WI0700080_GEO THERMAL_19981207

GROUNDWATER SECTION
December 7, 1998
MEMORANDUM
To: Willie Hardison
Groundwater Section
Washington Regional Office
From: Mark Pritzl {'1JJ. [e-mail]. us
Hydrogeological Technician II
UIC Group
Groundwater Section
Raleigh Central Office
Re: Receipt of Notification for a Closed-Loop Geothermal Water-Only Injection Well
System.
Notification to construct and operate an injection well system for a geothermal heat pump system
has been filed by Dennis and Mary Ross of Greenville, North Carolina and a copy of the
Notification is enclosed for your files. This injection well system is deemed permitted by rule
(NCAC T15A: 2C.211(u)2) and no regulatory action is necessary. If you have any questions,
please contact me at [phone] or Amy Axon at [phone] .
cc: UIC Files
WAROFiles
Enclosures
NORTH CAROLINA DEPARTMENT OF
x
ENVIRONMENT AND NATURAL RESOURCES
NCDENR
JAMES B. 14LFNT JR.
GOVERNOR
WAYFii _idC>]LVIT'r
SECRETARY
9r
' A. PRESTON KOVA ARIY,: i ,
JR., PE' y.�^
DIRECTOR- :+
December 7, 1998
Dennis & Mary Keehln Ross
3904 Cantata Drive
Greenville, NC 27858
Dear Mr. & Mrs. Ross:
DIVISION OF WATER QUALITY
In accordance with the notification submitted on your behalf by Climate Control
Heating and Cooling Co., Inc. dated September 1, 1998; the Groundwater Section
acknowledges your intention to construct closed -low geothermal water -only injection
wells for the operation of a ground -source heat pump. The system as described in
your notification will not require an injection well permit and is deemed permitted by
rule {North Carolina Administrative Code Title 15A: 2C.021 I (u)(2). The
Underground Injection Control Group has added your site to our inventory. If you
modify your system, please contact the Groundwater Section to verify compliance.
Thank you for submitting this notification.
If you have any questions regarding geothermal heat pump wells please feel free to
contact me at [phone] or Amy Axon at [phone].
Sincerely,
Mark Priul
Hydrogeological Technician II
Underground Injection Control Program
cc: UIC Piles
WARD Files
GROUNDWATER SECTION
P.O Box 29578, RALEIGH. NC 27626-0578 - 2728 CAPITAL BLVD., RALEimm, NC, 27604
PHONE [phone]x1 FAX 919-7 T S-OS88
AN EQUAL OPPORTUNITY I AFFIRMATIVE ACTION EMPLOYER • 50% REGYFLEDI10% POST -CONSUMER PAPER

Memorandum:
To:
Through:
DIVISION OF WATER QUALITY
GROUNDWATER SECTION
November 23, 1998
Mark Pritzl, UIC Group
~
Willie Hardison, Groundwater Supervisor
Washington Regional Office
\0 co
0 1 rn <
C'"') .
I
Scott ~ydrogeological Technician I
Washington Regional Office
:-0 •1
From: -,.:,
.--)~'"'.
Subject: New injection well permit
Closed Loop Geothermal Heat System
Dennis and Mary Ross
3904 Cantata Drive
Greenville, North Carolina
Pitt County
r" ( )
' c'
c::> -1
0 ( ' .
I made a site visit and system inspection of the heat pump system on November 20, 1998. The
inspection revealed that all thirteen (13) well heads are four (4) feet below land surface and the
geothermal piping extends to 200 feet below land surface. The well heads are covered and back filled
to grade. There was also considerable amount of construction material lying on the ground in the
vicinity of the well points. Because of these two factors, a determination as to grouting could not
be made at the time. The system design is similar to MCAS Cherry Point; Buildings 496 and 497
(WI0700020) in Craven County. At this time I am not aware if a variance to finish these wells
below land surface was granted before the wells were installed. Please contact me regarding this
matter at [phone] extension 225.
,
1 !
North Caroh.,t Department of Environment and NA.dral Resources
Division of Water Quality - Groundwater Section
INJECTION FACILITY INSPECTION REPORT - FORM B
INJECTION WELL PERMIT NO. WI DATEy►�. L lr', 'ov'o
NAME OF OWNERS i ;'�s _
ADDRESS OF OWNER-- CAA 4 k,,a ;�Fi 4,4,r
"W¢ e—vl�S
(Streetl road orllot and subdivision, county, town)
LOCATION OF INJECTION WELL (and source well(s), if applicable) Avs
{Street/ road or lot and subdivision, county, lawn, if dierent than owner's address, plus description of location on site)
Potential pollution sourceDistance from well -x
Potential pollution source Distance from well
Potential pollution source
Distance from well
Minimum distance of well from property boundaryS F =�
Quality of drainage at site Flooding potential of site
(goodadeguate, poor) (high,moderate, low)
DRAW SKETCH OF SITE (Show properly boundaries, buildings, wells, polenlial pollution sources, roads, approximate scale, and
north arrow.)
DESCRIBE INJECTION SYSTEM (vertical closed loop, encased borehole or cased water well; separate source well and
injection well; combination source and injection we1l,- or other description as applicable)
- sic E1
s

INJECTION FACILI"Y INSPECTION REPO' T -FORM S (CONTINuED)
WELL CONSTRUCTION
Date constructed Y
Drilling contractor: Name►,f
Address ' __�� I
k A s,..
Registration numb
Total depthof well,;-�fJr.7 Total depth of source well
(f applicable)
Inspection paint Measurement Meets minimum standards Comments
Yes No
Casing
Depth.
Diameter
Height (A.L.S.)
Grout
Depth
Screens
Depth(s)
Length(s)
I.D. Plate
Static water level
Well yield
Enclosure
Enclosure floor
(concrete)
Sampling port
(labeled)
Water tight pipe entry
Well enclosure entry
Vent
Functioning of heat pump system (Determine from the owner ifheatpumpfimcdons properly.)
INSPECTOR
kliflovelmizi
Office,?_-£
Address
WITNESS Address March 1998

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... ,\· ·. • : . ~:: .. .:' . .1 ':' · ... :: _:.
,/(]~MES B. HUNN~.
:''· '.GQYE~N ~R
J
. ~-. ;
WAYNE Ml;:DEVITT
SECRETARY
A. PRESTON HOWARD,
JR ., P.E . .
.;t ·· . _;,-. .
'·• DIRECTOR _ :
Dennis & Mary Keehln Ross
3904 Cantata Drive
Greenville, NC 27858
Dear Mr. & Mrs. Ross:
,
NORTH CAROLINA DEPARTMENT OF
ENVIRONMENT AND NATURAL RESOURCES
DIVISION OF WATER QUALITY
November 5, 1998
Your application for a permit to use a well for the injection of geothermal heat
pump effluent has been received and is under review. A member of the Groundwater
Section's Washington Regional Office staff will be contacting you to arrange an
inspection of the injection well and collect water samples as part of the review.
If you have any questions regarding the permit or injection well rules please
contact me at [phone] or Amy Axon at [phone] .
cc: illCFiles
WAROFiles
Sincerely,
Mark Pritzl
Hydrogeological Technician II
Underground Injection Control Program
GROUNDWATER SECTION
P.O Box 29578, RALEIGH , NC 27626-0578 -2728 CAPITAL BLVD., RALEIGH, NC, 27604
PHONE [phone] FAX [phone]
AN EQUAL OPPORTUNITY/ AFFIRMATIVE ACTION EMPLOYER -50% RECYCLED/I 0% POST-CONSUMER PAPER
GROUNDWATER SECTION
November 5, 1998
MEMORANDUM
To: Willie Hardison
Groundwater Section
Washington Regional Office
From: Mark Pritzl 1/f [e-mail]
Hydrogeological Technician II
UIC Group
Groundwater Section, Central Office
Re: Request for review of new injection well permit application for operation.
The CO-UIC has received an application by Mr. & Mrs. Ross for a new permit for the construction
and operation of an injection well located at 3904 Cantata Drive, Greenville, NC. The proposed
injection well will be part of an open loop geothermal heat pump system, therefore a type 5A7 well.
A copy of the permit application is enclosed for the W ARO-UIC files.
1. Please review the application and submit any comments to CO-UIC. Retain the
application for your UIC file.
2. Please inspect the proposed injection well site to verify that the location and construction
plans submitted in the application are accurate and that the NCAC Title 15A 2C.0200
standards are being complied with, using the enclosed Preconstruction Injection Facility
Inspection Report-Form (A) as appropriate.
Please return any comments immediately upon application review. You are requested to return the
completed Preconstruction Injection Facility Inspection Report-Form (A) to the CO-UIC by
November 30, 1998. If the inspection can not be accomplished by this date, please inform the CO-
UIC. The UIC Group appreciates your assistance in the review and evaluation of this permit
application. Please contact me if you have any questions or comments at [phone].
cc: UIC Files
Enclosures
NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
NOTIFICATION OF INTENT TO CONSTRUCT A CLOSED —LOOP
GEOTHERMAL WATER —ONLY INJECTION WELL SYSTEM
(GROUND COUPLED HEAT PUMP) —
Type 5QW Wells ..
a
In Accordance with the provisions of NCAC Title 15A: 02C.0204 +�
Complete application and mail to address on the back page.
This is not the proper form to he used for injection wells in an open -loop geothermal system.
Do not use this form for systems that circulate any substances other than water.
TO: DIRECTOR, NORTH CAROLINA DIVI ION OF WATER QUALITY
DATE: r 1 9 .
A. SYSTEM CLASSIFICATION Does the proposed system circulate potable water in continuous
piping that completely isolates the fluid from the environment?
YES X If yes, then continue completing this form.
NO If no, do not complete this form. Form GW-57 FIP, Application For
Permit To Construct And/or Use A Well(s) For Injection With A Heat
Pump System, should be completed.
B. SYSTEM FLUID Will any additives be introduced to the system's circulating heat transfer
fluid? This includes, but is not limited to corrosion inhibitors and/or antifreezes.
YES If yes, do not complete this form. Form GW-57 Imo', Application For
Permit To Construct AndlOr Use A Well(s) For -Injection With A Heat
Pump System, should be completed.
NO If no, then continue completing this form.
C. PROPERTY OWNER
Name: �ry-►�i e M s✓_M _��t �-+�n D SS
Address: 3cld 'SA
CState: 'J Z-- Zip Code: Z`1b S
County: V& Telephone: 3Ss— 301
D. STATUS OF PROPERTY OWNER
Private: FederaI:
State: Municipal:
Commercial:
Native American Lands:
GW-57 CL (May 1998) Page I of 4

• l
E.
F.
G.
FACILITY (SITE) DA TA
(Fill out ONLY if the Status of Owner is Federal, State, Municipal or Commercial).
Name of Business or Facility: _______________________ _
Address: ______________________________ _
City: _________ State: __ Zip Code: _____ County: ____ _
Telephone: __________ Contact Person: _____________ _
Standard Industrial Code(s), SIC, which describes commercial facility: ________ _
HEAT PUMP CONTRACTOR DATA_
Name: Climate Control Heating & Cooling Co., Inc.
Address: 269 Center Street
City: .Iacksomd 11 e State:NL._ Zip Code: 28546 County: Qnsl aw
Telephone: [phone] Contact Person: Mj chae] Had] ey
CONSTRUCTION DATA (check one)
(1)
EXISTING WELL(S) being proposed for use as a ground-coupled heat pump
well(s). Provide the information in (1) through (4) below to tl~e best of your
knowledge. Attach a copy of Form GW-1 (Well Construction Record) if available.
X PROPOSED WELL(S) to be constructed for use as a ground-coupled heat pump
well(s) . Provide the information in (1) through (4) below as PROPOSED
construction specifications. Submit Form GW-1 after construction.
,
Well Drilling Contractor's Name: Climate Control Heating & Cooling Co. , Inc.
NC Driller Registration number: 1633 ---------------------
Date to be constructed: ________ Number of borings: --~--P'~l~.5~· __ _
Approximate depth of each boring (feet):. ____ 2-o _ ___;O;:___ __________ _
(2) Well casing: ls the well(s) cased?
(a) YES If yes, then provide the casing information below.
Type: Galvanized steel __ Black steel __ Plastic __ Other (specify) _____ _
Casing depth: From ___ to ___ ft. (reference to land surface)
Casing extends above ground ____ inches
(b) NO -A-
(3) Grout (grout the vertical length of the borehole to a minimum depth of 20 feet b.l.s.):
NOTE:
(a) Grout type: Cement__ Bentonite ~ Other (specify) _______ _
(b) Grouted surface and grout depth (reference to land surface):
_E_ around closed loop piping; from tO to 2Q (feet).
__ around well casing; from __ to __ (feet).
THE WELL DRILLING CONTRACTOR CAN SUPPLY THE DAT A FOR EITHER EXISTING OR
PROPOSED WELLS IFTHIS INFORMATION IS UNAVAILABLE BY OTHER MEANS.
GW-57 CL (May 1998) Page 2 of4
H. INJECTION -RELATED EQUIPMENT
Attach a diagram showing the engineering layout of the injection equipment and exterior piping/tubing
associated with the injection Operation. The manufacturer's brochure may provide supplementary
information.
LOCATION OF WELL(S) Attach two maps.
(1) Include a site map (can be drawn) showing: buildings, property lines surface water bodies,
potential sources of groundwater contamination and the orientation of and distances between
the proposed well(s) and any existing well(s) or waste disposal facilities such as septic tanks
or drains fields located within 200 feet of the ground -coupled heat pump well system. Label all
features clearly and include a north arrow.
(2) location map referencing the site to two nearby permanent reference points (such as roads,
streams and highway intersections).
J. PERMIT LIST: Attach a list of all permits or construction approvals that are related to the site.
Examples include,
(1) Hazardous Waste Management program permits under RCRA
(2) NC Division of Water Quality Non -Discharge permits
(3) Sewage Treatment and Disposal Permits
K. CERTIFICATION
"I hereby certify, under penalty of law, that I have personally examined and am familiar with the
information submitted in this document and all attachments thereto and that, based on my inquiry of
those individuals immediately responsible for obtaining said information, I believe that the information
is true, accurate and complete. I am aware that there are significant penalties, including the possibility
of fines and imprisonment, for submitting false information. I agree to construct, operate, maintain,
repair, and if applicable, abandon the ground,-sm+ rce heat pump system and all related appurtenances in
accordance with the approved specificatioi and tonditions of Permit"
21
ignature of Well Owner or Authorized Agent)
If authorized agent is acting on beha f of the well owner,
please supply a letter signed by the owner
authorizing the above agent.
OW-57 CL (May 1998) Page 3 of

L. CONSENT OF PROPERTY OWNER (Owner means any person who holds the fee or other property
rights in the well being constructed. A well is real property and its construction on land rests
ownership in the landowner in the absence of contrary agreement in writing.)
If the property is owned by someone other than the applicant, the property owner hereby consents to
allow the applicant to construct each injection well as outlined in this application and that it shall be
the responsibility of the applicant to ensure that the ground-source heat pump system's well(s)
conforms to the Well Construction Standards (Title 15A NCAC 2C .0200)
GW-57 CL (May 1998)
(Signature Of Property Owner If Different From Applicant)
Please return two copies of the completed Application package to:
UICProgram
Groundwater Section
North Carolina DENR-DWQ
P.O. Box 29578
Raleigh, NC 27626-0578
Telephone [phone]
Page 4 of4
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North Carolina - Department of Environment and Natural Resources
Division of Water quality - Groundwater Section
P.O. Sax 29578 - Raleigh. N.C. 2762E-0578 �1
Phone [phone] f —
WELL CONSTRUCTION RECORD
DRILLING CONTRACTOR: --i fYl^ (1_
FOR OFFICE USE ONLY
QUAD. NO. SERIAL NO.
Lat. Long. RO
Minor Basin
Basin Code
Header Ent. GW-1 Ent.
STATE WELL CONSTRUCTION
f
DRILLER REGISTRATION NUMBER: J 63-? PERMIT NUMBER:
1. WELL LOCATION: (Show sketch of the location below)
Nearest Town: L'+`+° ,' V),, County'
!AGk� �sI W -Cc
(Road, CoTlimunity, or SubdJii�is�ion and Lot No.) DEPTH DRILLING LOG _
2. OWNER 6 A--oys s ICL]jS From To
ADDRESS 22691 CAV1,,_Ti 4dA-`
(Street or Route No.) _
r�r erfn Ile_ Aly 2_'WK V
City or Town tale /Zip fC,ode
3. DATE DRILLED '�a- USE OF WELL t:Z0>e+ellln
4. TOTAL DEPTH ~'Y7. O
5. CUTTINGS COLLECTED YES ❑ NOO
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO®
7. STATIC WATER LEVEL Below Top of Casing: FT.
(Use "+,, if Above Top of Casing)
8, TOP OF CASING IS FT. Above Land Surface*
Casing Term Inated eVor below land surface is illegal unless a variance is Issued
in accordance with 15A NCAC 2C .0118
9. YIELD (gpm):- METHOD OF TEST
10. WATER ZONES (depth):
11. CHLORINATION: Type
12, CASING. G-eU�kervv\& r
Depth
From To —
From - To -
From — _ To--
13. GROUT:
Amount — -
Q � S e4- 14- a �.
Wall Thickness
Diameter or Weights t. Material
Ft. ---
Ft, -- - Ft. —
Depth r Material ethod
From ToFt.
From To Ft.
14. SCREEN:
Depth
From
To
From
To
From
To
15. SAND/GRAVEL
PACK:
Depth
From
To —
From
To_
16. REMARKS:
Diameter Slot Size Material
Ft in. in.
Ft. in. in,
Ft. in. in.
Size Material
Ft.
— Ft.
If additional space Is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
SSE oil'WR'Oor
)_ + IL3
'V q_ c sX
_ 41 -a� Q
e )
W9 g Q a fl Sr
- X J
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS UCOOD qAS BEEN PROVIDEwD TO THE WELL OWNER.
le-z,/-��
SIGNATURE OF CONTRACTOR `,O GENT DATE
Submit original to Division of Water Quality and copy to well owner.
GW-1 REV, 1198

North Carolina - Department of Environment and Natufat Resources
Division of Water Quality - Groundwater Section
P.O. Box 29578 -Raleigh, N.C. 27626-0578
Phone (919) 73M221 _
WELL CONSTRUCTION RECORD
DRILLING CONTRACTOR: L1fPRA-' �Q - /IIjY�
FOR OFFICE USE ONLY
QUAD. NO. SERIAL NO.
Lat. Long. _ RO
Minor Basin
Basin Code
Header Ent, GW-1 Ent,
STATE WELL CONSTRUCTION
DRILLER REGISTRATION NUMBER: [ 3,1 PERMIT NUMBER:
1, WELL LOCATION: (Show sk�tch of the location below) ,(]
Nearest Town: r° • % County. -`_'�
(Road. Community, or Subdivision5nd Lot No.) DEPTH
DRILLING LOG
2. OWNER e-��� S SS From To
Formation Description
ADDRESS CAA 7_-4 774 idrl 0, r o'
t (Street or Route No.) e
G re en►Jy �+� IrvJW 27
City or Town State Zip Coded r 3G� lJ
3. DATE DRILLED `� USE OF WELL�i
, .
'
4. TOTAL DEPTH
5. CUTTINGS COLLECTED YES ❑ NO®
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO�]
7. STATIC WATER LEVEL Below Top of Casing: FT.
[Use ,+" if Above Top of Casing]
8. TOP OF CASING tS FT. Above Land Surface*
" Casing Terminated aVor below land surface is illegal unless a variance is issued
In accordance with 15A NCAC 2C .0118
9. YIELD (gpm):. METHOD OF TEST
10. WATER ZONES (depth):
11
12
CHLORINATION: Type
CASING:
k'r
Depth
From
-To
Ft.
From
To
Ft.
From
- To
Ft.
13. GROUT:
Depth
From
To sL+`
Ft.
From
To
Ft.
14. SCREEN:
P,�f0e
Diarnelef
Amount
Wail Thickness
or Weight/Ft, Material
Material Method
�r rr
Depth Diameter
From
To Ft in.
From
To Ft. in.
From
To Ft. in,
15. SAND/GRAVEL
PACK:
Depth Size
From
To Ft.
From
Ta Ft.
Slot Size Material
If additional space is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
Z c ---
a
I" L
e a 9
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED 1N ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECOR BEEN PROVIDED TO THE WELL OWNER.
SIGNATURE OF CONTRACTO R AGENT DATE
Submit original to Division of Water Quality and Copy to waif owner.
GW-f REV. 1198

North Carolina - Department of Environment and Natural Resources
Division of Water Quality - Groundwater Section
P.O. Box 29578 - Raleigh, N-C. 27626-0578
Phone [phone] -�
WELL CONSTRUCTION RECORD
DRILLING CONTRACTOR: r A (!�Itdn
FOR OFFICE USE ONLY
QUAD. NO. _ _ SERIAL NO. ____
Lat. _ . - Long. RO
Minor Basin
Basin Code _
Header Ent. GW-1 Ent.
STATE WELL CONSTRUCTION
DRILLER REGISTRATION NUMBER: IL 32 PERMIT NUMBER:
1. WELL LOCATION: (Show ske of the location below)
F
Nearest Town: County-
k411, AF3�4�fA
(Road. Community, OrSubdivlsi�jrL t No.) DEPTH DRILLING LOG _
2. OWNER 1fR�t1►�! r 1� From To
ADDRESS 4 C i I'� �`,.r —�� • d
(eItit1@11/iI1 Sera No.)
27 FS
City or Town State Zip Cade
3. DATE DRILLED %-9� USE OF WELL
C TOTAL DEPTH mod. C) `
5. CUTTINGS COLLECTED YES ❑ NOJ�S,
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NQJ
7. STATIC WATER LEVEL Below Top of Casing: FT.
(Use "+' it Above Top of Casing) 1a0() C)
8. TOP OF CASING lS FT. Above Land Sutface
Casing Terminated aDr below land surface is egat unless a variance is Issued
In accordance with 15A NCAC 2C .0118
9. YIELD (gpm): — METHOD OF TEST
10. WATER ZONES (depth):
11. CHLORINATION- Type Arno�rnt __
12. CASING: t d1`G,�r Q zop Z7;i
Wall Thickness
Depth
Diameter or Weight/Ft. Material
From--To—Ft.—
From—
Ta
Ft. - --
From
To
Ft.- — -- -- --
13. GROUT:
From
Depth Maprial ethoc�
CL U To c;kQ 0 Ft. e�
From
To
Ft.
14. SCREEN -
Depth
Diameter Slot Size Material
From
To
Ft in. —in.
From
To
Ft in. in.
From
To
Ft. in. in.
15. SAND/GRAVEL PACK:
Depth
Size Material
From
To —Ft.
—
From
To.
Ft. — _-_ --
16. REMARKS:
It additional space is needed use back of farm
0)00" 1/
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECOrjD Hq%.F$EyEN PROVIDED TO THE WELL OWNER.
SIGNATURE OF CONTRACTOR OR DATE
Submit Original w Division of Water Quality and copy to well owner.
GW-1 REV. 1198

North Carolina - Department of Environment and Natural Resources
Division of Water Quality - Groundwater Section
P.O. Box 29578 - Raleigh. N.G. 27626-0578
Phone (919) 733-Mi
WELL CONSTRUCTION RECORD`
DRILLING CONTRACTOR: Cli< wti,+f C. 5
FOR OFFICE USE ONLY
QUAD.NO. SERIAL NO.
Lot. Long. , RO
dinar Basin
Basin Coda
Header Ent. GW-1 Ent_
STATE WELL CONSTRUCTION
DRILLER REGISTRATION NUMBER: 11,33 PERMIT NUMBER:
1. WELL t_OCATIO►,j: (Show ske- of the location below)
Nearest Town: ,( l�fl'�=ter/ - --County: I
Tome - key as f w -e s
(Road, Com nity, or Subdivision� yd Lot No.}
` lid r S
DEPTH
DRILLING LOG
2. OWNER
From To
Forma''°n Descriptlon
ADDRESS_ 396+ A'r'
6. e — / 5, 0
l
N {street or Route No.}
Late Zi
City or Town ��
Cade
�r
1DATE DRILLED USE OF WELL
4. TOTAL DEPTH
5. CUTTINGS COLLECTED YES ❑ NOM
6. DOES WELL REPLACE EXiSTiNG WELL? YES ❑
NOg]
7. STATIC WATER LEVEL Beiow Tap of Casing:
FT.
(Else "*' if Above Top of Casing)
j��i� � ��Q eJ'
r
8. TOP OF CASING IS FT. Above Land Surface
r , ._
" Casing Terminated atlor below land surface Is illegal unless a variance Is Issued
In accordance with i5A NCAC 2C .0118
9. YIELD (gpm): _ _ METHOD OF TEST
10. WATER ZONES (depth):
11. CHLORINATION: Type Am unt
12. CASING���rma DC 5��._ d
From
From
From
13. GROUT:
Depth
To Ft.
To Ft.
To Ft.
C Depth r
From To S�,e-) Ft.
From To Ft.
14. SCREEN:
Depth
From
To Ft
From
To Ft.
From
To Ft.
15. SAND/GRAVEL PACK:
Depth
From
To
From
To
16. REMARKS:
Wail Thickness
Diameter or Weight/Ft. Material
Material M tP, hvd
Lr
Diameter Slot Size Material
in. in.
in, in,
in. in.
Size Material
Ft.
Ft_
If additional space is needed use back of form
LOCATION SKETCH
{Show direction and distance from at least two State
Roads. or other map reference paintsy
'19 r
r
e a�
i DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HA: N PROVIDED TO THE WELL OWNER.
4��I V -ZI - FjK
SIGNATURE OF CONTRACTOR OR AG _ jT DATE
Submit original to Civision of Water Quality and copy to well owner.
GW-1 REV. IM

North Carolina - Department of Environment and Natural Resources
Division of Water Quality - Groundwater Section
P.O. Box 29578 - Raleigh, N.C. 27626-0578
Phone [phone]—�
WELL CONSTRUCTION RECORD
DRILLING CONTRACTOR: G ►
FOR OFFICE USE ONLY
QUAD. NO. SERIAL NO.
Lat. Long. _ _ RO
Minor Basin
Basin Cade
Header Ent. GW-1 Ent,
J1 STATE WELL CONSTRUCTION
DRILLER REGISTRATION NUMBER: J� �3 PERMIT NUMBER:
1, WELL LOCATI{Show sk (ch of the iccation below)
[� r 1
Nearest Tow f>�! _ County; f
- 7 N'e-
(Road, Gam unity, orSubdivision d Lot No.) DEPTH DRILLING LOG
2. OWNER Corn
�r -r From To Formation Description
ADDRESS 3g� e_AA -
(Straet or Route No.) -- _ + j
City or Town State Zip�/Ade , d.. - m'
3. DATE DRILLED IIVPW USE OF WELL e�Torr_i�lri7e� C�� '���`�' _iLy-s7e
4. TOTAL DEPTH ,r
5. CUTTINGS COLLECTED YES NO® I odrd ~ I4 d
6. DOES WELL REPLACE EXISTING WELL? YES [] NCtF�n
7. STATIC WATER LEVEL Below Top of Casing- FT -
(Use +" if Above Top of Casing) f d
8. TOP OF CASING IS FT. Above Land Surface'
" Casing Terminated atlor below land surface Is illegal unless a variance is issued
in accordance with 15A NCAC 2C .0118
9. YIELD (gpm): - METHOD OF TEST
10. WATER ZONES (depth):
11. CHLORINATION: Type
12. CASING: 6eQ 4 ►WLQ ( Loop
Depth
From To Ft.
From Ta Ft.
From To Ft.
�ej;�sT1�
�t "�. Depth t,
From - e) _ To C� Ft.
From To Ft.
14. SCREEN:
Depth
From
To Ft
From
To Ft.
From
To Ft.
15. SAND/GRAVEL
PACK:
Depth
From
To
From
To
16. REMARKS:
Diameter
Amount If additional space is needed use back of form
' d LOCATION SKETCH
Wall Thi*ness
or Weight/R_ Material (Shaw direction and distance from at least two State
Roads, or other map reference points)
IU�.at rial thod ,
Diameter Slot Size Material
in. in-
in. in. _
in. in.
Size Material
Ft.
Ft. - — — -
I DO HERESY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A IN CAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS REC HA`' N PROVIDED TO THE WELL OWNER.
SIGNATURE OF CON T ACTOR OR A =NT DATE
Submit original to Division of Water Quality and copy to well owner,
GW-1 REV. 1198

North Carolina - Department of Environment and Natural Resources
Division of Water Quality - Groundwater 5eotion
P.O. Box 29578 - Raleigh, N.C. 27626-0578
Phone [phone] %7Y
WELL CONSTRUCTION RECORD
DRILLING CONTRACTOR: ■ 1 1
FOR OFFICE 115E ONLY
QUAD. NO. SERIAL NO.
Lat. _ _ Lang. RO
Minor Basin
Basin Code
Heads;, Ent. GW-1 Ent.
j STATE WELL CONSTRUCTIONDRILLER REGISTRATION NUMBER; { �g PERMIT NUMBER:
1. WELL LOCATIC N.- (Showtsketch of the location below)
Nearest Town: / I County:
(Road, Com unity, or 5ubdivist and Lot No.) DEPTH DRILLING LOG
2. OWNER •V-eJ r Z rl From To Formation,Descripiion
ADDRESS 3 `f
(Street or Routa No.) ' d'
City or Town state Zip Code
3. DATE DRILLED �fIr- USE OF WELL
4. TOTAL DEPTH
5. CUTTINGS COLLECTED YES ❑ NOg] d
6. DOES WELL REPLACE EXISTING WELL YES D NOg
7. STATIC WATER LEVEL Below Top of Casing: FT.
(Use '+" if Above Top of Casing) ' r r
8. TOP OF CASING IS FT. Above Land Surface*�
Casing Terminated attar below land surface is illegal unless a variance is Issued
in accordance with i5A NCAC 2C .0118
9. YIELD (gpm) METHOD OF TEST .
10. WATER ZONES (depth): —
11. CHLORINATION: Type A unt
12. CASING: v Fn � lzqo �'� 0 —6C c
Depth
From To Ft.
From -- Ta Ft.
From To Ft.
13. GROUT:
If additional space is needed use back of form
Wall Thickness LOCATION SKETCH
Diameter or WeightlFt- Material (Show direction and distance from at least two State
Roads, or other map reference paints)
r Depth Ma erial ethod
From d_-C) To c_22ci Ft. ``
From To Ft.
14. SCREEN:
Depth Diameter
From
To Ft in.
From
To Ft. in.
From
To Ft. in.
15. SAND/GRAVEL
PACK:
Depth Size
From
To Ft_
From
To Ft.
16, REMARKS:
Slat Size Material
Material
'.' 9 ,r• r
o �' �a a
b
I nd HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY =THISR HAS PROVIDED TO THE WELL OWNER.
SIGNATURE OF CON RACTOR OR AL iT DATE
Submit original to Division of Water Quality and copy to well owner.
GW-1 REV. 1196

North Carolina - department of Environment and Natural Resources
Division of Water Quality - Groundwater Section
P.O. Box 29578 - Raleigh, N.C. 27626-0578
Phone [phone] / f _7
WELL. CONSTRUCTION RECORD
DRILLING CONTRACTOR: 4,4tl tea'
FOR OFFICE USE ONLY
QUAD. NO. SERIAL NO,
Lat. Long. —_ SO _
Minor Basin —
Basin Code _
Header Ent. GW-1 Ent_
STATE WELL CONSTRUCTION
DRILLER REGISTRATION NUMBER: '3 PERMIT NUMBER:
1.
WELL LOCATION: (Show 's�kgtch of the location below)
Q 4
Nearest Town: �t`1 1-1-.L 1 County: !
T
(Road, Cam unity, or Subdivisio d Lot No.)
DEPTH
DRILLING LOG
2.
OWNER W-eAWO'.�i le=S
From TO
Formation. Description
ADDRESS N J+
�, -/S-. r�
Z7e
_
IN {Street or Route No.)
Cry-�e,v�n I� Arcs
_
_
r�
City or Town Slate Li Code
9
e
3.
DATE DRILLED /6-9 USE OF WELL
4.
TOTAL DEPTH
5.
CUTTINGS COLLECTED YES ❑ NO®
. d�
5.
DOES WELL REPLACE EXISTING WELL? YES D NO
7.
STATIC WATER LEVEL Below Top of Casing: FT.
[Use "+" If Above Top of Casing]
S.
TOP OF CASING IS FT. Above Land Surface"
_. . .
Casing Terminated atlor below Sand surface Is lltegal unless a variance Is tssued
in accordance with 15A NCAC 20 .0118
9. YIELD (gpm);_ - —_ METHOD OF TEST
10. WATER ZONES (depth):
11. CHLORINATION- Type
12. CASING:p�ry,�
Amount If additional space is needed use back of form
teop 561 A�- oleo,
Wall Thickness
Depth Diameter or Weight/Ft. Material
From To Ft.
From — Tq Ft. —
From To Ft.
13. GROUT
Depth Material et�ho ,
From QCL �� To Ft.
From Tv Ft.
14. SCREEN:
Depth Diameter Slot Size Material
From To Ft in. in.
From To Ft. in. in.
From To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To —Ft. --
From To Ft.
16. REMARKS:
LOCATION SKETCH_
(Show direction and distance from at least two State
Roads, or other map reference points) I
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF TH13 RE%'RE' H PROVIDED TO THE WELL OWNER.
AL'y'-1/ 1192
GW-1 REV. 1198
SIGNATURE OF CONTRACTOR OR AGEIT DATE
Submit original to Division of Water Quality and copy to well owner.

North Carolina - Department of Environment and Natural Resources
Division of Water Quality - Groundwater Section
P.O. Box 29578 - Raleigh, N.C. 27626-0578
Phone [phone]
FOR OFFICE USE ONLY
QUAD. NO. SERIAL NO.
Lai, Long, RO
Minor Basin
WELL CONSTRUCTION RECORD Basin Code
L
DRILLING CONTRACTOR: _ _ %j' owl /T j d 1 I Header Ent. GW-1 Ent.
STATE WELL. CONSTRUCTION
DRILLER REGISTRATION NUMBER: 33 PERMIT NUMBER:
1. WELL LOCATIO : (Show sketch of the location below)
Nearest T wn: eh L.' j hp County: P
es � s
(Road, cam sty, or Subdivision aV Lai No.) DEPTH DRILLING LOG
2. OWNER p� Nt S v-1 From TO
ADDRESS d`f "� r
Z?
City or Town St t gg ZCode
3, DATE DRILLED -5E OF WELL i +rf"
4. TOTAL DEPTH
5. CUTTINGS COLLECTED YES ❑ NO
6. DOES WELL REPLACE EXISTING WELL? YES [] NO©
7. STATIC WATER LEVEL Below Tap of Casing: FT. is
(Use "+" if Above Top of Casing) {Sip
S. TOP OF CASING IS FT. Above Land Surface -
Casing Terminated actor below land surface Is illegal unless a variance is Issued
In accordance with 15A NCAC 2C .0118
9. YIELD (gpm): METHOD OF TEST
10, WATER ZONES (depth):
11. CHLORINATION' Type Amount If additional space is needed use back of Form
12. CASING: Lvp� fir]
Wall Thickness LOCATION SKETCH
Depth Diameter or Weight/Ft. Material (Show direction and distance from at {east two State
From -To -Ft.- - Roads, or other map reference points} I
From Ta
Ft.
From -To-
Ft.
13, GROUT:
t Depth r . Mate 'al
FroTO Ft.�-
=hdm
From To
Ft.
14. SCREEN:
a•
a
Depth
Diameter Slot Size
Material
i3
'66 p
From To
Ft in.
in.
. f
•3
From To
FL in.
in.
fl
a e
From To
Ft. in.
in.
15. SAND/GRAVEL PACK:
Depth
Size
Material
From To
Ft.
From To
Ft.
`
16. REMARKS:
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C. WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECOR EEN PROVIDED TO THE WELL OWNER.
SIGNATURE 6F CONTRACTOR O , GENT DATE
Submit original to Division of Water Quality and copy to watt owner,
GW-1 REV. 1198

North Carolina - Department of Environment and Natural Resources
Division of Water Quality - Grounttwater Section
P.O. Box 29578 - Raleigh, N.G. 27626-0578
Phone [phone] ,
WELL CONSTRUCTION RECORD
DRILLING CONTRACTOR:
FOR OFFICE USE ONLY
QUAD. NO. SERIAL NO.
Lac Long RO
Minor Basin
Basin Code
Header Ent, GW-1 Ent.
i STATE WELL CONSTRUCTION
DRILLER REGISTRATION NUMBER: / 433 PERMIT NUMBER:
1.
aordance with
WELL LOCATION: (Show skiptch of the location below)
Nearest Town: I EL"f1 L' � / " County: _—
�c 1C4 tr— E S To+T-& S
(Road, Com unity, or Suhdivlsig� and Lot No.) DEPTH
U'�-I Gs:
_❑KILLING LOG
2.
OWNER S & From TO
ForrnWia E7ascription
ADDRESS I' + CA-A1 TA i
(Street or Routo No.)
�I�CrJIIi �� 2�71
r
3.
City or Town Slate �zE ode
DATE DRILLED 1% USE OF WELL CA,ip�rt----t-Rt
4.
TOTAL DEPTH
5.
CUTTINGS COLLECTED YES 0 NO,Z
6.
DOES WELL REPLACE EXISTING WELL? YES [] NQI[� j
f��r
7.
STATIC WATER LEVEL Below Top of Casing: FT.
(Use "+" if Above Top of Casing)
8.
—
TOP OF CASING IS FT. Above Land Surface"
,
• Casing Terminated at/or below land surface is illegal unless a variance is issued
In 15A NCAC 2C 0118
ac -
9. YIELD (gpm): METHOD OF TEST
10. WATER ZONES (depth):
_
11, CHLORINATION: Type
Amount If additional space Is needed use back of form
12. CASING: G-,�r�-,q'
�ooP 5e�- Al- . o
LOCATION SKETCH
Wall Thickness .
Depth
Diameter or weighVFt. Material (Shaw direction and distance from at least two State
From _ To Ft.
_ —, Roads, or other map reference points)
From To Ft.
—
From To Ft.
13. GROUT:
Depth
Material Method
From To Ft,
From To Ft,
14. SCREEN:
Depth Diameter Slot Size Material ■3 9 S
From To Ft
in. in.
From To Ft.
in. in. �a a
From To Ft.
in. in. W)
15. SAND/GRAVEL PACK:
. �!
Depth
Size Material
From To Ft.
_
From To Ft.
16. REMARKS--___
I ❑O HEREBY CERTIFY THAT THIS
WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS REqCRD HAS Pf ROVIDED TO THE WELL OWNER.
SIGNATURE OF _ ONTRACTOR OR AGE+ DATE
Submit original to Divislon of Water Quality and copy to well owner-
GW-1 REV. 1198

North Carolina - Department of Environment and Natural Resources
Division of Water Quality - Groundwater Section
P.O. Box 29578 - Raleigh, N.C. 2762"578
Phone [phone] w T
WELL CONSTRUCTION RECORD
DRILLING CONTRACTOR: �[1ca_
FOR OFFICE USE ONLY
QUAD. NO. SERIAL NO.
Lat. — Long. RO
Minor Basin
Basin Coda
Header Ent. GW 1 Ent.
77 STATE WELL CONSTRUCTION
DRILLER REGISTRATION NUMBER: �� J3 PERMIT NUMBER:
1. WELL LOCATION: (Show skgt�h of the location below) ;�
NearestTown:6_6r eI - County: -_-_ T
1G�e
{Road, Corn nity, or Subdivision dd Lot No.} DEPTH
Z. OWNER �i ,erc/nfi- - !Cd �S�l A /� From To
ADDRESS V �'�4 % !i ^ ^! tir 1
r (Streey or Route No.)
�,"W-eAIN, jf� IVY
City or Town State Zip Code ` e f /410- d ,
3. DATE DRILLS❑ 9�7-�'JPUSE OF WELL �f .
4. TOTAL DEPTH Q' -) n
5. CUTTINGS COLLECTED YES NO[a A�_ 6
6. DOES WELL REPLACE EXISTING WELL? YES [f NOpg,
7, STATIC WATER LEVEL Below Top of Casing: FT.
(Use "+" if Above Top of Casing)
S. TOP OF CASING IS FT. Above Land Surface`
Casing Terminated atlor below land surface is illegal unless a varlance Is issued
in accordance with 1SA NCAC 20 .01IS
9. YIELD (gpm): METHOD OF TEST
1 0. WATER ZONES (depth):
11. CHLORINATION: Type
12. CASING' G— f`A-a
Depth
From To _
From To -
From To --
13. GROUT:
Depth
From To
From To
14. SCREEN:
DRILLING LOG
Formation esc6ption
n h
A ount If additional space is needed use back of form
wall Thickness
Diameter or Weight/Ft. Material
Ft_
Ft.—
Ft. —
Material Method
Ft.
Ft.
Depth Diameter Slot Size Material
From To Ft
From To Ft. —
From To Ft. —
15. SAND/GRAVEL PACK:
Depth
From To Ft. _
From To Ft. _
16. REMARKS:
LOCATION SKETCH
(Shaw direction and distance from at least two State
Roads, or other map reference points)
-11
�1 f
B � �
in. in. -
in. in.
in. in.
Size Material
ma a&41y}i
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HA" N PROVIDED TO THE WELL OWNER.
SIGNATURE OF CONTRACTOR OR . RENT DATE
Submit original to Division of Water Quality and copy to well owner.
GW-1 REV. 1198

North Carolina - Department of Environment and Natural Resources
Division of Water quality - Groundwater Section
P.O. Box 29578 - Raleigh, N.C. 27626-0578
Phone [phone]
WELL CONSTRUCTION RECORD
DRILLING CONTRACTOR: 61
+f 44Cr- �s3
FOR OFFICE USE ONLY
QUAD. NO. SERIAL NO,
Lat. Long. RO
Minor Basin
Basin Code
Header Ent. GWA Ent.
j STATE WELL CONSTRUCTION
DRILLER REGISTRATION NUMBER: PERMIT NUMBER:
1. WELL LOCATIOvw sketc of the kxation Below)
Nea TOWn: i; �1' -1, ' r' a Gpunty:
(Road, Com unity, or 5uedivisioA a t No.) DEPTH DRILLING LOG
2. OWNER —�� r �t From To
ADDRESSMN L� Alryrb .r► d/- r - ,
t (Street o Route No.] r
City or Town Statu - 2i Cade • d I ���" d r
3. DATE DR] LLEt7!�- �-� USE OF WELL
4. TOTAL DEPTH r O
5. CUTTINGS COLLECTED YES ❑ NO;K] e5
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NQ
7. STATIC WATER LEVEL Below Tap of Casing. FT.
(Use "+` if Above Top of Casing) f
8, TOP OF CASING IS FT. Above Land Surface*�'��`--
Casing Terminated attar below land surface Is Illegal unless a var#ance is Issued
In accordance wlth ISA NCAC 2C .0118
9. YIELD (gpm):_ _ METHOD OF TEST
10. WATER ZONES (depth):
11. CHLORINATION: Type Amount If additional space is needed use back of form
12. CASING: G-`�p C' .i Lzoto 006d ,
LOCATION SKETCH
Wan Thickness
Depth Diameter or Weight/Ft, Material (Show direction and distance from at least two State
From To Ft_ Roads, or other map reference points)
From — Ta Ft.
From To Ft.
13. GROUT:
From � o
From
14. SCREEN:
Depth Material Method
ToFt.&24,dC_;�cau
To Ft.
Depth
From
To Ft
From
To Ft.
From
To Ft.
15. SAND/GRAVEL
PACK:
Depth
From
To
From
Ta
16. REMARKS:
Diameter Slot Size
in.
in.
Ft.
Ft.
Size
Material 2 m - — -'
in.
in.
Material
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RE' :O=APROVIDED TO THE WELL OWNER.
SIGNATURE OF CONTRACTOR OR AGAT DATE
Submit original to Division of Water Quality and copy to well owner-
GW-1 REV. 1198

North Carolina - Department of Environment and Natural Resources
Division of Water Quality - Groundwater Section
P.O. Box 29578 - Raleigh, N-C. 27626-0578
Phone [phone]
WELL CONSTRUCTION RECORD
DRILLING CONTRACTOR.
STATE WELL CONSTRUCTION
DRILLER REGISTRATION NUMBER: I L 33 PERMIT NUMBER:
1. WELL LOCATIO : (Show slaeftch of the location below)
4
Nearest Town.' County:
a 7�r S
(Road, Corn nity, or Subdivision nd Lot No.) DEPTH DRILLING LOG
2- OWNER � '�' 3 In FS From To � Form ]on ❑ip to
ADDRESSG�C� r�
(Street or Routo No.)
City or Town State Zip Coda
3. DATE DRILLED USE OF WELL -064hfLnAl`-
4. TOTAL DEPTH
5. CUTTINGS COLLECTED YES 1\10t�!j /Or 6 a o" -
5. DOES WELL REPLACE EXISTING WELL? YES [] NOF]
7. STATIC WATER LEVEL. Below Top of Casing: FT.
(Use +" if Above Top of Casing) l .0 �'0� of f 1c �
8. TOP OF CASING IS _ _ _ FT. Above Land Surface* - =1�7
Casing Terminated atlor below land surface Is Illegal unless a variance Is Issued
in accordance with 15A NCAC 2C .0118 - -
9. YIELD (gpm)-. METHOD OF TEST
10. WATER ZONES (depth):
11. CHLORINATION_ Type
ArRounj
+
`
12. CASING:
t-'dP SC f '-)do' e)
Wall Thickness
Depth
Diameter or Weight/Ft, Material
From To Ft.
From - To Ft.
From To Ft.
13. GROUT
FOR OFFICE USE ONLY
QUAD, NO. SERIAL NO.
Lat. Long. RO
Minor Basin
Basin Coda
Header Ent. GW 1 Ent.
If additional space is needed use back of form
LOCATION SKETCH
(Show direction and distance from at feast two State
Roads, or other map reference points)
From
i Depth r
(• O To tSO ( Ft.
Method
y
From
To Ft.
14. SCREEN:
pep
s�
Depth Diameter Slot Size Material
From
-To-Ft-
in. -in--
From
To Ft.
in. in.b�
iJ
From
To Ft.
in. in.
S'
15. SAND/GRAVEL PACK:
Depth
Size Material
From
To -Ft.
-
From
To Ft.
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD FN PROVIDED TO THE WELL OWNER.
SIGNATURE OF CONTRACTOR O, C3ENT DATE
Submit original to Division of Water Quality and copy to well owner.
GW-1 Am 1198

Borth Carolina - department of Environment and Natural Resources
Division of Water Quality - Groundwater Section
P.O. Box 29578 - Raleigh, N.C. 27626-0578
Phone [phone]
WELL CONSTRUCTION RECORD �r
DRILLING CONTRACTOR: �/_"a -1 ; d
FOR OFFICE USE ONLY
QUAD. NO. _ SERIAL NO.
Lat. Long. __ RO
Minor Basin
Basin Coda
Header Ent. GW-f Ent,
! STATE WELL CONSTRUCTION
QRILLER REGISTRATION NUMBER: ' �� PERMIT NUMBER:
1. WELL LOCATION: (Show skgtct� of the location below) "
7V-
Nearest Town: CAL(-6 r I J� I �S County: ]'
e,/ �s
(Road, Community, or Subdivisi and Lot No.) DEPTH DRILLING LOG
2_ OWNER From sd�r From To
ADDRESS PF 4f C4AI1L,
(fr'J">t t AI V. I `e {Street or �e nlo.} ? //
ot
City or Town State Zi Cods
3. DATE DRILLED _ USE OF WELL f
4. TOTAL DEPTH
5. CUTTINGS COLLECTED YES [] NO[79— I�-� ��d • d
6. DOES WELL REPLACE EXISTING WELL.? YES [] NC}�
1. STATIC WATER LEVEL Below Top of Casing: FT.
{USe "+,, if Above Top of Casing} I te1 r n", 0 L `
8. TOP OF CASING IS FT. Above Land Surface- !
Casing Terminated atfor below tend surface is illegal unless a variance Is Issued
in accordance with 15A NCAC 2C .0118
9. YIELD (gpm): METHOD OF TEST .
10. WATER ZONES (depth)
11. CHLORINATION: Type Amount If additional space is needed use back of form
12. CASING: � Loop - V1�90
Wall Thickness LOCATION SKETCH
Depth Diameter or Weight/Ft. Material (Show direction and distance from at least two State
From-- -To Ft. Roads, or other map reference points)
From To - Ft. - - -
From Ta Ft.
13. GROUT:
I p�j M terial ethod
From (0 To _- To F#. �
From To Ft. _ 49
14. SCREEN:
Depth Diameter Slot Size
From To Ft in. in.
From To Ft. in. in.
From -To Ft. in, in.
15. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To- Ft.
16. REMARKS:
Material o i
Material
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY PF THIS RECOR Q H PROVIDED TO THE WELL OWNER.
.041:4W.1 1&� — —_ 149. at -
SIGNATURE OF CONTRACTOR OR .4 -NT DATE
Submit original to Division of Water Quality and copy to well owner.
GW-1 REV. 1198