrier
®Stonnwater Drainage
OSubsidence Control
®1Yacer
®Other (explain under #21 Remarks)
4. Date Well(s) Completed/8/i 7
5a.
e6 Location:
1
4if-
Well ID#
Facility/Owner Name FacilitylD# ifapplicable)
2.4gZ N'c Vtenr,t{att filli e)ltr fife
NG
PbysicaamaniZip
0911440,
Du
County
Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well fiieeld, one Iat4ong is
sufficient) 8 q"
6. Is(are) the we0(s) ermanent or EtTemporary
7. Is this a repair to an existing well Etta or ONO
If this is a repair, frll out known 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: 9. Total well depth below land surface: 2 /5 (ft.)
For multiple wells list all depths if different (example- 3Q200 • and 2(3100)
10. Stack water level below top of casing: 57
Ifwater level is above casing, use "+"
11. Borehole diameter: G (in.)
,g0*1r
12. Well construction method:-
(i.e. auger, rotary, cable, direct push, etc.)
(ft.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: 0 (a Amount: ff
to
•
442452
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•. -'i .4 'cAba+V�
FROM
TO
DESCRIPTION
10 ft.
36-TC
SQe�e
/,53*
/Goff
SIN(A(
75 t)U1EE>dr�GA"SING":(idt'mLDikell€dOvd)
OR`ri1
%
.v
FROM
TO
DIAMETER
KNEriftsflSBeigie)t`
THICKNESS
MATERIAL
oft JI
..f6
Z •m
$4'o
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?1d aNIA'ERt811Si�ll!i$GoRtOB1CYG,°,igc"'dthe7�laGtla"s"ktIab`d)C}
„•WZ.{'.&c'x
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft
ft.
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_tt
ft.
iD•
ar:�)�:7c:�$ft,RE
a:?:f.,�t
n: :. R�.�:
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loran
O{A�t?:,:.1
9200.
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S
jevo
e_
ft.
ft
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3f':..zs...fc r , Ysrli
1COROtt a ?an I Mz
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
O ft
/ ft
� d-
//fp /—
/ ft.
5 ft .
s ��f
' 4°n r
ft./ZO
�' c'Vs
6kt
fit ,,1SWKN?GR*
Ec: ".'
1 t d 'ieflfl'.
FROM
TO
MATERIAL •
EMPLA EMENT METHOD
/ZOm
laseSft.
0414.0(
frstr
- ft.
ft
-
n07G3AG
bGAUaadilfaii
tita e p"ai :a m
TO
DEStJON eolar. hardnwa,➢oiVwcktype,aninsin, etc)FROM
0 ft
Zp ft
c
ZO"•
3,, ft
Safest
33-t.
/5ft
co/a y
fill
/69 ft
Sari(
Ala' RFCEt\1Pr
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2UD
2/5fr
L fG
'*�1fe`ik'FiffBiSVA¢C'�'±,'•i'":,y
.maYt:'"'.x.^N}'.a ksd".").. c
InformationvdCuack,
22. Certinca
rr�
Signature of Certified Well Cohtra for
27/47 •
Date
By signing this form, I hereby certt& that the well(s) was (were) constructed in accordance
with ISA NCAC 02C .0100 or ISA NCAC 02C .0200 Well Construction Standards and that a
copy of this record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach ngpagNCDEIVEDNR%DWR
SUBMITTAL INSTRUCTIONS
24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following: MAR 2 7 2017
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, RvieltbrI Kanitinal
24b. For Infection Wells: In addition t, ,.,s? i in §ost�ypyess in 24a
above, also submit one copy of this form wr furl' &�4 Oaf well
construction to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
•
24c. For Water Snook & Infection Wells: In addition to sending the form to the address(es) above, also submit one copy of this fore within 30 days of
completion of well construction- to the county health department of thecounty
where constructed.

WELL CONSTRUCTION RECORD (GW-1)
1. Well tractor lnformati
010
iv�
Well C/ontraaetoorrName
/• / f
NC Well Contra or Certification Number
/, 01/f0n Wu/ /1re
Company Name -
2. Well Construction Permit Si:
Liel alt applicable well construction permits (i.e. UIC, County, State, Variance, etc.)
3. Well Use (check well use):
Water Supply Well:
Agricultural ipal/Public
Geothermal (Heating/Cooling Supply) esidential Water Supply (single)
Industrial/Commercial idential Water Supply (shared)
lrric.tion
Non -Water Supply Well:
Monitoring
njection Well:
•'Aquifer Recharge
•rAquiter Storage and Recovery
II 'Aquifer Test
• Experimental Technology
•' Geothermal (Closed Loop)
•; Geothermal (Heating/Cooling Return)
Recovery
4. Date Well(s) Completed:e
ell Lac on:
k/
Facility/Owner Name
®Groundwater Remediation
®salinity Barrier
®Stormwater Drainage
®Subsidence Control
®Tracer
Other explain under #21 Remarks)
/i/Oiit/a lenu 4
Physics Address,,F ity, and Zip
County
Well ID#
cilityJDnifapplicable)
/4. 400/vc
Parcel Identification No. (PIN)
sb. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
Oil et,
field, one lat/lopg is sufficient)
N ,O
ieleO , �� ( N (kT 67ff 3(0. flS W
6. Is(are) the well(s)rmanent or DTemporary
7. Is this a repair to an existing well: ®Yes orrig;
Ifthis 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: 9. Total well depth below land surface: A `'7
I (ft..)
For multiple wells list all depths ifdifferent (example- 3Q200' and 2Q100)
10. Static water level below top of casing:
If water level is above casing, use "++'
11. Borehole diameter: O (in.) J /y
Ro 7
12. Well construction method:
(i.e. auger, rotary, cable, drectpusb, etc.)
/20
(ft.)
FOR WATER SUPPLY
s' WELLSEONLY:
132. Yield (gpm) Q✓ `,Method of test:
13b. Disinfection type: J✓QN,tfr Ur Amount:
An>
f J
For Internal Use Only:
442451
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DESCRIPTION
�r.
`O rt
5c.ifri /to _/S r-Se i
S-6dt.
Ln irk
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id:"OUTERCASo(G(fafmi(tisedawdis)Ofl1NERilf4Ppfe&
,"' •..
FROM
TO
DIAMETER
TB[CRNE9g MA RtaL
Oft.(3
—ft
q in.S
CVO 1
v C.
.1 INNER
,-C,:.ORTtIDXNO)tge
1hbbmiaibidral b iT
Mom;
FROM
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THICKNESS
MATERIAL
d"
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ry C.
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re- :7,� xr ts* .S �<<
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THICKNESS
MATERIALt
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ft
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EMPLACEMENT METHOD & AMOUNT
l rL/sr
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is A.O11091aF`iffaNe7
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EMPLACEMENT METHOD
ft
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it
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FROM
TO
DESCRIPTION(calor,hardness, soil/reek type, grain sire, etc.)
dt
4'5r
alecy itz- ito eta?"
ter
4O ft
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4- aft.
//go.
c/'y /Sr zir eft
//Oft'
//i"'
61f7DA.-a. ftr z/7 (tgam,
/1 rt.
, 47Oft
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/soft
/ Gast
dim y 40 27f Set ,d,
/boft.
1 DZrt
tau „past.
'72 a,li°. airL,s'"*:::as„^rss{-2"srzwr, ..`lava '""P w'3'.+`..fz ';
RP RRI
&I'A8l % .^ ,eaas
22. Certification:
Signature ofCertified hell Contractor ' Date
By signing this form, I hereby sere Mat the well(s) was (were) constructed to accordance
wide 15A NCAC 02C .0100 or 154 NCAC 02C .0200 Well Construction Standards and that a
copy of this record has been provided to (he 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: Subniij,jlyis& form within 30 days. of completion of well
construction to the followinga(t(,C / CDENR/owR
Division of Water Resources, Information Prosossipg Unit,
1617 Mail Service t Raleigh, NC 27 9fi 9-1617
Wit�i'7.2017-
24b. For Infection Wells: In addition to sending form to the address in 24a
above, also submit one copy of this form within 30 days of completion of well
construction
Division of Waterlllesojej Water Quality Regionalon Control Program,
1636 Mail Service OCtp �AW(t•9-1636
24c. For Water Suooly & Infection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
completion of well construction to the county health department of the county
where constructed.

12. Well construction method:
(i.e. auger, rotary, cable, direct push, etc.)
r a-,a,a-1 asi• U a It Vl. 11V1\ Eta VIM II.W-1)
1. Well Cont tor Information:
t4o �f1ifri;;L,.
Well Contactor Name
3rs�
N Well Coo` tor Certification Number
el j94Idirl4, W#CE QC( If(
Company Name rT
2. Well Construction Permit #: !�
List all applicable well construction permits (.e. VIC Com*,, State, Variance, etc)
3. Well Use (check well use):
Wafer Supply Well:
Agricultural
Geothermal (Heating/Cooling Supply)
�Industrial/Commercial
litigation
Non -Water Supply Well:
Monitoring
Injection Well:
®Municipal/Public
®Residential Water Supply (single)
®Residential Water Supply (shared)
Recovery
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
(Experimental Technology
Geothermal (Closed Loop)
Geothermal (Heating/Cooling
®Groundwater Remediation
°Salinity Barrier
DStomrwater Drainage
°Subsidence Control
°Tracer
Rem Other (explain under #21 Remarks)
4. Date Well(s) Completed:ie
Wen ID#
. Well Location: ,�
5ewty f lante-
Facility/OwnerName Facility ID# (if applicable)
!{Orz-,1 a/b&k t htek,Wk 4 urge Ae L
Phy/:i e1 Ad sss, City,, and Zip �/ D 7 %►
ist
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/ndnutes/'seconds or decimal degrees:
(if well field, one lat/long is sufficient)
N W
6. Is(are) the weIl(s)ePermanent or °Temporary
7. Is this a repair to an existing well: ®Yes or No
If this is a repair, fill out !mown well canstntcfion information and explain the nature of the
repair under #2I 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 surface: 2' O (R,)
For multiple wells list all depths if different (example- 3Q200' arnti20ii 100')
10. Static water level below top of casing:
"water !evens above casing, .,
use „+.,(l
11. Borehole diameter: / (in.)
74%
90
(ft.)
For Internal Use Only:
rt
ft.
Z
ft.
in.
treeettii9maCc CK14 SS
DIAhmTER THICKNESS
to.
ft.
FROM
0n.
es
TO
4110
60r
/WI
3�
"S151iiSnal;1L�'efaS;C,Yer° s "Y)r '?Ie�x y r„rew
DES N(colo�rdoesa, roiVrock type, gain tire, eta)
dfr
etc../csagay
2
r
iD
/ate
Xe
Signat6fe ofCenilied nnactur Date
By signing this firm, I hereby
t& that the
was (were) constnieted
whb 15A NCAC 02C 0100 or ISAt NCAC 02C 0200)Well Cons uctio Standalyds and accordancemt
copy ofthis record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also 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 Resour jjrt��((qq pp((7/�
1617 Mail Service Cen , Ildlt /M?P( ?,,,'4r ?'Ot,
24b. For Injection Wells: In addition to sending the form to the address in 24a
above, also submit one copy of this form fr r 30 �ay 01 ?Ompletion of well
construction to the following: l
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources, Und run In ti n Control Program,
1636 Mail Service Cente�t',, p `t�t�v�`Sectjo16
13a. Yield �j `'Ve a DS Mi'lgn
(gpm) 80 Method of test: A 24c. For Water Saab & Iniectior @il97g fit t ;;;,;;, bHHlsey(Ogthe form to
��wr���II etc.
Aid
the address(es) above, also submit one copy of this form within 30 days of
13b. Disinfection type5/'T/S(t tft Amount: Aid el/✓e 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

c. WATER LEVEL Below Top of Casing
(Use "+" if Above �Topp of Casing)
d. TOP OF CASING IS tr 7 FT Above Land Surface
Top of casing terminated t/or below land surface may require a
variance in accordance with ISA NCAC 2C .0118.
e. YIELD (gpm) .70 METHOD OF TEST )4 r
RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources - Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 7
1. WELL CONTRACTOR:
WellContractor Individual) Name
Well Contractor Company Name _ r�
L J f 4e,,d
Ate- ZiIf7Z
STREETD
City or Town State
(%fD)-17L-7rctr
Area code - Phone number
2. WELL INFORMATION:
SITE WELL ID # (if applicable)
STATE WELL PERMIT # (if applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check App lic e SoxQi Residential Water Supply 0
DATE DRILLED /!/ ((
TIME COMPLETED -'CO AM 0
3. WELL LO�CA1�j
/
CITY. �/j(���
Zip Code
PMCY.
^ !I COUNTY dam oUi
fret. WPCs( Jvet /
(Street Name, Num ers, Community, Supervis ,, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
0 Slope 0 Valley 0 Flat 0 Ridge 0 Other
(check appropriate box)
LATITUDE
LONGITUDE
May be in degrees,
minutes, seconds or
in a decimal format
(location of well must be shown on a USGS topo map and
attached to this form if not using GPS)
4. WELL OWNER
OWNER'S NAME.5110
STREE'1'D1
City or Town
Co *ASP, '/
/dam la- 4'TZ
( )-
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH:
State Zip Code
7-35
b. DOES WELL REPLACE EXISTING WELL?f YES 0 NOG.'"
4E—
FT
441481
f. DISINFECTION: Typelierette arAmount,fire a
g. WATER ZONES (depth)
From To From To
Prom To From. To
From To From To
6. CASING:
DDiageter
From Tepi� 5.--Ft. F[. L.
Prom To Ft.
From To Ft.
7. GROUT: Depth Material
From d To /z
From -Tr# To Ft.
From 5—To 1Ft.
Thickness/
5ta Mahal
tethod
8. SCRE Qepth7 p�,�D, r Slot Site
From+ To�J .7 Ft. s in 0 m.
From To Ft. in.
From To Ft. in in.
9. SAND/GRAVEL PACK:
DyP�° Jr
Ft. Material
From/ T 7 •• ,
From To Ft.
From To Ft.
10. DRILLING LOG
From
/Q
3a
/it
17— /70
114:termad7 tion Description
e!c
11:11:2
CQrnV
gay
47,0ce- typo,.
/7/ / Si on.?
_z/O zo C!>
47o 2.3.r-
11. REMARKS:
RErEIVED/eltiiii
FEB /1113 2017
FEB 13za
WHtar Qualit
I D0 HEREBY CERTIFY THAT THIS WELL 4 1a RCORDANCE WITH
ISA NCAC 2C.. WELL CONSTRUC IWi li COPY OF THIS
RECORD HAS BEEN PRV6D TO THE Office � / /c
SIGNATURE OF CERTIFIE/(/ WELL CONTRACTOR DATE
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt.,
1617 Mail Service Center - Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-la
Rev. 7-05

441479
RESIDENTIAL WELL CONSTRUCTION RECORD
blitge
North Carolina Department of Environment and Natural Resources - Division of Water Quality
WELL CONTRACTOR CERTIFICATION # J2/S fi
1. WELL CONTRACT
Well CoJv ual) Name
ed,i, a'// Ca'G<"'
Well Contractor am
e 9 //�
STREET AD $ESS ri Ja daziQ
/!/G_fi� �IGC-- /�Llll7J�
City or wn State
Area code - Phone number
2. WELL INFORMATION:
SITE WELL ID # (if applicable)
STATE WELL PERMIT # (if applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applic e Box,/ sidential Water Supply 0
DATE DRILLED L Ly /
TIME COMPLETED • iU AM 0 PM ir
lo7cn* 4t i
(Street Name, Numbers, Community, Supervisor, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
0 Slope 0 Valley 0 Flat 0 Ridge 0 Other
(check appropriate box)
LATITUDE
LONGITUDE
May be in degrees,
minutes, seconds or
in a decimal format
(location of well must be shown on a USGS topo map and
attached to this form if not usin3K3PS)
4. WELL OWNER
OWNER'S NAME
e 6OGL
STREET ADD JfSS 57 Wen ware
K�'Y'Gtir��(L
5. WELL DETAILS:
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES, NO 0
c. WATER LEVEL Below Top of Casing Go FT
(Use "+" if Above Top of Casing)
d. TOP OF CASING IS / 7 FT. Above Land Surface
Top of casing terminated t/or below land surface may require a
variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm) 07 0 METHOD OF TEST
RECORD HAS BPROVIDED TO THE
• ' � ': p
g. WATER ZONES (depth)
From To From
To
From
To From To
From To From
To
" - Amount
Thickness/
DiEter Wit, -a grial
7. GROUT: Depth Material
From_-_ To ✓S Ft.
From To� Ft.��—=
From TaMb F[ ,
8. SFromf_ . �,DT t 0"-- p tatq...- Slot�ize ?Veal
�ttal
Prom/a !A al G� O "/,/r�l _
From To Ft. in.
—_- m.
From To Ft. in. in.
9. SAND/GRAVEL PACK:
DAL SW/ / Material
From/ a To /.,Qt.
From To Ft.
From To
Pt
10. DRILLING LOG
Fe 3 r
11. REMARKS:
FED 1. 3 20I7rv,;1,t i ia.)
I DO HEREBY CER71ht THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
ISANCAC 2C„ WELL CONSTRUCTTONijt p.Frr. .t PY OF
Section ai°
Minna! Otfi eZ-,
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
PRINThu NAv1E OF PERSON CONS'1RUCIINO 1HE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt.,
1617 Mail Service Center — Raleigh, NC 27699-1617 Phone No. (9.19) 733-7015 ext 568.
Form GW-la
Rev. 7-05

WELL' CUN 1KULIMA KLLUICU IUW-11
1. Well Contractor information:
For Internal Use Only:
441478
Well Contractor Name
3/t1
F/ b
�.
NC Well Contra�/q/t�or Certification Number
Company {4am'/L'r�pj.C' wit' u`Gll ens
e
2. Well Construction Permit #:
List all applicable well construction permits (t.e. UIC, County, State, Variance, etc)
3. Well Use (check well use):
67r Supply Well:cultural
® Geothermal (Heating/Cooling Supply)
o Industrial/Commercial
'Irrigation
Non -Water Supply Well:
®Monitoring
Injection Well:
°Aquifer Recharge
°Aquifer Storage and Recovery
®Aquifer Test
®Experimental Technology
®Geothermal (Closed Loop)
°Geothermal (Ideating/Cooling Re
fMunicipal/Public
®Residential Water Supply (single)
®Residential Water Supply (shared)
®Recovery
®Groundwater Remediation
®Salinity Barrier
QStonnwater Drainage
®Subsidence Control
°Tmccr
Other (explain under #21 Remarks)
4. Date Walks) Completed: f//L7Well ID#
5a. Well cation•
/t«d isg-
Facility/Owner Name p Facility ID# (if applicable)
2Z7.7 kWc'y detdbpu.- kC .lfl3i
Physical Addresjt City, and Zip
QOlGt.„„aze4
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 W
6. Is(are) the well(s)rmanent or °ITemporary
7. Is this a repair to an existing well: ®Yes or ®No
7fthis is a repair, full out (mown well construction information and explain the nature of the
repair under #21 remarks section or on the back of this fora
8. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction, only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled:
9. Total well depth below land surface:
For multiple wells list all depths ifderent (example- 3Q200' and 2(i100')
2j
10. Static water level below top of casing:
If water level is above casing, one "+"
11. Borehole diameter: SP (in.)
AIZO *ry
Ss
12. Well construction method:
(i.e. auger, rotary, cable, direct push, etc.)
(ft.)
(n•)
FOR WATER SUPPLY WELLS ONLY:
/e
13a. Yield (gpm)
Method of test:
136. Disinfection type ..,fit � 'KULB•✓ Amount:
. d3:t4 =t+. b.,.:z;,a ...-.".�. ..-,.
FROM
TO
DESCRIPTION
3 v/ffff•
SD fr.
54 04// jjt 7 o
/;y•
(6s. ft'
atief _ . 41040r •
'L4 AYITER'tA3
tt ern
i-'wattEOLOWEtt(itteelnlc6bl ii Jx
FROM -
TO
DIAMETER THICKNESS
W,
I 'MATERIAL
jr.,
`$o rL
Le in.�4
I 'po C.18?
vNya
�sfrcPG,O-ntal$SfavoihdlsLs9tleSo'
-)4Diti i
Yf' A rr °
FROM
TO-
DIAMETER
THICKNESS
MATERIAL
18ot
vise.
2 in:
SCt.-it f
i- .
its1
ft.
In.
;17i"Sfi'.REAN..s,jY
1 3 3k,%i5e
hY.'Sv ±r k"`a dAi-.Y-SkT ^.Y=�$a..iN'��`Ti.uc
.z. ...t ria
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
92,44m
z7 dF
Lie•
r
sato
inc.
Yt.
ft.
in.
= ttratlDT
^? ..e h
akz,`.'.L4<:sZ %'`swag'.' ; ttel a`inv3
FROM
TO
EMPLACEMENT METHOD&AMO{O.N..T.
O ft
p
`Soft
/MATERIL
de
' C— 7
fL
ft.
J;Ar3iSAis714i
Ife,t (TE
iIab"lel fi(MA
FROM
TO
MATERIAL -
EMPLACEMENT METHOD
IL
ft.
. fL
ft.
Lh7311f7LLltfft)G'k1G%,'sits`a."cE'tDldi6n`a`>g(e'bic�'yl.,(};t<.4,,"""1!
»g""
FROM
DESCRDTf�caler,hardness, toil/rock type, grain size, eta)
O,.t
' O
C/�pvJ/CC/en
JVlt
�ft
_,-Tr•
rt.
6R•
7iPf. 1L
/�`�a
5441/e •- fatfri
r.7
rt
ern. ) / Y/'1.Q_
0 fit.
toot'
et
ft
��. y7D tL-
22, Certiticat'
Signature of Certifie8 Well Con
Off?
Date
By signing this form, I hereby certif that the well(s) was (were) consavcted N accordance
with ISA NCAC 02C .0100 or ISA NCAC 02C .0200 Well Cautrucit r�,S(andardsand#rut a
copy of this record has been provided to the well ownttr �n rz 9 '' y l' r
23. Site diagram or additional well details: -G
You may use the back of this page toIVW tr`. mi or well
construction details. You may also attach additions ages if necessary.
SUBMITTAL INSTRUCTIONS F`ert` tiZt O:nkwaell
24a. For AO Wells: Submit this form within 30days o completion
construction to the following:
Division of Water Resources,Wlr`(eYali NOW
T'"D et,
1617 Mail Service Centel 5
246. For Infection Wells. In addition to sending the Conn 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 Suuoly & 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

/lr
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Ta
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//1-
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for
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WY.LL t.1/1I Oa"V a. s. an alum,VSW 1'la .♦ an
/J'J
441477
1. Well Contr to nformation:
4190 l%)
Well Contractor Name
3/CI
NC Well Con or Certification Number
4 of i/nom_ etle7/ 4) //i dt;
Company Name
2. Well Construction Permit #: w tei / 7 00 4.i7
List all applicable well construction permits (te. UIC, County, State, Variance, etc.)
3. Well Use (check well use):
Water Supply Well:
['Agricultural
®Geothermal (Heating/Cooling Supply)
®lndustsl/Commercial
f inigation
Non -Water Supply WeB:
Monitoring
®Municipal/Public
▪ residential Water Supply (single)
®Residential Water Supply (shared)
® Recovery
Injection Well:
()Aquifer Recharge ®Groundwater Remediation
°Aquifer Storage and Recovery ®Salinity Bonier
Aquifer Test ®Stormwater Drainage
3Experimental Technology ®Subsidence Control
31Geothennal (Closed Loop) ®Tracer
Geothermal (Heating/Cooling Reetturn) Other (explain under #21 Remarks)
4. Date Well(s) Completed: //tT17 Well ID#
WeB Location:
//iOwn �
leyr
Facility/Own Name Facility ID# (if pliable)
.2170 '% arr fin y w�Nezdr+�
Physical ddress, City, and Zip
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/S.-minds or decimal degrees:
Orwell field, one lat/long is sufficient)
3 Y• /4.9 N 78.41.3 3
6. Is(are) the weB(s) ermanent or ['Temporary
7. Is this a repair to an existing well: °Yes or
If this is a repair, fill out (mown well constnction information and explain the nature of the
repair ender #21 remarks section or on the back oasis form.
8. For Geoprobe/DFT or Closed -Loop Geothermal Wells having the same
construction, only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled:
9. Total well depth below land surface: / / ✓
For multiple wells list all depths if different (example- 3Q200' and 2@100)
10, Static water level below top of casing:
If water level is above casing, use "+'/�_^
11. Borehole diameter: Y On.)
12. Well construction method:
(i.e. auger, rotary, cable, direct push, etc.)
st
O
W
Signature ofCertifed Well
?14 R"AM1'L'R:'mins
,-, :.si`-.: Fs ,.x ,:s.4 ,. ._,......
PR
TO
DESCRIP17TTON"
ESCI?
Leftf_t_
S E4a
((//SSD
;13'i'. Z
G SR4 (ftihn'[
hi #4x41,9tAIIR Yfai -Iiii r .. =
FROM
TO
DIAMETER
THICKNESS
'MATERIAL
O n
�.P�
/SJ
R:171BAG`ETERheamam!CIQ't'A.1[oopi°'>~'
Z hi'
(f! ,Eo
Pee.
c:a=='•,.t."'a=.
tam
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft
ft
in.
ft
ft
in.
ci7AitRBDOjA
„r
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
O R.
y
/Sr
2-ID.
3
Sccla
%G
n
ft
in.
tag
910,01 Oilil
rv,,.v.tb, ...
'%"
icte :rr ' -:`...:,cam
FROM
TO
MATERIAL
EMPLACEMENT METROD &AMOUNT
0 n
3 ft
a
(�/att ea
)4 _s
,3 ft.
1 o ft
c� tag
Cfi�
/ 9
0�'
pit
pinfr(a
t I s n ie—,
5, >'*N
13t °AC•
t`(t WilliablW' ;::
FROM
TO
MATERIAL
EMPLACEMENT METHOD
/ BP.
//rrt.
g4!a--
vie.,'
ft.
ft
1` d:
FROM
FROM
TO
hardness,grnina, etc.)
DESCRIPTION (color,hardsoinreek One, grain sire, etc.)
b 1t
3; t.
tf4y
3s-R,
S, Q ft
Ce; tie/
tt pt
70
clay
loft
7/ ft
02,41,,anrtfi-
7 tft'
It ft
.54nei
t qo
131
eg y .
I,
t�
/T r / to t. !a/
I To Ass' l ohdl • ,..... Dvitale,(,,
22. Certificati
(ft.)
(ft.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) 30
l�� Method' I
etof test: fie
13b. Disinfection type: J- 1• Amount: f/b
oda
entree ate
By signing this farm, 1 hereby tang that the well(s) was (were) cauhuded in accordance
with 15A NCAC 02C .0100 or ISA NCAC 02C .0200 Well Construction Standards and that a
copy of this record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach gittevEufNeDbligUsalaWR
SUBMITTAL INSTRUCTIONS
24a. For AB Wells: Submit this form withif0=0xlays Qf sp gp(etion of well
construction to the following: C U 1
Division of Water Resources, In��gAc�jaa��P�mt�otion Processing Unit,
1617 Mail Service Center, RMgsgaf 1Gbab 9SRtWi!inal
erations Section
24b. For Iniection Wells: In addition tMMbghdhigtbnambag Minis in 24a
above, also submit one copy ofthis 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 St uoly & 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.
nil
Fonn GW-1
North Carolina Department of Environmental Quality - Division of Water Resources
Revised 2-22-2016