WM0301152_GW-1 records for MW-47 through MW-92_20211101

Well Contractor Name
WELL CONSTRUCTION RECORD (GW-1)
1, WellelContractor Information:
ll�) .
l ranoS Xavier i1/4*f erL917;
NC Well Contractor Certification Number
•
WCy //Ce f t ; i C. ui ld /t-_,:›itevi a +2 l *4 I
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)
IndustriaUCommercial
Irrigation
DMunicipal/Public
Residential Water Supply (single)
Residential Water Supply (shared)
Non -Water Supply Well:
Monitoring
njectlen Well:
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
Experimental Technology
Recovery
Groundwater Remediation
Salinity Barrier
DStormwater Drainage
Subsidence Control
Geothermal (Closed Loop) DTracer
Geothermal (Heating/Cooting Return) rjOther (explain underr#21 Remarks)
4, Date Well(s) Completed: 9J/2/20Z0 Well IDl U/' 4'2
5a, Well Location:
t, cdr1t1iCl/ Ape 1/fie
Facility/Owner Name
/312' 1h'lers(11 /
Physical Address, City, and Zip
I)')PLk'1en 1nur�
County
Facility 1D# (if applicable)
Co t I G ).-cJ Re/
2809e
0/9'21212_
Parcel Identification No. (PIN)
5b. Latitude and longitude In degrees/minutes/seconds or decimal degrees:
(if well field, one Iar/leng is sufficient)
1/129 N fra 80 6/,S2,
6. Is(are) the well(s) <,Permanent or Temporary
7. Is this a repair to an existing well: jYes or iaa No
Ileitis Is a repair, Jill out known well construction information and explain the nature of the
repair under 1121 remarks section or on the hack of this form.
8, For GeoprobefDPT or Closed -Loop Geothermal Wells having the same
construction, only I GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled: 1
9. Total well depth below land surface: Z? (ft.)
For multiple wells list all depths if dierent (example- 3@200' and 2 100')
10. Static water level below top of casing:
If water level is above casing, use " i." r�
11. Borehole diameter: Q (in.)
12. Well construction method: .$Cjl]i(_;
(i,e. auger, rotary, cable, direct push, elc.)
(ft,)-
FOR WATER SUPPLY WELLS ONLY:
13a, Yield (gpm) Method of test:
13 b. Disinfection type: Amount:
For Internal Use Only:
ECEIVED/NCDEQ/DWR
v��—, aI V LVI—,
14.1V.ATER'2ONES
FROM
TO
DESCRIPTION
ft,
ft:
WQROS
MOORESA, ILLE
n.
ft
REGIONAL OFF
-5;441I}R CASDIGIfer moles trier weUy)iOR LTNDR (lf hp ucA o)
FROM TO
DIAMETER
THICKNESS
MATERIAL
ft. ft,
In,
` 6 ii`NEKGASTNWORMUB1NGi(Reotharreal,eose&leap)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
�- It,
i
•7
? ft,
L./ In.
/
se.13 4,1)
PV e
ft.
ft.
In.
'it SpREEN
:'
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
`7 ft.
2 I ft,
Cy . In.
,s 0 /0
SCA VD
AA:ft,
ft,
In,
18;4ROXIT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
S It'
7 rt,
ftlk7L.Y
Povrti / /-19,,
0 n'
rt,
Cr/+'IGn7L
.,lrci-/.
T^I-mitt ;G /2.70291-S
ft, ft.
19.:SAND/GRAVEL"PACK
(1Lnppllcable)
FROM
TO
MATERIAL
EMPLACEMENTMETHOD
7 ft'
29 n.
`2 Seriei
a�' UrGc/ %UihrrX. a
ft,
rt.
20ARICIIING
LOa(attach:adtilttogal-shEetsl betes}ary)
FROM
TO
DESCRIPTION color, hardness, soll/rock type, grain size, etc.)
© ft.
C ft,
R a/1'i si i/-`1 �,
S ft,
/v ft.
l� e71 err? w e hety c 51•/f
10 It.
I2, ft,
ervi.,1 Sr / C( C.V ,
Izmir.
/ ft.
A/ gro lV�'1 SI ll
/S.- ft.
29 ft
7; ft „/I- 1 -,1a
VI n'
2.9 ft.
/G✓l
'f�
A Q SGtf r [�G7C�j�fll,�''
ft, ft.
✓ ✓J
.:2I i IiEMAitICS
22, Certification:f.44,4V-4 )62441.2
Signature of Certified Well Contractor
CE
©/v 2v2°
Dale
By signing this form, I hereby certify that the well(s) was (were) constructed in accordance
with ISA NCAC 02C.0100 or ISA NCAC 02C A200 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 Mall Service Center, Raleigh, NC 27699-1617
24b, For Inlection 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,

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
For internal Use ONLY:
1. Well Contractor Information:
Thomas Whitehead
Well Contractor Name
2907-A
NC Well Contractor Certification Number
S&ME Inc
14. WATER Z01%,I)ES
Mom To ftEscftiplioN
ft.
Company Namc
2. Well Construction Permit #:
List all applicable well permits (te County, Stale, Variance, Injectionlc.)
3. Well Use (check well use):
Water Supply Well:
0 Agricultural
OGeotherrnal (Heating/Cooling Supply)
Olndustrial/Commercial
cation
Non -Water Supply Well:
0 Monitoring
Injection Well:
DAquifer Recharge
ElAquifer Storage and Recovery
°Aquifer Test
0Experimental Technology
DGeothermal (Closed Loop)
0Municipai/Public
DResidential Water Supply (single)
OResidential Water Supply (shared)
Ditecovery
OGroundwater Remediation
D Salinity Barrier
El Stonnwater Drainage
°Subsidence Control
OTracer
00eothermal (Heating/Cooliry Return) DOther (explain under #21 Rema
4. Date Well(s) Completed: 9/15/20 Wen BM MW-48
Se. Well Location:
Colonial Pipeline
Facility/Owner Name Facility IDti, (if applicable)
14511 Huntersville-Concord Rd
P
b. 'Lcal Address, and Zip
Mecklenburg 01940102
County
Parcel Identification No.
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(ifwell fieW, one lat/loag is sufficient)
610606.396 N 1461638.047 E
6. Is (are) the well(s): 0Permanent or OTemporary
W
7. Is this a repair to an existing well: DYes or INo
If this is a repair, fill out known well construction inhumation and explain the nature of the
repair under tt21 remarks section or on the back of this fornt.
8. Number of wells constructed:
For multiple injection or non -water supply wens ONLY with the same construction, you can
stibnite one form.
9. Total well depth below land surface:
For multiple wells list an depths if different (example- 3 a',„,2 00' and 2(41
46
Aft)
10. Static water level below top of casing: N/A (ft.)
((water level is above casing, use "+"
11. 10
Borehole diameter: (in.)
Auger
12. Well construction raethod:
(Lc. auger, rotary, cable, direct push, etc.
5. OUTER CASING multi -cased wells) OR LINER ff applicabiet
FROM I METER 1 THICKNESS MATERIAL
T
16. DINER CASING OR TUBING tgeotfternalcIosed-loopi
1 FROM 10 WAMETER TFIRCIONESS MAT
+3
ft.
17. SCREEN
FROM
ri- 46 ft-
11
4
ft. 1ft.
ft.
Sch 40
in.
LOT SIZE THICKNESS MATERIAL
.010 Sch 40 1 PVC
18. GROUT
moist To
0
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
b. Disinfection type: Amount:
ft.
MATERIAL
Grout
entonite
L19. SAND/GRAvKL PACK tif a ticaileL
FROM TO MATEtUAL
i 8 it• 46 #2 $and
CET METHOD & AMOUNT
Tremie
Pour
20. DRILLING I,f.lt; (attach ad AI sheets if 11C+41;411 '
FR( i.14 TO EiscRIETION (taloa% hardross. soil/rock tJ1K- iiruyi size. etc.
0 ft* 140 Gray brown Silt
C MENJ METHOD
Pour
40
ft.
ft.
ft.
i 21.
46 ft. Gray Silty Sand
22. Cer "cation:
/
Signature of Certified Well Contractor
11,2
1C7716 )
Date
By signing this form, I hereby certify that the weeks) was (were) constructed in accordance
with 15A hICAC 02C .0100 or 15A ATCAC 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 Su ) ilv & In-ection 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 Envhoruneut and Natural Resources — Division of Water Resources Revised August 2013

NC Well Contractor Certification Number
WELL CONSTRUCTION RECORD (GW-1)
1. Well Contractor Information:
-J 4ene.5 -it J�
Well Contractor Name
` )? Y19 NOV 0 4 2020
Cascade Drilling, LP
Company Name MOORESVIILP REGIONAL. i)f=(:ICE,
2. Well Construction Permit #:
List all applicable well construction permits (i.e. 111C, County, State, Variance, etc)
3. Well Use (check well use):
Water Supply Well:
Agricultural
Geothermal (Heating/Cooling Supply)
l Industrial/Commercial
Irrigation
on -Water Supply Well:
Monitoring
Municipal/Public
DResidential Water Supply (single)
DResidential Water Supply (shared)
Recovery
Injection Well:
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
Experimental Technology
Geothermal (Closed Loop)
Groundwater Remediation
Salinity Barrier
OStormwater Drainage
Subsidence Control
Tracer
Geothermal (Heating/Cooling Return//\ /
) [Other (explain under #21 Remarks)
4. Date Well(s) Completed: ? l c. Well ID# 1 r / rt6 9 /
5a. We14Locat7
� t
C70/0el Poe
Facility/Owner
/dO] w(ner Name Facility IIID# ,jf applicable)
j ! / ilorief oh' & (o,Alct fd l�'l
Physical Address, City, and Zip
a, c klea 4u.1
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
N W
6. Is(are) the well(s) ermanent or EITemporary
7. Is this a repair to an existing well: Dyes or ONo
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 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: / r
9. Total well depth below land surface:
For multiple wells list all depths ifdii different (example- 3@200' and 2@100')
10. Static water level below top of casing:
If water level is above casing, use "+"
11. Borehole diameter:
12. Well construction method:
(in.)
c..
(ft.)
(ft.)
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
6
nternal Use Only:
FROM
TO
DESCRIPTION
ft.
ft.
ft
ft.
iS, 0t13lER
CASING rti4iOulti
sed', wells)."
It=ONUItliTpp 1146te ::
FROM
TO
DIAMETER
THICKNESS MATERIAL,
ft
ft.
in.
26 ==`XNNER
CASXNV R '
-111NG (eo herniHI
cIo4ed loon). „ it
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft.
ft.
in.
ft.
ft.
in.
:11; tESNR ,W ...;a', • a•,..ur.,
) .
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
0 ft*
ft.
in.
//�{� ft.
, ft.
it m
Ii to
/ j�
„1�C/)f 9
Qy'/�
pig,.
Syy�
:1 tlGROVLD. . ":..,, 4i .. ....f
sff st.:.... .r� ,� H�-: �,,. .....:fir ,. .-....y ..i ..Y:„..,. .„,i
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
(3 ft.
.7 ft.
'Teed—
//t°f�'1/1) /W
ft.
ft.
ft.
ft.
19:,;SAN»/GItAYE1eP.A(gftf
appi cgble) ;: ,: 1 .." • .
FROM
TO
MATERIAL
EMPLACEMENT
�EMPLACEMENTMETHOD
S®> ft.
(
(3, ft.
/
Cj/tLt a
//i, 1/`4,ea(
ft.
ft.
20; D1kI)
Gi iatJG
ddiffia Laheett I pecea$awy3 _ < , .. ,, i.;
FROM
TO
DESCRIPTION (color, hardness, soil/rock type, grain size, etc.)
ft.
ft.
ft.
ft:
ft.
ft.
kr
ft.
ft.
> s~L ct
e "
ft.
ft.
ft.
ft.
0 4' % 6 lea
ft
li,v YOC gc�tYt nit
IVft
{�
2IT2fA1tILS.e, ,. x+ldf34iJt.r,:i;' r;. J?'
22. Certificatio :
, 4
Signatu
e11 Con actor
9'/6'0W
Date
By signing this form, 1 hereby certtfy that the well(s) was (were) constructed in accordance
with 15A NCAC 02C .0100 or 1SA NCAC 02C .0200 Well Construction Standards and that a
copy of this record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTRUCTIONS
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

WELL CONSTRUCTION RECORD (GW-1)
1. Well Contractor Information:
j,
CS
Well Contractor Name
(,) v?er / .!
NC Well Contractor Certification Number N O Y 0 202n
Cascade Drilling, LP
Company Name
MOORESVILLE REGIONAL orf jC:j
2. Well Construction Permit #:
List all applicable well construction permits (i.e. (IIC, County, State, Variance, etc.)
3. Well Use (check well use):
Water Supply Well:
Agricultural
Geothermal (Heating/Cooling Supply)
1 Industrial/Commercial
Irrigation
Non -Water Supply Well:
Monitoring
Municipal/Public
DResidential Water Supply (single)
DResidential Water Supply (shared)
DRecovery
Injection Well:
Aquifer Recharge
l Aquifer Storage and Recovery
Aquifer Test
Experimental Technology
Geothermal (Closed Loop)
Geothermal (Heating/Cooling Retum)
Groundwater Remediation
()Salinity Barrier
0Stormwater Drainage
Subsidence Control
()Tracer
Other (explain under #21 Remarks)
4. Date Well(s) Completed: 9 r /.4% 1 Well ID#
5a. Weq Location:
C/ cf,v,a Pipe
Fa/ /
Facility/Owner /' FacilityIIID# If applicable)
des
Physical Address, City, and Zip
jig dlen
/ County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
N W
6. Is(are) the well(s)Permanent or oTemporary
7. Is this a repair to an existing well: DYes or R 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:
9. Total well depth below land surface: J J
For multiple wells list all depths if different (example- 3@200' and 2@100')
10. Static water level below top of casing:
If water level is above casing, use "+"
11. Borehole diameter:
12. Well construction method:
(i.e. auger, rotary, cable, direct push, etc.)
(ft.)
(ft.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
For Internal Use Only:
. i:" "' r1T15ES , ?.,: w ,,.. : : 33r ' :t-t .,.
- FROM
TO
DESCRIPTION
ft.
ft.
ft.
ft.
•I3;flUT"ERASING(forulultip.eased;Wells)OItL1t4itt
if€*p
lienble)`, ..:z 1.,:'r
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft
ft.
in.
6 12 NdR.CAS1I!IG•4a11.:
,VBIND,(deofberrttal`kte
ed:loop)' f...
.: _ t..r "St .:
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft.
ft.
in.
ft.
ft.
in.
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
0 ft.
ft.
in.
/3 ft.53ft.
it in
j !!a
�%%j
j(4e f0
AiC
r .. ,r,
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
ft.
C, ft.
[
7 f-0
Jf6,tet r ro ,
rt.
ft.
ft.
ft.
t 4$' (t;0A8*L
i?ii..
if ti tilicable� ' ;:
FROM
TO
MATERIAL
EMPLACEMENT METHOD
// ] ft.
ft.
54,
747-e,, ,,,,,ey
ft.
ft.
'Ai20 DRiLLIII0:1
G.:iaiiacliiiii
t$ofiatiheet8 tiiiti ssa' , ' r - s v,;
FROM
TO
DESCRIPTION (color, hardness, soil/rock type, grain size, etc.)
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
r
ft.
ft.
ft.
ft.
ft.
ft.
0 U j 2 b Z®ZO
24,12EtViAR3zS.r < . t
. iPk A , 1)411�€ , •„
4, {+rl � �
lrifOr51- c'
SCIIOn
22. Certification:
SignaturrfetlPtt=.`"ell Con liactor Date
By signing this form, I hereby certify that the well(s) was (were) constructed in accordance
with I5A 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 Welis: 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 Welis: 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 & 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-I
North Carolina Deparnnent of Environmental Quality - Division of Water Resources Revised 2-22-2016

rmt;Form
WELL CONSTRUCTION RECORD (GW-1)
1. Well Contractor Information:
-J 4' c5 /ail JP�
Welt Contractor
%Name % r 1/F I t
tr
NC Well Contractor Certification Number
Cascade Drilling, LP
NOV 0 4 2020
WQfl.( ,
Company Name MOORESVIL.I_t REGIONAL OKmmch'
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
n-Water Supply Well:
onitoring
DMunicipal/Public
Residential Water Supply (single)
Residential Water Supply (shared)
Recovery
njection Well:
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
Experimental Technology
Geothermal (Closed Loop)
Geothermal (Heating/Cooling Return)
Groundwater Remediation
Salinity Barrier
0 Stormwater Drainage
Subsidence Control
Tracer
['Other (explain under #21 Remarks)
4. Date Well(s) Completed: / 1 ti 6 40 Well lD# J►" l r
5a. Wel Locatio
C,/Dl0ta PI?e
Facility/Owner Name Facility 1D# f applicable)
/�//OX /It, ifrrs vl/ii— (oAJc v gt/
Physical Address,dCity, and Zip _,
tC aft Ej61✓4 L.�✓ r
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat./long is sufficient)
N W
6. Is(are) the well(s) 'ermanent or OTemporary
7. Is this a repair to an existing well: ljYes or DNo
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:
9. Total well depth below land surface:
For multiple wells list all depths indifferent (example- 3@200' and 2 a0100)
9C r
10. Static water level below top of casing:
If water level is above casing, use "+"
11. Borehole diameter:
12. Well construction method:
(i.e. auger, rotary, cable, direct push, etc.)
(in.)
Ef/t/IC,
(ft.)
(ft.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
For Internal Use Only:
14. V{ATER'ZONES
FROM
TO
DESCRIPTION
ft.
ft.
ft.
ft.
=15::01JTERCASING (for mull-eased'wells) OR LINER"(ifap cable)
FROM
ft.
TO
ft.
DIAMETER
in.
.:.
THICKNESS MATERIAL
16. INNER CASING Q
FROM
TO
ING (geothermal
DIAMETER
THICKNESS
MATERIAL
ft.
ft.
in.
ft.
ft.
in.
17.SC
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
0
ft.
ft.
in.
ft.
1 ;.GRO
it in.
/0/ a
.5c.4t 90
PVC
FROM
TO
b ft.
ft.
ft.
ft.
MATERIAL
I: Clt f
EMPLACEMENT METHOD & AMOUNT
ft.
ft.
19. SAND/GRAVEL PACK (if applicable)
FROM
13 ft.
ft.
TO
e fSft.
ft.
MATERIAL
9'3(.2 s��d
EMPLACEMENT METHOD
20.11R1LLING L+
FROM
ft.
TO
(attach additional sheets ifnecessary):<- .
ft.
DESCRIPTION (color, hardness, soil/roek type, grain size, etc.)
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
21.'REMARKS"
ft.
O C T 2 6.2020
lf'•I`r1f1'ntIon =rnceP,sInj Unit
C3t�Ji ; Sect",oil
22. Certification:
Signatur t e Con actor
Date
By signing this form, I hereby cert y 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 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 Sunnly & Iniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
completion of well construction to the county health department of the county
where constructed.
Form GW-1
North Carolina Department of Environmental Quality - Division of Water Resources Revised 2-22-2016

WELL CONSTRUCTION RECORD (GW-11
For Internal tJse Only:
RECEIVED/NCDEQ/DWR
6. Is(are) the well(s)JPermanent or DTemporary
7. Is this a repair to an existing well: ryes or gallo
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 GeoprobefDPT or Closed -Loop Geothermal Wells having the same
construction, only I GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled:
9. Total welt depth below land surface:
(ft.)
For multiple welts list all depths if different (example- 3Q200') and 2@100
'a
10. Static water level below top of casing: 2 `T
If water level is above casing, use "+"
11. Borehole diameter: tS (in.)
12. Well construction method:
(ft.)
(i.aauger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
1. Well Contractor Information:
Well
(aac/ %' Xau e1 Hcrlr/►�g70,2
Contractor Name LJJ
/-7 c7 q l�
NC Well Contractor Certification Number ,.��..
teila /ker 141'1 / CI Vi le'vnr/►'I e PI I
Company Name
2. Well Construction Permit #:
List all applicable well construction permits (i.e. UIC, County, State, Variance, etc.)
3. Welt Use (check well use):
Water Supply Well:
Agricultural
DGeothennal (Heating/Cooling Supply)
Industrial/Commercial
n Irrigation
Non -Water Supply Well:
Monitoring
Injection Well:
DAquifer Recharge
DAquifer Storage and Recovery
Aquifer Test
Experimental Technology
Geothermal (Closed Loop)
Geothermal (Heating/Cooling Return)
DMunicipal,Public
Residential Water Supply (single)
DResidential Water Supply (shared)
Recovery
Groundwater Remediation
Salinity Barrier
fStormwater Drainage
DSubsidenee Control
DTracer
Other (explain under #21 Remarks
4. Date Well(s) Completed: 7/ 23/2li20 Well ID# (VW -S2
5a. Well Location:
Cvlvneti% f t elie
Facility/Owner Name
fn+ers u, //e
Physical Address, City, and Zip
me/No
Facility MN (if applicable)
- Cov1Corcl P[.[i'/. Mt ei7LerSv, //e
22096,
( /9L/0102.
County Parcel Identification No. (PIN)
5b. Latitude and longitude In degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
d6
' 14. WATER ZONES v `' L v L .
FROM
' TO
DESCRIPTTON
ft.
n:
WQROS
rt.
'ft.
• MOORESVILLE HEGIUNAL Ui-HUE
13.OUTER
CASING (for
multi -cased wells) OR LINER (if ap llcable)
FROM
TO
DIAMETER
THICKI'1ESS
MATERIAL '
ft.
ft.
In.
. 16.INNER
CASING OR TUBING
(geothermal closed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
t rt.
22 ft.
q in.
.5C.A 410
p VC
ft.
ft.
tn.
17 SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
22 fL
.2 rt.
In.
i 0l0
,CCYI 110
PVC
ft.
ft.
In.
18..GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
/ 8 Et.
2 e it.
Pe //ASS
Poured r I - Aug 4.44.
v H'
(g «'
Ce m e rci-
s',4 Al i e b-
ft.
ft.
19:BAND/GRAVEL PACK
(If applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
20 it'
S2 It'
2 Sq rid
%,,vied /ViIru'/
ft.
ft.
20. DRILLING
LOG (attach additional sheets if necessary)
FROM
TO DESCRIPTION (color, hardness, solUrock type, grain stze, etc.)
o rt.
2.5 ft.
.S'r /f 4( C lay
2.3 ft.
2a fL
i9ry wti C.00. S 1�
20 ft.
3 . $t.
G� c sri
3), 4 rt,
2 ft.
yy y
6rA g Nrf $;
ft.
ft.
/ /
rL
rt.
rt.
ft.
21. REMARKS
22. Certiticatlon:
- .J: L / 2 2 N G7 t1r (/ ‘tJ 21 W 444t.4
Signature of Certified Well Contractor
1n/13 /2vZv
Dale
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 Constriction Standards and that ct
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 Simply & 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.

WELL CONSTRUCTION RECORD (GW-1)
1. Well Contractor Information:
�ranCi}S' x r�r er �rrihq
Well Contractor Name �L//
NC Well Contractor Certification Number
(,sla lker 14111 :: v>t'ormierti
Company Name
2. Well Construction Permit #:
List all applicable well construction permits (Le, 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
njeetion Well:
Aquifer Recharge
Aquifer Storage and Recovery
I Aquifer Test
Experimental Technology
Geothermal (Closed Loop)
Geothermal (Heating/Cooling Return)
4. Date Well(s) Completed:
5a, Well Location: Colt7nrrt 1 p rrc%is c
Facility/Owner Name Facility ID# (if applicable)
hu n erjl% -Concord I7l•+7-ersu1 %/e
Physical Address, City, and Zip 612' 67
DMunicipauPubiic
DResidential Water Supply (single)
Residential Water Supply (shared)
Recovery
Groundwater Remediation
Salinity Barrier
DStormwater Drainage
DSubsidence Control
DTracer
Other (explain under #21 Remarks)
24) Well 1D# 070./
m cc k /en &t•rt. 0I9 L/©I 02—
Coun
h Parcel Identification No. (PIN)
5b. Latitude and longitude In degrees/minutes/seconds or decimal degrees:
(if well field, one IaVlong is sufficient)
3�, y1Sy�9 N 90 8'©S'72 /
w
6. Is(are) the well(s)MPermanent or DTemporary
7, Is this a repair to an existing well: jYes or No
If this is a repair, fill out known well construction information and explain the nature of the
repair under #21 remarks section or on the back of this form.
8, For GeoprobetDPT or Closed -Loop Geothermal Wells having the same
construction, only 1 GW-I is needed, Indicate TOTAL NUMBER of wells
drilled: 1
9, Total well depth below land surface:
For multiple wells list all depths if different (example. 3(4200' and 2@100'}
10. Static water level below top of casing:
IJwater level is above casing, use "+"
11. Borehole diameter:
12. Well construction method: .On / C
(i.e. auger, rotary, cable, direct push, etc.)
(ft.)
(ft.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
For Internal Use Only:
RECEIVED/NCDEO/DWR
SEP202021
'14: WATEIZONES
'
FROM
TO
DESCRIPTION WORDS
ft.
ft.
MOORESVILLE REGIONA OFFIC
ft.
ft.
15. OUTER CASING (for multi•caled wells) O13'LINER Of ap !feeble)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft.
ft.
tn.
16.INNER
CASING OR TUBING
(geothermal
closed -loop)
_FROM
TO
DIAMETER
THtICK)NESS
MATERIAL
1L3 ft.
!1 0 ft.
i
(,j in.
t
,7Gt�1 ilt7
�}
J (I,C
ft.
ft.
to.
17. SCREEN'
FROM
TO
DIAMETER
SLOT SiZE
THICKNESS
MATERIAL
J iU y^f ft,
110
/ ,�y ft.
Wf!
ID.
0 t'� / d
SY2 11/0i C
v,_,
ft,
i
ft.
In.
18. GROUT
FROM
TO
MATERIAL
EMPLACEMENTMETHOD& AMOUNT
3 ifi ft.
3g ".
e f /C4,.,�(„
Poured 6 1 - f✓c: 4.14
f� fL
(j
a� ft.
y/
C medn !
)i►.MM,e / - �.��
ft,
ft.
19."SAND/GRAVEL
PACK'(II
applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
3 ft.
ft.
`2 .7
R red /oki1u e.
ft.
ft,
20. DRILLING LOG (attach additional sheets If necessary)
FROM
TO
DESCRIPTION (rotor, hardness, solVrock type, grain Axe, etc.)
ft.
ft,
No Sol
ft.
ft.
ft.
ft.
ft.
ft,
ft.
ft.
ft.
ft.
ft.
ft.
21. REMARKS
22. Certification:
Signature of Certified Well Contractor
to Y/2v2v
Date
By signing this form, 1 hereby certify that the well(s) was (were) constructed in accordance
with i SA NCAC 02C .0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
copy of this record has been provided to the well owner.
23. Site diagram or additional 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.
SUBMITTAL IN$TRUCTIONS
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 Mall 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.

WELL CONSTRUCTION RECORD (GW-1)
1. Well Contractor Information:
r/- nC/ S /au er ham?
Well Contractor Name �L//
NC Well Contractor Certification Number
(,(/a /ke r 14f'1 / k'ri u rvrbi► t e r14 /
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)
Drn
IndustTial/Comercjal
Irrigation
Non -Water Supply Well:
'Monitoring
Injection Well:
IAquifer
Recharge
Aquifer Storage and Recovery
Aquifer Test
Experimental Technology
Geothermal (Closed Loop)
Geothermal (Heating/Cooling Return)
For Internal Use Only:
14. WATER ZONES
FROM
ft.
ft.
TO
SEP 2 0'20?]
ft:
ft.
DESCRIPTION
wonos
E EGIONAL OFFIC
15.OUTERCASING (for multi -cased wells) OR LINER (if ap Ikabto)
FROM TO DIAMETER THICKNESS hIATERJAL
ft,
ft,
In.
• 16; INNER CASING OR TUBING (geothermal closed -loop)
FROM DIAMETER
f ft. In.
ft.
TO
13°' ff.
ft.
In,
THICKNESS
5&4.'o
MATERIAL
P vC
DMunicipal/Public
DResideniial Water Supply (single)
DResidentiai Water Supply (shared)
Recovery
Groundwater Remediation
Salinity Barrier
DStormwater Drainage
Subsidence Control
EjTracer
Other (explain under #21 Remarks)
4. Date Well(s) Completed: %/%R/2112QJ Well ID# Ma"— „5/111
5a. Well Location: %/
CJ[t7>rIKI/ Pii)C/l.?N
Facility/Owner Name /J /Facili y 1Dt/ (if applicable)
ITitFi+e6Si/J //e -Cottf.Urd/ /&, , Nimi,SU//k
Physical Address, City, and Zip 2-690)e
mecklen%,:irt: vi94/0/&z
County Parcel Identification No. (PIN)
5b. Latitude and longitude In degrees/minutes/seconds or decimal degrees:
(if well field, one InUlong is sufficient)
1.//S3/. N go, 512AO 9 9
17: SCREEN
FROM
ft.
«.
18. GROUT
FROM
I ft.
Q ft.
ft.
TO
ft.
ft,
DIAMETER
11 In.
tn.
SLOT SIZE
•0/0
THICKNESS
ScIZ Ljo
MATERIAL
10114 ,
TO
".
t / ft.
ft.
MATERIAL
Pe /%SS
Cc men*
19. SAND/GRAVEL PACK(If applicable)
TO
FROM
I ft,
ft.
a R.
ft.
MATERIAL
EMPLACEMENT METHOD & AMOUNT
POUrec;/ / / - &,✓c 414
/3,
EMPLACEMENT METHOD
e44//fiihrNf-d
20, DRILLING LOG (attach additional sheets if necessary)
FROM DESCRIPTION (color, hardness, solUrock type, grain size, eIc.)
0 ft, / p IT y ay, ft.
I * �3 ra wrI Si4 /J/•ivt.✓M G/ur
ci0(y S Lf
J/J
ft.
did
ft.
ft.
ft.
TO
ft.
ft,
ft.
ft.
/No
ft.
21. REMARKS
ft.
22, Certification:
W &Nei,
6. Is(are) the well(s)lPermanent or DTemporary
7. Is this a repair to an existing well: DYes or Fallo
If this is a repair, fill Out known well construction information and explain the nature of the
repair under 1121 remarks section or on the back of this form.
8. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction, only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled: /
9, Total well depth below land surface: _ 60 (ft.)
For multtple wells list all depths if different (example- 3@200' and 2@100')
10. Static water level below top of casing: (ft.)
If water level is above easing, use "+"
11. Borehole diameter: (in.)
12. Weil construction method: Sp/1 / (;
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm)
13b. Disinfection type:
Method of test:
Amount;
Signature of Certified Well Contractor Daatete ' I y/�ZV
%
By signing this fortn, I hereby certify that the welts) was (were) constructed in accordance
with ISA NC.'AC 02C .0100 or ISA NC/IC 02C ,0100 Well Construction Standards and that a
copy of this record has been provided 10 the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTRUCTIONS
24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Injection Wells: In addition to sending the form to the address in 24a
above, also submit one copy of this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c, For Water Supply & Injection Wells: Ln addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
completion of well construction to the county health department of the county
where constructed.

WELL CONSTRUCTION RECORD (GW-1)
1. Well Contractor Information:
(mac/ S' )(au/
Well Contractor Name
Harr/trig% ot2
l3 62q ,7
NC Well Contractor Certification Number
t,{1a /ker 1101 11 EloiCermoicerk/
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
Yon -Water Supply Well:
Monitoring
Injection Well:
DMunicipal/Public
DResidential Water Supply (single)
DResidential Water Supply (shared)
DRecovery
Aquifer Recharge DGroundwater Remediation
uAquifer Storage and Recovery DSalinity Barrier
Aquifer Test DStottnwater Drainage
Experimental Technology DSubsidence Control
Geothermal (Closed Loop) OTracer
Geothermal (Heating/Cooling Return) nOther (explain under #21 Remarks)
4. Date Well(s) Completed: %/Z9/ 020 Well ID# /Yl (, ®
5a. Well Location:
Col o1lie 1 Pi fichoe
Facility/Owner Name
Facility EN (if applicable)
NunTerS(I1 //e -Concord &. 1 47'ersvl//e
Physical Address, City, and Zip 2,61,15,
mcckIembi_rt: 0194/002_
County Parcel Identification No. (PIN)
5b, Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(Hive!' field, one laUlong is sufficient)
e.�'I s i.?� N ©. 90 99f /
W
6, ls(are) the well(s)fPermanent or DTemporary
7. Is this a repair to an existing well: °Yes or gallo
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: /
9. Total well depth below land surface: 6 2
For multiple wells list all depths if different (example- 3@200' and 2@a 100')
10. Static water level below top of casing:
If water level is above casing, use "4"
11. Borehole diameter: (in,)
12. Well construction method: pn r e;
i.e. auger, rotary, cable, direct push, etc,)
(ft.)
(ft.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
For Internal the Only:
RFC,FIVEDINCDWDWR
SEP 2 0`2021
1.4:)1ATERZONES
FROM
ft.
ft.
TO
ft.
ft.
DESCRIPTION
15.OUTER CASING (for multi -cased
FROM TO
ft.
ft.
DIAMETER
wan
MOORESVILL
OS
ells) Oli LINER (if ap Ilcab'le)
THICKNESS MATERIAL
tn.
16. INNER CASING OR TUBING (geothermal closed -loop)
FROM TO DIAMETER
4.3 ft. L/'i ft. In.
ft.
17. SCREEN
FROM
if 2. ft.
ft.
18..GROUT
FROM
Q ft.
ft.
TO
ft.
6? ft.
ft.
DIAMETER
In.
In.
THICKNESS
&/, 2.ev
in.
SLOT SIZE
-0/0
MATERIAL
p vc
THICKNESS
SCALio
MATERIAL
-RCE
TO
Y© ft.
3,9 ft.
ft.
MATERIAL
Pe l/SS
Ccmen*
19.'SAND/GRAVEL PACK'(ff applicable)
TO
FROM
Y© ft.
ft.
EMPLACEMENT METHOD & A.MOUNT
Ptvrcd //- �;,�4c
J�i'tm,ie
MATERIAL
fs2 S4,,u/
EMPLACEMENT METHOD
e/Iv;h��ff�
20. DRILLING LOG (attach additional sheets If necessary)
FROM TO DESCRIPTION (color, hardness solVrock type grain size,
© ft. E v ft, tQ S /?‘
la So ft. A47 S, /f
? i) ft. a ft. f
L�^ /
ft.lJ8 �I H Si //1
J ft.ft. J +y S /f*
-‘9 ft. a urn .5.4 SI /74
1O1 ft. 69 ft. G� y s/ /1- i
21. REMARKS /
ft.
Sir? ft.
1 ft.
Y&2°
Date
By signing this form, 1 hereby cert fy that the well(s) was (were) constructed in accordance
with ISA NCAC 02C .0100 or 1SA NCAC 02C .0200 Well Constrnuctian 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 Mall 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. F'pr Water Supply & Ini a ction 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.
22. Certification:
Aezilfa:* .t,44601 ":411/14,"
Signature of Certified Well Contractor

Physical Address, City, and Zip
Facility/Owner Name
WELL CONSTRUCTION RECORD (GW-1)
1. Well Contractor Information:
KanC/rL
S a er �r�rrr/,� 4
Well Contractor Name `J
Y.3 (9q ,q
NC Well Contractor Certification Number
t (/a /ke, J-(/ 11 �":� v;f 2? ;41e
Company Name
2. Well Construction Permit #:
List all applicable well cotrshuctt'on permits (i.e. VIC, County, State, Variance, etc.)
3. Well Use (check well use):
Water Supply Well:
Agricultural
r Geothermal (Heating/Cooling Supply)
Industrial/Commercial
Irrigation
Non -Water Supply WeU:
Monitoring
njectton Well:
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
Experimental Technology
Geothermal (Closed Loop)
Geothermal (Heating/Cooling Return)
4. Date We11(s) Completed:
5a. Well Location:
C€ /0,liet / Pt)C
DMunicipal/Public
DResidcntial Water Supply (single)
DResidential Water Supply (shared)
0Recovery
Groundwater Remediation
Salinity Barrier
Stormtvater Drainage
Subsidence Control
Tracer
Other (explain under 421 Remarks)
O/20io WeU m# mW '•-5'6
Facility EN (if applicable)
/'ft. 04-erS i/f //E ' CC7n Cord /) M711rrStr, //e
meckle,,J)s:t .
County
0/94/Oi02
Parcel Identification No. (PIN)
5b, Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one let! ong is sufficient)
3.4// N l?N S'O£ 2.
W
6. Is(are) the well(s)Permanent or OTemporary
7. Is this a repair to an existing well: rYes or No
If this is a repair, fill out known well construction information and explain the nature of the
repair under 421 remarks section or an the back of this fornn.
8. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction, only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled: /
9. Total well depth below Land surface: 6/0 (ft.)
For multiple wells list all depths if different (example- 3(4)200' and 2@a I00`)
10. Static water level below top of casing: (ft.)
If water level is above casing, use "+"
11. Borehole diameter:
12. Well construction method: .,cen / (;
(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:
RECEIVED/NCDEQ/DWR
S E P2 0 .2021
14. WATER ZONES
TO
FROM
ft.
ft.
ft:
ft,
DESCRIPTION WOROS
MOUHLSVILLE REGIONAI Ui-F
13: OUTER CASING (for multi -cased wells) OR LINER (if ap Ucnble)
FROM TO DIAMETER THICKNESS MATE/UAL
ft. ft, in.
16:INNER CASING ORTUBING (gcotherulai closed -loop)
FROM TO THICKNESS
I_"2 ft.
ft.
1V
ft.
17i SCREEN:
FROM
/0 ft.
ft.
18..GROUT
TO
ft.
ZiU ft.
FROM TO
/".. ft.
42 ft.
ft.
ft.
DIAMETER
IJ In.
DIAMETER
lo,
lo.
In.
SG/i 1v
SLOT SIZE
• 0 / 0
MATERIAL
THICKNESS
P vc
Sell go
MATERIAL
s) ft.
6 ft.
ft.
MATERIAL
Pe flc-iiS
Ceme
19 SAND/GRAVEL PACK (If applicable)
TO
FROM
e ft.
ft.
Lib, ft.
ft.
MATERIAL
EMPLACEMENT METHOD & AAIOUNT
Paired / l - & 4
;1,11 e /2
f'2 54 a
EMPLACEMENT METHOD
20, DRILLING LOG (attach additional sheets If necessary)
TO DESCRIPTION (calar, hardness, salUrock type, grain size, ete.)
et ft. erdwh st /, C/
rU ft. ifibi S/ /,�y /'she Se,a�f�
12 rt. Rrr/ tvH CZvey Si hi-
23 n. Gr.� £ e1 /S /f'
2 S rt. Or />l 66 e r S if
FROM
0 ft.
7 ft.
10
/2
ft.
ft.
Z� ft.
2 �ft.
ft.
E
yn fL
21. REMARKS
ft.
2�ertiflcation:
Signattue of Certified Well Contractor
Date
By signing this farm, 1 hereby certify that the wells) was (were) constructed in accordance
with ISA NCAC 02C .0100 or ISA NCAC 02C .0200 Well Construction Standards and that a
copy of this record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of'this page to provide additional well site details or weli
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 Webs: 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
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 depattment of the county
where constructed,

RECEIVED/NCDEQ/DWG
County
WELL CONSTRUCTION RECORD (GW-11
1. Well Contractor Information:
KCMC, Xacti er
Well Contractor Name
Lf 3 t9q
NC Well, Contractor Certification Number
W/Ia/kcr 1�1!! vit'ormi
Company Name
2. Well Construction Permit #:
List all applicable well constuction permits (i.e. UIC, County, State, Variance, etc.)
3, Well Use (check well use):
Water Supply Weti:
Agricultural
Geothermal (Heating/Cooling Supply)
Industrial/Commercial
Irrigation
DMunicipal/Public
DResidential Water Supply (single)
Residential Water Supply (shared)
Non -Water Supply Well:
Monitoring oRecovery
Injection Well:
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
Experimental Technology
Geothermal (Closed Loop)
Geothermal (Heating/Cooling Return)
Groundwater Remediation
(Salinity Barrier
DStormwater Drainage
DSubsidence Control
Tracer
Other (explain under #21 Remarks)
4, Date Well(s) Completed: /C/I/72‘) Well LD# t1CI! �7
5a. Well Location: /
cD/t7/1;U/ l t/oC/1,')
Facility/Owner Name / Facility iDN (if applicable)
Hu tifersrr, I/e - Con cord /�r,� /7/.171?rSvf //e
Physical Address, City, and Zip / 2_8f7iV
m cc /C ler! bitro o/9'/o162
Parcel identification No. (PIN)
5b. Latitude and longitude In degrees/minutes/seconds or decimal degrees:
(if well field, ono lat/long is sufficient)
lFor Internal Use Only:
'14.:WATER ZONES
FROM
ft.
ft.
•TO
ft:
15.OUTER CA
FROM TO
ft.
ft.
DESCRIPTION
MOOncsV
WOROS
1NG (for mulfi•casod wells) OR LINER (if tap 1cable)
THICKNESS �MATERtAL
16. INNER CASING OR TUBING (geothermal closed -loop)
TO DIAMETER MATERIAL
P c
ft,
FROM
1-3 ft.
ft.
17. SCREEN
FROM
iv ft.
ft.
IS. GROUT
FROM
ft.
TO
La. ft.
ILJ ft.
© ft.
ft.
TO
ft.
THICKNESS
Li In,
DIAMETER
I la.
tn.
lo.
SLOT SIZE
•D/D
THICKNESS
fell 41v
MATERIAL
C
ft.
6 ft.
ft.
MATERIAL
t
EMPLACEMENT METHOD & AMOUNT
t(pe //Ss POUred / r - /�:.c t�t4
Cm�rt trimMie
19.'SAND/GRAVEL PACK (ff applicable)
TO
Lis'°' ft,
FROM
tp ft.
ft.
ft.
DIAMETER
MATERIAL
In.
2 Sao)
EMPLACEMENT METHOD
pLre /fliibrc Le.
20. DRILLING LOG (attach additional sheets if necessary)
FROM TO DESCRIPTION (color, hardness, solUroek type, grain sisc, etc,)
0 ft.
era id,Pi S/ / Clay
3 rt. I u ft. 61401 w i t_ la eif I55i /72.
o-
w ft. (► ft. �� 5,11 7i oT
ft.
ft.
ft.
ft.
21. REMARKS
3
ft,
ft.
ft.
ft.
ft.
3 , //6/66 N ?o /4.ketatm
22. C ttfication:
Y�
6. Is(are) the well(s)fPermanetlt or DTemporary
7. Is this a repair to an existing well: cYes or gallo
/frhis is a repair, fill out known well construction information and explain the nature of the
repair under 421 remarks section or an the back of this form.
8, For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction, only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled: /
9. Total well depth below land surface: L
Far multiple wells list all depths if different (example- 3 a 200' and 2(Ea 100')
10. Static water level below top of casing:
If water level is above casing, use °+"
11. Borehole diameter: t5 (in.)
12. Well construction method: Seri / (;
(i.e. auger, rotary, cable, direct push, etc.)
(ft.)
(ft)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
Signature of Certified Well Contractor v Date
By signing this form, 1 hereby cert{fy that the well(s) was (were) constructed in accordance
with 15A NCAC 02C ,0100 or ISA NCAC 02C .0200 Well Construction Standards and that a
copy of this record has been provided to the well owner,
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTRUCTIONS
24a. For 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 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 & 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,
OFFICE

CTION CORD G�
1, Well Contractor InformaHon:
CO
For internal Ilse Only:
RECEIVED/NCDEQ/DWFI
Well Contractor Name
NC
We
ll Contractor Certification Number
Company Name
2, Well Construction Permit #:
List all applicable well consinteh'on per
3. Well Use (check well use):
Water Supply Well:
r',gncul'inal
Geothermal (Heating/Cooling OMunicipal/Puhlic
g/Cooling Supply) QResidcntial Water Supply (single)
IndusiriaVComn crcial
�gRasidential Water Supply (shared)
ndustI011
Non -Water Supply %;'clIt
nlcetIon Welt,
Ar Recharge
Aquifer Storage and Recovery
Aquifer Test
-perirrtental Technology
Geothermal (Closed Loop)
Geothermat (1-leating/C,;ciirag R
Groundwater Remediation
Salinity Barrier
OStomr,vater Drainage
0Subsidence Control
DTracer'
t cr eefr,l<.i❑ under #21 Remarks)
4, Date Well(s) Completed: /.IL 1zoZv
WeIIID# mw•S%p_
5a, Well Location;
Physical Address, City, and
5b. Latitude and longitude In degrees/minutes/seconds or decimal degrees:
(if well hold, one la/long is sufficient)
g €
22, Certification:
' fiER ZONE$
(OM TO 1 AFSCttI,�,
ft, ft; 140.0RESvvttE EGIO -A QEwFICE
ft,
SEP2 O'2021
7', t2
orm
ft,
revs
ft,
ft. I
AV3s lc ices ttf-ablloals,cr
ff
ft,
tali& UR I,IAFR ap lee b
It J--I THICKNESSTERtAL
` _"�
t, ft,
jL_ ft, , ---- tt -1-
ft.
ait.Rtll,..
tAt ict. re TatertD &A,
LeNTtrsryte`r"HCJ,Y
adilittrxna 1 sheds lif necessary — --
ntsciti t tosN. voter rs"decIl trolLL(l-k t
?
-�^..�-- �'tait€ set tit,
D® 6
6. Is(are) the well(s)
Parcel loenti tSCattfrD No, (PIN)
N ( fe6-Si) w
anent or DTemporary
7. is this a repair to an existing well:
IPt/rG tS a epailll r Yes or
repair under +i1 r r bra s `tvii rorr°all can' ibr;`w, eorrnarhrr <rnree ,,rin the nar of the
pfr
oP Drrt kn/rhsfornrt,
8. For t;reoprobe/DPT or Closed -Loop Geothermal 1Yells having
constraction, only 1 GWI is needed. indicate TOTAL dulled the same
AL NUMBER of wells
9. Total well depth below land surface:
For multiple wells list all depths I d(,yerent (example- and 2@1
10. Static water ,,, below top of easing:
j',+sit 1 csl iN` ab xr .
casing. iSF „_f.,.
I1. Borehole diameter;
(in.)
12. Well construction method;
e, auger, rotary, cable, direct push, etc,)
1 FOR WATER SUPPLY WELLS ONLY:
13a, Yield (pm) _T __
13b, Disinfection type;
Form GV/•I
Method of test:
Amount;
North Carolina Department of Er
(ft.)
24b, lea �lis: In addition t above, submit one co o sending the form to the ad
above alsooe to the following: of this fora; within 30dress in ell
days of completion of well
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center,
Raleigh, NC 27699-1636
24c Ec€r 1'4'ater• addess(es) abasectto6 yells: In addition to sendin ove lso ubmrs
rrpletion of well coast construction to the county coy of s
ty health department of th
de g the
• n
mt to
:vm within 30day; of
he:c constructed.
e county
ontnenta' Ouatio, - Division of Water Resnnteec
Ile rhtc fnr�a
A rvCSIC Q3e xt t tr+ veil()) as (were) et, tit acearFlt a;g•t
Ult3parrf9NC•�1C,U2C h5r °rlur record has been prortr:rd to t! well
lE'eii Corer. rrc(iar, Slrmdarrls and tttni r;
r v °h 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 it'necessary.
SUBMITTAL INSTRUCTIONS
•l 24a, For AAll Wells: Submit this fo
c.onstrt:ction to the following; mr within30 days of completion of well
Division of Water Resources, Intorntatic,tl Processing Unit,
1617 Mail Service Center
Raleigh, NC 27699.1617

WELL CONSTRUCTION RECORD GW-1
1. Well Contractor Information:
Well Contractor Name
NC Neil Contractor Certification Number
I
Company Name
2. WelI Construction Permit #:
List all applicable well construction permits (i.e, UIC, County, State, Variance, etc)
3. Well Use (cheek well use):
Water Supply Well:
Agricultural
Geothermal (Heating/Cooling Supply)
Industrial/Commercial
Irri: ation
Non -Water Supply Well:
Monitoring
Injection Well:
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
Experimental Technology
Geothermal (Closed Loop)
Geothermal (Heating/Coolin: Return)
(27 trlct
°Municipal/Public
°Residential Water Supply (single)
°Residential Water Supply (shared)
4, Date Well(s) Completed: Loh
Well iD# Mgt"-
5a. Well Location:
Facility/Owner Name
Physical Address, City, and Zip
County
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(itwell field, one Iatllong is sufficient
11
°Groundwater Remediation
°Salinity Barrier
DStormwater Drainage
Subsidence Control
°Tracer
Other (ex lain under #21 Remarks)
Facility 1D# (if applicable)
ortl
%/e
ra
Parcel identification No. (PIN)
alLite s' NG'�
6. Is(are) the weU(s)iPermanent or DTemporary
7. Is this a repair to an existing well: °Yes or If this is a repair, fill out known well construction is forntattbn and explain the nature of the
repair under #21 remarks section or on the back of this farm,
8, For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction, only 1 GW-I is needed. Indicate TOTAL NUMBER of wells
9, Total well depth below land surface: _ 4/9,
For multiple wells list all depths if different (example- 3Q200. and 2@I00')
1Q. Static water level below top of casing:
if water level is above casing, use ^+
11. Borehole diameter;
12. Well construction method:
(i.e. auger, rotary, cable, direct push, eta.) —�
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm)
Method of tort:
13b, Disinfection type:
Amount:
(ft.)
(ft
.)
For Internal Use Only:
2021
11110111111111
15. OTJTER CASING for multl-cased wells WOR LINLri 11 a, , Ucable
FROMTO D1ArrfETER
rt,ila3'iifiif�
16. INNER CASING OR TUBING : eotbermei elosed.loo,
FROM TO DIAMETER
ft.
17: SCREEN
DIAMETER
MOORESVILLE REGIONAL OFFI
SLOT SIZP,
THICKNESS
WOMMEMIllemor
11111.1111
!1!AcE:NTM
19. SAND/GRAVEL PACK if a „lrcable
FROM TO tfv
ETHOD & A, OUNT
EMPLACEMENT METHOD
20, DRILLING LOG attach addldanal sheets rf uecessa
FROM TO DESCRIPTION ratan a �.�
ft, h rdaesa, solVrcrk pe yraln size, etc.}
Mari
Watil
rr. ' to an - GIEc
,�'t'� Ct..
xil■ IIA�xxsO
22?,rtfIcatlon:
Signature of Certified Well Contractor
Date
By signing this form, 1 hereby certifi, that the well(s) was (were) constructed in accordance
with ISA NCAC 02C.0I00 or /SANCAC 02C.0200 Well Carnrtruction 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 INSTRrCTIONS
24a. For Aii Wells: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Information Processing Unit,
1617 Mall Service Center, Raleigh, NC 27699-1617
24b. For [Die Hon 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 Infection Control Program,
1636 Mail Service Center, Raleigh, NC 27699.1636
24c. For Water Su001v & InlecHnn Wells:
the address(es) above, also submit In addition to sending the fame to
completion of well construction to the countyy of thistform within 30 days cof
ounty
where constructed, health department of the county

RECEIVED/NCDEQ/DWR
WELL CONSTRUCTION RECORD
1. Well Contractor Information:
Gt
Well Contractor Name
e
NC Well Contractor Certification Number
Company Name
2. Well Construction Permit #:
List all applicable well construction permits (i.e, UIIC, County, State, Parlance, etc.)
3. Well Use (check well use):
Ho
GW-1
Water Supply Well:
Agricultural
Geothermal (Heating/Cooling Supply)
Industrial/Commercial
Im:ation
Non -Water Supply Well:
Monitoring
Injection Well:
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
Experimental Technology
Geothermal (Closed Loop)
Geothermal (Heatin. Coolin Return)
ro tin e
DMunicipaUPublic
Residential Water Supply (single)
DResidential Water Supply (shared)
Recovery
Groundwater Remediation
Salinity Barrier
DStormwater Drainage
Subsidence Control
Tracer
Other (ex lain under #21 Remarks
4. Date Well(s) Completed: Well 1D#
5a. Well Location:
Facility/Owner Name
Physical Address, City, and Zip
iG
County
Parcel Identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one Iat/tong is sufficient)
Facility ID# (if applicable)
11/ LP N
6. Is(are) the well(s)Permanent or DTemporary
7, Is this a repair to an existing well: Dyes or
No
IJthis is a repair, Jill out known well construction information and explain the nature of the
repair under #2I remarks section or on the back of this form.
8, For Geoprobe/DPT or Closed -Loop :Geothermal Wells having the same
construction, only 1 GW-I is needed. indicate TOTAL NUMBER of wells
drilled: ��
9. Total well depth below land surface:
For multiple wells list all depths if different (example- 3Qa 200 and 2@100')
10. Static water level below top of casing:
If water level is above casing, use "+. " (ft.)
11. Borehole diameter:
tin)
12. Well construction method: _Lsn I t
(i.e. auger, rotary, cable, direct push, etc.)----�._
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type:
For Internal Use
111111111111DESC
IIIMI
15. -- CASH ulfMINIMEd wells OR LINER if a .. peable
FROM TO -
11111111111111
WQROS
DIAMETER
16.INNER CASING OR TUBING Gq conformal closes e d-loo
FROM TO DIAMETER
.f" . ft. Li In. E' iIERfil I
■
DIAMETER
18..GROUT
SLOT SIZE
rnwr TO
IMMINIMI EMPLhIE1'I{OD & AMOUNT
IMINIMENI
19.^SAND/GRAVEL PACK RA . liable
EMEMBIIIIli PLACEhfENT METHOD
if
111.11111113
20, DRILLING LOG attach additional sheets if necessa
FROM TO DESCRIPTION color hardness, solUrock e, :
�� rain size, etc.;
rM f7
22. Certification:
Signature of Certified Well Contractor
Date
gning this form, I
y
ity
y i/5A NCAC 02C.0100eobr 154tNCACr02C,0200)Well ConshotcaStandards and Standarand accordance
withthat o
copy of this record has been provided 10 the well owner,
23, Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTR CTIONS
24a. Qr All Welk: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Information Processing Unit,
I617 Mall Service Center, Raleigh, NC 27699-1617
24b. For Iniection Wells: In addition to sending the fonn 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.
H
ZaZO

For I1(erirai tJse On
in under #21 Remarks)
4, Date Well(s) Completed: //! Well ID#��_
5a. Well Location:
Physical Addre
County
t�4 t�i CONSTRUCTION RECORD OW
—
1, Weli Contractor Information:
Well Contractor Name
NC Well Contractor Certification Number
Company Nara
2. Well Construction Permit #:
List all applicable well construction permits (L
3. Well Use (check well use):
Water Supply Well:
Agricultural
Geothermal (Heating/Cooling Supply)
Industrial/Commercial
Pater Supply Well:
tlolme
Yell:
'Atttti€ Recharge
aquifer Storage and Recovery
aquifer Test
Experimental Technology
Geotheral (Closed Loop)
Geothermal (Hearin t Dolma
UIC, Count}', ,Stine, Parlance, e
OMttnicipaVPublic
Residential Water Supply (single)
Residential Water Supply (shared)
Groundwater Remediatiou
QSalinity Barrier
DStormwater Drainage
Subsidence Control
DTracer
) •Other(ex la
Parcel Identification No, (PIN)
5b. Latitude and longitude in deg rcc, /lninutesiseconds or decimal degrees:
(livid' field, one lot/long is sufficient)
7
6, Is(are) the well(s)
anent or
7. Is this a repair to an existing
IfthrsLrarepo;fill"oat bnewn «oilthottlr
repair carder n21 retnar4 section or an the back
t?6
Temporary
N
talft»
dun jartn.
W
lain the nature of the
8. For GeoprobefDPT or Closed -Loop Geotitertual Wells having the same
construction, only 1 OW -I is needed, Indicate TOTAL NUMBER of ells
drilled: /
9, Total well depth below land surface: For multiple wells 71st all depths if different (example- 3u 200' and ; ? (fL)
@tin')
10, Static water level below top of casing:
ff water le' el Is above casing, use "
11. Borehole diameter:
12. Well construction method: -____ISt:
(i.e. auger, rotary, cable, direct push, etc,)
FOR WATER SUPPLY WELLS ONLY:
13a, Yield (gpm) Method of test:
13b, Disinfection type:
Amount:
Form GW-1
RE
14, WATER `ZONES --
ROM TO UT ON
ft.
ft
UTI
----,----.. p0RESVtl I F REGIONAL OFFICE
ea svolls tI %amyl+'
�� TO DLII4]i7
7 e
fink t'jit'T
Ir.'IiO, T�
ft,
--_L 2 0 ft, fPr
ft. I
ft,
t, ft,
]
ft.
ft,
711CX
�lJYMmic
B.A:4.EL?AC:K Irarllaabte
_.TO n1ATIMAI,.
Z{1.1]lili t ING lrt3C `: zttuchiadditluunj cheeks tf eecisar-
F RL]ht TO € nFer is u,', ION feeler
— ....
' t,retlljjrrc'.i�t 'e.�r�dnslrt �ic�.....
itI'.'Ffk:'rIi()
FL114ACkAl ;'FII
22, Certification:
_r sihetu g (/q,, /Snrr, I hereby certljy that the well(s) }vas (wen) cm
WWI 1.5.4 NC.-ft O2c. 010 ar 154 NC.1C 02C .0200 ;fell Constrct/
cope of this record has been provided tut the 'veil 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 f )necessary,
SUI3MII'i"'1'AL CN ")'RUCTIONS
24a, For AAJ1 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-I617
24b, For ln''ection 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 4Yater Su I & the In'ectton Wells: In addition to sending the form to
add ess(es) above also ubtmmit one. py of :o
completion of well construction to the county health sdep artmentform tlofn 3the0 dcount
ays of
where constructed,
North Carolina Department of Environmental Quality • Division of Water 12esre reee
in accordance
rds and that a

sr
WELL CONSTRUCTION RECORD (GW-1)
1. Well Contractor Information:
4-Cfn�; X 1/er kettrl'+ Iad1
Well Contractor Name
1.1389
NC Well Contractor Certification NumberW- -
i{1j'Cdf i211� �.�tlli'vii)?G'i17/ci/
Company Name
2. Well Construction Permit #:
List all applicable well construction permits 0.e. U/C, Comity, State, Variance, etc.)
3. Well Use (check welt use):
Water Supply Well:
Agricultural
Geothermal (Heating/Cooling Supply)
Industrial/Commercial
Irrigation
Non -Water Supply Well:
�• Monitoring
Injection Well:
Aquifer Recharge
i Aquifer Storage and Recovery
Aquifer Test
Experimental Technology
Geotherrnat (Closed Loop)
Geothermal (Heating/Cooling Return)
DMunicipal/Public
QResidentiai Water Supply (single)
°Residential Water Supply (shared)
Recovery
Ei Groundwater Remediatio❑
Salinity Barrier
QStormwater Drainage
Subsidence Control
Tracer.
Other (explain under #21 Remarks
4. Date Well(s) Completed: {U /V/2t)2t7 Well Mt/ i nw • 6.0
5a. Well Location:
C•C, Int9/J
Facility/OwnerName r Facility ED# (if applicable)
)
13?26 1 hlZrs(,ltlie • ConcU, J�4rl�Q SV�
Physical Address, City, and Zip 2�1 f7
McCklen lour,' Z8G"��
County ___ f c/ 2 / 2 / '
Parcel Identification No. (PIN)
51,3, Latitude and longitude In degrees/minutes/seconds or decimal degrees:
(if well field, one laUlong is sufficient)
33: Ll/2Yy7
N
6. Is(are) the well(s) e,Permanent or DTemporary
7. Is this a repair to an existing well: DYes or JNo
/f this is a repair, fill out known well construction information and explain the nature of the
repair under 021 remarks section or on the back ofthls 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: 17/
For multiple wells list all depths ((different (example- 801200' and •^ • -__ (ft.)
10. Static water level below top (leasing:
if water level is above casing, use
11, Borehole diameter: (in.)
12. Well construction method: �y7i(e
(i.e. auger, rotary, cable, direct push, etc.)
F0t2 WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13 b, Disinfection type: Amount:
(ft.)"
22� i fM '/ f METHOD
`2o;0RILTANG LOGS. attta:eh addltlonal sheets•If necossa". ,
FROM DESCRIPTION color hardness soli/rock re •rain size, eta,
MIMI Cr"
11141111111111
ZlrRE
'"1
For Internal Use Only:
RECEIVED/NCDEQ/DWR
14.'WATER `ZONES
FROM TO
ft;
ft,
WQROS
MOORESVILLE REGONALOF
15 OUTERCtiSIN 'foi:infii,:casedweps 0RL1NE1I lfa;,llcable
FROM TO DIAMETER THICKNESS
MA1'EitL1L
ft,
ft.
In
6aN14.IEI1.CrA51NWQR MITRING? : eetheruial cIosed-luo,
FROM TO DIAMETER -... THICKNESS
v ti
2
ft
In.
ft - ft. In.
f7: SCREEN
Se 4 4/0
ATERIAL
Pt A:
OM TO
ft ft.
t.
18;..GRO tT.
FROM
20
a
1/
ft.
imansimi
POURIMMI
19.;SAND/GRAYEUPACK If
TO
FROM
ft,
DIAMETER SLOT SIZE THICKNESS
In.
In.
JOIO
MATERIAL
Pv'•
TO
MATE
EMPLACEMENT METHOD & AMOt1NT
7a I
r
TO
22, Certification:
ft
ft,
ft.
tt>
GIB
a
5
d
Dale
B
g this form, I
with
111 NC,4C 02C,0/00 hereby
1SA NCeICt 02C.02e 00)Well Construction Standaed rds fun'
!hint 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 Webs: 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 Mall Service Center, Raleigh, NC 27699-1636
24c. For Water Suy & Inlection Wells: In addition to sending the form :o
the address(es) above, also submit one copy of this form within 30 days of
completion of web construction to the county health department of the county
where constructed.
Signature of Certified Well Contractor

CON
1. Well Contractor Information:
'1i
Well Contractor Name
LY.3,9
vONWCORn(. CW-ij
NC Well Contractor Certi: cation Number
Company Narnc
2. Well Construction Permit #:
List all applicable well conshaterion pe
3. Well Use (check well use):
Water Supply 1Yeli:
Agricultural
Geothermal (Heating/Cooling Supply)
Industrial/Conutie:uial
its (i.a
Non -Water Supply Weil:
:v4cnii�;ling
Injection Well:Recovery
:Aquifer Recharge Groundwater Remediation
.Aquifer Storage and Recovery
Salinity Barrier
r quifer Test
DStorntwater Drainage
Experimental Technology
Subsidence Control
Geothermal (Closed Loop)
Tracer
Geothermal (Ile ting/Cooline, ltetunto rOther (:xplai under 421 ft
DMunicipal/Public
Residential Water Supply (single)
OResiden ial Water Supply (shared)
4, Date Well(s) Completed:
Well ID
5a, Well Location:
/Owner Name
Physical Address, City, and Zip
County
ty tD (lfapolicahl
Pavel Identification No. (PLN)
5b, Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if weft field, one larrhns is sufficient)
231/
6. [slate) the weil(s)Mpermanent or DTemporary
7. Is this a repair to an existing weB: Yes or tallo
if ltti is rrr
swab-, fill our knu wt well room s. wit ur a.d explain the nature of the
;nuiru;OW i 1 r a;a,-/ ar?alon or thdbuckaj;irisjur
S, For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction, only I GW I is needed. Indicate TOTAL NUMBER of wells
9. Total well depth below land surface:
For multiple wells list all depths nfdifferent (example 3@200' and 2 ri'(� lon;
10. Static water level below top of casing:
1; dater levet is above casing,
11. Borehole diameter:
(in.)
12. Well construction method:
e. auger, rotary, cable, direct push, etc,}3 t
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm)
Rlcthod of test:
13b. Disinfection type;
Amount:
111 [1Se Only:
RECEIVED/NCDEQ/DWR
14. WATER ZONES
i„ 1'ttt);4 i .._....,I TO _,._..,_..........: DVSCRIP73r)N. ....
ft.
_ WOROS
ft. rr SVILL EC atslAt
S. OIJTP,R CA It3G #or tuu1u eased well
'ROM TO DIA
ft. , rt,
FROM
f' ft.
ft.
7,
K`LtiyL''il }#a 4eable
TI{ICtc tiE59._.,_...._ Mouton
NO ld T'UBI1 G ,eo(Tterand eloaed.loo
In.
Tf? _E Dt:11rhlYft Sfti
ft.
IR. GRt")Ct'1"
I uos-i �t�u,
33 wit.
9, Sri11U/C RAYLI, PACK �If app lei to ____T
3 ft. -Y
ft. �" ,II
ft
20 DRILLING
t Ittat7 LOG attach additional�hectr i€accds4plt
10 '�.-& lti3fi rotor, hardness stritfxoc t
.-. .. � ns acLu Erb sa. 2a..._.._.
afAT oust .......
tr11L'<1kSS ( AIAntrum.
Ebirt CT ki\t VIETNUD @ ,1.Sin
20
67 ft.
ft, i
22. Certification:
ft.
!PIACb �tFl
ap ;IV_... S,
I4 _.
woLticr1
Signature of C nutlet hell Contractor
Date
By signing this form, 1 hereby certiA, that the we'll',) was (were) constructed in accordance
with i5.4 .11C4C 02C.0/00 or /5,4 ,VC'RC 01C .0200 Weil Construction Standard., and that n
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
IONS
24a, For All WetJ . Submit this form within 30 days of completion of well
consmltction to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For !n'tictinn 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 Muil Service Center, Raleigh, NC 27699-1636
24c. For Water Stu". Iv & lu'eetion Wells: in addition to sending the form to
the address(es) .(hove, also submit one copy of this font within 30 days of
completion of well construction to the county health department of the county
where constructed.

WLL C".ONS:l'IZUC1'ION RECORD GN'V-1
1, Well Contractor Information;
Well Contractor Name
y3 S
NC Well Contractor Certification Number
Company Name
2, Well Construction Permit #:
List all applicable well construction permits (de. UIC, County, State, Varian
3• Well Use (check well use):
ply Well;
Agric.tliurctl
Geothermal (Heating/Cooling Supply)
dustrialtC.ommetcial
. Non -Water Supply W
l4'Ion (uoriti
:lion Well:
Aquifer Recharge
filer Storage and Recovery
Aquifer Test
Experimental Technology
Geothermal (Closed Loop)
Geothermal (IleatirP/Coolie*. Return)
to)
EjMunicipal/Public
Residential }crater Supply (single)
OResidential Water Supply (shared)
der #21 Retntuks_)
4, Date Well(s) Completed: %/ %QZ Well ID#
5a, Well Location:
Facility/Owner Nama
Physic
Country
EDGroundwater Remediation
DSalinity gamer
Stormwater Drainage
Subsidence Control
Tracer.
Other (
1/4
LI Pa; Identification eta__
No, (p
5b, Latitude and to igitude in degrees/minutes/seconds or decimal degrees:
(if well.field, one ladlang is sufficient)
(o
6, Is(are) the well(s)
neat o
<1
7, Is ItIIS a repair to an existing well: Yes or No
/Prhis is a repair )ill Dirt htawn well an iracito ra crrruittort art, rapfain the nature of the
repair under 1121 remarks section or „n the bark -' •a....:.. .
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: �_-L
9, Tutul well depth below land surface:
!'oa' multiple :veth list all depths 1Jdi)jcr'rrt (example- 3 ;200 and 2@1o0`)
10, Static water level below top of casing;
Ij water level itabove ea:, r,g, rise •_: ,. (ft,)
11, Borehole diameter: (in.)
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:
Form (JW'.t
North Carolina Department of Enviroranenta
For internal i.)se On!y:
14. }Yd7'.BR'2t)?
FRO t41 3TO
RECEIVED/NCDEQ/DWR
......... ft. ff ....,___.__....,.�,._—..
fL ft, i MOO SVI
E��
�- r r�usysvri� vi
_lS OVFFR CASLNG.`foi•;' ttlul— tbcnscil tv jAr)li l:.t< IIR (lf u)r Ilcoble)_
moat Tn DIAINIrrEit
---�� I'IiICLNhSSVATEIIiiiL ,.....�_.
6.'i2S�i ltGhSI15 G
©1i' L1SFN;(gebtjertua ip L/!LL__._
Fn0:4i 1'O DaMETteR I`,t
• r "-
0. ft• - lc'KNFSS i SIA'1 ;kHIQC, _._.
In,
LA ;4f E'r'En
ft. ) In.
ft, 1
0I
''20.•lei
•rti.__.. hi
ft, ft.
ft, rt.
ft, ft.
[5t+
le
._r. TO IHATE,RL1L fall LACE:M1i>a\'7`i11 ft. I ft ------..
0'SIGL:_..1 fII1cIO:E4S
ROIPt,ACE.i'4rF:i
I10ii H LN U.
ft,
ft
r`f#G��t{tfach�prirfi'flnorilshcetcsnceessar�:} ---._.._.._.__L
r)P$CRrn9ION (enta 6armcss svn+rorkip,, Rrat)t xlcF va -s '"--
I ft I1 1 i1
ett
22, Certification:
'stied
riotg this farm, ( hereby ees t j that the well was (were) construct
with r S4 // 'AC 02C,0100 or 15,4 Ne c, 02 C WOO We11 Court uctioa Sta,
co,rsy of this r oovi d his Gaon pravided to the well owner.
23, Slte 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 uecessary.
SU13M1`1"I'AL INS`1'RC1C'l'IC1NS
24a, 11 Wells: Submit this form within 30 days of completion of well
omit ction to the following:
Division of Winter Resources, information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b, For. lnicmion Welt In addition to sendin t' s
above, also submit one copy8 the .ono oftthe lesion i' well
Construction to the followinof this Corse within 30 days completion of well
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c, l or }Vater tie a rl< 3t 1n'cc i nn 1}<<Ils: 1n addition to sending the form to
the addres (aa) above, also aubtnit tsar ceps of this form within 30 days of
completion of well construction to the county health department of the county
where eonslrreted,
I Oualtty - Division of Water Resm,rnrs
in acoo done,
rti and Mat It

1VELL CONSTRUCTION RECOR.
1. Well Contractor Information;
'•ra_tC/j.
Contractor Name
NC Well Contractor Certification Number
11ce/' 1
Company Nunn
2. Well Construction Penult #:
Lis! all applicable wail consF, uction permits (1
3, Well Use (check well use):
Water Supply Well:
tjAgrir_itliu ai
ueothE nml (plea •n ;:Cooling Supply)
ustrlal/Commercial
'EJgt
er Supply Well:
r;
:tilt
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
t xperimental Technology
tat (Closed loop)
then l ('1 t g/� i
fit:, Corn
/lance, etc,)
DMunicipaLpuh;ic
Residential Water Supply (single)
QResider.tial Water Supply (shared)
etc)vsty
Groundwater Remediation
Salinity Barrier
DStortnwater Drainage
Subsidence Control
D' Tracer•
/ :marks)
4, Date Wellf i�//
s) Completed: 22 Well LIM _ i
5a. Well Location:
f?
Pacility/Owner Name
a t. cn ut too ing Return) Othcr'expl"rn
under t d #2` R
l�n
nystcal .dines%, City, and Zip
County
Parcel Liiflcaticr: Ne. (PIN)
5b, Latliude and longitude In degreesilulnutesisecends or decimal degrees;
(if weal field, one'at/leeg is sufficient)
6, Is(arc) the well(s) Permanent o
7, Is thls a repair to an existing well;
/fthi to a repair; fill out known well construct,..,
repair finder nil remarks.rection or on the b;i,,k
Temporary
s or No
nation and explain the nature of the
8, For Geoprohe/DPT or Closed -Loop Geothermal Wells Laving the same
construction, only l GW•': is needed, Indicate TOTAL, NUMBER of wells
drilled:_...
9, Total well depth below laud surface:
Fa' muttiale %veils list ail depths if different (example Ai_ san"
„;Si✓o
10. Static water level helow top of casing:
If n'ater'ievcl is above casing, use +.
11, Borehole diameter:
(in.)
12, Well construction method:
(i,o, auger, rotary, cable, direct push,
FOR WA SL'PPL7' tiVELLS ON
I3a, Yield (gpm) Method of test:
13h, Disinfection type: Amount:
(ft.)
(fit.) -
r internal Use Only:
fit,
ft, fL
7`LF[t CAS lf £G ffoi
ft, ft.
itV�t l;C,iRING tii'ttIB1Nt caf e
Ott Co 111 ETEI
ft. ft j In,
It
E. 11PTtc)
RECEIVEDINCDEQIDWRI
--- -WQHQS
dulgpeE_SVILLE REGIONAL OFFICE
NI we U( LINER (if op livable) 1
itT&It THICKNESS ,MAT61t1Ai__
—1
al•Claw,! to
F11Ciii145 vtA'rb3MMAL
sLu r SIZE _ I
In,
ft, ft.
fit, It
tC1Ll;fytTo x Lf3(;,'itttath adilltirrnul
nE;SCEIP`1
fit. t fit, g
ft, ft,
ft, ft.
t. ft.
fL ft,
ft.
KS
22, Certification:
f tweet a
r.hartne
•
'h1PLA u't`rr41 r M1 1`I100
elllroektype, a all4
L'_ 1
Date
ur f this poll, 1 hereby certift that the IMR(rt liras (were) constructed In accordance
ISA NVCAGp2C 0100 or /SA NCAC 02C ,52Q02C ,0200 Welt Construction Standards and that a
copy of Ws 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; Suhmit this form within 30 days of completion of
construction to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Servicee Center, Raleigh, NC 27699-1617
24h, Uor Inicctlots }yells; n addition to sending the form to the address in 241a
above, also submit ¢ate c;vpy of this form within 30 days of completion of well
construction to the Co/lotting:
Division of Water Resources, Undergrr,und Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c, I or Water So & In(ecilon Wells: in addition to sending the form to
the address(es) above, also submit ono copy of this ;lanai within 30 days of
completion of well construction to the county health department of the county
urhere c rtsstructed.
11

Groundwater Remediatioa
Salinity Barrier
IStormwater Drainage
D+ Subsidence Control
Tracer
ring/Cooling Return) Other (explain under #21 Remar
4. Date Well(s) Completed; 1 /1/5/202© Well MN ry1(.{/'- 62 fl
Sa. Well Location:
!O%Dial Pipeline
Facility/Owner Name lr
Physical Address, City, end Zip
/�
lY1�r. klcn C�ttro 0172/212
Conn:),
Parcel Identification No. (PIN)
5b, Latitude and longitude In degrees/minutes/seconds or decimal degrees:
(if well field, one let/long is sufficient)
fr7092- t, LN
lc/4lS)f©. /9 ,
6. Is(are) the well(s) Permanent or (Temporary
7. Is this a repair to an existing well: }J}res or ¢ sNo
/I his rya repair, jilt ala k atva well consinrettnn it(/l 1 aa3ion an
repair' wulee 021. remark section „t on the book of MU jorrir,
the nature of the
3, For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction, only I GW-I is needed. Indicate TOTAL NUMBER of wells
drilled:
9, Total well depth below land surface:
For multiple wells list all depths if dWerent (example- 3@200' and 2 a 100)
I(1 Static water level below top of casing:
Si ore, levela rhFtue ertsing.:ire , (ft,)
11. Borehole diameter:
WELL CONSTRUCTION RECORD (G`V-1)
I. Well Contractor Information:
ha/10'5' Xavier l-/grrin
Well Contractor Name
NC Well Contractor Certification Number
u%/Icrr Hill EA info/71)1eh
Company Name
2. Well Construction Permit N:
List all applicable well cunshucnbn permits (Le, UIC, County, State, 'rariaece, e1c)
3. Well Use (check well use):
watt-r supply Welt:
[Agricuinlral
Geothermal (Heating/Cooling Supply)
trig u s tri a L'C o trrm etc is i
g- 'ott
Non -Water Supply Well:
Iap:ctiva Weal,
oMunicipal/Pubtic
['Residential Water Supply (single)
['Residential Water Supply (shared)
y
Ayuiter Recharge
uifer Storage and Recovery
A.quifer Test
Experimental Technology
Geothermal (Closed Loop)
eothermal (I
(in,)
12, Well construction method: `,..),V IiC
(i.e. auger, rotary, cable, direct push, etc.)
se
(ft)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test;
13b. Dislufeehon type: Amount:
,.'29..DRILLtlNG 1.i7fy-`Kaftaile nctttlttonal sheets rf ueccseser:i
i'ROM TO DESC13-1-r 3(I/ icolor tsvrtrosy, actara�L�ty r, 2rkbi shx
ft, Li
s
For Iutertt;tl Use Only:
RECEIVED/NCDE©/DWR r
I,4:WATE
t0M
ft.
TO
ft.
5. G3/1'Is- i CAASINC'(
FRO
ff,
DESCHIP1
St i 2
WOROS
MOO- ES�7ftLEREGIONAL-OFFICE
tl=atuati tvrlli
I:.4'4ab
In,
siti~S1iYCr:{i7%TEIBt1G'(I;ctitpeji
To
't• ff, j
ft,
ON t TO
ft,
t,
B ,CI30CJ.T'
ROM
O ft.
FROM
-iN1 1i- It's r lleabli)
UICKNESS h'fATRIIIAL
S� ! L/v P (
closed loop)
vss 1rYterrRty>
ft,
_ DIAMDTRIll
In.
Ti
^I13r it t urL PAC
ft.
ft,
ft,
0601 if
ERYPt.ACEhtRi3TM ('I{€ t
EMPLACEMENT METti0it
...‘a et. 0! o Pt
22, Certification:
/2.1? /202a
Dave
by .,erltag i/Ifs 1»9rt, l !rCrtbiy cerlr%y Thai She We i(s) Wa (were) eanSBIt tee,
with / SA N1'AC 02C.0100 or 114 ,VC ir) i 2C .,0200 5F // Cone014c;irr1 Stunts
cop), oj't/rr`s record has been provided to elle we/1 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 pttgts if necessary,
SUBMITTAL INSTRUCTIONS
24a, Ear All Welts; Submit this form within 30 days of completion of well
construction td the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
PI aCCOIVIanc
fr t t/ Mat t
24b, rot Infection NVells: 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
24e, ,For Water Supply & Infection Wells; bI addition to sending the form to
the add ess(es) above, also submit one copy of this farm within 30 days of
completion of well constriction to the county health department of the courry
where constructed,
Form C W-1
North Carolina Department o
nviro
ental Ouatiry - Division of Water Remnrees

hater Supply Well:
Agr'cultural
ernaai (Heating/Cooling Supply
dustriaL`Com uterc'a l
Nun -Water Supply Well;
Monitoring
njeetian Well;
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
1'sxperin,cntal Teciwology
eat n;thal(Closed Loop)
Geothermal (1°Ieating/Cooling Rehm))
4, Date Well(s) Completed;
Se, Weil Location;
I.LLzkI
Facility/Owner Name
Physical Address, C
County
,
, and Zip
'.tJiL CONSTRUCTION
1, Well Contractor Information;
if
Well Contractor Name
NC Weil Contrector Certification Number
Company Name
2. Weil Construction Permit #:
List all applicable well conshwction parrnils (t'eU'C County, Slate; rarrance
3. Well Use (cheek well use):
COI. Z fGW-
OtvlunicipaVPublic
) QResidential Water Supply (single)
Residential Water Supply (shared)
Groundwater Remediation
0Salir;ity Barrier
0Star1nwater Drainage
Subsidence Control
Q T racer
Other sex trot; under #21 ltentarks)
Z© VVeU ID#
Facility IUii (if appiicable)
Partial identifioation No, (PIN)
5b, Latitude and longitude In degrees/minutes/seconds or decimal degrees:
Orwell field, ono iat/Iong is sufficient)
S74/
6. Is(are) the well(s)
v (7. 0-;'
manent or
r to an existing we
of out known wellcalrarruc n
tton izrfoP�,
efnarks wort ,j 01`01 rhoback csf`the
Temporary
7
explain the nature of the
8. Fur Geoprohe/DPT or Closed -Loop Geothermal F1^`clls having the same
construction, only 1 OW 1 is needed. indicate TOTAL NUMBER of wells
Grilled:
9. Total well depth below land surface;
For multiple wells list ail depths if different (example- 3@20�t`a,f:l2@I00')
10, Static water level below top of casing;
If waterlevel is above casing. use .° "
11. Borehole diameter;
12. Well construction method; �f9liiC
(i.e. auger, rotary, cable, direct push, etc..)
FOR WATER SUPPLY WELLS ONL
13a, Yield (gpm) Method of test;
13b. Disinfection type;
Amount,
Form G11f•1
W
(ft.
(ft.)"
terna1 Usti July:
ROM _ r0
ft. ft:
tt ft,
li; °at3: I*R G,1rsrNcr fe
rRUtri •rn ...
UM TO
r2 r. ft
G9) ft. ; fL
ft.
SAr it/GR'A
ft.
ft. , ft.
22. Certification;
sCR1PTtvv
WQROS
—MOORFSVILLE REGIONAL OF
021
)4FTt�Jf' pileablu)
[chinas maTERtAi,
llrAlvr!O'ER 1'1❑CI• V S
SCh yp
1n,
IAhrLTrR
U ln.
tractor
il•H signing, this. /srr, 1 hereby iurtif,Y riial (ill (were) constructed in ocroi ilrlllCis
with 154 AIC.4C 02C 9/011 e t.5.4 Nc.lc 02 ` 0200 TS�e//Comm-action Standards and that
u opo ujthiv record hos bees prom -Yea' to Ow wet' owner:
23, Site diagram or additional well details:
You may use the back of this page to provide additions1 well site details or well
construction details, You may also attach additional pages if necessary.
SUBf1ft'1" I'Al.. INSTRUCTIONS
24a, For All 1}/oils: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Ir •'luatinn Processing Unit,
1617
LOT SIZE, 1 illC:Sf Vaa' ----1
r,�cr;lihta,
;0!©
IVIrit \:
C'1 MEN'f Ni K1:11 0
tJtdr�l
iGw cx..).
v:(velar h r�es�, unit eel; ttyp. p/ratn aus e€�:r
fi a ,y
SA
D
Mall
Service Center, Raleigh, NC 27699.1617
(in.)
24b. For Injeciln rt �yelis; In addition to sending the than 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
lac For Water Sir Wr•ll
)1j. a L:iectiurl s In addition to sendinghe tbrrn to
the address(es) above, niso submit utI copy of this form withi30 days of
completion of well construction to the aunty health department of the county
',were constructed.
North Carolina Department ofEnvirorumental quality • Division of Water Reannrne.c
ICE

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
1. Well Contractor Information:
Kevin White
Well Contractor Name
2973
NC Well Contractor Certification Number
Parratt-Wolff, Inc.
Company Name
2, Well Construction Permit #:
List all applicable well pernt/r (i e. County, Stall. 1'ariws,, hrj
3. Well Use (check well use):
Water Supply Well:
on. elc.l
❑Agricultural
❑Geothermal (Heating/Cool
O Industrial/Commercial
O irrigation
❑Municipal/Public
ng Supply) OResidential Water Supply ("single)
❑Residential Water Supply (shared)
Non -Water Supply Well:
CZ' Mon itoring
lnjeetitrn Well;
OAquifer Recharge
DAquifer Storage and Recovery
❑Aquifer Test
OE_xperimertal Technology
DGeothermal(Closed Loop)
C7Geothermal (Heating,/Cooling Return)
Recover
❑Groundwater Remediation
❑Salinity Barrier
DStormwater Drainage
❑Subsidence Control
❑Tracer
❑Other (explain under #2 Remarks)
4. Date Well(s) Completed: 12-19-20 Well ID# MW-64
5a. Well Location:
Colonial Pipeline Company
Facility/Owner Name Facility iDO (if applicable)
14511 Huntersville-Concord Road, Huntersville, NC 28078
Physical Address. City. and Zip
Mecklenburg
County Parcel Identification No (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
Orwell iield, one tat/long is sufficient)
35.413329 -80.804060
W'
6. is (are) the well(s): I21Permanent or ❑Temporary
7. Is this a repair to an existing well: ❑Yes or CriNo
this is a repair, fill out Anou,, well construction information and explain the nature it the
repair under r2/ remarks section or an the back of this farm,
S. Number ofwe►ls constructed:
Far multiple injection ar nun-water.supply wells ONLY with the scone eana'tracItan ;nx can
.suhniit one farm
9. Total well depth below land surface: 70
For multiple wells list all depths fd/jJerent (example- 302( ' and 2@/00')
1/water /eesl a ahoye casing, use
11. Borehole diameter: 2 (in.)
12. Well construction method: 8 1/4 HSA & 2" spoons
(ieauger, rotary: cable, direct push. etc.}
19. Static water level below fop of casing: 40 (Et.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm)
13b. Disinfection type:
Method of test:
Amount:
Form Gw-I
North Ca,olina 1.)epartmert of Envies -mown
RECEIVED/NCDEQ/DWR
For Internal Use ONLY:
SEP2 02021
14. WATER ZONES Ile - w
TO
DES RI _ r . �erOht�.�i.�=��
40 ft.
70 It.
r • ti
ft.
IIIINIIIIIIIIINIIIIIIIIIIIIII
() R Ar con to eased'weAMIIIIIIM
TO D1 /MFTFR MATERIAL
ft.
ft.
1y !TsINER
(mil 1i+rt OR TI P1 ( ua€lti 'fnrt.naati. uirte l
EMEMMIIjEI
MATERIAL
0 ft.
MU
sch40 sch40 pvc
in. IIIIIIIIUII
t�
IIIMMEMall MATEHIAL
Mill 70 ft.
.010 sch40 pvc
M_..
_11111■1■,11
IL
rGROUT
aaaiyta! TO
C?.STPI..t('FMINT METIIDII g .0.1fltINT
0 ft•
30 rt.
Portland Cem
Tremie
30 ft•
ft.
Bentonite Chi 1_-.
IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII
19. SAND/GRAVEL
PACK if a u... ,, e
1�
Af iTERI.tL EMPLACEMENT` METHOD
70 ft.
#1 Sand �I [
ft.
1 =�,:;a�
�I,r';eais auetssii..'
111=1.111
ft.
ft.
ft.
ft.
it.
11111111111111111111111111111.1
ft. IIIIIIIMIMIIIIIIIIIIIIIIIIIIIIIIIMIIIIIMIMIMI
IIIIIIIIMIIIIIII
ft.
21. REMAItKs
2 x 2 Pad
IIIIIIIIIIIIIIIIIIIIIIIMIMIMIMIIIIIIIIIIMIIMI
22. Certification:
iuro of c tt if Contractor Date (3 (
By signing this littler. 1Inreby twilit, that the well(s) was (were) cnnstrttned 1t accordance
with /S.A N('A(` 02(' _0100 or 15.4 N('d(` 02C 0200 Well Construction Standard). and that a
copy 5/ 1/,,s 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 wen site details or wen
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 web
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 font 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 \1 ate(' 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
nd Nat a'
rc
Division of \Nate, Resources Revised ,August 20 I3

WEI.J. CONSTRUCTION RECORD
This form can be uscdtfor single or multiple welts
1. Well Contractor Information:
Kevin White
Well Contractor Name
2973
NC Well Contractor Certification Number
Parratt-Wolff, Inc.
Comports Name
2. Well Construction Permit #:
List all applicable a r-/! perert: (L e County: Stang I nriaacd, hrynction, etc )
3. Well Use (check well use):
Water Supply y{'eli:
OAgriculttual
❑Geothenral (Heating/Cooling Supply)
❑ Industrial/Commercial
❑ Irrigation
Non -Water Supply Well:
©Monitoring
RECEIVED/NCDEQ/DWR
For inertial Use ONLY:
SEP 2 0 2021
14. WATER ZONFS
FROM
37
TO
40
ft.
IIF. CRIPTION
WOHOS
MOORESVILLE REGIONAL OFF
ft.
ft.
15.OUT
FROM
fr.
TO
ft
DL5A1I
R
ri
in.
©I
'et
Cfi
R
ap .licoblei
MATERIAL
FROM
0
ft.
TO
25
O
ft.
t)WG fgeothermai cord -loop)
DIAMETER TIIICKNFSS.
2
n
sch40
MATERIAL
pvc
ft.
ft.
17.SCREEN
❑Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
Injection Well:
CAquifer Recharge
OAquifer Storage and Recovery_
OAquifer Test
0Experimental Technology
❑Geothermal (Closed Loop)
DGeothermal (Heating/Cooling Return)
DRecovery
OGroundwater Remediation
❑Salinity Barrier
❑Stormwater Drainage
OSubsidence Control
❑Tracer
❑Other (explain under #21 Remarks)
4. Date Well(s) Completed: 12-21-20 Well W#
65
5a. Well Location:
Colonial Pipeline Company
Facility/Owner Name Facility tDC (if applicable)
14511 Huntersville-Concord Road, Huntersville, NC 28078
Physical Address. City, and Zip
Mecklenburg
County Parcel Identification No (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
35.412748 N-80.803857
w
6. Is (are) the well(s): OPermanent or ❑Temporary
7. Is this a repair to an existing well: ❑Yes or EINo
If this is a repair. fill OW known well cauelrnctinn inlbrmation and explain the nantre of the
repair under 421 remarks .section or on the back of this /brat,
8. Number of wells constructed: 1
liar timhiple injection nr nan•u•oter supply netts ONLY with the same construction, you ran
submit one him.
9. Total well depth below land surface: 40
liar nnrhiple ;Dells list all depUzs if different (example- 3(it200 `and 2(0)00')
(ft.)
10. Static water level below top of easing: 37 (ft.)
/J water /ere/ is above ['Ming, use "
11. Borehole diameter: 2
(in.)
12. Well construction method: 8 1/4 HSA tot 2" spoons
(i e auger, rotary, cable, direct push: etc )
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
Fong GW-I
Muth Carolina Department oi'F.n
FROM
25 ft.
TO
so ft
r I. kM£TER
2
fn.
SI
.010
Ttt
sch40
MATFRIAI
pvc
ft.
ft.
FROM
0 ft.
21
ft.
MATERIAL
Portland Cem
-FAI R%(-FM fNT NI
Tremie
21
ft.
23 ft
Bentonite Chi
Tremie
ft.
ft.
FROM
23
VEi.: PAC
tt.
ft.
To
40
20, »RILLINI
FROM
ft.
ft.
ft.
MATIIRIA
#1 Sand
EMI'
CEMENT METHOD
Tremie
TO
G {gttae6
ft.
E
b if *rcIsgry)
ION
irr..�tcarn ere. rte.r
ft.
t.
ft.
f4
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
21. REMARKS
2 x 2 Pad
22. Certification:
8" FMC
._..._._ t • t 3 • (
(nrre, e of Certified Well Contractor Date
ily sighing this than, l hereby eertifj, that the n•el/(s) was (here) canrlrtrrre, ie accar,/atce
,6111 /.5.4 N('.4(' 02C 0100 Or /51 :V(AC` 02C 0200 Well Construction Standards and that a
ropy of this record has been prortded 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 Conn 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 27699.4636
24c. For Water Suppiv 4 Injection %ells:
Also submit one copy or this form within 30 days of completion of
well construction to the county health department of the county where
constructed
CE
onment and Natural Resentes -- Division of Water Resources Revised August 2013

RECEIVED/NCDEQ/DWR
WELL CONSTRUCTION RECORD
This torn can be used for single or multiple wells
1. Well Contractor Information:
Kevin White
Well Contractor Name
2973
NC Well Contractor Certification Number
Parratt-Wolff, Inc.
Cornpam Nanie
2. Well Construction Permit #:
1.IS1 all applicable well permits (Le (
3. Well Use (check well use):
Ijrr. tiara
Water Supply Well:
❑ Agricultural
°Geothermal (Heating/Cooling Supply)
❑Industrial/Commercial
DIrrigation
°Municipal/Public
❑Residential Water Supply (single)
UResidential Water Supply (shared)
Non -Water Supply Well:
©Monitoring
r:] R ecove
Injection Well:
DAquifer Recharge
❑ Aquifer Storage and Recovery
❑Aquifer Test
DExperimental Technology
DGeothermat (Closed Loop)
DGeothermat (Heating/Cooling Return)
DGroundwater Remediation
❑Salinity Barrier
DStormwater Drainage
DSubsidence Control
❑Tracer
DOther (explain under #21 Remarks)
4. Date Well(s) Completed: 12/22-20 Well ID# MW-65D
5a. Well Location:
Colonial Pipeline Company
Facility/Owner Name Facility tDb (if applicable)
14511 Huntersviile-Concord Road, Huntersville, NC 28078
Physical Address, City, and Zip
Mecklenburg
County Parcel identification No (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one laUlong is sufficient)
35.412748 N-80.803857 W.
6. Is (are) the well(s): I JPermanent or °Temporary
7. Is this a repair to an existing well: ❑Yes or ElNo
/J1his is a repair, fill ant known well construction hr%ormatian and explain the nature Mihe
repair under „21 remarks .section or an the hock of this loan.
8. Number of wells constructed: 1
For nmlliple infection or non -water supply wells ONLY with the same construction, you con
.submit one JiIrm.
9. Total well depth below land surface: 46
I•or multiple ,cells liar all depths if chilirent (example- 3(@200' and 2 0 /00')
(ft,)
10. Static water level below top of casing: 1 18 (ft.)
If water level is above casing. use " "
11. Borehole diameter: 2 (in.)
a 1 /4 NSA & 2• spoons, 18 S/8 SAS 4' PVC ;using & 6 7/8 0 r Himmel
12. Well construction method:
(i.e: auger, rotary, cable, direct push, etc. )
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm)
13b. Disinfection type:
Method of test:
Amount:
FosmGW-1
For Internal Use ONL.I: 7 C EF 2 0 2021'
QROS
14. WATER ZONES WQROS
-
FROM
).....
To. I DESt'RIPTIOR,
118 r`•
150 ft
}t3{�E.S�%It
wet
IS. OUTER CAla 1 lformnitz-cased ellx)OKLINER (if applieabie)
FROM
TO DIAMETER.
TuteRNFSS
MATERIAL
ft.
ft.
in.
16, INNER
CASING OR TUBING fgeotbennnl elmed400p)
FROM
TO
IIIMF.TFR,
THICENTsS
MATER 1.ii.,
ft.
ft.
in,
ft.
ft.
tn,
t7. gCREEN
FROM
TO
Dt.i8tt:'1'1R
Si0T'8ILE.
Oil Clf\LSS
itA"1'f:RI=8L
ft,
ft.
tn.
ft.
ft.
in.
IS GROUT
FROM
TO
MATERIAL
FM PI TCEME I MF,Tt1On ¢r AMOUNT
ft.
ft.
ft.
ft.
rt.
ft.
19 S.iND1GR AVEI,PACK{dapplieaMe)
FROM
TO
_....
h1.tTERIit_
_........
€,MPL_4CFMENT i•16i1tOD
ft.
ft.
ft.
ft.
20.,ORILLP4GLOr
(attic
b:uditlt
FROM
TO
RFS('R(PT10N tenlgtt Gxrdnexc, stiilhuck typr.ar)xin size. rtr.t
ft.
ft.
ft.
ft.
_. _..
_. _..
ft.
_..
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
21. REMARKS
Open rock hole
22. Ccrtificatiou:
Signature ofCcrtificd 11ett Cootrectot
Date
By signing this form. I hereby cernj that the trell(s) was (carrel constructed in accordance
trills 1Sd Nc4( 02C J1100 or l5,1 WA' 02C ,p2. Xt did/ Construction Standards and that a
copy 0/ this record has been provider/ 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
SUBMITTAL INSTUCTIONS
ICE
24a. Fur 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 \i'ells 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 &i Injccliun 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.
North Carolina Department of Environment and Natural Resources - Division of Water Resources Revised August 2013

RECEIVEDINCDEDIDWR
WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
1. Well Contractor Information:
Kevin White
Web Contractor Name
2973
NC 'Well Contractor Certification Number
Parratt-Wolff, Inc.
Company Name
2. Well Construction Permit #:
List all applicable well permits ii.e. f liunly, State. 1 in•iar,ce, h
3. Well Use (check well use):
rion, etc 1
Water Supply Well:
❑Agricultural
OGeothermal (Heating/Cooling Supply)
O Industrial/Commercial
❑ Irrigation
Non -Water Supply Well:
7lMonitoring
❑Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
O Recover\•
Irtjecti(ill Well:
OAquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer Test
OExperimental Technology
OGeothennal (Closed Loop)
❑Geothermal (Hcating/Cooling Return)
4. Date Well(s) Completed: I2-23-20
❑Groundwater Remediation
❑Salinity Barrier
OStonnwater Drainage
❑Subsidence Control
0Tracer
OOther (explain under#2! Remarks)
5a. Well Location:
Colonial Pipeline Company
Facility/Owner Name
Well ID# MW-66
Facility ID# (if applicable)
14511 Huntersville-Concord Road, Huntersville, NC 28078
Physical Address; City, and Zip
Mecklenburg
County Parcel Identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(dwell field, one lat/long is sufficient)
35.413549 -80.804759
W
6. Is (are) the well(s): ©Permanent or OTemporary
7. Is this a repair to an existing well: Oyes or L1No
If this is n repair, fill out known well construction iu/nrnution and explain the nature of the
repair fouler =2/ remarks section ar on the hack in' this
S. Number of wells constructed:
For multiple injection or non -water supply rolls ONLY with du same construction, you can
subunit one form.
9. Total well depth below land surface: 54
bs,r multiple wells list all depths if different (example- 30200' and 2011100.)
(ft.)
l0. Static water level below top of casing: 37 (ft.)
1f water level is above casing, use " - '
I1. Borehole diameter: 2
(in.)
12. Well construction method: 8 1/4 HSA & 2" spoons
(i e auger, rotary, cable, direct push, etc. 1
For internal tise ONLY:
SEP 2 0 2021
14, WATER tiiS WOROS
FROM
ro
DESCRIPTION
VfLwetREG10NAL OFFICE
FRft.
ft.
54
ft.
ft.
15. OUTER CASING (tor moan -cased welts) OR i.BY R (if at pticabie)
FROM
TO
DIAMETER
THICKNESS
MATERIA1
ft.
ft.
tn.
t4 tfdNFR
ASING OR TOR ( tbemwl et gd-help)
FROM
TO
DIAMtIet5
THICKNESS
MATERIAL.
0 ft'
34 ft.
2 in.
sch40
pvc
ft.
ft.
in.
t7.;Sc Rt:E
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
34 ft'
54 ft'
2 in.
.010
sch40
pvc
ft.
ft.
in.
lg. GROUT
FR1lt5Y.....
10
MATFRIAI..
FAIN %CE 1F..N"TMETHOD?r,IMOI;NT
0 ft'
29 ft.
Portland Cem
Tremie
29 ft.
, 31 fL
Bentonite Chi
Tremie
ft.
et.
t9.SANilit,R#V LP,lCts(ifapptltable}
FROM....
TO
it %TERI-tl.
FMPI %l"EiNE\T Ni ET110D
31 ft.
54 ft.
#1 Sand
Tremie
ft.
ft.
20. DRULUNG
LOG (attach additional sheets if necessary)
FROM
TO
DESCRIPTION (color. hordne- a sni /rock tyne. grin size. etc.)
ft.
ft.
ft.
fr.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
21. REMARKS
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: _,- Amount:
22. Certification:
Signature ofeertitied Well Contractor
t.1 • Di, (
Date
Nv signing this lbrni. 1 hereby certify that the u'e'llr) was Orerr,1 constricted An accordance
n•11/n 15,4 NCAC 02C'.0100 or /5r1 NCAC 02(' 02011 Well ('onslructian Simulants 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
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 tollowing:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. Kir Water Supply & Injection Welk:
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 SW -I Nato Carolina Department of Environment and Natural Resouices — Division orWate, Resources
Rcvis
g0
2013

RECEIVED/NCDEQ/DWR
WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
1. Well Contractor Information:
Kevin White
Well Contraetor Name
2973
NC Well Contractor Certification
Parratt-Wolff, Inc.
N urnber
Company Name
2. Well Construction Permit #:
List a/1 applicable irrll permits (r. e. ('auras S)are, t'ariam e. Ltle•ciiart, etc.1
3. 1VcIl Ilse (check well use):
For Internal Use ONL.Y-
SEP'20 2021
I4. wATER'ZONES
FRONT
37
TO
45
ft.
WQROS
o1-sC"II1ORESWLLE RECIONAL OFFIC
wet
ft.
ft.
I5. C)1 1 FR C',i:il
FROM
TO
multi -eased wet
I)IAst t; fE
THICKNESS
R
ft.
rt.
In.
FROM
0
rt.
ASING f/R TUBING l lhen
30
rt.
1LL[IF
2
n
TI(I(:FNFSS_.
sch40
M.ATERlh1,
pvc
ft.
ft.
n.
Water Supply Well:
DAgricultural
OGcothennal (Heating/Cooling Supply)
O 1n d ustrial/Com m erc i a l
Olrrigation
Non -Water Supply Well:
1?II4lonitoring
Injection Well:
OAquifer Recharge
OAquifer Storage and Recovery
❑Aquifer Test
❑Experimental Technology
❑Geothemral (Closed Loop)
OGeothermal (Heating/Cooling Remm)
4. Date Well(s) Completed: 12-21-20
5a. Well Location:
Colonial Pipeline Company
Facility/Owner Name
OMunicipalfPubiic
OResidential Water Supply (single)
OResideneIal Water Supply (shared)
❑Recovery
❑Groundwater Remediation
❑Salinity Barrier
OStormwater Drainage
OSubsidence Control
DTracer
OOther (explain under 421 Remarxsl
Well ID#
IMW-67
Facility [D)i (if applicable)
14511 Huntersville-Concord Road, Huntersville, NC 28078
Physical Address, City. and Zip
Mecklenburg
County Parcel identification No (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if welt field, one latltong is sufficient)
35.413269 N -80.804708
w
6. Is (are) the well(s): ©Permanent or OTemporary
7. Is this a repair to an existing well: ❑Yes or tZiNo
11 this is a repair, J111 out known well construction in(i ation and explain the nature al the
repair order ,21 remarks section or on the back of this Arne
S. Number of wells constructed: 1
1•orntrrltlpte injection or non -water . supply u'eIs ONLY with the same canstrucrinn, You cot
submit one Jornt:
9. Total well depth below land surface: 45
lair multiple wells list all depths i/ dillerent (example- 3C200' and 20100')
10. Static water level below top of casing: 37 (ft.)
!l water level is above casin,S, use "
11. Borehole diameter: 2
(in.)
12. Well construction method: 8 1/4 HSA & 2" spoons
(i.e auger, rotary, cable, direct push. etc)
FOR WATER SUPPLY WELLS ONLY:
I3a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
Forte GW-I
Nord; Carolina Department of Environme
FROM
30 rr.
TO
45 rt.
DIAMETER.
2
SL.OTSIZF.
.010
THICKNESS
sch40
hI ATER IA
pvc
ft.
In.
FROM TO
0 ft' 24
MATERIA .
Portland Cem
\tE.MENT METI
Tremie
T
24
ft.
ft.
27
ft.
ft.
Bentonite Chi
Tremie
19,
FROM j TO
27 ft.
45
PAC
ft.
MATERI:IL
#1 Sand
EMFL:\
ti
ETIIOU
Tremie
ft.
ft.
R1LLtNG
ditional
FROM
To
ONfrn
trs
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
22. Certification:
c):6 •Z�
Signature or Certified Well Contractor
ttatr
Date
Rv signing this larnr, 1 hereby cent/v that the uell(0) ryas (were) constructed in accordance
;with L51,1 N('A(' 02(01100 or 15A ,V(A( 02(' ,0200 Well Construction Simulards and that a
copy al 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
24aabove, 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 viithin 30 days of completion of
well construction to the county health department of the county where
constructed
nd Xatwal Resources- Division of Water Resources Revised August 2013

RECEIVED/NCDEQ/DWR
For multiple wells list all depths' il different (example- 306o. aad 2 r@dlory)
10. Static water level below top of casing: 37 (ft.)
1/lrmer level is above casitrg use " "
II, Borehole diameter: 2 (in
WELL CONSTRUCTION RECORD
'rhis form can be used for single or multiple wens
I. Well Contractor Information:
Kevin White
Weil Contractor Name
2973
NC Well Contractor Cenification Number
Parratt-Wolff, Inc.
Company Name
2. Well Construction Permit #:
Hy! ! a// applicable n=rr/I p reunify ?Le, (ar o-r, Stare rarimue, to{lee(lt+r
3. Well 1. se (check well use):
Water Supply Well;
❑Agricultural
❑Geotherma) (Heating/Cooling Supply)
D(ndustrial/Commercial
❑Irrisation
Non -Water Supply Well:
la Monitoring
Injection Well:
[]Aquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
DGeothermal (Heating/Cooling Return)
etc
❑Munwipal/Pubiic
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
O Recovery
❑Groundwater Remediation
❑Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
OTracer
❑Other (explain under #21 Remarks)
4. Date Well(s) Completed: 12-23-20 Well ID# MW-68
5a. Well Location:
Colonial Pipeline Company
Facility/Owner Name Facility (DK (if applicable)
14511 Huntersville-Concord Road, Huntersville, NC 28078
Physical Address, City, and Zip
Mecklenburg
County Parcel Identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, eec fat/lone is sufficient)
35.413056 N-80.805275
6. Is (are) the well(s): GaPermanent or ❑Temporary
7. Is this a repair to art existing well: ❑Yes or RIND
If this is a repair, fill out known well construction itrfirrnratiatt and explain the nature o(Me
repair under -2/ remarks .section ar an the back al this farm..
8. Number of wells constructed: 1
For multiple Unn/ectian or non -water supply wells ONLY with the same construction. you can
snhmtt one firm..
9. Total well depth below land surface; 50 (It.)
12. Well construction method: 8 1/4 HSA & 2" spoons
(i. e auger, rotary. cable, direct push, etc. )
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
Form C}\V.t
For internal Use ONLY:
14. WATER Z
FROM
SEP202
WQROS
TO
DEsf_RtettMOORPSVU I F REGIONAL OFFK,
37
ft.
50
ft.
wet
ft.
(5. OUTF.
FROM
ft.
TO
ft. ft.
DIAMETER
6. INNER C.ASI iG OR TL?HEW
FROM
0
ft.
ft.
TO
35
17. SCREEN
ft.
ft.
In.
N'
THICKNESS
able)
MATERIAL
DIAMETER
2
In.
in.
rftci1-1n9R)
THICKNESS MATERIAL
sch40
pvc
FROM j TO
35
ft.
5
ft.
DIAMETER
2
In.
SLOT SIZE
,010
THICKNESS
sch40
MATERIAL
rt.
IL GROUT
FROM
0
fL
ft.
In.
pvc
31
ft.
MATERIAL
Portland Cem
CM Et s.CE41E:R'1' b(ET} OI I AMt)
Tremie
T
31
ft.
33
19. SAND/GRAY
FROM
33 ft.
TO
50
ft.
ft.
Bentonite Chi,
Tremie
ft.
MATERIAL
#1 Sand
EluPLif, EMENT
Tremie
ft.
ft.
20, DRILLING LAG to
FROM
ft.
ft.
TO
it.
ft.
uddli
DE`
abed If necessary)
PTR)N in,
M,thr,r, an}t/n lei, ,Ype. trap, c./cr, rrc,l
ft.
rL
It.
ft.
ft.
fr.
ft.
ft.
ft.
21.;REMARKS
ft.
22. Certification:
Signature of Certified 1t'e�.1"omm.:to
Date
By .signing MIs /ornr, I hereby certify that the u-el/(r) was (were) constructed in accordance
with 15 / NCAC 02C .0100 or 15,4 .VC4C 02(' .0200 Well Construction Standards and that a
cope q/'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 wen
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTUCTIONS
24a. For :Al) Wells: Submit this form within 30 days of completion of wen
construction to the following:
Division of Water Resources, Information Processing Unit,
16I7 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. Fur Wafer Supply & Injection Wells:
Also submit one copy of this form within 30 days of completion of
web construction to the county health department of the county where
constructed.
North Carolina Department o('Environmmnt and Natural Resources - Division of Water Resources
Reviser! August 20 t)I

RECEIVED/NCDEQ/DWR
WELL CONSTRUCTION RECORD
This form can be used rot single or multiple wells
1. Well Contractor information:
Kevin White
Well Contractor Namt
2973
NC Well Contractor Certification Number
Parratt-Wolff, Inc.
Company Name
2. Well Construction Permit #:
Lisl all Opphcahle well permits (i.r Colo +(r: State. I 7:tru,nce, /nli•c7h» e,c j
3. Well Use (check well use):
Water Supply Well:
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
Industrial/Commercial
❑ irrigation
Non -Water Supply Well:
El Monitoring
injection Well:
❑Aquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer Test
❑Experimental Technology
❑Geothermai(Ciosed Loop)
❑Geothermal (Heating/Cooling Return)
For Internal Use ONLY:
5E021
WOROS
14. WATER ZONES MOORESVILLE REG
mom
48
ft.
TO
60
ft.
DESCRIPTION
ONAL
wet
I -ICE
ft.
ft.
15. OUTER CASING tor multi-casedweal OR LINER (if app kalif
FROM DIAMETER 'rRICKNESS.
TO
ft.
ft.
FROM
0
ft.
Y
TO
30
t.
MATERIAL
In.
G (geneh erinal eft se 1 JS
MAMETER
2
TitICRNE,SS
sch40
MATERIAL
ft.
17.SCREEN
ft.
in.
pvc
❑Municipal/Public
❑Residential Water Supply (single)
0 Residential Water Supply (shared)
❑Recover'
❑Groundwater Remediation
❑Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑Tracer
❑Other (explain under #21 Remarks)
4. Date Well(s) Completed: 12- 16 20 Well ID# MW-69
5a. Well Location:
Colonial Pipeline Company
Facility/Owner Name Facility IDe (if applicable)
14511 Huntersville-Concord Road, Huntersvi(le, NC 28078
Physical Address. City, and Zip
Mecklenburg
County Parcel Identification No (PEN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
Orwell field, one lat/long is sufficient)
35.413842 N -80.804434
6. Is (are) the well(s): tdjPermanent or ❑Temporary
7. Is this a repair to an existing well: OYes or &JNo
ft this s a repair, fill out known well ctmstruction ityarmaliaa and explain the note al the
repair rimier 21 remarks section or on the back of this
8. Number of wells constructed:
For multiple injection ar non -water supply wells ONLY a-,th the same construction, you can
submit one Jorm.
9. Total well depth below land surface: 60 (
For mubmlr wells list all depths if di/Jerrm (example- 3 f 200' and 20100
10. Static water level below top of casing: 48
If water /erel iro above casing. use " ' (ft.
11. Borehole diameter: 4
(in.)
12. Well construction method: 8 1/4 HSA / 10 5/8 HSA
anger, rotary, cable, direct push, etc )
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm)
13b. Disinfection type:
Method of test:
Amount:
Form G W- I
North Carolina Department
FROM
30 ft.
TO
60 ft.
DIAMETER
2
In.
SLOT SIZE
.010
THIERN LSS MATERIAL
sch40
ft.
ft.
In.
pvc
FROM
0
ft.
TO
26
ft.
MATERIAL
Portland Cem
EM PI ACEM ENT METHOD & AMOUNT
Tremie
26
ft.
28
ft.
ft.
Bentonite Chi!
19. SAND/GRAVEL PACK (ifapplicahle)
TO NIA TER!AL
M
28
ft.
60
ft.
#1 Sand
Tremie
EMIT 'EMIENT MET
Tremie
ft.
ft.
FROM
TO
t.
additional Act
DESCRIPTION
lit
anillrn
bl's• cram
ft.
ft.
ft.
ft,
ft.
ft.
ft.
ft.
ft.
ft.
ft.
21. REMARKS
ft.
22. Certification:
t• 2i• 24
Signature ofCertitied 1Guli Contractor Date
By signing this form: I hereby certify that the well(s) was (were) constructed in accordance
with 15.4 M' cC 02('.0100 or 1 / NCCC 02C 0200 Well ('anvlructton Standards and that o
copy f#.ihis 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
246. 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.
nvuvnment and Natural Resources —Division of Water Resources
Revised August 2013

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
I. Well Contractor information:
Kevin White
Well Contractor Nance
2973
NC Well Contractor Certification Number
Parratt-Wolff, Inc.
Compact) Name
2. Well Construction Permit #:
List all applicable well permits (re Count • State. Carfance, L
3. Well Use (check well use):
Water Supply Well:
L Agricultural
❑Geothermal (Heating/Cooling Supply)
o Industrial/Commercial
0 irrigation
Non -Water Supply Well:
2Monitoring
•rrGrt, etc.)
❑Municipal/Pjublic
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
I:. Recovery
Injection Well:
0 Aquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer Test
❑Experimental Technology
❑Geothennal (Closed Loop)
❑Geothermal (Heating/Cooling Return)
4. Date Well(s) Completed: 12-20-20
5a. Well Location:
Colonial Pipeline Company
Facility/Owner Name facility )D# (if applicable)
14511 Huntersville-Concord Road, Huntersville, NC 28078
❑Groundwater Remediation
❑Salinity Barrier
0Stormwater Drainage
❑Subsidence Control
0Tracer
O0ther (explain under #21 Remarks)
Well iD# MW-70
Physical Address, City, and Zip
Mecklenburg
County Parcel Identification No. (PINi
5b. latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(dwell Geld one laV,ong is sufficient!
35.413302 „-80.804380
6. Is (are) the well(s): I JPermanent or DTemporary
7. Is this a repair to an existing well: [Wes or IlNo
ll this is a repair, jilt out known well construction h,lnrnmNo, and explain the nature orate
repair rooter :2/ remarks ,colon or on the hack o/ this /urns.
8. Number of wells constructed: 1
For nndnp/e injection or non -water supply wells ONLY with the same construction: )'or can
submit one fluor
9. Total well depth below land surface: 48
For nndriple well., Ilst ol1 depths ij d1J%rent (example- 3(c?00' and 2 a 100')
(ft.
Ill. Static water level below top of casing: 39 (ft.)
IJ'n•ater /ere/ is above eosiug• use "
11. Borehole diameter: 2 (in.)
12. Well construction method: 8 1/4 HSA & 2" spoons
(i.e. auger; rotary, cable, direct push, etc.;
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm)
13b. Disinfection type:
Method of test:
Amount:
fore GW I
RECEIVED/NCDEQ/DWR
For Internal Use ONLY
SIP 2 0`2021
14. INLR ZONES
FROM
TO
DESCRIPTION WOROS
39 rt•
48 ft.
MOORES V11.1,,,6 REGIONAL OFFIC
t4:OLT'ER ( MN ' afar
t11r€ eased wets) 01t 1111t:R tlfupp teahte}
FROM
TO
DIANFTER:
TIII(.`KNF-
:11ter FJtI: M.
ft.
D.
In.
_..
16.I vNh R C:ASING OR "i`UW',("e
(geothermal t#tiled-lo ip)
FROM
TO
DIAMETER
TIII('RNF-SS
M.A.TERIA1..
0 ft.
33 rr.
2 In.
sch40
pvc
ft.
ft.
in,
17.SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
33 ft•
48 ft•
2 in.
.010
sch40
pvc
ft.
ft.
in.
18.(ROU.I?
FROM
'rO
MATTRLIL
FMPLACFME.INT \IFTIIOD.SE 4MO I;NT
0 rt.
28 ft•
Portland Cem
Tremie
28 rI•
31 ft•
Bentonite Chi
Tremie
ft.
ft.
#4, 4<iND/(
RAN'Fit.!' iCK;fttapt)kfea#tfa)
FROM
TO
Ri%TFRL1L
OWL .SL''NI FNT METRO!)
31 rt•
48 ft.
#1 Sand
Tremie
ft.
ft.
Zit, IIRILLIN(=1.(l(;
tattaeh additti n,d slteetta lfneeessarv)
FROM
TO
DFS( RIPTIOti ItoIn, Iiardnes+. sn,11 ek typr. train sear, HO
ft.
ft.
ft.
ft..
ft.
ft.
_.................
ft.
ft.
ft.
ft.
ft.
ft
ft.
ft
21. REMARKS
8" FMC
2 x2 Pad
22. Certification:
Signalure of Certified Well Contractor
it •2,\
Date
'E
By rigniug this Jhrnr, I hereby cernfy that the well(s) was (were) constructed is accordance
with ISA NC'AC 02C .010(1 or 15,1 NC'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 well details:
You may use the back of this page to provide additional well site details or web
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 web
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 \`niter Supply .Yc. 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.
Ninth Carolina Department or Ell onment and Natural Resources - Division of Water Resources
d
is t 201?

RECEIVED/NCDEO/DWR
WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
1. Well Contractor Information:
Kevin White
Well Contractor Name
2973
NC Well Contractor Ceni ication Number
Parratt-Wolff, Inc..
Comport) Name
2. Well Construction Permit #:
List a// applicable well pw7nlis ti.w i'aantt: State, Parke
3. Well Use (check well use):
Water Supply Well:
❑ Agricultural
❑Geothermal (Heating/Cooling Supply)
D industrial/Commercial
0Irrigation
Non -Water Supply Well:
(1 Monitoring
❑Municipal/Public
°Residential Water Supply (single)
°Residential Water Supply (shared)
Recover -
Injection Well:
❑Aquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer Test
❑Experimental Technology
❑Geothermat(Closed Loop)
DGeothermal (Heating/Cooling Return)
❑Groundwater Remediation
❑Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
°Tracer
❑Other (explain under 421 Remarks)
4. Date Well(s) Completed: 1/5/21 Well ID# MW-71
5a. Well Location:
Colonial Pipeline Company
Facility/Owner Name Facility TD# (if applicable)
14511 Huntersville-Concord Road, Huntersville, NC 28078
Physical Address; City; and Zip
Mecklenburg
Counly Parcel identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well Geld. one IaUlong is sufficient)
35.414153 N-80.804562
6. is (are) the well(s): ©Permanent or DTemporary
7. Is this a repair to an existing well: °Yes or ElNo
If this is a repair, fill out known well construction information and explain the nattire of the
repair under 21 rentorkc sector or on the hack o/ this Am.
8. Number of wells constructed: 1
bar naldple injection or non -water supply wells. ONLY with the same construction, you con
Windt owe lia n,
9. Total well depth below land surface: 65
1-or multiple wells list all depths it different (example- 3@200' any/ 2 100')
(ft.)
10. Static water level below top of casing: 37 (ft.)
If water lerel is above casing. use "- "
11. Borehole diameter: 2
(in.)
12. Well construction method: 8 1/4 HSA & 2" split spoons
e anger, rotary; cable, direct push, etc. )
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
Form GW-I
For Internal Use ONLY.
SEP 2 O'20-21
14. WATER ZONES
FROM
TO
nESCR 11'110^
37 tt.
65 ft.
wet
ft.
ft.
I5, OUTER CASING (tor multi -cued wells) OR LINER Of epplieahl)
FROM
TO
DIAMETER
THICKNESS
SINTER IA I., - --
ft.
R,
In.
tb; lAs t R
f..4StP#G OR TUBING
(sealherntal dssed-Iaop)
FTtI)M1I
TO
DI;4\IFTF.R
TlIIC.'W'sFSS
sItrFRL41..
0 Et.
50 ft.
2 In.
sch40
pvc
ft.
ft,
in.
IT. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
TR ICI:NF_Cs
MATERIAL.
50 It•
65 rt.
2 In.
.010
sch40
pvc
ft.
ft.
in.
IL GROUT
FROM
TO
\IATF,R I:1,
F.NIPl tt"FAIFu,'TYtET110I0I; iT"
0 ft.
42.5 fr.
Portland Cem
Tremie
42.5 fr•
47 ft•
Bentonite Chil
Tremie
ft.
ft.
I?. NlidGR
#% E t. P:ii f
{if spjtlicatds)
FROM
TO
MATERIAL
EMPLACEM ENT METHOD
47 ft.
65 ft.
#1 Sand
Tremie
ft.
ft.
2tf, b121LLI
zG`i 17tC (sttseh
additionalabets if necessary)
F9OM
TO
DESCRIPTION reran,. hardness soii/reck tope. gain siee,etr.)
ft.
ft.
ft.
ft.
ft.
ft.
R.
ft.
rt.
ft.
_. _..
ft.._
ft.
ft.
ft.
21. REMtRKS
No cover
22. Certification:
Signature ofCettified Well
cw Date
:FICE
By signing this Jura, 1 hereby cerdfv that the n'e/1(0 Was (were) constructed in accordance
with 154 .NCAC 02C _0l00 or 15,4 NCAC 02C' 0200 Well Construction Standards and that a
copy of this record has been prorated 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
SUBMiTT.AL 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
24h. 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 Supplv & injection Wells:
Also submit one copy of this form within 30 days of completion of
web construction to the county health department of the county where
constructed
North Carolina Department of Environment and Natural Resamces - Division of Water Resources Revised August 2013

RECEIVEDINCDEOIDWR
WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
1. Well Contractor Information:
Kevin White
Well Contractor Name
2973
NC Well Contractor Certification Number
Parratt-Wolff, Inc.
Cornpam Name
2. Well Construction Permit #:
List all applicable nr!/ permit,' te. ('tuny, Stu
3. Well Use (check well use):
Variance, buck
t etci
For Internal Use ONI_\':
14. WATER ZONES
FROM
52
TO
54
ft.
I nEvoiLLE
I
SEP
wpROS
ilEGIONAL orrILE
wet
ft.
ft.
FROM
'TER CA IrN't: tfda`multi-ens ed wells) tdE LINER (if app_lic
TO 1C' c'E:S,ti
ft.
fr.
DIAMETER
In.
TI1
Is.
MATERIAL
16. INNER f ASiNG f)R TUB(NG sae
FROM
TO
DIAMETER
-loop)'
ill lf7CNFS9
MATERIAL
0
ft.
40
ft.
2
n.
sch40
pvc
ft.
ft.
in.
17; SCREEN
Water Supply Well:
❑Agricultural
OGeothermal (HeatingiCooling Supply)
❑ lodustrial/Commercial
Trri gallon
DMunictpal/Public
❑Residential Water Supply (single)
['Residential Water Supply (shared)
Non -Water Supply Well:
©Monitoring O Recovery
Injection Well:
❑Aquifer Recharge
❑Aquifer Storage and Recovery
DAquifer Test
❑Experimental Technology
❑Geothennat(Closed Loop)
❑Geothermal (Heating/Cooling Return)
❑Groundwater Remediation
❑Salinity Barrier
❑Stormwater Drainage
['Subsidence Control
['Tracer
OOther (explain under #21 Remarks)
FROM
39 ft.
TO
54 fr.
2
In.
SLO E SIZE
.010
TRICK NE S
sch40
MATERIAL
pvc
ft.
rt.
in.
)trr
FROM
0
32
ft.
MATERIAL
Portland Cem
EMPLACENI.ENT :ME.EIIOD & AMOUNT
Tremie
32
t.
34
ft.
Bentonite Chil
Tremie
ft.
ft.
10. S;1NDI(RAV•E
A
FROM TO.
36 r'•
54
ft.
(AL
#1 Sand
EMTLACEMEhT
:TROD
Tremie
ft.
ft.
rV)
PROM
TO
DESCRIPTION
ha.
'Free
star. cte.)
ft.
4. Date Well(s) Completed: 1 /9/21 Well ID # MW-72
5a. Well Location:
Colonial Pipeline Company
Facility/Owner Name -Facility IDI (if applicable)
14511 Huntersville-Concord Road, Huntersville, NC 28078
Physical Address. City, and Zip
Mecklenburg
County Parcel Identification No (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat./long is sufficient)
35.414969 -80.804731
6. Is (are) the well(s): ©Permanent or ❑Temporary
7. is this a repair to an existing well: ❑Yes or ErNo
if this is a repair, fill an known well construction information and explain the nature of the
repair under ., 21 remarks section or on the back of this 'brill.
8. Number of wells constructed:
For multiple injection or non -water supp/v n-e/ls ONLY with the same construction, you con
submit one farm
9. Total well depth below land surface: 54
For multiple wells list oil depths t/different (example-3n200'ana12( 100')
(ft.l
10. Static water level below top of casing: 51 (ft.)
1J water /eret is above casing, use "
11. Borehole diameter: 2 (in.)
12. Well construction method: 8 1 /4 HSA & 2" split spoons
(i.e. auger, rotary, cable, direct push,
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
ft.
ft.
ft.
ft.
ft.
ft.
rt.
ft.
ft.
ft.
ft.
ft.
21, REMARKS;
22. Certification:
Z.a• t• 7Jl
Date
By signing this Ibrnn, 1 hereby ceruji that the well(s) was (mere) constructed in accordance
with 15,1 NCJIC 02C 0100 or 15,4 ,N(2.1C 02(`.0200 Well Construction Standards and that a
copy of this record has been praritted 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. Fur 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
246. 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
Form G\\'-1 North Carolina Department of Environment and Natural Resources— Division of Water Resources Revi
August 2013

RECEIVED/NCDEQ/DWR
WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
1. Well Contractor Information:
Kevin White
Well Contractor Nacre
2973
NC Well Contactor Certification Nomber
Parratt-Wolff, inc.
For Internal Use ONLY,
SEP2020
WQROS
VILI F REGIONAL OFFiC
4
RON
T
L,
ft.
ft.
ft.
ft.
fS. OUTER CASING (foe
FROM
TO
delta) OR LINER
DLtMITE
Fes
ppticable)
MATERIAL.
ft.
ft.
Company Name
2. Well Construction Permit#:
all applkahie weft pernt!s (Le. Cbrrm(r, Stare, Fo•ionce. L?%ectiwq etc.l
3. Well Use (check well use):
NN0 It CASINts` t1R 'THING Witt
FROM
TO
IMAM F.
tarp
THICKNESS
MATERIAL
0
ft.
30
ft.
2
in.
sch40
pvc
rt.
ft.
n.
Water Supply 1YelI:
El Agricultural
OGeothennal (Heating/Cooling Supply)
O Industrial/Commercial
D lrrigati on
Non -Water Supply Well:
9,Monitoring
❑Municipal/Public
OResidential Water Supply (single)
❑Residential Water Supply (shared)
Recover•
jeedon 11°eil:
OAquifcr Recharge
❑Aquifer Storage and Recovery
❑Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling Return)
4. Date Well(s) Completed: 1/10/21
5a. Well Location:
Colonial Pipeline Company
Faciiiiy!Owncr Name
❑Groundwater Remediation
OSa6rity Barrier
❑Stormwater Drainage
OSubsidence Control
OTracer
OOther (explain under #21 Remarks)
MW-73
Well iD#
Facility ID# (if applicable)
14511 Huntersville-Concord Road, Huntersville, NC 28078
Physical Address; City, and Zip
Mecklenburg
Comity Parcel Identification No, (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
Of well field, one tat/lung is sufficient)
35.412179 N-80.805693
6. is (are) the well(s): t221Permanent or OTemporary
7. Is this a repair to an existing well: Oyes or tflNo
Il this. is a repair, fill out known well construction in/inrnution and explain the nature ofthe
repair inkier ,21 remarks section or an the back o/ this !arm.
S. Number of wells constructed:
For multiple infection or nun -water .supply wells ONLY with the same construction, you can
suhrait one farm..
9. Total well depth below land surface: 45 (ft.)
For multiple wells list all depths i/ dffJerent (example- 3 «r2©0' and 2kf 100')
10. Static water level below top of casing: (ft.)
1/ water level is above casing, use :. "
11. Borehole diameter: 2 (in,)
12. Well construction method: 8 1 /4 HSA & 2" split spoons
(i.e. auger, rotary, cable, direct push, etc
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
17. SCR
FROM TO DIAM1I ETER Sit r SIZE TIIICKNESS MATERIAL _..
30 ft.
45 ft.
2
In.
010
sch40
pvc
ft.
ft.
in.
1L GROUT
FRO51
0
ft.
TO
25
ft.
MATERIAL EMPL WE:MENT METHOD & AMOUNT
Portland Cem Tremie
25
27
ft.
Bentonite Chi Tremie
ft.
rt.
FROM
27
ft.
45
!SICK (if applicable)
ft.
MATERIAL
#1 Sand
EMPLACEMENT
Tremie
ft.
ft.
PROM
ft.
ft.
TO
G tattsteh additional sheet
ft.
ft.
ION
and
Pe.,
etea
rt.
ft.
ft.
ft.
ft.
rt.
rt.
ft.
ft.
ft.
21. REMARKS
22. Certification:
Signature tsCCertiContractor Date
By signing this Inc,,,, i hereby certij• that the treil(v) was' (were) constructed in accordance
with 15A WA(' 02C 0100 or 15A NCAC 02C .0200 Wall 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. Fur 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 1%stlis 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 Conn within 30 days of completion of
well construction to the county health department of the county where
constructed
Fortin OW -I North Carolina Department or Environment and Natural Resources - Division of Water Resources
Revised August 2013

WELL CONSTRUCTION RECORD
RECEIVED/NCDEQ/DWR
SEP'202021
This form can be used fin single or multiple wells
I. Well Contractor Information:
Kevin White
Well Contractor Name
2973
NC Well Contractor Certification Number
Parratt-Wolff, Inc.
Company Name
2. Well Construction Permit #:
Lint all applicable well permav (i.e. ('orom'. .hate, f ariance, Injection, eta,
3. Well Use (check well use):
For Internal Use ONLY:
14. WATER'I.oNES
WQROS
C f [GIONAI OFFICE
OREgVILL
FROM
TO
DESCRIPTION
30
33
ft.
wet
ft.
ft.
OUTER C.\St
FROM
ft.
TO DIAMETER I THICKNESS
ft.
In.
M:\TERIAL.
FROM
R CASING OR TURI�IG ( e
TO
DIAMETER
E t{oseil-lbop)
TItIC1VNES'
MATERIAL..
0
ft.
18
ft.
2
n.
sch40
pvc
ft.
ft.
In.
17.SCREEN
Water Supply Well:
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑ Industrial/Commercial
0 Irrigation
['Municipal/Public
❑Residential Water Supply (single)
❑ Residential Water Supply (shared)
Non -Water Supply Well:
Monitoring D Recovery
Infection Well:
0 Aquifer Recharge
❑Aquifer Storage and Recovery
(✓Aquifer Test
❑Experimental Technology
❑Gcothermat (Closed Loop)
❑Geothermal (Heating/Cooling Retum)
4. Date Well(s) Completed: 2/8/21
5a. Well Location:
Colonial Pipeline Company
❑Groundwater Remcdiation
❑Salinity Barrier
❑Storrnwater Drainage
❑Subsidence Control
❑Tracer
❑Other (explain under #21 Remarks)
Well ID# MW-74
Facility/Owner Name Facility ID# (if applicable)
14511 Huntersville-Concord Road, Huntersville, NC 28078
Physical Address, City, and Zip
Mecklenburg
County Patcel identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one IaVlone is sufficient)
35.414272 N.-80.-'804149
6. Is (are) the weil(s): ©Permanent or ❑Temporary
7. Is this a repair to an existing well: ❑Yes or ONo
If this is a repair, 1i/1 out known well construction in/ormatiorr and explain the nature 0/"the
repair under -21 remarks section or on the hack al this. faro,
8. Number of wells constructed: 1
For nudtiple injection or non -water supply trells ONLY with the saute construction, Von can
submit one fOrnt.
9. Total well depth below land surface: 33 (ft.)
For multiple wells list all deptlu if difJerenr (example- 30200' and 20
10. Static wa ter level below top of casing: 30 (ft.)
If water level is above casing, use " "
11. Borehole diameter: 2
(in.)
12. Well construction method: 8 1/4 HSA & 2" split spoons
e auger, rotary. Cable, direct push, ete
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) _, Method of test:
I3b. Disinfection type: Amount:
Form GW-I
North Carolina Department of Pnviron
FROM TO
18 ft.
33 rt.
DIAMETER
2
In.
SLOT $1ZE
.010
rmeicsrss I MATERIAL
sch40 j pvc
ft.
ft.
in.
FR0,5t
0 ft.
13.5 If
I1ATERIAL,
Portland Cem
FM1't.ACVMgt
Tremie
ETHO
AMOUNT
13.5 ft
15.5 fc
Bentonite Chil
Tremie
ft.
ft.
FROM
15.5 rr.
TO
33
ACK Ole C.41
ft.
MATERIAL
#1 Sand
EMPLACEMENTMETHOD
Tremie
ft.
ft.
FROM
ft.
tuft h
ft.
d
ON toil
hmttnesx,uiVruxh type, grain size.et
ft.
ft.
ft.
ft.
ft.
rt.
ft.
ft.
ft.
ft.
ft.
21
Eh
8" FMC
2 x2 pad
22. Certification:
K. Z.' �l
Sig'. tine o'.f (`e,(flied Well Contractor Date
By signing this /brut. 1 hereby eeru/i that the ,, lltst war (were) constructed in accordance
with 15.1 MA(' 02C 0100 or 154 NC4( 02C .0200 Well Construction Standards and that a
cony 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 web
construction details. You may also attach additional pages if necessary,
SUBMITTAL INSTUCTIONS
24a. Fur All Wells: Submit this form within 30 days of completion of well
construction to the fallowing:
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 web
construction to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mil Service Center, Raleigh, NC 27699-1636
24c. For Water Supply & Injection Wells:
Also submit one copy of this firm within 30 days of completion of
well construction to the county health department of the county where
constructed.
and Natural Resources - Division of Water Resources Revised August 2013

RECEIVED/NCDEQ/DWR
9. 8 `2021
WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
I. Well Contractor information:
Kevin White
FF'e(1 Contractor Nance
2973
NC' Well Contractor Certification Number
Parratt-Wolff, Inc.
Company Name
2. Well Construction Permit #:
I.kt all (mph able lid/ permits ti e, ('aanRt Sfate_ 1 ariance, Atjectiaa. or
3. Well Use (check well use):
Water Supply Well:
DAgricultural
°Geothermal (Heating/Cooling Supply)
Olndustrial/Commercial
°Irrigation
❑Municipal/Public
❑Residential Water Supply (single)
DResidential Water Supply (shared)
Non -Water Supply Well:
fZi Monitoring D Recover -
Injection Well:
❑Aquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer Test
°Experimental Technology
°Geothermal (Closed Loop)
°Geothermal (Heating/Cooling Return)
❑Groundwater Remediation
°Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑Tracer
❑Other (explain under #21 Remarks)
4. Date Well(s) Completed: 2/9/21
5a. Well Location:
Colonial Pipeline Company
Facility/Owner Name Facility ID# (if applicable)
14511 Huntersville-Concord Road, Huntersville, NC 28078
Well ID# MW-75
Physical Address, City, and Zip
Mecklenburg
County Parcel Identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
35.414285 -80.804117
6. Is (are) the well(s): °Permanent or °Temporary
7. Is this a repair to an existing well: ❑Yes or ONo
1,1 this is a repair, Jill out known well construction it juematiou turd explain the nature of the
repair under -2l remarks .vecrian or on the back o/ thisfarm.
.
S. Number of wells constructed:
For multiple injection or non -water supply wells ONLY with the same construction. you can
submit cue /brm.
9. Total well depth below land surface: 45 (ft.)
For multiple wells List all depths if different (example, 30200' and ?(at100 )
10. Static water level below top of easing: 41 (ft.)
lJ water 1ere1 as above casing, use " ., _..... _ .............
I I. Borehole diameter: 2
(in.)
12. Well construction method: 8 1/4 HSA & 2" split spoons
ti e auger, rotary, cable, direct push, etc. )
FOR WATER SUPPLY WELLS ONLY:
I3a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
Form G1 I
North Carolina Department of Envimnrn
,,"., haa, -
For monad Use ONL'i
WQROS
REOIUrtA► fit FI
14. W TIR rt)N MOORESV) LC
ITIOM
'r0
DESCRIPTION
41 fir.
46 fir.
wet
ft. ft,
t5 01)'!°PR('<",r/(/forand rirfxedweltsliiRLPkMt{lfap•ticshte)
FROM
TO
DIAMLI N K
THICKNESS
MATERIAL
ft.
ft.
In.
1a r tibii R
GASING 011 TU11IPHa
( thermal rios -loop)
FROM
TO
DTAMA.I F.R
THICleN`E.4S
M.ATERIA1_.
0 ft•
31 ft.
2 in.
sch40
pvc
et.
ft.
in.
f7. SCREEN
FROM ( TO
DMAMErER
SCOT SIZE
THICKNESS 1 MATER/.AL
31 ft. 146 ft•
2 in.
.010
sch40
_.._
pvc
_...
ft.
ft.
In.
id GRCOHT
FROM
TO
MATERIAL..
EMPLACEMENT METHOD .5,AMOU,rNT
0 ft•
27 ft•
Portland Cem
Tremie
27 ft.
29 ft•
Bentonite Chip
Tremie
ft.
ft.
I9. SANDIGR,
Yf t., PACKS
jtf appheabta)
FROM
TO
.MATERGtL
EMPLACEMENTMETIOD
29 ft•
46 fit.
#1 Sand
Tremie
ft.
ft.
Ift. DRILLING
Lt)G {attach
siddleiondle lb if necessary)
FROM
TO
DESC.RIFT )ON )role . hai driest. aroj/loth type. arain xi oo; ete.r
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
..........
ft.
ft.
ft.
ft.
ft.
ft.
21. REMARkS
8" FMC
2 x2 pad
22. Certification:
titre of Certified Well Contractor
a.• 12.2 \
Date
13v signing this Juno, 1 hereby certify that the we11(s) was (were) constructed in accordance
with 1 SA MAC 02C _0/00 or 15,1 N('AC' 02( .0200 Well Construction Standards and that a
copy q/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
CE
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,
t617 Mail Service Center, Raleigh, NC 27699-1617
24h. For lniection 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 & tniection 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.
and Natural Resources - Division of Water Resources
Revised Auuust 2013

RECEIVEDINCDE©IDWR
WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
1. Well Contractor Information:
Kevin White
Well Contractor Name
2973
NC Well Contractor Certification Number
Parratt-Wolff, Inc.
Comport) Name
2. Well Construction Permit #:
Lis/ ell applicable well pernritr (i. e.. t'nuun. 57ury
3. Well Use (check well use):
lc'e'tttnr, etC.;
Water Supply t!`e11.
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑ Industrial/Commercial
❑Irrigation
❑Municipali'Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
Non -Water Supply Well:
©Monitoring
❑Recover'
Injection Well:
❑Aquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (l leaf ingiCoutirie Return)
4. Date Well(s) Completed: 2/10/21
5a. Well Location:
Colonial Pipeline Company
Facility/Owner Name
❑Groundwater Remediation
❑Salinity Barrier
❑Stormwatcr Drainage
❑Subsidence Control
❑ Tracer
❑Other (e.'plain under #2l Remarks
Well ID# MW-76
Facility ID# (if applicable)
14511 Huntersville-Concord Road, Huntersville, NC 28078
Physical Address, City, and Zip
Mecklenburg
County Parcel Identification No. (PiN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one Wong is sufficient!
35.414299 N -80.804067
W
6. Is (are) the well(s): OPermanent or ❑Temporary
7. is this a repair to an existing well: ❑Yes or ONo
1l this is a repair, fill out known well construction hffarntation and explain the tonare of the
repair under .,21 rertmrke section or on the hack of this foray.
S. Number of wells constructed: 1
For multiple injection or war -hater supply wells ONLY frith the same cot traction, you can
submit one farm.
(ft.)
DI. Static water level below top of casing: 35 (ft.)
If hater level is above casing, use "
I i. Borehole diameter: 2 (in.)
9. Total well depth below land surface: 45
For multiple tee//s list all depths if different (example- 342n20
and 2k 10(P)
12. Well construction method: 8 114 HSA & 2" split spoons
(i.e. auger, rotary, cable, direct push, etc.)
14. WATER Z{3Nt 5 W t,) -
FROM
To
DESCRIPTION REGIONAL --Of
35 ft.
45 ft.
SVILLE
MOURfet
IS, OUTER (=tsl (. tformvin•ensed vvd } C>R i l) gft ftfap IteaMe)
TO
IMAM
AM ETER
THICKNESS
MATERIAL
ft.
ft.
in.
in.IN F.R C=tMNG f)It 7i;RING (gents rntat cl d400p)
FROM
TO
01AMETER
THICKNESS
MATERIAL
0 ft.
25 ft.
2 in.
sch40
pvc
ft.
ft.
in.
17. SCREEN
FROM
TO
06AMETER
SLOT SIZE
THICNeECC
MATERIAL
25 ft•
45 ft.
2 tn.
.010
sch40
pvc
ft.
- ft.
tn.
IL GROUT
FROM
TO
AIA 'i'k:RIAt.;
EMPI..I.('E 1ENTMI:TIItdII AM0INT
0 It•
21 ft•
Portland Gem
Tremie
21 ft.
23 ft.
Bentonite Chii
Tremie
ft.
ft.
I "s t 1(111GR f 1`E[. PACh
ft appUe*bie)
FROM
To
MATERIAL
FMPLAC'EMlL IIETIN)IS
23 ft.
45 ft.
#1 Sand
Tremie
ft.
ft,
20. DRILLING
LOG (attach addWm a) mbetffi If nor sary)
FROM
TO
DESCRIPTION. Hnlar, ',Wino., soil/fork type, ervin aze, ete.i
ft.
ft.
ft.
ft.
ft.
ft
ft.
ft.
ft.
ft.
ft.
ft.
_. _._..........
ft.
ft.
31, RE 41.UEKS
4" Stick up cover
2 x2 pad
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13h. Disinfection type: Amount:
22. Certification:
eeaI to ui`C'ertilied well Contractor Date
By signing this farm, 1 hereto certify that the ecU(s) wits (here) constructed in accordance
nil/r l.i.t N('AC 02(' .0/00 or 1.5,1 NV('AC 0_'-(' 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 of well
construction details You may also attach additional pages if necessary
SUBMITTAL INSTUCTIONS
24a. For All Wells: Submit this Corm within 30 days of completion of well
construction to the following:
FICE
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Injection %Veils 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 St 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
ConstructCJ.
Runt G W-1 North Carolina Department orFr:vironment and Natwal Resources — Division of Water Resources Revised .August 2013

RECEIVEDINCDEOIDwR
WELL CONSTRUCTION RECORD
This Corm can be used for single or multiple wells
1. Well Contractor Information:
Kevin White
Well Contractor Name
2973
NC Well Contractor Certification Number
Parratt-Wolff, Inc.
Cowan) Name
2. Well Construction Permit#:
;_tee all applicable welt permute ;i e. C'omuP, NUM', I'nriance, briertion, etc')
3. Well Use (check well use):
Water Supply Well:
OAgricultural
°Geothermal (Heating/Cooling Supply)
O industrial/Commercial
❑ Irri nation
Non -Water Supply Well:
QMonitoring
❑Municipal/Public
❑Residential Water Supply (single)
°Residential Water Supply (shared)
© Recovery
Injection Well:
❑Aquifer Recharge
❑Aquifer Storage and Recovery
°Aquifer Test
°Experimental Technology
DGcothemial (Closed Loop)
❑Geothermal (Heating/Cooling Return)
❑Groundwater Reimediation
❑Salinity Barrier
❑Stormw'ater Drainage
fl Subsidence Control
O Trace r
°Other (explain under 421 Remarks)
4. Date Well(s) Completed: 2/24/21 Well loft MW-77
5a. Well Location:
Colonial Pipeline Company
Facility/Owner Name Facility 1Dit (if applicable)
14511 Huntersville-Concord Road, Huntersville, NC 28078
Physical Address, City, and Zip
Mecklenburg
County Patcel Identification No (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field ouc IaUlong is sufficient)
35.412725 ,.-80.807561
6. Is (are) the well(s): 121Permanent or °Temporary
7. Is this a repair to an existing well: ❑Yes or ONo
1/ /hts is a repair, Jilt out known well coronation in/i+rnrution and explain the nntare 0/ the
repair under 21 ren+arks section or on the hack o/ this /hrnr,
8. Number of wells constructed: 1
f i,r multiple injection or non -water. supply wells ONLY with the saute construction, t'on can
submit one Jirrm.
9. Total well depth below land surface: 45 (ft.)
/ or multiple wells list all depths it di(Jereut (example- 3rc7i 200' and 2 «,100')
10. Static water level below top of easing: 25 (ft.)
If water level is above caving, use "
11. Borehole diameter: 2 (in.)
12. Well construction method: 8 1/4 HSA & 2" split spoons
(i. e auger, rotary, cable, direct push, etc )
Far Internal Use ONLY':
SEP ` 2 0 2021
14. WATER ZONES
FROM __ _ _ TO
25 rt. 45
ft.
ft.
ft.
DESCRIPTION VYsxs ""
MOORESki4 LE REGIO
LOF"'F
1S OUTER
FROM
TO
DIA
TER
1'OR LINER
THICKNESS
MATERIAL
FROM
0
ft.
ft.
ft.
in.
IlSG bfl;TiBING (geothermal claeed•l
TO
15
ft.
DIAItF.TER
2
in.
THICKNESS
sch40
MATERIAL
pvc
ft.
ft.
in.
17. SCREE
FROM TO
I I;;, NI ITF.R
SLOT srLE
THICKNESS I MATERIAL
15 ft.
45 ft.
2
in,
.010
sch40
pvc
ICE
ft.
R.
In.
FRONI
ft.
10
ft.
MATERIAL.
Portland Cam
EMPL4CF•M ENT NIETROI) & ANOINT
Tremie
10
ft.
13 ft• Bentonite Chit
Tremie
ft.
FROM
MATERL'.1..
F.SIPI,tr:F.:'
TtrOD
13
ft.
45
ft.
#1 Sand
Tremie
ft.
ft.
JN
did
FROM
TO
DESCRIPTION (calor. bardneei.
Y
CAR
tc
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
4" Stick up cover
2 x2 pad
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfecliou type: Amount:
22. Certification:
Signatute of Certified Well Con eactor Date
13y signing this Inrnt, I hereby <ern/v that the well(N) ICUs (were) constructed in accordance
with /54 ,V"( ,.K" 021 11100 as 15,4 N(:9C R?(' 1)200 Well Construction Simulards and that a
cons' 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 web
construction details, You may also attach additional pages if necessary
SUBMITTAL INSTUCTIONS
24a. Fur All Wells: Submit this form within 30 days of completion of web
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
lac For Water Supply & Injection Welts:
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
Porn GW-I North Carolina Deportment of Environment and Natural Resources- Division ofWatei Resources
Revised august /0t

RECEIVEDINCDEQ/DWR
SEP 2 0 2021
WELL CONSTRUCTION RECORD
This form can be used For single or multiple wells
1. Well Contractor Information:
Kevin White
1Veli Contractor- Name
2973
NC Well Contractor Cetttt'ication Number
Parratt-Wolff, Inc.
Comp<nn\ Name
2. Well Construction Permit #:
fist all applicable well permits (i.c, t' tint:•. State, f'ar/ant e, 1;ectioa. etc t
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
°Recovery
Injection Well:
°Aquifer Recharge
❑Aquifer Storage and Recovery
Aquifer Test
❑Experimental Technology
°Geothermal (Closed Loop)
°Geothermal (Heating/Cooling Return)
4. Date Well(s) Completed: 2/25/21
5a. Well Location:
Colonial Pipeline Company
Facility/Owner Name
❑Groundwater Rcmediation
❑Salinity Barrier
OStormwater Drainage
❑Subsidence Control
❑Tracer
DOther (explain under #21 Remarks)
Well iD# MW-78
Facility ID# (if applicable)
14511 Huntersville-Concord Road, Huntersville, NC 28078
Physical Address, City, and Zip
Mecklenburg
For Internal Use ON`L.l":
WQROS
MOORESVILLE REGIONAL OFFICE
14. WATER ZONES
FROM
35
ft.
TO
45
rt.
DFS
wet
rt.
rt.
15. OUTER CASING (for multi -eased wells) OR LINER (if applicahl )
FROM
TO
ILIMFEER
THICKNESS
MATERIAL
rt.
R.
n,
16. INNER C
FROM
0
ft.
ING OR TUBING (geothermal Oos
TO
25
ft.
DIAMETER
2
tn.
1) trn1
TRICKINESS
sch40
MATERIAL
pvc
ft.
ft.
in.
17. SCREEN
FROM I TO
25 rt.
50 ft.
IMAM TER
2
In.
SLOT SIZE
.010
THICKNESS I r tATE.R.IIAL
sch40
pvc
ft.
ft.
in.
18. GROiTP
FROM
TO
MATERIA .
FAIPIAC
0 ft.
20
11' Portland Cem
Tremie
20 ft.
23 ft.
Bentonite Chi(
Tremie
ft.
ft.
19,S+Nl'I/GRA'4ELPtCt
FROM
TO
PPikable)
MATERIAL
EMPI.
110D
23 n•
50
ft.
#1 Sand
Tremie
ft.
rt.
Id
otom
re.
ft.
ft.
ft.
T
Nteoinr,
wdne
oil(iart type, er
ft.
ft.
ft.
ft.
ft.
ft.
ft.
n.
ft.
21. RE6tAttifs
4" Stick up cover
County Parcel Identification No. WIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
Orwell field one lat/long is sufficient)
35.412904 N-80.807584
W
6. is (are) the well(s): t21Permanent or DTemporary
7. Is this a repair to an existing well: ❑Yes or EINo
if this is a repair, lUt ant known well construction infOrmatian and explain the nature aI the
repair under 21 renrurks .cell,# or au the back rt1 this lam
8. Number of wells constructed: 1
Ear multiple injection ar min -water supply wells ONI. Y imh the same construction, you can
snbttr one /Lrar
(ft.)
10. Static water level below top of casing: 40 (ft.)
if water level is above casing, use "
Borehole diameter: 2 (in.)
12. Well construction method: 8 1/4 HSA & 2" split spoons
e. auger, rotary, cable: direct push, etc )
9. Total well depth below land surface: 50
For umhtpte wells list ail depths t1 inherent (example- 3. 200' and 2:du 1 ai )
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm)
13b. Disinfection type:
Method of test:
Amount:
Form G\V-
2 x2 pad
22. Certification:
mature of
led Well Contractor
Date
By signing this Prot, 1 hereby certify that the u'eil(s) rr'os (were) cons/ructed in accordance
with 15A N('A(' 02C 0100 or 15A N('A` 02(' (/200 lkr'11(',instruction Standards and that a
copy a1 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 necessant.
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
24h. For (niectittn Wells ONI.Y: in addition to sending the form to the address in
24a above, also submit a copy or this Conn within 30 days of completion of well
construction to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24e. For Water 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
North Carolina Department of Environment and NaturalResotuces— Divisionof\Vase Resources Revised August20(3

RECEIVED/NCDEQ/DWR
WELL CONSTRUCTION RECORD
This form can be used For single or multiple wells
I. Well Contractor Information:
Kevin White
Well Contractor Name
2973
NC Well Contractor Certification Number
Parratt-Wolff, Inc.
Compam Name
2. Well Construction Permit #:
List all applicable well permits (/.e C `wm7}s .Stutr, 14rriance, inn
3. Well Use (check well use):
etc )
Water Supply Well:
❑Agricultural
OGeothermal (Heating/Cooling Supply)
O industrial/Commercial
❑lrriggatioii
Non -Water Supply Well:
ZMonitoring
❑Municipal/Publie
❑Residential Water Supply (single)
LlResidenuul Water Supply (shared)
❑ Recovery
tnjeetibll 1Ye11:
OAquifer Recharge
OAquiier Storage and Recovery
oAquiter Test
❑Experirnentnl Technology
DGeothennal (Closed Loop)
OGeothennal )Healing/'Co01(11uf etu
4. Date Well(s) Completed: 2/25/21
5a. Well Location:
Colonial Pipeline Company
Facility/Owner Name
❑Groundwater Remediation
❑Salinity Barrier
❑Stormwater Drainage
OSubsidence Control
OTracer
❑Other (eplain under 421 Remarks)
Well 1D# MW-79
Faciliry IN (if applicable)
14511 Huntersville-Concord Road, Huntersville, NC 28078
Physical Address, City, and Zip
Mecklenburg
County Parcel Identification No (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field; one tat/long is sufficient!
35.412541 N-80.807348
W
6. Is (are) the well(s): ©Permanent or OTemporary
7. Is this a repair to an existing well: ❑Fes or 1)tio
(1 this is a repair, fill ntrt known well caastructian rt,Jnrnration and exploit, the nature ul"the
repair under • 21 remarks section or an the hack of this firm.
8. Number of wells constructed: 1
For multiple infection or non -water supply wells ONLY with the sane construction. you cmh
.submit one form.
9. Total well depth below land surface: 38 (ft.)
t•or multiple wells list all depths if di(Jerent (example- 30200' and 20100')
ID. Static water level below top of casing: 30 (ft.)
l/ water level is above casing, use "
11. Borehole diameter: 2 (in.)
12. Well construction method: 8 1/4 HSA & 2" split spoons
{it. auger, rotary. cable, direct push, etc.)
For Intern!)
sc ONLY:
SEP 20 2021
TO
TO
18
TO
38 er.
ft.
ft.
ft,
ft,
DI .;t\t ETF.R.
IaS1
2
TER
nfUMMETER
2
in.
tn.
MATERI:
in.
in.
R
WQR©S
IVILLE REGIONAL
tit amp
'FSS
THICKNESS
sch40
SLOTSIZ_E
.010
Portland Cem
Bentonite Chil
t9.S. DIGR44 LPACft(ifanplicabte)
ON -Tti MATERIAL
ihlr)
ITt're.RI:)1_
MATERIAL
pvc
THICKNESS 1 MATFRIAI..
sch40
pvc
ESIPI-WE:NII E Al El HOD 5 AMIOIi NT
Tremie
Tremie
EMPLACEMENT METHOD
OFFICE
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
Form GW-1
Not tit Cat olio Department of Envitonto
6 ft. 38 ft. #1 Sand
flf: {attaetr dtdonutaheete 4f i
TO
ft.
ft.
ft.
ft.
ft.
ft.
22. Certification:
DESCRIPTION tcnlnr. hardne
4" Stick up cover
2 x2 pad
Tremie
aiVctick rype. gram the. rie;7
ill z
Sig s e re rtifiied Well Contractor Date
By signing this form, 1 hereby ceriif' that the well(,.) was (were) constructed in accordance
with 15 t N('. 1. 02(' .0100 or ISA NC:AC 02C .02110 Well Construction St nrdar& and that a
copy of this record has been provided to the well ower.
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 web
construction to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b, For Inieclian 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
ed Nato! al Rasouic
Division of Water Resources Revised August 2017

RECEIVED/NCDEQIDWR
WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
1. Well Contractor Information:
Kevin White
Well Contractor Name
2973
NC Well Contractor Certification Number
Parratt-Wolff, Inc.
Compan) Name
2. Well Construction Permit #:
i,iv all applicable welt permit, (ic_ Con rrr Stale, l iirtonce, It/PcNon, ctca
3. Well Use (cheek well use):
Water Supply Well:
°Agricultural
❑Geothermal (Heating/Cooling Supply)
OLdustrialiCommercial
❑Irrigation
❑Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
Non -Water Supply Well:
Monitoring °Recovery
Injection Well:
❑Aquifer Recharge
°Aquiter Storage and Recovery
❑Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
°Geothermal (Heating/Cooling Return)
❑Groundwater Remediation
°Salinity Barrier
OStormwater Drainage
❑Subsidence Control
°Tracer
❑Other (explain under #21 Remarks)
4. Date Well(s) Completed: 3"8'21 Well in# MW-79D
5a. Well Location:
Colonial Pipeline Company
Facility/Owner Name Facility ID# (if applicable)
14511 Huntersville-Concord Road, Huntersville, NC 28078
Physical Address, Ciry, and Zip
Mecklenburg
For Internal Use ONLY
SEP'2, 0 2021
14. WATER ZONES
FROM TO
30 ft.
48
ft,
\au)
D SCRIrrlomUQFiESVILLE.
wet
GIONAI OF -ICE
fr.
IS OUTE1
FROM
ft.
CASING, gar gnu
TO
DIAMETER
t3(t LINER (If epplie„
THICKNESS
ERIA
ft.
R.
in.
FROM
16. INNER CASG Oft TUBING.(geothermal doted loop)
THICKNESS I :MATERIAL
DL\METER
0
ft.
ft.
144 ft'
ft.
2
in.
in.
sch40
pvc
17.1
FROM
TO
DIA41ESER.
SLOT SIZE
THICKNESS
!MATERIAL.
144
154 ft.
2
in.
.010
sch40
pvc
ft.
ft.
11 GROUT
FROM
0
R I U,
MAN ENT METHO
0
ft.
89
ft.
Portland Cem
Tremie
89
ft.
115 It.
Bentonite Chii
Tremie
ft.
ft.
115 rr.
TO
154 ft,
MATES
Lit..
#1 Sand
F.MPLA
Tremie
PC.
ft.
FROM
ft.
ft.
TO
ti(`. (stoleit ri
ft.
R.
DESCRIPTION fcalor, hardness: scellrmek type, train sie. ?to? ,
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
County Parcel Identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
ofwet/ field, one lat/long is sufficient)
35.412524 N-80.807414 w.
6. Is (are) the well(s): EdPermanent or °Temporary
7. Is this a repair to an existing well: ❑Yes or ©No
if mix is a repair, lilt out known well construction inlbrnmtian and explain the nature of the
repair under 21 remarks section or on the hack of this /urnr,
8. Number of wells constructed: 1
For multiple injection or non-u•atersupply wells ONLY ivilh the same construction, you can
submit one form.
9. Total well depth below land surface: 154
For multiple +re/1s list all depths if iIi/Jerem (example- 3 2(10'anti7(a100')
(ft.)
10. Static water level below top of casing: 104 (ft.)
Ifuwer level Ls above casing, use "-
11. Borehole diameter: 2 (in.)
12. Well construction method: 8" casing and 4" Air Hammer
(i.e. auger, rotary, cable, direct push, etc
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
22. Certification:
Sig mute of Certified Well Cunha 0 t Dace
I/o signing this (ornt, 1 hereby certifi, that the well(*) was (were) constructed in accordance
with 15,4 NC'.9(' 02C 0100 or 15A N('A(` 02(' .0200 Well Construction Standards and that a
copy oJthis record has heen 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 .\II Wells: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Information Processing Unit,
1617 Mali 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
24e. For Water Supply & Injection Wells:
Also submit one copy of this firm within 30 days of completion of
well construction to the county health department of the county where
constructed
Form GW- I North Carolina Deparm:ent oFEnviroumcnt and Natural Resources - Division of Water Resources Revised August 2013
TO

RECEIVED/NCDEQIDWR
WELL CONSTRUCTION RECORD
This form can be used for single or multiple Hells
1. Well Contractor Information:
Kevin White
Well Contractor Name
2973
NC Well Contractor Certification Number
Parratt-Wolff, Inc.
Company Name
2. Well Construction Permit #:
iv ail applicable well permits (i.e ('Dual-, .Gate. iln•iarrce, 6r%eel, or etc.1
3. Well Use (check well use):
Water Supply Well:
JAgricultural
OGeothermal (Heating/CoolingSupply)
Olndustrial/Commercial
❑1rri4ation
[Municipal/Public
OResidential Water Supply (single)
❑Residential Water Supply (shared)
Non -Water Supply Well:
Monitoring ORecovery
For internal I se ONLY
R
FROM
23.5 rt•
TO
37
ft.
02
BOS OC DICE
DFsCRI [e-mail] REOIUNRL
wet
WO
Injection Well:
❑Aquifer Recharge
❑Aquifer Storage and Recovery
C)Aquifer Test
OExperimental Technology
❑Geothermal (Closed Loop)
OGeothermal (Heating/Cooling Retu
❑Groundwater Remediation
OSalinity Barrier
OStormwater Drainage
OSubsidence Control
❑Tracer
t) OOther (explain under #21 Remarks)
4. Date Well(s) Completed: 3/2/21 Well ID# MW-80
5a. Well Location:
Colonial Pipeline Company
Facility/Owner Name Facility ID# (if applicable)
14511 Huntersville-Concord Road, Huntersville, NC 28078
Physical Address, City, and Zip
Mecklenburg
County Parcel identification No. (Pitt)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(dwell Feld, one laUlong is sufficient)
35.412182 N -80.806945
W
6. is (are) the well(s): ©Permanent or OTemporary
7. Is this a repair to an existing well: ❑Yes or lNo
If this is a repair, fill out known well construction inJnrmalian and explain the nature of the
repair under =21 remarks section or an the back of this prin.
8. Number of wells constructed:
1 'br multiple infection or non -water supply wells ONLY with the same construction. you can
submit one fora..
9. Total well depth below land surface: 37 (ft,)
For multiple. wells list all depths if different (example- 3 re 200'and MOO')
10. Static water level below top of casing: 23.5 (ft.)
/J water level is above casing, use "
Borehole diameter: 2
(in.)
12. Well construction method: 8 1/4 HSA & 2" spoons
auger; rotary, cable; direct push, etc.)
ft.
ft.
0L)TER CASU
FROM
ft.
ft.
DIAMETER
in.
THICK-NES4
7M
atde)
ATERIAL
to. INNER CMIIING Olt TtIRL0
Oat
0
et.
TO
17
ft.
D1AM
2
R
in.
al
ed*lorap
111IC
SC
sch40
tttATERIA(.
pvc
ft.
ft.
in.
17. SCREEN
FROM
TO
Sta
St
KNESS
MATERIAL
17 fl.
37
ft.
2
in.
.010
sch40
pvc
ft.
ft.
Guetrr
FROM
0
ft.
TO
10
ft.
.,.MATERIAL
Portland Cem
EMF'r.:ACEM1 NT 11ETI O1.
Tremie
101:- T
10 n•
15 ft.
Bentonite Chi
Tremie
ft.
ft.
FROM
TO
FA
MAT
bit)
AL
EMU. ke
ENT M ET1100
15
ft.
37
ft.
#1 Sand
Tremie
ft.
ft.
20.I1
FROS'
f.iNG FIX; (attach etkellttatal sheets if oat entity')
ft.
ft.
TO
ft.
ft.
DESCRIPTION tcaTo r hardn s. sniUeoeh
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
4" Procover
-FOR WATER SUPPLY WELLS ONLY:
I3a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
Forst GW- 1
North Carolina Department of Environment
2 x2 pad
22. Certification:
1-1 fr
Signature n enuhedWell Conti( Date
Hy signing this farm 1 hereby certify drat the welt/s) was (were) constructed in accordance
with 15A N('A(' 02(' 010n or I5A •VC.A(` 02C 0200 Well Construction Standard,. amid that a
copy aJ 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 cm 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. hnr Infection 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
consuucted.
and Natural Resources- Division of Wate, Resources
Revised August 2013

RECEIVED/NCDEQ/DWR
WELL CONSTRUCTION RECORD
This form can be used For single or multiple welts
1. Well Contractor information:
Kevin White
Well Contractor Name
2973
NC Well Contractor Certification Number
Parratt-Wolff, Inc.
Compam Name
2. Well Construction Permit #:
List all applicable weli permas (i.e ('srtrete, Stare, i4rri<nrce, ht%eciian. etc.)
3, Well Use (check well use):
Water Supply Well:
❑Agricultural
°Geothermal (Fleating/CoolingSupply)
Ofndustrial/Commercial
❑Irrigation
❑Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
Non -Water Supply Well:
t 1Monitoring
❑Recovery
injection
❑Aquifer Recharge
°Aquifer Storage and Recovery
°Aquifer Test
❑Experimental Technology
°Geothermal (Closed Loop)
°Geothermal (1teating/Cooling Return)
4. Date Well(s) Completed: 3/3/21
5a. Well Location:
Colonial Pipeline Company
Facility/Owner Name
❑Groundwater Remediation
❑Salinity Barrier
°Stormwater Drainage
°Subsidence Control
❑Tracer
°Other (explain under #21 Remarks) i
Well ID# MW-81
Facility IDk (if applicable)
14511 Huntersville-Concord Road, Huntersville, NC 28078
Physical Address, City, and Zip
Mecklenburg
County Parcel Identification No (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if welt field. one lot/long is sufficient)
35.411672 N-80.806653
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, lilt out known well construction iglbrrnatiort and explain the nature or the
repair under ,21 remarks section or on the hack o/ this /drat:
S. Number of wells constructed: 1
For antliipte injection or non -Crater supply wells ONLY with the same construction, you can
tutbmit one jam
9. Total well depth below land surface: 37
For multiple wells list all depths if ditleren( (example- .3 -0200' and i+ic ift0')
Id. Static water level below top of casing:
!J water level is abuse easing, use
i t. Borehole diameter: 2
(in.)
12. Well construction method: 8 1/4 HSA & 2" spoons
(ft•)
(ft.)
e. auger, rotary, cable, direct push, etc.)
lanai
14. WATER ZONES
FROM
TO
1
DESCRIPTION WQROS
ft.
ft.
MOORESVILLE REGIONAL OEFIC
ft.
ft.
15.our ERCASLNG [farmultwea€edswills)OR%1 (ile
Rahte)
FROM
10
DIAMETER
THICKNESS
MATEREAL.
ft.
ft.
in.
16. INN'ER CASING OR TTJt%BIG
fetetheratat clo d ttxrp)
FROM
TO
DIAMETER
"tilt"KN tOlC
MATERIAL.
0 ft.
17 ft.
2 in'
sch40
pvc
ft.
ft.
in.
17. RUN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
17 ft
37 ft,
2 in.
.010
sch40
pvc
...
ft,
ft.
in.
tt€; GROUT
FROM
TO
:MATERIAL
EtiPL\CFME\'T S1ETI1/7U.:ic .i410t ",l
0 ft.
12 ft
Portland Cem
Tremie
12 ft
18 ft
Bentonite Chi
Tremie
ft.
ft.
19. SAND/GRA.k1L PAC fC (itapplkabte-
FROM
10
MATERIAL
EMPLA('1.11ENTMETHOD
18 it
37 ft.
#1 Sand
Tremie
ft.
ft.
1 DBf1,tJNGt)i3Gtanaehaddtdanai
lbws ifneeeasan7)
FROM
TO
i)tSCl1IPT IO'l Praha. harss, sattlrttek tyne, $t.iin bti5, etC.)
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
rt.
ft.
2i, R*M,iltti s '
8" Flush Cover
2 x2 pad
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
22. Certification:
Date
Signature of Certified Well Contractor
13y signing this litres, 1 hereby certify that the we/Ms) was (lucre) constructed in accordance
with 154 N('.d( 02C .0100 or 15A N(AC 02(' 0200 Weil ('oosrn110t m b'iatulards and that a
copy of this record has been provided to the u•e11 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.
SIBMiTTAL 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 fonn within 30 days of completion of well
construction to the tollowine:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
21c. 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 GWI No,tlr Cauolina Department o)-Environment and Natural Resources- Division of Water. Resources
Revised .August 2013

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
Fur internal Us ONLY:
I. Well Contractor Information:
Kevin White
Well Contractor Name
2973
NC Well Contractor Certification Number
Parratt-Wolff, Inc.
Cutnpanp Name
2. Well Construction Permit #:
List all applicable well permits rue.. County, Slaw, 1 nridnce, In/colon, etc-)
3. Well Ilse (check well use):
Water Supply II:
❑Agricultural
❑Geothermal (Heatina/Cooling Supply)
❑industrial/Commercial
❑irrigation
CMunicipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
Non -Water Supply Well:
t iMonitoring
DR
Injection Well:
❑Aquifer Recharge
:Aquifer Storage and Recovery
°Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling Return)
4. Date Well(s) Completed: 7-18-21
❑Groundwater Rem edianon
❑Salinity Barrier
❑Stnrmwatcr Drainage
❑Subsidence Control
❑Tracer
COther (es lain under #21 Remarks)
ell ID# MW-81 D
5a. Well Location:
Colonial Pipeline Company
Facility/Owner Name Facility iDt/ (if applicable)
13900 Huntersville-Concord Road, Huntersville, NC 28078
Physical Address, City, and Zip
Mecklenburg
County
4660193695/1921204
Parcel identification No (PIN)
fib. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one laulong is sufficient)
35.411707 'v -80.806545 W
6. is (are) the well(s): ©Permanent or ❑Temporary
7. Is this a repair to an existing well: ❑Yes or ©Nu
if this is a repair, fill ant known well construction ir(fitrnrrttion and explain the nature of the
repair under ,21 remarks section or on the hack (Ohl!: c /itri n,
8. Number Owens constructed: 1
For multiple in/ection ar non -water supply wells ONLY a ah the sane construction, you can
subunit one pm,
Total well depth below land surface: 1 13 (ft.)
hitr multiple tretis list all depths if d(// e, nt (example- 3 ct,200' Duna 2 a 100`)
ID. Static water level below top of'casing: 25 (ft.)
# water level is ((bare casing, nsu "
II. Borehole diameter: 2 (in,)
6 5/8 NSA & 2" spoons & 8" Air Hammer (4" PVC Casing
12. Well construction method:
fie anger, rotary, cable, direct push, etc )
14. W TER ZONE
FROM TO
OESCRfl1ION
25 ft, 113 ft,
Wet
ft. ft.
EP. °trait
Cht}ll+if tfwmuifFept
d Wi 1t;1'OR LINER (If $unifiable}
FROM
TO
DIAMETER
TIME N
MATERIAL
ft.
ft.
in.
i
)v
p)
( Itt?M1i
O
plyhit;TER
THICKNESS
M:VI) RIAI
0 ft.
98 ft•
2 In•
sch40
pvc
ft.
fc
in.
17. SCR gEt!i
FROM
TO...
bt,tMl rt0e
:4101 SI'
1'Hic:KNEES ...
MATERIAL
98 f•
113 ft
2 In.
.010
sch40
pvc
ft.
ft.
in.
I8 GROUT
FROM
TO
MATERIAL
EMI't_rw:kMEVI'?HEIR €)L)&A3IOttNI
0 ft,
89 f'
Portland Cern
Tremie
89 ft.
94 fl•
Bentonite Chi'
Tremie
ft.
ft
l9. Wlklliatl'i
l .rah lC
(tf ft 'Roble)
FROM
TO
MATERAAI,
rMIH_A('1 EIVI MI:I11011
94 ft•
113 ft•
#1 Sand
Tremie
ft.
ft.
moan, Ilif.l
(attach_
dttltirinal Ilse If It Crary) `
FROM
,1'O'
nt_ScKIPTION Nola',. has dues ell/tusk tyik.gtain i.ct, tie.).
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft
ft.
ft.
re.
ft
ft.
rt.
8" Flush Cover
2 x2 pad
FOR WATER SUPPLY WELLS ONLY:
I3a. Yield (gpm) (Method or test:
13h. Disinfection type: Amount:
22, Certification:
Signature ofCeitifie+d Well Cuntrsterur
Date
Hy signing this fn'nt, 1 hereby certify that the waits) was (were) constructed in arcortlttac'e
with 15A N('A(' 02C ,(1100 or 15A NIA(' 02C .0200 R'elt Construction Standards and that o
copy of this record has hero provided na the well owner.
23. Site diagram or additional well details:
You may use the buck or this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INST(ICTiONS
24a. For All Wets: 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 Inieetlon Wclic.ONLY: In addition to sending the form to the address in
24a above, also submit a copy of this farm 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. Fur Water SupplyA. Injection Wells;
Also submit one copy of this form within 30 days of completion or
well construction to the county health depannient of the county where
constructed:
Form CiW-i
North Carolina Department of'Environment and Natural Resources — Division of Water Rcsoutces Revised August 2013

RECEIVED/NCDEQ/DWR
WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
I. Well Contractor Information:
Kevin White
Well Contractor Name
2973
VC Well Contractor Certification Number
Parratt-Wolff, Inc.
Cornpam Name
2. Well Construction Permit #:
List all applicable well permits (i. e County. Shoe, E;rriance, !Mecum etc.)
3. Well Use (check well use):
Water Supply Well:
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑Industrial/Commercial
❑Irrigation
Non -Water Supply Well:
171Moni tori ng
❑ Municipal7Publ is
DResidential Water Supply (single)
❑Residential Water Supply (shared)
❑Recover'
Injection Well:
❑Aquifer Recharge
ClAquifer Storage and Recovery
❑Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (ifeating/Cooling Return
4. Date Well(s) Completed: 3/2/21
5a. Well Location:
Colonial Pipeline Company
Facility/Owner Name
❑Groundwater Remediation
❑Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑Tracer
❑Otherte'plain under #21 Remarks)
Well [D# MW-82
Facility IDi! (if applicable)
14511 Huntersville-Concord Road, Huntersville, NC 28078
Physical Address, City, and Zip
Mecklenburg
County Parcel identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field one !along is sufficient)
35.411508 N-80.806448
6. Is (are) the well(s): 121Permanent or ❑Temporary
7. Is this a repair to an existing well: OYes or l!Nu
lI this is a repair, fill out known well construction itl/iumatiott and explain the nautre of the
repair under ,21 remarks section or on the hack of this pros.
8. Number of wells constructed: 1
Mir multiple injection or non -water supply wells ONLY with the same construction, you con
submit one form.
9. Total well depth below land surface: 39 (ft.)
For nndtip/e wells list al! depths if different (erantple-
10. Static water level below top of easing:
If water level is above casing, ose " "
11. Borehole diameter: 2
200'and 2@ WO')
(in.)
12. Well construction method: 8 1/4 HSA & 2" spoons
(ft.)
(i.e anger, rotary, cable, direct push, ete )
For Internal Use ONLY
SEP 2 0 2021
*4.. WATER Zil.
FROM
ft.
TO
et.
DESCRIPTION
WQROS
MOORESVILLE RECTONALOFFtC
ft.
ft.
IL OUTER CASING (far
FROM`
ft.
TO
ft.
tti cased wetttt Qtt LtYER (tf►_9
DIAMETER
in.
ntichNES% t MATERIAL
16. INNER CASING OR TtURINC,F feentheenn&
FROM
TO
I DIAMETER
nnc
AL
0
ft.
ft.
14
ft.
2
in.
In.
sch40
pvc
17. SCE'
FROM
TO
DIAMETER
l:tf SIZE
THICK:
s
MATERIAL
14 ft.
39
rt.
2
in.
.010
sch40
pvc
ft.
ft.
in.
IS. GROUT
FROM
0
ft.
TO
9
ft.
, MATERIAL
Portland Cern
E31PL%CCM E:NTMET1100 & AMOUNT
Tremie
9
ft.
ft.
12 ft• Bentonite Chii
Tremie
ft.
AND/GRAVEL PACK:(
FROM
TO
pile bi
MATERIAL
EMPLACEMENT METHOD
12
ft.
37
ft.
#1 Sand
Tremie
ft.
et.
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm)
13b. Disinfection type:
Method of test:
Amount:
FROM
3NG I OG (are to h tddt
ft.
ft.
: tt )rat Bileet8 tf tt4e
TO ( DESCRtPT ION (cold ha,
ft.
ft.
secs, sniUWrk ij'ryr, grain sirs. eft.
fr.
ft.
ft.
ft.
ft.
fL
ft.
ft.
ft.
ft.
8" Flush Cover
2 x2 pad
22. Certification:
Ie of Certified Weil Contractor
Date
By signing this farm, I hereby certijb that the well(s) :vas (here) constructed nt accordance
u'idt (SA NC'02(`.0100 or /.5A NC'.AC 02/' .0200 Well Construction Standards and that a
copy ()Phis 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 web
construction details. You may also attach additional pages if necessary
SUBMITTAL INSTUCTIONS
24a. For All WelL: 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 web
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
Foi m GW-I North Catotina Department of Environment and Natural Resources — Division of Water Resources
Revised August 2013

WELL CONSTRUCTION RECORD
This form can be used for single or rnulliple %'ells
I. Well Contractor information:
Kevin White
Weil Contractor Name
2973
NC Well Contractor Certification Number
Parratt-Wolff, Inc.
Company Namc
2. Well Construction Permit #:
Liu all applicable well pr•rmi(s (i c (`oaaty, Strait, Varianee, lateen ere )
3. Well Use (check well use):
Water Supply Well:
❑Agricultural
❑Geothermal (HeatingfCootin
❑ Industrial/Commercial
❑Irrigation
❑Munieipal,(Public
Supply) ❑Residential Water Supply (single)
❑Residential Water Supply (shared)
Non -Water Supply Well:
C1 Mon itori ng ❑ Recovery
Injection Well:
❑Aquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling Return)
4. Date Well(s) Completed: 3/5/21
❑Groundwater Remediation
❑Salinity Barrier
0 Stormwater Drainage
❑Subsidence Control
❑Tracer
❑Other (explain under #21 Remarks)
5a. Well Location:
Colonial Pipeline Company
Well 1D# MW-83
Facility/Owner Name Facility ID# (if applicable)
14511 Huntersville-Concord Road, Huntersville, NC 28078
Physical Address, City, and Zip
Mecklenburg
Courtly Parcel identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field one fat/long is sufficient)
35.413250 -80.808001
w
6. Is (are) the well(s): OPermanent or ❑Temporary
7. Is this a repair to an existing well: ❑Yes or t 3No
11 this is a repair,, jilt our known well caar-trucllaa i formation and explain the nature the
repair under .-2/ rentaria .section or on the back of this firm,
8. Number of wells constructed: 1
For multiple injection or non -water supply wells ONLY with the same construction, you can
.submit one Berm.
9. Total well depth below land surface: 44.5 ill)
For multiple wells list all depths 1/ different (example- 3 tit 200' and 20100')
10. Static water Level below top of casing: 38 (ft.)
1.1 rraler level is above casing, use " "
ILBorehole diameter: 4(in.)
12. Well construction method: 10 5/8 HSA & 2" spoons
(te toter, ratan;. cable, direct push, etc.)
fECEIVFDINCDEOIDWR
Fur Internal Use ONLY:
S P" O'20Z1
14, WATrrR';
FROM
38 ft.
ft.
TO
44.5
t.
ft.
DESCRIPTION WQnOS
MOORESVfet F REGIONAL OFF
IS. (LITER C'AS!;v
FROM
TO
DIAMETER
OR LINE
THICKNESS
PII
M.
TERIAL
ft.
ft.
fn.
lb. INNER C':%SING AR TIIRI G trot uattrtnal d ad-ianl
FROM
TO
DIAMETER
THICKNESS
MATERIAL
0
ft.
ft.
24.5 ft.
ft
2
In.
in.
sch40
pvc
17. SCREEN
FROM
24.5 ft•
TO
44.5 re.
DIAMETER
2
f n.
SLAT SITE
.010
THICKNESS NIATERIAI_
sch40
pvc
ft.
ft.
tn.
la. GROUT
CE
I)
MATERIAL
EMPLACEMENT METHOD & AMOUNT
0
ft.
20 ft.
20
22
ft.
ft.
Portland Cem
Bentonite Chii
Tremie
Tremie
ft.
ft.
19 SAND/G W44 EL PACK (tf applieshit)
FROM
"f0
MATERIAL
ERIALL
CFMFNT METHOD
22 ft.
fL
44.5 ft.
ft.
#1 Sand
Tremie
FROM
LING LOG Is eddlRand sleets if 1
TO
DESCR! TION tcutar. hit rtfnns. soilfrock tc
et
ft.
ft.
ft.
ft.
ft.
ft.
ft.
R.
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
Form G\V-I
ft.
ft.
ft.
ft.
8" Flushmount
2 x2 pad
22. Certification:
lure of Certified Well Contractor
.(.-\
Date
By signing this hero, I hereby certify that the we/1(s) was (were) constructed in acevrdance
with 15A N(.'A(` 021' 0100 or 15,4 VC -A' (12C 0260 Well Construction Standards and that a
cow of this record has been provider/ to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details You may also attach additional pages if necessary.
SUBMITTAL 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 Infection 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 torm within 30 days of completion of
well construction to the county health department of the county where
constructed.
North Carolina Department of Environment and Natural Resources— Division of Water Resources
Revised August 2-013

nECEIVEDINCDECIDWR
a 0 •'2021
WELL CONSTRUCTION RECORD
This form can be used for single or multiple %setts
1. Well Contractor Information:
Kevin White
Well Contractor Name
2973
NC Well Contractor Certification Number
Parratt-Wolff, Inc.
Compam Name
2. Well Construction Permit#:
List ail applicable well permits (i. e. Conn nv, State, Variancniection, et.•,)
3. Well Use (check well use):
Water Supply Well:
DAgricultural
OGeothermal (Fleating/Cooling Supply)
O htdustrial/Commercial
❑Irrigation
Non -Water Supply Well:
@Monitoring
OMunicipal/Public
OResidential Water Supply (single)
:Residential Water Supply (shared)
O Recover'
Injection Well:
❑Aquifer Recharge
❑Aquifer Storage and Recovery
DAquifer Test
oExperimental Technology
OGeothermal (Closed Loop)
OGeothermal (Heating/Cooling Return)
❑Groundwater Rentediation
OSalinity Barrier
❑Stormwater Drainage
❑Subsidence Control
OTracer
❑Other (explain under #2 Remarks)
4. Date Well(s) Completed: 3/6/21
5a. Well Location:
Colonial Pipeline Company
Facility/OwnerName
Well iD# MW-84
Facility IDfI (if applicable)
14511 Huntersville-Concord Road, Huntersville, NC 28078
Physical .Address, City, and Zip
Mecklenburg
County Parcel Identification ication No. (PIN I
Sb. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
Of Well Geld; oue iat/long is sufficient)
35.413196 N-80.807938
W
6. Is (are) the well(s): ©Permanent or ❑Temporary
7. Is this a repair to an existing well: OYes or CJINo
if this is a repair, Jill out known well construction hjismmtion arcl explain the nature of the
repair antler = 21 remark+.vectioe or on the hack of this firm.
8. Number of wells constructed: 1
1 or multiple injection or iron -water supply bells ONLY with the same construction, r nt care
submit one (ornt.
9. Total well depth below land surface: 36.5 (ft.)
Jim multiple wells list all depths if di(/i rent (example- 3 a200' and 2@t00 )
10. Static water level below top of casing: 32 (ft.)
If water level is above casing, use "
1 I. Borehole diameter: 4 (in.)
12. Well construction method: 10 5/8 HSA & 2" spoons
(i.e. auger, rotary, cable, direct push, etc )
FOR WATER SUPPLY WELLS ONLY:
I3a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
Foem GW-I
North Carolina Department of Environment
For Internal t;se ONI_l';
WC2ROS
REGIONAL OFFICE
M FOR SVILLE
t4.'Si 3TER "LON1kS
FROM
TO
DESCRIP'i'tOIV
32 ft
36.5 ft
wet
ft.
ft.
t5 C3LITER
CAgING D. a`nIti.t aed'wells( OR i INEII tifuppiteab1e1
FROM
TO
DIAMETER
71€tt FSS
MATERIAL
ft.
ft.
In.
tt1 iN eFR
CA. I'ut oR T
xRla�r'G toot trout statist -loop)
FROM
TO
DIAMEl"ER
THICKNESS _---
RIATERINI.
0 ft-
16 fc
2 in.
sch40
pvc
re.
ft.
in.
f7 1L ILFE
FROM
TO.
DIAMETER
SLOT SIZE
THICKNESS ESS
MATERIAL
16 ft*
36.5 ft
2 in.
.010
sch40
pvc
ft.
ft.
in.
1L GROUT
101O0
'f0
MA HALAL
EMPL3CEMINTMETnOD&AMDUNT
0 ft.
9 ft.
Portland Cem
Tremie
9 ft-
11 ft
Bentonite Chil
Tremie
ft.
ft.
f9.5.i sD1CRAI
Et P.ACittifannbeabie)
FROM
TO
MATERIAL,..
Ehtl'L:iCEJ€EMT'41F.`rlit)D
11 ft•
36.5 ft•
#1 Sand
Tremie
ft.
ft.
29, DRI1.LINCr
f OG (attach ettditittnstt klluce if utra}apry)
FROM
TO
DESCRIPTION total h tdnas<. asittrvek type, grain siia,.atc.I
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
_._...
ft.
ft.
8" Flushmount
2 x2 pad
22. Certification:
Signature of Certified W,51 Cantu
Date
By .signing this jnrm, 1 hereby certiLe that the well(s) was (were) constructed in accordance
with 154 NCA' 02(' .0100 or 15,1 M'A' 02f' 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_
SUBMiTTALINSTUCT1ONS
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 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 web
construction to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supply S: 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
and Natural Resources — Division of Water Resources
Revised August 2013

EIVED/NCDEQ/DWR
S'',02021
WELL CONSTRUCTION RECORD
This Corm can be used for single or multiple wells
1. Well Contractor Information:
Kevin White
Well Contractor Name
2973
NC Well Contractor Certification Number
Parratt-Wolff, Inc.
Contpan Name
2. Well Construction Permit #:
List all applicable melt peruiire 0 (buns, .'
3. Well Use (check well use):
Lilection. etc./
Water Supply Well:
oAgricultural
OGeothermal (Heating/Cooling Supply)
Dindustrial/Commercial
❑Irrigation
OMunicipal/Public
OResidential Water Supply (single)
❑Residential Water Supply (shared)
Non -Water Supply Well:
ElMonitoring
^Recover'
Injection Well:
❑Aquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer Test
❑Experimental Technology
❑Geothemla( (Closed Loop)
OGeothennat (Heating/Cooling R
urn)
OGroundwater Remediation
OSatinity Barrier
❑Storrnwater Drainage
❑Subsidence Control
OTracer
❑Other (explain under 421 Remarks)
4. Date Well(s) Completed: 3/9/21
5a. Well Location:
Colonial Pipeline Company
Facility/Owner Name
Well ID# MW-85
Facility TEM (if applicable)
14511 Huntersville-Concord Road, Huntersville, NC 28078
Physical Address, City, and Zip
Mecklenburg
County Parcel Identification No. (PiN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one IaUlong is sufficient)
35.413253 N-80.807913
6. is (are) the well(s): I21Permanent or OTemporary
7. Is this a repair to an existing well: OYes or ©No
11 this is a repair, fill out known well construction in/nrmation and explain the nature al -the
repair under : 21 remarks section or on the hack of this fhrm.
8. Number of wells constructed:
For multiple injection or non -water supply wells ONLY with the same construction, you can
submit one Jinni,.
9. Total well depth below land surface: 36
for nitilriple wells list all depths //different (example- 3 a 200' and 2@ l0(!')
(ft. )
t0. Static water level below top of easing: 30 (ft.)
1/ water level is above easing, use "
II. Borehole diameter: 4 (in.)
12. Well construction method: 10 5/8 NSA & 2" spoons
e auger; rotary, cable, direct push, etc
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
Form Gw-1
North Carolina Department of Environment a
For loicro 1 Use ONLY;
WQROS
REGIONAL OFFIC
MO0RF.SVILLE
14. WATER ZONES
FROS1
TO
9ESf RIPTION
30 f•
366 f•
wet
ft.
ft.
15. OUTER
CASING lfor multi -eased efa) OR LINER (If appileabte)
FROM -
TO ...
DM.AMETER THICI4NFss..
St3TEut:it.
ft..
ft.
in.
16• ih3 Ell
dNG Ole fi
URI CI i t)trrmaf t i ism t tp)
FROM
TO
DI.aMETF.R 1 T1tICK'VE.CC
\I %TERIAt. --
0 ft.
ft.
16
2 in.
sch40
pvc
ft.
ft.
In.
17<SCBgk9
FROM
TO
DIAMETER
SLSJT SIZE
MICR CS
MATERIAL
16 ft.
36 ft.
2 in.
.010
sch40
pvc
ft.
ft.
in.
1# Ciitlt
FROM.
TO
MkTCR!At
GMPLACLMErrC LIFTij O. AMOUNT-
0 ft.
12 ft-
Portland Cem
Tremie
12 ft.
14 °.
Bentonite Chi
Tremie
ft.
rt.
19, SANDIC RAVttL P3 Cif
(if s€ptrticxltle)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
14 f'•
36 ft,
#1 Sand
Tremie
ft.
ft.
16IDRt LING
LOG (ottachatrfditttatutahseLv
tfuatic ary)
most
To
DESCRIPTION{eohm. .hardnrss, s,alirack rvpc, g,a naiae.
ft.
ft.
ft..
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
21, REM tttlia
8" Flushmount
2 x2 pad
22. Certification:
Sipnoluie of Certified Well Contractor
off -"al
Dote
By signing this form, 1 hereby certify that the we1100 11M (were) constructed in accordance
with 15A NCAC 02C 0100 or 1SA NCAC 02e _0200 HAW t`aostruction Standards and that a
copy of this record has hoes 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 infection 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 tollowing:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supply. & Injection Welts:
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.
rid Natural Resow ces — Division of Water Resources
Revised August_013

RECEIVEDINCDEQ/DWR
WELL CONSTRUCTION RECORD
This form can be used tot single of multiple wells
1. Well Contractor information:
Kevin White
Well Contractor Name
2973
NC Well Contractor Certification Number
Parratt-Wolff, inc.
Company Name
2. Well Construction Permit #:
iayt all app/kahte well permits fe ('nrtntrt state, 1'arian
3. Well Use (check well use):
1i
UM', eft:I
Water Supply Well:
❑Agricultural
^Geothernal (Heating/Cooling Supply)
O industrial/Commercial
0 irrigation
Non -Water Supply Well:
(21 Monitori ng
❑Municipal/Public
CJResiderttial Water Supply (single)
DResidential Water Supply (shared)
Recovery
Injection Well:
❑Aquifer Recharge
❑Aquifer Storage and Recovery
0Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling Return)
0Groundwater Remcdiation
❑Salinity Barrier
OStormwater Drainage
❑Subsidence Control
❑Tracer
❑Other (explain under #21 Remarks)
4. Date Well(s) Completed: 3/14/21 Well ID# MW-86
5a. Well Location:
Colonial Pipeline Company
Facility/Owner Name Facility IDA, (if applicable)
14511 Huntersville-Concord Road, Huntersville, NC 28078
Physical Address, City, and Zip
Mecklenburg
County
Parcel identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field one fat/long is sufficient)
35.412011 N-80.805826
W
6. Is (are) the well(s): ©Permanent or ❑Temporary
7. Is this a repair to an existing well: CYes or ENo
1/ 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 Firm
S. Number of wells constructed: 1
Par multiple injection or non -water supply wells ONLY with the sume construction,
submit one /iirm-
9. Total well depth below land surface: 46
't Cain
Par multiple wells list all depths /l d/(/¢rent (example- 30 00' and 2(i0latr)
10. Static water level below top of casing:
If water level IN above casing use "
11. Borehole diameter: Q (in.)
12. Well construction method: 10 5/8 HSA & 2" spoons
(ft.)
(ft.)
(i.c. auger, rotary, cable, direct posh, etc
FOR WATER SUPPLY' WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
Form G\V-1
North Catalina Department of Enviro
For I:sctna! tlse 0NLV': s�. Ei ! L' v ""' •
WQR()S
04-t-1GF
14. WATER ZONES. R SVILLE REGIONAL
FROM
TO
D I l
ft.
ft.
ft.
ft.
15. OUTER CASING [for multi.eaaed wells) OR LINER (If applicable)
FROM.
TO
DIAMETER I ?IIICKNESS.
iIATERI.L
rt.
rt.
In.
16. INNER CASING OR TUBING (geothermal dossed -loop)
FROM
TO
DIAMETER i Tt{ICRNESS
11 %TERI,tL
0 ft.
16 ft.
2 in. sch40
pvc
ft.
ft.
in,
17. SCREEN
FRO:N I 10
011\1E1 ER
SLOTS€zs:
TRICKNeSS ( M1TFR.1\1-
16 ft.
46 it
2 t"'
.010
sch40 pvc
fl.
ft.
in.
13. GROUT
FROM
TO I MATERIAL
Es1I'L\CEIIENT11E 110D.Y:tM0tNT
0 B•
7.5 ft
Portland Cem
Tremie
7.5 it
10 it
Bentonite Chit
Tremie
ft.
ft.
19, S Nb/GRAVEL i' ICK Of applkable1
FROM
TO
5IATERIAL
EMMA(E A N FTI14t)
10 ft
46 ft.
#1 Sand
Tremie
ft.
ft.
210.,Uittl,i.ING
LOG WWI] additianai 9heetx tf fxce soey)
FROM
'€f7
DESCRI0N 'calm, h.uJntss, "Euittruck type, main sir/ elf:)
ft.
it.
ft.
ft,
ft.
ft.
ft.
ft.
rt.
rt.
ft.
ft.
ft.
ft.
71. REMARKS
2 x2 pad and cover
22. Certification:
Att. el
soreefCertified Well Contractor "` + Date
By .signing this /i rrin, 1 hereby cerhfl' that the wells} tray /were) cons/menu/ bi acer rrkince
with /5A ,V('.d(02( 0100 or 15,4 Nt 4C 02C 0200 Well Construction Standards and that a
ropy 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 of well
construction details. You may also attach additional pages if necessary
SUBMITTAL iNSTUCTIONS
24a. For .11l 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. F'tir Injection Wells ONLY: In addition to sending the form to the address in
24a above. also submit a copy of this Conn within 30 days of completion of well
construction to the following:
Division of Water Resources, Underground injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24e. For Water Supply & injection Wells:
Also submit one copy of this form within 30 days of completion of
web construction to the county health department or the county where
constructed.
tent and Natural Resources- Division of Watt, Resources Revised August 2013

WELL CONSTRUCTION RECORD
This form can be used for single ur multiple wells
1. Well Contractor Information:
Kevin White
Well Contractor Name
2973
NC Well Connector Certification Number
Parratt-Wolff, inc,
Company Name
2, Well Construction Permit II:
List all applicable well permits fi ('attn. Slate. 1 itplance, Injection: etc,
3. Well Use (check well use):
Water Supply
0Agricultural
0Geotherinal (Heating/Cooling Supply)
0 Industrial/Commercial
o Irrigation
0 Municipal/Public
0 Residential Water Supply (single)
Residential Water Supply (shared)
Non -Water Supply Well:
0Monitoring
0 Recovery
Injection Well:
DAquifer Recharge
EAquifer Storage and Recovery
DAquifer Test
Experimental Technology
OGeothennal (Closed Loop)
DGeothermal (Heating/Cooling
4. Date Well(s) Completed: 4/23/21
5a. Well Location:
Colonial Pipeline Company
Facility/Owner Name
OGroundwater Remcdtaton
OSalinity Barrier
OStormwater Drainage
oSubsidence Control
0Tracer
00ther (explain under #21 Remarks)
Well ID# MW-87
Facility IDif (if applicable)
14511 Huntersville-Concord Road, Huntersville, NC 28078
Physical Address, City, and Zip
Mecklenburg
County Parcel identification No (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds ur decimal degrees:
(if weii field, one latilong is sufTicientl
35.415094 NI -80.804553
6. Is (are) the well(s): gallermanent or OTemporary
7. Is this a repair to an existing well: Dyes or JNo
1/ is a repair, fill oto known well construction ittiOrmation and explain the nature of the
repair ander ,21 remarks section or on the buck of this Ibrat,
S. Number of wells constructed: 1
!or multiple injection or non -water supply wells ONLY with the same construction, you can
submit wle firm,
9. Total well depth below land surface: 55
For multiple wells lis, all depths effliffirent (example- 3@200 and 2(i5100)
(ft.)
45
i 0. Static water level below top of casing: (ft)
1/ water level is above casing, nor
4
11. Borehole diameter: (in.)
8 1/4 HSA / 10 5/8 HSA / & 2" spoons
12. Well construction method:
(Se, auger, rotaiy. 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
45 ft.
55 ft•
Wet
ft.
ft.
ts...otrren
CASING (foe roulti-eased
wells) OR LINER Of up#StAblO
FROM
TO
DIAMETER
THICKNESS
MATtki.U.
ft.
It.
in.
I6 INNElt
CASING ORTURING
meetberoutl
dused-4aap)
FROM
TO
DW.DTIR
THICKNESS
M Al LR1AL
o "'
35 ft'
4 in,
sch40
pvc
ft,
ft.
in,
II.SCREEN
FROM
TO
W.METKR
SLOTSIZE
THICKNESS
MATERIAL
35 ft.
55 ft.
.
4 In'
.010
sch40
pvc
ft.
ft.
in.
IL GROUT
FROM
TO
N1ATERIAL
EMPLACEMEN1 MET AMOIJNT
0 ft.
28.5 •
Portland Cern
Tremie
28.5 ft.
31 ft-
Bentonite Chii
Tremie
t.
ft.
1L4J1ftAVfl.
PA
(If stmglotble)
FROM
TO
MATERT SI.
EMPLACEMENT METHOD
31 ft.
55 ft.
#1 Sand
Tremie
ft.
ft.
20. 011,a2ANG
LOG (a
addidataidsbeeta if esesemary)
FROM
TO
DESCRI N tenter, hardness. millirarli type, grain size.ere.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft,
ft.
ft.
ft.
ft.
ft,
ft.
2t. REMARKS
2 x2 pad and 6" Pro Cover
22. Certification:
Sipa itte of Certified Well Contractor
z•2. 2,
Date
By signing Mt x I hereby certil(' that the well(s) was ("were) constructed in accordance
with /Sri NC-tu 02cr:0100 or 15.4 feCAC (t.?(' ,0200 Weil Construction Standards and that a
copy of this record has been provided kJ 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 farm 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 tbllowing:
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:
Kevin White
W:111 Contractor Name
2973
NC' Well Contractor Certification Numher
Parratt-Wolff, Inc.
Company Name
2, Well Construction Permit #:
List all applicable well permits li,e.. ('many, Stole, !'arttnrce. h
3. Well Use (check well use):
nun, ets.i
Water Supply Well:
❑Agr icuitural
❑Geothermal (Heating/Cooling Supply)
Cl industrial/Commercial
❑irrigation
OMunicipal/Puhlic
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
Non -Water Supply Well:
•Monitoring
Recover
in„jeetinn 1Velli
❑Aquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer Test
❑Experimental Technology
OGeotherrnal (Closed Loop)
❑Geothermal (Heating/Cooling Retum)
4. Date Weil(s) Completed: 4128/21
5a. Well Location:
Colonial Pipeline Company
Facility/Owner Name
OGroundw'ater Remcdiation
❑Salinity Barrier
OStorrrovater Drainage
❑Subsidence Control
❑Tracer
❑Other (explain under #21
well ID# MW-88
Facility ID4 (if applicable)
14511 Huntersvifle-Concord Road, Huntersville, NC 28078
Physical Address, City, and Zip
Mecklenburg
County ParcelIdentification No (PIN)
5h. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one int/long is sufficient)
35.415269 N-80.804274
w
6. Is (are) the well(s): 2Permanent or DTemporary
7. Is this a repair to an existing well: OVes or No
IJ this is a repair, fill out known well construction inJbrnmrinn and explain the nature (/7Ne
repair antler •21 remarks section or on the hark of this,/our.
8. Number of wells constructed:
For multiple injection or nun -water supply wells ONLY with the same eanstractinn, , tnf Calf
submit one Pro)
9. Total welt depth below land surface: 63
Ear multiple a ells list all depths i/,/itlert'tu (example- 36000' and 2 l00')
(ft.)
10. Static water level below top .of easing: 50 (ft.)
)1 water ievel is above casing, use ' "
11. Borehole diameter: 2 (in,)
12. Well construction method: 8 1/4 HSA / & 2" spoons
0 e. auger, rotary, cable, direct push, etc
FOR WATER SUPPLY WELLS ON
13a. Yield (gpm)
13b. Disinfection type: ,,,,,,,. Amount:
Method of test:
For Internal Use ONLY
14. ti*A` E xo l
FROM
TO
i#ESCRtt*TION
50 rt.
63 ft.
Wet
fe.
ft.
t UTIIR CASING (for multi -eased wens) OR I. (If app
hre)
FROM
TO.
Ft1:lMETER
THICKNESS
MATER►AL.
ft.
ft.
in,
16. INNER
CASING OR'F€111INt. (geotlwrtnal
dosed-1o»p)
FROM
TO.
aL METER
THICKNESS
MA:I (AL -...
0 ft.
43 et.
2 in.
sch40
pvc
ft.
ft.
in.
17. SCREEN
FROM
TO
:DIAMETER
SLOT SIZE
TtitCK'YESS. -
MATERbAt..
43 ft,
63 ft.
2 In'
.010
sch40
pvc
ft.
ft.
in.
1$, GROUT
FROM
--. TO.
'MATERIAL
EMFI.,t:CE �M'NU MRTHO) & '.MOl T
0 ft.
36 ft'
Portland Cern
Tremie
38 ft•
40 ft.
Bentonite Chi
Tremie
ft.
ft.
19. S tiD/GI
AYGL PACK
iff a)ipkttobie)
FROM
TO
MATERI.}4
EMPt.ACEMEN'f 11ETHOI)
40 ft,
63 ft,
#1 Sand
Tremie
ft.
ft.
20 DRILL1N
:'i OG (atttotb
additltutat
FROM
TO
t)ESC111'Pi tt}Y leelar, rrardncsn, agtliraek tyrre. kraln she, rte.I-
ft.
ft.
ft.
ft.
__...
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
21. REr4i< ilia
22. Certification:
Si} tilt reviCtatilie Volt Contractor
HE
Hy signing INN form, 1 hereby certi/i? Owl the well(s) was (were) constructed in accordance
with 15A N('AC 02(' ,0100 or 15A lv('AC 02,C 0200 Well ('onstruction Standards and flint n
copy of this record /ta.c been prnrukd 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. Fur ,-tll:.WelLs: Submit this form within 30 days of completion of well
construction to [he 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
Ferro GW-( North Carolina Department of Euviranntettt and Nattuai Resources - Division of Water Resources Revised August 2013

WELL CONSTRUCTION RECORD
Fins form can be used for single or multiple wells
1. Well Contractor Information:
Kevin White
Well Contractor Name
2973
C Well Contractor Certification Number
Parratt-Wolff, inc.
Compam Name
2. Weil Construction Permit 4:
L.r.,7 oil rippiteohle trr'// pernrns• (i.r.. (`otuly, S'une, Variance Ire
3. Well Use (check +veli use):
ton, etc„
Water Supply Well:
❑Agricuitural ❑Municipal/Public
❑Geothermal (Heating/Cooling Supply) °Residential Water Supply (single)
°industrial/Commercial
❑Emulation
Non -Water Supply Well:
i�;Monitoring
Injection Well:
CGAquiter Recharge
°Aquifer Storage and Recovery
L'Aquila Test
°Exper€mental Technology
°Geothermal (Closed Loop)
❑Geothermal (NcatingJCooline Return)
4. Date Well(s) Completed: 4/29/21
5a. Well Location:
Colonial Pipeline Company
❑Residential Water Supply (shared)
°Recovery
❑Groundwater Remediation
❑Salinity Barrier
EStormwater Drainage
❑Subsidence Control
❑Tracer
00ther (explain under #21
MW-89
Facility/Owner Name Facility tD# (if applicable)
14511 Huntersville-Concord Road, Huntersville, NC 28078
Physical Address, City, and Zip
Mecklenburg
County Paicel Identification No. (PiN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well tieid. no lat/:ong is sufficient)
35.415251 N-80.804103
6. Is (are) the well(s): °Permanent or ❑Temporary
7. Is this a repair to an existing well: ❑Yes or ONo
//this is n repair, fill ow knots ten/ construction infbrnrat±on and explain the nature of the
repair under -21 remarks section or of the hock t;jthis prin.
8. Number of wells constructed: 1
i•or multiple injection or non-water.supply welts ONLY with the sums toasrrueliun.yo1 can
Suhmit one him.
(ft.)
IQ. Static water level below top of casing: 52 (ft.)
1/ wilier level is afore casing, use ''
11. Borehole diameter: 2
9, Total well depth below land surface: 53.8
For multiple hells list all depths 0-different (example- 31 t; 211(i
rut 247"100')
(in.)
12. Well construction method: 8 1/4 HSA / & 2" spoons
(i..c. auger, rotary, cable, direct push, etc.: )
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
Far h,retrial Use ONLY:
l t, WATER ZONES
FR{)ti
TO
DrSCRIPTION _........
52 rt.
_...._
53.8 ft.
Wet
ft.
ft.
15. C)I TER
C t SING tCnr
multi eased;wethi OR i,1NER (ifap i ahte)
FROM
TO _..
DIA11FTFR
THICKNESS
11;1TEH(AL
ft.
fr.
in.
16.INNER
I2tf OR iitRlllG(
eatheemalalrne
lcwp)
F11011.
Tt1
DIM TER
THICKNESS
111TERI.\I.
0 ft.
33.8 ft
2 in.
sch40
pvc
ft.
ft.
in.
l7.'SGREEIY
FROM
TO
PIA ;II
SLOT SIZE
THICKNESS
MATERIAI.
33.8 ft,
53.8 ft
2 In.
.010
sch40
pvc
ft.
18'GROL?
FROM
TO
MATdRIA.
E.'N PI.ACE141FNTM ETHOD& MO1dNT
0 ft.
28 ft.
Portland Cern
Tremie
28 ft'
30 ft.
Bentonite Chi
Tremie
ft.
ft.
Ni71GR. VEL P,1CK'(tt'appticable)
ROM
TO
MATERIAL....
F11PIdtfrME'NTMEmoo
30 ft,
53.8 ft
#1 Sand
Tremie
ft
ft.
ill Dtiit,t i(SG
LOG OMR
addttiafi shoe a #C' 3
Flow
TO
DESCHIPfION (crllpr..har intat;suiltruck iitle. grain ux, air j
ft.
ft.
$.
ft.
ft.
ft.
ft.
ft..
fr.
ft.
ft.
ft
0.
ft.
I1.'KEMARKS
2 X 2 Pad & Cover
22. Certification:
Signature of Certified Welt Contractor
Date
/1y signing this jinni, 1 hereby ccru/i• that the ire//(s) was (Werei constructed it accordance
with 15,4 V('AC 02(' -0)00 or 15A V(-a(' 02(' _0200 Well Construction Standards and that a
rimy of this record has been prorided 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 tollowing:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. Filr Injection Wells ONLY: 1n 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 fallowing:
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 four, within 30 days of completion of
well construction to the county health department of the county where
constructed
Form Gw-I
Notch Carolina Department ot'f=rvirwIntent and Natural Resotuces- Division of Water Resources Rev isedAugust 2013

WELL CONSTRUCTION RECORD
This Roan can be used for single or multiple wells .
For Internal tIse ONLY:
I. Well Contractor Information:
Kevin White
Well Contractor Name
2973
NC Well Contractor Certification Number
Parratt-Wolff, Inc.
14. SVA
2'ZONIiS
M
TO
ION
ft.
ft.
iS..t
FROM
;t C I *ifi Iran
TO
id.*elta)
DIAMETER
THIJCKNESS
applies
MATERIAI.
ft.
in.
Company Name
2. Well Construction Permit #:
List ail applicable well permits (i.e. ( t m, Steno Varian infecthttt, etc:i
3. Well Use (check well use):
Water Supply Well:
❑.Agricuitural
_.JGeothermai (Heating/Cooling Supply)
❑(ndustrialiCommereial
❑irrigation
❑Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
;Son -Water Supply Well:
/Monitoring Recovery
Injection Well:
❑Aquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer Test
❑Experimental Technotoey
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling Return)
❑Groundwater Remediation
❑Salinity Barrier
OStormwater Drainage
❑Subsidence Control
t-lTracer
['Other (explain under #21 Remark's)
FROM
0
CtrS NGt3R'
TO
50
ft.
G (geothermal elosed4mo
DIAMETER.
2
In.
THICKNESS
sch40
pvc
ft.
ft.
in.
17,SCIIN
FROM
10
IA:
T SIZE
Ii
49 fL
ft.
74
t.
ft.
2
in.
,010
sch40
•pvc
19.G
FROM
0
iaiaT
TO.
32
ft.
MATERIAL
Portland Cem
EMPLACF,MENT; METHOD & AMOUNT
Tremie
32
ft.
35
ft.
ft.
Bentonite Chii
Tremie
ANL1lfiRA# EL PACT€ d
FROM
35
ft.
TO
64
ft.
rp
MATERIAL
#1 Sand
EMPL%C£MFNT.:
Tremie
HOD
64 ft.
74
ft.
Sand (Riser)
FRO.
ft.
ft.
ON
la
Baron
aril/raek type..
re
4. Date Well(s) Completed: 6/2/21 Well LD# MW-92
5a.1Vel1 Location:
Colonial Pipeline Company
Facility/Owner Name
Facility iD# (if applicable)
14511 Huntersvilie-Concord Road, Huntersville, NC 28078
Physical Address, City, and Zip
Mecklenburg
County Parcel identification No, (PIN)
5b. Latitude.and Longitude in degrees/minutes/seconds ur decimal degrees:
(dwell field one latllong is sufficient)
35.414239 -80.804402
w
6. is (are) the well(s): ©Permanent or ❑Temporary
7. Is this a repair to an existing well: ❑Yes or ©No
If this is a repair, fill ow known well omstruc'tiwt infartsariott and explain the nature in:file
repair under ,21 remarks section or on the hack a/this, forn>i
S. Number of wells constructed: 1
For multiple injection or non -water slq /v wells ONLY with rite same construction,, a+rtr can
submit one Ihro
9. Total well depth below land surface: 74
l or multiple wells list ail depths if dillereht (example- 361200' and 20,p IMP)
(ft.)
10. Static water level below top of casing: 49_ (ft.)
If water level is above casing, use "
11. Borehole diameter: 4 (in.)
8
12. Well construction method: 1 /4 HSA & 2" spoons
e outer, ratan:, cable, direct push, ere,)
ft.
ft.
rt.
ft.
ft.
ft.
ft.
ft.
A<
4" Pro Cover
2 x2 pad
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
Signature tat iiic Tell Ctictnattur
By signing this form, 1 hereby cern&&' Burt the ire/Gs was /were) constructed in accordance
with 15,4 NOR' 02C',0100 or 15,1 N(AC 02C 020/) Well Construction Standards and that a
copy of this record NIS been provided to i/w well owner.
23. Site diagram or additional well details:
You may use the back of this page Co 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 linit,
1617 Mail Service Center, Raleigh, NC 27699-1617
2411 For Iniection ',ells. 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. Fur 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 G\V•I
North Caroiiva Department otEr,vir(lament
and Natwat Resources— Division of Water Resources
Revised August 2013