GW1 - Pender Dec-Nov 2017

WELL CONSTRUCTION RECORD (GW-1)
1. Well Contractor Information:
Donald Cummings
Well Contractor Name
2412-A
NC Well Contractor Certification Number
Applied Resource Management, P.C.
Company Name
2. Well Construction Permit ff:
List all applicable well construction permits (i.e. (RC, C'omtry, Stale, Variance, etc)
3. Well Use (check well use):
Water Supply Well:
Agricultural @Municipal/Public
Geothermal (Heating/Cooling Supply) Residential Water Supply (single)
Industrial/Commercial @Residential Water Supply (shared)
ation
Non -Water Supply Well:
onitoring
njectiou Well:
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
Experimental Technology
Geothermal (Closed Loop)
Geothermal (Heating/Cooling Return)
W1 7-023H
@Groundwater Remedimion
()Salinity Barrier
@Stormwater Drainage
@Subsidence Control
@Tracer
Other (explain under 521 Remarks)
4. Date Wen(s) Completed: 11/21/17 Well m# N/A
5a. Well Location:
Mike Turco
N/A
Facility/Owner Name Facility ID# (if applicable)
Lot 17 East, Majestic Oaks, Hampstead, NC 28443
Physical Address, City, and Zip
Pender
3292-05-8907-0000
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 21 50.38 N 077 42 17.44
W
6. Is(are) the well(s)@IK Permanent or @Temporary
7. Is this a repair to an existing well: @Yes or @No
If this is a repair, fill out known well construction information and explain the nature of the
repair under V21 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: 1
9. Total well depth below land surface: 85
For multiple wells list all depths ifdifirrent (example- 3@200' and 2@l00')
(ft.)
10. Static water level below top of casing: 17 (ft.)
If water level is above casing use "+ •
11. Borehole diameter: See Remark(in.)
12. Well construction method: Mud Rotary
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
I3a. Yield (gpm) 80
Method of test: Airlift
13b. Disinfection type: HTH Amount: 3%@10g
For Internal Use Only:
446039
Mil
14. WA R
ZONES
FROM
TO
DESCRiPHON ....
ft.
ff.
ft.
fi.
15.:MITER CASING (for a,MI,ased,vellq)
ORLtNER(if up Me)
FROM
TO
DIAMETER THICKNESS MATERIAL
PVC
0 ft'
60 ft•
4 in- SCH40
1b.:INNER
CASING OR T(tBING:
(isotherms (elosed-logy)
FROM
TO
DIAMETER
MC/CHESS
MATERIAL
ft.
ft.
in.
ft,
ft.
in.
17.SCREF.N
FROM
TO
DIAMETER
SLAT SIZE
THICK1iESS
MATERIAL
ft.
ft.
in.
ft.
R
in.
FROM
TO
MATERIAL
EMPLACEMENT METHOD @ AMOUNT
0 ft'
25 rt
Bentonite
Poured
ft.
ft
ft
ft.
19. SAND/G1tAVEl
PACK
(if ap icable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
n
I ft.
ft.
l n
204DkILLiN4i
LOG (athi
h addine aw)
FROM
TO
DESCRIFTION (color, harder, son/tvek type, grain size, etc.)
0 ft.
50 fr.
Sandy clay to clay
50 rt.
85 rt•
Limestone
ft.
ft.
ft.
ff.
ft.
ft,
p
p'�^�n4..,F.
ft.
ft.
`•-�»,+ ,.mgg° 7t '.m ls-,
ft.
ft.
02017
DECt2 aY
21: RE MARHS
Prcr::rb•,4t t1
,„4orr,siror
0-25/8" 25-85/6" (�sG•'uv
11/21/17
Signature ofCabfied Well Contractor 1 / Date
By signing this form. 1 hereby ceni/y that the well(s) was (were) constructed in accordance
with ISA NCAC 02C .0100 or I5A NCAC 02C.0200 Well Construction Standards and that a
copy of this record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTRUCTIONS
24a. For All Wells: Submit this farm within 30 days of completion of well
construction to the following: ��C�iu� �q
Division of Water Resources, InformationminWoes gMg Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Infection Wells: In additicL 61eij4 ?A ri7rtn to the address in 24a
above, also submit one copy of this form within days of completion of well
construction to the following:
water Quell y 30 Reg1011
Division of Water Resources, Uddyirgnimpd ---
1636 Mail Serviddi IR'(e Mt,
i`gC:ontrol Program,
-1636
24c. For Water Supply & Infection Wells: hn addition to sending the fort 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.
z....., nut ,

WELL CONSTRUCTION RECORD (GW-D
1. Well Contractor Information:
Donald Cummings
Well Contractor Name
2412-A
NC Well Contractor Certification Number
Applied Resource Management, P.C.
Company Name
2. Well Construction Permit #:
List all applicable well construction permits (te. UIC, County, State, Variance, etc)
3. Well Use (check well use):
W17-026H
Water Supply Well:
Agricultural
Geothemial (Heating/Cooling Supply)
Industrial/Commercial
Irrigation
Non -Water Supply Well:
�. Monitoring
fMunicipal/Public
Residential Water Supply (single)
()Residential Water Supply (shared)
()Recovery
Injection Well:
r:Aquifer Recharge
ri Aquifer Storage and Recovery
--.Aquifer Test
.Experimental Technology
Geothermal (Closed Loop)
Geothermal (Heating/Cooling Return)
4. Date Well(s) Completed: 11/30/1
5a. Well Location:
Mike Turco
Groundwater Remediation
DSalwty Barrier
®Stormwater Drainage
°Subsidence Control
°Tracer
(Other (explain under #21 Remarks)
7 well1D#N/A
N/A
Facility/Owner Name Facility MP (if applicable)
Lot 18 West Majestic Oaks, Hampstead, NC 28443
Physical Address, City, and Zip
Pender
3292-06-6014-0000
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 21 51.6 N 77 42 20.3
W
6. Is(are) the wel1(s)0Perrnanent or °Temporary
7. Is this a repair to an existing well: °Yes or x°No
If this is a repair, fill out blown well construction information and explain the nature of the
repair under 1121 remarks section or on the back of this form.
8. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction, only I GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled:
9. Total well depth below land surface: 80 (ft.)
For multiple wells list all depths ifdlerent (example- 3@200' and 2@100)
10. Static water level below top of easing: 17 (ft.)
If water level is above casing, use "+"
11. Borehole diameter: See Remarkon.)
12. Well construction method: Mud Rotary
(i.e. auger, rotary, cable, direct push, etc.)
For Internal Use Only:
4 4 6 0 3 S
14. WATER ZONES - - -
FROM
TO
DESCRIPTION
ft
ft.
R
R.
15 OUTER.CASING (for multi
-eased wells) ORLINER (if ap heable)
FROM
TO
DIAMETER
THICKNESS MATERIAL
0 R•
60 R•
4 in•
SCH40 PVC
16. INNER CASING OR TUBING
(geothermal closed -loop)
FROM
TO
DIAME 1 ER
TRIMNESS
MATERIAL
ft.
ft.
in.
tt
ft.
in.
17..SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS I
MATERIAL
ft
ft
in.
ft
fL
in.
amour
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
0 a
25 ft
Bentonite
Poured
fL
ft.
ft
ft.
19: SAND/GRAVEL
PACK
(if applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD.
ff.
It
ft.
ft.
. 20. DRILLING
LOG (attach
additional sheets ifnecessary)
FROM
TO
DESCRIPTION (color, hardness, soD/rock type, gain size, etc.)
0 R•
50 R•
Sandy clay to clay
50 it.
80 rt.
Limestone
ft.
ft
ft.
ft.
ft
D.
ft.
ft.
C i._l 4Pxt C
ft
ft.
.
^t
�dpp
2LREMARKS -. UEC 0 ::2017
t' Wi
0-25/8" 25-80/6" tutorFnatton 1Nr i vG btr
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) 80 Method of test: Airlift
13b. Disinfection type: HTH Amount: 3%@10g
22 Ce ' lion:
11/30/17
Signs o ertified Well Contractor
�� e Date
By signing this form, I hereby certify 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 this record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTRUCTIONS 24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
Division of Waterri
y. pp��tql((gqj�7r�(�pon Processing Unit,
1617 Mail Service a Etf�RE i� r-1617
246. For Iniection Wells: In addition to sending the form to the address in 24a
above, also submit one copy of tDEQnlw(thiCCn),days of completion of well
construction to the following: 1- Ll
Division of Water Resou n erground Injection Control Program,
1636 Mail Service, kit Mile tape N4 7699-1636
ra ions Secti
24c. For Water Supply & lYti i.11t$tPWlalgiotna p�, to sending the form to
the address(es) above, also submit one copy of ts rm within 30 days of
completion of well construction to the county health department of the county
where constructed.
Fnrm C:W.1
North Carolina Department of Environmental Quality- Division of Water Resources Revised 2-22-2016

WELL CONSTRUCTION RECORD (GW-1)
1. Well Contractor Information:
Donald Cummings
Well Contractor Name
2412-A
NC Well Contractor Certification Number
Applied Resource Management, P.C.
Company Name
2. Well Construction Permit #:
List all applicable well construction permits (t.e. VKZ County, Stme, Variance, etc)
3. Well Use (check well use):
Water Supply Well:
W17-025H
DAgricultural
Geothermal (Heating/Cooling Supply)
f industriavCommercial
Irrigation
Non -Water Supply Well:
Monitoring
Injection Well:
['Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
Experimental Technology
[Geothermal (Closed Loop)
(Geothermal (Heating/Cooling Return) nOther (explain under #21 Remarks)
4. Date Wens) Completed: 11/30/17
DMunicipavPublic
Residential Water Supply (single)
DResidential Water Supply (shared)
®Recovery
5a. Well Location:
Mike Turco
['Groundwater Remediation
Salinity Barrier
DStormwater Drainage
(Subsidence Control
Tracer
Well ID# N/A
N/A
Facility/Owner Name Facility ID# (if applicable)
Lot 18 East Majestic Oaks, Hampstead, NC 28443
Physical Address, City, and Zip
Pender 3292-06-6014-0000
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 21 50.7 N 77 42 19.5
W
6. Is(are) the wen(s) tx Permanent or Temporary
7. Is this a repair to an existing well: (Yes or ['No
Ifrhis is a repair, fill oat known well construction information and explain the nature of the
repair under n21 remarks section or on the back of this form.
8. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction, only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled: 1
9. Total well depth below land surface: 85 (ft.)
For multiple wells list all depths ifdferent (example- 3@200' and 2@l0(1)
10. Static water level below top of casing: 17 (ft.)
If water level is above casing use "+•'
11. Borehole diameter: See Remark(in.)
12. Well construction method: Mud Rotary
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) 80 Method of test: Airlift
136. Disinfection type: HTH Amount; 3%@10g
For Internal Use Only:
14. WATER
FROM
fL
ft.
ZONES.
TO
a
ft.
DESCR�T'!ON
44603
15. OUTER CASING (for multi -cased wells)' OR LINER -(if applipble)
FROM TO DIAMETER THICKNESS I) MATERIAL
0 D- 160 f- 14 in-
16.I N`NER CASING OR TUBING (geothermal elosed400p)
FROM TO
ft.
17..SCREEN.
ft.
SCH40 PVC
DIAMETER THICKNESS I MATERIAL
in.
D. in.
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
D• ft. is
ff. R is
It GROUT
FROM TO
MATERIAL EMPLACEMENT METHOD & AMOUNT
0 n. 25 n Bentonite Poured
ft
R ft.
19. SAND/GRAVEL PACK Of applicable).
FROM TO
ft.
fi.
ft.
MATERIAL
EMPLACEMENT METHOD
20DROd ING.LOG (attach additional sheets if necessary.)
FROM TO DESCRIPTION (color, hardness, soil/rock
tice, grain she, etc.) -
Sandy clay to clay
0 ft.
50 ft•
f.
ft.
ft.
ft.
ft.
MARKS
50 B•
85 ft•
ft.
ft.
ft.
0-25/8" 25-85/6"
22. Certification:
Signature ature oCertified W Contractor
Limestone
construction to the following:
DEC 0. zo17
Information •
11/30/17
Date
By signing this form, I hereby cen/fy that the well(s) was (were) constructed in accordance
with ISA NCAC 02C.0100 or ISA NCAC 02C .0200 Well Construction Standards and than a
copy of this record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL 'INSTRUCTIONS
24a. For All Wells: SubmNh�t.' wvh11/61#10FE completion of well
Division of Water Resources Information Processing Unit,
1617 Mail Service CORO, #aliigJlor 27699-1617
24b. For Iniection Wells: In addition to sending the form to the address in 24a
above, also submit one copy legrfetutal7 t ' 30 days of completion of well
construction to the following: tY iletinnal
Opoerraations Section
Division of Water ResotWies YJKDei3g&8i®IIajaifilikrontrol 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.
nn..,, rw_I
•

WELL CONSTRUCTION RECORD (GW-1)
1. Well Contractor Information
Donald Cummings
Well Contractor Name
2412-A
NC Well Contractor Certification Number
Applied Resource Management, P.C.
Company Name
0
0,le
2. Well Construction Permit#:
List all applicable well constuction permits (i.e. UIC, Comrty, Stale, Variwwe, etc)
3. Well Use (check well use):
later Supply Well:
Agricultural °Municipal/Public
Geothermal (Heating/Cooling Supply) 1°t' Residential Water Supply (single)
Industrial/Commercial nResidential Water Supply (shared)
h i • ation
W17-024H
Non -Water Supply Well:
Monitoring
Injection Well:
. Aquifer Recharge
)i Aquifer Storage and Recovery
,'Aquifer Test
Experimental Technology
Geothermal (Closed Loop)
Recovery
Geothermal (Heating/Cooling Return)
Groundwater Remediation
°Salinity Barrier
°Stormwater Drainage
[Subsidence Control
°Tracer
)� Other (explain under #21 Remarks)
4. Date Well(s) Completed: 11/30/17 Well ID# N/A
5a. Well Location:
Mike Turco
N/A
Facility/Owner Name Facility ID# (if applicable)
Lot 17 West Majestic Oaks, Hampstead, NC 28443
Physical Address, City, and Zip
Pender
3292-05-8907-0000
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 21 50.8 N 077 42 18.9
For Internal Use Only:
4-46036
14.WATER ZONRS
FROM
TO
DESCRIPTION
ft.
ft.
ft.
fi.
a OUTER CASING (for
mnhi-eased wells) OR LINER (if ap &able)
FROM
TO
DIAMETER TmCKISERS MATERIAL
0 ft
60 R
4 in* Li
SCH40 PVC
16. INNER
CASING OR TUBING
(geothermal closed -loop)
FROM
TO
DIAMETER TRICKNESS
MATERIAL
ft.
ft
in.
ft-
ft.
in.
17. SCREEN.
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
R.
R.
in.
n
ft.
in.
It GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
0 n
25 ft-
Bentonite
Poured
ft
n
n
n
19.: SAND/GRAVEL
PACK
(if applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD.
it.
n
n
ft.
20. DRILLING
LOG (flitch
additional sheets if necessary)
FROM
TO
DESCRIPTION (color, hardness. selhock tvpe, pain sue, etc)
0 R'
50 R•
Sandy clay to clay
50 ft
85 ft
Limestone
ft.
R,
R.
R.
R.
ft.
I
ft.
R.
ft.
ft.
GFG 0 5 21117
2L REMARKS ...
.
I}dprfn ntiOfl Pref., w.g l.:lilt
0-25/8" 25-85/6" rtrofan3 ;U
22. Ce
w
6. Is(are) the well(s)4x Permanent or °Temporary
7. Is this a repair to an existing well: °Yes or xDNo
Ifthis is a repair, fihl out brown well construction information and explain the nature of the
repair under #21 rattans section or on the back ofthisfotm.
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: 1
9. Total well depth below land surface: 85
For multiple wells list all depths if different (example- 3 .200' and 2@100')
(h.)
10. Static water level below top of casing: 17 (ft.)
If water level is above casing, use "4 "
11. Borehole diameter: See Remark(in.)
Mud Rotary
12. Well construction method:
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) 80 Method of test: Airlift
13b. Disinfection type: HTH Amount: 3%@10g
s
canon:
11/30/17
tractor , Date
By .signing this form, I hereby certify 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 this record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTRUCTS lit EIVED/NC®EIVR/DWR
24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
Division of Water ResourrECIn oirm*tib&Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Infection Wells: In a
above, also submit one copy
construction to the following:
4tmemmiorfaim to the address in 24a
gton 25 ona Office eifOtlays f completion of well
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Sunni), & 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.
Perm (,W-1
North Carolina Department of Environmental Duality - Division of Water Resources Revised 2-22-2016

WELL CONSTRUCTION RECORD (GW-1)
1. Well Contractor Information:
Donald Cummings
Well Contractor Name
2412-A
NC Well Contractor Certification Number
Applied Resource Management, P.C.
Company Name
2. Well Construction Permit #:
List all applicable well constriction permits (.e. UIC, County, State. Variance, etc)
3. Well Use (cheek well use):
Water Supply Well:
Agricultural Municipal/Public
Geothermal (Heating/Cooling Supply) @Residential Water Supply (single)
Industrial/Commercial ()Residential Water Supply (shared)
k.. Irri ation
Non -Water Supply Well:
Monitoring
Infection Infection Well:
)
5
W17-027H
DRecovery
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
Experimental Technology
Geothermal (Closed Loop)
Geothermal (Heating/Cooling Return)
()Groundwater Remediation
()Salinity Barrier
DStonnwater Drainage
()Subsidence Control
()Tracer
Other (explain under #21 Remarks)
4. Date Well(s) Completed: 11/30/17 Well ID# N/A
5a. Well Location:
Mike Turco
N/A
Facility/Owner Name Facility IN (if applicable)
Lot 19 East Majestic Oaks, Hampstead, NC 28443
Physical Address, City, and Zip
Pender
3292-06-4089-0000
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/ong is sufficient)
34 24 51.3 N 77 42 20.3
6. Is(are) the well(s)()x Permanent or ()Temporary
7.1s this a repair to an existing well: ()Yes or No
lfthis is a repair, fill out known well construction information and explain the nature of the
repair under 1121 rentarks section or on the back of this form.
8. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction, only I GW-1 is needed. Indicate TOTAL. NUMBER of wells
drilled: 1
9. Total well depth below land surface: 80 (ft)
For multiple wells list all depths if different (example- 3@200' and 2@100)
10. Static water level below top of casing: 17 (ft.)
If water level is above casing, use "-t"
11. Borehole diameter: See Remark(in.)
12. Well construction method: Mud Rotary
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) 80 Method of test: Airlift
13b. Disinfection type: HTH Amount: 3%@10g
For Internal Use Only:
446035
14. WATER
ZONES
FROM
TO
DESCRIPTION
ft.
L
f6
R.
-
IS♦ OUTER CASING (for
multi -eased wells) OR LINER (if art livable)
FROM
l0
DIAMETER
THICKNESS MATERIAL -
0 D•
60 H•
4 lit
SCH40 PVC
16. INNER
CASING OR: TUBING
(geothermal closed-loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft,
ft.
in.
D.
8.
in.
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
ft
ft
in.
ft
ft.
in.
IS GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD
0 ft'
25 ft
Bentonite
& AMOUNT
Poured
ft
ft.
f6
fk
19. SAND/GRAVEL
PACK
(if
FROM
TO
MATERIAL
EMPLACEMENT METHOD.
0.
B.
ft
tI
20.:DRILLING
LOG (ana
It additional sheets if necessary)
FROM
TO
DESCRIPTION (color, hardness, soil/rock type, grain size, etc)
0 ft'
50 ft
Sandy clay to clay
50 B•
80 ft
Limestone
fL
ft.
ft,
H.
ft.
ft.
f.
55
2L RE ItfARRs ..DEC 0 2017
0-25/8" 25-80/6" tlifalHfstis11`iCIIFSC .
22. CertiTi1. n:
Slyr!'r�'�'�,IJT^L]/!/
Signs
of Well Contractor
Water Quality Regional
Division of Water Resources,QTAiliagibiratbilehtlon Control Program,
1636 Mail SerWilliiiightIRRIeigh(Na tit99-1636
24c. For Water Sunnly & 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.
11/30/17
Date
By signing this form, 1 hereby certify that the wears) was (were) constructed in accordance
with 15A NCAC 02C .0100 or 13A NCAC 02C.0200 Well Construction Standards and that a
copy of this record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional -pages if necessary.
SUBMITTAL INSTRUCTIONS
24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following: RECEIVED/NCDENR/i)WR
Division of Water Resources, information Processing Unit,
1617 Mail Service Center,�Raleigh, NC 27699-1617
24b. For Infection Wells: In additlKiCo Lndingi We7form to the address in 24a
above, also subunit one copy of this form within 30 days of completion of well
construction to the following:

WELL CONSTRUCTION RECORD (OW-1)
1. Well Contractor Information:
Donald Cummings
Well Contractor Name
2412-A
NC Well Contractor Certification Number
Applied Resource Management, P.C.
Company Name
2. Well Construction Permit #:
W17-028H
Lisi all applicable well construction permits Be. [AC, County, State, Varionce, 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)
11Geothermal (Heating/Cooling Return) @Other (explain under #21 Remarks)
4. Date Well(s) Completed: 1 1 /30/17 Well toff N/A
5a. Well Location:
Mike Turco
@Municipal/Public
@Residential Water Supply (single)
@Residential Water Supply (shared)
}Recovery
@Groundwater Remediation
@Salinity Ranier
@Stoimwater Drainage
@Subsidence Control
@Tracer
N/A
Facility/Owner Name Facility ID# (if applicable)
Lot 19 West Majestic Oaks, Hampstead, NC 28443
Physical Address, City, and Zip
Pender 3292-06-4089-0000
County Parcel identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat./long is sufficient)
3421 51.5 N 77 42 22.1
6. Is(are) the well(s)01Permanent or @Temporary
7. Is this a repair to an existing well: @Yes or EINo
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 ofthisform.
8. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction, only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled: t
9. Total well depth below land surface: 80
For multiple wells list all depths ifd different (example- 3@200' and 2@l001)
10. Static water level below top of casing: 17
W
(ft.)
(ft.)
If water level is above casing, use "+"
11. Borehole diameter: See Remark(tn.)
12. Well construction method: Mud Rotary
(i.e. auger, rotary, cable, direct push, etc.)
For Internal Use Only:
446034'
14.WATER ZONES
FROM
TO
DESCRIPTION
ft
ff.
ft.
ff.
15. OUTER CASING (for
multi -cased wens) OR LINER (if ap licahle)
FROM
TO
DIAMETER
TmCK14ESS MATERIAL
0 ft.
60 ff
4 in•
SCH40 [PVC
16. INNER
CASING OR TUBING
(geothermalelosed-loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
it
ft
ink
ft.
ft
in.
.17.SCREEN
PROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
ft.
ft
in.
ft
ft.
in.
IS: GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
0 ft.
25 ft-
Bentonite
Poured
ft.
rt
ft
ft.
J9.SAND/GRAVEL
PACK
(if applicable) -
FROM
TO
MATERIAL
EMFLACEQIENT METHOD
ft.
ft
rr
ft.
20. DRILLING:
LOG (attach
additional sheets if necessary) ".
FROM
TO
DESCRIP TON (color, hardness, somreck type, grin size, etc.)
0 ft.
50 TM•
Sandy clay to clay
50 ft.
80 ft
Limestone
ft.
ft
ft.
ff.
It.
ft.
EC,qrF:e\, ..a.0
ft.
ft
21 REMARKS ".: DEC O 5 2017
0-25/8" 25-80/6" nforwtation Prcces ng 1.1ti1-it
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) 80 Method of test: Airlift
13b. Disinfection type: HTH Amount: 3° ©10g
I�UVt.il:;L
22. CertiGEation:
02-4
Cl(1/Ql/
Signature of Certified Well Contractor
11/30/17
Date
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 Carstruelion 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 ifnecessary.
SUBMITTAL INSTRUCTIONS
24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following: RECEWED/NOQENR/DNIR
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, gNC 27699-1617M�
24b. For Infection Wells: In addition td Fdndi(g lie?ftirto the address in 24a
above, also submit one copy of this form within 30 days of completion of well
construction to the following:
Water Quality Regional
Division of Water Resources, Undeeepetilit1Q,'itjee'$16tttl gtr_Q1 Program,
1636 Mail Service Cy0li iReeillyRis(CT/699=Y'6`3L
24c. For Water Suonly & 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.
c....., rrn n
Mneh Carnlina Penamnant ofpnvimnmental (Duality -Division of Water Resources
Revised 2-22-2016

RESIDENTIAL WELL CONSTRUCTION RECORD
4460,3 1
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 4119-A
1. WELL CONTRACTOR:
Sage Drilling and Pump Services LLC.
Well Contractor (Individual) Name
Michael C. Sage
Well Contractor Company Name
STREET ADDRESS 204 Tom Ave
Castle Hayne NC 28429
City or Town State
(910 )-231-6669
Zip Code
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable)
WELL CONSTRUCTION PERMIT# t`i'J tl
rye
- ®��jjO �S 1J
OTHER ASSOCIATED PERMIT#(if applicable)
3. WELL USE DATE DRILLED (Check Applicable Box):ResidentialWater Supply 0
iiPPA//M
``�®\\
TIME COMPLETED -e, n
0 PM I
4. WELL LO ATION: ' 9 _
CITY: CITY poi' COUNTY
(�
Pef aec
W L I JLO LW b' ' eg
Ski
(Street Name, Numbers, Commuai j, Subdivision, Lot No., PParce., Tip Code)
TOPOGRAPHIC TTING
0 Slope o Valle 0 Flat o Ridge 0 Other
(check a••-=="=ebox)
LATITUDE
May be in degrees,
minutes, seconds or
in a decimal format
LONGITUDE
Latitude/longitude source: o GPS 0 Topographic map
(location of well must be shown on a USGS topo map and
attached to this form if not using GPS)
5. WELL OWNER
OWNER'S NAME C I SA -Cie -VAC/
(
STREET ADDRESS JJ 3 tS (*eke\de
`'Ci o Town��oa State
Zip Code
Area de - Phone88number
8. WELLDETAILS: F�T
a. TOTAL DEPTH: ban1
YES 0 NO
b. DOES WELL REPLACE EXISTING WELL?
c. WATER LEVEL Below Top of Casing: t
0 FT.
(Use "+" if Above Top of Casing)
d. TOP OF CASING IS 4 FT. Above
Land Surface*
surface may require
2C .011$.tC Itn
TEST 41-
*Top of casing terminated at/or below land
a variance in actor ance with 15A NCAC
e. YIELD (gpm): METHOD OF
f. DISINFECTION: Type . Amount ♦Ce
g. WATER ZONES (dep/fh):
From Q To -. 7Y From To
From To From To
From To From To
7. CASING: Thickness/
Depth Diameter fight to i I
FromTo Depth,
Ft. El
_
From To Ft.
From To Ft.
8. GROUT: Depth ^� Material Meth
From -. To-3 Ft. I 5
From-. To- �� FL � M. r
From To Ft.
9. SCREEN: Depth / _ Dia¢tgter Slot_M erial
From-4b To-( Ft. of in. eln in.
From To Ft. in. in.
From To Ft. in. in.
10. SAND/GRAVEL PACK:
De
C
Fromi
To to Ft.we\I�
@ 9C '
From To Ft.
From _—_To ._ Ft. _
11.
11. DRILLING LOG
From To Formation
_ .
Description
n.- 1CD - er
10- 3s Cta1'
;Lc- 4r5
f C.
.___..
DEC 0 5' 2017
12. REMARKS:
inh-vvaa1ion Prcccse.:n9 ::9'NI
oWO/ BCA.
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15ANCAC 2C,WEL CON UCTIO STANDARDS, AND PY OF THIS
RECORD HAS BE PR 1 ED HE WELL NE 4 V
SIGNAT E OF R IE61Y on DATE
Michael C. Sage 6d�
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
DEC 1 1 2017
Submit the original to the Division of Water Quality within 30 days. Attn: InformAatioti?Af' 1tior�S Section
1617 Mail Service Center- Raleigh, NC 27699-1617 Phone No. 919 733-7015 ext 568w11'mm oft iteglonal Office Form GW-la
9 ( ) Rev. 3/07

WELL CONSTRUCTION RECORD (GW-1)
1. Well Contractor Information:
Donald Cummings
Well Contractor Name
2412-A
NC Well Contractor Certification Number
Applied Resource Management, P.C.
Company Name
2. Well Construction Permit #:
List all applicable well construction permits P.e. UIC County, State, Variance, etc.)
3. Well Use (check well use):
W16-051H
Water Supply Well:
w'.Agricultural
Geothermal (Heating/Cooling Supply)
1: Industrial/Commercial
litigation
Non -Water Supply Well:
Monitoring
InjectionInjection Well:
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
Experimental Technology
Geothermal (Closed Loop)
Geothermal (Heating/Cooling Retard)
@Municipal/Public
@Residential Water Supply (single)
@Residential Water Supply (shared)
@Recovery
Groundwater Remediation
@Salinity Barrier
@Stormwater Drainage
@Subsidence Control
@Tracer
@Other (explain under #21 Remarks)
4. Date Well(s) Completed: 10/19/17 Well lD# N/A
5a. Well Location:
Coastal Home Company N/A
Facility/owner Name Facility ID# (if applicable)
Lot 7 Majestic Oaks, Hampstead, NC 28443
Physical Address, City, and Zip
Pender 3292-24-0705-0000
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one latllong is sufficient)
34 21 36.6 N 77 42 03.2
w
6. Is(are) the wel((s) x@Permanent or @Temporary
7. Is this a repair to an existing well: @Yes or @x No
'phis is a repair, fill out known well contraction information and explain the nature of the
repair under #21 remaarsection or on the back afthisform.
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: 1
9. Total well depth below land surface: 210
For multiple wells list all depths if different (example- 3Q200' and 2@100)
(ft.)
10. Static water level below top of casing: 17 (ft.)
If water level is above casing, use "+'•
11. Borehole diameter: See Remas(fn.)
12. Well construction method: Mud Rotary
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) 80 Method of test: Airlift
13b. Disinfection type: HTH Amount: 3a/o@10g
For Internal Use Only:
44678!
14_ WATER ZONES
FROM
TO
ft.
ft
ft.
15. OUTER CASING (for 'multi -cased .wells OR LINER (if a Roble).-
DIAMETER THICKNESS MATERIAL
25 R 8 ia• l SCH40 1PVC
16. INNER CASING OR TUBING (geothermal :closed -loop).
DIAMETER
FROM
0
FROM
0
Pr.
fL
170 fL
TO
TO
180 ft-
190 R•
17..SCREEN.
FROM
190 ft•
TO
210 ft•
4 in.
2
DIAMETER
2
in.
ID.
THICKNESS MATERIAL.
SCH40 PVC
SCH40 PVC
SLOT SIZE
.020
THICKNSss
SCH40
MATERIAL
PVC
ft.
18. GROUT ,.
FROM
0
ft.
In.
TO
23 ft.
MATERIAL
Bentonite
EMPLACEMENT METHOD & AMOUNT
Poured
ft.
ft.
ft.
:.19.SAND/GRAVEL PACK (if applicable)
FROM
TO
fL
MATERIAL
EMPLACEMENT METHOD
ft.
ft.
20: DRILLING LOG (attach adtlitianal sheets if necessary)
DESCRIPTION (color, hardness, sogfrock tree, grain size, etc.).
Sandy clay to clay
FROM
0 R.
65 ft.
TO
65 R•
125 rt•
Limestone
125 ft.
180 ft•
180 ft.
190 R•
Clay/rock mix
Clay/sandstone mix
190 R•
210 ft•
Sandstone
ft.
ft.
ft.
21GREMARKS.,
ft.
RE
0-25/8 25-105/6"
NOV -0 2097
22. Certification: information Proa.s•-:,: $9 .;ail
eo 10/26/17
Signature of Certified Well Contractor Date
By signing this form, I 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 that a
copy of this record has been provided th9 at3ENR/®WR
23. Site diagram or additions Ewell details: IT YY
You may use the back of this page to provide additional well site details or well
construction details. You may also IVV �ttitllgtvad2itf�kna4�es ifnecessary.
SUBMITTAL INSTRUCTIONS 1)
24a. For All Wells: Submit th 'inpOyjllllhyibet9F k completion of well
construction to the following: Operations Section
ilmingtton Regional Office
Division of Water Re rces, nformation Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Infection Wells: In addition to sending the form to the address in 24a
above, also submit one copy of this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supply & Infection Wells: In addition to sending the 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
This form can be used for single or multiple wells
1. Well Contractor Information:
--aajc an-cke_,�
Well Contractor Name
3 a- A-
NC Well
^Contractor Certification Number
Arc g,oc4f- s
Company Name
2. Well Construction Permit H:
List all applicable well pernils (i.e. County, Stale. Variance, Inject
3. Well Use (check well use):
Water Supply Well:
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑Industrial/Commercial
❑ Irrigation
Non -Water Supply Well:
jvlonitoring
Injection Well:
DAquifer Recharge
❑ Aquifer Storage and Recovery
DAquifer Test
°Experimental Technology
°Geothermal (Closed Loop)
°Geothermal (Heating/Cooling Return)
For Internal Use ONLY:
446767
M. WATER 2b
FROM
TO
){,oft.
FROM
ft.
ft.
DESCRIPTION
iS, oureA CASING (for mu(q-eased
TO
ft.
R C
FROM I TO
ft.
ft.
ft
ft.
DIAMETER
db) 011 Ll!' R (ifap�fcable)
THICKNESS MATERIAL
in.
NG1Reath
DIAMETER
in.
in.
e
THICKNESS
MATERIAL
OMunicipal/Public
°Residential Water Supply (single)
❑Residential Water Supply (shared)
°Recovery
FROM
f ft.
ft.
FROM
lift.
ft.
TO
taR.
ft.
TO
Ot0 R.
DIAMETER
in.
MATERIAL
SLOT SIZE
ar.o to
5 ckrCt€
THICKNESS
54.
MATERIAL
PVC.
EMPLACEMENT METHOD & AMOUNT
Hetekd
°Groundwater Remediation
°Salinity Barrier
DStormwater Drainage
❑Subsidence Control
°Tracer
°Other (explain under 421 Remarks)
4. Dale Well(s) Completed: !' dD "t7 Well IDk Pr eW— (ro
5a. Well Location:
SA.wwtiauD t�- tire A/4
Facility/Owner Name Facility 1DU (if applicable)
Bg53 a' WWhf 53 W, $inrooua7 ► NC
Physical Address, City. and Zip 018 LE
I `.y 6—
Pe.VIdeerf ✓➢
County Parcel Identification No. (PIN)'
ft.
FROM
n.
VEL PACK
TO
la_ ft. 1 ft.
4:bR1LL 6
ft. R.
FROM L
0 R.
PI ft.
1I- R.
TO
t.
Ls"
R,
& cft.
9,40 ft.
irk ft. to ft.
0,Or tii0 ft.
ItbOR' )ft.
21� RE
pplic44 )-
MATERIAL
EMPLACEMENT METHOD
°aliUer5 Slut
NA) f0ttll'
iedd l sheets IfnecMsgry)
DESCRIPTION (color, hardness, soil/rock type, grain size, ere.)
Top xi1+- Gr&ss
brow. avicd4
0/CrIC Bunt,, -3 �_, SKad
t�ravlr5e et", (,(a
fire �ll(fn , - Y a- Sa
Or (ti
Sri- & San f1,
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field one lat/long is sufficient)
39;53 �a,�� N -78rv?oS9-7 w
6. Is (are) the well(s): 18Permanent or °Temporary
7. Is this a repair to anexistingwell: °Yes or �yy c�'o
If this is a repair, fill out known well canrtrnclian information and explain the nalura of the
repair under d21 remarks section or on the back aphis firm.
S. Number of wells constructed:
For multiple injection or non -water supply wells ONLY with the. same construction, you can
submit one farm
9. Total well depth below land surface:
For multiple wells Ayr all depths ifdifjrent (example-3©20— 0' andd2@100
1
12)
10. Static water level below top of casing:
If water level is above casing, use " r1 �./
11. Borehole diameter: 3r as" (in,)
12. Well construction method:
(i.e. auger, rotary, cable, direct push, etc.)
22. Certification:
/' l®'11
Signature of Certified Well Conn -actor Date
By .signing this Jornr, / hereby certify that the we//(s) $vas (mere) constn¢ved in accordance
with 15,4 M('A(102('.0100 or 114 NCAC 02(7.0200 Well Construction Standards and Oct a
copy 4f this record has been provided to the well owner,
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTUCTIONS 6�ECE'9y�n�tVC®NR/pWt�
/ NOV p,p.m?
well
LT {¢IV t� f'f g WII n I
All Wells: Submit this form within 30 days of completion of well
"\ tign to the following: ��(l
Division of Water Resources, INOrgat2nl}'r2i 4jing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617 -
111443DRRlion Prot ; o Injection Wells ONLY: In aAa o.. ( .. tt�i " to the address in
W�G� O°d'J(q!r"SO;a La'a ��e, also submit a copy of this f����,�,.dat�v, gtlLdmpletion of
construction to the followin 10
Wilmington Regional Office
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supply & Injection Wells:
Also submit one copy of this form within 30 days of completion of
well construction to the county health department of the county where
constructed
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type:
Amount:
Fenn GW-I
North Carolina Department ofEnvirmrment m d Natural Resources - Division of Water Resources Revised August
201;

WELL CONSTRUCTION RECORD (GW-1)
1. Well Contractor Information:
Donald Cummings
Well Contractor Name
2412-A
NC Well Contractor Certification Number
Applied Resource Management, P.C.
Company Name
2. Well Construction Permit ft: W17-031 H
List all applicable well conttna:tion permits (Le. LAC, County, State, Variance, etc)
3. Well Use (check well use):
Water Supply Well:
Agricultural - jMunicipal/Public
Geothermal (Heating/Cooling Supply) ®Residential Water Supply (single)
Industrial/Commercial QResidential Water Supply (shared)
Irrigation
Non -Water Supply Well:
Monitoring
Recovery
Injection Well:
Aquifer Recharge
�IAquifer Storage and Recovery
Aquifer Test
Experimental Technology
Geothermal (Closed Loop)
Geothermal (Heating/Cooling Return)
4. Date Well(s) Completed: 10/19/1
Groundwater Remediation
®Salinity Barrier
QStormwater Drainage
DSubsidence Control
Tracer
Other (explain under #21 Remarks)
7 Well rD# N/A
5a. Well Location:
Steve Vavra N/A
Facility/Owner Name Facility ID# (if applicable)
Lot 137 Scarlet Court,Hamptead, NC 28443
Physical Address, City, and Zip
Pender 4214-72-8519-0000
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one IatAong is sufficient)
34 21 36.3 N 77 42 03.0
W
6. Is(are) the well(s)jxPermanent or flTemporary
7. Is this a repair to an existing well: QYes or ONo
If this is a repair, fill out known well construction information and explain the nature ofthe
repair under d21 remarks section or on the back of this form.
8. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction, only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled: 1
9. Total well depth below land surface: 1 05
For multiple wells list all depths if different (example- 3@200' and 2@1005
(ft.)
10. Static water level below top of casing: 17 (ft.)
If water level is above casing, use '•> "
11. Borehole diameter: See Remalii (in,)
12. Well construction method: Mud Rotary
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) 80 Method of test: Airlift
0
13b. Disinfection type: HTH Amount: 3%@10g
For Internal Use Only:
446734
1& WATER ZONES.. -.
FROM
TO
DESCRIP,OIY
ft
ft
,'$1rri5
.. ....
ft.
ft.
15. OUTER CASING (for multi -cased wells) OR LDiER (if ap • Isle)'
FROM
TO DIAMETER THICKNESS MATERIAL
0 ft*
80 ft r4 in. SCH40 PVC
16. INNER CASING OR TUBING (geothermal closed -loop).
FROM
TO DIAMETER
THICKNESS
MATERIAL
R
ft in
ft.
ft. Ij in
17.SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
_MATERIAL
ft.
ft
in.
ft
ft.
in.
IS. GROUT - -.
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
0 ft
30 It
Bentonite
Poured
ft.
ft.
ft
f.
19. SAND/GRAVEL
PACK
(if applicable) -
FROM
TO
MATERIAL
EMPLACEMENT METHOD
ft.
ft.
R
R.
20. DRILLING
LOG (attach
additional sheets ifnecessary)
FROM
TO
DESORPTION (color, hardness, soil/rock type, grain size, etc.)
0 R•
62 a•
Sandy clay to clay
62 ft•
105 It•
Limestone
ft.
ft.
R.
ft.
C.
p
Ft.
It.
@'S eV�.E
ft.
ft,
NOV I: 4 2017
21. REMARKS
0-25/8 25-105/6" Information Prod«.yj uni,
Deffatete
22. Certification:
Signature of Certified Well Contractor
10/25/17
Date
By signing this form, 1 hereby cent)" that the Ad1(s) was (were) constnucted in accordance
with 15A NCAC 02C7.0100 or ISA NCAC 02C.0200 Well Constn,etion Standanls and that a
copy of this record has been provided to the well owner. �yg
23. Site diagram or additional �w�g$�s�lft��rd�N�I® tl+
You may use the back of thisitte rovide additional well site details or well
construction details. You may also attach additional Paages-if necessary.
SUBMITTAL INSTRUCTIONS NB
ON
24a. For All Wells: Submit this form within 30 Afpfa@ompletion of well
construction to the following: yteY �n_ailty $eCtlnn
W Bons V office
Division of Water Resource atji 4'9oacessing Unit,
1617 Mail Service Cgytbl)il ugh, NC 27699-1617
24b. For Iniection Wells: In addition to sending the form to the address in 24a
above, also submit one copy of this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supply & Iniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
completion of well construction to the county health department of the county
where constructed.
Form GW-I
North Carolina Department of Environmental Quality -Division of Water Resources Revised 2-22-2016

WELL CONSTRUCTION RECORD (GW-1)
1. Well Contractor Information:
Donald Cummings
Well Contractor Name
2412-A
NC Well Contractor Certification Number
Applied Resource Management, P.C.
Company Name
2. Weil Construction Permit #:
W16-050H
List all applicable well constnrclion permits (i.e. (AC, 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)
'Geothermal (Heating/Cooling Return)
0Municipal/Public
K®Residential Water Supply (single)
Residential Water Supply (shared)
['Recovery
['Groundwater Remediation
El:Salinity Barrier
DStormwater Drainage
Subsidence Control
(Tracer
Other (explain under #21 Remarks)
4. Date Well(s) Completed: 10/25/17 Well ID# N/A
5a. Well Location:
Coastal Home Company N/A
Facility/Owner Name Facility ID# (if applicable)
Lot 6 Majestic Oaks, Hampstead, NC 28443
Physical Address, City, and Zip
Pender 3292-24-1508-0000
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 21 36.6 N 77 42 03.2
W
6. Is(are) the wel(s)iIK Permanent or OTemporary
7. Is this a repair to an existing well: rYes or ONo
Iflhis is a repair, fill ont known well construction information and explain the nature of the
repair under 521 remarks section or on the back ofthls form.
8. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction, only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled: 1
9. Total well depth below land surface: 210
For multiple wells list all depths if different (example- 3®200' and 2@100)
10. Static water level below top of casing: 17
If water level is above casing, use "x"
11. Borehole diameter: See Remab(ln )
12. Well construction method: Mud Rotary
(i.e. auger, rotary, cable, direct posh, etc.)
(ft.)
(ft.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) 80 Method of test: Airlift
13b. Disinfection type: HTH Amount: 3% 10g
For Internal Use Only:
446733
14. WATER ZONES. -
FROM
TO
DESCRIPTION
fL
fL
ft.
R.
IS OUTER CASING (for molti-eased wells) OR LINER (Ka p�pRratRe).-
FROM TO DIAMETER THICKNESS T MATERIAL
0 180 ft 4
ft.
SCH40 PVC
16. INNER CASING OR TUBING. (geothermal closed -loop(
DIAMETER
FROM
170 ft-
ft.
17. SCREEN
TO
190 ft
2
in.
in.
THICKNESS MATERIAL
SCH40 PVC
PROM
190 R•
fL
I& GROUT
1t
210 ft-
2 ia• .020 �SCH40
TO DIAMETER SLOT SIZE TRICKNESS
in.
MATERIAL
PVC
FROM
0 fL
TO
23 ft
MATERIAL
Bentonite
EMPLACEMENT METHOD & AMOUNT
Poured
ft.
ft.
fL
fL
19. SAND/GRAVEL PACK (if applicable)
FROM
TO
fL
MATERIAL
ENIPL4CEMENT METHOD
ft.
20. DRILLING LOG (attach additional sheets if necessary)
DESCRIPTION (color, hardness, sotprock type, Grain sixes, etc.)
Sandy clay to clay
FROM
Q ft.
65 ft.
TO
65 ft
125 ft
Limestone
125 fL
180 R•
180 ft•
190 ft•
Clay/Rox mix
Clay/sandstone mix
190 ft.
210 ft.
Sandstone
ft.
ft.
ft.
ft.
RE
CEIVED
21. REMARKS.
0-25/8" 25-180/6" 180-210/4"
NOV
I 2017
22. Certification:
infOn raffof) PfOC:><,F. nsy `.,.
OWciau
ignature of ed Well Contactor 0
10/25/17
Date
By .signing this form, I hereby certify that the well(s) was (were) constructed in accordance
with /5A NCAC 02C .0100 or 15A NCAC 02C .0200 Well Construction Standards and that a
copy of this record has been provided to the well owner.
23. Site diagram or additional welTp a WED/NCDENR/nwR
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 N O V 2 0 2017
24a, For All Wells: Submit this form within 30 days of completion of well
construction to the following: Water QualityRegional
Division of Water Resau r mi(ni ��,en�,l,+y,,f"g�y� ,,trp��gg Unit,
1617 Mail Service Cen er, igh, WL'"2769 'Ih`f&
246. For Infection Wells: In addition to sending the form to the address in 24a
above, also submit one copy of this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supply & Iniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
completion of well construction to the county health department of the county
where constructed.
Form GW-1
North Carolina Department of Environmental Quality - Division of Water Resources Revised 2-22-2016