GW1 - Brunswick 2018

Print Form
WELL CONSTRUCTION RECORD (GW-1)
1. Well Contractor Information:
Shawn Davis
RECEIVED/NCDENR/DWR
Well Contractor Name
4246-A
NC Well Contractor Certification Number
Froehling & Robertson
Company Name
2. Well Construction Permit #:
List all applicable well construction permits (i.e. UIC, County, State, Variance, etc)
3. Well Use (check well use):
DEC 172018
Water Quality Region
Operations Section
Wilmington Regional 0
N/A
Water Supply Well:
© Agricultural
[Geothermal (Heating/Cooling Supply)
[Industrial/Commercial
[Irrigation
[Municipal/Public
[Residential Water Supply (single)
Residential Water Supply (shared)
Non -Water Supply Well: .
Monitoring Il Recovery
Injection Well:
[Aquifer Recharge
[Aquifer Storage and Recovery
ri Aquifer Test
Experimental Technology
[Geothermal (Closed Loop)
[Geothermal (Heating/Cooling Return)
©Groundwater Remediation
[Salinity Barrier
[Stormwater Drainage
[ Subsidence Control
[Tracer
Other (explainunder#21 Remarks)
4. Date Well(s) Completed: 11-12-2018 Well ED# W 3
5a. Well Location:
Brunswick Co. WTP
N/A
Facility/Owner Name Facility ID# (if applicable)
3954 Clearwell Drive NE, Leland, NC, 28451
Physical Address, City, and Zip
Brunswick
N/A
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
34.3020697 N W
6. Is(are) the well(s)jPermanent or DTemporary
-78.1065622
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 #21 remarks section or on the back of this form.
8. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction, only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled: 1
9. Total well depth below laud surface: 1 @ 23.01
For multiple wells list all depths if different (example- 3@200' and 2@100')
(ft.)
10. Static water level below top of casing: 5.9 (ft.)
If water level is above casing, nec "+"
11. Borehole diameter: 8.0 (in.)
12. Well construction method: Auger
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
For Internal Use Only:
14. WATER ZONES
FROM
TO
DESCRIPTION
0.0 ft
5.9 ft•
Static Water Level
ft
ft.
i i 1S. OUTER
CASING (for multi -cased wells) OR LINER (if ap 6cable)
FROM
TO
DIAMETER THICKNESS MATERIAL
ft.
fi-e
ft.
in.
1
16. INNER
CASING OR TUBING
(geothermal closed -loop) . '
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft..
ft.
in.
ft.
- ft.
in.
` 17. SCREEN
'
FROM
TO
DIAMETER
_ SLOT SIZE
THICKNESS
MATERIAL
21.0 ft.
11.0 ft•
2 in'
10.25
Schedule 40
PVC
ft.
ft.
in.
..18. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
6.8 ft.
0.0 ft.
Saylor's Type 1/II
Tremmied
ft.
ft.
ft.
ft.
19. SAND/GRAVEL PACK(if
applicable)_'
FROM
TO
MATERIAL
EMPLACEMENT METHOD
23.0 fL
8.5 ft.
GP #2
Tremmied
ft.
ft.
•20. DRILLING
LOG (attach additional sheets if necessary)
FROM
TO
DESCRIPTION (color, hardness, soil/rock type, grain size, ere.)
0.0 ft-
6.0 ft.
Loose to Med'uo, Dense, Brown Gay Weile, Moist, F to Mediun, SAND. Trace to Me SAt♦1[
6.0 ft.
ft
12.0 '
SoftNery Loose to Loose,Gray, Wet, Silty CLAY and Fine SANDii
12.0 ft.
23.0 ft'
Very Soft to Soft, Gray, CLAY, Little Fine Sand, Trace Decayed Wood
fL
ft.
rt.
ft.
ft.
ft.
V
ft.
ft.
f-
C
21. REMARKS ..:
.1 Z018 '
i c 2
. ,,n 0P1434 - th.4.
22. Certification:
Signature of Certified Well Contractor
12/5/2018
Date
By signing this form, 1 hereby certify that the well(s) was (were) constructed in accordance
with 15A NCAC 02C .0100 or 15A NCAC 02C .0200 Well Construction Standards and that a
copy of this record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTRUCTIONS
24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Iniection Wells: In addition to sending the form to the address in 24a
above, also submit one copy of this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water SuDDIV & 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

Smith
Client:
Project Name:
Project Location:
Project Number:
GROUND
SURFACE
Brunswick Co., NC
NW WTP Expansion
Leland, NC
232662
Monitoring Well Installation Log
Contractor: F&R
Driller: Shawn Davis
Ground EL: TBD
Riser EL: TBD
RECEIVED/NCDENR/DWR
DEC 1 7 2018
Water Quality Regional
Operations Section
Wilmington Regional Office
540
ROADWAY BOX
SURFACE SEAL:
(Thickness & Type)
BACKFILL MATERIAL:
(Type)
TOP OF SEAL:
SEAL CONSTRUCTION:
(Thickness & Type)
TOP OF SANDPACK:
RISER CONSTRUCTION:
(Type, Diameter Material)
TOP OF SCREEN:
SANDPACK TYPE:
SCREEN MATERIAL:
Boring/Well No.:
Date Installed:
Logged By:
Page:
0 Glenwood Ave #400
Raleigh, NC 27612
[phone]
W-3
11/12/2018
ZPM
1 of 1
Grout
Grout
6.8 feet
Enviroplug Bentonite
8.5 feet
2" Schedule 40 PVC
11 feet
DSI Well Gravel
40 slot, 2" PVC
(Type, Slot, Diameter Material)
BOTTOM OF SCREEN:
BOTTOM OF BOREHOLE:
BOREHOLE DIAMETER:
NOTE: All depths are in feet below ground surface, unless noted otherwise.
21 feet
23 feet
8 inches
Remarks:

RECEIVED/NCDENR/DWR
DEC 1 7 2018
BL BRUNSVVICK WTP .GPJ - 12/3/18
DIIII Water Quc
0peratic\ils
m g
1li111/llminton
lity Regional
Section
,egional Office
Boring
B-112
Number:
Sheet 1 of 4
Client: Brunswick Co, North Carolina Project Name: NW WTP Expansion and Upgrades
Project Location:Leland, NC Project Number: 250459-232662
Drilling Contractor/Driller:F&R, Inc / Shawn Davis Surface Elevation (ft.): TBD
Drilling Method/Casing/Core Barrel Size: 3 1/4 HSA & Mud Rotary / 4 in / Total Depth (ft.): 100
Hammer Weight/Drop Height/ Spoon Size: 140 lb / 30 in /2 in O.D. Depth to Initial Water Level (ft):
Bore Hole Location: N38.30205083, 1N78.10659833 Depth Date Time
Drilling Date: Start: 11/12/2018 End: 11/13/2018 NR NR NR
Abandonment Method:Backfill with bentonite
Logged By: ZPM
Depth
(ft)pE
a Q
5
V)
as
E- co E
CO z
at
E a,
u)
J
N ,c
; c
° ,_
mco
c
n is
E>
N°
d
re
3
j
Z
rn
,,
t
E
U
:9
N
Material Description
Remarks
0
-
—
SS
S-1
24
2
5
8medium
9
21
13
4" Topsoil
Moist, medium dense, dark brown, fine to
SAND, little silt & clay
- -
—
SS
S-2
24
5
5
6
24
11
5_fine
Moist, medium dense, light brown to white,
SAND, trace silt
- -5 -
—
SS
S-3
24
3
5
4
14
10
Moist, loose to medium dense, grayish
brown, fine SAND, trace silt
-
SS
S-4
24
2
1
2
24
4•
•
•
Top 12": Moist, loose to medium dense,
grayish brown, fine SAND, trace silt
Bottom 12": Moist to wet, soft, gray, CLAY,
trace fine sand
Sulfur Odor
- -
SS
S-5
24
2
2
2d
2
24
4
,�
? '• .'
2 . '
g
0SAND
Wet, very loose to loose, light gray, fine
and Silty CLAY
Sulfur Odor
10
SS
S-6
24
WOH
2
2••'
20
3
V
Wet, very loose, light gray and white, fine to
coarse SAND and Silty CLAY
SS
S-7
24
t
WOH
WOH
1
20
0
Wet, very soft, gray, CLAY
PP=<0.25 TSF
-
- 15
ST
U-1
24
24
�
U
Wet, gray, CLAY, little fine sand, trace
decayed wood
PP=1.5 TSF
- -
SS
S-8
24
WOH
WOH
3
3
24
3
LL
Wet, gray, CLAY, little fine sand, trace
decayed wood
PP=1.25 TSF
- -
ST
U-2
24
24
��
Wet, gray, CLAY, little fine sand, trace
decayed wood
Sample Types
Consistency vs BlowcountlFoot
Burmister
Classificatior
AS - Auger/Grab Sample HP - Hydro Punch
Granular (Sand):
Fine Grained (Clay):
and 35-50%
CS -California Sampler SS -Split Spoon
BQ - 1.5" Rock Core ST - Shelby Tube
NQ - 2" Rock Core WS - Wash Sample
GP - Geoprobe
V. Loose: 0-4 Dense: 30-50
Loose: 4-10 V. Dense: >50
M. Dense: 10-30
V. Soft: <2 Stiff: 8-15
Soft: 2-4 V. Stiff: 15-30
M. Stiff: 4-8 Hard: >30
some 20-35%
little 10-20%
trace <10%
moisture, density, color
Reviewed by:
Date:
Boring Number: B-112

smith
Sheet 2 of 4
Boring Number:
B-112
Client: Brunswick Co, North Carolina Project Name: NW WTP Expansion and Upgrades
Project Location:Leland, NC Project Number: 250459-232662
Elev.
Depth
(ft)
20
25
30
35
d
a) H
m
AA
Z
0.0
N
U
O
m fD
Cn Z`
E
Nre
a
a)
0
J
U
a.
0
Material Description Remarks
SS
ST
U-3
24
24
24
SS
S-10
24
3
11
10
11
24
21
SS
S-11
24
20
40
50
70
12 90
SS
S-12
24
12
18
22
33
16
40
40
SS
S-13
24
15
21
26
15
10
47
45
a
U
LL
1-Graded Sa
Wet, soft, dark gray, CLAY and decayed
wood
Wet, gray with orange, CLAY, trace fine
sand
PP=0.25 TSF
PP=0.25 TSF
Top 18": Wet, soft, gray, CLAY PP=<0.25 TSF
Bottom 6": Wet, medium dense, white and
orange, fine to coarse SAND, little clay & silt
Wet, very dense, gray, fine to coarse SAND,
trace silt
Wet, dense, gray, fine to coarse SAI COOVED/ CDENR/DWR
trace silt
DEC 7 2018
Water Qu lity Regional
Operati ns Section
Wilmington 'egional Office
Wet, dense, gray, fine to coarse SAND,
trace silt
Boring Number: B-112

BL BRUNSWICK WTP .GPJ - 12/3/1
-
-
_
_
_
-
_
-
_
CD1111Sheet
Smith
3 of
BoringNumber:
B-112
Client:
Project
Brunswick
Co, North Carolina Project Name: NW WTP Expansion and Upgrade
Location:Leland, NC Project Number: 250459-232662
Elev.
m�
£
10 F-
to
m 4)
T
1: =
co z
a
Ern
f0 c
m J
a
3
o •-
m m
e
c E
en u
Ix
=
> `�
o Z
rn
�
r
a
`
o
to
Material Description
p
Remarks
Depth
(ft)
e
Wet, dense, gray, fine to coarse SAND,
trace silt
- SS
S-14
24
1
��
11
g
33
50
•
io
._
�'
•
'
Wet, loose, dark gray, fine SAND, little
clayey silt
Wet, very dense, dark gray, fine SAND, little
clayey silt
Wet, medium densag i- r %�11G't * NR
little clayey silt i, G 1t/��+
DEC 1 7 2018
Water Quality Regional
Operations Section
Wilmington Regional Office
Wet, medium dense, dark gray, fine SAND,
little clayey silt
Wet, medium dense, dark gray, fine SAND,
little clayey silt
PP=<0.25 TSF
PP=2.5 TSF,
Cemented Layer
PP=0.5 TSF
PP=1.0 TSF
PP=1.0 TSF
- SS
S-15
24
3
4
5
12
24
9
55
.•„
: is
:• .•
..J•
'•
; .•:
_
60
SS
S-16
5
50/5"
-
SS
S-17
24
5
a
19
24
17
65
_
-
SS
S-18
24
5
18
24
11 .
70
'7.
_
SS
S-19
24
24
17 :
Boring Number: B-112
4

co
a'
a
9
95
100
85
Smith
Client: Brunswick Co, North Carolina
Project Location:Leland, NC
Elev.
Depth
(ft)
75
0
0
J
U
.0
a
0
Sheet 4 of 4
Boring Number:
B-112
Project Name: NW WTP Expansion and U
Project Number: 250459-232662 pgrades
Material Description
Wet, medium dense, dark gray, fine SAND,
little clayey silt
Wet, medium dense, dark gray, fine SAND,
little clayey silt
Wet, dense, dark gray, fine SAND, little
clayey silt
Wet, medium de
little clayey silt ""i�l�
DEC 1 7 2018
Water Quality Regional
Operations Section
Wilmington Regional Office
Wet, dense, dark gray, fine SAND, little
clayey silt
Remarks
PP=1.25 TSF
PP=0.75 TSF
PP=1.5 TSF
PP=2.0 TSF
Boring Number: B-112

WELL CONSTRUCTION RECORD (GW-1)
1. Well Contractor Information:
Shawn Davis
Well Contractor Name
4246-A
2. Well Construction Permit #:
List all applicable well construction permits (i.e. UIC, County, State, Variance, etc.)
3. Well Use (check well use):
RECEIVED/NCDENR/DWR
DEC 1 7 2018
NC Well Contractor Certification Number
Froehling & Robertson Water Quality Regional
Section
Company. Name Wil ingtonlons Regional Office
N/A
Water Supply Well:
®Agricultural
Geothermal (Heating/Cooling Supply)
Dlndustrial/Commercial
lilrrigation
Non -Water Supply Well:
ID Monitoring
Injection Well:
In Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
[}Experimental Technology
Geothermal (Closed Loop)
r,IGeothermal (Heating/Cooling Return)
fMunicipalPublic
DResidential Water Supply (single)
[Residential Water Supply (shared)
0Recovery
© Groundwater Remediation
SalinityBarrier
DStormwater Drainage
El Subsidence Control
0 Tracer
flOthet.(explain-under #21 Remarks)
4. Date Well(s) Completed: 11-5-2018 Well 1D# V1/-2
5a. Well Location:
Brunswick Co. WTP N/A
Facility/Owner Name Facility ID# (if applicable)
3954 Clearwell Drive NE, Leland, NC, 28451
Physical Address, City, and Zip
Brunswick N/A
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one Iat/long is sufficient)
34.3024040 N-78.1078017
6. Is(are) the well(s)Jx._ Permanent or [Temporary
7. Is this a repair to an existing well: a Yes or No
If this is a repair, fill out known well construction information and explain the nature of the
repair under h21 remarks section or on the back of this fonn.
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
13
9. Total well depth below land surface: 1 @ 23.0t
For multiple wells list all depths if different (example- 3®200' and 2®100)
(ft.)
10. Static water level below top of casing: 14.9 (ft,)
If water level is above casing, use '•+ "
11. Borehole diameter: 8.0 (in.)
12. Well construction method: Auger
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
Print Form
For Internal Use Only:
14. WATER ZONES
FROM
TO
DESCRIPTION
0.0 ft'
14.9 ft•
Static Water Level
ft.
ft.
15..OUTER CASING (for multi -cased wells) OR LINER (f aplplivable)
FROM
TO
DIAMETER THICKNESS MATERIAL
ft.
ft.
in.
16. INNER
CASING OR TUBING
(geothermal closed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft
ft.
in.
_
ft.
ft.
in.
17.SCREEN '
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
19.8 ft,
9.8 ft.
2 in•
10.25
Schedule 40
PVC
ft.
ft.
in.
18.. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
5.5 ft.
0.0 ft•
Saylor's Type I/ll
_
Tremmied
ft.
ft.
ft.
ft.
19. SAND/GRAVEL
PACK
Cf applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
23.0 ft.
8.0 ft.
GP #2
Tremmied
ft.
ft.
• 20. DRILLING
LOG (aliach additional sheets if necessary)
FROM
TO
DESCRIPTION (color, hardness, soil/rock type, grain size, etc.)
0.0 ft.
2.0 ft.
Loose, Black -Brown, Moist, Finale. Medium SAND. Some Silt 8 Clay (FILL)
2.0 ft.
8,0 ft,
loam to Medium Dense, &ovmblack. iny. Mulct le we, F to Medium SAND. Trace Silt
8.0 ft-
18.5 ft.
Soft to Stiff, Gray, Wet, Silty CLAY. Trace to Little Fine to Medium Sand
18.5 ft.
21.5 ft,
Soft, Gray, Wet, Silty CLAY and Decayed WOOD (PEAT)
21,5 ft,
23.0 ft.
Soft, Gray, Wet CLAY
rt.
ft.
nl`-
ft.
it.
'
21. REMARKS
3 @ ""
'DEC 1 2 2.01B
22. Certification: 4,10,Frttt UoG
Signature of Certified Well Contractor
12/5/2018
Date
By signing this form, 1 hereby certify that the well(s) was (were) constructed in accordance
with 1 SA NCAC 02C .0100 or 15A NCAC 02C .0200 Well Construction Standards and that a
copy of this record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTRUCTIONS
24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Iniection Wells: In addition to sending the form to the address in 24a
above, also submit one copy of this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water SusDly & 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
RPv:ePA 'y_'fv_,n t

Smith
Client:
Project Name:
Project Location:
Project Number:
GROUND
SURFACE
Brunswick Co., NC
NW WTP Expansion
Leland, NC
232662
Monitoring Well Installation Log
Contractor:
Driller:
Ground EL:
Riser EL:
F&R
Shawn Davis
RECEIVE©INCRENR/DWR
DEC 17 2018
Water Quality Regional
Operations Section
Wilmington Regional Office
TBD
TBD
ROADWAY BOX
SURFACE SEAL:
(Thickness & Type)
BACKFILL MATERIAL:
(Type)
TOP OF SEAL:
SEAL CONSTRUCTION:
(Thickness & Type)
•
TOP OF SANDPACK:
5400 Glenwood Ave #400
Raleigh, NC 27612
[phone]
BoringfWell No.: W-2
Date Installed: 11/5/2018
Logged By: ZPM
Pap: 1 of 1
Grout
Grout
5.5 feet
RISER CONSTRUCTION:
(Type, Diameter Material)
Enviroplug Bentonite
8 feet
2" Schedule 40 PVC
TOP OF SCREEN: 9.8 feet
SANDPACK TYPE: DSI Well Gravel
SCREEN MATERIAL:
40 slot, 2" PVC
(Type, Slot, Diameter Material)
BOTTOM OF SCREEN:
BOTTOM OF BOREHOLE:
19.8 feet
23 feet
BOREHOLE DIAMETER: 8 inches
NOTE: All depths are in feet below ground surface, unless noted otherwise.
Remarks:

BL BRUNSWICK W!P .GPJ - 12/3/18
smith
Sheet 1 of 3
Boring Number:
B-114
Client: Brunswick Co, North Carolina Project Name: NW WTP Expansion and Upgrades
Project Number: 250459-232662
Project Location:Leland, NC
Drilling ContractorlDriller:F&R, Inc / Shawn Davis Surface Elevation (ft.):TBD
Drilling Method/Casing/Core Barrel Size: 3 1/4 HSA & Mud Rotary / 4 in / Total Depth (ft.): 50
Hammer Weight/Drop Height/ Spoon Size: 140 lb / 30 in /2 in O.D. Depth to Initial Water Level (ft):
Bore Hole Location: N34.30239639, W78.10772944 Depth Date Time
Drilling Date: Start: 11/2/2018 End: 11/2/2018 NR NR NR
Abandonment Method:Backfill with bentonite pellets
Logged By: ZPM
Elev.
p
D(ft) h
!
a 0
u 1-
U)
m;
a43
co E
co 2
2
c.z
R=
u) J
Q 2
at
a E
COip
-
m"
n Z
m o
N 413
d
j
Z
rn
3
a.
E
:°
N
Material Description
Remarks
0
-
-
SS
S-1
24
1
4
4
4
11
8
F.
It.
4" Topsoil
Moist, loose, black and brown, fine to
medium SAND, some silt & clay
2
-
SS
S-2
24
6
6
6
16
12
; :;•:
Moist, medium dense, light brown, fine to
medium SAND, trace silt & clay
Sulfer odor.
Possible fill.
- -
SS
S-3
24
8
12
13
10
24
25
'`:
'•ti
�
(0
k
Moist, medium dense, brownish gray, fine to
medium SAND, trace silt & clay
Sulfer odor.
Possible fill.
-
SS
S-4
24
5
4
4
3
18
8
:y..••:
•'::`'.
Wet, loose, black and brown, fine to medium
SAND, some silt & clay
Slight sulfer
odor.
Possible fill.
- -
SS
S-5
24
WOH
WOH
2
18
2%/�
/
Wet, soft, gray, CLAY, trace fine to medium
sand
PP=0.5 TSF
10
- -
-
ST
U-6
24
P
s
H
24
Wet, soft, gray, CLAY, little fine to medium
sand
PP=0.25 TSF
-
-
SS
S-7
24
2
4
6
8
24
10
/
o
,�
Wet, stiff, gray, Silty CLAY, and fine to
medium SAND 12ECffVED/NCDENR/DWR
PP=1.5 TSF
- 15 -
_ _
/
DEC 1 % 2018
Water Quality Regional
Operations Section
Wilmington Regional Office
WOH
/
Top 6": Wet, soft, gray, Silty CLAY, trace
PP=<0.25 TSF
-
SS
S-8
24
2
2
1
24
4 -^A
_&" —
�-.
a
fine sand -
Bottom 18": Wet, soft gray, Silty CLAY and
decayed WOOD
-
PP=I.O TSF
Sample Types
Consistency vs BlowcountlFoot
Burmister Classificatior
AS - Auger/Grab Sample HP -Hydro Punch
Granular (Sand):
Fine Grained (Clay):
and 35-50%
BQ - 1.5"iRock Co epler ST - Shelby Tube
NO - 2" Rock Core WS -Wash Sampletrace
GP - Geoprobe
V. Loose: 0-4 Dense: 30-50
Loose: 4-10 V. Dense: >50
M. Dense: 10-30
V. Soft: <2 Stiff: 8_15
Soft: 2-4 V. Stiff 15-30
M. Stiff: 4-8 Hard: >30
some 20-35%
littlera1<1
°
<0 /0%
moisture, density, color
Reviewed by:
Date:
Boring Number: B-114

BL BRUNSWICK WTP .GPJ - 12/3/18
CD
Smith
Boring
B-114
Number:
Sheet 2 of 3
.Client: Brunswick Co, North Carolina Project Name: NW WTP Expansion and Upgrades
Project Location:Leland, NC Project Number: 250459-232662
Elev.
Depth
(n)
a a
RI-
0
I'm
as
16 '
coZ
v`
cs
R c
U)a,
d w
a= ua,O
o —
CO
y:
' o
COm
d '
To
2
o
.J
u
a
Ea.
10
Material Description
Remarks
20
�^^^-
PP=1.0 TSF
-1
_
p;.
- SS
S 9
24
1
e
24
2
j
.
Top 21: Wet, soft, gray, CLAY, trace fine
sand
PP=0.25 TSF
-
25
-
. •
Bottom 3": Wet, loose, brown, fine to coarse
SAND, trace silty clay
- -
SS
S-10
24
7
26
30
32
12
56
Wet, very dense, gray, fine to coarse SAND,
trace silt & clay
30
- -
-
SS
S-11
24
18
33
39
45
15
72
•
Wet, very dense, gray, fine to coarse SAND,
trace silt & clay
35
- -
v
s
- -
SS
S-12
24
12
14
17
17
17
31
•
Wet, medium dense, gray, Ai CiV �rseC
SAND, trace silt & clay n mDENR/DWR
40
DEC 1 7 2018
Water Quality Regional
Operations Sectior
Wilrningtor, Regional C
ffice
- -
SS
S-13
24
5
8
8
7
18
16
Wet, medium dense, coarse SAND, trace
silt & clay, trace fine gravel
45
Boring Number: B-114

smith
Client: Brunswick Co, North Carolina
Project Location:Leland, NC
Elev.
Depth
(ft)
as
as fA ~
d
as
co Z
0. W
0
3c
Oc0
Si
Sheet 3 of 3
Boring Number:
B-114
0
0
J
0
C.
Project Name: NW WTP Expansion and Upgrades
Project Number: 250459-232662
50
55
60
65
70
SS
S-14
24
2
3
4
19
Material Description
Wet, loose, dark gray, fine SAND, some
clayey silt
Remarks
Test boring terminated at 50 ft-bgs
RECEIVED/NCDENR/DWR
DEC 17 2018
Water Quality Regional
Operations Section
Wilmington Regional Office
Boring Number: B-114

WELL CONSTRUCTION RECORD (GW-1)
1. Well Contractor Information:
Shawn Davis
Well Contractor Name
4246-A
NC Well Contractor Certification Number
Froehling & Robertson
RECEIVED/NCDENR/DWR
DEC 172018
Water Quetlity-Regional
Company Name
N/A Operations Section
2. Well Construction Permit #: WiImintston Regional Office
List all applicable well construction permits (i.e. UIC, County, State, Variance, etc.)
3. Well Use (check well use):
Water Supply Well:
QAgricultural
Geothermal (Heating/Cooling Supply)
° Industrial/Commercial
IIrrigation
Non -Water Supply Well:
0 MunicipaUPublic
°Residential Water Supply (single)
°Residential Water Supply (shared)
ID Monitoring IJ Recovery
Injection Well:
EAquifer Recharge
°Aquifer Storage and Recovery
QAquifer Test
Experimental Technology
0 Geothermal (Closed Loop)
°Geothermal (Heating/Cooling Return)
Groundwater Remediation
Q Salinity Barrier
Stormwater Drainage
[Subsidence Control
Tracer
riOther (explain under #21 Remarks)
4. Date Well(s) Completed: 1 1-6-2018 Well ID# W 1
5a. Well Location:
Brunswick Co. WTP N/A
Facility/Owner Name Facility ID# (if applicable)
3954 Clearwell Drive NE, Leland, NC, 28451
Physical Address, City, and Zip
Brunswick N/A
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one latilong is sufficient)
34.3033418 N-78.1084890
6. Is(are) the well(s)JPermanent or E3 Temporary
7. Is this a repair to an existing well: ElYes or ONo
If this is a repair, fill out known well construction information and explain the nature of the
repair under #21 remark; section or on the back 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 © 23.0'
For multiple wells list all depths ifdifferent (example- 3@200' and 2@100')
10. Static water level below top of casing: 18.3 (ft.)
If water level is above casing, use "+"
11. Borehole diameter: 8.0 (in.)
12. Well construction method: Auger
(ft.)
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
Print Form
For Internal Use Only:
"pa
14. WATER ZONES
FROM
TO
DESCRIPTION
0.0 ft"
18.3 ft.
Static Water Level
ft.
ft.
15. OUTER CASING (for multi -eased wells) OR LINER (if a livable)
FROM
_ TO
DIAMETER
THICIINESS
MATERIAL
ft.
ft.
in.
16. INNER CASING OR.TUBING (geothermal closed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft.
ft.
in.
ft.
ft.
in.
17. SCREEN -
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
20.0 ft
10.0 ft
2 in'
10.25
Schedule 40
PVC
ft.
ft.
in.
I& GROUT -. .
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
7.0 ft.
0.0 ft.
Saylors Type UII
Tremmied
ft.
ft.
ft.
ft.
19. SAND/GRAVEL
PACK (f applicable)_
FROM
TO
MATERIAL
EMPLACEMENT METHOD
23.0 ft'
9.0 ft.
GP #2
Tremmied
ft.
ft.
20. DRILLING
LOG (attach additional sheets if necessary) .°_
FROM
TO
DESCRIPTION (color, hardness, soil/rock type, grain size, etc.)
0.0 ft
7.0 ft
Very Loose to Medium Dense, Mown, Moist to Wel. F to Medium SAND with Trace SIN & it
7.0 ft.
10.0 ft'
Very Loose, Dark Brown to Black. Wet, Fine to Medium SAND, Some Silt a Cllaay
10.0 ft.
12.0 ft,
soft to Medium Sue, Gray,Wet. Highly Organic Silty CLAY with Little Coarse Sand
17.0 ft.
23.0 ft.
Medium Dane to Done, &own.Wite, Wet, F to Come SAND with Trace to Lade Sit a Na
Y�
12.0 ft
17.0 ft
Very Soft, Gray, Wet, CLAY
rt.
ft.
ft.
ft.
M. REMARKS C V
DEC 1 2 2018
22. Certification:
i,cr e..41 'l)U 12/5/2018
letWEytDn PrO4:C'r Un
Signature of Certified Well Contractor Date
By signing this form, 1 hereby serf& that the well(s) was (were) constructed in accordance
with I SA NCAC 02C .0100 or 15A NCAC 02C .0200 Well Construction Standards and that a
copy of this record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTRUCTIONS
24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, 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 G W-1
North Carolina Department of Environmental Oualitv - Division of Water Resources

Smith
Monitoring Well Installation 1-na
5400 Glenwood Ave #400
Raleigh, NC 27612
Client:
Project Name:
Project Location:
Project Number:
Brunswick Co., NC
NW WTP Expansion
Leland, NC
232662
Contractor:
Driller:
Ground EL:
Riser EL:
F&R
Shawn Davis
TBD
TBD
GROUND
SURFACE
RECEIVED/NCDENR/DWR
DEC 1 7 2018
Water Quality Regional
Operations Section
Wilmington Regional Office
ROADWAY BOX
SURFACE SEAL:
(Thickness & Type)
BACKFILL MATERIAL:
(Type)
TOP OF SEAL:
SEAL CONSTRUCTION:
(Thickness & Type)
TOP OF SANDPACK:
RISER CONSTRUCTION:
(Type, Diameter Material)
TOP OF SCREEN:
SANDPACK TYPE:
SCREEN MATERIAL:
Boring/Well No.: W-1
Date Installed:
Logged By: ZPM
Page: 1 of 1
rof-bbLl.
11/6/2018
Grout
Grout
7 feet
Enviroplug Bentonite
9 feet
2" Schedule 40 PVC
10 feet
DSI Well Gravel
(Type, Slot, Diameter Material)
BOTTOM OF SCREEN:
BOTTOM OF BOREHOLE:
BOREHOLE DIAMETER:
NOTE: All depths are in feet below ground surface, unless noted otherwise.
40 slot, 2" PVC
20 feet
23 feet
8 inches
Remarks:

RECEIVED/NCDENR/DWR
Bl BRUNSWCK WrP.GPJ-12/3/18
Dill! Water Qua
illperati Operatic)
SM 1 U
�U1�
ity Regional
is Section
Uffic
Bo
B 101
ri n
g Number,
Sheet 1 of 3
Client: Brunswick Co, North Carolina Project Name: NW WTP Expansion and Upgrades
Project Location:Leland, NC Project Number: 250459-232662
Drilling Contractor/Driller:F&R, Inc / Shawn Davis Surface Elevation (ft.):TBD
Drilling Method/Casing/Core Barrel Size: 3 1/4 HSA & Mud Rotary / 4 in / Total Depth (ft.): 55
Hammer Weight/Drop Height/ Spoon Size: 140 lb / 30 in /2 in O.D. Depth to Initial Water Level (ft):
Bore Hole Location: N34.3033275, W78.10849111 Depth Date Time
Drilling Date: Start:10/31/2018 End: 10/31/2018 NR NR NR
Abandonment Method: Backfill with bentonite pellets
Logged By: ZPM
Elev.
Depth
(ft)
C,
° a
' 1-
CO
N �'
m
a.c
m=
cf Z
C
a,=
m e
N J
N SiO
a m
=
c ._
m e0
c
4) _
a 2
al c
tom
re
.
Z
rn
a
ea
C7
.s
Material Description
Remarks
0
- SS
S-1
24
2
5
7
18
12
:,,, •
•
••Moist,
�•�•••
•
���•4 •
4" Topsoil
medium dense, brown, fine to
medium SAND, trace silt & clay
- -
-
SS
S-2
24
4
4
3
4
22
7
•:;:•
•:O
••
•
•
••
iI
Moist, loose, light brown, fine to medium
SAND, trace silt &clay
-
SS
S-3
24
2
3
5
20
6
�;�;�•
•
`��;•
•••
•�•�•
Wet, loose, light brown, fine to medium
SAND, trace silt & clay
-
SS
S-4
24
5
2
20
3
i%:•
••O•
Top 12": Wet, very loose, Tight brown, fine to
medium SAND, trace silt & clay
_
1
2
Bottom 12": Wet, very loose, black, slightly
Organic fine to medium SAND, some silt &
Suffer Odor
- -
_
SS
S-5
24
2
1
2
2
10
3
: e`o
.
:, cn
\ clay.
Wet, very loose, dark brown to black, slightly
Organic fine to medium SAND, some silt &
clay
Sulfer Odor
10
- -
SS
S-6
24
1
2
2
1
24
4
—"J"`
-
a
Wet, soft to medium stiff, gray, highly
Organic Silty CLAY, little fine to coarse sand
Sulfer Odor
PP=0.25 TSF
Decayed wood.
-
ST
U-1
24
P
S
H
24
/
Wet, gray, CLAY
PP=0.25 TSF
- 15
SS
S-7
24
WOH
WOH-
2
24
1
•!II/�
R
U
LL
Wet, very soft, gray, CLAY
PP=0.25 TSF
Switch to Mud
Rotary at 15
-
ft-bgs.
_
co
- -
SS
S-8
24
5
11
11
7
12
22
....
Wet, medium dense, white, fine to medium
SAND, little silt & clay
Sample Types
Consistency vs BlowcountlFoot
Burmister Classificatior
AS - Auger/Grab Sample HP -Hydro Punch
Granular (Sand):
Fine Grained (Clay):
and 35-50%
CS - California Sampler SS - Split Spoon
BQ - 1.5" Rock Core ST - Shelby Tube
NO - 2" Rock Core WS - Wash Sample
GP - Geoprobe
V. Loose: 0-4 Dense: 30-50
Loose: 4-10 V. Dense: >50
M. Dense: 10-30
V. Soft: <2 Stiff: 8-15
Soft: 2-4 V. Stiff: 15-30
M. Stiff: 4-8 Hard: >30
some 20-35%
little 10-20%
trace <10%
moisture, density, color
Reviewed by:
Date:
Boring Number: B-101

BL BRUNSWCK WVP .GPJ - 12/3/18
-
-
_
-
_
-
-
CDR,'
i
sm_th
Sheet 2 of 3
Boring Number:
B-101
Client: Brunswick Co, North Carolina Project Name: NW WTP Expansion and Upgrades
Project Location:Leland, NC Project Number: 250459-232662
Ev.
a wanc•r
4$1-
w;
NfCO
m e
Jm
-
o
m�
cZ
R oj
re
-.I
a
472
.'9
Material Description
Remarks
Depth
20
> ...
0
Wet, dense, brown and white, coarse SAND,
trace clayey silt
R�Gfl��p/NCDENR�i
Wet, dense, gray, coarse SAND, trace wafer
clayey silt Operati
Wilrnin
Wet, medium dense, gray, coarse SAND,
trace clayey silt.
Wet, very loose, gray, fine to coarse SAND,
some clayey silt
DEC r 7 2018
Quality Re gional
°ns Section
gto,1 Regional Offn
- SS
S 9
24
16
is
23
32
17
42
25
SS
S-10
24
12
is
21
20
18
36
30
-
-
SS
S-11
24
6
e
7
7
12
15
35
(;.'
%:.'
:�,;
'
-
SS
S-12
24
2
2
2
1
6
4
40
_
tip.
•
•
o
.Z`
Wet, very loose, dark gray, fine SAND,
some clayey silt
PP=<0.25 TSF
-
SS
S-13
24
1
WOH
WOH
24
•.:.
1 ::
Boring Number: B-101

BL BRUNSWICK WTP .GPJ - 12/3/18
-
-
CD1111
Smith
Sheet 3 of 3
Boring Number:
B-101
Client:
Project
Brunswick
Location:Leland,
Co, North Carolina Project Name: NW WTP Expansion and Upgrades
NC Project Number: 250459-232662
Elev.
m �
°±
16 g
fin
now
Sample
Sample
Number
cu
at
m e
u) J
, in.,,
s
o c
m(0
CV
a2
m o
0 o
Ce
c
41
Z
Silty Sand Strata
0
m ..
N o
m
m c
CL '<3
w 3
R.m co
v CD v
=•,+ m
m x i
co
D al 'a
z o
0
Co C 0
3 m
m °'
a
Remarks
Depth
(ft)
-
50
-
1.
...
.
�`'
PP=0.75 TSF
Cemented Layer
from 51 to 52
ft-bgs
- SS
S-14
24
7
6
10
24
13
`:'':
-
- SS
S-15
24
4
4
11
24
g
;
'
55
-
-
65
Test boring terminated at 55 ft-bgs
DEC 1 7 2018
Water Quality Regional
Operations Section
Wilmington Regional Office
70
Boring Number: B-101

WELL CONSTRUCTION RECORD
can be mat ire single rrathipArreelli • ; iNcDENR/DWR
L. Well Contractor In&riatmiaer
d v(1,WIt
ConoactorName
-
NC Weil f,.*:noaciar Ccnilkainolienober Water QutyfegiO
A e (A/ ell Co ,•,111I'rlifrtOn ‘13'
QperatiOn.:. .
rt) Lk) AJ Co
2. Well nstructtatt Permit I 0
t 20.4 —06 /5 2
List aff oppliablde wel I permits- lit' &Com*. 41.-eaismt. dal
3. Well Use (cited:1mM use):
Wales -Supply Weil:
akgriculteral
OCrenthamal (leating.-C_ooline Supply)
CllochistrialiCconmrecial
Non -Water Supply Well:
Ohlonitatinr,
Trajection Well:
IDAquifor Recharge:
CAI:Nitre Storage and Rerovcr5-
13.Aquitet Test
ClEwrciountal Tcchuoiney
GIGenthamal (Cos.cd Loop)
OC.icolbconot (FicatingCoolim_. Rdnro)
ElkfusicipalPabfec
Cjdj1JWmcc•Sispoy
EIResidcatial Wr Supply obaccd)
ORcxorars•
EiGroimdscater limurdiation
ELSalinity Dania:
CIStocznoatrrDtaina_.-,r
ElSubskkac.= Control
°Tracer
ClOha- (ccyJain under '421 RcuLa)
, -I- Dare Welk.) Complete&
5.;--tiren Louition:
Facilikyitaancr Itame
Faciliky IIX-f tti-+ 121ri .
ic li
' K3r1.),A.)S. •'{.--' ( C .1(
Phy%iral Adcfrci.,-; City. anl Zip
County
Paseel hImaii:iewion Na IPZZ)
salinies0
Sh. Latitude andim Lvoiltttio
cxne belamrs
11....reeshninutesh„cowis eleatax:RI itMrec=
CLL5-- I,
6- is (are) thw. Intik* pKrIxollaalt Crretaparairy
7- Is this a repair to rib eSiS wen: Cries or . Ifni& ir a tepaiwillaot known ref( consainamo iriarmarion nod captain of the
the =nom"
repair tooter n2. I rommer realm, or 011,rke back ofabirjbon_
8- Number of -wens constructed:
submit one,tarro.
For multiple irstemian or non-trater soap& mils Or onlh the some onastructiMr. you ono
—
9- Total well depth below land surface:
For roultiple writs hit all depths 4r-d*rent iesampie- 200 ond2ia-
10. Static %eater level below top of ca..61w (IL)
If rater level ts ahem: °ming use
//
11. Borehole dim:atter: (iEL)
12_ Weil constetwaan method:
i e. ater, rotors-. rabic. eteect rash_
/11 u (14. 67-11
FOR WATER SUPPLY WELLS ONLY:
13a. Yield tun).___ 71 7t- Method of tea:
Lib. Disinfection type: '01 (17 Arafaseaz
Form OW•4
Far Internal Use ONLY:
21.
REkr.A.Itt;s_
SThaturc CcEntica %Al CaTnir-..ctor
Ey signing 114forto. I lzirt10- t10Z the trzn(s) tras ker.?) mmo•ezte4 azzaniar.:::
we*121 NC4CIPC_WOO or IS NC -IC 02C _0200 Comarstaion Star.rds cod rim a
.mpy es( this reattrd itas-lven pructried fo errtd1o,.
23_ Site diagram or zuhlitiollal well details:
Yon may use thr back of this pagr to providr additional wc11 site &tads or well
consbuctioa &tails. You may also attach additional pat..= if neer:nary.
SLIDMITTA3LINSTITElflONS
Ita. For Ali 1.1. Submit this form within 30 days of 4-capIction or „co
constracii,in thr followitur
DiviSion of Water Detainee% Infortiore Processing Unit,
1617 'Alan Service Center, Daleh27699-16I7
2.4b. r o-NLY, additi. scoding the Cerro to the addn:s; in
ratunuction to the following:
24a above, aka submit a c.opy of this eaccn within 30 days of completion of well
Division °Mater Resources, Underground illjection enten-al Pent -am,
onal ccithin 30 days of completion of
coasnucteal
Well Gansu-m.1M1 to utter comity health tkparoncot of thr county Ix-herr
North Cnotiru Department of Gueraoment and Namal Rei.ourecs -lhelsion Vt'aur Resoure
/ 6, 0
1636 7ilaa Service Center, I:talk-We, NC 276934636
Water So & In-ecticut %By
Also submit onc cap:
Reeked Amon 2_913

WELL CONSTRUCTION RECORD 11� n/i�ii;ia NR/ W°1
This form wed for s lerrcult
LWen Co is .j
I
Welt C«u,aaorName
NCWall - arrarCotihrationNumber
Iii
e (A/o
Comport), Nome
2. Well C,/ouust uct ou Permit _ �(� . C c)t ,C ` its
LEI 1OI baI W Will permits (L2. Cause Ste+& ram, f aYLI
a- Weds The (check well use
1.02018
Water tiIuality Regional
Operatioi,> ^coon {
Wilnl;nf'lon i"
t%1`,�
Non -Fate,- Supple Will:
011ftnitaing
Injection Weil:
°Aquifer Retharge
OAgnifer Storage and Retoycry
°Aquifer Test
°Etperimt l IrochnolcL.y
OGscothe may (CloscdLoop)
°t cothenmal (Heating Cool Return)
4 `Date Wdl(() Completed: /N, O
ell Location: /`
racilityalovcr,ame
�(J 04.
� ,ot 1 , Facility ii'\)r�tttiatpti9h1c) e
vci
PhysicalAakers, City. and Zip
County
Parcel Idattifi=oatiZia�F_ -�
Sb. Latitude and
of well ii J j aA lar:lats aeciirrin srus ar del
C g
1'''d' n.
6. Is (arc) the Zae(s): eracrntxit or °Temporary
IL Number toted:
For multiple itgq-ti ar nen-rrotermpplytrclllO +with due sal:nit awe _Arun, seiner cormauctiaa. room
7. Is this ti repair to an e
/j ahis rrA n t - Salt well:Ores or IkNo
repair
tauterI4=2a I wont &trnru well oohs r$Tiay 'iturtrau and crP(oFr, the nature of the
arks se.uibo or on Lk a j"eas janL
I
9. Total will depth 6elotr land sm-fuc
Far Aadripk wells list all dcpthsSidO.r.mjtrm:'+ie-.iS_tYl'ard=.-sltllTy (�)
f
I0 Stade water level helms topof
1Jwa�let.I h� u.
atom .a.�ra..._ :
11. Borehole diameter: j, I l (•.- r
12-1Vd1 entastructim.method:
it e. auger. rotary-, eal>k. dam rank etc)
FOR Yt_;TER SL-PPL! WELLS ONLY:
Zia. Yield ftnnr)
�r
Method erftesC C!
Lib. Disinfection type: 8 tc: t4 c
-\mmtnt:
Form OW-1
(ft)
°t3roanilwater Rmlcdiation
°Salinity Hamer
OStormwyicr Drainage
❑Subsidence Content
°Tracer
❑Ott r (cpplaiu under j Remark)
For Interco] Me ONLY
1=1VaTER
22 C
Suuttac of Certified Well Contractor
t?t- sigcieg thir-far-, t Icr.1?r ::rtyr that the w, ll(sl was (were) any
'rah I.a.; vC4C o- .O100 or l.i-t \'G-7C 02C -0200 tl �yl C'orvrr S.r .
`apye thir+Wardhauteur ard� :
provided m the wcllowurr. '�r3r cud that a
23_ Stec dira~crun or additional well details:
You may use the back of this page to penile additional well site details or well
constructionaadrYetyaii-ls. You may also attach athlitir�.il pn ifuccemary.
SL`-W211 �`1IONS
cc strvwsr GI the follouine-
2Ja.For All SF $
ubmit this form within 30 days ofp on of \tell
r . . Division of Water Ins"ottroat n Prot 1617 Mali Service Center, Unit,
�I�`h, NC 276994617
24h. For In" .. Welis ONLY: lu addition to
2-La also suhmit a copy of this form -within srndina form to thcaddnss in
construction to the follotiino-. 30 dues
ad eomPiat of trey!
I1it'isioa nt Water- Resepr
I636 Mali ' Ifud kiklg d N Injection Control
,curate Center, Raleigh, NC 27699-1�s6 O� un
24e For stater Su At7ht.S Iaieetion Welts
Also submit one copy of this form cti her 30 .
well c nstruditm to the county health taf the
completion oe
constuuthal d nrim�t of the .:oaot}• where
North Cvatitu l.Lgunr®i ofFann
ocancrit and Nanya! Roxav —Drcimior u Ll'atrr Rest
Revised Atp-t ±ttt

VVF_LL CONSTRUCTION RECORD
This icon Car. It used far.irsle or ameltiPleinen;
IL- VC Comata-Aston-
Wet I Co onaisorlttame
SYA
NC Well acts Orrtirleatie
We
etareft•TEly Mane
- prutinito.e.2,
Pppk:inal
"'row ij
2- W-ell Coostrottom
Listatonsfroahleneff Comte
3_ Wen Ike (check wen usrk
1Yet, ,k,i',:ECEIVED/11111ft,TP11.
DEC 1. 0 2013
Water Supply NVel
1211.-Nicuitural
OGitothanial (ficatiug:Conliim Supply)
Cirodustrin'Arronmerced"
Wen:
Ohlotaito
In jectunt nen:
°Aquifer ROCIt3I.,C
°Aquifer Storage and Ncear
OAquif'cr Test .=
CiExpecinialtal Teehnolmy laStrlisidmice Control
°Geothermal (Closed Loop) Orraecr
EIGeothermal Rettm) ClOthm- (e±aplaan under 21 Realm -hi
-L Date Welk's) Contookik //-e-acclifEW
in e0Ormikr-i-
Facititpillimer Name
/ 2 7 / At/ 3.
S 7-
Physica/ Coy. acid Zip
. /
0 OS)AJ L1c•
counts -
Parcel hi -is Nra.
Sh. I ntitstr&- and Lijj ilmnbsinTinutimis.maS CS' decizeral <Imre=
Elh.taakipulsPnblic
•
012.ui,i. I Irma -Supply (-.L.44
012..sidmial Wata• tamicd1
ORecovery
titer Quality !-R.
•ifwfltibL lataam is suffiecial
33 5.5— 2k./6 441 1.1 7ef g
EIGroundramer Roan:di:aims
°Salinity Barrier
OSoamaialerbrainate
6. Is (are) are well(s):Atennancot tar OTetnrinamry
7. Ls this a repuir to ao emir' beg wen: °Yes or ,Attr
/Irks an repsk fill onriumer camsrma lafoxnmatiact 4a2d crpkria tha arzarm: of ax
repair under =21 rcammtxxmxiM am dm bo.3-efthisforet
Nnatber rifseens commuted: /
For man)* Weaker ar nav-wzater /apply weilt (Mai 'ksrii dr same mmeamaxima. seberul ocejana.
9_ lista Iron 41eptla below baud .331-fam
Far atEdripiC MeRr /kr all ricpdas k' 4W-ram. (example- 3:SZIAY [801
111. Static sorter level helms top of =man;
if ...a, iere
it_ aoramar thainetert -.7"010 d /
12- Wen commas:do' o nattirork (1/4}
c =vet. retasy =We_ dacct mat. cte.
FOR WATER SUPPLY WF:f s ONLY,
L. Yield (moc) , Metimd oftes
Ithinfectiota [aim (3 4°4 c: k
k,ein OW-1
Forhaanal Vser ONLY:
• 26.1feclat CASECG TIO3iNG
FROU
1-11: Olt
Simiture a -Certified Contrachir
455759
—7:V// —111
Dare
kr Aftfrarg. I thra 74740 k-ox ker4 azzomir.,
CC or 4CJai GO or 1.14 Ar.IC WC -WOO WUC
ovir q'thisrcerndhaslecripranrkdro rar wen meter.
atc cli:*tatri or adcroMmd1I detil=
You may usc the hack Of this page to pecnide additional urn site dctal: or well
construction &talk. Yon may also attach adtruional pcw„c_ s if atcoe=my,
S1_41mITTAL1NSTUCTIONS
) ItsL For AR Wen= Submit Ibis' firm minim 30 da3:s of ,umphijon of wen
c,,nstructit to the folloozinE:
01)
Division of Water Rtstanots,,Itafentnatian Proemt,* ftoit,
1617 Man Service Conter„ limle-L4h. NC 2709-4617
24h, For Injection Wens ONLY: In addition to sendin2 the form to tbr addym,,
alimr., also submit a col:13- of this farm oathin 30 da3sofcosoractioit of nen
construction to the following:
nichioo ofWater Rest:earns, Umletgromad Injection Control
1616 Mr* &race ecuter, Rairth,NC 176994,06
24c. - ijWz- zel/
s
Also sit am cops of this lama tsidaii. 30 4a3s of completion of
cod1 consonidimt to the cocoa): health dincilt of ihe .sittaly where
North CatoSna Monument oiEmiianacig 4ael'unstnal R,=virots—Dircisio." orWatcrReorsoes
Rer-O,r1 Ammo 2._•13,

WELL CONSTRUCTION RECORD ( mED/NCDENR/Dv1Rr Internal I)se.Only:
1. Well Contractor Information:
n
455730-
Print Form
Donald Cummings
Well Contractor Name
2412-A
DEC 03 201
Water Quality Regic
NC Well Contractor Certification Number Operations Sectio
Applied Resource Managerr 'tl-.1gional
Company Name
2. Well Construction Permit #:
List all applicable well construction permits (i.e. UIC, County, State, Variance, etc.)
3. Well Use (check well use):
N/A
Water Supply Well:
Agricultural
Geothermal (Heating/Cooling Supply)
Industrial/Commercial
x Irrigation
Non -Water Supply Well:
Monitoring
Injection Well:
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
Experimental Technology
Geothennal (Closed Loop)
Geothennal (Heating/Cooling Return)
4. Date Well(s) Completed: 10/30/1
5a. Well Location:
Riptide Builders
DMunicipal/Public
Residential Water Supply (single)
Residential Water Supply (shared)
Recovery
Groundwater Remediation
Salinity Barrier
DStormwater Drainage
DSubsidence Control
DTracer
Other (explain under #21 Remarks)
8
Well ID# N/A
N/A
Facility/Owner Name Facility ID# (if applicable)
109 Forest Walk SW, Sunset Beach, NC 28468
Physical Address, City, and Zip
Brunswick 242HA005
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one Iat/long is sufficient)
33 54 32.74 N
78 31 09.09
W
6. Is(are) the well(s)JJPermanent or OTemporary
7. Is this a repair to an existing well: DYes or QNo
If this is a repair, fill out known well construction information and explain the nature of the
repair under F21 remarks section or 'mike back of this form.
S. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction, only I GW-I is needed. Indicate TOTAL NUMBER of wells
drilled:l.
9. Total well depth below land surface: 65
For nruMHple wells list all depths if different- (example- 3 200'anel2{m100')
10. Static water level below top of casing: 12
If water level is above casing, use " "
11. Borehole diameter: 8 (in.)
12. Well construction method: Mud Rotary
(i.e. auger, rotary, cable, direct push, etc.)
(ft.)
(ft.)
FOR WATER SUPPLY WELLS ONLY:
lift
13a. Yield (gpm) 6d Method of test: Air
13b. Disinfection type: HTH Amount: 3%@10 g
14: WATER ZONES
FROM
TO
DESCRIPTION
ft.
ft.
u al ft.
nsf155..
R.
OUTER CASING (for multi -cased wells) OR LINER (if a licable)
3' f166
M
TO
DIAMETER
THICKNESS
. MATERIAL
0 ft.
35 ft.
4 in.
SCH40
PVC
16. INNER
CASING OR TUBING
(geothermal closed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL :
ft.
ft.
in.
ft.
ft.
in.
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
45 ft
65 It
4 in•
.010
SCH40
PVC
ft.
ft.
in.
18. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
0 ft.
40 ft
Bentonite
Poured
ft.
ft.
ft,
ft.
19. SAND/GRAVEL PACK
(if applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
40 ft
65 ft
Coarse
Poured
ft.
ft.
20, DRILLING
LOG (attach additional sheets if necessary) -i
FROM
TO
DESCRIPTION (color, hardness, soiVrock type, grain size, etc.)
0 ft.
20 ft.
Sand
20 ft.
28 ft•
Clay
28 ft.
58 ft,
Sand
58 ft
68 It
Limestone/shell
68 ft
80 ft.
Clay/Rock alternating
80 ft. -
120 ft•
Clay
120 ft.
180 ft•
Alternating rock/clay
21. REMARKS
N-07-29Z018
22. Cer • cation:
Si 'n ure of Certified Well Contractor
10/31 /2 018
Date
By signing this form, 1 hereby certify 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 additienalwelLdetails:
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 font within 30 days of completion of well
construction ter the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Iniection Wells: In addition to sending the form to the address in 24a
above, also submit one copy of this fonn within 30 days of completion of well
construction to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Sunnly & Iniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
completion of well construction to the county health department of the county
where constructed.
Fonn GW-1
North Carolina Department of Environmental Quality - Division of Water Resources Revised 2.22.2016

%-1.JIMN-CRUCTION RR kla
This &Km can tc uscrl tor sictic- or madripicili
1- Vi:sn Cnotrateter
With Commune Nam.
yo
NC MAI Cannactar Colizkasion
LC/
2. Weil CatistruotintarmitReirattgp Section
Cum:piny Nazar .
/
tERIEVICDENR/D
NOV 0 6 2018
all applicable wall perraits fie. Coady. S,e... kiraiae, et.: I
3. Well the (cheek weal ttse
Note -Water Supply Wen:
°Monitoring
Leajectince Wein
°Aquila Reeact,.
°Aquiferor Stat, and Recovery
°Aquifer Test
IDE.voricnental Technolcmy
°Geothermal (Closed Loop)
°Geothermal alcatinA,Coonne Rtiltal)
• 4. Date WARS.) Contpletrd: Ing
idill_scrtfinte:
Farilitylthrrecc
2,z).AJ
Phy3- ALM-City City, alkiZtP •
ru
.s
Faziiity itiappltb, lc)
Parccl L.6tritikto, 1:POZ)
cac Qm0
ill. Laza ndc and Lcreinule et.oteso,„,TimicsIseconcie e.r eltrart21
9furcIll tih1 one laulis sur
- -sC C 1,
fe.. Is (arc) the well(s).;*ertnanzat or OTeropoeary
7.. Ls this repair to an existim Qie ur
s 1.1K0
;Pk& is- a repair.fill oat baton c000rnaton ir4a. name:az and explain tha naorra of Mr
repir azanier =21 noss.,,k reaiao or th oa e hoc* of *Of -arm-
& Number oTwells constructed:
Formadmele injOxiort or natt-snotar supply srellsOATT moth
submit one fetrra.
9. Total well depth helow Laud surface:
For ratdtiplc stalls list oll drprIer #ritipc-es. (Gearvic- 3g.2019.ele42-a-ki&J
Itt. Static scatter level lielaw to of easit:
If water keel is ether.? ustsarg. sue 4,-
1 I. Borehole eliameter:
12. 'Wen comahructim iednul:
c. anacc cutsa%. card arena rash etc)
Form GW.4
straw caostrocriata..lott..zin
74e) /0
'VeNt
Ot)
2 C
Sipnbarc of Czniticd Well Canb-actur
1 •1,-,11%, .7.-.71#5- &az rize ireNil was (were) .nstrazreii is .zzerelae..-;.•
aapr ai Mir moan:acre &en Nal-sled re the troll osrmr_
trait I 14 KC -IC Or _Of 00 or 15.4 xe-rc 02C -0200 Ira! Ccannnzsicc Sca-..al:',nir caul ri= a
23- &te diagram +or additinual well detils:
You may use the back of this pa-ge te3 pnenide additional well site details or wAl
construction deta&. You may also attach additional pal.....es if steceewary.
SUBMITTAL INSTUCTIONS
construetion to the followine:
24a. F 411 Welk Submit this form within 30 ela3 of ,x,raphdion ef
I3v
-1-617 Acih
fatter-ce a- rIt1994 6-17
2-11i. For Wefts ONLY he addition to sendino the Tam to the addoos; in
construction o
to the thilowino:
24a abov, also submc
it a op3- of tho tome vthio 30 days of completion of well
Division ofiNater Resources, lindergrnond Infeetinn Control Ft-trato,
106 BrIaB Scrcic" e Center lihdotic NC:17699-1+26
24c Water & hi-et:awl Wolk
Also submit onc Copy f eithin 30 da3s of completion of
wen contemn -lion to the ocenty health department of the
ecerisometrat
..azazary %vier:re
North C.nolina pcpannacne nirarenaniacnt and Nsintal Iteatracs --Thrisinn iltvcr Itesaunats
R3
evised -Atcl.nt -2n1
‘c,

WELL CONSTRUCTION RECORD (GW-1)
Print Form
For Internal Use Only:
1. Well Contractor Information: ,cCEIVEDINCUEQIUV‘
Well Contractor Name JUL t 3 2018
2082-A Vater Quality Rcgicr
NC Well Contractor Certification Number `")pration c.,r. o,_.
Applied Resource Management, P.C.
Sanford Sweeting
Company Name
2. Well Construction Permit #:
List all applicable well construction permits (i.e. 111C, County, State, Variance, etc.)
3. Well Use (check well use):
WI0800504
Water Supply Well:
_f Agricultural
Geothermal (Heating/Cooling Supply)
Industrial/Commercial
Irrigation
Non -Water Supply Well:
Monitoring
LJMunicipal/Public
Residential Water Supply (single)
LJResidential Water Supply (shared)
DRecovery
Injection Well:
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
Experimental Technology
Geothermal (Closed Loop)
Geothermal (Heating/Cooling Retum)
4. Date Well(s) Completed: 6/22/18
Groundwater Remediation
Salinity Barrier
0Stormwater Drainage
DSubsidence Control
Tracer
Other (explain under #21 Remarks)
Well ID# N/A
5a. Well Location:
Cape Fear Jet Port N/A
Facility/Owner Name Facility IDII (if applicable)
4019 Long Beach Road, Oak Island, NC 28465
Physical Address, City, and Zip
Brunswick 23600010
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
See Attached N See Attached
6. Is(arc) the well(s)0Permanent or DTemporary
7. Is this a repair to an existing well: JYes or XON°
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 salve
construction, only 1 GW-1 is needed. Indicate TOTAL NUMBER of swells
drilled:16
9. Total well depth below land surface: 300
For multiple wells list all depths iderent (example- .1.00' and 2rai100')
(ft.)
10. Static water level below top of casing: N/A (ft.)
Ifwater level is above casing, use "-"
11. Borehole diameter: 6 (in.)
12. Well construction method: Mud Rotary
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) N/A Method of test: `NIA
13b. Disinfection type: N/A Amount: N/A
14.WATERZONES -L I J V LUItS
FROM
TO
DESCRIPTION
ft.
ft.
Watcr Quality RegioRaa
ft.
rt.
Operations Section
15. OUTER
CASING (for
multi -cased wells) OIiIM1t1WNER. 11811:08raI (Alice _
FROM
TO
DIAMETER
THICKNESS
MATERIAL
0 ft•
+/- 300ft.
1 in.
HDPE
16. INNER
CASING OR TUBING
(geothermal closed -loop)
FROM
•r0
DIAMETER
THICKNESS
MATERIAL
ft.
ft.
in.
ft.
ft.
in.
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
TIIICKNESS
MATERIAL
fr.
ft.
in.
ft,
ft.
in.
18. GROUT
FROM
TO
MATERIAL
EMPLACEMENT MITI OD & AMOUNT
0 it•
300 ft*
Thermex
_
Pumped
ft.
iL
R.
ft.
19. SAND/GRAVEL PACK
(if applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
ft.
ft.
ft.
ft.
20. DRILLING
LOG (attach additional sheets if necessary)
FROM
TO
DESCRIPTION (color, hadness, soil/rock type, grain size, etc.)
0 ft•
35 ft.
Sand with shells
35 ft'
70 ft•
Silty sand some shells
70 ft.
90 rt.
Limestone with some silt
90 ft•
110 ft•
Limestone/sandstone mix
110 ft•
150 ft•
Limestone/sandstone mix with silty sand
150 ft•
160 ft•
Silty fine sand
160 ft-
300 ' fL
Silty fine sand some clay with limestone layers
21. REMARKS
22.Cer•,tca' n:
7/6/18
Sign m - . - _ ontractor Date
Ilv signing this faun, 1 hereby certin. that the wells) was (rrere) constructed in accordance
with 15A NCAC 02C .0100 or 15.4 NCAC 02C .0200 Well Construction Standards and that a
copy of this record has been provided to the well owner.
23. Site diagram or adtlitionatwelt details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTRUCTIONS
24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b, For Infection Wells: In addition to sending the form to the address in 24a
above, also submit one copy of this fonn within 30 days of completion of well
construction to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supply & Iniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
completion of well construction to the county health department of the county
where constructed.
Fonn GW-1
North Carolina Department of Environmental Quality - Division of Water Resources Revised 2-22-2016

IARM Project Number:
4019 Long Beach Road Cape Fear Jet Port
Oak Island, NC 28465
Driller: John Salmon
Date Drilled: Loop No. Loop Depth
5/14/2018 1 GPS Coordinates
300 33 55 51.07 78 04 37.10
5/17/2018 2
5/1 /2018 3 300300 33 55 50.86 78 04 37.37
5/22/201814 33 55. 50.67 78 04 37.64
5/22/2018 300 33 55 50.47 78 04 37.80
5 300 33 55 50.36 78 04 37.89
5/23/2018 6 300 33 55 50.27 78 04 38.17
6/6/2018 7 300 33 55 50.17 78 04 38.35
6/12/2018 8 300 35 55 50.06 78 04 38.79
6/13/2018 9 300 33 55 51.20 78 04 37.33
6/13/2018 10
6/13/2018 1300 33 55 51.00 78 04 37.64
6/14/2018 121 300 33 55 50.81 78 04 37.87
6/14/2018 12 300 33 55 50.60 78 04 38.19
6/1300 33 55 50.40 78 04 38.47
6/17/2018 /2018 114 300 33 55 50.19 78 04 38.63
300 33 55 50.00 78 04 39.08
6/18/2018 16 300 33 55 49.78 78 04 39.31
Pagel
RECEIVED/NCDENR/DWR
OCT 30 ?08
Water Quality Regional
Operations Section
Win -lino -tors Pncinnal Office

DATE DRILLED
TIME COMPLETED
RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2942
45�643
1. WELL CONTRACTOR:
Leonard Dorn, Jr.
RECEIVED/NCDENR/C
Well Contractor (Individual) Name
Well Done Well Drilling
Well Contractor Company Name
STREET ADDRESS P.O. Box 39 Water Quality Region
Operations Section
Shallotte, NC 28450/umirNion Regional 0
OCT 0 8 2018
Citv or Town State Zip Code
[phone]
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID Of appticabte)
09(9 0 2 jYo3
STATE WELL PERMMIIT#{!appIi a'bl�e)�, ,
OWQ or OTHER PERM T #(ifapplicab�ri) `e) s e, (5$ 5-
WELL USE (Check Applicable Box): R idential Water Supply er '
l zJ)t
AM PMQ-
3. WELL LOCATION:
CITY: 11.4 -tr /f'% COUNTY BrUnSWICk
2-36 7 r ('. Atv, 4,eQ / /J- 9r
(SUeet Name. Numbers. Community. SuoaHsron, Lot No.. Parcel, Zip Coae)
TOPOGRAPHIC / LAND SETTING:
Slope OValtey OFlat edge OOther
(check approPnale box)
LATITUDE 3
LONGITUDE j ,'('
Latitude/longitude source: Grer< °Topographic map
(location of well must be shown on a USGS topo map and
attached to this form not using GPS)
May be in degrees,
minutes, seconds or
in a decimal format
4. WE
LL
OWNER
OWNER'S NAME /c
STREET ADDRESS
c 2- 'g
City or Town State Zip Code
7T ( 15ZCY
code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES O NO
c. WATER LEVEL BelowTop of Casing: / , I FT
(Use'+' if Abova Top of Casing)
d. TOP OF CASING IS G FT. Above Land Surface'
'Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): / METHOD OF TEST A' ,,0-,
3
A
ie
f. DISINFECTION: Type
7),
g. WATER ZONES (depth):
From
From
From
6. CASING:
To
To
To
Depth
From 0 To qce Ft.
From To Ft.
From To Ft.
From
From
From
Amount
Diameter
0
To
To
To
Thickness/
Weight Mal iat
J 9) P --
7. GROUT: Depth Material
From To 24' Ft. ej,',( /Pr
From To FL
From To Ft.
Method
�'7 a
8. SCREEN: Depth D t r�"(' IopS¢e Maten4�
From G�� Tc Ft. i'/) in. , id'1-2lq. V -
From To FI. l/
From To F!
9. SANDIGRAVEL PACK:
Depth
Frorn To Ft.
From To F:.
Frorn To Ft.
10. DRILLING LOG
From To
v
t
11. REMARKS:
in. 4, 1149
in.
Forrnattcn Descnptlon
e YT
-c N6)
/45
SIGMArTURE OF CERTIFIED CELL CONTRACTOR DATE
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
10O HEREBY CERTIFY THAT TNLS WELL WAS CONSTRUCTED N ACCORDANCE Wm1
15A NCAC 2C, WELL CONSTRUCTION STANDARDS. AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIOEQTO THE' WELL OWNER_
V •LJ
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-ta
Rev. 7/05

RESIDENTIAL WELL CONSTRUCTION RECORD
Nonh Carolina Depanm(entttofcf�(E//n��v((iirr�onrpee�nntpt��and Natural Resources- Division of Water Quality
WELL CONTRA '1" F1jtCERY IhC'�(�FY t! 2942
1. WELL. CONTRACTOR:
Leonard Dorn, Jr.
Well Contractor (Individual) Name
OCT 082018
Well Done Well Drilling Water Quality Regiot
Operoti na Sectiol
A/ilmingoa Rezional C
STREET ADDRESS P.O. Box 39
Well Contractor Company Name
Shallotte, NC 28459
City or Town State Zip Code
[phone]
Area code- Phone number
2. WELL INFORMATION:)
SfTE WELL ID #Cif applicable) 2-- W 0 .7 5 _'t
STATE WELL PyER'MIMIIT#(it oplicable
DWQ or OTHEPt PERT#(l a (cable) ? 3Z 'TO 0/ /
WELL USE (Check Applicable Box): esidential Water Supply 0
DATE DRILLED 7/"16 / 7
TIME COMPLETED /
AM ❑ PM (�®
3. WELL LOCATION: /� 1
CITY: c tv-e691% COUNTYBrUnSWick
7-1 Oq k N6 s A dig s an -
(Street Name. Numbers, Community, 5u000nsion, Lot No.. Parcel, Zip Coae)
TOPOGRAPHIC / LAND SETTING:
❑Slope °Valley ❑Flat (;).Rfdge °Other
(check appropriatebox)) (
LATITUDE 3 3i -f Z Y 0/0
LONGITUDE ��n ��
Latitude/longitude source: PS ❑Topographic map
(bcation of wed must be shown on a USGS !coo map and
attached to this form l not using GPS)
4. WELL OWNER f
OWNER'S NAME Vi r/ gJf t / " t'l r
STREET ADDRESS / 9I / e rd-froliv1
02-t�� /) j/ C. 2 75
City or Torn State Zip Code
May be in degrees,
minutes, seconds or
in a decimal format
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH:
1®
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO [ ,
c. WATER LEVEL Below Top of Casing: / 0 FT.
(Use'+' if Abova Top of Casing)
d. TOP OF CASING IS l FT. Above Land Surface'
'Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): / �� METHOD OF TEST ic
lice
6. CASING:
f. DISINFECTION: Type I7 %—j AtOilunt
g. WATER ZONES (depth):
From
2I From
From
To
To
To
From
From
From
To
To
To
Thickness/
Depth Diam 1 r i�ht Mat tab
From 0 To CiO Ft. �C �" 6+ het! '1;( L
From To Ft.
From To Ft. <-hjn
7. GROUT: Depth
From 0 To c `t/
From To
ateriat Method
FL 64 (,4,4 ' L. /" c96','
FL
From To Fl.
8. SCREEN: Depth Diameter Slot Size Matenal
From To Ft. in. in.
From To Ft. in. in.
From To Ft in. in.
9. SANDIGRAVEL PACK:
Depth
From To
From To Ft
From To Ft.
10. DRILLING LOG
From To
11. REMARKS:
S:ze
Ft.
Material
Formation Descrptlon
$ /k )
L1,2
-)-10 N.40 .50- 0 r4
/AJG 2 d 20;,
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WITH
15A NCAC 2C. WELL CONSTRUCTION STANDARDS. AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO jk¢ WELL O R.
>�j� 4.
SIGNAT E O CERTIFIED W
PRINTED NAME OF PE
_L CONTRACTOR DATE
of -PP
SON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt,
1617 Mail Service Center — Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-la
Rev. 7/05

WELL ABANDONMENT RECORD)
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2942
I. WELL CONTRACTOR:
Leonard Dom, Jr.
Well Contractor (Individual) Name
Well Done Well Drilling, inc.
Well Contractor Company Name
STREET ADDRESS PO Sox 39
Shatlotte, NC
City or Town State
(910 ) _ 754-9311
Area code - Phone number
2. WELL INFORMATION:
SITE WELL ID W (if applicable)
STATE WELL PERMIT # (if applicable)
COUNTY WELL PERMIT # (if applicable)
DWQ or OTHER PERMIT # (if applicable)
Zip Code
ULI082018
'Hater Quality Regional
(lperatic,r)S s'ectiorl
Wilmington Regional Offic
WELL USE (Check applicable use): ❑ Monitoring OResIdentiai
❑ MunicipaUPnbUe 0 Industrial/Conunetrial ❑ Agrtculturttl
0 Recovery ❑ luJe tfon ❑ It•rigation
❑ Other (list use)
3. WELL LOCATION:
COUNTY Brunswick QUADRANGLE NAME
NEAREST TOWN: �1�'>e 6(Ia.t )t
%z G5 44),
(Strut/Road Nenx, Number, Comrnntity, Subdivision, Lot No., Patna], Zip Code)
TOPOGRAPHIC / LAND SETTING;
❑ Slope ❑Valley it ❑ Ridge ❑ Other
(Check appropriate setting)
LATfTUDE ZbY
LONGITUDE 7 -6 4 r 3 5
May be in degrees,
minutes, seconds, or 19 a
dccltnal fomret
Latitude/longitude source: 53GPS !Topographic asap
(Location of well must be shown on a USGS topo mop and
attached to th±r form if not using GPS.)
4a. FACILITY- The name of the business where the wells located. Complete 44 and4b.
Ufa residential well, skip 4s; complete 4b, well owner information only.)
FACILITY ID M(if applicable)
NAME OF FACILITY
STREET ADDRESS
City or Town State
4b. CONTACT PERSON/WEL OWNER;
NAME Jam/
Zip Code
STREET' ADDRESS 7 '2-6 S %
C
6.
WELL DETAILS:
a. Total Depth: 70 R Diameter. t'
/ 7
b. Water Level (Delon' Measuring Point): 1<.
Measuring point is / R above land surface.
CASING: Length
a. Casing Depth (if known):
b. Casing Removed:
_Rn.
DISINFECTION: y
(Amount of 65%-75% calcium hypochlorite used)
SEALING MATERIAL:
Neat (intent C/7j'
clt
Cement Ib. Cement
Water gaL s (-/pWater
Ei •
Bentonite y Ib.
Type: ❑Slurry filets`°
Water 7y gal.
(kher
Type material
Amount
in
Diameter
in.
1_.�v irr.
Sand Cr/slant.
lb.
gal.
AUG 28MCC)
EXPLAIN METHOD OF EMPLACEMENT OF MATERIAL.:
_` f >al
W e11 u lk( i vt S � ► C T t . r: th (_2'
ddnrCh� Rfn ,�� �rdcr rneft 91-
10. WELL DIAGRAM: Draw a detailed sketch of the well on the back of this
form showing total depth, depth and diameter of screens (if any) retraining
in the well, gravel interval, intervals of casing perforations, and depths and
types of fill materials wed.
11. DATE WELL ABANDONED
1 DO HEREBY CERTIFY THAT THIS WELL WAS ABANDONED IN ACCORDANCE.
WITH 15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF
THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF CERT( WELL CONTRACTOR
DATE
SIGNATURE OF PRIVATE WELL OWNER ABANDONING 'ME WELL DATE
(Mc private wall owner asset be ea individual who personally abandons his/her residential well
in accordance with I S A NCA2C .01 13.)
PRINTED NAME OF PERSON An ANDON ING'THE WELL
Submit a ropy to the owner stud the original to the Division of Water Quality within 30 days,
A ttn: information Msnagemrat, 1617 Mai! Service Center — Raleigh, NC 27699-1617, Phone No, [phone] eat 568, Form ('iO
Rev .Si(ki

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2942
45 3 45
1. WELL CONTRACTOR:
Leonard Dorn, Jr.
Well Contractor (Individual) Name
Well Done Well Drillin. CEfVED/NCUENR/RV4
Well Contractor Company Name
STREET ADDRESS P.O. Box 39 r C f 0 R 2018
Shallotte, NC 28459
City orToxn Slate VAIPPVItqalityRegional
Operations Section
Area code- Phone number vVilmillFton Regional Offit
2. WELL INFORMATION: j
SITE WELL ID #(if applicable) 01 !T
STATE WELL PERMIT#(a applicable))
ft* # }app Qcb G"
DWQ or OTHER P R #(i appli ble) (;' Z- 1 1'-1 1, /--3
• WELL USE (Check Applicable Box)' Residential Water Supply Er
sic/1
[phone]
DATE DRILLED
TIME COMPLETED AM ❑ PM DI
3. WELL LOCATIO
CITY: .'C/k�N� COUNTYBrun$W1 k
7/65 jen..,f)
(SUeel Name, Numbers. C muniry, Suaowsion, Lot No.. Parcel. Zip Coae)
TOPOGRAPHIC / LAND SETTING:
❑Slope DValley (.]Flat f3'Qidge ❑Other
(chedt appropriate box)
LATITUDE 3 , 2 G5 2
LONGITUDE `] I''J �� D 59
Latitude/longitude source: DGPS DTopographic map
(cation of wed must be shown on a USGS topo map and
attached to this form ' not using GPS)
A. WELL OWNER ,�J
OWNER'S NAME / %2( r`o- dZesikL" 4/ �;f
)
STREETADDRESS 7/ 2< �er n��p 12tT
City or TtiWn State Zip Code
Area code - Phone number
May be in deyees.
minutes, seconds or
in a decimal format
5. WELL DETAILS: /
a. TOTAL. DEPTH: f' f
b. DOES WELL REPLACE EXISTING WELL?
c. WATER LEVEL Below Top of Casing:
(Use'+' if Abova Top of Casing)
d. TOP OF CASING IS / FT. Above Land Surface'
'Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): 7 METHOD OF TEST
YES D NOIf17.-'
FT.
1. DISINFECTION: Type /f r)7)-
9. WATER ZONES (depth):
From To
From To
From To
6. CASING:
Depth
From 0 To 5 y
From To
From To
Amount J
From To
From To
From To
Thickness/
Olamgter Weight
Ft. 7t SLdt"yo
Ft.
Ft.
Material
7. GROUT: Depth Material .,p Meth
From () ToZt Ft. 63(AA e f7-0 Uir
From To FL
From To FL
8. SCREEN: Depth Dian/ r Slot Sae Material
From 3,z To 1O Ft9 in. Q/'Z in. C----
From To Ft
From To Ft in. in.
9. SAND/GRAVEL PACK:
Depth Size t.1a:eriaJ
From To FL
From To Ft. !r.
.1i�,
From To F .1, F;7 °'4)
10. DRILLING LOG
From To
—
2-6 3 /
11. REMARKS:
Formation Descnption
Pock
Z oc kA Sicji
AUG ?) 3 7013
DO HEREBY CERTIFY THAT THIS WELL WA.Z CONSTRUCTED N ACCORDANCE WfTH
15A NCAC 2C, WELL CONSTRUC1jON STANDARDS, ANO THAT A COPY OF THIS
RECORO HAS 6F„IN PROVIDEDTHE WELL OY NER.
SIGNATURE OF CER'fYFIED W
/.S/rt
CONTRACTOR DATE
pu
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt,
1617 Mail Service Center — Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-la
Rev. 7/05

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of -Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION #/ 2942
1. WELL CONTRACTOR:
Leonard Dorn, Jr, REGEIVED/NCi3ENR/®WR
Well Contractor (Individual) Name
Well Done Well Drilling
Well Contractor Company Name I i 1.1 ii (.018
STREET ADDRESS P.O. Box 39
Shallotte, NC 2845`jtereratiQunnsalitySectiRegional
n
City oxTown State WilmiZiptCodRenionalOffice
[phone]
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(i( applicable) / 90b ®9 5-Zs WV"
STATE WELL PERMIT#(dapplicable)
DWQ or OTHER PTRlIT #applicable) ,'/ r2 j (v9
WELL USE (Check Applicable Box) Residential Water Supply Ems'
DATE DRILLED l31 / J
TIME COMPLETED AM Q PM ©`
3. WELL LOCATION•
CITY. )9( %/sIj - COUNTY Brunswick
ci & d— ),1
(Sweet Name, umbers. Community, Suaa,Hsuon, Lot No., Parcel, Zip Coae)
TOPOGRAPHIC / LAND SETTING:
4TOIope OVal1ey ❑ Flat ❑ Ridge ❑ Other
(Check appropriate box)
LATITUDE 3 b Zgi
LONGfTUDE 7j Si' ' m 9 5-)`y
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: Eer6S ❑Topographic map
(location of we must be shown on a USGS topo map and
attached to this form Jnot usiv GPS)
4. WELL OWNER
Pee Aid/ 03eeA
OWNER'S NAME (::A", E ,1 y ldit / r yvte3
STREET ADDR SS /2 j.3 5 :�< �(V%try
//Vh t) :/% _ /(; _;_ z y7 2'
State Zip Code
City or To+m
L3L u _)- 3 6.1 — 3 ‘7.
Area code - Phone number
5. WELL DETAILS:
a, TOTAL DEPTH: / /
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO Q"
c. WATER LEVEL Below Top of Casing:
(Use'+' if Abova Top of Casing)
d. TOP OF CASING IS __I__ FT. Above Land Surface'
'Top of casing terminated at/or below land surface may require
a variance in accordertce with 15A NCAC 2C .0118
e. YIELD (gpm): METHOD OF TEST
45:AR 46
f. DISINFECTION: Type
g. WATER ZONES (depth):
From
From
From
6. CASING:
To
To
To
Depth Diarrygter
From ® To5 Ft.
From To Ft.
From To Ft.
7. GROUT: Depth
Amount E�
From To
From To
From To
Thickness/`-
Weight Ma r al
se h jra
Material Method
From 6 To O Ft. 0,e,, }vz,
From To Ft
From To Ft.
8. SCREEN} Depth Dame,
From �,S' To " 7 Y Ft .f ;
From To Ft
From To
Slot Sire Mj
in. �t�✓ I. e rac.._
in. in.
in. in.
9. SAND/GRAVEL PACK:
Depth S,ze
From To Ft.
From To Ft.
From To FI.
10. DRILLING LOG
From To
d
11. REMARKS:
t.ta:enal
C�� t
Forrr.attcn Descnptcn
100 HEREBY CERTIFY THAT THIS WEL1 WAS CONSTRUCTED N ACCORDANCE Wrni
15A NCAC 2C, WELL CONSTRUCTION STA :CARDS, AND THAT A COPY OF THts
RECORD HAS BEEN PROvIOED TO THE WELL OWNER.
th1ii&
CONTRACTOR DATE
0(t/V TO -
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

1
WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
1. Well Contractor Information:
Justin Radford
RECEIVED/NCDENR/DWR
Well Contractor Name
3270
NC Well Contractor Certification Number
Geological Resources, Inc.
Company Name
2. Well Construction Permit if:
List all applicable well permits (i.e. County, State,
3. Well Use (check well use):
OCT 022018
Water Quality Regional
Operations Section
Wilmington Regional Office
Variance, Injection, etc.)
Water Supply Well:
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑ IndustriallCommercial
❑Irrigation
❑Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
Non -Water Supply Well:
IEIMonitoring
Injection Well:
❑Aquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling Retum)
4. Date Well(s) Completed: 0 /6/1
5a. Well Location:
Sky Mart/MM #45
❑Recovery
❑ Groundwater Remediation
❑Salinity Barrier
❑Stormwater Drainage
❑ Subsidence Control
❑Tracer
❑Other (explain under #21 Remarks)
8 8 Well ID# MW-3
0-00029225
Facility/Owner Name Facility ID# (if applicable)
3221 Holden Beach Road
Physical Address, City, and Zip
Brunswick 232GCO26
County Parcel identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
33.927616 N 78.272823
6. Is (are) the well(s): 17Permanent or ❑Temporary
W
7. Is this a repair to an existing well: ❑Yes or i lNo
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. Number of wells constructed: 1
For multiple injection or non -water supply wells ONLY with the same construction, you can
submit one form.
9. Total well depth below land surface: 12 (rt.)
For multiple wells list all depths if different (example- 3@200' and 2@100')
10. Static water level below top of casing: 3.5
)(water level is above casing. use "+"
11. Borehole diameter: ' 3•5 (in.)
12. Well construction method: direct push
(ft.)
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
For Internal Use ONLY:
t,ileilM143
14. WATER ZONES
FROM
TO
DESCRIPTION
ft.
ft.
ft.
ft.
15. OUTER
CASING (for multi -cased wells) OR LINER (If applicable)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft.
ft.
in.
16. INNER
CASING OR TUBING
(geothermal closed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL.
0 ft.
2 ft.
2 in.
sch 40
PVC
ft.
ft.
in.
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
2 ft.
12 ft.
2 in.
0.010
sch 40
PVC
ft.
ft.
In.
18. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
0 ft.
0.5 ft•
cement
pour
ft.
ft.
ft.
ft.
19. SAND/GRAVEL
PACK (if applicable)
FROM
TO
MATERIAL,
EMPLACEMENT METHOD
0.5 ft.
1 ft.
Bentonite
pour
1 11.
12 ft.
sand
pour
20. DRILLING LOG (attach additional sheets if necessary)
FROM
TO
DESCRIPTION (color, hardness, soil/rock type, grain tire, etc.)
0 ft.
0,5 ft.
Concrete
0.5 ft.
3 ft.
Tan fine sand
3 ft.
4 ft.
Gray medium sand
4 ft•
12 ft•
direct push; no recovery
ft.
ft.
ft.
ft.
cam' t i
ft.
ft.
Cr..•.F,
Re:
21. REMARKS
2018
t y
SEP 1
22. Certification:
Sign. e o edified Well C
g1tZ/,g
Date
By ing this form, I hereby cert fy that the well(s) was (were) constructed in accordance
with 15A NCAC 02C .0100 or 1 SA 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 INSTUCTIONS
24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Iniection Wells ONLY: In addition to sending the form to the address in
24a above, also submit a copy of this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supply & Injection Wells:
Also submit one copy of this form within 30 days of completion of
well construction to the county health department of the county where
constructed.
Form GW-1
North Carolina Department of Environment and Natural Resources - Division of Water Resources Revised Aue- st 2n1 i

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
1. Well Contractor Information:
Justin Radford
RECEIVED/NCDENR/DWR
Well Contractor Name
3270
NC Well Contractor Certification Number
Geological Resources, Inc.
Company Name
2. Well Construction Permit if:
N/A
ULI 02 2018
Water Quality Regional
Operations Section
Wilminpfnn RPgJnnal nffire
List all applicable well permits (i.e. County, State, Variance, Injection, etc.)
3. Well Use (check well use):
For Internal Use ONLY:
14. WATER ZONES
FROM
TO
DESCRIPTION
ft.
ft.
ft.
ft.
15. OUTER CASING (for multi -cased welisa OR LINER (If applicable)
FROM TO
DIAMETER
THICKNESS
MATERIAL
ft.
ft.
in.
16. INNER CASING OR TUBING (geothermal closed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
0
ft.
2
ft.
2
in.
sch 40
PVC
ft.
17. SCREEN
Water Supply Well:
DAgricultural
❑Geothermal (Heating/Cooling Supply)
❑ Industrial/Commercial
❑Irrigation
❑MunicipaUPublic
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
Non -Water Supply Well:
tMonitoring ❑Recovery
Injection Well:
DAquifer Recharge
DAquifer Storage and Recovery
❑Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling Return)
❑Groundwater Remediation
❑Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑Tracer
DOther (explain under #21 Remarks)
4. Date Well(s) Completed: 08/6/1 8 Well ID,/MW-2
5a. Well Location:
Sky Mart/MM #45
0-00029225
Facility/Owner Name Facility ED# (if applicable)
3221 Holden Beach Road
Physical Address, City, and Zip
Brunswick 232GCO26
County Parcel Identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one let/long is sufficient)
33.927616 N 78.272823
6. Is (are) the well(s): ®Permanent or ❑Temporary
w
7. Is this a repair to an existing well: DYes 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 of this form.
8. Number of wells constructed: 1
For multiple injection or non -water supply wells ONLY with the same construction, you can
submit one form.
9. Total well depth below land surface:
For multiple wells list all depths if different (example- 3@200' and 2@100')
12
(ft.)
10. Static water level below top of casing: 3.5 (ft.)
If water level is above casing, use "+" 2
11. Borehole diameter: u+C (in.)
direct push
12. Well construction method:
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
FROM
ft.
In.
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
2
ft.
12 ft.
2
in.
0.010
sch 40
PVC
ft.
ft.
In.
18. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
0
ft.
0.5
ft.
cement
pour
ft.
ft.
ft.
19. SAND/GRAVEL PACK (If applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
0.5
ft.
ft.
Bentonite
pour
1
ft.
12
ft.
sand
pour
20. DRILLING LOG (attach additional sheets If necessary)
FROM
0
ft.
1
TO
ft.
DESCRIPTION (color, hardness, soll/rock type, grain size, ate.)
Brown fine sand
1
ft.
3
ft.
Tan fine sand
3
ft.
4
ft.
Gray medium sand
4
ft.
12
ft.
direct push; no recovery
ft.
ft.
ft.
ft.
gEc N ED
SAP
ft.
21. REMARKS
ft.
18
rtn'tioDo P t c'c r'Kn"
22. Certi catio
Signal
f Certified Well Contractor
2 1$
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 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 INSTUCTIONS
24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Iniection Wells ONLY: In addition to sending the form to the address in
24a above, also submit a copy of this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supply & Injection Wells:
Also submit one copy of this 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 Environment and Natural Resources - Division of Water Resources
Revised August 2013

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
1. Well Contractor information:
Justin Radford
RECEIJED/NCDENR/DWR
Well Contractor Name
3270
NC Well Contractor Certification Number
OCT 02 2018
Geological Resources, Inc. Water Quality Regional
Operations Section
Company Name Wilmingtofl Regiunl Office
ce
2. Well Construction Permit #:
N/A
List all applicable well permits (i.e. County, State, Variance, Injection, etc)
3. Well Use (check well use):
Water Supply Well:
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑ IndustriallCommercial
❑Irrigation
FROM
For Internal Use ONLY:
14. WATER ZONES
FROM
ft.
TO
ft.
4130
DESCRIPIOI
ft.
rt.
15. OUTER CASING (for multi -cased wells) OR LINER (if applicable)
THICKNESS I MATERIAL
ft.
TO
ft.
DIAMETER
tn.
16. INNER CASING OR TUBING (geothermal closed -loop)
FROM DIAMETER
0
ft.
TO
2
ft.
2
In.
TIHCKNESS
sch 40
MATERIAL
PVC
ft.
ft.
In.
17. SCREEN
❑Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
Non -Water Supply Well:
17Monitoring
Injection Well:
❑Aquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer Test
DExperimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling Return)
❑Recovery
❑Groundwater Remediation
❑Salinity Barrier
❑Stonnwater Drainage
❑Subsidence Control
❑Tracer •
❑Other (explain under #21 Remarks)
4. Date Well(s) Completed: 08/6/18 Well iD# MW-I
5a. Well Location:
Sky Mart/MM #45
0-00029225
Facility/Owner Name Facility ID# (if applicable)
3221 Holden Beach Road
Physical Address, City, and Zip
Brunswick 232GCO26
County Parcel identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
33.927616 N 78.272823 W
6. Is (are) the well(s): ❑Permanent or ❑Temporary
7. Is this a repair to an existing well: ❑Yes or ENo
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. Number of wells constructed: 1
For multiple injection or non -water supply wells ONLY with the same construction, you can
submit one form.
9. Total well depth below land surface:
12
For multiple wells list all depths if different (example- 3@200' and 2@100')
(ft.)
10. Static water level below top of casing: 3.5 (ft.)
If water level is above casing, n,.e "+"
11. Borehole diameter: 3.' (in.)
direct push
12. Well construction method:
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
FROM
2
ft.
TO
12
ft.
DIAMETER
2
In.
SLOT SIZE
0.010
THICKNESS
sch 40
MATERIAL
PVC
ft.
ft.
in.
18. GROUT
FROM
0
ft.
TO
0.5
ft.
MATERIAL
cement
EMPLACEMENT METHOD & AMOUNT
pour
ft.
ft.
ft.
ft.
19. SAND/GRAVEL PACK (if applicable)
FROM
0.5 rt.
1
TO
ft.
MATERIAL
Bentonite
EMPLACEMENT METHOD
pour
1
ft.
12
ft.
sand
20. DRILLING LOG (attach additional sheets If necessary)
TO
FROM
0
ft.
0.5
ft.
• pour
DESCRIPTION (color, hardness, soil/rock type, grain size, etc.)
Concrete
0.5 ft.
3
ft.
Tan fine sand
3
ft.
4
ft.
Gray medium sand
4
n.
ft.
12
ft.
ft.
ft.
ft.
direct push; no recovery
RECEIVED
ft.
21. REMARKS
ft.
SEP 2
2018
fttltOftittilbiC`it >'ri r,:•.
DWQI OC'
22. Certification:
S'latureofCertifi•. Well Tractor
9(1 Z-( r
Date
By signing this form, 1 hereby certify that the well(s) was (were) constructed in accordance
with 15A NCAC 02C .0100 or 1 SA 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 INSTUCTIONS
24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Injection Wells ONLY: In addition to sending the form to the address in
24a above, also submit a copy of this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supply & Injection Wells:
Also submit one copy of this form within 30 days of completion of
well construction to the county health department of the county where
constructed.

WELL CONSTRUCTION RECORD 1GW-1)
1, Well Contractor Information:
Vernon Dale Olsen 3ECEIVED/NCDENR/DWR
Well Contractor Name
2774—A JUL 3 0 2018
NC Well Contractor Certification Number
Cascade Drilling
Company Name
Water Quality Regional
Operations Section
2. Well Construction Permit is: Wilmington Regional Office
List all applicable well construction permits (i.e. UIC. County. time, Variance. etc.)
3. Well Use (check well use):
Water Supply Well:
Agricultural DMunicipal/Public
Geothermal (Heating/Cooling Supply) OResidential Water Supply (single)
ndustriaUCommercial D Residential Water Supply (shared)
irrigation
Non -Water Supply Well:
Monitoring
Injection Well:
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
lerimental Technology
Geothermal (Closed Loop)
Geothermal (Heating/Cooling Return)
4: Date Well(s) Completed: 6/20/18
5a. Well Location:
Duke Energy
Recovery
DGroundwater Remediation
DSalinity Barrier
DStormwater Drainage
DSubsidence Control
[Tracer
ElOther (explain under f121 Remarks)
Well IDNMW 42 D
Facility/Owner Name Facility ID# (if applicable)
233 Sutton Lake RD Wilmington NC, 28401
Physical Address, City, and Zip
Brunswick
County Parcel identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
or well field, one lat/long is sufficient)
N W
6. Is(are) the well(i$Dx Permanent or DTemporary
• 7. Is this a repair to an existing well: DYes or I No
'.ifthis is o 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:.•
9. Total well depth beinvi land surface: 99 (ft.)
For multiple wells list all depths lfd feient (example- 3@200' and 2(g1I00)
? 10. Static water level below top of casing: (ft.)
If water level isabove casing, use "+"
1 I. Borehole diameter: 6 (in.)
12. Well construction method: Sonic
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm)
Method of test:
Dab. Disinfection type:
Amount
Form OW -I
For Internal Use Only: 5? f
1
i lS.VATER ZONES ;.,;1,x,C,1“, . r: ,-:'z s _ .,,e, -:
FROM
TO
DESCRIPTION
ft.
ft.
ft. ft.
•15.01)fERCi191NG(formottitasidiretts
OR LINER Drip liable)
FROM -
TO
DIAMETER -THICKNESS
!MATERIAL
ft.
n.
in.
�
,I6:INNER'CASING
OR M:I
NG (geothermal closed -loop) ' - ;
FROM
TO
DIAMETER
THICKNESS
MATERIAL
+3 ft.
89 fL
2 i°
SCH 40
PVC
ft.
ft.
is
17:'SCREENr;cv -,Aii.i7iri. ^•- nor 1K.:7: i,.:�.ax
-~DIAMETER
FROM
TO
'e
SLOT SIZE
THICKNESS
MATERIAL
89 rt-
99 fL
2 to
.010
SCH 40
PVC
fL
fL
to
:,1S:GROVfkr
t,sre.r.a 1.,-f4 .. ., .
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
82 ft,
87 ft.
Ben Chips
Pour/ Gravity
0 ft.
82 ft"
Portland
Tremie/Pump/6/94 lb bgs
ft.
rt.
19 SANI
RAVEL PACK.titidplteable)
&rb+ tt., :,3i' r ;'>,;PM. . -
FROM
TO
MATERIAL
EMPLACEMENT METHOD
87 ft.
99 rt.
1-A Sand
Pour/ Gravity
ft.
re.
2d,'DRILLR(G:LOG(iittieb:addttidaalshee&Ifiiiotiairy)r:
�;-°,it fc:-,.:-
FROM
TO
DESCRIPTION (color, hardness. sea/rock type. grain size, etc)
ft.
rt.
R.
ft.
ft.
ft'
SEE GEOS LOGS
rL
ft
q ` . 7.,
• w I
s
rt
RECEV t...,....
,� d
rt.
ft.3
?o1a
ft.
ft.
JUL
431 AgmAlucs .-i. o >.t.:,:-.. 4 "�6 tit • %x .4..*;.`-2L ,,_'e? c.
ri3"Jai°Cyr
22. Ct
&WI/ idCA &6€/i
Signature of Certified Well Contractor
6/21/18
Date
By signing this form, 1 hereby certify that the well() was (were) constructed in accordance
with 1 SA NCAC 02C .0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that a
copy ofthls record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTRUCTIONS
24a. For All Wells: Submit this form within 30 days of' completion of well
construction to the following
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Infection Wells: In 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 Sumuly & 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.
North Carolina Department of Environmental Quality - Division of Water Resources
Revised 2-22.2016

WELL CONSTRUCTION RECORD (GW-11
I. Well Contractor information:
Vernon Dale Olsen JR RECEIVED/NCDENR/o
Well Contractor Name
2774-A
NC Well Contractor Certification Number
Cascade Drilling
JUL 302018
Company Name
For Internal Use Only:
'FI. WATER ZONES
FROM TO
ti
=459971
DESCRIPTION
n.
uERCkw(kr dllaztlwaCaORLINER OfspicaNr)
FROM DIAMETER THICKNESS h1.ATE.RIAt.
ft. ft.
I le.
2.Well Construction Permit q: Operations S('Aftinn FROM TO
Ia.,1NNLRCASINO OR Tt)Btrinan taernateleaed.t«tt)
II
list all apphoahle uvellconarsKYton permits (r.e. (halal( yFpwP(iFq, '1al Offic +3 R 42
3. Well Use (check well use):
Water Supply Weil:
Agricultural
Geothermal (I IeatinglCooling Supply)
Industrial/Commercial
Irrigation
Non -Water Supply Well:
xDMonitoring
Injection Well:
Water Quality Regional
�MunicipalPublic
°Residential Water Supply (single)
()Residential Water Supply (shared)
❑Recovery
Aquifer Recharge OCrroundwater Remediation
Aquifer Storage and Recovery °Salinity Barrier
°Aquifer Test DStonnwater Drainage
ExperimentalTechnology Subsidence Control
°Geothermal (Closed Loop) °Tracer
nGcethermal (HeatingiCooling Return) [other (explain under 21 Remarks)
4. Date W'ell(s) Completed:6/20/18 Well ID/4MW 42 C
5a. Well Location:
Duke Energy
Facility/Owner Name Facility tDd (ifapplicabk)
233 Sutton Lake RD Wilmington NC, 28401
Physical Address, City. and Zip
Brunswick
County Parcel Identification No. (PIN)
5b. Latitude aad longitude in degrees/minutes/seconds or decimal degrees:
(dwell field, one IaV amg is sufficient)
N
W
6. Is(are) the we1l(s)I Permanerl or °Temporary
7.1s this a repair to an existing well: °Yes or °No
/(this is a repair, fill ow known well construction information and explain the nature of the
repair under 621 remarks section or on the back of this form.
8. For Geoprobe/DPi 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 laud surface: 52
For multiple wells list all depths if different (example- 3@200' and 2t`d/tN1')
10. Static water level below top of using:
If water keel is abow casing. wse '« -
11. Borehole diameter. 6 (ia.)
12. We0 construction method: Sonic
(i.e. auger, rotary, cable, direct posh, etc.)
(R)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (glum)
13b. Disinfection type:
Method of teat:
Amount:
Form GIP -I
(L
SCREf,N
TO
iL
fr.
DIAMETER THICKNESS
2 in SCH 40
MATERIAL.
PVC
FROM
42 rL
11 GROUT
52 ft.I2
TO
rt.
DIAMETER
la
is.
SLOT SIZE THICKNESS
.010 SCH 40
MATERIAL
PVC
FROSI TO
34 R 38 r.
0 rt.
tt
34 a
(E
MATERIAL
EaiPLACEME.NT METHOD & AMOUNT
Ben Chips Pour/ Gravity
Portland Tremie/Pomp/4/94 lb bgs
19.SANDIGRAVLLPAOLO('spatinbk);t<:.oe.::,
FROM TO
38 It 52
MATERIAL
1-A Sand
ft.
EMPLACEMENT METHOD
Pour/ Gravity
- 20. DRILLING LOG (attackadditional sheets if Neeeatary), , `-:.,:r:,.t•: _
FROM DESCRIPTION (role Yardawprue,
, roWnck type. grain ne.)
TO
fL
(L
(L
R
ft.
(L
ft.
ft.
ft.
(L
ft-
(L
0.
SEE GEOS LOGS
a1.RENIARICs-: '^ t.,- '^nFit7«'•'t
luL
22. Certifcatiou:
Srgeaturc of Certified Well Contractor Date
By signing this form- 1 hereby car fy that the wo)1(,) was (we're) Ca,.irroi/ed In accordance
rah 13A NCAC' 0/C.0100 or 1JA NCAC 02C.0200 Well C'onstnimian Standards and that a
cagy of this record hos been provided to the welt 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.
Slla\II-ITAL INlrR(It r1p C
24ll Well
a. For As: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Injection Wells: In addition to sending the form to the address in 24a
above, also submit one copy of this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mall Service Center, Raleigh, NC 27699-1636
24e. For Water Snnnlo t r-I--.1_ •-- 1 : In addition to sending the form to
the address(cs) nbavo, also submit one copy of this form within 30 days of
completion of well construction to the county health department of the county
where constructed.
North Carotin Dcpemrtest of ERvironeental Quality -Division of Water Resources
6/21/18
Revised 2-22-2016
Scanned with CamScanner

WELL CONSTRUCTION RECORD (GW-1)
I. Well Contractor Information:
Vernon Dale Olsen JRRECEIVED/NCDENR/DWR
Well Contractor Name
2774-A JUL 30 2018
NC Well Contractor Cenifitation Number
Cascade Drilling
Company Name
2. Well Construction Permit a:
List all applicable well eonsIrac!ian permits (i.e
3. Well Use (check well use):
Water Quality Regiuf fnI
Operations Section
u0i,144.1.441,Ece,i99a{ Offic
Water Supply Well:
Agricultural 13 Municipal/Public
Geothermal (Heating/Cooling Supply) E3Residential Water Supply (single)
Industrial/Commercial QResidential Water Supply (shared)
Irrigation
Non -Water Supply Well:
Monitoring °Recovery
Injection Well:
Aquifer Recharge °Groundwater Remediation
Aquifer Storage and Recovery °Salinity Ranier
]Aquifer Test DStonnwater Drainage
]Experimental Technology °Subsidence Control
Geothermal (Closed Loop) °Tracer
Geothermal (Heating/Cooling Return) [Other (explain under 621 Remarks)
4.Mite weu(s)Completed: 6/20/18 Weu1DVMW 41 D
5a. Well Location:
Duke Energy
Facility/Owner Name Facility iDA (if applicable)
233 Sutton Lake RD Wilmington NC, 28401
Physical Address, City, and Zip
Brunswick
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees;
Orwell field, one rat/long is sufficient)
N �Y
6,1s(are) the welt(s)0Permanent or °Temporary
7. Is this a repair to an existing well: }Yes or °No
If tins is a repair, fill ow known well construction Information and explain the nature of the
repair under 521 rrmark...rection or on the back of this farm.
8. For Ceoprobe/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: 102
For multiple wells lira all depths ifdlerenr (example- J@200 • and 2(0100)
10. Static water level below top of easing: (rt.)
!fustier level is above rasing, use "s
I I. Borehole diameter: 6 (In.)
ILWell construction method: Sonic
(t e. auger. rotary, able, direct push, etc.)
(ft.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm)
13b, Disinfection type:
Method of test:
Amount:
FreOW4•- .
For Internal Use Only:
-14, WATER ZONES
FROM
TO
DESCRIPTION
fr.
ft.
n.
rt.
1 d. Ol1TER CASING (far tailti-erred wells] OR LINER (If a fable)
AMETER
DI
FROM
ft.
rL
f o.
'14. INNER CAS MOOR TUBING (aeelberotal doaM-loop)
FROM TO DLAMETER THICKNESS
+3 fr.
92
n.
2
in.
SCH 40
MATERIAL
PVC
ft.
17-SCREEN
fr.
la
FROM
92 rt-
TO
102 ft-
DIAMETER
2
in.
SLOT SIZE
.010
THICKNESS
SCH 40
MATERIAL
PVC
ft.
ft.
in.
le. GROUT
FROM
84 m
TO
92 m
MATERIAL
Ben Chips
EMPLACEMENT METHOD & AMOUNT
Pour/ Gravity
0
n.
rt.
84 rL
rt.
Portland
Tremie/Pump/9/94 lb bgs
19. SAND/GRAVEL PACK (if applicable) ., .
FROM
92 ft.
TO
102 rt.
MATERIAL
1-A Sand
EMPLACEMENT METHOD
Pour/ Gravity
ft.
rt.
20. DRILLING i.OG (attat6 additional alittlI If aecenary) . .
DESCRIPTION (color, herdnns, ,oatrock type, zeeie site, etc.)
FROM
rt.
TO
n.
ft.
ft.
fL
ft.
n.
ft.
ft.
TO
11.REMARKS '.
22. Cerliftcation:
fL
ft.
ft.
ft.
n.
SEE GEOS LOGS
Pli
THICKNESS MATERIAL
6/20/18
Date
By signing this form, 1 hereby certify that the well(s) was (were) const,ucred in accordance
with 15,4 NCAC 02C.0100 or 15,1 NC:AC 02C.0200 Well Construction Standards and that a
copy of this record has been provided to the well owner.
21 Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTRUCTIONS
24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For initction 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 hall Service Center, Raleigh, NC 27699-1636
24r. For Water Fnnnly R s 1.,.,,.._ ,., ..
the address(es) above, also submit one copyIn addition to sending the tam to
completion of well construction to the county he this form within 30 days of
where constructed. health department of the county
North Carolina Department of Environmental Qualify - Division of Winer Resources
`/1410�r �/ G
gnature or Certified Well Contractor
Revised 2.22.2016
Scanned with CamScanner

WELL CONSTRUCTION RECORD 001181/NCQENR/D
l.Wetl Contractor Information:
Vemon Dale Olsen JR
Well Contractor Name
2774-A
NC Well Canracror Certification Number
Cascade Drilling
Company Name
JUL 30 201
Water Quality Regio
Operations Sectiol
Wilmjp n Regional
2. Well Construction Permit #:
List aft applicable well cmarucaon Dermas ti,e UIC; County. Stare. Variance. etc.)
3. Well Use (check well use):
Water Supply Weil:
Agricultural
Geothermal (Heating/Cooling Supply)
Industrial/Commercial
irrigation
Non -Water Supply Well:
Monitoring
injection Weil:
Aquifer Recharge
Aquifer Storage and Recovery
QMunicipal/Public
[Residential Water Supply (single)
[Residential Water Supply (shared)
['Recovery
❑Groundwater Remediation
[Salinity Barrier
Aquifer Test QStormwater Drainage
Experimental Technology [Subsidence Control
Geothermal(ClosedLoop) [Tracer
Geothermal (Heating/Cooling Return) QOther (explain under #21 Remarks)
4. Date Well(s) Completed: 6/20/18 well Intl W 42 B
Ss. Well Location:
Duke Energy
Facility/Owner Name Facility ED# (if appiicabk)
233 Sutton Lake RD Wilmington NC, 28401
Physical Address. City, and Zip
Brunswick
County Parcel Identification No. (PIN)
5b. Ladtude and longitude In degrees/minutes/seconds or decimal degrees:
(((well field. one lat/long is sufficient)
N W
6. Is(are) the we11(s)[Permanent or [Temporary
7.1s this a repair 10 an existing well: ['Yes or EiNo
Ohl, is a repair, fill out known well construction information and explain the nature of the
repair under I11 remarks action or on the hack of Out form.
S. For Ceoprobe/DPT or Closed•Loop Geothermal Wells having the same
construction, only I CW-1 is needed. Indicate TOTAL NUMBER of wells
drilled:
9.Total well depth below land surface: 27.5
For maltple well, bit all depths if cane (example- S@200' and 1@l001
10. Stade water level below top creasing:
If wart lerellr shore rat tg. urn ".
It. Rorebele diameter; 6
is, Wel construction method: Sonic
p s env', rnlarry, calk, dhecl paste, etc.)
(R.)
(rL)
TOR WA'TPR St1PPIX WELLS ONLY:
fd:rr Yirt4 ({pm)
)S4r Dislareedon type;,,
btethod of test:
Amount;
Emu 611/4
Or Internal Use Only:
4529
IJ.: WATERS _ .
FROM
TO
DESCRIPTION
n.
R.
n.
rt.
n F 1IS. OUTER CASING (far lr.ti•naed
wells OR LINER (Ira kabtei
1 FROM
TO
DIAMETER ] THICKNESS
MATERIAL
3f ce n.
n.
in.
:16. INNER
CASING OR TUBING
(aeotheri
tl elaad-Nop) '
FROM
TO
DIAMETER
THICKNESS
MATERIAL
+3 n•
17.5 n•
2 In•
SCH 40
PVC
n.
n.
in.
17.SCREEN -:_ r;:
{,,ti'. e.;.4 'Wai0-,
FROM
TO
DIAMETER
SLAT SIZE
THICKNESS
FIAT ERIAI.
17.5 n•
27.5 n'
2 fa-
.010
SCH 40
PVC
rt.
rt.
to.
l&GROW'
.;:
FROM
TO
FIATERIAL
EMPLACEMENT METHOD& AMOUNT
12 ft.
15 n.
Ben Chips
Pour/ Gravity
0 n.
12 ft.
Portland
Tremie/Pump/2/94 lb bgs
n.
n.
-;19.SANDrGRAVELPACk
(if applicable) ..: 1-S+`i:.<:••,-..:°::-asaal.t..-:r..„•.,;r,:_:;r
FROM
TO
!MATERIAL
EMPLACEMENT FIETHOD
15 R,
27.5 ft.
1-A Sand
Pour/ Gravity
n.
n.
-10. DRILLING
LOG (alist
6 addithul sheets If Ineeesitri) r.•'<.r;..a.• a s a.::. -... ,.
FROM
TO
DESCRIPTION (color. Fordanr. wa/nek Iwo. xnin ,an. etc.)
EL
Ft.
n.
n.
1
n'
n'
SEE GEOS LOGS
n.
n.
g tg TT .
-
1.
R.
n.
-- ..f— -CT 4,
0.
E 3 'I."'
ft. Ju�
ii. REMAIEXs, ,4-*),0 tw 1.. s.,,,, , . ,,. IaS,w,t 3i. +ufe 5a A, ...
lr o,-F(saty i t j
2. Certif
afion:
/21/18
Signature o Certified Well Contractor Date
By signing this farm. 1 hereby certify that the walks) was (were) constructed in accordance
with 1SA NCaC 01C.0100 or ISA NCAC DIC.0200 Well Construction landardt and that a
ropy of this record has been provided to the well owner.
23. Site diagram or additional welt 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.
5unmiTTAL INSTRUCTIONS
24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Resources, information Processing Unit,
1617 hfail Service Center, Raleigh, NC 27699-1617
I4b. 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 Mlafl Service Center, Raleigh, NC 27699-1636
24c. For Water Snooty $i Inlrctlon Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
completion of well construction to the county health department of the county
where constructed.
North Carolina Department of EnWren menial Quality- Division of Water Resources
Revised 2.22.2016
8
Scanned with CamScanner

WELL CONSTRUCTION RECORD (GW-1)
1.IYell Contractor Information: R ECEIVED/NCDENR/DWR
Vernon Dale Olsen JR
Welt Contractor Name
2774-A
NC Wdl Contractor Catificalioo Number
JUL 302018
Cascade Drilling Water Quality Resioi,al
Company Name Operations Section
2. Well Construction Permit 8: Wilmington Regional Office
Isn oilappOcable wrllmurruaran permru (r e. U1C. Calory Stoke. r'anonce, etc/
3. Well Use (cheek well use):
Water Supply Well:
■ Agricultural
Geothermal (I feating/Cooring Supply)
(s Industrial/Commercial
w lrn • ion
Non -Water Supply Well:
Monitoring
Injection Welk
■ Aquifer Recharge
■ Aquifer Storage and Recovery
■ Aquifer Test
■ Experimental Technology
■ Geothermal (Closed loop)
M Geothermal (featin oolin: Return)
4. Date Well(s) Completed: 6/20/18
Sa, Well Location:
Duke Energy
DMunicipawwublic
°Residential Water Supply (single)
❑Residential Water Supply (shared)
Recovery
°Groundwater Rcmediation
❑Salinity Barrier
° Stormwatcr Drainage
°Subsidence Control
°Tracer
■ Other (ex .lain under821 Remarks)
Well IDuMW41 C
Facility/Owner Name Facility IN (if applicable)
233 Sutton Lake RD Wilmington NC, 28401
Physical Address, City. and Zip
Brunswick
Cowry Parcel Identification No. (PIN)
Sb. Latitude and longitude In degrees/minutes/seconds or decimal degrees:
, (if well kid, one 1a1/Iong is sufficient)
N N
6.Is(are)the wcll(s)°x Permanent or °Temporary
7.15 this a repair to au existing well: ©Yes or ONo
Ifthis 1, a repair, fill out brown we// cauUYntan tnformatton ,d explain !ha nature ofthc
'epav ruxier 12/ remarks senior or on the back of lhis form.
8. For GeoprobdJPf or Closed -Loop Geothermal Welts having the same
construction, only 1 GW-I is needed. Indicate TOTAL NUMBER of wells
drilled:
9. Total well depth below Land surface 45
For ayropltwells list all depth) tfdff rent(example-3 100•and jralt)0� A
10.Statir water level below top or easing:
/Hunter keel ts above careaR, Rse `4"
ll;Borehole diameter: 6 (in.)
-12. Well construction method:
(ie. auger, rotary, cable, direct push, etc.)
Sonic
FOR WATER SUPPLY WELLS ONLY:
Yield (gpm)
*Pretties type:
Method of test:
Amount:
_(ft.)
F
tar internal USC Unit': .' _ 452967
FROM
TO
IrrSCl11PTION
rL
rt.
rt.
•r.
1.OVTER CASING frFafaaah(.naed
wefts OR LINER (if apD�Pllirable)
FROM
TO
DIAMETER THICKNESS I MATF.RIAl,
n.
fr.
Ia. lj
. I. INNER
CASING OR TUBING
(aeat3ermal etase14N14
FROM
TO
DIAMETER
THICKNESS
MATERIAL
+3 R.
35 rt•
2 in.
SCH 40
PVC
ft.
ft.
in.
17.SCREEN,
- ...
FROM
TO
DIAMETER
SLOT SWF
THICKNESS
MAT/RIAI,
35 rc
45 n'
2 in-
.010
SCH 40
PVC
In.
J
IS. GROUT,
FROM
TO
MATERIAL
EMPLACEMENTMETI ODA. AAIM NT
30 EL
33 fL
Ben Chips
Pour/ Gravity
0 rL
30 IL
Portland
Tremie/Pump/3/94 lb bgs
ft.
H,
• 19. SAND/GRAVEL PACK
FROM
if applicable)
TO
MATERIAL,
EMPLACEMENT METHOD
33 rL
45 It.
1-A Sand
Pour/ Gravity
ft.
ft.
20. DRILLING
FROM
LOG Windt
addltlo.al sheets If.eteasary)
ft.
TO
ft,
DESCRIPTION Helm.. Y,rdw, s.W..eY type.Era1a Du. de.)
1
R,
It
ft,
ft.
rL
ft.
SEE GEOS LOGS
R.
ft.
ft.
ft
t1.REMARIC3.
22. Ctrs
Signature of Certified Well Con
Date
g this
. 1 herehy cert16, that the well(r) war
wisht1111MAC'02(t'.0lo or/IfA'C'ACO2C'.0100Wel!ConnruecttIonStandanructed t mnd�[
copy of this record has been Novak,' 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 pagcs if necessary.
SUBMITTAL 1\STRUCI7nNs
2-la. or 11 W lis: Submit this form within 30 days of completion of well
construction to the following:
6/20/18
Division of Water Resources, information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b, rfo_-__11kgi n W II : 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 of16.76 WaterMall Resources, Underground Injection Control Program,
Service Center, Raleigh, NC 2769.1636
24c. FQr Water Sunnly
the addresses � ISalsoubmttn Veih: In addition to sending the form to
completion ofconstructionconstmMionrtothecounty health depcopy of this artment within 30 days of
where constructed. pmfinent of the county
North Carolina Department of Environmental Quality - Division of Water Resources
Revised 2-22..2016
Scanned with CamScanner

WELL CONSTRUCTION RECORD (GW-1)
1.1Vell Contractor Information: RECEIVED/NCDENR/DWR
Vernon Dale Olsen JR
We I Contractor Name
2774-A
NC Well Contractor Certification Number
Cascade Drilling
Company Name
2. WC1l Construction Permit #:
LLu all applicable well construction perrnas (.e. (11(,( aunty Stole, lariance. etc.)
JUL 3 0 2018
3. Well Use (check well use):
Water Quality Regional
Operations Section
Wilmington Regional Office
Water Supply Well:
Agricultural
Geothermal (Fleming/Cooling Supply)
Industrial/Commercial
irneation
DMunicipavPublic
°Residential Watcr Supply (single)
DResidcntial Water Supply (shared)
Non -Water Supply Well:
Monitoring
Injection 1Ve11:
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
Experimental Technology
Geothermal (Closed
Loop)
Geothermal (Heeting/Cooling Re um)
4. Date Well(s) Completed: 6/ /'r?U18
5a. Well Location:
Duke Energy
ID Recovery
DGroundwater Rem ediation
OSalinity Barrier
DStormwatcr Drainage
°Subsidence Control
DTraccr
❑Other (explain under #21 Remarks)
Wen ID#MW 8 D
Facility/Owner Name Facility ID# (if applicable)
233 Sutton Lake RD Wilmington NC, 28401
Physical Address, City, and Zip
Brunswick
County Parcel Identification No. (PM)
5b. Latltnde and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/tong is sufficient)
W
6. hs(are) the wen(s)10Permanent or ❑Temporary
7. 1s this a repair to an existing well: °Yes or IDNo
lJth a is o repair, fill Out known well construction Information and explain the nature tithe
repair under 121 remarks section or on the bock of lhts form.
8. For Geoprobe/DPTor Closed -Loop Geothermal Wells having the same
construction, only t G W 1 is needed. indicate TOTAL NUMBER of wells
drilled:
9. Total well depth below land surface: 100 (ft.)
!•nrmuhiple wells Gat all depths jdii(jercni (example. 3@200' and 2 l00)
10. Static water level below top praising: (ft.)
JJwolerlevel it above casing, use "1-"
11. Borehole diameter: 6
12. Well construction method: Sonic
(i.e. auger, rotary, able, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm)
Method of test:
13b. Disinfection type:
Amount'
Form OW)
5?ci
For internal Use Only:
U. WATER ZONES
FROM
TO
DESCRIPTION
fi.
n.
ft.
fL
15 OUTER CASING (far at.iti-eased
welts OR LINER (if applt table)
FROM
TO
DIAMETER 1
THICKNESS ! MATERIAL
rI.
n.
ia.
16. INNER
CASING OR TUBING
(geothermal eiesed400p)
FROM
TO
DIAMETER
THICKNESS
MATERIAL.
+3 ft.
90 ft.
2 la
SCH 40
PVC
ft.
rt.
i..
17.SCREEN;
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL.
90 fL
100 rt-
2 in•
.ot0
SCH 40
PVC
rt.
ft.
in.
'IL GROUT - _,..•....
FROM
TO
MATERIAL
EMPLACEMENT METHOD& AMOUNT
84 H.
88 '
Ben Chips
Pour/ Gravity
0 ft.
84 ft.
Portland
TremielPump/9/94 lb bgs
ft.
ft.
19. SANDi 3RAVEL PACK (If applicable) • • . _ ... . , .
FROM
TO
MATERIAL
EMPLACEMENT METHOD
88 ft,
100 it.
1-A Sand
Pour/ Gravity
rt.
rt.
20. DRILLING
LOG Cattails
idditloaaiabeetsiftwmsary) -` -
FROM
TO
DESCRIPTION (ntar,Yardness, wLreck type. grai. size. etc.)
EL
R.
_
ft.
ft.
IL
e.
SEE GEOS LOGS
ft,
fL
ft.
fr.
S 3 Z®'IB
.AU- .
21. REMARKS - - . .
).140.rvr "D''„ Pro,,(' j.;i,
22. Certification:
Sibmature or Certified Well Contractor'd ei
6/14/18
Date
By signing this fw,ii. 1 hereby ceni%y That the well(s) was (were) constructed in accordance
with MA MAC 02C.0100 or 154 NCAC 02C .0200 Well Construction Standards and that a
copy of this record hos hero provided la the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
8U BM ITTAI. INSTRUCTIONS
241. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Resources, information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Infection Wells: in 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 or Miter Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c, For Water Sunpfy Bt inleedon Weill: 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.
Nort)t Carolina Department of Environmental Quality • Division of Water Resources
Revised 2-22.2016
Scanned with CamScanner

WELL CONSTRUCTION l`F
MUM NR/DWR
%.Weil Coatrattor Information:
Vernon Dale Olsen JR
Well Coatractor Name
2774-A
NC Well Contractor Certification Number
Cascade Drilling
Company Name
Z {Yell Construction Permit N:
()Null airlwathle welt ro.tun,rrunpennrn he. Lilt : ('aany. tale, t uriance. etc )
3. Well Use (check well use):
JUL 3 0 2018
Water Quality Regional
nperatinnc gectjen
Wilmington Regional Office
(1%ater Supply Well:
FL—JaAgricutturo2 [° Munic ipal/Puhiie
�Gecxhemal (Heating/Cooling Supply) °Residential Water Supply (single)
]IndustriaVCommocial ©Residential Water Supply (shared)
Irrieatiorl
Non -Water Supply Well:
Monitoring
Infection Well:
Aquifer Recharge
}Aquifer Storage and Recovery
Aquifer Test
Experimental Technology
]Geothermal (Closed Loop)
jGeothermal (Heating/Cooling Realm)
4. Date Weli(s) Completed: 6/20/18
Ss. Well Location:
Duke Energy
° Recovery•
❑Groundwater Rentcdiation
❑Salinity Barrier
°Stormuater Drainage
()Subsidence Control
°Tracer
❑Other (explain under (/21 Remarks)
Well IntMW 41 B
Facilib.O nerNone Facility ID/ (if applicable)
233 Sutton Lake RD Wilmington NC, 28401
Physical Address, City, and Zip
Brunswick
County Parcel Identification No. (PIN)
Sb. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(irwell field, one tat:long is au(fcient)
n
W
6. Is(are) the well(3)0 Permanent or °Temporary
7. Is this a repair to an existing well: 01'es or Ox No
Dins D a repair, fill out brow,, well roeulructirm rnformaltarr and erplaur the nature of the
repair infer tl1 remarks re rl'an or on the bock 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: 25
For mahrp/e wells lot all deplu fd�erent (example- J@200' and 2@ 100) (ft.)
10. Static water level below tap of casing:
If water lcvc1 IS above casing, sue `. '
11. Borehole diameter: 6 (In.)
12, Well construction method: Sonic
(Leauger. rotary. cable, direct push, etc.)
(ft.)
I. FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm)
13b. Disinfection type:.
Method of tell:
Amount:
For Internal Use Only:
ll. WAYR* Z0M1IX4
FROM
h.
TV
fl.
rltacturnos
ft.
IS,Othrtlt lWIttfpa# aW4we%"OR L(SF.R(irs onauh)
FROM TO t DIAMETER THICJOINS :MATERIAL
In.
le. INNER CASINO Qtt'flJBt e¢ (geothermal dared -feels)
DIAMETER N
+3 rt. 15 rL 2
h.
FROM TO
rt.
h. ft
'17,SCREEN '-
TIIICKNFS
its. 1 SCH 40
In.
FROM TO DIAMETER SLOT SIZE
15 n. 25 n• 12
n
n. .
In, GROUT
FROM
in ,010
in.
MATFR4.1L
PVC
THICKN ENS
SCH 40
NIATFRINI.
PVC
3.5 rt.
0
r1.
ft.
TO
13 n,
3.5 r1.
n.
MATERIAL EMPLACEMENT minion A AMOUNT
Ben Chips Pour/Gravity
Portland Tremie/Pump/1/94 lb bgs
19. $A NDIGRAVLL PACT% (If appllabie)
moat
MATERIAL EMPLACEMENT METHOD
13 n• 25 n• 1-A Sand
TO
n.
rt.
Pour/ Gravity
20. DRILLING LOG (stud addiclasat elects )(necessary)
FROM n. DESCRIPTION (robe. budgets• rwWtype. ants rfu:rat
er• r•1
rL
f4
fL
ft.
h.
n.
TO
ft.
ft.
h.
rL
ft.
SEE GEOS LOGS
yr� ivs rs'r+n fi v f
31. Rr.MARKS -
n.
R
JUL. 37013
tilfOr AOlar(I T'f�C,t.tv:,;:l:'!, •
22. cent cation:
Signature of Certified Well Contractor
Date
fly, signing this form, 1 hereby cenfy that the well's) was (were) constructed in accordance
wtrh ISA N('A(' 01C.0100 or 1 SA NCAC 01C.0100 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.
5UB:1TITTAT. INSTRI CTIONS
24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. for Inie� etion 1t'elts; 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 1Yater Clnnply J Inj lion %Yell.: In addition to sending the form to
the addresses) above, also submit one
completion of well construction to the copy he fop within 30 days of
where constructed. �h health t)r department of the county
North Carolina Department of Environmental Quality - Division of Water Resources
6/20/18
Revised 2.22-2016
Scanned with CamScanner

WELL CONSTRUCTION RECORD (GW-I)
1. Well Contractor Information:
Vernon Dale Olsen
JR
RECEIVED/NCDENR/DWR
Well Contactor None
2774-A
NC Well Contractor Certification Number
Cascade Drilling
Company Name
2 Weil Construction Permit A: pOpernations S�ection
Lin oilcryhcobk arlltertaranrav penes(. UK:aunty.. RF'i�j )fficf,
njt ot4 a r
3. WWI Use (cheek well use):
Water Supply Wen:
Agricultural OMunicipal/Public
Geothermal (Heating/Cooling Supply) OResidential Water Supply (single)
industrialr'Conuternal QRcsidential Water Suppty (shared)
lrnp-alion
Non-11'0ter Suppty Well:
Monitoring
Injection Vieth
❑Recovery
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
Experimental Technology
Geothermal (Closed Loop)
Geothermal (Heating/Cooling Return)
JUL 302018
Water Qudlily Regional
Q Groundwater Remed iation
Salinity Barrier
OStormwatcr Drainage
QSubsidence Control
Tracer
Other (explain under k21 Remarks)
4. Date Well(s) Completed: 6/ i W 18 Well 1DI1 MW 8 B
Sa. Well Location:
Duke Energy
Facility/Owner Name Facility Ink (if applicable)
233 Sutton Lake RD Wilmington NC, 28401
Phy:ice Address, City. and Zip
Brunswick
County Parcel Identification No. (PM)
Sb. L ititode and longitude in degrees/minutes/seconds or decimal degrees:
Orwell field, one taf/loeg o Iaffacient)
N
11'
6.Is(are)the well(s)1]K Permanent or °Temporary
7. Is this a repair to an existing well: ljYes or ElNo
1/thu u a repay, fi0 ow bv,m well ca,srrnction mformation and explain the whirr of the
types;, w+Ler i21 remark, maim or on the bock of thu form.
3. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction, only 1 GW1 is needed. indicate TOTAL NUMBER of wells
drilled:
9.Total well depth below land surface: 25
For pte wells hst all depths tf different (exam e- (ft)
pl JW'aul2ri`b100')
10. Static water level below top of casing:
1 water keel Is dhow tau rue -." (ff.)
11. Borebok diameter: 6
12. Well construction method: Sonic
(i.e. *um (otny, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (apm)
136. Disinfection type:
Method or test:
Amount:
i
For Internai Use Only:
4529R4 ..
tor. WATER ZONES- -
FROM
TO
DESCRIPTION
0.
n.
ft.
R.
'1S.OUTER CASINO (far *ut44asedmoms Ott LINER Ofappileab4)
DIAMETER THICKNESS Ile MATERIAL
In
FROM TO
B.
ft.
1111. lr t' ER CASING OR TUBING (aeabernial tlaeddaap)
DIAMETER
FROM
+3 ft.
ft.
17.SCR EEN
TO
15
A.
ft.
THICKNESS
2 In. i SCH 40
in.
MATERIAL
PVC
►RO.N TO DIAMETER SLOT SIZE THICKNESS
15 n• 25 ft. 2 la. .010 SCH 40
Ice. GROUT
FROM
8
0
ft.
fL
fL
ft.
MATERIAL
PVC
TO
12 fL
8
ft.
ft
MATERIAL
Ben Chips
Portland
i9.SAND/GRAVEL PACK (if appikaiak) .
FROM TO
12 ft. Y5 ft.
ft, ft.
EMPLACEMENT METHOD& AMIN. NT
Pour/ Gravity
Tremie/Pump/9/94 lb bgs
MATERIAL l EMPLACEMENT METHOD
1-A Sand (Pour/ Gravity
20,DRILLINO,,LOG(anti salting 'beets Ifworm ry)
FROM DESCRIPTION (roier, as rdaa,,,.litre type. ar.1 ,ore, NO
TO
k.
ft.
ft.
R.
n.
ft.
ft.
21. RLMAR1tS..
ft
f4
fa
R.
n.
ft.
SEE GEOS 1.9q§
„ •
JUL an8
22. Ceruryation:
Signature of Certified Well Contractor
6/14/18
Date
By signing this fora,, 1 hereby cent that the well(s) ens (were) cansnycte,J H aanrrb,ce
mth1SAW(4CO2C.0100orIS.tAY'ACO2C.0200Well Cotutrucrion Standards and Mata
colt' of this reconl 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.
11 I 15121. VS
24a. For All 11'etil: 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. potpor l acting Wjj1 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 I_JatiC Program
Igh. NC 27699-1636 1636 Mail Semler Center, Rile O0 o636
24e. ps\ynter S,nnly t, Inl
the address(es) above, also submit ctkoA 1 ' in addition to sending the form to
the copy of this form within 30 days of
completion of well construction to t
where constructed, county health department of the county
North Carolina Deportment of Lnviranmental Quality • Division of Water Reftereea
Revised 2.22.2(116
Scanned with CamScanner

WELL CONSTRUCTION RECORD itC�IV(GW-11NR/DWR
F'or Internal USc (illy: nJ C
oh
Weil Contractor Information:
�A S S
OiC)I C'ourrrl x Name
c I
NC C,ontraMf Ceriiric..2tion Nuiolpr
Company N:tnt
r,'1b'cll C`,00atroction Permit for
J.f.TI .JI aprpIK•ubie wolf t: HIvtrr' (w tx:rntit,Y (i.e. U/C. Crnm{v. Stuie. f/odra,cc. alc.)
3. Well tlse (check well mg):
JUt.
Water Quality Regional
Operations Section
y�ilyui•aton Realonal Office
Water Supply Wc1i:
Agriauitnral °Municipal/Put/lin
ieolhennai (HeatingrCoofing Supply) °R,esidentia► Water Supply (single)
IndatsviaUCotmnercial OResidontial Water Supply (shared)
Monitoring
Injection ' tilt
Aquifer Recharge IJGroondwater Rcatnediation
Aquifer S or ge end Recovery OSnlinity &atria'
Aquifef Test OStutmwottr Drainttge
l'=agcrimcnlal'rechnology QSubsida ltc Control
Geothermal (Closed Loop) afraexa-
Geothermal (i•icatio 'ooling_Retur flothcr (explain under(i2l Remarks)
Itecovery
a. Doe Well(s)Colttpleted; Weil1f)i1
Sn. Weil location:
Falk
Facilityer Name
11 4 S tN l 01-43` sr
physical Address. C. and it
County
/1
Factljly 1174 (if navlicali e)
OAJC —2, 51 o ..& PC -
Parcel Idehc;fiuttlon No. (PM)
lb. Latitude and longitude iu degrefts/minutxalscronds or decimal degrees:
(if well field, ooe laiflong i9 9u f iietenr)
330 S. aa(0 rl 02s' la 4Ii, N't)
6. Js(are) the well(s) lrermanemt or Q'femport r
7. (s. this a repair to as existing well: °Yes or i.No
frrhu' ix a rep iir,(rrll our knxiwn wr(( cocarructtoninforvrotinn oncl cxparum the narnm Of (tic
repoir umber a2i rI1111Qr1U: iCC'L(W! UrLW iwyk .a19 Lf J 44131um.
8. For Gcoprobeff.io or Clesed-Loop Geothermal Wells having the same
e(tnstfactiva. only 1 OW-1 is needed. Indicate TOTAL NU,M13P.R of welts
9. Total well depth bow and aarfzce: r
For muhfpte wR11s tie all depths tf deem( (example- SV,00 pa 44;1001
to. Static wafer level below tip uP casing:
1rw(i, r (eve( L+ ahoy owing. arc ' ."
1 t. 1'iprehple diameter: � (in.)
12. Well construction ►nuthod:
(i.C. ;qtr., minty, car, direct push, ctc:)
TUBING
■ rifAntrtxp4, ,. lorranEss MATERIAL
in.
ft.
FROM
'f0
OfnMErt:lY
WTSJZ
_I'ttl��(NyItS
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T �_
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•
FROM
7.O _
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ft,
ft.
xa7A11:1,111C11.1C ,lttaci, . did..,•. .;
FROM .
TO
ocackt IAN kein ,.biribeek +/'ree= Oitra friar etc:
ft,
ft-
ft
ft,
f.
A.
tL
it�.
�_ _.,_•o ,....
ft.
ft.
�., c:
FOR F1A'PXR RIPPLY W t1.1.S ONLY:
tam. Yield (gp+n) Method of te+:t:
13b.Pisipfeeuon type: Amount:
22. (:ertifltati
(nature of Cortiti
Date
1)y timing tits f y eerl fy (hot the Weft(s) tees (}ra epenvslruerc'd Or =Ionia
w1Th 'IMA M AC U 00 or /54 NC.'AG' y1( .O2 k Pith Conxrruct!(rn Mondurdi- mil di(
crrpy Of /hh raea(d der l'een provided to (k wr.(1 mgtrrr.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or w
cunsT'uction details. You may also attsett additional pages ifneoessttry.
24a. For All Watt Submit ft s form within 30 days of completion of W
consttuction to the following:
Division 'of Water RoSourcev, i>tforinaffoa t?rocceslog Unit,
1617MaH Service Center. Raleigh, NC 27699-1617
24b. FtrrJaleclino goblet to addition to sending the form to the address in 2
above; also submit one copy of Min form within 30 days of completion o1" w
construction to the following:
Diviaio>n of 'Water Resources, Undergrotand]ajectlon Control Progretn,
1G36 Mall Service totter, Raleigh, NC27699-1436
244, F 'a Wetr3llt)Iy {1 1nIRetion, Weis: OJl addition to sending the forth
the adcltoss(es) above, also submit one copy or Kris form within 30 days
completion of wolf anstivaion to the t.44mry• health department of Ile cant
whoa rnncrnu•r.'A

WELL CONSTRU UON RECORD (GW-1)
RECEIVED/NCDENR/DWR
1. Wet} (:olttraelor information:
well (: i a N:mlc
JUL 23 2018
WC Well Ctmuactor Ccdifieation Nurrtbor Water Quality Regional
/4 at - f f• f( e erations Section
Vur i t fl RbgttTTldt Niue
<:arnpanvt\etnc
3..WO Construction Farrah /s
1.rsr all applicable, +eali CYNr.011,1,rian 0eratI. a.r. Wt.: Cnun(v. Stole. D'orirmcc.
3. Well tine (check well use):
Water Supply Well:
Agricultural DMttnicipal/Ttiblic
Geothermal (Kaput r'Coofing Supply) oResiden[ial Wntar Supply (single/
YndustriaVGotnmercial DResidential Water Supply (shared)
Non -Water Supply Weft:
ltJectioe 1 cm
Aquiftr Recharge
Aquifer Storage and Recovery
Aquifer Test
1'xfscttmentai Technology
itGeothermal (Closed Loop) Claraecr
C,eothermal (t realm opting Return) f ottser (ex lain under #21 Remelts
e, Date Well(s) Completc4: ri /4y _ We11 1131f
S ..WeU t,,neariont
Facility/Outer Name Facility Ir)k Of applicable)
1a i tic, !4 1-C Qh.K., .ems'/°--ek
Physical Addrec.C, City; and Zip
L rc d
3(3roundwater Rvyttediation
Salinity Barrier
DStormwater Dwinagc
Q'Subsitlenee Control
C:army Parcel 1d,endfr:,trienioos (niN)
Sb. Latitude and laoagitttde is degreesJminutew/second9 or decimal degrees:
Orwell field, one lat/lorlg is suffielent)
6. Is(are) thcwefl($)fgPeranareerti or Ql'6empnrary
7- la this a reptatr to an existing watt: or 0Pto
ffrhr: it a ropalr.1111 char known well CranSrructian itybrmorinn and Nxplrrn, !ha atrium of dK
, pair utdfsr Y2 nu,prkx saecinn w• ell, 1hr, fwak oJ'rhrc f<„m,
$. For Gcollrobc/IDIF or Closed-lzmssp Geothermal Wells having rho same
construction. only 1 OW-1 is needed, Indicate TOTAL N1,TML>F.R ot'wells
drilled: --- _.
9. Total well depth below had surrace: A- -_ (ft-)
l ilr mrdtlple wells !!sr all depths rd c.lArezJ (cal We- 3(000'aand 2qp,t00)
10. Static water bevel helmPa top of easing;
l(L'Arer lc'e! l,` uhnvc eaNinh, roe "•l,"
t,1torebnle diameter: i (i0.1
12. Well eouarrucdon method: 1*97t'«
(i.c. *tiger, rotary, chic, 1e, d6ccH pvtah, cte.)
(Ft)
14. W(l'Ckdt' ?3 S•, ;sa;•'
FROM TO DF;C,ryP730,1
°fr R, Cp4tS S ' 4L
ft.
1.5.4)U 'Fl1 CASMC ike aigvuca [rp7.9tra INER` itir
rRODM ['r() Dupsiet1.tt ntrcrw s
tt. its ft. lira ya j tJC
AIAttrtiticrw
rera 9'H�r1:iSHpi`C. R4.
in.
mATesetAL
MamE,Toi iliTi r�6`.. TRx"r(NYSS MATgRX4l
ar 1. t yyl>x. ). a/o Aka
It, ft- in.
tkatotr.'.: r.:.:.::.i
IgpilAt, 1 C.Mrt.4.(:a'.•:51?:NT METHOD & AMU:
ratretAcznoserAtenton
ft.
n n.
O�1L1LEtN t LIEF'{AltitClf D urr1PO�1� iYrocit •
Ivpu Arwir Stet
ft. ft.
n.
ft.
A.
ft.
a
ft.
tt.
ti
ft.
JUI_ 1 9 1-1118
FOR WATER SUPPLY WP,LIA ONLY;
13a. Yield(gem) Method of lest:
1313. Rsaiafectiob type: A roovnt:
22, Certification:
Afp
13Y slgrrrng r . form, i' ' by teal jv altar the wee") eV over- <orrf{irict'ed D acrdo
wlih ISA ;AC: 02C .0100 or MI MCA! 02f' .0200 WI C 4fv,X t(on .Srorrclo,rly and rlt
copy of Fit r record hat been prtrvidatd tint wwil nterer.
23. Site diagram or attdittoual well details:
You may tlse dtc back of this page to provide additional wvell site detaits or Y
consmiction details. You may also attach additional peCgeS if vemesar'y.
6)» i TAAM.1Pt 114301IONS
24a, For An Well4: Submit this form within 30 days or completion of v
construction to the following:
Division of Water Ream:weed, Io6 niu tion 6huelsaslrig Unit;
1617 Mail Servitx Center, Raleigh, NC 27699-341.7
24b. Et tjakeetiQf WOW. In addition to Sanding the tbrtn to the address in
above, also submit one copy of this form within 30 days of completion of >r.
construction t0 the following:
Divrsipq of Water Rcsoarcea, Ueldergrovtsd lajeet,00 .COnirol i'rogram,
1636 Mail Service Ccntee% Rakirgh; Nc 27699443,6
24c. Fttr Wail * St,r,aly 1*.introki,1 Welfa: flu addition W sending lire forth
the, addniss(es) above. also submit one copy of txris form within 30 days
completion of well corts6ructioo to the county heath ctoparttneot of the coo.
whoro mncleurrn,l

WELL CONSTRUCTION RECORD) (CW-I)
I. Well Contractor Information:
Wctl r:'onlra, or Nnmc
NC Wel Cotitntrnor Canificotion Number
. e -?t • 0al ll•
Company Name. Q Q
2. Writ (:oontrucdon Permit IVater Qwjit
RECEIVED/NCDENR/DWR
Lt,t(,d(apt7liiah/r, ,Noll co,: rtrlK•(i(n (Krertil.r G•C.
3. Well title (cinch well use.):
2018
Wilmington Regional Office
Water Supply i7tteal:
Agricultural
Geothermal (Heating/Gboling SUppiy)
tndttctrial/Cotumerciai
trici aioa
Non-Watet'SapP Welk:
Motile rigs
11u9eetion well:
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
r.:xpericncntol 'Technology
C3oothermal (Clos<c 1 Loop)
OMunieipal/Public
agesidentied Water Supply (single)
OResidcntittl 'Weser Supply (she rod)
tccovery
®Groundwater (tcmcdiation
OSalinity Barrier
DStotmwates Drainage
QSubsidenec Control
OTr>acxr
Geolhemtal (HeMinsz/Ctx)iiat Return) flother (explain under 112I Remarks)
4. Date Wr1l(s) C;Ompleted: �� /'"li�4'di Ii]#• _.
5s. Weil Location:
Sat, N & N.
Rhhyy ice Addres,•, Cicy, and Zit)
-4.t.L..tr..'a.i.s s
County
ST
,facility IDl (if applicable)
Parcel IdenOfievion No. (t'rN)
5b. !Altitude and toPgitncle io degreeslminutctlsecends or decimal degrees:
(if well fteld, one 4aUlortg is sufficient)
a•
Ss: 12Q N a7r e6,3o�
6.1s(are) Rae welt(e).Nerutatnent or ®i•I"etttporary
7. Is this a repair to an existing weft: rYcs" or ONTO
y'rktr is a repuir,•I 11 out knows welt consT(crion inOnxation o>ad'etpluln tfro nature of the
ryalr n kr 412 (ro•tnwkv sas(uu ur oil lire hack elfl(fIs%ornh•
8. >gor.Gi probe/MI Or'C:los«!-L4op Geothermal Wells having the satno
cnnittiictioit only 1 GW1 is needed. 'Nicole TO'I'ALNUMMJ3P,Rofwells
dri lied �,...._._,.,�.,,.._.....,,...�..,.�.....M..,•�,,.,�..—..
9. Total well depth Dctuw land surface; sa2 ft'.)
For ofultip(5 welts list all depths l(difftrent (e osnnpto- gp20Q' and 2(4j7001
10. Static water level tattoo, top of casing:
water(unt ly ahoy clrrtn(1, ore "r"
t!. Porthole diameter: (in.)
12. Well construction nlctllod:
Grl.rTr
w
(i,o, suer, rotary, a tblc d tell push, ttc.)
FOR WATER SUPPLY WELLS ONLYI
13>a. Yield (pun)
M ATEtt' Ar.
1100Q-
,tY 4y1KATEit2,O I$8'.�«a.
FROM '{+Cl beit.CRFpnon -.-r....�.
j, o ri, a/- fi COua f SA—�
rt. ft.
15:O1ilP cASTIrCLk toith1-tea•
Mont 'ro nanarElleR
it, i 40, 0
et. •r m. 040
hAMR CA1311•16iOB ilitteRi {(no erdbai eP)
SN�r�le4
atom
it.
tx,GloYur
ft.
a1 /
TO
It.
D A.
A.
in.
MATT tIA
1t
ft.
i
R �trr SITE
AY
MAT£RIA
uC
RMPLAC,F,MEftYfl oL SMoUt
PRGM TO MAT.ERSAf
R.
ft,
fr.
£MPLACEM ..rtT*Kiliaoa
tc
20:'DF.i;l IANGIPG'itutRctd addltklea ie3Yt )....:_ .%...,'. _ `:'. • +
tuo►t
To,
hest: aura Ysytt itdsr ttarSsm, te0trsck qDm Irk, 464 etc-)
it.
le.
ft. ,
, ft.
ft,
ff.
Ss,
Ft
Y
°..ti F,, )ram
t
ay
JUL I P; 2018
Method of test,
!3b-1.1131okct>iem types hrttuunt: �_...�
vim; ;t"iir:{•i .r
22. Certification:
Ara
siaaatuce of Cartifr'• Wetl : • or Dale
My alg t g thfr forha; h li ccrllfr ON the welt(s) icat (warF) etinsr'suereti in•aecorda
w(ch 1SA NC rfC Q2C • +LAO t . SA NL'A Y 02' •Q200 RV f o MPucli pn tandardr cord tlx
Mpyofthis txtror4 leas eenprovickdto Ua well owner.
23. Site 61:tgrsm or atYdltiondl well details;
You may use the back of this page to litovido adi(itionhtl 'well, site details or ,i
'constriction details. You may also attacks additional pages if itassuiy.
141rrALIN$MIUCrlarlti
24a. For AU WAN; Submit fh(s form within 30 days of ean(pletion of w
tAttsttucti.Qn to the (b lowing;
Division. of Wafer Resources. lsfortttsttioo Processing !host., •
161? Meil servirce Center, Raletgb, NC 276994617
24b FOE Weeder) Wells: In addition to sending the form to the dddttag ith ;
above, also submit one copy of this form Within 30 days Of ro mptetiotf of w
construction to the following:
Di'issioo of Water sottrcey;!Underground.Injection CclrttrolProgtall,
1636'Mtil1 Service C,enter,'R& dill, iisC 2')699-106
24e. Fgr Water SujlY & t ier,004 Welk! 1n addition to sending the fonts
the; address(m) above, also submit one copy of this form Within 30 days
cotnp(orion of well enttetniction to the county healin den(utrnenc of the Cow
CYhprp rnnctnrr•tnri

WELL CONSTRUCTION RECORD fGW-11
woi C.Oalreef)r Information:
G� n7 c ea rr- S
Well con,raelu, N:unc
NC Wc11 Contractor Ccnification Nurnlxtr
Nu. may.... ? /(L (duality Regional
(,a,pi„YK, to p ations Section
Wilmington Regional Office
Wet) (`ondtract im Permit fJ:
Linn u(l a:??lreohlrt wrli ronx(nrcrum /Mrnlit r (i. r. 1/JC. Crxu, y. Srale, iorkoma. de.i
3. Well Use (check well use):
RECEIVE[)/NCDENR/DWR
JUL 2 3 2018
WaterSuppls Weil:
Agricultural QMuni cipallnublic
Geothermal (fieatirtg/Cboh'ng Supply) QRcsidential Water Supply (single)
industrial/Commercial jResidctltiotf Water Supply (shred)
Non -Water Snp¢ty Well:
Monitoring
1Djection
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
'64peritndntaI 'Technology
Goothermal (Mind Loop)
Rasgvery
Ej<houndweterR tncdiation
DSalinity Barrier
DSt n water Drainage
iPtibsideoce Control
()'Prager
Geothermal (lientin Cool ins, Return) 00hher (explain under li21 Remarks)
41. Th a Well(9) Completed: G — / 7 Wett no J Y
Ss. Well t,ozetlan:
21d1_ .TAB CL_�_.
Fzcility/Ow 7xr Nam
i_L, jT
3d1 Nr Sg"
Physical A i res;. City, and Zip
AdiZVN4a4„tr'
C:pnrM1'
t aciliiy (1A (itapplicry4lc)
OA)C toe
1'aroe1 Itkntiheaziun No. (PiN)
5b. Latitude and longitude in degreeshnlnaten/se nods or decimal degree;:
(if well field, one la?I1wtE is sufficient)
126 S..s. /! r N
7r
t76 06 . J' S w
6: is(are) the w.cll(e) rtaanent or j"6ctnporary
7. is tttia a repair to an existing well: JVcs. or ago
!!this i.r u repair, JNi „art b,oi wr/! r,,x,srnrisiun / 'J rmotkw, and etr.lu/n rho twos of the
lWair uu:Ger +i 2f nr,n00,4A 1001i1)11 v,' on the, back ul'llru'Jorm,
S. For GeaprobalfT or Closed -Loop Geotbermnl Wells laving the same
umstruciiot. only i GW-1 is needed. Indicate TOTAL NU2vi131311 ofwells
9. Total tq-ctl depot below taut/ surface: , r (D-)
l'or multiple wells 11 t all depncx ij dOra.rt (example- 3€73200' and 2(4).101
I.O. Sink water level below top of casing: 4 ((l.)
/fw'ntrrlcwel is•ahov., rosin!;, rear "+"
11. Borehole dlumeter: eza . (in.)
12. Well construcd4 oa method: t.,)l4-074,_
(i,e, au,vr, Mary, atblc, ducat pus),, etc.)
For Internal Usx: ()tly;
.14. Wh./FI 2Q}YEP3, . ;i:r; • . ! . :.. •+ .. ,
11194
'f -_
n>t 'ritoN
U, nh
g n'
41.9n.---f 5 wok
ft.
is
'15-'OUTER
CASfliC a+akS-ev..:d,;,
;,
a:; A4 •,. -Mc
a `ROM
'f�
owns - .
Curcio ens
MA'reR►at.
ft. j
4,d ft.
I e ia,
0
, ��
• t<.
tSI1 G.081111141
; Is:. t, :,a . ""... A)':...:..:'..::.•.,: ,. :,:
IAN
V
WAME T.trk
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tA;
....
ft,
n.
in.
ft.
fl,
in.
•
FROM
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„Aktr
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'sip4)&04T;,._ - ....
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r,F3PtACFMIEFITh4MUr►
.
n:
rt.
21_ s :�.......b. ..,
ttingi1 '"?. cs = t .; _.
FROM ')ill
[Ii�S{; M' kNara K, t�raeeasww rek Hue. x++k+ eat, cl -)
ft-
ft•
ft..
ft,
a
-
(t.
it
9
ZOl
ft,
fti
..,_.._ j�}{_ !t
;t: t tt tdits. ., , . , . t.-:•..tn5, ,t..,, 5;,
FOR WATER SEPP1,x WWI,I„s,ONI,`l:
13a. Weld (pm) . Method of' root:
13b. Disinfection type:
Amount:
22. Certification:
Signet= ofC cttifio Well ;!trader
1%y xigring riiir form,
w(ib JSA NCAC 02C
copy *phis record
Date
he R cer(i(. Maifhe WeJI(i) wa§ (weir) tWrsrrtuFPd In 4cc rda,
100 or JJA NCAC WC:.(1200 ff'eJl Ci.n.ark yion .SYondorc:(t and W<
iseorprpv(de4tonccs eRowrio'r.
23. Site diagram or additional wdl detalls;
You may use the back of this page to provide additional well site details Or V,
construction details. You may also attach additional Res if nrresserY.
PLOMirtAit ITV, t,>X'rl INti
24a. For ,ill Wetig: Submit this form within 30 days or completion of u
construction to the following;
Division of Witter Rasourcc s. Infonuation P. t'Cese(ng Unit,
1617 Mall Service Center, Raleigh, K.27699-161.7
241b. bar toleet(on Wefll: in addition to sending the form to the address in 2
above, a/so submit oile copy of this form within 30 daye of completion of w
construction to the following:
Division of69(ater Resources, Underground injection .Control Program,
trr3G Mail Scrvicc Ccnttr, Radighi NC 27699-7636
24e. F,4r W_Jity _Surnalyilc i litt-6On IrYt:liait fn addition to sending the foot
the addvcss(cs) above, atce su;,tnit pne copy of this form 'within 30 days
comtilerlotn of well eenattvetibat to the enemy health dcpsrtinent of the caul
soneh' CpndInirteri

WELL CaNS'd"RUCTION DECORO
1.. Welt ,Contt ae1nr lntorrnationt
iUl. 23 018
Wc7 Conn':t 'Mime
4
NC Well Contractor Cvnificador Wvmbof
Water Quality Regional
Operations
al Office
Wilmington Regional
(Company Name
2. Wctt C:ottttruetOR Permit (h', •
1.14( vj pl,•vtdr rwt( at».trra:ti'm peryrrit,4 6.6'. tilt" Corvu(t'. Start Vaderr(rt. etch
3, Well Vrie. (Check well use):
Water Supply Wc)1;
1111
Nog -Water Supply' Welt:
,Agricultural
Geothermal (ifeatine.bofing Supply)
[1hduStrl$1/Cotnmerc:ial
on,
Monitoring
Municilralfpubtic
Ellitl sidcntiai Watcr $tipptY Csingio)
QRmidential We Supply (shared)
(4:cow y
For [Inertial', U:4 Only:
9
•14.VIA
� 'r ,,•i::.
Posckir11O1+ .. .
9) rt.+ a �`;` , �t
�n.
O. �UfAM t' I. 7Sranror= ' Tairc'3(Pfxms
.it' tn- a/o byo
lB
JMOM To ) trM. EMPIAMME 1Ob d6
Injeetkoa elf:
Aquifer Rachatg4
Aquifer Storage and Reersety
Aquifer.Test
'F,xperimcrosl't'cefifiakrey ESubsi3lenoeControl
Geothermal (Closed Loop) DTrecor
Geothermal (ifeatin fC poling Return) Clther cx rain wtcf 'A21. Remarks)
00tOUntlwater R+:aftlediati0rt
jSaltnity Barrier
C3Stormwttter Drainage
4. Dee Wells) Compkted:. ?�/ �jV Wen JA#
5s. Weil Location:
, Sc.spetl- • Q3 �..'St-
Treil)ty/t>rent t r.ap,e facility 11)&(if npp]i;,eble)
/o 7 SE /5'°L.k
Physical Adfiop. City, and Zip
8ev&S
County
Nam et iduntiiiuuri(n No. (pile)
5b. l.etlttede auld.lony itude ip de, r-et9Irbitluttvisecotuls or decimal degrees:
(((well field, one let/lottg is sufficient)
a•
336, s~. N 02/- Dr.,6v-d' w
6. (stare) ctiowclt(e)'ertntutefat or r'Fcttlporary
7. its mils a repair to atr CeStictg wctl: !Yee or 0101O
It this IS a repair. cif out known watt cotfsrrteton Infonaut:1 and er/AI» the *MV ojrhe
meter unokfr ;F2i rsp,arka y ttilfo t ,r uar &c hur k td difkJornt.
$.For'Gto wobdl)F'd' or CJoeed-Loop Geothermal Wells' having'the Saoac
construction; Only 1 OW-1 is needed. Indicate TOTALNUM)3C?R ofwclls .
TTtai. wveif eleptbf below rand surface: c;/-
i'orm(,trtp( wdf. Pr: otldepthsi1dl ren((erempte-J4 f2OO'a.?dAgt001
1.0. 6tatic water leVr) below top Of taaita'g: . 6
If watrr t6`!'Ct 1• alifre t caving usr "'t•"
a 91, flore)o$e dlarneeer: (in.)
12. Well construction inetAod:
(lA RAM, q+utry, atbte, direct push, cr.)
(ft.)
it.
to ft.
FftON' .1)•
TAA'tEMAC ItaxrtAC hilt VME17
oiAc.' rfIrstrtsaairZbrdem;+Wrod,alp?Rom`
ft,
n. ft, t 7,1C 71,. i
1 i . k. -.• ., ---- _ -- k..
tR rt. ,.
ft. ft 1 t"
re. ft. JU1
1 !Olt WATER RDMIN WELLS ON111!
13a. Yield (gptu)
113b. fAsinreetiioo type:
Method, of test:
Amount:
22, Cer113icat',on:
Sit;nawct: of
ay8Ignrn. thfsf0 „(he
.wtdt JM NC:RC' .Old i
copy ofthtrMC. . dfrorbaen•
•
6r
Due
91. (Pict Ow Wie1(,* was (rrural•coiatfr'urtPcf f r
MAC ')2 .(i200 WP%t OftIrttnircglyn ,tilunflurdf
(tt /(4Yh,: v' Ii oWfrer.
2.3. Site' diagrst o ar u4dltioaatwei.details:
You trim/ use the back. of this page to provide additional well sire ticiai
tonshveti(m details. You may Also etttich•iedditifinal pg s ifnecessary.
24s. For. ,61E W49: Submit'thiS (Orin within 30 days of a>tnpletio
ontaieuction (o the following:
fieisitutof Water Rrs'urxes. titOirmarsors Fiocesaing floe.
1.611,Maii Service Cecter, Raleigh, NC 27699-161.1
24b. £A* Ietlecttoi1 in addition to .sending the form to the adds
above, also subedit ooe airy of this form' within 30 mays of mtplt•#k
construction to the fb1lowing:
fivi ion of Water Reno recS, Uadergrouet9l.Mgjeettou Control l'rc
1636 Malt.Serrke Center, Weigh; t 27d99-163d
24c. Fgr VW,etk $b=rdy & lniettio,n ket&: tb addition to rcctldins th
the atldttss(rx) above„ also submit one copy or min foffn within 3(
cautlItctiQrt or: 1N H oonshvetintt W rite county health department of ti
tV:1P>'P nooctrirtt"d

L.
WELL CONSTRUCTION RECORD (GAP -I)
I.We►I Contractor tnforrnatioo: REi, 1VFi)INCDtitJRiDWR
2E6Cr")_A '50)-e-5
NC!1 (.:anmeAn r N(rinc
NC Well t� lS U rtfflcrllAU Nwrbei
��k. .it-)tu P
Jul_ 23'10'2
Quality Regional
I ( akiops.SPrfion
Wilmington Regional Office
Weil (ortstrucdua Permit d.
l.r.cl uli npori 4'r. well ra»,,,Iry IFW (7
3, Weil t)se (cited( Tel) um)!
rrdricY�li:r, SITU. C:n:IA4V..SEate. Wartime.. Ktc.l
Wier Supply Wen:
A giciihttnil WitlnicipaliPublic
3c:Okelrnal (Heating:noting Sbppfy) ORcsidc'titiai Wafu Stip jfy (single)
CndttstriaUt vmmereial Ditosidential Wetter Sruppty (Misled)
oft
Sion -Miter Supply Wdl:
Monitoring:
Infection 'Well:
Aquifer Red iArge
Aquifer Storage and Recovery
Aquifer Teat
f;xpiximmtat'1'u>imo?(IgY
Sonsidenm Control
(knodteirnal ((=lo3ed Loop) OTC
Geothettit4gieatin /,Coolioa Rsti_L1 EC>ther. jRLkitt undo ii21 Remarks)
F'ar inters of U Only:
.152ms
v MM
'ro
pESCRtYT
N
ft.
15„.01r17,12'vAl=(fovn►ixk9-csri$
F m VrT()
it. 1�C)
ft.
TAICKNte
;,!_
MtrI VS,
MetTERIAt.
(1. F"^�
in.
0cco) ue-
,4
•gA kri•OR'3' rdtliMO-Teo
.• i .-,. :
.. 'AI
t1 mogreit
TakcKNP4'
RIAL
rt.
R,
in.
il-
/L .
�--��
tn.
I MR'
'll.
t SAT mn2,111,1're
sr elTC /Ai 1 411111-4(Nt!s
ttcctrvary
:DGrourfdwattr Rena diction
DSfllinity furrier
r)Stonmvatec Drainage
4. Aare Wrdd(s) Comp/eta: ?"4-7J Wen Ink
SSa, Weft i.,nca2ioa: r
'1;acility/Owotr Naurc
a a- i C 46 74. (:) .
Physi(at Address.,Clty,and Zip
..a.1 L.L4L_(LiC
(::mrnrV
5fi 9AaCntode and lanOltode in 6e;reesiroinutes/secondly or decimal degrees:
(if ,Nell Held, moisUtorrl:, is suflieienl)
f. ls(crc) tnewep(e) rmoneut Or` D"fcmpornry
7. is (ttik r rtpeir fA an ezisCtag dreLI: LlVes , or lv'o
1fthis i6 a rrtparir, / f1 fete !me(s
own well crrrtrt lkrn Ifjnrmtlrtpn Set explain the t'4tritt! of the
r opydr• if i i larr.'1,14, ol, ,) Nis
$. ForG'etrprobeirorr or CiordsilAxip 9eattlernaal Wells having the some
construction; only 1 OW -I is needed. 'Indict& TOTAL NUMBER ofwells
9. Total weft depth below land serfage: Of-)
l'nrmoltr. wells 1Tstedidp(s. ifdlfjtr'atr(stam3/ 00'arrd?C4;
1.0. Static sister Sege{ irc}ow VIP >yf t*sixrg:
/Iwnlarlcvclivchow (reing,use' ."
41. Borehole Uiaineter: , „4. (in-)
.12. Well construction nlctbod: L ' -' t
l l.a sus, rgtrrr)+, �blc, dncct push. e'r:)
�a ft 1 yyin. I . eyo
Ert
Tairst
0
�.19:,'t+t1 r11t"7��C`F�A+EsW i`4�iFf�Alir:a]saa)'...
FROM TO mATERrAt: KMFgAt Enftdt'rntb'l3
Eat PIACJOIVer torrnspo
re,
PROM T(l
ft.
ft. .
:agility ITN rif ttpoliesbie) Qt
rmreel'(eenEahcatiun Pao, ('IN)
(ft-)
Qtxcct Vt104.1(color, ►ontstn s r rail !
f . rt.
ft.
27- Certifra';a:
FOR WATER S'd7S'PLY WELLS MA
13n. Mid (gm) tklcttiod t,r itrsi:
131b. t)iatnitcdoe type:
Si ofCartifie4
gy.tYplhrg rhdrfornr. 1 hereby car
with 154 11'C.4C 02C',0166 or 1
wfiyofAUr !dhaykertp
Dole
e woo) ivcrs (ware)'cohs'tnrclaJ In
RC Ott; .u2r]n fv.z.tt avorrievon Sranrdorid,
to (lit well •9104. •.
23, Sitf: diagram or additional wail detait9:
You tnay use the back of this page to provide additional well site de1ai
construction details,. You may also attach sdditiOntd :pages i f tw.-'Sseiy.
' 31,41C1`CAL JNgraVEZERM
24a. yorSubntit. this £017n1 within 3C days Of complctia
costruotionwthe. A Qwtn:
MI5/6mo(Water Resontees, rofwmraSon 1iccesnirag (Jnit.
16171tdeil Servike Center: RAtt¢tgb,NC 27699-16f7
24b. , gjfi4 tisuL l!<e do addition to sending the form ib roc addr
obeyer nisi., silent o.oc coy of this form within 30. days of corn**
conStruetiu i to the followr),1;;
ilDiyision of Water Rtsourees-Vtadergronad 1•njestc0n Control PI"(
143.6'Mail Service (:•enter, Rakirgi 1 NC 27097,4696
24.e. rYiljtter S(;$! v dk }0j'stsek, ti'e: f'n xddttion to sliding u!
she addrc.;s(es) a'ouve, uisu sut'mit or'e copy of ruts Conn within 3(
completion of vrcl1 con_Araclirm to the (.m re), health department of r
urD(prn rnncmrr4nrf

WELL CONSTRUCTION RECORD (OW-1.)
RECEIVED/NCDENR/DWR
1.. Well Contractor Information:
Fointernal Ubt Otriy:
4 gi7
+Fell C:wurucl+ N r»1c
JUL. 23 2018
NC Wc1( ContractcT Certification Nwnl)cr Water Quality Regional
Operations Section
/4 Q-u_A t Yt' purl (tr-�,ugtL,n RPajanal Office
(;txnmmy i`s+r+c
2. 'Will Construction Permit N:
kar vU appIr(ahle )'rll enn.)Iflwtlon permits 0.e. 10C Cozurlx .Stale. remoter. etc.)
3. Web Use (check well use):
We ter Supply' ell:
Agricultural
Ciedthcimai (Heat.ing(Coo(ing Suppty)
Ind tictr i allCo mai ercial
No�Icr Saoply Well:
Monaoring
DiMunicipallPUhlic
C)Rosidential water Supply (single)
DResidentinf Water Supply (shoed)
Iojectton Welt:
Aquifer Recharge
Aquifer Storage and Reoovcry
Aquifer Test
i xperitt)entnl Tcohnoingy
Geothermal (Closed Loop)
Geothennsl eatin�CuOl�in k2vKn um1
al ccovcry
..1C Q1til'E17AM `'i*,: e ,
- y72QM `ra DESCRIPTION
«. f`
15:•01TER'eAS ./Lor loath rsect,kep'f3j1`CSRVORRIe
mom 4 TO mamma. ?ri1CKNISS$ A'TIMIA[,
O rt i>z U b a
f"ir�'ltsi,cn�a+l:txtsslrtc. (;del^
rctOM TO PU RIM -ER TalleRkidiS ------
ft.
QGrtundwater Reinedietion
°Salinity Barrier
DStotmwater Drainage
°ISubsidence Comm(
DTraax
QOttter (explain under #2L Remarks)
4. Date Well(s) Completed:'/9#'17 Wen ION
SA. iA¢!1 Goration: J.
331,7
Faeilily)Owoer Name Facility LrIN (if opplica6le)
/ G o 1 Y,p,lc.t.. At 04 K Zs/4,-4_
Physical Achhess,kity, and Zit
(Au 'c
Cn,asty
Parcel IttenoFanron n,u. (PIN)
ali. f,atiturie sod longitude in degreGdminutes'stxends far declmst degrees'
(if well field, one lat/tong is au rFic)tnt)
0.
)33 S3', 1. a- 1 hi c7 Cr ° el 7� 4. AN6. Ware) the wells) ' erountent or DTcmporary
7. is this a repair to an existing welt: [)' or NO
Ifthi .1.c u owalr, (Jll Nut known well eotslrttct(rm tnfnrmation and am rite nature (tithe
owed,' unJar+i21 ranr.arfo tncti un.en did beck Afthin farm.
E. ForGeoprobrll)PT or Closedloop Geothermal Wells having the some
construction. only 1 OW -I is nettled, Indicate TOTAL NLIMIS1 R ofwell.4
9. Totei wet! depth below land surface: 3 (f.)
1?or.n,ulrtpte wells list o11 depot rJWArrmt. (exp. s a�tt)a' end a(a,: (r)0')
tU. Static water level blow top of easing: %..2— (ft)
NwrArrr levei ix <Vow rasing, zit, ` r
)1. Bprebote diameter: M (in.)
12. Well eonal:ection method: Le) (9!wr . `/`"
ti.a, nngc, rotary, di :ct push,
ft-
ft.
in,
urAMM.,szic PIOTSF&S • Tti1•tInnTSFln1
O/D O(o
mom TO R4ATY.RIAI, KR(PrAr R rter IWKStOD &
R rt. '`'
ft, ft. r.c�
.14: `1rEtisPiteMifi l
FROM 1 TO IttartldAt,
ft
tt,
( $M1IPIACE(tlP.NTI %tii3l7
FOR WATER SUPPLY WOO ONLY:
13a. Yield (gpm) Method d or sear:
13b. Disinfection type: Amount:
ft. I ft.
ft.
h.
ft.
R.
f!:
g♦ )
al
Sigramry erect* ed wet!
QYFiCu11'MM colon, Ttimadal
or
Dale
i1y sigtang rhts form, 1 h: evr(y (hat (i c 14'd7(s) WQS ()wire) CUnsn,wcte[i in accord:
with 15ANCACO2C,01r IS4 WCitC 02C,0200 E6'efl (Iwiraetto 87ondrnrle nndlh
copy Of dais ret:or4 kas.Aeert provided (o the wet! owner.
23, Sift diagram or atidti1o1181 trdldetails:
Youmay use the ba(:k of this page to ptovida additional well site details or +
construction details, You may also WW1 ark tional pages `if necessluy.
(J;aMICfION
24s. For A!t '4YCgs: Submit this Corm within 30 daps of completion of
.colisfxnctlon to following!
Utvision of Witter Resourcw�, frefaha oSoa Processing (nit,
161'7Nfa l Service Center, Raleigh, NC 2709-I G17
24b. Fig tuleelioo Wet(,,: In addition, to sending the form to the address in
above, also submit one copy of this forme within 30. days of completion of:
enslstruetion to the followiry
Bivisign of Water Resources, Undergrottltd Objection Control Program,
1636 AIrta Service {:cater, realeighi NC 17699-104
24e. Pot %ter Somali, 8i. IniecO90 Wtjt: In seld;tion to sending the torn
phc addrras(es) above, also submit ono copy of this form within 30 days
cornp(otion of vfcll construction to the county health department of the rot
vI P rn+)cHawirrt

WELL LL CONSTRUCTION RECORDJGW-11 I C'or Internal Use Only:
t. Well Contrael'.; 1nforinn tion:
GA ,t. 7-' l -�
Well C:wdty Orr Name
2-1
NC Welt Contnwtor C.urtitltation Number
RECEIVED/NCDENR/DWR
JUL 2 3 2018
Water Quality Regional
/4.QL.J LJ -L% DILA!! 1�Se�tiar) .
r;onn:myName Wilmi ,ton Regional Office
Writ Construction Permit 4-
l.rt all upp/i. oMK wrll (Yrn.vrrvcrion p: roars (1;u. We, ( w,(v. ,5,14I3. T1, wrrr. etc.)
3. Well Use (check well use):
Water Supply Well:
Agritulturni £Mtmicipallikublic
Geothermal (Hearing/Cooling SLppty) OResideniial Wafer Supply (single)
DResiden+ill Water Supply (shared)
Todtrstrial)Gom m eraial
Non -Wafer Supply Wets:
MOriiroring
1'e.c'°very
Injection q'ell:
Aquifer Recharge
Aquifer Storage ancfRecovery
Aquifer Test
;xperinti:r+tal Technology
D(3rrundwater Remediation
}Salinity Barrier
DShttrtnvaicr Drainage
Q3ubeidcncc Control
Cnasal sed Loop) Tracer
Gsnthootetmel (CloIcatinf/C oc hi Return) tht • (explain under i121. Remarks)
4. Date Well(s) Completed: )1 S/ / y Wet) iM
5a. Weil Loudon:
7-64
�.• � K
t athliy/Own r N:1tne
//l SW 3
Physical Address, City, and 7,ih
ran. hs t.a_,,
Cotmty
Facill7y U)N{if applicable)
At( AAA-
Paroel Irhndliution No. (PIN)
5h. Uttitode and longitude in degrees/minutes/seconds rjr decimal degrter,:
(if %veil field, one latilong is sufficient)
33 Ss, r v lv 0,k , b�S6
6. Is(arc) the well(s)akermanent or frcmporary
7. tx this a repair to an eXiSting wtik DYcg or ri'WO
(/this it o rcruir,jll tort known wc-rd vornarc ainn tnf r,rrarlon and exrrluln the na!une ofthe
repair }ULIFI t; r remark,: nuutiw1 or on r11d n.'k of thLL jinni,
$.For GeoprobODP'f or Closed -Loop Geothermal Wells hayingthe sa$t0
snrr.,truction. only 1 GWt-1 i5 needed. Indicate TOTAL, NUMBER. ofweUs
9. Total Ted! depth (xfiw land surface: (9 d
For mufllp,'e wells 11si ant depths 4'4(1-arv1t (coomp%- 3@,200" and 2(4 It u )
10, Stalk water level the&rrw Fop of tmsifg: 5:D
i! t varrr laic! IN 01)6N crr,ving, use " F "
11. ftordfole diameter; .� . 6 (hi.)
32, Well construction method: 4,,J114:ar �
(l.e, waxer, rotary, txtblc, direct pooh, cto.)
(n-)
r'ROvf
TO Ilia ^' ....
.: V ,\ (I.
c ¢ fl• GJA,-.,
ft.
ft.
ft.
13.,OI:'TEPt CAIfl.,iai mmMi-cases.rrcVJy]. l$;(iC ip bk) ,;
b-ROM -o Totn.M'E17LR
1trictoiMi
hint ttAI.
�, fl, I (r,1 in.
s
t!J 0
u Q...
i&:ff!i1 i Stati R:TUBING (g e t
PROM
1n
DIAME"S'Ptt
'R1rcKytt*;
taA,t%R3i.4
ft-
ft,in,
ft_
ft
in,
YROM
TO
',woo
s o-r$Lzg
inxtKroe.ss
M.l1�AlRt
Ao A'
;-pft
/ jYy1n,
cyd
Qs-as-soLC.
ft,
ft.
to.
IL OtOtrt
ftl(Fa(
TO
MATERIAI.
EMPLACE MP,N'r��ML��irtiioURAMMAU
ff
dO f`
-.r
ft
R.
7
ft, ff.
:::19: 1t*t"virir,L''PA > jix8prueikt4e1,..'.: .. ..•
.FROM
TO MATFIttAL
itstPt %CCNIFNTSI TIKfl
ft.
It.
—r
R,
ft.
.__--
FROM
„VA
EnfiCRoYIiQN(vim., tbrpsoN gerWraet, Ir PG Ri+brAin, etol
i t.
it
ft.
i-t1
fir..._ p, -' Ra+:'
fd,
ft.
201�
ft.
A.
dUl_ �! -
ft.
ft.-1,
:)IS%
a.
ft
f 'tV l� 11.1. �-;
ataligoimms...
FOR WATER SUPPLY W11,I:S ONLY.
13a. Yield (get) hAethod of teat:
13b. t»iaiakerioo type: Antountt
21. Cef tiff . ODA:
sibnrtatte ofCcytired
kty signing iftfsfbrrrn 1' h t ' 1 f Utalthc ‘471(s) way (were) tansrinc7i*d Irr accords
wbh .154. 1C4C 0 .0100. • A NCR(.' 02C .0200 Walt Cousin cion Slonctardr and c5
cnry, o} ifs record • ban provided m. tied tvsL ow vir,
23. Site diagram or additional well details:
You TIM. use the back of this page to Provide additional well site dciails a N
construction details. You'may also attach additional pages i£ttececary,
503tvitrtALINSTRilatrONS
24a. Fog All We Submit this. form within 30 days' of completion of
canstlictian to die following:
Dtt'i$lonof Witter Jteruurcet, raforrnaCon Procarxfng Ciufit.
1.617 Moil Service Carter, Raleigh, NC 27699-I611
24h, VorJo t a,1 WOiri: in addition to sending the form to the addrese in :
obm o, a ]so submit.one copy of this form within 30 dnya of completion of N
construction to tau tbllowing:
Divi9ioll of Water Ressoniree9, Underground Injection Control frog iota,
I63+tiMat gerviceCenter, bi•I .:276S9-t636
Zoe For WREST $upp)v i& Iniectiwr wcl . •In ad4ition 1p Winding the form
the address(as) above, Also .submit one copy of this forth within 30 cloys
completion of well constnterion th the county health depnrtrn.ent of the 0)0
wh r Mnciv ter]
bate

Print Form
WELL CONSTRUCTION RECORD (GW-1)
RECEIVED/NCDENR/DWR
JUL 2 3 2018
Water Qti?litui4anal
Applied Resource Mana��misn
Company Nante
1. Well Contractor Information:
Sanford Sweeting
Well Contractor Name
2082-A
NC Well Contractor Certification Number
2. Well Construction Permit #:
List all applicable well construction permits (i.e. UIC, County State, Variance. etc.)
MIVOn egiunal Uttice
WI0800504
3. Well Use (check well use):
Water Supply Well:
Agricultural
DGeothermal (Heating/Cooling Supply)
Industrial/Commercial
Irrigation
Non -Water Supply Well:
Monitoring
Injection Welt:
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
Experimental Technology
x Geothermal (Closed Loop)
Geothermal (Heating/Cooling Return)
4. Date Well(s) Completed: 6/22/1 8
5a. Well Location:
Cape Fear Jet Port
fMunicipal/Public
Residential Water Supply (single)
DResidential Water Supply (shared)
Recovery
DGroundwater Remediation
DSatinity Barrier
fStormwater Drainage
Subsidence Control
Tracer
Other (explain under #21 Remarks)
Well ID# NIA
N/A
Facility/Owner Name Facility IDIO (if applicable)
4019 Long Beach Road, Oak Island, NC 28465
Physical Address, City, and Zip
Brunswick
23600010
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one latilong is sufficient)
See Attached N See Attached
W
6. Is(are) the well(s)JPermanent or DTemporary
7. Is this a repair to an existing well: JYes or xJNo
If this is a repair, fill out known well construction information and explain the nature of the
repair under 2I remarks section or on the bank 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
dri§led: •t�
9. Total well depth below land surface: 300
For multiple wells list all depths if different (example- 3@ 200' and 2..100')
(ft.)
10. Static water level below top of casing: N/A (ft.)
If water level is above casing, use "+ "
11. Borehole diameter: 6 (in.)
12. Well construction method: Mud Rotary
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) NIA Method of test: N/A
13b. Disinfection type: N/A Amount: N/A
For Internal Use Only:
14. WATER ZONES. F L.
FROM
TO
DESCRIPTION
ft.
ft.
ft.
ft.
15. OUTER CASING (for multi -cased wells) OR LINER(ifa licable)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
0 ft'
'Ft- 300ft•
1 in.
HDPE
16. INNER CASING OR TUBING (geothermal closed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft.
ft.
is
ft.
ft.
in.
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
ft.
ft.
in.
ft.
ft.
in.
1& GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
0 ft'
300 ft-
Thermex
Pumped
ft.
ft.
ft
ft.
19. SAND/GRAVEL PACK (if applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
IL
ft.
ft.
ft.
20. DRILLING LOG (attach additional sheets if necessary)
FROM
TO
DESCRIPTION (color, hardness, soiVroek type, grain sire, etc.)
0 ft-
35 ft-
Sand with shells
35 ft-
70 ft-
Silty sand some shells
70 ft-
90 ft-
Limestone with some silt
90 ft-
110 ft-
Limestone/sandstone mix
110 ft-
150 fL
Limestone/sandstone mix with silty sand
150 ft-
160 ft-
Silty fine sand
160 ft"
300 fL
Silty fine s� lay Ii est rze layers
@@L�."L
21. REMARKS Ii , •er :: ,..'
JUL 1 6 2018
22. Ce
Sign
ontractor
ickefirtatirxi
GWGNIO,CT16/18
Date
By signing this faint, 1 hereby ce,y g that the well(s) was (were) constructed in accordance
with 15A NCAC 02C.0100 or I5A AC -AC 02C .0200 Well Construction Standards and that a
copy of this record has been provided to the well owner.
23, Site diagram or additional wel ,details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTRUCTIONS
24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Iniection Wells: In addition to sending the form to the address in 24a
above, also submit one copy of this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Sunnly & Iniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
completion of welt 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

ARM Project Number:
Driller:
Date Drilled:
5/14/2018
5/17/2018
5/21 /201.8
5/22/2018
5/22/2018
5/23/2018
6/6/2018
6/12/2018
6/13/2018
6/13/2018
6114/201•B
6/14/2018
6/15/2018
6/17/2018
6/18/2018
6/18/2018
John Salmon
Loop No.
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
4019 Long Beach Road Cape Fear Jet Port
Oak Island, NC 28465
Loop Depth
300
300
300
300
300
300
300
300
300
300
300
300
300
300
300
300
GPS
33 55 51.07
33 55 50.86
33. 5.5 50.67
33 55 50.47
33 55 50.36
33 55 50.27
33 55 50.17
35 55 50.06
33 55 51.20
33 55 51.00
33 r55 50:81
33 55 50.60
33 55 50.40
33 55 50.19
33 55 50.00
33 55 49.78
Coordinates
78 04 37.10
78 04 37,37
78.04 37.64
78 04 37.80
78 04 37.89
78 04 38.17
78 04 38.35
78 04 38.79
78 04 37.33
78 04 37.64
78 04 37.87
78 04 38.19
78 04 38.47
78 04 38.63
78 04 39.08
78 04 39.31
RECEIVED/NCDENR/DWR
JUL 23 2018
Water Quality Regional
erationsetion
Wilminngton Regional Office
Pagel

WELL CONSTRUCTION RECORD
This farm c.tnbc used for irsk or multiple ordly
1.. Well GwtractnrInfbtaaation: RECEII! ILICDENR/DWR
Wt*eft Conn a.orbrame
3 YA
N C Well atsar Cc ititatioaN
e de
Company Mune . .110A.ilci p ; rplr Of 'nE ce
2. Well Construction Permit #: �` 15
List ell applicable wall primly (i.r_ Coarn: Slaw- (brimax It aYiar; .74-1
5. Well Ike (check : weft use):
JUL_ 23 2018
ter Quality Regional
Vilaccr Supply Well:
i Avicultural
°Geothermal (Hcttme.=Casoline Supply)
O fndostrial'Con mcrc al
atiaYt
'For Ino-ned Use ONLY:
11. WATER ZONES
1L5!3
550
DESCRIPTION
SS 7--„, SA
id_ OUTER. CASING Dar multi-usedethylOBI S or Mulcahta
FROM TO DIAMETER THICIZATESS
fl; J & ..1/ /t `/t.7
16 T1rumR CAMCG OR TIMING (geothermal )
FROM j TO I DIAMETER 1 TfII� MATERIAL
IE
ft.
la
MATERIAL
ft. 1
17. SCREE
OM uithpa Puhtic
❑Rc jdeattiai Water Supply (' n3k)
OR si lcatial Rats Supply (sham")
Non --Fleet Supply Wen:
°Monitoring
Injection Well:
o aquifer R.cbuge
©aquifer Storage and Recovery
°aquifer Test
❑Expe imental Technology
°Geothermal (C1o;edLi op)
❑Geothermal (Heatmg:Cooling Remus)
QRe.rotm
4. Date W[11(s) Completed:
Lo=tton:
0sem,ri <' a /9r
F,ieititylOttncr l lame Faatirc iD ttf appti blc)
,/a 37 d? MI Is/.ii-ci
OGrotnsfitater. Remc haiian
o Salinity Barrier
CIStormwater Dtaitta_ee
OSltbsidatcr Control
°Tracer
Q Oth.s (ctiRdain undo- €31 J2cruy-1m)
Physical Addro;, City. aral Zm
B4l et/�'s Gt./ i C G�
Gxmev
WelfTl
Parcel Iddifrcati.m Ma 041.1
5h. latitude and Iamitude in tIrntesitoinutesfseccuarls ar doaual
(tf well acid one 6o'o= ii h imi
h W.
6. Is (arc) the we@(s): i'tx1n neat or °Temporary
7_ Is this a repair to an siesi best earl D es nr a
if this a a repair, fill ma brown well eonsautrran iig:rmatiorr an captain the nstu . of rht
repair trader t'1 remark setioa or on tl. ba;k al t iajon,i
S. Number of wells constructed:
Far multgtfe 64a:rim or rma-voter supplyxc11r War Wills rho -.saute• can sauarida, ou om
out nu one j-ama
9. Total well depth below land surface: _
For multiple .tells fist all dcprhr ij dktr.at fox -ample- 36'00- and .2.a100')
Rt. Static letter level below top of r'sitig:
If rater lord actor:: oaring, us "DTP'"
/ f
11. Borehole diameter:: 6 r'.4r /O Cm)I / Y Lo r ('+6 r' tto
IL Well construction method: lDYI ve,�
2_
l
; t c. ati5cr, rotary. cable, t')n eat veil . etc.)
(ft-)
FOR WATER SUPPLY WET IS ONLY:
I3i Yield (lutist)
I3h. Disinfection type:
!torn OW-t
tllcthnd of test:
Amount: S 0 ?.,
FROM
ft.
TO
a (L
fL
nl.tMETER
/1yes'
SLorS1 'fFucrZ,cFiZ
Co /n st, sec
MLkTERLtt
e 5S
13, GROUT
FROM T
0
rt
IL
/ 0 ft_
ft_
MATERIAL EfPLAMIENfMETHOD St AMOUNT
kors PO
fL
ft.
19. SA I/GR AVEL PACK of vplitahlel
FROM TO I_MATERIAL
rL
ft.
mot-°cEMMtt'tton
fL
ft.
10,DR1L1NG1"'`t‘tt...,11 arlditiaml
sheets if neel
FROM TO
fL
IL
DESCRIPTION trcta. tuna°{_re;t;
r.k sac, noel
3 ft. 1 `.,
fL
fL
L
tL
fL
it
fL
ft.
2t. REMARKS
fL
(t
(L
o rE
•Asa IV.
Nit "`C3tJ
'--s CertsT tier
Siztratare of Crni[tcd W Lts b ctai �^ Date
des- iigcicg this for»; 1 IWrhr ccrrifr that the u-cl)jsl was rarer) ..mnrrrrr_tra. a :orlon. ufrh 15.1 \C4C 0_Z. _0100 ar 15_-I e.-IC 02C _0200 trill Comarti-Mon 5;�, dr and that a
coo- of this ra»ord has been provided to ihr ,tell our r_
s Site diagarasn ar additiarrai -writ details:
You ma} use the back of this page to provide additional well site details or \veil
construction details. You osav also attack additional razes it ticctssar}•_
SUB3IITT #L INSI'UCTIONS
24a. For All Wells: Submit this form within 30 days of timpjction of toll
ciMsstrucrian w the follonvte_
Division of Water Resources, I aferta rtlan Processing Unit,
1617 ?.fail Service Center, Raleigh, NC 27699-16I7
2-Ih_ For Injection Wells ONLY In addition to sending Use form to the address in
2-ta above, also submit a copy of this farm within 30 days of cntnpldion of Ma cottstsuctiou to the i'oUot�ia•,:
Division ofl.VaterRiemurces, Iindesgrnund Injection Control I'rogr..ut:,
1636 Mai Smite Center, Ralegft, NC 27699-Ifi's6
24c. For Water Supply & Injection Wells
Also submit one copy of this foam ccithin 30 days ofcompletion of
Rtil eonsttuctitm to the comity hackie department of the county. -there
coattructcai
North Cootitu Deporomeru of Eirciraamera and Manna- Reeses —IJ. in= of Water Rso.acv
Revised att°ust'_t�i=

Permit: 266971
Currituck
WELL PERMIT
•
AI Arkin„r E R.FCi10y,1i HfA6; H StR.'IC1,S
Parnters rct f'uhik Heelth
Applicant:
RECEIVED/NCDENR/DWG D1LEO, JENNIFER A.
105 RAKE FACTORY ROAD
JUL 2 3 2018 FLEMINGTON, NJ 08822
Location: Water Quality Regional
Operations Section
405 SHARK LANE Wilmington Regional Office
Swc S` ow L•T5 3.5'1 1/4 3 /f
obtov4-
-WELL MUST MAINTAIN SbrFEET MINIMUM FROM ANY
PART OF SEPTIC SYSTEMJREPAIR AREA
NELL MUST Be LOCATED AT LEAST 25 FEET FROM B Yf OUND
NELL. MUST STAY AT LEAST 25 FEET FROM ANY BUILDING
FOUNDATION
NELL MUST BE INSTALLED BY A NC LICENSED WELL DRILLER
NELL PERMIt MUST BE ON LOCATION DURING ALL'pERtDDS
DF WELL. INSTALLATIQN
BALL AT LEAST 1 BUSINESS DAY PRIOR FOR REQUIRED
NSPECTtONS OF GROUT AND WELLHEAD
-E}SlSTINQ trYEt.LI(S) ? iU3T BE FROPERLYAQANd€ ER AND
PROPER FORM suBMi htC} INTO This OFFI E ;. .
Vert a wNg.vt V im" i-°'r
0-4,3" J 7) whit 5 „r o kepa re-
6e,corioktt[.t+4
oki
4'00' t- L"rj
i'4„f t?y 54r)�.
Ot000t ,
o¥ otJ,cartt. y f,C.r d p
PIN: 087AO010035000S
Owner:
DI EL O, JENNIFER A.
105 RAKE FACTORY ROAD
FLEMINGTON, NJ 08822
w
ek
t 00' EASEMENT FOR
CANAL
1+09 2, PG 139 :
5 88'15'00" w 180,00'
w se%
M tic. v�7i �.. SHARK LANE 7`7'.\\��'C
y
'f'®rmit By:
Aidd iy finEY/K'R.- tadr-14,...,
14147 Certification By:
tZ'Rot IQ) t% g+ti-r"tf- p sate:
7••p n Construction has been completed, a Residential Well Construction Record Form GW-la has been
3 we_
submitted and inspections have been completed in accordance with 1SA NCAC 02C.030o.
ppp
7 a .1tAr"'4itciC rigkla Nrwis e
$0' AMATisgrar ArPWke
c,k
(L.
"'` „J z0''t `t
W
161Z44.-
34
LSO'
with
Date: 07/06/2018
obbs, Joe

For Intasml LTA ONLY
WELL CONSTRUCTION RECORD
Tiffs form can be used for it le or multipi r' k
1_ VSeliContractor Intoi
)�E�t1 �CDENR/DWR
Will Cormars4'Nante
NC l\'cEltaaAhacta TT
(1
Company tintne
JUL 23 2018
ter Qualit Regonal
�p�_ ppetrations Sectionf
2 WtII Caasa uctiotf Permit : P10444ill itcif egG' t d
Lint all applicable will penults fie. Condo: Star (mime_\; Iria-ara 0- 1
3_ Well Use (thee( well use)_
14. WATER ZONES
Mau
lf
TO
fr_
DESCTtIr'U0N
T- 1,9TcJ
IaOUTER CASING tfarmnlri-gilded s)ORiiIE&Qf _
iRR01i DL-ta1ETER Tritesznss MATERIAL
(
1. MOM R CASI\G OR TURiNG (geothermal l L 7 1 D
Mau To I mA!UETER TniCKNEss 1cximitLu.
it. ft_ in_
Water -Supply Well:
O aggricultlral
QGcothcmmal (Hctting.Crwline Supply)
❑ IndustriaLCommorcial
staRtAtt
DMtmis ipa1 Prtblic
OR. idential V sta'SupplS' ( k)
DRsidattia) Wama Supply tom)
tout -Water Supply Well:
DMouitotinn
❑Recovery
Injection Well:
❑Aquifer Rahargc
❑aquifer Storage and Recovery
❑aquifer Test
aE perimantal Tecfntology
Oficothumal (Closed Loop)
❑Geothermal (Heating Cooling Return)
4. Date Well(s) Completed: 13
aa. \ location:
Pirpic 1 ad'ko.s, City. :mkt Zan
•
°Groinrdwater RRnediatlan
❑Salinity Barrier
DStorm \aterDtaataee
0Subsideuee Control
DTracer
❑Otlts(ceplain under=2l Raoum)
Weil TM
Facility/Owner Name Facility lD.: tn(app let
1 30 NE. 7 /li einX tf/,9,/r
Patrcf bi�Jifn-�tian No (PL,,-)
SE latitude and J. o itude in efi*rerstminutesisecennis cr decimal da arets:
if %rol i1d L rmc ln.l t is satftaau)
6_ Is (are) thescell(s rmsneat or OTemporary
7_ Is this a repair to atn esisting [writ: O es or
Ij tllir it a repair, fill out known well corm amass information
repair under c_I remarEr section or on tls ha-t of thisjo.n.
1. Number of [sells eons/rutted:
ova
explaio the. error of :is
Forrmtlt.p& i4osrion or rnuamtrr supply wells MIX with the same Omstruction, rvn,:an
-admit orsel"arus. o /
9. Total well depth Endow Land surface:
For mOa mils t all dcpths $ d#rroor a -maple- 3!=OO nd _ :H0!/) (ft)
Ureter'm W
Icrr1 it gloring, use -T' % i (R )
I1_ Borehole constitutionia+ncter i,-9/ 0 ® ( 1 / // �i 7
t �)
1.2_ Weil constitution !method: r ,) e
ID. Static water fevci below top of tsvo g:
at�er, rotary, cable, ilia eta anal ele)
1
FOR WATER SUPPLY \VP :US ONLY:
I3a_ Iidd (gpm) S— Method after
I36_ Disinfection tape: 64,4 C ! / 7
Kirin tit\ -I
it
17. SCR ES:
L f
is
FffiU I TO
1L
7
[L ft.
DIAMETER
sLOTS/Ze
THICTCCE.
60 e: s •S4
a(ATER/AL
SS
1s GROUT
mom T
IL
0 f4
MATERIAL
� L mIENT M rsoo S.W[OtTT
fL
ft.
ft.
19_ SL\D/GP.AVEL PACK of smPIis hhl
FROM TO MATERIAL
ft.
ft.
ElIPL-acEM1 1: llx11OD
ft. ft.
1Q_DRTLLLNGLOG (amid,additional :berets:ifaera: )
FROM TO DESCRIPTION fddat hardacts, Inifireck [[ware_ Arsin size_ ea-1
27 fL [ SB,I C1
i) ft.
fL FL
fL fL
FT
tit- fL
(L fL
fL fL
2L RELLARES
?_z `
Sigruidee aS7 Candied R sintraetor Date
9 agaicg this burr, 11:.^rly crank eku thr lydl(s) war (wer} mnrtn._tca s u cordoszr
sr rh lit \C4C (}2C _O1f10 ar 15_1NC_4C 02C _0200 flzll Casson o Star-zvds coal that a
cop of this rtcord Aar hero provided to thr src11 meads
2.3. Stte diagram ar:ulditiotrai well details:
\ oli may use the back of this papa to provide additional tccll site details sir \['ell
construeiitsit details_ You may also attach additional pans i tteesary.
SUBMITTAL
242_ For AR Wells: Submit this form within 30 days of pldittn or n'cll
ce�ttslrttetiatt to the follottine:
Division of Water Resources. Information Processing Unit,
1617 Mail Service Center, Raleiwh, NC 27699-I617
24b. For Injection Wells ONLY: In addition to sending the form to the address in
24a above. also submit a copy of this form within 30 dais
of cotnstmt etiol to the folto\tin2: completion of well
Divi ion cirtijaterResources, Inuletmound Injection Control
I636 Mall Bernice Center, R:tlegh, NC 27633-1636 1
24c For Water Supply. Injection Wells_
Also submit one copy of this form Within 30 days of completion of
\\ttl eoustrodion to the .:.ouch' health d-partment of the ,;ommry where
constmemal
North C.otiru i)cpatrurnt of Fn iraamart and Nanaal Raising —Division of Water R aaac,n
Recited Atmust 201

WELL CONSTRUCTION RECORD
This toorm can be mod wr;issk or tnuLiple wrell t
For lntranit c ONLY
1. V�c11 InTormaticei
✓C %.5 0is=dt C«waciorx�
RECEIVED/NCDENR/DWR
3_s-- v 4
is•Tc Well t:.vpactor ia>iticatieciN
e1
Company Name ►�
L Well Catrstrnction Plitt sti r / '2 0 t? " 619OL
--
JUL 2a 2010
Water Quality Regional
e !�
Operations Section
nri T •gton Rnajgnal Office
List all applanhle well permits ta:�•. Corn. Sra lariat�X Icie tw rr`I
3. Well Use (check melt use):
Wirer Supply W ell:
DA icultu al
DGeudimuat (Heatina.Touliue Supply)
D�t bt_d�ustrrair'Com m credal
A€.2atlo n
Non -Water Supply Well:
❑Il[ouitoring
Injection Well:
❑Aquifer Rce-h- rrc
❑Aquifer Storage and Ra:al:crt.
❑ aquifcr Test
❑E' perimmtal Tcelutoloay
Dti.�othumal (Closed Loop)
°Geothermal (Ilcalmg_Co.�iinoReturn)
ElMnati4a1 Public
❑Raidcttial Waa• Supply (sink)
ElRestdrnte,l Walrr Supply l�har01]
❑Rcootcrr
Rn ❑Groundwater nediapnn
°Salinity Barrier
OSturmtt Draittaim
❑Subsidcacc Control
OTraccr
Clalhoz (ccplain under 421 Rt )
-I. Date Wd'I() Completed: lf� t?t , - ell! ED
Sa- t-Wc,11 Location:
Facility/On-nu Name
/ y f 3r s
Physic/alt] ""3rldi[ca. City. and Zro
Fa mite ID= ttf I§tlimbk)
OA
County Parcelr�dif.cptmaN rPi -'
ti Sh. Latta, and Langidtde in den-cestm=_,.teskecoruls to- decimal d eco-
If well held, one tat dam is such zonl
W
N
6_ Is (are) the wcef(sk er inanent nr °Te•�pn'aty
7_ Is this a repair n to aesisiing wt1k C]Yes or o
If this is a repay fell orrt kno. n well eora:ucnon iryonano:-rion explain tho nano:- of tic
repair tender =71 rcmarts seaioa or on rho of Air
8, Nimtber oftatl6 constructed:
Far multiple iujcctioa or ran -water suoplewelfr ONLT with the aurae amtsrruction. tax .n
sulvrit one jam`
9_ Total well depth bla low nd surface:
For multiple was hst all depths ijd jyeroar (example- 3:e200- and _:i I064- (R)
6
ILL Static water level below top of ci tttg:
If water lets/ is ahoy; cavne, ute
11. Borehole diameter_
7
Cm-)
1L Well construction method: / ✓ / / Qe^ 1�} r L?
auger, rotary. cable, del Amen molt. [tLl
((ft-))
FOR WATER SUPPLY WFI I S ONLY:
13a Yield C=dmt) �^ 9 / Method of test:
131x Disinfection trim: i3"� i4 c' �i tnoimt c�d 0
Fenn t3W-
20. DRIL7U1G LOG Oit t, additional slicers if oeres<ary)
Mom TO DESC41PITON tmiur saiFireck repo 4,te. sue.
/q
9 f`
fL ft_
fL rt.
it. tL
fL fL
21. ROLL-QM-5
21 Ccr ttit too
Si_ uture of Conned -all Contractor
45'4.
i1 WATER ZONES
FROM 1 TO
rL
nEcram1r0,�
IL
TO
• tt / 8d ft_ l ch
FIL,' EfER L THICKNESS
l . IN/QM C.%SING OR TIMING format
FROM TO 1 DLa.'t1ETER TIRCRNESS
ft ft. 1 la
1iOUTER C;SING!for =mki-casdArdis) oRLINER fiTagspricaldel
1LATERLAL
ft.
17. SCREEIT
FROM TO
eft_ 21f
ft.
13. GROUT
ft I
&LATE:RIM_
ft.
DIAMETER
SLOTSTZE
0i10
TWCIGXESS
- yo
MATEItLtt.
PV
FROM TO
fL
rt.
ALAIERLr1L
EMPLLCE1¢RT METHou S.ul1Ot YT
c5NJ r ��
ft.
ft.
19. SAAT1GRAVEL PACE Orawaiaehl
FROM TO MATERIAL SUM,
rL fL
METH D
Ovreel
tL
�� ft
Lyty i
Date
tar arcing thisform I Iwrdly :: n f' th a the wrllrrl was (Were) -otarrtLtcd s 4-ordar:: ash 114 \CIC[L'C'AIQJorISM! \'C.ICfLC-WOO t3etlCor,;mtt. Srm,, ds dapa
. pr 9t this rcconf lmsbeen provided to the wc11 oor, r
1 Site diagram or additinral well details:
you may trait tltc back of this par3c to prosidc additional wcll site details or well
construction details. You may also attach additional paces ifneca-sary_
SUBMITTAL INS rucTIONS
24a. For All Wells: Submit this form within 30 days of ximpldiem or well
cmistntetl.7n to the following:
-l�
Division of Water Resources,
Information Prue e
1617 Mail Service Center, Raleigh, Gar[
.T; NC 37599-] 6I7
14b. For Injection Wells ONLY: In addition to srnding rho form to the adtbtss in
2-a above.,also submit a copy of this form within 30 dais of completion of wall
cottsUuctirw to thc foilowin•_:
Division of Water Resources, Undergrannd Injection Control Program,
1636 Mail Scrrire Ceram, Ra1ei h,1C 27699-I656
7.4e For Water Supply & injection Welk
Also submit unit cum' of this form within 30 dais of completion of
we11 conshur1im to the ,.,omit health dc-pattmemt of thc county where
eoastruct al
II cam Cualilnt DspulItcu of Emiv vtmrnt and Nanatl Raanrcs—Di:'isi m of W cr Rcctntt
Reriscd 1.uc nt 2013

W ell Cont.
WELL CONSTRUCTION RECORD
Tha ii w canto wall for uric or muIi p we k
I. Wall Cmtsactom Infeaautiona
1
as
S'v /q
NC WellGAO ah CatifcationNuoi r
e Vie ( 6-
t t x
Curuputy %roc � t6Rs Ion
r t �.\.1.'�iY-i'n R of 7
Z. Well Construction P #: I aC
List all applla6Je well permits fin±. Conch: Staff . f'arf�K Ir_iccoo . ell
3. Well Use (cited; wen use):
Water Supply' 'Welt:
❑ griculntral
❑Geutht rmal (Hcalirg.Cooling supply)
❑Ind•ustxial Ccniiuc ntdl
,Xgncruet
Non -Water. Supply Well:
❑hlottitwrta8
Injection Well:
aquifer Recharge
❑ Agnifer Storage and Re:a� cry
❑ tquife•Tcst
❑Ecperimcatal Tcchnnlon
❑Geother al (Closed? Loop)
❑Geothermal (Dcatmg Coaling Realm)
RECEIVED/NCDENRIDWR
JUL. 2 3 2018
'Forinlam1UseONLY:
l.i WATERZONES
FROlf
L
TO
L/fL
fEs Ott• lo.v
45.25471
7✓..�✓N`�c� fie �l-t r � Ai e's.
ii OUTER CASING tfor multi-casnl ee}kl OR LINER
U ter QL1a11ry Regional � C7. it_ DIAMETER Ta actrEnt4y
fin
ICE I6,II ICAN �GORTIMING( �t l7 .. P(��`
FROM TO (DL-LltsrER
ft ft 1 fa
tc ft
17. Stye:
TtIIctactSs 7li4TERL4L
Cll funicipal,Public
❑Residential n-ate-Supply (sit )
ORtsidrnlinl Vt at.= Supply blared)
❑Rca:oucr
FROIJ TO
f9ft- 3
ft_
13. GROUT
FROM
.+'9
DL%lttt ER
a is
L
SLOTSt7F
0/0
THICTSiESS dIATFBLtL
s°cAA t%L9- Psi
1
TO
jJ ft.
fL
MATERIAL E\X0.1cEMFNT M1fROD S, otJl7
•�rC'Gr„ 3 - Pc(,ire,
❑Groun.itaatcr Rvat cdiation
❑Salinity Hamner
❑Sttsmctatar Drainagc
0Suixsidcar.= Control
QTrarcr
E1011ns (explain undcr 21 Rcroatts1
4. Date Well(s) Completed: f j/ r2 O id r111I#
t�til Location.
kev!,VI 11'/�,
FacihtviOunrrNaau
222 /i i
Phyteal _ dtlfe2ta, (Air. creel Zio
try/Lt." t.v, 1,
county
Fa.:dity ID=inf aPPlimhlc)
0,41 l /s/,-t7--
Y( 5
Parml Itimdiiutian Nn (P1�TI
Sh. Latiinde and Inrugitttde in drsftaitwtesls spuds ar deo aal
ri teen held om: htmaoa is stare enO
6. Is (are) the wel(s): `ea-taanrnc or E3Temporaty
7_ Is this a repair to an eristingg well: ❑Yes or
If this is a repair. fill out Iirorca well cortsa'u.:ion ipjarmatiorr
repair:rode, ' 21 remeuSs section or on this ba,-k of this form
8. NLn thcrofrtas constructed:
nvo
espial. tic nu:um of the
For mrnultipfe injcL-tam or mn.unttr supply wells ONTS with the .rare rnumuciart tau.:an
submit one joins
9. Total well depth hdotr htnd surface:
For multiple wells list all depths jd friar t'- mple- 3-z200' etrrJ2s100'1
I0. Static water level below top of cnsntn:
Ijrotcr let -el is altar: at.sin4, viz
11. Sor eho a diameter {[/ •
cm.)
(L Well construction method: ten Cr d:t /`— Li -r
o_ atL_'cr.rotas), calk diced 0n;h etc)
5/
(1L)
(ft-)
FOR WATER SUPPLY Rai3/SO�NLY:
13a.Iieid(gptn) 3 64 67/j"/ Mlethndoftest � 7
136. Disinfection type: /!f f)C v2 _ltnnnnr L,
Fu,m G1r-t
ft.
19_ SL D1 GRAVEL RICE triamdicalrkl
FROM TO MATERIAL EliPLAAMMEIT Menton
/ ft ft ft. 2. 6"14k6f
21t. DRit T esG LOG fait:wh addidmai Arc's it neeesa=10
DESCRIPTION' icalar6ardne:zs,;t t
ft
FRO• I TO
0 ft
9 fL 3 j% ft_
it-
ft.
it_
it_
ft.
ft.
1r.
fL
ft_ ft_
2t_ RE1CARLS
Jv—
v cc�`
EFso- o3c'.--
!2 Cc
S3 rut sic of Cnrtitted
`c0 CMiractor
x-Its
Data
Iy stain this torn: I i rater ccrttj, that the well(s) was (were) onirrrL
.r7n lit,\Cie tE'_0100 ear 15:t VCIC O'C.0200 Well Caen... trismxro'ds a'i1 z1�t a it
copy i this ravurd hos &en prtrtdzd to the well pawl._
rt. Sire diagram ar additiatral well details:
You may use thc had: of this page to proxidc additional well site details nit ytcll
cons(ntction details_ You may also attach additional pY6 if ncccasaty_
SLJB1IrL-f AI. INSTUC1TtONs
2da_ For Al Wells: Submit this form within 3D daps of iomph3ittn of well
cnsttuction to the follOWinn:
Division of Water Rrsources, Information ProcCSvgg Iinit,
1617 Mail Service Center, Ra1eiah, NC 27699-1617
24b_ For Ittiection Weller ONLY: In addition to seeding the !fart to the address. in
2-ta above, also submit a y- of this fern t days of
�P_ within 30 utmpldist of well
uatsttuctiou to the following:
Division of\l aterResnn"=, Undetgrowid Injection Control Pt•*t-nun,
1636 Mail Smice Centre; Raleigh, NC 27699-1656
2-ie For Water Supply & Injection Welts:
Also submit one copy of this form v ithin 30 dap of completion of
hell eowuueion to thc county health d�•panment of the catmry u$crc
rxtnstructe l
North Csolnu Ditpnt a,t of Err•, u vffirnt and Natural Itaotern—Di-itaus of Ware Rnaaca
Rcru«1 ;unit 201

This t xm Can be used for safe or =think wefts
452546
WELL CONSTRUCTION RECORD 1Ai,
Far lntnmlLtzc�fLT:
r
L Weil contracw•latortaatiotte
1 /
RECEI\IED/NCDENR/D
;tee / i re Sd
Well Co^«"tor Name
3S'O JUL 2 3 2018
NC 5Vdlt atp:sua ialihvtioa Number
V L P
Company Name
a er Quality Regional
erations Section
'Mt/OA 1 ington eoio
2. Well Construction Permi14: /i I t' ��®o tP 9
List ell appinnlale rdl pe aurs (i.•. CourJr: Star I arionrY, Irua-tion cr 1
3. Well the (aheei: well use):
Water Supply ClAgricuttural
❑Geothe pal (1-icating.-Coolin_ Supply)
O Li do strral'C two m actal
S71gatilW
No-R'atcr Supply WcII:
Ohloaitating
14. tV tTER2ONFS
FRiUI TO
tJ ft.
DESCRIPTION
S'A'ct
ft-
1a'. OUTER CASING [for math-casrdeellsb OEIIlNIER tf
TO DIAMETER rruetatEss 1 4fl .-u.
/7111111 FL
/` / S. ' 4I0 're'
s'6.1AIl¢ER C1Sfi'G OR TUBING .. _. , 1
OLLMETER
ft in.
ft. 1
OR4mii1-Public
❑Re idential Wain -Simply tsinglc)
ORcsidtaatial Wat,z Supply tslraail
ORe..•ovcrv-
InjectionWell:
❑aquiferRedlarge
t aquifer Storage and Ro:ovcry
O quiferTcst
❑Egrcrimmtal Tedniotoyy
OGcothunral (Closed Loop)
❑Gcnthcsmai (ilcating,Coaling Return)
OGrotmdwaterRcn ediation
DSalinity Daniel
OSnitm auler thai..ane
OSubsi.iatcc Conttul
Ortr
❑Oth. r (explain under =21 Rom)
-l. Date hell(,) Completed: 7 + toViaDO
Fic.tstt• Oa++..
_��JaIDt
F
ibrista Nobly
&Oy tN r�J 5; _ c�,� /rh -'
Physical :ltiird City. and Zit)
ii%/s/.S t c l
Cwatty Parcc113..tiftcttno No_
Sb. Latitude and Inttiaitude in d.•arees/min__esisecandc or decimal area_
ttf trill nal, on.: hVk- a is salt cut)
6. Is (are) the vtell(s): nett or OTempor a y
7_ Is this a repair to an \\existing veal: D es or u
if this it a repot . jtll atu known well cotamt xon infararatcur and Iota the nature of the
repair uerder er21 rrmertr sexton or on do ha.* ey• farm
8. Number °Issas constructed:
For multiple idittYion or tar enter sucplr reps O\2r snub the same rnam-tteritn. tnu atn
svhmit one form
9_ iutal vrdl depth below land surface:
t 2s�%
For multiple .yens list all depthr d. it,revtzianrpk-3tr'110•and 2a100't
10. Stacie venter level blow top of c ispD:
Ifrnte, level ' alp; Axesinq, tts: J111,
II. Bor ehote ' ai / ' .i47r 6 1'-- 14t��
12. Well construction method:
r e- ages. sous}. table, &leo oink de)
Form GI -I
P" P .e i\--1
(ft)
(f)
R.
!t
17. SCRES"II
FROM
iL
To
ia.
1taTERLAL
mum. =m Tlucr�
ft.is �!�
ft. ft.
1%. GROVE
FROM TO
MATERIAL
oS1
R %0 ft-
ft. a� ft
MATFRIAL. EMPLAC ME?.T Britton &AMOUN
FROM
0.
Ft_
-IN a P. off anpli.-„t,t-i
TO MATERIAL
ft.
£MPLACENSMT METHOD
m
1ft. DRILLING LOG tarot ,aditianal sheets if nor ,)
FROM TO f DESCRIPTION imam: hardens, s,aigruh
C f� iL 2 ,v.� ft �C sec su)
rt ••S] ft
fL it
fL ft
it ft.
tL it.
ft_ fL
RENLA.RI'yS
22 Certiitca
on:
f'�
Sinutmc of Cavtied Wc1I t tM-actor
at- sigciug this fors, I lzrthr c-rryr of t the rill r1 tress jacry mmtra;tcd s =coreac::
train Iif \C4C I.M .0100 or IS:I —IC 02C -iL00 (fell Corurrtombn S:aris,dr and tear a
copy of this reared has been prorded to the well omsr.
Ii Site diagram or _idz1itioaai well details:
You may use the back of this page to protide additional well site details or �ycll
construction details. You may also attach additional panes ifncc.anary-
SUBMITTAL L 1NSTUCTIONS
24a. For all Wells: Submit this form within 30 days of cotnpiction of well
construction to the follotsinn:
Division of Rater Resources, Information Protesting limit,
1617 Mail Service Center, Raleigh, NC 37699-1617
I4b- For Injection Brills ONLY: hi addition to warding the fort to the adtht s in
24a above.,also submit a copy of this farm within 30 days of
coastiuctiou to the follow-inn:tPlcti.st of steel
Division of ViaterResoUrces, l ndergrotmd Injection Control Program.
1636 Mai! Service Center, Raleigh, NC /76994636
24c Fur Water- Supply S hattsthin Whiles_
Also submit one copy of this form within 30 days of completion of
writ cansuudion to the county health department of the county nitcre
constructed
North Caotiru Derortreent of fir. ii v®cnt and ?lamest Result a-Daisi.vr of [hate Res awoes
Revised ate=rent 2tt13

Wry r _r . CUT RHC ION ft?ct�j
Ibis form motet sink or muhipte melh
L V�ell lashes
Well CormarsotNarem
NC Wal CO.
e
Company -blame
Z. Well jx.
Poet 4:
La„�Iaermisri. Co.rlrsafilaspae. iraa del
3- Well the (check area auk
Ave
RECEIV D/NCDEN
fart W
JUL. 2 3 201
Rater Supply Well:
O Agricultural
❑Creuthconal (I1ca(iog Connor Supply)
■ IndustrialiCommrxial
Wit, 'Qatin
h , Water- WrU
OR[onitacing
Well:
O_Aquifer Recharge
aquifer Storage and Rn:orcr3-
Oaquifer Test
OEy�r;mcutat Techook y
❑Geai.humal (ClaecdLoop)
Qtrcttthomaal (Elm 1CoaliReam)
Water Quality Regi
❑Gro>mdnata Rmnediation
OSalinity Barrio
E1Suamryter Draiva�c
OS.b- -a Cannot
Miaow
OOtlar (c�Lane
-l. IN -are Wall(s) Completed: •=— Li -ell Location:
FUSS
Name
FUSSEe/
Facitityr i
Physical rlIrc>;, etc, and Zip
erL/
County
Fa ,lit - Mgr if apptir�k;
uU4 OA 4 /al"..,.
0,,4/62S`
Panel Liatif+uti.•a Ain �P 7
a-b. latitude and Liarel ode m dramas _t.�__ s or a ,t�,e
jrveal ri :ht mD: taa1. rioter)
7_ Is this a reps- to an eS1sdi n wTii: Oyes
If the a a repair Jdl akaIse.ra leell co.a nsnme r
repair under 2i rr+aad zsreaim or cm tie bv1-ey- f wad
8. Number ofsre11 constructed: /
For atrtltrpie igca-tiara armsr.s , wells O_-i!LFrdb the wane
salmis meJorm,
9. Total well depth Inb ar Land surface:
For arldti c / un tryi rreUslutd/degtlardjper.�ert'�,r.^lti3So-=00'as.i?sltWl
I tt Static Rater Iced below top of
!f
irmer era
rerlevel tabor:. easing tar.•r-•
1 I. Borehole lea.:
12- Wen consteloakto method:
it e_ atti_;er. rotary. cable, dam Dash eel
FOR \E BITER S(ti'PLY WELLS ONLY:
3
13a. Yield (� t) (f� Method oftesc
1s'b Disinfection t�tc A1 cA Amount:
Form GW-t
cdmuu-e of the
rmormthm. ou,va
re SUBMITTAL IS7UCTIONS
ForIntaaal Use �1?
t4.1Vx1ERZUNS
a u
11111131•11111.1111111111.mouip
fL
11119MIMMENAMMMIM
,M1�t� Rl�s,
,
' ' WI i
SipramreofCantredV_i— ,,,
Dam
trill; du
1 farm.
_Ol00ar 1.7ta-! JC3C 02C wetted 4r� (vmt ,s. -a i ia �;o+xfn�:
. op . of this rea1ed lxir Fcen prorated m Me cell owne. fret, Corsra „ �- dr cad ri,rt a
33- She diagram or additional well detail
Y . ttsr Utc bac6: of this page to particle
cvnstrnctim details. You may also attach �xLeotial page net( site ddaik to gill
s ifttc.=aty,
(ft) 24a. For ag 1G Submit this form NciWat
cooshucaoo to the follonins: days of Sian of cell
(lL) Makin' of Water Resources, Ins P, accs:d_
1617 Mail Service Center; e �`�"`bUnit,
lZ�lt. NC 27699,I6I7
2 For Inucction Wells ONLY: In addition to
2aa above, also submit a copy of tt� within form in 9 the loco to the add f
coatsbuctian to the foflonins-_ 30 dais of completion o Ns -ell
7Rrjvoa ofWater
1636 Mad C Underground I°1�na Cotat6oj t yin
NC 37699-I426
24c. For heater- Supply & fa- 'cal DU&
also submit one copy of this font ttithiu 30
a - conviction t of
rrntsaarcindt constinaimt to the county hailldepartment of am imyrory'n$ae
North Caroliru Dq:urrnsent of ironment and ?L- -4 Rnsu,c es-Drrisien of firmer Raourom
Revi e:1 _4.1mm'_td t

For banal the ONLY:
Parcel lda difie-than ha ,Pt\')
Sb. Latitude and I,ortitade in dotres/rniatucs/seconds or dotal centres:
. tf well tee d. one iat;loris sun- reei)
yry �* RECEIVED/NCDENR/D
1. e 'J r,'7(e/R'� 0k
W H Connacsq-Name
ryea.tt,1—U1rISTRJCT1ON RECORD
This Corm cont. loin for sizylc or owl/inkwells
1. C..., or
CAlitip3TY blame
2. Well Coatir P
tuit ff:
JUL 2 3 2018
Water Quality Region:
0 er.tions Section
�r Wilmington Regiona
terryZ'Z. C1 S 0 Y
List all opplernb/e well permits tie. Co;untyStew. f'ario+n:t. Infection. mei
3. Well Use (check well use):
Wafer Supply 'Well:
agricultural
❑Geothe mal (Hcating,Cooling Supply)
D industreatrom mcrcial
ation
Noll- titer Supply Well:
°Monitoring
Injection Reno:
Q aquifer Recharge
O.-Aquifer Storage and Recovery
Qaquife r Test
DEeperimental Technology
❑Geothcamal (CimcdLoop)
❑Geothermal (Heating: Cooling Return)
QMuni Opal/Public
❑Residential Water Supply (single)
DRssidcntial Watt- Supply- (shared)
°Recovery
QGranndscater Ran ediation
°Salinity Barrier
❑Stormw,tcr Drainage
OSuhsidvxtee Control
°Tracer
OOther (cA-plain under =71 Bronal3)
4. Date Well(s) Completed: l i / ` Ct`ru IB ,
tea. Melt Location::
�ik./ I Crl'dlots vw
Fa6lityitTtncr \rats,
FacrliR' 1D= air a li,ohlc)
. 2 2 0 Z L'; 11i9c/, j A Plc /s /. ti t(
Physical lti1rns City. and Zip
County
'Y
6. Is (are) thewell(s), erfn:rneat or °Temporary
7-Isthis arepair toane mfl: �ishtg Oyes ur
If this it a repair, jtll out known wdl constrommn informati o: and lain arc note of the
repair tender o21 remarks ruction or on the hack of:hir ford
S. Number of wells constructed:
For multiple infection or non -water supply:veils GAIT frith the sane construction. mu can
submit one farm, .®�
For multiple wells !at all depths ifdife.-ntlerample-3%200'oml 2fe -100I
9. Total will depth below land surface:
(�J
IQ Static Heater k%cl blow top of osiig:
If water level is altoaa oaasing, use "_ " (ff-)
11. Borehole diameter: -�
r•
IL Well construction method:
i t e. steer. rotary. cable, avert acid rte.)
FOR 'WATER SUPPLY WELLS ONLY:
f 13a_ Yield (gptn)iilethod of test:
(in.)
(� d IQCJ J7i r
136. Disinfection type:
Fenn diW-t
11 WATER ZONES
FROM
TO
ft.
t 7:
CASING trot odd stied
FROM TO
cgs
FROM
OL-wETER
ORL1NE
imam
iS12GORTUBING
f. ... ..
r
2MCI
17.SCREEN
FROM
DIAMETER
is
11111111
kraiarsaD/AMETER ininTIUCIMEamon
amm
1S. GROUTridallinal_11111111111111111111
FROM TO
L
ft.
19. SAND!
FROM
ft.
IL
£Atf4.aCEA a T atE1HQ0.1v
LUOUIT
:MATER/ L
fr.
in.
ALI EL PACE (if 'table)
2RD:LLha. LOG tataseS adaitioml sheers it ateettmry
FROM
fL
fL
rt
it_
fr. 1fr.
21. REAL9,RES
7-2. Ccrtifica
Si;runae Ceaifitd Well C,M
Date
0i signing this forrn. 1 lxrebr crorip'- that the we/lfs) troy (were) comrr+r_tei is rsa rdmn_e
with I5.t NC.4C 02C .O100 or 15,1 NC..0 02C .W00 If cf! Contra v on Standards trod that a
copy of this record hot been provided to the well owner.
23_ Sttc drat -am a ihlitioaal well derails:
You may use the hack of this page to provide additional well site details or well
construction details. You may also attach additional pages ifuccessary-
SUB\IiTTA LINS7Zrcr(ONS
24a. For all Wells: Submit this form within 30 days of eompletim of ntll
construction to the following:
n
0
yr
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-16I7
246. Fur Inierr:.:. \�11 ONLY: In addition to sending the forth to the on of
in
74a altotr, also submit a
co
itsfuction to the: follo�� e.., )' at the torn �Aitltut 30 days of completionof nell
Division ofWaxer Re_snurcrs, Iittdergrmutd Injection Control Prugr-om,
636 Moil Smite Center, Rik'
fib, NC 27699-I636
lac For \stater 5fipuit S Injection Wells
Also submit one copy of this form within 30
well construction to the county health deportmentdays `�thecomity
completion he
cons: ictetL of county where
Norih Carobhu Dr4A rtrxcru of Fir.•v raucnt .mc1 i`t:um.d Resources -Division K Sl;atcrResarusti;
-mount
Revised Atw°ust ?eel_

WELL CONSTRUCTION RECOmfitICCDENR/DWR
I. Well Contractor Information:
Donald Cummings JUL 1 6 2018
Well Contractor Name
2412-A
Water Quality Regional
NC Well Contractor Certification Number Operations Section
WApplied Resource Management, F�e�lppal Offic
Company Name
2. Well Construction Permit #:
List all applicable well construction permits 'Le. WC, County, State, Variance, etc.)
3. Well Use (check well use):
N/A
Water Supply Well:
Agricultural
Geothennal (Heating/Cooling Supply)
Industrial/Commercial
X Irrigation
Non -Water Supply Well:
Monitoring
DMunicipal/Public
Residential Water Supply (single)
Residential Water Supply (shared)
DRecovery
Injection Well:
,Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
Experimental Technology
Geothermal (Closed Loop)
Geothermal (Heating/Cooling Retum)
4. Date Well(s) Completed: 6/6/18
5a. Well Location:
Mike Bostic
DGroundwater Remediation
Salinity Barrier
DStonnwater Drainage
Subsidence Control
Tracer
Other (explain under #21 Remarks)
Well ID# N/A
N/A
Facility/Owner Name Facility IDW (if applicable)
Lilliput Plantation, Winnabow, NC 27479
Physical Address, City, and Zip
Brunswick 1440000108
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(dwell field, one lat/long is sufficient)
34 4 50.1942 N 77 57 18.3888
W
6. Is(are) the well(s)fx Permanent or DTemporary
7. Is this a repair to an existing well: DYes or xONG
If this is a repair, fill our known well construction information and explain the nature of the
repair under it i remarks .section or on the bock of this firm.
8. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction, only I GW-I is needed. Indicate TOTAL NUMBER of wells
drilled: 1
9. Total well depth below land surface: 160
For multiple wells list all depths tf different (exaunple- 3Vt200' and 2_100')
(ft.)
10. Static water level below top of casing: 17 (ft.)
if water level is above casing, use "- "
11. Borehole diameter: 8" (in.)
12. Well construction method: Mud Rotary
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
Method of test: Airlift
13a. Yield (gpm) 80
HTH 0
13b. Disinfection type: Amount: 3% @ 10g
Print Form
For Internal Use Only:
452383
14. WATER ZONES
FROM
TO
DESCRIPTION
ft.
ft.
ft.
ft.
15. OUTER
CASING (for
multi -cased »ells) OR L1k R fif a
licable)
FROM
TO
DIAMETER
THICKNESS
MATERrAL
0 ft.
140 ft.
4 in.
SCH40
PVC
16. INNER
CASING OR TUBING
(geothermal closed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft.
ft
in.
ft.
ft.
in.
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
140 ft.
160 ft.
2 in'
.020
SCH40
PVC
ft.
ft.
in.
18. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
130 ft.
135 ft.
Bentonite
Poured
ft.
ft.
ft.
ft.
I9. SAND/GRAVEL PACK
(if applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
135 ft,
160 ft.
Coarse
_
Sand
ft.
ft.
20. DRILLING
LOG (attach additional sheets if necessary)
FROM
TO
DESCRIPTION (color, hardness, soil/rock type, grain size, etc.)
0 ft.
9 ft.
Sand
9 ft'
27 ft'
Sandy clay
27 ft.
60 ft.
Rock/sand shell mix
60 it.
138 ft•
Clay/mudrock
138 ft
165 it
Limestone
165 ft.
200 ft•
Green marine clay
ft.
ft.
21.REb1ARKS
RECEIVED
11 11 0 9 2Qi8
22. Ccelification:
`ion Pfoc. ng6 6/18
Signature of Certified Well Contractor r Date
By signing this form, 1 hereby certify that the well(s) was (were) constructed in accordance
with 15A NCAC 02C .0100 or 15A NCAC 02C .0200 Well Construction Standards and that a
copy of this record has been provided to the well owner.
23. Site diagram OF additional.welidetaiist
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTRUCTIONS
24a, For All Wells: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Infection Wells: In 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.

1. Well Contractor Information:
WELL CONSTRUCTION RECO PAl I DENR/DWR For Internal Use Only: '45 4�;�
j
Sanford Sweeting JUN 2 5 2018
Well Contractor Name
2082-A Water Quality Regional
Operations Section
Applied Resource Managemen �alCal Office
Company Name
NC Well Contractor Certification Number
2. Well Construction Permit#:
List all applicable well constriction penults (i.e. L7C', County, State, Variance, etc.)
3. Well Use (check well use):
Water Supply Well:
N/A
14. WATER ZONES . _..
FROM
ft.
ft.
0
TO
ft.
ft.
DESCRIPTION
ap e
TA1CfiNESS
SCH40 PVC
16. INNER CASING OR TUBLNG (geothermal closed -loop)
FROM DIAMETER THICKNESS
in.
in.
in.
MAT
15. OUTER CASING (for multi -cased 11
LINER (it f 1',ca bl )
FROM TO DIAMETER ERIAL
90 ft.
ft.
ft.
ft.
TO
ft.
ft.
6
in.
SIATERI L
Print Form
Agricultural
Geothermal (Heating/Cooling Supply)
Ind ustriallCommerciat
& 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)
DMunicipalPublic
Residential Water Supply (single)
OResidential Water Supply (shared)
ORecovery
IJGround>ti iter Remediation
Salinity Barrier
DStormwater Drainage
DSubsiderice Control
Tracer
Other (explain under #21 Remarks)
4. Date Well(s) Completed: 5/30/18 Well ID# N/A
5a. Well Location:
Belvedere Property
Facility/Owner Name
N/A
Facility IDi! (if applicable)
9149 Orton Road S, Winnabow, NC 28479
Physical Address, City, and Zip
Brunswick
1440000112
County Parcel Identification No (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/tong is sufficient)
33 3 7.5429 N 77 56 55.1674
w
6. Is(are) the well(s)jx Permanent or DTemporary
7. is this a repair to an existing well: Wes or xNo
If this is a repair, fill out known well construction information and explain the nature of the
repair under 421 remarks section or on the hack of this form.
8. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction, only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
driltod: 1
9. Total well depth below land surface: 120 (ft.)
For multiple Hells list all depths if different (example- 3@200' and 2@l00')
10. Static water level below top of casing: 10 (ft.)
If water level is above casing, use
11. Borehole diameter: 10 (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: Airiirt
13b. Disinfection e: HTH o
t3'P Amount: 3 /o @ 10g
17. SCREEN
FROM TO
90 ft. 120 fL
rr. ft.
18. GROUT
FROM
TO
DIAMETER
4
in.
in.
MLATERLAL
SLOT SIZE THICKNESS MATERIAL
.020 SCH40
0 ft. 85 ft- Bentonite
ft.
rt.
ft.
ft.
19. SAND/GRAVEL PACK (if applicable)
FROM TO
85 ft.
120 ft.
MATERIAL
Coarse
PVC
EMPLACEMENT MLTt OD & AMOUNT
Poured
EMPLACEMENT METHOD
Poured
ft.
ft.
20. DRILLING LOG (attach additional sheets if necessary)
DESCRIPTION (color, hardness, sod/rock (ype, grain size, ete.)
Sandy clay
FROM
0
ft.
10 ft.
60 ft-
70 ft-
TO
10 rL
60 ft-
70 ft-
85 ft.
Clay (sticky)
Limestone/limestone clay
Green Marine clay
85 ft.
-Ho ft-
Limestone
110 ft.
120 ft
Hard limey, '';
ft.
21. REMARKS
ft.
JUlq
22. Certifiyption:
15 ?M
5/30/18
Signa{6ie rtified Well Contractor Date
By signing this form, I hereby cer195, that the well(s) was (were) constructed in accordance
with I5 4 h'CAC 02C .0100 or 15A b CAC 02C .0200 Well Construction Standards and that a
copy of this record has been provided to the well owner.
2J. sit a ttiagrsexi or addiiitifial welt ttebtlls:
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.
SUBMTTTAL INSTRUCTIONS
24a. For All Wells: Submit this form within 30 days of completion of well
construction to the folfowing:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Injection Wells: In addition to sending the form to the address in 24a
above, also submit one copy of this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water 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

RECEIVED/NCDENR/DWR
WELL CONSTRUCTION RECORD (GW-1)
JUN 25 2018
1. Well Contractor Information:
Sanford Sweeting
Well Contractor Maine
2082-A
NC Well Contractor Certification Number
Water Quality Regional
Oection
Wilminngton Regional Offic
Applied Resource Management, P.C.
Company Name
2. Well Construction Permit #:
List all applicable well construction permits (i.e. UIC. County. State, Variance, etc.)
3. Well Use (check well use):
N/A
Water Supply Well:
Agricultural DMunicipal/Public
Geothermal (Heating/Cooling Supply) DResidential Water Supply (single)
IndustriaUCommercial DResidential Water Supply (shared)
X}Irrigation
Non -Water Supply Well:
Monitoring
injection Well:
DRecovery
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
Experimental Technology
Geothermal (Closed Loop)
Geothermal (Heating/Cooling Retum)
4. Date Well(s) Completed: 6/4/18
5a. Well Location:
Belvedere Property
Facility/Owner Name
Groundwater Remediation
Salinity Banier
QStormwater Drainage
Subsidence Control
DTracer
Other (explain under #21 Remarks)
Well In# N/A
N/A
Facility IDtI (if applicable)
9149 Orton Road S, Winnabow, NC 28479
Physical Address, City, and Zip
Brunswick
1440000112
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwelt field, one lat/long is sufficient)
34 3 45.9310 N 77 50 51.6046
w
6. Is(are) the well(s)JPermanent or Dremporary
7. is this a repair to an existing well: QYes or NJNo
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 Gcoprobe/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: 1 1 0
For multiple vs -ells. list all depths if different (example- 3@200' and 2.cc100')
10. Static water level below top of casing: 3
If water level is above casing, use "-"
11. Borehole diameter: 10 (in.)
12. Well construction method: Mud Rotary
(i.e. auger, rotary, cable, direct push, etc.)
(ft.)
(ft.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) 100
13b. Disinfection type: HTH
Method of test: Airlift
Amount: 3% @ 10g
For Internal Use Only:
Print Form
451458
14. WATER ZONES
FROM
ft.
? ft.
TO
w
ft.
DESCRIPTION
15. OUTER CASING (for multi -cased welts) OR LINER (if applicable)
FROM TO DIAMETER THICKNESS MATERIAL
+1 fr. 80 ft• 6 in. SCH40 1PVC
16. DINER CASING OR TUBING (geothermal closed -loop)
FROM DIAMETER THICKNESS b!ATERLIL
ft. in.
ft. in.
ft.
ft.
17. SCREEN
FROM
TO
80 ft.
ft.
TO
110 ft.
re.
DIAMETER
4
in.
in.
SLOT SIZE THICANES
.020 SCH40
S
MATERIAL
PVC
18. GROUT
FROM
0
ft.
TO
75 ft.
MATERIAL
Bentonite
EMPLACEMENT METI OD & AMOUNT
Poured
ft.
ft.
ft.
ft.
19. SAND/GRAVEL PACK (if applicable)
FROMTO MATERIAL
75 ft.
110 ft• Coarse
EMPLACEMENT METHOD
Poured
ft.
ft.
20. DRILLING LOG (attach additional sheets if necessary)
DESCRIPTION (color, hardness, soil/rock type, grain size, etc.)
Root mat
FROM
0
ft.
TO
3 ft•
3 ft.
12 ft,
70 ft.
12 ft•
70 ft.
110 ft.
Reddish brown sandy clay
Light gray sand some clay
Light gray sandy limestone
ft.
ft.
ft.
ft.
ft
ft:
21. REMARKS
l
,LUN152018
6/4/18
Sigma .re of Certified Well Contractor Date
By signing this forth, 1 hereby cent• that the wen(s) was (were) constructed in accordance
with 15A NCAC 02C.0100 or I5A NCAC 02C .0200 Well Construction Standards and that a
copy of this record has been provided to the well owner.
23.. Sffe Map' alb' or addlllotiat.wett defxfls:
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
construclfon fo the follow -Mg:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For infection Wells: In addition to sending the form to the address in 24a
above, also submit one copy of this form within 30 days of completion of well
constriction 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

WELL CONSTRUCTION RECORD (GW-I
J. Welt Contractor Information:
6,9r SAS
Wcl: ('U, irocl& Nome
NC Will Contractor Ccriification Nwobcr
Company Nome
c
NECEIVED/NCDENRIDWR t�
JUN 11 ?018
tiperations Section
2, Well Construction Permit tt WI(rnlncton Reg;onai Office
/.,s[ u;/ GIP/Via/hie soli v ltslrt iiun permit, line: OiC.. County. ,Spam. pant: m etc.?
3. Well Use (check well use):
Water Supply 'Weed:
Agricultural °Mta1 cinal/PubIk
Geotht:attat (Fleating/Cooling Supply) °Residential Water Supply (single)
indu,ttrir:i/Colttmcrcial DResidcntial Water Supply (shared)
Non -Water Supply Welt:
Monitorirl
ectr�(ent v►�
;In3
n:
Aquifer Ree barge
Aquifer Storages and Recovery
Aquifer Test
rxperitnUmai • 'oehlolosy
Geothermal (Closed Loop)
45/ves't'._cl(
ReCOwery
°Groundwater Rernedialion
OSalinity Barrier
QStoimwater Drainage
°,Subsidence Control
°Tomer
Geothermal ((•hhatinu(:ooling Return) iher (explain under 021 Remarks
4. pate Well(s) Completed: -f .a, 3-/2" Well 110/
Si, Well Location:
ff7/Ee ... %%/t/7f !Ai
Facility/Owner Mime .Facility IAN (if applicable)
Physical Addtt:xs, City, and Zip JV c. a, 8 9 e: r
(.:unary Parcel luuntitia,Kim No. (PIN)
5b. Latitude and llnttgiludr irl degrees/minutes/seconds or decimal degrees:
Orwell field, one 1at/)ong is sufficient)
3 3 ° S• iB I. N e>g °
6.(s(are) the well(s)gPertuanent or °Temporary
7. Is this a repair to an existing well: EjYcs or 131 No
!l rbls Lr a repair, fill nui 400kon will comoreoln» Wormorinn turd rxp(nin rho matt t of(+4c
repair under is 2,1 periwig moron fir uii the &axle of (h/.josh.
S. For ( eprot*JDFr or Closed -Loop Geothermal Weds havin the same
construction. only ! OW-1 is needed. Indictee TOTAL NUMBER of wells
9. Total weal depth bed laird surface: / (f .)
file maple wells list all clepths lfdeerettd (e;at rple. V.200' and 20)(00')
10, Static water level below top of Carling:
/,/wpm.- m,/ tr anvire wµ, arc .•v •,
ev0r
1 I. Borehole diameter: (In.)
12. Well construction nacIbod;
(i.e. augur, runny, tolble, duce? psh, cm.)
(D•)
FOR WATER SUPPLY WTLI S ONLY:
13a. Yield'(&pm) Mctbo+i of rest:
13b. Aioturcction type:
Aim ant:
1 SGRR
22. C,trtlfiea iort:
Nor internal Ilse
45�0774
Mn nEltrn I, --
•
_•.•attn1 MATE tAL .•..
^Si�� ..';,;�••„vs"+'> �•
lt/,`KNIL'�S r�Mn
tn. /
0 egr
MATERIAL
PTArl;aetr Kgryci a_,Ahlttri:
ttaart tACentEttrr•MET SI»n
Ut•Lop, lestrthttes.116iVmrrtyrzreladUee,ek,)
%nAtnro of Ce ' lied ti/ onitay ur r,�
Wiz
/ly signing Ihrs 1 NO ar/V • Mtn the Wets) wa (Ner el. cviterrivard In aecar& ,
with 154 NCAC 0.. , .t7100 or 11A NC,t(: 02..0207 ow, c:orprrectrora Niancrowis met mht,
GNIpY*Phil mere as been prpvk{uc/tuhewell Owner,
23. Site diagram or additional well details:
You may use the beck of this page to provide otltltlional well site details or w
construction details. You may also attach additional pages ifbecessary.
SOla)t9i iTAX..iIN 1Jr. DONB
24a. For 411 WO: Submit this forth within 30 days of completion of w
construction. to the following:
Division of Water Resources, Information ProcEacing f)nitt
1.617 Mail Service Center, Rate1gb,.NC 27699-161.7
24b. For ityeetion Wefts: In addition to sending the forth to the Mdrps in 2
above; also submit one copy of rhis Poem within .30 days of completion of•ve
constriction to the following:
Division of Water Rcsourentii Underground Injection Control ,Program,
1636 Mail Service (enter. Eealetghy'Nt,' 21f699-1636
24e. Par Wok!' Sunnite En addition to swirling the, farm
the addresses) above, also submit one copy of this form within 30 days
completion of well construction to the county health department of tin soup
where npnetmom

WELL CONSTRUCTION RECORD (GW-1)
J. Well Contractor Information:
Well COntrathu Name
ai4'
NC Well Coetracitlr Ccrtiircation Number
R€CEIVED/NCDENR/DW
lump y Name
MAY 0 6 2018
For Internet Use Only:
4494'4S
.eta, WATER ZONES • • ..
radta n To '� oeacaarnoN
NROM I '10 RMVICLLK-011(btNe,S
vvater t uanty tiegional f t It a b ... i°" . , o9 e
Operations Section :IXINORWCASINGOITOBING (>� •
i.
2. Well Cooetruetinn Permit 0:. Iltjllnpff)rr gppinpiI Off it °1°O61 TO -PIA" R �trrctoarrss MA arum
/as, VIl o13n!ioutrer wrl! c,Miltvcvian p! II tc (., r:, :i/(,', C'uun.(v .U'4vr. Ynri<nc:e d<:! ft. R•
r ,
3. Well Tsr (cheek y/ell use):
• Water Supply Well:
Agricurtural °Municipal/Public
DGcothc mal (Heating/COof(ng Supply) °Resident(a( Water Supply (single)
0Industriid/Conmertial DResidrsrtia) Water Supply (shared)
Non -Water Supply Well:
CiMonitorirg °Recovery
Injection Welt:
Aquifer Recharge OGroundwater Remediet;on
Aquifer Swage artd Recovery °Salinity Barrier
Aquifer Test • }Stormwater Omit ge
I;xperims:ntol Technology DSubsidenee Control
Gcotiielmal (Closed Loop) DTraccr
Geothermal (licaling/CroliatRetural ri,-lhe► (cafp(sin under il21Remelifsl..
4. Date Weil(s) Completed: y /0 -/r Well mil • . ._
:So. Wet; (,.ocstinn:
Sc.c 44 , /9�.i C
Far;i(ity/Owner Name Facility r7)R (if applicable)
e OAK 2sa4 NC a8sibr
Physical Address. City, and :ip
epwsilJ.c(C
county Parcel idontifcariun No. (I'iN)
5b. Latitude and longitude in degreesltolnutex/sesonda or decimal degrees:
t if well field, on latticing ts sufficient)
•
6. ia(are) the well(e) t '•crtaaaent .or DTemporary
7. la thia a rrepatr to an existing well; [ Yea or ONo
!Phis is 0 K/Joir„!r/1 OrM klx,wn melt eon vrurlion enfonnot are <wd rxpl/m, Ike MM.,' Q/lhe
repolr wrdGr ill rem: W o eeclion or on the lwek nj itusArm.
S. For GeoprobelDPT or ('lased -hoop Gcolliereoal Wells having the same
comtruction, only OW-1 is needed. Indicate TOTAL NUMBER of walls
drilled:
0 Total welt AarM below cant/ mrr ;e .� p :ft.)
t"0, M011p(6 wells list oil dd/xhs jd,Jjereltl (exam/a'e- .i6200' awl 2gro01
L0. Static water level below top of ea** Y fit)
/f tnver /furl it obott (=Ting. We '.
//,t•
'IL Borebotcdiameter: �aa (in.)
12. Well eomstrticlloa method: . W ea 'r ��
(i.e, aitkur, rotary, wrbk, direct path, etc.)
FOR WATER RIPPLY Wrl,l S ONLY:
113a. Yield (gpm) Method of test;
13b. Disinfection type: Amount:
n. d
n.
IS`(1urn CASTfiGl iodt,'•.t saboiltit.OR<l, *120 bit)•
MATERIAL
in.
47 SCREi? N .
FROM [¢ DlAMa It star SIZE 'r111(:3(11
ao R i t ft. , yy m. ,Of0 slod /°r!Q
ln-
ft A.
3& GROUT`
FROM TO A!ATEP WJ
n.
h
ft
$40/G/Ifel.
gmamc_7,MErfr. METHOD h Aha(21)
?4_
ft.
861Xfr>itIWZ PWc
,FROM T'() MATQRtAt:
1tWIAC6Mlf.NTMETHOD
T-
t
:_20;'gti1nget0G•Vlttcep It l Rf)...,.. •,;
r MOM TO 0 charnoN war.rtarb+eca,, tr e3r try R21.Xt. eteJ
ft tt
rt.
R (L
(t.
ft.
ft.
0.:a,2nta
22- Certification:
Signora, orCortiBod Wall" or
ftovyFits
irivoldi"mfir,:err=
then
QY $
/ n OR .A)a jonm. ( • •�! 0010 Utxv Oft iatl(el isat (nett! <Vrratnrored Ilt ogcord
with /Sr( NOW 0JC,0140 or 1sq hC'AC 01C.0200 Wel r.Ar+.Ynrelinh $1crt40rtI. mod,fl
crazy ofthis flacon; ifteboo provtio to1heKO mortars
23. Site diagram or addidonal will details:
Yon tray use the back of this page to provide addrtionel well site details 4r +
tonsttrtetion details. You may also toweb additional pages ifneccseaty,
StIlIM CfTA1, iNSTRI C`f'IONS
24a. For 40 i dgt: Submit this form wnrnn 30 flays oi' altttpletion or
t onal:r tctioon to the following;
Division of Wafer Re:Sourv. Information Processing Unit
1617 Mall Service Center. Rakigb, NC.27699.1617
24b. For Infection Willa: In addirion to sending the form to the address in
above. also submit one copy of this form within 30 days of completion of
construtaion to the following;
Diriaiob of Water Rcaortrced, Uedergi:oawd injection Colitiol.Pr gram.
1636'Mal ;Service Center. tiekiglq NC.` 27599-7636
24e. Per *icier Sonata di !Mee .% Wells: in addition CO tending tic fort
the addresses) above. also submit one copy of this form within 30 day.
completion of welt corMatraaion to the county hca)ti department' of the cox
wltoro. tvtnCtrtertprr

WELL CMSTRUCITON.RECOgD (GWL1)
1.. Well Contractor information:
tL'
Wcti Cum.:mid Name
NC Well Contractor Certification Number
RRCEIVED/NODENR/DWR
MAY 0 6 2018
CompanpName Water Quality Regional
Operations Section
2, Well Consrruv6on Permitp: htl/ilwin5! nal Qfc
l.w't all alyrlicvbk well e' nxttvetien permits, (i.e. WC. County. are. Paitanre. etc.)
3, Well 1)se (check well use):
Witter Supply Well:
Aviculture' DMt nicipal/Nublic
Geothermal (Heating/Cooling Supply) °Residential Water Supply (single)
indu..sttial/Commcrciel f Rcsidcntiel Water Supply (abated)
it'ation
Non water Supply Well:
Monitoring
lojeefion Well:
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
Experimental Technology
Geothermal (Closed K.00p)
Geothermal 'icntin CocUn: Return
DRecovery
Doroundwater Remediation
(Salinity Barrier
[DStormwater Drainage
DSubsidence Control
}Tram/
Miller (explain under 1l2t Remarks)
4. Date Wdl(e) Completed: y.-./D " /� Wen line
3aa.. Well [.oratiion`:
Facility/Owner Nam Facility iNµ (ifapplitable)
'7O(e fr.ca C1•1 k pQ , 50.41►po 1- owC
Physical Address, City, and Zip
County Parcel Identification No. (PiN)
Sb. Ladtude and 'co itade in degrees/minutes/seconds or decimal degrees:
(if well field, one 1allong is sufficient)
°L,o1 N G')S°
33 SD't,.5-03 w
6. is(are) the wcll(s) >•reaecnt or oTemporary
7. is this a repair to an existing well: °Yes or No
//figs es a repair, fill ow known welt ec»elruelten MJorwwNon ass the reran *On
repair cruder eV ',Gliwice secowl iw nee the hack oftltlxfortim.
8. For Gm/probelOPif'ur Closed -Loop Geothermal Welt having the same
ct:rrtstxueliun, only d OW-1 i$ needed. Indicate TOTAL. NUMBER of wells
drilled
9. Total well depth below land gurfitce:
For nru(up(e wells ll$f all &pelts (fd teed (emtnple- J@200' and 201)(00')
10. Static water level below iop of casing: /,-
gyrator fnved lr emery raring, ttcc "4- "
t t. borehole diameter: 6 (in.)
12. Well construction method: C.a )xis( 3....)
(i.e. anger, rotary, cable, davet push etc.)
(ft.)
FOR WATER SUPPLY WELLS ONLY:
13a.'Yield (gpm) A,temod of test:
I3b. Piainfection type: Amount:
For internal Ilse Only:
Th.
'to
ii (ZN
440 f1. _.,.
3 e h.
CCP/ar6-4►.
.k S
t. f
fl,
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FROM TO _4 DIAMETER 1IIICKNC jl MATERIAL
�l ft. 490 (t 1 47' in. O'( O
;46:ANNER 'ii6H!1!G•OMBIN6 (lraf iktrag city • _ ; :,; :::.
FROM TO AMMETER TEK1011959
ft. ft. in.
MATERIAL
rt.
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as
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EMPI. CEME T METHOD & AMOUNT
n
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FROM TO MATERIAL EMMACEMENTAfETHOD
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a.
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ft.
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ft.MAY 0 e ZOT8
w,gcspngtion PtOC..;.n.r,g
- •r
p.
fR
ft. ft.
22. Certification:
Jam-/ /,
clan imaw
By spring rhea Jbrm, I ber4rrriiY Mtn the wdrls). was Wend voosusickd in accordance
wldh 1JAA%AC Q.. ,0/00 or 154 NC;AC 02C.0200 Coironallon Standards and that a
copy of this +frond has been provided le the well owner.
Z3. 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.
s_ 11 mJTA ailffEUCI1O
242. ForAtl Welk: Submit this torn within 30 days of completion of well
oflsbnllxiin to the following:
Division of Water Resources, Information Processing unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For [tribe' Wells: In addition to sending the form to the address in 2Aa
above, also submit one copy of this form within 30 days of completion of well
construction to the following:
Division of WaterResourco , Underground lojectloo.Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For 3VatvAtusi,ly ,St. initiation Welk: In addition to sending the form to
the address(en) above, also submit one copy of this form within 30 days or
completion of well construction to the county health depetnent of the county
where rnneh" tHrA

WELL CONSTRUCTJON RECORD (GW-1)
1. Well Contractor Information:
�YCII (:cutruet )r Name
�19g
ECENED/DEI'R/DWR
NC Well Contractor Certification Number
O, . 12.41f M�
Pater t,ivality Regional
to
it
Company Name Operations Section
2. Well Coostructinn rermil!/: Wllminpnn RP innal__QifIce.
MAY 0 6 2018
Liz; all applicath waft twartruc'tlon tiertnitti (i.e. WC, C'ow iv..Vate. Narhme. etc.)
3. Well Use (check well use):
Water Supply Welt:
Agricultural OMunicipal/Public
(ieothermal (Heating/Cooling Supply) ORcsidentiai Water Supply (single)
indu.strial/Commercial f Rc,9identi21 Water Supply (sbltred)
Not. -Water Supply Well:
Monitoring
Recovery
lojeetiou well:
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
Experimental Teehnolo£,y
Geothermal (Closed Loop)
Creothermal (Hiealing/Coolisletuno)
DGroundwater 12cmedistion
®Salinity Barrier
QStormmwater Drainage
DSubsidcnce Control
()Tracer
• ther (ex . lain under lt2 t Remark
4. llute Wel1(3) Completed: y' a7 ' / g' Wcll illk
Sa. Well Lac' pn:
7zd1 DA 4<
Facility/Owner Nnme
Facility b) (if applicable)
/15 NE S'r OAK-Vs-IA.OAK-Vs-IA.4 fee
PLysical Address, City, and Zip
h+,.�3 I,lv.c
C'ouniy.
aa4Lr
Parcel Jdentihmtjon No. (PIN)
9'D. latitude and longitude io degret:shmnutes/sotonds or decimal degrees:
(if well field, one Iat/long is sufficient)
33 ° r-S..11.3 N Q`�rt vs • k s4
6. 1s(are) die wetl(s):rferomnent or OTemporary
7. 1y this a repair to an existing well: [JYes or C)No
If this it a repair. fell ouf known well enn,,vtruction rft%T abort and explain the nova of fhe
repair under i121 remarks ye,,tiure or ph the iwek of t/t(•rfornr.
8. For Gcoprobe/DPT or Closed -Loop Geothermal Wells having t11c slime
construction, only ! OW-1 is needed. Indicate TOTAL NUMi3ER of wells
drilled: .. ..... __......
9. Total wen depth below land surface:1•
For multiple wells list all depths f/djtfer©u (<ewmple- 31 200' and 2(19100)
10. Static water level below top of easing: 7
if water level ra oho.r casrng. arc "+"
1). Borehole diameter: 4- on.)
12. Well consrroction method: Ce.► Aeia/ �.
(i,c, auger, rotary, cable• direct push etc.)
(ft.)
(ft.)
)?OR WATER SUPPLY WELLS ONLY:
13a. Yield (pin) Method of teat:
13b. Disinfection type: Amount:
For (nternat Use Only:
•lWATER ZONES, ,,,rr.::, •...•
FROM
TO DI C, FIOn
/5 a.
'-7 t4
ea..rs S.a-.._
ft. ft.
:.151:1lSTER'CASIiV(;'ifotriitti-crsed: jblttENIRtit ble) '
FROM
TO
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PRW4
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ft
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. B; GROtiT • .
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it
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Zf grottigg` ,
(ntprt11:3tit+rl PrUCt :•c,.'•4} list
l.Jtf9fri r,:r%:
22. C. ificati
SigoaturoadCol od W j Cv t actor
Date
Fly .vi�i g this rm. l kevcb) cm tYy that the weft(.) war (warrl cansiruvtd in accordance
with /SA NCit or? .0(00 yr /J4 NCB(: 02C.020d well Constrvctiotr $farrdtln2r and that 0
copy o/thtr record hat 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 Ifoccessary,
,�Cn1t iF IAL N v1 ttol(s
24a, Est AU WeUw: Submit this fbnn within 30 days of completion of wets
construction to the following;
Division of Water Resources, fdfonnat(on Processing Unit.
1617 Mail Service Center, Raleigh, NC 27699-1611
24b, haplessly Weill: In addition to sending On 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 ResOaroes, Undergroaod InJectioo Control Program.
1636 lrlall Service Center, Raleigh, NC 27699-1(5,36
24e. For Water Spoof*. tjoirslim Welts: In addition to sending the form to
the address(cc) above, also submit one copy of this form within 30 days of
completion of welt construction to the county health department of' the county
wk, r rnndnrrtwl

fit
tF
WELL. CONSTRUCTION RF,CORD (GW-1)
1. Well Contractor Information:
GAay Sop4,
Wel, i rN:unc
a-1gg
NC Well Contractor Certification Number
1CLC9t�A
Company Name
For Internal, Use Only:
I EIVED,LNCDENR/DWII ""
ft.
MAY 0 F 2018
ru
PPZVRWI tQn
1'SY331TER CASING (fvs'iai:tbi-.cated we#9.6 i;1'lVERAI
',ROM TO nrAMr,'AErt
Water Quality R gionar i`I "' / 5 ft,
Operations Section ,,,l ;AMR.
2. Well Construction lrntnntnn Rif nnI (ia ffiCe,— tOM 7O
k Permit f!
Iasi all opplirable }-er1 coRatrucrh,n txrnul.i (rasa U.!C. !'nunry. Slane, ltodamre. etc.? R•
3, Well UR (check well use):
Water Supply Well:
Agricultural ®Municipalfl'ublic
(;eothermal (Heating/Cooling Supply) °Residential Water Supply (single)
)ndustria1/Commercial f Residential Water Supply (shared)
Ira' a • 'on
Non -Water Supply Well:
Monitoring
Injection Well:
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
Iixperimcntnl Technology
Rc enuetY
QOroundv ter12emcdialion
oSalinity Battier
DStormwatet Drainage
DSubsidurae Control
Geothermal (Closed Loup) OT7acw
CGeothetmal eating Cooling Return) FOther (explain under #2.1 Remarks
4. Date Well(s) Completed: 4" ?—/7/Well ID#
Sa, Weil Location;
70A TAit<
facility/(honer Name
I'ociliry I7)tt tit -applicable)
AJE a. o'µ` oAK xriesA.l 4 C. fieLr
Physical Addross, Oty, and zip
C'onrily Parcel Iclentifioatlnn No. (PIN)
Sb. Latitude and longitude in degrees/minutes/seconds or decimal degrns:
(if well field, out 1st/long is sufficient)
3 S" . �f) N 01)¥3'
W
6. le(are) the well(S)'ermanent or OTemporary
7. Is this a repair to au existing we(I: QYes • or EgNo
lfthts £s a ►CpGlr.l tl.out known %WI cvin.structinn infor,.w1on and cxpIol,i rite nature of MR
rBpalr und¢r (,'2l rcmarJu scion ur on the IlaCk of thin form,
S. For Geoprobe/DYT or Closed -Loop Geothermal Wells having the same
conWuetion, only 1 OW-1 is needed. lndieate TOTAL NUMI3I3R of wells
drilled:
0. Total well depth below land surfacer 1-7
for mutuple wells /W all depths if different (example- Kfp,200' and 2@!00)
10. Static water level below top of casing: •Z
If ware( hurt hr ahm•r rac-
1 1. Dorehnle diameter: 61, (in.)
12. Well construction method: C+J Mal/ Se_
tnrger, ,ablb, divert pl4ch, ac,)
(ft.)
FOR WATER SUPPLY WLIJ S ONLY:
1.3a. Yield (gpm) Method of test:
1311s. Disinfection type: Amount:
't411Q tense I newt —taunt.
in. Cl . dt.
NAME rc& THKKNISS
in.
MATERIAL
ft.
in,
MOM{ ' O PU 't' l ffir 71 'fiiragfit MATERIAL
/ 7 itA 9 ft, l J� in. ' to
tt ft. In.
18. G OITT
FROM To
MAr itUL
0 tt' / 8 fr. 11e fa elk.>
rc R
kMPLtC5 ENT Mi I OD & AMOUNT
rt.
FROM __,TO L MATERG4
ft.
t:hfPL1Ce'MErrr ATsrROD
ft
n,
10A1111.1.1311%1,0atittftehatielip idit; > ash
Mom To DERCRITTION teetorj Wrdw$, se6tro& iynn, Ann* 1,fre, etas..,
h. ft
n.
ft.
ft
ft.
(L
ft
R.
h.
RECF-H\!E .
at.
ft.
MAY 0
Inforrna,tUrl PiL':: Jy: •Q y� tli
2.2. Certificad
Signature of Corti
5-P/p/I'
ontrocior pate.
By sighing rhia joint, r hereby crnO' thaw the wc11(1) vat (ware) ennqrwred tar occortio.n t
with 15A NCAC 0Z(.' .0100 or I SA MCA() 02C' .0200 Weir Cnnsrrncitoo SYrotdorric and rf>ar o
ropy of this record has been provfdaf to th i d! QWlttr,
23. Site diagram or additional well details:
You may ttSe the back of this page to provide additional well sits details or well
consbvc ion details. YOU may also attach additional pages If necessary.
SUeh11:TTA1 t1iSCRUCTlON
20, For 6Ii Weft: Submit this form within 30 days of completion of well
construction to the following:
Division of Water 17esourccq Information Processing Unit.
1617 MAII Service Center, Raleigh, NC 27699.161.7
2417. for Ipjecu{po Wefts: In addition to sanding 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 lop:ctlon Control ,Program,
I<636 Mail Service Center, Rnteigh, NC 27699-106
24r- fur Witter Sunniv lniection W_efJS: En 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
whirr+rnnctntntert

WELL CONSTRUCTION RECORD !GW-1?
1. Well Contractor Information:
G A X U a v.1R-5-
Wen C ultirortw Name
I9
tie Well Contractor Certification Number
Company Name
R CEIVEO/NCDENR/DWR
MAY 0 6 2018
Water Quality Regional
2, Well Cooetruetitin'Permit ll: Ooerations Section
List all applleohle mall rruouvelion wildly (l.c.'wt... t'SAjykr*3'A0llt447/ 4w/01 Office
3, Well Use (cheek well use):
Water Supply Wei[:
Agricultural OMunieipal/Public
Cieothetmai (Heating/Giwting Supply) DRasiaentiaf Water Supply (single)
lodtt,ttiul/Commercial DResidential Water Supply (shared)
Non -Water Supply Welt:
Monitoring jater.Overy
ltvectiou Well:
Aquifer Rcettarge
Aquifer Storage and Recovery
Aquifer'fest
xperimcntel •i cc:hnology
Ccatherntttl (Cloxed Loop)
Geothermal (fieatinr ('ooting Rcturtl)
°Groundwater Rcmediation
DSolinity Barrier
DStotmwatcr Drainage
Q Subaidcnce Control
D'l'reeer
f o her (explain under 02I Remittal
4. )hate Well(s) Completed: $"/v'/ t' welt ma
Sa. Weil location:
sue- 44,
Facility/Oweer Wow FncIIIty tD!! (if 8pDlieable)
3S7y E 4e.Ack A.K zsiAA.1 .J
Physical Adth s . City, and Zip
f'ra544.eiC
county Parcel IrIrnD6aeII No. (PIN)
5b. latitude aud.{oogitade in degrces/minutesf onds or decimal degrees:
(if well field. one IaUlonr, is sufficient)
38° rcf N c»SO Al • S9d w
6. •[9(ere) the well(sygSPermaneot or C3Tentporery
7. lit this ti repair to as existing well: CIYcs or Ore
goats 1, a repair,/rll wit blows tvr((crurstrttc1ton Information and c .p ieln iha mom' of rite
r't'/tnir under K?I renarkr section or on the Id(,ko)'ads form.
8. For Geoprobc)DTX' or Clo ed•LOop Geothermal ermal Wells baying the same
construction, only I GW.I is needed. Indicate TOTAL NUMBER ofwelLy
drilled.
0. Total well depth below laud surface:
31
for multiple welts ((a all loot& tfd(krral (aruMple• 3(d,T00' and 2 @glP0
10. Static water level below top of easing: .y
Twofer teeth's above ming, ure �•+'
11. tiorehNe diameter; (in.)
12. Welt conatxuctlon turmoil: 441.414y 'rS4t
(i.e. mtger, roomy. cable, direct push, ate.)
(R.)
(f)
rFOR WATER SUPPLY WELLS ONl.Y:
13a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
For Intern( Use Only:
449434
is wA fait tiorlEs rr'; t :, ; ;:.:• :
MOM TO nrSCRIPTtt)N
10 A..l 28 f coAsks,
lx' OlTUR'CXS)NC (kr' 101464asitileelArleilt:7ilNA:/Fr 3tel:
FROM fa 4tAMETEA TPICKNFSS MAMMAL
aw ft. Z Fa, C tI p TTT
it.A81NtIOR YDRIN i Gatti ; ( `' : s �' .
nest OD OtilttRrRR l 't'N1(:6tatm tray rn_Al.
ft. ft. in, r
ft.
in.
s,17,a:£0,EAT'' •' .
!ROM T.Q OTA6 .YF'A ALOTS.= 77t/CKt1
ft. It / in, O l G Oti
O. ft, ltr. f
TO
_ MATERTA1, EM11.403IMr.NT MEpD k MINT
b (ft,,' R /44-/"3 gew-L-)4'117°
ft. ft.
::19JAhliriAltY11,43ibOtiniialitiltsay
,tltOM TO . Nankai,
ft. ft,
t oll,rlCBMPATMETHOD
ft.
20xDRll;?idNrr. �fit>a
FROM
R, fiG
Mctus ION koala. ,s.astik,
A.
. ft,
ft.
If.
ft.
ft.
n.
ft,
ft.
ft,
MAY 0 9. 2018
22- Cer
SIgnntuta ore W .G r stor
ay soilig rheaform, / - 6y catty then the tva(l(%) wa4'irereJ constructed to accordm c
with /5A t 4C 02C.0100or ISA ? AG' 02C .00C Wt ll Crinsosto(oo ..%Quiard,4mad that.
.copy of(hlsrecord ka hen' pro.idedta11retoe(!owner.
23. Site diagram or additional well details:
You may use the back of this page to prov(de additional well site details or wcl
oonstntctloo details. You may.atso attach additional pages 1f necacsary.
Wilivirr.rA IINS'1RucuoN$.
24a. for All' We: Submit this (tlrnt within 30 days or completion 6f we!
construction to the following:
Division of Water Resources. informatioo Prose slot 'irwit
1617 Malt Service Center, Rateigb, NC 27699461.7
24b. $prlolectitio:Wcfis: In addition to sending the feint to the addresS In 24
above, n)so submit one copy of this form within 30 days of completion of won
construction to the Following:
Uivitiioo of Water Resonrees, Undergr((iaad llq)ectioa Control Program,
636 Mail Service Center, Raleigh; NC 27699-f 636
24e. 1'or Water eg6tply y (niccti+la sVVelte: [n eddition to sending the form e.
the eddress(es) above, also submit One copy of this fisted within 30 days 0
tom/Action of well tonal:e beet to the county health department of the eoutIt
Whin. nrv+cino'trvt

WELL CONSTRUCTION RECORD'(«V411
',Well Contractor Information:
Well Conn ,ter Name
a (99
NC Well Connector Csrtificatlon Number
or ntcmal Use Only:
49413
►tl'eFI11F(1/ f41C tb/nun �'.td 1KA'C131t.:.
^� � ro nF4001
St' fl T 43‘ fe. Cc -VAS SA•..+(
MAY 0.6 2018
A k.4,9. tilt. .Da- ��rQ
Coir)pnnytfamr: ! bdatei Qutlily Regional
Operations Section
2, Weil Construction Permit It: Wiln1inuNtOn RP innal C1rfico
al!a/yrlicab/e WI corow 1iin pommy (Le..(I1C. Courtly.,Sr)le. Parirrruw, etc.)
3. Well Use (check well use):
Water Supply Well;
Agricularral
Geothermal (Heating/Cbofittg Supply)
lndustriiiVCommerciel
Non -Water Supply Well:
Monitoring
ell:
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Tot
3xperimentnI'f ethnology
Geothermal (Closed Loop)
Cooling. Return)
Geothermal
DMunicipal/Pablic
°Residential Water Supply (single)
°Residential Water Supply (shared)
ov
OGrouldwater Remediadion
r3Selinity Battier
0SW/ri eter Drainage
°Suboidcnce Control
°Tracer
Other (eir r fair: under #21 Retaatks
4. DateWell(a) Completed: 9— a•—i r Well Intl
Sa. Well IL/motion:
FacllitylOwner Name
Pthyairal Addre,es, City, and Zip
County
Facility Bill (if applicable)
Parcel klen¢ftcition No. (PIN)
:ib. Latitude and longitude in degrees/n mutes/ vvonde or decimal degrees:
(if well field, one laVrong L au0icIent)
6, ta(are) the well(S)Permanent Or °Temporary
7. is this a rcpetir to tuo.exlsting well: °Yea or 13No
//rare Cs a r. pair, fill ow Arrown wr(1 arrnvrrurx(on'orb/oration and explain tea notate gfUre
POW/ uAiier re21 newarkxa r iwr or•On Ihg bile* rtfIA&'from.
8. For Geoprobe/DrI' ur Clitiaad,l oop Geothermal Wells having the seine
construction. only 1 OW-1 is needed. lndicatcTOTAL NUMBER ofwells
'drilled:
9. Total wed depth below laud surface: f S�
For wells ibr al(dapurr ildi meet (are iple- 3@200' one 4100)
10. Static water (tvel below top of eksiog:
'"wu(er rove( irannvc' CWAVIIK.ucc "� •.
11.Borehole dameter:
0n.)
2. Well constructioe:rocthod: &.)Ain/
(i,e, salter, unary, nrLts, ct'rrsq persA, etc.)
(ft)
fr.
:MOL;ITTI1 AtU49Ifni'+rAtkaaed;tiragj:+ORXIN;4$Yi j..
VROM To OIAMb1!R 'rRJO Nry'SS MOM/J.1 it' v tr, . j p Yo totic
;:Z'. R CAi jG ll 1RCr l" .4 4t1 iiiiP)' •
VRQ0.� T TO tuatu ';6R 'n't_,190t_ rrRIAI
rt. It.i
ft, ft.
n,
in.
P OM TO urAktrms lztom SUS TRIO- NkSS
a !L ij.r sR / Yr In. /6 ore e9
fi. ft, to
aulLealar-
Pec
3B?G O1.f
Fqt 1
0
1'O MA r &L tater..4 71rr1 N7 tNLf8oO &Utotist'r
a
ft.
fl,
IL
.:1941AlikWilactiPX06 tl 44,0til1W:
PROM TO :MA'I'Fkt,L
fr.
fi.
XASP .A_rCt;AtT,N7',tdETnnD
Syr Qy:.0Vi •s
FROMTtN A ��ac ruin teeter.►nnta rq%ivroclt rvrc ? frrrblelJ
fr.
ft.
k.
h.
ft.
ft-
R
rt.
RECE VE '
MAY 0s2018
:titytt.P3u^t vtx161;iirll
DWO/g0
22 Certifi o>a:
5',. .. . ^/� oteetlifi-' , otl Con '•elor' ,
ay n'igr/t5, 1' him �oer1,1. thou t&' rwll(4 ww 'fete/ coastracI'd Or atomism
wkb ISA,NCAC 02C:.0100 0' /S4 MAC. 02C.0200 Wall OrwPratliOn Simian& wad rhos
cry a/rhk nteord has been prov(ded (n Me Welt mewur,
23. Sire diagram or additional well details:
You may use the back of this page to provide additional well site details or wel
construction details. You may also attach additional pogo ifneccsvary,
91G' NSTR'(1C'TIONS
24a, For AN Weller: Submit this form within 30 days of cotnpletiod of wel
(wnsanction to the following:
Division of Wafer Resources,Information Processing Ueit.
1(617 Mail Semite Center, Raleii, NC 27699-161.7
24b. Fqr htlettloaWells: In.addition 'to sending the ft;m to tho address in 24
above, also submit one copy of this forro within 30 days of corrugation of wel
construction to.thc fb11owing:
Division of Water Resources, Underground Wootton Control?tumuit°,
FOR WATER SUPPLY WELLS MIN: 1636 Mall Stroke Center.I?aloig>f, A'G'37094636
13a. Yield (gpm) Method of test: 24e. Fury/nice Snook &iaiecttoes Well;:: in addition to sending the form n
fire le/chest:0x) above, also submit one tx:py of this form within 30 days o
13b. W lofecdon type: Araouo r: completion of well cOn3 ivaioo to the county health department of the count;
whist,* eroctro'h'rt

Company Name
WELL CONSTRUCTION RECORD (GW-1)
1. Well Contractor information:
John Salmon
Well Contractor Name
3497-A
NC Well Contractor Certification Number
RECEIVED/NCDENR/DWR
APR 2 1 2018
Applied Resource Mangerpte%eP C .
2. Weil Construction Permit #:
N/A
Operations Section
Wilmington Regional Office
List all applicable well construction permits (Le. UIC, C:ouniy, Slate, Variance, etc.)
3. Well Use (check well use):
Water Supply Well:
Agricultural
Geothermal (Heating/Cooling Supply)
Industrial/Commercial
x Irrigation
Non -Water Supply Well:
Monitoring
Injection Well:
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
Experimental Technology
Geothermal (Closed Loop)
Geothermal (Heating/Cooling Retum)
DMunicipal/Public
DResidential Water Supply (single)
Residential Water Supply (shared)
DRecovery
EjGroundwater Remediation
Salinity Barrier
fStonnwater Drainage
Subsidence Control
Tracer
Other (explain under #21 Remarks)
4. Date Well(s) Completed: 3/19/18
5a. Well Location:
Thomas & Frances Lott
Well ID# NIA
N/A
Facility/Owner Name Facility 1Dtt (if applicable)
511 Caswell Beach Rd, Oak Island, NC 28465
Physical Address, City, and Zip
Brunswick 251JB027
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
33 53 59.35 N 78 03 50.90
W
6. Is(are) the well(s)fPermanent or oTemporary
7. Is this a repair to an existing well: DYes or x!No
If this is a repair, fill out known well construction information and explain the nature of the
repair under 921 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: 105
For multiple wells list all depths if different (example- 3 tr 00' and 20100')
10. Static water level below top of casing: 12
If water level is above casing, use "+"
11. Borehole diameter: 5 7/8 (in.)
Mud Rotary
12. Well construction method:
(ft.)
(ft.)
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) 50 Method of test: Airlift
13b. Disinfection type: HTH Amount: 3% ©10g
For Internal Use Only:
• 448654
Print Form
14. WATER ZONES
FROM
TO
DESCRIPTION
ft.
ft
ft.
ft
,
15. OUTER CASING (for -multi -cased wells) OR LINER (if a
Ruble)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
0 ft.
80 ft•
4 in.
SCH40
PVC
16. INNER CASING OR TUBING (geothermal dosed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft.
ft.
in.
ft.
ft.
in.
17. SCREEN -
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
ft
ft.
in.
ft.
ft.
in.
1 S. GROUT
FROM
TO
MATERIAL
EMPLACEMENT' METHOD & AMOUNT
0 fr.
20 it.
Bentonite
Poured
ft.
ft
ft
it
19. SAND/GRAVEL PACK (if applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
ft.
ft.
ft.
rt.
20. DRILLING LOG (attach additional streets if necessary) "
FROM
TO
DESCRIPTION (color, hardness, soil/rock type, grain size, etc.)
0 ft.
60 ft•
Sand shells
60 ft.
75 ft.
Clay layered with limestone
75 ft•
105 ft.
White limestone
ft.
ft.
ft.
ft.
-.- 1 N f 1"
ft.
ft.
4,„, ..., 's 4_...
ft.
(t.
4'.'
p ' M 3 G, U 113
[�
21. REMARKS ! f
22. Certification:
4
Si
a
ure ofCe Well Contractor
3/28/18
Date
By signing this form, I hereby certifr that the well(s) was (were) constructed in accordance
with ISA NCAC 02C .0100 or /SA NCAC 02C .0200 Well Construction Standards and that a
copy of this record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTRUCTIONS
24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Infection Wells: In 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 Sunnlv & 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

14865
For Internal Use ONLY:
WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
I. Well Contractor information:
Lawrence D. Opper
Well Contractor Name
NC3322-A
NC Well Contractor Certification Number
Regional Probing Services
RECEIVED/NCDENR/DWR
APR 2 1 2018
Company Name
2. Well Construction Permit 8:
List all applicable well construction permits (i.e. (
3. Well Use (check well use):
Operations Section
Wilmington Regional Office
btaNP, Shale, Variance,
14. WATER ZONES
FROM
TO
DESCRIPTION
ft.
ft.
ft.
ft.
15.OUTER CASING (for multi -cased wells) OR LINER (if applicable)
FROM I TO DIAMETER THICKNESS MATERIAL
ft. ft.
in.
16. INNER CASING Ott TUBING (geothermal closed -loop)
FROM TO DIAMETER THICKNESS
0
ft,
5.5 ft.
1
m.
sch 40
MATERIAT.
PVC
ft.
ft.
in.
17. SCREEN
Water Supply Well:
❑ Agricultural
❑Geothermal (Heating/Cool ing Supply)
❑ Industrial/Commercial
❑irrigation
Non -Water Supply Well:
Monitoring
❑)\'Municipal/Publ is
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
LlRccove v
Injection Weil:
❑ Aquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑(irnundwater Remediation
❑Salinity Barrier
OStormwater i)rainage
❑Subsidence Control
❑•Tracer
❑Geothermal (Heating/Cooling Return) ❑Other (explain tinder #21 Remarks)
4. Date Well(s) Completed: 2/612018 MW-2
5. Well Location:
Molpus Woodlands
Facility/Owner Name
Off Town Creek Road, Leland
Facility 1130 (ifapplieable)
Physical Address, City, and Zip
Brunswick
County Parcel identification No. (FIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
;if well field. one [along is sufficient)
34.18518
78.20213 w
6. Is (are) the weil(s): i 1Permanenf or ❑Temporary
7. Is this a repair to an existing well: ❑Yes or P3No
/1?his iv ,t repair,,/id ow known well MILVirtICIIMI ns/anntrr.'uut and explain the nature o/'the
relxaa• under .121 remarks secant; or on the hack at this./ornt.
8. Number of wells constructed: 1
hor multiple injection or non -water supply irelis ONL1' with the sane construction. you con
.submit one /farm.
9. Total well depth below land surface: 10.S (ft.)
For multiple wells /is: all depths rldiJ%i•rent (example- .i a, 200' and 2(4,1 ti0' )
10. Static water level below top of casing: approx 8 (ft.)
1Jlwater level as chore casing. use " • "
11. Borehole diameter: 2.5 (in.)
12. Well construction method: Auger
(i.e. auger, rotary, cable, direct push, etc.)
13. FOR WATER SUPPLY WELLS ONLY:
I3a. Vicki (gpm) Method or test: ._
13b. Disinfection type: Amount:
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
5.5 ft.
ft.
10.5 ft'
ft.
in.
in.
.010
sch40
PVC
18. GROUT
FROM '1'O
0 ft' 3
ft.
MATERIAL
Grout
EMPLACEMENT MET HOII & AMOUNT
pour
fr. 4,5 fk• bentonite
pour
fl. ft.
IS': SAND/GRAVEL PACK (If applicable)
FROM TO MATERIAL.
5.5 ft. 10.5 fL
#2 sand
EMPLACEMENT MET11OIr
pour
ft.
ft.
20. DRILLING LOG (atta h additional sheets if necessary)
FROM TO DESCRIPTION (color, hardness, soll/rock type, grain size, etc.)
0 ft' 10.5 ft.
Silty Sand
ft. ft.
ft, ft.
ft. ft.
ft.
ft.
ft.
h.
ft.
21. REMARKS
cz. <ta r) ;t„=
22. Certification: (/
Lawrence
,:"., r.w 3/27/2018
.10 2/ 11,4411V
Signature of Certified Well Contractor Date
By signing this Jsm, 1 hereby certiji' that the ereli(,$) was (were) constructed in acco,dhnh'e
with 15,1 N('a(' 02(' .0010 ar• iSA ,V('.4(' 02(• .0200 Well (bnavruetirnt Standards and that a
cap;' of'this record has h_en 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
24. Submittal Instructions:
24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Quality, information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699.1617
24b. For Iuiectio, Wells: In addition to sending the form to the address in 24a
above, also submit a copy of this form within 30 days of completion of well
construction to the following:
Division of Water Quality, Underground Injection Control i'rogram,
1636 \laic Service Center, Raleigh, NC 27699-1636
24e. For Water Supply & Geothermal Wells: In addition to sending the tbrm 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 (3W-1
North Carolina Department of Environment and Natural Resources - Division or Water Quality Revised )an. 2013

2. Well Construction Permit #f:
/ i.rl all applicable well t onslruc•tion permits (t. e. ('aunty, SYa e Variance, rle•.l
3. Well Use (check well use):
WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
1. well Contractor Information: RECEIVED/NCDENR/DWR
Lawrence D. Opper
Well Contractor Name
NC3322-A
NC Well Contractor Certification Number
APR 2 1 2018
Regional Probing Services Water
�crat�oQualityn, Regionalcolon Company Name Wilmington Regional Office
For Internal Use ONLY:
448649
14. WATER ZONES
FROM TO
ft,
ft.
DESCRIPTION
ft.
ft.
15, OUTER CASING (for multi -cased wells) OR LINER (if applicable)
FROM TO DIAMETER THICKNESS
ft,
ft. In.
MATERIAL
16.1f4NER CASING OR TUBING (geothermal dosed -loop)
FROM DIAMETER THICKNESS MATERIAL
0
ft.
ft.
TO
2.5
f't.
ft.
in.
in.
sch 40 PVC
17. SCREEN
Water Supply Well:
❑Agricultural
DGeothermal (Heating/Cooling Supply)
❑industrial/Commercial
❑irrigation
❑Municipal/Public
❑Residential Water Supply (single)
❑Residentiai Water Supply (shared)
Non -Water Supply Well:
JMonitoring
❑Recovery
injection Well:
❑Aquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (iieating/Cooling Return)
❑Groundwater Remediation
❑Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑Tracer
DOther (explain under 421 Remarks)
4, Date Well(s) Completed: 2/6/2018 MW-1, MW-3, MW-4
5. Well Location:
Molpus Woodlands
Facility/Owner Name
Off Town Creek Road, Leland
facility ID8 (if applicable)
Physical Address, City. and Zip
Brunswick
County Parcel Identification No. (PiN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
34,18518 78.20213
6. is (are) the well(s): OPermanent or ❑Temporary
7. Is this a repair to an existing well: DYes or E1N'
//71riN is a repair. fill out known well construction in/ornra,ion and C.rlauin llie Witten, of the
repair under -21 remarks secaan or on the hack of this.Jinnr.
8. Number of wells constructed: 3
/'or multiple tn/ectini or non -water supply wells ONLY with the sane canstrrtction, you ca,
submit one form.
9. Total well depth below land surface: 12.5 (ft.)
i•or multiple sells list all depths il'di(liu'ent (example_ i 1n200' aid 2( l00')
10. Static water level below top of casing: approx 8 (fr.)
Illrater level iv above easing. use
11. Borehole diameter: 2'S (in.)
12. Well construction method: Auger
(i.e. auger, rotary, cable, direct push. etc.)
13. FOR WATER SUPPLY WELLS ONLY:
I3a. Yield (gpin)
13h. Disinfection type:
Method of lest:
Amount:
FROM
TO
2.5 rt• 12.5 ft•
DIAMETER
1
in.
SLOT SIZE
.010
THICKNESS
sch40
MATERIAL
PVC
ft.
f1.
in.
18. GROUT
FROM
0
ft.
TO
1,5
ft.
MATERIAL
Grout
EMPLACEMENT METI OD & AMOUNT
pour
1.5 rt.
ft.
2
ft.
ft.
hentonite
pour
19. SAND/(RA V EL PACK (if applicable)
FROM
2
ft.
TO
12.5 It
MATERIAL
#2 sand
EMPLACEMENT METHOD
pour
ft.
ft.
20. DRILLING LOG (attach additional sheets if necessary)
TO
FROM
0
ft.
fr.
12.5 f1•
DESCRIPTION (color, hardness, soil/reek type, grain size, etc.)
Silty Sand
ft.
ft.
ft.
ft.
ft.
f.
21. REMMAR
ft.
ft.
ft.
X - �. ,
.5 i4.
ft.
rt.
R1320V)
KS
ttotOfi�i
22. Certification:
Lawrence ON °°; ° ,;„, a:kq
Signature of Certified Well Contractor
er
3/27/2018
Date
By .signing thisprin. 1 hereby cer1t1}' that the well(S) was (here) constructed in accordance
wait 15.4 N('A(' 02(' .010n or 15A N('A(' 02C .0200 Well Construction Standards anti that a
rope of this record has been prarided 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.
24. Submittal instructions:
24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Quality, Information Processing Unit,
1617 mail Service Center, Raleigh, NC 27699.1617
24b. For Infection Wells: in addition to sending the form to the address in 24a
above, also submit a copy of this form within 30 days of completion of well
construction to the lollowilig:
Division of Water Quality, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supply & Geothermal 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 Environment and Natural Resources - Division of Water Quality Revised Jan. 2013

WELL CONSTRUCTION RECORD
This torn can he used for siegle or multiple wells
1.Well .ractor
Af19-e ft i/NcDENEu/nW
Well Cm -manor -Rank
3, 9'O
NC W.11 t'_ionact.r: ,•• 11..71 brr
APR 14 2018
e. cru
Water Uuatily7tegiullai--
L , tier
Company Nave
2. Well Construction Permit 4:
List all applimhle well prints tie_ County. Smri- i vrian y Inaction. etc
3. \mall Use (check well use):
Water Supply Well:
❑ Agricultural
❑Geothe ntal (Heaths ,Cording Supply)
D Indu strial/Commercial
✓Km^_1tiont
Non -Water Supply W ell:
°Monitoring
ice
❑Municipal'Public
❑Residattial Wain- Supply tsingk)
DRisidnrtial Wat.7 Supply tsbard)
°Recovcty
Injection Well:
❑Aquifer Rc i.irgc
°Aquifer Storage and Recovery
°Aquifer Test
°Experimental Teehualu0y
❑Genthcmal (Closed Loop)
❑Gcothcamal (Heating,Caolin.. Return)
❑Groundwater Rancdiation
❑Salinity Barns
❑.Stofn watcr Diiii age
°Subsidence Control
°Tracer
DOth s (explain undo =21 Rrruariz)
4. Date Welt(s) Completed: 3 t9' It i-ell II g.
Sa licll Location:
' 0 c, 11-(1Ic a�
FacihtylOwner Name
0e - e. y4.c/ 'i r;
Physical _Added, City, and Zip
S 1()lrf 6z
Facditc 1Dr idappli whlct
Li
County Parcel ttifkin:or No. i,PLN)
Sir. Latitude and 1...omiitude in t.l reesittrinntes/secands ur der/acid dmrers:
tf swell tial & en: LIV(orb is sidticiav)
3 3 c5 S-'3%, lS. �" H 7 °y '3 3, yt y /t
6. Is (are) the wet(s); XrPertt nwcnt or °Temporaar�ry��
7_ Is this a repair to an esistit well: DYes ur ,lQi4u
Ij this is a repair. fill out inmrn well construe:ton information and explain the nano: of au:
repair under *_1 remarks section or on the ba.—k of This farm
S. Number of wells cons -eructed:
For multiple injection or non -water supply wells GAMY with the same c iruoion. too con
submit one jowl
fe
9. Total well depth below land surface:
For multiple wells list all depths ij eltffer.nt t sample- 3(d 200' and 21a 100')
10. Static inter level bdo\w top of casing:
If ater lct;1 it ohm: easing. use "T
r
11. Borehole diameter. �v1 Om),)
m
12_ Well construction method- I I J 1C'
i e. auger- rotary, cable. ducal ou:h etc.)
(ft-)
FOR WATER SUPPLY WTI I C ONLY:
13a. Field (gun) 3\Irihod of trot: ✓t }�
13b. Disinfection type: j 1p' jt) C �) -
_Antolini:
Form GW-I
Fix ird'n"11-48178
Li W4TER ZfhNFS
FROM
TO
DESCRIPTION
`i 0 ft
fr.
iley
e-c ft.
imes're / ?
la O1T1F$ CASING (formulti-easedwets) ORM M
FROM TO DL4N£TER THICKNESS
./../ ft _3 f` i°. s cJ K.)
16. INKIER C1tS11 G OR TIMING (geothermal anceddrierldi
FROM TO DIAMETER THICKIcESS
0. tL is
1
a tATERL4L
ai-\TrRIAL
ft
fL
17. SCREEN
FROM
IL
ft
19_ SAND/GRAVEL PACKof applkable)
FROM TO MATERIAL
ft.
ft.
EMPLACEMENT MEMO]) S_ AMOUNT
i%Itue4
E\t1L&C:\rRNT NARTttop
FL
ft.
20. DRILLING LOGtaliach
FROM TO
/7 ft 1 0 f .
f.
y fL
fL
ft
tL
ft
ft.
additinnnl sheets if necessary)
DESCRIF,10N tusks h-vdnn{ saWroct type, grin sue net
C/4. y
t-., t VVi e 1Z1 ��-
iL
ft.
ft_
21_ RE\L4RKS"
ft_
22Ccrtificati
Si_rutueoCortpaaor
t.
Dam
By signing this form. I F•rehv eerlifr that the Ire/1(sl was (wend rorurrn_tcd si a.-;ordar.,:
with li, :\C_4C O2C _IOU or 1 S.4 NC. -IC 02C .0200 f f ell Co>cmrctro.: Standards and Mar a
ropy of this rc rord has been provided to the well oten:.r.
23_ Site diagram. or additional well details:
You may use the back of this page. to provide additional well site detail; or well
cmnsisuctia n details. You may also attach additional pages if necessary_
SUBMITTAL INSTUCTIONS
24a. For All 'Wells: Submit this form within 30 days of completion of well
construction to the followine-
Division of Water Resotutes, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 276994617
24h. For Injection Wells ONLY: ht addition to sanding the form to the address in
24aabove_ also submit a copy of this farm within 30 days of completion of well
canstsuctioo to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-.1636
24c For Water Supph, S Injection Wells:
Also submit one copy of this form within 30 dais of completion of
wall coustrudimi to the county health dapanmutt of the county where
consttueted
Plcath CatnIiiu Dcpsrtru7u ofEri iraowcnt :uxl Vannes Rcotvrcs —Envision of Water R.aatrcm
Revised au,tut 2Ul3

WELL CONSTRUCTION RECORD
This foam can be used tar single or multiple wells
For Internal LSe ONLY:
.148177
1. V:ell Contractor Information:
Corilactor Name
A
NC well Contract x Certification Ntmh
e W'/i 6 ty
eg
2. Well Construction P 't it: CVO &I/ D to,rcrQuality Regional
List all applicable well penults (ie. County. State. 1 utiom.v lnt a�, Regional Office
3. Well Use (check well use): V r 1
Comparty Nvnc
14. WATER ZONES
FRa‘f
1 rL
TO
rf-
DESCRIPTION
50 rt.
Water Supply Well:
❑Agricultural
❑Geothe mal (Heating,Cooling Supply)
❑ Tn dustoal/'Commercial
gati.31
Nan -«rater Supply Well:
❑hlonitoting
APR 14 2018
❑\lunicipaLPublic
❑Re idential Water Supply (sin_le)
❑Resid,aitiat 4cat r Supply (shared)
❑Re'.ovrn•
Injection Well:
❑Aquifer Recharge
❑ Aquifer Storage and Rteoitr)-
❑ Aquifcr Test
❑Experimental Technology
❑Gcothamal (Chased Loop)
❑Geothermal (Hcating.Cooling Return)
❑Groundwater Ronediation
❑Salinity Barrier
❑Stwmwatcr Drainage
❑Subsidatcc Control
❑Tracer
❑Otter (explain under 21 Rianads)
4. Date Well(s) Completed:3
Sa.rell ocatio
e CLIATZ
Facility/Owner Name
Facility ID4 Ehf applicable)
07 0/ GC &fiA" b C)/14
Physical .Address, City, and Zip
County
Parcel !dcindiicatian No. UPI\)
Sh. Latitude and Lottwait ode in degrees/minutes/seconds or decimal degrees:
of well field one talons! is sufficient)
33 5Y ry S rs N 2?C1/3 . 6d°yp
6. Is (are) the well(s):. reertrcrnent or ❑Temporary
7. Is this a repair to an existing. well: ❑Yes or u
If this is a repair, fill out known wellconsa:rction information an xploin the nature of the
repair under n21 remarks section or on the bask of this form
8. Number ofw-ells constructed:
For multiple h jn-tion or non -water supply wills ONLY' with the same construction, your can
submit one form.
/
9. Total well depth below land surface:
For multiple wells lirl all depths ifdijerent (example-3¢_00' and 2:m'j100( )
1q. Static water level below top of rasing:
If water level it above easing. use "+'•
11. Borehole diameter: (.2 (in.)
12- Well construction method: / / { (✓ j
i h e auger, rotas}', cable, .Butch push. etc.)
Po 'FY3flj
(ft.)
FOR WATER SUPPLY WELTS ONLY:
�v
13a Yield (gpm) t7( Method of test: r ;4'
13b. Disinfection type: '3/F/� (Gj ,Amount / 6' D Ge
Fonn OW -I
kt `y ft.
es�
19. OUTER CASING (for moki•eased wells) OR LINER Cif apPlimht l
FROM I TO
0L4ht6T6tt THICKNESS M TERL�tL
Soh 5/U I i> /C.
T[i1t;7�euhetmal
t / iti SD
16. etoaeadoa INNER CASING OR p)
FROM DIAMETER
TO
rt.
ft-
THICIOV SS
ALATFRfiL
f-
ft.
is
17.SCREEN
FROM
ft.
ft.
TO
ft.
ft.
DIAMIETER
ia.
is
SLOT SIZE
P
THICIGtESS
'MATERIAL
18. GROUT
FROM
n.
ft
TO
5-0 fL
rt.
MATERIAL
E%(PLaCEMENT \MET HOD S ANIMIST
/pJ 'f` brI` 's> /Iitlr(
ft.
fr.
19. SANDIGRAVEL PACK (if applicable)
FROM TO
IL
ft.
MATERIAL EMPLACEMENT METHOD
20. DRILLLNG LOG (attucb additional 'leas if eececsars)
FROM
ft.
fL
v7JfL
y0 fL
fL
ft.
TO
%-' ft.
7 fL
fL
ft.
DESCRIPTION Icokr, harden. taitlrari• rvpn. 9.raie. hue• ac.t
J
ft.
ft.
ft.
ft.
ft.
(L
VrAR
g °,(1i6
21. RE4LARKS
U li
Signature of Certified Well Contractor Date
By signing this form I herein' ccrtifi' they the wellts1 was (here} constructed in ac;orda,re
w uh 13.4 VC.AC 02C .0100 or 15.4 NC.-[C 02C .0200 Well Constriction Standards and that u
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
cottstiuction details. You may also attach additional pages ifncesssary.
SUBAaTT.AL INSTUCTIONS
24a. For All Wells: Submit this f'otm within 30 days of completion of \cell
cottstfncti n to the following:
Division of Water Resources, Infartrration Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Infection Welts ONLY: hi addition to sending the form to the address in
24a above, also subunit a copy of this forte within 30 days of completion of well
cotisuuctioit to the following:
Division of Water Resources, Underground injection Control Program,
1636Mail Scrticc Center, Raleigh, NC 27699-1636
24c. For Water Supph• & Injection Wells
Also submit one copy of this farm within 30 days of completion of
well consuaction to the count health dcpartinc nt of the county where
uonstiuctnd.
Noah C:uoGai Department ofErt'rir vuuent and Natural Re saves —Dig is ion o f Water Resources
Revised August 2013

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
1. Well Contractor Infor
Well Conaactow Name
`/O /a RECEIVED/NCDENR/DW
NC Weil Connecter Certification Ntmi /•
��P( "Tciy APR 142018
Company N:une
2, Well Construction Permit #: ' V 8 0Q '. 7
List all applicable well pemrits tie. County. State. I uriane. �ni s �u Se ' � j33�'rfitiOns Section
3.Well Use (ciecl:well use): Wilmington Regional Offlc
Water Supply Well:
OA.gricultural
DGcothe real (Hcating.Cooling Supply)
❑ In d us trial/C ors m crcial
>r ination
Non -Water Supply Well:
❑Monitoring
Injection Well:
['Aquifer Recharge
❑Aquifer Storage and Recovrsv
❑Aquila• Tot
❑Experimental Tcchnoiogy
OGcothomal (Closed Loop)
❑Gcothamal (Heating:Cooling Return)
For Internal Use ONLY:
14. WATER ZONES
FROM TO
CY TL :�Z�
DESCRIPTION
ICrt��
V -te 5.70A-e.
i2. OUTER CASING (for multi.cased wells) OIll./ TER Of Me)
FROTO
��.. �at fL 3�' fL D ?IAM��ia. i S,C,�MATERIAL/ I (-
16. INNER CASis?G OR TUBING (geothermal cloud -loop)
FROM TO DL4.METER
ft_ in.
TH1CIa'FS
R
MATERIAL
6
17.SCREEN
ft.
in.
DM unicipal Public
ORcidtattial Water Supply (sinelex)
DResidential Water Supply (shared)
ORomvrn-
FROM
IL
TO
fL
D1.laMETER
SLOT SIZE
TmCRFESS
MATERIAL
fL
fL
la.
13. GROUT
FROM
• fL
fL
TO
fL
MATERIAL
�rNa c
EUPL%CEA T METRO')s AoUNT
4i,P..i tnr( �M/Ni
❑tiroundvvatcr Rernediatinn
['Salinity Barrios
DSturtnwatcr Dssin:r_c
OSubsidatcc Control
Dilater
❑Othcs (explain under #21 Rcrnarls)
4. Date Well(s) Completed: 0,3 / / �t1 ;'cp ID#
Sa.�'eI1 Location:
c✓� �/V , Ci' h ey
Facility/Owner Name Facility Mit ilia liable)
Physical Address, City, and Zua i
its Yvav j w r`CK
County Pared Identification No. ,PIN)
Ski. latitude and Lon itude in degrees/minutes/seconds or decimal degrees:
of well field, one lanlong is'''%/I suffieic n)
z$�/ �j
✓J.?-/33t i1//k N /u/0 1 7r 7/ Z w
6. Is (are) die well(s): bifernement ar ❑Temporary
7. Is this a repair to an existing well: ❑Yes or
If this is a repair, fill out known well construction information and explain the nature. of the
repair under u21 remarks section ar on tlz bank of Miriam,.
S. Number of wells constructed:
)@11Qu
For multiple injnxion ar non -water supply srclls ONLF with the same construction, sot can
sulvnrt one fonn.o
f
9. Total well depth below land surface:
For multiple wells list all depths ijdifferent (example-3•a^_00•and 2en•1001
10. Static water level below top Glowing:
(primer level a abort easing. use "+•'
11. Borehole diameter: 67 (in.)
tt� h)o•r-/truj
12. Well construction method:
i u e. auger• rotary, cable, deter punk etc.)
(II-)
(fi)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) + Method of test:
13b. Disinfection type: 1 /fed et47 _Amount: l / t/
Form Crly-1
fL
fL
19. S NDIGR VEL PACA Cdapplicable)
FROM To
fL
ft.
rt.
MATERIAL EMPLACE:MEAT METHOD
20.1)RiLLING LOG (attach additional sheers if aecessa,$)
DESCRIPTION color bantams. selVrock type. min she etc.;
FRO31
• fL
2a'L
rL
TO
;z L fL
32,
3 -2 fL
fL
C..) U fL
fL
1 e 5 '71st•-)
ft
fr.
ft
fL
21. REALARRS
fL
(L
M4 a62018
°4.k4r41'"4: t5
22. Ccrtifica
Signature of Ce ritied Weli Cone -actor
Date
By signing this form. I hereby cerriir that the mall') was (were) t u p_'d en accordance
with 153 \L.aC 02C .0100 or 15.4 NC.4C 02C .02001i Well Constrtr_dor. Standards and that a
cops of this record has been provided to the well owner.
23. Site diagram ar additional well details:
You may use the back of this page to provide additional well site detnii or wc11
cousin .tion details. You may also attach additional pages ifnccessary.
SUBMITTAL INST UCTI ONS
24a. For all Wells: Submit this form within 30 days of completion of well
construction to the following
Division of Water Resources, Information Processing unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Injection Wells ONLY: In addition to sending the tom to the address in
24a above, also submit a Copy of this form vnthin 30 days of completion of well
construction to the following:
Division of Water Resources, Underground Injection Control Pt•ogrua,
1636 Mali Service Center, Raleigh, NC 2769941636
24c. For Water Supply & Injection Wells:
Also submit one copy of this form within 30 days of completion of
wall consultation to the county health department of the county where
nunstructetj
Nunn Crrolisu DeNItnratt of Environment and Natural Resources -Division of Water Resources
Revised .August :013

WELL CONSTRUCTION RECORD
This foots can be used for sirrl< in multiple smells
For bi c,nal Use ONLY:
13a. Yield (-gun)
I3b. ilidafectioa type:
Fonn G1\ -1
141 Static water keel below top of cuing:
If nnmr Intl iioto . rasing, sac '+..
/ f
11. Borehole diameter: ([i' (in.)
e /Q So'
NC Well t vmaria iatihcatuw N� T uJ -
-e �(
Company Name (/ P�U zU(l(.d t) f IOflar
2. Well Construction P
List all applicable wdl permits fie_ Careers: State- I atia» e, iiifNRQj71gten Regional Offi ,e
3. Well Use (coed; well use):
Water Supply Wet(:
17_L ri cultural
❑Geothermal (Hctting.Cooling Supply-)
DIndustriat'Commwail
) 'Elation
Non -Wafer Supply. Wdl:
OMonitorina
A P fZ }. 4 2018
448175
14. WATER ZONES
.0 fL I J
I/ 0 fL
13. OUfEk CASING (for motif -used cells) OR UNEIt; CrI b1c1
FROM TO - DOME! c.R THICKNESS 1LATERTAL
ft_ 5 V) fL
147 (In
DESCRIPTION
fL
i� mac_
ft.
�cjC %J
1G INNER CASING OR TIMING ,rh_rn2n1 d-Inept
FRo1{ TO I DL-WEYER THICt.2iES5 ` iLLATERTAL
i . ft 1 in_ I
ft
17. SCRF-EEsN
ors
❑MunicipahPoblic
❑Re idential Water Supply (single)
DR.sidcntiat R'at. r Supply (shared)
❑Re oven•
Injection Well:
°Aquifer Recharge
❑ aquifer Storage and Rccovery
UAquifea- Tat
❑Experimeantal Technology
❑Gcothamal (Closed Loop)
DGcnthomal (Heating:Cooling Return)
3. Date Well(s) Completed: 3 •_l 9
&I:Well Location: //
PeJ.-er /I IP) r'`/4 / /
Facilit:Owner Name
/(`,atJf )4) cv,4'/
Physical A es.s City.;Ind Ztfr
i-1
0t3rtutnd atcr Ranediation
❑Salinity Barrier
❑Stumwatcr Drauta;e
❑Subsidcncc Control
❑Tracer
QOiher (ex -plain under =21 Remarl)
Well IDR
Factlitc Fi r I ni appti.mhlel
Al 1s/mac:
Count)' Parcel i icitifiutlan No. IPti\1
Sb. Latitude and Luir*itude in dean_:=/*..' utts/srcotzds or decimal degrees:
rz tees:
of well octet dttc 3at:loria is sutfxinu)
33 .5/'i34,1 78:Y i 3, '7(3 w
6_ Is (are) the well(s): , erns vtcnt or °Temporary
7. Is this a repair to an eristirw well: DYes or o
ff this- is o rapair, fill out known well conaractioo injarmation and a fain the nano of the
repair under 421 remarks section or on the bo,-k Miriam.
8. Number of wells constructed:
Formuhipk i yeetian or non -grater supply wells O111'srith the same caustmaion you can
stdma one font.
9. Total well depth below land surface:
For multiple tells fat all depths ifd j rent l ample- 31:5200 and 2Jd.100'1
/ (!
12. Well construction method: [ / / X.I c (C2 () /)1)/ ✓j
i l e .antra% rotaly, cable, daeci Uun1L etc.)
(i:-)
(ft)
FOR WATER SUPPLY \\'ELLS ONLY:
Method attest- ( t� ' '--ic- For Water Supply S Injection \FdL.
Also submit one copy cif this form within 30 daAs of completion of
well construction 10 the court' health department of the county where
constructed_
FROM TO
fL
fL
fL
13. GROUT
rROM
fL
111.1ULi tK SIMT212
TIiICI4\'E-LS
\LATERLIL
a
TO
0
fL
fL
ft.
MATERLAL E\IP15CEts -TatE'rtlon.s•.tittotlNT
tit s,/ 6rtl���
fL
ft.
19. S NDIGR4VEL PACK fif applicable)
FROM TO MATERIAL
2
ft.
£AIPI_ .CEM14 sT METHOD
fL
ft.
1st DINELLL' G LOG (attach additional sheets if ;lazy)
FROM TO DESCRIPTION orator hatdnai seilireek n
��v�in sus act
Sig-��
ft.
C`'fL
d,5 fL
(lo fL
fL
fL
tL
fL
21. rtEmArtus
I-
fL
fL
ft.
1r
tL
f.
C% •;- s h�/(
27 Ccrtifi
Si_rut of rt ted Well Croat -actor
;I
V-i2
Dace
Ey signing :his (ern:, 1 1rrebt' certift- that the v'ell(sf erns (Isere) eons -true -tad in a:co dorle
trim 13.4 :\-t'_-IC 02C _0100 or 15.4 :\'C.4C 02C-0200 Coamrs:riot: Standards and that a
copy of this rnrord has been pros sded 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 ifiteceasary.
SUBaMITf13.J STUCTTONS
242. For Alt Wells: Submit this form within 30 days of completion of hccll
construction to the following'
(e, ►gaunt:
Division of Water Resources, Information Processing Unit,
16I7 Nfai1 Service Center, Raleigh. NC 27699-16I7
246. For Infection Wells ONLY: In addition to sending the form to the address in
24a above. also submit a A of this form Ali
copy thin 30 days of compinixn of ttz11
carsGuctian to the following:
Division of Water Resources, Untie/ground Injection Control Program.
1636 Mail Service Center, Raleigh, NC 27699.-I636
North Carolina Dcpirtmcnt ofE,r,-irvvncnt and Mama{ Re; cs —Division of Water Resources
Revised ate;ust "MI1
TO
rumsw �2

WELL CONSTRUCTION RECORD (GW-1)
1. Well Contractor Information:
Sanford Sweeting RECEIVED/NCDENR/DWR
Well Contractor Name
2082-A
NC Well Contractor Certification Number
APR 1. 4 2018
Applied Resource Mana tg,r1ws<Rt,RP C l
Company Name 0 eratior s Section
2. Well Construction Permit#: Not found office
List all applicable well construction permits (i.e. IilC. County, State, Variance, etc.)
3. Well Use (check well use):
Water Supply Well:
Agricultural
Geothermal (Heating/Cooling Supply)
Industrial/Commercial
Irrigation
['Municipal/Public
QResidential Water Supply (single)
Residential Water Supply (shared)
Non -Water Supply Well:
Monitoring DRecovery
Injection Well:
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
Experimental Technology
Geothermal (Closed Loop)
Geothermal (Heating/Cooling Return)
Groundwater Remediation
Salinity Barrier
jStormwater Drainage
Subsidence Control
Tracer
['Other (explain under #2I Remarks)
4. Date Well(s) Completed: Various Well ID# N/A
5a. Well Location:
Village of Bald Head Island N/A
Facility/Owner Name Facility ID# (if applicable)
Edward Teach Wyd, Bald Head Island, NC
Physical Address, City, and Zip
Brunswick 300404719020
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
See attached N See attached
6. Is(arc) the well(s)fx Permanent or DiTemporary
7. Is this a repair to an existing well: ®Yes or [X No
If this is a repair, fill out known well consmuction information and explain the nature ofthe
repair under 1121 remarks section or on the back of this form.
8. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction, only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled: 24
9. Total well depth below land surface:
For multiple wells list all depths if different (example- 3 a,200' and 2 c@r 100')
300
10. Static water level below top of casing:
if water level is above casing, use "+ "
N/A
11. Borehole diameter: 6 (in.)
12. Well construction method: Mud Rotary
(ft.)
(ft.)
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) N/A NIethod of test: N/A
13b. Disinfection type: N/A Amount: N/A
14. WATER ZONES
FROM
TO
DESCRIPTION
ft.
ft.
ft.
ft.
15. OUTER
CASING (for
multi -cased wells) OR LINER (if ap licable)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
0 ft.
300 ft.
1 in.
HDPE
16. INNER
CASING OR TUBING
(geothermal closed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft.
ft.
in.
ft.
ft.
in.
-
17. SCREEN
FROM
TO
DIAMETER
SLOT ME
THICKNESS
MATERIAL
ft.
ft
in.
ft.
ft.
in.
18. GROUT
-
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
0 ft.
300 ft•
Thermex
Pumped
ft.
ft.
ft.
ft.
19. SAND/GRAVEL
PACK
(if applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
ft.
ft.
ft.
ft.
20. DRILLING LOG (attach additional sheets if necessary_)
FROM
TO
DESCRIPTION (color, hardness, soiVrock type, gain size, etc.)
0 ft'
30 ft•
Coarse grained sands
30 ft.
120 ft.
Sandy silt
120 ft.
145 ft.
Limestone
145 ft.
285 ft.
Dark gray silty clay
285 ft,
310 ft.
Hard limestone and sandstone
ft.
ft.
ft.
ft.
21. REMARKS RF C F V r
1
1 DJ 2 2 2018
22. Certification:
ligoninstion P roc-(i•-s.sav Unit
w/ 18
Signatt of Certified Well Contractor Date
By signing this form, 1 hereby certify that the well(s) was (were) constructed in accordance
with 114 NCAC 02C .0100 or 1 5A NCAC 02C .0200 1Ve11 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 ifnecessary.
SUBMITTAL INSTRUCTIONS
24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Infection Wells: In 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

ARM Project Number: Safety Building Bald Head Island
Driller: Sanford Sweeting
Loop No. Loop Depth
GPS Coordinates
1-1 300 33 51 24.4336 77 58 54.3073
1-2 300 33 51 25.8718 77 58 56.1968
1-3 300 33 51 24.3999 77 58 54.8798
1-4 300 33 51 25.2475 77 58 55.8091
1-5 300 33 51 26.1983 77 58 56.9215
1-6 300 33 51 20.2645 77 58 56.7844
1-7 300 33 51 26.0785 77 58 55.7829
1-8 300 33 51 26.2332 77 58 56.8438
2-1 300 33 51 25.1388 77 58 55.1552
2-2 300 33 51 26.104 77 58 56.3502
2-3 300 33 51 25.0356 77 58 55.2968
2-4 300 33 51 26.3124 77 58 56.7841
2-5 300 33 51 26.3718 77 58 56.9366
2-6 300 33 51 26.3837 77 58 57.0122
2-7 300 33 51 26.2379 77 58 57.0032
2-8 300 33 51 25.9999 77 58 56.3363
3-1 300 33 51 26.0015 77 58 53.7115
3-2 300 33 51 25.7075 77 58 53.8805
3-3 300 33 51 25.6414 77 58 56.5075
3-4 300 33 51 26.2545 77 58 53.834
3-5 300 33 51 26.0741 77 58 54.6759
3-6 300 33 51 26.0662 77 58 54.7508
3-7 300 33 51 26.1333 77 58 54.7387
3-8 300 33 51 26.1662 77 58 54.8147
Pagel

WELL CONSTRUCTION RECORD
This tcasn can be need for single or multiple wd6
1. Well Contractor Information;
��✓e 2ie1 6 ofecavEomcDENR1
\Fell Conuact. Name
35 `'® A
NC Well l:�rehr� CcrtitieaUon� �1 l7 V y
Comp.utyN:unc W �d
. WV 0 a00 Water Quality Region
2. Well Construction Permit II: 'tpp'�Cterations Section
List all applicable well permitstie- Couaz. State. PariamY,la. i gion Regional01
3. Well Use (check well use):
Rater Supply Well:
❑. ricultural
❑Geothemal (Hcltiug.Cuoling Supply)
❑IndustrisL Camruacial
mi`+ntirnt
Non -Water Supply \V dL:
❑Monnitoring
Injection Well:
❑_Aquifer Recharge
❑Aquifer Storage and Recovery
❑,aquifer Teat
❑Experimental Tcclutoloay
❑Gcothemal (Closed Loop)
°Geothermal (Heatitlg:Cooling Ream)
APR 14 2018
I
14. WATER ZONES
TO DESCRIPRON
ft_ 2 Y t 3 r P Ate, j
ft ft.
O. OUTER C•>,SING (for mad -cased OR LINER (if ZIP b!e
FROT'�1 LL I T1 b fL DIAMETER.O � tL� �'1
(•� SSA MATERIAL
16, INNER CASING OR TURING (geothermal eloseddoop)
IFROM TO DIAMETERTfDCh1V'� M%TFRLiL
0. R. in.CC
fL fL in,
17. SCREEN
❑Municipal,Public
°Residential R eta• Supply (single)
❑Residential Wats Supply (shared)
°Recovr:ry
❑t3round�tater Renediation
❑Salinity Barrier
❑Sty nn iZcr Drainage
❑Subsidatee Control
°Tracer
°Outs (cxplain under r21 Remarks)
4. Date Well(s) Completed: / /d Wen ID'd
Sal -Weil Location: ,�r 11 /
�'O�til bt,VeK)/Ij
Facility/Owner Nance �t
�/ Facility !Dr i tf applicable)
,Q0�, m (rI core,ery ST. 019lc (S
Physical Address. City'. and Zip / z si Y S
n J3wtc(�c
Cotmty
Parcel hierdificittan No. r11N)
Sb_ Latitude and Lnitude in d �grees/minntes/seconds or decimal degrees:
. f well field one latLon; is sufficient)
isrrTfvV'N
7�'°q,3o,ozzyrr \\
6_ Is (are) the wen(s): exit or ❑Teruporary
7. Is this a repair to an existing well: °Yes on iu
If this is a repair, fill art known ,cell construction iryormation and explain rho nature of the
repair under s2I remarks section or on tlr back of this fore,.
8. Numberofa-ells constructed:
For multiple injection or non -.eater supply wells ONLY with the same construction, you can
submit one Arm. �% /
9. Total well depth below land surface: f✓' y (f)
For multiple wells list all depths iifd, ferent (example- 3tFe200• and 2(47100')
/
10. Static miter level below top of casing:
If water level is above erring, urt "+"
11. Rorebole diameter: w Tt9 /°
1 L Well construction method:
/ rI
?,�r1-1./e
(ft)
is e. auger, rotary, cable, direct pushy etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test: P t�
I3b. Disinfection type: e44C Ii Amount: ,i OZ .
Font% GW-I
FROII
/G fL
fL
18. GROUT
FROM
TO DIAMETER SLOT SIZE THICENE&S
2 ©ft. - 1_60 47Pd- yes
ft is
11.ATERIAL
0 lL
ft
fL
TO
t 0 fL
1L
iL
M STERLAL
IQPM
EMPLACEMENT METHOD .9 s3IOLTT
GLI r,ro.r P� re orL
Z C3095s
19. RANDIGRAV£L PACK of nppticable)
FROM TO
fL
MATERIAL
EMPLACEMENT
METHOD
2Q DRILLLNG LOG (attach additional sheets if
DESCRIPTION (cedar hardness, sailired; ripe, grain sc, act
sRN�
FROM
fL
L
ft f
ft
LL
TO
a t/ (L
fL
ft-
fL
fL
it
ft.
ft
E C E I V
f
fL
ft
ft
fL
FEB 22ZO1&
21. R.E_kLARI:.T
4- 'ro:F;ror' i• t ...-
21. Cert1 lion:
Si_rnnte of Certified Well Contractor
Data
Sr signing this form• 1 hereby earth that the nell(sl was (were) construetcd ire. accordance
with I>.1 :\C.te 02C .0100 or 15.-1 NCfC 02C .11200 Well ConmrrNon Standards and that a
copy of this record has been provided to the well owner.
23. Site diagram ar:ulditionai 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_
SUBIIITT_AL INSTUCTIONS
2-la. For An Wells: Submit this form within 30 days of completion of well
construction to the following':
Division of Water Resources, Inforuration Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
246. For Infection Wells ONLY: cot addition to sending tiro Form to the address in
24a above, also submit a copy of this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Scrcicc Center, Rdeigh, NC 17699-1636
24c. For Water Supply & Injection Wills:
Also submit one copy of this form within 30 days of Completion of
well construction to the county health departrnatt of the county where
c0nst uetcd_
North Cauoliiu Department of Environment ent and Natural Resource; —Di: reran of Water Resource
Revised August 2013

WELL CONSTRUCTION RECORD (GW-1)
I
Well Contractor infnrmation: i14 8 1
Donald Cummings N CI tVED/NCDENit/nW
Well Contractor Name
2412-A APR 1.4 2018
NC Well Contractor Certification Nmnttxr
Applied Resource Mabiag®Ih t eregnii). C.
Comm) Hain Operations Section
2. %' ell Construction Permit #:
20fi6101t2d nei office
Li i i)I!oppli arble N'."1i,vv;strurll,'n perw/z.1t.e. / fir: (/,lIHIt: teed.'. 1 %r,:,;. •..7(._r
3. Well Use (check well use):
Water Supply Well:
DAgricultural
JGeothermal (Iieatittg;Cooling Supply)
LJ Industrial/Commercial
-llrrigation
Non -Water Supply Well:
cMonituring
Injection Well:
JAgirifcr Recharge
JAquifer Storage and Recovery.
j:Aquifcr Test
Experimental "Technology
Geothermal (Closed Loop)
(isothermal (I leating/Coaling Return)
DMunicipal/Public
E1Residentiat Water Supply (single)
E3Residcntial Water Supply (shared)
rRecover
airoundwater Rtmediation
Salinity Barrier
jStonnuater Drainage
DSubsidcncc Control
ETracer
f ()her (explain under #21 Remarks)
4. Date Well(s) Completed: 1 1 /14/17 well IDI+N/A
5a.11 ell Location:
Murray Construction N/A
Facility Owner Name Facility ID=' of applicable)
5092 Plantation Rd SE, Winnabow 28479
Physical Address. City. and Zi
Brunswick
1440000105
C'ounq Parcel Identification No. tPIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(d well field. one lat.E,onr t; sufficient
3445.4 • 77 56 86.5
6. 'stare) the wcl1(s)0Permanent or UjTemporary
7. Is Ibis a repair to an existing well: EYes or xJNo
ry ailS I. r lie r,rrr.1[11 nrd knower aril r'Mg rue Iu r nllllrnl,nfiai tIn f ;xln'n:+r the damn, olrhr
repair ton/4,- 2/ ,.....nark‘ ,. a v/rM/ er ::,t Me bock n1 de. - finwl.
8. For Geoprohe/DPT or Closed -Loop Geothermal Wells having the same
construction. only I G\V-1 is needed. indicate TOTAL NUMBER of wells
drilled: 1
9. Total well depth below land surface: 1 00 tft.)
or nrulnple a,:11, ,i a; at; ckl ens /1c1,/lc rear reNtimple- ? r; 2o11 cnul .!? NMt
10. Static +rater level below top of casing: 7 (ft.)
111t:ger level a above ...“:, '.
11. Borehole diameter: See Remark(in
12. 11-ell construction method: Mud Rotary
{I.e. anger, rotary. cable. direct push. etc.)
FOR WATER SUPPLY \\ ELLS ONLY:
13a. Yield (gpm) 80 Method of test: Airlift
HT
0
13b. Disinfection type: I i ,amount: 3 /o@1 0g
14. WATER ZONES "--
FROM
TO
DESCRIPTION
ft.
ft.
ft.
ft.
15. Ot TER CASING (for
multi -cased wells) OR LINER Of a
icable)
',Host
.10
DIA Mr. TER
'THICKNESS
A1:\TERt\I.
0 'I.
80 ft.
6 in.
SCH40
PVC
16. INNER CASING OR Tl
BING (geothermal closed-Ioopi_�
FROM
TO
MAMEr1:R
'THICKNESS
MAlERIAI
it.
f1.
in.
ft,
ft.
in.
17. SCREEN
FROM
'10
I IAME1ER
SLOFSILL
THICKNESS
MA'rf:RIAI.
80 fi•
100 ft-
4 in'
.020
304
Stainless
ft.
ft.
in.
18. GROUT
FROM
'10
MATERIAE.
EMPLACEMENT M1.T1 OD& ANIMA I
0 fl•
30 f .
Grout
Poured
70 it•
75 ft.
Bentonite
Poured
ft.
ft.
19. SAND/GRAVEL
PACK
(it applicable)
FROM
TO
MATFRIAI.
EMPLACEMENT METHOD
75 ft.
100 ft.
Coarse
Poured
H.
rt.
-
20. DRILi,t\(3 LOG (attach
additional sheets ifoecessar}')
FROM
1'O
DESCRIPTION (color, hardness. soif.'rock type. grain sine. NO
0 ft'
28 ft.
Sandy clay
28 ft.
40 ft•
Soft limestone
40 ft.
63 I'•
Clay/limestone mix
63 ft.
78 it.
Limestone with sands
78 n'
100 'i•
Sandstone
ft.
ft.
_
}} I Q
ft.
ft.
.1 J
2 �, '�. .�
L .
21. REIMARKS
0t/- 441=14" JAN 2 4 2018
40' - 100'=8"Ift-fee• s fir
22. itikication:
D\e('(�/%i
01/16/2018
Sigiatire of Ccnttiicd Well Contractor
I Tsie
11v wrung this thrill. 1 hereby ce'rIE/i• dart the a •/1(d rn u,.ot'dnle'r
woh I .5;1 \ C. i( 02C .010(1 ur I S: f /. (11( 02C .1,200 Well ('u»stn/rin.n Slcunla/:G mtrl that u
,,,1.i u1 dus rc. Ord has Ace') rrt+r,cL7i lu dray well rrrnrr.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
constriction details. You may also attach additional pages if necessary.
SU13\IITfAL INSIRL C77ONS
24a. For .tit Wells: Submit [his loran ltithin 313 days of completion of well
construction to the folk);\ ing:
Division of Water Resources, Information Processing Unit,
1617 fail Service Center, Raleigh. N(' 27699-1617
24b. For lnicction Wells: In addition to sendiil_ the form to the address in 24a
above. also submit one copy of this form within 30 day of completion of well
construction to Ole folloo.mg:
Division of Water Resources, Underground injection Control Program,
1636 Mail Service Center, Raleigh. NC 27699-1636
24e. For Water Supply; & Injection Wells: In addition to sending the limn to
the address(es) above. also submit one copy of this form within 30 day of
completion of well construction to the county health department of the county
aht.rt. conatru(k.d.
Form GR'-I
North Carolina Department of Environmental Quality - Division of Water Resources
Revised ' ?2-2016

WELL CONSTItUCTION ItECORI)
rm.; form an he ;wit fJrr Si1?ndlip1..'It ON
1. i'1'cli C'untrtttur Inrnnoativa:
Will Keyes
11'clt L'U r{rrin(1r f(:rnI
4220a
Nit ' 'd1 C iultrncrtlt C 4 rtiftc:d it,ll ti miter
SAEDACCO Inc
('ov>5r:un l _ii,
RECEIVED/NCDENR/DWR
APR 1.4 2018
Water Quality Rcgional
Operations Section
2, Wrli Construction Permit At: Wilmington Regional Office
f.l a AL' am..fig .:Po:' ' rtf Jirrnritr fi c Cowin is t.,' 1',Jnai r•., infection
3. Writ Use (checkvertl is self
WatrrSupil, Wtell:
t lAptrenlutial
L ICicothernial tlleatinn,`Cc' IInj Glpph
I;1itltlti trialiCpn menial
gimp/non
Ffr II't;•rlhll t'sr mit 1.
/ Z--01-1s
448472
r 1•i. WAt"8R NLO 1:4.._.�4..,.....�,....s....��,u�a:
;gam ? tit nr.tirHIFT1111V
rt. ft
ft. h.
1
IR0tI17t► DLi11rTER _TtIT€'A�_F.S3
R'.,�
t,1_
it, SCRLEN
IS. OUTER CANING lbw tnubi-ontd rick) OR LINER fir SO(
mom ! Tn IU'CUTTER , nitfK4rAs
0 ft. 47' ft, 4" ie. Sch 40
ta. WN[ft C,iSINf: OR.f118119tgegthcratrt clluxd kitio
0. - --1u
Ocotillo
',41TR1AI
PVC
r:IhAnaclpld:Pt►hh€
i IReiitkrlriot Winer Suf>Uh (sink)
t,IRt+sidi moil Water S.i pit rstc,rۥt1Y
Non -Water Supply Well:
Ci fvfonitonne
tujret(on Weli:
D Aquifer Eueharge
Aquifer StomiAt and Recoven
CI Aquifer
r3Vvpr:nlnentnl redulntoif
1:16eultlletnwl (Closed Loop
OGiotlieniwl tileaun Cuulini Retunn
4, Date WAIN, Completed:3'22-2018
ill• Well Locution:
Gary Shull
F.'clIIv !la toe
OReenv,R•
Clt:irtmgtlt}S:II T Remediat ton
D'tjfinitt Flamer
°Storm-11iter ihrttonpe
CISubsidencc C'ofurtrl
Cr I tier!
OOtkar te%pltutt under 021 Reitairks)
H''ۥit tlyp IW-1
Paean:. ir);r'if arplt:Ask+
161 NE 8th St., Oak Island, NC, 28465
Brunswick e ..�..�.._
lolr55?.111, ‘rklrny. 47i1t..HMI Zip
1'.iri'21111:=ndr..IlilsuNu Ii'14r
SIP. Latitude and Longitude in degrecslniitiutrsiscennds or decimal elci:reest
tlf xcll find. nj, Chin!..; I%.."I lit:r;:all
33.925027 N-78.152014
ft. Is tares the trellf!II: XIPerntaaent ur :1i'rurlruran
7. Is this it repair to An existing well: 2.V ev or X No
frJ;il opm., (?•.Y,1t,:l.0 CI,.•n,!tl„ 4.:' vrrin:!r • uurJl t,a,Nn r'"' Alirrlr• r ; li
, raft u,,d, 14,:1 rs m,:rA..;, . SrltW,r ,.vl Olt J i,'t
8. !AUrn►ber of well./ conalnrcted: 1
1'14 ,ir,ith).•rr •,r!'r!' 'I ,r 01.0, ,. i- JFt(1 .I n l Ow ' 1 utrllr r'Wt(rfht'fhr/r •: r_i:�
,efviurc•nr rnnrl
'). Final ilVII depth brims land %Orfila:: 6-:7'
,tft,l
For ,IIJIttJ)rJl I ,•:f' 11:J I,iJ IJI'i lli'I 1111:fi1'F, III..-I,,:)Ir,:� ri.['ii', �.1!4J ` I,.r N#....., .. .
1U. Shale w titer level hduw top of easing: 20 ' DI./
if:aUpJ t •rl •1 4a0.4 1.1•,,,• A.,'
1 I. Brirehote elillmrter: 4"
12- Well t:t,rtAtnretiott method: Sonic
tint
it c Ilircci NIA et 1
FOR WATER SUPPLY WELLS OM. Y":
IJ L Vida union
13h. Disinfection hIle;
Method of test:
-amount:
Mott L in : DIA•HItTFK
47' fl. 67' R.
4" In.
SUIT S1747 tIlr( 404 �t4
51,111111 I
.010 Sch 40 ! PVC
ft,
It.
Ia.
111. CROir r
• Y140!tl
1' It. 39'
ft.
11ATT.RL4F r Ei1PI Cf..tMENT METHODMOt'YT
1L Bentonite Petatessiad pumped
R,
ft.1 rt.
L._,..:....... .... ...1- _,_,-...
19. 4MND,GltAYEL PACK If able
rmltt ' rt) Iti14TFKrii
• 43' ft, 1 67' R. Sand
F:wri.•%( l: U 51'ttr:'rt1011
#2
D. ft.
DRILLfiirG LOG titltxk ■ddltirmid direr( if oecessaml
rI M Tel t[BYCItI/1-10Yfvelar. flat+ltit'a..rls'rm-kOpe.prftinw/n,({e.l
1fl. i 45' h. Silty sand
45' ft. ` 67' ft Limestone
j. �•-. ..... ' .� .. ....-. s , :� � a-rr.A .L''rn �i ,. l,g ��.�. �-..i
21.1tEIttAItKs n, -APR -¢ -- 011_ .
tL I ff.
rt. 1 R. I_
- __----4.- ._..
R. 1 0.
rt.. ffi
22. Certification:
Slrtiflwc,Ii C'tn+ire:: W- 11 C iller:mot
Dme
3/26/2018
Fr. ,tgrv:n':hr, b,rrrr f nrnJn ,err it r!afl ,J,r nrJhn,.. r. I• nr,.:u•,u:,.1 1 v •.. ' l,nv:
11•1J6 J4;1,j W'.t . Nit,' tr. i,'(• .011011'ni r� �•JI,r, Jiprl 4fu:I,t.,I ,t+1e�'Nf IJl:il.
•i,+ tfh•n•-uld,'JIi11.,•u, Of • 1.,1.5''t r.•y:. nN E•Ir,,,.
23. Site diagram or Additional !dell details:
}'tli 111iiY I1S1: the bark Alf this Nli;c Iil Ito,clt' kitbsl!`nill nit) odi.• Iic1,Uls nl 14ci1
emisetuctinit tennis. You Ina!• Alai,UMach :Jddllisnilt pages if Itrl'essun.
tiL111MLIJ J.IlV4'C►1["t1ON -
24u. I''ur All Wells: S11bm1I Ittis form %tulurl .o(lgiletit?o of isell
.,)nstnICnott to the (ilotsin
Division ision of Water Resources, Information Processing link.
161.7 Wall Set -lice Center. Raleigh. NC 699-1617
24b. fo1 litketfotiW'r)Js ONLY': ia:td4ainn to scndine the (Rmt 10 the tiditr€s u
abate.:Ilse salmi! .1 cup! Of this roan Itiliuu tits discs el completion or %twl
ronstnlctioll to the felk,wh s;
Division of Water RrsltUree%. ltlulergrrfund Injection Control Program,
10.16 Mall Service Centre. Raleigh. NC 2715994630
24e, For WIitcr Stipph & Injection Welts:
Also tnbnol one apt of this rams within ifs dins o'fcoUlplrlunitrf
stet! touitnictlon to Inc county hcolth depailnent tft rite couny where
olistmcre[I
I:1oll€elf-I
n p ( r ,Itlw ci•:-p nlltipit •}1 E:n'tour.; ,,f:d Natural it. ut+rcti4 - 1!n blot, tsr l4.uu Rraotrce;
ibis!, 41 kllgusrt 20I'

WELL CONSTRUCTION RECORD (GW-1)
1. Well Contractor Infortnation:
Sanford Sweeting
Well Contractor Name
2082-A
NC We11 Contractor Certification Nwnber
RECEIVED/NCDENR/DWR
Applied Resource Mana
Company Name
2. Well Construction Permit #:
List all applicable well construction permits (i.e. UIC, County, State, Variance, etc.)
3. Well Use (check well use):
Water Supply Well:
Agricultural
Geothermal (Heating/Cooling Supply)
Industrial/Commercial
Irrigation
Non -Water Supply Well:
Monitoring
Injection Well:
APR 14 2018
Aptitypeeti
poegitY) SWIMal
W108005
Wiltion Regional Office
For Internal Use Only:
14. WATER ZONES
FROM
ft.
TO
Print Form
448535
DESCRIPTION
ft.
ft_
15. OUTER CASING (for multi -cased wells) OR LINER (if ap licable)
FROM TO DIAMETER THICKNESS MATERIAL
+/- 0 ft• 300 ft' 1 '" I-SDR11 HDPE
16. INNER CASING OR TUBING (geothermal closed -loop)
FROM TO DIAMETER
QMunicipal/Public
Residential Water Supply (single)
UjResidential Water Supply (shared)
DRecovery
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
Experimental Technology
X Geothermal (Closed Loop)
Geothermal (Heating/Cooling Retum)
Groundwater Remediation
DSalinity Barrier
0Stormwater Drainage
}Subsidence Control
D1'racer
Other (explain under #21 Remarks)
4. Date Well(s) Completed: See attached Well ID# N/A
5a. Well Location:
Thomas & Frances Lott N/A
Facility/owner Name Facility ►D# (if applicable)
511 Caswell Beach Rd, Oak Island, NC 28465
Physical Address, City, and Zip
Brunswick 251JB027
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
See Attached N See Attached
6. Is(are) the well(s)4Permanent or OlTemporary
7. Is this a repair to an existing well: jYes or xON°
If this is a repair, fill out known well construction information and explain the nature of the
repair under e21 remarks section or on the hack of this form.
8. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction, only I GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled: 6
9. Total well depth below land surface: 300
For multiple wells list all depths if different (example- 3@200' and 2 )100')
10. Static water level below top of casing: 12
If water level is above casing, use "* "
11. Borehole diameter: 6 (in.)
12. Well construction method: Mud Rotary
(i.e. auger, rotary, cable, direct push, etc.)
W
(ft.)
(ft.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) N/A Method of test: N/A
13b. Disinfection type: N/A Amount: N/A
ft.
ft.
ft.
17. SCREEN
FROM
ft.
ft.
18. GROUT
FROM
0
ft.
ft.
ft.
in.
THICKNESS MATERIAL
TO
fL
ft.
TO
300 ft
DIAMETER
in.
in.
MATERIAL
SLOT SIZE THICKNESS
Thermex
AIATERLIL
EMPLACEMENT METI OD & AMOUNT
Pumped
rt.
ft.
ft.
ft.
19. SAND/GRAVEL PACK (if applicable)
FROM
TO
ft.
ft.
MATERIAL
EMPLACEMENT METHOD
ft.
ft.
20. DRILLING LOG (attach additional sheets if necessary)
DESCRIPTION (color, hardness, soit/roert type, gain size, etc./
Sand shells
FROM
0
ft.
TO
60 ft
60 rt.
75 ft
75 ft.
105 ff.
Clay layered with limestone
White limestone
105 ft.
125 ft.
Limestone
125 ft-
ft.
300 ft.
ft.
Layered sandy sandstone
ft.
21. REMARKS
ft.
22. Certification:
APR 61 2018
C.ItiLA) r"tit.;_'c*`a:
DV'''CIL C)C' 3/28/18
Certified Well Contractor Date
By si.ining this form, I hereby cent& that the urll(s) was (were) constructed in accordance
with 15A NCAC 02C .0100 or I5A NCAC 02C .0200 Well Construction Standards and that a
copy of -this record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTRUCTIONS
24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Iniection Wells: In addition to sending the form to the address in 24a
above, also subunit one copy of this form within 30 days of completion of well
constnuction to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Sunnly & Iniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this fonn 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

ARM Project Number: 511 Caswell Beach Road
Oak Island NC
Driller: Sanford Sweeting
Date Drilled: Loop No. Loop Depth
3/6/2018
3/7/2018
3/12/2018
3/13/2018
3/14/2018
3/15/2018
1
2
3
4
5
6
300
300
300
300
300
300
GPS
33 53 40.8955
33 53 40.7644
33 53 41.1151
33 53 41.8420
33 53 40.8129
33 53 41.0809
Pagel
Coordinates
78 2 39.8475
78 2 39.7901
78 2 39.3360
78 2 40.0315
78 2 39.6644
78 2 41.2562
RECEIVED/NCDENR/DWR
APR 14 2018
Water Quality Regional
Operations Section
Wilmington Regional Office

WELL ABANDONMENT RECORD
For Internal. Use ONLY:
1. Well Contractor Information:
Joseph L. Zuncich
Well Contractor Name (or well owner personally abat�g��vrl)� er ro e
�V�E /N DE�N�/ �UR
3324-A
NC Well Contractor Certification Number
Applied Resource Management,4Pt.1 4 2018
Company Name
N/A Water Quality 2. Well Construction Permit #: [[,, }} Regional
List all applicable well construction permits (i.e. UJ9 .j Milli'
r, Wt t known
Yrvr�t�n1ll''l1l�tggIIon egrona f�Ce
3. Well use (check well use):
Water Supply Well:
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑Industrial/Commercial
❑Irrigation
❑Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
Non -Water Supply Well:
•Monitoring
Injection Well:
❑Aquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer Test
°Experimental Technology
❑Geothermal (Closed Loop)
❑Geothenmal (Heating/Cooling Return)
❑Recovery
❑Groundwater Remediation
❑Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
°Tracer
❑Other (explain under 7g)
4. Date well(s) abandoned: 3/15/18
5a. Well location:
Orton Plantation
N/A
Facility/Owner Name Facility IDt1 (if applicable)
9149 Orton Road SE, Winnabow, NC 28479
Physical Address, City, and Zip
Brunswick 1440000111
County Parcel Identification No. (PN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/tong is sufficient)
34 03 27.13 N 77 56 54.47
W
CONSTRUCTION DETAILS OF WELL(S) BEING ABANDONED
Attach well construction record(.$)ifavailahle. For multiple injection or non -water supply wells
ONLY with the same construction•abandomnent, you can submit one form.
6a. Well ID#: MW-2R
6b. Total well depth: 14 (ft.)
6c. Borehole diameter: Unknown (in )
6d. Water level below ground surface: 4.62 (ft.)
6e. Outer easing length (if known): Unknown (ft.)
6f. Inner casing/tubing length (if known): Unknown (ft.)
6g. Screen length (if known): Unknown
(ft.)
WELL ABANDONMENT DETAILS
7a. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
well construction/depth, only 1 GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
7b. Approximate volume of water remaining in well(s): 0
(gal.)
FOR WATER SUPPLY WELIS ONLY:
7c. Type of disinfectant used: HTH
7d. Amount of disinfectant used: 1/8 lb
7e. Sealing materials used (check all that apply):
❑ Neat Cement Grout
❑ Sand Cement Grout
0 Concrete Grout
o Specialty Grout
O Bentonite Slurry
• Bentonite Chips or Pellets
❑ Dry Clay
❑ Drill Cuttings
0 Gravel
❑ Other (explain under 7g)
7f. For each material selected above, provide amount of materials used:
30LB
7g. Provide a brief description of the abandonment procedure:
Removed 2' casing and filled wit bentonite chips.
8. CertiG
APR f l: 2018
•
�--. 3/15/18
Signattu1 ofCertifie ontractor or Well Owner Date
By`dtigning this form, I hereby certify that the well(s) was (were) abandoned in
a9cordance with 15A NCAC 02C .0100 or 2C .0200 Well Construction Standards
fnd that a copy of this record has been provided to the well owner.
9. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
SUBMITTAL, INSTRUCTIONS
10a. For All Wells: Submit this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
10b. For Injection Wells: In addition to sending the form to the address in 10a
above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
10c. For Water Simply & Injection 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 abandonment to the county health department of the county where
abandoned.
Forrn GW-30
North Carolina Department of Environmental Quality - Division of Water Resources
Revised 2-22-2016

WELL CONSTRUCTION RECORD
This tixin r to be toed for single or multiple melt:
For Internal Use ONLY:
t44702
1. Well Contractor Inf
j>71Ae- rise i - cCJ
tYell Conaactor Name
35 vC A
NC Well C.iunact r CertifcationNum
��P r
Company Nmnc
2. Well Construction Permit #: w V (98 00 17 V
e Lj
List all applicable well permits (ie. Cotmn: S `• I orian:.. Injection. etc)
3. \;ell Use (check wen use):
Water Supply Well:
0A3ricultttral
OGeothamal (Hrating.Cooline Supply)
Olndestrial /Coln mcrcial
rination
Non -Water Supply WcJ1:
DMonitoring
14. WATERZONES
FROM
To
DESCRIPTION
ft
5,4A-(-1
It.
i n
rt. 1 I,,•i eTo
13. OUTER C_-sit'iG (for multi -cased wens) ORLTNER flop • Me)-,
FROMESS,
I3U R DJ MAT
tP 0
16. INMR CASING OR TURiNG (gentbermi d dosed -loop)
FROM TO ! DIAMETER THICK1tESS
11
it_
In.
h.
17 SCREEN
111
C
O CD rt7 tV
TLAT�,�rt.
7,0 0 Clo
(0
Injection Well:
OAquifer Recharge
OAquifcr Storage and Recovery
OAquiter Tot
DExperimental Technology
OGcothamal (Closed Loop)
❑Gcothamal (Hcati ng:Cooling Return)
0Municipa1Pablic
OResidaitial Water Supply (smile)
DRcsidcntial V('atn- Supply (;hared)
❑Rmovery
❑Groundwater Ranediation
❑Salinity Barrier
❑Sttamwatcr Drainage
DSubsidau:c Control
❑Tracer
DOdnct (explain under t421 Remarks)
4. Date U'ril(s) Completed: 3 / / •7 (1 V;'ell ID l
5a.I•V411 Location:
� fi' pes
Facility/Owner Name Faeditt•iDRtifa liable)
a 00 i civ > (` /4 -
Phy iicctl Address, City, and Zip
County Parcel Identification No. 4PbN)
Sb. Latitude and Loa gitude ha degrees/tninotes/seconds ar decimal degrees:
{d' well field, one latilon; is sufficient)
3 34,Cs 3 ,gi(%w N
7,00 V 7,7/2 w
6. Is (are) the well(s): 1ernxtnent or ❑Temporary
7. Is this a repair to an existing Kell: ❑yes or
If this is a repatr, fill out known well construe:ton information and explain the nature of the
repair under a2! remarks section or on rlw back of Miriam,.
8. Number of wells constructed:
For multiple inja:tion or non -water supply wells O<'Lr ten!, the same cansanction, ton on
snhnir one j"orm.
9. Total well depth below land surface: 6 o
)14iV`o
For multiple wells list all depths ij'dtjjtretu (example- 3.Q.=00' and 2(!001
10. Static water level blow top of casing:
If water level is afore casing. are " -"
11. Borehole diameter 67 (in.)
Lid
LL Wen construction method:
i t e. atiSer rotvy, cable, ituect pu;lt, etc.)
f
(ft)
FOR 'WATER SUPPLY WELLS ONLY:
+
13a. Yield (gpm) 5 V Method of tit: /9 i r-
13b. Disinfection type: (3/ T (l7 Amount: ! 4/
Fonn
FRO11
TO
DI.IAte t eR
SLOT SIZE
ft.
ft.
tt.
ft.
a
THICIMESS
MATERIAL
13. GROUT
FROM
fz
ft.
TO
j
FL
ft.
MATERIAL ENIPLACEMENcr METE s, smouNT
ft.
ft..
19. S_ANN D!GRaVEL PACK Cif applicable)
FROM TO MATERIAL
IL
ft.
EMPLACEMENT METHOD
ft.
It.
20. HAULM LOG (attach additional sheets if necessary)
FROM TO DESCRIPTION (color. hardmes. neiLrack• typS drain she. ac)
fL 2. 2- Ar-J
L Z fL
02,
ft.
Z fL
IL
0 ft.
ft.
L 1 e 5 7v;
it
it.
ft
ft
fL
ft.
MAR 2 6 2018
11. REMARKS
22. Cer•tiftca
Siansture of Certified Well Contractor
Th• signing this,foun. 1 hereby cer1i r than the irell01 war (were) constructed in a.,ordance
with 154 NC.4C 02C .0100 or 13.4 NC.4C 02C .0200 If ell Construction Standards and that a
copy of this record hos been provided to the well owner.
23_ Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
cunstntction details. You may also attach additional pattrs if nccasaiy.
SUIEMTTAL RNSTUCTIONS
24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Injection U'eIIs ONLY: Itt addition to sanding die form to the address in
34a above, also submit a copy of this fond within 30 days of completion of well
conshuctioa to the following:
Division of Water Resources, Underground Injection Control Fragrant,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supphv Injection Wells:
Also submit one copy of this form within 30 days of completion of
well construction to the comity health department of the county where
constructed.
North Caiolitu Dcpirinlcnl of Environment and Normal Reaottreci —Division of Water R yotocea
Revised August 2013
HMQ/JN3aoN/a3A13o]

WELL CONSTRUCTION RECORD
Thit &Iran ran be ucel for sismIc or muli+ptc back
For banal UUc ONLY:
1. Well Contractor Information:
Weil Coot+auo. Name
.S� Ll cis /{
NC Well Gwoattor%erckcatinoNumber
Company Name
2. Yrr1I Coaslmrtian Pci-r>di PP- v1 2.01 - oo a 2.
List ail applimble well Femurs fie. Come: Star Varian-v. Iniecriar; etch
3. Well Use (check well sue):
Water Supply Well:
❑Agricukural
DGcothennal (HcatingCo m; Supply)
Q Industriab'Com m czcial
�ri�:rtsleet
Non -Water Supply Well:
QAtonitoring
ti WATER ZONES
FROir TO
0 ft. % 2 2 ' R.
DESCRIPTION
447-021
L-. e S �L taw
la OUTER CASING far mniti-cased cells) OR LINER Of
FROM TO ft-
DIAMETER THICKNESS
r ft. 5-0 is I (� / yo
16. INNER CASING OR TURIN I f J �7
FROM
ft.
TO DIAMETER
ft_
is
o?
MA
Q•
s..
ec[ored-t ) p Grp----
rfuclaEss � -
O o Co
ft-
11 SCREE'
ft.
112.
Injection Well:
❑ Aquifer Rctargc
I/Aquife r Storage and Recovery
❑Aquifer Test
❑Experimental Tee/make]•
❑Creothi mal (Closed Loop)
❑ ticothamal (Heating:Cooling Return)
4. Date Well(s) Completed: 3 -/ 9
011.4tmicipal.Pubtic
❑Residential [\ ata Supply (single)
QRatdcutiat R',1.a- Supply (shared)
QRceovcry
EIGt undvatcrR=ncdiation
QSalinity Barrier
❑Sttxmuatra- larainaec
DSubsidatac Control
DTraccr
QOih r (explain under 421 Re:tthatl3)
WellID#
S a.-Well Location: /
4 f ri � ►�/� /1
/
FacilitylO vntu Namme �j Faa. 1iiittc ltDJ t+pple.- ale)
/(1 Ji `�r pv/U cv,4 L//`t"c 1f/r /c
Pityiaaat A ems, Cth-. anal Zip / ) !` / ._
Covritl- Parcel Iautttfeutty+ No. (P )
Sh. Latitude and Lon itude in d rcesirninnteskeconds or decimal degrees:
of well richt, one lat:loto is sutficieatt)
3 3 y' yv ,13t76'N 7 Y/ 3 ‘7(3 �.
6_ Is (are) the
ermanent or QTeruporary
7_ Is this a repair to an existing well: QYes ur u
If this. is a repair. fell oert brown well cm:san Pion information wed laic the mourn: of the
repair tender 1 remarks section or on thz bash -of this form
S. Number of wells constructed:
Forenuhipk 4ection or ewer-u-ater supply+relit ONLY with the same canstrtrttioet you can
srdvnit one form. /
9. Total well depth Mow land surface:
For multiple wells list all depths ifd :rent !example-3Q 00'and :T160-I
10. Static triter level helms top of casing:
If water level es abo+r casing, use 'T'•
11. Borehole diameter ([j' (in.)
12. Well construction method:
i t e. weer. rotary- cable. dneei own. ere.)
/0
(R.)
(ft-)
FOR ' WATER SUPPLY WELLS ONLY:
�t') i
13a. Yield (pm) 3V 117
Method of test:13b. Disinfection type: /[9/4 (y f _noun
Funs GIV- I
FROM
IL
IL
TO
ft.
DIAMETER
ia.
SLOT SIZE
TllCRTstss
1L%TERIAL
13. GROUT
FROM
0
IL
IL
fL
is
TO
1') fL
ft.
MATERIAL
EMPLIEENTST \IETI on
ft.
fr.
19_ S)N'BJGR1VEL PACK (if applicable)
FROXI TO MATERIAL.
fL
f6
S AMOUNT
,,4
EAIPL&CEAIEAT METfIOD
fL
CL
2Q D12II_LL\G LOG (attach ndalit/ma-I sheets if nccttsaryl
FROM TO DESCRIPTION eo:lar- 6zrd;a s,ay
l
z.7/0 ft
ft.
IL
CL
fL
21 REALraR1.S
rL
fL
IL
ft.
fL
C/14 '• Sher
�• / l '1 e
train sac. act
MIA R
2S Ccruui1
Sign t f Wired Well Contractor Date:
Br sigrieg ;F.ir form.. I hereby cc-rtifr that the ueiltsl was (wer.l —anstrrtred io o ordar:;:
arch i.i1 \('--(C )2C .0100 or 15-( NC. -IC 02C .0200 A1-11 Constriction Srcrr.ciards and that a
copy of this re.ard leas been provided to the well owner_
23. Site Seazgratn or :additional well details:
You may use the back of this page to provide additional well site details or u'c11
construction details. You may also attach additional panes if necessary.
SUBMITTAL INS UCTIONS
24a. For All Welk: Submit this form within 30 days of completion of \cell
construction to the foIlo\\inn-
3
Division of Water Resumers, information Processing Unit,
1617 Mail Service Center, Raieiett, NC 27699-1617
24h. For Injection Wells ONLY: La addition to sending the !form to the address in
24a above_ also submit a copy of this form within 30 days of cow
aarLStultatnn to the t& kwint_+; completion of tech
Division of Water Resources, Findergl'otmd Injection Control Prngt-am,
1636 Mail Sixties Center, Raleigh, NC 27699-I636
24c For Water Supply & Injection Wells:
Also submit one copy of this form uithni 30 da\s of completion of
ndl conittudion 10 the county health department of the aunty uilcre
coasttuctcai
Nth Co .tiiu 11.-pattrntsa ut En it rams mid 'Natural Ftc,xa.a—Dra.non N Wrier Beard
Revised Al(i;usZed;

WELL CONSTRUCTION RECORD
nit frtrsn can be tail for sinn,,lc or multiple wills
7.5
1. Welltutor• Information:
//, etef.s a w'
llydl Conttana Name
3 ,f0) 4
NC Well CtThariaont C m a ep )1Tititi sr)
CunipmyNatac 'j`th'Ci / (_
2. Well Construction Permit #• N P4:VYYt Lf.' `3 - �jOCi
List all applicable well permits tic. Corn .. Stalt - ritriar0.Y. f, j tiory crz l
3. Well Use (check Weft use):
Water Supply Welt:
❑Agricultural
❑Geot a mnal (Hlitut,•Ooofing Supply)
❑ in dus triaL''C oso m es- clay
✓m2atiowt
DMunicipai Public
❑Rc idential Water Supply (s-talc)
ORtsidential Wat.n- Supply (slued)
Non -:Water Snpjric Well:
❑Monitoring ❑Recovery
Injection Well:
°Aquifer Rcdtarge
t7Aquifer Storage and Recovery
❑Aquifer Tat
OE'q crimental Technology
OGcotheimal (Owed Loop)
❑Gcothcrmal (Hcatutg:Conlin'. Return)
❑Ground\vatcr Run Minion
°Salinity Barrier
❑Starml\a1Cr Drainage
OSubsidaicc Cuntrut
°Tracer
OOth r (explain under ; 21 Renralb)
4.Date Wags) Completed: 3 t?V '4 r11IIi
3a. aYiell Location:
rt ou,_)
Faeiliocihrtsu Nape< FaaIity Ii)= tt: appti •altle
( & . ya•tch a ( a/, k 2.85/(f.►
Physical Addicss. City, and Zip
County Patccl hicutiftiatiati No, .pNN)
5b. Latitude and Lor;gitude ixi sit nees/minutcs/secontis or decimal d4aree.s:
of well tick!, on., Ia;latta is sm)i�ct1)
3 3 `55-#3/t l� 2-" 0x 13 3., J'k y ,l
n•
6. Is (are) the well(s): )(Permanent or OTetuporary
7_ Is this a repair to an existing well: ❑Yet ur
grins- is a repair, fill ova iwoun cell construcoaa ityi rrnanran and explain the motor. of tyre
repair under e_I remarks section or on Me boel-of thirfamc
It. Number of welts constructed:
For muhipk injection or next -water supply wells ONLY with the an, causrruction, lou.an
rxlvnit one jar?,
9_ Total well depth below land surface: (�4'
For multiple wells list all depths if d cram (example- 313,'00' andp.) (fL)
10. Stacie inter level below top of teasing:
If water level it above casing• tan "+
�%/
11. Borehole diameter. (iru)
1 L Well construction method: [ / 1 Lid
;t c. atklist. rotary. cable, dncct nut h etc)
FOR WATER SUPPLY R'Ri IS ONLY: 13a. Yield (gpin) 73 -#' Method of test: /` %� ✓r` \ y�
I3h. Disinfection type: /e la 41 _Immune ' v2 %/al
Form OW-1
For Nicola] Use ONLY:
FRO..t1
[L
ft_
TO
13, GROUT
FROM
ft.
TO
(L
rt.
4470jj
nl.laMEIER
SLOT SIZE
TifiCIOCF_SS
IATERLIL
MATERIAL El(t'1-_aCEafFs.-F METHOD .1,.11lourvr
ft.
t.
[L
19_ Syt1i'D1GR VEL PACE (if a Is)
FROM TO \IATERtAL
El[4t_acENr1:KT VETtton
a. rL
ft_
It.
20,DRILLMGLOG tattlehadditi"*^ta,_.t..ifb tst-0
FROM DESCRIPTION oaks turtles., sail -rock
NC.--
[t.
TO
t7 ft_
e, .rain liZt etch
- .,.,.. -.
MEC
By signing this font:, 1 lxrchr crrlijr that the u.Rlil wets (were) 70nstrig led £t a:;ordan..•,
unit 1.3.4 ' CAC 0.2..OIW or 15.t NCAC 02C _11200 Il1,11 C0rttriw: Srandydr and that a
ropy of this rnrord has been provided to the trc11 owner.
Site diagram or additional Well details:
I'ou may use the hack of this page to provide additional well site details or avc11
contstructitm details. YOU may also attach additional pages ifueee�saty-
SDRIUITTAI..INSTIJCTIONS
24a. For All Wells: Submit this loom within 30 days of completion of well
construction to the follotinr:
Division of Rater Resources, information Processing Unit,
1617 Mail Service Center, Raleigh, NC 276994617
24h• For Initcton Wens. ONLY: hi addition to sending the form to the address in
24a above, also submit a copy of this form within
30 days oI completion of well
catshuctiari to the follotling:
Division ofWater Reaotures, Underground Injection Control Progr,
m.
I636 Mali Scr-vice Center, Rake h, NC 27699-I6.36
24c Far Water Supply & Injection Wells:
Also submit one copy of this foram within 30 days of completion of
latill cotsstiucjimm 10 the county health department of the county where
l:nttstructcr[
North Caatitu llspounc l ofFrisitonincrit arnlNafmalRo.xa,et—th:isivn aIVolta Rtsourse,,
Remised Atr"ust 2t4 3
SMQ/ N3a3N/C13A1333ei

For Internal Ilse ONLY:
WELL CONSTRUCTION RECORD
This turn can be wed for single or multiple order
1. Vte11 Contractor Information:
Well Contractor Name
S-vo A
NC N'dl C)Jeis Certification Nuxn
( Vv(/// 60,1
Company Name
2. Well Construction Permit II: W,V( CS'D 0 / l
List all applicable wc11 pemrus (ee. Counq; State, Variance, Infection. crap
3. Well Use (cheek well use):
'Water Supply Well:
❑Agricultural
❑Geothermal (Hcatirta:Couling Supply)
industrialiConmercwl
Irigation
hair -Waster Supply Well:
ONIonitoring
Injection Well:
❑aquifer Recharge
❑Aquifer Storage and Recovery
y
CI Aquifer Test
❑Experimental Techuolugy
❑Geothermal (Closed Loop)
❑Geothermal (HcatingiCoolina Return)
14. WATER ZONES
FROM
ft.
TO
DESCRIPTION
� 4VOW—
:off
la. OUT CASU G far tnubi-aced Wells) ORISNEit Clop ba
FROM TO DIAMETER THICK v_
6. C OR G `� 5/0
FROM TO DIAMETER 1 T1QcI dosed -loon)
)
ft.
ft_
is
tm
MAT
0
IV
ft
17.SCREEN
ft
in
❑ldunicipalPublic
❑Residential 1, ata• Supply- (single)
❑Residential Watt Supply (shared)
❑Rev:over
FRoa1
ft.
fi.
111. GROUT
TO
ft.
ft.
MANUA
a.
SLOT SIZE
THICIG1'ESS
FO
\LITFO,st
FROM
0 ft.
ft.
To
ft.
fL
MATERIAL EMPLACE E T MIETHO/D S AMOUNT
Fri C 6/PJ -f_' �')I"(`l//n% /purl
❑Groundwater Remcdiation
[]Salinity Barrier
❑Sttrnnw itcr Drainage
❑Subsidatcc Control
❑Tracer
❑Other (explain under 421 Rcn arks)
4. 11-ate Well(s) Completed:3 0f3 ION
_+a. \1 eU
/ e
eiNdP,1/4/ CA
FacilitylOivner Name Facdit IDr of appli -able)
02 0 / CC &AA, I) i± e)/a / /JAI/ -
Physical Address, City, and Zap
County Parcel Identification No. iPIN)
3b. Latitude and Lot-0111de in degrees/nthw csheconds or decimal degrees:
ittwelt field. one Inr]Ionet is sufficient)
33 511 / IPCY3 , Ci/P \\'
6. Is (are) the well(s):. (rnranent or ❑Temporary
7. Is this a repair to an existing well: ❑Yes or
If this is o repair, fill out known +red construction information an xplain the nature of the
repair under 421 remarks section or on the bock of thisform
S. Number of wells constructed:
f
For multiple injection or non -water supply wells ONLY with the sane construction, sale earl
submit one form.
9. Total well depth belay land surface:
� 9 /
For multiple welly list all depths if'd ferentrex-ample-3g200'and 2:m100')
10. Static water level below top of casing:
If water level it abort cos nq, tine / "
/T/
11. Borehole diameter- (, (i(n.)
IL Well construction method: / 1 / i✓ C`j /2G,2 'F.Y4
ire. auger, rotaiy, cable, deem pink etc)
(D)
(ft)
FOR WATER SUPPLY WELLS ONLY:
13a- Yidd (gpm) t;
Method of test:
I3b. Disinfection type: 4344 (' 4 Amount:
�MI//0
H'unat GW-I
ft.
ft.
19. S-IND/GR•1VEL PACK (if applicable)
FROM TO MATERIAL
ft.
ft.
E1PPL&CE3rENT METHOD
rt.
ft-
20. DRILLING LOG (attach additional sheers U urr..r. y
FROM TO DESCRIPTION alor. harden; salik e& fro
® fL
grahw sic etc
aJ ft.
yes
fL
ft.
ft.
ft.
fL
IL
21. REMARKS
ft.
ft.
ft.
ft.
fL
S %D ,l. —C
WHVR % 6 NIS
Signature of Certified Well Conbaetar
Date
St' signing this form., 1 hereby certii that the. we111s1 was (were) canrn-,e red or ae ordance
with 11,1 MAC 02C .0100 or 15.1 NC. -AC 02C .0200 Well Construction Standards and that a
copy of this record has been prosnied n the well owner.
23. Site diagram or:ulditional well details:
You may use the back of this page to provide additional well site details or well
cumshuction details. You may also attach additional pages ifneccssary-
SUDAUT F.&L INSTUCTIONS
24a. For Afl Wells: Submit this 1cnn within 30 days of completion of well
construction to the following:
Division of Water Resources, Infoa-,nation Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Infection Wells ONLY: Li addition to sanding the form to the address in
24a above, also submit a copy of this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Ijndet grotmd Injection Control Program,
1636 Mail Scrtice Center, Raleigh, NC 27699-1636
24c. For Water Supple & Injection Wells
Also submit one copy of this form within 30 days of completion of
well consuu:ion to the county health department of the county where
constructed.
.4Cj l/ iFi
North Carolina Department ofEnvizon ucnt and Natural Resources —Division of Water Resources
Revised August 2ki13
iMa/NN3a3N/Q3M13o3J

WELL CONSTRUCTION RECORD
This firm can be used for sirglc or multiple wells
I. Well Contractor Inf tion:
For Internal Use ONLY:
447730
14. WATER ZONES
welt co...., Name
35Y0 i4
NCWell Conoact,Ntmther
e Wei 6-Li5
Company Name
2. Well Construction Permit 8:
List all applicable well permits (ie_ County. State. i'urian . Iniection. ett.1
3. Well Use (check well use):
FROM
f ft.
TO
DESCRIPTION
J rJ Jct
fL
33_OUTERCASING (farmnki-casedwells)ORLINER(d 6k)
FROM TO DIAMETER THICKNESS MATERIAL
�Ch yv !V $ t'/
1- /�yin-
16_ INNER CASING OR G (geothermal daoed-loop)
FROM TO DIAMETER
R. ft. in.
R fL im
THICIOVESS
MATERIAL
17. SCREEN
Water Supply Well:
DAgticultural
❑Geutheimal (Hcttina,Cooline Supply)
D IndustrialiCommcrcial
1/11;nination
DMunicipal Public
DRc idcitiai A'atceSupply (single)
°Residential Veal.= Supply (shared)
Non -Water Supply Well:
Ohlonitoting
°Recovery
Injection Well:
D Aquifer Recharge
❑Aquifer Storage and Recora
D Aquifer Tot
❑Experimental TechnoIut y
❑Gcothamal (Closed Loop)
❑Gcothamal (Hcatntg:Cooling Return)
❑Groundwater Rarncdiatian
❑Salinity Barrier
DStormwater Draitta`c
OSubsidanx Control
DTracer
DOtha- (explain under 421 Romans)
4. Date 'Well(s) Completed: t 3 O /O WrU ID#
Sa.. N'eli Location:
Chris y?')orj»-&'
Facility/Owner 'Name
t 2 10 - let ST.
Physical Address, City, and Zip
tJ,LA/ 1
FacilityjD#drfapplt ahlej
GAb 1.s/, -ci dery's
Count• Parcel ldenlifieitran No. (MN*)
Six Latitude and Longitude in degrees/minutctlseconds or decnnal degrees:
.if wall field, one. latikIllEt is sufficient)
33`5/ / ti/ d�F fX� 7 ) e / _`
6_ Is (are) the well(s): fijeerneinent or DTempora\ry'
7. Is this a repair to an existing well: °Yes or .;Cis
If this is a repair. fill out known well consmtcuon it formation and explain the nature of the
repair under 421 remarks section or on iI,r back of this form.
8. Number ofwens constructed:
For multiple iry''ection or non -water supply wells Oral' with the same carstruaian. you can
submit one form.
9. Total well depth below land surface:
For multiple wells list all depths if difj:•rent (example- 3y200 ;end 22ta 100'i
1Q. Static seater level blow top of casing: (]
If a atcr 1ctr1 is oboyt easing, t/ ' i r , t/t j
11. Borehole diameter: � (in'.)� �I
12. Well construction method: ( • ea
e. auger, meaty, cable, duet push, etc.)
(n)
(ft_)
FOR V. ATER SUPPLY WELLS ONLY: %� /�
/
13a. Yield Lapm) 3 " % Method of test: / `I t7f'�
I3b. Disinfection type: (J `6'.4C`j _►mount: e 0 L
Font OW-1
FROM
/ ` fL
ft.
TO
2 ,/ fL
ft.
DIAMETER
1%ID-
to.
SLOT SIZE
THICKNESS
MATERIAL
IS. GROUT
FRO1I
V it
ft.
TO
10 IL
ft.
MATERIAL EMPLACEMENT METHODS 1.10LIr•T
Getv7— _h p.• - , rl re JI
fL
ft.
19. SAhNDIGII AVEL PACs. Of applicable)
FRO11
TO
;MATERIAL
EMPLACEMENT :METHOD
ft.
ft.
IL
ft.
20. DRILLING I.OG (aftaelt additional sheets if necessary)
FROM
ft.
TO
ft.
DESCRIPTION (color harden... saitirad: wpm. rain sae, act
tri
fL
fL
ft.
fL
fL
fL
ft.
fi
21. REMARKS
ft.
ft.
Ala C-2016
rOflr'JAi
, ,.l 1. 9 �..•.-`� -' `FJ
�}�Cit
Signature of Il'di Contactor � _ /�
_ Date
By signing this form. 1 hereby certify tsar the WOWS) tear (wren) constructed in a :ordance
with Ill KC.4C 02C .0100 or 15A NCAC 02C .0200 Well Consn-ttioa Standards and rhar a
ropy of this record has been prortded to the well owner.
23_ Site diagram or additional well details:
You may use the track of this page to provide additi yellsite details or welly
euusi,uction details. You may also attach additional page it.peaa sat. rif'I
SUBAIITT_a<LINSTUCTiONS m D 4C
O N jc� TJ rri
24a. For all Wells: Submit this forn within 30 day41 g iiinipletii>?!=of well=
catcctructian to the following: f, ,I/Z
Division of Water Resources, Infortrration f*ins Unite =
1617 Mail Service Center, Raleigh, NC V76394617 c'0
24b. For Infection Wells ONLY: In addition to scntii di four to the adth'cs
24a above, also submit a copy of this form within 3(fdays of completion of we 1
catstiuctiat to the following:
Division of Water Resources, Iitulerground Injection Control Program,
1636 Mali 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 cousuuctioti to the county hraltih deparitnant of the county where
constructed.
North Caroiitu Depaintcrn of Emir ountent and Natural Rcotcco -Di: aioii of Water Resources
Revised August 2013

WELL CONSTRUCTION RECORD
This tons. can t>r used for eirrja «noultipiemell;
1. Well Contractor I •
/�2r2t Sow
Wdl C000nctoe Mann
3sg0/
1iC Well t:.mn:tjr.= i,:o:oi1j�m 2.Trim6Cr
e e
Cuuapany !lime T(l
2. Well Construction Pcrnn i ti
\�: u m I rQ 00O ( Z
List c11 opplia;rk well permits fir- Copes.: Sai . l ariamv frge ti 1
3. Weil Lice (eared: well use):
Water Supply Well:
❑ kgricultural
❑Gcuthcmial (Hcating'Couling Supply)
OIndastri.•rI Caanmercal
�i�lirrc
Nowt- Vate-Supply Well:
Elhfouitarng
IFor meant tee ONLY:
!i WATFRZONFS
447729
FROII
TO
ZIFSCRIOrtoyt
J1g7-0 �%�IVY
L. OIITF.lt C $1NG (far mntu-..a 01.1INIEg01
FROM To DIAMETER THIC i�aL
I-1 ft-i ly e° Soh va
141I� 1t r car_ OR TUR G Gnu l
FROM TO nLaMETER f 'rIFIEKNERs LiaTFRLtL
R ft fa
QA4ami6pal,Public
11 ideutial Water Supply mingle)
QResidential Wars Supp'S khan)
❑R.:cm-err
Injection \Well-
❑Aquif Regalge
()Aquifer Storage and Rce-orcry
Q aquifer Tcst
❑Expuioratial Technology
()Geothermal (ClosodLoop)
❑Geolheimal g Cooling Return)
Physical A elo s, City. aria Zip •
�jr(JAIJ LL°( C.
QGioundwazGr R:_ln[hi i
DSalinit) Barrier
❑Storms. rDraina_c
O nh-irkuan Ccnitnil
❑Tracer
Milts (Main under =21 Ram)
4. Bate Wr l(s) Completed: .3— / 711 R-di III.
LI 1 .1i�l��i✓
Farituv/Omxr Name Faatitr IDr cif appti.mb)zl
-.2a0 A1E 3 -2-1 s;dAIr / aW
County Parcel r iaritlemiau I:a (PI\')
I ant udr and Lnn iwile in dmrrmhain art s/ coeds or decimal d-nrem:
.ti well field, one Iaalorm is srdti.Zan)
3 �3 °5s/ Yo ' 7 3, &,? f'Y w
6_ Is (arc) the well(s):ernennent or (3j-ernporary
T. Is this a repair to an ewis in veeU: ❑1 es or ..193to
If this irarepoeftUout known wellcomma..1nminfiunwoonandexplainfornaz, oft&
repent under =_ I remarks se tioa or on de ha:* of this form
i; Ntrmherofwells constructed:
For multiple injoaion or inn-rrour supply nrl r O\ZF .. a the same c nstruc ion. ybu.xrn
subilit one form
9. Total wr l depth bduw land stnfuc: (ft)
Foraxdtiptc rolls tut all depths ij-d fjrreat tanurpli.3a200' wu7_.s1001
10. Static water level below top of : f1 6)
!Crater ler:l aabase arising• rase /
Ile Borebokdiameter�•/TVP/ o' (in.)! /
J"r � ✓C'�
12. Well construction mrtimd:
e an_er, roar. cable_ darer resit del
7
FOR WATER SUPPLY WFJ IS ONLY:
r'
I3a. Yield (gp) a Method oftest:
13h. Disinfection type. e / ,44 %mum
F nn OW-1
2
17. SCREEN'
r.
in
FROIJ TO Iitait-TER
fL ft.
I3. aft0U'T
TRaV TO
/
ft
SLOTSIZE
/T7' A
TIECR3 Q
(.9
MATERIAL
ff.
/0 ire
ft.
MATERIAL E iFI-AC 2 IFR.r . F,TROD .LmouNr
ft.
fL
19. SA/GRAVEL PACK Of avohcthle)
FROM TO MATERIAL
R
rr.
E III-M F1TE,T METHOD
fL
tr.
2p nAlr 11NG LOG Wrath ..h sdditimal sl mcz itar ccz�rc)
FROM TO DESCRIPTION valorses1 Od
1l'TN �c, cici
f.
a '7 rr.
fL ft
fL fc
fL rt.
$jam Fxv t
ft_ tc
fL ft.
ft fr_
nummeminiliF
L RKS ,en9l m , lint
22Ce
Sig,ntturr f Gritecd Weil Contractor Fate
Er sigciag this lorr>; I ?wr7?i' :anjr' that tkr %raft) eras (reri .brlrrneNcei Ir nenudanzo
with 1i1 'CAC 02C .0100 or 1.24 NC -AC 02C _20011 11 ConsrmAioc Staaian a and rlor a
anpv of thir -rebid lms ken provided to thz well ou mzr
23 Site diagram or:ulditioanl well details: You may rue Wk of e bacthis page to provide additional well sic details or cell
construction details_ You may also attach additional poem ifnec
SUI3r\i1TTALTriSi LICTIOA S 3 a -
Jo 0
24a. For All Wells: Submit this form caithin 30 days
of construction to the follonine of AO
cU n �� i�
i
Divisioof Water Rm csn cos, Information Precis j I�
1617 Mail Service Center, Raleielt, NC 27699.. lt'QY.
C..)vi
24b. For Iuiectinn Wells ONLY: In addition to scndina the kern
24a above also submit a copy of this form within 30 day L$ m We on of x d
construction to the folloninn_ completion of vc'cff
Division of Water Resources, Underground Ia•{ecaon Control tam.
ICub MaB Scrvier Center, RaIr1S NC 1769941536
2-1e For Water Strppiv & Injection Welk
Also submit one cop} of this form Within 30 days of completion of
Rill cOtnIttlaina to the county be him dgnrtmcnt of the
coast:m t t county Where
Nandi Caoinu akin traaa of Cnr.•iraa nraa and Nana.a1 Reaoo rs—llrisi ire ofWa. ter Resooa rs
Revues! amust?ti1_
JA40/JN363N/03A1333ii

WELL CONSTRUCTION RECORD
This &sus am he used for ate or multiple wells
1_ `Q4 a stractmr I '
or Internal L*se ONLY:
Well Commeses Name
:dr)G/
NC Well Canon a
Company Name
Lec ath a 07(
L Well Coushztrimt Permit #1'
List all appli.roble well permits (E.•. Corson. Steles ['arias ir kicitiort.ucl
3. Well Ilse (check well use):
Water Supply Well:
°Agricultural
o Geothermal (NettinsCwtlirm Supply)
��❑ IIn/ndustrial:'Commcrci:rl
i�lrl"{?1t]lil
ETilmicipalPublic
DRd dkattnl Water Supply (saLk)
°Residential Wat. r Supply (shared)
Nast -Water Supply Well
❑Mouitonng
°Arne -cry
Injection Wen:
❑Aquifer Re -Aisne
°Aguifcr Storage and Recovery
17_\quifa-Test
❑ Egtcrimlatal Teclutulog
Ot3colhamal (Closed Loop)
CItaraun.h 1crRattcdiation
❑Salinity Barrier
OStormttatcr Drainage
°Sulnidcacc Control
[Maur
°Geothermal (HeatiugCo. tiny Return.) OOth r (m4alain tender _21 Rcrnatia)
4_',late Well(s) Completed: C 3 /t e1l IBR
LocRhnn:
rril MUl 1 JOA/
Facie. y Oor cr Name Fa litc (D=!si appti.-thk)
t.2ao 111‘AViS r cimo, Soo ri o n
Physical tiizcv'. City. an.l Zip- /
eVAf (A--Zc' 1l-
County Parcel Idrnttfwatan No. (PL\7
Sta. Lauttu)e and Lnnggiuide m datainnftsIs tangs or dotal dt rem:
91-well ricld uric. Imilarw. is suiti3Or n) 1, /
.33.���� c./. SY 2.2 N 72 0 /6.- C/)
6. Is (are) the wags): •l er[ronent or °Temporary
7_ Is this a repair to tare exiclin ' se%: Eires or a
If rr a repair, fiU out known .rellc snT<tim it tacmtran un at the astern of the
repair under =21 remarks sealon or on tM boa -of tit form
& Number ofsrell; muasu•ncted:
For multiple itge.siorr or mo-.ratr supply wells ONZF with the suit', oortsvaoion. ou,.vn
termn cute farm /
3S
9_ Total well depth below land surface:
For multiple wells fat all depths ij drfjtreat ex —ample- 31-3,200- tad 2 ¢l00-t
10. Static triter Level below top of =cane: / 0
If warer 1et:1 is °bore mashes!•
11. Borehole diameter: Can.)
1 L in
/�VI
1Ve11 construction method: iI f E i I' ,0 r
t e. auger. rainy. cable, dated pails de.)
()
FORWATER SUPPLY WF1 LS ONLY
I3a Yield (pens° ) i � / Method nicest:
13h. Disinfection type: !J/('A (71 -lmnua1:
PLJ Y f
t) L..
Farm
Lt. WATEiZONES `E'! i * v
FROM
TO
DESCRIPTION
/0 n
siq { ,J -1 c1/)fa /-
n
13. WEER
CASING Mr males-rsred cells) Oga2N R .. ....
- ..
FB.OI[
TO
DLbhETER
kJ Itrre;ta, 41.11
acariarL-u.
f vj..
"/"./ 11-
c 0 tL
A " -
j'c% (/0
I& 1NNElt
C.1vSt,G OR WRING(
^t awed Impl
F1tO]t
TO IITAMET R
TBIcJ
MATERIAL
ft.
ft_ 1 Fa
iFI
ft
fc
17. SCREE,:
FROM
TO
DIAMETER
S1.OTSPE
THIclOiEtp
,L1TEPrst
a0 EL
3;�fL
.0i0
Sc6, gO
Pvc_ _
rL
ft.
in.
12. GRO)JT
FROM
TO
NLaTE M AL
EliPi_-10Elik2T METHOD S AMOUNT
IL
2O IL
ch1PFJ
(4*0reel
FL
ft
fL
U.
19. SL\'DJGRAVEi RACK
(if •g °lie hit)
Moll
TO
MATERIAL 1 EMPLACEMENT 4ETIIOo
0 IL
.3 i `
�t,r. s� pi: V C
!_ / (Jr/ /
Ft
I_
21L I O17I rNG
LOG (°teach.dditional sbrcts if titassarv)
FROM
TO
DESCRIPTION tailor. isardnuc seitirnck RSC vales sacrcl
-
tr.erV
^c
WA./ jiy,..Ij
-9 3 f -
.ar rt
grV .v Jatit_1 + SAW/ s
— rt
.
C I0 ��+�
4.35*fL
2
rt.
iY
to
IC
yy q
... �S:xe E. " -,� tart C
rt
(t
it_
It
MAR 1 5 20t8
at. REALA ES'
boss -nation H^r,oI±�:t_ s ;fit �Jt)#1
/CW)0
It
2s C
Si_ru/tsc of Cc:Ttiticd Well Contractor
3 =1!2 —/
Date
Br sigrcg this-Iorrr.. I l~.rthr -crtifr that the !mils) war (here) ......cmeted c a<-carlian,:
wait 13.-1 CI4C 02' .0100 or 114 .VC --IC 02C .0200 Well (pram irr. Scansare& and ri.ir
wn'aphis rtvardhnrbeenprovidedtorhowellowrsr.
23- Sttt diasaratn or additional well details:
You may tuc the hack of this page to provide addititztal eccil sitk-tletails our well
construction dread` You may also:midi additional paps if noeeaain-
StitEMITT3tLIi'FS ACTIONS 73 -0� CO
2-la. For All Wells: Submit this form within 30 days of com4rlgt4, of %NAl.,
eooltatmrlitm to the follotcine- CD N =
liivaion of \\add- Rr=ourt cs, InfartaatIem Prot (n ry
1617 Mall Service Center, l2aIriwha,rb
N C 27699-I6)�
ill =I o0
bah. For Injection Wells ONLY ht addition to tans the O J
e fo[i*io the address in
14a above, also submit a copy of the farm within 30 days of ompleti m of well
conshuctioutothe tolloutns_
Division of\;aterResomrcrs, i u krsromtd injection Control Program.
I636 lain Service Center, Rxteih, NC 27699-1636
24 For Water Supph & injection Wells
Also submit our cope of this farm within 30 dalts of completion of
TOM consul dle:a to the county hrahh department of the . ounty where
caasitnet ,1
North Cv..6/u Ow-us/wet of En iraismcnt and N:ws.tl Ro xa a-Diethan..t Water Ramucv
Reviled Luaust'_•.I_
N3lXN/Q3At3 r3e

WELL CONSTRUCTION RECORD (GW-1)
1. Well Contractor Information:
Ronald E Stewart
4ECEIVED/NCDEN R/DWR
Well Contractor Name
Company Name
(NCWC) 3094-A
NC Well Contractor Certification Number
Mid -Atlantic Drilling, Inc
Water Quality Regional
Operations Section
\Nilmington Regional Office
2. Well Construction Permit #:
List all applicable well construction permits (i.e. U!C, 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
�iAquifer Storage and Recovery
Aquifer Test
1 Experimental Technology
Geothermal (Closed Loop)
Geothermal (Heating/Cooling Return)
QMunicipal/Public
Residential Water Supply (single)
Residential Water Supply (shared)
1♦ Recovery
QGroundwater Remediation
Salinity Barrier
EJStormwater Drainage
QSubsidence Control
Tracer
Other (explain under #21 Remarks)
4. Date Well(s) Completed: 2/2/2018 Well 1D# M W-1
5a. Well Location:
Halpern Ocean Isle
Facility/Owner Name Facility 1D# (if applicable)
1560 Market Place Blvd., Ocean Isle Beach, NC 28469
Physical Address, City, and Zip
Brunswick 243EC002
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
33 54' 11.69"
N 78 26' 26.85"
W
6. Is(are) the well(s)DPermanent or 'xfTemporary
7. Is this a repair to an existing well: QYes or XI No
flans is a repair, fill as known well construction information and explain the nature of the
repair under r21 remarks .section or on the hack of this form.
A. For Ceoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction, only 1 GW-I is needed. Indicate TOTAL NUMBER of wells
drilled: 0
MAR 1 2 2018
(ft.)
For multiple wells list all depths ifdiljerent (example- 3@200' and 2@100')
9. Total well depth below land surface: 12.0'
10. Static water level below top of casing: 6.46
!!water level is above casing, use "4-"
11. Borehole diameter: 8 1 /4 (in.)
12. Well construction method: Hollow Stem Auger
(ft.)
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
+3 ft. 2 ft.
For Internal Use Only:
Print Form
14. WATER ZONES
FROM TO
DESCRIPTION
ft.
ft.
ft.
ft.
15. OUTER CASING (for multi -cased wells) OR LINER if a icable
FROM TO DIAMETER
0.0 ft- 0.0
f,
in.
THICKNESS MATERIAL
PVC
16. INNER CASING OR TUBING (geothermal closed -loop)
FROM TO DIAMETER THICKNESS MATERIAL
2
in.
PVC
ft. ft.
17. SCREI:N
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
2.0 ft.
12.0 ft.
2 in.
.010
Sch 40
MATERIAL
PVC
ft.
ft.
18. GROUT
FROM
0.0 ft.
0.5 ft.
ft.
TO
MATERIAL
0.5
1.5
ft,
ft.
ft.
Cement/Bentonie Mix
CementlBentonle Mix
EMPLACEMENT META OD & AMOUNT
Hand pour(Outer Casing)
Hand pour (Inner Casing)
19. SAND/GRAVEL PACK (if applicable)
FROM TO MATERIAL
1.5 ft.
11.0 ft.
#2 Filter Sand
EMPLACEMENT METHOD
Hand pour
ft.
ft.
20. DRILLING LOG (attach additional sheets if necessary)
FROM TO DESCRIPTION (color, hardness, sod/rock type, grain size, etc.)
0.0 ft. 3 ft. Brown fine and medium sand - fill
3 rt. 7
ft. Dark brown fine and medium sand - fill
ft. 12 ft.
ft. ft.
Grayish brown fine and medium sand
fi.
ft.
ft.
ft.
fL
ft.
21. REMARKS
ill AR 0 7 20 18
22. Certification:
Si turre of CIA
Well Co
2/23/2018
Date
By signing this form, I hereby certifr that the well(s) was (were) constructed in accordance
with ISA NCAC 02C .0100 or 1 5A NCAC 02C .0200 Well Construction Standards and that a
copy of this record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTRUCTIONS
24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For 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.
Forst GW- I
North Carolina Department of Environmental Quality - Division of Water Resources Revised 2-22-2016

2. Well Construction Permit ii:
List all applicable well construction permits (i.e. UIC, County; Stale, Variance, etc.)
3. Well Use (check well use):
WELL T CONSTRUCTION RECORD (GW-1)
I
RECEIVED/NCDENR/DWR
1. Well Contractor Information:
Sanford Sweeting
Well Contractor Name
2082-A
NC Well Contractor Certification Number
MAR 1 2 2018
Applied Resource Manag tet taliPFional
peratlbns Section
CornpanyName Wi080021'1
f4
on Regional Office
Water Supply Well:
[Agricultural
EjGeothennal (Heating/Cooling Supply)
In dustrial/Commercial
FlIrrigation
Non -Water Supply Well:
Monitoring
Injection Well:
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
Experimental Technology
x Geothermal (Closed Loop)
Geothermal (Heating/Cooling Retum)
Municipal/Public
DResidential Water Supply (single)
Residential Water Supply (shared)
DRecovery
}Groundwater Remediation
Salinity Barrier
0Stonnwater Drainage
DSubsidence Control
Tracer
Other (explain under #21 Remarks)
4. Date Well(s) Completed: See attached Well ID# N/A
5a. Well Location:
Jerry & Joane Maggio N/A
Facility/Owner Name Facility 1DY (if applicable)
431 South Bald Head Wynd, Bald Head Island, NC
Physical Address, City, and Zip
Brunswick 300302695529
County Parcel Identification No. (PiN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
See Attached N See Attached
W
6. Is(are) the well(s):JPermanent or DTemporary
7. Is this a repair to an existing well: QYes or x©No
If this is a repair, fill out known well construction information and explain the nature of the
repair under t21 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:4
9. Total well depth below land surface: 300 (ft.)
For multiple wells list all depths if different (example- 3@200' and 2@100')
10. Static water level below top of casing: 13 (ft.)
If water level is above casing, use "+ ••
11. Borehole diameter: 6
(in.)
12. Well construction method: Mud Rotary
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) N/A Method of test: N/A
13b. Disinfection type: N/A Amount: N/A
For Internal Use Only:
447244
JPrint Form
14. WATER ZONES
FROM
TO
30 ft.
60 ft-
105 ft.
140 ft.
DESCRIPTION
FROM TO
15. OUTER CASING (for multi -cased wells OR LINER (if a licable)_
DIAMETER THICKNESS MATERIAL
+/- 0 ft. 300 ft 1 i"• SDR11
FROM
16. INNER CASING OR TUBING (geothermal closed -loop)
DIAMETER
ft.
TO
ft.
THICKNESS
HDPE
MATERIAL
ft.
17. SCREEN
ft.
in.
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
ft.
ft.
in.
MATERIAL
re.
ft.
in.
18. GROUT
FROM
0 ft.
TO
300 ft.
MATERIAL
Thermex
EMPLACEMENT METHOD & AMOUNT
Pumped
rt.
ft.
ft.
rt.
19. SAND/GRAVEL PACK (if applicable)
FROM
TO
ft.
ft.
MATERIAL
EMPLACEMENT METHOD
ft.
ft.
20. DRILLING LOG (attach additional sheets if necessary)
TO DESCRIPTION (color, hardness, soi lrock type, grails size, etc.)
Coarse
FROM
0
ft.
60 ft.
60 ft.
105 It•
105 ft.
140 rt.
Fine sandy silt
Limestone
140 ft.
270 ft-
Silty clay some sand
.270 ft.
280 ft.
280 fL 300 ft•
ft
ft.
Fine sand some silt
Sandstone/limestone
21. REMARKS
k
i,IAR 0 2 2018
22. Certification:
2/26/18
ed Well Contractor Date
By signing this form, I hereby certi that the well(s) was (were) constructed in accordance
with 1SA NCAC 02C .0100 or ISA NCAC 02C .0200 lirell 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 fonn within 30 days of completion of well
construction to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Infection Wells: In addition to sending the form to the address in 24a
above, also submit one copy of this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supply & Injection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
completion of well construction to the county health department of the county
where constructed.
Form GW-1
North Carolina Department of Environmental Quality • Division of Water Resources Revised 2-22-2016

ARM Project Number: 431 South Blad Head Wynd Pagel
Bald Head Island
Driller: Sanford Sweeting
Date Drilled: Loop No. Loop Depth GPS
2/12/2018 1 300
2/13/2018 2 300
2/14/2018 3 300
2/15/2018 4 300
3351 16.2598
33 51 15.9561
3351 15.81
3351 15.9553
Coordinates
77 59 25.971
77 59 26.5916
77 59 26.28
77 29 26.5555

L9/n )- - $? v 2
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: / 20
1. WELL CONTRACTOR:
RESIDENTIAL WELL c
1 RECORD
North Carolina Department of Environment and Natural Iktrati‘DIDIS.fttionf Water Quality
I min6*ton Regional Office
WELL CONTRACTOR CERTIFICATION # •
Dou las Hewett
Well Contractor (Individual) Name
w I 11 Drillin
Well Contractor Company Name
STREET ADDRESS 2172 Ocean Hwy West
City or Town ` s tate Zip Code
( 910 7.5:L-6.5�R
Area code- Phone number •
2. WELL INFORMATION:
SITE WELL ID #(ifappticabte)
STATE WELL PERMIT#(ifapplicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply ❑
DATE DRILLED/ H/ (
TIME COMPLETED l'w 0 AM ❑ PMt?r."
3. WELL LOCATION:
% CITY: D /den .13iVGA COUNTY V
�GK
/33I 3. ,, Ibr,o/ rd a89 z
(Street Name, Numbers. o,nmunit , Subdivision, -" Y vision, Lot No.. Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
❑ Slope ❑Valley eclat ❑ Ridge ❑ Other
(check appropriate box)
LATITUDE 3
LONGITUDE
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: ❑GPS ❑Topographic map
(location of well must be shown on a USGS topo map and
attached to this form if not using GPS)
4. WELL OWNER
OWNER'S NAME %/tCfth/
STREET ADDRESS )33) .5•Frnb..r)I r
St,PPII/ N� ?ylc
City or Town State Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NOQ'
c. WATER LEVEL Below Top of Casing: _ 12
FT.
(Use "+" if Above Top of Casing)
d. TOP OF CASING IS / _ FT. Above Land Surface`
'Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): METHOD OF TEST .tj']--
RECEIVED/NCDENR/DWR
MAR 052018
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt.,
1617 Mail Service Center— Raleigh, NC
27699-161
7 Phone No. [phone] ext 568.
f. DISINFECTION: Type
g. WATER ZONES (depth):
From L?DTo %_
From To
From To
To
6. CASING:
Thickness/
From DTpt " Dife e_r Weight M feria
From T- -- From
447116
8. SCREEN: Depth
From To
From To
From To
9. SAND/GRAVEL PACK:
Depth
From
From
From
Amount L/
Method
\Iv°s
Diameter Slot Size Material
FL in. in.
Ft. in, in.
Ft. in. in.
Size Material
From To Ft.
From To
Ft.
From To Ft.
10. DRILLING LOG
From To Formation Description
20 Skih
O, -"D
�1M
11. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
ISA NCAC 2C, WE CONSTR CTION STANDARDS, D THAT A COPY OF THIS
RECORD HAS B PROVII' ' TO THE WELL OWN�k.
ATU OF CERTIFIED WELL CONTRACTOR DATE
Douglas Hewett
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Form GW-1a
Rev. 7/05

WELL CONSTRUCTION RECORD
This foam can be used for sushi or multiple wdh
For Internal Use ONLY:
L Well Contractor Information- 2 e —
Ave l()
Well Contractor Name
3 /O ,g
ti.....1
NC Well - ailer e ` We/ C,.,
Contputy Natne
2. Wdl Construction Permit 4: W V ° too 'l N. Z
Liss all applicable WMl permits (ie. County, Stan. Variance. Infection. etc_)
3. Well Use (check well use):
Water Supply Well:
d_\gricultural
❑Geothermal (Hating:Cooling Supply)
D Inddusustriab•Commcrcial.
iaatitnt
DMuniaipalPubiic
❑Residential Water Supply (single)
❑Residential Watt Supply (;hared)
Note -Water Supply Well:
❑Alonitoring
❑Res:ov err
Injection Well:
DAquifer Recharge
D_\quifcr Storage and Recovery
❑Aquifer Tilt
❑Experimental Technology
OGcothamal (Closed Loop)
❑eieothamal (Hating: Cooling Return)
❑Groundwater Rem ediatinn
❑Salinity Barrier
❑Stuninwscr (?silage
OS'rbsidatce Control
❑Trace
OOther (explain under r21 Remark)
4. Date Well(s) Completed: -/ 6- lC Wolf IDd
aa.�sd! Location:
'ol 1311/43e1:4lij
Facility/Ownerhums Facility IT.t itfapplicable)
m'f ier� sue. o13-tc Is/,'d
Physical Added, City. and Zip DD Z
r1)Njwtc(rc
Pared fiLatificattvt No. (PIN)
Sb. Latitude and Lotitude in degrees/minuteslsecontis or decimal degrees:
..f wc11 field. one tatilong is sutiiciuu)
,3 c7aS� J5,SY9V tN
7e93orOa2yt, \\
6. Is (are) the wcll(s): ILIP£r sent or OTentpot-aly
7. Is this a repair to an existing well: ❑yes ur /4io
If this is a repair, fill out known well construction information and explain the nature of the
repair under 4.21 remarks section or on the back of Miriam,.
8. Number of wells constructed:
For multiple injection or non -water supply wells OM17.r with the same cxarstn :4am eau con
submit one form_
9_ Total well depth below land surface: c,a° y
For multiple wells list all depths ii difjrrenr (example- 3t5200' and 21 .100' )
10. Static water Ievcl below top of cuing:
IJ.rater level is above casing, as< "+" / / U
11. Borehole diameter: 6177 -0 /0' (in.�y 7b 2 7
12.1Vcll construction method:
it c auacr, rotary, cable, sinect pti;lt etc )
(ft-)
(ft-)
FOR WATER SUPPLY WELLS ONLY:
133_ Yield (fpm) Method of test:
I3h. Disinfection type: 6/04C 41 Amount: 02.
Form GR'-I
108
14_ WATER ZONES
FROM
TO
DESCRIPTION
4. ft.�/
Z l fL
3 /l t 3' J /9,✓..1
fL
ft.
IS. OUTER
CASING )for
multi -cased sills) OR LINER rda pplicsble)
FROM
TO
DG4,11t/i MI
THICKNESS
IL�a+TERIAL
+ f-
1 (o fL
� ' `t in
SCh Vo
J (9Al 1/. treed
1& INNER
C 1SIsNG OR TIMING
(geothermal dosed -loop)
FROM
TO
DIAMETER
THICt;TiFSS
MATERIAL
R_
ft_
in_
ft_
ft.
in.
17.SCREEN
FROM
TO
DIAMETER
SIZE
THICKN,'Fss
1LI(TERIIAL .
/G FL
2 ° fi
ia.
/ As
/SLOT
U gllsd
Jch Vo
t
J i .! .
ft-
fL
M.
t& GROUT
FROM
TO
:MATERIAL
EMPL CEME T METHOD S totr1jtT
0 rL
( 0 ft_
Ige/OT c.h
.
I PS r POL) re d
ft
ft.
Z 6405
ft-
ft.
19_ SAND/GRAVED..
PACK
of applicable)
FROM
TO
MATERIAL
E1wPLtcFAIE\-T METHOD
f6
ft.
ft.
ft.
20. DRII.LLNG LOG (attach additional slaters if necetsarv)
FROM
TO
DESCRIPTION icalor. 6Ardoam
; snflir ck type, in.. e,
o ft,
a y IL
etcI
sAN J
rL
fL
ft.
ft
IL
re,.
Tj-�, `
y�}fi��'-
ft
rL
FEB 2 z' ri I ()
IL
ft.
21.REMARKS •:M4`,XF,v2. K)re, I-!. ...
22_ Ccrti
lion:
Si1nrtln-e of -Certified \\`ill Contractor
2 -e1-le
By signing this form, 1 hereby xrtifr that the 11all01 eras (.rerr) constructed or accordance
with 15.1 :\t 4C 02C .0100 or 15.-1 :a'C.4C 02C .0?OO If ct/Constro- an Srandar-ds and that a
ropy of this record los 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 rtccessaiy.
SUBM1Tr •LINSTUCTIONS
24a. Fur All Welts: Submit this form within 30 days of completion of \yell
construction to the folioavina-
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24h_ For Injection Wells ONLY: he, addition to sending the form to the adth-cas in
24a above, also submit a copy of this form within 30 days of completMn of well
calsbuctiou to the foilowin•_:
Division of Water Resources, Underground Injection Control Program,
am,
1636 ;NIA Semite Center, Raleigh, NC 27699-1636
24c. For Water Supply & Infection Wells:
Also submit one copy of this form vaithnt 30 days of complctiou of
v.tll construction to the county health dep:utmcnt of tltn county where
constructed
Ntvth Carolina Department ofEr.-r , vuent and partial Review-Dtcuioo of \Vnier Raotuem
RECEIVED/NCDENR/DWR
Rcriscd august 2u13
FEB 2 6 2018
Water Quality Regional
Operations Section

1. Well Contractor Information:
l�.
11111.1
WELL CONSTRUCTION xECOI d CDENR/DWR For Internal Use Only:
I
FEB 2 6 2018
2082-A
Water Quality Regional
Not found online
10. Static water level below top of casing:
If water level is above casing, use "-,"
Sanford Sweeting
Well Contractor Name
NC Well Contractor Certification Number Operations Section
Applied Resource Manag r i Rep! Office
Company Name
2. Well Construction Permit #:
List al/ applicable well construction permits (i.e. UTC, 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 Retum)
DMunicipal/Public
Residential Water Supply (single)
Residential Water Supply (shared)
i Recovery
Groundwater Remediation
Salinity Barrier
JStormwater Drainage
Subsidence Control
Tracer
Other (explain under #21 Remarks)
4. Date Well(s) Completed: Various Well ID# N/A
5a. Well Location:
Village of Bald Head Island N/A
Facility/Owner Name Facility ID# (if applicable)
Edward Teach Wyd, Bald Head Island, NC
Physical Address, City, and Zip
Brunswick
300404719020
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
See attached N See attached
6. Is(are) the well(s)Jx Permanent or DiTemporary
7. Is this a repair to an existing well: tjYes or XONo
If this is a repair, fill ont 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: 24
9. Total well depth below land surface: 300
For multiple wells list all depths if different (example- 3@200' and 2@100)
N/A
11. Borehole diameter: 6 (in.)
12. Well construction method: Mud Rotary
(ft.)
(ft.)
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) N/A Method of test: N/A
13b. Disinfection type: N/A Amount: N/A
47105
14. WATER ZONES
FROM TO
ft.
DESCRLPTION
ft.
ft.
ft.
15. OUTER CASING (for multi -cased wells) OR LINER (if a 1' bl )
FROM TO DIAMETER THICKNESS MATERIAL
0 ft- 300
ft. 1 in.
HDPE
16. INNER CASING OR TUBING (geothermal closed -loop)
FROM DIAMETER THICKNESS MATERIAL
TO
ft.
ft.
in.
ft.
17. SCREEN
ft.
in.
FROM
ft.
TO
rt.
ft.
18. GROUT
ft.
DIAMETER SLOT SIZE THICKNESS
I
n.
in.
MATERIAL
FROM
0
ft.
TO
300 ft-
MATERIAL
Thermex
EMPLACEMENT METHOD & AMOUNT
Pumped
ft.
ft.
ft.
ft.
19. SAND/GRAVEL PACK (if applicable)
FROM
TO
ft.
ft.
MATERIAL
EMPLACEMENT METHOD
ft.
ft.
20. DRILLING LOG (attach additional sheets if necessary)
FROM TO DESCRIPTION (color, hardness, sotWrock type, grain size,etc.)
Coarse grained sands
0
ft.
30 ft.
120 ft,
30 ft.
120 ft.
145 ft.
Sandy silt
Limestone
145 ft.
285 ft.
Dark gray silty clay
285 ft-
310 ft•
Hard limestone and sandstone
ft.
ft.
ft.
ft.
21. REMARKS
RECEIVED
ILrr222018
22. Certification:
lotomation Proc-es& r g Unit
Id/is
Signan kofCertified Well Contractor Date
By signing this form, 1 hereby certify that the well(s) was (were) constructed in accordance
with 1 SA NCAC 02C .0100 or 15A NCAC 02C .0200 Well Construction Standards and that a
copy of this record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTRUCTIONS
24a. For MI Wells: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Infection Wells: In addition to sending the form to the address in 24a
above, also submit one copy of this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supply & Injection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
completion of well construction to the county health department of the county
where constructed.
Form GW-1
North Carolina Department of Environmental Quality - Division of Water Resources Revised 2-22-2016

WELL CONSTRUCTION RECORD (GW-1)
RECEIVED/NCDENR/DWR
1. Well Contractor Information:
1 111111 V1111
For Internal Use Only:
44
Sanford Sweeting
Well Contractor Name
FEB 2 6 2018
2082-A
NC Well Contractor Certification Number Water Quality Regional
0 erati ns n
Applied Resource Manage lot °Office
Company Name
2. Well Construction Permit #:
List all applicable well construction permits (i.e. U1C, County, State, Variance, etc.)
3. Well Use (check well use):
N/A
Water Supply Well:
Agricultural fMunicipaltPublic
Geothermal (Heating/Cooling Supply) DResidential Water Supply (single)
IndustriaUCommercial DResidential Water Supply (shared)
X Irrigation
Non -Water Supply Well:
Monitoring
Recovery
Injection Well:
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
Experimental Technology
Geothermal (Closed Loop)
}Geothermal (Heating/Cooling Retum)
DGroundwater Remediation
Salinity Barrier
fStormwater Drainage
Subsidence Control
Tracer
Other (explain under #21 Remarks)
4. Date Well(s) Completed: 1/7/18 Well ID# N/A
5a. Well Location:
Village of Bald Head Island N/A
Facility/Owner Name Facility ID# (if applicable)
Edward Teach Wyd, Bald Head Island, NC
Physical Address, City, and Zip
Brunswick
County
2642J00401
Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
33 51 23.55 N 77 58 55.89
w
6. Is(are) the well(s)x Permanent or DTemporary
7. Is this a repair to an existing well: }Yes or �X No
If this is a repair, fill out known well construction information and explain the nature of the
repair tinder #21 remarks section or on the back of this forin.
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: 1
9. Total well depth below land surface: 310
For multiple wells list all depths if different (example- 3@200' and 2@100)
10. Static water level below top of casing: 13
If water level is above casing, use "1-
11. Borehole diameter: 6 (in.)
12. Well construction method: Mud Rotary
(ft.)
(ft.)
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) N/A Method of test: N/A
13b. Disinfection type: N/A Amount: N/A
t4. WATER ZONES '
FROM
TO
DESCRIPTION
H.
ft.
ft.
rt.
15. OUTER
CASING (for multi -cased wells) OR LINER (if a icable)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
+2.5 ft-
290 ft.
2 in•
SCH40
PVC
16. INNER
CASING OR TUBING (geothermal closed -loop) -'
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft.
ft
in.
ft.
ft.
in.
17.SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
290 ft
310 ft
2 in'
.020
SCH40
PVC
ft.
ft.
in.
18. GROUT
FROM
0 ft.
TO
275 f •
MATERIAL
Bentonite
EMPLACEMENT METHOD & AMOUNT
_
Poured
275 ft
285 ft
Neat Cement
Tremmie
ft.
ft.
19. SAND/GRAVEL
PACK (if applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
285 ft
310 ft.
#2
Poured
ft.
ft.
20. DRILLING LOG (attach additional sheets if necessary)
FROM
TO
DESCRIPTION (color, hardness, soi crock type, grain size, etc.)
0 ft,
60 ft,
Coarse sands
60 ft
75 ft.
Fine sands
75 ft.
105 ft.
Fine sandy silt
105 ft•
135 ft,
Limestone
135 ft•
265 ft
Silty clay some sand
265 ft.
275- ft•
Fine sandy silt
275 ft•
310 ft.
Sandstone/limestone
21.REMARKS RECEIVED
FEB 2 2 201B
22. Certitication:
i'rt•C sssrtg Und
ignatuf of Certified Well Contractor Date
By signing this form, 1 hereby cert fy that the well(s) was (were) constructed in accordance
with 1 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 well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTRUCTIONS
24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Iniection Wells: In addition to sending the form to the address in 24a
above, also submit one copy of this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
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

ARM Project Number: Safety Building Bald Head Island
Driller: Sanford Sweeting
Loop No. Loop Depth GPS Coordinates
1-1 300 33 51 24.4336 77 58 54.3073
1-2 300 33 51 25.8718 77 58 56.1968
1-3 300 33 51 24.3999 77 58 54.8798
1-4 300 33 51 25.2475 77 58 55.8091
1-5 300 33 51 26.1983 77 58 56.9215
1-6 300 33 51 20.2645 77 58 56.7844
1-7 300 33 51 26.0785 77 58 55.7829
1-8 300 33 51 26.2332 77 58 56.8438
2-1 300 33 51 25.1388 77 58 55.1552
2-2 300 33 51 26.104 77 58 56.3502
2-3 300 33 51 25.0356 77 58 55.2968
2-4 300 33 51 26.3124 77 58 56.7841
2-5 300 33 51 26.3718 77 58 56.9366
2-6 300 33 51 26.3837 77 58 57.0122
2-7 300 33 51 26.2379 77 58 57.0032
2-8 300 33 51 25.9999 77 58 56.3363
3-1 300 33 51 26.0015 77 58 53.7115
3-2 300 33 51 25.7075 77 58 53.8805
3-3 300 33 51 25.6414 77 58 56.5075
3-4 300 33 51 26.2545 77 58 53.834
3-5 300 33 51 26.0741 77 58 54.6759
3-6 300 33 51 26.0662 77 58 54.7508
3-7 300 33 51 26.1333 77 58 54.7387
3-8 300 33 51 26,1662 77 58 54.8147
Pagel
RECEIVED/NCDENR/DWR
FEB 2 6 2018
Water Quality Regional
Operations Section
Wilmington Regional Office

WELL CONSTRUCTION RECORD fGW r
1. Well Contractor information:
Well Cofitraeto • aruo
t-) 9 `1'
NC Well Contractor Certification Number
it
Company Nome
2, Well Construction Permit It:
all appfibla Wall comeovesion mem/re (i•e. WC Cris„
rY, .Stare, pwrwcx- trteJ
3. Well Use (check well use):
ECEIVE
FEB 192 3
Y.
Water Supply Well:
Agricultural �Municipai(Publk
Geothcimal (Healing/Coofing ,Supply) QRcsidential Water Supply (single)
lnduitrial/Commercial 0Residential Water Supply(shared)
Irrl.
Non.Wa ter Supply Well:
•
iR
Monitoring
IoJeedon Well:
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
Experimental Technology
Geothermal (Closed Loop)
Geothermal eetin Cooiin: Return
4. Date Wd!(s) Completed:
Sa. Well Location:
Eacilttyf&wi rNamc
Recovery
DGuAundweter Romediation
QSaiinity Barrier
E3Stormwatcr Drainage
JSubsideoce Control
QTraoer
Other e . lain under /(21 Remarks
Well Intl
Facility Met (ifappficabl e)
° 3 %A) o l< s /'1A 4 c,
Physical Address, City, end Zip
County
Parcel fdentifiiation No, (P/N)
(If(VWell t Latitude
tulle snaad knigiieudelong is c a minutes/seconds or decimal degrem
S� iglrN j% lO ai)
6. 1s(are) the wells) Per ,n,tcat or Ci'femporary
7.19 this a repair to as existing well: OYes
ythisiyarrpair/pllauiknown weft ennarver or ONo
repaio Winer a'Ti Pom4'nkasudian or on pre hock lform.
fLrdQY/lia/n Me noire of1hr
M loran..
8. For Geo rdieJDYr or Cloned-1 crop Geothermal Wells having rho serge
construction, only 1 GW-1 iS heeded. Indicate TgrrAL NUMBER of wells
drillcd:� - _Y
9. Total well depth below land surface. a")
For er yk(pie wefts ld r all depths (di front (cram a 3 (ft,)
P+ (�z44'arttf Ida N141
1,0, Stalk water level below top of casual:
if Water has/ is above easing nee ,rd. •' (ft)
11. Borehole diameter: (In.)
12. Well construction method:
auger, Mazy. cubic, direct pith )
ore.
FOR WATER SUPPLY WlSLII 9 ONLY:
13a. Yield (gprn) Method of test:
1.3b, Disiafectioo type: Amount:
For lntcrtia( Usc Un(y:
446948
1tr'-.ice � � ...
I SCREEN
ti 7 al ft.
WNW
kirmizaTmcion
„
mAttettAt
.0M TO
!'S
MtY
om
MUM
mumummer
NMI
ft.
dER
J.,
22. Certification:
sruse of Certu3 Conine/or
Oars
SY agniag (I1R fa r hereby berr0 tnat the well(s) was NOV ecinslraMd fn Uabrda
with ISA "'TUC C.4100 or iSrt NC:tC 02t7. o2 We!( CnruUacrtan S:mtdard/ and du
etspy ophls nItterd wit own
23. Site diagram or Additional well details:
You may use the back of this psi .lo provide additional well site details Or w
aonstrucaloll details. You may also atop additional page ifnocessary.
.ELQAMALZSIEVaam
241' &Adagi= Submit this form within 10 days of completion of w
construction to the following:
h/A7'CA/Ar.
NAT
At
Anaxotr
1041°LACEMtiNT1 WI1 OD
+o reds �a+eaeaa •eOhad, rtirathe
Wean of Water Rtaoereca, ratormattoa i'race:Nang Anil,
1617 MA Service Center, Raleigh, NC 27699 f 6(7
24b. on initszt7_ttu: In addition to sendingilk to Above, else submit one Copy of this form mt of
m letion an w
construction to the following: within completion of w
Divlsfon el Water Resources, Untlergrottad fojectiota Control Program,
1636 Mall Service Center, Rakigt NC 27699-1636
2Qc. �Or Weber Sennty rnueetdOd __.�"`,
24 naatrss(es) above, also sob ' In addition to uncling ate form
Completion a well ve. am t ` Copy of this form within 30 days
comp enoafr,Mfeil construction to the county health department of tltc cow

NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2540-A
1. WELL CONTRACTOR:
Jeffre A Stewart
Well Contractor (Individual) Name
Mid -Atlantic Drillin Inc. 2 9 2)
Well Contractor Company Nanie
PO Box 315
Street Address
Carolina Beach
City or Town
(910 ) 458-5020
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT# N/A
OTHER ASSOCIATED PERMIT#(inapplicable) N/A
SITE WELL ID #(inapplicable) MV►!-1
3. WELL USE (Check One Box) Monitoring / Municipal/public 0
Industrial/Commercial 0 Agricultural 0 Recovery 0 Injection 0
Irrigation Other ❑ (list use)
DATE DRILLED 12/15/2017
4. WELL LOCATION:
218 Village Road
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: Leland couNTY Brunswick
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope ❑Valley QfFlat ❑Ridge ❑Other
LATITUDE 34 ° 14 5.7900 DMS OR 3X.XXXXXXXXX DD
LONGITUDE 78 ° 0 . 2.2600 " DMS OR 7X.XX�XX DD
Latitude/longitude source: ❑GPS
US
(location of well must be shown on a USGS topohmap andattached to
this form if not using GPS)
5. FACILITY (Name of the business where the well is located.)
HarrlndtQi: Village N/p
Faculty Name Faclllty ID# (if applicable)
21 R 1/ill iri D,.,. -i
Street Address
City
oanTown C 2Rd54
State Zip Code
Contact Name
Fin ( rinnr r Ra-.-r ali
itP 1
Mailing Address
CIt�Yo1rRTIIow�n Nt^ �Rd�d
State Zip Code
( 910,6 .13.2.3524
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH:_
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO q/
c. WATER LEVEL Below Top of Casing:
(Use "+" if Above Top of Casing) FT,
NC
State
rl
�r��ttir
28428
Zip Code
d. TOP OF CASING IS +
*Top of casing termina
a variance in
e. \YIELD (gi61tl�°
f. DISINFECTION: Type
`: g•~WATER ZONES Vd ):
Top Bottom
Top Bott
Top Bottom_ ,
Wilm-
7. CASING: Depth
Top + 1 Bottom_
Top Bottom
Top Bottom
8. GROUT: Depth
Top 0.5
Top 0
Top
Bottom 2
Bottom 0.5
Bottom
9. SCREEN: Depth
Top 3 Bottom 12
Top Bottom
Top Bottom
10. SAND/GRAVEL PACK:
Depth
Top 2 Bottom 12
Top Bottom
Top Bottom
11. DRILLING LOG
Top Bottom
0
/
12. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A C 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
REtDO H� EEN PRIDE �e a WELL OWNS^
T. Above Land Surface*
ow land surface may require
h 15A NCAC 2C .0118.
METHOD OF TEST
0 Amount
--may Rtt n• Bottom__
ST& 1 Ee Bottom_
ReM3op—__. Bottom
Thickness/
Diameter Weight Material
Ft. 2" Sch
Ft.
Ft.
Material
Ft. be n tonite
Ft. comae
Ft.
Diameter
Ft.2 in.
Ft. in.
Ft. in.
Slot Size
0.01 in.
in.
in.
Method
our
our
Material
VC
Size Material
toroedo sand
Ft.—__ natural pack
Ft.
Formation Description
Orange fine sand
mark gray clayey fine _and
�]ledlum sand `
r
CTOR D
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality - Information Processing,
1617 Mail Service Center, Raleigh, NC 27699-161, Phone : [phone]
1
Form GW-lb
Rev. 2/09

12. Well construction method:
it.e. auger, rotary. cable. direct push. ere.l
FOR WATER SU'PPI.i 11 ELLS ONLY:
13a. Yield (gpnl) 80 Method of test: Airlift
9. Total well depth below land surface: OQ
Pry' nrtdnp er,d?, h,r a)i <ic!•ri), rr,!n;; n'ru rt'.cuarp/e - ; n 2(ar,
n;r1 _'rat IItG'}
1(1, Static water lend below top °teasing: 7
!! cent. r• lrr�l rs above c,ren:ff. "
11. Borehole diameter: See Remark
(in.)
Mud Rotary
13b. Disinfection type: HTH ►3% 10
mount: g
34 4 5.4 \ 77 56 86.5
6. !stare) the well(s)Ox Permanent or l"i'ernpornri
7. Is this a repair to an existing well: rk`es or ONo
repair
ill r r
/k a,...>J du+Joan_
S. For Geoprohe!DPT or Closed -hoop Geothermal ells having the same
construction. only I G\1'-1 is needed. Indicate TOTAl. NUMBER or wells
drilled: 1
Wells
alum)
WELL CONSTRUCTION RECORD GW_1
I. 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 4:
2015072016
! r.,l nu appliv rrn!r. r,.. a <Y>rrvr,,, n» 1V.,r•�urn ii..' t 1(1 l irnnh : ... l ;anent,
3. \yell 1;se (check well use):
Water Supply \fell:
.-lgricuhural
Geothermal t t teating/Cooling Supply )
Industrial/Commercial
Irrigation
Non -Water Supply Well:
Monitoring
%Veil:
/\gitifcr Recharge
'Aquifer Storage and Recovery
Aquifer Test
Experimental •fcchnofog-
GeGeothermal (Closed 1 oop)
Geothermal (1leatins':'Cooling Return)
1_.(Municrpal!Puhlic
Residential Water Supply (single)
JResicicntial Water Supply (shared)
DGroundwater Rcmeiiatiun
❑Safinits Barrierf Stormwater Drainage
1 Suhsidence Control
lJ Tracer
Other (explain under k21 Remarks)
4. Date Well(s) Completed: 11 /14/17 well Ho N/A
Sa. Well Location:
Murray Construction N/A
Facilih (Acner Name
Facility (if applicable)
5092 Plantation Rd SE, Winnabow 28479
Physical Address, City. and 'Lip
Brunswick 1440000105
Parcel Identification N. (PIN)
5h, Latitude and longitude indegrees/minutes/seconds or Jecimai degrees:
(it %setll field. one (along is sufficient)
run: J, r• YrrN)
!! this
l / r, known. , 1l..nr.n'rarren ndurrrr.aadt andc.rnlant them.rrrtre or. ilk
?/rrrvr1I :..r<.rr•,ur rhr
1t
14. WATER J-O�—'rI —
FROM
DESCRIPTION
15.O1'IFR ('.‘SING for mniti-caiet=OR t.(NER if a licab(c)
IREOMME
.... fl rn. SCH40
16. INNER CASING OR TURING (cothtrmat closed -too
iP lttttntsrr ">_ TntrkAuss
17. SCREEN
FRo31 'jcl
Bentonite
t9. S,►Ni)/GRAVE:(. PACK ifa limbic
FROM so
75 ft. 100 rt Coarse
Poured
£\IPL:\(•I:NE\'f METHOD
Poured
20. DRILLING LOG attach additional sheets if -necessary
FROM •1'O DESCRIPTION (rotor. hardness, soiltrock h-.. rain sire, err.)
0 rt. 2g e. Sandy clay
22. C - •neation:
Soft limestone
Cla /limestone mix
Limestone with sands
Sandstone
OW) • r,
01/16/2018
Signs tire of Certified %vel1 Contractor
I )die
ht a nnr� am. !bunt. d h.'r h1• crrgh' that rh,r irr!!(sJ na'u'crer , ()Mink -fed m accordance
wlrh 13.1 \'(:f( 02( MOO or 15,1.\('AC pA'.1)21fr Jti'/l('onsina'a!of .):lanr/ar,!., and dial a
cY)/,t of ra(n+dlnrc/rC'n,rr;t,cledfothe Tr4'!l.nrndr.
23. Site diagram or additionftfirtllr n �l
You may use the back of this pagelo MitreDi 1 Rif !% i site details or veil
construction details. You may also attach additional pages if necessary.
S1"131I1JT L INSTRUCTIONS JAN 2 9 2018
lft.) 24a. For ,►ells: Submit this Inrm within 30 days of completion of well
(fr.) Division of Water VotQp 9
1617 Mail Sers1'trt<IN1f,10 Ogr(9'1�3' essing t nit,
246. rDr u►ieetion 11'llc: In addition to sending the roan to the address in 24a
above. also submit one cope of this form within 30 da)s of completion of well
construction to the tbiI 111g:
Division of Water Resources, Underground Injection Control Program,
1636 flail Service Center, Raleigh, NC 27699-1636
24c. Far Water Su ly n In'ection Wells: In addition to sending the [Orin to
the addresses) above. also submit one cope of this tom, within 30 days o1'
completion of Irell construction to the county health department of the count)
where constructed.
Form GW-I
North Carolina Department of Environmental Quality • Division of \Voter Resources
construction to the fllllolL Mg:
Water Quality Regional
ReriscII 2.22-2o t a
r nil r 1,1111